In real life, the uterus looks just like it does in picture books. Springing forth from behind a curtain of fat and abdominal muscles in the depths of an incised abdomen, it's a strange, almost whimsical shape which is easily recognized as "uterus!"-- even by the unseasoned medical student. On the inside, the uterus looks just like a blood-soaked sponge, and it's easy to imagine that if you were just to rinse and wring it out, it might be ready for another go on the kitchen counter.
These were my observations today on my first two C-sections. This operation is easily the most unique of the common operations: whereas it is extremely invasive, the patient is awake-- and very aware of what is happening to her body behind the sterile drape.
It all begins with a nervous mother-to-be seated on the operating table with her bare back to the door. Regardless of how fat or thin she may be, and despite the funny shower cap surgical hat she is wearing, I am struck by how beautiful she looks in her nakedness. This is her monologue under the bright OR lights; she is the quiet center of commotion as the OR staff prepare for the procedure.
The operation will involve up to 20 people, from OR staff to anesthesia to OB/GYN to pediatrics, each a perfect gear turning in time with its colleagues. An anesthetist sterilizes and drapes her back, then injects a spinal block. Her legs go numb, then limp; she loses pain sensation from her abdomen down. She is helped to rest on the operating table and draped: she becomes nothing but a vast blue sterile field with a hole on the abdomen. The freshly scrubbed obstetric team enters, dripping, and is gowned and gloved. The OR nurse hurries to set up her arrays of instruments. Pediatrics people shift impatiently from foot to foot next to the empty, expectant incubator. The stage is set.
From here, the plot thickens and becomes free to veer off wildly in unimaginable directions. She may be hugely pregnant and ready to burst with triplets... or barely showing with a 14 week premie who will tip the scale at scarcely more than a pound and make only faint, exasperated movements of the head and arms. The first incision draws superficial blood, some of it squirting skyward in its great eagerness to get out of her body. The underlying connective tissue is carefully dissected. The rectus muscles are revealed, glistening and taut. They are pulled violently aside by the obstetrician and his assistant to widen the sight line into the peritoneum; a maneuver that requires strength remniscent to me of the Army football team playing tug-of-war with Navy.
The uterus appears through the translucent peritoneum, protecting its precious cargo. Inside the soft muscle is a living soul preparing to enter the world. The rest of the operation is a blur because here the emotions begin to run high. After we enter the uterus, a gush of fluid (here I silently thank my lucky stars for choosing the mask with a face shield) signals rupture of membranes, and suddenly a grey, drowned rat is being pulled free from its mother's abdomen. I stand transfixed, shocked: it's almost like a scene from... what's that movie where the aliens take over human bodies and burst forth from their abdomens? The rat mews weakly. Mouth and nose suctioned. Quickly rubbed dry. Cord clamped and cut. Handed to mom. Tears rolling down her face. Her new child. The pediatrics team swarms in.
Our emotions spent, we turn our attention to undoing the hole we've made in mom's abdomen. And what a hole it is... her uterus hanging outside the skin, the muscles separated like a drawn curtain, blood everywhere. So we clean up our mess with what tools we have: sutures here, electrocautery there, more sutures, staples. What intricate handiwork! When we've finished, the neat incisional scar mocks the havoc we wreaked beneath it. We apply the white dressing, just to make further assurance that its tight lips will never divulge her secret.
I look over at the incubator several minutes later, and see that the rat has turned into a plump, pink infant. I can't help but smile behind my mask; it is only fitting that this first chapter of life makes such a traumatic, exuberant, and eloquent preface to all the rest. Happy birthday, kid.
Tuesday, November 6, 2007
Saturday, October 20, 2007
Medicine: "And I hate when things are over...there's just so much left undone." -Breakfast at Tiffany's (Deep Blue Something)
Hello my lovelies, long time no see! It's been a while since my last entry, be it a testament of how busy Medicine has kept me or how bad I am at multi-tasking. In any case, it's the day after Medicine is over and time to reflect on the past 8 weeks, so without further ado...
I want for you to share this feeling with me. It's somewhat described by the following metaphor: When we first get these new sneakers, they're unfamiliar and uncomfortable, needing some breaking in. But since they're still shiny and novel, we're excited to wear them anyway. We wear them in for a while, finding moments that they're hard to keep on. In time, we discover the magic (aka sticking power) of velcro and apply them to our sneakers. There! Much easier but somewhat awkward-looking. So we continue to look for a better way to keep these sneakers on. Eventually, we learn how to tie the shoe laces and no longer need the velcro. Now we're really walking confidently and effortlessly (relatively speaking...). For a while that's what we do, until the end when someome tells us too soon that it's time to get a new pair. As fun as that sounds, we're now comfortable...and perhaps attached...but we reluctantly give these up, and ready ourselves for the next pair.
If the above made absolutely no sense, all I'm trying to say is that I'm going to miss Medicine.
...to be continued...
I want for you to share this feeling with me. It's somewhat described by the following metaphor: When we first get these new sneakers, they're unfamiliar and uncomfortable, needing some breaking in. But since they're still shiny and novel, we're excited to wear them anyway. We wear them in for a while, finding moments that they're hard to keep on. In time, we discover the magic (aka sticking power) of velcro and apply them to our sneakers. There! Much easier but somewhat awkward-looking. So we continue to look for a better way to keep these sneakers on. Eventually, we learn how to tie the shoe laces and no longer need the velcro. Now we're really walking confidently and effortlessly (relatively speaking...). For a while that's what we do, until the end when someome tells us too soon that it's time to get a new pair. As fun as that sounds, we're now comfortable...and perhaps attached...but we reluctantly give these up, and ready ourselves for the next pair.
If the above made absolutely no sense, all I'm trying to say is that I'm going to miss Medicine.
...to be continued...
Saturday, September 15, 2007
Medicine: R/O Radiology
Today, I went down to Radiology to get a preliminary reading of a CT on a patient. I had never been to where the radiologists work before. I've heard all sorts of jokes about how if you're afraid of the dark you should go into ophthalmology, and if you're afraid of the light you should go into radiology, but I've never seen what it's like firsthand. Now I know that I never want to go there again. The radiologists sit in the dark (and I'm not even kidding in the slightest here) in a large, labrynthine room of cubicles, each with 2 huge flat screen computer displays. They stare at the computer screens in the dark. All day. I can officially say that within the first 30 seconds, radiology was ruled out as a career for me-- if I wanted to spend the rest of my life sitting in a dark cubicle staring at a computer screen, I could have skipped the 4 wasted years of youth in med school and $150K of debt, and started off at twice the salary I'm going to make as an resident using my Bachelor's degree as a computer programmer.
Radiology? An emphatic noooooo, thank you.
Radiology? An emphatic noooooo, thank you.
Monday, September 10, 2007
Medicine: My First Brush with Cancer
I am proud to announce that in the last 2 weeks, I have figured out how to get from South Building to 4-West, not just what a sign-out is but also how to do it, and settled neatly into my spot at the bottom of the medical totem pole. I still do the 180 outside every elevator, though. I don't think I'll ever be able to kick that ritual. I followed my very own patient from a quivering wreck on Dilaudid in the ER through to happy, ambulating discharge 4 days later, and although everyone else on my team got a handshake, I was the only one who got a hug (I'm unabashedly proud of that-- and it was a big, badass guy, not a touchy-feely little old lady). I feel integrated. I feel like I am actually making a difference.
Midway into week 2, I was asked to "look up" rare coinfections with Lyme disease (namely, Babesiosis and Ehrlichiosis for those who care for such pedantry). Ehrlichiosis presents with fevers, myalgias, thrombocytopenia (low platelets), and elevated liver enzymes. I don't believe I will ever forget the symptom complex for Ehrlichiosis, because a patient came in that very morning with a symptom complex and history of present illness so definitive for Ehrlichiosis that we might as well have watched the tick bite him. He was our Ehrlichiosis patient. Or was he?
We began the standard treatment regimen with doxycycline and sent his blood out for serology at a lab in Utah-- the only lab in the country that performs the blood test for Ehrlichiosis. His fevers and joint pains went away, and then returned with a vengeance. Despite the appropriate treatment, his blood labs continued inexorably on their negative course. He was in pain, a pathetic body on the bed, sweating and asking us daily why we couldn't do anything. We increased his pain medication. We gave him laxatives. We increased his pain medication some more. We waited for the serology to return, to confirm the diagnosis we were so sure was true.
Our patient's condition continued to worsen. Confidence in our diagnosis waned to hope against hope, because by this time, we had widened our differential diagnosis and set up plan B: if our serology for Ehrlichiosis came back negative, we would have to start thinking cancer. We would go where the money is and biopsy the bone marrow. Our patient had stopped looking like the classic case of Ehrlichiosis and started looking just like an atypical presentation for leukemia or lymphoma-- and we had ruled out almost everything else.
One morning, his daily blood count came back with "atypical lymphocytes" on the smear (under the microscope). A marrow biopsy was performed the very next day. As we began preparations for transfer to the Hematology-Oncology service, our Ehrlichiosis serology fell by the wayside, forgotten. I don't even know what the results are, if they ever came back; I assume they were negative, but it really didn't matter anymore.
It was almost a blur how quickly he was gone from our service, whisked up by Oncology into a world of immediate chemotherapy, considerations for bone marrow transplantation, and months of suspense about whether he would live or die. I would have imagined that a patient diagnosed with cancer would need weeks to come to terms with the diagnosis before he could begin to undergo chemotherapy. In reality, things move at a breakneck pace; there was barely time to turn around, blow a kiss, and wave before this huge change took over his life. But time is a mysterious beast; inside my patient's mind, life may have turned to slow motion. I don't know.
I think I learned 2 important lessons from this patient's case. The first is a principle I was taught in the abstract last year: YCMTDIYDTOI. What the heck does YCMTDIYDTOI mean, you ask? Well, its name illustrates its principle: You Can't Make The Diagnosis If You Don't Think Of It (and you certainly can't figure out what this acronym stands for if you don't already know it-- and think of it). The best clinicians have been said to use pattern recognition, but sometimes patterns are not the be all and end all of diagnostics. Solving problems in the real world is totally different from solving textbook cases in my first and second year lectures, where anyone who had pneumonia came in with a cough, a fever, and a dullness to percussion over the right lower lobe. You have to start somewhere-- but from there, you must grow.
The second, and more important, lesson I learned from this patient is that cancer is never expected. Nobody comes into the hospital thinking "I must have cancer." It is sobering to know that at any point, any one of us could walk in with a fever and some aches, and walk out with a diagnosis that might change our lives. The line between health and illness is finer than I had ever appreciated, and every step we take on the side of health should be a thankful one. When we do cross that line, we won't know how far we've gone-- whether we'll be cured in a week with antibiotics, or whether life will start being measured in probabilities of survival months. The journey is seldom in black and white, and it is always frightening and confusing. It's a good lesson for me to have learned now, because I will spend the rest of my life escorting my patients along that road.
Midway into week 2, I was asked to "look up" rare coinfections with Lyme disease (namely, Babesiosis and Ehrlichiosis for those who care for such pedantry). Ehrlichiosis presents with fevers, myalgias, thrombocytopenia (low platelets), and elevated liver enzymes. I don't believe I will ever forget the symptom complex for Ehrlichiosis, because a patient came in that very morning with a symptom complex and history of present illness so definitive for Ehrlichiosis that we might as well have watched the tick bite him. He was our Ehrlichiosis patient. Or was he?
We began the standard treatment regimen with doxycycline and sent his blood out for serology at a lab in Utah-- the only lab in the country that performs the blood test for Ehrlichiosis. His fevers and joint pains went away, and then returned with a vengeance. Despite the appropriate treatment, his blood labs continued inexorably on their negative course. He was in pain, a pathetic body on the bed, sweating and asking us daily why we couldn't do anything. We increased his pain medication. We gave him laxatives. We increased his pain medication some more. We waited for the serology to return, to confirm the diagnosis we were so sure was true.
Our patient's condition continued to worsen. Confidence in our diagnosis waned to hope against hope, because by this time, we had widened our differential diagnosis and set up plan B: if our serology for Ehrlichiosis came back negative, we would have to start thinking cancer. We would go where the money is and biopsy the bone marrow. Our patient had stopped looking like the classic case of Ehrlichiosis and started looking just like an atypical presentation for leukemia or lymphoma-- and we had ruled out almost everything else.
One morning, his daily blood count came back with "atypical lymphocytes" on the smear (under the microscope). A marrow biopsy was performed the very next day. As we began preparations for transfer to the Hematology-Oncology service, our Ehrlichiosis serology fell by the wayside, forgotten. I don't even know what the results are, if they ever came back; I assume they were negative, but it really didn't matter anymore.
It was almost a blur how quickly he was gone from our service, whisked up by Oncology into a world of immediate chemotherapy, considerations for bone marrow transplantation, and months of suspense about whether he would live or die. I would have imagined that a patient diagnosed with cancer would need weeks to come to terms with the diagnosis before he could begin to undergo chemotherapy. In reality, things move at a breakneck pace; there was barely time to turn around, blow a kiss, and wave before this huge change took over his life. But time is a mysterious beast; inside my patient's mind, life may have turned to slow motion. I don't know.
I think I learned 2 important lessons from this patient's case. The first is a principle I was taught in the abstract last year: YCMTDIYDTOI. What the heck does YCMTDIYDTOI mean, you ask? Well, its name illustrates its principle: You Can't Make The Diagnosis If You Don't Think Of It (and you certainly can't figure out what this acronym stands for if you don't already know it-- and think of it). The best clinicians have been said to use pattern recognition, but sometimes patterns are not the be all and end all of diagnostics. Solving problems in the real world is totally different from solving textbook cases in my first and second year lectures, where anyone who had pneumonia came in with a cough, a fever, and a dullness to percussion over the right lower lobe. You have to start somewhere-- but from there, you must grow.
The second, and more important, lesson I learned from this patient is that cancer is never expected. Nobody comes into the hospital thinking "I must have cancer." It is sobering to know that at any point, any one of us could walk in with a fever and some aches, and walk out with a diagnosis that might change our lives. The line between health and illness is finer than I had ever appreciated, and every step we take on the side of health should be a thankful one. When we do cross that line, we won't know how far we've gone-- whether we'll be cured in a week with antibiotics, or whether life will start being measured in probabilities of survival months. The journey is seldom in black and white, and it is always frightening and confusing. It's a good lesson for me to have learned now, because I will spend the rest of my life escorting my patients along that road.
Tuesday, August 28, 2007
Medicine: Overwhelmed
I think the dictionary should be revised. Next to "overwhelming," the definition should be changed to read, "a third year med student's first day in the hospital."
I can't say I've been in very many hospitals, so I don't have any basis for comparison... but I'm pretty sure they imported the Labyrinth straight from Greece, put some hospital beds in it, and called it Hospital. I'm convinced that any one of these days, I'm going to make a wrong turn going from South Building to 4-West and run into the Minotaur himself. My greatest daily embarassment (actually, come to think of it, a ritual) is getting out of the elevators in the morning, walking purposefully forwards, realizing I'm going in the wrong direction, and making an abrupt 180. I think the fact that I'm wearing a white coat (and thus look like I actually know what I'm doing) makes it only more comical. I hope it will get better.
But the overwhelmingness doesn't stop there. Never mind that there are 30 residents per year, 4 teams, one cardiology teaching service, an utterly confusing calendar involving A, B, C, and D, call on every 4th day, P which stands for goodness only knows what on the calendar, different levels of hierarchy between interns, residents, and attendings, and only 1 day off per week. Never mind the 7 am sign-outs (and what the hell is a sign out?), pickups (huh?) and "caps" on admissions. And DEFINITELY, never mind that I look like an idiot as soon as I open my mouth and ask, very innocently, "what the hell is a sign out?"
I can't say I've been in very many hospitals, so I don't have any basis for comparison... but I'm pretty sure they imported the Labyrinth straight from Greece, put some hospital beds in it, and called it Hospital. I'm convinced that any one of these days, I'm going to make a wrong turn going from South Building to 4-West and run into the Minotaur himself. My greatest daily embarassment (actually, come to think of it, a ritual) is getting out of the elevators in the morning, walking purposefully forwards, realizing I'm going in the wrong direction, and making an abrupt 180. I think the fact that I'm wearing a white coat (and thus look like I actually know what I'm doing) makes it only more comical. I hope it will get better.
But the overwhelmingness doesn't stop there. Never mind that there are 30 residents per year, 4 teams, one cardiology teaching service, an utterly confusing calendar involving A, B, C, and D, call on every 4th day, P which stands for goodness only knows what on the calendar, different levels of hierarchy between interns, residents, and attendings, and only 1 day off per week. Never mind the 7 am sign-outs (and what the hell is a sign out?), pickups (huh?) and "caps" on admissions. And DEFINITELY, never mind that I look like an idiot as soon as I open my mouth and ask, very innocently, "what the hell is a sign out?"
Thursday, August 9, 2007
Family Medicine: The Happy Ending
My last day of Family Medicine. I should be cramming for my shelf exam tomorrow, but I just wanted to take a moment to make note of all the things I will miss after today. Yes... miss. I can't believe I'm actually getting nostalgic about a workplace, but these are the people I've been seeing day in and day out for the last six weeks, and for a person with utterly no life (a. k. a. med student), that's a big deal. They were like a second family! I'm going to miss the lady from the front desk who is perpetually asking us if we've eaten because she's seen med students hit the floor in dead hypoglycemic faint before. I'm going to miss the PA at the charity clinic who speaks Spanish so that even I can understand it. I'm going to miss the kooky attending, the attending who accused me of being in Slackers Med School, and the jaded (but jolly) fellow.
My preceptor was something else-- literally taking my hand and pushing it toward instruments while he performed procedures, holding onto my hand with the instruments until I was confident enough to do it myself. I sat in the hot seat and performed a cryo on cervical neoplasia in an HIV+ patient today, something I only wish all my other student colleagues could have the opportunity to do. I'm going to miss that teaching. I'm going to miss the nurses: sweet, crazy, caring, always prepared with coffee. I'm going to miss the little flags on the walls next to each exam room that made me feel so included-- red for patient, blue for nurse, yellow for doctor... and white for student (yes, student! we get our own flag!) in the room. I'm going to miss the schedules taped up at the nurses' station. I'm even going to miss the clock on the wall near the computers. OK, now I'm going a little overboard, but still... the place has its own rhythm and I had finally fallen into step, but now it's time to move on.
On a lighter note, I actually volunteered to do a rectal exam yesterday. You're probably wondering why a sane person wouldn't run screaming away from the opportunity to stick a digit up someone's ass. First of all, you've probably already figured out that I'm not sane, so that cat's out of the bag. More importantly, though, I was doing it for the patient's sake. You see, I was seeing a patient with Dr. Sausagefingers, and if you could just have a look at Dr. Sausagefingers' digits and then compare them to mine, you might see how compassion would move the heart of a young medical student to take mercy upon the sick and ailing, even at the cost of having poopy fingers.
OK, I'm done grossing you out.
My preceptor was something else-- literally taking my hand and pushing it toward instruments while he performed procedures, holding onto my hand with the instruments until I was confident enough to do it myself. I sat in the hot seat and performed a cryo on cervical neoplasia in an HIV+ patient today, something I only wish all my other student colleagues could have the opportunity to do. I'm going to miss that teaching. I'm going to miss the nurses: sweet, crazy, caring, always prepared with coffee. I'm going to miss the little flags on the walls next to each exam room that made me feel so included-- red for patient, blue for nurse, yellow for doctor... and white for student (yes, student! we get our own flag!) in the room. I'm going to miss the schedules taped up at the nurses' station. I'm even going to miss the clock on the wall near the computers. OK, now I'm going a little overboard, but still... the place has its own rhythm and I had finally fallen into step, but now it's time to move on.
On a lighter note, I actually volunteered to do a rectal exam yesterday. You're probably wondering why a sane person wouldn't run screaming away from the opportunity to stick a digit up someone's ass. First of all, you've probably already figured out that I'm not sane, so that cat's out of the bag. More importantly, though, I was doing it for the patient's sake. You see, I was seeing a patient with Dr. Sausagefingers, and if you could just have a look at Dr. Sausagefingers' digits and then compare them to mine, you might see how compassion would move the heart of a young medical student to take mercy upon the sick and ailing, even at the cost of having poopy fingers.
OK, I'm done grossing you out.
Tuesday, August 7, 2007
Family Medicine: The Talkers
This morning, the Talkers came in droves to my humble outpatient care facility (the nurses would have a bitchfest followed by withdrawal of all tetanus immunization privileges if they heard me calling it a clinic).
Who are the Talkers? Talkers are just like other patients, but they are afflicted with a special condition which makes them entirely unable to shut up. Quite apart from that, they may be either incredibly nice people or horrible jerks; sick, sick puppies or perfectly well. Dealing with them simply takes a different tactic from what our training teaches us.
In school, we learn to elicit a detailed history from the most stubborn patient. I have an armory of talking points to force every piece of information out of any patient who doesn't want to tell me what's wrong-- from simple compassion to dead silence. We are taught that the first 2 minutes belong to the patient, how to ask only open-ended questions ("describe your pain" vs. "is your pain sharp or dull?"), and how to normalize any potentially embarassing disclosure-- no matter how bizzare it may be. Yes, many of my other patients have diarrhea after eating boiled peas; please do tell me if yours is bloody.
How to make someone with verbal diarrhea focus on what I'm trying to deal with in my patient encounter, however, is a proficiency I am apparently sorely lacking. I tried asking only closed-ended, yes-or-no questions, only to be foiled into derailment from "do you have palpitations?" to "I feel like I'm going to fall, especially on concrete." "Does your pain radiate down the arm? Please answer yes or no," turned into "You know, this one time, 5 years ago, I had shooting pains in my foot and it went away after a week." Patient after talkative patient, I was helpless in the face of torrential verbiage rushing my way. 15 minute patient encounters became 20, even 25 minutes. Problem lists grew from 2 to 3 to 5 long. The waiting room got crowded. My hungry stomach begged for mercy.
My preceptor and I saw Talker number 3 together, and it was then that I was relieved to realize that focusing an interview with a gregarious patient is not only difficult for me. But I am happy to say that I've learned a few tips along the way-- and Talker 3 leaned in conspiratorially near the end of his interview to say, "I know I like to talk a lot." At least he's not in denial.
Who are the Talkers? Talkers are just like other patients, but they are afflicted with a special condition which makes them entirely unable to shut up. Quite apart from that, they may be either incredibly nice people or horrible jerks; sick, sick puppies or perfectly well. Dealing with them simply takes a different tactic from what our training teaches us.
In school, we learn to elicit a detailed history from the most stubborn patient. I have an armory of talking points to force every piece of information out of any patient who doesn't want to tell me what's wrong-- from simple compassion to dead silence. We are taught that the first 2 minutes belong to the patient, how to ask only open-ended questions ("describe your pain" vs. "is your pain sharp or dull?"), and how to normalize any potentially embarassing disclosure-- no matter how bizzare it may be. Yes, many of my other patients have diarrhea after eating boiled peas; please do tell me if yours is bloody.
How to make someone with verbal diarrhea focus on what I'm trying to deal with in my patient encounter, however, is a proficiency I am apparently sorely lacking. I tried asking only closed-ended, yes-or-no questions, only to be foiled into derailment from "do you have palpitations?" to "I feel like I'm going to fall, especially on concrete." "Does your pain radiate down the arm? Please answer yes or no," turned into "You know, this one time, 5 years ago, I had shooting pains in my foot and it went away after a week." Patient after talkative patient, I was helpless in the face of torrential verbiage rushing my way. 15 minute patient encounters became 20, even 25 minutes. Problem lists grew from 2 to 3 to 5 long. The waiting room got crowded. My hungry stomach begged for mercy.
My preceptor and I saw Talker number 3 together, and it was then that I was relieved to realize that focusing an interview with a gregarious patient is not only difficult for me. But I am happy to say that I've learned a few tips along the way-- and Talker 3 leaned in conspiratorially near the end of his interview to say, "I know I like to talk a lot." At least he's not in denial.
OB/GYN: Mami
Once upon a time, mami was simply a pet name in my book - you know, something along the lines of hunny or sweetie that a guy calls his girl. It's cute, try it out. Next time your girlfriend calls, pick up the phone and say "Ay mami!" and listen to her smile.
So what does it really mean? I babelfished it and found no exact Spanish to English translation, but I'm pretty sure that it means mommy. Now you might be thinking, "What the hell? You want me to call my girlfriend mommy?" Because 1.) You're not interested in getting all Oedipus rex on anyone and 2.) You're not thrilled about knocking anyone up either. Yet in a typical day's work on this rotation, I often hear women being called mami or mamita.
Without having to look at the patient's chart, I already know a few things about her. She is a young Latina who speaks no English and is having her third or fourth child, has only had free clinic prenatal care (if at all), is simultaneously grateful for and terrified of medical attention, and she'll deliver vaginally without complications, and not complain about any discomfort. All this I know because med school trains us well in pattern recognition; she is another mamita.
And now that sweet title becomes bittersweet to me, because I wouldn't want that life for myself. But maybe I'm just being all judgey and ignorant. Who knows? She might see me as another medical student, which means that I'm a young adult who speaks no Spanish and is in my third or fourth year of school, has only had free time on weekends (if at all), is grateful for and terrified...wait no, I'm getting off track here.
All I'm trying to say is that I want to know that she chose this path for herself. And if she didn't, I want to know what she wants her life to be. And if we can, I want to know how we can help her. Most of all, I want for us to know her and her name, so that she is no longer just another mamita.
So what does it really mean? I babelfished it and found no exact Spanish to English translation, but I'm pretty sure that it means mommy. Now you might be thinking, "What the hell? You want me to call my girlfriend mommy?" Because 1.) You're not interested in getting all Oedipus rex on anyone and 2.) You're not thrilled about knocking anyone up either. Yet in a typical day's work on this rotation, I often hear women being called mami or mamita.
Without having to look at the patient's chart, I already know a few things about her. She is a young Latina who speaks no English and is having her third or fourth child, has only had free clinic prenatal care (if at all), is simultaneously grateful for and terrified of medical attention, and she'll deliver vaginally without complications, and not complain about any discomfort. All this I know because med school trains us well in pattern recognition; she is another mamita.
And now that sweet title becomes bittersweet to me, because I wouldn't want that life for myself. But maybe I'm just being all judgey and ignorant. Who knows? She might see me as another medical student, which means that I'm a young adult who speaks no Spanish and is in my third or fourth year of school, has only had free time on weekends (if at all), is grateful for and terrified...wait no, I'm getting off track here.
All I'm trying to say is that I want to know that she chose this path for herself. And if she didn't, I want to know what she wants her life to be. And if we can, I want to know how we can help her. Most of all, I want for us to know her and her name, so that she is no longer just another mamita.
Saturday, August 4, 2007
Medicine - BM Bx
Yesterday I got to watch a BM Bx - the heme/onc fellow's abbreviation for bone marrow biopsy. Our pt had been in the hospital about a week before our service took over - 1st of the month phenomenon - and in the 3 days we had her, we could still not figure out why she had had multiple embolic strokes without a single risk factor, and eosinophilia up to 45% of WBCs. But in those 3 days the heme/onc fellow managed to convince her to let him take a little piece of her bone to try to figure out why she's got all those damn orange/pink-staining cells in her blood.
I happened to be on the floor when the heme/onc fellow arrived, 6pm on a Friday evening, which seemed an odd time to biopsy a woman's hip. I walked into her room while he was prepping her lower back with iodine, looking up as I stuttered the question "Can I watch?" I quickly added, "I'm the medical student who's been following her this week," mostly so that the pt, lying face-down-in-a-pillow and getting an IV ativan push, might recognize me.
She gave her muffled consent to me being present, and I realized that I was the least of her concerns. I know she had been nervous about the procedure and I tried to think of a way to help console her, coming up short. Instead I tried to imagine what she was going through: multiple strokes that put her in the hospital for 10 days, a slew of tests including a lumbar puncture that took 3 tries, and now going through the painful-sounding procedure that might diagnose her with cancer. And only 50. No, I couldn't even imagine it.
I couldn't help her right now, but I could help him: I rolled her pajama bottoms down from the biopsy site with my gloveless hands, to keep the fellow's gloves sterile. Her pj's kept rolling back up, so I had to expose most of her butt, apologizing silently to the back of her head. The fellow set up his slides and made small talk to the nurse assisting, who shamelessly flirted back to him. The fellow was young enough that I found myself glancing at his ring finger (as I've only started doing since starting in the hospital) though of course his hands were covered with gloves. The patient liked him too, a day ago she was dead set against the biopsy but, as she put it, "he seemed nice."
And he was. While he numbed the area and injected more anesthesia, he continued to talk to her with his soothing voice, explaining what he was doing but also frequently asking if she was doing ok. Observing his bedside manner, I decided that he could have a piece of my hip bone marrow too, if he smiled at me like that.
It wasn't until it was time for the biopsy that there was a problem. The fellow's procedure was perfect. He progressed a long needle into the sit, continually asking the pt if she could feel anything and giving more anesthesia accordingly. My eyes were glued to the skin, the indentation of the needle, and the slow rotating motion of the fellow's hands screwing the needle further and further into bone. I started to feel funny. The pt gasped a few times, but did not speak, tensed the upper half of her body but did not pick up her head. And the fellow continued digging into bone. I had to sit down.
I silently ducked into the next bedside and sat down, leaning back and trying to recover from my vasovagal reaction. All the associated symptoms were there: dizziness, palpitations, diaphoresis, blurry vision, and nausea, and I damned my weak stomach. How embarrassing. I hoped that the fellow didn't think I was bored and just left.
Once I felt well enough to stand I returned to the bedside, in time to watch the fellow make it to the marrow and draw a vial of it. He told me, "It looks like blood, but it's called 'marrow,' it's where blood cells are first made before they go into the blood." I wondered if there was a polite way to tell him that even though I look 16, I did in fact pass step 1 and he didn't have to simply so much.
For the end of the procedure he progressed a hollow needle into bone once again this time to take a biopsy of tissue. I had to leave to sit two more times. Man. I don't know how he could do it. He wasn't one of those surgeons we hear about who can depersonalize the patient and just cut, he was interacting with her personally, checking in with her and explaining each step of the way. He could watch her struggle through the anxiety and pain and continue drilling into bone, all the while consoling her and explaining to me how blood cells start in the marrow.
I wonder if this is what humanism in medicine is. I had thought that by trying to put myself in the patient's place, that I was being humanistic, but by doing so I couldn't even stand through the procedure. If it were me, as much as the patient would have liked me holding her hand, she would have had to console me to get through the biopsy.
After the procedure, I followed the fellow and fetched the chart and a progress note for him, getting rewarded by one of those smiles. "How was it?" he asked me. "I was getting a little vasovagal, sorry I had to keep leaving to sit down." "Really?" he answered, looking confused. Pause. Then his brow furrowed, and he solemnly continued, "Yeah, I remember the first one I did, it was hard." Apparently after 500 procedures he was able to perform a biopsy while attending to the patient humanistically, but I can only imagine how "hard" that first biopsy was.
I happened to be on the floor when the heme/onc fellow arrived, 6pm on a Friday evening, which seemed an odd time to biopsy a woman's hip. I walked into her room while he was prepping her lower back with iodine, looking up as I stuttered the question "Can I watch?" I quickly added, "I'm the medical student who's been following her this week," mostly so that the pt, lying face-down-in-a-pillow and getting an IV ativan push, might recognize me.
She gave her muffled consent to me being present, and I realized that I was the least of her concerns. I know she had been nervous about the procedure and I tried to think of a way to help console her, coming up short. Instead I tried to imagine what she was going through: multiple strokes that put her in the hospital for 10 days, a slew of tests including a lumbar puncture that took 3 tries, and now going through the painful-sounding procedure that might diagnose her with cancer. And only 50. No, I couldn't even imagine it.
I couldn't help her right now, but I could help him: I rolled her pajama bottoms down from the biopsy site with my gloveless hands, to keep the fellow's gloves sterile. Her pj's kept rolling back up, so I had to expose most of her butt, apologizing silently to the back of her head. The fellow set up his slides and made small talk to the nurse assisting, who shamelessly flirted back to him. The fellow was young enough that I found myself glancing at his ring finger (as I've only started doing since starting in the hospital) though of course his hands were covered with gloves. The patient liked him too, a day ago she was dead set against the biopsy but, as she put it, "he seemed nice."
And he was. While he numbed the area and injected more anesthesia, he continued to talk to her with his soothing voice, explaining what he was doing but also frequently asking if she was doing ok. Observing his bedside manner, I decided that he could have a piece of my hip bone marrow too, if he smiled at me like that.
It wasn't until it was time for the biopsy that there was a problem. The fellow's procedure was perfect. He progressed a long needle into the sit, continually asking the pt if she could feel anything and giving more anesthesia accordingly. My eyes were glued to the skin, the indentation of the needle, and the slow rotating motion of the fellow's hands screwing the needle further and further into bone. I started to feel funny. The pt gasped a few times, but did not speak, tensed the upper half of her body but did not pick up her head. And the fellow continued digging into bone. I had to sit down.
I silently ducked into the next bedside and sat down, leaning back and trying to recover from my vasovagal reaction. All the associated symptoms were there: dizziness, palpitations, diaphoresis, blurry vision, and nausea, and I damned my weak stomach. How embarrassing. I hoped that the fellow didn't think I was bored and just left.
Once I felt well enough to stand I returned to the bedside, in time to watch the fellow make it to the marrow and draw a vial of it. He told me, "It looks like blood, but it's called 'marrow,' it's where blood cells are first made before they go into the blood." I wondered if there was a polite way to tell him that even though I look 16, I did in fact pass step 1 and he didn't have to simply so much.
For the end of the procedure he progressed a hollow needle into bone once again this time to take a biopsy of tissue. I had to leave to sit two more times. Man. I don't know how he could do it. He wasn't one of those surgeons we hear about who can depersonalize the patient and just cut, he was interacting with her personally, checking in with her and explaining each step of the way. He could watch her struggle through the anxiety and pain and continue drilling into bone, all the while consoling her and explaining to me how blood cells start in the marrow.
I wonder if this is what humanism in medicine is. I had thought that by trying to put myself in the patient's place, that I was being humanistic, but by doing so I couldn't even stand through the procedure. If it were me, as much as the patient would have liked me holding her hand, she would have had to console me to get through the biopsy.
After the procedure, I followed the fellow and fetched the chart and a progress note for him, getting rewarded by one of those smiles. "How was it?" he asked me. "I was getting a little vasovagal, sorry I had to keep leaving to sit down." "Really?" he answered, looking confused. Pause. Then his brow furrowed, and he solemnly continued, "Yeah, I remember the first one I did, it was hard." Apparently after 500 procedures he was able to perform a biopsy while attending to the patient humanistically, but I can only imagine how "hard" that first biopsy was.
Thursday, August 2, 2007
Family Medicine: Time to Pap a Paraplegic
Actually... it's a quadriplegic, but I thought the alliteration between Pap and para was pretty cool. I'm about to go in and do it... this should be interesting. Do not EVER assume that just because a person is disabled, he/she is not having sex. That would be called NARROWMINDEDness (a long, but appropriately descriptive word for the mental condition in describes).
Wednesday, August 1, 2007
Medicine - Thank you, Doctor.
For this new round - err, new month - in the hospital, I've been assigned to the cardiology service and today met my new team. I began the day by hitting "off" instead of "snooze" and waking up at 7:05 this morning, and made it to the hospital late and disheveled. (M, are you sure you weren't talking about me??) ;) Trying not to obsess about this great first impression I'd be making on my new team (and cry about losing my last team), I paged my senior resident and found her on the fourth floor. My resident is an R2 instead of an R3, so this would be her first shift on floors as the senior resident on the team. We would be her first student and intern.
Spending the morning listening to the resident orientation, I realized that as my resident and intern both spent the last month on elective and night float shifts, I could actually help them find their way around hospital, figuratively and literally. I spent some time after the orientation (which was NOT meant for me) showing the intern how to find labs and vitals on the computers, and by now I'm actually feeling that I'm a seasoned part of the team. Except that its 9:30 and I have to pre-round on two pts and write their notes in the next half hour.
I scurried through the hospital, running into the new fourth year on my old team, who asked me some questions about a pt I had been following. I insisted that he and the new team not hesitate to page me for any other questions that come up. I found my pts' charts and copied the pertinent information, starting my notes and feeling efficient. A unit secretary made some copies for me without me asking her (I later found out that her nephew is in our class). Then I saw my first cardiology pts.
One of my pts spoke only portugese, and his granddaughter translated. Later that morning I would correct my resident about 3 times in the pronounciation of his name, and my attending would get it wrong when addressing him. Later that morning I would also insist that my attending go back to talk to the granddaughter who was still confused about the treatment plan, and end up bringing her out of the room to talk to him. But for now I just noted his lower extremity edema and that I could not hear his S4, try as I could.
My other pt was a filipino lady in her 70's who told me that she couldn't sit up or eat a full meal because her blood pressure would go up into the 200's, but that she wanted to go home. Later that afternoon as I was at my outpt clinic, she would be discharged. But while I examined her, I just noted her PERRLA and other normal physical findings. I told her I would talk to the doctors and that we would be back that afternoon.
As I walked out of the room, she said, "Thank you, Doctor." I don't know why, but I didn't correct her.
Spending the morning listening to the resident orientation, I realized that as my resident and intern both spent the last month on elective and night float shifts, I could actually help them find their way around hospital, figuratively and literally. I spent some time after the orientation (which was NOT meant for me) showing the intern how to find labs and vitals on the computers, and by now I'm actually feeling that I'm a seasoned part of the team. Except that its 9:30 and I have to pre-round on two pts and write their notes in the next half hour.
I scurried through the hospital, running into the new fourth year on my old team, who asked me some questions about a pt I had been following. I insisted that he and the new team not hesitate to page me for any other questions that come up. I found my pts' charts and copied the pertinent information, starting my notes and feeling efficient. A unit secretary made some copies for me without me asking her (I later found out that her nephew is in our class). Then I saw my first cardiology pts.
One of my pts spoke only portugese, and his granddaughter translated. Later that morning I would correct my resident about 3 times in the pronounciation of his name, and my attending would get it wrong when addressing him. Later that morning I would also insist that my attending go back to talk to the granddaughter who was still confused about the treatment plan, and end up bringing her out of the room to talk to him. But for now I just noted his lower extremity edema and that I could not hear his S4, try as I could.
My other pt was a filipino lady in her 70's who told me that she couldn't sit up or eat a full meal because her blood pressure would go up into the 200's, but that she wanted to go home. Later that afternoon as I was at my outpt clinic, she would be discharged. But while I examined her, I just noted her PERRLA and other normal physical findings. I told her I would talk to the doctors and that we would be back that afternoon.
As I walked out of the room, she said, "Thank you, Doctor." I don't know why, but I didn't correct her.
Medicine - This month . . .
Today is the first of the month. It's the point when somewhere in the hospital there is a bell that DING!s and all the residents, interns, attendings, and even students, all stand up from their chairs, move one spot over, and sit back down for another round of the hospital's version of speed dating.
Since we've now been on this rotation for a month, I'd like to take a chance to reflect. Over the last month I've experienced -
getting lost trying to find the cafeteria, getting locked between two swipe-only doors, and getting trapped trying to exit the building (no ... damn ... exits!!!).
nearly fainting when my super nice actually-gave-us-the-leture-on-humanism attending asked me again what the symptoms of uremia are (we had gone through them the day before, and bless his soul, I can't remember what the I and U of AEIOU stand for).
having my pager go off without knowing it and needing a nurse to gently tell me that that sound is actually coming from my pocket (me: "but they said they wouldn't be paging me!" nurse: "oh sweetie, they lied to you.")
walking into a pts room and not once thinking the pt would be annoyed with my presence.
not being able to sleep because I wasn't sure whether my resident really wanted me in an hour early the next day or if she was being sarcastic. (She was.)
going from following 1 pt to following 2.
seeing a classmate I've never said two words to and being so excited to see a familiar face that we got into a 10 minute conversation about how our respective rotations were going.
feeling that my intern was being a bit possessive when referring to me as his medical student.
finding that I was never eager to leave the hospital and go home after a long day, actually meaning it when asking my residents what else I could do and not using code for "please let me go home!" . . . and being surprised about this.
noticing that my angry psych pt is actually more sarcastic then angry, and that she's started to say "thank you" when I'm done pre-rounding on her every morning.
going from following 2 pts to following 3.
getting called 18 yrs old by a nurse who wasn't kidding.
getting called "that 4 yr old med student" by a pt's daughter, who was.
finally feeling comfortable taking care of the handful of patients that are mine, all mine! and feeling wronged when my resident changed the dosage of a beta blocker without telling me.
not nearly crapping myself on rounds and actually answering questions and getting the compliment from my attending "sorry to keep directing these questions towards you, but you seem to be on a roll."
deciding from the above that I would go into medicine, open a private practice with that attending, and babysit her children on weekends because I am that excited about this rotation.
joking to my angry/sarcastic psych pt that when she gets that transfer, she's going to miss waking up to me shining my pen light in her eyes every morning.
feeling pride that I'm not only being useful to my residents, but also lightening their work load and helping them get out a few hours earlier.
actually thinking that maybe they could use that time to hang out with me and tell me what its like to be a resident. (But not daring to suggest it!)
having an elderly pt report to me that she's only on ambien and listening to her insist for an hour that she's the healthiest woman in her nursing home and everyone envies her health, only to go out to her chart and find that she's actually on 21 medications, has severe AS and is in CHF.
going through pre-test with my resident and making her depressed because she wasn't getting the questions right either. then my intern insisting he try the same questions, with the same result.
wishing that my intern would just tell me how he takes his coffee instead of insisting he can't scut me because he looks so stressed out and tired that I want to take care of him.
not thinking that last line was possessive at all.
getting so excited to get the news that my two psych pts (in PsychBuilding) had received transfers that I ran into their rooms and told them myself. then, saying good-bye to each of them on the same day, and telling them that I'd better not see them again!
seeing a pt in the ER whose chest pain is obviously musculoskeletal (it hurt when he pressed on it) but insisting we admit him because he reminded me of my father and though, like my father, he only has 1 or 2 risk factors for MI and is in near perfect health, I was afraid that he could clot any day now.
being able to tell that pt and his wife that we ruled out every possible serious cause of his chest pain and that he could rest easy now (but don't forget to follow up with your doctor!) ... though really I'm the one who can rest easy.
going from following 3 pts to following 4.
finding out that my team had spent the morning meeting to evaluate me . . . and still working my ass off for rounds even though they were done grading me.
hanging around the last day of the month with my team and finding every excuse not to leave even though the work was done and we had put in 12 hours. Feeling that my resident actually considers me a friend and that she meant it when she said I can call her anytime. Knowing she meant it when she said I'd better not like my next resident more than her.
Well ok I didn't know I had that much sap in me, but there it is.
Since we've now been on this rotation for a month, I'd like to take a chance to reflect. Over the last month I've experienced -
getting lost trying to find the cafeteria, getting locked between two swipe-only doors, and getting trapped trying to exit the building (no ... damn ... exits!!!).
nearly fainting when my super nice actually-gave-us-the-leture-on-humanism attending asked me again what the symptoms of uremia are (we had gone through them the day before, and bless his soul, I can't remember what the I and U of AEIOU stand for).
having my pager go off without knowing it and needing a nurse to gently tell me that that sound is actually coming from my pocket (me: "but they said they wouldn't be paging me!" nurse: "oh sweetie, they lied to you.")
walking into a pts room and not once thinking the pt would be annoyed with my presence.
not being able to sleep because I wasn't sure whether my resident really wanted me in an hour early the next day or if she was being sarcastic. (She was.)
going from following 1 pt to following 2.
seeing a classmate I've never said two words to and being so excited to see a familiar face that we got into a 10 minute conversation about how our respective rotations were going.
feeling that my intern was being a bit possessive when referring to me as his medical student.
finding that I was never eager to leave the hospital and go home after a long day, actually meaning it when asking my residents what else I could do and not using code for "please let me go home!" . . . and being surprised about this.
noticing that my angry psych pt is actually more sarcastic then angry, and that she's started to say "thank you" when I'm done pre-rounding on her every morning.
going from following 2 pts to following 3.
getting called 18 yrs old by a nurse who wasn't kidding.
getting called "that 4 yr old med student" by a pt's daughter, who was.
finally feeling comfortable taking care of the handful of patients that are mine, all mine! and feeling wronged when my resident changed the dosage of a beta blocker without telling me.
not nearly crapping myself on rounds and actually answering questions and getting the compliment from my attending "sorry to keep directing these questions towards you, but you seem to be on a roll."
deciding from the above that I would go into medicine, open a private practice with that attending, and babysit her children on weekends because I am that excited about this rotation.
joking to my angry/sarcastic psych pt that when she gets that transfer, she's going to miss waking up to me shining my pen light in her eyes every morning.
feeling pride that I'm not only being useful to my residents, but also lightening their work load and helping them get out a few hours earlier.
actually thinking that maybe they could use that time to hang out with me and tell me what its like to be a resident. (But not daring to suggest it!)
having an elderly pt report to me that she's only on ambien and listening to her insist for an hour that she's the healthiest woman in her nursing home and everyone envies her health, only to go out to her chart and find that she's actually on 21 medications, has severe AS and is in CHF.
going through pre-test with my resident and making her depressed because she wasn't getting the questions right either. then my intern insisting he try the same questions, with the same result.
wishing that my intern would just tell me how he takes his coffee instead of insisting he can't scut me because he looks so stressed out and tired that I want to take care of him.
not thinking that last line was possessive at all.
getting so excited to get the news that my two psych pts (in PsychBuilding) had received transfers that I ran into their rooms and told them myself. then, saying good-bye to each of them on the same day, and telling them that I'd better not see them again!
seeing a pt in the ER whose chest pain is obviously musculoskeletal (it hurt when he pressed on it) but insisting we admit him because he reminded me of my father and though, like my father, he only has 1 or 2 risk factors for MI and is in near perfect health, I was afraid that he could clot any day now.
being able to tell that pt and his wife that we ruled out every possible serious cause of his chest pain and that he could rest easy now (but don't forget to follow up with your doctor!) ... though really I'm the one who can rest easy.
going from following 3 pts to following 4.
finding out that my team had spent the morning meeting to evaluate me . . . and still working my ass off for rounds even though they were done grading me.
hanging around the last day of the month with my team and finding every excuse not to leave even though the work was done and we had put in 12 hours. Feeling that my resident actually considers me a friend and that she meant it when she said I can call her anytime. Knowing she meant it when she said I'd better not like my next resident more than her.
Well ok I didn't know I had that much sap in me, but there it is.
Tuesday, July 31, 2007
Pediatrics
I will admit as many of you have heard - I entered Peds with an open mind and much excitement -burning with desire to take of patients (finally after two years). Unfortunately most of my rotation has been boring as heck. The residents don't let us do histories and physicals. We either shadow them or go in and ask the patient "How were you overnight, any nausea, vomiting, diarrhea, pain, fever, etc." and then do a 2 min exam (which can include ears, throat, chest, lung, abdomen, but usually not even all of these). That's it. I have been demoted to the ranks of a first year medical student who does nothing, knows nothing etc. I did more in physical diagnosis!!!
Changing tunes : maybe it's because I've been so bored, maybe it's the patients, the neurologist or all three -but this past week I have literally been on a high. I have seen the most incredible peds neuro cases. I came home today with so much excitement over a patient I saw that I can't even focus. All I want to do is look up articles about the condition(s) I will describe. I have a shelf in almost one week and know nothing about peds as a whole. All I want to do is study these neuro cases - as I said - I can't even focus on anything else. I have not felt this excited about anything in a while. This does not mean I can do peds neuro as a career (b/c I do not think I would enjoy peds residency) - but I am sad that the rotation is ending when I finally found something interesting.
The neurologist is awesome - despite a strange and harsh sense of humor. I was scared of him at first when he came bolting down the peds floor, busted into patient rooms, and went in and out so fast it was a blur. He asked us some questions - I had no clue about (like 3 types of infantile spasms). He asked who was interested in neuro. I said I was - and he simply laughed and said "you don't have to lie just to impress me." I was somewhat mortified. One time he asked a question and when a student began responding he suddenly interrupted "Stop. Just stop speaking now...nevermind." Geez I thought. However despite other harsh comments and several unsettling encounters I realized - hey - this guy may be a bit harsh - but he actually teaches! He taught me a lot! And turns out.........the patients LOVE him - not just like him - LOVE him - as in they will miss him when they stop having appointments. Pictures of patients with him and thank-you notes adorn the walls of both his office and the peds floor.
TO BE CONTINUED.....................
Changing tunes : maybe it's because I've been so bored, maybe it's the patients, the neurologist or all three -but this past week I have literally been on a high. I have seen the most incredible peds neuro cases. I came home today with so much excitement over a patient I saw that I can't even focus. All I want to do is look up articles about the condition(s) I will describe. I have a shelf in almost one week and know nothing about peds as a whole. All I want to do is study these neuro cases - as I said - I can't even focus on anything else. I have not felt this excited about anything in a while. This does not mean I can do peds neuro as a career (b/c I do not think I would enjoy peds residency) - but I am sad that the rotation is ending when I finally found something interesting.
The neurologist is awesome - despite a strange and harsh sense of humor. I was scared of him at first when he came bolting down the peds floor, busted into patient rooms, and went in and out so fast it was a blur. He asked us some questions - I had no clue about (like 3 types of infantile spasms). He asked who was interested in neuro. I said I was - and he simply laughed and said "you don't have to lie just to impress me." I was somewhat mortified. One time he asked a question and when a student began responding he suddenly interrupted "Stop. Just stop speaking now...nevermind." Geez I thought. However despite other harsh comments and several unsettling encounters I realized - hey - this guy may be a bit harsh - but he actually teaches! He taught me a lot! And turns out.........the patients LOVE him - not just like him - LOVE him - as in they will miss him when they stop having appointments. Pictures of patients with him and thank-you notes adorn the walls of both his office and the peds floor.
TO BE CONTINUED.....................
Family Medicine: The Service and the Addicts
This week I'm on the inpatient service at the hospital, and boy is it different from the clinic. I arrived at 7 AM in the hospital cafeteria for morning sign outs... the cafeteria was abuzz with people of all different species; the loud scrubs with a sleepless night etched under their eyes, the manicured hairstyles who got up an hour early just to look pretty, the confused medical students who accidentally turned off the alarm instead of hitting sleep in the morning and therefore have flyaway hair... wait, that's me! Dammit. Amidst the ruckus, I found my group tucked away in a quiet corner going over complicated sheets covered with observations, lab values, and treatment plans. The goal was to cut through the din and simultaneously to make sense of the chaos on the sheet. We got to work with intense focus. I feel that in the hospital environment, that's 3/4 of the battle on a regular basis.
The hospital is a whir of activity, sometimes enough to confuse you to oblivion, at other times enough to literally make me feel nauseated. Five hours in the hospital seeing only 3 patients is significantly more draining than five hours in the clinic seeing 10 patients, and that's just the nature of the beast. Imagine, then, what it's like to be a patient. You come in, by car or ambulance, and you're placed in a stretcher. You're admitted and wheeled through a crowded hallway where dozens of people are walking past you at breakneck speed, into an elevator, and up to a room that you will share with someone's smelly grandfather (unless you are someone's smelly grandfather... then you're the lucky winner of a room shared with the lovely young MS patient with a devastating pulmonary embolism). Your wife, or husband, or daughter, or son, gets to sit on a vinyl-lined seat next to the bed, and place her/his handbag on the table at the foot of your bed... all of which (bed, seat, and table) are generously covered in MRSA. You wait. Sometimes for hours at a time. Your wife/husband/daugther/son grows tired and can't lie down. You freeze in the tiny hospital gown. People in scrubs and white coats come in and out of the room, but you haven't quite gotten the hang of figuring out which ones are doctors, which ones are nurses, which ones are techs... which ones are medical students (we're the ones in the short white coats, by the way... and why the heck am I giving that away??? it must be really late at night). Sometimes they explain something complicated to you, but you're embarassed to asked for clarification. They come and sedate you and then shock your chest so that you squeal in pain and writhe in the bed (by the way, I actually saw this today... it's called cardioversion).
Anyway, the point I'm trying to make is that all that touchy feely stuff is not strictly bullshit. I now know firsthand-- this weekend, I brought a friend into the hospital and witnessed for myself how important patient comfort, communication, and amenities for relatives/friends can be! At 1 AM, after waiting in the ER for 5 hours, I found out exactly how welcome a cot for the companion could be. I reflected on how our children's hospital is so ridiculously proud of its pediatric floors, with their special sections in each room where parents can sleep. It's no wonder that studies have shown: when the loved ones are also cared for, the patient is also healed faster.
After treating a couple more patients in the ER and scarfing dinner, I attended a meeting of what's equivalent to AA for former jail inmates. I listened to these stories with total compassion but a helpless feeling of greenness; there was no way I could ever comprehend what it is like for these people, with this disease of addiction, to walk down the street... to wake up each day and fight the urge to use. I've never been there. A young lady, V, spoke up, saying that the evening group meeting time is difficult for her because walking home, she has to walk the night gauntlet of her addictions, passing every dealer on her street in her neighborhood to make it to the safety of her house. I can't even imagine what it would be like for each day to be a struggle against myself; not a struggle for anything more than just to stay away from heroin, or alcohol, or cocaine... for just one more day...
I drove V home to her grandfather's place on the outskirts of the city and dropped her off at her front stoop, where 4 people were in the process of getting high. I gave her a hug and went back into town, where I contemplated my long day over a draught at the local brewery...
The hospital is a whir of activity, sometimes enough to confuse you to oblivion, at other times enough to literally make me feel nauseated. Five hours in the hospital seeing only 3 patients is significantly more draining than five hours in the clinic seeing 10 patients, and that's just the nature of the beast. Imagine, then, what it's like to be a patient. You come in, by car or ambulance, and you're placed in a stretcher. You're admitted and wheeled through a crowded hallway where dozens of people are walking past you at breakneck speed, into an elevator, and up to a room that you will share with someone's smelly grandfather (unless you are someone's smelly grandfather... then you're the lucky winner of a room shared with the lovely young MS patient with a devastating pulmonary embolism). Your wife, or husband, or daughter, or son, gets to sit on a vinyl-lined seat next to the bed, and place her/his handbag on the table at the foot of your bed... all of which (bed, seat, and table) are generously covered in MRSA. You wait. Sometimes for hours at a time. Your wife/husband/daugther/son grows tired and can't lie down. You freeze in the tiny hospital gown. People in scrubs and white coats come in and out of the room, but you haven't quite gotten the hang of figuring out which ones are doctors, which ones are nurses, which ones are techs... which ones are medical students (we're the ones in the short white coats, by the way... and why the heck am I giving that away??? it must be really late at night). Sometimes they explain something complicated to you, but you're embarassed to asked for clarification. They come and sedate you and then shock your chest so that you squeal in pain and writhe in the bed (by the way, I actually saw this today... it's called cardioversion).
Anyway, the point I'm trying to make is that all that touchy feely stuff is not strictly bullshit. I now know firsthand-- this weekend, I brought a friend into the hospital and witnessed for myself how important patient comfort, communication, and amenities for relatives/friends can be! At 1 AM, after waiting in the ER for 5 hours, I found out exactly how welcome a cot for the companion could be. I reflected on how our children's hospital is so ridiculously proud of its pediatric floors, with their special sections in each room where parents can sleep. It's no wonder that studies have shown: when the loved ones are also cared for, the patient is also healed faster.
After treating a couple more patients in the ER and scarfing dinner, I attended a meeting of what's equivalent to AA for former jail inmates. I listened to these stories with total compassion but a helpless feeling of greenness; there was no way I could ever comprehend what it is like for these people, with this disease of addiction, to walk down the street... to wake up each day and fight the urge to use. I've never been there. A young lady, V, spoke up, saying that the evening group meeting time is difficult for her because walking home, she has to walk the night gauntlet of her addictions, passing every dealer on her street in her neighborhood to make it to the safety of her house. I can't even imagine what it would be like for each day to be a struggle against myself; not a struggle for anything more than just to stay away from heroin, or alcohol, or cocaine... for just one more day...
I drove V home to her grandfather's place on the outskirts of the city and dropped her off at her front stoop, where 4 people were in the process of getting high. I gave her a hug and went back into town, where I contemplated my long day over a draught at the local brewery...
Sunday, July 29, 2007
Surgery: The pimping
This past week I just realized something: There's no such thing as being prepared enough for your attending pimping sessions. Here's my story to back that up.
I've seen many lap cholecystectomy by now, and this past week, there was another one. I scrubbed in, feeling confident I had a pretty good knowledge about the billiary tract and all about gallstones, even though for this specific patient I didn't get a chance to review her charts (had grand rounds that finished after she was prepped in the OR). Well, we started, I grabbed the camera, had my position and everything, and my attending said: "This lady has a gallbladder polyp. What's the most common type of gallbladder polyps?" And of course that question met my blank stare. My brain started working hard, trying to find that piece of information that I've memorized once upon a time that seems so long ago, namely during 2nd year pathology course. Well, it was unsuccessful....couldn't remember. Then it continued to more clinical stuff: "How do you diagnose it?" "How do you differentiate between polyp and stones on ultrasound?" "Is it benign or malignant?" and so on....Ouch!
The other one was during attending rounds. One of the patients have cecal bascule. I read everything about it. I even read about volvulus and incomplete malrotation. We had 3 attendings with us this time, and any of them can ask questions. 1 attending asked several basic questions which I could answer pretty well. Right when I was about to breathe a sigh of relief after he's done with his questions, my attending asked me: "How about complete malrotation? How do you treat it?" Yeah, of course I didn't know. Argh!
Isn't surgery rotation just fun?
I've seen many lap cholecystectomy by now, and this past week, there was another one. I scrubbed in, feeling confident I had a pretty good knowledge about the billiary tract and all about gallstones, even though for this specific patient I didn't get a chance to review her charts (had grand rounds that finished after she was prepped in the OR). Well, we started, I grabbed the camera, had my position and everything, and my attending said: "This lady has a gallbladder polyp. What's the most common type of gallbladder polyps?" And of course that question met my blank stare. My brain started working hard, trying to find that piece of information that I've memorized once upon a time that seems so long ago, namely during 2nd year pathology course. Well, it was unsuccessful....couldn't remember. Then it continued to more clinical stuff: "How do you diagnose it?" "How do you differentiate between polyp and stones on ultrasound?" "Is it benign or malignant?" and so on....Ouch!
The other one was during attending rounds. One of the patients have cecal bascule. I read everything about it. I even read about volvulus and incomplete malrotation. We had 3 attendings with us this time, and any of them can ask questions. 1 attending asked several basic questions which I could answer pretty well. Right when I was about to breathe a sigh of relief after he's done with his questions, my attending asked me: "How about complete malrotation? How do you treat it?" Yeah, of course I didn't know. Argh!
Isn't surgery rotation just fun?
Thursday, July 26, 2007
Family Medicine: Inmates, Indigents, and Ill
Thursday or Friday of each week is the day I get to go to jail. This morning, I got there to discover that I had left my driver's license at home (you need to turn over ID to get past security), which naturally led to many jokes about "did they let you into jail?" I am happy to say that they did, indeed, let me into jail today. And they even let me back out; imagine that.
A classmate and I participate in a program for substance abusers at the county jail. So far, the thing that has struck me most about people in jail is how similar they are to people not in jail. Actually, my most interesting observation so far is that the main difference between people in jail and people not in jail is a peculiar inability to control one's emotions, especially the negative ones. Next time you feel fury, frustration, or despair, remember that self-control goes a long way.
After jail, I headed over to the Catholic charities clinic for an afternoon of women's health. I work with my preceptor and the world's most wonderful PA there; this afternoon I observed 2 colposcopies with endocervical curettage (ECC) and biopsy, and an attempted endometrial biopsy. I didn't do much more than hold the patient's hand, but I somehow managed to get thanked for it. I guess when people are sticking things up your vagina and cutting bits out of your cervix, the person who holds your hand is pretty darn important.
Finally, some quotes of the ill:
M: Do you have a runny nose?
Patient: Who in our state doesn't have a runny nose??
Dr: She used to be psycho... but now she's sweet as a button. A little dab of Zoloft makes all the difference!
A classmate and I participate in a program for substance abusers at the county jail. So far, the thing that has struck me most about people in jail is how similar they are to people not in jail. Actually, my most interesting observation so far is that the main difference between people in jail and people not in jail is a peculiar inability to control one's emotions, especially the negative ones. Next time you feel fury, frustration, or despair, remember that self-control goes a long way.
After jail, I headed over to the Catholic charities clinic for an afternoon of women's health. I work with my preceptor and the world's most wonderful PA there; this afternoon I observed 2 colposcopies with endocervical curettage (ECC) and biopsy, and an attempted endometrial biopsy. I didn't do much more than hold the patient's hand, but I somehow managed to get thanked for it. I guess when people are sticking things up your vagina and cutting bits out of your cervix, the person who holds your hand is pretty darn important.
Finally, some quotes of the ill:
M: Do you have a runny nose?
Patient: Who in our state doesn't have a runny nose??
Dr: She used to be psycho... but now she's sweet as a button. A little dab of Zoloft makes all the difference!
Family Medicine
The nature of my specialty right now is that I don't have glorious stories of pulling tumors out of abdomens or waking up at 4 AM every day (wait, did I say glorious?? I think I meant seriously sadistic). My people-- yes, I feel like I OWN them after a mere 3.5 weeks together-- deal with the seriously mundane business of taking care of what, to the untrained eye, are the most superficial aspects of medical care.
But if you actually agreed with what I just said, you would be horribly, horribly wrong. It is estimated that for every 1000 people in the community in a typical month, 800 feel medical symptoms. Only 327 of those even CONSIDER medical care. 217 of them visit a physician's office (113 visit a primary care office), 65 visit an alternative/complementary medicine provider, 21 visit a hospital outpatient clinic, 13 go to the ER, 8 are hospitalized, and FEWER THAN ONE are hospitalized in an academic medical center.
What does this all mean? For one, it tells us what we can and cannot believe about clinical trials, which are mostly done in the academic medical centers visited by the fewer than 1/800 symptomatic patients in every month: they are not necessarily representative of the total patient population. Secondly, it tells us something about the attitudes towards medicine, and the (in)accessibility of medical care out there in our communities (about 500/1000 don't even consider it). Most importantly, it illustrates the importance of primary care: providers in outpatient settings and family practice clinics are on the front lines of almost every medical battle.
I used to brag that I hate people. I am shocked to find that I actually like them very much. I like how each one comes with a wholly different set of challenges, and how many of them are eager to form an alliance with their medical caregivers (and that now includes me, I'm part of the team, too!) to surmout these challenges. I like the stories I hear, and the stories I get to tell. I even like the patients that don't really get it, or try really hard and are just too weak to do it, whether it's quitting smoking, eating healthier, getting more exercise, getting out of an abusive relationship, or checking blood sugar levels every day-- those are the most challenging ones (and anyone who knows me at all knows I like a challenge).
I got my first taste of continuity last week. I have been seeing patients in one situation or another for longer than many of my classmates, since I worked as an EMT for 2 years before I started medical school. But it was always "Hi, nice to meet you!" and never "It's great to see you again!" Of all the things that have happened to me in the last couple of weeks, I have to say that the first time "It's great to see you again!" happened to me was the most transcendant: continuity of care is really all that it's cracked up to be. I think back to all the stories I've heard about doctors who delivered a baby and remained its care provider for 20 years... what an honor to be a part of an individual's life in that way.
The first 2 minutes of any patient encounter belong entirely to the patient. I have a whole cheat sheet of tips and tricks to make someone talk without the use of torture devices (apart from my presence in the room, that is). My first "It's great to see you again!" patient rewarded me by opening up to the incredibly vague, general question of "So, what's going on your life?" with "well, it's been pretty bad since my wife died five years ago." By the time I left the room ten minutes later I felt like I had died. I thought I was ready to "be there" for people, but that was the arrogance of youth speaking. How could I, without mourning for five years, match the magnitude of sadness this gentle old man felt? In ten minutes, I had drained every ounce of sadness out of my being to share with him in empathy (in school they love to teach us this in abstraction, they call it "humanism"), but it I knew couldn't possibly be enough.
The "don't get burned out" answer is NEVER to let a patient GET to you. I'm still letting them do that. Being in the room with one particular patient, who had a sinus infection and obvious depression, felt like meeting a group of dementors (YES! A Harry Potter reference!) in a dark alleyway-- it was cold, you felt like all the happiness had gone out of the world, despair took over. Why is interviewing her like pulling teeth? Why do I feel so angry at the patient I'm trying to help? There is no hope left. I am helpless... She made me so angry I could barely get my presentation out to my attending afterwards. Her passive agressivism frustrated me: why was she here, in our place of healing, if she didn't want to be healed?
I'm still green, so my frustrations and joys soar and crash with the tide of human drama that is all around me constantly. Eventually, I will become the rock that others depend on for shelter in that stormy sea.
But if you actually agreed with what I just said, you would be horribly, horribly wrong. It is estimated that for every 1000 people in the community in a typical month, 800 feel medical symptoms. Only 327 of those even CONSIDER medical care. 217 of them visit a physician's office (113 visit a primary care office), 65 visit an alternative/complementary medicine provider, 21 visit a hospital outpatient clinic, 13 go to the ER, 8 are hospitalized, and FEWER THAN ONE are hospitalized in an academic medical center.
What does this all mean? For one, it tells us what we can and cannot believe about clinical trials, which are mostly done in the academic medical centers visited by the fewer than 1/800 symptomatic patients in every month: they are not necessarily representative of the total patient population. Secondly, it tells us something about the attitudes towards medicine, and the (in)accessibility of medical care out there in our communities (about 500/1000 don't even consider it). Most importantly, it illustrates the importance of primary care: providers in outpatient settings and family practice clinics are on the front lines of almost every medical battle.
I used to brag that I hate people. I am shocked to find that I actually like them very much. I like how each one comes with a wholly different set of challenges, and how many of them are eager to form an alliance with their medical caregivers (and that now includes me, I'm part of the team, too!) to surmout these challenges. I like the stories I hear, and the stories I get to tell. I even like the patients that don't really get it, or try really hard and are just too weak to do it, whether it's quitting smoking, eating healthier, getting more exercise, getting out of an abusive relationship, or checking blood sugar levels every day-- those are the most challenging ones (and anyone who knows me at all knows I like a challenge).
I got my first taste of continuity last week. I have been seeing patients in one situation or another for longer than many of my classmates, since I worked as an EMT for 2 years before I started medical school. But it was always "Hi, nice to meet you!" and never "It's great to see you again!" Of all the things that have happened to me in the last couple of weeks, I have to say that the first time "It's great to see you again!" happened to me was the most transcendant: continuity of care is really all that it's cracked up to be. I think back to all the stories I've heard about doctors who delivered a baby and remained its care provider for 20 years... what an honor to be a part of an individual's life in that way.
The first 2 minutes of any patient encounter belong entirely to the patient. I have a whole cheat sheet of tips and tricks to make someone talk without the use of torture devices (apart from my presence in the room, that is). My first "It's great to see you again!" patient rewarded me by opening up to the incredibly vague, general question of "So, what's going on your life?" with "well, it's been pretty bad since my wife died five years ago." By the time I left the room ten minutes later I felt like I had died. I thought I was ready to "be there" for people, but that was the arrogance of youth speaking. How could I, without mourning for five years, match the magnitude of sadness this gentle old man felt? In ten minutes, I had drained every ounce of sadness out of my being to share with him in empathy (in school they love to teach us this in abstraction, they call it "humanism"), but it I knew couldn't possibly be enough.
The "don't get burned out" answer is NEVER to let a patient GET to you. I'm still letting them do that. Being in the room with one particular patient, who had a sinus infection and obvious depression, felt like meeting a group of dementors (YES! A Harry Potter reference!) in a dark alleyway-- it was cold, you felt like all the happiness had gone out of the world, despair took over. Why is interviewing her like pulling teeth? Why do I feel so angry at the patient I'm trying to help? There is no hope left. I am helpless... She made me so angry I could barely get my presentation out to my attending afterwards. Her passive agressivism frustrated me: why was she here, in our place of healing, if she didn't want to be healed?
I'm still green, so my frustrations and joys soar and crash with the tide of human drama that is all around me constantly. Eventually, I will become the rock that others depend on for shelter in that stormy sea.
Wednesday, July 25, 2007
OB/GYN: Ma'am, yes ma'am.
"Oh hey! I didn't recognize you in civies!" exclaims Sue.
Civies? What the hell are those? It's got to be a noun: a place, a program, a ... what? Sue explains and I look down. Oh, I get it: civilian clothes - I was wearing a dress shirt, skirt, and my trendy-grandma shoes, as opposed to my "jade" (yes, it actually says that) colored standard-issue scrubs and sneakers.
Armed with my stethoscope and protected by my white coat, I was on a mission. Like a true soldier, I was prepared: my stethoscope had just received its daily alcohol-pad polishing and my coat proudly sported its lapel pins. Only 20 minutes until 13:00 hours. Will I make it?
Ok, so before you all think that I've completely lost it since I've gone MIA for the past three weeks, let me reassure you that I haven't. I just feel like I've been duped into some sort of medical military that is OB/GYN clerkship 1. And seeing how it's now 21:31 and I need to be AAO (alert, awake, and oriented for all you lovely normal people) at 04:45, I'll leave with three little thoughts: 1) Thank your mother for birthing you, no matter how %&#$ing annoying she has been/is/will always be. 2) If you want to decrease teen pregnancy rates, show 6th grade girls an uncensored video of labor and delivery. 3) Coffee is king.
Civies? What the hell are those? It's got to be a noun: a place, a program, a ... what? Sue explains and I look down. Oh, I get it: civilian clothes - I was wearing a dress shirt, skirt, and my trendy-grandma shoes, as opposed to my "jade" (yes, it actually says that) colored standard-issue scrubs and sneakers.
Armed with my stethoscope and protected by my white coat, I was on a mission. Like a true soldier, I was prepared: my stethoscope had just received its daily alcohol-pad polishing and my coat proudly sported its lapel pins. Only 20 minutes until 13:00 hours. Will I make it?
Ok, so before you all think that I've completely lost it since I've gone MIA for the past three weeks, let me reassure you that I haven't. I just feel like I've been duped into some sort of medical military that is OB/GYN clerkship 1. And seeing how it's now 21:31 and I need to be AAO (alert, awake, and oriented for all you lovely normal people) at 04:45, I'll leave with three little thoughts: 1) Thank your mother for birthing you, no matter how %&#$ing annoying she has been/is/will always be. 2) If you want to decrease teen pregnancy rates, show 6th grade girls an uncensored video of labor and delivery. 3) Coffee is king.
Sunday, July 22, 2007
Medicine
I'm thinking that I actually like medicine. I know, I know, scheduling it first was to "get it out of the way" and maybe its just that I actually like third year but either way I'm feeling pretty good. I don't know who else has their med rotation right here but I thought I'd write a little about how the average day goes for your reading pleasure.
We meet in the call room at 7am to get the sign outs from the night float residents. The intern actually gets in around 6:45 because he/she is anal like that (I'm not being vague - first we had a she, now we have a he, and apparently md's their first few weeks are the most stressed out anal people we'll ever meet - and we've been to the ivy & med school). The senior resident PGY3 strolls in about 7:05 looking non-apologetic and the sub-I right behind her even less so. As I gulp down my first diet coke of the morning the res doles out the pts to our team; its the 5th day of my third week and she deems me ready to take 3 pts. Lucky for me they are all on the pseudopsych floor just next to the call room.
I settle into what I'll call PsychBuilding and get my first pts chart. Tina** is a 26 yr old woman who presented with drug overdose of her antidepressant, her son's seizure meds, ambien, and a triptan she takes for migraine solely because she knew it interacted with her antidepressant. I saw her a few times last week when she first came in but my attending thought the case was too boring for me and switched me to some others; since then the mid-month attending switch happened and my res gave me back to Tina. She was pretty cold last week but came around quickly once she saw that I wasn't judging her for her suicide attempt. Having currently 3 suicide pts on our service I've come to the realization that doctors take this shit personally - anyone who harms their bodies with intent like Tina or noncompliance gets this reaction from doctors like they are actually giving their blood pressure meds to the doctor's puppy instead of merely neglecting to refill the prescription.
This morning however was Tina's 9th day in the hospital and she was pissed. The first two days she was here she was intubated and seized a few times - apparently drugs are bad - but since then she's been laying in bed waiting for transfer. I gently prodded her awake at the fresh hour of 7:30 and once she blinked her sleepy eyes she started going off about how her psychiatrist consult is trying to kill her by not getting her into the inpt facility she wants to go to and how we aren't doing a single thing for her. That actually isn't true - not about the consult, I don't really know if Dr. StandsInTheDoorway is trying to kill her or not - but we are doing a single thing for her: her bp was in the 140s so we prescribed a low dose of hctz. Other than that we are waiting for her to get a psych transfer to an inpt facility, and until then we are feeding her three meals a day and keeping a 1:1 watch on her in case she gets her hands on some more migraine medicine. (The 1:1's love when we come to see the pts because they get to go pee! They are really excited about it!!)
I told Tina I'd put her complaints in her chart - which I did - and examined her pupils, heart, lungs, abdomen, and checked for edema. This is what it looks like in her chart:
PE gen: well-appearing young female in NAD, AAOx3
HEENT: PERRL, sclera anicteric, mucus membranes intact
CV: RRR, no murmurs, rubs, gallops or thrills appreciated
Pulm: CTA [clear to auscultation]
Abd: + BS 4 quadrants, soft, ND, NT, no hsm [nondistended, nontender, no hepatosplenomegaly]
Ext: no c/c/e [cyanosis, clubbing or edema]
This is what you get if you are actually 100% physically healthy and waiting a week for transfer. I made my sad sorry-you-aren't-enjoying-your-stay look and waited for her to get out the rest of her morning angst and headed out to write my note.
I got out Ronald's chart next. Ronald is a 30-something black male who p/w epigastric pain and shaking of his hands. He usually drinks a 6-pack of beer/day but stopped around Monday, started shaking on Wednesday and presented to the ED on Thursday. (Ok folks, what's the treatment plan for acute pancreatitis?) When I saw him on Thursday he was not looking well, we had him on a banana bag (saline, thiamine, folate, multivitamin) but it was probably more withdrawal than his pancreas that was hurting him. I went in with Res. This morning he had only a little bit of pain, and was hungry. Res told him that if he felt ok to eat that we would start giving him food.
Ok so last night I decided to read up on pancreatitis because Dr. Attending told us that she would pimp us on it today. Treatment for pancreatitis should be NPO to give the pancreas a break, and generally unless its necrotizing it resolves on its own. Give morphine as needed, and in Ronald's case he gets benzos for his withdrawal - ativan and librium on a standing basis. When we left Ronald's room I asked as politely as I could if it would be ok for us to give him PO, or if we should keep giving his pancreas a break. Res said if his pancreatitis was still bad he wouldn't want to eat, and she put in the order for PO.
Third and my last patient of the morning was Ms. Helen. Ms. Helen is a 49 yo divorced mother of two who presented after injecting herself with 90 units of her son's insulin in a suicide attempt, which resulted in a seizure. Several hours later she was able to call 911 and get herself to the hospital. Today was her 3rd day here and she was looking well. I saved her for last because she is my favorite patient, she is so sweet and pleasant I wonder why anyone would ever want to hurt her, including herself.
I'm worried about Ms. Helen. I've been following her the few days that she's been here and while she brightens up my day and makes me feel good about myself, I'm worried that she's in some denial right now. Here is how the typical exchange goes:
J Ms. Helen? Good morning.
H (waking) Good morning dear! Look at that smiling face!
J How are you doing today?
H Oh I'm doing fine. I'm much better. But how are you doing?
J Well this morning is dragging a bit-- (wait, she is the patient.) Any pain today?
H Not really, my calves feel much better, they aren't as tight. What is your day like today? Long day?
J Well tomorrow we are on call . . .
H On a Saturday? My they work you so hard, don't they?
J It's a lot of work but I am really enjoying it. (Back to the patient, damn it!!) How is your tongue feeling today?
H I think it's healing, but it still hurts.
Ms. Helen's tongue hurts because she bit it pretty hard during her seizure. Her calves are tight because her muscles contracted so hard during her seizure that she had rhabdomyolysis. (What is the number 1 cause of rhabdo in the US?) When she came in, her CPK was elevated in the 3000s so as opposed to Tina, we are medically treating her, bolusing her with fluids to get it down, before she can be transferred to inpt.
Ms. Helen's physical exam was benign, except that I'm pretty sure I heard an S4 at the left sternal border. I don't know why she should have a gallop or how I could be the only one to exam her to actually hear it, but I note it in her chart anyway. I stay in her room talking to her (me desperately trying to keep the conversation on her) until it's time for rounds at 10.
Part II: Rounds, coming soon.
** Names have been changed, and while I usually try to refer to my patients by their last names I'm only using first names for added privacy.
We meet in the call room at 7am to get the sign outs from the night float residents. The intern actually gets in around 6:45 because he/she is anal like that (I'm not being vague - first we had a she, now we have a he, and apparently md's their first few weeks are the most stressed out anal people we'll ever meet - and we've been to the ivy & med school). The senior resident PGY3 strolls in about 7:05 looking non-apologetic and the sub-I right behind her even less so. As I gulp down my first diet coke of the morning the res doles out the pts to our team; its the 5th day of my third week and she deems me ready to take 3 pts. Lucky for me they are all on the pseudopsych floor just next to the call room.
I settle into what I'll call PsychBuilding and get my first pts chart. Tina** is a 26 yr old woman who presented with drug overdose of her antidepressant, her son's seizure meds, ambien, and a triptan she takes for migraine solely because she knew it interacted with her antidepressant. I saw her a few times last week when she first came in but my attending thought the case was too boring for me and switched me to some others; since then the mid-month attending switch happened and my res gave me back to Tina. She was pretty cold last week but came around quickly once she saw that I wasn't judging her for her suicide attempt. Having currently 3 suicide pts on our service I've come to the realization that doctors take this shit personally - anyone who harms their bodies with intent like Tina or noncompliance gets this reaction from doctors like they are actually giving their blood pressure meds to the doctor's puppy instead of merely neglecting to refill the prescription.
This morning however was Tina's 9th day in the hospital and she was pissed. The first two days she was here she was intubated and seized a few times - apparently drugs are bad - but since then she's been laying in bed waiting for transfer. I gently prodded her awake at the fresh hour of 7:30 and once she blinked her sleepy eyes she started going off about how her psychiatrist consult is trying to kill her by not getting her into the inpt facility she wants to go to and how we aren't doing a single thing for her. That actually isn't true - not about the consult, I don't really know if Dr. StandsInTheDoorway is trying to kill her or not - but we are doing a single thing for her: her bp was in the 140s so we prescribed a low dose of hctz. Other than that we are waiting for her to get a psych transfer to an inpt facility, and until then we are feeding her three meals a day and keeping a 1:1 watch on her in case she gets her hands on some more migraine medicine. (The 1:1's love when we come to see the pts because they get to go pee! They are really excited about it!!)
I told Tina I'd put her complaints in her chart - which I did - and examined her pupils, heart, lungs, abdomen, and checked for edema. This is what it looks like in her chart:
PE gen: well-appearing young female in NAD, AAOx3
HEENT: PERRL, sclera anicteric, mucus membranes intact
CV: RRR, no murmurs, rubs, gallops or thrills appreciated
Pulm: CTA [clear to auscultation]
Abd: + BS 4 quadrants, soft, ND, NT, no hsm [nondistended, nontender, no hepatosplenomegaly]
Ext: no c/c/e [cyanosis, clubbing or edema]
This is what you get if you are actually 100% physically healthy and waiting a week for transfer. I made my sad sorry-you-aren't-enjoying-your-stay look and waited for her to get out the rest of her morning angst and headed out to write my note.
I got out Ronald's chart next. Ronald is a 30-something black male who p/w epigastric pain and shaking of his hands. He usually drinks a 6-pack of beer/day but stopped around Monday, started shaking on Wednesday and presented to the ED on Thursday. (Ok folks, what's the treatment plan for acute pancreatitis?) When I saw him on Thursday he was not looking well, we had him on a banana bag (saline, thiamine, folate, multivitamin) but it was probably more withdrawal than his pancreas that was hurting him. I went in with Res. This morning he had only a little bit of pain, and was hungry. Res told him that if he felt ok to eat that we would start giving him food.
Ok so last night I decided to read up on pancreatitis because Dr. Attending told us that she would pimp us on it today. Treatment for pancreatitis should be NPO to give the pancreas a break, and generally unless its necrotizing it resolves on its own. Give morphine as needed, and in Ronald's case he gets benzos for his withdrawal - ativan and librium on a standing basis. When we left Ronald's room I asked as politely as I could if it would be ok for us to give him PO, or if we should keep giving his pancreas a break. Res said if his pancreatitis was still bad he wouldn't want to eat, and she put in the order for PO.
Third and my last patient of the morning was Ms. Helen. Ms. Helen is a 49 yo divorced mother of two who presented after injecting herself with 90 units of her son's insulin in a suicide attempt, which resulted in a seizure. Several hours later she was able to call 911 and get herself to the hospital. Today was her 3rd day here and she was looking well. I saved her for last because she is my favorite patient, she is so sweet and pleasant I wonder why anyone would ever want to hurt her, including herself.
I'm worried about Ms. Helen. I've been following her the few days that she's been here and while she brightens up my day and makes me feel good about myself, I'm worried that she's in some denial right now. Here is how the typical exchange goes:
J Ms. Helen? Good morning.
H (waking) Good morning dear! Look at that smiling face!
J How are you doing today?
H Oh I'm doing fine. I'm much better. But how are you doing?
J Well this morning is dragging a bit-- (wait, she is the patient.) Any pain today?
H Not really, my calves feel much better, they aren't as tight. What is your day like today? Long day?
J Well tomorrow we are on call . . .
H On a Saturday? My they work you so hard, don't they?
J It's a lot of work but I am really enjoying it. (Back to the patient, damn it!!) How is your tongue feeling today?
H I think it's healing, but it still hurts.
Ms. Helen's tongue hurts because she bit it pretty hard during her seizure. Her calves are tight because her muscles contracted so hard during her seizure that she had rhabdomyolysis. (What is the number 1 cause of rhabdo in the US?) When she came in, her CPK was elevated in the 3000s so as opposed to Tina, we are medically treating her, bolusing her with fluids to get it down, before she can be transferred to inpt.
Ms. Helen's physical exam was benign, except that I'm pretty sure I heard an S4 at the left sternal border. I don't know why she should have a gallop or how I could be the only one to exam her to actually hear it, but I note it in her chart anyway. I stay in her room talking to her (me desperately trying to keep the conversation on her) until it's time for rounds at 10.
Part II: Rounds, coming soon.
** Names have been changed, and while I usually try to refer to my patients by their last names I'm only using first names for added privacy.
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