Neonatal Abdominal Mass: Part 2

This is a picture of the gross specimen from the mass removed from the patient.


For background, visit this thread at Medscape's Med Student Connect board and the imaging posted earlier.

Neonatal Abdominal Mass

I am posting this image here so that it may be accessed elsewhere on the internets. Obviously, I do not post to Hope for Pandora at this time. Check me out at New Haven Resident, sometime, though!
Want to know what this shows? Join the discussion! (I won't be posting here much, so you can take this url off of your blogroll.)

Updates on The Differential

Even though my posting here at Pandora has been anemic, I've continued to write columns at The Differential. (After all, I'm under contract for a few more weeks.) If this portal is your reminder to read them, and you're looking for convenient links, here are my most recent posts.

May 17: As I tried to pack for my cross-country move, I categorized my stuff left over from umpteen years of education. If only I'd figured that out earlier!
May 23: You may have already read my musings on the significance of graduation - the day that is.
June 2: While teaching some second year students during their transition to the wards, I learned that an expert medical student is only a mediocre intern and a horrible attending.
June 14: I jotted down dome of my thoughts and emotions on the eve of my first responsibilities of internship.
June 27: It took a little while until I actually had my first shift. But soon after, I wrote just a bit about that.
July 4: I think hand washing is one of the easiest ways to reduce complications in medicine. Yet it remains the hardest for us health workers to actually do...

I've a few more entries in me until I put blogging on hold in favor of learning to be a doctor. But at least this will give you something to chew on. And maybe you'll see me back at Medscape in another capacity someday!

Emergency Advocacy

In my first weekly conference as an emergency medicine intern at Yale, we had several lectures. Topics included D-dimer in pulmonary embolism, atrial fibrillation, chest x-ray reading and emergency medicine advocacy. What? Advocacy in the classroom? One of our EM professors is an expert in the subjects of accident prevention policy, so she gave us a primer on what we can do as new doctors to contribute to the current health care debate. Here's the letter I wrote this morning on my day off.

Dear (Insert CT lawmaker name here),

I am a resident physician in the Yale-New Haven Hospital emergency department. I'm writing to tell you a little bit about ER conditions so that you will have a sense of how emergency care is an important issue that should be included in the currently debated health plan. A health care plan in our country cannot be comprehensive if it does not address emergency care.

When I show up for my 12 hour shift at Yale's level one trauma center, I am immediately inundated with an atmosphere that to an outsider could be perceived as chaos. The scene is far from the clean depictions on your television set, and believe me, there is not time for the intrigue that home viewers expect from “Grey's Anatomy.” Every night at many of the top hospitals in this country, patients sit in emergency room hallways for lack of private rooms. It is not unusual for these folks to receive all of their care in the hallway. I will personally wheel patients in and out of rooms so that they may have the dignity of a private exam. It breaks my heart to tell these folks, “We'll only be in here for 10 minutes before I take you back out into the hallway.” Can you imagine your doctor saying, “You have appendicitis and will need surgery, but until then try to make yourself comfortable on this hallway stretcher,” like I have? When you are having the worst pain of your life, you can't understand there is someone sicker than you.

This brings me to the health plan. There are always really sick patients. President Obama has been championing primary care as the centerpiece of his plan; and rightly so: prevention and a steady relationship with one doctor will go far to reduce health care costs. But increasing resources to primary care will not alleviate the overcrowding problems we face in delivering emergency care. For example, with 97% of the population in nearby Massachusetts insured, ER use has increased by nearly 10%. A refrain we physicians wish to emphasize is: coverage does not equal access. Where do people go when they get sick after hours?

I am familiar with and applaud sections 214 and 215 of the current Senate bill (“Systems for Emergency Care...” and “Trauma Centers...” in “Quality, Affordable Health Care for all Americans” submitted by Sen. Reid), and hope you will support these provisions. The grants and mandates are based on recommendations a 2006 Institute of Medicine report and will go far to improve care through one of the most frequent access points for people in need. In the interim, I'll do my part to see as many patients as I can safely handle so that our ER's hallways are used for walking, not patient care.

Sincerely,

Thomas Robey, M.D., Ph.D.

If you are wondering why I don't post more here in the next year, it's because I'll be using my time to write other things. Such as letters like this...

Where's Thomas?

We made it to New Haven and have unpacked most of our boxes. My Facebook friends out there will know that I've finished my orientation week, and have started my orientation month. If there's one thing important about being a resident, it's being oriented...

My posting frequency will be much less this year. I'm afraid I just won't have the time to polish my writing in a way I'd be comfortable presenting to the blogosphere. But I am still writing. And I'll be back. There's still plenty of 'Hope' around. Hopefully I won't lose it through internship!

Shipping Container

By this time tomorrow, the entirety of our belongings, including this desktop computer, will be packed into an 8'x9'x16' space. That excludes clothes, an air mattress, family photos and a few beloved plants. I will spend my REM sleep this evening summoning the requisite packing skills for the job.

Transitions, Continued

We are packed. I've been reading Connecticut newspapers even though I haven't quite found one I like. There's a house waiting for us in New Haven, and my wife and I are debating the merits of being called Yalies or Yaliens. She prefers the latter. We're squeezing as much as we can out of the nascent Seattle summer. Two recent activities we recommend are hiking at Ingalls Creek (on US Highway 97 between Bluett Pass and Leavenworth) and an afternoon canoeing through the Washington State Arboretum on a boat rented from the UW WAC.

Today's looking like another beautiful day.

Urban Phantom

The Urban Phantom has been relocated.

The black bear that seen earlier this week in Seattle was found yesterday in Everett, WA, just 30 miles north of where is was first sited. The bear turned up in another urban area, so wildlife officials tranquilized him and transported him out of the urban area. Hopefully for him, the adolescent male was dropped off along Highway 2 in an area that is not already claimed by an older, stronger bear. In the end, I'm happy the animal did not meet the same demise that the poor creature found in the University District three years ago.

According to wildlife officials, at no point were humans at risk from the bear; they claim that the bear was more at risk from cars or from dumpster diving. Evidently, human food doesn't do much good for bears. It probably doesn't do best for humans either!

Final Day

Today's my last day in clinic or hospital. At least of medical school. How will my wife and I celebrate? By packing, of course. But school is not quite over. After two days off next week, we teach second years procedures for a few days and then have a week of a summary course called "Capstone." I think that consists of advanced procedure training and learning the basic stuff that may have slipped through the cracks the first time.

Anyway, I am so happy to be finished with one more task that I could yip with joy. Fortunately, I can save myself the embarrassment because the neighborhood coyotes are at this moment doing just that. Well, at least they are yipping for some reason.

If you would like to read more of my reflections, consider following this link to my column at The Differential.

Seattle Bears

No. We are not getting another sports team. (Though I hardly noticed the NBA SuperSonics' absence.) A few years ago, a bear was found in Seattle's University District. It met a grisly demise at the hands of untrained law enforcement officers. Hopefully, the city has learned its lesson. Because there's a bear in Ballard. It's been sited in Seattle's West Shore: Magnolia, Ballard and the area. According to the Seattle Times, wildlife officials are involved. This guy is reading the ingredients on a tranquilizer dart.


I hope this bear is not destroyed. I wonder how much cash has been spent on the bear thus far. Multiple squad car chases and a helicopter have been involved... Read the article. You're not going to believe it.

Update 5/20/09

The bear, now named "Urban Phantom" has made his way back north and east of the city. Hopefully, we will find a spot more to his liking in the Cascades. Here's a map detailing many of the animal's sightings.

Packing...

As I've been packing, I've begun to realize which "stuff" from medical school is important and which is not. Read about my ideas over at MedScape this week. As a bonus, I can offer you a glimpse into the social dynamic between my wife and me as we pack for the big move!

Need a hint? My wife is an awesome packer. I am not.

Hearkening Back

When Susan and I move next month, we are planning to leave our televisions behind. Part of that decision is that they are older. Part of it is to reduce the volume of stuff to move. One of the things I am looking forward the most to is not having cable television. Lately I've been sucked in to programming (namely on the SciFi, Animal Planet, History and Comedy Central channels) when I should have been writing, studying or packing. So the move is something like a "practice what I preach" opportunity. (As an adult, I alternate between tolerating and railing against the boob tube.) Find stronger opinions than mine at the Kill your Television web site. Rather than release lead and mercury into whatever space I'd be weilding a sledgehammer, I've turned two old TVs into fish tanks...

So what will I do with my time? I'll try gardening, home improvement, internet ideas and reading... These things I already do and actually enjoy more than commercial programming. For example, I liked this piece in the New York Times by its editorial observer Verlyn Klinkenborg about reading aloud. Reading aloud is fun. I just need to find some people who agree with me. I bet there are a few in New Haven!

And what about other screen entertainment? Movies? Internet? We will still be able to do that, but on my desktop computer. I think the screen is bigger than our TV's anyway. And shows I really want to see? I guess I'll have to try out BitTorrent for size. In the mean time, I've got some packing to do!

Rotation Schedule

This week, I assumed my place in the national online call reqistry known as amion.com. (That's pronounced, "Am I on?") Like every other resident, my call schedule is available to anyone with the proper login. Since I'm not sure how protected said logins are, I'll relay for all those who are interested which rotations I've been assigned.

6/21 - 7/20 Yale ED & Orientation
7/21 - 8/17 Bridgeport Hospital ED
8/18 - 9/14 Bridgeport Hospital ED & EMS
9/15 - 10/12 Bridgeport Hospital ED
10/13 - 11/9 Pediatrics at Bridgeport Hospital
11/10 - 12/7 Medical ICU at Yale
12/8 - 1/4 Ultrasound & Anesthesia
1/5 - 2/1 Ob-Gyn at Bridgeport Hospital
2/2 - 3/1 Yale ED
3/2 - 3/29 Cardiac Care Unit at Yale
3/30 - 4/26 Orthopedics
4/27 - 5/24 Medicine at Yale
5/25 - 6/21 Yale ED

This is just one more step in my transition to residency!

Goodbyes

ED Shoes, click on the image for a Flickr interactive view.

There comes a time when all that's left to be said is, "Goodbye old friend." This week I used that phrase twice. Once to the Harborview emergency department and later in the same day to my clinic shoes. Over the past 2 years I've used a dedicated pair of shoes during ED shifts and overnight call. The day I stepped out of the Harborview ED was the same day I said goodbye to these old friends. The left toe bears the badge of ortho (plaster). The right foot has a spatter from irrigating my last wound in Seattle. Both bear marks from my away rotation at San Francisco General, as the heels and laces retained a tinge of the scrubs' cranberry pink dye. The real reason for discarding this pair was the torn apart left heel and loss of sole traction. Otherwise, with a splash of bleach they'd be ready for another shift!

An expanded version of this article was published at Medscape's student blog, The Differential.

911 Blogs

There's a blog published by the now online-only Seattle Post-Intelligencer called Seattle 911: A Police Blog. Many cities have similar sites that act as 21st century police scanner bulletins. While surfing for news this morning, I happened to find that the top three stories on the site involved patients I saw at Harborview Medical Center during my last shift. There are also pictures to help understand the injury mechanism. Here's one:

The entries each indicate transport to the hospital where I was on call. My willing compliance with HIPAA and patient confidentiality rules prevents me from saying any more about the specifics of the cases, but I will comment briefly on a facet of patient care that could use improvement. Information is often lost in the transition from witnesses to emergency response personel to emergency physicians to their hospital consultants. (I was a student on the orthopedics team at the time.) We hope that the important information is maintained, but invariably, there is something that we wish we had known at the time.

Even with excellent sign-offs between providers, patients come in to the hospital with limited histories. Patients could be 'out of it' due to shock, pain or pain medicine. There could be a language barrier. Patients are sometimes intubated. Important features may have been observed but not documented on the scene, in transit or during an initial physical exam.

One of the important questions in the patient's history for emergency docs are: How did this occur? Among providers, this question becomes: What was the mechanism? Discovering or confirming this info with the patient is one way emergency providers evaluate patient alertness and orientation while they do their injury surveys, so patients sometimes get annoyed at having to tell the same story over and over again. But that's if the patient can tell the story. Sometimes they cannot.

It turns out that the Seattle 911 blog had information that may have been helpful for providers to understand these patients' injuries. In two of the cases from Friday, the entry was made while (or soon after) the patient was in the emergency department, further underscoring the potential utility of electronic documentation of pictures. One of the patients described the accident in a way that when I saw the image, I thought, "I saw the person involved in that accident." The other image generated a, "So that's how that happened" response in me. The importance of pictures (yes, worth a thousand words) is well known in emergency care; the soon to be history Polaroids of automobile accidents are often taped to critically injured patients' charts. The photo below is more a reminder of how beautiful it was on Friday that how the accident occured.

It wouldn't have changed how we treated these patients to know the specifics documented in the blog entries; the primary determinants of treatment are derived from the physical exam and what the x-rays and CT scans reveal. But one wonders if speedy documentation of accidents and injuries in the field could ever be incorporated into the electronic medical record. iPhone medicine is already being practiced in many emergency departments. The fellow on our service used his Blackberry to photograph one of our patients' wounds. He only partially joked with the radiology tech that he needed it to plan for a surgery. The image was later used to communicate with the attending surgeon and was reshown the next morning during a sign-out conference.

Reforming and universalizing the electronic medical record is central to the Obama plan to reduce health care costs. I hope the software programmers include a mechanism for documenting accident photos. In the mean time, maybe I should keep the local injury blogs open on one of the ER's computers.

Photos are from the Seattle 911 blog and were taken by Ben Otteson and Dana Vander Houwen.

What to do Post-Call...

Earlier this week, I was feeling a bit wiped out from my overnight call on the orthopedics trauma team. I made the mistake of rambling a bit about my thoughts over at the Differential. Today I'm post-call and haven't been able to sleep yet. What a difference two hours in a call room makes!!!


Yes, this is the obligate link to another page post. Sorry about that.

Fancy Steel Water Bottles

In relation to this week's Earth Day the New York Times is running a comparison between the energy costs of stainless steel water bottles and disposable plastic ones. Given the intensive energy input to steel production, it will take between 50 and 100 reuses of the steel water bottles to balance out an equivalent usage of disposable bottles. That seems reasonable enough to me. In my water drinking prime, I refilled my Nalgene bottle twice a day, which was the volume equivalent of 4 or 5 disposables. The problem I have with this analysis is that the author used disposable plastic as a straw man. I'd like to see the balance between a stainless steel container and the polycarbonate bottles that you can use just as much. I know, if you drink 6.02x10^23 liters of water from polycarbonate bottles, you might get cancer. But there are other durable plastic choices.

There's another kicker in the feature (that seems a little off): the carbon costs of marketing and storing a steel bottle on the shelf of an REI or equivalent store may be as much as producing it in the first place!

The bottom line seems to me to be: Use old stuff. Reusing anything is better than buying a new 'green' object. The worst steel bottles are the red colored ones - every time I see someone drink from one, I think, "Noooo! Don't drink that kerosene!" But that's just the Boy Scout in me...

Missing Seattle

I haven't even left, and I miss Seattle already.

Perhaps it was this cartoon by Milt Priggee...


Not that I'm not a sports fan. I root for the Cubs and try to find places to watch my beloved Pitt Panthers. But it's the other stuff I'd rather do. And the study has particularly suspect scoring methods for 'misery.' Namely not including pro soccer, for which many Seattlites go bonkers for and for giving more misery points to teams that reach the finals but lose... Maybe Seattle residents just find ways to celebrat that they actually got to the finals...

Lest you think this cartoon inaccurate, I live in Seattle, and routinely see eagles, owls, red tailed hawks, Cooper's hawks and ferocious hummingbirds from my window. Salmon spawn within city limits. Seals hang out near the Ballard locks to harvest said fish. And we see snow-capped mountains on any day with clouds above a 7,000 foot ceiling. You can rent a kayak two blocks from my apartment.

Ahhh, Seattle.

Dream a Dream

Evidently, television coverage of the "Tea Party" on tax day was pre-empted by another story. Since I've given up using the television for acquiring my news in any form other than presented on Comedy Central or in live broadcasts (debates, live speeches, CSPAN and the lot), I didn't catch this other story until it was echoed in the morning newspapers. Yesterday, a 47-year-old Scot performed a rendition of "I Dreamed a Dream" from "Les Miserables" on the UK's equivalent of American Idol and brought down the house. Much rubbish was made of her frumpy appearance, older age and romantic status in advance of (and after) the performance. Which reminds me that our current day conception of talent is inectricably linked to looks and social status. I'm glad that the show (titled "Britain's got Talent") actually brought out the talent it advertises. Especially if it drowned out some of the shouting about the illogical Tea Party. I actually enjoyed sending in my check this year. But then again I like the idea of the government funding science, cleaning the air, caring for the poor sick and lame, building roads and even defending freedom. I think the rich conservative broadcasters who orchestrated this Tea Party are celebrating a la David Horsey...

I've not embedded the clip because YouTube has restricted it and because if you are visiting my front page, you still get to hear the "Imperial March" in the background. Wondering why? Read this. Then watch Susan Boyle live a dream.

Senioritis

This week at The Differential, I took a stab at suggesting an entry for the new Diagnostic and Statistical Manual of Mental Disorders. (The DSM V will be coming out in May 2012.) Nothing serious, though. My disease has been informally diagnosed for decades: senioritis. Head over there to check if you feel any of the symptoms or demonstrate any of the major or minor signs...


I'd say I had some senioritis before I started my current orthopedics trauma rotation. The schedule alone cured it for me...

Zone 6b!!!

Was I ever excited a few minutes ago when I learned that New Haven is located in USDA climate zone 6b! That's the dark yellow zone on this map.It's no 9a as in Seattle, but 6b is better than Chicago's 5a or Pittsburgh's 5b - two places I've gardened in the past. It's looking good that we will have a yard (0.09 acres minus the house's footprint), so if we have any time after (1) being residents and (2) minor remodeling projects, the yard will offer us an urban oasis. And vegetables. This year even!

Anyway, this is the sort of information that helps you get through the labor of packing...

Emergency Policy

Now that I'll be moving to Connecticut to further my medical education, I've tried to start paying attention to health policy in that state. An article in the New York Times today sated my weekly appetite for such information. The punchline is that in this difficult budget cycle, the governor of CT (M. Jodi Rell) has proposed cutting state support to the state's only emergency flight system. LifeStar is headquartered in Hartford, but as this map shows, conducts about 250 flights a year to the Yale-New Haven Hospital.

If the cuts are approved, there will be financial capacity for only about half of the flights now made. The governor's office cites that this program is run from a private hospital as a reason to be included in the cuts. The problem with this reasoning is that there is no other service in the state making this kind of transport. According to the article, legislators on an appropriations subcommittee recently recommended restoring the entire $1.4 million that was cut. Even so, I think it's reasonable to engage in discussions about the cost of emergency transport. It seems to me the $9000 per flight cost is worth saving a life.