So, the boards went about as well as can be expected from a 9 hour long test. There were many a moment when I’d find myself gazing at the computer screen, uncomprehending. Seconds later I’d snap out of it and realize how obvious the answer was. Ah, well. At least I’ll never have to take it again.

On to bigger and better things! I’m on the Northwest coast right now staying with two good friends from college… should be a blasty blast. I hear the ER I’m rotating through is one of the busiest trauma centers in the nation.

A few weeks back I had to leave our med school tailgate to put in a shift at the urgent care. While I was truly saddened by my inability to contribute to the shotgunning of copious beers, alas, some of us are productive members of society. Then again, I’m of the mindset that shotgunning beers at tailgate is productive, but that’s a debate for another time.

I had a pretty great shift, mostly because drunk college kids were brought in for various and sundry complaints†, and they were stoked to see the school colors under my scrubs. Halfway into the night, though, there was something… different. Cruising around the corner, I immediately noticed two things.

Firstly, my nostrils were assaulted with the pungent odor of vast, unimaginable quantities of shit; a horrific wall of feculent odor that knocked me backwards. This was shit to be reckoned with. This was shit that didn’t take “no” for an answer.

Second, there was a very attractive sorority girl in school colors and butt shorts screaming blindly “I’m NOT as DRUNK as you THINK I am” at the nurse who was unsuccessfully trying to start an IV.

The incongruity of these two simultaneous events was difficult for me to comprehend, so I used my carefully honed powers of medical observation. “Ah, there’s the problem” I thought to myself, “that lovely young lass has shat herself”.

I mean, folks, I didn’t realize you could even poop that much††. It was all over the poor guy drawing blood, the bed, the floor. It was splattered on the wall like a Jackson Pollock painting. It was a veritable cornucopia of fecal matter. It was Shitterhouse-Five.

That, my friends, is why I both love the ER and could never make it as a nurse. We love you so very much, you don’t even know.

† If by “various and sundry” you mean “solely related to alcohol and the imbibing thereof”. Pearl: if a piece of a broken beer bottle pierces through the insole of your Chucks, your antibiotics must cover Pseudomonas Aeruginosa.

†† let alone a girl who couldn’t have weighed more than 90 pounds.

In the States, one of our over-the-counter painkillers is Tylenol (generic: acetaminophen). English-speaking countries oveseas refer to it as Paracetamol†.

Pharmacology books often refer to it as APAP… but I’ve never gotten a good explanation as to where the abbreviation APAP comes from.

Turns out, the full chemical formula for acetaminophen/paracetamol/tylenol is N-Acetyl-Para-AminoPhenol (APAP), or simply para-acetylaminophenol. Ready for some word magic?

PARA-aCETylAMinophenOL
para-ACETylAMINOPHENol
para-aceTYLaminophENOL

I’m as giddy and excited about this as I was when I found out what MaAlOx stood for. I’m sure absolutely nobody else cares… but if you’ve ever met me, you know it’s the small shit that gets me every time.

† They also have the metric system, and most of them don’t have a retarded monkey running the country… but that’s a different story for a different time.

Monoamine Oxidase Inhibitors (MAOIs) are a class of medications commonly prescribed for severe depression. One of the major side effects: Tyramine Syndrome, which causes a rapid rise in heart rate and blood pressure if certain foods are eaten.

Foods that are verboten? Eating liver with some fava beans and a nice Chianti. I doubt it’s coincidence that Hannibal Lecter - a brilliant psychiatrist who would be well versed in pharmacotherapy - mentioned those three specific foods.

Touché, Thomas Harris. Well played.

I ran into one of my favorite residents the other day at the coffee shop, and as we were reminiscing about our awesome Internal Medicine rotation together, we started chatting about the worst patient in the world. While on my rotation, this woman plagued every waking moment of every day. She was nasty, spiteful, and on top of it all, a blatant liar. Her name was Terry.

Terry was a 40-something vile excuse for a woman. I doubt it had anything to do with her illness; in fact, all that was wrong with her was a fairly mild case of Rheumatoid Arthritis. Usually, RA is treated with a class of drugs known as DMARDs, which help to slow the progression of the disease. High-dose steroids are typically reserved for when things go acutely downhill; the side effects are pretty nasty.

Terry, however, had been taking steroids - lots of them - for years. They had eaten away at her bones, ripped holes in her stomach, and prevented her from healing any minor cuts or abrasions on her body. Our hospital service accepted her because she hadn’t been able to eat for weeks.

As with any good team of hospital docs, we busily started drawing blood, instituting intravenous feeding, and brainstorming for a cure. Terry’s boyfriend and son looked on, writing down our every word in spiral-bound notebooks. Terry’s son, you see, was in school studying to be a nutritionist, and her boyfriend wanted to be a nurse.

It quickly became apparent there was absolutely nothing we could do. Terry’s intestines had simply shut down, preventing her from eating or drinking anything. The only solution was to stop the steroids and continue intravenous feeding until her gut came back online. Unfortunately it would take weeks to months, but it was really all we could do.

We went to work doing what internal medicine docs do best: placement. We called every nursing home and hospice program in the state, trying to find somewhere that would agree to continue her IV feeds. The solution was simple. Switch her to methotrexate (a DMARD), taper her off the steroids, place her somewhere that could handle IV feeds, and wait for her stomach to function again. We told her our plan 3 days after admission.

Shit hit the fan. Terry’s son informed us that intravenous feeds were dangerous† and were therefore unacceptable. Terry’s boyfriend started “fixing” her IVs and bedclothes, at one point forcing us to replace her lines due to contamination. Terry started lying about other doctors’ plans - utter fabrications like “the surgeons are going to operate in a week” - to extend her hospital stay.

Things got relayed up the chain of command. Eventually the Chief of Medicine, the Chief of Gastoenterology, and the Chief of Surgery became her three primary doctors, desperately trying to accede to her every whim. She and her two attack dogs vomited verbal abuse at anyone who so much as walked by her door. What’s more, it was obvious that she took some sort of perverse pleasure in being hospitalized and bending everyone’s will to hers.

A month later, her hospital room had been transformed. Stuffed bears and flowers hung off every wall, and her whiteboard listed daily schedules of rotating consultants. Our 7AM rounds took 3 hours; half for all our other patients, and then half for Terry. Casually mentioning her name would draw venomous looks from any doctor, nurse, or tech unfortunate enough to have met her - which was 3/4 of the hospital.

We finally kicked her out the last day of my rotation, threatening to call security if she refused to leave. The 3 Department Heads stood in her room and told her she had no other option; she hadn’t met criteria to be in the hospital for weeks and her insurance had finally stopped paying.

The discharge plan, by the way, was completely unchanged from a month prior. She fanagled one more trick; instead of going to a care facility, she would go home with a full-time nurse who would probably hang herself within the week.

Last I heard the methotrexate was working out just fine, she had no complications from our treatment, and she’s eating and drinking normally. She also broke up with her boyfriend.

† No shit, Sherlock. It was our last resort. I really hated this kid.