Wednesday, July 20, 2016

3rd Year Chronicles: Emergency Medicine

"I was trying to get a buzz," he slurred before closing his eyes and dropping off to sleep again.

I had just walked in to an evening shift in the ER and had picked up my first patient of the night. He had come in after taking about five tabs of methadone earlier that morning that he had bought off someone. After ingesting them earlier this morning, he spent the next few hours "falling out" (fainting) about four times at home. Once he had "sobered up," he decided maybe that wasn't normal and he should come and get checked out.

Probably a good idea.

We went through all of the usual questions – no, he said he didn't take anything else. No, he wasn't trying to kill himself. No, no other medical issues. He was groggy but conversational, his vitals were normal at the moment, and he wasn't having any acute issues so after we talked and I examined him I left to go find one of the ER attendings to discuss what to do about this guy going forward. Even though he had been using sedating medications, passing out several times and falling at home isn't normal. Also, his EKG (an electrical picture of what his heart was doing for a few seconds) was a little bit abnormal, so he was likely going to buy himself a bit of a workup and likely admission.

The night went on. I walked out of another patient's room a little bit later and went to a computer to check on the workup of some of my patients so far and noticed that the methadone guy had been moved to one of the resuscitation rooms. Turns out he had an episode of ventricular tachycardia (a very fast, abnormal heart rhythm) that was caught on the heart monitor in his room. It was short but that's definitely not normal, so he was moved to a room where we could watch him more closely and intervene if needed.

Turns out, that was also a good idea.

Shortly after his first brief episode of "v-tach," he went into another one – longer this time. He had a pulse but wasn't responding – the heart wasn't able to pump enough blood to the brain. We had already put the defibrillator pads on him, so after he became unresponsive we started charging the machine and delivered the shock. He almost jumped off the stretcher, but immediately he was awake and the monitor was demonstrating a normal heart rhythm again. The attending started a constant infusion of a medication called amiodarone to hopefully keep his heart rhythm normal and we started working to get this guy upstairs to the ICU for further observation and care.

Turns out, his heart had other plans. As we were working in his room, he became unresponsive. V-tach again. He had a pulse. Charge, clear, shock, jump, awake. Breathe. Time to get this guy upstairs. We began to wheel him out of his room into the hallway towards the doors to the elevator when he became unresponsive again. Again, he still had a pulse. Charge, back to the room, clear, shock, jump, awake. Breathe.

This happened five times in a space of a few minutes. This guy needed to be sedated so we could continue to care for him and shock him if needed. That means we needed to "take his airway," or intubate him – put a long breathing tube down through his mouth, past his vocal cords, and into his lungs.

As it happened, the day before we had just had a (timely, it turns out) skills session learning how to intubate, run a code, and use the defibrillator. As we were preparing to intubate him, the attending turned to me and asks, "Have you ever done this before?"

"Nope… but we did just practice yesterday."

He hands me the blade, a short curved metal instrument with a handle that you insert into the patient's mouth while standing behind their head to sweep the tongue to the side and lift up the soft tissues of the jaw to expose the vocal cords, which hide deep in the throat. "You're up."

Well ok then.

We run through the pre–intubation checklist (in medicine, as with most things, the most important part of any task is the preparation). Suction. Bag-valve mask at the ready. Oxygen on the patient. Blades. Tubes. Meds. All of the tools we need to place the airway and make sure it's in the right place when we are done. Finally, it's time. He has been paralyzed and is now depending on us to breath for him, which means we have a limited amount of time to get things in place.

The day before, we had practiced on plastic mannequins. Their airways were, well, plastic and actually really hard to work with. You have to lift up on the handle of your blade once it's inserted in the mouth to expose the cords, but you have to be careful about how you lift – if you lift the wrong way, you'll break their teeth. With the mannequins, you almost had to lift the disembodied torso off the table to visualize the cords.

Human tissue, it turns out, is a lot more pliable. I opened the patient's mouth, inserted the blade (this is the side to put it in on, right?), swept the tongue aside, and lifted the blade towards the corner of the room, surprised at how easy everything was move out of the way.

Breath in.

This is the part where everything falls into place or falls apart. Almost immediately, I could see the floppy epiglottis hanging down, obscuring my view.

"Push the blade in just a bit further."

I eased the tip of the blade in just a bit further behind the epiglottis, lifted up just a bit more… and there they were. Beautiful pearly white cords.

"I see the cords."

Breath out.

I held out my hand and someone handed the endotracheal tube to me. They tell you that, once you see the cords, you should never look away – you don't want to risk losing them. I inserted the tube into his mouth, guided it towards his glottis, and was relieved to see the tube passing easily through the cords.

"I'm through."

My job was over for now – I removed the blade, we secured the tube, and began taking care of all the other tasks that need to happen once someone is unconscious and depending on a team of strangers to help them breathe.


That night was probably one of the more memorable moments of my month in emergency medicine and certainly embodies some of the reasons why I personally think the specialty is one of the best jobs in medicine, but it certainly isn't how the whole month went. Every other shift was filled with hours of seemingly more mundane encounters – sorting through which chest pain patient might actually be having a heart attack, which belly pain patient was actually having an abdominal emergency, helping patients who came in short of breath to rest a bit easier, and figuring out which kids were potentially sick or not. Not all of it was fit for prime time TV, but I thought it was one of the best months of medical school.

It was very different than all of the rest of my third year rotations. The pace, the patients, the focus – it was a huge paradigm shift from working on the floors or in clinic. In the ER, you had to move fast or drown in the sea of patients waiting just outside the double doors in the waiting room. While upstairs I might have had the opportunity to spend an eternity chart reviewing a new patient, poking through their old medical records, and even writing most of my note before I even had to go see them, when I was in the emergency department I was lucky to see their initial vitals and a triage note before I walked into the room. You had to think on your feet and form your differential diagnoses at the bedside and walk out of the room after a brief encounter with at least an initial plan of action.

One of the doctors, on my first shift, spent a few minutes giving me and another student a few pointers before sending us off to see patients. "In the ER," he said, "you don't have time to think. Don't think. Just do. You have to do your thinking outside of the ER." And for the most part, that proved to be true. If there was something I didn't know about on the floors, it wasn't unusual for me to have some time, at least in the afternoon, to sit down and read about a topic for a few minutes. That wasn't typically the case here – if I needed to look something up before presenting a patient, I had maybe a couple of minutes tops before I would start running behind. You really had to spend time off of your shift thinking through how you would react in the first few minutes of any given patient encounter, what your initial actions would be, what questions you'd ask, what physical exam portions you'd emphasize, what your top differential diagnoses would be, and how you'd go about working that patient up, if at all.

We spent about half of our shifts over the course of the month working at Loyola and the other half working at a community hospital nearby. Personally, I actually really enjoyed the community shifts more – at Loyola, a large tertiary care center, there was a "team" for everything (strokes, heart attacks, trauma, etc.) and a separate pediatrics section. So while we stayed plenty busy, it seemed like everyone had their hand in the pot. At the community center, it was you, a couple of other docs, and the waiting room. You saw all the patients, did most everything that needed doing, and functioned like you'd imagine an emergency medicine physician would.

As I've mentioned in previous posts, as I progressed through third year I realized I really enjoy practicing the breadth of medicine. As I spent time in various specialties, I was always impressed at the level of knowledge required within that particular field but always missed "everything else." I knew that I didn't want to be a "knee guy" or a "liver guy." Instead, I always have found it appealing to do a bit of everything. In the introduction chapter to Harwood–Nuss' Clinical Practice of Emergency Medicine, the author writes the following:

"Practicing emergency medicine is like carefully lining up a putt, then dropping the putter, picking up a tennis racket to return a volley or two, quickly side–stepping an onrushing tackler, and then returning to sink the putt."

Another doctor/writer said that "Emergency Medicine is the most interesting 15 minutes of every other specialty." Essentially, it's perfect for someone like myself who enjoys most aspects of medicine in general and really doesn't have an interest in spending the rest of my career focusing on a limited number of medical conditions. That said, EM provides plenty of opportunities to become a "master" at whatever particular bit of medicine you find more interesting than the rest – for example, sports medicine, toxicology, emergency cardiology, resuscitation, and so on.

I've been interested in EM since before medical school. In fact, it's what got me interested in medicine in the first place. Going through medical school, I've tried to put it on the backburner, keep an open mind, and explore other fields, but nothing else really sticks out to me like this one. When I picture being a "doctor," I've always pictured someone who could handle just about anything. There are few fields that fit that description, but I think EM is one of the best at meeting that criteria. Obviously no field does everything. Medicine is a team sport and every field has its limits, EM included.

One interesting thing about EM is that it is practiced in bit of a fish bowel – that is, everyone is watching. All the hospital staff who take over on the patient you admitted for whatever reason can see everything you've done so far in that patient's care and workup. And at least at academic centers, and especially in residents, it's sometimes en vogue to make fun of something that was done during the patient's stay in the ED. It seems to be less of an issue with actual attendings or in community settings, but it's just an interesting phenomenon I've noticed. What's often overlooked is that the same Monday-morning quarterbacking is often done from the comfort of a small, quiet room somewhere tucked away in the hospital with the benefit of 1) more time (the best diagnostician, by far) and 2) more complete information (in part because of the workup that is currently being mocked). Sure, we know the patient's not having a heart attack now, the morning after they were admitted. But that's something you only can tell using your trusty “retrospectoscope,” which unfortunately wasn't available to the ED physician at 1 am last night. Additionally, the practice of EM can be radically different than the practice of medicine on the floors – less information, higher stakes, faster paced. Sometimes that means maybe an extra test or two were ordered in the interest of time, or maybe some treatment was initiated that technically could have waited, but that's the game. Finally, what they may sometimes forget is that for every admission, veritable hordes of patients were seen, treated, and “street-ed” from the ED.

If you're interested in EM, just be aware that there are those with very vocal opinions about the field (and often other fields as well). I would just say to smile and nod and realize 1) they honestly have no idea what they're talking about. It's not their fault; they just don't know how things work in the ER. And 2) I've noticed that oftentimes the loudest critics (whether of EM or any other field) seem to be trying really hard to convince themselves that they chose the right field for themselves. If you want to learn the pros and cons of the field, talk to an actual ER doctor. So there's that. Just play along, keep a thick skin, and don't lose sight of what's important – that is, choosing the right field for you, not your burned–out resident.

Speaking of burnout, that's another concern that's commonly voiced about emergency medicine. More than likely, it's a valid concern for a lot reasons – the shift work can be brutal (especially as you get older), the actual practice can vary a lot depending on what environment you are in, the pace can be soul–crushing, etc. But if you look at some of the burnout data from the Medscape surveys, burnout is really an issue with medicine in general, not just EM. And while EM can be found near the top of lots of the charts related to the prevalence of burnout in various fields, you'll notice that the difference between EM and the next ten fields is pretty minimal (a few percentage points). What's also interesting is that while the prevalence of burnout in EM may be a little bit higher than other fields, the severity of that burnout is lower (even that that of, for example, family medicine, a number of surgical fields, and even internal medicine). The problem isn't so much with EM as it is with medicine in general – the landscape of medical practice is shifting and more and more is being expected of doctors as it relates to metrics and paperwork in addition to good old patient care, which is what we all – presumably – went into the field for in the first place. Preventing burnout is a topic unto itself and has a lot written about it by people smarter than myself, but suffice it to say that there are things we can do to minimize the risk of burning out. For example, keeping your priorities straight (e.g. decreasing shifts at the expense of some income), keeping yourself healthy, quickly doing away with your medical school debt and setting yourself on the path to achieving financial independence so you aren't chained to your job, and making room for a Plan B (e.g. a fellowship into a different niche of medicine or perhaps a different career path entirely) are all good places to start.

Ultimately, finding the specialty that's right for you can be a bit of a journey. You might have one in mind at the beginning of medical school. Or not. You might end up sticking with that specialty. Or not. You might bounce back and forth between several seemingly unrelated specialties throughout third year and maybe even into the beginning of your fourth year when you absolutely have to choose (or just go into internal medicine to defer the choice for another three years… I kid, I kid). For me, though, I'm excited to begin the residency application process for emergency medicine and looking forward to what the future holds.

Sunday, July 3, 2016

3rd Year Chronicles: Medicine, Neurology, and Choosing a Specialty

Third year is officially over now, which means I’ve completed three more rotations without posting anything more on the blog. Which means it’s time to sit down and write something. I’ll try and briefly cover my internal medicine and neurology rotations in this post, and then emergency medicine (my last rotation of the year) will get its own post. 

Internal Medicine
How to Choose Your Specialty

Together with surgery, the internal medicine (or simply “medicine,” as it’s more frequently called) rotation forms the latter half of the third year gauntlet through which we all must pass. Ideally, after completing these rotations, one is expected to have a very rough idea of the expanse of medicine and at least a general idea of what they may want to do when they grow up. That may or may not be the case in actuality, but that’s another post entirely.

My medicine rotation was eight weeks long. The first half the rotation took place on the “wards” or “floors” at Loyola and the second half was at the VA hospital immediately next door (or at least a long walk away). The hours were fairly typical hospital hours but significantly better than surgery – we were there at 6 am to get sign out from the overnight team and, depending on which site we were at, how busy the day was, and whether or not our team was admitting new patients, would get out between 4 – 5:30 pm. The one weekend day we had to work was shorter – we’d usually be done by noon, sometimes a little later, sometimes sooner.

Most of the work happened in the morning. We’d get in, hear about any overnight events for our patients, round on them, and see any new admissions we knew about already. Depending on the morning, we might have a meeting or lecture, and if we were lucky we’d have a few minutes to touch base with our residents to talk about our plans before we rounded with the attending. Some of the attendings like to sit down talk through the patients first and then go see them (this was ideal, I thought, and typically a bit more efficient), while others liked to do bedside rounds. Either way, this process could take anywhere from an hour and a half on a good day to three hours or more on a… less good day. Once that was over, the rest of the day was spent seeing any more new patients that were admitted, writing notes, following up on consults, or whatever busywork was left over.

Each day was fairly routine. The medicine itself was sort of the “bread and butter” of hospital medicine. This was the biggest service in the hospital and accounted for the vast majority of the inpatients. Day-to-day work usually involved tweaking medications to achieve the desired result and seeing what happened or waiting on labs, imaging, or other workups while we were trying to get at a diagnosis. There was something nice about the predictableness of everything – there was a certain way everything was done and certain time to do everything. While it was busy at times, this was the service, more than any other (except for perhaps neurology), where our attendings loved to sit and discuss what was going on and what odd things might be (but probably weren’t) contributing to our patients’ current problems. This was also the first rotation for a long time where I didn’t have some form of clinic – everything was on the floors.

Since this is one of the third year “gauntlet” rotations, it was busy and when it came to studying I had to pick and choose which resources I actually could use. As usual, I started out the rotation with grand plans of getting through Step Up to Medicine, all of the UWorld medicine questions, and reading about individual patients. As it turned out, Step Up just put me to sleep after a long day on the wards and I didn’t have the time to get through even half of all my original goals as it was, so about three weeks in I just switched to reading about different patient problems on UptoDate and doing as many UWorld questions as I could (ended up getting through around half of them). That said, since I had had surgery first, that seemed to be sufficient to do well enough on the end of rotation shelf.

As with most rotations, I enjoyed medicine. I already know I wanted to practice the “breadth” of medicine, and general medicine certainly fits the bill. Also, doing an internal medicine residency is a fairly safe bet – this is the path you need to go down anyway to “unlock” many of the fellowships into medical subspecialties (think cardiology, gastroenterology, rheumatology, critical care, etc.). That being said… I am not a fan of rounding. There are certainly ways to make it less painful, but sitting around talking about patients for hours every day just isn’t my idea of a good time. I like seeing patients and doing things for them, but that only comprised a small portion of my day. The rest was spent mostly on the phone calling consults or on the computer chart reviewing or writing notes. Stuff that needed to be done, sure, and not exactly unique to medicine (emergency medicine certainly has more than its fair share of phone and computer time too), but that was all. day. long. I did appreciate the intellectual aspect of the field – medicine people like to sit around and talk about the endless possible etiologies or sequelae of a given disease process. And that’s not a bad thing – I enjoy learning or refreshing my memory about a given disease process as much as the next guy, and many of the residents and attendings I had the privilege of working with were incredibly intelligent and had a lot to teach (some, not so much, but hey – that’s life). Of course, all of this isn’t necessarily reflective of what one’s day-to-day would look like in one of the many possible subspecialties, but that’s a conversation for later. All in all, I feel like this is the field I might fall into if EM didn’t exist and I decided to not go down the family medicine path. I might consider doing a combined medicine-pediatrics residency if that were the case, though, because I really do enjoy seeing kids – not something you get to really do with a run of the mill IM residency.


Once I crested the hill of the third year, fourth year and its fruits were in sight. My first taste was with neurology – a four week rotation that, by some odd design, was almost more “shadowing” than actual work. With medicine and surgery and most other third year rotations so far, I had been busy working as part of the team, seeing patients, and increasing my workload as much as I could (or at least pretending to do all of that, even if what we were doing wasn’t all that important). With neurology, things were a bit different. First off, instead of having maybe one or two other medical students on your team, there were five of us, which made for a bit of a different dynamic. Second, the residents weren’t quite sure what to do with us. Finally, we had all just made it through the hardest part of third year and were ok with relaxing at least a little bit. Regardless, there were no weekends with this rotation, which was beautiful, and we typically didn’t need to get to the hospital until 7 – 7:30 am, which was also beautiful. To top it off, the residents started looking at us funny if we were there past 4 pm, and often sent us home closer to 3 pm or so. This must be why all the fourth years look so happy.

We spent two weeks of the rotation on “wards,” or the neurology inpatient service, and two weeks on the neurology consult service with some clinic smattered in there once a week or so (which was actually one of the more useful parts of the rotation where I actually got to practice my neuro exam a bit and get some one on one time with an attending). I will say that most of the residents and a couple of the attendings (well, one) did try to take some time out of their day to teach us some useful things (reading MRIs, managing seizures, etc.) which is always helpful and appreciated by students.

Most of our patients were either on the floors or in the neuro ICU after having a stroke, being worked up for seizures, or having some other assorted neurological condition (multiple sclerosis flare, intractable migraines, etc.). This, above all else, is the rotation where people loved to stand around and talk about exactly what part of the central or peripheral nervous system was probably affected by some lesion, and then order or look at imaging or some other study where possible to confirm it. Unfortunately, unless you were an interventional neurologist (a fellowship that allows you to go in and pull out clots within a certain timeframe after a stroke), it felt like most of our energy was spent figuring out what was going on and then watching and waiting to see what happened. There were exceptions, of course, and obviously there are important things that need to be done or medications that need to be started to reduce the risk, for example, of having a future stroke or seizure, but overall I felt like time was the most important treatment for many things (“Oh, you had a stroke? Well, we have a clot-busting drug that may or may not actually work, depending on how long ago the stroke was and if you believe the industry-funded literature or not, and might cause harm, but we can try that. And then we’ll start some meds to hopefully prevent this from happening again, and see if time and physical therapy might fix some of your new deficits. Thanks bye.”). This isn’t to bash neurology – it’s an incredible field with many new developments coming down the pipeline, and many of its practitioners are incredibly intelligent with an amazing grasp of neurological anatomy and pathophysiology.

Again, though, I found myself missing the “rest” of medicine. I brushed up on my neuro exam, but I think I might have used my stethoscope maybe a handful of times the entire rotation. Overall, it’s not for me but I really do think it’s a great field with a lot of opportunities and some cool fellowships (for example, interventional neurology or movement disorders, where you really can change people’s – with Parkinson’s, for example – lives for the better).  

Some Thoughts on Choosing a Specialty

Figuring out what you want to do when you grow up is hard, and it doesn’t stop once you figure out “Hey, being a doctor seems like a good idea.” Then you have to sort out which niche in the house of medicine is the one you want to spend the rest (or at least most) of your career in.

Thankfully, there are enough different paths in the broad world of medicine for almost everyone to find something they can at least tolerate. It’s generally a good sign if you get through your preclinical years and especially your third year feeling like you enjoyed most things – if you’ve hated every day of your life up until this point, all hope isn’t lost but you may have to work a bit harder to seek out your field. There are a lot of things we don’t get exposed to in our core rotations, and a number of fields that we may not see in our entire medical school experience unless we actively seek them out. AAMC’s Careers in Medicine website is a good resource for exploring many of the possible branching paths in medicine that may be a helpful place to start.

Many people start with the “medicine vs. surgery” decision, and that’s a good place to begin. Another way to think about things is to consider if you want to be "the expert" in a particular field (e.g. a heavily subspecialized IM or surgical field). The downside to that is you spend your days doing just that. Or would you rather be comfortable with and deal with a lot of different things on a day to day basis (family medicine, general IM, med/peds, EM)? The downside there is you may be good at certain things (e.g. with family medicine - taking care of the “whole person,” etc.; in EM, you're an expert in working up an undifferentiated patient, managing every field's emergencies, etc.) but won't necessarily function at the level of an "expert" in whatever field you happen to be dabbling in that day. Do you want your life to be all or mostly medicine (e.g. a surgical field or some procedural-heavy medicine subspecialties) or do you want to do things outside of medicine (e.g. 9-5 office based practice, etc.)? And again, there's also lots of nooks and crannies in medicine that you don't really get exposed to until much later in school, if at all.

Also, (almost) every field has its “action hero” moments, but most of your time on a day-to-day basis will be bread-and-butter cases. It’s important to differentiate between the two and not pick a field with few-and-far-between “action hero” moments that you love but a daily grind that you hate. You need to find something that you can at least tolerate on a day-to-day basis or you’re going to hate life and burnout quickly. Using emergency medicine as an example, you get to do some cool stuff – run codes, intubate patients, maybe bring people back to life, do some awesome procedures, and maybe save some lives. But most every day, your shift will involve endless waves of chest pains that aren’t heart attacks, belly pains that aren’t emergencies, and the drunks who consume time and resources you don’t have. If you can’t do the grind, don’t do the field. The “awesome saves” in EM certainly aren’t happening every shift or even every month. But we can talk more about EM in the next post.

Bottom line: keep an open mind. Explore things. Talk to people. Try and arrange rotations or at least shadowing experiences in fields that you are interested in. Understand that you likely would be happy in more than one field. Don’t feel pressured to choose a field right when you start medical school, or even when you’re halfway through third year. Maybe start feeling a little pressure once fourth year is about to start, but beyond that… take your time finding your field, and choose it for you, not based on any expectations that you think your friends or family have. Don’t choose a field to impress, choose one that you truly enjoy.

And regardless of what you choose… maybe think about a Plan B, just in case. That’s life, sometimes.