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