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.

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.

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.

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.

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.

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.

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)