Wednesday, November 30, 2011

surgery: day 37

2 preceptors down, 1 to go
Tonight I will hopefully watch organs being harvested!!!
Some moments in the OR are pretty dang cool
An oral exam and shelf exam approaching way sooner than I'm ready for
No motivation to study at all.  What so ever.
At least I made flash cards for the oral exam though
That's a start, right?
16  days until winter break!

Tuesday, November 29, 2011

Listen to your patients

"Listen to your patient, he is telling you the diagnosis" -Sir William Osler

Over my past 2.5 years of medical school, I have heard this quote over and over again.  It is mostly used in stressing the importance of taking a complete and detailed history.  It is used to say that the patient will relay the pathological signs as puzzle pieces, pieces that even a low level clinician can put together.  Think about the big wood toddler puzzles where there is no way a piece can be places in the right place.

My surgery attending, an old seasoned veteran surgeon, has recited this quote every time a patient comes in with mid-epigastric pain that radiates to the shoulder and is accompanied by years of "reflux" pain that is non-responsive to medication.  The patient may not use those exact words or explain it in text book order, but the patient is painting a clear picture of gallbladder issues.

I was recently reminded that listening to the patient can work the other way too.  Patients who come in with complex, in-congruent, complaints.  Patients who have pathology that clearly did not read the textbook.  These are the patients who are negative for every horse and most zebras, the patients who end up with diagnoses of exclusion.  The amazing part though?  We as providers approach the patient totally defeated, as if we have only apologies to offer, and they respond with complete affirmation and relief, as if they have known this to be true all along.  Their shoulders sink down, their spine uncurls, and they relax for the first time in a long time.  Then, when empowered, the patient begins to tell stories about why they expected this diagnosis long ago or how this diagnosis explains so many seemingly trivial signs they didn't mention before.

It amazes me how many different ways there are for a patient to tell you the diagnosis.  We just need to learn all the different, and subtle, ways to listen.

Tuesday, November 22, 2011

11 things I'm thankful for in 2011: MS3 edition

11. The PxDx app on my smart phone that lets me log actual patients on the go instead of having to make them up at the end of a rotation.
10. The MyFitnessPal smartphone app that is allowing me to not gain weight while living off crappy hospital food.
9. Protein bars & peanut butter packets for keeping my energy up when meals don't exist.
8. Big pockets in my white coat as I'm not sure how else I'd manage to keep my whole life on me at all times.  Seriously, my white coat may weight 20 pounds, but I can survive anything with it on!
7. Old handed down notes & advice.  Save time, save energy, learn from someone else's mistakes.
6. Finally being done with step 1!
5. Knowing exactly how many exams stand between me and the end of medical school: step 2, 4 shelf exams, and 1 departmental exam.
4. My immune system for keeping relatively healthy while expose it to every germ under the sun.
3. Nurses.  Particularly scrub nurses.  They repeatedly save my ass over and over again when I have no clue what I'm doing on the floor.
2. Family & friends that seem to understand why I don't have time to call them back.
1. My patients for being extraordinarily patient and generous with their time and bodies as a bright eyed and bushy tailed medical student learns from them.

What are you thankful for this Thanksgiving?

Saturday, November 19, 2011

Becoming a statistic

Monday, 3 weeks into my surgery rotation, I became a statistic.  I stuck myself with a suture needle in the OR while attempting to close the patient.  There was a moment of silence in the OR.  The scrub nurse and my attending glared at my with wide eyes while their masks concealed their facial expressions.  Were they smirking?  Were they frowning?  The sound track of "shit! f#@k! Damn! I screwed everything up!" echoed in my head. 

As per the scrub nurse's orders, I placed the needle on a non-sterile field and pulled off my glove to have my hand inspected by the circulating nurse.  There, on the palm on my left hand was a small little speck of blood, signifying that I broke skin.  The circulating nurse's response was "shit!... well, I guess you need to go to the ER now."

What did I do?  I went to the sink and washed my hands with soap & water for a good long time.  I looked through the patient's medical chart weighing my options.  Then, in one of my less proud moments, I decided to forgo the OR in trade for going home.  I had been at work 11+ hours for the last 8 days.  I was exhausted, and embarrassed, and not wanting to make a stick of something with such a low risk. I didn't want to be put on HIV prophylaxis as I'm sure it'd screw up my diabetes big time.  There isn't anything that can be done for Hep C...  Plus, since being on surgery I've heard so many attendings tell war stories of being stuck and mocking the whole contact precaution protocol. 

"Researchers surveyed surgery residents at 17 medical centers and, of 699 respondents, 415 (or 59 percent) said they had sustained a needlestick injury as a medical student. Many said they were stuck more than once. Of the surgeons-in-training whose most recent needlestick occurred in medical school, nearly half of them did not report their injury to an employee health office, thereby avoiding an evaluation as to whether they needed treatment to prevent HIV or hepatitis C." -Medical Students Regularly Stuck By Needles, Often Fail To Report Injuries 

The story doesn't end there though.  I fixated on the needle stick, kept contemplating my decision, weighing my options.  I talked to my girlfriend, a few other medical students and a few residents whose opinions I trust.  Then, on wednesday, I made the mistake of mentioning the stick to my program site director & the surgery clerkship director.  That was it.  Wheels started turning leading me to employee health.  Phone calls were made.  Documents were filled out, papers were faxed, and emails were sent.  4 tubes of blood were drawn and plans were discussed to report back in 6 weeks, 3 months and 6 months.  

Nearly a week after the initial stick, I still feel like an idiot.  My dexterity is clumsy when it comes to using a needle driver, as was pointed out in my mid-block evaluation yesterday.  It did prove to be a lot of hoopla for a little event, a tiny tiny stick.  But you know what?  Wednesday night I went to bed with a clear conscious that I was doing the right thing.  Yesterday I breathed an even deeper sigh of relief in learning that I'm currently HIV and Hep C negative and Hep B immune.

Wednesday, November 16, 2011

View from the other side of the curtian

I got a call last night that my grandma was being taken to the hospital.  She had an acute change in mental status which prompted a blood draw from the visiting nurse which lead to a realization that she's significantly hyponatrimic (low sodium). 

When I went to bed last night, she was still being evaluated and stabilized in the ED.  Soon after I woke up, my mom called to ask how invasive central lines and arterial lines are.  She informed me that she's in the ICU, still lethargic, low serum sodium & high WBCs, and the doctors think this is all from a UTI.  She's maintaining her pressure relatively well on just simple fluids. 

While my 94 year old grandma has been DNR for a long time, there is no clear delineation on what falls into the resuscitate category.  There wasn't going to be any gastric tubes 5 years ago when a stroke meant she could no longer eat without aspirating, but then she was deemed confident enough to make that decision on her own and somehow that tube has kept her alive all this time.  So, the G-tube stays put.  My mom & uncle have decided that there is to be no intubation, no CPR, no trips to the OR.  But what about the gray area?  IV fluids, antibiotics, pressors, medication to stop an arrhythmia, etc...

So many times throughout 3rd year, I've heard physicians tell family members "if it was my mother/grandmother/sister/daughter I wouldn't want them to go through this, to suffer..." From the outsider's perspective, those conversations always seem relatively straight forward with a clinical decision based on the laws of probability.  From this perspective, it is much less straight forward.  She has already proven that she can overcome the impossible as she has been at death's door too many times to even count.  She's completely content with a dependent life, even if it one that I would never want for my self.  I'm realizing that making these decisions based on emotion and knowledge of the person is much more complex than making them clinically. 

Being the person the MY family turns to for medical advice is much more difficult than playing that role for others.  I'd like back to the other side of the looking glass now.

Saturday, November 12, 2011

Adding to the short list?

Yesterday morning during surgery lecture we had a specialty talk on urology.  Guess what?  I found it fascinating!  It is a procedure biased specialty.  Procedures that often allow for significant improvement in the lives of some patients.  The doctor patient relationship can develop over long term care.  It involves reproductive and sexual health.  And, on top of it all, robotic surgeries?!!!  Yep, urology is now on my short list of potential career options. 

New short list:
-ob/gyn: general, MFM, gyn onc, adolescent
-peds: general, adolescent health, PICU, neuro, GI

Wednesday, November 9, 2011

A day of firsts

Today's been a day of firsts:
*my first time scrubbing into multiple consecutive surgeries, 3 to be exact.
*my first time using a scalpel on living human flesh.  Gross anatomy was the first time I had cut into other types of human flesh.  
*my first patient died, as in a patient I had followed from the very beginning of her hospital course to the very end.

Driving home I kept thinking about a comment a friend made to me when I started med school: "Keep a journal because medical school will change you.  You'll want to look back and see how." It is days like today when I realize how very right she was.

Monday, November 7, 2011

No on Mississippi Initiative 26 tomorrow

I'm a little afraid to see what tomorrow's election in Mississippi brings.  Why?  Rather than write up my own thoughts directly, I figured I'd compile a sort of meta analysis of what others are saying. 

        "Mississippi Initiative 26, the “personhood” amendment on the November 8th ballot, is not only dangerous for women’s health and lives—it is dangerous for our democracy. While not recognized as such, it is an openly theocratic endeavor. We should be talking about theocracy because this amendment is not just being fielded in Mississippi—it has been introduced in at least six other states, with more to come." -Carlton Veazey ('Personhood’ Agenda is Theocracy)
        "The term “fertilization” — which is sometimes considered synonymous with “conception” — could mean at least four different things: penetration of the egg by a sperm, assembly of the new embryonic genome, successful activation of that genome, and implantation of the embryo in the uterus. The first occurs immediately; the last occurs approximately two weeks after insemination (or, in the case of embryos created through in vitro fertilization that do not get implanted, never). Thus, on some reasonable readings of the amendment, certain forms of birth control, stem cell derivation and the destruction of embryos created through in vitro fertilization would seem impermissible, while on other equally reasonable readings they are not." -I. Glenn Cohen & Jonathan F. Will (Mississippi’s Ambiguous ‘Personhood’ Amendment)
        "...the amendment reaches so far beyond legal precedent and public opinion that even some abortion opponents — including the National Right to Life organization — are warning that it could harm efforts to overturn Roe. It's the legal equivalent of a poorly aimed grenade, one that could define as murder anything that results in the destruction of a fertilized egg or a zygote or an embryo."-Rogelio V. Solis (Editorial: Mississippi 'personhood' measure goes too far)
        "For all their sincerity and fervor, proponents of the personhood movement represent a small minority nationwide. In Gallup polls, support for a total abortion ban is almost exactly where it was in 1973 —at just over 20%, despite a rise in backing for limitations. Most people certainly don't want homicide charges brought against women who choose to have abortions or doctors who perform them." -Rogelio V. Solis (Editorial: Mississippi 'personhood' measure goes too far)
        "Many of us will vote against Initiative 26, believing it to exclude tragic conflicts in some life situations and to have unintended and unexplored consequences." -Reverend Hope Morgan Ward, Bishop of the Mississippi Conference of the United Methodist Church. (Thank you, Bishop Ward!)

If you're registered in Mississippi, please think carefully about the implications of your vote tomorrow.  Please, regardless of your political views, seriously consider voting no on this very destructive bill for the sake of women's lives, birth control, and fertility treatments.  History has shown that abortion wont stop on the basis of political decisions, but women's lives will be needlessly risked because of other people putting unnecessary barriers in front of competent health care.

Sunday, November 6, 2011

Impostor syndrome

noun fraud, cheat, fake, impersonator, rogue, deceiver, sham, pretender, hypocrite, charlatan, quack, trickster, knave (archaic), phoney or phony (informal) He was an imposter who masqueraded as a doctor.
Collins Thesaurus of the English Language – Complete and Unabridged 2nd Edition. 2002 © HarperCollins Publishers 1995, 2002

Imposter syndrome is a common phenomenon among medical students.   A malignant idea that you aren't actually smart enough to be a medical student, don't have what it takes to be a doctor, and were just accepted to medical school because someone accidentally confused your file with someone else.  

I struggled a lot with impostor syndrome when I was struggling through gross anatomy my first year, and again when I was retaking step 1.  It currently seems that surgery is bringing on another flair up.  Left unchecked, it can be a crippling condition and self fulfilling prophecy.

The acute onset began during an M&M presentation I had to do on friday.  I stumbled over my words.  Unable to present an orderly case and lacking the clinical terminology I have been taught to use.  It was a fine presentation but very elementary in nature.  Sure, I'm a medical student, of course my presentations wont be as crafted as my superiors.  However, I was sub-par to my contempariers in presentation style.  This event coming on the heals of receiving my mediocre pediatric shelf exam score, and immediately prior to not knowing the answer to the ONLY question I was asked by my attending that day just left me feeling defeated. Acute events of impostor syndrome lead me into a tail spin of desperation: just skidding by on my rotations, not matching for residency, culminating in unemployment and failure. Destructive thinking.

Hopefully this week I'll prove my knowledge and abilities, both to my attendings and to myself.  I sure as hell could use a confidence boost right about now. 

Wednesday, November 2, 2011

"Grey's Anatomy" didn't lie

Surgery is chock full of drama.  Unfortunately, it isn't the fun sexy drama, but rather the drama that comes with clashing strong personalities.  My day is filled with strong egos and quirky neurocies attempting to co-exist in a high tension environment. 

I love the procedures.  I find the breadth of pathology that we treat on general surgery to be fascinating. I'm even okay with the slow pace and meticulous nature of the day to day.  However, the surgeon's personality?  After only 9 days, I'm already ready to shove a scalpel into my own eye.  The god complex is painful on a whole other level.  Plus, I'm finding that the answer to everything is always "cut it out" which doesn't fit neatly into my idea of being a comprehensive [primary care minded/preventive medicine based] medical provider. 

44 more days to go...