Christmas Break Adventures.

So i get a week and a half off for Christmas. I also got, thanks to my mom's connections, to have lunch with and also shadow a few different ER docs.

At lunch, I learned a bunch of things- things that I want to remember. So I've recorded this for me but take from it what you will. She talked to me about the cons of the ER and the politics of it. This is what I remember.

• if i want to be an attending (teacher) then I have to take a job in it right out of residency- its harder to go backwards than forwards 
• 90% of what she does to pts in the ER doesn't matter, they would be fine without any intervention. Its that 10% that she lives for, less than a patient a shift. You have to be fine with this to go into ER
• Be sure to remember there are multiple kinds of ER docs. private sector gets the $$, urgent care gets the time off, locum tenums gets the stories, and the academic get the insurance benefit and retirement plan. 
• I can specialize later in EMS administration, something an ER doc does on the side very basically free. But it means you're the head of the ambulance company and it might be something fun to do when you're retired (or if you are a part time mom part time doc :)
• Almost all ER doc contracts are for hours spent in the ER per year, not when or how. You can always work 3 months straight and have the next 6 months off-- the question is do you want to?
• Ask about who makes the schedules, how early the schedule comes out and how often you can request time off when you get your first job.
• Live in state where there is Tort reform, especially if you are paying your own malpractice. 
• Its hard to get over being sued, because your confidence decreases. there are no easy answers to getting over this other than avoid being sued as best you can from the start.
• Get a letter from a more established program because that carries more weight than a younger program. Two SLORs are recommended but a SLOR plus a letter from just 1 ER doc looks pretty good. 
• Getting a letter from a charge nurse, especially of ER, is probably the best its gunna get.

Shadowing was good. It was interesting to be at an ER without a residency program. The docs didn't know how to really handle a student and they weren't familiar with how to teach. In the end, I got the impression a few of the docs wanted me to admire their skills more than teach me something. But I did get to see a few good cases over the course of a few hours. One in particular was so good that I had to take pictures of it. It was a bouncer at a bar who tried to break up a fight. The guy got in a good punch and knocked him down and kicked his face. This is what it did to his eye.

And yes, he couldn't see out of his eye, you can see how large the pupil was (we call it a blown pupil since it doesn't respond to light).  We called the opthomologist who refused to get out of bed so eventually we called the plastic surgeons and they tried to repair it as best they could.  Seems like the guy kinda got a little screwed to me... but at least the plastic surgeon cared enough.

FM: sarcoidosis

I decided to follow a resident who I hadn't previously followed. He was somewhat younger and more inexperienced and as such I could speak more and explain things to patients. Got to see some cooler stuff.

Sarcoidosis

The female in the room was apparently afflicted with something. She was more than willing to talk about about it. And even more than that she allowed me to take pictures, which are below. She said that everything in her life is affected by it, but she is not on any medications. She doesn't have any long term problems as far as lung issues. It's just the skin that seems to be affected. She came for a simple check up, and she's in good health minus sarcoid.

Fam Med: I hate that I like it

I hate that I like family med. It's full of owning your own business and time restraints (must see patients for no more than 30 minutes) and horrible pay.  Despite all this, family med turns out to be what i think of when i think doctor. They do some procedures, some ob/gyn, some minor surgeries and get to follow up on their patients. They get to counsel the patients about their options and make diagnoses because despite the specialists the patients get referred to, most people pawn most of the patient care on the family doc. All specialists it seems state "follow up with your PCP in 2-3 weeks" after doing important tests and really leave it to the PCP(primary care physician) to discuss what the test results mean and how it changes the patient's life.

I hate to say that being a PCP would be frustrating and long hours and lots of paper work but it would be more fulfilling. You get to have a broader knowledge base and are expected to advise the patients about every step of their care.  And there is a huge range of different types of things that a PCP can do to 'specialize' so you can own your own practice, you can do OB/GYN, you can work in the ER, you can work as a hospitalist for your patients, you can work in urgent cares, you can work in planned parenthood, you can do a fellowship in minor surgery, you can do geriatrics, sports med, international medicine, academic medicine, you can do sooo many different things and once you have a few years of experience under your belt you can change every couple of years. Which sounds INCREDIBLY attractive-- no burn out and amazing flexibility.

An interesting aspect of family med is that the residents are trained more about billing codes and what insurance companies cover and what they don't than any other residents i've seen. They seem to be more in tune with what meds cost what and what their patients are ready for and what they're not.  PCP's are also very aware that they get paid based on how many patients you see that day.  And are required to see a patient every 30 minutes. In 30 minutes, you can really only address at most 2-3 complaints per patient.  That is the rule actually, any more than 3 complaints and the residents get yelled at.  However, lots of patients don't show up, which means you get caught up on your paper work. But it drives me a little crazy.

Still this rotation I got hooked up with a resident this week that got so behind and didn't really want to be bothered teaching me, so he had me go see his patients first, and i hopped from patient to patient and then updated him and told him what i thought and what suggestions for patient we should do. I felt like a resident, which is sorta cool. There were several patients he didn't even go see because he was so behind and it was just a contraception consultation or just a med refill.   He trusted me and even listened to my suggested plans. It was pretty freakin awesome!

 I managed a diabetic patient on my own, which means I got to recommend types of insulins, give the flu and pneumonia vaccines, prescribe baby aspirin, explain why an annual eye and foot exam is necessary, counsel smoking cessation, order a fasting lipid panel, start an ACE inhibitor, and tell the patient exactly what having diabetes means.  This is a standard new or uncontrolled diabetic appointment. I've probably seen it maybe 30 times. Thank goodness I remembered it all.

I also got people who come in with cough and I argued against the residents and attendings who wanted to give antibiotics for an obvious viral illness.  We got well child visits (like 1 and 2 and 3 year olds who need their shots).  I got a 19 year old girl who wanted to discuss types of contraception.   I got a few other teens who were concerned about STDs.  (funny its mostly girls).  We also get tons of people who have chronic limb pain (shoulder, knee, back, hip, you name it i've seen it.). These patients are hard because you want to help them but you cannot prescribe narcotics too easily.  The best we can do is give tramadol (ultram) and refer to a pain clinic. I got an older woman who had CHF and several people who wanted to follow up after their ER visits.

That said this rotation is what you make of it, several other students essentially just shadow the residents. Nobody really cares about students. If i said i wasn't supposed to be there except M,W,F  they would say "okay" and even the residents don't take things all that seriously because they arrive  30 minutes late most of the time.  And nobody pays attention in didactics. I had to force the residents to let me talk and present and stay late to help with paperwork etc.  (cuz its not like i have anything else to do). But I think they know that I want to learn even if I may not be the smartest student they had.

And the truth is despite its reputation, i could be a PCP and be happy enough. I state this now, because I want to remember feeling competent at something. In Jan I start surgery and I know its gunna be a whole new ball game.

FM: G clinic & denial

So I'm pleased to report that the G clinic is so much better than the N clinic. I got hooked up with a few residents (more like I figured out) who would let me talk to the patients on my own or at least conduct the interview while they were typing. This electronic medical records system is really slowing them down alot.

I feel like even the seniors are a feeling a little behind with their patients.  These residents are funny because they have such a different perspective.  They always compare how many patients they have that day and 8 per half a day is "a lot." The way it works here is everyone gets a hour and half lunch break.  Usually you spend the first half an hour finishing up your patient or your paperwork and then you get an hour lunch. I always feel a little bit of a loser going out to lunch downtown surrounded by people in suits, eating alone with a white coat and stethoscope on.  Hahah.

Lots of these residents are foreign. And i got assigned to a guy who is Arabic. One of our patients, DL, is a small Arabic woman who doesn't speak much English, comes in.  She has been diagnosed with breast cancer that is 80% curable. However, she is in such denial that she doesn't believe she has cancer. It doesn't hurt and despite the 4 biopsies she insisted on that turned out positive for cancer, she won't be convinced.  It took doctors 4 years to talk to her into chemo where she complained that she felt worse after the first treatment and since the lump did not shrink it must not be cancer.  She also was offered a surgical option and she talks in horror about losing her breast for no reason and despite reconstruction refuses.  Doctors including her primary care physician (PCP) and oncologist and surgeon all of whom speak arabic have spend over 60 minute appointments in the last 5 years trying to talk her into getting treatment since her cancer hasn't metastasized yet.  It was the one of the most frustrating patients i've seen yet. I am ashamed to say I just wrote her off after about 15 minutes into the discussion. We can't make her do it, all we can do is explain it and offer options.

There was another case I saw that same day that I again wrote off in the first probably 10 minutes. She was a 19y.o. female but she just kept changing her story. She came in for vaginal pain, but every time we asked her questions about her symptoms or history she changed her story.  Her first time having sex was last year then at 14 then at 16. She said she only had 2 partners then 4 then over 20.  She then didn't have discharge then did then didn't but it was a smell.  Basically, we ended up not even knowing how to present the patient to the attending doc. And we did a full panel for all STDs, UTIs, and yeast panel. We also did a pregnancy test, which was negative.  But these cases are very hard-- and i am only a third year.  And I already wrote her off within 10 minutes.  I feel a little ashamed, but I don't really know what else to do about it.

Family Medicine: Intro

So family medicine. Its set up a bit different for students than for residents. So to start we have to talk legestics. There are two clinics that take 4 PGY-1s (first year residents aka interns), N clinic and G clinic.  So I spent thanksgiving week at the N clinic, it was extremely uneventful. I got thanksgiving off since the office is closed and I took my USMLE so I worked 2 days and one was full of didactic lectures. I saw maybe 4 patients total. It sucked. Apparently, FM has a big problem with getting patients to actually show up for their appointments.

I can say I had a pretty shitty intern who did not let me participate in patient care. He just had me follow him around and it sucked. I pretty much watched him blow off patients. Not to mention the clinic just switched from  paper charts to electronic records so the interns, most of whom are foreigners are struggling.

Actual situation:  68y.o. white male with Diabetes, in apparent distress.

pt: "My wife died last week and she was always the one who handled my blood sugars. I don't even know what number is a good number."

shitty intern: "Uh-huh. When you have last colonoscopy?"

pt: "Oh. I don't know, maybe last year or the year before. My wife, she kept track of that. Can you tell me what number is a good number for my blood sugar?"

shitty intern: "Uh-huh. We talk about that later. You have flu shot recently?"

And the situation went on as such. And we never addressed his diabetes, never explained what it was or what number was good. Although he did send him to a diabetic nutritionist who the patient can't afford. Handy right?

My second week was on inpatient FM.  We are there to take care of the 2 clinics' patients in the hospital. In the morning we are supposed to round on the patients and then we round with the doctors and then we sit in this room til 5 and wait for the ER to call with new admissions.

The first day I showed up at 7 as instructed and no residents showed up until 930. needless to say I was panicking. But apparently we did not have a single patient in the ER. That happened the second day too. I was getting pretty tired of it. Luckily toward the end of the week had a couple ER admits and 4 patients. So i got to see something, finally. But it wasn't anything of note.

All I can really explain is when we got to go to the ER, I was so relieved. I was like the ER!! Thank you GOD!  And after my shift ended I just chilled out in the ER and followed a resident I knew and saw a bunch of patients. I was like kidney stones, AWESOME!  Drug seekers, I MISSED you! it was so much better than FM. I saw twice the patients I saw in FM that day! Granted I only stayed for like 2 hours because I was tired (i mean i did work/sit around all day). I thought about staying until 10. Maybe I should have. I dunno. I got to meet several of the attendings tho and hopefully they will remember me later. I do feel dumb as a rock when I go in there tho. I don't know what tests to order next or what drug to prescribe and that is basically what you do in ER.

I just ended the inpatient week knowing that although its fun to get to know the residents, I'd rather be in the ER.

The USMLE

So i completed the USMLE step 1 today.  Everyone always asks how i think it went, but i don't have any answers. When you spend so long studying for a certain test, it just is the way it is. You become numb. I was rather surprised that I was able to comprehend most of the questions and either knew how to guess or didn't (and didn't care). Maybe that's the advantage of having done rotations, no wonder the foreign med grads do so well on it. I do know one thing, to study for it, I started drinking lattes, despite my strict no coffee until residency rule. I brought two lattes to the test and drank one after the first section and one during lunch. i was epically focused.  I guess that i felt like for all the half-assed studying I did I probably didn't deserve the score I got, because somehow I might have been having a good day.

Watch I'll get my scores back and i'll have to eat my words. (gah. dec 14th!)

Anyhow, study tips for those of you who want to know. Don't worry tooo bad about pharm. Its probably what i'm most rusty on and as long as you cover your anti-arrhythmics and psych meds you'll be covered for most of them.  Biochem pretty much focused on those enzymes with an associated disease-- common disease (think Gaucher's and SCID and pyrovate dehydrogenase deficiency).  Micro bugs were more fair than the COMLEX- since the COMLEX focused on all the unusals and fungi and my USMLE seemed to cover tons of viruses. I got lots of questions about understanding why-- like if you have a certain immuno deficiency you are more susceptible to Neiserria or how a certain bacteria causes a problem (aka virulence factors)...  Immuno was really mixed in with everything else. If you know it its a huge plus but you can figure it out with all the other clues if you know your micro and biochem.  I guess focus special on the deficiencies. There really is no more advice i can give, do lots of USMLE World questions. Read first aid at least once.

I guess i will post more later once i have the score back.

EDIT: so scores are back. Passed but didn't do well. Def not the equivalent of what i did on the COMLEX. I don't really know what that means. Am I not smart enough for the things I want to do, did i have a bad day, am i behind?  I don't know.

IM 2: Fun Fun Fun... study

So I've been pretty busy this month, not with the rotation but with studying for the USMLE step1, I kept flaking out rather than taking it and now its down to the wire.  Hello 10 days till my test date. I will try not to completely crazy since I haven't gotten through even half of the material! *hates life*

Anyhow... Yesterday was suddenly really eventful.  We had a patient who we talked to because he had fallen down at home and broken his ankle. The doc and I were dicussing why on earth this guy was in the hospital when suddenly he went code blue on us (as in his heart quit beating and he quit breathing).  The saddest part is we weren't in the room when it happened, we were down the hall. But I got to be in the room and shouting the past medical history to like 8 residents and 4 doctors and rush around all important-like. The amount of people who respond to code blue's is massive. Its every person on the trauma team, the on call IM residents, not to mention the doctor's whose patient it is and at least 1 ICU nurse. Its like a flock of people who are literally running down the hall trampling people (think medical version of black thursday shopping at best buy). I am so pumped to be on the trauma team at the end of the year. I have ALWAYS wanted to run down the halls.
Anyhow, They told me if i had witnessed it I could have done the CPR compressions. Alas, I was not. I had to settle for calling like every doc on the case on the phone to report the code. The good news: he made it. We were all so close that he came back within about 15 minutes. He went to the ICU and I got to talk to him about what happened. I tried my best not to be all "You DIED but then we resurrected you... how was that?" and I discovered it's harder to be professional that it looks. :D

Hmm.  Other cool things that happened this month....

I also had a  39y.o. white lady who insisted she had PVC's (pre ventricular contractions) which means the heart beats randomly when its not supposed to. It can hurt and make you pass out. But the problem was none of her doctors believed her. So when i went in the room I got this big lecture about how doctors should believe their patients. Surprisingly, when I told her I was just a medical student, she cooled down.  We talked about all her problems and it was like the longest history i've ever taken, 2 hours. But it was rather interesting and I managed to calm her down. I also discovered she had scleroderma which started as CREST syndrome. Its a really rare collagen problem that causes your skin to be too tight. I got really interested in it and so she took the opportunity to teach me about it. It actually worked really well. She even let me take this really crappy picture.  You can see here how smooth the skins looks because its so tight on her fingers she can no longer make a fist. You can also see the clubbing of her fingernail (indicating the lungs have the dz too).  If you look really close there is a also multiple white calcifications that you can see on her finger (another symptom).   This poor lady ended up being one of my favorite patients. She very calmly informed me that she knew her time was limited because the disease didn't stay in just the skin it was progressing to all her organs. She was very sobering.

Let's see I also had a patient who had the most massive case of cellulitis I had ever seen. Her legs swelled so much that she and her husband sat around inventing ways to apply compression on her legs so the swelling would go down.  (take into account that her body habitus was rather corpulent).  However, she was  a very nice lady and really patient with me since I had to ask her a million questions about how it felt and she even let me take a picture.  I know you can't quite tell how red her left leg really is because my flash is so bright, but i think you can appreciate just how much inflammatory fluid is in her skin. If you touched her leg, besides her screaming in pain, the fluid under the leg sorta moves like a water balloon would.  Hello, lymphedema. 

Hm. I have a few other stories but they'll have to wait until I have more time. I should probably go back and take more pictures. hmm....

IM2: lame

Oh back to IM. I miss my cool residents and rockin team from last time. This one is a bit less... stimulating. The attending this week is brand new outta her residency and feeling overwhelmed with her normal patient load. So we see 1 patient each (1 other girl with me) and then we go home. And its not like it was with the other team where 1 patient is enough, she just wants the quick and dirty why they here, what's new and then says that's enough. She has spent a little more time forcing me to write better notes, but that's about it then we go home. That's like 7-10 (RIDICULOUS!).  But Since I am studying for the USMLE Step 1 I guess its good.  Now if only i could quit procrastinating....

Peds ER: Ambulance ride-along

Even tho my rotation is technically over, I am required to do 1 ambulance ride-along. Its a 12 hour shift and I got to go hang out at the firehouse. Apparently, the firefighters and the paramedics are the same people! I totally didn't know that. The different alarm sounds tell them what truck to drive and what gear to put on.

I had a really good time. They go to the grocery store to buy meals, they have a nice kitchen, a huge TV, a study table, and bunk beds.  Its actually a pretty sweet setup.  I was sad in a way that I hadn't considered being a paramedic instead of medical school.  You get all of the fun but less of the responsibility.  The paramedics laughed when i told them this.  I guess I deserved it since about 80% of the calls are not emergencies (free ride to the hospital).

After this whole experience, I think the paramedics opinions about patients are under appreciated simply because they get to take in the patient's home and surroundings. It really can tell you more about the problem than anything else.

Overall, it was a 'slow day' they called it. Only 4 calls and several calls that were cancelled on-route. The rest of the day I spent getting to know the paramedics around me, why they had chosen what they had and trying to glean any helpful information I could.

I did learn that usually on a 911 call here, there are first responders who appear on scene first. Then if further assistance is required or if the original 911 caller explains the situation well enough, then the paramedics are paged. I don't know who or where the first responders come from, but they were at all our scenes.

The paramedics I worked with were eager to teach me and more than happy to have me ride along. Things I learned were more about myself than medicine I have to say. The paramedics treated me like a doctor. They asked my opinions on things, forced me to do IVs and a few random other procedures.  Many of the more serious calls have more than one paramedic team present. There is a call for a known diabetic in hypoglycemia (he is very agitated). So when we run in there is no time for introductions, everyone is running about. He is being held down on his bed, his has no pants or underwear, and he doesn't know where he is. The oldest paramedic in the room, maybe 40 comes up to me and hands me an EKG. He explains what he sees and asks if I agree. Then another paramedic who cannot get the IV in his hardened veins (on 8th try), says let the doctor do it.  Then they hand me a bunch of needles (i have never done an IV before, much less a hard stick) and I try and try until I say, "its not happening." And they agree and hand me a needle and some glucagon. I try to explain I've never done it, but they keep insisting and saying things like "move for the doctor" and I try to stab the guy with the needle but I don't push hard enough. The needle bounces off and I have to do it again. Now this might not sound that exciting to some of you, but this is the first time people who have more experience than me are looking at me for answers. It was my first terrifying experience into the world of authority I suppose.  I wasn't able to clarify I was just a student until later. And I can't help but have some doubts about my capabilities. Granted I'm only a third year, but it still makes me a bit nervous.

Other calls we got to go on were about a choking child, chest pain at a doctor's office, and a car crash that the helicopter had already arrived at and took the one critical patient. The picture is below of the helicopter as it took off...

Overall, a fun, educational experience. I hope to go on more ride alongs.

Peds ER: end of the story

So despite some disappointing turns in the middle of this rotation, it ended on a good note. I did feel like I finally had at least a small handle on what was going on, I felt well-liked and that I fit in, and of course that is the time that we end and move on. Seems to be a theme with these rotations.

So I did have some some amazing pictures of torn achilles tendons and whatnot, but unfortunately my phone screen fizzled out and i have no way to recover any of those pictures. So bummer on the fun stories, but yay I got an iphone so more pics soon.  The cool factor in the ER stories seems to be related to how this injury happened and what it looks like rather than words on a page that would be fun to hear. So without pictures less cool.

I do still think I like ER the best tho. I just get along with everyone, you get to go home and have a life.  The big issue is do I have the board scores. ER is becoming more competitive because it is so perfect a job. So I decided to sign up to take USMLE step 1 on Nov 22.  That means that I have to spend more time in this next rotation studying for USMLE rather than a shelf or the rotation itself. *sigh* i don't want to study for boards again....

EDIT:  So I got the resident to send me the picture of the achilles tendon rupture. Its the heel on the right, if the bruise doesn't tip you off, look closely at how the heels are lying.  Also notice the tendon 'bump' on the left foot (you an feel it on your own foot) and note how the right is flat.  + Homan's sign! BOO YEAH!!

Peds ER: new experiences.

So after a full half of the rotation is over I find I'm disappointed.  I'm disappointed with the amount of action that we're seeing (despite my posts mostly its very quiet) and I'm disappointed in my connection with the ER attendings and staff. I am constantly being told that I am 'not  thinking about things properly.' And that I need to read more or something.   I made well enough friends with the residents, but nothing to hang out after work or whatnot.   And it has been made abundantly clear that I am behind my fellow students in aptitude and even the residents know it. There is nothing more frustrating!  I hate feeling stupid.

So after a particularly miserable shift, where I didn't seem to be able to answer any of the docs BASIC questions, I decided to cheer myself up with some hot drink at the hospital cafe. I ran into one of the interns from my internal med month. She is an OB/GYN resident (who had to do 1 IM rotation) and she invited to me come up and talk because its been slow.

But before we know it there is a lady who comes in at 6cm dilated and is rocking back and forth in pain. She is 23 y.o. female and is somewhat mentally immature. She was scared out of her mind and it was too late for an epidural because she was rapidly progressing.  So i got to witness my first birth, without epidural.  Gotta say it was different than expected. It was faster than normal and it was sure painful, but she was less pain and more scared during the majority of it. You could just tell. She was rocking back and forth and crying. She couldn't decide if she wanted her husband there or not. This was even her second child.  It was the end that was the big kicker. I guess it was the most painful part. Her legs started shaking uncontrollably and she said it was so much pain she couldn't talk (which was unusual for this patient).  Gotta say it made me want to cringe in the corner a bit. I maybe thought that being female wasn't so great after all.   The baby did have meconinum (the first baby poo) in HER amniotic fluid, which is dangerous. If the baby cries and breathes before we get it out her mouth then she can breath it in to her lungs and get pneumonia (=bad). So they immediately started suctioning her and tried to keep her from crying. She began to turn blue, so they sucked as much out as they could before she started crying on her own. Usually babies require stimulation (vigorous rubbing) to begin to breathe.  It was crazy because when she came out she looked like she was made of jelly or cartilage or something, all white and green and covered in muck. But a couple minutes of breathing she looked like any other baby.

But the baby came out great and the mom didn't tear and had no complications. So overall good night. And one I really wasn't supposed to have... good thing I went for a hot drink.  

Peds ER: weird names

okay so i know this has nothing really what to do with medicine but there are some very weird names of some of the patients. And I find I must share them, to remember them later.

• Amgine (Uh mag  ine)
• Casonova King and his twin sister Jasonova King
• Marvelous Beltcher
• La-ia  (la dash ia)
• Vagina  (Vuh geena)

Peds ER: First Procedure!

So today was pretty exceptional because I got to actually DO something! It was the busiest I've ever seen the peds ER.  I actually didn't get dinner. AWESOME!

Not that bad
15 y.o. female comes in with an 'intense' headache since thursday. Had headaches on and off since tuesday that start in the back and then spread over the cortex. Had one episode of vomiting this morning (1am) and has had a temp of 102.4 since this morning despite tylenol and motrin twice a day. She is photophobic and claims to have shooting pains down her neck. It hurts her to tip her chin to her chest. She complains of general myalgias (muscle pain). She has some horizontal nystagmus when looking to the left. Most medical professionals will start thinking meningitis-- at least I did.  So I decided to present to the attending instead of the resident to expediate the process.  And of course, I was apparently so wrong. He said she didn't look that sick. He said i shouldn't go over the resident's head unless she was really sick. Which apparently it was just a 'bad virus'. I felt very stupid.


The KNEE
17 y.o. male comes in after a football game injury to his knee. It looks like this... (yes, this is the actual knee! we're allowed to take pictures at the hospital!)

He says its painful and is unable to bend it. And the doctor says it needs to be aspirated. And I got to do it!!  It was pretty awesome shoving a needle in there and pull ing out over 120cc's of blood. Traumatic bursitis-that's the diagnosis the doc's think. The problem is a bursitis shouldn't be bleeding. He was given dilaudid and started hugging the entire staff as often as he could. Which was sorta adorable.  It filled up again within 10 minutes, so we called the ortho guys. Blood should be clotting, by now. So the senior resident comes down and yells at us in front of the patient's mother that we are incompetent and why didn't we aspirate it, and then why didn't we send the aspiration to be cultured. We're like its blood, not an infection. It happened because of an injury.  He's like didn't you get an xray? MRI?  We're like what else could it be? He's like cancer! And his mother is basically peeing herself at this point. He proceeds to explain that ER docs are the people who couldn't make it in any other specialty. He continued to berate the ER resident about all her decisions and almost had a stroke when she told him I aspirated the knee.  The patient told him that he thought I did a good job, but the ortho guy decided to aspirate it himself, which he did and of course it filled up again even bigger than the first time.  Then he decided to order and xray and MRI. Which showed blood above the knee cap of course.  So he called the attending and she wanted to operate for exploratory surgery.

It was an intense experience. First big argument between physicians that i've witness. I just thought that ortho resident was an ass. But I got to aspirate it! which was awesome...


more later...

Peds ER: O.M.G.!!!!

Okay so today is my day off (ha!) in which I have to attend lectures/grand rounds for ER residents. So I listened to a few good lectures then i was told we were going to attend trauma lab (dun dun dun!).

We were lead down a labyrinth of hallways lined with pipes and broken 70s tile. The woman pointed to a stack of paper gowns, hats, booties, and other surgical coverings and told us to 'gear up'. We were then divided into teams of 3 and lead into a sterile room with two steel slabs. There are two human-sized, hairy pigs laying upside down tied down with a tube coming out of their mouth.

A dorky, gangling guy in bright blue scrubs, who I assume is in charge, walks into the middle of the room. "These pigs are anesthetized." Without hesitation he leans over grabs a large cleaver and stabs one pig in the chest 4 times and then grabs a bat and smashes the other pig a couple times as hard as he can.

I fight off this wave of nausea and suddenly got really sweaty under my green latex gloves. I am trying not to think about the crunching noise of the pigs ribs or the twitching of his legs. I am thinking don't get sick, don't get sick.

"What are you doing standing around? SAVE YOUR PATIENTS!" The guy yells pointing at the injured pigs.

Suddenly the room lurches into motion and everyone swarms around the pigs. I don't even realize what's going on, but I am moving without thinking- standing beside the stabbed pig. Its' blood is throbbing and spurting out the stab wounds, its obvious the heart and lung was punctured.  I look up because this girl is handing me a scalpel to do a thoracocentesis (pop a hole in the chest wall to release the air that is preventing the lung from inflating). I'm kinda nervous because its not like I've ever done this procedure or seen one or even really paid attention to reading about it.  The other team is frantically moving about and my team members are splitting open the chest to try to stop the bleeding from the heart (which we have to visualize). So I take a deep breath, find the intercostal space and make the incision. The muscle twitches and warm blood trickles down to pool on the tray. I shove my finger in the hole trying to find the appropriate space to get through the muscle. I put a hemostat in the warm muscle with my finger and spread them apart hoping that this is the appropriate technique. The girls are now shouting because they are pulling apart the rib cage on the other side of the pig- the hole is smaller than we thought, which makes it harder to plug up. They need me to hold some things open.  I shove a plastic tube in the hole I've made and wait for the barely audible rush of air before i struggle to throw a few stitches around the hole i've made so the tube doesn't slip out. I then rush to wrench the metal contraption that is holding the ribcage open. The purple red heart is pulsing furiously, the phrenic nerve is beautiful!  They insert a foley and inflate it to stopper up the heart temporarily. She says we need to establish an airway since the heartbeat and become unstable. So they hand me the equipment and keep calling me Crystal which I don't really correct at the time.

The man in blue scrubs comes to observe our table and shouts at me "to get it together." And i try to insert the tube down the pigs throat. In the meantime, one of the interns at the other table shrieks while a spurt of blood shoots at the ceiling and narrowly misses my paper cap. And I slipped, the tube enters the esophagus and I have to pull it out and retry.  I try to ignore the fuss happening at the other table as they urgently buzz from one side of the table to the other. The intern at our tables also began to yell as blood began to seep past the seal. I didn't see what exactly went wrong but soon the blood began spurting and I failed intubating a third time. I attempted a cricoidotomy but failed just as the last of the seal broke off. The blood was flowing freely now and had stopped spurting so much as oozing. We realize that we are in deep here and somebody shoves me outta the way and fixes the airway. They ask me to help on a femoral line to get a pacemaker in but before I am able to get the equipment the man in blue scrubs demanded we call it.

He promptly berated us and demanded we discuss what went wrong. He demonstrated the use of a transcutaneous pacemaker on the quivering heart that still oozed despite the lack of fluid pumping through its walls.

It was only at this point I explained I didn't know who Crystal was and that I was only a third year student. The man in blue scrubs was the third year resident and he said we did alright considering. The pig was given some extra drugs to make sure he would never wake up.

I stayed afterward and sewed him up. I wanted to give what thanks I could for the life he gave. I truely hope he didn't feel out botched central line attempt or our interosseus femoral line or any of it. Plus it was good suturing practice. So thanks piggy.

So a bit of of history.... (because i had to ask.)
I found out this has been done one time a month since the 70s. They used to use dogs, but pigs are more anatomically similar to humans. This activity is approved by the animal rights people. I was told that we justify it by knowing that as future physicians in this scenario we will use this information and would rather practice on a pig rather than a real human.

Peds ER: day 1

so. today is the first day of pediatric ER. It is different than internal med. Somehow I don't feel quite so overwhelmed as I did there. It still wasn't easy-- but it was more comfortable.

So i get to work with one doc, two residents, and a nurse. There are only 8 beds and its attached to the main ER.  Its only open at nights because most parents don't bring kids in till after school anyway.

It was an ER just like any other-- lots of kids are sick or hurt-- fingers need stitches,etc.   I only saw about 6 patients or so where I got to do much... i know i didn't really impress the doc, but i wasn't totally retarded I hope. I have lots of hope for this rotation.

IM: presentation

so today we were getting pimped on stuff and me and my fellow student disagreed with the attending on a particular point that we had read on the night before.  He was like "oh well, why don't you do a presentation for me in 3 days?"  So it was about Proton Pump Inhibitor Side effects (things like pneumonia, C. diff, and fractures).

So we did all this research on studies done about it. And put together a powerpoint and then the doc was all, well i forgot about your presentation so why don't you just present it tomorrow in front of the ENTIRE hospital at grand rounds. Besides peeing our pants, we were surprised. So we presented this in front of the entire hospital. We had print outs of the studies and out powerpoint and we had NO IDEA what we were supposed to say.  But I guess everyone was impressed. Residents came up to us after and said we did a really good job and the program director for IM said he wanted to write a letter to our dean. He actually wrote that letter and recommeded me for honors! Which is totally awesome!! YAY.

IM: a week summary

So I'm surprised to say this-- but I definitely like internal medicine. I was walking around the floor with the interns and still unable to answer questions and still not the favorite and-- i felt relaxed anyway. I felt like the team I was with was good and I liked what I was doing. It wasn't thrilling, but it definitely made me think internal med could be an option.

IM gives you time to think about your patient and research it. There is something to be said about time to think. There is something to be said about constantly thinking about your patient, seeing them several days and googling things. The residents had time to cancel their stat orders or reorder wrong tests. It takes a bit of the stress off.

Anyhow, I don't know if i'm learning as much I should be. I have two patients everyday and I follow the interns around. I probably ask too many questions, but I do it anyway. I think they got used to it because several of them asked me to hang out outside of work.  One I even went to dinner with at this amazing jazz club bar.   But I wish I was getting pimped more questions and going through more ways to diagnose. I should be reading more instead of doing these stupid presentations for lazy doctors who don't want to read the new studies they use the medical students to do it and then present the important stuff. Genius really. I should be reading more though.

I've noticed that the doctors linger more at the nice people's room. The little old lady with the fecal impaction gets tons of attention while the guy with pancreatitis who screams in pain we only go in for about 5 minutes. And what's worse.... I think i'm starting to do it too.  I spent over 3 hours reviewing her chart and about 20 minutes researching pancreatitis.  I have to be careful of falling into the trap like so many doctors do.

This week I also witnessed my first death note. The patient died on the floor and we had to come in and declare them dead. Had to do all the reflexes and listen to heart and lungs and all the legal stuff. The lady was 40 and starting to go into rigor mortis already. She was very waxy and just staring at the wall with her eyes open.  Even though I knew she was dead before going into the room, seeing her like that made me instinctually back out of the room and my veins fill with adrenaline.  I have no idea why, i've seen plenty of dead people-- but this lady just freaked me out.  Turns out death notes are really important if a legal case gets brought up. There is a particular way to do them and its so unlike SOAP format.  You have to state not just time of death and reflexes but also discuss organ donation, funeral arrangements, things for the mortician, you have to list every device or line on the body (including IVs and foleys which you can't remove).  It was educational.

I have to go to bed now.... but more cases to come.

IM: new eyes

Yesterday, we had a new chief resident. She swept in and organized everything. Patient lists and defined our roles and what we can and cannot do... It was amazing! What a difference it made.

Today, we got the new interns. The senior resident always changes first so they can get a handle on what has been done so they know where to go.  We have the best possible team.  One black guy who really likes to teach, one OB resident who doesn't know what she's doing but is confident she can learn and help us learn, and one indian resident girl who doesn't know what she is doing but knows enough to recognize it and let us help.  I am floored by the difference this made in the day.

To top it off, we were long call today, which means our team admits patients from the ER until the night team takes over. So i was chilling in the ER. We had about 4 admits. I only got to see one, but the important part wasn't even witnessing the admissions. It was having the interns, who had down time, take the time to teach us HOW to think about the case.  The black intern is really good, he took me step by step through what i should do, questions i should ask, and how i should think about the answers. It's probably all stuff that other people know or figure out. But since I'm slow or something, I benefitted from being told.

Doing rounds with this new team and watching how they make decisions I suddenly understand much more about what IM at least is about.  We don't have to research and understand the entire picture of the patient like i was trying to do earlier. Its more about preventing any complications and simply treating them to be stable enough to leave the hospital. You don't have to fix them, you can't even if you wanted to.  You just get them stabilized enough that they can go back to their lives.  That may sound harsh, but its the only way we can handle our 20 patients a day.

Let me give an example of JJ- he was my patient the second day. The one I said I couldn't finish even in 4 hours.  He's an 82 y.o. african american male who was admitted because of a 66lb weight loss, unexplained. He said he didn't want to eat for the past 4 months. He gave me several reasons why over the past 4 days (because i've followed up with him) 1- he was afraid to swallow because he choked 2-because he wanted to die 3- because he couldn't swallow.  Now while these seem like tiny differences and some ppl might say this discrepancy is because I asked the same question for 3 days in a row, each answer points to different causes- drastically different.  Psych, cancer, and muscle spasm.  The worst part is because he's so old and he's also sick with (to name a few)  COPD, diabetes, hx of cancer and now has malnutrition symptoms it could be any of the three possibilities.  This makes how we treat him, what tests we do, and what questions we ask change everyday (maddening, i know).

I've been following JJ for awhile now and then one day in front of the new attending he gave drastically different answers(making me look like an idiot)- which made the doc think of several more tests to run. Then there was a big hulla-bullo because his family said do the test but they aren't going to treat him for anything. So we ran the test- He has a hiatal hernia, which explains his weight loss. But the doctors weren't happy about it. Its an easy fix and would increase his quality of life. So the family doesn't show up for 2 days.  But there is something else that is going on because his blood pressure keeps dropping suddenly now. We keep having to call a code purple on him-- that's get the paddles ready he's failing.  And the docs are getting frustrated. Several days ago he was fine- we were sitting at his bed laughing about his son and how i had to ask him these silly questions everyday. Then the family comes back and says we never said that fix our dude! So now we're trying to fix the guy who we've let tank almost too far. Nobody knows what to think about his case now. We were going to send the guy home, but now... now we're admitting him to the ICU.  He may have been a thin man before, hadn't eaten really in 4 months, but now he was near unrecognizable. The jutting cheekbones and the fact that you knew he didn't have any teeth before he opened his mouth made him look like an alien. He can now barely talk. ANd i still don't understand why he changes his story everyday or what we could have done differently.

His story makes me understand why we round everyday. IM is simply about keeping the patient alive for another day. IM isn't about cures or diagnosis. Its about staying one step ahead of the complications and of things getting worse.  Which i still don't feel capable of doing-- but even though I still feel overwhelmed everyday I feel like I have a better grip on what is happening. At least for now.

IM:On my own

Holy Shit. I feel shell shocked. I can't quite explain how lost and insignificant i feel. How stupid. 

It was simple. I was on my own. I was told to pick a random patient. I was told to see them and write a note in the chart recommending my plan for patient care. I was told to get to as many as i could before rounds at 10. I had four hours. 

I couldn't even get one finished!  There were an insurmountable pile of co morbidities- so many people who have 5 and 6 and 10 and 15 serious illnesses. And one illness prevents you from treating the other and the other etc.  Its maddening and it takes hours to even understand the full scope. Then I am still at a loss.  

I went home today and feel like i'm choking on information I will never integrate. I am overwhelmed. I question whether I'm smart enough for this profession and wonder how in the hell anyone else is. Its an impossible job. One that the residents are expected to do in under 30 minutes. I could read a million pages and still not 

IM: Daily Dynamics

So i started Internal Medicine today. It wasn't nearly as bad as I'd heard--- knock on wood.  All of the residents and attendings are Indian. Not that its a problem except I can't understand them. They talk very quietly and mumble-- often switch from Hindi to English. But they answer my questions and seem nice enough.

I followed one of the residents to watch about 8 patients and then do rounds on 20. The social dynamics of the hospital are exactly and I mean exactly as portrayed on television. I was surprised that the stereotype turned out to be true. Rounds get announced over the intercom, but there are 4 IM teams so announcements are constantly being blared in the halls. When you finally find where you're supposed to go you give the attending approx 4 sentences to update them on your patient you just spent 1 hour checking up on.  He nods, mumbles in an indian accent and then goes to see the patient himself with his gaggle of white-coated students (pharmacy, medical, and nursing) and residents.  We crowd around the bed and he asks the patient the same questions you did only to get a better and more complete answer from the patient. The chief resident, also indian, tries to get the last word in edgewise and must always be at the attending's side, even if that means shoving you out of the way to do it. The attending, who must practice this, struts down the hall at freakin light speed with the chief resident trying not to run to keep up, shouting facts about the next patient.  It was ridiculously hilarious. The attending didn't actually ignore me or the other students and often told the chief resident to shut it with a derogatory finger. The questions he asked were ones I used to know once upon boards. Things like: What are the contraindications to metformin?  Why are we using coumadin here? What are the side effects of ACE inhibitors?  What are the complications of liver failure?   etc.

The attending also gave us assignments or topics to read about that night. It felt like every other sentence was "read about that." At the end of the day my palm sized notepad had 3 pages front and back dedicated to subjects to read. Let me tell you, none of them were simple readings. For example, he said to read about anemia. There are so many categories, subcategories, causes, etiologies, treatments, tests that you could write a 200 page book on it and still not know everything. I left the end of the day at 3 and couldn't wait to start reading on topics to hopefully know what was happening better than I did today.

I felt like an idiot constantly getting lost or going to wrong wing. I didn't know where charts were or how to use the computer. I was also mildly surprised at how little interaction the nurses actually want with you.  They didn't want to help me, they told me what I needed to know so i would go away.  Or at least that's the impression I got.  And it probably is frustrating because not only do students rotate in and out every month, but so do the residents. I didn't know that residents also have to do rotations except they are in charge of the patients.  And that's a scary notion, one i was vaguely comforted and horrified by. The first year intern girl I was with didn't know anything more than I did. She could do a good physical exam but then would summarize and look at me actually asking "What do you think I should do next?" or "What do you think that means?"   and I was all WHAT! I DON"T KNOW ANYTHING!

I thought for at least 2 cases she was just quizzing me, but when the attending asked her the same questions she admitted she didn't know.  So then I took her questions more seriously. There were several cases where she just took my word for it (what it said in the chart)  or wrote down my possible differentials and claimed them as her ideas (that actually made me kinda proud).   At the end of the day, despite my lack of confidence in her ability as a doctor, I asked to be with her tomorrow. It forces me to learn and think on my feet (i hope).

PSYCH: Final Thoughts

Well, first I have to apologize for not meeting my goal. I was unable to write every single day. I think its a combination of being completely exhausted and also maybe just a lack of interest after awhile. The repetitiveness of the day was less than thrilling after you saw one case of ADHD you saw them all. However, there is much to be said about seeing the physical difference in the kids through follow up and the true magic present in one single pill that can make (or break) some parent's life. 

I must admit i will be sad to see psych go, mostly because my preceptor (and his staff) was so awesome. Especially towards the end of the rotation I started feeling like I fit in. We had inside jokes and goofed around about crazy stalker patients who stalked one of the front ladies. We also teased the doctor. It was definitely a community, and I felt accepted. It is hard to leave that since I have heard bad things about my next rotation. I have to say that for those people out there who have never seen a "serious" gay man-- you have to meet my preceptor. His sexual orientation did not cause any awkwardness or impact at all on my experience. Actually, the saddest part was when his patients saw his wedding ring and asked about his wife. He always just said "she's fine" and ignored their deeper probing. There was one time when an older patient remarked that I was a "pretty one" and it was "too bad" that my preceptor was married. (talk about awkward on multiple levels). 

As to whether I think I could ever do psychiatry... I don't know. I suppose I could. It is a lot of follow up and control over who you see and when.  Since my preceptor doesn't do therapy (said he's not very good at it... too blunt) it was usually a day full of med checks and making sure there were no side effects. I told him I felt that he did a small amount of therapy in the med check meetings, telling parents the truth about what he thought or calling the kids on their bullshit. Its amazing what 15 minutes with him can do and... not do.   I can understand how there would be less of a burnout. It was hard to see a number of parents who just wanted you to give them a pill to fix their parenting skills. But then it was balanced by the parents who were so desperate to try anything and to see something work for them. 

In the end I would say its not off the list, but its not on the top, at least for me. I still want to excitement and variety that I haven't really found in psychiatry- outpatient psychiatry.   I was constantly talking to the preceptor about wanting to see rare disease or unmedicated patients for the experience. My preceptor appreciated me for that. He wrote me the best evaluation and honestly told me that I'm going to make an excellent physician. I'm glad to have his support.  I asked him to write me a letter of recommendation. And he agreed. I can already tell that its going to be one I'm going to use for every site, because despite our rocky start and the fact I was outshined by my fellow student-- he took the time to recognize my strengths. Maybe its because he's a psychiatrist, but i think he likes everyone. 

And I suppose I need a few words in here about the psych Shelf exam. It whipped my butt. I wasn't expecting so many neuro questions. I felt like it was all about vit b12 dementia and neurotransmitters. I got at least  3 questions on theophylline, an asthma medication. I used first aid for psych and tho it helped I should have studied a bit more out of my step 1 book. I hope I don't have to retake it, but at least if I do-- I can do significantly better on it. 

PSYCH: Assessments & worker's comp

so today wasn't a normal day in pscyh-land.  The doc was required to do a whole day of nothing but 1 hour worker's comp evaluations to decide for the courts if this person really deserved to be off work or not. Two evaluations by two different psychiatrists are required. These work ups are long and tedious. He uses the students to listen, take notes, and type up the notes in a particular, elongated psych SOAP.

PSYCH: Lame sauce

So, thursdays are always didactics. That means that its the weekly lectures. They are essentially the same kind of lectures I've been sitting through for the first two years. So i haven't escaped lectures yet. The sad thing is they really aren't of much use. Usually its a resident who gives them and they tend to be boring, but we do get a free breakfast. Since they are required, we don't go in to our regular rotation that morning. Once the lectures are done (around noon) we drive back out to his office.   Its sadly a big waste of time because we only see about 2-3 more patients. So not much to report.

What makes this even worse is the doc has been sick for several days so he's going to cancel all his patients tomorrow which means we get a day off. Although many students pray for this to happen, I'm sad because it means i see less and have less experience. Plus I hate not having anything to do. Since I don't know anyone, its even worse.

So no patients today after didactics, and no patients tomorrow either. Lame sauce.

PSYCH: Jail time

So jail wasn't what i thought it would be. I guess it wasn't what my doc thought it would be either.

So the first thing I learned is the difference between jail and prison. Jail is somewhere you go to wait to be sentenced or its somewhere you go for a short period of sentencing.  If you go to a prison it is long term and it means the court found you guilty of something pretty big. We went to jails.

The first one was way out in the middle of a corn field and it was full of guards and barbed wire. Every door frame you entered through had a glass door that had to be opened from the guard station. Only certain guard stations could open certain doors and as a rule, it was never the closest guard station. There was no control room that could open every door, so if you wanted to open all the doors you'd have to go from guard station to guard station- which is impossible unless there is a guard somewhere else to open your door. (confused yet?) Not to mention many doors came as pairs and if one door was open the other couldn't be unlocked until its match was closed. So moral of this story= if you are thinking of a zombie escape plan and need somewhere safe- don't go to the prison because chances are you won't make it out. Not because of the zombies but because of the complexity of the doors. And the inevitability that some person in a guard room will be eaten so they cannot open the door for the other group hence starvation.

The first jail we went to was clean. I was later told that certain less security inmates were offered '1 day free' if they helped tidy the jail facility. 1 day free means they get out 1 day earlier than sentenced. I always wondered how people got out of jail for 'good behavior.'  We didn't go to the inmates, but instead they came to us. We were put in the visit room and the guards let in one inmate at a time. The inmates wore different colored jumpers, they almost resembled scrubs (oh the irony). The color indicates what security level the inmate was on.  So Lime green was maximum security. Navy blue was lowest security.  There were 6 different levels.  The lowest allowed the inmates to go out into the community to work but they had to report back whenever they were not at work. So you could understand that the majority of the inmates who refused to come see us, were those who got to go to work.

Yes that's right, certain inmates can refuse to come see the psychiatrist. And frankly, he wishes all of them had that option because those who are required are generally pretty nasty. That said the majority of the  inmates were polite and even thankful that we were there. Not only were we a chance to get out of their cell but also somebody who would actually listen to them when they spoke. Guards are required not to. Most of the guards I ran into were rather portly and didn't instill a sense of security to me. However, the jail ran like clockwork. It was strict and well organized. The cells themselves, 'dorms' as the inmates called them, came in two varieties: normal and glass house.  the normal dorm was a bed, metal toilet, a small triple reenforced window about the size your fist, and a solid teal door with a lunch slot in it.  The glass house contained the same amount, but the doors and in many cases the walls were glass, so the guards could see what you were doing at all times. And let me tell you inmates and guards have absolutely no sense of privacy or shame at being naked. (more on that later)

We only got to go to the 'units' or cells when a patient was required to be seen and was too behaviorally challenged to be let out of their cell.  No guards accompanied us. We only saw one of them today.  He was rude in the way a teenage boy is rude to his mother for not giving him what he wanted. He slammed his hands on the table (aka picnic table screwed to the floor) and that was as violent as he got.  He wanted meds that we couldn't give him.

That's what they all want actually. Believe it or not most people in jail are depressed and report crying and wanting to be out within the first two-three weeks.  And nobody sleeps good.  They all want something to sleep.  Some even go as far as to say they want to be sedated so they don't have to feel 'guilty'.   I haven't decided if this is a con or not.  Many accept that we don't give sleeping meds, which is one of my docs rules for jail.  He says they are too habit forming, which is true. You can tell they aren't too happy about it, but very few are stupid enough to make any big thing out of it. Many actually pout like a three year old refusing to talk to you, or they just walk up to the door. Many also try to rationalize you into it, much like high schoolers did to your parents when they said no.  There were some that graciously accepted the explanation as well.

This jail had good record keeping and we saw probably 30-40 patients from 5:30-10:00 which is a pretty good stint. we get just a few minutes to assess each patient and determine if they are lying, seeking or real. I still haven't mastered this but the doc has got it down to a beautiful art.

The second jail is dirty and dungeon like. They have actual bars everywhere as opposed to glass. The cells are something i haven't ever seen. They have only 3 levels of security and they are the county jail. They have had several escape attempts and therefore the inmates MUST behave or else they don't get to see the doctor, their lawyer or anyone else. But i did get to see the medical cells. They were nothing but a large fuzzy blanket and a toilet. There is no bed, no windows, no nothing. These cells were about the size of a closet. They were more of what i was thinking of degrading. These inmates were not allowed outside or to the gym but once a week. The other jail gave their inmates outside time everyday.

This jail i saw many naked people just walking around the hallway with the guards. I guess the inmates refused clothes, which legally guards can't do anything about. Most patients in this jail were angry, young or immature. But nothing really exciting happened. The guards here were also alot angrier and more immature. One guard got pist and won't respond unless you use her first name only. She was also offended we didn't invite her to lunch.  The doctor told us that last week there was a fight but it was between the guards not the inmates, and worse, none of the guards were fired.

So anyway more stories later. :)

PSYCH: ugly truth

We had more disturbing cases today than I truely want to admit. I mean the majority of the troubled teens or the ADHD kids aren't that much of a psych problem as much of an environmental or behavoral problem. Things that need to be fixed with therapy rather than drugs. But they aren't evil. They are kids who have crappy parents or never learned right. Usually when they discover they can't push the doctor around they shape up. That's why the jail system works so good I am told, they get consistancy. My doc was telling me the other day that consistancy is required to deal with people in general so they know they can't walk all over you. And its proved over and over in his sessions. He has certain rules everyone must follow: 

• no meds until you've been sober (drugs or illicit drugs) for 6 weeks no exceptions
• no cussing, threats or raising your voice or you get kicked out and still have to pay for the session
• no video games or books in his office (for the kids) because we're talking about you and you need to know what we're saying (appts are only 15 minutes)
• the doc is under no obligation whatsoever to see you, and at any point he can kick you out of his office or refuse to see you. End of story.
• if you are late, you will not be seen that day and will be charged $50. You won't be able to schedule another appointment until you pay that money.

His rules apply to his staff (including us) as well. Can't be late and he doesn't have to put up with your crap. Its intimidating but nobody's been late yet. The doc was also telling us that some people are just evil and there was nothing their parents could do about it. These people realize at a young age that if they manipulate or are cruel they can get the things they want. Honestly, some don't recognize the line they cross and others do but cross it anyway. Today, we saw some of those cases.

One little girl came in with parents who wanted therapy, drugs and were willing to work on whatever. You could see their desperation. They only had two kids and the little boy was very well behaved. His sister however, was said to say or do things simply out of spite. Her father gave examples of how she at age 9 was screaming "i will kill myself if you don't..." blah blah. I guess she also steals things from other kids and doesn't respond to spanking.  The parents regale us with stories of manipulation that I would chalk up to teenage level and the whole time the little girl is sitting quietly in the chair in between her parents... GRINNING.  When the doc asks her why she does it, she shrugs and smiles bigger. It was probably one of the most disturbing things I've ever seen. I keep have this recurring thought that one day I'm going to be in my room in the dark and i'll turn around and see that little girl with a knife standing behind me with that little grin.  SERIOUSLY freaks me out.

There was also a little 7 year old boy who was brought in in a straight jacket. He had been brought from the hospital several days ago (who lent the straight jacket to the mom).  Apparently he stabbed someone in an attempt to kill them. The attempt was unsuccessful but the boy screams he's not sorry. He said he doesn't think they should live. He seemed a somewhat normal kid talking about toys and TV. He wouldn't talk to us about the incident and kept wanting to be let out of the straight jacket.  His mom was hysterical and begged us to do anything to fix him. I think she was afraid of him. It was hard for us to tell her there is no pill that would fix that, her little boy was just a bad person.

it wasn't all bad, though. There was a little girl,8, who told me I was pretty and wanted to sit on my lap the entire appointment, which is definately a first. It was cute. Until I realized she was totally playing me and actually stole the $20 I had in my pocket. I didn't notice until the girl had left. I felt incredibly embarrassed when I realized what had happened and how I hadn't noticed. The doc laughed at me and bought me lunch. 

PSYCH: the patients

Today went much like yesterday. It was even harder to get up at 4:00am than it was yesterday. I got home and I am bone tired. I have no idea how the doctor arrives everyday at 3:30am. But it went fast.

There were some very interesting cases. I have a few good stories to tell that will help you understand the typical cases and interesting people.

A typical girl
She is around 15 and covered in circle scars on her face and arms. They are 'bug bites'  that she 'picks' at. Her parents say she gets mad and scratches herself until she bleeds. She also had several episodes where she snapped tweezers in half and used them to cut her arms. Her parents were completely bewildered about what to do. She often threatened suicide and meds don't help. She says she's "not worried about scars." The doctor said to make her wear a thick rubber band on her wrist to replace the cutting. She still gets the pain and the parents get to keep their daughter with less permanent damage.

Mighty Mouse
She is as tall as me, weighs 94 pounds with red curly hair and acne. She is dainty, mousy and timid with crooked teeth. Her parents come in with her and they are overweight and stocky. Her mother has breasts below her elbows although her belly is not as proportional and very quiet. She is a new patient who has recently been hospitalized because she was "mad."  The father goes into stories about how the daughter gets raving mad and beats him with a broom handle. When asked what happens after that, he says he tries to walk away but she follows him.  He is convinced that this must be bipolar disorder to such an extreme point that he spends a huge amount of time trying to talk to doctor into it. The doctor immediately cuts him off and says no. The doctor explains there is a difference between blind bipolar rage and directed controlled rage. He says she acts out at home because its safe and she knows her parents won't do anything about it. He says that she is in complete control of her anger and she chooses what she does.  He got her to admit it by asking if she acts out in front of her friends or at school to which she immediately replied, "I don't get mad in public, that's just stupid- I don't wanna go to jail."  When the doctor suggested her parents call the police the next time she does it she gets upset and says "I"m not going to jail, I know what I need to do." which she keeps repeating. She gets very upset and threatens her father that he cannot even say that word to her or she will "get very upset." She begins to warn doctor he is making her upset.  She begins to cry and the father begins to quaver. Yes, quaver as in shake in his chair and he asks the doctor to stop saying the word.  The doctor actually laughs. He then yells at the father and says he should be ashamed for letting a little brat threaten him and get away with it. He yells and exchanges so many words he finally gets the father to freely admit he spoils her and wants to. He gets so frustrated that he just admitted it he goes silent for the rest of the lecture.  Then when asked to return the daughter replies "if i'm still here."

The Asperger's boys
Two college aged boys came in with their parents. Both were overweight and wore glasses. It was they way they walked maybe, or the way they fought over who was going to weigh more that I knew something about them was off. Not delayed, just socially not quite there. It was hyper rational, the kind you see on TV. The eldest was a little more lower functioning as far as intellegence went and he was more well behaved. But he kept saying "that's it I'm cut it out" without explaining the it.  The younger boy was so intellegent that his parents had put him in college. He had a very high IQ but he came back with a 2.0 GPA because he was "surprisingly social." Through the course of the interview, the younger kept rationalizing all his mistakes and admitting he had "complete lack of self control" as well as going off on a tangent about how he was "spoiled" by his mother, who also admitted it. It was discovered that she gave him $200/week spending money so he could have fun in college. Even though the importance of studying was discussed with everyone in agreement, the mother abashedly admitted that she couldn't stop giving him the spending money. She knew she shouldn't but she didn't want him to stop hanging out with his friends (who were probably only hanging out with him for the money). It became chaotic when the mother keeps talking and admitting she's a guilty parent for birthing two asperger's boys, while the dad is trying to comfort her, while the youngest is rationalizing over everyone, while the eldest puts his hands in his ears and rocks back and forth saying "everyone's crazy."  It was a new experience because these boys were true asperger's and truely smarter than me. It was an odd feeling to have to think that this disease is simply a social inadequacy rather than one of the mind.  It also convinced me that a certain pathology teacher of mine doesn't have true asperger's.

more cases later...

PSYCH: Day 1

As expected: Most of this job is actually about smoozing the ladies at the front. They are fun and talk about car crashes, dates, kids, husbands and restaurants- pretty much all the subjects I know nothing about. I continue to feel minorly socially retarded because I never seem to be making the right comments or laughing at the right jokes. There are two other students in the office, one a charming male who got on everyone's good side with his laid back yet secretly brilliant personality. The other is a girl who is leaving tomorrow, but the doctor constantly teases her and refers to her as 'exceptional'.  I get the distinct impression I'm a bit too gunnerish and maybe overexcited-- which was expected. I just hoped I would be able to make a comeback a little quicker than this.

Unexpected:  My preceptor primarily works with kids  (minus jail days). We see a patient every 15 minutes and he is a stickler for being on time. He is a no-nonsense person who has no problem with telling parents how to do their job and that they are awful (if they are). He also tells kids exactly what they don't want to hear but need to. This makes me inherantly respect the guy and it makes the fact that I am an 'average' student a little harder to bear.


About the patients:
Troubled teens with parents who let them get away with too much or ADHD kids are the primary part of his practice. Several other cases were a survivor of a car crash when she was an infant and as a result she is now brain damaged. Another was a man who does and has always believed he was a woman. A case of PTSD from an old veteran. Thus far there haven't been any drug seekers, at least not that I have seen. At least thus far, I feel like its alot of problem parents who pass their problems on to their kids--whether its genetic or by example.

The good news is I'm writing progress notes and next week we ar supposed to start writing prescriptions. I'm actually kinda excited about it. More soon.

Postponed.

Because the jail has not yet cleared my papers, I was not able to accompany my preceptor to the jail today. Instead, I was asked to take the day off. So I slept in, checked out the medical library, and went to the grocery store.  Lame. Til tomorrow.

An Intro: a bit on what to expect

For those who don't know, third year of medical school is the part of schooling where we essentially 'apprentice' a physician in the hospital. So after a lifetime of classroom work (and passing the mother of all tests), they sorta drop us off at the hospital with a "good luck." It is both thrilling and terrifying.

For each month (about) we 'round' with a certain doctor (called a preceptor) on a different speciality. So for example, my first month is psychiatry. After that month, I take another couple tests and then I move on to my next speciality, internal medicine.  Not everyone has the same schedule but everyone has to go through the same basic specialities. Those are: internal med (IM) x2, family med (FM) x2, surgery x2, psychiatry, OB/GYN, and pediatrics.  You'll notice some of these I have to do twice. The school claims it gives us more patient contact and the opportunity to see more basic cases.

Since we are only doing classwork 1 day a week (thursdays) and only for a couple of hours, third year is all about social skills. It is about balancing your learning and observing with your volunteering and enthusiasm to jump in. The biggest change beyond the move into the hospital is the fact that our grades are now determined subjectively by a single doctor (preceptor). It is everyone's secret fear that they might get a preceptor who doesn't like them based off some personality quirk and receive a bad grade or worse they do something stupid the first day and can't seem to recover from it in the doctor's mind.  This type of situation is the primary content of the horror stories in third year.

It has got me on edge of what to expect and also instilled a bit of terror since I don't know what is expected of me. To top it off, each preceptor expects different things of their students and these expectations are hardly ever mentioned. The constant awareness of your social responsibilities is often blamed for changing you as a person and as a physician, sometimes for the better and sometimes for worse.

So I remember what happened and how, I wanted to chronicle my experience to see what changes and how. My goal is post something on everyday I work (we'll see if that happens).  I have divided it up into three parts: Doctor's Notes, Patients of Interest, and Notes to Self.

I must confess when I was pre-med, I did something similar when I worked in the ER for a summer. You can read that blog: here.

Otherwise, my first rotation is Psych (as mentioned above) and all I was told was to report to the jail and "look as ugly as possible."  Should be interesting times. Starts Aug 2nd.