one section of a Fifth Chance Media book, ISBN 978-1-944861-02-5.
From the editor: Health care is nearly 20 percent of our GDP. The surest way to be a full participant in this massive and growing sector of the economy is to get an MD. But it is a substantial commitment for a young person to prepare for, enter, and complete medical school. What is it like day-to-day? To help young people (and old people advising young people) answer this question, I placed a mole in one of America's medical schools. We pick up the story in the middle of 2018.
To preserve patient confidentiality, ages and other details are slightly altered. Students and teachers are also pseudonymous.
Students return for Year 3 of medical school. We've had a 2-4 week break depending on when we took our Step 1 exam. Most students, including me, are still waiting on their Step 1 scores. Lanky Luke surmises that we took a new test, which required aggregation of a few weeks of tests to normalize the scores to previous versions. Five classmates met up in Seattle for a road trip through San Francisco, San Diego, and the Grand Canyon. I visited family, and relaxed with Jane before she departed for boot camp. She returns next week.
"I am ready to learn some real skills," exclaims Lanky Luke. "When friends and family ask about their various medical issues, I realize how little I know." Hard Working Harold: "Give me a multiple choice question and I'll answer the shit out of it. Send me into a patient room, and I'll have no idea where to start."
Orientation begins at 7:00 am with an introduction from the clerkship director, a practicing psychiatrist. "When I went to medical school, we used to call you clerks. You are no longer a student. You no longer shadow." She lays out some basic principles for success:
Our next presentation is by the Dean of Student Diversity. Her new assistant, the Inclusion Coordinator, joins her and helps pull up her PowerPoint. Title slide: "In pursuit of cultural sensitivity and awareness."
She begins by explaining her own implicit biases and insensitivities. "I want everyone to go home and take Harvard's implicit bias test. I learned a lot about myself. For example, I have an implicit bias that males are better leaders than females. I apparently have a bias that women are not as good at science. I didn’t even know that about myself."
The talk concluded with a request that students share microaggressions that they had suffered personally. Fashionable Fiona shared that one of her relatives told her, "You should go to nursing school instead of medical school. It's too hard. I was pleased to say, 'I already got into medical school.'" [She got an award for her year 2 block exam performance.] Several women shared that patients mistake them for nurses instead of medical students. One student shared an experience in pediatrics when a nurse asked who the mother for the name of the child's father. She replied that the kid has two mothers. The nurse replied, 'But who is the dad? I need to fill this in on Epic.'"
The Dean of Student Diversity concluded: "I hope everyone goes home and reflects about their own implicit biases. We each should strive to learn about a new community everyday. I will admit that I am ignorant about much of the transgender community. I am trying to learn about their language and customs. I don’t know much about them."
The next day we begin with a presentation from a Department of Health official about vaccination. "As you begin your rotations, you are going to interact with patients that do not believe in vaccines. As a healthcare worker you need to know about the misconceptions that are out there."
The biggest misconception is that vaccines cause Autism. She explained that this movement originated in Dr. Andrew Wakefield's study that found eight children who got MMR around the same time autism symptoms presented. This caused havoc in the UK. MMR vaccine rates plummeted, yet Autism rates persisted. The UK now has 80 percent MMR rates, well below the 95 percent required for herd immunity. Measles is now endemic in the UK.
"We find that physicians are a key communicator in the community to get vaccine rates up. Most of the time, the parents will change their mind if you delve into their thought process. That takes time that most physicians unfortunately don't have anymore."
Orientation concludes with a presentation on social media pitfalls and patient privacy. The Privacy Officer: "Long story short: don't snapchat or instagram. Talk about patients in the resident lounge not on elevators." [This advice was not heeded as Pinterest Penelope decided to snapchat a drug-screen result testing positive for benzos, cocaine, meth, heroin, and thc for a patient with the caption, "Must have been a crazy party."
Friday afternoon, I volunteer at the free clinic associated with our university. I interview the patient first, and then present the findings to an M4. We then interview the patient together and give a final report to the attending, typically an internist, family medicine physician or emergency medicine physician. The first patient: 56-year-old female with a history of depression and type 2 diabetes presents for a diabetes check up. She has been doing fantastic, losing 50 in one year while keeping her A1Cs in the 6 percent range. However, last year, she has gained 40 pounds and her A1C this visit has jumped to 7.5. As I do a medication overview, she says she has been taking depakote (valproic acid), a mood stabilizer for bipolar disorder. Why? She explains she was prescribed it when she was brought to the ED while using heroin. She lied to the physician who took her symptoms as a manic episode. She has not seen the prescription physician since her ED visit. I ask, "Do you have a history of bipolar disorder?" She responds, "No." She began the depakote around the time she began gaining weight. I speak with the M4 who recalls that depakote can cause a metabolic syndrome. We both go in an complete the exam. He quickly goes through a focused diabetes physical exam, complete with assessment of peripheral neuropathy and retinal exam. He fluidly asks questions focused on diabetes symptoms, e.g., polyuria, visual changes, numbness/tingling in the feet, shortness of breath. We propose our plan to the attending who decides to decrease her dose by half and have her follow up in a few weeks. Overall, I realize how out of practice I am with patient interview and physical exam skills. I recognize that I need to be able to do a diabetes exam, including retinal exam, peripheral neuropathy exam, like the back of my hand. It was exciting to see the M4 perform the exam with such fluidity.
Statistics for the week… Study: 0 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: Jane and I attend our class' July 4th BBQ on the weekend at a classmate's house. We had an excessive amount of food and beer featuring ribs, burgers, chicken thighs, and local craft beer for a cost of $4 per person paid via Venmo. We eight, including me, who are starting on surgery on Monday are the butt of jokes. Mischievous Mary: "Throwing you to the wolves." I talked with a refugee-status immigrant from Lebanon who attends the same church as a classmate. Straight-Shooter Sally overhears this and adds, "Oh, have you talked with Geezer George? His family is from Lebanon and he visits there regularly and is always talking about how great it is and encouraging us to come with him."
Eight of us arrive Monday at 6:00 am for surgery rotation orientation in a small conference room tucked away in the basement of the hospital. The surgery clerkship director introduces himself, and demonstrates suturing, hand ties, and laparotomy technique using a neat simulator device for 45 minutes.
He then leads a 45-minute discussion on postoperative care and complications. "Everyday the attending wants to hear the vitals, labs, and I/O [input/output]." The first two or three days after a surgery, the stressed body will hold onto water. Beginning Day 3 or 4, the body will begin to mobilize fluid. If you don't see this happen, you should start to worry." Does anyone know when is the highest risk for postoperative MI? [blank stares.] "It's day 3 or 4 if the patient does not mobilize fluid. The fluid overload basically causes congestive heart failure." We learn about the five most common causes of postoperative fever [5 W's pneumonic]: Wind (pneumonia/atelectasis), Water (UTI), Wound (infection), Walking (DVT), and Wonder Drugs.
General Surgery at our hospital is organized into four different services: (1) elective, (2) emergency, (3) trauma, and (4) pediatric. The speciality services, for example, cardiothoracic, urology, otolaryngology, orthopedics and vascular are seperate teams. If a trauma alert comes in from, e.g., a car accident, the trauma service responds by meeting EMS and patient in the trauma bay. If someone comes into the ED for an appendicitis, emergency will go to the consult and determine if they need emergent surgery or if they can wait for an elective surgery later in the week. Each team has one attending, one chief resident (PGY4 or PGY 5, postgraduate year 4, i.e., 4 years into residency), one mid-level (PGY 3 or 4), an intern with 1-3 medical students. The interns started only a month before us so they are also learning the ropes.
For the next three weeks I am assigned to the elective general surgery service along with classmate Christian Charlie. His fame among classmates was assured during the first year mock breast exam when he exclaimed, "Is this what breasts feel like?!?" During anatomy lab, he asked, "Is this where the clitoris is located?" (He was engaged when these questions were asked, then married at the end of Year 1.)
Orientation wraps up around 7:20 am for us to meet our team for a few minutes before the first case of the day. I meet my Chief as she downs one of her favorite La Colombe coffee cans in the Surgeons' Lounge. The PGY3, Quiet Quincy, and intern, Bumbling Brad, walk in shortly after me. Quincy is pretty open about his situation. He originally wanted to do orthopedic surgery, but did not get into a residency program. Having failed to match, he did two preliminary years in general surgery at two different institutions before finally getting a "categorical match" in general surgery (starting as a third year) at our institution. The intern couple matched with his girlfriend who is doing plastic surgery.
[I asked Brad about the couple match process. "It was terrible. We didn't get any of our top choices for her to do plastics while I did general surgery. Two spots makes up a large percentage of a residency's slots." He didn't have to be married to his match partner? "You can couple match with anyone. You don't even have to match to the same institution. You can couple match as friends, as same sex." He joked that if you really detest someone, you could couple match and rank hospitals at opposite sides of the country.]
Charlie and I are assigned by the Chief Resident to one of the two attendings operating today. The Chief joins one attending while the PGY3 and intern manage the floor of post-operative patients. The PGY3 may occasionally scrub in if the chief declines the case, if the attending requests him/her or if the PGY3 has been following the patient for a takeback (additional surgery following a complication). The intern never scrubs in. Brad explains: "They want you to be begging for the OR." The intern, PGY3, and I head off to the floor to manage post-operative patients while the chief and Charlie head to the OR for the first case, a lap sig col (laparoscopic sigmoid colectomy).
Around 9:00 am, I head down for my first case, a melanoma (skin cancer) excision from the left thigh. I introduce myself to the patient in the pre-op with the chief. I then go through the "OR tunnel," turning around once to grab a hairnet after a nurse yelled, "Where's your hair coverage?". I walk in and the four individuals in the room look up briefly as they continue their preparation. Fortunately, Quiet Quincy told me to always introduce myself when walking in: "Hi, I am a third-year medical student who will be scrubbing in." The circulator nurse responds, "Get your gloves." I don't know where they keep the gloves… I look around and see the cabinet. The goal to pick up two layers of gloves and get them on without anything non-sterile touching the outside of a glove. The packaging of the gloves is considered contaminated. Only what's inside the package is guaranteed to be sterile.
I grab "8.5 under, 8 over" gloves (two pair) and walk over to the sterile field. With my contaminated hands, I peel back the glove pack so that Loudmouth Lilly, the surgical technologist (surg tech, aka scrub tech) can grab the gloves without touching the outside contaminated plastic covering.
Lilly enjoys poking fun at my surgical oncologist attending and, especially, medical students. She grins and asks, "So how many gowns will we need with you?" (Assuming that I will "break the field" and have to re-scrub.) I nervously smile, "Just in case, I'll grab another one."
The patient is rolled in by a nurse and the anesthesiologist begins propofol [Editor: Michael Jackson's first choice] and the inhaled anesthesia. I ask the circulator nurse to help me place the "foley" (foley catheter, a plastic tube placed into the urethra to empty the bladder). We both grab another pair of sterile gloves, just for this procedure, so that she can guide me through it. There are subtle tricks to make it easier, for example, pulling the plunger out of the lube syringe so you can anchor the foley tip. This stabilizes the foley so it stays in the sterile field until you are ready to insert it into the urethra. "Make sure you grasp the shaft firmly, once you place your hand down, it needs to stay there because it is no longer sterile." I advance it until I see the flash of urine, retract it a little bit and blow up the balloon to anchor it in the bladder.
Quincy and I then go to scrub in just as the attending arrives. He is a new attending in his 40s who completed a surgical oncology fellowship after completing a general surgery residency. I take the chlorhexidine sponge and scrub for 10 minutes. After I rinse off, I struggle for a few seconds to push the OR doors open (a practiced butt maneuver; everything below the elbows must remain sterile), upon which the circulator nurse opens them for me.
The surg tech hands me a towel to dry my dripping hands. Lilly then opens the gown as I spread my arms into it. "Keep you hands inside." The circulator nurse ties the gown from behind. I struggle to dip into my gloves as the surg tech opens them up. My fingers are in the wrong glove holes, but this can't be fixed with a non-gloved hand so I need to wait until the other hand is gloved to try to fix the situation. "These gloves are way too big. Get 7.5/7.5". Once the circulator nurse hands the new gloves to the surg tech, we reglove again. The surg tech whispers, "You'll get better." My second glove dive goes much more smoothly. I start walking towards the OR table. Lilly: "Hey, your card!" Oops. I need to finish gowning by wrapping the belt around. I hand the tech a card attached to one end of the belt. She holds it while I spin around thereby wrapping the belt around me. I then yank the belt end, detaching it from the card, and tie it in front. The nurses hoard these little cards. Why? "We write notes down on them. It's kind of a bragging right if you get a bunch of them." I take my place next to the PGY3 on the patient's right with the attending, surgical tech, and her Mayo stand (stand over patient with accessible instruments) on the opposite side.
The pimping starts immediately. What are the different types of melanoma? Easy. Sarcastic Samantha gave me her copy of Surgical Recall. I keep this book in my white coat and reviewed the section and also UpToDate before the case. He realizes this, and changes the subject to soft tissue tumors. What is a sarcoma? I respond: "A neoplasm derived from mesoderm." What kind of animals are they classically found in? I'm stumped, and take a wild guess. "I'm going to guess dogs." He scolds me: "You need to answer confidently. It's okay to be wrong, but be confident. You know more than you think, and you must be confident with patients. I would rather you be confident and wrong than be right and timid. Now is the time to be wrong when you have attendings and residents to correct you… And by the way, dog is the right answer. We've learned most of what we know about sarcomas from studying them in dogs."
[Editor: A peek into the often-in-error-but-never-in-doubt factory!]
The pimping continues as we sterilize and drape the patient's left thigh and inguinal (groin) region. I am tasked with taping the scrotum up to prevent contamination. How large an incision do we want on this melanoma? I respond, "Margins are based on the depth of the lesion. His lesion is under 1 mm and not ulcerated, so we need 1 cm margins." He respond, "Okay, that's not answering the question. Quincy, how will you make your incision?" He turns his attention to Quincy but summarizes every step in a confirmation of my presence. Quincy uses a sterile ruler to draw a 1 cm margin around the 1 cm circular lesion. He then creates a 9:3 cm ellipse to get good closure." The attending asks me: "Do you know why we drew this ellipse?" "Is it easier to close? I mean, to make it easier to close." He responds, "Yes, but why?" I don't have a good explanation. "You need to stop us if you do not understand something. I assume you know it if you say nothing." He moves on to continue the case. The questions cease once he watches the PGY3 make the incision and inject "Local" (lidocaine with .25% epi mixture in a syringe). Once they removed the entire ellipse down to the rectus femoris fascia, the attending marks the superior and lateral margin of the specimen with a long and short suture that I get to cut with a suture scissors. I use Army/Navy retractors to retract the skin as they mobilize the skin around the thigh. The attending asks Quincy, "How would you close this?" The PGY3 responds, "I would do a deep dermal with 2-0 vicryl, then a running subcutaneous with 4-0 vicryl and dermabond." "Okay do that." He turns his attention to me while he watches Quincy's shaking hands at work.
He asks me, "How do we determine what lymph nodes to remove?" I respond, "We injected contrast for the PET/CT scan, and we inject dye that flows down the lymph node [I'm not sure when we injected the dye, perhaps with the local?]. "Yes, you must do a sentinel lymph node for any melanoma that is not in situ. Clearly this had 1 mm depth so we know it spread beyond the basement membrane. I'll look for the black dye we injected in our lymph dissection, and we'll use the scintillator to trace for nucleotide uptake. We're good once we get all the nodes with a hit less than 1000." We finish the lymph node dissection in about 30 minutes, and then the attending scrubs out while Quincy and I close -- Quincy sutures, while I cut the knots. The first few cuts I am freaked out that I will ruin the knot by cutting too close, but I quickly learn to slide the suture scissors until I hit the knot. I get out of the OR at 5:30 pm after two more melanoma cases, each requiring a lymph node biopsy. We never get a lunch break.
Our team meets with the night team in the OR lounge for the evening handoff. We also divide up responsibility for checking on ("rounding on") particular patients the next morning.
Tuesday is the first day that is typical of the rest of the rotation. The surgical oncologist (attending) starts his rounds at 6:30 am, requiring the Chief (resident) to start her rounds at 6:00 am. I have to see my patients before she starts and therefore wake up at 4:00 am, shower, and try to grab breakfast at Chick-Fil-A (discovery: they open at 6). I eat a few granola bars on the way to the OR locker rooms to change into hospital-provided scrubs. I arrive at the PCU (patient care unit) at 5:00 am and talk to the overnight nurse and night team intern about my two patients. No changes. I had not been present for either of my patients’ surgeries so I have to read the notes that are made confusing by Epic's auto-populated SmartText templates (two pages of insignificant labs before the assessment and plan sections).
I review the patient's overnight vitals, I/O (input/output), and labs (at a minimum, CBC and CMP (complete metabolic panel) every night). Being unfamiliar with the most efficient summary screens (e.g., the "Rounding" tab), how to customize Results Review, and how to read I/O, I don't get into the first patient's room until 5:30 am.
My first patient: "Greg", a 70-year-old s/p pancreaticoduodenectomy, commonly known as a Whipple procedure, for a biliary duct neoplasm on POD #6 (Postoperative Day 8, meaning he had the surgery on Wednesday of the preceding week). He has a pancreaticojejunal anastomosis leak, a common complication. This requires three peritoneal drains and NG tube decompression. The bilious drain output is increasing. His wife and two daughters are there (at 5:30!) and requesting a pathology report from the surgery. Is this a malignant tumor? I tell them the pathology report is still pending, but I will bring this up with the surgeon (same as this week's attending). After I examine the patient, I write a progress note on the patient using a student SmartText template on Epic. Medical student notes require a co-signature from a resident, so the result is that the resident spends more time than if he or she did it to begin with. My classmate and I keep getting kicked off the limited number of computers by nurses and residents from other teams. I finish his note around 5:50, leaving little time to interview and document the second patient.
When the Chief arrives with her La Colombe coffee, the intern, resident, Charlie and I sign off our computer and follow her lead. Our pack of five travel the hospital and stop outside each of the ten patients on our service. The resident, intern or med student assigned to the patient presents the case in a 30-second-maximum presentation: one-sentence description of procedure; any highlights for vitals, labs, or overnight events; I/O including drain output; medications (pain control, dvt ppx (deep vein thrombosis prophylaxis); and plan (diet advancement, tube removal, imaging required, etc.).
We get back to the nurses' station a few minutes before the attending arrives at 6:30 am. We repeat the rounds with the attending. I mention the family requesting pathology results. He interrupts and instructs the whole team to never go over pathology reports with Whipple patients. "It is essential that I tell them what the pathology report says. We never discuss this while the patient is in the hospital. His goal right now is to get better, and only after will we begin that discussion." The pathology report is released that afternoon: Adenocarcinoma of the biliary tract. A death sentence. Even if he gets out of the hospital, he is going to have to get non-curative chemotherapy.
The Surgeons' Lounge is where surgeons get frustrations off their chest. I ask the Chief: Do you think my patient was a good candidate to get a Whipple? "Surgeons are by nature optimistic, especially <surgical oncologist>." One surgeon joked: "I do not know where he finds these patients. They're cockroaches, they just won't die." One attending chimed in: "One of his patients was so fat it took 160 Liters [of air] to insufflate. My god." [insufflation: before laparoscopic surgery, the abdomen is punctured with a needle and pushed full of air until 12 or 15 mmHg. This allows better visibility when the other laparoscopic ports are inserted. Normal insufflation volume is 5-10 Liters.]
Quincy and I step out to refill our water bottles and he offers advice about the surgery rotation: "Much different criteria than internal medicine. Internal medicine wants to see how smart you are. That’s the time to show your intellect, to pontificate about the nitty-gritty details. Surgeons want to see you’re willing to put in the time and effort. You need to be competent, but hard work is a lot of what it takes to become a good surgeon." He adds, "Also, make sure you know something about the patient before you go into the OR. You’ll get chewed out if you walk into a case and don’t know the patient name or HPI [History of Present Illness]."
After the nurse rolls Tuesday's second patient in for a cholecystectomy (gallbladder removal), around 9:00 am, the anesthesiologist begins Propofol in a peripheral IV. I learn that if I want to do procedures, get to the OR early and make friends with the anesthesiologist. She guides me through placing a radial arterial catheter line ("A-line"). It takes me three sticks. "Good job, those are some calcified arteries." (The Patient Care Unit (PCU) nurses that evening express concern about a large bruise on the wrist.)
The OR team can tell by the small details if you are competent or a newbie. Do you pull your arms all the way through when you spread your arms through the gown or stop at the white cuffs? Do you reflexively hand the belt card to spin around after your gown is on? Do you wait for the surg tech to acknowledge you or just open and hand your gloves to the surg tech? Do you grab the razor to shave the patient once he/she is under anesthesia? Do you get the Foley package or do you hover around the nurses until they grab it? The hardest part is learning the terms and abbreviations for different instruments and dressings. Once you master the smaller details, the surgeon will let you do more important things, such as closing the 5-port (smallest lap port incision) or suturing in a drainage tube.
The team discusses where to place the first port. Our attending: "What are the layers of the abdomen here, pointing to midline under the umbilicus [belly button]?" Me: "We are above the arcuate line, so from deep to superficial: Transversalis fascia, followed by the anterior and posterior aponeurosis." The surgeon interrupts: "We’re midline…" Me: "Sorry, sorry, we have the linea alba, and the transversalis fascia."
The Chief makes an incision and burrows down with her fingers. The attending watches and asks me, "What is the first step in this operation?" Me: "We need to insufflate the abdomen to 15 mmHg." Silence, indicating a correct answer. The surg tech hands the Chief a trochar (rigid hollow tube with valves) to penetrate the fascia and enter the peritoneal cavity. I see the pop, they blow the balloon up and begin insufflating the abdomen with air. As the belly rises, the Chief slaps it.
The Chief: "Why do we slap the abdomen?" My guess: "To make sure it’s all the way in?" She is too polite to point out my error: "Yeah, we want to make sure we are pumping air into the peritoneal cavity, and not into the colon or small bowel." Once insufflated to 15 mmHg, they remove the trochar, and place the laparoscope into the abdomen. I look on the television screen as the greater omentum appears followed by the small bowel and liver. They look down into the pelvis as they poke on the belly to place the next ports. They make two incisions and use blunt dissection (with their fingers or dissecting scissors) to create a path for the ports. The Chief hands me one of the port and trocars. "You do it." I apply pressure, but the fascia is not giving. "Rotate it, it’s more of twist and shove than just a shove." The transversalis fascia eventually gives and we have the ports placed.
Our overall goal: remove the gallbladder after gaining control of the cystic duct and artery. The attending grasps the gallbladder with "a Maryland" (forceps) while the Chief dissects the soft tissue attachments until the cystic artery and duct are two distinct structures. She applies 1 cm metal clips across the proximal and the distal end of what we believe is the artery (but was actually the duct). The Chief applies a clip to what we think is the duct and makes an incision with the scissors. The blood squirting into the abdomen tells us that we switched the artery and cystic duct. Attending: "Give me suction." Now that the blood is being vacuumed out we can see and apply two clips to stop the bleeding. Fortunately this artery won't be needed after the operation is complete. It takes the Chief six attempts to get a catheter into the duct so that we can inject contrast for an X-ray (fluoroscopy). The Chief and attending express frustration at the 5-minute wait for a tech. "They knew we would need them." Her results shows two stones in the common bile duct (CBD). We call in a gastroenterologist for an ERCP (endoscopic retrograde cholangiopancreaticography). I hold the port while he drives the scope. We get to the duodenum quickly, but it takes 10 minutes to locate and cannulate (push tube out from the center of the scope) the Ampulla of Vater. We are looking for a pyramidal projection of mucosa where the liver and pancreatic juices drain into the duodenum for digestion. He finally finds it and injects saline to dislodge the stones. After injecting more contrast to confirm there that we got all of the stones, the GI leaves while the surgical team begins again. The Chief uses the Mother of All Staples to place 200 staples along two inches of ligaments attached to the liver. This is a two-minute procedure with the Ethicon rep in the room available to answer stapler questions. We use an in-abdomen bag-and-seal device for the gallbladder and yank it through the large endoscope port. I remove it from the plastic and the walls are slimy. When compressed I feel about five hard rocks.
The attending scrubs out, and allows the Chief and me to close the fascia and ports. Three more operations, no lunch break, and I get home at 7:30 pm. Pass out at 9:00 pm. Wake up at 4:45 am and do it again.
Jane is on her psychiatry rotation. She goes in from 8:30 am to 4:00 pm. She loves her Chief resident and attending. They bonded over the Harry Potter pin on her white coat. She interviews admitted psych patients while the attending observes.
In addition to AM rounding and cases, we eight students on the surgery rotation attend two lectures/round-table-discussions per week. This week is on appendicitis and diverticulitis by the surgery chairman. He's a smiling portly fellow who wears bowties and pimps residents and students alike on the history of surgery. Our class president, a huge suck-up, asks, "Isn't it tough for a surgeon to have so much pressure. How do you cope?" The Chair asks everyone to introduce themselves and say what their interests are. Everyone says they are interested in surgery. I know they are not.
Friday morning we round 30 minutes earlier so that we can get to the M&M [Morbidity and Mortality] conference and resident lecture. Med students sit in the front with residents behind and attendings in the back. After M&M, an attending lectures on a surgical topic focusing on Boards. The attending selects an intern to answer questions. If he/she is unable to, the attending goes back a row to a PGY2, etc. Medical students are never called on.
Statistics for the week… Study: 0 hours. Sleep: 5 hours/night; Fun: 1 night. Example fun: Burger and beers at 5:00 pm. Mischievous Mary is the first to complete her 100-beer list. We joined in for the celebration, but leave at 7:00 pm for my 8:30 pm bedtime. Year 3, Week 2
"The first week was pure adrenaline. I never felt tired. This week I'm crashing hard," comments Surgeon Sara, a classmate on the emergency surgery service, as we head up in our scrubs to the PCU at 4:45 am. I've learned that I need more time so I wake up 15 minutes earlier at 3:45 am. We both reminisce how we should have studied basic postoperative recovery timeline (e.g., Enhanced recovery after surgery (ERAS) protocol, pain medication regimens, anxiety meds, etc.).
Several of the attendings are on vacation so we have a light caseload for elective (non-orthopedic) surgery with the exception of the surgical oncologist's cases. The Chief is very excited about "her Whipple" on Thursday. I let my classmate Charlie scrub in on some more melanoma cases while I try to get in on some cases on other services. There are always ample orthopedic cases going on all hours of the day (including Saturdays), so my goal is to find a joint replacement.
The first step is to check Epic for the "Status Board" of scheduled surgeries. There are no private desks or offices. Using a personal device is challenging due to VPN requirements for accessing the hospital's Epic system. I take a rolling cart containing a Windows PC, which will connect via WiFi and Citrix, to the end of a deserted hallway. I find a shoulder replacement that looks interesting and watch a couple of videos in prep while consuming Cheez-Its and granola bars at 10:00 am.
Second step is locating the attending to ask if I can scrub in. Epic shows his name, but not a photo. His university profile page contains a photo, but these images are usually 10-20 years old. There are six attendings in the OR lounge, identified by badges, and I find him on my third attempt. "Of course, I’ll see you there in ten minutes."
We're doing a total shoulder replacement. I help retract as the surgeon hammers in the prosthetic joint parts. When finished, the surgeon steps out to begin another scheduled case and the PA allows me to close the incision sites under her guidance. I ask where I can get trauma shears, the most coveted item for medical students hoping to be useful during rounds and trauma alerts. They can be used for cutting clothes off a trauma patient, during dressing changes, and for chest tube removal."Stay here" She disappears for 30 seconds and returns with a brand new pair.
I get out of this case and a follow-on shoulder arthroscopy (minimally invasive procedure using endoscopy to evaluate and clean out a joint) at 12:30 pm and find my team in the OR lounge. The cases are finished, and they are planning to check in with the intern before the Chief heads out for the day. I check the status board and notice an organ procurement procedure is posted. I ask my Chief if I can see that. "Yeah, they might already be finished." As we are in the elevator, Christian Charlie mentions, "That’s awesome you’ll be watching an organ harvest. Good luck!" The Chief responds: "We don't use the term harvest; it's 'organ procurement'. But yeah, they are surprisingly quick, in and out in 30 minutes, but you can’t beat the anatomy experience." I head down to OR 10.
When I arrive, there are 10 people sitting on the floor outside the OR. The donor is 35 years old, suffered a car crash a week earlier, was declared brain-dead yesterday and had care withdrawn, thus initiating the donation cycle. Three different transplant programs have arrived -- a heart, a lung, and a liver/kidney team. They're waiting for final approval from the hospital's legal department while the donor is kept perfused by the anesthesiologist, the one remaining member of our hospital's team. The patient checked the organ donor box for his driver's license years earlier, but the organ donor program (typically a contracted company for the state) also sought and received written consent from his wife, which initiated the transplant program (the care team never brings up the possibility of organ donation with a family). Two hours, the wife withdrew her consent and requested a delay for reasons that are unknown to us.
The heart team includes an attending, a cardiothoracic surgery fellow, and resident. I take them to the cardiology reading room so they can review the TEE (transesophageal echocardiogram) images to confirm an acceptable heart. Everyone agrees it is a strong heart. When we return, there is no resolution on the consent issue. I check back in with my team still in the OR lounge. Christian Charlie went home around 2:00 pm, and the Chief is packing up. I head back to the OR and take a seat with the transplant teams.
The surg tech explains that he is on call for blocks up to 72 hours, and has to be at his local airport within one hour of a call to board a business jet.
[Editor: Our Boston-area organ program has a Cessna CJ4 and the pilots work week-on/week-off shifts.]
The state-authorized transplant coordinator finally gets an update. The wife wants to cancel the donation. This ignites a tense discussion among teams and four institutions legal teams (our hospital's, plus lawyers from each of the three hospitals that have sent transplant teams). The attending from the lung team wants to go ahead; the other two are leaning towards declining. A life-or-death situation calls for people to drawn on all of their philosophy, moral background, and legal training: "I'll decline, if you'll decline," says the liver/kidney attending to the heart surgeon.
The lung team calls home to see if they can use the other organs, but the transplant coordinator begins calling further down the list. "We have to continue going down the list as long as my program and legal say its a go."
"My responsibility is to my patients and their families back home," says the lung surgeon in an Old World accent and a tone that would earn him a role in the next sequel to Silence of the Lambs. The heart attending: "If the wife starts talking to the press, this will set back transplant medicine a decade. I know we might have legal ground, but as a doctor if you are not comfortable with something you always have the right to decline." The perfusionist on the lung team: "This doesn't seem right."
I leave at 7:00 pm and learn the next day that the organ procurement occurred at 3:00 am. Hannibal Lecter got his lung and two new teams jetted in overnight for the two two. Ultimately the widow had agreed to the procurement.
Thursday is the big day. The Whipple, a 6-11-hour procedure to remove a bile duct tumor (see Week 1). We are the first and only case scheduled for our OR. Only one student can be officially scrubbed in at once, so Christian Charlie and I agree to alternating two-hour shifts. We finish rounding at 6:45 am and head down to Pre-op to introduce ourselves to the patient. We help move the patient from her stretcher onto the OR bed, and the CRNA (Certified Registered Nurse Anesthetist) lets me intubate the patient!
Charlie scrubs in first. I'm not officially scrubbed in, but watch from a stack of three step stools behind the drapes at the head of the bed.
The chief begins with a large midline incision from one inch below the xiphoid to one inch above the pubis. Christian Charlie helps suction and retract. Once the parietal peritoneum is opened, the Chief uses clips and the Bovie to dissect the lesser omentum of the stomach. The attending questions Charlie: "What vessels are we cutting?" (short gastrics) and "What space are going into when we cut this omentum?" (lesser sac). Charlie won't admit ignorance: "It's something in the abdomen." From my perch I ask, "Why don't we have to remove the fundus if we take the short gastrics [that are supplying the fundus with blood]?" The attending explains, "The stomach is one of the most collateralized organs in the body. You can take a few vessel groups and it will still be happy."
After about 30 minutes, they've gone too deep for me to see anything so I head off to my secret alcove and find the computer still there on its rolling cart. I watch YouTube videos of the Whipple procedure and read UpToDate as I eat Cheez-Its.
Charlie and I swap for the rest of the day. The most exciting part was when we were dissecting the common bile duct off from the portal vein. The tumor had spread into the adventitia of the portal vein requiring extreme care. "Careful, careful!" exclaimed the attending as he takes control from the Chief. The team will work until 11:30 pm, but Charlie and I have to leave for a required "learning environment" session at the medical school hosted by the Chief Diversity Officer. Charlie is unhappy about missing the rest of the operation and as we walk over, we encounter Ambitious Al, who had to scrub out of an exciting rib plating on a car accident victim ("MVC" for "motor vehicle crash"). "They might have let me do the chest tube."
We are 10 minutes late, but people are still filing in. We watch the same PowerPoint that we've seen four times previously in two years about types of reportable mistreatment. The Chief Diversity Office maintained an excited high-energy tone through slides defining harassment and avenues for reporting it, but many students took advantage of this break to check Facebook and Amazon from their laptops. Those on surgery rotations whispered about what they were missing. Last year's 45-minute lecture has been extended to 2 hours and 15 minutes total, including a 1.5-hour block for 8 students to go through scenarios with a dean.
We get a one-paragraph description of a case and each student is required to say something before we move on to the next one. A sample of the 11 cases...
Case 1: A surgeon hits a student's hand that is holding an instrument and yells, "Don't do that." The student begins to cry. Our Chief Diversity Officer opens: "The attending should never hit a student. Period." Lanky Luke: "We don't know the full story. Maybe the student was about to do something really bad on the patient, and it was a light tap, saying don't do that." Canadian Camy: "That is still inappropriate. It makes you feel very uncomfortable, especially if it is a male hitting a female."
Case 2: The chair of the department notices a female medical student studying in the library. The chair begins asking questions about the subject, which she can't answer. He continues to press, until she begins to cry. Class President: "There is a clear distinction between teaching versus emotional distress. There is no reason to push someone until embarrassment and mental distress." Type-A Anita: "Sounds like a douchebag old white male getting off on a powertrip." Chief Diversity Officer: "I love that! I'll have to use that with next year's group."
Case 3: Two males and two females are on an away rotation. The two males become good friends with the residents while playing basketball after work. They start to go on "boys night out". The two female feel like they are getting less OR time and less teaching time. Is this inappropriate? Type-A Anita: "Everyone should be given the same opportunities." Chief Diversity Officer: "I think there is a win-win scenario here. The women should ask to meet up with the team for drinks after basketball so everyone gets to know each other." [Editor: What if the two females are Muslim and don't drink?]
We get out at 7:30 pm and start at 4:30 am Friday morning for more of the same.
Christian Charlie and I begin a 24-hour call shift at 6:00 am on Saturday. We join the Chief, Quiet Quincy (PGY 3), and Prego Patricia (an intern who is 7 months pregnant) for a 45-minute morning report from the Friday night team on about 100 patients.
Patricia covers the entire floor while Quincy, Charlie and I cover only ED consults. The attending goes to his office and waits for any urgent calls. Our job is to determine if a patient has an urgent (requiring operation now), emergent (requiring within 72 hours), elective, or non-operative condition. Our home base is the trauma bay physician's lounge, a small alcove with comfortable seating for two and three computer terminals. Heat from the trauma bay, set to 80 degrees to prevent hypothermia, seeps into the alcove. The Chief hangs out in the trauma bay unless the intern (her career as a physician started three weeks ago!) needs assistance: "Interns are so cautious and self-doubting. Last week we had a patient who became hypotensive after surgery," she explained. "He called me up: 'I want to give a 200 mL bolus of LR [Lactated Ringers, similar to saline]. Is that okay?' 200 mL, come on!" [A typical fluid resuscitation protocol includes at least 1 L.]
Charlie and I interview patients as a team. I'll ask basic questions, and then he'll follow up with a clarification question. One of us will present the findings to Quiet Quincy.
We see a 25-year-old female with acute appendicitis. She came to visit a patient hospitalized after a car accident. "Her belly started hurting so we decided to come down two floors to the ER." As we go back to the trauma bay lounge to give report, the attending and chief spot us and whisper, "Hey come here. Go into this room, don’t look at anything in his chart before reporting back to us."
The 60-year-old university professor has been getting progressively yellower for the past several months and now positively glows. Charlie and I look at each other. We go through the causes of jaundice. Any pain? No. Any exposure to transfusions or IV drug use? No. History of a blood disorder? We report back that he has painless jaundice, most likely due to a neoplasm (cancer). The Chief informs us that they had already discussed his CT finding of a pancreatic mass, a death sentence, with the patient. The chief explains, "We asked him if our medical students could interview him for learning." I exclaim: "What a nice guy! The attending responds: "It's always a nice guy. If it's a nice guy you know it'll be cancer."
Our next consult is a 45-year-old diabetic man suffering a perianal abscess. Weighing in at 450 lbs., he has not walked in several years, bed-bound in a nursing home. We roll him down to the OR in a special heavy-duty patient transporter. It takes the entire OR team with the special bean bag mover to get him onto the OR table. It takes about 30 minutes for us to get his legs in the lithotomy position to fully expose the anus. The attending exclaims: "Any other county this patient would be dead. Go USA!" Charlie attempt to insert a Foley, but as he is prepping the glans of the penis (head), urine shoots out and covers his pants and shoes. "Oh, God!" Charlie screams! The nurses laugh as they grab towels to stop the stream. Charlie repreps the patient and successfully inserts the Foley. Another 2 L pour out into the bag. "That's a neurogenic bladder," notes the attending as he watches from the computer in the corner. The Chief and I scrub in as the nurses prep the abcess site.
After we drape the patient, the Chief hands me the scalpel. "Do the honors." My eyes go wide -- first time I've held a loaded scalpel since anatomy lab. I cautiously make a 2 cm incision in the skin of the abcess. Pus and blood shoot out as the Chief dodges the jet. Some gets on my shoes and the smell makes us both choke. The Chief squeezes the skin to accelerate the drainage. The chief calls out: "Wintergreen! Wintergreen!" The nurse instructs Charlie to grab a small bottle in the cabinet. He breaks the seal and applies small dollops with a Q-tip to our masks. The pus-poop smell disappears as we breathe in the cool mint. The attending puts her fingers, then entire hand, into the abcess. She lets me insert my hand into the fist-sized cavity. We rinse the abcess out with saline, and leave a drain. The attending, watching, "He'll be back in a few months."
Afterward the perianal abscess, I scrub in on the 25-year-old's appendectomy, which is done laparoscopically and is done within 45 minutes by 1:30 am on Sunday. Things are quiet until 3:00 am when a 100-year-old patient presents for worsening abdominal pain. Charlie is in an appendectomy case, so I see her alone. She alert and oriented. The chart from from the ED shows tachycardia and borderline hypotension that they treated with low-dose phenylephrine (to increase blood pressure) and fluids. A CT scan shows a massive amount of fluid in her abdomen, but no definitive source. She lived independently until two years ago, when she moved into a daughter's house. The attending discusses the case with the patient, daughter, and son-in-law, explaining that recovery is unlikely, though there is a small chance of a relatively benign cause of the fluid in her belly. The patient elects to have a exploratory laparotomy. The attending brings the family into the hallway and explains: "This will most likely be the last time you speak to her. I recommend that you say your farewells."
During our 30 minutes together in preop, the patient complimented my smile and explained how her daughter is the best person in the world. "She forced me to move into her house after I fell." She is unafraid of death, perhaps partly because it would reduce the burden on her favorite child. She described meeting her husband in church prior to World War II (he ended up stationed in Hawaii with the U.S. Navy). The daughter is trying to get her brother to come the hospital, but can't reach him. I allow the daughter to say farewell and come with us to the OR tunnel entrance.
The Chief makes a midline incision and we smell feces immediately. A gloom descends over the attending and Chief. The belly is tainted by a brownish red tinge covering every abdominal organ. They use their hands to feel around the belly and locate a 3 cm grey discoloration in the colon wall with a 5 mm perforation in the descending colon leaking brownish fecal material. "There is nothing we can do." The Chief and Attending continue looking and identify that the bladder and uterus are also perforated (by cancer?). "This is incredible," the attending exclaims. "She could have have been like this for months, and just recently perforated her colon. You can have urine in your belly and not be that symptomatic. " She scrubs out, and informs the Chief that she will explain to the family that there is nothing for us to do, we'll close her up and palliate her so she can be comfortable and alert for her last few hours. You teach until I get back to close." The Chief begins showing me various techniques. She shows me how to do perform a trauma evaluation on the mesentery for a "bucket-handle" injury (injury to the mesentery in a rapid deceleration injury). She hands me a segment of bowel and I feel along the mesentery and then pass the bowel to her with both my hands. She shows me the Ligament of Treitz. "Push down here, do you feel the SMA?" I move my hands along the superior portion of the bladder, feeling the too-small-to-see perforation leaking urine. The uterus perforation is large enough for an index finger. The attending: "Do you notice the adhesions?" "Yeah, the entire small bowel is adhered to everything. Itself, the large colon, the bladder."
I developed a much better understanding of the impact of cancer and the fragility of our organ systems. A barely visible hole in the colon can lead to devastation in the abdomen. The attending comes back, and reports the family agrees with our plan. We suction some of the feculent fluid out of her belly and close her up so that she can communicate with her son (he showed up just as my shift ended at 6:00 am) before dying.
Statistics for the week… Study: 0 hours. Sleep: 5 hours/night; Fun: none. My feet are killing me. I sleep all day Sunday.
How should one prepare for a week of nights on surgery? Class president: "I drank a pot of coffee, and stayed up as late I could on Friday." Adrenaline Andrew: "I went out to bars on Friday. Kept me up later than if I had stayed in. Worked quite well in fact. If you're trying to stay up as late as possible come out with us." I elect to go out with several classmates to a few bars, get to bed at 2:00 am and sleep until 10:00 am. In retrospect, bar hopping was a mistake...
We start on Saturday at 5:30 pm in the surgeon's lounge for handoff from the day teams, which include separate groups for colon, liver, plastics, urology, orthopaedics, cardiothoracic, ENT (maxillofacial), etc.. All of these groups' patients will become the responsibility of the night team, which can decide to call a specialist back in for anything urgent. The night team also consults as necessary with the ED and other units, such as oncology.
Our team consists of a critical care fellowship-trained attending ("trauma surgeon"), a senior resident (PGY4-5), a mid-level (PGY2-3), an intern, my classmate Surgeon Sara and myself. The senior resident is a calm 31-year-old aspiring to follow in his father's footsteps providing medicine in developing countries. Navy Nate, the PGY2 mid-level, is a snarky, brilliant 36-year-old who steered a desk for 9 years. "I should've probably should've stayed for another 11 years to retire with a pension. But medicine was my calling. I just couldn't think of doing anything else except surgery. It's the thrill." His wife is a family medicine resident. Pregnant Patricia is the intern who immediately speeds off after handoff to run the "floor," i.e., every floor in hospital with postoperative patients. The chief and I head down to the ED trauma room to wait for consults, while the attending, a 46-year-old tall pensive former philosophy major with a unkempt beard, slips away to his call room.
Our first ED consult is at 6:00 pm. Navy Nate sends Sara and me to interview the patient: "Hey, you have ten minutes to report back. Don't look at the chart. What is the problem? Is this surgical or not? Ten minutes."
Surgeon Sara and I struggle to navigate the packed ED, looking for "Bed 4". The rooms have filled up and patients are on beds in the hallways. A 27-year-old nulliparous female is lying on a hallway bed curled up with her boyfriend, whose family is in the hospital for an MI (myocardial infarction). The energetic female presented for worsening abdominal pain over the past 5 days. She has a family history of Crohn disease (named for gastroenterologist Burrill Bernard Crohn). On physical exam she has significant tenderness on light touch in the lower abdominal quadrants.
After a discussion while walking back to the trauma bay, we present our findings. Sara does the HPI (history of present illness) and PMH (past medical history), while I present the physical exam and A/P (assessment and plan). "It's unlikely to be appendicitis or ovarian torsion. The timeline does not fit. It could be PID or inflammatory bowel disease although she has no diarrhea." The ED had ordered a CT, which Navy Nate studies. The radiologist report is in Epic: "Cannot rule out appendicitis" given the mild edema around the appendix. Nate: "Radiologists can be so useless sometimes, but this is a pretty unimpressive appendix. I agree the timeline does not fit with appendicitis." As we look through her CT we begin to see other involvement of the gut, including striations in the rectum and small bowel. We admitted her for serial exams to see if she worsens, and put in inflammatory labs for IBD.
(Appendicitis usually presents over 48 hours. Umbilical or epigastric abdominal pain transitions to nausea and vomiting followed by localized pain over "McBurney's Point" (halfway between the umbilicus and the anterior superior iliac spine of the hip. The key is that after 48 hours, the patient becomes acute (fever, peritonitis) with either a free rupture or abscess formation.)
Trauma Alerts text messages pop up on our personal phones starting around 8:00 pm. First a 23-year-old MVA (motor vehicle accident). He is talking and does not appear to have any significant injuries, but 10 hospital workers will do a complete trauma evaluation nonetheless. There is a primary survey for airway, breathing, cardiac activity, active bleeding, then a secondary survey for spine fractures, and finally a trip to the CT scanner for a "Panscan".
Trauma Alert at 11 pm: 20-year-old African-American with multiple gunshot wounds and a tourniquet placed by the EMTs. He is having trouble breathing and blood pressure is dropping. A CXR shows a massive hemothorax (collection of blood in the space between the chest wall and the lung) in the right side. The intern places a chest tube guided by the attending. Immediately the patient improves, and we consult plastics for reconstruction of the median nerve.
The chief and I see a patient stabilized in a rural hospital and then flown to us for treatment of septic shock from decubitus ulcer. The 22-year-old was in a MVA three years ago resulting in a T10 transection. He cannot feel anything below his belly button. He is cared for by his aunt. The senior resident and I help him rotate to his left side so we can see the pressure sore. I shine an iPhone light onto the wound. Pus oozes out of the necrotic tissue. I see spongy red bone of the ischial tuberosity. The wound grows every kind of bad bug: KPC, MRSA, VRE. We begin stabilization. "This how paraplegics die. It's a slow nasty death. We'll probably clear this episode up but we'll never get ride of the underlying deep infection. And he'll just develop another one. It's sad to say, but this is what will eventually happen to the ATV boy earlier tonight unless his family takes exceptional care of himself."
Surgeon Sara and I all head to a consult for an 45-year-old 250 lb. male with RUQ (right upper quadrant) pain, tachycardia (rapid heart beat) with stable BP and O2 saturations. When we report back, the Chief, midlevel, and attending are poring over the patient's CT scan and labs. "How's he doing?" "Bad, he has rebound tenderness, intense pain." Labs showed slightly elevated bilirubin, but normal liver enzymes and Alk phosphate. We quickly got hooked on cholangitis even though the liver enzymes were not elevated. The attending arrives from his call room. The chief asks the attending, "See that inflammation around the entire duodenum, not just the gallbladder." "Yep, that's why I came down. Let's get him to surgery." (We still don't know what is wrong with this buy, but it is time to explore.)
Sara: "I am surprised how much the surgeons use imaging before the radiologist gives the final report."
We learn he is a habitual cocaine user and, in fact, had used cocaine just a few hours earlier. He has an acute angioedema attack requiring rapid intubation in the ED and a 10-minute trip upstairs to the OR. The resident opens him up. The belly is a mess, with damage that was not visible on the CT. The gastric juices was eroding away at the tissue in the belly. The attending and resident pass the bowel back forth ("running the mesentery") to look for any perforations in the bowel blood supply. This all happens so fast, I have no idea what is happening. They then identify maybe a five millimeter hole in the stomach from a gastric ulcer perforation. Attending: "Probably from the cocaine. Not his lucky day. Angioedema and a perfed ulcer."
Navy Nate: "I need you do a med reconciliation on this patient [a 35-year-old female who came in for a rule-out on appendicitis]. Her chart says she takes 30 medicines." Sara and I have to hold back laughing as we go through each medication. I ask if she takes X dose for X medicaition X times a day and Sara would write down the answer. It takes us at least 35 minutes because she wouldn’t stop about her experience in nursing school. By the time we finish, it's time for morning handoff. We leave the hospital around 7:00 am.
Wednesday night is memorable. Around 9:00 pm, we get consulted for a 73-year-old Army combat (Vietnam) veteran with a six-month history of worsening fatigue, melanotic stools, anemia and a 15 lb weight loss . He presents to the ED this evening because of an acute abdomen. The ED places him on two pressors for unstable vitals and fentanyl. When we arrive he appears quite comfortable, accompanied by his wife and daughter. Sara asks, "Have you gotten a colonoscopy." He responds: "No I never thought it worth it to get colonoscopies. I am so active." We get a CT that reveals a large mass in the colon with distal metastases to the liver and lung.
I call the VA to request his medical records. The attending instructs me to request only H&Ps, labs and imaging, "No progress notes." 100 pages come out of the fax machine. We find that he has gotten a "CT ab" (abdominal CT scan) with follow-up needle biopsies of the mass about two weeks ago, pathology results still pending. Our patient doesn't know why he got the biopsy and is unaware that colon cancer was the most likely diagnosis.
We go into his alcove in the ED and meet his wife, daughter, and 12-year-old granddaughter. The attending explains that the cancer has grown large enough that it is obstructing the small bowel. The recent onset of pain is most likely from a small perforation in the bowel. The attending explains there are two options. We could take him back to the OR and try to repair the perforation. "It's unlikely that will work because the bowel around it is also invaded with cancer. It will be difficult to find good bowel to close." He emphasizes that this is not a long-term treatment. "You are going to die from this cancer. The other option is palliative care." We tell them to think about the options and go back to the OR lounge to look more carefully at the imaging.
"There is no way we can operate on him," the attending tells us. "He is unstable and the chance of success is so low. Everyone says they are a fighter. Well if you were a fighter you would have gotten a colonoscopy. No one is a fighter. It's the disease. I had an uncle who died suddenly, my whole family was so shocked but I see this every day. No one knows what they would do if given three months to live. No one knows what they find meaningful in their life until life runs out."
Surgeon Sara: "I am calling my parents first thing in the morning to tell my parents to get a colonoscopy. My mom has been hesitant, saying she eats a good diet." I also call my parents to encourage them to get their colonoscopy. Sara and I still have an hour before a required lecture on postoperative management at 8:00 am. We visit the 73-year-old veteran. "We're here not to answer questions, but to give you some questions to ask the colon specialist on the day team."
He confides in us: "I've done everything on my own. I didn’t depend on anyone. What's the word… Pride, that's the word. Pride. I wont have no pride if I am a vegetable. Just last year I was building a foundation in my backyard, lifting 50 lb bags of concrete. I was so active less than a year ago. How can this be?"
Jane and I are two ships in the night. I get home around 9:00 am and she is already gone for her psychiatry clerkship at the state mental asylum. I call her as I walk back to the car. She's had a rough week. She walks around with a massive keychain.. Every door, to hallways, stairs, etc. is locked and requires a physical key. Her first patient: "You're going to die tonight". She believes that she will unconsciously kill everyone around her. "Get away from me," she tells Jane. Jane relates that "I asked her to 'tell me more,' but wanted to say, 'I''ll just be outside if you need anything."
Statistics for the week… Study: 0 hours. Sleep: 5 hours/night; Fun: none. By the time you get adjusted for night schedule, my time is up.
After sleeping all day Friday and Saturday, I am nearly recovered from a week of night surgery and it is time to start a two-week trauma rotation. Morning report starts at 6:30 am with M&M (morbidity and mortality).
"Ted," a burly, soft-spoken 6'4" 32-year-old PGY4 resident described by Surgeon Sara as a teddy bear, is presenting a trauma case on a MVC (motor vehicle collision) patient in hemorrhagic shock from abdominal bleeding. The case was chosen because the team deployed an aortic balloon to maintain blood flow to the brain before exploratory laparotomy. Ted wants the entire surgery team to be familiar with the proper uses and indications for an aortic balloon. The attendings reduce Teddy to blubbering as they grill him on management of this patient. My former chief comments as we walk up the stairs: "[Teddy] was stumbling, but he was answering all questions right." After M&M, we head up to the floor to round on our twenty trauma patients, fifteen of which are fractures following falls, ten from alcohol and five from old age.
I am assigned a 21-year-old patient beginning her second in the hospital following an MVC that resulted in an epidural hematoma (bleeding in the skull) and multiple fractures. She was driving back from work at Subway when a drunk driver hit her head-on at about 45 miles per hour. She was ejected from the car. Most of the ICU team did not expect her to recover any brain function. She has become somewhat of a miracle on the floor as she has regained consciousness, primitive motor function, but is cognitively at the level of a 5-year-old. She underwent emergent craniotomy by neurosurgery to release intracranial pressure from the epidural hematoma. She has a wound vac (sponge-packed wound hooked up to a continuous vacuum) on her scalp from the craniotomy site and a tracheostomy tube that can be capped to allow her to speak. The trach does not bother her as much as the spine brace that is needed for several weeks due to her cervical and thoracic vertebra fractures. Her 45-year-old mother stays quiet in the back as we pile into the room.
(The drunk driver was placed in the ICU bed next to her and passed away a few weeks ago.)
Rounds last about two hours as we go room to room for each trauma patient. I meet my 38-year-old attending. At barely 5'4" she is known to put chills in medical students and residents alike. She is also Jane's role model in surgery.
(We met her in Year 1, Week 17, starting a meeting of a "women in surgery" interest group:
There is no such thing as work-life balance. Anything not work becomes a distraction against surgery... Getting married, distraction. Having children, distraction. I was in surgery on my son's birthday. He waited until 10:00 pm to give me a slice of his birthday cake. His birthday was a distraction.
Dr. Cruella says that we deal with "bullshit" faux trauma (e.g., drunk person falls and is screened for head injury) rather than transfer patients to the internal medicine service or orthopedic service, as was conventional at the hospital where she trained. Her theory is that this relates to enhanced revenue if a trauma note is dropped into Epic. After rounds, we head to the OR for a rib plating (one plate per broken rib) on a 60-year-old alcoholic who was run over by a car after he passed out in the middle of a road. Eleven ribs were broken, but miraculously he suffered only a mild lung contusion.
Dr. Cruella hasn't used this brand of rib plates, so the manufacturer's rep is here to teach her how to use the drill and deploy the plate. After she gets the hang of the equipment, she asks about my background. She describes her experience as a resident. "This old guy in the 'golden age of surgery' used to sexually harass every female -- med student, intern, resident, nurse, you name it -- except the surgical techs. He would never mess with a surgical tech. I was writing a note as a second-year resident and he pulled down my scrub pants in front of the entire OR."
Had she ever been written up for unprofessional behavior? "I got written up for intimidating the blood bank personnel. I was doing a splenectomy and we needed blood urgently. We kept calling the blood bank and they said they would bring it down. I called two more times, and finally they tell me they need a form, which they could have told me right at the beginning. I had to speak with the Chair and attend anger management." Like the movie?!? "No, it's on the phone. Most surgeons have a monthly session."
What's the worst thing you've seen in the OR? "Well besides getting pantsed by my attending, watching a hotshot surgeon throw a spleen full force at the wall. It exploded with blood everywhere and on everyone's face. That was pretty bad." She jokes, "I've never done that, but I've wanted to!"
Has any surgeon gotten written up by a medical student? "At least once every year. Last year, a medical student wrote a surgeon up for 'throwing a scalpel at me'. There was no blade on it. Not sure what was going on, but it could have been just him tossing the scalpel to the student."
The rib plating takes about 2 hours. I assist in retraction of the skin folds while the attending and chief attach the plates between the fractured rib fragments. At the end they allow me to place a chest tube on each side (it will be removed three days later after testing for leaks). Ted patiently teaches me his special "D" suture technique to anchor the tubes in place.
While rolling the patient back to the ICU, a nurse says, "Natural selection, it's a real thing. You get drunk and pass out in a road, Nature is coming for you."
The rib plating ends at 1:00 pm. I wait in the medical student lounge for gold alerts, but there aren't any, and get sent home around 4:00 pm.
The next days are similar. I round on my 21-year-old MVC recovering patient. I also check in on the rib plating, although there is a different service and attending that covers the ICU patients. This can be quite frustrating as many patients that we may do the initial trauma evaluation, and possible surgical intervention, will be transferred to the ICU team for further management until they are ready for downgrade to the PCU (progressive care unit) or "floor" (the most basic level of inpatient care).
Thursday morning: trauma alert for an overweight 28-year-old who fell while running from U.S. Marshalls. He was cornered on top of a two-story building, and decided to jump. Why is he not in handcuffs? "He wasn't arrested," explains the EMT. "That's pretty common. Law enforcement will arrest him after he's out of the hospital so that the Department of Corrections doesn't have to pay for the trauma care."
He arrives on a stretcher. We transfer him to a trauma bay bed, and begin the initial assessment. About 10 people are around him: three trauma nurses, a respiratory therapist, a scribe, an EM resident, a general surgery resident and intern. I grab my valuable trauma shears and cut off his clothes, while the intern evaluates for airway (he can speak), breathing (good air entry into both lungs), and circulation (good peripheral pulses). He has severe pain in both arms. Vitals are stable. We get a chest x-ray to ensure no rib fractures, and a mid humerus x-ray showing a closed, displaced fracture. His right arm has a mid-humerus fracture, and his left shoulder is anteriorly displaced. He also has an anteriorly dislocated shoulder. Ortho tells us via text they will put him on the case list for tomorrow.
Friday morning I pre-round on the patient. He is pensive. He asks, "How old are you?" and then shares some hard-earned lessons. "Make sure you choose the right woman, man. I got two baby girls, and their mom doesn't care about them or me. But I am going to be a man and take care of them." It seems that the drug dealing that led to the encounter with U.S. Marshals was motivated by a need to pay court-ordered child support in excess of his legitimately earned income. The orthopedics PGY2 comes into the room and I stay to see his examination. He tries to "reduce" (put back into place) his left dislocated shoulder. After three failed attempts with just a 50 microgram dose of fentanyl, he decides to just do the reduction during the operation while he is sedated. Orthopaedics take him for open reduction, internal fixation. He stays for seven more days working with PT/OT until he has some movement restored in both arms. Arguably disproving his theory that baby mama doesn't care about him, she was his only visitor during this week.
Statistics for the week… Study: 8 hours. Sleep: 6 hours/night; Fun: 1 night. Dinner party with Lanky Luke, Sarcastic Samantha, Jane and me at Put-Together Pete's apartment. Jane and I successfully made Tres Leche cake.
After a Sunday reprieve, Monday begins two back-to-back trauma alerts that force us to cut rounds short.
A 16-year-old 220 lb. 6'6" African American high school football star flipped an ATV during a morning ride. As he is transported onto the trauma bed, he repeatedly screams, "I can't move my legs!". He has no movement or sensation in either of his legs. A CT shows numerous vertebral fractures. Most likely complete transection of thoracic spinal cord. Neurosurgery is consulted. Nothing to do now but wait. The attending: "We won't know final outcome until about 48 hours when spinal shock resolves."
He spends two weeks in the hospital working with physical and occupational therapy. He is paralyzed in both legs. He becomes agitated and aggressive with the therapists, calming down only when his mother and brother are present (there is never a visit from the father and we are trained not to ask). His football team visits after one week in the hospital. After one week, he is ready for rehabilitation, but the social worker struggles to find a good child rehab facility that will accept our state's Medicaid insurance. My attending: "He would be a fantastic candidate for a few out-of-state adolescent rehab facilities, but I doubt this state's Medicaid will cover them." I am reminded by the young paraplegic who was admitted last week for a Stage IV decubitus ulcer (to soft tissue or bone) and sepsis rule out. If he does not take care of himself, this will also be his eventual fate.
The next trauma alert arrives while the 16-year-old is in the CT scanner. An 18-year-old presents with a gunshot wound to the right leg. He appears stable, with intact pulses and sensation in the lower extremity. EMS reports that he was running away from a gang shootout (our patient is African American; perhaps he got on the wrong side of our active Hispanic gang, MS-13). Somehow the bullet missed all vital structures, just piercing muscle and fat. The attending comments: "The cardinal rule of trauma is that only the good die. If you are a productive member of society, paying taxes, a respectable member in the community, father of three, then that bullet will have bounced off the femur into the abdomen ripping up the pancreas, and piercing the lung. If the patient is a gangbanger, then it'll just miss everything. The good die young." I throw a suture in the entry wound, and we admit the patient to the floor. (I heard a news story about the gang battle during the drive home.)
We continue rounds where I meet an overnight MVC admission from yesterday. He is a suboxone clinic patient (monthly group therapy for opioid abusers ending in the dispensing of opioids) and is anxious to avoid being stereotyped as an addict. His trauma from the car accident was not severe, but the ED gave him tons of pain meds to overcome his years of tolerance for opioids.
He has not had a bowel movement in three days so we explain we need to transition him from scheduled Q6H (every six hours) to "as needed" narcotics. We propose scheduled acetaminophen and NSAIDs (e.g., Advil) with breakthrough Toradol for pain control. "Oh I don't want that stuff. NSAIDs are bad for you."
The rest of the week is uneventful except for another ATV accident, this time in a 14-year-old. She has a Colles fracture (fracture of distal radius from falling onto outstretched hand), and a few abrasions. We also have two elderly ground falls requiring hip surgery: trochanteric fracture requiring pin, and femoral neck fracture requiring hip replacement.
I had expected two weeks of running all around the hospital in response to urgent pages and watching dramatic life-saving surgeries. Instead, despite the best efforts of our local gangs, drug abusers, seat belt scoffers, ATV enthusiasts, and motorcycle riders, it was mostly waiting around. We had more "trauma" during the week of nights (Year 3, Week 3). Much of "trauma" turned out to be social work, e.g., predicting who would be a motivated candidate for inpatient rehab and persuading insurance companies that OT/PT will be effective. Patients may occupy a bed for a week receiving no significant care while the social worker enrolls the patient in Medicaid and then negotiates with Medicaid regarding the new beneficiary.
Summary of two weeks of trauma: I learned the ABCs (Airway, Breathing, Circulation) for initial trauma evaluation and some fracture management. Work started just after 6:00 am and I was usually gone by 4:30 pm. The emergency surgery service option probably would have been more educational due to its higher caseload.
Saturday: Jane's sister is at the hospital until 10:00 pm, well past her 7:30 pm scheduled shift conclusion, and stops by our house on her way home. "An 18-wheeler going 65 mph hit three highway workers, father, his son, and the son's best friend. The father dies on impact, the 30-year-old son is medevaced to our hospital, and the best friend is medevaced to an outside facility because our ICU is full. Now, keep in mind about 30 minutes before he shows up, we get a self-inflicted GSW [gunshot wound] to the chest resulting in a massive pulmonary contusion and injury to the IMA [inferior mesenteric artery, supplying the colon]. He had shot his girlfriend who had died in the trauma bay. So we have one patient who is bleeding out into his chest and abdomen, and [Dr. Cruella] comes running in and performs a bedside thoracotomy [opening of the sternum and ribs] and x-lap [exploratory laparotomy] on the GSW. Meanwhile, we are coding the 30-year-old as he goes in and out for 30 minutes of VFib [ventricular fibrillation, serious cardiac arrhythmia]. His wife is crying holding their one-year-old daughter. Dr. Cruella is running between the GSW and the highway worker. We finally get both patients stabilized. He is brain-dead, but everyone except Dr. Cruella is in denial. We perform two nuclear perfusion scans before the wife accepts.
"Time of death is called. My CNA [certified nurse assistant] and I then have to deal with post-mortem poops before the family comes in. And let me tell you, post-mortem poops are the worst. Everything comes out. Worse than C diff [clostridium difficile infection of colon]. I tell my CNA to watch out as we turn him. As we're dealing with this, three gigantic birds, maybe vultures or something, fly right up to the window. It was the freakiest out-of-this-world experience ever, like a sign from God. [coworker nurse]'s jaw dropped. Was that the three souls leaving this world?
"After we cleaned the room and changed the sheets, my coworker and I offer to get a handprint for the daughter. The wife thanks us. We then realize he has a huge cast on his hand. We try prying it off, then ask if a footprint would suffice. We then don't have enough ink in the ICU so we're struggling to just get a toe print. We eventually find some from upstairs. The family comes in to say their farewell before we remove him from life support. They stay in the room for more than an hour."
Statistics for the week… Study: 12 hours. Sleep: 6 hours/night; Fun: 0 nights. Jane and I grab a beer Friday evening, and then study the weekend away before exams.
Sunday and Monday with the trauma service team. They don't expect much from students this week because they know that we're thinking about the exams that start on Tuesday. Ted, my chief, tells instructs me, "You can go study in the student lounge. We'll let you know if anything interesting pops up."
There are only 183 UWorld surgery questions. It takes about five minutes per question, each of which has five possible answers, to pick an answer and then read the explanations associated with each possible answer. I have studied all but 44. M4s and previous clases recommended getting through the Internal Medicine gastrointestinal and pulmonology questions as well because they all overlap with the Surgery SHELF exam. Surgeon Sally and Christian Charlie both finished the 113 GI and 123 pulmonology questions on top of the surgery questions.
In the ED, we have a skinny 26-year-old patient who was in a head-on collision. He is in no apparent distress, with some minor hip pain that is well controlled on 5 micrograms fentanyl. An x-ray shows a femoral head (top of femur) fracture extending into the acetabulum (hip bone). Was he drinking? He replies in a muted, monotone voice: "No." Use any drugs? "I've used meth and heroin in the past. I wasn't using anything." Nurses keep telling him how amazing it is he came out with only minor injuries after a 65 mph crash, but he doesn't perk up.
What do you do for a living? "I worked in a mechanic shop, but I'm between jobs. I lost my job two weeks ago." He shrugs. "It's whatever." Ted joins me in the ED, recognizes the last name, and we admit the patient to our service ("trauma"), and consult orthopaedic trauma service. Our job is mostly coordination with more specialized services.
We are placing orders in the ED when the patient's father and mother arrive. The father is a well-respected doctor in the hospital. Out in the hallway, the parents report that their sonhas been diagnosed with schizophrenia and major depressive disorder, but refuses to seek help for the past two years. "He'll live with us for a few weeks, then we won't see him for moths. He currently lives out of his car.. He'll keep a job for a few weeks to get money for drugs, then quit." We go back in and ask about his psychiatric history. He admits that he purposefully drove across the yellow lines into traffic. (The mother and back-seat child in the other car were not seriously injured and had been taken to a hospital without Level 1 Trauma certification.)
We place him on suicide precautions (1-1 sitter, paper gowns) and consult psychiatry. A classmate on the psychiatry service shows up. We interview the patient together. He reports that he has no active suicidal ideation since he drove into the oncoming car. The job of an inpatient psychiatrist is to determine whether the patient needs to be admitted to the psych after being medically cleared by the primary team. Even a patient who tried to kill himself 24 hours prior does not meet criteria without active suicidal ideation. Therefore, he will be referred to follow up with a different psychiatrist in an outpatient clinic two weeks later. It is the patient's responsibility to call and make the appointment and then show up. Everyone knows that this won't happen, but nobody takes ownership of the patient's mental health and, even if the patient did take the necessary initiative there would be no continuity of care.
He undergoes surgery that evening for his hip. We also get a consult for radiation oncology. Why? Fractures that involve the acetabulum have a high risk of developing impingement as remodeling creates spurs into the hip joint. To prevent this, there are two options, a two week course of strong NSAID, or radiation to the hip joint to stop remodeling. He undergoes radiation the following day.
Tuesday is the simulated patient exam, starting with with mesenteric ischemia (poor circulation to the small bowel). I walk in to a screaming 60-year-old. The challenge is to perform a physical exam while she is squirming on the bed in pain. After the encounter, I'm writing a note and able to view the PMHx (medical history). The diagnosis becomes clear after reading about the two previous heart attacks and paroxysmal atrial fibrillation. The second patient has classic cholecystitis (inflammation of the gallbladder). The patient reports nausea, vomiting and RUQ abdominal pain. When I ask her to take a deep breath while applying pressure under her right ribs, she jumps off the table (positive Murphy's sign). She also fits the "Fat, forty, female and fertile" saying for gallbladder pathology.
The SHELF exam consisted of 110 questions over 2.5 hours. Questions were mostly second order. They would present a patient, and you would have to determine the initial management step for this diagnosis. Examples:
I got 79 percent right. The mean across all medical schools is 74 (standard deviation: 8), but these are averaged without regard to rotation order. Surgery, Pediatrics, and Internal Medicine are known as the most challenging SHELF exams. Studying more wouldn't have helped much. Recommendation: study the indications for exploratory laparotomy, management of appendicitis, and cholecystitis.
My Step 1 score is back. As the exam questions are changed, it takes a few months before any scores can be calculated. I get 237, disappointing because my last two practice scores were 245 and 252. (Passing is 194, mean across all medical schools is 229 with a standard deviation of 20.) Starting with the questions and practice exams earlier in the year would have helped. The best strategy seems to have been starting the UWorld questions in August and resetting the program to go through them again during the study period. Jane didn't do that, but she made it through all of the UWorld questions and snagged a dermatology-worthy 249. Our Dean of Student Affairs is ecstatic with the class average score of 239.
[Editor: The 237 should be fine for dermatology if our author/hero checks the "Related to Elizabeth Warren in the Remnant DNA Tribe" box!]
Statistics for the week… Study: hours. Sleep: 6 hours/night; Fun: 1 night. Burger and beers with Mischievous Mary, Lanky Luke and Geezer George.
Work starts at 8:00 am at an outpatient pediatric clinic that is a one-hour drive from the hospital. I'm the only student in the clinic. I meet the three attendings, one advanced care provider ("ACP," typically a PA or NP), and lactation consultant) before the first scheduled office visits at 8:30 am. Two of the attendings are hot off the press, having finished their residencies a year ago. Momma Mabel had a baby in December and is back after three months off [Editor: fully paid thanks to the extra work put in by the childless.]. Her husband is a stay-at-home dad who brings the baby in during lunch. Mercedes Mike, the other new attending who drives a new SLC Roadster, and Busy Belle, a divorced pediatrician in her 50s who is booked weeks out except for two unscheduled daily sick slots.
They have fifteen 15-minute well-child-checks ("WCC") scheduled each day, thirteen 10-minute scheduled sick visits, and two open 10-minute sick-visit slots at the end of the day. A complicated patient, e.g., chronic headache, may be allocated two 10-minute slots. Five minutes out of the 15 are allotted for rooming. The nurse will get vitals while the physician writes up notes from the previous encounter. The physician then has either 5 or 10 minutes to see the patient without falling behind. I go in with Mabel for a 4-month-old WCC. Mabel invites me to listen to the patient's heart and I hear an early systolic murmur. When I tell Mabel about that, after the encounter, she says "Yep, good job. That's called a Still's murmur. It classically is described as having a musical quality. I didn't tell the parents because it is a benign murmur of childhood." Mabel pumps during the one-hour lunch break as I head over to the other side of the office for lunch with Busy Belle.
Belle explains the different pay structures for primary care. Some health systems use a flat salary. "You are required to see a minimum number of patients." Many health systems are transitioning to a relative value unit (RVU) reimbursement structure. Mercedes Mike stops by and adds: "I considered working for another system that is completely based on RVUs. I'd get paid more per patient, but if I decided to go on vacation for two, I would get nothing. I felt this was a little nerve-wracking for me just starting out with a young family." Another factor emerging is scorecard evaluation. "We get evaluated based upon peer performance across selected metrics, e.g., smoking cessation, weight loss."
I shadow Belle for the remainder of the day and we're done with patients at 4:30 and out the door at 5.
Tuesday I graduate from mere shadowing and begin to interview patients alone prior to the attending coming in. My first interview is with the mother of a 2-year-old presenting for a two-day history of sore throat, fever, and runny nose.The kid just started daycare, and the parents took an ear temperature at 100 degrees, which means she's technically afebrile because fever starts at 100.4. I complete a physical exam before presenting the findings to Mabel while she fills out an Epic SmartText template. Students are allowed to write notes for surgery, but not for pediatrics due to concerns about insurance reimbursement. We then both go into the room. Either I got the history wrong or the mother has changed her story. The sore throat began three days ago, not two and nasal saline rinse has been used, contradicting my report of no medications. Afterwards, Mabel completes her own physical. We send them home and recommend symptomatic management with Tylenol and ibuprofen if needed.
Our next four patients come in with sniffles or sore throat. I can't find signs of bacterial infection. "What is your assessment?" asks Mabel. "She has a viral pharyngitis that can be managed symptomatically. Let's tell them to keep hydrated and make sure there are 3 or 4 wet diapers per day. Return in case of fever." In the afternoon, I see a 6-month-old with conjunctivitis, bilateral otitis media, and pharyngitis caused by a suspected adenovirus infection. Mabel: "Notice the difference? Treatment is symptomatic, but these kids can get really sick. Tell me the serious complications of adenovirus?" She goes into the next patient while I look at UpToDate. I report that the main complication of adenovirus is pneumonia. Fifteen percent of childhood pneumonias are caused by adenovirus and myocarditis (a rare heart infection) is usually caused by certain strains of adenovirus. Finally, I report an outbreak of serotype 7 that caused a serious outbreak in 2014 with 136 (69 percent) of 198 persons with adenovirus-positive respiratory tract specimens were hospitalized, out of which 18 percent required mechanical ventilation, and 5 patients died ("Human Adenovirus Associated with Severe Respiratory Infection, Oregon, USA, 2013-2014", Emerg Infect Dis. 2016)
After I finish a 17 year-old WCC and sports physical, my attending grabs me to come take a listen to 9-month-old twins with bronchiolitis. "Could my medical student listen?" she asks the parents. These are the sickest patients I've seen today and show classic signs of adenovirus: conjunctivitis, runny nose, cough and pharyngitis. I listen to their lungs and hear inspiratory crackles with an expiratory wheeze. There are no signs of dehydration, such as lack of tears while crying, poor capillary refill, poor urine output. They are not in respiratory distress, e.g., nose flaring, intercostal retractions, abdominal muscle use. We sent the family home with instructions regarding what would merit a follow-up visit.
I'm learning that most of a pediatrician's job is educating parents on the basics: when to brush teeth, how often to breastfeed, what car seat should the child be in, how much should the baby drink, when to stop using the bottle. The format of a well child check is standardized for each age. Despite the hundreds of millions of dollars spent to install Epic, it doesn't default to the practice's preferred form for, e.g., a 10-year-old, when a 10-year-old patient is being seen. The efficient physician populates a custom-made SmartText for a 10 year old, and then fills out certain milestones that were filled out by the parents on paper.
Statistics for the week… Study: 5 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: best friend from college visits this weekend. He is an M3 at a different school who has already been on rotations for six months: "Third year sucks. Physicians claim that they remember third year as the best. Bullshit. It is mostly waiting around doing nothing, and yet you have no free time." He adds: "Scary to think this is all the training we have in some areas. For example, if you don't want to be a surgeon, you will be a practicing physician with only a few weeks of surgery experience. It wouldn’t surprise me if some physicians don’t even know how to start an IV anymore." He is looking forward to psychiatry: "You talk to each patient for 30 minutes, chart a note during the interview. Pay for psychiatrists grew 15 percent last year. If this continues for 5 years, a psychiatrist will get paid as much as an orthopedist and get out every day at 2:00 pm."
Second week of outpatient pediatrics. My job for 80 percent of the visits is to differentiate between viral and bacterial upper respiratory infections ("URIs"). I take the history and physical for each cold and respond to questions about medication dosing. Then it is time to present the patient for two minutes while the attending fills out a SmartText in the clinic's Epic system. Mother Mabel: "Once we realize you know how to conduct a basic exam, we want to see if you can parse the relevant findings from the ordinary."
We see an 5-year-old who has red macules and patches all over her body. She's not scratching and doesn't even notice them. The rash started on her leg, and spread over her entire body. I have no idea what the rash is because it does not fit the standard viral exanthems (rashes) of childhood that we learned in medical school. As I am describing the case to Mother Mabel, she starts smiling. "I know exactly what this is." Pityriasis Rosea. We tell the patient there is nothing to do but wait. "We believe it is caused by the immune system's reaction to various viruses."
We see a 13-year-old patient with Addison's disease for a URI and dizziness. She and her mother knew a huge amount about managing her disease, including about the need to take extra stress dosing. Addison's disease is an autoimmune attack destroying the adrenal glands. Without any cortisol, the body can become hypoglycemic in times of stress. During an infection, the patient is instructed to take an additional "stress" dose over her daily hydrocortisone level.
Mabel also gets excited by this one. We check her blood glucose to rule out hypoglycemia and prescribe antibiotics for a sinus infection: high dose amoxicillin. I talk to Busy Belle, the patient's regular pediatrician, about management of Addison's disease such as stress dosing and risk of other endocrine gland destruction. "I'm not sure, my N is 1." Last year, Busy Belle saw the patient at the office in hypoglycemic shock. Her blood sugar was in the 30s, blood pressure was 80/35. She gave her some pedialyte solution and sent her to the hospital in an ambulance where she was diagnosed with Addison's disease. Her most recent labs in the chart show a slightly elevated TSH (thyroid stimulating hormone) at her last visit with the pediatric endocrinologist, with whom she has an appointment next week. It seems that all the exciting management is done by the specialist.
A similar experience occurred on Wednesday with Mercedes Mike. He has accumulated several patients with congenital heart defects. I see an adorable 4-year-old with hypoplastic left heart syndrome who came down with the sniffles. The mother brought her in to ensure she didn’t need immediate intervention. Her oxygen saturations were fine, so we sent her home until her F/U ("follow up") with the cardiologist in a week. We talked afterwards about the various surgical management of hypoplastic left heart syndrome. Once again, all the interesting management, e.g., echocardiograms, CT surgery referrals, EKG evaluation, etc., is performed by the specialist.
Patterns emerge around risk factors by age group. Every girl with a chief complaint of back pain is going to be either a dancer or cheerleader. An 8-year-old who presented for a typical URI tells us that she dances competitively five days a week. I asked if she has back pain. The mother lights up: "Oh yes, tell him honey." The expected five minute visit, turns into a complicated 20 minute neurological exam. Afterwards, Mercedes Mike asks: "What's the elephant in the room you have to rule out in these patients?" I don't know. I look it up and get back to him. Spondylolisthesis, where one vertebra slips forward from the one below. This can cause serious spinal cord injury if not treated.
My next patient stumbled and hit her head on the gym floor during cheer practice. My presentation: "A CT is not indicated. She has a benign neurological exam, no LOC [loss of consciousness], and only mild headaches. My assessment is she has a mild concussion from the fall and should return to practice only after she feels comfortable at school for a few days." He responds: "I agree with you, but it's better to not use your gut when there are evidence-based protocols. Look up the indications for a CT scan." After 10 minutes of googling I find the PECARN (Pediatric Head/Injuries Trauma Algorithm) guidelines and summarize: "As long as there is not prolonged LOC, signs of basilar skull fracture and no altered mental status, it is unlikely to have a significant TBI requiring further intervention." Mike responds, "Yep, look above your screen." Taped to the wall above the nurse's station is the algorithm figure from the original PECARN paper. According to the these guidelines, there is less than a one percent chance of a clinically-important TBI as long as there are no signs of LOC > 5s, Glascow Coma Score < 14 (GCS, standard metric to assess neurological status) or palpable non-frontal skull fracture. Mercedes Mike: "I'm a new attending, so if I were talking with a more experienced doctor about a patient with suspected TBI, I would definitely mention PECARN just so they know that I am familiar with the guidelines. As a new attending, you need to build trust with other doctors."
[Later, to Jane: "If we ever have kids, they are not doing dance or cheer."]
A middle-class white 16-year-old girl is next. Mom wants to increase her ADHD medication dose because of bad behavior at home. Instead of acquiescing, Mercedes Mike asked, "Why are you poorly behaved at home?" Teenager mumbles: "I just get mad when my mom and sister ask me to repeat myself." Mike: "Well neither of you are perfect, but she's in charge right now until you pay the bills. So try not to mumble" Teen: "I'm going to be working at Taco Bell soon." Mike: "You're not paying the bills yet." Decision: no change in meds.
[Busy Belle suggests skepticism regarding schools' recommendations for ADHD evaluation. "We always get teacher and coach evaluations as well as a parent evaluation of each kid. The symptoms need to be occurring in at least two different environments. I started to notice a lot of kids at one school were being recommended for ADHD medication. It turned out that the evaluations were the exact same letter with the names substituted. Boy, did they regret that. I contacted the county superintendent and the principal's secretary was fired with a stern warning to the principal." (Editor: the stern warning to the bureaucrat was softened only by a monthly paycheck, lifetime health insurance, and lifetime pension.)]
Outpatient pediatrics is helpful for understanding why diagnoses take a long time. A common reason for patients to come in is non-specific abdominal pain without any diarrhea, constipation, or vomiting. It's not reasonable to get a full work up (CT, CBC, CMP, inflammatory markers) for a one-week history of GI pain. Patients arrive with only a vague story of off-and-on symptoms rather than a precise timeline. One of our common responses is handing out a symptom diary. Mother Mabel: "As a new attending I keep a slightly closer eye on my patients. Instead of telling them to come back in a month with a symptom diary, I'll have them come back in two weeks for a follow up visit."
The best part so far is playing with the adorable 4-8 month olds. However, most of what a pediatrician does is educate parents or tell students to get their act together and listen to mom (our typical patient lives primarily with a "single mom" and is well-behaved every other weekend with dad, but out of control in the mom's house). Should seven years of training be required for this? A successful parent of four could do most of this job. A pediatrician is involved in the "interesting" kids only to manage common illnesses that pop up in between their visits to specialists.
Mike delivers a mid-clinic eval. "You're doing fine. Use a template when you interview patients to not forget anything, but overall good job."
Jane on pediatric hematology/oncology, an elective rotation, and has been bored because one of the hematologists is on vacation. Jane's typical day: arrives at 8:30 am, her first two patients are (Medicaid) no-shows so her attending fills out paperwork in the office. She sits around waiting until her lecture at 12:30 for a journal club on the use of antibiotics and reflux medications in childhood leading to allergies. She waits all day to see two patients at 3 and 4:30 pm. She returns home: "I wanted to strangle a 7 year old today." Strangle a kid with cancer? "He wouldn’t shut up, and he was in remission."
Statistics for the week… Study: 8 hours. Sleep: 8 hours/night; Fun: 1 night. Meet classmates downtown for happy hour margaritas. Pinterest Penelope, also in pediatrics but in a different clinic: :"What I hate about third year so far is that you cannot plan anything. I rescheduled my own doctor's appointment today so that I could be there for all the patients. The last two were no-shows. It's just so much waiting, yet no free time." (Penelope's clinic serves an all-Medicaid population and there are no charges for failing to show up.)
My week in the nursery starts at 7:45 am. My attending, a specialist in NAS clinic (babies born addicted to opioids from addicted mothers), strolls in at 8:15 am. After residency two years ago, she did a fellowship in pediatric palliative care, and took the job at our institution expecting to be mentored by the palliative care team. However, the position evaporated, and she took the job in the nursery instead. "I needed a job," she explained. "The goal of this week is for you to become comfortable being around a baby." She goes over a basic newborn exam on newborn baby in the nursery receiving phototherapy for jaundice. "Tomorrow we'll give you a newborn for you to follow. Today just follow me around."
Afterwards, she catches up on the computer while I configure my Epic with all the best screens to view weight changes, bilirubin values, feeding schedules, and diaper changes. The 35-year-old PA student training with us arrives around 10:00 am, and I help set up his account. We then go into a conference room. She hands us a folder that every mother gets when she arrives on the floor. It includes information on breastfeeding and postpartum blues information. She also hands us a H&P (history and physical) form where we record all the patient's information for handoff to the night team. She asks us to introduce ourselves.
The attending does newborn checks on the four babies born overnight and this morning. Around 11:30 am, she sends us over to work with the lactation consultants. They instruct us to read a packet, titled "Breastfeeding for Dummies", describing good breastfeeding technique and detailing the number of times a baby should feed in the first week of life. After 30 minutes, we each follow one lactation consultant. "No, no, no. That must be painful." she explains to a mother, showing her how to get a good latch. "If it hurts at all, you need to start over. Babies are lazy, you need to teach them good habits from the beginning or it will be harder to breastfeed." She breaks the latch with her finger, and then grasps the areola with her palm, opens the baby's mouth and shoves the breast into the babies mouth. The mom exclaims, "Wow much better." Are there any male lactation consultants? "I've been doing this a long time and have never worked with one, I think I saw one at a conference, but he may have been a doctor." [Editor: Perhaps this male-appearing individual identified as a woman?]
The next patient is a baby who is not gaining enough weight. The pediatrician put in an order for formula, but the mom wants to breastfeed exclusively. The lactation consultant disagrees with the order, but shows the parents how to feed with a syringe and tube on which the baby will have to suck. "If you start the bottle this early, the baby will start to only want to use the bottle. You'll have to pump all the time, but your supply will slowly go down. You need those hormones to kick in to keep the supply going."
Our attending is trying to work her way down from 180 lbs. with salad and sends me out to grab lunch with Jane at the hospital outside the coffee shop. Jane is on her orthopaedic elective. She was in clinic this morning, and arrived at the hospital two hours early for her first OR case. Jane hasn't done surgery yet, so I give her the basic tour of the OR, the various staff members in the operating room, where to get gloves, and how to help the nurses. "Make sure you wear a mask into the OR!"
After lunch, I watch the attending perform two circumcisions. The nurse grabs a chair and puts it behind me. "If you feel queasy, sit down." A medical student last year passed out during the procedure. I give the baby sucrose ("Toot Sweet") drops which help the baby ignore the pain. "It distracts them." I squeeze the sucrose tube so hard that the entire tube is emptied by the end of the procedure. The nurse laughed: "That usually lasts their entire hospital stay!" The attending does one later in the afternoon demonstrating the World Health Organization technique to the residents. It's definitely less efficient. I learned that a circumcised infant has a 1 in 1000 chance of a UTI in the first year of life compared to a 1:100 chance for an uncircumcised boy.
The PA and I leave at 1:00 pm for lectures in a nearby outpatient clinic lecture room. We have students present a 10-minute topic of interest followed by a 3-hour discussion on failure to thrive ("FTT") led by the clerkship director, an 50-year-old pediatrician. She talks at the speed of light. We learn that she lives with her mom in a small apartment complex next to campus known to us graduate students as the party apartment. She tells us about yelling through the window at kids swimming in the pool without a parent present. "My mom tells me to stop, but I can't help myself. I just can't. What parent would leave their kid alone in a pool? Right, Right?" Southern Steve counts the number of times she says "Right" -- 54 times in 3 hours of lectures.
Pinterest Penelope presents on the causes of hypoglycemia (low blood sugar). The clerkship director interjects: "What is the number one cause of hypoglycemia around Christmas time or New Years?" Blank stares. "Alcohol ingestion.The kids get up early and drink all the eggnog left over. [excess alcohol consumption increases insulin secretion, decreasing blood glucose levels.] We have lots of these patterns. Halloween is DKA season [diabetics eating too much sugar]. Halloween is also costume dermatitis season."
Our clerkship director strays from the advertised topic of FTT. "We are so spoiled with vaccines. I've been in practice for 18 years. My mentor would tell me how they used to go into the hospital with 100 kids, and leave with only 30 on some days. That's how bad HiB [the Haemophilus influenzae type B bacterium] was. It would decimate entire counties. The medical community worked hard to develop HiB vaccine. I was around when Prevnar 13 was developed from Prevnar 7. I had babies die from Strep meningitis."
A student asks: "How do you deal with parents that refuse vaccines?" She explains: "Being a doctor means dealing with difficult decisions. Get used to it. Some practices refuse to see patients that do not get vaccines. If you see a nonvaccer baby, you'll get sued by another patient who catches measles in the waiting room or if the child dies from a vaccine-preventable disease you'll be sued cause every dead baby is a lawsuit. We have a large refugee population here. [Editor: Maybe the next caravan from Honduras will take refuge around the pool in mom's apartment complex?] We need to take care of them, but they are all not vaccinated. Do we just refuse to see them? Where do they go? Well they come to us, we take everyone in the community. Everyone is different, but I love this part of our job."
Wednesday starts with patients at 8:00 am and then presenting three babies to the attending. The first baby was found to have agenesis of the right kidney on prenatal ultrasound and, during the newborn exam, was found to have a sacral dimple. We take the baby down to get an ultrasound of her spine and her abdomen.
The PA asks why? I respond: "I think it is because of the VACTERL association (Vertebral abnormalities, Anal agenesis, Cardiac abnormalities, TracheoEsophageal fistula, Renal agenesis, and Limb defects). A baby with one of these anomalies has a much higher risk of another congenital defect." We order a genetics consult to help us rule out any syndrome. The nursery turns out to be mostly a filter for identifying complicated babies that are sent for further evaluation.
The ultrasound exam takes about 30 minutes because of the newborn's difficulty.
Several hours earlier, the mom had asked that the baby be moved to the nursery so that she could get some sleep. I go to ask if she would like the baby returned to her room for phototherapy. "Yes, please." No one had been to see her for hours, so she'd never had a chance to ask for the baby back. I'm surprised how docile patients can be, afraid to ask for more information from the nurses and doctors. I ask, "Has anyone explained the ultrasound results?" She responds, "No."
"Well as you were told a few months ago [at the 20-week anatomy scan]," I begin, "your baby doesn't have her right kidney. We want to make sure she doesn't have some other anomalies that can occur with this. It is possible this is an isolated finding. We are getting a genetics consult to rule out any syndrome." She was really calm and relaxed about the whole ordeal.
After lunch, the attending invites us to go home, but I decide to wait around for the genetics consult. I fill the hours until 5:00 pm by taking notes on "High Yield Pediatrics" by Emma Holliday Ramahi, a slide deck of everything relevant to a pediatrics clerk. I shared the link on our Peds clerkship GroupMe, receiving six hearts. The geneticist still hadn't show up, so I went home.
[The geneticist ultimately arrived at 7:30 pm and ordered genetic testing to rule out some rare syndromes. I opened the check a week later and found that the patient was discharged without any further abnormal findings.]
Jane is not enjoying the first week of her orthopaedic surgery elective. She is working with a new spine surgeon. "All he wants to do is operate so he is quite brisk with the patients in the office. He's probably a great surgeon, but I am not in the OR until next week." What does the surgeon do if they're not in the OR? "He has clinic three days per week and sees 50 patients per day, including post-op follow-ups. Out of roughly 25 evaluations, he might select 5 to have surgery."
She describes the orthopaedic lounge: "They talk about sports all the time. And the female pediatric orthopedist leads the conversation. She would've been the center of every fraternity party doing keg stands back in her day." Jane is frustrated about the uncertain schedule. "We have no scheduled free time that we could use for studying, but a lot of time is wasted waiting around."
I attend dumpling-making night with a few Asian classmates. Our vice president, Sleek Sylvester recounts his experience on OB/Gyn, specifically Maternal Fetal Medicine [MFM] service. "MFM has a pretty sick gig. They just consult for the obstetricians— confirm normal fetal growth or diagnose weird condition. They have no patients they are on call for. He described his week: "I work with the ultrasound techs a lot. We noticed this one kid... " Ditzy Daphne, a classmate who can regurgitate Anki decks, but is slow at applying the information to a patient case, interrupts: "careful what you call the fetus." Sylvester continues: "fetus sorry. Anyways, I know nothing about reading an anatomy ultrasound. But even I could see that this fetus did not have a normal arm. The tech zoomed in on the extremity. I suddenly realized that the extremity ended at the olecranon [elbow] and it had one small digit coming off of it. We could clearly see the fully formed single finger -- with the MCP, PIP and DIP. It was moving! I looked at the tech, and wanted to say, 'What the Hell?!?" The tech just nodded her head. When we left, I was like what the hell was that. She replied, 'That was an elbow finger. I've only seen one other in my career.'"
Sylvester explained that the MFM attendings receive a live feed from the ultrasound machines. "We were doing an ultrasound on a woman told she was having a female child. We kept focusing on the groin area of the fetus because we saw a scrotum but no penis. We went to the attending who asked, 'Why were you guys looking at the scrotum so long?' The ultrasound tech replied, 'Because she thinks she's having a girl.' The attending responded, "Hmmm, well no. That's a boy with a micropenis. I'll go talk to her.' He went through the ultrasound with the patient from head to toe in a very methodical manner. At the very end he showed the scrotum and nonchalantly mentioned this is a boy, not a girl. Never expected to wake up and see a micropenis."
Ditzy Daphne added: "I had a pretty terrible time on OB. They didn't let me do anything, and I always felt unwanted."
Sleek Sylvester shared "[Ortho Oliver] has been telling me how bad his OB rotation is. The OB resident he is following [High Horse Haley; see Year 3, Week 13] won't tell him when she sees patients. When he catches back up with her in the lounge, she'll say she is too busy while looking at eBay and Amazon clothing. She neglected to tell [Oliver] that they were starting rounds and skipped him when doing his assigned patient."
Statistics for the week… Study: 8 hours. Sleep: 7 hours/night; Fun: 1 night (the dumpling party).
First week of inpatient pediatrics starts at 7:00 am. The team consists of a PGY3 ("senior resident"), a PGY2 ("the mid-level"), two interns (would be "PGY1"), an M4 in the role of an intern ("Acting Internship" or "AI"), and two M3s, including me. The PGY3 pediatrics resident is a short quiet 31-year-old. He looks at the floor and around when he speaks to someone. He took several years off after college to live in NYC with his librarian girlfriend. The idea was to work as a researcher to improve his medical school application, but working as a "manny" for wealthy Upper West Side families turned out to be the job that paid enough to afford an apartment. The PGY2 is a 29-year-old Oregonian native who loves her three cats and is married to a tenuously employed man back home. Rockstar Rita is the attendings' favorite intern. Her girlfriend is a resident in a city that is a four-hour drive away so they rarely see each other.
After meeting the team, I shadow the interns and residents on Monday while getting accustomed to the basic structure of the day. First, we preround on each intern's 3-4 patients. The interns plus the "AI" write notes at the resident station until morning handoff at 8:00 am, packed into a 10-person conference room attended by the residents, interns, medical students, our pediatric hospitalist attending, and the hematology/oncology attending and/or fellow as well. We first go over the oncology kids. Rockstar Rita has all of these notoriously complicated cancer kids. She presents a patient summary for each of the four "regulars": two acute myelocytic leukemia ("AML kids just get sick" [from the drugs used to destroy their white blood cells]), a rhabdomyosarcoma, and a Ewing's Sarcoma. She highlights actionable items such as thresholds to transfuse platelets or red blood cells, when to draw another blood culture if they have a fever after 24 hours, and pain medication regimens. The night team then presents the new patients admitted overnight. Finally, we leave the conference room to round on each others' patients in our pack of 8 and finish at the resident station for everyone to write notes.
The resident station is a short hallway outfitted with five computers that connect the nurses station with the snack room in the middle of floor. It is hidden from patient's view but clearly not out of range from the loud conversations going on. "Alright, team lets get em out," as he whistles. "The Discharge train begins." Rockstar Rita complains that her "T1D" [12-year-old type 1 diabetic admitted for diabetic ketoacidosis] should be ready to leave the hospital, but is acting lazy: "She just won't get up. She is lying in bed, not drinking or walking. This is a perfect job for a medical student [looks at me], Go get her up. I don't care how you do it but get her to chug a glass of water." What do we do if a patient doesn’t want to leave?" The senior resident chimes in: "Same exact thing with gastroenteritis girl. Vomiting is not a reason to be admitted to a hospital. They were admitted for concern of an appendicitis, which we have now ruled out. Go have diarrhea at home like everyone else." The AI chimes in: "We ask him if he wants to go home and he replied, 'No, let's stay, it's fun.' Could we take the TV cord? (Oh no, cord broke what happened?)"
The senior resident added afterwards: "It sounds heartless, but we need to get these patients out of the hospital. The PICU is completely full so when we don't have a room patients may have to be transferred to a less capable hospital. Also, the best thing for these patients is to get home and back to a normal schedule."
I wake up our T1D, walk her to the water station for a drink, then drop her off with the video games in the Teen room.
I then sit down with my classmate Diva Dorothy, one of the younger class members at 24. She's a great resource now that our class has dispersed because she keeps up with gossip from every year within our school. She started a week earlier and gives me some advice about Inpatient Peds. "Unlike with adult medicine, pediatric patients recover so quickly that it's tough to do any patient presentations. Grab any patient who will be here for a few days. Also, bring your own laptop because there won't be room at the resident station."
She confides her struggle during the previous week. "They think I'm lazy or not interested and ignore me. I'm sitting in the next room over and they'll just leave and go to the consult without me. No one gave me any orientation, each medical student has had to rely on the previous medical student to get situated. We have no idea what note templates to use [within Epic]. No one gives me the AM rounding sheet showing new patients that they print out for everyone else. How did you get one?" (me: "I try to get in at least 15 minutes before the official 7:00 am start time. Then I can ask the night team resident for a printout.")
Dorothy: "I'm sad about this whole experience because I loved outpatient pediatrics. I've had such a bad time here that it's making me question doing pediatrics." I agreed that it is a shame that an unapproachable team during a clerkship can discourage someone from pursuing a residency. She complained last week to the clerkship director. Apparently this was conveyed to the pediatric hospitalist attendings because Dorothy remarked that this week's orientation was substantially improved.
[Discussion with Jane that night: "all of the rotations are poorly organized." By Wednesday, Diva Dorothy is absent. Our team is told that she is sick with a stomach bug, but she texts me to say that she has been moved to hematology/oncology clinic at a different location.]
After rounds we sit at the residents' station. I am surprised at how little we actually see patients. After the initial morning round, most patients do not get seen by a physician until the next day. The night team does not go in unless a nurse asks them to. Residents during the day spend most of their time writing notes, ordering labs, and finishing discharge summaries. The senior resident mentioned that one thing a medical student can do to help the team is check periodically on patients. [Editor: Doctors are so busy typing at computers that the medical students have to do the actual doctoring.]
We get two new admits from the ED at 4:00 and 4:30 pm. Diva Dorothy was packing her stuff. The attending had to convince her to stay later than the normal 4:00 pm sign out. The attending: "You can go, but it would be good practice to admit a patient." She responds: "Okay, I'll stay." (We are only supposed to do one late sign out per week). The residents/interns regularly stay late.
Tuesday is a typical day. I get in at 6:45 am for prerounding on my one patient. At 8:00 am, I head to the conference room for morning handoff. Diva Dorothy is complimenting Rockstar Rita on her new short haircut. "I love short hair, but I never know if I should get it. My parents are Sikh so they frown when I cut my hair." (She references a tattoo, though, but I have never seen it.) Once everyone is present, we hear about the cancer patients. Rita is doing a fabulous job despite constant interruptions from the PGY2. The Attendings are chatting with each other, oblivious to this rivalry between the two young women. I pick up a new patient who was admitted by the night team.
The medical student or intern present the patient to the patient and the whole team in the room. We are instructed to use "layman's terms" or explain the term if you use it to a patient: e.g., "afebrile means no fever overnight"; "leukocytosis with bandemia means high white blood cells with markers suggestive of immune response". The quality of our presentation is a big part of how we're evaluating, but it is challenging to select the right amount of information for the team and the desired level of detail will vary considerably depending on whether we're ahead of or behind schedule. One attending later complimented me after I brought up a potentially disturbing question with him privately before we entered a patient's room. I didn't tell him that it was Rita's whispered idea.
I struggle to present my patient in the clear "SOAP" format [Subjective, Objective, Assessment, Plan], forgetting a few lab values and symptoms that I mention in the wrong section. I need to work on this. Much different that presenting a surgery patient.
She's six months old and was taken to her pediatrician for a three-day history of diarrhea, nbnb (non-bilious, non-bloody) vomiting, and lethargy. The pediatrician gave the baby some Pedialyte and sent her to an outside ED, which administered a fluid bolus (20 mL/kg). and took an x-ray to look for possible obstruction. The extra hydration led to rapid improvement in her symptoms. The x-ray did not show any signs of obstruction, but there is a concerning left upper quadrant opacification suggestive of a mass. An abdominal ultrasound showed a large, heterogeneous mass separated from the kidney and spleen. The outside hospital did not feel prepared to evaluate this patient, so an 80-mile helicopter transfer to our tertiary hospital was ordered.
[Editor: Yay! Creating jobs for East Coast Aero Club graduates and Eurocopter mechanics.]
The baby arrived looking well and entertained the residents as the cutest kid on the floor. Morning report from a night intern: "Given the location of the mass, our differential needs to remain wide. This includes: Wilm's tumor, nephroblastoma, neuroblastoma, lymphoma, and other neoplasms of the adrenal gland, kidney, stomach cancer, etc." PGY2 chimes in with statistics about the most common pediatric malignancies. Our Attending: "I called down to radiology and our pediatric radiologist is not convinced this is a mass. He wants us to insert a NG [nasogastric] tube to better visualize the stomach." The heme/onc noted that the abdominal ultrasound did not show much vascularization of the unknown mass. We need to CT before we can have a definite plan. I'd like to CT before we biopsy." The hematologist/oncologist attending goes in and tells the parents that there is a concerning mass that may be a tumor. The parents start crying.
A few hours later, after we get through our critical note-typing, I am tapped to insert the NG tube under Rita's guidance. Every NG tube must have a x-ray to confirm correct placement, i.e., not in the lung or perforating the stomach into the peritoneal cavity. The baby gets her second x-ray.. We send the baby down to get another abdominal ultrasound while water is poured into the NG tube for better visualization of the stomach.
I look at the NG tube-confirmation x-ray and notice that the mass is gone. I bring this up to the resident. "Hmmm that is very interesting." A few minutes pass and the ultrasound tech calls to say that she cannot locate the mass. We go down to the radiologist who believes this "mass" was just a distended stomach. "Look at the air-fluid levels on the ultrasound. It's just a really distended stomach from a large feed." We learn that mom is feeding the child 9 oz of formula every 2-3 hours, about 3 times the recommended amount." The senior resident jokes: "We just discovered a new disease: malignant constipation."
We have two boys on our floor for constipation requiring manual disimpaction. The senior resident: "This would be a perfect job for our medical student. Ask the nurse to supervise." The nurse explains how to do the procedure before we go in. I perform the digital disimpaction and insert an NG tube hooked up to a Golytely solution drip for clean out. The resident joins: "Now we wait until we see yellow watery diarrhea, no brown." The patient's girlfriend comes in to support him. The resident explains: "I'm explaining to the 16-year-old about how to prevent this from happening, not holding stool in, how his colon is distended so he may have some fecal incontinence over the next few weeks. His girlfriend is cuddling in his bed while I'm explaining this. Weirdest experience ever."
This prompts our attending and the heme/onc attending to share horror stories. "I remember we had a disimpaction of a 8-year-old that resulted in such a stench that people started coughing and residents fled from the station. It permeated the entire floor.." Our attending: "My worst experience was my Ob/Gyn rotation. We had a 500 lb female pregnant woman undergoing a CS [cesarean section]. I had to hold up her FOPA [unfortunate acronym for "fat over pussy area"; sometimes FUPA for "fat upper pubic area"] where there was an yeast infection growing in the folds. Worst thing I have ever smelt. Worse that the C diff [clostridium difficile] C-section. C diff diarrhea was oozing off the OR table onto the floor."
On Saturday, Jane and I go to the school library. She is scheduled to to give two school tours to the interviewees. We don't recognize anyone with the new first year class. Our library is featuring 10 new book purchases, 8 of which are on LGBT health issues, e.g., LGBTQ Health and How to Teach LGBT Psychology. Jane, as part of her admissions committee work, gives two tours of the school to interviewees. "They think that I have no say on their application, but I am noting which are my favorites. We will use these comments for the admissions committee meetings every month."
Jane and I have completely different schedules during the week. Jane is on her radiology clerkship, described as a "Radiation Vacation" by the clerkship director at orientation. She gets in at 9:00 am and spends two hours with a radiologist in the morning, followed by a break until 1:00 pm followed by another 2 hours. She has two morning classes and one afternoon workshop per week. "Radiologists are so deprived of human contact that when they have a captive audience they will not shut up. After 30 minutes of word vomit, I wanted to shout 'Shut up and show me some goddamn images!!' One radiologist explained his dream of a single payer health care system. He gave a talk on 'relative value units [RVU] math' and said 'I need to read 150 x-rays and 10 CT scans to just break even.'" Jane: "We only got through two images for the entire two hours. I wanted to yell at him to shut up."
Mischievous Mary commented at lunch: "I don’t see the long game if you want to become a radiologist. It’s like the one off-ramp for those who realize they can't deal with other humans, but have already sold their souls to medicine. If you never want to talk to anyone, just become an engineer or something instead of going through med school and residency."
Statistics for the week… Study: 5 hours. Sleep: 8 hours/night; Fun: 2 nights. Jane and I attend a concert in the pouring rain on Saturday evening. We learned later from Instagram that at least two of our classmates were also there.
The last week of inpatient pediatrics is shortened by Thursday's Shelf exam. I am woefully unprepared, having completed only 100 of the 400 pediatrics UWorld questions. Gentle Greg, a soft-spoken classmate: "No one has figured out a good balance between clerkship and studying.There is just no time.". His father is a critical care hospitalist who trained as a physician in his native India and practiced in both India and England before emigrating to the US.
A new team of residents and attending start on Monday. I introduce myself and take on two overnight admissions, both asthmatics. Our hospital has had two deaths from asthma attacks the past year. The pharmacist who joins us on morning rounds comments: "There is no excuse for kids dying from asthma. It's a completely controllable disease. More so than even T1D [Type 1 Diabetic]. The best insulin control and medical communication can still sometimes not be enough to control hyperglycemia. The five-month-old who died from status asthmaticus is tragic but can be justified as unavoidable. There was no prior history. But that 16-year-old who died at her Subway job should have been flagged by her family and physician for using a rescue inhaler [albuterol] every few hours rather than taking her [steroid] controller medication daily as instructed."
I take care of a 13-year-old T1D admitted for DKA [diabetic ketoacidosis]. We were taught about different types of insulin, but we were never taught practical lessons, for example, the three types of standard sugar control regimens, how to administer the insulin, how an insulin pump works. I ask my resident to go through the basics before I go into the room and make a fool of myself and the team. Most diabetics take daily or twice daily long-acting insulin (Lantus or Levemir) to act as the foundation. In addition, after every meal they do a carbohydrate correction (e.g., 1 unit for 15g carbs for lunch and 1 unit per 30g carbs for dinner). Lastly, they do a sliding-scale adjustment every 2 or 3 hours, where they administer 1 unit for every 30 mg/dL glucose above 130 mg/dL. She has been hospitalized six times in the past 2 years for DKA after relatively good glycemic control since the diagnosis at age 3. We are not exactly sure what happened. The residents suspect that, given her age, she is refusing to take insulin as prescribed as a weight loss strategy ("diabetic anorexia").
[Editor:A friend who has managed Type 1 Diabetes since childhood wrote the following private message: "I always see people posting on Facebook how they go to CVS to buy insulin and it is $500 a bottle (lasts me a month but lasts fat people 2 weeks) and they are so mad that companies are 'allowed' to charge this. I ask them why they go to CVS and pay retail when the same insulin is $40 a bottle mail order from Canada, including shipping. And the older kind is $29 a bottle at Walmart. Almost no one in the UK has insulin pumps because their health system doesn't provide them for free. Pumps are $6000 here new, but I got two for free on Facebook and you can buy them on Craigslist for $300 except do-gooders report the listings and get the listing taken down as Facebook, eBay, and Craigslist don't allow them to be resold."]
An 8-year-old is admitted for poor weight gain (4th percentile for weight and BMI) and acute episodes of diarrhea. We need to get his charts from an outside institution also on Epic to determine when he fell off the growth chart. In theory this should be easy with Epic's "Care Everywhere" reconciliation. However, we spelled his last name wrong in our system, causing a failure to synchronize with the outside institution. IT informs us we that it is impossible to correct this error until after the patient is discharged.
Part of the medical student's role is to get medical records from outside institutions. How does this work, nearly 10 years after the American Reinvestment & Recovery Act, which included the "Health Information Technology for Economic and Clinical Health (HITECH) Act" that provided taxpayer funds for computerization of medical records? The core technologies are the telephone and a FAX machine. Here are the steps:
This is not to say that the electronic medical record (EMR) has had no effect on the process. EMRs may automatically add vitals at 15-minute intervals to the record and therefore even the simplest data request usually results in at least 10 pages of irrelevant notes before you get to the information that is sought. I learned that it is more efficient to ask the patient to call the institution and speak with a nurse who can relay relevant labs over the phone. I then type them into our Epic system. Even triple-checking the values on a voice call, the total time and effort is much less than using EMR+fax.
I say farewell to my team and head off Wednesday afternoon for a lecture on childhood GI bleeding. The lecturer speaks in a monotone, reading verbatim off the slides of a presentation that someone else created. I ask classmates if it was obvious that I was dozing off. Anki Alex, a class gunner who does 300 Anki cards daily on rotation: "Big Dawg, every person was dozing off. There was a wave of head bobbing. The few times that I myself wasn't sleeping it was hilarious to watch."
We take our exam Friday morning. Crisis ensues at the exam. The hospital WIFi is intermittent so every 10 minutes the private secure browser in which we take the NBME Shelf exam shuts down. Nervous Nancy's computer works fine and she is taking her exam while the other 25 students shriek and hollar. Exams are typically proctored by two people: a clerkship administrator and someone from IT. Today, the IT proctor is sweating and scrambling. His best theory is restarting each computer after every shutdown, but today this is providing only another 10 minutes before the next shutdown. After 30 minutes, the clerkship coordinator kicks everyone out to give Nancy some quiet. We are then called in one at a time to log on and restart the exam. This process of getting people restarted for the 2-hour, 45-minute exam takes about 2 hours.
The exam is probably the hardest exam I have taken throughout medical school.The average is low enough the passing score is rumored to be 60 percent correct. The pediatrics shelf includes questions on childhood skin lesions, upper airway versus lower airway disorders the amoxicillin drug reaction from mononucleosis, several challenging autoimmune disorders (e.g., compare Bruton-K agammaglobulinemia versus Common Variable Immunodeficiency), and an annoying nephrology biopsy image (Pinterest Penelope: "blast from Step 1 past").
Type-A Anita complains to the administration that the disruptions affected her exam performance after we finished the exam. We got an email on Saturday:
We apologize for any added stress caused by the technology issues during testing this week. Thanks to the determination of our IT professionals, we understand now that the issue was beyond our control and that it has been resolved with the necessary groups. … Although we will not receive results from the NBME until this weekend, please understand that all contextual factors will be considered in the case of any undesirable outcomes.
Statistics for the week… Study: 15 hours. Sleep: 7 hours/night; Fun: 1 night. We grab burgers and beer with Mischievous Mary who just finished her OB rotation. "You hear the most ridiculous stories. The residents and students sit in an alcove that is obscured by walls from the patient hallways. An African-American in his late 20s came up to the nurses and said: 'Ma'am, my wife and girlfriend are in rooms next to each other. Could we move them so they are not near each other.'" She continues: "You'll also hear the worst baby name choices. I asked the attending if she ever tries to change their minds? The attending responded: "Only once: the patient wanted to name their daughter Chlamydia. I talked them out of that." She concluded: "I never appreciate how obstetrics is such a surgical field. I am actually considering OB now instead of CT surgery."
Wildflower Willow after our pediatrics exam. "I loved my OB/Gyn rotation--actually doing something instead of just talking for hours about a patient on internal medicine. We would be relaxing in the resident lounge area and then hear a yell for BRT -- that's the Birth Response Team -- and we would run." She continued, "I am pretty bummed that I didn't get to deliver a baby. I wasn't proactive my first week. My second week I had four perfect multips [multiparous mothers, i.e., those who have previously delivered a baby] but each of them had a complication requiring either a CS or an operative vaginal delivery [vacuum delivery assistance]."
OB/Gyn orientation starts at 8:00 am Monday morning. The clerkship director, an attending obstetrician, provides a well-organized pamphlet with details about each component of the block, one week each: Labor and Delivery ("L&D") days, L&D nights, outpatient gynecology, outpatient obstetrics, surgical oncology, and either Maternal Fetal Medicine (MFM) or Reproductive Endocrinology and Infertility (REI). She picks Device Denise, a short, cheerful 27-year-old who worked for two years in medical device engineering, as a schedule example. Denise comments, half sucking up (she wants to go into Ob/Gyn), half truthful: "This is by far the most organized clerkship we've had." The clerkship director responds: "Well, it is the most complicated schedule. A lot of students complain about moving around among locations and specialties. You run around because we do so many different things in OB/Gyn." My individually printed schedule shows that I will start with L&D nights.
At 9:00, we head over for a 30-minute tour of the hospital and end at the simulation center to practice suture technique and delivery of a baby on a $60,000 model. The simulation technician: "This isn't even one of the more expensive ones. We have a $110,000 model of a kid the EM residents practice on." Half of us have already done surgery so we are quite proficient in scrubbing in and sutring. The simulation model is a plastic female with her legs spread. Southern Steve comments: "Her feet look quite manly. Are they interchangeable with some other models?" Technician: "No that's just the way she's built." She then presses start on a computer and a motor pushes a rubber doll out of the model's vagina. This is followed by a rubber pancake connected to rubber tubing, representing the placenta and umbilical cord. The attending goes through correct technique to deliver a baby. When the technician and attendings leave the room, I ask, "Do you think this was a worthwhile investment?" Device Denise: "It's better than not knowing what is going on with a real patient." Lanky Luke: "It was helpful but it could have just as easily be done by observing a real patient."
Orientation ends at 11:00 am, and I head home to take a quick nap. I come back in to meet the night team at 5:00 pm for the handoff from the day team. The team consists of an attending, the senior PGY4 High-Horse Haley, a mid-level (PGY2 or PGY3), a OB/Gyn intern Teacher Tom, a Family Medicine intern Tangled Tiffany, and myself. Despite having been an intern for only a couple of months, Teacher Tom has already been recognized with a teaching award due to great medical student evaluations in the preceding two blocks. Tangled Tiffany has long tangled red hair and an open personality. She is a great teacher, her patients love her, but she clashes with High-Horse Haley. If she were a man, Tiffany might not survive in a #MeToo world. When I ask her the brand of neck heating pad she recommended, she responds, "Well, I could look through the texts with my ex-boyfriend, but no… I shouldn't. Nobody wants to see those."
Tiffany asks if I want to interview her patient in Triage. I lead the interview by asking questions (how frequent are your contractions, any bleeding, prenatal care history, etc.), while Tiffany fills in the numerous gaps. She then performs a cervical exam to measure cervical dilation, effacement, and station (position of baby relative to hips). We then report to our mid-level and senior resident in the resident computer area. After 10 minutes, High-Horse Haley scolds Tiffany for performing a cervical exam without supervision. Apparently, a family medicine intern was not supposed to do this without either an upper level or the OB intern. She explains: "I was worried she was about to push the baby out any second."
I scrub into a Cesarean section. The patient is a 26-year-old inmate at a nearby prison and suffers from Hepatitis B and C. She had been arrested for shoplifting and was then convicted of being a meth dealer. There are two armed guards looking through the OR door. (I asked them later how frequently they're at the hospital. One responds "I'm here almost every day. I think I might have learned enough to work as a nurse.")
It is unnerving that the patient is awake throughout the entire procedure talking to her sister behind the drape as the PGY2 makes the initial midline transverse incision. They bluntly dissect down to the abdominal fascial layer. The attending pimps me on the layers of the abdomen. Attending: "You speak like internal medicine doc -- I would know, I'm married to one. Not a bad thing. You'll find most OB/Gyn give short answers but we do have a few deep divers." The resident makes a small cut with scissors into the fascia, then the attending and resident yank laterally ripping the fascia -- it's pretty violent. They then pull the uterus through the fascial opening -- it looks like a turkey! The resident makes a small inferior transverse incision into the uterus. Membranes rupture with a gush of amniotic fluid and then the resident pulls the baby out. Whole process takes about 10 minutes. We suction the baby, clamp the cord after 1 minute, and then hand the baby to the neonatologist in the room. We don't know what's happening with the baby after that.
Haley then proceeds to suture the uterus as the attending guides through. They talk about different suture technique among attendings. After they place the uterus back into position, the PGY2 closes the fascia with help from the attending. The attending allows me to do a running subcuticular to close the initial incision. They were impressed because most of the students this year have not done their surgical rotation yet.
I ask the attending if she operates on patients with Hep C frequently? "Yes all the time. Also HIV. Some of my partners get tested every six months and I probably should start too."
Around 10:00 pm, everything slows down. No triage patients, no one close to delivery. I go with the OB resident to watch him do two cervical checks for actively laboring. No one is past 5 cm dilation. Both the FM and OB resident know how to speak Spanish fairly well and could get their interpreter licenses. The FM resident asked the OB resident: "What do you think about the Spanish license and phone interpreters?" "The phone interpreters are terrible. I asked a patient if they were soaking more than three pads per day. They asked do you need three pads? I do not get certified because of the liability. If something happened to a Spanish-speaking patient, they will grill me on my Spanish. Even if you did nothing wrong, they'll blame the language barrier due to not using an interpreter and cross examine you to see how well you speak Spanish. You will be made to look like an idiot on the stand."
Tiffany: "My patient is 29 years old with six kids, soon to be seven, who doesn't speak a word of English after living in the US for over 10 years. I have nothing against refugees or old people who are not going to be able to learn a new language. But she has been here for over 10 years and doesn't work. I did my training in Miami and I use Spanish here more than there. Everyone speaks English [in our city]. How does she take care of her kids?" She added: "Geez, I'm sounding Republican now that I make money. Mom always said I would become one. But I'm not, I am a hardcore Democrat. Weird. I just can't stand lazy people." Teacher Tom: "Better get used to it."
[Editor: She doesn't like lazy people, but votes to give anyone who doesn't work a free house, free health care, free food, and a free smartphone?]
Our team has very little patience for non-laboring patients. The surgery service "made us take care" of a multip at 24 weeks who underwent hemorrhoid surgery. The surgery service threw the patient on our service because of an unequivocal fetal heart rate test (Non Stress test) requiring a more expensive rule-out test (BPP). Surgery is consult, OB is primary even though the only reason she is in the hospital is for recovery from the hemorrhoid surgery. She was told this is an excruciatingly painful surgery that will take two days to be bearable. The surgery resident went into the wolfden. "She is a weiner, very low pain tolerance." The resident came to us afterwards to say nothing is wrong with postoperative course, and no more pain meds can be given. "This is a direct quote from the surgeon, 'I don’t see them for two weeks because they will chew me out."
We read the operative note for the surgery. High-Horse Haley comments: "You see everyone says OB is disgusting. Look at this. During the surgery they dilated anus to get access. Babies are meant to come out of the vagina. Anuses not meant to be dilated."
The mid-level explains that there is no medical necessity to be in the hospital and we are just giving you meds that can be given at home. You'll recover better at home. The husband responded that they won't leave because it would be difficult to get into the car and get her up the stairs to their bedroom. "Sleep on the damn floor. We're not keeping them because he doesn’t want to deal with her at home." Are they private or Medicaid? Private. "There is no way that Anthem is going to pay for this hospital stay. It'll be out of pocket. Most expensive hotel stay ever. $4,000 just for the night, not including outpatient med costs."
After they are informed about cost, they leave within 30 minutes.
Around 2:00 am, Tiffany delivers her patient's baby with the attending and Haley and myself in the room. I get to deliver the placenta and perform a uterine massage. Haley: "Tomorrow we'll try to get you a baby to deliver. Good job."
Things become dead at 4:00 am. We don't have any patients to report to the morning team so we make up names to put on the sign out sheet. We come up with: Bree, Frank; Rea, Gunner. Tom: "Let's see how long until they notice they're all fake."
Wednesday night starts off with a few rule-out ROM (rupture of membrane) ferning tests. Tangled Tiffany swabs the vagina and wipes the swab on a glass slide. If the amniotic fluid has ruptured, the salts will crystalize into snowflakes at 40x magnification.
My patient for the night is a 24-year-old pregnant with her first child. I walk into her room at 6:30 pm to introduce myself. The similar-age father is snuggling on the pull-out bed with the patient's sister. The expectant mother is concerned about pain. "I was promised I wouldn't feel anything. Is this true?" There were enough similar questions that her day nurse requested reassignment. The epidural is in and we know that it's working because she can't move her legs, but the new mom continues to complain about pain. Haley joins five minutes later: "You are going to feel some pain. Delivering a baby is painful. Pressure is okay." As delivery gets closer we finally acquiesce and ask the anesthesiologist to add another dose of fentanyl/bupivacaine. Haley: "She should have enough pain medication to not feel anything." The patient is still uncomfortable. About 15 minutes before complete dilation, we have to adjust the fetal monitor on her abdomen. "We need to move this to make sure your baby is alive." She screams: "I don’t give a fuck what happens to him. I need this pain to stop. Get him out."
While walking back with Tom I ask, "Why can't I see a happy family deliver like in the movies?" He responds: "You're probably not going to see that. Med students are not permitted to see privately insured patients, so you're stuck with a skewed population of Medicaid and uninsured."
Haley coaches me in the resident lounge with a basic delivery model. There are four steps to deliver a baby in the desired OA [occiput anterior] position: (1) protect the perineal body as baby's head comes out; (2) push down on baby's head; (3) make a "C" with your hand around baby's neck and push down until the shoulders come through; (4) pull up once shoulders are through. Our patient's nurse interrupts and tells us that she feels like she needs to poop. I run ahead and begin putting on my sterile gown and gloves. High-Horse Haley supervises closely as I grab the baby, directing my arms to the right position. It happens so quickly that you have no time to think. APGAR 7 at 1 minute and APGAR 9 at 5 minutes.
The mother has moderate bleeding after delivery of the placenta. She tries to kick Tom while he performs uterine massage for bleeding after delivery of the placenta. Her nurse caught the leg. "We don’t kick." The nurse had to leave the room before she said anything untoward. Haley contacted CPS (Child Protective Services) due to concern for the baby, but they decide to not take the case.
[Editor: In most states CPS tends to be busy because the typical custody lawsuit plaintiff can shortcut the process by dropping a dime on the defendant. See "The Domestic Violence Parallel Track" within Real World Divorce.]
Tom and I see A 20-year-old nullip [nulliparous, no prior pregnancy] at 24 weeks in Triage. She has depression and wants to deliver the baby now. We counseled her that the baby needs more time in the womb. Haley: "This is not uncommon. A lot of depressed pregnant women want their baby delivered now to give them company."
Tom and I go see a 25-year-old pregnant mother, father, and cute chubby 3-year-old twins. Nobody in the family speaks English. She is 26 weeks pregnant and complaining of chest pain so was admitted despite being apparently healthy. We struggle to convey basic information about acid reflux and anxiety through a Swahili interpreter on the phone. Tom complains to the team in the resident lounge: "I just spent 30 minutes telling a patient how to take Pepcid. Why the hell is this patient in the hospital? This could all be done in clinic."
Thursday night I have my real, "unassisted" delivery. My patient is a 26-year-old G2P1 (one prior pregnancy, brought to term) at "40+5" (40 weeks plus 5 days of pregnancy). She is here for IOL [induction of labor]. She has an uneventful labor until it is time to push. Haley: "She is a 26-multip but she's acting like a child. Maternal effort is zero. Pit [Pitocin, oxytocin hormone analog] is not going to help unless she tries. She is contracting, but it's also about maternal effort." The delivery goes great. The attending comments afterwards: "That was one of the best student deliveries I've seen. You should consider OB/Gyn. Perfect mix if you're torn between medicine and surgery."
[When I share this recommendation story with Lanky Luke, he responds with "In 10 years it will be illegal for a man to work as an OB/Gyn. Maybe you could do an OB/Gyn residency if you start to identify as a woman."]
Friday night. Haley: "Every night has a theme. Yesterday's was lack of maternal effort. Tonight's is preterm labor." There are several laboring patients but they are all privately insured and thus I am prevented from being involved. I follow the mid-level to a few consults in the ED and hospital floor. The attending and I go see a patient in the ED for POD3 [post op day 3] after CS [Cesarean Section] pain. She has a small hematoma on CT imaging but this pain is from an anxiety attack. The attending takes 15 minutes to calm her down with slow breathing and applying pressure to her frontal bone pressure point.
A 19-year-old nullip at 24 weeks presents for onset of contractions. Her boyfriend brought her to a hospital one hour away and she was transferred to our NICU-equipped facility via ambulance. The OB intern performs a cervical exam which reveals bulging membranes. "I didn't want to push too hard to feel the cervical dilation out of fear of rupturing her membranes." Her family arrives quickly while the father's family is en route from about 3.5 hours away.
Eventually there are 12 family members packed into the room. This includes three grandmothers: mom of patient, stepmom of patient, mom of father. The patient's mother comes running out yelling, "I think her water broke." We ask everyone to leave but they trickle back in as we perform a ultrasound to confirm. The patient lies exposed during the cervical exam in preterm labor with two-and-a-half families surrounding her bloody, wet sheets.
I go downstairs to the NICU to expedite the consult for PPROM of extreme prematurity (preterm, premature rupture of membranes). I return to the patient's room with the neonatologist who explains the situation to an audience of 13. A baby at 24 weeks has a 50-60 percent chance of survival with a 25 percent risk of severe developmental delay. "Every week is crucial. There is about a 5 percent increase in survival per week." The neonatologist explains: "She is going to remain in the hospital bed-bound for as long as possible. Our goal is to slow the labor so the baby can get a few more days in the womb. Because her membrane ruptured she is now at risk for infection. If she spikes a fever we have to deliver immediately ." She continued: "After the baby is delivered, she is going to have to stay in the NICU until at least term dates, so we are talking about a 2-3 month stay at least. A baby her age has about a 25 percent chance of requiring surgery." I could see tears welling up in the patient's mother's eyes as she strokes her daughter's cheek at bedside.
Statistics for the week… Study: 6 hours. Sleep: 5 hours/night; Fun: 0 night. Recovering from night shift.
I arrive for L&D days at 7:00 am and meet the all-female team before our 7:30 am handoff. Nervous Nancy is leaving from the night shift: "I'm loving OB/Gyn. All the good parts of surgery, with none of the soul crushing."
The Chief resident is a wide-shouldered fit new mother who periodically attaches her $480 wearable Willow breast pump. The Chief explains to me: "You'll find that days are full of admissions from clinic and triage. You will have some elective C-sections, but nights are where all the deliveries happen."
The intern is an Indian-American only half the size of the Chief. Though specializing in OB/Gyn, she's still struggling to perform a cervical exam and gushes when talking to the Chief. She asks how to rotate a baby from OT to OA [Occiput Transverse to Occiput Anterior, positions of the baby's head during delivery]. "Wow, that is so amazing."
My first patient: a 39-year-old G9P8 (9 pregnancies; 8 births) admitted the previous day for induction of labor at 37 weeks for "PreE" (preeclampsia; high blood pressure with proteinuria). The night team resident, Teacher Tom: "I asked her why she keeps having kids. She explained that all her previous kids were taken away from her so she needs to have another one. Does she think she's taking this one home? CPS took her kids away because of her meth habit." Nervous Nancy: "I had a G13P11, with no twins. At first I read it as G1, but then realized we were in double digits. Just how?"
I follow the mid-level resident who is in charge of all OB consultations in the hospital outside of L&D. For example, there is an "antepartum" unit for pregnant patients who are not expected to give birth. We check on a 26-year-old African-American G3P2 patient with a BMI of 62. She stopped taking her birth control while breastfeeding the second child. The resident attributes this to a "lactation consultant who told her not to keep taking her Micronor because it'll decrease milk production. This is what happens, when people go outside their expertise. Do they realize how dangerous short interval pregnancies are on the mother and baby? The only studies show that estrogen might have an impact on breast production. No study has shown any change in breast production with progesterone. It's online voodoo and look what's happened."
Our 350 lb. patient is 29 weeks pregnant and on tocolytics (medications that prevent labor) and BMZ (betamethasone steroid). "The purpose of the tocolytics is not to prevent preterm labor," explains the resident, "but to give the steroid enough time to improve fetal lung development." The patient was taken to the OR for a classical C-Section (vertical incision rather than low transverse incision of the uterus) due to non reassuring neonatal stress test (NST) and a malpositioned baby (transverse). A classical C-section has a much greater risk of uterine rupture in future vaginal births and therefore all future deliveries will require a C-section.
Our next consult is in the ED. A tearful 26-year-old mother, PPD #5 (postpartum day 5) from LTCS (low transverse C-section), is panicking. In between tears, she sobs, "I need to be at home taking care of my baby, but my belly hurts so much." The resident, in a calm voice: "Breath in, Breath out. Slow your breathing." A CT scan shows a small hematoma in the abdominal wall, which is why we were consulted. The resident explains: "She is totally fine. Everyone is going to have that size hematoma after a CS. This is simply a panic attack from being a new mother. She needs to get evaluated for postpartum depression, but doesn't need to be in the hospital for this." The resident applies pressure with her thumb on the patient's forehead at a "trigger point" to calm her down. As we walk back to the elevator, she explains, "A lot of what you do as the mid-level [resident], is finesse and coddling patients."
Thursday afternoon I deliver a 22-year-old "self-pay" (did not fill out the Medicaid paperwork) G1 African-American mother. Unlike with any of the previous deliveries at which I had been present, the father had accompanied the mother to the hospital. He was a 21-year-old Caucasian pacing and asking questions every few minutes.
She appeared to be progressing slowly, typical for nullips. She started to feel the urge to push at 8 cm dilated, but the resident said to wait until completely dilation (10 cm) so as to avoid cervix damage. The team steps out to see other patients, leaving me and the 45-year-old highly experienced nurse in the room. Having heard the word push, I eagerly gown up. Five minutes after the team left, she starts pushing and the baby pops out. The nurse and I rush with outstretched hands toward the newborn boy, but I am closer and catch him. I put the baby on mom's chest, as the nurse and I scream for the BRT (Birth Respond Team). The nurse and I clamp the cord while the team rushes through the door and gowns up. With supervision from the attending, I instruct the father to cut the cord, and then I deliver the placenta. I earn a "good catch" comment from the nurse.
While shadowing the intern the next morning, we see the mother again. She complains of belly/breast pain. The intern is anxious to get back upstairs and deliver babies. She listens, but doesn't touch the patient's abdomen. During the intern's presentation to the attending, a 60-year-old who had his own practice for many years, she explains that the first-time mother is ready for discharge. The attending says "Something doesn't add up. Why is she still in pain after a vaginal delivery?" We return to the patient's room together. When the attending presses on the patient, she jumps off the bed: rebound pain (inflammation of abdominal cavity). We get an ultrasound and CT of the abdomen showing appendicitis. I chalk this one up as an example of specialists having a tough time seeing the big picture.
The attending debriefs us in the resident room afterwards. He comments: "My favorite quote from teaching was by an intern. 'I don't know what's wrong with the patient, but I don't think we need to do anything.'" The Chief replies: "Dr. P, you told me intern year that I didn't have even the competence of a second-year medical student." Dr. P: "That sounds like something I would say."
Also Friday morning, I ask my favorite family medicine intern, Tangled Tiffany, if she's examined the postpartum patient we are both following. She responds, "No, let's go in together. You do the talking." I ask the 28-year-old PPD #1 after SVD (spontaneous vaginal delivery) basic questions: "Are you walking, eating, stooling, passing gas, peeing. How are you breastfeeding? Any pain? Has lactation come?" She reports a mild cold. I then conduct my physical exam. After just one week on OB, I had become accustomed to performing a half-hearted physical examination. I use the stethoscope through her robe and report, "Everything sounds good, maybe a few occasional wheezes, on her right lung base." We have only a few minutes before I have to get my note in and head to the 7:30 am handoff. Tiffany replies, "Are you sure, look again. I came in before and found a few things. Maybe take her gown off." I take her gown off, and hear inspiratory wheezes, likely from a cold. She also has a Grade III/VI diastolic (heart) murmur.
Tangled Tiffany smirks at my shame: "This was a test. I came in before and examined her. She was nice enough to play along, and [to the patient], might I add, you did it perfectly! She's had this murmur since childhood, but has never gotten it checked out. She promised me she would follow up this time." When we leave the room, she comments: "Not a single OB/Gyn mentioned this in a note at any time during this pregnancy. Just remember, don't skimp on the physical exam. It takes two seconds, but I see this all the time. A doctor listening through clothing is not doing a full exam. Unless the patient has a Grade VI murmur, you're not going to hear anything." We arrive for handoff at 7:35 am, but people are still strolling in.
This was the first week where I did not feel welcome and had to chase after team members who seemed anxious to see patients without me. One time I ended up following the intern on the way to the women's bathroom. I confided this to Nervous Nancy the next day. "Oh, yeah, that happens all the time with me. I just play it off that I was also going to the bathroom." When I offered to stay late on Tuesday for a C-section, they responded with, "You can go home now. We don’t want to violate your Duty Hours." When I offer to stay for handoff to present my patients: "You can go home. It'll be too crowded in the resident room. Go home."
It is small consolation, but they don't seem to like the patients any better. There is a lot of trash talk in the lounge, and sometimes just outside patient rooms, about obese patients. Example:
"I still have to do cervical checks. I'm elbow deep struggling to keep the legs out of my way." (our intern)
The team is only slightly more impressed with family medicine colleagues, one of whom notes "It's family medicine not family practice. I wouldn't mind when they call us family practice, but it's in context of everything else. It's just the icing on the cake -- they have no respect for us. They look down on us as if we don't know how to correctly deliver a baby. We do C-sections. I do them just as well as the interns. We know how to handle intrapartum complications. They think that because we are not as specialized as they are, we don't need to know how to practice these skills."
Classmates are active on Facebook regarding the Brett Kavanagh nomination hearings. Type-A Anita and Pinterest Penelope get one-day excused absences to attend a protest. There is a picture of them holding signs of "KavaNope". After the confirmation:
well this is horse shit, but what else would I expect from white men in power? welcome to the bench Kavanaugh, I look forward to losing the rights I’ve won in the past 5 decades.
One hour later, she admonishes "Ladies, make sure there are video cameras and eye witnesses the next time a man violates you" and brackets a quote from President Trump:
Absolutely. Fucking. Disgusting.
"I do stand with women, but we need to show the evidence. You cannot just say to somebody, 'I was sexually assaulted,' or, 'You did that to me,' because sometimes the media goes too far, and the way they portray some stories it's, it's not correct, it's not right," said Trump
Absolutely. Fucking. Disgusting.
She also shares her boyfriend's Facebook post:
I stand with all the survivors currently reliving their traumatic experiences and seeing their legal and justice systems fail them. I cannot apologize on behalf of all men, but I can say that I’m a proud feminist 100 percent and you have an ally in me.
Male friends: how many of you called senators? How many of you made the time to protest? How many of you had hard conversations with your other male friends? Don’t talk to me about much “this sucks”. Goes double for @white people for issues on police brutality and gerrymandering
[Editor: The construction of bizarrely shaped districts to make certain that one party wins (gerrymandering) may be required by the Supreme Court's 1986 decision in Thornburg v. Gingles to protect the rights of minority voters from having their votes "diluted".]
Statistics for the week… Study: 8 hours. Sleep: 7 hours/night; Fun: 1 night. Christopher Robin movie night with Jane.
As part of our OB/Gyn rotation, we selected a week-long surgical subspeciality, either urologic oncology ("UroGyn") or gynecologic oncology ("GynOnc"). GynOnc is known to be an intense rotation featuring surgery hours with operations that frequently last more than four hours and extend well into the night. Lanky Luke responds to hearing that I chose GynOnc: "I loved UroGyn last week. It's all old ladies with urinary incontinence, but the surgeries are really neat."
GynOnc begins at 6:30 am on the oncology floor. My Chief, Marvelous Martha, is a big and tall 34-year-old who loves talking about her adventures on the Bumble dating application. The residents and my classmates adore her. Nervous Nancy: "All her patients are taken care of, even the small details about nausea, ambulation, pain. I don't know how she stays so on top of all the patients on the floor." The intern is a short, 45-year-old mother of two college-age kids. She worked as a project manager for GE before going to medical school. Nervous Nancy was shocked to hear about the two kids in college: "She looks so young!"
[Editor: How long would a 34-year-old guy talking about his Tinder adventures last at this hospital?]
The case load is light so I go to the medical student lounge and meet Lanky Luke and Particular Patrick. Particular Patrick says that he misses the "intensity of surgery" and is "bored out of [his] mind on Family Medicine." Lanky Luke is not enjoying L&D nights. "I have to watch what I say around my team. They were complaining that Medicaid would pay for the Mirena IUD, but would not pay to remove the IUD unless medically indicated. I wanted to say, 'Maybe we shouldn’t be taking it out. If you can't pay the $100 fee to have it removed, maybe you're not able to afford a child. Taxpayers paid for five years of contraception. They'll pay for 18 years of housing, health care, and food if a baby is pushed out. Why can't the Medicaid customer scratch up $100 in the middle?'"
Luke's team was not entirely humorless. "This hippie couple brought in an eight page labor plan document. The [male] resident showed me a cartoon in his locker in which a sheet of paper labeled 'labor plan' was being shoved up someone's butthole." Proving the old adage "no plan survives contact with the enemy," labor was prolonged and the fetal heart rate was "nonreassuring." They got a C-section. The father took his shirt off in the middle of the OR and had the newborn placed on his chest ("kangaroo care") while the mother was getting sewn back up. A nurse joked: "It'll latch onto you if you're not careful." The father was excited. "Really!?" Should I let him?" Luke fought the urge to add "No, no you should not. You want that baby to suck on your hairy nipple? He'll never latch onto another one after that traumatizing experience."
Our weekly afternoon lecture begins at 1:30 pm and is on contraception and miscarriages. The generalist OB/Gyn describes the different techniques for an abortion (medical versus surgical). "Most states limit abortions beyond 24 or 26 weeks and some as early as 22 weeks. Most women do not get results for their fetal anatomy ultrasound until 22 weeks. Whether or not you support abortion, it's important for everyone to understand the harrowing choice some women have to make, sometimes in a matter of days to get an appointment." We also go over the various types of birth control and the uses of OCPs [oral contraceptive pills] beyond contraception per se. For example, patients with BRCA1 mutations have a 60 percent chance of getting breast cancer by age of 70, and a 50 percent chance of getting ovarian cancer by the age of 70. Every year that a patient takes COCs (combined oral contraceptive) decreases the risk of ovarian cancer by 5 percent." We get out at 4:45 pm and are done for the day.
Tuesday is more typical. I get to the hospital at 5:45 am to pre-round on two patients. Both were admitted for intractable nausea and vomiting. The first was admitted two days after getting her first cycle of carboplatin/paclitaxol chemotherapy for stage IV endometrial cancer. She's about 55. My other patient is a 57-year-old with ascites (fluid in her belly, in this case over 20 liters) that has led to the classic protuberant "beer belly" that suggests ovarian cancer (stage IV in her case).
We have four cases today: two "majors", both TLH/BSO (total laparoscopic hysterectomy with bilateral salpingo-oophorectomy); two "minors", a laser ablation and a cervical stenosis repair. The attending is a 55-year-old gyn onc surgeon. She's sarcastic, but quite patient.
I run to meet the first two patients in pre-op before heading to the OR for gown and gloves. Our first case is a robot-assisted TLH/BSO with lymph node removal and an omentectomy (removal of a fatty lining) for ovarian cancer staging. The 53-year-old patient underwent neoadjuvant chemotherapy before this surgery. "Ovarian cancer responds well to chemotherapy," says the attending. "Sixty percent of ovarian cancer will go into remission. That's why we need to be thorough and not leave any protected spaces of tumor that the chemo can't access. Unfortunately, 90 percent of our patients will have recurrence and over time the cancer develops resistance. The big ticket item in ovarian cancer research is finding a maintenance therapy that prolongs remission."
Two of the OR technicians have been on staff for only a couple of months. It takes 90 minutes before we get the robot docked, and the arms attached to the laparoscopic port sites. The attending and Martha head to the robot control panels, about 15 feet away. They're still in the OR, but they've scrubbed out for comfort. I hold the uterine manipulator and the mid-level resident uses a grasper under direction from the attending. The attending sounds frustrated as she coaches Martha: "Never buzz with the scissors open."; "Angle the scissors. Use your point of strength!"
We begin to remove the omentum from its connections to the gut tube. "This is the biggest omentum ever!" says the attending. "I just don't know." After more came out: "This is unreal how big this omentum is."; "This is a really fucking big omentum." After 3.5 hours with the robot, we give up and perform a laparotomy (conventional opening of the belly with a large incision; the opposite of laparoscopic) to finish the removal. The da Vinci Xi robot ($2 million base price; accessories additional; $10,000 in disposables for each operation) turned out to be useless.
It is nearly time for a UroGyn lecture covering content easily found with UpToDate or OnlineMedEd.com.
I tell Martha that I will skip the lecture because the surgery is far more interesting. "Sorry we can't let you do that," she responds. "We've gotten in so much trouble for students being late to lecture. Appreciate the enthusiasm."
The next case is a laser ablation of the cervix to prevent cervical cancer. The OR staff lug in a giant CO2 laser. The attending commands, "Arm the laser beam". Just as in Austin Powers, the nurse responds, "Laser armed and ready." The attending lets each of us have a quick experience looking through the microscope and aiming the laser. The nurses made the surgeon insert a wet 4x4 gauze into the anus to prevent the release of any methane gas that might be ignited by the laser.
Thursday features two hysterectomies and a fibroid removal. We use the robot (da Vinci) for the first two cases, and opt against it for the more challenging third case. Our attending is relatively new and extremely cautious, so each case takes at least three hours (one hour would be normal). The residents are not afraid to express their frustration in the OB lounge. "I hate working with him. Everything takes three times as long as it should." The second case is removal of a two-centimeter fibroid at a patient's insistence. The 40-year-old Eastern European is convinced that all of her problems stem from this benign tumor. The intern ungratefully complains about the attending to another OB/Gyn team: "No one should ever remove a fibroid that small." The Gyn Chief adds: "I cannot believe [the attending] went ahead with that surgery. Either do a hysterectomy or tell her we're not removing it."
The third case, removal of a uterus with a 10 cm fibroid, starts at 3:30 pm, right when we would ordinarily be heading home. The chief is driving with the laparoscopic graspers while I wield the uterine manipulator. By the time we get the fibroid dislodged, it is 8:30 pm. Then the fibroid won't fit through the vagina. We then have to do a laparotomy (open the belly with a knife, thus rendering all of the laparoscopic work and extra time pointless). On the bright side, the attending allows me to make the incision with the scalpel. It feels heavy. The attending sends us home at 10:15 pm while he closes up. He felt bad for keeping the chief from her 14-month-old.
We sit in the OR lounge and chat with another OB/Gyn attending. He explained to the young team members that our medical education and experience would transform us into superior beings with respect to uncovering microaggressions and revealing implicit bias: "Doctors are more in tune with bias than other people in society because we deal with the consequences of bias all the time. A patient comes in for the 10th time in two months for the same nonsense problem, we are prone to blow it off and send them out. The patient comes back to the ED in crisis because of what we missed. Every doctor in practice for more than twenty years has had this experience."
[Editor: "Your Surgeon Is Probably a Republican, Your Psychiatrist Probably a Democrat" (nytimes, October 6, 2016) lends some credence to this theory. Surgeons, notorious for not doing any long-term follow-up with their patients (so they would never learn about the consequence of holding a bias), are much more likely to be Republican than Internal Medicine docs.]
I leave early for lecture on Friday. I chat with Nervous Nancy in our medical student lounge. Nervous Nancy, age 31, confided: "After going through L&D, I sometimes think to myself, screw it I am going to have a baby. I am vastly irresponsible, and underprepared. But look at some of these mothers. Then I remember that they are terrible people. They'll have a child without batting an eye when the kid is going to the NICU because of the mother's unrepentant cocaine use."
[Editor: In the 1990s, a social worker friend in her mid-30s said that she had been agonizing over whether she was sufficiently prepared to take on the responsibility of caring for a child. She then reflected that one of her clients was 15 years old, pregnant with her second child, and living, without apparent health impacts to mother or child, almost exclusively on a diet of Coca Cola and Doritos.]
Statistics for the week… Study: 2 hours. Sleep: 5 hours/night; Fun: 0 nights. I leave the hospital early on Friday afternoon to catch a flight to a college classmate's wedding. We chatted with the groom's cousin the morning after the wedding. My best friend, also a third year medical student at a different school, asked, "Did you notice something about him?" I quickly responded, "Yep, pinpoint pupils." He grins back, "Yep, must have been partying all night with some opioids."
Gynecology rotation starts at 7:30 am in the outpatient surgery center. The chief texted the previous night to skip hospital rounds and just meet the team at the outpatient surgery center for the first 8:00 am case (this is an inpatient week, but if there are no scheduled surgeries at the hospital we go with an attending to the outpatient center). I appreciate the extra sleep! Our first patient is a 27-year-old who had an unfortunate uterine perforation after IUD placement by a Planned Parenthood Nurse Practitioner. "I think it was her first IUD placement. Looking back, she was so nervous." After a brief physical, we have about 30 minutes before the OR is ready.
Did it hurt getting the IUD placed? "It hurt so bad, but they told me that's expected. Over the next week, the intense pain got better, but I just kept having these sharp lightning bolts of pain once or twice a day." She saw an Ob/Gyn for a regular check up three months later who ordered an abdominal x-ray that showed a "T"-shaped device in the right upper quadrant.
The 70-year-old attending arrives. She meets the patient and confirms the consent is signed. I grab gloves for the attending, the intern and myself. We perform a laparoscopic removal of the IUD. It was lodged in the omentum requiring three port placements (three holes in the belly). Throughout the entire procedure, the 60-year-old anesthesiologist, a former dentist, tried to convince me that anesthesia is the best route. "Hospitalists are miserable," he began. "They have 80 patients, they work 12-hour shifts. It's not good for the patient, but it's the way medicine has gone. In anesthesia, we have only one patient at a time, and we are done after you leave the office. And the physiology is just awesome."
As the OR is prepared by the nurse, surgical tech, and OR tech,s for the next case, we head to post-op to talk to our recovering patient. After a brief conversation with the patient and her mother, we head to the nurse's station where the intern is instructed to prescribe 10 OxyContin 5 mg. "It's crazy how much opioid pills we still give out. Epic defaults to 30 pills for a prescription," says the attending. "I still have dozens of narco left over from my breast cancer surgery. Everyone is talking about the opioid problem and how doctors created this monster, perhaps, but I still blame the government. They started to adjust reimbursement rates based on patient-reported pain scales. No wonder the ED gave out Oxy like candy."
Before our next procedure (hysteroscopy, camera through the cervix into the uterus to look for, and possibly biopsy, cancerous polyps), I chat with the attending about the future of Ob/Gyn: "Ob/Gyn was a beautiful field because it combines surgery with long-term patient relationships. I am the primary care provider for a lot of my patients. We're succumbing to the specialization tsunami. I've been grandfathered in, but most hospitals require you to choose a track: gynecology or obstetrics." She continued, "The days of having clinic in the morning with two afternoons of gyn surgeries alternating with a week of obstetrics are ending. Administration is chipping away at the scope of practice for every field."
After a total of three procedures, I leave the outpatient OR at noon to attend lectures at the hospital on urinary incontinence by a "UroGyn" (Urogynecologist, 4-year OB/Gyn residency followed by 3-year fellowship).
The next day starts with hospital rounds before surgery at 6:30 am in the main hospital OR. We have two laparoscopic fibroid removals and a hysterectomy scheduled. Dr. McSteamy is the attending. He is a 37-year-old whose recent marriage occasioned despair among the residents (all female, except for one gay guy, a junior resident, who shared their grief). The chief, now four years out of medical school, struggles with basic laparoscopic techniques, incorrectly locating the ureters, a critical item given the risk of damage during the procedure. She also has a six-month-old at home, which might explain some of her deficiencies, but her parents have moved here to assist the software engineer husband in taking care of the baby. She is trying to find a job next year as a general practitioner in a smaller hospital setting.
During the second hysterectomy, the junior resident gets a page for two ED admits. He and I step out to evaluate a 24-year-old bartender with a three-day history of excruciating labial pain. She had a similar episode several years ago. Her right labia majora is swollen, erythematous (reddened), and extremely painful when she walks or moves. As I prepare to present the findings to Dr. McSteamy, I look up management of Bartholin abscess in my trusted Comprehensive Handbook of Obstetrics and Gynecology by Zheng, a $30 book that fits into a scrubs pocket. The bartholin glands, located at 4 and 8 o'clock in the vaginal introitus, secrete lubricating fluid through a small duct. Some women develop a blockage in the duct leading to an enlarging cyst that becomes infected. Once McSteamy is out of surgery, we head down as a team to examine the patient. We then gather supplies (numbing medication, Wort catheter, scalpel, iodine prep) to drain the abscess. Before we go in, the ED attending asks if the resident has performed one of these. No. Dr. McSteamy then describes the procedure. The ED attending also wants to watch as she has never seen one performed. We transfer the patient into an ED procedure room with stirrups. The resident injects lidocaine in the 3 cm labial abscess and she cries out in pain. After 5 minutes, the resident makes a small incision in the labia, which results in screams and "sorry, sorry." He then slips a 3 mm-diameter drainage catheter into the abscess. She is supposed to leave this in for 2-4 weeks, but the attending admits that most will fall out within a week. If this happens again she might consider getting a bartholin gland excision or marsupialization surgery (turns the gland inside-out) to maintain duct patency.
Friday morning: round on two post-op patients and then am sent off to study before a mandatory class meeting at 1:00 pm. Nervous Nancy is in the student lounge watching Grey's Anatomy on her phone. She is on outpatient Ob/Gyn week and was told not to bother driving to the clinic today. "Whenever I get nervous before exams, I instinctively watch Grey's Anatomy. My excuse is I might learn something from it while calming my nerves by binge-watching." We talk about her experience on Obstetrics. "I sometimes think, screw I am going to have a baby even though I am vastly irresponsible and underprepared. Look at these moms. Then I remember that they are terrible people." I recount my experience with the G9P8 having the ninth baby. When asked why she keeps having babies, she responds: "Well all my children are in foster care so I need to have another one to actually keep one." Nervous Nancy laughs, and says, "I've seen those too. Maybe your children are in foster care because you are a crack addict."
We head over to the school for confessions of a medical student. We were instructed to prepare by writing a two-paragraph anonymous confession from this year. We are divided into 10-person groups, each led by a physician who shuffles them and hands them out for presentation:
Nervous Nancy: "I just feel like I am always in the way. That no one is grateful for us, and the people that actually care for the patient would have it easier without us present." The physician leader asks, "Do any of you wish you were invisible?" Every student grinned, and nodded. Gigolo Giorgio, who sports a beer belly after gaining several pounds on psychiatry, comments: "I think you mean we all want to be flatter against the wall."
Statistics for the week… Study: 10 hours. Sleep: 6 hours/night; Fun: 1 night. Halloween celebration. Gigolo Giorgio hosts a pregame before the class Halloween party downtown. We reminisce about our rotation experiences. Buff Brad and his girlfriend dress up as Gamora and Warlock from Guardians of the Galaxy, Adrenaline Andrew and his girlfriend win first prize with homemade jellyfish costumes out of Christmas lights and clear umbrellas. Classmates are downing shots and beer. Once we arrive at the rented out bar's upstairs room, students dance Top 25 Pop hits while a line grows at the private bar for $5 mixed drinks. Gigolo Giorgio jokes: "[Put-Together Pete] is on his 24-hour night shift for surgery, we should all get blackout and visit him in the ED."
Outpatient gynecology week begins at a clinic with two nurse practitioners. Two-thirds of appointments are routine obstetric visits; one-third are gynecology visits (annuals and acute problems). Sixty percent of patients are enrolled in Medicaid; the remaining 40 percent are typically uninsured, but a social worker employed by the hospital is tasked with signing them up for Medicaid. The office runs like a typical doctor's office… except there is no doctor. In theory, the NPs can call the inpatient gynecology attending who will drive over (20 minutes) from the hospital, but this didn't happen during my two days.
My first patient is an outgoing postmenopausal 54-year-old botoxed blonde presenting for vaginal itching. She divorced her husband six months ago and co-founded a rental business with her handyman, with whom she now files. Their first property on the market was the ex-husband's former house. She reports that during the early phase of her relationship with the handyman, she had sex with her ex-husband "a few times, huge mistake". She emphasizes that for the past month she has been faithful to her new lover, but reports vaginal itchiness and discharge. She is concerned that she may have an STD. "I just pray I don't have to tell my ex-husband. The bastard would tell my [teenage] children to turn them against me." The NP supervises while I perform a speculum exam. I swap the cervix then prepare a wet (saline) and KOH slides to analyze under the microscope. Urine sample tests negative for chlamydia and gonorrhea. We reassure her that she does not have an STD, just bacterial vaginosis (multiple clue cells under microscope are diagnostic) and prescribe a seven-day course of Flagyl (metronidazole) 500mg BID (twice daily).
The NP schedules me for all three gynecology visits so I can practice speculum exams (nurse chaperone in room) while she keeps on time with the short routine OB. I see two OB visits on my own before she comes in. The last patient I see jointly with the NP. She is a withdrawn 17-year-old G2P1 at 16 weeks presenting for her initial OB visit. She is accompanied by an older sister. I communicate the schedule of upcoming OB visits (e.g., 20-week anatomy scan, glucose tolerance test, bacteriuria screening, Rhogam at 28 weeks, etc.). "I'll have to make sure I can get out of school and that my sister can drive me." The older sister says that she hopes the soon-to-be-mother-of-two will stay in high school and graduate. "Is the father aware of the child?" The older sister responds, "Yes, he's in school, but isn't going to be involved. Our parents are going to take care of the new baby."
After the visit, the NP recounted her experience as a nurse on the obstetrics triage floor. "We had a 12-year-old come in for a missed period. We asked the patient if she was having sex. No. Intercourse? No. Then a resident finally comes up and says: 'Are you doing it?' 'Well yeah, I'm doing it.' We immediately started to get worried about incest. Back in the day you'd get worried about a 12-year-old having sex. Now we don’t even bat an eyelid."
I leave at 3:00 pm for the afternoon gynecologic oncology lecture. Our attending goes over the common gynecologic cancers: ovarian, endometrial, and cervical. She summarizes: "Ovarian cancer patients die of malnutrition, endometrial cancer patient die of a heart attack [patients are generally obese with multiple comorbidities]." She continues: "Does cervical cancer run in families? After a pause, Nervous Nancy responds, "No, it's not a genetic disease, it's about behavioral risk factors -- HPV exposure and smoking." The attending answers: "You're correct about the risk factors, but cervical cancer does end up clustered in families because failure to access the health care system runs in families. My cervical cancer patients have not been to the doctor in over 10 years, or at least haven't gotten a pelvic exam in 10 years. Sometimes they have been seen by an internist a few times who just have given up performing pelvic exams in their practice. Cervical cancer patients die of renal failure, that's a good death. Uremia, you just fall asleep. The patients are young, typically 50 years old but it's a good death unlike ovarian cancer." (The working lower middle class are in the worst shape for access, suffering from massive insurance co-pays and being ineligible for the various free care options.)
She describes the challenges of patients consuming online information and the Power of the Pink Ribbon. "I had a sister who sent me an article saying OCP [oral contraceptive pills] increase the risk of breast cancer. I followed the link and it cited a 2014 article assessing high-dose estrogen-only pills, which are never used now. It just shows you how much false information is online. This stuff can impact your health. OCPs actually prevent breast and gynecologic cancers." She continues: "Now keep in mind the vast majority of women who get breast cancer do not have ANY of the risk factors we talk about. There is a high enough baseline risk that every woman over 45 should be getting a mammogram."
[Editor: See "National expenditure for false-positive mammograms and breast cancer overdiagnoses estimated at $4 billion a year." (2015), a study done using the insurance claim database that we have at Harvard Medical School. "Populationwide mammography screening has been associated with a substantial rise in false-positive mammography findings and breast cancer overdiagnosis." Many of the lives saved from cancer that have been chalked up to mammograms were in women who did not actually have cancer. It turns out that waiting for a lump is as reliable a way of finding true cancers as mammography. Switzerland, which spends much less on health care and enjoys longer life expectancy, has eliminated routine screening mammography. The U.S. meanwhile, is doubling down on medical interventions. The government issued a February 11, 2019 recommendation to put all higher-risk women on aromatase inhibitors.]
On Wednesday, I am in a different outpatient clinic: the "resident clinic" for high-risk OB. This one is led by a 5'4" no-nonsense PGY4. My first patient is an uncontrolled obese T2DM G3P2002 (type 2 diabetes; third pregnancy; two babies delivered at term; zero pre-term; zero miscarriages; two living children) presenting for her initial OB visit at 8 weeks. I go in first to get a history and complete a basic physical with doptone heart rate, waiting for the resident before beginning the pelvic exam. The unkempt diabetic single mom does not check her sugars. She hasn't followed up with her endocrinologist because she owes $150 (she should be eligible for Medicaid, but hasn't jumped through all of the paperwork hoops).
The patient describes vaginal discharge. We perform a speculum exam. I have to hold up several abdominal folds leading to a foul smell from candidiasis (yeast infection) while the resident performs the exam. We explain that she needs to use contraception if she doesn't want to get pregnant again. "Those pills bad for the body." (She may be correct; her uncontrolled hypertension is a contraindication for oral contraception.) The resident: "Yes, but it's also unhealthy to keep having unwanted pregnancies, especially when you are overweight and have uncontrolled blood sugar." She says she will consider contraception, but rejects the offer of an IUD insertion after delivery. The resident gets frustrated when her lecture on risks to the baby from uncontrolled diabetes is interrupted by incoming calls and texts on the Medicaid-eligible patient's unsilenced iPhone X.
After several obese women described by the resident as "simply refusing to take care of themselves, let alone their multiple kids," I see a young immigrant couple. They earn too much to qualify for Medicaid, but found that insurance was unaffordable. The 24-year-old Indian 26-week nullip has a normal BMI, but was diagnosed with gestational diabetes at screening. The husband brings a notebook of sugar logs. I circle two fasting and one 2-hr postprandial sugar value that were elevated within the past two weeks. Wow! I present the patient to my resident. "If they are tracking their sugars, they have good sugars," the resident explains. "For every five terrible patients, many of whom have several children in foster care, you see a couple like this one. I'm glad you were able to see them. They can't afford private practice so they come here, and they will be terrific parents."
The outpatient clinic employs a full-time Spanish-language medically certified interpreter and she is present for roughly 50 percent of the visits. Visits with a Mandarin-speaking patient and an Arabic-speaking patient are cumbersome. Within the hospital, full-time Mandarin and Arabic interpreters are available in person. From the clinic, however, we use a phone-based service for interpretation, but it isn't nearly as efficient as having a live interpreter in the room.
[Career tip from the Editor: the typical certified interpreter earns about $35/hour, or $70,000 per year working full time.]
Jane is on inpatient pediatrics. "After rounds we sit at a table finishing notes on our laptops. After a while, she does UWorld questions. She is partnered with Awkward Arthur, a 5'5" Asian 28-year-old who has had to remediate following most clinical skills exams. "He keeps looking over my shoulder. I eventually ask if he wants to do questions with me. And he starts trying to show me up. He does this in rounds too. He seems innocent, but he is a total gunner."
Statistics for the week… Study: 4 hours. Sleep: 7 hours/night (showtime for outpatient work is 8:00 am); Fun: 2 nights. We see an Americana jam-band at a church turned into a concert hall by a local foundation with Sarcastic Samantha and Lanky Luke.
Reproductive, Endocrinology, and Infertility (REI) elective begins at 8:00 am at the newly-constructed clinic, a 30-minute commute. I work with a 33-year-old first-year attending straight out of her three-year REI fellowship. Infertility is defined as failure to conceive after one year of unprotected intercourse. During the 45 minutes before the first couple arrives, the attending quizzes me on the basic menstrual cycle.
We see eight patients throughout the day. A typical new patient visit: the couple referred for infertility sits across from the attending's L-shaped desk while she draws a diagram and goes over the "four pillars of conception": (1) viable, motile sperm, (2) viable egg that ovulates (is released by the ovary), (3) open fallopian tubes for conception, and (4) implantation into uterus. (Starting with the 4th new patient, she has me draw and explain the pillars.) She will then order basic fertility labs, including a hysterosalpingogram (abdominal x-ray with contrast injected into uterus), sperm analysis of partner, ovulatory labs (Anti-Mullerian hormone, LH surge level, mid cycle progesterone), and a saline-infused sonogram evaluating the uterus cavity for implantation obstacles (e.g., intracavitary fibroid, uterine anomaly). She emphasizes that her therapies cannot fight nature's fertility decline with age. The goal of therapy is to get back to the age-dependent cycle fertility rate.
She advises all female medical students to freeze their eggs before they hit 35.
[Editor: Better advice from a purely economic perspective would be for the prospective medical student to fertilize her eggs (with an appropriate partner and in the right state) and thus graduate debt-free.]
The clinic offers three types of fertility therapies: (1) timed-intercourse with drug-induced superovulation; (2) intrauterine insemination (IUI) with superovulation; and (3) in-vitro fertilization (about $10,000 - $15,000 per treatment). Superovulation is associated with a 5-8 percent twinning risk. Most of the couples have already done their research and been performing effective timed intercourse using over-the-counter ovulation kits. For women under 35, she recommends 2-3 IUI therapies, and, if these fail, advance to IVF.
(Why does IUI, injecting sperm into the uterus, work when ordinary intercourse doesn't? It saves low-quality sperm some of the swimming effort.)
A woman comes in for transvaginal ultrasound prior to ovulation induction. We're looking for 5-6 mature follicles between the two ovaries. She will have been taking letrozole (an off-label use of an inexpensive generic aromatase inhibitor used for breast cancer treatment) or clomiphene (higher risk of twinning, out-of-fashion) to stimulate superovulation. The ultrasound shows sufficient follicular development, so we instruct her to have intercourse for the next three days and, on Day 2, induce ovulation by injecting herself subcutaneously with beta-HCG (Human chorionic gonadotropin) to mimic the natural FSH/LH (Follicle-stimulating hormone/luteinizing hormone) surge.
I was fortunate to witness my attending's first successful IUI pregnancy in this clinic. The couple tried to have kids when they were in their 20s, gave up, and returned at the husband's initiative when the aspiring mother was 36. They cry when they see see their "little gummy bear" on transvaginal ultrasound. Nearing the end, the wife asks to see the sperm analysis, "You had mentioned something wrong with [John]'s sperm over the phone. What was it?" John comments, "Well, clearly, my sperm are good enough." The attending jokes: "Not if you're not the father." The father: "I'll have to get a paternity test now."
[Editor: Depending on the state, if one of these two decided to end the marriage, John will have to pay child support regardless of the DNA test results. See "Who Knew I Was Not the Father?" (New York Times, November 17, 2009) for an all-American tale of extramarital love and litigation: "I pay child support to a biologically intact family," Mike told me, his voice cracking with incredulity. "A father and mother, married, who live with their own child. And I pay support for that child. How ridiculous is that?"]
The next day we are in the OR back at the hospital. My REI attending, an intern, and I perform two hysteroscopies on women with uterine anomalies that had prevented pregnancy. The intern is not allowed to move the hysteroscope, a fiber optic cable equipped with a camera, shaver device, vacuum, and saline injector). From the first patient, we remove a uterine septum (congenital divider; first noticed during a CT scan for appendicitis). From the second, an intracavitary fibroid (smooth muscle tumor that distorts the uterine cavity lining). Both of these are covered by insurance due to their potential to cause bleeding or other medical issues unrelated to fertility.
The REI attending devotes one afternoon per week to PCOS (polycystic ovarian syndrome) cases. We start by ignoring the elephant in the room (literally; obesity is the main cause of PCOS) and testing for extremely rare disorders that could also account for menstrual irregularity.
The first patient is typical, a 27-year-old secretary with a BMI of 34 (obesity begins at 30). She's not planning on children in the near future, but wants to know what her prospects are. The petite fit attending lectures her on the need to lose weight, recommending cutting back on restaurant meals and making smoothies. The patient starts crying, recounting her unsuccessful attempts to lose weight.
The next patient is not typical, a 35-year-old obese female with history of bipolar disorder recently released from a state mental asylum. For her bipolar disorder, the discharge summary says that she is supposed to be on lithium, which is teratogenic (causing birth defects), but she can't remember what medicines she is taking. She struggles for half of the visit trying to log into MyChart from her iPhone. She also has uncontrolled type 2 diabetes. Her chart shows several ED visits for substance abuse: cocaine and fentanyl. "It's hard for me to get a job, so I want my job to be mother." We give her pamphlets about sperm banks. The attending: "Well, that was interesting… I am not getting her pregnant. I am not sure how she even got an appointment here."
REI is cut short by exams. As we walk into the testing center, Nervous Nancy asks, "You guys ready to look at some nasty vag pictures?" Sample questions that accompanied numerous photos of vulvar lesions:
(Why a screening test after an abortion? Rhesus (Rh) antigen is a sugar chain on an individual's blood cells. If a mother who is Rh - (for example, A-) has a baby with a Rh+ father, her immune system becomes sensitized to the Rh+ antigen from recognizing the Rh+ fetus' blood cells that cross the placenta into maternal circulation. If she does become sensitized and has another Rh+ pregnancy, the fetus will be killed by the mother's immune system. Therefore, during any large blood volume transfer (e.g., abortion, vaginal delivery), mothers are given Rhogam, an antibody against Rh+ that binds up the Rh+ antigens before the mother's immune system can become fully activated.)
Ob/Gyn also requires an oral examination with the clerkship director. We each go into her office for 15 minutes of questioning. We first go over a case regarding cervical cancer screening and urinary incontinence in an elderly female. We also prepared eight cases from our rotation, and she chose two to discuss (on pre-eclampsia and ovarian cancer).
After exams, I meet classmates at a new downtown brewery. Type-A Anita just finished her internal medicine rotation. "That was the first time I saw some shady medicine. A lot of the second and third year is learning about billing. You could bill for a COPD exacerbation, or you could code hospitalization as respiratory distress with hypoxia." Lanky Luke afterwards: "Reimbursements for Medicaid patients lose money so they have to make it up by overcharging Medicare and privately insured patients. They have an army of billers to deal with this." I respond with the positives of REI: motivated and healthy patient population, great lifestyle, no insurance hassles.
[Editor: The wise central planners in the Commonwealth of Massachusetts force private insurers to pay for in-vitro fertilization, without any limit to the number of cycles. Come to our local airport to see the business jets that the fertility doctors fly!]
Facebook status from a fourth-year medical student: "Please read this. Even a progressive institution such as Planned Parenthood can still have unconscious bias. Wake up people! My trans friend was disappointed in his care at Planned Parenthood and switched to Hope and Help." Underneath, a shared post from the born-female-identifying-as-a-male patient: "After dealing with fat phobia and transphobia with the nurses, as well as issues with filling my prescription, I decided it was time for a change. My doctor confirmed my fear that my dose has been far too low to yield the typical results of 9 months on T [testosterone] and worked with me to find a reliable pharmacy and be on the right dose.The staff was incredibly welcoming and I left feeling I had a voice as a patient."
Our school can't be accused of bias against LGBTQ community members; the Facebooking fourth-year student hasn't had to write any tuition checks thanks to national and school-specific scholarships limited to applicants who identify as LGBTQ and/or can be characterized as part of an "underrepresented" group. The rest of the country, on the other hand, disappoints our class. From the fourth-year scholarship student, just before the 2018 elections:
I am sick and tired of being scared, and being sad, and waking up every day wondering what’s it going to be this time. Of an administration that galvanized hatred against people based on their sexuality, religion, race, ethnicity, identity. I refuse to stand for an administration that says we shouldn’t let committing sexual assault ruin a man’s life, ignoring that it has done irrevocable damage to the life and mental wellbeing of his victims. And I’ll be damned if we don’t vote these monsters out of office." Vote for democracy. Vote for change. Vote like your life depends on it. Because it absolutely does.
From Pinterest Penelope, cheered by our school's recent award for "diversity in higher education":
Out of darkness, there is LIGHT! Thanks to all who work to make our university a more diverse, safe, and welcoming environment! Now, vote like your life depends on it. Because it does.
[Editor: government attacks on physicians under the Trump Administration were so severe that taxpayer spending on Medicare and Medicaid in 2017 was cut to less than $1.3 trillion (CMS.gov), projected to grow at 5.5 percent per year through 2026.]
Statistics for the week… Study: 8 hours. Sleep: 7 hours/night; Fun: 2 nights. Over beers and burgers on Saturday, Mischievous Mary talked about finishing her six-week cardiothoracic elective rotation. Lanky Luke and Jane's eyes glaze over as she goes into details about helping to cannualize the aorta for bypass. Another exciting moment: "We were sitting at the CT surgeon lounge looking at the strips in the CCU, and we see a patient in torsades de pointes [sinusoidal wave]. We run out, and no one had noticed. We start doing compressions, pushing magnesium. It was awesome! Saved his life."
Internal Medicine clerkship starts at 7:00 am. My classmates and I meet the clerkship coordinator at the hospital coffee shop to receive schedules and team assignments. Gigolo Giorgio is frustrated we did not receive our schedule a few weeks ago to allow us time to plan Thanksgiving and Christmas. We can choose five days off within the next six week block in addition to two post 24-hour call days. The IM service treats weekends the same as weekdays. Giorgio complains, "I could have scheduled those five days to go home for Turkey Day."
Each IM team has two interns, a senior resident (PGY2 or PGY3), an attending, and a medical student pair. For this block, our team happens to have an additional (third) medical student. The attending rotates every week.
We sip coffee as the clerkship coordinator goes through the rotation schedule for 30 minutes. The senior residents for each team come down, introduce themselves to their respective medical students, and whisks them away to meet the rest of the team. Sleek Sylvester, Ditzy Diane, and I are stuck waiting for about one hour trying to reach our senior resident. It turns out to be her day off. We locate an attending from a different team who says that three medical students should not be on one team. We follow him to locate the clerkship coordinator. She informs him that we have an extra student this rotation so the team will have to manage.
We wait around until noon. The interns have academic half day after rounds so our entire team is off at lectures from a nephrologist. A senior resident from a different team sends us home around 2:00 pm: "Your team isn't taking any admissions today, and the senior is off. They already finished rounds so just head home."
The next day we get in at 6:30 am. We still do not have any patients assigned to us. Our senior resident, a 6'3" Vermonter with a six-month-old, sits us down to go over expectations. "It is all going to depend on the attending. Some attendings will be okay with the medical student going down to the ED to interview the patient first. Some will want the intern and medical student to tag team. I'll usually pop in to see if the patient meets admission criteria or needs ICU level of care. The most frustrating thing you'll experience is doing a really great exam and you come up with a detailed assessment and plan, all to hear that the patient is going to go to the ICU."
How many patients should an individual student follow? "Depending how busy we are, between 2-3 patients. I try to have medical students follow patients that they admit. Step downs and overnight admissions are always harder to understand. Leave those to the interns." Advice for rounding and presentations? "You have to feel what the attending wants. Dr. [Bubbles] likes things a little shorter once he trusts your judgement. Watch the interns today, let's head up for rounds."
We head to the conference room for morning report at 7:15 am. Interview season is upon us so there are 30 fourth-year medical students (hoping to obtain residencies) in the front. Our senior resident comments, "You'll notice that all the attendings show up on interview days, even if they have no interaction with residents at all. It's pretty funny seeing an attending that never teaches us reflect for ten minutes about the good ole days and tidbits on how to read a CBC (e.g., monocytes are the first cell line to respond in an aplastic crisis)." A senior resident from a different team presents a case on leukostasis in acute myelocytic leukemia. Leukostasis occurs when there are so many blasts (immature blood cells from the bone marrow) in the blood that the increased viscosity leads to uncontrolled clotting and bleeding in every organ (disseminated intravascular coagulation). The patient died from a hemorrhagic stroke.
We meet our attending on the 4th floor PCU (Progressive Care Unit, with round-the-clock monitoring of vitals; essentially synonymous with "Step Down Unit") for rounds. He's a balding, quirky 58-year-old with round high-power glasses. Sylvester jokes that he looks like Bubbles from Trailer Park Boys. The interns are busy writing notes. We gather outside a patient's room, and the intern presents overnight events and any changes to the current plan. If there is an overnight admission, or a new admission the attending has not seen, the intern will present a full H&P (History and Physical). The presentation is primarily an opportunity for the intern to practice articulating medical information; the attending has already looked carefully at the chart. The team then walks into the room and the attending takes over to ask the patient some questions. This may be the only time that the attending sees the patient in a 24-hour period, but Dr. Bubbles likes to return later in the day.
There are several COPD exacerbations from poor outpatient management and persistent smoking. There are two old ladies in a shared room both admitted for COPD. We are considering sending the first one to skilled rehab given her poor support system at home. The attending asks, "Do you have any help at home?" She responds: "My two sons don't give a damn about me except for my money. You guys don't give a damn about me. I haven't slept in four days, I'm just going to walk out of here. Where is my cane? God dammit, I left it at home."
[Editor: In the Victorian era, arsenic was known as "inheritance powder." And it would be interesting to see whether the American health care industry's passion for elder care would survive the elimination of Medicare.]
The other lady is in a similar mood. Outside, the senior commented, "Well someone is having a bad hair day." The attending smiled, "That will get you when you haven't slept in four days. Let's get her to sleep." The intern asked, "Melatonin?" The senior responded, "No! Something that will work. Let's try her on ramelteon or trazodone." We finish rounds around 11:00 am. The attending returns to his office while the rest of us go to the residents' lounge.
While the interns type at Epic, our senior resident goes over management of atrial fibrillation and congestive heart failure. Some of the medical students on other rotations join in the teaching session. We're all clueless, even on these basic IM topics.
Sleek Sylvester and one of the interns step out for the first and only admission. Ditzy Diane and I are each assigned patients that have been here for one day. We read up on our respective patients and introduce ourselves later that afternoon. We get sent home at 3:30 pm by the senior resident: "Tomorrow is our call day, so we'll be here pretty late. Get some studying and sleep before."
Each team is "on call" for one or two times per week. The on-call team allocates admissions to the rest of the teams. Most teams want 12-14 patients post-call depending on the comfort of the senior resident with his or her interns. The call team also responds to all codes in the hospital outside of ICU beds.
I get in at 6:30 am to preround on my patient, and try to get away for morning report at 7:15 am. Sleek Sylvester, Gigolo Giorgio and I lack the knack of extricating ourselves from conversations and we're all 10 minutes late to the morning report.
During morning report we get a page for a "code blue" (patient with no pulse). We run up seven flights of stairs (the elevators are excruciatingly slow) to find ten people standing in the room with a 60-year-old man who recently underwent a radical tonsillectomy for squamous cell cancer of the pharynx. Our Vermonter chief steps into the crowded room, which contains no doctors, and asks if anyone is leading the code. No answer. One nurse is performing CPR while another is trying to get a blood pressure. The other eight people are essentially spectators. "Fuck, okay, let's begin." He immediately takes over. "How long has he had no pulse?" "What happened when you walked in?" "What's his blood pressure?" "Can we get an EKG?"
I step up to take over compressions from the nurse who is sweating and has been performing compressions for several minutes. Diane and Sylvester line up behind me and we switch every 2 minute ACLS (Advanced Cardiac Life Support, standard algorithm to respond to cardiac arrhythmias) round. The nurses say that they found him hemorrhaging "from the neck". We activate the Massive Transfusion Protocol to transfuse 6 rounds (1 unit of blood, 1 unit of platelets, and 1 unit of FFP per round) in rapid succession. Anesthesiology and the surgical critical care teams are also paged.
The anesthesiologist shows up after five minutes and, due to all of the blood, struggles for six minutes to intubate the patient, but eventually succeeds. The surgical critical care chief arrives five minutes behind the anesthesiologist and identifies the bleeding as coming from inside the mouth, not the neck. She stuffs gauze down the patient's throat. We perform compressions for about 20 minutes, with his pulse coming in and out. I grab the ultrasound machine, which comes in handy when they ask for better venous access. The critical care intern places a femoral central line. We transfer the patient to an ICU bed, where his pulse returns, and then wheel him to the OR. Diane, Sylvester, and myself are all following. I tell them only one of us will be able to scrub into the surgery. We settle on Diane. But when push came to shove with the elevator doors closing, I jumped on. Sorry Diane.
I scrub into surgery, and peek into the mouth as the ENT surgeon identifies a failed clip on the tonsillar artery. He cauterizes the pulsating artery and places several more clips. The tonsillar artery hemorrhage led to aspiration of blood leading to respiratory arrest, then cardiac arrest. The ENT surgeon asks, "Who stuffed the gauze down the throat? That saved his life. It was never hemorrhagic shock that led to cardiac arrest." (i.e., it was blood in the lungs that starved the heart muscles of oxygen, not loss of blood).
The senior resident: "It was like something out of the movies. That was awesome. I've never had something like that." Everyone, especially the medical students were congratulating him on a smoothly run code. He responded, "White coat doesn't mean anything. You just have to take charge. Code Blues are algorithmic, it's pretty simple compared to a rapid [Rapid Response Code] where you have no idea what you are walking into." For me, this was the first code in which the patient actually survived. (Unfortunately, when I checked on his chart over the weekend there were notes of severe neurological deficits.)
With rounds complete, we head back to the resident lounge to work on notes for the remainder of the day. We have four rapid codes. The first was induced by a double dose of metoprolol for atrial fibrillation. She had taken one dose at home, and was given another 50 mg dose in the hospital when the doctor continued her home medications in Epic. The other three rapids were opioid-related: overdoses leading to respiratory depression and acute mental status changes. The senior instructs the nurse to administer narcan, the patient comes back. One patient had two rapid responses called because the narcan wore off. Senior resident: "Narcan is a short acting drug, some of these opioids act for a long period of time."
The interns and I admit two patients throughout our call day. One intern is a fully licensed Iranian physician retraining so that she can practice in the U.S. and the other is a young American preoccupied with planning his next beach vacation (booze-lubricated encounters with women will be a big part). Each H&P is supposed to have a full examination including neurologic. The American intern doesn't even press on the patient's belly, and listens one time for each anterior lung field over the gown for a patient in respiratory distress. (If the patient had a pneumothorax or pulmonary congestion, we would have missed it). The Iranian doesn't know how to calculate maintenance fluids on a patient who requires aggressive fluid resuscitation due to acute pancreatitis. As we walk up to the lounge, I suggest we get an abdominal ultrasound to evaluate for a gallstone obstructing the pancreatic duct.
Statistics for the week… Study: 3 hours. Sleep: 6 hours/night; Fun: 0 nights. I work Saturday and Sunday through early afternoon. When the attending leaves, the residents will typically let the students go. Four of us grab lunch at Gigolo Giorgio's favorite hole-in-the-wall burrito spot.
Same rotation, but the second week of Internal Medicine brings a new attending and new residents. I get in at 6:15 am to pre-round on my two patients from the weekend (one was discharged on Sunday). I run into one of the interns for the service. Terrific Tiffany appreciates the patient summaries from Sleek Sylvester, Ditzy Diane, and myself -- we are the only ones that know the patients because everyone else has left the service. Tiffany is refreshed after her 3-week stint at the resident clinic before she slaves away for a month on inpatient "wards". We head to morning report and then directly to our new attending's office to meet him. Formal Frank is infamous for long bedside rounds in which we present in the patient room. He expects formality and professionalism in all interactions with patients. Every time we go into the room we introduce each member of the team: "Hi, my name is Student Doctor [Sylvester]." The medical student and intern are responsible for performing a comprehensive history and physical (including neurologic exam), medications ("always have note of their medications and dose in your pocket"); the senior is responsible for presenting the assessment and plan. He also goes through expectations for an intern and resident. The resident is in charge of allocating work, a brief synopsis note, and deciding how many patients to take on the census. The intern should each hold about 7 patients. He concludes the meeting by asking Ditzy Diane, "When do you call me?" blank face. "Anytime you need me."
His reputation does not disappoint. Rounds last until about 12:30 pm. Bianca is a little nervous because we haven't done any "work" (writing notes, discharge orders, etc.). We each present our two patients in the room. The attending expects a full H&P instead of the shorter SOAP update note. Tiffany always adds a few items we forget. She knows everything about the patient. When we are finally done, our classmates on IM have been studying in a circle in the resident lounge for at least an hour. Gigolo Giorgio asks us, "Why are you guys all smiling?" We look at each other. "I don't know, we're smiling? We just got done with rounds, maybe that's why?"
Boss Bianca, a PGY2 internal medicine resident who completed an intern year of surgery before switching to internal medicine (3 years of training) sits down with us in the lounge after rounds while the interns hit the computers. She's classic type-A, getting up at 4:00 am each day to read a new journal and read in her favorite Harrison's textbook for residents, but she has an insatiable passion for teaching.
"I'm really impressed how good your presentations are for medical students. I've made a template that I shared with each of you for notes in the morning. Try to organize your morning presentations just like the note." She concludes, "It'll take us a few days to get used to how Dr. [F] wants us to work together, but we'll have plenty of teaching times." We work for two hours on notes before Boss Bianca pulls us over again. We go over some of her myriad powerpoints on every medical topic. Today is how to interpret a urinalysis ("UA").
We are pre-call so we admit four patients. Ditzy Diane takes a 50-year-old stroke patient with expressive aphasia presenting for COPD exacerbation. Diane: "It was really hard completing a history on him. His family had left when I got there." I admit a 73-year-old lady for acute on chronic hypoxic respiratory distress secondary to COPD exacerbation and CHF exacerbation. Around 3:00 pm, we meet Formal Frank, our attending, in the ED and present our patients. Sylvester, who admitted the first patient, reads verbatim from his H&P note. I just admitted my patient around 2:30, so I do not have any time to start writing a note; instead I struggle to verbalize my disorganized notepad.
Call day: we have several rapids and one code blue. Bianca and I get there first, and I watch her take over the show. She clearly instructs the nurses to get vitals, blood sugar, and EKG. The patient goes in and out of having a pulse. She starts checking for the 5H's and T's of PEA. She listens to his lungs for a pneumothorax. We do a bedside needle decompression before the attending arrives and we cart him a few rooms down to an ICU bed.
She recounts her first rapid response as an intern. "I was called at night to a rapid response for bradycardia [slow heart rate]. We worked the patient up, and it was clear that this was caused by an overdose of her home metoprolol. The unit nursing director came in and questioned why I was not giving her atropine. There was no indication for atropine. She was not symptomatic. The unit director then called several attendings saying the intern did not know what she was doing. Two attendings arrived. I gave report: 'patient developed bradycardia after double dose of metoprolol. Her blood pressure is 120/68, without mental status changes, pulse in 40s with no st changes on her ekg' The nursing director was furious. I stared into her eyes and told her to go get glucagon [a medication used for hypoglycemia, clearly not needed in this situation]. The attendings smile at me, and walk out." Slyvester laughs, "Go get me glucagon. What a classic! You are such a boss."
Bianca gives some handy advice: "When you first arrive, make everyone feel calm. The room should be quiet in a well run code. Assign the nurses to do specific tasks so people aren't idly standing around. For example, get a 12-lead EKG, put the pads on, check blood glucose, and ABG. This will also highlight who doesn't need to be in the room. People gravitate to a code situation and the room suddenly becomes packed. If there is someone crowding the room, or not following your orders, send them out of the room politely to grab something. Doesn't matter what."
I admit a patient with alcoholic pancreatitis with Terrific Tiffany. I lead the interview, with Tiffany starting her H&P and placing basic admission orders on the computer. The IM service gets evaluated based upon how quickly admission orders and transfer orders are placed on ED admissions. This is the patient's second admission for pancreatitis (2 years prior) with no change in his alcohol consumption habit. We start him on aggressive IV fluids. Tiffany quizzes me on pancreatitis management. How do we diagnose pancreatitis? How do we risk-stratify pancreatitis? I don't give convincing answers. "The most prognostic lab value is blood urea nitrogen on admission and if it remains elevated after 48 hours. Look up the various pancreatitis score system and we'll chat about it."
Over the next few days Bianca sits down with us to go over several useful topics. I appreciate her because she gives concrete examples about disease, and will provide specific data about interventions. For example, instead of saying statins are helpful in primary prevention of CV events, she will explain that statins have about a 20-30 percent relative risk reduction in cardiovascular events over 10 years.
We have an afternoon lecture with one of our professors. We walk around the hospital in a group of six watching people walk by. We see one patient who has a diagonal ear lobe. "Frank's sign" is more specific for CAD [coronary artery disease] than any stress test. We walk by a 50-year-old obese female with an antalgic gait [unusual way of walking in order to avoid pain]. "What do you think could be causing her pain? Look at her knees." Ditzy Diane responds, "Her knees are bent out." The professor continues: "Yes, look at how her leg is in valgus. Women have wider hips which make their legs into valgus strain. They are at much higher risk of arthritis and knee injuries because of this."
We continue down to the hospital lobby to people-watch. We notice a patient with jaundice. We get distracted by our doctor going on a rant about the rise of autoimmune conditions as a result of glyphosate, the active ingredient in Round-Up. "A high dose results in the gut wall epithelial cells' tight junctions opening up in seconds. A low dose results in gut wall opening in hours, but when you add various antigens like gluten it opens in minutes."
[Editor: "Roundup Maker to Pay $10 Billion to Settle Cancer Suits" (New York Times, June 24, 2020): "The longest and most thorough study of American agricultural workers by the National Institutes of Health, for example, found no association between glyphosate and overall cancer risk, … The Environmental Protection Agency ruled last year that it was a 'false claim' to say on product labels that glyphosate caused cancer. The federal government offered further support by filing a legal brief on the chemical manufacturer’s behalf in its appeal of the Hardeman verdict. It said the cancer risk 'does not exist' according to the E.P.A.’s assessment."]
Our next call day, Bianca gifts the pager to Tiffany, a bundle of nerves. Tiffany gets a page during morning report and steps out. As the ultimate demonstration of trust, Bianca doesn't go with her. Morning report: 45-year-old real estate agent who is transported from home via EMS at 8:00 pm for anaphylaxis. His 15-year-old daughter used her EpiPen, which likely saved his life. He reports flushing, scratchy throat and occasional hives that occur around 8:00 pm most days for the past month. In the history, we learn that he gets a burger almost every day at a diner near his work. We work him up for Alpha-Gal, or "Midnight Anaphylaxis" (delayed reaction from lone star tick leading to red meat antigen). We catch up with Tiffany walking back to the lounge and she is out of breath and sweating. "That was crazy. My first rapid alone. Oh my God that was scary." Bianca smiles, "Awww, I remember my first rapid." She turns to the medical students. "Rapids are way more nerve-wracking than codes. Codes you have a clear ACLS protocol. Rapids you have no idea what you'll be walking into. You have no idea about the patient's medical history so you have to quickly absorb the information while dealing with an acute problem."
Statistics for the week… Study: 4 hours. Sleep: 6 hours/night; Fun: 0 nights. We do our 24-hour call on Friday. There is not much activity so the night team sends us home at 10:00 pm. We have Saturday off after morning report and return Sunday.
Monday morning, Terrific Tiffany and I admit a 59-year-old HIV-positive patient (my first) with coronary artery disease for a pre-syncopal (nearly fainting) episode and chest pain. His Hepatitis C and liver cirrhosis suggest a history of drug use. He presented because of the chest pain and running out of his nitroglycerin sublingual tablets. During the interview, he also reports a two-month history of black tarry stools. Fecal occult stool test is positive, his hemoglobin is 6.4 (normal: 13.5-15; worry: 9; transfuse: 7). Tiffany allows me to put in the basic orders for practice: 2 prbc (packed red blood cells), H&H (hematocrit and hemoglobin tests) q6h (every 6 hours), gastrointestinal consult, cardiology consult, troponin q6h, normal saline at 1.5x maintenance, protonix 40 mg iv q12h, and 2 large bore IVs.
If he is not having an acute GI bleed, his hemoglobin should increase approximately 1 Hg for every 300 mL prbc bag. Six hours later, his hemoglobin result is 8 Hg and his chest pain has resolved.
Diane, Sylvester, and I join for the afternoon Esophagogastroduodenoscopy (EGD) study in the endoscopy ("endo") suite. Under supervision from a GI attending, the GI fellow makes the scope do a U-turn to look backwards at the stomach. He points out GAVE (gastric antral vascular ectasia; dilated blood vessels in the stomach antrum leading to a "watermelon appearance"). We find three arteriovenous malformations (AVMs, dense collection of friable vessels) in the duodenum. "GI attendings love to pimp on this," notes the fellow. The attending requests a pediatric colonoscopy scope to go further into the small intestine to investigate the jejunum (middle part of the small intestine, typically found empty in autopsies and therefore derived from the Latin for "fasting"). The fellow struggles to advance the longer endoscope, so the attending takes over and explores another 3 feet of bowel.
We find 2 more AVMs, none bleeding. The endoscope has a sprayer for liquid nitrogen and they use this to freeze off the AVMs. Each of us is then allowed to practice driving the scope from the stomach through the pylorus. Sylvester: "Just like a video game." Afterwards, I ask the GI attending, "Do you really think AVMs were the cause? Can he do anything so this doesn't happen again." GI attending: "We do not know what causes AVMs, but there is a clear relationship with aortic stenosis [AS]. If you cure the aortic valve stenosis, the AVMs go away! He doesn't have significant AS, so he just has to live with them. He'll have to come in every few months and get a transfusion. More importantly, his multiple comorbidities would not make him a good candidate for aortic valve replacement."
During lunch, Boss Bianca goes over the REDUCE (Reduction in the Use of Corticosteroids in Exacerbated COPD; chronic obstructive pulmonary disease, typically from smoking) trial with us. Sylvester and I had prepared by reading up on the REDUCE trial… for prostate cancer. Our discussion was delayed 15 minutes so that we could read the correct "REDUCE" study.
REDUCE investigated whether steroid use could be reduced from the standard of care 14-day course of 40 mg of prednisone to a 5-day course without worsening the estimated 33 percent re-exacerbation rate within 180 days of index hospital discharge. Bianca explains, "Before this trial, you would get 20 different answers about duration and indication of steroid use for patients from 20 different doctors. This was a pivotal trial because it allowed evidence to treat quick-responding patients for only 5 days, but you have to treat the patient until they improve. If they are not improving on day 3, by God, you are not going to stop giving them in two days."
Sylvester, who struggled in our statistics course, tries to impress Bianca. "I am just a sucker for statistics. I loved how they took the stance of the two groups assessing if they were 'noninferior' by using hazard ratios." Bianca stares blankly and continues, "How might our patient population differ from the study population in Switzerland?" Diane brought up one difference: everyone in the study received antibiotics. "We don't give antibiotics to every COPD exacerbation so this could be a factor."
Wednesday call day. We have two rapids in the morning. One page was called for bradycardia (heart rate in the 40s). Bianca decides not to initiate any intervention, as the 75-year-old patient, admitted for hip fracture, is asymptomatic. She had received an extra dose of metoprolol due to miscommunication during the medicine reconciliation on admission; she had already taken her AM metoprolol before coming to hospital. (Our attending, Formal Frank: "This is what happens when we put elderly folk on two or three antihypertensives [amlodipine, HCTZ, and metoprolol for our patient] Have you ever heard of the Osler's sign for pseudohypertension? No one does it anymore for some reason." He explains how to perform the quick test to evaluate for falsely elevated blood pressure reading from a cuff due to excessively athersclerotic arteries that cannot compress. "We keep adding antihypertensives to the elderly, and our readings don't go down until they go down. I want you to perform the test on the next elderly patient we have. Remember: Always ask, What did we do to the patient?")
Rounds continue after the rapid with Sylvester's 42-year-old obese female admitted two days ago after a pulmonary embolism. She is on oral birth control [OCP] and has well-controlled hypertension. She was initiated on low molecular weight heparin injections and will be transitioned to an oral anticoagulant for at least three months. Formal Frank: "A serious conversation should've been had with this woman several years ago. She is obese with hypertension, all risk factors for DVT, and she is still on OCPs. This could have been prevented, now she has to be on anticoagulation for at least three months, which carries its own side effects. Once again, always ask, 'What did we do to the patient?'"
Do we need a cardiologist or hematologist consult to manage the pulmonary embolism? "I know the guidelines and studies better than most cardiologists do and feel confident in managing this disease. That's the beauty of internal medicine, you choose what you are interested in, and get consults for things you are not interested in." Sylvester and I spend ten minutes with our noses almost touching the screen trying to identify the occluded segmental artery on the CT angiogram without looking at the radiologist report. Sylvester: "Ah, we found it. Look at that wedge!"
Diane follows a 38-year-old overweight diabetic mother with depression and a foot ulcer admitted for a foot amputation. Her son has Down Syndrome. She will have fantastic sugar control for 8 months, but then binge for two months on pizza and soda, possibly due to "caretaker burnout." Her affect is labile: she was extremely cheerful during pre-rounds, but now she is in tears. Formal Frank: "She's in denial. Wouldn't you be if you were about to lose half your foot from a small ulcer?" He continues, "If she wants to walk again, she should get a BKA [below the knee amputation] and begin PT immediately. Evidence is quite clear that the best functional outcome is from a BKA. She is unlikely to walk after this partial foot amputation, but the system doesn't think that far forward. She'll be back in a year requiring a BKA so what's the damage besides a few thousand dollars, right?"
I pick up a 58-year-old patient admitted by the night team. He is admitted for acute hypoxic respiratory distress secondary to congestive heart failure (CHF), undiagnosed COPD, and atrial fibrillation with rapid ventricular response (fast heart rate). Coding for acute hypoxic respiratory distress leads to significantly enhanced revenue.
We discuss his prognosis, and if we should order an echo. The patient is on minoxidil, an old antihypertensive that is seldom used (except topically for baldness). He is also not on any CHF medications, e.g., a beta blocker or an ACE (angiotensin-converting enzyme) inhibitor, that have a survival benefit. Formal Frank asks the team to check the chart for the name of the patient's outside private cardiologist. "Ah, well I assure you he has had an echo in the last six months. Anything this guy can bill before the end of his patients' life." Sure enough, after several hours on the phone we get his outside records faxed showing echos and carotid duplex studies every six months. Although we typically do not make major changes to medications prescribed by outpatient doctors, we discontinue the modafinil and begin beta blocker and ACE inhibitor.
This patient exemplifies the dangers of overspecialization in healthcare. The patient does not see a general internist. His (mediocre) cardiologist is essentially his primary care doctor. The cardiologist ignores everything except cardiac issues. So there are great images documenting the continued ejection fraction decline, but he is not even on the simplest albuterol inhaler for COPD. Most of the problems likely originate from the patient's uncontrolled COPD. Over several years this leads to pulmonary hypertension, thereby leading to CHF and atrial fibrillation. We perpetuate the specialization blinds by placing an outpatient consult to pulmonology to manage his COPD rather than a consultation with a general internist. Part of this is due to insurance, Medicaid, and Medicare realities. The specialist can bill far more for the same management that could be provided by an internist, thus reducing internists to a screening function.
The nurses don't like Sylvester's patient, admitted for alcohol withdrawal. She and her husband have moved into the hospital. There are suitcases strewn across the room, with clothes on the floor marking a path to the hallway, despite pestering from nurses that these make it harder for them to use the blood cuff, CPAC, and other machines. Security was called after a fight over mealtimes. The patient is medically stable for discharge, but requests the ride home to which she is entitled. The social worker informs us that there are no more "Medicaid taxis" available for the afternoon. Boss Bianca: "We should've gotten our discharge note signed earlier. No reason to waste a whole bed for one more night." She orders a $15 Uber on her own account to pick the couple up. The nurses cheer.
I get out around 4:00 pm on Friday. I meet Jane's two college friends at a local brewery. Her best friend is still using U.S. student loans to complete her master's degree in New Zealand, primarily as a way of staying in the country to be with her boyfriend. She's writing a thesis on "sex workers" and explains the power dynamics between workers and cultural oppression.
She cites Jane's other friend at the table as an example of a "forgotten sex worker" because she'd been hugged while working as a waitress in a small-town diner. "This older gentleman who was the diner's best customer would expect a hug from all the younger female employees. These are the forgotten sex workers oppressed by cultural norms that I am writing about."
[Editor: In February 2019, the New York Times covered an incident involving commercial sex at a Florida strip mall. The (undocumented) immigrant women working there were described as "prostitutes." Native-born women working in the same industry, however, were described in previous articles as "sex workers" (example).]
We are joined for dinner by Lanky Luke and PA wife Sarcastic Samantha, and Jane's sister and her veteran boyfriend for dinner. Jane's sister has been completing the 22-pushup challenge for veteran suicide awareness, posting a daily Facebook video to increase awareness that an average of 22 veterans kill themselves daily. Her boyfriend was initially supportive, but now is concerned about creating a stereotype that the typical veteran is suicidal. "Few of the veteran suicides were combat veterans from Afghanistan and Iraq. They are Vietnam vets, most of whom didn't see a day of combat. This whole PTSD phenomenon has been hijacked by non-combat vets trying to get on disability. It takes away resources from the people who actually struggle. It's not just in the military, It's become common in society when we idealize victimhood. You start searching for a victim group to belong to." (Fortunately, his own application for disability was approved in time for him to collect 100 percent college tuition reimbursement for his children.)
Lanky Luke's dad recently underwent colectomy for colon cancer at a prestigious academic hospital. "The surgeon who did the case was barely seen during post-op recovery. There were a lot of PAs and NPs." Samantha jumped in: "Luke literally was writing questions on the whiteboard about his care. 'His hemoglobin is less than 7. He is symptomatic with shortness of breath. Why are we not transfusing?'"
On Facebook this week, from Type-A Anita:
So many times I’ve had to walk in the room and had to clarify that yes, #iamyourdoctor .
No, I’m not the nurse, the janitor, the medical assistant or the nursing aid (even though I truly respect all of these positions).
So many times I have had to defend my position because I am a woman and society does not instantly look at those characteristics and think doctor. I’ve been told that I should not make people feel uncomfortable because their implicit bias doesn’t allow them to associate my presence with what a doctor looks like.
I am so grateful to all those young doctors that are using the hashtag #iamyourdoctor to show how diverse medicine truly is and bring to the forefront that it is not as diverse as it should be because yes, #iamyourdoctor
Statistics for the week… Study: 4 hours. Sleep: 6 hours/night; Fun: 1 night.
Week 4 of Internal Medicine clerkship, same team. Monday is call day. Our team is responsible for divvying up admissions to the hospitalist service. Our team has a low census (only about 6) after all the discharges so we'll admit 6 patients today. I take the first admission. A 93-year-old female with Alzheimer's and vascular dementia and COPD (chronic obstructive pulmonary disease) presenting via EMS (ambulance from the nursing home) for worsening shortness of breath. Typically, the medical student is tasked scouring through the 40-page stack of medical records sent from the nursing home for prescription medications. Fortunately, her three children, one granddaughter, and a great granddaughter are present to give a full history of her health. Her daughter: "She never smoked a cigarette in her life.She got COPD from second-hand smoke; her husband was the chain smoker." Tiffany: "Now you see the challenge with the elderly. If they don't live near family, it can be a crisis. Her past medical history is an enigma. We don't know her goals of care, or if she already has a living will."
Her wheezing is audible from the hallway, but she is oxygenating well on 2 liters NC (2 liters oxygen delivered via nasal cannula prongs). We step out into the hall and explain her GOLD Stage 4 COPD (most severe) to her family members. She arrived in actual (as opposed to coding gimmick) respiratory failure. She has a severe acute respiratory acidosis with chronic metabolic compensation shown by ABG (arterial blood gas sampling). We avoid intubation by giving back-to-back DuoNeb nebulizer treatments until IV methylprednisolone (steroid, similar to cortisol) kicks in (about 30 minutes). We order a BiPAP (bilevel positive airway pressure) machine from the resident lounge. Briana emphasizes as we wait for the elevator, "BIPAP is never used unless there is a foreseeable improvement from a specific intervention -- when in doubt, intubate. It is the safest intervention."
We head up to the resident lounge to type H&P into Epic. Two hours later, we meet the attending, Formal Frank, in the ED to present our admissions. Sylvester describes a newly diagnosed lung cancer patient. Diane presents an undifferentiated pericardial effusion (fluid around the heart). In the room with my patient, the attending notes her inability to speak more than two words and that she is using accessory muscles (e.g., between ribs or in the neck) to breathe.
Formal Frank asks the granddaughter, "What is her baseline?" A great-granddaughter responds, "This isn't her, she's a stubborn old bat, but she's as sharp as a whip. She remembers small details from our childhood. Right now she doesn’t even know who I am."
Formal Frank asks us, "You ordered BIPAP, but is she using BIPAP?" We stare at each other. "Just because you put something in the computer doesn’t mean it happens. Nurses think of our orders more like recommendations." He had guessed right. Due to a combination of our patient improving and her dementia, the respiratory therapist had apparently given up after setting up the ($2000 billed to Medicare) machine.
As far as I could tell, the 45-year-old granddaughter stayed in the room for the entire five-night stay. She worked from her laptop and phone and slept in the recliner chair. Every time a nurse came in, she would ask what the next step would be. She related her concerns about the nursing home. "Her medications are ordered PRN [as needed]. That becomes an excuse for them not to give them," says the granddaughter. "Their nurses are lazy, not like the ones you have here." I work with the granddaughter on an updated list of medications, including an inhaled steroid for the GOLD stage 4 COPD.
My next admission is a 22-year-old patient with two-day history chest pain. A CT angiogram performed in the ED showed a pulmonary embolism. She also has numerous skin lesions. She has clear moon facies (swollen "moon face") from steroids used for immune system suppression since age 9, when she received her first kidney transplant.
We get a deeper medical history from the mother, although she did not know the cause of the initial kidney failure. Either the kidney biopsy that would be standard today was never done or the mom can't remember the result (or was never told). After all of the billions of dollars spent on electronic medical records, we're forced to rely on the memory of laypeople for a continuous history of anyone who has been seen at multiple institutions.
We restart the patient's immunosuppressive medications and start her on a heparin infusion for therapeutic anticoagulation.
I present the patient bedside to Formal Frank and Boss Bianca. The patient doesn't have any questions, and we go into the hall to discuss. Formal Frank: "This is an exciting case! Think of everything this could be. What could cause a PE?" Sylvester, Diane, and I can't come up with anything other than a run-of-the-mill PE from a DVT. Bianca: "Dig Deeper! People on immunosuppression are at a 100 times risk of developing cancer. She could have a nephrotic syndrome that causes you to be hypercoagulable. People with kidney transplants are at increased risk of glomerulonephritis. She's also on a fibrate, maybe she has a heart attack." (We don't get to explore these issues, unfortunately. The patient's shortness of breath resolves and she is discharged after two days to resume her job at Subway and see her outpatient specialists.)
On Thursday, Boss Bianca corrals the three of us after rounds. We head to the supply room, tucked away in the labyrinthine basement, to get several punch biopsies. "I have a surprise for you." A patient admitted overnight to a different team may have syphilis. The 26-year-old relapsed on meth two weeks ago after his girlfriend left him. He has had several ulcers, largest in diameter about 4 cm and 1 cm deep, pop up on his body, including on his forehead, elbow, wrist, and back. "Look at me. I can't go to work or anything." We each choose a location and perform a punch biopsy. Later, I checked his chart and the syphilis tests came back negative. A dermatology consult did not result in a definitive diagnosis, but noted the possibility of an immune reaction to meth, possibly a necrotizing vasculitis?.
[Editor: Parents of couch-bound Xbox-playing youth nationwide should use this guy as an example. Even a meth head had a girlfriend and was passionate about going to work.]
Bianca and I run upstairs for a code blue for a 80-year-old DNR ("Do Not Resuscitate") who is scheduled for transcatheter aortic valve replacement on Friday. He went asystole (flatline EKG). Boss Bianca instructs a nurse to get basic labs, a 12-lead EKG, and to get her the family's phone number. "DNR does not mean do nothing. Check glucose, hypoxia, treatment arrhythmias." She taps my shoulder to look at his Cheyne-Stokes breathing pattern. He would take 4-5 deep breaths, then stop breathing for several seconds. Bianca speaks to the daughter and explains the situation that he is DNR, and therefore no further interventions are indicated. The family understands, and says that they knew this was likely and that the valve replacement was extremely risky. Bianca instructs Tiffany to call the surgeon and tell her that the patient is dead.
[Editor: Medicare would have paid over $60,000 for the valve replacement, had the patient survived long enough to receive it.]
Friday is the medical students' "24-hour" shift, from 6:00 am until morning rounds on Saturday (i.e., about 9:00 am). We work with our normal day team with rounds, followed by notes in the resident lounge. We attend a few procedures on our patients, e.g., endoscopy for GI bleeds, and then join the night team at 6:00 pm.
The chief resident functions essentially as an attending. She was asked to stay for an additional "chief" year following PGY3. She and I head to the med/surg floor to perform paracentesis ("tapping the belly") on two patients with alcoholic cirrhosis.
[Editor: The good news that I learned at Harvard Medical School in 2019 is that these patients are not "alcoholics." At worst, they are suffering from "alcohol use disorder."]
I use an ultrasound to locate a pocket of fluid on a 35-year-old alcoholic cirrhosis patient with a belly swollen from ascites. She is animated, intelligent, and sober following two days of detox. It is tough to imagine that she is on disability and suffering from end-stage liver disease. I locate a pocket that is clear of bowel and mark it with a pen. My chief then preps and taps the belly. We get 4 liters, four test tubes of which we send to the lab for albumin ascites gradient (SAAG) to determine if there is portal hypertension or an inflammatory process.
The chief lets me do the next one, on a 65-year-old former alcoholic. After sticking a needle into the belly, advancing the catheter, and retracting the needle. The patient feels better after 2 liters, but we keep going until we've extracted 10(!). We increase his IV fluids to compensate for the expected dehydration.
We are beginning to fade at 1:30 am, fighting over who will get stuck with the next patient rather than who will get the privilege of taking the next one. The chief sends us home at 3:00 am. Sylvester and Diane both sleep at the hospital in the medical student call room. I decide to go home for 2 hours before returning for Saturday morning rounds at 7:00 am. I finished my notes before heading home so I leave after rounds and sleep.
We get the rest of the weekend off.
Jane had an exciting week on inpatient gynecology. A 65-year-old patient presented with stage 4 cervical cancer and necrotic tissue in the vagina. She'd been having regular checkups with a nurse-practitioner who ordered labs and assumed that the patient was seeing a Ob-Gyn and getting standard-of-care Pap smears. The doctors were outraged that this had been missed and now this otherwise healthy patient was sentenced to death.
[Editor: Although this patient plainly would have benefitted from screening tests, there is debate about whether the U.S. standard of care is the right one. See "Harms Of Cervical Cancer Screening In The United States And The Netherlands" (Habbema, et al. International Journal of Cancer 2017, 140:5): "Our main finding is that harms occur much more frequently in US than in NL, while the levels of incidence and mortality have been quite comparable between the two countries…" (the Netherlands screens at only about half the rate of the U.S. and only for women 31-60)]
Jane is exhausted and sore when she returns home. She spent five hours total driving the uterus with a uterine manipulator. "I was pushing so hard, my feet were slipping, but they kept saying, 'Harder. Harder. Lift the uterus.' Afterwards my hands were shaking. I could barely squeeze." She continued, "And of course they then asked me to suture. They thought I was really nervous, but actually I was having trouble gripping the instruments."
Statistics for the week… Study: 6 hours. Sleep: 5 hours/night; Fun: none.
Week 5 of internal medicine clerkship. During Monday morning rounds, Formal Frank asks, "Bianca, why do you keep giving Diane the vegetables? Our goal is for medical students to get practice talking to patients." Diane's first patient was a patient with primary aphasia, then a patient with dementia that had progressed to aphasia. She once again has taken an overnight admission who cannot speak but a few words due to Lewy Body dementia.
I admit an 85-year-old patient with acute mental status changes brought to the ED after a "fall from standing". He is accompanied by two women: 40 and 45 years old. It turns out that the 40-year-old is the wife of five years while the 45-year-old is the daughter. The wife is the one who knows everything about his care, answering all of our questions with a heavy Vietnamese accent. Boss Bianca and I check on our patient around 7:00 pm. He was lethargic, but oriented to person, time, and place. After the wife and daughter step out, he calmly said, "I know I am not going to make it to my granddaughter's wedding."
I arrive Tuesday at 6:00 am to learn that our patient died overnight, perhaps due to undifferentiated sepsis. The family declined an autopsy. The night team reports he went in and out of ventricular fibrillation twice over a 30-minute code. "We even gave him a bicarb bolus [last resort in severe metabolic and respiratory acidosis]. The family was present and they understand." This was the first patient death for Tiffany and Bianca. Bianca took it pretty hard: "That's crazy, we talked to him a few hours before this happened. Isn't that surreal how he almost knew?"
The residents have their weekly "didactics" seminar this afternoon, so they let us go after we finish our notes at 2:00 pm. Sylvester, Diane and I grab burritos. Sylvester describes his experience on surgery. "We had a patient with Fournier's gangrene [necrotizing fasciitis of the scrotum]. We performed a scrotectomy [removal of scrotum] leaving his balls hanging exposed with just gauze covering them. As soon as we cut into the scrotum, gas was released, no pus. The entire OR staff gag from the smell at the OR entrance tunnel with the door closed. " He had a more enjoyable trauma rotation. He describes a stab wound causing a "shish kabobing" of multiple small bowel loops at different sites, and a hemothorax.
Diane, settling on pediatrics after her experience on IM: "I can't deal with adults. They are just like babies, except they never grow up." Both Sylvester and I are interested in internal medicine, though I say, "hospitalists sometimes seem like micromanagers with specialists doing the interventions. Sometimes all we do is give the patient IV fluids and send them home."
With only one week left before exams, everyone is trying to cram in the 25 LCME-mandated online cases. A typical case starts with six photos, one of which is relevant to the medical questions. The other five depict a non-white-male physician and a non-white-male medical student talking to a patient, e.g., an elderly white man suffering from COPD. There are 10 questions (3 short answer, e.g., summarize relevant history and exam findings) embedded in 5 pages of text. Diane says that she is finished with the questions and actually found them valuable. Everyone else clicks randomly through the multiple-choice questions and responds with gibberish to the short answer questions. Due to rumors that some clerkship coordinators look through the student report, including the time spent on each case, Gigolo Giorgio opens four cases in four separate browser windows in order to build more clock time per case. Sylvester has copied this strategy.
Wednesday after rounds, Bianca takes me to remove a jugular vein hemodialysis catheter on a patient with dementia who cannot speak or react to speech. We discuss the steps while walking up the stairs. First, place the patient in Trendelenburg position (feet elevated above head). Why? Bianca: "Air bubbles travel up, we don’t want to send an air embolism to the brain." Second, pull the catheter out on an exhalation when there is more intrathoracic pressure. If patient is awake, ask him or her to hum. Third, apply pressure to the site for three to five minutes if the patient has no coagulopathy (change in normal coagulation function, e.g., from warfarin or heparin anticoagulation). Apply Tegaderm and a folded "4x4" (standard gauze) for air seal. The patient survives my first removal of this type of catheter!
Nearly all of our patients have congestive heart failure listed in the Epic chart, but their last echo often shows only "grade I diastolic dysfunction," not clinically significant. During initial interviews, patients are confused when I ask how their heart failure is controlled. They'd never heard about this diagnosis. Boss Bianca, "Don’t take things the notes and problem list in Epic at face value. Just in our time here I've submitted five safety reports for medicine issues. Transitional cell cancer, are you sure…? Look at the original doctor note [frequently a scanned image from an outside institution, available under the Media tab]; don't play Telephone." She continues, "At my medical school, a patient was labeled for three years as HIV-positive. The patient only found out this was in his chart when he requested his medical record after moving to a new city. It turned out a nurse originally meant to put HCV [hepatitis C virus] in the past medical history, and the physician just signed off on it. Let's just say the patient won a lot of money."
(Hospitals have a financial incentive to mark patients as having congestive heart failure and other serious conditions because they are entitled to get paid for more of their readmissions if they are treating a sicker population.)
Friday morning report. A senior resident goes over a recent case of tuberculosis (TB): "An 35-year-old undocumented immigrant presents for several weeks of hemoptysis [coughing up blood] and generalized malaise. She had seen by two urgent care providers who prescribed antibiotics. What risk factors did our system miss?" She answers her own question: "Well, first she is an immigrant with barriers to healthcare access. Her boyfriend recently was in prison. We also learned that she was smoking cigarettes picked up off the ground." She describes the challenge of caring for this patient because she kept wanting to leave the hospital. "She did not understand the contagiousness of TB. She left AMA [against medical advice], exposing her family [5 kids from 3 fathers] to TB. She frequently would get out of bed and walk around the halls despite pleading from the nursing staff. The boyfriend and cousins would visit, but, despite the provision of Spanish language interpreters, could not be made to understand the need to wear specialized N95 masks when visiting her in the negative pressure isolation room."
One nurse contracted TB and five more had to go on long-term isoniazid treatment for tuberculosis prophylaxis. The senior resident concludes: "Efforts to reduce TB have been so successful that we forget about TB in our immigrant communities." The trend is toward U.S. physicians seeing patients with more advanced TB, 18 percent of cases in 1995 and 24 percent in 2006.
[Editor: If the boyfriend was in prison, shouldn't that have made it easier for her to access health care? One fewer household member to take care of.]
Diane admits a 55-year-old for alcohol withdrawal. His BAC is 0.35 g/dL (blood alcohol content; the legal limit for driving is 0.08). Bianca orders a measured osmolality test, mostly for student benefit. We sit down in the resident lounge to go over the results, which show an elevated osmolality gap ("Osm gap"). "Most osmoles are captured by a CMP [complete metabolic panel] -- those are sodium, glucose, and BUN [blood urea nitrogen]. Not many compounds can significantly alter the osmolality of blood, except your solvents: ethanol, methanol, ethyl glycol. So we can calculate the osmolality from a CMP. Whenever you see a severe metabolic acidosis, consider getting a measured osmolar and compare to the CMP-calculated osmoles." Bianca sends a group iMessage: "Why is this called a teaching hospital? Because we do a lot of tests." Regarding the concern that our edification was driving up costs for patients, Bianca responded "He's on Medicaid so he won't pay anything."
Last day of Formal Frank. I appreciated his high standards and his professionalism with patients. Further, he engrained the need to not forget basic physical exam skills in the work up of patients. Every patient with a GI bleed gets orthostatics. Every chest pain patient gets bilateral blood pressures to rule out aortic dissection. These are simple low-cost tricks that can significantly change patient care. He had a good understanding of cost and benefits. For example, he mentioned that "we spend about $100,000 for every folate deficiency diagnosis. So rare if the patient is eating any kind of food." [he still allows residents to order folate work up.] I hope to use the Osler test to prevent the misdiagnosis of hypertension in the elderly when I do my outpatient family medicine clerkship.
Pinterest Penelope promotes a school-run LGBTQ awareness event: "Just because someone 'doesn’t know' if a person is trans, does not give them a free pass when they misgender that person."
Shortly after reading this Facebook post, I had my first encounter with a trans patient. He presented to ED for alcohol detox and, after determining that he had no other medical issues, we transferred him to the inpatient psychiatric unit, which handles all uncomplicated detox cases. He is listed as female in Epic, which shows multiple similar detox visits, one each of which he received a pregnancy test. Formal Frank: "They want to change their sex to their identified gender, but if they succeed insurance will frequently not pay for the appropriate screening tests. Our Epic department has spent a lot of time developing an item for gender and a pop up message to alert the provider about the correct gender. We'll let psych deal with that."
Statistics for the week… Study: 10 hours. Sleep: 5 hours/night; Fun: 1 night. Saturday afternoon guitar jam session with Gentle Greg to practice for upcoming coffeehouse medical school open-mic night. He's going through a difficult time with his girlfriend of three months. They're both Indian-Americans. He's studying to be a doctor and she is studying to become a physician assistant. However, her family is Hindu while his is Muslim. She is concerned that her family won't accept him, despite the fact that he is not observant. (They will later break up and then reunite after she talks to cousins who've successfully navigated initial family disapproval.)
Last week before exams and our first break for the year. Sleek Sylvester, Ditzy Diane, and I are worn out, our motivation waning. We have a new team of residents for the last three days and none of us have the desire to impress them. The senior resident: "Let us know if you have any questions. You guys can just study if you want. We'll let you know if anything exciting is happening."
We are actually helpful on Monday during rounds, having previously admitted many of the patients on our service. We provided the only continuity of care for these patients and were tasked with presenting a formal H&P for each of our three patients to the new team.
We also play "Stump the Med Student" on rounds. A 36-year-old gas station clerk, whom I admitted three days ago, has acute renal failure from multifactorial causes -- hypertension, uncontrolled diabetes, and three-month long ibuprofen use. He stopped taking his diabetes and blood pressure medications five years ago. The senior resident asks, "Why is his sugar low and his Hemoglobin A1C in the normal range if he is an uncontrolled diabetic?" Sleek Sylvester, Ditzy Diane, and I put our heads together and come up with nothing. "Insulin is cleared by the kidneys," explains the senior resident. "If you see a patient whose diabetes suddenly becomes remarkably well-controlled after years of noncompliance, it's likely a result of his kidneys failing, not that he has seen the light and has started to listen to your every piece of advice. It's ironically the first sign of a serious complication. Our patient likely will be on dialysis for the rest of his life. I don't think his kidneys will recover." He concludes: "Well, I've done my job for the week; go study."
After rounds, we do UWorld questions in the lounge, disrupting the residents who are trying to get their notes into Epic. We relocate to the cafeteria for lunch and find Geezer George and Mischievous Mary. Geezer George is doing his elective orthopaedic rotation. "I'm determined to do ortho. I am ready to be miserable through the application process." Are you concerned about getting into a residency program? "Yes, but my mentality is if the average step score is 245 for ortho, and I know people with 260 are being accepted, that also means they must be letting people in with 220." Sleek Sylvester questions his symmetric Bell Curve assumption: "Why stop there. People get in with 270, that means they are letting people in who barely passed!"
Jane has had a slow end to her Ob/Gyn rotation with no surgeries scheduled for Monday. She did, however, enjoy M&M (morbidity and mortality) conference. "The attending was pimping the residents. I was like, Bitch, don't stop! The residents were squirming, it was great."
I arrive for the three-hour 8:30 am NBME clerkship exam on Thursday at 8:00 am. Type-A Anita and Southern Steve just finished their radiology rotation. They struggled to stay awake in the dark reading room while getting pimped by the radiologists. "The radiologist would put up a study, and select one of us to give an impression on what is wrong. We would utterly fail most of the time." Steve: "Do you remember that one abdominal CT? We kept focusing on what we were convinced was a hernia. Turned out to be just a normal penis… Apparently there was small bowel thickening from gastroenteritis." Anita: "Boy, did he get a laugh out of that."
Internal Medicine exam questions focused on adverse effects to medications (e.g., Stevens-Johnson syndrome in anti-epilepsy medications), management of acute coronary syndrome, and several rare autoimmune disorders.
On Friday starting at 9:00 am, I had two 15-minute encounters with standardized patients, each followed by a 10-minute write-up. One patient was suffering from new-onset chest pain patient while the other had worsening shortness of breath from CHF versus COPD. We are alone with the "patients" while a video recording is made. Our grade is based on a review from the standardized patient ("Did the medical student empathize with my situation?"; "Did the medical student cover me appropriately during the physical exam?"; "Was the medical student's interview organized?"), a review of the video by a physician or another standardized patient, and the quality of the write-up, again reviewed by a physician or another standardized patient. This prepares us for the pass/fail fourth-year Step 2 Clinical Skills (CS) exam (good news: 98 percent pass rate; bad news: the all-day test costs $1,290 plus travel expenses to a designated testing location, e.g., Los Angeles, Houston, Chicago, Atlanta, or Philadelphia).
Statistics for the week… Study: 8 hours. Sleep: 5 hours/night; Fun for me and Jane: visit her sister and one-month-old nephew. Not fun for Jane's sister: We practiced testing the baby's primitive reflexes.