Two Minute Drill VI Special Edition: Hell Freezes Over

Physical Medicine and Rehabilitation

“It’s the end of the world! The end is here!” shouted the unit clerk as she pulled out clumps of her hair and rocked in her chair. This sort of thing is normal for a unit clerk so I wasn’t too alarmed until I saw the nurses tearing their scrubs and smearing ashes on their faces. The respiratory therapist pushed a vat of Koolaid towards the back and everywhere I looked there was wailing and gnashing of teeth. When I asked what was wrong the charge nurse, who had changed into sackcloth scrubs, pointed in horror to the “cubby.”

“He’s in there, Panda. Oh the humanity! It’s past 5PM! Surely the horsemen are abroad!”

Cautiously I made my way to the cubby (a little alcove where admitting physicians sit to do their paperwork) and was surprised to see a pleasant-looking fellow sitting at the computer studying lab values. But there was something odd about him. His white coat was not just white but pristine. It glowed under the fluorescent lights and the starched creases on the sleeves crackled as he moved his arm. His scrubs, too, were of a strange color the likes of which I had never seen and they appeared new or so clean that he must have been an ethereal phantom passing unsoiled among his ghostly patients. A shiny, electronic stethoscope with the price tag still on as if it had never been used glinted like burnished bronze from his pocket.

“Hi,” he said, turning from the screen, “I’m Dr. Jones, one of the PM&R residents. I’m almost done admitting one of my patients if you need the computer.”

And I was afraid.

But as I am a good (if sometimes wayward) son of my church and made of sterner stuff than the medical students outside in the hall cowering in the corners in the fetal position, I confronted this impossible creature.

“Spirit,” I said, “whether you come as a dark portent of the end times or whether you are merely a phantasm is it not true that Physical Medicine and Rehabilitation is a specialty which treats a wide range of problems from sore shoulders to spinal cord injuries as part of a multidisciplinary team and whose particular focus is planning and implementing physical and occupational therapy to alleviate these conditions?”

“This is so,” intoned the so-called Dr. Jones.

“And is it not true,” I continued, “that you are sometimes called Physiatrists and part of your dark art is to predict the long term consequences of muskuloskeletal injuries and to develop treatment strategies to alleviate these?”

“In this also you are correct,” said Dr. Jones quietly but with obvious menace.

“Is this not the specialty that deals with prosthetics? With orthotics?” I asked, “Is this also not true? Confess, spirit!”

“All of those things of which you speak are correct,” said the corporeal representation of the entity known as Dr. Jones, “But know you that my dominion extends also to movement disorders, muscle pain syndromes, and even unto manipulative medicine in whose service I have made a dark covenant with osteopathic physicians among whom my name is Legion.”

“But spirit, how can this be?” I was perplexed. “The hour is late. The sun sets behind the hills and you, a PM&R resident yet labor in our department, a department whose walls have never seen the likes of you in the morning much less after normal working hours. Is it not written that a PM&R resident knows not the lethargy of the early morning hour nor does he keep the watches of the night (or the late afternoon for that matter)? Does not your kind slumber on the weekends and know not the sting of call or long hours? How can these strange signs be ascribed to anything else but the apocalypse?”

“Oh, don’t worry,” laughed Dr. Jones, “This is the first patient I’ve admitted in two years. But I’m done so if you’ll excuse me…”

And then he was gone.

We still talk about that day when hell froze over.


Two Minute Drill VI Special Edition: Hell Freezes Over

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 5

(Some schools offer students the chance to rotate in the Emergency Department in third year while some only offer it as an elective in fourth year.-PB)

Emergency Medicine

Your Real Responsibilities:
Nothing. You’re a medical student. You don’t count. But that’s all right. We’re happy to have you. It’s true you’re not much help but you will pull a few charts from the inexhaustible supply and it’s not like you’re in our way or anything like that. And, unlike almost every other rotation, we won’t fill your day with mindless scut. Even if we did, you don’t have to go very far to do it. Not to mention that as a rule, Emergency Medicine Physicians are pretty easy-going and you will rarely find the type of malignant personality that is common on some other rotations.

Your Pretend Responsibilities:
Pretty much what we do, albeit at a slower pace. Grab a chart, evaluate the patient, formulate a plan and present it to your resident or attending. You don’t have to move the meat. If you see five patients in a ten hour shift and do a really thorough job that’s not bad.

Things You Should Learn:
1. How to be succinct. It is generally not necessary to do a medicine-type presentation for every patient but the surgery-type (“Patient looked OK from door”) is not enough either. As an example, you can spin a long story about how badly the patient’s chest hurt after he mowed his lawn and how it felt like he was being stabbed and how he got, like, all sweaty or nauseous and had to, like, sit down and rest.

Or you can just say, “Mr Smith had sharp, severe exertional chest pain with diaphoresis and nausea relieved by rest.” Learn medical language. Not only is it precise but it saves time.

Bad: “Mr. Smith was feeling nauseous last night and threw up all over himself several times since yesterday. He’s hasn’t been feeling well lately and has been coughing up green stuff. He can’t hold anything down now and hasn’t eaten anything in two days. He has a burning pain in the left, lower part of his abdomen which he won’t let me touch. In fact, his abdomen is rigid.

Better: “Mr. Smith has a one-day history of nausea, vomiting, malaise, and a cough productive of green sputum along with constant left lower quadrant burning pain and and guarding.”

Best: “Mr. Smith was hurling like my prom date and I think we need to call surgery.”

2. How to let go. Come on. You can do it. There comes a point in every Emergency Medicine relationship when it is time to let somebody else have your patient. Tentative diagnosis made, appropriate tests ordered, patient stabilized, and admitting service notified. It’s time to wave goodbye to your pride and joy and hope that you raised them right and they won’t forget what you taught them. Why, you knew them when they first came in and now they’re all stable and pain free.

It almost brings a tear to your eye.

3. How to joke around a little. It’s all right. Some of the patients are idiots. It’s Okay to laugh at their exploits. You don’t have to get all pissy at some of the nicknames the nurses bestow on particularly odious patients either. There’s “The Lord of the Flies” in bay ten. “Mrs. Jabba” and “Jabba Junior” in room twelve. Not to mention “Your girlfriend,” drunk and stupid with garlands of crusted vomit in her hair screaming profanities in room six.

“Hey, Panda, can you keep your girlfriend quiet?”

“She’s my sister and no, I can’t.”

4. Maybe try to get a few procedures. Certainly offer to suture lacerations. You probably won’t get a chest tube but if you are interested, we might coach you through a central line or two. You can check for blood in stool all you want.

5. Look at a lot of CT scans, ultrasounds images, and films. This is high yield because almost everybody gets some imaging study or another and you can sit with an attending who, while not a radiologist, can point out most of the findings you are likely to encounter in any but the most obscure specialties.

Things That Will Suck
Everything if you don’t like it. Not everybody likes the pace. Some people like to deliberate a tad more and have just a little more information before they make a decision. They call this specialty “Internal Medicine.” No shame in that, of course. With the exception of those lazy bastards in PM&R, we are all a team and every member of the team is important. But if it bothers you to not have a clear diagnosis on every patient you will be desperately unhappy. I can only hope that you, at least, do not become one of those specialists who look disdainfully at Emergency Physicians when we do not immediately identify an obscure but obvious disease involving an organ system which they have spent seven years of residency and fellowship studying in excruciating detail.

Or, you just might be lazy and miss the opportunity to just sit around doing nothing like you do on a lot of other services.

You will also see a lot of smelly, nasty, obnoxious, and sometimes dangerous patients. You will either revel in it or not but there they are, scooped up and delivered fresh from the street in their natural condition which often involves a protective crust of vomit, feces, and other unspeakable substances. They don’t get sanitized for your protection until much later.

Cool Things About the Rotation:
If you can get over your brainwashing that every patient encounter must be a long, slow, mutually gratifying and environmentally pure simultaneous orgasm with metaphysical post-coital spooning, what’s there not to like? A huge variety of patients. Fast pace. Sassy nurses who won’t kiss your ass. Major trauma. Procedures. Even a lot of primary care if that’s your thing. And if you have a heart and like medicine at it’s most visceral, this is your specialty as it deals with a chief complaint which is addressed immediately and completely leading generally (believe it or not) to immense satisfaction on the part of the patient (if they are really sick, I mean, and not just looking for drugs or attention).

Call:
None. Zip. Zilch. You will work shifts and at most places, the medical students will only work the “rotator” schedule which is something like fourteen days in a month. Sure, the hours are screwy but I’ll take vampire hours with twelve or fourteen days off a month over Q4 call and 13-hour days with one day off every week.

Slacking Potential:
Good, because you are not tightly supervised unless you want to be an we are usually too busy to care where you are. It’s not like we have a lot of scut for you to do. But why would you want to be a slacker given that the hours are so good? Nothing motivates me to work hard more than the sure knowledge of when quitting time is. This is not to say that you will always get out exactly when you shift ends but at least you know when to start wrapping things up.


Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 5

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 4

(Disclaimer: I hated surgery with the burning fire of a thousand suns so you may have a different experience-PB)

General Surgery

Your Real Responsibilities:
Nothing. You’re a medical student. You don’t count. Your job on the surgery team is to be the butt of jokes and to give everybody someone to laugh at. Hey, I don’t make the rules. I’m just telling you how it is.

Your Pretend Responsibilities:
Post-operative management of patients on the wards. Assisting in the operating room although you can easily be replaced by any one of many finely crafted retractor frames. I all but refused to go to the OR after I learned about these things. “You mean to tell me that there is no reason for me to stand in the same place holding a retractor for six hours when all you have to do is hook up the frame and clamp the retractor to it? Why those no good, sadistic, lazy….”

But I digress.

Your other pretend responsibilities will include following patients as you would do on a medicine service as well as attending clinic where you will pretend to evaluate patients before presenting them to your attending.

Things You Should learn:
Ranson’s criteria are huge. I must have been asked about these at least once a day. (Ranson’s criteria help predict mortality from pancreatitis.) Also things like Charcot’s triad (fever, jaundice, and right upper quadrant pain), Reynolds pentad and other eponymous collections of symptoms. Surgeons love these things and if you can rattle them off your attending will think you are the best medical student ever even if you are an otherwise lazy piece of shit.

Don’t forget Panda’s Triad which is boredom, disinterestedness, and clock-watching.

Know the twenty-or-so common abdominal surgeries, their indications, and how they are done. If you know what a whipple is, for example, and the relevant anatomy you will do just fine in the OR under the pimping gun. Don’t ever say “Roux-en-Y” unless you know what it means. Also, don’t ever go into a case without at least knowing the patient’s name, his diagnosis, and the planned procedure.

Know how to scrub and what to do and where to stand in the OR. Extra points for knowing how to “self-glove” in a sterile manner because you might be expected to do this. Apparently, many scrub nurse have a clause in their contracts stating they don’t have to hold gloves for vagrants, migrant workers, cheerleaders, medical students, and others with no real purpose in their operating room.

Also know about wounds, how they heal, and the various methods used to dress and debride them. And for Mohammed’s sake learn how to tie a few common surgical knots. Practice before your rotation. Nothing says “dork” like throwing a granny knot.

Things That Will Suck:
Everything.

No. Really. If you don’t like surgery (and you will know how you feel about it after, oh, maybe five minutes) It all blows hard combining as it does all of the worst aspects of every other rotation with real hard work. Standing in a case holding a retractor or trying to stay awake and not falling into the sterile field (which I saw happen) is grueling. Medicine, by comparison, is not hard, just annoying.

The higher than usual numbers of malignant attendings and tired, bitchy residents just adds a little kick to the fecal jumbalaya which is your surgery rotation. But I have no sympathy for them and you, also, need to resist that temptation. Sympathy is in the dictionary between shit and syphilis. We lay in the beds we make. Nobody holds a gun to anybody’s head and forces them into this career. It sucks but it’s not as if your tired, pissed-off residents didn’t know this before they matched. Your third year rotation gives you a pretty good overview of the life of a surgery resident. You will be getting up just as early and leaving just as late. I hated every single minute of my surgery rotation, the only good thing about it being that it was my first rotation of third year and nothing that came after even came close to sucking as hard.


Cool Things About the Rotation:
Nothing. Seriously. If you don’t like it and have no interest in being a surgeon it is all a grind. Even surgeons will tell you this. Surgery is a calling. You either love it to the exclusion of almost everything else in life or you will resent it mightily. Family medicine, psychiatry, Emergency Medicine, and Internal Medicine residency programs are littered with ex-surgery interns who discovered that they had other interests in life and that, while it may have seemed cool at one time, it just wasn’t worth it in the end. Married surgery residents have almost a one-hundred percent divorce rate for a reason. You cannot have a family life as a surgery resident. Period. The eighty hour work week is still a joke in most programs and the simple mathematics of the week dictate that you can’t have Q3 call, work 100 hours a week, get the bare minimum of sleep, and spend the time with your wife and family that they deserve. There are 168 hours in the week. How much sleep do you need? Forty hours a week? Do the math. It’s five long years, sometimes six.

By contrast, as an Emergency Medicine resident I work about sixty hours a week for three years and will probably make more as an attending for half of the hours and about a third of the bullshit.

But you know, it’s surgery. There is no question that it is a useful, highly challenging field which will never be replaced by mid-levels or outsourced. If you’re young, healthy, and motivated and like this kind of thing you may find your true calling in life on your surgery rotation. A lot of my classmates loved this rotation and yearned for fourth year when they could line up more of it.

Call:
Useless like most medical student call but not completely useless. On trauma call you will be handed the “Monkey Sheet” (the History and Physical) and filling it out during the trauma will help your tired residents immensely. And you may be a real help during cases late at night or early in the morning when nobody is around. You’ll still hold the retractor but at least you’ll be standing opposite the surgeon and not leaning in at an impossible angle.

Slacking Potential:
Excellent. Other than rounding in the early, early morning your residents and attendings will be busy during the day and not making a career out of leading you and the rest of their entourage around the hospital. I’m sure your school has a minimum number of cases in which you must participate but nobody ever failed the rotation for not getting into a whipple. Maybe during your rotation nobody needed one. A colectomy here, a hernia repair there and you can build up enough cases to keep the wolves from your door. After this there are a dozen perfectly legitimate reasons not to scrub in on a case without having to ever resort to the “I’ve had the runs all day” ploy. If you don’t like it and would rather be a Slurpee jockey than a surgeon, OR time is pretty low-yield anyways. No reason to kill yourself.

Miscellaneous:

How to Scrub 1
How to Scrub 2
My First Day of Third Year

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 4

Ten Things I Like About My Job

Anonymous writes: “Say, Uncle Panda, you’ve convinced me that medical training blows and that the only difference between being somebody’s prison girlfriend and residency is that your cell-mate/husband usually lets you sleep after he sodomizes you. Are there any good things about your job? “

Excellent question. Naturally, it is easier and more interesting to complain about things. If all I did was opine about how much I liked everything and how wonderful, kind, and wise the entire medical profession was I think I’d probably have about six readers, all of them geeks, and all of them regularly exclaiming, “Darn, that Panda guy sure can write!” And, there would be just too much competition from one of many fine Smurf homage sites.

Not to mention that you would find reality far different than the rosy picture I painted.

Still, I do like my job and here are a few reasons. Some of them apply to my job in particular as Emergency Medicine is somewhat different than many of the traditional specialties, others apply to medicine in general.

1. I don’t have to internalize my patient’s complaints. Many of them are sick, really sick. The kind of sick that you, reader, may find hard to imagine living as you do in the prime of your youth and health. I see, almost every day, some example of the body’s seemingly inexhaustible capacity to hang on in the face of failing organs, deranged chemistry, brain damage, and absolutely horrific injuries. But it’s cool. I’m not that empathetic. I don’t believe the patients want that kind of thing anyways. Given a choice, most patients would prefer an authoritative physician who thoroughly understood their aortic stenosis and their congestive heart failure over some smarmy, slobbering empathy-whore.

2. Every now and then a patient comes in who is dismissed by the nurses, laughed at by the mid-levels, and generally treated like a malingerer until you walk in, bring your medical training to bear, and make an obvious diagnosis. Sheepish looks all around. Respect from the nurses who take pride that you have been brought up so well, envy from the mid-levels who keenly feel their lack of knowledge, and a gratitude from the patient who finally gets the respect he deserves. Medicine at it’s most visceral and gratifying. Cheeses and hams all around. (Absolute Doctor Rule Number One: Everybody gets the benefit of the doubt.)

3. I don’t care what you’ve heard, physicians are still respected by almost everybody, especially when either they or a family member are sick or injured. In our “Call-Me-Bob”, I’m OK, You’re OK society a physician is one of the few people still called by his title. I occasionally have a young, tattooed, patient making a career out of fighting authority who never-the-less struggles with the correct way to address a doctor. He knows first names are wrong. “Mister” is out of the question. It is finally, with relief, that he discovers “Doctor” is acceptable. Kind of sets the mood. If you act like a physician, you will be treated with respect. This goes back to not slobbering on the patients. They want kindness and respect but they don’t want you smothering them either or being their best friggin’ friend.

By the way, I always call patients by their title which is, at a minimum, Mister, Miss, or Mrs. My mother (who reads my blog, by the way) taught me good manners.

4. My colleagues are as profane and irreverent as I am making for a really fun work environment even when things are ostensibly blowing hard. While we are circumspect around the patients and in areas where the usual compassion fascists prowl, I have only heard Marines and sailors swear as much or tell more off-color jokes. This may bother some of you but (and I say this with respect) you can pound sand. If you don’t like it, go into a specialty at a program where they wouldn’t say shit if they had a mouthful, gather up your skirts, and waggle your fingers while making tsktsk noises to your heart’s content.

5. We get to avoid most of the rush hour traffic. I once had to drive to work at a normal time and it took me three times as long. Good Lord. It may be dark when I leave but all the traffic lights are blinking yellow.

6. Free food. Don’t underestimate it. At my program, we eat for free in the cafeteria. I probably drink about eight or nine Diet Cherry Cokes (the official soft drink of Panda Bear, MD) per day so the savings are huge. Plus it’s nice to have a perk or two. It makes one feel special.

7. Emergency Medicine gives me the opportunity to practice Christianity. I may hate doing it, it may make me ill, but if Christ washed the feet of beggars I can certainly remove some disgusting wino’s urine-soaked socks and examine his filthy, gnarly, fungus infested feet without complaint or change of expression and without making the wino feel like he is bothering me by coming in for some warmth and a meal. I hate doing it, of course, as I am no Mother Teresa but I hope the Lord gives me some credit for the action, not the thought.

Except for action, most compassion is metaphysical crap anyways.

8. Going home. It’s the best feeling in the world to get done with a shift, especially on or around the designated quitting time. This is probably unique to Emergency Medicine, especially in residency. Most residents have the devil’s own time escaping at the end of the day. There is always something that can stall your egress and it is usually something trivial or people without families, outside interests, or lives who get all of their social interaction at the hospital and want you to hang around. Not to mention that there is always work to do. You can stay at the hospital 24-hours a day seven days a week if you want and nobody would complain.

But that’s why they have a on-call team, not to mention night-float. I hate call but I do it. And I don’t try to pass off consults and admits that come in at 4:55PM to the day team because they came in during the day.

9. It is an interesting job. We see a little of just about everything from genital warts to leukemia. Sure, some things are bread-and-butter but not everything is. Major trauma is pretty cool too and I am working towards being as calm and collected as my senior residents and attendings.

10. I get to wear pyjamas to work.

Ten Things I Like About My Job

Just a Few Random Things

Fast Freddie Johnson and the Man

The patient, a young black man, eyed me suspiciously. Apart from telling me that his name was Kareem, he had said very little during the initial assessment in the trauma bay and had made it to the CT scanner and back without saying more than ten words, total, to anybody. His GCS was 15 and he was hemodynamically stable so this was initially attributed to pain and fear. Other than the obviously fractured tibia, he was uninjured but as the pain medication kicked in and things settled down he still seemed reluctant to give us any information.

A group of his friends were in the hallway outside the trauma bay and they, too, were noncommittal even in regard to his last name. They eyed the two police officers from whom their friend had been fleeing before he smashed his stolen car into a tree and elected to plead the fifth in regard to their alleged friend.

“Come on,” said one of the cops, “You hang out with this guy and you don’t even know his last name?”

Shrugs all around. They had the police in check.

“Kareem,” I said, “I’m Doctor Bear, one of the residents on the trauma service. We’re going to get the orthopedic surgeons to look at you and I imagine they’ll be taking you to the operating room to fix your fracture.

“Kareem?” said the patient’s mother who had pushed her way into the trauma bay, “His name ain’t Kareem, it’s Freddie, Freddie Johnson …Baby, why you be tellin’ them yo’ name is Kareem?”

Mr. Johnson, demoted and revealed, shot his mother an angry look and I fully expected her to deny knowing her son.

The police left after we assured them that Mr. Johnson wouldn’t be going anywhere for awhile which was probably a mistake as only one day after an ORIF (Open Reduction, Internal Fixation) of his tibia, the taciturn Mr. Johnson limped out of the hospital on his crutches and we never saw him again. I guess we underestimated his desire to evade the law. Although we never really had a conversation and he glowered at me whenever I went into his room, I can’t find it in my heart to dislike Mr. Johnson. If you have to leave Against Medical Advice (AMA) this is the best way to do it, avoiding as it does the usual song and dance, the cajoling and stroking, that these things usually entail. I have often found myself earnestly trying to persuade a recalcitrant and unappreciative patient to stay when my heart yearns to say, “Hey, if you want to leave before I can arrange to have home IV antibiotics then don’t let the door give you a staph infection as it hits you on your ass on the way out.”

Of course you can’t really say something like that.

Residency and Call Revisited.

I despise call. And I don’t care to justify my dislike for it by claiming that patient care suffers if the residents are tired. I don’t even know if I really buy into the notion that tired residents make a lot of mistakes, and frankly, I don’t care. It certainly seems like a difficult hypothesis to test and I would hate to have my sleep dictated by the results of some pointy-headed geek’s study.

No, I dislike call for the more visceral but just as legitimate reason that it is inhumane to deprive a person of sleep for anything short of combat operations or genuine medical emergencies. The problem is that everything nowadays is an emergency, even things that aren’t.

“Call” is a misnomer by the way. It’s not “call,” it’s “work.” Attendings have call. They get to go about their business until called in for an actual emergency. Otherwise they take a phone report from the resident on call and say, “Okay, admit the patient and I’ll see him in the morning.” Residents on call generally work nonstop from the early evening until they are allowed to go home the next day. If it’s not an admission in the Emergency Department it’s an issue regarding one of the many patients they are cross-covering.

There was a time, many years ago, when the whole crazy system began when resident call did not mean a sleepless night every third or fourth day. Because people routinely died from the first major illness they acquired instead of collecting them over the years and living longer thanks to medical advances, hospitals were a lot slower-paced then they are today with a more stable census for a service (as hospital stays used to stretch for weeks for things that are treated as an outpatient today) and fewer acute issues that needed to be managed. As a result, the house staff in the fifties may have stayed overnight in the hospital often but I guarantee they slept a lot more than we do today.

But, as I said, today everything is an Emergency and has to be done right away. Not only are we dealing with an older and sicker population but expectations of the public are a lot higher than they used to be. Fifty years ago it was recognized that some diseases were death sentences and the priest and the undertaker were more likely to be called than the doctor. Today, we never say die and we routinely admit, treat, and discharge people who fifty years ago could not possibly have lived long enough to acquire so many comorbid conditions. The combination, for example, of congestive heart failure, diabetes, emphysema, chronic renal failure, morbid obesity, and ischemic heart disease (any one of which was fatal a generation ago) is so common that I’m thinking of having a stamp made so I don’t have to keep writing it on the chart.

So there is very little down-time on a typical medicine or surgery service and you can count on a steady stream of admissions from the Emergency Department to keep you occupied through the night. The Emergency Department, for it’s part, is turning into a miniature and almost self-contained hospital complete with a census of admitted patients who linger in the department waiting for a bed.

What to do about it? Who knows. I only mention it because, with the exception of one month next year, this month is officially my last call month in my medical career. Nothing but shift work from here on out. Emergency Medicine, Baby!

No point, just wanted to gloat.

Letter to A Patient’s Husband
(With a nod to Scalpelorsword for the idea-PB)

Dear Mr. Jones,

I know you accused me of not caring and, on the surface, it may appear that way but I assure you the reality is more complex than that. I know your wife is morbidly obese. I know she suffers from a host of serious and eventually lethal medical conditions. I realize she was in a car accident last week but other than a few bruises, she is all right and while I can understand your reluctance to take her home, you must because she can’t stay here.

Yes, she is a big woman. In fact, she could barely fit into the CT scanner. Yes, she has trouble walking. I have had physical therapy working with here and they inform me that they have done all that they can do. I also am well aware that he has trouble breathing. This is a combination of her emphysema, her current smoking habit, and obstructive sleep apnea from her obesity. I also realize that she seems tired but as you probably noticed, she’s not getting a lot of sleep at night, particularly because she refuses to wear her CPAP mask.

Yes, I understand it’s uncomfortable. I’d hate to have to wear it myself but it’s all I’ve got in my bag of tricks.

I am sorry. We can’t keep her. She came to us in poor health after an automobile accident and she’s going to leave in the same condition that we got her because there is nothing more that we can do about her chronic medical conditions. We took great pains to rule out any occult injuries to her brain and spinal cord and she has been in the hospital on our service many, many days longer than we typically keep uninjured trauma patients, many of who we discharge from the Emergency Department after a few hours of observation.

I can understand your reluctance to take her home. I believe you when you tell me that all she does is sit on the coach and watch TV except when she struggles out of it to use the bathroom. I wish that we could send her to a skilled nursing facility but as she has no insurance and you can’t afford it, this is not an option. She may or may not qualify for Medicaid but we can’t keep her here waiting for the decision. You will just have to take her home.

How will you get her up the steps? You have two sons. I saw them here yesterday. They may live a couple of hours away but they’re just going to have to drive back to town and help their mother. She is your responsibility and theirs. That’s why they call it a family. In fact, the stability of our world depends on families acting as self-supporting units. Break the bond of family and you have either a decaying European-style welfare society dying a selfish and lingering death or a catastrophe like the former Soviet Union which proved that if everybody is responsible for everyone else, no one is.

I’m sorry to place the whole burden of Western civilization on your shoulders, what with you living in a trailer with nothing but basic cable, but there it is. She is your burden. We need this bed for the never ending backlog of patients, some even sicker than your wife, many of whom are sitting in hall beds in the Emergency Department as we speak.

So you see, it’s not that I don’t care, it’s that I can’t care. I can’t take her home with me and assign my wife as her nurse. We can’t keep her in a scarce hospital bed for the rest of her life with her own private nurses and therapists to assist her. Despite what you may have heard, we are not magicians and I we cannot cure what afflicts your wife. I’m not even sure that we could help her if she wanted our help which she apparently does not. I can’t, for example, hold the CPAP mask on her face all night against her will or force her to take insulin shots. She could have me arrested for assault. She’s an adult. We all lay in the beds we make. We’re not doing a thing for her but catering to her whims, something you might want to stop doing by the way.

She can get up if motivated. I have seen her, just this morning, heave out of her bed and transfer to the bedside commode. I suggest if she asks you for some food you tell her to get it herself.

You asked if I am sending her home to die. Of course not. But she is going to die. I’d say her chances of being alive five years from now are zero as she is a setup for all kinds of medical badness. But, like I said, we can’t keep her here for the next year or two hoping to preempt the next medical crisis. Call the ambulance if there is any sudden change in her condition.

You were right about one thing. In the end, hiring a nurse to help you at home would be a lot cheaper than the inevitable hospital costs your wife will incur over the next five years as her health continues to deteriorate and fruitless regular hospital admissions turn into fruitless and spectacularly expensive ICU admissions. But I’m just a resident. I don’t make public policy. Even if I did, while your idea makes sense economically, I’m not sure I’d want to structure society to completely remove the burden of individual responsibility.

Good Luck. I wish I could do more but I can’t.

Sincerely,

Dr. Bear

Just a Few Random Things

How to Write Your AMCAS Personal Statement

Feel Free To Use These…

(As many of you know, the personal statement on your AMCAS application is an important piece of the medical school admission puzzle. A good personal statement can land you an interview while a bad one can make an otherwise strong candidate look insipid. I was going through my computer and I found a few ideas to start you off on your personal statements. Feel free to use them-PB)

Sample 1
I had been arrested two weeks before for obstructing logging in the Xocaatl tribe’s ancestral hunting grounds and it was hot in that Mexican jail. Damned hot. The kind of heat that sneaks up behind you and throttles you in manner very similar to that employed by my cell-mate Fernando as he fumbled at his belt while hissing dark Spanish threats into my ear. I think he was warning me not to shout out for the guards, something that I would never do as our personal morality should never be forced on others. Then the pain came. I gritted my teeth and forced back the tears. Homophobia is wrong, I told myself…

Sample 2
His name was Lavon Quintravion Jones, a 24-year-old white male…

Sample 3
The genital mutilation ritual practiced among the Laconda Tribe in the Peruvian foothills looked painful. And it was. Very, very painful. And, as the cermonial dagger was first dipped in the urine of a llama, I don’t think it was very sanitary either. Never-the-less I have always thrived in diverse cultures.

“We need to celebrate diversity.” I said to the flight medic as the Peruvian Army helicopter airlifted me to the hospital in Lima where emergency surgery would later save most of my penis.

“El dumbass mas grande en el mundo,” The flight medic said as he adjusted my oxygen mask and I was gratified that he agreed. (I guess my six-day immersion Spanish course was not a waste after all!)…

Sample 4
It’s all about the kittens. I remember my first experience with my pregnant tabby Snowball as the genesis of my desire to be a doctor and my hope to eventually specialize in OB/Gyn. “Hold her still,” I said to my friend Skeeter, “I’m counting parts here and I think we only have enough for five and a half kittens.”

Even then, at the age of twelve, I was strong believer in reproductive freedom for all female mammals…


How to Write Your AMCAS Personal Statement

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 3

Internal Medicine (“Medicine”)

Your Real Responsibilities:
Nothing. You’re a medical student. Remember those red-shirted crew members on Star Trek? That’s kind of like you. Your only function is to walk around filling out the scene. Sometimes bad things will happen to you, sometimes you will provide comic relief, but mostly you will just fade into the background, indistinguishable from any other medical student.

Your Pretend Responsibilities:
Managing patients on the wards. Seeing patients in clinic and presenting them to your attendings and residents. Admitting and discharging patients under the supervision of your residents and learning to write the appropriate orders.

Things You Should learn:
Everything. Internal medicine (along with General Surgery) forms the backbone of the entire medical profession. It is medicine in its purest form complete with meticulous history-taking, a thorough physical exam, a comprehensive differential diagnosis, a sound plan with the appropriate testing, and either a definitive treatment or the appropriate referral. It is both traditional, as the internal medicine ethos would not be unfamiliar to the ancients, and cutting-edge, as new research is continuously incorporated into the profession.

So there is a lot to know. Rather than trying to list things, let me give you one of the only really useful mnemonics in medicine which is “VINDICATE.” I generally hate mnemonics but this one will let you systematically come up with a differential diagnosis from which further testing and treatment may be derived. The causes of every illness known to man are:

Vascular
Infection
Neoplasm (Cancer)
Drugs
Inflammatory/Idiopathic/Iatrogenic
Congenital
Autoimmune
Trauma
Endocrine/Metabolic

When you’re in a bind and staring at and acre or two of blank space on your note for your assessment and plan, just take a deep breath and remember VINDICATE.

Things That Will Suck:
Did I mention it was medicine? As bears shit in the woods, the Pope is Catholic, and death invariably follows taxes, medicine attendings love to round. And round and round and round, often well beyond the point where you care about anything but making it stop.

Rounding, for those of you who don’t know, involves visiting, as a group, every patient on your census to discuss their illness and the plan. Surgery rounds are sometimes of the variety, “Patient looks fine from door, let’s move on.” Medicine rounds, however, proceed at a glacial pace as every single aspect of the patient, his disease, his lab values, and his prognosis are discussed in excruciating detail. This is where you may have a 45-minute ad hoc lecture about a patient’s normal but slightly low sodium value and what it means for him. Then you will discuss the next patient’s potassium for half an hour.

Merck developed a probe that gave continuous readings of serum electrolytes but they had to take it off the market after internists started hanging themselves with their stethoscopes.

Not to mention that every possible cause of the patient’s symptoms, no matter how unlikely, will be trotted out like so much horseflesh to be poked, prodded, examined, and finally sent back to the corral. It is a good way to learn medicine, don’t get me wrong, but my feet hurt all the time on that rotation and I developed plantar fasciitis from standing up and walking for eight hours a day.

“Don’t they have anything better to do?” you ask. Well, no. This is what they do. Internal medicine is light on the procedures but heavy on the thinking.

Cool Things About the Rotation:
1. Morning report: Almost every program has a formal teaching session in the morning where a case is presented to the residents. It is usually in a question and answer format where the presenter starts with the presenting complaint and symptoms and the residents ask appropriate questions about the history, review of systems, physical exam and all the other elements of a good patient encounter. This leads to the creation of a differential diagnosis which is narrowed down to the most likely disease after which a short presentation on the final diagnosis is given. For my money, this is the best way to learn medicine. It’s interactive, it’s fun, and even the pimping is usually in good spirit.

2. The opportunity to rotate on sub-specialty services: I landed nephrology and cardiology (two weeks each) as my subspecialties during my two-month-long medicine rotation. Nephrology attendings, for their part, are like general medicine attendings on crystal meth, at least when it comes to their preoccupation with electrolytes and they are, as a class, perpetually exasperated that their medical students, most of who are just trying to survive, cannot identify garden-variety mixed acid-base disorders. Still, these kinds of rotations give you good exposure to the whole range of medicine.

3. Medicine is very cool. Internists have my deepest respect but it’s not something I wanted to do, what with my short attention span and poor memory.

Call:
Useless, like most medical student call. You’ll basically just follow your resident around as he grinds out admission after admission in the best cookie-cutter fashion. As there is no difference between an admission done at 8PM and one done at 3AM (except that at 3AM you are too tired to give a crap) there is no reason to lose sleep. You can learn all you need to know and still get a good night’s sleep except that your faculty is bound and determined that as they suffered, so shall you.

Slacking Potential:
Medium. Rounds don’t actually last all day. You may have a couple of hours to vanish and either take a nap or study. Generally, after formal rounds you have “work rounds” where your residents will go back to their patients and implement the plans discussed on rounds. Since you are not responsible for any aspect of patient care, your presence is not required and after you make yourself aware of what is going on with all the patients you are following, the day is pretty much your own unless until sign-out in the late afternoon. Like most inpatient rotations, expect early hours but not as early as OB/Gyn or surgery where they round early to get it out of the way so they can do their real work.

Miscellaneous:

A Typical Day on a Medicine Service
A Typical Day as a Medical Student Part 1
A Typical Day as a Medical Student Part 2

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 3

Panda’s Quick and Dirty Guide to Third Year Rotations: Part 2

Pediatrics

Your Real Responsibilities:
Nothing. You’re a medical student. You don’t count. I hear that in Arizona they’re going to replace medical students with migrant workers. Sure, they’ll have to pay them minimum wage but this is peanuts compared to the cost of educating a medical student. This way the hospital will save money, the employees will still have somebody to look down on, and the migrant workers can always mop the floors or do other useful work, something that you can never get out of a medical student.

Your Pretend Responsibilities:
Managing pediatric patients on an in-patient service. Attending pediatric outpatient clinics and learning to handle the breathtaking excitement.

Things You Should learn:
Presentations and treatments for common pediatric problems like rashes, diarrhea, colds, and vomiting. Developmental stages of childhood, normal milestones, and what to do or who to call if the child is not meeting them. Common congenital conditions. The major chromosomal abnormalities (like Trisomy 21), common congenital heart defects. Diagnosing and managing the more serious pediatric diseases. Identifying child abuse (a big one in my book). Learning how to examine sick and well kids without having them scream in fright during the whole exam.

Otitis Media. The big one. Deserves a whole blog of its own.

Things That Will Suck:
1. Well, it’s pediatrics. It all sucks if you don’t like kids. I have my own kids so I had a running start at disliking it. Other than that it’s not too bad. Inpatient pediatrics is as bad (or as good) as inpatient medicine. You will round, present, and take call. The primary philosophical difference between pediatrics and medicine is that most kids will get better and make a complete recovery, something you will not see that often on an adult medicine service where you sometimes feel like you are playing “Keep Away” with the grim reaper. But ward months are ward months and call is call. Rounding sucks no matter on what rotation you do it.

2. There is no clinic known to man more boring than outpatient pediatrics. Most kids are just not that sick but their parents bring them to the doctor with distressing frequency. The major culprit is the “Well Child Check.” The Well Child Check is a periodic screening exam to make sure that kids are growing appropriately and have all of their immunizations. If you can think of something more mindless than asking the same questions over and over about usually healthy children and plotting their height and weight on a growth chart then you have probably worked at more crappy minimum wage jobs than most of us.

Like two men and a ham, pediatric clinic can seem an eternity. The hours flow like thick syrup. Having to ask the questions in Spanish cuts the excitement in half.

Cool Things About the Rotation:
1. Well, they are kids after all. Who doesn’t like kids, especially if they are not yours and you don’t have to take them home? They are kind of cute and every now and then you will get a stupid smile on your face which you can’t get rid of.

2. Their are few things as gratifying as seeing a really sick kid get well through medical intervention. And, while you may not see this as a medical student, running a successful code on a child is probably the best feeling in the world (just like having to call the code is one of the worst).

3. The residents and attendings are fairly benign. Malignant people, as a rule, don’t go into pediatrics preferring as they do to keep their options open in Med/Peds. Additionally, if you want to know the one specialty that is a calling it’s pediatrics. The pay is bad, the hours are long, but people do it because they love it.

Call:
Fairly lame like most medical student call. You will soon grow tired of hiking down to the Emergency Department to help admit yet another asthma exacerbation. Or dehydration and fever from gastroenteritis. Still, kids are generally not as sick as adults even when they are admitted to the hospital so for the same size census, you will get fewer floor calls. I suppose that’s something. You know how I feel about losing sleep. As a resident it’s unavoidable as not only are you responsible for the patients but you are also getting paid, things that are not true for medical students. Have I said this before? I think it’s dumb for a medical student to answer floor calls as he is just going to have to page his resident for guidance. I say eliminate the middle-man.

Slacking Potential:
Not so good. Terrible in fact. It’s just medicine for kids with all of the rounding, morning reporting, conferencing, and other mandatory activities. When you’re doing your ward months you will pretty much be stuck with your team all day, every day so if pediatrics isn’t your bag you are out of luck. Clinics are, of course, mandatory, usually pretty busy, and dull.

Panda’s Quick and Dirty Guide to Third Year Rotations: Part 2

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 1

Obstetrics and Gynecology (OB/Gyn)

Your Real Responsibilities:
Nothing. You’re a student and you don’t count. Every medical student in the hospital could vanish and apart from less crowding on the elevators, nobody would notice.

Your Pretend Responsibilities:
Following pregnant woman pre-, ante-, and post-partum. Assisting in vaginal and Cesarean deliveries. Assisting in gynecological surgeries including hysterectomies, vulvecvtomies, and salpingectomies. Seeing patients in clinic with various gynecological problems who you will present to your attendings and residents. You will probably “shadow” a resident at first. Your level of independence will depend on the school, the attendings, and your level of interest.

Things You Should learn:
1. Pelvic Exams. Don’t be squeamish. They call it a bimanual for a reason. The first fifty you do all you’ll be able to say is that it’s warmer in there than outside but after a while you’ll get the hang of it.
2. Assessment of labor. Learn how to assess the cervix for dilation and effacement. Recognize the stages of labor and which stage the woman is in if you feel the baby’s ears while checking the cervix.
3. Recognizing common complications of pregnancy (placenta previa, accreta, malpresentation, pre-ecclampsia, etc), knowing who to call and what to do in the meantime.
4. Treatment of STDs.
5. Causes of abnormal vaginal bleeding and what to do about them.
6. Common gynecological malignancies.

Things That Will Suck:
1. The hours. The early, early hours. Best to just suck it up and go to bed early every night. Tivo American Idol if you must but it is not unusual to pre-round at 0500 on OB which means that unless you sleep in your clothes and don’t brush your teeth you will have to get up at hours that would make dairy farmers cringe.

2. Vaginal Discharge: Are you some kind of freak? How could anybody possibly enjoy looking at and smelling green frothy discharge pouring out of an orifice that would turn Puff Daddy gay if he were to merely gaze at it. I have seen some horrific sights in Gynecology clinic. Visions of terror that have made even hardened OB/Gyn residents recoil in horror while their less-seasoned colleagues wept and spread ashes on their faces. They don’t call it the whiff test for nothing.

3. OB/Gyn residents. I’m conflicted on this. They’re not necessarily malignant, just cliquish. Definitely cold towards medical students unless you really show an interest which, frankly, is hard to do if you’re not interested (obviously).

Cool Things About the Rotation:
1. Once you get past the feces, urine, smells, screaming, and other truly frightful aspects of childbirth which they don’t show on the Discovery Channel (but I don’t have HDTV) it is kind of cool. Everybody is usually pretty happy to see the baby, even mothers who you know will be going back to their crack pipe an hour after discharge. Hope springs eternal.

2. A good variety of things in one rotation, ranging from primary care to incredibly intricate oncological surgeries. If you don’t like looking at “wedding tackle” this is also your rotation. Plus, although there are exceptions, female patients are generally less nasty than men.

3. Clinic weeks: Generally, when you are on the outpatient part of your rotation the hours will be nine-to-five with no call.

Call:
Idiotic, like most medical student call. Still, take advantage of the opportunity to get more involved in deliveries at night when there are fewer people around and you have a better chance to assist in a C-section doing something more than holding a retractor. You will mostly do call in OB triage.

Slacking Potential:
Not so good. On clinic weeks you definitely have to be in clinic and it’s hard to stand around doing nothing in that kind of exposed environment. Still, you can work slow and “just miss” picking up a chart from the door of a new patient. Although I kind of liked OB/Gyn, I can understand completely how after a couple of “close encounters” one might decide that they have had enough.

On Obstetrics you will have to round and since OB is busy, they have very well organized rounds and morning reports. No getting out of it. If you don’t want to go to the OR you can probably hide-and-slide when you are on “Benign Gyn” or “Tumor Gyn” but you will get dragged into a certain number of C-sections even if you have sworn an oath to all of the pagan gods that you will cook and eat your own entrails before you would match into OB/Gyn.

Misc:

What you will do an intern.

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 1