Last night, I was innocently sitting on my couch watching Real Housewives of New Jersey (don't judge me), when I was struck, out of the blue, with a craving for an apple festival.  It wasn't just a craving for an apple dumpling, or fresh apple cider, or warm chicken soup.  It was for the entire festival.  The smell of fall, fresh apples, corn husks, and cool air.  Sitting in the grass watching kids try to eat candy apples, and browsing the craft stands and going on hay rides, or walking a corn maze. 

I think it's because I am SOOOO ready for fall.  I love fall, for many of the same reasons I love apple festivals.  Cool weather, sweatshirts, hot coffee, changing leaves, football, apple pie.  Ohh, I can't wait for it. 

I'm not sure why apple festivals make me so happy outside all the stuff you can get at them.  Fall, in reality, signifies the coming of cold, death, hibernation, stillness.  It's a warning, for the squirrels to collect nuts, for the bears to build up some blubber, for southerners to stockpile bread and milk (oh, wait, that doesn't happen until the snow is coming...).  But apple festivals make me feel like everything is perfect.  I get all warm and tingly inside just thinking about it. 

And, if on the way home, we happen to stop and get a pumpkin spice latte, someone might have to remind me I'm not in heaven.

I've had a lot of friends who aren't in the medical field ask me if medical school is like TV.  Between Scrubs, Grey's Anatomy, House, ER, and all the other medical shows, you can pretty much get a totally clear picture of what being in medical school is like...

Okay, maybe not.  But there are occasions when it feels like I'm living in a TV show.  Sometimes it's when rumors spread about who is dating who.  But sometimes, it's because of a patient who actually fits the picture of one you might see on TV.  It's especially rare to have a patient resembling a patient that you might see on House.  Mostly, that's because those patients don't really exist.  Sure, there are crazy odd diseases that you only learn about it books and rarely see.  But when someone has one of those, you generally end up ruling out the normal stuff in a couple days, and then shotgunning until you find the one strange disease.  And it takes longer than normal to make a diagnosis... maybe a week.  But you find it.  And treat it.  And they get better, or not.  But it's exceedingly rare to have a patient who you can't diagnose, and when you do, you treat them, and then their spleen blows up, or their eyes start to bleed, or their blood turns green.  That's just not how it happens. 

Usually.

Which means that occasionally, VERY VERY occasionally, you get one of those patients.  I have one of them now.

Back in January, she started having some muscle weakness.  Nothing major, just felt like she didn't have the strength she usually did.  They didn't find anything obviously wrong with her, and thought it was likely related to a sinus infection, which was treated with antibiotics.  She had a bit of a reaction to the antibiotics, but seemed to do okay.  Through the spring, her muscle weakness got a progressively worse, and she started having regular fevers to about 101F.  Workup didn't reveal any source of infection, and neurology didn't initially know why she was weak. 

In May, she came into the hospital because of abdominal pain.  If you go back a couple days, you'll see my post on abdominal pain, and how easy it is to figure out what's wrong.... right.  So she got the whole workup, including ultrasounds, CT scans, blood work, etc.  It revealed that she has many enlarged lymph nodes throughout her body, and a splenic infarct.  There was concern for some sort of cancer, which would explain the lymph nodes, as well as the clot causing her splenic infarct.  She was stabilized, and sent home to continue the workup as an outpatient.  During the next few months, her muscle weakness progressed to the point where she could no longer stand, and barely could lift her arms.  She continued to have fevers, was anemic, and underwent two lymph node biopsies that did not show any cancer.  They decided to get a muscle biopsy to see if it would reveal the cause of her weakness.  It showed likely dermatomyositis, and inflammatory myopathy that is an autoimmune disease frequently (about 25% of dermatomyositis cases) associated with cancer. 

So she was admitted to the hospital again to begin treatment for the dermatomyositis.  Rheumatology recommended high dose steroids, as well as IVIG.  She started this therapy, and was also seen by nephrology because her kidneys were not working.  Previous biopsy of her kidney showed glomerulonephritis likely caused by Lupus or something similar.  But all of her lupus labs had been negative.  Lupus would likely also respond to the steroids, which it did initially, then her kidneys started getting worse again. 

A couple days after her steroid dose was decreased, she suddenly developed a hemolytic anemia, and her hemoglobin dropped from 8.9 to 6.2 in about 24 hours, and her platelets dropped to 30 (from about 200).  We called heme/onc again (they had signed off on her, saying they couldn't find any source of cancer that might be associated with her dematomyositis).  They listed a number of things that might be causing the anemia, and wanted to do a bone marrow biopsy to see if they could find anything.

Meanwhile, our patient had worsening of some "floaters" in her vision, so ophthalmology saw her and said she has some sort of vasculitis or inflammatory process affecting the capillaries in her retina. 

So, after the bone marrow biopsy, nephrology and rheumatology wanted to start cytotoxic therapy for her likely lupus/autoimmune overlap syndrome, but they wanted to make sure she wasn't infected at all because if she was, she could quickly become very very sick.  As if on cue, she started spiking fevers to 104F, became short of breath, and started coughing up blood. 

We got a chest CT that showed "ground glass opacities" (no one really knows what that signifies), which could be bacterial, fungal, PCP, hemorrhage, fluid, or something else.  She also had pleural effusions that were pretty large.  Because no source of infection can be identified, infectious disease was consulted, and recommended bronchoscopy to get a sample from inside her lungs, and also recommended draining the pleural effusions to look for infection or occult malignancy.  Heme onc agreed, and also wants to do a core biopsy of one of her lymph nodes.  Most people thinks there is still a high likelihood that there is underlying cancer, but we can't find it.  She's had everything scanned, had endoscopy and colonoscopy, and biopsies.

We've consulted infectious disease, rheumatology, nephrology, pulmonology, and ophthalmology (interventional radiology and anesthesiology are likely on the list for tomorrow...).  She's also seen neurology and neurosurgery. 

And we still can't figure out what is causing all this. 

I think I'm going to call House and see if he can help.

This morning, I made a pot of coffee and say down to watch Meet The Press, like I do practically every Sunday.   The news has been covering the 5th year anniversary of Katrina all week, but today is exactly 5 years since the storm made landfall, and Meet The Press was live from New Orleans today with Brian Williams to take a look back at the devastation and the recovery.

I'd forgotten how bad it was. 

They didn't spend as much time looking back as they did looking forward.  But the time that was spent replaying old videos and photos reminded me of how desperate the situation was and how helpless I felt from PA. 

One of the things I find most frustrating in this world is watching people get sick and die from preventable causes.  Diseases we have vaccines for, starvation in a world of plenty, dehydration while surrounded by water.  Maybe it's the (future) doctor in me... There are things that we can't cure, can't save people from.  Cancer, old age, trauma.  There are things that kill people, despite our very best efforts.  That is understandable; it's a fact of life.  But there is no excuse for people dying from preventable causes, and that happened in New Orleans and the rest of the gulf after Katrina. 

One of the big issues that surrounded and still surrounds Katrina is what role race and class played in the response and provision of aid to the region.  Many have asked, "If this happened in Martha's Vineyard, or NYC, or DC, would the outcome have been different?  Would the response have been faster?" 

I don't know.  I don't want to pretend to know.  This was one of the questions they discussed at the round table on Meet The Press this morning.  One person said that to this day, no one has been held responsible.   I though about this, about who we would hold responsible for a systemic malfunction.  And what good would it do?  What is the point?  What are we trying to achieve? 

In the best of scenarios, we would learn from Katrina, from the flaws in the system, the failures of infrastructure.  We would remember the faces of suffering we saw in the weeks following Katrina.  We would ingrain in our brains the feeling in our guts that people should never experience what those people did.  We would look, honestly and openly, at what led to the pictures of bodies covered with blankets, dead from lack of water and food.  Ideally, we would do everything humanly possible to make sure that Katrina never happens again. 

The discussion at the round table today made me think of Apartheid in South Africa, and the post-Apartheid reconciliation that took place.  I'm having flashbacks to a quote, but can't remember who said it, or what exactly said said, but it was something along these lines.  We could blame people for Apartheid.  We could round them up, put them in jail, punish them for the injustices forced upon the people of South Africa.  But that would fix nothing.  That would heal no one.  That would do nothing to prevent something similar from happening in the future.  If we start pointing fingers and blaming individuals for a policy, for a systemic flaw, we lose all hope of frank and honest communication.  And it's through that communication that we can understand, to the most basic and human level, the ideals that brought us to the darkest hours of Apartheid.  And through that understanding, we can begin to heal, and we can make sure that it never happens again.

Okay, so I took some serious creative liberties in there, but that's the gist.  And I think the same applies to Katrina.  The more we try to blame individuals for the systemic failures that took Katrina from being a hurricane to a disaster, the more we will harbor anger and prevent progress.  And in ten years, I don't want to be watching the same thing happen somewhere else, wondering how we could let it happen again, and how we missed an opportunity to learn from ourselves, to prevent suffering. 

And in case you don't remember, here are some pictures to remind you of Katrina...

I realize that I am again straying from the medical topics.  Don't worry, I have an idea for a medical-related post for later in the day.  I was going to write that one now, but I happened to come across something that can't go without mentioning.

I was on Amazon this afternoon, because I earned myself a nice little $5 gift card on Swagbucks, and I signed up for a free Amazon Prime membership.  I've been looking for an interesting wine rack for quite some time, and thought maybe I could find something interesting on Amazon.  Boy, was I right.

In addition to finding a wine rack that I'm actually going to buy, I found THIS.  This is not what I was looking for.  Who knew such a thing existed?  I was going to put a picture up, but want this blog to remain family friendly, and not attract the wrong kind of audience, so you'll just have to follow the link to Amazon. 

When I come across things like this, I wonder what people are doing when they come up with this kind of invention.  Like, when I'm out running, or really doing any activity that involved a sports bra, I don't frequently think, "wow, I could really go for a swig of wine right now!".  I'm thinking it come in more frequently when some security dude makes someone throw away their half consumer beer when they're standing in line for a baseball game.  "Man, I really wish I had a hidden way to sneak this tasty beverage into the stadium!"  There are many more directions I could take conversation about this invention, but they would all be digressions far beyond where I am willing to go.  I just thought I should put it up here as my interesting find of the day.

FYI, this item did not make it into my shopping cart.  The real wine rack did, as did a copper french press and some lotion I'm too lazy to look in the store for (read: I can't go to the store to get myself...)

Enjoy the weekend!

Love,
Your gimpy friend who's spent too much time online today.

Based on the overwhelming response to facebook status update (the source of all worldly truths), it has become clear to me that I am not the only one who thinks that breakfast for dinner should be at least a weekly occurrence. 

I was reading CNN while at the hospital today, and read about the nation wide egg crisis that seems to be going on.  There are bacteria in our eggs, and it's making people sick!  They are recommending that to prevent this, you cook them.  I find this somewhat less than national-crisis level news, given that every restaurant menu contains, at the bottom of at least one page, the disclaimer, "Consuming raw or undercooked meat, seafood or egg products can increase your risk of foodborne illness."  Anyway, I stray from the topic.  So I was reading this story about eggs and thought to myself, "self, I think I should have eggs for dinner!  Maybe over easy would be tasty...."  It just so happens that I have many an ingredient perfect for an egg scramble.  Yum.

I still have lots of fresh veggies that my mom brought from her barn garden (as I like to call it, some day I'll explain why), and I know I'm starting to push my luck with the shelf life of some of them... So I decided to use up some home grown green pepper and tomato, throw in some onion (from the store), a little roast beef (for some protein and a little saltiness), in addition to the necessary eggs and cheese.   Add to the side a piece of whole wheat toast with some good ole PA dutch made strawberry jam, and a glass of OJ, and it's the perfect breakfast for dinner!  Unfortunately, it's not the perfect picture of it... because I use my phone because it takes about 7 steps out of the "getting the picture onto the computer" process.  Anyway, here's the end result... minus a bite of toast!

Abdominal pain is one of the most common complaints seen in the emergency department, as well as in medicine in general.  Now, this wouldn't be so bad if there weren't a BILLION things that could cause abdominal pain!  We've got to figure out if a patient has an "acute abdomen" (ie, something that could kill or maim them... soon), and then figure out what to do with/for them.  The other complicating problem is that sometimes you can have abdominal pain without lab findings or obvious signs on imaging (CT, X-Ray, ultrasound).  Which means that people who don't necessarily have pain can say they do, and we can't really definitively say otherwise... enter "drug seekers".  Not that they are the majority by any means, but they are there.  So, someone comes in complaining of "abdominal pain", and there are just a few things to think about. 

First of all, there's all the things IN the abdomen.  Lets make a very non-exhaustive list...
Diaphragm
Liver
Esophagus
Stomach
Pancreas
Duodenum
Jejunum
Ileum
Gall bladder
Bile ducts
Ampule of vater
Colon (ascending, transverse, descending)
Rectum
SMA, IMA, Celiac (those are all arteries)
Kidneys (x2, for most people)
Renal artery
Renal vein
Ureters
Bladder
Ovaries (if you are a woman)
Uterus (see above)
Fallopian tubes
A baby (maybe... and then you've gotta find it!)
Appendix
Spleen
Peritoneum
Muscle
Belly Button
Skin

And then there's all the stuff that can happen to all those things....
They can rupture
They can leak
They can bleed
They can die
They can get blocked
They can stop working
They can work too much
They can get stones
They can get distended
They can get infections
Then can get other infections
The infection can cause them to rupture... or bleed... or die... or leak.
They can tear
They can grow
They can shrink
They can get cancer
There can be too many
There can be too few

You just never know.

So, when someone comes in complaining of abdominal pain, we've got to figure out which thing is causing it, and then what exactly is happening to it.  Sometimes it's easy... sometimes it's not.  Most of the mystery is solved with a good history and physical exam.  Which is why we go to medical school and not WebMD school.  And while a LOT of the things listed above can cause an "acute abdomen", most people who have abdominal pain do NOT, I repeat do NOT have an acute abdomen.

But you've got to check.

Just in case their spleen is about to implode.

So Happy Things is supposed to be about things that make me happy disproportional to their role in my life...  So maybe this one doesn't fit.  Because ice cream is extremely important in my life.  But I thought that I could make an exception, because maybe ice cream shouldn't be as important as it is...


My Jeni's Ice Cream arrived a couple weeks or so ago, in it's Styrofoam lined, dry ice packed box (on a 97 degree day, no less).  I put it in my freezer right away and have only broken into the Salty Caramel so far (you must understand how rich this ice cream is, and how slowly I tend to eat it... because it's pricey and not good for my heart).  I'm still not entirely sure how they fit the flavours that they do into this ice cream.  It has so much flavour that I really feel it's necessary to add the "u" to flavour, because 6 letters wouldn't do the word justice.  I'll report on each flavor as I dive into it.  There are still 5 I haven't touched.  That's a lot of happiness left to experience.

What's your favorite flavor of ice cream (or other summer treat)?

This morning, I took the bandage off my ankle and could take a shower WITHOUT a garbage bag and oodles of duct tape.  It was lovely.  When I took all the gauze away, I noticed two things.  1) There wasn't as much swelling as I thought there might be... Score!  and 2)  They gave someone an anatomy lesson on my ankle.  Here's what it looked like (well after I took a shower and put bandaids over the slightly oozy portal incisions...)

I'm sitting on my couch, ice in place, while my mom warms up left over dessert from last night.  I will describe the dessert more later... now for the ankle.

Everything went as planned today with my ankle surgery.  They asked me about sever times what I was having done (as they are supposed to), and I said right ankle arthroscopy each time... although I was tempted to say "left ear amputation" once, and see what happened.  The anesthesiologist and I decided on general, because apparently it's pretty hard to do a regional block for an ankle joint without hitting the femoral or doing multiple blocks.  Which sounded interesting academically, but not fun in the being stuck with needles many many times department.  I'd finished telling Dr. T and the anesthesiologist how mom and I had gone for dinner and pedicures last night to celebrate out birthdays, when the nurse anesthetist came in and said, "didn't they tell you to take the polish off you toes?"  I looked terrified, silent.  The anesthesiologist said, "She's fine.  We don't need to. Don't worry about it."  She said "but we need to be able to check her circulation."  He said, "We can check her arm or something".  She said, "No, they're working on her foot."  I said, "They'll use a tourniquet.  I won't have blood supply anyway."  He said, "Yeah.  It's fine."  She said, "Well, just so you know, last time I got my nails done my big toe turned white and I had a foot fungus and hat take medication for it."  I think she was just jealous of my toes.

And that's how the anesthesiologist because my favorite.  That, and he let me listen to my heart murmur, which I didn't know I had. 

So, in surgery, the found that the osteochondral defect had pretty well been covered over with cartilage, which was excellent.  There was a lot of scar tissue that they cleaned up and Dr. T thinks it will help with the pain a lot.  I've just got a bandage (with lots of gauze), but no split.  Which is not, because that was the most uncomfortable part last time I had surgery!  I can't put weight on in until I see Dr. T on Sept. 2, but hopefully these findings will lead to a quicker recovery!  I have plans to get on the bike or swim pretty quickly. 

Anyway, I spent the day sleeping, watching TV, and eating leftovers of our dinner last night.  Let's talk more about that.  We went to Milners, a Southern Cuisine place that's supposed be fantastic.  It was.  We went after mom, Jen, and I got our pedicures!  I'll take a picture and post it at some point.  Anyway, back to dinner.  Since it was our birthdays (my mom's is actually today... HAPPY BIRTHDAY MOM!), we decided to go all out... wine, appetizer, entrees, dessert.  Here's the line up.  Sorry I don't have pictures of everything!

In today's installment of Things That Make Me Happy (ie things that make me disproportionately happy when compared to their role in my life), I will talk about The Likelihood List.

How many of you have taken statistics in your life... and thought "there is no way this will ever be applicable in my life... ever"  Well, you are wrong.  You will need to bust out your college-level statistics skills to understand this post.  Call it likelihood ratios made less scientific and applied to real life.

Have you ever wondered what someone means when they say something is "likely", or "more likely than not".  What kind of percentages are we talking here?  Well, have no fear.  Betsy and I had the SAME question one night when out for dinner.

Let me set the stage.  We were sitting at a booth in Ruby Tuesdays.  We'd both ordered turkey burgers... but they were out of turkey burgers, which was tragic.  So we got something else.  Unimportant.  As we were sitting, waiting for our non-turkey burger dinner to arrive, one of us said something involving the phrase "more likely than not" (or something along those lines).  Which sparked a very in depth conversation about what that really meant.  So, we did what any two normal people would do in the same situation... we made a list... on a napkin... and then took a picture with our phones.  Here's the masterpiece:

It's kinda like a prisoners last meal... except mine is only temporary.  Tonight I went for a quick run when I got home from work... somewhere between 1.5 and 2 miles.  I decided to run short and fast because I didn't have a ton of energy after getting home at 7:30 from a long day at the hospital.  I wasn't even going to go when I got home, but I realized it is most likely the last time I will run before my ankle surgery Wednesday, which means it's the last time I'll run for probably a good few months.  Sad, I know.  But hopefully when I start back, I won't have to worry about it hurting all the time! 

So, farewell to the road for a while... I see lots of pull ups and crunches in my future... maybe a little one legged biking.  At least when I return, I'll get to bust out my new Brooks Glycerin running shoes... my current ones have died a slow and painful death and need to be retired very badly.  The new ones will give me motivation to get through those first few weeks of low mileage slow pace pain.  Boo.

I do plan on being in shape (and fast) for the spring racing season... my last collegiate racing season. 

Farewell for now... Tomorrow I will talk about my new service, patients, and all sorts of medicine fun!

Cheers,
Kari

I am officially done with four 4th year rotations!  That means I'm 1/3 of the way done with it... which is mild to moderately crazy.  I'm also in the midst of my residency application, trying to figure out where I want to apply.  I'm planning on using the shotgun approach... apply to a bunch of places that fit my criteria and are in places I would consider living, and then interview and see what strikes my fancy.  Maybe not the best strategy, but I've gotta use SOMETHING to narrow down the 400 something family residency options.  So I'm going with academic programs with sports medicine fellowships that really aren't in places warmer than this.  Because I like seasons.  Anyway, I'm done with 4/12 rotations... lets do a little recap.

Rotations: Done

• Pediatric ICU
• Step 2 study month
• Rehabilitation
• Emergency Medicine

Rotations: To DO

• Family Medicine (Inpatient)
• Orthopedics (Foot/Ankle/Trauma)
• Burn Surgery
• Campus Health at WFU
• Vacation/Interviews
• Law and Medicine
• Sports Medicine
• Community Medicine

So, that's what the rest of the year looks like!  It should be fantastic.  After the last rotation, we have a few weeks of final lectures and a couple packing/moving weeks of vacation... then it's GRADUATION TIME!  Yay.

Have you heard the song "Smile" by Uncle Kracker?  If not, go here to watch the music video.  My favorite part of the song, by FAR, is the line, "cooler than the flip side of my pillow".  Because that's saying a lot to a person.

Really, the flip side of my pillow is maybe one of my favorite things ever!  First of all, it generally means you get to sleep a little longer.  I mean, who wakes up to their alarm clock, realizes they're 7 minutes late, and flips their pillow over to enjoy the rejuvenating temperature change?  No one, that's who.  Flipping my pillow over and enjoying that not-been-slept-on-since-the-last-time-you-flipped-me-over feel is just so lovely and refreshing.  The song seems to capture that moment so well.  Every time I hear it I think a couple things.

"Man, do I wish I could feel the flip side of my pillow right now!"
"Who do I know that is cooler that the flip side of my pillow?" 

Not many people are cooler than the flip side of my pillow.  And I know a lot of cool people.  Just not THAT cool.

You wanna know the best part?  I have four pillows.  That's one used side and seven cool sides.

Who do you know that's cooler that the flip side of YOUR pillow?

Throwing rocks is, in general, a bad idea.  I've thought for a long time about exceptions to this rule, and have only come up with skipping rocks across a lake, and maybe using a large stone tied to a rope as an anchor for your canoe.  In those two cases, by all means, throw away.  But in all other cases, if you find yourself with stone in hand, arm cocked and ready to release, ask yourself "is this a good idea?".  I can pretty much guarantee the answer is no.  If you answer "yes" to that questions, ask a friendly unbiased passer-by if THEY think it's a good idea.  They will likely say no.  Listen to them, they have better judgement and insight than you do. 

I'll give you two examples of stone throwing gone awry.  Warning: This somewhat humorous post will have a sad ending and a moral (just call me Aesop).  If you can't handle the heavy stuff, only read the first story then close the window and live in blissful ignorance.

Example 1: 6th grader ideas, better in head than in action.

My dad tells a lot of stories.  You see, he has a twin brother, and when they were growing up, they did a lot of things that were story-worthy.  I can say with some confidence that some of these stories were probably embellished over the years, but I imagine they all start with a grain of truth.  This story starts with my dad and his brother in 6th grade (I think... Dad, feel free to correct my historical mistakes).  He, his brother, and some friends decided that maybe they would play a game involving rocks.  They stood on opposite sides of the street, and started throwing rocks at each other.  Not surprisingly, one of the boys got hit in the head, leaving him with a sizable gash to his scalp, and a pretty big dent in his pride.  This event was somehow relayed to the school (maybe they were in front of the school?  I don't remember that detail), and they boys were all forced to go to each class in the school and talk about why throwing rocks is a bad idea.  Lesson learned.

Example 2:  Teenage boy, poor impulse control, poor(er) outcome.

A few nights ago in Davidson County (just south of Winston-Salem), a group of kids were having a party.  A 17 year old girl was on her way to the party when a 21 year old guy threw a brick through her windshield.  It fell into her lap, seemingly harmlessly causing her some pain where it hit, but luckily not causing her to crash the car, or hitting her in the head.  Why he threw the brick remains unclear.  It may have something to do with her previously dating his cousin, it may just have been a joke.  Whatever the reason, it did more damage than anyone knew.  Hours after the incident, the girl began feeling ill, and was taken to the hospital by a friend.  She was found to have massive internal bleeding due to a liver laceration, and died shortly there after.  I doubt the kid who threw it planned on lacerating her liver and killing her.  I doubt he planned much of anything.  He probably picked up the brick, though about how he was pissed and wanted to do something to her because of it.  He should have thought more.  Because now she is dead, he's in jail facing a life sentence or the death penalty, her family is distraught, and her classmates are in shock.  Because he threw a rock.

We can't predict all of the cascades of events that might happen because of our actions.  But we can predict the ones that are just a stones throw away.  Don't drive drunk if you're not prepared to crash and hurt yourself or someone else, or lose your license.  Don't do drugs or smoke if you're not prepared to be addicted.  Don't buy a plant if you're not willing to water it.  Don't buy a big house if you can't afford the electric bill to heat or cool it.

Whether you think about them or not, you will be forced to live with the consequences of your actions.  So you'd better think about what those consequences well be before you act.

Because tragedy can be just a stones throw away.

Kari

What makes you happy?

I am continually amazed by the amount of force the human body can withstand, the significant injuries that it can sustain and still survive, and heal.  I am also amazed by the little things that seem insignificant that can cost a person their life, but I will leave that post for another day.

Last night in the ED, I saw a patient who was the unrestrained passenger in a motor vehicle accident (MVA).  The exact circumstances surrounding the accident were not clear by the time I left, but the gist of it was that the car hit a tree or pole head on.  This passenger, a teenage girl who was getting ready to start college in two weeks, luckily did not seem to sustain any life threatening injuries, despite the fact that she was not wearing her seat belt.  She did, however, sustain a very severe jaw fracture, multiple facial fractures, a skull base fracture, and a wrist fracture.  When we first evaluated her, she had obvious facial bone deformities, and CT scan showed that her lower jaw had been fractured on both sides, and displaced laterally and posteriorly... basically her jaw was being shoved into her mouth and neck.  Best and we could tell, she took the majority of the force of the crash with her chin, resulting in these fractures.

In all likelihood, most of her injuries would have been prevented had she been wearing her seat belt.  Now, this is not meant to blame her for the injuries by any means.  Most of us have driven somewhere and forgotten to put out seat belt on, or thought we were just driving a short distance and it wouldn't matter.  But it does.

Over 50% of people who die in car accidents would have survived had they been wearing their seat belts.  No one really disputes that seat belts save lives.  And yet there remains a significant disconnect between what we know and what we do.  Seat belts aren't meant to protect us from the daily driving that doesn't end in an accident.  They are meant to protect us from that one unlucky second, when the stars align in just the right way, and we are in an accident.  I can't predict the future (sad, I know), and I'm assuming most of you can't either.  So why take the risk?  Why have the chance that you're family will be standing in an ED or ICU, saying "well if he'd just worn his seat belt, he'd be alive." 

There are a lot of things in this world that we can't prevent.  Bad stuff happens all around us that we have no control over.  Take control of the things you can control.  Put your seat belt on every time you get in the car.  Don't ignore that annoying beep that persists for just a bit if you forget to put it on.  Take it as the little voice of your child, or mother, or grandchild, saying, "don't you want to be here to see me tomorrow?"  And put on the dang seat belt. 

Drive safe,
Kari

PS.  Don't forget that you can adjust the height of the seat belt on the door so it doesn't slice you're neck :)  Makes it way more comfy...

I just got home from a short shopping trip to Lowes (I make a lot of those in a week... good thing it's close by).  On the list today were a new broom (one for the inside, since the outside one is so gross), a couple spare apartment keys, and some new sponges for the kitchen sink.  I usually get the no scratch blue Scotch Brite ones... no particular reason, its just my norm.  Today, though, I was drawn to the pink ones, which I think are virtually the same, but they're pink!  For whatever reason, these sponges made me extraordinarily happy.  I don't know if it's because they are pink, or because I really get good tingly feelings when I bust out a new sponge.  But anyway, I love them.  I should have bought more, just in case they don't have the same ones next time I need new sponges. 

What simple things make YOU happy?

Kari

So I decided today was the day I would finally take the cross bike out on the trail after it's makeover a few weeks ago.  I'm not sure why I chose the hottest day of the week (where temps are supposed to reach 97 degrees without the heat index...)  So I loaded it up on the car, drove to Salem Lake, and set out.  I got about a mile down the trail when I realized my brakes were not really working.  If I squeezed both, really really hard, I could slow to a slight blur.  But if I kept going, I realized I would likely run into a tree at 20 mph.  Which doesn't sound like fun.  So, I stopped to see if i could work any magic on the brakes.  When stopping, I realized something else.  I hadn't adjusted the tension on my new pedals and had to work very hard to get my feet unclipped before crashing into a bench, or the creek just past the bench. 

So, I tried to fix the brakes and couldn't.  It required tools I didn't have with me.  Well, I had no tools with me.  So, I turned around, rode the mile back to the partking lot, loaded back up, and came home.  Boo.  I suppose I'll just go to the gym later.  I went for a run yesterday afternoon and it was just too hot.  Today is hotter... no running for me. 

Kari

Alternatively titled "Today is NOT Monday!"

Shift work has a way of messing with a person's sense of time.  I've been working a strange concoction of different shifts in the ED (Emergency Department: new term for the Emergency Room... since it's not just one room...), and they don't really let you get on much of a schedule.  I had some lectures Friday morning, then worked Friday night in the Peds ED from 6pm to 2:30am, then yesterday (Saturday, right?) from 5pm to 1am, then today from 9am to 5pm.  I think because I came home Sunday morning, I figured the next time I'd be back was Monday morning... lies.  So all day I wondered why we kept getting DFO's from church, and why there wasn't much traffic by the mall.

Now, for those of you who are not from the South... and even those of you who are, but have never thought to abbreviate your colloquialisms, you may be wondering what DFO means.  Ahhh, the education you are about to receive.

So those of you who go to church (and it's okay if you don't... you've just missed out on lots... hymns, Jesus, DFO's...), you've all seen a DFO.  You're sitting there in the pew, listening to the preacher preach his or her sermon.  You're enthralled, focused, and attentive.  And then, out of the corner of your eye, you see someone get out of their seat, and slowly walk to another pew, next to an old person.  An old person who has slumped over in their seat.  Or, after the service, you are all standing around chatting about Sunday dinner menus, and someone passes out.

I don't know exactly what makes Sunday morning and church such a passing-out friendly location.  But it seems to happen on a weekly basis.  DFO'ing is not exclusive to church though... it can happens in moments of extreme emotion (maybe finding a super-awesome sale at the mall), or during physical exertion (planting beans in the garden), or really just about any other time life is really excellent, really bad, really hard, or maybe even just different. 

So, what DOES DFO mean?  Welll, clearly is means "done fell out"!  As in, "wellll, we were just sitting there eating corn bread and meemaw stood up to get some more pinto beans and she just don fell out!"  In general, people who DFO turn out fine.  Of course there are exception (like there are to all rules), but if it didn't turn out okay, I wouldn't joke about it. 
It was just one small step in my learning of the southern language that has taken place in the last three years.

Dear person who smoked inside the restroom in the hospital,

I am writing this letter to thank you for sharing your smoke with me.  While I was on my way out of the hospital at 1am, I had to pee.  And so I stopped in at the women's restroom, in the middle of the hall, in the middle of the (nonsmoking) hospital.  I'd been working for over 8 hours, and wanted to get home.  What I didn't know is that I really needed some second hand smoke to make my night better.  Luckily, you knew, and came to my rescue.

When I went into the restroom, not only could I smell your cigarette, but I could see the leftover haze.  Phew, I thought I was going to have to walk the whole 4 minutes out of the hospital without my daily dose of second hand smoke.  Usually, I have to get the whole way to the sidewalk before you all start sharing your smoke with me.  But not today!  Today, you decided that the 4 minute walk outside was too far for you also.  So you decided to light up INSIDE.  But I guess you figured people might look at you funny if you smoked a ciggy right there in the middle of the hallway... especially if you are one who also requires supplemental oxygen.

So back to the point of this thank you letter.  Thank you for giving me the opportunity to remember why I don't smoke.  I mean, the whole eye burning, coughing, hacking experience is a good time and all.  But I'd say life is pretty good without it.  Plus, I save like $30 a week, most likely won't get chronic lung disease, lung cancer, throat cancer, mouth cancer, an abdominal aortic aneurysm, cardiovascular disease, and I won't "appear older than stated age," which is a favorite phrase of the ED (that you DON'T want someone to say about you...).  But then again, I'm sure you've grown fond of standing in the rain, heat, snow, old, wind, etc to smoke your beloved cigarettes.  While leads me to the question of why you chose to forgo that awesome experience to smoke in the bathroom.  Was it so you could come back later and relive the fun?  Or because you couldn't remember which way the door outside was?  Or because were visiting and didn't know where the cool place on campus was to smoke?  Either way, I think you may have started a new trend of hiding in the bathrooms to smoke illegally... it's kinda like high school, huh?  I hope you really liked high school...  They always did say it's the best time of your life!  I'm glad that was not true for me.  But you keep living the dream.  I'll watch from a distance... and use a different bathroom.

Keep smokin',
Kari

My birthday was on Tuesday!  I turned a quarter of a century old... it's probably all down hill from here. 

In order to ease me through the next 25 years of life, I bought myself a present.  A wonderful, wonderful present.  Let's rewind two years...

I was working at Kutsher's Sports Academy in Great Barrington, MA for the summer between 1st and 2nd year.  I was working in the infirmary taking care of sick kids, and the infirmary was in the bottom floor of one of the main buildings, and had no air conditioning.  In addition, in the small space, I was running a small fridge, a big fridge and freezer, an ice maker, and a dehumidifier.  Needless to say, they put out a LOT of heat.  So, I was hot.  All the time.  This was conquered by eating ice cream, which I could conveniently store in my freezer.  So, my birthday comes along, and I got a box.  A Styrofoam box.  I've learned that only good things come in Styrofoam boxes.  So I open it, and what do I find but a little piece of heaven in the form of 6 pints of ice cream from my friend Cody. 

This is not ordinary ice cream, however.  This is Jeni's Gourmet Ice Cream from Columbus, Ohio.  Now I am a big proponent of high quality ice cream to begin with.  I think if you're gonna eat it, you should eat something that tastes good.  And if you've never had high quality ice cream, you will realize it's worth the extra cost.  Anywho, Jeni's ice cream trumps anything I've ever had before.  It's smooth and rich and the flavors are more important than the sweetness.  Some are simple, common flavors taken to a new level, and some are complex, odd flavor combinations you would never think would be good... but are!

So today I finally settled on six flavors (you have to but at least 4 pints, but I figure I might as well go for 6 if I'm gonna do it!) and placed the order.  It'll ship Monday, arrive Wednesday, and I'll start letting you know how jealous you all should be!  The flavors I ordered are: Bangkok Peanut, Salty Caramel, Belgian Milk Chocolate, Kona Stout, Riesling Poached Pear (Sorbet), and Sweet Corn and Black Raspberries.

Check out the link to the website for descriptions about the flavors!!

Cheers,
Kari

PS.  Remember the post about Waiting For the Wolf to Come?  I had one the other night in the ED... a 24 year old kid who liked to ask for IV Dilaudid, and also had a history of some pretty serious medical problems who came in with abdominal pain.  We couldn't send him home in case something really was wrong, but we certainly didn't give him all the IV Dilaudid he said he needed...

Have you ever had a day where you really did nothing?  And had a splendid time doing it?!  I think those can be the best days, and I had one yesterday. 

I will preface this story by saying that everyone needs a friend who you can share a day like this with... who will spend the whole day doing really nothing with you, and you can laugh and still have awesome stories.  I've had a few of these friends through the years... you know who you are!  Right now, I have Betsy.  This was our day.

We started out planning to do something fun, new, and adventurous.  Something that, come 2.5 weeks and my ankle surgery, I won't be able to do for a while.  Horseback riding, kayaking, and hiking were at the top of the list.  We planned on picking up a couple cowboy hats, and heading to this beautiful farm to hop on a couple horses and ride clumsily into the sunset with a well-trained guide to pick us up if we fell off.  Good plan.  Unfortunately, they didn't answer when I called to make reservations AND the weather was a bit gray and shady.  So we decided to not pursue the horseback riding too heavily, and scratched kayaking because falling into the water (which we would most certainly do) would be cold.  So we settled on hiking Grandfather Mountain, a mountain we haven't been to yet, that's on the list of things to do before we leave North Carolina (ooo, I will have to post that list one day...).

So we were reading on the trusty Blackberry all about Grandfather Mountain and the things to do there, as we drove north/west towards Boone.  And then, we ascended into this.

How many of you have a scar on your knee?  One that required stitches?  How about one on your chin or forehead?  Congratulations, you have officially lived a normal unsheltered childhood!  In the last two shifts in the pediatric ED, I've decided that if you come out of childhood (which I will say includes college, because lets face it, it's four years of regression in the decision making and coordination/balance department), without a scar on your chin, forehead, or knee, you've probably spent a lot of time in a bubble or small padded room, were never allowed to go to parties and Chuckie Cheese, and your mom put neosporin on everything, including bruises, just to make sure they didn't get infected.

I've had the privilege of introducing two young kids to the world of stitches.  Both on the left knee.  One was the victim of an AC grate, and one the victim of his bicycle.  It's like a rite of passage into childhood!  The mom of the kid I stitched up tonight said to her son, "she's done this a lot before, it looks good as new!"  I chose not to tell her this was the 4th time I'd even done it, but I get much better every time!  I thought it would be better to let her live in the world of oblivious faith in my skills.  There's a reason I don't wear my (short) white coat in the ED... none of the patients would ever let me do anything! 

One of the things I'm enjoying about the ED is getting to do procedures... laceration repairs, abscess I&Ds, lines, etc.  I was pretty uncomfortable with them before this rotation because we just never got much practice.  Now's I'm totally comfortable with most of it!  Ahhh, progress.  It's a beautiful thing. 

I suppose there IS a reason we go to school for 4 years... we work hard to become something beyond glorified WebMD readers, contrary to the belief of some patients... 

Tomorrow Betsy and I are going to try to go horseback riding...  I hope neither of us end up needing stitches.