Thank you NYT!

The New York Times just launched a pretty amazing interactive section about LGBT youth in current American society. Titled "Coming Out" it is a conglomeration of photos, videos, stories, and audio clips. I can't believe how much has changed in the last 11 years since I began coming out, and as a result, am hopefully that I may live to see the day that LGBT youth are given their due space to flourish and grow into themselves rather than to feel persecuted, alienated, or marginalized.

DKA

I really don't know how people I see in the hospital seem to handle DKA so well. Sure, they look sick and uncomfortable, but not nearly as bad as I felt with transient mild ketosis this afternoon. I only peed 3 times over the 6 hours ketones were present. I didn't even have fruity breath or acidic vomit!

I (unknowingly) kinked my pump site while inserting a new one this morning. A blood sugar of 330 and vomiting up all of my breakfast was not a fun encounter. Since I was staying with my girlfriend 70 miles from home, I had no urine ketone strips to check. Just in case, when I started to feel nauseated, I took a shot and attempted to change my site again. I managed to screw up by pulling out the new site right after inserting it. My blood sugar began to creep down and my nausea subsided. The shot sustained me long enough for me to drive home. Just in time to be nauseated again, and find that I had large ketones.

Moral of the story: I will be packing up an emergency kit to be kept at the girlfriend's house since she now lives more than a few blocks away from me. Even after 21 years (this past week!) my diabetes is still teaching me important lessons.

VOMIT

Today I learned a new term: VOMIT
Victim of Medical Imaging Technology

The idea being that if you begin searching too deeply, you'll find something that may not even be there. One elevated number on a blood test leads to an x-ray, which leads to a CT scan or MRI for more detail, which leads to a biopsy, which leads to an infection, which leads to prolonged course of antibiotics with side effects... which eventually leads to the realization that it was just a touch of dehydration and a bad x-ray angle to begin with. It's like the "If You Give a Mouse a Cookie" story we read in elementary school.

Sure, there are times where advanced testing leads to early diagnosis, but most of the time it leads to unnecessary diagnostic procedures which each carry their own large risk and price tag. In the 2.5 weeks I've been on medicine I've already seen it numerous times. Patients coming in for chest pain, or abdominal pain, or mild limb swelling end up spending multiple nights in the hospital, get poked like a pin cushion, exposed to nasty bugs, and end up going home perfectly resolved without any real treatment or known causative agent.

I don't know what the right answer is though. Clearly these tests and procedures have their role in medicine. I reckon that it is all about finding the balance between the view that every life is as valuable as the world and the oath that all doctors take to do no harm.

Reusing needles

Growing up with [type 1] diabetes there were a few non-talked about norms: taking insulin shots through bathing suits, telling my parents my blood sugar was "normal" when I actually forgot to check, sneaking Halloween candy from the pile piece by piece, and pushing off changing pump sites until I ran out of insulin. However, there were other big no-nos that I never messed with out of fearing serious complications. One of these was reusing sterile disposable insulin syringes. My doctors had taught me that I should never reuse them as the needle blunts, the plastic breaks down, and that injecting myself and then reintroducing the needle into the sterile insulin bottle allows for the propagation of bacteria. I knew of people who reused needles on insulin pens, but no one who did so with disposable syringes.

Imagine my shock last week when we sent a newly diagnosed [type 2 diabetes] patient home with a prescription for a 1 month supply of insulin and only 6 needles. I looked at my attending like he was crazy! He looked back at me like I was a naive medical student who had never met a diabetic before. When I voiced my concerns, he sent me to google. I was shocked to find out that there is actually little risk in reusing your own disposable insulin syringes. There is this article in The Lancet in 1983, and this article was published in 1989 in General Internal Medicine. Even the Pediatric Advisory Network came out with tips for more safely practicing syringe reuse in 2010. Sure, there are some naysayers too. Take for example BD's statement on this issue. BD happens to be on the big syringe manufactures so it is really shocking that they don't encourage the practice (sarcasm).

This has gotten me thinking about what other practices exist in chronic illness communities to lower costs and reduce medical waste? Where else is there significant discourse between the scientific literature and the company/suppliers stance? How else can I better advocate for my future patients instead of simply support the industry?

low note to end the week

Yesterday, at the end of my first week, I began to feel very sick. To sum up the story: I turned white, grew clammy, and ran off to the restroom to vomit. This was immediately followed by my attending doc sending me home. While totally relived that I could get off my feet, go home and go to sleep, I also felt like I was letting my patients and team down. It made me acutely aware of how self sacrificing/super human medical school trains us to be. I'm a bit concerned that this episode of "weakness" is going to screw over my grade but also grateful that I still have many weeks to prove how committed and hard working I am.

words from experience

Words from a friend [who is finishing her residency] about my fear that I'm not working enough hours on my medicine clerkship:

"... experience comes with time, and getting sent home early on your first fri pm as a 3rd yr is not going to ruin your medical training."

I guess I'll trust her advice, and take advantage of this early afternoon to get some studying done and then try a new shul for services tonight!

Start of 3rd year clerkship

Yesterday was my first day of 3rd year clerkship. I'm starting on internal medicine. An orientation called for 7am turned out to be sitting in on morning rounds before being assigned to teams and sent on our merry way. From the first moment, we were thrown in head first. Besides being pimped about current US health economics, I was asked to conduct a focused physical exam (on a real patient!) and to write out my first H&P.

One of the more important lessons from yesterday was about the value in listening to patients and their families. When I was sent back into a room to glean a bit of missed information, the wife pulled me aside with a concerned look on her face. She wanted to reiterate her fears over the prescribed medication. She felt like "the doctor who had just been in" (the attending) hadn't taken the time to listen to her and didn't care what her opinion was. While I was in no authority to give her answers, simply listening seemed to do the trick. I took the time to hear what she was saying, to tell the family that I would find out the answers, to actually inquire about the information from my attending, and then to report back to the family.

Empathy is not really taught in medical school. Taking the time to sit with a family and listen to their concerns without interruption isn't easy in the fast paced and over taxed world of hospital medicine. Humility of saying "I don't know but I will find out" doesn't come easy to us type A professionals. Yet, after a single day of clerkship, I have learned that being empathic, humble, and truly listening will be a huge part of the rest of medical school and needs to continue over my coming career.