So today I had a mock / real exam of sorts which was painful, because its always difficult to hear how you need to improve, but excellent at the same time because we don’t get a lot of chances to *do* mock exams. The Royal College exam in Internal Medicine has both an oral and written component; however, the oral component is the one which requires a lot of practice because of what’s required in such a short amount of time.

They give you a stem (essentially the clinical scenario), and you’re either required to walk through exactly how you would manage the patient, examine the patient, or communicate with the patient (with standardized patients, i.e. “mock patients”). The time frame is 10 minutes.

In many ways, its as much a test of how you can preform under a time-limited stressful situation, and as a means of how you can perform what you need to do while looking graceful, organized and co-ordinated as well. For that reason, its important for us that we not only know our Stuff, but be able to show that we know our Stuff …

… which is why doing mock exams are actually quite good.

The best scenario of the day, today?

“Examine this patient for an overactive thyroid. But don’t examine the thyroid itself. And … go.”

At some stage in every medical trainee’s career, at some point you hear about someone describing being in a situation where not one, but *two* medical crises are happening at the same time — and there’s only one of you.

Classic example: you’re in the middle of managing a cardiac arrest, and a *second* cardiac arrest is called — <gulp>, what then? Well, the answer is that you would probably send of the anesthetist to manage the second one, or perhaps, send off a junior resident.

Funny thing, however, is that when a patient arrests in the intensive care unit, you don’t “call” a cardiac arrest, no code blue gets announced over the overhead, and no help comes. In that way its a lot like the emergency department, in that arrests don’t get publicly called overhead — in academic hospitals in Toronto anyway. It probably has to do with the fact that they are adequately prepared and equipped to deal with (and have the personnel for) arrests in those areas to begin with.

The problem, however, if you’re in the intensive care unit, and someone arrests … well, its just you and some very capable nurses.

Interesting thing that happened last night though: for about 2 hours, I was running between two patients. Both had been resuscitated after a cardiac arrest, both arresting because they were deathly sick from infections. But one of them kept on re-arresting in the intensive care unit, and the other was decompensating and on his way to re-arresting. Both of them were on either side of the unit.

And if you can imagine two groups of nurses and allied health were calling me for these critically ill, or dying patients, at what must have been at around 1:30 in the morning — I was in a position where I had to make a decision: who am I going to try and save? Who am I going to spend the next 5 minutes with, where those next 5 minutes might mean the difference between hanging on and dying? There’s only one of me, after all.

What I ended up doing was seeing the one patient where I had to directly and actively be present to administer shocks to, all the while shouting at the nurses at the other end of the hall to start compressions and begin administering medications (no shock was necessary as it was a pulseless electrical rhythm).

At the end of the evening (or morning), only one of the patients had survived. In retrospect, the one that died probably could have had anything more done than what was done (which was “everything”), and furthermore, probably had poor chances to surviving the hospital stay at all. It was, for example, unclear how long the patient was “down” for, when the nurses noticed there was no pulse (could have been half an hour or more) whereas the patient I managed to resuscitate and stabilize had a “witnessed” arrest.In that circumstance, the patient went pulseless right in front of someone, and therefore, was only without a heartbeat for a few minutes, which portends a much better prognosis.

Anyway, last night was one of those stories you only hear about it, and last night I actually lived through it. I’m still digesting what it was like, but the sheer horror of knowing that you can’t be in two places at once and still trying to make a best decision was a surreal experience … and something that I’m not sure anyone can ever get used to.

I’ve taken a short hiatus from DJI as a result of higher-than-usual work loads at hospital. The next month may (or may not) be spotty thanks to the fact that I am working in the intensive care unit, where we see the sickest of the sick. Last night was one of the roughest nights of “call” I have been on in the longest time, which was capped off by seeing a gentleman brought in after trying to kill himself.

His method of choice was drinking two and a half cups of anti-freeze.

Now, drinking anti-freeze can kill you by a few means (such as kidney failure) and sure enough, when he arrived his level of consciousness fell to the point of requiring artificial ventilation (because he fell so deep into a coma we thought he wouldn’t be able to breath on his own). We then had to clean out his blood by hooking him up to a dialysis machine.

What was rather interesting is that most times getting a person hooked up to a dialysis machine requires one giant tube hooked into one of the major vessels; when someone has a poisoning or overdose issue, you have to hook up *two* giant tubes. One in one side of the groin, and the other, in the other side.

We’re hopeful that we saved his kidneys, as the dialysis was slowly working as we were able to get the level of his anti-freeze levels in his blood to almost zero after only a few hours.

If there are any science fiction and fantasy fans out there, you might be saddened to hear that Robert Jordan, one of the masters of fantasy story telling, died today. His magnum opus, the Wheel of Time series, remains officially unfinished, as he was on the last book. From what I understand he took a great deal of notes and told his wife and nephew how the last book should unfold. The Wheel of Time was a series I started in grade 11 — over 10 years ago. As a work of fiction, it has a very special place in my heart as one of the first pieces of fantasy that that I really enjoyed. It had endless twists and turns, and a quality and depth of characters that I had never encountered before.  And it almost seemed like it would never end.

I mean, with each book averaging somewhere between 3-500 pages (and some being longer), that’s a whole lot of story. ;)

I’m sure that his last book will finally be published, but tonight I’m saying a quiet prayer for his family, and a small prayer of thanks that such a master storyteller got a chance to influence so many people all over the world.

Yours truly included.

{via digg} 

File this under “off-topic”, but I couldn’t help notice a post by Mark Cuban (which has some how made it on to Techmeme), involving how he basically realized that he’s lost the ability to write quickly and take notes, as he probably hasn’t done so in years (he usually does it via laptop or some kind of electronic device).  But more specifically the following:

I literally couldn’t take notes fast enough because as I wrote, I realized I couldn’t read my own writing. Not only could I not read my own writing, when I tried to slow down so that everything would be legible, I realized that actually writing each letter as part of a complete word was actually difficult

When I started clerkship, the second half of medical school (and an incredible seven years ago) where, in North America, you spend the majority of your time in hospital and not actually in class, did I actually learn the same lesson Mark did.  And the reason why, I suspect, that most doctors hand writing is chicken scratch.  Its not that they were always this way, or that they enjoy writing illegibly.

Rather, that at some point in their career, they’ve had to write faster and faster because of how busy you are (that was one thing about being in a hospital that I just didn’t appreciate at the time). And in writing faster, and quicker, you tend to develop shortcuts in how you write, and of course, the writing tends to get a little bit more illegible over time.  What makes it worse (to lay people) is that on the only bit of communication that patients see, the prescription, we tend to use abbreviations as well — but not just English abbreviations, *Latin* ones, which make it doubly hard to understand.  If you’ve ever read “PO” on a prescription, it stands for “Per Os”, which is meant to be “by mouth”.

Anyway, I thought it was ironic that this kind of phenomenon would pop up, and be documented by, one of the biggest personalities in *Technology*.  I wonder if anyone else has noticed this kind of phenomenon by other people in other industries?

Something for everyone to chew on on a sunny Sunday afternoon. ;)