Year-End Newsletter

As I'm writing this, it is quite overcast and there is a flurry of snow breezing past my window, so it is finally starting to look like winter here in unseasonably warm Colorado. About this time last year, I was taking a sailing class in St. Petersburg, Florida. I had a most enjoyable time - if I could make a living of it, sailing would be a strong contender against surgery. Shortly after returning home, I got a scare at the dentist when I went in for a standard check-up. After several visits with that dentist and a periodontist, I was told I have gingivitis and need to get tooth cleanings every three months, get deep cleanings (read: elective torture), and possibly get surgery to graft bone onto my jaw around my tooth sockets. All very unsettling, but after the initial shock wore off, life resumed and my latest appointment was yesterday, seven months after my last cleaning (they weren't happy about the four-month delay). Still doom and gloom on the dental front and I'm going to need a mouth guard at night since I have cracks in my teeth from grinding them.

I started my last lecture-based semester in mid-January and also started going out with one of the librarians at school. She was my first girlfriend and we dated for two months before I decided we weren't as compatible as I had thought, plus I couldn't really handle a relationship being thrown into the med school mix. In some ways, I wish we hadn't started going out to begin with; it throws a twist into the overall flow of my life, but you don't get as much out of life by keeping on the same boring track, and I'm glad for the experience. Regarding the academic aspect of the beginning of the semester, I came across this line I wrote only four days after the semester started: "while starting well, [this semester] has already turned into another sleep-deprived exercise in deciding how best to manage falling behind." I'd say that typifies the med school experience, even now that I'm doing rotations. There is still a lot to read and study. It is more enjoyable getting to work in the "real world" while simultaneously being more stressful since your attending holds you accountable to rigorous daily studying.

The rest of Spring semester was the typical med school roller coaster and ended with a review course for our first board exam. I took both the mandatory DO exam and the MD exam a week apart from each other, which made for a stressful week (more detail on these exams is in the third and fourth paragraphs here). I ended up passing both of them, though, which was not the case for all of my classmates. While my scores fall in the "passing" range, they are not really in the "competitive" range, so I still have my work cut out if I want to keep my residency options open.

After boards, I went to Virginia to see a friend from college. I was glad to be able to catch up and see some sights around the area with him. They were having record high temperatures, which was miserable for a Coloradan, especially with the humidity. In a humorous twist, though, we got to cool off once at the end of our day at Colonial Williamsburg when it started raining in sheets as all the buildings were closing and we had to walk back to the car. It was a good trip overall, but I neglected to keep in mind my 1 to 1.5 week limit when staying in new places with people. By the end, I was a bit of a grump, which was an unfortunate end to the visit.

Third year started with a less than informative prep course for rotations before we actually hit the clinics. My first rotation was Family Medicine, and I was thrilled about it for several days. I have always known I don't want to do primary care, but being in the clinic was great. The novelty quickly wore off, but I still enjoy rotations more than the lecture-based years. I finished off August by doing my third annual Pikes Peak hike with a couple classmates. A brief description is in the fourth paragraph here, with pics at the bottom.

My subsequent rotations have been Cardiology, Family Medicine month 2, Psychiatry, and Internal Medicine. I have enjoyed Psychiatry the most so far. For one, it was focused on one aspect of medicine, and for another, I already had a decent conceptual understanding of psychiatric ailments. Plus, my attending gave me a good deal of responsibility and explained concepts well. This contrasts with Internal Medicine, which was three straight weeks of getting raked over the coals and shown how much I don't know. Thankfully, I was rotating with a classmate, so neither of us was stuck feeling incompetent alone, and our attending let us have this last week of December off.

I start General Surgery this Tuesday, and I'm excited to finally be getting to something more up my alley. I won't be learning many techniques and my main focus has to be all the medicine pertaining to the surgeries, but at least it's closer to my desired field than past rotations.

Have a great 2011! I'll post again at the end of January and hopefully sooner.

Scott

First-Hand Medical Experience

In addition to being really busy, I've had a GI bug since Saturday morning. I made it to work yesterday but decided to skip today and finally saw my old family doctor, who gave me some Cipro. I thought it humorously counterintuitive that his treatment plan includes a medication that can cause severe diarrhea in the form of Clostridium difficile colitis. Oh well - a five-day course should be fine. Plus, he told me to take Imodium and keep taking Pepto, so I should be back to normal in just a few days. Much as I'd like to go into gooey details, I have to read up on systolic dysfunction for tomorrow. It is the main problem in heart failure, which is the final common pathway of just about everything in cardiology, so I'll sign off and hope to post more in-depth and interesting info soon.

Scott

Good Day and Passing with Honors

After yesterday's post, I thought I should follow up to clarify that the world hasn't come to an end. Today was quite good. There was a light patient load, it went well interacting with patients and my preceptor, and we got off early. It's nice to be back on track so quickly after a bad day. It's just tough while you're in the midst of a hard experience to see past it. I'm sure I'm going to have more rough days on this rotation, but things are looking well right now (not that I like internal medicine, but the rotation is looking up). It's been a hard-learned lesson, but I truly do know that I shouldn't base important opinions and decisions on single negative experiences. Anyway, to top off the day, I just learned that I not only passed Psychiatry, but did so with honors. Some classmates and I were thinking it was impossible to get such a score on these Shelf Exams, but apparently it is possible, at least on the reputedly easy psych test.

Updating you on the patient I mentioned yesterday, he eats minimal amounts and GI (short for gastrointestinal, but can refer to gastroenterology) should have placed a PEG (percutaneous endoscopic gastrostomy) tube today to help in the administration food. A PEG tube goes through the skin directly into the stomach and is a last-ditch effort to continue using the gut to digest food when a patient isn't eating enough. Using the gut is greatly preferable to TPN (total parenteral nutrition), since the body has a lot of autoregulatory mechanisms and it's hard to get the nutrient balance just right when sustaining someone solely through an IV tube. Aside from the typical issues with having a tube in the belly, I'm worried about this patient's bed-wetting. He does not have a Foley because of the infection risk, but now he's getting an even more invasive tube in him, and his whole mid-section gets soaked with urine when he urinates. Barring a UTI, urine is sterile, but bacteria love it when they can get it, so he's turning himself into a petri dish a few times per day. His mood was a bit more positive today than yesterday, but still not back to where it was. I'm hoping he can stay positive in the long run with the long hospital stay and the recurrent procedures.

Scott

Bad Day

This past week has definitely been a challenge for me. My preceptor has an odd way of communicating. He has an accent, plus he speaks in partial sentences and uses a lot of imperative statements, so it's hard figuring out what exactly he means even if you understand the words. He sometimes just stares at the patients or at me for seconds on end; these are always uncomfortable times. Plus, he asked one lady how she has been since the recent death of her husband, and after she talked a bit and stopped to cry, he just stared at her, then said, "Don't cry. It'll be all right," and kept staring. There's obviously a cultural gap, but he seems to be somewhat Spock-like at times, expecting people to act solely on reason and practicality rather than emotion and desire. My classmate is mostly amused by him. I tend to be bemused and irritated, but in any case, we both had a rough day today. On my part, it's starting to get to me that our preceptor seems to misunderstand me and respond in ways that indicate that he thinks poorly of me. I feel it's detrimental to be confrontational with him, but since he'll be evaluating me, I also feel it's detrimental to let him misunderstand me and get the wrong impression of my intent. Damned if you do, damned if you don't, I'll just be glad when this damned rotation is over. I hate internal medicine.

Anyway, with that off my chest, we get to go in later tomorrow. Also, tomorrow should be a lighter day with patients. Speaking of patients, the one I've been rounding on this past week has pressure ulcers on both feet as well as his sacral region. The ones on his feet had become infected, so the podiatrist debrided them and in the process discovered that the infection had spread to the bone. So the patient went back for bone debridement yesterday. He is usually chipper and energetic even when I wake him to talk, but today he seemed to just want to go back to sleep and he couldn't remember having had the procedure yesterday. I'm hoping it's just part of the procedure recovery process, but I'll find out tomorrow. The bacterial cultures of his bone came back with Staph and Strep, which are common in osteomyelitis from skin ulcers, as are anaerobes, gram negatives, and mixed infections. Osteomyelitis from a plain skin infection is likely to be Staph aureus or Strep, but when the skin is eroded away by a necrotic ulcer, it's a free-for-all in the unprotected underlying tissue. It's important to keep the skin intact as the first line of defense against invasive organisms.

I mostly needed to vent, but I figured some substantive info would be good, too.

Scott

Preliminary November Newsletter

Sorry, I got distracted at the end of November and today Internal Medicine hit hard with a lot of studying to do for tomorrow. This should be a difficult, but hopefully informative, month. There is much to learn and it's not at all focused, so it'll be a challenge for me.

Psychiatry was great. My interest didn't make a big decline until near the end, versus other rotations, in which I started getting antsy and ready to move on by the end of the second week. My only disappointment with Psych was the lack of interaction with psychotic patients. I saw one adult who seemed to be hearing voices but wouldn't admit it and was quite on edge. Also, there was an adolescent who came to the acute unit from the residential area of the hospital who had been gradually becoming more grandiose and unrealistic with the stories he would tell. For example, he apparently was dead lifting 300 lbs the weekend before coming to acute and tore muscles in his neck and chest and ruptured some blood vessels in his head, causing him to pass out and be rushed to the emergency room. He said this incident is why he was wearing a sling; I never really got a good feel for what parts of his stories were legit, exaggerated, or plain made up. He was pleasant enough to talk to, though.

A classmate and I will be working with the same doctor this month. Thankfully, this is a classmate with whom I enjoy spending time, so it should be a good month being able to confer and just chat with him.

I think the thoroughness and regularity of my posts will be inversely proportional this month (as I mentioned last month, I'll try to post a couple times per week and I'll sum up in the monthly newsletter, but I only send notices of the newsletters).

Scott

Psych is Going Quickly

I just realized with glee the other day that I'm already 3/4 done with this rotation. Then I realized that I've been enjoying it and I'll be somewhat sad to move on. I typically have about a 2-week limit on rotations before they become drudgery, but for psych I've held out this long. Surprisingly, along the way, psychiatry has moved up my ranking of specialties. It's still not at the top, but I would actually consider doing it in an inpatient setting if surgery didn't work out.

Speaking of surgery not working out, I've been in some denial about a tremor I developed this past spring. It started off barely noticeable for an hour or two in the morning, but it's gradually become worse. It's such a slow progression I keep hoping it's plateaued, but I'm not sure. In any case, my psych rotation has somehow made me able to accept the thought of life without surgery and I've been thinking of other specialties I would enjoy. As mentioned, psych is at least on the table, but I'm leaning toward pathology and maybe radiology, both of which require little interaction with people. Ironically, one of the therapists at the hospital says I'm too personable to be a surgeon (and I suppose by extension, a pathologist or radiologist), but the thing is, being personable is not natural to me and it's very draining. Perhaps I should get this tremor checked out, but mumble, mumble, mumble, mumble. I'd probably just get put on a beta-blocker, anyway.

I'll post more case presentations as the week progresses.

Scott

Critical Mass

Apparently, putting a dozen troubled little boys and a couple of adolescents together causes a spontaneous reaction. Between two wards, you can only separate so many volatile patient pairs. There are obvious laws about male and female patients not sharing the same room, but other laws also limit the age difference between roommates to 36 months. Then, there's also a law or hospital policy preventing a patient who has a history of sexual misconduct from even being in the room at the same time as the roommate, so at night they have to take turns sleeping out in the common area. In case you're not adequately disturbed, keep in mind I've been working with kids. On one ward, there's a 9-year-old who has a history of sexual misconduct, and the other ward has a 13-year-old in the same love boat... er, same boat (I'm sure that's an example the type of twisted humor you develop to help cope with the knowledge of what's been done to these kids and what they in turn do to others). The 9-year-old is annoyed with not being allowed in the (single-occupancy) bathrooms at the same time as the 7-year-olds. My preceptor described "insight" as the ability to appreciate the consequences of one's actions and the effect of those actions on others. I'm seeing a lot of patients, even older kids, who are totally clueless about cause and effect of their actions.

Anyway, all this logistic juggling is made worse by the fact that both wards are near capacity. Several kids on the more full one decided to lose their cool today. It was a rough afternoon. I learned I am not naturally gifted with the patience to deal with the loud, outbursting types of patients day in and day out. One little boy had a penchant for loudly screaming a couple octaves higher than should be possible and slamming doors repeatedly. Another decided to make it his personal mission to attack a younger kid who's kind of an outcast and just mopes about all day. Then there is a teenage girl who has borderline personality disorder (alternates between desperately clinging to you and beating the crap out of you, not always figuratively). Bradley, a boy she knows, was admitted today. So, with the aggravation of little boys screaming and the desire to show off for her newly-formed soul mate, she reverted to her coping method of choice: regressing to the maturity level of a three-year-old. On the way back from one of several trips to the seclusion room and after a boat load of meds, she yelled, "It's ok, Bradley, it's ok! I'm calm now! It's ok, Bradley!" She's screaming this, mind you.

While I'm discussing totally odd behavior, there was a certain teenage boy admitted for combative, defiant behavior. He was one of the first patients I saw here, and the doctor said to imprint him in my mind as a classic case of bipolar, which is apparently overdiagnosed these days. During his stay on acute, this guy had one or two run-ins with staff, being physically aggressive and just defiant. I saw the staff bodily drag him to the seclusion room; if all you could have seen was his face, you'd have though he was just enjoying a competitive sport. No wild psychosis glinting in his eye, no hatred seething out of his pores. They asked him at one point why he was acting this way and he said, "I don't know. It's fun." His behavior eventually leveled out, so he was transferred to the residential unit, which allows more freedoms while still providing intensive treatment. Last week, he decided it would be a good idea to fill his toothbrush holder with feces. I'm not sure if that was "fun," or if there was some other driving force. My attending said it was a subconcious way of testing others' acceptance of him. "Here's a part of me, what do you think of it?"

Not all the patients are so oddly colorful, however. One was a teenage girl who was just dealing with several stressors and started cutting and having some suicidal thoughts. Her family is supportive, and she just needed some quick inpatient therapy before being set up with outpatient follow-up. She had a positive outlook on life in general and got along with people well and should be fine.

Back to cutting and other self-destructive behavior. Cutting and similar actions are distinctly different from suicidality. Cutting is not an action meant to harm or kill; it's like sighing long and hard at a complex problem. It's an emotional release. It's a way of transferring abstract, intangible, inner distress to a tangible, concrete, external locus. It does some other things, too, but that seems to be the consistent theme amongst cutters. They probably won't have thought it out in such detail, though.

As a poor analogy, think of suicidality and cutting as being like flames and smoke. They often coexist, but it depends on what's being heated, and they are two separate entities. Smoke and flames are simply the obvious signs of the combustion process, which is what really needs to be stopped. Similarly, putting an end to the angst and depression leading to suicidal ideation and cutting is the only effective treatment for them. If you want to treat the symptoms, the best action you can take to prevent these thoughts/actions directly is to equip the patient with healthier coping mechanisms. You can't cure suicidality. You can't cure cutting. You can't cure suicidality. You can't cure cutting. Should I say it again? You have to cure the underlying cause. If I seem emphatic on these topics, it's due to personal experience with both. I should specify that's past experience, so don't go locking me up.

Speaking of personal experience, it's both a benefit and a detriment. On the one hand, I'm non-reactive when patients relate suicidality and cutting, which facilitates their sharing, plus I understand their thought processes fairly well. One the other hand, I feel detaining most of these patients is such overkill (no twisted pun intended). I keep thinking, "so they cut themselves and want to die, what's the big deal? I had the same thoughts and I'm still here. (And I walked five miles to school in the dark barefoot in the snow uphill both ways and in my day...)"

So as not to leave on a negative note, consider this: this sentence has seventy-five letters... q.

Scott