Foo Fighters!

First off, before I say anything about the INCREDIBLE concert that Dave Grohl and his Foo Fighters put on last night, I must thank my EVEN MORE INCREDIBLE flatmates who surprised me with concert tickets. I admit I was genuinely surprised - they presented it to me less than 24 hours before the concert was supposed to start. It helped that my actual birthday is still more than a month away but hey, I'm not complaining ^_^

I came real close to missing the Foo as I ran into problems with transit on my way to the Brisbane Entertainment Centre. I hopped on a train to Shorncliff at Toowong station. Everything was going along alright until the train stopped at Northgate station - 4 stops away from Boondall where the concert was. They told us that the train line ahead was not working, that we had to get off the train, and that they would send buses to take us the rest of the way. This was at around 7pm. There were hundreds of us waiting outside before the first bus came at maybe 7:45pm. I think I was able to get on the 4th bus they sent and by this time it was 8:20pm. The concert had started with the couple of opening bands at 7:30pm and the Foo Fighters were scheduled to take the stage at 8:30pm. Luckily I did make it there maybe 5 minutes before they started...

I was sitting pretty far back and pretty high up so the acoustics weren't the best. Both concerts sold out of standing room tickets last year - that's definitely where you have to be. They lowered a stage from the roof down to the centre of the arena and did an acoustic set from the middle circular stage. The great thing about the Foo Fighters is that they have so many hit songs. Their set included most of the stuff from their latest album "Echoes, Silence, Patience and Grace" as well as songs like Breakout, Learn to Fly (one of my favs), Stacked Actors, Generator, All My Life, Times Like These, Monkeywrench, My Hero, Everlong, Best of You... They threw in a few drums solos and guitar solos between Dave and Chris Shiflett, the lead guitarist. For a few songs they added percussion instruments, keyboards, a cello (for The Pretender) and a violin for some of their acoustic stuff. Snapped a few pics with my crappy phone cam...

During the break before the Foo Fighters take the stage. Made it just in time!

Lowering the stage into the middle...

Dave Grohl kicking off an acoustic set from center stage.

Who's invited for dinner at God's place?

According to Eugene Peterson's paraphrase of Psalm 15, this is how you get yourself on the guest list for a dinner party at God's house.

"Walk straight,
act right,
tell the truth.

"Don't hurt your friend,
don't blame your neighbour;
despise the despicable.

"Keep your word even when it costs you,
make an honest living,
never take a bribe."

I don't know about you but I'd sure like to get on that guest list myself. From what I've heard, His parties are pretty fun and can go on forever. The trouble is that these entry requirements are pretty tough to meet and if this was all there was to it, I don't think I'd be invited sadly enough. In fact, I think the guest list would be pretty empty based on those qualifications.

For those of us who happen to not be perfect, we're in luck 'cuz there's one other way inside through a back door that was opened by Jesus Christ. Just a little bit of faith and a ton of grace is all it takes to get you in through here. Looks like you and I don't have to miss that dinner party after-all! ^_^


Why can't I come up with some Gregory House-worthy metaphors? >_<

Breaking Bad News

Just yesterday I had my video recording for the breaking bad news portion of our clinical communication skills module. I ended up having to tell this standardized patient/actor that his wife was in a serious car accident and sustained several injuries including a fractured skull, broken right clavicle, and three broken ribs. She was in a coma (GCS 4) with pupils unresponsive to light and placed on a ventilator. I had to tell him that there was a 85% chance she would die and if she did pull through, the road to recovery would be very difficult.

I order to prepare for this, I tried doing some role plays with my housemates. We went through a number of scenarios including:

1) Telling a guy who's worried that his wife will leave him because they are unable to have children that he's infertile.
2) Telling a woman she has breast cancer
3) Telling a woman that her fetus has Down Syndrome

It was really hard to try to mimic the emotions and feelings that would be running through the minds of the doctor and patient in a real life situation. Most of the time we'd end up laughing at each other as we attempted to make ourselves cry or get angry at the doctor for not being able to reverse the situation.




There's this instinct to avoid using words like "die" or "death" - even if it means being a little bit confusing or misleading. I read through this article that talks about how maybe physicians should just say, "You are dying," and stop beating around the bush with euphemisms and vague references that we hope will lessen patient distress. There were a couple examples given of what doctors say in discussion with a dying patient in a role-playing scenario that simple mean, "You are dying."


"Most people with the disease will have problems soon. Time may be short - a few weeks to a few months. My suggestion would be to prepare for the worst and hope for the best."

"Your time may be short."

"Out of a hundred people in your situation, most will have major problems in a month or so."

"It sounds like the disease is really threatening your life."


I think the bottom line is that you have to have a genuine care and love for your patient. Not the eros type of love but a phileo form - a brotherly love and compassion. Using the right words will help but at the end of the day, your actions and ability to manage the patient in a palliative care manner will come naturally from loving your neighbour as yourself...

Three Things Today

A guy back home told me that if I can aim to learn and retain three new things in medicine each day, then I'll be good to go. That doesn't seem like much at first, but it would mean that over the course of a year, 1095 new concepts would be "mastered" and committed to memory.

#1: Mechanism of Anemia in Infective Endocarditis (IE)

So we're just wrapping up a four week cardio block with a look at valvular heart disease. One of the things that IE can present with is anemia. We weren't sure of the mechanism behind this form of anemia. Someone in my PBL group suggested that the pathogen (Strep viridans, Enterococcus, Staph aureus, Staph epidermidis, HACEK orgs, Candida, or other G -ves) attacked the red blood cells, resulting in a hemolytic anemia. But when I thought about it, it seemed like there weren't too many pathogens that routinely infect red blood cells. There are a couple parasites I know of (Plasmodium spp in malaria and some Mycoplasma bacteria) and a mention of hookworm in Robbins that infect RBCs, resulting in hemolytic anemia.

It looks like bacterial endocarditis falls under the impaired RBC production in anemia of chronic disease. This is what Robbins had to say:

1) Low EPO.
Chronic inflammatory state results in release of many cytokines (particularly IL-1 and TNF from macrophages and IFN-gamma from Th1 cells) that reduce renal EPO generation. They also stimulate hepcidin synthesis in the liver --> inhibits release of iron from storage (ferritin). This leads to...

2) Reduced serum iron. There is high ferritin iron storage but low serum iron and reduced TIBC suggesting a problem in getting iron from storage to erythroid precursors in the bone marrow. Lack of iron --> Fe deficiency. May mimic Fe deficiency anemia (hypochromic and microcytic) but the high serum ferritin and low TIBC rule out Fe deficiency as the 1º cause.

I read some stuff from Google about decreased RBC half-life and some effects of cytokines directly on the bone marrow. Not sure how reliable those sources are...

#2: Polycystic Kidney Disease

So last thursday during my clinical bedside coaching, I got pimped out pretty badly. My preceptor (a registrar) was running a bit late so she had one of the registered medical officers (RMOs) on her team take us around to see the patients. Thus began one of the longest GI exams ever, during which my preceptor came back and I got tag-teamed drilled for what seemed to be like an eternity of questions that I had no answers to. Some I should have known the answer to - like guessing that his abdominal bruising was from his enoxaparin if I had known that he had been in hospital for a long time. Others I had never even heard of doing before like auscultating for splenic infarcts or hepatocarcinomas. Didn't realize you could actually hear a carcinoma...

Pimper: "What else would you listen for?"
Pimped (me): "Other than bowel sounds? umm...renal bruits?"
Pimper: "No"
Me: "Uh...check the aortic bifurcation for bruits?"
Pimper: "No, this is a GI exam"
Me: "Uh...i'm not sure."
Pimper: "What did you just do earlier?"
Me: "I palpated for his liver, spleen, and kidneys."
Pimper: "So...what would you listen for?"
Me: "Uh...I don't know"
Pimper: "You need to listen for splenic infarcts and hepatocarcinomas."
Me: "Oh...what do they sound like?"
Pimper: "They sound like friction rubs"
Me: "Okay..."

One thing that I should have known was that a top differential for a palpable kidney is polycystic kidney disease. I found out that there are two forms. The adult version is the most common (accounts for 5-10% of chronic renal failure) and is autosomal dominant whereas the autosomal recessive (childhood) variant is rare and often presents perinatally. The more you know...

#3: Chest X-ray in Left Heart Failure

Doing some revision, I came across a nice little mnemonic to help with remembering what you would find on a CXR in LHF. It's as simple as ABCDE!

Alveolar Edema
Kerley B lines
Cardiomegaly
Dilated prominent upper lobe vessels
Pleural Effusion


Hopefully, blogging this stuff will help it stick to my long-term memory...

Figure 1. Me in my small group room looking super impressed with the fact that I need to basically memorize Talley and O'Connor cover to cover so that I don't get pimped out so badly next week...

Oops...

So anyone who has seen me in the last couple weeks have noticed my lack of hair. It's not the first time I've had a really short hair cut but this time it was unintentional. I bought a set of clippers to give myself a buzz cut but I had only planned to use a #2 on my head. For whatever reason (perhaps it was the bit of wax that was still in my hair), it just wouldn't cut my hair. So I pulled off the #2 attachment and tried it on my sideburns a bit. I'd like to think my hand slipped (or maybe my coordination just absolutely blows) but I went waaaaaaaaaaaaay waaaaaaaaaay to far and took a HUGE chunk off the side. Real smooth on my part. I guess I didn't want Albert to feel lonely with his shaved head. I've come to love mechanisms so here's the mechanism of me losing my hair.

Clippers fail to work with #2 attachment --> removal of #2 attachment --> slippage of hand while testing out clippers --> big bald patch --> prompt shaving of head

Pocket Sized Books

I like to try to keep my shopping down to a minimum by only buying things that I need. Sometimes that's pretty hard - especially when it comes to academically related stuff. Does it pay to be cheap when it comes to textbooks and resources? I decided to pick up a couple more books online that I think might come in handy over the next few years.

They're both referred to as "pocketbooks" but I don't even think the side pockets on my cargo shorts can hold these. Nevertheless, I plan to carry these around with me and read them whenever I have a break or I'm on the go (ie. the bus). There's a fairly heavy focus on pathology this year and I'm finding myself reading Robbins on a weekly basis. So I thought that this pocket companion might be handy to have around since the big Robbins is heavy enough to kill someone and at about $25-30 a piece, not a bad investment IMO.

Lately I've had some discussions about the post-grad future. There seems to be three major options to explore: head back home to Canada (which is definitely numero uno), head to the US, or stick around here in Australia. Staying here in Australia would require me to gain permanent residence status and that shouldn't be too difficult as my degree alone will basically be enough points to qualify. Securing an internship position might be a bit trickier but also shouldn't be too bad considering the physician shortage here in Queensland. The Aussie option will definitely be worth choosing especially if I fail to match anywhere in Canada or the US and have to wait another year. The timing of the different programs might be a bit tricky to work out though...

All this revolves around the big question of whether I should gear up to write Step 1 of the USMLE sometime after 2nd year. It's a huge undertaking that will cost me a lot of time, stress, and frustration. The only reason I can think of for going to the US would be for a more competitive specialty that would not be available to me in Canada. But the more I think about it, I would choose basically anything in Canada over pretty much anything in the US. So maybe that's the answer to my question? Forget about the US and just focus on home? This is going to require a LOT of prayer...