How about some formatting?

I send a lot of emails. I recently wanted to purchase a pair of UFS-20 stands (off ebay/craigslist) because I'm not paying $100 for two pieces of metal (off the Bose/Best Buy website). The guy responded with "yes, where do you want to meet?"

No capitalization, no time-wise greeting, no greeting at all. Are you kidding me? Lots of people add 'thanks' to the bottom of their email and it essentially means nothing. Sort of like:

Like - "Hi, did you have a chance to read that paper I sent you? Thanks!" Just a reminder/formality so you don't sound like an ass. But time-wise greetings? Awesome. No one says "Good morning" and doesn't mean it (especially by email). The same goes for good afternoon / evening / night. You also have to think about when they'll open the email (is when the greeting should be applicable for).

Also, if I write "Have a good weekend", I mean it. If it's Sunday, and your weekend sucked, give me a call and we'll do something about it.

Enjoy this picture of me from years ago:

A fucking lifeguard, that's what.

Family medicine in the 'burbs

My family medicine rotation is in Baytown, which I'm not terribly enthused about. I show up in the morning, round on the hospital patients in the morning (3 or less), then go to the clinic. Outpatient medicine can be interesting or as boring as you make it out to be.

I've probably had more appreciation in the last week than I have in the last year.

The attending also introduces me as Dr. Dash, which I'm not sure how to take. It always starts off as "Here is my medical student [doing fine..], Dr. Dash [ohgodwhy.jpg], and he'll be asking you a few questions." I don't think I ever want to be called that actually. I'd rather use it in case I need to throw down the hammer.*

What you don't see out there (directly) is death and destruction and that's a nice change of pace. It's nice to not hear that some patient isn't coming to clinic because they threw a large pulmonary embolism and fell face first into a bathtub or developed DIC a week ago and bleed out from every orifice.

I read this piece a few days ago : http://www.nytimes.com/2012/05/27/opinion/sunday/when-doctors-grieve.html

It's true. More importantly, I remember when I was on ICU, where a good 30-40% of my patients died within days of admission, I developed this furrowed browed look whenever I was down about my patients. It could have been interpreted multiple ways.

Are you furrowed because:

1) you realize you could have done more or
2) you're here too late and you don't want to deal with this, or
3) you're actually distressed by this patient dying or
4) some other miscellaneous cause.

Other people on my team had more unambiguous reactions. On top of that, after the "viewing" of the body and before the body would be transported down to the morgue, the family would leave the room, some would shake my hand and say "Thank you, doctor"

First of all, doctor?
Second, thank you? For what, exactly.

Baytown is a nice break.

*: Recall the short coat hammer from a few posts ago. 

Getting things done

I may have figured this out. There are two keys to making life simpler & better.

1. Automation - Automate everything. Bill pay? Automate. How often do you need to look at your bill and dispute charges? (Look at it anyway). Rent? automate. Dividend reinvestment? Automate. Morning routine? Automate. Become that robot so everything goes smoothly. Make a checklist and follow it religiously.

2. Tolerate (and be good) at things you don't want to do but have to do - This is crucial. I'd rather be reading about family medicine or gliomatosis cerebri or something, but I have to do these evaluations. Or clean my place. Or cook for tomorrow. Or think of a schedule for later today. No thanks. Maybe one day I can automate all of that too.

I just finished reading Better by Atul Gawande. It's a good book. Reflects that quote 10,000 hours to mastery? I believe that.

A few years ago, I was roaming around my dad's office, looking at posters, pilfering sodas and coffee creamer and I came across a poster, most of which's details I don't remember, but I remember there was a huge picture of an aircraft carrier and it was advertising "carrier class" reliability (with respect to server uptime).

I looked it up a few days ago, and here we are (wiki):

In telecommunication, a "carrier grade" or "carrier class" refers to a system, or a hardware or software component that is extremely reliable, well tested and proven in its capabilities. Carrier grade systems are tested and engineered to meet or exceed "five nines" high availability standards, and provide very fast fault recovery through redundancy (normally less than 50 milliseconds).

 99.999%. That's a goal worth shooting for. 

Second week on neonatology

Babies. Very small babies. I come in the morning, and they're all wrapped like little burritos with their heads sticking out. Wrapped - three blankets, each tucked in three different ways, as if you wanted to ensure they could never ever get out of their burrito-blankets if they wanted to.

So you approach the crib, very cautiously. Like a ninja. Survey your territory. Where's the nurse to give you disapproving looks while you're taking apart the burrito-blanket? Not around? Excellent.

Then you look at your little masterpiece. Boy or girl? Doesn't matter. Survey your territory. Find out where those corners are. You've got less than 10 minutes to unravel the burrito and listen to the heart. Like a bomb. More importantly, mess up the unraveling with sudden or improper movements and you will unleash the fury of a thousand dragons.

Slowly, you start to tug at the corners of layer 1 of the burrito. Sometimes you realize you have to turn the baby. Can't arch its back at all, else it'll wake up. You then do some complex calculations in your head, find out where to provide pressure points and roll that burrito like a plane banking into a turn. Boom, blanket corner out.

Rinse and repeat. Do your exam. Finally, very quickly wrap that baby up as fast as possible while still maintaining movements around its principal axes. Often, the baby will wake up. All you need to do is rub its back while making clicking noises from your palate - tk tk tk tk tk tk tk tk tk tk - and it calms down.

Leave the poorly wrapped burrito in its half awakened state and rain down some burrito destruction elsewhere.

Sometimes, it'll wake up completely and start crying. You have to pick it up and hold it (support its neck!).

In that moment, right after it stops crying, it fidgets. It fidgets like never before. He's fed, consoled, hydrated, warm, evacuated* and ready. Its sole purpose in life is to get away from you. It knows nothing else. It puts 100% of all of its energy and every underdeveloped neuron it has into strategizing ways to remove himself from your vicinity/arms. And your job? To employ some Red Queen Hypothesis business to keep three steps ahead, and not provide any kind of feedback but a firm grip. Turn into the human Cesar Millan and show him who's boss. Do it right and he becomes terrified at your sense of control and awe-struck at the show of confidence.

*No. 1 and No. 2

Outpatient paediatrics

I spent 2 weeks on the mobile clinic, which... is kind of cool? Two fully equipped exam rooms, refrigerated medications, a mini crash cart, two nurses, two doctors, one med student and that goal to get every kid in Houston immunized.

Ridiculously cool.

After a while, you learn how to give vaccinations. The giving part is not nearly as bad as the consoling part, and every age group needs their own system.

• Babies - no prep required. Snap your fingers in two different directions, flash your penlight so they reach for it, and the moment their hands go up - Bam! right in the Vastus lateralis. 
• Little boys - little boys cry* far too much, almost more so than the girls. Just do it. They'll realize it wasn't so bad.
• Little girls - less crying**, but it's more dramatic. Minimal prep required, although they will need consoling afterwards. Stickers, pencils, hugs, what have you. 
• Older (7-10 y/o) boys need reminding of how macho they are. Usually come in with slick gelled up hair. Dude you can't have hair like that and be afraid of this needle? Right? Jab.
• Older girls are a bit more mature than the older boys. Usually not problematic.

These schools we visited were much nicer than the one I went to, but I'm not so sure about the teachers. They also all ate fried crap for lunch so naturally there were kids that weighed more than me - > 165lbs. 

Also, taco trucks and mexican bakeries galore. So cheap.

*: This type of cry being "my god this is going to hurt"

**: This type of cry being "I have accepted death as my fate"