I wasn't thinking clearly - I jumped on the "cardiac arrest" bandwagon. The layfolks out there don't really see a difference between cardiac arrest (when your heart stops beating), myocardial infarction (the death of cardiac muscle, most commonly due to coronary blockage), and sudden cardiac death (death due to cardiac problems without prior warning signs). I was thinking about it today after our test, and I realized something - everyone who dies has cardiac arrest. The fact that that was what was reported does not mean that the cessation of his heart's beating caused him to die, as it sounds like in the media.
When we think about cardiac related causes leading to death in a 50 year-old black man, several things come to mind. First, being black is a risk factor. Next come obesity, diabetes, smoking, atherosclerosis, drinking, etc - all things that contribute to general cardiovascular disease. However, the King of Pop wasn't fat, nor was he - as far as we know - diabetic or in possession of any serious genetic risk factors. His parents and siblings are still alive, and if there was any familial link there, we'd know.
When we think about death in celebrities, however, our differentials shift completely. They tend to either die when they are old, as most people should; they die violently, in accidents and such; or they overdose. If, in fact, his death was related to heart problems (that no one seems to know about), and drugs, cocaine is known to be a serious cause of myocardial infarction in young folks.
Know what I think happened? I think the King of Pop has always been a little eccentric; while being incredibly talented and arguably the best and most beloved entertainer this side of antiquity, he probably wasn't entirely in touch with reality. Perhaps he signed up for all of those shows, thinking it would be fun - you know, recapture some of his former glory (because the last few albums he released were nowhere near as hot as Thriller). However, perhaps he then became overwhelmed with this 50-show prospect, and decided that life wasn't worth living anymore. I think he had his doctor, whom no one can find, helped the King of Pop end his life - and that we'll have a very interesting tox screen reported over the next few days.
Perhaps, though, it was just an accident.
I also grieve that we aren't grieving more for Farrah Fawcett. She was kinda hot back in her day; she did a lot for cancer and....you know.....sex.
Friday, June 26, 2009
Thursday, June 25, 2009
Stroke of Chance
I didn't' worry too much when the economy started crashing; I'm in school, and on student loans, and I'm not as affected as the rest of the world. Nor did I seriously worry when I heard about the monumentous bailout given to Bank of America, with whom I bank. Part of the reason I wasn't so worried is that they've always made my life much easier, so I figured they'd be OK. I've never had any hassles with them and their services were always easy to use - the tellers were always friendly and helpful. Their fraud prevention is top notch - when I first moved to Miami, I got several calls to confirm that I was, in fact, the person who had been using my card. Needless to say, they stay on top of things.
Here's where the strange string of coincidences starts. I just received my new bank card, and couldn't call in and activate it - like one is supposed to be able to do. So, sometime this past week (maybe Monday), Nicole and I went down to the bank to activate it and deposit some checks and such. That done, I didn't think much of it - until I tried to use my cards at Au Bon Pain yesterday on our lunch break from class. Both cards were declined. I figured it was no big deal - one card expired this month, and the new one hadn't been used yet.
When I got home, I called the bank, and in addition to their continuing to monitor my account for fraudulent usages, they'd received word that someplace I'd used my card had had a security breach - and that the integrity of my card information had been compromised. That being said, they'd put a hold on the card, effectively shutting it down completely. This was only a minor convenience; I realized that I'd much rather have them freeze everything than be nonchalant with my accounts. I was told that I could just head to the bank to pick up a temporary card, and that would be that. So once again, Nicole and I drove down to the bank, and I hopped out at about 4:50. Apparently, they were already closed, even though some folks were standing in the door talking. It still wasn't a huge deal.....but it was an uncomfortable, lost feeling; there was a disconnectedness, almost as if I was in a foreign country, didn't speak the language, and didn't know how long I was going to be there. I wasn't panicked, but I was uneasy.
Nicole and I were back at the clinic today, and I figured we'd just stop on our lunch break. I'd spent some time google-mapping out a route from the clinic to the Bank of America in Homestead (I'm sure I've talked about wonders and horrors of streetview). We actually got out of lunch a bit later than usual today; the patients were all very talkative, and just seemed happy to have someone to listen to them. Generally, if the patient only speak Spanish, I'll take the interview, and let Nicole do the physical exam. Today, we had chatty patients in all languages. Once lunch rolled around, we headed straight for the bank.
When we parked, Nicole was just going to sit in the car and study (which I probably oughta be doing right now - we have our first test tomorrow), but I told her that I had a feeling she should probably come in, and she did. I signed in and waited around for a few moments, until I was called back by a very amicable, very friendly middle-aged woman. She began asking me questions to verify my account, and then she opened up completely when it came out that I was a medical student - she loved doctors, and had the best of relationships with her personal physician. As she typed away, she started telling me about how she still had to lose 5 lbs from her mother's cooking in Colombia, etc. etc, that she thought lawyers were all arrogant, etc. We went to take my picture for the new card, and on the way back, I saw Nicole waving me over from the chairs in the corner of the room.
I'd seen her over there on the way to get my picture taken, and from what I could see now, I figured she'd just found some cute kid and was giving free reign to her pre-pediatric instincts. Such was not the case, though - there was a girl sitting in the chair beside her, shaking like a leaf (it almost looked like she was seizing) and looking absolutely terrible. The bank manager was holding her infant son, while Nicole talked to her. I quickly went over and tried to figure out what was going on. She was having some strange lower abdominal pain, had her arms folded in what looked like Trousseau's Sign, so the first thing I thought was hypocalcemic tetany - about which there was not a single thing I could have done. She wasn't breathing rapidly, but her pulse was rapid, and she said she felt nauseous, light-headed, and numb. Luckily, Nicole had seen her when she had - she'd been in line for the teller, and had started to lose her balance. The bank manager took her son from her arms and led her to the chair, where Nicole swooped in, announcing that she was a 3rd year medical student.
Once I got there, we continued gathering the history - it was fairly obvious that she was stable. They'd called her mother, they'd called 911, and now were were just trying to calm her down. The story that came out was that she was probably pregnant, but didn't want to be - she'd just broken up with the father ( same father as the other son), and was struggling to work enough hours to pay the bills - quite a bit for a 22 year old to deal with. What with the morning sickness and the anxiety over suddenly having 2 young kids with no father, she hadn't slept or eaten much for a week, about the length of time this had been bothering her. As we talked, she stopped shaking so much, but she almost swooned once or twice. Nicole and the bank manager comforted her when she burst into tears. The differentials included ectopic pregnancy and appendicitis, among other things, but finding out that she'd gone through the exact same thing with her first son was certainly nice to hear.
911 took their time getting there; several tellers remarked that they'd never taken this long before. When they came, they kind of brushed us aside - but Nicole and I managed to corner one of them. We didn't announce that we were medical students, but I'm sure that, 99 times out of a 100, they don't arrive on the scene and hear things like "bilateral tetany" and "afebrile without rapid respirations".
We grabbed a quick lunch at Chilli's after that, and all I could think was that, after this near-emergency, I was going to go back to a very calm, very bureaucratically burdened community clinic. I started thinking that maybe I'm supposed to do emergency medicine - granted, this was no huge catastrophe, but when faced with a person who was obviously not well, surrounded by a building full of people who are less qualified to deal with it than myself, I reacted right away and did what I could. My first thought, though, was "what can I do?" It's not like there's anything actually useful in my medical bag; it's just a student's bag. I've got a stethoscope and a blood-pressure cuff and a pen-light. I don't need any of them to tell that someone's not feeling well, or to see that they may need help. If someone loses consciousness, I don't need any of them either - there's really nothing in there that can help anyone, and I realized then, that the true and honest benefit of paramedics - their whole purpose, essentially - is to get sick people to a doctor.
The rest of the afternoon wasn't perhaps as boring as I'd feared; I saw a patient who'd had 3 heart attacks and a quadruple bypass - a hell of a lot of heart problems. Last week, Nicole attempted a cardiac exam on a fat woman, but really couldn't hear the heart sounds - with all that adipose flesh, it's understandable. This guy, though, was probably 150 pounds, 5'8 - not a large guy by any stretch of the imagination - and I couldn't tell what I was hearing when I listened to his heart. Part of it was that his pulse rate was 40 beats a minute - but it all made more sense when he returned the strangest EKG I'd ever seen. Seriously - he had PVCs and PACs, pathological Q waves, inverted T waves, wide QRS complexes - I'd never seen anything like it.
And now, with that exciting day done, I'm going to go back to studying about childhood rashes. Speaking of heart attacks, though, I'm very, very sad to report that The King of Pop is dead at age 50. Remember what I said about famous people dying in twos? Farrah Fawcett is gone, too. It's suddenly a somber day.
Here's where the strange string of coincidences starts. I just received my new bank card, and couldn't call in and activate it - like one is supposed to be able to do. So, sometime this past week (maybe Monday), Nicole and I went down to the bank to activate it and deposit some checks and such. That done, I didn't think much of it - until I tried to use my cards at Au Bon Pain yesterday on our lunch break from class. Both cards were declined. I figured it was no big deal - one card expired this month, and the new one hadn't been used yet.
When I got home, I called the bank, and in addition to their continuing to monitor my account for fraudulent usages, they'd received word that someplace I'd used my card had had a security breach - and that the integrity of my card information had been compromised. That being said, they'd put a hold on the card, effectively shutting it down completely. This was only a minor convenience; I realized that I'd much rather have them freeze everything than be nonchalant with my accounts. I was told that I could just head to the bank to pick up a temporary card, and that would be that. So once again, Nicole and I drove down to the bank, and I hopped out at about 4:50. Apparently, they were already closed, even though some folks were standing in the door talking. It still wasn't a huge deal.....but it was an uncomfortable, lost feeling; there was a disconnectedness, almost as if I was in a foreign country, didn't speak the language, and didn't know how long I was going to be there. I wasn't panicked, but I was uneasy.
Nicole and I were back at the clinic today, and I figured we'd just stop on our lunch break. I'd spent some time google-mapping out a route from the clinic to the Bank of America in Homestead (I'm sure I've talked about wonders and horrors of streetview). We actually got out of lunch a bit later than usual today; the patients were all very talkative, and just seemed happy to have someone to listen to them. Generally, if the patient only speak Spanish, I'll take the interview, and let Nicole do the physical exam. Today, we had chatty patients in all languages. Once lunch rolled around, we headed straight for the bank.
When we parked, Nicole was just going to sit in the car and study (which I probably oughta be doing right now - we have our first test tomorrow), but I told her that I had a feeling she should probably come in, and she did. I signed in and waited around for a few moments, until I was called back by a very amicable, very friendly middle-aged woman. She began asking me questions to verify my account, and then she opened up completely when it came out that I was a medical student - she loved doctors, and had the best of relationships with her personal physician. As she typed away, she started telling me about how she still had to lose 5 lbs from her mother's cooking in Colombia, etc. etc, that she thought lawyers were all arrogant, etc. We went to take my picture for the new card, and on the way back, I saw Nicole waving me over from the chairs in the corner of the room.
I'd seen her over there on the way to get my picture taken, and from what I could see now, I figured she'd just found some cute kid and was giving free reign to her pre-pediatric instincts. Such was not the case, though - there was a girl sitting in the chair beside her, shaking like a leaf (it almost looked like she was seizing) and looking absolutely terrible. The bank manager was holding her infant son, while Nicole talked to her. I quickly went over and tried to figure out what was going on. She was having some strange lower abdominal pain, had her arms folded in what looked like Trousseau's Sign, so the first thing I thought was hypocalcemic tetany - about which there was not a single thing I could have done. She wasn't breathing rapidly, but her pulse was rapid, and she said she felt nauseous, light-headed, and numb. Luckily, Nicole had seen her when she had - she'd been in line for the teller, and had started to lose her balance. The bank manager took her son from her arms and led her to the chair, where Nicole swooped in, announcing that she was a 3rd year medical student.
Once I got there, we continued gathering the history - it was fairly obvious that she was stable. They'd called her mother, they'd called 911, and now were were just trying to calm her down. The story that came out was that she was probably pregnant, but didn't want to be - she'd just broken up with the father ( same father as the other son), and was struggling to work enough hours to pay the bills - quite a bit for a 22 year old to deal with. What with the morning sickness and the anxiety over suddenly having 2 young kids with no father, she hadn't slept or eaten much for a week, about the length of time this had been bothering her. As we talked, she stopped shaking so much, but she almost swooned once or twice. Nicole and the bank manager comforted her when she burst into tears. The differentials included ectopic pregnancy and appendicitis, among other things, but finding out that she'd gone through the exact same thing with her first son was certainly nice to hear.
911 took their time getting there; several tellers remarked that they'd never taken this long before. When they came, they kind of brushed us aside - but Nicole and I managed to corner one of them. We didn't announce that we were medical students, but I'm sure that, 99 times out of a 100, they don't arrive on the scene and hear things like "bilateral tetany" and "afebrile without rapid respirations".
We grabbed a quick lunch at Chilli's after that, and all I could think was that, after this near-emergency, I was going to go back to a very calm, very bureaucratically burdened community clinic. I started thinking that maybe I'm supposed to do emergency medicine - granted, this was no huge catastrophe, but when faced with a person who was obviously not well, surrounded by a building full of people who are less qualified to deal with it than myself, I reacted right away and did what I could. My first thought, though, was "what can I do?" It's not like there's anything actually useful in my medical bag; it's just a student's bag. I've got a stethoscope and a blood-pressure cuff and a pen-light. I don't need any of them to tell that someone's not feeling well, or to see that they may need help. If someone loses consciousness, I don't need any of them either - there's really nothing in there that can help anyone, and I realized then, that the true and honest benefit of paramedics - their whole purpose, essentially - is to get sick people to a doctor.
The rest of the afternoon wasn't perhaps as boring as I'd feared; I saw a patient who'd had 3 heart attacks and a quadruple bypass - a hell of a lot of heart problems. Last week, Nicole attempted a cardiac exam on a fat woman, but really couldn't hear the heart sounds - with all that adipose flesh, it's understandable. This guy, though, was probably 150 pounds, 5'8 - not a large guy by any stretch of the imagination - and I couldn't tell what I was hearing when I listened to his heart. Part of it was that his pulse rate was 40 beats a minute - but it all made more sense when he returned the strangest EKG I'd ever seen. Seriously - he had PVCs and PACs, pathological Q waves, inverted T waves, wide QRS complexes - I'd never seen anything like it.
And now, with that exciting day done, I'm going to go back to studying about childhood rashes. Speaking of heart attacks, though, I'm very, very sad to report that The King of Pop is dead at age 50. Remember what I said about famous people dying in twos? Farrah Fawcett is gone, too. It's suddenly a somber day.
Sunday, June 21, 2009
Many miles
I just had my first week of clinicals - it brought a smashing and resounding end to all of the free time I'd thought I was going to have during 5th semester. We've got to be extra-prepared; no more of my customary wait-till-the-last minute, fly-by-the seat-of-my-pants attitude. On Sunday, Nicole and I drove out to see exactly where we were going to be for the week -we hopped on one of the many turnpikes, and made our way down to Cutler Bay, 20 or so miles from home. Strangely enough, we were going to be one place Monday and someplace else entirely the rest of the week. This made more sense when we arrived at one of the main buildings for Community Health of South Florida Inc (CHI), "a not-for-profit corporation partially sponsored/funded by the Florida Department of Children and Families". Having laid eyes on the place, we turned around and returned to south Miami.
Bright and early the next day (Monday), we showed up at CHI entirely too early; given the traffic-jam fiasco from the last clinical assignment, I thought it best to leave way early. The thing is, rush hour traffic in the morning is coming into Miami, and in the evening is leaving Miami - thus, heading the way we were, it was against the traffic both ways. If I recall correctly, we arrived roundabout 7:30 am for our 8:15 scheduled time. No matter - whereas I should have been studying, I dove back into Irving Stone's The Agony and the Ecstasy (No...it's not a trashy romance - it's the life story of Michelangelo). Around 8, we went and sat inside the community health center, waiting for the great gates to open. I really didn't like this part - there was a little seating area where folks had gathered, but separating them from the business end of the health center - doctor's offices and such - was locked gate, that promptly opened at 8:10 or something. It bothered me to see folks line up in front of the gate, as if they were waiting for the only bread they could count on all day.
As if often the case when I'm standing someplace wearing a tie, people came up and asked me when things were going to be open, etc. etc., assuming that I worked there. Happens all the time.
Once they opened the gates, Nicole and I headed back to the information desk. Once we found out no one knew where we were supposed to be, we waited with some other Ross students. Eventually, we were taken to the cafeteria, to await the 8:45 opening (I'm not sure I'm correctly recalling all of these specific times, but the chronology is fairly close) of human resources. Once they opened, we read tons of sheets of paper (auto-orientation), signed even more, and took a rather laughable cultural competency test. Following that, they herded us to security so that we could have new ID pictures taken - and then we were free. Actually, before leaving, we spoke with one of the head docs, who explained to us the imminence of universal care and medical-student-professionalism. At first, he seemed a little gruff, but it quickly became apparent that he loved teaching, and wanted to see us all succeed.
Since we were finished early (they actually didn't tell us when the orientation would end, but Nicole and I were prepared for an all-day affair), we decided to go and locate the clinic where we'd be stationed for the rest of the week. So, I whipped out my little brown book (which is, in actuality, only a wal-mart approximation of a mole-skin journal), opened it to my page of directions, freshly copied from Google maps, and we were on our way (the head doctor we'd spoken with, upon hearing where we were placed, told us how to get there, but I figured we'd better follow the directions). So we drove, and did our best to follow the lefts and rights and slight rights, eventually finding ourselves hopelessly turned around in an area full of farms and citrus trees that looked much more like deep south Texas than Florida. We eventually found the road that this clinic was supposed to be on, and followed it - until the road ended. You know something's wrong with your directions when you hit a "private road" sign. I called the clinic (which is actually closed on Mondays) and was switched over to the urgent care hotline. When I read off the address to them, they replied with a simple "Yup - that's where they are" - and that was that. We burned a bit more gas, circling the area to see if maybe we'd missed the clinic - maybe it was tucked in between....I dunno.....trees, or something.
Finally, we decided to just drive the other way down the street, and hope for better luck. And so we drove. You know, street numbers can be remarkably hard to figure out in non-residential areas of town - no simple mailboxes or numbers on the doors. We continued to the other end of this road, finally finding the clinic right where the road ended. *sigh of relief* As we headed back down the turnpike, what the doctor had said now made perfect sense - the exit he'd named was exactly the right one. Thanks, Google. I think we stopped and had lunch at Chili's - so much aimless wandering and bad directions had made me very cranky, and for that, coffee is the only cure. Coffee and margarita grilled chicken (no, there were no margaritas. Shame, that.).
So, the next day, we set out bright and early with all of the essentials - our neatly pressed white coats, fully stocked doctor's bags, notebooks, and a fistful of dollars (for the ubiquitous toll booths - theory about that in a minute). We got on the now-familiar expressway and were making great time, when traffic started to slow, just as we were getting up to the first toll plaza. Since Nicole's driving, she was very kind and let people move over in front of her when the lanes narrowed down from 4, to 3, to 2, to 1. Up ahead, the turnpike was entirely empty, and all traffic was being diverted off the nearest exit.
I glanced at the clock - we had to be there at 8:30, and it was probably 7:30 at this point, so I figured we'd just be able to hop back on the turnpike and still make it in good time (little did I know). We followed the traffic as best we could, figuring that the big semi-trucks in front of us would be getting back on the highway at the first available opportunity.
Red light. Inch forward. Red light. Inch Forward. Red light. Inch forward. By now, there was a growing sense of panic, more for Nicole than for myself, as we watched the minutes tick away. Being the positive person that I am, I told her not to worry, and that we'd get back on, and make it with time to spare. Red light. Inch forward. Red light. Inch forward. Red light. I promised her that if we weren't back on the turnpike by 8am, I'd call in to Ross and the doctor's office. Luckily, we had the Black Eye Peas new album, The End, to listen to. It's not as good as the first two.
As we moved along, it became more apparent that folks were driving a little aggressively - I've come to the theory concerning the way things work down here: you see, to get to where we were hopefully going, it was going to cost us $4.50 in tolls - every day. That's a lot of money when you consider how many cars are going through each and every day - highway robbery, if you will. However, because of this, I don't think there's such a value placed on speeding tickets. This is readily obvious - Nicole's a stickler for the speed limit, but we get passed like we're standing still - often by the cops themselves. The driving aggression is more than a theory, though - it's a fact; Miami has the second most aggressive drivers in the country. Add to that the fact that the roads resemble a map created by a slightly autistic 4 year old - what with the avenues, streets, courts, places, ways, and lanes that at times have no numerical relationship to each other whatsoever - and you get a frustrating driving experience. Especially if the turnpike is shut down. Especially if you're supposed to be starting a rotation that day.
Red light. Inch forward. Serious panic was setting in, as the little CHF-mobile (that's what we call the rented dodge charger - it sounds like an old guy whose struggling to breathe) putted along, and the minutes unmercifully drained away. I called the doctor's office, but they weren't open until 8:30 - the possibility getting there early to make a good impression was dissipating like morning fog. I called the Ross office - no answer. It was roundabout here that we remembered Nicole's new phone has a yellow-pages GPS capability - and so we began plotting our way once more.
We turned off one of the main road, following the traffic, which was finally picking up. Soon we were moving nicely, following the GPS-charted course that would hopefully bring us from our current destination to the clinic. All the while, I was still hoping that we could make it a few minutes early. We kept on driving (thank God I'd filled the tank the day before), cycling through the radio stations to see if there was any traffic update - any explanation I could feed back to Ross and the doctor concerning our predicament. We continued following the directions until we ran into another hope-dashing snag. Ahead, to our left, was another entrance to the turnpike - the one the GPS had been directing us towards - which was blocked off by a police cruiser.
So we kept on heading down the road, trying to decipher the best way to get to this place that we'd already had a hell of a time finding. The GPS thing updated the directions based on our currently location (and didn't yell at us when we got it wrong, like a Tom-Tom or Garmin). Beyond the reach of the turnpike, I eventually managed to plot out a course to our destination, which is no easy feat on a 1X1.5 inch screen; it's a trade off between actually seeing where you're going, and being able to read the street names. As 8:30 came and went, I was finally able to call and speak with the medical director at the clinic, and let him know that the turnpike was shut down, and we were on our way.
45 minutes later, we pulled into the parking lot, not knowing whether or not this doctor would be benevolent and understanding, or an old-school "yell-at-med-students-to-relieve-them-of-pesky-self-esteem" dragon. We headed into the clinic, and began profusely apologizing to the medical director - who told us not to worry, that the doctor was easy-going, and that, if ever again they shut down the turnpike, to just hop on US-1. Finally the doctor came out - more apologies - and she told us what she expected of us, and what had been her general experience with med students. *WHEW*. Unfortunately, I later found out that the reason for the turnpike closure was that an officer lost his life in a car accident.
The first patient we saw was a middle-aged woman with pulmonary nodules -who didn't speak any English. This being a community clinic, it attracted a lower socio-economic class, and many of them were Spanish speakers. So we sat in for a while, interviewing this woman, trying to remember Spanish words for things like "have you ever" and "lightheadedness". After a while, the doctor came in, spoke with the woman, and examined her. Then, she sent the woman on her way, and we moved on to the next patient. Even though I don't want to go into family medicine, I'm enjoying this rotation - I'm looking forward to going back next week. I enjoy talking with the patients, I enjoy how they open up when they see that I'm concerned (and some of them certainly just want someone to listen), and I enjoy the physical exams. Hearts are fun - I haven't heard any abnormal ones yet, but the retinas are cool - it's still new to me, and I'm trying to squeeze an eye exam into the visit of every diabetic or hypertensive patient. It can be a relatively quick one, and since the doctor is still trying to run a business, she's suggested that following our history, we try one (or two) physical exams with each patient.
I really like this doctor-she's very patient (with us), taking the time for teaching points. I have to get better about presenting cases, but with each patient, I learn (1) a new Spanish word or phrase, graciously volunteered by the patient as he or she realizes what exactly I'm flounderinginly trying to translate and (2) another significant question I should have asked, given the patient's presentation, as I relate the details of the case to the doctor.
We haven't seen anything terribly interesting so far, but I did manage to determine a case of drug-seeking behavior - in Spanish! While Nicole and the doc were off with another patient, I was sent in to do an interview. There sat before me a weepy, heavy-set woman, whose lower lip was trembling ever-so-slightly. I introduced myself, told her that I was a medical student working with the doctor who would be in to see her shortly, and asked if I could ask her a few questions. She agreed, and we got down to it. She was a walk-in, who had complained of a sore throat. Before going in the room, I'd learned that she was now reporting that she' fallen the previous week, and was in some pain. I went through all of the questions about the cold - since when, where does it hurt, runny nose, associated symptoms, what makes it better and worse, etc. etc, and finally got to her fall. She was sitting there in such obvious pain, that I reassured her the doctor was coming. This woman appeared to be very stably set on the verge of tears; tremble as her lower lip might, it never changed, and though she blotted her eyes with a tissue, I never saw the dams burst, like I was expecting. She told me about her fall, and how the tylenol hadn't made it better, but that her son had given her some..."what was it? Oxy....oxy something?" Oxycodone, I volunteered. "Yes - that's it". BIG red flag.
Generally, unless patients have drug-seeking behavior or chronic pain, they don't ask for serious narcotic pain meds by name. It didn't strike me as funny at the time - I firmly believed that she was in pain, but it was still very strange that this was specifically what she'd asked for. When the doctor and Nicole came in, I gave them a brief rundown, and watched the doctor's eyebrows elevate in surprise as I relayed the request. She then proceeded to examine the woman's throat and lymph nodes, and sure enough, she had some pharyngitis - the doctor said she'd give her something for it. As she turned away, the woman's lower lip began trembling anew, and she called out in a whiny little girl's voice. "Doctor....."
She then retold her tragic fall, and how nothing had cut the pain but the big guns - to which the doctor replied "No, you don't need that - I'll give you something else". And after only the smallest protest, that was that. Did she really have a cold? Sure - I'll buy that one. Did she fall? I'll buy that too. Was she in serious pain? I have no trouble believing that one - I'm not so jaded yet. So sure - she the pain was real -but I agree with the doc; she didn't need narcotics for a fall. I'm looking forward to going back next week.
On to other things - when I was first applying to med school, and even years before, I had it in my mind that I was going to be a psychiatrist. I had a somewhat difficult time choosing a major in undergrad, staying far away from the sciences (despite premed prereqs) and settling on anthropology. It wasn't until my junior year that I realized I cared nothing for pots or bones, and that everything I loved about the classes had to do with psychology. Thus, I switched my major and dove headlong into personality and abnormal psych (the really fun stuff), the history of psychiatry, doing brain surgery on rats, and rounded out my undergraduate education with a senior essay on exercise and motivation. One of the things I enjoyed most was my "psychiatry in the community" class, in which I spent time every week with severely emotionally disturbed adolescents living in a group home, journaling and researching about them all the while. After graduating, I took some time to speak with a psychiatrist/family friend, seeking to gain more insight into what it really meant to be a psychiatrist. I loved the idea of the human mind being capable of genius and madness, and of the oftentimes tenuous line between the two. I was fascinated by the power of a person's psyche to shape their reality, to morph and wall off parts of itself, and, despite advances in neuroscience, to continually deny explanation. However, like all red-hot love affairs, it was not meant to be; it was based on fantasy, and not reality.
The first hint that perhaps psych wasn't for me came when I was working for the health insurance company. I read several books about psychiatry - some of them resident level - and just had a blast with it. I like to say that I read psychiatric case-studies like other people read romance novels; they give me the warm-fuzzies. I soon learned, though, that psychiatry today is little more than drug management; the insurance companies pay the Ph.D counselors to do the talk therapy, cognitive behavioral therapy, and the like - while the psychiatrists are only paid to manage medications and avert emergencies.
That realization shattered the romanticism I'd built up around the idea of helping people wade through their mental illnesses to triumphantly burst forth on the other side, stepping out into fully-realized, stable mental health. The next blow came when I first began studying in the anatomy lab on the island. There was something so visceral and so exciting about the dissections, that I knew that whatever it was I chose to work with, I'd have to do something with my hands. I wasn't as gung-ho about the idea of surgery (as I may be becoming), but I think that was the death knell for my love affair with psych.
There have, however, been various little sparks of the former love - minor flings, I suppose. We went through behavioral science in my third semester, and one of the professors we learned from was a clinical psychologist - his outgoing, somewhat unorthodox though incredibly disciplined approach brought back all of the feelings I'd tucked neatly away. I was more mature, though - instead of thinking it might work this time around, I knew to just enjoy the fling for what it was, take my pleasure, and turn my attention back to pathology and pharmacology.
Now, I must make a distinction between two professors. I will identify neither of course, and I will attempt to pass no judgments - all I will do is tell you how I feel about my old flame when they're professing.
Professor B really doesn't seem to care. I get the impression that he sort of fell in with psychiatry, because no other girl would go out with him - because he couldn't match into any other specialty. I could be wrong, but hearing him talk about psychiatry is like listening to a public service announcement. In fact, his lectures are very similar - stay away from "crazy people - but if you encounter them on a test question, here's how you should answer". They're presented almost as if they're a bother; he holds no fascination for those with mental illness, as I once did. Of course, he knows far more than I, and far better understands the subtle nuances of the fracturing and warping of the mind. Why, then, is he not bursting with enthusiasm on one hand, or shuddering at the near-horrifying implications on the other? His lectures are not that interesting - they're the bare bones. How can someone make personality disorders boring? I suppose anything can be made boring, but I'm surprised that this professor is able to make something I once considered the goal of my life - into tedium.
Professor A does not treat patients - he treats people. His lectures are punctuated with empathy, as he tells us how difficult life is for these suffering people and their families, and how success stories still keep in touch with him. He is genuinely excited about psychiatry, and obviously cares for the people he treats. Rather than "taking what he can get", it seems that psychiatry is his first love, and his enthusiasm is always infectious. Hours of his lectures pass like minutes as I fondly recall why I was first excited about mental health - and the longer I listen to him, the more I begin looking for loopholes...maybe I'd settle for psych and neuro, and could then have the best of both worlds, like Oliver Sachs. The details feel like desiderata, rather than detritus. How can two such highly trained professionals approach their career - what should be their passion - so differently?
I don't know. I can theorize, but I can't know. No one knows a man but himself. I, for one, am still excited about medicine, and couldn't see myself doing anything else. Clerkships will be difficult, residency will be draining, and beauracracy will be frustrating, but hopefully I will never lose that sense of wonder and awe. This is medicine - it's not just a job.
Bright and early the next day (Monday), we showed up at CHI entirely too early; given the traffic-jam fiasco from the last clinical assignment, I thought it best to leave way early. The thing is, rush hour traffic in the morning is coming into Miami, and in the evening is leaving Miami - thus, heading the way we were, it was against the traffic both ways. If I recall correctly, we arrived roundabout 7:30 am for our 8:15 scheduled time. No matter - whereas I should have been studying, I dove back into Irving Stone's The Agony and the Ecstasy (No...it's not a trashy romance - it's the life story of Michelangelo). Around 8, we went and sat inside the community health center, waiting for the great gates to open. I really didn't like this part - there was a little seating area where folks had gathered, but separating them from the business end of the health center - doctor's offices and such - was locked gate, that promptly opened at 8:10 or something. It bothered me to see folks line up in front of the gate, as if they were waiting for the only bread they could count on all day.
As if often the case when I'm standing someplace wearing a tie, people came up and asked me when things were going to be open, etc. etc., assuming that I worked there. Happens all the time.
Once they opened the gates, Nicole and I headed back to the information desk. Once we found out no one knew where we were supposed to be, we waited with some other Ross students. Eventually, we were taken to the cafeteria, to await the 8:45 opening (I'm not sure I'm correctly recalling all of these specific times, but the chronology is fairly close) of human resources. Once they opened, we read tons of sheets of paper (auto-orientation), signed even more, and took a rather laughable cultural competency test. Following that, they herded us to security so that we could have new ID pictures taken - and then we were free. Actually, before leaving, we spoke with one of the head docs, who explained to us the imminence of universal care and medical-student-professionalism. At first, he seemed a little gruff, but it quickly became apparent that he loved teaching, and wanted to see us all succeed.
Since we were finished early (they actually didn't tell us when the orientation would end, but Nicole and I were prepared for an all-day affair), we decided to go and locate the clinic where we'd be stationed for the rest of the week. So, I whipped out my little brown book (which is, in actuality, only a wal-mart approximation of a mole-skin journal), opened it to my page of directions, freshly copied from Google maps, and we were on our way (the head doctor we'd spoken with, upon hearing where we were placed, told us how to get there, but I figured we'd better follow the directions). So we drove, and did our best to follow the lefts and rights and slight rights, eventually finding ourselves hopelessly turned around in an area full of farms and citrus trees that looked much more like deep south Texas than Florida. We eventually found the road that this clinic was supposed to be on, and followed it - until the road ended. You know something's wrong with your directions when you hit a "private road" sign. I called the clinic (which is actually closed on Mondays) and was switched over to the urgent care hotline. When I read off the address to them, they replied with a simple "Yup - that's where they are" - and that was that. We burned a bit more gas, circling the area to see if maybe we'd missed the clinic - maybe it was tucked in between....I dunno.....trees, or something.
Finally, we decided to just drive the other way down the street, and hope for better luck. And so we drove. You know, street numbers can be remarkably hard to figure out in non-residential areas of town - no simple mailboxes or numbers on the doors. We continued to the other end of this road, finally finding the clinic right where the road ended. *sigh of relief* As we headed back down the turnpike, what the doctor had said now made perfect sense - the exit he'd named was exactly the right one. Thanks, Google. I think we stopped and had lunch at Chili's - so much aimless wandering and bad directions had made me very cranky, and for that, coffee is the only cure. Coffee and margarita grilled chicken (no, there were no margaritas. Shame, that.).
So, the next day, we set out bright and early with all of the essentials - our neatly pressed white coats, fully stocked doctor's bags, notebooks, and a fistful of dollars (for the ubiquitous toll booths - theory about that in a minute). We got on the now-familiar expressway and were making great time, when traffic started to slow, just as we were getting up to the first toll plaza. Since Nicole's driving, she was very kind and let people move over in front of her when the lanes narrowed down from 4, to 3, to 2, to 1. Up ahead, the turnpike was entirely empty, and all traffic was being diverted off the nearest exit.
I glanced at the clock - we had to be there at 8:30, and it was probably 7:30 at this point, so I figured we'd just be able to hop back on the turnpike and still make it in good time (little did I know). We followed the traffic as best we could, figuring that the big semi-trucks in front of us would be getting back on the highway at the first available opportunity.
Red light. Inch forward. Red light. Inch Forward. Red light. Inch forward. By now, there was a growing sense of panic, more for Nicole than for myself, as we watched the minutes tick away. Being the positive person that I am, I told her not to worry, and that we'd get back on, and make it with time to spare. Red light. Inch forward. Red light. Inch forward. Red light. I promised her that if we weren't back on the turnpike by 8am, I'd call in to Ross and the doctor's office. Luckily, we had the Black Eye Peas new album, The End, to listen to. It's not as good as the first two.
As we moved along, it became more apparent that folks were driving a little aggressively - I've come to the theory concerning the way things work down here: you see, to get to where we were hopefully going, it was going to cost us $4.50 in tolls - every day. That's a lot of money when you consider how many cars are going through each and every day - highway robbery, if you will. However, because of this, I don't think there's such a value placed on speeding tickets. This is readily obvious - Nicole's a stickler for the speed limit, but we get passed like we're standing still - often by the cops themselves. The driving aggression is more than a theory, though - it's a fact; Miami has the second most aggressive drivers in the country. Add to that the fact that the roads resemble a map created by a slightly autistic 4 year old - what with the avenues, streets, courts, places, ways, and lanes that at times have no numerical relationship to each other whatsoever - and you get a frustrating driving experience. Especially if the turnpike is shut down. Especially if you're supposed to be starting a rotation that day.
Red light. Inch forward. Serious panic was setting in, as the little CHF-mobile (that's what we call the rented dodge charger - it sounds like an old guy whose struggling to breathe) putted along, and the minutes unmercifully drained away. I called the doctor's office, but they weren't open until 8:30 - the possibility getting there early to make a good impression was dissipating like morning fog. I called the Ross office - no answer. It was roundabout here that we remembered Nicole's new phone has a yellow-pages GPS capability - and so we began plotting our way once more.
We turned off one of the main road, following the traffic, which was finally picking up. Soon we were moving nicely, following the GPS-charted course that would hopefully bring us from our current destination to the clinic. All the while, I was still hoping that we could make it a few minutes early. We kept on driving (thank God I'd filled the tank the day before), cycling through the radio stations to see if there was any traffic update - any explanation I could feed back to Ross and the doctor concerning our predicament. We continued following the directions until we ran into another hope-dashing snag. Ahead, to our left, was another entrance to the turnpike - the one the GPS had been directing us towards - which was blocked off by a police cruiser.
So we kept on heading down the road, trying to decipher the best way to get to this place that we'd already had a hell of a time finding. The GPS thing updated the directions based on our currently location (and didn't yell at us when we got it wrong, like a Tom-Tom or Garmin). Beyond the reach of the turnpike, I eventually managed to plot out a course to our destination, which is no easy feat on a 1X1.5 inch screen; it's a trade off between actually seeing where you're going, and being able to read the street names. As 8:30 came and went, I was finally able to call and speak with the medical director at the clinic, and let him know that the turnpike was shut down, and we were on our way.
45 minutes later, we pulled into the parking lot, not knowing whether or not this doctor would be benevolent and understanding, or an old-school "yell-at-med-students-to-relieve-them-of-pesky-self-esteem" dragon. We headed into the clinic, and began profusely apologizing to the medical director - who told us not to worry, that the doctor was easy-going, and that, if ever again they shut down the turnpike, to just hop on US-1. Finally the doctor came out - more apologies - and she told us what she expected of us, and what had been her general experience with med students. *WHEW*. Unfortunately, I later found out that the reason for the turnpike closure was that an officer lost his life in a car accident.
The first patient we saw was a middle-aged woman with pulmonary nodules -who didn't speak any English. This being a community clinic, it attracted a lower socio-economic class, and many of them were Spanish speakers. So we sat in for a while, interviewing this woman, trying to remember Spanish words for things like "have you ever" and "lightheadedness". After a while, the doctor came in, spoke with the woman, and examined her. Then, she sent the woman on her way, and we moved on to the next patient. Even though I don't want to go into family medicine, I'm enjoying this rotation - I'm looking forward to going back next week. I enjoy talking with the patients, I enjoy how they open up when they see that I'm concerned (and some of them certainly just want someone to listen), and I enjoy the physical exams. Hearts are fun - I haven't heard any abnormal ones yet, but the retinas are cool - it's still new to me, and I'm trying to squeeze an eye exam into the visit of every diabetic or hypertensive patient. It can be a relatively quick one, and since the doctor is still trying to run a business, she's suggested that following our history, we try one (or two) physical exams with each patient.
I really like this doctor-she's very patient (with us), taking the time for teaching points. I have to get better about presenting cases, but with each patient, I learn (1) a new Spanish word or phrase, graciously volunteered by the patient as he or she realizes what exactly I'm flounderinginly trying to translate and (2) another significant question I should have asked, given the patient's presentation, as I relate the details of the case to the doctor.
We haven't seen anything terribly interesting so far, but I did manage to determine a case of drug-seeking behavior - in Spanish! While Nicole and the doc were off with another patient, I was sent in to do an interview. There sat before me a weepy, heavy-set woman, whose lower lip was trembling ever-so-slightly. I introduced myself, told her that I was a medical student working with the doctor who would be in to see her shortly, and asked if I could ask her a few questions. She agreed, and we got down to it. She was a walk-in, who had complained of a sore throat. Before going in the room, I'd learned that she was now reporting that she' fallen the previous week, and was in some pain. I went through all of the questions about the cold - since when, where does it hurt, runny nose, associated symptoms, what makes it better and worse, etc. etc, and finally got to her fall. She was sitting there in such obvious pain, that I reassured her the doctor was coming. This woman appeared to be very stably set on the verge of tears; tremble as her lower lip might, it never changed, and though she blotted her eyes with a tissue, I never saw the dams burst, like I was expecting. She told me about her fall, and how the tylenol hadn't made it better, but that her son had given her some..."what was it? Oxy....oxy something?" Oxycodone, I volunteered. "Yes - that's it". BIG red flag.
Generally, unless patients have drug-seeking behavior or chronic pain, they don't ask for serious narcotic pain meds by name. It didn't strike me as funny at the time - I firmly believed that she was in pain, but it was still very strange that this was specifically what she'd asked for. When the doctor and Nicole came in, I gave them a brief rundown, and watched the doctor's eyebrows elevate in surprise as I relayed the request. She then proceeded to examine the woman's throat and lymph nodes, and sure enough, she had some pharyngitis - the doctor said she'd give her something for it. As she turned away, the woman's lower lip began trembling anew, and she called out in a whiny little girl's voice. "Doctor....."
She then retold her tragic fall, and how nothing had cut the pain but the big guns - to which the doctor replied "No, you don't need that - I'll give you something else". And after only the smallest protest, that was that. Did she really have a cold? Sure - I'll buy that one. Did she fall? I'll buy that too. Was she in serious pain? I have no trouble believing that one - I'm not so jaded yet. So sure - she the pain was real -but I agree with the doc; she didn't need narcotics for a fall. I'm looking forward to going back next week.
On to other things - when I was first applying to med school, and even years before, I had it in my mind that I was going to be a psychiatrist. I had a somewhat difficult time choosing a major in undergrad, staying far away from the sciences (despite premed prereqs) and settling on anthropology. It wasn't until my junior year that I realized I cared nothing for pots or bones, and that everything I loved about the classes had to do with psychology. Thus, I switched my major and dove headlong into personality and abnormal psych (the really fun stuff), the history of psychiatry, doing brain surgery on rats, and rounded out my undergraduate education with a senior essay on exercise and motivation. One of the things I enjoyed most was my "psychiatry in the community" class, in which I spent time every week with severely emotionally disturbed adolescents living in a group home, journaling and researching about them all the while. After graduating, I took some time to speak with a psychiatrist/family friend, seeking to gain more insight into what it really meant to be a psychiatrist. I loved the idea of the human mind being capable of genius and madness, and of the oftentimes tenuous line between the two. I was fascinated by the power of a person's psyche to shape their reality, to morph and wall off parts of itself, and, despite advances in neuroscience, to continually deny explanation. However, like all red-hot love affairs, it was not meant to be; it was based on fantasy, and not reality.
The first hint that perhaps psych wasn't for me came when I was working for the health insurance company. I read several books about psychiatry - some of them resident level - and just had a blast with it. I like to say that I read psychiatric case-studies like other people read romance novels; they give me the warm-fuzzies. I soon learned, though, that psychiatry today is little more than drug management; the insurance companies pay the Ph.D counselors to do the talk therapy, cognitive behavioral therapy, and the like - while the psychiatrists are only paid to manage medications and avert emergencies.
That realization shattered the romanticism I'd built up around the idea of helping people wade through their mental illnesses to triumphantly burst forth on the other side, stepping out into fully-realized, stable mental health. The next blow came when I first began studying in the anatomy lab on the island. There was something so visceral and so exciting about the dissections, that I knew that whatever it was I chose to work with, I'd have to do something with my hands. I wasn't as gung-ho about the idea of surgery (as I may be becoming), but I think that was the death knell for my love affair with psych.
There have, however, been various little sparks of the former love - minor flings, I suppose. We went through behavioral science in my third semester, and one of the professors we learned from was a clinical psychologist - his outgoing, somewhat unorthodox though incredibly disciplined approach brought back all of the feelings I'd tucked neatly away. I was more mature, though - instead of thinking it might work this time around, I knew to just enjoy the fling for what it was, take my pleasure, and turn my attention back to pathology and pharmacology.
Now, I must make a distinction between two professors. I will identify neither of course, and I will attempt to pass no judgments - all I will do is tell you how I feel about my old flame when they're professing.
Professor B really doesn't seem to care. I get the impression that he sort of fell in with psychiatry, because no other girl would go out with him - because he couldn't match into any other specialty. I could be wrong, but hearing him talk about psychiatry is like listening to a public service announcement. In fact, his lectures are very similar - stay away from "crazy people - but if you encounter them on a test question, here's how you should answer". They're presented almost as if they're a bother; he holds no fascination for those with mental illness, as I once did. Of course, he knows far more than I, and far better understands the subtle nuances of the fracturing and warping of the mind. Why, then, is he not bursting with enthusiasm on one hand, or shuddering at the near-horrifying implications on the other? His lectures are not that interesting - they're the bare bones. How can someone make personality disorders boring? I suppose anything can be made boring, but I'm surprised that this professor is able to make something I once considered the goal of my life - into tedium.
Professor A does not treat patients - he treats people. His lectures are punctuated with empathy, as he tells us how difficult life is for these suffering people and their families, and how success stories still keep in touch with him. He is genuinely excited about psychiatry, and obviously cares for the people he treats. Rather than "taking what he can get", it seems that psychiatry is his first love, and his enthusiasm is always infectious. Hours of his lectures pass like minutes as I fondly recall why I was first excited about mental health - and the longer I listen to him, the more I begin looking for loopholes...maybe I'd settle for psych and neuro, and could then have the best of both worlds, like Oliver Sachs. The details feel like desiderata, rather than detritus. How can two such highly trained professionals approach their career - what should be their passion - so differently?
I don't know. I can theorize, but I can't know. No one knows a man but himself. I, for one, am still excited about medicine, and couldn't see myself doing anything else. Clerkships will be difficult, residency will be draining, and beauracracy will be frustrating, but hopefully I will never lose that sense of wonder and awe. This is medicine - it's not just a job.
Saturday, June 13, 2009
Friday night in Miami
I'm livin' la vida loca down here in MIA - here's the breakdown. We had a small group session Friday morning, concerned with the presentations and treatments of right-heart failure, cardiogenic shock, and atrioventricular block. It was nothing new, but it's always fun to to take some seemingly random facts I'd learned a while back and apply them to a patient I might actually see. Then there were some errands run - the necessary foodstuffs acquired - and we headed back to Ross for the first session of their Step Review course (it's called UMBR, but I've yet to expend the energy to figure out what that stands for).
The first few sessions will be taught by my favorite Russian immunologist - a bubble, slight woman who taught when I was at MERP. She has a way of teaching that minimizes powerpoints - in which she explains by drawing, for example, the various events in lymphocyte development - that just seems to make the information stick that much better. The micro and immuno taught on the island went all the smoother for me because of her introduction.
After that, the real Friday night fun began. Last week, our small group session centered around GI pathology - covering everything from eating disorders to diarrhea. One of the things we covered was the bingieng and purging behavior of bulimics (old hat since I was a psych major, but it was still like chatting with an old friend). And thus, yesterday, after class, I dragged Nicole back to Winn-Dixie for an precisely architectured binge, built of coffee ice-cream, magic shell, and those little pirouette cookie-sticks.
After 2 bowls of that decadent goodness while watching the season premier of the bachelorette (don't laugh - it's a fascinating study on dating rituals and media expectations in our society), I simultaneously polished off my biography of Genghis Khan and the last bottle of Killian's Irish Red.
This may, in fact, be the last time I get to relax - next week, I'm scheduled for 30 hours in a family practice clinic, on top of lectures, Spanish, and UMBR.
The first few sessions will be taught by my favorite Russian immunologist - a bubble, slight woman who taught when I was at MERP. She has a way of teaching that minimizes powerpoints - in which she explains by drawing, for example, the various events in lymphocyte development - that just seems to make the information stick that much better. The micro and immuno taught on the island went all the smoother for me because of her introduction.
After that, the real Friday night fun began. Last week, our small group session centered around GI pathology - covering everything from eating disorders to diarrhea. One of the things we covered was the bingieng and purging behavior of bulimics (old hat since I was a psych major, but it was still like chatting with an old friend). And thus, yesterday, after class, I dragged Nicole back to Winn-Dixie for an precisely architectured binge, built of coffee ice-cream, magic shell, and those little pirouette cookie-sticks.
After 2 bowls of that decadent goodness while watching the season premier of the bachelorette (don't laugh - it's a fascinating study on dating rituals and media expectations in our society), I simultaneously polished off my biography of Genghis Khan and the last bottle of Killian's Irish Red.
This may, in fact, be the last time I get to relax - next week, I'm scheduled for 30 hours in a family practice clinic, on top of lectures, Spanish, and UMBR.
Wednesday, June 10, 2009
A Taste of the Interim
Most med schools, I've heard, don't have a 5th semester. What I mean to say, is that they have no transitional semester - they dump you right into your clinical years directly following basic sciences. I'm all for the way Ross does it - I've heard that our students shine as beacons of clinical know-how among these US med students, and I guess this is the reason. For in this 5th semester, we're learning to be available at all hours, busy every single day of the week, and accommodating of schedules that are only finalized days before indispensable events. All sarcasm aside, they're holding us by the hand, and leading us from station to station, showing us what's expected of us, while giving us tons of help. Granted, this is all in favor of increasing their bottom line - but it's in my best interest, so I can't complain.
Remember that patient I went to see? The write-up (Doc-Jargon-translation: H&P) was due sometime Tuesday last week, and I've got to say we were lucky - first of all, having it due earlier in the week freed up a lot of time, and minimized conflicts. For example, I didn't have to follow a sleepless night (redolent of undergrad), spent feverishly revising and re-rechecking my paper with a 12-hour shift in the ER. It was nice to get it out of the way - I still don't know how it went, but at least it's over, and it sort of got me back into the study mindset.
Another part of their getting us ready for stuff is making sure that we're certified to be more than just in the way in the event we're in a hospital and something actually happens. 2 weeks ago, we went through our ACLS/BLS certification. I may not have all of the drugs down completely (amiodarone/adenosine/atropine), but I have some idea of what oughta be down. I can give CPR now, and perhaps even keep someone alive - I may in fact be legally obligated to stop and help if there was some emergency - which I'd do anyway.
The second part of that certification - BTLS -was much more fun. It started off with a rather uncomfortable discussion about domestic violence and violence against women in general. I suppose it's important to be aware of all the possible psychosocial situations surrounding our patients.... Anyway...we started off learning how to scrub in for surgery. To hear it told, surgeons are the dragons of the hospitals (and, according to today's personality disorder lecture, all narcissists), thus it is of the utmost importance that, if we are allowed the honor of watching a surgery, we be immaculately and aseptically prepared, lest we incur their wrath or - heaven forbid - the ire of the head OR nurse. I may be leaning a bit more towards surgery with every passing day (keep in mind my.....25 year absence from any OR...), so it was nice to finally learn how to do it.
After that came the fun stuff. I'd done suture clinics on the island, so wielding forceps and a hemostat was no strange chore; it was made especially easy since we stuck to interrupted stitches. They're easy enough to do, and they're you basic closure of a skin incision - unless we're talking plastics, in which case you don't want the scars to be seen, and will go for some skin glue or subcuticular stitches (my personal favorite.....of the three that I know....and have never done on any living person...). We used pigskin this time as opposed to the fixed flesh of generous people who willed their bodies to science - because, apparently, pigs are so similar to us in constitution. Next came the IV and shot-giving station. Not a whole lot new here - I'd never given shots before, but I've plunged enough razor sharp needles into veins to have some idea of what I'm doing. All of this paled in comparison to the IO needles.
IO (intra-ossesous) needles are generally employed in the event that an IV can't be established within 90 seconds, and, at its crudest iteration, looks like nothing short of pre-Roman torture. The whole point, though, before I get into the gory details, is that you need to give a patient medicine, or they'll die - and so, veins failing, you go straight to the marrow. These needles pierce the outer layers of the bone (most commonly the flat part of the tibia), establishing a site for the infusion of medications. The one they told us the Army used way back when looked a lot like a corkscrew and worked exactly the same - you pressed it against the skin, and use a corkscrew motion to drive the needle and sheath down through the skin, coring away the subcutaneous tissue as you drove this little steel spike down through flesh and blood, piercing the bone until you reached the center. Others weren't so bad; there was a little gun-typed-device, which you could load and shot directly into the bone. There's also a drill - quite literally, just like one you'd pick up from the hardware store, though without the bells and whistles. And you'd drill into the bone. We practiced on the drumsticks of chickens, and successful procedures were marked by an audible *POP* as the periosteum gave way, as well as the sudden disappearance of resistance once you hit the bone marrow. Very, very nice.
After that came a station about the proper insertion of foley catheters, birthing basics, and backboarding. Do doctors do all of this stuff? Not really. But I'm a long way from there, and, like I said, if ever I find myself in the middle of a code, or some other unforseeable emergency, I'll actually be able to help someone.
Another thing Ross is doing for us this 5th semester is sponsoring a medical Spanish class. I may work as a TA, I may not - I don't know yet. I do, however, know that, if our professor wants anyone to come up and sing and dance in front of the class in order to help everyone learn the parts of the body, she can count on me. Again.
Remember that patient I went to see? The write-up (Doc-Jargon-translation: H&P) was due sometime Tuesday last week, and I've got to say we were lucky - first of all, having it due earlier in the week freed up a lot of time, and minimized conflicts. For example, I didn't have to follow a sleepless night (redolent of undergrad), spent feverishly revising and re-rechecking my paper with a 12-hour shift in the ER. It was nice to get it out of the way - I still don't know how it went, but at least it's over, and it sort of got me back into the study mindset.
Another part of their getting us ready for stuff is making sure that we're certified to be more than just in the way in the event we're in a hospital and something actually happens. 2 weeks ago, we went through our ACLS/BLS certification. I may not have all of the drugs down completely (amiodarone/adenosine/atropine), but I have some idea of what oughta be down. I can give CPR now, and perhaps even keep someone alive - I may in fact be legally obligated to stop and help if there was some emergency - which I'd do anyway.
The second part of that certification - BTLS -was much more fun. It started off with a rather uncomfortable discussion about domestic violence and violence against women in general. I suppose it's important to be aware of all the possible psychosocial situations surrounding our patients.... Anyway...we started off learning how to scrub in for surgery. To hear it told, surgeons are the dragons of the hospitals (and, according to today's personality disorder lecture, all narcissists), thus it is of the utmost importance that, if we are allowed the honor of watching a surgery, we be immaculately and aseptically prepared, lest we incur their wrath or - heaven forbid - the ire of the head OR nurse. I may be leaning a bit more towards surgery with every passing day (keep in mind my.....25 year absence from any OR...), so it was nice to finally learn how to do it.
After that came the fun stuff. I'd done suture clinics on the island, so wielding forceps and a hemostat was no strange chore; it was made especially easy since we stuck to interrupted stitches. They're easy enough to do, and they're you basic closure of a skin incision - unless we're talking plastics, in which case you don't want the scars to be seen, and will go for some skin glue or subcuticular stitches (my personal favorite.....of the three that I know....and have never done on any living person...). We used pigskin this time as opposed to the fixed flesh of generous people who willed their bodies to science - because, apparently, pigs are so similar to us in constitution. Next came the IV and shot-giving station. Not a whole lot new here - I'd never given shots before, but I've plunged enough razor sharp needles into veins to have some idea of what I'm doing. All of this paled in comparison to the IO needles.
IO (intra-ossesous) needles are generally employed in the event that an IV can't be established within 90 seconds, and, at its crudest iteration, looks like nothing short of pre-Roman torture. The whole point, though, before I get into the gory details, is that you need to give a patient medicine, or they'll die - and so, veins failing, you go straight to the marrow. These needles pierce the outer layers of the bone (most commonly the flat part of the tibia), establishing a site for the infusion of medications. The one they told us the Army used way back when looked a lot like a corkscrew and worked exactly the same - you pressed it against the skin, and use a corkscrew motion to drive the needle and sheath down through the skin, coring away the subcutaneous tissue as you drove this little steel spike down through flesh and blood, piercing the bone until you reached the center. Others weren't so bad; there was a little gun-typed-device, which you could load and shot directly into the bone. There's also a drill - quite literally, just like one you'd pick up from the hardware store, though without the bells and whistles. And you'd drill into the bone. We practiced on the drumsticks of chickens, and successful procedures were marked by an audible *POP* as the periosteum gave way, as well as the sudden disappearance of resistance once you hit the bone marrow. Very, very nice.
After that came a station about the proper insertion of foley catheters, birthing basics, and backboarding. Do doctors do all of this stuff? Not really. But I'm a long way from there, and, like I said, if ever I find myself in the middle of a code, or some other unforseeable emergency, I'll actually be able to help someone.
Another thing Ross is doing for us this 5th semester is sponsoring a medical Spanish class. I may work as a TA, I may not - I don't know yet. I do, however, know that, if our professor wants anyone to come up and sing and dance in front of the class in order to help everyone learn the parts of the body, she can count on me. Again.
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