cranquis

[cranquis]

Wanted to send you a message - I'm from another country, but wanted to match into the US healthcare system for the longest time for several reasons. Followed you for the wisecrack insights, stayed for the soul.

I've matched into my dream Anesthesiology PGY1 spot this year <3

Thank you for all that you do.

I am so excited for you, my friend and colleague! Congratulations!!! Now keep your chin up as PGY1 year does its best to smother your dreams with scutwork and stress and lack of sleep.... this too shall pass!!!

#cranquis mail #ya know 'dream anesthesiology' would make a great name for a your future medical group #medicine #medblr #pgy1 #residency #intern year #med school #encouragement

[cranquis]

HI I just wanted you to know, I'd stumbled across your Tumblr like maybe 10 years ago??? While I was a teen? And your blog has given me light and reasons to smile and laugh during very trying times, and motivation to go on all throughout my journey from med school applicant to getting my medical degree. Now I'm an emergency resident and I'm the happiest I've ever been and I just wanted to thank you for each and every post, 4 making me smile, being a reference, & making me excited to become MD<3

Do you have any idea how big I'm grinning right now? Sitting here during the middle of a downright awful shift at work, just grinning at my laptop??! I am so honored to have been a source of YOU CAN DO IT motivation during your medical journey -- but you have to know, your message is now paying me back, giving me motivation to smile and keep going, too! :)

Congratulations, my friend from work!

#medblr #medical journey #blogging #encouragement #motivation #cranquis mail #might just print this one out and tape it inside my desk drawer for future encouragement

[cranquis]

That's actually a terrific answer LOL

Doctor: What is the most likely diagnosis for this patient?

Student: Since this is the COPD seminar, I’d say COPD.

Doctor: ... seriously?

#med school #medblr

[cranquis]

I think many of us will find this useful. Thanks for sharing!

The weirdness of high school.

And university too maybe.

Plus or minus med school. But not residency. Watching THis is Us and other bingeable shows recently.

There's a lot of flash backs and flash forwards in the show.

There's the high school ones, which like all TV shows is very stereotype'd. They go to an alumni event, and the nerdy girl now surgeon is estactic to hang out with the former football star/cool guy. Who is very thick.

I was a super weird, nerdy, socially awkward kid. Afraid of a lot of social things, but not afraid of science, history anything academic or what I looked like. I wore oversized sweats all day everyday. I never knew how to say the right things or act in a crowd. I hated crowds. 2 or 3 close friends was great, and the best I could muster. I was terrified of their parents.

But funnily enough, I never knew I was weird. I wasn't unhappy either.

I liked having 2-3 close friends, nothing more or less.

Then close to graduation, one of the guidance counselors (the non-crazy one) said to me, she didn't have a great high school experience either. But it gets better after high school. I'll see. It took me years as a teenager to understand what she meant.

Later on I realized that other people felt sorry for me. Thinking because I didn't have the stereotype of the great high school experience I was some how sad, ashamed, unhappy.

Ironically I never even thought about it and was actually happy in my own world and space. I had my separate universe in academics. Like it never dawned on me that I was missing out on anything.

I felt embarassed, in a strange way as an adult reflecting on those experiences. Slightly embarassed for me, but more embarrassed for the small town/city around me. I did not fit in that place, but I didn't know it either back then or didn't care to. We were very much ships passing in the night. I didn't and don't hate where I grew up, I actually loved it in my own way. I got a great education there, and it got me where I wanted to go.

Looking back, plenty of kids probably made underhanded mean comments or passive aggressive statements - but it all went over my head. I suppose I would have been unhappy, had I read between the lines back then. Someone even stole my math text the week of the math exam, but I was actually flattered. That hey, someone thought I was that smart (imposter syndrome starts when you're young). It was one of the best days of my life.

It was also hilarious to me then, that stealing the text of one of the nerds during exam week would sabotage anything - because they spend their entire free time studying the whole year. They don't cram. Cramming was a terrible habit I acquired in university/undergrad. In med school, I'd fail exams because I crammed.

Another time I had left my draft math home work in a common room table, a classmate told me (2 weeks after the fact) that 5-6 different kids grabbed it and copied it. unfortunately for them, it was a draft full of errors, so I completely disregarded as trash. the final copy I submitted with the correct formulae was substantially different. Our math teacher of course realized that everyone had the same errors, but couldn't figure out the source. No one ever said anything mean or confronting, so it wasn't hard to brush aside. they self-sabotaged themselves, nothing actually happened to me.

Again, it was like we lived on different planets. Had they asked, I probably would have helped them out, I didn't get the grades I got by myself either. My far smarter co-nerd friends taught me a lot. On the other hand, I was intensely shy, they probably interpreted it as being "aloof." Or worse, condescending.

I'd felt my entire time during school, that it was the path to something else. I wouldn't get there till about 10-15 years later. Maybe even 20. It was a means to an end. If I was going to be working, then I wanted that work to have meaning. Or what would the point of all those hours. My parents worked in jobs they grew to hate to just go home and be tired.

Med school was a bit like high school. After the first few months of first year, i spent most of it hiding from other med students. (They were fucking crazy, a good chunk of them although not all, the anxiety, stress, competitiveness, the back stabbing, entitlement and bravado --> by the way, people do mature and get better. of course not all them do. anyhoo).

It was after selecting a vocation and starting residency that I found "home." Where I suddenly was comfortable having more than 2-3 friends and happy to be in crowds. Because everyone in the crowd was pretty much like me. We wanted to talk about all the same things. Maybe I grew more comfortable in my own skin along the way too.

But you know, it wasn't me that need to grow and change. I had found the environment where I finally could be myself in.

#medblr #med school #undergraduate #high school

[cranquis]

if house was a drag queen his name could be ms.diagnosis

#house md

[cranquis]

I'm not a cat person, so I automatically assume the cats are in administrative positions: Cat 1: Petting levels continue to drop, and I will not stand for it. Or for anything actually. Cat 2: I blame the required sexual harassment online meowdules! The residents must have assumed that we cats were included in the "no unwanted touches" guidelines. Cat 3: Uh, hello? We're cats? ALL touches are unwanted-- Cat 1: --unless they're not-- Cat 3: --unless they're not, in which case we will appreciate the touch and not destroy the human's hand-- Cat 1: --until they stop petting us, THEN we destroy. Cat 3: Precisely. Cat 2: My proposed solution is to have IT assign an online meowdule on "prioritizing cat satisfaction", with a deadline of... this evening. Cat 1: Ooh! Yes! With a prize for the department that has the highest percentage of meowdule completion before the deadline. Cats: PIZZA PARTY!

#hospital #medical administrators #cats #princeton medbloro teaching hospital #pmth

[cranquis]

You've been my celebrity crush for the longest time and I just wanted to let you know that I got an ER fellowship position starting in summer and I am SO so happy about it :)

SUCCESS!!!!! Congratulations, my colleague. :)

#medblr #congratulations #emergency medicine #fellowship

[cranquis]

Dang, I remember when I used to have time to write well-researched informative (and interesting!) posts about medical stuff. Glad others like @flyonthewallmedstudent are still doing that for us. :)

Q Fever

Aka, Query fever. What a weird name for a disease. Imagine telling people that's what you got.

in the 30s-40s, an Australian pathologist in QLD/Brisbane, came across an outbreak of the same or similar illness among abbatoir or slaughterhouse workers.

At the time, he called the disease "Q" fever or query as a temporary name until the pathogen could be identified. Unfortunately it stuck.

decades later, now nobel prize winner and virologist, MacFarlane Burnett isolated and identified the microbe responsible. I think this discovery contributed to his prize. i forget already.

Microbe responsible: Coxiella burnetti. Named for Burnett and HR Cox, the American bacteriologist who found the genus Coxiella where C burnetti falls under.

Initially they felt it was related to Rickettsia, responsible for Rocky Mountain Spotted Fever, but as science progressed, this was disproven.

Now for a Case Report

A 55 yo Italian man with a history of aortic valve replacement was diagnosed with pyrexia of unknown origin twice. Further signs included myalgias/splenomegaly/night sweats. The 2nd time he was admitted for PUO he deteriorated rather dramatically and was put on meropenem and teicoplanin.

A host of organisms was tested for on serological testing based on the man's travel and epidemiological history, all negative. Even a rheumatological panel was done, also less revealing. He also had a history of MGUS (a haem disoder), which is kind of a red herring here.

Cultures were negative, no vegetations were seen on a TTE - so they did consider IE. Which is an important differential for PUO.

Eventually a PET-CT was done (often favoured when investigations do not yield much for a sick patient with fevers), finally revealing a focus of infectious on his ascending aorta, where he'd also had previous surgery done. And in a round about way, they also further identified Coxiella Burnetti. He was treated doxycycline and hydroxychloroquine. As it's so rare in Italy, it wasn't really considered even though he mentioned rural travel.

Bottomline: Q Fever is an important consideration in the work up for culture negative IE. Further to this, always consider IE in the differentials for PUO particularly if they're at increased risk for IE (prosthetic valves, damaged valves, select congenital heart issues, previous IE). IE can present with night sweats, fevers, weight loss and splenomegaly. It can be insidious and chronic in nature. other risk factors can be more suggestive as we'll get into below.

Causative organism

Coxiella burnetti, it's a zoonoses - i.e. transmissible from animals. Special powers: very tough/hardy, can survive extreme environments (high temps and UV light etc.) over prolonged periods and is resistant to many common disinfectants/surface cleaners.

It's an intracellular pathogen and gram negative coccobacilli (PINK!)

name coccobaccili reminds me of cocopuffs.

it's mainly associated with farm animals, which the CDC so wholesomely displays on its website on Q fever (wtf).

goats, sheep, cattle typically (but many other animals, even birds, dogs and horses can be reservoirs)

in particular bodily fluids - amniotic fluid, placenta, faeces/urine, milk etc.

you can get it through unpasteurized milk and through inhaling it if it lands on dust in the area

ever visit a farm or petting zoo lately? OMG WASH YOU HANDS.

That said, it's typically inhaled in inorganic dust. You inhale it, it goes to the lungs, and then the bloodstream.

Increased risk for Coxiella burnetti (What to take on history of exposures and when to strongly consider it)

live on a farm or near one

exposure to a farm

work as a vet on a farm

farm worker, dairy workers, researchers on these animals/facilities

slaughterhouse/abbatoir

Also from CDC:

Clinical presentation

Most won't get sick after exposure and remain asymptomatic, a very small minority does. even though it is highly infectious.

incubation time is 2-3 weeks (consider this time in your history of exposure, did they work on the farm 2-3 weeks ago as opposed to yesterday).

Nonspecific acute infectious symptoms:

nonspecific systemic fevers/malaise/arthralgias/myalgias--> key is high fevers though and can be associated with headache and photophobia.

non specific GI - N/V/diarrhoea

respiratory ones - SOB or cough, consider it as atypical cause of community acquired pneumonia.

rare: hepatitis and jaundice (granulomatous) or encephalitis with neurological complications such as demyelinating disease or CN palsies, also haemolytic anaemia and HLH (yikes)

really it's the history of exposure that will lead you down the garden path to Q fever.

Chronic Q fever is perhaps worse, and can present as culture negative IE/PUO. Months/years later, as B symptoms as above above + LOW/LOA, night sweats. More likely to occur if you are predisposed for IE as above, have a weakened immune system for any reason, including pregnancy.

Chronic Q fever has a mortality of 10% if left untreated. About <5% of those with acute Q fever develop this if left untreated. Speculation is that it's more of an autoimmune process or abnormal immunological response to the bacteria.

To be honest, most who walk in the door with community acquired pneumonia get treated empirically for atypicals anyway, (standard course of doxycycline), so we hardly really ponder the question of Q fever in every patient. But if they present chronically and did not have atypical cover at the onset of acute symptoms, then it's something important to consider.

Other important conditions - can cause complications in pregnant women and 20% will get post Q fever syndrome. like chronic fatigue.

investigations

Serology! nice and easy. Look for IgG antibodies in the chronic presentation. Or PCR. Down side to serology - can take 2-3 days for the body to make said antibodies to the bacteria for detection. PCR can be done on any fluids/tissue sent.

Cultures useless, hence it fall under the umbrella of culture negative (hard to grow outside a host cell, it is an obligate intracellular pathogen).

Other hints on bloods (as serology/PCR takes time to return) - elevated or low platelet's, transaminitis with normal bili, opacities in CXR with hilar lymphadenopathy, CSF will show raised protein levels if done when encephalitis is suspected.

imaging can also support the diagnosis.. as illustrated by the case report.

Treatment

Acute disease - as standard for atypical bugs, doxycycline 100 mg BD for 14 days. Alternatives - TMP SMX or Clarithromycin.

Chronic Q fever or IE:

native valves: doxycycline and hydroxychloroquine (200 TDS) for 18 months

prosthetic: same but 24 months

why hydroxy: enhances the action of doxycycline (increases the pH of the phagolysosome)

Follow-up: look for 4 fold decrease in IGG

Sources:

CDC

Stat Pearls

Wiki as linked above

#infectious diseases #medblr #med school #medical history #eponyms

[cranquis]

Source

Source

#us health care #medicine #doctors #healthcare administrators #and their stupid wellness incentives #can bite my shiny metal ass

[cranquis]

Hello! I have OCD and am currently taking abilify, prozac and trazodone at night for that, depression and issues with sleep schedule, and i was just wondering because i forgot to ask my psychiatrist, are there any foods or drinks i should avoid because they’ll mess with my meds?

Greetings! So you have a few other resources for finding this information (which I would recommend over my own shaky knowledge of psychiatric medications -- I don't manage those at all in Urgent Care):

Look at the medication information paper that is usually included with your prescription at a pharmacy.

Ask the pharmacist.

Search each of your drugs on a website such as WebMD (I know, I know, I rag on WebMD - but it does have positive uses also) or Drugs.com

As for some of the most common foods/beverages that interact with categories of prescription medications, this is a good "Top 10" list.

#this is probably the first #cranquis mail #in like 5 years #so feel honored I guess? #psychiatry #medications #drug interactions #pharmacy #pharmacology

[cranquis]

Me: *walks into room at 4AM* Hi, I'm the supervising pediatric emergency doctor. I've heard about you from Dr [resident] and I just want to make sure that we have all the details straight, so-- Parent: It's been 8 hours and no one has seen or done anything for my child. Me: I'm sorry for the wait, but we can get things going if I can just-- Parent: Is it normal for a child with a fever to wait 8 hours to be seen? Me: Unfortunately, yes, when the emergency department is very busy and many children are very sick. Parent: How can that be okay?! My child has had a fever and no one came to see her-- Me: We are here now and we'd like to help, would it be okay for me to do a check so we can make a plan? Parent: You should be concerned! Me: ...I am concerned, which is why I want to do this check to figure out what we can do to take care of your child. Parent: Why didn't anyone do anything before? Me: ...The nurses cannot order tests or medications for patients until the doctor has-- Parent: LAST TIME we came here, the nurses just gave us a cup for her to get a urine sample as soon as we got here, and I've never had to wait this long and I've been here many times. Me: I'm glad that your experience previously has been as such, but unfortunately tonight there have been many children needing care. Parent: You have absolutely no bedside manner, you know that? Absolutely none. You have no compassion for a parent that's been waiting here with their child for 8 hours, I haven't slept, and no one came to see us. Me: I'm sorry you had to wait. I'd like to assess your child to help you now, if you'd like. If not, that's your choice. Parent: Of course you have to do something! I've been waiting here--I am not just going to go back home with nothing. --Exam done, tests ordered, parent again questions wait times and rants, there are many other kids in the department who have ALSO waited 8 hours to be seen, I have multiple acute respiratory patients on escalating oxygen therapy that I am now overdue to reassess, oncology patient comes in with fever and needs acute assessment, blah blah blah emergency department blah--

Nursing note x2 between triage and my resident's first assessment: Parent up to nursing station asking about wait time, writer expressed we are unable to estimate due to acuity of department. Parent upset; writer offered to reassess pt now, parent refused as child is sleeping.

...You have been here for 8 hours and no one came to see you.

I have no bedside manner.

#medblr #pediatrics #parents say stupid things #emergency room #medicine #us health care

[cranquis]

Few years back, the whole UC team dresses up as characters from Wizard of Oz. Impressive costumes, fun stuff (I was Toto with dog nose and whiskers).

Then we get paged to a medical emergency in the main lobby - patient had fainted. Toto manually immobilized her c-spine, Dorothy checked a glucose, the Cowardly Lion began taking vital signs, the Flying Monkey put up a privacy screen, and Auntie 'Em was response recorder.

Patient wakes up, looks around groggily: "What happened?"

Toto considers the options, decides on the obvious reply: "Hi, you fainted and you're not in Kansas anymore. Is your neck hurting?"

I’ve told this story ten thousand times and I will tell it for the ten thousandth and first: whenever I think about wearing a costume to work on Halloween, I remember the time I saw a doctor breaking what must have been devastating news to a sobbing patient while the doc was dressed as a ketchup bottle.

#urgent care #halloween #costumes #medicine #medblr #true story kiddos

[cranquis]

faded blue house portrait hanging on the wall at the local urgentcare

#urgent care #i'm liking the aesthetics tho #secret identity

[cranquis]

If you ever see a healthcare worker in my workplace being stupid about sterile procedures or masking, I, a physician, want you to report them.

Because odds are, I, a physician, have already tried to kindly or bluntly educate them about it, but they'll just keep on doing it when it's "just the patient" in the room (and whining about those obnoxious coworkers who keep on insisting on things like "wearing a mask around patients with covid-like symptoms" and "washing your hands all the time")... until administration gets enough complaints and fires their stupid ass.

You are not "causing trouble for the whole urgent care because of 1 lousy worker"...

You are helping to prune out the stupid.

The anti-mask brain rot is penetrating the hospital system in a terrifying fashion.

Masks are necessary for accessing central lines, and more and more nurses are starting to have issues with wearing a mask during STERILE PROTOCOL.

These lines are going right into our hearts and nurses are throwing tantrums about having to cover up their faces for 5 minutes.

This has not happened at my infusion center personally but I have mutuals and friends who have had to beg their nurses to put on the mask that literally comes in the sterile access kit.

#healthcare workers #us health care #medicine #urgent care #infectious disease #public health #morons #don't get me started on the administrators who try to convince sick workers to come to work without testing for covid

[cranquis]

Medblrs - make this analogy part of your vocabulary for understanding chronic pain and developing management plans. 👆

THIS!!

THIS IS AN AMAZING WAY TO THINK OF CHRONIC PAIN

#pain #pain management #chronic pain #hospice #palliative care #medications #doctors #patients #medical vocabulary #communication

[cranquis]

This is beautiful self-care advice.

it's been said before and i'm sure said better than i can phrase it. but really, really - if you like making "i'm going to kill myself" jokes, please try switching to being ironically conceited instead.

anytime something goes wrong, say things like "ah well at least i'm beautiful and charming and everyone loves me." when you forget something, try "my big huge brain is so smart and thinking about too many other very big wizardly thoughts you wouldn't even understand." when you're frustrated by one of your symptoms, start talking like you're in My Immortal. "Life has come for me but my eyes are beautiful pools of gorgeous fire and my hair is amazing. I stuck my middle finger up at life and told it to fuck off and it did."

just... try it for a month or two. try saying the most absurdly self-congratulatory shit you can think of.

i know it's tempting to make suicide or self-harm jokes. and for me at least, a decade ago (!) when someone suggested i stop making those kinds of jokes, i was kind of at a loss for what to replace them with. i wanted to make light of these moments, but genuinely (at the time) my first thought really was suicidal ideation. there was a part of me that even felt like ... i was kind of "making light" of that voice. that if i could say i want to die lol, it would help take the sting out of that genuine (albeit passive) desire. like i could turn my illness into a joke.

when i started complimenting myself instead, it felt awkward and stupid. it felt really, really ironic. what i was actually saying was nobody would ever think this stuff about me, that's what makes it so fucking funny.

but. the effect was immediate. first thing i noticed was the people around me. when i dropped a glass and said ah my skin is too beautiful and sleek the glass has swooned and broken for me, other people were suddenly overjoyed to jump in with the joke. rather than making an awkward moment, we'd both start cracking up. ah princess sleek hands, i've heard of you.

i was 19. i hadn't noticed i'd been making others tense when i said i want it all to end. i know now that it's incredibly hard to know how to walk that moment - do you talk to them about your concern? do you potentially make them uncomfortable by asking if they're okay? do you ignore the situation? do you help them pick up the glass, or do they need to do it by themselves? are they genuinely made suicidal over this small moment? and most importantly, how do you - without professional training or supplies - actually help?

most people want to help you pick up the glass in your life, they just have no fucking idea how to do it. they don't want to make anything worse. they don't want to make assumptions about you. they love you, they're scared for you - and being scared makes people kind of freeze up. it's not because they don't love you. it's because they do.

now when something bad happens, my first thought is how can i make a stupid joke about this. it isn't my brain saying you're a dumb fucking bitch. i spend more time laughing. i spend more time being gentle with myself. i spend more time feeling good.

and the thing is - what's kind of funny - is that you'd be surprised by how many people agree with you. the first time i said i'm too pretty to understand that, someone else said to be fair you're the prettiest person in this room. i promise - you really don't know how kindly your friends see you. but they love you for a reason. they sort of reverse-velveteen-rabbit you. your weird and ugly spots fade away and you just become... the love they want to give you.

go love yourself ironically. the worst thing that happens is that you end up tricking your reflection into actually loving you.

#self esteem #self care #psychology #mental health

[cranquis]

As a doctor, I would really like to see our profession adopt this!

Screw that dumb "on a scale of 1-10" pain level crap.

my pain scale invention. it goes from 0-16. you fill it out like this:

i made this because i find pain to be a multifaceted thing that influences me in different ways. i can accomplish lots of small tasks while in pain but that doesnt mean i can move around or even think clearly. its name is the goldstein expanded pain index or gepi. you can use it if you want. or not.

#medblr #pain #chronic pain #pain scale