December 24, 2007

Merry Chrismakwanzanukkah

Driving by the OHSU emergency room today, I thought back to three years ago, when I shadowed an OHSU ER doc on Christmas Eve. Being in a hospital during the holidays is a very unique and interesting experience. The hospital staff seems to work together a little better, and those who have to give up their holidays with their families to roam the wards seem to understand the sacrifices each other had to make in order to care for patients. There's a certain soldier mentality to it, and the bond between staff seems to be a little more palpable around Christmas time. And inevitably, the holidays are some of the busiest days of the year.

During my shadowing experience, I saw a gunshot victim do into v-fib (ventricular fibrillation), bleed out and die on the table. I saw the doc have to tell a diabetic that they would have to amputate his legs. I saw countless people come in trying to score their pill of choice. Difficult experiences in medicine are always difficult, but seem to hit a little closer to home in the holidays. It's not coincidence that suicide rate is at its highest around Christmas. Christmas, for all its warm and fuzzy intentions, can often be an isolating time for those who don't have the family and friends to share it with that most of us do. Tragedy on Christmas has the unfortunate effect of bringing us back to reality, and a hospital around Christmas time is full of tragedy. To put a bit of an exclamation on the sights I saw, I left OHSU that Christmas eve three years ago and went directly to another hospital, where a friend's mother was in intensive care after having a stroke behind the wheel of her car. No one thinks they would ever have to spend Christmas in a hospital - until they do.

Be safe this year everyone. Take a moment and really appreciate the blessings you have. And have a merry Christmas!

December 16, 2007

Dear Journal,

Christmas break. A time to sleep, I mean, reflect.

As I write this, I started med school exactly 100 days ago. It's really hard to quantify the change I've undergone in that time, but its really fascinating for me to think about it. I've been challenged more then I've ever been before: academically, socially, emotionally. I've developed an incredible capacity to absorb information, beyond what I ever thought was physically possible. I've witnessed medical miracles, children given life who in the past would have left behind grieving parents and a book full of "what if's." I've witnessed tragedy, people who I was talking to one moment and who slipped into death moments later as their heart quivered inside their chest. I've learned the power of the scalpel to flesh, the power of a pill. I've learned the subtlety of disease heard through a stethoscope, the devastating effects of a cancer that spreads to every reach of the body. I've experienced the thrill of putting someone back together with a needle and thread. I've learned I currently suck at putting someone back together with needle and thread.

I recently went back and read my med school application, skimming through all the points I spilled to schools about "why I want be a doctor" and "what I know about the medical field." It was amazing how much I was wrong about things. Medicine is definitely one of those fields that is difficult to "get" until you are in it. I remember back in August coming into school being afraid that once I learned what being a physician is all about that I would find it wasn't really for me. I think its a danger that we all face entering medical school, and there are stories of people who find out once they're in that they don't really want to be doctors.

Luckily, I've found myself more committed then ever to my career choice. Medicine is highly romanticized in our society and on our televisions, and I'm glad that after that glossy veneer was taken off that I still like what I see. But my visions and thoughts of who I will be when I finally move to practice on my own have definitely been shaped and shifted by the past 100 days. I think most of us come to realize we will not be those shining saviors riding into work every day curing disease with the touch of our stethoscopes. Real daily medicine is a lot more mundane then that. But there's still a thrill in it (and there still is the thrill of that truly miraculous cure every once and a while).

They say the changes you undergo in medical school only get swifter the longer you are in it. If I've experienced this much in only 100 days, I cannot even begin to predict what the next 100 (or 1000, yes I will sadly be in school that long) will be like. The time has been flying by, but the next 3.5 years still seems like a truly insurmountable climb. Luckily, I've learned that I can function much better if I break things down to much smaller pieces to chew on. The next week ain't bad and the next day is definitely do-able.

I think above all, I'm looking forward to continually gaining more skills in what I do. While being the wide-eyed new med student who looks at everything with wonder has been fun, I'm truly in my element in the realm of competency. It makes me frustrated to get pimped in clinic or the OR and to not know the answer. But I know I have to have patience, because such a large breadth of knowledge and such a radical transformation of my person can't come overnight.

Here's to the next 100 days.

December 6, 2007

Jiffy Lube Hospital.

My car has a bad belt at the moment.

Which means it makes this awesome squeaking sound when the engine idles at a stop light.
(Which gets me plenty of looks from the ladies when driving downtown - 'Yeah baby, wassup? I'm ass-load in debt and my car is broken. But I'm gonna be a doctor! Wanna hop in?')

Since my life as a med student is a combination of incredible busy-ness and incredible laziness (for example, today I went to four straight hours of lecture, a presentation from a cardiothoracic surgeon, came home, passed out face down in my bed with my clothes and coat still on cause I felt like it, drooled on my pillow, woke up 20 minutes later in said drool, went to the gym, studied for four hours, and am now home effectively wasting my evening), I haven't been able to get my car in to get the sound checked out. But while idling at an unusually long stop light today and listening to the musical tones coming from under my car's hood, I had an incredible flash of insight.

Mechanics = Doctors. Or Doctors = Mechanics. Whatever.

The key is that there is an eerie amount of similarity between how a mechanic tackles a problem with a car and a doctor tackles a problem with you. Being the massive nerd that I am (contrary to my reputation), I just had to take the analogy further. So without further ado, here's the SOAP note for my car.

For those of you not in the know, a SOAP note stands for subjective, objective, assessment, plan - it's a specific method of writing notes in a patient chart used in health care to track patient history, progress, and future planning. There are specific sections to be covered in a specific order with a specific type of language - its one of those "medicine things" you never knew about until you get on the wards and realize you don't know jack. I'll break this one down for y'all.

ID/CC (Identifying Information/Chief Complaint): Patient is a black '00 Nissan Sentra XE Sedan who presents with an irregular squeaking sound deep to the hood which began unexpectedly three weeks ago. Patient reports squeaking as high pitched and inconsistent and occurs when engine is idle but ceases when engages in acceleration. Patient has not noted any worsening of squeaking since it began. Patient is concerned and annoyed by squeaking but has reported no other more significant symptoms.

PMH (Past Medical History): Patient reports no serious mechanical work done prior to the initiation of squeaking. Patient has no history of serious accidents. Patient has had routine maintenance performed at appropriate times throughout lifetime.

FamHx (Family History): '00 Nissan Sentra Sedans have a history of surge and hesitation, engine clatter, and transmission failure. Patient believes both parents exhibited symptoms of engine starter squeal and 5th gear popout.

SocHx (Social History): Patient reports aggressive but not reckless driving style. Frequently takes corners at above average speed. Does not drive while intoxicated. Undergoes frequent oil changes.

ROS (Review of Systems): No reported decrease in power of acceleration or performance in day to day driving.

Meds (Medications): Patient reports usage of regular unleaded gasoline.

Vitals: Engine idles @ 750rpm. Gas mileage 24mpg. Radiator temp 170 deg. F

Physical Exam: Car appears clean and functioning well. Mild stratching and denting of fender observed. No abnormal smell noted from engine. Consistent shrill squeak emanating from drive belt. Sound ceases upon depression of accelerator.

Labs: Couldn't think of a good analogy for a blood panel or CT scan. So sue me, its almost christmas break.

Patient is a black '00 Nissan Sentra XE Sedan who presents with an irregular squeaking sound deep to the hood.

For the problem of the engine-focused shrill sound, the likely cause is misalignment of the drive belt. The following are recommended:
-Further tests performed on engine performance to rule out deeper issues.
-Replacement of drive belt.
-Further followup for reckless driving habits.

So there you have it, a SOAP note. These things are the bane of the medical students existence, making for long tedious hours of paperwork as we learn how to effectively write one, but to tie my analogy full circle, I'm sure mechanics would go through the exact same sequence when a car is brought in for service. They ask the customer what the problem with the car seems to be (chief complaint), whether the car has had any serious problems before (past medical history). They begin service with an idea of common problems for that make and model of car (past family history). They ask the customer a few specific questions about the nature of the problem (review of systems). They examine the car and run appropriate tests to find the problem (physical exam and labs). They then draw up what the problem is and what they need to do to fix it (assessment and plan).

So there ya go. Your doctor tackles your abdominal pain the same way your mechanic tackles your RAV4's windshield wiper problem.