I’m going to interrupt my progressive catching-up to report a seriously incredible, I’m-really-going-to-be-a-doctor experience.
I was doing a shift in the Pediatric ER the other night, seeing a lot of lacerations and a cute little girl whose mom was afraid she had swallowed a piece of plastic, when a resident told me that 3 traumas from a car accident were en route and suggested I go over to the Critical Care ER to watch. I ran into another medical student there, and together we stood and watched in awe as a stretcher came barreling in. The patient was a young man, lying there naked and intubated as doctors and nurses swarmed around doing CPR, inserting IVs, and giving medications. He had suffered a traumatic brain injury, though, and ultimately the resuscitation attempts were unsuccessful.
As I walked away realizing that I had just witnessed my first death, we went to a nearby room where another team was working on a young girl. A resident turned to us and said, “Med students, if you’d like to do compressions, now would be a good time to gown and glove.” We scrambled to grab gloves and plastic gowns amid the chaos, then stood in line behind the guy doing chest compressions.
Chest compressions are not easy; it requires some force to push someone’s chest down far enough to force the heart to pump blood. A person can only do them effectively for so long before tiring.
When I moved into position to relieve the person before me, I stepped up onto a little stool wondering, How is this going to feel on a real body? The answer is that the dummies used in CPR classes provide an eerily good approximation of how hard you must push. I pumped from my shoulders, bending at the waist to put my whole upper body into the effort. Inches from my fingers, someone had cut between the ribs and was suturing a chest tube into place. To my right, someone worked the bag to force air through a tube into her lungs. There was blood everywhere. I realized that I was the only one not wearing scrubs, since I had worked in the clinic that day. I’m wearing Ann Taylor. At a trauma code.
When I tired, someone else took over and I stepped aside to watch. Eventually they called this one, too; she could not be saved. It was anticlimactic; as everyone stopped what they were doing, stripped off their gowns and gloves, and walked away, my mind screamed, But she’s so young! Shouldn’t we keep trying? She’s young! But of course, that had nothing to do with it. You don’t try harder based on someone’s age, or give up sooner because of it. They had done their best – we had done our best – and despite that, her heart would not beat on its own.
The accident occurred not far from where we live. It has been in the papers, and on the way home from the gym today we saw the flowers people have stuck in a fence right near the site. I don’t know if I’m completely over it or if it hasn’t actually hit me yet, but the whole thing doesn’t seem real, that that was an actual person under my hands, who was alive last week, who is now gone.
Wednesday, November 17, 2010
Sunday, November 14, 2010
Ambulatory
Ambulatory Medicine – adult outpatient medicine – taught me about patterns. At first it seemed that third year would be all about revisiting the facts I had learned during the first two years, but with patients to illustrate them. That would be interesting and rewarding; I certainly don’t know all the details of even the main diseases and disorders of each organ system yet, and I have definitely been looking forward to finally developing a working knowledge of the many drugs that I memorized for the boards, but whose names and side effects I still mix up (I’m looking at you, psych drugs). It turns out, though, that third year isn’t just about going over these things again in a clinical setting. It’s actually about gelling all of your knowledge (the facts you come in with and the many more that you learn along the way) about diseases and treatments into a form that is actually usable on a daily basis.
I did my four-week Ambulatory rotation with an endocrinologist. The downside was that I didn’t get to see the full range of ailments that bring people to the doctor’s office; no low back pain or upset stomachs or coughs. It did, however, give me the opportunity to really master the assessment and management of patients with diabetes and thyroid disorders. (Plus I got to see one patient with Klinefelter’s Syndrome, which is when a male has an extra X-chromosome. He was just there for follow-up, though; it would have been more exciting to be in on the initial diagnosis.)
What I learned through seeing the same diseases over and over again is that doctors function based on patterns. At first, when I would leave out some important question during my interview with the patient, I would wonder, How do doctors remember what all to ask a diabetic? And then it hit me: because they ask the same questions of every diabetic! They don’t go into a room and start from scratch, thinking, Let’s see, what are the effects of high blood glucose? It can hurt the retinas, the kidneys, and the peripheral nerves. So, I guess I should find out if this patient has had any trouble with vision. That’s a good start, right? And maybe ask about peeing and if s/he’s had any tingling in the feet. Same goes for a patient with hyperthyroidism; there are certain questions to ask, certain things to pay particular attention to on exam, and a certain way to adjust the medication as needed and a certain timeframe for follow-up.
Of course this is an oversimplification; doctors certainly need all of their medical knowledge on hand to figure out what’s going wrong whenever something doesn’t fit the pattern, or when they get an unexpected answer to one of their templated questions. But this realization was empowering in that it gave me a framework in which to start to organize my knowledge. Remember my little metaphor about the dewdrops on a spider web from my post about the boards? Well, grouping things into patterns allows me to continue connecting those drops and constructing separate little groupings of web for each area of medicine. It makes the entire endeavor of learning medicine seem just a bit more feasible. And I’ve already reaped the benefits: part of my final exam for Ambulatory was an encounter with a standardized patient. The patient had diabetes and needed an exam and counseling. And I knew exactly what to do.
I did my four-week Ambulatory rotation with an endocrinologist. The downside was that I didn’t get to see the full range of ailments that bring people to the doctor’s office; no low back pain or upset stomachs or coughs. It did, however, give me the opportunity to really master the assessment and management of patients with diabetes and thyroid disorders. (Plus I got to see one patient with Klinefelter’s Syndrome, which is when a male has an extra X-chromosome. He was just there for follow-up, though; it would have been more exciting to be in on the initial diagnosis.)
What I learned through seeing the same diseases over and over again is that doctors function based on patterns. At first, when I would leave out some important question during my interview with the patient, I would wonder, How do doctors remember what all to ask a diabetic? And then it hit me: because they ask the same questions of every diabetic! They don’t go into a room and start from scratch, thinking, Let’s see, what are the effects of high blood glucose? It can hurt the retinas, the kidneys, and the peripheral nerves. So, I guess I should find out if this patient has had any trouble with vision. That’s a good start, right? And maybe ask about peeing and if s/he’s had any tingling in the feet. Same goes for a patient with hyperthyroidism; there are certain questions to ask, certain things to pay particular attention to on exam, and a certain way to adjust the medication as needed and a certain timeframe for follow-up.
Of course this is an oversimplification; doctors certainly need all of their medical knowledge on hand to figure out what’s going wrong whenever something doesn’t fit the pattern, or when they get an unexpected answer to one of their templated questions. But this realization was empowering in that it gave me a framework in which to start to organize my knowledge. Remember my little metaphor about the dewdrops on a spider web from my post about the boards? Well, grouping things into patterns allows me to continue connecting those drops and constructing separate little groupings of web for each area of medicine. It makes the entire endeavor of learning medicine seem just a bit more feasible. And I’ve already reaped the benefits: part of my final exam for Ambulatory was an encounter with a standardized patient. The patient had diabetes and needed an exam and counseling. And I knew exactly what to do.
Sunday, November 7, 2010
Internal Med: the Nitty-Gritty
Want more details about my time on Internal Medicine? (If not, skip to my other post about this rotation: http://beckymacd.blogspot.com/2010/11/internal-struggles.html)
If you want to know more, here's a day in the life...
Each team consisted of one attending (a "real," fully-trained doctor who oversaw everything and was ultimately responsible for the team), one senior resident (a doctor in the 2nd or 3rd year of the 3-year Internal Medicine residency, who essentially ran the team, divvying up responsibilities and doing a lot of teaching), two interns (doctors in their first year of residency, who had finished medical school and gotten their MDs about 5 minutes ago), and 1-3 medical students.
A team was assigned up to 20 patients on its service at a time, and during morning rounds, we visited each of them. Outside the patient's room, the intern responsible for the patient would present the case (patient's age, pertinent medical history, current condition(s) being treated, today's vitals and physical exam findings, and treatment plan) and the whole team would go into the patient's room and talk to/examine him or her and the attending would decide whether the team’s plan was a good plan or an entirely stupid one, possibly quizzing medical students and/or teaching us something along the way. If we were lucky.
The day really started long before rounds, though, with interns and medical students pre-rounding on patients. Students started at 7am (interns at 6am), and visited each of the patients we were following, inevitably waking them up to question them about any new symptoms and poke and prod them, then going and checking the results of their morning labs and any other new tests and writing all of this down in a progress note. All of this needed to be done by 8:30 (or 8, if you were on a team that had social workers assigned to it, in which case you met with them from 8-8:30), when medical students and residents went to Morning Report. This was a teaching conference for the residents, each day based on a different interesting/tricky patient case. Then we went back to the floor for rounds, which could last anywhere from 3-6 hours, depending on the patient load, complexity of patient problems, and speed and rounding of the attending. After rounds, the interns, residents, and students go to work, carrying out the day’s plan for each patient (ordering tests or medications, following up on the results of labs or tests, doing discharge paperwork, talking to patients and their families) and going down to the emergency department to admit any new patients assigned to our team.
I stayed each day until someone sent me home. (Guess how much I loved that lack of power over my own time.) Then I went home, ate dinner, tried to study a little bit, occasionally made it to the gym, visited with/complained to Tay, and went to bed. And got up to do it all over again.
If you want to know more, here's a day in the life...
Each team consisted of one attending (a "real," fully-trained doctor who oversaw everything and was ultimately responsible for the team), one senior resident (a doctor in the 2nd or 3rd year of the 3-year Internal Medicine residency, who essentially ran the team, divvying up responsibilities and doing a lot of teaching), two interns (doctors in their first year of residency, who had finished medical school and gotten their MDs about 5 minutes ago), and 1-3 medical students.
A team was assigned up to 20 patients on its service at a time, and during morning rounds, we visited each of them. Outside the patient's room, the intern responsible for the patient would present the case (patient's age, pertinent medical history, current condition(s) being treated, today's vitals and physical exam findings, and treatment plan) and the whole team would go into the patient's room and talk to/examine him or her and the attending would decide whether the team’s plan was a good plan or an entirely stupid one, possibly quizzing medical students and/or teaching us something along the way. If we were lucky.
The day really started long before rounds, though, with interns and medical students pre-rounding on patients. Students started at 7am (interns at 6am), and visited each of the patients we were following, inevitably waking them up to question them about any new symptoms and poke and prod them, then going and checking the results of their morning labs and any other new tests and writing all of this down in a progress note. All of this needed to be done by 8:30 (or 8, if you were on a team that had social workers assigned to it, in which case you met with them from 8-8:30), when medical students and residents went to Morning Report. This was a teaching conference for the residents, each day based on a different interesting/tricky patient case. Then we went back to the floor for rounds, which could last anywhere from 3-6 hours, depending on the patient load, complexity of patient problems, and speed and rounding of the attending. After rounds, the interns, residents, and students go to work, carrying out the day’s plan for each patient (ordering tests or medications, following up on the results of labs or tests, doing discharge paperwork, talking to patients and their families) and going down to the emergency department to admit any new patients assigned to our team.
I stayed each day until someone sent me home. (Guess how much I loved that lack of power over my own time.) Then I went home, ate dinner, tried to study a little bit, occasionally made it to the gym, visited with/complained to Tay, and went to bed. And got up to do it all over again.
Internal Struggles
You know it's a good day when you wake up before your 5:30AM alarm on a Sunday and make funny little popping noises with your mouth - just because it's fun - as you head into the shower to get ready for a day at the hospital. Then again, there are the days when you stagger toward the bathroom in the dark and accidentally drop your retainers into the wastebasket, then have to kneel on the cold tile floor to dig for them because you've already taken off your glasses and refuse to turn on the light just yet. I had a lot of both types of mornings during my eight weeks on Internal Medicine.
On the first day, I wanted to quit almost immediately. The nine third-year medical students doing the Internal Med clerkship at my hospital during July and August had an orientation session for an hour and were then sent up to the floors to join our teams on rounds. I received the briefest of introductions to the team and then was swept up into rounds, feeling completely overwhelmed and unsure whether to try to participate (and if so, how) or to try to be as unobtrusive as possible. I became sure that I would be completely unable to function in this setting and that my performance would score far below expectations, and that this was absolutely not what I wanted to do for a career. There was no way I would be able get through this one day, I suddenly knew beyond a shadow of a doubt, let alone the eight weeks of Internal Medicine and the remaining two years of rotations.
Yes, fine, roll your eyes. I made it. It's just that I'm not good with change. I always hate the first day of school/work/anything because I just can't take the uncertainty. What should I do and how will I learn how do it and when should I do it? What is the schedule? (Oh please, God, let there be a schedule!) What I always want to know is, Is this how things are going to be? And if I can't know all of that right up front, can't someone at least show me where the bathroom is and tell me when I'm allowed to eat lunch??
You can measure how comfortable I am in a situation based on how many times I use the bathroom. None of us peed on that first morning, I think. Because really, how do you ask the attending or senior resident, "Excuse me, may I take a quick bathroom break while you continue with the whole healing-and-saving-lives thing? And if you don't mind my asking, where might I locate said bathroom?" You don't. You just figure it out, make a mental note whenever you pass a door with that relieving symbol on it, and stop drinking anything at breakfast, or, for that matter, throughout much of the rest of the day, at least until you get a better sense of when you might be able to run off quickly to relieve yourself.
Eight weeks is a long time to work 10- to 12-hour days 5-6 days a week with a lecture for your lunch “break.” I guess you could say it builds character. I did indeed figure out how to make myself useful, and at times I would like to think that I actually contributed to patient care. I definitely struck up some good relationships with my patients, and the feedback I received was, for the most part, quite good. I think it’s safe to say that internal medicine will not be my field of choice. It’s obviously an important field, training most outpatient adult providers, hospitalists, and those who go on to further subspecialize in cardiology, gastroenterology, hematology, etc. But there aren’t enough procedures for me, not enough laying on of hands other than for the daily palpation of a patient’s abdomen and the quick check for edema in the ankles. There also isn’t enough decisive action for my taste; many times the internists call consults from specialists and then decide which recommendations to follow. They monitor blood pressure and electrolytes and watch out for infections. But mostly, at least in the hospital, they coordinate and deliver care to damp down the latest exacerbation of a chronic illness that will not be cured upon completion of the patient’s hospital stay. Patients with COPD will still have COPD when they leave; they will just be able to breathe a bit better than during their most recent attack. Until we see them back again the next time.
Although it’s not for me, I’m glad that I started out with Internal Med because it gave me a great base on which to continue building my clinical knowledge and skills. But I’m really glad it’s over.
On the first day, I wanted to quit almost immediately. The nine third-year medical students doing the Internal Med clerkship at my hospital during July and August had an orientation session for an hour and were then sent up to the floors to join our teams on rounds. I received the briefest of introductions to the team and then was swept up into rounds, feeling completely overwhelmed and unsure whether to try to participate (and if so, how) or to try to be as unobtrusive as possible. I became sure that I would be completely unable to function in this setting and that my performance would score far below expectations, and that this was absolutely not what I wanted to do for a career. There was no way I would be able get through this one day, I suddenly knew beyond a shadow of a doubt, let alone the eight weeks of Internal Medicine and the remaining two years of rotations.
Yes, fine, roll your eyes. I made it. It's just that I'm not good with change. I always hate the first day of school/work/anything because I just can't take the uncertainty. What should I do and how will I learn how do it and when should I do it? What is the schedule? (Oh please, God, let there be a schedule!) What I always want to know is, Is this how things are going to be? And if I can't know all of that right up front, can't someone at least show me where the bathroom is and tell me when I'm allowed to eat lunch??
You can measure how comfortable I am in a situation based on how many times I use the bathroom. None of us peed on that first morning, I think. Because really, how do you ask the attending or senior resident, "Excuse me, may I take a quick bathroom break while you continue with the whole healing-and-saving-lives thing? And if you don't mind my asking, where might I locate said bathroom?" You don't. You just figure it out, make a mental note whenever you pass a door with that relieving symbol on it, and stop drinking anything at breakfast, or, for that matter, throughout much of the rest of the day, at least until you get a better sense of when you might be able to run off quickly to relieve yourself.
Eight weeks is a long time to work 10- to 12-hour days 5-6 days a week with a lecture for your lunch “break.” I guess you could say it builds character. I did indeed figure out how to make myself useful, and at times I would like to think that I actually contributed to patient care. I definitely struck up some good relationships with my patients, and the feedback I received was, for the most part, quite good. I think it’s safe to say that internal medicine will not be my field of choice. It’s obviously an important field, training most outpatient adult providers, hospitalists, and those who go on to further subspecialize in cardiology, gastroenterology, hematology, etc. But there aren’t enough procedures for me, not enough laying on of hands other than for the daily palpation of a patient’s abdomen and the quick check for edema in the ankles. There also isn’t enough decisive action for my taste; many times the internists call consults from specialists and then decide which recommendations to follow. They monitor blood pressure and electrolytes and watch out for infections. But mostly, at least in the hospital, they coordinate and deliver care to damp down the latest exacerbation of a chronic illness that will not be cured upon completion of the patient’s hospital stay. Patients with COPD will still have COPD when they leave; they will just be able to breathe a bit better than during their most recent attack. Until we see them back again the next time.
Although it’s not for me, I’m glad that I started out with Internal Med because it gave me a great base on which to continue building my clinical knowledge and skills. But I’m really glad it’s over.
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