ER: presentations

I have sad news. Due to some resident posting a picture of a liver on facebook, our hospital is up in arms about us no longer being allowed to take any pictures. *Sigh* this really really sucks. I have seen so many good patient photos this month. I realize that posting pictures on facebook is idiotic, but can you really call that picture of a liver a HIPPA violation?  I mean who could say, yeah that's so-and-so's liver?  You would have no idea if it was male or female or even what race. And we do multiple liver surgeries in the day so there is no way you could know what date and assume its this one person. I call this bullshit. Most patients are happy to have their pathologies looked at by a room full of doctors and discussed. Plus how else do we get photos for our textbooks?  So my blog will be full of photos from google now... which disgusts me somewhat. But now you know. Maybe other hospitals i go to will be less freakin-out about it.

So at this point you've had exposure to trauma and surgery. So the big cases aren't the impressive ones this time. Now in the ED, they are judging me to see if i'll make a good resident. And that is almost exlusively determined by how I present. In the ER, the presentations are hard. You have to display your skills but keep their attention, you have to balance giving them the basics with letting them be confident you did a through exam. So I decided todays stories would be about crazy presentations....


First, is an elderly man who comes to us in the middle of the night from a local nursing home. The patient is demented and barely knows his own name. He cannot answer any of my questions and this means the pressure is on to do a through physicial exam. The complaint on the chart and EMS squad says his PEG tube is cracked (if you don't remember what a PEG tube is, you'll have to back to my surgery months).  The poor guy gets scared everytime he is able to see the tube because he has no memory of ever having it. I look all over the stupid tube, i even pull a tiny bit out of him, but i see no crack. I grab a syringe flush from the nurse and flush water down the tube, nothing leaks no cracks to be found.  And I decide that since I'm on my audition I'll call the nursing home and find out what is going on .  The nurse who sent him over talks to me for about 5 minutes about how the tube leaks and how there is a crack at the top of the tube near the cap. Finally I realize. The nurse is describing to me the part where the plastic tubing stops and the cap starts. She finally says yes, it comes off if i pull it hard enough.

Now I tried. I really really tried to make myself as least judgemental as possible, when i told her that typically all PEG tubes have a cap installed and while there are a few models where the tube and cap are connected, most PEGs are seperate parts. This is how its supposed to be. Immediately when i hang up, the attending comes up to me and says "wow that was a bitchy tone." I still can't figure out whether this guy was joking or not.  Then i had the pleasure to try and present this patient.

"so why is this guy here"
"the nurse thought he had a crack in his PEG tube."
"oh. Well, where is the crack?"
"there isn't one. I flushed it, there was no leaking. I called the nurse. It seems she thought where the tube and the cap came together was a crack."
"so what you're saying is the nurse didn't know what she was talking about?"
"yes."
"aren't you alittle young in your career to make those calls?"
"not if they are this obvious, sir"
"aren't you a little arrogant shit."

So that went well. I am definetly going to get a residency here after that.... *sigh* can't win.


Another case was actually the same night. the complaint on the chart read "sumac poisioning"  and you konw immediately that this patient went on the internet and self diagnosed or has had it before.  It was also weird that this person had it for 5 days and it was 4am.  So i went in and tried not to be too surprised by how the patient looked.  The chart said the patient was 55, but I couldn't figure out if it was a male or female.  There were boobs but, manly other parts.  Anyway I just took the history of this chart and the patient showed me the rash, which was a contact dermatitis. I took a through history and then went out to present.

Most presentations begin with an age and sex of the person as well as the most important big symptom/complaint they have. Like :  89yo M presents with chest pain.  or 43yo F complains of abdominal pain and fever.

I take this structure of the presentation for granted. So I started saying " This is a 55yo...." and then i get stuck. I'm like is it male or female, male or female... how can i be a doctor if i don't know this....
So i lean in to the resident and say "I don't know if the patient is male or female" And the resident immediately laughs and puts his head on the desk.  "I don't know what to do with you med students" Just as that happened, the attending came up right behind me and asks the resident "you seen the patient in 17?"
"No sir, the med student was just reporting."
He looks at me "so what's your vote? male or female?"
The residents eyes get really big. "what is going on?"
"i bet transgender, pre surgery." I say.
"i'm going to see this patient," the resident heads off...
"wait don't you want to know why they're here?" i call, resident just keeps walking. completely ignores me.


So for those of you who don't know... a basic presentation goes something like this:

"56yo M complains of chest pain x4 days intermittently that he describes as squeezing pressure. Episodes last 2-3 minutes and are relieved by sublingual nitro. Tonight he took 3 nitros but the pain was not better and has lasted 4 hours. Pt states pain shooting down his arm, no sweating or shortness of breath or back pain. Denies fever or cough. Pt has 3 stents placed last year, no previous MI, but he is diabetic. EKG shows no ST elevation but some T wave inversion in v1-v3. Pt is tachy and BP 210/48. He looks like he's in trouble to me, i'm worried about a heart attack. I think we need to get an IV in him stat, the nurse already gave aspirin. I recommend chest xray, heart enzymes, chest xray, and some pain medication.  Here is the EKG. "

So for those unfamiliar, presentations should include:  what complaint is, how long its been there, description of pain, what makes it better and worse,  what patient has tried, if the pain radiates, if he has had anything like it before, what made him come in today.  Also you must include pertinent risk factors and negative findings.  This can be the trickiest part of the whole presentation and i think its the trick to impressing them. I showed I was thinking about heart problems by including high blood pressure, asking about diabetes and previous history of stents.  Including what the patient did NOT have, means you know what to look for and shows what you asked.  In this patient, the list of things that could be causing his chest pain is LONG. So to show I've ruled out some of the causes I include the negatives.  Chest pain that radiates to the back is a symptom of aortic dissection a big big problem, but he doesn't have it.  He also don't have fever or cough, which means is probably not pneumonia or a heart infection. I also listed his vitals and physical exam, what's been done, and then the biggest part that is NEW for fourth year is MY PLAN.  I told them what I wanted to do and also that I had looked at the EKG and the test results.  I don't always have a plan, which is bad. But i always try to come up with an general idea of tests I want to run to find out what my diagnosis is.  Oftentimes, I'm wrong, but the key is they know i"m thinking about what I would do.

For auditions, having that plan and including those negative findings and risk factors.  This is what I want to master by my rotation in december.

ER: med wars

So med wars is a BIG DEAL.  It happens all across the country and is divided by region. Medical professionals (including residents, med students, nursing students, nurses, etc) are all encouraged to participate. But it usually ends up being residents and usually ER residents, maybe because they have the time or maybe because they tend to be outdoor people. Who knows.

They pretty much go to a national park, camp and then do a sort of adventure race competition during the day.  Each team has 3 people. The one i saw they began at the starting line in canoes. Their task was to make it to the first "station" within the hour.  They had to paddle some 5miles, where we were waiting. There they were given a scenario where an event happens and someone is "hypothetically" injured. They must make medical decisions in front of judges (like me!) and  we grade them.  This year's theme was an ALIEN INVASION! The first station they were told that purple clouds spouting lightning descended upon them and one of their team members ended up with a severed leg.  They had to put on a tourniquet and carry the patient out of danger before they could get their next clue and map.  While they did not sever anyone's limbs, they did have to apply a tourniquet and carry their member up a hill.   Each map had only enough information to get them to the next station, where more plotline was discovered and more wilderness medicine challenges had to be completed. Along the way there were "mini games" which included trees with signs on them asking medical questions, like when to give which medication, lightning safety, or which animal is associated with which disease.  Many of the stations were heavy physical work, including saving a baby from aliens by swimming through a lake to rescue a baby (baby doll) then swimming back without getting the baby wet. Of course then they had to do baby CPR.  In the end you had to fight the aliens and save the world. Can't tell you how, it would ruin the surprise...

The total race ended up being 20 miles including canoeing, swimming, hiking, and going through a swamp. I was a judge for many of the different stations. There were a total of 5 stations and 25 mini games. Time was a factor but they also had to get as many of the questions in the mini games right as possible, this would subtract time for you. Players start at 7am and most don't finish until 5. We had several that got lost and had to send out search parties.  This whole situation is celebrated at the end with  hundreds of pizza, snacks, drinks, soup, chile, ice cream, cookies, brownies, hot dogs, etc. Basically the biggest bonfire you've ever seen and then we sit around and camp another night talking about how crazy that plot line was or how hard it was to wade through the mud, etc.

Residents that win the med wars, get bragging rights and often get to be the makers of next year's race. Personally, i was heart broken I didn't get to be on a team. It looked so fun! But at least I got to go. This year we had 35 teams of 3. So there were lots. And it was SOOOO FUN.

Next year, i'm making a team. You all should too!! Go look it up by your region and enter your team early. Besides 3 days off it only costs $12-14 per team to register. All that money goes towards food.

ER: audition #2

So I'm back in the ER. I'd like to say that the smell of blood and urine and the anxiety hanging in the air excites me yet again. But this time, I am just numb. I feel like my confidence has been shredded into tiny pieces--- what with all the residency application stress of writing my personal statement, getting my lower than average step 2 scores back and the reality of the application submission opens saturday I am just exhausted and way too over stressed. Not to mention this is now audition season and next several months will be having to prove to everyone around me that I am a smart candidate that they should want.  

I go to work and instead of looking around at patients and stories of those in the ER, I stare at the first year interns instead. Wondering what they did to get in that spot and desperately hoping I have what it takes.  The whole of it exhausts me. I am tired of feeling inadequate and trying to prove to them that I am worth something. Not to mention, the prospect of dozens of exhausting interviews to try and make my mark--or worse no interviews at all...

The good news is that a few residents here have said they have my back. These residents get to vote when our applications come through. So now I have to decide if i want my audition rotation to count as my interview or if i want to come back for a formal one.  The option to save money is always nice, but I don't want to be out of their minds or not get a chance for the faculty to remember me.  So I don't know what to do with that.

I was also invited to Med Wars, so I'll have some pretty good stories then.

Since I have only done 1 shift in the ED, i'm going to take this opportunity to say, I'm applying on saturday for residency in the ER.  I have already sent 11 applications to DO places and i will send 30 more to MD places.  After that it is all a waiting game hoping that I get interviews and don't screw things up.  I'd like to chronicle here some of the struggles I've gone through and some of the answers I've realized, but since there is a small chance that while I am applying someone else could steal my answers, I won't risk that right yet. HAHA nothing like feelings of inadequacy to bring out my competitiveness......

Radiology: medical humor

So radiology was a bright idea of mine. I signed up for it knowing that I would be studying for my USMLE step 2. I wanted a quick and easy rotation and I wanted to be good at radiographs for my ER auditions.   This was a great idea in theory, but I can't say I couldn't have learned what I got out of my rotation in a single day.

The structure was to watch the test being done in the morning, and then watch radiologists 'read' them in the afternoon. Needless to say, this rarely ever happened.  Watching a single MRI, CT, ultrasound, is enough for me to know what i need to know. While watching the actual test wasn't all that great, I was happy to sit with the radiologists and read the panels.  I can see how some people would be attracted to this lifestyle. While many people don't give credit to these guys sitting in the dark looking at shades of grey, there is a real art to it.  And the amount of people contact is vastly underrated.  Physicians of all specialties are constantly calling and asking for clarification or questions.  Not to mention the nervous patients in the hallway, who often want to meet the radiologist.

I did have a single day in interventional radiology and I must say, this specialty might be the best kept secret in medicine. You interact with patients all day long, doing diagnostic procedures. Things like difficult lumbar punctures, artery embolization removal, and any other procedures you can think of. And when you are done, you call and tell other doctors the answer then move on to the next patient.  So if you like procedures, patients, and knowing answers who wouldn't like it?  For me, it lacks the urgency of the ER, but it was pretty close to awesome.  Since I was not able to grab any pictures, I decided to post on here a few super funny ones the Radiologists showed me.

During that day, I saw a 14 year old male with a large thrombus in his ARM.  Now for those of you not in medicine, a thrombus is a blood clot in your vein. If the blood can't leave the area, the area will swell. Thrombi can happen anywhere in your body but its is mostly in your legs.  Certain conditions can cause your blood to be sticky or clot easily, some of them include: pregnancy, cancer, or taking oral contraceptive pills.  But a clot in a kid happens very very rarely and for a clot to be in the arm is even more rare.  So it was probably a once in a lifetime patient.  The interventional radiologist did end up clearing out the clot, but we never did find out why the kid had one.

The only other neat story I have from this rotation I wish I had grabbed the CT.  It was a 'stat' read on several CT images for a patient in the ER that had been hit by a car. We were discussing the pneumothorax in the lungs (a hole that was popped in the lungs) when suddenly the radiologist leaps up and yells shit and calls the ER frantically. He asks for the resident and shouts this patient has an aortic dissection, call the trauma surgeons! Luckily, the resident had already called the trauma surgerons and the patient was whisked off to surgery. I never did find out if she made it. But it was intense. :D

*the majority of these images came from this website.  It was a pinup calendar that a radiology company (Eizo) produced to help with marketing. I thought it was hysterical. Several radiologists had it hanging up in their secret radiology 'batcave" :)

cardiology: cath lab

I'm a bit frustrated with this rotation, as nothing is expected of me. However, I did get to spend a whole day in the cath lab after I requested it.

It was an interesting day. For the most part, it was placement of stents and pacemakers.  It was almost like a mini operating room. The interventional cardiologist confessed to me that he actually wanted to be a cardiothoracic surgeon but knew since he was an international medical grad, he became a interventional cardiologist. He said that now he is happy, not only does he like his job, but fewer and fewer cardio surgeries are happening these days.  Most people opt to have procedures done by him, with all the advances in technology, as opposed to getting surgery.  So his business is booming. These pictures are him at work. He doesn't have to boast about how good he is at his job because his reputation proceeds him. Almost everyone in the hospital knows how good he is.

I got to see it first hand, when the ER called. A lady was complaining of chest pain, and her EKG showed she was having a heart attack. When a heart catheterization occurs, the doctor makes a small whole in the leg and inserts a small wire tube through your artery all the way to you heart.  We inject dye and take pictures of your heart, watching the dye be pumped through.  This is how we identify which arteries to your heart are blocked. Then the doctor inserts a stent, a metal wire mesh to hold open your artery, as pictured here.  Stents are a genius invention, a way to keep the heart beating despite what you have eaten and how much you haven't exercised.  But for all the genius of the stent, it is only a bandaid. I think I've posted before about how disappointing it is to know that even tho this wire is holding your artery open, it didn't fix the blockage, it just smashed the cholesterol against the sides. Its not really a permanent fix, but then I guess I don't know what is in medicine anymore.

In the end, it was an educational day. Repetively seeing both emergent and non-emergent pacemakers and stents. I understand now what happens to my patients as they go through heart problems and fixes.  But I also saw that I don't really want to be a cardiologist, exactly like what I learned in my Anesthesiology rotation. *sigh* I'm sorry if I repeated what I had already said there, but it surprises me how much of a waste this rotation was for me. I am sad that I did not learn any new information.

let's talk cardiology....

So, on to more medicine. Cardiology is a weird rotation. Hours are usually from 8am to noon. Which sounds short, but it can be long and very very involved.  Most patients in cardiology are complex, because patients who have heart problems also have other problems. The best way to show this is to share the risk factors for heart disease:

• Diabetes
• age > 70
• high cholesterol
• obesity
• smoking
• family history of heart disease men before 50 women before 60.   

There are a plethera of criteria lists and risk factors in medicine but it seems to me that the lists in cardiology are particularly applicable. Almost every patient we see fits at least half if not more of this list.  On top of those risks patients often have renal failure, liver failure, and GI problems.   Its never just controlling the heart symptoms, it always involves working around their other problems. We can't give certain medications if you have renal failure vs. liver failure.

Another complexity prevalent on the heart service is compliance. The vast majority of heart patients don't 'feel' sick. As we all know, high blood pressure is alot like high blood sugar, you don't feel sick despite the fact your organs are slowly dying inside you. Its easy to sit on a couch with swollen legs and say you feel fine.  (most heart symptoms don't show up until you NEED a high blood pressure, like exercise). Oftentimes, noncompliant patients can be given a better education and it will at least make a dent of a difference.  But a large majority of patients-- no matter how often we try to explain it--- don't want to understand that taking their blood pressure pills or controlling their diabetes can prevent them from going blind or starting on dialysis. It can prevent a heart attack even. We call these conditions 'silent killers'. This aspect of patient stubbornness is particularly frustrating for me and makes it hard for me to care about a patient who won't care for themselves.

The last complexity is blood thinners, some examples of these are Coumadin, Heparin, Effient, Plavix. These medications are often very important to prevent blood clots, stroke, and a repeat heart attack. But these meds are a big pain in the butt. Everytime a person bumps something, hits something too hard, etc they get a bruise. Every cut bleeds excessively.  Nose bleeds become a nightmare.  Nobody wants to be covered in bruises and lots of patients hate it.


more info later....

Study Month & $$$

So, for those of you reading this, you should know July is my study month, so i won't be updating til Cardiology starts in August.

So, I thought i'd give a little tiny glimpse into the more complicated life of a med student.  And what better way to understand than to talk $$, especially when applying for residency. Because so many people out there don't understand exactly how much it costs to become a doctor. So here are a few fun $$ amounts that I have to deal with:

So Licensing exams. There are 3 of them that every doctor takes.  Step 1 is written and after second year. Step 2 is both written and oral after third year.  And Step 3 is written, only pass or fail and is taken your first year of residency (also known as intern year).  This year these are how much it cost me.

• Licensing exam - Step 2.   Written:  $500   (i'm taking 2 the MD & the DO)
• Licensing exam - Step 2.  Oral:   $1,500 + plane ticket + hotel + rental car (this is a 2 day event)

Total cost here: $2,500 to simply take my exams + plane ticket + hotel + rental car

Actual Application process:

• Applying to programs costs money.  So the first 10 programs in 1 specialty cost $92.00 flat fee   for 11-20 programs add on extra $9/program   21-30 programs add on $15/program   and 21-30 programs  add $15/program   31+ programs add $25/program    (i plan on a minimum of 50). Some people apply to more than one specialty. I don't know if i can afford it.
• release for my licensing exam scores costs $70 each (so x2)
• transcripts from the school cost $5 1 time fee
• registration for the MD match costs $50
• registration for the DO match costs $60

So generally to only apply the first go round I'm looking at $1,237 plus the cost of my exams, plus any extra fees.  Don't forget that if the residency program likes you they will offer you an interview.  This will cost plane ticket + rental car + hotel and 3 days of your time for every interview.  Most interview seasons last about 3 months and almost everyone's rule of thumb is that you need 10 interviews to have a good chance at matching into a residency program. By this time next year it will probably be 15.   So that's a lot of money and plane rides in a 3 month period.  Lots of suits and questions and travel and being tired. So yay.  That's my future if i pass step 2.  Yay.

Plus it doesn't help that I am officially going to be close to a million dollars in debt when I'm out. This means my minimum monthly payment is going to be over $3,000/mo for the next 10 years or more of my life.   Is there any wonder why so many people aren't a fan of capping doctor's salaries? Or so many don't go to medical school anymore?

Also, Is there any wonder why I have no motivation to study for this exam?  It is never-ending. Now I have to go force myself to study.