Sunday, August 30, 2015
Friday was our first game of the flag football season at my school. Whereas the first and second year students each field a handful of teams, with all our our classmates dispersed to hospitals throughout the tri-state area, my whole class of 200+ students only is fielding one team. This week we only managed 6 players, but by the "luck" of the draw, were playing the scrappiest of first-year teams and won handedly.
Remembering back, playing flag football with some second- and third-year students in front of the ER during my first weeks on campus was really the first time I felt like I had really made it to med school. Now I'm the third year, strolling lazily out of the hospital with my stethoscope and crumpled patient list. It's a nice reminder that I'm over half-way done.
FridayIL: Finding the cause of a first-time seizure is actually worst prognostically than not finding one. Statistically, if we find the cause, you are more likely to have more seizures in the future, but if we work you up and can't find an answer, then odds are, you won't have another.
SundayIL: Rhinitis medicamentosa is nasal congestion brought on by extended use of topical decongestants. Essentially, your body adapts to the decongestant and causes the baseline state to be a mildly congested one. Yet another medical condition caused by treating a medical condition. Only use medications as instructed!
Thursday, August 27, 2015
Amidst the series of disasters yesterday, there was a pretty interesting lecture on radiologic findings in pediatrics. The dark room very nearly put me asleep, but the topic was interesting enough to keep me semi-conscious. An hour and one game of "find the fecalith" later, we stumbled out of the conference room. Then a surprisingly big moment occurred: I went and got coffee with my classmates.
I have never been a coffee drinker, and by that I don't mean that I like tea more than coffee but rather that, excluding one cup accidentally served to me with dessert at a family dinner, I have never had a cup of coffee. My joke has always been that I'm saving it for med school; I guess the time has come. I was exhausted, it was morning, soda/tea just wouldn't cut it: I needed some coffee.
And then, of course, I immediately did two things: I burned my tongue and I spilled on my patient list.
WednesdayIL: A normally inflated lung goes down to the 9th or 10th rib... unless the patient has abdominal distension. Then it becomes a physics problem. If the abdomen is pushing up against the diaphragm just as hard as the overinflated lung is pushing from above, then the lungs will appear to be normally inflated, even though they are at a much higher than normal pressure.
Cardiomyopathy (heart muscle disease) in patients using TPN (total parenteral (injectable) nutrition) is likely caused by a deficiency in the element selenium.
Look carefully at an x-ray of a swallowed "coin" in a child. A dime is fine to go through the digestive tract; a watch battery is not.
TIL: Scoliosis causes respiratory difficulties not because the bend of the spine constricts the lungs, but because the curve offsets the left and right sides of the chest, restricting the normal "bucket-handle" motion of expansion of the chest cavity.
|Normal bucket-handle expansion|
Tuesday, August 25, 2015
At the moment, I'm on the subspecialty team as opposed to the general pediatrics team. This means that we get interesting patients, but our day is a little more chaotic because instead of having one general pediatric attending physician to travel around with during rounds, we have half a dozen depending on which specialties are responsible for our patients. The big ones seem to be pulmonology, neurology, GI and adolescent med. So each day we need to coordinate with all of these specialists to see when they will be ready to lead our herd of doctor-y people around the hospital.
Day one was pretty nerve wracking but, by day two, I feel like I've got a handle on what is expected of me. Pretty fun, if a bit tiring.
MondayIL: Chronic right middle lobe atelectasis (aka right middle lobe syndrome) is the damage or partial collapse of only the middle lobe of the right lung. This lobe is particularly prone to collapse because of its relatively narrow branch point and because it is surrounded by lymph nodes. Mucous, inflammation, cancer, or lymphadenopathy can all restrict that narrow opening. Or, even without touching the opening, the encompassing lymph nodes can all become inflamed and collapse the lung on their own.
TIL: Always have a replacement tracheotomy tube (a tube that passes through a hole in the throat allowing air into the lungs, usually to bypass some blockage of the airway in the mouth or upper throat) at the bedside in case of emergencies.
Also, a common problem with asthmatic young children is getting them to sit still long enough to get a nebulizer treatment. Sometimes they get upset and start crying and parents/nurses/doctors will say, "At least we know that they're getting the medication every time the breathe in while crying!" This is not true. The breathing you do while violently crying is very different from the kind you do while calm. The turbulent airflow causes most of the aerosolized medication to get stuck on the patient's tongue or throat rather than getting into the lungs where they actually work.
Sunday, August 23, 2015
I had one other classmate who was on-call yesterday, only this was his first day in the ER and this was my last. We had a good laugh as he made the same mistakes I did last Tuesday by treating the ER like an inpatient ward. When a patient is admitted for an inpatient stay, we need to know everything about them. We need to ask about this illness, all other illnesses, their family's illnesses, their living conditions, school, social life, habits, etc, etc. But in the ER, all we really need to know is how long the fever/rash/vomiting has been going on and what body part needs to be x-rayed.
Our most anxiety inducing task in the ER is presenting the patient's case to the attending physician (the head honcho who oversees all care in the department). In the ER, the attending really only has the time and need for a very bare bones assessment and plan. So when my colleague jumped into the most thorough presentation I have ever heard, we all listened wide-eyed and I was reminded of this:
YesterdayIL: If a patient asks you if you've done a simple procedure before, the answer is yes. It might more accurately be, "Yes I've done something not entirely dissimilar to that procedure once, two years ago and it only went so-so," but for the sake of your education and the patient's mental well-being, just say "yes."
It seems dishonest, but especially if you're inexperienced, you will be guided through every step by an extremely qualified overseeing physician. The whole point of teaching medical students for years before putting them in clinical situations is so that we know exactly what the instructing physician means as s/he guides us through each step. We know all the whats (body parts, medications, tools) and most of the whys, we just haven't had an opportunity to master the hows. With proper instruction we are essentially a new pair of hands acting out an old physicians wishes.
Of course, if a patient asks point blank how many times we have done this exact procedure, none of us are going to lie. Hopefully if the routine nature of the procedure is adequately explained, the patient (or parent) would be willing to let us continue even knowing our inexperience. But when possible, it can be useful to use confidence to garner some mutually beneficial trust, even at the expense of full-disclosure.
Saturday, August 22, 2015
Thursday, August 20, 2015
Today (I didn't get off until 10, so I'm writing this "tomorrow", but whatever - my blog, my rules) was much better. Chaotic, but fun.
The most work-intensive thing I did was to help hold down a crying baby as he was stuck with a needle six times in an eventually successful attempt to put in an IV. It's actually pretty funny how easily pacified he was by, well... a pacifier. Screaming bloody murder until some sugar-water on a pacifier is put in his mouth, then it didn't matter that we were fishing around his pudgy arm with a needle for another half-hour. I never thought I could be so happy to see blood coming out of a baby. #contextiseverything
The most fun I had today was talking to the little cousin of a patient, who kept sneaking out of their room to creep on the other sick kids while wearing this huge jacket his uncle gave him. He could barely walk with the jacket coming down past his knees, but he still somehow managed to peek on tip-toes at the sick girl next-door.
TIL: ...how to do oral and nasal swabs for sputum culture lab tests. Uh... Stick the stick in the patient's mouth or nose. Tada! Not as easy when they're crying and biting down, but simple enough in theory.
Wednesday, August 19, 2015
There were some tough cases today - cases that I'm not ready to share with the internet yet. Some of you may know that I used to work in an ICU back in California. Part of my job involved rotating through as a clerk in the pediatric ICU, and that's where you see some of the most heartwarming and heartbreaking stories in medicine. At the time, I feel like I had built up a sort of immunity to the emotional toll; I still felt for our patients (and there were still tears at the end of the day), but the impact was blunted. I wasn't quite ready to deal with that right out of the gate today, on day two of my Peds clerkship.
All of that aside, it is fun to be back in a medical hospital. I really enjoyed psych, but physical medicine (pediatric or not) really seems more my cup of tea.
TIL: A Wood's lamp, named for physicist Robert Wood, is the medical term for an ultraviolet (aka black) light. A common portable version is essentially two small black lights surrounding a magnifying glass used to look for corneal abrasions (eye scratches) as visualized by a fluorescent dye. The dye is a very subtle yellow under normal light, but under UV it glows very bright. If there is a scratch on the surface of the eye, you'd never be able to see it normally. But the dye is like glitter; it gets everywhere. Once you turn the Wood's lamp on, the scratch will show as a neon-yellow line on the surface of the eye.
Monday, August 17, 2015
Today was the orientation day for my 6-week pediatric rotation. And boy did I need orientation; this is an incredibly complicated clerkship.
I will be spending one week in the pediatric ER, two weeks on the inpatient subspecialty service, one week on the inpatient general pediatrics service, one week in the neonatal unit, and one week at an outpatient pediatric office. My hours vary from 5 hours in the ER to 10 hours on the inpatient units. I will also be doing four call shifts: two on weekdays, extending my day to 16 hours, and two on the weekends, varying from 10 to 12 hours in the ER or inpatient units respectively.
There are 10 categories of assignments that we must complete on top of our patient care duties and "extracurricular" studying (does that even make sense?). If I manage to keep all of this straight I will be amazed.
As we were led around the hospital today, we were wrapped up in our complicated near future. One of my classmates was literally rereading the call schedule list while walking on the tour of the hospital. Others of us hadn't seen each other in months and were enjoying catching up after being at various different sites for the past 6 weeks.
Then a hush fell over our chatter in the hallway. A nurse needed to get by us with a big fancy hospital bed. Adrift in the center of this comparatively vast bed was a very tiny, very sick little boy. It only took a few glances around the group to see that we had all remembered why we were there.
A pediatric intensivist at our school once described his patients as the most deserving of our professional energy. That seems crass at first, but it's a harsh truth. That little boy didn't do anything to deserve being in that bed with tubes and IVs coming out of every orifice and limb. He never smoked or over-ate or made any mistakes unexpected of any other kid. And now, thanks to him, I'm ready to work through any long hours or tedious assignments over the next six weeks if it means helping kids like him feel even a little better.
TIL: It takes between 3 and 6 months to progress from a raking sort of grasp (using all four fingers and the palm) to a scissoring grasp (using the knuckles of the index finger and thumb) and finally to a mature pincer grip (using the tips of index finger and thumb).
Wednesday, August 12, 2015
Tuesday, August 11, 2015
I've said goodbye to hospital staff before, when I worked and volunteered in various capacities at hospitals prior to med school. It's always a little bittersweet, but no different from other jobs. One of the things I'll miss about this bunch is their (dark) humor. The unit was getting pretty busy with more admissions today and few discharges. Someone joked that we should look into discharging patients to nursing homes around the South Bronx because the Legionnaires disease outbreak there is probably opening up beds...
But today I said goodbye to my first patients. When patients leave the hospital, it's great! They're usually doing better and often grateful for the work that we (read: almost entirely other people) have done. Today was different because I was leaving and the patient's were staying. There was no closure. I was sad to say goodbye, but more so, I was sad that I had to leave before my patients had gotten better. In a way, I almost felt like I was abandoning them to their fate; apparently it doesn't matter to my brain that I'm abandoning them to being cared for nearly exactly as they were when I was working, by wonderfully talented professionals. Still, it felt weird.
MondayIL: A diagnosis of rapid-cycling bipolar disorder is made if a patient experiences four or more mood symptoms (major depression, mania, hypomania, or a mixed state) in one year.
TIL: Brugada syndrome is a rare genetic heart anomaly caused by altered sodium channels that, among other things, may kill you at any time and makes you a pain to take care of for inpatient psychiatric care.
Friday, August 7, 2015
For the past five weeks, I've gotten a very in depth look at the sort of psychiatry practiced on a locked, inpatient psychiatric unit. This is the best place to see the most dramatic diagnoses that most medical students will never get a chance to see again in their education or careers. But the vast majority of psychiatrists don't practice in this setting. So if you're trying to educate us on not just the rare diagnoses but on this potential career in general, we need to get off the unit for a while. The past two days I got to see a couple of these other settings.
Yesterday, I got to take a mini field trip across the VA's medical campus to the long term geriatric care building. Ironically, the first patient we saw was actually crazier than any of the patients on my usual inpatient unit! Conveniently, this was the perfect case to demonstrate the difficulties of dealing with psychiatric symptoms in elderly patients. There are three things that can cause these symptoms: dementia from old age, delirium from an acute medical problem, and psychosis from a chronic psychiatric condition. The trick is figuring out which of the three are in play at any given moment.
ThursdayIL: Dementia is chronic, progressive, gets worse before bed each day, and is characterized by confabulation (making up answers to questions you don't know the answer to). Delirium is acute, waxing and waning irrespective of the time of day, and frequently presents with hallucinations and altered mental status. Psychosis is a really general term and can refer to many types of symptoms. The big ones are hallucinations, delusions and cognitive changes. As you can see, there is a decent amount of overlap that makes this differentiation difficult.
Today, I traveled another half hour north to another VA hospital that is less psychiatrically focused. Here, the chief psychiatrist primarily does consults on medical patients who have developed psychiatric symptoms during their treatment for other conditions. The other common reason for a consult is to determine the decision making capacity of a patient, either to accept/refuse treatment or to make decisions at home (like how to spent money or whether to drive a car).
FridayIL: The four attributes that you must document to determine a patient's capacity to make a medical decision are understanding (Can they describe the procedure/test/treatment?), appreciation (Can they explain what the expected outcomes/side effects are?), rationality (Do they have a rational way of making the decision?), and communication (Can they articulate a consistent choice?). Note that the rationality requirement does not require that their logic be popular or even reasonable, just that it's rational. For example, "because my obscure religious cult does not allow it" is totally fine. But if the rationalization involves a clear delusion, e.g. "President Obama told me not to through the chip that aliens implanted in my brain", then that's not ok.
Thursday, August 6, 2015
Wednesday, August 5, 2015
TIL: When transitioning from oral dosing to long-acting injections of paliperidone (Invega®), an atypical antipsychotic, you start with a loading dose of 234mg, then on day 8 you give a 156mg booster, and then on day 36 you start the regular monthly dose which can vary from 78 to 234mg.
In a previous post, I mentioned that lithium gets a bad rap as a dangerous drug during pregnancy. At the time, I mentioned that untreated bipolar is more dangerous than the tiny risk of an obscure birth defect associated with lithium use. This is still true, but additionally, all the other mood stabilizing drugs we use to treat bipolar disorder cause other birth defects and at greater rates. Valproic acid (Depakote®) and carbamazepine cause neural tube defects like spina bifida in 3-5% and 1% of pregnancies, respectively. By comparison, studies have shown lithium's Ebstein anomaly happens only 0.05-0.005% of the time.
Monday, August 3, 2015
Saturday, August 1, 2015
Think about a patient in a coma. Research has shown that talking to the unconscious patient can be beneficial to their recovery time. However, that doesn't mean that it's something you need their doctor doing. On the other end of the spectrum, several psychiatric disorders are exclusively treated with counseling. This is exactly when you want the doctor taking time to talk to the patient.
The trick comes when you see a patient that is in the weird gray area of acute schizophrenia, for example. The main symptoms* of this are hallucinations (sensing things that aren't there), delusions (thinking things that aren't true), and disorganization (thinking in an unusual way). In the midst of an acute decompensation, we talk with the patient, but nothing they say makes sense. We still meet with them regularly, but the conversation is rarely productive. As their treatment progresses (typically once the medications start to kick in), their thoughts begin to make more sense and our interactions are more useful, both to the patient and the treatment team.
But, let's come back to my initial example. You're walking down the hall, on the way to your office but with nothing pressing on your schedule, and a patient flags you down. You stop to see what he wants, but without any perceptible end-point, the patient launches into an extremely detailed story of a friend of his from 30 years ago. Moreover, the patient has a hard time both physically speaking and finding the right words, so his speech is significantly slurred and slowed. After 10 minutes of patiently listening in the middle of the hallway, the patient seamlessly transitions his story into one about aliens from outer space.
This can be useful information to know during an admissions interview when you don't know the patient or how their mind works. But when they've been on the unit for two months and the stories haven't changed in all that time, is it useful to listen? As a medical student, I have the freedom to spend a half hour talking to a patient, so I usually do. I get to see a glimpse of what and how they're thinking, even if what I see is sometimes just a disorganized mess. But on the third, fourth, or fifth time, I'm not sure it's helping anyone anymore. Maybe I should just stop every two or three times they flag me down or once a week. I don't know. A lifetime of interacting with mostly non-psychotic people has trained me to stop and listen when someone wants to talk. I'm not sure that I want to consciously make exceptions to that rule.
*These are called positive symptoms, because they are additions to or exaggerations of normal processes. There are also negative symptoms (a loss or dampening of normal processes) but they aren't as relevant to this discussion.