Memories

During the first month on my medicine rotation, I met one of the most memorable patients I have ever known. She was a 23-year-old woman with scleroderma who presented to the ER with nausea, vomiting, and decreased appetite. When I went down there to see her, I practically stopped dead in my tracks. She was a textbook example of all the complications of scleroderma, but I was wholly unprepared for what exactly that looked like.

Cachexia is a poor descriptor of the degree to which she was wasted; she barely weighed 80 pounds. Her skin was pulled taut around what little muscle remained. Her gaunt face was accentuated by a small oral aperture, insensitively termed a “fish mouth.” Contractures deformed her upper extremities, with digital ulcerations affecting the distal tips. Large amounts of calcium had deposited along her arms and knees and they constantly elicited excruciating pain. Her legs were wrapped in gauze and hung over the edge of the bed with a special pillow underneath her knees.

Removing the gauze caused such significant pain that it wasn’t until the next day on rounds that I was able to see what was underneath. Her foot had been amputated and a massive non-healing ulcer had formed around her heel, encompassing the entire stump and delving deep into her flesh. Watching her mother unwrap that dressing was a harrowing, heartbreaking experience for me. Instead of screaming in pain—which would have been easier for me to handle—she simply became quieter as her eyes filled up with tears and her mouth transformed into sobs. And she needed dressing changes twice a day.

But despite all her disease, she was a pleasant and gregarious young girl. She was taking online courses at Arizona State. She had gone on a family vacation to Puerto Vallarta a few weeks prior. For all intents and purposes, she had been leading a relatively normal life. That is, until this hospital stay.

Listening to her heart revealed tachycardia. We tried repleting fluids to counteract her decreased PO intake, but all the extra volume would drain out of her leg ulcer and require TID dressing changes. We gave her a Dilaudid PCA to help resolve any pain that might be increasing her heart rate, but we could neither control the pain nor the pulse. We eventually sent her for a CT angio to rule out PE, which again came back negative. Out of options, we consulted a cardiologist who specialized in scleroderma. None of us were expecting the cardiac MR he recommended to show severe ischemic damage with reduced ejection fraction, but that is precisely what happened.

Earlier in her stay we had consulted plastics to examine her ulcer. They were not impressed by visual inspection, but they recommended an MR anyway. The scan revealed osteomyelitis, but her arterial supply was so severely impaired that she would not tolerate a bone biopsy or surgical debridement. She would need 6 weeks of empiric IV antibiotics and follow-up discussion of a possible above-the-knee am­putation (where her blood flow remained strong) sometime in the future.

To make matters worse, she was started on TPN (a poor prognostic indicator) and was still losing weight. We discharged her home from the hospital on my last day on the floor. She was still nauseated and in severe pain, but she wanted to be with her family for Easter Sunday. We were powerless to make her better. Instead we just made her parents all the more aware of just how sick their little girl was. I felt awful.

I took care of her during my entire month on service and she has stayed with me every day since.

Patients

Every patient I’ve taken care of has fallen on a spectrum. On one end are people I enjoy being around. On the other are those patients I dread rounding on each morning. The way I act around these patients also falls on a spectrum. I know for a fact that when I’m taking care of people who smell foul, I spend less time in their room attending to their needs. Likewise, when I’m with someone who treats me well and is easy to get along with, I don’t mind spending a little extra time in their room. That’s just human nature. We like being with people we like. We hate people with putrid odors and those who speak down to us.

During my medicine rotation, I had two patients who were severely demented. One was pleasant and one was mean. Ms. Pleasant had a very demanding family of lawyers. When her son first came in to the hospital, he paged the nurse to talk to someone on our team. I broke off rounds to speak with him, and he immediately asked for “my rank.” Quickly realizing that I had little actual authority, he didn’t hesitate to let me know it: “I need to speak with someone two pay-grades above you.” (Sam joked that two pay grades above a medical student is probably environmental services.) Ms. Pleasant’s family aggravated our entire team and forced us to spend an inordinate amount of time answering all their questions, to the point where we were always working late just to give all of our other patients a fair level of care.

Ms. Mean also sucked away our time. She couldn’t see and felt compelled to have her room phone at arm’s length at all points in time. She made me spend more than 5 minutes adjusting the position on her lap so that she could reach it in the off-chance that someone might call. Whenever I tried to leave, she would always yell at me to come back. Usually it was to reposition the phone or make a phone call for her. Eventually I had to tell that it was not my responsibility. I reminded her that she was in a hospital and not a nursing home. We have lots of duties around the hospital and we can’t spend our time doing those things. I found it really hard in that situation to strike the balance between making sure she was cared for appropriately and making sure everyone else I was responsible for was as well.

The question when it comes to these variable feelings and actions is whether it affects patient care. I certainly don’t enjoy spending my time holding my breath and trying not to grimace, but I make sure I leave with them understanding their disease and why we’re ordering the tests we’re ordering. Even if it takes five different ways to explain something, I don’t ever cut a conversation short if they still have questions. I might linger a little more with friendlier patients, telling jokes or making chitchat, but I don’t ever do it at the expense of other patients. I have yet to break the rules for anybody just because I like them (but maybe that’s because I don’t have any power to break any rules). Still, walking this line will always be a fine balance. There’s no easy way to make sure you’re always doing the right thing. There’s no rule book. Taking care of patients is an art in constant flux.

Complaining

People love to complain. Medicine complains about nurses. Nursing complains about doctors. Surgeons complain about anesthesia. Patients complain about food. Consults complain about getting consulted. Neurology complains about anything and everything. People love to do it, and I’m especially thankful for the people who can do it in hilariously sarcastic fashion. But at some point it just gets old. It ceases to be playful and simply becomes antagonistic. Complaining eventually harbors an atmosphere of negativity and pessimism that is detrimental to team-based care. Worst of all, it reflects poorly on you. It makes it seem like you don’t want to be a physician.

We’re doctors. We should want to help people. We should love doing our jobs. Yes, some families are more difficult to deal with than others. (I’ve had one family member tell me that they need to talk to someone “two pay-grades” above me. I’ve had another tell me her husband was a partner with Feinberg and that “if he knew what was going on here, he would take back this building!”) Yes, some parts of our job are less glamorous than others. But being a doctor is a privilege, not a right.

We are lucky that we can go up to a stranger and earn their trust instantly. We are lucky to be able to break the news that they have metastatic lung cancer to their brain. And we are especially lucky when we can tell them we can cure their disease. We should spend more energy remembering how lucky we are and less energy complaining about how unlucky we are.

But it still goes on. And if there’s one specialty that bears the brunt of all this complaining, if there’s one department that is universally dumped on, it’s emergency medicine. Everyone makes fun of them. Even the nicest people on the planet have a joke on hand to poke fun at emergency. We all understand that their priorities are different than ours, but for some reason it’s still humorous to suggest that they put a CT scanner at the entrance of the ED. If we don’t know why a test was ordered on admission, we just brush it off as being expected from the ED. All these jokes are fun to laugh at now, but what about next year when I’m on the receiving end? I don’t want to be reduced to a stereotype, certainly not a witless and wasteful one at that.

The one reassuring thing I’ve taken from my experience is that people complain about what they don’t want to do. I’m glad the people complaining about emergency medicine are not the ED docs. I just hope the same people who complain at least get energized and excited by whatever it is that they practice. Because who wants to be a Negative Nancy anyway?

Impressions

Impressions are damaging. They’re mocking recreations of others’ peculiarities and speech habits. And I’ve heard more than my fair share of them in medicine.

Now, I’m not sure why the people doing these impressions are physicians, because they’re so good they could be stand-up comedians. They are pitch-perfect facsimiles and hilarious ones at that. And they’re not always negative or bad. (One resident enjoyed quoting my attending Dr. Rosenow by saying, “Rose like the flower, now like right f***ing now.”) But more often than not they’re done out of frustration or exasperation, when they’re tired and stressed, overworked and underappreciated, without any thought to the person they’re aping.

One particular impression struck a chord with me during my neurosurgery rotation. One of our patients was somewhat of a curmudgeon at baseline. He was also hard of hearing. For a few weeks he had been encephalopathic and there was not much to do for him besides daily exams during rounds and fruitlessly attempting to get him placed at a skilled nursing facility.

He had a distinct personality, preferring some residents over others. His responses to our questions of person, place, and time were oftentimes disoriented. Or they were completely unrelated statements. “Where did BETTY go?” he would shout. When I was removing staples from his scalp incision, he would periodically jerk his head and grunt nonsensical sounds. I grew fond of him as the residents grew weary and annoyed.

During down time in the resident conference room, one of the junior residents did an impression of him that was nothing more than loud grunting. The senior resident commended him, “Hey, that’s actually pretty good.” I laughed, although I wish I hadn’t. I felt embarrassed and ashamed, and found it difficult to look him in the eyes the next day on rounds. I had to step outside of my environment, where it’s okay to say and do stuff because I know I’m not being watched or judged, and assess myself. Is this the kind of thing I can stand behind if someone were to overhear me and confront me about it?

Rising from the dead

My title isn't referring to something awesome. It's more of a reference to the fact that I'm posting on here again. I looked back and found that the last time I posted anything was in August and it was a stupid youtube video that is actually a dead link now. Yay. Deleted.

I've been reading Steve's posts and every time I think that I should post something about my parallel experiences since we're both in medical school. So I've heard. (Although he has to do short writing assignments for school.) But this is generally how things go for me I guess as all of my posts seem to start with "So I haven't written in a while..."

The inherent issue with publicly writing about experiences within medical school are the obvious HIPAA, or confidentiality difficulties. We have to watch out for 'patient identifiers' but they can be pretty damn vague sometimes so in the past I've attempted to write about something wild and crazy in the hospital, but I was hesitant to post at that time because, however ridiculously unlikely, someone could figure out location, time of year, and specific problem to a specific patient. I just didn't want the potential conflict. At least I wasn't posting pictures on facebook.

Anyway, in April I finished taking my last rotation exit exam, which are called our 'shelf exams' - they're a group of standardized questions for each specialty developed by the National Board of Medical Education (NBME) and they're pretty damn hard. What this really means though is that I'm done with all of my third year rotations and now I'm starting up fourth year. It's really hard to believe that I've finished all of my core rotations and that 5 of 12 months were spent at away sites like Roanoke Memorial, Salem VA Hospital, and Shore Memorial. In no particular order:

Psychiatry (Roanoke)
Internal Medicine
Ambulatory Internal Medicine (Eastern Shore)
Family Medicine (Fairfax)
Pediatrics (Roanoke)
Pediatric rehab
Plastics
Orthopedics
General Surgery (Salem)
Hepatobiliary Surgery
Neurology
OB-Gyn
Geriatrics/Anesthesia/Emergency (kind of a weird mutant hybrid rotation)

So far for my fourth year I've taken my big Step 2 Clinical Knowledge exam, rotated through the MICU (medical ICU), hematology consult, and now I'm in Sacramento working for a month in the UC Davis Medical Center Emergency Department. It's funny that this post comes right after Steve's post about complaining about the Emergency Department because that actually was a big hesitation for me until I finally decided to pursue Emergency Medicine for my future. In short, I didn't realize that people complained about everything and that the ED was just a natural target and so I just kind of saw EM docs to be shitty doctors. Well, I didn't want to be a shitty doctor, but now I really realize that it isn't up to the specialty that I pick, but rather it's more up to me anyway. Plus I love working in the ED. I'm currently in California trying to get a foothold out here and getting my face and name recognized so that when residency match comes along, hopefully I'll land a position somewhere out here.

Anyway, future posts will be rather quick and I'll probably go back and tell some funny or engaging stories from my third year rotations, like the guy who thought he was one of the four horsemen of the apocalypse, the 650 lb lady that I was assigned to deliver her baby (how did she get pregnant?!), or 13 hour surgery that I was scrubbed into, unable to eat, piss, or bring my arms below my waist. Forget sitting down.

Bright futures, bitches! Rising from the dead! Zombie medical student! Working hard to be a zombie doctor! "I CARE ABOUT YOU!!! GARRRARGGHHH!!"

Update!

Hi friends!

It's been too long. I'm going to break Steven's iron grip on this blog and share a little piece of news. I can elaborate more on the details to you guys separately since I don't want to spill everything in this forum, but...I got offered a job in DC! I applied for it before I went off to Australia in January (oh yeah, I went to Australia) and spent the past couple months interviewing. Just got the thumbs up yesterday.

So I would've killed for this job a few months ago, but now that I actually have the offer I have to think a bit harder. Would love your advice if any of you are free!

Medical Education

Neurosurgery and pediatrics are two very different rotations, especially when it comes to teaching. At Children’s Memorial Hospital, there are two hours (8am and 12pm) reserved every day for resident teaching. There are signs at every nursing station that remind them not to page during those hours unless it is absolutely urgent. The sessions are set up for case discussions and they focus on the important, relevant points of diagnosis and management. It was set up so that I could contribute and not feel stupid (even though I never did).

On neurosurgery, there are four conferences each week that students are required to attend. Two of them are for residents only, with presentations given by either attendings or fellow students. The topics themselves can be fascinating, but they often cover very specific details that are irrelevant for students rotating through. The latest conference I attended was nothing more than an overzealous attending and a 90-minute pimping session. Even if I knew an answer, there was no way I would offer it up, because the resident who didn’t know would probably feel insulted and proceed to make the rest of my rotation miserable. The other two meetings essentially consist solely of attendings arguing over the minutiae of rare and complicated cases and their surgical plans while the residents answer pages or stare at their phones for the entire duration.

On pediatrics, this constant learning mentality extends into the resident-student interactions as well. The residents took the time out to give us lectures, review cases, and quiz us. If anything, they were afraid that they were spending too much time teaching us. The first day on my inpatient infectious diseases service, the chief resident took me and my teammate aside, told us how the computers worked and where to find important information, printed out flow sheets for us to use, gave us advice on how to present, explained the team dynamics and roles, and made us feel welcome.

On my neurosurgery block, I blundered around my first day feeling ignored. No one seemed to care that I was there until I got in their way. After following them around on rounds not really knowing what was going on, I found a friendly face to scrub in with. By the end of the day, I had no idea what my roles or responsibilities were, how I could help out, or what kind of information I was supposed to learn from my rotation. It wasn’t until the end of my first week that I started feeling comfortable and part of the team.

It’s no mystery that I feel like pediatrics got it right and neurosurgery got it wrong. There is an inherent problem with how “teaching” occurs in neurosurgery. Everyone is always expected to know everything about neurosurgery before the rotation begins or even before their residency begins (except maybe the finer details of management, which you can argue about once you’re an attending). If you don’t know the answer, you feel embarrassed and study furiously after you get home from working for 14 hours. There really is no teaching; there are only unrealistically high expectations. As I was watching the train wreck that was one resident’s attempt at a logical answer to a question, I couldn’t help but think to myself how much more effective it would have been if they had just taught it first.