Emergency Dept: week 4

Monday: chest compressions and a resident too busy to staff with me
Tuesday: no cath for you, more abdominal pain
Wednesday: just had his nose done and now it's broken, back pain, allergic reaction
Thursday: it's not your shunt but we'll scan you anyway, can't stop pooping
Friday: exam (that doesn't count)

Emergency Department: Week 3

Monday: name that heart rhythm...
Tuesday: just plain crazy x2, abdominal pain
Wednesday: off! pumpkin surgery.
Thursday: immunosuppressed and febrile, attending gave me homework?!
Friday: chest compressions, large bore IVs and a bladder scan
Saturday: mr anxious, mrs crazy and the guy smoking though lung cancer
Sunday: off (again)

Emergency Dept: week 2

Monday: Lupus, vomiting blood, strep throat, passing out.
Tuesday: Multiple orbital fractures, pelvic exam and a cheerleader with the flu.
Wednesday: Tech shift - peripheral IVs, appendicitis.
Thursday: Splints x3. Asthma. Oops, the baby ate mommy's pills.
Friday: Stitched up a chin, a forehead and an ear.
Saturday: Biliary colic, drunk, drunker and drunkest.
Sunday: off

Emergency Dept: week 1

Monday: orientation. started an IV on a classmate.

Tuesday: orientation. splinted a classmate.

Wednesday: abdominal pain x2, chest pain and hypoglycemia. started an IV.

Thursday: seizure, abdominal pain x2, chest pain. did an NG lavage and placed an a-line.

Friday (peds): poison ivy, lip abrasion, abnormal labs, abdominal pain, seizure

Funny thing about that poison ivy... the little boy had a small patch of it on his hand and a big patch of it in his groin area...

really?!

Me: What illnesses run in your family?

Patient's mother: My high blood pressure was giving me seizures so they took out my spleen.

Emergency Medicine orientation

"Sometimes the facial structures are traumatized, complicating the intubation. Although, it is a lot easier to get the jaw and tongue out of the way when they are disconnected."

"You want to make sure the NG tube is not in the lungs; it can't really decompress the stomach from there."

"He came in with a skeleton of a finger, no flesh, and said 'fix me.' Well, sorry dude, you're f*cked. There's no saving that finger. Degloving injuries require amputation."

"In Europe, not everyone who goes into a trauma bay gets a rectal, but here we log roll everyone and do a rectal exam. The surgeons love it."

it shouldn't bother me, but it does

I'm talking about medical inaccuracies on television. We won't even get into the inaccurate representation of resuscitation, which is so egregious that there is published research on it. Recent errors I've noted:

1. Nurses, unless they are CRNAs, don't intubate patients.

2. There is no such thing as part-time medical school.

3. You don't get a long white coat at the white coat ceremony, you get the short one.

4. Diabetics requiring insulin do not leave needle impressions on their hip bones.

5. Hospitals cannot turn away acutely ill patients because they don't have insurance.

6. You are not forbidden from speaking with a person after neurosurgery because getting them emotional could cause their brain edema to worsen.

7. If you coded, you would be moved to an ICU, not put on a stretcher along the hallway. And a lot of people would show up, not just one nurse.

8. I don't care if there's a killing spree, a random nurse would not be authorized to read confidential patient data (about a potential victim) over the phone to a police officer. She would be fired.

9. If a trauma victim is talking, they don't go straight to the OR. They go to the ER to be stabilized or for images. There is no magic hallway connecting the outside door to the OR.

10. If you sprained your pinkie finger, you would not have a hard cast placed on your hand.

Another time I'll let loose on the absolutely ridiculous depictions of medical school. I have yet to see anything that remotely resembles actual medical training on television.

Quatrains

I'm apparently late to the party, but I just stumbled across the poet Rumi. Some favourites:

You think you are alive
because you breathe air?
Shame on you,
that you are alive in such a limited way.
Don't be without Love,
so you won't feel dead.
Die in Love
and stay alive forever.

It is your turn now,
you waited, you were patient.
The time has come,
for us to polish you.
We will transform your inner pearl
into a house of fire.
You're a gold mine.
Did you know that,
hidden in the dirt of the earth?
It is your turn now,
to be placed in fire.
Let us cremate your impurities.

I am so drunk
I have lost the way in
and the way out.
I have lost the earth, the moon, and the sky.
Don't put another cup of wine in my hand,
pour it in my mouth,
for I have lost the way to my mouth.

More at http://www.rumi.net/rumi_poems_main.htm

Little m, big P

It occurs to me that I haven't really talked about residency applications, which actually comprise a lot of time and mental energy during the beginning of M4 year. I'm applying for a medicine-pediatrics residency. It's a four year program, at the end of which you sit the boards for both internal medicine and pediatrics. You are then eligible for any fellowship in either medicine or pediatrics, though 60% of graduates go into primary care. Not me - of course - I will be headed to fellowship.

There aren't very many med-peds residency programs, and each one takes very few candidates. Thus, this residency is competitive because demand outstrips supply. Nevertheless, my advisors tell me I will match.

For those of you who don't have relatives in medicine, I will briefly mention what "the match" is. Basically, as a 4th year you apply to some residencies. The ones interested in you will invite you to interview. You rank all the places you interviewed. The hospitals rank all the people they interviewed. It goes into a big computer program called the NRMP. In March you get an email telling you where you matched - not all the places, just the one place you will go to. It's not a choice and you are not guaranteed to be chosen anywhere. Rather appropriately, this process causes a tremendous amount of anxiety - will I match at all? Will I match somewhere I actually want to go?

Right, so I've been told I will match, it's just a question of where. My current list of programs is 19 deep and I hope to get 10 interviews. I've had to get four letters of recommendation, two of which must come from the chair of the peds dept. and the chair of the internal medicine dept. I have to get a letter of endorsement from the dean of the medical school as well. I have to put my CV and all my publications into the online program (one item at a time). I have to provide transcripts and copies of my USMLE step 1 and 2 scores. I have to write a personal statement and include a photo. I have to pay money (of course). All of this gets submitted September 1st, so you can imagine the past three months have been spent getting all of this together. But soon - so soon - I hit submit and then... I wait. Wait and hope. Hope for interviews.

I will keep you updated.

Heartbreak cardiomyopathy

This month I had a patient with an interesting and rare condition called TakoTsubo Cardiomyopathy, also known as "broken heart syndrome." It involves myocardial stunning after a highly stressful event such as the death of a spouse or a natural disaster. Basically, you are so overwhelmed that you literally go into heart failure. The physiologic mechanism is incompletely understood, but leading theories revolve around catecholamine release. Thankfully, the significant majority of people recover their full heart function in days to weeks. It is most commonly seen in Japanese post-menopausal women, however it has been described in the US and Europe as well. It can be accompanied by an NSTEMI (heart attack) and frequently QT prolongation (repolarization abnormality - sorry, I don't know how to translate that better without a tutorial on EKGs).

It gets its name from Japanese octopus traps. Why? Because this particular heart failure displays what we call "apical ballooning." Basically, the upper and middle parts of the ventricle contract, but the apex (the point) of the heart does not. That means that blood, which is ordinarily squeezed from the bottom of the heart towards the top, is now being simultaneously pushed up and down. the down-going blood has nowhere to go so the tip of the heart balloons out (see diagram).

My patient began recovering heart function very quickly, but her QT prolongation was impressive. Almost write-it-up-in-a-journal impressive. Thankfully, that also resolved quickly. We never got a good sense of what her precipitating event was, but I suppose all stress is relative.

Welcome to M4!

One whole week into my fourth year you may be wondering, what have I done with myself? Well, I am starting the fourth year much the same way I started the third year: studying for a USMLE exam.

This week I have covered cardiology, dermatology, GI, endocrine, biostatistics and some infectious disease. I am reading, highlighting, making flashcards and doing lots of practice questions. Fun fun.

However, life is not all work. I had a lovely day and night out (we started a little early) after completing third year: there was sangria, there was gin, there were pancakes the next morning.

I've also been helping to orient the rising M3s, which is a nostalgia-inducing process. It really makes me realise how far I've come in the last year in terms of my comfort in talking to and evaluating patients. It also points out how different the focus in teaching is now - I spend much more time thinking about details: drug choice, dosing, treatment length, etc - whereas before it was about having a workable list of potential diagnoses. A lot of what I struggled with at the beginning of my third year is assumed knowledge in the fourth. My review books don't even bother to classify antibiotic types, for example, it's assumed I know azithromycin is a macrolide that acts on the 50S ribosomal subunit and has good efficacy against gram positives and atypicals. The new questions is: how much and how many days worth for a patient with strep pharyngitis in a COPD patient?

In an effort to stay balanced while studying, I've joined a tennis clinic. I had my first practice yesterday and got a little sun (oops) as well as losing half a toenail jamming my foot in my shoe on some abrupt directional change. Worth it. I'm horrendously inconsistent at the moment, but I hit a few aces and a couple of solid put-away shots. I'm considering joining a USTA team this summer, but I'm not sure I'll have time with the sub-i's etc.

Motorcycle lessons start next week and I'm now involved with admissions for the medical school too - so hopefully those will yield some good stories for a post. In the meantime... nose to the grindstone to (hopefully) pull out a good Step 2 score.

?! #492

I was reading a NYT article on hospital compliance with hand-washing when I came across this gem of a comment:

"I'm confused. I thought the only way hand washing would kill bacteria is if the water was boiling hot."

Um, have you heard of SOAP?

Little old man

I had a cute four year old patient today with two old-man problems: a bald spot and urinary hesitancy. His mother brought him in because of the bald spot: an oval stripe towards the front-top of his head roughly the size of a kiwi. It first appeared a month ago as a painless, small spot the size of a dime and it had steadily grown. He was otherwise well.

While the attending conferenced with his mother, he came up to me and announced "I have to go potty!" I took him by the hand and we walked to the clinic bathroom. I waited outside the door. Thirty seconds go by and I hear "Mr. doctor. Mr. doctor!" I crack the door and he's standing there with his pants around his ankles. "I want to use the giant bathroom!" I pull his pants up, take him by the hand and walk him to the other end of clinic where a more spacious bathroom is located. Again, I wait outside the door and soon hear "Mr. doctor, mr. doctor!" I crack the door. "I'm scared!" I enter the bathroom, kneel and say "How can I help you? Do you want me to lift you up or get you a stool to stand on?" He replies "I just kidding. I don't have to go potty!"

The question everyone in the office is asking me all day: what happened to that little kid's head? The answer: he's pulling his hair out.

Maybe the grown-up sized toilet at home is freaking him out.

PIckled penis

One of my preceptors recently taught me about a physical exam that was commonly done in the late 1980s: androscopy. It's an exam aimed at finding and treating HPV warts on the male genitalia. It is analogous to a (cervical) colposcopy in women.

The male is undressed from the waist down and lies on the exam table with feet in stirrups - similar to a woman undergoing a pelvic exam. The genitals (penis, scrotum, perineum) are wrapped gauze soaked with vinegar for five minutes and then inspected with the naked eye and with the colposcope (a special microscope). Lesions, if present, may be excised, cauterized (acid or freezing), or laser vapourized.

Interestingly, a pub med search has revealed that 51-65% of men who were clinically asymptomatic had lesions on their genitals when viewed under the microscope. However, up to 20% would continue to be seropositive for HPV even with negative follow-up colposcope exams; suggesting that androscopy was not eradicating the disease from the male population. For that reason, and because penile cancer is a very rare complication of male HPV, the exam was largely abandoned as routine practice.

It may come back into favour for the rectum, however, as anal cancer rates increase. Just as we now recommend screening anal pap smears for persons practicing anal intercourse, a vinegar anoscopy of the anus would be a logical follow up exam for a positive result.

For the men out there - yes, they put vinegar on the cervix for a colposcopy.

Let's talk about sex, baby

Lately, there has been a lot of talk about sex. From the lecture I had today on contraceptive counseling to the recent public debate over federal funding for Planned Parenthood to the omnipresent national abortion conversation. For some reason, I thought that people had at least some basic knowledge about sex and contraception from either their parents or their junior high health classes or, hey, the internet. Apparently this is not the case, so let's clear a few things up.

1. “The fact is that 95 percent of the contraceptives on the market kill the baby in the womb,” said Jim Sedlak of the American Life League.

INCORRECT. The American College of Obstetricians and Gynecologists defines pregnancy as beginning with the fertilized egg’s implantation. Even if you believe that life begins prior to that - at the joining of sperm and egg - the majority of contraceptive measures intervene BEFORE the sperm and the egg meet. Let's review:

a. Hormones (aka the pill) - birth control pills prevent a woman from ovulating. If there is no egg, there is nothing for the sperm to fertilize and thus no baby is formed. The pill also has the happy side effects of decreasing the risk of ovarian cancer, reducing acne, and decreasing period-related pain. There are plenty of reasons women take the pill that have nothing to do with sex; it is a first line treatment for dysmenorrhea, endometriosis, ovarian cysts and fibroids.

b. Intra-uterine device (aka IUD) - One form of IUD, the Mirena, contains hormones and thus partially acts via the same mechanism as the pill. All IUDs also cause alterations in cervical mucus, which prevent sperm from being able to fuse with an egg. There are enzymes in cervical mucus that aide the sperm in 1) getting to the egg and 2) penetrating it. Without these cervical enzymes, fertilization does not occur.

c. Condoms - okay, I should hope this is self-explanatory. If the sperm is in a wrapper and not in the vagina, it's not going to make contact with an egg and create a baby.

2. If I have anal or oral sex then I won't get STDs.

INCORRECT. In fact, if you are having anal sex you should be getting regular anal pap smears. A cotton q-tip is swabbed in the anus and the cells analysed the same way they are for a cervical pap smear. HPV will do the same thing to the cells in the anus as it does to the cervix: cause cancer. Recall that some strains of HPV do not cause symptoms so you're not safe just because you don't have warts. Famous case: Farrah Fawcett died of anal cancer. HPV has also caused a rise in mouth and throat cancers, however we do not routinely swab for oral HPV at this time.

3. Guardasil (the HPV vaccine) is only for girls.

INCORRECT. It has been FDA approved for men as well. Men can transmit HPV to their sexual partners and, when infected, HPV causes an increased risk for penile cancer (still rare though). HPV will cause anal and oral cancers just as effectively in men as women.

4. “Fertility and babies are not diseases,” said Jeanne Monahan of the Family Research Council’s Center for Human Dignity

SORT OF. Many physicians consider pregnancy a natural and healthy state; however it does have a diagnosis code (an ICD-9) and it does dramatically and sometimes permanently alter the physiology of the mother. If it were totally benign we wouldn't require so many pre-natal visits, lab tests, ultrasounds and testing. There are diseases a woman can have that make pregnancy a clear and present danger to her health, even potentially fatal. There is also the issue of implantation in an abnormal part of the body (ectopic) which is also extremely dangerous to mom.

Public debate is healthy and I don't expect everyone to hold the same opinions as me; however I think is important that we are at least factual and informed about the topic. Let's not pass laws in ignorance.

Extra-curriculars

A friend recently made me aware of the BANF film festival, which had a showing in town over the weekend. Talk about inspiring! It's essentially all movies about extreme athletes of some kind: mountain biking, whitewater kyaking, speed freeclimbing, etc. Two movies stuck out for me at the showing for both their striking visual content as well as their kick-butt soundtrack choices:

LifeCycles

Song: Saskatoon by Data Romance (this is a remix of Levee Camp Holler)

The Swiss Machine

Song: Welcome Home by Radical Face

I called it!

Warning: this post involves some bragging. Let me state that I frequently get things wrong (thus, still in training), but that's not as fun to write about.

How clinic works: The attending sends me in to each room ahead of her to get a history and perform a physical exam. I then briefly present the patient to her as well as any recommendations I have. She then finishes the appointment with the patient (I'm in the room too).

I go in to see patient X who is supposedly here for a routine physical. I ask her how she's been feeling lately and she says "my optometrist said it was important I keep this appointment." On questioning I discover that she is having positional headaches and some intermittent nausea, but otherwise feels well. She denies any vision changes.

On physical exam, patient X had bilaterally blurred optic disc margins (papilledema), full visual fields to confrontation, but otherwise appeared well.

If you're in medical school, make your diagnosis now...

During my presentation I state that idiopathic intracranial hypertension is at the top of my differential, but that a mass lesion should be ruled out. I state that papilledema merits an MRI but that ultimately a lumbar puncture should be performed. My attending smiles at me, pats my hand and says, "please don't be offended if I disagree with you, that's a pretty rare thing to find."

We go in together to see patient X. My attending examines her and begins counseling her. Guess what turns out to be at the top of her differential? Guess what test she wants first? Yup. I may have given myself a mental pat on the back.

you know you're in medicine when #253

You're watching a television show and during a scene in which a character is getting blood drawn you look at the syringe and remark "that's not what blood looks like."

When I grow up...

A big focus in life at the moment is answering the question: What kind of doctor do I want to be? Unfortunately for me, I am currently undecided. Here's where I am:

Internal Medicine (likely fellowship in cardiology or critical care)

Pro: Some patient continuity, variety, acute care, flexible lifestyle

Con: Not heavily procedural unless I go into the cath lab

Total time: 3 years residency + 3 years fellowship

General Surgery (likely critical care fellowship)

Pro: Very procedural, the OR is fun, prestige, variety, some patient continuity

Con: Not sure I love GI problems, tough lifestyle, required lab year

Total time: 7 years residency, with fellowship as one of my research years

Pediatrics (likely fellowship in cardiology or critical care)

Pro: love the patient population, patient continuity, flexible lifestyle

Con: not procedural (again, unless cath lab), limited places to practice

Total time: 3 years residency + 3 years fellowship

I've ruled out anesthesiology for lack of patient continuity. Plus, if I'm going to be in the OR, it's going to be my OR. I would likely match in any of these, though surgery would be toughest. Current plan: subi in each, await my surgery grade and see where we stand.

ps note the M4 schedule has been posted on the sidebar, for those who are curious.

Overdue Update

I apologise for my absence. I was on rotation in downtown Detroit and the temporary crash-pad did not have internet (?!). I was on neurology, which is not at the top of my super-interesting-material list, but I did get to spend two weeks in the neuro-ICU and I do so love any kind of ICU. Bring me your super-sick, your actively dying and I will go to work with enthusiasm and diligence.

One of the wonderful things about this new hospital was the white chocolate macadamia cookies. And the Monday schwarma lunches. Yummy. Also interesting was editing my fellow's notes for proper English grammar and spelling (yes, I was called upon for spelling).

There was one very sad case: a patient who had a stroke at the young age of 41. We don't know why. He's now densely hemiplegic (can't move half of his body) and non-verbal. While under our care his wife found out she's pregnant. She's going to have a new baby and a husband in inpatient rehab who also needs her care. While rounding each morning he would start crying; he is cognitively intact and aware of his prognosis: he will likely not get much movement back.

In personal life news (yes, neurology is one of the rotations in which a life is possible), I've taken up P90X, which is quite challenging, but awesome. I finally had a good night out dancing, which I sorely needed. Sometimes there's just nothing like a cocktail and a good song to dance too. I even made some friends in Detroit, so hopefully I'll spend some more time exploring the city. Oh, and I signed up for motorcycle classes... shhh... don't tell my parents. It's going to be awesome when I visit them in May and hop on dad's Ducati! I'm working on signing up for tennis clinic, but it might be full. Boo.

Tomorrow morning is the beginning of Family Medicine... in Toledo. Also, the ramp up for studying for Step 2 (the second board exam, scheduled for June 2nd). Nevertheless, weekends off for another month so hopefully I'll be able to continue this whole "balance" thing.