Is it okay if I rant?

Last week I was assigned to follow a Physician Assistant for a day since the MD was out of the office. I have nothing against PAs. But this one was really starting to rub me the wrong way (figuratively speaking). 

PA: Medical Student, go assess these patients.

Medical Student: Okay.

Medical Student: Patient number one has a cough that comes in paroxysms with post-tussive emesis. He has had the cough for 6 weeks. I think we should cover for pertussis.

PA: Um, no. It's just viral.

Medical Student: (what the @#%$@!!)

Medical Student: Patient number two is a well child check. Everything was fine but there is a 2/6 systolic murmur at the apex. I think it should probably be checked out.

PA: (listens at the 2nd and 4th ICS) Nope. No murmur.

Patient's Mom: I think he's right, we have been told he has a murmur and that he should have a "heart ultrasound."

PA: (listens at the apex) I found a murmur here.

Medical Student: (glares at back of PAs head)

Medical Student: Patient number three has perfect circular patch of hair loss with a boggy mass on his scalp. It's classic for a fungal infection. I think we should treat him with an oral anti-fungal.

PA: Nope. This is a lipoma or maybe a sebaceous cyst.

Medical Student: I really don't think...

PA: We need to cut it out.

Medical Student: Should we try an anti-fungal first?

PA: Nope. We need to cut it out. (makes an incision on patient's head) Weird, there is nothing in here. Oh well, stitch this up.

What a day.

How the Dementia Patient Out-smarted Me

Every once in a while you have to let go of your pride and admit that someone has gotten the better of you. Whether it be sports, politics or even the world of medicine, the time is sure to come. It just sucks when the person who gets the better of you has dementia. 

One of my patients in clinic today appeared rather confused so I decided to perform a mental status exam on her...

Medical Student: Okay, can you spell world backwards?

Patient: No.

Medical Student: You don't want to try?

Patient: Why would I do that?

Medical Student: Okay. um, I'd like you to take this pen and draw a picture of a clock face showing ten past eleven.

Patient: Fine. (starts drawing) There. (shows me picture of a circle with 11:10 written inside of it)

Medical Student: What's that?

Patient: It's a digital clock. 

Medical Student: You win. I don't care if you think the president is Woodrow Wilson. 

Learn from the best

As I go through medical school I like to see what I want to incorporate into the way I practice medicine by watching those who have gone before me. For instance, humor:

Attending: Well, you haven't been taking your medication, you aren't changing your diet, you aren't exercising and you aren't losing weight. Your kidney function is failing. It looks like you are going to have to start dialysis if you can't get with the picture.
Patient: What? Oh no! I don't want to do that. My children would just die!
Attending: No, you would be the one who dies. (chuckles)
Patient: ("I don't find that funny" stare)
Attending: (continues to chuckle)

I'm learning so much!

Moving On

Family Medicine. The "who the hell knows what is coming in next" specialty (second to emergency I suppose). My first day on family went a little something like this:

Medical Student: Hello 75-year-old lady! Lets talk about what kind of exercises you have been doing since we saw you last.
Patient: Huh? Are you kidding? The only exercise I want to do is at night in the bedroom.
Medical Student: I wish you didn't look like my grandma

Hour later...

Medical Student: Hello super stressed out angry guy! What brings you into the office today?
Patient: My wife is bipolar, has scleroderma and addicted to oxycontin.
Medical Student: (practicing his empathy) I'm so sorry to hear that. That must be really stressful for you.
Patient: Look at these pictures I took of her on my phone of her passed out on the floor.
Medical Student: I wish you hadn't shown me that.

Oh what joys will come next!?!

Make sure you lock the door

So I found out the hard way that the bathroom door on the peds unit doesn't lock that well. Actually, I would say the poor old filipino nurse who walked in on me found out the hard way. Oh well, nothing she doesn't deal with every day right?

Pneumonia

Sorry for the gigantic lack of updates. The reasons are two-fold. Firstly, everyone is so nice to me on peds that I feel like there is nothing interesting to report. I mean, it seems writing everyday that everyone loves me and gives me respect would bore most people. It's only funny when I'm getting abused. I miss surgery. Second, this happened:

Medical Student: Hello small child and family with pneumonia! I see you were just seen yesterday in the emergency department and given amoxicillin. 

Small Child: (all cutesy) mmmhmmm! (big smile) (little cough)

Medical Student: Aww, how cute, here is a sticker of mickey mouse!

Small Child: Yay! Thanks! (cutesy smile)

Medical Student: What a polite little girl! Now open wide for me!

Small Child: Okay! (coughs in my face)

Medical Student: (!#$^%@) 

Small Child: (cutesy smile) sorry...

Mom: Oh, I'm sorry...

Medical Student: (you can take sorry and shove it...) That's okay! Here is another mickey sticker!

Small Child: Yay!!

So, yes, I have been sick all week and weekend. I did not know it was humanly possible to shed this much mucus onto the earth. I wish I could extract all my goblet cells. Also, I don't care if that was gross. Suffer with me!

I cannot escape it

It's understandable when you are in the academic medicine environment to expect a certain level of pimping. I've done my fair share of griping on this blog about the questions I've received as a medical student, but in all honesty things haven't been too bad. When you exit the academic world and escape into real life, however, you tend to let your guard down. Especially when you or your family member is now a patient.

My wife needed to have a minor surgical procedure performed and was undergoing general anesthesia for the operation. I, the loyal husband that I am, was waiting by wife's side in pre-op and inevitably the surgeon came by to do the final pre-op check and asked me what I did for a living.

Surgeon: (lighting up like he just found his next hit) "Ah, so you're a medical student! What are you interested in?"
Me: "Well, I'm still trying to decide. I like peds a lot."
Surgeon: "Well, try to stop liking that. There is no money in it."
Me: "Okay..."
Surgeon: "So I'm currently injecting your wife with Versed, you know, midazolam. Then we will give her some propofol for induction."
Me: (feeling he is about to go deeper with this) "Alright..."
Surgeon: "You remember your pharmacology?"
Me: (No freaking way is this guy about to pimp me as he is about to induce my own wife) Yes...
Surgeon: "Well, what is the mechanism of action of Midazolam?"
Me:(Are you freaking kidding me?!?) That's evading me...
Surgeon: "Well, it acts on the GABA receptor."
Me: "Ah, yes, of course."
Wife: (looking off into the distance) "Is this what being high is like..."
Me: "Yes, sweetheart."

So, in the future, whenever I'm asked what I do, I am going to say that I'm an accountant. Because you never know where a pimp addict may be lurking. And the surgery went fine, in case anyone was wondering.

I don't know

Peds. Gotta love those kids.

Medical Student: Hello little 5 year old girl! How did you get this bump on your leg?
Child: (excitedly) I was asleep and then my friend woke me up and then... and then... and then... (big breaths, getting more excited) I was just jumping on her spongebob pillow and then she pushed me off and then I fell on a sharp thing and then I pulled it out all by myself!
Medical Student: (jotting down everything) Wow! How did you do that?
Child: Do what?
Medical Student: Pull out the sharp thing!
Child: Huh?
Medical Student: You fell down on a sharp thing right?
Child: Yeah!
Medical Student: After you fell off the spongebob pillow...
Child: What? No!!!!
Medical Student: Okay... Then what happened?
Child: I don't remember!! I was sleeping silly!

I love it when you write out a whole H&P and then get to write a big "X" through it.

*There was nothing wrong with this kid (no concussion, brain damage etc.) she was just being her five year old self.

The Dark

Radiology. I just finished it. Let me give you a little taste of my glorious schedule:

9:00am - Arrive at hospital

10:00am - Attending arrives at hospital

11:30am - Attending takes lunch, so I go too

2:00pm - Go back to hospital

3:00pm - Go home

Granted, going into the reading rooms is like entering Gollum's cave (Yes, I did just make a Lord of The Rings Analogy), but that schedule freaking rocks. 

On a more serious note, I did meet one radiologist that looked like Gollum. Sounded a little like him too, but wow, could that guy read a chest x-ray.

Yeah, well, I made another one

This is a slightly embellished, real life conversation.

Am I missing something?

I've been pondering this one for a while. Can anyone show me exactly what I'm missing?

Attending: Medical Student, this patient has bilateral pitting ankle edema, shortness of breath and borderline hepatomegaly. What do you think could be going on here?
Medical Student: Well, it sounds like it could be right heart failure.
Attending: I don't think so. It's most likely Cor Pulmonale.
Medical Student: (confused) oh.

This is the second time I've had this conversation. Lesson: Always use latin when available.

Kids

I never thought myself one to enjoy the kids on my rotations, but they are starting to grow on me. They actually have quite a few qualities that I am jealous of. Mainly, they know how to say "no," they demand what they want, and they will do nothing for you until you give it to them.

Me: "Hello little 4 year old child, can I listen to your heart?"
Kid: "No!"
Me: "I really need to listen to your heart."
Kid: "I want to draw my name"
Me: "You know how to draw your name?"
Kid: "Yes! I'm the best at it! I want to draw it!"
Me: "Okay, okay, can I listen to your heart after?"
Kid: "mmmmmmmmm. okay."

So I give the kid a marker and await his masterpiece. He proceeds to draw a circle and a triangle.

Me: "Okay! Good job!"
Kid: (beaming) "I'm the best"

So to recap. I am 25 years old. Kid is 4. I have no control of the room. Kid has total control. I don't get to decide what my name is (usually I'm called, "move" or "I need to be standing there" or "watch out"). Kid gets to call himself circle triangle.  Ah, the lessons we can learn from children.

Wash Your Hands!

Sometimes it's the patients that give you a hard time. I don't know if I just had a look about me or what...

Medical Student: Hi There, I understand you've been having some stomach pain and I came by to do a quick exam.

Patient: Okay.

Medical Student: Great. Let me just wash my hands and we'll get started.

Patient: Yeah, you better.

Medical Student: (nervous laughter) why's that?

(Why did I ask him that? I don't know.)

Patient: Cause I can tell by lookin' at you that you just sit around touchin' yourself all day. I don't want all your junk germs on me.

That's it. I'm shaving my mustache.

I'm so confused

Look. I can handle the pimping, the long hours, the belittling comments, the general craziness of it all... but can we please at least agree on what the heck I am supposed to be doing on this service?

Intern: Go pre-round now on these 8 patients.
Medical Student: (feigning interest) Okay!

Later...

Intern: Why did you do the physical exam? Only we do the physical exam. Just get numbers.
Medical student: (Hiding confusion) Okay!

Next day...

3rd year Resident: Go pre-round on these 8 patients.
Medical Student: (Feeling confident in his role) Okay!

Later...

3rd year Resident: Why didn't you do a physical exam on any of these patients? Did they teach you the proper way to write a soap note here? Don't forget that again.
Medical Student: (confidence shattered) Okay!

Next day...

Senior Resident: Go pre-round on these 8 patients.
Medical Student: (Hell No!) Okay!

Later...

Senior Resident: Please don't write your physical exam in the chart. It's not as reliable as ours. Just get the labs.
Medical Student: (Through clenched teeth) Okay!

Someone. Help me.

Superpowers

Today I realized that one of my Attendings has a superpower. Let me explain. Perhaps you have been in the situation where you need to get somewhere but someone is in your way. Usually in such a situation you would say something like, "excuse me" or "I'm sorry, could I get by you real quick?" Not so with this Attending. He has the ability to move you using only his eyes (or maybe it's mind control, I'm not sure.) Basically this guy walks up to you and stares at you until your body just moves out of his way. It works every time too. Not once have I had the balls to just stare back at him and not move.

Caveat: This does not work on nurses. I have tried.

The Layers of the Abdominal Wall

I'm on Peds Urology now. Believe it or not, I have only been asked the layers of the abdominal wall one time on my entire 12 week surgery rotation. Being that I am now on subspecialties I felt I would be safe from this question. I was wrong.

Attending: What are the layers of the abdominal wall?
Me: Skin, subcutaneous fat, campers fascia, scarpa's fascia, rectus, external oblique, internal oblique, transversali...
Attending: Transversus abdominis, you mean.
Me: Oh yes, sorry. Then transversalis fascia, preperitoneal fat, peritoneum.
Attending: (silence)

So I mixed up one thing. Pretty good I thought. But no....

Resident: That's weird you don't know the layers of the abdominal wall
Me: I thought I just mixed up one thing...
Resident: I mean that's really important to know. Seems like you should know it.

Well, that's life. 91% just doesn't cut it these days.

What has medical school done to us!?!

So today one of my friends said:

Friend: I think I might have Otitis Media. When I exert medial pressure on my tragus I have 5/10 pain. There must some sort of infectious process going on.
Me: You have an ear ache?
Friend: Yeah.

I, for one, pledge to try and remain normal. In spite of medical school.

General Surgery Movie

I made this little clip to chronicle every single day on the general surgery service. Enjoy!

Last Day

Thursday was my last day on the general surgery service. I never thought this would happen to me but I was so happy that I burst into song in one of the hallways when no one was looking. I don't remember exactly what I was singing but it had the phrase, "Today is a beautiful day" in it. It was one of those moments you see in musicals where the lead character starts spinning around and singing. I half expected people to start joining in the chorus with me but, unfortunately, no one did. It was quite enjoyable really. So for the rest of the day any time I was on an elevator by myself I would repeat my musical performance. I think I may have a future outside of medicine.

Stupid

Today I found out I was stupid. Today the "Star Wars" attending led me into the ICU for a pimping onslaught.

Dr. Attending: What class of drug is imipenem?
Medical Student: A macrolide, no, wait, that's not right
Dr. Attending: That was stupid. Well, what's the mechanism?
Medical Student: (blank stare)
Dr. Attending: Are you special or something?

Good times.

The Infamous Whipple

For the surgeon the Whipple Procedure consists of the following: Cholecysectomy, Pancreaticoduodenectomy, Truncal Vagotomy, Antrectomy, Choledocojejunostomy, Pancreaticojejunostomy and a Gastrojejunostomy. For the medical student the Whipple Procedure consists of standing in a hot gown, gloves and mask for 9 hours while being grilled on whatever random anatomy fact may cross the surgeons mind, while holding a retractor or two.

Here are things that I learned after being scrubbed in on this procedure: 1. Take an ibuprofen before starting. 2. Do not ask questions. 3. Even if you are right, don't expect to be acknowledged whatsoever.


Now, point number 1 is self explanatory, but let me explain point two and three.  It may seem odd that a medical student shouldn't ask questions, but it is absolutely imperative. If a medical student does slip up and ask the surgeon a question, this is the conversation that will follow:

Medical Student: Dr. Attending, I'm not sure I'm oriented here, is that the external oblique we just transected?
Dr. Attending: Good question! Is it?
Medical Student: Well, I'm not sure, that's why I was asking.
Dr. Attending: You should know that.
Medical Student: Yes, you are right. I will study more. (Note to self: Do not ask Dr. Attending anything)

So the lesson again is: NO questions. Let the attending be in charge of questions.


Point number three can also be explained in this simple, real life conversation:

Dr. Attending: Okay, so is the Superior Mesenteric Vein anterior or posterior to the pancreas?
Medical Student: (feeling confident) It is posterior.
Dr. Attending: Are you sure?
Medical Student: Uh, yes.
Dr. Attending: Really?
Medical Student: Well, I was... Why? Is that incorrect?
Dr. Attending: (Silence)

So, as you can see, there is really no way to win. That is why I came home and ate a large bag of french fries and watched 24 all night.

Star Wars

I often wonder what I will be like as an attending physician someday. On call last night I witnessed the following conversation between my resident and the on-call attending:

Resident: "This patient came in presenting with right upper quadrant pain, nausea, vomiting and..."
Attending: (waving hand in front of resident's face) "These aren't the droids you're looking for."
Resident: "...on exam she had moderate tenderness to palpation with a positive murphy's sign and..."
Attending: (repeating hand motion) "These are not the droids you're looking for."
Resident: "Okay. Yes, I'm familiar with Star Wars."

I guess I can be however I want. It's going to be great!

Exercise

Medical students follow attendings everywhere they go. I have almost followed attendings into the bathroom about 4 or 5 times. In fact, we have a tendency to follow all kinds of people: Interns, residents, nurses, patients, janitors, basically anyone who seems to have some kind of clue about what they are about to do next in their day because we generally don't have any idea.

My Attending is well aware of the fact that I follow him everywhere. My attending is also a marathon runner. So yesterday we had to go from the first floor to third floor for some reason (again, I often have no idea what is going on) so being impatient my attending decided to take the stairs. No problem. I can handle that. It's just a few flights of stairs. As we start jogging up the stairs (again, he is a marathoner) I begin to get a little winded. No problem. 3rd floor is within sight. We finally get to the 3rd floor, but he passes it and continues to jog. "Okay," I think to myself, "I never know anything anyways so we are probably going to see a patient somewhere on 4th." We don't stop on 4th, or 5th, or 6th. At this point I feel as though I am literally about to die (luckily I'm with a doctor) and am all but gasping for breath as my attending makes it to the roof level and triumphantly states, "Yeah! Okay! That was fun! You want to do it again? Going down is even harder cause your legs are like jello!"

Have you ever been the only winded person in a group of people after moderate or mild exercise? You know how hard it is to pretend you aren't winded? On the one hand your muscles and vital organs are screaming for oxygen and begging you to gulp down as much air as possible, and on the other hand the social situation demands that you risk passing out in order to avoid the embarrassment of being out of shape. So you just stand there and talk in slow bursts and try to breath through your nose only. Well, I couldn't pull that off. I was gasping like a newborn. His reply, "What's wrong with you? I'm like 30 years older than you."

So I'm preparing for my evaluation to say, "Well, he's okay in surgery but he's out of shape and a little fat." Yeah, that's going to look good on the dean's letter.

Belly Buttons

Perhaps some of you out there are familiar with the term "pimping" as it relates to medical students? For those who are unfamiliar, it is not what you think it is. Basically, whenever one of us students is asked some medically related question by one of our attending physicians we say we are getting "pimped." Why do we say this? I have no idea. I've yet to make the connection. I have accepted the terminology, however, and it has become a part of my vocabulary. 

One of my Attendings is addicted to pimping (in the sense described above), especially during surgical procedures. So, being the studious guy that I am, I decided to study up on some anatomy before going into an umbilical hernia repair. As we began the procedure I was expecting lots of very difficult questions to start flying at me. In the past I have received such jewels as "What oncogene is responsible for MEN type 2a?" and "Tell me every cause of hypercalcemia." As I brace myself to recite all the layers of muscle in the abdomen he says the following:

Attending: "Are you ready for your first question?"

Me: "Yes, Sir."

Attending: "Tell me every name you know for the belly button."

Me: "Um..."

Attending: (pointing at scrub nurse) "Don't help him! I want him to think!"

Me: "Navel? Umbilicus?"

Attending: "That's all you know? What about Bebo?"

Bebo? So much for studying. I give up.

General Surgery - Day 1

Well, to be quite honest, I am starting this blog already half way through my 3rd year of medical school. I'm done with my Medicine, OB and Psych rotations. I never really felt compelled to tell anyone anything about what's been happening to me in medical school until I started surgery. Now, not unlike the surgeons I am working with, I feel that I am the center of the world and everyone needs to know what is happening to me. So here was my orientation to the hospital I am doing surgery at:

Me and fellow student: "Hello, we are here for the surgery rotation."
Surgeon: "Have you had an orientation yet?"
Us: "No."
Surgeon: "Well, basically this is what you need to know: (pointing at me) You suck, (pointing at fellow student) and you suck."
Us: "Yes, thank you."

So hopefully this thing works out. Now, off to 30 hour call!

So Here's My Plan

I've never really had a blog before. My original idea was to give a "twitter" like update at the end of each day to kind of chronicle my journey through medical school. I now think that will probably not happen. Instead I will probably just do whatever I want. So brace yourself world!