Lessons from a n00b - The end of the beginning

12 months of clinical rotations has swept by in the blink of an eye, and here I am, approximately 8 weeks away from taking the biggest exam of my life so far (my first licensing exam). It's a somewhat nostalgic time, and thus a good time for reflection. A few more lessons I've picked up along the way:

Lesson 1:
A lot of times, attendings say words that I try to avoid. For instance: the word titrate. Do most people understand what titrate means? I mean, even I have only dull memories of the word from my chemistry classes in high school. I've heard attendings and residents often tell a patient that we'll start them on a low dosage of a particular medication, then titrate the dose as we see how the patient responds. I suppose this isn't such a bad usage, since it's the physician side that does the titration. But sometimes they'll tell patients to "titrate" the dosage of over the counter medications, based on their response, and I always have to wonder if patients understand what they're telling them to do. It's interesting what words we do and don't use in various situations, and sobering to think how important words are in a field like this.

Lesson 2:
Neurology is kind of boring to me. Maybe that's because I don't understand the basics well enough, or maybe that's because it really is boring to me. Whatever the cause, I know for sure that it's not the field for me.

Lesson 3:
On a related note, I often felt, on neurology, that if we didn't know the exact reason a patient presented with particular symptoms, we'd chalk it up to a psychogenic etiology--which means that their brain, for some reason, believed that they were weak, or felt tingly and numb, or couldn't walk, or whatever, and so they experienced those symptoms--but there was no physical abnormality causing them. I had SO many patients who we concluded had psychogenic causes for their neurological symptoms, that now I'll always wonder if a person's neurological problems are psychogenic.

Lesson 4:
Contrary to what I believed at the beginning of this year, shelf exams really do get easier to perform on and study for as you take more and more. This is great news. The key, at least for me, was to repeatedly do practice questions until I got them all right...then rinse and repeat.

Lesson 5:
It's amazing how often you'll hear interesting stories from your patients, especially when you're treating outpatients. Almost every day when I was on family medicine, I'd meet a patient or two who had had interesting life experiences, had cool goals for the future, or were interesting in various other ways.

Lesson 6:
A year's worth of clinical rotations definitely teaches you a thing or two. It's amazing how much my confidence has grown, along with my knowledge base. This is a good thing.

Lesson 7:
Shingles comes in many shapes and sizes. So does mono.

Lesson 8:
I still have a lot to learn in terms of handling patients, especially those I would call "difficult." I was impressed by my family medicine attending's ability to entertain even the wackiest of patient requests without missing a beat. And she did it all while maintaining the patients' respect and trust. Hopefully this is a skill I'll gain with time and experience.

Lesson 9:
It's surprising how many people are vehemently opposed to the flu shot. It's also surprising how many people think that the flu shot "injects the flu into you" (not quite), a belief that implies they don't realize that most other vaccines also inject the disease-causing entity into you. For the record: the flu vaccine, and the majority of other vaccines, inject a dead virus, or an inert part of a bacterium, into you. The point is to teach your body to react against the disease-causing entity, without giving you the disease itself. However, since your body is supposed to launch a counter attack (which is what you're experiencing when you feel "sick:" fever kills bugs and helps the body fight infection better; runny noses are meant to flush out bugs living inside your nose, and so on), you often do end up feeling a bit sick after getting a vaccine, any vaccine. It sounds like more people get sick after getting the flu vaccine than after getting other vaccines, but that's probably because more people get the flu vaccine, more often, than any other vaccine. Basically, my point is that if I had to choose between getting sick after getting the flu shot, but never truly getting the flu, and actually getting the flu--I'd choose the shot every time. You should too. Just saying.

Lesson 10:
Time flies. I've said it before, and I'll say it again. Forgive me for the repetition. But these 12 months flashed by in an instant, and I'm sure the next 18 will do the same. At that point, I'll just be Dr. n00b.

Past Medical History

This morning I did an initial History and Physical on a patient who was new to my preceptor's practice. Before I went in to meet him, I learned his chief complaint (rash), and his name: Wilbur. Funny, I remarked to my preceptor. That's a pretty old-fashioned name.

When I walked into the room, I was greeted by a sandy-haired balding gentleman in a crisp white shirt, khakis, and boots. He was wearing too much cologne, which portended sleaziness, but his manner was respectful, professional. We talked about his rash for some time. It had been around for about 5 days, he was developing new spots every day, and they were slightly painful. I think it might be shingles, he said, Or Ramsay-Hunt Syndrome. Usually, patients with shingles complain of terrible pain, I told him. Have you been taking any medication for the pain? No, he said. I've dealt with a lot of really bad pain before, took extra strength Vicodin (Vikodayn, with his Texan accent) for a long time, and now I'm off all that stuff. My eyebrows raised at this hint of a significant medical history. Yeah, he said, I was taking morphine IV and everything, because of a plane crash I was in, but I'm getting off topic. Yes, I told him. We'll get to all that later.

A few questions later, we arrived at the Past Medical History, that fateful part of the initial H&P. Finally, he could tell me what had happened. It was a plane crash, he said, in the mid '90s. Right femur broken. Right arm nearly amputated. Right ulna lost proximally, right radius lost distally. Both shoulders dislocated, sticking out "right here," he told me, indicating his mid-clavicular region bilaterally. He was in the hospital for months, out of work for over a year, underwent 27 surgeries in that time and many more for the reflex sympathetic pain syndrome he developed as a result. He underwent intensive psychiatric therapy and rehabilitation to wean himself off of the megadoses of narcotics required to manage his neuropathic pain. Nearly twenty years later, he was fully functional, working and traveling without any hitches.

The most remarkable thing in all of this was that I never would have guessed at this incredibly traumatic history until he rolled back his shirtsleeves. The scars on his right hand were barely visible, and the hand was stupendously functional, considering the trauma it had undergone. The man sitting before me was shockingly unscathed, at least outwardly.

The interview over, I examined his rash, listened to his heart and lungs, and felt his distal pulses (To my surprise, the right radial pulse was intact). Then I smiled at him and said I'd be back soon with my preceptor.

In the hallway, I gave her a quick rundown of his rash and his storied medical history. A plane crash? she asked. Wow.

When we re-entered the room, after some cursory questions about the rash, she asked what I hadn't: So tell us about this crash. You've gotta tell us the whole story.

It's a long story, he started. (And long it was; we probably ended up listening to him for 30 or so minutes; at one point, his wife called the receptionist and asked why his appointment was taking so long.) Little by little, the details came out. A private plane, a complete engine failure right after take-off. 78 seconds from take-off to hitting the ground again in a terrifying crash. The other passenger 76 years old, hurt, but not as badly as our patient. Our patient lost a lot of blood. His blood pressure was 40 over nothing, a first responder said. Our patient, declared dead on the scene. Our patient viewing the entire scene from above, in an out of body experience.

And there were three people there, he went on. I remember them so vividly, but I couldn't possibly tell you if they were male or female. I just know they were there. One placed my head in their lap, another held up my feet, and a third held my left hand and fed me some cool water. Later, I saw those three people move the other crash victim's gurney into the life flight helicopter.

Once he arrived at the hospital, my patient remembers being wheeled down a cavernous hallway, with a white sheet covering him. He saw fluorescent lights and ceiling tiles flash past as his gurney progressed, until finally he passed through a set of double doors large enough for all of humanity to enter at the same time. On the other side, he saw his wife in her wedding dress, his kids in their Easter clothes, and his father in his coveralls lined up along the right wall. As he began sitting up to speak to his family, my patient felt a hand on his left shoulder, pushing him back down. A voice said, "Lie back down. There will be time to talk to them later."

Next thing my patient knows, he sits straight up in his hospital bed, lines and tubes coming out of many natural and artificial orifices. "Holy shit, God's hand was just on me," he says. From her chair to his left, his mother turned to him and said, "There you are, son. I was wondering when you'd come back."

In bits and pieces, my patient learns that he's been unconscious for days. The doctors and his family had no idea if he would regain consciousness, no idea if he would be the same man he was before. But he has and he is. Over the next year, our patient is "put back together" by a brilliant surgeon who gave him back full function of his right arm, hand, and leg. He suffers from reflex pain syndrome, taking megadoses of Vicodin and other opioids, just trying to stave off the pain. Eventually, he undergoes intensive inpatient rehab and gets off the narcotics for good. Years pass, and now he sits before us, mildly distressed by shingles.

By this time, over half an hour has passed, and my preceptor and I have exchanged many a quick glance communicating anxiety over the increasing length of this patient encounter. There are other patients out there waiting for us. But our patient says, "I'll just tell you one more thing, and then I'll finish the story, even though there's much more to it," and we say all right. He needs to tell this to us.

A couple years ago, our patient entered a local grocery store in search of a squeegee for his shower. "I know, you're wondering where I'm going with this," he assured us as our eyebrows raised skeptically. "But don't worry." After searching the store himself with no luck, our patient asked a little old man working at the store if he could help him find the squeegees. Why sure, the little old man said. But, he said, glancing at our patient's scarred right arm, what happened to that arm there? A plane crash, our patient said stoically. I bet that's a good story, the little old man said gamely. Why don't you tell me about it while we walk? And so our patient related the whole tale to this perfect stranger. By the time they reached the squeegee aisle, the tale was nearing its end. The little old man cleared some space on a low shelf, and they sat together while our patient told the part that bugs him the most. "Whenever people hear this story, they look at me (and here, he squinted his eyes in a way that said goshdarnit I'm sure of it) and say, God saved you for a reason. You have a purpose in this life. But that's the whole problem. I don't know what my purpose is. Here I am over 10 years later and I still don't know what I'm supposed to be doing. God never told me what He wanted me to do," our patient bemoaned. The little old man put his hand on the patient's shoulder, said "Yes I did, son," and walked off.

Here our patient choked up for the first time, and my preceptor and I exchanged a look altogether different from the ones before. This was a special moment, a moment neither of us was likely to forget. Moments like these remind me how lucky I am to be in the medical field. Being a physician means being let in on the most intimate details of strangers' lives. People trust you immediately, and tell you things they don't tell others, even those they love and know well. It's a position of immense power, and one that keeps me in touch with my own humanity. For this I am grateful.

The n00b Files - Weeks 1 and 2 of Emergency Medicine

Working in the EC of my school's county hospital was a welcome break, to a medicine-minded (as opposed to surgery-minded) girl like me, from being in the OR a lot. It was also an opportunity to learn yet more things, some of which I shall record here:

Lesson 1:

Sometimes patients flirt with you. This can lead to very conflicting emotions. On the one hand, these patients are often people with debilitating, chronic illnesses, and you can see that this is an exciting interaction for them--and they don't get very many of those. On the other hand, you kind of want to clock them super hard for hitting on you in your workplace.

Lesson 2:

Apparently, as women progress into the later stages of pregnancy, their bellies get so heavy that if they sleep on their right side, their inferior vena cava (IVC) is compressed by the uterus, and they can't breathe well at night as a result. So a lot of women who are pregnant end up preferring to sleep on their left sides or backs instead. I found this news a little upsetting, since I LOVE to sleep on my right side. Does this mean that if/when I am pregnant I'll have to switch sleeping sides? And if I do switch sleeping sides, will I find myself continuing to sleep on my left side after delivering, or will I switch back to my old habit? There's so much uncertainty in my future!!

Lesson 3:

It's amazing how quickly two days off from work can make a person feel lazy to the bone and utterly useless. It's also amazing how one 12-hour shift in a county hospital's ER can make a person feel like they've worked for days on end, even when they've just come off of 3 days of vacation.

Lesson 4:

Turns out I'm pretty interested in women's health issues. I saw a lot of interesting OB/gyn cases while working in the ER, and I found myself really wanting to follow up with those patients and find out what happened to them. Kinda cool.

Lesson 5:

Altered mental status sure can sneak up on you. I had a patient who just seemed to be in a lot of pain and probably had strep throat with complications. A couple hours later this patient started acting strange and forgetting simple things. BAM, the patient is transferred to an isolation room and I'm sitting around worrying that I have meningitis droplets all over myself and my white coat. Thankfully, the patient probably didn't have bacterial meningitis. Something weird was definitely going on though, and I totally didn't realize it at first.

Lesson 6:

A lot of people show up in ERs for completely non-emergent reasons. Some people just call ambulances when they feel lonely or are suffering from slightly-more-than-normal pain from their arthritis. While it can sometimes be gratifying to help these patients by giving them some human interaction (which I'm pretty sure is all they're really looking for), it can also be frustrating to see them taking up beds in the ER when patients with actual medically urgent ailments are still in the waiting room.

Lesson 7:

I put in an IV while I was in the ER! I know this isn't a lesson, but I was kind of proud of the accomplishment, so I decided to count it as one. Here's the lesson: with a good teacher (a really nice nurse showed me how), even a daunting task can be accomplished successfully. Of course, it didn't hurt that my patient had really nice veins, too.

Lesson 8:

If a patient complains of generalized throat pain that gets much worse when you push posteriorly on their hyoid bone, they might have epiglottitis, which is a pretty scary thing to have, indeed. Most young people can't get it, since it's caused by a bacterium that people have been immunized against for decades now, but patients 50+ are still at risk.

Lesson 9:

Learning the dosage of narcotic pain medications is worth one's while. I'm sure most people have it completely memorized by the time they finish med school, or at least intern year, but here it is:

for morphine, give 0.1 mg/kg

1 of Dilaudid is worth 8 of morphine

for Fentanyl, give 1 microgram/kg.

Keep in mind that Fentanyl is really short-acting, despite being very strong.

These lessons may have been a little boring...

The n00b Files - Week 4 of General Surgery

More things I'm learning:

Lesson 1:

An NG tube is used to suction/drain fluid that is building up in the stomach. I used to be under the misguided notion that NG tubes were used to feed people. Wrong.

Lesson 2:

When examining a patient with a diabetic foot, make sure to feel for their distal pulses if you don't want to feel totally silly when your upper-level comes in to check up on the patient.

Lesson 3:

It feels pretty darn cool when your team's patients run into you outside of their rooms and address you as "doc." It also feels a little scary; I'm always quick to correct them by saying, "Well, I'm almost a doctor.."

Lesson 4:

Working with a good group of teammates makes all the difference. The other medical students on my team are nice and funny and very accommodating when I need them to cover for me. I'm glad I started out my time in clinics with them. My sister told me that one of her favorite things about clinicals was getting to know many of her classmates much better than before. I'm really grateful for this, too, and I'm off to a good start!

Lesson 5:

Taking time to engage in your interests really improves your quality of life. I've started writing these n00b lessons, and I've also redoubled my efforts to publish my latest essay. Both of these pursuits give me great joy.

Lesson 6:

Finding beauty everywhere makes you pretty happy. I think bowel is beautiful. Weird? Yes. Good for my mental health? Arguably, yes.

The n00b Files- Week 2 of General Surgery

More words of wisdom from a certified n00b:

Lesson 1:

The nicest people during the day become terse and impassive when you're on overnight call with them. It's hard not to take that personally, especially when you're fresh out of pre-clinicals and normally only saw authority figures in the bright light of day (or in the dim light of the lecture hall, as the case may be). However, one should try to keep in mind the simple fact that people are cranky when they're sleep-deprived and/or hungry. Even doctor-people.

Lesson 2:

Planning ahead helps make your life a lot easier/happier when you're on clinicals. For instance, when you're going to take overnight call and know you'll have to sit through boring meetings/lectures the following morning instead of going home before rounds like you wish you could, make some coffee at home and bring it to the hospital with you. That way you don't have to spend an arm and a leg getting coffee to keep your sad little eyelids open. Also, throw an extra granola bar into your lunchbag so you can use it for breakfast the following morning.

Lesson 3:

I can now recognize the smell of dried blood. I'm not sure how I feel about that.

Lesson 4:

Chest tubes, while very important clinically (they're designed to suck out air, fluid, blood, etc out of the cavity around the lung, so that a collapsed lung can reinflate and get back to normal), are really freaking gruesome to put in. They're also pretty unpleasant to remove, but not quite as bad as the insertion process. Shudder.

Lesson 5:

I'm pretty scared of trauma cases, and tend to tense/freeze up when I'm in the shock rooms when a trauma comes in. However, I'm glad to report that I haven't felt nauseous or faint in trauma situations so far, and that's an improvement over some of my previous experiences. Hopefully writing about said improvement won't jinx me.

Lesson 6:

When asked if you're interested in a field in which you have absolutely no interest, a very diplomatic answer would be, "I think it's a great learning experience, but I don't think it's the field for me." Not that I've had the presence of mind to utilize that phrasing so far. Still, it's a good thing to keep tucked away in my brain.

Lesson 7:

Take care of any chronic and/or annoying health issues you may have ASAP. I've had this annoying cough for the last three weeks and it's really cramping my style. I'm pretty sure it's an asthma flare-up, but who knows. Anywho, I have an appointment to get it worked out tomorrow, and I'm very excited about that. Ailments begone!

Lesson 8:

Use an alcohol wipe to clean your trauma shears or stethoscope between patients, especially for the trauma shears. You never know when the dressing you're undoing covers a wound infected with MRSA, and it's best not to spread that from one patient to the next...for obvious reasons.