#im at the point in my life when im unpacking the severe trauma that i grew up in so i have a lot to say and think about

[pipcoded]

is it weird that i don’t see the sexual assault/abuse I went through as a kid as the worst thing possible, like yeah it was bad and it shouldnt have ever happened, but like… i usually see this type of thing being perceived as causing you to be irreparably broken, and im not. And there were a lot of things that happened to me as a kid that i’d consider to be much worse

[smiggles]

This is gonna be abit of a mouthful, but I need to get it off my chest now that years have passed and we've (hopefully you have too) matured by now.

I once looked up to you, but that was a very long time ago. The trauma you caused me is irreversible. tbf I used to be a brat and if I could go back in time to backhand my younger self I would, I own up to that. But I was only a teenager, still growing and learning about myself and how to talk to others properly. Turns out I was pretty much autistic, so communication wasn't my strong point at all back then.

But even then, your two-faced behavior of proudly shitting on and bragging about how much money you were ripping off the furry community, the people who actively supported you, loved your work and paid your bills, was appalling. I had every right to call you out on it. Instead of accepting it was wrong, you sent your roommates out like attack dogs to fight your battles, defend your toxic behavior and harass me. Every time I blocked them they would find a different site to attack me on. I struggled to make friends for years after that incident, I felt I couldn't trust anyone because of what you guys did.

Years passed, and I genuinely hoped you had changed for the better, only to see a callout post during pride of all times, about your grossly acephobic attitude. I had friends who were blocked by you and didn't understand why. You need to understand your damaging actions have severe affects on real people, and when you make public apologies, the people who comment saying they forgive you don't count if they weren't the ones hurt by you. They don't speak for those affected.

I'm not looking for an apology, even if given one I probably wouldn't accept it after all the damage you've done to me. I have zero interest in you being in my life again. I just wanted to give you this perspective to get it off my chest and for you to mull on, I want you to use it to improve yourself as a person moving forward. See the wrong in your actions, how badly it affects others, and make the choice to make things right.

But that's up to you now.

Hey, I know who this is an I want you to know that I think about you often.

Read more below

Sometimes your stuff shows up on my feed or someone shares something with me that youve made because we have common interests and I think to myself Im glad theyre doing well and I hope youre surrounded by people who support you. I dont say this as a way to like Save face because this is a public anon. I would say this to you in private if I could. I was a very nasty person years and years ago and no apology will take back the pain Ive caused others from that. Especially not you. But I am sorry. I wish things could have been different. I do. For the acephobia. Yes. I was acephobic and horrible about it. I hurt a lot of people from that and cant ever take that back but know that Ive learned a lot about how to treat others and unpack the internalized hatred towards my own ace'ness and how others present themselves. I also want to say I never sent my roommates on you. That was a choice they did on their own without my knowledge. I never ever want someone to go after anyone on my behalf and while it is likely hard to believe that those who have known me these past 5-6 years can vouch that as true. I have on multiple occasions asked my friends to leave people alone I end up disagreeing with. I never name drop people I dont get along with. I dont even tell people besides my very very private close friends about what happened between me and you and that might be about 3 or 4 people at most. As for blocking? I block very liberally LOL and its almost never personal. I block people for the smallest things just to curate my social media experience. If you ever wanted to reconnect and try again Im here. And I have no hatred in my heart. I have held myself accountable all these years for things I should have done better. Handled softer. In the end Truly. Im glad youve made a beautiful career out of something you love and no matter what happens between us I hope you continue to thrive. With all my heart.

[isa-ah]

i'm just super nervous about asking about it because i know very little about it. but like idk it seems like a possibility i should explore, but I don't even know if the info i do have is true and i'm scared of barging into a space i don't belong

tbh its really hard to self identify a system by design. you have to consider what it is and why you have it- a dire means your brain takes to break off pieces of yourself to contain childhood trauma within so that you can still function baseline. its by definition something thats really hard to confront or grasp bc its all about repression and divvying up things that would make it difficult to impossible for you to function. this is called a covert system, and some systems Stay that way. theyre functional, either without defined alters, or with alters that stealth and keep things smoothed over.

that said, there are flags you can look for. when youre triggered, how do you process it? do you feel depersonalized? not like yourself, or even not able to reflect on what happened even if you felt cognizant AS it happened? some people black out entirely when an alter fronts, leaving black hole memory gaps, but for me its more of a grey out; like im aware as things happen but in retrospect my memory of it is VERY fuzzy or nonexistent. i know where the time went, but i cant remember anything specific about it. i also feel a bit like im being puppeted around, esp bc none of my alters communicate the same way i do. (ie bentley is pretty harsh w a thick twang, shy is nonverbal, arthur is deep voice king autism, etc).

in my experience, my system didnt become more overt until several years out from living with any of my family, and with only relatively shitty things going on in my life. i felt safe in my environment and so my brain settled in and began unpacking things that i had previously been too busy in a survival mentality to be able to handle. bentley kinda shambled forward after a few days of feeling really out of it and our relationship went from there. lo says he thinks my role in the system is as a protector (which makes sense ig) so it was really difficult for me to talk about it for a good couple months bc i felt like i needed to keep it hush hush to myself & safe. its VERY hard to reach a point of confidently proclaiming you have a system by virtue of it WANTING to be covert. having a support system of friends really made the difference for me, i think.

as far as getting in touch with yourself, there are a few things you can try; art has been a big way for my alters to express themselves through something i enjoy doing, so finding something to bond over could be good. journaling often, leaving up little notes for yourself, or maybe pulling threads you feel compelled to follow (clothes you wouldnt normally wear, a strikingly specific character design, a comfort xyz that you dont necessarily vibe with, specific music that makes your brain buzz) have also all been pretty noteworthy i think.

idk at the end of the day i think if you feel like you have some kind of disturbance like that, you probably do. it might not necessarily be alters, or a system, but trauma can have a really wide range of effects on your brain and theres a spectrum of ways it can manifest. if this one is compelling you to dig into it, then you should i think! its not like youre taking resources out of other peoples mouths, it really doesnt work like that.

anyway ive been typing for so long i dont remember if i had a good conclusive wrap up so! if you have any questions just lmk :->

[flyonthewallmedstudent]

Re-watching House as a Physician. Pilot Episode. Neurology in the young.

I’d actually recommend this as an exercise.  Re-watching this as a means to motivate studying. It’s truly terrible watching it. So much so, that you want to do it properly or throw shit at the TV. 

If I had students and we couldn’t physically see patients I’d probably tell them what episode to watch and we’d go through the cases together. Go through all the things the team does wrong. Then discuss the things you don’t know yourself.

Because that is actually how you learn best.  Recovering from your mistakes. Identifying gaps in knowledge. 

Unfortunately, all my current students are final years and they do have to see real patients. 

Opening episode: 29 year old female, no past medical history has expressive dysphasia then a first seizure.  How do we know it’s expressive dysphasia?

IN the episode, the patient notices she’s having trouble getting words out, and is able to write. Then has a seizure. Wilson actually has a good introductory statement here. House finds the case boring, this really isn’t boring. If it doesn’t excite a physician it should certainly terrify them. A la house of god, rule number X = Treat the dying young. With urgency. The majority of patients I see in IM are in their 70s-90s, have predictable issues like metabolic syndrome, heart failure, arrhythmias like atrial fibrillation, infections like community acquired pneumonia and dementia. These are my bread and butter. 

More often than not, my primary role is to ensure a dignified end of life care. Many of them come in already at death’s door or will be imminently there. To continue to push them through medical treatment when they no longer have resilience to go through them, is to prolong suffering. 

You can’t predict how someone young will respond even to the most aggressive of treatment. You give them every chance you have. OFten if the young are sick, it’s really bad. With the elderly, a common cold can make them really sick as their body is in decline. 

Young patients with a single organ system issue will usually go to a subspecialty.  Actually any medical subspecialty or IM in general is considered “diagnostic medicine”. It’s just different flavours of it. 

1st seizures: - it’s rare to have a second.  - usually the cause of underlying seizures is infection - follow-up is clinic with neurology. It’s rare to require further.  - we could go into differential seizures, but that’s a whole other post in itself

(Epilepsy only occurs if you have a number of them and this is rare)

In the case of House, they jump straight to cancer like webmd.

Before they do much, she jumps straight to radiation therapy. This is completely unrealistic. This sort of thing requires multidisciplinary teams to pour over all her results and discuss the best way forward. Chemo and radiotherapy are notorious in the general public for having crazy toxicities. For obvious reasons.

It’s weird re-watching these, where medicine is no longer a foreign language. Actually, it’s watching someone for whom English is a new language and they haven’t really gotten it yet. The tense and grammar are all wrong. 

I watched the Queens Gambit - holy fuck is chess a foreign world and language. I know the basics, but none of the strategies. Sicillian sounds like a great name for a tasty pizza. Or something else. 

Anyways, it takes a whole lot of time before they get to differentials. 

Honestly, you would be getting to these the minute you hear the presenting complaint. Then considering how to rule them in and out. For students, always have the surgical sieve in mind. 

Differential diagnosis of expressive dysphasia in a young woman are then addressed in the episode. here’s what they consider: - Aneurysm and stroke (haemorrhagic stroke in this case if we’re talking aneurysm), incidentally most common cause of berry aneurysms is high blood pressure. this is a decent consideration. but you would have seen it on imaging from the start. 

- CJD = very much mad zebra. I wouldn’t even suggest this. You would if it was rapid onset dementia or behvarioural changes and they came from high risk areas (eg ate burgers in the UK in the 1980s and 90s). But rapid meaning weeks to months. Not sudden onset within minutes. It’s more stroke.  - Cncephalopathy: requires an LP to go over this, and she doesn’t present with a fever either. regardless, important to consider. would always consider an LP in addition to imaging.  - Wernicke’s: only consider if they have a nutritional disorder like severe, chronic anorexia (which she doesn’t have) or heavy alcohol use. This is caused by thiamine/VitB1 deficiency. A thiamine level test takes days or weeks. We would never wait for a thiamine test to come back, you’d treat IV thiamine straightaway. I mean it’s vitamin B. This is a terrible differential to consider so near the top. She also doesn’t really have the other symptoms.

Then there’s the more obvious differentials they didn’t bother to consider: The greatest mimic for a stroke particularly in young women is migraine. You can have similar neurology, but it’s often associated with a headache.  If we wanted to chase zebras in the young, you could consider a PFO (holes in the heart that are congenitally there) and thromboemboli causing stroke. (In other words, you develop a clot, normally the lungs will pick up the clot like a filter before it gets to the brain. But the clot can bypass the lungs via holes in the heart and give you a stroke). This is always the consideration in cryptogenic strokes (in which you have a young patient without any reason for having an atheroma causing stroke). Risk factors for thromboemboli can include the oral contraceptive pill (estrogen can be thrombogenic) and then long periods of immobility, think long haul flights or trauma to the long bones or surgery. IN rare cases, those who had particular types of heart surgery as an infant, like a Fontan’s. But this is very niche mind you. And they’re often already on preventative therapy. Infection is a key thing to consider, where there are risk factors. she’s not immunosuppressed or done any exotic travel or eaten raw foods she shouldn’t have eaten (raw pork, bad sushi etc.). It’s a shame they didn’t mention it early. THere’s a few infections that go to the brain but you’d often have these in mind with the risk factors as stated before. THe imaging is often a giveaway

Learning point here - always eat cooked pork! Finally, cancer. But it’d be obvious on imaging if you’d already developed seizures or focal neurology, the lesions would already be large enough to pick up. the sad part to many brain tumours is that they’re already very large by the time of presentation. Beau Biden for instance, presented with acute confusion before his diagnosis, preceding that he had weakness and altered sensation (the lesion was likely too small at the time to be picked up on imaging and was diagnosed as a stroke). 

I would rarely be referred brain tumours, the emergency department will have scanned the brain and seen something that would prompt referral to the neurosurgeons. When you’re young and have a lesion/tumour, any team will try everything, including majority surgery, to salvage what life is left. it is very tragic. 

Anyway, stopping here. Already too much stuff to dissect and unpack from just the first episode alone. Note that I’m in IM, no doubt a neurologist or neurosurgeon will have different opinions on this episode. Ha. 

[ssfghfrrggf]

talk to me more about your tag saying something is up w Casey more than just Brett. bc I’ve got Casey as 100% having ptsd and probably depression/anxiety symptoms for like his entire life and I would love for his reaction to the whole sylvie situation not be him just being dumb but maybe having some sort of trauma/depression episode. And I honestly think that would be more in character of him than just fully not having the emotional intelligence to “fight” for sylvie. We’ve seen him outline what he wants in a relationship several times both to Gabby and Hallie and those relationships had their issues but I don’t think you can point to either of them and say Matt had it easy, that he didn’t have to chase or make a move. And to the note of trauma and relationships I think there’s plenty to unpack about dawsey that maybe borders the realm of more than just toxic but even if you don’t go there I think it’s pretty easy to see Matt’s reaction to sylvie bringing up gabby so suddenly as much more than having residual feelings. —literally don’t even bother reading that it just felt to get out lmao

Im kidding 😂 i got time and i have yet to write a Casey essay, so this is long over due, and i'll probably go off on some unrelated tangents.

First and foremost i'll explain what i meant by "there's more up with Matt than just whats going on with Brett." For the most part I can't really put my finger on it. I said this to my wife earlier: it's like the writers are dropping bread crumbs that something's wrong and I'm picking up on them dropping the crumbs but i can't find or place the actual crumbs? And i think that him having depression/anxiety/ptsd isn't really a stretch to say. He definitely has a very down feeling to him and he just seems off to me. He seems like he's feeling old and tired? When he was talking to Gallo at the end of last night's episode he just seemed heavy? Like the way he was talking and acting just made me feel heavy. I think maybe the job is starting to weigh on him more, and i think what Gallo did reminded him of or brought those feelings to the surface. He's lost three firefighters under his command, four if you count Jimmy. Losing any firefighter is detrimental hit, but when they're under your command and you're responsible for them it's that much worse. I think those losses (Andy, What's her name (that one girl candidate who's name i cant remember to save my life), Jimmy (in a way), and Otis) are really weighing on him and Gallo doing what he did made it worse because he's scared Gallo is going to get added to the list. That may be the root of the off feeling i got from him, but it seems like there's more. Idk. It's really hard to explain.

I think what Matt is doing with Brett i think both makes sense for him as a character and i think him giving her space isn't him being emotionally stunted or even being an idiot. I think it's respectful and the right thing to do. Sometimes when people say they need space THEY NEED SPACE and NOT for the person they want space from to keep pressuring them into being together!!! Like yes Matt needs to tell her how he feels, but i don't think he needs to do it right now. They both need to get their ducks in a row before they can be together and be together successfully. And think him not chasing down what he wants and not disregarding the needs and wants that Brett expressed to him actually shows a good bit of emotional maturity and I will die on that hill! The way he's handling himself over it probably isn't the best or healthiest, but the over all decision not to put pressure on Brett and quote not from you "go get his woman" is right.

I honestly find it refreshing. So many times in shows we get the guy who has been turned down being all like "oh, she doesn't know what she wants. But i know what she wants (it's me) so i'm gonna go get her!" So it's nice that we have him respecting what she wants and not trying to push that what he wants is also what's best for her. I'm beating this dead horse to death and i'm sorry but you gave me the perfect opportunity to word vomit all my pent up Matt feelings

On to the next point about this being very in tune with Matt's character. For a long time Matt has thrown himself into things and really shot for what he wanted and it hasn't really worked out for him. Hallie for example: they broke up because she didn't want kids. They got back together then Matt pushed for kids again and they broke up again. Then they got back together and he probably would've ended up pushing for kids again if she hadn't gotten killed. Now the same thing didn't happen with Gabby. And honestly i'm not really gonna go into that one because i don't feel like dealing with a bunch of angry Dawsey shippers, but i'll say this much: that relationship also ended with a lot of heart break for Matt. Like the guy has just had a really stinkin shitty time with serious relationships, and i honestly think it has him just a little bit traumatized. AND CAN WE REALLY BLAME HIM??? It is literally human nature like deep primal instinct to avoid things that hurt us. The stove is hot. You touch the hot stove. The hot stove burns you. You go YIKES! that hurt! Im not gonna touch the hot stove again! I think a similar thing has kind of happened with Matt. He's been hurt by all of his major relationships, and hurt pretty dang bad at that. For him serious relationships have become like a hot stove, and his answer to Brett's question about Gabby was him metaphorically avoiding touching the hot stove. He did a bit of self sabotage because he didn't want to get hurt again and you know fucking what? That's fucking understandable! And okay! Like fucking me too buddy!

Now ironically and honestly sadly he still ended up hurting himself in the process of trying to avoid opening himself up to potential hurt. We know he wants love and family, and it's what he deserves but he's had such a shitty time trying to get that, that i think its going to take a lot of time for him to open himself back up to trying. He also knows that if he were to start something with Sylvie it wouldn't be a fling. They have such a deep personal friendship that there's no way it could be. And he doesn't want it to be either and he doesn't want to be hurt again. So he's taking his time- he was buying himself time with that line about Gabby.

Looping back to the "Matt did the right thing in giving Sylvie space" dead horse. I think Matt has an understanding with Sylvie and what she's been through. She's also had a pretty crappy run with relationships. She's been engaged twice and hurt ample times. I think he gets that so he doesn't want to move in too soon and hurt her. I think her planting that kiss on him when he went to check on her took him by surprise then he got caught up in it. Then she asked him about Gabby and it got real and he panicked.

That was kind of all over the place and im sorry! But i had to let that all out! I also hope it made sense and hope it answered your question at least a little! I feel like i got kind of off topic there 😅

[ryollie]

really grateful for all the overwhelming nice messages from the ask game!! after some thought i decided to share why i keep disappearing for days and a bit about how my feelings work. i’ll put it under a cut because it’s personal and can contain triggering content!

i have borderline personality disorder, post-traumatic stress disorder and paranoid scizophrenia. unfortunately, bpd is genetic, my dad had it, and now i do. there’s a lot to unpack for bpd, but in short what i experience is mostly:

fear of abandonment

intense self-hatred and distorted self-image

very black/white thinking (”oh, i love this person, they’re great!” can become “fuck this person. i wish they were dead.”)

very unstable moods. sometimes i’m so happy and the next five minutes i’m very upset

bpd is very hard to handle in a relationship. and its really unfortunate that when i was 16, i got into a relationship with an adult who was extremely abusive, both physically and emotionally, and it worsened my bpd severely. i wont describe what happened in specifics but i developed ptsd and paranoid scizophrenia from it. i managed to leave this terrible relationship when i was 19, which is still quite recent (i turned 20 last november.) after i left, i was in one of the worst mental states i could’ve been in, i felt used and broken by my abuser, and i didn’t have a sense of identity anymore. i would flinch and have a full-on panic attack when someone raised their voice at me or accidentally hurt me (pushing me, a light hit etc.) to cope with a lot of the abuse i’ve been put through, my brain has simply decided that the only way to defend myself from bad situations in the future, as minor as they can be, is to lash out at others, saying hurtful things, and even physically hurting them so they’d leave me alone. this isnt acceptable behavior. i’ve been going to behavioral therapy to get better at managing my feelings and thought processes. i really cannot handle bad situations, even now. its ironic in a way, that they seem like completely minor issues compared to the things ive been through before but my brain doesnt think that way. i have a very set way in dealing with bad situations and it always ends up hurting other people and i never want that. i dont want to end up like my abuser just because i’ve been a victim. 

whenever something bad happens, i use all my mental energy to isolate myself from my friends, family, everyone, until the abusive, bad defense mechanism thoughts die off on its own. this is to ensure i wont act out onto it and hurt other people. during the period of isolation, i end up generating a lot of self-hatred for myself, like why am i so messed up, why am i like this, why am i feeling this way, why won’t it get better? so unfortunately, sometimes the self-hatred is overwhelming and i have episodes where i try to harm myself or even end my own life (depending on the severity of it) and i end up in the hospital too often for my liking. when i say im really exhausted, i mean it. im really tired that even isolation is so difficult, and i feel like im taking so many steps back when i relapse. i do take my medication, i do go for therapy, but its so difficult to undo the years of trauma he inflicted on me. replying to conversations require mental energy for me. so if i’m using all of it to isolate, i can’t reply quickly.

i wish i wasnt this way. i want to be a better me. so dont worry too much about the next time i disappear for a few days, im just isolating myself so i dont hurt other people. im really grateful for my best friends who understand my condition and give me space but still reminding me they care about me. i made this blog bc i was inspired by some artists in the fandom. i wanted to learn to live again and used my blog as a fresh starting point. i wanted to make friends. develop characters i made from my own hands. practice drawing until i get better. rlly little things that make a big change in my life. my life is really messy and i dont know what im really doing, but i hope my efforts in trying to make small changes to improve my life can make me happier in the long term. i really hope one day i can make it to the finish line, wherever that is.

[madefate-a]

don’t reblog !! / im gonna talk abt yennefer because i have THOUGHTS ( & also i love her. ) i’m just starting to make my way through the books so forgive me for misinformation but ?? i need to talk about the djinn and emotional maturity & yen’s very beautiful flaws, but also not her flaws. 

i’ll probably make a better and more coherent headcanon when i’m further into the books and it’s not one am, but apparently ?? her reaction to g eralt’s wish is somewhat more subdued in the books & if that’s the case that’s not ,, not really gonna fly with me. because i think her reaction in the show is incredibly important for a LOT of reasons, and she IS going to be angry whether or not it’s entirely justified. ( spoiler alert it’s like -- 50% justified. ) 

i think yen’s emotional maturity ( specifically: her lack thereof ) is fascinating. she has lived a long, long time and she still reacts to things as if the hurts she’s experienced are fresh wounds. which, in part, is understandable. her formative years were spent in worlds that dealt in usefulness: how much can you sell someone for? how much magic can you produce? how do you fit into someone’s view of what they want their life to be -- how do you make them fit? surviving in these systems meant living your life being used -- and using, in return. knowledge and power were always kept out of reach by the rigidity of this structure, and agency was always just out of reach. every time she had achieved something -- it was almost always given to her or taken away by the whim of someone else, someone outside of her reach and her control. 

the changes to her body were, as we see, a hurt she has been nursing for decades. because it was traumatizing, and it was a decision made in an environment that did not encourage healthy, informed decision making. it was her choice but it’s incredibly difficult to say how much her choice was influenced by her desperation to ascend, to live. to claim something for herself -- to make something of her life, to force open a door of opportunity that was quickly closing shut. 

but for a long time yen never grows out of this desperate, power hungry mindset. we see her making her own choices for at least two or three decades -- breaking away from the brotherhood and the courts using her and her power, setting out on her own, forming relationships through her own will. she’s regained some agency long enough to start healing from the trauma she’s experienced and she -- doesn’t. she chooses, instead of the difficult work of working on the things in your control ( you can’t change the world and the things you’ve suffered, but you can choose how you live your life ) she wants more, more, more, and is fairly severely triggered by not getting what she wants. lifetimes pass and she is always terrified of everything being taken away, even though she has had the power and freedom to prevent that from happening for a long time. 

her reaction to geralt’s wish is this very complicated mess of: her deeply set trigger of being controlled; her simpler, purer feeling of betrayal; her shame and regret at feeling as if she’s been made a fool; her vindication that of course she was right, of course you can’t have any trust in this world because it is cruel, just as she thought it was; her stubbornness and fear at having to change her perspective on life -- because seeing things as black and white, good or bad, is much easier than seeing things as nuanced, individual actions. 

( * EDIT: an important note i forgot is that part of that shame and regret comes from feeling as if she’s been violated emotionally. she’s grown accustomed to people wanting her body and her power, and using herself physically to either survive, or get what she wants. but the times we see her confronted with her emotions being betrayed -- istredd, geralt’s wish -- are the times we see her sad, angry, and looking for any way to deflect. ) 

in reality, a wish intertwining her fate with geralt’s is a violation of agency -- but it also arose from her misguided, near-fatal attempt to get what she wanted. ... which stemmed from her coerced and hasty decision to remove her womb. ... which stemmed from wanting what she was promised! ... which stemmed from being sold to a new life that she knew nothing about to the point of absolute desolation. it’s complicated, and until that point, yen would much rather blow off complicated than do the work of unpacking it and coming to terms with it. 

it’s not until the battle of sodden that yennefer actually begins to grow. she finds purposes, and finds a way to use both restrained and uncontrolled power to do something larger than herself, and i think she’s going to find fulfillment in exercising her power, magical or otherwise, for others. but her anger at geralt is real and present, and something that will only fade with honest communication and genuine introspection. 

[flyonthewallmedstudent]

Watching House as a Physician.  Season 2 Episode 3. Infectious diseases & Respiratory.

Welcome to another episode of medicine done badly.  I’ve been watching House on Amazon prime.  Got the subscription during the pandemic, as like everyone else, I’ve garnered an online shopping habit now. 

Alright. In the opening scene a young roof worker falls off the roof presumably due to acute shortness of breath. i.e. trouble breathing. (why do we use the term shortness of breath? it’s the english version of the greek term dyspnoea - the actual preferred language of Western doctors. Fuck do I know why we like Greek and Latin so much. Moving on.) Then cut to Dr. Cuddy examining him in the back of the ambulance. 

This would never happen in real life. Yes you can be on the scene and handover to the paramedics or EMT when they arrive as a doctor. But they would take over. I personally wouldn’t have the balls to look after a patient in a different environment, different resources and field I’m not familiar with. You can have field Emergency docs - but requires different training. 

Also, ethically, you’re not meant to treat family or friends. Dr. Cuddy later in the episode gets a bit emotionally involved - this is why we don’t treat people close to us. We lose objectivity. We make mistakes. And you see later see Cuddy do some pretty bad ones. 

I feel like much of this episode is not really IM. THere’s less differential diagnoses being made. More side tracks into trauma, emergency, intensive care or vascular surgery. 

Anyhoo. Trauma and emergency would manage the fall and post fall traumatic injuries. And the trauma protocol was either not shown or completely off in this episode. Surgeons don’t seem to exist in House, at least not very much. Similarly, no other doctors exist except surgeons in Grey’s anatomy.  Also you can’t clear a C Spine clinically, which is what Dr. Cuddy does in the back of the ambulance. You’d need a CT first and clearance both radiological (by a radiologist) and a clinician. 

Aaaanddd, you can’t just listen to the chest and go no pneumothorax (air in lung or collapsed lung) - yes it’s reassuring, but again you’d need imaging to confirm this, given how serious a condition this is. It is realistic to consider in the setting of a fall, particularly if there are rib fractures that can puncture the lung.

Once the more critical injuries are managed, we would look after the IM side to things. 

So. Finally.. differential diagnoses.

Takes what seems and feels like days before they finally sit down and go through differentials. Really not much on that white board. Dark fingers, broken ribs, fever and lung infiltrates. Time line’s not clear on when he developed the fever.

Presenting complaint isn’t really addressed. It could be: - Dyspnoea, leading to the fall, he’s requiring O2 via nasal prongs, which suggests that he’s hypoxic (this is definitely odd in a young guy who’s normally very physical fit if he works as labourer). so much to unpack here, but they never get into this well.  Post fall, Cuddy notices his ring and pinky finger becoming dusky, which becomes very central in this episode. Very few things would cause this. pains me that they do no differentials on a white board for this alone. 

Then a lot of throwing around medical terms. 

PTT prolonged and Fibrinogen off. These are markers of your coagulation pathway and signs that you’re not forming the clots the way you should if you have an injury.  DIC is also thrown around. What is DIC? Disseminated intravascular coagulopathy. Certainly severe sepsis and trauma can cause this and lead to severe bleeding. It will throw off your coagulation pathways (things that stop bleeding). It’s not common. I’ve treated it once, while I was rotating in ICU, it is not standard ward medicine practice. Standard therapy is fresh frozen plasma (FFP) and even large metropolitan hospitals only have a limited supply. It’s a huge concern for surgery and post-op (as you patient will just not stop bleeding after you cut them open, and if not treated, potentially bleed to death). Cuddy mentions ARDS. Acute respiratory distress syndrome, it could be a complication, but it’s not a cause. Again, falls more into the realm of critical care (a la ICU). However, patient had SOB prior to the fall. Finally HOuse makes the observation. of “what if he was sick before he had his run in with gravity...” Everyone jumps to Pneumonia. And this is where it gets confusing.  If he was unwell, the minute he entered the emergency department with a fever and hypoxia, they would have worked him up for any garden variety pneumonia, bacterial or viral. Cultures would have been sent and imaging. Any young hypoxic patient would prompt a closer look at the chest. And no one waits that long to start antibiotics - “sepsis kills” is a slogan often used around hospitals. You have to initiate empirical therapy within 30 mins, to reduce mortality and morbiditiy. 

Ordering an Echocardiogram (USS of the Heart) also makes no sense in the context of a lung infection. I would order one, but not to look at the lungs.

Then there’s the most unrealistic thing about this series. Doctors breaking into patient homes.

It is however, a good way to showcase social history. It’d be boring to watch a doctor ask the patient outright about their living situation etc, but it’s far more interesting to see exactly how they live. We try as much as possible to illustrate to each other and ourselves what the living environment and working environment of our patients are like. 

In the context of infection, a good social history can point out exposure. As they exemplify by showing dead rodents and mould. This leads to 2 further differentials: Rat bite fever (caused by streptobacillus, something you’d see in the US, but probably not anywhere else), it’s an unrealistic differential in general. And the 2nd is aspergillosis.  Okay..  So aspergillus is a mould commonly found in our environment. In fact it’s everywhere around us. 

THere’s few times when it’s an issue.  It is a concern in respiratory syndromes like asthma or bronchiectasis. And also as an opportunistic infection in immunocompromised individuals. in the context of asthma, it’s not so much the aspergillus itself that causes issue, it’s our body’s over reaction. It’s a hypersensitivity issue that causes inflammation in the lungs or a pneumonitis. We even gave it a name. Allergic bronchopulmonary aspergillosis. It’s still badness, but it doesn’t happen that quickly. We also have specific tests for this, which were obviously not considered in this episode of medicine done badly. In the immunocompromised host (steroid therapy in transplant patients or those on chemo, etc.), you can get the invasive mould as an opportunistic infection.  I don’t really understand why they think it would be the case here. Also, killing the bug with heavy duty anti fungals will only give more issues rather than do anything. They start him on amphotericin. this is not standard practice.  And now it flips to why amphotericin is not standard practice or first line treatment for invasive aspergillosis. The patient has now become anuric (not making any urine). (First line drug by the way is voraconazole, superior efficacy in trials with a lower mortality rate and ADRs) Also, note that they have just jumped straight to dire renal failure from the amphotericin. No work up. That said, heavy drugs like amphotericin are often a cause, but  It’s often temporary with the appropriate supportive measures (stop insulting agents, give hydration, monitor fluid balance), reversible, even if you require temporary dialysis or haemofiltration. Anyways, would get into AKI another day, that’s a whole other post in and of itself.  Then his hand is apparently “dying.” There’s pain on light touch, but it’s not a cold, pulseless limb. Or discoloured. doesn’t add up. This now enters vascular surgeon territory. Again. It’s interesting that there’s never any referrals to any other teams. If he has good circulation, I would imagine they would try to save the hand and consider other differentials. 

The only time I can think of an emergency amputation in this situation is necrotising fascitiis. That’s the only thing that would occur that rapidly  AND necessitate losing tissue or limb.  With a young person who’s this ill, there’s often multiple subspecialties involved by this point. I’m also surprised he’s not in ICU.

Then there’s a buncha filler scenes of the cast of house getting emotional. Ho my god, they’ve taken the hand of a young 20 something physical labourer. Indeed, this is badness. Unlike House, we actually are trained to always consider how a patient’s illness impacts their activities of daily living and livelihood. 

I find the general population assumes that we practice medicine in a vacuum, we merely treat the clinical illness and ignore everything else. They imagine that we all must be like house. 

Actually we try to put things in perspective as much as possible and knowing our limitations in this area, we often enlist the help of friends - physiotherapists, occupational therapists and social workers. They never exist on TV or on the movies. Ever. Unless it’s to portray how terrible it is to be a social worker.  From time to time in this episode, Cuddy laments that being chief of medicine is too administrative and she hasn’t been a doctor in years. That also doesn’t happen in real life. If you’re chief you’re still a doctor. You have admin shit to do deal with yes, but you still practice. It’s like being chief resident, in all the TV shows with one of these, you still seem them working as residents, be it scrubs or grey’s anatomy. 

Back to the differential. They finally get to endocarditis. Culture negative to be precise. That indeed would explain the bilateral dusky fingers that led to unnecessary amputation. Septic emboli. 

Going to stop here, more out of exhaustion now. I’ve created quite a lengthy post. Happy to reblog thoughts on culture negative endocarditis on request later. This is a worthy topic to study up on for students or residents. At least review Duke’s criteria and think about your clinical features like Roth Spots and Janeway lesions or Ouch Osler’s nodes. 

The ending is also a far fetched connection to make, but is one that we would consider. In fact, we would ask in detail every time from day one - have you had any exposure to animals. It’s very rare to see someone so young be that sick out of the blue when you’re immunocompetent and have no underlying predisposing conditions. If there’s no focal source, then we would even ask about injectable recreational drugs, exotic travels, sexual health. 

Most of the time, patients that sick are honest to their doctors. 

But what about..

Frankly, much as we lie as humans, when our lives our on the line, we’re generally pretty honest (sometimes too honest) with the people we want to save us. 

Any patient who is young and comes to hospital requiring inpatient admission, they’d be investigated by subspecialties with expertise in certain areas such as infectious disease. The dept of infectious disease would either be home team, or all over this patient as they special in the realm of both common and rare infectious diseases, culture negative endocarditis would have been considered before a hand amputation.

The term, “department of diagnostic medicine is laughable,” particularly when they consider it the only department in the world in the show. 

In actuality, it’s a department that is universal and exists everywhere. it’s Internal medicine. Dr. Vivek Murthy, the next surgeon general (and also the last one under Obama) is an internal medicine physician. Ken Jeong of Community and the Hangover fame is also a physician of internal medicine. 

Beginning to get the sense that most episodes are going to end with a diagnosis that is either infectious disease, rheumatology or haematology. But generally those tend to be most interesting and give the most plot twists or meaty differentials V.s. a stroke or acute myocardial infarction is fairly straightforward to diagnose. 

This is a very twisty episode in all the wrong directions. 

Dyspnoea is a very common presenting complaint. There’s a properly done approach to this in the podcast by the Curbsiders by the way.