October 2006 Archives

... creeps in this petty pace from day to day, to the last syllable of recorded time. And all our yesterdays have lighted fools the way to dusty death. Out, out brief candle!

Macbeth may have been describing his resignation to the barren futility of life, but this, my favorite of all Shakespeare quotes, is apt in describing my own resignation to the futility of my own fate:

Tomorrow I take the boards.

However, unlike Macbeth, who goes on to be attacked by an army disguised as a forest and then decapitated in a fierce dual by the man whose entire family he had murdered on a selfish, power-hungry whim, I hope to enjoy a more successful outcome. I will fight with determination and honor. And oh, it will be a long, tiresome battle that may push me to the utmost end of human reserve, a battle that will consists of sitting in front of a computer screen for 9 hours, frantically answering question after question after question. To this fate I am resigned.

I wish I could say that I felt more prepared. I have been studying, yes, but, as you know, I have also struggled with procrastination and distraction and an acute case of 5th year senioritis. To make my own situation more difficult, I decided to take 4 days off right before the exam and attend the national conference of the American College of Emergency Physicians in New Orleans. New Orleans!! So what was I doing this past weekend when I should have been studying and taking practice tests? I was walking around the French Quarter, and eating beignets, and attending lectures on pediatric rashes, and seeing the governor of Louisiana give the opening address, and meeting with residents of programs I am applying to, and getting beads thrown at me from balconies on Bourbon St (without exposing anything, I promise), and sitting in dark jazz clubs, and wandering around centuries-old cemetaries, and developing a sense of pride and belonging in a specialty that I will soon call my own. And let me stress that this was completely and entirely worth it.

I might not be as confident in my medical knowledge as I would like to be, but what's done is done. I am here. I will review my notes today, I will take the nasty test tomorrow, and then I will develop my photos from New Orleans. And there is a good chance that while staring at the bright, subtly flickering screen tomorrow for hour upon hour I will begin to hallucinate, perhaps about horses going insane and devouring eachother's flesh.

So if you think about it, dearest urban honking community member and/or internet friend, send me some good luck vibes tomorrow. I will most certainly need it.

My job as a medical student doing a Toxicology rotation at the Oregon Poison Center is to follow up on patients who are admitted to the hospital for tox-related issues. Most of these patients, unfortunately, have attempted suicide by overdosing on varying combinations of medications, both prescription and over-the-counter. And the particular combination or amount that they happened to chose was not immediately conducive to death, hence their admission to the intensive care unit instead of the morgue.

I arrive in the morning and get a list of the hospitalized patients that are scattered across the Poison Center's coverage area, which includes Oregon, Alaska, Nevada (except for Las Vegas), and Guam. An unlikely geographic collection, to be sure. You should see the timezone clocks hanging in the call center. After divying up the list between the other student and resident, I start making long distance phone calls, putting on my official Poison Center voice and asking the hospital operator to transfer me to the appropriate area of the hospital. Once transferred, I ask to speak to the patient's nurse, and then usually listen to smooth jazz versions of beatles songs for between 1 to 10 minutes. Once I have the nurse on the phone, I introduce myself again in my professional yet conversational, friendly yet no-nonsense, official medical voice with my pattened, well-rehersed tag line: "Hi [RN's name], this is Fiona with the Oregon/Alaska/Washoe (NV) Poison Center (no calls from Guam yet, unfortunately). I'm calling to follow up on patient Toxy McPosions. How is she doing today?" I then collect the appropriate information about status, vitals, EKG changes, and any relevant labs, in addition to the therapeutic interventions that the patient has received to date.

Once the hospital operator accidentally transferred me directly to the patient's room. "Hello?" said a gravely, sleep-drenched male voice. "Uhhh..." I said as my mind reeled in confusion and panic - this is not what is supposed to happen!! "Is this Mr. Johnson?" "Yeah." Oh my god. What do I say. What do you say to the person who is recovering from their unsuccessful suicidal overdose? "How are you feeling?" "Fine." .... pause... "I'm calling from the Poison Center... to check up on... on how you are doing." I can't believe these words are coming out of my mouth - this is awful. "I'm doing fine." "Great. Is your nurse available?" Very slick exit - the patient then presumably attempted to summon his own nurse, who I spoke with minutes later when I called back and asked to be transferred to the NURSE'S STATION. The nurse, of course, is much better equipped to give me a summary of the trend in liver function tests than the poor patient.

At rounds everyday we sit in the conference room and discuss each patient with the attending toxicologist. This is known as "rounding." At these sessions, decisions are made about starting treatment, stopping treatment, what other labs need to be ordered. This is also the appropriate time for testing the med student's knowledge of the stages of aspirin overdose, the symptoms of Neuroleptic Malignant Syndrome, or the one kind of toxic alcohol that does NOT cause an anion gap metabolic acidosis (its isopropol). This is known as "pimping." I then call the hospital back with the official Recommendations.

The whole process is quite interesting. Its odd, when you think about it, to be having long conversations about how to keep alive someone 2,000 miles away who was unsuccessful in their attempt to kill themselves. Its crazy. I suppose I simply can't imagine what it would be feel to actually come to the conclusion that ending your life is the only feasible option. This is inconcievable to me, and it makes me very sad that other people fight such deep horrible depression.

Interestingly, a very common intentional ingestion is acetaminophen (Tylenol), mostly because I don't think people know how bad death from liver failure actually is. Take it from me - its bad. Maybe I'm wrong, but I think people generally know that overdosing on tylenol can kill you. Atleast, the people who attempt suicide by taking a whole bottle are probably aware of this. But perhaps they think you will just go to sleep and never wake up, insead of gradually developing intractable abdominal pain and vomiting as your liver becomes inflamed to the point of complete dysfunction, eventually leading to acidosis, bleeding, and gradual decline in mental function as ammonia builds up and your brain swells within the skull. This is assuming that you are not a candidate for a liver transplant.

Anyway, I am enjoying my rotation so far. And blogging about it is providing excellent procrastination material.

Instead of getting much boards studying done over the weekend, I spent my time reseaching venomous snakes. I'm sure there will be numerous questions about this topic on the exam, so my time is well-spent (and should in no way be considered a procrastination tactic) . And when I arrived to the Poison Center on monday, I insisted on getting a poisonous snake lecture for our post-lunch activity (yes, the other students LOVE me). Here are some basics:

There are 7-8000 venomous snake bites per year, of which 5-6 result in death. In North America there are 4 kinds of venomous snakes, comprising 20 different species. There are Rattlesnakes, Cottonmouths (aka water moccasins), and Copperheads, all of which are pit vipers (Crotalines). Then there is the coral snake, which is its own special entity (it has red, black and yellow stripes). In Oregon the Western Diamondback Rattlesnake (or "rattler" as I like to call 'em) is the most common.

The only states without venomous snakes are Alaska, Hawaii, and Maine. (Mike, your parents had the right idea). If you want to avoid venomous snakes, do not under any circumstances go to Australia - they have like 20 different kinds.

Here's an exciting fact: The bite reflex is so strong in snakes that they are able to inflict bites even after they are dead or even decapitated! So don't pick up recently killed snakes. Come on now, surely they could have worked that into Snakes on a Plane? "I just chopped this motherfucker's head off with an axe, see - AAAH! Motherfucker's decapitated head just bit me on the ass!" Samuel L, I'm counting on you for this in Snakes on a Plane 2, or Snakes on a Cruise Ship - Revenge of the Pit Vipor.

My favorite quote from the New England Journal of Medicine article on snake bites: "The most common reaction to snakebite is terror, which may cause nausea, vomiting, diarrhea, syncope, tachycardia, and cold clammy skin... Autonomic reactions related to terror must be differentiated from systemic manifestations of envenomation."

So who gets bitten? The classic story is just someone who was out innocently wandering through the desert, minding their own business, when out of nowhere a snake exploded through the bushes and viciously attacked them. This may or may not be the case, but in emergency medicine there is a Rule of T's that describes who gets bitten:
Testosterone (victims are almost always male)
Twenty-something (average age is 17-24)
Too much to drink (and we're not talking water)
Toothless (maybe they're all on meth?)
Taunting the snake (so much for the "minding my own business" theory)

Point is, snakes are mostly terrified of you and will not bite you unless you drink a bunch of Miller High Life and corner it against a wall and poke sticks at it to impress your buddies (trust me, we've all been there). The general exception to this rule is when hundreds of snakes are secretly loaded onto a plane and exposed to hawaiian leis soaked with "pheromones": this causes them to be incensed into a blood-thirsty frenzy. Snakes in this situation should generally be avoided.

But then what do you if you or your buddy gets bit by a rattler? If you were to base your first aid technique on Snakes on a Plane, you would be a hot young latina mother who learned how to deal with snake bites while growing up in the desert; you would take a knife and slice into the wound on the ridiculously swollen forearm of the adorable blond little boy who was bitten by a king cobra, huge amounts of fluid would gush out, and then you would apply your lips and attempt to physically suck the venom out of the wound. Onlookers would invariably find this incredibly sexy. Because, as we all know, there is nothing in this world that is sexier than a woman sucking poison out of the oozing, swollen arm of a small child.

This is exactly what you are NOT supposed to do. IMPORTANT NOTE: Do not apply tourniquets, do not incise the wound, do not attempt to suck out the poision, do not apply ice. These actions are strongly discouraged. Instead, keep the person warm, immobilize the injured body part below the level of the heart, take off any rings, watches, or constrictive clothing, and transport the person to the nearest medical facility. Oh, and call the Poison Center so they can get the anti-venom ready.

Which brings us to venom. Venom is basically an ultra-concentrate of the snake's digestive enzymes, designed to immobilize and then digest a small rodent before swallowing it. It is comprised of complex mixtures of many different proteins, many of which are enzymes that break down cell components. These proteins damage the walls of blood vessels, causing fluid and electrolytes and blood cells to leak out. Venom can cause toxic damage to every organ system, and the effects in humans range from localized swelling to shock, generalized bleeding, and death.

Its a good thing, then, that a Brazilian doctor name Dr. Brazil invented anti-venom. Seriously - that's his name. They inject a horse or a sheep (the sheep are better) with the venoms from different snake species, and then wait for the sheep to create antibodies. The sheep serum is then removed and the antibodies are filtered out and chemically altered a little bit. Several vials of these processed antibodies are then injected into the body of a human snake-bite victim, and they bind to the venom proteins and deactivate them. The antivenom available here is effective against almost all poisonous snakes native to the US.

Now you know. But you should still consider watching Snakes on a Plane.