Tuesday, October 31, 2006

Clinical Experience: High and Low

Just got back from another great day at my Family Practice preceptor's clinic.

High: Gave my first IM injections today! We walked in and our doc said, "The flu shots have arrived. You're going to immunize me." After a quick briefing, myself, my clinic partner, and I went around the circle giving each other shots. It was kindof bonding, in an endearing sort of way, kindof like drug addicts? ok, probably not. We did use clean needles, of course. I lucked out because I was the only one who got stuck by someone who had done it before; I injected my partner and she injected the doc.

High runner-up: Our doc is great as far as clearing out his clinic so we can get lots of experience and have lots of time with patients. While my clinic partner was in a room interviewing a patient, he had nothing to do for a few mins, so him and I had a really good chat about choosing specialties. I wanted to know more about what radiology is about, since I ranked high on that in an online matching-test toy thingy; I wasn't sure if it was more than just looking at films all day. He told me that the field of interventional radiology involves lots of procedures (yay) but it can be difficult to get into (boo).

Low: I watched our amazing preceptor get a needle stick today. He stabbed his thumb after immunizing an elderly woman who was already in a population at risk for Hep B. "Ow," he said, after he tried to throw out the needle, missed the sharps container, and picked it up again. I feared the worst, and after we left the room, I asked him, "did you just get a needle stick?!" His response: "yep..." I know this is a hazard of the occupation, and took a deep breath and was ready to watch him go through the post-stick procedure, pictured him going to the ER and the like.

What did he actually do about it?


"It didn't draw blood, I just pricked myself a little bit."

Wow. I was shocked. Talk about getting desensitized after years of working in the profession... but hey, he's the doc...

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Thursday, October 26, 2006

The Sacrifices I Make for Your Health...

Not even two months into med school and they're already subjecting us to self-torture.

First, we weren't allowed to eat anything for the last ten hours. That was rough enough.

And now we've got to stick a needle into our fingers six times over the next two hours. For the more unfortunate people such as my lab partner, who apparently is some sort of mutant demon reptile and doesn't have any of hat substance we humans call "blood" (a requirement necessary for this lab), she is forced to poke herself many more times (and with much more force).

At least we got something to drink for free. That cheered me up, until I read the label and realized that this supercharged Minute Maid is actually "Glucose Tolerance Beverage" and cointains 75 grams of glucose in just a little bottle. It's so sweet that they have explained to us that we must drink it within five minutes...not a simple task, considering that I now have a massive headrush and the entire room is spinning.

My lab partner got off to a slow start after poking herself several times, unsuccessfuly, and was caught by the instructor chugging the radioactive-looking beverage well after everyone else had downed theirs. "Get it down, already!" he said in his British accent. "You must be a cheap drunk." She did not take well to that comment. (Her friend at our lab bench swore he was right, though).

We've been told to 'bring some studying' or something because all we're really doing is sitting here, poking, and the like. Fortunately this is taken place in the computer lab, so I can at least blog.

Apparently after these two hours we'll have learned something about fasting glucose levels or something like that. All that I've learned is that I'll have a bit more empathy towards my future diabetic patients.

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Tuesday, October 24, 2006

Best Day So Far.

Why was today the best day so far in my medical education?

Two reasons.

The first, and minor reason - it was my first day in the doctor's clinic for our family practice class. We go four times this semester to a clinic and shadow the doc, watch procedures, and depending on the preceptor, do some procedures, interview patients, and the like. Today, however, was a bit more watching than doing; I took a lot of BP's and was advised to bring my own watch next time. The watching involved seeing a man's scrotum, a breast exam on an elderly lady, a rectal exam, and the like...oh, the glamour of family practice. From here on in, though, I've been promised the chance to give lots of flu shots - once the vaccine arrives in a couple weeks.

The second, and better reason, I GOT MY STETHOSCOPE TODAY!!! And my otoscope and opthalmascope kit. Wearing my own stethoscope today in clinic around my neck, and starting to feel more like a real doctor, is definitely worth the $800 I shelled out for them. It even came with a CD of heart sounds. And, as much as I'd love to hear more, I've got this CD to listen to!!!

Only kidding. I'm not that nerdy. I'm just doing homework.

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The Dreaded Inevitable: First Patient Death

This week's Grand Rounds is great, as usual. I don't have the time to read all the posts I want to, as usual. For some reason, though, long after I should have been in bed, I went through some of the posts.

I quickly realized that this GR holds two posts on the same topic: two separate med students,
Ali Tabatabaey and Jenn, tell of the first time a patient of theirs has died.

It was hard to not feel my eyes getting wet as I read those, one after another. I've heard and read so many accounts of physicians, on blogs and in medical journals and textbooks, about how they simply do not forget their first patient death.

I won't forget the first time I learned about this. I read it on Incidental Finding's
blog the summer before I started med school. He wrote, "The first patient of mine that died, in my 3rd year of medical school, I can recreate her history and physical exam from memory. If I sat down for 10 minutes, I could probably come up with her medication list as well." He titled that post, "One is too much."

It's something that will happen to me, inevitably. And it will stay with me until the day I die. As vital a part of my education it will be, I can't help but feel that I want to put it off as long as possible.


I'm adding to this post after I initially wrote it, just to note that there are already emotionally heart-wrenching things I've experienced in medicine that will be with me forever.

I won't forget the sight I saw when I walked into an OR
while I was in Nigeria to find a stilborn infant, fully formed but seemingly asleep, laying abandoned in a kidney pan as the surgeons closed up his mother.

And, when I was shadowing an ER doc, I experienced a truck driver dealing with the devestating realization that - even though it was an accident -
he had ended human life.

Tonight, after writing this post, I tried to fall asleep, but couldn't, because in my head, I could still hear that man crying.

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Saturday, October 21, 2006

The most intensively studied medical devices - ever

"I think it's safe to say that these medical devices are the most intensively studied medical devices in medical history."

What was the person who said this talking about?

  The heart stent?

    The ventilator, perhaps?

      Or maybe the latex glove?

None of the above. According to Supriya Sharma of Health Canada's therapeutic products directorate, the silicon gel breast implant fits the above description. Canada is finally de-regulating the use of these well-researched devices after nixing their use in 1992.

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Wednesday, October 18, 2006

Post-ER-shadowing Advice

[Formerly a part of the post Back in the hospital: ER shadowing]

Advice I got from the MSIII at the hospital:

  • Enjoy first and second year! Go to all the social events. After hearing this, I went and signed up for the ski trip and the killer Halloween party that the med class has a reputation for. Both sold out shortly thereafter.

Advice I got from the ER doc I shadowed a couple months ago, and was reiterated by my own personal experience:

  • If you're working in a clinic, get a box of disposable pens without lids, and carry two or three with you. Yeah, you'll be writing lots and may want to get a pricey pen for that reason, but you'll go through it so fast it won't be worth it with all the time for refilling. Also, if you use disposables, you can chuck them in the garbage when they run out, and use another one from your lab coat pocket. Finally, make sure they don't have lids; you won't have the time to be uncapping and capping all shift long. Efficient ER docs use their lab coat pockets to always have their own scissors (they can go missing easily in the ER) and tongue depressors.

And my final piece of advice, from the R1:

  • When you're saying goodbye to a doc you've been shadowing, don't tell them, "Well, it's about time I head out, I don't want to be late for the pub." Apparently it's better to say that you're going to be working on a research project or something. The doc found my comment pretty funny and announced to all the nurses, "This student would rather drink beer than experience clinical medicine!" He seemed pretty amused, though, and commented that he was disappointed that he wasn't responsible for filling out an evaluation for me or anything like that. In retrospect, I probably could've made a better impression by omitting that info.

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Back in the hospital: ER shadowing

School is great so far, but the general basic biology review that comprises our first term is a bit slow and lacking in clinical experience.

Things will brighten up when I get my stethoscope / otoscope / opthalmascope next Tuesday. Also that day, I start my first of four experiences in a family physician's office, which is going to add an exciting element to my medical education.

The doctor I'll be shadowing seems pretty cool, and excited to have us, which is nice. He sent me an e-mail that got me really excited. Part of that e-mail:

In my office, you will be doing more than just talking. I expect you to do limited physical examinations under my supervision. So yes, bring all your instruments. You will also have a chance to do some minor procedures, like giving shots or taking out sutures. In another word, you have to work. Flu shot season is coming up. Hopefully you will be an expert in giving shots by the time you leave.

I hope you will have a good experience and at the same time, have some fun. Books can be very boring.

That's all you need to tell a med student to get them very excited. As well, his practice is about 60% Chinese, "so polish up your Cantonese." And, I don't have to wear a tie. Nice.

Though I'm required to get that experience, I'm still trying to get some more exposure to the specialties I'm most interested in right now, namely, OR and ER. I finally have had enough of trying to smother my itch for clinical exposure and signed up to shadow an ER doc for a couple hours yesterday. Our school has a comprehensive online list of about 100-150 local docs in all sorts of specialties who are happy to have med students to shadow them, so I looked one up, and yesterday found myself wandering towards the big city hospital a short walk away.

I haven't been orientated to that hospital, or any hospital here for that matter, so I wandered in through the paramedic ER entrance, put on my short lab coat in a hallway and wandered over to meet the doc.

The doc I was following looks EXACTLY like a younger, shorter, blond Greg Kinnear. I kept doing double takes all night. He was great to shadow; it was pretty busy and he also had a R1 (first-year resident) and a MSIII (third-year medical student) following him around, but he was happy to have me there.

It's only the second ER I've ever shadowed in, too, so it was neat comparing the two places. This big city hospital had all sorts of neat stuff: a very belligerent HIV+ homeless individual who got drunk on rubbing alcohol and bumped his head and subsequently cussed out the doctor at full volume when the doc tried to get info about his HIV condition; a lady with alpha-1 antitrypsin, sepsis, lung transplant (alpha1 is one of the few conditions we've actually learned something about so far); a 50-year-old Fijian gentleman who had recently had a SEXTUPLE bypass (never heard of that before)!

It was also my first experience with actual teaching-hospital-attending-doc pimping, something I had only heard about to date in the medical blogosphere. The doc asked me a few medical questions, which I wasn't expecting. Fortunately, one of the ones he asked me (why do we give thiamine when we give glucose?) was something I learned this week in class. He seemed almost surprised that I knew the answer.

I enjoyed seeing what the MSIII does, as well. It'll be exciting to finally be on the floors and doing medicine and interviewing patients and doing procedures. He did a great job of presenting cases to the attending; I wonder how some of the people in my class will end up when it comes time for them to coherently present cases. At this point, at least, they don't seem nearly as confident...or competent...as he was.

[Formerly the first half of a longer post; second half can be found at the post Post-ER-Shadowing Advice]

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Monday, October 16, 2006

Learn from someone else's mistake #2: The Day my Sense of Humour Died

I told my last med school joke today.

So much for my mark for "Professionalism" for this block of case-based learning.

We were given a case and on one sheet, the information provided said that "vital signs were normal." Then, on the next sheet, the respiratory rate and heart rate were elevated. One person in our group said, "I thought we were told that the vitals were normal!"

My fateful response: "Don't trust nurses."

Ha, ha. I though it was funny. Most of the people laughed, too, and realized that I WAS JOKING, and that comment is NOT exemplary of what I feel about nurses.

Please let me provide context (perhaps my first mistake; I made my comment in the first session with a new group, so they probably didn't realize that I try really hard to respect everybody and every profession and every member of the health care team).

  • I know from personal experience, and I strongly believe that nurses are an important and valuable part of the health care team and play hugely significant and essential roles. Without them, hospitals wouldn't function.
  • I know that nurses can be a doctor/med student's worst enemy or best friend
  • I have several good friends who are currently nursing students, or just became nurses. Heck, I read nursing blogs, I dated a nurse once, I have friends whose moms are nurses, and my mom's a nurse, too.
  • I wouldn't wish anything bad upon a nurse and plan to treat them with the respect and admiration they deserve.
  • my only exception: when there is incompetence or danger to a patient, then I have no tolerance (but this goes for anyone working in a hospital)

Anyways...the tutor asked me to repeat what I had said. I told him I was joking, and he went on a rant about how his wife is a nurse, how nurses are important part of a team, how what I said wasn't funny, and on and on and on. When he finished talking and I had turned red enough and sunk deep enough into my chair, I blubbered out an apology.

Serves me right - when we were laying out ground rules for this case-based learning block, I offered, "Be willing to give and accept constructive criticism." I didn't expect to have to accept some so soon. The funnier part was that, according to our case, it wasn't a nurse who presented the vitals - it was a paramedic.

Figures. Don't trust param.... i mean, nevermind! ONLY KIDDING! man, I really haven't learned my lesson. (Oh dear, do I have to make it clear that I love paramedics now, too?! okay here goes: that's what I originally wanted to do with my life, and a former paramedic in my class drove me to school today :) )

The tutor did say he was sorry for singling me out and later apologized again, and I had a chance to try to redeem myself and say what I really feel about nurses and that my flippant comment wasn't what I really believe. Good thing it was in a small-group session with only 8 other people.

I definitely am much more aware that I need to be careful with my jokes, because usually they don't emphasize the amount of respect I usually have. Also because this isn't the first time I could've been more tactful. Maybe it was my enjoyment of other blogs where med humour abounds that led me to say things like that...regardless of where it came from, from now on I'll keep it to the written word.

Wish me well in beating down my sense of humour. Class clown, signing out.

**Postscript (10/24/06)**
Our tutor has lightened up a bit; I think perhaps he feels bad for reaming me out. I've noticed a distinct - almost forced - effort on his part to laugh at all the (very sterile and non-offensive) jokes I've made since then.

**Post-Postscript (07/24/07)**
Since I've linked to this post I read it again. Fortunately I've learned from this (and I know better now, thanks Captain Constructive Criticism below who called me an ass). In my review for the block my tutor made mention that I shouldn't be too careful lest I lose my 'endearing' sense of humour.

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Sunday, October 15, 2006

Top 10 list: Things you don't want to hear in the cadaver lab

Our group got a little carried away with our lab the other day, in a good way. Tasked to find the part where the thoracic duct drains into the bloodstream, as well as perhaps the vagus nerve and its branch the recurrent laryngeal nerve, instead of being one of the first groups done - our usual reputation - we chose to be thorough.
It was worth it, too. We learned so much. We impressed even the lab instructors. And we were really into it. So into it, in fact, that at the end of it, my lab partner told me he might have been a little too close to resting his chin on an exposed surface of the cadaver while peering in at the details of the mediastinum. So close, in fact, that the #2 on the list below was actually said to me. (I wish I could give him the coveted #1 spot...but you'll probably agree that the premier location has been rightfully assigned.)

And so, amidst this outstanding level of learning which will undoubtedly make us better clinicians due to our increased level of knowledge thanks to our body donor, was born the idea for the latest Top 10 list, Things You Don't Want to Hear in the Cadaver Lab. I encourage you to not read on should you be sensitive or assume that humour in the cadaver lab is unconditionally synonymous of a lack of respect. That being said, the list lies below, complete with colour commentary.

10. "Um, you got me in the eye with that splatter."
Actually heard.

9. "Um, you got me in the mouth with that splatter."
Actually heard. Not by me, fortunately. But it's a horror story that still looms from last year's class. Maybe I'll tell it in its entirety sometime.

8. "It happens."
The anatomy prof's actual response to a student uttering number 10 to him, said while he kept chiseling at the vertebrae without so much as looking up.

7. "Hey! That looks like pulled pork!"

Actually heard. I haven't eaten pulled pork...or spare ribs...since.

6. "OUCH"

Bad enough if it's a student saying this. The person who suggested this as an addition to this list, though, was thinking, 'what if the cadaver...' - - - nevermind. That being said, one person in my group did get the cadaver's hand caught in their lab coat last time...it was somewhat eerie how the cadaver apparently 'grabbed' her, with enough force to undo a button on her lab coat...

5. "Let me just tug a bit on this spermatic cord."

Actually heard. Fortunately, the prof was not referring to a body part other than the spermatic cord.

4. "This might make you a bit squeamish..."
Actually heard. The prof was right. Whenever the scalpel meanders over to the inguinal area, brace yourself.

3. While putting a foot into the body cavity: "I'm going to jump right in, swim down the aorta, and take a look. No, it's okay - I saw this on the Magic Schoolbus once."

This one didn't happen. Fortunately.

2. "Do I have a piece of pleura in my teeth?"
Actually heard.

1. "Grandma?!"
...upon removal of the bags on the cadaver's heads. I wouldn't wish this upon anyone.

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Saturday, October 14, 2006

First Midterm response: Conflicting advice from the second-years

Apparently by not giving us take-home work in the first five weeks (in my naïvety, I actually wrote a post entitled "Med School is So Slack") our school was giving us lots of time to prepare for the first midterm.

I should have taken advantage of that time.

After the midterm, our school gives us an Exam Review Session. When time is up, we hand in our answer sheet and test booklet; then everyone goes into the same lecture hall where we sign out our exam booklet and a sheet of paper with the correct answers. If you were bright enough to mark your answers in the test booklet you can find out how many you got wrong; the point of the session is not only to find out how you did but they want us to learn from our mistakes, so they encourage us to discuss questions in small-group format. If we're not satisfied with a correct answer, we can go to a 'master test booklet' and voice our concerns; "it only takes one comment for a question to be investigated." There were actually one or two questions on the midterm that everyone was convinced that the provided answer was incorrect.

All that to say that barring the administration changing around the correct answers / the values of some questions, I know how I did. I didn't fail. I passed. Not by a whole lot, though. I was a little surprised, especially since the second-years were offering advice along the lines of, "Don't be afraid of the first midterm - it's SO easy! EVERYONE gets like 85!" I shouldn't have listened to them.

Okay, it's only pass/fail, and it is worth only like 3 percent of our term mark, and because of those factors combined, in the days preceding I didn't take it that seriously and probably could have studied a lot more. But I'm the type of person who needs pressure deadlines for motivation, and frankly, there was not a lot of pressure with this midterm.

Because this midterm isn't worth a lot, I'm not tearing up or traumatized from not doing better than everybody else in the class. In fact, my inferiority complex is telling me that I am lucky to even be in med school, so I should expect to get ranked at the bottom of the class (those thoughts are always accompanied by that little voice in my head, "You can't fail med school!")

However, this test was really beneficial. It will change the way I study from now on in. All of the second-years before me told me, "Keep up with the work," and unlike their comments about the midterm, I should have taken this advice more seriously. I'll pass on that advice to aspiring medistudents. I plan to devote more of my evening and weekend time to reviewing the preceding week's content. I'd rather study all throughout the semester than cram all at once before the test; apparently, the second method doesn't get you really good marks, as I found out.

I know I didn't give it my all for this midterm, and I'm not too worried beacuse I could have done better if I sacrificed spending the preceding thanksgiving weekend for studying instead of hanging out with friends & family. From now on, if I fail a test, I'll have to go to the committee designed to help students, and then take a remedial exam. I'd rather not partake in that sort of thing. I'll definitely be taking the tests a bit more seriously from now on.

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Friday, October 13, 2006

Some advice for future cadaver dissectors: Smell

Or, What I Have Learned Thus Far through Observation, Experience, or Trial and Error

Sorry for all the cadaver-related posts; that's all I've done so far that's really 'doctor-ish.'

Anyways, as far as cadaver lab advice goes, here's what I have to offer so far (I can forsee myself adding to this list in the future),

Today's entry is on Smell. On the way out of lab, I was chatting with a fellow classmate, who commented to me that the excitement of anatomy lab is starting to wear off, due in large part to the odours thereof.

As I learned while witnessing an autopsy a few years back, and through my now more frequent cadaver experiences throughout my medical education, I can assure you that the odours of a cadaver lab, and the changerooms preceeding entrance to said lab, are like none other. Though our school uses the chemical Infutrace to neutralize the formaldehyde odour (breaking the formaldehyde down into an alcohol), as can be expected, the inside of what was a long time ago a living, breathing person does not exude the most pleasant odour in the world.

To make it worse, some of the bodies are less well-preserved than the others, and in addition to organs being dark and crumbly, as can be expected, there is an increased intensity of questionable aromas which grace the nasal passages.

There are some strategies available to combat this unpleasant aspect of anatomical education.

  • Lip Treatment. Spread a swath of Vapo-Rub or similar menthol lotion on your upper lip before entering lab. By the time this odour has faded, you will have mostly adjusted to the smell.
  • Hand Protection. While the gloves are the obvious universal means of maintaining a healthy barrier between one's hands and the items those hands are caressing, they can - IF used properly - play a crucial role in odour protection. In my zest to appear macho or non-squeamish during my past anatomy lab experiences, I used to only wear one pair of latex gloves; however, I was unwitingly exposing my hands to a great amount of odours, many of which were retained for hours after leaving lab and even making numerous visits to the sink.

    I have since learned that this amount can be significantly reduced, shouldst one use the Vitum Medicinus patented double-glove technique. Instead of simply using two layers of Latex gloves, avail yourself of the nitrile gloves, but make use of these underneath a pair of latex gloves. This specific arrangement serves a number of purposes.

    First, I have found the nitrile gloves to be effective in odour-penetration preventance when used in conjunction with latex.

    Second, limited direct exposure to latex is a good thing; more and more people are developing hypersensitivities each and every day, and God knows we'll be exposed to plenty of latex throughout the course of our medical careers.

    And third, while the nitrile gloves should be closest to the skin, an overlying layer of latex glove will allow the gloves to fit tighter to the hand, improving grip, accuracy, and dexterity.

Although the preceding exhaustive and unquestionably useful description will undoubtedly lead you to believe that I an expert on odour control in the cadaver lab, I will make this honest confession; I have actually a lot more yet to experience as far as the anatomy lab is concerned. We haven't yet dissected deep into the abdominal cavity. That being mentioned, I'll confide in you that I am not looking forward to dozens of individuals using their scalpels to penetrate the membraneous containers that the good Lord intended never to be opened - let alone months after the spirt has left the body - due to the odorous nature of their contents.

Indeed, the worst is yet to come.

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Friday, October 06, 2006

A Pair of Warnings for Medical Students to Heed

  • You'll come across them. Old folks who, try as you might to explain there's nothing wrong with them, they'll continue to pop up in your clinic. We call them Gomers. It stands for, Get Out Of My Emergency Room.
    - from
    House of God, I believe. The person I know reading this book told me, "I'm not sure if I can recommend it to you." Read the online reviews at the provided link and see what I mean...it's pretty intense.
  • There are two types of patients that you can tell right away are crazy:
    First - the people who wear headphones. Old-school headphones. Usually crazy.
    Second - the people with a tooth-to-tattoo ratio of less than 1. If they have 29 tattoos and 28 teeth...crazy. If they have 3 tattoos and 2 teeth...crazy.
    - from the doc acting as a preceptor for my buddy's elective.

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