Tag Archives: health

Emergency Medicine from the eyes of a novice

18 Sunday May 2014

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Having a week of my Emergency Medicine experience under my belt, I’m sure I totally qualify as a veteran.

With my novice eyes-here are some observations and thoughts.

1. ER Docs aren’t your family docs or internists: Just yesterday I saw a lady with a slightly elevated blood pressure who’d been sent in by her visiting nurse because she hadn’t taken her medicine and needed a checkup. Talking to the patient revealed that she needed to follow up with her PCP who she’d not been able to see in a few months, and the nurse had figured that the ER would do that for her. The thing is the ER is a place for emergency care. If you’re having a heart attack, a stroke, delivering your baby, got hit by a baseball bat you need the ER. If you need a checkup and the wait times are too long at your PCP then the ER isn’t the best place for you. Between the traumas, the people with heart attacks and strokes and all the rest you’re not going to get the care you need.

2. Emergency Medicine is based on treating or ruling out emergencies: If you’re entering your EM rotation your attending wants two things from you on the differential- the bad things that could kill you and what it probably is. They’re far more worried about your chest pain being a heart attack and ruling it out before they send you home, consequently what could likely be something benign like a strained muscle can be treated once we’re sure it’s not a heart attack.

3. Not every patient in the ED will have (or needs) a diagnosis: As gratifying as most physicians find it to get an answer they can hang their hats on, the ER is often not the place for it. You’d like to, in an ideal world, figure out what’s going on with a patient but realistically when there’s a 3.5 hour waiting and 40 patients outside in the waiting room with a couple of traumas rolling in and the guy in bed 4 actively seizing you prioritize. That ends up leaving some of the things that need to be worked up on an outpatient basis as just that- waiting to be worked up outpatient. The ER is an incredibly expensive place to receive medical care as is the hospital in general so ED physicians try to judiciously use resources.

4. Sometimes people will hate you: The ER is a busy place, and there are always people you’ll be admitting. Often when you’re admitting someone to a service the resident on staff may be flabbergasted that your history and details didn’t include a more detailed family, social or physical exam- and that’s fair from their perspective. The problem comes, from an ED perspective a lot of those questions and answers won’t change an initial management. Secondly, anyone who’s causing your already busy workload to increase is likely not going to be your favorite person. For that reason, you may have the odd consultant who doesn’t jump for joy each time you call. That’s okay though. As long as the patient ends up being cared for.

5. Emergency Medicine is heavily weighted towards management:  Something I learned the hard way in a simulation session is that EM is a heavy management specialty. The traditional paradigm is for one to get a history, do a physician, collect an assessment and make a plan. In EM- you start with a plan then you keep going. And you modify your plan as you go. It seems rather obvious but if someone is coming in with chest pain that could be a heart attack you don’t want to spend 30 minutes getting a history and physical while the guy is actively losing heart muscle. Obvious it may be- it’s often challenging to make the switch from sitting and talking before you’re touching the patient and doing things to them. That said- 1 week in I’m already beginning to talk to, examine and treat my patients simultaneously.

 

In case you were curious I’m going to go into EM. Aka:

12 medical specialty stereotypes

 

 

 

 

 

 

 

 

 

Nihilism in Medical School

19 Wednesday Sep 2012

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So, I’ve been tossing this around in my mind for awhile.

The first two years of medical school are packed. You’re going through material at a breathless pace, learning more than you ever thought you could remember and trying to package and digest that material at ever quickening rates. You begin to feel like a robot, learning about an alien race- with the Krebs cycle, Beta adrenergic receptors, P hormones that feels satisfied with fatty food.

As you wade through the lakes of material, knee deep with a quicksand like consistency you change. Who you are takes on a different meaning- you begin to define yourself more so by the amount of work you’ve done, the things you’ve learnt and the hours invested. The things that gave you pleasure BMS (before medical school) still do, but they’re guilty pleasures. You find yourself living more so in the seven deadly sins than ever.

From gluttony…

To lust… (yes, I’m a HIMYM fan- though a full season behind)

Either way, you find yourself suddenly feeling this sense of emptiness, this lack of meaning, the fleeting feeling that nothing really matters and life is meaningless. You find yourself asking if saving a person’s life from an MI or a PE or any other part of the alphabet soup of conditions really means anything. You ruminate on the purpose of life, on the why, the what for and the who cares. (Or maybe that’s just me)

You look at your life, filled with pathology, viruses, bacteria, anatomy, physiology and the like; devoid of most everything else. And then you realize how vast a gulf separates you from the rest of the world- the seeming naivete and rosy-eyed view they have is hidden from you.

So, how do you cope? Well you find and create meaning. You give your life purpose, add to it. Make it worth something to yourself and to others. Personally, I exercise- I run, I lift weights and I work up a good sweat. Some people turn to religion, I’m an atheist. So, I turn to yoga. I cook making the very act of making food cathartic and therapeutic. Doctor Who is my new guilty pleasure, letting me escape to worlds beyond this one- and the quintessential loneliness of his character resonates, I imagine, with each viewer. Most importantly, I enjoy the support of an amazing group of people. From my family, friends, acquaintances and more.  I spend time with them all as often as I can- even if it’s remotely. I find writing handwritten letters to my grandfather to be a more candid way of communicating than when I’m sitting in the room with him sometimes.  I make my own meaning.

For that’s my view of nihilism- at least in medical school. Nothing means anything. At least not on its own. We give it meaning by what we choose to value, what we choose to believe and what we choose to cherish. So give your life some meaning today, give it a purpose. Live vicariously, purposefully and powerfully.

And while you’re at it, make someone else’s life a little better too. That never hurts.

In case you’re wondering what brought on this philosophical reflection and random spewing of words- its a book (“Hannibal and Me”). I highly recommend it more so since it uses some of my favorite quotes of all time:

“If you can meet with triumph and disaster and treat those two impostors just the same”

Ode to an ENT surgeon

09 Monday Jul 2012

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So over the last few days, I started shadowing an ENT surgeon. At 8:30 AM (we got lost trying to find the Operating Theater) we met him in his operating room where he had already started the first surgery.

As an ENT surgeon, he was responsible for ear, nose and throat. However, he was more of a rhinolaryngologist- he focused on the nose and the larynx. His surgeries that day, back to back reflected that. He started by removing nasal polyps- an unsatisfying surgery he said since they often return. Almost all his procedures were done endoscopically with a great deal of precision and speed. He often finished a *(more minor) surgery within forty minutes or an hour. As time progressed, we saw him remove a tubercular abscess from the vocal cords, a very finnicky looking surgery which would likely completely repair a man’s voice. We also saw him help reconstruct an ear with a missing incus (middle ear bone) which he fashioned from a piece of cartilage harvested from an earlier patient as well as a damaged eardrum from the fascia of the temporalis muscle.

We observed him doing over six surgeries in a little over six hours. It was amazing to watch and I’m going back soon!

30 seconds to Diagnose

21 Thursday Jun 2012

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Today we observed a day in the Outpatient Department of the Orthopaedic Clinic at the hospital I’ve been observing at. To give you an idea of the day, let’s start with this. 10 or 12 doctors saw over 250 patients in a little over an hour and a half.

Yes, that was 10 doctors and 250 patients. Yeah, that means they saw 25 patients each. In one and a half hours. Which means each doctor saw 16 patients an hour. Each patient got 3.75 minutes. Which seems higher than what we observed.

To paint the scene for you, we were sitting in the doctors office, in two chairs facing a eminent ortho surgeon. He was sitting in one chair, and the chair next to him was for the patient. Patient’s treatment cards were dropped off, and he called them in the order of the cards arrival. (Speaking of the cards, they cap patients at 250 per OutPatient Day- the first 250 get cards and subsequent treatment). So, the doctor would call out a name-  said patient would come in, and they’d sit down, by which time the doctor had asked them what the problem was. As the patient spoke, the doctor would be looking at their X-rays, CT scans, or MRI’s. Then, as they went along, the doctor would do a quick physical exam, without asking the patient to disrobe, scribbling in the card the whole time, tell the patient the treatment or tests required and send them off. Then, the next patient and so on. As time went along, the room got more crowded as patients started waiting within, other doctors would pop in for consults and more patients would be standing around while the patient being seen was being questioned about their ailments.

How different from the ideal patient encounters we’re taught in medical school. Forming a bond with your patient, open ended questions, exposing an area for a physical exam, vital signs, not to mention washing one’s hands all went out the window. The doctors worked like automatons, seeing patients one after another, sorting, treating, prescribing and diagnosing.

As it went along, we saw things we’d never heard of in the US. Skeletal Fluorosis, and Osteoarthritic Tuberculosis. Patients who had TB in their L3-L4 vertebrae, and patients who’s teeth and fallen out and bones were brittle due to excessive Fluoride. It was astounding, and though the doctor was swept off his feet, in minutes snatched between patients, or while the patient was sitting there we’d learn about these diseases and unique presentations of others.

I saw the benefits of the paternalistic model of physician-patient relationships once again. Patients who’d religiously follow the doctors lifestyle prescriptions. Anything they said, from exercise, to stop eating this, stop doing that, was met with a Ji, Doctor Sa’ab (Yes, doctor). The doctors would say, quite clearly, “This problem you’re having is due to your weight. Lose weight.” and the family would follow their orders to the letter.

Part of me considers that perhaps we should move back to a paternalist model of medicine, where the doctor knows best- you’ll solve the problem of non compliance. But, at the same time, doctors aren’t equipped to make a value judgement based on their patients lives. The only one who can do that is the patient. If I were enough of an idealist, I’d imagine that a perfect blend of the two exists to have neither’s drawbacks and both’s positives. I share no such hope- I just realize that some systems work in certain places and others work well in different places. It’s all about the culture and society you set it up in.

Thoughts?

A Year in Medical School: Reflections

12 Tuesday Jun 2012

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It’s almost been a full (calendar) year since medical school began. I’m officially a second year medical student- and this year’s been a momentous one. As I look back on it, here’s some of the things that I learnt along the way.

Fire Hose: Med School really is like a firehose you’re supposed to drink from. It’s high pressure, it’s intense, it’s humanly impossible to get it all down your throat. The idea is that you gulp, swallowing big but manageable amounts and manage to just keep drinking. That’s the challenge.

Intelligence may not help you: If you’re one of those people who managed to get through PChem class napping, or didn’t have to freak out about Biochemistry, or Immunology in college- you’re probably going to have a tough time in med school. ‘Cause no matter howsmart you are, there’s no way of intuitively getting a lot of the material that you’re supposed to learn. A lot of it’s just good old fashioned memorization. And you might as well resign yourself to having to learn to actually work- because the material may be made easier by your intelligence, but you’ll have to learn to work really hard in a disciplined manner- which for me has been terribly challenging.

Big Fish, Big Pond: Everyone in medical school will be a copy of you. Some will be better copies of you. One of my classmates, went for a 10 mile (I think) run, before taking his MCAT. A group of them get up every morning to practise crossfit before coming to class. Others still, run half marathons, or teach part-time, or design prostheses, or are involved in every single thing at the school. Prepare to deal with a lot of people who may do things you do- and to your mind better than you can do them. That’s the idea of moving from where you were the best (or the only one) to being a group that has an MCAT average of 34, and a GPA of 3.8

Find Your Bliss: Med School’s not nice to you (scratch that- life’s not going to be nice to you). It’s important to find what you love to do, your anchor to sanity and stress release and make it a part of your routine. For me, that’s exercise. If I don’t go to work out for a couple of days, I start feeling a little down. For other classmates (who are musically gifted, unlike my tone-deaf self)- it’s music. For others, it’s running, or cooking, or playing with their dogs or significant others… It doesn’t matter what it is- just find what you need and do it regularly.

Open Up: Med School seems to foster this intense belief that you need to hide your feelings as weakness that your classmates will use against you. Firstly, if that’s true- you go to a terrible med school. Secondly, nine times out of ten, what you’re feeling is common to a majority of your classmates. Try to share and see- you may be surprised.

Social Life: They say you can’t have a social life in medical school. They say a lot of things. They’re wrong. It’s important to have one- it’s essential to your state of mind, and it’s easy to do. Just don’t make your social life the center of your existence, and you’re good. For example, I go out for meals with friends fairly regularly. I go visit people when I can, and I go do fun things when I can.

Time is Short: I started med school a somewhat different person than I am today.  Who didn’t. I specifically mean in terms of a willingness to do stupid things. Let me explain. I started, not averse to, but not searching for adventure. Now, I’m setting up sky diving plans for the end of the summer. I’m hosting a Thanksgiving dinner at my house (it’s adventurous because I’ve never made a roast Turkey…), I’m trying to make international trips when I can, to see the world when I can.

Live with Someone: I’m someone who needs a degree of human contact from time to time. That’s called being a human being. Some people are capable of managing without any for a week at a time. Hats off to them- I can’t do that. So, I suggest living with someone. You can choose someone in med school or not. Pro’s are that they’re not going to throw a party the night before the anatomy final- unless they’re really fun. They’re going to get your stress, and you can help each other out. Cons are- they’re in med school. You need friends from outside of med school. I live with a classmate, and it’s great- but in that situation, find people not in medicine you can connect with.

Be better: Every day of your life, you should be better than the day before. It sounds exhausting. But it’s important. So, this summer, I’m learning to cook a few more dishes than I have in the past, as well as continuing to try to get into shape. Find what you’re weak at, or want to be better at, and go.

Don’t get doughy: I say this with the conviction of being a recovering Pillsbury Dough Boy. I started college, and over the course of college, put on 60 pounds. The first year of med school I lost 20 of those. A lot of my classmates gained instead. Med school’s stressful, and we all like to stress eat. So, try to exercise, stock up on healthy food, don’t eat at every pizza thing the school does…

Prepare to be Poor: I’m going to graduate medical school $250,000+ in debt. Accept that, and chant it to yourself. It’s not meant to scare you, and you’re meant to push it to the back of your mind. It makes failing out of med school an expensive proposition but they actively work to prevent that. Still, that leads me to…

…But don’t live like a pauper: Since you’re going to be $250,000 in debt, at least live a little bit. Don’t subsist on Ramen noodles and water, and don’t live in a cardboard box. But, at the same time, no need to mistake yourself for a Rockefeller. Moderation in all things, as Petronius said. Still, sometimes a nice dinner at a nice restaurant, with a good bottle of wine can make a week. Just saying.

If you’re a medical student, or were one, drop your words of wisdom in the comment section. Do you agree/disagree? What would you suggest?

If you’re going to med school, ask away.

And if you’re a layperson, thinking, wow, doctors (and doctors in pretension) are crazy- you’re right.

 

 

Thanksgiving over a cadaver

01 Friday Jun 2012

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Written in a narrative medicine group at Temple- this is one of my first pieces about medical school.

An interesting conversation occurred this Thanksgiving, when I went to visit a family friend. I found that automatically, as I spoke, my thoughts and words drifted back to my experiences these last few months. And so, over a dinner of turkey and mashed potatoes, I was talking about my cadaver. Some looked at me in horror, some in disgust, and some in a sort of awe. Most in some combination thereof. They asked me how it felt to have your hands deep in someone’s remains, if I felt queasy, if my hands shook. All the while there were murmurs, “inappropriate Thanksgiving conversation” and “Yeah, talk about cutting dead people like meat while I eat turkey.”

So in deference to some of those opinions, I spoke of cheerier subjects- health care reform, politics, football, cricket. Yet later, as we sat sipping Shiraz at the fireplace, our talk again turned to the morbid nature of my calling. I found myself giving accounts of the ED- of patients with AAA’s and sub-arachnoids; my experience in he psych ward where someone was brought in for having sex with a cat; and the psychiatrist’s gallows humor- asking what breed the cat was to see if the act constituted bestiality. I spoke of how comfortable my lab group became with our cadaver; leaning over and resting an arm on her as we scoured her abdomen for the superior mesenteric artery.

And as I spoke of all these things, I wondered where my past self had disappeared. The person who before med school would talk at length about Dostoevsky and Nietzsche; not aortic dissections and canker sores. I wondered at the ease and even the glee with which I had recounted stories of gun shot wounds and PCP addicts- of lives torn apart and limbs rent by the violence I was becoming accustomed to. I wondered, was I in the name of learning to “fix” humans, giving up my humanity?

This means of cloistering one’s mind, one’s emotions from one’s work is a survival mechanism in medicine. Or so I’ve been told. One must wonder- is the cost perhaps too high?