Update II - Paris

This could actually be pretty good.

I've been trying hard not to get a pessimistic attidute on this trip, and believe me, it has been a challenge many times. Like today, for instance. I wake up in Nîmes, France this morning, having spent the previous evening in a beautiful Roman colloseum seeing Arctic Monkeys and Arcade Fire perform. Naturally, my spirits were high as I went downstairs this morning to collect the breakfast I had paid 4 euro for the previous day. Oh, did you say breakfast was over at 9:30? Hm, nobody told me that yesterday. Well, is there anything you can give me? Oh, OK, a piece of bread and some weak coffee. Boy, that was good. Totally worth nearly $6 US. May I use the internet now, so I can get directions to my next hostel? Oh, 1 euro for 15 minutes? OK, let's see where this next hostel is. Oh, I have to call somebody to let me in because you don't post the address? OK, let me write down a page full of instructions first. Oh, you say I need to bring my own sheets? OK, that'll be a problem.

This was all before noon.

I've had many days like that, where it seems like every move I make is an overpriced fiasco. Maybe I'm not suited for travelling like this, or maybe I need another person or two with me to share some of the responsibility. Who knows. At any rate, I'm here and I'm not giving up. You think I'm going to let France get the better of me?

Anyway, this morning made me grouchy all over again, as I took the high-speed train north to Paris. I got out of the train station and called the number of this hostel. A nice woman picked up, gave me a few directions for the subway, and said two guys from Finland would meet me at the station to show me the apartment. Wait... apartment? Turns out I'm not going to a hostel, but one of several little apartments all over the city, each with 4 to 6 beds, and a full kitchen, bathroom, and living room.

So fast forward one hour, where I am sitting in my cute little Paris apartment in Montmartre. I've got ten days in this city, and this could actually be pretty good.

Update I

I am sitting in the sweaty internet lounge of my "hotel" in Nice, France right now. It's about a quarter to six. I've got time to kill, because I realize now that I committed myself to more days in Nice than I really needed. Before I came to Europe, I thought that situations like this wouldn't be a problem. Finished with a city? No big deal. Use my Eurail pass to hop on a train to another city, blow into some hostel that I found in my guide book, and spend a night or two somewhere new. But in reality, when I say "committed," I truly mean committed. I've had to make reservations for every night of every hostel, and most of them have a 48-hour cancellation policy. You don't let them know in time, they charge you for the first night's stay. No excuses. And forget about trying to make a new reservation somewhere with less than a week's notice. This being the high season, everything is full. So at times like this, when I'm ready to move on from Nice, I'm locked in. I can't find anyplace else to stay in a new city, and even if I could, I can't cancel the reservation I already have here.

This trip has been the most stress I've had in a long time. The first week especially, when I realized that my vague itinerary wasn't going to cut it, and I began having to plan my entire trip around which cities had places to stay, rather than which cities had interesting things I wanted to see. The lack of space in hostels and on trains means that I won't be going to Spain and Portugal like I had hoped. It's a scary and vulnerable feeling to walk out of the train station in a new city without a place to stay that night and have to go around asking hostel after hostel if there's any room. You may gush breathlessly, "Well Dave, that's the beauty of traveling. That's fun!" Don't give me that bullshit. Your idea of traveling is my idea of being a bum.

It hasn't been all bad. I've been to some nice cities and seen some truly wonderful things (eg, the Sistine Chapel, the ruins of ancient Rome, Michaelangelo's statue of David) and I've got more wonderful things coming up with the concert in Nimes and all that there is to do in Paris. I've met some good people and discovered I love falling asleep on night trains. But I find myself asking if it's been worth all the stress and worry. I could have saved myself a lot of trouble had I done a lot more research back home and made hostel reservations before I left; don't think I don't regret that now. And things would have been a lot easier if I weren't by myself right now, too.

But hindsight is 20/20, right? I haven't lost hope yet, and I am looking forward to the things I have yet to see. But I miss being home right now, too.

F/U

I received this comment regarding my last post on abscesses:

"Anonymous" said:

"You don't seem that curious about how the lidocaine got on the shelf. Do you think patient could have an addiction? Could she be coming in for treatment to get the drug? Is there someone in the hospital supplying it? Did you mention the incident to anyone? What did you have to do that took you out of the room briefly? Is there a protocol for dealing with a patient who just "ain't tellin'"?
Too many questions?"

**********************

OK, let's run down the list.

1. I know how the lidocaine got on the shelf: she took it out of her bag.

2. This patient likely had multiple addictions, and probably more serious ones than a jones for lidocaine.

3. I have no idea who in the hospital supplies lidocaine in those quantities.

4. If you read carefully, you'd see that I made the physician aware of what had happened. There was also a nursing student working with me.

5. I had to get a larger packing strip to fill her enormous abscesses.

6. Thumbscrews.

What are you implying here? Negligence on my part? I'm a medical assistant. My job that day was to do the menial dressing-change-related tasks and report any abnormalities to the physician, always keeping the patient's best interests in mind. I am not a detective, drug counselor, or interrogator, and acting as such would have been inappropriate.

No, I wasn't too curious about how she got the lidocaine. Just as when I find a crack pipe in some guy's pocket, I'm generally not too curious about how he got it, unless he's here for OD'ing on crack. if that's the case, ok; we'll talk about crack. But if he's here to get his dressing changed, then dammit, we talk about the dressing-change. If his crack problem comes up in the course of the dressing-change, we might offer him somebody to talk to about that, but I'll bet you dollars to donuts he won't take us up on it. And even then, it's the doctor who offers that. Not me. I'm a medical assistant.

Again with the abscesses?!

Well, I've seen a lot of them in the ER, and while most have made me want to run from the room leaving a trail of vomit behind me, sometimes you just have to laugh.

We had another one of these poor souls who, upon meeting them your first thought is, "Wow, you're only 45?" Drugs will age you folks, and not gracefully either. She needed the dressing changed on her abdominal abscess. Simple enough. If you get your abscess opened and drained at the hospital, typical treatment involves packing the hole with a long strip of damp fabric and slapping a bandage over the whole thing. You usually get a course of antibiotics and some pain medications, and you're instructed to return daily to get the wound flushed out and the packing strip changed. Over time, the abscess heals from the inside out, and you need to stuff in less and less packing strip each time. It's a pretty easy procedure to do (which I guess is why they let the medical assistants handle them).

I'd been doing this all day, so my mind was probably elsewhere as this lady laid down and lifted up her shirt. I took off the old bandage and saw two holes in her rather large belly, each about the size of a golf ball. OK. Next step, remove the old packing strip. I started pulling it out of the top hole, and to my surprise, saw the stuff in the bottom hole start to move... wait a second... oh God, they're connected! OK, so now I know we're dealing with a "tunnelling abscess." By the time I had taken out all of the packing strip, I had removed several feet of the stuff.

By this time, the lady was starting to squirm. She said that putting the new packing strip in always hurt her and said she needed some lidocaine. We rarely give anesthetic for this procedure, so I gave her a minute to collect herself while I left the room to do something else. When I came back, I noticed she was wet. This was odd, since we don't even have a sink in that room. Our conversation went like this:

Me: "You're wet."

Her: "No, I'm not."

Me: "Yes you are. See, right there. What happened?"

Her: "Oh that's just lidocaine."

Me: "Where did you get lidocaine?"

Her: "From over there. See?"

She points to a large brown bottle on the counter. I looked at the label. Sure enough, lidocaine. But not in the quantity that we'd ever give to a patient; it looked like a liter bottle.

Me: "Where did you get that?"

Her: "Mmpf. I ain't telling."

Me: "What did you do?"

Her: "I put some lidocaine in it. I told you I needed it."

I looked at her abscess, which was now literally full of lidocaine. The next twenty minutes were spent removing several syringe-fulls of the stuff out of her belly-holes, checking with the doctor to make sure that she wouldn't die from an overdose of self-administered topical anesthetic, finishing up the dressing change, and taking away her liter of lidocaine while she called me a "stupid power-trippin' doctor-man." The Aristocrats!

The Hospital that I work at is a county hospital, meaning that it is primarily funded by the taxpayers and Medicare/Medicaid. In other words, patients pay if they can, but if they can't, that's ok too. The Hospital served nearly 500,000 patients in 2006 (including 81,000 in the ER). Of these, only about one-third were able to pay with commercial or private insurance, and 12% were unable to pay at all. What this means, at least for the ER, is that many of our clients come from severely underserved populations, including the poor, the homeless, and the addicted. These are the folks for whom our Emergency Medicine services are the only kind of primary care they receive.

An interesting case I saw recently was a 29 y/o female who, due to chronic IV drug use, looked like she was about 15 years older. She presented with massive opened abscesses to both arms, which were extremely painful and draining copious amounts of foul-smelling pus, or "purulent discharge," in medical terms. (To see an early-stage closed abscess, click here. To see a later-stage opened abscess, click here.)

I overheard one of the nurses say that the patient used about 6 grams of heroin daily. (Slight tangent: I'm not sure if I believe this. 6 grams daily is a tremendous amount, even for a seasoned junkie. Currently, the purest heroin can cost over $100 per gram.)

Anyway, this case led me to do a little research on the cause and formation of drug abscesses, which typically result from using dirty needles when shooting up. An infection starts brewing under the skin, creating a pocket of pus. Left untreated, the infection will spread, destroying the surrounding tissue, including the overlying skin. At this point, the abscess has opened. Treatment for small or shallow abscesses includes antibiotics, plus a debridement of the abscess itself followed by daily gauze packings and dressing changes. Treatment for large abscesses, like those of the woman I saw, could be amputation.

In my research on this topic, I came across King County's "Harm Reduction" website. (Incidentally, this page is the first that appears if you Google "drug abscess"). If you are not familiar with this, harm reduction is the theory instead of criminalizing a certain behavior, the general population is better served by providing the resources to make that behavior safer. In drug terms, harm reduction programs generally consist of needle exchanges, distribution of clean supplies like new cotton balls, spoons and alcohol pads, and information about the safest ways to use drugs. Naturally, these programs are strongly criticized, as it can appear that they are supporting or condoning drug use.

My position: neither theory is perfect. The government's War on Drugs is problematic, and has been largely unsuccessful in reducing overall drug use (this is a topic for another day). And while harm reduction programs may make IV drug use safer, I believe that it's not the only solution, and emphasis must also be placed on helping addicts get off drugs.

What do you think?

So I've been doing this EMT job for about two months now, and so far it has been about 90% routine (transporting old folks between nursing homes and hospitals, etc.), 8% exciting (car accidents, major trauma, etc.), and 2% "Oh shit." I'll tell you about the 2% here.

STORY ONE
Nearing the end of our shift, we're dispatched code-red (priority, with lights and sirens) to assist with a possible overdose. Police, fire, and paramedics are already on-scene. In a case like this, the paramedics evaluate the patient and determine how sick he/she is. Sick patients are taken by the Fire Dept. paramedics (advanced life support, or ALS), not-so-sick patients are taken by us, the private ambulance companies (basic life support, or BLS). Let me repeat for emphasis: paramedics, who have much more traning than EMTs, evaluate the patient and determine whether they need ALS or BLS en-route to the hospital. Truly sick patients should not be transported by BLS, because we have neither the training nor the equipment to keep them stable.

We arrive at a private residence and go inside, where we find a bunch of cops and medics circled around a female in her mid-forties, who is ranting and raving at everyone in Russian and broken English. The report we got from the medics was that the woman had emptied 7 bottles' worth of various prescription meds into a Tupperware and started tossing back handfuls of them, washing it all down with swigs of vodka. Nobody knew how many pills she actually took, nor did we know what all of them were, as some of the bottles were labelled in Russian. We did know that one of the meds was amitryptiline, an antidepressant, and this was the one that made the paramedics nervous.

With the help of her Russian-speaking neighbor, we finally convinced her that she needed to go to the hospital. Because she was still shouting at us, the medics were confident enough to let her be transported BLS by us. We loaded her up into our ambulance, and one of the paramedics and myself attempted to get her vital signs before we left. It was while we were doing this that she started getting much more sluggish. It soon became obvious that whatever drugs she had taken were starting to kick in, and I started wondering if maybe she should be taken by the medics instead. By the time we were ready to leave, she had become completely unresponsive. The medics told us to take her anyway.

The entire time we were flying towards the hospital, the patient got worse and worse. She became completely unresponsive even to painful stimuli (grinding a knuckle into the sternum, pinching the earlobe), she lost her gag reflex (tested by touching the back of her mouth with a tongue depressor), her pupils were pinpoint and fixed, and she lost her muscular reflexes (a cool medic trick tested by holding the arm up above the face and dropping it; people with this reflex will not let their arms hit them in the face). Her breathing became labored. She did not vomit, and while this was nice for me, this was bad for her as it meant whatever she had taken stayed inside her body.

Things I was watching out for:
- A slowing of her breathing, or a reduced tidal volume. She would then need me to help her breathe, using a bag-valve-mask setup. This uses a big rubber bulb connected to compressed oxygen that I squeeze to drive oxygen into her lungs through a mask.
- Vomiting, which would require me to suction her airway to reduce the risk of her aspirating (inhaling) the vomit.
- Bradycardia, or a slowing of her heart rate. Not much I can do for this, except for start chest compressions if her heart rate drops below 40 beats per minute.

As it was, we got to the hospital before I had to do any of these things. They ended up intubating her (putting a tube into her trachea and having a machine breathe for her) and doing a gastric lavage (removing her stomach contents and flushing her stomach with many liters of saline).

When we opened the back doors of the ambulance, her friend was there and asked, "Is she dead yet?" Apparently, she's tried this before :)

Story Two soon to come...

--From PostSecret

I think I'm a bit susceptible to OCD myself. I had a period when I was younger where I would check every lightswitch and outlet in the house to make sure there were no bad connections that could start a fire. I did this several times a day, frequently waking up in a sweat, terrified the house was burning down. Today, I no longer have that particular fear (thankfully, considering the house I'm living in now is over ninety years old, and probably retains some of the original wiring... they did have electricity back then, right?). My new thing is feeling crippling waves of guilt every time I eat something remotely unhealthy. Note that this does not prevent me from eating something unhealthy, but just prevents me from enjoying it. Cheers!

Best quote of the day, overheard at the airport in Chicago: "I've got to get away from this football on TV. I can't stand this crap anymore. It reminds me of my ex-husband."

Just finished watching one of my favorite episodes of Scrubs, called My Philosophy, from Season 2. The episode's finale features a Broadway-like rendition of Colin Hay's Waiting for My Real Life to Begin, performed in perfect harmony by the cast and guest star Jill Tracy. Her character is in need of a replacement heart valve, and earlier in the episode, when J.D. asks her what she thinks death is like, she replies that she hopes it's like a big Broadway play, where "you go out with a real flourish." The finale takes place in one of J.D.'s imagination sequences, where Tracy's dying character gets her wish and assumes the lead in her own musical. But what makes it so impressive is how well it also ties up the rest of the episode. Some of Hay's lyrics fit pretty well with what happened in the episode, and when they do, the appropriate character has his or her chance in the spotlight to sing the part.


I love smart TV.

Day One

My first post. This blog will describe what happens to me as I pursue my dream job. It will be a record of my experiences, my people, and my ups and downs. You will see a lot of this last one. My dream is to become a physician.

I will be writing a lot about the two main facets of my life right now: the application process to medical school, and my new job. When I write about the former, feel free to skim. Look for big news, but don't expect anything thrilling. I'm not. But I should have a lot of interesting things to say about my new job, as I've just been hired as a medical assistant for the best ER around.

In a nod to the ways of modern medicine, identifying information will be limited. My hospital is not really called The House, but that's we'll call it for now. You don't need to know what it's called to read about what goes on there. You don't need to know the names of my coworkers or my bosses, and you really don't need to know the names of my patients.

My patients. Wow. Not mine in the sense that I make big decisions about their healthcare, but mine in the sense that I'm working around them, with them, and on them. This new responsibility is both exciting and scary at the same time. Today, we learned how to restrain patients, run lab tests, and draw blood, among other things. Not a big deal to some of you I'm sure, but I can't believe I'm actually doing this. Unreal.

Next week I fly to Rochester, NY to interview at the U. of Rochester. My first and only interview so far. Also exciting and scary.

This week at The House has been all orientation, and I've got two more days to go. After that, I have about ten one-on-one shifts with my preceptor until I'm ready to be let loose on my own. All these 0700 mornings are wearing me out.

I know this blog will be primarily friends and family, but I hope you enjoy it. I hope you look forward to new posts, and I hope I can keep them coming. Lord knows there will be enough to talk about!