Shelf Exams

I’m starting to study for our shelf exams (subject exams for each of the 6 disciplines - which our school makes us take all at the end of the year). Our first two are Ob-gyn and Pediatrics. I love ob-gyn and don’t mind studying for it at all. It just makes sense to me (except perhaps all the insane and ever-changing guidelines for PAP smears haha).

But pediatrics is HARD! There are 9 billion different congenital anomalies, a gazillion different infections – with different ways of diagnosing, treating and preventing each one, and really, WHO invented that stupid table with all the developmental milestones? My brain hurts so much right now, and I’m only 4 hours into pediatrics.

For example: this is a very accurate way to describe my frustration with pediatric rashes:

http://doccartoon.blogspot.com

The worst of it is that 99.5% of pediatrics involves determining whether “the sniffles” is due to a virus (90% of the time, in which case you do nothing), or a bacteria (10% of the time, in which case you give amoxicillin). But of course 99.5% of the shelf exam is all the OTHER stuff that you never see during a regular outpatient pediatrics rotation. Sorry. That was a lot of percentages.

Sometimes it’s tough being an MS3

Today I went to go check in on a patient of mine that I’ve been following. He had a pancreatectomy/splenectomy last Thursday, and I had the opportunity to scrub in and assist. I met him before his surgery – a sweet man of 72, who was fairly healthy before his diagnosis of a mysterious “pancreatic mass.” The surgeon (my preceptor) told him that it wasn’t a good idea to take chances with pancreatic cancers, and the best thing would be to just take it out.

Everything went well, and I saw him the next day in the hospital. He had been transferred from the ICU to a regular room on the surgical floor, and when I walked in he was sitting up in a chair, smiling, talking, and grateful to be there. He was seriously one of the sweetest men I have ever met. Of course, he was weak, but in good spirits.

I didn’t see him Saturday, but then today I went back in to check on him. As I was getting there, the hospitalist was just leaving. He looked like he was in a rush, so I didn’t bother him for info (which in hindsight wasn’t the best move). I checked the chart briefly before seeing him, and just glancing at the orders for Haldol and Ativan, I knew something was very wrong. When I walked into the room, he was restrained to the bed, and his eyes were glazed over as he muttered something unintelligible.

Unfortunately, he had taken a turn for the worse over the weekend and had slipped into some type of psychosis. His daughter and wife were distraught. The daughter said that she never heard her father curse so much in her life, it was like he was a possessed by an evil spirit.  As she bombarded me with questions, I tried my best to scramble for a differential diagnosis, but I was coming up blank. What could cause such severe psychosis in such a short time? He had a morphine epidural in, (which he yanked out during the night in one of his fits), but morphine-induced psychosis is fairly rare. He looked dehydrated, but he had IV fluids going and his urine output was good. His pancreatic enzymes were  fairly high, but can that induce psychosis? Was it just all the hormones going wacky? Or maybe it was simple hospital-induced psychosis. All I could tell them was what I had read in the chart (which wasn’t much). If only I had Harry Potter’s magic wand.

It just drives me nuts when doctors don’t take the time to sit down and explain what was going on with their patients. That hospitalist had just seen the patient, but the patient’s family had absolutely no idea what was going on, which makes me wonder, did he explain anything at all to them? They were asking me for answers that I wasn’t qualified to give, and for possibilities that I couldn’t (and shouldn’t) expound on at my level. But they weren’t to blame – if my dad was psychotic I’d be pretty darn worried too. The plan that I had read in his chart were for stat labs and a stat CT of the head. I tried my best to comfort them by laying out the immediate plan for his care and assuring them that I’d be back to check on him the next day (my feeling of uselessness at this point was unparalleled). Anyway, that did seem to help give them something to focus on, and they calmed down a bit.

Anyway, it’s not like I have something profound to say here. It’s just one of those days, which seem to come more and more often as 3rd year winds down, where you ask yourself: “When will I ever be a real doctor?”

Family Med in a Small Town

Today I saw a patient who was a 79 year old retired dairy farmer. Farmers really aren’t a fan of going to the doctors, and they pretty much think they are invincible. For example, his hemoglobin A1C was 10.9 which was excellent for him (the HA1C is a measure of long-term glucose control, normal is between 5-6). It had been as high as 14.7 in the recent past.

Anyway, I introduced myself and asked him how he was doing. He responded with the following:

“Listen kid, I done found myself the Fountain ‘O Youth, okay?”

“How so?” I asked, slightly bewildered.

“You know, I worked on a dairy farm for 50 some years, and I’m Italian. So I says to myself, ‘Them old Italians, they used to drink a couple a glasses of wine every day for health reasons’, right? So I says, I gotta combine this. So I goes up to the farm, and gets me some milk straight outta the cow. Then I mixed 2/3s milk with 1/3 red wine and drank it down. Now, it doesn’t look too good, in fact, it looks like someone done throwed up  in your glass. But lemme tell ya, it’s the Fountain ‘O Youth!”

Then he pulled off his cap and showed me his hair. It was white with patches of dark gray.

“See this here? My head used to be fully white! Now my hair is growin’ back in dark. I’ll tell ya, it’s the Fountain ‘O Youth!”

Getting impatient!

Our chapter of CMDA (Christian Medical and Dental Association) hosted a practicing gynecologist from the area to come speak about his medical mission work in Kenya and Haiti. It was so uplifting and encouraging – he spoke straight from his heart and even teared up a few times when recounting a particularly difficult case. It was also really cool to connect with other Christian doctors from this area who came out to hear his talk.

Hearing such stories also makes me super impatient for med school to be over with and residency to start so that I can get overseas sooner!

Silly patients

Sometimes, you just have to laugh at some of the things people come up with during their visits. I’m not trying to be condescending or mean, but honestly there really are some ridiculous patients that come through the offices I rotate through. For example, on Wednesday I was at my general surgeon’s office hours, and a lady came in who had a thyroid nodule and was referred by her primary care doctor. She was an elderly woman, with bright pink nails, a leopard spotted fur coat, and immaculately done hair (which was thinning on top a bit). The surgeon looked at her ultrasound report, and made the decision that she didn’t need surgery at the moment, but he would follow it for further observation.

When he went in to tell the patient the good news, the woman cut him off midway through his explanation, and said: “Doctor, I have to tell you something. After I got that ultrasound, I noticed this flap of skin in my neck (which was normal old lady skin), and I am convinced it must have been from the ultrasound. It’s hideous! I don’t care what I have, but I am not getting another one of those horrid tests done ever again!”

She continued to berate him for allowing her to get a saggy neck, while whining that he had to fix it now. Needless to say, the surgeon was getting madder by the second, and told her he wasn’t a plastic surgeon and that there is no way an ultrasound could have caused her neck skin to sag. She flounced out, yelling about how “awful the service was.”

All I could think of was, “and you don’t care that you might get thyroid cancer?”

Melancholy day.

Last week I found out that one of my psychiatry continuity patients that I had been seeing all year committed suicide. He was only 26, like me. He was a really sweet guy, he had been doing so well too. He was slowly weaning himself off his medications (his dx was intermittent explosive disorder), and he was working and thinking of going back to school. Two weeks ago, he purchased a gun, took it home, and shot himself in the head.

His psychiatrist, a hardened veteran of the field for 30 years, teared up when he told me. “I’d like to go find out where he is buried and scream at his grave,” he said.

Last week was so hectic that I didn’t really get to process it at all. Today, I’ve just been reflecting on the briefness of life, the fragility of the human mind, and the depth of the abyss in which we are all teetering. At least it feels like that sometimes. It’s a constant push and pull not to give into the temptation to loose it completely. My psychiatry patients know this feeling best. The rest of us may approach it once in a while, but they live on that brink. I didn’t think he was that close. I didn’t even consider that possibility.

He was supposed to be one of my success stories.

“My time has come, and so I’m gone. To a better place, far beyond. I love you all as you can see. But it’s better now, because I’m free.” – Anonymous

It’s gettin’ to be that time…

When I figure out what I want to do when I grow up…

Sometimes, I just wanna crawl back into the womb, and be all like, “Mommy, feed me!” Not that fetuses feed, but you get my drift… (I hope.) I also love that in this photo, “Doctor” is 7th on the list, and under LAWYER of all things. I’d much rather be a ballerina than a doctor if we are being honest here, but that ship has come and gone long ago. Plus, I just don’t have the legs for it.

Anyway, so the past 6 months or so have been kind of a whirl-wind immersion into “doctoring.” I’m a little over halfway through the 3rd year LIC model (longitudinal integrated curriculum) so by now I have a fairly good idea about all of the specialties and what they involve. Theoretically, I should have SOME clue about what I want to do, but I’m still wavering. Thankfully, I have discovered what I do NOT want to do (and that’s how all the experts say to pick your specialty, right?) So here goes…

I do NOT want to do:

1) Psychiatry: I love my psych preceptor, but I don’t get hardly any inpatient psych during this rotation unfortunately. We did a few consults at the local hospital (which was a 20-bed joint in the middle of freakin’ NO-where) and a bunch of tele-psych conferences with the local jail, and I even did one consult at the jail myself (with a convicted murderer which was fairly intimidating), but as much as I try to love it, I come home every day drained and exhausted. Listening to people with serious mental health issues all day requires a very VERY special person. I find myself wanting to pray with every patient, not give them more meds! That’s another thing – outpatient psych is 99% medication visits. My preceptor does very little therapy because they have counselors at the psych clinic I rotated through who took care of that. Sorry Lucy, but I think you and I both should find a different specialty.

2) Surgery: Ok, I love the OR. No really, I do. (This is coming from the person who used to pass out at the sight of a needle.) I have two surgical preceptors, an orthopedic surgeon and a general surgeon. I usually go to the OR 1-2 times per week, and do 1/2 day of clinic. My orthopod is a fabulous teacher, I love rounding with him and seeing consults and he usually lets me close most of his cases. (For the non-medical – that means he finishes the majority of the case, closes the deepest layer of tissue, then hands me the needle and is like, go for it.) I get a majority of my suturing experience with him. However, he only really teaches me stuff about ortho. My gen surgeon is a fairly crabby, unhappy person who really really REALLY enjoys pimping and watching me sweat when I don’t know an answer. He rarely lets me do anything too complicated (basically – I am a human retractor for the most part, except when he lets me staple). However, although the pimping is painful, I learn a TON from him – he’s seriously like a genius. And I think he is starting to like me more now that I’m not intimidated by him anymore. So between the two of them, I think I have a fairly good surgical rotation. The only thing is… I could never see myself doing the same thing day in and day out, over and over again, for the rest of my life. My ortho is basically a knees and hips guy – I’ve scrubbed into probably fifty total knees and hips, with the occasional fracture or dislocation thrown in. I could do it in my sleep. I honestly almost did fall asleep during some of those cases – so bored was I! The gen surgery is more interesting – we do everything from gallbladders, colon resections and amputations, to carotid endarterectomies and fistulas. He also does a lot of breast biopsies and colonoscopies. But still… I think I’d get bored after a while, because for the majority of the time it’s gallbladders, hernias and colonoscopies. I’m pretty sure my grandma could do a hernia repair. So anyway, I learned that I am ok with blood (Praise you JESUS!) and I do like procedures, but anything past half an hour long and I want to slit my wrists.

Not to mention that all my classmates who want to do surgery are like this:

   

well, let’s just say… I’m no gunner.

3) Internal Medicine: Ok, my internal medicine rotation is somewhat disappointing. My preceptor started utilizing the hospitalist program right before I started, so I had no inpatient internal medicine except for two 1-week “bursts” in the hospital. I loved those. But the clinic is just like my family med clinic. Don’t get me wrong, the preceptor is great, I love his staff, and we have a fabulous and fun time, but I don’t feel like I am really getting the “flavor” of internal medicine. The bursts were definitely fun – I spent two different weeks assigned to 2 teams with an attending, a resident, an intern, sometimes a pharmacist, and me. They gave me a 4-5 patients to follow during the week (I totally could have handled more, but oh well.) We did ER admissions too which was fun. The experience was great, but I think that chasing around labs all day every day on chronically ill patients would get rather frustrating after a while. I liked being in the hospital, but I think that might also get tiring (i.e. I wouldn’t want to be a hospitalist.) And I definitely am not really interested in being super specialized and never getting to do any procedures, so I think internal medicine was out for me fairly early on. Plus, I do want to see kids (at least some kids – more on that later.)

Ok, maybe that’s slightly unfair – but internists do seem to order an absurd amount of tests. Maybe it was just my experience…

4) Pediatrics: Ok, by FAR my least favorite rotation. I hate hate hate outpatient peds! UGH. Not to mention my preceptor can be really annoying. He is one of those people who is jolly and happy in the room, but complains about every single patient the second he walks out of the room. And it is so incredibly boring. A typical day is 5 well child visits, a few “cold-like symptoms” visits, more well child checks, a kid with abdominal pain that turned out to be gas or constipation, more well visits, and maybe some kids who needed ADHD medicine thrown in at the end. And every parent thinks their child is DYING. I do very little inpatient peds which is really frustrating, (the lack in inpatient medicine is one of the serious problems with the LIC model, and I think there may be some changes in store for next year’s class). I do round sometimes with my preceptor in the hospital nursery, and once in a great while, he will send me to pre-round on an interesting case that he had admitted the day before, but other than that, it is outpatient, outpatient, and more outpatient. He is a brilliant teacher though – and a grueling pimper. Every single time I am with him, he picks a topic and endlessly questiosn me about it. He also makes me write up a full H+P on every patient I see (which meant I see only a few patients per day because I have to go write up the whole thing, by hand, and present it to him). However, I am getting very good at my H+Ps. Anyway, bottom line: I like kids, I want to see some kids, but I could never see kids full-time!

Yeah. Peace out, pediatrics!

5) Anesthesiology: Oops, almost forgot about this rotation. We had a 1-week rotation in anesthesiology, and I thought it was fabulous! They just kind of stuck us in pre-op (2 students per week) and said, “have at it!” The anesthesiologists that were working were more than happy to have a student to teach, because they never have students, and all the nurses in pre-op were wonderful and so nice. The nurse anesthetists were a little more grumpy because of their insane work hours, but I found one nurse anesthetist who we referred to as “The Colonel” who kind of adopted me and showed me everything he knew. I got to do a bunch of intubations, started tons of IVs, pushed meds and everything in between. By the end of the week, the Colonel let me have complete charge of an entire case – I intubated, drew up and administered all the meds, kept an eye on everything, and then extubated when it was over. It was so much fun! However, getting to do short procedures was the fun part. Learning about all the meds and airways and stuff like that… not so much. And their hours are horrible! So although it was a great rotation, I have to say, I don’t think I could do that full-time.

Nerd moment: A sweet view of the vocal cords through a Glidescope – which is by far the best way to do an intubation. Just gotta stick your tube through those two cords and you are golden!

Ok, so I need to go do some studying, so I’ll leave it here. Stay tuned next time for the specialties that I AM interested in doing. Can you take a guess as to what’s left?

So sorry!

…For the long hiatus. To the 2.5 people who read this blog, I really really really do apologize. My 3rd year of medical school has been a lot busier than I imagined. It’s a lot more difficult to do 6 rotations at once than you might think.

Well, ok. Let’s not kid ourselves. I’ve also been INCREDIBLY lazy since boards. After I get home from clinic or where-ever, exercise, eat something, and study for a bit, it’s already 10:30 and I turn into a pumpkin. So the blog took a backseat to rediscovering what a normal life feels like again. And let me tell you, this year has been fabulous so far. I love all of my rotations, and I’ve had some incredible experiences.

The LIC (Longitudinal integrated curriculum) is tough and sometimes crazy hectic, but there are some really cool things about it. For instance, a few weeks ago I was scheduled to be with my orthopedic surgical preceptor, but he only had one surgery scheduled for the day. So after the surgery, I found another surgeon and asked if I could jump on the rest of his cases for the day and check out some ENT surgery. He said of course, and I hung out with him the rest of the day until I had to leave to go to a different hospital for my ER shift. Turns out he had a consult there anyway, so I went with him to see the consult, which was a girl with an infected ear from a piercing gone bad. He drained the abscess and sutured it up, and then I then finished my ER shift. The next morning, I rounded on the patient, then went to my pediatric rotation. Turns out the girl was a patient of my pediatric preceptor, who had seen her right after I finished rounding – so he saw my note and gave me some pointers about her case. It’s crazy how integrated all of my patients are. One of my ob-patients I’ve seen for obstetric visits weekly for about a month, I did her C-section, then I saw her in the ER for an acute GI viral infection, then at my pediatrician’s office for her kids’ well visits. It’s so cool to start recognizing my patients and have them recognize me!

Anyway – I digress. So as a way to catch up on the last couple months, I’m just going to jot down a few quotes from my rotations that I’ve been keeping track of in my handy-dandy little notebook.  Some are hilarious, some are sad, some are just ridiculous. I am finding that I love people more and more each day. They say the funniest things and make me laugh and cry at the same time. Enjoy.

“Doc, I’m so stressed out right now, and on top of all that, I’m trying to get pregnant. Do you REALLY think now is a good time for me to stop smoking?” (Doc: “…”)

“I can’t sleep good no more, cuz I’ve got that swollen prostrate, and I gotta wake up every five minutes to take a leak.”

“It’s better to be bored than agitated, aggravated and irritated by the TV.” – Patient with paranoid schizophrenia.

“I’m smoking about 2 packs a day, but it’s ok, cuz I’m on oxygen, you know.”

“Doc, aren’t panic attacks kind of like tripping?”

“If my kids get married, I don’t know that I’d want him to come to the wedding. I just don’t think he would know the first thing about renting a suit. But he’s not that bad looking once he gets a haircut. It’s just that, well, he’s a hillbilly, Doc.”

“demen-SHI-ah.” = dementia

“Aurther-E-itis” = arthritis

“Doc, It’s my youngest son. He’s got me all a mess.”

“If they videotape you when you are under the influence, well, there’s not all that much you can do about it.”

“Hey Doc, I got that di-ver-tic-LEE-itis, and it’s hurtin’ real bad. Can’t eat them seeds no more. Cain’t do nuthin’ no more. Jeepers.”

“Doc, it’s my stupid mental shit. They just won’t give me my licence!”

“She went and told me she was going off with another man. How can a woman you’ve been with for over 30 years do that to you? She killed me. So I shot her. Oh God, I shot my wife. It should have been me. Why wasn’t it me?” (5 minutes later…) “So, I should probably get a lawyer, right?”

Sometimes medicine is just funny

This is an atrial myxoma (the most common tumor of the heart):

The sound that it makes if it somehow reorients itself and falls from the left atrium into the left ventricle is called, literally, a “tumor plop.”

I wonder how you would tell a patient that. I mean, you are ascultating their heart, and all of a sudden you go, “Oh HEY! You’ve got a TUMOR PLOP!”

Somehow I don’t think that would go over well.

Fun with Psych

In honor of our final block for Systems II – and succinctly put by our favorite Kaplan video personality:

“You do not catch a personality disorder, you ARE a personality disorder.”

Right now I believe I have a combination of schizophrenia, generalized anxiety disorder, and hypochondriasis – with the “bizarre delusions” being that I may actually make it to 3rd year.