clinic · PGY-4 · residency

A one-act play

Staff message from clinic nurse: Mr. Scrooge called, he has some questions about his follow-up appointment. Can you give him a call?

** ring ring **

Timid Female Voice: Hello?

Me: Hi, this is the Scrivener calling from University Hospital. I’m returning a call from Mr. Scrooge?

** hang-up sound, then silence. Our new VoIP phones don’t have a dial tone, just soul-eating silence. Dial again….

** ring ring **

Hearty Man Voice: Hello?

Me: Mr. Scrooge? This is the Scrivener, returning your call.

Hearty Man: Oh yeah! It’s about my wife. She’s not your patient, but she has a follow up with The Ghost of Christmas Past next week, and she wanted to cancel it.

Me: Uh… You’ll have to call the Ghosts’ clinic and tell the receptionist. I can’t do that myself, they are a different department.

Mr. Scrooge: Oh, ok. Can you tell me their phone number?

Me: Well, according to Google, it’s 867-5309. Sure, I’ll hold while you find a pen. 8.67. 53. 09. No, nine, nine as in … as in cat o nine tails

** Co-resident gives me the side eye **

Me: Cat. Not at, there is no at sign on a phone. Nine. Oh, hold on, let me just transfer you.

** attempt to transfer the call on the new VoIP phone, accidentally drop the call **

Me: Mr. Scrooge? Are you still there? No? Well humbug to you too.


Merry Christmas, all!

chart lore · PGY-4 · residency

Chart biopsy

I was reviewing tomorrow’s patients and came across this little gem:

“Patient with feared complaint in whom no diagnosis was made (Primary Diagnosis)

It’s going to be a fun visit.

PGY-4 · residency

Honoring the Stories of Illness

Once upon a time, as an intern, I wrote a post comparing my life to that of a college friend I ran into on my way home from a brutal MICU shift. It’s predictable: I’m so busy and emotionally exhausted woe is me; she’s living the good life with a toddler at home and a steady job that doesn’t involve pronouncing people dead.

Well. About a year after that post, I took care of her in the hospital. She was very sick. It turns out even back in college when she was so carefree (so I thought) she was dealing with some really serious health problems that worsened over the years. Just goes to show. Anyway, she didn’t do well under my care. We did a brain biopsy, which showed Disease X, and gave her meds. She seemed to do better for a time, to the point where we had real conversations about our college days. She went home; I presented her at an Interesting Case Conference: Look at this super rare disease you only read about in books! Here it is in a real live person!

Then she came back ragingly worse. She went to the MICU, where I was consulted on her (continuity, it’s a beast.) By that time she was too ill to recognize me, I think, or even have a conversation. Eventually she died, and went to autopsy (pathologists say “came to autopsy,” which creeps me out, like there’s a special autopsy chamber where path just waits around all day for dead people to show up). It turns out we had misdiagnosed her. Like, pretty flagrantly. Rare Disease X was a red herring. What she actually died of turned out to be untreatable anyway, but the fact remains that we misdiagnosed her. We might have spared her several weeks of unnecessary treatment.

Shortly thereafter, one of my attendings, who had taken care of her too, came to me asking if I wanted to write this up as a case report. I agreed, but I dragged my heels for a long long time. Partly, yes, I was busy, but also … this was a friend. How could I write a case report of a friend? How was that going to be ok? And yes, it’s hypocritical that I was totally fine presenting my friend as an Interesting Case when we thought we had the diagnosis, but as a case report of a missed diagnosis? That made me nervous.

But another friend pointed out a very true thing: that case reports are how medicine moves forward first. A 2010 report of a 58 yo man with advanced Parkinson’s being unable to walk but able to bike (watch the video) has led to improvements in therapy and understanding of neuroplasticity in patients with PD. So I could honor my deceased friend by acknowledging her story publicly, hopefully improving general understanding and maybe one day down the line, leading to improvements in that brain biopsy test that led us up the garden path in the first place.

Once it was framed like that, honoring a story rather than profiting off the dead, I found the paper much easier to write. It still went through multiple rounds of revisions, of course, but I’m pleased to say that it’s going to be published shortly.

It’s been an instructive process for me, both in terms of the basics of journal publishing but also in terms of grieving my friend. And more to the point, I’ve been reading others’ case reports differently since this whole incident, pausing before the Discussion to imagine the person that was.


Adventures in Ganache*

I ditched the housestaff Halloween party on Friday in favor of baking pies to take to our own Neuro-IM Halloween/birthday/engagement/let’s-just-have-a-party party.

2015-10-31 16.48.18

Aside from the storebought chocolate crust, all of that was made by hand! A giant can of pumpkin puree, two cans of evaporated milk, a bunch of spice…. and chocolate. Oh god, the chocolate.

My idea, you see, was to do something like this, piping chocolate on the pumpkin pie to make a spiderweb design. So I bought Ghirardelli’s chocolate (mistake #1: should have done a trial run with the cheapy stuff!) and went to work.

The recipe, and all similar recipes I found online, has you zap the chocolate in the microwave to melt it. Fair enough. Except I tried that and succeeded only in scorching my chocolate to death. Seriously, when I pulled it out of the microwave it was smoking so hard I thought my fire alarm was going to go off. So then I tried again, with a makeshift bain-marie/double boiler constructed out of my piping bag:

bain marie

Took about half an hour, but I finally got enough chocolate to melt. Piped the pie on the right with non-equidistant lines…. spatial reasoning was never my strong suit … and put it back in the fridge to set.

But as I was piping the pie on the left in that picture, the resistance in the piping bag started to climb, and climb…. I pressed harder and harder …. and the coupler and tip went flying across my kitchen, schmearing chocolate on everything including me. (Thank goodness I wasn’t be-costumed yet!) Turns out a piece of unmelted chocolate had wedged itself in there and had blocked up the tip until everything exploded. Like when a patient is constipated and then has overflow diarrhea around the blockage. (You’re welcome for that visual analogy in a post about food.)

So now, my pie was covering in goops of chocolate, which was setting fast. I had to think quickly. Grabbed a knife outta the drawer and began spreading the chocolate across the top like icing. A very dark, bittersweet icing. I had to remelt more chocolate (another 30 minutes!) because I didn’t have enough to cover the whole pie … good thing I bought extra (expensive!) chocolate!

Then it looked sort of boring and plain, so I softened cream cheese, dyed it orange with food coloring, and piped a carved pumpkin face. It looks sort of yellow-white in that photo, but it real life was bright neon orange. Like HELLO I AM A PUMPKIN PIE.

Morale of the story: things go wrong unexpectedly, a little flexibility saves the day. Not unlike residency, actually. But pumpkin pie is waaaay more delicious.

* Astute cooks will recognize that this is not ganache. Actual ganache has cream and therefore remains soft and spreadable, doesn’t harden within minutes like pure melted chocolate. But ganache sounds fancier than “That melted candy bar,” and so ganache it is.


A few more quickies

Book #16: Orphan Train, by Christina Baker Kline:   [2 stars]
Very weird, this book. It’s supposed to be about the contrast in the foster care system now vs a hundred years ago, when kids were apparently shipped across the country in trains (literally) to be delivered as farm hands to random families. I guess this was the premise of Anne of Green Gables, but I never really thought about that period in social history, so that was good, I guess. But the writing was stilted and characters wooden. This could have been a good American Girl book, and even that’s pushing it. But as grown-up literature? No thanks.

Book 17: Learning to Bow, by Bruce Feiler [2 stars]
An American dude goes to Japan to teach English and essentially writes an anthropological text on Japanese society. Mr Feiler clearly has a lot of respect for Japanese culture, and does a good job of viewing it with distance and awe. But I had no sense of HIM as a person … I guess that’s the point of anthro, but I’ve had enough narrative to know that there is always a bias, unconscious or not, and Mr Feiler comes across as so objective (falsely so) that its hard to care much about him and his book. The sections on him struggling to teach and engage his class were great. The ones about how many honorifics to include in a Japanese letter, meh.

books · clinic · PGY-4

Notes today, and some Twitter-style book reviews

“[Patient] arrived 53 minutes late for a 60 minute appointment, so evaluation was somewhat limited.”


Book #13: The Martian, by Andy Weir: [1 star]

Left for dead on Mars. But rebuilt the oxygen converter. YAY!

[I was a chemistry major. I enjoyed chemistry quite a bit. But let’s face it, narrative descriptions of the Wagner-Meerwein rearrangement does not make for compelling reading. For an action-adventure-scifi novel, this was a snoozefest.]

Book #14: Boy Snow Bird, by Helen Oyeyemi [3 stars]

Snow White Re-Told: The mirror reveals hidden secrets.

[More “inspired by” than “modern retelling,” to be honest. A meditation on race and identity and mimesis. The switch in narrators part way through, then switch back to the original voice, was jarring. The plot twist at the end felt gratuitous. But overall, an enjoyable read from a compelling writer. I’m interested in her other modern fables, too, like Mr. Fox, and the Icarus Girl.]

Book #15: Hundred Foot Journey, by Richard Morais [2 stars]

Edward Said rolls over in his grave.

Oh god. This book. It got super hyped cause of the movie (which I still haven’t seen) but it was extremely simplistic and more like a fairy tale than a book. And a Kiplingesque fairy tale at that. India is heavily Othered, throughout the book. The protagonist was dull and diffident — the real characters are Papa and Mme Mallory, and the second half of the book without them slogs. Avoid.