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Sing a Song of Sixpence
Pocket full of rye
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I have the best freaking nurses in the whole entire world.
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Brief ED post, no need for editing - nothing gross:

The next chart in the rack is Duncan Weisner, an 18 year old with chest pain. He's got no medical history, no relevant family history, no real risk factors. I don't know what's going on but I figure before I go into the room that he's not dying of a heart attack.

In the room there is a chunky young guy clutching his chest.  He's hooked up to a monitor which shows an extremely normal heart rhythm. The nurses have put the EKG on the counter and it could not be more normal.  Duncan has an equally out of shape friend with him who limps painfully around the bed, holding a half eaten bag of Doritos and winces visibly as he sits down.

"What's going on, Mr. Weisner?" I ask.
"I think I'm having a heart attack," he gasps. He does look miserable but I'm not convinced he is having a heart attack.
"Well, tell me the story of your pain. When did this start?"
"Cooper and me," he gestures towards his friend, "we're trying to get in shape. We're going to join the army so we want to get in shape." City X donates a lot of young men and women to the armed forces. It is the only way out for many people - and there is possibly a smaller likelihood of being shot in a foreign country than there is on the streets of City X. I see a lot of vets in my ED and a lot of very sad parents but I don't think I've ever seen people attempting to get into the army before.
"It's great that you're trying to get into shape. When did the pain start?"
"Well we rented this DVD that was supposed to be like basic training and, shit man, that shit is hard core. We were running and doing crunches and stuff. We must have done like, a million crunches and a million push ups and a million squats. Maybe more. But we're going to get in shape!"
"Did the pain start when you were exercising?"
"Nah. We both finished and then we had a couple of 40s. We deserved them after that shit. And when I woke up this morning I was having a heart attack."
"Hmm," I say, and do a physical exam.

Mr. Weisner needs to lose about 50 lbs but his heart has a regular rate and rhythm with no murmurs, rubs, or gallops; his lungs are clear. He's got mild diffuse tenderness in his quadraceps , hamstrings, gastrocs, deltoids, biceps, triceps and impressive tenderness along both sides of his anterior chest wall. I diagnose him with acute inflammation of his pectoral muscles from doing way too many push-ups. He is mortified. Cooper  teases him. I mention that Cooper is limping and perhaps shouldn't throw stones. Mr. Weisner laughs uproariously and Cooper retreats into his bag of Doritos.

"So what motivated you to join the army now?"  I'm killing time while I finish up my charting. This guy was brought back as an emergent patient and I need to get him out quickly to free up the monitored bed for someone who might actually be having a heart attack. The question agitates my patient.
"This country is a bunch of pansies who don't know how to fight. We're willing to go and kill a bunch of Arabs, but we won't stand up for our own people!" This confuses me.
"Do you mean the situation in Afghanistan?"
"No! They're just another bunch of towel heads. I don't even know what the fuck we're doing there, that Osama guy has moved on by now. I'm talking about America. America is being attacked and nobody is doing nothing."
"Um," I say.
"Yeah, we used to have a cold war and everybody was all nuts about it but now we have a hot war and nobody cares."
"Ah," I say.
"See?" Cooper says, heatedly, "She doesn't care either!" He turns addresses me directly, "I don't know what is wrong with you people!"  I'm not sure what part of being a short, four-eyed, overeducated female he means by "you people," but regardless, I've been called worse.
"Lady," says Mr. Weisner, grabbing my wrist and then remembering who I am and releasing it as if he had been burned, "I mean doctor. Doctor, the Russians invaded Georgia. My grandma is from Georgia. Don't you care?!"

I discharge Mr. Weisner with a prescription for Ibuprofen and orders to ramp up more slowly on his exercise plan.
-----------------------------------------------------------------------------------

and, yes, this is a compilation of multiple patients. This seems to be a common misperception.

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http://www.benjerry.com/features/i_voted/

I give all my patients a prescription to vote. I don't care who they vote for but they have to vote. They don't like this but they don't like a lot of the other things I give them prescriptions for either...and this is easier than taking a pill 4 times a day for 10 days.
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I am going to be first author in a JAMA article in the 10/22 health of the nation issue.

For those of you not in medicine/academia, this is a super big deal. Unimaginably big.

And it is basically unheard of for someone's first paper to be published there.

I am very, very happy. I could not be happier unless someone gifted me with a whole lot more sleep.

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Continuation of the previous post.....

Thanks to Dr. Memory who told me how to improve my formatting and to all the lovely people who wrote comforting/encouraging things after my last cranky post. I'm still sleep deprived, so if you see any huge typos/editing errors let me know and I'll fix them.

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Remember: all patients and staff are compilations. Behind a cut as usual for length and grossness. Broken into two parts because LJ doesn't like the length of my posts

Continued in the next post...

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Hubbell FA et al, Functional status and financial barriers to medical care among the poor.  Southern Medical Journal. May 1990, 83(5), 548-550

In the results and conclusion section:

"...patients who experienced financial barriers tended to be poorer."


Thanks for clearing that up, Dr. Hubbell. I was under the misguided notion that people with financial barriers were rich.

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It's been brutal at Hospital X.  The nurses are short staffed and this is hitting the overnight shift particularly hard. We've got float and agency nurses who are perfectly nice people, but the ED at 3am is a bizarre place and the world's best nurse in the family practice clinic can be frustrated to tears -or screams- in the ED.  We're so short staffed that the ED has become a complete log jam. There are open beds upstairs but we can't spare a single nurse or tech to move patients with ready beds from the ED to the floor because otherwise the unstable patients in the ED will die. This is definitely suboptimal but I've been too tired to do much more than keep my head down and see more patients.

I'm in a ghastly stretch of five overnight shifts followed by a DOMA (I get out of the hospital for my day off at 8am following an overnight shift and am due back at 6am the following morning for day shift; doma = "Day Off, My Ass") and 5 day shifts. I'm going to be fairly crispy by the end. I've told my boss twice in the last week that I have had it, that this is it, that there is no way I'm coming back. Both times he said that he was terribly sorry to hear that and could I pick up an extra shift. Both times I said yes, of course.

Last night we had an acute MI that went to cath lab, an acute stroke in a 34 year old mother of 3, a horrible trauma (car fell on a guy and burst into flames), two gun shots, a stabbing, an unstable GI bleeder, a rape victim who had been set on fire, and all the usual other stuff we see. Oh, wait. Maybe that was the night before. I think last night was the leaking aortic aneurysm, the crazy woman who stabbed herself repeatedly in the abdomen with a arm-long sliver of window glass and managed to hit every organ in her body, the young woman who appeared to have been beaten and raped but wouldn't talk and was in the middle of multisystem organ failure, and the 5 year old who inhaled a plastic something and required a surgical airway. It's all sort of running together now. The City X cops who were supposed to be guarding a murderer who had run in front of a car left to get us food because we were so overwhelmed. The murderer was intubated, he wasn't going anywhere.

There was another riot by another family. The victim was drunk, high, and going 100mph the wrong way on the freeway without his seatbelt. The semitruck did everything possible to get out of his way but it wasn't enough.  The guy went through the windshield and was stuck, a la "Signs," between his car and the semi; the highway needed to be shut down to get in an ECHO truck to extricate the guy . Unbelievably, he was still alive when he got to the ED. In addition to me, 2 residents, the trauma surgeon, the surgical PA, and half the nurses in the department did everything we could for over hour before we pronounced him. The deceased family did not take this well. We were accused of not doing anything to try and save his life, of being happy he was dead, of wanting him dead for spare parts.  I had to walk away before I lost my temper. Multiple family members ended up handcuffed after threatening the police officers who were attempting to de-escalate the situation. I heard about that later, I was already taking care of other people.

This morning, when I left the ED 3 hours past the end of my shift, it was grey and raining. Perfect sleeping weather. The non verbal woman still bothered me, I hope I didn't miss anything on her. I slept -sort of- until hot sun on my pillow woke me up and I realize that the jackhammer in my head does not mean I had a great time last night but that there is construction outside my window. I look out. The neighbors both sides of me have suddenly decided to have work done; I hate them with the passion of ten thousand fiery suns. I'm too tired to sustain that so if quickly fades into grumpy annoyance.  I try to go back to sleep but it doesn't work.  I get up, do some laundry, unload and reload the dishwasher, make some food for dinner (or breakfast or whatever the one meal a day I end up eating when I work overnights is called). Normal stuff, but I feel like I am moving through mud. I'm so tired that thinking hurts.

I open the door to get mail and see that part of the construction crew belonging to the house on the right is lounging against the hood of my car. I know I should say something, but I'm just too tired. I stand there  on the porch in my bathrobe in the afternoon sun and stare at him. He stares back.

"Nice time to wake up, Lady!" he calls derisively, "Maybe you should get a job!"

I close to the door, realize I have still not gotten the mail, and trudge up the stairs. Maybe I can get another hour of nap in before I have to be back in Hospital X. As I drift off - despite of the sun, the heat, the jackhammers- I realize that today is June 30th; we'll have brand spanking new, fresh out of medical school interns tomorrow.

When I finally sleep, I have nightmares.

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Link goes to video. I cried with laughter.

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From a piece in Eating Liberally called "How the War on Drugs take Horticultural Hostages" comes this fantastic /ridiculous bit of over-the-top food politics rhetoric:

"...diabetics outnumber crackheads in the U.S. by a big fat margin, but the corn cartel’s got carte blanche to fill us (and our gas tanks) with their Beltway-blessed by-products. So U.S. drug policies focus more on coke addicts than Coke addicts, despite the fact that soda’s the more abused substance."

Horticultural Hostages
Beltway-blessed by-products
coke addicts vs. Coke addicts

Having nothing to do with whether or not I agree with it, this purple prose needs to be read loudly from a pulpit by a fire and brimstone preacher with a thick southern accent.

Sheer AWESOMENESS!

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