Tales out of medical school

Just like the poisoned deposit enevelopes at the ATM, the cellphone that exploded a gas station, and the toilets that flush backwards in Australia, medicine is full of urban legends. I don't know how many of them are true, but I thought they'd be interesting to keep track of in case someone knows if they hold any water or whether they're just another Letters to Playboy Magazine that no one will ever be able to verify.

1) Anti-retroviral therapy for HIV positive patients is full of side effects. Nausea, constant vomiting, liver and kidney failure, life-threatening infection, cancer and death are just a few of the more notable complications an HIV positive patient can get if they undergo this treatment. Not only are the side effects bad, but the pill regimen is complex and the outcome of treatment is uncertain at best.

Legend: In order to communicate the extent to which these pills affect a patient's life, an attending physician in the infectious diseases department at an unnamed hospital made it mandatory for all the residents under him to undergo a week's worth of treatment, just so they could see how bad the side effects really were.

2) Hospitals have to be prepared to deal with anybody who might present at their door. While many hospitals are equipped to handle almost any medical condition a patient might have, not all of them are outfitted to handle any criminal tendencies a patient might have. Convicted felons are often in need of medical attention, and when in-prison visits aren't enough, prisoners are taken to the hospital.

Legend: A hospital employs 2 crash carts. One is a normal crash cart with an automated defibrillator, induction drugs and resuscitation paraphanalia. The other crash cart also carries induction drugs and resus equipment, but instead of a defibrillator it carries a taser. Of course, both crash carts are painted the exact same colour and are located right next to each other at the nursing station. An inmate at the hospital goes into cardiac arrest and the wrong crash cart is brought in. Somehow, the resident on the crash team fails to recognize the subtle differences between a taser and a defibrillator, and tasers the patient. Outcome? The inmate's rhythm returns to normal.

3) Legend: Premarin, a hormone replacement therapy for women is made from pregnant mare's urine.

Let the debunking begin.

The debits and credits of life...

25 y/o male presents to the ER, suicidal ideation - consult psychiatry

58 y/o male presents to the ER, suicidal ideation - consult psychiatry

38 y/o female on the psychiatry ward, admits suicidal ideation - you betcha, a consult.

And then there was this man in the cardio-resp ward. 77 years old, can't breathe from his COPD and can't keep his head upright because of a CVA. He's DNR now but when I asked him whether he wants die?

NO (as if I'm talking crazy)
I want to go home and live with my wife *breath*, my dogs, my kids *breath* and their kids.
*head slumps into pillows because his arm to too tired from hoisting it up*

I'm writing this tonight because I think I'm suffering from a mild case of TMS. Too Much Suicide. As much as I've tried to separate myself from the despondence that comes with the stories that I am hearing everyday it's hard not to feel a little sadness about the world when I come home. How could there be a 25 year-old who wants to die when there's a man more than triple his age struggling to hold on to his? To be fair I understand everyone I've met who wants to commit suicide has SOME reason to - not necessarily a good reason, but there is a reason. But I guess a guy can only take so many awful stories before he begins to lose that once-a-week 5 minutes of sunshine he gets on his walk to work on sleep-in day. (Note: once-a-week is a gross exaggeration - the reality is more like once a month)

Clearly I still haven't completely made sense of what I'm experiencing as you can tell from the disorganization of this piece but ultimately this is my reaction to my experiences in psychiatry so far. I have been told to expect some sort of reaction from psychiatry patients. Their weird and wonderful delusions will not sit well with you sometimes. Their awful stories will give you pause to take stock of how good you have it. And their racist, vulgarities that they spit in your face aren't personal - so don't take it personal.

More to come.

Courage

The other day one of my friends remarked how scary it must be to be at least partially responsible for people's lives in the hospital, and how medical students are either all crazy brave or crazy crazy to do it. While I can't say for certain I'm not crazy crazy, I don't think I have to be particularly brave to take care of patients. What you have to be crazy brave to do is to be a patient being cared for by me.

All the patients I've seen don't put up a fight. "Hi my name is X, I'm a clerk and I'm working with Dr. Y today. I'm here to do a bit of a workup before he comes in..." and they all acquiese with little more than a smile, a grunt, or in the case of that frontal lobe patient the other day "JESUS FUCK OFF JESUS FUCK OFF JESUS FUCK OFF". Since he was saying that to everybody, I didn't think he really minded me working on him.

If it was me on the other side of the clipboard though, I think I'd have some problems letting a clerk suture up my face, or do superficial surgery over my lungs. Sure there's a real doctor making sure everything's going well, and sure the clerk's probably a smart cookie... but it's me we're dealing with here.

So thanks, patients. Thanks for letting me learn.

Thanks to the man with the huge abscess who had pain while I drained it because I didn't anesthetize a large enough margin around the site. Because of your suffering, the next patient I had that needed to be drained didn't feel a thing because I froze her like a wrist shot from center ice freezes Andrew Raycroft.

Thanks to the guy who tore his hand open on a rusty nail. Because you let me put in the stitches, I learned how much of a pain it is to need more sutures after you've used up all the ones you have.

And thanks to the man who let me feel his prostate. Again. It's already unpleasant enough having it felt once, but you sucked it up and now I have a better idea of what a normal prostate feels like.

All of these things I've learned are lessons that I wouldn't have learned in lecture, or by taking notes while someone else did it. I don't think patients understand how helpful it is to be able to do some of the things they let me do on them, so to those people, I say, thank you.

Now turn your head and cough.

The Perks of a Clerk

It's been a few weeks into clerkship, and I'm finally starting to feel I can control that sheer terror I've got deep in my gut a little better now. I've also been pretty lucky, no one has really drilled me in my sandbox-sized field of knowledge too hard -- perhaps it's because I wear my incompetence on my sleeve, thus rendering proving my ineptitude similar to coping a cheap feel on a drunken sorority girl.

There are myths out there - ones about the almighty "doctors-to-be" and the kinky business that goes down in the call rooms; about patients moaning a little too loud for comfort during a breast exam (or the dreaded rectal exams - not that there's anything wrong with that). Thus far, I've slept in the call room for many silent nights, palpated multiple pairs of pecs, and had my finger up more rectums than I'd like to admit. Still, no dice. Until now.

Looking at my triceps flickering about as I jotted down her history in her charts, she asks "do you work out?". Noticing my boyish good looks as I stared intently at her face, looking for the slightest hint of discomfort while palpating her abdomen for peritoneal signs, she inquires "what nationality are you?". Oh man, the myths are true. It was happening to me. Then the clincher: "you know, you're very handsome... "

I knew it! I AM McDreamy!

"... just like my grandson". So much for those myths.

Alright, so nothing spectacular happened. The truth is, clerkship is not very sexy, or glamorous. But really, there are perks to the job. This lady received some terrible news that evening -- she has late stage pancreatic cancer, and it's not likely curable. During her stay in the hospital, I've seen her everyday, and everytime I see her, her face lights up just a little bit. It's really not me or anything I did special, but if by reminding her of her grandson can bring just a hint of familiarity of family to this cold hospital, then yes, there are definitely perks to being a clerk.

Too emergencied

I like the emergency room. I get to do a lot of stuff, like drain abscesses. I drained two yesterday, and one was the biggest zit you will ever hear about. There must have been enough there to fill a sleeping bag.

The emergency room's also interesting. There're always pretty good patients to see, who have things that you can set right pretty quickly. Dislocated limbs, coughs, colds, etc etc. And the people you can't fix right away, (or don't want to deal with) like the psychiatric patients, you can send off to someone else who can take care of them.

The one thing I don't like about emergency is how you don't get to hear the rest of the story. Oftentimes, I find that the people I meet and treat are people I'd like to see again so I can find out how they're doing. Especially after I heard about all the stories about stupid emergency doctors missing diagnoses. Sure, we all laugh at them. Dumb doctors! How could they be so moronic? HA HA HA!

But wait... I'M probably making those same mistakes! I'll never find out though. Or rather, the only time I'll find out is when someone's lawyer comes calling. It'd be nice to know how your patients turn out so you won't develop a habit of undertreating or overtreating or improperly treating them later.

The other reason why I'd like to hear the rest of the story sometimes is because there're some patients I root for. I saw the nicest guy the other day, joking and upbeat even though he'd been waiting for hours to get his headaches looked at. He was a middle-aged guy with a family, and was just checking in to make sure his new onset headaches weren't anything serious.

I worked him up and didn't find anything unusual. His story was textbook migraines too. I reassured him that it probably wasn't anything dangerous, but a CT was ordered anyway cause he'd waited so long.

Turns out he had a huge tumor in his temporal lobe. The news wasn't easy to give, and I'm sure it was harder to take. Here was this guy coming in to see if there was anything we could do for his migraines, and now he has cancer in his head. It looked like he was overwhelmed with the pace at which things happened after that. Requistions for more CTs, more referrals, more consults, more directions to more hospitals for more appointments... suddenly his whole life changed. I bet he'd been planning to go home and hang out with the kids before work the next day. Not so anymore. Now he's in a battle for his life.

So he was referred to a neurosurgeon and we gave him what little information we could. And that was that. I'd like to meet him again to find out how he's doing, but that won't happen in the emerg.

Dr. Cox's Winter Stash

Looking back on my life, I've noticed that people don't praise me as much as they used to.

Nobody claps when I successfully crap in a toilet, flush and wash my hands.

Nobody gives me a gold star for remembering to put my chair on top of my desk so the janitor can mop under it.

Nobody remarks positively on my vocal participation in high school sexual education classes. It's even frowned upon nowadays.

So far, this trend has held steady into clerkship. I rarely find myself getting praised for anything. This isn't because I haven't been able to adequately demonstrate a clerk appropriate mastery of the history, physical and treatment, rather I haven't been praised in spite of it. Shouldn't someone who's inept at even the most pedestrian maneuvers and evaluations be congratulated whenever they leave an interview without being served a subpoena?

The bright side to receiving scant words of encouragement is that when something does go right, it becomes the highlight of your week. Like last week, I found a 1/6 murmur and showed my preceptor how to do a McMurray test. He said "You're quite good with your physical findings." Like a woman with a broken bikini buckle, I clutched those words to my chest and didn't let go for the rest of the week.

And then today, after hitting my first 3 venipunctures, he said "You've turned pro pretty fast!". Again, clutching, savouring etc, etc.

So far, this strategy's served me well. The sheer number of dumbasseries I make everyday are enough to cause anybody to quit, especially medical students who positively thrive on achieving. If I focus on the few things I do correctly though, maybe it'll keep me going long enough for me to learn how to do everything properly.

PS - Needlestick history is negative for infectious disease. Clutching, savouring...

Needless needles

A guy came in today with a minor facial laceration. I was sent in to stitch him up and I thought my biggest worry would be if I could keep everything that needed to be sterile sterile.

I was in a little bit of a rush cause I'd been slowed down previously by another patient's overbearing wife, and I didn't want to keep my preceptor waiting. I hastily grabbed the suture to load it into the needle driver when I felt something sharp go deep into my thumb.

Fuck.

I yanked my hand back and looked at it intently. Luckily, my patient's head was covered with the surgical drape so he couldn't see what was going on. I didn't see any puncture on the glove so I kept on working, but the thought of a needlestick infection was niggling me until I sewed shut his injury. It felt like it went in pretty deep though... No blood from my thumb but it was a pretty fine blade to begin with.

The worst part about this was I didn't do anything about it. I didn't tell anyone cause I thought it wasn't a big deal and that nothing would come of it. The patient got his tetanus shot and left, and by then I'd started wondering if I shouldn't have taken a more thorough medical history. All these shortcuts I take in emergency seem to come back to haunt me...

He didn't seem like a high risk individual, but god dammit. Who knows who's really high risk and who isn't? The stupidest thing for me to do was wait and not do anything about it or tell anybody about it. I studied my thumb intently. Still no blood and still no sign of puncture. Does that mean I didn't get stuck? Couldn't a virus stil be transmitted subcutaneously? I was so terrified of having contracted something evil I filed it under F for Forget About It and saw some more patients. It's probably nothing, I thought.

But every second that ticked by made me feel stupider and stupider for not having said something a second ago, but I felt like if I said something now I'd seem even stupider for not having said something earlier. I knew I was being an idiot but I couldn't help myself. I should have stayed in bed today.

I googled needlesticks and looked at the stats. 1 out of 300 needlesticks with HIV positive patients will cause an infection. Good odds, I supposed. I didn't even know if this guy was HIV positive or not. Hep B I've been immunized for. Hep A, whatever. I can deal with Hep A. Hep C though...

I looked at my thumb again, and squeezed it, checking it under a bright light for any sign of trauma. I knew I wouldn't see anything, and even if I did what did I expect to find? It's not like the virus is going to let me know I'm there. Until my liver dies or I get AIDS.

Now I was starting to get worried. Partly cause I had been exposed, and partly cause I couldn't stop acting like an idiot and just tell someone I'd been stuck. Why couldn't I just suck it up, look like a moron and get some help?

I ended up talking to my preceptor about it in the end, and he said to call the patient and ask about risk factors and leave it at that. I called and nobody was home. While I was waiting, my preceptor told me about the time he got a needlestick while working on a guy who had recieved multiple transfusions. Nothing happened to my preceptor in the end, which is nice. But what about me?

Still waiting for the guy to get home. Good lord I hope I'm worrying about nothing.

Today, unruly children who have stupid parents. Tomorrow, the world!

I attended a problem based learning session a little while ago. It was my first one outside of medical school. I didn't know that doctors used PBL after they graduated, but hey. The ice caps are melting, Israel and Iran both have nuclear weapons, Scrubs looks like it's going into its last season... everything else is going down the tubes, why not education for doctors?

Anyway. This session's PBL was on sleep disturbances in kids and what family doctors need to do about it. One of the doctors who was completing the session with us commented on how there was no limit to the scope of family practice, and GPs nowadays are expected to be prepared to deal with all facets of the everyday life. I wasn't sure what she was getting at until I read what exactly the sleep disturbance we were to learn about was: resisting bedtime.

Resisting bedtime! It's exactly what it sounds like. Little kids who don't want to go to bed when their parents say it's bedtime. I'm sure I'm not the only one who thinks this is something that you DON'T have to make an appointment for. If a kid doesn't want to go to bed, then you MAKE them go to bed. HMOs and publically funded programs, you'll receive invoices for this doctor trip cash money saving 3 step consensus statement I've provided.

To make your kid go to bed

1. Take off your belt. Belts with rhinestones generally frowned upon. Generally.
2. Psh-snap!
3. Celebrate parental victory by indulging in primetime television complete with cursing and borderline softcore pornography.

Done and done. You get to watch your Heroes, and for the rest of your child's life, his ass will really start to tingle around 8pm and he'll never ever figure out why until he has a kid of his own.

You don't need to visit a doctor for "resisting bedtime". I think there're too many issues out there that have been medicalized way beyond the point of there being effective medical management for any of them. One of my teachers once told me that we should all be teaching our patients masturbation as part of sexual education. Now, is that really a medical issue or is it just something that nobody wants to deal with so they leave it to the doctors? If someone's masturbating or not, is it really anybody's business? For crying out loud, I already have to stick my finger up your ass. I don't know if there's a way I can make that relationship anymore awkward, but if there is, I'm sure it's talking about masturbation.

Quit making doctors do things that doctors aren't qualified to do, like disciplining your kids. That's Supernanny's job. If you need pills, I got pills. If your kid needs a belt, you need to start wearing some pants, my friend.

More people should know about... : Germ Killing Soap

This is the first in a series of public service bloggings about things the public should know about their health but generally don't. As a broad disclaimer, any information contained in the body of this post and any other post should not be taken verbatim or as a substitute for real medical opinion. If you have real questions, ask a doctor you know, not somebody who may be pretending to be a doctor in the media... I'm looking at YOU Sunjay.

While using soap that kills germs sounds like a good idea in the first place, here's why it isn't. All the germ killing soaps out there say they kill 99.999999% of all bacteria. Why does it kill only 99.999999% of bacteria? Because out of the millions and billions and trillions of little microbes that live on your hands, there's always one bastard that has to be "resistant", and can't be killed with the soap. Pretend this picture below is your hand (Figure 1). The smileys are bacteria. None of these bacteria can cause disease. The resistant bastard is represented by the green smiley. The yellow smileys are unresistant bacteria which are about to not be so smiley cause THEY'RE GONNA DIE!

Figure 1

So you wash your hands and after you're left with only the green resistant bastard on your hand. Of course, he's not hurting anyone. He's just a tough little cookie. So cute! So square! Well, wait till he reproduces a few times (Figure 2).

Figure 2

Now you have an assload of resistant bacteria on your hand that aren't going anywhere. But wait! There's more! Not only are they now resistant, but through some bad luck and some mutation, one of them has gone rogue. That's right, he's not a happy smiley anymore. He's become one that's gonna give you the runs all day and all night...(Figure 3)

Figure 3

And, little known fact, bacteria can talk with each other. And when they talk with each other they give each other all kinds of information. Like how to turn into a red triangle (Figure 4).

Figure 4

And before you know it, your hand is chock full of red triangles just itching to ruin your formerly non explosive watery diarrhea day (Figure 5).

Figure 5

And the worst part is when you go to the hospital to get it taken care of, the drugs don't work cause all the bacteria on your hands have become resistant to them. How's that for suck?

So why does regular soap work better?

Well, regular soap doesn't get rid of all bacteria either. The difference is regular soap leaves behind random bacteria, not necessarily the ones that are resistant to antibiotics. So instead of getting only the green bugs seen in Figure 2, usually only yellow bugs are left behind. And whenever green bugs are left behind, there're usually enough yellow ones around to take up enough real estate and eat enough food to stop the greens from growing up and taking over your hand. In this way, if any of the bugs on your hands becomes evil (red triangles) the chances of them being evil AND resistant are very low. And your friendly neighborhood doctor will be able to fix you with some medication (Figure 6).

Figure 6

Play ball!

No matter how many times I start an elective, I always goof the first patient. It's like not swinging for the first pitch. And then the first pitch beans you in the head. Except the not-swinging-beaning process repeats itself everytime you start a new game.

Starting clerkship was no different. Clerkship started in some small town in some rural area with some nervous little clerk in the emergency department. The first patient I saw was sweaty, short of breath and could only speak Italian. The first clerk he saw was also sweaty, short of breath and could only speak gibberish. The hundreds of lectures and hundreds of hours of clinical experience I've had since starting school might as well not have happened. It's as if I was starting all over again at the beginning of my education, and in many ways I suppose I was.

I didn't ask many pertinent questions, and did a limited but accurate physical assessment. I managed to put a couple of decent diagnoses on my differential and went to report back. As soon as I started to give my report to my attending physician, I realized I'd forgotten to write anything I'd learned in my history or physical on the chart.

Ahh crap.

We've been taught that people who suffer from mania may display a speech pattern known as a "word salad" (http://en.wikipedia.org/wiki/Word_salad_(mental_health). I think I could have managed to produce a pretty awesome word salad of a report but instead a sliced boiled word egg from the word salad caught in my throat and the only sound I could make was sort of like that sound you hear when you get static on your tv late at night.

khkhkkhkhkhkhhkhhkakaaaaaaaaaaaaaaaaaaaakhkhkhakaa.

It didn't go over well.

However, when the next few patients come along everything usually falls back into place. And today everything came rushing back as soon as I'd had time to think a little bit about what my job in the department was. I resolved to improve for the rest of the night, and improve I did.

For the remainder of the evening I was the future of medicine. Like baby Jesus, except without the miraculous healing powers. My medical knowledge base returned quicker than if someone had slapped me in the face with Harrison's. Everything clicked somehow after I got that first one out of the way. I think after I allowed myself some mistakes with patient number one, the pressure was off for the rest of the night. I managed to convince my preceptor that I wasn't an idiot, and everything was great. We had pizza. And breadsticks.

So next time I step up to the plate, make sure you head for the bleachers. Cause even though the first pitch is gonna get me right in the face, my big thick skull is gonna hit it so hard it'll clear the park.