Tag Archives: medicine

Bleeding by a Firehydrant

14 Friday Sep 2012

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Firstly, my apologies for the long silence. Microbiology as a block is quite high volume -capable of leaving one with little time for other things.

Now, a funny thing happened some days ago. As my roommate (also a second year medical student) and I left the house to go to the gym we saw someone lying on the side of the road next to a firehydrant. There were two women near him talking excitedly. My roommate, smart man that he is, asked “Was he shot?” Why does asking that question make a difference you ask? Because the first thing they teach you to do in an emergency situation is to make sure your scene is safe. If it isn’t, you leave and wait till it is- since your being in an unsafe scene increases the likelihood of there being two

The women respond that he wasn’t shot, that he had simply fallen over. So we started following our training- which took a few moments to recall. He was breathing, had a pulse and was non responsive. Thankfully by this time the ambulance had arrived. We helped the medics get him on the backboard, and as they’re putting him on the stretcher my roommate and I spitball ideas. Was it some kind of a stroke? Did he have a hemmorhage? Low blood sugar? Brain tumor? (Now you know we were grasping at straws…)
As the paramedics finish putting him on the stretcher and start collecting his items, one of them grabbed a slipper that had fallen. Then, they grab a paper bag none of us had noticed. He glances inside, chuckles derisively and holds it up for us to see. A almost empty bottle of vodka, which suddenly explained why he passed out and fell over.

“When you hear hoofs, think horses not zebras” a doctor once told me. Case in point.

Limits

19 Sunday Aug 2012

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A few weeks ago, as I rotated through neuro in India I was working with this really nice resident. Excited or at least tolerant of having me there he bombarded me with questions- quizzing me on trivia about neurology. I was asked to recall through the fog of months of other material the tests for cranial nerves, how to determine mental function, and where the lesion was if a person couldn’t move his eyes together…

As the quizzing progressed and I did decently (much to my surprise, since I was convinced I’d forgotten most of my neuro) he seemed to grow more confident of my abilities. He then looks me in the eye, says I need to go talk to the attending about how to disposition some patients. Take the histories and physicals of the next few patients, will you?

I said yes, and sat down, secure in the knowledge that I’d been fairly well trained during doctoring and in the ED in how to ask a patient questions. Interpreting the answers- not quite yet.

Secure in my little knowledge I sat and started talking to patients. One of the first, was an elderly gentleman who’d developed a neuropathy in one eye losing sight completely. He seemed to be in excruciating pain, rocking back and forth in his chair with moans of agony. Now, he and his relatives were freaked out- totally terrified since they had been told by the person who referred them to this hospital that the eye in question was lost and the other could go too. The resident, was looking at over 12 patients waiting who needed full neuro exams and histories- an arduous task at least. He had been a little short with them before.

As I started seeing them, they answered all my questions and showed me the MRI’s. To my semi-trained eye, there was a lesion. However I’d at times been convinced something was a lesion only to be told later that it was an “artifact”.

I had a rough idea in my mind that I knew what the lesion was. And I thought I saw it on the scan. I anticipated answering the residents questions, but I hadn’t anticipated the patients. He and his family started questioning me. For them, I was the “doctor”. A term that showed the promise of understanding what was happening and a way to fix or treat it.

They started asking me what was wrong with him. I started trying to answer their questions with a simple I don’t know. They couldn’t accept it, even when I explained that I was a “junior doctor” green to the ways of medicine. They kept saying, we understand that, but what do you see? Unsure of what to say, I stayed quiet, waiting for when the resident would return. I sat there, realizing my not answering their questions was prolonging their agony. At the same time I realized if I answered their questions I’d add to their agony if I was wrong.

All the arrogance and pride I felt in my taking an excellent history had faded, and all I felt was the realization that I was doing a disservice to this patient. So I left and left the rest of the exam to the resident.

Diagnosing my first stroke

09 Thursday Aug 2012

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I was spending a couple of days in neurology where the residents were kind enough to let me take histories of some of the patients and use their diagnostic imaging to try to diagnose them.

One of the patients I was seeing was describing his symptoms as weakness. As I spoke to him, I realized he had a slightly less pronounced naso-labial fold on the one side, as well as a slight slurring of his words. As I had him raise his hands and close his eyes, he had a slight drift of one of those hands.

A feeling of excitement grew within me as I realized that this could be a stroke. I looked at his MRI and noticed from it that he had a Middle Cerebral Artery infarct. Basically, the MRI showed me where his stroke was.

With a hint of a smile on my face and excitement in my voice, I told the resident who’d just entered the room that I thought our patient had a stroke. As he looked at my outstretched finger pointing to a spot on the image and heard my concise history, he nods and says good job. The self congratulation begins, as I chuckle that I remember something from my neuro block.

Then, I catch sight of my patient. My patient who heard my tone of voice (he didn’t understand English, which is how I was communicating to the resident) and the excitement within was hopeful of a cure. My excitement at taking a step forwards in my medical education came at a cost to my patient. The fact that I had done something of medical significance suddenly paled in the realization that my delight came from another person’s misery, that a step in my education involved perhaps the toughest time in this persons life.

It was sobering to be returned to Earth at that moment and to realize that I was facing the conundrum countless medical students had faced before. Every learning experience, each disease etiology we identify, each finding we learn to identify on imaging comes from a patient suffering the consequences of that disease. The more bizarre or rare a condition is the “cooler” it is for us, and the more heart rending it is for the patient.

Perhaps the resident understood my dilemma, or perhaps he was overworked. Getting up, he told me to start explaining it to the patient. So, sitting in that office I began to explain to my patient that his life was going to be forever altered. And I hoped that my perceived glee at making the discovery would be tempered by the gentle way I was trying to break it to him. That’s something I’m afraid I’ll never know.

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!

I want a surgery

04 Wednesday Jul 2012

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So a few days ago there was a patient who’d come into the out patient department to see the orthopedist we’d been shadowing. She was a follow up patient, who as soon as she walked in repeated her complaint. Let me give you an idea of how it sounded.

“You should do surgery”

“What surgery?”

“My knee hurts.”

“So should I replace it?”

“Well, I cant walk”

“That doesn’t mean I should do surgery”

“Well, why can’t I walk?”

“Because you’re overweight…. Lose weight…”

That was the gist of the conversation. And then, the patient smiling sheepishly left.

It’s a conversation that I can’t imagine being repeated in a US hospital. It’s a conversation unique for being so blunt and requiring a certain relationship between patient and doctor that is present in India, but harder to find in the hospital.

Is that something you’d prefer to hear? Or do you prefer the system presently in place in the US.

How to Deal with Pharmaceutical Reps

03 Tuesday Jul 2012

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I recently discovered, courtesy of one of the doctors I’ve been working with here in India a brilliant way of dealing with pharmaceutical representatives. Let me lay it out for you.

In an outpatient department where one is supposed to see about 25 patients in a little over an hour, as patients crowd into the doctors room surrounding him from all sides the doctor has pharmaceutical reps push their way through. As they approach the table, they place some sort of literature, cards, pamphlets etc. on the already crowded desk and begin to whisper in his ear. As soon as this happens, the doctor closes his eyes. Once, a pharma rep asked why he did that. His response, not bereft of sarcasm was that he was closing his eyes to better focus on what the rep was saying.

He listens usually nodding along, and bids the pharmaceutical rep goodbye. As the rep leaves, he balls up the materials and throws it over his shoulder, or sweeps it to the floor. Now I know what you’re thinking- littering is just terrible. But, I quite like the way he chooses to deal with these reps.

He refuses to be nudged in one direction or another, treating his patients in the way he knows best at minimal cost to them while providing maximal benefits.

How would you like to deal with a pharma rep? Or do you think the way this doctor functions is wrong?

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?

Of Broken Spines and Missing Metacarpals: Observing at an Indian Hospital

20 Wednesday Jun 2012

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Over the last few days, I’ve started observing at one of India’s most advanced, most crowded and most over-utilized and understaffed hospitals. I’m starting in the Orthopaedics department, so in the last two days I’ve seen things clinics, outpatient departments and a couple of surgeries- including two spinal fusions (or spondylosyndesis- for the technically minded) as well as the beginning of a surgery involving a severely cut hand which was spurting blood from a severed radial artery branch.

It’s a different world in this hospital- there are patients in all directions, waiting in hallways, on floors, in every situation imaginable. The patients are waiting patiently, waiting for a doctor to come through quietly enduring whatever they’re suffering. As the doctors come through with a bevy of senior and junior residents on rounds they spend barely a minute talking about a patient. They don’t talk to the patient, nor do they attempt to explain anything. They discuss it amongst themselves, reaching a decision on how to treat the patient, with a look at the diagnostic imaging, a glance at the wound, and a few words from the resident who looks after the patient. The first few patient interactions, I was shocked- how could one responsibly be doing this, I wondered? Then, I saw the number of patients. Day one, we rounded on over a hundred patients in a little over an hour. After that, each resident had to run to get to doing all they had to do- be it treating, testing, surgery or whatever. As they do so, they speak to their patients, telling them what decision has been reached, how they will be treated and an estimation of when.

These residents and attendings are treated by patients and patients families with a reverence that is amazing to see. The paternalistic philosophy of medicine is very much alive and well here- the patients are not consulted about their decisions, they are simply told. Decisions are made and communicated to the patients, and for a vast majority of them, they seem to like it. The physicians act and are treated like rockstars, with admiring glances and awe in their wake. It’s a heady combination this, and I can admit to getting swept up in it as I go along. But, for one, I feel like a bit of a fraud in that white coat- I’m a second year med student, not a practicing orthopaedist and I still have a little trouble reading CT scans. So each time a patient comes up to me, with a look on their face that grants me that same level of awe, I feel not yet worthy.

Day two, as we rounded, I saw a woman badly injured, lying on a gurney unconscious. We didn’t speak about her or discuss her, nor did we even acknowledge her presence. But as I walked by and looked her mother and sister in the eye, I felt this sudden urge to speak to them- not for the minimal medical advice I could have given, but to perhaps offer comfort in a difficult time. I understand why it can’t be done in the restrictions one works under in this type of system. Yet it makes me wonder if doing so for years will make one detached and cold to the people one came into medicine to treat.

Each day more patients requiring an OR come in than can be treated by the staff and resources available. So, the backlog grows day by day. The numbers of patients who need closed reduction grows in such leaps and bounds, that they require a day in the hospital but stay a week.

That being said, I’ve seen some of the faculty do amazing work- surgeries with a cleanness and economy of time, energy and resources that speaks of their comfort and competence. At the same time, as you walk the floors of the wards, you see what they’re up against- the sheer numbers that could overwhelm their prodigious skill, and the constant fear in such overwhelmed hospitals- infection. I can only imagine how they must feel, their pride in a perfect spine repair or reduction being reduced to bitterness when their patient dies from an infection acquired due to too many people in too small a space.

I will try to post regularly as I go along, but that’s assuming time permits.

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.

 

 

The Joys of Travelling- Random Selection

09 Saturday Jun 2012

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So, for the first time, as I’m taking someone along on a trip I’ve done at least 8 times, walking through Newark I reach security where I’m supposed to go through the Body Scanner machine. I’m not the biggest fan of the concept, but I choose not to make a fuss. I walk through, and after, as I’m waiting the guy tells me that the image was blurry and they need to search me. No problem I reply, and we walk to a private room. As we enter this private room, one of the two gentlemen tells me that the area that was blurry was my crotch.

 

At this point, I’m just shaking my head and saying to myself, of course it was. So, I assume the position and my search began. Then, as he’s searching my back, smartass that I am, I told him that my back was really hurting and would he be able to just press a little harder while he was searching my back?

 

I’m pretty sure the poor guy jumped- he started saying “Whoa man, that’s just so inappropriate” and slightly chuckling. I apologized, laughing, telling him that I was a med student and I had picked up this bad habit around patients. So, he continues to search me. Funnily enough, as he was “lightly grazing my groin region with the back of his hand”, he seemed  more uncomfortable than I was with the whole thing. Later, I realized that this was a bit of a switch. Usually, I’m the one who’s slightly uncomfortable around standardized patients as they tell me to take a femoral pulse or something- while they’re perfectly comfortable. The role reversal I experienced that day was interesting to say the least.

Now, to be fair, I got through that experience with minimal effects. However, I did find myself thinking that the whole process was unnecessary. Body scanners have been found to be minimally effective at what they do (Refer to: http://travel.usatoday.com/flights/2010-12-27-bodyscan27_ST_N.htm and http://www.eturbonews.com/29190/air-passenger-group-body-scanners-would-not-detect-underwear-bom). Further, they led to the need for me to be searched in private (in a somewhat invasive and demeaning way), my ID photocopied, my luggage to be opened and searched (without my knowledge) for no apparent reason other than a blurry crotch?- none of which happened at any of the less technologically advanced airports where I walked through a metal detector. And don’t get me started on the attitude of the TSA agents in comparison to both Heathrow and Indira Gandhi Intl. agents- they were by comparison rude, brusque and dismissive.

So, long story short, I’m going to be writing a bit of a novella to TSA, and the House and Senate urging them to reconsider using this technology. Thoughts?