A Trauma Story
The type of Emergency Medicine story that gets your heart racing. (Also got a nice kick out of him linking to MDCalc for the Parkland Formula.)
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The type of Emergency Medicine story that gets your heart racing. (Also got a nice kick out of him linking to MDCalc for the Parkland Formula.)
(If you’re squeamish, this isn’t the post for you.) There’s a total RIBBFOMP story and photo over at White Coat Rants, hand versus snowblower. If you’ve always wondered what the tendons look like that allow your fingers to flex and extend, but never wanted to take the anatomy class, there’s a perfect specimen in the post. Wow.
A good stepwise process, for future reference in residency, from a lecture today in Family Medicine. This applies to both deaths and bad news in terms of studies, lab results, etc. (It’s also often a good idea to have the social worker or chaplain with you if you can.)
Shadowfax finds a kidney stone in a “known drug seeker” and treats her with toradol. Success. I had a somewhat similar case with a “known homeless drunk” who had pretty severe electrolyte derangements after I bothered to check, despite nurse balking. Only re-iterates the point: trust no one.
In two common infections of the vagina, bacterial vaginosis (and sometimes in trichomonas vaginalis) your doctor may do a “whiff” test, where he or she takes some discharge, drops some potassium hydroxide on it (a base, KOH) and smells it for a fishy, foul odor. The base causes some foul-smelling amines to be released: cadaverine and putrescine. What great names.
Interestingly, some women will complain of foul odor after intercourse, and the reaction is the same: semen is basic, and when it mixes with the discharge, you get the same release of cadaverine and putrescine. Cool.
Flea (RIP) used to talk about the medicalization of childhood–that kids don’t just run the spectrum of normal variation, that everything nowadays has to be a diagnosis or a pathology that requires treatment. I’ve started to come across the same thing in pregnancy.
There’s this strange phenomenon that several of the docs, nurses, and assistants have commented on–that women will come in, having missed their periods, taken several at-home pregnancy tests, all positive, and still want or need the doctor to “deem them” pregnant. (Plus often a number of the pregnancy changes: nausea, vomitting, breast tenderness, bleeding gums, etc.) Just seems strange that in some ways we’re so out of touch with our bodies–or at least the “natural” changes of them–that we need some “authority on bodies” (doctors) to concur with our own diagnosis.
I guess you can take this a step further and apply it to a lot of common complaints: a weird twitch somewhere, a strange sensation. In some ways it makes sense–you see plenty of patients who wait too long before they see a doctor for what turns out to be a heart attack, or cancer, or stroke, or out of control diabetes–and you wonder how they could possibly have waited so long. And on the other hand, you have people coming in for weird aches and feelings that are just typical, natural weirdness of our bodies.
Sometimes I wonder if a lot of the extremes are due to the break up of the extended family, and the more migratory lives of people. Had a newly-pregnant woman been living with her parents or grandparents, the mothers would just immediately recognize, “Duh, you’re pregnant.” Likewise, the guy who looks green and is clutching is chest might be convinced to seek medical care if his family members urge him to.
Started Family Medicine this week (my last clerkship!) and very much agree with the philosophy, probably more than the Internal Medicine approach: that you must take the patient in context. That much of what we consider “health” doesn’t fit within the conventional boundaries of medicine, and that a person’s environment greatly affects his or her health. A couple of thoughts from the introductory lectures, one by a patient advocate on Advance (not Advanced!) Directives:
And finally, via the wonderful Gooznews:
If you ever had any interest in knowing what Violet the Vulva looked like from my standardized patient encounter last month, look no further. Tyra Banks and guest doctor provide said puppet, and an educational lesson to boot!
My own ED is blogging? How did I not know this? Straight Talk from the Stanford ED: go Cardinal. Maybe people will realize we see more than just horse accidents down at the Farm.
This is a post about immigration from an obstetric point of view.
I’ve seen (and delivered) a number of 1st generation immigrants over the past several weeks, and come to understand the immigration debate from a totally new point of view: governments, laws, and artificial borders versus the human spirit.
I have no idea if these women I saw were here legally or not–I know that any woman in active labor must be cared for by EMTALA law, but most of the women I saw had some degree of previous prenatal care, even if it was late. I probably used to know the policy and laws of insurance and everything, but my brain had to delete those to make room for the plethora of OB-Gyn facts I’ve been cramming in there recently.
I was most amazed by a woman at 39 weeks who arrived in this country 7 weeks ago from El Salvador. That means at 32 weeks of pregnancy, less than 2 months from delivering, she somehow got here, speaking little to no English. I wanted to ask her how she arrived–plane? boat? bus? pickup truck? walking?–but she was a little too ready to push, we were a little too busy, my Spanish is a little too poor, and it’s really none of my business.
I wondered what would drive these women to take such risks, even if they were here legally–move here while they were gigantically pregnant, picking up and leaving their families, support systems, jobs, houses, clothing, speaking almost no English–and it’s the human spirit and the maternal instinct. It’s the same thing that all of us want for our children and loved ones: a safe, solid place to grow up with access to education, health care, and jobs. It’s done out of love.
So many of our fairy tales, movies, and stories focus on this theme that I find it interesting there’s often such vitriol and hatred in the immigration debate. We love stories where the individual wins, love triumphs, often against all odds, but somehow, these immigrants, who seem to want the same things we all want–are different.
I guess the point of this post is that we can spend waste as much money as we want on borders and laws and regulations and security cameras, but the human spirit is so dedicated–exponentially so when you throw in the maternal instinct–that it seems like we’re almost trying to stop the inevitable.
If we want to prevent people from other countries from coming to ours to make a better life (and most of us “Americans” ended up here because our immigrant ancestors felt the same way), maybe money would be better spent trying to help other countries to better their own citizens’ lives.
(I’m well aware that the immigration debate is a hot topic and incredibly complex; I do not claim to be a scholar on the subject, just one man with a perspective I don’t often hear in the debate.)
Bonus perk to OB and L&D, besides the happy-happy joy-joy stuff and everyone’s in a good mood and telling a patient “Congratulations” gains you instant rapport with them: some of the best ice to chew on can be found in the L&D and post-partum floors. As an avid ice cruncher, good ice makes all the difference.
Still first place ice in my heart: my grandmother’s old nursing home (but this will likely always be number one, as me getting my grandmother ice was one way I felt like I could make her feel better).
I was just working with Dr. Druzin yesterday in our perinatal diagnostic center, observing amniocenteses and interpreting fetal strips with him, and today I see him quoted in the WSJ Health Blog about fetal heart tracings. Pretty cool.
Before my week on Labor and Delivery (affectionately known as “L&D”), thoughts danced through my head about what I’d be blogging about. Joyous, momentous, wondrous times delivering new humans into the world, tears falling from everyone’s eyes; laughter and hugs and happiness and rainbows and unicorns.
But no no, dear readers, no rainbows radiated from any of my patients’ vaginas. In fact, I felt very little happiness at all. I’ve come to realize that there’s one particular emotion that beats out happiness, joy, excitement, and all that sweetness. And that would be fear.
Now I will be the first to admit that my first observed delivery (the “see one” in the see-one-do-one-teach-one methodology) was crazy happy. It went smoothly, I had been checking up on mom and dad and gotten to know them as well as one can. Tears happily left my eyes as the intern delivered the baby, the woman sighed with relief, and the father, so overwhelmed, didn’t feel as ready to cut the cord as he thought he would. It was a beautiful, amazing, emotional time, and I just wanted to hug everyone in the room.
My first delivery, however, remains firmly under the category “Oh Crap/Fear.”
Baby delivery is not, in a word, pretty. In fact, it is, in a word, ugly. Messy. Dirty. Gross. (And even grosser but somewhat more normalizing to realize we all had to go through the process.) I don’t care what health video you saw in high school, but it clearly digitally-removed most of the blood, fluid, and poop that ends up under the woman pushing. It is not a pleasant affair. From a purely physical perspective, you have a woman pushing a bowling pin through a nostril, and in the process, blood is sliming or gushing out; amniotic fluid (clearish with specs of white floating in it) is seeping out as well. And because she’s pushing so hard, often she’s pooping accidentally at the same time. This wonderful mixture is sometimes accompanied by one more wonderful substance, baby poop (often a sign of stress in the womb), which is sometimes thick and tarry, sometimes clumpy, always disgusting. Luckily I like disgusting, or at least don’t mind it. (It’s a dominant trait, inherited clearly through my mother, who loves popping zits and whiteheads and such.)
And this is only a few minutes around the time of birth. The rest of the time you’re just checking on the woman, seeing how far she has to go before her cervix is fully opened and ready to let the baby out. You check her every 2 hours or so.
For clarification, medicine doesn’t scare me easily. I find almost all of medicine somewhere on the scale between “interesting” and “awesome,” but boy does human-sticking-out-of-another-human freak me out. It’s almost a hypersensitive version of my pediatrics rotation: scared to death that by holding an infant wrong, its head might pop off. So you’re standing there, encouraging your patient to push push PUSH! your other patient out, and everyone else is in there encouraging and yelling too, and then the head gets closer and closer to OUT with every PUSH. You’ve got one hand below the vagina, trying to help support and stretch it out safely, and another head above the vagina, trying to keep the baby’s head flexed toward its chest. And then with the next push, the baby’s head finally makes it out, and then the gush of fluids starts. It’s like a suction cup came off a wall. Everything happens so quickly. You get the head out, push DOWN to get the top shoulder out, rock back UP to get the bottom shoulder out, and the little thing FLIES right out at you! Some clearly insane or memory-deficient person described his first delivery of medical school as “one of the happiest times of his med school career,” but I’m here to tell you, it’s anything but. No happiness chemicals come surging out from your body. No no, dear friends, those would be the chemicals of pure terror.
Mother Nature, in all of her infinite wisdom, forgot to add a gripping pad for babies. They squirm and scream, covered in slimy, slippery goop, and you’re asked to grab hold with one arm, while using the second for various other tasks like suctioning, clamping, scissoring–not the easiest task in the world. In fact, I think my favorite part of the delivery was handing the baby off to mom’s belly. “Here, you hold onto him, he’s your responsibility now!”
Then you think, “Wow, I did it, I just delivered a baby!” only in time for you to try to get the placenta out. You clamp the cord and slowly put traction on the cord, ask the mom to push, and push on her uterus until the placenta comes loose, and you get hit with a second wave of blood. The placenta is this gigantic purple pancake-like thing. It’s freaky-looking.
So that’s the baby-delivering process. The scariest parts are when the baby isn’t coming out, and everyone’s yelling at the mom, “Come on, you HAVE TO PUSH! Harder!” and things aren’t moving. Sometimes you have to get out a vacuum, sometimes you have to use forceps, and the baby’s heart rate is going down, and it’s pretty scary and touch-and-go. But then the baby comes out, and everything’s better. A sigh of relief. (I haven’t seen an emergency c-section yet, but I can imagine it being pretty scary as well.)
I always try to remind myself that we all went through this; that women have been delivering by themselves for centuries; that in most cases they did just fine without us doctors medical-izing everything. But that doesn’t mean that your heart doesn’t skip a beat when things aren’t going as planned. L&D isn’t something I could see myself doing, but I’m glad we have men and women who do it–every so often you find a baby or a mother who need medical and surgical care, where delivering at home would be dangerous–especially with new reproductive technologies and supportive care are allowing many women to get pregnant who even 10 years ago wouldn’t.
Lesson 573: Just because your patient is named “Betsy” or “Kelly” does not mean she speaks English. You will look less stupid if you ask first, instead of rapidly explaining her pap smear and ultrasound results in English for two minutes, only for her to finally get up the courage to interrupt you. That is all.
(Also, “discharge” in Spanish is “secreción” or “reflujo.”)
According to my patient Virginia:
Write a book about sex for older people! I’m comfortable talking about it, but most of us aren’t, but we should be–we have so many questions!
(Of course right after I post about patients not wanting to see a male student, Virginia was incredibly warm and welcoming, totally open to talking about everything.)
(Of course right after Virginia I was politely asked to leave by the next patient.)
I’m sure my male classmates will back me up on this one: I swear, every time I knock on a door, open it and say hello, I get a little look of awkwardness and discomfort from my patients. It’s a mix of surprise, disappointment and disapproval. Only once has a patient said, “Wow, great, a male in the field, you don’t really see that very often anymore!” Maybe I’m over calling it, and some of it is just made up in my head, a product of my own insecurity with the exam–but I swear it’s there at least half of the time.
In some ways, it makes me try harder, which I guess is a good thing. I try to be even more respectful and caring; I try to make even more outward shows of compassion than I do already. Empathize, use normalizing statements (“I ask all my patients about their reproductive and sexual health,” “This is an incredibly common problem among women, even if it’s not discussed very often in public,” etc.). I realize the exam puts a person in an incredibly vulnerable situation, and it probably doesn’t help that I’m a young man and that many of my patients are my age or younger. I also realize this may be the first time a male physician has seen their genitalia since before puberty (or any male unless they’ve been in a relationship with one), but I feel like the look still exists in many of my older patients as well.
I realize all of this, but still. It’s discouraging and frustrating. I’m not present to make my patients feel uncomfortable. If I could somehow learn everything I need to learn without making anyone uneasy I would, but I can’t. Unlike many other fields of medicine where you’ll never do another pelvic exam in your life, I actually need to know how to perform them adequately as a future Emergency Medicine physician.
For the most part, I’ve actually been enjoying my rotation thus far, but it’s been the first and only where I’ve felt so actively discouraged by patients. Usually my upbeat attitude and smile engender (no pun intended) some points from the patient, but during the past three weeks most of what I detect is disappointment. The nurses and attendings have been absolutely positive, enthusiastic, and encouraging, which has been immensely helpful, but I think I’ve discovered another reason why OB-Gyn is such a woman-dominated field.
(This is not a boo-hoo, woe is me post, just an observation I’ve made. I wouldn’t be surprised if it’s just as awkward–if not worse–for my female colleagues when examining men. It’s not the end of the world, and is a minor annoyance at best: I’m professional, get the job done, ask the questions that need to be asked, and do my best. This is what defines medicine as a profession: we put our patients’ needs and concerns ahead of our own. This does not, of course, mean that we as professionals are not affected by these situations, just that we work past them.)
Margaret Cho has this great bit about her experience with hematuria, and finally it is somewhat relevant enough to post! (I have no idea who she saw that employs a “vagina washer,” but maybe that’s how it works in the private OB-Gyn world. Who knows.)
A friend just told me about a co-worker who smoked throughout her pregnancy but when offered an epidural during labor she initially declined, citing that “she didn’t want to hurt the baby.” (She later accepted the epidural.) Her child did well without complications, weighing a healthy 8 pounds. (Let’s just hope the child is a miracle baby, and doesn’t develop asthma from mom’s continued smoking.)
Nice mnemonic for the phases of puberty / sexual development in girls:
Boobs, pubes, grow and flow. (In medical lingo that’s thelarche, adrenarche, growth spurt, and menarche.)
A psychologist in New Mexico has found variation in strippers’ incomes based on their menstrual cycle: lower average incomes while menstruating, and higher average incomes while ovulating. Women on birth control pills had no variation in their incomes.
This of course led my OB-Gyn resident to suggest an IUD–they’ll earn more money but won’t get pregnant!
During my OB-Gyn rotation, I’ve been working with the great staff of our local Planned Parenthood, and let me just say: Planned Parenthood rocks.
I will admit, fully ignorant of Planned Parenthood beforehand, I thought I’d be doing abortion evaluations. Planned Parenthood equals abortions. That was the extent of my knowledge. I spoke with friends–well-educated, public health-type friends, and that was their same response. “So, did you do any abortions today?”
I was so far, far off base it’s not even funny.* In fact, it may sound ironic, but I’m pretty confident when I say this: No matter what your feelings are about the subject, there would be more abortions performed in this country if Planned Parenthood didn’t exist. Let me explain.
The patients I’ve seen have been, in general, young, healthy women, ages 12 to 26. They come in primarily for three things:
I see patients of all socio-economic statuses, but most are immigrants or lower-middle class women. Their health knowledge runs the gamut, from the highly educated 12 year-old I saw today, who curiously asked “how exactly do the birth control pills work?” to the 23 year-old who shrugs and answers questions with a dull, empty look on her face. Almost every single one uses some form of birth control.
This makes sense. Over 90% of women of childbearing age use some sort of contraception method. I quickly became aware that my male gender has allowed me to pass through medical school (and life!) totally ignorant of all of this. My patients came in using almost everything–condoms, the pill, the patch, Nuvaring, Depo–and I was left perplexed. What a humbling role reversal–this was one of the first times it’s been so painfully obvious that my patients are more informed about their health and medicines than me. (This also made me realize that I generally assume I generally know more about medicine than my patients.) Not that the pharmacology or physiology is at all complex or difficult–just that the topics had never really come up before. Birth control was birth control was birth control.
I’ve been having a fantastic time at Planned Parenthood–I’m able to perform a number of pelvic exams and get a good sampling of “normal variation,” and probably the harder part–I’m able to talk very candidly with my patients about their sexual health. It’s great practice just to get used to figuring out how to talk about “sexual activity” and “sexual intercourse,” because it certainly takes practice. You have to unlearn (or at least disengage) the typical social cues in your head that encourage you to avoid the subject or the word, especially since almost none of my patients have had any complaints or concerns with their sexual health. It’s great to see patients in an environment where discussing sexual health is the norm, as it also helps bring a level of normalcy to the encounter.
We give out a ton of contraceptives every day. Condoms, pills, patches, rings, shots. And none of the patients I’ve seen are taking these medications for anything other than preventing pregnancy. They are sexually active, almost always with one, monogamous partner, and they do not want to get pregnant. And by enrolling these largely uninsured teens and young women in California’s Family PACT program, we’re able to provide them with free contraceptives and reproductive health services.
55% of pregnancies in the US are unintended, and of these, 43% are live births, 43% are terminated electively, and 13% end in miscarriage.
All the women I see in clinic are sexually active. And most are working or middle class at best by income standards (the average 2 bedroom apartment in the area runs you at least $1400 a month), most are uninsured, and most do not have another source of medical or reproductive care. And none want to get pregnant.
Now just take away Planned Parenthood, add in the costs to see a health care provider and pay for contraceptives, and imagine how many more of my patients would become pregnant. Keeping everything else the same, you’d find many more women in the difficult position of considering an elective termination of pregnancy.
I am far from zealot or activist–as I said before, I knew nothing before a few weeks ago–but I’ve been incredibly impressed with my short time there, and I’m hoping I’ve educated you as to what Planned Parenthood does in your community, since I was woefully ignorant myself.
*Planned Parenthood provides reproductive health services, annual female gynecologic evaluations, breast exams, pap smears (and management and followup of abnormal pap smears), the HPV vaccine, STI testing including HIV, emergency contraception, vasectomies, patient education–the list goes on and on.
The dreaded standardized patient pelvic exam was much less dreaded this time around. In contrast to Boobies, written three and a half years ago (seems much longer than that), the breast, genital, and rectal exams are no longer cause for alarm for me. They’re no longer mysterious, frightening territories full of stigma and social awkwardness, amazingly.
Six weeks of OB-Gyn started with a refresher on the female pelvic exam–which was greatly appreciated–and the nervousness I’d previously felt with prior genital exams just wasn’t there. I kept searching for it internally, waiting, expecting at some point to become shaky, laughing as to reveal my discomfort, but it never really happened. Maybe it was that the “patient educator” was a nurse practitioner, and so I felt more comfortable with another health care professional–that this was strictly education, passing information from one generation to another. Maybe it was her 2 foot long, plush, purple model of the female anatomy (Violet the Vulva, of course) that broke the awkwardness. I’m not really sure.
More than anything, I think, it’s just my level of maturity and comfort with patients. It’s a part of the exam that needs to be done for certain complaints, and I need to know how to do it. Step up to the plate, assume the responsibility, and get it done. It’s this new-found attitude and outlook–rapidly advancing especially during last month’s sub-internship–that I think is making me a more assertive, competent medical student (soon-to-be-physician). It’s this same outlook that probably also makes physicians sometimes appear cold or impatient to our patients. While we’re trained to always be emotionally, mentally, and physically ready to perform a potentially emotionally, mentally, and physically uncomfortable portion of the exam, patients aren’t. They often want and need time to “get ready” for it, especially when it’s unexpected. (Sometimes that time isn’t readily available.)
The attitude overall, however, probably makes the exam less awkward. Projecting confidence and normalcy to the exam–that you’ve done it many times, and that it’s pretty much standard operating procedures–helps alleviate some of the potential anxiety a patient may feel. Communication is key. I find using medical terminology to be helpful–asking patients to move their “buttocks” toward the end of the bed, instead of their “butt” just makes it at least sound much more objective–that I am simply the doctor asking a female patient to do something, nothing more. Telling the patient beforehand what will happen, and explaining what he or she may feel helps, too. Body language I think is also key. I often close my eyes and lower my head when listening to heart sounds to help me concentrate on them, but I believe it has the added benefit of ensuring patients that I am touching them for medical purposes only. You never know what prior experiences a patient has had that may make them uncomfortable.
It’s fun to go back and read old blog entries–one of the reasons I’m thrilled I’ve documented this experience–to see where I’ve been, and where I think I may be headed. (Oh, and by the way, Boobies still gets a ridiculous number of hits–it’s listed on the 14th page of Google search results for the word. I can’t possibly imagine what people are actually looking for.)
The rumors of my demise have been greatly exaggerated, even though my first night of call as a sub-intern was incredibly, incredibly painful. It’s scary to actually admit it, but I… kind of enjoyed my Internal Medicine sub-internship. Yes, I know, this is crazy talk, especially having found my prior medicine months a bit slow, but the constant hypervigilance required to make sure all your patients’ labs get drawn and studies get done is, in a small, small way, similar to the constant nature of the ED.
I enjoyed it so much, and felt so comfortable managing the patients there that I even wondered for a few minutes, “Am I going into the wrong field?” Of course all my medicine colleagues asked me the same thing, and always had their own opinions about Emergency Medicine (I’m used to getting ragged on by pretty much every service by now, so it’s fine).
Calls went incredibly smoothly–probably another reason I enjoyed the month so much. We only capped (received the full number of patients we’re allowed to have) twice in the entire month, once on our first day, and the other we’d capped by 11am, since most of our patients came in overnight and were already tucked in by a fantastic night float resident (thank you, Cheryl!). Taking a note from the ED playbook, I was king of dispo, able to discharge half of my patients by post-call time! (Which often makes you wonder if they needed to be admitted in the first place.)
I definitely learned a ton, and feel comfortable writing diet and DVT prophylaxis orders now. Overall, a really great month.
I think the deal-breaker, however, is summed up today in clinic. I was reading the latest ACEP Newsletter. In the Tricks of the Trade session (written by an awesome mentor of mine, Dr. Michelle Lin!), she mentions unique uses for wall vacuum suction, including how to remove a foreign rectal vegetable using vacuum tubing and bulb suction. What other specialty talks about that in their monthly newsletter?
The short white coats are all over the hospital these past several months*: the visiting sub-interns are here, hoping to get a leg-up on interview season in their chosen specialties.
*We’re spoiled here at Stanford, as we as medical students get to wear long coats, too. (Our residents sometimes give us crap, saying we never went through the humiliation of a short white coat. We don’t miss them.)
Maybe this is just a west coast thing, but here’s essentially the only times residents refer to themselves as “Dr. Suchandsuch:”
Well, that was much better than last time. I went into call with one patient, came out of call with… one patient. Our team went into call with 7 patients, and came out with… 6 patients.
Thank you, gods of call. (And I got most of my ERAS application done wasting my beautiful Saturday away in the hospital!) Now just that damn personal statement.
Pronounced my first patient just now. The hospice unit called down to our team room, so my resident and I put on our white coats, buttoned them up to look presentable, and headed upstairs.
Luckily there was no family in the room–I’m sure it would have been much more uncomfortable if there had been. Felt the patient: warm; checked for a pulse: none; saw no reaction of the pupils to light. It was very strange, putting a stethoscope to a warm, lifeless chest wall. You’re so used to hearing the rhythmic whooshing of the breath sounds or the lub-dub of the heart that it’s a little un-nerving when there’s nothing there. I moved my stethoscope to a few other places–wait, did I hear something?–but there was simply nothing there.
After a quick confirmation by the resident, we turned turned around to the nurse, looking at the clock on the wall. “Okay, we’ll call it Eight Thirty-Seven. Thanks.”
Had my first night of subintern call last night. We capped; I admitted 4 patients.
Man it sucked.
I fully recognize it will get easier: that I will get more efficient at entering orders, more comfortable with how detailed my H&P’s need to be, and more able to focus with less sleep. But still, it sucked, and will probably continue to suck.
Now, it wasn’t particularly difficult or anything, and wasn’t far from what I was doing as a medical student on my Medicine clerkship–I was seeing patients on my own, coming up with a differential, assessment/plan, writing the H&P, deciding management, etc. But man, it’s different as a sub-I. I’m essentially being treated as another intern on the team by my attending, resident, and co-interns–which is how I should be treated, and I’m glad it’s that way. But boy, just the slight upgrade in my status and responsibility has made me a wreck: being fully responsible for a patient’s orders, making sure they’re getting the right meds at the right doses, making sure the labs that I ordered get drawn, and the studies I ordered get done is a nightmare. Especially at 2 in the morning.
Things I am sadly but quickly learning:
I think I hated mostly the fact that I didn’t feel like I was doing a very good job, on account of my lack of sleep. I really pride myself on the fact that I really try to do my best, and that I’m almost always on top of everything. But during call, I just felt the constant onslaught of work prevented me from having a chance to really think about the patients, read up about them in detail, or even really go through the differential. Most of my patients were pretty straightforward, so it wasn’t much of a problem, but I felt so pushed to constantly be getting orders in, and then seeing the next patient that I wasn’t able to really solidify patients’ stories in my head like I normally am. My presentations the next morning weren’t where I’d have liked them to be, forgetting small bits and pieces and having to go back. Perfectionist, guilty as charged, but I don’t like the feeling of being unsure if I’m providing the 100% best care to my patients, only providing good enough care to get them admitted, stable, and start initial treatments. (Maybe this is just the way call days work, I’m not sure.)
Old school docs and your ragging on the 80-hour work week be damned: interns on little sleep who’ve admitted patients all night, who are writing orders at 2 or 3 in the morning is, in the best of worlds, sub-optimal, and in the worst of worlds, dangerous. Having run around all day and night long, with patients’ stories and allergies and medications confused in your head, and then trying to write orders on them is awful. The mental poop that was coming from my brain was so foul and uncontrollable that it took easily twice as long for me to focus and concentrate to think through my patients. After 3 hours of sleep, the fog and haze was truly no better: I would sit down at a phone, desk, or computer and stare blankly, trying to remember what I was supposed to be doing. I wasn’t particularly sleepy or tired, just with a profound inability to focus. I hated being so out of control of my head, since it’s normally so easy for me to power through things.
It’s not the workload of the resident that’s the taxing part–all of us have pulled our all-nighters, with diminishing returns as the night carries on–it’s the frequent interruptions and constant shifting of attention. If you could just focus on admitting one patient at a time, it’d be great. But at the same time you’re admitting one patient, you’re gearing up, overhearing that your next one has just arrived in the ED; you’re getting a page that a patient needs pain medications when he’s already written for them; you’re trying to ignore your stomach that’s asking to please find something to feed it, while trying to concentrate and remember which is the antibiotic that covers urinary tract infections and which is the one that doesn’t.
I think I can see where Panda is coming from sometimes now. He writes about his frustration with patients, hospitals, and residency training, and from my N of 1 call night, I kind of get it. (Now, this does not mean that I agree with his solutions or placing of blame, of course–it’s not a patient’s fault that the system is messed up, or that they got sick at 4am–but you go through this and think, “God, there has to be a better way.”)
Enough bitching and ranting, as I’ve already talked several people’s heads off today, and now yours, too. Time for bed, and to hopefully work on getting my two other patients discharged: I’m on call again on Saturday.
Now that I’ve survived my month of ICU (and actually enjoyed it–love that high acuity stuff), I should clear up some misconceptions about the ICU that I definitely had coming in (and that likely most people have about ICUs).
You walk through an Intensive Care Unit and see almost everyone totally sedated and out of it: on a ventilator, with lines going in their arms, legs, necks, urethras, and rectums, and lines of plastic tubing entrapping them, and you think, My God, why are we keeping these poor people alive on a ventilator? They’re too sick to make it, just let them go already! Americans don’t know how to let their loved ones go!
So it turns out: while most people in the ICU at any one time are really sick and totally out of it, every day there’s at least a few people who are getting better, getting various tubes removed from them, and actually getting out of the ICU. I had this big impression that few people make it out of an ICU–that most people die, and the ICU is some sort of “last ditch” effort. While it’s true that we can’t save everyone, and some people are just too sick for us to save, the vast majority of our patients did really well after suffering some seriously major insults to their bodies. It’s truly miraculous what people’s bodies can deal with with some support during the really bad times from the ICU.
Started my Medicine Sub-I today; anyone have advice for the sub-intern (or intern, for that matter)? Tips and tricks appreciated.
My thoughts about the ICU, starting chronologically from my first day until now, starting my third week:
Pre-ICU:
Boy, I think I’m really starting to get decent at clerkships–I feel like I’ve got a good grasp of management for most diseases, I can present pretty well, I’m keeping up with the interns on my service. I’ll learn a lot in the ICU!
ICU, Days One and Two: (aka Why Being A Med Student Sucks)
I hate this. I hate hate hate this. I am stupid, I don’t know anything. These patients are too complex! They’re overwhelming! It takes me an hour just to collect data on all these patients! What the hell are all these ventilator settings? All these random numbers? And the numbers keep changing! And there’s like 4 ABG’s drawn every day! Ugh, this sucks! I don’t know how to present, I turned bright red trying to present this patient to the 19 person team, full of residents, fellows, and attendings (no interns, just med students), and my attending had to take over and explain everything cause I screw it all up! And I called LeMierre’s Syndrome Meniere’s Disease and ugh, did I mention I HATE THIS?
ICU, The Rest Of Week One
Well it’s a brand new team of residents and first year fellows, most of which haven’t done the ICU in a long time or ever before, so I’m on more equal ground now. Lectures are starting over with “What Is ACLS?” and “How do I manage shock?” and everyone is getting confused on how to present patients in morning and afternoon rounds. This is muuuuch better. I feel much less like a dumbass. (But still a dumbass.)
ICU, Week Two
Okay, I’m getting the hang of this. Stuff’s starting to make sense. I can round on my patients pretty quickly, get all the relevant data and not fall too far behind. Big picture. Remember the big picture–what’s keeping the patient in the ICU? What are we doing for them that can’t be done on the floor? Why are they so sick? Still getting lots of suggestions for management from the rest of the team, but I’m getting a better hang of things–what needs to be presented and what can just be recorded in the note. The patients are really sick, and really interesting, and man, one patient can be a review of every system in the body. Kind of… cool. (For learning, not for the patient.)
Two weeks down, two weeks to go!
A bunch of people bit my head off on my A Better Way To Round post, assuming that I was ignoring patient communication. Idiot Savant’s comment pretty much sums it up–the point I was making was that because we spend so much needless time rounding, we often lack time for patients, in terms of communicating properly, frequently, and promptly, updating them and them families, doing procedures, etc.
I want to improve rounding so that we medical students, interns, residents, fellows, and attendings have more time for more important stuff than collecting numbers from a computer screen and copying them down multiple times. (Each person in the above list spends at the very, very least one hour doing this. Every. Day.)
Other ideas for improving patient care and communication:
I don’t think I’ve ever seen so many young people in the hospital before. And they’re all in the Intensive Care Unit (ICU).
Scary how many people are around my age or younger, and how really sick they are, with diseases and on drugs I’ve never even heard of. We youngin’s are generally a healthy bunch, but man, when we get sick, we tank.
And man, when us youngin’s are taking care of you, we’ve got a lot to read. Posting may be light this month. Ugh.
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Shadowfax’s hilarious and freaking bizarre story of a guy seeing Christmas elves reminds me of a patient 2 months ago who, when asked if he knew why he was in the hospital, answered, “I’m here for a meat inspection.” He told this to multiple people.
And my roommate’s girlfriend had a patient who, when asked the date, would frequently answer “6007″ for the year.
So, what’s your weirdest chief complaint/response to orientation question? (Comments are open!)
(Update, I take that back, my best one-liner was in the ER awhile back. The chief complaint, which I’m sure the triage nurse got a kick out of writing–since she’d normally just write “altered mental status” was “911 called by roommate, patient was meeowing like a cat in his room.)
My attending on anti-coagulation in the hospital (okay, I’m paraphrasing):
“I think anti-coagulation is one of the most frustrating and unrewarding parts of medicine, because you never see the positive outcomes, you only see the strokes when you don’t anti-coagulate, or the bleeds when you do.”
Agreed.
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I’m on the floor today typing up my note (go electronic medical record go!) and I see a patient call his nurse into his room. “It’s really bothering me,” he mumbles, and the nurse whooshes the curtain closed.
“Turn over,” she sighs.
A few seconds later, the patient says, “I think it’s a cling on, but I can’t seem to find it!”
I shutter. The poor nurse is being asked to look for a piece of poop stuck between the patient’s butt cheeks.
Here’s to you, nurses.
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How to be an ER doctor from Shadowfax and Why to get EKGs by 10 outta 10.
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Wanna be a rich man or woman? Work on wireless monitoring of EKG leads and heart rate, pulse oximetry, blood pressure, and temperature. The cords and wires in the OR are always a ridiculous mess, but the anesthesiologists are great at untangling them. (I’d love to see their Christmas lights and computer desks.)
Me? I’m working on an even more revolutionary invention: the wireless IV.
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On a 2-week rotation of Anesthesia recently, hence the not posting. I find myself using my eyes to pretty much express every emotion, since the rest of my face is masked. (This happened while I was on surgery, as the surgeons do it too, but I’ve become quite skilled at it recently, since the nurses and attending and I will often try communicate silently in the OR, since that whole “people with scalpels and needles should probably be able to concentrate if they want” mentality is quite popular around these parts.)
Figured I’d give my little rundown of expressions that I use through the power of the YouTubes.
Video is below. If you’re viewing the feed or get the email and want to see the video, just click on my page or the Youtube link.
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How it works in the ER, because it’s all shotgun medicine. Talk with patient, ask questions, feel belly. Most of the time the patient is waiting is either because there are sicker patients, you’re doing a procedure, or you’re playing phone tag or following-up on labs that are pending or didn’t get sent. Great writeup.
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Thank you to the great attending and residents who trusted me, supervised me, and allowed me to do so much today!
Done most of these before, but it was in such rapid succession–one procedure after another–that I totally felt in the zone. It was great!
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Sewed up several intraoral lacerations lately, one attending never mentioned antibiotics, the other was pimping me on which to give. Looks like there may be some benefit in compliant patients for reducing likelihood of abscess formation.
(Actively bleeding through and through lacs (ie: they go thru the skin and all the way thru the lip and gums into the mouth) are a pain in the ass to close and close well, especially when they don’t respond to lidocaine with epi! That being said, I think I did some pretty good vermillion border work, even with the crappy throwaway instruments and blood everywhere.)
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Resident: “My patient snorted 3 grams of cocaine today. That seems like a lot. Is that a lot?”
Attending: “I don’t know, it seems like a lot.”
Me: “Isn’t an 8-ball like an eighth of a gram or something? So that’s like 24 8 balls?”
Other Resident: “How much did Al Pacino snort before he killed that guy in Scarface?”
Clerk: “Oh, it was a lot, cause it was in a big pile, then he cut it into three lines.”
Resident: “You sure know a lot about Scarface.”
Clerk: “It was just on TV 2 days ago!”
Attending: “I guess it just depends on how wide your lines are.”
Me: “And how long they are.”
Resident: “So… 3 grams, is that a lot?”
Everyone: “No idea.”
So there you go. And much less than that is enough to give you a stroke or a heart attack, because cocaine causes spasm of your arteries and cuts off blood supply, so not only be careful, don’t use it.
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Dearest Mayor Newsom, could you please remove the crazy pills from the water?
The ED was like I’ve never seen it last night, just busy to the brim. And on the drive home, 7, yes, SEVEN people ran across the street in front of my car. They were just *asking* to get a PVA.
And to my patient who the deputies dropped charges on and you pulled out your IV and left, after I did all this work-up AND made the diagnosis of hyperthyroidism based on history alone, with a very low TSH and a very high free T4, you really should have stayed to at least get your diagnosis. I was proud of making it, and you’d probably feel better sooner rather than later if you had gotten hooked up with an outpatient provider. Sorry dear.
Random ED terminology I’ve made up (feel free to add your own):
Laction: The act of suturing/stapling/closing a laceration. “Man, I’ve had a lot of laction today.”
Awheezile: Like afebrile, but for wheezing. “Yeah, this patient with asthma was wheezing really bad, but after a neb, he’s awheezile.”
May I plleeeease sit at the cool kids table at the ER now? I have conquered the MTFers, withstood the trials of the Neuro Lecture, and even ass-kissed preemptively.
Also, my scrubs do not taper.
Maraka and I’m a Dude; we will *totally* go to a Bootie Mashup Party.
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The season finale of Lost was amazing, but could we get some wound eversion for Jack’s laceration repair, TV ER doctor? Hell, that little thing could be dermabonded. And while we’re at it, you might not want to use absorbable, practically transparent suture since those need to come out in 3 days to prevent scarring. Snark off.
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Shadowed/eavesdropped on calls today at the California Poison Control Center, which was pretty cool. The center here in SF shares the duties with 3 other centers in the state, operating the 24 hour, toll-free number to answer pretty much any question and either make sure people get the right treatment or some needed reassurance. Each state has its own poison control center and the people are incredibly helpful, knowledgeable and friendly–definitely call if you have any questions.
My one experience with it involved my mother making some sort of pasta or tuna salad, while also getting out some hydrocortisone cream for a rash or something, with a tiny bit of the steroid cream ending up in the bowl. Don’t ask me how this happened. I just remember my brother and I freaking out and SCREAMING for her to throw out the entire bowl of food, not wanting our mother to die. She called poison control and they said it would be fine (she’s a nurse so she knew this anyway) but I think we put up such a fit she tossed it anyway. (Or at least she told us she did.) So everyone does silly things, and children eat everything. No matter how silly, it’s no reason not to call. The call centers have heard everything.
Most calls dealt with toddlers eating pills. One “licked the coating off a bunch of Advil and Tylenol.” One important point: Tylenol is actually incredibly dangerous in overdoses–which is hard to do unintentionally in adults–but isn’t so difficult for small children, since overdoses are generally based on weight. Tylenol in overdose has been bad enough to cause patients to go into liver failure and require a liver transplant. Keep pills out of the reach of kids!
Oh, interesting fact: Those little freshness packets in shoe boxes that say “don’t ingest?” They’re just silica, and non-toxic. It’s like eating sand, apparently. (This is not medical advice!) Update from the comments:: Silica gel, the desiccant in “freshness packets,” isn’t always harmless. Sometimes it’s packaged with a moisture indicator and some of those are quite toxic.
I’ve been watching Grey’s Anatomy to relax in my few hours of freedom per day, and I must say, nurses totally get the shaft on the show. Addison is always rooming patients in the ER, checking vitals, and hanging fluids, as if the physicians on the show are these solo practitioners who can do everything for everyone (surgical interns staffing a free clinic, ha!)
ER nurses can laugh with the best of them, and are incredibly fun to work with when the patients are stable. They’re even more amazing to watch when patients go bad. One patient went from looking mildly uncomfortable to coding (needing CPR) in the span of about 3 or 4 minutes, and just like a switch was flipped on, the nurses swooped in and knew exactly what to do. Two secured IVs, another started documenting, and a fourth was pulling meds. I’ve seen the phenomenon a number of times now, and it’s really, really impressive. The teamwork is fantastic. One of the reasons I love the ER.
I remember a patient once asking a Peds nurse why he went into nursing. His reply: “I wanted to help patients. Doctors diagnose patients, but it’s the nurses that actually treat them.”
My hat is off!
4 hour “orientation” shift today.
Already learned how to put someone in restraints and tie them down, saw a patient from the county jail, and re-did an IV on an altered patient who had already ripped it out twice. I was also told to “fight for a suture room and grab it before someone else does.” Grabbed my patient, maneuvered her bed around the drunk man who had urinated in his bed and the onto the floor.
This month is going to be awesome. And crazy.
Possible theme for the month, advice given to me by an attending today: “Better to ask for forgiveness than permission.” (Did I mention I can write my own orders?)
Another year, another reason not to get sick in July. That’s right, it’s the guide to clerkships/rotations/clinics/whatever you wanna call it. (If you’re not there yet, you should be reading Graham’s Guide to Boards.) Probably not worth reading if you’re not a med student.
Let’s begin at the beginning.
The transition to clerkships can be rough, and at times, very lonely. You go from spending every moment with your classmates as a preclinical student to being thrown around different rotations at different hospitals with different schedules. You often lose your support network, because they’re all busy, too. Lean on non-medical friends if you have them. They’ll enjoy hearing your gross stories about doing rectal exams and weird diseases you’ve seen, and you’ll get a chance to catch up with them.
Oh, and I found a nice physical exam review site tonight if you’re interested. Those skills tend to weaken while you’re studying all night and day for Boards.
Manch Medic’s post reminds me to ask: Any tips from EMers on transitioning to a week of night shifts? I’m incredibly excited to dive back into clinics with another ER month next week, beginning with a week of 10pm-6am shifts. Sleeping suggestions, napping suggestions, caffeine suggestions? Thanks in advance.
Clutch quote from an OB resident 3 weeks ago that’s still been bothering me, in reference to a patient with metastatic cancer who was in pain and needed a CT scan but was refusing contrast:
“I am so sick of these patients. Just suck it up already and deal with it. God.”
If you’re ever working with me, and I ever say anything as remotely cruel and disgusting as that about a patient, especially one with metastatic cancer all over the place, please, please, sock me in the gut, or slap me, or something. There’s ranting, and there’s bitching, and then there’s just plain inability to have any sort of compassion or caring for your patients.
I feel guilty that I didn’t speak up and put the resident in her place. Granted it was 3 residents versus one med student, but I wish I would take the right path rather than the easy one a little more often. Sigh.
I’m getting really sick and tired of the media’s portrayl of Cho as a mentally-ill individual and all the following of “leads” from his psychiatric hold and the fact that two girls complained about him to police.
People with mental illness–and that’s 1 in 4 of Americans–are NOT dangerous. Even schizophrenics, those with the classic disorder that comes up when someone says “crazy person”–are NOT dangerous. They are suffering, sick patients. Did you know that the prevalence of schizophrenia in the population is about 1%? That’s 2.2 million Americans. If schizophrenics are so dangerous, we should be expecting to have about 2.2 million more school or workplace shootings sometime soon. (t’s absolutely important that if people need treatment, they get it, and there’s follow-up to make sure they’re getting it.)
Are there exceptions to the rule? Of course. Was Cho a very sick individual? Absolutely. But if we take aggressive, radical steps against every student or person who gets evaluated or placed on a psychiatric hold, we’re going to be hurting a huge number of people based out of fear and ignorance–and wasting a lot of time, money, and energy in the process. Terrible things happen in the world, and I’m sorry World, but there’s not always someone to blame.
Mental illness often reveals itself in the late teens and early 20s, and it’s often genetic. It takes a terrible toll on patients–they go from functioning in the primes of their lives to becoming isolated, lost, and removed from the world that they know. Imagine for one minute that you’re schizophrenic. Voices from inside your own brain tell you things–they’re so real that your brain’s auditory centers actually light up as if they’re hearing things. They tell you terrible, horrible things, 24 hours a day. That you’re a terrible person, that the police are coming for you, that you’ve done something terribly wrong. Want to know why schizophrenics so often are wearing headphones or earplugs, or are singing to themselves? They’re trying to find some way to drown out the voices that speak to them all day long.
These people don’t need our judgment and punishment, they need our compassion and help.
While reviewing infections of the neck and complications of strep throat, I read about PANDAS, which stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections.
I hereby decree that all new Pediatric Syndromes must have similarly-cutesy acronyms. Like BUBBLEGUM or DUCKY or KITE or BINKY or BUNNY. Alternative spellings, like ELEFUNT, are acceptable.
(Not trying to offend anyone here, the name of the disease is cutesy, obviously the disease itself nor the patients it affects are being joked at.)
Have you ever read a comment someone posted on your blog, and then they double-dipped and turned it into a post on their blog, so you decide to triple-dip and post their comment from their blog from your blog back onto your blog?
I didn’t think so.
I’ve been meaning to follow-up on last week’s GOMER post, and Nick is just the inspiration.
I was intending to be snarky with my “Get Out of My ER” title, as I am far from the jaded, paternalistic assholery that would say such a thing. I got lots of great responses, everything from the short and sweet to the longer explanation to the scolding for ignoring a possible influenza to the “don’t do that you’ll just make trouble for yourself.”
I think Nick’s wins, or is at least the closest to what I try to do. I believe as ER professionals we’re not only supposed to evaluate, treat and determine dispo, but we’re also supposed to educate–all physicians are. We know the most about the human body out of the entire society, and it’s our job to not only provide education about the body, but also about normal and healthy.
This mostly happens seeing pediatric patients, and often it seems that the pediatric ER visits are frustrating for all parties involved: docs, nurses, staff, parents, and the kids themselves. Kids are, in general, healthy and resilient. And most pediatric ER visits that I’ve seen are in general, healthy.
These kids are fine. They have a cold, or a GI bug. They are eating well, peeing and pooping fine, they’re active and well-hydrated. Their vitals are all stable. Sometimes they have a fever.
These are kids that will, in general, do fine at home, or at the very most, need a sick child appointment at the pediatrician. It’s not an emergency. It’s not life-threatening.
Have things changed? Has it always been like this? If not, where’s this coming from?
The medicalization of childhood, where everyone is freaked out their kid has some killer nasty terrible disease?
Or how about the breakup of the extended family unit? When you don’t have grandparents around or aunts or uncles or friends with older children who can re-assure a parent, maybe they’ll take them to the ER more often?
Or lack of access to pediatricians? And maybe lack of health insurance? More and more patients tell me that the advice nurse in the pediatrician’s office told the parent with the kid with a cold and a 101 fever to go to the ER, since the pediatrician was booked solid for the day.
The “I want it now” culture? An inability to just let a child be sick for a week or 10 days? An inability to be patient?
Cultural norms? I read somewhere that seeing a doctor in Latin and South America generally means spending hours in a waiting room, so it’s perfectly normal to just go to the closest, most accessible doctor instead of calling one’s pediatrician to schedule an appointment.
Lack of education about what are normal things for a sick kid to do, and what are abnormal ones? Maybe it’s just that the population has grown, and we haven’t kept up to provide the resources to educate them all?
Sometimes I wonder if it wouldn’t be more efficient to have the triage nurse take a kid’s vitals, and watch the kid in the waiting room, and if he or she looks fine, suggest heading to the local clinic–the wait is probably shorter, anyway.
(All of this is spoken from a non-parent of course.)
A call to all the ER docs out there: how do you tactfully, non-insultingly tell patients who come in with minor complaints, “You’re fine, go home, this is not an emergency, you should not come to an ER for a problem like this?” (For example, kid with a cold and low grade temp who is otherwise playful, active, eating and drinking well, with good sats, etc.)
They always tell you the first thing you should always do when looking at an imaging study is verify the patient’s name and date of study.
Today I got nice and burned by it, but luckily the attending caught it. Nothing deathly serious, just a stupid, stupid mistake, which I will not do again.
As I’ve always said, I’d much rather make stupid mistakes as a med student than as a doctor.
While a somewhat amusing look at med student clerkships like Medicine, Pediatrics, and Ob-Gyn, I’d be doing a disservice if I didn’t say that I felt like Panda took the wrong approach to clinics.
Maybe it’s just different med school cultures, but he mostly starts out each one essentially saying the med student doesn’t matter, and isn’t really important to the team. If you don’t feel like you’re a valued member of the team, prove to your attendings that you are. Ask questions, take an active role, challenge yourself, ask for more responsibility, and most of the time, you will be rewarded. I was treated like an intern during my Medicine, Peds, Psych, and ER months. I had my own patients, and my attendings and residents pretty much let me manage my patients myself (with their oversight, of course). I wrote the H&Ps, daily notes, and discharge summaries. On my inpatient Peds month when I was on call, it was just me and the attending in-house! We managed the entire floor and PICU together ourselves. Did I do anything the attending couldn’t have done him or herself? Of course not. But I wrote orders, responded to questions from nurses, and got called throughout the night for admissions and procedures (again, with attending oversight). The medical student knows the patient better than anyone else on the team, and often I was able to provide medical history or dispo information that no one else on the team knew. Are you saving peoples’ lives? Often, no, but you’re learning how to, and if you don’t feel like you’re contributing to the team, you’re missing the experience.
Note: if month after month you’re having plenty of “slacking potential,” complain. Maybe it’s just me or my teams, but more often than not I was busy almost all the time–if not with patient care activities, note-writing, order-writing, etc, then with didactics or classes. Call me goodie two-shoes, that’s fine, but I’ve always preferred to work my butt off during clerkships and really try to learn a lot now than when I’ve got the MD after my name and people expect me to know stuff.
So an overall thank you to my programs and attendings and teams–I’d hate to be the exception! Make yourself matter, you’re paying for it dearly!
I may possibly be the last person to discover them, but UpToDate has a bunch of really good ECG tutorials broken up into a ton of different sections. Just search for “ECG Tutorial” and you’ll find them.
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It’s funny what people can live their lives with thinking it’s just normal–that everyone operates on the same assumptions. If it’s always how it’s been for you, how can you know any better?
Three patients reminded me of this fact.
The first is a teenage Russian mother. Her 4-month old adorable little baby had a terrible case of eczema. She was seen in the ER a week ago, given some medications, and told to get a pediatrician at a local clinic. A week later, she shows up in the ER again. For the eczema. There are mutterings and under-the-breath annoyed words spoken–what the hell is she doing back here with her baby’s eczema? This is not an emergency. We ask her why she didn’t go to the clinic, as instructed, and she says, “I went there and they said I was going to have to wait 3 hours.” We say, “Well, yeah, you’re going to have to wait, it’s a clinic. But if you make an appointment, you’ll be able to get in faster.” She kind of nods, and we kind of stand there for an extra beat, hoping she gets it. We re-iterate to her that we cannot manage the kid–she needs to see a dermatologist, and get a referral from her pediatrician. Once we explained how referrals work, I think she figured it out.
My instincts were to think, “What, is she stupid, does she not understand how doctors work? Does she not realize this isn’t an emergency? Is she just lazy and abusing the system?” But the more I thought about it, I think she just honestly didn’t know how the medical system works. She didn’t know how to get care, or how to get a pediatrician, or get help for her baby, so she went to the one place she knows there will be doctors: the ER.
The next is a 30-something administrative clerk at a law firm, with an exquisitely tender ingrown toenail. Ouch. She tells me she gets these rarely, and I ask, “How rare is rarely?” and she shrugs, “Oh, about once a year or so.” (She usually gets a pedicure, but was too busy with the holidays to get one this year.) She has special clippers to prevent it from happening. She is bewildered when I tell her that I think that’s pretty frequent–that most people don’t get them so regularly. “They don’t?” I tell her there are ways to remove the nail matrix causing the ingrown toenail, and suggest she ask her doctor about it.
Again: she’s had ingrown toenails since she was a kid, and just thought it was your normal, everyday thing. Maybe her family had them too, so the notion was enforced. (This also supports my theory that “All families are weird,” because you’ll hear someone describing what traditions they do for Christmas, or birthdays, or whatever, and you think it’s totally bizarre because it’s not how your family does things.)
The last is a 24 year-old student with a chronic cough. He’s got a pretty good family history of atopy and a brother with asthma. He describes the coughing fits as generally after exercising, like running on a cold day–but sometimes even after weird things like drinking a Slurpee too quickly. They last for a good hour or so–but as far as he can remember, he’s had them his whole life.
Now you may be thinking that these patients are just uneducated about their disease, or don’t have a whole lot of medical knowledge or background. But this last one is nothing of the sort. Turns out he’s a medical student. Turns out his father is a doctor. His mother is a former nurse.
Turns out that it’s me, and my cough-variant asthma.
I had no idea–no freaking clue–that other people didn’t cough and cough and cough like me–I just thought that was normal human behavior, a normal reaction to exercise, or cold air, or… Slurpees. It wasn’t until I was reading about asthma that it finally hit me, Mr. Medical Student.
Don’t make assumptions about what you know, what you think you know, or what you think your patients know. Educate, educate, educate, and if something doesn’t seem “normal” or “right,” there’s probably a good reason (or maybe you’re the weird one, and there’s no good reason at all).
Ahh, medical ambiguity.
Found this “Guide to Being an Intern” online–it’s for UMich residents, but has some good little tips that I’ll definitely be referring back to when I hit my SubI and finally graduate.
Doctors, nurses, med students, patients, we should be embarrassed.
Welcome 2007. You can email, send instant messages, order airline tickets in seconds, track that airplane as it flies across the globe, manage your calendar, work on documents and spreadsheets in real time with your friends and colleagues, even read newspapers from around the freaking globe. But our computerized medical records (or whatever you want to call them) can’t even print out labs in the right order. This is, in a word, ridonkulous. Hospitals and clinics should demand more. The big medical record makers should provide more. Their interfaces, truly, look like they’re from 1990.
I have spent a little over a year in hospitals, working as an upcoming doctor, and I’ve seen 8 completely different electronic medical records. (This is working at only 4 different hospitals.) Some are better than others, some are definitely worse than others. The government’s own Veterans’ Hospital’s CPRS software is probably the best, and honestly leaves much to be desired. (This is what it looks like.)
Over the year I’ve tried to collect ideas about the best features (and worst) of these different systems, and I’ve put them all together in something I call (for lack of better): the GMR (Grahamazon Medical Record). It’s an interface only–doesn’t actually save patient data (yet!)–but sadly, I think it’s lightyears ahead of what I’ve seen (and I live in Silicon Valley). It’s mainly a proof of concept–that this could be done, and can be done. (Note: It works in all modern browsers: IE7, Firefox, Safari.)
I’ve put together a screencast that walks you through some of the features. Watch it, and then play around with the interface. My goals, basically:
Note: This is obviously not optimized code for efficiency, it’s my hacking-so-it-works Web 2.0 interface. It could definitely be improved, but it’s a start.
Feedback, as always, is appreciated. (Oh–forgot to mention in the video–you can easily access any of the tabs by doing “Ctrl+letter” on a Mac or “Alt+Letter” on a PC, using the underlined letter.)
First time seeing one of these, two weeks ago. Off to the cath lab for him!
(For the non-medical, that’s an acute MI–active heart attack–in progress. The big rounded convex lines look like tombstones for a reason.)
I can’t believe I haven’t written about one of the most evil, most frustrating things about being a med student: the dreaded Attending Effect(tm).
The Attending Effect, by definition, is the magical, mystical powers that the presence of an attending has on your patient’s history. The mere sight of an attending will transform the words that come from your patient’s mouth from those he or she told you to a different story entirely.
You’ll get the story from your patient, “Okay, so it’s been 3 days of vomitting, but you’ve been keeping liquids down fine, and there’s no blood in your stool, or black, tarry stools.”
You go tell this fascinating story to your attending, give your assessment and plan, they agree, and you feel good–”The attending said I’m doing the right things! Yes!”
Then, you either go back with your attending to examine the patient again–or worse, your attending sees the patient without you–and the story the attending gets is totally different. Your attending tells you, “She told me it’s been a week and a half of diarrhea, sometimes bloody, and she can barely drink anything.”
The first few times this happens, your eyes bulge out, your jaw drops. You sweat, your heart races, you panic. You are convinced that the attending thinks you totally lied to him or her, or that you weren’t listened to the patient, or that you’re just a total dumbass. You quickly re-tell the story the patient gave you, and you swear you didn’t make it up. You are so totally pissed at this patient.
Once this has happened a dozen times or so, you just kind of shrug it off. You’re annoyed, wonder what the patient was thinking. But you know it’s just the Attending Effect at work, there’s nothing you can do about it, so you just adjust your assessment/plan and keep on moving. There’s more patients to see.
(Reminded of this by Flea, whose stories are totally depressing lately and really getting to me, and making me wonder “Is this really what being an attending is like?)
I guess this post has been a long time coming, and probably why I haven’t written for awhile. It’s a culmination of a year of clinical training, and what effects it has had on me, from the good, to the bad, to the ugly. I think I’ll start with the bad and the ugly, because that’s what’s really been bothering me for awhile now.
Medicine has made me into a shitty person. Or, maybe more appropriately, the shitty-person side of me was always there, but the stress of medicine brought him out. Many of the problems, I believe, stem from behaviors in medicine that I can’t shake from my person when I’m not in my medical role. Shitty Graham takes several forms:
I don’t want to make this sound like I’ve become some sort of terrible monster, but it’s just the little occasioal interactions and thoughts that run through my head that didn’t used to be there.
I haven’t really talked about this at all with any classmates, probably mostly out of shame and the fear that no one will feel the same way, and it’s just me that’s a terrible person. But somehow the pseudo-anonymity of the web and the written word makes it easier to type the words than to say them. I’m just trying to be honest with myself and figure out what I’d really like to focus on in the coming year–mainly why I went into medicine and how I can rediscover some of my humanity and virtue, because the path I’m taking right now won’t lead me anywhere I want to be.
The Good I referred to above will, I guess, be left for another post. Believe me, there’s plenty of it, but I’m just not feeling it right now.
As for this blog–what will I write about since I’ll be doing a year of research and not seeing patients? Several people have asked. I think I’ll spend more time reflecting on the year as a whole (I love reflecting, if you can’t tell), and then who knows, probably some thoughts on research, being a teaching assistant, and then of course my 2 month jaunt to Guatemala next year.
(And welcome back to MedPundit, who thought she was giving up blogging but it’s reeled her back in.)
(Editted, I total was unclear by what I meant by incompetence.)
The end of clinics, year one, is now complete, and was completely anti-climactic to boot. It’s off to a family vacationn, some rest and relaxation, before I begin my research year that I don’t think I ever announced. (I guess that last sentence was the announcement.) More on that, as well as a wrap up of clerkships year one, when I return. Ciao!
Some of these are inherent to going to an Emergency Department; others are just the difficulties of clinical medicine.
For next time: the great things about the ED, of which there are many.
These are the words that start to change my diagnosis from “kidney stone” to “drug-seeking.”
Two weeks ago, I pull back the curtain, introduce myself, and see a woman writhing around in (supposed) pain, tears in her eyes. She tells me she’s had 4 kidney stones previously. They’re all uric acid stones, which are generally undetectable on X-ray. That she went to a urologist, was on allopurinol, but stopped it two months ago. This all happened in Texas. She tells me where her pain is, and that it radiates to her back and down to her groin. “Kidney stone! It’s a kidney stone!” I tell myself. I am brilliant. I examine her, find some tenderness on her right flank. Her urine has already been sent to the lab. I tell her I’m going to go talk to the doctors to discuss what we can use for pain control. She warns me that she is allergic to aspirin and Tordol–a strong pain reliever but not a narcotic. (Think super-Advil.) Her mouth swells up when she takes either of these. “What terrible luck, a woman with chronic, painful kidney stones and allergies to common pain relievers!” I think. She then finishes her pain medication story: “Whenever this happens, I usually get dilaudid and phenergan, and sometimes ativan because I have anxiety attacks.” And it all goes downhill from there.
I pause, skepticism and cynicism running through my mind, but I give her the benefit of the doubt. Assume nothing, I remind myself. Moments later, the patient’s nurse chases after me in the hallway. “She’s a frequent flyer here, you know. She was just here 2 weeks asking for the same thing. And I guarantee you next she’ll ask for Fentanyl.” Add more skepticism to the pot.
So we check her name–first time she’s been at the hospital. Maybe she’s using an assumed name? We check her urine, and it’s strongly positive for both blood (going along with the stone story) and white cells, indicating an infection. We’re stuck–her story and labs say maybe she’s telling the truth, but everything else is leaning toward malingering. So we start antibiotics for her infection, give her yes, some dilaudid and phenergan for pain control, and I tell her she’s going to need a CT scan. We get the scan setup, and she continues to ask for more pain medication–”It helps for like 2 seconds and then goes away!” Just when she’s ready to go to the scan, she starts asking for some ativan (similar to valium) for anxiety, because she gets claustrophobic in the scanner. We point out her head won’t be in the scanner, just her abdomen and pelvis. She continues. We tell her she’s already had a good deal of pain medication, and we don’t want to continue giving medications that could suppress her respiratory rate. She starts crying, and starts loudly asking, “Why can’t you just help me?? I’m in pain here, I’ve never been treated like this before.”
My resident pops into the room and helps with the authority bit, and later tells me she recognizes the woman too.
She misses her chance in the CT scanner, so we wait. She, as the nurse predicts, starts asking for Fentanyl, a very strong narcotic. She then starts cycling–”I’m in pain,” then “I’m nauseous!” then “I have a headache,” then “I have a sore throat,” then “I’m anxious,” each time asking for a different medication for her symptoms. She finally just goes to the CT scanner, but leaves the scanner with an anxiety attack.
If the woman does have a stone plus an infection, the infection could start climbing up toward her kidney. She could get an infected kidney, could get septic, could die. I discuss this at length with her. I tell her we believe she needs this scan to make sure she doesn’t have such an infection. She gets upset again and says she wants to leave. (I’m leaving out plenty of copious details, as this dragged on for hours.) We talk about why this is a terrible idea, but she wants to leave anyway. I go get the paperwork for her to sign to leave Against Medical Advice. I come back and note 2 things: her hand is down near her genitalia, under the blanket. (This was the case the last time she was here.) She’s either masterbating or giving herself an infection. I try my best to ignore this, which is totally disgusting, and hand her the paperwork to sign. She can barely grab the pen, she’s so sleepy and out of it from the narcotics. She’s still complaining of pain. She signs and initials here and there, and finally leaves. (I throw away the pen.)
Meanwhile, we have 10 other patients that have been waiting to be seen by a doctor; she’s wasted a bed for at least 4 hours. I’m angry, frustrated, and annoyed–and the rest of the nurses and doctors are, too. I sigh, quickly eat a granola bar for dinner, and pick up my next chart: a woman that’s been waiting 6 hours in the lobby to be seen for a simple clogged NG tube.
Update: I forgot to mention the final kicker–the woman asked for “Vicoprofen,” which is like Vicodin, but has ibuprofen in it instead of Tylenol, which is in vicodin. (She says the Vicodin makes her throw up.) My attending was smart, and realized the real reason she asked for the vicoprofen: it has a larger amount of narcotic in it per pill than the vicodin. Another trick of the trade, apparently.
I have a habit (don’t we all?) of walking around the ER (especially in the trauma bay) to see what’s happening with patients. It’s all the rubbernecking goodness without wasting any gasoline. You see someone with some big gashes in his forearm, or an arm that’s totally deformed, and you think to yourself, “Man, that must hurt like hell. That sucks. Glad that’s not me.”
This same sick curiosity happened last week with a jaundiced patient. This guy was the brightest yellow I’ve ever seen in my life. The whites of his eyes were fluorescent-highlighter yellow. I had just caught him out of the corner of my eye, and the “Oh man, that really sucks” thoughts came flowing right in.
But then I did a double-take–I knew the guy. He was actually one of my favorite patients that I had taken care of back in February. And I felt really sick for giving him such a cursory thought–and one of pity at that. I went over and we talked for a few minutes–that I was sorry to bump into him in such circumstances, how his kids were doing, how he was feeling.
And then the conversation quickly went from superficial to serious, confiding in me that he didn’t want to be one of those poor guys that dies on the transplant list. His eyes filled with tears, and a lump grew in the back of my throat. I touched his forearm, and said I didn’t want that to happen, either. Right after that the transporter came in to take him to his bed in the hospital, and I said goodbye for the time being.
While I don’t know if I’ll ever be able to get the rubbernecking thoughts from my head, I know I’ll be less superficial with their impact–it’s not just that an arm is broken–it’s that the person’s arm is broken.
Enjoying emergency medicine, but we’ll see after this 4-day stint is up. Finished a shift last night at around midnight, now I’m back on today at 10am, then 8am on Sunday, then a day off. Our clerkship director is right–working an 8 hour shift in a busy ER is like working a normal 16 hour shift on call.
With states now allowed to make changes on eligibility requirements for Medicaid, West Virginia will be requiring many beneficiaries to sign a contract in which they promise to use the ER only for emergencies and to keep their doctors’ appointments. Failure to do so will result in loss of benefits. And why not?
Medicaid spending is out of control and is squeezing state budgets. ER visits for non-urgent conditions are hundreds of dollars more expensive than an office visit so that seems like a good place to start to try and control costs.
He goes on to note that low-income people disproportionately make up a good percentage of ER visits, and goes on to say that “only about 16% of ER visits among all patients are considered to be true emergencies so the potential exists for a substantial reduction in unnecessary ER visits among Medicaid beneficiaries.” In the comments, another doctor, Flea, agrees.
I’ll throw another mess into the pot here before drawing my conclusions. A retired orthopod, Dr. Thompson, frequently comments on my blog, and left this zinger today: “I personally see nothing wrong with health savings accounts and allowing patients to be in charge of their health care decisions.” Wha-wha-what?
What is it with these doctors? I’m at a loss. We’ll go point by point here:
Can we please, please, PLEASE stop with the patchwork nonsense where we try to eliminate limit health care for the poorest and sickest and drive all the burden onto our already-burdened-with-their-illness patients? Can we see the forest amongst those trees? Can we see that hitting one group with this policy or that one will only create more burden in the long run, and that the only real solution is one that affects us all? Single-payer, multi-payer, I don’t even care at this point–I just wish people would see the big picture. (And no, not the big picture of your specialty. Zoom out one more time. The big picture of everyone.)
They don’t call it the Emergency Department for nothing.
I’m sitting there, talking with a 40 year-old woman complaining of lower back pain who had a kidney transplant, and then she adjusts herself to try to get comfortable, and shakes a couple times. She starts gasping for air; she is unresponsive to my questions. I immediately call for help, and a nurse comes in. Neither of us can get her to respond, and her eyes are glazed over. The nurse goes to get the attending, who comes in. We’re having trouble getting a good O2 sat on her (that gives us a rough idea of the oxygen in her blood), and once we do, we realize she needs to be intubated to help her breathe. We intubate, and then have to start CPR; she now has no pulse. Her blood pressure is dropping. We code her for 11 minutes. Her pulse comes back, and she’s maxed on the medications for blood pressure support. Her heart on ultrasound is pumping, but barely.
I have my hand on her femoral artery. We lose her pulse again. We code her for 24 more minutes, and eventually the family decides to do comfort care and have some time alone with her. We lose.
I could go into all my analysis of how my resident did a great job and set a good example of following the basics–Airway, Breathing, and Circulation. But something scares me more than not knowing exactly what to do when this happens next time.
What’s really bothering me is how okay with it I feel. That we spent 2 hours trying to bring someone back to life, that she crashed right in front of me–basically died right in front of me–and I was totally okay with that. That 5 minutes after it was over, after I finished writing up what happened, I just went about my business and picked up the next chart. I moved right on.
I keep waiting for some delayed grief reaction or something, like I’m going to be just walking down the street and suddenly feel really sad or something, but it’s not happening. I mean, this person I just met died, but I’m not all that upset about it. Maybe I just didn’t know her long enough to need to grieve about her. Maybe I somehow knew that after the first code, things weren’t looking good, and I didn’t have much hope when the second one began. Maybe this makes me a great, objective, detatched doctor. Maybe this makes me a terrible, distant, detatched human. I don’t know.
I’m hoping that either my over-analysis of this event over the past week is my grief reaction, or that whatever part of me I think I’m currently missing can come back, because it seems pretty damn ironic if I’ve somehow lost my compassion and empathy during the practice of medicine. Never saw this one coming.
So Psych is over. I really, really liked it, and found the patients fascinating–how someone seemingly “normal” can become psychotic, hearing voices, believing strange things–and not even understand that the things they hear or believe are abnormal–is surreal, frightening, and incredibly terrible. I’ve also known people that think mental illness (especially depression) is a bunch of crap, that people should just suck it up–and these are clearly the people that have never seen depression. They’ve seen sadness.
Interesting cultural-cum-insurance caveat (how often do you find those!?): the psych service sees a good number of Stanford undergrads (at least 1 per week) in the locked unit for mania, psychosis, etc. One of the major problems is insurance, as some programs have terrible mental health coverage and won’t pay for hospital stays or outpatient programs. Notoriously difficult are students from Asia with insurance from their home country; there’s a pretty strong disbelief in the notion of “mental illness” in many Asian countries, so often these students have absolutely NO mental health coverage whatsoever. Disaster.
I will miss my team, as psychiatrists tend to have just the right amount of quirk for my tastes, and I will definitely not forget Gertrude walking down the halls screaming the most random of things, “These are the poisonous snowflakes of Santa Claus!” “I need a silver bullet… because I have acne! Zits! Pus! Pustules!” I would seriously just lose it in the halls. It was kind of bad. She later grew fond of me, “Hello gorgeous, you’re quite a ticket!”
Psych is great, but I always had something of a hard time with treating the black box that is the human mind. I’m sure it’s the art of the practice, but I’m so used to having more data, I guess. I also felt a little weird using my own life or experiences as the norm by which to judge a patient’s thoughts, actions, behaviors. I may pull off normal well, but I’ve had my share of issues and poor coping mechanisms, not to mention my, uh, “unique” personality traits and general dorkiness.
I’ve found that I really enjoy the psychosocial of medicine–it’s why I liked psych so much, it’s why I really enjoyed adolescent medicine. And I think it’s what draws me to the ED (Emergency Department, the correct way to refer to the “ER” now), too. I love the idea that you can walk in and see anyone, with anything, speaking any language. It’s a real cultural mashup.
This is also the reason that I’m nervous tonight about my first shift, tomorrow afternoon. I could see anything walk in the door. And it’s been a couple months since I’ve been on adult medicine. Granted stuff usually comes back pretty quick for me, but the idea that I could be seeing just about anything scares the hell out of me. (I of course assume I will only see very scary, serious things, no colds or chronic lower back pain.)
So there we are. The ED tomorrow, working my butt off. Back to studying for now.
My attending told me she’d gotten a call from an outpatient psychiatrist who was complaining about our choice of medications while patients are acutely psychotic in the hospital. “You put them on Zyprexa and they all get fat!”
When you’re in the acute hospital setting (and this is one of my big beefs with residency training in the US), you kind of forget that patients go out into the real world after you discharge them. So when you want to quickly get control of their symptoms, you use a strong antipsychotic, which has the risk of pretty severe weight gain–sometimes 30-40 pounds. Now, I absolutely believe that a person being not psychotic is a higher quality of life than being a little overweight, but 30-40 pounds is quite a lot; you get into the range that people are going to develop diabetes and have bad cholesterol levels.
The problem is that whatever you start a patient on in the hospital, they’re likely to stay on as an outpatient. (If something works, you don’t mess with it!) So where’s the balance? Do you put someone on a newer antipsychotic like Geodon that has less weight gain? If it doesn’t work, do you switch to a weight-gaining one? I wish I knew the answer.
I humbly present, for your approval, evidence that most spammers are really, really schizophrenic and need to get back on their meds. We’ve got some serious derailments, thought blocking, and loose associations going on. Some recent messages:
with lower spurs of the Mountain. Two of these here thrust forward west
from the main mass in long steep-sided ridges that fell ever downwards
towards the plain. On this western side there were fewer signs of the
dragons marauding feet, and there was some grass for their ponies. From
this western camp, shadowed all day by cliff and wall until the sun
began to sink towards the forest, day by day they toiled in parties
if they saw him stoop; and even grownup he had still spent a deal of his
time at quoits, dart-throwing, shooting at the wand, bowls, ninepins and
other quiet games of the aiming and throwing sort-indeed he could do
lots of things, besides blowing smoke-rings, asking riddles and cooking,
that I havent had time to tell you about. There is no time now. While
he was picking up stones, the spider had reached Bombur, and soon he
mommy porterhouse kulak remorse attrition chimeric callahan drophead studio pigtail
permitted salaried cityscape whelan daphne concession secretary bella liturgic
impregnate antagonist bandit coed cognitive nude trudy afterglow cordite lens stoichiometry
angling thetis polecat birthday mattson coachmen mackerel serendipity
booky obeisant spartan carfare percent elect amplitude adagio
phlox ferocious kite plight sandpile leper typesetter ciliate
You see, when some schizophrenics are really sick, their speech gets all garbled up. People start speaking circumstantially–you ask a question and they’ll eventually answer it, but only at a very roundabout way. If they’re speaking tangentially, they go off on a tangent, and never actually answer your question. Even worse, they might start to have a flight of ideas–they start saying phrases that are somewhat related to each other, perhaps the last word of one sentence starts the next sentence: “All around the mulberry bush, the monkey chases the weasel… Weasels are great pets!” (Sometimes if it’s all rhyming words together, that’s clanging.) The most confusing are phrases using loose associations–the sentences don’t even relate to each other anymore. Thought blocking occurs when patients stop talking mid-sentence, and report having their train of thought totally disrupted.
I’d say the spammers need some Haldol, stat.
(And other rare, fascinating psychiatric syndromes.)
I’ll quickly admit that psych has some of the most interesting disorders and syndromes in all of medicine. You don’t actually see any of these in your month of psych, because they’re so rare, but you learn about them when you’re studying for your shelf exam. Some favorites (many taken from this great Wikipedia entry, which seems pretty in-depth with a cursory glance):
I sometimes forget how influential a person’s mental state is on their physical appearance. Two of our young schizophrenics have really come around this past week, and it feels so great to see them functioning at much higher levels. Steve has laid in bed most of the week, with a pretty flat affect (this means he interacts with very little emotion). And almost miraculously (the miracle being an anti-psychotic medication called clozapine), Steve started smiling on Friday. I was walking by him in the hallway, and he was on the phone. Smiling and laughing.
Joe, who hasn’t showered in about a week, and he lays in bed all day. When he actually does get up to eat or go smoke, his hair stands straight up, something we’ve affectionately been referring to as the “Joe-hawk.” For him, a shower went a long way to making him look better.
Another patient maybe illustrates the more subtle; she came in extremely delusional and just didn’t look well. It’s kind of how doctors can tell when someone is concerningly-sick; Jenny didn’t look so great. But there’s also something else–I don’t know if it’s a glimmer in the eye, or just a more interactive set of facial movements–or just basic body language during conversation–but when you really get these patients doing better, they look better. Healthier, more attractive. It’s an incredible change, and really feels rewarding.
I don’t think this will come off as funny as my attending tells it in person, but she once had a medical student who thought that the abbreviations “BID” and “TID” were just doctor speak for “I agree” or “Yes, that’s all.” (BID actually stands for “twice a day” and TID stands for “three times a day.” As in, take this pill, three times a day.)
My attending found this out the hard way; she’d always ask the medical student about a patient’s medication doses. The medical student would say “The patient is on Haldol 5mg.” And my attending would ask, “BID?” And immediately the student would nod back with a smile, “BID!”
Schizophrenia, as I talked about earlier, is clasically a disease of delusions and hallucinations, often auditory (hearing voices). Some interesting data was brought up yesterday in class, and it goes something like this (I don’t have the reference, sorry):
When you or I want to say something, there’s an excitatory signal sent to the nerves that control our mouths and tongues so we can say the words properly. But there’s also an inhibitory signal that goes to the temporal lobes, when auditory information is processed. However, if you only listen to yourself say the words (from a tape recorder, for example), you don’t get that inhibitory signal in your temporal lobes. Researchers believe this is a way the brain tells the difference between sounds originating from the inside and the outside.
And, as you might expect (or else I wouldn’t be posting this), schizophrenics seem to lack that inhibitory signal when they themselves speak. The theory then goes that perhaps schizophrenics can’t tell the difference between thoughts or signals from inside their heads and outside, causing them to hear voices “from outside” that are saying things.
Besides maybe Emergency Medicine, there’s probably no other medical specialty that appears in pop culture and entertainment more than the pyschiatric diagnoses. And there’s definitely no other medical discipline with so much stigma attached to each and every diagnosis. Here now, in order that I think of them, my examples of pop culture psych:
Dissociative Fugue: Usually after some traumatic event, a person forgets their entire past life, moves to another city, and starts a totally new life. Geena Davis in The Long Kiss Goodnight, and maaaybe Kermit in The Muppets Take Manhattan, when he starts working in the ad agency after being hit by a car. Probably also “amnesia,” but I’ll just include it here.
I could go on and on, but I think you catch the drift: psych diagnoses are everywhere, and they’re often totally off-base.
Shoutout question to my Psychiatry bloggers Shrinkette and Maria (okay, my dad too):
Is there a name for the laugh that one makes when talking about a patient who it just totally psychotic or manic or out there? Because if there’s isn’t, there should be. I propose the “slaugh” (that’s sad because the patient is so sick + laugh) or the “DeMlaugh” (short for Defense Mechanism + laugh). I’ll use it in a sentence:
My resident showed me a picture a patient drew of her, labeled “Space Devil.” The Space Devil’s body was a playing card, featuring a heart, diamond, clover, and lightning bolt, featured the words “smoke” and “sex” around the waste, and had a long, blue-highlighter-colored tube (a colon?) pooping out Zodiac signs. It was so bizarre, my only possible reaction was to slaugh.
Being on psych this month, learning and reviewing all the psych diagnoses, you can’t help but fearfully self-inspect for psychosis, personality disorders and the like. Look what I learned in school today: I’m a schizoid narcissist with passive-aggressive tendencies and a history of anxiety problems!
I’m really enjoying psych, and I wonder if it’s because I can relate to some degree. I think most of my classmates enjoy it, but some just don’t, and perhaps it’s because they’re just not neurotic enough, or don’t have a good sense of how challenging life can be with mental health problems.
Just a thought.
An attending told us today in our first psych lecture, “Medicine is not about stamping out disease, it’s about helping people.”
Boy have the days of medical school applications passed.
No longer do I try to figure out how to rephrase “I want to help people,” and fit it into a 500-word essay. But along with it went the whole initial notion of medicine–that is, a profession built on helping people, improving lives, easing suffering. Now for me it’s about turning a patient’s story, signs, and symptoms into a diagnosis, and then figuring out what to do for that diagnosis. Sure, often the goals overlap–but in the end, I’m not out to relieve suffering, I’m out to cure disease.
I expect (or hope?) that this will come back to me once I get the whole “diagnosing and treating” thing down pat–hell, a large part of the reason I write this blog is to remind me and others of the important stuff, because it’s just so damn easy to forget.
Part of the reason I decided to study social policy in college was the fact that I knew that as a doctor, I’d primarily being trying to improve the health of individuals, but I saw far too many individuals for any one me to help. So when I read about the legal aid services for children, and the fact that it’s going national, I couldn’t have been happier.
It turns out that doctors tend to work in a pretty specific realm (the medical one, surprise surprise). But health tends to be affected by multiple realms. Doctors are great advocates for their patients for their medical health–giving medications, for example–but when it comes to more systemic, structural problems, I’d give doctors as a whole an F. That’s why we work with social workers, child life specialists, home health nurses–these people have better footing in the non-medical health arena.
What the Boston legal team has been addressing is another level of advocacy–administrative and regulatory advocacy. This entails ensuring that laws are enforced and people are held responsible for their responsibilities–for example, ensuring that a landlord keeps his apartments’ habitable. Lawyers know how to push the right buttons (and have the time to do so) that often doctors don’t.
It’s possible that these lawyers are having a greater impact on health than the doctors with whom they work.
This story is awesome, in the sense of “full of awe.” It is almost unbelievable, in the most literal sense. It questions my assumptions about the limits of the human mind. It is what I love about neuroscience.
40 year-old AJ says that she can remember individual days of her life, starting in 1980. Researchers are calling it hyperthymestic syndrome. I first heard about this story on NPR, and there was a follow-up short interview with her today. I luckily found a free PDF of the published Case Report (thanks Google!) from the journal Neurocase, and it’s very readable–something in-between a New Yorker piece and a scientific journal.
AJ has been rigorously tested over the last 5 years by neurologists in Los Angeles to both confirm that she’s not a hoax, and to learn more about her condition. On two separate occasions, two years apart, she was asked to recall the dates of all the Easters since 1980 (this is especially impressive, as AJ is Jewish). She also recalled what happened on each Easter; these were verified from meticulous diaries AJ has kept since she was 8: 
You ask her any date, and she says that she can go back and feel the day, almost relive it. A gift and curse: she vividly remembers each day of her childhood–her earliest memory is as an 18 month-old–but she remembers every bad day just as vividly. She doesn’t appear to have any other type of profound memory ability; she can’t memorize long lists of numbers, and she can’t tell you days of the week in her past or future. She has only an average IQ when tested (although her IQ memory component scores much higher). It’s almost too amazing to believe; you’ll have to read the report yourself to see all their verification steps.
Before this, I had assumed that the human mind would be simply uncapable of recalling so much detail–how neurons could somehow store so much information is beyond me–but it seems that it can recall, but perhaps at a price. AJ appears to also have OCD tendancies (as evidenced partially by her meticulous journaling); she appears to have some brain lateralization abnormalities; she appears to have some executive functioning deficits, as well as some dysnomia (naming objects the wrong but associated name) and decreased motor speed in her dominant hand.
It’s hard to imagine a world where all my days are recalled so vividly. Most of us only have small bits and pieces of our memories remaining; I remember going to the hospital to see my brother when he was born, but only in small faint outlines. I remember playing tetherball in the 4th grade. I remember a trip to New York in high school. But these are only little punched-out experiences that for some reason my mind chooses to recall, maybe only a couple each year of my life. But AJ can tell you the day she had conjunctivitis in 1987, or which boy she was going out with during high school when you give her a date.
I would imagine there’s a reason we don’t all possess this ability–that it perhaps distracts us from the rest of our lives, such that if we’re recalling so much about what happened on July 17, 1984, we won’t notice the tiger creeping up behind us to eat. I would imagine that the system of memory most of us have is at least somewhat optimized–balancing all the functions the brain has to manage.
There are three phases of memory: recording, storage, and retrieval–but it’s not yet known where AJ’s “talent” lies–is she just a better recorder? She was very retrospective as a child, looking back at her life often–did she teach her brain to do this? Or does she have better storage–she just can store more memories than you or I. Or is her brain better at finding the memories–is it more organized, like her OCD tendencies? And what would that mean for the rest of us–are all of our days just locked inside our brains, inaccessible, but actually there? Could this be turned on somehow?
I thank AJ for stepping forward and being so open to testing at her expense for the benefit of medicine–often in science, it’s the outliers that teach us the most about the rest of us.
PS: If you like this brain stuff, you’ll love Vilayanur S. Ramachandran’s Reith Lectures from 2003. He’s a neuroscientist at UC San Diego. Free streaming audio.
Our clerkship director has a nice catch phrase that sums up the medical student experience pretty well: “You have one foot in the medical world, and one foot in the real world.” By this, she means that as medical students we’re not completely totally 100% sucked into the crazy world of medical jargon, probabilities, and doctor-think. And because of this, we’re a valuable asset to our teams; we’re able to spend more time with our patients and our families, and we often act as translators from Medicalese to English (or Spanish, as the case may be).
I’ve always prided myself on being very perceptive of the medical jargon, and I’ll even go so far as to interrupt my attending to translate if necessary–but I’m losing my touch. Because the Pediatric patients are pretty quick and to the point, I can usually do a pretty quick presentation. But between trying to improve my speed and translating for most of the past two weeks into Spanish, my brain hasn’t had enough processing power–I caught myself asking an English-speaking patient if her child has been “afebrile,” and got a confused stare immediately. “Uh, I mean, has she had a fever!?” I asked apologetically.
And yesterday, more evidence that my medical training is starting to influence the things I assume: a 6-year girl came in for a red streak (mom thought it was blood) around her stool, and going through my history with the mom, she said that cancer ran in the family. I ignored the fact–didn’t even present it to the attending–no way cancer is relevant to this case. My astute attending, however, asked mom: “Any intestinal problems in the family?” and the mother replied, “Yes, my grandma just died of intestine cancer, and it started with blood in her poop.” Of course! No wonder the mother is coming in–she had assumed her child might have colon cancer. Me, medical student that knows that colon cancer in a 6 year-old would be extremely, extremely, extremely rare (as well as most other cancers), just skipped over the fact, assuming that cancer had no role in this case.* (It did have a role–but psychological, not medical.)
The deeper down the rabbit hole you go, it seems the harder it is to even know your assumptions. Until you get burned. All of a sudden they become much more apparent.
* I know someone is going to comment about FAP or HNPCC or ulcerative colitis, and how those could have a child presenting with colon cancer. I know, I know.
Two tidbits from my Pediatric Urgent Care Clinic:
I was alerted by my Nana to a mumps outbreak back home: 365 confirmed or suspected cases in Iowa, 33 in Nebraska, 13 in Kansas and 18 in Illinois. One of the concerns is that the mumps vaccine offers only 95% protection–that is, 5 out of 100 people will still be susceptible to mumps if they’re exposed.
So please, please, vaccinate your freaking children. (Vaccinate your non-freaking children, too.) Do you want a 5% chance of mumps if your child is exposed, or a risk much higher than that? (Mumps classically causes swollen parotid glands in the cheeks, but can also lead to meningitis, and infertility in post-pubescent boys.)
Just look at the news around the world. Just today I count officials in four different countries worrying about measles outbreaks. If you think this doesn’t matter to you, think again. For most of you, I can guarantee that someone from each of those four countries is coming to your area. Today. (Measles is generally infectious 4 days before the rash appears to 4 days after.)
Joey is twelve. No, wait, fifteen. His face is twelve. His neck, scarred from pepper spray, is a bitter eighteen. His abdomen, with a line from a stab wound, is a harsh twenty-five. I guess it averages out. Okay then, fifteen it is.
Joey is the third minor I see by myself today at a well-child checkup in Fremont; his parents are working. I’m starting to get the hang of it–medical history is quick, social history is long and involved. Tells me his grandmother had just passed away and his one-year old daughter–yes, daughter–was sick in the hospital with pneumonia. (I double-check his age, yes, he’s 15.)
Up until this point, most of the other teens I’ve seen have tried to play it cool, or curse a lot, or are in good moods. They like to think they’re adults, but I still talk to them like they’re teenagers. Not condescending, but just not… adult. But Joey’s just lost a family member. “I’m so sorry to hear that” is my automated response. Not that I don’t care enough for spontaneity. That’s just what I’ve found as the easiest, non-judgmental, non-assuming thing to say whenever someone says someone is dead or has died. That, and some silence. Respect for the dead.
I find out Joey’s sister has diabetes, and Joey has a cough. He smokes cigarettes. We discuss coughing and cigarettes, and the irony. I smile, he smiles. He uses marijuana infrequently. He doesn’t drink alcohol.
Joey is sexually active, with his “lady.” He doesn’t use condoms. He doesn’t like they way they feel. His lady uses birth control. His “ex-lady” and him had a daughter.
Joey gets quiet. He tells me his daughter, the one with pneumonia, died yesterday.
He starts to cry.
I want to, too.
I’m speechless. The automated reply doesn’t fit. Only silence will do. I glance back at his age; he’s lost a child. He’s a parent who’s lost his one-year old daughter. I feel sick in my skin. I apologize profusely, painting him with empathetic words, trying to remain calm while my eyes water briefly.
We talk a little bit about it after he grabs a tissue–she had had a pneumonia because his “ex-lady” didn’t know how to take care of a baby (he does, he raised his three younger brothers). His daughter had had the infection for two weeks, and went into the hospital after it was just too late. I’m still in this shocked state of disbelief. We talk some more, and I try to let him know that we can talk about this as much or as little as he wants, and that there are lots of people who can talk with him and help him, too. I tell him that I find talking about difficult things helps me sort through it all in my head.
The rest of the talk goes on its way; I fumble two or three times, awkwardly trying to figure out how to continue the exam respectfully. He was beaten up by his stepdad when he was 7; he educates me about the two different gangs he has been in. He tells me that they have the right to take his life at any time because he left them.
I talk with him more than I usually do with the other teens. I go into more depth about what he wants to do in a few years. I educate him about the heart and the lungs and the thyroid gland. I have some foolish wish that an extra 4 minutes talking about hyper and hypothyroidism and diarreha versus constipation will magically grab his interest in science and medicine and solve all his problems, heal all his pain. It makes me feel better more than it does him.
Joey is fifteen, but life-wise, he’s eighty. He deals with these catastrophes as best he can. As best any fifteen year-old can. He tries to be tough. I can’t help but wonder if he thinks that this is just his lot in life–how his life (or anyone’s, for that matter) is supposed to be–or if he really knows how much adversity and despair he’s already experienced.
I sigh. I think it’s the former.
What is with this? Why do we want some sort of tangible intervention when we leave the doctor’s office? Why is education and discussion not enough, and how can we do a better job of both increasing patient satisfaction while decreasing unnecessary medications and other treatments? I’d be especially interested to learn if this is an American or Western concept, or whether this sort of expectation exists throughout the world–or even if this has only come to exist recently?
I wouldn’t be surprised if there’s a monetary “value for your money” component to it; either you pay a co-pay or a ridiculous amount for your health insurance, so you carry over the expectation of money exchanged for goods (arguably you don’t get “service,” as your doctor may be running late).
I think there’s also a degree of discomfort with “just watching” someone’s condition–either from an impatience standpoint or a worry factor. Or maybe the feeling of the physician abandoning the sick patient, or not showing the patient some sympathy or empathy. “You want me to what? Go home, rest, and drink some liquids? I’ve felt awful for 3 days already, and you’re not going to give me anything for it?” (I’m definitely guilty on this count.)
It looks like physicians as a whole are pretty clueless about patient expectations; perhaps figuring out what a patient wants to get out of the visit will help to head off some patient disappointment at the end of the visit. I also like the concept of not downplaying a person’s illness; I’m guilty of telling patients “it’s just a virus” many, many times.
A cursory Pubmed search didn’t turn up much, but I wouldn’t be surprised if patient satisfaction increased if all patients were just given a little one-page handout on their condition. It would satisfy the tangible need, reassure them that they have information–including when to expect to feel better, or medication side effects, or when to return for a follow-up appointment–and wouldn’t lead to excess antibiotic usage. It’d be simple to customize the handout with the patient’s name and some other personal info to make it feel even more individualized; anyone know if this has been studied?
I’ve spent some time over the past couple weeks at Juvenile Hall. I think it’s one of those experiences where I learn more than I actually contribute, and I just hope that I’m sensitive and understanding to these kids’ problems, and not just look at them like they’re this foreign world to me (which they are) which I can’t do anything about (which I can).
You don’t know how frustrating and condescending it is when you’re doing your best to speak your patient’s native language as best you can (and not doing half bad given that you haven’t really practiced in a couple months), and your patient’s mother and grandmother start laughing and making fun of the way you pronounced a word. Yes, I had my stethoscope on, ladies, but it ain’t exactly soundproof. And I can understand much better than I can conjugate.
I’m as obviously gringo as they come, but it’s obvious that I’m trying my best, and I’m making an effort. I don’t care if I’m a medical student or your doctor or the guy who cleans your toilet; it’s rude, flat out.
I’m all for doctors and medicine trying to be as objective as possible, but it’s just so damn cute when doctors think they actually are objective. As if we don’t bring our own values and assumptions to the table. I’m doing well-child checkups this week at a county health clinic. I walk in, see a 9 month old baby, a 40-something year-old woman, and a 16 year-old girl, and immediately turn to introduce myself to the 40-something year-old woman, because clearly she’s the mother of this child; 16 year-olds don’t have babies!
I cringe every time I recall this story.
Next is the number of superstitions we go through as physicians (luck and superstition are clearly objective, too). For example, I will never, ever mention how a day or night of call is going smoothly, or how quiet the pager has been, or how empty the floor is. I will think it, and consider bringing it up for casual conversation, but it stops there; for if I mention anything to that effect, I will jinx the team and we’ll magically have 20 new admissions that night. I know this is totally crazy, but I totally, 100% abide by this. I don’t know that I totally believe it, but I’d much rather keep my mouth shut and hopefully have fewer admissions.
And it’s only medical things that I’m superstitious of, which makes it even more ridiculous–in the medical world, where we base everything on risk, benefit, and predictions from data and randomized, double-blind controlled trials, I truly act in a certain way, hoping my behavior will somehow influence the outcome.
Another reason to dissuade parents from asking for antibiotics for viral infections: Does Antibiotic Exposure During Infancy Lead to Development of Asthma? Could this be the reason we’re seeing more and more asthma in pediatrics?
March 25th, 2006The first expression of religion I’ve seen from an attending happened more than 9 months into my first clinical year:
A very, very sick pre-teen that we made sicker with chemotherapy wasn’t initially improving when he should have been, and the oncologist told us that she hasn’t slept in days, worrying about the child’s health. After another sleepless night, she told us that she
“Sat down and just prayed. Just prayed that [the child] would be okay, and that his counts would come back. I figured it couldn’t hurt. And then my daughter came into the room, and asked me what I was doing. And I said, ‘I’m praying for a little sick child who needs to get better,’ and my daughter decided to pray with me. And then my other daughter walked in, not saying a word, and sat down, bowing her head as well. After about a minute, she whispered, ‘What are we doing?’”
The attending on staff said that he knows an Indian adult oncologist who can get 1,500 people praying for a patient back in her hometown at a phonecall’s notice.
Desperate times call for desperate measures, I guess. Kate and Matthew discuss a Forbes article noting that doctors are more religious than the general public, at least according to the survey. I think it’s easy in medicine to lose faith in God or religion day-to-day; you see terrible tragedies walk into your office or hospital on a regular basis. But I think there’s probably a part of many physicians that at least hopes there’s something more to all of this, something out of our control. It’s not something that we can rely on–but at least something that we can try to call upon when our medicines simply aren’t enough, or when we could really use the scale to tip in the right direction.
One of the many reasons medicine’s an art, not a science.
Busy learning Peds, which I’m really enjoying. A quick eval, starting with the pros:
The cons:
Well medbloggers, the time is here. Readers, meet MDCalc, The Clinical Calculator. MDCalc, meet the readers. MDCalc is a free website to help you do the medical calculation grunt work.
I got tired of wading through Google searches to find a calculator for all those medical calculations that you often have to use, but don’t use often enough to remember: the A-a O2 Gradient, the Calcium Correction in Hypoalbuminemia, the FENa, the MDRD. And countless others. (Easy ones, too, including the BMI and a patient age calculator.) I’m going for the Guiness Book of World Records, Most Medical Equations on One Website.
I’ve also included a number of scores and risk calculations, including the Framingham Cardiak Risk, the PORT Score/Community-Acquired Pneumonia Severity Scale Ranson’s Criteria for Pancreatitis and the Strep Pharyngitis Probability Score. Not to mention the TIMI Scores.
You can even download the equations to your PDA.
So please try out the site, and tell me what you like, what you don’t, and what I’m missing. Feedback is greatly appreciated! And if you feel like it’s worth a link, please link to it on your blog!
(Special thanks to those who volunteered to help test!)
Oh hellll yes. Did my first lumbar puncture (aka spinal tap) today. On a 5 year old. Champagne tap! (A “champagne tap” is when you get clear CSF fluid without any red cells in the fluid, as they can often contaminate your results.)
My attending, being the awesome guy he is, ran out and bought me a mini bottle of Korbel to celebrate.
I love procedures.
It is really, really refreshing when your patients have no other medical problems, are taking maximum one other medication, have a short history of present illness, and are really cute and wide-eyed.
And don’t talk back.
Thank you, Pediatrics.
Now would be a good time to wrap-up my long two months on my Internal Medicine clerkship, seeing as though I start Pediatrics tomorrow, which totally scares me because kids definitely don’t get my wry sense of humor and frequent pop culture references. In no particular, bullet order, because I’m just not in a paragraph writing mood tonight:
And so the morning routine begins, checking morning labs. I turn on the computer, login to the medical record system, and up pop a bunch of lab results for my favorite patient–he’d been transfered off my service to the surgeons, but I liked to keep an eye on him and his labs (I’m very protective), and I had forgotten how to turn off his lab notifications, anyway. I had just seen him the day before when I stopped by to say hello just briefly.
He has abnormal labs every day. A high blood sugar from his diabetes, a moderately low sodium, an elevated creatinine from his chronic kidney disease. I skim them again today. That’s weird. A critical result?
I double-click the chemistry panel. It’s probably just a high potassium before his dialysis.
CO2 9 L
RESULT RE-CHECKED AND REPORTED TO NURSE.
My heart skips a beat. What the hell? 9? That’s too low. Wait, CO2, that’s not pCO2. That’s bicarb. Bicarb is supposed to be 24. Oh shit. What the hell is going on?
I move the mouse over to the Notes tab of the system to get more information. I’m overwhelmed with the slew of the last 100 notes written on the patient. The most recent one is selected automatically.
Pupils fixed and unresponsive.
No! What the fuck. Wait, does that mean coma? What the hell does that mean? My eyes somehow skip ahead to the last line of the short note, as if they’ve already read the conclusion before my consciousness has.
Patient pronounced dead at 9:40pm.
I go back to read the lines again. Pupils unresponsive. No sign of breathing. No pulse or heart beat. This can’t be happening. Tears wet my eyes. I read through the last 5 notes. ICU transfer accept note. Pt found unresponsive, E-team notified. Patient intubated, blood pressure stable on pressors. Family arrived. Discussed patient’s status, and care was withdrawn. Pt extubated, put on comfort care.
I’m just stunned. That’s not how things go, I tell myself. You don’t go from smiling and with it and happy and you don’t just go see your favorite patient one day for 20 seconds, run off to do your work, and read that he’s dead the day you come back. You don’t die that way in a hospital. You die a long, protracted course in the ICU, where we throw everything but the kitchen sink at you. And you get better. And you get worse. And then you get better again, and then you get really sick. You don’t just fucking die like this.
I went up to the ICU to talk to the intern about what happened. Luckily I knew him, and luckily he’s a very outdoorsy, in touch with his feelings kind of guy, so I wouldn’t feel stupid to ask him what happened, and how the patient died, and if he was comfortable, and if his family got to see him before he passed, and what we tried to do to save him. He explained everything to me, and my mouth kind of did that little involuntary frown thing it always does when I feel just really sad and like I want to just lose it but I have to fight back the tears. He could tell I was upset. But it was okay to be upset.
So I walk back to the team room to finish my work on both my patients who are cranky and crotchety and tell one intern about it, and there’s not much reaction. The patient wasn’t his. I understand. I assume there will be a larger showing of grief with the other intern–the one seeing the patient with me. She finds out, and there’s a minute of a surprise, and sigh, and a discussion of what happened. But then it’s business as usual.
Both are incredibly caring people and will be wonderful, compassionate physicians, but more than anything I fear–no, I know–that this will become me. That I’ll have so many patients die on me that often their deaths will be only a minute of my time. Now maybe I’m wrong, maybe they grieve privately, on the inside, like I am. Or maybe not.
I guess I’m mainly so torn up about this patient because he was mine. And maybe it’s some sort of screwed up egotism. Or just that his death was so unexpected. Or that I spent so much time fighting for him, worrying about him, and trying to make sure he got his surgery and his studies as soon as possible. Or that I feel guilty for only giving him a casual Hello, how are you today as our final words. Maybe that’s all our relationship was to him to begin with.
But I think, most of all, I was upset was because he treated me like his doctor. I was the first one to greet him every morning. I was the one that helped him put in his hearing aids and change their batteries, getting his ear wax all over my hands time and time again. I was the one that always complimented him on the really great deep breaths he’d always take so I could listen to his lungs. And no matter how often I corrected him, he always called me Dr. Walker. He was the one that woke up one day, confused from getting too much medication, and didn’t understand he was in a hospital. He cursed at me, and I told him we were all here to help take care of him, and he groggily but immediately said he wanted a second opinion, as if I was his first.
After he was transfered over to the surgeons for his operation, I visited him every day, and he told me how much me missed my morning exam, and how much he loved hearing me encourage his deep breaths. He had gotten in the habit of mimicking me, without his hearing aids, to the point that he was practically yelling to the entire floor.
“Wonderful, just wonderful, Dr. Walker,” he used to say.
My interns and residents had been talking for weeks about how bad a code situation is, and so when the patient was found unresponsive in his hospital bed today, I figured it’d be neat to go watch. Neat being my Hollywood, glam and glitz, heroic understanding of a code; terrifying would probably fit better. Yes. I figured it’d be terrifying to go watch.
I was amazed at the scene when I arrived, watching from outside the door. I got there only 10 seconds after the Code 66 had calmly been announced overhead (Code Blue scares patients, I guess), and already 25 people were in the room, with supplies, the crash cart, and it was loud. About 8 people were actively around the patient, with others supporting the 8, while some other people were trying to move the patient in the next bed out of the room. I did my best to stay at the periphery, out of the way, and help out when I could. People were quietly talking about how the patient was found, that he was supposed to be discharged today–and who knows where the rumor mill went from there.
A small woman was doing CPR on the gigantic patient (and luckily soon switched with a much larger male nurse), while others were checking pulses or trying to configure the defibrillator. Interns and residents were trying to start femoral lines, palpating weak pulses that trickled by with each chest compression. Two people were bagging the patient with oxygen. The ICU fellow was calling for meds and thinking aloud (I would soon learn the 5 H’s and 5 T’s), while the intern responsible for the patient was announcing the patient’s morning labs and vital signs (“K was 3.6 this morning! Blood pressure was 110/65!”), all of which were stable and within normal limits. The pharmacist was doling out medications from her kit as fast as they were being called for.
Toward the end, the senior resident responsible for the patient was in tears, and the room grew more quiet, with fewer audible voices drowning out the sounds of the code equipment and the oomph of each chest compression. There were fewer looks at the patient, and more at the clock. The pharmacist announced the passing time. “Four minutes since arrest” became “nine minutes” became “fourteen minutes” became finally “twenty minutes,” and the patient was pronounced dead.
“The key is to stay calm,” my resident told me. I told her I didn’t think I’d ever be calm in a situation like that, and she shared her secret: “I just assume the patient is already dead, and anything I do can only help them.” I think she may be right.
Flawed and unethical, but I bet it would work:
You would’ve thought the Terry Schaivo thing would’ve done this already, but I seem to get all the patients who have no idea what they want. Just last night, an elderly Hispanic man was admitted for possible heart failure and possible heart attack, and after a lengthy discussion about code status, he tried to give me this innocent little indecisive giggle-shrug-smirk, as if I asked him what type of food he wanted to eat for dinner and just wanted to be agreeable. This ain’t one of those types of questions. You need an answer.
On a more ethical but medically ethical topic, some people propose making the organ donor system an opt-out system, where one would automatically be consenting to donate their organs unless they specifically said they didn’t want to.
*A person’s code status tells the health care system what he or she would like done if their heart stops or lungs stop working–would they like everything done (full code) at one extreme, or would they like no measures taken (DNR, DNI – do not resuscitate, do not intubate). You can pick any level of code status, and have specific parameters as well.
Call me crazy (“Hi, Crazy!”), but I think we need to start changing the medical school curriculum a bit.
One of the main focuses of the pre-clinical and clinical curricula is teaching the medical student the art of the differential diagnosis. You basically take someone’s symptoms, and try to figure out what’s causing their disease–any number of body systems can cause similar systems. And as the saying goes, “You can’t treat what’s not on your differential.” That is, you’ve got to consider everything, so if it’s not what you think it is, you’ve got a fallback 2nd or 3rd idea for what the problem could be. Obviously important to reinforce this concept into our heads. Over, and over, and over again. And then over some more.
But one area where I think we’re lacking–because medicine has changed so much–is the treatment of the chronic disease. We focus so much on the acute still in medicine, when our patients have primarily shifted to the chronic. Sure, as residents we have clinic time where we see patients as outpatients in a chronic disease setting–but most of our residency (and much of our medical school) training is still focused on the acutely ill patient. While this definitely hammers home important concepts in many diseases, which can then be translated to the outpatient basis, I wonder if there’s more we should be learning. If you look at physicians as a whole, they’re not working in hospitals, taking care of acute patients. They’re working in private practices, seeing outpatients.
What should change? A couple ideas:
A lot of this you can pick up on your own with trial and error, tips and tricks from attendings, and good social skills–but it seems like it’s this gaping hole that medical training is de-emphasizing, even though it’s the bulk of “practicing medicine” as professional physicians.
So I got pimped mercilously by my attending two days ago, while I was sick, feeling like crap, and had only seen my patient for like 20 minutes. So it never happens to you, I present the quick’n'dirty acid-base disorder step-by-step guide:
And on to the mnemonics for the causes:
Anion Gap Metabolic Acidosis: MUDPILERS
Non-Anion Gap Acidosis: HARDUPS
Acute Respiratory Acidosis (Chronic Respiratory Acidosis = COPD/restrictive lung dz): any hypoventilation state
Metabolic Alkalosis: CLEVER PD
* = Associated with High Urine Cl levels
Respiratory Alkalosis: CHAMPS (think speed up breathing)
I’ll often use “pimp” in a sentence, and non-medical folks give me a strange look. So, to set the record straight:
pimp, verb. To question a medical person lower than oneself on the spot about a medical fact or truism to see if said person knows the answer show how smart or dumb the person is in front of a group.
Examples:
So I’m reading through this Wikipedia list of cognitive biases, and it’s pretty apparent that almost all of these factor in to our discussions of patient care. A sample, with the definitions provided by the Wikipedia:
Note: I’m not saying these happen all the time. Just that they can, and we’ve got to be on the lookout for them.
I’m no expert on the topic, but now that I’ve worked with 4 electronic health records / electronic medical records (EHRs/EMRs), I’ve seen the good, the bad, and the ugly. (Usually the two latter are due to interface design and data display done by engineers, not by clinicians or nurses.) My rules first, and then my suggestions:
And the suggestions:
I realize that a good deal of the time is spent on putting the database and backend together; I’ve seen the schema and code for our free clinics’ medical record system. But a little more attention to the front end (which is the whole point of the electronic system) would go a long, long, long long way.
More as I think of them, and please comment and add your own.
My frustration continues to grow and grow with the more I work and work. I find it extraordinarily hard to believe that with all the great minds in computers and medicine, we don’t have a system that makes practicing medicine more quick and error proof. Even at the VA, a hospital system that has arguably the best computerized medical record, things ar incredibly inefficient.
An example of my day: get to the hospital, see my patients from the night before. Write down their labs from the computer onto a sheet of paper for my “progress note”–my assessment of what’s going on with them over the last day, if they have any new problems, and what I’m doing to diagnose and treat their problems. So I get their labs from the computer. Then I go to their chart, and write down their vital signs (temperature, blood pressure, pulse, breathing rate, O2 saturation) and Ins and Outs. Then I go to their nursing clipboard and write down their medications. Then I write out my assessment and plan for the patient (what I think each problem is caused by, and how I’m diagnosing/treating it).
Once this is all done, then I copy most of it to a little reference notecard, listing the patient’s recent labs, their ins and outs, and any changes or updates to their medications.
After all that, I present the patient to my attending, where I have to read aloud the vitals, the lab numbers, the changes in the lab numbers, any study results, and on, and on, and on.
An absolute, horrific disaster. A waste of time and paper.
I can imagine a system where we all have computers, or PDAs, and all our patients’ latest data just automatically appears. But it’s just a dream.
You know, you’re in school for so long, for so many years when your papers or writings or assignments are only going to be read by your teacher. They’ll be skimmed or perused, commented on with red ink, and given a grade, but that’s the end of them. You get the paper back, maybe hold onto it for a bit, put it on the fridge for the family to see your gold star, but it ends there.
So sometimes I forget that my notes really do truly matter now. They’re no longer just going to be turned in to a professor or TA. They’re actually going to be used, and depended upon, for a number of people who are going to see a patient. They’re going to read my history and physical examination report, and then my assessment, and based on those, get a sense of what the patient’s problems are. It’s really different knowing that my notes matter. And by different I mean, “feeling like I’m contributing to the patient’s care, and also being kind of freaked out if I miss something or get something wrong.” I guess that’s why there’s interns, residents, and attendings double-checking me.
So I’m watching this trailer for this documentary called “39 Pounds of Love,”, about a 42 year-old man with Spinal Muscular Atrophy Type 2 , whose doctor had predicted he would die by age 6. He’s now an animator, weighs 39 pounds, and goes in search of this doctor. From the trailer, I get the sense that he’s out to tell off the doctor for giving him such a grim prognosis. I don’t know if it’s how the story goes, but if it is, it surely isn’t fair.
As doctors, we’re in a predicament: taking away someone’s hope is, in my opinion, a mistake that I hope I never make, but probably will. At the same time, false hope is maybe worse. I try to remain cautiously optimistic, especially when things take a turn for the better. In fact, initial studies suggest that doctors are way too optimistic: one study found that doctors over-predicted prognosis by 5 times–so that in terminally-ill patients given, say, 10 months to live, they only lived about two.
This kind of makes sense–sunny-side up people are probably going to be more attracted to medicine than half-empty folks. Doctors like to imagine believe that we can truly fix every patient–or at least help them.
So especially in a condition as rare as Spinal Muscular Atrophy (4 cases per 100,000), especially back in the 1960s (there are 190 papers on it in Pubmed from 1900-1960, and only 40 in English), I don’t think the doctor was a bad doctor, or intentionally hopeless. If anything, if we believe the studies on prognostication, he was probably a little too optimistic.
“Above all, do no harm,” is pretty much bullshit. Let me warn you.
You do not want to be a patient in a hospital. One, it means you’re sick enough to need to be in a hospital, which is pretty sick. Two, we’ll make you feel much worse until you feel much better. If you do get admitted, please just expect the following to happen. If you’re in a teaching hospital, with attendings and residents and medical students, more of this may happen. Be prepared in advance, so that you don’t get all crabby when I try to be happy-nice medical student and ask you some questions. (I realize you probably don’t mean to take it out on me, and that I’m always trying to put on my nice-happy face so that you won’t want to take it out on me, but you’re probably tired and frustrated and you’d take it out on Mother Teresa (may she rest in peace) if she were in my place, too.)
I’m not condoning this behavior or this system, but I’m saying often, it’s how it works. Many of the causes are medical–part of diagnosis or treatment–but others are political, legal, structural, academic, technologic and institutional in nature. We have a nursing shortage; we must teach future physicians; the law requires this; unions require that; paperwork must be done accordingly; technology is from the 1980s; there are limited resources available for health care. And on and on and on. If I could design the hospital system over again I would–and maybe I will when I’m older–but in 2006, this unfortunately may be your hospital experience.
Just more reason to stay healthy, eat well, exercise, and wash your hands, right?
At the community hospital where I was working a couple months ago, a 10 second lullabye-type jingle plays over the intercom, signaling that a new baby has just been born. My attending says people either love the little reminder, or it drives them absolutely batty. I’m firmly planted on the side of the former. It reminds me that even if I’m busy, or tired, or frustrated waiting for a lab value to come back, at least someone has probably just become happy. That life goes on amidst all the hussle. Sometimes it’ll play twice. For twins.
And then I started wondering about a more solemn tone. Maybe it’s shorter, an elegant or graceful piano progression of chords, with a slower tempo. One recognizing that someone has just died. Now, granted, I think patients and doctors alike would get a little worried if it sounded 5 times within the hour–but I wonder how people would respond. Would it scare them? Upset them? Would they pause for a second? Think of their own mortality? Maybe it would remind them that life is short. And fragile.
But more than anything, I think it would upset them and scare them. Chime in here if you’re from another culture or tradition, but I think we as a society have some sort of obsession with youth–and some fear of death–that doesn’t exist in most other cultures. (I myself am utterly floored by the fact that I could (okay, fine, will) die.) And what kind of ramifications does this have for medicine?
First let me note that there are two deaths I’m speaking of here: one inevitable, one failure, both tragic. One may seem like clinging on to scraps of ife because of our fears, and the other is truly medical failure. Everyone has to die of something, and I think most doctors want it to be something other than what they specialize in. But medical errors do exist–mismanagement, drug errors, etc.–and it’s those that we must fix. The scope of them is vast, and truly unacceptable.
The ultimate deaths, as I guess I’ll call them, are a harder sell. I absolutely respect people’s wishes, but I wonder how much of their wishes are influenced by our anti-aging culture. Are we guilty of trying to have as many breaths possible in our lives, at any cost? And how much of this worldview is cultural, and how much is just the human spirit? And yet I’m still torn, because our ability to prognosticate as doctors is so poor. You can take two patients, seemingly very similar, with similar diseases, risk factors, and prognoses, and see one make a fully recovery, and see the other wither away.
I just see too many people who are dying, of course in my opinion, poorly. If you want to die in an ICU, with tubes and machines and beeps and alarms, that’s your choice, but I think too often both patients and physicians see death as a failure of medicine, or as a failure of family members to make the right decisions for their loved ones. I think we’ll all face this issue more and more with the baby boomer generation, and I hope that more people will become aware of hospice care. Did you know 70% of people will die in a nursing home or hospital? Take a moment to imagine your ideal death. Is it anywhere close to how people are dying today?
Who knows, maybe the progress is already happening, just happening at a medical (slow) pace. An attending today told the team, “Mr. Doe expired. He went home.” Initially we were very confused, but then she explained that with the patient’s last hours left, and no more medical treatments available, he went home to die, with his family at his side.
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Email was down, so if you emailed or commented, I didn’t get it. Sorry for that. I ask for your forgiveness. (I also ask for you to vote for me for best medical blog–I’m in the second half of the page.)
And just to know how my day went: One patient was hallucinating so much he thought he was eating a burrito; the other patient just started dialysis, had really bad abdominal gas cramps, and then looked at me and said, “Dude, I just pooped myself.” Ahh, medicine.
Medicine, on my second day in, is kicking my butt, seriously. Expect this site to be quiet until I get a hang of things.
I presented my patient today and was horrible at it, but made up for it with handouts with a killer font. My interns told me, “Great Handouts!” Going at this rate, I’ll take any compliments I can get.
Syndney Smith, author of Medpundit, is so out of touch with medical students (and probably the future generation of doctors) it’s not even funny:
Maybe medical schools should treat medical students the way an employer does an employee – make attendance count, and have quarterly evaluations of behavior in addition to grades. But do it for everyone, not just for the problem students.
The scary thing is, I can’t tell she’s the exception or the norm. Doctors? Doctors? Bueller? Bueller?
Make attendance count? Have behavior evaluations? I’m pretty sure I signed up for medical school, not choir class. I’m an adult. If there’s a problem with my behavior or attitude or professionalism, I expect my preceptors to discuss it with me–or at least bring it up on my formative comments of my clerkship evaluation. I don’t need another hoop to jump through, showing that I go to class and that I’m a caring, respectful, professional guy (I do, and I am, according to my evaluations so far).
That being said, I agree that medical students should be on-time, professional, and working hard. If a student isn’t, it’s a problem, and it needs to be dealt with. That also being said, I’ve seen examples (uncommonly) of attendings and residents act with prejudice, act using stereotypes, or make gross assumptions about patients–so the assumption that a preceptor is necessarily a model of good behavior and professional conduct isn’t all that valid for certain people.
“Attendance” is a problem when one’s classes are broadcast online for classmates who study better at home or want to pause the lecturer to write things down. “Grades” are a problem when they don’t exist at a medical school to begin with.
I really, really enjoyed Geriatrics. And since medicine is going to practically turn in to geriatrics in a few years when our parents (and maybe you) get older, there are a number of really important things to remember about our elderly loved ones:
So I had this great idea to writeup all these practical tips for patients, not just medical professionals, but the devil’s always in the details. (The details being that I forgot to actually write them.) Better late than never.
Radiology. This is most “imaging” you get: x-rays, CT (aka CAT) scans, MRI scans, ultrasounds. All that jazz. Most radiologists don’t see patients, unless they’re doing some sort of procedure (swallowing contrast or barium, putting contrast or barium up your butt, etc.); there are interventional radiologists, who see patients, but that’s more specialized.
I hope that clears things up about radiology, or at least some of the fears and concerns. If you really want a primer on radiation, try this.
Man, I had forgotten just how bad our health care system is if you’re lacking health insurance. And if I’ve forgotten it after only a couple months, I can’t imagine what kind of skewed perspective most physicians have.
We have two excellent free clinics run by the medical students, Pacific Free Clinic, and Arbor Free Clinic. Medical students, PA students, and undergrads see patients, and then an attending sees the patient with the student. I used to work on the steering committee at both clinics, and spent many weekends at both helping to run them. But since my own clerkships started, I hadn’t been back. So this weekend, I volunteered to see patients at both, and what a shocker I was in for.
I saw a man and his wife at one of the clinics–both overweight, both diabetic, both with high blood pressure–and neither with health insurance. They weren’t checking their blood sugars regularly, they had run out of medications. (They were fine up until he lost his job a year ago.) This meant that when we checked their sugars and blood pressures, they were of course sky high. Long-standing high blood pressure is a major risk factor for strokes, heart attacks, and kidney disease. Long-standing high blood sugars are major risk factors for developing diabetes complications–heart attacks, nerve damage, retina damage, etc. So we diagnosed the problem of these uninsured folks, but treating them was the bigger challenge. An aside: I was completely surprised by how much I really have learned in only 6 months–I pretty much knew how to manage these patients from a theoretical standpoint. Their lack of insurance, however, upgraded the treatment to a level of complexity for which I hadn’t trained.
How do you treat them? With education, medications, and doctor visits every few months. We could do some basics of education in the clinic, but understanding diabetes is a pretty hefty bit of education, since so much of it requires patients to manage themselves. Medications we could also do to some degree–we have donated meds in clinic, and we can also give vouchers for free meds through a local pharmacy (the clinic foots the bill). Unfortunately these patients had been on a bad set of medications–some wrong ones for diabetics, and we wanted to start some new ones. This meant we needed labs. We drew some blood, and Stanford gives the clinic a great deal on blood processing. Finally, for the doctor visits, we referred the patients to a local clinic, but judging by their body language, they were hoping to get their long-term health care through our free clinic. Now, we’re happy to try to see patients like this, but our list of similar patients has grown so large that we’re not able to see them as often as they need to be seen. Throw on top of this that it’s a teaching clinic, with bad continuity of care and mostly students, and the clinic is less than ideal for chronic disease management. But we tell ourselves (and patients probably tell themselves the same) that some care is better than none, and hope that today just means that we’re one day closer to some sort of better health care system.
Fast forward on this DVD to the next chapter, where I see an uninsured patient whose chief complaint is “shortness of breath and leg swelling.” Heart failure? The undergrads have put the poor guy in an isolation room because of our constant vigilance about TB, and after getting a few more details from the patient about his “cough and night sweats,” I determined tuberculosis wasn’t my main concern. So we moved into a normal exam room, and I could have sworn I was on Med School Candid Camera (or for the kids out there, Med School Punk’d). Every question about heart failure I asked seemed like it was a scripted response–exactly what one might expect. Almost too classic of a presentation. He had chronic atrial fibrillation, thyroid dysfunction, and had been taking medications for heart failure already. He had run out of medicines three weeks ago, right when this shortness of breath and leg swelling started. He had huge legs, full of fluid. He had huge neck veins, full of fluid up to his jaw. He had a previous heart attack, he thinks. He had had this before, and taken a water pill — “furomide, I think” — and everything got better. So I go present to the attending, and she’s scared of even touching this patient, with all these problems. We tell the patient he needs to go to the ER to have his medication levels (digoxin, coumadin) checked, as he doesn’t get them checked regularly, and we’re worried that his heart is in trouble. The attending asks the patient to promise that he’ll go to the ER, and while he does, I’m skeptical. (The patient I’m sure knows that he’ll get a huge bill from the ER that he can’t pay.) Three hours later, I’m in the lobby calling another patient in, and I see this first patient, waiting for his son to pick him up. I seriously doubt the patient went to the ER.
Don’t like my story-telling? If that’s the case, try these similar stories: one about a family who has been denied health insurance by the only insurer in the state, because he, his wife, and their daughter have all been seen for medical conditions in the past. Or a Sacramento Bee Op-Ed about how one man’s family is dealing with the health care system.
Don’t like my story content? Well I’m sorry, but this is becoming more and more common. You’re going to hear these stories over and over, if you haven’t already.
If you’re not having good days and bad days as a medical student, you’re just not trying hard enough. This whole experience is at least partially preparation for the real world of medicine–that there’s two sides to every story, that there’s an art to dealing with all sorts of people, and that you must learn from every encounter you have with a patient.
So there I am, two weeks ago, with a good day and a bad one in the same 24 hour period. It starts off with a patient with an autoimmune disease. I go see the patient with a fellow. (A fellow is a doctor done with residency that is now specializing.) This fellow is well-liked by all of his patients, as far as I can tell. His interview style is very focused, however. Question, answer. Follow-up question, follow-up answer with tangential comment… question to get interview back on track.
Today we walk in to see this patient, and I can already tell he’s a little agitated, or frustrated or uncomfortable, for whatever reason. I don’t know if the fellow doesn’t pick up on this, or just ignores it. Fellow asks a bunch of questions about how the patient is feeling, the patient says crummy, that he’s constantly aching, and isn’t getting any relief from his current medications. Fellow addresses this to some degree, but doesn’t offer any solutions. Fellow is looking down at his notes; I’m sitting on the exam table watching the interaction from the sidelines. The patient starts to say, “Well then, here’s what I’d like from you,” but is cut-off by the fellow’s next question, something about “any nausea or vomitting?” Aaaaand, the fellow has officially lost the patient. For the rest of the interview, the patient answers quickly with rapid nodding, wanting to get back to his request. I’m thinking to myself, “Do I say something? I mean, of course I say something, but how do I say it without butting in–” And then I realize I’m Super Patient Advocate, and it’s my duty to step in. I wait for a pause, which the patient then takes to start asking again, and gets interupted a second time. The patient is now eyeing me, and I’m kind of nodding in agreement, trying to let him know I’ll say something. The patient is getting more and more visibly annoyed with the fellow, but the fellow can’t see because he’s looking down taking notes. Finally, finding a half-second pause somewhere, I blurt out, “Did you want to say something?” to the patient, and he gets his request in for some pain medications.
Now, I have to admit, this encounter was fascinating. When presenting to the attending, the fellow described the patient as “a kind of cantankerous gentleman,” and I could clearly see the reason the fellow found the patient cantankerous–the patient was annoyed with being ignored! I’d be pretty damn cantankerous too.
At the end of the visit, I got a direct “thank you” from the patient, and I nodded, somewhat apologetically. In the end, each party got what they needed from the appointment, but it put both parties on the defensive to some degree.
Which makes my second encounter all the sweeter. That same day, in lung clinic, I pick up a chart of a new patient and start taking notes from his file (he’s an hour early, by the way, but there were no other patients at the time). He’s got a number of severe medical problems that have caused very catastrophic complications, making him wheelchair-bound. (He’s been waiting in the room maybe 7 minutes while I’ve been reviewing his file, and asking a question about a drug’s effects on the kidney.) Just as I’m about to stand up, he starts to leave, complaining to the nurse about how long he’s been waiting (he’s now 53 minutes early). I walk toward the room to introduce myself and apologize for making him wait, and he makes some snide remark to me about how he was just getting ready to leave. I go in, we talk, and immediately get the sense that for whatever reason, he hates hospitals and doctors. (I later find out he has good reason to be skeptical; he’s had several major medical problems caused by shoddy medical care.) He talks to me about how terrible doctors are, and doesn’t really know why he’s at this appointment, continuing with a tone I interpret as him blaming me for forcing him to come today.
I finish my history and physical, and tell him I’ll be back “in a bit.” I probably should have warned him that since he was so early, he would have to wait awhile so I could discuss his case with the attending (lesson learned). Granted, it’s still 20 minutes before his appointment is even scheduled. He opts to leave the door open, which is right across the hall from the workroom, and he stares at me while I work on the computer and talk with the residents, probably thinking I’m ignoring him, or not doing anything productive, just making him wait. 20 minutes later, the attending is ready for me, and I present his case quietly, as he continues to stare me down from across the hall. We then go in together to see him, and he loudly comments, “Finally, a real doctor.” I quickly retort, “Yes, I just play one on TV,” and go along with the joke. We see him, and he talks about buying his 16 year-old daughter cigarettes, and I can fully tell we are from practically different planets. As we’re leaving, he complains again to me about having to wait (it’s now 15 minutes into his scheduled appointment time), and that does it. I turn around, pissed, and get about two words out about his appointment time, “Well, it’s…” and I smartly bite my tongue, turn back around, and just walk away.
He knows he’s gotten to me. And I’ll admit it: he had. From the moment I entered the room. The community health side of me kept reminding me, “There’s probably a great reason why he didn’t seek medical attention early and now has all these severe problems that he’s angry with: maybe he didn’t have health insurance, or he knew a doctor that was a total jerk, or he didn’t have the education to recognize the warning signs of his disease, or he was too busy working three jobs to support his family that he never found time for it.” But with each jab (and the fact that I took it personally), the individualist crept in. “This is his own fault. He didn’t seek medical attention for a long time, he didn’t take his doctors’ advice, he thought medicine was a load of crap. He screwed up, big time, and now he’s paying the price.”
And therein lies probably one of my biggest challenges of being a physician: not taking things personally, not getting so easily annoyed, and continuing to provide the highest-quality care to all my patients, no matter who they are, or what they say, or how they react to me. And it’s definitely a challenge. Other professions don’t carry such an obligation. Part of the reason I’m writing this out is to get a handle on it, understand it, and do a better job next time. I think sometimes it’s soothing to rationalize behavior as pathology–that my patient has a personality disorder, and that’s why he was being such a jerk to innocent little me–but I don’t think that’s right, either.
I can see why physicians and residents get jaded now. For me so far, the late night pages didn’t seem like they’d be that bad. And while scut work sucks, it’s not jade-developing. But being treated poorly by someone you’re trying to help could turn me bitter pretty quick.
But there’s a part of me that wonders if my patient was annoyed with me for the same reason the first patient was annoyed with the fellow, and maybe that’s what frustrates me: not knowing if I could have done better.
We’re still a long way from great electronic medical records, but it seems like we’re not even picking off the low-hanging fruit. I was at the VA last month (which, among some unofficial surveys of many physicians, is by far the best electronic medical record out there right now), and saw a patient with gout. He had had an acute attack 3 weeks ago, after his physician had put him on hydrochlorothiazide, a medication for hypertension, but one that can also cause attacks of gout, because it increases uric acid levels in the body. Now, he had a diagnosis of gout listed officially in the computer, and he was taking two gout medications. The physician made a mistake, for whatever reason, but the computer should have figured it out. We’re still better than computers, but I’d be happy to have one double-check my work in the background.
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Saw a really kind patient today that is a Harley rider, complete with the leather vest and boots and all. He’s a big guy, obese, and has obstructive sleep apnea (he stops breathing when he sleeps because there’s lots of fat around his airway). The usual treatment for sleep apnea is a CPAP machine (continue positive airway pressure. You wear this mask at night that’s hooked up to a machine that blows air into you so your airway stays open).
He hated the mask–felt claustrophobic with it on–so now he just goes out and rides his Harley down the highway, and tilts his head up a bit so his nostrils hit the air stream. Similar effect, and works well for him, he reports.
A couple examples, recounted in class today:
More you’ve come across? Post them in the comments.
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A classmate recently recounted a story to me of some not-so-great assumptions one of her attendings had made about a young girl recently diagnosed with diabetes:
The girl, of Hispanic origin, was in clinic with her family and the attending was giving her family her diagnosis for the first time–diabetes. But what bugged me is that he told me he didn’t want to spend his time explaining the cause of diabetes to the family, because he assumed they weren’t educated enough to understand it in the first place.
Let’s assume, for the sake of argument, that this attending didn’t start off this way; I’m hoping this is a safe assumption to make, as I think it would be among my classmates. I hypothesize, then, that this is the downside of physician training. Physicians are masters of pattern recognition–one of the reasons we haven’t been totally run out of business by computers (yet). You start to see certain patterns of diseases, drug side effects, and diagnostic workups that things truly start to reveal themselves, and then burn themselves into your head. You tell me your list of drugs, and I can probably tell you which diseases you have. You tell me your dosages, and I can probably tell you how bad your disease is. Or show me a picture of someone with a certain symptom, and I could probably come up with a couple guesses as to other symptoms they’re having (I’m still working on this ability). We are predictors, trying to make sense out of the world with the clues we’ve gathered.
But there’s always two sides to a coin. Perhaps some of us (like the above attending) take our prediction powers too far, and use them not for diseases or treatments, but for people. Maybe the attending had seen several other similar girls before, and he tried explaining, and felt like he was wasting his time. Maybe he’s seen hundreds. Either way, I think we’ve got to separate one from the other. Otherwise, we risk missing golden opportunities with patients.
This is no easy task. I’d imagine the doctor spent his time getting something else done with the time that he saved–calling a patient with abnormal lab results, spending more time with another patient, etc. Were the patient white, would he have skipped the pathophysiology speech? We can’t say.
Maybe one solution is to give patients a handout to read over at first, so when the doctor comes in, she or he can answer questions about it.
We’re big fans of the KISS method (Keep It Simple, Stupid) of health, and thus I now present to you the tried and true dieting secret:
3500 Calories equals 1 pound.
I kid you not. Many patients are surprised when I reveal this number to them–amazed that it even exists–and it’s probably the basis for The Weight Watchers Points system and most other similar products. The idea is simple, but just for repetition: 3500 Calories equals 1 pound. That means that for every 3500 calories you expend, you lose a pound, and for every 3500 Calories you take in, you gain one. (This is not a perfect correlation, but it’s pretty accurate.) Want to lose a pound a week? Eat 500 less calories a day. Or eat 250 less and exercise 250 more. I found a nice simple chart that gives some rough estimates of various exercises one can do and their Calorie expenditure per 10 minutes.
So how many Calories do you “need” each day? 2,000-2,500, depending how active you are. For a better estimate, try the male or female Calorie calculator.
And remember, you didn’t gain weight overnight. It was a gradual process–over months to years–so it’s not fair (although we’d all prefer it) for the weight to come off in a couple weeks. Slow and steady wins the race. 4 pounds a month is almost 50 pounds a year. And don’t forget to reward yourself; losing weight is a difficult process. Your body will fight you as much as it can; it’s still stuck in the evolutionary adaptation of trying to hold on to as many nutrients as possible.
Portion control is one of the easiest ways to lose weight; you just have to eat less. (Exercise has many of its own benefits as well, aside from helping you lose weight.) If you normally eat until you’re stuffed, try this: eat until you’re not hungry. They’re very different entities.
Great noon-time talk today about prognosis and predicting outlook for terminal diseases (until about the last 72 hours). Summary, from a palliative care and Hospice doc: Medicine is still terrible at predicting how much time any one individual has left. We can say “Most people with your condition and your status will live this long,” but it creates a ton of anxiety for physicians if they’re asked for a specific number, because it’s totally worthless. I thought her analogy would be helpful in explaining this to patients.
It’s like weather versus climate. I can tell Californians that it’s probably going be sunny there, and I can tell Alaskans it’s probably going to be cold there, but if you ask me to tell a particular town on a particular date what the weather’s going to be, I might as well just pull it out of a hat. Until it gets very close to that date, I really can’t say if it’s going to rain or going to be sunny.
Her last list was really touching and rang true. The 5 Things All Patients Want to Tell Their Loved Ones Before They Die:
The director of our Ambulatory Medicine clerkship loves to show this graph to try to put our medical education into perspective (or better, show its severe lack of perspective): if you take 1,000 people, 750 will have some ache or pain or medical problem, 200 of that 750 will actually seek a doctor for advice, even fewer will be admitted to a hospital, and even fewer will be referred to an academic medical center (that’s my patient population, mostly). So should I, or you, really be surprised that today was the first day I’ve seen a patient with a cold?
Probably… not. In fact, colds, flus, and sore throats were my probably main personal exposure to physicians as far as my own health went. But I’ve focused so much on the things that medical professionals consider common (lower back pain, right upper quadrant abdominal pain, hypertension, diabetes, dyslipidemia) that I had a few seconds of deer-in-the-headlights when my patient came in today complaining of “feeling terrible” and having a runny nose, stuffed up nose, and cough. Had I taken a step back to my own personal experience to think “what other problems did I have when I had her symptoms,” I probably would have done even better.
I almost get the feeling that I’ve become less comfortable with my own experience and gut instinct as I’ve been working my way through clinics. There are just enough treatments that are somewhat counter-intuitive on first glance that I’ll sometimes hesitate on what I would have been sure (and correct) about even before I started medical school. So my gut has been torn down, and will be rebuilt as gut-of-physican (another reason I’m dreading graduation; have you noticed your physician’s stomach lately?).
But luckily my mind’s still powered for faster-than-Google medical searches. Give it a few seconds to warm up, remind it of the category of information the patient requires (“antibiotics for sinusitis and bronchitis,” “common bacteria causing sinusitis,” “anatomy and drainage of maxillary sinus”), and it kicks into action. It’s pretty damn amazing.
(Oh, and just for anyone who doesn’t know this, I’m currently wowed with the transdermal sinus illumination trick. Next time you’ve come down with a sinus infection on one side, put a flashlight against your cheekbone–that’s the zygomatic arch–near your nose, and point it toward your mouth. The clogged sinus won’t show any light, but the clear one should shine the light into your mouth.)
(Medicine. Swoon.)
One of my attendings this month is a big history buff, and I get the sense that he enjoys discussing it, as he discusses it with me all the time. He even gave me his copy of Truman to read in my “spare” time. Of note was a particular conversation we had where he quizzed me on the cause of FDR’s death–hypertension, as it turns out. (Stroke, to be exact, but it might not have happened had his hypertension been controlled.)
I just thought it interesting that things we take so for granted now were still so poorly treated 60-some years ago. There’s a great history on the treatment of hypertension, and our favorite agent, a diuretic (water pill) called hydrochlorothiazide, made its basic debut back in 1958. (Note: we still don’t exactly know why hydrochlorothiazide is so good for hypertension.) Prior to that, we tried terrible diets that were bland and intolerable.
There are a couple really great President Medicine sites, including a summary of the causes of the deaths of all the US Presidents, and a Medical History of all the US Presidents. As we move from acute to chronic care in the US, there’s far fewer deaths from pneumonia, and more from heart failure.
These goats have a congenital myotonic seizure disorder that causes them to fall over whenever they get excited. (It’s cuter when it happens to goats than kids.)
November 27th, 2005I’m really enjoying clerkships so far. Besides the long hours, I can’t really complain. I have, however, been a little annoyed with the off-handed homophobic remarks made by certain people. In all other aspects, they seem like really great people, but I don’t think they realize how much respect I lose for them when they make some little snide gay joke to a colleague.
It’s never anything blatantly offensive, always just little things. Asking a straight male colleague if he’s dating anyone, and then saying, “Oh, did he break your heart?” for example. It reeks of the old boys club mentality, and hell, we’re 30 minutes outside of San Francisco. I can’t imagine what it’s like anywhere else. I’m always curious why this is socially acceptable, but if any person were to make a similarly snide racial or gender comment, they’d get disgusted looks from their team.
It’s really easy for me to type out here that I should challenge these remarks. I should try to change people’s thinking. That if I’m not part of the solution, I’m part of the problem, and that if no one ever stood up against this kind of thing, we’d be much more regressive in our thinking and behavior than we are now. But man, even if I was the most confident guy in the world (which I’m not, I just fake it), it’s hard to decide when to say something and how to say it, especially when it’s your superior, and they probably have some part in your evaluation.
I’ve now seen two really excellent physicians really stumble when it comes to using an electronic medical record, and it puts them at a severe disadvantage. While they could easily perform a better and faster physical than me, take a better history, and come up with a better list of possible diagnoses, I’ve got them beat hands-down when it comes to entering orders, medications, consults, or clinic notes. They hunt and peck with two fingers, staring at the keyboard, and click everywhere very cautiously. They’ve learned one way to get the system to do what they want it to do, and while it works, it makes a lot of wasted time. One of the physicians even told me he has to come in on weekends to get all his notes written, because it takes him so long.
We’re moving toward a medical record; if you’re not comfortable with computers, and don’t know how to use them effectively, hire the neighborhood whiz to come give you a few lessons. You’ll save immense amounts of time in the future.
Part of the difficulty of medicine is turning the qualitative into the quantitative, so various physicians have come up with rating or scoring scales to try to make one able to compare one patient’s state to another. I’ve been reviewing a number of these recently, so I thought I’d start a collection. Feel free to add your favorites.
Pulses are rated on a scale ranging from 0 (not palpable) to 2+ (normal). In the event that the pulse is not palpable, the doppler signal generated is also rated, ranging again from 0 to 2+.
1+ Mild pitting, slight indentation, no perceptable swelling of the leg
2+ Moderate pitting, indentation subsides rapidly
3+ Deep pitting, indentation remains for a short time, leg looks swollen
4+ Very deep pitting, indentation lasts a long time, leg is very swollen
5/5 Normal strength: movement against gravity with full resistance
4/5 Movement against gravity and some resistance
3/5 Movement against gravity only
2/5 Movement with gravity eliminated
1/5 Visible/palpable muscle contraction, but no movement
0/5 No contraction
I. Motor Response
6 – Obeys commands fully
5 – Localizes to noxious stimuli
4 – Withdraws from noxious stimuli
3 – Abnormal flexion, i.e. decorticate posturing
2 – Extensor response, i.e. decerebrate posturing
1 – No response
II. Verbal Response
5 – Alert and Oriented
4 – Confused, yet coherent, speech
3 – Inappropriate words, and jarbled phrases consisting of words
2 – Incomprehensible sounds
1 – No sounds
III. Eye Opening
4 – Spontaneous eye opening
3 – Eyes open to speech
2 – Eyes open to pain
1 – No eye opening
Glascow Coma Scale = I + II + III.
A lower score indicates a deeper coma and a poorer prognosis.
0: absent reflex
1+: trace, or seen only with reinforcement
2+: normal
3+: brisk
4+: nonsustained clonus (i.e., repetitive vibratory movements)
5+: sustained clonus
Grade 1 = very faint
Grade 2 = quiet but heard immediately
Grade 3 = moderately loud
Grade 4 = loud
Grade 5 = heard with stethoscope partly off the chest
Grade 6 = no stethoscope needed
Color
All pink (2 points)
Blue extremities/pink body (1 points)
Blue/pale (0 points)
Heart rate
over 100 (2 points)
less than 100 (1 points)
Absent (0 points)
Respirations
Good/crying (2 points)
Irregular/slow (1 points)
Absent (0 points)
Response to nose catheter
Sneeze/cough (2 points)
Grimace (1 points)
None (0 points)
Muscle tone
Active (2 points)
Some extremity flexion (1 points)
Limp (0 points)
Class 1: Can see PUSH Pillars Uvula Soft Palate Hard Palate
Class 2: Can see USH Uvula Soft Palate Hard Palate
Class 3: Can see SH Soft Palate Hard Palate
Class 4: Can see H Hard Palate
Quote of the Day, to an 84 year-old Asian woman with Hepatitis C from an attending:
Doc: So we’d like to figure out what the subtype of your viral genotype is…
Patient nods.
This woman had no, I mean no idea what a genotype is, let alone a subtype of it. Please don’t forget, when you’re talking to a patient, speak to his or her level, not MEDICAL. I would look just as dumbfounded as my patient today, and probably nod as well if a lawyer spoke law to me, or if a mechanic spoke car to me. I’m sure I’m at fault myself sometimes, but I think I’m pretty good at catching myself, and pretty good at detecting the dumbfounded “what the hell are you talking about” look, too.
There’s evidence to suggest that patients will be more adherent if you speak their language, too. Everyone wins.
Being the goodie two-shoes student that I am, I’m reading ahead in the 2006 edition of Goroll’s Primary Care Medicine, learning about screening tests, and I see these two listings (my emphasis):
Condition: Susceptibility to hepatitis B virus. Risk factors: Male homosexual, exposure, occupation (health care worker), pregnany.
Condition: Syphilis. Risk factors: Male homosexual, other sexually transmitted disease, pregnany.
I looked at some of the other entries to see if I was being overly sensitive. They list a risk factor for sickle cell disease as “African American.” And that’s true, to some extent–it’s more likely that people of African descent will have the sickle cell mutations in their genes.
But this “male homosexual” bullshit is entirely different. It’s not like the “male homosexual” has some sort of genetic makeup or inherent compromised state that makes him more likely to contract hepatitis or syphilis. So what is it? Is it the HIV+ male homosexual? If so, why not just say HIV+? Is it the male homosexual who has unprotected sex? Why not say all people who have unprotected sex? Isn’t “exposure” to Hepatitis B a requirement for infection, as well as a risk factor? It’s not like us male homosexuals somehow grow Hepatitis B inherently, like some people of African descent make sickled red blood cells.
I’ll admit medicine (and society) is getting better with acceptance of all people that are different, but it’s these little remnants of inherent pathology or deviance that just piss me off to no end.
Maybe I’ll email Dr. Goroll and see what he says.
Update: Dr. Goroll emailed back in a day with a very kind response, and forwarded my question (stated a little more gracefully in the email) to the author of the chapter. He also noted the book is constantly being updated and corrected in OVID.com and eScholar.
The powers that be (or, if you prefer, the Power that be’s) have a funny sense of humor. Take medical student who thinks feet are totally disgusting, and sign him right up for Podiatry clinic. Ambulatory Medicine clerkship, we are not getting off … on the right foot. (Pun intended.)
Last month, on Geriatrics, I had a diabetic patient in clinic, so I took off his socks, only to have little flakes of foot skin (eczema? xerosis?) fly up into the air and be inhaled by yours truly. From now on, I’m just asking the patients to take their own damn foot apparel off.
If it’s anything, medicine is damn humbling.
It always just amazes me that there’s so much variety in the human experience. That you and I can be so genetically similar, and yet have such different backgrounds and understandings of the world. I saw a professional today in clinic for high blood pressure, and as I was going through my laundry list of questions, I found a pertinent positive:
Me: Any recent illnesses?
Him: No.
Me: Weight loss?
Him: No.
Me: Fevers?
Him: No.
Me: Chills?
Him: No.
Me: Night sweats?
Him: Yes, every couple nights.
Me: Any cough?
Him: No.
Me: And you said no weight loss, right?
Him: Right.
Me: … Okay.
And he didn’t bat an eye. I followed up skeptically: “Night sweats that soak through your t-shirt?” And again, not batting an eye, “Yeah, soaked every 3-4 days.” Taking his perspective, I guess it doesn’t seem that strange–he’s just sweating a lot at night. Maybe due to a nightmare or something. But I instantly took my own perspective–at the first sign of night sweats like that, I’d get to a doctor! (You’re probably wondering, I’d imagine. Night sweats, coughing up blood, and weight loss are the “classic” findings in a patient with tuberculosis.)
Sometimes you forget not everyone has all this information and experience. You use your medical knowledge so frequently, and the medical associations and logic become so commonplace to your brain that you start to feel like they’re as elementary and commonly-learned as addition, the state capitals, or Shakespeare. “They have temporal arteritis? Well of course they’re having vision changes. Duh! Next you’re going to tell me you didn’t know Dorothy was from Kansas!”
So we’re placing a PPD (TB skin test). Another possible point for my diagnosis pickup. Cha-ching!
Attention all clinical folks: there’s a reason you always at least listen to the heart and lungs. (I previously thought this was just a cruel med student joke.)
Guy comes in, typical geriatric patient with multiple chronic diseases, and I notice that he’s huffing and puffing, walking about the 30 feet from the waiting room to the exam room. I comment about this, and he and his wife note that he’s had this over the past month, but never before. Curious.
We talk through the rest of the visit, talking about his memory problems (dementia), his recent falling 20-30 times per week, his getting-up-to-pee 5-6 times per night, his chronic 10/10 lower back pain, and then I do the physical exam. Rales (also known as crackles) on both sides of the bottoms of his lungs. Pitting edema in his ankles. Curious indeed.
So I’m presenting to the attending and fellow, and they’re blown away. “Wow! Great job! Good pickup!” So we order an echo, get an EKG in the clinic, and put in an urgent cardiology request.
Not bad for a third year, huh?
I saw an elderly Russian woman in clinic two weeks ago, and through the translator, she asked me, “Why are you asking me all these questions? I’ll die when I die. You can’t fix old.”
I told her that she was right; we can’t fix old, but we can try to address disease. Many people confuse the two, assuming that getting old just comes with certain diseases, like urinary incontinence. It’s not true. Older people are more likely to have hearing loss and worse vision, but some things aren’t so much a product of aging as they are more common in the elderly population.
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Polypharmacy is the taking of multiple medications for multiple medical problems. My winning patient so far had 24 when I saw him in clinic on Wednesday. If anyone honestly thinks that patients are taking all of those medications, with all of their different schedules (two of this one in the morning, 1 at night; 3 of this one every 8 hours; one-half tab of that other one every day), they’ve got to be kidding themselves. How many of us can reliably even take a course of antibiotics for 10 days?
Prevention is the only solution, people. Eat better, exercise more, stop smoking, and wash your hands. That’ll lead you to a healthier life than any pill.
I’ve been on service a week, and I’ve already seen quite a range of presentations and stages of Alzheimer’s. I had no idea there was such variety.
The first patient, diagnosed at the young age of 57, had deteriorated rapidly. She was very aphasic–meaning she couldn’t find the words she wanted, nor could she understand some of the things I asked. She scored a 3/30 on the MMSE, a quick test of one’s cognitive functions. This is very poor. Often I would ask a question, and she would respond with “Well, I… you know, I am… and so, it is, because, you know, it… is. And it’s okay, because what it is… is.” It was very difficult emotionally to continue; I felt really uncomfortable asking her more questions. This was complicated by the fact that her partner was in the room, a psychiatrist. He looked like he was on the verge of tears with every question I asked. I asked him how he was doing, if he might like some help caring for his wife, but he said he was fine.
On the exact flip side, I met another woman who has Alzheimer’s and was very happy-go-lucky. Maybe her disease had just progressed less. She still recognized her children, but didn’t know much else. Besides that, she seemed content. When I asked her the year, she smiled and replied, “Oh, I don’t keep up with that.” What an outlook. Her children, who were at the appointment with her, seemed to have accept their mother’s illness. They smiled and joked with their mother, and tried to make the best of the situation.
Sometimes, I guess all you can do is laugh.
An idea for a meme that the medbloggers could start: bloggers posting their wishes/advanced directives/durable powers of attorney. As with the Terry Schaivo mess, everyone was talking about people writing out (or discussing) their wishes with loved ones. With a simple blog entry, a person could provide a written document of their wishes. There’s 5 million bloggers out there, maybe it’d help?
Medbloggers could draft a template, define terms, and explain some possible scenarios, and then people could copy->paste and link to other people’s? Whatchya think? (I realize a durable power of attorney form would be more useful, but this could be a start?)
People post their five favorite songs, or favorite book, or favorite quote, why not something a little deeper? (They could password-protect the entry if they felt that it was too private for the general public.)
Man. I forgot how nice it is to actually see human beings patients again. Staring at films and CTs and MRIs (oh my!) made me forget that there’s actual people that surround those images, not just bone structures, opacities, densities, consolidations, and strictures. We started out today at a local nursing home, rounding on some patients. Kind of wish I had already had my Medicine clerkship, but I’m usually a quick learner.
Depending on the patient, sometimes the surgical service will send a patient to the nursing home for long-term recovery, and it just so happened that I got to see a surgical patient from many months ago at the nursing home. It was definitely some delayed continuity of care, and he had no idea who I was, but it was great to see the spectrum and time-course of healing.
The great thing, I’m hoping, about this rotation, is its variety. We rotate through a nursing home, an inpatient ward, a hospice unit, a palliation clinic, a geriatrics clinic, hypertension clinic, and andrology clinic, as well as attend Internal Medicine conferences, so I get exposure to a lot of different geriatric sub-specialties.
Today we had an inservice from the hospice chaplain discussing how to take a spiritual history, how to understand some of the spiritual/religious concerns of the dying or elderly patient, and some advice on how to answer patients’ questions that are religious in nature. (I’ll be the first one to admit that I’m struggling right now with figuring out my own spirituality and belief system, with my interests in religion and spirituality a seemingly distant memory from college.) I’d feel much more comfortable dealing with patients’ questions about living and dying and the Unknown and God (or god(s)) than questions directed toward my personal belief system (I get a knee-jerk reaction to questions like, “Do you believe in Jesus,” or “Have you found Christ,” mostly because of obsessively-persistent Christians from my undergrad). As one of my residents pointed out, however, most often questions like these are efforts by the patient to feel out the physician–to see if the physician is “safe” to talk with about spiritual matters. It’s actually probably pretty similar to how LGBT folk try to feel out someone to see if they’re LGBT-friendly before opening up.
I couldn’t help but compare this service to Neurology and Surgery, and initially feel like the others were leaving out this spiritual component. I can see how in some cases, it’s probably a back burner topic: people want their gall bladder out, not a discussion of the Universe. (Or maybe they do?) Or perhaps it’s just that there’s not time on those other services to discuss these matters? At the least, however, I would think asking one or two questions about it (“Do you have any spiritual beliefs you would like to be respected during your care?”) might be useful, especially in cancer surgery or terminal illnesses.
On to clinic, where I saw one patient, an elderly, World War II veteran who had just turned 95. He has terminal cancer, but refused treatment, and two years later, still has no symptoms from it. We caught a previously undiagnosed problem with incontinence, but otherwise he was in reasonably good health for his age and condition. He said he didn’t fear death; he’d been a rifleman in the War and noted that “If you worried about dying while you were out there, it didn’t do you any good.” Kind of a privelege that I have the time to worry about death at all.
If anything, I can tell that this will be a month of lots of thinking about ethics, living, dying, and Life in General. Good for the soul.
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I haven’t written much about radiology, namely because there isn’t much to write. Our clerkship has, unfortunately, been less than productive. I don’t know if it’s just poor scheduling plus lots of conferences and flus, but we’ve had a number of classes cancelled, and the morning readout sessions seem more focused on getting through the images than teaching about them. A number of us think it would have been better to just get a textbook, some websites, and take the month off to study. Most of the other clerkships I’ve had so far at least had some component of teaching during the physicians’ work day.
I’ve also become pretty frustrated with the constant radiologist obsession with income. It’s definitely more prominent in the younger docs and residents than the older physicians, but more than anyone else so far our lecturers have expounded the virtues of radiology for the amount of money one can make. Maybe I’ll feel the same way in one year’s time–I’m not above saying that I won’t–but as a third-year student, still fairly new to clinics and not-so-jaded, it was really unattractive.
I spent 45 minutes one day waiting for a fellow and an attending to start reading films while the attending whispered to the fellow about his new job, how much money he can make a month, and how much time he gets off per year. After being told “we’re about to start reading” 5 or 6 times, I finally got up and walked out of the room, feeling so frustrated. Had I spent another second in the room I felt like I would have started to turn jaded and bitter down to my core. (This was in addition to the fact that the radiologists in the room had described clinicians as “annoying” when they ask the radiologist for help reading a film.)
We must, of course, remind ourselves that this is not all radiologists, and maybe it’s not even a fair representation of the radiologists about which I write; maybe they had a bad morning, or didn’t get any sleep last night, or who knows what. But their effect on me was the same. Just another personal reminder that my behavior, attitude, and actions do affect the way other people see the world.
In light of the lack of time spent in the classroom, I have come up with a great list of radiology online resources, which are truly excellent:
LearningRadiology – My favorite, by far. Talks specifically for medical students, quizes, cases of the week, all in really easy to understand format. I thank this website for helping me to get a general understanding of the chest radiograph.
Yale Cardiothoracic Imaging – A beautifully-designed website, easy to use, with great images and illustrations, all annotated. Has normal anatomy plus a number of basic diseases.
Radiologyeducation.com and medicalstudent.com have a huge number of links; the UCSF Radiology website also has a great number as well.
I’ll be adding more as the week goes by; I have a number that are bookmarked, but I’m not ready to give the full Over My Med Body stamp of approval.
I wanted to solve a problem I’ve seen on the wards and in clinics, as well as mess around with some new web technologies, and thus Medslist was born. Simply, it’s a way patients can store their list of medications online, email a copy to themselves, update them later, print a copy out for their physicians, etc. Sometimes people come in with lists of medications, which is great, but often they’re illegible or hard to follow.
Medslist allows people to list a good number of facts about their medications–including the reason they’re taking it–and perhaps this may encourage some patients to learn why they’re taking it, and have a more active role in their treatment, management, and health.
For now, it’s only working on PC Firefox, Mac Firefox and Safari. I’m having trouble reproducing a bug where the login feature doesn’t work in PC Firefox; if you have this problem, try reloading the site a couple times, and it should work.
How did I have time for this? I’m on Radiology right now, which provides a certain amount of free time (I think they’re trying to get us to be radiologists based on the radiologist lifestyle.)
Please post your criticisms, comments, and suggestions here. If you have bugs, post’em. Feature ideas? Post’em. Right now the feature set is limited, I know: No way to get your password if you lost it, no way to edit medications, etc. But please brainstorm and go wild; what would you like to see on a medication list that your patient carries into the clinic for you?
I don’t know where MedPundit went to medical school, but her experience couldn’t be different from mine. Other med students, are you on my side or MedPundit’s? Comment below.
It shouldn’t be surprising – medical school is a crucible of change.
Students leave their homes, their families, their friends.
It’s definitely a big change, and not without its stressors, but most of us have gone through this before when we went to college. Clerkships are, without a doubt, lonely. It’s nice to be on a service with a classmate, but I barely see anyone these days. Just more encouragement for me to do a better job with time management and setting some time aside for a mild, tempered social life.
They lose the academic standing they had in college and high school, and with it sometimes, self-esteem and respect.
Yet another reason to make things pass/fail like we are here.
They see and learn things they’ve never seen or heard of before. They learn, in fact, a whole new way of being. It is a completely transformative process in a way that few other processes (except perhaps joining the military) are.
Absolutely, but what an amazing transformation it’s been! There’s good parts to it, and bad as well, but I think my mind has been made 100 times sharper.
It is not a pleasant process. I remember one of my medical school classmates describing it as “the shrinking of her soul.” The reasons for this are all those mentioned in the above article, with the exception of one glaring omission – the role of the teaching process. The third year of medical school, when students enter the hospitals and see patients, also marks the moment that their teaching is handed over entirely to practicing physicians – and they are brutal. The brightest and best students are treated as know-nothing scum and burdens to be born by the rest of the medical team. There is never, never, any praise – only denigration. At least, that’s the way I remember it, with few exceptions. It’s like being stuck in a House episode.
This sounds like some other world she’s describing. Are clerkships hard? Yes. Do some of them suck? Yes. Is there some degree of scutwork involved? Sure. Do they turn your view of medicine on its head, and teach you the frustration of paperwork, hierarchy, and difficult patients? Absolutely. There are definitely days where I feel down, feel like I’ve worked hard and haven’t felt appreciated. There are days that I think, “This is medicine? I seriously signed up for this?” But my soul is not shrinking, and the attendings are not brutal. I’m given praise by attendings and residents, my family and boyfriend, and I dole out some healthy self-praise, too. Do I feel stupid for not knowing things? Sometimes. Do I feel loved and needed by the attendings and residents? Not always. But more often than not, I feel like I’m respected as a member of the team, feel like I contribute and can teach residents and attendings things they’ve forgotten, and I get feedback that is constructive about how I can do a better job. It’s natural for me (and probably med students in general) to beat myself up over not knowing an answer to pimping session question, but that’s because we have such high self-expectations. I don’t think the attendings are purposefully trying to shrink our souls or denigrate us.
So, how do we get through it? Our hides grow a little thicker (or is it that our souls shrink?); and if we’re lucky we meet some good roll models along the way. But, at some point, we come to the realization that our teachers are not gods, but frail, flawed men and women with bad management and teaching skills.
My skin is definitely thicker after 2 months of surgery already, and I’m thankful for it; I’ve been through the worst already. I’m less intimidated, and more willing to just do my best, keep up on my reading, and accomplish the goals I have set for myself during the rotation. My attendings are not gods either, but they’re hard-working, incredibly intelligent men and women with somewhat-decent management and pretty good teaching skills.
Let the record show that I’m in between clerkships while writing this, and just finished a relatively low-intensity month on pediatric neurology. This is also not to say that there are no depressed students here; I know of several.
There’s a number of types of seizures, but here’s a short list of the most common with common descriptions (every person is unique!), in case you’re concerned in a child, friend, or loved one. Seizures are divided into partial and generalized. Partial means they affect only part of the brain, whereas generalized affect the entire brain. There are usually medications that can treat these seizures.
(This is the first in what will be a series of practical tips I’ve learned on my clerkships that are applicable to everyone, not just medical professionals.)
There are many types of seizures, not just the classical shaking ones you see on television. If someone should have one of these seizures, however, or another one where they fall down or lose consciousness, there’s some basic first aid guidelines, and also some myths that need to be dispelled. Use your common sense, keep the person safe, and reailze that in most cases, the seizure will end on its own. If it lasts more than 5 minutes, then you should call 911. From epilepsy.com, one of the best medical websites I’ve found for a specific disorder
After the seizure, the person should be placed on her left side, in the recovery position. There’s a small risk of post-seizure vomiting, before the person is fully alert. The left side is better than the right because the left side has a sharper angle of the lungs, so there’s probably a slightly smaller risk of vomit going into the lungs. Therefore, the person’s head should be turned so that any vomit will drain out of the mouth without being inhaled. After the seizure, the person enters the postictal state, which is just medical lingo for post-seizure. People can be very sleepy or confused at this time, so stay with the person until she recovers (5 to 20 minutes).
I’ve always thought that one way to tell if you’re truly fluent in another language is if you can make a joke in the language–humor requires not just meaning and proper grammar, but a level of comfort with the language and a good sense of comic timing. It’s totally true for the medical languages, too.
Case in point: at the beginning of this month’s rotation, I attended a weekly neuroradiology conference where the attendings kept making these only-funny-to-neurologist jokes about patient’s MRI scans, and I didn’t get a single one. They all went right over my head, but everyone else in the room was just cracking up.
Yesterday in clinic, I found myself making an only-funny-to-neurologist joke while evaluating a teenager with chronic daily headaches. As I sat down to present to the attending, I said, “Looks like a pretty classic case of giant cell arteritis,” and I got a good laugh from her.
Giant cell arteritis is a headache disease, but only presents in people over the age of 55. Ha! Err… ha. Sigh. Soooo lame.
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I totally ruined the last post with my humor-cum-neurotic antics. So back to the difficulties in examining pediatric patients.
The whole “take a good history and physical” mantra kind of goes out the window when the human you’re trying to help doesn’t do that whole “talking” thing or that whole “sitting up” thing, or especially the “can you do what I’m asking you to do” thing. It really makes you hone your ability to draw conclusions from limited information and to use tricks to get the information you need. A couple things I’ve picked up (post yours in the comments!):
Checking reflexes requires the patient to relax their joint, but it’s a tough sell on a squirming infant. Even distracting them doesn’t always work.
“Follow my finger” to check eye movements can be tough. Following a toy or a face seems to be much easier.
Use the parent. They can soothe the savage beast, and keep the child’s attention while you’re busy poking and prodding them. Plus, they’re usually all you’ve got for the history, if the kid’s too young to talk.
Let kids see your instruments before you use them. Makes them less scary. Warning: the hyperactive children will throw your reflex hammer, and may almost hit a nurse in the eye. Keep instruments away from them.
Get on the child’s level. You’re much less intimidating there.
Other tricks, my medblogging colleagues?
This just in: it is certifiably impossible to walk into a room with a smiling baby without your maternal or paternal instinct immediately raising the pitch of your voice at least two octaves. It is simply uncontrollable.
The first week of my neurology rotation was incredibly dry. It consisted mostly of library time, awaiting the consults that never really came. The week was slow, and seeing as though it was the first week, I naturally felt stupid, frustrated, and lame for asking seemingly obvious questions. After a nice mature little internalized tantrum last Sunday (“I hate neurology! This is so stupid! Waaah!”), things are starting to make sense and get busier. Not a whole lot of sense, but plenty busier.
The problem with all of this, however, is the selection bias. Because only the really sick people end up in the hospital, you get a very skewed view of the population. While most of us will remain fairly healthy throughout our lives (minus some high blood pressure, high cholesterol or weight problems), the medical student and the resident see the worst of the worst. Since every patient we’ve seen so far in the hospital has been for a seizure workup, I’m thoroughly convinced that every child has had a seizure in their lives. (Time out for reality: a febrile seizure occurs in 2-5% of the population, but 2/3 of those kids never have a second seizure, so neurologists don’t generally get their panties in a bundle about a first-time seizure assocation with fever. Then again, 80% of neurologists prefer boxers to panties, so pantie-bundling isn’t all that common among neurologists, anyway. Surgeons, however…)
So I’m somewhat convinced that I had a seizure, and my parents are keeping it from me. That, or the old evil babysitter they hired named Alva Camp that made my brother and I eat only rice cakes and choose between taking a nap or cleaning our rooms while they chilled in Barbados just never told them about it. (And they say psychiatrists’ children are neurotic. Clearly I’m an exception to the rule.)
I’ll take “Signs I’m Now On Neurology” for $800, Alex (via IM to my friend Mike):
Mike: want to come have some beers tonight?
Mike: or do you have to work early?
Me: oh. i would, but i need to clean my room and try to find my reflex hammer.
Me: that’s like the lamest excuse ever, but it’s true.
The VA is the scariest of all health care systems–it’s paid for and run by the government! It probably has the efficiency of the postal service and the compassion of the military, right? You might be surprised. On many screening measures and actions shown to improve outcomes, the VA’s winning. Another piece from US News:
Three summers ago, Augustin Martinez’s skin was yellow. He was in pain. And physicians at Kaiser Permanente, his usual source of care, were baffled. The frustrated Martinez, a retired Lockheed Martin engineer in San Jose, Calif., asked his brother, a New York physician, for advice. After consulting colleagues, his brother advised him to go to the Department of Veterans Affairs hospital in nearby Palo Alto. Martinez, a former Navy petty officer 2nd class, was entitled to VA care (eligibility depends on several factors, including date and length of military service, injury, and income). But his brother’s recommendation took him by surprise. Better care at a VA hospital? But he went–and was quickly diagnosed with pancreatic cancer by Sherry Wren, chief of general surgery, who operated on him within days. He has relied on VA hospitals and clinics ever since. “They run a good ship,” says Martinez, now age 72.
Yes, it’s just an anecdote. But Dr. Wren is a mentor, and they definitely run a good ship there.
Turned 25 today. Pretty damn uneventful. Me, internal monologue style:
Wake up, groggy.
Ugh, it’s 5am.
Look at phone.
No one called. Sad.
Oh, wait, you went to bed at 9:30, and the bf called at 10:10. You barely remember the conversation, but you’re sure he was sweet.
No one else called. Sad.
Oh, wait, it’s 5am. Who would be up this early, and even if they were, would they expect me to be up this early?
Get in shower.
Put shampoo in hand. Hey, it’s your birthday.
Joy. Rapture. 25. Car insurance now cheaper.
Finish shower. Get dressed.
Two days left of surgery, and on Monday I’ll start with Neurology. My, how time flies. Down to LA this weekend for a birthday celebration. A little delayed gratification is always good now and then. Especially when you have a scary surgery exam in two days and have no idea what to expect.
My dad’s a psychiatrist. Ever since I can remember, I would always see pieces of paper laying around the house in a certain configuration: 8.5×11 inch sheets, folded length-wise and width-wise, with a pen clipped to the top. I always found this to be an incredibly strange thing to have with you at all times–one might be in our computer room where he often works, whereas another might be next to his nightstand; you could probably find at least one or two more on the dining room table, where he unloads his pockets after work.
Now, of course, I find myself taking blank pieces of paper, folding them length-wise and width-wise, and then clipping a pen to the top. I don’t think I ever really noticed myself doing this until I started reminding myself of my father. The secret? You always need to be carrying a piece of paper and something to write with, and it’s the best configuration to get it to fit nicely into a shirt pocket. Even when I’m scrubbed in on a case, I keep the paper in my chest pocket for after the case.
So just to clear things up–you’re not a weirdo, dad. Just a doctor. (Okay, maybe you’re still a weirdo, but not for the paper-folding reason anymore.)
I’m pretty convinced a big plus of going into the surgical or emergency medicine fields is the stories that you get out of it. Blatantly stolen from an attending:
“You wouldn’t believe the kind of lies people make up when they present to the ER with something stuck up their butt. My favorite? A man comes to the ER with a zucchini up there, and proceeds to tell me, ‘Yeah, I was gardening naked tonight at home when I fell backwards and it got stuck up there.’”
Another hint from the attending–”If you ever get a votive candle stuck, don’t just pull on the wick. It’ll come right out, because your body has warmed up the candle wax, and you just won’t get anywhere.”
I’m tellin’ ya. It’s all about the stories.
Even though it’s sometimes hard to see a patient as more than just their disease, I’ve really started to think about how this is, for most people, just a tiny little part of their life. You forget that you’re seeing a patient at their worst–sick as stink, post-operation, and feeling crummy. They haven’t showered in days, they’re eating crappy hospital food, they’re too weak to do more than lay in bed most of the day, and they’re away from their families, their cultures, and their homes. Sometimes they’re unconscious, or so drugged up that they’re not even with it. And because this is almost all you see of the patient, it’s not uncommon to make what’s called the fundamental attribution error in psychology–believing that a person’s actions or behavior is due to the patient’s own personality than it is due to the situation he or she is in.
Even in clinic, seeing the patient before they’ve had any sort of procedure or treatment, the attribution error can stick. The clinic is usually running late, so the patient has been waiting for awhile; he or she is probably nervous about seeing the doctor and learning what kind of treatment will be necessary (especially when they know they’re in a surgeon’s office for a reason); he or she might not be feeling well, and any other number of reasons. So if the patient (or a family member in the room) is crabby when I enter the examination room, I automatically assume it has nothing to do with me or the other person. I’ve learned to take no offense. I automatically give the person the benefit of the doubt. It’s not uncommon for patients to get a disappointed look on their faces when I enter the room anyway–they’re expecting to see the surgeon, and then I introduce myself as “the medical student on the team.” (I do think, however, they are slightly relieved to find out that someone as young as me will not be performing the operation.)
This all came about because of a sick-as-stink patient we’ve had on our service recently. He’s been in and out of the ICU, unintelligible when he attempts to talk, and pretty much out of it–due to his own neuro issues or the psych drugs we give him to keep him calm. (He’s been pulling out his drains.) One day, however, I guess a family member must have brought by a little collage of photos of the patient and his family. I couldn’t believe it was the same man. Him as a 30 year-old with his wife. Him in his 40s riding a horse with his daughter. Him with his extending family at a 50th birthday party. Scanning from picture to picture, none of them matched the dehydrated, sickly, wasted man lying in the bed next to me. All this time I had thought of this patient’s life as culminating in his surgery, cancer, and hospital stay, and I hadn’t even realized it. The egotism of my idea of the man blew me away.
Although I’m spending countless hours in the hospital with little thanks or appreciation, the ice machines here rock. That is all. Back to your regularly scheduled programming.
Working in a hospital with so many highly-educated patients that seem to know more about their diseases than we do, I think we probably run a greater risk of making assumptions about our patients’ education, intelligence, and vocabulary.
Many times I’ve noticed doctors, even when trying to explain things in “English” (as opposed to medical-ese), start using terms like “distal” and “proximal,” and patients start to get a look of confusion on their faces. I try my best to stick around and explain things better to the patient, but many times I don’t even think we realize we’re doing it. Even words like duodenum and common bile duct I would imagine could be very confusing. I assume that most patients have heard of the liver, the intestines, the stomach, and the pancreas, but don’t have a clue how they’re connected, where they are, or what they do. This has nothing to do with their intelligence or ability; they’ve just never felt the need or had the interest to learn. Many were probably never taught about them.
I’ve been thinking about carrying around some pictures of the abdomen to show them to patients and explain their problems and the surgical procedures to correct them. It’d probably go a long way to making them feel a little bit more in control of their care and their bodies.
One of the things we’re taught in our ethics classes is that we, the medical staff, don’t get to decide what treatment a patient gets. The patient does. We can recommend until we’re blue in the face, and suggest as strongly as possible, but ultimately, it comes down to the patient’s choice. It shouldn’t be any other way, but sometimes it can frustrate both staff and patients, and patient care gets nowhere.
Before you get to this blue-in-the-face step, however, I’ve learned it’s important to make sure everyone’s on the same page, and everyone’s communicating on the same level. If a doctor understands a disease process differently from the way a patient does, each party may interpret the other’s actions, behaviors, or treatment suggestions as hostile, insulting, or punitive.
Take for example, Mr. Gouda. (Not his real name, but I’ve been craving cheese lately.) Mr. Gouda presented with all the classic–I mean, classic–signs of a small bowel obstruction. (A small bowel obstruction is when the small intestine gets blocked, either because it’s twisted, crimped, or squeezed from something outside of the intestinal tube. It’s usually caused by scar tissue from prior surgery or hernias.) He was throwing up, not pooping, not passing gas, and had lost his appetite.
The treatment for a small bowel obstruction is, for the first few days, watching and waiting (later it can be surgery). Give the patient some IV fluids to re-hydrate them (they’ve been throwing up and not eating), and also give the patient an NG tube–a tube that goes down your nose and into your stomach, which sucks out air and fluid that’s built up in the intestines. The only problem is this: having an NG tube placed is incredibly uncomfortable. Probably the most uncomfortable thing we do while people are fully conscious. We stick a tube up your nose, pass it down your esophagus as you gag, telling you to “Swallow, swallow” until it’s down in your stomach.
In the ER, they had tried to place Mr. G’s NG tube without any success. He hated it so much that he was willing to keep throwing up as opposed to having another tube placed. Please note that this was not normal vomit. This was feculent vomit. Translation: partially digested food, starting to look (and smell) more like poop than food. He was more willing to throw up poop than have the discomfort of another NG tube. That’s, uh, pretty severe in my book.
So we go down to talk to Mr. G, who absolutely refuses the NG tube. He says “Just put me out and do it!” We tell him that we can’t–if you’re unconscious and gagging, you can vomit and have it go into your lungs (this is called aspiration) and you get a really, really severe pneumonia and can die. Next, he asks us why we can’t just give him “some medicine to dissolve the blockage,” and I start to realize we’re not on the same page. This, my friends, is the key. That same visit, the team kept arguing with him, both sides got frustrated, and we gave up for the night.
Mr. G had thought, totally understandibly, that this “small bowel obstruction” was a blockage in his intestines. Something like a clogged drain. You pour down the Drano, dissolve the gunk, and voila, clean drain. There’s even a medical correlate: if you have a blocked heart blood vessel, you can insert some medicine inside the vessel to break up the clot.
My colleague and I went back to Mr. G the next day and explained that the blockage was external–like a kinked garden hose, or a clamp over a tube–and everything instantly changed. I get the feeling that he thought we wanted to do the NG tube just as punishment for being a “difficult” patient, but he finally understood that we couldn’t have him drink some substance–the obstruction was outside his intestines. Once he understood that, he was totally willing to try the NG tube. Our chief placed the tube, much easier than the ER resident, and two days later Mr. G was out of the hospital, with a referral from us for a primary care physician.
It’s always important to make sure everyone’s on the same page. We all have different definitions of words, especially in the medical field.
It’s amazing how different the feel of a rotation is depending on all the different factors that make it up: the hospital, the type of patients, the attendings, and the residents. I’ve just started my second 4 week jaunt into the surgical world–now at a different hospital–and it’s completely different.
After coming down from a really great rotation elsewhere, some really positive feedback about my performance, and getting my board scores back (phew!), it’s frustrating to switch to a new facility and new team, having to re-learn how to look up vitals, labs, and x-rays. It’s new computer passwords, new clinic layouts, and new time schedules. Just when you’re finally getting the hang of things you’re back to square one.
I guess I should get used to it: this jumping around is my life for the next two years, and there’s probably more continuity now (going from surgery there to surgery here) than there will be when I start neurology next month. I find myself drawing on the familiar when seeing patients (the familiar being abdominal and rectal exams), which, surprisingly, just isn’t that high-yield when you’re seeing patients with breast disease all day long. It seems like I was just really getting good at asking the poop and fart questions, but now I’m quickly learning the new list: “Any nipple discharge? Breast pain? Masses? History of breast cancer in your family?”
This change is relatively small, in retrospect; last month at my hospital, I saw so many men as patients that I was surprised to remember today that women get sick, too. Out of sight, out of mind, I guess.
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I’ve come to realize in the past couple of days that there’s a huge danger associated with smoking that I’d never heard about before: smoking makes you a really poor surgical candidate.
Surgery is a really stressful event on the body: it basically challenges every organ in your body, from your brain to your heart to your lungs to your kidneys and everywhere else. But surgery is especially hard on your heart, and requires good lungs to provide oxygen to the body. Smoking hits both of these pretty hard. It destroys the lungs with emphysema and chronic bronchitis, and it leads to heart disease and damages your arteries as well.
So if you’re a smoker, and you find out later that you need surgery, some surgeons may consider you a “poor surgical candidate,” meaning you’re a high risk patient that may not respond to the surgery’s stresses well, and may have many more complications and a higher risk of death from the surgery. This is for all types of surgeries: everything from routine hernia repairs to cancer removals to gastric bypasses for obesity. Not only does smoking cause many types of cancer, but it makes you less likely that a surgeon will want to operate on you in the first place. And that’s a place that no one wants to be in their future.
Surgeons, as a whole, are not the jerks you see on television. They are the jerks you see in the OR. Kidding! Really! Some of my best friends are surgeons! (Look. There are jerks in every field.) However. Surgeons, I’m going to fathom, are the most direct of the Homo sapien medicus sub-species. This took some getting used to.
“You’re holding this wrong.” “You’re moving too fast. It’s making me sick.” “Stand up straight and ask them to raise the table.” “No, that’s incorrect.” “No, that’s absolutely contra-indicated. That is the last thing you’d want to do.” There seems to be less gray in the surgical mind than is in mine right now, and for the first couple of days, I took all these direct challenges to my actions as a put-down to my post-Boards medical self-esteem. It’s not an uncommon association we make: someone gives us direct, blatant feedback about our actions, and we take it personally. This is totally inaccurate, however, in my experience so far.
If you make a mistake, or do something incorrectly, you’re being told how to do it correctly in the future. In surgery, if you fall down, you get back up, take a deep breath, and keep moving cautiously. As my chief relayed some advice for medicine in general to me: “What’s the worst thing a chess player can do when he knows he just made a mistake? Rush his next move and make another mistake.” We’re human, unfortunately. We have that whole “imperfection” thing going pretty strong for us. But it’s the actions that follow that are much more important to both the patient’s and the doctor’s success.
Mistakes are always worse if you never analyze them to learn from them.
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Last week I started to have patient dreams. They normally fill some sort of supportive role–rarely are they the main characters–but they’re generally lacking their disease or IV poles. I’d like to interpret this as “seeing the patient as the person, not the diagnosis,” but I’m not totally convinced.
At first this kind of freaked me out: I was diving too far down the rabbit hole, or obsessing too much, but I’ve come to the realization that I generally have dreams involving the people I spend time with or think about. And since I spend a pretty sizeable amount of time at a patient’s bedside, talking to them, and then talking about them to my team, it’s no wonder they’ve invaded my dreams.
I’m also feeling really attached to my patients, and I wonder both if this will fade with time, and if they feel the same way. On my service a couple of patients were “mine;” I saw them each morning and afternoon, and reported about them to the rest of my team on rounds. I’d start to get to know them, their personalities, and little tidbits about their personal lives, and I looked forward to greeting them each morning, watching them progress from very serious surgeries to almost full recovery. When one patient in particular was discharged from the hospital on a day I was off, I was a little offended. “What, he didn’t even say goodbye?” I thought to myself, and then had to remember that I was probably not at the top of his list of importance; he’d been in the hospital 12 days and couldn’t wait to leave.
I guess it requires me to add another type of relationship to my list now: patients. You expect certain things from different types of relationships: brothers are different than parents are different than friends are different than co-workers are different than significant others are different from teachers. I guess I was still applying the “friend” mentality to my patients, and expecting them to say goodbye when they left.
The patient relationship is a fine line, and is sometimes two things at once. On one hand, you want to be objective: the scientific, square medical doctor that provides advice and data without emotion or attachment to get in the way of the best treatment. But if you remain in that camp, you miss out on the reason you became a doctor: because you truly care about people, want to help them, want to do what’s best for them. Just like you do for your loved ones.
I get the feeling that surgeons like control (now now, don’t get testy; takes one to know one). “Management” sounds much better than “control,” so I guess that’s why they use the former, but I was really blown away by how much of surgery is patient, uh, management. And it’s my favorite part of the surgical rotation so far. I expected to just be in the operating room for 12 hours a day (sometimes it’s close to that), and wash my hands of patients once they’re stable in the recovery room, but the surgeon takes a patient from pre-op and diagnosis all the way to recovery and discharge from the hospital.
One of the neatest parts of surgery, says my attending (and I agree), is the fact that in surgery, you get to make a diagnosis, and then see if you were right. You see a patient acting a certain way, with a certain set of signs and symptoms, and you make an educated guess that their gall bladder is inflamed. So you open them up, go in, and see if your pre-operative diagnosis matches your post-op diagnosis.
The other great thing about surgery is that there’s really a limited number of things you’re really worried about. As opposed to internal medicine, where you’re trying to manage 20,000 chronic diseases with 30,000 medications to treat them, surgeons seem to care about, in order that I’m thinking of them: infection, farting, pooping, blood clots, fluids/dehyrdation, peeing, nutrition, vital signs, and walking around. If you’ve ever had an inpatient surgery, you have been asked these questions. Over, and over, and over, and over, and over again, by the medical student, the intern, the resident, the chief resident, the nurse, and the attending. We cheer if you pass wind, we applaud when you eat all of your meal, and we scold when you lay in bed all day.
This is not to say that a patient’s other medical problems are unimportant or ignored; many times a disease can affect something on the above list: diabetes can complicate nutrition, medications can complicate bowel movements, and so on. I think if surgeons had the time, they’d try to help manage a patient’s mental health status, or their heart disease, or their kidney failure, but sometimes the daylight’s wasting and there’s 10 other patients that require your management, too.
The cutting itself is pretty fun too-when you’re allowed to do anything. The medical student’s role is usually reserved for observing, being pimped (asked questions rapid-fire by a resident or attending), suctioning, retracting and, if you’re lucky, suturing incisions closed at the end. During the first week, you’re no help anyway: your sense of awe at the human body leads to an inevitable puddle of drool that collects at the bottom of your mask. I remember the first time I saw laparoscopic surgery (where they use a camera to look in the abdomen), and I was Simply. Blown. Away.
Next when I was invited to stick my hand in an open patient and feel a liver, a spasming colon, the aorta, and then the beating heart, it was almost too sci-fi to be real. This is a person. MY HAND IS INSIDE A PERSON! I’M INSIDE A PERSON AND THEIR HEART IS HITTING MY HAND! Does their heart have any idea this is going on? This whole surgery thing? That it has a HAND next to it?
And then the seriousness of it all comes down at you like an anvil from 100 feet above. The fragility of life is taken to a whole new level when something starts bleeding during your first surgery, even a little bit, and you think to yourself, “Holy shit. This guy could die. Right now. On this table.” It’s even stranger when you take care of the patient after their surgery, and you think to yourself, “My hand was inside you.”
I’m going to stop all this “hand inside you” crap now because I’m starting to feel a rectal exam joke coming on.
Going from the classroom to the hospital can easily be boiled down: white socks and black socks. I came to a realization yesterday that I now have an incredible surplus of white socks at my disposal, while my black sock supply just keeps depleting. I’ve gone from a student, wearing messy clothes in the library, seen only by my peers, to a professional, seen only by my team and my patients. It’s very yin and very yang: the intellectual pursuits of the first two years; the practical, hands-on management of the last two. The goals are very different: first came memorization of detailed facts and pathways. Now comes dealing with a real human.
The two are without a doubt complimentary, but the two require incredibly different thought processes. In preclinical, you’re looking at disease with 20/20 hindsight: you’re memorizing the symptoms, the complications, the treatments, and the physiology. Here’s the disease, what are the symptoms? In clinical work, you’re looking at… the patient. He or she comes to you with a couple symptoms, you try to ask questions to get a couple more hints, and then try to use that information to figure out the disease. Here are the symptoms, what is the disease?
This week has really felt like the honeymoon has ended. The excitement and eager anxiety has started to slow; I’m no longer completely new to the routine. I’m expected by now to be able to contribute to the team without major goofs. It actually feels like… a job. It’s harder to wake up in the mornings, I’m requiring more coffee. My awe of the human body has started to subside. (It’s a necessary evil, says the boyfriend. Otherwise we’d never get anything done, and our patients would wait endlessly while we marvel at cirrhotic livers and sebaceous gland cysts.)
One of the most challenging and humbling parts of clerkships is how often I find myself having to say “I don’t know.” On anything from things that I do know but can’t recall on the spot, to things I truly have no clue about. Some things are even obvious but I’m just nervous thinking on my feet. I stall, turn beet red, try to answer, and then after several attempts, give up. It’s a life skill that’s really important to learn as a physician: I’ve always strived to be a know-it-all (the good kind, I swear!), recalling stupid little details just to feel like I’ve studied hard, filled my head with knowledge, and done my part. I’ve always been pretty successful at getting the answers right, understanding the material, and being on top of my game. But practicing medicine has as much to do with experience as with knowledge, and right now my experience reserve is running on empty. In the end, it’s the second half of the phrase that’s more important: “I don’t know, but I can find out.”
And so our fateful hero returns (that’s me, if you were unaware), after an exhaustion-induced hiatus, secondary to starting clerkships. Specifically, the surgical clerkship. I’ll start with my thoughts about clerkships in general, and then maybe dive into the life of a surgeon (or surgical clinical student).
Quick background: medical students do two years of classroom work (known as pre-clinical), then take a really freaking hard 8-hour test (known as “The Boards” or “Step One”). Then we spend our next two years working in the hospital in different specialties, seeing which ones we like, which we don’t, and trying to get exposure to that which is actually medicine.
So it’s the Sunday night before I’m about to begin, and I’m just nervous as hell. I know that the next day is going to be only orientation, with no actual patient interaction or anything, but my eager/anxious pit in my stomach has been swelling all night. Monday is very orientation-ish, with nothing too boring, and nothing too exciting. We talk about expectations, learn how to scrub into surgery, how to get into sterile gowns, get a basic idea of how clerkships and clinics work, have a couple lectures on surgery, and a workshop on suturing and tying knots. More on that whole business later. I iron all my shirts, have the better half show me which ties go with which shirts, and try to go to bed early.
Tuesday is the first official day. I’ve reviewed how to talk to a patient (called “taking a history”) and examining a patient (called “examining a patient”). I’ve read suggestions from classmates and previous students, and I’ve excitedly received my first page to learn what time to report to my team. Tuesday arrives, I wake up early (“early” still means about 6am, ha!), shower, get dressed, and drive over to my hospital where I’ll spend the next month.
I meet my team, which consists of a chief resident, two interns, and myself. Lots of personal attention, but lots of responsibility. I’m starting to already realize everything in medicine (and life?) is a trade-off. More attention, more responsibility. Give a drug for this problem, it causes that one. Perform this procedure for a disease with risk amount X, and hope that it’s less than the new risks you’ve made from the surgery.
You’re really, I mean really, just thrown in there. You finish second year taking your boards, and you think you’ve got medicine down pat. You know what every drug does and what it treats, you know how every disease process works. And then you get into clinics, and you’re immediately humbled. You know nothing. There are new acronyms, strange new drug names, new locations, new computer systems, and new people. But to everyone else, it’s totally normal. You’re already playing catch-up.
You don’t want to seem like an idiot, but you’re also excited and inquizative. But you don’t want to be annoying, either. Your team isn’t just your team, it’s also people that are evaluating you, and trying to feel you out to see what kind of a team member you’re going to be. So you ask questions about things you’ve never ever heard of, and take notes to try to look up the rest later. You learn to mutter questions quietly and secretly to nurses and your interns, who will probably help you out (and aren’t really evaluating you as critically): they just finished medical school 3 weeks ago, so it’s easiest for them to remember where you’re at.
I quickly realized that real medicine is very different from ideal medicine. You’re supposed to give everyone a full check-up, look in their eyes, ears, and nose, and feel for their thyroid, but who has time for that? And different specialties want different things. Surgeons are obsessed with infections, fluids, nutrition, pooping, and farting. The obsession with the latter two is still novel to me. A patient told me he had a “tremendous fart,” and I was disappointed when no one else on my team even smirked at the description.
Feeling stupid makes you learn quickly, which is one reason I’m usually not too distraught when I get an answer wrong: I know it’ll be locked into my head from that point on. At the same time, “don’t get sick in July” is just way too true. Your doctors won’t be as quick to get a diagnosis, and your sutures won’t be as straight. Everyone’s supervised by multiple people, but July is usually especially hectic. You get a flood of new medical students, newly-graduated doctors, new residents, and new official attendings. Everyone’s trying to figure everything out, and it can be difficult.
The feeling has faded now, but I was so surprised at how very entitled I felt after my first week in the hospital. I was working 12-14 hour days, 80-90% on my feet, and I really felt like I should be getting some sort of special treatment because of it. That I should be rewarded or recognized for it. I wanted to go to the mall in my scrubs with my operating room hat hair so everyone would see that I’m a hard-working medical student. It was cognitivie dissonance at its finest: I’m paying $50k a year to work my ass off, so I figure there must be something I’m getting out of it right now. It was such a strong feeling that it really took some conscious effort to remind myself that I chose this path (and thank you, blog, for reminding me).
I’m incredibly exhausted, but incredibly happy. I’ve really started to get the hang of this whole clerkships thing (so far, at least), and it’s been a really amazing experience to see many of our patients go from the ICU to the wards to being discharged. I’m going to miss seeing them so frequently. And to you, the patient that we lost two weeks ago, and to your family, who allowed me to be part of the discussion about you: you’re one I will never forget. Thank you for your friendly smiles and waves each morning, and for trusting me into a most private part of your life. That physicians have the privelege and honor to be part of patients’ lives is a most amazing and sacred part of the practice.
This is a medical weblog--a collection of thoughts about medicine, medical training, and health policy--written by a fifth-year medical student.
I recently stopped blogging, as I graduated from medical school and I'm now a physician in my residency training in New York City. But feel free to read and enjoy!
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