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.