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