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.

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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.

People were handing me bags of saline to squeeze, in an effort to restore his blood volume as quickly as possible, as the machines pumped donor blood into his body. Doctors were scrambling to put in chest tubes, central lines, and stop the bleeding from where his arm and shoulder used to be. After about fourty minutes, we stabilized him, in a manner of speaking, and sent him off to surgery. And six hours after the surgery, they're saying he's gonna survive.

Rural medicine can be pretty interesting, that's for sure.

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Mmmm, sweet black nectar of bean.

My loftiest goal at the start of medical school was to not get addicted to coffee.

Yeah, that went real well.

I decided this after going to breakfast with a friend in residency, who, after her 3rd cup of coffee, declared "Now my caffeine headache is gone!" I could stand to do without headaches, I concluded, and set my noble goal which probably made you shake your head at my naive foolishness.

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).

I started to drink my coffee, and now I tell myself it's because I love the flavour. Once a day, then twice a day, sometimes more. I would never say that I'm addicted...just that I love the taste of a Tim Horton's (and a Starbucks if needs be). My dad only fed this wonderful addiction by supplying me with a bountiful Tim Horton's gift card...perhaps the best gift I have ever received. And, it always made a convenient excuse to rally the study buddies for a study break - "I've had enough of studying these neurology / gastrointestinal / hematopathology / whatever notes. Let's go grab a coffee."

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?

Actually, the drug reference has a bit more credence to it than you might think - during our first week of orientation way back in first year, the physician support hotline sponsored a session in which a doctor and a dentist warned against the dangers of drug use, and that as professionals we weren't immune to it - and of course, one of them was adamant that his progression to cocaine and heroin had began way back in medical school, when he started trying to augment his studying using caffeine pills (and then ephedrine...and so on down the slippery slope). Never underestimate the pressure that medical students feel.

After hearing that, and admitting to myself that the pills didn't really give me that much of an extra kick (unless I took 5 or 6 at a time, which I wasn't interested in doing), I decided that paying $2.00 for the pleasure of a brew wasn't that bad.

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.

I've already scouted out the nearest coffee sources by the hospital I'll be working at in third year, and can't wait to get back to the grind.

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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!

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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."

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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.

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