VACATION!

Day 1 of vacation! I've managed to get a few re-entry things done today. I have been able to do my laundry. Have been able to do some preliminary cleaning. Have made a few calls, and made a list of things to get done in the coming days.

I almost booked a flight back to Denver, to leave tomorrow. It would be great to get a few days to spend with people... but decided what I really need is a few days here to just relax, and to start getting stuff in order!

Here are some pics from Xmas dinner:

"I'm Going to Die."

This is what she told me.

And she said it with acceptance, almost in reflection.

I. Am. Going. To. Die.

Well, not tonight, but soon I guess. And I stood by her bedside, with lots of things to say. But I didn't need to say anything. She didn't need to hear me talk. She just just needed to think and say some things out loud. She knew. Those aches in her bones were due to the holes where bits of cancer are eating away. She thought maybe those aches were in her head. "Well maybe it is in my head," she points to her skull and grins, "I mean I thought the aches were things I imagined, but I guess the cancer's in my head too." She made a joke. I smiled, and thought it was funny. She tells me, "I have a dark humor." No wonder I like this woman.

She's known. She knew when her bone scan was done last week. Her biggest concern is not her dying. It's the pain and suffering her sister will endure when she dies. I wouldn't have asked before, but now I'm learning that my own discomfort in asking certain questions is really my issue. Why I ask.

Only in the past few years have these sisters become close. And now that close bond will be cut prematurely short. I think about how my own brothers were celebrating one of my nephews second birthday yesterday, and how through many twists and turns we've managed to become close, and I feel lucky.

"What do I do, I don't want chemo again." We talk about what's important to her. I'm not a specialist in palliative care. And I don't know much about cancer. And maybe that makes the conversation easier. It's important that she enjoys the quality of her remaining time, quantity is not the issue. We talk about pain control, no chemo, and other details, and I add, now it's ok to eat all the chocolate and ice-cream she wants. "Yeah," she grins, "you're absolutely right, chocolate and ice-cream."

Bad News

1) Tomorrow I have to tell one of my clinic patients that they have cancer. I haven't seen this person in a while. I would imagine that the clinic calling to schedule a test result would invoke a bit of panic, given that pts usually can't get in to see us.

2) We started our day, at 8:30 am with telling a mid-20s woman (who is a patient on our team) that her mother had been pronounced dead in the ICU. Her sister died yesterday as well. We then took her to her father's room (who is also a patient on our team) and she told him that his ex-wife was dead, and his daughter had died the day before. Not fun stuff.

3) I had to call a family member of another patient to tell them that it was possible we would be intubating her brother by the end of the day. As it turns out, he has been able to avoid the tube so far.

I'm tired.

Hanging out with Jameson

Just chilling.

Jameson is the emergency break for my mind. Pulling the handle, making the craziness of life grind to a stop.

I'm hanging out with Jameson, listening to Dar Williams wondering how the fuck I've gotten to be 32, single, living here, working in a great hospital, in a job I like most days, contemplating taking a year out of my life going to South Africa, wondering when I'm ever going to have time to see friends in Washington, Dublin, Geneva, California, Australia, New Zealand, Pittsburgh, Burlington, Hawaii, wondering when I'm ever going to have time to email/call those I'm on the verge of losing touch with, leaving dinner tonight wondering why I'm single, realizing that I'm tired now and should just go to bed, thinking about how HW and I had a pact to discuss at dinner what was fun and fabulous about our days and realizing that day go by now without any fun or fabulous events, thinking about a crush and why I never told him, thinking about last night and how my friend is such an amazing person and if I were straight I would marry her in a minute and then realizing that this applies to many women I know, but very few men, wishing I had a dog, realizing that all of the above is pointless because I'm going to work tomorrow and for the next 12 days in a row and will have no time to think about any of these issues again until I am on break, and wondering if life is simple or complex, and trying to remember a conversation I had this summer with KE in which the summary was that there will never be enough time to do everything, and just wishing that I had met up with JA who knows how to keep life simple and fun, and that is what I need in life, a partner who would make life simple and fun, and now the nip of Jameson is gone, and somehow there is no resolution on any of the above issues but it doesn't really matter because I have flannel sheets on my bed which await me, and I will wake alone tomorrow, and somehow will become comfortable knowing that I may wake solo for the rest of my life but in the big scheme of things, that's a minor detail, the major details are that I am lucky to be working in my chosen profession and somehow have amassed a beautiful collection of family and friends, and Jameson is a friend who slows things down so I can think about these things.

The above isn't open for conversation when you see me. It's random thoughts that Jameson had me write down so that I can go and sleep in peace.

24 hours

In the past 24 hours I have:

-slept 3 hours
-rounded on 11 patients
-attended one holiday party
-bailed 1 friend out of jail
-pronounced one patient dead
-gone to the gym
-told one man his wife of 52 years was dying, and should go to hospice on Monday
-made a list of all the people I should call tomorrow, doubting that I will manage to get in touch with half of them

Displaced Coloradoan

A foot of snow... Get out of here. One of the problems of not having a TV is not watching the news, and then not knowing that it is going to snow A FOOT.

This news made my day. It's so nice to get dumped on, and when I got off work tonight (an hour late because the night residents had problems getting in), I had damn ball cruising through the snow. The Liberty is a joy to drive in the snow.

I got the sense that I was the only one who was happy about the snow...

Xmas Party #1

Dave had his annual tacky christmas sweater part. A great time to get the group together and let loose a bit. Though, this year was by far the tamest year. I don't think I posted any pics from last year, and for good reason..

Beth and John
Christina, Kenny, Me, Todd
Ted and Sharon
The Med-Peds 3rd year photo (minus one resident)
Why do parties always gravitate toward the kitchen?

Eire

Friday night Mayu and I drove down to see Mason and Kim and their gorgeous daughter Eire.

Mayu and Eire
Kim and I

Dinner

"...must be nice to be able to stop for dinner."

It's 6pm, I'm in the cafeteria.

"Actually, this is breakfast, lunch, and dinner."

Aside from commando runs to the resident room to grab an apple, or banana, 6pm was the first break of the day. Just one of those days. But it was kind of fun.. I rounded on patients, and it was one of those days where I really felt like I was making good decisions, where my attending agreed with my plans. Kind of a nice feeling.

Ethics

This is one of the few nights were I can't seem to sleep. There is no logical reason to be awake at this hour.

This evening, right as I was getting ready to sign out (telling the covering resident about my patients), a nurse paged me about a patient who was a bit tachycardic. Made sense... she was febrile, and thinking about her course for the day figured she was likely a dehydrated as well. (I make a mental note to review appropriate IV fluids with the interns). But, she'd been getting more ill as the day went on, and for some reason I decided to go to the bedside and just see her myself.

She has an illness, which her family doesn't know about. It isn't something simple. It's causing her to be very unwell. And I worry that she will die. In my multiple family meetings today, I asked again and again her medical history, watching this woman's husband, her brothers, her sister for some kind of sign or even a flinch, which would tell me that they knew about her illness. But nothing. The husband re-affirmed that she was to be fully resuscitated.

Arriving at the bedside, I saw the monitor, and she was tachycardic, but it looked sinus to me. Fever to 103. Pulse strong. What the hell, might as well get the EKG to be complete. It was done, and as I walked back into the room to tell the nurse she could go to radiology, right before my eyes she coded, and right behind my back was her family, who I had just re-assured that the EKG was as expected, and that her heart rate would settle with tylenol and IV fluids. Family out. Code cart in. She's back in sinus rhythm. And then the decision to intubate.

Fuck.

Fuck.

Fuck.

Back to talk to the family.

They understand the seriousness.

And all I can think about is that if/when she dies, this illness will be listed on her death certificate and they will be shattered.

Next Chapter & Final Chapter

Next Chapter: as I was getting ready to leave from work last night, one of the pediatric residents paged me to let me know that PJ (Sept 07) was back in the emergency department. We haven't seen him since he was discharged to a specialist for further care of his brain tumor. Apparently, he has been receiving radiation treatment and a new experimental chemotherapy. It was nice to see him and his mom, and to get an update on the status of his condition. However, he looks remarkably different than when I saw him back in September. His long-term prognosis is still not very favorable.

Final Chapter: JP died this week. She was admitted to the pediatric intensive care unit with an infection, and her prognosis was extremely poor. Her family and the team made the decision to withdraw life support, and she died within a matter of minutes. Inside her small room in the PICU, just before she died, were all of her family members. And they had a birthday party. She would have turned two this coming Thursday. So her family gathered, had cake and ice cream at her bedside, and celebrated her short life. I will continue to be amazed by how incredible JP's mom is.

I am back on medicine wards this month, as the senior ward resident. In addition to covering my own patients yesterday, I was responsible for precepting all of the new admissions that the interns did.

Home

Where is home? What is home? Is it Home or home? Ever since moving to Ireland, this concept of home has been difficult to define. For the longest time, I told people that "H"ome was where my dog was, and "h"ome was where I was living. But what really is home?

Looking at Urban Dictionary Definitions:
1. What a house becomes after the person owning it has had sex in every room.
2. [skipped]
3. A word that means something different to each person who uses it. A person's home can be the place where they live, the place they grew up, or the place where the people they care about live. In the case of some people, home is a variable concept, changing dependant on the placement of another person or object, or a person may even consider his or her own body the only 'true' home.

I think I will finally admit that, for me, Denver is home. It just feels right. Knowing so many great people who live there makes it feel right. Watching the clouds coming over the mountains makes it feel right. Running in the foothills makes it feel right.

When I left Denver I didn't really think it would ever be home again, and that's been an idea which has been hard to part with. When I left, I never really imagined going back there to live. I didn't think so many friends would still be there, or have moved back. I never imagined that my family would grow as much as it has.

I don't know what will happen in the next 2 years... But, I'd say there is a good chance that Denver will be Home and home in the coming years... time will tell.

More Photos...

Piper and Bailey Decadent dessert with Mykel

Decadent Dessert with Ona (and Stacey) in Breckenridge

Awfully big bite...

Ryan and Jordan chillin with books

Am back home in MA. I had a great trip home.

Home..

Giving Haley a better view..
Jordan and Haley climbing on the Columbine Memorial
Jordan and Ryan playing
Seeing Julia (pregnany belly not shown) and Travis
Family Dinner at Tom and Irene's

Having a great time in Denver. Fresh snow today.

Have a great Thanksgiving.

36 Hours...

Until I see these cool kids..

Happy-ish Place

end of the changing colors

look, snow

I went to a lame lecture this week, well two of them, and both times thought how I'd never get those hours of my life back. Similar feeling this morning as I was surfing the web at home for useless crap. I was so disgusted with my recent foul mood and wasting time that I jumped out of my chair and grabbed my rucksack and hit the trails. Was so nice to be out and about. Nice and cold and crisp out. Very refreshing. Hence, the genuine smile.

This

blog

is

blank

until

i

have

something

nice

to

say.

Please

reread

old

posts

until

I

find

my

happy

place.

1

week

til

Denver.

Uno Mas Dia

Yep, that's it. One more day.

This month has been a test in stamina. I was going to say that it has felt like a marathon, but having run a marathon, I actually thought the marathon was tougher.

Last night I admitted somebody with an asthma attack to the CCU service. At 2:30 this am, I just didn't have the spark needed to try to block the admission. I didn't have the energy anymore to tell the ER resident it was bullshit admitting this patient. I didn't have the energy to tell the medicine service to admit this patient for asthma. Rather, it was easier for me to spend the half hour and admit him to my service knowing that we would treat his asthma and send him home today. The best part of admitting him was knowing that my attending was going to have a minor fit, and that was part of the reason to not fight the admission. Every call I've blocked at least 2-4 bullshit admission to the CCU service, and quite frankly last night I just couldn't care less about bullshit admissions...

Sinking Ship

Bailing out a sinking ship, with a spoon.

It is 3am.

I'm in the ER. I have 3 admissions in the ER. Patient #1 is intubated after acute decompensation having had a new heart attack. Patient #2 is in florid heart failure. Patient #3 is pregnant with twins (yay for being med-peds, I can handle twins and know some OB), and may have had, or be having a heart attack. I'm just opening the chart when the ER residents finds me to tell me about admission #4...

"Code Blue, Cardiac ICU."

Two thoughts:
1) You've got to be fucking kidding me.
2) Oh fuck, who is it now.

I run back to the Cardiac ICU, having left it 5 minutes previous.

Let me explain...

All hell broke loose about 1am. I knew I wouldn't sleep. Ms G was having unstable angina, and she was screwed. Would she go for cath? Would she go for emergent bypass? Forget the details, but the idea was to medically manage her overnight, and likely she would go for cath in the am, bypass in the pm. Except that I couldn't get her pain free when this all started for the 3rd time at 1am. And her EKG wouldn't normalize. Wicked ischemia. Likely infarcting as well. Oh, and now her blood pressure is down to the 70s. Hypotensive, 8/10 chest pain, EKG changes. Not a good combo.

And then they call Code #1 of the night. Adios Ms G... run off to another part of the hospital. Bring Code #1 into the CICU, the ICU resident (thankfully a med-peds colleague) is helping me stabilize her, getting in central lines. Now I have 2 very unstable patients, on opposite sides of the CICU. And I have 3 admission in the ER which have all come in since 1am.

So, there I am, running up the 2 flights of stairs, wondering which of my patients has coded. I have 2 likely candidates, but also there are 4 other patients who are on the suspect list. And much to my horror/surprise/relief, it's a cardiac surgery patient. That small sigh of relief is knowing that it isn't a patient I'm responsible for. And interestingly, the nurse (who is phenomenal) had kindly told me this guys story earlier on in the night. Which is immensely helpful since now I'm running the code and I already know his story.

3:45 am he is pronounced.

And the night just doesn't get any better...

Somehow, though, the morning comes.

9 admissions
2 codes
1 frazzled senior resident.

Sunday New York Times

Post call. Managed to sleep last night. After a wild start to the day, things settled, and I actually slept more last night that I had on all the previous call nights this month-COMBINED. So, the cloudless blue skies, and changing leaves, and new tires on the Liberty beckoned a little day trip in southern Vermont, cruising the dirt roads and old dead-end logging roads. Finally settled to read the New York Times, outside. Perfect escape from civilization, and some much needed mindless driving, listening to music, and being in the mountains.

White Russian & Into the Wild

I remember vividly being at Coors field, for a Rockies game. Mike and I were there. It was an afternoon game in the middle of the week. A carefree day. We got there early to have a drink before the game started. The bartender asked me what I wanted, and I ordered a white russian. I asked the bartender if she knew how to make one, and she acted all blond and put on this act trying to figure out what was in it. I didn't know that they were a common drink. I tipped her well. That became my drink in that period of my life. A White Russian. I drank them clubbing at Proteus. I occasionally had them after working night shift in the ER. I'd sit on the couch, relax, and sip a white russian, and our cat (Guinness) would lick the cup afterwards getting the last few drops. What 21 year old drinks white russians?

Chris McCandless drank white russians. I was reading Into The Wild at the time. I had a group of friends at that point in my life who got it. Who understood that the most valued things in life were morals, and honesty. That life wasn't about settling down and collecting trophies. This side of the story isn't presented so clearly in the movie, but it is clear in the book.

Seeing that movie reminded me of who I was when I was 18, 19, 20, 21, and last night, part of me was saddened by who I have become. Though, in a way it has been refreshing. I've thought about this more and more today. The movie was a wake up call reminding me of things I use to believe, which are still true, and reminding me how I wanted to live my life. It was a gentle nudge to getting back on track. It was a gentle nudge reminding me why I am in medicine. It was a gentle nudge reminding me what I value in my life.

I think I'll have a white russian thursday when I'm post-call and ready to sleep.

Into the Wild

It's very late, and I should be in bed by now, but I went and saw Into the Wild tonight. I have lots of thoughts, that will have to wait til I have some time to jot them down.

In a box in Colorado, I have an autographed copy of the book, from when Krakauer spoke at the Tattered Cover in LoDo back when I was in college. And at that engagement, were some family members of Chris McCandless-it was very moving. I hope that when people see the movie, they remember that this was a real person.

I doubt many people will get it.

Black Cloud

"Every month, one resident gets the black cloud designation. This month, it's you."

Yeah, thanks. Why me? I dunno. 9 admission last night. 8 admissions Thursday night. 3 patients transferred from outside hospitals arrived in the CICU within 5 minutes of each other. The fact that the sickest patients who remain intubated were ALL admitted by me in the past 1-2 weeks. The fact that on our current list of patients, I have admitted more than half of them. The fact that on my last 2 calls I have gotten, at best 30 minutes of sleep-TOTAL.

Oh, maybe I get it.

But ya know what.. even with that black cloud *knock on wood* I'm keeping afloat, and there haven't been any unexpected outcomes.

Time for a nap.

Health Food

This is a pretty cool article on easy things to incorporate into every day eating. I'm reading this as oatmeal-chocolate chip cookies are baking. I wish they would have included oatmeal daily with blueberries for breakfast.

Post call yesterday I went and hung out with Jess and Amy and their adorable daughter Mirena, then joined up with David and Dale for the Friday gay mens pot luck dinner (I'm always the youngest, by a decade maybe-but it's a nice group). Then I had a quick scotch with Ted-who may be the only other single male resident in our group so we had a nice commiseration session about life in the valley. And then I crashed.

Today's agenda:
1. Baking cookies for work
2. Going to the gym
3. Nothing.

Yep that's right. Nothing. Absolutely nothing. I may stare at a blank wall for the rest of the day and listen to music. This is my only day off this week and I'm afraid my neurons need a day to not process any information. I'm on call again tomorrow.

Cheers,
B

Double Red Bull Breakfast

I confess that by this morning I needed the ultimate jumpstart. A double red bull for breakfast.

It's funny what 30 hours of being awake will do to you. This is the second call where I was in bed for maybe 10 minutes out of my 30 hour shift. Think about how long 30 hours is...

Thankfully it was a steady pace, and not too out of control. There was a period this am, about 6:30 am when I got my 7th admission of the night when I just had to shrug and make my way to the ER to start the new admission.

Young at Heart

Or young, with old hearts may be more appropriate. I wish I could count the number of times somebody has remarked recently on how YOUNG our patients are right now. 39, 41, 42.. all in the Cardiac ICU on vents.

On call last night. Decent night.

Couldn't fall asleep cause one of the patients, who was stable, had some issues that were perplexing, and all night long I fought the urge to CT him (my clinical exam gave no indication for the CT), but then I caved at 6am hoping that the CT would give some miraculous insight into what was going on.. and alas the images didn't have the answer.

B

Rockstar moment

On my last night in the Pedi ED (Wednesday, I think), I had a Rockstar moment. And it all has to do with the ultrasound from above (from the net, this isn't the real ultrasound from the patient I took care of). What you're looking at is the ultrasounds of the stomach, that bulge is called Pyloric Stenosis. An idiopathic condition where the pylorus becomes enlarged and obstructs the stomach from emptying, which results in vomiting. Or projectile vomiting, which is what we're taught in med school and residency. This kid didn't have classic projectile vomiting after every feed. But, while I was examining him, there were some forceful perstaltic waves, which were easily palpable. Right time, right place, the kiddo had just taken some pedialyte before I saw him. And that "palpable olive" that is classically described wasn't really appreciated. (Although after my exam, he did have a nice forceful vomit). I was hoping that this kiddo would have simple gastro (the story wasn't the classical version), but it was just unusual enough that my gut (pardon the intended pun) felt the need to get the ultrasound and rule out pyloric stenosis. The Rockstar moment was sticking to my history and physical and writing down pyloric stenosis as my first differential, and then gastro. The real Rockstar feeling is knowing that taking a good history and performing a good physical examination helped this kid get the right diagnosis early on--he had perfectly normal lytes, not even enough time to develop the classic hypokalemic hypochloremic metabolic alkalosis...

Shopping in Soweto

Looks like shopping in Soweto has moved up a notch. I must confess, that the only shopping I did when I was in Bara was on the bridge that crossed the road and lead into the hospital complex. I was able to buy some fruit and chips there when I was on-call.

Shared Experiences

Last night I was in Burlington, VT, chatting with Seamus (training for General Practice in Ireland), Nathaniel (Internal Medicine), and Jean (Family Practice), and it was interesting how common the experience is, regardless of where/what we were studying. I think the common thread was that residency is tough, regardless of where or what you're studying.

Seamus arrived Wednesday. Thursday we left early, ate breakfast in Woodstock, Vt, and then made our way to Mt Washington (NH), drove to the top, and then made our way to Burlington.

Just a plug for Burlington... While I think Telluride is, perhaps, the most perfect place on earth, I think Burlington is a close number two. If I ever disappear, and you want to find me, I'm sure I'll be hiding out in one of those two towns.

Anyway. Then yesterday we took the ferry across the lake, and went to Lake Placid and around the Adirondacks.

Last night, we cooked outside, and ended up having a lovely feast outside, in the dark. It was stellar.

Back to the grind now. Need to cram a bit for the exam Friday and Saturday.

First Snow (In Colorado)

Looks lovely, doesn't it.

Not much going on. Working again tonight in the Pedi ED. Clinic tomorrow. Then headed to Burlington, VT Thursday and Friday. The month is cruising by, can't believe Step 3 is going to be here so quickly. Oye.

PJ

I suspect a majority of the pedi residents will know about PJ in the coming days. That's not a good thing. He will be added to the list of kids with cancer. Kids, who we residents know well, who we happily take care of, who we protect when we see them in the ED. He will be in and out of the hospital. He will be the kid that when he dies, we'll stop and recall when we first met him. And for me, that was last night when he was in the ED. Giving his parents the CT report, and trying to maintain some optimism about not having a final diagnosis was difficult-it's obviously going to be a horrible cancer. I can't even fathom how a parent would be able to deal with this news.

It's been a bit brutal the past few nights. We've seen sick kids. Not much in the way of snotty noses and coughs. Admitted a kid to the Pedi ICU last night with a bad pneumonia, and admitted a kid with meningitis recently as well.

Overall, aside from finishing work at 1-2am, (which means not getting to bed til 3 or so, and not getting up til 10 or so) it's a great month. It's nice to have that immediate gratification of making kids feel better, or giving guidance to parents about their sick kids, and sending them home (even if I have to pay for the taxi myself-like last night).

I'm suppose to be at my second site in 6 hours, so should probably hit the sack...

"Doctor, promise me one thing,

"Doctor, promise me one thing, don't drink alcohol out of a plastic bottle."

This is a quote that I heard tonight from:
A) a patient in clinic
B) a random stranger at the bar
C) my attending in clinic
D) the voices in my head


Yes, C!

Dr G is my hero. She was my first attending physician on July 1 2005 when I stepped foot on the pedi ward, and was convinced that the only thing I knew was my name. And tonight she was my attending in the moonlighting-pedi clinic. I can't even describe her to you. Long gray hair in a pony tail. She has the respect and love of all the residents. She is the definition of liberal, but married to a guy who owns a gun store. And, she drinks her Jameson neat. That's where this all began. After the miserable experience last week, we decided that there would be post-clinic liver rounds tonight to help detoxify the mood after clinic, and we tried to convince Dr G to join us.

"What do young doctors like you drink these days, beer or hard stuff?"

"Beer, tonight. Maybe whiskey at home."

"Well Doctor, promise me one thing..."

No Water

Just for fun, check this out. No Water at Bara.

 

It reminds me of then I was at Mosvold Hospital, and occasionally the hospital, and all the staff who lived on the hospital grounds, wouldn't have running water. We had water stored in the apartment so at least we would have drinking water. In fact, I recall scrubbing for surgery with one of the OR tech pouring running water from a bucket over my hands as I washed...

Feeling Fall

Leaves are changing.

Albeit slowly.

Air is crisp today.

Sweatshirts are back out.

The evening is spectacular.

 

I'm taking a study break, and happened to come across these two clips, which make me very happy.

1- Coffee's Holy Grail

2- To Burundi and Beyond

 

Am off tonight. It was nice and mellow last night at work, to make up for the somewhat crazy Monday night. Checked up on the kids I admitted on Monday, and they were doing well, should have been discharged today.

 

Back to the books.

B

I Wanted Ice Cream

And she wanted to pee.

I ran up from the Pedi ER to the pedi floor to help Amy (the night resident) do a LP (spinal tap) on a kiddo that I had taken care of in the ED. I felt a little guilty cause I didn't tap the kid in the ER, and then the admitting attending (who has the luxury of hearing the story from home, not seeing the kid) wanted a tap done (even though this kid has been on antibiotics for 14 days), which defaulted to Amy. She was going to need some holding help. And, I was starving, and the pedi floor has those cute small ice-cream-in-a-small-styrofoam-cup with wooden spoon that make you feel like a kid again, so I offered to run up and help her. I grabbed an ice-cream, and she realized that in the time it would take me to eat that small container, she could zip to the bathroom. It's going to be a long night for her!

Tonight was a good warm up to the upcoming Pedi ER Winter Season. We admitted at least 7 kids this evening. Sick kids too..

Say a little Prayer

M is a 12 year old whom I took care of tonight. He dislocated his pinky, at the proximal interphalangeal joint. (The joint closest to the knuckle). He was a tough kid, but even with with a digital block (numbing the finger) reducing the dislocation was proving difficult. I tried twice, the attending tried twice, and we were about to place a call to the orthopedic team to have them do it. We pleaded for one more attempt, and that's when M turned his back to us and said a very soft prayer, and viola-it went back in place.

I sutured another kid, those skills are coming back, albeit slowly. I haven't sutured since I was in South Africa back in 2003, but this is the second time I've sutured in the pedi ED. It's like riding a bike.

That's my Joya for today. Praying put joints back in place, and suturing kids.

Way past time for bed.

B

Joya Del Dia

Translation: Jewel of the Day.

Joya is a happy coffee. I don't really know how else to describe it. It's snappy. It jumps in your mouth. It is nice and simple. Simplicity has been woefully deficient in my life recently. Well, for probably a bit longer than "recently."

It was nice to be away and to have time to do nothing but study and relax. No TV. No Internet. No old journals/newspapers begging to be read. It was a jewel really. A retreat. A chance to just escape from life and take time out to get some much needed studying done for Step 3 (USMLE) and a chance to review for CCU (October).

I had the Ubora blend (at Starbucks) on Wednesday, and thought it was delicious. On Friday, I ran out of coffee and picked up the Joya blend by accident. I'm a bold guy-not a big fan of medium blends. But as I settled down Friday night with a new pot of Joya and a practice test in surgery, overlooking the East River, in a contemplative mood, free from distractions, I was pleasantly surprised when I sipped the Joya. It was simple. There was nothing to analyze-no hidden agenda.

And that was when I realized that I dearly miss simplicity (maybe that's what I like best about pediatrics). Don't get me wrong, I like the complexity of a nice cup of Yemen, but in my personal life right now, I'm moving toward "Joya." Correction-I can hear people already protesting that I don't know how to simplify life. I should learn how to move to Joya.

Walking back to Starbucks today, I felt relaxed for the first time in a while. I had a productive jam session of studying, while being removed from the world (yet, in the center of the world at the same time), and felt that I had shed some accumulated layers of aggression and frustration that had built up recently.

This afternoon, I hit the wall (to borrow a running term) while studying... so, I went for a nice long walk in the city. I just walked aimlessly... Watching people mostly.

While I learned and reviewed a plethora of medical knowledge, I also learned that there should be a little "Joya" in every day.

$4315.05, Hiding Out, Compromise

$4315.05:
That's my bill from the ER. For my rabies immunoglobulin and vaccine. Outrageous, isn't it. But really, given that rabies is universally fatal, I guess it is worth it. And thank god for the $50 co-pay only!

Hiding Out:
Finally, my pager is off. I have NO clinical responsibilities. I feel like I am on a mini-vacation. I'm catching the train to New York tomorrow. I think it's going to be the perfect few days away. Will have my books with me, and will enjoy some serious down time. Am looking forward to coffee breaks walking around the city, hanging out studying in busy coffee shops. I'm looking forward to some anonymity. I'm pretty tempted to go out Friday night too :)

Compromise:
In the evening moonlighting well child clinic I saw 10 kids in the span of a few hours. Not my kind of medicine. Decided that while the moonlighting money is nice (and each shift will cover half a month of rent next year in Jo'burgh), it's not the kind of medicine I want to practice, so have decided that my shift next week will be the last of the moonlighting shifts for me. Can't put a price (or roof?) on the quality of medical care I want to deliver to my patients.

So, don't plan on being back until Sunday, and then it's back to work on Sunday afternoon...

Day #12

It's finally here. This is day # 12 in a row (or day #19 if you consider the fact that I was on-call over the weekend a few weekends ago).

I'm escaping tomorrow morning. I'm going to head down to New York for the weekend and hide out in Lucia's flat while she is away-and hopefully have a very productive study session.

Not much else...

Ian and Emily

Pamper Hats!

Adorable. Ian (on the left) decided to wear his diaper in a bit of an unusual way, and then decided that his sister needed to join in his new fashion statement. I had brekky this am with a good friend from work (who is in anaesthesia) and we made french toast. Nice relaxing morning, and nice to take a break off from studying.

Pedi ED

Past two nights were pretty busy. We're seeing a fair bit of enteroviral infections, with a fair bit of dehydration. Think pedialyte people. Keep those kids hydrated. Also took care of a infant yesterday, who had intussusception. It's the third kid for me. And none of them have had any resemblance of the classical presentation. The money is in the history. Sad how each time others had passed-over what were seen as trivial parts of the history. The infant should do well.

Back tonight. Am sure that on a holiday Monday, it's going to be FUN FUN FUN, and busy busy busy.

Am seriously looking forward to my day off (starting on Thursday). Am pretty tired by now.

End of the Month

1) Double Espresso-Hold the baby: I couldn't resist. One of our last newborns of the month was born in a coffee shop. I happen to think that this is a sign of divine greatness for this child, and I resisted the urge to ask about naming the kiddo Mocha, or Latte, or Kenya, or Doppio. Happy to report that the kiddo is doing well.

2) 140: If it felt like a busy month, it was. We (my two star first year residents and I) rounded on 140 newborn babies. Of those, we only had one go to the NICU (who did great), 2 to the custody of DSS and the remaining 137 were discharged home to their parent/parents. I skimmed the list this afternoon of those 140 kids, and it's pretty amazing the number of names which I don't recall, but also there are many names which evoke visual images of proud new parents holding their precious new children.

3) Pager Off: Finally, and for another 17 hours I am off/free. Today was day #5 of a 10 day stretch.

4) Pedi ER: Tomorrow I switch to the Pedi ER. I'm actually looking forward to it. It's a 4pm-1am shift all month long. It's been almost 2 years since I was in the pedi ER, and I feel like I've learned a significant amount in those two years. I feel like this is a time to hone in on clinical acumen, as well as a great chance to brush up on some ortho and other topics. I am also approaching this as a warm-up to Bara.

5) Dropping off the grid: Heads up on the upcoming 2 months... I'm working late shift this month, and days will be spent studying for part 3 of boards (USMLE) as well as doing some review for Cardiac ICU in October. It's a bit frustrating because I already feel slightly out of touch with a bunch of people, and know I'm headed into a long 2 month stretch, where it's going to be tough to keep in touch. Did I mention that in October we do overnight call every third night?

That's about it really...

Enjoy labor day.
B

Jen & Dawn

I spoke to my cousin Jen tonight, and got to hear the great news. (They were one of the 6 couples who brought about the lawsuit for same-sex marriage in Iowa). I hate to admit that when I saw the headline on CNN I had this intense feeling of guilt because it has been a long, long time since we chatted on the phone. This photo is from June 05, (I stopped by on my way from Colorado), so it is a bit dated-but it captures what great parents they are. It was nice to catch up on family news as well. Anyway, Jen is incredibly special since she was actually the first family member I came out to, and she has been such a great support and role model. She was funny, when one of the reporters called her this evening and asked her how she was going to celebrate, she said "make dinner and get the kids to bed."

B

The Family

Finally got some pics from my trip to Chicago last weeekend (combined 90th/85th birthday party for my grandparents). It was great to see the entire family. Look at my amazing niece and nephews. Aren't they adorable? Even playing in the rain water and getting all dirty...

Home to DSS, PPI, Pregnancy Testing

1) Home to DSS: This morning we discharged 2 of our newborns "home." For them, home meant into the custody of the Department of Social Service. On many levels, this situation is less than ideal. Less than ideal because it means that these kids came into the world, and their biological creators were deemed unfit to take care of them. Deemed unfit by the pediatricians (us), who notified the state about our concerns for the welfare of these children. The state then investigated and went to court to take custody of these precious 2 and 3 day-old children. The children then end up in a foster care for the night, or for their life, or get adopted, or maybe get re-united with their parents. We gamble that going into the world of foster care means that these children will be loved, sheltered, and fed to the extent that they wouldn't have received from their bio parents. I think it is a shitty way to start life. The protective pediatrician in me almost would have preferred taking these kids home myself!

2) PPI. Or proton pump inhibitor (ie, omeprazole-Prilosec, esomeprazole-Nexium). I was chatting with a fellow resident about my upcoming month in the CCU. I start in October, and it's a bit anxiety provoking. She was kind enough to point out that she had to start taking meds for ulcers during that rotation. Comforting. Thanks.

3) Pregnancy Testing. If you walk into a clinic, and you ask for a pregnancy test, and while waiting for the results you GIVE BIRTH TO A BABY-is the test positive? I kid you not. And, this woman has had a baby before. I know there is some serious comedic potential here... What bothers me most is that there has been no prenatal care. I've thought about this for a few hours now.. no prenatal care. We've done such a good job medicalizing a normal process like pregnancy and birth that I had to stop and think this afternoon about what to do for this kid. The kid looks great. But what if mom has hepatitis B, or HIV, or untreated group B strep, or or or... Or the fact that this woman, who admitted that she "knew but didn't know" she was pregnant made no attempt to ensure that the child she was carrying was healthy. Is this woman fit to be a parent? Am I passing judgment or am I really just focusing my concerns on the welfare of this child? hmmm

Coffee Culture Withdraw

I was suppose to go hang out with my friends Jess and Amy and roast coffee this morning. We roasted a few batches about 3 weeks ago, and compared notes about a week ago. I normally have brunch with them and their adorable almost 2 year old daughter twice a month. It's usually an all day affair, with the consumption of multiple pots of coffee. Anyway, since they have a garage, and since roasting coffee makes a good amount of smoke, my coffee roaster is now up at their place...

 

I went to Amherst Coffee last night. The serve probably the best cup of coffee in the immediate area (ie, less than half an hour away). I'm pretty sure they are serving coffee from the Great Barrington Coffee Company. The ambiance was pretty good as well (though there is a wine bar which is always a bit weird to me, but I guess it's kind of chic and trendy). They have a community table, which I always love. Even better, the place had newspapers strewn all over..

 

That's what this post is about this morning. I really just want to pluck myself out of here and magically appear in a buzzing coffee shop, with lots of copies of the New York Times, and plush couches, and fun people watching. That's the ideal Sunday morning for me... I'm meeting a friend for coffee in a bit, and I think I'm going to give Blue Moon another chance. I recall their coffee may have been a little weak, but they definitely have the best ambiance. Sadly, the Starbucks around here just don't do it for me anymore..

 

Then it's home to study.

 

Bara on NPR

People have been asking about Bara (short for Chris Hani Baragwanath), the hospital that I plan on going to next July. Here is a clip of a piece that NPR did a while back. There is a photo-essay part as well. Worth checking out..

A Week of J2 & Neonatology

I'm on pedi second jeopardy. For a week, which started at 8am on Friday. So far, so good. I'd be surprised if I get jeopardized this time of year. It's quiet in pedi-land. That being said, the head neonatologist said he was going to try and jeopardize me this weekend for a transport. He was, of course, kidding. They would essentially need to have 3 transports going at the same time for the second jeopardy person to get called in. Usually the NICU team can cover a transport, and if needed, they call in the Jeopardy resident to go on a transport if the NICU is busy. Or, if there is an intern working overnight in the NICU, then a senior resident will get called in to go with the intern on the transport.

I've been in the NICU a lot this month, more or less hanging out since the transitional nursery is next to the NICU, and there is a resident call room in the NICU. I've also been hanging out in the afternoons trying to improve my neonatal IV skills. (I suspect that next year in Johannesburg I will be responsible for doing a lot more procedures than we do here).

The NICU staff have been asking when I will be back in the NICU. (It won't be until January). A few have asked if I'm considering a NICU fellowship. I guess after everything that happened in February, I have a bit of a fan club in the NICU. I have actually pondered a NICU fellowship, more than once. From an international perspective, infant mortality is a significant issue and neonatology would be a great skill to take abroad. But, the idea of adding three more years of training is not appealing. Maybe if there were a combined NICU/Pedi ICU/Adult ICU fellowship, I could be tempted to consider it...

If you hear me talk about applying for a fellowship, knock some sense in me. I can easily see myself applying for a fellowship to defer figuring out what I want to do after residency...

The right start to the day

The nice thing about this month: I get to spend the better part of my morning holding newborns.

There is something inherently calming about cradling newborns, and just watching them. I find myself often wondering what will come of them. I know my nomadic tendencies will keep me from taking care of kids for long enough periods to watch them grow up, and see who they become. (Although, my niece and nephews will give me that joy). So, I just hold them and try to imagine them growing up, and hopefully living happy, healthy lives.

More Bats

This is the most recent Bat sighted in my apartment. Granted, this one arrived from a twisted (though dearly twisted) friend, via Fed Ex.

Good thing I have my rabies shots.

Failing Teens vs Failing Systems

"You look like a smart kid, what's really going on with school." And the tough 17 year old started to cry. I felt my visit grind to a halt. I was consciously aware that this would add on an extra 10 minutes to my visit with him. And in that 10 minutes I was scheduled for another "Well Child Exam." I moonlight (sort of) in this evening clinic every now and then (or as much as possible given my future year of poverty), and we're booked 10-15 minutes for well child visits. (Thankfully with a no-show rate of 25% or so, we usually have a bit more time).. You just can't provide good care when in the middle of a jammed pack schedule you have neat teenager, with little support, who at the age of 17 thinks his future hopes are diminished cause he's been screwing up in school. No father figure. No mentor. In a school system that could care less about his future. And he sits in front of me, finally at his breaking point, finally having the courage to admit that he has this inner turmoil. Some of my colleagues wouldn't have gone there. They have the mentality of divide an conquer. And I am learning to do that more and more, that I can't really solve every problem for every person at every visit.. But most days I think that is a pathetic approach to taking care of people. To make a profit, a primary care physicians must see a ridiculous number of patients & triage complaints... They are sorely missing out on the Art of Medicine, and that is tragic. Outpatient primary care is not for me. I can't operate on a schedule mentality. Knowing that somebody needs an extra 5 or 10 minutes of my time should not jeopardize a schedule. And since when does a "schedule" have more priority than taking care of "people."

Hmmm.

Boston and Life...

A friend of mine and I made an impromptu break for Boston on Friday night. I really (no, really) needed to get out of dodge and have some drinks and be around some gay men. Well, gay men with taste. Sometimes it is just so suffocating living here. I can't believe after 5 years of hating the scene in Dublin I moved to somewhere with even less of a scene. Well, not that there is even less of a scene here, in fact there is no scene. (I have to remind myself I came here because I'm in a great residency program). We had a lovely (albeit expensive) dinner, and then plucked ourselves down in a lounge and enjoyed a night of catching up and enjoying some strong Jack and Cokes. (Jason would be proud)! I think I got home about 4am. I think of it as a night of being on call. Being awake fore 22 hours is really no big deal anymore. We made a pact to make it a point to go to Boston (or NYC) monthly. Life is too short to not take advantage of getting out of Dodge more often...

The rest of the weekend was mellow. I spent a few hours working on my application for South Africa. I loathe paperwork. Sadly, work email has been down all weekend, and one of the documents I need to fill out is trapped in my work email. Fingers crossed, I think it will probably take about 2 months for all the paperwork to be completed. Once I get registered with the Licensing Board and the Foreign Workforce Management Program, it should be mostly smooth sailing from there. And then it will feel real.

As for dates, I should be flying to Johannesburg at the end of June (2008), and will return to complete my final year of residency in June 2009, and will finally be finished with formal medical training on June 30th, 2010.

Wow, I just had to sit for a few minutes and look at that date. June 30th, 2010. Wow. It still seems so far away. Ironically, one of the nurses asked me on Wednesday if I was already an attending. I laughed out loud. "No, it just feels like I have been here forever."

Anyway...

I am really looking forward to seeing the family next weekend. We're meeting in Illinois for the grandparents 90th and 85th birthday celebration. I'm really looking forward to seeing my niece and nephews!

Alright, time to go for a bit of a run. I'm trying to run outdoors once a week...

Cheers,
B

Newborn Nursry

Newborn nursery has to be one of the most delightful months of residency. It's a happy day, every day. Well, more or less. It's nice to be in the nursery again. Now that I've had 2 year of pedi under my belt. I finally know what's normal, and what's not. I finally feel like I have a little authority/insight when talking to new parents about how to parent.

As I was examining a kiddo yesterday, it dawned on me that I was the first physician to ever examine this new human. I was the first physician to listen to his heart. I was the first physician to look in his eyes (not that you can see much at this age). The first to feel his femoral pulses. The first to make sure his hips were normal. The first to make sure his back was straight. There's a sense of responsibility that goes along with being the first physician to examine a patient. And then, when I told the mom that his exam was completely normal, I had this sense of responsibility wondering what would it mean if I had missed something on my exam... Who would catch it? (Well, likely the attending)...

I almost did battle with a nurse yesterday. I find L&D nurses can be extremely judgemental-passing judgements left and right about parents and their capabilities to raise children. It's pretty gross really. I almost feel like unless the parents are middle-upper class, English speaking caucasians who kiss ass to the fucking nurses, the nurses tend to have less than favourable opinions about the parents. Don't get me wrong, I'm not a (total) saint, I don't believe that just because you have a pulse means that you will be a decent parent, but I'm all for giving the benefit of the doubt. It's my job as a pediatrician to help these new parents (and all parents) be as successful as possible in raising happy, healthy children. Being a good parent has nothing to do with money, or with the ability to speak the national language. I looked at this nurse, and thought of how my brothers and I were raised, and I think we turned out ok. (Certain sister-in-laws may feel different). I was embarrassed for this nurse. She doesn't have a fucking clue. And she doesn't deserve to be in the L&D ward.

B

Rabies Shots...

HURT! All 6 of them. I have new found sympathy for the kiddos when I order up the 3 or 4 shots at a time. I started the Rabies vaccine series (4 more shots to go) and also go the immunoglobulin today, and that was what made it 6 lovely shots. I referred to it as the mackerena of immunizations.. Shoulder, shoulder, butt, butt, thigh, thigh, oomph!

Fucking Bats.

More Bats

Bat #2 just made a guest appearance. I'm annoyed. And now am DAMN WIDE AWAKE. How am I suppose to save lives tomorrow given the lack of sleep? Oh wait, it's adolescent clinic... don't need much sleep for that..

The answering service didn't consider "bats" to be an emergency... It will be an emergency when I go ballistic if I get a third visitor tonight. I called MS, who suggested that they may be coming from the vent in the bathroom.. which doesn't work, and never has, and may be providing a nice one way ticket into MY DAMN APARTMENT. Retrospectively, the noise from the ceiling, which I always assumed was from a squirrel, may have been, in fact, FROM BATS. Holy Bat Shit! (is that guano?).

So, what does the CDC say about bats??

Q: How can I tell if a bat has rabies?
A: Rabies can be confirmed only in a laboratory. However, any bat that is active by day, is found in a place where bats are not usually seen (for example, in a room in your home or on the lawn), or is unable to fly, is far more likely than others to be rabid. Such bats are often the most easily approached. Therefore, it is best never to handle any bat.

Q: What should I do if I come in contact with a bat?
A: If you are bitten by a bat -- or if infectious material (such as saliva) from a bat gets into your eyes, nose, mouth, or a wound -- wash the affected area thoroughly and get medical advice immediately. Whenever possible, the bat should be captured and sent to a laboratory for rabies testing (see: How can I safely capture a bat in my home?).
People usually know when they have been bitten by a bat. However, because bats have small teeth which may leave marks that are not easily seen, there are situations in which you should seek medical advice even in the absence of an obvious bite wound. For example, if you awaken and find a bat in your room, see a bat in the room of an unattended child, or see a bat near a mentally impaired or intoxicated person (NOT ME TONIGHT), seek medical advice and have the bat tested.

Bat #2 is currently flying in the hallway of the apartments (ie, not my fucking problem right now).. thank god other tenants are leaving for work before me tomorrow..

Argh,
B

Bats

I came home, and there was a bat flying in my room. From where, I cannot tell. It freaks me out. I may sleep in the living room. Where the hell did it come from?

Stacking Stones: A Year Off... Going to South Africa

I've read my post from April 14th, numerous times... There was nostalgia. And then I remembered thinking one day how I wanted to return to Bara to learn at some point as a resident. I had been debating if I would go to South Africa or Peru for my away elective in my 4th year.. And then I began to entertain the notion of going to Baragwanath, but not for a month.. what about going for a year. Yes, what about taking a year off of my residency to go train at Bara for a year... and I got excited... and ran the crazy idea by a few friends, who didn't think it was so crazy...

Here's the deal:
I was offered a 6 month pediatric training post, and a 6 month medicine training post. My program director supported my idea. And today, the chair of academic affairs granted approval for a year leave of absence from my residency program.

I'm going back to Johannesburg, for a year, to train in the most amazing hospital. I am lucky.

I took the stones and re-stacked them, and to my amazement, they didn't fall this time.

Wow.
Brian

EBM is bullshit...

I have to present a patient at pedi morning report on Wednesday am. It has to be an adolescent topic. This is what kills me... I wanted to talk on some relevant topic. Something, oh say, big picture. Something that applied to many adolescents. I wanted to do some teaching about choosing appropriate contraceptive methods, (and review Plan B). Some simple spoon feeding. There are a lot of choices.. pills, patches, injections, rings, all with pros and cons, some with contraindications... My preceptor wanted it focused, and, and wanted something that was topical in the current literature, ie, bullshit "Evidence-Based Medicine" (EBM).

EBM should be renamed boring mental masturbation. What the fuck is the purpose of looking up minutia bullshit when people don't even understand the damn basics. I asked around earlier this month, and realized that we residents (both internal medicine and pediatric residents), had a weak grasp of the basics on contraception. And some spoon feeding (oh sure, I would have done it in a case-based format so it was applicable and interesting), would have really helped to increase knowledge. But instead, I have to talk about some fucking random question that most of us won't have to deal with when we talk about contraceptive methods, and to top it off, there is no official consensus on the question that I am presenting on Wednesday morning.

Mental Masturbation without a climax. Isn't that worth it?!

I'm calling it BEBM from now on... Yep, you guessed it. Bullshit Evidence Based Medicine.

The more I train in the US system, the more I am beginning to think that I'm not being prepared to really take care of patients. I'm being trained to look shit up constantly and to fill out fucking forms.

Back to BEBM.

Brian

HtoTD

How to of The Day:

How to stop being a people pleaser.

Just for fun.
B

View of the East River & Stacking Stones II

On the 33rd floor of a friends flat here in Manhattan looking out over the East River. Walking the city today. Walking through the West Village and Chelsea. People everywhere. Street festivals. dIvErSitY. People of all colors. Admiring the men in the city. The view is addictive. Watching barges, boats go up the river. Looking out to Brooklyn.

Tomorrow at this time, back home. But it's temporary. Finally, I'm coming to terms with the decision I made before residency. I decided to choose the best med-peds program for me, knowing I wouldn't like where I lived. I tried to like the place. I explored the mountains. I looked for good coffee shops. I looked for a solid base of friends. I looked for love. I looked for a group of gay friends. I looked, I looked, I looked. And didn't find these things. I am sitting here in my friends flat, which has a couch, a table, some chairs. It is one bedroom. It is simple. I fell into the trap of accumulating a ton of shit in my apartment, and in truth, what I needed was a simple space.

I am stacking stones (see July 4th entry). I am going to keep stacking stones; I am stubborn and will persevere. But stupidly, I couldn't use my imagination when re-stacking stones. I kept placing them in the same order, looking for the same things, and watching it all crumble. I've started the re-stacking. I think I finally have some peace about my decision about where I live, and quite honestly, I'm done complaining about it.

I have gotten past this unhappy hurdle which kept tripping me up.

Now, I am going to read here in my friends flat, and watch the view.

Cheers,
Brian

1) Shattering ones own confidence 2) Reading

I had been feeling pretty confident lately. In fact, recently I've had a few conversations on how a few of us in our program have hit that stage where we begin to feel like we do, in fact, know a few thingsThat's the tough part about acquiring knowledge, especially medical knowledge. It's impossible to explain what you know. Sure, you can recall some stuff off the top of your head. But in a larger sense, a large part is the application of knowledge. We residents tend to spend a fair amount of time looking things up. And not just looking up, but also printing up stuff to read "later." Like later when I'm bedridden in a nursing home, because that's likely about to be the next time I have leisure time to read.

Tonight, I have decided to throw away all the stuff I haven't read in the last 2 years. (It's a fucking shame there is no recycling in my area. I'm killing trees here)! It's haunting to see the vastness of knowledge I am throwing away. I feel like, OH MY GOD, I DON'T KNOW JACK SHIT LOOK AT ALL THIS STUFF I HAVE NEVER READ, I AM DOOOOOOMED! (The corrolary to this is: OH MY GOD, I DON'T KNOW JACK SHIT LOOK AT ALL THIS STUFF I HAVE NEVER READ, MY PATIENTS ARE DOOOOOOMED!)!

Sometimes I want to gag when I hear the term "Lifelong-learning." I thought I was signing up to learn the bulk of stuff during residency and then do some little learning here and there, preferable at medical conferences in nice hotels, surrounded by ski slopes or warm sandy beaches.. but the closer I get to the end of my residency, the more I realize that residency is preparing me to 1) Not kill people 2) be able to treat the bulk of patients, and treat to a minimal-moderate standard 3) know when to call in backup.

As for reading... between the 4-6 journals a month that I feel compelled to try and read, plus the shit I print regularly, plus the books/study guides for that months rotation, plus the few pedi books that we recommend to parents, plus the stack of books that have nothing to do with medicine, but are a nice escape, I need about 5 more hours in a day to read. Remember when you read a book and had to do a book report in junior high. You wanted to mention some small specific details from the middle of the book so that the teacher knew that you actually read the book. That's how I use to feel about journal articles.. now I read the beginning and the ends.. the boring shit is in the middle... who cares what the delta co-efficient raised to the sputum power of the random blah blah blah... I need to now the level of detail so that I 1) Don't prescribe a drug that will kill somebody 2) can stay current on treatment guidelines so that I can give the best care possible to patients, and 3) what what drugs the back-up docs are using so that when the patient comes back to me from the specialist, I don't look like a fool.

No wonder I almost need bifocals.

Cheers,
I'm off to read.

Brian