4th year = decision time

We were told that 4th year was the best year of medical school. We were lied to.



Don't get me wrong---I've had a lot of fun this year, and definitely enjoyed not having exams after the end of every rotation. But undoubtedly there is this HUGE pressure to make big decisions---something I've never been fond of.



Flashback to senior year high school----I could not decide where to go to undergrad. So much so, that I almost took a year off in order to prolong the decision making process. What ended up happening? I signed up for the Unv. of Denver on the last day acceptances were due---and secretly hoped my letter got lost in the mail so I'd have to take the year off. Good choice? It took a year before I fell in love with Denver, but once I did, I was so happy I ended up there.



Now to present time. I actually joked a couple days ago how I will be in Nepal (whohoo!) when our ranking list is due. And how Internet may not be so great out there, so maybe I wont get my rank list in and then I'll have to take a year off.



For some reason I'm seeing a pattern.

you know it

You know you're an emergency resident wanna-be when after you run a half marathon and then jump on a plane to get to an interview, your main worry in life is getting a DVT.

thought for the day

A medical students LEAST favorite question in the whole wide world:

"Do you have any questions for me?"

I wonder if I could throw that question back to the director as my question........

My right hook

One would think after my interviews I would have quickly written a response to my last posting, but to be completely honest, my final interview sorta hit me hard and I wasn't quite sure what to think.

My standard question to the directors is "How are the residents evaluated?" Its a an easy way to get the program director to chat away and I can think of a follow up question, or we can move on.

Well at my final interview, I think this program director took this question the wrong way. He gave me the quick run down, told me that I will do just fine in residency, and then quickly shot me a question that to this day I'm still thinking about. He asked me if I beat myself up.

The question seems innocent enough. Just say no and move on. But I paused. Because the truth is---to a point, I do beat myself up. I don't want to say my family was particularly hard on me, but when you grow up with work-alcoholic parents, your options are to rebel and be a slacker or follow in their footsteps. I clearly chose the later.

So after the pause, I attempted to explain this. I fumbled. I came across sounding like I'm super competitive which, I guess I am, but truthfully, I'm only competing against myself. The program director finally saved me and said, "Listen, we all appreciate excellence."

And that's when I shut up.

Interview season!

www.glasbergen.com

This week I start my first rounds of interviews. I had hoped that I could have started the interview process with a program that I wasn't hanging my life on getting into, but that is just how things go.

So in order to put my best foot forward (is it my left or right?) I've been practicing. A LOT.
I've been caught talking about myself while running along the canal. But thinking back to the really weird faces that I passed--- it is possible that I was yelling since I always listen to Boston's "More than a Feeling!" full blast while practicing (and running). It has been my theme song for fourth year---I wrote my entire personal statement while listening to this song over, and over, and over, and over (angela--you know what I'm talking about!).

I found an excellent website with practice questions. So today, on my final day off, I found an awesome coffee shop and tackled them. I was quite surprised to find the potential questions I might get asked:

* Tell me a joke.
* Teach me something non-medical in five minutes.*
* Besides medicine, how else are you intellectual?
* Present to me a patient you seen in the past, as if we were in the clinic.
* Ask yourself a question, and then answer it.

And of course the infamous: do you have any questions for me?

Now maybe these don't seem so bad just reading them over, but imagine if you just introduced yourself and the program director asks (or demands) a joke! I know that my head will go completely blank under the pressure. My plan? I'll just giggle a lot.

*I'm gonna teach that program director how to swim---that'll get him/her out of her comfort zone! I'll just have to bring a small kiddie pool....

Politics

It is election day!! Go vote!

But I have to say neither candidate has a really good handle on the health care issue. And just cuz health care is sorta my life I wanted to bring up some facts that we went over yesterday in class...

Why people go to the ED:
- they have a true emergency
- they are traveling to that city and get sick
- lack of alternative access: uninsured, no PCP appointment available, PCP closed
- societal outcasts: homeless, illegal immigrants,etc
- drug seekers

Average cost of an EM visit: $383
Average cost of a PCP visit: $60
(although this is not comparing apples to apples---most people who visit the ED are generally sicker, although 55% of the 90 million ED visits were deemed unnecessary in 1996)

Number uninsured:
- 47 million uninsured

Who pays for the uninsured?
- The insured. Premiums and such don't just cover the individual needs. We're all paying for everyone to get medical help. The money has to come from some where

Why is this important?
--if the insured are paying for everyone else---wouldn't we all want everyone to be insured and then no one would be paying extra??

Just some food for thought!

My Favorite Day!

It's the most wonderful time of the year!!!

Happy Halloween!

If you're looking for a spoooookkkkyy flick---try The Strangers! Its the scariest thing I've seen in a long while.

Med student informs attendings and isn't beaten down!

Being back in the ED again, and being sincerely happy about it, definitely makes me a bit more confident about the whole EM/Peds thing again--cuz I have to say---there are days that I very much miss the OR. And being on the Peds side for the past few months got me thinking that maybe Peds was more my thing, but after one shift downstairs, I realized my heart is totally into the ED thing too.

I am currently doing my first, and only, away rotation. It is pretty interesting to see how the ED works here compared to back home. Firstly, for all lacerations: the nurses numb up and scrub them out for you. This lets me get other work done like calling surgery or pediatrics, or discharging someone. Secondly, I never have to look up a single number to page someone---I just tell one of the three secretaries that I need to talk to Dr. C and they take care of it---within ten minutes I'm getting paged overhead that he is on the line waiting. Lastly, people here are ridiculously friendly.

Last night I had a sick kiddo. In the ED the main purpose is to decide who is "sick" and who is "not sick." I have to say as a second year I thought everyone was considered "sick"---I mean why else would they have gone to the ED?? Now I think I finally have it down. So this kidddo had a fever of 104, hadn't eaten/drank anything all day, was tachycardic and tachypnic and just looked out of it. I was worried. So we started an IV, got cultures from her urine and blood and gave her Tylenol and Motrin. She perked up after the second bolus and I felt much better. Her urine came back with a UTI and we decided we were gonna send her home, but my attending really wanted me to talk to her pediatrician prior to sending her home. Of course the parents had no idea which Dr. F it was in town (there were 3 by the same last name) so I had to do some serious searching.

Around 10:30pm I was pretty sure that I narrowed it down to the correct doc. I was nervous to page this doc late at night just to do a "let you know" conversation, but it was important. So I dialed away. She responded about 10 minutes later and was amazing. She was completely appreciative that I informed her. I couldn't believe it. I hung up the phone with a smile on my face. And that's when I started thinking---I hadn't called a single consult so far that resulted in someone getting nasty or being rude---people here were happy to help out! What an amazing concept---we were all on the same side --trying to do best by the patient. And that's when I started thinking, maybe I could live here.

tying up the PICU

I finished my rotation and at PICU--- I know I didn't report much on it, ok like nothing really on it, so I am gonna sum it up here!

It was intense. And as a close peds mentor told me---you have to be deranged to like it.
Call me deranged!

Because I liked it enough that I actually applied to a pediatric program. Who woulda thought?!?! I was able to cardiovert a stable arrhythmia twice, I did my first LP on a kid, and I saw more central lines placed that I believe I could now do one on my own. I took care of a ventilated congenital cardiac kiddo---balancing lasix and fluids carefully. I took care of a very sad head bleed teenager---she was in the bed of the truck when it rolled over. I managed a very dehydrated kiddo (sodium=170!) and normalized her sodium carefully. All in all--I learned a ton but I also experienced awful things.

My second to last day we had 3 children die. It was probably one of the worst days of my medical school career. (I had a hanging death of a college student while on trauma which now is in second place) The first death occurred around 9am: it was a previously healthy 6 year old who had a T&A (tonsil and adenoid removal) the previous day. At 4am, mom gave him hydrocodone and by 8am he was blue and not breathing. We coded him for 90 minutes. And just before we were about to call it, someone found a pulse. So we put him on a epinephrine drip to allow mom & dad to say goodbye. It was so sad. By the time it was all settled it was around noon. I grabbed a quick lunch and then was told there was a 2 month old boy coming in coding. He was sleeping on the couch with dad and dad woke up and he wasn't breathing. We coded him for 60 minutes, but he did not make it. The final death was a cardiac kid who went to surgery. I came up from the ED after the 2 month old didn't make it to find out that the cardiac kid died while in surgery.

I pretty much cried all day. But it got me thinking which is "better"---having a sudden situation, where your child passed away suddenly and out of the blue, or having a chronically sick child and them passing away in a high risk situation---aka surgery---but a situation that you believe will save their life. I am not sure which one "wins."

Things I learned way before med school....

So I recently (aka Monday) started my rotation in the PICU -Pediatric Intensive Care Unit- and let me tell you---its intense! More on that later....

We had about a 10 minute break the other day and started looking up kids on the floor that might come up to to the unit. At one point the peds resident recognized a kiddo there and started telling me their story:
Its a 10 month old kiddo who has had chronic diarrhea since birth. They've done all kinds of tests to figure out the cause. They found out the kid is unable to digest both proteins AND sugars. This is actually quite rare. Apparently kiddos usually just have one problem or the other, but not both at the same time---this is a good thing because if you cannot digest proteins, then we give the kid sugars to eat, and if you cannot digest sugars, we give them proteins. For this kid they are playing a fine line in feeding him.

The lesson with this kid??

Don't marry your cousin.

Boo-ya!

Jokes made by Dr. S:

How do you hide medical information from an orthopod?
----publish it!


How do you hide patient information from an orthopod?
----put it in the chart!


Booya!

Bonding

This morning was clinic day with Dr. S. I was pretty excited about it because Dr. S told me that we would have at least one HIV positive kid, and not to sound morbid, but I was looking forward to it, because I find HIV fascinating and I've not met a known HIV kiddo before and I wanted to learn about how they were diagnosed and what their prognosis was like, etc.

18 year old R was our first patient. I walked into the room and there sat a healthy appearing cute kid. Cute enough that I would let my daughter date him. He was polite, and answered all my questions. He was diagnosed with HIV as a small child---it was passed on perinatally meaning while his mom was pregnant. He is currently on four medications to suppress his virus*---some of which he has to take twice or three times per day adding up to at least 9 pills per day. His viral load has been undetectable for several years. Meaning he is doing great. So great that Dr. S has wanted to change his meds so that he only needs to take 2 pills per day. But R has been reluctant to do so because he is doing so well and he is worried about going downhill once he changes his meds. Pretty amazing for an 18 year old. Most 18 year olds can't even remember to brush their teeth or put on deodorant.

When Dr. S walked into the room R jumped off the table and gave him the biggest hug. I didn't start crying (that would have been my usual reaction) but I felt this over whelming joy --- like Dr. S and R had this amazing bond and all I could do was to hope that some day I would have the same bond with my patients. After their inital hellos, R opened up and told Dr. S that he was smoking 6 cigarettes per day and pot about 2 times per week. I was impressed with his honesty but sad he was headed down that road. So Dr. S and I gave him a talking to, where I suggested running instead of getting high because it is a "natural high."

And alcohol and rock n' roll will send you to hell!! Sigh..... kids probably think I live in the 1950s.


* in talking with the mom and the kiddo---I realized they knew more about antivirals and HIV therapy than I probably ever will.

Data Collector

I've been working my butt off in Peds Infectious Disease. We cover two hospitals, plus there is clinic so basically we're constantly picking up new cases and finishing up others. We've got some sick kiddos recently: a Rocky Mountain Spotted Fever, lots of osteomyelitis, Leptospirosis, bacteremia sepsis, and today I diagnosed malaria!



But part of the hardest part of this rotation is getting my thoughts together in order to get the assessment and plan ready to present. I am good at getting the information--I can ask the important questions, and I can pick up abnormal findings on the physical exam. I can also get the vital signs and the lab values off the computer. After that I am supposed wrap it up with a simple one line sentence and explain my thought process for what I think it is. This is where I falter. While I was on ED I could get it together, but on Peds ID, I am usually so confused and have a billion things running in my mind that it sounds like blllllaaahhh.



Lucky, my attending sort of expects this. He believes our teaching was geared at making us great Data Collectors and looking back over 3rd year I actually completely agree. For example, on surgery I would wake up early to "round" which really just means I would make sure to find out if anything bad happened to my patient while I slept. If that was a no---did they eat? did they have a temperature? did they get out of bed? how was the pain? after I collected that info and their vitals and labs (which we rarely ordered anyway) I would just recommend that they eat, get out of bed and make sure their pain was controlled. Done and done. On OB it very similar only I'd mention something if they wanted any form of birth control. On psych I never rounded. On medicine we were told by the ED what they had, and we just consulted various services so I'd make recommendations on that and I'd look up journal articles to learn.

So it seems like I really didn't have any creative thought of my own when it came to summing up the patients---I was medical student, the Data Collector.

off it went

www.cartoonstock.com/lowres/jkn0020l.jpg

I submitted my application for residency last night (AGHHH!!) and I am freaking out (AGHHH!!). I tried drinking a beer after submitting, but in all honesty---it didn't help. So I might go towards heavy drugs---like chocolate.....

I wasn't going to submit until next week (I'm still waiting for a couple of letters of rec) but after talking to the Peds Residency Director---it changed my whole outlook. It was a simple run in---we both happened to grab our lunch at the same time. He is super friendly so he asked me how I was doing and what rotation I'm on, etc etc. Just plesant chat until we hit the elevator. Thats when he asked if I submitted yet. I said, I was working up the courage. Thats when he mentioned that he already had 250 applicants. 250!!! The option to apply was only open for 30 hours at that point and he already had 250?!!?! So I went home and stared at my computer until I finally hit enter. And off it went.

So I've checked my email about 30 times today in hopes to have an interview request. But no such luck. The worst part is you can look up who has downloaded your application. Several have downloaded it. Still no interview requests. AGHHHHH

Having a kid is just like owning a pet.....

http://www.cartoonstock.com/lowres/amc0336l.jpg

My first patient on Peds Infectious Disease (Peds ID) was supposed to be a kiddo who lives in the near-by bigger city. I find it absolutely amazing that the neighboring city which has about 4 million more people does not have a single Peds ID doc. Instead they have to come here or the docs from my city, go up there. Well aparently this kid doesn't even have a doc to begin with---he's been seeing a veterinarian.

He got diagnosed with MRSA---the strongest bug there is out there! Its a resistant strain of staphylococcus (a bacteria) which will definitely need some big gun antibiotics. But instead of going to a doc for this diagnosis, his family took him to a vet. Aparently, it only costs $17 per day for the kid to stay at the barn shelter. Which I guess compaired to hospital bills ---this is a fabulous deal. Why did he go to a vet in the first place? no idea. What kind of MRSA does he have? no idea. Why do I not have the vital information on this kid? Because he was a no show in clinic today.

Meeting with the Big Guy

Yesterday I had one of the most important, and yet terrifying, meetings of my life (ok I am known to exaggerate). I met with the Residency Director for the Emergency Department at my Medical School. He is known to be a bit blunt and tell you exactly how he sees things, so I was ready to be tackled down and told that I was never ever going to become an Emergency Pediatric Doc.

He surprised me.

I first sat down wishing I had not worn a white top because I knew that sweat marks were already shining through, when he barked "So why did you want to talk to me?" I took a deep breath and opened my mouth and replied "I came here for 2 main reasons. First I want to know about what you think about letters of rec...." and I really didn't close it much after that. For some reason he responded well. He went over each and every one of the residencies on my list and graded them for me based on what I said I was looking for. He then did a mock interview and told me how to revise what I said. Which is when I decided it was time to know, to really know, how I stood up against other applicants. Because I'm gonna be honest---sometimes I'm like an ostrich--I just like to keep my head in the sand and push on through without realizing everyone is running away from the lion.

So I told him my Step 1 board score---its pretty much the mean of what his department takes--which I expected. We discussed Step 1 for a bit. And then I mentioned that I honored everything except for medicine. Now, here comes the hard part. I am pretty sure I prefaced that with "In third year I honored everything but medicine," but looking back, I am not so sure. He was impressed. He asked if I was AOA (they are the ones to be impressed by!). I said "No--I have a very competitive class." And thats when he said, "Well if you rocked Step 2 then I think this whole Em/Peds Residency is a reality for you." My head swelled up 2 sizes and I floated away from that conversation elated. ELATED.

It wasn't until 7 hours later when I realized he might have thought I meant I honored EVERYTHING except for medicine---meaning everything first year, everything second year, everything third year----except for medicine. My elated feeling fizzed and now I'm back in the sand again with the lion circling. I mean what was I thinking?? I knew that conversation went too well. My luck isn't that amazing. So I wasn't sure what to do with this new thought. Some of my closest friends (I love you guys) told me thats definitely not what he thought, it was clear that we had moved on to 3rd year when I mentioned that. And hopefully they are all correct. I am just having a hard time shaking this one off.

Tuesday I start Peds Infectious Disease---you all know how I love the little buggars!!!

Selling my soul part 2

I've said it once, I've said it a million times, but I have FINALLY made a choice about what kind of doc I'm set out to be. (have I already posted this?) Anyway, just so the record is straight--I am applying for the combined Emergency Pediatric Residency programs (there is only 3) and then Emergency on top of that. It all sounds so simple, but after a year of liking almost everything, and then changing my mind every 3 days or so, you would think I could catch a break once I made a decision, but this application business is anything but.

ERAS, or Electronic Residency Application Service, is where the thousands of medical students send in their first 3.5 years in hopes to land their dream residency. Whats interesting to me, we go through these ass kicking years, thinking we're working so hard, signing up for extra projects, etc etc, when in reality we're just like every other medical student out there. Signing up for the extra stuff, studying your butt off to honor every rotation except one (TRUE STORY!), turning down social events, saying no to your family---is no big deal when you are compared to everyone who is just like yourself. The residency has already heard of it before. About 500 times before.

So how do you stand out? What will make me special? I actually know of a medical student who started hiking (she went 2 times) in order to have something to say at the interview when they asked about hobbies. (saying it now makes me want to puke) As I fill out my personal statement and my resume I think about the random things that I wish I could add: making good luck cards for every class member for a year, organizing several trips to mexico, camping, lake tahoe, planning dog park days, surprise parties (x2), etc etc etc. I wonder if the 60-somethings attendings on the admission committees will appreciate that stuff. Somehow I doubt it.

And so it continues.....

So I know I haven't posted in a while, but the stress level really hasn't died down and haven't had anything non-stressful to post.

I am currently studying for Step 2 of the Boards. I've decided this is the worst name for this test. I am a 4th year. I think the Boards by now should be Step 186 or maybe Step 309. I mean Step 2??! It seems like I haven't made it that far with just the second step. I am going to propose this to the headquarters. After I take the test, of course.

On a happier note---after the boards I'm heading to the wild territory of Las Vegas! Any suggestions of what to do while I'm there?? We'll see if that helps with the stress. :)

Things that are stressing to me

Picture from: http://1927cafe.wordpress.com/2007/09/26/stress-qoutes/

I usually don't go too negative on this blog, but today, I need to vent!
4th year med school is usually the best thing ever---but I've discovered that the party doesn't actually happen until March 20th, 2009. Until then these are things that stress me out:

1. I have no money: Money can be a stressor to everyone, but usually I'm stress-free about it. Today that is not true. The gov't has not distributed my loans to my lender for the year yet. This means I haven't paid tuition yet. This also means I do not have money to pay rent, buy ridiculously expensive gas, or go on that awesome trip I had planned for "party time fourth year". My stress relieving options? either take out short term loan or sign with a different lender.

2. I'm in the middle of moving: I am literally moving 4 blocks away, but having half my stuff in one house and half in the other is daunting. I've got to finish the move (but not for another 3 days which means I'll be anxious about it until its over), clean up the house, do the walk through and pray that I get a decent amount of my security deposit back (this would also be a stress reliving option for #1) but seeing as how my land lord is threatening a law suit, I doubt that will happen. Options: finish the move, do the walk through and pray

3. My landlord is threatening a law suit: enough said. Options? Hire a lawyer, but see stressor #1.

4. I have got to be dependent: 4th year means in the first few months you've got to be on top of your game so you can impress the attendings and hopefully hear the phrase that every med student hopes to hear, "Please let me know if there is anything I can do to help you." Once you hear that, its like a golden ticket for asking for a letter of rec, which is your entire point of impressing them in the first place. These letters of rec are on the minds of each 4th year--until about October when you won't be able to get it into the system for your ERAS application so we just give up. Options? Kissing butt, asking about 100 attendings in hopes of getting 3 good letters, changing your entire shift schedule so you can work with at least one attending twice, etc.

5. In sending my request for a letter of rec, it was sent twice: I hated the idea of asking attendings by email. I thought it should be professional and in person. But I was not going to work with this particular nationally known attending again, so I thought it was my chance. The day after my shift I decided to email him for a letter. Getting a letter from him would be like getting a letter of rec from Steven Spielberg if you were an actor. I drafted my email and attempted to send it. The Internet went out so I quickly closed the email and redrafted it. Feeling more confident with the second draft I restarted my email and attempt to send the second version. Several hours later I checked my sent messages to see the horror of my life: the first version did send. I had sent two emails, both with the same question but written completely differently. AGHH. I still can't get over this one. Options? I asked my roomie if I could send an "OOPS!" email, but he said I've sent enough emails for the night.

6. I'm 26, single and my moms asking for grandbabies. Oh wait that's more of a Sex and the City episode. No worries about that one!! :)

The eerieness of the ED

Prior to a trauma coming in, the patient is assigned a trauma name since usually they come in altered and cannot completely register. This expedites the process of getting labs, xrays, CT scans, etc. Usually they are just random nouns such as Wade, Ij or Taco, Iv, but lately it seems like the patient's findings are correlating nicely with their trauma name.

The first situation occurred last week: he was a 20 something year old male who was arrested that day due to reckless behavior---he was drugged out and drunk. He decided that instead of posting bail, he would run at full speed toward the nearest brick wall, head first. He had a positive loc (loss of consciousness) and was altered. He also had a very large goose-egg on his left frontal head. His trauma name? Unicorn, Ij.

Last night another 20 something year old male was getting out of his car at a friends house when a male jumped him and started hitting him repeatedly in the face. He came in complaining of jaw pain. When we looked into his mouth we noticed a positive step off in his teeth, suggestive of a mandible fracture. His trauma name? Enamel, Ij.

Coincidence? Or is someone playing a trick?? I will get to the bottom of it!!

This one is on me.....

So at precisely 12:32pm yesterday I had a series of unfortunate events while in the ED that, again, made me turn a nice shade of red as well as go numb in the face. Let me explain.....

I was setting up for my first lumbar puncture (LP). While having butterflies in my stomach, I was also really excited and had visions of getting spinal fluid on my first try and the resident congratulating me on a job well done. (who doesn't envision this?) Anyway, I as I pulled back for some lidocaine (the stuff that we inject to decrease sensation) I shot a bit too much (about 8 ccs too much) of air into the bottle. It exploded and the stuff went all over my face. This all occurred when a dear friend of mine, who is a surgical resident, just happened to be walking by to see how I was doing in the ED. My lips started to go numb, and of course I yell at the top of my lungs, "I've had an exposure!!" Now, I guess I could have called it an exposure, since I was technically exposed to some lidocaine, but this phrase is generally used for when we get exposed to a patients' bodily fluids, not sterile lidocaine. Luckily the ED is a loud place, and only 3 patients, my friend, and 2 RNs heard me.

I only drooled once and the sensation came back to my face/lips by the time I had a chance to eat some lunch---around 2pm. =)

Not the brightest color in the crayon box!

A 23 year old male comes to the ED after a motor vehicle accident. He was a driver and rear-ended the car in front of him when he didn't see the car slow down to make a right hand turn. He wasn't wearing his seat belt, no air bag deployment, and no loss of consciousness. He was a trauma green, meaning he was pretty stable. In a sense he was fine.

To practice, we did a Focused Assessment with Sonography in Trauma, or a FAST exam, which finds free fluid (usually blood) in the belly. To be humorous we added, "Sir, we are going to use this machine to make sure you are not pregnant." The patient got an upset look on his face and replied, "There is no way I'm pregnant---I'm not a bisexual!"

Maybe he did have a head trauma afterall.....

First shift in the ED

I experienced my first shift in the ED on Thursday. At first I was just so anxious that I stood around trying to act calm and collected. This means I tried to hide in a corner and not be in the way, but really I bumped into about 2 physicians, 3 nurses and knocked over an entire large diet coke. It spilled every where. My face has not turned this shade of red in a long time.

My first patient was a lady with a headache. At first I thought she was a drug seeker, but after doing an MRA of her brain we found an aneurysm! I felt like I saved a life, but truthfully, we didn't do anything except admit her for pain control.

It was my second patient that made my pulses rise and really got me excited for Emergency Medicine. It was a 25 year old man who works as a carpenter. He had shot a nail gun in which the nail ricocheted off a knot in the wood and went through-and-through his ring finger on his left hand. He and I were both lucky that it did not go through the bone---he was lucky because it meant no surgery,while I was lucky because it meant I got to pull it out. I did a digital nerve block on his ring finger, held down the finger while the attending held the wrist and I did a 1,2,3 PULL!! I gave it tiny tug at first to see how hard it was going to be, realized it was really stuck and pulled with all my might! It came out with a gush of blood and I couldn't hide the smile off my face. What a rush.

4th year

So this week I started my first week as a fourth year medical student and my first week in Emergency Medicine!!! Have I saved lots of lives? Done tons of procedures?? No and no. We've been in lectures all week--but they think they have learned us enough to set us free!! Thats right folks---I set out for my first shift tomorrow night! Watch out!

And for all the non medical people out there---stay out of the hospital (and clearly the ED) this month! This is everyones first month--- meaning everyone is being trained---from the medical student to the resident to the attending---NO ONE IS SAFE! :)

Pushing the years

In lecture this week we discussed taking care of the elderly. Seeing how our population base is getting older and older, and since my parents are in the beginning of pushing their years, I thought this topic pretty relevant.

The professor was talking about the issue of what to do when you believe your patient should not be driving anymore, ie) when you may have to take his or her license away. The ability to drive is very liberating; the idea of taking away that freedom is actually quite depressing. I remember a patient while I was on psych that was a 70 year old woman who we were consulted on to assess her capacity for decision making. She wanted to leave the hospital and go home---not to a living facility that her medicine team was trying to set up. She was able to answer our questions---although most of the them were wrong--she just made stuff up. Once we figured this out and found out that she still drove---but not much, only to the bar and back---we were a bit worried about her (and the rest of the drivers out there). It was difficult but we recommended that the medicine team consider to take her drivers license away (I dont really know why we didn't do it ourselves). And we also recommended some anti-alcohol therapy since her driving to the bar excursion happened daily and not weekly.

The professor brought up a patient of his----a father, son situation where the father had severe alzheimers--he wasn't able to remember day from day. The son and doc both believed it was time to prevent the father from ever getting behind the wheel, even though it was one of the father's favorite activities. So instead of making a big to do about it, before they went anywhere, the son would just say, "Dad, I really like to drive too, and since you got to drive yesterday, I think today I should get a turn." The father being a sharing loving man would always say alright.

The son said that to him everyday.

Lost in Translation

A joke to lighten the mood, but also why some patients just don't seem to here what we say....

Fred a 92 year old man had just been to the doctor for a physical. A few days later the doc saw him on the street with a goregous young lady on his arm.

"Fred, what do you think you're doing??" his doctor admonished.

"Why just what you said, Doc!" Fred answered. "Get a hot momma and be cheerful!"

"No," the doctor replied, "I said you've got a heart murmur. Be careful."

A few things happened this week:

*I made the decision to do EM/Peds. I am tired of switching around and although I did think about OB again for about 10-20 minutes Friday afternoon, I am going to stick with it. I visited the residency director for the peds department and he promised me the world---"we'd love to have you here....i've heard such great things about you..."

*we had a class meeting where a favorite doc said "don't listen to residency directors. they tell everyone they want them. they don't usually mean it."

*I am newly single. I dont have much to say about this one. I dont really talk about my private life here. But there it is.

*I have one more week of 3rd year left. I cannot believe this year is almost over. It has been a whirlwind of a year. And although I am so excited for 4th year, I am also terrified.

On top of the world

As second year med students, we are paired up with a doctor who is supposed to teach us how to properly interview and do a physical exam on a real patient. In addition they should go over how to come up with a differential and start to think of what to do for the patient. My "preceptor", as they were called, was an ED doc. She did a great job of just throwing me into a patients room and letting me do my thing. She also did a great job of making the ED a classroom. We'd pass by a random x ray left up and she'd have me read it. A resident would present a case and before they could get to their assessment, she'd have me go through it. I learned a lot.



By the end of my second year I remember feeling on top of the world. I was almost done with a whole year of path---I was taught the most common diseases as well as some of the most random ones. I knew my shit.



I went down to the ED one day to work with my preceptor. There was an emergent case of giant man with kidney failure and leg weakness. She handed me the EKG and I had no idea what was going on with the squiggly lines but she was giving tons of orders, so I knew it wasn't good. He ended up having hyperkalemia and the EKG showed a prolonged PR and peaked T waves (the classic sign for hyperkalemia). She went over the treatment (C BIG K is the mnemonic) and what to do as I furiously scribbled it down in a little note book trying to hide my shock. I remember looking up from my notebook and asking "Dr. C--when am I supposed to be learning this stuff? I mean I am almost done with my second year and I've never heard any of this." She sorta chuckled and said, "You didn't know this already??! Hahaha, just kidding. No worries--you will."



Looking back on that instance and then where I am now is astounding. The amount we learned in this one year is incredible. But again, I feel on top of the world. But the main difference is, I am starting to worry---this time around, I know there is STILL so much to learn and I'm worried there may not be enough time before I'm given real responsibility.

don't give in

I am currently reading this amazing book called Complications: A Surgeon's Notes on an Imperfect Science by Atul Gawande. It is a fascinating book and all --science or non-science minds should give it a try. Below is an excerpt from one of my favorite paragraphs--he's attempting to diagnose a person with abdominal pain:

"I am sure I can figure out whats wrong with her, but, if you think about it, that's a curious faith. I have never seen this woman before in my life, and yet I presume that she is like the others I've examined. Is it true? None of my other patients, admittedly, were 49 year old women who had had hepatitis and a drug habit, had recently been to the zoo and eaten a Fenway frank, and had come in with two days of mild lower right quadrant pain. Yet I still believe."
I still believe.

what it made me think of.......

Today we had a lecture on STIs (the new acronym replaced the old STD; it stands for sexually transmitted infections)--which just so happens to be one of my favorite topics. This, I suppose, is an odd statement, and usually I keep it to myself, but in all honesty--I am FASCINATED with STIs. I like trying to figure out which one it is based on the history, and I also like treating them--most are very easily treated (minus HIV) and you get a chance to educate patients about them. So all in all, they are awesome cases for me.

Anyway!

We were discussing douching--and how some women can get a chemical irritation from basically washing away the normal bacteria from the vagina. But this is not how the doc put it. He described it as washing the normal "flora and fauna" away. This immediately made me think of a dense jungle, with lots of branches and gigantic leaves everywhere, maybe some tree snakes. What a disturbing image! Especially when you try to put that into a woman's unmentionables. And thats why, I've decided, men (and some women) have no idea what's going on down there.

Giving Advice

Here is what I do well: I am a good listener. People feel reasonably comfortable sharing secrets. Most of my closest friends know that I will listen and be understanding to what is going on in their lives. I am comfortable asking lots of questions to get to the bottom of how a person is thinking or feeling. And usually it is done in a completely non-judgemental tone (I am usually without judgement-- although there was this one time where I was "practicing" interviewing a patient---he was a homeless man who smoked tons of crack cocaine. For some reason I was completely fine with that. It wasn't until he told me that he had 9 kids til I freaked with out with a high pitched "Nine kids?!?!" response. The med student I was working with completely lost it) I think I've been able to apply this to medicine---I can get a good story from the patient--the who, what , where and why and also how they were feeling, and what they think the reason this occurs.

Here's where I need help: So once I find out that my 15 year old patient has been having unprotected sex and drinking every weekend, I fail at telling them why it's a bad idea to be doing what they are doing. I am good at getting the info, I just stink at giving them the medical advice. (I think I may stink at giving friends advice as well). So then I go report to the attending that they are doing this risky behavior and they always ask "So what did you tell the patient?" Thats when I stutter and say something about how I wanted to see how the attending handles it because I've never crossed this bridge before. When in fact, I've had at least a dozen patients like this and I just stink at at it. I think I am worried about coming off as being judgemental. I can remember my dentist making me feel bad when I wouldn't floss---I never wanted to see him again!!! I am worried that I will lose the patient forever and then when they do get an STD, or start coughing up blood after 50 years of smoking---they won't come into the doctor and ask for help; instead they will pass the disease on or die of cancer.

On my current rotation---family medicine---I've started trying to speak up. This is part of a doc's job---recommend some actions (take this medicine) and to dissway patients from others (pretty much everything else) Here's to me finding a voice!!

Sometimes its painful being a med student

One of my favorite meals as a child was a rice cake with peanut butter and honey (I severely disliked jam or jelly). The other day I got a craving for my past time treat and went to the grocery store. Just as I was about to put the honey bear into my basket the word "Botulism!" started ringing in my ear. (botulism is a rare, but fatal, disease where muscles become paralyzed. It has been linked to eating honey) And even though I'm more likely to be held up at gun point after my visit to the grocery store, I couldn't bring myself to buy the honey. Curse medicine!!!

selling my soul....

So in continuing themes of hot debate, I decided to discuss the whole pharm rep thing this week.

I started my family rotation---I'm at a clinic on the south side of town which means I see a lot of patients who do not have much money, especially for medications, and most of them are on 4 or 5 chronic meds. This gets pretty pricey. In starting this year, I signed a pharma free pledge, meaning I wouldn't except anything from pharm reps except for information. I lasted 3 weeks before I accidentally ate a breakfast that was hosted by some pharm company ( I had no idea at the time). Since then, I've had a couple of lunches here and there. As much as I hate it, I am broke, and its nice not to have to buy my lunch everyday. But at the same time I know it increases prices of the meds to my patients.

Apparently, at the clinic I'm working at they have pharm lunches everyday. The entire staff partakes. Today was a half day for me, but the person I was working with really wanted to "support" the pharm rep because "it must be really difficult to be a pharm rep." So I stayed. I wanted to see this person eating up everything they had to say as well as their free lunch. We got our food, sat down and started munching away while the pharm reps asked the doc how she was doing, what her plans were for the summer, how her kids were, etc. I finally piped up and asked how their bisphosphate drug compared to calcium and vitamin D supplements. They quoted a couple of studies and then discussed how pharm reps weren't allowed in several clinics around town, and how this was the detriment to medicine. I didn't really listen then---It was the first time I've ever questioned a pharm rep---I usually run for the hills, worried I will be consumed by the ads and free pens, but I have to say, it felt good to ask questions---kind of like it does while I'm in class.

I hope to never sell my soul, but to continue to question. I hope to not rely on drug supported lunches someday. But for now, while I'm broke, I'm going to eat and question.

To be remembered by our patients

Yesterday we started the conversation of to circumcise or to not circumcise. It can be a pretty serious debate between physicians as well as families. (has anyone seen the scrubs episode??) But there are some real medical advantages such as decreased incidence of childhood phimosis---a condition where the male foreskin cannot be retracted from the head of the penis. (phimosis is normal in infants, but pathologic in children or adults) The real problem is when phimosis gets infected or if paraphimosis occurs. And its the treatment of paraphimosis thats the kicker.

This brings me to the title of this blog. Its wonderful when patients remember you and have nice things to say about their doctor. Every doc wants to be remembered for something. The treatment for paraphimosis can be circumsion or it can be done the hard way. This entails 4 people to hold the kiddo down. Then one person grabs the foreskin and forcefully pulls it down. This results in mild to moderately bleeding, and a severely traumatized kid. A doc described the aftermath of this treatment: He was walking down the frozen food isle in the local grocery store about 6 months after treating paraphimosis on a 4 year old uncircumcised kiddo. The kiddo took one look at the doc, grabbed his penis, and ran screaming toward his mother. The family actually had to change doctors because the child was so traumatized.

And we say we all want to leave an impression on our patients.

Looking back

I remember back to my first few months of medical school when I was studying neurology. It happened to be one of my toughest classes in medical school, but at the same time I remember thinking the brain is amazing. This was also the time that I thought medicine was amazing and that we could heal all.

I attended a wedding that fall and met a friend of the family who had a 12 month baby. He was adorable. His mom told me he was recently diagnosed with cerebral palsy (CP). I quickly searched my my mind for that disease, but my mind was blank. I hadn't learned about it yet. His mom found out I was in med school, and typically started asking me tons of medical questions about CP, to which I knew none of the answers, but feeling reassured that medicine could save all, I told her that neurologists were doing amazing things these days and I was sure there would be an answer for her. I went back to school and looked up CP in our huge neurology book, and found that it didn't exist in there. I let it go and completely forgot about the whole thing.

Until now.

I've seen several CP kiddos in clinic and in the hospital. Although the severity of the disease is different for each kid, the prognosis is not good. I feel horrible for dropping the ball on that cute kid I saw 2 years ago. I had no idea what his mom was experiencing and I just played the "everything will be alright" card without really thinking and then moved on. I am sorry.

Billy Rubin

Today we had a 2 day old kiddo come into the hospital because of increased bilirubin levels or a fancy medical term that I've been known to use---hyperbilirubinemia. The treatment for increased bili is to expose the kiddo to UV lights. It binds up the free bilirubin and takes care of the job.

The two other med students and I, plus a resident, and a nurse went in to meet the happy couple and the brand new baked-duck-to-be. One of the main reasons why this disease occurs is because of dehydration. Mom and dad were pretty freaked out, but were eager to learn how to breast feed their kiddo better. The resident had mom de-gown and show her what she's been doing during feeds. The resident was explaining how to engage the entire breast to help the kiddo out, while we stood behind her trying to get a peek of what was going on. Dad just kept shouting "Stick the whole thing in her mouth!" "Stick it in her mouth!" "Just stick it in!" I would have loved to be a patient on the other side of the curtain.

Bacteria infested humans

After 2 weeks I am still loving peds (whohoo!!). But there is something to be said about the bacteria infested little buggers they are (booo). It is quite known to the med school population that the pre-adults are notorious for getting the med students sick. Some how the residents and attendings have built their immune system up so well, that they are resistant to every bug there is out there (somehow I must market residents and attendings as antibiotics....). As students we are sent in to look at the throats, check the ears, and sometimes, see what color phlegm it really is. And just as your telling your three year old tike to stick out her tongue and say "agghhhhh" she decides its the perfect time to sneeze or cough.....right into your open mouth, because lets be honest, you're saying "aggghh" with her.

Yes, after only 2 weeks, I've come down with a sinus infection.

But I am still really excited for work. :)

rash

Last week I treated a 2 year old girl with a diaper rash. The kiddo had a rough social life---she was living with her parents when they got charged with drug trafficking. CPS got involved and she was put into a foster home. She is now currently living with grandma & grandpa (they just got custody). The attending and I took a look at the rash, and although it was difficult to get a good look (grandma had coated it with Desitin) we thought it was infected with staph/strep and wrote her a prescription for some meds and told the family to bring her back if the rash got worse or didn't go away.

The rash didn't go away. Today we were able to get a good look because grandma purposefully did not cover it with any meds. Today it did not look bacterial. Today it looked viral. This means one thing---genital herpes. Which means, most likely, this kiddo was sexually abused.

Today I hated adults.

Kiddos

This week I started my peds rotation. After the last month of Eternal medicine, I thought I could no longer enjoy being a medical student and going into the hospital. I was wrong.

Pediatrics has lifted my soul. Every day this week I was excited to go into clinic and do anything from well child check ups on 4 day old kiddos to 16 year olds with pink eyes (oh and a burning pain while urinating). I haven't felt this good to be doing something since being in an OR, and I am not getting yelled at by anyone!

Oh and I call kids, kiddos. A fourth year once told me that if you have a "positive kiddo sign" (meaning you use the word kiddos instead of kid or child) then you're most likely going into peds.
Well, I hate to continue to contradict myself, but I am back to thinking emergency peds might be my route of choice.

Wear and tear.....

In medical school we are taught how the body works, how the body can break down after diseases, and how we can treat the body. In a completely different class and mind frame, we are also (supposedly) taught how to deal with the patients soul-- asking open ended questions, bringing up end of life issues, and offer anything that will make them more comfortable while at the hospital (within reason, of course).



Meanwhile we, as physicians, as medical students, are to check our own lives at the door. Any situations that may be going on at home---emotional, financial, even our own sickness---is just not acceptable. In any other job, this would be irrational, but for some reason, in ours, its not even thought over twice. So I guess that it's not surprising that at this point in our short career---as third year medical students---we are all feeling the wear and tear of this process. The process being, weighing the importance of taking care of ourselves vs taking care of our patients.



I think we all started this year eager to learn, ready to go the extra mile. Now we're exhausted and are finally hitting the repercussions of letting everything else besides the hospital go--we're paying bills late, forgetting relatives birthdays, and letting the stress build. Conversations now start with "back before med school" or "a couple of years ago, you know, when I had a life". I look at some doctors now and think it might just get worse. I am not sure what the answer is to fixing this situation.

bad jokes

"A Pharmacist handing a prescription to a customer: 'Take one of these every four hours, or as often as you can get the cap off.' "

telling it like it is

So this week was my first week of letting myself say, "I'm going into surgery."(yes I have issues) And I am not going to lie---there was actually a wave of relief when I said it out loud. I was always an indecisive child, but when I would finally make a decision, I'd get a sudden rush of just feeling right in the world. And I would know that I made a good choice. Saying it out loud, well, was kind of like that.

Over the next couple of days I let the surgery idea sit. I wanted to get to the bottom of why I can't commit to it. And I now know why I hide from surgery. Here's the brutal truth.

1. I am scared of the hours. I'll be honest, I am a morning person. Most of my friends find it very annoying how much of a morning person I am. But I also like my wind down time at home, maybe with friends, maybe alone. So I while I'm not scared of the mornings, I wont make it without my personal time. Plus I dont want to be alone for the rest of my life. What kind of husband and/or kids could put up those hours?

2. The idea of associating with surgeons with the rest of my life is unsettling. Surgeons don't always treat other people nicely (understatement of the year) and I dont want feel like I need to defend them because I am one. I know there's an awful story for every type of doctor out there, but surgeons seem to have a lot of them.

3. I am afraid surgery life will make me become angry and mean. This is a continuation from #2. But its true. I worry about getting hard. I am usually a pretty bubbly person. I dont want to lose that.

4. My dog will hate me. (as will my parents, sister and brothers) Being on call every 4, 5 or 6 nights means my dog will have to chill at home alone a lot. I would definitely feel guilty about that one.

I know I am supposed to make this decision for myself. Its supposed to be what I like to do. But all these other things start messing with my head and then I sorta loose sight of what I want. My good friend, C, reminded me of the first C-section that I scrubbed into. I had completed surgery 6 weeks prior. As soon as I scrubbed in and stepped up to that table, I got a rush of excitement and then a sudden peace like I was supposed to be there. I felt amazing. Lately, going through medicine, I had forgotten all that. Thank goodness C reminded me.

"Because the underwear is pulled up from the back until ... it wedges in."

Being in outpatient medicine means you get to experience a day-in-the-life-of each specialty. Last week I was at rheumatology clinic which usually means a lot of arthritis and back pain. I got to see this interesting case of ankylosing spondylitis--which is basically an arthritis of the spine which will lead to fusion of the joints. Its pretty painful and debilitating.

I went into the patient's room with my attending, who is this bubbly middle age woman who is so awesome that by the end of the day you actually consider rheumatology as a field to go into. After introducing the patient to the doc, the doc wanted to show me some key features of AS. She had the patient stand with his back facing her while she attempted to untuck his dress shirt, which was tucked into his pants a top a white undershirt. She freed the dress shirt, but the white undershirt was really stuck in there and she just kept pulling and pulling and had it almost to his arm pits when we both suddenly realized that she had grabbed his tightie whiteys, and instead was giving him the largest wedgie ever. Meanwhile the patient did not utter a single word, as if this was a standard of care and it occurred at every doctors appointment. Both the doc and I turned bright red, apologized and gave it our best shot at keeping the laughter to a minimum.

For future clinics, I apparently need to work on keeping the laughter to a minimum.

the answer is in the urine

On a recent camping trip my friends and were discussing a book that I had meant to bring with me called "Why do mean have nipples?" Its a fascinating book, about all the crazy things patients want to ask their docs, but are too afraid to bring up until their third martini. And before you ask, no, I'm still not sure why men have nipples.

The discussion lead to why asparagus makes your pee smell awful. Well low-and-behold, the second question is aimed at answering that!

"Asparagus contains a sulfur compound called mercaptan. This is also found in
garlic, onions and in the secretions of skunks. The signature smell occurs when
this substance is broken down in your digestive system. Not all people have the
gene for the enzyme that breaks it down, so some people can eat all the
asparagus they want and never stink the place up. One study in Britain found
that 46 % of British people produced the odor, while 100% of French people
tested did. Insert your favorite French joke here__________________-."

we need a doctor joke

A patient complained to his doctor, "I've been to three other doctors and none of them agreed with your diagnosis."

The doctor calmly replied, "Just wait until the autopsy. Then they'll see that I was right."

Time after time

When I envisioned being a doctor, I dont think I really realized how time consuming it would be--in almost every field. I pictured going into work, doing some things for a little while (aka helping people) and then leaving it all behind and going home. But until last year, I also thought doctors made about $50,000.

When you talk to the last generation of docs, they are shocked we new docs want a life outside of the hospital. They were bred to live and die by that hospital. While somehow, someone, told us or showed us a life separate of the hospital, and all of a sudden we wanted it. Who wouldn't? This also means, we new docs will always be the less dedicated, less interested, and less helpful if we actually slept 6 hours and maybe went out to dinner. Which is always interesting when the old docs start bitching about how many times they've been divorced.....

But I have to say that even though we've been told or shown this outside life, the old docs and the hospital do a pretty good job of sucking us in anyway. I just finished two months of inpatient medicine. Two months of being on call every 5 days, working 6 days a week, spending ridiculous time at the hospital. As much as I fought it, I got into a pattern and it was just a way of life. This week I switched to outpatient aka the sweet life. I told a non-medical friend how happy I was to get 2 days off each week when they replied, "You mean like the rest of us? You're excited to be normal?" Yeah, I'm excited to be normal.

Becoming a patient

I recently had the opportunity to experience our health care system from the eyes of a patient. Lets just say, it wasn't pretty.


The other morning I was finishing a shower, when I started feeling really hot and lightheaded. Worrying about passing out, I got out of the shower, and called to a friend who happened to be over. I walked back into my bedroom, sat on my desk chair (my dog happened to be sleeping on my bed) and tried to take some slow deep breaths. Whatever was happening, was progressing, and I remember saying "Please don't be scared." I then slumped back into my desk chair, went unconscious and had about a 15 second seizure like activity. All of which, I have no memory of. I woke up and, although scared and very embarrassed, was doing alright. But to be on the safe side, I went into the emergency department to make sure.

They were able to get me back really quickly (one of the perks of being in the medical field!), but they set me up in a hallway bed which was a bit annoying since I know a lot of people who work in the hospital---Emergency docs, surgical residents, med students, medicine residents, psych residents, etc. All were stopping to ask how I was doing, very nice, but embarrassing. Luckily I was put next to a very entertaining psych patient who kept me and the family all entertained while I waited 5 hours for blood work, urine tests, EKG, Chest Xray, Head CT and a neuro consult. After all that I was diagnosed with a syncopal episode which lead to a seizure---a very lucky diagnosis because it means I can still drive. (if it was a seizure event I wouldn't be allowed behind the wheel for 6 months!) The bill?? Still undetermined until I hear from my insurance company--but I'm interested to see what that'll cost me.

All in all, not a fun experience. But those folks in the hospital took good care of me. I know its not that way for every patient, but I hope it is for most.

Surgexperiences

Hey everyone---

Check out Surgeperiences 116 @ other things amanzi! My blog about Slash was added to the list---thanks for including me!

ding!

I think my attending said it best to me at the hospital yesterday.

"We're not actually treating any of these patients. We're just trying to keep them from coming here."

And it hit me like a ton of bricks---there is so much in this life that I cannot "fix". It is something that I struggle with quite often. Therefore professionally, I want to fix.

Here I come--surgery, emergency or OB!!!

can you grab the knife in my back?

So I started this post back when I was on surgery and didn't want to finish it because I was worried about offending someone, or calling someone out, but after the last few weeks I've decided its important to say.

Med students do not always have the best intentions for other med students.

Take my dear friend, Joe, who was brutally f-ed over by a fellow med student, Kristi. She told him all he needed to do in the morning prior to rounding was to get vitals on every patient. So thats exactly what he did. Imagine his surprise when the attending lashed out on him when he didn't do a physical exam or find out why the patients needed surgery.

Or how about when my friend Alexis was working with John on medicine. They were on call together, and their team told them to go home for the night. John acted like he was going home in front of Alexis, but turned around (after she had left) and stayed the night, bonding with the residents to screw her over.

The worst is the med student who talks to residents about a fellow med student--in a not-so-positive-way.

And heres the other thing. As third years we are graded both subjectively and objectively--its to the benefit for some and to the detriment for others. As for my personal opinion---it can stink. You work your butt off to get a mediocre eval? Thats not good. But truthfully, I sometimes have a hard time with standardized tests, so to be praised for my hard work and have descent test scores is rewarding.

Plus! When did we stop being happy for one another? When did we stop saying "Congrats!" to a fellow med student when they found out they rocked a test? Or when did we stop saying good luck to other students prior to tests? My first year of med school I made over 400 good luck notes to each classmate---and I sincerely meant it. We're all a team here---we can do this by ourselves and be miserable, or we can work as one and succeed together ---even if it's just one of us succeeding at the moment. I miss that in my fellow students. Lets see more of that.

yeah, he's gonna die

So maybe I'm just a bit too sensitive lately. Or maybe I'm just too much of a novice, but lately the phrase "he's going to die" is really starting to tick me off. My next thought is "do something about it!!" Which is weird because when we're in the patient's room and they're on death's door, all I can think is man, I wish someone would help put them out of their misery.

So I guess I'm really conflicted with the whole death thing. On one hand I think we should do something when the patient is headed in that direction (that is definitely the surgeon mind in me). And on the other, if they are elderly and can't do anything for themselves, I think why is physician assisted death so bad?

I think the other thing my attendings have failed in mentioning, or perhaps even doing, is when a patient is on death's door and it seems like we're not doing anything to prevent it, its a really good time to talk to the family, make sure the patient is comfortable, if there is anything the patient would have wanted in those final days, and work on those kinds of things. Otherwise it seems like getting that final CT of their abdomen really isn't that important anymore.

frusteration builds.....

Recently we got a patient who is well known for leaving AMA (against medical advice). She continues to pop her hip out of place, get surgery, and then just when we're about to send her to an inpatient rehab, she leaves AMA. This has happened 4 times. None of the nurses like her; the case manager is ready to pull her hair out when we ask her to find placement; and now the surgeon refuses to fix her hip again.

Now I can understand the frusteration. I can't imagine doing this over and over and over and over. But guess what? Thats what we do anyway---its just on different patients. So part of me thinks, just suck it up and do your job. We're here to help people. That's what we signed up for. Residents, nurses, case managers get paid the same amount every year and it doesn't matter who we help, how many we help, etc. So you can understand why I got tiffed when the case manager said, "And just think-- Hillary Clinton is going to tell us we have to do this for everyone!!! Like hell I am! I am retiring if that happens."

I guess I just don't understand why it matters. People could care less if a medical student delivers their baby, and yet, the idea of everyone having an oppertunity to get well again by having health care available to all, absolutely freaks people out.

A person is a person is a person. Now make the f-ing phone call and get Ms AMA inpatient rehab.

why health care cost so much....

In continuing a story about Larry (see previous post) I thought I'd give a little more information about his 4 night stay with us in the hospital. He is a 40 something year old obese male with congestive heart failure (CHF), acute renal failure, and a possible GI bleed. Our work up for the GI bleed on day 1 was to do a fecal occult (checking to see if his stool had blood). On day two we got the results---it was positive. So we scheduled a barium enema for the next day. That night Larry needed to drink about 4 liters of "go lytely" which washes your whole system out. I spoke to the RN to see when he should start, they suggested 5pm. So I wrote the order to start at 5pm and then for him to be NPO (ie nothing in the mouth) after midnight---standard orders before this procedure. Well on day 3, I went to visit my friend Larry to discover he had only finished half of his go lytely. Why ? you might ask. Apparently he was sleeping at 5pm and the RN didn't want to wake him. He started the 4 L at 8pm and wasn't able to finish it before midnight---at which point the RN made him NPO. This means no barium enema for Larry. Frustrated, we kept him NPO that day and had him finish the go lytely and rescheduled for day 4. On day 4 he he was ready to go, but we get a call from radiology saying he is too big to even fit in the CT machine. No barium enema for Larry ever. What do we do? We discharge him and tell him to follow up with his outpatient physician.

Gotta love our health system.

taboo

The Health Insurance Portability & Accountability Act or HIPAA was established in order regulate group health plans so they do not accept or deny patients based on their genetics, medical history, etc. It does allow group health plans to refuse pre-existing conditions under certain measures. This stinks for the patient. But the main way it affects doctors, nurses, medical students is the privacy act--which basically means: do not discuss patient information in the elevator, the cafeteria or the hallways. SHHH!!! So how do we get around it, you ask??? By practicing our Taboo skills!

Taboo--one of my favorite board games--helps us master our talking about the patient without actually saying the patients name. For example if we need to "run the list"* in the cafeteria, we just start with the first patient as "the guy who suctions all his breakfast out of his mouth." We immediately know its Bill** on the 4th floor. Or if we need to jump ahead to "the guy who can't fit into the CT machine" we all know we're discussing Larry**, and we can proceed in a timely matter, while filling our guts with awful cafeteria food.

I am so glad I've had younger siblings who were into board games, otherwise I may not be good at avoiding HIPAA violations as I am today.

* running the list is probably one of the most important things you do in a day. and trust me, we do it probably 2 or 3 times per day. its when you discuss patient by patient what else you need to do before you can escape from the hospital.
** you thought you caught me! But I'm too clever---this name is made up to protect the real suctioner and large man.

Deflated

I am deflated. I dont even know if thats a word, but I'm using it. My 31 year old female pt, the one who had nausea and vomiting for 2 months along with a growing liver and jaundice, has sadden me. She came in to the ED (emergency department) last week complaining of seeing yellow. With no past medical history, she denied any blood in her vomit, denied taking any vitamins, denied IV drug use, and said she rarely drank alcohol. She denied this everyday for a week. (I like to triple check) So we started working her up for hepatitis and cholecystitis.

Everything came back negative. I mean everything. She had a CT, MRI, HIDA scan, MRCP which just showed a fatty liver. We ran almost every autoimmune liver disease possible. Finally we had no choice but to take a liver biopsy (which was pretty cool---it was a transjugular IR bioposy). What were the results you ask? Alcoholic hepatitis.

At first I thought they mixed up the patient's results. But my resident said it was definite. I couldn't believe it. I had forgotten the first House, MD rule: "Everybody lies." or "I dont ask why patients lie, I just assume they do." When confronted, she said "Oh I am just so glad it was something as simple as that." She must have known the whole time. Or she is in incredible denial. Either way I was deflated. If I can't trust my patient then what is our purpose?

The beginings of medicine

So I'm currently in week 2 of a 12 week process, or what we call medicine rotation. I am following 3 patients, we're currently on call Q 5, meaning every 5 nights we're on overnight call, and my residents are fantastic--they teach, they're friendly, and I wouldn't mind hanging out with them outside of the hospital. But when people ask me "how was your day?" a response hasn't really jumped out at me. I guess I'm just sort of blah. I feel like I am going through the motions. I'm not bored at work. I am tired. My patients are interesting. I enjoy figuring out what is wrong with them. But then...well...I am kind of over it. So living every day is just a way to get to the next. It sounds terrible. Like I'm having a horrible time, which is definitely not the case--I have been laughing all the time at work, but I think I need something else to spark the situation. It hasn't happened yet.

paging the resident

its a ritual that occurs with each new rotation. we get a packet of information. we're told what is expected of us. and how often we will be spending the night at the hospital each week. they explain what is mandatory and what we can skip. and then we get a pager number and we're instructed to page our resident to meet up with our teams. We walk in a herd to the nearest phone and line up, single file. Each one of us takes a turn, dialing the 4 digit number and the rush of anxiety builds as we await for the return call. Will we look like a fool and be asked a thousand pimp questions today? Will we be scutted around the hospital? Or get lucky and leave early? What will really be asked of us? Will we get along with our team? Will lunch be involved at any point? Where is the nearest bathroom? Its these questions that plague our minds during the paging of the resident. Luckily the anxiety only builds for a few minutes, until they call back, we introduce ourselves over the phone (they either sound happy, indifferent, or bothered) and they tell us where they are and we leave the line of med students to join our teams.