Several weeks ago while I was on primary call, I was called by the emergency room (ER) attending physician about a woman who had left eye pain. The ER doc had dutifully checked the vision in her eye and found it to be 20/200 while the unaffected eye was 20/20. He added that she complained a sudden loss of vision in that eye as well.

I had just stepped into my apartment right before getting called, around 12:02am. Painful loss of vision is concerning by all means, and I rushed back to the ED while glancing through my Will’s Eye Manual for help.

My patient was a 40-yr old woman comfortably sitting in the exam chair. Her eyes were white, and on first glance, I could not determine which eye was in question. On brief exam, her vision in the left eye was indeed poor, although she did not have an afferent defect or a shallow anterior chamber. The fundus on the left eye was clearly severly myopic compared to that of the other eye. I suspected that she had poor vision in the left eye all along.

I began with more questions (in broken Spanish):

Me: Which eye is the better eye?

Patient: [points to right eye]

Me: Has your vision in your eyes changed in the last year?

Patient: No, but he said my left eye was bad.

Me: Who?

Patient: The doctor

Me: What doctor?

Patient: The doctor on 186th street.

Me: What kind of doctor is he?

Patient: eye doctor

Me: As a child, did you see well out of your left eye?

Patient: No, but the doctor said I don’t see well.

Me: What doctor?

Patient: That doctor. [points out to hallway where the ED physicians work]

…

The dialogue continued for 15 more minutes with uninformative dictum speckled with non-sequiturs. I now envy those folks who specialize in pathology or radiology.

It seems like hardware has caught up the power race, and most desktop systems are capable of handling all but the most processor-intense applications. I’ve been one to believe that current computers are overpowered for their intended purposes. Who needs a dual-core with 2gb memory and 1gb video ram to browse the ‘net and word process? Indeed, there is no role for this in routine use, but I recently discovered that new hardware helps even with light software use.

I recently installed Microsoft’s Visual Studio with SQL Server onto my 1.7ghz Thinkpad. The installation burned through about 15gb of disk space (out of a 40gb disk) and took over an hour to complete. After the ancillary drivers were installed in place (.NET, Powershell…etc), the laptop ran like a 500-lb man after going through a Vegas buffet. I promptly uninstalled the software.

It’s probably time for an upgrade.

I had the displeasure of trekking to the post office today to pick up a piece of certified mail. The local branch opens its doors at 9am. I came at 8:50am in hopes of beating the crowd. Apparently, the lobby opens its doors 8:30am in preparation for the day. When I arrived at 8:50am, I was the 8th person in line! I waiting approximately 1 hour to reach the front of the line, and another 13 minutes for them to find my mail.

It may be time I invest in a 3rd party mailbox service, such as mailboxes at the UPS Stores. Does anyone have experience using these services?

It seems like the common theme this year is digital screen technologies, like OLED televisions and E-books. The concept of e-book readers like Kindle and Sony’s Reader is enticing, but the weak .pdf support and huge restrictions on certain file formats makes the device an imperfect scientific reading device.

I wonder how many of these devices have application in the medical community. Portable readers? Not really. See-through OLED screens? Nice, but not a necessity. Portable dictation devices? Absolutely. We need to transcribe our referral letters. I will be following Android’s dictation engine closely. Since Google has been harvesting 411 voice data onto its Voice system for the past few years, I can only expect things to improve. It will be an exciting year.

I’ve begun to reconsider the notion that these academic centers are anything beyond extraordinary. For one, academic centers are training centers. There are residents of all levels caring for the ill; no matter how qualified the housestaff are, there will always be shortcomings. I’ve been at the blunt end of poor decisions too many times already.

One morning, I received a page at 5am from a medicine PGY-2 resident who noted that one of my colleagues had written “I/L: 2+ NS OU” on one of the consults but failed to address any intervention in the plan (The consult was for diabetes evaluation, which is already a dubious inpatient consult). The same resident called me again last weekend at 5:09am requesting a consult for a gentleman with multiple myeloma who was bleeding from his gums and was anemic. He had read of some reported complications of central retinal vein occlusions in hyperviscosity syndrome. The patient had absolutely no ocular symptoms. Moreover, the medicine resident congratulated me for recognizing that there were no pathognomonic ocular findings for hyperviscosity syndrome, but demanded a stat consult anyway. Since when does the “consultee” openly flaunt demands to a consultant? At the same time, I had a corneal ulcer that I was managing in the ED.

It is disgraceful for a notable academic institution to have such prideful individuals with limited insight. I trained at a community center during internship, and never called a stat ophthalmology consult. Most people knew their limitations. In fact, most cases never need emergent eyecare intervention.

Some might say that the mission of the academic center is different from that of a community center. In these differences lie a training and research center that necessitates inefficient consults and a higher operating overhead. Not so much. The community center I worked in certainly had a higher inpatient load than my current academic institution. The community center isn’t burdened by deadbeat unionized employees who show up to work half the time. Many workups are governed by protocol; those that are not are rightfully so. The profit that the community center–a non-profit organization–is converted to education and expansion of the hospital. Complicated cases are indeed transferred to the local academic center, but rarely so. The more common cases are managed far more efficiently than their equivalents in a large academic center.

Indeed there is a role for each type of hospital in every city. However, the discrepancy in the two is startling. Academic centers should excel in “complex case report worthy” medicine, but they should not have to sacrifice quality and efficiency of the entire hospital in doing so.

Bastard. What do people think I’m doing? I’m sure that everyone tries to be particularly alert, but there’s no reason to be paranoid.

Last week I received a call from a gynecologist who worked at the hospital but was 2 hours away. She noticed that her eye was  “bloodshot”, and described to me signs of a subconjunctival hemorrhage. Of course there was nothing I could do except offer her a ticket to my emergency room if she wanted an examination. She declined.

On Saturday morning at 4:30am, I received a page from the hospital’s cardiothoracic (CT) surgery fellow worried about his own red eye. I had just stepped foot in my apartment 10 minutes earlier, after a horrible slew of ED consultations. I asked him to drop by our weekend clinic at 8:30am for examination, but he stated that he was scrubbing into “a case” and probably would not be finished until 10am.

As angry as I felt for being paged for likely non-emergent personal consultations, I actually felt sorry for the CT fellow.

Then I realized the reason for the high volume of non-emergent calls is that people, no matter how educated they are, know very little about the eye. Who knew that you shouldn’t wear daily contacts for 4 days straight? Yes, if you wear inch-thick eye liner, some of it will get into your eyes.

I guess that’s why ophthalmologists still have jobs.

I was unfortunate to be covering the primary pager for the hospital this weekend, which is Academy weekend. Generally speaking, this is the worst weekend to have an eye problem, because your primary ophthalmologist is probably out of town in a meeting (or getting drunk). My pager rang early yesterday morning with a long distance callback number. Bad news. When the emergency room or floor resident pages me, I usually receive the hospital extension. A long distance number always means that you’re getting shit that you don’t want to (and should not have to) deal with.

The call turned out to be from one of my attending’s wife. She woke up with an itchy eye and foreign body sensation. Her husband was at the AAO meeting in San Francisco, and she did not wish to bother him with a call. Her son-in-law, daughter, nephews, and nieces were all ophthalmologists at the meeting as well. Her primary ophthalmologist was in town, but she did not wish to bother him either because it was Saturday (Jewish sabbath).

WTF?

I suppose that leaves me, the on-call resident. I offered advice to the best of my abilities over the phone and offered to see her in the emergency room (the one where patients wait 4 hours to be triaged). She politely declined.

Lesson to be learned: if everyone in your family is an ophthalmologist except you, you should go with them to the Academy meeting.

I remember when Instant Messaging flooded the workplace computers back in the tech-boom days. My colleagues working at IBM would get company-wide emails stating that IM decreased productivity and was prohibited. When company threats weren’t heeded, port 5190 was blocked on the company firewall.

Now that instant messaging has been superseded by text messaging and MMS, I see my colleagues “texting” away during conferences and lectures. It’s become a nuisance. If you’re simply notifying your spouse that you’ll be late for dinner, that’s one reason to be texting during fluorescein conference. However, checking the stock ticker? Chatting with your medical school classmate? What are you thinking? That is simply abusing technology. Perhaps I say this only because I don’t have a data plan on my phone, but there is a point in which your attention should be directed toward the lecturer and not your iPhone.

Our eye clinic is in the basement, where our cellphones unreachable by the outside world. You’d think that there wouldn’t be any contact with the outside. Wrong. Last week one of the technicians (who are supposed to be obtaining visual acuity for our patients) was logged onto her MySpace page. Another computer was logged onto Facebook.

I wonder how much social networking affects workplace productivity. A quick search online shows that this actually increases productivity. USAToday also states that we work better with social networking… The caveat? None of these companies are involved with healthcare.

I hailed a grey taxi to help me move an air conditioner 5 blocks away from my apartment.  I offered $10 for his assistance in carrying the unit to and from the cab in addition to driving me. He agreed. Afterward, he didn’t help me move the A/C, AND he charged me $15 because my A/C was “big”. Asshole. A $15 cab fare would normally get you at least 20 blocks.

My friend Bob had a more harrowing experience. After agreeing to a standard $8 fare to travel between hospital campuses, the cab driver demanded $14 when they arrived at the destination. Bob refused, and the driver locked the doors to the cab and refused to allow him to exit. He spent over 30 minutes in the cab until the driver gave in and let him out.

I understand that any business is difficult to run these days, but knowingly ripping off your regular customers is no way to remain profitable.