Two quick thoughts about psych before heading off to bed for the night. First, as much as I hate it, it really forces me to count my blessings and realize how good my life really is. I've been seeing a lot of depressed patients recently, and I'm realizing that they generally have very good reasons for being depressed; many of their stories are heartbreaking. I should really never complain about anything again ever...what little trials I have to deal with, what minor crosses I have to bear, are completely insignificant compared to the true suffering some of these people endure.
Second, and more positively, psych is not a super time intensive rotation. So tonight I was able to take a couple of hours and get together with some classmates I haven't seen in a while, to just chat and catch up and do the kinds of things that normal people do. Remember when as kids it was the most boring thing in the world to sit at the table while the grown-ups talked? Now I understand the attraction. When you're just chatting with a group of great people (particularly when sitting around a table of delicious food), there's not much else that needs to be happening to make it a great time. We've known each other for only 2 1/2 years, but it feels like we've been friends all our lives.
So yeah, I guess the point of tonight's post is what the title says. One of my favorite quotes of all time is from Gandalf in The Fellowship of the Ring: "All we have to decide is what to do with the time that is given to us." On a day to day level, I think that means helping the people we can, counting our blessings, and taking advantage of the opportunities for good times with friends and family. To live life means to see the grace given to us in each new day and to make the most of it -- work, play, and (most importantly), pray.
That's all for me tonight...time for sleep. Hope everyone's doing well; till next time, peace and God bless!
Wednesday, December 15, 2010
Monday, December 13, 2010
Not much to say
For better or for worse, a relatively quiet day on the medical front. My very depressed patient went home over the weekend, apparently improved; I pray that everything goes well and she doesn't bounce back anytime soon. I don't know if she'd be able to handle that. My other patients...well, not much has really changed. Did see on fairly young guy today who was floridly, classically manic. Like with bells on. We had a guy who played at being manic for our OSCEs (Observed Standardized Clinical Exams) that I thought did a really good job. But the guy today was absolutely textbook. From what the resident was saying, I might never see that again in my career, so this guy was a great patient to be exposed to. Really friendly, really polite, but with VERY loose associations and absolutely no insight or judgment. Really a riot though.
Otherwise, a few minor activities in the afternoon (research meeting, mandatory neuropathology lecture, required observation of an AA meeting which actually turned out to be much more enlightening than I'd feared) and a walk home through the cold, snowy night in Pittsburgh pretty much rounded out the day. Still excited over the last few Patriots games and hoping they can keep this going (36-7 over the 9-3 Bears in Chicago? A week after a 45-3 dismantling of the 9-2 Jets?) You have to think the rest of the NFL is getting a little nervous right about now. Of course, the Patriots have always done better when expectations were low, but hey...
Anyhow, hope everyone is doing well. I'm counting down the days till Psych ends and I get to go home for Christmas -- 7.5 for the former, 8 for the latter. Can't wait! Till next time, folks, peace and God bless!
Otherwise, a few minor activities in the afternoon (research meeting, mandatory neuropathology lecture, required observation of an AA meeting which actually turned out to be much more enlightening than I'd feared) and a walk home through the cold, snowy night in Pittsburgh pretty much rounded out the day. Still excited over the last few Patriots games and hoping they can keep this going (36-7 over the 9-3 Bears in Chicago? A week after a 45-3 dismantling of the 9-2 Jets?) You have to think the rest of the NFL is getting a little nervous right about now. Of course, the Patriots have always done better when expectations were low, but hey...
Anyhow, hope everyone is doing well. I'm counting down the days till Psych ends and I get to go home for Christmas -- 7.5 for the former, 8 for the latter. Can't wait! Till next time, folks, peace and God bless!
Friday, December 10, 2010
Some days you get the bear...
...but today was one of those days when the bear got me. The whole week has been busy between seeing patients, trying to put together presentations, working on my scholarly project, etc, but today was exhausting and depressing.
It didn't start off too badly. One of the attendings brought in hot chocolate and doughnuts, so the day had a pretty promising beginning. And it looked like our list was fairly manageable -- just a handful of follow-ups to see, most of whom we'd seen at least a few times before and appeared to be progressing well. We had a pair of new consults to see over in Magee, but that was it. Seemed like it was shaping up to be pretty easy -- maybe we'd get out early!
...Yeah, not so much. I went in to see my first follow-up patient, a woman with recurrent medulloblastoma whom I'd seen three or four times before today. She had been cheerful and smiling the last time I'd talked with her, and had apparently been making good progress. So I figured it'd be a routine visit, just a couple of minutes. She still wasn't sleeping well, she said, but otherwise things were going ok. I asked a little more about the sleep and then asked how her mood was. She was fine, she said, but her answer seemed just a little off. So I prodded very gently but got nothing new. I was getting ready to leave the room, just asking my last questions, when I noticed that she seemed to be struggling to keep her face under control. Soon she was crying. Turns out she wasn't fine after all. She was horribly depressed, barely finding enough energy to keep going each day, struggling with the uncertainty of her diagnosis. She'd been trying to hide it (very successfully) because she was desperately afraid that we'd make her stay in the hospital longer if she told us, and the one thing she wanted more than anything in the world was to go home and see her kids. There was much more to the story, but it's not for sharing. Let me just say that the burdens on this poor woman's shoulders would have been enough to break my back ten or twelve times over. Regardless, rather than the five minutes I had initially intended, I ended up spending over an hour in that room, dealing with something that was completely out of my reckoning. After I had talked with her, I was drained, overwhelmed, and kind of scared -- scared enough to call the resident and basically tell him that I needed to talk with him immediately. First time I've ever felt that inadequate to deal with a situation. Hers is a horribly sad story, all of which came out at once today. I was privileged to be the one the hear it, but it affected me badly for the rest of the day.
This, of course, is on top of another patient who's been in the hospital for over 4 months for a partial small bowel resection secondary to mesenteric ischemia. The other day, one of his family members passed away before he had a chance to see her and say goodbye. Now it doesn't look like he'll even be able to go to her funeral because he's simply not well enough. And then there was the patient who once served in the armed forces but turned to cocaine when she fell on hard times and lost, in quick succession, her son to Child Protective Services, her boyfriend (who blamed her for the boy being taken away), and the baby with whom she was pregnant. Also, she's been living in boxes on the street for the last couple of months because she had nowhere else to go and had been forced to turn to prostitution to earn money. Such a horrible story...
So yeah, bit of a rough day. And then I came home and I'm pretty sure a mouse has taken up residence in my apartment, so we'll deal with that tomorrow. Hopefully things will get a little better from here.
Anyway, hope everyone is doing well. Till next time, peace and God bless!
It didn't start off too badly. One of the attendings brought in hot chocolate and doughnuts, so the day had a pretty promising beginning. And it looked like our list was fairly manageable -- just a handful of follow-ups to see, most of whom we'd seen at least a few times before and appeared to be progressing well. We had a pair of new consults to see over in Magee, but that was it. Seemed like it was shaping up to be pretty easy -- maybe we'd get out early!
...Yeah, not so much. I went in to see my first follow-up patient, a woman with recurrent medulloblastoma whom I'd seen three or four times before today. She had been cheerful and smiling the last time I'd talked with her, and had apparently been making good progress. So I figured it'd be a routine visit, just a couple of minutes. She still wasn't sleeping well, she said, but otherwise things were going ok. I asked a little more about the sleep and then asked how her mood was. She was fine, she said, but her answer seemed just a little off. So I prodded very gently but got nothing new. I was getting ready to leave the room, just asking my last questions, when I noticed that she seemed to be struggling to keep her face under control. Soon she was crying. Turns out she wasn't fine after all. She was horribly depressed, barely finding enough energy to keep going each day, struggling with the uncertainty of her diagnosis. She'd been trying to hide it (very successfully) because she was desperately afraid that we'd make her stay in the hospital longer if she told us, and the one thing she wanted more than anything in the world was to go home and see her kids. There was much more to the story, but it's not for sharing. Let me just say that the burdens on this poor woman's shoulders would have been enough to break my back ten or twelve times over. Regardless, rather than the five minutes I had initially intended, I ended up spending over an hour in that room, dealing with something that was completely out of my reckoning. After I had talked with her, I was drained, overwhelmed, and kind of scared -- scared enough to call the resident and basically tell him that I needed to talk with him immediately. First time I've ever felt that inadequate to deal with a situation. Hers is a horribly sad story, all of which came out at once today. I was privileged to be the one the hear it, but it affected me badly for the rest of the day.
This, of course, is on top of another patient who's been in the hospital for over 4 months for a partial small bowel resection secondary to mesenteric ischemia. The other day, one of his family members passed away before he had a chance to see her and say goodbye. Now it doesn't look like he'll even be able to go to her funeral because he's simply not well enough. And then there was the patient who once served in the armed forces but turned to cocaine when she fell on hard times and lost, in quick succession, her son to Child Protective Services, her boyfriend (who blamed her for the boy being taken away), and the baby with whom she was pregnant. Also, she's been living in boxes on the street for the last couple of months because she had nowhere else to go and had been forced to turn to prostitution to earn money. Such a horrible story...
So yeah, bit of a rough day. And then I came home and I'm pretty sure a mouse has taken up residence in my apartment, so we'll deal with that tomorrow. Hopefully things will get a little better from here.
Anyway, hope everyone is doing well. Till next time, peace and God bless!
Friday, December 3, 2010
Lipstick on a pig
Another week down. Spent part of the morning today doing electroconvulsive therapy (ECT), which is used as a treatment for major depression refractory to other medical management. Yeah, it's exactly what it sounds like. No, it's no fun whatsoever. Basically you take a pair of electrodes, place them on an anesthetized patient's head, and zap their right temporal lobe (or both temporal lobes) with anywhere from 5 to 100 joules to induce a seizure. This in turn apparently results in the release of most or all major neurotransmitters in the brain, helping by some mechanism to fight depression. It also directly stimulates facial muscles causing an excruciatingly painful-appearing grimace (note: in fairness, it's not actually painful -- the patient is still under anesthesia). Yeah, it's a fairly primitive treatment all dressed up in pretty clothes and lipstick. However, although I hate the whole idea of ECT, both the literature and anecdotal evidence from some patients indicate that it can be pretty effective. Still, I'd rather never be within several miles of ECT ever again if I can possibly avoid it.
The rest of the day was ok. I'm still not a fan of psych, but at least I'm getting involved and am getting some worthwhile teaching. That's pretty much all I'm hoping for out of this rotation. No particularly interesting cases, unfortunately, so no good [HIPAA-compliant] stories.
Not much else going on at the moment. I'll be back with more thoughts sometime in the near future. Till then, peace and God bless!
The rest of the day was ok. I'm still not a fan of psych, but at least I'm getting involved and am getting some worthwhile teaching. That's pretty much all I'm hoping for out of this rotation. No particularly interesting cases, unfortunately, so no good [HIPAA-compliant] stories.
Not much else going on at the moment. I'll be back with more thoughts sometime in the near future. Till then, peace and God bless!
Monday, November 29, 2010
Back to psych
Hope everyone had a terrific Thanksgiving! It was back to work today after my longest break since starting MS3 year -- 4 whole days that were sorely needed. Unfortunately, I don't really have any good stories from today as I spent quite a lot of it standing / sitting around. This rotation so far is making me very negative, and that bothers me a bit, but on the plus side, there are only about 3 weeks to go, and the end of the rotation can't come soon enough.
In other news, it's Advent...beginning of a new liturgical year and a new start that's very much appreciated. This is my favorite season of the year, when we "wait in joyful hope" for the One Who makes all things new. There's something special, something profoundly unique about this season, although I can't quite express it properly. I think maybe it has to do with the sense of anticipation, the growing awe and wonder at the Christ Child's approach and birth, but there's more to it than that. Regardless, I plan on enjoying that aspect of the next four weeks, and can't wait to get home to spend the last few days of it (and, of course, Christmas!) at home with my family.
For now, though, it's a question of taking things one day at a time and reminding myself to look for the blessings each day rather than just the challenges. And there are always things to look forward to as well, so all in all life is still pretty good. Anyway, hope everyone is doing well...till next time, peace and God bless!
In other news, it's Advent...beginning of a new liturgical year and a new start that's very much appreciated. This is my favorite season of the year, when we "wait in joyful hope" for the One Who makes all things new. There's something special, something profoundly unique about this season, although I can't quite express it properly. I think maybe it has to do with the sense of anticipation, the growing awe and wonder at the Christ Child's approach and birth, but there's more to it than that. Regardless, I plan on enjoying that aspect of the next four weeks, and can't wait to get home to spend the last few days of it (and, of course, Christmas!) at home with my family.
For now, though, it's a question of taking things one day at a time and reminding myself to look for the blessings each day rather than just the challenges. And there are always things to look forward to as well, so all in all life is still pretty good. Anyway, hope everyone is doing well...till next time, peace and God bless!
Wednesday, November 24, 2010
Not my cup of tea...
Ok, bottom line...psychiatry just really isn't very much fun. I don't like the subject matter, I don't like the approach, and I really don't like the patient population. I don't like working with adults in general, and to work with this subset of the population makes me extraordinarily uncomfortable...I wish I could find an excuse to leave early every day. I know, I know, psychiatric diseases are illnesses too. I get that. But I hate that there's nothing that I can do about them. And I hate that they make frail 65 year old women threaten my classmate with physical harm, because even though I'm aware that she's not entirely in control of what she's doing / saying, it makes me angry. I don't like when friends are threatened without cause, especially when they're going out of their way to try and be helpful, and my internal response is largely predicated on that. To summarize: I wanna be back at Children's.
Another thing I find disconcerting about psychiatry: there is absolutely NO "laying on of hands." There is no physical exam, no attempt to assess the patient in any way but via history and mental status. At least the neurologists remembered how to use their stethoscopes. I'm convinced that many of these psychiatrists couldn't pull off a full physical without a checklist, and that bothers me. They specialize in an important area of medicine, but I feel like they neglect some of the most basic medical arts. This is truly unfortunate...many of them seem to eschew understanding of the body to focus on the study of the mind, forgetting that mind and body are intimately interconnected and cannot truly be studied separately. I really don't understand why the physical exam is so routinely shunned...it's a question I'll have to pose to the psychiatrists I work with.
Anyway, that's enough griping out of me. Things could be a lot worse (I could be back on Ob-Gyn), and I'll survive. I did want to mention one other thing before I sign off for Thanksgiving. You may have noticed the story making the rounds in the press lately about a "paradigm shift" in the Catholic teaching about condom use. Pardon my irritation here, but that is a gross misinterpretation (at best) and criminal misrepresentation (at worst) of Pope Benedict's remarks. The mainstream media, assuming the best case scenario, completely misunderstood what the pope had to say. His basic concept was that in some cases (an HIV-positive individual having sex out of wedlock, for example), it is the lesser of two evils to use a condom than to have unprotected sex. What he said was that the use of a condom out of concern for a partner's welfare may be the first step towards a greater recognition of charity and the natural law. What he did NOT say was that this was morally unobjectionable. Please understand this: the lesser of two evils remains an evil!! This is not a question of "good" vs. "bad"; it's a question of "bad" vs. "worse." The example he used to illustrate his point is a simple one: it is less wrong to rob a bank with an unloaded firearm than a loaded one, because it reduces the chance of someone being hurt or killed in the process. But using the unloaded weapon does not make the act of robbing the bank any less fundamentally wrong, NOR does it make it acceptable to carry an unloaded weapon to rob a bank. As George Wiegel points out, the media's representation of this story does a grave disservice to the Church and to Truth, as it suggests that the moral teachings of the Church can become passe, can be changed on a whim. The Church is not a democracy; its teachings do not reflect the opinions of some electorate. Rather, the teachings of the Church are rooted in unchanging, unchangeable Truth and in the life of the One who founded her. Unfortunately, the fallout from this episode promises to be spectacular. (Note: if you have any questions about the teaching of the Church on this issue or about anything I've written here, I'll be happy to discuss it with you insofar as I am able).
Anyway, those are my rants for the day. Off to Virginia tomorrow to spend Thanksgiving with some extended family...should be a pretty good day :-) Happy Thanksgiving, everyone, and until next time, peace and God bless!
Another thing I find disconcerting about psychiatry: there is absolutely NO "laying on of hands." There is no physical exam, no attempt to assess the patient in any way but via history and mental status. At least the neurologists remembered how to use their stethoscopes. I'm convinced that many of these psychiatrists couldn't pull off a full physical without a checklist, and that bothers me. They specialize in an important area of medicine, but I feel like they neglect some of the most basic medical arts. This is truly unfortunate...many of them seem to eschew understanding of the body to focus on the study of the mind, forgetting that mind and body are intimately interconnected and cannot truly be studied separately. I really don't understand why the physical exam is so routinely shunned...it's a question I'll have to pose to the psychiatrists I work with.
Anyway, that's enough griping out of me. Things could be a lot worse (I could be back on Ob-Gyn), and I'll survive. I did want to mention one other thing before I sign off for Thanksgiving. You may have noticed the story making the rounds in the press lately about a "paradigm shift" in the Catholic teaching about condom use. Pardon my irritation here, but that is a gross misinterpretation (at best) and criminal misrepresentation (at worst) of Pope Benedict's remarks. The mainstream media, assuming the best case scenario, completely misunderstood what the pope had to say. His basic concept was that in some cases (an HIV-positive individual having sex out of wedlock, for example), it is the lesser of two evils to use a condom than to have unprotected sex. What he said was that the use of a condom out of concern for a partner's welfare may be the first step towards a greater recognition of charity and the natural law. What he did NOT say was that this was morally unobjectionable. Please understand this: the lesser of two evils remains an evil!! This is not a question of "good" vs. "bad"; it's a question of "bad" vs. "worse." The example he used to illustrate his point is a simple one: it is less wrong to rob a bank with an unloaded firearm than a loaded one, because it reduces the chance of someone being hurt or killed in the process. But using the unloaded weapon does not make the act of robbing the bank any less fundamentally wrong, NOR does it make it acceptable to carry an unloaded weapon to rob a bank. As George Wiegel points out, the media's representation of this story does a grave disservice to the Church and to Truth, as it suggests that the moral teachings of the Church can become passe, can be changed on a whim. The Church is not a democracy; its teachings do not reflect the opinions of some electorate. Rather, the teachings of the Church are rooted in unchanging, unchangeable Truth and in the life of the One who founded her. Unfortunately, the fallout from this episode promises to be spectacular. (Note: if you have any questions about the teaching of the Church on this issue or about anything I've written here, I'll be happy to discuss it with you insofar as I am able).
Anyway, those are my rants for the day. Off to Virginia tomorrow to spend Thanksgiving with some extended family...should be a pretty good day :-) Happy Thanksgiving, everyone, and until next time, peace and God bless!
Monday, November 22, 2010
Psyched up or psyched out?
Ok, so I really haven't been good about posting here...I really need to make a better effort to do that. If I was able to post every night during Ob-Gyn (when I was getting up at 0330 to make it to work by 0430), I should be able to pull it off easily during rotations where I don't have to be in till 8. I'll work on it.
Anyway, first day of psych today. Yikes. This could be a long few weeks. On the plus side, at least it's not a toxic environment with the moral and ethical challenges presented by Ob-Gyn, and that's definitely something to be thankful for (seriously, that's something that every rotation from now till the end of med school has going for it -- it's not Ob-Gyn). There are, however, serious flaws in the system. For example, we have OSCEs (Observed Standardized Clinical Exams, a sort of dry run / preparatory mechanism for Step 2 of national boards) tomorrow. Yeah, on the second day of the clerkship. I might even have seen one whole psych patient by then. Yep, it'll be a great learning experience because clearly it's not something you need to be trained to do or anything. Even better, from the sounds of things we basically spend our first week and a half shadowing our residents. Don't get me wrong, shadowing is great for an MS1 or 2, or maybe even a brand new MS3. But we're closing in on our eighth month on the wards. We have a clue. We don't need to stand like the useless statues we were today -- four of us watched a medical student who's been on the rotation for a few weeks already interview a consult patient as the attending looked on and evaluated said student (no, that wasn't awkward at all or anything...). We are perfectly capable of seeing patients, and we learn best by doing. Trust me, since the residents and attendings will need to see the patients anyway, just accelerate the learning curve by throwing us in there (on consults, anyway; I might feel differently were I on an inpatient psych service). There are other sources of frustration, but those are the big ones for the moment.
However, it's not all bad. The course director is a terrific individual who cares deeply about medical student education and about the clerkship, and I think he'll do everything in his power to make this as positive an experience as possible. Then, too, it will be a useful learning experience figuring out how to diagnose psych issues in patients with other underlying medical conditions that may be masking psych symptoms, even if these patients are adults (aw, I wanna be back at Children's...oh well). So it could be a useful month, but it may be less than overwhelmingly appealing at times.
Regardless, just a couple of days till Thanksgiving...my first stretch of four days off since April. And then just a few more weeks till Christmas break...Hallelujah! So there are a few things to look forward to :-) (Not to mention a second stunning Patriots victory in a row...go Pats!)
Anyway, I hope everyone is doing well...till next time, peace and God bless!
Anyway, first day of psych today. Yikes. This could be a long few weeks. On the plus side, at least it's not a toxic environment with the moral and ethical challenges presented by Ob-Gyn, and that's definitely something to be thankful for (seriously, that's something that every rotation from now till the end of med school has going for it -- it's not Ob-Gyn). There are, however, serious flaws in the system. For example, we have OSCEs (Observed Standardized Clinical Exams, a sort of dry run / preparatory mechanism for Step 2 of national boards) tomorrow. Yeah, on the second day of the clerkship. I might even have seen one whole psych patient by then. Yep, it'll be a great learning experience because clearly it's not something you need to be trained to do or anything. Even better, from the sounds of things we basically spend our first week and a half shadowing our residents. Don't get me wrong, shadowing is great for an MS1 or 2, or maybe even a brand new MS3. But we're closing in on our eighth month on the wards. We have a clue. We don't need to stand like the useless statues we were today -- four of us watched a medical student who's been on the rotation for a few weeks already interview a consult patient as the attending looked on and evaluated said student (no, that wasn't awkward at all or anything...). We are perfectly capable of seeing patients, and we learn best by doing. Trust me, since the residents and attendings will need to see the patients anyway, just accelerate the learning curve by throwing us in there (on consults, anyway; I might feel differently were I on an inpatient psych service). There are other sources of frustration, but those are the big ones for the moment.
However, it's not all bad. The course director is a terrific individual who cares deeply about medical student education and about the clerkship, and I think he'll do everything in his power to make this as positive an experience as possible. Then, too, it will be a useful learning experience figuring out how to diagnose psych issues in patients with other underlying medical conditions that may be masking psych symptoms, even if these patients are adults (aw, I wanna be back at Children's...oh well). So it could be a useful month, but it may be less than overwhelmingly appealing at times.
Regardless, just a couple of days till Thanksgiving...my first stretch of four days off since April. And then just a few more weeks till Christmas break...Hallelujah! So there are a few things to look forward to :-) (Not to mention a second stunning Patriots victory in a row...go Pats!)
Anyway, I hope everyone is doing well...till next time, peace and God bless!
Monday, November 15, 2010
Blessings and frustrations
Just read some posts from a friend of mine who's currently serving overseas. Sara, I have no idea if you read this, but we are blessed beyond all measure to have people like you defending us. I don't know how you guys manage to do what you do, but I can't tell you how grateful I am to have you and so many soldiers like you undertaking something that I could never have the courage to pursue. Keep your chin up, keep your head down, keep doing the right thing, and know that you and all your soldiers are in my prayers and the prayers of a grateful nation.
On the medical front, things are pretty quiet at the moment. Students don't get a lot of responsibility on the neuro rotation, and that's kind of frustrating, but it can also be a blessing sometimes -- no hanging around for 5 hours after a shift to write 7 or 8 notes. It's also a little tough because so many of the cases we see are things we can't do a lot about -- like the little girl with HSV encephalitis who's had much of her brain wrecked by the virus and will likely be neurologically devastated. The saddest part? It's possible that this could have been prevented. Sounds like she had a suspicious lesion on her head at one point that suggested the possibility of HSV, but a pediatrician somewhere either missed or misdiagnosed it. This really scares me -- if an experienced pediatrician could miss something that led to disease of this magnitude, what mistakes might I make? I can't even imagine how that doc must feel...one mistake, one small oversight, and a child's life is potentially ruined...not to mention that all the lives that doc has saved, all the kids he / she has made better, now essentially come to nothing. Medicine sucks sometimes.
Unfortunately, there aren't a lot of success stories in neurology -- everything is about damage control, about making things tolerable. It's one of the hardest things to accept about this discipline and one of the major reasons I'll never specialize in it. Fortunately, smarter people than I are working tirelessly to solve some of these problems, so maybe someday we'll have actual solutions rather than short-term patches.
Anyway, that's all for tonight. Back Wednesday evening with more updates. Till then, peace and God bless!
PS - Patriots 39 - Steelers 26. Yessssss!! :-)
On the medical front, things are pretty quiet at the moment. Students don't get a lot of responsibility on the neuro rotation, and that's kind of frustrating, but it can also be a blessing sometimes -- no hanging around for 5 hours after a shift to write 7 or 8 notes. It's also a little tough because so many of the cases we see are things we can't do a lot about -- like the little girl with HSV encephalitis who's had much of her brain wrecked by the virus and will likely be neurologically devastated. The saddest part? It's possible that this could have been prevented. Sounds like she had a suspicious lesion on her head at one point that suggested the possibility of HSV, but a pediatrician somewhere either missed or misdiagnosed it. This really scares me -- if an experienced pediatrician could miss something that led to disease of this magnitude, what mistakes might I make? I can't even imagine how that doc must feel...one mistake, one small oversight, and a child's life is potentially ruined...not to mention that all the lives that doc has saved, all the kids he / she has made better, now essentially come to nothing. Medicine sucks sometimes.
Unfortunately, there aren't a lot of success stories in neurology -- everything is about damage control, about making things tolerable. It's one of the hardest things to accept about this discipline and one of the major reasons I'll never specialize in it. Fortunately, smarter people than I are working tirelessly to solve some of these problems, so maybe someday we'll have actual solutions rather than short-term patches.
Anyway, that's all for tonight. Back Wednesday evening with more updates. Till then, peace and God bless!
PS - Patriots 39 - Steelers 26. Yessssss!! :-)
Monday, November 8, 2010
The dark side of peds
Don't get me wrong, I still love pediatrics, but today was kind of a downer from a medical perspective. One patient I saw is a wrestler, really good at it, been doing it for a while, and loves it. But he came in with a concussion -- and a history of previous severe concussions. He was out of it -- first time I've been able to use the word "lethargic" legitimately to describe one of my own patients -- but his parents understood what we were saying. They know that some time not too long from now, when his head has cleared up some, they're most likely going to have to tell him that for the sake of his health he can no longer do something he loves. That's gotta be a pretty terrible feeling.
Of course, that kid had a pretty good day compared to another one I saw -- this one just a few days old. She was born with a congenital diaphragmatic hernia (CDH); that is, part of her diaphragm failed to form properly and so a big chunk of what's supposed to be in her abdomen (stomach, bowel, etc.) is up in her chest. Sometimes this is fixable. The danger, though, is that this can prevent the lungs from forming properly ("hypoplastic" lungs) and the child can be unable to breathe well enough to supply oxygen to the rest of the body. And that's what happened to this baby girl. For the moment she's on ECMO (ExtraCorporeal Membrane Oxygenation; they basically run her blood through a machine that artificially oxygenates it and sends it back to her), but it sounds increasingly like it's a short-term fix for a bigtime problem. The last child I saw in a similar situation didn't make it, and it looks like this little one may be headed along the same trajectory. And I stood there watching her, sedated and intubated, with wires and lines and monitors attached to every part of her tiny little body and realized that, for all our knowledge and expertise, she was beyond the capabilities of modern medicine to fix. And so, helpless to aid, all I could offer was a simple prayer: in manus Tuas, Domine. Into Thy hands, O Lord.
I think that regardless of how long I do this I will never come to terms with a child dying. I think that feeling will only intensify as the care of these children becomes increasingly my responsibility. And already, only being involved around the periphery, the feeling of helplessness and uselessness SUCKS. I only hope that God will grant me the grace to take those feelings as reminders to trust in Him. I don't think this job would be possible if not for faith.
Anyway, that's all for me tonight...back Wednesday with more updates. Till then, peace and God bless!
Of course, that kid had a pretty good day compared to another one I saw -- this one just a few days old. She was born with a congenital diaphragmatic hernia (CDH); that is, part of her diaphragm failed to form properly and so a big chunk of what's supposed to be in her abdomen (stomach, bowel, etc.) is up in her chest. Sometimes this is fixable. The danger, though, is that this can prevent the lungs from forming properly ("hypoplastic" lungs) and the child can be unable to breathe well enough to supply oxygen to the rest of the body. And that's what happened to this baby girl. For the moment she's on ECMO (ExtraCorporeal Membrane Oxygenation; they basically run her blood through a machine that artificially oxygenates it and sends it back to her), but it sounds increasingly like it's a short-term fix for a bigtime problem. The last child I saw in a similar situation didn't make it, and it looks like this little one may be headed along the same trajectory. And I stood there watching her, sedated and intubated, with wires and lines and monitors attached to every part of her tiny little body and realized that, for all our knowledge and expertise, she was beyond the capabilities of modern medicine to fix. And so, helpless to aid, all I could offer was a simple prayer: in manus Tuas, Domine. Into Thy hands, O Lord.
I think that regardless of how long I do this I will never come to terms with a child dying. I think that feeling will only intensify as the care of these children becomes increasingly my responsibility. And already, only being involved around the periphery, the feeling of helplessness and uselessness SUCKS. I only hope that God will grant me the grace to take those feelings as reminders to trust in Him. I don't think this job would be possible if not for faith.
Anyway, that's all for me tonight...back Wednesday with more updates. Till then, peace and God bless!
Wednesday, November 3, 2010
Yeesh
Boy, I'm managing to make a great impression so far on peds neuro (<-- sarcasm). Part of it isn't my fault (although I still feel bad about it) and part of it is completely and totally my fault. The part that's not my fault: I've been on the rotation for 3 days so far but have yet to spend a single complete day with the neuro team at CHP because of all the lectures and other things that are scheduled into the clerkship. On the other hand, however, it's a pretty good bet that when you start to panic because you think you've lost the team's video camera only to realize 10 minutes later that oh yeah, you must've plugged it in on 8a, not 7a like you could have sworn you did, the team is going to be openly laughing at you for the rest of the week. Also, the neuro rotation is a bad time to realize that you must have left your oto-ophthalmoscope somewhere in Magee because you can't find it anywhere. *Sigh* oh well.
In terms of the rotation, this one could hardly be more different from the Peds EM rotation I just finished. The emphasis is on direct teaching by the fellow and attending, and I really don't see my own patients, nor do I write notes. It's a very different feel, but given the nature of the specialty, I'm more ok with that than I might be otherwise. Neuro is not a strength of mine. I've been surprised about how much I've known / remembered, but it still seems like a totally insignificant amount compared to the necessary knowledge base for a practicing neurologist. I've been awash in EEGs, mental status exams, neurologic evaluations, blood work results, target genes, and an enormous variety of other medical information. It's a bit overwhelming, really, and for that reason I'm kind of glad I don't have a huge amount of responsibility...I don't have the ability to gather and synthesize the information properly as yet in this particular discipline. Fortunately, my fellow and attending are tremendous and I've thoroughly enjoyed working with them so far. I'm starting to think that the neuro section of this clerkship will be altogether too short.
Anyway, that's all from me for now. Back later this week with further updates. Till then, peace and God bless!
In terms of the rotation, this one could hardly be more different from the Peds EM rotation I just finished. The emphasis is on direct teaching by the fellow and attending, and I really don't see my own patients, nor do I write notes. It's a very different feel, but given the nature of the specialty, I'm more ok with that than I might be otherwise. Neuro is not a strength of mine. I've been surprised about how much I've known / remembered, but it still seems like a totally insignificant amount compared to the necessary knowledge base for a practicing neurologist. I've been awash in EEGs, mental status exams, neurologic evaluations, blood work results, target genes, and an enormous variety of other medical information. It's a bit overwhelming, really, and for that reason I'm kind of glad I don't have a huge amount of responsibility...I don't have the ability to gather and synthesize the information properly as yet in this particular discipline. Fortunately, my fellow and attending are tremendous and I've thoroughly enjoyed working with them so far. I'm starting to think that the neuro section of this clerkship will be altogether too short.
Anyway, that's all from me for now. Back later this week with further updates. Till then, peace and God bless!
Monday, November 1, 2010
Back on track
Finally starting to get days and nights straight again. All it took was ten days and several days of work / class following virtually sleepless nights. Yep, it's the profession I've chosen, and I couldn't be happier with it :-) So since my last post I've finished my pediatric EM rotation (hands down the best yet), had a week of a geriatrics intersession class that was designed to be "interprofessional" because the school received a grant for it (their idea of interprofessional was to toss about 25 nursing and pharmacy students in with 150 medical students who have been working and training together for the last 2.5 years...yeah, that's gonna work), and started pediatric neurology. If you think you're starting to sense a theme in my clerkships, you're probably right. What can I say, kids are just more fun than adults (cuter, too)! This clerkship, however, is a bit more complex than most. It's split into two sections -- 3 weeks for neurology, 5 weeks for psychiatry (why 3&5 vs. 4&4? Who knows?). The first week and a half for me are on the inpatient service at CHP which seem like they should be very good. The workload is manageable, the residents are good, and the fellow and the attending are outstanding -- all in all, not a bad situation. After that, I'll have outpatient for the next week and a half, which sounds like it will be mostly consults and a few scheduled visits. Thrown in there next Friday will be an OSCE (basically an exam of an actor roleplaying some illness), and the Friday after that will be the neurology shelf exam. After that comes 5 weeks of psych, but I have no information about that part yet, and then I'll have almost a week and a half at home for Christmas. Can't tell you how much I'm looking forward to that! We'll see how this goes...it probably won't be as much fun as peds EM, but it seems like it should still be ok.
Oh, one ethical question that I'd appreciate opinions on: one of the attendings that I worked with in the ED insisted that I ask residents to put in the orders I wanted on patients. I understand her reasoning; she's already busy enough that there's generally a line of people waiting to present patients to her at any given time. On the other hand, though, if I were a resident and a medical student (even one I knew well) approached me and asked me to write orders for a patient I hadn't even heard of, let alone seen, I'd be pretty reluctant. I mean, that's really putting your neck on the chopping block if something goes wrong, or if the med student misinterprets the discussion with the attending. I mean, orders don't take THAT much time to put it, and I'd much rather have someone who actually knows the patient better than as a two-sentence description given by the MS3 putting in those orders. I'd really like to know what other people think about this, so please leave comments!
Anyway, that's all for tonight. My goal for this rotation will be to post MWF with possible occasional Sunday ruminations; we'll see how well I stick to that. Hope everyone's doing well; till next time, peace and God bless!
Oh, one ethical question that I'd appreciate opinions on: one of the attendings that I worked with in the ED insisted that I ask residents to put in the orders I wanted on patients. I understand her reasoning; she's already busy enough that there's generally a line of people waiting to present patients to her at any given time. On the other hand, though, if I were a resident and a medical student (even one I knew well) approached me and asked me to write orders for a patient I hadn't even heard of, let alone seen, I'd be pretty reluctant. I mean, that's really putting your neck on the chopping block if something goes wrong, or if the med student misinterprets the discussion with the attending. I mean, orders don't take THAT much time to put it, and I'd much rather have someone who actually knows the patient better than as a two-sentence description given by the MS3 putting in those orders. I'd really like to know what other people think about this, so please leave comments!
Anyway, that's all for tonight. My goal for this rotation will be to post MWF with possible occasional Sunday ruminations; we'll see how well I stick to that. Hope everyone's doing well; till next time, peace and God bless!
Thursday, October 21, 2010
All turned around
So I've been working almost exclusively nights for the last two weeks, and as a result I'm hopelessly turned around as far as days and nights -- I'm normally going to bed around 6 or 7 AM and getting up at 3 or 4 PM (depending on which shifts I'm working). Hence, no posts. I've got plenty of good stories (slightly edited to protect the HIPAA compliant), but since I'm on my way to work again (11P - 8A), they'll have to wait for the time being. I promise I'll get something up here soon.
Oh, just by the way...heard back a little while ago that I officially passed Ob-Gyn. Not surprisingly, my clinical grades were outstanding and my test grade was just barely passing. Wonder why that could be. I'll be having a chat with the dean about that one, but for now, I'm just happy that it's over and not coming back.
Anyway, till next time, peace and God bless!
Oh, just by the way...heard back a little while ago that I officially passed Ob-Gyn. Not surprisingly, my clinical grades were outstanding and my test grade was just barely passing. Wonder why that could be. I'll be having a chat with the dean about that one, but for now, I'm just happy that it's over and not coming back.
Anyway, till next time, peace and God bless!
Monday, October 11, 2010
A little behind
Whoops...I've been slacking just a little recently. So now might be a good time to make up for that a bit and write about one of the more interesting kids I've seen over the last couple of days. The patient I remember most vividly was a teenage girl who came in complaining of abdominal pain in the right lower quadrant. She and mom were particularly concerned about appendicitis, and with some reason. The onset of the pain had been rapid and severe, and it had kept her from wanting to eat or drink anything. It was worse with moving around, and had been excruciating when they had hit bumps on the way in. But she didn't have any fever, her appetite was starting to return, and her pain was improving as time went on (very rare with appendicitis). We still wanted to try to rule it out, so we ordered a CBC and an abdominal / pelvic ultrasound. The CBC came back stone-cold normal with maybe a little left shift. Probably not appendicitis, we thought then, so what could it be? Our temporary theory was an ovarian cyst -- many of the symptoms overlap. When the ultrasound came back, we found out we were half right -- the ovary was involved. Instead of a cyst, however, there was a solid mass of unknown origin. When we broke this news, both patient and mom were pretty upset. After all, when you tell someone about a "mass," the first thing they'll think is "tumor." The only comfort we could offer at the time was that it was very unlikely to be cancer given her age and background. The radiologists backed us up on that -- we had ordered a CT scan at the behest of pediatric surgery, and it was read as showing an adnexal mass, probably benign. So at the tail end of my shift (by which I mean two hours after I was scheduled to leave, but worth every minute), we went back to tell her this as well as let her know that surgery would be down to see her. I guessed that since she was feeling much better they would probably decide to send her home and have her follow up as an outpatient. When I went back in the following day, I had a rare moment of down time which I used to check and see what had ended up happening. Peds surg had, in fact, evaluated her and decided to take her to the OR, where they had discovered a ruptured ovarian cyst and a medium-sized benign-looking mass that they had sent for biopsy (results on that were still pending...I should check and see if that was ever completed). It was a bit of a zebra, definitely not a common pathology, but we had managed to come up with a (mostly) correct diagnosis and now it sounds like the problem should be permanently taken care of.
Sorry, bit of a long story there, but definitely a good case (especially since she had a good outcome) and one I was glad to be a part of. And that's true so often in the emergency department -- it's nearly always a blessing, one way or another, to be involved. Some cases are tragic (for example, the 10 month old with a depressed skull fracture and massive subdural bleed that were 100% non-accidental; even if she survives she'll likely be neurologically devastated), but it's still a privilege (not to mention a valuable learning experience) to be involved. Every day, unless you actively avoid doing anything, you'll be making a difference in someone's life, and occasionally, that difference is profound (sometimes even the difference between life and death). You get to make kids' lives better, to watch them heal right in front of your eyes. They come in sick or broken and they leave healthy and whole. It's a feeling unlike any other in any job one could possibly imagine.
Anyway, that's all for tonight...I'm exhausted. I likely won't be posting tomorrow (I'm working 5P-1A) unless I actually get home reasonably close to 1 (it normally seems to be closer to 3 or 3:30), and I'm working the same shift on Wednesday, so unless I get some unexpected free time, it may be a couple of days before I'm posting again. But I'll be back. Till then, peace and God bless!
Sorry, bit of a long story there, but definitely a good case (especially since she had a good outcome) and one I was glad to be a part of. And that's true so often in the emergency department -- it's nearly always a blessing, one way or another, to be involved. Some cases are tragic (for example, the 10 month old with a depressed skull fracture and massive subdural bleed that were 100% non-accidental; even if she survives she'll likely be neurologically devastated), but it's still a privilege (not to mention a valuable learning experience) to be involved. Every day, unless you actively avoid doing anything, you'll be making a difference in someone's life, and occasionally, that difference is profound (sometimes even the difference between life and death). You get to make kids' lives better, to watch them heal right in front of your eyes. They come in sick or broken and they leave healthy and whole. It's a feeling unlike any other in any job one could possibly imagine.
Anyway, that's all for tonight...I'm exhausted. I likely won't be posting tomorrow (I'm working 5P-1A) unless I actually get home reasonably close to 1 (it normally seems to be closer to 3 or 3:30), and I'm working the same shift on Wednesday, so unless I get some unexpected free time, it may be a couple of days before I'm posting again. But I'll be back. Till then, peace and God bless!
Wednesday, October 6, 2010
8-6 in the ED
I was on the 8-6 shift today and ended up working till about 7:15, and while every minute was worth it, it's left me with very little gas in the tank...and I'm working the same shift tomorrow, so some sleep is probably in order. Sleepy as I am, though, I have to say that this is by far the best rotation I've been through to this point. I love having as much responsibility as I do for taking care of patients and doing basically everything that needs to be done -- calling consults, looking at labs and images, reading previous records, and coming up with plans. It's expanded my comfort zone tremendously -- I'm willing to make the call on some things now. Granted, they're small things, but at the beginning of the rotation I'd have said "Hold on, let me ask the attending" rather than just saying "yeah, it's ok for him to eat" or "sure, since we're going to discharge her, you can pull the IV now." Every day I'm learning, not only how to diagnose and manage patients, but how to improve and exercise my medical judgment -- and I'm learning to trust that judgment.
Today's kids were a varied bunch. My first little guy came in struggling to breathe; once he got an albuterol nebulizer, he began to wheeze like crazy. He was working hard, retracting, flaring, and his lungs sounded like junk. He came in as a level 3 (moderate acuity) in orange pod; after a couple of hours with no improvement in his respiratory symptoms and deterioration of his general clinical picture, we sent him to the red (high acuity) team; they told me later on that he had ended up being admitted to PICU. Poor kid...I just hope he maintained sufficient respiratory function to avoid an ET tube. The second kid, a girl, came in with abdominal pain that she'd had for the last two weeks. Her story was kind of scary, involving intense, rapid-onset abdominal pain for several days that suddenly became much better; it stayed that way for a day and a half before the pain began to resurface. All the medical people reading this are now wondering if she had ruptured appendicitis -- but her exam was fine. Mild pain and tenderness in the right lower quadrant, but nothing serious, and no decreased appetite or anything like that. So we sent her for an x-ray. Final diagnosis? FOS -- Full Of Stool. Her colon was pretty backed up from the looks of things, so we gave her a decent-strength laxative and sent her home. Then there was the young lady who came in with abdominal pain for a month. I'd tell you her story except that after history, physical, and several tests, we're still no closer to figuring out what's going on. Almost as frustrating for me as for her. The only other interesting case of the day was an energetic little guy who looked absolutely peachy. Mom said he'd had an asthma attack yesterday and she had taken him to the doctor this morning; they did an exam and sent him over to Children's for a chest x-ray. I was frankly wondering what they were thinking. The kid was afebrile and looked like a million bucks. And then I listened to him. His right lung was ok, but his left lung had textbook crackles at the base. I mean, they were absolutely perfect, exactly like the sounds they record for the training videos and such. So we got that CXR, and sure enough, even though he didn't appear to be the least bit sick, it showed an apparent pneumonia (although the radiologist read it as a right lung PNA, which didn't correlate with the clinical findings -- looking at the film, though, I could see what they were looking at). So he came in for asthma and left with a 10 day prescription for antibiotics. Also interesting was the fact that after he got a breathing treatment, his wheeze reappeared and his crackles became much more pronounced. He still looked great, though, and we ended up discharging him with his meds. (I saw two other patients as well, but there wasn't really anything interesting about either of them).
So yeah, that was the day. I think I still owe a description of Monday; hopefully I'll get to that at some point. In the meantime, though, I'm going to bed, so until next time, peace and God bless!
Today's kids were a varied bunch. My first little guy came in struggling to breathe; once he got an albuterol nebulizer, he began to wheeze like crazy. He was working hard, retracting, flaring, and his lungs sounded like junk. He came in as a level 3 (moderate acuity) in orange pod; after a couple of hours with no improvement in his respiratory symptoms and deterioration of his general clinical picture, we sent him to the red (high acuity) team; they told me later on that he had ended up being admitted to PICU. Poor kid...I just hope he maintained sufficient respiratory function to avoid an ET tube. The second kid, a girl, came in with abdominal pain that she'd had for the last two weeks. Her story was kind of scary, involving intense, rapid-onset abdominal pain for several days that suddenly became much better; it stayed that way for a day and a half before the pain began to resurface. All the medical people reading this are now wondering if she had ruptured appendicitis -- but her exam was fine. Mild pain and tenderness in the right lower quadrant, but nothing serious, and no decreased appetite or anything like that. So we sent her for an x-ray. Final diagnosis? FOS -- Full Of Stool. Her colon was pretty backed up from the looks of things, so we gave her a decent-strength laxative and sent her home. Then there was the young lady who came in with abdominal pain for a month. I'd tell you her story except that after history, physical, and several tests, we're still no closer to figuring out what's going on. Almost as frustrating for me as for her. The only other interesting case of the day was an energetic little guy who looked absolutely peachy. Mom said he'd had an asthma attack yesterday and she had taken him to the doctor this morning; they did an exam and sent him over to Children's for a chest x-ray. I was frankly wondering what they were thinking. The kid was afebrile and looked like a million bucks. And then I listened to him. His right lung was ok, but his left lung had textbook crackles at the base. I mean, they were absolutely perfect, exactly like the sounds they record for the training videos and such. So we got that CXR, and sure enough, even though he didn't appear to be the least bit sick, it showed an apparent pneumonia (although the radiologist read it as a right lung PNA, which didn't correlate with the clinical findings -- looking at the film, though, I could see what they were looking at). So he came in for asthma and left with a 10 day prescription for antibiotics. Also interesting was the fact that after he got a breathing treatment, his wheeze reappeared and his crackles became much more pronounced. He still looked great, though, and we ended up discharging him with his meds. (I saw two other patients as well, but there wasn't really anything interesting about either of them).
So yeah, that was the day. I think I still owe a description of Monday; hopefully I'll get to that at some point. In the meantime, though, I'm going to bed, so until next time, peace and God bless!
Monday, October 4, 2010
Quick update
Just a quick update from my Saturday night shift since I'm working again tonight and need to take a nap. Weekend night shifts are invariably busy, and this one was no exception. It has to be a little tough on the attendings; there are three of them and probably ten or twelve students / mid-level providers / residents that they have to supervise and take report from, and they have to see all of the patients who come through. Boy do they keep busy...
Anyway, it was a fun night. I saw six patients, one of whom was signed out to me, one who I sort of stumbled into taking over from the previous shift, and four whom I picked up on my own. The ones I picked up included a young kid with a respiratory virus (admitted), a kid who'd swallowed a penny and had enough bad luck that it stuck in his esophagus (sent to the OR and discharged from PACU), a kid with a headache who'd fallen out of bed that morning whose mom was concerned that it was a head injury (examined and discharged), and a young kid with a 3 day history of fevers to 104 who looked happy as a clam (worked up for UTI and discharged; her parents were miffed about the wait but oh well). The other two patients...well, there's a story behind those, but I won't get into it now. Suffice it to say that I learned two things:
1) When you're leaving, sign out ALL your patients to the person relieving you; otherwise, when the attending asks me about the patient that you forgot to sign out to me, I will have no idea who or what she's talking about.
2) If you did a history and physical on a patient before signing him/her out to me, take ten minutes and write a note. Otherwise, when I go back at 2 in the morning, an hour after my shift was supposed to end, to addend the note with the radiology / lab findings and final disposition, I will look through the list of notes twice more after not seeing it the first time, shake my head in disbelief, mutter a string of curses (which I don't do often, just in case you're not aware), and ask the intern sitting next to me if she has any thoughts on how the handle the situation. It will ultimately result in there being ZERO documentation of any H&P on the patient, repeated comments in my note that I didn't do a history or physical because the patient was signed out to me, and a fuming blog post on the subject from an annoyed colleague (yes, that would be me). Ahem. Rant over.
Anyway, I'll try to give a few more details tomorrow, but if yesterday is any indication of how I'll be feeling, it might end up being postponed again. We'll see. Till next time, peace and God bless!
Anyway, it was a fun night. I saw six patients, one of whom was signed out to me, one who I sort of stumbled into taking over from the previous shift, and four whom I picked up on my own. The ones I picked up included a young kid with a respiratory virus (admitted), a kid who'd swallowed a penny and had enough bad luck that it stuck in his esophagus (sent to the OR and discharged from PACU), a kid with a headache who'd fallen out of bed that morning whose mom was concerned that it was a head injury (examined and discharged), and a young kid with a 3 day history of fevers to 104 who looked happy as a clam (worked up for UTI and discharged; her parents were miffed about the wait but oh well). The other two patients...well, there's a story behind those, but I won't get into it now. Suffice it to say that I learned two things:
1) When you're leaving, sign out ALL your patients to the person relieving you; otherwise, when the attending asks me about the patient that you forgot to sign out to me, I will have no idea who or what she's talking about.
2) If you did a history and physical on a patient before signing him/her out to me, take ten minutes and write a note. Otherwise, when I go back at 2 in the morning, an hour after my shift was supposed to end, to addend the note with the radiology / lab findings and final disposition, I will look through the list of notes twice more after not seeing it the first time, shake my head in disbelief, mutter a string of curses (which I don't do often, just in case you're not aware), and ask the intern sitting next to me if she has any thoughts on how the handle the situation. It will ultimately result in there being ZERO documentation of any H&P on the patient, repeated comments in my note that I didn't do a history or physical because the patient was signed out to me, and a fuming blog post on the subject from an annoyed colleague (yes, that would be me). Ahem. Rant over.
Anyway, I'll try to give a few more details tomorrow, but if yesterday is any indication of how I'll be feeling, it might end up being postponed again. We'll see. Till next time, peace and God bless!
Friday, October 1, 2010
Best job in the world
I can't get over the fact that eight or so years from now, someone will be paying me to do what I did today. As much as last month was a struggle, that's how much this month is a joy. You know you love what you do when you look forward to each of your shifts as much as you do to your days off.
Today was a pretty busy one. All told, I saw five patients, each with a different complaint and needing a different workup. That's one of the many benefits to the ED -- you'll see anything and everything. (Of course, at times I suppose that's also one of the drawbacks). I actually felt like I was holding my own with the junior residents today in terms of seeing patients, although I definitely need to learn how to take care of administrative tasks (consults, admissions, discharges) more efficiently. (It would probably help if I had a pickle phone, but who in their right mind gives a third-year medical student one of those?!) Regardless, though, I saw (and admitted) a patient with recurrent severe abdominal pain (also did my first guiac test for occult blood, but like all the other tests we did, it didn't really help us figure out what was going on), had another kid with a wrist injury after wrestling with his sister (x-rays were negative, so we splinted his wrist and sent him home with ortho follow-up), one girl who was less than 2 years old but had an extensive history of hospitalization for asthma (mom and dad had brought her in pre-emptively because they recognized the warning signs, and I think we cut off a more extended hospital stay at the pass), a little guy who had sat around in another ED for 6 hours before being transferred to CHP by ambulance (as soon as he got through our doors he perked up and looked great, so he got sent home after some IV fluids), and a kid whose PCP swore he had a dangerous complication of strep (he was reacting to a medication). If I wasn't in a patient's room, I was bugging GI (I talked with at least two fellows and one resident, possibly more), presenting to an attending, writing a note, or preparing discharge instructions. I was there a full hour and a half longer than my shift was supposed to run, but the entire day went by in a flash.
Still, though, as fun as this is, there's room for some serious improvement. I need to start thinking about management much earlier in the process so that I have something semi-intelligent to say when the attending asks "So what do you want to do for this kid?" I'd really, REALLY like to get the right answer to that question a few times before the rotation ends.
Anyway, that's all for now...tomorrow I work from 5 PM until 1 AM, and I strongly doubt I'll be in a fit state of mind to post immediately after that, so I'll write something on Sunday. Until then, peace and God bless!
Today was a pretty busy one. All told, I saw five patients, each with a different complaint and needing a different workup. That's one of the many benefits to the ED -- you'll see anything and everything. (Of course, at times I suppose that's also one of the drawbacks). I actually felt like I was holding my own with the junior residents today in terms of seeing patients, although I definitely need to learn how to take care of administrative tasks (consults, admissions, discharges) more efficiently. (It would probably help if I had a pickle phone, but who in their right mind gives a third-year medical student one of those?!) Regardless, though, I saw (and admitted) a patient with recurrent severe abdominal pain (also did my first guiac test for occult blood, but like all the other tests we did, it didn't really help us figure out what was going on), had another kid with a wrist injury after wrestling with his sister (x-rays were negative, so we splinted his wrist and sent him home with ortho follow-up), one girl who was less than 2 years old but had an extensive history of hospitalization for asthma (mom and dad had brought her in pre-emptively because they recognized the warning signs, and I think we cut off a more extended hospital stay at the pass), a little guy who had sat around in another ED for 6 hours before being transferred to CHP by ambulance (as soon as he got through our doors he perked up and looked great, so he got sent home after some IV fluids), and a kid whose PCP swore he had a dangerous complication of strep (he was reacting to a medication). If I wasn't in a patient's room, I was bugging GI (I talked with at least two fellows and one resident, possibly more), presenting to an attending, writing a note, or preparing discharge instructions. I was there a full hour and a half longer than my shift was supposed to run, but the entire day went by in a flash.
Still, though, as fun as this is, there's room for some serious improvement. I need to start thinking about management much earlier in the process so that I have something semi-intelligent to say when the attending asks "So what do you want to do for this kid?" I'd really, REALLY like to get the right answer to that question a few times before the rotation ends.
Anyway, that's all for now...tomorrow I work from 5 PM until 1 AM, and I strongly doubt I'll be in a fit state of mind to post immediately after that, so I'll write something on Sunday. Until then, peace and God bless!
Tuesday, September 28, 2010
Lessons learned
Ok, so for everything I did right today, I made at least two mistakes. I've definitely got a lot to learn. One of the things I learned today is that attendings are attendings for a reason, and when you disagree with them, prepare to be proved wrong. Twice today I was surprised by the conclusions and management plans of attending physicians, and both times it turned out that their "gut feeling" had caused them to interpret the evidence correctly (even though my explanations seemed more obvious). [Also I should point out that I wasn't stupid enough to SAY anything in either case...good thing, too.] First case was a little kid who had been in a couple of days ago after lacerating his eyelid with a colored pencil. He had a superficial lac and was sent home with some erythromycin ointment (that's an antibiotic for the non-medical folks keeping score at home). Today he came back because his eyelid was swollen shut. And I mean SHUT. It took four of us to hold the kid down that the resident could peel back his eyelid and the attending could get a quick look at his eye. Still, though, his eye was moving ok and didn't look super-bad, and when we weren't poking at him the kid was in a pretty good mood, so I figured the attending would give him a dose of IV antibiotics (probably clindamycin as the kid had a history of drug reactions to penicillins), observe him for a while, and probably send him home on PO ( = oral) antibiotics. Thus, I was fairly surprised when she said "You know, I wasn't able to get a great look at the eye, and I don't feel comfortable sending him home. I think we should get a CT of his orbit to make sure there's nothing going on there." I mean, it's a textbook superficial cellulitis, right? ...not so much. An hour later, I ran into the resident in the work station. "You're not gonna believe this," she says. She pulls up the CT, and there in the kid's orbit is a decent-sized lesion. Apparently some of the lead from the colored pencil had embedded itself in the orbit. Last I heard, he was scheduled to go to the OR with ophthalmology. Bit of a turnaround from wondering if we could send him home, and my first lesson on the ability of the attendings to integrate experience, "gut" instinct, and data to arrive at the proper course of action.
The second case involved a teenage girl with abdominal pain. A resident and I saw her together, and when we came out, we were pretty confident that it wasn't appendicitis. After all, her pain had been getting a little better rather than worse, she was eating and drinking fine, and her obturator and psoas signs were negative. So we were talking about ultrasounds and other testing for ovarian pathology and the like. I presented our findings to the attending who listened attentively and then went to do a quick check of her own on the kid. She was back five minutes later. "I think this kid has appendicitis." Again, I was skeptical. Again, I was wrong. As the day progressed, the girl's pain went from midline to right lower quadrant and it didn't improve. She began to display rebound tenderness and her white count was elevated. By the end of the day, it looked like pretty classic appendicitis. Attendings 2, SL 0. Once again, an integration of multiple sources of insight allowed the attending to reach the correct conclusion even before all of the data was in evidence.
Still, though, despite my stumbling and bumbling, I had the time of my life today. I started picking up and following patients on my own (a 1 year old with possible dehydration + asthma-like symptoms and a 5 year old with a supracondylar fracture [translation: broken elbow]), and realized that I actually have the tools to be able to do this successfully. It's a gratifying feeling to realize that even though I still have so much to learn, I'm already in a position where I can be successful in patient care (albeit with a little guidance). I can't tell you how excited I am to go back tomorrow! This is going to be a great month, and I'll be looking forward to every single shift.
Anyway, that's all for now...back tomorrow with more tales from the ED. Till then, peace and God bless!
The second case involved a teenage girl with abdominal pain. A resident and I saw her together, and when we came out, we were pretty confident that it wasn't appendicitis. After all, her pain had been getting a little better rather than worse, she was eating and drinking fine, and her obturator and psoas signs were negative. So we were talking about ultrasounds and other testing for ovarian pathology and the like. I presented our findings to the attending who listened attentively and then went to do a quick check of her own on the kid. She was back five minutes later. "I think this kid has appendicitis." Again, I was skeptical. Again, I was wrong. As the day progressed, the girl's pain went from midline to right lower quadrant and it didn't improve. She began to display rebound tenderness and her white count was elevated. By the end of the day, it looked like pretty classic appendicitis. Attendings 2, SL 0. Once again, an integration of multiple sources of insight allowed the attending to reach the correct conclusion even before all of the data was in evidence.
Still, though, despite my stumbling and bumbling, I had the time of my life today. I started picking up and following patients on my own (a 1 year old with possible dehydration + asthma-like symptoms and a 5 year old with a supracondylar fracture [translation: broken elbow]), and realized that I actually have the tools to be able to do this successfully. It's a gratifying feeling to realize that even though I still have so much to learn, I'm already in a position where I can be successful in patient care (albeit with a little guidance). I can't tell you how excited I am to go back tomorrow! This is going to be a great month, and I'll be looking forward to every single shift.
Anyway, that's all for now...back tomorrow with more tales from the ED. Till then, peace and God bless!
Monday, September 27, 2010
Starting Peds EM
Ah, the first day on a new rotation! Actually, though, there's not much to say from today...all I had was a half-hour orientation to the CHP ED. It sounds like this is pretty much going to be an AI (acting internship, for those of you who aren't crazy enough to do the whole med school thing) where I'll be responsible for taking care of patients largely on my own. This makes me very happy :-) Anyway, first shift is tomorrow from 10A - 6P; we'll see how that goes. I'm just a teeny tiny bit excited. For those of you who don't know, this is likely what I want to do with my life (pediatric emergency medicine), but this will be my first time with actual patient care responsibilities in the ED, so we'll see if that changes anything. My money's on "no," but I suppose stranger things have happened. At this point, though, I'm rambling, so I'm gonna head to bed before I crash. Back with stories (hopefully) tomorrow evening...and with any luck, there won't be a need to focus on moral dilemmas this time around. Till then, peace and God bless!
Friday, September 24, 2010
Quick wrap
I'll have to push back my more extensive comments till tomorrow, but here are some quick hits from the day:
-The Ob-Gyn test is basically written to force any pro-life students to choose between their beliefs and their grades. Nearly a third of the questions on the exam dealt with abortion and contraception, and many of them were value-laden (e.g. "most appropriate contraception," "best method of terminating the pregnancy," "what counseling would you offer about abortion" and the like). It was not a fair test, it did not reflect course content or learning objectives, and it punished pro-life students for our beliefs. Assuming I pass the exam, I'll be having a chat with the dean about that little gem.
-Overall, I was pleasantly surprised by the residents but still worn down by the clerkship. Being immersed in an environment like the one at Magee takes a significant toll and I think it'll be a while before I'm entirely over the effects.
-Something I never mentioned and have been meaning to...the ID badges we were given at Magee didn't have pictures, so most of my classmates opted to display their Presby photo IDs. My little protest during the rotation was to display my Children's Hospital badge, a reminder that the kids (whether born or unborn) are our patients too. It probably didn't make much of a difference, but at least it was something.
-The meeting with the new pro-life group was very promising and gives me hope that in the near future pro-life students will have viable options that will not suck every last drop of life out of them. However, it also reiterated the scope of the problem here and just how hostile an environment this is.
Ok, that's it for now. Hopefully a more considered post will follow tomorrow or Sunday. Till then, peace and God bless!
-The Ob-Gyn test is basically written to force any pro-life students to choose between their beliefs and their grades. Nearly a third of the questions on the exam dealt with abortion and contraception, and many of them were value-laden (e.g. "most appropriate contraception," "best method of terminating the pregnancy," "what counseling would you offer about abortion" and the like). It was not a fair test, it did not reflect course content or learning objectives, and it punished pro-life students for our beliefs. Assuming I pass the exam, I'll be having a chat with the dean about that little gem.
-Overall, I was pleasantly surprised by the residents but still worn down by the clerkship. Being immersed in an environment like the one at Magee takes a significant toll and I think it'll be a while before I'm entirely over the effects.
-Something I never mentioned and have been meaning to...the ID badges we were given at Magee didn't have pictures, so most of my classmates opted to display their Presby photo IDs. My little protest during the rotation was to display my Children's Hospital badge, a reminder that the kids (whether born or unborn) are our patients too. It probably didn't make much of a difference, but at least it was something.
-The meeting with the new pro-life group was very promising and gives me hope that in the near future pro-life students will have viable options that will not suck every last drop of life out of them. However, it also reiterated the scope of the problem here and just how hostile an environment this is.
Ok, that's it for now. Hopefully a more considered post will follow tomorrow or Sunday. Till then, peace and God bless!
Thursday, September 23, 2010
What we have here is a failure to communicate...
Nothing is ever simple on this rotation. Thanks to another communication foul-up between the course administration and the residents, the residents thought that the students were supposed to work tomorrow (our test day for the clerkship). Apparently the residents have been hassled before for letting the students out too early before the test, and so they didn't want to get in trouble and didn't want to get us in trouble either. However, getting up at 3:30 to work at 4:30 on the day of a major exam (which starts at 10:15) generally doesn't do much for reasoning capacity or resulting grades. After much confusion and some consultations (one of which involved our no-nonsense AI telling us that under no circumstances were we to come in tomorrow morning or she'd phone the dean about duty hour violations), we finally had to end up talking (well, actually, my more courageous classmate did the talking, I just stood there and nodded occasionally) to the incredibly nice, helpful, student-friendly PGY-3 who had originally brought this up (it should be emphasized, however, that it was NOT her idea) to tell her that per the course director we wouldn't be coming in for rounds. She took it really well, but it didn't stop either of us from feeling bad. On the other hand, as the AI pointed out, we would feel a lot worse if we ended up failing the exam 2/2 sleep deprivation. Again, I don't think there's any blame to be placed here except on a flawed communication system; the residents here (particularly the PGY-3 I mentioned) have been nothing short of outstanding (and I can say this despite my significant differences of opinion with them on major moral issues). Anyway, we'll see how this works out. Otherwise, it was a pretty slow day. There were only 3 OR cases and a limited amount of floor work that we could help out with, and after sitting down with us and essentially going through the highlights of "things you need to know for an Ob-Gyn test" (interestingly, neither abortion nor contraception came up during the discussion...food for thought) our PGY-3 sent us home.
So that's that...the final hurdle will be this exam, which I hear is rather tricky. We'll see how it goes. Prayers would be appreciated; I'd really like to be done with this clerkship forever. Anyway, I'm gonna go study for a while; back tomorrow (hopefully) to wrap things up for this clerkship. Till then, peace and God bless!
So that's that...the final hurdle will be this exam, which I hear is rather tricky. We'll see how it goes. Prayers would be appreciated; I'd really like to be done with this clerkship forever. Anyway, I'm gonna go study for a while; back tomorrow (hopefully) to wrap things up for this clerkship. Till then, peace and God bless!
Wednesday, September 22, 2010
One more day
Long day today, but a fairly decent one. It helps when you're doing something that makes a difference, you know? Even if your part in that is very small (as mine most assuredly is at this point), it remains a day well-spent. And in this point is the fundamental irony of Magee (and of too many other hospitals around the country): that at an institution ostensibly dedicated to healing and saving lives, the business of death is the primary focus. It's an unwelcome shock to look at the board where all the surgeries are listed and realize that a full third are abortions of one kind or another. So while in one room we're doing a radical hysterectomy and lymph node dissection in an attempt to stage and begin treatment of endometrial cancer, the team next door is likely to be performing a suction dilation and curettage (which seems to be the favored form of abortion here). And that spectre is always lurking in the background, particularly since it's just part of life at Magee -- virtually no one who works here has any problem with it (or even thinks anything of it). So I guess my sense of satisfaction at being able to play a role in saving a life at least for a time is to a large extent annulled by a growing awareness of what's going on around me.
Regardless, however, I only have one more day to go. One more day of getting up at 3:30 to pre-round at 4:30, round at 5:30, and present at 6:30. One more day of trying to save lives surrounded by a culture of death. One more day on a rotation I've dreaded since the first thoughts of applying to medical school entered my mind. One more day. I'll catalog that last day tomorrow, and then on Friday I'll share some closing thoughts about the rotation. After that, it's on to pediatric emergency medicine, which I've been looking forward to since signing up for it back in March. It's my payoff for surviving Ob-Gyn, and hopefully it'll bring good stories and ruminations much less discouraging than those from this rotation. First, though, I need to get through my last day at Magee and survive the test, so prayers would be tremendously appreciated. Hope you're all doing well...peace and God bless!
Regardless, however, I only have one more day to go. One more day of getting up at 3:30 to pre-round at 4:30, round at 5:30, and present at 6:30. One more day of trying to save lives surrounded by a culture of death. One more day on a rotation I've dreaded since the first thoughts of applying to medical school entered my mind. One more day. I'll catalog that last day tomorrow, and then on Friday I'll share some closing thoughts about the rotation. After that, it's on to pediatric emergency medicine, which I've been looking forward to since signing up for it back in March. It's my payoff for surviving Ob-Gyn, and hopefully it'll bring good stories and ruminations much less discouraging than those from this rotation. First, though, I need to get through my last day at Magee and survive the test, so prayers would be tremendously appreciated. Hope you're all doing well...peace and God bless!
Tuesday, September 21, 2010
Exhausted
Memo to those who don't have a car: signing up for gyn-onc isn't really an option. 4:30 start time today, 4:45 tomorrow...buses don't start running (or rather, won't get to to Magee) until after 5. The work is good, and there are really no moral dilemmas involved -- you're taking care of women who, for the most part, either are or may be in serious cancer-related trouble. Sometimes things go well (specimens return from pathology as benign; tumors are resected with clear margins and no evidence of spread) and sometimes things go poorly (a routine procedure suffers a serious complication and the patient ends up losing several liters of blood into her chest or we go to do a simple laparoscopic procedure and find that the tumor has grown and spread), but either way you're doing something that's worthwhile. If you can deal with the early wakeup times (3:30 or so isn't uncommon), I'd definitely recommend this service over benign gyn surgery (as one of my friends noted, "the case before and the case after mine were both abortions").
Today went more or less ok. The attending I worked with was phenomenal, and I wouldn't at all mind working with him again tomorrow if circumstances allow. I also got to see a robotic surgery for the first time -- unbelievably cool. The machine is undoubtedly expensive, and so is the equipment for it, but the incredible freedom it allows the surgeon may ultimately end up justifying the cost as the technology improves and the surgeons gain more experience. Unfortunately, also saw one of my patients made CMO (comfort measures only); she's unlikely to survive more than a few days (if that). Once again, prayers for her and her family would be tremendously appreciated.
Anyhow, I'm exhausted and barely coherent, so I'm gonna head to bed so I can do this all again tomorrow. Hope everyone is doing well...peace and God bless!
Today went more or less ok. The attending I worked with was phenomenal, and I wouldn't at all mind working with him again tomorrow if circumstances allow. I also got to see a robotic surgery for the first time -- unbelievably cool. The machine is undoubtedly expensive, and so is the equipment for it, but the incredible freedom it allows the surgeon may ultimately end up justifying the cost as the technology improves and the surgeons gain more experience. Unfortunately, also saw one of my patients made CMO (comfort measures only); she's unlikely to survive more than a few days (if that). Once again, prayers for her and her family would be tremendously appreciated.
Anyhow, I'm exhausted and barely coherent, so I'm gonna head to bed so I can do this all again tomorrow. Hope everyone is doing well...peace and God bless!
Monday, September 20, 2010
Not much to say
Not much happened today...got in at 5, rounded with the team, spent about 3 hours in the OR (all very short, straightforward cases), and then spent most of the rest of the day reading. Even got to go outside for some of that reading. Of course, this is sort of balanced by the fact that I'm supposed to be in by 4:30 tomorrow, which means I need to be up by 3:30. Yikes. Otherwise, not a lot to say.
The rotation is drawing to an end, and I can't really find it in me to be sad about that. Despite the pleasantly surprising lack of intolerance (with the one previously described exception), the culture at Magee is manifestly a toxic one. Indeed, the lack of open confrontation is in some ways deceiving; things like abortion and contraception are here so ingrained that I'm afraid it would be possible, almost without realizing it, to begin to accept these things over time. It is not the overt challenge of the abortionist that worries me most; it is the passive immersion that presents the greatest threat to one's beliefs regarding the value of life. When the rotation finally ends on Friday, I'll give a few tips in this space on how I think that insidious trap can best be avoided.
Anyway, that's all for now. If you haven't yet, please take a look at yesterday's post on randomized controlled trials and vote in the poll -- I'd really be interested to hear what people think. Hope you're doing well, everyone! Peace and God bless!
The rotation is drawing to an end, and I can't really find it in me to be sad about that. Despite the pleasantly surprising lack of intolerance (with the one previously described exception), the culture at Magee is manifestly a toxic one. Indeed, the lack of open confrontation is in some ways deceiving; things like abortion and contraception are here so ingrained that I'm afraid it would be possible, almost without realizing it, to begin to accept these things over time. It is not the overt challenge of the abortionist that worries me most; it is the passive immersion that presents the greatest threat to one's beliefs regarding the value of life. When the rotation finally ends on Friday, I'll give a few tips in this space on how I think that insidious trap can best be avoided.
Anyway, that's all for now. If you haven't yet, please take a look at yesterday's post on randomized controlled trials and vote in the poll -- I'd really be interested to hear what people think. Hope you're doing well, everyone! Peace and God bless!
Sunday, September 19, 2010
The debate over clinical trials
Just read an article about the ethicality of randomized controlled clinical trials, particularly in oncology. The central argument that the author seems to be supporting is that these trials prevent patients from receiving treatments that could prolong their lives and / or relieve their suffering. This, she indicates, is a more important consideration than the "statistics" and "science." While I understand her position, I'm of the opinion that the reason we do randomized controlled trials is to make sure that the therapy being studied is a) safe, and b) effective. Sure, we could prescribe it to everyone right off the bat, but what if it ends up (as so many chemo alternatives seem to) being less useful than existing medications, or has intolerable side effects? I don't think it's corporate greed; I think it's good science and good medicine. I appreciate that it's a terrible decision to have to randomize people into the control arm, to not offer them this hope, but I think it's crucial to know what we'll be offering if and when it is approved. Would I think differently if I or one of my friends or family was affected by melanoma? It's possible. But I think overall it's too important to know that a drug is more than anecdotally effective before making it available. Any opinions or comments would be greatly appreciated.
Peace and God bless!
Peace and God bless!
Friday, September 17, 2010
Road trip
Up at 4, in at 5, and freezing all morning...that was how the day started. Fortunately, it got better from there thanks to having a good team and a very good senior resident. After morning teaching (which was actually really good...one of the residents did some nice tumor board presentations and one of the surg onc attendings gave a really good look at a relatively new procedure that may allow partial rather than complete removal of the uterus for certain cancers, which in turn often permits retention of fertility -- neat stuff!), the senior told us that there were really no cases for us in the OR today, and that she was going to head to UPMC Passavant (about 30-40 minutes north of Pittsburgh) to help one of the attendings there with a couple of cases. She told us that one of us was welcome to come along, but we were also welcome to stay and help out with floor work. After a brief discussion with my classmate, I decided what the heck, why not? A change of scenery would do me some good, right?
I have to say, it turned out to be a good decision. I got to scrub in and assist with a pair of cases (including some suturing), got some studying done (our first case started almost 2 hours late), and got some really good one-on-one teaching with the attending and senior resident. Our first procedure was a laparoscopic bilateral salpingo-oophorectomy (removal of the ovaries and fallopian tubes, abbreviated BSO) and laparoscopic assisted vaginal hysterectomy (removal of the uterus through the vagina; it's actually a pretty cool procedure) in a patient with complex endometrial hyperplasia with atypia (very high risk of becoming or coexisting with cancer). It was a semi-involved procedure, particularly the hysterectomy -- all three of us crowded into a small space, with the attending and I holding retractors so the resident could see what she was doing. It went pretty smoothly, though. Afterwards, I got to stitch up the umbilicus and got some very useful suturing tips from my very, VERY patient resident (subcuticular suturing is something I need a little practice at...). The other case was just a brief dilation and curettage (D&C) in a 63 year old patient with cancerous lymph nodes but no known disease focus. It took about 10 minutes to rule out endometrium as the primary source.
That was pretty much my day at Passavant (well, other than the nurses trying to set me up with their daughters...much laughter was had at my expense). It was definitely a worthwhile experience, so if you're a medical student and doing gyn onc, definitely take any opportunities that arise to help out offsite. It's good times -- and highly educational.
Anyway, that's it for me for tonight...I'm bone tired, so I'm gonna head to bed. I'll be back on Monday with further updates and tales (and possibly briefly over the weekend to comment on football, but we'll see...I'd give that one a Bill Belichick "questionable.") Till then, peace and God bless!
I have to say, it turned out to be a good decision. I got to scrub in and assist with a pair of cases (including some suturing), got some studying done (our first case started almost 2 hours late), and got some really good one-on-one teaching with the attending and senior resident. Our first procedure was a laparoscopic bilateral salpingo-oophorectomy (removal of the ovaries and fallopian tubes, abbreviated BSO) and laparoscopic assisted vaginal hysterectomy (removal of the uterus through the vagina; it's actually a pretty cool procedure) in a patient with complex endometrial hyperplasia with atypia (very high risk of becoming or coexisting with cancer). It was a semi-involved procedure, particularly the hysterectomy -- all three of us crowded into a small space, with the attending and I holding retractors so the resident could see what she was doing. It went pretty smoothly, though. Afterwards, I got to stitch up the umbilicus and got some very useful suturing tips from my very, VERY patient resident (subcuticular suturing is something I need a little practice at...). The other case was just a brief dilation and curettage (D&C) in a 63 year old patient with cancerous lymph nodes but no known disease focus. It took about 10 minutes to rule out endometrium as the primary source.
That was pretty much my day at Passavant (well, other than the nurses trying to set me up with their daughters...much laughter was had at my expense). It was definitely a worthwhile experience, so if you're a medical student and doing gyn onc, definitely take any opportunities that arise to help out offsite. It's good times -- and highly educational.
Anyway, that's it for me for tonight...I'm bone tired, so I'm gonna head to bed. I'll be back on Monday with further updates and tales (and possibly briefly over the weekend to comment on football, but we'll see...I'd give that one a Bill Belichick "questionable.") Till then, peace and God bless!
Thursday, September 16, 2010
Gyn Onc
I'm exhausted to the point of incoherence, so this will of necessity be brief. Gyn onc is, in some ways, a sad but fitting bookend to the experiences of labor and delivery. In L&D, the patients are new mothers and their children as they make the transition from "unborn" to "born." Every day is an encounter with the miraculous; every day is filled with lives just starting out. In gyn onc, however, the spectre of death is very real. One quick story for purposes of illustration. Prior to heading into the OR for her surgery, I quickly met and introduced myself to the next patient on the schedule. MRI had shown an endometrial cancer in her uterus, and the uterus needed to be removed to ensure clear margins. She had been scheduled for a laparoscopic hysterectomy, and since she was nulliparous (no children) and hadn't had any prior abdominal surgeries, it figured to be a quick and easy case.
Of course, Linakis's First Law (coined by my father) states that "the plot ALWAYS thickens" and this case failed to become the first known exception to said law. I had scrubbed in and was watching the procedure. The attending was saying that it probably wasn't going to turn out having been worth scrubbing for; he correctly pointed out that during a laparoscopic procedure you can generally see as much from halfway across the room as you can with your hands on the operating table. Less than five minutes after he made that comment, he finally located the uterus among all the abdominal adipose tissue. It should have been normal-looking. It was not. A large gray-white tumor was clearly protruding from the top of the uterus. Immediately things became more serious. This was no longer a quick and easy procedure that could be done laparoscopically. She needed a laparotomy; that is, her belly had to be fully cut open so that we could go searching to see whether the cancer had spread. Still, though, we were hopeful; if this protruding tumor was an isolated lesion, the patient's odds would still be pretty good. That optimism lasted an even shorter time than the laparoscopic attempt. When we opened her abdomen, we found small, nodular tumors everywhere. Her omentum (a large fat pat in the belly) was liberally spotted with metastatic disease. The colon appeared to be involved. And all of a sudden, the once quick and easy case had turned into a nightmare. Don't know who had to discuss our findings with the patient, but I'm glad it wasn't me. Please keep her in your prayers tonight; the prognosis is (obviously) pretty poor.
Anyway, that's it for me. It's time for bed; up at 4 tomorrow to start work at 5. Yay. Oh well, at least I have a good team! Back with more updates in the evening. Till then, peace and God bless!
Of course, Linakis's First Law (coined by my father) states that "the plot ALWAYS thickens" and this case failed to become the first known exception to said law. I had scrubbed in and was watching the procedure. The attending was saying that it probably wasn't going to turn out having been worth scrubbing for; he correctly pointed out that during a laparoscopic procedure you can generally see as much from halfway across the room as you can with your hands on the operating table. Less than five minutes after he made that comment, he finally located the uterus among all the abdominal adipose tissue. It should have been normal-looking. It was not. A large gray-white tumor was clearly protruding from the top of the uterus. Immediately things became more serious. This was no longer a quick and easy procedure that could be done laparoscopically. She needed a laparotomy; that is, her belly had to be fully cut open so that we could go searching to see whether the cancer had spread. Still, though, we were hopeful; if this protruding tumor was an isolated lesion, the patient's odds would still be pretty good. That optimism lasted an even shorter time than the laparoscopic attempt. When we opened her abdomen, we found small, nodular tumors everywhere. Her omentum (a large fat pat in the belly) was liberally spotted with metastatic disease. The colon appeared to be involved. And all of a sudden, the once quick and easy case had turned into a nightmare. Don't know who had to discuss our findings with the patient, but I'm glad it wasn't me. Please keep her in your prayers tonight; the prognosis is (obviously) pretty poor.
Anyway, that's it for me. It's time for bed; up at 4 tomorrow to start work at 5. Yay. Oh well, at least I have a good team! Back with more updates in the evening. Till then, peace and God bless!
Wednesday, September 15, 2010
SNAFU
Today was kind of a short day, mostly spent in the OR with Dr. Jaja. Saw a couple of patients with fibroids getting different kinds of myomectomies and one patient undergoing endometrial ablation for heavy bleeding. I had some reservations about the ablation because of its apparent effects on fertility, but this patient was already infertile and was actually having the procedure for fairly legitimate reasons (including failure of more conservative therapy). Because there were residents present and fairly little space available, I didn't scrub in; I just watched either on the screens or from whatever angle I had available. Cases for the day finished about 2:30 or so; I talked with Dr. Jaja for a bit and then headed home. All in all, my week with him was a good experience that I would recommend, especially in the absence of true pro-life alternatives.
Then came the snafu. Ob-Gyn here doesn't require night or weekend shifts on the theory that then we have no excuse not to study. I worked last Saturday because of the program with Dr. Jaja, so my schedule called for me to have tomorrow off. In a classic case of a genuine favor backfiring, one of my classmates (currently on Gyn-onc) emailed me with instructions from the senior resident regarding who to contact for the start of my gynecologic oncology subrotation. He cc'ed the email to the intern and AI who are in charge of where and when the students are supposed to meet the team. Normally, this would be great because it's tough to get all of that information from outside the team; unfortunately, neither he nor the residents were aware that I was supposed to have tomorrow off. Thus, instead of getting some sleep and meeting with my SP advisor, I will be at Magee at 4:45 tomorrow morning. Oh well...there's no crying in medicine, right? Although there might be if I don't get to bed stat; I'm pretty useless when I'm sleepless. Anyway, back tomorrow with updates from the first day of Gyn-onc. Till then, peace and God bless!
Then came the snafu. Ob-Gyn here doesn't require night or weekend shifts on the theory that then we have no excuse not to study. I worked last Saturday because of the program with Dr. Jaja, so my schedule called for me to have tomorrow off. In a classic case of a genuine favor backfiring, one of my classmates (currently on Gyn-onc) emailed me with instructions from the senior resident regarding who to contact for the start of my gynecologic oncology subrotation. He cc'ed the email to the intern and AI who are in charge of where and when the students are supposed to meet the team. Normally, this would be great because it's tough to get all of that information from outside the team; unfortunately, neither he nor the residents were aware that I was supposed to have tomorrow off. Thus, instead of getting some sleep and meeting with my SP advisor, I will be at Magee at 4:45 tomorrow morning. Oh well...there's no crying in medicine, right? Although there might be if I don't get to bed stat; I'm pretty useless when I'm sleepless. Anyway, back tomorrow with updates from the first day of Gyn-onc. Till then, peace and God bless!
Tuesday, September 14, 2010
OB and ID
I really need to try to write these earlier...when it gets to this time of night, I have little energy and only marginally more motivation to write about the events of the day. I was in clinic again today, and once again it was pretty standard. I saw several patients, both OB and Gyn, wrote notes, and ended up accidentally walking off with one of the office Dopplers. Oops. Topics for today included leiomyomas (uterine fibroids), causes of urinary incontinence, and effects of pregnancy on the pulmonary and cardiovascular systems. Also got a decent look at hormone replacement therapy in PBL thanks to a couple of trials from a few years back. Anyway, not much exciting today, but also nothing in the way of moral dilemmas or controversies.
On a health-related but Ob-Gyn unrelated note, I very briefly saw an article on MSN about a new plasmid that's popping up in Asia that confers broad-spectrum antibiotic resistance on (generally) Gram negative organisms. Apparently these bugs are resistant to any and all beta-lactams (carbapenems included), fluoroquinolones, aminoglycosides, and basically everything except colistin (which hasn't been widely used in the US for years). Anyone know anything more about this?
Anyway, that's all for tonight. In the OR with Dr. Jaja tomorrow; we'll see how that goes. Till then, peace and God bless!
On a health-related but Ob-Gyn unrelated note, I very briefly saw an article on MSN about a new plasmid that's popping up in Asia that confers broad-spectrum antibiotic resistance on (generally) Gram negative organisms. Apparently these bugs are resistant to any and all beta-lactams (carbapenems included), fluoroquinolones, aminoglycosides, and basically everything except colistin (which hasn't been widely used in the US for years). Anyone know anything more about this?
Anyway, that's all for tonight. In the OR with Dr. Jaja tomorrow; we'll see how that goes. Till then, peace and God bless!
Monday, September 13, 2010
Another day at the office
Pretty run-of-the-mill day today. Worked for a few hours, did a few histories and pelvic exams, and called it a day. Not much in the way of learning points or interesting cases, just some very nice, very...well, patient patients who allowed me to sharpen one of the more awkward skills required of a medical professional. The only small issue was that one patient wanted information and counseling regarding her IUD (IntraUterine Device, a contraceptive gadget implanted in the uterus for any non-medical types); Dr. Jaja basically told me not to worry about that, that he'd take care of it. I really have to say (as I've noted before) that this is a very good alternative for anyone like me with issues of conscience surrounding some of the mainstay topics of Ob-Gyn until we get a truly pro-life alternative in place.
Anyway, that's really it from me for tonight. Hopefully I'll have more to say tomorrow...second day in Wexford. Hopefully I won't get lost this time! Peace and God bless!
Anyway, that's really it from me for tonight. Hopefully I'll have more to say tomorrow...second day in Wexford. Hopefully I won't get lost this time! Peace and God bless!
Saturday, September 11, 2010
Sorrow and joy
This will come as no shock to anyone who's done an inpatient rotation, but rounding isn't very much fun. Especially when you're covering three teams and it lasts for four hours. UGH. Worst of all, the last patient we saw was on her first post-op day after a C-section to deliver a baby that had suddenly and unexpectedly died at nearly 40 weeks gestation. Dad told us that an ultrasound last week had showed that everything was normal. At this point, no one is really sure what happened. I wonder what they'll tell their other kids...I'm sure they said they would come home from the hospital with a new brother / sister. How do you go about explaining to children that their new little brother / little sister died? What a horribly, terribly sad situation...prayers for that family would be greatly appreciated.
On a happier note, to sort of balance out the sadness of death, I got to catch another baby, a 9 pound boy. Little fella was kind of slippery, but I managed not to drop him (dictum #1 on Ob-Gyn: "don't drop the baby." In case you're wondering, it's also #2 and #3). It's really hard to stop smiling after an experience like that. He was perfectly healthy and mom was in good shape; dad had a rather dazed grin on his face after the little fellow finally decided to pop on out. He got a rousing chorus of "Happy Birthday," but apparently our little buddy didn't care for the rendition -- he cried from start to finish and quieted down almost as soon as the song was over. *Sigh* everyone's a critic...
Anyway, that's all for now. I have tomorrow off, which means I most likely will not be posting, but I'll be back again on Monday. Till then, peace and God bless!
On a happier note, to sort of balance out the sadness of death, I got to catch another baby, a 9 pound boy. Little fella was kind of slippery, but I managed not to drop him (dictum #1 on Ob-Gyn: "don't drop the baby." In case you're wondering, it's also #2 and #3). It's really hard to stop smiling after an experience like that. He was perfectly healthy and mom was in good shape; dad had a rather dazed grin on his face after the little fellow finally decided to pop on out. He got a rousing chorus of "Happy Birthday," but apparently our little buddy didn't care for the rendition -- he cried from start to finish and quieted down almost as soon as the song was over. *Sigh* everyone's a critic...
Anyway, that's all for now. I have tomorrow off, which means I most likely will not be posting, but I'll be back again on Monday. Till then, peace and God bless!
Friday, September 10, 2010
30 second post
It's late, I'm tired, and I'm working tomorrow morning, so this is going to be short. Today cured me of any smidgen of desire I might ever have had to a) practice anything related to Ob-Gyn, or b) to work as a primary care / outpatient physician. I got to do a fair amount (bimanual exams, speculum exams, Dopplers for fetal heart tone) but the work in an outpatient Ob-Gyn clinic is mind-numbingly boring. Seeing one patient after another for six or seven hours is draining after a while, particularly when four or five in a row are simply well checkups. Ugh. Oh well, working with Dr. Jaja is still very much a positive thing, as his humor and willingness to teach and get me involved help at least make the day productive. At this point, I'd suggest anyone in my position at least consider volunteering for the experience with Dr. Jaja rather than doing the resident clinic -- better variety, more continuity, a good degree of involvement, and respect for strongly held beliefs. Of course, if the rotation at Mercy comes through...
Anyway, that's pretty much it for me...back tomorrow with a weekly wrap-up. Till then, peace and God bless!
Anyway, that's pretty much it for me...back tomorrow with a weekly wrap-up. Till then, peace and God bless!
Thursday, September 9, 2010
The good and the bad
On the surface of things, today was a pretty good day. I saw several patients with Dr. Jaja, did a couple of pelvic exams, and best of all I got to catch a baby more or less on my own (although I felt really bad for the family medicine resident who had probably spent more time with the new mom than I had). It was a good day for learning. The less promising part of the day was more subtle and centered on seemingly innocuous questions of language. Part of what I'm required to do each day for Dr. Jaja is to write a very brief (half-page or so) summary of a single patient to be discussed the following day. My writeup yesterday was about a woman who was worried because she'd had an episode of bleeding after being pregnant for several weeks. She verbalized this by saying "I'm nervous about my baby." Thus, in my writeup, I described her probable diagnosis as "threatened vs. complete miscarriage" and referred to her unborn child several times as a baby. Why is this significant? While I was discussing the write-up with Dr. Jaja, he mentioned in passing that the more correct terminology was "spontaneous abortion" instead of "miscarriage" and "fetus" instead of "baby." He brought these up just by way of explanation, and not with any ulterior motive, but it was emblematic to me of the culture in the country in general and at Magee in particular. Its net effect is to make the word "abortion" less loaded by linking it with something that unfortunately occurs naturally and to minimize the humanity of the unborn child. It is thus no surprise that the pro-abortion establishment has inculcated the use of this language in medical parlance, especially in the world of OB-GYN.
Anyway, that's all I have time for tonight...back tomorrow with reports on my first outpatient experience in Wexford. Till then, peace and God bless!
Anyway, that's all I have time for tonight...back tomorrow with reports on my first outpatient experience in Wexford. Till then, peace and God bless!
Wednesday, September 8, 2010
First day of clinic
Ok, so I know I promised details, but it's already 10:30 and I'm exhausted. So here's the abbreviated version. The schedule for today said that I was supposed to start at noon. I had a hard time believing that, but I found nothing to the contrary. Still, I couldn't countenance waiting till noon to get to the hospital, so I got there around 10:15 and found Dr. Jaja's office, then went down to the library hoping for a miracle. God came through. The library had purchased -- and JUST received -- several new copies of the Hacker and Moore textbook that's the recommended reading for the clerkship. So I spent the time until noon reading and then went up to meet Dr. Jaja. The afternoon was pretty good. After Dr. Jaja laid out his expectations and the learning objectives, and after I explained what as a Catholic I was and was not willing to participate in (he not only didn't have a problem but was supportive of my following my conscience), we dove into the rather extensive patient list headfirst.
Today I was largely just shadowing. This was due in no small part to the fact that I have virtually no experience with obstetric / gynecologic histories and physicals. I know most of the theory, but my comfort level is low and my skills are still poor. One of the major goals of this part of the clerkship is to remedy those weaknesses, and it seems as if Dr. Jaja has a plan for how that can be accomplished. Today I watched (and semi-participated in) several obstetric antepartum visits (learned how to perform the Leopold maneuvers among other things) and a couple of gynecologic exams (learned proper use of the speculum and how to perform a Pap smear). Tomorrow I'll be back in L&D, where I have at least a little bit better background (one whole week's worth!), and I think that'll be fun.
The rest of the afternoon was ok. The ethics session was intellectually stimulating (sort of) but not especially helpful, and PBL was decent (relatively poor cases on prenatal counseling followed by better ones on STDs). Otherwise not much to tell.
Anyway, that's all for tonight...back tomorrow with a report on L&D. Till then, peace and God bless!
Today I was largely just shadowing. This was due in no small part to the fact that I have virtually no experience with obstetric / gynecologic histories and physicals. I know most of the theory, but my comfort level is low and my skills are still poor. One of the major goals of this part of the clerkship is to remedy those weaknesses, and it seems as if Dr. Jaja has a plan for how that can be accomplished. Today I watched (and semi-participated in) several obstetric antepartum visits (learned how to perform the Leopold maneuvers among other things) and a couple of gynecologic exams (learned proper use of the speculum and how to perform a Pap smear). Tomorrow I'll be back in L&D, where I have at least a little bit better background (one whole week's worth!), and I think that'll be fun.
The rest of the afternoon was ok. The ethics session was intellectually stimulating (sort of) but not especially helpful, and PBL was decent (relatively poor cases on prenatal counseling followed by better ones on STDs). Otherwise not much to tell.
Anyway, that's all for tonight...back tomorrow with a report on L&D. Till then, peace and God bless!
Tuesday, September 7, 2010
Back to work
Ok, didn't post over the weekend. But it was back to work today, so back to blogging. For better or worse, not a lot to write about today. The woman I was following looked like she was on the verge of delivering all day...and finally started pushing just as I left for PBL. And there weren't enough C sections to go around. So I ended up doing a lot of reading today...hopefully that'll help me not embarrass myself tomorrow when I start doing clinic work with Dr. Jaja. We'll see how that goes, but having met and worked with him briefly last week, I think this might turn out ok. I'll be as detailed as possible in my description of how the days run to give anyone who might be interested in signing up for this alternative a feel for what happens on any given day.
I guess the one thing that did happen today was a PBL that spent a great deal of time discussing contraception and sterilization. It really sort of made me think...the way the facilitator approached the topic (and the way that medicine and, indeed, society in general approach the topic) was from a mindset of contraception being a fundamental right. The underlying corollary to this, of course, is that sex is also a fundamental right. Furthermore, there is an even deeper and more insidious understanding that we as human beings should be able to do whatever we want without consequences or responsibility. And by these flawed understandings, we have taken an act that stood at the pinnacle of human relationship as a total, reciprocal self-giving and turned it into a cheap tool of quick pleasure, a Saturday night "hook-up." It has been said by many theologians that sexual intercourse, the act of conjugal love, is the nearest we can come in this life to approximating the love of the Trinity. But by removing the consequences and the need for commitment, by removing the responsibility and gravity that once attended sex, the act itself has become meaningless and emotionless, having no particular value over and above any other means of showing affection or obtaining pleasure. The message today is that sex is fun, babies are inconvenient, and that the individual's enjoyment is the most important thing. Hakuna matata, right?
...but didn't Simba eventually realize he was wrong for leaving his responsibilities behind? Maybe, someday, we will too. Anyway, that's my sermonizing for the day. Back tomorrow with new and exciting stuff! Till then, peace and God bless!
I guess the one thing that did happen today was a PBL that spent a great deal of time discussing contraception and sterilization. It really sort of made me think...the way the facilitator approached the topic (and the way that medicine and, indeed, society in general approach the topic) was from a mindset of contraception being a fundamental right. The underlying corollary to this, of course, is that sex is also a fundamental right. Furthermore, there is an even deeper and more insidious understanding that we as human beings should be able to do whatever we want without consequences or responsibility. And by these flawed understandings, we have taken an act that stood at the pinnacle of human relationship as a total, reciprocal self-giving and turned it into a cheap tool of quick pleasure, a Saturday night "hook-up." It has been said by many theologians that sexual intercourse, the act of conjugal love, is the nearest we can come in this life to approximating the love of the Trinity. But by removing the consequences and the need for commitment, by removing the responsibility and gravity that once attended sex, the act itself has become meaningless and emotionless, having no particular value over and above any other means of showing affection or obtaining pleasure. The message today is that sex is fun, babies are inconvenient, and that the individual's enjoyment is the most important thing. Hakuna matata, right?
...but didn't Simba eventually realize he was wrong for leaving his responsibilities behind? Maybe, someday, we will too. Anyway, that's my sermonizing for the day. Back tomorrow with new and exciting stuff! Till then, peace and God bless!
Friday, September 3, 2010
Lots of cutting
Just a brief post today. It was a day for C-sections (kind of like yesterday), and I scrubbed in on two; I think we only had one or two women deliver vaginally during the entire day today. The only other clinical event of any significance was a pregnant patient who had a condition called for her when it appeared she was having a seizure. From what little I could gather, neuro thought that this was another (likely deliberate) pseudo-seizure, as she has been found to have similar events many times over the last few days. This was particularly sad because she had been told by one of my residents earlier in the day that seizure meds (Ativan) were bad for her baby but if she appeared to seize he'd have no choice but to give her that medicine because seizures would be even worse. I hope there's another explanation, but it'll have to wait until Tuesday.
The "I'm kicking myself" special of the day: I wasn't paying close enough attention right after I came out from my first C-section of the day, so I completely missed an opportunity to scrub on a delivery of twins. That may end up being the biggest regret I have from this rotation.
Anyway, that's all for now...if I have a little discipline, I'll post on other topics over the weekend. Till next time, peace and God bless!
The "I'm kicking myself" special of the day: I wasn't paying close enough attention right after I came out from my first C-section of the day, so I completely missed an opportunity to scrub on a delivery of twins. That may end up being the biggest regret I have from this rotation.
Anyway, that's all for now...if I have a little discipline, I'll post on other topics over the weekend. Till next time, peace and God bless!
Thursday, September 2, 2010
A Tale of Two Days
It was the best of times, it was the worst of times. We'll start with the bad so that we can finish with the good. The day finished with a lecture on abortion delivered by a prolific abortionist(who, ironically, is associated with the "Family Planning Center"). The lecture, billed by the course director as being focused on the medical aspects of abortion, sadly failed to live up to that description. Instead, it was an hour long cheerleading session about the benefits of abortion and how low the risks are compared to delivering a baby with occasional tidbits of actual knowledge thrown in. The words "studies have shown" were thrown around a lot, but with no actual citations to back them up. Having reviewed the literature myself in the past, I think his claims were greatly exaggerated; when I have a little time, I'll go back through and find some of the articles I've read in the past. He also dismissed the pro-life movement as being "anti-choice" and our ethics, arguments, and evidence as "just rhetoric." Just for kicks, he also threw in an incredibly inappropriate description of the abortion process that is not suitable for print; if for some reason you really want to know, ask me by some other means.
Anyway, after the lecture ended, I introduced myself to him as one of the pro-life students he had spoken about. I said that I respected his opinion though I disagreed with him, and I asked him to please have a little respect for my beliefs and those of like-minded people. His response? "Sure, I respect your beliefs, but that doesn't change the fact that you're anti-choice." I told him that I respectfully disagreed, and that I didn't think that name-calling by either side was conducive to a productive dialogue. He replied "I won't argue with you. You can't call me anti-life, I'm very pro-life. I believe that people should be able to live however they want. You're anti-choice. You don't think a woman should be able to choose how she wants to live." I again told him that I respectfully disagreed and that I could produce evidence to support my beliefs ("It's just rhetoric," he snorted), but that I wasn't looking for an argument, merely for a little respect. "Psh," he said, "fine. I respect your opinion." And he walked out of the room. So yeah, first serious challenge of the rotation there. Dunno how this will play out long term, but if I never have to work with this individual again, it'll be too soon.
Anyway, the good...today I actually got to deliver a baby. Not to watch one delivered, not to have the intern's hands doing all the work over top of mine, but to really, truly be the one to work the baby out of the womb and into the world. Before too long, everything in the preceding paragraphs will be forgotten. This I will NEVER forget. It was a C-section delivery, and the PA had just incised the uterus so that we could bring the baby out when the attending said to me "Hey Seth, do you want to deliver this baby?" I don't remember what words found their way out of my mouth at that point, but the upshot (clearly) was "heck yes!" "Ok, here's what you need to do..." I had learned all the techniques, but many of them deserted me in the face of this actual delivery...and the fact that it's a lot less scary to push really hard on a mannequin than to exert serious pressure on a baby. And I do mean SERIOUS pressure. It takes a lot to get the shoulders out. I didn't do it perfectly, but I got the little guy out in one piece and in perfect health, and that's what counts, right? Hopefully I'll have a chance to do that once or twice more before this part of the rotation ends, but regardless, I think (and hope!) that this delivery will forever remain etched in my memory.
Anyway, that was the day. I'm sorry to have to spoil the delivery of such a beautiful, awesome creature with a story of a sad, confused, insecure individual, but I promised I'd chronicle the challenges associated with the rotation, and unfortunately, that's going to be one of them. Still, though, disheartening though that encounter was, it'll drift away with the morning breeze and leave the memory of a beautiful newborn baby boy screaming his lungs out while resting in my hands. Still can't get over the sheer awesomeness of that. Anyway, until next time, all...peace and God bless!
Anyway, after the lecture ended, I introduced myself to him as one of the pro-life students he had spoken about. I said that I respected his opinion though I disagreed with him, and I asked him to please have a little respect for my beliefs and those of like-minded people. His response? "Sure, I respect your beliefs, but that doesn't change the fact that you're anti-choice." I told him that I respectfully disagreed, and that I didn't think that name-calling by either side was conducive to a productive dialogue. He replied "I won't argue with you. You can't call me anti-life, I'm very pro-life. I believe that people should be able to live however they want. You're anti-choice. You don't think a woman should be able to choose how she wants to live." I again told him that I respectfully disagreed and that I could produce evidence to support my beliefs ("It's just rhetoric," he snorted), but that I wasn't looking for an argument, merely for a little respect. "Psh," he said, "fine. I respect your opinion." And he walked out of the room. So yeah, first serious challenge of the rotation there. Dunno how this will play out long term, but if I never have to work with this individual again, it'll be too soon.
Anyway, the good...today I actually got to deliver a baby. Not to watch one delivered, not to have the intern's hands doing all the work over top of mine, but to really, truly be the one to work the baby out of the womb and into the world. Before too long, everything in the preceding paragraphs will be forgotten. This I will NEVER forget. It was a C-section delivery, and the PA had just incised the uterus so that we could bring the baby out when the attending said to me "Hey Seth, do you want to deliver this baby?" I don't remember what words found their way out of my mouth at that point, but the upshot (clearly) was "heck yes!" "Ok, here's what you need to do..." I had learned all the techniques, but many of them deserted me in the face of this actual delivery...and the fact that it's a lot less scary to push really hard on a mannequin than to exert serious pressure on a baby. And I do mean SERIOUS pressure. It takes a lot to get the shoulders out. I didn't do it perfectly, but I got the little guy out in one piece and in perfect health, and that's what counts, right? Hopefully I'll have a chance to do that once or twice more before this part of the rotation ends, but regardless, I think (and hope!) that this delivery will forever remain etched in my memory.
Anyway, that was the day. I'm sorry to have to spoil the delivery of such a beautiful, awesome creature with a story of a sad, confused, insecure individual, but I promised I'd chronicle the challenges associated with the rotation, and unfortunately, that's going to be one of them. Still, though, disheartening though that encounter was, it'll drift away with the morning breeze and leave the memory of a beautiful newborn baby boy screaming his lungs out while resting in my hands. Still can't get over the sheer awesomeness of that. Anyway, until next time, all...peace and God bless!
Wednesday, September 1, 2010
Long day = short post
Mostly a good day today. On post-partum rounds this morning got caught briefly in the awkward situation of being in the room while the intern was counseling a patient about contraceptive use. For better or worse, it was short enough that I didn't have time to leave the room. Otherwise, the day was highlighted by two vaginal deliveries (aptly described by one of my classmates as "so gross but SO AWESOME!") and an uncomplicated C-section resulting in three healthy children and three ecstatic families. The residents were also in full teaching mode today for some reason that I'm not going to question, so it was a productive day both in terms of skills and knowledge. No other real issues, blessedly. That will, unfortunately, likely change tomorrow when an attending with whom I've unfortunately crossed paths before delivers a lecture on abortion. Suffice it to say that if it's at all similar to the one he delivered 6 or 7 months ago, I'll have plenty to say about it in this space tomorrow.
Anyhow, I guess so far this hasn't been bad. I hope and pray that lasts, and that the good news delivered by another classmate (maybe we'll get a pro-life Ob-Gyn option after all!) comes to full fruition before next year. That's all from me for tonight; hope everyone's doing well. Peace and God bless!
Anyhow, I guess so far this hasn't been bad. I hope and pray that lasts, and that the good news delivered by another classmate (maybe we'll get a pro-life Ob-Gyn option after all!) comes to full fruition before next year. That's all from me for tonight; hope everyone's doing well. Peace and God bless!
Tuesday, August 31, 2010
Pure wonder
Early start this morning...got onto the floor a little before 5:30 to meet the intern. I got to hang out in the nursery while we were waiting, so no complaints there. Shortly thereafter we began helping out with postpartum rounds. Once more the issue of contraception came up, as one of the expected questions for the new mother is "what kind of birth control do you want to use?" It's kind of sad, really...you're talking to this woman, often holding her child, and you're supposed to ask how she wants to make sure that she won't be holding another one anytime soon. Anyway, once again the intern (different intern this time) rather surprised me with the pleasantness of her reaction to my statement that I could not and would not counsel about contraception. Of course, the patient I saw had had a tubal ligation after her delivery, rendering the question rather pointless...
The next thing for the day was grand rounds, which was a pretty decent account of the history of obstetric anesthesia. The presenter's occasional references to religion caused a bit of eyebrow raising on my part (I may have been reading too much into it, but it seemed like she set up a sharp contrast between the logical, humanistic view and the "religious" view which was exactly the opposite), but it wasn't a focus of the presentation. From there it was back to the clinical floors.
At one point when all three of the MS-3s were together in the central team area, one of my classmates asked me about what I had said on rounds about contraception, wondering if I could clarify a little about my moral stance and the reasons for it. In the end, it turned into a pretty decent discussion among the three of us; I'd like to think I did something to clarify my understanding of (and the Church's teaching about) abortion, contraception and sterilization. As a quick aside, if anyone has questions about any of those things, I'll be more than happy to speak with you about them.
After that came the true highlight of the day. I had signed up to participate in a 10:30 C section, but when I got to the OR at 10:17, I was just in time to see a real live miracle. One moment there was nothing but a hole in a woman's abdomen; not ten seconds later the surgeon was holding a baby girl. She was pretty blue (which I'm told is fairly common), but otherwise looked great. I couldn't see mom, but the look on dad's face told a story more eloquent than any ever written. It took a couple of minutes for the pediatrician to assess the infant (she was a breech baby, relatively cyanotic as previously mentioned, and needed a bit of a workup, which I was blessed to be able to help with), but when he was finally able to bring the child to her father...it'll have to suffice to say that no words exist that could do justice to the beauty of the moment. Everyone should have the opportunity to witness that at least once...it was an instant of truly pure wonder.
The rest of the day was pretty smooth, although nothing nearly so exciting as the delivery happened. I met a few more expectant mothers and nervous families, went to a lecture, and did the standard clinical-ish things. So far, two days in, things have been ok; I'll be hoping and praying that that continues.
That's all I've got for now...back with more updates tomorrow. Till then, peace and God bless!
The next thing for the day was grand rounds, which was a pretty decent account of the history of obstetric anesthesia. The presenter's occasional references to religion caused a bit of eyebrow raising on my part (I may have been reading too much into it, but it seemed like she set up a sharp contrast between the logical, humanistic view and the "religious" view which was exactly the opposite), but it wasn't a focus of the presentation. From there it was back to the clinical floors.
At one point when all three of the MS-3s were together in the central team area, one of my classmates asked me about what I had said on rounds about contraception, wondering if I could clarify a little about my moral stance and the reasons for it. In the end, it turned into a pretty decent discussion among the three of us; I'd like to think I did something to clarify my understanding of (and the Church's teaching about) abortion, contraception and sterilization. As a quick aside, if anyone has questions about any of those things, I'll be more than happy to speak with you about them.
After that came the true highlight of the day. I had signed up to participate in a 10:30 C section, but when I got to the OR at 10:17, I was just in time to see a real live miracle. One moment there was nothing but a hole in a woman's abdomen; not ten seconds later the surgeon was holding a baby girl. She was pretty blue (which I'm told is fairly common), but otherwise looked great. I couldn't see mom, but the look on dad's face told a story more eloquent than any ever written. It took a couple of minutes for the pediatrician to assess the infant (she was a breech baby, relatively cyanotic as previously mentioned, and needed a bit of a workup, which I was blessed to be able to help with), but when he was finally able to bring the child to her father...it'll have to suffice to say that no words exist that could do justice to the beauty of the moment. Everyone should have the opportunity to witness that at least once...it was an instant of truly pure wonder.
The rest of the day was pretty smooth, although nothing nearly so exciting as the delivery happened. I met a few more expectant mothers and nervous families, went to a lecture, and did the standard clinical-ish things. So far, two days in, things have been ok; I'll be hoping and praying that that continues.
That's all I've got for now...back with more updates tomorrow. Till then, peace and God bless!
Monday, August 30, 2010
...Well, I guess that wasn't so bad...
Actually, today could have been a lot worse. The day started off with an orientation by the course director and course coordinator, which was fairly routine. During one of the breaks, the course director asked me to hang around and chat for a minute. He told me that my beliefs would be respected completely during the rotation, but warned that there might be a few "hiccups" along the way. These, he told me, he wants to know about so that he can take appropriate action to prevent recurrences in the future. That was promising, if slightly ominous. After lunch, we began the clinical part of the rotation. I'm starting with labor and delivery (L&D), so two classmates and I reported to the central control area in the L&D suite. There we met our residents, who began to orient us to our surroundings. They seemed genuinely interested in teaching and began doing so immediately. One of the things that came up was post-partum rounds in the morning. The PGY-2 we're working with had compiled a one-page summary of key questions to ask, facts to include and abbreviations to know for progress notes. One of the questions specified that the patient was to be asked what kind of birth control she would be interested in going forward. A few moments later, I had an opportunity to go see a patient with the intern. On the way over, I took a deep breath and explained that I wouldn't be able to recommend or counsel patients about birth control. I frankly expected her to be annoyed, but she just nodded and basically said "Ok, just remind me that you haven't discussed that with the patients." She kept teaching, too, and didn't seem to treat me any differently. She even let me use the ultrasound (highlight of the day, definitely!). She and the PGY-2 also taught us how to read the fetal monitors, which promises to be a useful skill for the rest of the week. All in all, I was pretty happy with the residents and had a fairly good clinical experience today. The day finished with a lecture on peripartum care and the delivery process which was OK but pretty scattershot; the lecturer often went off on tangents before completing full thoughts. Oh well, given that the rest of the day mercifully went pretty well, I can deal with a disorganized lecture.
Anyway, that was day #1 on Ob-Gyn. All in all, I have to say it was a pretty decent day. If all my residents and attendings are like the ones I met today, maybe this won't be such a nightmare after all. We'll see how it goes...day #2 starts at 5:30 tomorrow morning. Back with more tomorrow evening; till then, peace and God bless!
Anyway, that was day #1 on Ob-Gyn. All in all, I have to say it was a pretty decent day. If all my residents and attendings are like the ones I met today, maybe this won't be such a nightmare after all. We'll see how it goes...day #2 starts at 5:30 tomorrow morning. Back with more tomorrow evening; till then, peace and God bless!
Sunday, August 29, 2010
A true "defining moment"
Actually, it's a "defining month," but that's just semantics. So here's what's going to happen...each day for the next month (while I'm on Ob-Gyn), I will be chronicling my adventures (and my misadventures) in this space. I will attempt to be as fair and objective as possible, but I will warn you now: I WILL make editorial comments on both the good and the bad. Also, in case you haven't gathered from the title of the blog (and from my bio), I am a practicing Roman Catholic and I have strong objections to abortion, contraception, and sterilization. Part of the objective in my taking time to do this each day is to give a firsthand account of how these issues arise in daily practice at Magee and to what degree a pro-life student will be affected by them.
All I can say now is that I'm terrified. I don't quite know what to expect...I've heard so many different stories from so many different people, and I have no idea what my experience will be like. I guess I'm hoping for the best, expecting the worst, and praying for the strength to stand strong and not falter. Orientation starts at 8 tomorrow...prayers would be tremendously appreciated, both then and throughout the rotation.
One last thing: I've decided I'm going to make a conscious effort to be as positive as I can, so as a theme song of sorts I've decided on one of my favorite hymns (sorry, this was the best version I could find on YouTube). Peace and God bless!
"And whether our tomorrows / Be filled with good or ill, / We'll triumph through our sorrows / And rise to bless Thee still!"
All I can say now is that I'm terrified. I don't quite know what to expect...I've heard so many different stories from so many different people, and I have no idea what my experience will be like. I guess I'm hoping for the best, expecting the worst, and praying for the strength to stand strong and not falter. Orientation starts at 8 tomorrow...prayers would be tremendously appreciated, both then and throughout the rotation.
One last thing: I've decided I'm going to make a conscious effort to be as positive as I can, so as a theme song of sorts I've decided on one of my favorite hymns (sorry, this was the best version I could find on YouTube). Peace and God bless!
"And whether our tomorrows / Be filled with good or ill, / We'll triumph through our sorrows / And rise to bless Thee still!"
Sunday, July 11, 2010
Things I've Learned...
I guess the best-laid plans end up in about the same place as all those good intentions... Anyway, I'm done with my first clinical rotation (surgery / anesthesia) and a week into my second (infectious disease up at the VA). Some things I've learned from my patients and colleagues during that time (edited to ensure HIPAA compliance):
-It's a terrific idea to play with a loaded firearm. Because it's not like the .357 hollowpoint will blow a sizeable hole in your leg that will require the EMS paramedic and I to take turns holding pressure on the wound for nearly an hour in the trauma bay. You're just lucky that the bullet and all the shards missed the femoral artery.
-It's been said before, but it bears repeating. There is one action that will inevitably land you in serious trouble. So whatever you do, avoid minding your own business. Whether you're standing on a corner or you're hanging out in some park, a bunch of dudes will seek you out and beat you and your buddy to a pulp. When you are telling me your story, I will be hard-pressed not to laugh out loud because, according to you, you were SOCMOB (if you don't recognize the acronym, go to the "Things I Learn from My Patients" link on my blog and read a few entries) when this all went down. The sad part? You're probably telling me the truth.
-If you're an kindly, mild-mannered older gentleman with diabetes and you whack your head on some sharp edge, by all means ignore the laceration and the egg-sized lump on your head and try to tough it out. No reason to trouble the doctors and nurses with something so minor, right? A week later, you'll end up coming in because the wound isn't healing and is purulent and you have a substantial hematoma besides. Bonus: you'll end up with sepsis and round out an evening by coding and being brought to the ICU (first of my patients to code on me...sure he won't be the last).
-As an FYI: if you're going to call an ID consult for a patient to make sure you know what course of meds he/she needs to go home on, you might want to do that BEFORE discontinuing the patient's antibiotics. And if by some chance they do get cancelled / lapse, it's probably not a good idea to wait for a week(!) before checking with ID to see if the meds should have been stopped.
There are more (both ironic and genuinely useful), but that's all I have time for tonight. Till next time, peace and God bless!
-It's a terrific idea to play with a loaded firearm. Because it's not like the .357 hollowpoint will blow a sizeable hole in your leg that will require the EMS paramedic and I to take turns holding pressure on the wound for nearly an hour in the trauma bay. You're just lucky that the bullet and all the shards missed the femoral artery.
-It's been said before, but it bears repeating. There is one action that will inevitably land you in serious trouble. So whatever you do, avoid minding your own business. Whether you're standing on a corner or you're hanging out in some park, a bunch of dudes will seek you out and beat you and your buddy to a pulp. When you are telling me your story, I will be hard-pressed not to laugh out loud because, according to you, you were SOCMOB (if you don't recognize the acronym, go to the "Things I Learn from My Patients" link on my blog and read a few entries) when this all went down. The sad part? You're probably telling me the truth.
-If you're an kindly, mild-mannered older gentleman with diabetes and you whack your head on some sharp edge, by all means ignore the laceration and the egg-sized lump on your head and try to tough it out. No reason to trouble the doctors and nurses with something so minor, right? A week later, you'll end up coming in because the wound isn't healing and is purulent and you have a substantial hematoma besides. Bonus: you'll end up with sepsis and round out an evening by coding and being brought to the ICU (first of my patients to code on me...sure he won't be the last).
-As an FYI: if you're going to call an ID consult for a patient to make sure you know what course of meds he/she needs to go home on, you might want to do that BEFORE discontinuing the patient's antibiotics. And if by some chance they do get cancelled / lapse, it's probably not a good idea to wait for a week(!) before checking with ID to see if the meds should have been stopped.
There are more (both ironic and genuinely useful), but that's all I have time for tonight. Till next time, peace and God bless!
Sunday, May 16, 2010
Starting MS-3 year!
Wow. Baptism by fire seems to be the rule as a third-year medical student. I've been on my surgery rotation for one week now. Generally, a day now consists of getting up at 4 so I can get ready and walk to Children's by 5:30, review charts and calculate I&Os till about 6:15, rounds with the chief resident or the fellow until a little after 7, then meeting with all of the on-service residents, fellows, and attendings to go over the flow for the day before heading off to the OR a little after 8. Of course, some days the flow is a little different -- there may be pathology conferences or morbidity and mortality (M&M) meetings to attend, or grand rounds, or some other variation. In any case, once everything else is done, the vast majority of the rest of the day is spent in the OR. Most days I spend 8 or 9 hours in there, and I consider it all time well spent. I usually end up leaving between 6 and 7 PM, picking up a new set of scrubs for the next day, and heading back home to eat, sleep, and get ready to do it all over again. The days are long, but the surgeons are beyond terrific (and I'll be honest, I never expected to make that comment about surgeons) and it's been a wonderful experience so far. Funnily enough, the best part of the whole thing (at least to this point) didn't even happen at CHP. After I finished at Children's on Friday (about 11:30 AM), I headed over to Presby for 3 hours worth of lecture. Note to whoever is in charge of the lecture sessions: turning the light off during a lecture filled with sleep-deprived medical students is probably not a good idea. For most of my classmates, once lecture was done for the afternoon, they had to go back to work for a couple of hours before the day ended. Not me. Instead, I faced one of the many rites of passage of the third year medical student and a true "defining moment": my first overnight call.
Next time: notes on my call night. Till then, peace and God bless!
Next time: notes on my call night. Till then, peace and God bless!
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