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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Trauma Team vs. Delirium team?

My Internal Medicine attending made an interesting point today, brought up at a lecture by Dr Rivers (famous for his work on treatment of shock/sepsis in the emergency department, published in the NEJM):

• Number of hospital staff who work on a trauma patient who just arrived at a large hospital: usually ~10-20


• Your chance of dying from an auto accident if you make it to the hospital alive: ~10%

• Number of hospital staff who work on a patient with delirium who just arrived at a large hospital: perhaps the medical student at first, then the doctor when s/he gets around to it


• Your chance of dying from delirium: ~50%

A bit of a disconnect, perhaps?

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