December 26, 2009

Flying Solo

Few things represent the hierarchical and tradition-seeped natures of medicine better than the operating room. As many med students will attest, half of the battle of the general surgery rotation isn't learning the post-operative management of surgical patients or how to properly manage a wound infection - it's learning the ebb and flow of the operating room. Tales abound which serve to strike fear and trepidation into subsequent generations of medical students of students being yelled at for touching something, looking at something, breathing improperly, blinking improperly, etc, etc. There's a procedure and tradition for every minute detail of the choreography of the OR, and you are expected to know it all before you learn it all, which contributes to awkward or embarrassing moments aplenty for medical students as they rotate through. I remember when I got yelled at while participating in a patient transfer off the operating table. I was the one pulling the majority of the weight on the rollerboard, and assumed it was my responsibility to do the countdown. 3... 2... 1... I get glares. I'm told to step away from the patient and not touch anything anymore. Turns out it's always Anesthesia which does the countdown, which is logical as they are overseeing/moving the airway, everything that happens in the OR is logical, but how in the hell was I supposed to know that beforehand? Such is life sometimes for a medical student in the OR - expected to know these things, before anyone tells them. In my own limited time in the OR, I have collected a small bundle of mortifying anecdotes. The time I almost desterilized the entire instrument table with a sneeze, the time I put the SCDs on upside down, the time I almost face-planted into the operative field when I slipped on some sigmoidoscope-associated KY jelly which had dribbled onto the floor... the list goes on.

But this post isn't about embarrassment; it's about hierarchy. When standing around the surgical field, there's also a rigid structure to where one must place one's feet. Traditionally, to the upper right of the patient, by the patient's right armpit, stands the lead surgeon. The lead surgeon is, by virtue of the position, the individual in charge of directing and performing the majority of the operation. To the left of the lead surgeon stands the scrub nurse or scrub tech, whose job is to, among other things, maintain sterile technique during the operation, pass instruments to surgeon during procedure, and help perform counts of surgical instruments throughout the procedure. To the upper left of the patient resides the individual providing first assist to the operation - who, among other things, uses the bovie to cut vessels and tissues at the lead surgeon's discretion, helps provide traction to tissue planes to aid in dissection, etc. And to the right of the first assist lies the domain of the medical student: the position of second assist. Here one typically aids in the operation by holding retractors to open the operative view, use suction to remove smoke, fluid, and blood from the operative plane, and tightly covet the Mayo scissors that one uses to cut suture ties. But with the myriad of surgeries and surgical approaches out there, there's also a wide variety of places where the surgeon and assistants stand to get the best exposure into the surgical field. And just likes plays on a football field, its up to the medical student to learn where to proverbially 'line up' for the snap. In an academic institution like my own base of operations, typically a resident provides first assist during the operation and the medical student stands beside as second assist for the operation. But during chance opportunities, such as when the resident is taking the lead on a case, med students are given the opportunity to run first assist, which is infinitely more fun for obvious reasons - namely, being able to more actively participate in the case. Rarely, a med student is offered to take the lead on simple cases (appendectomies, cholecystectomies, etc), which is always something worthy of writing home about, no matter how mundane the case may be for everyone else in the OR.

So a couple weeks ago I was spending a day in the OR with the ENT surgeon who I'm doing research with and a third year resident. We were powering through several of the half dozen cases on the docket for the day and next up on the case list was a simple tonsillectomy. The resident gets called down to the ED for a consult, and suddenly the attending turns to me and says:

"Want to take a whack at it?"

The third year of med school is a lot like the game of golf. All too often, you find yourself feeling incompetent, frustrated, disheartened, or some combination of the three. As your shot out of the shrub grass careens off the tree and lands in the water hazard you didn't take into account, you begin to ask yourself why you even play this stupid game to begin with. But a handful of times during a round, the balls rises gracefully into the air and plops, like it should, down onto the green within spitting distance of that birdie. And before you know it, you're paying another set of green fees and are back for more. Likewise, third year is full of foibles and f*ckups, sometimes asking yourself why you're doing this for the rest of your life. But every once and a while, you get to see or do something incredibly cool that reminds you why you're in it in the first place. And you come back for more.

Well this moment was my proverbial 240 yard approach shot plopped down 6 inches from the pin. The first time I get to take the lead during an operation. I step into position above the patient's head and gaze down at the base of the mouth. Just as I get bovie in hand, the attending laughs and says: "Don't worry... the first tonsillectomy I ever scrubbed on, the patient lost 1800ml of blood. The bar's set pretty low." Great. My resting tremor kicks up a couple notches.

But before I know it, we're off. I go in alongside the anterior tonsillar pillar, find the capsule, and before I know it, the procedure is over. Less nervous than I thought I'd be, but still trying to contain the 8 year old inside of me jumping off the walls going "WOW! That was COOL! Let's do it AGAIN! WHEEEE!"

Yup, back for more.

December 4, 2009

Respect Mah Authoritah

Wow, has it really been a month since I've posted? Apologies, my loyal reader(s) (hi mom!). I successfully survived my family medicine clerkship and sat through long hours of lecture during our "continuity curriculum" week (sidenote: how in the hell did I ever survive the first two years of medical school? I can barely sit and listen to a presentation for an hour now; I can't believe I used to do it for 4-8 hours straight every day).

Which brings me to my current location within the lands of an "Elective Block". Unlike some of my classmates who decided to do something clinical with that time, I decided to pursue a research elective, which I have concluded (as I sit in Starbucks and sip on my delicious holiday drink) was quite possibly the most awesome decision I've made this year.

The original plan was to have one study I was going to pound out in this 4-6 week period. Well, that 1 study turned into 2, and the 2 turned into 3 (well, more 2 1/2) and suddenly I am growing research protocols out of my ears and dreaming of HIPAA waivers of authorization. Yet despite all the madness, the simple fact that I get to set my own schedule has been incredibly refreshing. No sitting around in the afternoons on the wards bored out of my mind, no scut work, no asking permission to leave, no early mornings unless I am feeling particularly motivated. Ahhhhhh.

There is one thing that has been particularly maddening though; it's $%#@$%ing impossible to get anyone to do something for you if you're "only" a "medical student." It's the sad reality of the authority purgatory we reside in. On the wards, we can make treatment recommendations but can't prescribe medications. We can place orders but they have to be co-signed. Our notes are part of the medical record but residents must write separate notes for billing purposes. Because there is so little we can actually accomplish independently, we exist in this strange limbo where we can do a lot but there's very little we can actually "do." So it's understandable that there tends to be this dismissive attitude towards med students in the hospital, and I'm cool with that. But the reverse is also true - it often seems impossible to get anyone to do anything for you as a med student. On the wards, I've learned to stop signing my pages with "MS3" because if I do it'll be over an hour until I get a call back. I always go back to a moment on my psych rotation when one of my fellow students on the team slammed down the phone and yelled "Do they REALLY think its only the med student who wants this CT? Just for sh*ts and giggles?!? I'm CALLING because my ATTENDING wants the damn CT scan! RESPECT MAH AUTHORITAH!"
Yup, been there before.

Well, I've found that the research realm is not exempt from this phenomenon. Every email I send needs at least one follow-up before I get an answer. Every voicemail I leave requires at least one call-back before I get a reply. Being that I have precious few weeks where I can devote all my focus and time to this, I'm trying to get things done in an expedient manner, but too often it's like trying to work in quicksand where every action requires twice the normal effort. It's almost a daily occurrence where I want to have a cow and just yell "I'm CALLING because my PI wants the damn form signed!"

So, if there is anyone from the IRB reading this: Please. If a medical student is asking for help in getting something done, try to help the first time. We are not rogue anarchists set loose in the hospital to do what we want all willy nilly. If we're trying to get something done, there's typically a damn good reason why we are.

Now, back to my delicious holiday drink.

November 10, 2009

Snap, Crackle, Pop.

One of the difficult things about learning the art of the physical exam early in medical school is learning to differentiate pathology from normal. I remember when we first were instructed on the lung exam. We learned about these ambiguous terms... rales, rhonchi, egophony, stridor, tactile fremitus. I learned that you could have crackles in your lungs, and set about listening to the lungs on all my patients very closely. And I discovered a funny thing. Vesicular (aka normal) breath sounds can sound kinda-crackley if you listen close enough. All my patients started having crackles. I asked a doc I was working with one day "What do crackles sound like? Because it sounds to me like all my damn patients have crackles."

Eventually, I had a patient with real crackles, and like anything else with the physical exam, once you listen and touch enough normal patients the pathology begins to jump out at you. But this story isn't about that patient. It's about a patient I saw earlier this week, a 65 year old man with chronic kidney disease and congestive heart failure who presented with shortness of breath. He was actually my first patient I've seen with 3+ pitting edema, I damn near lost the entirety of my index finger into his left shin. But this story is about crackles, and I noticed a certain quality to his voice as I was talking to him in the exam room. No hoarseness or changes in phonation. But it sounded like someone had just poured themselves a bowl of rice krispies and set it in the corner. The snap, crackle, pop became more audible with each labored breath he took. For some reason, the moment brought me back to my early days of listening to the lungs, waiting for total silence and listening intently, hoping to catch a crackle or two in passing. And here I had a patient sitting in front of me with so much fluid brimming out of his lungs that I didn't even have to place a stethoscope on him to hear the crackles.

Sadly, in this economy, I'm not sure Kelloggs is looking for any new spokespersons anytime soon.

November 8, 2009

Coin Flip

So I was in clinic the other day, and the next two patients on the schedule looked like this:

10:45am - 21 yo male - abdominal pain
11:00am - 28 yo female - abdominal pain

Hrmmm... which one of these is the appendicitis? The doc I'm working with decides to leave it up to a coin flip on which one I see and which one he sees. Heads, I get the 21 yo dude. Tails, the 28 yo dudette.

Heads.

Cool, 21 year old guy with new onset abdominal pain is about 'classic' for appendicitis as you get. I knock, enter the room, and the exchange does something like this (abridged for everyone's sake):
Nice to meet you, Mr. Abdominal Pain Dude, tell me what's going on.
"My stomach's hurting."
How long has it been hurting?
"Oh a while."
A while as in several days? Several weeks? Months?
"It started at 9 pm last Tuesday, I was sitting on the couch eating french fries and watching Biggest Loser."

...I could see in a hurry that this conversation was hurtling out of control into the "awkward patient encounters" category...

Can you point to where it hurts?
*points to RUQ*
Does it hurt anywhere else?
"My back hurts all the time, and spine pain. And my jaw has been hurting recently. Is that related? I also have nerve sensitivity, like if you touch me here, it hurts. See? That hurts. So don't touch me."
Any nausea or vomiting?
"Well I just throw up sometimes. So I don't know."
Hrmmm, interesting. Have you thrown up since this pain started?
"Oh yeah. In fact, I think I could throw up on your face right now."
Any change in your stool? Diarrhea or constipation?
"I always have diarrhea."
Also interesting. Any other symptoms?

...I see the patient take a deep breath in preparation to respond. This is not a good sign...

"My neck hurts, and my hips hurt when I walk. Is that related? And can I get injections today? My anxiety is really bad recently and I'm out of xanax, can I get a refill? My therapist says I need a refill. I'm also out of my vicodin. I've had a fever of 98.9 all week, and I feel really sweaty. I lost weight but then gained it back. I have to get up to pee sometimes at night but I think thats all the water I drink right before bed. My grandpa had colon cancer... oh my god is this colon cancer? I'm also pretty sure I have fibromyalgia. But that doesn't cause stomach pain, right? Could this be herpes? I'm pretty sure I have herpes. I've been tested 6 times and they were all negative but could this be it? I read on google once that herpes can attack your liver. But I'm pretty sure this is gallstones. Can I get them taken out?"

Long story short, I had no clue what to say after that, and felt that asking too many questions more would just further convolute the picture. Physical exam (yes, he ended up letting me touch him) was very benign, with maybe some very mild tenderness to palpation in the RUQ. We ordered up a chem10 (because, hey, he was right, herpesvirus can cause a fulminant hepatitis, despite the fact that he was not bright yellow) which showed a mild bump in alk phos and total bili. RUQ ultrasound found some very small gallstones. Whether they were the etiology of his abdominal pain or an incidental finding, who knows. He left with a GI referral. But no xanax refill.

Oh, and the 28 yo woman at 11:00 ended up having classic appendicitis.

October 28, 2009

Third Year and Dog Poop

It's well established in Medical Lore that the third year of medical school is the most taxing of the four. Over the past 4 months, I found myself doubting that assertion. Sure, the hours of third year are substantially longer and the clinical years require a more concerted effort to "bring it" every day, but I found myself having so much fun and time was passing so quickly that the days did not necessarily feel more "difficult."

Then I hit The Wall.

It hits your subtly. The fatigue from the chronic sleep deprivation becomes more pervasive. Your physiologic response to that third cup of coffee becomes less marked. The days drag on longer than you're used to. I was walking downtown the other morning, and unknowingly stepped in a pile of dog poop. I went the majority of my day ignorant to the fact that it was stuck to the bottom of my shoe until later in the day when I caught a firm whiff of it while charting at my station. Burn out is a lot like dog poop. It gets stuck to your shoe, lingers with you the whole day, and before your know it its stinking up your living room. When you finally smell it, its quite unpleasant.

So the days feel a lot more "difficult" lately. I know I'm burnt out, and just like the smell of dog poop, the sensation is quite unpleasant. Feeling tired all the time, feeling like you are just trying to survive your days, finding yourself feigning interest - it is not the ideal way one hopes to spend their days. And unlike the preclinical years, you are not afforded the luxury of being able to take a couple days or a weekend off to recharge your batteries. The alarm is going to go off at 5 AM tomorrow, rounds are going to start at 6:30, your first patient is going to show up in clinic at 8, your notes need to get done, you need to read up on your patients, you need to take that call night, whether you like it or not. That's the true challenge of third year and clinical medicine in general. Your patient's illnesses do not know nor care whether you are having a good day, a bad day; whether you're tired, or sick; whether you're rearing for a new day, or working for the weekend. Your responsibilities do not change with the color of your mood ring. Fatigue breeds complacency and apathy, both of which can be very dangerous, and the real difficulty in third year is learning how to suck it up and be at your best, even if you may not feel at your best.

Luckily, I have 2 1/2 weeks left on this rotation, then a week in the classroom and a 4 week block of research. The halfway point of third year. And a good time to wash off some dog poop.

October 20, 2009

Marty and Me

One of the most overused cliches in medicine is the oft referenced: "When you hear hoofbeats, think horses, not zebras."

It's a valid reasoning in which to guide one's thought processes. After all, common things are common, uncommon things... aren't. But part of the responsibility of a physician also is to provide comfort and reassurance. It's our job to think "worst case scenario," to work up patients for those conditions, and provide reassurance when evidence is sufficient to quell our suspicions. Another common phrase in medicine is "until proven otherwise." Vaginal bleeding in a postmenopausal woman is cancer until proven otherwise. Acute onset of dyspnea or hypoxemia is a pulmonary embolism until proven otherwise. Severe epistaxis in an adolescent is a nasopharyngeal angiofibroma until proven otherwise. I recently had two patient who elucidated just how true this axiom can be.

A 62 year old woman presented with lateral chest pain of two weeks duration. On physical exam, her pain seemed very musculoskeletal in nature. Pain to palpation, pain on deep inspiration and with sneezing/cough, etc. The horse in this situation is a simple intercostal muscle strain. Regardless, we ordered a chest xray which showed ambiguous opacification of her right lower lung. It just didn't quite add up with the lack of any pulmonary symptoms. So, congresspersons and escalating health costs be damned, we decided we couldn't quite be comfortable with just writing things off, and sent the patient off with a referral for a CT scan and instructions for prn ibuprofen and heat. We saw her back today. The CT scan showed findings pathognomonic for lung cancer. Turns out, her pain was musculoskeletal in nature, as the cancer had begun to invade into her 8th rib. It had also spread to her spine. Zebra. Ironically, the patient returned to say that the heat and ibuprofen had really helped with the pain. If it wasn't for the CT, she would have been sent on her way with the belief that it was all just an intercostal muscle strain, while the cancer continued to grow in her chest.

A 22 year old woman presents with a painful unilateral cervical lymphadenopathy which had been present for 1 month. The horse in this situation is some form of infectious etiology: mononucleosis, cat-scratch fever, occasionally HIV (though this didn't jive with her history). She had been to several urgent care centers, and, going with horses instead of zebras, prescribed two antibiotic regimens, with no improvement of her symptoms. There was still a high likelihood her neck mass was viral in etiology, but we ordered a chest xray "just in case." It ended up showing an extensive mediastinal mass. One biopsy later, the diagnosis returned nodular sclerosing Hodgkin's. Zebra. Luckily, her prognosis is excellent and the delay in diagnosis likely will have no significant effect on her therapy. But it is never easy telling a previously healthy 22 year old that they have cancer, and there is a certain level of embarrassment that it took 5 visits to a physician to reach a diagnosis.

I think the most telling thing I've taken away from these experiences is how important the differential diagnosis remains in clinical practice. Most common symptoms can be attributed to the relatively benign conditions that afflict the gross majority of the general population. But it is important to always consider what else can be consistent with a clinical picture that is truly dangerous, as just because a condition is rare does not mean it cannot be affecting the patient sitting in front of you. Bacterial pharyngitis is common and fairly benign. A retropharyngeal abscess is not, and can often present identically. It is the responsibility of the clinician to use their clinical judgment and work up a patient to the point that they can confidently feel the patient is safe in the context of their illness.

After all, just one day, you may come across a zebra in downtown New York.

October 14, 2009

Choosing a Medical Specialty (Part Dos/Deux/II/0b10)

As a continuation on my previous thoughts on picking a medical specialty, I've once again channeled my Dear Abby and have a new column up over at Headmirror.com.

Check it out here: Why ENT? Choosing a specialty and what drew me to ENT (navigate to Medical Students -> Blizzog)

On the road again

So I have to say, hindsight being 20/10, I ended up enjoying my psych rotation a lot more then I expected. I'll readily admit my preconceptions of patients with mental illness were too skewed by popular culture; I think I was expecting more of a Hannibal Lecter flavor. A "What are the voices in your head telling you Mr. Williams?" "TO KILL YOU!!!" sort of thing. But, fortunately, I found my interactions with patients to be generally pretty interesting and much more pleasant on the whole (exempting one interview with a drunk patient with narcissistic personality disorder). Especially gotta love the schizophrenic patients. Such a sad disease, but a rich source of some purely AWESOME conversations.

Anyways, like it happens time and time again during third year, just when you get comfortable in a rotation, the dean's office picks you up and plops you down in another unfamiliar location. For me, for the next 5 weeks, into a low income family practice clinic on the southeast side. It's been a tough adjustment coming from a rotation where I was afforded a great deal of autonomy and input into patient care, namely because the physician I'm working with has somehow come under the assumption I have the IQ of a sheet of dry wall. Cue one interaction I had today in clinic:
*MedZag, presenting patient to attending while in patient room (I know, awkward.)*
MedZag: Ms. Rogers is here today complaining of persistent worsening of allergies of the past 8 months. She states her main symptoms have been rhinorrhea, nasal stuffiness and sneezing, sore throat, and some intermittent wheezing. No sinus pain or pressure, no cough, no shortness of breath. She tried a trial of Claritin for 2 week...
Attending: So what brings you in today Ms. Rogers?
*Physician and patient proceed to start talking and cover all pertinent points I was about to distill in my presentation*
*Attending begins physical exam*

Attending: Now, if you see here MedZag, if you look up her nose you can see fluid.
*biting tongue*
Attending: You can also see swelling. This is very characteristic of allergies.
MedZag: Hmmm, yes, interesting. I also noticed that when I performed a physical exam (not so subtle hint). I had some ideas of an assessment and plan, would you like me to continue?
Attending: Oh no, that's ok. We'll just give her some Allegra.

This is going to be an interesting 5 weeks.

October 6, 2009

Monkey See, Monkey... Don't Do

One of the unofficial purposes of the clinical rotations of medical school is to expose students to a wide variety of "styles" of doctoring by rotating beneath a wide breadth of physicians. At its core, medicine is a service industry, and there is much to be learned on how to navigate the landscape of illness besides basic science and "standard of care." One of the benefits of working with a variety of clinicians is the opportunity to steal small techniques or tricks to incorporate into your own future practice. I learned how to use the otoscope on children by pretending there's a bird in their ear, then asking to see the other ear because it flew across. I saw a brilliant and humbling example of how to break bad news when I had a patient die from a PE and sat it on the conference with the patient's parents. From discussing end of life care, to learning how to sternly (and compassionately) say to patients "sorry, I will not prescribe you vicodin," to motivational interviewing, to diagramming medical conditions in an understandable way on a piece of paper, I've been fortunate to have hoarded a small arsenal of personal experiences up to this point which aid in my clinical acumen.

Along the same lines, ever so often you come across an experience where the way a physician handles the situation makes you grimace on the inside. These are also valuable pieces of information to incorporate into your own clinical style, as who you are as a person is just as much who you aren't, as who you are (courtesy of the Department of Redundancy Department). I recently had such an experience today. So, without further ado, I will now impart upon you the latest addition of Things MedZag Will Not Do As A Doctor:

If you are interviewing a patient and are faced the opposite direction to update their active medications list on your EMR, and the patient begins to talk of their recently deceased spouse of 40 years and breaks downs in tears, PLEASE do not continue to chart with your back to the patient while they sob in your general direction. For the love of God, turn around and face the patient.

The medication list can wait. That is all.

October 5, 2009

Hula Hoops



Jumping through hoops is a familiar feeling for any medical student. After all, it's something we have been doing at every level of our education. High school had its own set of hoops, filling college applications with National Honor Society merits, projects, AP classes, and the ilk. When time came to apply to medical school, there was a whole new set of hoops to tackle. Dean's lists, president's lists, scholarships, shadowing experience, personal statements, activities lists. Many experience a sense of relief on the arrival of that medical school acceptance letter. A feeling that you're finally reached the upper echelon of your training and the jumping of hoops is finished.

But alas, medical school brings its own new set of hoops. Anatomy, physiology, pathology. Step 1 and Step 2. Networking, schmoozing, research, clerkship grades. Once again, I will be pounding my head against a keyboard attempting to coherently produce a personal statement within the coming months. With my decision buck up and shoot for an ENT residency, the theme of the past month has most definitely been one of hoop jumping. I've been (somewhat) frantically trying to throw things together for a research elective coming up in November/December. Working on trying to network and get some clinical and OR experience in the process. Basically filling up my free time afforded to me by psych with numerous small projects all to play the game. Who wants to be bored anyways?

I tell myself this is the last time, but know that's just a personal delusion. But hey, I hear hula hooping is a great core workout.

September 28, 2009

New content... but not here

As I mentioned before, I'm going to be guest authoring over at headmirror.com with articles talking about my experiences pursuing an ENT residency, and hopefully offering some good advice and useful information along the way. Sort of like Dear Abby, but without the botox or perm.

Anyways, my first post is up. You can check it out here (navigate to the Medical Students section), if you're feeling whimsical.

And now... a picture of a kitten.


September 22, 2009

The Mind Is A Beautiful Thing To Waste

So I am in the midst of my 3rd week on psychiatry, and I would be remiss if I didn't at least talk about it a bit. My duties are relegated to the locked ward in the VAMC of my city (or the "Vah" as its affectionately referred to here), which means more substance abuse, PTSD, and homelessness than you can shake a stick at. I can confidently say that I could never be a psychiatrist. I have a great deal of respect for those that enter the field, and find many of the conditions patients carry very interesting (I was a philosophy major in undergrad, what can I say?) but the pace of the field is maddening to say the least. I'm the type of person who likes to have my work and get it done in an expedient manner, but often find my days filled with dawdling waiting for x to happen. "In 15 minutes" can mean up to an hour and a half later. Especially coming off of general surgery, the adjustment has been... interesting to say the least.

Alas, I do not have any amusing psych stories yet. Just a lot of sad ones. Between the limited resources social work has to deal with, the intractable condition of many of the patient's disorders, and the high relapse rate on substance abuse, there just aren't many warm fuzzies to come about. I've been experiencing a pretty good amount of countertransference while on service, and many of the days can feel emotionally exhausting. Plus the nature of the physician-patient relationship carries a very different flavor. Sure, the hours are nice, but I just do not feel the same get-up-and-go in the morning I've felt on other services.

Unfortunately, that's about all I can say about the matter. Such is the life of the third year med student. You do some things because you like to, and you do a lot of things because you have to. 2 1/2 more weeks until I'm on family medicine, and definitely looking forward to getting back in clinic and interacting with patients on a normal playing field again.

September 19, 2009

MedZag Picks A Specialty.

There are few decisions more consternating to a medical student that choosing their eventual field. Sure, there's a few students born to be pediatricians or neurosurgeons or ED docs out there who know it, but the gross majority of us go through a great deal of waffling and procrastinating when it comes to deciding what more we want to be when we grow up besides the esoteric "I wanna be a doctor! Cause its cool!" Even those who were convinced they were going to go into x when they entered med school often do a complete 180 once they rotate through the clinical aspects and their face is to the table saw as they hover over the "submit" button on their ERAS residency application.

There's a certain progression to the process:
(1) Panic: The Lifestyle Specialties
When you first come into medical school, you have these idealistic views of what being a physician entails. Then you actually get into medical school, and a disenfranchised attending comes along, convinced the entire field of medicine now sucks, and blows that idealism into tiny, sparkly little pieces. You begin to become convinced that the only way you could possibly be happy is if you find your way into one of the highly-touted ROAD specialties: Radiology, Ophthalmology, Anesthesiology, or Dermatology. You begin to become convinced you could be happy staring at a computer screen all day, or rashes for that matter. After a while, you realize that all rashes look the same to you anyways, and you move on to...

(2) Resolve: Screw What Everyone Thinks
You encounter a doc who absolutely flippin' loves what they do. They tell you that it doesn't matter what area of medicine you go into, as long as you love what you do. You begin to convince yourself the same. You tell yourself that the disenfranchised attending from step 1 can go to hell, and you're going to go work for Doctors Without Borders as a surgically trained general practitioner. As medical school and the ongoing debate about healthcare reform progresses, you begin to notice that little "Total:" line on your student loans climbing at a otherworldly pace. You then move on to...

(3) Hopelessness: It All Sucks Anyways
Why does it matter anyways? In a few years, you're either going to be a government employee, and make peanuts, or privately employed, and make peanuts. Either way, you'll be working your glueteals off the rest of your life. You'll never pay off your loans. You're going to be driving that 1995 sentra for another 20 years. Your daughter is going to grow up with daddy issues because you'll never be home. You procrastinate thinking about what you want to do, because its no longer fun to think about it. Some stay in this stage perpetually, and become the attending referenced in Stage 1. If you're lucky you get to move on to...

(4) Chance: Your Specialty Picks You
The residents and attendings I've talked to who really enjoy what they do, and are pleasant people in turn, almost universally give the same advice about picking a specialty: get rid of your preconceptions, analyze your strengths and weaknesses, the things about practice which are important and unimportant to you, prune your list, then go out there and experience as many areas as you can. When you come across your specialty... you'll know. It'll be the one where you don't want to go home at the end of the day. Where you'll look and read about things not because you have to, but because you want to.

I came into medical school convinced I was going to be a surgeon. My friends told me as much, I told everyone as much, my ESTJ Meyers-Briggs personality evaluation told me as much. Now granted, my concept of "being a surgeon" wasn't all candycanes and lollipops - I had shadowed enough in undergrad to have a general idea - but I will be first to admit I had a very naive and limited view on the scope of medical practice and the proverbial "potpourri" of options afforded to me early in medical school. I found out in a hurry that telling people in the Real World™ that you want to go into surgery evokes an entirely different response to telling people in the medical field that you want to go into surgery. Namely, that instead of eliciting the token "Ooooo! Like Gray's Anatomy!" response, they instead try to scare you the hell out of considering the field. And granted, much of that behavior is grounded in either reality or stereotype of the field. And so began my progression of through the steps.

First was "what have I gotten myself into? I don't want to work 120 hour weeks for the rest of my life!" Followed "I'm going to do it anyways! It'll be fine!" I eventually just resigned to telling myself "you'll know when you rotate through surgery if its for you." But alas, my surgery rotation came and went, and by the end I was still just as on the fence about the whole surgery conundrum as before. So I began to break it down. I knew that there was nothing like being in the OR for me. That time flew when I was in it, and I missed it when I was out of it. But surgical clinic also left a bad taste in my mouth. I found myself enjoying the clinical aspect of medicine more than I anticipated, and I found clinic in general surgery too fixated on "to operate or not to operate?" Yet after leaving surgery and venturing into the realm of psychiatry, I found myself missing the faster paced lifestyle of the specialty.

ENT was a specialty that first caught my eye during second year. I had a small group doc who specialized in laryngeal surgery and speech therapy, and he really tried pushing us to take a look at the field. But at the time, I was too hung up on the "to surgery or to medicine?" that I never stopped and said to myself "self? how about both?" It was a field I kept on my list but never really investigated... namely, because I had no idea what in the hell an "otolaryngologist" was or did. With no frame of reference, I wasn't in a position to realistically examine the field. But the seed was there, and as third year started and I began to have more interaction with various specialties, I began to notice that I was really digging this ENT stuff. The more I read about the field, the more it seemed to jive with my expectations and desires for how I wanted to practice medicine. There was a monday morning report I went to that was presented by the ENT department... and instead of sleeping through it I found myself taking notes. I scrubbed on a pharyngolaryngectomy with a free jejunal transplant and even though I was on the colorectal service and was parked by the abdomen, supposed to be focused on the jejunal resection, I found myself fixated instead on the bilateral neck dissection. It was the small things that slowly roped me in, and after extensive email conversations and a few tall coffees with a couple members of the faculty, I've finally come to a decision. I said to myself: "Self, you're going to match into otolaryngology."

Along those lines, I'm going to be guest-posting about my experiences in discovering ENT, rotating through ENT, applying, and such over at headmirror.com (see the new side banner). If you're considering ENT, I suggest you check it out - there's a lot of great info on the site. All I can say is that its incredibly exciting to find that niche of medicine which really vibes with your persona. When I decided to commit myself to the field and really get after it, all I felt was this overwhelming sense of relief. I think that was really telling.

Till next time.

September 13, 2009

Friday Night Lights

So I happen to be attending med school in the same city I grew up in. There's a lot of advantages to the situation: I know the area really well, the city "feels" like home, I'm close to friends and family, in-state tuition, etc. There's also the annoyances that come from returning to your hometown. Namely, running into old acquaintances, especially high school classmates, everywhere from the deodorant aisle at Safeway to the self-help section at Borders (you to!?!). Now, these aren't the good friends from the old days - those I've actually kept in touch with over the years and still make plans with from time to time. These are the people you see in a crowd, recognize the face and try to place their name, and before you can think of it they jump you with with the "Heeeeyyyy how are yoooouuuuu? What are you uppppp to? *awkward pause*" before you can make a quick getaway. At first these spontaneous encounters were kind of fun, namely because my younger self got to pull the "I'm in medical school card" (Yeah. I know. You don't have to tell me.) But after a while it becomes an annoyance more than anything. That being said, there's one place I never expected to bump into an old high school friend.

I was on trauma call on Friday night and going through my usual routine. Which means I was in the cafeteria at 10 at night, justifying to myself that I should get the ham and cheese sandwich and fries instead of the halibut and grilled veggies because "You deserve it. You're on call." Before I could contribute to my future coronary artery disease, the trauma pager goes off and I hand the delicious ham and cheese sandwich back to the cook and shrug, mumbling "Sorry. Trauma." I do my best doctor walk (you know, the walk where you don't look like you're running but you're tearing down the hallway on pace for a 4.0 40) down to the ER and work my way over to Trauma Bay 3. Ten minutes later the action starts as the paramedics wheel in the patient in a c-collar. My role is the lower extremity exam so I work on peeling away the patient's trauma-sheered pant legs, feeling for pulses, checking capillary refill, etc. The presentation of the patient begins.

"25 year old male was swimming with friends in the river. Dove off a rock and misjudged the depth of the water. Landed head first into shallow depth and immediately lost use of all extremities."

I examine the legs in front of me for lacerations, abrasions and such. The ED resident begins to talk to the patient.

"Sir, can you hear me?"

"Yeah," the patient replies.

"Can you tell me your name?"

"Mike." The appointed scribe sets out her form and begins to write in the elucidated info. "What's your last name, Mike?"

"Jergens."

Mike Jergens*. The two names snap together in my mind and I immediately glance up to the patient's face poking out above the c-collar. He had a beard now, but there was no mistaking his face. This was the same Mike I sweat and bled with during countless hours of football practice back in high school. He was a linebacker, I was a cornerback, and we spent more than a few hours shooting the sh*t in the huddle back in the day. I think back to my last vivid memory of him - also a Friday night, 7 years ago. We were walking off the football field my senior year, knocked out of the state playoffs in the quarterfinals in a royal butt-kicking from our local rival. He had cried that night in the locker room. I suddenly had the urge to cry myself.

I somehow pull myself together enough to help finish the triage and he is sent off to imaging. It would find that he had a C6-7 fracture dislocation. His cord was compromised. He was taken to the OR the next day.

Mike would eventually regain some motor use of his upper extremities. He had a long hospital stay with a rocky course including a ventilator-associated pneumonia. He was eventually discharged home 4 weeks later with a trach, facing a long road ahead I cannot even begin to fathom.

I never let him know I was there in that trauma bay. I tried to muster the courage several times to go visit him in his ICU bed, but the best I could do was to post a message on the website that had been erected for friends to send well-wishes and prayers. I still don't know what kept me from stepping into that room, but I carry a certain amount of guilt knowing that we now face such divergent paths in life. If anything, it has certainly helped me to gain perspective on how precipitous our lives can be and how quickly they can change. The minor annoyances in life, such as being "forced" to make small talk with an old acquaintance, are suddenly seen as blessings instead. An opportunity to see and know that that person is well. It's a strange world we live in.

As if to emphasize this point, the next night on trauma a patient in his early twenties was life-flighted in with nearly the exact same injury. He had dove into the river off a large boulder. Misjudged the depth. Landed head first in shallow water. But he escaped with only a hairline skull fracture.

It's a strange, strange world we live in.


* = Name obviously changed to protect his identity.

September 8, 2009

MedZag's First Night on Surgery

If there's one thing you can count on during your surgery rotation, it's that you'll have at least one occurrence a week where you will stop, survey what is going on in the room, and think in your head "what the f**k is going on in this room?!?" The residents take a certain amount of glee in finding ways to induce nausea and/or vomiting in the new, cute and cuddly little medical students on service. So of course on the first day of our rotation, with the knowledge they will be soon gaining some fledgling MS3s on service, the residents on my team saved all their *ahem* hands-on *ahem* floor work for the day for evening rounds when we would be joining them.

Case #1 was a patient we called Boss. Ms. Boss was the first patient I saw on my surgery service. Now keep in mind, I had just rotated off pediatrics, where I was used to seeing adorable kids all day. Sure, they may have been covered in poop, or really sick, or doing their due vigilance to prevent atelectasis by screaming for 23 hours a day, but they were still kids, and I freakin love kids. So we roll into The Boss' hospital room here I am confronted with a 350 pound elderly woman lying in her bed as Jerry Springer blasted from her television set. Our resident instructs myself and my fellow med student to glove up as it was time to change The Boss' wound. He peels back the dressing to reveal no wound but rather a massive gaping hole. You see, Ms. Boss had had a previous ventral hernia repair with a mesh. She got discharged to her nursing facility and the mesh subsequently got infected - necessitating removal of said mesh and all surrounding infected tissue. What was left was a 14" crater in her abdomen, with loops of bowel showing through a thin layer of tissue at the base. The tissue was still infected and I was immediately struck with the smell of... sherbert ice cream. Needless to say no sherbert ice cream was consumed this past month. So we get the supplies together and the resident gets to packing the "wound" with xeroform and two packs of kerlex. As I watch the resident place gauze on the exposed bowel, I step back for just long enough to think to myself: "what the f**k is going on in this room?!?"

Later on in rounds we come to a patient who the team had come to call Mr. Rabbit, for reasons which HIPAA will not allow me to explain but unfortunately not due to resembling a rabbit in appearance or size. Mr. Rabbit has originally presented to the ER with what was originally diagnosed as a rip-roaring case of panniculitis. As Mr. Rabbit was homeless and weighed in at a hefty 628 lbs, there was obviously quite a bit of pannus to become infected. He was taken to the OR where they found that while yes, his pannus was infected, it was actually due to a large sack of herniated bowel which was eroding into the skin. His hernia was reduced and he got a non-cosmetic panniculectomy (aka tummy tuck). The weight of his excised pannus: 78 lbs. So we reach Mr. Rabbit on rounds, now a svelte 550 lbs, who was beginning to show signs of a wound infection: rubor, dolor, calor, tumor (you have to say these in as dramatic a voice as possible). The team decides its time to open the wound to let it drain, a staple of proper wound care on surgery. The protocol for opening an infected wound is to (1) open, (2) assess drainage, then (3) follow the pocket of infection to get a sense of how large it is and where it tracts. For small wounds, this can be done with a wooden q-tip. For larger wounds, a gloved finger is often necessary. Our resident gloves up, removes the necessary staples, and begins to follow the pocket of infection. More and more pus begins to pour out of his abdomen. Despite his newfound surgically-enhanced physique, Mr. Rabbit still had quite a bit of subcutaneous fat, and before we know it, the resident has his entire hand, up past the wrist, inside the patient's infected incision. I stand back, take the scene in, and think... well you already know what I think.

August 6, 2009

Surgery... Is Tough

The general consensus of the third year rotations is that surgery is the toughest rotation to get through. I didn't necessarily pooh-pooh this assertion, but I said to myself: "Self, you enjoy surgery. How bad can it really be?" After the first week of 3:30am mornings, walking home at 8pm realizing I need to be awake in 7 1/2 hours, still have to eat (since I haven't all day), and read up on my cases the next day, I have come to the conclusion that surgery... is tough.

This definitely creates a tension for me regarding my future. Surgery has been at the top of my list since the start of med school, and I've really enjoyed the rotation. I love being in the OR and time generally flies by while I'm in the hospital. But the moment you step outside those hospital doors, you realize just how tired you are and just how much your life sucks. There's been a lot of criticism of med school graduates choosing "lifestyle" as one of the major determining factors in choosing their future medical specialty. But when you're in the middle of a 96 hour week (sssshhhhh, we're only supposed to be working 80), watching the attendings crawl home at 7 or 8pm daily just as you are, you start to realize in a hurry just how much lifestyle can bolster or sink your happiness.

I'm on the colorectal surgery service. Which means obesity, obesity, and morbid obesity. I'm hoping to post some stories soon, because I've seen some crazy sh*t (no pun intended). But tomorrow is my birthday, so I plan to spend it how anyone would hope to spend it: On call on trauma service on a Friday night. Woooooo surgery!

August 2, 2009

The Bee Gees, Storage Closets, and Medical Education: A Thursday

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

It was my last day in the PICU and last day on pediatrics. I had come in at my usual time of 5:30 to pre-round on my patients. One I had carried for a week and was very familiar with and the other was a little boy with an epidural for who most of the heavy lifting had been done overnight. 7:30 came, I presented my last 2 patients, and rounds flew by, finishing ahead of time mostly due to our light census. It was looking like it was going to be a light last day, and that I would have time to fit in some much-needed studying for my shelf exam the next day. It was 8:30am and I had just settled down with a paper on PRVC ventilation when the voice on the overhead speaker system chimed on: "Code 99, 9th floor, room 4. Code 99, 9th floor, room 4."

The PICU chief takes off running down the hallway, the team a few meters behind. We arrive up at the code in under a minute, finding ourselves the first responders due to the fact that most of the attendings and residents in the hospital were a building over in morning report. Our team would be running this code.

A code in real life is nothing like in the television shows (big surprise). It is a much more controlled chaos. There isn't any yelling, pounding on chests, doctors screaming "don't quit on me! DON'T QUIT ON ME!," or any of the other stereotypes that people think of when you say the words "code blue." We had actually had a mock code for the residents and students with a sim-patient the week before - our institution is big on assigned roles and closed loop communication. So I settled into my role of information gatherer and runner: finding the patient's most recent labs in her chart, getting ice to cool the patient's body, running blood gases down to the PICU, etc.

The patient was a 3 year old little girl who was actually set to be discharged later in the day. She had nephrotic syndrome and had spent half a day in the PICU earlier in the week with some mild pulmonary edema. Her labs looked completely normal and she hadn't had any issues besides intermittent hypertension. While her parents were showering her that morning in her hospital room, getting her clean for the ride home, she suddenly collapsed and became unresponsive. Within 4 minutes of that moment she was receiving chest compressions from the PICU chief.

137 minutes of chest compressions, 8 boluses of epinepherine, 4 boluses of atropine, 4 boluses of bicarbonate, 3 doses of calcium, 3 cardioversions, 2 boluses of ibutilide, 2 IO lines, and a bolus of insulin later, there still wasn't a pulse. Since she was a previously healthy child and was remarkably stable during the course of her hospital stay and had started getting chest compressions so soon after her event, the decision was made to get her down to the PICU and put her on ECMO (cardiopulmonary bypass) in hopes that giving the heart a break would allow it to snap back into rhythm. She was wheeled down the hallway with my resident straddling her on the bed, continuing to give compressions.

Down in the PICU, her room was converted into a field OR, and the cardiothoracic surgeons arrive to prepare to get her on ECMO. I am standing outside the room, looking for more opportunities to help and absorbing the controlled chaos, when the chief turns to me and says:

"MedZag, why don't you relieve David from compressions. He needs a break and I think it would be a good experience for you."

My adrenals dump a massive load of catecholamines into my system. I somehow find a way to utter "Yes, sir."

During our "Transition to Clerkship Week" at the beginning of MS3, we were forced to re-certify in our healthcare provider BLS (basic life support) training. Which basically entailed kneeing on the hard ground in dress clothes for 2 hours doing practice compressions on blue plastic mannequins which looked like they got misplaced from the set of I, Robot. There was no way I could predict that in 6 short weeks, my mannequin would suddenly morph into this brown-haired little girl.

I gown and glove up and go and relieve the fellow doing compressions. I was determined to do everything exactly correct - probably a delusional desire in the given circumstances, but I became fixated on a study I remember reading where residents and medical students who were instructed to do chest compressions to the beat of the Bee Gee's "Stayin' Alive" were much more likely to hit to target heart rate.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

The surgeons incise in her neck and begin to dissect down to the carotid artery, a difficult prospect as with every thrust of my palm down into the little girl's ribcage, her neck jerks and blood flies into the air.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

I become fascinated by how strong her ribcage is. Sweat begins to bead on my forehead, my respirations steadily quicken, and my arms begin to burn as the lactate accumulates in my muscle tissues.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

This little girl was going to make it. She was supposed to go home today. This will be a fantastic experience to look back upon. I had images of the thank you card the PICU will receive when she starts first grade - the little girl grinning in a photo, missing her front baby teeth. The little girl who nearly died but now has her entire life, a full and rich life, to look forward to.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

Bypass in on. Her body is once again receiving fully oxygenated blood. Chest x-ray shows everything is properly in place. Her heart regains a rhythm. Sinus. But 45 seconds later it fades. Asystole.

A repeat echocardiogram would eventually show a massive saddle embolus in her pulmonary arteries. You can't get blood to the body if blood can't get to the left heart. MRI and clinical exam showed absence of all reflexes and fixed, dilated pupils. There would be no first grade photograph.

I was in the room for the conference with the patients. Our chief explained what had happened. The scene felt surreal.

When stepping out of the room, one of the residents broke down in tears. The chief stares off into space. His words resonate in my head.

"Hope and pray that you never have to do that enough in your career that you get as good at it as I have."

Bypass was stopped 2 hours later. Within minutes, the brown-haired little girl, who should have been home watching cartoons, had passed on.

I was sent home to study for my shelf exam. I sat starting at my question book, but no studying would be happening that night. I logged onto the EMR and looked at her chart again. I looked at her echo again. I read the note I had written on her earlier in the week when she had been in the PICU. We had been instilled with the proper fear of a saddle embolus during our first two years of med school, but this was the first time I had seen one clinically and wanted to make sure all the information about the situation was seared into my brain. But mostly I simply sat there. And thought. I couldn't shake the feeling of guilt clawing at my stomach. This will be one of those centennial moments of my medical training: the first time I actively participated in a code, the first time I performed CPR on a patient, the first time I witnessed a truly horrific conference with parents, the first time I saw a member of the team collapse in tears, the first time I watched a patient die without forewarning. This was an important day in my medical career. But it is a sadistic reality that my education requires bad things to happen to good people.

So, to the patients of that little brown-haired girl: Thank you. Through your tragedy, I gained valuable experience that one day may perhaps enable me to save someone else's life. And know that I would gladly exchange all that experience for a picture of your daughter, clutching her pink backpack, grinning with her missing front teeth, on her way to start the first grade.

July 24, 2009

Tough week.

Death count for my PICU rotation: 4 and climbing...

Worst by far was the mother who found her 15 year old daughter down in her room. EMS resuscitated but her pupils became fixed during transport and she was brain dead by the time she got to the PICU. Her cerebral perfusion scan was eerie for the complete and total absence of all blood flow. It was like someone went in and performed a total lobectomy, the cutoff was so precise. Tox screen negative, all lab work negative, no signs of trauma, asphyxiation, etc. We have no idea why this perfectly healthy girl was suddenly found essentially dead.

There are true tragedies in this world.

July 22, 2009

Waste Management

There's a protocol around here for how you attack an infant with a fever of unknown source (FUS). Basically, the justification is that since babies can't tell you they're sick, and are at risk of serious infections, every one of them gets a full sepsis workup. Blood culture, urine culture, lumbar puncture, CSF culture, and a cherry on top - and then they get parked in the hospital while those cultures cook in the lab.

While I was on my general peds inpatient stint, we averaged around 5 of these a week; almost every day we have another "rule out sepsis" touchdown in our ward. They begin to blend together - a day or so history of fever, maybe some lethargy or poor feeding, occasionally some sniffles or a change in stool. The cultures always come back negative, of course, and if the bigwigs on Washington saw my life as a 30min episode of reality TV, they would be up in arms bemoaning the "Waste of healthcare dollars! Defensive medicine! Rabble rabble rabble!"

My last FUS was a little different, however. He also had the classic history - 2-3 day history of fever hovering around 101, not feeding as well, a little fussy. But mom didn't take him to the doctor. After all, its just a little temp. Babies get sick, it happens. Until she was holding him and watched his eyes roll back in his head as he stopped breathing and turned blue. EMS got him resuscitated, and that's when I met him in the PICU, after the damage had been done. That moment little baby turned blue, his body could no longer compensate from the bacteria and cytokine storm raging in his body. Brain MRI showed diffuse bilateral watershed infarcts; he was brain dead. Blood cultures taken in the ED grew gram negative bacteria.

That's the crazy thing about all this preventative medicine, rule out sepsis, empiric treatment mumbo jumbo. It lulls you into complacency until that moment it blindsides you. One of the classic lessons of medicine is "learning diligence"; to never settle with an innocent diagnosis until you have ruled out the dangerous ones. It's often a lesson learned the hard way. Would the money spent ruling out sepsis on that one kid have been worth all the money spent on the other kids ruling out sepsis? I bet you his mom would have said so.

The worst part of all about this case is that his blood ended up growing out Haemophilus influenzae type B. A bug he SHOULD have been vaccinated against. But mom was afraid of vaccines.

As one of the residents macabrely put it: "At least he never got autism."

You go Jenny McCarthy!

July 7, 2009

Balls.

So during our pre-clinical years we had this wonderful class called "Principles of Clinical Medicine" which was "designed" to impart onto us all the skills we need to survive in the clinical world that you don't learn out of a basic science textbook. We had lectures on giving bad news. Lectures on disaster preparedness. Lectures on healthcare reform. Lectures on "adapting to a chronic illness." The culmination of the class was something called the (Group) Objective Standardized Clinical Examination (GOSCE if as a group, OSCE if solo), where you had to perform a history/physical exam on fake patients often with one of the "difficult" issues lectured on, such as substance abuse, non-compliance, divulging a medical error, etc and graded in checkbox style on whether you washed your hands, shed appropriate tears, preserved modesty whilst sticking a finger up a man's inguinal canal, and such. Did it help me prepare for my clinical years? Yeah, I think so. But as far as preparing me for what I do 75% of my day, it didn't help squat. So instead, in order to better prepare MS1s and MS2s for what the wards are actually like, I propose the OSCE be replaced with... the SACK (Subjectively Arbitrary Clinical Klusterf*ck - with a K 'cause SACK is a way cooler acronym than SACC)

Here is how it would be conducted. 10 students would be unleashed into a mock ward with 1 patient assigned to each of them. There is a workroom with computers. The student must:
(1) Log onto the records system on a computer terminal to read up on the full H&P, course, vitals, labs, and imaging of their patient and commit them in some form to memory
(2) Go see their patient and get overnight updates/perform a physical exam
(3) Go talk to the nurse for the patient to find out what really happened overnight
(4) Come back to computer terminal and write a progress note complete with assessment and plan with a "well thought out and thorough" differential and relatively accurate plan
Now the rules of the exam:
--The student must perform all of the above tasks on a timer of 120 minutes. At the end of the 120 minutes, the student must present their patient while individuals in long white coats stand around, shuffle their feet, and clear their throats
--Even though there are 10 students and 10 patients, there are 8 computers in the work room. Additionally, throughout the course of the 60 minutes, 8 individuals in long coats representing consults, attendings, and residents will come in and sit at terminals to check their google mail and book airline tickets to exotic tropical places. The students have no choice but to defer to hierarchy and rescind a computer terminal if needed by said individuals. Said individuals can sit at any station as long as they want, and if all 8 individuals decide to use computers, students have no choice but to stand there wasting precious time
--There will be 5 nurses for the 10 patients. At any moment 2 of the 5 nurses will be missing and no one knows where they are.
--60 minutes into the exam, the students will all be herded into a room and forced to listen to "morning report" for 30 minutes, denying them access to patient, work room, or computer terminal and cutting their effective work time down to 90 minutes
--Patients will either be too tired to give a good history of last nights events or physical exam, too cranky to give a good history of last nights events or physical exam, or too drugged to give a good history of last nights events or physical exam.
--You are allowed to print your notes for aid in your presentation at the end, but only 2 of the 8 computers will send to the printer

Now that's real wards experience.

BTW... saw my first code today. A parent of a patient seized and collapsed in the hallway right outside our workroom. He hit his head on a counter, cracked his skull open, and went apneic. I stayed out of the way, since simply observing the carts and the medical supplies and the pooled blood on the floor was way too much for me. But good lord, within minutes of the code being called there were 50 docs and nurses all in that narrow little hallway while people tried to get supplies and a stretcher to the patient. It was like pigeons at a bird feed sale.

Cryptococcus!

(You might be a med student if you get that joke.)

July 6, 2009

The Big Leagues

I was a big baseball player growing up. T-ball, coach pitch, Little League, American League, all the way up through high school ball. The developmental leagues in the American ball system have a very specific method to their madness. Each level has its own set of skills it develops. T-ball is all about learning the rules of the game and the fundamentals - how to field a ball, how to throw a ball, etc. Little League is all about proper technique, learning how to turn a double play, who to hit as your relay man, and such. By college ball/minor leagues, the fundamentals are all supposed to be in place, and you focus on refining technique and maximizing talent. Then you reach the big leagues and its all about delivering on your talent.

Academia is a similar sort of setup, especially when it comes to medicine. High school is your t-ball. Developing study skills, learning the fundamentals of each subject, starting on your critical reasoning. College is your little league. Experimenting how to efficiently learn, developing your reasoning and communication (and drinking) skills. The pre-clinical years of med school are the minors where you are working on adding the necessary information to your cranium to step up to the top level.

Lame analogy? Super lame. But the nickname around here for the clinical years is the "Big Leagues" and after a week of getting my feet wet I can see where it comes from. No more syllabus to hold your hand and feed your orange slices between innings. No more cute little "classic presentation" clinical vignettes to tell you to lower your elbow on your swing. Just you, the patient history, the physical exam, some lab tests, and a team of individuals grossly more experienced and knowledgeable than you waiting impatiently for your assessment and plan. It's terrifying but infinitely more fun.

Anyways, enough melodramatics. I think the rub is that third year is an entirely different beast. Peds has been a great rotation to start on. By its very nature it tends to accumulate more nurturing personalities and its been a good atmosphere to hopelessly stumble around in during the first few days. From the intern to the attending, everyone has been great at understanding and helping me with my incompetence. Kids are definitely my fave patient population and we've had some real cute ones on the floor this past week. I'm glad my first H&P was with a mother concerned about her adorable little daughter instead who was previously healthy and not on a 47 year old chronic patient with a PMHx and a Meds list the size of the US deficit. So I'm having a blast so far. Some moments from my first week:
--10 year old little boy who presented with focal hemiparesis. Was originally given diagnosis of acute disseminated encephalomyelitis, until the CSF came back with oligoclonal bands and tests showed myelin basic protein antibodies. Diagnosis of Multiple Sclerosis, that was a real heartbreaker.
--Little 2 month old baby admitted with poor feeding and failure to thrive. MRI showed diffuse hypomyelination of the CNS. In medicine, generally the more names in a condition, the worse it is. Especially if they're German names. This baby was suspected of having a condition consisting of 3 German names. Such a bummer, and the worst part was that he was perfectly healthy at delivery and until 8 weeks of life.
--On call when the intern gets a page that a patient admitted the night before for UTI was "turning blue." We run down to the room and see a poor child who was inconsolable in her mothers arms, had just had an impressive bout of diarrhea, and who had purple extremities with cap refill of 4-5 sec. Luckily everything turned out alright and she was discharged today.
--The family practice intern walked in on two cystic fibrosis patients doing the horizontal handshake. Yes, we all know the hospital is a boring place when you're a patient, especially when you're there 1/4 of the year, but probably not the best way to exchange nosocomial organisms.
--Poor 8 year old girl who presented with a history of 3 days of fever including a fever of 105.7! I can't even imagine how miserable she must have felt. Blood culture grew Streptococcus. Thanks to the miracles of medicine, her stuffed Tigger and she were discharged today.

That's it for now. I'm post-call and it's time for bed.

July 1, 2009

Post Call Delirium.

Had my first night on call last night. Lot of fun!
Time really flew by, even though of the 31 hours in the hospital, I was working for 29 of them.

3 admits. Asthma exacerbation, viral tracheolaryngitis (croup), and cellulitis.
1 PICU tranfer. DKA.
0 emergencies.
2 Starbucks venti coffees.
1 presentation of childhood nephrotic syndrome prepared.
2 H&Ps completed.
2 bloodshot eyes.
1 pair of dirty scrubs.

We're on holiday this Friday so I'll try to update with some thoughts of my first week in The Big Time aka the wards at that time.

June 25, 2009

So, Third Year.

So tomorrow marks the end of our "Transition to Clerkship" week, which means at this point I'm supposed to be pretty much transitioned to whatever this "clerkship" thing is supposed to be.

In the past I had (arguably) witty food analogies for the first two years of medical school. First year is like a hot dog eating contest. Second year is like trying to polish off that 72oz steak at Billy Joe's Steak Emporium. If I had to come up with an analogy for what transitioning to MS3 would be like... it'd probably be analogous to that NBA commercial involving Yao Ming (still one of my faves):



Yes, third year is like trying to eat a live crustacean. It's new, it's exciting, it's exotic, and you have no idea what the f*ck you're supposed to be doing. You can google how to eat a live crustacean, people can tell you how to eat a live crustacean, but until you've actually gotten out there and done it, you really have no sense of what its like. And when you try for the first time, its awkward, you fumble around, and you generally look like an idiot.

Our week started off with a morning full of "talks" from the big wigs in the School of Medicine who never appear unless something "important" is going on, which basically consisted of them reminiscing to us about their own days at the beginning of their clinical days. Luckily things picked up at that, and the rest of the week has been very fun. Finally had my first quasi-patient which I had to do a full H&P on and present the next morning. The rest of our time has been filled with workshops filled with how to scrub for the OR, knot tying and suturing, intubation, accessing/reading/interpreting path reports, how to place an IV, managing acute patients, etc, etc. The material has varied from interesting to repetitive, but the best thing is that is have all been HANDS ON. It's all been simulated, but actually getting your hands dirty and having things be interactive beats the hell out of sitting in lecture all morning and then hurrying up to sit in front of your syllabus the rest of the day.

Start peds on Monday. 2 weeks on the general wards then 3 weeks in the PICU. Hoorah.

June 16, 2009

The Aftermath

I survived Step 1.

It still seems surreal to say it. That the seemingly insurmountable task that has been hovering over my head for such a long time is now over and done. In the past.

All that remains is the aftermath. My First Aid binder with pages ripped through their 3 hole punches, hanging out like a dog's tongue after chasing one too many frisbees. Dead highlighters on my desk. Sheets full of self-made diagrams and flowcharts. Sentences underlined in red with "QUESTION!" written next to them. My Goljan book, with its binding cracked down the middle and the second half of the "Hepatobiliary and Pancreatic Disorders" chapter hastily scotch taped back in. 3,400 QBank questions tucked somewhere in my cranium. 2,400 notecards sitting no longer of use on my laptop.

I'll post more about my experiences with my progress doing questions, taking NBMEs, and the like when I get my actual score back and know how accurately it actually projected how I'd do. But I thought I'd talk a bit about the experience of the test. My actual test day went pretty well. My immune system made one last rally and with my prophylactic DayQuil in hand I kept the congestion and runny nose at bay throughout the day. I arrived for the test a half hour early, and found myself starting the exam early at 7:40am. All those hours doing questions paid off and I found my stamina was good enough that I could bang out two hours of question blocks at a time between breaks. Time goes VERY quickly while you're taking the test. You find yourself so focused on each question that blocks can seem to fly by, and hours of the day silently tick away. Before I knew it, block 7 rolled around and I clicked that final "End Block" button and half-assed my way through the survey at the end.

What does it feel like when you step out of the testing center? It's a strange combination of exhaustion, exhilaration, and denial. It didn't sink in for almost two days that I was done. That there was no more studying to do. The day itself almost felt like just a long day of doing USMLEWorld, as the interface, pacing, and question prompts were all so similar.

But it does finally sink in. And its a great feeling when its over. The sheer amount of concentrated will it takes to study endlessly, day after day without reprieve, was honestly something I wasn't sure I had in me. Its a time filled with highs and lows. Lots of lows. Frustrations, and sometimes despair. You realize you have gone days without talking to another human being, and find yourself unable to engage in normal conversation when you do. You become robotic in your routine. Wake up, study. Eat only because you have to. Study. Sleep. Repeat.

I think if I had to sum up the entire experience it would be: I would never want to repeat it. But I'm damn glad I went through it. And now its time to sleep.

June 12, 2009

Step Prep: 503 hourzzzzzzzzzzz

So after all this hubbub, after everything of the first two years of medical school inevitably being tied to this day, I take Step 1 tomorrow.

I tried reviewing pharm today. My brain wouldn't cooperate. Took my last diagnostic yesterday, it said I'm right where I want to be.

Still sick, but what can I say? Life sucks, then you die.

Game face.

June 10, 2009

Step Prep: Day 19

6:00am - MedZag awakens for another day of relentless Step 1 studying. Man, he feels tired today.
11:00am - MedZag has to blow his nose.
11:15am - MedZag has to blow his nose, again.
11:30am - MedZag is noticing he sure is blowing his nose a lot today, and as he is noticing this, collapses into a fit of sneezing.
4:00pm - MedZag notices an insidious onset of headache, sore throat, and myalgias.

Well, crap. Of all weeks, of all days, my body chose 3 days before the boards to get sick. I know not who the culprit is: adenovirus, coronavirus, rhinovirus, or friends. I do know that this blows. No pun intended.

I've loaded up on the antioxidants and am pushing the fluids. We'll see if my immune system can muster one last Spartan defense before the big day.

And with that, I'm off to bed.

June 4, 2009

Step Prep: Day XIVa (The Clotting Cascade Tribute Post)

Has it really already been two weeks? That just blows me away. Really, for as exhausting and monotonous all this board studying is, the hours and days fly by. Probably because every day feels the same.

I'm in the final stretch, I take Step 1 a week from Saturday, so I really only have 7 days left of studying. Which is probably a good thing, because my mental stamina is fading faster than your libido after starting an SSRI. I've been doing 100 questions + full explanations every morning, which normally lasts me from 8am-noonish. I then take a lunch break and have grandiose plans for the rest of the afternoon, but generally can only really buckle down and really concentrate another 4 hours before the caffeine-induced diuresis and pressure sores on my ass proceed to tell me I need a change of scenery. I go home, telling myself I'm going to "finish", and proceed to "study" till late. By "study" I mean have something open in front of me and distractedly "look" at it while not retaining anything. This has not bode well on me making any progress on any of the items on my steadily growing "You're Behind On This, Get Your Ass In Gear" List.

I'm starting to notice some holes in my study schedule. For example, I only gave myself 1 day to learn micro for the first time, instead of the 652 days required to memorize all the necessary info as I am quickly realizing. But finding time to plug in additional micro studying when I barely have the mental stamina to slog through 80% of the stuff I'm supposed to study for the day has not proven humanly possible. I'm still trying to figure out how I'm going to remedy this. Without the use of illicit substances.

At least it seems like all the effort has started to pay off, as my QBank blocks have finally started to climb over the last 3-4 days. Of course, each one feels like a fluke to me, and I still expect every next block to come back and give me a big fat 40% in my face, but so far it seems I've been able to stave that off. I think I've hit that quasi steady state where any additional info I learn is desperately trying to offset all the information slowly leaking out of the back of my head. We'll see. A week is hardly any time but a ton of time at the same time.


And only during Step 1 time does that seem like a good sentence to end on.

May 29, 2009

Step Prep: Day 7... or is it 8? I don't know anymore.


So I had all these "stay balanced" things planned into my study schedule. Gym time, free time in the evenings, all that wonderful stuff. Unfortunately, I think my schedule was a bit too ambitious and as a result those days I was supposed to be done at 6pm are more like 10pm and gym time has been forsaken to make up on lost sleep. But what other choice do I have, really? If I don't get through the material now, I won't ever... and the thought of going into the test having NOT finished a subject scares the crap out of me.

So much for balance.

I was ambitious, I mean, masochistic enough to believe I could get through all of neuro today. I did it... but it took me 10 hours. On a Friday night.

Questions continue to oscillate up and down for me. I'll do a pretty good number on a subject and think I have it hammered down then drop 15% in the same subject a day later. But the fluctuations are getting less dramatic and my scores are slowly trending up, even if it doesn't feel like it. I created an excel spreadsheet with a graph and trendline to prove it to myself. Yes, its gotten to that point. Today was a down day for questions. That coupled with the sadistic enterprise that was neuro and the fact that its Friday but I hardly noticed since it was just like any other day made for a pretty down day for me. I have heard of medical students being reduced to tears during board studying. If I was one of those more sensitive types, today probably would have been one of those days. Instead, I did what any testosterone-fueled male would do... and raged. I have developed a habit of verbally abusing my QBank when reviewing questions. OH! ALL I NEEDED TO KNOW IS THAT tRNA HAS 94 NUCLEOTIDES AND ENDS IN CCAGGG ON THE 3' END! THANKS USMLEWORLD! YOU'RE A GREAT HELP! I've also developed a habit of talking to myself when studying now. That's a new symptom.

14 more days...