Its alive!!!!  maybe not.

Rice EMS

Man who collapsed, died on track thanks workers who saved his life

Congratulations to RICE EMS for this save!

You guys do an amazing job.  Click the link below.

http://www.khou.com/community/Man-who-collapsed-died-on-track-thanks-workers-who-saved-his-life-199607971.html

-EN

ACEP clinical policies

While working on any shift in the ED you are constantly surrounded by people with various levels of medical knowledge.  I often get asked by junior residents as well as medical students, "How did you make that decision to scan that pt's head with syncope?" or "How do you know what kind of opioid to prescribe?"  I have as of late been recommending that all our residents, medical students and nurses take a look at the American College of Emergency Physicians clinical policies.  There are about 21 of them and I do find them useful.  I think you will to. Check em out.

-EN

 

Dr. Speer for TMA president 2011

I was asked to shoot videos and make a website for a candidate running for the TMA president and he won!  How sweet it is.  Check it out at:

www.drspeer.blogspot.com

"Lessons Learned by Random International Surgical Interns" Vol. 1

I just graduated from a very international medical school, The Royal College of Surgeons Ireland (RCSI for short).  

About 80% of my colleagues hailed from around the world (only 20% of my class was Irish).  I have asked my various associates who just started "interning" to send me "lessons" that they have learned since starting their internship just a few months ago.  

So, compiled from all around the world by newly graduated doctors who are now "minty fresh interns......"

Educated Nobody proudly presents...  

"Lessons Learned by Random International  Surgical Interns"

Lesson 1: "Newly instituted Hospital Visitor Infection Control" 

Dear Educated Nobody, 

A completely bald man entered the hospital reception and sterilised his hands with the Spirigel.  The man then proceeded to rub the alcohol gel into his shiny scalp.  6 years of medical school and I am quite unhappy that  this "New" sterilizing technique was never taught to me before I became a Surgical Intern.

p.s.  You know I have great hair.

Lesson 2:  "Tricksyness lives in the Radiology Department"

Dear Educated Nobody, 

The key code to the x-ray department so you can sneak into and schedule a CT that was rejected by the radiologist three times. (the pass code is 4,3,2,1)

Lesson 3: "Why take the Stairs?"

Dear Educated Nobody, 

The key code to the consultants lift (elevator for your Americans) is 1,2,3,4.

Lesson 4: "Monks On Call.  Seriously!"

Dear Educated Nobody, 

Did you know that your hospital may have a monk on call?  I had no idea.  If you bleep the right, or in my case wrong bleep number,  You may find yourself having to answer to a holy man in brown robes and sandals!  I had no idea! He was nice though.

Lesson 5: "I realize I suck at IV cannulation"

Dear Educated Nobody, 

After 6 years of medical school and 4 weeks of being a surgical intern, I am still not as capable as an "IV user" in putting in a venus cannula (He put it in his first try for me.  I had stuck him twice.  Sorry!  Regardless, we were both pleased with his result rather than mine).

More to come later I am sure, 

- E.N.

(image courtesy of http://www.brighamandwomens.org)

USMLE Step 1 Study Guide (by a hairy Neanderthal)

I have been reluctant to write a post about the USMLE Step 1 because I believe there is a lot of advice out there already. I also believe that when the time comes to take the Step 1, you already will have been in medical school for a while and have a sense for how you study as well as a serious collection of books (most of which you bought and never read). 

At this stage in your higher education, you are probably reluctant to take exam related advice from your colleagues as well.

The reason for this exam related mistrust most likely has its roots in the speculation and scuttlebutt that revolves around your medical school's exams. Really, consider how many times have you heard statements like, "I heard the professor say that (insert random topic) is DEFINITELY going to be on the test," or, my personal favorite, "Oh dude, I barely studied."  All of these "tips" probably ended up as pure unadulterated B.S.  So, you don't trust your medical school pals.  I don't blame you. Liberal Arts students are a lot more fun. Go get some new friends.

Since I went to medical school like you, I don't expect you to trust me either. So, to gain your trust, I will hang my head in shame and admit that I did not get a 99 on my USMLE Step 1 Exam.

Dang! 

Trust me now?

I believe it's a simple fact that by the law of averages, you probably won't get a 99 on Step 1 either. The addendum to the previous statement is that you should still work very hard and do your best (that's what your mom would want and who can disagree with your mom).

When I was looking for advice on message boards online, I found that most of the advice was coming from people who claimed to have done really really REALLY well on the USMLE. Still don't trust me? Check out the student doctor network forums and have a blast. It takes about three minutes to realize that most people are living in a world of rumors where he said she said talk reigns supreme. This is usually coupled with the uncanny knack for bloviation (I spot it very easily since I consider myself the master).

You know who these people are on the message boards. They sit amongst you in class. They are a different breed of person. They like to upload pie charts of their practice tests, study guides, pictures of themselves studying and time tables that include a regimen for a 36-hour workday. They document there preparation with meticulous detail including tips on how to avoid your girlfriend, when the optimal time to go to the bathroom is and diet advice that will make your Gastroenterologist envy your perfect pooh.

After you read the crap that's posted about the USMLE, your brain will probably (if it didn't, I'll spot you this one) jump to the logical conclusion that more people seem to get 99s than actually take the stupid exam.  Or at least it certainly feels that way.   I believe that the majority of people who write about their Step 1 experience do no reflect the silent majority of people who fit into the rest of the bell curve that must exist.  It's simple; not everyone can get a 99, but the people who write about their Step 1 experience sure do! So...

If you are looking for advice from a "man" who has a distended cranium, slumped forward shoulders, ridiculous kyphosis, with hands that hang past his knees, you my friend are in the right place!  If you are the medical student who has no grasp of the wheel and have no clue how to start a fire, you may join the club of intellectual knuckle dragger's like me! Read on my Neanderthal brothers and sisters!

The list below is the materials I used and recommend.

 

THE LIST

(It's Kaplan heavy, so watch out)

 

Study like you are taking the test - The day you take your exam is really long. I quote Wikipedia,

"The exam was an eight-hour single-day computer-based test composed of seven 50-question sets (350 multiple-choice questions in total). However, as of May 9, 2008 the number of questions has been reduced to 48 questions per set with a total of 336 questions for the day. The time provided for each section has not changed. Each section is one hour long, allotting a minute and fifteen seconds for each question. ^[1] The test taker is permitted 45 minutes in total for the whole day for the purpose of breaks that can only be taken between sections. There is a 15 minute tutorial at the beginning of the exam, which the test-taker can choose to skip, and have the time added to the break time. If the taker finishes any section before the allotted 1 hour time limit, the remainder of the time is added to break time. ^[2] The test is administered atPrometric testing sites around the world.

Study the same way. I assume your getting my drift.

Kaplan Videos - These are great when accompanied the Kaplan lecture notes. The videos are lectures of professors teaching with power point. What I like is the fact that word for word is taken from the lectures and put directly into the Kaplan lecture notes. I am not sure if it is illegal to bootleg copies of the books or videos, so I don't sell them. I will just tell you how to get them! There are a lot of videos--about 24 hours of lecture per subject. At six hours per day, you can get through them in about a month or a month and a half. I purchased the videos is from the site UsmleStep.com. There is also a host of other study materials for Step 2, etc. if you are interested. http://www.usmlestep.com/2005-kaplan-step-1-dvds-lectures.htmKaplan 

Kaplan lecture notes (the holy blue books) - The Kaplan lecture notes can be found on ebay and are a stack of blue books. The prices range from 250-350 dollars plus or minus shipping. If you click this link, you should see the search "USMLE Step 1 Kaplan." I like the idea of these books because it's what the fine people at Kaplan recommend. You really don't have to use any other books except maybe First Aid (which is not the only book you need contrary to popular belief).

You really don't need any other books. I am serious about this. Don't bother with your other books except for reference. All the Kaplan people do all day is study what comes up on the USMLE. That's it; KAPLAN people have no lives. Trust them. They are serious. I have never seen anyone from Kaplan Smile. Serious.

First Aid - I am not a huge fan of this book. It's for the memorizers amongst us. If you can read lists with no context and interpret graphs with no explanation this is the book for you (why are you reading my blog if you are?). I heard a lot of talk about First Aid before I took my exam. "It's the bible without Jesus." "It's all you need." "Dude, best book ever! You're reading something else?" Bollox. If someone says any of these statements in your presence please take the following advice:

Walk towards this soothsayer slowly. Make sure your arms are akimbo for effect. Smile, deep down you are a nice person. Now that you are in position take a slow deep breath and proceed to kick this person in the kneecap. You have just met a person who is in medical school who "barely studies!" You're a hero! Now go call the on call Orthopedic Surgeon because you're a nice guy and went to medical school in the first place to help people.  Now help that jackass. 

I do believe you should look at the First Aid book. I do believe it helps for memorization. I do not believe it should be used as your primary text! If you are planning to stare at this book for two months and do well on the exam, think again.

Pass Videos - There are three DVD's that come with this set. The teacher is a very large dude who teaches good USMLE concepts in an entertaining way. Plus he loves a kid in the back who makes connections to other topics. "Jesus (that's the kid's name)! My man! Making connections!" Entertaining, hilarious, slow at times, but well worth watching.

Goljan Pathology Mp3's - You must know who Goljan is already. Goljan's pathology mp3 lecture course with notes can be found online. Since I took my exam, I don't think I could listen to him ever again. He teaches very well, and I think he is very smart but his voice just got grating after a while. Use it until you hate it. By then, I am sure you will know your stuff so well that pathology will be a breeze.

Question Banks - Do as many questions as you can.  Your life's ups and downs should revolve around questions. Girlfriend broke up with you?  Do some questions.  Wondering what you should do right before you are about to get a new haircut to replace your mullet? Do some questions.  You turned 32 and have a quarter million in debt because you went to an out of state medical school?  STFU and do some questions. 

I think question banks are great. It's no secret that the more questions you do, the better off you will be. As for the rumors regarding the Q-banks, word on the street is that Kaplan is the best to use. USMLE World is harder, but still very good as well as being the cheapest.  I liked the fact that USMLE world also uses diagrams to explain some of their answers. I recommend doing all of them (I still did not get a 99, but my mom is proud).

USMLERx - Made by the people that make the first aid book. If I were to choose between the First Aid book and the USMLERx question Bank, I would take the question bank, because you get asked on the whole drop knowledge questions you either know or you don't. It is a question bank of essential, must-know facts. The answers for the questions are actually pages copied directly from First Aid book.  It's like studying from the First Aid book with a clinical vignette that the first aid book left out. 

Step 1 Score Estimator - When your doing q-banks, if you go to medschoolforums.com or click this link,http://www​.medfriend​s.org/step​1_estimato​r/ You can estimate your two and three digit score using Kaplan's Q-bank. It's really helpful and frighteningly accurate.

NBME exam - A lot of people take stock in the NBME practice exams. They can be found at www.usmle.org The advice is take the first exam when you begin to study just to get a feel for your weak areas (don't freak out if your score sucks). The rumor is that NBME exam 2 is the most accurate predictor. I took it a week before I tested, and it was within a few points of my real score. I have heard this same type of talk from a number of students and colleagues.

That's it. I hope it helps. It's only the essentials. If you think there is stuff I should add delete, etc., leave a comment or shoot me an email.

Trust me now?

Surgical Recall Audio (plus a hot chick)

Anyone in medical school who aspires to be a surgeon knows that Surgical Recall is the book to memorize. If you hate reading or would like to imagine your mom and dad are teaching you about surgery as you are about to fall asleep, I have the perfect remedy for you.

I was cruising around online and found a version of Surgical Recall that is in mp3 audio format. It is literally a woman's voice reading the surgical questions from each chapter. After a brief pause, a very manly man's voice answers the question. There is no additional pause to show the whole class the pictures. You can read along with the book or just listen and try to answer the questions faster than the woman. She sounds pretty hot as well. Sa-Weet!

The audio format is also useful for wasting time when traveling to the hospital via the car, bus, camel, magic carpet, elephant, Viking war ship or knacker pulled wagon. My school is very multicultural, which is represented by the students' various methods of transportation.

You can buy the audio book from Amazon.com (I have put a link on the lower right). The chapter files will download automatically and you only have to open the zip file which should open magically into I-tunes. I assume it works the same way with a PC; I am not sure, because I roll with a Mac.

The cost of Surgical Recall Audio is between 33 and 39 dollars. This sucks if you're buying the product in dollars, but if you are purchasing Surgical Recall via Euro to dollar conversion, then your only spending about 3 Euros or 1.98 million pesos (insert bitter sarcasm here due to the fact that a certain student's loan check is in dollars which is later converted to Euros). Dang!

Regardless, the Surgical Recall Audio is a good purchase. I like it so much I take it to bed every night! "Oh really?" Oh Yes! The same students who listened to Goljan when studying pathology will be interested in this download.

Later

BJM

Resuscitate me, Carlos! Book review get's published, jealousy ensues!

I am correct when I say that you read it here first.

This is a screen shot of the author's proof that is sent out before publication. The author added my name in red (because he has authorship guilt) because I kept on yelling at him to write something for me so I could selfishly post it here. He wrote a review of the book, "Fluids and Electrolytes in the Surgical Patient."

It annoys me to no end that the first thing he wrote for me got published (what an ass). I did not write a sentence in his work and it's obvious… It's good!

Congrats to the author.

Although, it is within the scope of my personality to write a crappy review of the book review out of pure jealousy!

The original post is here.

If you have not read the book yet, you should, I really like it. Carlos Pestana can rehydrate me anytime.

-BJM

Paediatric study guide for the (average) RCSI medical student

As of today, my medical school class has finished all the pediatric learning that my fine medical institution (RCSI) has to offer.

Now that I have finished paediatrics (pending my results), I am just going to write a few lines about the resources I wish some one would have told me about before I started my rotation.

As a child, my mother told me many times that I was special (in a good way, jackass). As a result of her nurturing policy, I do not use the marks I score on exams as a measure of anything other than my ability to take that exam on that given day (most days, I am in the middle of my class). SO, if you are looking for a list of resources and books compiled by some one in the top of the class that gives advice on how to kill a herd of Zebras, you ain't in the right part of town stripy.

But, I assume by the law of percentages you're somewhere near the middle of your class as well, and that's good -- this is meant for you.

1) The Pediatric book with the sunflower on it is reviled by most medical students, yet somehow it is the standard recommended text. Dutifully I bought it. I opened it. I closed it. It really was terrible. BUT, there is a copy of notes floating around that were disseminated in the back RCSI library corridors, under cover of muffled cell phone conversations and Butlers coffee. They are a distilled version of what's HOT in "The Book That Will Not Be Named." Essentially, a student read the book and took out all "the fluffy bits." The end result is a really well written list of topics with only the essentials. Go ahead. Ask around. These are worth getting a hold of. You can always shoot me an email if you have not been able to tap the "appropriate network."

2) Pediatrics at a Glance is a good book to start with. I always enjoy the pictures from that series. The unforgettable picture at the top of this post is in the book concerning Sudden infant death syndrome; We added the "bollox." As per usual, all books in that series are lacking in written text. So, if you are into visual learning, it is a good resource and a rapid review. Today before my exam, I flipped through the whole book in an hour, just looking at the pictures. I guess it gives you a decent quick revision of topics some medical artist deemed important enough to draw.

3) If you like lectures and Kaplan, I do recommend the Kaplan lecture series and the yellow books for Step 2. They are not tailored for the RCSI course, but it is well worth the 12 hours of video and a glance through their version of what you have to know for on Step 2. Think of it as a two-for-one deal; you're studying for your exam and your Steps (and that sucks!). If you stumbled upon web page, then I assume you know enough about the web that I don't have to tell you how to find them on eBay.

4) Paediatrics and Neonatology in focus by Ros Thomas and Dave Harvey is a small book with a lot of pictures that will take you a day to read cover to cover. Again, it is fast revision of conditions that present visually.

5) Pocket Essentials of Paediatrics by Nandu Thalange et.al. I used this book on the wards. It's not a must have, but I know a lot of people who liked it.

7) For the OSCE, those of us who had an 8 month gap between our paeds rotation and the exam were a little nervous since we had not examined a kid in quite some time. I found the book OSCEs in Paediatrics by M.A Khan and M. Pandya useful, and it really put my nerves at ease.

8) Paediatrician Dr MDK video-blogs is a series of short interviews with a host of his Paeds colleagues on an A-to-Z list of topics in General Paediatrics. I'm not totally sure if these are aimed at parents or medical professionals as the language falls awkwardly between the two. That having been said, it is a fairly comprehensive, succinct review of the frequently asked questions and common presentations in the Paediatrics clinic that is well worth 2-3 hours. If you find New York accents grating, viewer discretion is advised. His videos can be found at www.drmdk.com

So, that's the list. I think it served me well... We shall see.

As always, if you have any additions to this list or want to tell us how you feel about it, feel free to comment below. Feed back is always appreciated.

Also, A very good friend of mine just matched in Paeds in Canada today (Not an easy task. Canada hates it when their students leave and try to come back). Giles, congrats, and remember back up at least 10 feet for all cases of pyloric stenosis

-BJM
-GAB (secret ghost writer)

Smithfield Horse Market Dublin Ireland

Today, I walked out my front door and found myself in the midst of the Smithfield Horse Fair. Instantly, I was in the company of hundreds of people, hundreds of horses and more than a ton of horse shit. Being a Texan, I felt right at home even though there was a genuine lack of tobacco spit.

For the last two hundred or so years, horse and pony traders (and spectators like myself) have been congregating at the Smithfield Market while skipping church on the first Sunday of every month. People come from all over Dublin to the horse fair for many reasons: to speculate on horses, buy the horses speculated on, hang out, smoke, drink, litter and ride their horses as fast as they can through crowded areas while yelling at innocent by standards, who are obviously in the way.

The Smithfield Horse fair is not organized, it just happens. The lack of organization is obvious. There are no official set of rules, no official start time, no official end time and certainly no officials to officiate. It’s pretty much a free for all.

This was made very clear to me when I witnessed a Dublin youth throw a glass bottle about 15 feet in the air (with a big shit eating grin on his face), which shattered into a million glittering pieces at the hooves of a innocent horse. A man who was holding the reins quickly lifted his arm, pointed his finger and yelled, “Bollox!,” at the boy. It was a pretty futile gesture. The boy smiled, chucked the unfriendly deuce at the man and ran off laughing.

(The boys in the image to the left were not responsible for the bottle chuck and run)



While trekking through the market I met Johnny and his horse named Spot. Johnny was kind enough to let me take his picture and I honestly admit I was surprised at how nice this young man was. After I took the photo, he asked me if he could see the picture. He posed, I clicked and he then looked at the image closely for at least ten seconds. He looked at me and smiled. He was impressed with himself; he knew he looked good. I asked him, "Who looks better, you or Spot?" He said, "Spot!" and I am sure he thought I was an idiot for thinking anything otherwise.

You can be the judge.

Johnny asked me to send the picture to his email and made me repeat his address more than once. His accent was pretty thick, so, Johnny, if your out there, email me and I would be happy to send you a copy. All in all, I can say that Fun was had by most at the Smithfield horse fair.



I'm Out

BJM

From Scrub Skirts to Pants: The Evolving Role of Women Physicians

Guest Writer: Educated Nobody's Brah
MD, LRCP&SI

I have the good fortune to be related to three generations of women physicians: my great-grandmother, mother, and wife. Although each of their stories is different, they also bear the hallmarks of the times in which they lived; this is the connection among them.

Nettie Solomon, my great-grandmother, was born in 1896. She was a talented opera singer, rode a motorcycle, smoked a pipe, and graduated from Women’s Medical School in Philadelphia. Grace Goldman, a younger relative who shared some of her childhood, remembers my great-grandmother in her memoirs:

Nettie was irrepressible. She was the warmest, most outgoing, most self-sufficient person I ever knew…Her laughter was a pure cascade of silver. Whenever Nettie visited it was a holiday; she brought sunshine and radiated a feeling of joy and vitality. She was famous for her escapades. She had a motorcycle and would go tearing about Passaic, N.J., when this was hardly considered seemly for a young lady. But because it was Nettie, it was a lark. She matured early, and love affairs were legion. In her parents’ eyes, no one was good enough, or aristocratic enough, but Nettie had her own way. She chose her friends as independently as she chose her clothes. No one could dictate to her, and yet she was the warmest and most unspoiled person. Everyone adored her.

Although I never met Nettie, I am told she loved babies and small children. After graduating from medical school, it was her intention to become an obstetric surgeon. However, she was promptly informed that women did not perform surgery, and so she entered family practice instead. Nettie married Louis Edeiken, a kind and affectionate radiologist beloved by the Philadelphia medical community. Antique sepia photographs, surprisingly candid for the time, document the obvious affection and happiness between these two remarkable physicians (picture below). I can only assume that Louis’ love for Nettie had something to do with her accomplishments and independence. However, he was also, like her, subject to the conventions of the time. Upon the birth of their first child Nettie abandoned medicine forever. Like most of us who enter medical school, she had once devoted her life to the art, science, and challenge of healing. She now faced an even greater challenge: abandoning her life’s passion. I often wonder if that sacrifice was advocated by Nettie, Louis, both, or neither. Regardless, there is a discrepancy between the Nettie in the photographs and how her granddaughter, my mother Beth, remembers her.

My mother Beth recalls her grandmother Nettie as a stern and mean-spirited woman. A kind word was rare, and a smile rarer still. Later in her memoirs, Goldman describes the elderly Nettie in stark contrast to the photographs and recollections of her youth.

In the last years of her life…Nettie knew the pain of loneliness and sorrow. Her eyes were often shadowed with sadness. Through physical and mental torments, her strength did not falter.

When my mother was a small child Nettie asked her what she would like to be. “A doctor” replied the child thinking only of her father, a physician whom she adored. Because Nettie had abandoned medicine before my mother was born, Beth was unaware that her grandmother was a physician. “Oh Beth: keep very quiet, study very hard, don’t make a spectacle, and they may let you do just that until the day you die” was the old woman’s advice. My mother considers this a solitary kindness offered by her grandmother, although the true intimacy of it was lost on her youth. It tells me a little about how Nettie viewed her life in retrospect. Could she have been both a successful physician and mother? My own childhood experience tells me yes, but I grew up in the seventies after so much had changed.
******
Beth Edeiken, my mother, was born in 1948. An all-American field hockey goalie, she struggled with dyslexia before it was a well-accepted diagnosis. Thus, she was unable to earn her undergraduate degree due to the foreign language requirement. Based on her science and math scores she was admitted to Jefferson Medical College, and graduated in 1973. In those days, female medical students wore white hose, white nursing shoes, and scrub skirts. The women of her class circulated a petition protesting this inequity. When asked to sign, Beth remembered the advice her grandmother Nettie had given her so long ago. She declined to participate, and avoided risking her career through “spectacle”. Soon after, several of the petitioners were expelled. In spite of her grandmother’s advice, my mother had finally had enough.

As she sat in the Dean’s office, Beth explained the intricacies of performing compressions on a patient in cardiac arrest. She told the Dean that because of their height, most of the women could not perform compressions of gurneyed patients from the floor. Instead, they straddled the patient to gain adequate leverage. She made a point of illustrating how, in a skirt, the straddling women were forced to expose themselves, flashing those present, while trying to save the patient’s life. The Dean flushed, and shortly thereafter scrub skirts disappeared from the hospital and were replaced by pants. The expelled students were reinstated. Eventually, like her grandmother, Beth chose the road less traveled. She married a foreign-born physician, my father, whose origins were not considered “seemly” in her generation. Against her mother’s advice, but with her husband’s support, she continued to work as a resident, and thereafter a radiologist, through two pregnancies and thirty-five years (and counting) of marriage.

In contrast to her medical school exploits, my mother did not spend her career as an activist. She wanted to be an orthopedic surgeon, but was told it was not a “woman’s specialty”. Remembering the words and life of her grandmother, she kept quiet and maintained a low profile while being paid half the salary of her male peers. On night-call she dutifully taped the requisite sign to the call room door that read, “Girl Sleeping in Here.” At conferences the men normally referred to each other as “doctor,” or by their last name. My mother was commonly referred to as “The Girl,” or Beth. None of that has ever mattered to her; she tells the stories out of interest, not complaint. She is satisfied, and even feels lucky, that it is better for her than it was for Nettie. Beth fondly recollects the men of the previous generation, including her father, who generously shared with her the secrets of medicine. She is happy to have been allowed to follow her professional passions while raising a family. She has achieved some recognition, and if you are a radiologist you may be familiar with her work. From my perspective as her child I had a female hero who was out saving lives. I grew up happy, and more than a little proud. From my perspective as an adult Beth is not only my mother. Along with my father, she is my personal and professional mentor. Since my marriage to a medical school classmate, my wife finds Beth a valuable source of insight and advice. I often wonder what it would have meant for my grandfather if his mother, Nettie, had been able to fulfill that role for him.
*****
My wife, Maria Gule (pronounced goo-lah), was born in 1980. She is the daughter of a dairy farmer from a tiny, rural village on the northern coast of Norway. The village, also named Gule, sits next to Gule River, and is overshadowed by Gule Mountain. Growing up she attended the Gule Skule (pronounced skoo-lah), and a recent visit to the local cemetery revealed that most of its inhabitants share her surname. Never satisfied with the opportunities available in her isolated hometown, she traveled to Ireland for medical school. At The Royal College of Surgeons she was among the top five in our class. Although I represented the other end of academic achievement, she allowed herself to be wooed. At our wedding ceremony far from Norway, performed at a Houston steakhouse by the Enron judge, we made an odd-looking pair. She is 5’3” in heels, strikingly beautiful, and a buck-fifteen after a large meal. I am 6’4”, less than beautiful, and double her weight after a month’s strict diet. I love my wife for her brilliance, independence, and moxie. It was no surprise to me when she declared her intention to apply for a general surgery residency. I warned her of the rumors of brutality, but she was not dissuaded. Why, she asked, come so very far to abandon your dream because of fear or adversity? I had to agree. I was keenly aware that her decision was a luxury not available to my great-grandmother and mother.

During medical school, while on her first stateside elective in general surgery, Maria shared her goals with the administrative assistant of the Chairman. “You have no business being married and becoming a surgeon. Your husband will want you to give him children, and a surgeon cannot afford to take time off to be pregnant. Why don’t you do something like pediatrics, or family practice instead” said the woman. Maria is no complainer. She described this exchange to me in a matter-of-fact way, added a laugh, and promptly went on studying. I, however, was enraged. Five minutes later, I called my mother for advice. Surely she would understand my anger. Surely she would want to fight back. Beth’s first question was, “Douglas, does Maria still want to be a surgeon?” I looked through the glass door to my wife’s home office. She was blissfully content, using the skin of an unpeeled orange to practice surgical suture knots. I gave my mother the truth. Beth replied, “Oh Doug: tell her to ‘keep very quiet, study very hard, not make a spectacle, and they may let her do just that.’”

During the past few years I have heard numerous stories about contemporary women physicians who are treated badly for being ‘in the family way’, or for simply being women. These are not unique, or indeed new, stories. There are times when I wonder why someone as gifted as my wife should expose herself to that kind of ignorance. There may be times when she wonders the same thing. Luckily, those times never seem to be the same for both of us. I know she will become a gifted surgeon. She would never say so, but I know that she knows the same thing. I often remind myself how much better it is for her than it was for my mother Beth, or great-grandmother Nettie. Maria, on the other hand, needs little encouragement. She has the singular, awe-inspiring focus of most surgeons. Like most surgeons, and indeed most physicians, she simply plods on, ignoring adversity, one step at a time towards her goal. I know she will achieve it no matter how many curveballs come her way. And that is the rub.
*****
On a recent tour of a surgical residency program at a level one trauma center, one of my fellow applicants asked the question, “do the residents in this program really adhere to the legally-mandated 80 hour work week and, if not, do they document when they exceed it?” His question was met with a blank stare from the obviously sharp, young, black, female chief resident wearing scrub pants, and not a skirt and hose. Before she answered, I had to smile at how far we really have come. She replied flatly,

Of course we adhere to the 80-hour work week, which is the law. But let me add one thing, hypothetically of course: if I, or any of the other residents here documented a breach of the law, it would put my residency program, and thus my chances of becoming a surgeon, at risk. Would that be smart?

Indeed, I thought, it would not be smart at all. I understood her angle completely.

In the future, should I have daughters who choose medicine, I know that it will be a little better for them because this woman, and others like her, chose to keep very quiet, study very hard, and not make a ‘spectacle’… at least in one sense. In another sense, of course, each of these women is a remarkable spectacle.

ASK DOCTOR CLARKE Medicine review (part 2)

I attended the 16-hour "Medicine for Finals" review session by Dr. Clarke in mid-January, which was a two-day course sponsored by the British Medical Association. If you read my previous post, you will know that I was pretty excited about attending Dr Clarke's review. In my opinion any person who tries to review all of medicine in one day has to be a bit crazy. They also have to be pretty good at what they do in order to pull it off. The following few paragraphs is my personal review of his course. However, I have left out the surgery review. GAB will probably do that soon, and it will be published shortly (we have finals coming up so don't hold your breath).

I arrived to St. James hospital around 8:45 a.m. and was greeted by Dr. Clarke and a representative from the BMA. Dr. Clarke's goatee in real life is just as cool as the cartoon one on his website. I also have to say for completeness that Dr. Clarke is much thinner in person (his web caricature does him no justice). Upon arrival, I was then given a red hat pin for neurological exams, a free orange pen from the BMA, a booklet covering the days lecture which contained extra reading to supplement his power point lectures. He also provided coffee. It was the coffee in the morning that made me think the following three things:

1. This guy knows his medical students. Coffee in the morning even though we paid for the course was a total unexpected surprise.

2. Aside from the bonus coffee, we also received a medicine and a surgery booklet. The books cover his lectures word for word. This was nice to have during the lecture, because I was never worried about writing anything down. I have since sat down and reread a lot his notes with great recall. His book also contained extra notes on topics that we might not have totally covered in his lectures. Now that Dr. Clarke is back in England, I can happily report that I stole an extra three hat pins as well.

Come get me, SUCKA!

I know I know, Pitiful. Anyway ... Finally I thought:

3. It was going to be hard not to outwardly show my platonic love for Dr Clarke over the next 48 hours without embarrassing myself, Dr. Clarke and my medical school.

The syllabus was refreshingly simple. For the final med student interested in reviewing as much as possible in as little time as possible, he was as Shaft would say, "Right on."






The topics and time table were as follows:

9:30 Cardio
11:20 Renal Med
12:00 Neuro
13:45 Neuro 2
14:15 Rheumatology
15:20 Diabetes
15:50 Endo and finally Resp

Coffee breaks and lunch were put in between. Before each section we usually took a quiz on the topics we were about to cover. The quizzes gave you a no BS assessment of what you did not know. They also helped you focus on what you needed to pay attention to in the coming portion of the lecture.

Without giving away all his secrets, I will say that his teaching style is interactive to say the very least. He uses various methods to reinforce your memory of certain topics. He uses a combination of patient videos, power points, quizzes, lecture booklets and various ridiculous hand gestures to teach you in a high yield fashion what is essential to know for finals. I swear you will never forget Hyperkalemia (if you went to his course you know what I mean). He also got the entire class involved to remember Murmurs. It's pretty hilarious when you have a room full of final medical students yelling "Lub De Drrrrrrrr!"

So, overall I believe the course was well worth it. If you asked me in one word I would say "illuminating." The concepts you might not have understood or ones that really never quite got in medical school were explained simply, with ease and in a memorable way. This is not a course where you are just given more lists to memorize. You will remember concepts, and as a result, the lists will come to you. I know it sounds hokey but trust me, it's true.

A few weeks before my written exam and a few months before my orals, I have a much better grasp of what to cover and how to cover it. Throughout the day, he also reviewed materials covered last year in medical schools, because students emailed him what they had on their exams. I plan to email Doc Clarke when I finish my exams as well.

Topics Covered: A+
Cartoon Goatee: B+
Real Goatee: B-
Revision workbook: A+

Overall score: A+ with distinction

I also just attended the MPS finals revision and when I have time I will write something up. If you are curious in the mean time you can email me EducatedNobody@gmail.com

I'm Out

BJM

ASK DOCTOR CLARKE (part 1)

As a medical student I am always looking for new books or resources to study from. The Internet has made medical education very accessible especially when you know what you are looking for. You also have to venture forth with the understanding that some of the information on the internet is “crap.”

If you are interested in seeing what the academics are saying about the topic you can do a pub med search on “medical education.” The list of papers is embarrassingly long. In your search you will find lists of “original” papers that all say the same thing. Amazing! These papers use fancy words like “vertical integration” and “systems based learning.” These papers all espouse the novel idea that if you are teaching the cardiovascular system, its new and innovative to teach the anatomy, physiology, pharmacology as well of pathology of the cardiovascular system at the same time. Eureka! Was I the first one to ever write that? I bet I was. I should be published.

As a professional student, I see most of these papers as old wine in a new bottle. I refused to write a paper on “medical education” at one stage in my medical school career. Lets just say we weren’t received with “smiles” at the time.

When I have a question about anything medical I do a Google search or just use Wikipedia and I have yet to be disappointed. I am also now convinced that the line in the movie Good Will Hunting about a library card being better than a ivy league degree is true, "How you like dem apples!" I only say this after blowing a quarter million on my medical school education so I obviously have a right as John McCain would say, "to do some straight talk here." As a friend of mine once said during lecture, “I think this power point lecture was taken straight from Wikipedia.” For 35,000 Euros per year, it pisses me off to no end that he was right! Dang!

I am in the process of convincing myself you could be a fantastic doctor not ever having gone to medical school. It seems as long as you were pointed in the right direction in terms of what to read you would for the most part be ok (aside for your utter lack of clinical skillz but you know what I am getting at here). In some medical schools, including mine, we call going off and reading “self directed learning.” They even allocate time in our schedule for it. Most of the time it occurs when a lecture has been unduly canceled. "Self directed learning" is code speak from any medical educator for, "piss off I am to busy to teach you because.......

A) "I am saving lives....Duuuuhhh!"

B) "I am trying to make this golf trip happen"

C) I forgot about your silly lecture but I will say aloud, "Its quite obvious you are all being spoon fed so I don't see why your complaining lecture is canceled!" (which is my favorite because its not really an excuse as to why lecture was canceled)

D)" I am enjoying this damn fine cup of hospital coffee with this moderately attractive secretary."

Its so awesome when they charge me to go read alone! Medical education in Europe is not as socialized as Americans think. There are some serious capitalists over here!

Whats so neat about medical education aside from the plethora of crappy papers out there on the topic is the ability to tap into to all this information. For example you can go on Ebay and get video lectures from Kaplan for all your USMLE exams. You can download Goljans pathology lectures (30+ hours of them "its on boards") or get your hands on emergency ICU surgery rounds on Itunes. You can even watch a live operation on ORLIVE.com. All this while sitting at home slugging down a diet coke and eating pork rinds. The best part is, most of it is for free. Free goes very well with pork rinds and a diet coke.

So why I am writing this you ask? Because I have found a resource that I have enjoyed called www.askdoctorclarke.com (FREE). I have also signed up for his revision lectures on the 26 and 27th of this month in Dublin which are co sponsored by the (MPS) Medical Protection Society. It cost me $ 233 bucks and I payed it with a smile because his website is just so damned good. He has already sent me homework to do before the two day lecture extravaganza. Nerd alert! He appears to be very organized. I like that in a man. I also like his goatee in cartoon format. Actually I am pretty jealous of his goatee in cartoon format.

I must admit Dr. Clarke has left my bank account hurting like a fat kid playing Dodge Ball (Dodge Ball is capitalized because it’s a serious game that has left thousands of children scarred for life, Awesome!).

My account statement reads as follows:

Transactions 1 - 32 for Lifeline Checking account @#$%@#$%^^
January 14 2008
Available Balance: $71.15
Date Description
January 14 2008 POS DEBIT DR ROBERT CLARKE BARNET $233.19

Dr Clarke you better be worth it or else I will complain on my blog! Yeah I am so empowered (sarcasm).

Go to his website http://www.askdoctorclarke.com/ sign up and check it out. It is free and his clinical videos are straight to the point and excellent for clinical finals. Plus, the violin music is class.

I plan to write a review of Dr Clarke and his two day Medicine and Surgery Bonanza and you better read it. If the course totally sucks, I might save you 233.18 smackers.

It is also within the scope of my personality to write a stunning review even if the course is truly awful. You never know, stay tuned for the thrilling conclusion in part 2!

How exciting! (sarcasm)

-BJM

Intellectual kleptomania: USMLE step 2 CS

I love the word mnemonics and I love Kleptomania. I usually steal whenever I can. Well, not really but a man can dream! Below is a list of mnemonics that are from the website http://csprotocol.blogspot.com/. He has a great site over there and I suggest you check it out. Unfortunately you have to do some digging for his mnemonics. I have just typed a few that are great. These are not my mnemonics, I don't take credit for them but man are they helpful for the USMLE Step 2 CS. Feel free to highlight and paste these onto a word document. Be sure to visit http://csprotocol.blogspot.com/ The work he has done there deserves serious props. He answers questions that people ask. He even answers the really dumb questions seriously.

Impotence questions to ask Step 2 CS "LIMP PENIS"
Libido changes?
Injury?
Medications Beta blockers?
Past medical history: HTN, DM, Vasc
Prostate, performance anxiety?
Erection at all?
Nocturnal erection?
Incontinence?
Stress, Depression?

Hematochezia differntial- which is the passage of bright red blood and not to be confused with Melana. "DRAIN"
Diverticulitis
Rectal bleed aka piles fissures
Angiodysplasia + anal sex
Inflammatory bowl disease Ulcerative Colitis & Crohns, Ischaemic colitis + injury
Neoplasm

Chest Pain questions to ask is "CHEST P"
Cough? Haemoptysis? Emesis, diahrea, Oedema sacral or ankle? Temp change, tender chest, tender legs? Palpitations?

Headahe differential diagnosis list "MM..IT..ACHES"
Migraine
Meningitis
Increased ICP
Tension headache, Temporal arteritis
AV malformations
Cluster headache
Hypertension
Eye disorders
Sinusitis

Questions to ask in a domestic violence case "SAFE GARD"
Safe at home?
Afraid of husband?
Family or friends know?
Emergency plan?

Guns at home?
Alcohol use?
Relationship with husband?
Drugs or depression?

This last one is something that I found useful. Its just a list of questions that are used to take a sexual history in a logical way. I always thought asking "are you married" never really got to the point.

1)are you sexually active?
2)How many partners do you have
3)are your partners male or female?
4)do You use protection?
5)If you use protection what type do you use?
6)How frequently do you use it?

Ok thats it for now. Enjoy those. I have found them very useful.

Fluids and Electrolytes in the Surgical Patient reviewed by GAB

Guest Writer: GAB
founder of MedSchoolForums, a great friend of mine and a man I would never trust with money or a girlfriend but, he writes a great review!

Review of the book

Fluids and Electrolytes in the Surgical Patient (Paperback) by Carlos Pestana

Care of the in-patient, in particular one who for whom oral food and fluids have been withheld, is rather like juggling chainsaws in requiring assiduous attention to detail. The tidal influx and efflux of water and the complicated, co-ordinated dance of serum electrolytes must be catalogued, synthesised and catered for. This vital care, which one is expected to master on the first day of internship, is a very practical skill-set whose foundations are rooted deeply in the abstract knowledge-base of the pre-clinical physiology classroom.

In “Fluids and Electrolytes in the Surgical Patient”, Dr. Pestana contends that these pre-clinical lectures, for all their excellence and value, do not provide a guide-book to the treatment of patients “whose electrolytes are out of whack. Clinicians do that. You rub elbows with clinicians in the clinical years of your medical education but often that’s all you do. You are in close physical proximity to someone who may be too busy to explain why the order reads D5W rather than D5½NS.”

The author later points out that one of the consequences of this is the house-officer who has not been taught to think in terms of patterns of volume and tonicity change affecting his patients. “He is the guy who stops you in the hall waving a lab slip with a serum sodium report in it and asks you what to do about it but tells you nothing about the patient to whom the report belongs”. Indeed, it is the experience of many medical students and junior doctors that there is a gap in their ability to translate the weight of basic science they are taught into ‘fit for purpose’ clinical know-how; some confess that the extent of their practice was to prescribe 3 litres of clear maintenance fluids – one of normal saline and two of 5% dextrose, each with 20mmol KCl and run over 8 hours, without a clear integrative understanding of why they were doing this.

There is no cerebral self-aggrandisement or obfuscation in this little book, which takes on the comfortable character of a series of bedside tutorials on fluid maintenance and replacement, volume changes and tonicity, specific electrolytes, acid/base balance and nutrition. As the work of a single experienced author, all topics are tackled with a consistent voice. I found myself happily taken-in by the single author’s avuncular yet masterful explanation of concepts and their clinical application and I finished each chapter with a satisfying sense of having deeply learned something of immense practical value.

Extensive and useful reference tables are provided, but the real strength of this book lies in the author’s insistence that no concept or association is left unexplained. Each chapter ends with a short list of the salient points, values and formulae necessary for memorisation and understanding, and all of these are tied together in a beautiful ‘troubleshooting’ addendum to the book.

I predict my pristine copy of “Fluids and Electrolytes in the Surgical Patient” will become dog-eared with constant re-reading, and I unreservedly commend this book, both for the replacement of specific deficits and for timely maintenance.

Reviewer:

Gary Bass MSc, Final Year Medical Student, Royal College of Surgeons in Ireland Dublin and Founder of www.medschoolforums.com

Click to buy it