Lumbar Puncture

The nurse scrunched up the 7 week little girl into a ball so her spine was curved, exposing her intervertebral spaces.

The resident counted her vertebrae, felt the spaces, and started prepping the area of entry.

I dipped the pacifier into the sugar water again and tried to get her to suck vigorously on it.

The resident sticks the needle into her spine, the end of the needle remains dry.

She screams and tries to wriggle free.

I put more sugar water into her mouth.

We start over.

The attending tries.

I put more sugar water on the pacifier.

Only blood comes out of the  other end of the needle.

The attending calls the hospital director.

We put the baby in the sitting position.

The nurse scrunches her down.

I try to get sugar water in her mouth.

She stops trying to break free and relaxes into my hands

I cradle her little head

Nothing comes out of the needle

Overheard in Egleston

A 7yo boy born with 4 fingers on his left hand: "Some people say God made everyone with 10 fingers and 10 toes, and that's not true."

Same boy, when asked about napping: "Yes. I napped 12 minutes ago!"

A 3yo girl with a pinwheel for incentive spirometry: "Abra Cadabra!"

An 8yo girl when asked about being ready to go home: "I'm afraid of falling and having to come back to the hospital"

A 10yo boy with recurring Guillan-Barre "I'm afraid of dying from this"

10 Fingers, 10 Toes

I've started my inpatient Pediatric rotations by working in the nursery at Grady, a pretty happy place to start :)

Babies are adorable. To celebrate their adorableness, here are some baby haikus.

Babies are cuties
Ten fingers and toes I count
Tiny hand grasps mine

Learn swaddling skills
Wrap babies cozy and tight
Sleep peacefully now

Baby Reflexes
Morrow, Babinski, and suck
Soothe baby, me, both?

Needless to say, this week has been nice... happy moms, mostly happy babies (as long as they're being fed), + happy doctors = happy med students.

Breaking Bad News

I have always thought that it would be too difficult for me to be an oncologist due to the emotional burden of sharing devastating news with a patient and their family. During this rotation, I spent the afternoon with an orthopedic oncologist. He had one of the best bedside manners that I have seen.  With every patient, he just seemed to build rapport effortlessly, and he seemed to have a deep connection with the patients he had treated that were now in remission. I not only saw him interact with the patients that were now doing well, but also patients who faced an undesired disease progression, specifically one patient with stage IV disease.

We walked into the room and he introduced me to the seventy-year-old patient and her daughter. He started off asking the daughter about a tattoo on her arm, and making friendly conversation. He then examined the mother’s shoulder where a tumor was growing underneath. He explained how the CT scan showed spots in her lungs in addition to the tumor on her shoulder, and what her options were for treatment. He explained this all in a calm and straightforward manner. He did not go into the medical specifics and what this meant for her prognosis, but instead discussed in simpler terms how he could help her.  I could tell the patient and her daughter were both shaken up by the results. The patient was trembling while tears formed in her daughter’s eyes. The physician allowed them to process this information with silence and again told her how he could help her in his role as the surgical oncologist.  He also provided a plan of action for them. He encouraged them to see the medical oncologist within the week, and he advised them to contact him with any questions or concerns they may have.

Cancer is horrible. There is no way to alleviate the shock, fear, and pain of that diagnosis. I have never been sure how I would break that news as a physician. Seeing this doctor tell his patient and her daughter about her cancer showed me a good way to do it. He was straightforward with his explanation, yet calm and empathetic in his delivery. He did not promise a cure, yet he did not take away all hope. Although I felt extremely sad for the patient and her daughter, I could appreciate the way the physician handled the situation.

This specific experience provided me with insight into a way to share difficult news with a patient. It is a balance between showing empathy and serving a source of strength and hope. It is explaining the diagnosis in clear and simple terms and taking the time to let the family process in the information. It is not leaving the patient feeling hopeless about their condition, but instead providing a plan of action and reassuring them that you are available to help them. Through this experience, I hope I am similarly able to discuss difficult diagnosis in a way that makes the experience as easy as possible for the patient.

Thoughts on Family Medicine

After 6 weeks on this rotation, I have become somewhat familiar with the practice of family medicine. Ultimately, I've realized you need to be a REALLY good doctor if you want to go into family medicine because you essentially need to have a mastery of three subjects: internal medicine, pediatrics, and ob/gyn. However, due to the reimbursement rates and restrictions on patient care, family medicine doesn't generally attract the top students. Even if you're a pretty good student, it is really difficult to know three broad fields very well. It seems that end result is a "jack of all trades, master of none" situation.

Coming off of the ob/gyn rotation, I think that there is a reason a "speciality" exists for this field. Those doctors are putting in IUDs everyday, talking about birth control options every day, looking at cervices everyday. Therefore, they have a better grasp on diseases affecting those patients. Yes, doing a pap smear isn't very difficult but fully managing a women's ob/gyn needs can be, and I think it should be left to the ob/gyns to do that.

However, I also realized the utility of the "family doc" in rural areas. If you have a good base of knowledge in internal medicine, pediatrics, and ob/gyn, and you're the only doctor for a few hundred miles, it makes sense. However, in the urban setting, I feel that patient receive better care going to the specific subspecialty of pediatrics or ob/gyn.

Overall, I have enjoyed this rotation. It's patient-care focused. There is a lot of preventative medicine. The hours are pretty nice (but you hours outside of clinic are generally filled with paperwork). You see a wide variety of patients. Other times it can get pretty monotonous (for example, having 5 physicals back to back). Ultimately, I don't think it's my passion. I don't feel as excited coming to clinic every day as I do going into the OR.

On Hurting Patients

As the other students in my class, I came to medical school because ultimately I want to help people. However, I didn't fully realize that with the intention of helping people, you sometimes I have to hurt them (ex: vaccines, drawing labs, IV medications, sometimes even physical exam maneuvers).

We had a young women come into clinic the other day because she has tenosynovitis. One of the treatments for tenosynovitis is a steroid injection into you wrist, underneath the tendon sheath. I went into the room, introduced myself to the patient and her family within the room (husband and 2 small children), and explained to them about the procedure. I was working with a resident that day.  As the resident is preparing the injection, she tells me "I'll do the first one and you'll do the second."

Medical school is about learning and that includes procedures, but I had never given a steroid shot before, especially not into the wrist where there are about 20 other things in that small space. This was also the first time the resident was doing this particular procedure. I didn't say anything and just tried to get into the mindset to do it. The resident puts the needle into the patients left arm and starts injecting. The patient flinches and starts crying. The resident finishes, looks at me, and asks, "you want to do the next one?" I am conflicted. I don't want to look like a bad/afraid/uninterested medical student, but I am not comfortable with this procedure and the patient in front of me is crying out of pain. I say, "I'm not really comfortable doing that." The resident gives me a look and does the injection. As we walk out of the room, she tells me that I'm doing the next steroid shot even if I'm scared. I tried to explain to her it was more to do with the patient crying in front of me and unfamiliarity with the procedure than fear. 

The experience made me realize how much I DON'T like doing procedures outpatient. Even though I am a procedurally geared person, I like surgeries because the patient is anesthetized. They can't feel you cutting through their skin; they don't FEEL. I have found outpatient procedures really difficult, especially joint/steroid injections. It's hard to want to try something for the first time when it includes inflicting pain on a patient.

"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.