The n00b Files - Week 3 of Internal Medicine Wards

I've made it all the way through my Surgery rotation (a 3-month slog!) and I'm 4 weeks into my Medicine rotation (another 3-month slog...what was I thinking?). I'm still learning something every day, but I haven't been very good with recording my discoveries. So here's a braindump of lessons from the wards:

Lesson 1:

Your first shelf exam will crush your soul. Twice. First, you will leave the exam hall wondering if shelf exams are supposed to feel the way you feel at that moment. Then, you'll get your grade and wonder if you've been learning anything at all and/or whether you're cut out to be a physician or if you should just quit now with fond memories of pre-clinical success to look back on. Unfortunately, there's no way to go back and change your performance on your initial shelf, and as Abraham Lincoln (or someone) said, If at first you don't succeed, try, try again. Learning during clinicals is a whole different ball game from learning during pre-clinicals. All of a sudden, you have to not only work all or most of the day (and often 6 days a week), but also go home and study. It's kind of a cruel joke, really. But I figure if thousands of doctors have done it before me, I can do it too.

Lesson 2:

It's really difficult to deal with emotional patients. I like to think of myself as a compassionate person, but I find it hard to comfort a patient when he or she is crying, or talking about how rough life has been lately. It just feels very strange.

Lesson 3:

On wards, you'll probably work with pretty darn awesome scientists/clinicians without even realizing it. In the past week, I've worked with one doctor who was instrumental in discovering the connection between H. pylori and ulcers, who is now working on curing C. diffcolitis, and another who may have found a cure to Hepatitis C. No big deal. [For those of you not in medicine, those are both really big deals.]

Lesson 4:

I've said it before and I'll say it again--having a good team makes all the difference, for real. I have some pretty darn sweet interns, a friendly upper-level, and a couple of great fellow students on my team right now, and if I have to spend the day in the hospital, it's fun to talk to them while I do it.

Lesson 5:

A lot of the time, when it rains, it pours.

Lesson 6:

You're more likely to hear an Internal Medicine resident complain about a pointless admit (for instance, a patient with a history of cancer who's had a 12-hour history of nausea and vomiting and shows absolutely no signs of dehydration) than a very complicated patient. I found that pretty interesting: residents prefer not to have a really "easy" patient who doesn't really need to be hospitalized. They'd rather take care of patients who really need tertiary care, like a hospital provides.

Lesson 7:

When you're a medical student, you can't do a whole lot to help your patients. You can suggest lab tests or imaging studies to your residents, or perhaps pick up on the fact that a patient isn't receiving an important drug to prevent blood clots. But not really much else. What you can do is simple things for your patients, like getting them a toothbrush when they ask, or helping them take their hair out of a ponytail (which was placed when the patient was intubated). Patients tend to be pretty grateful for these sorts of actions, and if something so simple can brighten a hospitalized person's day, it's worth doing, especially when, as a student, you have many fewer constraints on your time compared to your residents.

Lesson 8:

That being said, there will always be patients who seem to need to complain about at least one thing every day. And sometimes you can't do anything to address their complaints, and you don't really want to stand around and listen to them. But like most people who are venting their frustrations, many patients benefit simply from having someone commiserate, if only for a little while every day.

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 1 of General Surgery

I'm now one week into my general surgery rotation, and I've learned a great deal in a short amount of time. Some of the knowledge is clinical, some is more in the life lesson category, and some is simply important knowledge about my own self. In the effort to record what I've learned and perhaps share it with those who might benefit, I've decided to start writing The n00b Files, filled with the edification I gain on clinical rotations. Here's to a great new start.

Lesson 1:

Everyone on the surgery rotation is nicer than the general reputation of surgeons would have you believe. I expected my interns, upper-level residents, and attendings to be much more brusque or impatient with me and my many mistakes, but nearly everyone has been nothing but kind and patient. It's a really nice thing.

Lesson 2:

You're going to mess up at first. It's inevitable. But the nice thing about a month-long rotation is that it gives you ample opportunity to learn from your missteps and do better next time. I think I'm finally starting to be useful to my team, and that feels good.

Lesson 3:

When you're scrubbing into a surgery, you might be asked if you want to double glove. If asked, say yes. Wear a blue pair of gloves as your "under glove," and a white/cream pair over those. The under glove is typically a half-size larger than the over glove, which was somewhat surprising to me, but now makes sense.

Lesson 4:

Being a surgeon basically consists of two main things: actual surgeries and wound care. Nobody becomes a surgeon because they enjoy wound care. Wound care is gross. So basically, if you're not super excited by surgeries, then you probably wouldn't be happy as a surgeon. I'm glad to report that having discovered this, I have confirmed that though surgery is a rotation that's enjoyable and informative, and though I respect surgeons a great deal, I do not want to be a surgeon. It's nice to know that my initial stance was correct.

Lesson 5:

I really, really, really enjoy the clinic setting. Today, during our first day of surgery clinic, I enjoyed myself more than I have throughout the last week. Which isn't to say the entire rotation has been a drag so far. It hasn't. Clinic has just been the highlight. Compare this to my interns' advice to avoid clinic at all costs, and you have further evidence that I am not made to be a surgeon.

Lesson 6:

Shockingly enough, waking up at 4:20 AM isn't all that horrible. It helps that the first few hours after I get to the hospital keep me very busy, so I don't have a chance to get sleepy. It also helps that I go to bed around 9 PM every night now.

Lesson 7:

While free food was the best thing ever during pre-clinicals, free coffee is the best thing ever during clinicals. I probably drink too much coffee now. I should start putting in less sugary creamer so that I don't get fat off of coffee alone...

Lesson 8:

The laparoscopic camera is pretty confusing to drive, and the medical student often has the privilege of driving it during surgeries. You can get some explanation of the camera prior to surgery, but try to ask someone to give you a quick run-down on how it works when you're scrubbed in. The scrub tech is a good resource for this (at least, that was the case in my experience), and knowing how it works will not only make you more useful during the surgery, but also make you feel like your upper-level resident doesn't think you're a total n00b.

Lesson 9:

It is truly a privilege to care for patients. It doesn't always seem that way, and I've found it difficult to interact with some of my sicker patients because I simply don't know what to say or how to act when they seem to be in such pain or so badly damaged. But when I finally did start talking to some of them (while changing their wound dressings, for instance), I felt like I was making my own small contribution towards their healing process. It's a nice thing.

Lesson 10:

Life is good when you're doing what you want to do. Weekends are wonderful for seeing friends you're not rotating with. There are always challenges to overcome and more mistakes to be made, but there's little to complain about.