Case Presentation

The setting: MS-2 year, Sahuaro Hall.
Present: MS-2 class, Dr. Finch in a sweet blue Hawaiian button-up shirt and his wavy blonde hair that needed to be cut about six months ago.
Dr. Finch: Ok guys, it's time to do another ICM case. This was submitted to me from a Dr. Jensen in Wray, Colorado. I'll start out by giving you guys some pertinent information, and I want you guys to come up with a differential diagnosis.
CC: "I can't poop"
HPI: 32 year old Mexican male with no past medical history is brought into the ED by his wife and family in moderate distress. He states that he awoke this morning around 2 AM with abdominal pain in his LLQ. It comes and goes, he is unable to describe the character of the pain. It's worse with standing upright, relieved by lying down. He notes that the pain has moved from his LLQ to his RLQ over time. He admits to some rectal bleeding this morning when attempting a bowel movement. He also admits to some nausea, but no vomiting.
PMH: None
PSH: None
Meds: None
Allergies: None
Social: No tobacco, had some drinks at a friend's home last evening.
ROS: No fever, chills, otherwise as above.

Dr. Finch: Okay guys, what is your differential?
Number 2: GI Bleed
Finch: Ok, good
Damon: (says to Jeremy, "That number 2 is a real prude. It's clearly appendicitis.") Appendicitis
Finch: Good Damon, what else can we come up with?
Caywood: How about a butt tumor?
Finch: You mean like an adenocarcinoma?
Caywood: Sure.
Kevin: Tapeworm
Finch: How do you figure a tapeworm into your differential?
Kevin: When I was a cop up in the Northwest I saw a guy with this same presentation who we did a drug bust on and we ended up hauling him in to the ED and he had a tapeworm.
Finch: Okay, if you say so.
(Kevin shakes his head in disgust)
Slice and Dice: What about a diverticulosis or diverticulitis? See, I spent nine years in the OR and I saw this kind of thing all the time. We cut guys open all the time for abdominal pain; maybe he needs surgery.
Jeremy: How about an abnormal skin lesion?
Brizzee: Psoriasis?
Finch: All right, you guys are getting way out in left field here, let's redirect. LLQ pain moving to the RLQ, nausea, comes and goes, what else do you guys want to know?
Trent: It could be a kidney stone or even a testicular torsion.
Finch: True.
Fake Tarmac: How about a Suave deodorant bottle stuck in this guy's rectum?
Finch: How in the crap did you guess that?
Fake Tarmac: Just a feeling I've got.
Finch: Yup, that's right. And here's the x-ray to prove it.

So what's the rest of the story? I went through a 15 minute HPI with this freaking guy on the interpreter phone and finally at the end of it he said, "Last night I went over to a gay friend's house and we had some drinks. I passed out and I think he put something up there."
Ok, so if only he had come into the ED and said, "I think I have a deodorant bottle shoved up my butt" it would have made things a lot easier. Needless to say, the rectal exam revealed a round plastic object high up in the rectum. I tried like the dickens to get the sucker removed, but ended up needing to transfer him so that GI could do the dirty deed.

If anyone really wants to see the x-ray, just email me, not sure if I should post it on the web.

Have you ever met a proctologist? Well, they usually have a very good sense of humor. You meet a proctologist at a party, don't walk away. Plant yourself there, because you will hear the funniest stories you've ever heard. See, no one wants to admit to them that they stuck something up there. Never! It's always an accident. Every proctologist story ends in the same way: "It was a million to one shot, Doc. Million to one."

passes step 3...barely

i was going to take step 3 a while ago but then i wasn't able to schedule it until recently. i got my score today and could tell by looking at the score that i must have barely passed but didn't realize by how narrow a margin until i read the score report that the minimum passing 2 digit score is a 75 and i got a 78. i would say how glad i am that i can finally forget all my omm but apparently i all ready forgot it. congrats to all of you who seem to be multiplying like crazy. hope residency is going well for you all especially my fellow gas passers. everyday in the OR i am so greatful to not be on the other side of the drapes. are you still out there shane? i think you and i are the only ones left that can go to a restaurant and fit our whole family in one booth.

It's Another Boy

Rock Thomas Kalcich

Born 10/15/08
20.5 inches
8 lb 8 oz

Delivered via C-section (no OMM required)

Mom and baby at home and doing well.

It's a Boy

Finally, we will be having a boy to end our family. The only question left is can he swing a golf club?? Early March we are expecting.

Hope everybody is having a tremendous learning experience, and keeping up on the OMM skills. There will be an exam at the end of residency. I will not be using CV4 from now on.

Anyone up for fantasy football?

Can we get enough people (8-10)?

ED Thoracotomy #2 this week

So I'm driving in to round on Sunday morning, and I'm about two minutes from the hospital hen my pager lights up: "Code 1 GSW abdomen"

I get to the hospital, cruise down to the trauma bay, and the on call resident is opening the chest. I throw a gown on and help out. We get a weak, thready pulse back. Off to to OR.

On the way, we pass the family in the hallway. They are (understandably) going nuts. We get to the OR, can't identify any bleeding in the thoracic cavity, and decide to open the belly. Blood gushes out (despite our clamped aorta). We lose our pulse. Quickly mobilize the left colon/kidney/spleen, and find a huge aortic injury.

We try and resuscitate/repair, but to no avail. Patient expires.

When my attending tells the mom, she runs out of the hospital and has a seizure. Luckily, she is caught by another family member, or she would have been a trauma consult too, and thus on our service. I feel a little guilty that instead of feeling bad for her, I was happy that she was caught so that I wouldn't have to admit and round on her.

Sometimes, cleaning up the list seems to matter a little too much to me. I'm not sure what that means, but there it is. Anyways, we're 1 for 2 in lifesaving thoracotomies this week.

Things I only saw on bad TV shows

I used to watch the TV show "ER", and "Trauma: Life in the ER". Nowadays, I really wonder why I wanted to watch a show about work.

Anyways, I got to participate in an ED thoracotomy today (The 3rd one in 6 weeks here). A guy took a sawed off chotgun blast to the leg and back. He had an obviously catastrophic leg injury, but he coded twice during the resuscitation. We had yet to even roll him over to look at his back because we had airway issues and needed a Cordis. Right when we flipped him and noticed holes in his back/neck, he lost vitals, so we cracked his chest.

It was awesome. Did internal compression until his heart started beating again. He had a pulmonary laceration that was bleeding pretty good, so we whip stitched it and ran to the OR. Gave him a wedge resection, tons of blood, and cut off his leg. (And you thought you had a bad day.). First pH in the OR was 6.6.

Good news is, he awake and alert in the SICU. He'll probably get ARDS, but he's alive for now. Pretty freaking awesome day. Then I had to go to stinking clinic, and be the king of Vicodinland for the afternoon. All in all, a good day.

A new title for the blog.

Because The BackRight was a lame name that came to me when nothing else would, this blog was so titled.

But no longer.

Let it be dedicated to the veterans (and brothers in spirit) of the Conshohocken Convoy, many of whom suffered (and still suffer) from Hotpocket Fever. Symptoms include an irresistible desire to drive over rumblestrips and a craving for red beans and sausage.

It is rumored that brother Jason Caywood still has loose stool from said disease, and brother Shane Taufer might be dead.

Paging "the guy called" Dr. Lohman

Rhett, I don't know what kind of internet "scheme" you have going, but my wife just got this post on her blog a few days ago:

"Hi Anne, you don't know me, my name is David, I live In Spain where the guy called Rhett Lohman was serving a mission. I have tried to find him for more than 10 years! He was serving in the Santa Cruz branch. I don't know if he remembers me but please, give him my email if you can, I would be eternally grateful.
bubuni08@gmail.com "

Can you please ask "BUBUNIO" to stop emailing my wife!

Thoughts from the ICU, and why Detroit is a scary place

I've been meaning to type up some stuff about the transition to 2nd year, being at a new program, etc. I'll get to all that stuff in a few days. But today I'm post call, and I had to tell you guys about the amazing volume of trauma I get to see.

Now a lot of people talk about trauma, but they're talking mainly about blunt trauma. Blunt trauma is boring. For a resident, it means chasing labs all night, cajoling radiologists for stat reads on imaging, and waiting for a drunk guy's EtOH to get back to double digits so I can send him home. If blunt trauma goes to the OR it'll be the Ortho or Neurosurgery guys taking them. (You're welcome for the babysitting.) So when people talk about trauma, they usually aren't describing anything cool, but rather just a bunch of tedious (albeit nessecary) work. Nothing for a surgery resident to get excited about.

Penetrating trauma is different, although at most places much more rare. Nothing quite like the rush of going to the OR with an unstable GSW. Don't get me wrong, I'm still a junior resident and don't do much to actually fix the guys. I'm just a small cog in the machine. As an intern, I did the H+P thing, acted as the scribe, did all the erannds and followed up everything. If I did go to the OR, it was as a third set of hands. A few times I did get to break scrub and eyeball a new trauma code while the attending and chief operated. It was a whirlwind of activity, and I was in the middle of it all, even if I was as important as trash blowing in the breeze.

Fastforward to 2nd year. Now I'm in the SICU. I'm barely out of second year, and I'm expected to manage critically ill patients by myself. I usually want to pull a Caywood's dad in my own shorts. But the cool thing is, I'm finding I can handle most stuff. I do have to call the intensivist with big stuff, but 90% of the time I'm running the show. Mananging vents, starting drips, doing procedures, the whole thing.

My first call I had a textbook case of severe hemorrhagic shock, and I was all alone. 18 yo male with GSW to right eye, belly x2, scrotum, and both lower extremities. Systolic out of the OR was in the 70s, refractory to fluids. I admit the patient, start some basic orders and call the attending with the admit, and give him exactly what I've typed here. He says "Sounds good. Get him a subclavian and a CVP at 8 or higher. Good luck."

I was almost constantly at his bedside for 18 hours. He was in shock, sedated, ventilated, the whole deal. But the guy lived. I can honestly say that my post op management saved that guy's life. Not that I'm anything special, any resident could have done it. But I did it. Even though he'll look like a pirate, that kid is alive because I helped him. (Two day later, we were able to extubate him, and amazingly he did really well. He even remembered me from that long night. So I guess he wasn't that sedated. Rarer still, he thanked me!)

This guy was the first of 5 GSWs that I would admit and manage that day. The crazy thing is that this number was not unusual. Being in Detroit provides us with an amazing volume of penetrating trauma (we still get plenty of blunt). The gangs here taunt each other on the streeet by touching their throat and belly simultaneously, as if to say "You're going to need a trach and PEG after we get to you." (We have medically savvy gangs here in Detroit.) We get a lot of patients purposely shot in the neck, and these are celebrated as "wheelchair shots".

I used to think Maryvale was a tough hospital (one time James Matthews and I watched his car get stolen from the 7th floor). But here last night there was a double homicide directly across the street from the hospital. Last week someone attempted to abduct a hospital employee standing outside in broad daylight. Three months ago a guy walked right through security into the ED with a loaded semiautomatic shotgun. He was upset that his grandma died in the ED earlier that week. He raised the gun to fire and it jammed. People started diving out of the way, and security caught up to him and shot him in the ED. A vascular surgeon got carjacked while driving up to the hospital for a case late one night. Crazy, crazy stuff. And it doesn't shock people here at all.

It's definately scary. But I love it. Despite the violence, a lot of the patients are good people. I really like my co-residents. (It's interesting how green we all are, under the same pressures, working together constantly. Sometimes it feels like it's us against the world. You bond with these people in a way that reminds me a lot of being on the mission.)

I am amazed and inspired by the two surgical intensivists I'm working under. Some days I even feel like a doctor, instead of usually feeling like I'm just a poser. I'm absolutely drinking from the firehose and learning tons every day. And then I come home every day to a big party with happy kids and a great wife. Who, despite being pregnant in the humid summertime, still has a pretty great attitude.

(And I'm dang glad I'm not an intern anymore.)

email addresses

Everyone survive intern year? Glad that is over. I'm sure mine and Jon's wasn't as bad as some of yours. Just glad to be moving on. Hoping everyone can post their current e-mail address. Or if you are afraid of spammers just e-mail at jeremykbingham@gmail.com. I'll put them all together and send them out.

Enjoyed the nursing horror stories. The "look it up yourself" comment was classic Damon. Would have paid to be there.

Be planning ahead for the Backright reunion in Hawaii 2014 (or recreating a 6 day roadtrip to Conshohocken, we'll jury rule it). There will be plenty of advanced notice so everyone can make it.

Jeremy

Small world

Damon,
I worked with this nurse all year and I just found out that she is from Farmington NM. I asked her if she knew any Kalcich's and she said she knew of them. And then I asked if she knew any Fishburns. She says, I know Ann Fishburn she use to babysit me. Her name is Gentry, I don't know her maiden name. I thought that was pretty cool.

Moving Day is Over

Just moved us into a home. (We rented for a year while we tried to figure out the Detroit real estate scene).

I am so sore this morning. That's what eleven months of lifting nothing heavier than a Bovie will do for you. But we're in, gotten most of the big stuff put away. The first 48 hours stink, but it's pretty nice now that we're a little more settled. Watching the Lakers/Celtics game was pretty cool.

I am still amazed that half of our stuff is children's toys and clothes. Even my unborn son has more stuff than I do.

Tornado

We're all okay. One of the tornadoes touched down just two miles from our house, killing a guy who was in his RV. Rachel didn't even know there was a tornado watch/warning in effect when that one came. The big one that destroyed part of Windsor was just 10 miles from us. Pretty crazy. Rach and the boys spent most of the afternoon down in our basement (that's where you're supposed to go when there's a tornado, I didn't learn that until yesterday). I was in clinic when all of this happened and we had to go down to the basement of the clinic with out patients for about 20 minutes or so. But did we cancel clinic? Stop working? Nope. We didn't lose power at our house or anything, so we got off pretty good. Just makes you think about how truly unprepared we really are; we have 72 hr kits, but that's about it -- no supplies of batteries, extra flashlights, supply of water... makes good sense to get some more food storage, I think I'll do that.
So I'm on call today at the hospital and we have another tornado watch, but don't be afraid. We have trained tornado spotters that go up on the roof and watch if we move to full tornado warning status. Sheesh.
Check out some photos from it here: http://www.greeleytribune.com/article/20080523/SPECIAL_MEDIA/4697714 On photo 16, I'm glad the goat was okay.

- Adam

Heads up Adam

Check out the freak weather in Colorado. Hope you guys are fine.

Life Flashes

So, Steve and I have had a few shifts together in the ER this month--tonight was another. We were sitting there talking about my hyponatremic seizure pt when all of a sudden we hear, "GSW at the door--NOW!" There was a massive rush to the main entrance of the ER, where a car was waiting with a guy in the back seat. He had a bullet entrance wound in his anterior neck. As we all approached the car to help the guy out, out of nowhere, a second car whips around the corner and screeches to a halt right behind the first car. Out jump 5 very scary-looking guys. Steve backed up to where I was already standing (just inside the entrance to the ER), and we waited for the guns to be pulled and the shots to start out. Visions of the TV series "ER" came to mind as my life flashed before my eyes--no way this was going to turn out well. Luckily, they ended up being our guy's "brothers," there for moral support.
I ended up climbing into the back seat of the car to help carry the pt out and to help get him on a stretcher. Unfortunately, the pt was offering no help (all limbs completely lax) and complained of difficulty breathing (yes, he complained of paralysis and difficulty breathing before we started helping him out). C4 and C5 Fxs. Pretty sad life left for our guy.
Unfortunately, less than 2 minutes later we had another GSW arrive by ambulance and then about 5 minutes after that another GSW arrived by car. We had already had one. My shift was over, so I left right after number 4 got there. Who knows what else came in afterwards--maybe Steve got to see some more?

One of Steve's comments caught my attention

Steve (or is it katiemama?) mentioned how a couple of interns at his hospital get written up frequently by nurses. It made me wonder what the working conditions there are like. I can't imagine that it's a positive working environment if you are going to get "written up" all the time.

And what's with getting written up anyways? Is that supposed to scare me? It's not like the useless nurse managers have any authority over me anyways. (A note about nurse managers: they are not actual working nurses. They wear business clothes, wear a long white coat, eat in the doctor's lounge, park in the doctor's lot, and do nothing in terms of patient care as far as anyone can tell.)

The vast majority of the time, the nurses treat us okay, and we treat them okay. We all have to work together. It would be tough to do that if we were writing each other up all the time. So I was wondering, do you guys have this issue in your hospitals?

Passed Step 3

Took 3 days of study of NMS practice questions (about 400 questions), read OMM Review 1 hour the night before, passed w/ a 92. Look out Ohio, I'm getting my license (and moonlighting pays 2 1/2 times what I'm getting now--nice!).

Suns

Anybody else watching the Suns crash and burn? I was ready to hang myself after game one when Duncan hit that three. To make matters worse the Jazz are doing so well.

Off the hizzle

Great news, just in time for Conference.

http://www.benderboyz.com/2008/SHOWBIZ/Music/04/01/

My OB/GYN Vacation

So today is Day #2 of my time on OB. Guess what I did today? Wrote an order for a transvaginal ultrasound. That's it, no notes, no rounding, no sitting in triage. Definitely no deliveries. They occasionally let the off service surgery interns scrub some cases.

It sounds like OB is pretty boring, but I wouldn't have it any other way.

Anyways, internship is 75% over. I have OB, ER, and floor Medicine left. Easy-cheesey. This must be what radiology residents feel like every day.

Is this story about you Dave?

http://www.foxnews.com/story/0,2933,338295,00.html

Headline reads: Naked man creates havoc in vandalism spree in Pennsylvania

Finally home in the ER

After 8 long months of trauma, OB, Pediatrics ICU, and other off-service rotations, I finally made it to my new home--the ER. My first month was a full month of nights--20 shifts in 28 days--not too bad. Some of the highlights included 12 intubations (the ER residents are the responders to all calls for intubation help on the floors), 5 central lines, 2 LPs, multiple laceration repairs (I was pretty proud of some of the stuff I got back together), 4 STEMI alerts that went straight to the cath lab, a bunch of CHF exacerbations and SVT arrhythmias, and a few full arrests and trauma arrests (like the gunshot wound to the left chest). Of course, I had a few colds/flus, stubbed toes, and hang nails in there as well. All in all, it was a great month, and I can finally say I'm glad I'm going into emergency medicine. Of course being a resident in the ED is way different than being a medical student in the ED--I'm glad I still like it. Now I've got 4 months in a row in the ED before I have to go back to the floors (with trauma, neurology/neurosurgery, ICU, etc).

cold spoon

i'm sitting on my couch a few days ago and i for some reason start thinking of the myth of the cold spoon and i realize that since we are all officially doctors and unless one of you has had a different experience than i, i believe the myth of the cold spoon can officially be laid to rest. Man Law?

Update on Step 3?

I have come out of the woodworks. Life is good but busy as you all know.
I looked back at a few comments about step 3 that some of you wrote. Has anyone taken it yet? when do you plan on doing it? I signed up for the end of April...I'm on "Radi-holiday" that month so I should have some time to study. I plan on using Boards and Wards and maybe Crush Step 3 but I would be willing to go in on USMLE World with somebody if they are doing that. Let me know.

By the way remember never to mix heroin, alcohol, and sawed off shotguns. They don't mix very well. The unfortunate kid that did somehow managed to shoot himself in the buttock, shatter his proximal femur, and nearly miss his man parts as it exited his front anterior thigh. Fortunately for him, he did miss those parts. Unfortunately for the rest of the world, he can still pass on his smart genes to the next generation. Good times doing ortho!

Two items of business

Two items of business on the agenda. First, the big news: I am not sterile. Initial testing is positive (see the picture), with confirmation expected in October.

Second, I will be changing residency programs. As many of you know, I matched at a place that shut down shortly after the match. I was placed at a new hospital, but it just isn't what I'm looking for. I have accepted an offer to be a PGY-2 at a new osteopathic general surgery program here in Detroit. It's at a large, inner city hospital that has trauma and all that good stuff. The most penetrating trauma in Detroit, which is saying something.

drew daniels

to shane and andersen and anybody else buying a house in the near future, you guys asked if i had drew's number for the compass bank loan and i just found it. so if you are still interested in using him his number is 512 419 3435

"The Packet"

Who else got the packet asking for money from midwestern? More importantly who put a copy of their loans in and returned it to Dr. Geoppinger's office? I think this is a task for Jason, you have such tact when it comes to these delicate matters.

Remember this guy from OMM Class?

And who said surgeons don't have sweet hats?

Oreopath featured on Monk

on the new episode of Monk they had this cult leader and his doctor was an "osteopathic surgeon" and was treating this guys back pain. he was treating it with steroid injections though instead of OMM. i guess he was really an oreopath.

"THE TRIP"

It only gets better with time. There are some guys in the ward that want to go play Bethpage Black, the golf course where the 2002 US Open was held and the site of the 2009 US Open and I volunteered to put the trip together. As I was researching the logistics for the trip, I informed the others we would have to drive about 7 hours after work on a Friday and then sleep out in the car at the course, because the line to get a tee time starts the night before so we can play on Saturday. They did not know if they could sleep in a car for a night. I informed them that I drove from Arizona to Philly and back in 6 days with 12 grown men in an RV. One night in a car is nothing. They were amazed. That trip will not be beaten any time soon, it is something I speak of proudly to others. Well done men.

On a side note I will be running in a half marathon in South Bend, IN on May 31st if anyone else would like to go. The finish line is the Notre Dame football stadium with you running through the "RUDY" tunnel to deafining music. Some guys ran it last year and said it was pretty amazing. Jason please do not ask why I am not running the full marathon, lets just say I hope to finish the half.

Intern is over half over.


Glover

here's funny poem for you all

i was bored and got onto student doctor and was looking on the osteopathic portion of the site and found this poem. thought you all might get a good laugh from it.

'TWAS THE NIGHT BEFORE CHRISTMAS (The Osteopathic Medical Student Version)Written by SawBones, MS-IV
Twas the night before Christmas, and all through the house.Bones were a'crackin' while I manipulated my spouse.
It appears she was shopping, and this was her plight,Her bags were too heavy, her spine now sidebent left... rotated right.
She entered our house, all stooped and in pain.Screaming, "Thank Goodness you're an osteopath, please fix me again.
"Excited to treat so my skills I could hone,So I led her to our table, that was paid for with loans."
One moment," I said, as I looked at the pile,Of folded laundry that's been atop my table for awhile.
Once clear, I bid her lay atop the black rigid table,For I would now manipulate, (tho' I'm just barely able).
So I moved my hands up and down and back along her spine,"Releasing tension" said I, though I was just buying time...
While trying to recall the proper setup and force,To place her spine back in place where it was once before.
Now was it high velocity or low, low amplitude or high?Oh why, oh why did I sleep through OMM lab, oh why, Oh, why?
Then it occurred to me, the solution I sought.It was a technique so unique that only my school has taught.
I believe the professor, his name may have been Seuss.A funny old lad, with a tall hat and large caboose.
And the technique that he taught and for which he was proud,Was the "Spine-Wackem'-Now-Go-Backem'-WallaBoom-Osteo-POW!"
So I took my poor wife, and wrapped limb over limb.Over limb then once more, and for good measure, once again.
By now she was a pretzel and I more confused,This is the price I have paid, for my skills I have not used.
I put pressure on the sacrum and made a fulcrum somewhere else."Take a deep breath now," said I as I prepared to pounce.
Then I leaped on top of her with a thudding kaboom,I swore I would move SOMETHING and finish this soon!
And to my relief (and surprise), I did heard something crack!But it didn't sound right... oh no, what WAS that?
I imagined my wife's eyes rolling back in her head,Spewing blood from her mouth as her body went dead.
But to my suprise, she was fine and shouted "That's it!"By George, I actually fixed her... Damn, I'm the s**t!!"
It was nothing" I said, full of confidence and pride.Not letting on just how nervous I had been feeling inside.
She arose from the table, and walked across the floor."I feel so great," she said. "I think I'll go shopping some more."
And as she did leave, I did sit in my chair.Pondering what I would do next time, when she asks for my care.
If I don't use my skills, and I become rusty at best,I could kill my own wife, cracking the bones in her chest.
So alas, should I study and then practice and drill?Hell no, I'm a fourth year. Screw that... she can take Advil.

Can you believe we are now officially half way through intern year. hope the second half goes by faster than the first.