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Dear Gateway Customer Service,

On July 14, 2008 you received my Gateway FX 7026 serial #CSX84K1002958 at your service facility. Thank you for promptly responding to my problem of the misaligned USB ports and for quickly sending me a box with a prepaid shipping label. Since that time I have had several conversations with your friendly support staff who tell me that my computer was mistakenly shipped to Never-Never-Land. Normally, this would not be a problem but, as I understand it, the Never-Never-Land facility is now closed. I understand that strikes by the recently unionized Darling children were unexpected and largely beyond your control and that Peter Pan's contract was up (I hope he is enjoying retirement at his Malibu beach house). Captain Hook, I am not surprised to hear, continues to turn in substandard work and so I thank you for rerouting my computer to your other repair facility in Texas where it was received on July 21. But now, I need it back.

I understand that you are very busy with the large influx of computers coming in from the Never-Never-Land facility so, while I am on hold with customer service, I am writing this post using my Compaq Presario which I bought in 2001. This thing has 128 MB of RAM and there has never been any space on the hard drive in recent memory. I can't take it anymore. I can live without USB ports but, if I have to wait 5 minutes for another web page to load, I may have to shoot myself. Therefore, I propose the following.

Please send me proof that my FX 7026 is unharmed. A photo of my computer holding a newspaper with today's date will suffice. Upon receipt of said photo, I accept whatever you demand in exchange for 7026. And, please hurry. You have my contact information. My service request number is 1-3OYUV6. As my letters have gone unanswered and as I continue to hold for "the next available representative" I can only hope that you happen upon this post so that I may have his matter promptly resolved.

Sincerely yours,
James Logan, M.D.

The patient had already been intubated when I saw her in the ER, so I wasn't able to get much history. The story was basically - asthma exaccerbation, can't breathe, intubated.
We extubated her this morning. Great! My opportunity to find out her story and get a better handle on this patient.

"So, tell me, what were you doing before you came into the hospital?"
"I was at my boyfriend's house. We were watching a movie about this guy, who takes out your eyeballs and eats them!"
"Oh, wow. Ok. Then what happened?"
"Then, it turned out that he was really an alien from outerspace. But he was just disguised as a human. And he wasn't really eating the eyeballs, but just collecting them for experiments!"
"I see. But what was it that brought you to the hospital?"
"An ambulance."
"And the ambulance came because..?"
"Oh, my boyfriend knew something was wrong, so he called 911."

This is a theme I've been meaning to bring up on this blog for a long time but haven't gotten around to it until now: is there anyone else out there but me who feels that there is something drastically wrong with the way medicine is taught on the floors? Don't get me wrong, some attendings are fantastic. But there are some who continue to rigidly adhere to the attitude that they are somehow teaching us by not giving us the answer.

"Dr. Pulous, how many days of treatment would you give for a patient with this type of pneumonia?"
"Why don't you look it up and tell me?"

"Dr. Song, in what situations do you give bicarb to an acidotic patient?"
"That's a great question. What do you think?"

Yes, I am an adult learner and I am perfectly capable of looking up the information myself. But, since I happen to be in the presence of someone who knows the answer and whose job it is - at least on paper - to teach me thing about medicine, I just thought maybe you might be gracious enough to share some of that information with me.

One attending's reasoning behind not giving us the answers was, "If I tell you the answer, you won't remember." Well, Jesus Christ! That may be true. But, if you don't tell me the answer, I'm sure as hell not going to remember!

Where did this warped concept of what it means to teach come from? In any other teaching situation, information is supposed to flow downhill - from the people who are more knowledgeable to those who are less knowledgeable. Many readers of this blog will be familiar with the adage - If an attending asks you a question and you don't know the answer, a great response is "I don't know, but I'll look it up. To all learners in the medical community, I now propose a coup. If someone in a teaching position asks you a question and you don't know the answer, do NOT offer to look it up. Stand firm at the gates. There is knowledge is that brain; he can only hold onto it for so long. Hold your patients hostage, if you have to. You're the one writing orders, after all. Make your teachers understand that they can either tell you how to properly take care of your patients, or allow your patients to be subject to your guesses at how to take care of them. Medical learners unite, and we shall overcome!

Nothing forces you to come face to face with your own inadequacies quite like medical school and residency. I certainly have my share and there are many posts in store in which I plan to reveal my failures, shortcomings and flat out disasters. By contrast, there are two particular areas in which I have always excelled. Namely, maintaining objectivity and withstanding the various sights and smells of blood, pus, feces, urine etc. Except when it comes to the male genital tract.

While on call last week, I received the following page: "Mr. Gephardt has pulled out his foley; there's blood everywhere. You should probably come see." The nurse's words were calm and measured - as if she'd seen this a thousand times before. She seemed almost apologetic at having to wake me for something so trivial. I walked over to Mr. Gephardt's room. There was, indeed, blood everywere. The nurse didn't need to say another word as the blood splashes on the floor told whole story. The story began with Mr. Gephardt pulling out his foley while still in bed, walking over to the bathroom to urinate blood, walking from the bathroom to the nursing station (with no clothes on, mind you, and still dripping blood) and back to his bed after being chased there by the nurse from whom I had received the page. And the most relaxed person in the room was Mr. Gephardt himself.

"Mr. Gephardt, you pulled out your foley." I tried to sound as matter-of-fact as possible.
"No, it just sort of fell out."
"Did it hurt?"
"Yeah, it hurt!"
"Does it hurt now?"
"No."
He wasn't actively bleeding anymore. So, I went back to the call room, arriving just as my vision was about to turn completely black and just in time to pass out on the bed rather than on the hard tiled floor.

When there is blood coming from the female genital tract, I've never had an issue. During my former life as an OBGYN, I used to handle buckets of it! When it's coming from the male genital tract, I need to put my head between my knees and take some smelling salts. I could never have been a urologist.

For those of you unfamiliar with the concept of a foley catheter, this illustration should help you understand what I'm talking about.

I made quite the startling diagnosis in clinic today. The patient was brought in by her mother with complaint of a fever 2 days earlier. She had also had some diarrhea but otherwise no complaints and no significant past medical history. Sound like a straight forward case of gastroenteritis, right? WRONG.
On physical exam, I could tell immediately that something about this patient was grossly abnormal. She stood 36in in stature at most, weighed 38lbs and appeared to be a stage I on the Tanner scale of sexual development. Her language and intellectual capacity also appeared to be markedly underdeveloped as she mostly appeared to understand what I was saying, but didn't speak throughout the whole encounter and was uncooperative during the physical exam.
Before going to present to my attending, I scoured the medical literature for what might cause the bizarre confluence of findings. And then, like a blot of lightening, it all made sense and I was able to confidently give the patient a diagnosis of...child!

Before today, I hadn't seen a pediatric patient since my first medical school rotation - now going on four years ago! It kind of throws you. If someone had brought in their cockatiel into the clinic for an evaluation, I'd have been just about equally flustered. To be fair, I actually had seen one or two pediatric patients during my tenure as an OB resident, mostly either for injury related to sexual abuse or to remove a foreign body. Those cases are kind of different though. OB's don't have to medically manage the patient. To us, she's just a minature vagina that has some strange creature attached to it.

The fact that I'm now a doctor somehow causes everyone around me to assume that, if they have a problem and there is no other specific person who has the solution, I am the one to turn to. "Doctor, I've noticed my dog's farts smell a lot worse lately." "Doctor, I think my son might be gay. Can they do hypnosis for that?" "Doctor, I have a nearly uncontrollable urge to shout obscenities when I go to church." This is a priniciple I have been familiar with since childhood. The reason this knowledge did not deter me from going to medical school is that I believed, naively as it turns out, that medical school would actually prepare me to answer these questions. After all, there must be some reason people feel their doctor should have an opinion on whether or not they should let their child play violent video games. I figured, as many others do, that doctors must have access to some secret, ancient knowledge to which only a chosen few are allowed access. In fact, somewhere deep in my subconscious, I'm still hoping my program director will turn a wall-mounted oxygen dial in a particular sequence opening a hidden passage leading to a dark room deep below the hospital where he will gather all the interns, tell us to forget everything we learned in medical school as it was just to keep up appearances for the general public, and unlock a dusty, leather-bound book containing the real answers.

Clem Bronson, a 70 year old army vet from Oklahoma who wears cowboy boots, gray hair down to the shoulders, a thick bushy mustache and a face that appears to have been left out in the sun too long had been admitted two days earlier with a COPD exaccerbation. On the way to his room this morning, I was confronted by the respiratory therapist. "Mr. Bronson really made upset Rachel this morning." Tall, blond, 25 year-old Rachel was his nurse today.
"How so?"
"He was making comments about her legs and her butt. Rachel told him to stop, but he didn't. She was really upset."
And, the fact that I went to medical school and wear a white coat makes me qualified to deal with this situation how?

That morning on rounds, we decided to have a little chat with Mr. Bronson about his behavior. His response, "Yeah, I know she's upset. She'll git over it." Great. And in regal fashion, the men in white coats come charging forth in order to...have virtually no impact on the situation. If it happens again, plan B is to recruit the second large category of professionals one goes to when there's nobody else who is specifically qualified to deal with their problem - the police.

I had a few projects to work on tonight - none of which really panned out. The problem is that my beautiful new Gateway FX7026 (which has apparently already been discontinued as I can no longer find it anywhere on Gateway's website) is currently in the custody of DHL, en route to the Gateway mothership for some repair. In the meantime, I'm using my old 128MB of RAM Compaq which is broken in so many subtle ways that I want to stab it with a pitchfork. Therefore, I'm not going to be doing any structural work on my blog for a week or two. I will, however, continue to post daily or at least semi-daily.

The FX7026? He's fine - thanks for asking. His motherboard was just slightly misaligned. This, unfortunately, was making 5 of the 7 USB ports unusable. Otherwise, he's running great! I'll keep you updated on his condition. He should be getting discharged very soon!