My week has been good, but for some odd reason, I've been absolutely exhausted, which is odd, because the hours have been decently cush. I'm still loving the ICU; we were with this doc for only a week, but we'll be with another one, who'll also have some ICU time. I've mentioned my new fascination to other people, and my declarations have been met with horror; as if my morbid excitement is indicative of some character defect. Nevertheless, it is awesome - whether or not I'll end up as an intensivist is known to God alone, but if I go into internal medicine (a likely scenario), then I will be caring for those on the Precipice - those men and women, young and old, who find themselves perched precariously on the border between this life and the next, standing on a bare and windswept landscape, staring down into the yawning Chasm of Death.
For some, it's simply their time, and no amount of medical heroics can slow their inexorable leap. For others, however, as they find themselves drawn towards the Chasm, the long arm of medicine can pull them back. This happened on Tuesday or Wednesday with one of our doc's patients. We were rounding somewhere else when they called the code - we didn't exactly rush because Cedars has dedicated code teams - and by the time we got there, they'd cancelled the code. Our doc explained her medical history to us as we walked down the longest hallway in the world - she's a type 1 diabetic, blind, in kidney-failure, and bedridden, in her early fifties. They'd stabilized her, and a gaggle of nursing students had clustered around the room. It must have been the head nurse who canceled the code; he was explaining to them his reasoning, and as I walked into the room behind the doc, he turned his full attention on me, as if I was more than a third year medical student. According to Nicole, the nursing students turned their full attention on me as well.
I have no desire to silently convey incompetence. And so I posture a bit; I hope it isn't too much - I merely try to carry myself confidently. However, my ID says "observer" rather than "M.D.", and I always feel like I'm one question away from being exposed as someone who has no clue what to do in the ICU; a pretender. It's not really a front; I've just noticed that, occasionally, the words "I'm a medical student" evoke the same reaction from patients as "I'm going to cut your tongue out". They freeze up for a second, with a wide-eyed deer-in-headlights stare that occasionally makes me want to look over my shoulder to check for the Headless Horseman. Do I misrepresent myself? No....when I'm interviewing the patients on my own, I tell them who I am and that I'm a med student working with the doc (who will, of course be right in to see them, lest they fear that they're not going to get any sort of medical attention whatsoever but mine which, in their eyes, is nil) but if I walk into a patient's room with the doc, I'm just not going to do anything other than greet the patient, and listen to whatever I can. It's stressful; I feel incredibly inadequate not knowing what to do all the time. This is compounded by the drug names. In school we learned the generic names, and I learned them very well; once I know what it is, I have a good idea of what it should do and shouldn't do. The problem, however, is that in the real world, they use trade names -the patient knows what it is, of course the doctor knows what it is, and I'm in the corner with a dunce-cap, tapping away at my blackberry, trying to figure out that Crestor is rosuvastatin, that levophed is norepinephrine, or that Tinoretic is atenolol and chlorthalidone (those damn combinations get me every time).
But I learn more every day. There's hard work (which has been, perhaps, lacking this week; I am so tired of reading about diabetes), smarts, and a little bit of serendipity. While I was failing to force myself through a re-read of endocrinological disease, I found my way to one of the videos on the NEJM app - chest tube insertion. I watched it, figuring that if I wasn't going to dig deep into the different kinds of thyroid inflammation, I might as well learn something. And so Friday morning comes, we have a delicious lecture on major depressive disorder with a focus on pharmacology, and get to the hospital. We round a bit with the doc, the day passes, and what should present, but an opportunity for a chest tube! This poor old woman had been having some heart problems, and someone had dropped her left lung by putting in pacemaker leads. The surgeons who'd generally do this procedure were doing what they do (surging? Surgering?), and so our doc went to put it in - and it was almost exactly like the video.
Here is a trustworthy saying that deserves full acceptance: "See one, do one, teach one." This is a medical motto, defining the natural course of procedural knowledge and, in some cases, it is quite literal. This strikes fear into the hearts of medical students everywhere (it should strike fear into the hearts of patients) - but not me; I love it. Only.....I'm not going to just "see one" - I'm going to watch the doc do it, I'm going to youtube videos, I'm going to read about it compulsively, and I'm going to practice in my mind while pantomiming in the air. And then I'll do one, because they won't let us do anything we're not ready for, and they're not going to leave us alone. As the OB I rotated with said "Let me know when you're ready to jump in and do things; there's nothing you can screw up that I can't fix".
Nicole and I met up with PAgirl for lunch today, and then found ourselves drawn back to Dolphin mall (we were last there.....yesterday). I took along an article on the revised thyroid cancer guidelines, thinking I'd park myself at Starbucks and let the girls go play. What I thought would be a quick trip turned into an all day affair, as I searched for the perfect pair of Miami shoes - those loafer-looking shoes you wear without socks. I'll never give Nicole a hard time about shopping again - looking back, I am the super-shopper.
And now to the reason I snagged your attention: his name is Stevens Johnson. You see, there's a trend in medicine - according to correlations between board scores and specialties, the best and the brightest of medical students do not go into the hardest specialties, or those where their big, meaty brains can be of the most benefit for mankind - but rather, they go into specialties that pay the most *cough* plastic surgery and orthopedics *cough*, and so-called lifestyle specialties - those nice ones where you can reasonably expect to sleep through every night, epitomized by dermatology. Seriously - those derm guys have some of the highest board scores, and they deal with rashes all day. However, there is one hellishly feared complication; in fact, it's just about the only dermatological emergency. Rather than a single entity, it's a continuum, beginning with erythema multiforme, continuing into Steven's Johnson, and ending with toxic epidermal necrolysis. This is essentially an allergic reaction (generally to medications) in which the skin self-destructs, eventually looking like a horrific third-degree burn, and killing the patient. This is exactly what just happened to Manute Bol. I've never heard of it killing anyone, but I new that it could.
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