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!

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!

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!

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!

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!

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!

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!