Vitum's Field Guide to Hospital Grunts - Patient Edition

1. HHUUUUUUUNNNNGGGGHHHH

ID: Reproductus cornicopious, the common multip (i.e. multiparous woman, who has delivered a few babies already)
HABITAT: Maternity Ward
ACTION REQUIRED: RUN AND DON GLOVES. She is about to pop.

BACKGROUND: There is a saying on the maternity ward: “Never turn your back on a multip.” It is a known medical phenomenon these women, who have already had a few babies, have shorter and shorter labour for subsequent pregnancies, to the point where you better not ever be too far away or you’ll be picking baby up off the floor.

I have actually been trained that these multips often make a loud, primal, guttural grown the moment before the serious pushing begins. If you’re not in the room, and you hear this, hustle.

2. GAHHHHHHHHHH GAHHHHHH GAH GAH GAH GAH GAHHHH

ID: Narcoticus demandilus, the drug seeker
HABITAT: Emergency Department
ACTION REQUIRED: Holistic support up to and not including writing an opioid prescription

BACKGROUND: The loudest patients demanding pain medication tend to be the ones for whom Tylenol just doesn’t work, they’re allergic to the stronger anti-inflammatories, and gosh darn it your only option is to prescribe the good stuff. The ones who are bad at it are the ones who only seem to be in pain when the doctor walks by, and are easily fooled (i.e. “Let me examine your back.” “Ow ow ow! Even the slightest touch on my back hurts!” “Funny, when I felt your back earlier and didn’t warn you that I was examining you, you didn’t seem to notice…”
A good rule of thumb is the more convincing the patient, the more you should look for signs they’re trying to fool you.

Be careful, though. Every so often you’ll get someone who you are convinced just wants drugs, and then you are later corrected and find out with convincing evidence they are in legitimate pain. Looking back and realizing you denied a cancer patient some form of relief makes you feel really bad.

The hard part is, there is a legitimate argument that drug seekers need treatment too, just not the drugs they’re looking for. This is something I wish modern medicine could treat way better than it does.

3. MMGGGGNNNNNHHHHHHHHHHH

ID: Constipationaticus fecalis, the bunged-up ones
HABITAT: Old folk’s wards
ACTION REQUIRED: Grab a diaper. Just in case.

BACKGROUND: I was called one night to see an ornery elderly woman, and recognized her from seeing her in the emergency department, shouting at the nurse. “Closer, I’m deaf! Closer! Louder! I can’t hear you! Closer! WHY ARE YOU SHOUTING AT ME? *smacks the nurse*” I thought she was hysterical.

I’m not even sure what the original call was about, probably needing a sleeping pill or something basic like that. All I do remember is walking in the room, and she was moaning, as above. “MMGGGGNNNNHHH!”

“Why are you groaning?” I asked of the woman laying in the bed, gripping the siderail for dear life. “I’m POOPING!” she shouted at me. “I’m POOping in my DIAper!”

I was only a third-year medical student at the time, so not an expert in things medical. But I did know a few things, and took haste to correct her.
“Ma’am, you’re not wearing a diaper.”

The ruckus stopped. She looked down, and stopped to think for a minute.

“MMGGGGNNNNHHH!” I went and got someone who knew where the diapers were.

4. HUUNFGH

ID: Cardiovascularis joltishockus, or defibrillating a semi-sedated patient
HABITAT: Emergency department, cardiology ward
ACTION REQUIRED: Increase sedation!

BACKGROUND: Some patients who have a heart arrhythmia need to be shocked with the defibrillator, or cardioverted, to get their hearts back in normal rhythm. They are given sedation, then, under strangely close supervision, the medical student is often allowed to push the button with the little lightning bolt on it. One or two, sometimes three, shocks, and their hearts are back to happy beat (Yes, that’s what we call it when the patients are sedated and can’t hear us).

There was one patient who didn’t seem to have very much sedation. He had just barely fallen asleep, and the doctor turned to me and said, “Vitum, push the button!” “Uh, does he need some more propofol?” I asked. “No! Push the button!” So I pushed it, wincing a bit as I did, sending 100 joules of electricity through this young, muscular man’s heart.

The machine clicked, the patient jolted just like on TV, uttering a HUUNFGH, and his eyes went COMPLETELY wide open. And he turned his head, and stared directly at me. And stared. And stared. His eyes were bugging out of his head, and he was clearly sending the first silent death threat I had ever received, probably trying to kill me with his mind.

And then the doctor said the words I didn’t want to hear: “Hmm, he needs another one. Shock him again, Vitum.”

I asked the patient later if he remembered. Fortunately, the doc was right – he’d had enough sedation, which made me breathe a huge sigh of relief. I swore he’d be waiting in the parking lot for me after work.

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The best part of spending two weeks with medevac? Not what you might think.

As my third year was winding down last month, I had the opportunity to do a two-week elective in anything I wanted. Supposedly it had to be medically-related, but given that some of my classmates were approved for two weeks of wakeboarding or a 3-hour first aid course*, spending two weeks in paramedicine made me look like an overachiever.

The elective was pretty incredible from a medical point of view. Among the dozens of calls we attended, we picked up a young lady whose ATV had gotten away from her, crushing her leg to the point where she might never walk again. We also treated a few patients who had fallen off ladders or nearly drowned, and a nailgun injury. As well, there was a variety of medical patients too complex for the rural hospitals who needed to be brought to the big city for super-specialized care.

There were things that I didn't anticipate. There were heart-wrenching moments, like talking to one of our patients, a young lady who had been poisioned by carbon monoxide...intentionally. Sadly, she was not the only suicide survivor that we saw during my two weeks. As well, we went to a few car accident scenes and I saw some things, tragic things, that I wish I hadn't.

One thing about the elective really surprised me. Those of you who have read this blog for a while might remember that I have shadowed flight paramedics in the past. Back then, it was fascinating for me to see what the paramedics did...treat and transport the sickest patients in the province. What surprised me is that this year, my time with the paramedics served as a stunning eye-opener, revealing to me how little I knew about not only paramedicine, but medicine in general back then.

In other words, until I had completed my third year of medical school, I had no comprehension of just how sick the patients were that we were transporting. Not only that, but I had no idea the elite level of training of the flight paramedics. Back then, I did not understand the skill demanded when handling ventilator settings for patients with severe lung disease, or the implications and specialization required in order to keep alive a patient with bacterial infection coursing through their entire body. I only now realized just how sick these patients were, having been involved in identifying and treating sick patients myself, and also that some of the drugs that the paramedics were trained to prescribe are typically only used by intensive care specialists.

It was exciting to be able to understand at a deeper level the diseases affecting our patients, and to be able to have a new level of conversation with the flight paramedics, actually discussing treatment options with them. To put it another way, before I had completed three years of medical school, I didn't even know what questions to ask.

Needless to say, my understanding of the complexity of the patients and the difficulty of their management gave me a new level of respect for the critical care flight paramedics.

Retrospect, for me, is a valuable, meaningful experience. In fact, one of the reasons I started this blog was so I could look back and see how far I've come; in a program that is years in length and where you rarely realize how much you have learned from day to day, sometimes looking back is the only time you'll realize how much you are learning. It was a huge privilege to be invited back to spend time with these highly-trained paramedics, and it was a great surprise to discover that without realizing it, I had signed up for two weeks of seeing how much I have learned. Glad the $45,000 I've spent so far on tuition seems to be paying for something!

*In defense of my classmates, they did have to write a 500-word essay relating their elective to medicine

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Part 2: Vitum Loses 85 Pounds...and the mistakes that kept me from doing it earlier

Continued from Never Trust a Skinny Chef. A Fat Doctor, however...

For several years, I was eating healthy, knew about the dangers of obesity, and yet found myself at 280 pounds... so overweight that I was considered class 2 obese. So why wasn't I losing weight?

There are three reasons - three mistakes I was making. Once I corrected these mistakes, and took on a lifestyle of a healthy, balanced diet and exercise, the results were amazing:

• In September, I weighed 280 pounds. By January, I was down to 230 - I had lost 50 pounds.
• In April, I met my long-term goal of running a 10 kilometer race, something I thought was a big deal
• In May, I blew that goal away - and successfully completed a half marathon. That's right, I ran for 21.1 kilometers. Never thought I'd pull that off. Ever.
• My weight now is 195 pounds. That's 85 pounds lost so far (I say so far because that puts me - believe it or not - still at an overweight BMI. 10 pounds to go.)
• Finally, I don't feel like a chump telling patients they need to lose weight to be healthy... and in fact, if I want to show them it can be done, I just point to the photo of me on my ID badge from September.

So, what were those mistakes that kept me from doing this earlier? Well, for three easy payments of $9.99 sent to.... just kidding! Here they are:

1. I thought QUALITY was more important than QUANTITY.


Healthy eating is important for disease prevention - I ate multigrain bagels and chose sugar-free fruit juice for years, never buying pop, chips, donuts or cookies... and only gained weight.

Consider this: I would go to Tim Horton's for a snack between morning classes and proudly ate a healthy 12 grain bagel with cream cheese, instead of what I really wanted - a chocolate glazed donut. Despite my choice being overall more healthy, I was eating 471 calories of healthy goodness instead of the 260 calories in the donut - almost DOUBLE! If I ate one of those bagels every day, and didn't jog for half an hour to burn off those extra 471 calories, I would gain almost 50...that's right, FIFTY... extra pounds in a year.

So, I changed my mindset to cut down on how much food I ate, instead of just choosing healthy foods. And wouldn't you know it, the pounds started coming off. That's why I like to tell people I started on the "put less stuff in me diet."

2. I used to only think of my weight when I stepped on a scale.

In order to actually make a difference and lose weight, my goal to lose weight had to become something I thought of every minute of every day, not just for the moment when I stepped on a scale in the morning.

I knew you had to eat less to lose weight, but I always found myself only thinking about this between meals, and forgetting about it when the food was in front of me.

So what had to change? Every decision I made, such as getting in the elevator, and every time I put something in my mouth, such as my morning coffee or cereal, had to be filtered through the perspective of "how could I change this to increase calories burned or decrease calories taken in?" The answers were easy - take the stairs instead, switch to milk in my coffee, only 1 bowl of cereal instead of 2 (okay, who am I kidding, 3). I just had to ask myself the question...dozens of times in a day, before I did anything.

My weight loss goals had to be something that influenced everything I did and every thought I had. Sure, it might sound a bit obsessive, but after years of unsuccessfuly trying to "eat healthy," for me, that's what it took - a complete mindset change.

3. I didn't use a simple strategy to overcome my hatred of exercise.

I hate exercising. I was able to run regularly for a while a few years ago, but that dropped off. I didn't really have anything to keep me going.

But now I found three things to keep me getting out there and exercising. First, I combined exercise with diet modification - and started to see results. Seeing the weight come off, and having people comment on it, is a great way to keep you excited about getting out and running.

Secondly, I began to time myself, and try to break my records. I got RunKeeper, a free app for my iPhone, and tracked how long it took me to run a certain time. The next time, I would try to run the same distance just a second or two faster.

Thirdly, I signed up for a 10k race. This gave me a goal to work towards, and an exciting event to participate in when the day finally came.

Now I just have to come up with a way to overcome my even more intense hatred of lifting weights...

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Never trust a skinny chef. A fat doctor, however...

U.S. President Obama with Dr . Benjamin, Surgeon General nominee. Source: The White House

Today's LA Times has an interesting piece about a new Surgeon General nominee in the USA, who herself is obese. Her nomination has generated discussion about whether or not doctors should be overweight.

Let me explain why this article caught my eye.

Last year, in a family practice rotation, I was in the room when my preceptor was counselling a patient on theimportance of losing weight to cut down his risk of heart and stroke (and countless other diseases). The patient was obviously feeling a bit sheepish about the lecture, and awkwardly tried to draw the attention away from his waistline. He pointed at me, and said, "Well, this guy will be needing to lose some weight too then, won't he?"

This was the first time somebody had said something about my weight since I was teased in high school, and afterwards, my preceptor apologized profusely for the behaviour of his patient. However, even though it was a bit more surprising and amusing to me than offensive, he did have a point.

At that point, I was 6' and weighed almost 280 lbs. That means my BMI was 38.0 - not just obese, but class 2 obese... and my disease risk for high blood pressure, heart disease, and type 2 diabetes was a few pounds short of extremely high.

If you think this is starting to read like a diet book, it actually does. I had always "eaten healthy," and had even done some jogging in the past. My list of reasons to lose weight was long...pages long. But not long enough to get me to have a healthy weight.

At the start of third year, my list of reasons to lose weight got longer. I began to spend over 8 hours a day seeing patients....most of whom were fat, and most of whom were dying or very sick... because they were fat.

In fact, every ward I rotated on showed me new ways people were suffering from obesity. I expected to see fat people with heart attacks on the cardiology wards, but I began to see obesity-related diseases and complications in ALL of my other rotations, almost ENTIRELY due to the patients' obesity, in other words, PREVENTABLE - in orthopedics, ophthalmology, surgery, maternity, emergency, dermatology, anesthesia, and scarily enough, even in pediatrics.

I knew that obesity caused disease, but that didn't really frighten me. Until I saw the complications of the diseases first-hand. They can lead to heart failure (which is a slow death with fluid in your lungs just like drowning), heart attack (pain and sudden death), stroke (paralysis and loss of ability to speak), dementia (to the nursing home we go, and hand in your driver's licence and memories of your family and friends on the way), permanent loss of sensation (can't tell if you stepped on a tack, so it could stay in your foot for WEEKS until you notice - yes I have seen this happen), osteoarthritis (waking up with pain in your knees every single morning increasing until you can't walk anymore), limb amputation (I have seen black toes and feet from the arteries getting so clogged with fat that they stop supplying blood to the feet) and blindness (a complication of diabetes). All because of obesity...all almost entirely preventable.

Seeing all this helped me get my butt in gear. I took a close look at my lifestyle and eating habits, and was surprised to find some mistakes that I was making. That's right - I discovered that even as a reasonably bright, educated medical student, there were simple things staring me right in the face, easy things to change in order to lose weight, that I was oblivious to (I'll talk about these in another post shortly).

And soon, I began to see results. Dramatic results. I've lost so much weight that people barely recognize me anymore.

Continued at Part 2: Vitum Loses 85 Pounds...and the mistakes that kept me from doing it earlier

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"...and that's when I broke the child's arm in my bare hands."

The surgery I was watching was getting into the tedious stages, fitting and re-fitting a bone chunk that cracked off when the elderly woman had slipped on a banana peel (yes, you read that right). They already had an assist, so I wasn't scrubbed in for this one. Just as I was looking for a new distraction the orthopedic surgeon's pager went off.


A five-year-old boy had fallen out of a tree, and landed on his arm, which was broken. The emerg doc was going to re-set the bone, but wanted the orthopedic surgeon to have a quick look at the x-ray first. They called it up on the computer screens in the OR, and the surgeon gave his blessing that the emerg doc could set the bone himself.


I asked the surgeon if I could go watch the reduction of the bone, and soon was on my way to the ER where I found the doctor. I knew him from working with him in the ER a few weeks prior.

"I heard you're doing a closed reduction - can I watch?" I asked.

"No," he replied.

I was a little surprised, but didn't have time to react before he said, "You're going to do it."

"Uh, I'll give it a shot, but just so you know, I haven't done one before," I admitted.

"That's fine, I hurt my wrist. Come look at the x-ray."

That's when things got exciting.

This wasn't just going to be a regular reduction.

The doc showed me on the x-ray where the wrist had broken through the smaller of the two arm bones, the ulna - but not quite all the way through the radius.

Turns out that for a break like this to heal correctly, rather than just pulling the bone into place, like is done with most reductions, it was important to make sure that the break went all the way through the radius.

And how would that happen?

You guessed it... breaking the radius would be my job.

Sure enough, after a quick briefing, under close supervision, and as soon as the child was COMPLETELY sedated (what, you thought we would do this with the poor kid awake?!), it was time to hold on to the arm just above the wrist, and see-saw it back and forth at 90 degrees until I heard a pop and crunch. And that moment was just as the doc had predicted: "That's when all the eyes of nurses and staff watching will bug out of their heads." Fortunately, the child's parents weren't there to see what was involved.

Once the bone was broken, we were able to tug it into position, and put a cast on while still applying traction with our hands, just long enough for the cast to harden. By then, the patient was just starting to wake up from the sedation.

And while the patient didn't remember a thing - thank goodness - I definitely won't forget doing this for the first time.

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I sterilized a man today.

Sticks and stones may break my bones...

...but you better watch out, because I now know how to do a vasectomy.

Thanks to my nimble fingers, three men limped out of the urology office this morning, their virility forever compromised...at least we hope it is.

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First do no harm...unless you haven't gone to medical school

Albert was on the phone with his sister on a sunny afternoon last week, telling her about the trip they had gone on over the weekend and his wife's bingo winnings at the local senior's centre that week, when suddenly she interrupted. "Albert, don't be silly."

"What are you talking about?" he replied.

"Albert, I can't understand you, what's going on?" He was confused - he was speaking perfectly fine, as far as he could tell.

His wife walked into the room, and noticed that he was indeed slurring all his words, and rushed him to their naturopath. The naturopath saw his mouth drooping on one side, and told him he knew exactly what was going on. He promptly gave him a glass of water, into which she had mixed several spoonfuls of salt, and told him to drink up, and encouraged him to do this over the next several days. Why?

Because, as the wife explained to me, "Well, when the left side of the mouth droops, he has a deficiency of sodium. And when the right side droops, he is low in potassium, you see. When both droop, then he needs more calcium."

Sure enough, in about half an hour, his droop had resolved, and his speech returned to normal. So the naturopath was right, right?

Unfortunately, in this case, his naturopath was wrong. Because he'd had a heart attack in the past, and his heart muscle didn't contract the way it should anymore, giving salt to this patient was a bad decision. In fact, research shows that patients with heart failure have worsening of their symptoms when they have salt in their diet, and the most recent heart association guidelines recommend low-salt diets for these patients.

And why did he get better? It had nothing to do with chugging brine. He'd had a TIA, or a transient ischemic attack, exactly like a stroke except it's just that - transient. The brain is starved of oxygen for a short time because of low flow or a small clot blocking an artery, but then the flow is restored before brain tissue dies. Had this lasted long enough to kill the brain tissue, it would have been called a stroke; in his case, the symptoms - temporary paralysis of his facial nerve innervating the orbicularis oris muscle, causing a mouth droop on one side - went away about half an hour after he drank the salt water. Though it looked like the natural treatment worked, it in fact had nothing to do with his symptoms resolving.

But, because of this advice, his wife faithfully gave him several spoonfuls of salt every day, causing more and more water to build up in his blood vessels. And it wasn't long before his failing heart couldn't cope with this excess salt. He soon could walk shorter and shorter distances without having to stop for air, and would wake up gasping for breath in the middle of the night. His heart muscle's ability to pump blood, which had been measured right after his heart attack as still being still quite reasonable, couldn't cope with the extra water in his blood vessels and took a drastic turn for the worse.

I saw him when he came into the hospital with his wife, unable to breathe, but it was too late. Despite receiving massive amounts of diuretics, vasodilators, and being placed on a breathing machine, it was too little too late. A few weeks later his heart gave out completely, he died with his lungs full of water instead of air, with a look of panic on his face, gasping for oxygen, because of the misinformation the wife had been told naturopath.

It doesn't worry me that naturopaths provide a whole-person approach, and attempt to treat the cause of patients' ailments rather than the symptoms.

It does worry me when they cause harm to patients, and make their health worse.

Any doctor that prescribed salt to a patient with heart failure... not to mention miss the diagnosis of a stroke... could be sued, successfully, for malpractice.

It also worries me that out on the western coast of this country, in British Columbia, naturopaths have been given the right to prescribe medications,which not only seems to go against their entire profession's objective of treating things naturally, but is possibly dangerous given that they are quite simply not trained in this area.

But going back to the story...you know what the worst part is? Had he seen a physician earlier, this could have been avoided... but the wife didn't see it that way. She left the hospital, without her husband, thinking that traditional medical treatment had failed to save her husband, when in fact the damage had been done long before he got to the hospital. Hopefully, her stronger belief in natural therapy doesn't kill her too.

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That poor, poor transcriptionist. I almost admitted it was my first dictation.

I picked up the phone with a shaky hand, and slowly dialed the number for the hospital dictation system for the first time.

"Welcome to the Excelleris Express Dictation Service. Enter User ID , followed by the pound key," a cheerful voice said.

Good, I thought. She doesn't yet know that I have no clue what I'm doing.

I keyed in the number for the doctor who was dumb enough to ask me to dictate for him. 6-2-1-0-9-#.

Enter hospital ID. 1-6-#.

Enter work type. 1-0-#, specialist consultation of a patient.

Enter patient number. 2-1-6-2-7-8-1-#.

Beep beep. . . . beep beep. . . bee- okay, are you going to make me wait all day? this is where you start talking, idiot. Fortunately, it didn't actually say that to me.

I pressed 2 to begin, and slowly began to talk.

"This is Vitum Medicinus, M-e-d-i-c-i-n-u-s, medical student intern, dictating on behalf of Dr. Doe, a consultation note on patient James Smith, S-m-i-t-h, unit number 2162781, date of birth 02/20/1949. "

This isn't so bad, I thought. I picked up speed.

"Copy to Dr. Doe, copy to Dr. Wilson. Date of consult March 6 2009, date of dictation March 6 2009. New heading, patient identification. Mr. Smith is a previously healthy 60-year-old Caucasian male who presented to the emergency department with his wife and daughter. Period. New heading. Chief complaint. Open quote, I passed out in the McDonald's parking lot, close quote."

I was doing it just like all the doctors I had seen dictate before! I was dictating! How exciting! I went on.

"New heading. History of presenting illness. This afternoon Mr Smith was getting out of his car at McDonalds when he began to feel presyncopal, period, before he could stop himself he fell to the ground, period, he described his presyncopal symptoms as open quote I was light headed comma I felt like I was going to pass out, close quote, but denied vertiginous symptoms, period. he lost consciousness for approximately ten seconds and in this time did not have any tonic clonic movements comma nor did he lose control of his bowel or bladder or bite his tongue period."

Okay, it didn't go that smoothly. My actual transcription went something like this... or at least what it would have looked like if I hadn't known how to pause, rewind, and re-record:

"Uh.... um.... uh... consult...dictation.... on ... patient .... copy to... Dr.... heading...new heading.... History of, uh, no wait....go back... Mr. Smith..." ... well, you get the idea.

Starting to dictate on behalf of the physicians has been really helpful. I've done a fair bit since that first one, and the process has made me realize that as far as taking the history and presenting the physical exam goes, I've started to really get the hang of it. It's when it comes time to dictate the assessment of what the patient has going on, and the plan of how to treat them, that I kindof fall apart and realize that I still have a lot to learn; with my first dictation, I had a fair bit of trouble with it even though I had discussed the case with the doctor already. Obviously, that's what I'm here to learn in third year, and throughout residency.

After I finished my first dictation, I sat the phone down, and began to gather my notes. I took a deep breath in and out. I noticed that one of the other emerg docs had sat down at the same desk about two-thirds of the way through my dication, and turned to him and asked, "Do you remember your first dictation?"

He smiled really big, and laughed, as he replied, "I try not to!"

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Planning for my 4th year

"When are you going to be a doctor?" is a question I get asked by patients quite often.

I like to think they are asking because they are interested in my progress and eager to see me fulfilling my dreams.

More likely, however, the question is based on a thought process along the lines of:

"Is THIS GUY going to be a doctor soon!? He started out by asking me all these irrelevant questions - what's he thinking when he asks how many pillows I sleep with at night?* What's he going to ask next, what colour my blankets are?

Then... he moved on to a fumbling, shoddy excuse for a 'physical exam,' making sure he touched me in every part of my body. Why on earth is he "feeling for the pulses in my groin?" Is he making this stuff up? And now he is using his stethoscope 'down there,'** is he crazy?!...ohhhh dear, when is the real doctor going to show up??

Good heavens, how long until he is unleashed to practice his incompetence on me and my friends and family? I'd better ask so I can move out of town by then."

In my defense:

* This is how I ask about orthopnea, or increased difficulty breathing when you are laying down flat, a symptom suggestive of impending heart failure.

** I'm listening for bruits in the femoral artery, which could indicate arterial blockage or disease... and I always ask if its OK for me to proceed.

The answer to the question is, just under 1.5 years, and trust me, I'm even more frightened by the thought than you are.

More on fourth year...

As I get closer to graduating, however, a few more decisions need to be made. My classmates and I are at the point in our education where we are choosing what we want to do for our fourth year.

While our first two years were mostly lectures, and the third and fourth year are mostly clinical, the third and fourth years are quite different.

Our schedule is quite firmly set in third year - we rotate through a number of "core" specialties (internal medicine, pediatrics, surgery, obstetrics, etc), and the only thing we can have any input on is the order in which we do these (and even still, need to enter a lottery to decide which students get to pick first).

However, in fourth year, we have a huge amount of flexibility in that we choose a number of electives. These can take place anywhere in Canada, the USA, or in some cases, elsewhere in the world, as long as I meet the requirements for the individual programs (some American schools, for example, want you to take the US Medical Licensing Exam after my 2nd year of medical school, which is not required in Canada).

The dirty details (for those who care...or can offer me some help!)

Based on how I understand it, what a medical student chooses for their senior electives is prompted by a number of factors, such as -

• the requirements of their school - I have to do at least 1 elective in each of the following: medical, surgical, primary care

• the career and residency programs they are interested in - someone interested in Plastic Surgery will obviously want to do many electives in the same, and check out the cities and hospitals where they might do their training

• geographic preference - a specific city might be chosen for an elective because they have a good residency program the student wants to check out, or because the student can easily arrange accomodation there with family / friends (it helps to avoid paying double the rent for the months you're away!), or simply because the student wants to visit a city they've never been to (my friend did a 3rd year elective in Pittsburgh so he could go watch a Penguins NHL game)

• interest - a student applying to a generalist (i.e. Family Practice) or less competitive specialty will probably spend more of their electives experiencing a variety of specialties they find enjoyable and interesting, rather than ones they think they "need" in order for their application to be impressive

As well, I also need to consider some other things regarding when I do an elective, based on applying to residencies:

• whether or not the elective has a lot of call - if so, it might be tough to work on an application for residency at the same time!

• whether or not it's likely to yield a good reference letter for residency - this only applies to the first few electives until the reference letter due date - you're more likely to earn a good reference letter from a specialty in which you work with 1 preceptor quite often, rather than something like emergency medicine, where you are supervised by someone else every shift.

Here's what I'm thinking so far, given that I am mostly interested in emergency medicine but may apply for a family medicine residency so that I can have a variety of options when I finish (ie. spend my time delivering babies, working as a hospitalist, or doing surgical assisting):

• Places - I'm thinking of doing my electives mostly in Alberta, BC and Ontario, because that's where I'm thinking of doing my residency, they're most familiar to me, and I know more students who have done electives in these places and therefore can get the scoop on them

• Basics - I'm interested in spending time in ER and obstetrics, so I'll likely do at least 1 elective in each of those

• Helpful add-ons - For someone interested in ER, I would probably benefit from spending some time in pediatric emergency, trauma surgery, and/or anaesthesia

• Just for fun / interest - If I have time, I might as well do some shorter electives in things I don't know much about, that intimidate me, or that I have simply never seen - such as rheumatology, or neurology

There are a few deadlines for choosing coming up, so now, the question is to decide where I want to do each of these electives, and if there's anything I'm missing. If you can think of anything, by all means, let me know!

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Drinking from the fire hydrant

My facebook status this week:

Vitum is entering one of those hell weeks that usually end with his friends asking, "Why don't we see you anymore?" Trust me, my bed feels the same way.

I spent most of Christmas describing third year to my friends and family like this: it's like working full-time (a doctor's definition of full-time, which is often 50 or 60 hours a week), plus being on call for an overnight shift every fourth night, plus studying for a major exam every month. Wheeeee!

Like I've said many times before, though, I am careful not to whine too much. Not only were my first two years of med school two of the most fun-packed years of my life (as I was reminiscing with a classmate just this afternoon), but as hard as I am being worked right now I'm doing what I love, and worked hard to be able to do.

After all, it is indeed my signature at the bottom of the application to medical school from three years back.

Yet, sometimes I check just to make sure.

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The strangest thing said to me during a pelvic exam

She had been fairly relaxed about the whole situation, considering, and after taking her history and doing the rest of the physical examination, I was standing at the foot of the bed. She had assumed the unpleasant position, and I was cautiously brandishing the well-lubricated speculum, when she said to me,

Don't lose your gum, Vitum!

Hope I didn't look that eager...

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My first NBME board exam

It's Christmas break.

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?

"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."

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.

~~~

One more thing - thanks to Medblog Addict for including me in the unique Christmas feature interviewing a different blogger for the 12 days of Christmas. You might enjoy the picture of myself that I submitted :)

Check out my (admittedly quite clever) responses to the interview questions!

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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.

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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,

"Make sure you know what medicine is like before you sign up for it."

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.

::: part two to come... :::

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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.

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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

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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.

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:

• Name
• MSI (which stands for Medical Student Intern...or we can write Clerk instead)
• our provincial College of Physicians number
• our pager number
• the Dr. we discussed the note with
• the date and time
• our favourite ice cream
• a pencil-sketch drawing of ourselves acting out a favourite childhood memory
• and which character we most resemble on the TV show Scrubs.

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.

8. Suturing can be difficult, because if the real thing is anything like our training sessions, our patients' skin will be thick, easily bruised, very fragile, yellow, and smell and look like banana. (There was an "issue" with the bureaucracy with bringing in pigs' feet, as we've used in the past.

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.

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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.

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Unleash the medical students.

I just found out that, should I pass my finals and make it to third year, within just a few months I'll be able to prescribe things and order some lab tests.

Here I thought you had to be a doctor to do those things. But no, they'll be letting me and my classmates, fresh out of the pre-clinical years of med school, play doctor. With real patients.

The best part is they're giving us plenty of time between us learning how to do these things... and us actually being on the wards.

That's right. Rather than putting us in the hosptial as soon as we have written our finals, which is when we have proven that we know which lab tests to order and which drugs to prescribe....ok, well, we've really more just demonstrated that we can memorize thousands of PowerPoint sides containing millions of trivial details (example: "in UK, 1 unit is defined as 8 grams absolute alcohol = .5 pint ordinary beer")...they've chosen to give us an entire summer to forget the relevant parts of medicine before they set us on the wards.

I'll even be allowed to order some investigations without permission: X-rays, electrocardiograms, most blood tests and cultures.

Don't get too concerned, though. I won't be handing out scripts for narcotics, heart medications, or medical marijuana anytime soon (note to friends: notice that last one, and please stop asking). Here's what I will be allowed to prescribe without permission:

• Non-controlled analgesics and anti-pyretics (examples: aspirin, tylenol)
• Shampoos, dermatological preparations other than those containing steroids (examples: head & shoulders, pert)
• Vitamins (examples: umm... Vitamin C, Flinstones multivitamins)

Okay, you're probably a lot less worried now. And I'm not sure they even call it "prescribing" - it's no secret that anyone can buy all those things at a 7-11.

Still, I'll be able to write those things in the patient's chart...me, who doesn't really know anything about medicine yet...and the nurses will actually go ahead and give it to the patient.

Those poor, poor nurses.

I'm not sure who I should feel more sorry for... the nurses? or the patients?

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Studying Scared

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

Good intention? A desire to do well?

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

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

1. Life around finals time sucks.

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

2. Finals are gonna be brutally hard.

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

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

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

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

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


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

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

====

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

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