What's More Important - Your Kindle, or Your Eye?

So we have had this wonderful patient at JEI who developed a corneal ulcer which ultimately bought her very frequent visits at the clinic. They always do. She was always very religious about making it to her appointments and always did what we asked. It's not an easy course if you've never done it - drops every 30 to 60 minutes in the beginning, sometimes even throughout the night the first few days. That's worse than having a hungry midnight infant.

She always had one thing to talk about which, to her, seemed far more interesting and important than her eye. It was her Kindle. Or her Cruz. Or whatever her most recent e-reader purchase was. She would buy one, take it for a spin (or a read), decide she didn't like it, and then turn around and sell it on Ebay for a profit. And they sold - every time. This lady made a profit turning over e-readers. What was even better was her ever longing desire to show me her latest one. I think it was only becuase I showed an interest.

It was only polite.

The Starving Artist

It's comical to me (so I crack myself up, what of it?) that I often say my patients in the ER, as I'm sewing their face back up, that I compare myself to a starving artist. Okay - so the comparison is weak. But simply draw the thin line between an artist not making any money but trying with his artwork to an underpaid resident trying to delicately put a face together.

The big abdominal surgeon doesn't really care (nor should he) about the resultant belly wound after a big aneurysm repair. The patient could go about his life with only those very close to him knowing of the scar. The case is quiet different when someone has a big laceration on their face. There's this expectation, if not a defined duty, to fix the wound such that any scarring is minimized. It truly can be an art sometimes.

Fortunately, the face tends to heal quite well - especially when talking about around the eyes.

Projectile On Exam

I mentioned once before the difficulty of trying to examine someone when they keep wanting to vomit. But every time in the past there was fair warning; a "Whoa, I really don't feel well." has generally sufficed. Things got just a little too close recently.

I went in to see a patient with orbital fractures who had just been brought up from the emergency room. I'm sure by that point he had been pumped full of IV morphine on an empty stomach. I had done the first part of the eye exam some time ago while he was still in the ER and had only to wait for him to dilate. The story at this point is not embellished in any way. He was lying in bed and seemed quiet and perfectly content; that is not to say there was a smile on his face or anything. I had my fancy light strapped to my head and my fancy lens in my hand. I was leaning in, though not for a kiss, when he suddenly sat bolt upright in bed and spewed across the room. My hand was inches away. Inches.

Fair warning is nice.

The Roast

No - THAT'S a roast.

It has been tradition in our program to roast the outgoing residents on the infamous Resident's Day. It's funny - you spend all day "honoring" the chief residents only to end it by making fun of them. 

There are all kinds of levels, bad to excellent, in which a particular roast may fall. I had see one of the bad types when I was a student - I basically spent the whole time wondering what exactly was going on. At first I thought it may have something to do with the fact I wasn't that close to the resident being roasted. But I later found out that, no, it was in fact just bad.

This past year, I can honestly say they were all pretty good (and not just because some of the roasters/roastees are occasional readers.) Things were tasteful yet still humorous. It can be easy to go overboard, beat a dead horse, or repeat things which have been overdone in the past.

I have since then been wondering how things will go when I do it. I think I have a fairly good idea who I will be roasting. I also think I have a fairly good sense of humor. Only problem is, it is a bit dry for a lot of people. I've been known to be pretty sarcastic yet overly blunt. Sadly, I have already been trying to keep a log of things potentially worthy of a roast.

We'll see.

No - I can't Accept That

It is very common place, particularly at a tertiary referral center like UAMS, to get patients transferred to us who are in need of more specialized care than can be provided at their current location. In ophthalmology, for the most part, this occurs on an outpatient basis. But there a couple examples of people trying to send patients to the inpatient ophthalmology service (what??!?!?) in need of better eye care. (Hey, in our defense, we do occasionally have our own inpatients.)

One patient was one with sudden decrease in vision in one eye, not to mention multiple other systemic vascular issues going on. We don't even admit those people unless IV steroids are warranted.

Another was a surgical patient who complained of blurry vision. This patient had multiple surgical issues going on (as in not having healed from the surgery and now with infection). Would we please accept the patient? Um, no. Try the surgery service for a surgical patient and we would be glad to consult.

What are we, doctors?

It Can be Hard to Go Back to Routine

Old picture, but she still pulls it off much better than I.

For about eleven months of the year, we have morning lectures on Monday, Wednesday, and Friday. Between the time of the OKAP exam and resident's day, the whole morning conference thing went to the wayside.

Naturally we've been back at if for about a month now. Probably one of the more difficult things to do was to get back in the routine of keeping up with a defined study schedule. I have always really enjoyed the fact that our didactic component of the program is rigidly organized - it forces our hand to keep up with reading regularly; whereas in other programs this may not be present and reading is just supposed to happen during  magical free time. I was once told by a smart man that while surgeons may work at the hospital 80 hours a week and we maybe 50, we make up for that other 30 with extra reading. I'm not sure I get in 30 hours a week of reading, but you get the point.

Anyways, I suppose I should get back to reading about the biochemical oddities of the human lens.

Check a Blood Pressure Sometimes

Even an eye doctor can use this.

I have mentioned before the feast or famine nature of the Children's emergency room - I'm either told way less than the actual truth, or the picture is painted way out of proportion. I'm used to it. But what is even worse is when I am consulted to see a patient with an "eye" problem when there is clearly something else going on. This has happened a couple times in the last couple months - and both times at the VA.

The first was a patient who had an episode of decreased vision in his only good eye, the other being nearly lost secondary to glaucoma. So surely I would want to see the patient right away, right? I walk in the patient's room in the ED to find him attached to a blood pressure cuff with fluids running into him. This was his second liter of fluids, with a systolic blood pressure still barely over one hundred. I already knew the problem - hadn't even stated my name yet or seen an eyeball. After further (proper) questioning of the patient, I come to find out he hadn't been eating or drinking, while on diuretics, and had this episode of decreased vision after he stood up and got dizzy and subsequently fell. Most non-physicians could diagnose this - LOW BLOOD PRESSURE. EYE = FINE.

The second was a patient sent from the vascular surgery clinic because he was having intermittent, brief episodes of dimming of his vision. Medications? Oh yeah, he was recently switched from one beta blocker to another because of excessively low blood pressure. What he was not counseled well on was to actually stop the first. So he went home from the hospital taking both. And his symptoms usually occurred while he was standing on a ladder painting the ceiling. Clearly another case of hypotension-induced vision change. Again, LOW BLOOD PRESSURE. EYE = FINE.

Moral? Check some vitals, ask some good questions, be a doctor, and then consult. Only then. These are two gleaming examples of textbook, board-worthy, EASY scenarios.

I Won't Miss the Consults



Not really.

Tomorrow marks the end of the new first years' orientation stretch. This means a few things - all of which are generally good.

First, at least at JEI and the VA, I will never again be responsible for the consults. For the most part. There will always be vacations to cover, but those only come a week at a time. And of course at Children's the consults are done by both the junior and senior resident on a day-to-day basis, but oh well. I can't even begin to tell you how glad I am to be rid of the JEI/UAMS consults.

Second, their help will be present in the clinic. Lightened clinic or not, the extra hand is ALWAYS appreciated, no matter how many or few patients that one person can see in course of a clinic. I remember being in that position and feeling like I didn't contribute much by seeing a small handful of patients,  but I later realized the luxury of (almost) anyone's presence.

Third, they are two weeks closer to taking call which only means less call for the rest of the junior residents. Yay.

"What? Candidemia? Call someone else! . . . .Please."

Ahh Yes, That Was a VA Monday

Everybody likes to tell you about what makes their Monday worse than yours. Maybe it is. Maybe it isn't. Either way, most people have a Monday that sucks for them. For the last eight months, Monday was just another day of the week - busy but manageable.

But now that I'm back at the VA, Mondays are different. I can't really say that I almost forgot what they were like - nobody does. Mornings can be shaky - full AM clinics with a large uncertainty of what level of help will be available. Afternoons are always shaky. There is an overabundance of retinal patients scheduled, and again, uncertainty of what level of help will be available. The retina attending is excellent with his patients and has an excellent bed(chair)side manner. But this comes at a sacrifice for efficiency. Now some people are able to do both, but that can be difficult in a retina clinic. The unfortunate thing is, as a resident clinic, it should be residents doing the lasers and the injections - that's our time to learn them. But instead, to extend more good manner, the attending has a tendency to do them. This takes him away from staffing patients while everyone waits in the hall for him. I myself am not too worried about it since I plan on doing plastics and retinal lasers will be far out of my league.

But as I have said before, the chances are low. So I have to be prepared to do other things.

Awkward Moments

This is another trip down memory lane type of post, but couldn't call it that for duplication of a prior title.

Every medical student goes though four years of school (or I suppose more in some less fortunate cases), and in probably every case, there is at least one encounter with an attending that makes you uncomfortable at least once. The biggest one for me was as a third year medical student.

I was rotating on the surgery service. As part of the deal, we had to spend a couple afternoons in the breast oncology clinic. This was a surgery rotation, and a surgery clinic, so naturally these patients had or were going to have surgery. For those of you who haven't figured it out yet, those shiny, white things in the corner are breast implants. At any rate, one of the attending surgeons who will remain nameless was very eccentric and somewhat odd overall. On a Stamp Out Smoking day she walked around with a fake cigarette in her mouth. Twisted, no?

Apparently at some point she saw an opportunity to make a medical student uncomfortable. Me. She came out of a patient room and practically demanded I come into this room with her. I went into the room and find sitting right there a bare chested woman. I think she even had a bit of a mock grin on her face, knowing what was about to happen. Behind her I swear there was a gathered crowd for the show: a fellow, maybe a resident, a family member or two, and there may have been a clown.

"What do you notice about these breasts?" the surgeon said.
"Well, uh, I. . ." I stammered. Usually there is a rapport established with a patient before you see her breasts. Usually.
"Well go ahead, touch 'em," the surgeon said.
So I did. What else would I do? Firm yet soft, well rounded. "Okay."
"Well, what do you notice about them?"
"I. . .I don't know. They feel different, but okay."
"They're fake!" I think at this point party streamers and confetti flew across the back of the room.
"Oh. Well good job, doctor." Then I turned and left.

Nothing like a wacky attending paired with a woman who is ready and willing.

I Would Be Catatonic Too

As you well know, pretty much every hospital room comes with a TV, and most with a full range of basic cable channels. In fact, at the children's hospital, there is a full X-box set up in most of the rooms, making it difficult to convince them sometimes that it is time to go home.

At the VA, it seems as though the televisions are mostly controlled by a central output. I remember making medicine rounds (now over a year ago!!) at the VA and catching time lapsed segments of the same news broadcast (or Lawrence Welk rerun) as I went from room to room. By the way, as I'm writing this, beer and Starbursts don't go well together, but I keep it up anyway. At UAMS in any patient room that is intensive care or otherwise empty, there is some nature scene with serenading elevator music playing.

But one time, there was something else. I walked into this man's room in the ICU. He was getting frequent followup eye exams by us for something in his orbit. As I walked in, I found on the TV an invigorating episode of Curious George. He was, of course, just staring blankly at the screen.

I think I would also remain catatonic if someone left that on TV for me. I just hope it wasn't on a loop.

The Excitement of the New Guy

You know I'm interested in doing a fellowship in oculoplastics. You know how much it would mean to me to gain a spot in such a fellowship. So naturally when I found out we were looking for a new oculoplastics physician, I was intrigued. Then, I found out we had actually hired one (tough to do on the tight JEI budget). Then I was truly excited.

After his arrival I found out what true excitement is. He is a young guy, fresh out of fellowship and after a stint in the military. He is far more published that most people this early in his career. His sheer enthusiasm for doing more research is nearly infectious.

We have a couple more new folks starting the coming months, but I somehow doubt they will match his excitement at being where he is.

You Know You're Ready to Rotate When. . .

This may be a bit dated since it applies more to when I was nearing the end of my UAMS rotation, but I feel it will soon apply again since we are now on two-month rotations instead of four.

Because of the way things are, I spent eight straight months at Jones Eye Institute. I like most of the people there, enjoyed the relative ease over there, but was more than ready to leave. There are certain telltale signs to prove ones readiness.

One of these is counting down to the end of a rotation by the number of clinics. For example, at one point, I know I was saying, "Only three more Friday afternoon clinics until I leave this place," or, "Only two more neuro-op clinics left this block." It seems small to you, but these are milestones. Yeah, yeah, Mia sat up at six months, and that too is a milestone. But she never had to sit though contact lens clinic, she never had to sit through Friday afternoon optics lectures.

I know, I know. Big baby. Still, all countdowns come to an end. And I was happy.

An Update From the Fourth

From Happy Bear Fireworks

The Fourth of July is an ophthalmologist's worst nightmare. That and New Year's Day. These are the two times a year when people can legally shoot fireworks, so naturally the do. Hey, we did too, but more on that later.

We at UAMS hate it even more because that is when the community ophthalmologists disappear (smart) for the weekend and their respective community hospitals are left with no coverage. As we start to roll into the weekend, so do the injuries.

As a general rule, injuries are secondary to things like bottle rockets and roman candles causing blunt trauma to the eye, resulting in a hyphema, or bleeding in the eye. But sometimes, the larger fireworks unexpectedly explode before people have a chance to get back. This has happened. And in one case, the eye injury was significant enough that the eye had to be taken out.

So we did fountains, sparklers, and smoke balls, but overall nothing projectile. I leave that for others, and watch from a distance.

Back At The VA

I may have ended the first year yesterday, but with the beginning of the second today, I have returned to the VA. There isn't a busier rotation.

It will have its upsides, though. During this block I will start operating on a regular basis. I will be starting with cataract surgery, though at the children's hospital others will be starting with different things. Don't get me wrong, there are cataract surgeries done on children on a regular basis; but, the residents don't generally do much of them.

We'll see how things go. Currently my first cataract case is on Thursday next week. It would have been Tuesday, but that one already cancelled. Don't even get me started on what will be that huge headache. There are a lot of ways to cancel a cataract surgery, particularly at the VA it seems. And anesthesiology folks are often the driving force behind them (though not in this particular case). It's almost as though they just don't want to have to sit around during our cataract surgeries. Why not? They require minimal effort by anesthesia at the start of the case; the rest of their time is spent on an iPhone or with a magazine. Not being mean here, just simply stating a fact. The job doesn't get much easier than being in a cataract case.

Anyway, I have bid farewell to eight straight months at JEI. And not that there was any one person to blame, but that was just too much.