I'm in a Coat!

Life as a third year medical student

Operative Notes

Filed under: Patient Stories, Surgery — Henry on January 11, 2010 @ 8:32 pm

As much as I love spending time in the operating room, even I have to admit that my general surgery rotation is a touch brutal. For instance, I just got home around 6:30 pm. I have to go to bed soon so I can wake up dark and early at 4 am. I just threw together some leftovers for dinner, which I’m currently scarfing down. I’m not really sure why I bother showering anymore, but I think my patients appreciate it. I have to work on an oral presentation due tomorrow and hopefully read a couple pages of surgery study notes. Then I’ll probably round out the night by checking friends’ updates on facebook. And maybe blog a little bit.

I don’t want to paint a drab picture of IU surgery, though. I got extra lucky and got placed on one of the busiest surgery services at IU, so your mileage may vary. I love seeing my classmates’ smiling faces as they come in later and leave earlier than me every day. But I’ve gotten to scrub in with some phenomenal surgeons and see some wild cases, like the gentleman whose spleen was bigger than my head, the lady who had a sizable amount of her GI tract removed for metastatic carcinoids, and a lady with a stomach perforation whose CT scan showed an impressive amount of free air. It was amazing she was somehow walking around with that kind of pain. Our surgeons also perform Whipples like nobody’s business. It’s a fairly involved procedure for conditions like pancreatic cancer, and we do so many that I think my chief resident could probably do it in his sleep. Maybe he does. I don’t know. He’s pretty good. Now, if only I could be that good when I’m awake. Maybe I’ll sleep in until 4:15 tomorrow.

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Sleight of Hand

Filed under: Patient Stories, Surgery — Henry on December 14, 2009 @ 2:32 am

I entered the operating room just as the neurosurgeons were about to expose the patient’s dura mater, the outer layer of the sac that surrounds the brain. All I could see in the operating field was the exposed skull and the flaps of scalp at the periphery. Like a typical operating room, everything was draped in sheets of blue paper and plastic. In the OR, you must assume that everything in blue is sterile. An important rule we learn as medical students is: When in doubt, don’t touch it. If you’re not scrubbed in, it’s a cardinal sin to contaminate the sterile field. If that happens, the only thing dirtier than you is the glare you’ll get from the scrub nurse. We learn some tough lessons in med school.

I hadn’t see the patient before, but I tried to imagine the 5-month-old baby tucked away on the operating table, engulfed in layers of protective drapes. She had craniosynostosis, or premature fusion of the plates in her skull. Her brain was essentially encased in a bony prison with no room to grow. The surgeons would have to saw apart her skull and piece it back together with spaces in between, creating artificial suture lines. Interestingly, I learned that much of the procedure was not being performed by neurosurgeons, but by plastic surgeons. The neurosurgeons helped open the scalp and the cranium, but the plastic surgeons performed the reconstruction, which involved screwing in dissolvable plates to hold the skull fragments together. When drilling holes in the cranium, we obviously have to avoid drilling into the dura underneath. We do this by holding malleables, or flat metal retractors, between the skull and the dura. At that moment, you’re the main barrier keeping the surgeon’s drill from penetrating into the patient’s brain. Yeah, no sweat. We also did some measuring, fitting, and chiseling in the process. Essentially, we were performing carpentry on this little girl’s skull. We were building a new home for her brain.

In the end, the surgeons got the patient’s skull plated together with extra wiggle room for her brain. They assured me that new bone would bridge the gaps we had created in her cranium. That’s the great thing about kids. They’re resilient. Then her scalp was closed up and cleaned off. The sterile drapes were pulled back, and I saw the infant for the first time. Bathed in the glow of the surgical lights, she was like a little angel emerging from a sea of blue. I left before the anesthesia wore off, but her tranquility did not betray the flurry of activity that had gone on around her for the past 7 hours. To think of the collaboration that came together to pull off a feat like this is simply mind boggling. The neurosurgeons, plastic surgeons, anesthesiologists, radiologists, and nurses were like players in one big magic show. Apart from bandage wrapped around the patient’s scalp, it was as if we were never even there.

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Plastic Surgery…

Filed under: Surgery — Henry on December 8, 2009 @ 9:24 pm

…is awesome! I’ve seen so many interesting cases, including hand fractures, breast reconstructions, burns, skull fractures, skull malformations, lacerations, wound infections, and yes, even liposuction. I’m keeping busy, but I will attempt to pull myself away from surgery to add some sweet updates by this weekend. Now, if only I could blog my way into a plastics residency…

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Special Deliveries

Filed under: OB/GYN, Patient Stories — Henry on November 11, 2009 @ 3:50 pm

Okay, I’ll admit it. I really enjoyed my OB/Gyn rotation. The final exam didn’t treat me so well, but let’s not blog about that. I went into this rotation expecting to get a lot out of it since I considered it one of the more nebulous medical specialties. I wasn’t disappointed. When you take into account the invasiveness of some procedures, the sensitivity of some topics, and the fear of desecrating the miracle of childbirth, it seems like a recipe for disaster in the hands of a third year medical student. It helped that our clerkship director told us from the start that it’d be hard for us to screw up patient care. She was right. I didn’t drop any babies, the patient encounters were pleasant, and I only messed up my sterile technique a few times, thankfully with no major consequences. This rotation consisted of a lot of memorable experiences for me. Here are some highlights…

I saw a giant baby emerge from a 400+ lb lady.
We saw a patient with Prader-Willi syndrome. She wasn’t quite as obese as I expected (or as our medical education would have us expect).
A patient came into triage bleeding out profusely from a placental abruption. Mother and baby ended up fine after an emergency c-section.
Another patient came to the ER bleeding into her abdomen from a ruptured tubal ectopic pregnancy. Estimated blood loss was 2.5-3 L, or over half her blood volume. The patient recovered with surgery.
A gravid patient with H1N1 was taken to the OR for an emergency c-section. Baby came out fine, but the mother went to the ICU on a ventilator. (Get your flu shots!)
I got to hold down an unruly patient. The patient was half sedated. I won.
I met someone who got surgery to move her belly button back to midline because it had shifted from a prior surgery (?).
We had a patient with bike chains permanently welded around her wrists. This sort of posed a problem for the use of electrocautery during her c-section, since metal contacts can cause burn injuries. Towels were shoved between her skin and the chains as insulation.
A patient gave me some good advice: “Don’t drop out of medical school. And don’t do cocaine!”
Speaking of which, we saw a pregnant psych patient whose drug screen tested positive for cocaine. No ma’am, your fetus doesn’t like that.
I am more thankful than ever that there is no remote chance I will ever give birth. Ladies, you have my undying respect. Cheers.

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Where Every Day is Labor Day

Filed under: OB/GYN — Henry on October 28, 2009 @ 10:02 pm

Sorry for the lack of posts lately. I’m on my obstetrics and gynecology rotation. I’m clocking a lot of hours (never exceeding the legal limit of 80 per week, of course), which means that I’m seeing and doing a lot of cool things, but it also means a lot less free time to rave about how awesome it all is, in blog form.

Just to clarify, there is some distinction between obstetrics and gynecology, although the two are always thrown together as OB/GYN. Very simply, OB is dealing with pregnant women, and gyn deals with non-pregnant women. I didn’t even realize that this distinction existed until just this month. Doctors can choose to practice both, or one and not the other. For instance, I worked with a doctor who stopped practicing OB years ago because the hours were more taxing. Apparently, you can’t tell a baby to crawl back in the womb at 3 am and wait until sunrise to reemerge. With gynecology, you have more flexibility to schedule procedures because babies aren’t involved, so they’re less… emergent.

I started inpatient OB this Sunday with a delightful night on call. Incidentally, I did take part in a 3am delivery that night morning and got a solid 2 hours of sleep. It sounds terrible, but it still beats some of the nights last year where I stayed up nonstop to study for exams. Unfortunately, it’s not all laughter and sunshine on baby patrol. During that one day/night on call, I also saw some severe vaginal bleeding, a woman in labor swearing up a storm, and a sad case of intrauterine fetal demise, where we performed a cesarean section to extract a dead fetus.

This is the first rotation where I’ve gotten to scrub in for surgeries, and it’s neat to be marginally useful. Obviously, not being competent enough to perform surgeries ourselves, students are relegated to suctioning blood, holding retractors, and cutting sutures. It’s not as if I would know what to do if I were put in the driver’s seat, anyway. I don’t have the greatest attention span, but I’m captivated by a surgeons’ technical skill and the fact that we’re manipulating the insides of people’s bodies. You learn to anticipate the next step and can actually help make the surgery go more smoothly, like having scissors ready to cut a suture or wiping blood from the surgical field at appropriate intervals. You also give your arm muscles a workout by fighting off the pain that comes with holding objects for long periods of time. I think I’m getting really ripped. Speaking of which…

Q: What do you call an inanimate object at the end of a retractor?
A: A medical student.

One of the most interesting things I’ve done so far in the OR was using my finger to provide traction on a patient’s rectum during a rectocele repair. The doctor told me, “At this point, the patient will probably extrude some stool on your finger, so don’t be alarmed.” Not sure how to respond, I said, “Great.”

I think I did a crappy job.

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Eat Your Veggies

Filed under: Fun, General advice, OB/GYN — Henry on October 15, 2009 @ 8:43 pm

After I got accepted into medical school, my grandmother gave me a preview of what I would learn in my medical training. She said, “Vegetables are good for you. You’ll learn that when you’re a doctor.”

Thanks, Grandma. You are so wise. In these four year of medical school, I can only hope to learn a fraction of the medical knowledge that you possess.

It seems that everyone these days is a medical expert. I sometimes wonder why I don’t see more people giving out free legal or financial advice. Aren’t all of these fields equally mysterious and replete with incomprehensible verbiage? Understandably, misconceptions about medicine abound. Even so, we learn a lot from our patients. They clue us in to medical stories in the news we might have missed, alternative remedies, patients’ fears, etc. It would be great if these misconceptions didn’t exist and if patients knew what doctors knew, but then I’m pretty sure that would make them doctors.

The truth is, even with the knowledge that doctors have, there are still mixed opinions on health issues. We don’t know all there is to know about medicine (which is what research is for). There are many gray zones with risks and benefits that must be weighed. Take estrogen replacement, for instance. If you’re a typical OB/gyn, you may be under the opinion that it’s reasonable to offer estrogen replacement for post-menopausal women since it has some positive effects, such as reduced bone loss, increased sexual well-being, and cardioprotective and neuroprotective benefits. If you’re an oncologist, you may steer women clear of hormone replacement because you tend to see more cases of breast and endometrial cancers that are fed by estrogen. Of course, the medical histories of individual patients must also be considered. But the bottom line is that it takes some reading of the medical literature to really understand how to counsel patients regarding estrogen use. I would bet most patients don’t exactly comb medical journals like doctors do, and nor should they have to. That’s what doctors are for. Ask them for the real scoop. People just need to understand that what they read and hear should always be taken with a grain of salt, and just because my grandmother says vegetables are good for me doesn’t automatically make it so. Why are they good for me? Which vegetables are good for me, and in what ways? Show me the data. I think Grandma has some explaining to do.

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Pearls of Wisdumb

Filed under: Fun, General advice — Henry on October 9, 2009 @ 11:16 pm

I have a terrible memory. That’s why I blog, so I can read my entries a few days later and figure out what happened in my life a few days back. My roommate and I recently had a discussion about how mentally stunted we both are. We can’t memorize movie quotes to save our lives. That also means we have a hard time memorizing random facts. It’s too bad medical school seems to be a conglomeration of random facts. If you can spout off movie quotes after one viewing, you should be a med student. Just pretend your professors are actors in some terrible movie about medical school. All you have to do is memorize the lines that come out of your professors’ mouths and you’ll ace your exams. It’s that easy!

Memorable med school quotes:

“You can handle any emotional abuse I give you.”

“You cannot possibly learn everything. However, you are responsible for everything.”

“Good job! I was setting you up for failure.”

“You’re eating your lunch on a beautiful day and a bird comes by and drops Cryptococcus neoformans in your area and you sniff it in and… you’re doomed.”

It’s too bad most of my favorite quotes aren’t educational in nature.

If you’re like my roommate and me, learning quotes/anything is hard. But luckily, medicine becomes much easier when you understand the pathophysiology of disease and why things are the way they are, instead of just memorizing disjointed facts. So I present to you the first edition of Pearls of Wisdumb, or POW, since they’re tailored for dummies like me.

For instance, it’s known that hyperthyroidism leads to symptoms like heat intolerance and increased metabolism, secondary to overproduction of thyroid hormones (i.e. T3 and T4). But why? Could it have anything to do with the fact that thyroid hormones are structurally similar to catecholamines, which trigger the fight-or-flight response? Thyroxine (T4), triiodothyronine (T3), and epinephrine are all synthesized using tyrosine as a precursor. POW!

For the longest time, I wondered why syphilitic chancres don’t hurt despite looking like painful open sores. Perform a Google image search if you want, and compare those painless chancres to the painful chancroids caused by H. ducreyi. Because syphilis is a disease that causes a vasculitis, the blood supply to the chancre is compromised, which deadens your nerves. Thus, no pain. POW!

How does selecting the right blood pressure cuff affect BP readings? If the cuff is too large, your reading is artificially low, and vice versa. For instance, if you use a regular adult cuff on a person of generous proportions, the BP reading might be falsely elevated. ¿Porque? Having too large of a cuff means you are compressing a greater length of the brachial artery at once. Therefore, it takes less pressure over this longer distance to achieve the same resistance to occlude the vessel. And the opposite holds true as well. No more memorizing meaningless relationships and wondering to yourself if that mnemonic you made for yourself was big-high/small-low or big-low/small-high. Use physics! POW!

Sometimes, you understand the concept, but the terminology messes you up. For example, maybe you know what Broca’s aphasia is, but in neurology terms, is it an “expressive” or a “receptive” aphasia? Well, Broca’s area is on the cerebral cortex right next to the primary motor cortex. Motor equates to expression, whereas sensation is receptive. So Broca’s aphasia is an expressive aphasia, where you have trouble getting out words (motor output). Likewise, Wernicke’s aphasia is receptive because it’s next to the sensory strip, and you have trouble understanding words (sensory input).

POW!

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¿Dónde está el baño?

Filed under: General advice, Internal Medicine — Henry on October 4, 2009 @ 9:23 pm

If you have any desire to learn another language at any point in the future, my best advice would be to do it now. I’ve lost track of the number of times I wished I could converse with a Spanish-speaking patient beyond the basics. I’ve learned that you can’t do a whole lot to comfort patients when all you can say in their native language are: “Hello,” “How are you?” and “Do you have diarrhea?” Here’s a typical conversation I might have with a patient:

Me: Hola. ¿Cómo está?
Patient: Bien.
Me: ¿Tengo dolor?
Patient: [confused stare]
Me: No wait, I mean… ¿Tiene dolor?…?
Patient: Si.
Me: Uh… bien…

During my inpatient medicine month at Wishard, our team had our fair share of Spanish-speaking patients. Luckily, we always had someone on our team who was able to speak Spanish, so we didn’t need translators. Attendings and residents rotate in and out just like students do, and at one point, my attending was a native Spanish speaker, and my resident had lived in Latin America for a couple of years. Another student on my team was also fairly fluent in Spanish. And then I got a patient who had immigrated from Mexico about a year ago. Cool. Give the Spanish-incompetent guy the Spanish speaker. Bueno? Muy.

I’ve been trying to pick up more Spanish in my spare time. My goal is to get comfortable with medical conversation by the time my family medicine rotation rolls around in the spring. I hear that’s usually a good opportunity to encounter a lot of Spanish-speaking patients because you’re out in the community and have more contact with the underserved.

Obviously, different communities have different populations, but you never know where speaking another language might come in handy. At one point, I got to converse with a Taiwanese couple in Mandarin and helped them fill out their patient intake forms. Unfortunately, I didn’t know how to say “hepatitis” or “interferon” in Chinese, but my attending was fluent in Chinese and received a lot of referrals for this reason.

I’d like to leave you now with an excerpt from a rap I wrote in Ecuador several years back:

¿Dónde está el baño?
That means where the john, yo.

Word to your madre!

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Student Outreach Clinic

Filed under: Service — Henry on September 25, 2009 @ 8:36 pm

Several weeks back, I visited the IU Student Outreach Clinic to interview some volunteers and get their feedback about the new clinic. (You can skip down to the bottom for the video if you don’t like reading.) The clinic came about through a student-led effort to address a missing but important component of our medical education. Many other medical schools have student-run clinics, which give students the opportunity to augment their clinical and leadership experience while providing a public service. It seemed out of place that the IU School of Medicine, one of the largest medical schools in the nation and arguably one of the largest human medical schools in the entire universe, did not have such a program. The effort to establish the clinic was mostly led by members of the Class of 2010. The clinic is still growing, and details are still being fine-tuned, but it makes sense that every successful venture should continuously improve and adapt to changing needs.

The clinic has grown by large strides since the first time I visited in the spring semester. The patient load is heavier, there are more volunteers, many legal issues have been worked out, doctors can prescribe medications from the clinic, and there is greater collaboration with other health care organizations. The clinic is also a hub for free clothing distribution and a reading program for children. Also, there are mountains of free bagels for patients and volunteers.

The flow is pretty standard and gives students of all levels the opportunity to learn and contribute. Patients are usually first seen by an MS1 or MS2, who take vitals and get histories. These students accompany an upperclassmen to an examination room, where the more senior student performs a more focused history and physical and formulates a differential. All this information is then presented to the doctor staffing the clinic, and an assessment and plan is ironed out. The doctor accompanies the students to see the patient and make sure nothing important is missed. Doctors can write referrals and prescribe medications. We have Butler pharmacy students and pharmacists on site to deal our drugz.

Unfortunately, I couldn’t get much footage of people in action, since much of that would have involved footage of patients and thus violated HIPAA regulations. And I probably would have had to disclose to these patients that I have a blog. And then they would have pointed at me and called me a big dork. And I would have cried a little. On the inside.

[youtube=http://www.youtube.com/watch?v=7qFPisbgsdY]

Thanks to Ray, Kyle, and Aliese for starring in the video! You can find more information about the clinic online at http://iu-soc.org.

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Only Human

Filed under: Neurology, Patient Stories — Henry on September 21, 2009 @ 1:15 am

Sorry for the lack of posts lately. I was under the weather. I supposedly know a whole lot about random diseases, but I still can’t diagnose myself whenever I catch something. Is it a cold? Is it H1N1? Mono? I need someone to tell me my symptoms , characterize them, and summarize all of my clinical findings in a concise paragraph that includes medically relevant buzzwords. As medical students, we get used to everything being presented to us in this format, with a tidy multiple choice diagnosis to top it off. It’s too bad our patients don’t come in with a clinical vignette and multiple choice options taped to their foreheads.

Even when patients come in with what appear to be “classic” findings for a particular pathology, things don’t always turn out the way we expect. Even when you think you’ve got a neat, picturesque summary constructed in your head of the patient’s symptoms, an additional lab finding can come in that turns your world upside down. Or maybe there was something there all along that you didn’t pick up on. Or maybe the patient didn’t tell you the whole story. Or maybe patients just aren’t the clean vignettes that are depicted on our standardized exams.

There is a law known as Segal’s law, which states, “A man with a watch knows what time it is. A man with two watches is never sure.” Of course, I had to google this to figure out what it meant. I mean, why would a man have two watches? If he’s got two watches, he’s probably delirious and already confused, regardless of how many watches he has on. I’m still not sure about the meaning of this expression because ironically, I came across conflicting information online. Nevertheless, I think we can apply this adage to our patients. If we have just the right amount of information, the diagnosis is clear. Throw in some additional clinical findings, and there’s a chance we’ll probably confuse ourselves. Medicine is full of red herrings, but we have to acknowledge all of the false leads to figure out what’s really important. For instance, I had a patient who presented with a focal seizure. Half his face was twitching. Initial CT scans showed temporal lobe lesions, which suggested herpes encephalitis. That would have been a great explanation and all, but he didn’t look sick. We treated him empirically with acyclovir just in case. Later, the radiologists read his MRI and suggested he had a subacute stroke or a mass. But he didn’t seem to exactly fit the presentation of a subacute stroke. A mass was possible, but the scans didn’t quite look like a neoplasm. The patient also had a very high white blood cell count, but again, he didn’t look sick! Befuddlement all around.

There were some other interesting findings, like abdominal tenderness, inability to draw CSF even with a fluoroscopy-guided lumbar puncture (No CSF? Preposterous!), a focal abnormality on his chest x-ray, and later, acute renal failure that was likely due to acyclovir crystals precipitating in his urine. What appeared to be a straightforward neurology admission quickly escalated into a case requiring oversight from internal medicine. Having too much information seemingly muddled the clinical picture, but these were findings that could not be left unaddressed.

It can be difficult for students to juggle all of the symptoms that patients develop. We’re told to apply Occam’s razor, which is the principle that you should look for the simplest explanation. However, there didn’t appear to be a simple explanation for this gentleman’s findings. Is is encephalitis? Is it a stroke? A neoplasm? A metabolic derangement? None of these seemed to fit exactly. The only unifying explanation for this patient’s condition, as far as I can tell, is that he’s human. It runs in his family.

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