Look at Your Feet

I recently heard a physician compare practicing medicine to balancing on a tight rope.  If you look at your feet - concentrate on what's right in front of you - it's easy to fall.  But if you can find a point in the distance on which to focus - think about your long-term goals - then it's a lot easier to stay balanced.  I often feel that way when I'm working a crazy shift or just having a rough day - looking toward my future goals makes it easier to deal with the mundane or ridiculous.  Sometimes it really helps to think about being a pediatrician and having a office in the community where I can help patients and families.

But there are also times, where I want to "look at my feet" and embrace the fact that they are balanced - at least for right now.  There are some amazing moments that I don't want to miss because I'm too focused on my future.  Today, I did a circumcision on a baby not even 24 hours old on my own.  An attending supervised me, but I did the procedure independently.  It's quite possible, even likely, that I will never do a circumcision once I'm in my actual career.  I could have blown off the opportunity as useless to my future goals - but it was an incredible experience.  I did a procedure on my own after having watched only two and received glowing praise from the attending (she told me I should look into surgical specialties, to which I could only laugh).

Look at your feet sometimes - look at where you are, right now, and embrace it - because you may never be here again.

~~~~~

Attending: Where's the patient?
Resident: She's on the floor. (meaning in her room on the 3rd floor)
Attending: Well you should probably get her off the floor and into a bed.

~~~~~

While discussing a patient's parents who were especially frustrating because of their refusal to feed their baby, an intern asked if there could be some mental deficits in the parents.  To which, my resident replied, "Just remember, 50% of people are below average."

~~~~~

I went in to examine a five year old boy who was complaining of stomach pains.
Me: J, can you tell me what it feels like?
J: It feels wike I'm pwegnant.
Me: Oh yeah?
J: Yeah...Doug's in heewah.

~~~~~

A four year old boy had a bruise across one of his eyes.  Anytime a young child has bruises, we ask what happened as an informal screen for child abuse to see if the story matches the bruise.  I was not expecting the story I heard (from someone born in 2007):
Me: D, what happened to your eye?
D: I was playing with my brother.
Me: What were you playing?
D: World Trade Center.
Me: (thinking I must have misheard) What?
D: World Trade Center!
Me: And how do you play that?
D: You build towers and then you fly things into them so they fall down.

~~~~~

I thought I'd finish with one last joke about surgeons (told to me by my uncle, who happens to be a surgeon):

How many surgeons does it take to change a light bulb?

Only one.  They just hold the light bulb up and wait for the world to revolve around them.

~~~~~

Being a "Kid" and Working with Kids

My surgery rotation is now officially over and relief does not begin to describe my feelings.  I worked an average of around 70 hours/week and had one week where I worked 105 hours, including two 30 hour shifts.  Even if I loved surgery, those hours would be exhausting - but my disinterest for the field made the hours nearly unbearable.  I'm not one to complain, so I'll just reiterate that I'm glad the experience is over.

I try to not feed in to stereotypes, but certain stories may do just that (though I hesitate to take any blame when I'm merely telling actual events).  I want to clarify that I do not think ill of all surgeons, and I certainly appreciate what they do - I just happened to work with a group of particularly arrogant and egocentric surgeons.  Here are a few more stories I collected over my months of surgery to sum up what parts of it were like:

~~~~~

[A quick review of rankings in medicine, from most seniority/authority to least]
Chief of Staff
Attending Physician
Chief Resident
Senior Resident
Junior Resident
Intern
Everyone Else
Medical Students

~~~~~

Most (if not all) fields within the hospital have conferences referred to as "M&M" which stands for "Morbidity and Mortality" and is specific to their field.  The purpose of the meetings is meant to be a discussion of things that went wrong and how they can be prevented in the future.  When I was on the Internal Medicine service, the conferences covered occurrences such as giving an incorrect insulin dose or missing a diagnosis - with the intention of learning from complications and mistakes.  On the Surgery service, I was amused to realize that most of the M&M presentations were about mistakes that other physicians had made which the surgeons, in all of their wisdom, were able to correct.

~~~~~

When starting one of my surgery months, I attempted to make small talk with one of the chief residents to get to know him a little and make conversation.  I was promptly told to stop by his saying:
"The more questions you ask me, the more I'm going to find to complain about - so you should just stop!"

~~~~~

While talking with a patient about their medical history and trying to get a list of the medications the patient was taking, I was told: "I'm on a drug for memory too, but I don't remember what it's called."
Me: "Sir, I'm not sure that medication is working."

~~~~~

The med students' value on the team was clearly established when the junior resident called our intern and said: "Meet me in the emergency department...and bring the kids if you have to."

~~~~~

A 94 year old WWII vet who clearly wasn't used to not being in charge, was not happy about the intern trying to put a Foley catheter into his penis.  Suddenly, the trauma room was filled with screaming: "Hey!!! What are you doing?!  GET OUT OF THERE!"

~~~~~

Chief Resident: "Wait...how old are you?"
Me: "24"
CR: "You look 12"
Me: "I know"
CR: "Do you get that all the time?"
Me: "More than you can imagine..."
CR: "I'm just going to call you 'kid' from now on."
Me (sarcastically): "Awesome."

~~~~~

An attending who was apparently too used to examining the abdomen in describing a disagreement within the team: "There is distension among the forces!"  I believe he meant dissension.

~~~~~

One attending who was known for being unreasonable showed up for morning rounds two hours late one day and was absolutely furious that the nurses weren't in the patients' rooms waiting for him.
Attending (with expletives removed): "Why weren't you in the room?!"
Nurse: "Sir, we didn't know when you were coming."
Attending: "I don't care, you should have been waiting!"
Nurse (sarcastically): "My apologies...sir."

~~~~~

One trauma patient that came in was drunkenly belligerent and was cussing and screaming at all of the nurses and physicians.  She eventually left AMA because we wouldn't take her C-collar off until she was sober.  In the short amount of time that the patient was in the hospital, she was extremely disrespectful and rude to everyone who was attempting to take care of her.  She kept insisting that she needed to leave so that she could work her shift at a steak house.  One attending had a great idea: "We should all show up to the restaurant where she works and show her how it feels to be disrespected and annoyed at work!  We can scream and cuss about our orders being incorrect and demand to speak with her manager!"

~~~~~

Med students are frequently quizzed and drilled by those above us.  Quiz questions to med students have become known as "pimp questions".  I have no idea how the term originated, but any med student knows what "Did you get pimped today?" means, and it's not remotely close to what it would mean for much of society.  One morning on rounds, I was pimped on a question that I had no idea how to answer - and this is what happened:
Me: "I'm not sure what the answer is, but I'll look it up."
Attending (to the other med student on the team): "Do you know it?"
Med Student: "I'm sorry, I don't know either."
Attending (to the junior): "You?"
Junior Resident:  "I have no idea."
Chief Resident: "I can't believe you all don't know that...you have to know these things!  It's just ridiculous that you don't know the answer to that question."
Attending: "Why don't you tell them the answer."
Chief Resident: "Um...well...uh...I actually don't know."
Attending: "Then why the ____ were you giving them a hard time?!"

~~~~~

On Monday, I start my pediatrics rotation.  I'm really excited about these next few weeks because I truly think pediatrics is what I will do with my career.  And as my mom said once, "I bet you like peds because kids are the only ones who take you seriously since they don't realize how young you look!"

Learning How to Bite My Tongue

~~~~~

A 3 year old heard the surgeons say that when he started eating again he would be able to leave the hospital and go home.  His recorded intake improved immediately.  Several meals later, the nursing staff discovered that he still wasn't eating, but was merely stashing the food under his pillow.

I was quite impressed by his problem solving as a 3 year old and the fact that it took the adults around him several meals to figure it out.

~~~~~

Typically, patients' issues are summed up in a quick phrase on their chart that gives the physicians a quick idea of what's going on.  "MVA" for motor vehicle accident or "intestinal dysmotility" for example.  I couldn't help but laugh when I looked at a patient's file and saw, "ran over by an Amish buggy."  You don't see that everyday - though it was not the only buggy accident I saw in my few week rotation there.

~~~~~

I try to not endorse stereotypes, but one surgeon recently reinforced the negative views on surgeons when she showed up to a meeting with the team an hour late and promptly yelled at the rest of the team for not accomplishing things on time.

~~~~~

To capture some of the ridiculousness I have encountered as a medical student:
Surgeon: Med student, where's the tape? (Once again, we don't get names)
Me: I'd be happy to go find you some.
Surgeon: You don't have some with you?
Me: No, I'm sorry, I don't.
Surgeon: You should have some in your pocket in case I need it.
Me: I'm sorry.  I'll go get some.

Apparently, I should have multiple supplies in my pockets just in case someone asks for them.  If nothing else, surgery is teaching me how to bite my tongue.

~~~~~

And lastly, a quote from a TV show I was watching recently that sums up how this year has been:
"Treat me like an idiot...like I'm a medical student!"

~~~~~

Growing up?

You probably shouldn't be at a children's hospital if...

...you're 17 and telling us about your tattoos of your "baby momma" and your 3 year old son.

...you're 20 and we unintentionally walk in on you laying on top of your lesbian lover.

...you're 21 and came here because you have a baby, even though she didn't need treated.

...you're 19 and married...even if you do still live with mom.

...you're 21 and your tox screen comes back positive for opiates, marijuana and amphetamines.

(All true stories of recent encounters I've had)

This is a children's hospital...made for kids and childhood conditions. Never growing up doesn't qualify you as a childhood condition.

Things I've Learned & What I Want to Do:

Throughout my first rotation in internal medicine (and my first week of my surgery rotation), I learned a bit more about what I like and what I don't and how that affects what I'm interested in choosing for my future career.

1. I like teaching patients.  One of my favorite parts of working with patients is being able to answer their questions and teach them about aspects of their condition they don't understand.  I loved being the one patients could talk to about anything they wanted to know. One of the highlights of my rotation was sitting talking with a patient and his wife for an hour about a whole list of questions they had that no one had taken the time to answer.  I think teaching patients is something that can be part of any medical practice but can be incorporated even more in primary care because there is more time to talk about preventative medicine.
2. I don't like adults. I've mentioned it before, but the more experience I have, the more it confirms that caring for adults is not something I can see myself doing every day.  Many of their conditions are a a result of their own poor life decisions and non-compliance is the norm.  I also don't have any desire to manage diabetes and hypertension, which is a huge part of adult medicine.  Obviously, this is pushing me even more strongly into pediatrics.
3. I like caring for the whole patient.  I really enjoyed being able to look at all aspects of care for my patients when I was on a general medicine service.  It was frustrating for me when I was on heart failure because our team was only concerned with things relevant to cardiac issues.  That was amplified even more when I was on the infectious disease consult service and my team was mostly in charge of tweaking antibiotics.  I didn't like seeing aspects of care that should be addressed, but not having the ability to do so.  Wanting to care for patients as a whole makes primary care seem like a much better fit that being a specialist.
4. I need variety. I also don't like that as a specialist, you deal with that one aspect of care all day every day.  It took me about two days to be tired of heart failure management.  Infectious disease was a little more interesting to me, but I still wouldn't want to do only that.  This is yet another reason why I'm leaning towards primary care.
5. I want to be the patient's advocate.  When I was on the general medicine service, I enjoyed being the one who coordinated care between the different specialist teams and the one who was in charge of making sure everything that needed to be addressed was being managed.  As a primary care physician, this would be a big part of what I would be doing.
6. I can't do emergency medicine. During my first week in surgery, I responded to two traumas with the trauma surgery team and both of them broke my heart.  The first one was an eight week old baby who had multiple skull fractures from being abused by his parents.  Twenty minutes later, a fifteen year old boy was brought in who had tried to hang himself and if he survives will be brain dead.  Those two traumas showed me that there is no way I could do emergency medicine every day.  I couldn't deal with seeing that daily nor would I want to be desensitized to those kinds of tragedies.  Before this realization, emergency medicine was fairly high on my list of possibilities.
7. I'm not interested in surgery.  I already knew this, but even just a week in surgery has confirmed my suspicions.  I don't enjoy the hours, the type of work or the reduced interaction with patients.  Surgery was never really on my list of possibilities, but now I can officially mark it off.

With all that said, my old list has been updated to:

1. Peds
2. Genetics
3. Peds Heme/Onc
4. Family Medicine
5. Med/Peds

Colonoscopy: to look at your heart!

~~~~~

"NURSE!  NURSE!" I heard a patient screaming for a good ten minutes as I was sitting in the hall working on a computer.  "NURSE!  NURSE!!!"  I was beginning to wonder if something was seriously wrong with the patient and thinking about going in to see what was going on just as the nurse finally made it to the room:
"Yes, Mr. Johnson? What's wrong?!"
"Can I get a 7-up?"
"No."

~~~~~

As a med student, part of what I do is see the patients on my own then summarize everything that's going on and come up with a plan to present to my attending (the physician that oversees the team).  Typically on rounds, the med students give a 5 minute oral presentation on each patient which covers all the relevant details and presents what we think should be done next.  (Which is often promptly followed by multiple corrections and the team doing what they would have if we weren't there at all.)  One day on rounds however, I was interrupted before even getting through the patients name by the attending spelling out exactly what she would like done with the patient.  After she had dictated everything in her plan, she turned to me and said, "Oh...go ahead with your plan."  I quickly replied, "It was exactly what you just said." with just a hint of sarcasm.

~~~~~

One of my presentations on a patient ended by my saying, "At this point, we're just waiting to see what the EP team recommends after they see him."
Attending (in a condescending, "I can't believe you don't know this" tone): "No, they came on Friday.  I already got their recommendations"
Several minutes later after thoroughly discussing other aspects of the patient, the attending concludes by saying: "So we'll just wait and see what EP says before we move forward."
Another med student looked at me and whispered: "Isn't that what you said?"
Yes...yes it was.  Ten minutes ago.

~~~~~

While attempting to get a history from a patient who, to put it kindly, was not medically savvy, I asked what cardiac procedures had been done.
Patient: "A colonoscopy."
Me (thinking I must have heard incorrectly): "A what?"
Patient: "You know...a colonoscopy...where they go through your veins to look at your heart."
Me: "Ah...yes...a colonoscopy.  Ok."

I believe he meant a catheterization.

~~~~~

Simple Ohio?

~~~~~

One patient that my team saw weighed over 400 pounds and had numerous medical issues because of it.  He needed a heart transplant, but his weight and comorbities made him ineligible.  Our attending, trying to encourage him asked if he had ever considered bariatric surgery (As a side note, I find it humorous that spell checker is trying to correct bariatric to barbaric).
He replied: "But I don't eat that much!"
Attending: "With all due respect sir, you weigh over 400 pounds, you must be eating something."
Patient (quite seriously): "Not really...but I do drink a few liters of vodka every day."

~~~~~

Medical notes are often uninteresting, mostly informative and [hopefully] usually accurate, but one I saw lately had me quite perplexed.  I was reading a patient's history before I went to see them attempting to figure out what the story was before I went to see the patient and this is what I read:
Smoking history: 1/2 pack per day for 20 years, since age 15 (patient is 62)
Drinking history: 3 drinks per week, 1.5 ounces per week; drinks socially 1-2 times/month

~~~~~

My attending, while describing a patient that we theorized was mentally challenged: "Maybe he's just simple!"
Resident: "That simple?"
Attending: "Maybe he's just an Ohio guy."
Resident: "What, what?!"
Attending: "No...I think he's just really sweet."
Me: "I don't think I understand how you're using these terms..."

~~~~~

One patient was admitted because his ICD had shocked him ten times in 24 hours.  Having an electrical impulse jolt your body unexpectedly is life saving but can also be quite traumatic for the patients.  This particular patient was in heart failure and desperately needed a heart transplant.  Part of the work up for heart transplant is a colonoscopy - in part to be sure a heart doesn't go to a patient who has active cancer. Upon hearing that he would need a colonoscopy, the patient calmly stated:
"Man, I hope this thing doesn't shock me while something is up my butt...that would suck!"

~~~~~

One patient I saw had numerous issues including a history of Munchausen syndrome, bipolar disorder and panic attacks.  She was admitted for "fainting spells" that were seeming more and more factitious as we worked her up for medical causes.  The patient was also struggling with some bad constipation and hadn't had a bowel movement in several days.  At one point, I walked in and asked: "What's going on?" to which the husband replied, "She's full of sh**."  To this day, I'm still trying to figure out which issue the husband was describing.

~~~~~

AAA

I may be a nerd, but I think this is easily the coolest picture I have seen since I've started my rotations.  This is a 3D reconstruction of one of my patient's abdominal aortic aneurysm and abdominal blood vessels from a CT scan.  The fact that we can see to this detail something going on inside of a patient without having to open them up at all is incredible to me.  The ballooning out where the arrow is pointing shouldn't be there and is dilated because of a weakening of his vessel.  These aneurysms are at risk for rupturing and can be very serious and life threatening.  The faint red shapes above and beside the aneurysm are where his kidneys are, which you can see in the cartoon representation as well.

"Well, I guess she won't be a surgeon."

Well, the thing I have feared for a while happened last week.  I passed out in the hospital.  I became that med student.

I was assisting with a CVC placement (catheter placed into a major vein) and my job was to hold the pannus out of the way.  Pannus is the medical term for "huge fatty abdomen" which is always heavy and rarely easy to hold - but I had to hold it throughout the procedure.  And it was apparently a bit too much.  The procedure wasn't gross, or disturbing to me in any way - but something triggered my vasovagal response. After the procedure had been completed, but I was still holding the pannus until they could get the sterile bandage ready, I felt the room fading out.  I knew it was only a matter of time at that point and quickly said to the resident, "Can you take over for me?  I'm feeling a little lightheaded."  I was intending to sit down and wait it out, but the world went black.

I don't remember anything immediately after that but apparently the resident caught me just in time and eased me into a chair so I never actually fell.  I came to a little in the hall way, but I was still quite out of it because they couldn't lay me down.  I was somewhat mentally alert but everything was still black and I couldn't see anything.  I remember they checked my blood sugar (88 = not bad) and checked my blood pressure (75/50 = very low!) and then they finally were able to get me into a bed and I instantly felt much better.  Once I was able to rest for a bit, drink some juice and eat some crackers, I was back up doing my work (despite them telling me to go home).

All in all, it was slightly embarrassing, but it could have been much worse.  I didn't get hurt and they didn't call a code blue (which they're supposed to do if anyone falls).  I heard a few jokes in the following few days, but it was to be expected and I threw some out as well.  The resident gave me quite a glare the next time he was placing a CVC and I asked, "Need any help with the pannus?"  Later, when I was assisting with another procedure, he looked at me and asked, "You ate breakfast, right?"

Just as I was waking up that day, I heard a nurse sum it all up beautifully: "Well, I guess she won't be a surgeon."

Fake Doctoring

Well it's official, I'm 1/3 of a doctor. 

That is, if you measure it by the licensing exams. 

I've passed the first step of the boards - which means I'm allowed to keep being a fake doctor.  And it also means that I will be able to continue bringing you more stories from those adventures.

Code Assist!

Some more amusing stories from recent encounters:

~~~~~

Our attending referring to an elderly Italian patient: "Be nice to him, he might be in the mafia!"

~~~~~

On an intern's progress note: "Discharge to sniff."  I'm not sure if that means to smell the patient before discharge, but I'm pretty sure they meant to write "Discharge to SNF" which stands for Skilled Nursing Facility.

~~~~~

Me to a patient: Is your COPD worse than your baseline?
Pt: Oh yes, much worse!
Me: What makes you say it's worse?
Pt: Well, I know it's really bad when I can't hit a cig.  I mean...when I can't take a deep enough breath to even finish a cigarette - I know that my lungs aren't good.
Me (only slightly sarcastic): That sounds...terrible.

Note: The patient refused smoking cessation help and asked if she could take her oxygen tank outside to smoke.
No...no, you cannot.

~~~~~

A common occurrence in the hospital: The attending spoke very loudly and slowly to a Spanish-speaking patient who had an interpreter with them.  The patient isn't hard of hearing, or slow to comprehend...they just don't speak English.  Speaking slower or louder doesn't suddenly give them understanding.

~~~~~

An elderly patient was told that he may need to have back surgery and replied "I would rather die right now than have to go through that!"  Later on, when he realized that surgery was his only option for being able to walk again he said:
Pt: I have a really tough decision to make!
Me: What are you deciding between?
Pt: Well, I'm not sure what to do!  I either need to have the surgery so I can live in my home again, or I'm going to have to live with my daughter because I won't be able to live alone.
Me: What are your thoughts on that?
Pt: I'm honestly not sure if surgery or my daughter would be worse.

~~~~~

Occasionally over the hospital-wide speaker system, we hear a "Code Assist" called.  Those codes are called when someone who isn't a patient needs help.  Often, it means a patient's visitor or family member has fainted or fallen and needs assistance to be sure they aren't seriously hurt - but there were some amusing codes called recently.  When a code assist is called, several high level physicians have to respond and rush to the area...just imagine high ranking physicians rushing to these codes:

One Code Assist was called recently because someone walked in the main entrance doors and kindly asked the information desk where the ED was.  Taking that as a sign that the person must need serious help, the volunteer decided to push the code assist alert button rather that just direct them to the correct doors.  A team of 10 doctors came running, just to point someone in the right direction...

My favorite code assist call happened in the bathroom.  A woman, I'll call her Jane, was using the restroom when she realized that there wasn't any toilet paper in her stall.  Jane asked a woman in the next stall, Renee, if she could help get her some toilet paper.  Instead of simply handing the woman some toilet paper, Renee decides to walk out to the nearest information desk and say "There is a woman in the bathroom who needs help" and then walk away without further explanation.  Next time you ask for toilet paper, consider if you would like it delivered by 10 doctors.

~~~~~

We don't count.

Resident 1: Why do they have the med students work so much?
Resident 2: It's not as bad as residency.
Resident 1: Sometimes it's worse!  We get more days off!  Don't they have work hour restrictions?
Resident 2: I don't think so.  They don't need them.
Me: Why not?
Resident 2: Because your decisions don't count, so we don't care if you're tired.

Well...I'm glad we got that straightened out!

I don't like adults.

My night week ended up being slightly different than expected.  I was told to not go to lecture so I could have more time off, then also told to not go into work Thursday night because I had already worked enough nights in a row.  So the week wasn't quite as bad as it could have been, but I still worked 56 hours in 4 days.

My week also wasn't quite as amusing as my first week and thus I don't really have any stories that can rival last week's blog.  Although I do have some observations:

~~~~~

I don't like adults.  I really don't like adults - at least in the healthcare setting.  Chances are, if you're reading this - I like you and you're the exception to the rule - but I found adults very frustrating this week.  90% of the adults I admitted from the ED (Emergency Dept) had their health issues because they had done something to get themselves in that position.  Not only that, but they won't own up to the decisions they've made.  I'm not perfect - I've made unhealthy decisions (such as the massive quantity of chips I ate yesterday) and I've been non-compliant with medications...but I would not be shocked, or blame other people, if something happened as a consequence of those decisions.  A 70 something year old man who had smoked for 50 years asked me why I thought he had COPD.  A woman who refused to take her prescribed medications was shocked that her blood sugar was over 500 (normal is <100). A woman came in with "excruciating pain" but refused to take the recommended meds in the ED because she knew better than the doctors what would be the right meds for her.

All of that to say - I know it's only been two weeks, but I'm leaning even more towards pediatrics.  It really hit me when a woman came in to the ED and I was supposed to examine her and get her story but all I wanted to do was check out her 4 day old baby.

~~~~~

I also witnessed my first code blue this week, which is basically when someone's heart stops working.  The patient was brought back to life after a few shocks, but it's most likely only a matter of time until he wont be able to be revived.  It was a strange realization during the code knowing that I could be a few feet away from a patient that may die any second.  It was an interesting reminder that at any point I could be seeing someone die right in front of me - which isn't a side of medicine you can really prepare for.

~~~~~

I "have an intense face"

Next week I'm on night shift - which will be quite the adjustment!  I work Sunday night through Thursday night from 5pm-7am.  Five days in a row of 14 hour shifts will be tough, especially with trying to adjust my sleep schedule at the same time.  The worst will be Monday/Tuesday.  I have to work 5pm Monday night - 7am Tuesday morning.  Then I have just 5 hours off to drive home, eat, sleep, shower, and drive back.  Then I have a 5 hour lecture followed by another 14 hour shift.  So I basically work 14 hours, have 5 hours off, then work another 19 hours.  I'm not sure how I'm going to survive that one!

~~~~~

Here are some of my favorite quotes/stories from my first week:

~~~~~

On a radiology report I was reading: "Patient was short of breast and therefore laying flat was difficult for her."  It's tough for me to lie flat as well.

~~~~~

A transgender (M2F) and likely high patient gave me an interesting interview (as a note, I have no disrespect for the transgender population, this particular patient was just quite the character) :
Me: Do you identify as transgender?
He/She (imagine in the most stereotypical flamboyant male voice possible): Yes.
Me: Would you prefer to be referred to as "he" or "she"?
He/She: You know girl, I just don't even know!
Me: What do you identify as your sexual orientation?
(Still) He/She: You know girl, I guess homosexual.  But I love girls too.  I got a sister, and she's one of the coolest people I know.  I just love hanging out with girls too.  But I guess I'm gay.
Me: (Silence...trying to figure out what the answer was to my last question...)
He/She: (Patient hits the button that turns off the lights to the room) DID THE SUN JUST GO DOWN?!
Me: Um...Maybe!  (It's 8am...)

This patient's tox screen on admission was positive for cocaine, opiates and alcohol.  Also, the patient was dozing off in the middle of the conversation, sometimes mid-sentence...until the sun went down - then it was party time!

~~~~~

One of my colleagues had to deliver the news to a patient that her lab results came back positive for gonorrhea and chlamydia.  Before the doctor was even out of the room the patient was quickly calling her fling: "*#&% you!  You gave me chlamydia!"
I was down the hall and could hear the screaming as the doctor politely dismissed himself from the room.

~~~~~

Resident: Do you med students (we aren't important enough for names yet) know what field you want to go into?
MS 1: Maybe OB/Gyn.
Resident: I could see that.  What about you?
MS 2: Family Medicine!
Resident: I totally would have guessed that, it really suits you.  (Turns to me) What about you?
Me: You seem good at guessing - what do you think?
Resident:  Something intense.  Maybe surgery.
Me: Seriously? Why?
Resident: You have an intense face.  You should do something intense.
Me: What does that even mean?!
Resident: I don't know...but you should do something intense.
Me: I was thinking Peds actually.
Resident: No way - that doesn't suit you at all! (She's spent about two days with me).  You should do Med-Peds if you insist on Peds!
Me: We'll see.  But I'm still thinking Peds...even if it isn't intense.

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Officially a Med 3!

My first day as a clinician started today with getting up at 6am (after only a few hours of sleep), spilling coffee on my white coat, being given the wrong directions to the room to which I was supposed to report, and thus showing up a few minutes late to the correct room.  Later in the day I was given 20 minutes to eat lunch, drive to another hospital, and find the next place to which I needed to report.  The day ended with attempting to take a history from a patient who wanted nothing to do with me unless I could find her some tomato soup.

It's going to be a fantastic year.

No really, it's going to be a fantastic year.

As much as all of these little bumps today could have thrown me off, I can honestly say I enjoyed today.  Despite little sleep and feeling entirely incompetent the entire day (I don't even know how to turn my pager on - seriously, who still uses a pager?!), it marks the beginning of an incredible journey that I am eager to begin (and eager to finish).

My patient today, despite mainly being concerned with tomato soup, was my first real patient in the hospital.  And despite the patient's intense depression and lack of desire to do anything but lie in bed, I was able to get her to smile.  As cheesy and cliche as it sounds, that was enough for me.  A few weeks or months into this year, I may not be so easily encouraged - but I'm going to enjoy it while it lasts.  I need patients like her to remind me why I'm investing so much in this education.

I'm actually looking forward to seeing her tomorrow and trying to get another smile out of her.  I'll be doing well if all it takes is tomato soup to make my patients' days.



A side note on my rotations: As part of privacy laws, I have to be extremely careful in talking about any patients and their health issues.  Because of this, I'm not going to specify which of the many hospitals in the Columbus area I will be assigned to each month.  I also will often change certain details (dates, age, gender, etc) to make it impossible to identify the actual patient to which I am referring.  If I ever refer to a patient by name, it will never be their real name.  I may make up a name to help with story telling without revealing the patient's identity.  I also, to protect myself, will change the names of any staff/other medical personnel I talk about.  Not because it's illegal to mention them by name, but because it's stupid.

I hope to use this blog to tell some interesting and entertaining stories about some of the situations into which I will be thrown this year.  If I'm going to be stressed or humiliated, I figure you might as well be entertained.

Step 1: Check!

I took the first part of the boards on June 14th and am so relieved to be done!  I won't get my score back for a few weeks, but I am so enjoying having a few weeks off before my rotations start!

I'm doing a lot of relaxing and traveling in these few weeks off before starting my full-time rotation work in the hospitals on July 5th.

Dr. Death Dies

Dr. Kevorkian died at 83 on June 3.

I wonder if it was assisted.

Too much studying!

I haven't been updating much, because there isn't much worth blogging about going on.  I'm in the middle of studying for the boards, which I take on June 14.  The boards are a huge exam that covers the entire first two years of med school.  The full name for the exam is USMLE (US Medical Licensing Exam) Step 1.  There are three steps to the USMLE.  The first step is taken between the second and third years of medical school, the second step is taken during the fourth year of medical school and the third step is taken at the end of the first year of residency.

The first step is the hardest and the most important.  This exam is the single most important factor in determining what your options are for residency.  Other things matter, but the board score is the number that programs look at first to see if they even want to interview you.

Because this exam is so important, we are given several weeks off of classes to study full time for the exam.  I'm in the middle of that time now and basically study as many hours each day as I possibly can.

July 5th will be when I start rotations and will hopefully have some more blog-worthy things happening!

34 days until the boards!

Med 3 Schedule Switch

Turns out, I was able to trade rotations with someone and now I have the exact schedule I wanted!

1. Internal Medicine (July - Aug)
2. Surgery (Sept-Oct)
3. Pediatrics (Nov-Dec)
4. OB/Gyn (Jan-Feb)
5. Psych/Neuro (Mar-Apr)
6. Family Medicine (June-July)

Med 3 Schedule

I just received my rotation schedule for next year with rough dates during which they will occur:

1. Internal Medicine (July - Aug)
2. Surgery (Sept-Oct)
3. Pediatrics (Nov-Dec)
4. Family Medicine (Jan-Feb)
5. Psych/Neuro (Mar-Apr)
6. OB/Gyn (June-July)

For the most part, I got my top preferences.  I really wanted Peds third or fourth and I really wanted to start with IM.  Those two things were most important to me - so I'm excited I got those two things.  I'm happy that I'll get to do surgery second so that I can get it over with.  I was hoping to not end with OB/Gyn because it's a tough rotation and I wouldn't mind ending on a lighter note - but it's not a huge deal.  I also was hoping to have Fam Med in a warmer block because there is a chance I may have to drive up to an hour each day to an outside site and the fourth rotation is in Jan/Feb.  There's a chance I may find someone that has OB/Gyn fourth and Fam Med sixth that would like to switch - but those odds are slim and I'm not counting on it.  The up side to having OB/Gyn during the warm months is that it can have some strange hours and having to go there in the middle of the night won't be as bad with nicer weather.

Overall I'm happy with my schedule.  In a perfect world, all I would do is switch 4 and 6, so I didn't do too badly.  Ultimately, the schedule doesn't matter much - we all experience each field eventually! 

I'll be starting IM on July 5th!

Huge Step Forward

Two major things happened today that make this doctor thing seem a lot more real:

1.) I registered for a pager.  I won't get it until June, but to me having a pager is one of the symbols of the medical profession.  Signing up for a pager gave me the strange realization that before long I will truly be a part of a patient care team.  There will be people paging me to do various tasks and there will be times where I am needed...actually needed...for the care of a patient.  That idea is simultaneously exciting and terrifying.  Getting a pager also marks the beginning of the medical field's ability to reach me whenever anyone wants to.  I'm already not looking forward to those middle-of-the-night pages and on-call nights!

2.) I scheduled for Med 3.  I don't know my official schedule yet, since all we've done so far is state preferences - but it still made it very real that in a few short months I will be doing patient care full time.  Thinking about my schedule for next year is exciting, although there are several rotations that I am anticipating I will not enjoy.

The six rotations (eight weeks each) we have to do next year are:

• Pediatrics
• Internal Medicine
• Surgery
• Psychology/Neurology (4 weeks of each)
• Family Medicine/Elective (4 weeks of each)
• OB/Gyn

For various reasons, my ideal schedule would be this order: IM, Surgery, Peds, OB/Gyn, Psych/Neuro, Fam/Elec.  I will know at the end of April what my official schedule is.

IM, Surgery and OB/Gyn are said to be the hardest rotations, and I am most dreading Surgery and OB/Gyn because I have no interest in pursuing those fields and the rotations are difficult.  For all 6 rotations, current Med 3s have told us that the average day is 6am-6pm in the hospitals and that we are expected to study once we get home in the evenings for the final exam we have at the end of the rotation.  Next year will surely be a busy one, but I am looking forward to the patient interaction and all of the opportunities to learn more about medicine.

Nutrition Advice

A Blunt Approach

Career Choices

I noticed that exactly one year ago, I documented what I thought were my top specialty choices at that moment.  You can find that post here if you're curious.  Since it's been a year,  I thought I would take the opportunity to reflect and see what has changed.  My experience with the different fields has hardly changed (if at all), but my perceptions have changed a little and my idea of what is a good fit for me has been refined some.  The list of fields that I am not at all interested in hasn't changed at all.  My list of good possibilities has changed slightly, but mostly just in order of preference based on what I happen to be thinking at the moment (if you asked me next week, the order may change again).

Here was my list last year:
Good Possibilities: (roughly in order of most likely to least)

1. Med-Peds (combined internal medicine/pediatric training)
2. Peds
3. Emergency Medicine
4. Heme/Onc
5. Genetics
6. Family Medicine

And here would be my current order:

1. Peds
2. Med-Peds
3. Family Medicine
4. Genetics
5. Heme/Onc
6. Emergency Medicine

I fully expect this list to change again, but I find myself leaning more and more towards pediatrics.   I'm still trying to keep an open mind and just see what experiences come my way, but I think it's constructive to document along the way.

A Good Reminder

Recently, we had an assignment which involved interviewing a standardized patient (paid actor to aid in our training).  We were to obtain a complete medical history, a description of their chief complaint ("What brings you in today?"), do a focused physical exam (only the parts that we thought were relevant to their case) and try to come up with what we thought was the condition being described by the patient.  We were going to be graded not on if we got the diagnosis correct, but on how we talked to the patient and if we asked about and checked relevant details.

It would be easy to blow off these assignments as just another thing we have to do and to get through it as quickly as possible before moving on to our next project.  But it didn't feel like just another assignment to me.

My "patient" came in with a chief complaint of pain in her chest.  There are a hundred things that could cause that.  She was a young woman, which narrowed the likely possibilities.  Throughout the history taking, I picked up on several clues that directed my thinking towards what I thought was going on.  I strongly suspected a pulmonary embolism (PE) - which is when a main artery of the lung has become blocked by something traveling through the blood stream, often a blood clot.  PEs can easily be fatal, especially if not caught and treated quickly.

I knew this was a fake patient.  I knew that nothing would have changed whether I diagnosed her with a PE or a stubbed toe.  But it still felt good.  It felt good to know that I would have saved her life because I picked up on the clues.  Through talking with the patient for only ten minutes, I  was able to gather the necessary evidence and deduce what the problem was.  For the first time in months, I remembered very clearly why I am in medical school.

It wasn't a real patient, and clues will often not be so clearly presented to us in real practice, but I'm making progress towards truly being valuable to patients and the medical community - and that feels good.  I left that assignment walking a little lighter with a smile on my face, because I am reminded now that I get to do that the rest of my life.  It won't be every day, or maybe even every month, that I catch a potentially fatal but treatable condition, but I'm going through the lectures and the exams now so that I can catch them.  I have to sit in class now so that when I'm sitting in an exam room later, I can put the pieces together.  Every long lecture or seemingly pointless assignment will contribute to my ability to better serve my patients in the future, and it's good to be reminded of that.

Medical Management

The five days of five meds experiment is over, and I surprisingly did very well.  I didn't end up missing a single dose of any med.  I am certain though that I would not have such a high compliance if I had to continue the project for more than five days.

What made taking the medications easier was that I wrote out a schedule as soon as I got home.  I knew that I had to take one pill at 8am, three at 10am with breakfast, two at 6pm with dinner, and one at 10pm.  Having that schedule established allowed me to not have to keep track of all of the specifics of the medications (12hrs apart, with food, without food, etc)

I found that the hardest medication for me to take was one that I had to take in the morning on an empty stomach.  The reason why it was difficult was not an issue of remembering, but rather I just didn't want to take it because it interfered with my established routine.  I'm in the habit of going for a caffeinated beverage as soon as I get up (we all have our vices), and I had to wait at least thirty minutes after taking the med before I could eat or drink anything.  If I woke up especially tired, I seriously contemplated just skipping the medication.  I held in there, partly because I knew I had to report how I did and partly because I knew it was only for five days.

I also think that it was easier to take the medications than it normally would be because the project happened to be just before an exam, which meant that I was at my desk studying much more than normal and was out doing things much less than normal.  Had I been going out to meetings, dinners and other events more, it would have been much more difficult to stick to my medication schedule.

Lessons learned:

• Discuss with patients if a medication schedule may conflict with a routine they have and talk with them about ways to make compliance easier
• Be sure patients fully understand how to take their medications and help them with easier ways of remembering, such as writing out a schedule.
• Help patients figure out ways to work the medications into their routine, rather than expecting them to miss out on their routine because of their medications.
• Most important: make sure patients understand the instructions that come with the medications.  If they don't understand how to take the medications, the treatment cannot be successful.

Overall, while inconvenient at times, I do think this exercise was extremely helpful in giving us more of the patients' perspective.  I have a much greater understanding of how difficult it can be for patients who are taking multiple medications.

Mystifying Medications

I’m a Type 2 diabetic with hypothyroidism, high cholesterol, heart problems and inflammation requiring steroid treatment.

At least, I have to act as though I am and take the medications appropriate for these conditions for the next few days. We recently were assigned a project for class that aims to try and help us understand how difficult it can be for patients to take multiple medications correctly when they all have different instructions.

 

We were given five different medications (placebo versions labeled as real medications) to take for these conditions and each one had very different instructions. Some have to be taken with meals, others not. Some need to be taken twice a day while others are only once a day. Most are only one pill a day, but one has a different number of pills for each day. Several of the medications have to be taken in the morning while others have to be taken at night.

Here's a summary of the medications and instructions (none of these are real medications):

• Glucozide (for blood sugar): 1 capsule twice daily with meals
• Cardiolol (heart): 1 capsule twice daily, roughly 12 hours apart
• Prednitab (steroid): 4 capsules on day 1, 3 capsules on day 2, 2 capsules on day 3, 1 capsule on day 4; all in the morning with food
• Lipistatin (cholesterol): 1 capsule every evening
• Thinsroid (thyroid): 1 capsule every morning on an empty stomach (at least 30mins before a meal)

I'm sure you can see how challenging it will be at times to correctly take all of these medications every day. In real life, I have two medications that I take every day that don't have any specific instructions and I have a hard time even remembering those - let alone adding the new five medications. I'll post again once I am done with this project as a report of how I did with taking all of the medications correctly.

The real value of this project, in my opinion, will be the reminder of what some patients have to go through just to take their medications correctly and why it is so frequent that medications aren't taken correctly or at all.  In all reality, if I truly had all of those health problems, I would be taking a lot more than five medications. Many patients are on 15+ medications, all with different requirements for how they should be taken. As future doctors, it's so important that we understand the difficulties patients can go through and not be quick to judge them for not following instructions perfectly. Many doctors don't even explain to patients just how to take their medications.

In modern medicine, with all of the incredible advancements we have, nothing will be treated effectively if the method of treatment is not understood and can't be followed. Simply taking a few extra minutes to be sure patients can follow medication instructions could make a world of difference in their treatment and effective care.

We're studying the GI system...

Excuse the language, but this picture is just so appropriate for the block that we're in. :)

A sign of [dis]respect?

I know I haven’t written in a long time, but I often don’t have any new updates that I feel are worth writing about since most of my days aren’t any different from the day before. I should have more interesting stories and thoughts once I deal with patients more regularly.

An observation from today…

While walking through the medical center courtyard this afternoon, I noticed that the flags were at half mast. I honestly have no idea why the flags have been lowered specifically, but it struck me as odd and quite disrespectful. I recognize that often businesses will lower their flags as a sign of respect for someone that has passed, but it really bothered me that a hospital had done it. While most would probably view flags at half mast as honoring or respecting whomever it was intended for, I felt as though it was incredibly disrespectful to the families that had recently lost a loved one at the hospital. Lowering the flag for one person and not others implies superiority of that person’s life over others’ lives or more implicit value in one life over another. People die every day in hospitals, and the flag is not normally at half mast. Do those lives not also deserve respect and honor? I think flags at hospitals should either be permanently lowered or never lowered. Lowering the flag based on the perceived value or celebrity of a particular loss over others seems quite unjust and unfit for a hospital to do.

Perhaps I was thinking too much into a simple attempted sign of respect, or perhaps some people weren’t thinking enough into it.