The Eight Types of Signout

1. The Entirely Too Casual

OK, so, yeah she’s a 34 y/o female, no real medical history, coming in with some fevers and chills. Dirty UA. BP in the ER was like 80s/50s (but she generally runs low). Mild fevers. Wait, actually, the last one was kindda high, but it was probably axillary or something. Cultures are drawn and she’s on antibiotics. Shouldn’t give you any problems. Floor patient for sure.

2. The Minstrel

He’s a lovely, kind, wistful, old soul. 67 years young, strong as on ox, and just the most lovely family. From New Hampshire, actually! He actually taught for a while…was it architecture, or philosophy? Or maybe philosophy of architecture? Oh no it was a class called The Architecture of Philosophy. Basically, about how Frank Lloyd Wright was a secret Buddhist. Wait, or was he a Daoist? Hah, I’m rambling! Anyway, he’s a 67 year old (just so lovely) who presented with a faaaaint twinkle in his throat. He thinks it’s just a cold, but he did smoke for a while. Now mind you, he smoked from a proper pipe (like a real man, this observer astutely notes), and not cigarettes….

3. The Youtube 2X speed

Fiftythreeyearoldwithdiabetesrealbadistartedheroninsulinsojustmakesuretochecksugarsq4iactuallydidntwritethisonthesignoutsheetsocouldyoujustrememberthatokthanks!

4. The Haven’t Really Committed to a Plan

Hey man. Um. Yeah. So, this guy. Tough one, for sure. He is aaaaaaa – OK, so he has a lot of stuff going on. I think his fevers are resolved? Wait let me – Wait can you check something for me real quick? OK, yeah, so his fevers are down. Hm. OK so actually do we still need to be covering him so broadly? His cultures were negative…but he actually did have a lot of epis in that sample. OK so I think what’s going on is that this is just really bad pneumonia, but maybe with an atypical presentation? Do you think histo could do this? Maybe I should start..like itra? Wait let me call my upper level. Hold on one sec. Hello?

5. The Ninja Hangout

Hey dude! What’s up?? Pretty short list, can’t complain. Yeah dude, things are going well over here. Saving lives, man. Hey, so, where were you on Saturday? Oh, night float. Yeah, yeah, that makes sense. We gotta hang out more often, man. Nothing really on most of these people. Great job on morning report, man, if I didn’t tell you that already. Relapsing polychondritis. Wow. Oh, I did already tell you that? Oh, well, anyway, just give me a call when you’re free?

6. The Helicopter Intern

He’s on colace BID, miralax PRN w/ meals, and maalox. And he just pooped! So he should be good. But just in case he doesn’t poop again, all the orders are in, and I already spoke to the nurses, so everything is all set. And I told him what to expect, what food items to avoid, made a graph of fecal colors and consistencies that he can easily chart, so I think everything is prettty much covered. Oh, but if you have any trouble, and I mean ANY trouble, here’s my cell. And my pager. I’ll be here for the next few hours anyway. Anway, PLEASE don’t hesistate to call me. I love you. Wait what? Oh I was talking to my patient, we have this one way video chat thing. Good night!

7. The Obi-Wan Kenobi (upper level signout)

This is a list with 2 patients on it, and they’re tucked away. This is the list of an upper level. Not as clumsy or random as intern signout. It’s an elegant list….for a more civilized age.

8. The Happy Hour Started 45 Minutes Ago

Jones, cancer, palliative. Martin, diabetes, stable. Stevens, social admit, chillin. Leslie, cirrhosis, watch out. Ables, CHF, lasix. Rodriguez, DTs, ativan!

The Sun Also Sets; or, the benefits of being nocturnal

Sometimes in life, but more specifically during a medical residency, you have to stay up all night. As a kid, staying up all night could pretty much only be awesome. It meant:

  • A sleepover* was happening
  • A snow day was imminent
  • The olympics were happening in some foreign country, and for that week you and your whole family became ice skating experts at 3 AM (“She’s nervous…I can just tell. Her axels seem way off base.”

*Sleepovers are basically raves for little kids. Except that the drugs are video games, the club was just the house with the best food (this was critically important – you had to know whose house had the real snacks, and whose house had the rice crackers and soy paste), the promoter was your friend’s older brother, and the owner was a shadowy authority figure upstairs, wearing a robe.

As we progress through life, the night becomes more necessary and less charmed. The night becomes less of a buffer against what you failed to do during the day, and becomes more of the prime working time. Homework happens at night. Ditto for test studying. Sometimes it is preferable to working during the day – you aren’t taunted by sunlight and the promise of a frisbee toss, or whatever it is that real humans with respectable work/life balances do in their spare time outside (Run? Catch fireflies in jars? Laugh giddily in cornfields?)

I’m now working at a hospital nocturnally for a few weeks. The dreaded “night float” rotation. I’m covering for the primary teams while they are sleeping. I’m keeping watch. I’m like Jon Snow at the Wall. I’m like Batman, if Batman were called for very mundane and routine bureaucratic hold ups (“Help! Batman! Our W2’s were filed incorrectly!”). Now, I’m being a little hyperbolic (obviously). You never know when you will be called for a code, or a rapid response, so you always have to be sharp. And awake. But you have to admit, it would be sort of funny if Batman were called to the scene, and it just turned out that someone needed Tylenol for a minor headache.

BATMAN, (in his ‘dark and scary’ voice, whispering into the ear of a frightened old man): TAKE TWO. YOU SHOULD BE ABLE TO GO TO SLEEP NOW. IF YOU NEED ME, FLASH THE BAT SIGNAL. OR JUST HAVE YOUR PHARMACY CALL MY OFFICE.

OLD MAN: Thank you, Bat-

FWOOOOSSSSSHHHHHHHHH

[The OLD MAN‘s window is open, curtains flapping. BATMAN is gone]

[Bewildered, the old man is about to take his medications, when-]

FWOOOOOOSHHHHH

BATMAN: AND DONT FORGET TO CLOSE THE WINDOW. YOU’LL CATCH A COLD.

What are the benefits of working at night? Honestly, this is tough, as it really does just make a lot of sense to not do things when it’s dark and to do things when it’s light. But here goes:

  • It’s peaceful, in the sense that ghost towns are peaceful before all the weird paranormal stuff starts happening. Sort of like the movie Hancock, except that you aren’t as cool or productive as Will Smith in your spare time when everyone else has died. Seriously, he was like cracking jokes to himself, and still working out despite no one else being alive. What a go getter. Wasn’t he a god or something in that movie? I forget. If everyone else died I think I’d probably stop going to the gym.
  • You are actually at home during the day, so if you need to do anything to function in modern society like buying clothes or food, coordinating repairs, or going to the dentist, you can do it**
  • You get an incredible sense of victory going home at 7 AM. It just feels like you’re winning more than you should, like you’ve dominated everyone else who is waking up because you’ve just been doing more than they have. Of course, this is fleeting, as you then get mediocre sleep in a too-bright room, then have a raging headache, and then curse yourself for working a nocturnal job. But there is that initial feeling, which is cool.

**This is, however, at the expense of sleep, which makes it utterly not worth it.

OK, that’s all I’ve got. I’m really excited to get back to a normal schedule.

The Virtues of Hypomania

Bipolar disease is awful. Let’s just get that out of the way right out of the gate. It’s a mood disorder characterized by large swings in thoughts and behavior, from peaks of mania to valleys of depression. To have bipolar disease is to know what it must feel like to be zooming through life on a roller coaster blindfolded.

Most of us know what it is like to feel depressed, or have seen a close friend or loved one go through it. It is characterized by:

-Sleeping too much during the day / not enough at night

-Lack of interest in activities that used to be meaningful

-Feelings of guilt and worthlessness

-Fatigue, lack of energy

-Difficulty concentrating

-Loss of appetite

-Anxiety and lethargy

If anyone feels these symptoms for a significant amount of time, they should seek psychiatric help immediately – this is treatable!

Perhaps less well understood generally is mania. It is a period of incredible intensity which can sometimes lead to overt psychosis. Here are the classic mania symptoms:

-Distractibility, easily frustrated

-Irresponsibility, erratic and uninhibited behavior

-Grandiosity

-Flight of ideas / racing thoughts

-Increased goal-directed, often high-risk activity (gambling, sex, improbable business ideas)

-Decreased need for sleep

-Extreme talkativeness

These are generally thought of as the two ends of the mood spectrum: doldrums on the one hand, and rock and roll on the other. However, to what degree is mania a part of, and even integral for, modern success? Does anyone know an ICU doctor who gets enough sleep? What about a CEO who didn’t have a grandiose vision of the company? Wasn’t Steve Jobs famously easily frustrated? Aren’t most worthwhile investments high-risk?

Enter hypomania. As with most things in medicine, it started with Hippocrates. Its definition has changed a bit since the Greeks were running things, but at varying times it has meant “partial insanity,” “craziness,” and “monomania.” It now generally means “less than mania,” in that it shares similar features, but does not result in psychosis and doesn’t affect people’s functioning as much as mania or depression. Here are the descriptors of hypomania:

-Extremely energetic

-Talkative

-Confident

-Creative ideas

-Excitement

-Highly productive

Now, look at the above list. Pretty impressive. What exactly is this thing? Is it a disease? Or the profile of your dream spouse/senator/graphic designer? Should you be treated for this, or be happy that your brain’s neurochemistry allows for you to be a motivated, competitive member of society? Here are some more ridiculously advantageous benefits of hypomania, from Christopher Doran’s 2007 book called The Hypomania Handbook: The Challenge of Elevated Mood.

-“Euphoric”

-“Visionary”

-“Overflowing with new ideas”

-“Significant correlation between hypomania and creativity”

-“immune to fear and doubt”

-“negligible social and sexual inhibition”

-“life of the party”

-“offer solutions to problems”

-“finds pleasure in small activities”

Again, what is this thing? It’s made it’s way into the DSM-IV, so it’s currently listed as a disease, with treatment options. But what does it mean to have hypomania? Don’t we all get this, to some extent, at varying points in our lives? Think to a time in your life when you’ve been your most productive. That night that you stayed up until 3 AM, made a pot of coffee, and wrote the essay. That day off where you made a list of 10 things, and then gleefully ticked them off as you got groceries, went to the gym, paid your rent, hung up that picture you’ve been meaning to hang, and called grandma. That party where you had a bit too much to drink too quickly…and liked the resulting confidence, disinhibition, and euphoria of finally feeling like you just don’t care what other people think.

I think most of us experience hypomania. If I’m being totally honest, I wish I experienced it more. It’s enjoyable. It’s no wonder that people generally do not want to be treated when they are diagnosed with it. We treat and medicate and diagnose and define deviations from normal. But it’s usually the people who aren’t normal that propel our humble race forward. Building a civilization is hard, and it wasn’t that long ago that we lived in trees. If the key to creativity and success lies in psychological deviation from the norm, is it a disease? Or our salvation?

Hiding in Plain Sight

The field of medicine evolved, principally, as a field of observation. Hippocrates (the first, and perhaps most famous physician, for whom the oath is named) would press his ear up against his patients to listen to their innards, a precursor to the common modern technique of auscultation. People used to dig up skeletons in graveyards and drew them for a better understanding of anatomy.  The french realized that you can tap on wine casks to see how full they are, and then realized you can basically do the same thing to people. Our attempts to understand (and ultimately fix) the human body have relied on thousands of years of looking and listening.

Describing a patient well has, and will always be, useful in medicine. A concise, accurate description of a patient’s history and physical examination remains one of the most elusive and difficult skills to master as a medical student and resident. This skill has proved especially useful in modern medicine, where patients are handed off between colleagues more and more as duty hour restrictions have hardened.

An interesting consequence of medicine’s collision with modernity has been the devaluation of physical exam findings. Ultrasound, CT,  and MRI imaging techniques have all brought the insides of our patient’s bodies into crystal clear focus. What used to be either inferred, missed, or seen retrospectively on dead patients, is now rapidly available, usually in under an hour. Modern imaging is something like a miracle. I dare you to even try to understand the science behind an MRI,  for which the nobel prize in medicine was awarded in 2003. A friend of mine is a medical physicist, which is an entire scientific field devoted solely to understanding the physics of medical imaging modalities like MRI and operating them. He once described the science of MRI’s to me as “basically indistinguishable from magic.”

Modern imaging has collided head on with the physical exam. Because imaging can catch so much that the physical exam misses, the physical often feels somehow fake. Forced. Like the opening ceremonies at the Olympics, it’s glitzy, it’s expected, it’s analyzed (albeit by fashion blogs), but in the end it ends up being a lot of arm waving before the actual games are played.

Recently on the wards, I saw a patient who had obvious signs of congestive heart failure. Edematous, swollen legs. Fatigue. Trouble laying flat. His blood, unable to be pumped fully throughout his body, was backing up into his lungs and his extremities, collecting in places it wasn’t meant to collect. He, indeed, had heart failure. This was proven to the team by echocardiography (sound wave imaging) only hours after he was admitted to the hospital.

He had a special kind of heart failure stemming from aortic insufficiency – blood was flowing back through his aortic valve, causing a buildup of fluid in his lungs. Aortic insufficiency has a characteristic murmur on auscultation: an out-of-place whoosh that trails off in a decrescendo where there should be only silence.

I imagine that in the days before transthoracic echocardiograms, this murmur would have been the crux of the case. The physician that found the murmur would have solved the riddle. I can picture several physicians, stooped over the man’s chest, ruminating for minutes on the exact degree and characteristic of the murmur, comparing it to others they had heard, debating the acoustics and dynamics.

Today, things are different. The murmur was heard, but it wasn’t heard. It was noticed, and promptly forgotten. The echocardiogram was ordered, and it did the heavy lifting. “Severe aortic insufficiency seen. Left Ventricular Ejection fraction 20%. Recommend CT for full characterization of aorta; concern for aortic root dilation.” Pressures, gradients, valve areas, and outflow jets velocities given in neat tables.

After receiving this information, we went back to the patient’s bedside the next day to find the murmur. There it was, waiting for us the whole time.

Starting a BAND

Hello, internet! I’m excited to enter the blog-o-sphere. It’s not actually as round in here as people make it out to be. Much flatter. Almost dismayingly flat. But I suppose that the ‘sphere’ part is pretty catchy. It’s better than ‘blog-o-normal-dimensions,’ or a BOND. Although, people, let’s be honest. We are not aiming for a BOND. We are aiming for a BAND. A blog-above-normal-dimensions. That’s right. I want this thing to be so good that it proves string theory (string theory is only correct if there are 10 or 26 dimensions). So lets kick this BAND off in style, with some good old-fashioned mind blowing neuroscience quotes. Here are two:

“There are more connections between neurons in a cubic millimeter of brain tissues than there are stars in the milky way galaxy.” -David Eagleman

“There is no such thing as color in the physical universe.” -A neuroscience textbook I read in college

With those thoughts in mind, I’m going to head to bed. Goodnight!