The daily life of a med school student.

The blog.

2009-10-08T16:20:52Z

The decision.
The answer was always the same, the question inevitable. "If I were to specialize, it would be for Pulmonary/Critical Care."

The rash.
"Classic Presentation! Very interesting." It's remarkable to see the change in an attending's attitude when a board-worthy illness pops up in real life. Especially when the patient is one of the residents.
See also: Scrofula.

The hobby.
On the first day of med school, I was told that you needed one thing that was just yours, completely unrelated to medicine that you could fall back when times got tough. As an intern, I finally found it.

The test.
Internal Medicine Inservice exams are coming up. Everyone has their own way of preparing for it, and even the attendings are in full-on board prep mode, regaling us with memories of when they took their own board certifications.

The cycle.
Just a little less than a year ago, I was sitting in the same seat, savoring the same crab stuffed, bacon wrapped shrimp. Feels strange to be the one scrutinizing potential applicants, instead of the reverse.

The one page history and physical.

2009-09-04T01:54:37Z

Now that I'm on night float and doing H&P's every single night, I've come to recognize and love the one page H&P.

Obviously, the one pager is a special kind of patient. They're not the 76 year old with heart disease, diabetes and chronic renal failure, who inevitably have an assessment and plan that's 10 points long. These are the younger, softer admits who have one specific problem (chest pain rule out, cellulitis, acute pancreatitis, overdose, etc.) that really only need one page to fully explain what's going on and convey a thorough assessment and plan.

And here it is. The key is to take advantage of the minimal history - the people who are generally healthy, aren't on 10 medications and only have one or two medical issues.

Believe it or not, 3 lines is sufficient to document 2 points in 10 systems, especially if you're thoughtful about what are pertinent positives and negatives in the HPI.

The other part is to be succinct in your HPI. I used to write 1 page histories of present illness with "The patient was watching television and sitting on the couch when they experienced sudden onset of the pain" which in reality is a lot of useless information. "Pain is substernal, sudden onset at rest." gets your point across, and the attending immediately knows what they need to know.

In my view, an HPI should be like a resume - get all of the information out before the person reading it loses interest.

And of course, the exam. If a patient is straightforward, they're going to have findings in one to two systems, tops. The rest of it is assuring people that yes, their belly is soft and no, they don't have left sided weakness. So what I do is take half a line to write my "Lungs are CTAB w/out wheezes/crackles, no dullness to percussion" and take more room to fully document the erythema and tenderness of their left foot. I'll arrange the order of my H&P to either lead or end with the most important system.

**Just avoid the trap I fell into - I would write "S1, S2 heard, reg rate/ryth, no mumurs, rubs or gallops." which is actually 5 or 6 points, but they're all based on auscultation. So I have to remember now to include a visual or tactile finding - comment on thrills, the PMI or JVD. (Or for lungs, dullness to percussion or symmetric expansion/accessory muscle use)

Of course, as a student early on, I would encourage you to continue writing your lengthy notes and H&Ps - at this stage of the game people are looking for you to be thorough, because you're learning what's pertinent and what's not.

It's an interesting transition, that point where you realize that you can anticipate what the people above you are going to want to know, and it's not found in any kind of book. You only learn from presenting patients over and over and getting feedback.

It's been said over and over, but residency is there for a reason. You could have every drug and every disease process memorized the day you graduate med school, but you're not a doctor until you work with people who have cared for patients with years, and are held accountable for every treatment decision you make.

When I studied in school, I would get a sense before the test "I know X material, and can spit it back out for the test." Now, I don't even have a sense that I'm learning, but when I am asked a question, the information is there - because I've done it before, seen it before, thought about it before.

Of course, I wonder how much more would stick in my head if I actually got to sleep normal hours, but it's residency and you can't have it all. :)

Caution: Wet Floor.

2009-09-03T10:26:07Z

So, some background.

At the hospital I trained at in med school, codes were bad news. There was no Medical Emergency Team, no Rapid Response, no surgical residents, or respiratory techs that would magically appear to save the day. At night, I had the pleasure of being one of the first to a code as a student. That was fun.

So now, when I hear Code Blue, I book it. Even though now I'm at a more functional hospital, and really there's a fairly skilled MET to help with the code until we get there, I book it.

Enter the floor-washers. The floor washers is this huge crew of people with mini-zambonis and floor buffers who are CONSTANTLY cleaning the floors.

We're sitting in the very back of the ER in our little admissions cubbyhole, and the code goes off at 4 AM. We barrel out of our area to find the floor washers at work. "You need to go around" they say, and I'm looking at the hallway I need to get to - three steps and I can get to the stairs to run to the code. "I'm sorry, I need to go Now, and I need to get there." And I wade into what I thought was just a regular wet floor.

Evidently the floor cleaners use some pretty potent stuff. That turn floors into oil on a skating rink slippery mess.

Down I go. And I mean down - arms flailing, on my rear, soaked in floor goo. My upper level is behind me, clutching the rail with just one foot in the stuff.

After trying to get up twice more, one of the guys has to drag me out on my knees. Now that I'm absolutely covered in the stuff, we finally get to the code, only to find that another resident has things well in hand. So we trudge back to the ER to finish admitting, only now my shoes are coated in soap - foaming out the sides with each step.

The story gets funnier with retellings and the knowledge that the code went just fine, the patient got a pulse back, etc. My senior cracks up every time she tells it.

And of course, I walk into morning sign out with an illustration of the whole event with a "Kat, beware of wet floors!" warning.

I love my residency. And right now, I love motrin.

The curious case of Mr. Gibley.

2009-08-27T00:22:10Z

*Note: names and details changed.

Enter Mr. Gibney. A middle aged man with a rather unique diagnosis - neutropenia. His white blood cells were generally low, but he had absolutely no neutrophils, leaving him open to infection. Of course, the narcotics that showed up in his urine weren't helping the picture.

My fellow intern Wes rounded on the patient with the team every day, but since we put the patient under infection precautions, he never actually went in the room, as we needed to minimize exposures.

Two weeks later, enter Mr. Gibley. It's come around that I'm on night float, while Wes is covering a ward team and on call overnight. "Oh", I say. Mr. Gibley's back with neutropenia again. Oh, and he's positive for narcotics again.

Wes ultimately takes the patient, but we're confused - we can't find records from the previous hospitalization anywhere. Meanwhile, our senior resident who saw the patient in May, is talking about this right arm infection that I never saw during the last visit.

Weird.

We check for extra Medical Record Numbers, I look back in my old records to see if I had missed something. Ultimately Wes figures it out, with the help of his upper level who say him in July. There's two Mr. Gibleys.

Now, let's state this for the record. Two patients with the same last name, roughly the same age and ethnicity who are both neutropenic and have problems with narcotic abuse. Not that durg use is all that unique in our population, but Gibley is a reasonably uncommon name, and severe neutropenia is not an every-day diagnosis.

FInally, I just go in the room and sure enough, the Mr. Gibley in 307 is not the patient I took care of. None of us realized it because of the neutropenic precautions - only the resident treating the patient at the time actually laid eyes on them. So my night was definitely more surreal thanks to Misters Mitchell and Michael Gibley, and their dueling neutrophil counts.

How'd that happen?

2009-08-26T06:51:32Z

Well, there went another month. I blinked once and it all flew past.

Finished up Green team, a grueling haul to the finish with a huge census full of terminally ill, kind people. I gave the "Your loved one is dying, it's time to make them DNR/get hospice on board" talk about 8 times.

In 2 weeks.

Compassion fatigue is real. I would collapse on the couch at the end of the day, too drained to have a conversation besides "I'll make dinner in a bit." and tune into mindless television. I'd actively tell my sainted husband "I know that really sucks, but I'm just done." when the job search took a depressing turn. (Happily, that aspect is looking up. We looked at our finances and with some juggling and him bringing in part-time monies, we can get him through EMT school. Husband is excited, and I'm already buying him test books.)

Ultimately, my team got me through. A fellow intern who never fails to make fun of me (in return I mimic his thick-as-honey southern accent) and an upper level who is equally as adept at paracentesis as he is at Friday night Karaoke, and the kindest attending an fledgling intern could hope for.

And now, nights. Kids, if I could give you one piece of advice for those who are about to float 7P to 7A, blackout curtains would be it. Blackout curtains are crucial in being able to come home at 8 AM, fall into bed and sleep past noon. Ultimately, I've settled into an 8AM-2PM sleep along with a 1 to 2 hour nap in the afternoon before I head back at 7.

Husband has been very tolerant of my zombie status during the day, and doesn't mind an increase in lean cuisine microwave meals. (5 for 10 dollars on sale!)

I really like the work of night float though - I've gotten to know 1 radiology, 2 surgery and 1 pediatric resident very well as we all hang around the resident lounge at 2:30 AM and watch reruns of shows that normal people watch during primetime. I'm getting better and better at history and physicals every day, which is a skill that I'm glad to brush up on.

The best part is simple though. Once I dictate the three admissions I did tonight, I am absolutely sure there are no pending dictations. ESPECIALLY no discharge summaries. (The un-fun-ness of discharge summaries could get a post all of its own.)

But since it's late, I'll sum up with the following.
-Aim toward the gooshy spot for paracentesis. That's the potential space where fluid is pooling, instead of the tense belly above it.
-Neutropenia/Anemia are huge and interesting topics. If not for my inability to deal with kind people and their unfairly high rate of terrible cancers, heme/onc would be a good field. Possible cyclic neutropenia, aplastic anemia and pernicious anemia, all in one month. Bone marrow biopsies, ahoy!
-Neurologists are scary smart. I would cry if I ever had their job, but still - wow.

A sum of parts

2009-07-30T03:28:48Z

Back in medical school, we had the wonder that was streaming video of almost every single lecture. Professors who you could pause and rewind (for either bathroom breaks or incomprehensible concepts) were a fantastic resource, and something that I would often take advantage of. I could stay in my comfortable warm bedroom and avoid the nightmare that is Detroit traffic during a full-on Michigan winter.

But even though the whole strategy was beneficial to my grades, I found myself craving contact with my fellow medical students - a set of people who proved themselves to be excellent students and now wonderful young doctors. I needed to talk with the people who understood my frustration with memorizing cancer drugs and would laugh at our respiratory professors latest in-class antics.

And again, during residency I find myself relying on the bits of downtime in our resident lounge, providing running commentary on who has the longest census or what horrible pun our infectious disease attending inflicted on us at the last morning report. Intern year is such a strange and singular event to go through, it becomes a uniting event for all residents, as if you replaced hardcore learning instead of drinking while pledging a fraternity. (Though to be fair, some EtOH helps the Harrison's go down.)

A medical team, starting at the attending right on down to our brand new third year medical student (more on that later), is more than meets the eye. Yes, the interns do a bunch of legwork after the students take histories, and run back to their senior for questions and the team will finally go to the attending for final decisions on patient management.... but at each step there's a "How are you doing?" or "Do you need any help?" The team will always provide better care than a similar number of practitioners working solo - medical bugs are rarely shallow, but extra eyes always help.

I am so thrilled to be in the Memorial program, because we truly are "non-malignant", the watchword of so many scutwork reviews. I've heard of the things that happen when pressure to excel and gain access to high powered fellowships trumps that camaraderie between residents - and cringe to think about what it would be like to work in such an environment.

Our residents routinely pull together and help each other out - at current count, there's a pregnancy, a recent birth, and a wedding - every single one taken care of because we as a group are committed to helping each other. We do this not only because we could easily be the one needing a hand next time, but also because we like each other. My fellow residents are kind, funny and good at their jobs - people who I am proud to call my colleagues.

Don't ever underestimate the need to connect and spend time with your fellow residents and students - family and friends are your bedrock, of course, but there is a comfort that only the ones who walk beside you on that long and sometimes grueling road to becoming a physician can provide.

One of my favourite quotes is from Spider Robinson, as Callahan's law: "Shared Joy is increased, Shared Sorrow is lessened."

This is how 34 physicians can come from all over the map, with different destinations and ultimately become a residency, it's why we are more than a sum of our parts.

a light to you in dark places when all other lights go out.

2009-07-23T03:23:50Z

The patient sat quietly in the chaos of the ER, not paying any attention to the people who constantly bustled by their slot as "Treatment hall 3" .

He answered my questions honestly, even admitting that yes, he'd smoked marijuana lately because the cancer had taken his appetite as well as his strength. I told him I understood, but please could consider trying pot brownies and avoid the smoke exposure? My typical staunch opposition to pot and the people who abuse it tends to disappear when I see a white blood cell count that runs at 26K on a really good day.

He was actually relieved to find out he had a rib fracture, something to explain the horrible chest pain that wasn't a metastatic lesion or a heart attack.

My heart went out to him though, hearing about the endless rounds of doctors and tests that comes with any cancer diagnosis.... but my brain kept fixating on his not eating, especially seeing how thin he was. Not cachetic, but certainly heading in that direction without something being done.

I knew about Megace, and its obscene price tag (something on the order of 590 dollars for 2 doses)... but I also knew about their bare-bones insurance.

Knowing when to run for help, I asked one of my favourite attendings about what I could do to help them get this horrifically expensive drug on an admission that wasn't for weakness, fatigue or wasting.

And then came the magic words. "Why don't you just try cyproheptadine? That stuff is cheap as dirt!"

Turns out there's an "old timey" antihistamine that in addition to treating hay fever pretty well, makes patients ravenous as a side effect. 4 milligrams about an hour before meals does the trick.

The next time I walked into my patient's room, I saw a half-devoured lunch tray instead of the untouched food I'd seen every time before. The gratitude in his eyes was something I hope every doctor can experience some day.

"No more pot!" he crowed. "Thank God, I can eat. Thank you... thank you so much, you have no idea what this means to me."

This is a win today. This is a light I'll hold close when all other lights have gone out - when we can't get someone back, when the grandmother comes in with signs of elder abuse, when my patients scream at me for trying to help.

How to teach a student in 5 minutes.

2009-07-15T00:41:35Z

So the fantabulous Anna was doing research on how Wayne could better train fourth year students to teach. Because not only is she going into family practice in an underserved area, she wants to teach the next generation coming up.

Anyways, the Irby method is great and with it being July, I thought everyone could benefit in a low-stress, quick, high yield teaching method.

It's 5 questions, that you ask your student after they've gone to interview the patient and want to staff it with you. For best results, let them sit down, don't do it in front of anyone else and give them at least a minute to answer each question, with gentle prompting if they need it.

Question 1: What do you think is going on?
-Make the student commit to at least a loose diagnosis. This is not the point to pin them down on systolic or diastolic dysfunction. It's also ok for them to have two competing diagnoses, as long as they support it. Once they commit to a diagnosis, go through the rest of the questions - even if they're really wrong. They'll figure it out, and you can start over, but it provides a solid teaching moment for them - you can have a wrong diagnosis and have to go back to step one. (Like the patient we were SURE was having a CHF exacerbation and came back with an EF of 59%)

Question 2: Why do you think that?
This question gives you insight into how they got to the diagnosis, and gives you an opportunity to correct a wrong line of thinking. Unacceptable answers include "Because that's what the ER doctor said". Ask them to pull from physical exam, history and lab values separately.

Question 3: How would you like to work them up?
This is where they tell you what tests they want to order. Labs, Radiology, and all that jazz. For any outliers, ask why they want to order it, and work with them from there. The phrase "Anything else" is especially useful

Question 4: What do you think your labs are going to tell you?
Don't get too technical about specific values, it can be as simple as "elevated creatinine" or "an infiltrate on chest x-ray." But it will help them reflect on #3 and reinforce the point that we don't order things unless we think it's going to tell us something useful.

Question 5: What do you want to do about it?
As a student, the part I was always weakest on was treatment plans. It's a good time for them to learn common orders, common meds and dosage. Ask them specifically if the patient needs to be in observation, on the floor, in the unit. That way, they get an idea of what comes with admitting a patient.

Once they're all done, give them one specific teaching point. For pneumonia, talk about a CURB-65 score or Community vs. Hospital acquired antibiotics. For heart failure, talk about why they need to be on an ACE. Don't try to overwhelm them about the whole epidemiology/pathology/diagnosis/treatment - just end it with one salient, practical point.

I really, really like this method for two reasons. One, it's because I don't need to rattle off a big prepared talk about a specific disease - it draws on the strengths that any resident should have already. Two, it's quick. and Three - it makes the student be proactive when thinking about a patient, because so much of rounds as a student is listening to residents and attendings debate diagnosis and treatment plans without being able to suggest something to try or think about.

247 reasons for not posting.

2009-07-15T00:07:16Z

That would the number of hours I've worked since June 22. As an intern, I'm not surprised I'm hitting the 80 hour mark every single week, but wow. Tired.

I had something like 5 Twitter updates in a row that all started with "I am so bloody tired" or some variation thereof.

I have so many things to talk about and precious little time to do so properly.

I got through my first call, even though I was scared stiff - first day on the wards, first intern to be on overnight. Since then, I have learned how to admit a patient in 30 minutes or less, how to properly cross cover 25 patients from bed, and that dictations - when not done ASAP somehow breed and create a crop of baby dictations.

I learned how to teach, a bit. I hope I did well by our med student, which ultimately means teach them what's going to be useful for them at that point without being a pushover or a slave driver. Hopefully he learned ABG's - because the only thing I learned from that conversation is that 8 AM on a post-call weekend morning is NOT the time to teach.

The exhaustion, the constant feeling you're on a treadmill that can't slow down, the worry and stress have been worth it. It doesn't seem like I would be able to learn this quick, but in the last month the white coat and the "I'm Dr. Zechar, I'm going to be your doctor" feel less strange.

It helps that it's stuff I love. Pancreatitis, Diabetic Ketoacidosis, Heart Failure, COPD... I know it doesn't seem as sexy as the major trauma the surgeons see or the baby my fledgling ob-gyn colleagues have caught, but we keep people alive and that's what counts.

...Except for the times we don't. I had two deaths on the service, and one person still critically ill in the unit. With each death, I've questioned what could have been done to have a different outcome, and it keeps coming back to stuff I couldn't have stopped - you can't undo 100+ pack year smoking history or 150 tylenols in a night.

What I can do is get right back on the horse and take the next hepatitis patient who walks through the door.

The goal right here is to stay afloat, but I know in the back of my mind that this is the time to push myself harder than ever before. Because each patient that dies with AST/ALT over 15K or a CO2 over 100 means that the liver patient or COPD-er I treat out on my own after residency has a better chance to survive.

I meant to post, I really did.

2009-06-29T02:26:22Z

This is what 80 hours looks like. And I'm running with a relatively light load! To learn this week: time management.

Thoughts from my first call:
have been a doctor for real for 6 hours and nobody has died yet, including me. Probably b/c my team is awesome.
12:16 PM
They really are. The attending is efficient, open to resident suggestions for treatments, and teaches. My upper has yet to get even mildly upset at us interns for the stupid things we do, and helps keep us on task. My fellow intern is a superstar, and fun to hang out with. The student is completely on top of his patients, and really puts in the effort.

Hour 12 and people are still alive. For the record: testing the code blue system on the interns first day is MEAN.
5:40 PM
TWICE.

Cross coverage is like doing a word-search, except you get interrupted to do a Sudoku puzzle, while simultaneously trying to do a crossword.
10:41 PM
The individual tasks aren't difficult or complicated (Potassium is 3.3? Give 20 mEq PO) but do require some amount of attention to detail, so when you are constantly interrupted, things get hairy.

Law in the hospital: the Very Second your head hits the pillow on overnight call, the pager goes off. I mean, immediately. Like murphy.
12:57 AM

Walked in at 6:45 AM on Monday, walked out at 12:45 PM today. Up 4 patients, down some sleep and very happy to have my 1st call over.
4:22 PM Jun 23rd
Current post-call strategy: fall face first on couch and don't move for ~2 hours, then get up and be a person again.

So far, call has been ok. I am slowly learning the art of cross-cover. So far, there seem to be a few rules to go by.
1. No controlled substances without going to see the patient.
1.5. If you get more than one call on a patient (that doesn't deal with poo), go see them.
2. The phrase, "Do (X), check (Y) and call me with the results, please" is magical. Because I can't guarantee I'm going to check on Y in 45 minutes on my own.
3. Take good notes at sign-out, and keep them next to the phone. The hospital is wireless enabled and computer based, but at 3 AM I want paper. Paper is simple and gives immediate information.
4. Sleeping for even half an hour is better than not sleeping at all.
5. The 10 minutes you in the AM spend brushing hair & teeth, putting on deodorant, etc will keep you going until 1PM.
6. DRIVE SAFELY.

And finally: The coffee maker in the resident lounge has a vendetta against me. It broke (at my hand) on my first day, and now mixed up a nice cup of warm steamed milk when I pushed the cappucino button.

Warm milk at 6 AM after call is the opposite of helpful.

Upcoming topics:
Our very awesome med student and the things I try to teach him.
My first patient death. Yes, in the first week. It's not the typical story, though.

Also, naps PRN.

2009-06-21T04:32:06Z

Hope all the Dads out there have a great father's day.

HIPPA disclaimer: all golf and cookie levels were fabricated. Any resemblance of the patient in the video to my own father is completely on purpose - but it's ok, he's my Dad. :)

Residency, Day -7

2009-06-17T00:37:34Z

And so it starts, as it always does.

Orientation. Find the room, nibble on the continental breakfast, size up your fellow classmates-now-coworkers, introduce yourself with your name/school/interesting quirk, and then sit and try to absorb half the information they throw at you.

I definitely absorbed one piece of information: my schedule.

My first month? Wards.

My first overnight call? My first day.

Yes, like on Scrubs.

I'm actually feeling pretty good about it. I met the other resident and my senior, and both appear to be friendly, upbeat and very level-headed. So I might as well jump in with both feet - besides, if you get through the scariest part of being a resident on your first day, then things can only get better from there.

The only other surprise today is that my program has been forced to start a hybrid night float schedule - another service decided that they simply weren't taking call anymore and instead of making us Q4 overnight, we're Q8 overnight with a call until 7 PM in between. I still dislike the night float model, but I firmly believe that Memorial is going to Make This Work. Their handoff system is beautiful, and it sounds like everyone is supporting it, right down to the ER holding all admissions from 6:15-7 (both AM and PM) so the teams have protected time to sign out.

This I believe

2009-06-16T03:16:04Z

Concept taken from the Edward R. Murrow and continuing NPR series, "This I believe" - a series in which everyday people talk about one thing that they believe in.

I believe in daring. Not daring as in double-doody-dog dare, where one is forced into action by another but in taking actions that make people who don't quite understand take notice and say "How dare you!"

Daring to be and do outside of the norm is a genetic for me. Our family motto "Audentes Fortuna Juvat" assures all descendants of the Clan McKinnon that fortune will assist them when in need if they simply dare to take action. This action began with a rural Scot defending himself against a wild boar by shoving an already feasted upon bone vertically into the swine's mouth, and continued through my maternal lineage. My grandmother, who has never failed to speak her mind in her 80 years upon this Earth even when society told her it did not befit her gender. My mother, who dared to go back to school after practicing as a nurse for nearly 30 years so she could climb the hospital ladder, and now gives marching orders doctors who used to throw charts at her.

Having been steeped in audacity, I now dare to speak up about our broken healthcare system. I dare to maintain a visible and critical presence in the medical blogosphere and refuse to pretend I don't see patients suffering because they don't have the money or power to advocate for their interests that pharmaceutical and insurance companies use so freely.

I dare to practice primary care medicine, even though I know the hours are longer, the paychecks are smaller and the battle will always be uphill.

So I say to everyone who is struggling against something bigger, stronger or more entrenched to be daring; be slightly reckless, make the kind of noise people don't want to hear, and don't give in to complacency. You may find that fortune smiles upon you as well.

In sum.

2009-06-07T02:59:04Z

I made it through. I am a Doctor.

It still doesn't feel "real", and I'm sure it won't until I have my first terror-filled day on the wards, but knowing that our current address in Savannah is helping to make things more concrete.

I could say so many things about the journey, about the ups (honoring my first (and only!) exam, the first time an attending told me I'd make a good doctor, going to my Savannah interview and *knowing* I wanted to work for them) or the downs (failing an exam, my first patient dying, going to my 5th interview in a week and falling asleep) but I can say that every second was worth it.

It's worth the money, time, and tears to spend the rest of my life doing a job that I've dreamed of for about 20 years now. The bad times taught me the things I need to know about being a doctor - the importance of being patient, thorough and kind. The good times got me through the bad times.

Of course, I'm not done. Not by a long shot. I look around and see so many examples to live up to - my training truly begins now.

I started this whole blog with "I'm just a bit nervous", and I've come back around to that. Excited, of course - but still dealing with the knowledge that it's my signature on the line now.

I hope to once again return to prolific blogging. This journal has been such a joy - not only to record my thoughts along the way, but also the people I have met through it. The end of 4th year was a bit of time off - taking care of some important real-life issues - getting married to my wonderful and supportive husband, honeymooning, graduating and then immediately packing up & moving 945 miles.

(And yes, the above was crazy. Also fantastic.)

I'll leave you with a photo from the wedding, care of our awesome photobooth. The lovely people in the background are my parents, who have also shown themselves to be wonderful and supportive on occasion. :)

For the record

2009-05-14T02:15:54Z

Getting married/moving 944 miles away (Mom, stop crying)/Graduating from med school/Starting residency?

Plays merry hell with any kind of regular blogging schedule.

As a mea culpa once again, here's the talk I did at Penguicon - How to Kill a Character 2.0, No bullets or pointy bits.

Topics I would have loved to cover and forgot:
Infections (flesh-eating bacteria and the plague)
Compartment syndrome (I don't think I covered it last year, and it's always good for an EWW.)
Seizures (not all seizures thrash around on the ground, and status epilepticus is v. scary)

As you can see, I pick topics on a basis of how common they are, how interesting they are...but mostly if I can get my audience to say "Oh my."

Once again, it was standing room only. :) Penguicon next year is April 30th through May 2nd, in Troy Michigan - you should come!

I hate to think what might have been...

2009-05-01T06:14:39Z

If I had tried to manage a cardiology consult/ICU month this last month instead of Radiology.

Life lesson: If there is ever a month to take a rotation that focuses on "self motivated learning", make it April of your 4th year. Weddings, bridal showers, trip to Georgia to find an apartment, trying to sign a lease from Michigan, residency paperwork, finding furniture and a dishwasher for the new apartment, my own wedding...this whole month has been a series of "Let me get through X, then I'll work on Y!"

Y right now being the finishing touches on a presentation for Penguicon 2009 "How to kill a character 2.0: No bullets or pointy bits." Y'all should come.

There's also something reasonably exciting that just went down today, but let me get through Frostbite and Full-body radiation first. :)

Instead, a fun exercise: describe your chosen field of medicine in 6 words or less.

Mine (internal medicine): "Take insulin or lose your foot" or "Yes, 220 over 140 is high."
legeix How's this: "I'm going to cut you open." or "Just turn your head and cough." or "This wont hurt me a bit." I like this game! (Oh, surgeons...)

spartanmd "Recieved in formalin is a tan . . ." or " The decident appears to be a . . ." (Pathology has a definite form to their notes...)

Hazelrah@twitter Mine is: What did the diarrhea look like? (my sister-in-law-to-be, the Vet student.... we are REALLY good at playing the gross out game during family dinners)

turnberryknkn "Today, your child's blast count: zero." Jeff cheats with colons. But he's got peds heme-onc fellowship results waiting to come out, so we'll cut him some slack. :)

exxorcyst "Say peace out to your gallbladder." (Again, with the surgeons. If they weren't such great guys, I'd worry.)

"Thoughts of hurting yourself or others?" and "So tell me about your mother...." a pair of Wayne alum psychiatrists, my first med school mentor and the other newly minted.

Allergic to all meds except Dilaudid??? or He wants a sandwich? D/C home... (One of my favourite new ER docs. She also believes in the Sandwich Sign)

"Yes you must brush AND floss" My cousin, the Dentist. Ask her why you need actual tooth left to have a crown put on.

"You put WHAT in WHICH orifice?" My brother-in-law-to-be, in nursing school and just assigned to his clinicals. Godspeed man, Godspeed.

Rat A differs from Rat B. Karen's that kind of Dr. that sounds more like "Fudd" than "Mudd".

"So...is it like physical therapy?" The battle cry of PM&R. Lucky guy gets to practice out in Colorado, too.

fuzzyfoxtess I'm the jack of all trades. She's not kidding, folks. Looking to do underserved/rural family med, even.

"Seriously, you all have Aspberger's Syndrome." Or does computer programming not count as a medical profession? (The source works for an unnamed large computing conglomerate that has an operating system named after a paned glass housing feature. I have no doubt that some of their colleagues have "difficulty engaging socially with their peers")

inked_caduceus @ 2009-04-23T00:27:00

2009-04-23T04:24:04Z

PS. Still love NPH.

Day In The Life 2009

2009-04-17T04:18:01Z

The last one of medical school! We'll see if I can manage one as an intern. :)

If it's in my ER case logbook, it's gonna happen. For this month, that pink cardstock spent more time nestled up against my backside than my favourite warm fuzzy blanket.

The day starts at 8 AM, which wouldn't normally be an issue but night shift plays all sorts of merry hell with my circadian rythymn. I try to go with "awake" for the 9-6 shift.

And since I'm headed for the ER, I suit up in the best reason to set foot in an ER or OR: scrubs. They're pyjamas that you can wear to work & are dispensed from a giant vending machine!

Email and breakfast of champions. I require choice in the mornings.

Inexplicably, my cat wants to be let out in the cold. I tell him to stuff it and instead sniff the pretty pretty flowers my parents got me for match day.

The urge to go back to bed is strong. It looks so warm and comfy and...
NO! BE STRONG AGAINST THE SIREN CALL!

Instead of bed, I content myself with new makeup. Everyday minerals was recommended by a kick-ass friend of mine, and the makeup has proved itself to be of equal caliber. (Better than bare minerals and half the price!)

Off to work. The commute is short for this rotation, which is why I can get away with an 8 AM alarm for a 9 AM shift.

As you can see, it's been a busy month.

And it looks like it's going to be a busy day...

However, once I make it through to the peds unit, I find the overflow bay blessedly empty. Perhaps it won't be too crazy after all.

And so I am vindicated with a rack of colour-coded and empty charts! 9-10 AM proves to be a magical lull where nobody brings their kids to ER - it's after the cutoff of "kid's sick, we should take them before work".

I take this opportunity to chug c-boost hippie juice in the vain hope of fending off the crud that had been advancing (crud won, but only for about a day). Then I get to talk to a mom about a kid and their rash. Turned out to be Coxsackie virus and they all got sent home with some motrin. And a sticker. (Note the ease of ER history taking. I was really, really good at ticky boxes by the end of this)

A few more cases brings us to lunch time and afternoon lectures, accompanied by the ever-present drug lunch. (They were shilling for a new and "improved" alternative to mucomyst for tylenol overdoses. Who knew that they'd try to target the ER crowd?)

I scoot out of lecture a bit early - I'm due downtown at the school and there's paperwork to be turned in! Hurley greets me (and his chew toy) warmly. Nick updates me on plans for the weekend while fending off the ferocious beast.

PS. THIS is evidence of the damage a Kai Ken can do to a freshly vacuumed carpet over 24 hours in full shed. It's called "blowing their coat" for a reason.

The other reason for stopping off at home: fresh caffeine infusion. I swing by the ER department ladies and finally get my EMT ride-along scheduled. Sunday night, 7P-7A. Fun!

Re: 6D - I really, really wanted to stop in and ask if they had Schoo-Be branded snacks. Instead I resign myself to being a grownup and follow up on a lead we got for housing down in Savannah, scrawled on practice questions for the upcoming ER exam. Spoiler alert: we got the place, and I passed the exam. Including the HI-LARIOUS, but sadly protected clinical exam.

I do a quick check on how the makeup is holding up. Need to look presentable, because now we as fourth years are up on the podium giving advice at a panel. I am wizened. Mostly, I spout off about how you don't need to go to a hardcore academic residency program to be happy, especially in internal medicine. Jenn holds forth on the myriad joys of cutting open bowel.

Gorgeous sunset on the way home, and I find my dearest has left the porch light on for me. (It's the little things, really).

However, my respite at home is short-lived. Nick and I head back out to pick up a wedding gift for the upcoming nuptials in Kalamazoo, with a detour via Tim Hortons. I am blissfully happy for chicken soup while Nick supports his new Georgia football team.

Bed, Bath and Beyond gets major points for ease-of-registry use. In no time, I have my manly man carting a fancy cake dome around the store.

They do a nice wrap-job for free too. I decide that it's far too pedestrian for the impending couple and spruce it up with some stickers. Note: I am so braindead at this point, Nick reports that I would say "Fish" each time I put down a sticker while decorating. This is sufficient indication that I should retire to the couch and watch an episode of the Shield before crawling into bed.

And yet again..

2009-04-14T18:50:44Z

It's been brought to my attention that my blog has been horribly neglected for the last month. While there are good reasons (post-match celebration, 2 weddings, a bridal shower, a week of nights at the ER, an EMT ride-along, a written final exam, wedding cakes, wedding dresses, a trip to Georgia for a week of apartment searching, signing on an apartment, moving logistics, finding a suitable dishwasher for said apartment, prepping for my sequel to my talk "How to Kill a character"....and somewhere in there - sleep.), watch this space as I do have posts lined up and ready to go.

A preview of coming attractions:
My final Day In The Life (one a year for four years - how life has changed from the first!)
The worst head CT I've ever seen, and what we did for the patient
Riding along at 60mph on Detroit surface streets - bouncy AND educational.
The 4th year dilemma - take a breather or a last-chance opportunity before you're a real Doctor?
A retrospective for the "must take" electives.
The books I'm keeping, those already tossed, and those I'm buying for next year.

The verdict...

2009-03-19T19:13:11Z

Starting this July 1st, I will be an internal medicine resident at Memorial Health in Savannah, Georgia

From Match Day

Getting a big hug from my Mom after letters were opened.

From Match Day

Live twitter coverage, provided by both me and spartanmd

From Match Day

I have the envelope, but have to wait for everyone to open it together.

From Match Day

Jen, Myself, Autumn and Katie show off our envelopes. Contents: Surgery in Detroit, Medicine in Georgia, Ob-gyn in Hawaii, and Medicine in Troy, MI.

From Match Day

The moment of truth. :)

It was my first choice, and Nick and I are very much looking forward to moving down after the wedding. Even though I'm going to melt in my first down-south summer!

And to you dear readers, thank you - thank you so much for your support over these four years. Livejournal has given me some of my biggest cheerleaders, mentors who helped guide me through the occasionally bewildering process of med school & friends who held me to promises I made to work hard and not give up... it means so much to me to know that I had a few hundred of you pulling for me to get where I am today. Thank you again, to every single one of you, and yes - I will still try to blog during residency! (We'll see how that goes!)

1/2 down, 1/2 to go...

2009-03-19T03:33:20Z

The promised ER tweets. They're in backwards chronological order this time, so scroll up from the bottom!

This is also a reminder to watch http://twitter.com/inked_caduceus tomorrow for up-to-the-minute coverage of match day, 2009!

Tried to keep a poker face as my attending pulled out tobacco chew. Effect ruined by eyeballs falling out of head & rolling across floor. 10:42 PM Mar 13th from web
...I still have no words for this. Spit cup and everything - if anyone should know better!

Said in a voice more calm than I could have managed last year: "Doctor, could you come in here? My patient's heart rate is 170."1:58 PM Mar 12th from web
Relatively healthy young person, went into a supraventricular tacycardia due to a re-entry rythymn. They had no clue, and I wouldn't have either if I wasn't watching her monitor and then listening to her heart right after. The ensuing cardiac workup ruled it due to low magnesium. Happily, 6 of adenosine fixed them right back up - textbook stable narrow complex tachy.

Me: I can't let you eat because then we can't give you sedation to reduce your hip. (pt eats). Me: I vote to reduce w/out the meds! 6:38 PM Mar 11th from twitterrific
I was so, so angry at this guy. Stupid doesn't even begin to cover it. Ended up getting a 23 hour admit so we could wait the 6-8 hours and put him down for conscious sedation.

If one is ever so foolish to say "It's 8 & I haven't had a finger in an orifice yet" they WILL have to do a rectal on a 400lb patient at 9 9:36 PM Mar 10th from web
It was... an ordeal. And I brought it all on myself.

Sickle pain crisis is ugly. Treat with IV fluids, Oxygen and the question "How much IV dilaudid (10x morphine) do you usually get?" 6:57 PM Mar 10th from web
The patient in question ended up with about 4mg of dilaudid every 2-3 hours. For reference, half that dose could kill the rest of us.

Nasal packing. Our fancy kind are basically flat tampons: use lights at home for nosebleeds. Bonus: we soak ours in lidocaine + epi. 4:41 PM Mar 10th from web
Seriously, if you're at home - use tampons. The lidocaine and epi really do help - and if you think it's going to be really bad, you can shove some cotton balls (on clamps, of course) up there first to numb them a bit first. Because nasal packing is not comfortable.

Is wary about her first ER shift scheduled a) under a full moon and 2) at night. I already had a little old lady swearing at me yesterday. 1:02 PM Mar 10th from web
Real charmer. Decided they didn't like their roomate at the adult foster home, so spouted off "I'm going to kill them" in hopes of getting a private room on our inpatient floor.

Me: Do you drink, sir? Pt: Not really. EMT (making drinky-drinky gesture) Me: How much did you drink today? Pt: About a pint. Of vodka. 6:17 PM Mar 9th from web
I really like our EMTs - and am continually amazed by the amount of EtOH in a person's system. The legal limit is .08 - to join the ethanol 500, you need a .5, but to win it you have to walk in with that number.

Must. Stay. Vertical. This will require caffeine. Thank god for hospital coffee - it'll strip paint, but the stuff works. 7:41 AM Mar 7th from web
It requires two sugars and a creamer, though.

What are the odds of two angioedema cases (one ACE, one ARB) coming in within 5 minutes of each other? New definition of "difficult airway". 9:00 AM Mar 6th from web
Man, swelling around the airway is Scary. The worse case of the two was a bad anatomical setup to begin with (short, fat neck). The guy came in sounding like Andre the Giant, the muffled speech which is what the medical community calls "hot potato voice". Even the anaesthesia guy who came down breathed a huge sigh of relief when get got the tube down (with assistance of fiber-optic)

New game: most unlikely symptoms to generate a "they're faking" diagnosis. ie, fixed&dilated pupil or st segment elevation. 1:54 PM Mar 5th from twitterrific
Most likely symptom to be faked? Abdominal pain. Far and away the diagnosis most likely to get sent home.

Advanced resus model who has blinking eyes that react to light - cool & very useful (is that wide or narrow tachycardia?) but also creepy. 11:00 AM Mar 5th from web
It also has palpable pulses, a blood pressure, heart & breath sounds and generates its own rythymns. We've been running codes on it for the last two weeks, and I'm thankful to have the refresher before I go out and try to be a Real Doctor.

Waitress, when scrub-wearing me grumbled about night shift. "You're too young to be a nurse, what do you do?"8:01 PM Mar 4th from web
I just laugh about it at this point...

Dr, I did vigorous irrigation of the head wound like you asked, and it's bleeding-vigorously. "oh, him? I'm sending him for CT now instead." 12:42 PM Mar 4th from twitterrific
ER doctors are not known for their attention span.

Meticulous repair of a deep laceration means that my pig's foot will be unscarred and functional, should it ever be reattached to said pig. 10:44 AM Mar 4th from twitterrific
Oh, where would we be without cheap & legal intact body parts with almost quite nearly analagous skin to a humans?

The department is q-word. Eerily q-word. (if you actually say the word, the nurses will hurt you)
6:44 AM Mar 4th from twitterrific
It stayed Q-word too - I like the 6A-2P shift, if not for the 6A part.

Trying hybrid sleep schedule for ER month, phasing out nightime sleeping for longer daytime naps as I go day->night shifts. Naptime=now! 3:11 PM Mar 3rd from web
It worked just fine for the 2-10 shift, but switching to the 10P-6A shift still left me fuzzy for about a day.

Very happy that my combative demented pt decided to like me, given the trauma shears within easy reach. 12:15 PM Mar 3rd from twitterrific
So far all my really crazy patients have been female. This one tried to stab their son before coming to the ER.

@inked_caduceus Unless there are kids in the car. :( Also, wear your damn seatbelt.
8:54 AM Mar 3rd from twitterrific in reply to inked_caduceus
PLEASE PLEASE WEAR YOUR SEATBELT. So many deaths could have been avoided this month already. Unfortunately, this was an especially tragic case as it was a family of 4 who were t-boned by two stupid kids in a stolen car.

On medical codes, not trauma. Down one urethral swab before the sun rose. Drive however you want, just wear condoms. 8:07 AM Mar 3rd from twitterrific
Asking a woman in the ER if "there is any chance you could be pregnant" is the IT equivalent of asking "Is the computer plugged in?"

FUCK IT IS EARLY. Everyone in the St. Clair shores area: drive safe, don't take drugs (except insulin-take that) and no shooting people.
So far no shootings, a few out-of-control diabetics (ewww feet) and several accidents.

The match, defined.

2009-03-18T06:51:37Z

So it's half way through match week, and I find myself with a relative lack of ER shifts. And while Felicia Day's (the redhead from Dr. Horrible) blog and independent project The Guild was all I could brain while I switched to night-shift circadian rythymns, I'm finally mostly on track.

And so, the match. The short version I give to aquaintances is that "I interviewed at a bunch of programs and made a list of which ones I liked the best. But at the same time, they rank all their applicants, everything gets put into an enormous computer & spit out on March 19th"

Here's the slightly more detailed version.

Much like the application process for any school or professional position, you comb through everything you've done for the past 5-20 years and compile it into a CV, personal statement, etc. Then you have a few people write you very complimentary letters and send it all off in hopes that programs will invite you out for an interview, usually with dinner the night before.

Of course, everything you do and say during both of these is scrutinized to determine if you'll be a good fit. (But you shouldn't be so harsh on the programs, because the applicants are doing the exact same thing.)

The end result is a list on both sides. They start with either the program or applicant that would be the number one ideal, and ends with the option that will be acceptable.

So once the computer chugs through all the data, two separate notices are sent: the first to applicants, letting them know if they matched or didn't match. There's a 24 hour lag, and the programs find out if they filled all their available slots. (I have NO IDEA why there's a 24 hour difference, especially given that all the information is available at the time).

Once the programs and applicants are both notified, the scramble starts. At that point, all the organization previously seen in this agenda goes out the window. The contact information for the unfilled programs is released and applicants basically stampede to get to any open spot left in the area & specialty they want. Generally, it works out - it's ugly, but people get a spot they can work with, and programs fill up. The scramble is allotted two days (Tuesday afternoon and wednesday) and once all is said and done, everyone else gets their notification for where they're going.

And just think... if I want to do a fellowship, I get to do this all over again!

I matched!

2009-03-16T16:33:42Z

And so did quite a bit of the Twitter population. :) (All taken from a search of "matched" on twitter.com)

MATCHED!!!!! :-D
well i matched. at least not everything went wrong. now i have to wait till thurs to find out WHERE i matched.
MATCHED! find out where on thursday :)
Emily matched! The medschool system is screwed tho, so have to wait till Thurs to find out where we're going to live, come June .
I matched! I'm going to be a surgeon!
I matched! Now Thurs needs to hurry up and get here so I know where!
Well I matched, stage one down
So incredibly relieved to have couples matched successfully!
So happy right now! I have officially matched!! Now I just have to wait 3 more days to find out where.
Matched in dermatology...somewhere
I matched. Huzzah!
Word has come out and it official, I have matched! So at least now I know that I am employed next yet and will be studying emergency med!
I matched (somewhere)!
matched as well. congrats
MATCHED!
Congratulations to my gf Genny who found out she matched today. Hopefully it UofL!!
I MATCHED...now i just have to wait 3 days to find out where
Match status in! I matched! The prize: wait another 3 days to find out where.
Yay! I get an envelope on Thursday. I matched!
I matched :-) ill find out where on thursday
I matched! 3 more days to know where I'll spend the next 4 years!
Hakunamatata! Kat got an email explicitly stating that she matched. No more anxiety! Except for the WHERE question.
I matched! Just 72 hours until I find out where!
Well, it's official - I matched! Now I just need to wait until Thursday's ceremony to find out where.
Oh, thank God. Matched. And wal-mart was definitely not on my rank-order list, so there goes that recurring dream. Thursday, get here!
I MATCHED! ! !
I matched!!!! :-)
So I matched somewhere... (thanks NRMP for drawing this out as much as possible).
Holy Fuck.... I matched!!!!
i have matched
I MATCHED.

All of the above posted in the space of 35 minutes. Admittedly the Jon Stewart vs. Jim Cramer got more coverage, but not nearly so enthusiastic.

PS. I have another post coming up of my Day-shift ER tweets. It's indicative of the ER lifestyle that I can only manage to blog 140 characters at a time. Most of them are incredulous.

Congrats to everyone who matched, and thank you very much to all those who helped me through my very silly anxiety over the whole thing.

Survey on Priorities in Medical Education: Diversity, Career Aspirations, and Indebtedness

2009-03-05T05:29:47Z

And no, it didn't affect my choice in specialty.

11 days until I get the you matched/you didn't match notification.

In recognition of this occasion, I refuse to eat scrambled eggs from now until the 16th.

Clinic, 15 minutes and 140 characters at a time.

2009-03-04T02:54:01Z

Had a long & serious talk re: putting a 13 yo kid on a statin (for high cholesterol) today. Bonus: Kid knew more about nutrition than mom. 9:26 PM Feb 24th
This was the last theme of pediatrics: Kids are not little adults, so what do we do when they get adult diseases? Diabetes (Type II) and High Cholesterol were sadly all-too-common.

FYI "chest pain" and "extreme fatigue" are NOT best classified in the "10 minute visit" slot. Especially when they are at 4:40 & 4:50 PM. 8:12 PM Feb 23rd
Thankfully, I had a doc who was able to walk that fine line between "Stuff that really needs to be dealt with today" and "Stuff than can wait for a 2 week follow-up visit."

My clinic took Nick and I out for dinner. And I got a bag of pharmaceutical rep goodies. YAY trauma shears - but WTF is "enablex"? 8:08 PM Feb 23rd
The office ladies really were lovely. It was strange to be in an office and see reps only bearing samples, though. Pharm swag is a thing of the past, and we'll all be better off for it. Even if I lost my nice paid-for pen in the space of 2 hours today.

Over-the-counter meds exist because they work & don't require a doc. So please TRY SOME before you come to clinic and whine about a cough. 11:15 PM Feb 20th
Tylenol, Motrin, Sudafed, Robitussin, Mucinex, and NyQuil/DayQuil. It's not rocket science, but if you want to get fancy, try some hot tea and extra sleep.

Smart-alec almost two year olds cure the baby rabies. She wanted me to go home so mom (Melissa) could read to her. "Bye bye!" (repeatedly). 8:17 PM Feb 17th
Two year olds are the example of that "too much personality" end of the spectrum I mentioned earlier. They're also able to make noises I have only before heard from howler monkeys at the zoo.

Dr: How's that earwax buildup we treated last time? Patient: Sorry, what'd you say? 12:52 PM Feb 12th
Ba-dum-TSSHHHH. But seriously, folks. Cerumen impaction happens. We have little plastic scoopers and a HUGE syringe for irrigation.

And other med students think House is real. See term "questionable admission". 2:46 PM Feb 10th
This and the previous entry were provoked by me being cranky during lecture. Not entirely unwarranted, the kid's response to "Is my mother dying, please tell me what's going on!" in a roleplay scenario was "Are you her durable power of attourney?"

Learning that some of my fellow students should not be allowed to talk with patients. You can lead him to medicine, but he's still an ass. 2:38 PM Feb 10th

My patient today requested the bubbblegum flavoured Ear Drops today. The kind that go in your ear. Pink makes everything better. 10:15 PM Feb 9th
I actually got pretty good at ear exams (even on screaming targets) by the end of the month. "It's just a special flashlight!"

Full migraine turn-around in less than 4 hours. Sumatriptans are a godsend. 3:54 PM Feb 8th
Doctor, heal thyself.

Mom in clinic: She's not eating enough formula! Ma'am, your 4 month old is the size of a small 9 month old. Any more & she'd eat Tokyo. 5:54 PM Feb 6th from web
Theme #2 of Pediatrics: Too big, too small, and how much food is required to make them grow. The answer: There's a pretty wide range of normal, so stop worrying so much.

@aiela Grab some of those Shower Soother things, and then if you can get over the gross, blow your nose while in the shower. Miracle! 2:19 PM Feb 5th
More than anything, clearing sinus/nasal congestion in a timely fashion (before it turns into chest congestion, etc) is the hallmark for treating much of the winter nasty

TEXTBOOK cases of benign positional vertigo (maneuvers worked!) and Fifth's disease (it DOES look like slapped cheeks!) today. 11:29 PM Feb 4th
BPV is much, much more common than I had realized. Quite a few were provoked by sufficiently nasty head colds

Baby rabies is transmitted through chubby 6 month olds who drool and grin at you while not crying. I narrowly avoided infection today. 6:07 PM Feb 4th
4 monthers are pretty cute too - it's that golden age where they have some personality, but not too much. :)

Toddler during clinic: "I go chuck e cheese if I poo poo!" Evidently Mom has resorted to bribery during toilet training. 9:52 PM Feb 3rd
Theme #1 of pediatrics: Poop, and the frequency/consistency/placement thereof.

Lecture titles for the ambulatory rotation: bad news, pain, and suffering. It's going to be a fun month.
1:34 PM Feb 3rd
The lectures turned out pretty great - learning about pain medicine from someone who is no stranger to dispensing 200 mg of morphine a day. Palliative care is an under-appreciated specialty.