doc w/ Pen

journalist + medical student + artist

Tag: clinical rotations

My window to the world

I didn’t get much natural light while I was on my medicine rotation, so I made a point to look out the picture windows near the unit where I worked. It’s a lovely view.

This morning at 9 a.m., my class has an orientation meeting to our four-month research block. When I exit the door of my apartment building around 8:45 or so, I hope to see something I’ve had very little of on my medicine clerkship: sunshine. (The forecast today calls for clouds, but that’s ok — there are other sunshine-y days ahead.) For the last several weeks while on medicine, when I’d leave my apartment in the morning, it was dark. When I left the hospital in the evening, it was dark again.

It’s disorienting. Without daylight, you lose track of time. It happens to everyone in the hospital. I remember seeing a patient in the ED late one morning. She asked me what time it was. I told her it was 11:30. She looked surprised, and told me she thought it was later than that. I quickly realized she thought it was 11:30 p.m., not 11:30 a.m. Granted, she was rather confused to begin with, but the lack of windows in the ED (and the lack of a clock) only made matters worse. I honestly told her that being in the hospital, I sometimes lost track of time too.

I was fortunate enough, though, to get regular glimpses of the outside world that grounded my circadian rhythm. To get from the elevators to the ward where I worked, I had to pass a series of gigantic picture windows. Look straight out, and you got a lovely view of the East River, and one of the bridges in the distance. Turn slightly to the right, and you got a lovely view of the New York City skyline. Every morning on my way in, and several times throughout the day, I would take a moment to look out those windows. To chronicle the various views — of sunrise, snow, and sparkling city lights — I started taking pictures through the windows with my phone. Here are my favorites, broken up into two groups, the skyline view and the East River view.

Click on any of the images to open a larger, slideshow view. Oh, and pardon the glare — you know, those harsh hospital lights.

 

Skyline view:

 

East River view:

My post-medicine to-do list

While on my internal medicine rotation, I’ve done lots of steps and stairs, as my iPhone attests. But when the clerkship ends, I need to get back into a regular gym routine.

As I write this, I’m almost done with my internal medicine clerkship. Just 12 hours to go. Wednesday was my last day in the hospital. Thursday I crammed for my exams. Today I plow through a 110-question multiple choice test, and a 2-hour EKG-reading test.

It’s been an exhilarating, and exhausting, eight weeks. I’ve taken more ownership of my patients than in any other clerkship. I’ve gotten to know them better, and been more intimately involved in their care. All of that has been immensely rewarding. I’ve truly felt like part of the team, like I’m contributing in a meaningful way. It has also been devastating, for example when a patient took an unexpected turn for the worse, a turn from which they were not expected to recover.

The work schedule has been intense too. Monday through Friday were generally 12-hour days, counting both in-hospital time and time I spent chart-reviewing my patients at home in the morning. Saturday, we generally were let go a couple of hours early. Sunday was my day off. But not really. It was really my day to catch up on studying. Because when I got home Monday through Saturday, it was hard to bring myself to do more than 10 (maybe 20) practice questions before my mind shut down. Forget trying to read or memorize anything. So Sunday was my day to study. Doing “life stuff” got put on the back burner. “Survival” was my mantra.

It’s been too long since I’ve visited the Tiffany windows at The Met.

That means that this coming weekend, I have a lot of catching up to do. It won’t all happen in a day. Thankfully, next up is my four-month research block. This will be plenty of work too, but won’t involve the same crazy schedule. So here are some items on my to-do list, in no particular order:

Spend time at places other than the hospital and my apartment. I’m looking forward to seeing the sun (other than through a window), and visiting some of my favorite NYC haunts (like The Met), as well as exploring some new ones (like the 9/11 Memorial).

Spend time with my friends and family. I’ve done very little of that recently, given my lack of time and energy post-work. It’s time to catch up, both in person with those who live in New York, and on the phone with those who live elsewhere. (You know who you are!)

For too long, my vacuum has sat abandoned in my closet.

Clean my apartment. I especially need to vacuum. Now that I have long hair, fallen strands have a tendency to collect in little clumps along my baseboards. Scooping up the biggest ones with my hands is really not cutting it.

Do laundry. I mean ALL of my clothes, and in actual washing machines, not just emergency items in my bathroom sink.

Do my dishes. Regularly. The other morning, I had to use a fork to stir the sugar and half and half into my coffee. Not ideal.

Eat better. I need to get back to cooking regularly, rather than slapping together a ham sandwich for dinner, or picking up unhealthy take-out. (E.g., no more orange chicken from Panda Express, which is directly on my way home from the hospital.)

Exercise. While working in the hospital, I run around a lot, from floor to floor, so get in quite a few steps and stairs. But I need to get back to a regular gym routine, and back to doing my mat Pilates.

Meditate. This is something I’ve wanted to try for years. Medical school is stressful, and I know residency will be too. I think meditation could help with that. Ironically, all the stress lately has prevented me from trying something that might reduce my stress. So as I head into a less stressful block of time, I want to establish the habit so it hopefully sticks when I really need it next. A friend of mine recommended a couple of apps to try, including the Headspace app pictured at left, so that seems like a good place to start.

On a side note about stress, I’ve had multiple residents tell me that they much prefer the stresses of residency to those of third year. In residency your day off is actually a day off; you don’t have to study. You’re also not worried about constantly being evaluated by everyone around you, which is one of the major pressures of these clinical rotations (and something I plan to write a separate post about). A classmate said that one resident told her: “My worst day as an intern was still better than my best day as a third-year medical student.” I’m not sure everyone feels the same, but at least some of the stresses of medical school (studying for exams in the evenings and on your day off; having to always be “on” since you’re always being evaluated) will dissipate. And, I’m sure, be replaced with other ones.

Be creative. Using my hands to make things is such a rewarding outlet for me. I simply haven’t had the time or energy for it lately. I’ve missed it.

One of my new favorite songs, Snake River Conspiracy’s cover of The Cure’s “Lovesong.”

Write. I have a long list of essay ideas that I simply haven’t had time or energy to tackle. Several of them relate to things that have happened during my medicine clerkship. I look forward to sharing those experiences with all of you in the coming days and weeks, as I process all that’s happened lately.

Find new music. Over winter break, my youngest sister, Joy, convinced me to join Spotify. I’ve managed (barely) to keep up with the “Discover Weekly” playlist that Spotify sends me every Sunday night, saving the songs I like to a new playlist I aptly call “New discoveries to explore!” I’d like to delve into that list (which currently has 119 songs on it) and to investigate some of those artists and their albums more fully.

Watch TV. I don’t normally do much of this to begin with, but I haven’t even turned on my set in weeks. It would be really nice to relax on my couch in front of a good movie or TV show episode without feeling guilty.

My purchases at City Hops. Several of the beers are local, brewed here in NY state — pretty cool.

Learn about beer. And drink it, of course. For the longest time, I thought beer was simply gross. The closest I got was Mike’s Hard Lemonade. I stuck to wine, or my favorite, gin & tonic. Then I dated someone for a little while who enjoyed beer, so I would try what he bought. Turns out it wasn’t so bad, though still not my choice of adult beverage. Then my sister started bringing craft beers to family gatherings, and not only did I tolerate them, I actually liked them. It was a revelation. I’m particularly partial to IPAs, of all things. But the selection at the grocery store down the street is atrocious, and a six-pack costs about $5 more than it should. There’s a place called City Hops on 2nd Avenue not far from me. I’ve walked by it dozens of times, and often thought about going it. Yesterday I took a study break and did just that, and about $40 later, was the proud owner of seven different craft IPAs. I’m definitely drinking one tonight night to celebrate making it through medicine intact.

Pamper my plants. Many months ago, I bought some lovely houseplants from Home Depot, and some lovely plant stands online. The idea was to infuse a little bit of “green” in my environment as I live amid the concrete jungle. Unfortunately, I dramatically overestimated the amount of natural light that would be cast onto the corners where I put these plant stands. My poor plants became bedraggled over time. Luckily, they quickly perked up when I put them on my kitchen windowsill. But I can’t really enjoy them there. So I want to buy and install some grow lights, so I can put my plants back on their stands, where I can see them better, and enjoy them more.

My plants are fine on my windowsill, but once I get some grow lights I can put them on my plant stands (which are in places that don’t get much natural light, but are where I can see my greenery better).

The home page for FREIDA, the American Medical Association’s online gateway to exploring residency programs … *gulp*

Think more about my future. Before I know it, September will roll around, and I’ll be submitting my residency application. That means I need to figure out where I’m applying. And THAT means I need to do some leg work (well, more like “finger work” as I explore residency programs on the Internet). This is a little terrifying, as you might imagine. It’s also thrilling.

Clearly, I have a lot to catch up on. But it’s good stuff, fun stuff, stuff that’s rewarding in a different way than patient care.

Now, in anticipation of this upcoming reprieve, I wonder where my TV remote has gotten to …

Only in medical school … (#3)

… will you come across the description “steamy cornea” and actually take it seriously.

I read said description this morning as I was doing UWorld practice questions in preparation for my medicine shelf exam. The description was in reference to the eye exam seen in angle closure glaucoma, which is also associated with a red eye and a nonreactive, moderately dilated pupil (see the photo below).

Just in case you were wondering.

What the eye looks like in angle closure glaucoma, a medical emergency that can lead to vision loss if not immediately treated.

 

Running the mental gantlet

This essay was first published in the online magazine The American. You can see the original version here.

 

Learning about a patient is like digging into a demanding novel: plot and characters need fleshing out.

Running the mental gantlet

Some people compare starting a new clinical rotation in medical school – something you do every six or eight weeks for an entire year – to starting a new job. A job you’ve never done, and one you feel wholly unprepared for. I liken the experience to being dropped into the middle of a novel. Dialogue explodes around you. But the speech lacks context and you struggle to make any sense of the words. Characters fall in love, have sex, shoot each other, but you can’t always tell the good guys and bad guys apart. For heaven’s sake, you don’t even know where you are. Russia? Iowa? The moon?

That’s how I felt when I started my inpatient psychiatry rotation on a summer Monday last year. I arrived promptly on the unit at 8:20 a.m. as I’d been instructed. I knew the names of the attending, resident, and medical student I would be working with, but not their appearance or where I was expected to meet them. I sheepishly hung out with a kind, chatty nurse until the 8:30 a.m. team meeting – a meeting I had no idea I was supposed to attend until the friendly nurse told me. A dozen or so of us entered a room and sat or stood around a big table to discuss general issues – safety concerns, upcoming discharges, new admissions, staff absences, special activities.

After this combined meeting, we had another meeting just with my team to discuss more specific updates on our own patients. Since I was new, those present introduced themselves. Overwhelmed by it all, I promptly forgot most of their names and their roles.

I got slight comfort in telling myself I’d pick up the details after everything settled down.

I noticed that the woman running the meeting had two binders. One bore the name of my attending psychiatrist, the other the name of a different attending. Not all the patients were covered by my team, which made me wonder where exactly they wanted my focus.

As the meeting progressed, with notes and updates on specific patients, I noticed that my medical school colleague, who was sitting next to me, occasionally scribbled a few notes. “Should I be taking notes?” I wondered.

I didn’t want to be perceived as not paying attention, but I had no idea who these patients were, which ones (if any) were my responsibility, and which updates mattered.

One of these updates might consist of something like this: “On Saturday, Jane Doe took her medications. She spent most of the day with her family. She expressed her needs appropriately. She slept well.”

That sounds bland, but perhaps this was the first day Ms. Doe had agreed to take her medications. Perhaps sleeping well was a major improvement for her. I just didn’t know.

With patient names and behaviors swirling in my head, I did my best to keep the confusion at bay, reminding myself that this was my first day, my first hour. I couldn’t be expected to keep things straight. Not yet.

Then the team resident, my classmate, and I talked individually with patients in one of the unit’s small, private meeting rooms. The resident immediately launched into questions. Sleep? Appetite? Mood? Hallucinations or delusions? Medication side effects? Thoughts of hurting yourself or others?

Between patients, my classmate tried to give me a brief synopsis of the next patient: diagnosis, treatment plan.

With only that to go on, I struggled to make sense of the encounters. The journalist in me cried out for each patient’s fuller story. Understanding the past would help me understand their present, and their prognosis.

As the patients answered the resident’s questions, in my own mind the replies only provoked more questions. One patient made a vague reference to a brutal childhood trauma. Another hinted at magical powers. How could I not want to know more?

Making matters even more complicated I had little understanding of what my supervisors (the psychiatry resident and attending) expected of me for the next four weeks. The medical student told me what he’d been doing – interviewing two of our five patients one-on-one daily, and writing a progress note on each. But more concrete information was hard to find.

I finally went to the source, asking the resident what her expectations were. She told me to do essentially what my classmate was doing — pick a patient or two, spend some extra time with them, and write my own notes. I had figured as much, but now it was official.

I selected my patients and dug into their medical records, combing through the notes in each person’s electronic chart. I was back to reading the novel, starting at the beginning and working my way forward. I began with each patient’s presentation to the psychiatric emergency department. That gave me a sense of how they were when they first came to the hospital compared to how they were now. I then moved to the initial evaluation note from the psychiatric unit (where I was now working). These two comprehensive notes helped me understand each patient’s present psychiatric illness, as well as past psychiatric history, medical history, family situation, and other life factors. I also read what are called “collateral” notes. These are conversations between a medical practitioner (often a medical student) and someone else in the patient’s life — a spouse, friend, psychiatrist, therapist, or caseworker, for example. They provide an outsider perspective on how the patient’s current condition compares to their norm. Last, I read daily progress notes, finishing with the one written that morning. These brief and focused progress notes told the story of the patient’s day-by-day existence on the inpatient psychiatric unit. How they were eating, sleeping, behaving, and overall living while in the hospital. These daily updates clued me into whether someone’s delusions or insomnia had improved, for example, or whether they were tolerating an increased dose of a medication.

At the end of that first day, I was still in the middle of the novel, on page 200 or so. But I’d gone back and at least skimmed the first 199 pages. And with that background, I was now ready to move on to the next chapter: the next day.

Be my doctor

Like it or not, medical school is full of tests. Some are useful. Others seem pointless. In a recent clinical assessment, I received important feedback that let me know that when it comes to patient care, I’m on the right track. I tell the story in this essay, which was originally published in the online magazine The American. You can see the original version here.

Be my doctor

On every medical school rotation, we have at least one OSCE, the clunky acronym for Objective Structured Clinical Examination. If I had my way, “structured” would be replaced by “stressful,” because that’s what it really is.

You’re asked to interview and examine a standardized patient (aka actor) while being both videotaped and watched live by real doctors, usually the people in charge of your clerkship, and your final grade. The observers work from a checklist (that’s where the “objective” comes from, I think) to measure your performance. Your “patient” has a different checklist.

I confess that being watched, videotaped, and assessed against a detailed to-do list makes me nervous, which makes me more likely to forget things that I otherwise wouldn’t.

Two weeks into my eight-week internal medicine rotation, I endured a particularly stressful OSCE. You had 20 minutes to conduct a focused history and a physical exam. (In an encounter with a patient, “focused” means tailoring your questions and physical exam to respond to the person’s “chief complaint.”) You’re given five minutes to discuss your diagnostic impression and develop a plan. On the spot, you needed to figure out what was wrong and what to do about it. After which you left the exam room, had five more minutes to organize your thoughts, before explaining your findings, assessment, and plan to the observing “attending” in a three-minute presentation, morning rounds-style.

Unlike most OSCEs, you didn’t know what was on the checklist ahead of time. As with most OSCEs, you had to make good on a certain number of items to pass. If you didn’t pass, you had to repeat the exercise.

Anxiety is built into this territory. But once I get going, I’m fine. Early nerves give way to clinical instincts.

This OSCE was no different. About 10 minutes before we each met our patient, we received a clinical scenario along with some lab values and vital signs. After reading up and thinking through what I’d ask and do, I met with and assessed the patient to synthesize her signs, symptoms, and story with what I’d read. I asked my questions, examined her, and quickly thought through my differential diagnosis. I then presented her with the most likely diagnosis, along with my proposed treatment. As a medical student, I informed her I would discuss everything with my team before proceeding.

I asked if she had any questions. Though she’d been hospitalized with pneumonia, she was most anxious about her breast cancer, which had been diagnosed earlier. She told me she wanted her family involved in understanding what was happening. I was impressed with her acting skills – tears seemed to well up in her eyes as she lay supine on the examining table. I put my hand on her shoulder and reassured her we would bring her family in, and together discuss everyone’s questions.

I was about to continue comforting her when a loudspeaker announcement abruptly informed me the encounter was over. I should leave the room immediately. I felt myself flush with frustration. My patient was in distress, on the verge of tears, and I had to abandon her — something I’d never do to a real patient.

I followed protocol: I left, thought through my findings, and returned to present them before my attending and the patient. Then came the feedback. The physician asked how I thought I’d done. I said I thought my physical exam skills were rusty since I hadn’t been practicing them much since an earlier rotation several months before. The “patient,” who apparently has been performing this same OSCE for years, emphatically disagreed. She said I’d just performed one of the most thorough physical exams she’d experienced in this OSCE go-round. More significantly, at least to me, the patient told me she wanted me as her doctor. “What kind of medicine are you going into?” she asked me. “Are you going to be practicing in New York?”

Yes, the patient was an actor, but I got the feeling she was only half joking. She said she felt genuine empathy and compassion from me, things she doesn’t sense from everyone. When she was distressed, I stood closer to her (but not too close) and actually touched her. I offered to bring in her family to answer their questions. She described me as confident but not arrogant. For example, while I was sure of myself in explaining my diagnostic impression and treatment plan, I also emphasized my role as a medical student, and how I’d first confirm everything with my team. She said I had a sense of humor – I’d made an impromptu joke about hospitals based on something she said, and I’d gotten her to laugh. She told me I was a good listener, explained things well, and made her feel comfortable.

Her compliments disarmed me. All I could say was “thank you.” Both patient and preceptor also offered constructive criticism, which is essential so I can improve.

But when it comes to improvement, compliments can be just as important as criticism. My patient’s invigorating observations reminded me that I was on the right track and needed to stay on it.

The experience was a boost on a number of levels. Maybe it’ll help calm my nerves before the next OSCE. Maybe it’ll help bolster my confidence when I finally treat real-life patients on my own. Though I haven’t even graduated from medical school yet, I now know there’s at least one person who wants me as her doctor.

The order: An important first

As many of you know, I write a monthly column for the online magazine The American. Here is my latest piece, describing an important first of my medical career. You can read the original article here.

 

“The order”

I placed my first medication order yesterday. Nothing exotic. It was a one-time dose of the drug Labetalol for a patient, my patient, whose blood pressures had been elevated. As I typed in my password to sign the order, I took a deep breath.

“By signing this,” I thought to myself, “I’m telling people that I think my patient needs this exact medication at this exact dose at this exact time.”

Suddenly, caring for this patient was no longer abstract or hypothetical. It was as real as the prescription I was about to issue. I wasn’t just writing out my daily plan for her care in my morning progress note. I was putting it into action.

As a medical student, any orders I place require a physician cosigner, either my resident or attending. The safety net exists for obvious reasons. Still, learning how to issue orders for my patients — whether it’s for laboratory tests or medications or fluids — and then doing so is part of assuming greater clinical responsibility. It’s also part of progressing from student to doctor.

But from a logistical perspective, just entering these orders is far from easy. Take the blood pressure medication. It is normally dosed twice a day, morning and night. It was about 1 p.m. at the time. If we ordered it twice a day to begin immediately, the patient would get it at 1 p.m. and 1 a.m. — not ideal if you’re the patient. You’d have to be awakened in the middle of the night to take a pill.

So I placed a one-time order for the medication to be given by the nurse immediately. I then placed another order for the same medication, same dose, this time twice a day, but starting that night. Going forward, the patient would be getting her pill at 9 a.m. and 9 p.m.

Making small things happen in the electronic medical record system is another thing entirely. It requires selecting or unselecting many checkboxes and highlighting the appropriate fields in various drop-down menus. I’m sure once you do it repeatedly it becomes second nature. But as a medication order novice, I needed someone to show me around the system. Thankfully, my kind resident took the time to walk me through the process step by step. Attention is paramount. If you don’t click (or unclick) one of the required boxes, you get an error message that reroutes you back to the order screen to fix your mistake. And if you don’t click (or unclick) some other box that’s important for your particular instructions but not technically required for the order to go through, your order may inadvertently tell the nurse to do something else altogether.

The “how” of these orders is the easy part. It’s the “what” and the “why” that require the real thinking. Why is the patient’s blood pressure elevated? Does she need a medication? If so, which one? At what dose and frequency? How long will you assess her blood pressure levels to determine if this medication is effective before either increasing its dose or adding another drug? And this is only her blood pressure. We haven’t gotten started on her antibiotic regimen.

It’s an iterative process that goes on throughout any given day. Sometimes you’re doing the investigating. Sometimes it comes in response to changes in vital signs or laboratory results (or urine output or an MRI). This means you’re monitoring all these details — vital signs, lab tests, urine output, and imaging, among others — over the course of a day to see if you need to change your handling of the patient.

To a third-year medical student just introduced to the world of inpatient internal medicine, it’s dizzying. But it’s also deeply exciting for obvious reasons. The more clinical responsibility I assume, the more I learn, and the more tangible the “live” practice of medicine becomes. And the more I am prepared for the time when I’ll be the one signing the orders on my own.

Weird surgery perks

Beneath my white coat, you can see the maroon OR scrubs that I wore every day while on my trauma surgery rotation. Wearing these scrubs every day provided an unforeseen benefit: less laundry to do.

My enjoyment of this surgery rotation thus far has been a pleasant surprise. Besides learning about, well, surgery, I have encountered important life lessons. But I have also accrued some unforeseen benefits. I think that understanding these perks will provide additional insight into what life is like on the surgery rotation.

Chore relief. On trauma surgery, you wear scrubs all day every day, with the exception of Monday morning’s Morbidity & Mortality conference. That meant I had less laundry to do. Given that I have to lug my dirty clothes up and down several flights of stairs and down the block (I’m in a walk-up apartment, and the laundry room is in the basement of a different building), that’s no small thing.

Budget boost. When I was working with the trauma surgery team, I would leave my apartment at 5 a.m. and get home somewhere between 6 and 8 p.m. That’s a long day, by any standards. I noticed that over four weeks of that schedule, I bought significantly less toilet paper. Actually, my grocery bill was lower overall. I was so busy that I simply ate less. In part because the workday on surgery was so hectic, and in part because when I got home at night I was too exhausted to do more than shove some food in my mouth and collapse into bed.

Free medical supplies. Yesterday, while I was cooking a batch of chili, I managed to slice open my thumb on a can of diced tomatoes. I ran to the bathroom, thrust my thumb under a stream of running water, and scrubbed the cut with soap. Before reaching for the box of Band-Aids in my medicine cabinet, I turned to grab a Kleenex to dry my finger. Then I remembered that I had something much better — sterile gauze! A packet from the hospital had made its way home in my white coat pocket. Hm. Maybe I should grab some more?

I wouldn’t consider these reasons to do a surgery rotation, exactly. But since surgery is a medical school requirement, I certainly won’t turn down the random fringe benefits.

s/p surgery rotation, week #1

My 6-oz. water bottle, which fits in my white coat pocket, helps keep me hydrated throughout the day. Its small volume keeps me hydrated enough that I don’t get lightheaded, but not so hydrated that I have to go to the bathroom all the time. In surgery, hydration is a delicate balance.

Medical student with a past life history significant for journalism, art, and piano, s/p* starting her surgery rotation 1 week ago, presents with aching feet and legs. The symptoms are most consistent with walking all over the hospital and standing for hours in the OR with inadequate footwear. The student does note that these symptoms have not affected her enthusiasm for the surgery rotation, and that assisting in several surgeries last week has only enhanced her desire to improve her surgical skills. Recommend the student continue to read more about the field of surgery, practice suturing and knot-tying at home, and buy shoes that are more comfortable to stand in for extended periods.

Part of writing up a patient note is including your “Assessment and Plan.” It’s just what it sounds like — a very brief synopsis of the person’s presenting symptoms, what you think the cause is (and why), and what you plan to do about it. The paragraph above is my own Assessment and Plan after 1 week of my surgery clerkship. In other words, the main issue is that my tennis shoes simply aren’t cutting it. Aside from that (and being tired from waking up at 4 a.m. — which is just a given), I’m really enjoying the rotation so far.

Of course, I did learn some lessons from my ob/gyn clerkship that have helped. Those of you who follow my story may remember my near-fainting incident during a C-section earlier this spring (see “Getting back up” from The American, the online magazine I write for every month). After that experience, which I attributed to hunger and dehydration, I now keep quick snacks, as well as an adorable 6-oz. water bottle, in my white coat pockets. They come in handy.

I’ve found several flavors of KIND bars (high protein, lower sugar) that keep me fed when there isn’t time for a real meal. String cheese is great too.

On Friday, for example, we had a lot of cases booked, and in two different rooms — eliminating the room cleaning break in between surgeries that gives you time to get something to eat or drink, and use the bathroom. It was around 4 p.m., and I hadn’t had time for lunch. I was staying late that evening too, and didn’t anticipate time to eat dinner either. At the completion of one case, as everyone readied to go to the next, I approached one of the residents.

“Do I have for a 2-minute snack?” I asked.

She looked intently at me as she quickly thought about my question, knowing we were on a tight schedule.

“Two minutes,” she replied.

Thank heavens for that packet of string cheese in my white coat, which was hanging in the hallway just outside the suite of operating rooms. I ate it in three quick bites, and was indeed back in about two minutes.

The clerkship orientation I mentioned in my last blog post has also come in handy. During a laparoscopic cholecystectomy (gall bladder removal), I got to “drive” the camera for part of the procedure. I also did my best to suture closed one of the port sites used to insert the instruments. Getting that needle just where you want it is harder than it looks though, so the resident had to rescue my effort. But I’m resolved to improve.

Those were things I’d practiced (a little), and expected to try. I didn’t expect to get to help with an ulcer debridement. Debridement is the process of removing dead or damaged tissue from a wound, and in this case it was done to try to help the wound heal. After watching the resident and intern, I was allowed to snip away bits of the yellow, gooey fibrinous exudate that we wanted to eradicate. But even after we cut away as much as we could, there were little bits still stuck down, too small to remove with scissors. So we (that includes me!) used another tool.

Before we started with it, the resident picked up the handheld device, and asked me what I thought it was.

“Well, it looks like a water gun,” I told her.

She told me that’s essentially what it was — a combination water gun and suction device. It sprays a high-powered stream of water into the wound, loosening the remaining gunk, and simultaneously sucks it up.

The resident then pointed to a shield surrounding the nozzle.

“This is to keep us from getting sprayed,” she said. “Don’t spray us.”

Then after a brief demonstration, it was my turn. I considered my time with the fancy water pistol a full success: I helped clean up the dead tissue, and I avoided spraying my resident and intern in the face. Even with our eye protection, that would have been … less than ideal, to say the least.

The ulcer debridement was a procedure I had really wanted to scrub in for. Having talked so much with my mom, a hospice and palliative care nurse, about wound care, I wanted to see it in action.

Along those same lines, it was interesting for me to see bedside wound care too. Several times last week, I went along with an intern to change a dressing. The intern did most of the medical work. My main role was to distract the patient from the pain, inevitable in spite of pre-medication. So I put my palliative care hat on, glad to help ease a patient through this temporary, painful event.

More than once, an intern has apologized to me that there isn’t anything “interesting” going on for us to see. The intern was referring to the fact that some days, there are few, if any surgeries going on while us medical students are there. On the other hand, there are also days when we’re booked back-to-back, plus emergency add-on procedures. You simply never know. My response is always that (of course!) while I’m excited to scrub in for surgeries, I’m also just glad to be part of the team, helping with the little things like gathering supplies for a bedside dressing change or procedure.

It’s all part of the learning process. And that’s why I’m here.

 

*s/p, which stands for “status/post,” essentials means “after.” It’s often used in reference to procedures, such as surgeries. For example, a patient who had their gall bladder taken out 5 days ago would be referenced to as “s/p cholecystectomy 5 days ago.”

The one thing I can do as a medical student: listen

Show me a medical student who only triples my work and I will kiss his feet.

This is one of the “laws” from the satirical novel The House of God, by Samuel Shem. Now that I’m a medical student, I can see the truth in what that fictional medical resident said. It does take extra time to involve the medical student. And the scope of what I can do as a student is very limited. Of course, being included is the only way I’m going to learn — it’s the only way any doctor has ever learned. But when there’s so much to be done, I know there are moments of frustration for the nurses, residents, and attendings.

What I’ve discovered in the last few weeks, though, is that there is one job I can always do: listen. I’m in a unique position to do this. Most of the time the doctors and nurses simply don’t have time to sit there with a patient for very long. They have other patients to attend to, other more pressing tasks.

As I saw during my time rotating through ob/gyn, patients are often scared or upset. Just being present in the moment, hearing a woman’s concerns and holding her hand, makes a huge difference. Two encounters where this happened stand out in my mind.

One woman had presented to labor and delivery after falling. Trauma in pregnancy can induce labor or potentially cause a placental abruption (where the placenta prematurely separates from the uterus, resulting in painful, dangerous bleeding). She didn’t have any worrisome signs or symptoms, but was there for monitoring. I was the one to initially take her history, and noticed right away how anxious she was. Women who come in to triage, which is the emergency department for pregnant women, are all put on electronic fetal monitoring. She kept asking me how her baby was doing. After taking her history, I left to present the case to the resident. We returned together to see the patient. A little while later, my gut told me I should go back to check on the patient. She was still frightened. My reassurances that the baby was doing fine didn’t seem to help. So I went for the distraction technique. I asked whether she had a name picked out, whether she had a nursery ready. Almost immediately, the woman’s demeanor changed. For a few minutes at least, rather than concentrating on the angst of the moment, she focused on how excited she was to welcome this baby into the world in a few short weeks. Clearly wanting to share her excitement, she urged me to feel the baby kicking against her bare belly. It was obvious that a deep love for this unborn child was driving this woman’s fear. My heart went out to her. I know I didn’t take away the anxiety. But for the time I was there, I think she felt understood, cared for, and listened to. I believe that made some sort of difference — if only temporarily.

While on labor and delivery, I was also involved in many births. Some went smoothly, others less so. One woman in particular had a rough labor. This was during one of my night shifts. She’d been in the hospital for hours and hours, accompanied by her very supportive husband. She was exhausted. Her labor was not progressing well. I had been in the room for about two hours, helping her push. When the attending physician came into the room and recommended a C-section, the woman was devastated. The husband and I listened to her frustration. He held her hand, and I put my palm on her shoulder. The next morning, after the surgery, I ran into the husband as I left the unit. I was headed home after my 14-hour overnight shift for much-needed sleep. I walked up to congratulate him on the birth of his child. He dodged my outstretched hand and engulfed me in a hug. He thanked me for being there for his wife. He told me I had a marvelous bedside manner, and that I would make an excellent doctor. Suddenly every moment of my brutal night shift was worth it: I had really helped these people in their time of need. I walked the few blocks home exhausted, but on an emotional high.

Spending time with patients like these, listening to their life stories, jokes, or concerns, may not lessen anyone else’s work load. But I think it does help the patients. And that’s what I’m here for.

A Kind Word Turns Away Wrath …

Words we've all heard: "What do you think you're doing?" "What is wrong with you?" "Don't you know any better?"

Words we’ve all heard:
“What do you think you’re doing?”
“What is wrong with you?”
“Don’t you know any better?”

We’ve all been there: borne the brunt of whatever the woman in the photo to the right is saying. Had fingers pointed at us. Been yelled at. Criticized for something that wasn’t our fault. That’s a given, in life. What differentiates people is not whether that happens, but how one responds.

I’m headed into a world – medical school, and eventually a career in medicine itself – where the people around me will not always be nice, no matter how nice I am to them. Another fact of life.

I was reminded of this fact recently as I talked with a friend who is currently in medical school, and doing her hospital rotations. She recently started in general surgery, and BOOM. Another med student, who wants to go into a surgical specialty, immediately showed himself to be a know-it-all, and a pretty nasty person all around in terms of making my friend feel incompetent and useless (even though this was her first week on the rotation). My friend, thankfully, maintained decorum and professionalism all the way through. (I’m so proud of you!) When this other med student was breathing down her neck about her not being able to figure out a charting issue, she told him that she understood that it was taking her longer than it might take him, but in a few days, she would have the system figured out. When he responded that he was just trying to help, she told him, basically, that she appreciated that fact, but that his standing right behind her and raising his voice was actually more distracting than helpful.

My friend could have easily gone off on this guy, yelled back, and from some people’s viewpoints, she would have been justified in doing so. But in the world of medicine, where there will be people like this, you have to learn to deal with them in an appropriate, healthy way (albeit not letting them walk all over you). Because if you let them get to you, it hurts only you, not them.

My mom, who is a hospice nurse, and I talked about this topic this morning. She reminded me of a biblical proverb:

A kind word turns away wrath, but a harsh word stirs up anger.

While I’m not a religious person, I do believe in this sentiment. If you respond in kind to harsh words, things tend to escalate and get worse. That’s not to say you let yourself be a doormat – you can have a backbone but still be respectful and professional.

That’s how I want to handle such situations when I’m in medical school, and when I am a physician. And now is a great time to start doing just that.