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.

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.

Neurology

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.

The End of the First Year

As May fades away in the rearview mirror and we delve deeper into the first hints of summer, it’s hard to believe that the end of the first year of medical school has arrived. Much has happened in the past months. It seems as though we have learned more information in one academic year than many of us learned in most of our undergraduate experiences. We’ve been transformed from relative newcomers in the world of medicine to perhaps the most basic level of initiate – familiar enough to poke our way around and recognize a thing or two here and there, but with so much remaining incredibly foreign to us. We’ve been taught the basic skills of patient interviews and exams, and have gone from bumbling around in our standardized patient sessions (what do you do with this otoscope? Or is it an ophthalmoscope...?) to being able to perform relatively fluid interviews and make our way through a rudimentary exam (although, really, we’re still bumbling around – perhaps just in a slightly more polished fashion). Finally, my wife gave birth to our son almost four weeks ago – a busy addition to an already busy life, but a more than welcome one. We’re happy to have him here.

We’ve learned so much that sometimes it’s easy to think that we have come far in our medical education. And, to be sure, we have – but by no means as far as we might like to think. I was reminded of this once again while recently shadowing my third year student preceptor while he was rotating on pediatrics. While listening in on their table rounds, I was able to pick up on certain little things here and there (hey, beta-2 microglobulin? I know what that is!), but most of it flew far above my head. But while I don’t understand most of the finer points of what was being discussed, or at least only understand certain things on a rudimentary level, I found it incredible to watch how the providing team took all of these random minutia (most of which I hadn’t learned, some of which I had but was surprised to see show up in such a practical way) and fit the seemingly-unrelated pieces together to construct a coherent diagnosis and treatment plan. It was simultaneously daunting (we have to learn all this stuff?) and encouraging (it will be pretty cool to be able to do that…) to watch their finely-tuned performance.

Though I’m frequently reminded of how far I have yet to go, sometimes we get the opportunity to flex our “clinical muscles,” so to speak, and practice what we’ve learned – which is always a satisfying experience. One of the ways I was able to do this was while shadowing my physician preceptor, an internal medicine/pediatrics physician, at her clinic. There, I was able to interview several patients, including one who came in concerned that she had been feeling down for a while. She put on a brave face for the first few minutes of our interview, but when we began delving deeper into what was going on her life, she broke down into tears. My first instinct was to reach out and comfort her in some way, but I had to stop myself – this wasn’t a loved one, but rather a patient, and it probably wouldn’t help her much to have some random medical student wrap her in a bear hug. Still, though, I tried as best as I could to talk through things with her and encourage her. After I finished the interview, I presented her case to my preceptor and she came in and arranged further follow up with the patient. It was encouraging to see the patient leave with at least some hope for the future and a definitive plan in place to take care of her.

I also had the opportunity to volunteer at some of the different free clinics around the greater Chicago area. With a multitude of patients to be seen and oftentimes only one, maybe two, attending physicians present, it’s a place where bright-eyed medical students can actually, sort of, kind of be somewhat useful. Or at least we’d like to think so. In any case, it does give us the opportunity to take our interviewing and examination out of the safe walls of our clinical skills center and into the world of real medicine.  One patient in particular that I remember came in complaining of pain and swelling to his right lower leg over the past two weeks. He had a vague history of surgery to the area around six years ago or so in a different country, though he wasn’t sure what the procedure was or what it had been for. He’d now quit work because it was too painful to stand, and thus didn’t have insurance. I had the opportunity to interview him and perform an exam, noting things like pitting edema, good pulses, calf tenderness, and a distended area in his popliteal fossa that was tender to the touch. From some prior experience working in an emergency department, I was concerned that one possible cause for his symptoms might be a deep venous thrombosis. After leaving the patient’s room, I presented the case to the sole attending that was there, and after examining the patient he was also concerned that that might be the case, and started the process to get the gentlemen the care that he needed. While the role I played was small, it was still satisfying to have reached a point where I at least could recognize that something wasn’t right and build a case, using different points of evidence from the history and exam, to support what I thought was going on.

So it’s been a busy year. Even though we’ve been done for almost a week, it took me a few days to realize that it was all over and I really, actually, honestly didn’t have any more material to study. I remember thinking over Christmas that it was cool to be halfway done with our first year, but then I would remember that it was only an eighth of the way through the entire thing. It’s nice to be able to say we’re now a quarter of the way done, and half of the way through the bulk of the classroom stuff. This summer, I’ve got a clinical research project lined up that shouldn’t consume too much time, at least after a couple of semi-busy weeks, which will leave me free to hang out with my wife and our new son. We’re all looking forward to it.

 

P.S. I’ve been receiving more questions about how I use Anki. I’ll probably be doing a Anki Q&A: Part 2 sometime in the near future (the first one can be found here). That said, feel free to send me any questions you’d like to see addressed, either via email (bloggeradmin@dysgraphicmusings.com) or the comment section below. 

A Terrible Day at the VA

Oh. My. Gosh. What a day.

For our Patient-Centered Medicine course, we are paired with a physician and an M3 student mentor, both of whom we have to shadow a couple of times over this semester. Since my wife is due in April, I figured it’d be best to get those out of the way now. So, today, I shadowed my M3 mentor. He was on an inpatient psych rotation at the VA hospital near Loyola. Which is probably the most terrible place in the world (ok, not really, but the events of today have left me rather ill-disposed towards it at the moment…).

After navigating my way to the main entrance, where I was supposed to meet my mentor, I discovered that, as it turns out, there are actually two main entrances. On opposite sides of the freaking building. So, I continued to navigate my way into the bowels of the VA and eventually found where I was supposed to be. I met up with my mentor, and he took me to a little psych consult room where a couple of other junior/senior medical students were working on stuff. After reviewing the past history of the patient we were about to go interview, we went and found the psychiatrist (whom we’ll call Dr. J) my mentor was working with and my mentor introduced me to him. He seemed nice enough, perhaps a little eccentric. We started walking back through the maze of hallways while talking about the next case. Dr. J asked if I had been here before, and I said no. They both smirked – in a friendly, yet knowing way – and said, almost in unison, “Welcome to the VA.”

Huh.

As we were nearing the elevators, Dr. J turned back to me and said, “You’re welcome to take the elevators, but we take the stairs. We’re going to the 8th floor.”

Of course you are.

I went along with it though, like a good little medical student. After we huffed and puffed our way up to the 8th floor (I really need to do more cardio…) we stopped at the nurse’s station. “We always catch our breath before going into a patient’s room,” Dr. J said, in between breaths.

After recovering there for a bit, we finally knocked on the patient’s room. He was a male in his mid-thirties who was, at the end of the day, a pretty normal guy. He had had a tough few years, though, with family members dying, a divorce, and some tough luck. He had apparently had some chest pain recently (which he had experienced before) and presented to the VA seeking help. They had started to rule out a cardiac etiology, though they still wanted to do a stress test. Dr. J was here to investigate the possibility of generalized anxiety disorder and/or panic attacks causing his symptoms.

In the emergency department, where I worked for two years before medical school, a “long” interview was maybe 15-20 minutes. Today, though, we spent almost an hour interviewing and talking about the patient, which my mentor said was fairly average. We sorted out how best to get him some help in the form of outpatient counseling and a little Ativan for the odd anxiety attack, and went on our way to check on another patient, who was on the second floor. This time, mercifully, we took the elevator. This patient was in surgical ICU while recovering from abdominal surgery. He had apparently been a bit delirious, mostly at night. Last night, he had ripped out his ostomy bag, making a mess. He also apparently was telling people that he was actually dead and didn’t know how he was talking to them.

Today, though, he seemed mostly normal. Mostly. In talking to him, you could tell all of his oars weren’t in the water, so to speak, but he had apparently decided that he was in fact alive now. That’s good. But we’ll keep you here just a little longer. And give you something to sleep at night.

After that, I headed out. I had a bunch of stuff on my plate to do that afternoon, mostly in the form of actual school work I needed to get through. Before I left the VA campus, though, I wanted to pick up my ID card that had taken forever to sort out. Back when we first started, we had to fill out an hours-long set of forms online for a background check and then get fingerprinted (which took hours and hours of waiting in line at the ever-so-efficient VA HR department) so we could get a government-issued ID for our rotations at the VA hospital in third year.

Turns out, though, the person in charge of handling the paperwork for my entire class left the VA while it was processing, and somehow all of our applications were forgotten about. And after sitting in some electronic holding vat for too long, the VA system terminated some of ours, depending on how long they had been sitting there. Those of us who had gotten them done early, for example. Like me.  And, by the time they told us, our original fingerprints had expired. Lovely.

So I had gone back to HR a few weeks ago to get my fingerprints redone, and tried to figure out what was going on with the online forms. Someone took my name and said they’d figure it out and get back to me.

Which never happened.

I ended up calling the person in charge of “endorsing” us for our badges, who said don’t worry about it, we really didn't need that form anyway (so we spent hours filling it out then because…?). Your fingerprints are all you need for the background check. Go get your card.

Awesome. So, finally having a free moment from school, I thought that I’d run over to the ID card office and pick it up real quick. Hahahahahaha……

Turns out the office is in the middle of a seemingly mile-long building that stretches across the entire VA campus. And looks like it’s abandoned. And only has one entrance (that I could find) labeled “Suite C.”  I needed Suite E. I couldn't tell where along the mile-long expanse to park, so I called the office number and asked them for some type of landmark. “We’re in building 1.”

Yeah, I got that.

“Oh, we’re at the north side of the building.” Great. So I drove to the north side of the campus/building…no entrance. The frick.

Drove back to Suite C. Parked. Went in. Was told to walk up a long hallway to Suite E. So I did, and finally found the office. Then I found out I wasn’t actually going to be able to pick up my badge, I actually needed to start the process. Which means more fingerprints and pictures. Buuuut the fingerprint machine wasn’t working – its server is busy. Can you use the extensive fingerprinting that I had completed at HR? No, our systems aren’t connected like that. Fine. Let’s try again. And again. And again. Let’s wait and see if the system suddenly becomes not busy. I did some Anki while waiting. Try again. Wait again. More Anki. Try again. Wait again. Try again. Oh, let’s change this parameter – great, it’s fixed (an hour and a half later). Oh, remember those online forms you were told you didn't need? You actually do need it. We can’t give you a badge. Sorry.

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So I walked back out of the building, toyed with going home and just doing the stuff I needed to get done, but decided that I’d better just go over to HR and sort out the online forms thing now and save myself a trip back to this dreadful place. So I walked over to HR, and actually ended up speaking to a lady there who was actually very helpful, which was a nice change of pace. She even stayed a little over her shift to sort things out, revived my forms from their electronic grave, dug some of my old paper forms that I had signed months ago out of some stack in a corner so I didn't have to go through them again, and got things moving again. I should be able to finally get my ID card in a few days.

I hope.

The Stare of Death

I’ve been on fall break for the past week…and it’s been glorious. Loyola starts a little early, but that translates into a week-long break halfway through the first semester. Which is most excellent – and much needed. It’s been a long few months. My wife and I have spent the break basically trying to be as non-productive as possible (i.e. watching a ton of old movies that we watched as kids, eating ice cream, and occasionally doing more big-person things like shopping, home repairs, etc.). We’ve had a blast.

We also got to go to our first ultrasound, which was awesome. My wife is twelve weeks along now, and he?/she? is starting to look like a little human being. It was quite the moment when we got to see our child moving around, kicking, and generally looking cute on the ultrasound screen. Just because I can’t resist, here’s one of the pictures we were given to take home with (awww....). His/her feet kind of look like claws in this view, actually. But they’re really quite normal – we checked. I may or may not have tried to count his/her fingers.

But, alas, break is soon going to be over, and back to the grind we go. We started anatomy a few weeks ago. It’s actually been really interesting, but it’s also been really, really busy. The tried-and-true fire hose analogy that people use to describe the volume of information coming down the pipe at you in medical school – all of which you have to know, and know well – continues to be proven true, if not even more so than before.

Loyola actually recently changed up their anatomy curriculum. Their overall goal was to cut down on required time slogging through excess adipose tissue in the lab and increase the time that students had to master the material on their own. Personally, I’m a fan of that goal. Dissection is an awesome experience, and somewhat of a rite of passage for doctors-in-training, but it can nevertheless be somewhat of a drain on one’s limited amount of time. So, instead of having close to twenty bodies for the class and everyone in the lab at once with only a few instructors to go around, they’ve cut the body number down to six, posted a faculty member at each table, and split the class up into rotations, with each rotation dissecting a certain region of the body. I was assigned to the thorax and abdomen, which should be interesting. Students can, by the way, go down whenever they want, but only absolutely have to be there during their rotation. Additionally, instead of making us sit in lecture, they’ve tried to summarize the key points of lectures in short-ish videos that we’re supposed to watch before coming to class (which, during anatomy, only goes for about an hour or two max – which has been awesome). During class, the idea was that we’d go over board-style questions that made us really think through the relevant material to arrive at an answer.

There have been a few glitches in the execution of their new curriculum, however. The biggest issue has been with the videos and “lectures.” Unfortunately, trying to pare down anatomy to a few “key points” leaves a lot missing. It’s difficult to then go forth and memorize crap when we really don’t know where to stop – we could, of course, go on memorizing forever (and, being the neurotic medical students that we all are, we would). We really didn’t know where to stop. Additionally, we were supposed to watch these videos the “night before” the “questions lecture,” which really gives us no time to process and learn the information…which means that the lectures really turned into a waste of time, since we had no idea what we were supposed to be doing. Finally, some people weren’t happy about the change in lab setup – I remember one of the questions that always seemed to come up in tours of the schools on interview day was something along the lines of “What’s your student-to-body ratio?” (As an aside…this really isn’t all that important. Really.)

Thankfully, Loyola is pretty responsive to its students. We had a Dean’s forum, where we basically were given free food and were able to ask the Dean of the school any questions that we had. Anatomy was a hot topic. We all expressed some of the above concerns, and within a few days we started to see some changes. First, the “question lectures” became more “lecture-ish.” This was actually the most helpful change, in my opinion, as it’s nice to have someone walk you through certain things that don’t come as easily from a short video or staring at a textbook. Next, the professor produced a more definite list of what we should focus on. Finally, for those students who wanted more lab time, the professor started doing short, daily reviews in the lab of the previous day’s dissection, just so we can see things on an actual human body instead of simply in pictures and to save us the pain of going down on our own and trying to pick through things. So far, I think things are shaping up for the better – we’ll see how things go.

I have had a few opportunities to get out of the classroom, though. One of the things I did was volunteer at a free clinic in Chicago that Loyola students basically take over for one night a week. First year medical students essentially observe, might take a history, and pretend to listen to heart and lung sounds. Second year medical students, on the other hand, really get to run the show – they’ll interview the patient, examine them, come up with a plan of treatment, present the case to an attending, talk it through with them, and write a note. It’s really a great opportunity to get out of class and use some of the skills we are learning. So far, first years have only covered the patient interview and spent some time interviewing standardized patients, but as the year progresses we’ll learn more physical exam skills. That should be fun, and the clinic should be a great place to practice and take a break from class.

Loyola’s anesthesiology interest group also has a program called APEP, or Anesthesiology Preceptorship Enrichment Program. It’s essentially a program that pairs students up with an anesthesiologist mentor with whom they meet once a month for a few hours during the anesthesiologist’s shift and discuss some basic science concepts in the operating room. It’s a great way to translate some of our bookwork to the real world. I’ve met with my preceptor once so far, and had a great time. We talked about different sedation methods, intubation, difficult airways – and there was mention of a possible opportunity to intubate in the near future. That’d be fun. The program isn’t just for students interested in anesthesiology. I personally didn’t have a huge interest in it coming in to medical school, but I do want to explore different specialties and see what’s out there. Also, it’s a great opportunity to spend some time in the hospital and learn some practical stuff that one might not get through a lecture.

Finally, I was able to spend an afternoon shadowing an emergency physician. Since I worked for a few years in or around an emergency department before medical school, and this is the specialty I have had the most exposure to, it’s also the specialty I’m most interested in at this point (supposedly, I’m supposed to change my mind about this at least twelve-bazillion times in the first couple years. Or so I’m told. I’m sure I probably will). It was a good shift – it’s different being introduced as a medical student and getting the opportunity to participate more in the patient’s care. As a scribe, I was used to standing in the corner and writing down what was going on. Now, I actually get play some small role, and that’s a lot of fun.

About halfway through the shift, we heard the EMS radio come on. Through the static, we gathered that there was a full code about to come through the door. The usual calm before the storm ensued – people began to prepare one of the trauma rooms and gather around the stretcher, double-checking their equipment and wrestling their uncooperative gloves onto their hands. Then the double doors to the ED flew open and a stretcher came through. It was being guided by two people with another person trying their best to continue chest compressions while walking alongside the stretcher. I didn’t catch most of the story, although it didn’t sound like there was much of one – male in his mid-sixties, found down. CPR started at the scene, epinephrine given just outside the ED doors, no response.

The doctor I was shadowing didn’t have this patient, but followed the stretcher into the room to see if the other doctor on wanted a hand. My scribe instincts kicked in, and I started to look for a corner to stand in and stay out of the way. Before I found one, though, she motioned me to follow her in and threw me a pair of gloves. The poor soul who had walked in beside the stretcher doing compressions had been relieved by fourth year medical student who was rotating through the ED, but he was starting to look a bit fatigued. Before I knew it, I was standing over a very dead-looking patient, bouncing up and down on his chest, and trying to keep time to “Stayin’Alive” in my head.

This was my first time doing CPR on a real person. The first thing that struck me was how everything seemed to slow down a bit. There was plenty of time to think. The second thing that struck me was how grey the fellow looked. After that, I was surprised by how “rubbery” his chest felt – somehow, I didn’t expect the rib cage to have that much rebound. Finally, I quickly started thinking that I really should do more cardio – compressions are exhausting!

The doctors did a great job of making it a teaching experience. They showed me and the other students where to check for a pulse to make sure that the compressions are effective, and after using ultrasound to check for cardiac activity, walked us through what they were looking for and what showed up on the ultrasound. It was really interesting. They also made sure I saw the “fixed and dilated pupils” – the stare of death. That was…weird. It really was a truly empty gaze. With cadavers, their eyes are usually closed. It was different staring into the eyes of a person who, moments ago, might have been thinking about what they were going to eat for dinner that night.

The gentleman didn’t make it. Or, more correctly, he stayed dead. And life went on. We went and saw another patient, the body was prepared for viewing, and…that was it. I had seen people die before, but this was the first time I had really been involved in their care. That said, it really wasn’t sad so much as it was more of a profound moment. I wonder if that feeling will stick around.

Medical school continues to be a blast. This week off has been awesome, and I wish that it didn’t end in a couple of days, but at least the material we are learning is, I think, really interesting and fairly relevant to our future careers. So, back to the grind we go.