One of the blogs I read recently had a patient come in with Flea-bitis. It reminded me of a mother who brought her son in to neurology clinic for a second opinion. Apparently he had been diagnosed with something that sounded like Gardenias. The neurologist and the NP threw out a series of potential neurologic conditions... Guillian-Barre, maybe? After a quiet moment, I volunteered, do you mean Myasthenia Gravis? Yes, she did.
Recently, characters on tv have taken to enrolling in medical school. For example, the revamped Scrubs show will be set in medical school (the original started in residency). I'm actually quite curious to see what Scrubs does with this as the first few seasons were a fairly realistic portrayal of life as a resident.
On Brothers & Sisters, the youngest son and war vet, Justin, started medical school this season. His classes don't really seem anything like mine, but that could simply be a curricular difference. Medical schools all teach the same facts the first two years, but the approach to disseminating the information is quite varied. What was interesting though, it that they wrote him as a stressed out character that became removed from everyone else in his life. He lost track of much of the family gossip and was not there to support his girlfriend during his midterms; even telling her "there are going to be times when I'm not there for you."
I actually really appreciated this portrayal because honestly, that's how it happens. Like it or not, everything else comes second to medical school. Right before a final exam, your laundry, the dishes, phone calls to parents, gchat - everything is put on hold. If you're dating a medical student and you have bad news - hold on to it until the exams are done. Think of it as a preview for life to come: if you marry a doctor you will always come second to whatever patient is on the other end of that beeper. My 10 year anniversary? My daughter's first ballet recital? Your father's funeral? If I'm on call and that pager goes off... I have to go.
We joke about it sometimes, but I'm a little scared. In not too long I will be responsible for people's lives. I am leaning towards pediatric subspecialties; that could be your child. And if it was your child - consider - aren't you glad that I put everything else second to my education?
While gchatting (ostensibly studying neurology) a friend sent me a news story (from the science section?!) detailing how much skin a woman should show to maximize attractiveness to nearby men.
Methods: This was an observational study in which the authors used percentages of the body to determine the amount of exposed skin. Each arm was 10%, each leg 15% and the torso 50%. They they counted how many times each woman was approached. Neither the men or the women knew they were being studied.
Results: Women showing more or less than 40% exposed skin were approached less frequently.
Conclusion: Women showing less than 40% sent "prude" signals and women showing more sent "whore, adulteress" signals.
My immediate reaction was not "what a stupid thing to study" or "how can they claim to know what the men were thinking" or even "how does the methodology account for the possibility that the 40% women just happened to be the hottest regardless of clothing".
No, my reaction was: they got the body percentages wrong! Commonly used body surface area percentages for estimating burn injury are shown in the picture.
picture from UofM burn website: http://www.traumaburn.org/referring/fluid.shtml
Thanks to medical school I now know:
- The annoying twitching that my left deltoid has been doing all day is called a fasciculation.
- My myopia will likely mean a later onset of presbyopia (compared to non-myopes).
- When I was a child I had a form of parasomnia (I sleep-talked; c'mon, who's surprised?).
- Neurologists like disorders with either 1) long names or 2) eponyms 3) both for the same syndrome (ex. acute demylinating polyradiculoneuropathy aka Guillian-Barre)
- Ophthalmologists also like long names, but prefer they end in "-ia" (ex. internuclear opthalmoplegia)
- If you eat contaminated pork, you can get pork tapeworm (T. solium), but if you eat a carrot contaminated by someone with pork tapeworm you get neurocysticercosis so cook those carrots good (see picture above).
- Laser Assisted Subepithelial Keratomileusis (LASEK) surgery involves shearing a flap into your cornea, while you are awake (with analgesic eye drops, picture).
- Anesthesia is technically only central nervous system depression. When you are put under you also get neuromuscular blockade (paralysis), analgesia (pain control) and amnesia (no memories).
- A symptom of hepatic (liver) failure or renal (kidney) failure is asterixis (characteristic hand flapping). It is likely accompanied by encephalopathy (altered mental status). Oh, and you're in danger of dying, soon.
Recent quotes from lecture:
"Our country handles schizoid personalities very well. That's why we have software engineers, pathologists and Montana." -Dr. J
"Biopsying an aneurysm is not a successful procedure." -Dr. G
"If someone's head is cut completely off, that's not an emergency - that's a tragedy." - Dr. G
Medicine is full of big words with very specific meanings. Here is a fun paragraph from today:
Internuclear ophthalmoplegia (INO) is indicative of a particular opthalmoparesis. It is a disorder of conjugate lateral gaze in which the affected eye shows impairment of adduction. When the partner eye is abducted, it diverges from the affected eye. This produces horizontal diplopia. During extreme abduction, compensatory nystagmus can be seen in the partner eye. Convergence is generally preserved.
You realise you washed suture with your white coat.
AND you're excited it's still in tact so you can practice.
I felt a certain pressure to match last year's pumpkin. I fear I did not manage it.
Last year:
This year:
I'm pretty sure I just heard Chase, on the show House, order Streptokinase and heparin. That would be a no-no. You can use tPa with heparin, but not streptokinase.
The environment of medicine is all wrong on the show, but usually the medicine (diagnostically) is accurate. Where was your physician-fact checker? Tsk tsk. I'm disappointed.
Time I got paged this morning: 5am
Hours of sleep I got: 3.25
Time I waited for my patient to pee: 8hr 37min
# 12oz coffees I drank in that time: 2
# times I peed in that time: 3
A recent assignment for school caused me to recollect a patient from my previous hospital. An excerpt (the original essay is several paragraphs longer) from my assignment summarizes the story...
The patient, an 8-year-old boy, was the elder of two sons of a recently immigrated family. He had been admitted for status epilepticus, which proved to be refractory. He was ultimately placed in a medically induced coma (which he continued to seize through for a month) and the parents were asked whom else they would like present for a discussion of his prognosis.
The family requested that a doctor from their home country be involved and so a teleconference was established. Various members of the care staff reported their opinions and summarized the boy’s course to date. There was almost as much silence as there was talking and each person was careful to solicit and answer questions. The questions themselves guided the discussion. The parents really needed to believe that every option had been exhausted. They believed that because we had been able to find an etiology, we should be able to find a cure.
From a physician’s perspective, after a month of seizing and coma there was likely to be little brain function left. A multitude of testing revealed a genetic defect in a sodium channel, which was blamed for the seizure activity. The boy was not a surgical candidate because the seizures were multi-focal and originated from both hemispheres. Everything had been tried and nothing would break the seizures, which were still occurring roughly every three minutes. There was nothing more that could be done.
Most of the conversation centered on the futility of our treatments. That we, as doctors, could not even promise he would wake up if we took away the sedatives. Eventually the parents chose to withdraw support. I think they knew their decision from the moment they sat down; they just couldn’t say it out loud. I didn’t get the sense we had persuaded them; more that we gave them a safe and justified way of letting go and not feeling as if they were bad parents, that they were simply giving up because it was hard.
It was then, when they stated their decision, that I was so thankful for the private room (not a patient room) the whole conversation took place in. The family had somewhere they could be where they wouldn’t be disturbed or overheard. Not by a nurse who needed to take vitals, not by a doctor checking on another patient. They couldn’t hear the business of medicine still working around them, healing some of the other children who would eventually be able to go home to their parents. But the room also allowed us, as the medical staff, to separate the conversation we just had from the rest of our work. When you walk out the door and back onto the ward, you leave the heaviness in that room and focus on health and healing on the floor. The spatial separation aids the mental and emotional one.
That separation is not learned with one conversation. Or maybe it’s always imperfect. But I do know that I was unusually quiet the rest of the day. When a friend needed sympathy later that night, I just couldn’t muster any. His problems seemed so petty. The boy was only eight and he was dead. Dead because of a sodium channel, which seems like such a insufficient and small reason. He had a little brother who clearly didn’t understand what had happened. He had a mom and dad that somehow had to keep going. And while I wasn’t consciously dwelling on it, something in me didn’t let it go immediately. Within the week though, the petty problems regained their gravity and the pressing concerns of work and medical school applications took over.
- * - * - * - * - * -
I have to admit that delivering bad news became easier. Maybe not in the moment, but my recovery got much faster.
With regard to the family in the story, the little brother had ongoing issues coping with his brother's death. I personally think some of this had to do with the fact that the parents never allowed the younger son to visit the older one (they didn't want him to see his brother sick or in pain). Then again, I am neither a parent nor a psychologist, so I am not at all qualified on the subject.
Today at noon the National Physicians Alliance Foundation and the American Medical Students Association held a National Grand Rounds policy panel discussion on the current legislation on health care reform. There were three panelists: one from the House, one from the Senate and one from Health and Human Services. The questions were relatively predictable, centering on access to primary care, the public option, tort reform and quality of care. The answers were similarly predictable: sound bites encapsulating pretty much what we want to hear and how historic this whole endeavor is. Pleasantly vague and bland, with little actual substance.
I would really like to see some of the legislators being honest about some of the real, and short-term unsolvable problems we're facing. How do we increase the number of primary care physicians to what we need when there aren't enough doctors going through school? How are we going to decide what medications and procedures are covered under the new insurance? How are we going to reduce the paperwork burden? How are we going to pay to insure/care for all these new people - most of whom cannot pay themselves? Because let's be honest, there will be a physician shortage in the short term and ERs will get even more crowded. We won't be able to cover everything for everyone. All these new committees and program will produce bureaucracy and without some planning, that will fall on docs and hospitals. And we don't have the money to cover all this new healthcare - either taxes will need to go up or spending will need to be cut. Public hospitals will need cash from the government to cover the services they have to provide to the population. Those are just realities.
The panelists all indicated in their introductions that their comments were off the record for any press attending, so it would have been nice if they had actually said something.
Interesting fact: Identical twin transplant recipients do not need immunosuppression.
Another interesting fact: The first dialysis machine was made out of sausage casings and a bathtub. (picture)
Health disparities fact: While ethnicity is not a match criteria for organ transplant, blood type is. Caucasians (who form the majority of donors) tend to be O & A blood types. African Americans, who have the highest need (for kidneys) have a much higher incidence of type B blood. (source: http://www.bloodbook.com/world-abo.html)
abscess
arrhythmia
component
dilated
epididymis
etiology
exercise
fourchette
gynecomastia
immunoflorescence
staphylococcus
wenckebach
I made an appearance at a local bar's grad night last night. None of my friends would go, but I met up with some classmates and made an appearance anyway. I was hoping at least one of the two cute guys I notice would be there. Neither was. A friend introduced me to his friend, an attractive German who was doing two months of research here. The German and I chatted for 30 minutes or so. Today I find out the German thinks my classmate is the most beautiful thing he's seen and that I was supposed to introduce them.
This comes after last weekend's fantastic ego boost of being told that I don't seem to know how to have fun. Not only did I let that slide, I was supposed to meet up with that guy later in the evening. He never showed.
FML.
Old woman to doc: Dr, When I arrived at the hospital I had one leg and now I have two!
Doc: Well, there is a war on, is it possible you miscounted?
-Dr. Who [episode 10 season 1]
