Something Cute

As I pulled into our apartment complex today, post-call, my husband was walking our dog nearby. After a moment, J-dog perked up, looked over at my car, started wagging his tail, and RAN over to the car, stopping right by my door as I parked. I guess he thought he was going for a ride.

It prompted me to think, how does he recognize our cars? He doesn't get excited by other cars. Is it a visual recognization? That would be difficult without color vision or knowledge of make/model/year. Is it smell? Does he smell me on the car? Does my smell come out the exhaust? I didn't have the windows open and I hadn't opened the door. I know he saw me through the window at some point, but I still wonder. He will also run to our cars while we're walking him. He LOVES going in the car, I think mostly because he and I traveled so much by car when I first had him.

Sometimes I am just amazed by my dog's cuteness, and I just have to share.

Bah Humbug

I think I have sinusitis. The post-nasal drip is giving me a scratchy throat, and I have a lot of nasal stuffiness and head pressure. It's more annoying than anything, but it's making it hard to sleep, and I think my sense of smell has been affected, because food isn't appetizing. I'm getting hungry, but nothing looks good. This is a problem, because I like to eat. Big girl's gotta eat, ya know.

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So I'm on internal medicine at our large private hospital, and I think I'm done. My residents all said "but you would be such a good medicine doc!" last night, and one even said "you work too hard to go into urology", but I think I'm done.

I realized that the attitude of internal medicine is what bothers me. The doctors tend to treat patients like "great teaching cases" or "fascinating differential diagnoses", treating numbers and lab values instead of the patients. The doctors I'm working with are all competent and empathetic, and I am not trying to bad-mouth them at all. I just don't want to be like that.

My First Aid for the Wards had a quote that, to me, summarizes the best and worst of internal medicine in one fell swoop: "If it's not in your differential, you can't diagnose it." This is entirely true. At morning report, we write out probably 10-15 differential diagnoses on the presented cases, some of which are truly "out there". I'll admit, formulating long differential diagnoses is not my strongest suit. In fact, I tend to get too narrowed in, focusing on one or two diagnoses, and not looking too much further, so I need some practice in this. Considering rare or unusual diagnoses can help in the cases when a patient has an unusual presentation, or you suspect something further, or something just doesn't fit, or you are feeling particularly academic.

So what is wrong with this mindset? The opposing viewpoint is fairly well-summarized in a truism I got from Surgeonsblog: "Common things are common, and rare things are rare." After you get through thanking Captain Obvious, you realize the wisdom behind this statement. In medical school, and academic medicine, we look for rare things, and are often referred unusual cases, and sometimes we forget what is the most common.

An attending asked the students yesterday, "What is the most common cause of osteomyelitis in sickle cell patients?" Almost every one replied in unison, "Salmonella." "No!" hollered the attending. "It's staph! Sickle cell patients just tend to get osteo when they get salmonella." Everyone knew that association, drilled into their heads by USMLE Step 1 studying, but no one stopped to think about it. (It's the same when you're asked "What's the most common cause of pneumonia in AIDS patients?" It's strep pneumo, just like the for the rest of us; they are more susceptible to common as well as uncommon pathogens.)

I presented a new patient to my attending yesterday afternoon. She was a middle-aged lady with diabetes, HTN, chronic renal insufficiency, and cocaine abuse; she had a chief complaint of belly pain. Crack was her drug of choice, documented in multiple discharge summaries. As she was too zonked on crack and benzodiazepines to talk, I spent nearly and hour pouring over her old chart, reading about multiple admissions for belly pain (dx: constipation), hypertensive emergency (dx: cocaine), and foot abscess with 4 toes amputated (dx: glucose 400+). My assessment: she's zonked on coke; her belly pain is likely constipation, like last time (she was eating, she was not tender to palpation, afebrile, CT showed nothing acute); her elevated creatinine is likely chronic + dehydration, and caused by her diabetes (if she'd had toes removed, and painful neuropathy, it stood to reason that she'd have nephropathy as well); her hyperkalemia on admission likely due to renal insufficiency, spironolactone, and lisinopril in combination (her EKG was normal, and she responded to insulin + kayexelate). Her echo was mostly normal except for pulmonary hypertension; I could explain that, too: as she slept through my exam, she snored so loudly you couldn't auscultate her chest. Dx: obstructive sleep apnea, due to her obesity and massive neck size.

I thought this was reasonable; this was what the resident, intern, and myself came up with.

As I presented the case to the attending, she started looking at stuff in pieces. "Why is she anemic? We should work that up!" (It's already been worked up.) "Why are her kidneys not working well? Her A1c is too low for that!" (A1c only measures 3 months of compliance, and hers had been much higher in the past.) "Why are her eyes protruding? Maybe her thyroid is malfunctioning, that would explain her hypertension, and if she had other pituitary malfunction, that could explain the hyperkalemia!" (She had a normal TSH on previous admission, 2-3 months ago.) "Maybe we should check the TSH again--it could be early thyroid." (??) "What is this thing in her kidney on the CT [it showed a tiny hypodensity/cyst, no hydronephrosis]? Have we figured out why her kidneys aren't working? Could she have an obstruction?" (Again, no hydronephrosis, bilateral enlarged kidneys, chronic renal insufficiency, improved with fluids, DIABETIC HYPERTENSIVE!)

"I just don't think she's been worked up properly, I think there's something going on here, I don't understand all her findings." Shit. Those are like the worst possible words to say to a busy resident.

So this morning, when I talked to the patient, who was off her coke and benzo trip, she told me she'd last done crack on Monday, that she'd indeed been constipated prior to her belly pain, that she'd pooped in the hospital and felt fine now, and wanted to go home.

At least the attending let us let her go today. My old attending from LBJ, Dr. C, would probably have kept her.

Yes, I Did This on Purpose...

The medical specialty for you is.... Urology

Urology is the best of all specialties. No, really. As a urologist, you will have the privilege of feeling literally thousands of prostates. And if for some reason you enjoy this, urology is definitely the best of all specialties, you freak.

To find out what specialty best fits your unique personality, go to:

What Medical Specialty Is For You?


That test is pretty funny, actually. And if you take it, and realize what answers I had to put to achieve that result, you would never speak to me again.

drunken posting

I'ts really hard to type afte r4 sangritas, did you know htat? Also, tapas goes really well with drinking. My fingers keep wanting to go to the backspace ar, and I'm trying not to let them, becase that's cheating. Although this is probably not too muc worse than pre-bckspace non-drunk me, but still. It's cheating.

So several of my second year friends took me out ot drink and eat tonight at a tapas restarautn, and it was lovely. except we ended up talking about seoond year tests, USMLE step 1, etc, and one of the 4 girls was offended. sorry, sweetie! i really am. screw the shift key, who kneeds caps? I'm also watching "What Not to wear" and it's hard to concentrate on one or the other.

fuck neuro. screw it. who needs it? (excpet you, barbiegirl, you sicko, who likes neuro--you can be my neurologist when i turn retarded from studyin gneuro!) i'll study the 15 or so pages in baords and wards and BE DONE with it for the step 2.

i still can't feel my lips. and i'm having a hard time avoid ing the backspace bar, even aftr 4 sangritas (yes, i'm fully aware that i have no tolerance. so what!) time to cuddle with my adorable husband!!!!!! except rolling my head back makes me really dizzy--is it bpv, or am i just drunk??? DRUNK! ha, fuck you, neuro test!

Neuro's Over...

...and the test kicked my ass. Hard. All these patients with headaches and trouble walking and facial droops and lower motor neuron problems and localize this lesion narcolepsy somatization conversion stroke neurofibromatosis WHAT THE HELL DO YOU WANT FROM ME OH GOD MAKE IT STOP I'LL BE A GOOD GIRL I SWEAR!!!!!

There will be drinking tonight. Oh yes, there will be drinking.

Psychosomatic Illness

I can't easily forget a patient we saw earlier this week. Loudly denying that she was depressed, she exhibited multiple signs of psychosomatic illness: irritable bowel syndrome, fibromyalgia, and, most recently, "facial droop" and "trouble walking". On exam, she had what is known as "astasia-abasia", or hysterical gait. She would wobble all over the place, yet JUST manage to catch herself before she fell. Her Romberg sign, or ability to stand with her eyes closed without falling, was negative, so her actual balance was unimpaired. The rest of her neuro exam was similarly normal. She continued to deny depression, despite her recent cruel divorce, her lost job, her difficulty concentrating, her recent weight gain, and her generally unkempt appearance. In fact, she even informed us that "I quit seeing my family doctor because he kept saying I was depressed!"

I felt really bad for her, yet what could we do? She was already taking an SSRI "for pain", and she clearly wasn't interested in any further psychiatric workup. The power of her denial was impressive, and sadly, was contributing to her condition. If she could only have been willing to admit that there was a possibility that her stressful situation was making her feel ill, she would have stood a chance of some relief of her symptoms.

I would like to point out that this patient is not simply faking her symptoms (not consciously). It would likely take lengthy psychotherapy and possibly antidepressants to relieve her symptoms, even after she came to believe that her mind was causing them. Rather, her mind was turning her anxiety onto her body, against her will. It is my understanding that this is the reason conversion disorders are more commonly found in lower SES groups--these are groups that are probably less likely to discuss anxiety or depression, and are less likely to realize that the mind could play such tricks. (This is simply my simplistic explanation; feel free to disagree with me.)

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Since I am rather anal-retentive/OCD (I'm a med student, duh), I picked up a copy of "First Aid for the Match" today, after meeting with the urology course director. I also scheduled a meeting with the school's residency advisor for tomorrow, in order to discuss away rotations and writing a CV. Why the rush? In order to obtain an away rotation over the summer, I have to apply by March. Before then, I have to get a CV written and fill out all kinds of crazy applications. The urology director recommended that I try to do two away rotations in order to increase my exposure to local urology programs (and get letters? Please?), so that's a lot of forms to fill out between now and then. I also need help scheduling my third year, so that's why I need to meet with the residency guy.

I, too, have irritable bowel syndrome (hence my obsession with fiber). Every time I start thinking about applying for residency, my stomach cramps up. I'm perfectly aware of the cause of my discomfort (my anxiety over trying to match into a competitive residency oh my god what if I don't get in or I don't get in near my husband!!!!!) Thus, in order to try to decrease my discomfort, I bought the "First Aid" book, and whenever I feel too stressed, I pick it up and read through sections on writing CV's, etc. If I can ACT, I can decrease my stress (theoretically).

I see many similarities between myself and this patient. I felt sorry for her, and the way the team dismissed her as hysterical (although you can only do so much for someone who refuses help). I just try to remain aware of my propensity for somatization, and acknowledge my depression, so hopefully I don't end up wobbling down a hospital hallway in front of a team of medical students and residents who all know there's "nothing really wrong with me."

One More Day of Neuro!

...and that says it all.

Devil's Advocate

I am such a bitch.

When I am in a political discussion, I tend to have a reaction to people making extreme statements. When someone makes a statement like "what x party is doing is morally wrong, therefore y party is morally right", I tend to start playing the other side. Therefore, even though I don't necessarily disagree with the policy we're debating, I tend to promote the opposite just out of irritation.

It's partly out of my fear of putting my own political opinions into the spotlight and having them mocked in this same way. However, it's also because I think it's rude to throw out statements like that, especially in the presence of people whose opinions you don't know. To me, when you're willing to open a statement like that, saying your party is morally superior to the other, you're either a) convinced that your audience is all of like mind (even though you don't know that) or b) you are so convinced you're right that you don't really care.

I'm happy for people who don't care what other people think--I like individualism, and I'm proud of people who stand up for their beliefs. I don't like that I don't stand up for mine more often. I guess it's just the manner in which this statement was made that raises my hackles.

This is partly why I became more liberal in college--I went to an extremely conservative school. I think that I would have had the opposite reaction to a liberal school (which would have been interesting, since I started off pretty conservative, thanks to my Republican dad). I get irritated when people aren't interested in debate, yet they're willing to throw their idea of moral superiority in my face--either I'm in, or I'm morally inferior, but they're really not listening to mine, or anyone else's opinion.

It's all a question of belief versus thought. I'm pro-choice, myself, but I don't take offense at the idea that someone would be against the choice for abortion. After all, I don't think science tells us the answer of when a human life becomes a human life, so each of us makes that determination according to personal belief. If you believe that life begins at conception, then you probably should be anti-abortion. If you believe that life begins when the heart beats, or when the brain begins to fire, or when ten fingers and ten toes appear, then you may have a different opinion. I don't think that making either choice makes a person morally inferior. I think making these decisions without good data is morally inferior, and I think forcing policy upon other people based on an emotional decision is not so wise either.

I guess it's mostly the attitude behind the statement. Tell me you are pro-life or pro-choice, and hey, that's cool. Tell me you are pro-life because people who are pro-choice are murderers, and I tend to have a little more problem with that. Tell me you are pro-choice because anyone who is pro-life is morally wrong because it's your body, godammit, and I tend to get more offended.

In my personal quest to try not to dislike people for their opinions, I work very hard to understand both sides of many equations. Therefore, if you are going to malign a group of people for a political opinion (not for a behavior like cannibalism, or murder, or for being a mean person), and it's an opinion that I think a rational person could hold (not an opinion like, the government should give us all ice cream sundaes on Fridays), then I tend to get offended for people on the other side of the equation, no matter which side I am on, personally.

All of the above adds up to: I dislike talking about politics. Especially around people I don't know well. Especially around a couple of women who make me feel slightly uncomfortable, because I am paranoid and suspect they are whispering about me when they are whispering in my presence. It reminds me of middle school, when I was even less cool than I am now (which is damn near impossible) and rather unpopular.

Why is it so much easier to hang around with guys? I rarely feel like I am in the clique with girls (and then I get nervous, and I start annoying myself). Perhaps this is yet another reason my interest in urology could pan out--guys are easier to be around than girls. This could also mean that my 6 weeks of ob/gyn will suck hardcore.

Ugg-h

I'm saddened and ashamed of the human race that this kind of style is so popular. However, I could imagine that if you were in a cold place, with snow and ice and coldness, that it might behoove you to wear warm, fake-fur boots, and that it might actually be kind of practical to tuck your pants into the boots to keep them dry and warm.

That said, this is the Gulf Coast. The temperature today was in the 50's; it was cloudy, but dry. I'm a cold-natured girl, but I can handle 50 degree weather okay.

Therefore, there is NO EXCUSE TO WEAR KNEE-HIGH FAUX-FUR BOOTS WITH YOUR JEANS TUCKED IN. It just looks fuckin' uggly.

Of course, it's even worse when your boots are too tight for the jeans to go in, so you have ugly faux-shearling mid-calf boots with rolled-up jeans on top.

Oddities

It's 10:32 pm, do you know where your children are?

• Somehow, my blog got set to post in Pacific Standard Time. I fixed it, but I don't know why Blogger ever decided I was in California (or was it Oregon?).


• Why does this Office Depot "We Can Lend You a Hand" commercial creep me out so much?? It's like they took the Staples "Easy Button" commercial, added Cousin It and a bad song, and voila!


• On this "Take on Orbitz" commercial, the announcer says "It's that easy" at the end, and I keep thinking he's going to add "It's that cheesy." It would certainly be appropriate.


• This Mythbusters Pirate Special is cracking me up. They're currently showing a fake infomercial for the cannon they built. Just remember, when you call the Piratical Institute to purchase your air cannon, that they advertise "Balls not included", "Slaves not included", and "Don't aim at face." Arr!


• I made pot roast yesterday, so when I came home from a rather crappy afternoon, the whole apartment smelled like pot roast. I used this recipe from Recipezaar, but I added a good splash of Worcestershire sauce and a lot of garlic. I love garlic. I also just stuck the whole thing in my handy Crockpot before I left for work, so the only real work I did was to chop the veggies. When I'm post-call Friday, I'll be making chili.


• I'm on call tomorrow, so I'm post-call Friday, and I'm taking the whole weekend off since I haven't had a day off since Sunday the 7th. It's a truly Golden Weekend! It's also my fourth Neuro call, out of four, so I'm done with call on Friday!
  


• One of the MS-4's on our team is matching tomorrow in Ophtho. This means two things: a) we're all bringing food-type items tomorrow to celebrate, and take the edge off his nerves until he receives his page and b) his medical school experience is essentially over tomorrow. Lucky bastard.


• I think one reason this rotation is so hard for me (other than that I hate neuro) is that I knew going into this rotation that I wasn't going to do neurology. I figured out quickly that I didn't want to do peds, but I didn't enter the rotation making that assumption. It actually surprised me greatly. I haven't entirely given up on internal medicine, so I didn't feel like taking a rotation in IM was a waste of my time (the time-wasting came from attendings and residents). This rotation, however...


• I just bit the bullet and emailed the urology residency coordinator about meeting to discuss research and/or residency. I'd put it off till today, because I kept trying to convince myself that I was more interested in ENT. Perhaps it's just easier to tell people you see ears all day instead of perineums? Here are some of the final numbers: residency in urology, 5-6 years; residency in OB/Gyn, 4 years; fellowship in uro/gyn surgery, 3 years; residency in ENT, 5 years (2nd most competitive match). For a surgical specialty, the hours in urology are not too bad (and almost certainly better than OB, especially after residency). I'm prepared for residency to suck, especially intern year; I just want a little more control of my life after those 5+ years.


• Why is it that I'm now less frightened by 5-6 years of residency? I used to think 3-4 was my max. I guess the difference came when I started considering specializing.
  


• Advantages to urology: I doubt it will be a common occurrence to answer "curbside" consults during cocktail parties. "Oh, I have this troublesome incontinence issue, what do you think?" For some reason, dermatologists seem to have a problem with this. After a pathology lecture in derm, our poor lecturer was mobbed by students asking "What is this mole? Is this cancer? See my rash? It's gross huh?"

And that is all for Wednesday, January 17, 2007. Good night.

Grand Rounds

If you're coming from Six Until Me's excellent Grand Rounds, the post she's referring to is here.

This also gets that sadness off the top of the page.

Sea of Sorrow

Yesterday, we switched teams: stroke went to general (adult) neuro, and vice versa. Ooh, boy, the general neuro people were mad!!! Those of us on stroke did little happy dances of joy. Yesterday proved our point: we arrived at 0800 for morning report, rounded till 1100, then went home, as it was MLK day and the on-call team was handling consults and admissions. Woo!

This morning, I arrived at 0730 for the consult service, ran to try to get a MMSE on a LOL with dementia, failed to get it (she was too sleepy), then ran to morning report. We went through a list of new patients and consults (it was kind of long), then we began to round at about 0915. I got a consult to see at about 1000, so I ran to the CCU (Coronary Critical Unit) to see my patient.

Fast forward to 1530, when I have seen and examined 3 patients for brain death (absent gag, corneal, pupillary light, cough, oculocephalic, or cold caloric reflexes; absent movement to pain; ventilator-dependent), and I have participated in 3 family discussions of brain death and withdrawal of life support in their loved ones. I have doled out Kleenex to 3 families, been hugged by multiple people, and witnessed intense, personal grief that no outsider should ever see. My senior resident walked out of the third one and said "There are days when I hate my job. I HATE doing that."

I don't know why today was brain death day. I do know that families react VERY differently. One patient, an elderly man, had survived several cancers prior to his cardiac arrest over the weekend. His family cried quietly; his wife of 60+ years said bravely "We don't want him to suffer no more." One patient, a young woman with mental illness, had OD'd on the many prescriptions she finagled out of multiple doctors. Her mother was grateful when we explained the brain death criteria and told her the choice was not hers to make, it belonged to the doctors. Her husband, however, told us that he was praying for a miracle, and asked why we couldn't wait a week or so to make SURE she wouldn't wake up. He struggled to master his grief and anger, but we left knowing he didn't understand. The third patient had suffered cardiac arrest following years of untreated diabetes, hypertension, hepatitis C, and heart failure; her three children wailed and sobbed (I bit my lip to fight back tears; the resident stared at the floor), while her sister quietly asked how long we could wait to turn off the ventilator, as the impending icy weather could affect when the family could arrive to say goodbye.

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I certainly didn't create this blog just to talk about sadness, or to depress my audience, but I feel like if I didn't write about this that it would eat me alive. How can one witness such terrible grief and not be affected? The first patient, the elderly gentleman, reminded me of my beloved grandfather, who died shortly after my wedding this summer. I am so grateful we never had to make any "decisions" in his case; his passing was almost instantaneous, a thunderbolt from the blue, which left me bereft but slightly relieved in knowing he didn't suffer.

The medical technology which produces miraculous cures (people waking up after unthinkable injuries) also produces the most complicated ethical issues. I can't imagine looking at the shell of my loved one, breathing, with a pulse, and being told that they are actually dead. I can understand it, on a purely cognitive level, but emotions don't always obey cognition.

Now, I'm just praying that my pager doesn't go off again.

Addendum to Last Posts

In my last post, I yet again exhaustively detailed what I like and dislike about various career choices, and made a stab at guessing what I might end up doing. It has been brought to my attention, however, that I forgot an important point, or several. So here we go, part deux:

Potentially Interesting:
ENT: I knew I was forgetting to mention something. ENT could definitely be cool. Head and neck surgery could be exhilarating. My sister had chronic otitis externa as a child (which is rare) and she visited an ENT every 6 months or so for ear cleaning (we always knew it was time for her to go because she'd become hard of hearing and we'd have to holler at her). Her ENT was an unbelievably nice lady; thus, a positive experience.

ENT has outpatient clinic, OR time, and inpatient non-critical care. Many inpatient ENT patients may be in critical care, needing trachs and such, but the ENT is not managing any of it; they place the trach and sign off.

ENT is a 5 year residency and is also very competitive. (Oh, and I looked up local urology programs, and 2 of the 3 are 6 years, not 5).

Flying Below the Radar:
PM&R: I've never really thought about it.
Geriatrics: Nuh-uh.
Nuclear Medicine: What do they DO, really, other than stress tests and VQ scans and HIDA scans? It sounds like a fancy version of radiology.

More No-No's!
Oncology: We've discussed that I'm a wuss, right?
Orthopedic Surgery: I'm not very good at lifting heavy objects. I also like to think that I am not very much like The Todd.
Pathology: I do *occasionally* like to see patients. Living patients. Although autopsies could be cool.
Plastic Surgery: I think this could be extremely cool, and it would be extremely gratifying to do reconstructive surgery. So, what's the problem? a) I don't really love skin grafts. At least, not on a daily basis. b) I wouldn't want to deal with 16 year old girls asking for boob jobs. c) Most importantly, being a good plastic surgeon requires a special kind of vision, an ability to picture in advance what you're going to be able to accomplish. It's almost like being an engineer.

I spent a semester and a half in biomedical engineering in college. I hated it. I could not take the principles of physics and apply them to raw materials to BUILD something that would operate according to certain parameters. For example, I can build something with wheels and I'll be certain it will roll. I canNOT build something with wheels that we wind up with rubber bands and get it to stop on a certain spot (the distance was randomly chosen by the prof, and then we had to adjust the car). Despite having two engineer grandfathers, I just cannot think that way.

After watching some plastic surgery shows with before and after shots, I've come to appreciate what this vision can do. "I take off a snippet here, and a tuck there, and your nose will look like Jennifer Aniston's nose." I can tweak, and take a little off here and there and play with the outcome, but I doubt I could properly appreciate the physics and aesthetics of the human body enough to rebuild it stronger, faster.

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I think I've covered the big specialties, as far as ERAS is concerned. As The Fake Doctor over at Ah Yes, Medical School likes to say, it's not too late to go to business school.

Revisiting an Old Issue, Not For the Last Time

My taste in residencies, and therefore careers, changes weekly, it seems. In fact, some of what I said in this previous post, I am now going to directly contradict here. So get ready!

My top two of the week:
#1: OB/Gyn--an excellent mix of outpatient clinic, inpatient NON-critical care, and OR time. Hours can definitely suck, but it's a field that is trying to work on this. It's also a field that tries to understand family time (the key word is *tries*; I didn't say *succeeds*). Residency: 4 years. Should not be difficult to get into residency, even with trying to stay here.

#A: Urology--Also a mix of outpatient clinic, inpatient non-critical care, and OR time. Residency would suck, at least for a while, but I'm willing to trade suckiness early for *hopefully* a better life later. Residency: 5 years. Extremely competitive; will be difficult to get in, even more so with trying to stay here. And pee? Not so bad, comparatively.

Possible Choices (in no particular order):
#1: Derm--Sometimes I feel like I'd be selling out, practicing "fake" medicine. Other times, I think, the victories would be small, but numerous, and there would be basically nothing life-threatening. Plus, lifestyle, lifestyle, lifestyle.

#2: GI--Could be satisfying to remove polyps and diagnose early cancers; not sure I'd want to manage cirrhotics, and I'm not sure I want to go through Internal Medicine to get there.

#3: Cardiology--Sometimes I think this could be really cool, sometimes I think this could be really boring. Plus, I am not so good at listening to heart murmurs. Plus plus, I'm not sure I want to go through Internal Medicine to get there.

#4: Infectious Disease--I still think bacteria are cool as shit, but I don't think ID docs really DO much. They show up, they say "Woo, cool bacteria", they recommend which antibiotic to use for how long, and they leave. Oh, and I think they do Gram stains. Ooh, ah.

#5: Internal Medicine--I get very frustrated in IM. I've also met the dumbest, most incompetent interns and residents in IM; my guess is because it's a sort of catch-all choice, a pathway to get to other specialties, and it doesn't really require a *positive* decision, only a ruling out of other specialties.

#6: Family Practice--Could be nice. Could suck. I hate tweaking meds every 6 months, so maybe not so good.

#7: Surgery--I love the OR, I hate the lifestyle.

#8: Emergency Medicine--I think it could be cool to be on the front line of medicine, but I think I would get even more cynical and bitter, and I don't really want to be that kind of person.

#9: Ophtho--Lifestyle, lifestyle, lifestyle. Except I do not find the eye so exciting.

Definite No's:
#1: Pediatrics--I'm a wuss about really sick kids.

#2: Anesthesia--I hate saliva. I have a kind of saliva-phobia, in fact. The thought of sitting in an OR while the guys on the other side of the curtain do the cool shit, sucking drool and phlegm out of someone's mouth... *shudder*.

#3: Radiology--Ugh. Only cool if you do interventional, and you have to do like 7 years of residency/fellowship to get there.

#4: Neurology--I realize this is surprising to most of you, but I hate neuro.

#5: Psychiatry--I love talking to people, and I think psychiatrists can do some good work, but it would drive me crazy. (Get it? Ha! I KILL me!)

Things I like:

• Being in the OR
• Sleep (negotiable)
  
• Doing small but gratifying things

Things I dislike/despise:

• Critical care: I really don't like being around long-term ICU patients. It reminds me of my fear of becoming such a patient.
• Rounding. Dear sweet jeebus, I HATE rounding.
• Incompetent colleagues.

And, some days, I just think I'm in the wrong profession. Sometimes, I envy my friends who have 9-5, M-F jobs. They get actual weekends! Weekends, people! And with a little luck, no one tries to drool on you (babies don't count)! And you don't see little containers of poo sitting on bedside tables (if you do, I don't want to know what you do for a living, but perhaps you should talk to Mike Rowe). I could go on, but I won't. You're welcome.

Breaking Bad News, Part II

Since making this post about the lecture we had on giving bad news, followed by a standardized patient encounter (in which I did fairly well), I've had lots more experience with it. I've seen a couple of different styles of news-giving.

My second medicine attending, Dr. C, was a heme/onc specialist. After examining her neck CT, I saw him tell a woman that her chemotherapy hadn't worked, that her tumor had continued to grow, and that it was now her decision whether to continue chemo or call home hospice. She cried. He repeated himself a lot, spoke calmly but empathetically; I believe he even held her hand.

My first call night on neurology, a man came in with a massive pontine hemorrhage. Virtually his entire brainstem was wiped out. I walked in to find the resident talking to his wife. We walked out to look at the CT, then we walked back in, the resident said simply "It's really bad. If there's anyone who needs to come see him, I'd have them come see him tonight, because it's possible he won't make it through the night." His wife cried. The resident apologized for giving her such news, and then we walked out.

My first neuro attending had to explain why he put a medical DNR on a comatose patient. He repeated himself over and over, because the family didn't understand at first. They thought we meant "we're withdrawing care", not "we won't resuscitate in case his heart stops again." Even though we were in the middle of rounds on a Saturday (and we wanted to get the hell out of there!), even though we were in the middle of a hallway, he continued the discussion until the family appeared to understand. They thanked him.

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There will always be bad news in medicine. I'm not sure I can be as *cool* as these doctors in the face of such raw emotion. Every time I see a radiology report with cancer, it's almost like I hear the "DUNH-DUNH" from Law & Order, or church bells, or some other very somber sound. I appreciate these doctors' examples, and I want to learn this skill. I just hope it's possible to learn this skill of communicating effectively and sympathetically, without either continuing to bring it all home, or going the opposite direction and becoming hardened by it all. I am inspired by these doctors, however, not to run from such things. All of them took it upon themselves to deliver bad news; none of them tried to run away, or shirk this responsibility. I admire that, and I think that if I can learn how to do this, I can be a good doctor.

On Call Again

Call II of neurology, and I'm sitting in the computer lab at the med school typing in my blog. Thus far, there have been no patients. I'd actually kinda prefer a patient or two (but not any more, ye gods of luck!!!) to this sitting, since I've been here since 6 am and I'm a little crankier than usual. I could be reading, but, you guessed it, I hate neuro.

Oddly, I hate neurology itself a leetle less after this rotation. At least on the stroke service, we do as much as possible, with the tPA and the aspirin. I do, however, despise the stroke service. Today, we got a new, (very nice) slower attending, and so we rounded from 0900-1200, broke for his conference + staff meeting, and rounded from 1400-1800. Seven total hours of rounding, followed by scut work. Whine, whine, whine. I whine even more because a) there are fourth years on our service, and you should hear THEM whine and b) most of my friends in this rotation are on services where they actually get weekends, or they don't work 13 hours a day. I almost cried with happiness when the coordinator told us we'd be switching with general neuro at the halfway point (and the general neuro kids were not too happy about it, which did not make me unhappy).

GGGGGRRRRRRRRRRRROOWWWWWWWWWWWWLLLLLLLLLLLLL!!!!!

Okay, I swear I'll quit whining now.

It's January now, and it's time for a new round of the game "What is TS going to do with her life?" I'll make a new post to follow...

Quote of the Day

My attending on the stroke service, asking about a patient from whom all life support had been withdrawn: "Well, I checked the obituaries for him this morning, but I didn't see him. I try to read the obituaries every morning to see which of my patients are in there."

Nicely sums things up, I think.

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The stroke service is an amazing dichotomy. Some of our patients recover fully and rapidly, leaving the hospital as healthy as they were pre-stroke. Some will leave for inpatient rehab to regain functions knocked out by the stroke. Some of our patients leave on stretchers, bound for "LTAC" (long-term acute care), to monitor ventilators, IV's, rehab, etc. Some don't leave, and some die quickly. For the 80% of patients who experience ischemic strokes, we can do a lot of things: tPA, keep blood pressure high to maintain perfusion, manage risk factors, etc. For the unfortunate 20% with hemorrhages, it's more a waiting game. Those patients can end up with ventriculostomies, on long-term ventilators, or worse.

I'm not as depressed by this service as I was by pediatrics, surprisingly. I feel like we're truly on the edge, "salvaging" those whom we can, trying to be compassionate to those whom we cannot. My attending does a good job, I think, of doing everything he can for those patients who have any chance of waking up, but conversely, not doing too much for those who don't. We've signed 3 physician's DNR's in the past two days. He's explained to the families that these patients already have severe brain damage, and that he feels it would be cruel to "bring them back from the dead" should their hearts stop, likely killing any remaining brain from global ischemia.

There's an element of selfishness to my train of thought. In really cliched terms, I've had to "confront my own mortality" while on these services. It's not really death I fear; it's pain, or losing my self. If I have to have a stroke, I'd want either a small one from which I can recover, or a huge one that just ends it all immediately. It's the middle ground that scares me. I could learn to live with paralysis, or restricted activity, or other disability; but I like being me. Usually, anyway.

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If you're ever in a coma, one way to assess your level of neurological functioning is to cause pain and observe the reaction to it. For example, pushing the handle of a tuning fork into a fingernail bed would ideally cause a patient to jerk their hand away. Rubbing knuckles deep into a patient's sternum would normally cause the person rubbing to get slapped (take my word for it, it really freakin' hurts). The levels of response (better to worst) are localization, withdrawal, posturing (flexor and extensor), and no response.

What could be worse than a sternal rub, or a fingernail press? My attending demonstrated today, on a patient whom we were assessing for brain death. "You see, you bring down the covers, take their nipple between your thumb and forefinger, pinch, and twist."

@#$@!!!!

The patient didn't respond. The audience (me), however, gasped, covered their chests, and turned away. Apparently, my visual response to someone else's pain is localization, which is appropriate.



And that, my friends, was a day's work on the stroke service.

Superman

Why is it that attendings no longer feel pain? We rounded for three hours this morning, and the med students are all griping about back pain and hunger. Our attending is totally impervious to such lowly physical needs, and only broke at noon for a conference, giving us an excessively long two hour break (which means we may not finish rounding until 6 pm or some such). I have a few theories as to why attendings are so stalwart:

1. Attendings have been standing on hard floors for so many years, they've killed all the nerve endings in their feet and back. I shall prove this with research, and call it "Attending Polyneuropathy."
2. Attendings are so passionate about their patients and medicine that they are able to ignore the pain in their feet and the growling of their stomach. If this is the case, I'm screwed.
3. Attendings have enough money to buy extraordinarily comfortable shoes that disguise themselves as ordinary fashion.
4. Attendings don't wear a white coat carrying 20 lbs of books, pens, tuning forks, etc., making them less accessible to gravity than the rest of us. I guess that the more you carry in your head instead of your pockets, the happier your spine is.
5. Attendings are rarely seen to eat or drink (unless it's coffee), and I've never seen an attending take a bathroom break (well, I did once on surgery, but the guy was 75+ years old). Perhaps they carry discreet battery-powered IV pumps for glucose and saline, and wear Foleys under their expensive clothing.
6. Perhaps the time difference is the answer. I arrived at 6:30 this morning to start seeing patients; my attending arrived at 9. Perhaps the extra hours of sleep he surely got have given him strength and fortitude to face the lumbar strain; certainly, eating breakfast later than 6 am would give him an advantage in making it until noon to eat.

I could be reading with my 2 hour break, but I'm not, because I hate neuro. I did, however, pick up a great new saying yesterday in lecture: "Time is Brain." You thought it was money, but I'm here to tell you, it's brain.

Good Book

For a very interesting read, check out I Am the Messenger by Markus Zusak. My aunt recommended it. It's set in an unnamed town in Australia; the protagonist is a "failure at life", a 20 year old cabdriver who starts receiving a series of anonymous messages he's supposed to deliver to perfect strangers. It's very funny, very moving, and totally unexpected; I loved it. It's technically teenage/young adult fiction, but whatever, I liked it.

I also recently allowed my husband to watch Firefly in my presence (which means I finally let him talk me into watching it). It was a sci-fi type show by Joss Whedon (maker of Buffy and Angel) that aired on Fox a few years ago, but was aired at different time slots out of order, and was canceled in its first season. Internet-types liked it enough that Universal Pictures bought the movie rights and made Serenity last year out of the story line and characters. Despite the fact that I was leery of the, uh, rather over-exuberant fan types, I guess I have to admit that it was a good show and movie. I'm kind of sorry the story is over now, actually. Yes, I'm admitting my geekiness publicly. It's just kind of hard to come out of that closet.

Back to Mythbusters (see above comment). I had intended to study tonight, but I hate neuro.

Stroke Team

Apparently, at our very large hospital, there's only one resident on call at night for neurology. One resident for seizures, one resident for strokes, one resident for kiddoes, one resident to bind them. The students on this neurology service take a kind of general call, seeing all kinds of patients. Therefore, even though I'm assigned to the stroke service, I saw two adults and one kid with seizures last night. The serious pontine bleed that came in, which should be on my service, I didn't actually get to see, because I was seeing the kiddo.

While I was in the EC, someone pulled the fire alarm. A piercing siren and flashing lights came on, and after a minute a recorded announcement played: "Warning: a fire has been detected in your area of the building. If you see any evidence of fire, please proceed to the nearest exit using the stairwells. Do not use the elevators." This played over and over, in between the ear-splitting sirens.

I found this message funny for several reasons. My whole life, I've always thought you were supposed to exit a building immediately when a fire alarm goes off. Countless fire drills in school have, well, drilled this message into my head. Last night's recording gives us the choice to evacuate, which both makes sense and doesn't make sense in a hospital setting. It's awfully tough to evacuate a large hospital full of patients, especially if it turns out to be a false alarm; however, if there truly is a fire, and everyone ignores the alarm, it becomes even harder to evacuate hundreds of people in a panic once they "see any evidence of fire."

There were actually a couple of lab workers who did evacuate the building through the EC. A hospital official laughed at them.