Giving Medicine the Business: Inside the life of an MD/MBA student

A Grain of Salt

Filed under: Uncategorized — Tags: First Year, What to Expect — Adam Nevel on February 11, 2012 @ 2:15 pm

A common question I’ve gotten over my 4 1/2 years at IU is “What is medical school like?” and “What can I expect in my first couple years?”. Understandably, future medical students want to know what to expect and how their life may change as they start the medical school journey. Although I’m always willing to share my own experiences on the matter, I try to do it in a way that makes the students realize that I don’t represent the entire school. I’m one student (of a class of 300) from 1 campus (of 9) who went through medical school at 1 institution (of 160 -MD & DO) in 1 specific year….

That being said, my response to these types of questions (regarding my first couple years in medical school) is usually pretty standard: ’It’s like nothing I’d ever experienced’. Exams were immensely harder than they were in undergrad. Expectations were infinitely higher. Course loads seemed almost comical. And the ability of my classmates as a whole was mind-boggling. Because of this, I found myself constantly buried in school work during my first two years. Weekends became ‘catch-up’ opportunities for textbook chapters. My evenings were spent at a variety of desks scattered around the Notre Dame campus. And mealtimes became my one chance to relax, before jumping back into the anatomy, biochem, or histology topic of the week. I was, in a single word, overwhelmed.

My bright-eyed 1st year class in South Bend - 2007

Not everyone was like this, however. Many students are straight up champions at memorization and exams. They’re able to spend half as much time studying (still far more than undergrad…) and do twice as well. They balance their social life and academic life extremely well and would argue that the first two years were easy and totally manageable. I saw firsthand the variability in medical students and the ways medical school affected each of them. Everyone was different, and to paint the situation as a cut & dry one would be wrong.

I remember getting frustrated at the panel of students at my medical school orientation as they all seemed to contradict one another about what to expect during first year. ”I went out every weekend and barely studied”….”I was at the library constantly”… “It’s not too bad”….”It’s awwwweful”. Back and forth, the students talked about what their experience was like in medical school and what the bright-eyed students in the crowd should expect going forward. As they continued their arguments back and forth, one thing became increasingly clear to me…

I couldn’t trust a single word.

Priorities, expectations, personal ability, and previous background will, in my opinion, mold one’s medical school career. Everyone varies in these areas and no two students will experience school in the same way. Some will love the first two years and hate the next. Others (like myself) will be overwhelmed during the first two ‘basic science’ years, but will find their clinical years to be some of the best ever.

Nobody can tell you exactly what to expect during medical school, they can only tell you how it was for them. The rest is up to you…

Quote of the Post:

“If today were the last day of my life, would I want to do what I am about to do today?” -Steve Jobs

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It’s Been Awhile

Filed under: Uncategorized — Tags: Kenya — Adam Nevel on January 9, 2012 @ 7:06 pm

Dang it. I promised myself that I would never be one of those bloggers that has to start posts with “it’s been awhile…” due to constant swings of inactivity, but nevertheless…

It’s been awhile.

I’m back from Kenya, I’m almost done interviewing for residency, I start my MBA classes back up MBA tomorrow, and I take Step 2 CS in two weeks. I am in no shortage of topics, that’s for sure…

I’m going to try and break the topics up into separate posts so that I don’t force anyone to read stuff that doesn’t pertain to their interests.

Let’s start with Kenya.

Since my last post was on October 15th, I still have two weeks of the rotation to briefly discuss, which I think can best be done with photos:

Rafting the Nile:

The other students & residents and I decided to go rafting down the Nile river in Uganda for a weekend trip. It was amazing. I’m the submerged rafting expert in the front of the raft. We were told there weren’t any crocs left on this stretch of river. Hopefully true…Check out the full video here.

Tumaini Children’s Center:

A requirement for the rotation (and an excellent one at that) is that all students spend at least 1 day at the Tumaini Children’s Center giving a talk or hosting an activity. Tumaini is aimed at providing street children a safe place to spend the day away from their normal life on the street (click here for more info). As my activity, I talked about music and taught the kids how to make kazoos out of combs. It got pretty noisy, but they all seemed to love it. Afterwards, when they saw me taking photos of the house, they insisted that I snap some of them too. They were a fun group to be around. A ton of energy regardless of their difficult living situation.

Orphanage:

Another fantastic requirement for the rotation is visiting an orphanage just on the outskirts of town. Actually, the term orphanage isn’t exactly correct since, according to the couple that runs the place, once a child is excepted there, they are treated as the couples’ own child and are then raised and educated there. The children are nearly all either HIV+ or have lost their mothers to the disease. Not to play favorites, but this little guy was awesome…

Maasai Mara:

As is not uncommon with students on the rotation, I saved my vacation days for the last week so that I could travel. In fact, my family (and my girlfriend’s family) came to Kenya at the end of the trip and traveled with us (my mom and her dad -both physicians- even did some volunteer work while there). We started with the famous Maasai Mara National Reserve.

Mombasa:

After that, my Dad and I branched off and traveled to the coastal town of Mombasa. Much like the rainforests of Kakamega, this was not at all what I associated with Africa. It was a nice change of scenery and a great place to relax for a couple days.

Lake Nakuru:

After Mombaasa, we headed to the Lake Nakuru National Park. It is best known for its bountiful supply of flamingos (as seen in the movie Out of Africa) and for its large Rhino population. Since most of the flamingos were elsewhere for the season when we got there, the Rhinos were the main attraction.

Lake Baringo:

The final stop was at Lake Baringo, where we stayed at an island resort on the lake. The island is home to hundreds of species of birds. At sunset, we went out to a lookout point overlooking the lake. Great way to end the trip.

Amsterdam & Home

After that, we all made our way back to Nairobi to catch our flights out. We once again flew through Amsterdam, giving us the opportunity to stop at the Rijks Museum for a couple hours. Rembrandt’s ‘Night Watch’ was pretty impressive.

And then, after two wonderful months in Africa, I was home, preparing for a busy residency interview season. Although part of me was ready to come back, it feels as if some of me never left. Not only will I always remember the experiences I had abroad in Kenya, but I know now that I want to stay involved in global health in some way moving forward. There are just too many people depending on it…

Quote of the Post:

Life isn’t about finding yourself. Life is about creating yourself.

~George Bernard Shaw

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Ann & Jane

Filed under: Uncategorized — Adam Nevel on October 15, 2011 @ 6:40 am

**I actually wrote the following during the first few weeks of my rotation here, but have not posted it until now**

Ann was sick. Things hadn’t been right for the past week, and her headache seemed to grow as the days went. Her throbbing head slowly evolved into neck pain, lethargy, and confusion, and by the end of the week, the symptoms had become too much for her to bear. As her mind seemed to slowly slip away, her daughters took it upon themselves to bring her over to the Moi University Teaching and Referral Hospital (MTRH). The doctors there, they hoped, would be able to help…

Jane was sick too. She hadn’t been quite like herself over the last few days, appearing disoriented to family and friends. A stroke had robbed her of her speech three years ago, but she normally still had plenty of smiles and gestures to dole out to those she loved. But for those last few days, things had changed. Jane was confused. She was breathing fast and was moving as if she was stuck in slow motion. Drool slowly dripped from her mouth, and it didn’t take long for family to realize that things were not right and Jane needed immediate medical treatment…

By the time both of these patients arrived at MTRH, the severity of their illnesses was undeniable. They were admitted to the Amani Wards and placed on Firm II, where I had been working for just over a week. They both looked awful. Ann was no longer able to speak, instead staring blankly at the wall, not tracking or following any sort of command. She had just tested positive for HIV in Casualty (ER), and a lumbar puncture confirmed the suspected diagnosis of meningitis.

Jane was not much better. While her mental status was not nearly as declined as Ann’s, her body was cold and her breathing labored. Her heart seemed irregular and an oxygen saturation read 75%. An x-ray done in Casualty showed a consolidated right lower lung lobe, along with a massive heart. Jane had pneumonia, tipping her enlarged heart into decompensated congestive failure along the way. Without intervention, both patients would likely die. Even with intervention, however, their outcomes were still far from assured…

Jane responded well to interventions and medications. As her cardiac output improved, so did her mental status, and by the end of a week, her initial drooling appearance was slowly replaced by a daily smile at each visit on rounds. She was a gratifying reminder of all that could still be done on the wards, even without the back up of 20 ICU beds, vents, and a full array of medications.

Ann, sadly, did not offer the same reminder. Even after initially responding to antibiotic therapy, her health took a turn for the worse by day three, and, despite our resuscitative efforts, she passed just before rounds on a Tuesday. As we closed her eyes and pulled the sheet over her face, I could think of nothing else but what her two college-aged children had said to us just a few days earlier:

“Please, save our mother”

Although I have mostly come to terms with the difficult conditions in which I work here, interacting with a severely sick patient’s family and friends remains one of the most saddening parts of the rotation. Watching the family mourn for the death of a loved one is truly heart breaking, and even after doing ‘all you can’ for a patient in those circumstances, you are left with the inevitable question of ‘could I have done more?’

Jane and Ann demonstrated the fine line between life and death on the wards here in Kenya. Sick patients are bountiful, and attempting to predict who will survive and who will pass is futile. We just continue to do what we can with what we’ve got, and pray that that is enough…

Quote of the Post:

Far and away the best prize that life has to offer is the chance to work hard at work worth doing.

-Theodore Roosevelt

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Farmer for a Day

Filed under: Uncategorized — Tags: AMPATH, Kenya — Adam Nevel on October 10, 2011 @ 4:17 pm

One of the requirements of the rotation here in Kenya is that each student work a morning at the AMPATH farm in town. As a background, AMPATH (Academic Model Providing Access to Healthcare) is the official title of the IU/Kenya Partnership. It is a wide-reaching organization providing healthcare to over 120,000 patients at sites throughout Kenya. (For the full spiel, go here: http://www.iukenya.org/). It truly is an inspiring organization offering true hope with regard to the eradication of HIV in Africa.

In addition to treating the diseases of their patients, AMPATH also realized early on that nutrition was a huge factor in successful outcomes. Simply put, a patient with HIV can take all the medications in the world, but if they are starving to death, their ability to fight the disease will remain poor. To combat this, AMPATH has also become the largest feeding program in sub-Saharan Africa, providing food to over 30,000 patients and their families every month. This food comes from a wide variety of sources, including AMPATH owned & operated farms. Alas, the focus of this post…

To work on the farm, Kait and I signed up last week for the following Monday slot. We then showed up at IU House this morning at 9am and grabbed a ride to the farm (~5 minutes away). There, we were greeted by Evelyn (see picture) and several other workers (of 30 total) who were already busy working on the 10 acre spread of land. The farm had all kinds of crops, from mahindi (maize) and nyanya (tomatoes) to Sikuma Wiki (Kale) and Mhogo (Beans). Each day, the farm harvests some of the crops and sends them off to the AMPATH clinics to be distributed to food-insecure patients and their families. While working on the farm, Kait and I did a wide range of chores, including turning soil on new crops and clearing brush from crops already harvested. Although the morning did include some back-pain-inducing labor, it was a wonderful and inspiring experience nonetheless. Plus, I got to try my first taste of typical Kenyan porridge called ‘ogi’. It will also be my last…

AMPATH Farm Day

Quote of the Post:

Work isn’t to make money; you work to justify life.

~Marc Chagall

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How about Motor Oil?

Filed under: Uncategorized — Adam Nevel on October 2, 2011 @ 3:18 am

Last week, I sat down in front of a group of Kenyan parents and took a deep breath… I was about to teach those parents all about ‘First Aid for the Family’ and I really didn’t know how the session would go.

I was at the Sally Test Center, a ‘playroom’ and educational center for pediatric patients and their family at the hospital. In addition to acting as a safe haven for pediatric patients during their hospital stay, the center also hosts parent talks during the week focused on medical care for the family. The topics can range anywhere from sickle cell anemia to dehydration and are given by one of the students/residents/volunteers currently rotating through the program. As someone interested in emergency care, I found the topic of ‘first aid’ to be very appropriate and useful for the families. My fear though was that I’d be making idealistic suggestions that could never be accomplished:

“Run warm water over the wound for several minutes….even though you may not have a faucet or electricity…”

“Place a clean gauze or bandage over the wound…that you’ll get from the pharmacy 30Km away…”

“Immediately bring the child the hospital…far across town, in the middle of the night, with no car…”

I adjusted my talk as best I could, trying to take these situations into account. I phrased it as ‘drinking water’ instead of tap. I avoided suggesting too much medical equipment (gauze, bandages, etc.) and focused on using clean garments and clothes as bandages. I conceded that, although ice may be great for a limb sprain, it likely wouldn’t be an option, and so the family should focus more on things like elevation, rest, and avoidance of initial heat therapy. I tried my best not to suggest that every injury be seen by a health care provider, while still trying to make sure that they understood how infection presented and why it needed to be taken very seriously.

Throughout the talk and afterwards I took questions from the 25+ parents in attendance to make sure that we were addressing all of their concerns. While many of the questions were similar to those in the US (i.e. what causes infections, etc.) many others were quite unexpected:

“It’s common to put things in the wound to help healing, like dirt, ash, or motor oil…is that ok?”

“Egg, or flour, is frequently put on burns….does that help it heal?”

“My child had a fever last week and kept wanting to put his hands in cold water…what could have caused that?”

I took every question seriously and explained why many of those practices should be avoided, and what should be done instead. The parents seemed to be most interested in the ‘how to treat a nose bleed’ section of the talk, giving out a universal ‘aahhhhh’ when I demonstrated that the head should be tilted forward, not back. By the end of the talk, the families seemed to have gotten a good grasp on the topic, and warmly thanked me for the lesson. They then finished their tea, gathered up their children (for those that came with), and began filing out of the large room. As they did, I couldn’t help but think back on the session and smile, thinking just one thing to myself…

‘Please tell me they won’t put anymore motor oil in their wounds…’

Quote of the Post:

“If a seed of a lettuce will not grow, we do not blame the lettuce. Instead, the fault lies with us for not having nourished the seed properly.”

- Buddhist proverb

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If you hear hoofbeats…

Filed under: Uncategorized — Tags: Kenya — Adam Nevel on September 19, 2011 @ 2:24 pm

In medical school, there is an overused saying that paraphrases to “if you hear hoofbeats behind you, think Horse, not Zebra”. The idea is a good one. If a patient presents with a headache, for instance, you should think migraine before thinking of something like a brain cyst secondary to echinococcus.

Many medical students struggle with this concept early on during their training. After learning about all the different pathologies of the human body, it can sometimes be difficult to not let your imagination run wild. Chest pain suddenly means miliary tuberculosis. Abdominal pain equates to a parasitic infection. Back pain can be nothing other than Ankylosing Spondylitis. Instead of thinking heart attack, gastroenteritis, and lumbar strain, students are eager to dig for the ‘Zebras’ instead of the ‘Horses’.

In Kenya though, this saying doesn’t quite carry the same weight. American ‘Zebras’ are suddenly horses, and things like Malaria, Leishmania, Typhoid, Tuberculosis, and HIV quickly jump to the top of any differential diagnosis. Similarly, many of the ‘Horses’ I’ve come to look for in the US are no longer guaranteed regulars on my ward rounds. Rampant American diseases, like type-2 diabetes and coronary artery disease, play second fiddle on the Kenyan Wards.

This saying popped into my head recently for two reasons, both of which can best be summed up with photos. The first photo shows a disease process that truly is a ‘Zebra’ in the US: Hydatid Cysts secondary to Echinococcosis. Simply put, this is a disease caused by tapeworm that harbor in farm animals and dogs before settling into humans, causing cysts in the lung, liver, brain, heart, or kidney. Unfortunately, there is a patient in the wards with exactly this. He is a farmer, who (from my understanding) presented with gradual worsening neurologic symptoms. His actual head CT is shown below.

The second reason this saying popped into my head is because, quite frankly, I spent this past weekend surrounded by actual Zebras while at Crescent Island, off of Lake Naivasha.

You didn’t think this Kenya Rotation would be ALL work, did you…?

Quote of the Post:

In a gentle way, you can shake the world.

-Ghandi

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What antibiotics do we have?

Filed under: Uncategorized — Tags: Kenya — Adam Nevel on September 11, 2011 @ 4:35 am

My first lesson on the Wards at MOI hospital in Eldoret is that resources are limited. As the title of this post indicates, we do not have the luxury here of tossing broad spectrum antibiotics to all of the ‘really sick’ patients (which make up a great number of the ward patients). Instead, we are forced to determine what antibiotics are available at the hospital on that day. Currently, we are limited mainly to penicillin and gentamycin. I’ve been told that there is a small stash of Vancomycin, but I’ve only seen it used once thus far. If the patient really needs something other than what’s on hand, the patient is instructed to have family members go to the local pharmacy and purchase the other antibiotics. If the funds are unavailable, then things get really difficult…

These limited resources extend beyond medications too. ‘Urgent’ echos can sometimes take several days and certain lab tests (ABGs in particular) are quite dependent on the operational status of the related machines. The hospital is out of IV contrast for CTs and even simple items like lubricating jelly for NG tubes are a scarcity (it took me 4 different stations to find a tube). For many patients, diagnosis of treatable disease does not necessarily equate to treatment/survival. The ICU is nearly always full and resuscitation necessities like central lines and AEDs (Acute External Defibrillator) are unavailable on the floor. Even the most crucial of treatments, Oxygen, is difficult to come by as there aren’t nearly enough tanks or condensers in the hospital to support all those in need.

To say that things are different here than in the States would be a gross understatement. The mortality rate on the WARDS here is roughly that of the US Intensive Care Units and losing patients overnight is an occurrence so common that, after only 1 week, I have unfortunately come to expect it.

We do everything we can for the patients, and there are many success stories on the Wards as well. Even some extremely sick patients come back to health and are discharged from the hospital. Unfortunately, even once ‘discharged’, they must stay at the hospital until they can pay their bill. This often leads to a new infection or disease (pneumonia, Tuberculosis, Deep Venous Thrombosis) that requires readmission and new treatment. It’s a sad merry-go-round that can sometimes swallow a patient whole, turning a happy 1 week recovery into a sad 6 week hospital stay, bankrupting a family and leaving them to try and pick up the pieces.

But for every sad story, there almost always seems to be one to re-boost morale. For every deadly meningitis I see, there seems to be another case that we successfully treat. For every heart I watch fail, I see another that is helped. It can be a sad experience being surrounded by disease and death, but being able to help even the occational patient makes all the difference in the world…

Quote of the Post

How wonderful it is that nobody need wait a single moment before starting to improve the world.

~Anne Frank

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From ERAS to Kenya

Filed under: Uncategorized — Tags: Away Rotation, ERAS, Kenya, Match — Adam Nevel on September 4, 2011 @ 5:07 am

I have to warn you all up front: This is a pretty dry post! I just wanted those who may be interested to hear a bit about the residency application process as well as the ins and outs of my travels to Kenya…

It’s been a busy time for me over the last few weeks. In august, I finished an Emergency Medicine away rotation in Chicago and returned to Indianapolis. For those who may not be familiar, an away rotation typically consists of spending a month at a school or hospital different then your own med school working in the field of your choice. Most students will pick the location of the elective based on program reputation. Typically, you want to try and get a good grade and a strong letter of recommendation out of the rotation so that it will strengthen your residency application. At other times, students pick the elective based mainly on location…a month at ‘Hawaii hospital’ sounds pretty sweet…
Following the away rotation, I (like most students) had to turn my attention to residency applications. This mainly involved filling out and submitting ERAS, an online application accepted by almost all residencies. The main components involve describing any volunteer, research, or work experiences, and writing a ~1 page personal statement. The application must also include 3-4 letters of recommendation (depending on residencies) from physicians and faculty. It’s a pretty painful process in terms of details. It’s especially painful when you must scramble to finish it before leaving for Kenya…

Currently, I am sitting outside one of the houses in the IU House compound in Eldoret, Kenya…the product of a looong 3 day journey with my girlfriend, Kait. We left Indianapolis on Weds night and stayed with her parents in Fort Wayne. We stayed up late, and woke up early, to submit our residency applications the next morning, Sept 1st (the first day in which applications can be submitted, as well as the day of our flight out of the country). We then traveled to South Bend and picked up my Dad, who would be driving my car back from Chicago later that day. By 2:30, we were at O’Hare international making our way through security and towards our KLM Royal Dutch Airlines flight to Amsterdam.

Once we got to Amsterdam, we had a 9 hour layover. We did this intentionally so as to a) be able to visit Amsterdam a little and b) ensure getting into Kenya during the AM instead of late PM. We got off the plane and headed into the city with ease on the railway. In the city we did a number of touristy things, like visit the Anne Frank house and take a boat tour through the canals. We ate some pancakes, had a Heineken, and walked for miles around town. By the end, we successfully made it back to our plane on time and headed off to Nairobi on what had become Friday night.

In Nairobi, we hired a cabbie for the day and checked out the city. We saw a bead factory, a giraffe park, an elephant orphanage, and a place that turns used flip flops into art (check out their website: http://www.uniqueco-designs.com/) Really cool stuff…

We finished the trip by taking the final leg of our trip to Eldoret that evening. It was a short flight on a small airplane. We were greeted by ChaCha, a well known local cab driver, and taken to IU House. At that point, it was ~8pm on Saturday night. I’ll describe some of the details of IU House, Eldoret, and the hospital later this week. So far, everyone has been extremely nice and I’m excited for an amazing next two months…

In a couple hours, I will be playing soccer (fine…football) with a bunch of the other students, residents, and staff, as well as a bunch of local Kenyans. I’m excited to show off my 7th grade skills…

Other than the news of season-opener football losses by my beloved Hoosiers and Irish, it’s been a wonderful morning thus far. Hopefully I can fend off Jet Lag for the whole day.

I’ll be trying to give frequent updates over the next 2 months and am happy to answer any questions people may have! I’ll also try to toss some more photos in here and there. Maybe I’ll even make a post in Swahili! That may be a long shot…

Cheers!

: IU House – Part of the compound

Quote of the Post:

I am always doing that which I cannot do, in order that I may learn how to do it. ~Pablo Picasso

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Unavoidable Death

Filed under: Uncategorized — Tags: ICU — Adam Nevel on August 13, 2011 @ 10:10 pm

The title of this post likely triggers a number of different images and thoughts from those of you reading it. Some may take it philosophically, relating it to the idea that we are all dying just as much as we are living. Others may think of it more pragmatically, conjuring up images of sick patients, friends, or family members, for whom an imminent passing was expected and truly unavoidable. When I wrote the title, however, I meant neither of these. Instead, my intention is to to discuss a realism facing medical students (and all healthcare workers) on an everyday basis:

Death is unavoidable.

From the second we are handed our white coats until the day we hang them up, med students and physicians are faced with a unique exposure to human mortality. Death is a part of the job. Whether its oncologists (cancer), cardiologists (heart attacks), Ob/Gyns (Ectopics), Infectious Disease docs (HIV), or even Dermatologists (Skin cancer), physicians face a daily reminder that life is a gift that can be taken away in an instant. Although the shock of death eventually expires and (I’m told) the physician becomes used to its unfortunate occurrence, the early years dealing with it are far from enjoyable. Every medical student (and current physician) could almost assuredly tell you about the first time they experienced the death of a patient.
For me, it was on my surgery rotation; the outcome of the very first surgery I ever scrubbed into. The patient was a ~35 yo woman with metastatic cancer whose quality of life was ruined by her extensive tumor burden. Willing to try and help provide some sort of relief to the woman, my surgery attending agreed to take her to the OR in an effort to debulk the tumor load. The patient was well aware of the significant risks of the operation, but adamantly pushed forward with the surgery insisting that living her last few months in her current shape was simply not an option. Sadly, the woman never made it off the surgery bed. Despite over 6 hours of attempts at bringing her bleeding to a hault, we had to eventually decide to simply close the wound, make the patient presentable, and allow her to pass peacefully surrounded by her loved ones.

This death was only the beginning. Just as any other medical student at my stage in training will tell you, deaths are truly unavoidable. In the ICU, you feel helpless as you witness a mortality rate over 20% on average. In the Emergency Department, you are forced to watch patients literally die in from of you, despite every possible medical, procedural, and surgical intervention. Even on a more cheerful, ‘life-promoting’ rotation, like obstetrics, you are unable to avoid death, seeing an unfortunate handful of stillbirths and miscarriages.

This exposure to death, while depressing and hard to get used to, does help reinforce exactly why we all got into this ‘business’ to begin with: to help impact lives. This holds true not only for those acting acutely to save a life (CPR, surgery, etc.), but to those who help ‘preemptively’ save people’s lives (diabetes control, disease management, etc.) as well. For every death we encounter in medicine, I believe there are hundreds of other examples of lives we have helped to improve. While the death of a patient may always stand out in a medical student or physician’s mind, hopefully it is the life of a patient that sticks with us the longest….

Quote of the Post

A man who dares to waste one hour of time has not discovered the value of life.
Charles Darwin

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“I dont’ know if this changes anything…”

Filed under: Uncategorized — Tags: Emergency Medicine, Lessons Learned — Adam Nevel on June 15, 2011 @ 12:23 pm

One of the things I like the most about working in the Emergency Department is the variety of patients: GI, Cards, Peds, OB, Neuro, and Psych patients all have emergencies and therefore filter through the ED at some point. While many times there are clear cut boundaries between complaints (i.e. chest pain with exertion or a simple laceration), there are other times when the underlying disease process overlaps specialties. Such is the case with one of my recent patients….

When I saw the patient’s name on the board, it simply said it was a middle aged person with abdominal pain. What I found out as I dug deeper was that this was a psychiatric patient who had already been worked up for the abdominal pain a week earlier and was told at that time that it was not appendicitis. While interviewing the patient, however, I realized that the ‘non-diagnosis’ was not sufficient. The patient believed surgery was necessary and had therefore arrived at the hospital with plans to be admitted that evening. After interviewing the patient, it became quite clear to me, however, that this was not appendicitis, nor anything close to an emergency. The patient had a Normal CT 1 week prior, had no anorexia, no change in pain over the last 48 hours, minimal-to-no pain with palpation, no rebound tenderness, and in general, an overall healthy-looking appearance. After informing the patient of the ‘great news’ that it did not appear to be appendicitis and it looked like surgery would not be necessary, the patient nodded with understanding while I finished my explanation. The patient’s final statement, however, indicated that we were still not quite on the same page….

“I don’t know if this changes anything, but my appendix has been hurting a lot lately”

Clearly, rationalization was not going to get me too far with this patient. I choked back a smile, told the patient we’d get everything taken care of as best as we could, and stepped out of the room to discuss the case with my attending…

To get back to my original point, some patients’ complaints are not so clear cut. Every patient is different and every ‘abdominal pain’ has some different twist for the doctor, nurse, etc. to decipher. Do psychiatric illnesses make the situation more difficult? Absolutely. But adding that layer of complexity is what keeps the job fresh and interesting.

For those of you out there who may be interested in med school, or those others who are currently enrolled and are working through the first two ‘academic’ years, I use this patient as an example of what lies ahead: You will see things throughout school that will never cease to amaze you. Patients will make you happy, sad, angry, scared, and relieved. Some with be easy and straightforward, while others will tax your brain to no end. Each patient will slowly help turn you into a doctor and prepare you for residency and life beyond. By the end of it, you’ll feel like you can handle any situation and any patient thrown your way. It’ll be right at this moment, however, that you come across the patient whose ‘appendix has been hurting’ and you’ll realize that you still have so much more to see…

Quote of the Post:

The purpose of life is not to be happy – but to matter, to be productive, to be useful, to have it make some difference that you have lived at all.

- Leo Rosten

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