M Modal Phrases

 

Insert appendicitis

 

  • RLQ pain and appendicitis on CT

  • Leukocytosis

  • Surgery

  • Will keep NPO

  • Will start ceftriaxone/metronidazole

  • Will follow up surgery reccs

  •  Will give IVF

 

Insert arterial

 

ARTERIAL LINE (A-Line) PLACEMENT
Date: <____>
Time: <____>
Indication: Hemodynamic monitoring
Attending: Pranay Parikh

 

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. Allen’s test was performed to ensure adequate perfusion. The patient’s <right/left> wrist was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the area. A 18G Arrow arterial line was introduced into the <radial/femoral> artery under ultrasound guidance. The catheter was threaded over the guide wire and the needle was removed with appropriate pulsatile blood return. The catheter was then sutured in place to the skin and a sterile dressing applied. Perfusion to the extremity distal to the point of catheter insertion was checked and found to be adequate

 

Estimated Blood Loss: 5 cc
The patient tolerated the procedure well and there were no complications.

 

Insert asthma

  • Will start Solumedrol

  •  Will start salmeterol, beclomethasone, montelukast

  • Will give albuterol nebs

Insert bleed (ICH admissions)

  • Dr. neurosurgery consulted

  •  Dr. neuro consulted

  •  Last known well

  • NIH

  •  Will keep SBP 100-140

  •  Will repeat CT in 6 hours

  •  Will follow up neuro/neruosurg reccs

  • Will admit to ICU

  • Will do q1 hour neurochecks

Insert central

Central Venous Catheter (CVC, Central Line) Placement
Date: <____>
Time: <____>
Indication: Hemodynamic monitoring/Intravenous access

 

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in a dependent position appropriate for central line placement based on the vein to be cannulated. The patient’s <right/left> < neck/shoulder/groin> was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the surrounding skin area. A triple lumen Cordis catheter was introduced into the the <subclavian/internal jugular/common femoral vein> using the Seldinger technique and under ultrasound guidance. The catheter was threaded smoothly over the guide wire and appropriate blood return was obtained. Each lumen of the catheter was evacuated of air and flushed with sterile saline. The catheter was then sutured in place to the skin and a sterile dressing applied. Perfusion to the extremity distal to the point of catheter insertion was checked and found to be adequate.

 

Estimated Blood Loss: 5 cc
The patient tolerated the procedure well and there were no complications.

 

Insert chest (chest pain admissions)

  • Saturating well on RA low concern for PE

  •  No signs of pneumothorax, pericardial effusion, or esophageal rupture on CXR

  • Given ASA

  • Troponin so far negative

  •  Heart score

  • EKG

  •  Will trend troponins

  • Will get echo

  • Will check a1c and lipid panel

Insert Chole

  •  RUQ pain and leukocytosis

  •  Imaging consistent with cholecystitis

  •  Will start ceftriaxone and flagyl

  • Will consult surgery

  • Will give IVF and pain meds

  •  Will keep NPO

Insert cirrhosis

  •  MELD Chigh Pugh

  • Secondary to alcohol

  •  EV: History of hematemesis

  • SBP: No history of ascites or SBP

  • HCC: No lesion on CT

  •  HE: No history of hepatic encephalopathy

  • Transplant: Not a candidate due to current drinking

  •  Will give ativan for possible withdrawal

  •  Will give banana bag

Insert coag

  • Most likely nutritional

  •  No signs of bleeding

  •  Will monitor, no need for acute intervention

Insert COPD

  • Continues to smoke

  •  Worsening dyspnea

  • No PNA on CXR

  •  Will start prednisone 40 mg PO x5 days

  •  Will do duonebs

  • Will council to stop smoking

  •  Will start azithromycin for anti-inflammatory effect

Insert critical care

 

DVT PPx: SCDs
GI PPx: Not needed, consider pepcid after 72 hours intubated
Diet: NPO
Activity: Bedrest
Code Status: FULL CODE
Disposition: Will admit to critical care

 

Insert diabetes

  • A1c pending

  • Will start SSI

  • Will start diabetic diet

Insert dialysissets (catheter)

Dialysis Catheter Placement
Date: <____>
Time: <____>
Indication: Hemodialysis
Attending: Pranay Parikh

 

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in a dependent position appropriate for dialysis catheter placement based on the vein to be cannulated. The patients <right/left> < neck/shoulder/groin> was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the surrounding skin area. A triple lumen diaylsys catheter was introduced into the the <subclavian/internal jugular/common femoral vein> using the Seldinger technique and under ultrasound guidance. The catheter was threaded smoothly over the guide wire and appropriate blood return was obtained. Each lumen of the catheter was evacuated of air and flushed with sterile saline. The catheter was then sutured in place to the skin and a sterile dressing applied. Perfusion to the extremity distal to the point of catheter insertion was checked and found to be adequate.

 

Estimated Blood Loss:
The patient tolerated the procedure well and there were no complications.

 

Insert DKA

  • Anion gap

  •  Secondary to medication non-adherence

  • Complicated by AKI

  •  Will stat insulin drip

  • Will start LR + KCL at 150 ml HR

  •  Will check BMP q4h

  •  Will switch to d5 1/2 NS once sugars <250

     

    Insert heart (CHF systolic)

  • Acute on chronic

  • EF

  •  Most likely secondary to

  • NO prolonged QRS on EKG

  • Will get echo

  • Will start BB

  • Will hold ACEi given AKI

  •  Will give lasix

  •  Will give nitro ointment to reduce afterload

Insert home (for home meds)

  • Will get list of home meds and continue

  • Insert hypokelamia (in alcoholics)

  • Acute

  • Most likely related to diuresis from excessive alcohol intake

  • Will replete

Insert ICU (for admissions)

 

DVT PPx: SCDs
GI PPx: Not needed
Diet: NPO
Activity: Bedrest
Code Status:
Disposition: Will admit to ICU

 

Insert intrinsic (for AKI)

  • Unknown baseline

  • BUN:Creatinine <20:1

  •  Concern for intrinsic kidney injury

  •  Will get renal US

  • Will give IVF

  • Will recheck in the AM

    Insert intubation

Endotracheal Intubation
Date: <____>
Time: <____>
Indication: Respiratory Distress
Attending: Pranay Parikh

 

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in a flat position. Sedation was obtained using Ketamine 60 mg, and additionally with Rocuronium 20 mg. The patient was easily ventilated using an ambu bag. The <GLIDESCOPE TECHNOLOGY/ MAC 3.5 BLADE> was used and inserted into the oropharynx at which time there was a Grade 1 view of the vocal cords. A 7.5-french endotracheal tube was inserted and visualized going through the vocal cords. The stylette was removed. Colorimetric change was visualized on the CO2 meter. Breath sounds were heard in both lung fields equally. The endotracheal tube was placed at 23 cm, measured at the teeth.

 

A chest x-ray was ordered to assess for pneumothorax and verify endotracheal tube placement.

 

Estimated Blood Loss: 0 cc
The patient tolerated the procedure well and there were no complications

 

Insert macrocytic

  •  Most likely nutritional deficiency

  • No signs of bleeding

  •  No need for acute intervention

  • Will check b12/folate

Insert normocytic (anemia)

  • At baseline

  • Most likely anemia of chronic disease

  •  No signs of bleeding

  •  No need for acute intervention

Insert prerenal

  • Most likely prerenal

  •  BUN:creatinine 20:1

  •  Will give IVF

  •  Will recheck in the AM

 

Insert pseudo

  • Pseudohyponatremia secondary to hyperglycemia

  •  Should improve with better glycemic control

Insert SAH

  •  Will keep SBP <140

  • Will do q1 hour neurochecks

  •  Will give keppra

  •  Will give nimodipine

  •  Will trend troponing and lactate q6hrs

  •  Will give platelets

  •  Will get transcranial doppler

  •  Will get echo

Insert sepsis

  •  SIRS /4 (tachycardia, tachypnea, leukocytosis, fever)

  •  Probable source

  • Most likely organism

  •  Unlikely meningitis due to

  •  Lactate

  • Shock index

  •  Complicated by

  •  Blood cultures drawn in the ER prior to abx

  •  Will give

  • Will give IVF

  • Will follow up blood cultures

Insert shock (cardioversion)
PROCEDURE: Direct current cardioversion.

REASON FOR PROCEDURE: Atrial fibrillation.

 

PROCEDURE IN DETAIL: The procedure was done emergently due to patient’s clinical status. Patient was intubated and sedated and additional sedation was not needed. The pads applied in the anterior and posterior approach. With synchronized biphasic waveform at 150 J, one shock was successful in restoring sinus rhythm. The patient had some occasional PACs noticed with occasional sinus tachycardia. The patient had no immediate post-procedure complications. The rhythm was maintained and 12-lead EKG was requested.

 

IMPRESSION: Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.

 

One shock was unsuccessful in restoring sinus rhythm. The patient was briefly in sinus tachycardia and then reverted to atrial fibrillation with rapid ventricular response.

 

Insert TPA

  • Aborted ischemic stroke due to thrombolysis

  • Duration; Acute, old

  •  Last known well

  • NHISS on admission

  • Caused by Thrombosis (atherosclerosis, vasculitis), Thromboembolus (atrial fibrillation), Infected embolus (endocarditis), Type A Aortic dissection, Aneurysm

  •  Causing: Hemiparesis/ hemiplegia/ weakness, Seizure, Hemorrhage, Cerebral edema, Cerebral herniation, Encephalopathy, Acute respiratory failure, Aphasia, Dysphagia, SIADH, Neglect

  • Status: Improved, worsened, stable, resolved

  • Neruology Dr. consulted

  •  Given TPA

  • Will admit to ICU for q1 hour neuro checks

  •  Will keep SBP <180

  • Will check a1c and lipid panel

  •  Will get echo in the AM

  •  Will get MRI in the AM

 

 

 

Fear or Procrastination?

Fear or Procrastination?

Just hit the button. That’s what my brain has been telling me for the past 30 minutes. How hard could it be? Well, let me take a second and read the news. Oh, I wonder what the score is for the game. 

 

I haven’t talked to my mom for a few days. Let me see what she’s up to. Another hour goes by.

 

Look at the time. I should probably do one more read-through of my blog post before I publish it. It’s getting late, let me read it again in the morning. 

 

I went through different variations of the above scenario many times. Each time it was time to publish my blog post. What I thought was procrastination was really something else…

 

Fear.

 

I was afraid of publishing. I was afraid to put it out in the world. The perfect idea of my blog post was already tarnished by me putting it to words. How did I get here?

 

How it started?

 

It started with an idea. A thought. Something I recognized in the world.  Maybe others would agree. Or even disagree. It would create a dialogue.

 

So I wrote it down. Just the title. I let the thought sit in my head. 

 

It was going to be great. I added a few thoughts to the idea here and there. It was perfect. Soon I’d make it real. Let me just add a little to it.

 

Some more words. Some more thoughts, observations. More of everything. 

 

This is where the first part of my fear started. I was scared to put something that was perfect in my mind on pen and paper. Or Microsoft Word. 

 

But I did. Eventually. And I was right. It wasn’t as good as it was in my head. It never is. In my head, it’s just a blob of thought. I’m able to shape it freely.

 

The real world is not that easy. It felt tainted. Putting words to a feeling, you can never quite explain it right. 

 

But I had to try. Words were the best way to let others know how I felt. Or the observation that I made. Maybe it would help someone else. 

BOX BREATHING TECHNIQUE

How I got over that fear

 

There was a small trickle in the back of my mind. Quietly. Maybe this would help someone. 

 

Maybe this would help someone else. I know I’ve resonated with stories. Blog posts, podcasts. Were they perfect? Probably not. I can’t remember any faults though. 

 

It didn’t matter if it wasn’t. The story made an effect on me. I still remember many of them to this day. Only the good parts.

 

Someone may resonate with one of my stories. It could help them out of a rut. Or show people that everyone gets into ruts. Or faces fear. 

 

It helped to think about someone else. I was being selfish by not publishing. Thinking about only my needs and not other people’s needs. It helped. 

 

Not only that I was able to make my story more personal. Now that I had a person I was speaking to. Here’s what I did. Here’s what you can do. 

 

Some introspection

 

I’m a chronic procrastinator. Many of us are. I remember the days back in medical school, biochem would always be last on my study list. I hated it. 

 

Was that really procrastination? Maybe it was that fear again. Or frustration of having to study something I wasn’t good at. 

 

It was so much more satisfying to study something that I was good at. It’s pretty defeating getting scores of 30% and 40% when doing questions. 

 

Now it’s the same with publishing. There’s a fear. Fear that it won’t be as good as what it’s in my head. Fear no one will read it. 

 

And I might be right. No one might read it. Or people may. The only way I’ll know if by publishing it. So I get past my fear. Put it out in the world and hope to help someone. 

The World Needs Two of You

The World Needs Two of You

Unfortunately, that’s not possible. The next best thing we can do is to help you get more done in the time you have. That starts off by asking yourself, “Do you need to be the one that completes everything on your to-do list?” 

 

Let’s come back to that question. First, if we all looked at our lives there are some common tasks that are the same. We need to eat. That means getting groceries, cleaning, and cooking. We need to clean. That means getting cleaning supplies and finding the time to clean. 

 

You need to outsource

 

Now we all need to eat. The problem is how to get food worth eating. It’s easy to get fast food or food that you can microwave. A lot of times it’s actually delicious. That makes sense because food scientists, yes that is a thing, spend an inordinate time trying to convince your palate that the fast food or junk food you are eating is delicious. 

 

Not so delicious that you don’t want to eat more. Just delicious enough for you to eat it and probably a bit too much of it. Diabolical, I know.

 

No, I’m talking about good-for-you food that tastes delicious. That takes time. Time I don’t like to spend. 

 

There’s a few options:

1. Find ways to minimize time

2. Have it done for you

 

How to save time and still eat good food

 

Let’s break down number 1. Eating good food requires going to the right grocery stores and getting the right high-quality ingredients. That takes time. Not just time spent at the grocery store, but time to get ready, drive, park, pick up the stuff, and wait in line. 

 

Fortunately, there’s an app for that. A few actually. You can have Whole Foods delivered to you from Amazon for free within 1 hour. There’s also the app Instacart. You end up paying a little more for Instacart, but it even goes to Costco for you without you needing to be a member.

 

Now you can focus on the more fun part, actually cooking. That starts with getting the ingredients ready. Maybe, you don’t like to do that either. I know I don’t. 

 

There are services that will do all the shopping for you and send you the perfect quantity of materials. It even sends you the recipe and you can pick what you want to eat. Services like Blue Apron will let you shop recipes and then send you everything you need to make it. 

 

My brother loves to do this. He’s an ER resident and enjoys cooking, but just doesn’t have the time to research what he wants to eat and buy all the ingredients. He buys the basics and let’s Blue Apron send him the rest of what he needs.

 

Lastly, if you are like my wife and I you don’t like any part of cooking, but love to eat. There are services for you as well. Meal delivery services like Trifecta will send you ready to cook meals. They are as healthy as can be and you can choose between different types of food. We choose paleo, but there are others as well. You just put it in the microwave, warm it up, and it’s ready to eat. 

 

The food is pretty good and most importantly healthy. It even has calories and nutrients on there, so I can plan out the rest of the food I can eat in that day. 

 

Learning from Books

Cleanliness without a time sink

We all like to have a clean place to live. It’s personally hard for me to free up my mind for creative activities if I see a ton of stuff everywhere. Or a bunch of dust mites. 

There’re two steps that I’ve done to try and keep my apartment from becoming a den of filth:

1. Spot cleaning

2. One deep clean a month

 

Have you ever been into a room that you haven’t used in a while? What did you notice? Dust everywhere. How does it even get in there? It’s hard to say. One thing is for sure: dust will find a way. 

This typically shows up on the floor. Dust everywhere. Even more so for us with pets. Dust and dog hair. There was no way I could wait till the end of the month to do a deep clean. The dust would take over my small apartment. 

I’ve enlisted help. I got a Roomba You can get simple ones that do most of the work. It’ll vacuum around the house/apartment and even come back to charging station when it’s done. 

 

You can even get fancy ones that you can control with Wi-Fi. They work best when there is your place is all one level. 

 

This will only keep your place clean for so long, which is why I invest in one deep clean a month. The key word is invest. It’s either an investment of time or money. There’s only so many hours in a day, and I’d prefer not to clean.

 

I can recognize the mental health benefits of having a clean place though. And I always thought that hiring someone to clean my place was a needless expense and one that I couldn’t afford. Something for just the uber wealthy. 

 

I even did a quick google search one day when I was really busy and the dust was winning. $100 an hour for a maid? Would have been nice at the time, but I was a resident and that was way more than I could afford.

 

One day someone told me about Taskrabbit. You can use it to find people who will do common tasks such as helping you move or clean your house. I was able to find someone for $35/hr. My whole place could be cleaned for about $100. Now that was well worth it. 

 

So now, take all that time you saved and do more of what only you can do.

Why You Should Be Tracking Your Performance?

Why You Should Be Tracking Your Performance?

In elementary school, I was always picked last when it came to any sports. Football, basketball, track & field. Sometimes, I’d get picked in the middle in soccer, but part of me wonders if they just needed a goalie.

That changed a year ago when I got into spinning. Spin classes are where you are in an indoor gym and use these stationary bicycles called spin bikes. They are crafted to look and feel like professional bicycles. 

The most well-known one is the peloton. Well, a long time before I had my peloton. I was going to spin classes. And I thought I was good.

I’d always be the fastest in the class. One of the few things in life I could do better than my wife. We had a friendly rivalry. 

 

It was fun to race each other. 

We went up to a few times a week. So I thought I was good. Getting stronger, faster, and able to endure more. 

Then COVID happened. I, like many others, got a peloton.

Learning from Books

Life gets interesting when you measure it

I was excited to get the peloton. Of course, I was happy to start exercising again. But the Peloton offered me something that the bikes at my spin studio didn’t: tracking metrics. 

 

Now let’s take a quick step back to how spin studios work. You go in and there’s an instructor in the middle. There’s music and you usually try to cycle your feet to the rhythm.

 

The instructor will tell you to either decrease or increase the resistance. That makes it easier or harder to pedal. 

 

I always thought I was at the upper limits of what the instructor was saying. Would always try to pedal the fastest and use the most resistance I could. 

 

But I had no idea how I was doing. That’s where the Peloton came in. It measured how fast I pedaled and how much resistance I used.

 

It even had a leader board. You could see how you were doing against people that were spinning at the same time as you. You could also see the all-time leader board. 

 

Time to eat my Humble-pie

 

Now I think a little competitiveness is good. As long as you’re detached from the outcome. I’m happy when my wife is better at something than me (this happens often), and it pushes me to be a bit better.

  

I’m always also competing versus the old me. 

  

So what did I see when I looked at the leaderboard on the Peloton? The person who was the fastest in class in a small spin studio on a Wednesday evening in Downtown Los Angeles? 

  

Disappointment. I was humbled. 

  

I was nowhere near the top, let alone even the middle. I was closer to the last percentile.

 

The benefit of tracking your performance

Had I not started tracking my numbers I would have had no idea where I was compared to other people. Not only that, I realized that my own performance varied tremendously between sessions.

 

I found that I was weak on fast pedaling at low resistance. I was able to pinpoint exactly where I needed to improve. The rest of my spin game was fine and working on that specific area improved the quality of my spin session overall. 

 

Where have you wanted to improve? Have you been keeping track of any performance measures? 

 

Maybe you already are performing well on that aspect or that you need to work on something else. The numbers that the Peloton gave me where direct feedback. I’d be able to take a look at each session and see where I could improve. 

 

What kind of feedback have you sought out?

 

How to Resist the Urge to Keep Scrolling

How to Resist the Urge to Keep Scrolling

I keep scrolling away. Sometimes, I finally hit the “You’re All Caught Up” sign on Instagram. No worries. I can just click on the explore tab. That’ll show me random pictures from random people. Hard to run out of those.  

 

The scrolling continues. All of a sudden it’s been an hour. Or has it been two? I got lost in all the funny comics and puppies. There’s never enough puppies. 

 

That’s the issue, isn’t it? There’s so much to do and an endless amount of distractions. The goal of companies like Instagram is to keep your attention. There is always more to see. More to scroll. 

 

Now I know that I shouldn’t be just mindlessly scrolling Instagram, but it got me wondering. Are there other parts of my life that I just scroll away? 

 

I saw the endless scroll in a few different places. The todo task that never had an end. Let me look up this. Or let me read the news. 

 

There wasn’t an endpoint. It just kept going and going. There was always more to read. Better research that could be done. The endless scroll was still there. However, instead of guilt, I felt some satisfaction knowing that I was working. 

 

But the endless scroll sucked out the productivity. I was productive for those first few scrolls, sure. After a while, I hit diminishing returns. 

Learning from Books

How I Tamed Endless Scroll

I’m a disorganized man who wished he lived in an ordered world. I love being organized. I hate organizing. It’s hard to say which I care for more. I go through fits of organizing everything. Unfortunately, it never lasts. Entropy always wins. 

 

It always started simple enough. The diminishing returns wouldn’t be hit right away. All that scrolling was for a purpose. Find more articles. Do more reading. There wasn’t a way to stop it while I was still being productive. 

 

So I had to find another way. I’ve had to create some rules to tame my disordered half. This worked just as well against the endless scroll. 

 

I had to give myself a time limit. I would only be able to work on this project for a certain amount of time. Or the research could drag on forever. 

 

One of my favorite reasoning for procrastination was research. It’s easy to keep looking up more information. It’s much harder to get started. Start that blog post. Record that video. 

 

An hour for this. 30 minutes for that. The limits jumpstarted my creativity. Forced me to actually work instead of taking time to warm up. Reading the news really quickly. Or answering a few emails. 

 

Just as important to the time limit was accountability. When the timer went off, I had to stop. Unless I was in a flow state that happens once in a blue moon. I had to stop working and switch to something else. 

The Constraints Helped My Creativity

 

I’ve always found a certain surge of creativity on the last day of a deadline. That inspiration that had escaped me for weeks all came in as a rush.

That last-minute rush didn’t give me much time to edit. Or proofread. 

I would barely have the time to finish my papers before I had to hand it in. Even now, I’d often get blog posts done right before the need to publish. 

The dedicated time for my project gave me a new deadline. Instead of the one right before it was due. I only had an hour to work on it.

After that, I would have to switch to a new project. There are always other projects to work on.  I know it was an artificial deadline, but it worked. Somehow I’d squeeze out some creativity. 

I’d have plenty of time leftover to edit. Editing is the easy part. It takes effort to come up with something new. To fill up an empty page.