Newsletter Catch-up, Year-end Wrap-up

As you know, I've not posted for a good long while. I've been going through a patch of uncertainty regarding my career, but have been able to work out a manageable plan. But I'll start at the beginning of the year.
2011 brought the second half of my third year of med school, to round off my first year of clinicals. I enjoyed some rotations, endured others, had doubts about becoming a doctor, and swung back with experiences that reminded me why I want to be a doctor. In June, I was able to rotate with my uncle, a doctor, and one of his colleagues, which was a good experience for me. My school told us to use July as a study month to prepare for our second run through the gauntlet that is the boards. In August, I had my first audition rotation, the idea of which is to impress the director of a residency program you're interested in. Having no audition rotations set up for September, I did emergency medicine since it's a fourth year requirement for my school.
I thought my rotations would be good preparation for the second board exam, but right at the end of September I found out I had failed it. This news came at a critical juncture, shortly after I had finished my first audition rotation and right before I headed off to start a gruelling four-month stretch of audition rotations. During this stretch, I had planned to pack my belongings into a storage space, be without a home, and literally live out of three or four bags. With feelings of inadequacy always lurking below the surface, failing the board, intimidation by the long string of difficult rotations, and the thought of being basically homeless, I started considering non-medical careers. That is, of course, putting it mildly. I was going to drop out of med school outright, but thankfully was able to think it through and decided the best course would be to at least graduate.

I think one of the major issues I had with medicine was feeling it had taken so much from me: the ability to have a relationship, a family, having free time outside of work, basically just having a life. Several events have shown me that I can have a real life, and I came to realize it can even coincide with a medical career (sorry, explaining the events would take too long). I have started warming up to medicine again and can stomach the idea of finishing med school and even going on to internship or residency. This is still a daunting task, but I am hopeful for what the future holds and am more grateful than ever for the support of loved ones.

Hope you all had a merry Christmas and will have a happy New Year!

Scott

EM Month Winding Down and First Interview

I was very proud of myself recently. I saw a patient with a history of panic attacks and meth addiction. Supposedly the meth from her most recent relapse had worn off and she was solely under the influence of a panic attack when she got to the ER, but I have my doubts. In any case, what I'm proud of is that I was able to calm her down with with a reassuring tone, redirecting her attention, and having her do deep breathing. This was an ego boost not only because I was able to calm a distraught patient, but more so because the whole time I was thinking what a mess her life is and how I didn't want to be dealing with her. So, yes, I'm bragging about my hypocrisy in some ways. It's important, though, to be able to get over your own feelings, judgments, etc. about a patient and be able to provide appropriate treatment. I thought I was already cynical, but this month in the ER with at least a third of my patients being drug seekers has really been an eye-opener and tried my standpoints on the cutoff between providing for patients' needs and being an enabler of unhealthy habits.

Another interesting patient was a quite mature, almost precocious, teen with abdominal pain. I needed to examine the patient's abdomen, and decided it would be best to do so without pants in the way (US pants, not UK pants). I was reminded of the Scrubs episode in which Turk is reluctant to see his doctor because he has to take his pants off for all visits. "Oh, you have a sore throat? Ok, take off your pants and I'll be back in a moment." This ER patient is also a Scrubs fan and I was able to connect over the pop-culture reference. With this patient's maturity level, I had already been able to establish a good rapport, but it was good to see how that personal connection can further put a patient at ease. After the initial ER workup, the general surgeon admitted the patient for observation since the pain was reminiscent of appendicitis, but wasn't as severe as would be expected, plus the appendix was not assessable on CT.

It's worth while to highlight some differences between the two patients above. For the drug addict, I had to step up my interaction with her from my default of not wanting to deal with her. For the teen, I was drawn into conversation and had to rein in my desire to chat in too informal a manner. In both cases, it was important to form a personal connection with the person while maintaining objective professionalism.

I was invited for my first interview yesterday. I have applied to both Orthopedic Surgery residencies and Traditional Rotating internships in case I don't get into an ortho program. The traditional path of medical education was to finish med school, do a generic internship year rotating through all major specialties, then do residency. Some residency programs, ortho included, have wrapped an internship into the curriculum as the first year of the program, and therefore take one step out of the process. My interview offer is with one of the internship programs, and the most convenient available interview date is this coming Monday. So, I had a flurry of activity booking a flight and hotel today. Thankfully the airport, hotel, and hospital are within a 3-mile radius of each other, so transportation is easy. Unfortunately, booking a 36-hour trip only five days in advance is pricey, and all the numbers are starting to run through my head: several hundred per interview trip, times 23 programs applied to, subtracted from what remains of my student loan for this semester... ugh. I'll be panhandling by November.

Scott

EM Rotation and Setting Up Auditions

This month has been fairly low-key as far as my emergency med rotation goes. Somebody in some office not affiliated with the ER docs' group set up my schedule, each day with a different doc, and the docs don't know I'm supposed to be there until I show up at the beginning of their shift. The unfortunate thing is I have to take both parts of my level 2 boards this month, plus go to a doctor's appointment an hour away. I asked the "somebody" if he could alter the schedule, which he obligingly did. However, I was left with an awful 11-day stretch with no days off amongst being at the hospital, taking an all-day test, flying to take another all-day test.... I decided to add in my own days off to even things out. Every now and then, there are perquisites to being in a new program with no one knowing what the hell's going on. I don't want to take advantage of this loophole by being lazy, so I may switch around the end of the month so I can experience an overnight shift instead of strictly day shifts.

I took the computer-based portion of my board the 6th and will fly out the 13th to take the practical portion, only offered in PA. In addition to these tests complicating the month, I am trying to set up audition rotations at hospitals that have orthopedic residencies to which I want to apply. I have been more successful than I expected, as I applied for the rotations a bit late in the game. I'm finding that sites' rotation coordinators can take several months to get back to you regarding whether you can rotate. When they do, three in a row have responded with a large packet of information that I had to fill out quickly and remit along with information directly from my school since the rotation had apparently already been scheduled for me. Twice, I have had to tell the coordinator that I already set up a different rotation while waiting to hear back.

The really embarrassing event was when I mixed up a couple programs. I already have a rotation set up at HFHS for October, and someone emailed me from BGMC, only identifying the program by its initials. Well, all the initials ran together in my mind and I thought she was contacting me about the rotation I had already set up, asking for paperwork I thought was already completed. So, I faxed back the completed paperwork, most of which was thankfully for BGMC. In my panic and confusion, I faxed back a few pages from HFHS as well. Totally mortified, I had to email the BGMC rotation coordinator, apologize profusely, and explain the situation with as positive a spin as possible. Not much room for spinning, unfortunately. In my defense, though, her email said something like "we have you penciled in for October but don't have any paperwork on you, so fill it out and send it in." Realize that this is the first time I have ever heard from BGMC, and had no idea I had been "penciled in" there. In any case, this all happened late Friday, so I won't hear back on the issue until Monday at the very earliest.

If you were able to follow that whole story, then I could sure use a personal assistant. I sill feel like I'm in Vegas, and I've been in Pueblo, CO for two weeks already. All this trouble keeping track of rotation sites and dates has been a good experience. I only have a handful of potential audition rotation sites, whereas my list of residencies is over a dozen if you include traditional internship programs. Since the rotation arm and the residency arm of a program are somewhat separate, I'm hoping my little mix-up doesn't reflect poorly on my quality as a residency applicant at that location. In any case, I'm determined to be more organized as the residency interview and application process gets more involved. It just wouldn't do to be in an interview and answer the question "What sets our program apart from the others?" with a list of things I like about another residency.

Well, it's after midnight and I still can't sleep, but I should try since I have to be at the hospital tomorrow.

Scott

August Newsletter

August brought my first audition rotation, on which I was trying to show off to the program director and other VIPs of an orthopedic residency program. This particular program is in Las Vegas, and it will be brand new when I graduate med school next year (May 19th, 2012). It was an interesting feeling doing an audition rotation. The knowledge that I might spend the next five years there made the experience sink in a little deeper. All in all, it was a good month and it went faster than I expected. The four weeks in Vegas ended on a high note when, on my last day there after work, I saw a woman helping a collapsed man and got to help get an ambulance and provide emergency care for him. I've been analyzing my actions so I can improve next time something like that happens and I'm trying to get a hold of the 911 recording to remind myself what all happened. The city communications person is not getting back to me on the matter, though.

My parents pointed out that this collapsing man was a good segue to my current rotation. Since August 29th, I've been doing emergency med. I like the diversity of cases that come through. I've seen a couple of patients who needed intensive care: a drowning victim and a patient with a STEMI. Other patients just need a pat on the wrist and are sent home, like a kid who had mild RUQ pain and a completely normal workup, and a psych patient who basically wanted someone to talk to and a bite to eat. There have been many patients filling in the middle of the spectrum, either. My only problem with EM is there is entirely too much medicine and too little emergency. I prefer the lacerations, fractures, etc. that can be fixed by slicing, casting, jabbing, or suturing. All this abstract stuff with lab values, liver function, body temperature, heart rhythm is too much for my concrete mind to wrap around. I'm improving, though. Each time I start a new rotation, it's taking less time to get in the swing of things. I am also getting better at general medical tasks like doing a complete H&P, which was a bear when I first started.
In the coming months, I have two more audition rotations set up. Sadly, they are both scheduled for October, so I'm trying to move one. In personal news, I am still struggling with my 30-year-old motorcycle. It's back in the shop, and I don't even want to think about how much it's going to cost to fix up all the little things going on with it. I swear, I should have been a mechanic. You make practically as much as a physician, don't pay malpractice out the nose, and your worst disgruntled customers are biker gang members, who mercifully won't sue you, and will resort to much more minor forms of retaliation like arson, murder, and the like. Anyway, once it's out of the shop, I plan on using it as my main form of transportation this month since it gets roughly double the gas mileage of my car.

Scott

First Few Days of ER

Today an attending told me about a four-month-old he had seen in the ER. The mother's only concern was tachypnea, and on exam, the kid didn't show any other signs or symptoms. The doctor normally doesn't get lab work on kids that young, but he decided to and just happened to catch a case of DKA, which is very rare in this age group.

Patients I've seen include a drowning victim, a burn victim, a young adult with DKA, a depressed/psychotic patient who can only say three words, and an infected thumb laceration. There have been many others, and I appreciate the diversity of cases in the ER. One pregnant patient was exposed to low levels of carbon monoxide, and though she was fine, she had to stay a while as we figured out what to do about the fetus. Hemoglobin prefers binding CO over oxygen, and fetal hemoglobin binds both gases with higher affinity than adult hemoglobin. My attending had me call poison control, and they didn't have specific recommendations for a pregnant patient. We got in touch with a OB/GYN, and my feeling is they didn't know what exactly to do, either. I looked it up later on UpToDate, and for mild to moderate exposure, there seems to be no adverse affect on the fetus.

I plan on getting my newsletter posted today amongst reading, so I'm cutting this post short.

Scott

Paperwork on the Road

For all the papers I have to fill out and send in for rotations and residency lately, it would have been nice to have a portable printer/scanner that I can use while away from home. I have to print things off, sign them, and fax or email them in. I'm looking into getting a small printer/scanner so I can fill out and sign a hard copy, scan it back in and either send it as an email attachment or fax it via an online fax service. There's at least one website that rents you an individualized fax number and you can email in a document to be sent out via that fax number and receive electronic versions of documents faxed to the number.

These are ideas I've toyed with in the past, and now I wish I had devoted some funds to them in the past so I wouldn't have to shell out so much money right now when I've got travel and other big expenses fourth year.

Scott

Late-night, End of Rotation Studying

I am up late reading about metacarpal fractures. I was worried that I would have trouble studying in sleep-deprived mode during residency, but I think I can hack it if it's ortho related. This stuff just clicks in my mind. It's so much more concrete than the rest of medicine, and holds my attention better. I'm nearing the end of this month, and it looks like I won't get the time I had hoped to recover from the drive back home. I'll be starting an emergency medicine rotation two days after I get home, and the kicker is it'll be 50 miles away from home. Thankfully, I was able to set up free housing in the area so I won't have to commute the full distance.

I've seen some interesting knees lately. If you don't know what the typical radiographic signs of arthritic change are, you should look them up. Osteophytosis, sclerosis, subarticular cysts, and joint space narrowing are the four big ones, and I've seen these pretty bad of late as my attending is a big knee and shoulder guy. One young adult patient in particular had a nasty case of bilateral arthritis, the severity of which normally wouldn't set in for another 30-40 years. Another doctor had recommended moving straight to knee replacement, but the patient didn't want to use that drastic of treatment right away. This patient came to clinic for a second opinion and my attending explained that usually there is a progression in treatment from conservative measures like steroid injection, physical therapy, viscosupplementation, and bracing, to more intermediate treatment with arthroscopic surgury and "cleaning out" the joint, to more radical treatment like knee replacement. The pateint appreciated this approach a lot more and understood that conservative measures may fail, but we could cross that bridge when we come to it. My attending said some patients come in and can't be talked out of knee replacement, so he's willing to do that, too if it's indicated. You can't force a patient to adhere to a certain treatment regime, so matching the proper management with each patient is part of the art of medicine. That sounded less cheesey in my head.

I was thinking a bit ago that as I progress in my medical career, anything I distribute publicly can be taken as medical gospel and cause liability for me,which I would like to reduce when possible. Hence the ugly disclaimer at the top of the page.

Hopefully I'll have some more ortho cases to post about and maybe some ER cases before my next newsletter.

Scott

July Newsletter

I know, I'm late. No excuse. July was designated by my school as a study month to prepare for our next round of boards, which I thought was a universal concept. Apparently*, other schools don't waste... I mean, utilize the month in this way. I'm over the bitterness; it's not like I was chomping at the bit to go straight through the year on a rigid schedule anyway. In any case, since July was just a study month, I don't have any exciting clinical stories to share, but there was some excitement in the form of getting my motorcycle license and buying a motorcycle. The following conversation always ensues when I tell people I bought one: What did you get? It's a Kawasaki KZ750 LTD. Oh, so it's a crotch rocket? No, it's not a crotch rocket. So, what kind of motorcycle is it? A cruiser. Which is what exactly? The stereotypical around-town and cross-country bike.

If you have further questions, the internet is infinitely more knowledgeable than I and your favorite internet browser would love to guide you to the answers. More details of my entrance into the world of motorized bicycle riding are here.

In more academic/medical news, I'm getting a crash course (no intended reference to the afore-mentioned motorcycle riding) in applying to residencies. Becoming a doctor is a long, arduous process of gracefully navigating a series of applications. I'm pretty sure the rest is just details. The latest installment will decide where I will spend what are purported to be the most difficult consecutive five years of my life. No biggie. Here are more details on applications.

Right now, I am halfway through the second week of my first audition rotation, which happens to be in Las Vegas (WHOO VEGAS!!). The "audition" modifier refers to the fact that I'm trying to impress the director and anyone else involved with deciding who gets into the ortho program here. So far, I have no idea how I'm doing. Again, no biggie. It's just the rest of my life. Speaking of the rest of my life, I learned a valuable lesson on the Vegas (WHOO VEGAS!!) strip. I lost what I consider a profane amount of money in a casino after initially doubling my starting amount of $20. My compulsive side kicked in and I kept thinking I just needed to hold out for the big win and I could get back the increasingly large amount I had lost. Thankfully, I finally snapped out of it and left, my deflated ego and the damning atm receipts trailing behind me (yes, Sister, I kept the receipts). I was just talking with a friend who pointed out that I could think of my losses as having sacrificed a vacation to, say, Arkansas. Not a devastating loss, but if I keep it up, I'll lose Hawaii, then Europe, etc. Actually, I need to save up so I can make a trip to Scotland with my mom and sister next year. Ramen noodles for me, I guess.

Back to studying.

Scott

*My little cousin (cousin's daughter) didn't know what "apparently" means, so my Granddad and I explained it to her and I now think of her every time I use this word. She and her siblings are cuties; I thought only women were supposed to have biological clocks.

Applications

As this month is a study month for me, I've not had many clinical encounters to comment on. What I have been doing is studying for the next board exam, which is currently scheduled for September 6th. Nothing new there; I imagine we all have an idea of what it's like to study. What has been sort of new is beginning the long, arduous process of applying to residencies. I say "sort of" because I have done an important, extensive application every few years for the last decade. College wasn't too hard to get into, med school was much harder, and residency is looking to be at least on par with med school.

I have just revised my curriculum vitae based on suggestions by our dean of clinical affairs. We have a mandatory meeting with a dean to touch base and make sure our dean's letter is as accurate and as supportive as possible. Also, we get feedback on our CV, personal statement, generalities about which letters of recommendation would be good to use, etc. I received feedback on my personal statement, too, but I decided to revise the CV first because that came down to simply reformatting a list of facts about my life. For the personal statement, not only had I barely written anything, but I was headed in the wrong direction. The dean said I shouldn't focus on the past and what has led to my choosing medicine and ortho, but instead should focus on "Why ortho, why now?"

So, I need to justify why I'll be a good orthopedic resident and ultimately ortho surgeon, and explain what is currently driving me to seek orthopedics. Marketing myself has always been awkward, and now trying to explain why I want to be an orthopod without dragging up the fact that this has been my goal for half of my life will be a challenge. Perhaps residency directors are looking to see that applicants have actively re-evaluated their desires and skills instead of just defaulting to what sounded good in high school. I think I may incorporate my insight during my EMT training, which confirmed that I need to have more than a technician's level of understanding. Then in med school, I wavered in my drive to become an orthopod, initially because I was worried about being competitive enough, then because I realized I had little experience with many specialties and should at least keep an open mind to other avenues. After stepping back and re-evaluating my career goals, I ended up choosing ortho anyway. Until just now as I'm writing this post, I thought of my "wavering" as a liability and wanted to sweep it under the rug as a possible indicator that I can be easily swayed from my goals. I now think I will include that experience as a demonstration that I am able to re-evaluate my direction in life and don't blindly continue pursuing plans that were based initially on ignorance.

Back to it.

Scott

No medicine, just life

Getting back to the details of my motorcycle, I bought it off Craigslist. It's a decent-sized motorcycle with a good amount of power. A freind said its looks match my personality, and I rather agree. I wish I could post a picture, but it's in the shop getting tuned up. It was a whirlwind of a few days leading up to my buying it. A was on a hike with a friend who reminded me that I had wanted to get motorcycle training, and I realized I could do so this month. On a Tuesday, I bought a helmet. Wednesday, I started a two-day class which included the requisite testing to get a motorcycle-endorsed driver's license. At the end of class Thursday, I went to see the motorcycle and arranged to pick it up the next morning, then bought motorcycle insurance online and planned out the next morning. Friday, I had to get cash to pay for the new license, go to the DMV to update my license, get a cashier's check to buy the motorcycle, then drive out with Dad so he could drive my car back as I rode the bike. The couple selling the bike had built thier own house, and Dad, having worked in the housing development business, started talking about the home building process. The wife was only too happy to give us a tour of the whole place while I was only too anxious to get the motorcycle and ride it home. I finally did just that, taking the long, slow way home so I could enjoy the bike longer and not kill myself getting used to it at 80 miles per hour. I can't remember the last time I drove a vehicle and could feel the acceleration when I opened the throttle. It's a good feeling.

In more personal news, I have had a general upturn in my mood since April and have gradually been reconsidering the idea of getting in a relationship and even (gasp) eventually getting married. For the last year or so, I've been growing closer to a friend and becoming more attracted to her, contemplating asking her out, when out of the blue someone I knew several years ago gets in touch and it turns out she wants to re-connect and possibly start going out. So, now I'm trying to figure out what to do without hurting anyone, damaging relationships, or being a fence-riding sleazeball. Whenever I see a happy-go-lucky bird singing contendedly, I wonder what it's like not having to worry about taking motorcycles to the shop, applying to residencies, or navigating relationships. Then I realize it's pretty good being able to enjoy the deep complexities of the human experience. I'm just hoping I clear the hurdles as they continuously pop up. And maybe learn to pick a metaphor and stick with it.
Scott

Motorcycle

I GOT ONE! I'll post details soon, by I wanted to share the exciting news while it was still fresh. Briefly, it's a 750cc that's older than I am, but it's got a lot of power. I'm not used to opening up the throttle and actually feeling the acceleration. Anyway, that's one thing I can cross off my bucket list.

Scott

June Newsletter

My sister is getting married today!
Getting on to my comparatively mundane news, June has been fun. I again took electives, this time two weeks of radiology with an interventional radiologist, and a week of orthopedic surgery with an orthopedic oncologist who happens to be my uncle. I liked the hospital-based nature of this radiology practice, compared with the strictly outpatient setting of a radiology center that I experienced before. The radiologist still did the routine of sitting in front of a computer reading imaging studies, but he would get called away to do procedures, even more so than a typical radiologist, since he did interventional. The interventional aspect entailed more invasive studies than just barium swallow or enema. He would put central lines and other invasive catheters under fluoroscopic guidance and biopsies under ultrasound and CT guidance. The intravascular work was painful. Poking a hole through the skin into the vessel was the most exciting part, and then it's a tedious series of threading a guide wire into just the right vessel branch, sliding a catheter over it, taking out the original guide wire, inserting a different guide, then removing the catheter, then placing a wire-guided whatever, then taking that out, then putting the catheter back in, then taking the wire out.... I'm glad there are people who enjoy this type of work because it's not my cup of tea. It was a good experience to see what the interventional side of interventional radiology is like.
Working with my uncle in orthopedics reaffirmed again that I need to be an othopod. Every time blood gets splattered or bones get hewn, I grin from ear to ear. This type of barbarism would normally land you in an asylum for the criminally insane, but you can actually improve patients' quality of life by playing wood shop on their internal parts. Working with my uncle, who knows and I assume trusts me better than a typical attending would, I was allowed to do more than a typical third/fourth-year would. The procedure that stands out the most was an above-elbow amputation for synovial cell sarcoma of the elbow. I did the large-scale work and my uncle stepped in when more finesse was needed. I could go on for pages about orthopedics, but I'll finish by saying arthroscopic procedures are a lot harder than they look; I wore myself out hardly doing anything.
Off to studying and wedding preparations.

Scott

May Newsletter

May was an interesting experience for me. I had two two-week rotations and both of them were electives. I'm not sure if this is always the case, but both preceptors repeatedly told me I had all sorts of latitude on activities and duties since I was doing electives. I've had the past week off and have been trying to sort out which residencies I want to apply to. Once I figured that out, I was able to work on the more immediate step of applying for audition rotations at those sites so I can hopefully impress them and improve my chances of getting into the residency. I finally finished all of this so I just have to wait to see which ones will allow me a rotation. Next is packing to go to El Paso to work with a radiologist my uncle knows there, as well as working with my uncle, an orthopod, so I can have some clue of what I'm doing when audition rotations start.

July is designated as a study month at my school, which I assumed was standard practice among med schools, but apparently not. The bummer is that our "study month" eats up a potential audition month. I guess it will be good to have time to read up on orthopedics plus study for part two of the boards.

Life is hectic right now, as may be apparent from this hastily-written, brief newsletter, but it's all just a part of the process. What really got to me recently was looking at the various programs' weekly schedules for orthopedic residents and how very convoluted they can be. There is an 80-hour cap on the work week; earlier in med school, I was annoyed that the work week had been shortened because of the decreased patient contact and learning time. I may feel differently when I start next July. Regarding the work week, residents keep track of their own hours, and yes, there's an app for that. I just downloaded HoursTracker and it seems quite handy.

Scott

Let's Have Some Perspective

I got to do a hip injection on Tuesday. It was fluoroscopically guided so we could tell that we hit the right spot; the hip joint is deep and the bony landmarks are hard to palpate, so fluoro guidance is standard for hips. It was interesting to hear a radiologist's perspective on joint injection. He said he prefers doing all joint injections under fluoro to prove that he's in the joint space instead of accidentally injecting into surrounding soft tissue. This is a sharp contrast (no pun intended) to what the IM and ortho docs do. I wouldn't have given any credence to the idea that proper palpation and careful placement of a joint injection could miss the joint space in simple joints such as knee and shoulder. My radiology preceptor said he's had one or two cases where he was doing knee and shoulder injections and saw on fluoro that he wasn't actually in the joint capsule. Part of me thought, "Silly radiologist, leave the joint procedures to the orthopods, we'll do it right," but it's also good to know that something so simple can be a bit more complicated. Nonetheless, at this point in my training, experience, and understanding of things, I'm of the mind that it's not worth the extra time, expense, radiation exposure, etc, to use fluoro guidance for simple joint injections. This is a good example of how my fully-trained, well-experienced preceptors can arrive at different opinions of the best way to go about the same procedure. Extrapolating a bit, we arrive at the broadly-applicable "too many chefs spoil the broth" axiom.

This radiology rotation is only two weeks long, to finish off the month after my two-week nephrology rotation. I live in my primary rotation city, an hour from school, and my preceptor mentioned getting some hospital experience working with his partner at a hospital near school. I will soon do a rotation of nothing but hospital radiology, but a friend lives near school and I decided this would be a good opportunity to crash on her couch for two nights and spend time with her. Of course, we would get to talking, develop a deeper connection than we had yet discovered, decide to get to know each other better, somehow start dating long-distance, I'd get allergy shots to be able to deal with her cat, she would develop a love for sailing if she isn't enamored of it already, I would devise clever ways of cooking for her food intolerances, we would get married, sail the world, fulfill our mutual wanderlust with travels to far-off places and medical mission work, and have at least two kids.

I don't know how common this way of thinking is among med students, but I know several other student docs who plan a series of key events stacked back-to-back then catastrophize over the prospect of any one of the steps not playing out exactly according to plan. For example, a buddy was worrying about doing well on boards, so he'd be competitive enough to do an audition rotation at the residency location he wants, so he would have a better shot at getting into that residency, so he'd be better set up to get into the fellowship program at that location. Don't get me wrong, it's good to plan ahead, but I need to calm down and realize that there is more than one path to my ultimate goal and not freak out when one step along the way starts looking like it will fall through. To finish my earlier thought, I'm one night down, one to go staying at my friend's place, and I don't think we're connecting like I hoped. Now I'll never get married ;)

Scott

April Newsletter

April has been OB/GYN month, and I realized I had not given this specialty much thought in the past. I enjoyed it quite a bit, especially Obstetrics (pregnancy-related health). I got to catch about ten babies during the month, and saw several more delivered by C-section. I wasn't thinking I would use much of this knowledge beyond my tests, but I was talking with an old friend today about the work he does. He's a missionary pilot and the region he's going to be stationed in has some unhealthy childbirth practices. This is relevant to me because I was hoping some day to use his connections to do medical work overseas, and when you're in a third-world environment, "orthopedic surgeon," "obstetrician," "neuroradiologist," etc. are all seen as "doctor," and I'll need to be able to address at least the basic issues outside of my specialty area.

One memorable event this month was seeing the vaginal delivery of twins. There are so many things that can go wrong around the time of delivery with twins that at least one is usually delivered by C-section, but the stars or at least these two boys aligned just right and out they popped. Plus, since they were identical twins, they were the perfect teaching opportunity for me to learn to do circumcision. They made much less of a fuss than I would have expected, considering what the procedure entails. Of course, neonates' primary goal in life seems to be to fall asleep, regardless of circumcis... er, circumstances. Outside of medicine, a memorable event was heading to the airport with my preceptor in between surgery and clinic and taking a quick flight in his plane. The first time I tried flying a plane was with my uncle, and I did a lot better this second time, but I can see where one would need a lot of training and hands-on time with a more experienced pilot before being able to handle a plane solo. Anyway, it encouraged me in my desire to get into sailing by showing that I don't have to take a large block of time to engage in hobbies - I can fit them in a work day sometimes.

I was going through some old notebooks and wanted to share some funny quotes from a preceptor. Regarding a new medication compared with a discontinued one: "It's kind of worth it for it not to work as well to avoid the side effect of death." Regarding an insurance company's lack of coverage of psychiatric treatment by primary care providers: "[The company] doesn't take any mental health diagnosis codes, which is retarded."

This was the last of my required rotations for 3rd year, so I'll do electives now, starting with two weeks of Nephrology, then two weeks of Radiology to finish off the month.

Scott

OB/GYN Week 4

I met a patient today who described herself as "delayed." It took me at least 5 tries to ask her if her periods are regular. Note to self: if a patient doesn't understand a question the first two times, maybe try wording it differently the third time (roll eyes at self). I've been listening to Audio Digest's OB/GYN series of lectures and one from '09 highlights some medical-legal issues, one of which is lack of patient understanding. The lecturer, a former nurse, now lawyer, mentioned an AMA study in which the researchers video recorded patient/doctor interactions, then separately interviewed patients about what they were just told by the doctor. Appatently, a surprisingly high percentage had failed to understand key components of the interaction, and they weren't all the type of patient you would expect to be "delayed," and may have seemed to comprehend perfectly. Illiteracy rates are higher than we may expect and patients will not usually be as open about it as my "delayed" patient today. The lecturer mentioned not using medical words with patients, which they have taught us from day one in med school, but being indoctrinated into the medical community, one loses one's sense of which words are common lay terms and which are medical jargon. "Appreciate" no longer refers to having a feeling of gratitude, but instead to noticing a significant finding. "Anorexia" does not necessarily conjure images of emaciated teens with anorexia nervosa, but simply indicates a loss of appetite. Are abdomen, neoplasia, laceration, analgesic used in common parlance? I just don't know anymore. Before I get too tangential, I'll sign off for the night. If I get around to posting before my next newsletter, I'll try to include more case-based info next time.

Scott

LEEP, OB/GYN Week 3

I just got sprayed in the face with cervix juice. I should back up. A patient was in clinic today for her second LEEP (loop electrosurgical excision procedure), which is a method of removing a portion of the cervix. This procedure is done when less invasive tests have shown the cervix to have certain stages of pre-cancerous cells. Practically the only way a woman gets these cells that slowly progress toward cancer is to be exposed to certain types of HPV, or human papilloma virus. The way a woman is exposed to HPV is unprotected sex, which can obviously expose her to any variety of nasty bugs. Anyway, this patient had a LEEP some time in the past, and her tests came back positive again for the late precancerous cells, so she came in to have a second LEEP. I've learned that the cervix doesn't have the same type of innervation as other parts of the body - you can hold onto it with sharp pinchers without anesthetic - but when cutting off part of it, you need to inject some anesthetic first, which is what I was doing. I had to jab a needle into the cervix, which is a firm muscle covered by mucous membrane, and inject. Because the muscle is so firm, I had to push on the syringe plunger quite hard, and I was trying to move the needle out slowly to get anesthetic both deep and shallow in the muscle. I pulled out a little too far, and all that pressurized fluid shot out straight back around the needle, and onto the most readily available surface, which happened to by my face. For things like this, I am a non-reactive person, which as a rule is a good thing whenever you have to do a procedure involving looking into the vagina. It just doesn't do to jump back and start wiping your face frantically when the patient is lying back in sturrups, speculum in place. Despite my mind working through the above concepts of nasty bug transmission, I was able to finish what I was doing and wash my face and glasses after I was out of the room. In all honesty, the incident wasn't a big deal; I was wearing glasses, so my eyes were protected, and nothing got in my nose or mouth, and all my facial skin is intact, so the risk of catching anything is somewhere around 0.00%. Still gross, though. Speaking of gross, I've noticed more random stains on my white coat this month than any previous one. I'm not sure I want to think about that.

On the obstetric side of things, I am up to catching 3 babies now. I've also helped with a few C-sections. It's amazing to me when the pale purple lump that initially is motionless starts flailing and crying. The first time I saw the baby in the warmer after a few minutes of being able to breathe on her own, I thought she was a different kid she looked so much better. They really pink up a lot even in the first minute. I may never use any of these skills or knowledge in my career, but it is quite amazing when I step out of the objective clinician's viewpoint and realize that I'm seeing a baby brought into the world.

Scott

OB/GYN Week 2

Today I helped with the tubal ligation of a one-and-done 22-year-old and the delivery of the baby of a 40-year-old who is willing to have yet a third kid if menopause doesn't get her first. Whenever I think I've acquired a sense of how varied people's views are, I get thrown another curveball.

I have been enjoying OB/GYN quite a bit. I am getting a good amount of hands-on experience. The doctors I'm working with are a married couple. Only one of the husband's patients has declined to have a male student in the room, while over half of the wife's patients have declined. We figure many of her patients sought out a female doc specifically, so more of them would have issues with a male being part of their exam. I personally am less concerned with such things in regard to my health care, which I assumed applied to males in general. However, one of my female classmates, who's working with a male doc, is asked to sit out of most men's hernia checks, so maybe men are just as sensitive about personal matters as women.

Time for bed. I'll hopefully see a twin C-section tomorrow.

Scott

Peds Wrapup and Start of OB/GYN

I enjoyed Peds a lot more than I anticipated. I thought it would be too hard for me to figure out how to communicate with the kids and I was afraid of all the crazy parents people talk about. I figured out quickly you can't direct all your attention at the little kids; it's hard to describe, but you almost talk to the little ones as if they're a side thought while you're busy with the exam or doing somehing else, otherwise they'll get all self conscious and shy. As for the parents, there was only one mom I really had any issues with. She was polite, but you could tell if I didn't stop what I was doing, she was coming across the table at me. This brings up a good point, because I was doing exactly what I should (would you expect otherwise?) but she had received poorly-explained child care directions from another doc, and she was being a very concientious parent (neurotically so) trying to follow those directions. If the other doc had taken the time to explain better, she would have had a better idea of good child care and it would have saved her and me some frustration. Also, I've seen that by far the most common avoidable cause of patient anger is poor communication. Explain to your patients what's going on and why - they'll think you're at least ten times as competent as you really are and will love you forever. Not to mention they're less likely to sue you should something untoward happen.

I just had my first day of OB/GYN today, and let me tell you I'm so glad I don't have to force a softball out of my genitalia. Even with an epidural, it's a lot of hard work and pain. It was nice getting to see a C-section and two vaginal deliveries on my first day. It should only be another day or two and I'll be catching the kids as they pop out.

Scott

February Newsletter

February was Orthopaedic Surgery month. I had confirmed in January how much I like surgery with General Surgery, and this past rotation verified that ortho is what I want to do with my life. I was sort of bummed I didn't get to see a wider variety of cases, but I know knees and to a lesser extent shoulders pretty well since those are the areas my preceptor focused on. I'm still leaning toward Orthopaedic Trauma, hoping to add Pediatrics and Hand at some point, but that's partly because I like the title "Orthopaedic Pediatric Hand Trauma Surgeon." In any case, I've just started Pediatrics for March, and I've liked the first few days a lot more than I expected to, so I think doing a Pediatric fellowship somewhere down the road would be something I would enjoy a lot. March is already another busy month, but I wanted to get out a quick update.

Scott

January Newsletter

I was very excited this past month to have finally begun surgery. I took General Surgery and liked it a lot more than I expected to. I still want to become a trauma surgeon, and have not decided between general and ortho trauma, so I'm glad that I have just today begun an Orthopedic Surgery rotation. During my General rotation, I was able to tag along for a couple ortho procedures and I was grinning the whole time. Sawing bones and popping hips out of socket is really exciting, so I have high hopes for this coming month. I'm starting to feel some pressure to decide on a specialty, since my previously undecided classmates have started deciding on specialties and others have even started setting up audition rotations. Audition rotations, or subinternships, are taken at the site at which one would like to do residency/internship in an effort to show off one's abilities and get one's name and face known. I need to start applying for these, but I need to figure out my specialty first, so it's good I'll have ortho this month to help decide.

Personally, I've been about average. My dad is living with me for three weeks, which is stressful on both of us I imagine. I guess if nothing else, it's good confirmation that not having a roommate is my ideal. In regard to my future, I'm worrying about whether I'll be able to handle residency and whether medicine was the right choice for me. Several classmates have expressed similar sentiments, so I guess it's a common doubt to have at this stage of the game. In fact, it's not the first time I or my friends have felt this way, so if you're a new medical school student or aspiring to become one, hang in there when you have nagging doubts.

Well, I've a lot of reading to do, so this newsletter will have to be pretty short.

Scott

Jaded Patient; More Splenic Issues

I was running through a history and physical on a consult before my attending got there but it was truncated to just a history. The patient was a poor historian, not giving very detailed information even when I would ask the most focused questions, and ultimately saying she was tired of questions and did not want me to examine her. Part of the problem was that she has had more operations than she cared to or was able to recall. I think the real problem, though, is probably psychiatric. She has the demeanor and body habitus of one who is poorly motivated and tends toward depression. With mental stress can come physical manifestations of that stress, i.e. somatiform or factitious disorders. It's difficult, though, because while she seems concerned with tallying up vague medical issues, she could be someone who has been dealt a poor hand medically, has needed much treatment just to live somewhat normally, and is not interested in wasting time dwelling on thoughts of an unpleasant medical history.

She insists that during her last operation (2 years ago) either something was left inside her or some other complication arose. She has had a low-grade fever since then and mild pain in the region of the procedure, both of which have been documented on a previous hospital visit. She said the pain flared to a significant level recently, so she finally sought treatment. My attending looked at her CT, asked her a few clarification questions, did a physical exam, and decided that there was no indication to do even an exploratory procedure on her. He said if something had been left in her, there would be evidence on CT: a layman could spot an instrument, and sponges have radiopaque elements in them for ease of visualization. Her symptoms and physical exam are not consistent with any process amenable to surgery. I got the feeling that even with a magic procedure that could cure her pain, she would still have a complaint up her sleeve, which is one of my red flags that there is more than just a physical medical component to a patient's presentation.

The other case mentioned in the title is a man with sharp left upper belly pain for several days. He had a low-grade fever and unproductive cough for the week prior, which he thought was unrelated. His spleen extended 2 cm below the rib cage. My attending asked me what can cause fever and unproductive cough; I couldn't think of an answer, but he said to look up Mycoplasma pneumoniae and autoimmune hemolytic anemia. M. pneumoniae causes pneumonia with a dry cough and fever, and can cause transient cold agglutinin-mediated attack of the red blood cells, leading to transient splenomegaly, which can take longer to resolve than the hemolytic anemia. My attending suspects this etiology, so he has added an M. pneumoniae test to the large battery of tests the internist has already ordered. The surgical treatment for splenomegaly with hypersplenism (overactive spleen chewing up red cells, white cells, and platelets) is splenectomy, but as my attending is fond of saying, a monkey can operate, but it takes a surgeon to know when not to operate. We should find out tomorrow whether Mycoplasma is to blame, and can hopefully give the patient a better idea of what the future holds.

Scott

Splenectomy, ICU Psychosis

Surgery was quite tough at the beginning, as I mentioned in my last post. Several days in a row, I truly was trying to figure out how I could make a living by sailing so I could drop out of med school because I didn't think I could finish this rotation, let alone five years of residency. Thankfully, I was too tired and worn down to figure out how, because I think I would have gone through with it if I had thought of a way. I have, however, risen to the challenge of this rotation, and am again excited to be on my first surgery month. Yet another example of both the roller coaster that is med school and the wisdom behind "Illegitimi non carborundum."
The first big thrill I got was when I was on call with my attending this past weekend, was going home after having worked a straight 13 ¹/₂ hour stretch, and realized I wanted to stay to do more! Since deciding to be a doctor, I have never wavered in my desire to be a surgeon, but it is so encouraging to get reassurances that I've made the right choice. Unfortunately, my top two choices are Orthopedic Surgery and General Surgery, which are among the most competitive specialties to get into, and my grades and test scores are not competitive. That means I have to rely more heavily on my rec letters and audition rotations, when you rotate at the place you want to do residency with the hope of getting your name/face known and impressing everyone there. I mention this because we recently had a presentation on residency application considerations. That's a worry for another day, though.

One of the cases we saw over the weekend was a lady who had slight pallor, poikilothermia of the extremities, and abdominal distension. CT scan showed hemoperitoneum and lesions in the spleen. History was positive for metastatic lung cancer. The radiologist's report indicated spontaneous splenic rupture as the cause of the bleed (odd, since spontaneous rupture is rare), so she was prepped for emergent splenectomy. As a side note, she reported to us at the time that she drank a beer per day. When she was opened up, almost 4L of blood was removed from her peritoneal cavity. The average adult has 5L of blood, so she was holding 75% of her blood in her belly. The spleen came out well, she received several units of blood during the process, and was admitted to the ICU, where she was alert and doing well.

Sunday, I walked into her room and she was on a CPAP machine and only oriented to person and time (in a normal mental state, you know who you and those around you are, the day/date/season/year/etc., and where you are). She had become acidotic the previous night, which can normally be compensated for by increasing breathing rate* if the kidneys are failing or by flushing more acid out with the urine if the lungs are failing. In her case, the hypovolemic hypotension decreased her renal perfusion, keeping the kidneys from working well; the lung issues and opiate-induced decrease in respiratory drive prevented good lung function, so her two acid-handling methods were crippled. A nephrologist and pulmonologist were called to consult and they removed her from opiates and corrected some electrolyte imbalances. Another aside: the patient told one of these consultants that she drinks three beers per day.

Her blood work was better Monday morning and she was off CPAP. She was fully oriented, but was complaining of feeling neglected by the nursing staff. I asked the nurses about this (non-accusatorily; remember, nurses are your friends and can make or break you as they see fit) and they said she had been difficult and complaining all night and morning. I attributed her mood to homesickness and feeling cooped up. Her medical condition was improved enough for her to be transferred off ICU to the floor, so they moved her later that day.

On Tuesday, I first thought she was simply a little sleepy. Her attention was poor, she would nod off, and she had her dentures in loosely and was enunciating poorly, making communication difficult. When I started talking with her, she seemed fully oriented, but as I continued, she started saying odd things and trying to get out of bed to "go home." I reevaluated her orientation and she was only oriented to person. Then it became clear that she was having persecutory delusions, possibly illusions, and maybe even hallucinations**. The nurses relayed that she had been agitated and combative since the previous night. My attending said she likely had ICU psychosis, common in the elderly, with the constant light, strange environment, and altered physiologic functioning. I asked if she could be undergoing alcohol withdrawal, which my attending said was a possibility.

Today, Wednesday, she was much calmer. She was sitting in the bedside chair and was apologetic about the disturbance she caused yesterday. Interestingly, she still held the veracity of her illusions/delusions. From her point of view, people had put away "the brass knuckles," so she was friends with everyone again. I'm not sure if she'll ever realize that her experiences were not actual, but I think the prognosis is fairly good that she will stop being delirious. The internist on the case also seems to have suspected alcohol withdrawal as a contributing factor, so he started a benzodiazepine (first line treatment for alcohol withdrawal) late yesterday. According to the internist's note, the patient told him she drinks a six pack per day. There is a slightly tongue-in-cheek rule of thumb that you can double the reported amount of alcohol a patient drinks***. I'm sure not everyone reports only half their alcohol use, but let's put it this way: it's a very rare patient who overestimates his alcohol consumption. Anyway, I wanted to blog about this case since it has such a diversity of info in it. There are other, more straightforward cases to blog about and I'll try to do that regularly.

Scott

*The the mechanism behind increased respiratory rate reducing acidity is due to Le Chatelier's Principle as it pertains to this formula:
CO₂ + H₂O <--> H₂CO₃ <--> H⁺ + HCO₃^-
Atmospheric air has minimal amounts of CO₂, so each breath "blows off" CO₂, shifting the above equation to the left, decreasing H⁺.

**Delusions: fixed beliefs that are incongruous with rational though or truths held by society; e.g. the patient somehow knows Brad Pitt sleeps in their attic, but has never seen or heard him up there. Illusions: misinterpreted sensory perceptions; e.g. seeing a car and thinking it's a hedgehog. Hallucinations: sensory perceptions without any stimuli; e.g. hearing a voice narrate your actions and thoughts.

***I've also been told that you can safely add five pounds to a woman's self-reported weight, but that's another matter...

History Taking

I'm practicing thinking through a complete history and thought I'd make a post of it, so the following list will be of little interest to non-medical types, and rather mundane but very important to fellow aspiring doctors. Technically, this isn't a complete history, but it's about as complete as most practicing physicians will get. I've been told several times I am too slow and too thorough in my History and Physicals, so I'm trying to work on being faster and more concise. In school, we are taught to be as in-depth as possible, but on rotations, the attendings have been practicing long enough to know what to leave out and what to ask. The problem for students is each attending has their own set of questions they have found to be important, so as a student walking into a new rotation, you have the original, complete list of questions floating in the back of your mind, plus a hodge-podge of truncated lists from each attending you've had. I've never felt entirely comfortable interviewing patients during the H&P, and I tend to be a perfectionist about anything remotely related to a checklist, so I am quite slow and thorough, and my attending now is having me see all his clinic patients before he does, including the new patients, who need a "complete" H&P. And he is not easing up much in regard to making me practice patient interviews and has told me repeatedly that I need to speed up and be more concise. This is stressful for me since I respond poorly to any sort of negative feedback and since I'm being pressured to do something I'm poor at and also dislike. I keep coming back to the fact that I need to get better at interviewing and write-ups and realizing that this will be a good experience for me. I'm already getting slightly thicker skin and not emotionally shrivelling up when my attending tells me a new thing I've done wrong or need to improve. As for getting better at clinical skills, that's why I've typed out the History template below, so I can have it fresh in my mind again, in roughly the format my current attending prefers.

Chief complaint
History of present illness
 Onset
 Provoking/palliating factors
 Quality
 Radiation
 Severity
 Timing
 Related symptoms
 Any attempted treatment and result
 Past similar history
Allergies
Medications
Medical conditions
Surgeries
ROS
 Gen: Wt change, heat/cold intolerance, fever/chills, energy level change
 Resp: coughing, hemoptysis, dyspnea, (asthma, COPD, emphysema if not addressed above)
 CV: palpitations, skipped beats, murmurs, MI, HTN
 GI: N/V, diarrhea, constipation, hematemesis, dyspepsia, hematochezia, melena, BRBPR, clay-colored stool
 GU: dysuria, nocturia, poly/oligouria, urgency, hematuria, tea-colored urine, dribbling, sexual dysfunction
 MS: joint/muscle pain, swelling, weakness
 Neuro: numbness, tingling, tremors, stroke, seizures
Habits
 Tobacco: pack-year hx, quit date
 EtOH
 Drugs
Fam Hx
 M
 F

I'm having fun in the OR (OT if you're in a British-influenced area), and learning a lot about the logistics of surgery. I love that I am finally getting my gloves bloody digging around inside of people. That is, of course, a glorified version of what I do; I'm the designated retractor holder, the med student specialty, but my involvement grows slightly each time I assist. The main hospital at which we have worked thus far has had ongoing issues with the agreement with my school as to the level of allowable student involvement, and this issue just had another flare-up, so I've been demoted to observer (not even scrubbed in) when my attending performs surgery at that hospital, but I'm hopeful the issues will get ironed out before too long.

Scott