Intubation

Today, I intubated my first (human) patient. I used a MacIntosh laryngoscope to displace the epiglottis so that I could insert a breathing tube down a patient's windpipe (trachea) so that she could be comfortably anesthetized during a surgery to remove her thyroid. The anesthesiologist had let me insert the plastic tube twice on other patients while he held the blade. He then let me do #3 from start to finish. #4, however, was not so successful. The patient's short chin and other factors made for a difficult process. At least I got one!


And let me say, my experience ventilating mice was not of much use as preparation. (I've probably intubated 750 rodents.) In the case of the mouse procedure, a cotton swab is the laryngoscope and a 10-100 piece of beveled tubing is the endotracheal tube. Evaluation of proper intubation (visualizing vocal cords, seeing fog on the inside of the tube and symmetric chest inflation) is however the same...

I can usually put patients at ease when I sew up their cuts if I say I've lots of practice stitching mice. Based on today, neither anesthsiologist nor patient will learn of my previous 'experience' with rodent intubation...

This Morning

I went in to the hospital extra early this morning to get some studying in, but decided to visit the ER to see if anything was going on. The first person who rolled in at 5:30 or so had broken her arm last night. It was clear she would need IV access for a probable surgery. I jumped up and put in an anticubital IV like it was nothing. I know doing these simple tasks will get old after a while, but seeing her immediate relief after giving nausea and pain medicine (through the IV, of course) was quite gratifying.

Shown above is a schematic of a self-retracting IV catheter needle like we use to place peripheral lines.

I'm in the hospital's library studying right now and just heard the helicopter land. You might be an aspiring ER doc if the sound of chopper blades makes you think "Airway Breathing Circulation" and inspires you to flip in your trauma surgery notes to the section on the four main types of shock...

Must... Keep... Focus... On... Studying...

If...

If I didn't have sensitive hands...
If I were 5 years younger...
If I wasn't married...
If I could be content doing one thing at a time...
If I could put up with the hierarchy just a little longer...

I would totally pursue a career in cardiac or vascular surgery. In its favor is:

The 'get in there and fix it' mentality,
The meticulous microsurgery,
The dependence on bioengineered technologies,
The adrenaline of cutting open the aorta (on purpose), and
Working on a team.

I suppose I can find those things and a lot more elsewhere. Well except for the cutting open the aorta part...

Trauma And Sore Throats

For those keeping track, I'm back in Spokane and in my surgery clerkship. On Saturday, I took call. Whenever a patient comes in to one of Spokane's ERs and needs surgery, they call the doc I'm working with to do it. In addition, today that surgeon was also on trauma call. After we rounded on the practice's patients on the floors, I could have gone home to study or wait for calls. (And the calls would come, a this is the first warm weekend of the year.) Instead of being unproductive at home, I hung out in the ER where the trauma cases would go. It happens to be the same ER I worked in previously as an internal medicine student, so I knew the staff and my way around. From noon to midnight, I managed the following problems:

• Torus fracture of the radius in a ten year old
• Sore throat
• Tooth pain
• Hypotensive emergency
• Strep throat vs. mono vs. peritonsilar abscess
• Bleeding in a 6 week pregnancy
  
• Altered mental status
• Wallpaper induced migrane
• Alcohol + ATV = Badness
  

Technically, the only trauma case was the last one. For that, I put in a chest tube to treat a pneumothorax. But that doesn't mean I only did one procedure. I also:

• Wrapped a soft splint
• Took throat cultures
• Placed an IV line
  
• Did pelvic and bimanual exams and ultrasound
• Inserted a nasogastric tube
• Spoke several times with a social worker

Even though only one actual trauma case came through (so far! I'm on call from home until 7AM), today was great. It's because I was in the emergency room. I'm comfortable enough there that I know where stuff is and can contribute as a team member. And that's what I like about medicine.

Four Of Twelve

I just spent a good 15 minutes leaning back in a La-Z-Boy staring at a popcorn ceiling thinking about precisely nothing. My wife is cuddled up on the faux leather sofa mumbling about blanket transplants.

These are the small joys of being a third year medical student.

It's nice to be home. Kindof. We've transformed this very brown apartment that the University of Washington provides for us into a semblance of home. Cut apart calenders adorn the walls, her orchids contrast with the snow outside, and my art projects sit around screaming out for explanation.

Today was our last day of inpatient call in Spokane, WA. Eight more weeks of medicine to go, but more on that later.

Today offered nice closure for me. At 1:00 I was invited to do a knee arthrocentesis. (At 12:45, I watched a video about how to do it.) After one unsuccessful poke (not deep enough), the syringe started to fill with a slightly cloudy yellow fluid. I pulled 20 cc out, disconnected the needle and proceeded to extract another 25 cc to reduce the joint space pressure and provide symptomatic relief. We then sent three vials to the lab for cell counts, Gram stains and chemistry.

A successful procedure.

But wait! There's more!

My senior resident had arranged for a rheumatologist to look at the sample. We were thinking septic arthritis (arthritis caused by infection), but had a suspicion that something else was going on. The patient didn't have a fever, both knees hurt and both wrists hurt; this is all a little strange for an infectious cause.

The thing is, the rheumatologist happened to be across town. Guess who filled the role of messenger. I've written about how medical students don't do a lot that is not duplicated. How could I forget about the vital role of urgently transporting samples? I was surprised about how important I felt walking around with a biohazard transport container. (Thinking in my head the irony of the statement, "Get this to rheumatology, STAT!")

When I found the office where the sample was to be read, it turns out that the doc was really busy and someone had totally botched up his microscope. He was having a dandy of a time getting the sample in focus. Isn't it convenient that I spent four years in a pathology research lab hunched over scopes? When I had finished preparing the wet mount, I called him over to look at something like this:

I've said it before, and while it may come off as a little pretentious, I kindof like the sound of:

What's your diagnosis, doctor?

After leaving the scope much better than I found it, I headed back to the hospital, where we promptly started dexamethasone therapy and discontinued the vancomycin he was on (His ears had started to ring).

My adventures concluded by visiting the patient to update him about what we found and how we changed his medicines. I left his room at 3:45.

This is medicine: suspicion, diagnostic procedure, microscopic laboratory examination, diagnosis, therapy decision. Hopefully the result is a patient free of pain and home for the Super Bowl.

You better believe I'll think twice before telling someone "I'm waiting for a lab result" again.

This patient agreed to my writing about him on the internet. ("After all, it's not like you're sticking me with a big needle," he said.) Also, my wife attests to the accuracy of my portrayal of our evening .

Only A Medical Student

About the only thing a medical student doesn't duplicate on the hospital care team is time spent with patients. With their time, students contribute to care in a manner others cannot.

A thorough exam to assure nothing is overlooked. Tucking in the developmentally delayed adult with her stuffed animal. Listening to a hero's WWII stories.

This is the medicine no drug company will ever invent. It is the treatment Medicare will never reimburse.

Is this year the only period of my life when I dispense the prescription of time?

Metastatic Prostate Cancer

This one is heavy.

"You and I talked yesterday about the blood prostate test that came back with a very high value. That combined with your low blood counts is why we did the bone scan this morning. It looks like some prostate cancer has spread to your pelvis and tailbone."

It's taken a while for me to work this first experience delivering a cancer diagnosis into a cogent journal entry. When it comes to this blog, I have the most success transcribing ideas and feelings immediately. This one required more drafts; a whole folder of entries spanning several days sits tucked away on my hard drive. What I keep coming back to is that through my entire experience with this patient, I never felt uneasy.

Sitting on his bed, without my white coat, without my clipboard, and without a rehearsed statement, I was simply present with him. I still can't find the words to describe my feelings in that moment. Why can I not pin down my emotions? Was it confidence about a puzzle solved? Relief that the patient was finally given an answer? Surprise at how much the patient already knew (even without symptoms or knowledge of lab results)? Was I feeling an adrenaline rush due to an awareness that I was participating in an important point in this man's life?

In the end, the question I need guidance about is: Is it wrong to be comfortable delivering bad news?

This patient gave me permission to write about these experiences but asked me not to use his name.

Evidence Based Obstetrics

One of the great things about blogs is how a post about one topic can quickly morph into a good discussion about another. I bet early meetings of Ben Franklin's Junto (or later the American Philosophical Society) were similar to what happens when a good discussion gets hijacked by a barely related intriguing idea.

Anyway, Drugmonkey posted an informative update about the current presidential candidates' positions on science. If there is one topic that has been wrongly overlooked by candidates this election season, it is a proper airing of their perceptions about science and health research funding, the role that science should play in public policy decisions and how science education can be improved. Head over to this DM post for a digest of Science magazine's handling of the candidates' positions on science. Within the comments thread, is a sub-discussion about the lack of scientific evidence for the choices obstetricians make during delivery. The specific question that I argue has no scientific answer to is: Do fetal cardiac decelerations necessitate Caesarian section? I admit: the left turn was kind-of my fault,but my appeal to you, dear reader, is to find your way to this thread and chime in about the role of evidence in Western obstetrical care. (Read about the candidates' views, too!)

I have a love-hate relationship with the current emphasis on 'evidence based medicine.' It is certainly indicated, even needed in many cases. Enough of the studies are poorly designed or in conflict of interest, that it is hard to change a policy because some perspective made it through peer review. I suppose I would advocate a slow transition to evidence-based practice. Meta-analysis means more to me as a mode for medical decision making.

But bringing this full circle, what does it say about the role of science in society that one of the areas of life that is perceived of as being influenced the most by science (medicine), is actually not very scientific? If science cannot be practically applied to medicine, or more specifically birth, can it really be applied to policy decisions? It's not like there's any shortage of research material.

Continuity

Today is the midpoint of my family medicine clerkship. For the past three weeks, I have seen kids with coughs, guys who want Cialis, dislocated joints, pregnant mommies, runny noses, depressed senior citizens, strep throats, Caesarian sections, annual physicals, lots of funny skin spots, uncontrolled diabetes... the list could go on.

You know what I have liked the most out of my experiences so far?

Continuity. It is rewarding to see a women who formerly had oxygen saturations of 85% on O2 nasal cannula walk into clinic (from her home) and have no problem finishing a sentence. It is nice to be able to pick up a skin color change from mild jaundice to something to be concerned about. It is heart-wrenching to see an 80 year old man deteriorate from a compassionate caretaker for his demented wife and palsied son to a fetal position writhing in pain from a pelvic bone infection. (I hope and pray he recovers.)

These are all aspects of medical care I would miss out on by pursuing the top two specialties I've been considering recently: emergency medicine and hospitalist.

We shall see about this!

Playing With Kids

I will miss working in an environment that permits (dare I say, encourages) interactions such as:

Me: "Would you prefer me to listen to your heart with or without my batman mask?"
Kid: "With it, please." (Said in all seriousness)

or,

Me: "What color is your pee?"
Kid: "Green."
Me: "When is it green?"
Kid: "At school."
Me: "When you go to the bathroom at school, is the water in the toilet blue before you use it?"
Kid: "Yes."

It's hard to believe that my 6 week rotation is over. I take my pediatrics final tomorrow. Then I am off to Anacortes, WA to study family medicine. Hopefully the families there have kids.

Medical Translators

This week, I had a very good experience using an interpretor on the wards. My meager Spanish skills are hardly even sufficient to ask mom how the patient feels and if there is anything I can do to help. By using one of my hospital's legion of interpretors, I was able to get all of the pertinent information about her child.

Latino parents identified language problems as the single greatest barrier to health care access for their children. A cross-sectional survey of 467 native Spanish-speaking and 63 English-speaking Latino patients at a public hospital emergency department found that an interpreter was used for only 26% of Spanish-speaking patients; professional interpreters were used for only 12% of patients.

It is bad that the hospital in the study had in-house interpretors on call, but worse is that a shortage of interpreters is a common problem in Emergency Departments in the United States. Failure to appreciate the importance of culture and language in medical emergencies can result in multiple adverse consequences, including difficulties in obtaining informed consent, miscommunication, dissatisfaction with care, lower quality of care and clinician bias.

I don't like the thought of any of these interfering with medical care. That's why I like medical interpretors.

Baker DW, Parker RM, Williams MV, Coates WC, Pitkin K. Use and effectiveness of interpreters in an emergency department. JAMA. 1996;275(10):783-788.

People That Give Me Papers

I like people that give me scientific and medical papers to help me learn about diseases.

So I think it's the PhD training, but for some reason I've developed this affinity for the dense prose of academic journals. I might actually learn well from reading (and dissecting) them. Anyone in my entering medical school class could attest to the strong correlation in me between lectures and drool, so I know the classroom's not the best way for me to learn. I've always been a tinkerer, so being on the wards and actually doing stuff works for me. But how to learn about the umpteen diseases I actually will not see this year? Maybe journal articles...

On the other side, I bet the people giving me these papers already think they are good - it's a built-in screen for quality. I bet there are a bunch out there that I might not learn so well from. I do not remember primary literature playing any role in the first two years of medical school. I wonder if my colleagues learn this way.

Patty Cake

I like that I can play patty cake with my patient, and not have anyone think I'm crazy. More specifically, I can help Olivia the bear play patty-cake with my patient.