I'm Crazy For You But Not That Crazy 

Just a quick note for now, since I'm post-call. Delirious patients are quickly becoming my favorites to work with. I love watching their improvement on the MMSE - there is little that brings me as much joy as seeing a patient evolve from a state of total confusion to being able to recall objects after a three minute delay and being able to subtract 7's. Generally, though, I tend to be very protective of them, and I find myself getting angry when I overhear nurses and other docs making fun of things they said or did in their state of delirium. Sometimes, however, everybody needs to lighten up a little. So I give you the best patient response to a question I've heard all year, which came from one of my 3 ICU patients, who is just now waking up, 7 days after an attempted suicide by overdose.

"Do you know where you are?"
"I have a nickel in my ear."



"I Already Made Like Infinity of Those at Scout Camp." 

Can it really be five days later already? I guess so, because I'm on call once again. This time, I'm decked out in brand-spanking-new hospital scrubs, as opposed to the disgusting old ones I wear every other time I'm on call and which I stole from the Labor and Delivery floor of the hospital at home. Of course, attaining these new scrubs could not have been the simple process that one would imagine, but had to involve once again reliving my nightmare of being caught in a sterile hallway without a surgical cap or gown on, surrounded by hundreds of glaring scrub nurses and surgical residents, saved only by Catherine's materialization out of thin air and quick work at the scrub dispensing machine. Or something like that.

What I really want to talk about tonight, though, is this presentation I had the privilege of witnessing on Thursday morning, which served as the highlight of my entire time down here. Every weekday morning, at 7:30, all of the internal medicine attendings, residents and medical students gather in the conference room for Morning Report, which theoretically involves a case presentation by one of the teams, followed by interactive discussion and a brief presentation on a related topic. On Thursdays, the usual crowd is joined by a group of terrified-looking applicants for residency, which generally consists of 5-6 male foreign medical students dressed in identical black suits who speak very quietly and in broken English, 1-2 female foreign medical students inevitably dressed in some sort of beige pants suit involving frills, and 2 very bitter looking male American medical students with spiky hair and slightly more acceptable ties. Ideally, the team in charge of presenting that morning, which also happens to be the team that is on short-call for the day (in charge of admitting patients from 12-6pm) and therefore always seems to be slightly more frazzled than usual, as if the odds weren't insurmountable enough to begin with, is supposed to present a patient that they have taken care of recently that either posed an interesting diagnostic dilemna or that highlighted some particularly intriguing aspect of a specific disease. The other residents are supposed to formulate a differential diagnosis based on the presentation and try to figure out what is going on with the patient. Once everybody in the room has grown exasperated with this process, the power point gets revved up, and one of the team members offers a hastily put-together presentation on a related topic. I've attended about 12 of these sessions by now, and I have yet to see one that was not incredibly chaotic in some way, shape or form. I have even been a presenter on two occasions, waxing eloquently first on the topic of hereditary angioedema and later on the key aspects of alcoholic hepatitis. (My subtle humor has unfortunately gone largely unappreciated. Nobody seemed to understand, for example, that the name of my second presentation, "Alcoholic Hepatitis: Insert Witty Subtitle Here" was actually the intended title. This probably wasn't aided by the fact the three-quarters of those in attendance were ESL. (Go Molly Meek!)) Thursday morning's presentation was by far the best I have seen in four weeks. I think I had a preexisting case of the giggles going in, but nothing could have possibly prepared me for the hilarity of what would ensue. It was, honestly, the closest I have ever come to running out of a room in the middle of a formal talk because I could not control myself. If I had made eye contact with anyone in the room after the first ten minutes, I seriously would have peed my pants. Allow me to introduce the players:

The Attending: The role of the attending physician during this exercise is supposed to be one of pure observation. The day on which his team is in charge of the report is the only day that the attendings are actually required to be at the meeting. The attendings have no role in the preparation of the discussion, other than perhaps guiding the team towards the selection of particularly interesting cases. Prior to Thursday, I had never seen any of the attendings speak a word during the actual conference.

We'll call Thursday's attending Uncle Rico. I don't know the guy at all, but basically, I would describe his appearance by saying that, with a slightly different outfit, he would fit in unbelievably well at a gay leather bar. He's got the crewcut, the thick, bushy mustache, the sort of permanent scowl, and the broad shoulders. In terms of personality, he's clearly a little Type A, and he likes to have a handle on the situation at all times. He tends to be a bit old-school in his approach, and he's not beyond teaching by intimidation.

The Resident: Each team has one second- or third-year resident who is second-in-command. He is responsible for all the patients on the team and for dividing the workload between the two interns. During morning report, the resident generally guides the discussion, allowing the interns to do most of the talking, but summarizing when necessary and often taking notes on the board.
Thursday's resident, who we'll call Deb, is the lone American female resident in the department. She's a third year, and she knows her shit. She's a little bitter, though, because, for the first time ever, one of the current third years was asked to be chief, and it wasn't her. It was a foreign med school grad. If Uncle Rico is a little Type A, Deb is headed for a heart attack within the next 3 months. She likes to randomly call on people to answer questions during the presentations. She totally resents being stuck at the program down here, and she definitely has already become completely fed-up with the interns she was assigned, despite having only been working with them for 4 days.

Intern A: This is your token foreigner on the team, who we'll call Pedro. He is from an ill-defined country that may be located in either South America or Eastern Europe, or perhaps on the Mediterranean. It's difficult to say, really. What's important is that he does not speak English very well. He also perpetually looks like he got 1 hour of sleep the night before. And he is extremely happy to be here. I think he may be the only person in the program who has not yet had his naive idealism completely destroyed in a fiery pit of burning flames. This kid is always smiling. For no apparent reason. And he always tries to answer questions that he cannot even begin to comprehend. I'm not talking about attempting to formulate an answer after being called on, either. I am talking about voluntarily raising his hand and then saying something that either makes no sense or that has very little to do with the query and then laughing when he is unsympathetically refuted. All of these qualities make him by far the most endearing member of the team. He's the protagonist of this story.

Intern B: If you've caught on by now, you'll know that Intern B must be Napoleon. This kid is freaking sweet! He's American. He wears his scrubs hiked up the his midepigastric region, with the top tucked in tightly to the pants. He wears dirty white sneakers that are definitely not name brand. He parts his hair. On the side. And there's a cowlick in the back. He has a vagina goatee. And he assumes bizarre postures that occasionally make me wonder whether or not he's suddenly gone catatonic. When he stood up behind the podium, I seriously expected him to start talking about the Japanese scientists in Scotland who tried to blow the Loch Ness monster out of the water and how a group of wizards had formed a cirle of power around the lake to save our beloved Nessy. I also really wanted to ask him for some tots.

God, this post is freaking longer than a Kuhn entry. OK. Thursday's presentation was somewhat unique because it involved two distinct cases. Pedro was presenting the first, which involved an upper GI bleed, with Deb taking notes. This was to be followed by a presentation on Upper GI bleeds by Pedro. This was supposed to last for approximately thirty minutes. Following this, Napoleon was scheduled to briefly summarize the case of a patient with tophaceous gout and then discuss this rheumatologic phenomenon.

The morning began typically enough. Pedro discussed the case of a 50 year old man who had presented with Upper GI bleed, had been scoped but not cauterized, discharged on an H2-blocker, resumed use of NSAID's at home and presented 1 week later with massively bloody stool. At this point, Deb took charge. Targeting one of the disgruntled preliminary interns who clearly would rather have been anywhere else that morning, she asked for a differential diagnosis. "He could have some sort of perforation, I guess." Poor choice of words. This angered the Russian attending in the audience, who demanded to know what the intern meant by perforation.
"You know, he could have an ulcer with a massive vessel at the base."
(Imagine the worst Russian accent you've ever heard in a James Bond movie) "This is not PERFORATION! You tell surgeon perforation, they ask what the hell you talking about! Perforation is between two things. It is issue of semantics." (The rest of the room, at this point is dumbfounded. The Russian hardly ever speaks. He usually just sits at the table picking his nose and making incredibly animated movements which involve some sort of attempt to wrench the skin off of his face whenever someone says something that isn't correct. He later gets up, still in the middle of the presentation, walks over to the intern, who really could not care less about the earlier interaction, and apologizes loudly enough for everybody in the room to be distracted from the speaker.)

The rest of the first case presentation was pretty uneventful. Deb interrupted Pedro at least ten more times to point out minor discrepancies, and continued to demand answers of the other interns in the room, who were clearly not amused. There was also a great exchange between Deb and Pedro towards the end.

Pedro: When the patient came into the hospital, he was on Indomethacin, Prevacid, Ranitidine, and HCTZ. He was---
Deb: The patient WASN'T on Prevacid when he came in.
Pedro: Right, he was on Prevacid. He also---
Deb: No, Pedro. He wasn't on Prevacid.
Pedro: OK, so the meds were Indomethacin, Ranitidine, HCTZ and Esomeprazole.
Deb: Pedro...Esomeprazole is Prevacid.
Pedro: Yeah, that's what I said.
Deb: He wasn't on Prevacid. That's the whole point of this case.
Pedro: Are you sure?
Deb: Yes.
Pedro: OK. Patient's allergies are....

After the case was solved (this actually happened immediately, when the initial intern was called on, as he rephrased "perforation" as "Dieulafoy's Ulcer" (Deb was clearly pissed at this point, since the whole reason for presenting the case was that it posed a diagnostic quandary)), Pedro began his Powerpoint presentation on Dieulafoy's Ulcers. Actually, Pedro seemed to think that the topic was Upper GI Bleed, because that's what he titled his presentation. Let's begin by saying that Pedro chose as his powerpoint backdrop "Mountain," an option I had seen the day before during the preparation of my presentation. (I settled on "Pulse," a Bruce-dog specialty.) "Mountain" consists of a blue background with a black silhouette of a pine tree, cabin and mountain peak at the base of every slide. I can not possibly imagine what this has to do with GI bleeding, but a the time, I thought that nothing could have better epitomized the thinking of the presenter. Pedro's presentation was supposed to last five minutes. It was supposed to describe the etiology of Dieulafoy's ulcers and talk about possible treatment options. It was supposed to be brief enough to allow time for Napoleon's case presentation. Pedro began speaking at 7:55. By 8:10, he had not mentioned Dieulafoy's ulcers. He had, however, almost made me spit out my smoothie on at least five separate occasions. There had been a recent trend of incorporating Boards-style questions into presentations in order to encourage audience participation. I had been guilty of doing this the day before. These questions were generally centered on vital points associated with the topic that might arise during the Step 2 or Step 3 exam. Usually, the questions presented a brief case and asked either for a treament decision or for a diagnosis. Discussion was usually stimulated as the resident's debated the potential merits of various options. It seems that Pedro did not grasp all these intricacies. Here is a sampling of his questions.

1: What is the incidence of GI bleed?
A. 1 in 100
B: 1 in 1000
C: 1 in 10,000
D: 1 in a million
E: 1 in a zillion

(Sadly, he actually read each option out loud, waiting for people to raise their hands. I supported Answer E simply because I honestly don't think I've heard anyone use the word "zillion" since fifth grade.)

2: What is the most likely site of bleed during endoscopy?
A: The stomach
B: The duodenum
C: The ear

(I can't make this shit up.)

3: What is the treatment for Upper GI Gleed?

(I have no idea what the options were. That's his typo, not mine. The moment I saw that, I literally started shaking in my chair. I was biting my lip so hard that I actually drew blood. I do not know how no one in the room managed to let out a sound. As I write this now, a day later, I am still audibly cackling in the library.)

At this point in the presentation, at 8:10, Uncle Rico piped up for the first time. "Pedro, do you have any slides that actually talk about Dieulafoy's ulcers?"

Pedro literally had to scroll through 30 more slides to get to the ones on the case topic. I would give anything to find those lost slides. He discussed Dieulafoy's ulcers for another 10 minutes before Uncle Rico simply started clapping, in the middle of a sentence, and basically yanked him off the stage with a shepherd's crook.

Uncle Rico: Napoleon will now talk about tophaceous gout in seven minutes.
Napoleon: (Bitterly, under his breath) Seven minutes? Maybe I will. GOSH!

Napoleon began his presentation with a disclaimer about how Powerpoint is an inferior client and he would never choose to use it, but that he had to make do since it's the only program supported by the conference' room's computer. (Worst program ever, what do you think?!) He then assumed a posture whereby he stood in front of the podium but crossed one leg so far behind him that his left foot was actually behind the podium, and thrust his pelvis forward, perhaps in an attempt to accentuate his green on green scrubs combo. He was about 30 seconds into his presentation when Uncle Rico interrupted.

"Why don't you just do it as a slide show?"
"I'll get to the pictures in a few minutes."
"We're running out of time.
"Fine. Geez." (Pounds the space bar way too aggressively.)

Napoleon: This patient is a 50 year old black woman. (The picture on the screen is clearly not the hand of a black woman. It is the whitest hand I've ever seen. Minor details, I keep telling myself) She--
Uncle Rico: That picture is terrible.
Napoleon: I'd like to say that I'm much better with film photography than with digital. I find that-
Uncle Rico: What happened to the pictures I took?
Napoleon: I couldn't get them to load on the computer at the library, so I went back up and took some more pictures. I think that the wrist here-
Uncle Rico: I mean, you can't even see anything. My pictures were really clear and showed the tophaceous deposits excellently. These are like the worst pictures ever. (There's no way you could even know that.)
Napoleon: This picture is of the elbow, which highlights-
Uncle Rico: Wow, that is so blurry!
Napoleon: The elbow here clearly has evidence-
Uncle Rico: I don't think you can really say "clearly."

Afterwards, Uncle Rico publicly reiterated the superiority of his pictures while Napoleon bitterly ejected his floppy disk. Deb had a "private" conversation with Pedro, which I'm pretty sure was overheard by everyone in the room, during which she offered many condescending tips for future presentations. I immediately ran into the hallway and exploded in a fit of hysterics.



They Say You Curse at Girls 

Oh man! On call again! Tonight is progressing slightly better than last week - I've already seen one patient, and I just had dinner with my resident at Blimpie, despite the fact that it's 10pm. I'm getting very close to achieving my quest of sampling every meat, cheese, topping and dressing that Blimpie has to offer. My personal favorite combo so far is turkey and provolone cheese on whole wheat bread with lettuce, tomato, pickles, and horseradish dressing. Nothing says "heart healthy" quite like that. Not much to report here. I continue to spend most of my free time at Barnes and Noble. I drove back home for the soccer game last night - I'd love to say that it was worth the 2 hour trip back that left me with 5 hours of sleep on my pre-call night, but I really can't. In fact, it was a heartbreaking disappointment and I was seriously saddened. (Don't worry; I managed to not cry about it.) Last night's game did represent a noble effort on my part to overcome a problem that has been plaguing me recently. My reaction to specific incidents during the previous week's game had highlighted for me once again the fact that I have somehow managed to adopt an embarrassingly liberal use of profanity in public, a problem that is apparently refractory to all my efforts to control it. This is not a new issue. For years, I was constantly reprimanded for screaming obscenities in front of Jeff's little brother during heated Nintendo battles. (As far as I know, Ryan suffered no ill effects from my episodal Tourette's). I would then point out that Jeff's reactionary destruction of 5 N64 controllers was probably also not setting a good example, but the point was well-taken nonetheless. The kid was 9 years old, and probably did not need to hear "Fuck!" that many times in a 20 minute period. More recently, there have been some equally offensive moments. As alluded to in an earlier post, there was the time I screamed "Jesus Christ!" in the finals of the doubles ping-pong tournament in front of the extremely pious Dean of Students. There was also the time, during med school orientation, when I went bowling with one of the Mormons and honestly dropped the F-Bomb every single time I rolled the ball, always turning around immediately to realize that he was standing directly behind me. Last weekend's soccer game, though, was the culmination of this trend. I got to the game late, having driven all the way from NJ in the pouring rain, so I was packed in tightly to the family sitting next to me. I struck up a conversation with the Dad, and was inquiring about the action I had missed. It eventually came up that I was a med student and had been at the school for 7 years. Upon this revelation, he turned to his 8 year old son and said, "You hear that Bobby? This guy's going to be a doctor. He went here for college and medical school." Turning back to me, he noted, "My son is crazy about this school. He'd do anything to be able to go here." I said Hi to the son, smiled, and turned around just in time to see our defense get beaten by the right wing. "MOTHERFUCKER!" was probably not the best choice of follow up comments, but it's definitely what came hurling out of my mouth. I sheepishly turned to the family and apologized. They were understanding and admitted that it was a terrible play on our part. I managed to keep my outbursts in check until the game went into Penalty Kicks. Despite all my will power, there was simply nothing I could do to control myself once the game came down to a series of instantaneous outcome-changing events. UVA was kicking first. Here is my monologue, which I'd like to say was internal, but was actually about as far from internal as one could get.
"Yeah, Motherfucker!"
"Jesus Christ!"
"Thank God!"
"Son of a Bitch!"
"No way, Holder! You Fucking Suck! Motherfucker!"
"Oh My GOD! Holy Shit!"
"Yeah Baby!"
"Holy Fucking SHIT! Holy Shit! WOOHOO!"

I didn't get a chance to say goodbye to the family for some reason. I turned around to slap the Dad high-five but they were gone.

This really is a sort of humiliating problem. I don't think I curse that much in general. I tend to use a lot of profanity in the blog, but that's more for dramatic hyperbolic effect. And because it makes me feel more like David Sedaris. Of course I curse a lot as part of my rap career. (For those of you who have not heard this hilarious aside, my mother actually said the word "Motherfucker" for the first time ever after she came to see us play in August. We were discussing my use of profanity onstage, which she clearly was not very pumped about, and she was asking me why I felt the need to use such language, which she found extremely offensive. I explained to her that I didn't find such words objectionable, as they held no particular meaning for me, and were simply multi-functional global parts of speech. I added, however, that there were certain words I would never use because, given my particular demographics, I could never claim ownership of them. To which my Mom briskly replied, "So you feel like you own 'Motherfucker?" I think my Dad spit his Chinese food all over the dining room table at this point.)

-----I got called away. It's now 16 hours later, and I've had another 2 hours of sleep.------

With regards to the rapping, though, that's more of a stage gimmick and not really reflective of me as a person. The uncontrollable outbursts during times of excitement are really a problem, though. I need to get a handle on this shit. This weekend's game was a moderate improvement, as I managed to only slip up on 8 or 10 occasions. I can only hope that next season will bring a renewed sense of self-respect that will render me unable to curse in public, or at the very least, that we won't fuck up as much at crucial moments.



Don't Wake Me - I Plan on Sleeping In 

There's nothing quite like being post-call. It's 4 pm in the afternoon, and aside from a brief 2 hour nap from 4am-6am this morning, I have been awake and going strong since 6am yesterday morning. This is really minor compared to some of my fellow med students' achievements, but it's quite a milestone for me, as someone who never pulled an all-nighter in his life and whose longest episode of continuous consciousness was 30 hours during the trip to Paris, at which point I nearly passed out in my bowl of delicious pasta prepared by an 11 year old. The last 36 hours have been insane. Here are some highlights:

I sat in the library of the hospital for 8.5 straight hours last night waiting to be paged. My only objective during the entire time I was on call was to admit at least one patient so that I would have someone to present on rounds this morning. My resident was supposed to page me as soon as the first patient came in, as he had assured me that I wouldn't be staying very long and I could go home and sleep for most of the night, since he remembered how much it sucked being on call as a med student. Let's see how that worked out for me. Here's a timeline:

5:45pm - Stumble out of my dorm room, which is located on the sixth floor of the hospital. That's right. I live in the freaking hospital. You have no idea how depressing this is until you realize that you haven't been outside for 96 hours straight. It is somewhat nice, however, to be able to roll out of bed in the morning and appear at your patient's bedside 5 minutes later, no doubt sporting an awesome hairstyle. I'm feeling nauseous at this point, but we'll get to that later.

5:50 - Page my resident from the library, located on the 1st floor of the hospital to ask him where we are going to meet. He tells me he'll page me when he decides.

5:55 - Start reading article in American Journal of Psychiatry.

7:45- Finish reading entire Journal of American Psychiatry as well as the special addendum on Disaster Mental health. Still no word from the resident.

8:00 - Feeling slightly less nauseous, head to Blimpie, located on the Ground Floor of the hospital for delicious nightly dinner and hilarious interaction with workers who neither speak English nor understand how time could possibly be an important commodity in a hospital setting.

8:10 - 8:20 - Eat sandwich and watch The Parkers with awesome cafeteria workers, one of whom answers her cell phone, "Who this?!"

8:30 - Page my resident to find out what the hell is going on. He informs me that not only has the team decided on a meeting place, but they've also already met, discussed all the old patients, and admitted and worked up three new patients. "We'll let you know when we get a good one."

9:00 - Check email for the 6th time in less than 2 hours. Resort to reading Zach Braff's old blogs. Jesus, I am fucking bored out of my skull.

10:00 - Decide that I should probably do something productive while I'm in the library. Go back to my room and get an Internal Medicine Boards book with 1100 questions.

12:00 - Realize that I've done over 100 questions and all I've learned is that you should avoid barbiturates in acute intermittent porphyria.

12:05 - Remember that I learned that in psych.

1:00 - Start walking laps around the library, which is approximately the size of my apartment, because I'm starting to develop restless legs secondary to lack of sleep and excess caffeine.

1:30 - Converse with security guard who comes by to inspect the library for the fourth time.

2:30 - Page my resident.
"Hey, it's S-"
"Your med student."
"Oh. You're still awake?"
"Man, you're persistent."
"So what's up?"
"Did we get any new patients for me to see?"
"Oh yeah. Yeah, we just got one in. You can come up and we'll talk about her."

2:35 - Arrive on floor. Find my resident.
"Hey, man. She's in that room. You can go interview her. Here's my note. Round on her in the morning and then you can present her unless we get to her while you're still at morning report. I'm going to bed. "

So, back to the nausea. I'm still not sure what that was all about, but throughout the course of the night, I managed to convince myself at various times that I had viral gastroenteritis, a gastric ulcer with concomitant upper GI Bleed, positional vertigo and impending Boerhave's syndrome. Given the fact that I ate 6 pieces of pizza for lunch and just had a mammoth smoothie, however, I'm now hanging my hat on a parasite of some sort. I'm personally hoping it's a trematode, because how cool would it be if I pulled an earthworm out of my nose during my patient presentation? Huh?

Speaking of smoothies, I'd like to point out that it's very hard to look professional when you are wearing scrubs and Dansko's, curled into a ball, sitting in a cushiony chair in the lobby, shivering and sipping smoothie through a straw. Trust me.

Finally, perhaps as a result of my progressive delirium, I cried in the hospital for the first time today. Thankfully, it was not one of those "Oh my God my life sucks and I hate surgery" cries that everyone else seems to experience on a pseudo-daily basis (That would be kind of weird, after all, considering I don't do surgery until April, but you never know.) I was standing by the bedside of one of my elderly patients, watching him have a second heart attack as I spoke to him, and listening to the cardiologist explain the various options to his 50 year old son, who has stayed in his father's room in the SICU for the past three days. The son looked at the cardiologist and said, with tears in his eyes, "You're the doctor. I trust you. I just want you to do whatever you'd do if that was your Dad." I lost it. It wasn't one of those embarrassing scenes where I threw myself on the patient's bedrail and started having convulsions. But there were definitely tears involved. I don't think anyone really noticed though, given the fact that the person next to me was potentially dying. But it relieved me in a way. I've found lately that I get easily emotional during vicarious experiences. I think it started with Big Fish, but it's been getting ridiculous. Of course I cried at Garden State all three times. And I cried at the end of The World According to Garp. I even cried on the drive back here the other day listening to The Shins. But, until today, I haven't cried at anything real in a long time. I've had patients tell me the most heartbreaking stories you could ever imagine, and yet I don't shed a tear. It's nice to cry at something real, though. It's nice to be able to feel alive on your own, without any help from mass-produced media. It's nice to not always feel so numb. And most of all, it's nice to be reminded from time to time of why you chose to be a doctor, and to remember exactly what kind of doctor you want to be - the kind that doesn't have to ever be caught off guard by that family member's request, because it's how you operate anyway. God, when did I get to be such a depressing blogger? We'll return to regularly scheduled programming soon. I promise.



The Heat is On (Omigod, do you get the double meaning?) 

Wow, talk about news. First of all, I'd like to send a big shout-out to my newest group of readers, the trauma surgeons! Great to have you in the house. I always enjoy increasing my readership and diversifying the demographics a little bit. I look forward to working with all of you in April and introducing you to the Mini Mental Status Exam. It's awesome, I promise. You'll love it. Seriously. And I didn't mean any of that stuff I said about surgery. You guys rule. Instant gratification, etc. I'm down with it.
For those who haven't heard, some serious shit has been going down in the blogosphere. In a way, I'm largely responsible, but, have thus far remained unscathed. The final verdict, though, is that I'm basically not allowed to mention where I live, what affiliations I have, or talk about my patients in any detail at all. This, clearly, leaves me with very little about which to ramble incoherently and make fun of. It seems that, despite books like House of God and Complications, and far more successful blogs such as Pushfluids.com, my daily (ok, pseudo-weekly) discussions may be in violation of patient confidentiality rules, and I could potentially get kicked out of school, die, or even worse. All this because some damn resident wanted to have a party at the freaking Flower Market! It's a crappy space anyways - be warned. And the floor is slippery.
So I'm back to living in a depressing dormitory in some bunk town. I decided tonight that I'm going to spend every free hour at the Barnes and Noble. It's bright, has kick-ass foccacia sandwiches, and apparently employs every single gay man in this town. The level of sass is nearly unparalleled. And I've already established repor through my attempt to borrow a pen.
That's it for now. I thought I was going to write a big entry, but the heat in the computer room is jacked up to 100 degrees and I'm about to sweat through my khakis, so I'll leave it for another day. Suckas!



We Gotta Get Out of This Place 

It's my next-to-last day in the burg and I've got an hour left in my lunch break. The caterer for the office is on vacation this week, so it's fast food for all the docs. Yesterday was Pizza Hut and today was the most magnificent buffet of KFC I could ever imagine. I had 4 biscuits, 3 breast pieces and some mashed potatoes. I think I might vomit so I apologize if I have to cut this post short. What if I vomit in a patient? I had a great interaction with one of my patients this morning. He is a 50 year old man with hypertension and diabetes who was in to have a genital lesion checked out. (Score!) I often forget to take myself out of psychiatry mode. This is a problem. I need to learn to recognize that open-ended questions are not optimal for every patient. I should have realized this early on in the interview, when he was relating to me a ten minute drama regarding his job interview last week, after I asked him how he was doing. I mean this guy talks almost as much as fourth-year-Maggie. I'm persistent, though. And I honestly like to hear patients' stories, which is mainly why I love being a doctor. So, unfortunately, I failed to keep the questions direct in an attempt to adhere to my fifteen minute timelimit. Instead of asking him, "Is your diet generally low in cholesterol and sugars?," I queried, "What's your diet like?" Signal fire alarm noises. Here is the reply as best as I can remember it.

"Oh you know it's good I mean like for example now in the morning for breakfast I usually eat you know some wheat cereal but I don't use sugar because I use cinnamon instead and sometimes I mix in some of that fiber cereal too you know like that health food Oriental stuff or whatever and I mean I like cereal that's usually what I eat and I'll have maybe a bowl or two of that first thing in the morning and sometimes I'll have like a third bowl except on Sundays when my wife makes bacon and eggs because I figure you know that I'm allowed to have bacon and eggs at least one day and then after breakfast I'll usually eat some fruit like an apple or something and I really like apples or maybe an orange but you know it's getting cold and all the oranges are coming from Florida and I don't really like the Florida oranges so much and I know you're thinking that I should be eating more bananas but I eat a fair amount I mean I usually have one in the morning and maybe another one later on so I guess I don't really eat very many bananas but that's still probably more than most people don't you think because I was talking to my friend Bobby and he doesn't eat any bananas but he gets leg cramps something terrible and I told him that he needs to eat more bananas cause they've got like some anti-cramp chemical or something and I mean I like the taste of bananas alright it's just mainly that I like other fruit better you know and apples are really my favorite and then for lunch...."

"OK, that's great. Let's see that penis lesion."

My interaction with this patient was also notable for the fact that he was the most excited patient I've ever seen who has just been told he may have genital warts. The doctor I was working with was explaining in rather grisly detail how he would like for the patient to test for hidden genital warts by wrapping his penis in a washcloth dipped in a solution of 1 part vinegar and 6 parts water. (Seriously, this is the type of shit they are recommending in the burg. Can you imagine if I started telling this to patients in the C-spot? I mean, there were hand motions involved and everything.) The doctor explained that any warts will stain white with this solution and can be more easily visualized. Before he had even finished talking, the patient exclaimed, "COOL! That is really neat to know!," with enthusiasm that suggested he might have been considering taking a shortcut back home so he could see the magic for himself. And I'm sitting there like "What the fuck?" But different strokes for different folks I guess. I feel like this advice is going to spread like wildfire though. I mean, there is no way the patient is keeping that to himself. He's telling everyone he knows as soon as he gets home. I have this disturbing image of all the mechanics in the burg going home tonight, mixing the solution wrong, and causing serious damage to their genitalia. At least I won't be around to see the destruction. Suckas!



Our Aspirations Are Wrapped Up In Books 

Seeing as not one, but two fellow bloggers have posted about The Curious Incident of the Dog in the Night-time within the past 3 days, I figured I should weigh in as well. I borrowed the book from my grandmother the last time I was home, after noticing its prominently stenciled red cover amongst boring-looking hardcover books by Peter Jennings and John Grisham. When I picked it up off of the coffee table, Gram scoffed and said, "You can have it. I hated it. It's one of those weird books." Now, normally, my grandmother and I have pretty similar tastes in literature, although she goes a bit more for the historic biography than I do, and I'm probably a slightly bigger fan of Bret Easton Ellis. And there's the fact that she absolutely despises Harry Potter. On the other hand, we both love Truman Capote, and we both like to make fun of people who read The DaVinci Code. So I was a little skeptical, but the back-cover blurb was very enticing and the author looked just gay enough for it to be a must-read. I ended reading it in a sort of whirlwind session on my second day down here in Lynchburg, having finished I Know This Much is True the previous evening, and determined to beat Beestang's AIM record of 13 novels so I could sculpt a scene of me lying by a lake reading at our next Clinical Reflections. I've noticed that recently, one of the most important factors for me in judging a contemporary, hip author is the number of times I laugh out loud. Dave Eggers blows everyone else out of the water in this respect, because his sense of the bizarre is so well-honed and because his jokes are sudden. I can't tell you how long I laughed when Hand in You Shall Know Our Velocity writes "Here I Am...Rock You Like a Hurricane" on the pieces of paper. I was literally crying and my chest hurt so much I thought it was going to explode. Other authors that seem to have a similar ability include David Foster Wallace and David Sedaris, which leads me to think that my brother Dave got seriously screwed in the sense of humor department given his name. I mean, by all accounts, he should be fucking hilarious. Mark Haddon is no Dave Eggers. He's slightly less ironic, better looking and far more gay. But he does have a pretty good sense of the tragically absurd. Like the idea that the most crushing moment in the life of a child with Asperger's Syndrome, a disease related to but distinct from Autism in which the patients are higher functioning and slightly more socially adept (according to my Bible, the DSM-IV-TR), is not when he finds his next door neighbor's dog dead in the yard, not when his Mom dies (I'm not spoiling anything, don't worry), but when he realizes that he can't be an astronaut. Or the fact that he barely talks at all, but yet is able to defeat the local pastor in a spontaneous debate about heaven in front of his fellow special-education classmates. I was also impressed by Haddon's treatment of the disease. I agree with Vickie that it's become a bit cliche to create books and movies told from the perspective of people with mental disorders. As a budding psychiatrist, though, I must admit that I am generally fascinated by such attempts, as long as they refrain from beating the reader over the head with stereotypes (I feel like this was one of the few faults of I Know This Much is True, as Wally Lamb really tried hard to cram every single detail he read about schizophrenia into the character of Thomas, and while I'm sure it was very educational for the general population, I kept thinking to myself things like, "Why the fuck does he have to have his psychotic break his freshman year at college? Couldn't he be atypical in at least one department?") In this respect, I thought Haddon did an admirable job of portraying life from the point of view of an Asperger's child without torturing the knowledgeable reader. I found Christopher to be an engaging protagonist, and I'm pretty sure I gave a crap about what happened to him, which is always a good way to judge these things. I was legitimately scared when he was about to be run over by a Tube train, so there's that at least. The third and final thing I really liked about this book (Jesus, am I writing a fucking eighth grade book report?) was its use of math. I love math. I miss math so much. I'm not talking about addition and subtraction or fractions or even prealgebra, all of which is great, but all of which I still use on a day to day basis and therefore can't feel any sense of nostalgia for. I'm talking about word problems and trigonometry and calculus. I never knew how good I had it in middle school and high school. I was a Mathlete once, for God's sake. Actually, I was on a quiz bowl team. Actually, I was captain of my quiz bowl team. There is little that has filled my life with such excitement as racing furiously against the smartest kid at Lawrenceville (Kenny Easwarn where are you?) to determine what x and y are. Christopher loves math even more than I do, and that makes me happy to no end. And there are real live math problems in the book. Shit that I could actually sit down and try to figure out. And there's a whole chapter about a problem that appeared in Ask Marilyn in parade, a column that I have actually mailed in responses to. (Oh my God, seriously, this could be the most damaging post yet.) So, in the end, TCIOTDITN-T is not a masterpiece. Mark Haddon is not the next Barthelme. He's not even the next Nick Hornby. But he is a pretty tight author with a keen wit and a good sense of character development, which makes him sort of rare these days. So, if you have a few hours to kill, I'm putting in my recommendation for this book, even if Vickie disagrees with me and revokes my Tres Coloures trilogy.
I'm currently reading The World According to Garp after about 1000 recommendations, the latest of which came from someone whose opinion I can't ignore. Initially, I really disliked it. I only confessed this to Vickie, because I think everyone else would have attempted to lynch me. It's grown on me, though. I don't think Irving will ever be one of my favorite writers. He is too deliberate, his jokes are too drawn out and eventually predictable, and he tries a bit hard to be shocking. He does manage to create some truly amazing characters, however, and I think he may be one of the best observers of human nature I've read in a while. I'll let you know my final verdict later this week, before moving on the Midnight in the Garden of Good and Evil. Anybody read either Garp or Haddon? Anything else I should add to my list? Angela? Suggestions?


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