It's Christmas break. "You study your butt off for 8 weeks for one of the subjects, you live and breathe it, you learn everything there is to know, all the basics, all the obscure rare diseases you'll never see, and then you show up to the exam and feel like you get 0 of the 100 questions correct. Everyone thinks they failed. Everyone does just fine."
Thank God.
I just wrote my Surgery exams and they were well-timed to occur just before the break. I'm not sure I would have lasted if I had to go back to work the day after my first NBME (National Board of Medical Examiners) written & oral exam of the year.
Now only 4 more to go. We write 5 NBMEs in our third year - Psychiatry, Obs/Gyn, and the "Big Three" - Surgery, Internal Medicine, and Pediatrics.
Before I wrote my first NBME, I was given a heads up about what they're like. The way these exams were explained to me by those who had written it?
Another piece of advice, which I'm not sure how it was supposed to help me prepare for the test (other than psychologically):"People walked out of the exam room crying. I heard someone sobbing during the exam."
On the test day, we had to sign and be read a few dozen disclaimers about the exam and not sharing questions, so the following isn't word-for word, but it suffices as a sample question:A 42-year-old man presents with bilateral ear pain. Choose the correct diagnosis from the following list of options (a through f):
Or, to compliment the questions with too little information, there are also long, detailed clinical scenarios of patients who present with a plethora of symptoms, have every known comorbidity, and their family history, social history, physical examination results, and lab data are all spelled out for you. So, you read through and underline the pertinent information, convert the lab data from American to International units, and then realize the question at the end of the scenario has nothing to do with the scenario and simply asks something like, What is the most common cause of small bowel obstruction?
I'm not sure the point of writing an exam that gets curved so vehemently that it doesn't really help you learn what you know and what you don't, or why we aren't given the opportunity to see where we went wrong and use the questions as a learning experience.
Just another hoop to jump through, I suppose. Just like the oral exam.
I'll rant about that one another time.
For now, you'll find me on the couch by the TV, sipping egg nog.
Friday, December 26, 2008
My first NBME board exam
Thursday, December 04, 2008
I don't think your arm is "bruised"
He was coming into the family doctor's office I was placed for an entirely different reason, this pleasant, absent-minded, blissfully unaware old chap. "Hello, young fellow!" he said, when I came into the room.
I returned his happy greeting, and asked what brought him in. "Oh, nothing much, just here to get my prescriptions renewed, then I'm on my way! Sorry to trouble you!" He was such a cheery guy.
"Why are you wearing that long hankerchief around your neck?" I asked him, making small talk as I started copying out his drug list.
"Oh, just for a bruise on my arm, it's a little sore. I tripped over my shoelaces while I was getting my morning paper a couple weeks ago." He held up his arm.
My eyes bugged out when I saw it.
His bruise had gone away, but he had much more than that left over - about six inches up his arm from his wrist, he had what is called a "step deformity" - his arm bone was simply no longer straight. An obvious sign, visible from across the room, that his arm was broken, not bruised.
Not surprisingly, the doctor I was working with sent him to the emergency department to get his arm casted.
On my way back home from the office at the end of the day, I stopped at the hospital and called up his x-ray on the computer. Sure enough, he had a definite Smith's fracture of his distal radius, typical of a fall onto a closed fist.
By chance, the emerg doc was walking by, saw I had dropped in to look at the x-ray, and said, "We're about to reduce that patient's fracture - do you want to do it?" Nice!
So, we put the jolly old fellow into an even more blissful state with some propofol ("milk of amnesia," as this white liquid is sometimes called), and yanked and pulled and tugged on his arm to get it back in the right place, then wrapped a cast around it. I love working in small hospitals - a pretty neat chance for followup on the patients, and no other resident or student there at the time so I could just jump in and do the procedure.
Epilogue: I didn't stick around to look at the post-reduction x-ray, but a few days later, I came back to the emergency department and called it up to see if the bones were set in the right place. Randomly enough, there was an orthopedic surgeon charting at the desk next to me, so I told him the story and asked him what he thought of the post-reduction x-ray. He was not impressed - turns out that if someone's arm has been broken for two weeks, it shouldn't be reduced in the ER because it's too far into the healing stages - surgery would have been more appropriate. Well, now I know.
Thursday, November 27, 2008
Med Student Syndrome: I have ADHD.
Med Student Syndrome: A disorder, commonly seen among medical students, in which the student feels they suffer from every medical condition known to mankind.
It's hard not to feel this way when you are learning about attention-deficit hyperactivity disorder, with which I have diagnosed myself (along with depression and many other conditions).
A selected portion of the diagnostic criteria. Let's see how many of them I fall under:
- Often has difficulty sustaining attention. Check.
- Often avoids tasks that require sustained attention. Check.
- Often is forgetful. Check.
- Often loses things necessary for activities. Check.
- Often fails to give close attention to details and make careless mistakes. Chk.
- Often does not seem to listen. Pardon me?
- Often is forgetful. Check.
- Often does not seem to follow through.
- CHECK - organizing tasks: often has difficulty.
- Often is forgetful. Check.
- Often is easily distrac - hey, it's nice outside...
Saturday, November 22, 2008
Make sure you know what you are getting into... [part two]
When I give that advice to pre-med students, I say it knowing full well that they'll respond to that advice the same way I did - by spending a bit of time learning about medicine, being fascinated by the great parts, and pretty much completely whitewashing any challenges that come up without ever experiencing what they are like:
"Being on call and getting to sleep at the hospital after a full office day sounds exciting!"
"Having a patient stop breathing and everyone looking to me for a decision sounds like it would be a thrilling challenge!"
"Not seeing my wife and family because I am spending 16 hours a day studying sounds like an honourable sacrifice!"
And some of them last well into med school: "I can't wait to have a pager!"
It's not necessarily Mr. Eager McPremed's fault. A large part of it has to do with the fact that it is so hard (especially in North America) to get experience shadowing physicians one-on-one, let alone living the life of a physician day in and day out with full office days and on call nights.
Another reason pre-meds tend to brush off the difficult parts is because the pull towards the pursuit of medicine is so strong, especially when the pre-med student has the capability to succeed in it. It is so hard to be honest with yourself and walk away from a career path that impresses everybody you tell about it.
When you tell someone you're thinking of applying to medical school, the look on their faces, the eyebrows going up, the subtle gasp, and the inevitable story of their friend's nephew with an A+ average who now works for a drug company because he didn't get in after four times applying to med school gives you a feeling as addictive as some drugs. ..and coming to the point where one realizes that a life of medicine is not for them would mean having to give up the dream and everything that comes with it... including the look on peoples faces when you tell them.
I had this in mind the other day when I read a Starbucks cup quote, only the second one to ever make an impact on me (the first one that ever impacted me I read the day of my med school interview, ask me about that one some other time):
The Way I See It #26
"Failure's hard, but success is far more dangerous. If you're successful at the wrong thing, the mix of praise and money and opportunity can lock you in forever." - Po Bronson, Author of "What Should I Do With My Life"
That's why I have frequently recommended reading medical blogs, which have a great way of showing all sides of medicine if direct experience can't be obtained. I have also often recommended Ifinding's series of blog posts, the Don't Become a Doctor Series.
Hopefully reading those will encourage medical school hopefuls to realize that getting into medicine is an extremely serious decision that should be fully investigated before it is pursued.
It might sound like I'm regretting going into this. I'm not - I've just come to a challenging part of the journey that makes me stop and be thankful for what is driving me and giving me the motivation it takes to get through this. It also makes me feel really, really sorry for those people who are going into medical school for superficial reasons, like the money, their parents' wishes, or that look on peoples faces... beacuse when they get to the rough patches, I really don't know how they'll keep putting one foot in front of the other if that's all that is driving them. If those are the driving reasons, and not something deeper, spare yourself... dragging yourself through this gauntlet just isn't worth it.
Saturday, November 08, 2008
Make sure you know what you are getting into... [part one]
One of the pieces of advice I was given as a pre-med, and that I frequently give to pre-med students (it's #7 on my Top 10 list of advice for pre-med students) is,
That was ringing quite loudly in my mind when I started my call shift the other night. I had had a busy week in surgery. There were some really long days of showing up on the ward at 7am then a full day of office then going straight to the hospital at 5pm and seeing emergency patients and eventually taking them to the operating room and getting home well into the wee hours of the morning... with a full day in the office after that.
Most of the surgeries were routine, but some came with the emotional stress of having to tell a patient and their family they had a 50% chance of dying on the operating table, and a 50% chance of us opening them up, finding that we could do nothing, and closing them up to face their death within the next few days. (One patient's response to that speech? "Bloody hell." Yeah, no kidding.)
I also had a long academic half-day full of lectures on things that I need to know but had no energy to learn, that also went late into what was going to be my evening relaxation time.
I had to try and fit in studying for my two upcoming exams in between all that, and then on top of that I tried hard to make time to get some exercise and spend some quality time, either on the phone, online or in person, with the people in my life who mean a lot to me. And no, there was no time for going to my buddy's poker game, watching the Leafs get their butts kicked (I haven't watched one game this season!), an afternoon round of golf, or any of the other things I would have enjoyed doing that resemble this "having a life" thing I've heard so much about.
As soon as I finished work in the surgeon's office for the last day of this tough week, I headed to the hospital to get my pager and start call - and within five minutes of my call shift starting, my resident and I had five patients to see, all of whom were pretty sick. Just as we were trying to figure out who to see first, the pager went off two more times. We didn't get a break longer than ten minutes until 2am, when I got a bit of sleep before the pager started going off again (getting a bit of sleep means it was a lucky call night).
I'll admit when all those pages were coming in right at the start of the shift, I was feeling the stress of the whole week on top of having a lot on my plate all at once, and I fell into a rut I find myself in once every year or so when all the negative thoughts come rushing to me. I find myself seriously asking if I am in the right place, if I made the right career decision, if I will ever be able to treat patients on my own, if I really knew that medicine was like this before I invested all that effort and money into pursuing it.
Fortunately, the five minutes the resident gave me before I had to meet up with him on the ward was just enough time to break down, almost re neg on my no-crying policy, and beg for some strength from heaven.
Fortunately, God was listening and obliged. And all in all it ended up being a really good call shift. For me, that means a night with some varied, useful cases that are important for me to learn how to manage, and with some good opportunities for me to see patients on my own, evaluate their situations, and develop a plan and present it to the resident for their approval and questioning. We triaged those first cases well, and got through them and all the other calls throughout the night, and put off studying for just a few more hours in order to do those therapeutic things like write this post and sleep in late for the first time in a while.
Monday, November 03, 2008
Poking a screaming child? That'll put hair on your...
"Bet you feel the testosterone surging through your veins now, eh?" the ER doc supervising me said. "That'll put hair on your chest."
Then again, I'm sure everyone else in the ED (and all the other wards on that floor) also had a snappy comment for me, seeing as how each and every one of them could hear the screams of my patient.
A young girl had gotten a huge gash in her arm after falling through a plate-glass window, and the emerg doc took one look at her chart and handed it to the resident, who handed it straight to me. At that point I was still unsuspecting, super keen to sew up yet another wound. Boy, was I naive.
After looking at the wound I flattered her quite nicely about being such a trooper, such a large gash and all and so little crying.
Turns out that all my buttering up was for nothing, which I found out as soon as she asked if she would be needing a needle.
That's where I went wrong.
She sensed my instant of hesitation before my answer, and took that as her cue to start screaming at the top of her lungs.
The screaming didn't stop. We tried everything from distraction, to warm blankets, to massaging her temples, to topical anesthetic and intranasal fentanyl, all of which seemed to only fuel the screaming, which lasted well into the procedure, despite the gallon or so of lidocaine I used to freeze the wound.
Even though I have sewed many a wound with very little fanfare, this whole experience actually stressed me out a lot -- much more than I expected it to.
You see, I still have enough compassion left that it makes me feel REALLY bad when I know I'm hurting a patient, especially a child, and I get uncomfortable when I see a pouty look, let alone screams of bloody murder and "PLEASE STOP! NO MORE NEEDLES! OH FOR THE LOVE OF...' Yeah, I didn't know 11-year-olds knew that many swear words. Kids these days.
It was made even better with the parents shooting me the look of death the entire time for causing harm to their little angel. Fortunately, the father's claim that he wouldn't be bothered by the blood soon proved to be quite false, and the emerg doc saw him starting to reel and whisked him away, saying "OK, come with me, you are sitting down over here. Put your head between your legs."
As well, with all the the flying fists and limbs I was pretty scared of buring the syringe or suture needle in my own hand.
In fact, I was even more stressed that I'd be poking the care aide holding the child down. Keeping this saint happy had risen to a very high priority ever since she set aside one of the leftover hospital meals for me (which, despite being hospital food and looking like it had already been digested once, was still food).
The procedure finally ended, and she finally went home, and a strange calm fell over the emerg. In fact, with the young girl gone I could only really hear monitors beeping, ambulance sirens, nurses shouting, and other patients yelling, which was so much more quiet than when that girl was there.
Later on, one of the doctors told me that he used to feel bad poking children because they would cry so much. "Then," he said, "I had my own kids, and realized they cry all the time... even if you are not doing anything to hurt them."
That did make me feel a bit better. But I was still so worked up when it was all over that I considered going to the homeless gentleman and ask if he was gonna finish that bottle of rubbing alcohol he was using to get drunk (tuition is due soon, so I am trying to get all the free hospital food and free alcohol - of any form - I can get). I figured if dealing with the screaming child didn't put my hair on my chest, perhaps some isopropyl alcohol will.
Either way, any more shifts like this and I think I'll start losing hair rather than growing any more.
Friday, October 17, 2008
The call any med student in Emerg is waiting for: "There's been a massive accident."
It was shaping up to be quite a boring shift. Only a couple hours to go, and nothing very interesting. There must have been a notice in the paper that the super keen medical student (myself) was going to be working a shift in Emerg, because there really could not have been any other explanation for the massive numbers of people showing up in droves with a chief complaint of "I have a runny nose."
Then suddenly the night got very interesting. Here's the play-by-play.
6:30 pm :::
A call came in from ambulance dispatch, and the unit clerk quickly summoned the doctor and charge nurse to keep them informed: "There's been a massive car accident down in the valley. A minivan and a car carrying six people in total crashed into each other head-on, somehow got entangled to the point where they were attached, and then both went over the side of the bridge, careened down an embankment, ran into a few trees and then burst into flames. We're setting up for massive burns, tree trunk impalements, major trauma and who knows what else. The medevac helicopter will likely take out the most serious victims to the larger hospital in the next city over, so we'll likely get a few of the less severe tramas...but by the sounds of it, even those will be pretty serious. By the time they get them extracted and bring them in, they should be here in about 50 minutes."
6:40 pm :::
There is a buzz around the department. The night shift MD shows up to start what he had hoped would be another routine shift, and is instead informed about the upcoming chaos, with several curious other ER staff crowding around to hear the briefing. More reports have come in - the area is too heavily forested, meaning the helicopter can't land. All the traumas will be brought in by ambulance to our hospital!!
7:00 pm :::
The night resident has been paged to show up earlier, the afternoon shift MD (whose shift was just ending) made the decision to stay a bit later, and people are busy in the trauma bay setting up IV bags. The care aides and clerks are suddenly finding solutions to the longstanding province-wide 'no beds in the rest of the hospital' crisis, magically clearing up four beds in emerg in anticipation for the incoming carnage. I'm helping out a lot, too, I'm told, by going to see a patient who had a bookshelf fall on her head. And another runny nose.
7:10 pm :::
Another report comes in. The meat wagon won't be in with what's left of the survivors for yet another hour; it seems as though the army or search & rescue might have to be called in to access the area. There's even a suggestion that there might even be gunshot wounds if the drivers got into a road rage argument after the dust settled. In the meantime, my patient with the bookshelf falling on her head turned out to only end up having a textbook fall on her head, the rest of the shelf narrowly missing her body. Her friends were quite concerned, and brought her in. Oh, and she also wants me to assess her runny nose.
7:20 pm :::
The latest from the disaster zone is relayed to the physician: there is an indication that things may not be as serious as they were initially thought. Three of the people walked out of the accident unscathed, but the other three still seem to be pretty serious. No word on the accuracy of the gunshot rumour. For my patients, I continue to prescribe kleenex, one of the few things that I as a medical student can actually dole out, like it's nobody's business.
7:40 pm :::
Word arrives - the ambulances are on their way! One is coming Code 3 - lights and sirens - with the major trauma victim. The other two will follow, as they're coming routine, without lights and sirens, as their patients aren't too serious. The afternoon shift doctor figures that she may as well go home, since things aren't as bad as they first seemed.
8:00 pm :::
Things have somewhat died down, until the first ambulance is heard in the distance bringing in what must be the major trauma victim. A crowd of ER staff instantaneously gathers at the ambulance bay entrance to greet the incoming disaster. Notably absent from the crowd are the seasoned veterans among the emerg staff, and the doctors, who are going about their own jobs.
8:05 pm :::
The ambulance has screeched to a halt, and the paramedics are throwing open the rear doors to reveal their mangled cargo. The crowd that gathered utters nearly an audible, collective groan of disappointment as the patient is wheeled out of the ambulance, sitting up on the stretcher, laughing and joking with the paramedic, without so much as a single indication of major burns, tree trunk impalements, or missing limbs or appendages. In fact, the patient has a makeshift splint on one of his legs, and other than that, appears to be completely well. The patient is deemed non-urgent, and the doctor sends me in to see him. He explains that the accident was pretty much a fender-bender that ended up with his car ramming the guardrail. And despite having what might have been a broken leg, he says that it doesn't hurt that much, and that actually the major thing bothering him right now is his runny nose.
Sunday, October 12, 2008
She was one of those 'natural' people, and the odd x-ray terrified her.
She was one of those 'natural' people, who always wanted to do things naturally, and even the odd x-ray terrified her. Too much radiation. She once wore a cast on her arm for 6 weeks after falling off a horse, for what could have been just a sprain, just to avoid the two x-rays it would have taken to rule out a fracture.
So, obviously, getting a mammogram was out of the question.
Her doctor tried over and over again to explain to her that a mammogram gives you a very minimal amount of radiation, the same amount as living in a city for 7 months (0.7 milliseverts) - the average U.S. citizen is exposed to 3 mSv per year of 'background' radiation.
The mammogram would have picked up her breast lump long before she felt it, long before it was diagnosed as cancer, and long before she would have to get her breast surgically removed.
A few years later, she started losing weight suddenly, then one day coughed up a startling amount of blood. She had never smoked, so lung cancer never even crossed her mind. Fortunately the radiation dose of 1 chest x-ray (0.1 mSv) no longer scared her, given her past experience, so she got the x-ray her doctor recommended to check it out. Unfortunately, however, breast cancer can spread to the lungs, which is what her doctor found on the x-ray. She died a few weeks after I met her in hospital, surrounded by her family, and countless beautiful flowers and cards showing how much she would be missed.
The week before she died, she said to her doctor over and over, over the sound of her oxygen and between short, gasping breaths, "I should have listened to you. I should have gotten that mammogram."
I had a conversation with another patient last month who is younger than my dad, an incredibly friendly and cheerful man, who is dying because he was too afraid to have a doctor stick a finger up his bum. Had he done that, his prostate cancer would have been discovered a long time ago, long before the it had the chance to spread to his spine, ribs, and legs, forcing him to live his last few months unable to get out of bed and suffering from excruciating pain every time he tried to take a breath. While you are celebrating Christmas with your family this year, his family will be celebrating their first Christmas without him.
It takes a lot to wrap my head around the fact that I am meeting and treating patients who will be dead very soon.
It's harder to accept the fact that a good number of these patients, who drink litres of alcohol a day, smoke like a chimney, don't get off their couches, and especially those who don't bother getting screened for cancer, could have had much longer lives.
Yeah, the screening tests we have aren't perfect, and some of them are uncomfortable and seem a bit undignified. But they do save lives, and so if you are in that age group, there is no excuse to not get them done.
This is not the place to get medical advice, so talk to your doctor about getting a prostate exam, a pap smear, or a mammogram. Sooner rather than later, please.
Monday, October 06, 2008
If this post ends abruptly...
Note - I'm writing this in the hospital as I'm on call, so if it ends abruptly it means I got paged and have to run and was up all night and didn't get the chance to finish it.
While most of my call shifts have been pretty interesting, tonight seems to be very slow. So far, I've just been sitting around in the library, doing noth
Saturday, September 27, 2008
The curse of the medical student on obstetrics
Number of babies delivered on Monday and Tuesday morning while I was scheduled to be in the obstetrician's office: 9
Number of babies delivered on Monday and Tuesday afternoons while I was on the ward waiting for deliveries: 0
Number of babies delivered on Wednesday when I had been scheduled for a day of looking at rashes with a dermatologist: 6
Number of babies delivered on Thursday when I had been scheduled for academic sessions: 5
Number of babies delivered on Thursday night and all of Friday when I chose to give up sleep and instead sit on the ward in order to assist with some deliveries: 0
Plan to increase the number of deliveries for my second week of Obstetrics: Release prostaglandin into the city water supply, show up at the hospital, and wait. (For those who don't know, prostaglandin is used to induce labour)
I did get to see two c-sections, including an emergency one at 3:00 am for a prolapsed umbilical cord - very intense - but so far, no natural deliveries here.
Friday, September 19, 2008
When patients try to fool doctors - four interesting types of fakers
Most people have heard of Munchausen's syndrome, a fascinating condition in which patients try to fake a condition in order to draw attention or sympathy.
There are a few syndromes that doctors need to keep in mind, some of which are quite fascinating, in which the patient tries to fool the doctor for various reasons. Here are some of those conditions, how the patients fool the docs, and how the docs avoid being fooled.
1. Drug-seekers
What are they –
In a sentence, the bane of any ER physician's existence. They're either addicted to pain meds, or obtain and fill prescriptions then sell them on the street to addicted people for a huge profit.
How they fool doctors -
Drug seekers can be very slick. I have seen a patient had another doctor vouch for them, one who wore their full police uniform, an adorable 80-year-old church organist, and even nurses and doctors ... all of whom were found to be getting prescriptions for pain medications and selling them illegally.
How doctors recognize them -
Besides being highly suspicious of any patient who asks for narcotics, some regions have databases that doctors can use to determine if a patient has filled a suspicious number of pain prescriptions. However, some drug seekers raise a lot of suspicion on their own. They'll claim to be allergic to every non-addictive type of pain medication, which is statistically unlikely. Others are just bad actors. They’ll shriek and cry at the lightest touch when a doctor pokes their back to find out which part hurts… then later, the doctor will give them a friendly pat on the back, and find that the supposedly painful spot no longer seems to hurt.
2. Malingerers and Insurance Hopefuls
What are they -
A "malingerer" is defined as a person who fakes an illness with the intention of avoiding duty or work. I'll lump these in with patients who fraudulently fake or exaggerate illnesses to try and get insurance payouts.
How they fool doctors -
Malingerers will seem to have a lot of pain, and some actually are suffering from very real pain. They use this, however, to prey on a doctor’s empathetic side. They can also be quite convincing actors when they demonstrate just how incapacitated they are.
How doctors recognize them –
By knowing the physical exams and anatomy very well, doctors can get suspicious if the results of a few different tests of the same joint or muscle aren’t consistent. Some malingerers, though, can be fooled quite easily. Even I have had my suspicions raised with a patient who struggled to raise her arm a few inches when I asked her to demonstrate her range of motion. When I then asked her to show me how high she could raise it before her accident, she effortlessly shot her arm up high above her head!
3. Psychogenic nonepileptic seizures
What are they –
This is a term for people who appear to be having seizures, but it turns out that they are actually not suffering from epilepsy – for various reasons, they’re faking the seizures.
How they fool doctors –
Anybody in a doctor’s office or emergency room who is having what appears to be having a violent seizure, will obviously get the benefit of the doubt. In fact, in some cases, it is many years of investigating and giving high doses of seizure medications before a doctor realizes that the patient has been having nonepileptic seizures the whole time.
How doctors recognize them –
Research has shown that nonepileptic seizures occur more commonly in a doctor’s office or waiting room, or when there is a witness around. Some medical textbooks suggest giving such patients a sugar pill or an injection of water while telling them that this medicine has been known to cause seizures, and seeing if the patient starts shaking. While this can seem deceitful, the lie isn’t usually necessary: some patients still have these fake seizures even if they are told that they are being given something that can induce both real and fake seizures. Other things doctors look for are things such as where the patients bite their tongues, which is often in a different location for real and fake seizures, and the length and frequency of the seizures.
4. False comas
What are they –
Hopefully I don’t need to explain what a fake coma is. I will mention though, that people fake comas for a variety of reasons. Some people with psychological conditions feel safe in a hospital, and fake a coma so they are surrounded by doctors and nurses. Others have been found to fake being knocked unconscious on a ski hill, because they can’t afford a bus ticket home and would instead prefer taxpayers pay for a helicopter to fly them to the nearest city.
How they fool doctors –
By laying very, very still.
How doctors recognize them –
While there are some non-invasive tests that can be done to determine if a coma is indeed real, sometimes doctors aren’t even trying to “catch” a fake coma when they do their neurological exam and find that some results don’t add up. Also, patients who appear to be in a coma but resist the doctor opening their eyes, or flinching when the doctor’s stethoscope swings close to their face, obviously raise suspicion. Obviously to determine legitimacy it’s important the doctor knows what is normal, because strangely enough, patients with legitimate comas have been seen to do odd things such as cross and uncross their legs.
That’s not to say, however, that these “fakers” don’t need help. While the financial gains for drug-sellers or insurance scammers are usually based on greed alone, people who are addicted to drugs, or feign comas and seizures, can have very real and complex psychogenic conditions (to give you an idea of how complex these conditions can be, some patients may not even be aware they are faking). While they can make a doctor’s work more challenging, at the end of the day all of these people do need real treatment – not with narcotics or anti-seizure medications, but with psychological counselling to determine the underlying reasons that are compelling them to fake these conditions.
Saturday, September 13, 2008
Join me on my first on-call shift, and find out why I slept so little
For the future (and pre-clinical) medical students out there who are wondering what being "on call" is, I have just completed my first call shift. Therefore I am now a reliable source for information about what being on-call means. Here's how my night went:
5:00 pm ::: Start of on-call shift. On the phone with a friend in residency asking for some on-call tips. #1 tip: While on call, eat, sleep, and pee when you can. You don't know when your next chance will come.
5:21 pm ::: Fell asleep on the toilet while eating a granola bar.
5:36 pm ::: Woken up by a patient who claimed I was sleeping in his bathroom.
5:37 pm ::: Patient's claim corroborated by nurse, who is kind enough to explain to me what an "on call room" is, and where I could find it in the hospital.
5:41 pm ::: Changed out of my scrubs into pyjamas. Realized scrubs are more comfortable and changed back. Fell asleep.
6:12 pm ::: Woke up. The pager they gave me is making weird, loud beeping noises and has stopped showing the date and time. Now the display was just showing "911" and a few extra random numbers. Must be broken.
6:22 pm ::: Finally figured out how to make the pager stop malfunctioning and making such loud noises: take out the battery. Able to sleep again.
9:38 pm ::: Woke up abruptly. Some dude is banging on my door and shouting something about being "my resident" and how they have called me "100 times" in the last two hours. Must've had my phone on silent. Turned up the TV so I couldn't hear him, going back to sleep.
10:26 pm ::: That same dude got hospital security to unlock my door and wake me up. He is telling me to go to the sixth floor to "see a patient" with "delirium." Not sure what that means. Not sure what delirium is, either.
10:34 pm ::: Saw the patient - turns out the he is actually just a really nice guy who is a government agent, and he explained to me that he is being held against his will and that the nurses were trying to poison him. Helped him find his way out of the hospital so he could get back to being a secret agent.
11:17 pm ::: Back in the on-call room. Spent an hour propping all the furniture against the door so that my resident and the security guard couldn't come wake me up again.
12:19 am ::: Jumping on the bed.
2:54 am ::: Removed the pile of furniture from my door when I started getting hungry. Roaming the hospital looking for unconsumed foodstuffs on patient trays.
3:19 am ::: Found half a brownie and some cold soup on a patient's tray, and drank some apple juice that a patient thought they could hide from me by putting it in a pan under their bed. The apple juice wasn't very good, but it was free.
3:40 am ::: Running from the paediatric nurse who caught me drinking all the infant formula.
4:51 am ::: Back in the on-call room - can't sleep. Damn ambulances keep going by my window.
7:36 am ::: Woken up by security, who came in through the window this time, clever fellows. They told me to get out. Figure that means my call shift is over - going home to bed.
Turns out this call thing isn't so bad. It's basically watching TV, eating and sleeping. I think I could get used to doing this every fourth night.
Monday, September 08, 2008
Top 10 List: Ten things I learned in the first week of third year medical school
1. If you give a bunch of medical students pagers, many of those pagers will go off during the very next lecture. Oh, and we have to write something about the patient, too. 7. A hospital tour by a doctor who helped design the hospital will be much more engaging than a tour by an administrator who is reading the signs on the walls.
2. If you train and test medical students in anatomy, physiology and pathology for two years, when you give them a schedule saying "Monday - On Call" they will likely have no idea what this means or what they are supposed to do. Or if they should bring their pagers.
3. Lectures by fourth-year students explaining what "being on call" means and what to do when on call are very helpful. Lectures by senior faculty describing the abstract, theoretical concepts of effective learning aren't so much.
4. Rounds are not to be confused with rounding. Rounds come in two types, teaching and grand. While teaching is done on grand rounds, it is not the same as teaching rounds. Likewise, teaching rounds are not necessarily grand, though I suppose they could be, in the same way that nice people can be jolly. Of course, the internet phenomenon Grand Rounds is entirely different and could be considered a third type.
5. Properly scrubbing for surgery as a medical student simply involves making sure you scrub your hands for longer than any of the other surgeons or residents.
6. Every time we need to write in a patient chart, we need to write the following:
9. The summer is plenty of time to forget all the things medical you learned in the first two years of medical school.
10. Even if you remembered everything from the first two years of medical school, you would still know pretty much nothing compared to what a doctor knows.
Friday, September 05, 2008
The real first day of medical school... a moment six years in the making.
I told a group of first-year pre-med students today, "The moment I'm at right now is where you want to be."
True, they all want to become doctors, so technically the moment they really want is med school graduation.
But what I'm talking about is that the learning I'll be doing this year - on the wards, seeing patients, learning medicine - that's the learning they wish they were doing this year.
Unfortunately for them, they are a long, long way away from this moment, and the learning they have to go through now is very different.
For them, they have to take courses in intro biology, biochemistry, organic chem, physics, a whole degree's worth of courses... the MCAT... the application process including interviews and admissions...and then two years of medical school which are fun and exciting and horrible and challenging and gruesome and interesting all at the same time.
All in all, at least a six-year process...one that many of them might not make it through... and yet all they really want to be doing is learning how to take care of sick people in the hospital.
I know that it will only be a couple of months before I'm burned out from the day shifts, the night call, and the studying in every spare moment around those shifts, but right now, I'm so excited to start.
I had to keep myself from showing up to shadow at the emergency department tonight, after the doc orienting us this morning told us we could drop in anytime. Maybe I should wait until orientation week is over, I told myself.
Finally, we get to do what I signed up for.
Finally, there is a light at the end of the tunnel... only two years until I graduate.
Finally, it's starting to feel for real.
And talking to people who are six years of hard work away from this moment reminded me of what it took to get here, and made me appreciate it so much more.
Tuesday, September 02, 2008
Job Title: Medical Student / "Health Remedy Engineer"
Job duration: Full time (approx. 168 hours/week, some additional overtime required)
Job location: Local university and all hospitals in a 3-hour radius, including some national travel in Year 4 (not compensated)
Advancement potential: significant
Experience: Will train
Required equipment (Textbooks, etc.): Supplied by employee (not compensated).
Term length: 4 years
Duties & Responsibilities:
- Learn all common diseases and conditions and how to diagnose and treat them
- Work well with people pushed to their extremes (and become one yourself)
- Successfully pass frequent extensive examinations
- Deal with life-threatening emergencies with a calm, cool head
Qualifications:
- Must have university degree (or nearly completed one), preferably a Ph.D. or M.Sc.
- Excellent GPA
- Vast array of extracurricular activities
- Olympic medals and superhuman powers helpful but not necessary
- Sense of humour is the common denominator noted among survivors of this position
Skills and Abilities:
- Ability to stay awake for days on end
- Ability to be on call (sample schedule of a night on call)
- Ability to memorize large volumes of data
- Ability to take verbal abuse and harassment in stride
- Ability to deal with human remains in a respectful fashion
- Be familiar with the following computer applications: MDConsult.com, UpToDate.com, CMA website, provincial medical association website, patient care database, X-ray viewer software, university website, course websites, patient logging websites, PDA software such as Epocrates, Archimedes, Merck Manual, Microsoft Word, Microsoft Excel, university tuition payment website, Solitaire
Compensation:
Hourly Wage: Starting at -$10,000, increasing to -$55,000, dependent on campus of emploment (no raises, and yes, that's correct, you pay us).
Benefits: 10% "student discount" at local pizzeria upon surrender of employee ID card. No dental, health or other benefits.
Scholarships: Some, available only to the people who are smarter than you
Application procedure:
Applications due date: September
Notification: May
CV: Include all details of employment and extracurriculars, being sure to account for every moment of your waking life. As well, include a contact person for all items on your CV that we can phone to ensure you are not making these things up.
Please note this is a very competitive position and that only successful applicants will be contacted. We thank you for your interest and hope you are insane enough to apply.
Wednesday, August 27, 2008
Casting - learn by doing (and making mistakes)
It is being made very clear to us, in our orientation to our third year, that in medicine some mistakes result in deaths.
Others result in really annoying tiny chunks of fiberglass on your fingers for a few days.
At a practical clinical conference I went to recently, one of the workshops offered an hour of putting on learning about various fractures and practical casting and fracture re-setting tips, followed by an hour of putting casts on each others' arms.
We learned some neat practical tips to make slightly casts, from how to cut the material so it doesn't bunch up between the thumb and pointer finger, to how to apply a bit of extra padding where the cast is likely to have a few extra pressure points.
For example, we learned "a good cast is an ugly cast" - if the cast is made properly, and is applying enough immobilization at the right area of the bone, there will be knobs and finger indententations from where the person applying the cast moulded it correctly (I don't think that the teacher was referring to a "really" ugly cast, like the one in the picture, that my friend Jordanna moulded... unlike me, though, at least she remembered Step #1...see below).
Or, we learned that any forearm cast - even for a single broken tiny bone in the wrist - should go up to within two fingerbreadths of the antecubital fossa (elbow crease). That way, if you fall on the cast, you don't end up with a radial/ulnar double bone fracture halfway up the arm where the cast ends (which could end you up in surgery) - instead the elbow joint can take the brunt of the force.
When it came time to apply the casts, though, I unfortunately forgot step #1.... put on gloves. I've had some experience applying plaster casts, where you can easily wash your hands afterwards with no residual... uh, residue.
However, for fiberglass casts, if you don't wear gloves, your fingertips get coated in tiny chunks of fiberglass cast material. Try as you might to wash it off, it's there for good for the next few days to wreak havoc on your sensory nerve endings and make your hands feel like they're desperately in need of moisturizer.
Fortunately this mistake didn't kill anybody. All the same, it's still one that I'll chose to not make again.
Wednesday, August 20, 2008
He barely made it out alive
The rain was pouring into the windshield. The headlights may well have been candles, since they did barely anything to light up the dark night, especially around the corners and over the crest of the upcoming hills.
And of course, it had to be in these horrible driving conditions, was when he heard and felt a definite THUMP. He'd hit something. His wife started shrieking. "You killed it!"
After slowing down to a stop on the side of the road, he sat and took a breath and thought in apprehension about how cold it would be stepping out into the rain. As his wife's yelling got louder, he realized that no matter how cold it would be outside the car, at least it would be quiet, and he jumped out into the rain.
First was the priority of seeing if his car was damaged. Great, he thought to himself. That bumper is going to be at least a thousand bucks.
Then was the important part of checking on what he had hit. Groundhog? No, it seemed bigger. A deer, perhaps?
As he walked towards the black figure on the road about twenty yards back he could tell it was injured, but definitely still alive. Any doubt of that was eliminated when his wife made the assessment from the safety of the car, at a loud volume - "Oh noooo! It's still alive! It's suffering!"
She begged him to put it out of its suffering. But what was it? As he got closer, the figure, barely lit up by the red taillights of his car, started to take on a familiar shape... that of Jeddy, his favoured teddy bear from when he was a child.
Oh my goodness, he realized. He ran over a baby bear cub.
"Dooo something!" his wife yelled, as he watched it trying to lift its broken body, to drag itself to the side of the road. It was clearly suffering. What should he do? Run it over again, he thought? No, that's inhumane. Hit it on the head with a shovel? Maybe, if he had a shovel.
Going back to the car, and rummaging through the trunk, the rain now soaking completely through his dress clothes, he found that no, he definitely did not have a shovel, and that the only suitable tool of humane death in his trunk was the noble tire iron. "Come on, honey, let's just go," he pleaded. "It will die on its own."
"Nooo!" she protested. "You have to do something!"
Back he went to the dying creature.
"I can do this with one swift blow to the head," he thought.
After one blow, he knew his estimate of one blow was way off. He hit again. Not enough. And again.
It was somewhere between the fifth and fourteenth blow, from what I'm told, that the bear cub's mother lumbered onto the road. She saw this unfortunate this man leaning over her baby, beating the last breaths of life out of the cub with a tire iron. And so, rearing up on her hind legs to her full height, she reacted, in the way that only a mother grizzly bear can.
And that's the story of how I, working a nighttime ER shift, got to see a patient who had been attacked by a grizzly bear.
Rural medicine can be pretty interesting, that's for sure.
Mmmm, sweet black nectar of bean.
My loftiest goal at the start of medical school was to not get addicted to coffee.
After seeing Alice admit she gave in to the aromatic stranglehold of the percolator, I can now come out and admit that my determination lasted only until about the start of 2nd year. I am clearly much weaker than Alice (but I already knew that).
For a time, I'll even admit I tried caffeine pills on the advice of a friend. A few people I know had resorted to this in undergrad, and I was able to abstain then, but my curiosity overcame me when I was approached in a back alley at night by a fellow medical student and was offered one of a variety of caffeine pills hidden in the inside of his overcoat. Why pay $2 for coffee when you can pay $0.15 or whatever for one of these magic pills, I thought?
When second-year finals were all over, though, and my coffee intake plummeted, I started getting headaches by mid-morning. At first, I chose to believe I had an aneurysm, or a massive brain tumor. No way my sacred brew of black nectar is responsible for causing me this cranial throb, I told myself. I refused to admit, until finally, after demanding numerous CT scans and MRIs (and having to fake a large number of seizures in order to get those scans...ok now I'm really exaggerating), I admitted... it was the caffeine. I was addicted.
Saturday, August 16, 2008
Valuable principles for my upcoming clinical year
I've heard that on the words, nurses can be your best friend, and your worst enemy.
I have also heard that the more careful attendings, when asked to write a reference letter for you, ask your residents, nurses and other hospital staff about their experiences with you when the attending wasn't around... and you should therefore always act as though your attending is right beside you. Rumors can travel fast in hospitals, especially small ones.
This week I experienced a situation that reinforced both of these points quite well.
I was job shadowing an anaesthesiologist in the OR, and our second-last case of the day was the cutest ten-year-old girl, who charmed the socks off every single person she smiled at. She was such a sweetheart that everyone was disappointed when we had to put her under for her tonsillectomy.
Later on, when we were bringing our last patient into the recovery room, the nurse there came right up to me and took a good look at my ID badge. She then turned to the doctor who was supervising me, and told him, "You should know that your medical student Vitum is outstanding. He came in and checked on that little girl with the tonsillectomy to see if she was awake yet, and I was so impressed with him."
That would probably have really impressed my supervising doctor, had he not known the truth. But he did, and I couldn't take the credit and explained to the nurse: "Thanks, but I was just doing what I was told... the anaesthesiologist asked me to check on the patient!"
While I still believe that sometimes the things you do that go unnoticed are the most rewarding, the reality of medical school is you need those writing your evaluations and reference letters to be able to put down something tangible and positive if you want to to get where you want to go.
So maybe this is a third good principle for me to take with me to the wards in third year: it's sometimes the little things, just as much as the brilliant life-saving interventions, that will impress your supervisors...and more importantly, your patients.
Let me know if you have any more nuggets I should keep in mind next year on the wards!
Monday, August 11, 2008
Every doctor has a needle story or two
If you ask any doctor to tell you an interesting story from administering an injection, they probably have plenty. Most of them involve patients with countless tattoos and piercings who have to get one small needle to freeze a wound before it is stitched shut, but the fear of the needle is just too much, and the patients protest violently.
I was reading a needle story at Scalpel or Sword, along with the additional stories in the reader comments, and was reminded of a few of my own.
One of them did involve a huge, burly motorcyclist with a very, very worried look on his face, who kept asking the paramedics, "I'm not going to have to get a needle, am I?" He had too many tattoos to count. I'm not sure how he survived getting those if his fear was that intense.
Another involved a man who must have had more than half his body weight consisting of metal from piercings. He had cut open his arm with a grinder at work, and was placed in the minor procedures room at the ER to be stitched up. By the time I was in to see him fifteen minutes later, he was clutching the sheets, face down in the pillow, crying and screaming at the top of his lungs. As soon as he saw me, he shouted, "Get me out of here! There are needles in here!" I looked around, and didn't see any. I told him they were all put away, which didn't console him at all. "I don't care!" he screamed. "I know they're in here somewhere!"
While the freezing can burn a bit when people are given needles in a wound, vaccinations don't usually hurt very much if they're given properly. I've gotten 16 needles in the past five years or so, and given many more than that, and have hurt or been hurt hardly ever. While technique is most of it, anecdotal evidence is strong that a good portion of it is in the way you prepare the patient - if you tell them that it won't hurt very much, they often shout a lot less than the ones you tell them "this is really going to hurt."
Thursday, August 07, 2008
Medicine still amazes me...and still lets me down
As I learn all the physiology, pathology and pharmacology that medical school has to offer, sometimes there are unique things I see during my medical training that really, really impress me.
Whether it's the capabilities of a 3D reconstruction of a CT scan of a bone or the heart, or watching a patient's debilitating tremor disappear instantly at the press of a button activating a microelectrode in their brain, or re-starting the still heart of a dead person inside the chest of someone else, I occasionally find myself with my jaw on the floor when I learn things that medical practitioners are able to do and see that, only a few years ago, were an impossibility.
Then again, judging by something that happened earlier this month, perhaps I'm just easily impressed.
The doctor I'm working with was called from his office to go see Catherine, a pregnant woman in the hospital. She is early in her third trimester, but started having contractions. Of course, he explained, calls like this come right at the end of the lunch shift to provide the maximum inconvenience to him and the patients waiting in his office. He also explained that disruptions to the office like this are a part of the reason many other family practitioners don't do obstetrics anymore.
We're taught that a lot of information from a patient can be gained from the first part of the physical exam - from "five feet away," or the first glance of the patient at the foot of the bed. This patient was a great example of this. We had barely entered her room, and right away, we knew that Cathy was not doing well.
More than anything, Cathy was incredibly anxious, and for good reason. On the drive over, the doctor had explained to me that Cathy had never been pregnant, and it had been her dream to have a child. She and her husband Dale had been trying for years. No reason for her and her husband's infertility could be found, and finally, after several tries of drug-assisted and then subsequently in-vitro fertilization attempts at a high financial and emotional expense, this woman was now pregnant. And at 41 years old, Cathy knew just as well as we did that if something went wrong with this pregnancy, there likely wouldn't be another chance.
The doctor did a quick exam, and was convinced that the cervix had not begun to dilate. The baby's heart was still beating normally, and monitoring of the uterine muscle contractions revealed uterine muscle activity, but it wasn't clear if this was due to actual contractions or more minor uterine irritability.
Just a few years ago, Cathy would likely be admitted for observation, at a cost of a couple thousand dollars a day. She might not end up being in labour, and might not end up delivering for weeks... meaning a long, expensive stay in the hospital, with an expensive air ambulance transfer to a big-city hospital, with little benefit. On the other hand, she could be sent home, then suddenly go into full-blown labour, and deliver a premature infant away from the hospital after being sent home. How do you spell "lawsuit" again?
I was surprised to hear that this dilemma is not faced nearly as often thanks to an expensive but convenient lab test looking for fetal fibronectin. This protein, made by the fetus, is found in the mother's cervical secretions only if the mother is likely to deliver within the next four weeks. By taking this swab, and getting the results from the lab a mere twenty minutes later, we were able to conclude with resonable certainty (the lab test is correct 15 out of 16 times, according to the packaging) that Cathy was not going to have a premature delivery, and that she could safely go home.
Despite the things I learn that amaze me, large or small, there still times that I am disappointed by the failures of modern medicine. So many diseases cannot be cured, and many can barely have symptomatic relief.
Earlier this week, I had to look into the eyes of a 83-year-old woman in a wheelchair who was begging me to fix her legs. She could no longer walk, and she desperately wanted to be able to. After she had left, my supervising doctor told me that she lost the use of her limbs because of a progressive neurodegenerative disease for which there is no cure, and she often forgets that this happened years ago because of her long-standing dementia. She has two diseases that, despite all of the advances in medicine these days, it still seems as though we can't do much more for her, and the millions with similar conditions, than apply a band-aid.
I'm told that throughout my medical career the advances in medical technology are expected to be staggering. Who knows what clinical decisions will be made much easier because of medical advances, or which devestating diseases will soon become relics of the past. Waiting to hear what the future will bring, and the chance to put these discoveries into action to change peoples' lives, is yet another exciting part of living a life of medicine.
Thursday, July 31, 2008
Speeches for Medical Students
A little while ago somebody googled my blog looking for "SPEECHES FOR NEW MEDICAL STUDENTS." (Yes, I do sometimes look at the things you type in order to find my blog. Sometimes I even make fun of the weirder ones.)
I'm not sure if the googler was a professor who needs to give a speech to welcome new medical students, or a new medical student who can't wait to hear what you're going to learn about when you start classes.
My money is on the first one... in the many times I end up helping older people with basic computer things, I have found that lots of them aren't aware that the CAPS LOCK button does something other than ensure your cap doesn't get blown off in the wind.
Digressions aside, for whatever your intention, here is a summary of some of the speeches we have received in medical so far. Hopefully here you find what you are looking for.
SPEECH # 1: "CONGRATULATIONS!"
SPEECH OCCASION: First day of medical school (Morning)
SPEECH GIVEN BY: Faculty member up to but not including the Dean.
SYNOPSIS: Congratulations! You are the best of the best! Here is a slide show of all the people in our department. Come see us anytime! Don't forget - you're the best - and congratulations. And one more thing: from all of us, congratulations.
# OF TIMES THE WORD "CONGRATULATIONS" USED: 529
SPEECH #9: "SEEING PATIENTS"
SPEECH OCCASION: Second day of medical school (Afternoon)
SPEECH GIVEN BY: Faculty members of the Family Practice course
SYNOPSIS: Congratulations on making it in to medical school and starting a career of giving professional advice to patients! But don't try giving anybody advice while you're still in medical school. You're allowed to ask patients what their expectations are of the visit, though. Congrats!
# OF TIMES THE WORD "CONGRATULATIONS" USED: 116
SPEECH #4, 9, 10, 12, 13, 15, 18, 19, 22, 28: "PROFESSIONALISM"
SPEECH OCCASION: Following an expectation of our faculty that is not met by the students, or the sending of an inappropriate e-mail by a single inappropriate student
SPEECH LENGTH: Variable, usually 10-30 minutes
NUMBER OF STUDENTS PRESENT: Variable, declines throughout the semester
SPEECH GIVEN BY: Faculty member, increasing in rank and decreasing in familiarity to the students
SYNPOSIS: Don't talk during lecture, don't bend the bendable microphones in the teleconferencing rooms, don't bring coffee into the lecture hall, and don't send inappropriate e-mails to professors.
# OF TIMES THE WORD "CONGRATULATIONS" USED: 0
SPEECH #11: "EXAMS ARE COMING UP"
SPEECH OCCASION: 1 week before end-of-first-year finals
SPEECH GIVEN BY: A faculty member introduced to us in the first week whom none of us remember
SYNOPSIS: Just because you pass all your finals, it doesn't mean we will let you pass first year. Also, if you fail a final, most people get to re-write finals they fail, but don't expect this. Remedials are a privilege, not a right. Study hard.
# OF TIMES THE WORD "CONGRATULATIONS" USED: -1
SPEECH #29: "WELCOME TO SECOND YEAR"
SPEECH OCCASION: First day of second year
SPEECH LENGTH: 10 minutes
SYNOPSIS: First year was a cakewalk. This year, you have to study your butt off. You have to read outside the lectures. The teachers aren't really here to teach this year, just to give you an idea of what you need to study on your own. This is my office staff, they work for me. Study.
# OF TIMES THE WORD "CONGRATULATIONS USED: once, sarcastically
