Tuesday, November 24, 2015

WILTIMS #385-9: Family Med catch-up Part 2

Last week saw me become comfortable with my new settings - too comfortable, it turned out. The first three days I was with my usual preceptor and I finally felt like I understood her routine and what she expects of me. But Thursday and Friday, that same doctor was out of office for a continuing medical education conference in the city. Conveniently (or so it might seem) the course director for all of Family Medicine at my school works on Thursdays at this same clinic. It wasn't until the night before that I realized how much of the recommended curriculum my preceptor was ignoring. I survived the day, but definitely didn't establish myself as the Hermione of my med school*.

On Friday, I rotated to another doctor at the clinic and had a great time. He is the doc that takes the most complicated (and interesting) cases. Besides the TIL below, I also got to draw the blood for one of our patient's lab work. This was my first successful blood draw! Strangely enough, drawing blood off an extremely hypertensive man is a bit easier than the obese, edematous, dehydrated pregnant women I was tasked to draw from during OBGYN. (Psych and Peds frowned upon us practicing on the patients...)

MondayIL: Double crush syndrome is an unexplained correlation that has been found between wrist and neck pain in patients with carpal tunnel. The hypothesized mechanism for the joint joint pain (see what I did there?) is that the nerve axons that travel all the way from the neck to the hand are damaged one one end and become more prone to damage on the other end.

TuesdayIL: An APRN may or may not be the same thing as an NP. My preceptor shares an office with a spectacular nurse practitioner (NP). In New York state, NPs are able to practice totally independently from MDs and DOs as long as they have doctors that they can refer patients to if a patient's problem goes beyond their expertise. I specify that this is the case in NY because laws and regulations regarding NPs, PAs, and Doctors of Nursing vary all over the country. Generally though, an advanced practice registered nurse (APRN) is a blanket term for any of four kinds of doctorate level healthcare workers who approach medicine from the perspective of nursing. They are: certified registered nurse anesthetists (CRNAs), certified nurse midwives (CNMs), clinical nurse specialists (CNSs), and nurse practitioners (NPs).

WednesdayIL: I know a lot of Spanish (but no Bengali). The one choice from my past that I have most consistently kicked myself for is not taking Spanish in high school (actually I really did love French and my awesome French teacher, but still... [kick]). The patients at this clinic are predominantly Spanish-speakers, so I do a lot of detective work as the doctor talks to them to figure out what's being said, but I all but never speak the language myself. Initially, I thought I knew only a tiny amount of Spanish and that I was getting a lot of information from gestures and context. But then my preceptor slipped into Bengali with a patient from her native Bangladesh. Suddenly I was totally in the dark. At first this seemed depressing but then I realized that this meant I'm not as inept at Spanish as I initially though.

ThursdayIL: Prurigo nodularis is a mysterious illness that causes itchy nodules to appear all over the body. We don't know what causes it, how to treat it, who gets it or how often.

FridayIL: HIV patients can present very diversely. On Friday I helped take care of some very different HIV+ patients. Patients who reliably take their medication and who are socioeconomically stable can do fantastically well. Even looking at their blood work, let alone their outward appearance, you'd never know that they have such a scary illness. Other patients look like they are on death's door, in part because they aren't compliant with their lifesaving medication, and in part because they have several other problems that are speeding them towards the grave (like active cocaine use!). With this second group of patients, you can see all sorts of weird, rare infections straight out of our seemingly esoteric exam questions.

*10 points from Gryffindor! :(

Monday, November 23, 2015

WILTIMS #380-4: Family Med catch-up Part 1

I'm ok! Apologies for the unplanned hiatus; I apparently needed a break. Family medicine has been a lot of fun and the hours are superficially better, so one would reasonably assume that blogging through this clerkship would be no sweat after Peds or OBGYN. But though it's true that I'm no longer working 10-11 hour days and getting up at 4am, every minute of my 8 hour shift I am either in a patient room or running to the next one. 15-30 minute appointments are exhausting when you have 27 of them a day!

The clinic I'm working at for this rotation is frequented by the uninsured and underinsured. Most of the patients are immigrants, very few speak English, and almost all have chronic health problems exacerbated by their socioeconomic status and their previously sparse access to health care. I have already learned and revisited an amazingly diverse amount of medicine, and learned even more about the community I'm helping serve.

I will try to catch-up over the coming days and we'll see if I can stay up to date from here on out!

TuesdayIL: Chondromalacia patella is the erosion of the cartilage behind the kneecap. The only treatment is to limit activity (by cutting down on knee-strenuous activities, or losing excess weight).

WednesdayIL: When a patient is having an acute gout attack and reporting that indomethacin (an NSAID) and colchicine aren't helping, make sure to check the dose of the colchicine before adding a corticosteroid like prednisone. Many gout patients are on a maintenance dose of 0.6 mg colchicine daily, but an acute attack can be treated with up to 1.8 mg. So, make sure that they have tried that full dose before risking the complications of a whole new medication.

ThursdayIL: There are several ways of calculating whether a patient has left ventricular hypertrophy (LVH) based on a 12-lead EKG. Anyone who has studies EKGs knows a massively hypertrophied heart when they see one, but when it's a borderline case, how do you decide if it breaks the threshold? Here are some of the competing criteria:
  • If the sum of the amplitude of the S wave in lead V1 and the amplitude of the R wave in V5 or V6 is ≥35 mm
  • If the sum of the amplitude of the S wave in lead V3 and the amplitude of the R wave in aVL is >28 mm for men or >20 mm for women
  • Other criteria break it down lead by lead (but you have to account for axis deviation).
FridayIL: Many people think that there exists some combination of vitamins that will give them strength and health at any age. Over the past week, we had several people - young, old, fit, obese, healthy, disabled - come in for a physical or because of some fairly benign health maintenance follow-up and ask for a "super-vitamin." Many of these same patients are against vaccines and traditional medications, and are very bad at watching their diet and exercising like we recommend. I'm sorry, but we have yet to discover a magic pill to make the 75 year old landscaper feel as strong as he did in his twenties, or allow the morbidly obese 40 year old to more easily walk down the street, or help the 92 year old not feel like an otherwise healthy 92 year old.

Monday, November 9, 2015

WILTIMS #379: Family Medicine orientation and video torture

Today was the first day of my fourth and final clerkship of the fall semester: family medicine. People are often confused by what this "specialty" is; essentially, it is what a general practitioner does. There is a lot of overlap with internal medicine, but more emphasis on preventative care and chronic illnesses.

For some reason our orientation day for this clerkship was particularly intensive. We were on campus for about 12 hours between a full day of lectures and a medical errors clinical skills session. One of the lectures was on the diagnosis and treatment of hypertension. A few minutes into the lecture I googled the national standards and realized that the whole subject could be summarized by the following flow chart.

Image from JAMA
Pretty simple, really.

During the evening session we had a standardized patient encounter where we apologized for a medical error that we committed, as told to us in a one page prompt. We then gathered in small groups and had to watch the video replays of each other's encounters. It was a very special sort of torture.

Quote of the day: (Paraphrased from a talk by the Chairman of Internal Medicine) "The problem with cross-sectional research is that it only takes a snapshot of a population at one time point. If you do this in Miami, you might conclude that people are born hispanic and die Jewish."

TIL: "Blessed errors" are not holy mistakes, but actually incorrect answers on a common dementia test that is for some reason named Blessed. After a good 15 minutes of poking around the internet, I can't actually figure out whether the name came from a Dr. Blessed, a Blessed Hospital, or something else. If anyone reading this knows, leave the answer in the comments!

Friday, November 6, 2015

WILTIMS #378: OB/GYN Wrap-up

Wednesday was my last day on the floor for OB/GYN and this morning I took the shelf exam. Cancer and antibiotics; cancer and antibiotics everywhere! Man, I hate the shelf exam writers. Not personally - I'm sure they're nice enough people, but I take issue with what they stress on our tests. If you look back on all my TILs for any given clerkship, you'll get a good idea of what isn't on the self exam - namely anything practical or useful day-to-day for the field in question.

Anyways, not much interesting happened during our last shift, but apparently a lot happened the previous night. We almost lost a patient from intra- and postpartum bleeding. The story was exciting, but, for whatever reason, it feels too invasive to tell in this setting. That woman has been through enough and doesn't need her story, anonymous or not, plastered over my small corner of the internet. In any case, the result of the chaos was that by the time we arrived that morning the patient was in the surgical ICU.

A surgical ICU clear across the country is where I got my start in medicine (outside of family issues, of course) by volunteering and then working as a unit clerk. I have been trying to find out, ever since, whether intensive care or some other aspect of medicine is my calling. And by calling, I mean the specialty or subspecialty that I want to try, despite bad grades and long years of training, to be allowed to practice in 5-10 years.

And still to this literal day, I have loved getting any chance to be in an ICU. I love when things have gone horribly, horribly wrong.  I love the clarity that comes with needing to prioritize basic functions and then slowly getting to address everything else as the patient gets more stabilized. I am so jealous of the ICU doctors who got to take over our patient when she was in truly dire straits. It's fun and frightening to think that I could still do that as a career.

WednesdayIL: You can use the doppler function of the fetal ultrasound machine to see if there is an umbilical loop in a pocket of amniotic fluid. As I mentioned in a previous post, amniotic fluid pockets are one of the important signs of fetal health. The measurement of these spaces requires being sure they are empty and, as umbilical cord is nearly invisible on ultrasound, having a way to visualize it is very useful. The doppler function color-codes movement as either come towards or going away from the probe. Amniotic fluid doesn't move, but the blood through the umbilical arteries and vein does. So if you see blue and orange in your amniotic pocket, keep looking for another one.

Tuesday, November 3, 2015

WILTIMS #377: Codes and cuts

Today was a pretty mellow review day. We got to sleep in a bit before attending morning conference. After that there was an hour long meeting on ICD-10, the new medical coding system that is very very slowly being adopted in the US. It was finished by the WHO in the early 1990s, but we've been dragging our feet on adoption in this country, in part because our lack of a national health care system means that the ICD-10 transition must be rolled out individually for every hospital, insurer, doctor's office, etc.

Our hospital uses one of the many terrible EMR systems fighting for dominance across the country and the unfortunate IT team is trying to update it with the ICD-10 coding system. This means trying to make it intuitive for health care providers, many of whom are not super tech-savvy, to sort through the 6-7 times more diagnostic codes that comes with this upgrade. I'm sure we'll get it all finalized by the time the WHO releases ICD-11 in 2018...

The rest of the day was mostly spent as a group going through an old oral exam (which, thankfully we don't do anymore) with the clerkship director. It was surprisingly helpful and a bit of a confidence booster going into our shelf exam on Friday.

TIL: There are very few reasons to do a classical vertical incision for a c-section. The horizontal incision is preferred for many reasons, including less damage to the uterine muscle, less potential for herniation after the procedure, and of course less visibility for aesthetic purposes. The older, vertical type of incision is slightly faster so, in emergent situations, vertical might be the way to go. It's also simpler, so if by some tragic circumstance the mother is dead but fetus is still viable, then there's no reason to make things complicated. If the woman already had a classical incision in the past, then it might make sense to do one again, but you wouldn't be faulted for doing a horizontal instead. Really, the last, best reason for a vertical incision is if the fetus is in one particularly bad orientation in the womb. If the baby is sideways with the back facing down (instead of the head or feet) then you won't have anything to pull on if you do a lower horizontal cut, so it's best to do a vertical instead.

A B-Lynch suture is a treatment for uterine atony where the doctor essentially ties the uterus into a ball with two big loops of suture thread. This artificially contracts the uterus (something it should be doing on its own after delivery) and stops postpartum bleeding.

Vanishing twins, when a pregnancy starts with two babies and one is reabsorbed, is becoming a more common finding simply because we are doing better ultrasounds, earlier in the pregnancy. Who knows; maybe you were a twin?