"I've never ridden in an ambulance before"

The reason for appointment read "follow up for cough." Reading through the notes, I see several visits over the last few months for the same reason, cough. Something didn't feel right.

I walk into the patient's room and introduce myself. He looks thin, anxious, fragile. He tells me about his cough, how it's been going for a few months, how thinks he might need some antibiotics this visit. He goes on to tell me how he's developed diarrhea in addition to his cough, how he's lost 25 pounds in the last 3 weeks, how he feels weak, how he has unresolved skin rashes on his sides. Something really doesn't feel right.

I do a physical exam. I don't hear anything in his lungs the first time. Listening again, there is something in his right lower lobe, but it's not typical pneumonia. His chest xray from a week ago was perfectly normal. I continue my exam. He's breathing fast, his heart is beating fast, he is not doing well. I look at his abdomen, the rash is still there. There is fungus on his toenail that just isn't going away. I ask him to open his mouth, so I can look in his throat. My fears and suspicions are confirmed. His mouth is covered in thrush. I try to remain calm and tell him that I will be back in a few minutes with the doctor.

My heart and thoughts racing as I leave the room -- "Oh my gosh, oh my gosh, oh my gosh. My patient has HIV, and he doesn't know." I scan the records looking for a previous HIV test. I don't see one. I tell the doctor about him. We go in to see him together.

She asks some of the same questions. She also asks about his sexual history. He seems uncomfortable talking about it. We measure his oxygen, and it's low. The doctor explains to him that due to his unstable vital signs and low oxygen that we're going to have to call an ambulance to come take him to the hospital. She then tells him that based on his signs and symptoms that he most likely has HIV and a pneumonia caused by the HIV that they will treat in the hospital. She then asks him about which hospital he would like to go to and we leave the room.

I go back in to check on him. I ask him how he feels about what the doctor just told him and if he has any questions, and he replies "Well, I've never ridden in an ambulance before." I don't know if he just didn't process what the doctor had told him or if he was in denial, but he wasn't ready to about it.

Medicine just got real.

Self Reflection – The Importance of Self Care

As part of the assignment for this rotation, we have to write a letter on the importance of self care. When we are in our intern year of residency, the clerkship director will mail these letters to us to remind us to take care of ourselves. I think this will serve as an important reminder during that stressful period of my life -- if I don't take care of myself, it's going to be pretty difficult to take care of patients.

___________________________

Dear intern me,

1. As Dr. X said, if you’re not waking up excited to go to work and see patients every day, talk to someone. Talking to someone can help solve a difficult work situation, or it just feels good to express your feelings and have someone listen and understand. Whether it’s your superior, a peer, a friend, or a therapist, just talk to someone.
2.   Keep exercising. It really is the best way to deal with the stress, exhaustion, and emotional baggage of the day. Even if you can’t make it to a crossfit workout, at least try and go for a walk or a run. You will feel better. I promise.
3. Make time for family and friends. Even if you feel that you have to study, read about a patient, or prepare a presentation, make time to spend with those people who make you happy. It will be worth it. There will always be another deadline to meet or more to do, but those who you love most won’t always be around.
4. Don’t sweat the small stuff. Try and let negativity roll off your back. You never know if someone else’s rude or insensitive comment was due to their level of stress, exhaustion, or personal conflict. Just remember that 99.9% of the time, it isn’t a personal attack. When it is, try and find the good in the situation. In that comment/attack could be something you can improve upon.
5.  Don’t feel that you have to be perfect in everything. You don’t have to be the perfect housewife, perfect doctor, perfect daughter, and perfect friend.  For example if you don’t have time to cook every night, don’t worry about it. Do what you can, and remember you have supportive friends and family who love you, understand you, and want to help you.

 You’ll be fine. You are a strong, capable woman, and you can handle more than you think.

Love,

M3 me

"This isn't The Notebook"

I've been spending some time in the neuropsychiatric ward, the saddest place I've ever been, taking care of some patients. I guess the neuropsychiatric ward is what people thing of when they think "psychiatric hospital." Patients are either so medically sedated that they are just passed out in their wheelchairs, heads on the table, or they are aimlessly wondering around, going into other patient's rooms, and following you wherever you go.

My first time in the ward, a patient came up to me, crying, asking "can you take me home?" It turned out that she was one of our patients. Talking to her was difficult through her broken sentences, confusion, and word finding difficulties, yet I felt I could follow some train of thought she was trying to convey. She pointed to the attending rounding, and said "I know him." I was excited by this -- she recognized her doctor, but when I tried telling the attending that, he dismissed me saying, "She just recognized a white male figure -- she doesn't know who I am."

Am I too idealistic? Am I biased in working with my patients with dementia to hope for the best, to only see the good? I have another patient with progressive Alzheimer's dementia with receptive and expressive aphasia, meaning she has trouble understanding and using language. Yet, I try and talk to her and understand as much as I can. I ask her name, and she tells me, "Penny*." I ask her where she is, and she tells me, "hospital." Every time I talk to her, I feel that I can see the person behind the confusion -- if I'm patient enough, I can understand what she's trying to tell me. When discussing her with my resident, I reported that she knew who she was and where she was, and that I thought she might know more than we give her credit for. My resident responded, "This isn't The Notebook. She is confused and doesn't understand us and doesn't know where she is."

It might not be The Notebook, and I understand Alzheimer's is a progressive disease that doesn't have periods of improvement/return to normal function, but that doesn't mean we shouldn't try and find the remainder of the person left inside.



*name changed for patient privacy

"Ethical Erosion"

I read an interesting article in the New York Times today. It discusses how the third year of medical school with block clinical rotations lead to the "ethical erosion" of medical students -- how medical students stop being patient focused and start being disease focused.

It's hard not to fall into that trap. Just earlier today, I found myself talking about my "schizoaffective patient" and my "depressed patient" instead of "my patient WITH schizoaffective disorder" or "my patient WITH depression." I think as long as I try and stay aware of how I am talking ABOUT patients, how I am talking TO patients, and how I feel about patients, it will go a long way to preventing this "ethical erosion."



P.S. On a less serious note, this blog is a hilarious insight into the last two years of med school

"They're trying to kill me"

I've started my psychiatry rotation this week at Wesley Woods Hospital.


1)
I've talked to my first schizophrenic patient. This Modest Mouse song, "World at Large" reminded me of him.


Went to the porch to have a thought. 
Got to the door and again, I couldn't stop. 
You don't know where and you don't know when. 
But you still got your words and you got your friends.


I know that starting over is not what life's about. 
But my thoughts were so loud I couldn't hear my mouth. 

2)

coun·ter·trans·fer·ence/ˌkountərˌtransˈfərəns/

Noun:

The emotional reaction of the analyst to the subject's contribution. (google dictionary)

3 days in and I'm definitely feeling it. I have felt unusually anxious the last few days, and it's not "the crazy rubbing off on me." Rather, I think it's the effect of talking about these incredibly personal details of people's lives and having to remain stoic and objective about it. It's sad. It's draining.

This sounds like a pretty negative post, but I am actually excited about the rotation. I think I'll learn a lot, but I also think it's going to be difficult.

3) 

I learned my "tell." 

Today we had to practice the psychiatric exam with a partner in the class. The clerkship director said he would be coming around to give us feedback and specifically let us know what our "tell" is -- what gives us away when we're nervous. He said by knowing our "tell," we could work to not let it show during patient interviewing.

My "tell" is that I flush -- my face and neck turns bright red. Awesome -- because I can really change on working that, ha.

When you start dreaming about hemorrhagic ovarian cysts

you know have been on ob/gyn too long ;)

This last week marked the end of my ob/gyn rotation...ending on a high note with gynecologic surgery (gyn surg).

The last two weeks have been my favorite of rotations thus far. Yes, you have to be at the hospital early. Yes, you have to present patients to intimidating attendings. Yes, you will mess up and get yelled at by scrub/circulating nurses. Yes, people can be grumpy for no reason. Yes, you will be on your feet for so long during surgery that you put ice packs on them when you get home. BUT IT'S SO MUCH FUN. I can honestly say that I've enjoyed every day that I've gotten to be in the OR.

I love the hands-on aspect. Here is a list of just a few of the things I've gotten to do the last two weeks.
--sewed up a patient with a subcuticular suture
-- cut a fibroid uterus in half (after it was removed to be sent to pathology)
--biopsied a lesion on a cervix
-- played with hysteroscopic tools
--closed fascia by tying knots

Surgeries I've seen:
-- total abdominal hysterectomies
-- supracervical hysterectomies
-- ovarian cysts removal
-- ovarian mass removal/omentectomy/bowel resection
--laser ablation of vulvar lesions
-- cystoscopies
-- dilation and curettage

I also just started feeling more comfortable as an M3 by the end of the rotation. Some residents are nice, some residents are mean -- same with attendings. I don't know if I have just gotten used to being the bottom of the totem pole, or if I've just become a more competent M3, but these last two weeks I have felt good about where I am.

A Haiku: Gyn Surg

Uterus, pregnant?

No, big with fibroids, so large

Took out, now it's small

Hysterectomy

Alien head uterus

filled up with fibroids

Scraping uterus

 for too much bleeding, and so

biopsy will tell