Area Woman Rushed to the ER with Fatigue for One Year

Area woman presents to the ER looking pale as a ghost and complaining of fatigue for one year.  Labs showed that she was quite anemic and iron deficient.  When asked why she waited so long to be checked out, she was unable to provide an answer.

Area Woman Has Emergent Menstrual Period

Despite having no indication of being pregnant, such as missed period, morning sickness, breast tenderness, 24 year old area woman reports to the local emergency room at the time of her normal period complaining of vaginal bleeding thinking she was having a miscarriage.  When asked if she was pregnant, she responded "I don't know."  When asked if she had taken a home pregnancy test, she answered "no."  A serum beta HCG was run stat which was negative, and a much relieved patient was discharged home I am sure to return to her much productive life.

Tales From the ER

I finished pediatrics last week and have since moved onto emergency medicine.  I enjoy seeing kids quite a lot but not enough to do it full time.  I like the variety of seeing both kids and adults.  One of the things that makes pediatrics challenging is that it involves a fair amount of hand holding (i.e. reassurance) and you get a lot of non-medical questions.  In medical school we learn about things like omphalocele and intussuception.  In reality, most of the questions in pediatrics seem to involve how much formula the baby should be drinking and how often they should be pooping, neither or which was discussed much or at all in school.  Just like everything else in life, the more you do something, the better you get.  I am much more comfortable discussing such things now than I was a year ago.

As I mentioned, I have started emergency medicine.  Working in the ER is quite a bit different than working in outpatient medicine.  There is really one goal: decide if the patient is sick enough to be admitted or treated at home.  Despite being clearly labeled as a room for emergencies, it is really quite fascinating the number of patients who walk in who clearly do not have an emergent condition.  I am sure there are a number of reasons for this and to investigate these numerous reasons would be way beyond the scope of this post.  At any rate, I thought it would be amusing to share some of the chief complaints and diagnoses that come into the emergency room, most of which clearly aren't emergencies.  In a tribute to one of my favorite web sites, I will try to write the posts in a news story fashion, a la the Onion.

Shot Time!

Schools have started around the city and for the past couple of weeks we have been getting the typical "The school says he/she needs shots before they can start." routine.  What gets me about this is that I am sure they are notified earlier than 12 hours before school starts, and yet they wait until the day before school starts and call and expect us to drop everything we are doing to fit their kid in last minute.  We can usually do it but some of the parents are kind of pushy about it, which can be annoying.  How about some planning?

Sarah and I were in Cincinnati this past week for the Western & Southern Open.  We saw some good tennis, and most of the big stars were there, except I missed Maria and Maria (see below).  I took a pretty cool picture of the stadium with a colorful sky in the background, which I posted below.    I have a wicked raccoon-like sunburn on my face from my sunglasses, and I think the sun got to me a bit because Thursday morning I put my shoes on before my pants!  We enjoyed the tennis and got to see Sarah's uncle and cousin which was fun too.

Maria Sharapova:

Maria Kirilenko:

The Hardest Part

In general, my profession is pretty rewarding.  With that being said, there are some hard parts to the job.  Probably the hardest part is telling someone their family member passed away.  I had to do that last this morning.  Absolutely my least favorite part of my job.

A Beautiful Mind

I've spent the previous month in a locked geriatric psychiatry unit at the hospital.  A few of the patients were admitted for depression and suicidal ideation, but the overwhelming majority were admitted for poor behaviour from their nursing home or assisted living facility.  Poor behaviour typically includes verbal abuse towards the staff, but can also include physical abuse towards the staff or other residents, and sometimes sexual misconduct, sometimes eloping from the building.  The patients would be admitted so that some concoction of medicines could be generated that would improve their behaviour to at least acceptable levels to return to their previous environment.

Except for the patients there for just depression, everyone was confused.  They had no idea why they were in the hospital, or even that they were in a hospital at all.  They thought it was Christmas Eve despite sitting outside in extreme Midwest heat.  Some had hallucinations and many had delusions.  One woman insisted that she was pregnant and that her kids were still in school, despite the fact that she was 85 years old herself.  Attempts to redirect the often pressured behaviour often resulted in agitation and sometimes aggression.  Reasoning was completely out of the question.  I interrupted this behaviour as ranging from amusing to downright unbearable.

Every Tuesday we would have meetings with the patient's family.  We would have to explain to them why their parent's are behaving this way and why they have a completely different personality now compared to the past.  We would have to explain the multiple side effects of the medicines being used (one of Zyprexa's side effects: death) and the unfortunate situation of not having anything better to use.  We would have to explain to them the terminal nature of the diagnosis, that eventually they would forget how to walk and even swallow which would lead to their death, and that there was nothing anyone could do about it except hang on for the ride.  Interacting with the families made a sad situation even more depressing because you realize that the patients were "normal" people at one time with real lives.  Sometimes just seeing them in their confused and crazy state makes it easy to forget this.  I learned a lot this past month, mostly on how to talk to family members with parents who are going through this terrible process.  I also learned that I do not want to get old.

Two Down, One To Go

It's hard to believe this, but tomorrow I start my first day of my third year of residency, which for me is the last year until I finally go out on my own and get a real job.  Last week the incoming first year residents had orientation and while I didn't spend much time with them during their orientation I did spend all day Thursday and Friday with them during ACLS re-certification (Advanced Cardiac Life Support).  It was interesting to talk to them and answer their questions and hear their fears about the upcoming year.  So much has happened in the past two years that I kind of forgot that I had the exact same concerns and fears when I was first starting residency too. Now I just go to work everyday and don't really think about these things much.  It just goes to show you how many things I've learned in the past two years.

I now have one more year of monthly rotations.  I spend three days per week at my rotation which changes at the beginning of the month.  I spend the other two days per week at my clinic, seeing my own patients.  It should be an exciting year.  I anticipate within the next couple of months I should have a pretty good idea on where I'll be working full time in the future.  One year from now I will finally be out on my own, which is both exciting and scary (I will likely have the same concerns when I start my real job as the new residents have about starting residency.).

They released a flier to post in various departments of the hospital with the name, picture, and pager number of all the residents.  Being a senior, I am at the top of the page along with my lone senior classmate.  The picture is symbolic of me making it to the top of residency.  I better enjoy being on top while it lasts.  Next year I start all over again at the bottom of the totem pole.

Number One or Number Two?

I am doing Opthalmology right now.  Suffice it to say that I am very bad at eye diseases.  At times it can be a bit embarrassing but then I think about how complex the eye really is and how specialized you'd have to be to be any good at eye exams and that thought eases my mind.  A lack of education, testing emphasis, and training is what limits me.  I really have learned a lot of information in the past 6 years but I think it's the nature of the business to concentrate on what you don't know and not give enough credit for what you do know.

The Guy in Gynecology

As a primary care doc I see anything and everything that walks through the door. I'm lucky enough to get a first chance at most patients before they are sent off to a specialist. You'd actually be surprised at some of the patients who come in to see me. Anyway, this past month I spent up in Lafayette doing gynecology/Women's health. I've always enjoyed women's health professionally (it involves a lot of endocrinology and physiology, and delivering babies is probably the most rewarding thing I've done in my career). With this being said, the topic is a bit frustrating to me. Between my resident clinic and moonlighting clinic, I see between 20-30 patients per week. If you figure that women make up half that population, and a certain subset of that population will have health care needs specific to women, you would figure that I would deal with the topic a fair amount. Let's be honest, women's health is about as primary care as it gets. And yet, in the 18+ months of residency that I've completed, I can probably count on two hands the number of patients that I've seen with these complaints. Even up in Lafayette I met some resistance, despite having a medical degree and license (i.e. I couldn't be more qualified).

I'm kind of glad the rotation is over. On the one hand, it was an easy rotation, but I get tired of watching other people work. As I said, this topic is pretty primary care and I feel pretty comfortable being able to handle 95% of it. I find that the longer I do rotations, the more I know and my questions are now different than what they used to be. I guess that these are all signs that the educational process is working. I want to just work with my own patients now and not watch other people work.

On a different note, Sarah and I made a quick trip to St. Louis this weekend to see Radiohead in concert. Radiohead is my favorite band and in my opinion, are the best rock band of my generation. This is the second time I've seen them, the first being in Cleveland in 2008. They played a great show, with a surprising and variable set list, and the light show behind stage was awesome! Sarah and I really had a good time. Below is a video for the song "Separator" from the "King of Limbs: From the Basement." Enjoy!

Sick...As...A Dog

All of these kids I've been seeing the past month carry some nasty germs, and I was afraid that it was only a matter of time before I too got ill. I was a little sick over the Thanksgiving week with some sinus congestion and cough. That went away within 4 or 5 days and I thought I dodged the major bullett. However, starting this week I've felt pretty bad all week. On Tuesday I went to bed at 9:30. On Wednesday I went to bed at 4:30. I've been sleeping a lot lately. I just have this nagging cough, chills, muscle aches, and fatigue. I don't feel like doing anything but rest. I haven't missed any work but it's pretty difficult to work when feeling like this and honestly I probably should've missed, especially on Friday. I can't remember the last time I have been this sick for this long. It has been a really long time. I think I might get my flu shot next year. I always pass on it because I never got sick in the past.

I'm still using my 2005 Dell XPS desktop for my main computer and it was becoming a mess. It had three operating systems on it, including a corrupted version of XP that was worthless. My Ubuntu kept giving me warnings about being low on hard drive space so I thought it was time to upgrade my system and clean things up a bit. Doing this was one of my goals for the weekend and I got the project done despite being sick.

I did a clean install with Ubuntu 11.10 (Oneiric Ocelot). They've made a lot of changes to the GUI on this new version compared to the old one. The big thing is that they've added a Mac style task bar that sits on the left of the screen instead of the bottom. Also, following in Apple's path, they've placed all of the "file" and "edit" buttons for programs on the very top task bar within the OS itself, separate from the window the program is actually running in. Those of you who have used Apple computers will know what I'm talking about, otherwise this might be a bit confusing. Suffice it to say there are enough new changes that were made that it feels almost like using a new computer for free! Also an important thing to note was the ease of install. Ubuntu continues to make this distribution of Linux more and more user friendly. I got my printer to install with no problem at all this time. I haven't had time to mess with the network settings but have my fingers crossed that sharing folders won't be too difficult.





The feature I'm really excited about is the VirtualBox program. This time, instead of having a dual boot system where I have to restart the computer every time I want to get into Windows (yes, I still have to use Windows occasionally), I am using a program which simulates a different computer to run Windows within Ubuntu, which means no more restarts. Thus far I have had no difficulties (Excluding the phone call I had to make to Microsoft because apparently when you try to install an "upgrade" version of Windows on a computer that doesn't already have Windows, the product key doesn't work. This is so stupid and typical of Microsoft. Luckily they fixed the issue but I was prepared to go off over the phone if they told me I had to buy a different version.) with the program and it seems to be running fine, so I'm really excited about this integration.

I also got an electronic car starter for my car from my parents this weekend for Christmas. I'm pretty excited about this too. It's so James Bond like. It will be nice to have on those snowy and icy mornings.

No Antibiotics?

There hasn't been a whole lot going on over the past few weeks except work which is why there has been a lack of updates on the site. After several months of paperwork I finally started my moonlighting gig which is both exciting and a little stressful. I now work Tuesday and Thursday evenings at a medical clinic seeing overflow patients with acute problems who couldn't be fit in during the day. It is the first time I've done my job without a supervising physician directly overseeing what I'm doing or without there being someone else around I can ask for some advice. Like I said, it can be a little stressful but overall I think it is going pretty well and I'm enjoying the extra experience (and money).

By far the most frequent ailment I've seen while moonlighting is the dreaded sinus infection. We all know the symptoms: sinus congestion, runny nose, ear pressure, sore throat, and in general just not feeling well. I wanted to quickly go through my treatment regimen for a sinus infection, as backed by evidence-based medicine.

• The overwhelming percentage of sinus infections are caused by virus infections (>90%). This has been shown in studies using CT imaging and sinus cultures. Unfortunately, this isn't practical in an every day clinical setting so practice guidelines state to assume the infection is viral unless it lingers more than 7-10 days. Since viral infections don't respond to antibiotics, that means no antibiotics unless you've had symptoms for over a week.
• Intranasal steroids have the best evidence supporting them to relieve sinus pressure and head congestion
• If there is a cough from post-nasal drip, I'll use a codeine-containing antitussive, especially if they've failed over the counter cough medicine.
• I suggest Tylenol for throat pain and plenty of fluids.

In summary, intranasal steroids (Flonase) and cough medicine is generally what I prescribe. I don't give antibiotics unless symptoms have been going on for 7 days at a minimum. Most people are used to getting antibiotics initially but usually when I explain to them why they won't help for a viral infection most people are understanding.

Things To Come

This should be an interesting week as starting on Tuesday I will begin working evenings at Brownsburg. I will be working a few hours there on Tuesdays and Thursdays and this will be the first time I am working on my own as a physician, unsupervised. I'm a bit nervous but I think things will go OK and should be a great learning experience for me. I'll have more on this in the future once I get rolling out there.

Sarah and I both got new phones over the weekend. She updated her Blackberry with a newer Blackberry (seen here) and I updated my old Windows phone to the new iPhone 4s. I'm hoping to get it within the next couple of weeks. I'll have a full review once I have received the phone and have had time to play around with it a bit. I'm pretty excited about it to be honest. However, at this point I am in the process of starting to figure out how to best run iTunes through Ubuntu without having to log out of Ubuntu and back into Windows. Hopefully it goes smoothly, but this honestly is one of the unfortunate costs of running Linux over Windows.

As for an update on my thumb, I think the moxibustion killed about 90% of the wart. Unfortunately, the 10% that is left is enough for it to start growing again, despite Compound W treatments so I think I'm going to have to go back in this week and have a second round of moxa performed.

Also of interest, I got my car back from the body shop on Friday. This car seems to be a magnet for dings and scratches, unfortunately. I took it into the shop because something nicked the paint on the front bumper and made a little defect that started out the size of a quarter and was growing. By the time I took it into the shop it was about the size of a baseball. I was afraid my whole front bumper was going to chip away if I didn't fix it so I bit the bullet and took it in. I was pretty nervous about it because they had to take the whole front bumper off the car to fix it properly. I was satisfied once I saw the car because the bumper looks great and they completely detailed the car so it looks like a brand new car! Before and after pictures below.

Traditional Chinese Medicine and Osteopathy

I frequently get asked "What is a D.O.?" or "How is a D.O. different than an M.D.?" The short answer is that there isn't much difference. Statistically speaking, most DO physicians don't regularly perform musculoskeletal manipulations (OMT) and basically practice medicine like an M.D. physician would practice medicine. Philosophically speaking, there is a difference and there are some osteopathic physicians who truly use these differences to influence how they practice. I've been taught that the body is an entity and that everything that goes on within the body is interrelated, so that dysfunction or disease in location A can and will affect location B (including psychiatric dysfunction/disease). This is done through impairment in vascular and lymphatic flow as well as through dysfunctions in the musculoskeletal system. Because of these beliefs, we are taught how to do OMT or various musculoskeletal adjustments to improve lymphatic and vascular flow and place the muscles and bones back into a neutral and more natural location. Yes, this is similar to chiropractors, and yes, there are differences but explaining those differences is beyond the scope of this post (actually the guy who founded chiropractors learned from A.T. Still, the guy who founded osteopathy).

It is my understanding that M.D. physicians learn to focus more directly on a disease entity and not so much on how it relates and affects other parts of the body. Of course all of this is generalized. I'm not saying that MD docs don't care about a persons feelings, and like I said most DO docs practice like MD docs, a generalized western approach. But the root of our education is different and I mention these differences because the osteopathic philosophy is undeniably similar to the Chinese philosophy of treating the whole body and individual and not focusing so much on the specific entity causing the problem.

An excerpt from the book The Web That Has No Weaver talks about why in recent years there have been increasing numbers of patients trying more Eastern styles of medicine:

• ...many people have begun to see that too often biomedicine is simply not concerned with general well-being because it can only assess very small, discrete bits of information...Our medicine parallels our society. New cures often produce side effects of unexpected virulence. More over, our central medical institution, the hospital, is structured like nothing so much as a health factory - a contradiction in terms. And probably most important, people feel that there is no place for their feelings, intentions, beliefs, and values in the biomedical perspective. Biomedicine often leaves the "person" in the waiting room.

The effectiveness of modern, Western medicine is being questioned within its own medical circles. An excerpt from the Journal of the American Medical Association mentions the:

• ...limitations of a linear, reductionist approach in our attempt to describe natural phenomena...There is an acute awareness of the havoc that the modernist worship of science has wrought upon Western popular consciousness...Science can tell us nothing about an individual. Science speaks in terms of probabilities, of means and standard deviations, the behavior of groups of people, not of individuals.

I bring all of this up because TCM attacks symptoms and complaints at the level of the individual, not the specific disease. Osteopathy, at its roots, has a very similar approach. And while many of these TCM therapeutic modalities don't test well in our scientific studies, there seems to be some question as to how effective these studies are at developing optimal treatments in medicine.

With all of this being said, even though I am an osteopathic physician, I am still trained in the West. I believe in the scientific method and for the most part will continue to practice evidence-based, western medicine. However, the next time someone doesn't respond to a treatment the way people in the studies responded, I will try my best to think out of the box and integrate the whole person and their circumstances in order to provide them with better care.

This concludes my posts on Traditional Chinese medicine. I hope people found them to be interesting if nothing else. Seeing this completely different approach to medicine was an eye opener for me for sure.

Moxibustion: A Case Study

It's my opinion that there are few if any forces known that are stronger than the desire to reproduce. This force doesn't just apply to humans, but to all living things. For the most part, humans have the ability to plan their families, as in the number of children they want and the reasons why they want children. Most biological entities don't have the cognitive abilities to do such planning. Plants, for example, are designed perfectly for reproduction and they do so without any thought at all. Plants, however, perform important functions for many living beings, namely photosynthesis. As you move to smaller and smaller living things, the picture starts to become fuzzy. While various bacteria perform many important functions, including nitrogen fixation, some just seem to exist because they can. This existence, of course, relies on reproduction. And then there are viruses. Viruses are so small they can't be seen with traditional microscopes. They contain a small amount of DNA or RNA and that is it. They don't even have the molecular machinery needed to reproduce on their own. Instead, they rely on molecules found in other living cells for them to reproduce. They seem to exist for no other reason than to reproduce and exist and annoy us.

Case in point: The human papilloma virus continues to reproduce and exist for no other reason than to cause women anxiety about their PAP smears and produce unsightly warts. As many of you know, I've had this unsightly wart on my thumb for about three years now. I've tried almost everything imaginable to get rid of it. I've had it frozen, I've had it surgically cut out twice, I've used Compound W, I've used duck tape. Most of these therapies have worked to some extent, but the wart continues to come back. So like many other people who have tried and failed Western treatments, I turned to the doctor I am working with for a TCM approach to wart treatment. His treatment of choice for warts: moxibustion.

Moxibustion involves placing the smashed mugwort herb on the skin over the affected area and burning it. I'm not going to lie, it hurts like a mother to have your skin burned. It feels kind of like having your thumb smashed in a car door. But like all of the other patients he treats, I have failed Western treatment modalities and am desperate. I am ready to do anything at this point. He did 30-40 burns over a three day period. Each burn hurts for like 2 seconds then the pain goes away. He says that this one treatment course should get rid of the wart. I'll let you know what happens here in a few weeks.

Moxibustion burn on my thumb:



The next post is about TCM and how it relates to my job as a family medicine physician in the United States.

Improving Health Through Meridians

The other major treatment modality commonly used in traditional Chinese medicine (TCM) is acupuncture. I've read a text on acupuncture now and I'll be honest, it is much more confusing than I expected. In fact, it doesn't make any sense to me at all. I'm inclined to say that it is crazy, hocus-pocus stuff. Two reasons why I don't say this is because people have been using it for thousands of years with results, and I've seen the results myself this month, though I don't think they are as dramatic as the results seen with cupping. I'll try my best to explain at least the general principles, but as I mentioned, I don't understand them well myself.

In TCM, it is believed that the organs are connected through channels called meridians, and that anything that inhibits the flow through the meridians causes disease. Here's the thing: the meridians don't physically exist. There are maps of where these meridians should be, but when you dissect through the tissues there are no such channels there. Here's the other thing: some of the organs themselves don't physically exist (see triple burner), and often the organs that do physically exist have completely separate functions in TCM than they do in Western medicine. For example, Western medicine views the liver as having important functions in protein synthesis, digestion, and lipid and sugar metabolism. In TCM, the liver is important in thinking, consciousness, and planning with insight. It is called the general of the armed forces. So if a patient comes in with anxiety and panic attacks with symptoms of palpitations, it is likely that the heart and/or brain won't be treated at all. Instead, the liver will be treated along its meridian points as it is too excited and causing an imbalance with the other organs.

Besides history, TCM uses other clues to help diagnose the deficiency needed to be treated. Of most importance is the tongue, including size and consistency, and the pulse. Checking three points along the radial pulse on both the right and left arms and using a complex system of describing each of the six pulses helps determine which organ system is unhealthy. There are other diagnostic aspects, such as a person's color and smell and their body temperature over different parts of their bodies. There are other aspects of treatment as well, such as certain people tend to have deficiencies in certain organs (called their constitutional factor), and certain organs are excited during some parts of the day while deficient on other parts of the day, and on and on and on. The more you read, the more confused you get because things get more and more complex and abstract. The thing is, people claim it works, and have made this claim for thousands of years. I'm going to try to explain below why maybe it shouldn't be ruled out as an option for some people and what benefit can be gained from using such thinking to treat illness. I will do this using a patient example.

A patient has epigastric pain. After doing an EKG and chest x-ray and ruling out cardiac causes, they are diagnosed with GERD, or acid reflux. They are then placed on a PPI medication, like protonix or prilosec. Everyone diagnosed with GERD will be placed on a PPI. Why? Because it's first line for acid reflux. And why is it first line? Because the proton-pump inhibitor has been shown to reduce the amount of acid production, improve symptoms, and reduce complications such as peptic ulcers and erosive esophagitis. This has been done using double blinded, randomized, placebo controlled studies, the highest level of evidence known. Treatments for pretty much every disease in Western medicine uses this study-backed concept, meaning everyone gets basically the same treatment for the same disease (with some variations here and there for specific details, allergies, etc). I love evidence based medicine because it gives me a purpose when selecting treatments and I know that statistically speaking I am doing what is best for the patient. Here is the problem with this approach: Not everyone responds to the first line medicines, and sometimes people don't respond to the second or third line medicines. Often at this point Western docs often throw their hands in the air and can't offer much else.

Whereas Western medicine uses a very scientific approach to diagnosis and treatment, TCM uses a much more individualized style. If five people walk into a TCM doctor's office and are diagnosed with acid reflux, it is likely that each person will receive a different treatment because their treatments are based on which "organs" are deficient in qi. To the TCM doc, the patient's acid reflux symptoms have nothing to do with excess acid production or H. pylori infection, so a PPI may not even help. So whenever usual treatment modalities don't work, I think that TCM and acupuncture can teach us to think outside of the box and use a different approach instead of just throwing our arms up in the air and not knowing what to do. Of interest, most of the patients the doctor I am with sees have failed many treatment modalities Western medicine has to offer and don't know where else to turn, which is why he is so busy.

In case you were wondering, there have been several randomized controlled studies trying to assess the effectiveness of acupuncture. These studies have shown mixed results, many concluding that there is insufficient evidence to suggest or not suggest acupuncture as a treatment option. It should be noted that randomized controlled studies are a relatively new phenomenon (1950s), and they frequently don't focus on patient-oriented outcomes, instead they focus on physiologic outcomes. For example, studies might show drug A is better than drug B for acid reflux, not because there is better subjective pain control, but because drug A inhibits more proton pumps than drug B. Also, rigorous randomized controlled studies are difficult and expensive to design and carry out. Major pharmaceutical companies sponsor many studies and frankly it's difficult for acupuncture to get the kind of funding necessary for the large studies needed to be accepted in Western medicine.

Up next, my own personal experience with TCM.

A Different Perspective

This post is the first in a series of posts on traditional Chinese medicine.


I've spent the past month with a doctor who went to medical school here in the U.S. and thus was trained in traditional Western medicine, but has a strong background in Eastern and Chinese medicine through his father who is originally from Korea. This unique combination of backgrounds allows him to have a mixed practice where he uses both Western and Eastern techniques to help people. Some of my former co-residents have actually been trained in acupuncture and because of hearing them talk about these treatment modalities I decided to check them out for myself. I must say the whole experience has been a bit of an eye-opener. He uses two main treatment modalities from Eastern medicine perspective, acupuncture and cupping. Most people have at least heard of acupuncture so I'll first talk about cupping.

Pain can be divided into two main categories: neuropathic and non-neuropathic pain. All non-neuropathic pain (i.e. not involving nerves) is caused by hypoxia, or lack of oxygen. Since oxygen is carried by hemoglobin in red blood cells within the vascular system, it makes sense that in order to increase the amount of oxygen delivered to a certain area of the body you should increase the blood flow to that area. This is where cupping comes in. Using heat within a cup placed on the skin, a vacuum is created literally sucking blood to the area. This helps remove stagnant blood and deliver new blood to the area, bringing oxygen and other inflammatory and healing cells to the area. I think it's pretty well known that lack of blood causes injury. Lack of blood flow causes heart attacks, strokes, and sores not to heal. So while this concept of cupping, along with the pictures below, seems very odd and foreign, if you think about the principal of what's going on, it makes a lot of sense. And more importantly, the doctor I am with this month gets great results from cupping.

A patient receiving cupping:


A patient's back after cupping:



I wanna give you an example of why this is so important. The following case is a patient I saw in clinic and is a model example of how Western medicine approaches pain. SJ is a 28 year old male with pain in his elbow radiating toward the hand. I was 99% sure he had tennis elbow. I gave him a prescription for steroids and told him to get a brace for the arm to wear at night. I saw him two weeks later, and he said he felt a bit better while on steroids but once the prescription ran out his pain returned. I then sent him to neurology, which did imaging of his neck and performed an EMG, an expensive and painful nerve study which doesn't even help SJ with the pain, it just helps to diagnose the problem. The next step for SJ is likely to be a minor surgery at the elbow to help relieve pressure on the tendon causing the pain. Relief after several months of the symptoms and several thousand dollars spent. If the doctor I am with saw the same patient, he would diagnose the problem on history alone, put cups on SJ's arm, and SJ would have at least some relief on the same day! I've seen it happen about 100 times this month.

The next post will be on acupuncture.

Why It's Called "Practicing" Medicine

I'm in this awkward period in my career right now where I want to work independently most of the time yet I still like having that comfort level knowing I have people to turn to and ask for help when I'm just not quite sure about something. I have good days where I seem to know all of the answers and then I have days where I am confused on what to do and I have to run to my attending and ask for help. This month has been an eye opener in terms of what I don't know. Keep in mind that not only have I graduated from an accredited US medical school, I also have a medical license from the state of Indiana. What I'm trying to say is that this isn't exactly my first day on the job.

As I do dermatology this month, I repeatedly don't know the answers. People come in and point to some random area on their body and ask "What is this?" My attending then asks me the same question, to which I respond "I don't know." He then informs me that it is a case of sebaceous gland hyperplasia, identified by its yellow color, central clearing, and the telangiectasia surrounding the lesion. Of course, how could I not have noticed that? I do have two defense points. First of all, I have never been taught dermatology. I never had a class in medical school and I never had a dermatology rotation until now. My second defense is that dermatology is very low yield on our boards and a lot of what they ask is fairly rare stuff like Stevens-Johnson Syndrome.

I had clinic today and low and behold I had a dermatology complaint with one of my patients. He had a "rash" on his knee. I walked into the room and his entire knee was bright red, warm to the touch, it blanched with pressure, part of it was crusty, part of it had pustules. I looked at the area and tried to use the systematic approach my dermatology attending taught me for rashes and I was coming up with nothing. It had so many characteristics I couldn't fit it into one type of rash. I honestly had no idea what it was, and thus no idea how to treat it. I went to my attending with my tail between my legs, explained the rash to him, and honestly told him that I had no idea what it was. Long story short, my attending somehow determined it was fungus with a secondary cellulitis. Now I've seen people with ring worm before and I'm gonna tell you it looked nothing like this guy's knee. We did a scraping of his knee and a KOH prep and sure enough, we saw branching hyphae of fungus (see below). We treated him with antifungal and antibiotic and he is coming in early next week for a follow up.

Moments like this really put my confidence down in terms of being able to go out on my own. If I were by myself and had no one to turn to (which I might be here in a month or so when I start moonlighting) I honestly don't know what I would have done. I probably would have just done the best I could have until I could have got him into someone smarter. Don't get me wrong, more times than not I have a pretty good idea on what to do, but every once in a while I get stumped like this and it is a humbling experience. I learned quite a while ago that medicine isn't black and white like I thought it was. Most of it falls into this gray area where diagnoses can get mixed up easily, especially to the unexperienced. I guess this is why it's called "practicing" medicine instead of "performing" medicine or some other word.

Getting Old Is Tough

I've always been a pretty healthy person and in general this still holds true today. However I am starting to have more and more health problems. Granted, they are all minor and not life threatening, but still things are happening to me health wise that I never had to deal with in the past. I am currently on 4 prescription medicines. Most of my health issues are dermatological in nature. I have a steroid cream for some random rash I was getting last summer/fall which has pretty much resolved. I am on an antibiotic for this boil that popped up a few weeks ago that had a pretty large area of cellulitis around it and I was afraid it might be MRSA. The antibiotics quickly took care of it. I still use topical antibiotics for my face for acne. Yes, even in my late 20s I still get pimples. Very annoying. My fourth prescription is a steroid eye drop. I have had minor problems with my right eye off and on for the past few years. Over the past month, however, the problems escalated to the point where I couldn't wear my contacts and thus had to wear glasses. I went to the eye doctor last weekend and was diagnosed with Giant Papillary Conjunctivitis. Today is the first day in two weeks that I've worn contacts and so far it is going well. I am supposed to use the steroid drops for another week and switch to a different contact solution. In addition to these problems the toe I injured a couple of years ago still looks ugly (I think it might have a fungal infection) and that damn wart is still on my thumb! I honestly cannot get rid of it and I've tried everything. I think I am going to make an appointment and have it surgically removed again, for the third time. Again, all of these problems are minor and not serious health conditions but I didn't have to deal with any of these annoyances 3 to 5 years ago. Sometimes I wonder if I have a vitamin or mineral deficiency that is causing all of these random things to happen.

On a side note, I had a last minute rotation change. Instead of doing internal medicine I am doing pulmonology, which is considered a medicine selective (sub-specialty). I am happy with this switch honestly. I've done medicine several times in the past at my hospital and think it's more beneficial to work with some other people to get a different perspective. Plus I still get medicine when I work the weekends. I see a ton of people in my clinic who have COPD so I think it will be good experience overall. My attending is fellowship trained in pulmonology and critical care medicine. He has a bit of an unusual clinic in that he employs a lot of physician assistants who seem to do a lot of work for him. With that being said I still think it should be good.

Climbing the Ladder

Today was my final day doing OB. Tomorrow I switch to internal medicine (again!?!). For the most part I am ready to move on. This is mostly because I am ready to switch back to working days. I don't know if your body ever really gets used to working nights and sleeping days. It just seems like you are fighting nature when you do this. Plus I am ready to not spend two hours a day in the car commuting. On the other hand, however, I do enjoy OB quite a bit so it's kind of sad to see it go. I delivered over 50 babies this month which is pretty darn good I think. I don't know when I'll do OB again. I am thinking of applying for the Maternity Care fellowship at Methodist Hospital once I'm finished with residency. That decision hasn't been made yet, just something I have in the back of my mind.

Focusing on the big picture, tomorrow I transition from a first year resident to a second year resident. I have more clinic days this year along with more electives in my schedule. It's a little scary because soon I'll be on my own completely. I am in the process of applying for an unrestricted medical license (my current license is classified as "residency permit" meaning I can only practice within the confines of my residency program). This will allow me to moonlight to supplement both my income and experience.

Night Babies

I've been working nights the past week which completely throws off my sleep and eating cycle which is one of the reasons why there haven't been any new posts lately. Truthfully not much exciting has been going on other than work so there hasn't been a lot to post about. My rotation is going OK. It was a little awkward at first because they kind of just drop you off and don't tell you anything in terms of when to be there or what is expected. After I had been there a few days and met everyone and got used to the situation I relaxed a bit and things have been better since. They've been really busy up there. There are 24 beds in their OB wing and when I was last there Saturday morning they were completely full. I've been getting an average of 2-4 deliveries a night which is pretty good I think. One of the docs went through a systematic way to deliver a baby which I have been using and I think works well. It gives you a lot of control over the situation and allows for a free hand to suction or do whatever is needed. Most doctors just kind of throw you into the situation and let you figure it out as you go so it was kind of neat that he gave me steps to follow. We practiced on a pelvic model they had at the hospital (see below) which I thought was kind of amusing. I felt like I was playing sports again, going through the motions of a play at practice or something.