Haikus to Internal Medicine

Oops, I kind of disappeared.  No worries, I'm around, just got busy.  Doing internal medicine right now.  While I might have liked it in medical school, no more.  I miss the operating room.  

Haikus to Internal Medicine

Pager, I hate you

You beep constantly at home

You are here to stay

Thirty hour call

You suck. I am so sleepy

Who invented this?

Potassium, you

Are always low, I am sick

Of repleting you

EKG, no clue

How to interpret you but

I pretend to know

Volume overload

Bores me, they should sell lasix

Over the counter

Sticking needles in

Fluid collections is fun

Cytology pending

Full Moon Pies

AAOOOOOOOOOOOOOOO!  The 23rd is a full moon.  Time to get your werewolf self ready for the big howl.  Besides bringing out beasts and goblins, full moons are thought in the obstetrical world to bring out babies.  As an already overworked and overwrought poor little intern running around labor and delivery, this can’t be a good thing.

But are full moons actually related to the onset of labor? Most studies suggest that, in fact, they are not.  A 1979 study of 11,681 live births at UCLA hospital showed that there was no correlation of lunar cycle to births.  These results were reproduced in a smaller study of 3706 births in the 1990s in New York City.  However, some studies suggest otherwise.  One small Italian study suggests that there might be a small effect on multiparous patients (those that have had more than one baby) with the lunar cycle. 

Not only is tonight/tomorrow (the calendar says tomorrow but it looks full tonight) a full moon, but it is also a harvest moon.  Besides being a great Neil Young album, a harvest moon is when there is a full moon at the autumnal equinox.  Supposedly the harvest moon appears bigger and brighter than a normal full moon.  Time to get out the scythe and start farming.  

To celebrate the full moon, I made a traditional southern classic, the moon pie.  A moon pie is 2 graham cracker cookies filled with marshmallow and topped with chocolate.  To celebrate my day off, I made my own graham crackers and my own marshmallow.  Although it seems difficult, it isn't too tough.  Just takes a candy thermometer. Graham crackers require graham flour, which I know some people have had trouble finding.  I like Bob's Red Mill which is in the health food section with the other whole grains.

Full Moon Pies

For the cookies (adapted from Martha Stewart's baking)

1 1/2 cups all purpose flour

1 1/2 cups graham flour

1tsp baking soda

2 tbs cocoa powder

1/2 tsp salt

1 1/2 sticks unsalted butter at room temp

3/4 cup packed light brown sugar

2 tbsp honey

Preheat oven to 350.  Combine flour, baking soda, cocoa powder and salt and set aside.  In mixer, beat sugar, honey and butter until fluffy.  Slowly mix in flour, stir to combine.  On floured surface roll out cookies thin about 1/8 inch and cut with 1.5 inch round cookie cutter (or glass or jar which is what I used).  Place on baking sheet and bake about 7 minutes until brown and crisp.  

For the Marshmallow (from Food Network)

1/4 cup water

1/4 cup light corn syrup

3/4 cup sugar

2 egg whites

1 packet plain gelatin

2 tbsp cold water

1/4 tsp vanilla

Combine the 1/4 cup water, the corn syrup, and the sugar in a saucepan fitted with a candy thermometer. Bring to a boil and cook to "soft-ball" stage, or about 235 degrees F.

Meanwhile, in a standing mixer fitted with a whisk, whip the egg whites until soft peaks form. Sprinkle the gelatin over the 2 tablespoons water and let dissolve. When the syrup reaches 235 degrees F, remove it from the heat, add the gelatin, and mix. Pour the syrup into the whipped egg whites. Add the vanilla and continue whipping until stiff.

Transfer the mixture to a pastry bag fitted with a round tip. Pipe a "kiss" of marshmallow onto half of the cookies, and top with the rest to make sandwiches. Let set at room temperature for 2 hours.

For the Ganache

8 oz chocolate chips

1 cup heavy cream

Over double boiler on medium heat, melt chocolate and cream, stir together.  Dip cookies in ganache.  Also can make white chocolate for an extra drizzle

Abell, GO.; Greenspan, B. “Human births and the phase of the moon.” New England journal of medicine, v. 300 issue 2, 1979, p. 96.

Joshi, R.; Bharadwaj, A.; Gallousis, S.; Matthews, R. “Labor ward workload waxes and wanes with the lunar cycle, myth or reality?.” Primary Care Update for OB/GYNS, v. 5 issue 4, 1998, p. 184. 

Gabriele Ghiandoni, Roberto Secli, Marco B. L. Rocchi, Gilberto Ugolini, Does lunar position influence the time of delivery? Eur J Obstet Gynecol Reprod Biol. 1998 Mar;77(1):47-50.

Tik Tok Board Doc

This month has been awesome.  I'm what is called board doc which means I run the labor and delivery board making sure everybody has been examined, monitors are placed and all of them are delivered.  It's been a blast but it's probably the most crazy experience of my entire life.  There is no time for sitting, or eating, or thinking.  In honor of board doc, I have re-written the words to a favorite pop song, Tik Tok by Kesha.  In medical school we used to have a show Doc Opera with a very similar feel to it, and I used to direct the band.  Since there's no Doc Opera in residency, I've spent my few minutes of free time re-crafting the song.  So here ya go!




Wake up in the morning feeling oh so S%ty
I got my glasses, I’m out the door, I’m lookin oh so gritty
Before I leave, brush my teeth and I pull my hair back
Cause when I leave for the night, I ain’t coming back

I’m talking danskos on our toes toes
Scrubs instead of clothes, clothes
Blood all over ourselves, selves
Pulling out all the babies
Sewing up all the ladies
Trying to get a little bit messy

Don’t stop, make her pop
Nurse will you run my pit up high
Tonight, push it right
Till that baby sees the light
Tick tock on the clock
But the babies don’t stop, no-oh-oh no-oh-oh-oh

Don’t stop, make her pop
Turn the epidural up to high
Tonight, imma write
Notes til I see the sunlight
Tick tock on the clock
But the pager don’t stop, no-oh oh oh

Ain’t got no sense in the world but got plenty of fear
Ain’t got no food in my belly but nobody cares
Now the tasks are lining up, can I work any faster?
There are 8 million things I’m not sure I can master

I’m talking about everyone running around round
Feet never leave the ground ground
Gonna pit her if she’s moving too slow
Decels so she can’t no second miso-so
Can’t wait until she crowns crowns
Wait until she crowns crowns
Wait until she—

Don’t stop, make her pop
Nurse will you run my pit up high
Tonight, push it right
Till that baby sees the light
Tick tock on the clock
But the babies don’t stop, no-oh-oh no-oh-oh-oh

Don’t stop, make her pop
Turn the epidural up to high
Tonight, imma write
Notes til I see the sunlight
Tick tock on the clock
But the pager don’t stop, no-oh oh oh

I’m cramping up
I might break down
The heart, it pounds
FSE
With my hands in
I got it through
I think we’ll know
IUPC
Let’s build it up
Head come on down
We’re hoping for
Adequacy
With my hand in
With my hand in
Get your hand in

No the party don’t stop when I walk in

personal SOAP note

A SOAP note, for those not in medicine, is a progress note to assess and evaluate a patient.  First, one starts with the subjective, what the patient tells the provider.  Objective includes things that the provider notices and provide more information about the physical state including physical exam, vital sign, imaging, and lab reports.  Assessment and plan are more straight forward.  This is a personal progress note…

S: Feeling well today. 

Back aches, relieved by rest. 

Infrequent voiding, poor PO intake 

Occasional palpitations--worsened by pager, improved by alcohol.

Denies chest pain

No shortness of breath

Ambulating rapidly

O: Vitals:

Pulse 110

BP 120/80

Temp 37

General: alert, questionable orientation to time of day or day of week, smiling and grimacing simultaneously, pressured speech.  

Denies suicidal or homicidal ideation—usually.  Mood labile

Lungs: Clear

Abdomen: hyperactive bowel sounds

Labs:

Glucose 60

A: 26 y/o G0 s/p day #34 OB/GYN internship initiation. 

Patient making questionable progress in her treatment course resulting in exhaustion and occasional idiocy. 

Condition improving. 

Tachycardia secondary to physical exertion and anxiety. 

Hypoglycemia due to poor oral intake

P:

Residency is a condition that can only be cured with time, 4 years on average. 

Treatment guidelines include constant focus, increased caloric intake (perhaps a bag of peanuts in the pocket or a granola bar that can be rapidly consumed), increased fluid intake and very comfortable shoes.

Breathing is also advised

Will reassess

COOKIES!

Not much to say this week.  Still working, still surviving.  The highlight of my week was some delicious, crunchy, sweet, chocolaty, nutty, tangy cookies I stockpiled with unusual ingredients such as malt balls, malt powder, graham flour and pretzels.  I brought them to work to seduce the nurses to correct all of my poorly placed orders.  Seemingly it worked. 

Elizabeth’s slightly unusual but unusually good cookies

½ lb malt balls (such as Whopper’s)

1 to 1 ½ cup sourdough pretzel pieces

¾ cup butter (a stick and a half)
½ cup peanut butter

¾ cup brown sugar

½ cup granulated sugar

2 eggs

1 tsp vanilla

¼ cup malt powder

3/4 cup graham flour (or whole wheat flour)

½ cup oats

1 tsp baking soda

½ tsp salt

1 cup all purpose flour

Preheat oven to 350.  In food processor, pulse pretzels and malt balls until bite sized.  Alternatively, place in large ziplock bag and pound with rolling pin until bite sized.  In medium bowl, combine malt, graham flour, oats, baking soda, salt and flour.  Cream butter, peanut butter, and sugars until fluffy with mixer.  Add eggs and vanilla, stir to combine.  Stir in flour until well combined, then add pretzels and malt balls.  Using tablespoons, drop onto ungreased cookie sheets and bake until barely brown (8-9 minutes).  Cookies burn on bottom quickly so take em out fast!

Cool and enjoy.  

Contraceptive Confections—IUDs, you are so sweet

Disclaimer: These cookies do not prevent pregnancy.

In my last post I celebrated the birth of oral contraceptives.  Today I will salute another favorite form of birth control, the intrauterine device, or IUD.  IUDs have an interesting history of their own.  They have a very bad reputation among many of the lay population, but in fact, they are an extremely effective and safe form of birth control.  I would say that IUDs are a great form of contraception because they are very popular for OB/GYN docs [1].  If that doesn’t speak for itself!

The bad reputation of the IUD comes from a previous form of the IUD called the Dalkon Shield released in the 1970s.  The Dalkon shield caused a lot of controversy because it was blamed for causing an increased rate of pelvic inflammatory disease and infertility. A 1981 study showed that woman were 5 times more likely to have pelvic inflammatory disease from the Dalkon Shield than from other IUDs [2,3]. The Dalkon Shield is banned, but won’t be forgotten because it’s also a band.  Although, not a very good band.

In the US currently, there are two FDA approved IUDs--the Mirena and the Paragaurd.  The Mirena is impregnated with progesterone and is effective for five years, and the Paraguard, the more traditional device wound with copper wire, is effective for ten years.  The Mirena works by secreting progesterone into the uterine cavity and makes the uterus inhospitable to implantation as well as thickening cervical mucus (yeah I know, cervical mucus…kind of gross to some).  The copper in the Paraguard reacts with the uterine cavity to inhibit implantation.

The IUD is an highly effective form of contraception, more effective than birth control pills, with a pregnancy rate of <0.5% over 5 years [4].  The side effect profile is low; women are at a minimally increased risk of PID if they have an STD at the time of insertion [5,6].  Women can experience cramping, abnormal bleeding, and expulsion. The IUD does not affect fertility, and fertility returns once the device is removed [7]. 

Along with the birth control cake for my contraceptive confections series, I made IUD cookies.  What could be more delicious than a simple sugar cookie decorated to look like a plastic device inserted into the uterus?  Nothing really.  My fiancé ate them all.  I used my favorite childhood sugar cookie recipe straight from nothing else but the Betty Crocker Cookbook.  I fashioned up some simple royal icing and with my two surgeon gal pals, we delicately iced the ladylike cookies.  So thanks girls and I’m so proud of you!

IUD Cookies
Sugar Cookies from The Betty Crocker Cookbook
Makes about 50 IUD cookies

T shaped cookie cutter (purchased at Sur La Table and the only thing in the ENTIRE store that costs $1)

Cookie dough
1 ½ cups powdered sugar
1 cup (2 sticks) butter softened
1 tsp vanilla
½ tsp almond extract
1 large egg
2 ½ cups all purpose flour
1 tsp baking soda
1 tsp cream of tartar

Royal icing
4 cups powdered sugar
6 tbsp heavy cream or 4 egg whites

Beat powdered sugar, butter, vanilla, almond extract and egg in large bowl.  Stir in remaining ingredients, cover and refrigerate for at least 2 hours.  Heat oven to 375.  Roll dough to ¼ inch thick on floured surface, cut into T shape.  Bake 7-8 minute or until edges are light brown. 

Combine icing ingredients until smooth.  Color some and leave some icing white.  Pipe shape with pastry tube.

If you are interested in an IUD, please discuss with your doctor.  I might be a doctor soon, but I’m not yours.  There are other risks and side effects not discussed above. 

1. 2003 ACOG News Release. Gallup Survey of Women
OB/GYNs. Available at: http://www.acog.org/from_home/
publications/press_releases/nr12-09-03.cfm. Retrieved February
2. http://www.cdc.gov/mmwr/preview/mmwrhtml/00000072.htm
3 Burkman RT. Association between intrauterine device and pelvic inflammatory disease. Obstet Gynecol 1981;57(3):269-76.
4. Thonneau, PF.; Almont, T. “Contraceptive efficacy of intrauterine devices.” American Journal of Obstetrics & Gynecology, v. 198 issue 3, 2008, p. 248-53.
5. Mohllajee, AP.; Curtis, KM.; Peterson, HB. “Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmitted infection? A systematic review.” Contraception, v. 73 issue 2, 2006, p. 145-53.
6. Shelton, JD. “Risk of clinical pelvic inflammatory disease attributable to an intrauterine device.” The Lancet, v. 357 issue 9254, 2001, p. 443.
7.  Hubacher, D., et al. “Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women.” New England journal of medicine, v. 345 issue 8, 2001, p. 561-7.

Time for some Vitamin D (Part 1—with FLAN FAIL!)

Fiesta!  Time to celebrate!  I’m done with classes in medical school and just hanging out until graduation on May 16.  This includes some much needed sun in Mexico (we leave on Sunday) with my best friend from high school. 

When I went home last month to visit my mom, I had a skirt on to honor springtime.  She was aghast the pastiness of my white legs.  We went on a walk that night and my two stumps were aglow in the moonlight.  

While this complaint of lack of sun seems vain, it elucidates the negligible amount of time I’ve spent in the sun in the past three years.  Not only have I lived in Cleveland, voted by Forbes to have the worst winter weather in America, but seemingly, for the past two summers, I have done my absolutely hardest rotations during peak summer sun hours.  Going into the hospital before the sun’s up and catching only the twilight zone at the end of the day just does not help. 

Even though basking in the sun puts people at increased risk for deadly skin cancers, one benefit from our favorite burning ball of gas, besides sanity, is that the skin reacts with sunlight to produce vitamin D.  Vitamin D, if you haven’t noticed, is all the rage right now.   A quick literature search reveals research blaming vitamin D deficiency for everything from heart disease to diabetes, low birth weight babies, chronic pain, pelvic floor disorders and neurologic deficiencies. 

Obviously this is a rapidly growing area of interest, but is the hype real?  Even three years ago in my first year of medical school I was taught the vitamin D deficiency was quite rare and remember the lecturer saying that “only some old lady who doesn’t eat anything and is locked up in her bedroom all year” could lack this essential nutrient. 

Vitamin D deficiency is actually much more prevalent than once previously thought.  When I did an endocrinology rotation all of the fellows who are young and healthy tested their vitamin D blood levels.  They were all insufficient.  In the National Health and Nutrition Examination Survey from 2001-2004 of 6275 nationally represented children from ages 1-21, 9% were deficient and 61% were insufficient [1].  A study of 2500 mothers and infants in urban Boston showed that 58% of infants and 35.8% of mothers were severely deficient [2].  People of darker skin color and colder climates are at the highest risk.

In the next post, I’ll discuss the role of vitamin D in the body, and review some of the literature about the health effects of deficiency.  I’m sure you’re wondering how you can boost your own vitamin D levels.  Get outside and get some sun.  Supplemental tablets  (the Institute of Medicine is about to release new dosage guidelines) and foods with vitamin D such as fortified milk products, eggs and fish, are also good sources. 

To prepare for my Mexican adventures and to boost all of our vitamin levels with eggs and milk in a sweet way, I tried to make some cinnamon infused flan.  I just love anything custardy.  In fact, my very first memory wasn’t of my parents or our cats but of custard that our neighbor made.  And the donuts we ate at the beach.  I’ve been a life-long food lover, and now I want to share it with you. 

Well, you see, I wrote this post and had a FLAN FAIL!  It looked great until I tried to flip it and it turned into a puddle of soupy caramel egg mush.  So, for the next post, I’ll try a new recipe that is guaranteed to succeed.  For now, I give you my stages of flan grief. 

1.  Kumar, J., et al. “Prevalence and Associations of 25-Hydroxyvitamin D Deficiency in US Children: NHANES 2001-2004.” Pediatrics, 2009.
2. Merewood, A., et al. “Widespread vitamin D deficiency in urban Massachusetts newborns and their mothers.” Pediatrics, v. 125 issue 4, 2010, p. 640-7.

Mi Favoreet Foood Ees Mango

My life has been laced with mangoes.  My most endearing mango-related memory took place the year I took off between college and medical school.  Before I left for Chile, I worked odd jobs including a daily volunteer job teaching adult Mexican immigrants English. 

The class was designed to teach these vibrant adults survival English.  We taught them their addresses, the different coins and money, body parts and the doctor’s office, how to take the bus, and how to navigate the grocery store.  One of the sentences we taught the students to say was “my favorite food is” and had them fill in the blank.   Invariably, every person would say “mi favoreet foodd ees…mango” regardless of how many other food words we taught them.

Well, can you blame them?  Mango is one of the most addictive foods I have ever encountered.  When my family lived in Asia when I was in junior high, my dad used to bring the most amazing mangoes back from the Philippines by the dozens, and we would heartily devour them.  Those Philippine mangoes are the best ones and they come dried and pre-packaged by the kilo at Costco.  I can only keep the bag around for about one day, and for the sake of my tummy and my blood sugar, I only buy them about once a year.

Since I’m done with medical school and on vacation until I start residency, I’ve decided to screw science for this post and just give you a recipe for yummy mango fried rice.   I’m sure mangoes have amazing scientific, nutritional and genetic properties, but I just think they taste really good.  So there!

The trick to mango fried rice is to use slightly under-ripe mangoes.  They are tart and cook up to be tender, with the slightest bit of sweetness.  This recipe balances tartness, sweetness, spiciness and saltiness and has lots of veggies.

Mango Fried Rice

1 lb pork loin finely chopped (optional) you could also use chicken, shrimp, tofu...or nothing
3 tbsp vegetable or peanut oil
1 under-ripe mango cubed
3 scallions sliced into ½ inch pieces
4 cloves garlic smashed
1 large shallot diced
¾ cup green beans cut into ½ inch pieces
1 carrot diced
1 inch of gingerroot peeled and finely chopped
2 tbsp cilantro chopped
1-2 red finger peppers sliced with seeds (depending on spice level desired)
1 egg
4 cups cooked jasmine rice
Juice of one large lime
¼ cup soy sauce
1 tbsp sugar
2 tbsp oyster sauce
¼ cup cashews toasted and ground

In separate glass, combine lime juice, soy sauce, sugar and oyster sauce.  With wok or large cast iron skillet, preheat 1 tbsp oil over high heat.  When oil is smoking, add pork and cook until pink is gone.  Remove pork and juices onto plate.  Add another 2 tbsp oil and allow to reach smoking heat again.  Add mango, scallions, garlic, shallot, green beans, ginger, carrot, red pepper and cilantro and cook, stirring frequently until green beans are slightly tender, about 7 minutes.  Add about ¼ of the soy mixture and stir.  Add egg and scramble.  Add pork and allow to reheat throughout.  Add rice and incorporate.  Add rest of soy mixture.  Stir until rice is hot and has started to brown on sides.  Put in bowl or on plate, and add cashews to the top.  Enjoy!

BRAINFREEZE!

The first appliance that I bought when I got my own kitchen 4 years ago was an ice cream maker.  I already and a microwave and toaster; an ice cream maker was the next logical purchase.  Every time that I waltzed down the Costco appliances aisle, it was screaming my name.

While purchasing an ice cream maker might seem like an excessive, unnecessary purchase, I think it is not.  Chocolate peanut butter ice cream cakes?  Chocolate chip cookie ice cream sandwiches, homemade?  People love this stuff.  If you make ice cream at home, you will make friends.

The hardest part about making ice cream is remembering to put the maker in the freezer at least a day ahead of time.  Good ice cream is made of so few ingredients that the assembly is simple.  So, you make the ice cream (or frozen yogurt in this case), you freeze it for a few more hours for it to harden up, and you take a spoon directly to the container and BAM!  As you ravenously destroy your homemade delicacy you get a chilling headache running from your eyes to the back of your head.  BRAINFREEZE!

What causes brain freeze or ice cream headache anyway?  Current neurologic models suggest that vascular constriction and referred pain are to blame [1].  A life-saving randomized trial performed at Dalewood Middle School showed that ice cream headaches were more prevalent in the group that ate the ice cream in less than 5 seconds versus the group that savored every last spoonful [2]. 

A survey of over 8000 Taiwanese adolescents showed the prevalence of ice cream headache is about 40% [3].  Boys were more likely to have brain freeze than girls, and older children were more likely to have brain freeze than younger ones.  Those that had chronic migraines were much more likely to have ice cream headache.  The association between ice cream headache and migraine has been shown in the past, however is still disputed considering one study showed that people with brain freeze were less likely to have migraines [4,5]. 

The best brain freeze is self induced.  Therefore, I recommend making this creamy chocolate malt frozen yogurt.  It is very tangy from the yogurt, not like the chemically altered, gooey sugary stuff from the mall, so if you don’t like yogurt, you probably won’t like this either.  The yogurt is strained for about 4 hours beforehand to remove excess water so the result is very creamy with a lot less calories than regular ice cream, although I do add some cream to give a good texture and flavor.

Chocolate Malt Frozen Yogurt
4 cups low fat plain yogurt
1 cup heavy cream
¾ cup sugar
½ cup cocoa powder
½ cup malt powder
Cheesecloth

Place a couple of layers of cheesecloth over a strainer over a bowl.  Add yogurt and cover.

Refrigerate for at least 4 hours until the yogurt has lost most of its moisture.  Sift chocolate powder into cream, add sugar and malt powder.  Stir to combine.  Whisk in strained yogurt and add to ice cream maker as directed.  Freeze until hardened. 


1. Kaczorowski, M., &  Kaczorowski, J. (2002). Ice cream evoked headaches (ICE-H) study: randomised trial of accelerated versus cautious ice cream eating regimen. BMJ: British Medical Journal, 325(7378), 1445-6.

2. Hulihan, J. (1997). Ice cream headache. BMJ: British Medical Journal, 314(7091), 1364.

3. Fuh, J., Wang, S., Lu, S.,  & Juang, K. (2003). Ice-cream headache--a large survey of 8359 adolescents. Cephalalgia, 23(10), 977-81.

4. Raskin NH, Kittle SC. Ice cream headache and orthostatic symptoms in patients with migraine. Headache 1976; 16:222–5.

5. Bird N, MacGregor A, Wilkinson MIP. Ice cream headache-site, duration, and relationship to migraine.  Headache 1992; 32:35–8.