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!

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!

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!

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!! :-)

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!

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!

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!