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.
Saturday, September 15, 2007
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.
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