Feeling lowly.

It's nice to hear that I should start to notice a feeling of "I am actually needed" eventually...

...even though I haven't yet been able to find any evidence that the feeling of "I have no idea what I'm doing" ever really goes away.

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Words I'd use to describe med school: Honour

There are a number of words I'd use to describe med school. This blog post is the first of a small series I'll devote to expanding upon these words.

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I've heard people joke about it before. "You know, you're lucky... as a doctor you're one of the few people who can get someone to to take their pants off for you within minutes of having met them!"

That's not necessarily always a fun thing, considering how unpleasant it is to perform a digital rectal exam on, say, a patient who has lost control of their bodily functions and hasn't showered in weeks.

But that borderline crude statement has a lot more to it than just humor.

Statements like that only scrape the surface of the depth of the honour it is to be able to practice medicine...something that we med students can occasionally tend to lose sight of when we are in the midst of 80-hour work weeks on the wards, or in our tenth 15-hour study day in a row, or when we've just been humiliated by a preceptor in front of both our colleagues and patients.

While I can use this blog to complain about finals or how much stress I'm feeling at times, I probably don't say enough that I do feel honoured to be a part of this profession.

There are so many ways in which this honour is revealed. Here are a few I can name:

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• Medicine: a profession to which people are willing to donate their bodies...their most personal possession....after they die. It's an honour to be a part of that.
  
• Medicine: a profession to which people are willing to give you a huge amount of trust just because you are a part of the profession. Depending on where you look, physicians may not be the #1 most trusted profession, yet around the world, they almost always fall in the top 10 (BBC: Doctors #1; Harris: Doctors #1; Ipsos Reid Canada: Top 5; Reader's Digest Australia: Top 10). It's an honour to be a part of that.
  
• Medicine: one of the professions in which there are so many sides and approaches to the common goal of health, and in which those various health professionals are starting to work harder to work together to achieve this goal. It's an honour to be a part of that.
  
• Medicine: one of the few reasons that a driver, though enraged by the thick of traffic, would still be willing to pull over. I've seen people grumble when a cop turns on the siren to whiz through a red light, but never when an ambulance has come through. It's an honour to be a part of that.
  
• Medicine: one of the few professions legally allowed to self-regulate by the Canadian government. It's an honour to be a part of that.
  
• Medicine: the reason why people will open up to me their deepest secrets, the greatest extremes of their emotions, their first and last moments on this earth...all because of my field of study. It's an honour to be a part of that.
  
• Medicine: one of the areas of study that thousands of the most intelligent university graduates fight for the chance to be able to enter every year. It's an honour to be a part of that.
  
• Medicine: one of the professions where you are able to call some of the most brilliant, accomplished, fascinating and devoted people your colleagues. It's an honour to be a part of that.
  
• Medicine: one of the professions with a longstanding legacy throughout centuries, and is continually looking back into its history and deep into its future to better itself for the good of the patient. It's an honour to be a part of that.

===

Even if I could think of all the reasons why it's an honour to be studying medicine, I don't think all of them could be put into words.

That being said, I know I've missed some... if anyone is reading this and can think of some I've missed, I'd love to hear your thoughts in the comments!

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When the dust settles

It was just as if a hurricane had passed.


The merciless pounding stopped,

     and everyone began to come out of their makeshift shelters,

          wandering bleary-eyed into the streets,

               looking at the destruction around them,

                    assessing what little they had left of their friends, and social lives, and dignity.


And they began to talk to each other,

     wondering aloud,

          putting into words the thoughts they were all thinking...

"Did that really happen?"

          "I can't believe I made it. There were times when I didn't think I would."

               "Can it actually get worse?"

                    "I'm not sure anybody would understand what this was like if they didn't see it with their own eyes."

Yep... finals for the term are now done... and another semester is over.

Time to enjoy the precious few weeks of recovery before it all starts again in January.

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You know you're consumed by studying when...

I found this list in a friend's Facebook notes... and with her permission, am reproducing it here for your reading pleasure. I won't pretend that I'm coherent enough to be this creative at this point right before finals... this many 15-hour study days in a row is enough to shut down most basic cognitive functioning.

You know you're consumed by studying when...

10. You think osteoclasts are cute (white furry balls!)

9. It seems like you're studying more than breathing

8. Things that secrete mucus are mucous-secreting
(clarification for those not in our class: incorrect spelling = incorrect answer = no marks. because we don't have enough stress!)

7. Breaks consist of eating

6. You don't sleep, you nap

5. You look forward to sleeping

4. Taking a shower is a relaxing activity

3. A change of scene involves studying a different block

2. Hearing "6 days til the holidays" provokes fear, not excitedness

1. You think personal hygiene is an option, not a necessity

Okay... back to work!

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Final are depressing. No, really - I can prove it.

School in itself is a challenge for most of my classmates and myself, especially with finals study time in full swing. Apparently they want doctors to know a lot of things.

I looked at a post I wrote about this time last year and it's very similar to how I feel right now.

One of the differences this year, though, is I know my classmates a lot better, and so I'm much more aware this time around that many of us have a lot of additional stress outside of class. There are a number of students that I am genuinely worried about - I honestly don't know how they have the strength or stamina to get out of bed every morning, considering what they have going on in their lives.

This year in clinic I learned about a questionnaire called the PHQ-9, which the physicians gave to some patients as part of a comprehensive assessment for depression.

As I got to know the questions better, I began to realize that if you took a survey of my class right now - in the middle of finals season - based on this questionnaire I wouldn't be surprised if the vast majority of them would register as "severely depressed."

In fact, to prove it to you, I'll go through it right now:

PHQ-9 QUESTIONNAIRE
Over the last 2 weeks, have you been bothered by any of the following problems?

a. Little interest or pleasure in doing things
Check. Even things I used to like doing, like learning about medicine. Too much of a good thing, you know? Like a dump truck full of ice cream.

b. Feeling down, depressed, or hopeless
Check. Despite the overwhelming statistical precedence that 99% of us will pass, everyone I talk to thinks they will be the one person who will fail.

c. Trouble falling asleep, staying asleep, or sleeping too much
Some of my classmates are so revved up that they are self-medicating just so they can sleep at night.

d. Feeling tired or having little energy
Try exhausted. And I don't think it's African Sleeping Sickness.

e. Poor appetite or overeating
One classmate told me that her theory is that "everyone in our class either gains or loses weight during finals."

f. Feeling bad about yourself, feeling that you are a failure, or feeling that you have let yourself or your family down
Wow, I swear the writers of this questionnaire talked to my classmates

g. Trouble concentrating on things such as reading the newspaper or watching television
Haven't had time to do either of those. But trouble concentrating while studying...check.

h. Moving or speaking so slowly that other people could have noticed. Or being so fidgety or restless that you have been moving around a lot more than usual
Absolutely. Mini-anxiety attacks will do that to ya.

i. Thinking that you would be better off dead or that you want to hurt yourself in some way
Not me in particular, but there are some in my class who might...I've heard comments like "I want to crawl in a hole and die," "Maybe I should just drown myself in the bath," and "If only I had a gun." Which ones should I be taking seriously?

Major Depressive Syndrome is suggested if:
• Of the 9 items, 5 or more are checked as at least "More than half the days."

Proven. Voilà.

In fact, if I could find a checklist for "Cabin Fever," given the number of students cooped up in a study room for the last few weeks I can guarantee we'd score pretty high on that one too.

At least our faculty isn't like some other ones I know of, which, in response to student comments that the curriculum is stressful, recommend that the students a) seek counselling - kind of not an option given the limited free time during finals study time - and b) take anxiolytics, ie. medicate the stress away. Thanks for your support.

Gonna get back at it. Wish me luck.

(Again, this is not a place for you to be getting medical advice, but if any of the above apply to you - and things won't return to normal on a set date ie. you aren't in the midst of finals - please book an appointment with a professional!)

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The Opposite of Turnstile Medicine

My clinic experience this year was an incredible treat for me. It was a rare setting where the doctors are paid a set salaried wage, rather than based on the the number of procedures they did (fee-for-service). I was amazed at how differently the day went than it might go in a walk-in clinic.

Instead of racing through the patients as if there was a turnstile at the door that went 'ka-ching' for every patient in and out, the doctors were taking the time to address the whole-body health of the patient - something I hadn't seen a whole lot of in family practice so far.

Though I could give many examples, I keep thinking about one particular patient for whom this clinic worked particularly well. He presented with a rash.


If he had gone to a walk-in clinic, he would probably have gotten some steroid cream within a minute and been told to come back if the rash didn't go away.

At this clinic, however, knowing that she had fifteen minutes for this patient, the doctor took the time to take a full history, considering a wide possibility of conditions that could be causing the problem.

Through this history, the doctor learned that the patient was in a high-risk relationship for a number of sexually transmitted infecitons, and as a result, was able to counsel the patient on a number of risk-reduction measures and vaccinations that he should consider.

Another benefit of this clinic was that it was incredibly integrated - there were counsellors, nurses, a travel medicine specialist, a mental health intake worker, a sexual health specialist, and a physiotherapist all on site. I have heard a lot of team medicine, but haven't seen it come into play very often, so it was amazing seeing these professionals work together for the best interests of their patients.

For example, with this same patient, when the relationship came up in the history it became evident that his partner was a source of a lot of stress. Upon going over the additional stresses in this patient's life, and calculating the toll they were taking on him, the doctor uncovered that the patient was at risk for suffering from depression... and scheduled a follow-up visit - not only with a doctor - but with the counsellor on site as well.

Not only did the doctors simply refer the patients to the other health professionals, but I saw on a routine basis these other clinic staff come chat with the physician - or the physician go to their offices - to talk about a particularly unique patient and brainstorm on how to best take care of them.

These doctors really cared for their patients, more so than just getting the right diagnosis or catching the most medical conditions. Time and time again, they were willing to go above and beyond, even if it meant pouring a bit of extra effort and energy into a certain patient. It was obvious that time and time again they were making a difference in their patient's lives, and occasionally actually saving lives.

Don't get me wrong - there are rarely any physicians who don't want to take good care of their patients, and a number of family practitioners work as their own business and thus have to work extremely hard just to make ends meet - but after my past experiences observing family medicine, I was amazed to be coming home at the end of each shift thinking, "If family practice can really be like this, instead of just trying to cram in as many patients as possible, maybe I could see myself doing that kind of medicine in some form." Up until now, family practice was near the bottom of my list of interests.

I don't think the uniqueness of this clinic could all be attributed to how the payment schedule is structured, especially considering how much care these doctors had for their patients. But when I look at how this clinic is structured, and how every work day isn't a race to pile up completed charts, I now have a bit of a better idea of what type of career I'd prefer for myself, and also what I'll look for when I choose my own family doctor.

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Listen, the patient is telling you the diagnosis

There's an old saying attributed to Sir William Osler that you'll hear dozens of times even one year into medicine:

Listen, the patient is telling you the diagnosis.

We've also been told that if you've done an extensive list of investigations and still don't know what the patient has, re-taking the history can sometimes bring a diagnosis to light.

Being able to spend time in clinic is great, but to be honest, we don't really know what questions to ask yet. Yeah, we know a few: does it hurt? how much? where? and for how long? But it takes a long time and a lot more training to learn all the important associated conditions - that I should ask the patient with Crohn's disease if their joints hurt, or the patient with chronic hypertension how their vision is.

Some of these things come second nature for doctors who have been doing this for years, but when you're new at this, you feel like getting a diagnosis just by asking the patient a few questions can be pretty difficult.

Getting the diagnosis from the history has started happening to me, though. At my clinical exam at the end of the year (the OSCE - Objective Structured Clinical Exam) where medical students go from room to room at the sound of the tone, read the instructions on the door, then either take a history or do a physical while an examiner watches, there was one station I won't forget - I figured out what the patient had, just by asking the right questions.

She presented with a cough. As I asked her more and more questions, I was able to determine that she had been coughing up blood, and she had been exhibiting what are known as constitutional symptoms - fever, weight loss, and fatigue - all indicating a serious, chronic condition. As I finished asking her my questions, it began to dawn on me in my head... oh my gosh, lady, you've got lung cancer... and you've probably only got a few years left to live.

Okay, yeah, the patient was an actor, and it was a strucutred environment, and that was the point of the entire exercise, but it was still a neat feeling to almost be certain about a patient's diagnosis just by asking her some questions.

I was pretty excited about my success. Inevitably, however I came crashing down to earth while chatting about that patient with another student.

I'm still kicking myself - as I spoke with my friend I realized I didn't ask the patient the most obvious respiratory history question:

"Do you smoke?"

I won't make that mistake again.

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Can't be too careful with physical exams...can I?

"Well, given the problems you've mentioned, I'm going to need to do a quick physical exam."

Now that I'm in second year, that's something that I've been able to do, and be confident doing: if a patient presents to me in clinic with an ear/nose/throat issue, a heart or lung problem, a musculoskeletal problem, or an abdominal problem, I'm able to do a focused physical exam before the doctor comes in.

"The doctor will come in and do an exam as well in a few minutes, but for now could you lay on your back and lift up your shirt so I can examine your abdomen please?"


I turned my back to wash my hands as the patient, a friendly, effervescent girl my age, set her backpack down from her lap and hopped up onto the exam table.

She had been explaining that she had been going #2 once every four or five days, and that was "normal" for her, and even though she had been that way for a while she constantly felt abdominal pain and fullness and bloating. So, after asking her a few more questions, I decided to put my new-found gastrointestinal clinical skills to good use and see if I could palpate any abdominal masses or liver enlargement.

I dried my hands, threw the paper towel away, and turned back to the patient. "I'll just start with a general visual inspection before I begin the exam, looking for asymmetry or scars or any abnormalities," I explained,
before I moved on to the hands-on part. Everything looked normal.


"Now, I'm going to do a procedure called percussing your liver, which basically involves me sortof tapping on your stomach. Your liver is a bit behind your rib cage so can I ask you to lift your shirt just a bit more?"

Her shirt was only half exposing her stomach, and in order to percuss the whole liver the shirt usually needs to be lifted up to right where the bottom of the bra is. (On a really good exam the patient would be in a gown and that wouldn't be an issue, but in clinic I'm not going to ask a patient to gown up for an abdominal exam.)

I always feel awkward asking a patient...especially a girl...especially one my age... to remove more clothing, so I try to explain myself really well. As well, despite what I've seen some doctors do, I always try to get the patient to remove their own clothing rather than 'help them out.'


She complied without hesitation, and pulled up her shirt a bit... but when she let go, it fell back down to basically where it was before.

Great, I thought. Now I have to ask her to lift her shirt again. Awkward.

I worked up the courage and asked again. "Um... could you lift it a little bit higher please? Just about an inch or two, just to expose the whole liver."

"Sure!" she replied. She grabbed the bottom edge of her shirt and promptly pulled it ALL THE WAY UP to her neck, revealing her entire chest, pink bra and all.

Call me a prude, or whatever you want, but I had a bit of a minor freak-out.


"Woah.... no, no! It's okay! Not that high!" I exclaimed reflexively. I almost grabbed her shirt and pulled it down.

"Um... Vitum..." she said slowly, almost condescendingly.

"Yeah?" I murmured.

"It's okay...

...You're a doctor."


Up until then I had never before been corrected for being too cautious, and it was a bit of a relief to have a patient remind me that while it is important to be respectful of a patient's privacy, it's also important to be thorough. That's what patients are expecting when they see the doctor, after all.

It's still gonna take some getting used to, though, being able to tell complete strangers to remove their clothing, and while this might not seem like that big a deal I still try to be very careful around issues like this. Hopefully I don't ever get too comfortable, though. And for now, I think I'll try to always err on the side of modesty.

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SurgeXperiences 107 Blog Carnival

Welcome to SurgeXperiences 107!

On the forefront: Robotic SurgeXperiences

• Aggravated Docsurg talks about what robotic surgery is all about.
  
  
• Once you've read that, another perspective can be found at surgeon's critique of robotic surgery.

Patient and Provider eXperiences

• Bongi tells the story of a surgery hopeful who had an unfortunate experience in the OR. I'd recommend if you read this one, you don't miss the postscript.
  
  
• While it may be minor as far as surgical experiences go, JD had a thyroid nodule biopsy performed recently, and explains the process from the patient's perspective.

Surgical eXperiences Abroad

• Kathryn provides a description of surgery in less than optimal conditions in a less than first-world country: "...The residents even tried to do surgery with sterile drapes wrapped around them because there aren’t any gowns at the moment..."
  
  
• Going to a different country to get surgery or other medical procedures done can be intimidating, but the Medical Tourism Guide provides a how-to guide for Researching a Doctor's Credentials - a must-read for anybody considering getting treatment abroad.

eXperiencing Surgery outside the OR

• If your friends ask you to play "a game of recreational surgery" with them, you may be interested in joining them since that's the name of a board game. I'd suggest you politely decline if any of your med student friends ask you the same thing, however.
  
  
• If you prefer a surgical game of the online variety, take a look at simulated Open Heart surgery.
  
  
• When I was a kid, I thought "plastic surgery" was akin to a game and had something to do with fixing people using doll parts. How fortuitious I corrected this bad impression by reading this excellent description of plastic surgery, lest I bring a Barbie to my first plastics elective in an attempted show of preparedness.

That's all there is to eXperience in this edition!

Special thanks to Jeff from SurgeXperiences for asking me to host this edition! Next week's can be found at Aggravated DocSurg on November 11.

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SurgeXperiences 107 Blog Carnival ::: Call for submissions

Vitum Medicinus is proud to be hosting SurgeXperiences 107 on October 28, 2007.

What is SurgeXperiences?

SurgeXperiences is a bi-weekly blog carnival featuring posts on a variety of surgical experiences. Find out more...

Deadline

The deadline to submit blog posts is October 25, 2007 at midnight local time.

Submission Procedure

Submissions will be accepted via a Blog Carnival. Click here to submit your blog post.

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Education mirrors reality in a series of random coincidences

I got a text message from a friend this morning:

"Leafs forward Jason Blake diagnosed with CML (Chronic Mylegenous Leukemia) - More at TSN.ca."

The guy who sent me this text message is a huge Ottawa Senators fan, and he knows how much I love the Leafs (I still owe him $5 because of a game that Toronto couldn't pull out of the hat last week). As often as he can, he tells me how much he thinks the Leafs suck, even though the Sens haven't won a Stanley Cup for way longer than the Leafs.

So, combine that with the fact that our last week of class involved learning about all the types of leukemia, lymphoma and myelodysplastic syndromes, and it's obvious that I would interpret this text message as him reaching a new low in mocking my favourite sports team.

But then I checked it out. He wasn't kidding.

Odd coincidence? Yep. Virtually impossible? Okay, probably not even close... but still weird.

It's not just with this story, though.

This week's Extreme Makeover: Home Edition built a new home for a family of a girl with another type of cancer we learned this week. Don't ask me how I know that.

It gets better. Last week, the cover article of the Canadian Medical Association Journal matched exactly what we were learning that week. We were learning about blood formation - and the cover article was on Erythropoitein, a hormone that influences red blood cell growth, and its role in the therapy of critically ill patients.

And - get this - that's happened almost half a dozen times with the CMAJ. I'm talking cover stories, too - not just articles within the journal.

During our pulmonary unit, the week we learned about deep-vein thromboses, there was a cover article on that in the CMAJ. Our intestine week was accompanied by a CMAJ cover story on colon cancer screening. And there was a cover article on Ovarian Cancer right about when last year's class was learning about reproduction.

Not only that, but a cover article on alcohol use was right during the week when we medical students were drinking a lot of alcohol (okay, that one wasn't a coincidence at all... that could be any week).

But, to top it off, during the very week we learned about Congestive Heart Failure, not only did the cover story match that topic... but my PBL small-group tutor had written an article in that edition of the CMAJ.

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Studying Scared

What does it take to get Vitum off his butt and into study mode?

Good intention? A desire to do well?

Try fear. Plain, simple fear of failure. That's all it takes.

Unlike last year, when around this time I was enjoying how slack I thought medical school was, this year is different. Not just for me - I've noticed that a lot of people who took it easy early in the semester for the last two terms are turning up at the hospital & university study rooms on the weekends / evenings. And I've got three things that are giving me enough fear to get me studying scared this early into the semester.

1. Life around finals time sucks.

First of all, now that I've been through a year of medical school, I'm more aware of what it involves. I know how hard I had to work when last year's finals were approaching. I spent entire days and entire weeks studying with few breaks. Seeing few friends outside of med - and even friends in med - was not an option, and how the only thing that kept me going was the thought that "if I don't work my butt off, I'm gonna fail." I don't want to be going through that again come finals at the end of this term, so I'm studying now. Hopefully, as a result, around finals I'll feel a bit more prepared and the stress level will be a bit lower.

2. Finals are gonna be brutally hard.

While that should be reason enough to get my nose in the books, there's another reason. If there's any truth to what the third-year students say, my finals this year are going to be tough... much harder than last year.

That could be because for some of our units, the course directors have decided that providing us with lecture notes and lectures that cover all the topics that will be on the final are ineffective strategies for teaching physicians, and so we're expected to do a lot of reading from a variety of sources outside our lecture material. That's intimidating... as is generally the case with medicine, there's not enough time to learn everything, which means I can only hope that which I've learned is enough to get me through.

3. I don't want to fail and have to repeat second year!

In addition to those first two reasons, there's something else. There are a few people in my class this year who are repeating second year. Their reasons for doing this span a wide range - personal reasons, lots of stuff going on in their lives, MD/PhD students who are doing bits of the program at different times as their classmates, and not doing well enough academically last year.

Despite the fact that I don't know the individual reasons that these people are in my class, every time I see them around I think of the last reason. Yeah, it's hard to fail out of med school, and if I do fail a few courses I'll be able to repeat the year, but the third reason I'm getting my study on is because the last thing I want to be doing next year is repeating second year. Med school is a long time and I'm excited for the clinical part of medicine, which doesn't happen until next year. I would hate to be stuck in another year of PBL and our physician and society course.


The funny thing is, I'm sure this year will be a lot like last year in that it seems 90% of the class is scared of failing, but 99% of the class ends up passing. I think it's because we former pre-meds are used to undergrad exams, which we would routinely go into feeling like we knew all the material. Med school exams are scary because there's no way you will know all the material... and getting your 60% for a pass is much harder and requires much more knowledge and understanding than getting a 95% in undergrad.

There's a few people I've talked to that are afraid of third year. Rightly so - from all accounts 80-hour work weeks, being on call all the time, and having the stress of working with attending physicians, seeing patients, and trying to figure out where all the equipment is - let alone knowing how to use it - will be stressful enough. But I'm not even thinking about that yet. I just want to get through second year.

====

By the way, Happy Thanksgiving, y'all. That's right, it's Thanksgiving weekend in Canada. (early holiday, our soaring currency, our pristine health care system...bet you want to move here now!) Seems like everybody is doing family stuff this weekend, but since school is so far from the family - and since the 'rents are coming out here in two weeks - I'll be going to a friend's house for the festive meal. He's a master in the kitchen and I'm looking forward to it.

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Getting used to palliative patients might take some time.

For our clinical skills classes, we spend most of our time on actors / standardized patients, who come into our clinical skills training rooms at the hospital and we learn how to do basic exams on them.

However, the odd time we'll go onto an actual hospital ward and get the opportunity to examine symptomatic patients.

Last semester we were at the hospital practicing our cardiac exams on a couple of hospitalized patients. My group was assigned a patient who was really friendly, and such a great sport - she didn't complain once about the four medical students percussing and auscultating her chest, tapping for a lung here, listening for a murmur there, asking her to sit up and lie down, even though it was obvious that due to her bad back the ordeal wasn't entirely pain-free for her.

Over the twenty or so minutes we spent at her bedside, she told us more and more about her condition, but she also talked her life - her job, her family, and the things she enjoyed doing before she ended up in the hospital. She wasn't too old, and she was pretty coherent. She seemed like a really nice lady, and I really enjoyed the chance to get to know her.

After our exam, we went to the nurse's station with our physician tutor, who called up the patient's lab tests and CT scans on the computer. We talked a bit more about the patient - she had a few other conditions that weren't related to our cardiac exam which we briefly talked over - and then were ready to move on to the next one, when the doctor said something that hit me like a truck.

"So that's Mrs. Walters. With all of that going on in her body, she doesn't have much longer to live."

I was shocked. I had just spent twenty minutes with this patient. She seemed to be functioning cognitively pretty well, and I figured she was in the hospital getting fixed! Never in a million years would I have thought she was about to die.

The seriousness of her situation started to set in, and from a medical perspective I realized that yeah, if I had been given this patient as a narrative case, I probably would have figured out that the prognosis was dismal. But because I met the patient as a person first, and didn't know all the details of her condition while I was talking to her, I hadn't really thought about what her prognosis was. Even while our tutor was going through the patient's chart, listing her conditions, the impending outcome of the sum of her conditions never hit me until the doctor put it into those words.

I suppose that now that I think of it, I might as well get ready for my clerkship year next year, when I will be meeting dozens of patients on a regular basis - some of them who don't have much longer to live. I've never really been in that situation before, and I think it's going to take some getting used to.

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New poll on VM: Nice Doctors (and Sicko poll results)

For RSS readers of this blog who can't see the updates on Vitum Medicinus -

Check out the newest poll at Vitum Medicinus, and provide your opinion on the question:

Based on the doctors you've met, what is your impression of physicians?

• All doctors are nice to patients.
• Most doctors are nice to patients.
• It's about 50/50.
• Most doctors are mean to patients.
• All doctors are mean to patients.

Find the poll in the right-hand column on any page in this blog, under the heading "Vitum Pollicus."

Previous Poll Results:

Vovici Online Survey Software

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It had to happen eventually: "That sounds like something I read on a blog once."

When I'm hanging out with med friends, as much as we may try to avoid it, every conversation turns to school somehow... some gross thing we saw, some cool clinic case, or general hatred or love for certain professors. (The professor who approached me and told me he reads my blog fits into the latter category, of course).

The other day I was at a classmate's house having some incredible steak, and for some unknown reason, the conversation turned to our cadavers.

We were talking about the nature of our cadavers and how some of the ones with high BMIs are really hard to dissect... some of them you're cutting through the skin and you cut and there's fat, so you go deeper and there's more fat, and you go really deep and you're in the muscle, and so you go back and realize that there isn't any distinction really between the fat and the muscle like there is on the really nice cadavers; instead, on the more fatty ones it's more of a gradient and the fat and muscle is all mixed together, making learning the muscles of the thigh and buttock a much different experience than if you had a different cadaver.

Anyway, a girl who's also in my class piped up that on some of the cadavers, at room temperature the fat is mostly liquid, and this requires suction to get rid of the extra liquid.

"Mine's a lot like that," I said. "It seems like every lab I'm suctioning the fluid... the dead human body fluid... mine had so much I ended up with it dripping all over my leg once."

At this point, my buddy's brother, piped up. He's not in medical school but is interested in going; otherwise he probably wouldn't be able to stand hanging out with med students and listening to their med chatter. He was apparently interested - not grossed out - by my story. "How did that happen?" he asked me.

I explained the story that I've written here before under the heading of Great Moments in Anatomy Lab, where I had proceeded upon a course of actions that resulted in DHBF (Dead Human Body Fluid) dripping down my leg.


This is where things started getting weird. Not dead body weird, but, well, read on.

After I told him the story of how I ended up with DHBF dripping down my scrubs pants, he looked at me and said, "That's funny, there's this medical blog I read, some medical student somewhere in the Carribean - the exact same thing happened to him."

I knew right away where this conversation was going to end up.

"Vitum writes a blog," said his brother. "Maybe you read it there."

"No," he replied, "this one I read was from a student in the Carribean, I think. The exact same thing happened to him - he ended up with DHBF all over his leg."

Either somebody is plagiarizing my blog, I thought, or he's referring to my story. "Yeah, I think that's my blog," I said.

"No, no," he insisted, "I really think this was some medical student in the Carribean that wrote the story."

I loaded up my blog on my mobile phone's web browser and said, "Read this."

Before he read it, he said, "Okay, okay, the story I read on this blog ended up saying the guy was upset that he had cadaver juice running down his leg, but the worst part was that this was the second time it had happened."

Which is exactly the premise of my story.

I handed him my mobile phone and stood back, watching it sink in.

He finished reading and looked up. "Weird... so that's you... well, I've read a fair bit of your blog. I had no idea."

I thought it was funny but he seemed a bit weirded out. Ten minutes later he was still talking about how weird it was that he'd been reading my blog all along, and he knew me, yet didn't know I was the author.

I did warn him I'd be writing about this. Still, I hope that reading about himself here won't be too weird.

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"I'll show you, bitch!"

The other day at the hospital, while I was shadowing in the emergency department, a physician called me over to the x-ray computer terminal.

"Vitum, come take a look at this."

He showed me an X-ray very similar to the one I've borrowed from Wikipedia thanks to the GNU Free Documentation License, photoshopped to match my story, and placed here.

"What's wrong with this picture?" he asked.

"Well," I replied, "I haven't done my musculoskeletal study unit yet, so I could be way off... but aren't hands supposed to be attached to arms?"

"Right!" the doctor replied. "Trust me, the story is just as good as the X-ray. It even made the newspaper."

Assuming that a story in the newspaper presents fewer issues of confidentiality, I'll share the exciting story with you here, with only a few altered details. Truth is indeed stranger.

Apparently, this gentleman was involved in a fight with his girlfriend, and all hopped up on drugs. The fight got more and more heated to the point where our patient reached his boiling point. "FINE!" he shouted. "I'LL SHOW YOU, BITCH!!!"

And show her he did. He proceeded to leave the house, go to the garage, and fire up the chop saw. He placed his arm under the saw, and sliced his hand off clean through at the wrist.

It gets better.

He realized that he was bleeding profusely, as typically happens when you slice your hand off (I assume), so he figured he should do something about that.

He went into the kitchen, fired up the stove, and in tribute to what happens in one of the Rocky movies - so I'm told - he mashed the freshly-severed stump of his arm into the red-hot stove element, cauterizing it to stop the bleeding. SSSSSSSssssssssttttttt.

I'm sure his girlfriend feels bad now. I hope she at least admitted he won the argument.

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One Story, Two Endings. Clearly I'm not a doctor yet.

The doctor looked at the patient's chief complaint on the chart. "Palpitations, SOBOE." He looked up at the nurse and made a joke out of it. "SOBOE - Shortness of breath on exertion... even I get that. Who doesn't get short of breath when they exercise?" The nurse laughed.

The doc grabbed the patient's ECG, which the nurses had already done and clipped to the patient's chart. One quick glance told him that it was a textbook example of normal sinus rhythm with the odd premature ventricular beat (PVC) - when the ventricles contract before they receive a signal from the sinoatrial node - something that happens in normal, healthy adults and is absolutely nothing to worry about.

"Hi, I'm Dr. Vitum Medicinus," said the doctor, scrawling his initials on the ECG sheet to show he'd read it, while walking into the patient's room. Dr. Medicinus took a quick history, and the patient described the thump in his chest that was consistent with a PVC. "We'll take a few blood tests and see how they turn out," said Dr. Medicinus, as he scrawled "MI Protocol" in the orders section of the chart. He was just covering his ass. He knew that the patient didn't really have a heart attack.

Sure enough, the blood tests for a heart attack were normal. "Nothing to worry about - PVCs are entirely normal if they're as infrequent as yours. You'll be just fine," said Dr. Medicinus as he walked back into the room. "If it gets worse, come on back in, but you're good to go now."

-----

The medical student looked at the patient's chief complaint on the chart. "Palpitations, SOBOE." He looked up at the doctor he was shadowing and made a joke out of it. "SOBOE - Shortness of breath on exertion... even I get that. Who doesn't get short of breath when they exercise?" The doctor laughed.

The doctor picked up the patient's ECG, which the nurses had already done and clipped to the patient's chart. One quick glance told the doctor that it was a textbook example of normal sinus rhythm with the odd PVC. Even the med student picked up on this.

"Hi, I'm Dr. Alex O'Brien," said the doctor, walking into the patient's room, "and this is Mr. Vitum Medicinus, a medical student working with me today; is it okay if he watches?" The patient nodded. Dr. O'Brien took a quick history, and the patient described the thump in his chest that was consistent with a PVC. "We'll take a few blood tests and see how they turn out," said Dr. O'Brien, as he scrawled "MI Protocol" in the orders section of the chart. Vitum thought to himself, "There's no way this patient is having a heart attack."

Vitum was right. Sure enough, the blood tests were normal. However, the doctor's years of experience told him to be cautious, and keep his mind open to other possible diagnoses. "I'm going to order one other test," he said.

Dr. O'Brien told Vitum that because the patient had just had his appendix out a few weeks ago, and was complaining of shortness of breath, he should check the patient's D-dimers - a blood test to measure if the body is breaking down a blood clot - as the patient was at risk for a pulmonary embolus - a clot in his lungs.

Vitum kicked himself. He remembered quickly dismissing the patient's complaint of shortness of breath. Actually, worse than that - Vitum had made a joke out of it.

Sure enough, the D-dimers came back slightly elevated - not too high, but enough that the doctor wanted to get a CT to make sure. An hour later the CT came back positive for a pulmonary embolus - a blood clot in the patient's lung.

---

In our pulmonary pathology lecture a few months ago, the lecturer described a pulmonary embolus as one of the worst ways to die. "I've seen somebody die from it once," the lecturer said. "The guy just gasping for air like a guppy, breathing as hard and fast as he could. The air was getting in alright, but the blood wasn't, and he suffocated to death with lungs full of air."

If I was the doctor, I would've sent that patient home. Maybe killed him. Just as described above.

Apparently it's a good thing that I'm not actually responsible for any patients yet. I'm glad thing medical school is four years, not one... I've still got a heck of a lot to learn.

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Great Moments in Anatomy Lab

Today in anatomy lab I was using the suction to clean the fluid out of the body bag. This fluid, scientifically known as DHBF (or Dead Human Body Fluid) is comprised of melted fat, extra embalming fluid, and random juices from the cadaver.

Unfortunately, I had an accident.

While I lifted up the body bag to try to get the DHBF to pool for easier suctioning, I accidentally inverted the corner, releasing a hidden pocket of DHBF which streamed directly for my leg.

As I stood there, feeling somebody else's fat running down my leg, I thought to myself,

"The worst part about this isn't the fact that I have DHBF running down my leg.

"It's that this is the second time I've done this to myself."

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Summer Facelift - What's New at Vitum Medicinus

Summer
+ job supervisors kind enough to realize that this is my summer
= free time to do some tune-ups at blog.vitummedicinus.com.

You may not have noticed all the upgrades, especially if you're reading VM in a RSS reader. In order that you don't have to pore over the blog looking for them like a radiology resident scanning an x-ray film (I had to tie in that photo somehow), here's the improvements listed for you.

• New Blog Header Photo
  I had to change it anyways since I grew a year older since I started this blog; but I figured I might as well change the photo to something that actually happened in medical school, rather than something I did during my pre-med years. This photo was taken in a hospital on my cell phone camera when a bunch of us were waiting around for a pediatric clinical skills session to start. My favourite part of it is the subtle tribute to Canadiana - there's a Tim Horton's coffee cup sitting on a table in the photo.

• Favourite and Most Popular Posts
  a.k.a. Vitum Posticles Popularis, now available in the right-hand sidebar as an easy springboard for anybody who wants to read the best of VM right away. None of the fluff. Just the top stuff. Favourites include First Post, First Breast Exam, and the Top 10 List Category.

• Feedburner RSS Feeds
  By becoming an RSS reader user I developed a lot more respect for those who use RSS readers, especially those who read VM via RSS. I also developed a healthy bit of embarassment at this up-until-now-ignored aspect of my blog, and now that I've delved into the world of RSS I added Feedburner RSS feeds to maximize the functionality of my feeds. Subscribe to Vitum Medicinus via RSS... or get a Feed Reader (Google Reader is great).
  

• E-mail Updates
  For those of you who, like me, are reluctant to jump head-first into RSS without really understanding it, you may prefer to get VM posts e-mailed to you whenever they're written. If so, you can subscribe to VM via e-mail.
  

• Polls & Poll Results
  You can now view all polls that have been hosted at VM, and vote in any of them or check out the results. Jump to polls...

• Grand Rounds Hosted at VM
  VM had the privilege of hosting Grand Rounds for the first time; version 3.43 was hosted here on July 17, 2007. Reviews include "best GR in recent memory, there, I posted that for you, now where's my cheque?" and "you put way too much time into this." Jump to GR...

• Post to Facebook, del.ici.ous
  For those of you who care about your friends enough to share a VM post with them, you can now post a VM story to Facebook or del.ici.ous thanks to the convenient links at the bottom of each post - whether you're reading it on VM or in RSS.

• New to Medical Blogs? Vitum's Guide for the New Medblog Reader
  Okay, this one is kindof just another post on VM, but it's included because it's a tool for people who - like me just over a year ago - don't know Web 2.0 from a medblog. Especially important now that I've indicated that reading medblogs is important for any pre-med. Check out Vitum's Guide for the New Medblog Reader.

If you have any more suggestions on how I can improve your VM reading experience, please let me know by comment or via e-mail - and thanks to those of you who have been kind enough to bear with me as I tinkered with the settings of VM, or have suggested improvements already.

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Top 10 List: Terrific Tips for Stupendous Suturing

Today, while shadowing in the ER, I sutured real people for the first time. Twice.

Clearly, this makes me one of the world's leading expert on skin sewing. Ask any doctor.

This, and watching dozens of lacerations put together, and taking part in a suturing workshop with very realistic artificial materials designed to perfectly simulate human skin (those materials being made of box cardboard).

Fortunately, it was the second patient - not the first - who asked, "Have you done this before?"

I answered him truthfully. "Yes," I said.

So, having learned so much from my great wealth of experience, I have decided to benefit you, the reader, with ten terrific tips for stupendous suturing of lacerations.

If you're a medical student, like myself, use these ten tips and you will blow away your classmates.

If you are a nurse or patient, read this list then verbally chastise any physician you see who does not follow these ten tips.

If you are a doctor, verbally chastise yourself right now, out loud, under the assumption that you do not know all of these ten tips.

I request no repayment for this tremendously valuable guide, other than the act of "suturing" be re-named "Vituming." With a capital V.

10. Don't have your stethoscope draped around your neck while you suture. Place it in a pocket or on a desk.
It will get in the way and ruin your sterile field (not good) - very important for emergency department laceration suturing.

(Actually, research has shown that sterile gloves and sterile saline are not needed for ER suturing, as they don't significantly reduce the rate of infection.)



9. Don't have your ID badge on a lanyard. Use a clip instead.
It will get in the way and ruin your sterile field. So not good.


8. Don't have your lab coat on. Roll up the sleeves or remove it.
The sleeves will get in the way of your sterile field. Like, totally, so not good.


7. If the patient is getting woozy, tell them not to look at the wound.
The patient I saw was very pale. Research shows that by telling them not to look at the wound, they will not get woozy (research pending). Research also shows verbally demeaning or physically assaulting the patient will help with compliance on this point.


6. Don't bend the needle.
This will make it a pain to get through the wound. This is partially accomplished by grasping the suture needle at the right point with the needledriver - close to the end.


5. DON'T POKE YOURSELF.
Generally, getting patient blood inside you is something you should try to avoid. Mostly for the pain, I think that's what I was told once, but there are supposedly some blood-borne illnesses that are nasty.


4. Poke the patient.
You can't suture a patient if you don't puncture their skin with the suture needle. Trust me on this one. This is more important than #5; as well, the comedic value is decreased if it is ranked higher than #5.


3. Ignore the fact that the image associated with this post shows suture removal, not suture administration.
Allowing little errors like this to cloud your mind while you suture will distract you from doing a good job. Your patient will complain, and likely sue you.


2. Efface the edges.
For improved wound healing. Or something like that.

1.

Sorry I couldn't come up with a #1. What did you think I was, an expert on the topic? I've only done this twice.

By the way, before you follow any of these, make sure you read the disclaimer below. Especially the part about not listening to any advice on this blog.

(If you actually are an expert, by all means, post your tips.)

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The day the ER nurses ganged up on me

I swear I was being good. Really, I was! Honest!

But still, they hunted me down and cornered me, like an angry, bloodthirsty pack of shewolves avenging the death of their young. Or something like that.

Tonight, during a ER shadowing shift, I was sitting unsuspectingly at a computer (I don't know how else to sit), looking up the difference between ringworm lesions and lyme disease target lesions. You know, minding my own business. I thought I heard some nurses off in the distance saying something like "student" or "medical student"... but I brushed it off and ignored it. I went back to my googling.

And then it happened.

I felt a massive shadow coming up behind me.

I turned around... in time to see half the ER nursing staff approaching me in a pack akin (great word) to a pack of shewolves (yes that word is worth the repeated reference).

I hadn't done anything wrong (other than written a certain blog post several weeks ago which shall remain unnamed here) but I figured I was screwed.

I felt like those folks must feel when the infamous Sumdude - a.k.a. 'some dude' - jumps them without warning, rhyme, or reason. By the way, for those who don't know, Sumdud is an emergency medicine phenom (another great word) documented by paramedics, respiratory therapists, nurses, and doctors alike.

Anyways, they surrounded me, towering over me - only because I was sitting down - and shone a light in my face. And thus they began their brainwashing session.

"Be nice to nurses!" they said. "Nurses know best." The skinny one in the back of the herd adjusted the giant, whirling spiral which I can only assume was meant to hypnotize me into oblivion. "And nurses love coffee - bring your nurses coffee."

I shifted uncomfortably. Their tactics were working. I was feeling their efforts to convince me were working. I nodded my agreement in an attempt to signal to them that the giant stainless steel probe they were holding just inches from my face wouldn't be necessary.

Okay, I was wrong about the light, the whirling spiral, and the probe. But a group of nurses did corral me today, and did tell me to be kind to nurses. They were mostly joking, but obviously there is a certain level of seriousness to their comments - I'd be dumb to assume that these nurses haven't been cruelly treated by a doctor at one time or another - though the doctors I was working with today were outstanding.

Fortunately I was able to explain to them the same thing I said in that other, previously mentioned but unnamed post, that I've been told all this already by my nursing friends and my nurse mother.

I wish this story had a more dramatic ending, but that was it, really; my comments seemed to appease them. The rabid pack broke apart, most of the nurses wandering off into the meds room, still laughing about their indoctrination method, and sharing stories of nursing back in the days when nurses used to stand up when doctors entered the room and mustard poultices and turpentine were common treatment methods, and I went back to my Tinea corporis and Borrelia burgdorferi.

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