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.