Sunday, September 30, 2007

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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Thursday, September 27, 2007

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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Sunday, September 23, 2007

"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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Monday, September 17, 2007

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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Tuesday, September 11, 2007

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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