Tuesday, November 9, 2010

Chest Tube #3

Last night I performed my third thoracostomy. My first two were in a more controlled environment than occurred in the minutes after an overhead page implored all available medical personnel to go to the triage area.

A tube thoracostomy is when a large plastic tube (about a third the diameter of a garden hose) is inserted into the chest to drain blood or air. One indication for the procedure is a penetrating trauma to the chest with impaired vital signs.

This occurred at the end of my shift, so all I know about how the patient did I read in the paper.

Monday, September 13, 2010

Lost In Tensive Care


I'm heading into my 10th 30 hour ICU call in 28 days.

This morning, 20 meters from where I sleep, a machine the size of my house was tearing up Eagle St. The road is full of potholes no longer. (I've blogged about the similarities between our street and the 80s arcade game Moon Patrol before!) In fact, the pavement has been stripped down 2-3 inches in preparation for complete repaving!

But the point of my story is that though the pavement miller was shaking the timbers of this old house, I slept on. Exhibit A: The effects of sleep deprivation. It's a good thing that I don't have to make life and death decisions under these conditions.


One thing I've learned after 4 months working in intensive care units is that I am not cut out for 30 hour shifts. I will continue to do my best and give my all when on call. But I am looking forward to my next shift in the emergency department: Thursday night trauma.

As usual, I don't want to see you at work!

Saturday, June 19, 2010

Lily of the Valley

That's right folks, beware of your flowers, or perhaps harvest them for good effect. Need to measure the levels of lily or foxglove in your blood? Now you are talking... Anyway, it's time for me to get back to work.

Thursday, April 22, 2010

Bicycling New Haven

The Spring weather in New Haven is turning into a nice perk of being at Yale. It makes it incredibly easy to hop on my bicycle to commute and for errands. So in honor of Earth Day, I thought I'd post some critical elements of my bicycle commute that have helped me bike through all four seasons.

1. Get a bike that fits. If it hurts to bicycle, you won't do it! I'm 6'4" and weigh a sturdy 240 lbs BEFORE you account for the messenger bag that could carry one of my smaller co-residents! I shopped around for big boy commuter bikes and settled on a 25" Trek 7.3. I don't have to jack the seat up super high and I like how hybrid handlebars can let me ride home leisurely after overnight call and the frame lets me lean into rides for exercise. It's also very nice not to have to stop pedaling between standing and seated positions! So far it has helped me ascend both San Francisco's hills (when I spent a month working at the county hospital there) and the winter streets of New Haven without any problems. I got the factory model, which I'd probably do again, although I've had to tune the gears a few times and let my chain get too rusty through use on the heavily salted streets.

2. Find a safe route and stick to it. If you know your route like the back of your hand, you'll be familiar enough with traffic patterns, potholes and the more dangerous intersections to predict trouble spots. That way, you can also focus on ice spots, playing kids and other potential threats to your balance. I use the Orange St. bike lane until it ends and then the regular lanes until turning right on the sleepy Crown St. on my way in to the hospital. Several other bicyclists take this route so drivers are almost used to seeing us...

3. Secure your bicycle in a safe place. I got a key to the enclosed bike locker across the street from the hospital. I keep my lock there (NOT OCCUPYING A PRECIOUS STALL!) so that I don't have to lug it around. I park my bike in the same safe place every day and then walk to wherever I need on campus.

4. Find a shower at work. I've located 4-5 that I can use in a pinch. Not only is this useful if you sweat, but also if there is a downpour and you need to refresh. It also helps that my work uniform is always available in the form of a scrubs locker. Otherwise, you will need to bring in clothes. When I needed to wear a tie, I kept two pair of dress pants in my locker and carried my shirts in with me every day.

5. Waterproof packs, whether they be over the shoulder (hurts my back), saddle bags (not for me) or a full-on messenger backpack are vital. Otherwise you will worry about your clothes, papers or computer getting wet and you will break down and drive in.

6. Clothes are important, but you don't need to overdo it. I wear sweats with cheap rain gear or windbreakers as needed most of the year. Warm gloves are vital when it rains or when it's cold. In the summer, I'll don the biker shorts & suspenders, but then you run the risk of co-workers pointing out that you forgot to put on your pants as you walk in... But then again, I also wear a fluorescent reflective construction vest to draw drivers' attention to me.

7. Biking at night? You cannot have enough flashers or reflective tape and clothing. I'm up to 7 lights and am looking for more to clip on to my backpack clothing and helmet.

8. Be nice. I admit, I am an aggressive biker. But I observe traffic or pedestrian laws (whichever is more convenient), and only pedal between two lanes if it's clear I can cross with the walkers. Otherwise, if you ride in the road, observe the rules of the road. If drivers don't like that you are riding at the speed limit or with the flow of traffic, I'm always aware of an out should they try to run you off the road. And never assume that a driver sees you.

9. Learn about your bike. I can't true wheels, but I've tinkered with my rig enough (and watched people who know what they are doing) to do minor repairs. When in doubt, take it in to have a professional work on it. But if you need to do a quick fix, it helps you stay out of the car to know how to change a chain or adjust the shifter.

10. Have fun. I ride only to commute. But I live near East Rock Park, which has a challenging ascent. If I'm up for it, I'll divert to there on my way home. Or if you see a friend walking home, take the opportunity to stop and say hi. Having portable transportation makes interacting with your community easier!

Happy Earth Day from New Haven!

Thanks to my cousin-in-law for inspiring this post by asking me about my Robey-sized bicycle.

Monday, April 19, 2010


I signed up for my own domain name and am building an online empire. Want to monitor my progress? Visit ERobey.org for, well... not very much right now. But soon and very soon, you will be amazed by its majesty!

Wednesday, April 7, 2010

Journal Club

This morning, I will be leading a journal club discussion for the Yale-New Haven Hospital emergency medicine residency. The topic is "Fight or Flight in the Face of Epidemics: Making a Case for Codes of Ethics." We will be looking at some of the ways codes of ethics succeed in shaping physician behavior and where they might break down.

As an icebreaker, I am asking my colleagues to put themselves in the context of various disasters to think about how they might respond. Since all three questions are New Haven-themed, I thought I would pose them here, as well!

1. A SARS-like illnes broke out in NYC two weeks ago. There are 76 fatalities, including five physicians and 7 nurses. Boston just reported its first death, and there are 5 patients in YNHH with the disease. Will you:

A. Volunteer for MICU coverage
B. Come to work as usual
C. Call in for backup
D. Head for the hills

2. The Indian Point (north of NYC) nuclear reactor's cooling system was sabotaged by an environmental terrorist group, resulting in a meltdown that was not properly contained. New Haven is in the predicted fallout area, but the extent is still unknown. Will you:

A. Sign up for surge (ED surge that is) duty
B. Work for the first few days, then leave town
C. Avoid the chaos entirely

3. Hurricane Zelda slams Long Island Sound in a late season perfect storm situation. Manhattan experienced a storm surge of 15 feet, incapacitating the health care system in NYC. New Haven has flooding, but the hospitals still function. FEMA and the military are looking for docs to staff tent hospitals. Would you:

A. Stick around to treat the victims of this disaster
B. Get out of harm's way but stay close enough to help radiation-contaminated victims
C. Take an extended holiday yo the West Coast

... and now, your answers please!

Tuesday, March 30, 2010

Gene Patents

If you didn't know, about 20% of all human genes are currently patented by companies or universities. This is important to people wanting genetic tests. Myriad Genetics is probably the most profitable of these organizations, having secured rights to the BRCA1 and BRCA2 genes. You are at increased risk for breast, uterine and possibly colon cancer if you have mutations in these genes. If you have a family history of one of these cancers, knowledge of the mutation can help decide treatment. But the price of the test is around $3000, which can be argued is the price for innovation or conversely, the effect of a monopoly.

Yesterday, the financial security of gene patent-owning companies fell into question when a District Court judge invalidated gene patents on BRCA1 and BRCA2. This could open the floodgates to more affordable genetic tests or stifle R&D, depending on who you ask. But the upshot for this New Haven Resident is that the Laboratory Medicine Resident I'm married to may have a different way of doing things in the near future. (Lab medicine physicians are the docs who do and send off tests in hospitals.)

Indeed, the NYTimes article about this case cites a leader of the Lab Medicine professional society as calling the decision “a big deal.”

“It’s good for patients and patient care, it’s good for science and scientists,” he said. “It really opens up things.”
I'm sure the folks at ScienceBlogs will be picking this story up. Indeed, check out what Genetic Future and The Questionable Authority have written. We will see how the appeals process works with this one.

Tuesday, February 23, 2010

The Exams That Never End...

Yes they go on and on, my friend...
Someone started writing them not knowing what they're for
And now we'll keep on taking them forever, asking them for more...

Exams that never end...

I'm taking my in-service exam this Wednesday. It's in the neighborhood of four hours long, and is all about emergency medicine. The best part is that it happens to be in the midst of the New Haven portion of my vacation! Thankfully, the number of exams has diminished to the frequency that makes them useful for self-improvement. I expect that there will be plenty of room for improvement between this year's and next year's installments.

And you thought exams ended with graduation. Medical residents in all specialties take in-service exams once yearly, and generally in the same week.

But wait! There's more!

We also must take the third installment of the licensing board exam at some point. It is a general topic exam that covers all specialties. Fortunately for ER doctors, there is not a lot that we don't see walking through the door.

When it comes time to be board certified in emergency medicine, however, there is a whole new round of EM boards, which include oral exams in a hotel in Chicago!

When I think about it, though - keeping myself sharp enough to pass these difficult exams is just another way to do justice by my patients. Who wants a doctor who forgets (insert important medical fact here) when said patient experiences (insert relevant medical condition here) in the middle of the night?

For any of my EM colleagues who happen their way to these parts, good luck this week!

And for other New Haven residents (i. e. my neighbors), we know that the tests that we sometimes complain about actually make us better docs!

Tuesday, February 9, 2010

Color Career Test

Working nights for five weeks does a number on the circadian rhythm!!! What do you do when you wake up at 2:30 AM and cannot get back to sleep? Tonight, I studied a bit, watched part three of the excellent Masterpiece Classic presentation of "Emma", and surfed the web. I'm more prone to take online tests in the middle of the night! Anyway, have you read about the non-verbal personality test using colors?

It's called the Dewey Color Test. If you take it, answer the question asked. Don't pick your favorite color, pick the one you most prefer to look at...

This is a short test, but I think worked pretty well for me. As expected, the top two options have a bit of built-in conflict...

Best Occupational Category



Independent, Self-Motivated, Reserved, Introspective, Analytical, and Curious

e investigative types gather information, analyze and interpret data, and inquire to uncover new facts. They have a strong scientific orientation, enjoy academic or research environments and prefer self-reliant jobs. Dislikes are group projects, selling, and repetitive activities.

Suggested careers are College Professor, Physician, Psychologist, Pharmacist, Chemist, Marketing Research, Inventor, Sales Forecasting, Project Engineer, Dentist, Identifying Consumer Demand, Chiropractor, Dentist, Medical Technician, Optometrist, Research & Development Manager, Respiratory Therapist, Real Estate Appraiser, Chiropractor, Veterinarian, Geologist, Physicist, Science Teacher, Medical Technologist, and Author of Technical Books.

Task-oriented careers where you can become absorbed in the job, be original and creative, and not conform to rigid company rules will work best for you. Unstructured organizations, for example, that allow you to sail your own ship are vital.

Suggested Researcher workplaces are universities and colleges, home office positions, medical facilities, computer-related industries, scientific foundations and think tanks, research firms, and design laboratories.

2nd Best Occupational Category

You're a CREATOR


Nonconforming, Impulsive, Expressive, Romantic, Intuitive, Sensitive, and Emotional

These original types place a high value on aesthetic qualities and have a great need for self-expression. They enjoy working independently, being creative, using their imagination, and constantly learning something new. Fields of interest are art, drama, music, and writing or whether they can express, assemble, or implement creative ideas.

I am a physician first and then a writer, and will probably end up in academics... go figure.

Tuesday, February 2, 2010

The better to see you with...

One of the great things about emergency medicine is the ability to incorporate ultrasound as an extension of the physical exam. Ultrasound is not just for babies folks! We can use it to see clearly through the skin to diagnose numerous conditions.

After getting this image, the patient went back for emergency laser surgery. Any guesses about what this person's problem was?

Friday, January 29, 2010

Link All About It!


There's lots of stuff I'd like to blog about, but, well... I have not enough time for it. So if you are dying to read things I've written or are thinking about in the world of medical or New Haven residency, here are some links:

My performance evaluations so far agree that I'm always working on improving my own medical case presentations, so I guess I'm an expert worth asking how you should present cases on rounds.

I continue to try and stir up some controversy in the ethics conversation board over at MedStudent Connect, but still thus far, I've not had any takers...

If ever I have the time, I'm thinking of joining the Elm City Cycling advocacy group because of the excellent ideas they put forward in their recent recommendation to leaders in New Haven's City Hall. Biking in New Haven has kept me from putting on the pounds that interns typically gain.

Like my sister, we are gearing up for a small seedling farm to stock our backyard garden. Until I get a chance to write about our activities, read what she is up to.

At the end of December I attended and spoke at an aldermanic committee meeting about red light camera legislation. It was actually a meeting to recommend support for a resolution to be voted on by the full city council to indicate that New Haven supports proposed state legislation permitting municipalities to install red light cameras should their citizens approve them. Were there enough condionals in that sentence? I learned a little bit more about how municipal government works and spoke for a policy I support. We shall see if anything comes of it!

And I know everyone is out there waiting with bated breath for the June 2010 issue of Virtual Mentor because it will focus on ethical dilemmas in emergency medicine. Until then, you'll just have to read other excellent issues about different topics in medical ethics.

Finally, I am pleased to announce that our kitchen remodel is nearly complete. For your viewing pleasure, here are before and after photos.

The low image quality is because I used the iPhone. But methinks the shots are good enough for you to get the idea. I'm going to go install the dishwasher right now!