Carrie's blog

Lifelong learner of science, art, and fresh spins on kindergarten

Rarity

Filed under: Learning from Doctors & Patients,Satellite Campus Life — Carrie Rupprecht on April 10, 2011 @ 2:50 pm

I’ve heard we’ll see rare diseases in Indianapolis during third year that we likely won’t see when we’re practicing medicine later. But surprisingly, I’ve seen uncommon cases in Lafayette, too. Studying neurology and dermatology in school reminded me of a few.

Sneddon syndrome is so rare that it is barely mentioned in Harrison’s, the book with whole chapters devoted to diseases. The patient I saw could not speak, had reduced mental functioning, and could not move parts of her body due to multiple past strokes. These started in her thirties due to her blood’s tendency to clot. Another component of the syndrome is a red-blue net-like discoloration of the skin. The cause–or in other words, why she has it, and why I don’t–is unknown.

Another patient had Ramsay Hunt syndrome. The virus causing chicken pox in childhood can reactivate to cause shingles, with blisters affecting a patch of skin. It’s very painful–especially in Ramsay Hunt, in which shingles affects the ear. This involves the nearby nerve that controls the facial muscles, so that one side of the face droops, a component individually called Bell’s palsy.

I used to think that with all that can go wrong, from the pre-conception separation of chromosomes to falling off of our bikes as kids, it is amazing that (relatively) good health is so common. I still think that. But I’m learning it’s less common than I thought. Now when I see an elderly lady who looks like she’s doing alright, I realize that if I listen to her lungs with my stethoscope, I might hear the “crackles” of backed-up fluid from congestive heart failure. The more I see at the hospital, the more I become aware of what a precious gift good health is–something worth protecting!

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Just What the Doctor Ordered

Filed under: Uncategorized — Carrie Rupprecht on April 3, 2011 @ 10:18 pm

Research and my back say that sitting most of the day is bad for you (even if you punctuate your week with workouts). So I created a stand-up desk using a crate and my Robbins [pathology book]. It’s already made me so much happier! Its strongest feature is that it’s temporary because of course, after a couple hours, you remember why you sit down.

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Spring Break ’11!!

Filed under: General Life as a Med Student,Specialization Rumination,Step 1 — Carrie Rupprecht on March 17, 2011 @ 10:48 am

It’s been a strangely busy spring break! I’ve tended to numerous chunks of my personal life that I put off when school is in session, like finalizing plans for my move to Indy, buying a computer, and having regular-length conversations with my family. I’ve also been working on a module for a project we’ll be doing with local high school students in April. I haven’t gotten to writing outlines for our upcoming neuro oral exams and have hardly studied for boards like I planned. But I’ve also had some time to relax and have fun. Rock For Riley and the Medical Missions Student Interest Group (MMSIG) hosted a concert at Birdy’s: Trevor Hall with Matthew Santos opening. I wish I could be here for R4R’s main event April 7th!

This month we’re also submitting our preferences for the sequence of our third-year rotations. There are three blocks, each lasting 16 weeks. Medicine consists of inpatient (IP) and/or outpatient (OP) medicine, neuro, and psych. The peds block has IP and OP peds, family medicine, and vacation–but if like 60% of third-years, you take an elective during this time, you can tack an extra month of vacation onto fourth year’s schedule. Or you can save your vacation for last and start your sub-internship early instead. The surgery block keeps us busy with general surgery, ob/gyn, and a surgical subspecialty.

You’ll hear advice ranging from “take no more than 15 minutes to plan your schedule” to emphatic (and sometimes differing) opinions on what to pick and when. I appreciate all of it and am trying to settle somewhere in the middle. Like a lot of med students, I’ve always erred on the side of creating multi-year plans. One of my classmates is the same way: “Want some of my colored markers to mark which sequences are your favorite?” …Yeah, yeah I do.

Anyway, all this got me thinking about which specialty I like, especially since certain electives require third-year prerequisites and so a little extra planning. And I remembered that the last couple times I’ve left the hospital, where I work with mostly elderly patients, I’ve run into kids on my way out. And they cheered me up each time.

Waiting for the elevator, one little girl broke away from her cousins to approach me. “May I ask you a question? …Do you get to go out and pick up people to bring them here?!” I had to tell her no, but my friend does! I loved her enthuasiasm.

As we all stepped into the elevator, one boy looked up and started talking to his sister. They all giggled gleefully as they realized the elevator ceiling was a mirror and talked to each other’s reflection. I’d never noticed! If laughter’s contagious, kids’ laughter definitely is.

Another day, I befriended a little guy wearing an awesome Spiderman shirt: a web was attached to its sleeves and trunk so that it was very impressive when he stretched out his arms. As the elevator doors closed on me, he started crying. I was touched, thinking I’d made an impact, until I realized it was probably because he couldn’t ride on the elevator.

Later at school, a pediatrician reviewed videos and write-ups of our standardized-patient interviews and physicals with us individually. I asked her if examining a child is more difficult. She said no; it is less complicated because they have a cleaner slate: no long list of medications, rarely comorbidities. Also, sometimes a caretaker is the best source of information for a patient too sick to think of everything, and this is certainly the case when the caretaker is a parent.

So I am going to investigate pediatric oncology. While I love the diagnostic process when a patient walks in with what could be anything, I want to specialize because I like to know all the details and explanations, but this is difficult to do unless you stick to one field or two. With oncology, I’d have the chance to help patients feel better and hopefully get better too. Patients who recover may go on to lead long lives. I would strive to be there also for their parents, who might have a greater sense of the gravity of the situation and more worries on their minds in addition to their main concern for their child. I haven’t had cancer, but my mom has had cancer over the years, so in some ways I dealt with it in childhood and know what kind of doctor my mom appreciated having. And I would be able to build relationships with patients and their families, as they’d be there for more than a day; but the goal would be that they not stay too long, either.

Being in pediatrics, whether in a subspecialty or general, may also make me a better public health advocate. Starting with children (and their parents) is the best way to effect change. Sifting through storage over break, I came across a Seventeen magazine from 1969 with an ad for a weight GAIN product. How fast our society can change!

And how fast time flies when I’m writing about specialties. The next two years’ experiences will be the best way to explore them.

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Adaptations

Filed under: Extracurriculars,Learning from Doctors & Patients,Specialization Rumination — Carrie Rupprecht on March 7, 2011 @ 11:19 pm

“Be flexible, be considerate, and keep your sense of humor.” These are the keys to surviving medical school straight from Dr. Chuck Dietzen, Founder and President of the Timmy Foundation. He is an alum of IUSM – Lafayette, so he recently returned to our campus to share stories and answer questions over lunch. His talk reinfused us with motivation.

To be flexible, friendly, and fun–sounds simple enough, but it requires a conscious effort, on some days more than others. To be flexible is not only to go with the flow; it is to actively adapt to changing situations and feedback. We constantly modify our study habits, approaches to the patient, or whatever. My most recent example: In my last post I wrote that I was planning to run the Mini-Marathon; now I’m planning not to! Training was fun while it lasted, and I’d rather run it. But everything considered, I’ve decided it’s best if I don’t this year. Maybe later.

It’s inspiring to meet with doctors–visible reminders of our goal, of who we’re training to be. That’s one reason why we also recently held a “Doctors’ Day” event where we spoke with local physicians from various specialties. One thing I learned: a “people person” can be a happy anesthesiologist. I met one who assured me that anesthesiologists can have plenty of patient interaction beyond “Count backwards from 10.”

And now I’ll end the night with some anesthesia pharmacology. 10…9….8…..

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Tract Team

Filed under: Balance — Carrie Rupprecht on February 16, 2011 @ 11:31 pm

We’re studying the gastrointestinal tract along with hepatobiliary and pancreatic disorders…which means we’re studying 51368 diseases with slightly varying names and symptoms. I like it so far, but I admit–I’m stressin’ a little bit. Thankfully, spring is on its way: Punxsutawney Phil didn’t see his shadow, birds are chirping, ice is melting.

While it helps to have the hope of sunny days and sand volleyball, we need more tangible stress relief. So most of us love to exercise. If you have the discipline, medical school is a great way to get in physical activity. Simply do wall sits while reading. …Most of us opt instead to work out together in our free time. Some swim (the sharks), others of us run (the wolf pack), some of us are yogis, and the guys have a no-girls-allowed racquetball club.

This photo (courtesy of Andrea Kent!) is of some of us after a six-mile run in the freezing wind and snow. I think we liked it for the same reasons we like med school–kind of painful but challenging and even fun. (I’m training for my first Mini-Marathon; the others are veterans, and we also have an excellent triathlete in our class. He’s the real deal–is a vegetarian, likes Clif Bars, and everything. These people are so motivating!)

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Questions and Answers

Filed under: Learning from Doctors & Patients,Satellite Campus Life,Step 1 — Carrie Rupprecht on February 3, 2011 @ 7:32 pm

I’ve noticed that one of my mentors, Dr. Jeffrey Brown at IU Health Arnett, often asks certain questions: “What are the most cost-effective next steps or tests in caring for a patient with [X]?” If X is syncope like a recent patient had, the answer is orthostatic (standing) blood pressure measurement and cardiac telemetry.

Another question he often asks: “How would you summarize that in one sentence?” It’s a great exercise, forcing the student to synthesize information, decide what’s most important, and express it clearly. For example, someone entered the room right as I was finishing my presentation of an article from JAMA’s The Rational Clinical Examination which answers the question, “Does This Woman Have an Acute Uncomplicated Urinary Tract Infection?” At his prompting I succinctly shared with her which symptoms, historical findings, and/or test results make a UTI likely enough to be diagnosed without a urine culture. I used to fear that I wouldn’t be able to explain well what I knew to patients (or to other doctors).

Another illustration of the importance of asking the right questions: One woman had diarrhea and vomiting; she thought she had caught something from her grandson. She confirmed that his symptoms had come first, so I thought her assumption was likely correct. Later, though, I found out from her physician that her symptoms had been present earlier than her grandson’s symptoms and had followed her taking Omnicef. Omni- means “all,” so it kills a lot of the normal bacteria in your gut, letting C. difficile grow unchecked in its newfound space. Vomiting is not a characteristic symptom of C. diff colitis, so I didn’t suspect it and ask the right questions.

Dr. Brown also encourages us to ask ourselves what we like and what we don’t like and to allow ourselves to feel that way. We will better serve patients if we choose our specialties by acknowledging and following what we love.

In other GREAT news, we have our first class baby! We are so excited that our “framily” has become multigenerational. The new baby girl came just in time to get home before the ice, snow, and freezing rain fell–otherwise, our classmate’s first delivery might have been of his own daughter. In an e-mail, my grandma let me know that she was thinking about her mom, whose birthday was Jan. 29, 1897. “Imagine having a baby in a sod house about 15 miles from any town. She was the middle child of thirteen, so I suppose there were family around during the ordeal, oh my!!” This made me thankful for modern medicine and less sorry about my own cabin fever from consecutive snow days. At least I’m in a solid cabin with heating. Besides, these days off have given me time to go through some USMLE World QBank questions and realize that I need to review only a few subjects:
-Microbiology
-Biochemistry
-Neuroanatomy
-Pharmacology
-Cardiac physiology…
etc. I’m thinking that from now on, my blog should be mostly about medical stories or mnemonics which aid in my preparation for boards. For example–the patient with syncope? It was likely due to a combination of overdiuresis, mild aortic stenosis (if the opening of this heart valve is too narrow, less blood gets pumped through it and to the brain), and other factors. I guess the helpful thing about Step 1 is that each question has only one answer.

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Snow Days Increase Growth Hormone

Filed under: Learning from Doctors & Patients,School — Carrie Rupprecht on February 1, 2011 @ 2:47 pm

It’s my second snow day in five years at Purdue. This time, unlike in my freshman year of college, I live far enough from Slayter Hill that I wouldn’t walk there to go sledding, and the snow is crunchy with ice instead of fluffy. So, what’s a girl to do? Sleep in and eventually snuggle up with my books to study endocrinology? Yes, that’s right. Ah…all I need is a fireplace…which would also be helpful if the power goes out.

The first few weeks were full with IUSM’s St. Vitus dance, nephrology exams (including an oral exam), presenting an article to the hospitalists I follow, practicing a focused history and physical exam with a standardized patient, and performing a full physical exam on a hospital patient. The feedback we receive from physicians is invaluable. Interviewing and examining a patient is harder than it looks: Not only must the technique be right, but you have to think about what each answer and each finding means; you constantly shuffle the differential diagnoses in your head as you find out more about the patient.

I really liked nephrology. Right now we’re learning endocrinology, and our time with it is short–a little over week. It’s also interesting, partly because an understanding of it is applicable to many people’s lives. Oftentimes, the kidneys do what they do; the layperson can get away without knowing much about their kidneys’ complex inner workings, especially if they don’t have poorly-controlled diabetes or heart problems. But hormones find their way into Internet homepage headlines.

For example, I’ve heard personal trainers bark about growth hormone (GH). Sleep, protein, exercise, and low blood sugar all stimulate the production and release of GH. GH, along with the mediators it stimulates, has many effects, including an increase in muscle mass and decrease in central fat, the kind we read about as being so bad for us. Education about endocrinology is important because it makes us more aware and confident of what we observe: for example, sleep and exercise make my waistline smaller like magic, even when my diet stays about the same. (Other factors like cortisol are of course involved….)

Next up: a trip through the GI tract. Sounds like an episode of The Magic School Bus. Stay tuned.

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IUSM-Lafayette Art Show

Filed under: Art,Learning from Doctors & Patients — Carrie Rupprecht on January 14, 2011 @ 12:05 am

During our student presentations in genetics last semester, Bo-Kyu Kim (he goes by Bo) drew portraits of many of us. We can only trust that our presentations were so riveting that he did not need to take notes, but internalized every word.

I thought I would have a mental break from genetics, at least for a while, and I thought I would not get the chance to see many of the diseases we studied, at least for a while. But when following an obstetrician-gynecologist, I met a woman with neurofibromatosis. Afterwards the doctor quizzed me, “Type 1 or type 2?” It was type 1; these patients have raised mole-like tumors and “cafe au lait” spots all over their skin, as well as nodules in their irises. Real people deal with these rare but real diseases. The doctor relayed to me the story of another mother with neurofibromatosis who identified that her baby had inherited the same, even though her doctor had not thought so. She made the baby cry. “Look,” she said, as the cafe-au-lait spots showed up on the baby’s African American skin. Often in medicine, as in life, mothers know best.

Again, a patient renewed my motivation to pay attention to details. The doctor advised me to read about diseases whenever I encounter them at the hospital because I will more likely remember the associated details if I place them with the memory of a patient.

Below, Bo’s art show.

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Emergency Alert

Filed under: Learning from Doctors & Patients — Carrie Rupprecht on December 30, 2010 @ 1:19 pm

I didn’t plan to follow an emergency medicine physician over break, but I am so glad he offered me the opportunity.

During our first Clinical Medicine unit this fall, I learned that tardive dyskinesia is a side effect of the old antipsychotics. But when I saw an Emergency Department patient whose tongue involuntarily moved in the telltale vermicular way, and after I was told she had schizophrenia, this didn’t come to mind. Now that I’ve seen it, though, I won’t ever neglect to think of that association. (By the way, this wasn’t her main problem; she had a UTI, which I learned can cause dizziness in older people and may have caused her to fall.)

Wait…did I say Emergency Department? Yes, that’s right; I visited one and was not stressed out or scared by the experience. I’d always assumed that the high-pressure situations and short-term relationships with patients weren’t for me. However (as people have tried to tell me), the ED atmosphere is surprisingly calm most of the time; and connecting with patients, even if only for a day, brings the same happy feeling. Having predictable shifts instead of being on-call would be nice, too, although I don’t think I would love working overnight sometimes.

Working in the ED definitely wouldn’t be boring. It was fascinating to watch the morning evolve and figure out was going on with each case. A CT scan of a patient’s stab wound revealed a hemorrhage and damage to one kidney. Another lady’s mouth was dry, and she displayed Kussmaul breathing. Labs confirmed what the doctor suspected: diabetic ketoacidosis. A patient who had stopped his warfarin (blood-thinning) medication due to financial concerns presented with a terrible headache and also left fifth and sixth cranial nerve deficits–facial tingling and numbness, left eye unable look to the left–likely due to another venous thrombosis. A man kept going into supraventricular tachycardia and then converting himself back into a normal sinus rhythm by doing the Vagal maneuver (what you do to “bear down” when you’re constipated).

I saw an otherwise healthy young man with pneumonia that had become sepsis leading to Acute Respiratory Distress Syndrome and saw his muscles intially twitch from the paralytic he was given before being intubated. His chest X-ray looked like a heavy snow was falling on the hills of his diaphagm. Another man had burns on his hands and face from a kerosene fire, and I just wanted to stand there with him. I had trouble hearing breath sounds in a man with COPD, and the doctor assured me it wasn’t a problem with my stethoscope. A 100-year-old man who is still able to take care of himself came too, but we didn’t visit him when I was there.

Spending time at the hospital as a second-year student is the best of all worlds. There is no grading or hugely-high expectations, so it’s not too distressing to get an answer wrong; yet we know enough to appreciate the experiences, learn from them, and ask intelligent questions about them…and most fun of all, guess the diagnoses. If you’re willing to make mistakes, whether you know better or you don’t, then get thee to the hospital as often as possible. For me, it’s a nice way to avoid diving into the question bank I just purchased while still investing in my future boards performance. (Step 1 is in May!)

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Inspiring Physicians

Filed under: Balance,Learning from Doctors & Patients — Carrie Rupprecht on December 20, 2010 @ 10:48 pm

On Dec. 2, Dr. Connie Mariano spoke at Purdue. As a Filipino-American woman and Navy Rear Admiral, she had unique stories to relate regarding her path to her position as The White House Doctor, the title of her book I’m reading over Christmas break. What I noticed most about her was that she conveyed confidence. Of all qualities, patients most want to see kindness, competence, and confidence in their physicians. She told of how she got the job after a short interview in which she simply declared her desire to give back to her country and to be “not a desk doctor…a trench doctor.” She had prayed for a sign and had received it upon entering the room: she had spotted a Band-Aid on the interviewer’s forehead and, recognizing his humanity, was able to approach the interview more confidently and thus appear at her best. She went on to serve nine years in D.C. and abroad, following and taking care of her “first patients.” The job gave her a special perspective on the physician-patient relationship; she advised that treating all patients as if they were the President of the United States would bring the best outcomes in patient care.

I have read about another great physician, Dr. Mark Pescovitz, whom I did not get the chance to know but whom many in the IUSM community knew to be outstanding in his many roles, including transplant surgeon, artist, and volunteer. He had a remarkable life story as well. It is told by his brother and in The Indianapolis Star.

A first-year friend during finals week shared with me some of the same thoughts and feelings I was having one year ago. If you are feeling burnt-out, be assured that next year will be better. A break, this Christmas and next summer, will restore your sanity and revive your passion for medicine. The more you learn about the fascinating details of diseases and see the patients who deal with them, the more you will love it. Get support from those around you, and be thankful for and attentive to the people in your lives today. As we learn from the news of Dr. Pescovitz, we cannot be certain that we will have one more day with our loved ones. Enjoy the holidays with your families; I am sure you have never felt readier for a break.

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