The .Plan

Courtesy of the Marginal Revolution blog, a quote from economist Joseph Sabia’s soon-to-be-published paper entitled, “Reading, Writing, and Sex: The Effect of Losing Virginity on Academic Performance”:

Controlling for a wide set of individual- and family-level observables available in the National Longitudinal Study of Adolescent Health, ordinary least squares (OLS) estimates show that sexually active adolescents have grade point averages that are approximately 0.2 points lower than virgins. However, when information on the timing of intercourse decisions is exploited and individual fixed effects are included, the negative effect of sexual intercourse disappears for females, but persists for males. Taken together, the results of this study suggest that while there may be adverse academic spillovers from engaging in intercourse for some adolescents, previous studies’ estimates are overstated due to unmeasured heterogeneity.

My friend Kathy is currently in the Land Down Under, and she has this beautiful shot of the Devil’s Ladder:

Looks like it would a dream to drive.

Only 5 more days and I am done with medicine forever!

“Good morning, Mr. Smith. How are you doing?” [*]

He looked a little pale. Which was about par for the course ever since he had surgery 8 days prior. Vital signs taken 30 minutes earlier had been fine, with systolics in the 130s, oxygenating well on room air.

“I feel — /huff/ — okay.”

He was a little sweaty, and I noticed then that he was breathing rather rapidly. I could feel my pulse quicken.

“Mr. Smith, you don’t look so good. Let me sit you up so I can have a listen to your lungs, okay?”

I leaned forward.

“/huff/ — okay. Let me– /huff/” — BRAW3ERGUGHGUGHkkk.

He coughed up some dark red blood. It streaked down his chin. A few flecks of blood hit my eyeglasses and I thought I could feel some wetness on my cheek.

“Mr. Smith, you don’t look–”

“BRROWWFJKFKLLFLFLAKAKA. KKK- BW3RRRRRRSALFKJ.“.

Red blood against the drab yellow of the cheap hospital linen. Red blood against my crisply ironed and newly bleached white coat. Red blood against the cheery green of my tie. Blood everywhere. Blood. Blood. Blood.

F*ck!

His eyes lolled back and he was unresponsive. I turned his head to the side. Still breathing, but every breath Mr. Smith sucked in sounded frighteningly gurgly. Then no breathing. I cleared my throat and called out to a nurse walking by in the hallway and tried to ask her as calmly as I could, “Code 199. Get the Med A resident here now. Page anesthesia.” No pulse. My voice must have sounded shrill, squeaking past the huge lump in my throat and betraying my own uncontrollable pulse. “Code! Code!” I yelled as I started chest compressions.

*

The convenient thing about the computerized notes at our hospital is that much of it is automated. At the click of a button, it fills in electrolyte measurements, intravenous fluid volumes, urine outputs, and so forth. Most conveniently, it extracts from the hospital database the most recent laboratory values to insert into your note. So if you are typing in your note that morning, the values from the morning’s blood draw are automatically inserted into the note. If there are more recent laboratory values, say for example if you ordered a recheck at the noon draw, then the more recent values will be preferentially filled into the automated note.

Later that afternoon, I saw the ortho note:

Subjective:
No events.

Physical Exam:
Comfortable. NAD.

…
Laboratory Measurements:
…K 12.1
…ABG 6.69 / 112 / 12 / 20
Lactate 25…

Plan:
Cont drsg chg.

I laughed maniacally. This was absurdly funny. It would have been funnier if the note had not been dated 3 hours after my patient died.

–
[*] All names, dates, and other HIPAA non-compliant details have been confabulated.

Nodding off while writing an admission note at 06:30.

[beep beep beep]

“Hi Doctor Chai, thanks for calling back. This is Theresa on Third East. Can you come see patient Smith?” [*]

“Sure, what’s up?”

“I was turning him when he coughed up a little blood. I also noticed that he was very sweaty. He didn’t complain of any chest pain. Respiratory rate in the 30s, systolic in the 90s. He also desatted to the mid 80s–”

I was already tachycardic myself.

“Uh. Please put a face mask on him. And have someone get an ABG syringe for me. Also EKG, CBC, Chem 10, cardiac enzymes. Call radiology for a stat portable chest. I’ll come on up. Oh, and please have someone page my senior.”

To make a long story short, my favorite non-medically complex ortho dump turned out not to have a heart attack; but when I sent him downstairs for a CT-angiogram, he turned out to have a very large pulmonary embolus lodged in his right pulmonary artery. He’s doing fine now with a bit of oxygen and a heparin drip.

Later this afternoon, I read the second funniest ortho note I have ever read in my entire life:

“Subjective:
NEON.” [no events overnight]

My goodness, I am so toxic right now. Only 55 days to go.

–
[*] All names, dates, and other HIPAA non-compliant details have been confabulated.

Orthopedic surgery is an extremely difficult medical specialty to match into. As the saying goes, you have to weigh 240, bench 240, and get a 240 on your boards — otherwise you’ll get screened out. Given that it requires so much work and studying to get there, I am routinely befuddled by how much orthopedic surgeons’ brains stop working once they make it into residency. Occupying my burgeoning census are 3 patients who should be on the orthopedic service, but because they are too “medically complex” they were admitted to the medicine service. The definition of “medically complex” is often interpreted loosely, for example, a lady with a broken hip and large volume blood loss is admitted to medicine because she has diabetes requiring a sniff of insulin.

If you read an orthopedic surgeon’s daily progress notes, they are typically incomprehensible. One might read, “ID: 46F POD#1 s/p RHAP / LFN-ORIF. Physical Exam: Doing well. Plan: FROM. TED/SCDs BL. WBAT BLE.”

I, on the other hand, take great pride in my daily progress notes. There are few abbreviations. Everything is formatted nicely. And whenever I can, even when I am pressed for time and trying to get out at a reasonable hour, I still make time to include a nice quoted sentence from the patient or a sarcastic comment about one of my many IV drug abusing, alcoholic, diabetic, noncompliant patients.

Today I read the funniest ortho note I have read in my entire life. This is a patient with a broken hip who should have been admitted to the orthopedic service but was admitted to the medicine service because he was (and now no longer is) going through alcohol withdrawal:

Physical Exam:
Patient obtunded, diaphoretic, BP 86/50, 6L O2. Medicine on their way.

If you can top that, then please post a comment.

This is quite possibly the most beautiful state in the Union.

Click through for the full set.

Somehow I managed to make it through the winter without getting too burned out. For most interns, burnout peaks in January or February.

Now it has caught up to me.

I need a vacation.

Only 10 weeks. Ten weeks until this:

You head out to Point Lobos State Reserve when it opens at 9 a.m. — partly because the rangers go to a “one-in, one-out” policy once the 250 or so parking spaces fill up, partly because the light is better.

“I can’t even describe the color the water was this morning,” said reserve docent Patty Oglietti. “There is no name for that shade of blue.”…

You give yourself time to head south to Garrapata State Park, where rocks and water do astounding things on two miles of often-empty beach, or you head to Big Sur beyond that.
–Christopher Reynolds, “A view of Weston country in Carmel, California”, Los Angeles Times, April 13, 2007

More fascinating stuff from John Tierney. Look who’s at the bottom of the dating hierarchy:

African-American women said yes about 30 percent less often to Hispanic men [i.e., were less willing to see Hispanic men again]; about 45 percent less often to white men; about 65 percent less often to Asian men.

White women said yes about 30 percent less often to black or Hispanic men, and about 65 percent less often to Asian men.

Hispanic women said yes about 20 percent less often to black or white men, and 50 percent less often to Asian men.

Asian women didn’t discriminate much by race (except for showing a very slight preference for Asian men over black or Hispanic men).
–Single Female Seeking Same-Race Male, TierneyLab@NYT, April 13, 2007

The Associated Press has a story about a 52 year-old who spent 65 days swimming all 3,272 miles of the Amazon River. Note the following paragraph:

He said he was lucky to have escaped encounters with piranhas, the dreaded toothpick fish, which swims into body orifices to suck blood, and even bull sharks that swim in shallow waters and can live for a while in fresh water.
–Slovenian man ends 65-day swim down Amazon River. Associated Press, April 7, 2007

The ‘toothpick fish’ (candiru) preys upon larger fish by detecting urea and ammonia as well as subtle changes in the water current generated by exhaling gills. When its prey exhales, it swims into the gill and starts sucking on its blood. The candiru has poor visual acuity, so it cannot differentiate between an exhaling fish and… injudicious urination into the Amazon waters. What happens next?

A detailed description of the horrific events, from the Straight Dope (see here, and the update here):

On 28 October 1997, one of us (Samad) attended a 23-year-old man from the town of Itacoatiara on the Amazon River who sought medical attention with obstruction of the urethra, having been attacked by a candirú. Prior to being attended, the patient remained untreated for three days and was only administered medication for pain. By the fourth day the patient presented with fever, intense pain, scrotal edema [swelling of the scrotum], and extreme abdomen distention from urine retention. Surgical removal of the fish was considered, but rejected in favor of endoscopy [insertion of a TV-equipped tube into the urethra]. The patient was anesthetized with 5% lidocain and the procedure was performed. The fish was grasped using an alligator-clip attachment on the endoscope and removed in one piece. Fortunately the fish was dead, and decay was beginning to soften its tissues. Tension on the spines had relaxed in death, and they no longer gripped. Had the candirú been alive, its removal would have been more difficult and resulted in greater trauma to the patient.

The fish penetrated the victim’s urethra while he was standing in the river urinating, actually emerging from the water and entering his penis, filling the entire anterior urethra. He reported trying to grab hold of the fish, but it was very slippery, and it forced its way inside with alarming speed. The candirú’s forward progress was blocked by the sphincter separating the penile urethra from the bulbar urethra. With the passage blocked, the fish had made a lateral turn and bitten through the tissue into the corpus spongiosum, creating an opening into the scrotum. Perfusion [flushing] of the urethra with sterile distilled water prior to endoscopy induced further immediate and pronounced scrotal edema, making it evident that the opening had allowed the perfusate to enter the scrotum. Although the patient had remembered the fish as being small, after extraction it measured 134 mm (51/2 in) [long], with a head width of 11.5 mm (7/16 in). . . . Some coagulated material was removed, revealing a wound on the bulbar urethra of 1 cm in diameter and associated with a small amount of local bleeding. Although the patient suffered immediate trauma, no long term effects of the attack were noticed 1 year after the incident.

Click here for the previous episode in this series, Orifice Watch.

Is this a dig at eHarmony enthusiasts or a ringing endorsement of The Tao?

When I first identified the Flaw-O-Matic, in a 1995 column, it seemed primarily a mechanism to kill romance. After studying picky daters — like a guy who couldn’t tolerate dirty elbows, and a woman who insisted on men who were at least 5-foot-10 and played polo — I predicted that they would remain permanently single….

Just as Darwin could have predicted, [scientists] have found that women are pickier than men. While men concentrate mainly on looks and will ask out a lot of women as long as they’re above a certain threshold of attractiveness, women focus on fewer prospects…

Online dating reveals the most exquisite calibrations of the Flaw-O-Matic because the daters fill out questionnaires listing more attributes than could ever fit in a personal ad. They can spend all day finding minute faults in hundreds of potential partners. But that’s also why so many people never make a lasting match.

“When you have all these criteria to consider, and so many people to choose from, you start striving for perfection,” Dr. Ariely says. “You don’t want to settle for someone who’s not ideal in height, age, religion and 45 other dimensions.”

It’s the same problem afflicting New Yorkers: with so many prospects in the big city, they refuse to stop searching.

But something very different happens at a speed-dating event… [Paul Eastwick and Eli Finkel at Northwestern University], working with Daniel Mochon and Dr. Ariely of M.I.T., analyzed the preferences of more than 150 students at the sessions.

The students were particularly turned off by prospects who exhibited what the researchers call “unselective romantic desire.” Another way to put it would be “desperate.” The speed daters were very good at guessing which of their partners were indiscriminately friendly — willing to go out with lots of the other people — and which dates had eyes only for them. They much preferred the ones with “selective desire.”
–John Tierney, “Romantic Revulsion in the New Century: Flaw-O-Matic 2.0″, New York Times, April 10, 2007f