I finished neurology a while ago... three weeks ago, actually. It was a good rotation--although it was so boring and we saw so few patients at our rotation site that I actually managed to read about 75% of our recommended text book (the most I've ever read of a text book ever!) [12.20.13 Update: Turns out I did well above average on the Neurology shelf exam, suggesting that contrary to my hopes and wishes, patient care does not help you learn. Textbooks do.] The clerkship director is both nice and sarcastic, wise yet modest. He also has a beautifully maintained walrus mustache. Irregardless, I learned a lot and finally feel competent in at least one clinically relevant thing: the neurological exam.
I didn't realize how important that would be until I posted up in Emergency Medicine and found myself running through the neuro exam in approximately half of my patients. Strokes, seizures, headaches, falls and other assorted traumas--a lot of what passes through the emergency room requires some neurological assessment, and for the first I actually feel semi-competent in something. Also adding in my understanding of vasculature from surgery and my knowledge of medications and bedside procedures from internal medicine, and I sometimes--occasionally--feel like an actual medical student, no, an actual physician.
My favorite thing about Emergency Medicine is that I get to see my own patients before anyone else--and I get to physically examine them. I have no choice! It's a requirement I can't get around! Now that I am forced to see people on my own, I have actually developed some strategies to forming good rapport with patients. Of the thirty odd patients I have seen so far, only one of them has been difficult and unwelcoming. Everyone else--even when they are in excruciating pain (manufactured to receive dilaudid or otherwise)--has been incredibly nice to me or at the very least incredibly tolerant of my prodding questions and my poking hands.
A few encounters stick out to me in particular, and I guess I'll review them below:
Linda the Finger Lady
So this is a fun fact: BOTH OF MY PARENTS ARE SURGEONS. Because of this, I feel over competent in my ability to suture. Or at least, I did until I was asked by my clerkship director to suture shut a centimeter long laceration on a patient's pointer finger. I observed the clerkship director inject a ton of lidocaine without epinephrine into this woman's finger, then I was left alone with the suturing kit and Linda. It was an overnight shift. During the day, there are enough attendings and PA's around that suturing is done by the more competent. But it was two-thirty in the morning and I had already stitched a guy's hand exactly six days and twenty-two hours ago, so dammit! I felt comfortable in doing this myself.
Linda, as it turned out, was incredibly friendly. But she was also incredibly sensitive to pain. I couldn't blame her, of course, because fingers are very sensitive things. But as I was still analyzing the pad of her finger--trying to determine how to best suture a tiny laceration with subcutaneous fat spilling out and making it difficult to stitch--Linda began to wince. The lidocaine was wearing off! And I still had at least one more stitch to go. I could have grabbed the lidocaine and given her another shot--but since lidocaine shots are the only part of the suturing process that is painful to patients, I felt uncomfortable causing Linda--who had been sharing small, humorous anecdotes of her life while I pondered and sutured the wound--additional pain. So I rushed out of the room and found the clerkship director.
"I have a problem!" I blurted out. The attending casually turned around so that she could stare me down despite being almost a foot shorter than me. "The lidocaine is wearing off and I used up all of the suture material." I was embarrassed, of course, but I know when to admit defeat--when your actions, no matter how minute and insignificant, could potentially get the hospital and attendings sued. "You ran out of suture material?" She asked, cocking her head slightly to further inspect me, although I was uncomfortable making eye contact and was instead staring at her ID badge that announced she was a medical doctor. She had already turned around to walk to the suture crash cart as I said, "I guess I wasn't judicious with my ethilon."
I followed her back into Linda's room, closing the curtain behind me to deny the few people left in or unable to sleep in the emergency department. As the clerkship director injected lidocaine and began suturing the rest of the laceration--still opened and unable to heal properly. I panicked a little when she took the small scissors from the laceration kit to cut out one of my three stitches. How embarrassing! On her last stitch I turned to face Linda, placed my hand on her shoulder and said, "I am so sorry." Linda told me several times that I had nothing to apologize for, but I still felt bad that I had hurt her because I wasn't quick enough with the stitch.
I felt as though I had disappointed both the attending and the patient. As we left the room to sit at a computer terminal, I made a mental note to myself: "For the sake of Linda, I will get better at suturing.
The Old Man on Coumadin watching the AMC Turner Classic Movies channel
Literally the next day my emergency medicine attending found himself with his hands full--a patient who's doctor had yet to fill out her DNR paperwork had fainted and her heart had entered ventricular fibrillation. Much of the day was spent counseling the patient's family and calling other doctors to figure out what we could do for an unresponsive person. I was sitting at a computer terminal twiddling my fingers when my favorite attending told me that she had a patient that required sutures. I jumped at the chance. He ended up being an eighty year old man on coumadin who had had a mechanical fall and formed a six inch long laceration on his forehead. She informed me of several things:
- How to properly inject lidocaine into a patient--even if they are screaming from the pain.
- Digits and ears and noses should not get lidocaine with epinephrine--this can negatively affect circulation, leading to poor healing or gangrene [12.20.13Update Although later a plastic surgeon will inform me that the epinephrine wears off in about 1 hour, and considering you can reattach digits 12 hours after they've been amputated with acceptable deficits, 1 hour of poor circulation is worth the benefits of epinephrine (less bleeding, longer effect of local anesthetic).
- As a student, I should pick up double the amount of sutures I think I actually need.
- Especially if I am using 5-0 ethilon, which is not much thicker than a strand of human hair.
- Irrigating the wound is essential.
Anyway, the man was mildly demented, so besides moving his hand to rub his nose twice, he did not interact with me at all as I put in 11 stitches while watching a black and white film about zapatistas. AND THEY WERE BEAUTIFUL STITCHES (the movie was also beautiful). It took a lot of self-restraint to not pull out my phone when I was done to take a picture of the closed-up laceration that had been spilling thinned-out blood for the last several hours. I cursed the fact that the clerkship director would never discover that I wasn't actually terrible at suturing. But I was still proud that I had stitched well completely unassisted.
The Seizure in the Random Genetic Disorder Patient
Another overnight call and at four in the morning the EMT's stroll in with a woman holding onto a small child, both laying on a stretcher, bundled up in blankets against the cold. Five or six minutes later, my attending turns to me from his seated position behind a computer, and tells me: "It's a pediatric case with seizures. Most likely febrile. You're up." Ever enthusiastic about my pediatric cases (seriously, you see no children in surgery, medicine, or neurology) I bound into the room and am immediately struck by something. Amelia. The child has no hands, no forearms. One arm has a single digit sticking up into the air around where the elbow should be. The other just ends at the humerus, the skin sharpened into a point akin to a what a wing looks like on a rotisserie chicken. I stop cold in my tracks. Six hours ago I had finally had a child as a patient who didn't immediately cry at the sight of my white coat. I was enthusiastic because I could stand next to him with my stethoscope for auscultation without him crying his eyes out making heart sounds and lung sounds inaudible. I think he even smiled at me. I had no problem getting into the kids face. Now I was uncomfortable and didn't know how to proceed. But within a few seconds of observing the nurses buzz around completing their tasks, I realized I could just treat this child the same way I treated another kid who presented with fever and vomiting two days ago--and who began crying whenever I got within five feet of her--I would just talk mostly to the parents.
It turned out that that was the most I could do, since the child was non-verbal. Still, I kept feeling as though I was offending the mother in some way. The kid was cute, actually, but since I got the feeling she couldn't understand me--or even pay attention to me--talking directly at the child would be of little benefit. Usually, even if someone is very opposed to me examining them, I attempt a few maneuvers--heart and lung sounds. Now I just stood around and asked history questions from the guardians, realizing more and more that this probably wasn't a febrile seizure like my attending had suggested.
I left the room to confer my results with the doctor, which could be summed up in one sentence: "this kid is a lot more complicated than you thought." The attending agreed--while I was asking questions and observing the patient, he and the scribe had been looking up the patient's past medical history in the computer. We all walked back into the room to talk to the parents. I paid more attention than usual at how the doctor talked to the family, but just like almost every other patient-doctor interaction I'd observed thus far, it was more fluid--and in this particular doctor's case friendlier--than any medical student-patient interaction.
What hurt me though was when the doctor started breaking down the plan. At one point he said something like, "If this was any other kid, we'd do x-y-and z to rule out causes for her seizure." The mother at this time began crying. "I want you to treat her like you would treat any other child," she said. It wasn't very logical. Before proceeding with the plan, we should confer with the patient's pediatrician who would likely be more knowledgeable about the sequelae of the disorder, in which seizures are more common. That would be more efficient. We wouldn't have to irradiate the child as much by subjecting her to a CAT scan. But in that moment I realized that the child wasn't simply cute despite her genetic disorder. I realized she was cute because her parents had cared so much about her that they had spent the time to brush out her hair and braid it into pigtails, to dress her in a nice outfit, to hold onto her no matter what. More importantly, they made it much easier to connect with someone who can't speak. It was heart-breaking and endearing. Also insightful. We are not so much our genes as we are the effort our caregivers put into us. Which is why, despite her disorder, this young girl was more fortunate than many of the drug addicted individuals who had no choice but to enter the emergency room, broken and useless, still suffering from psychiatric illnesses implanted in childhood. [1.6.2013 Update: Ugh. So depressing.]
The Emergency Room Tech and... I'm not a Physician Assistant student, sorry.
I was just standing around minding my own business. A woman decked out in scrubs and holding onto a medical device on wheels, was awkwardly looking in my general direction. I get this behavior a lot from patients' family members who want to ask me questions about the care of their loved ones and if it would be okay to leave and come back later after we've run our tests. But this was the first time I had noticed a staff member staring at me. I acknowledged her presence by making direct eye contact and she walked over to me, invading my personal space. "What are you studying to be? A PA?," she mumbled quietly. "Um... no. I'm a medical... doctor... a med student. Why? Am I not good enough for you?" I asked. "No. It's just that there's something going on with my ears." "Oh, I know how to do an otoscope exam." I said, slightly offended. The tech than smiled and said, "oh well then, follow me." And she dragged me into the nearest abandoned emergency room, darkened due to the absence of patients. Progressive worsening of sinusitis with ear involvement was the indication for the exam, and I found nothing. Ha. Med students can do something... like assessing the general appearance of tympanic membranes.
Delirium Tremens
First off, let me just say that I have seen many more cases of alcohol withdrawal and potential delirium tremens in the white people of Libertyville and surrounding commons than in the inner city patient population of Mount Sinai. I'm going to go ahead and assume that all cultures abuse drugs at roughly the same rate, but every group has their own preferences. Sadly, a lot of the alcohol withdrawal patients I saw at Condell were middle aged white women. I've developed an attitude towards (upper) middle class white women who stay at home all day. My mom is an upper middle class white woman.... but who has also been fully employed for my entire life. She's not a stay at home with a raging drug addiction.... although as a female surgeon she does drink quite a lot. Regardless, I had so much bitterness in me towards this demographic of rich white women without jobs and without purpose, living cushy lives without fear of poverty, that I was actually surprised when I went in to see a middle aged, middle class, white women, vomiting profuse amounts of saliva into the pink plastic bucket she held in her tremulous hands, and wasn't immediately morally disgusted.
As I presented the patient to my attending, and the other doctors and scribes discussed their complete misunderstanding over why anyone would drink so much, I realized that I cared a lot about this woman because clearly no one else could. "She's actually quite pleasant," I had said, to which my attending responded, "For now."
"Oh," I added, "And she actually wants to quite drinking."
"I'm sure," she had said, sarcastically. I laughed nervously. Then spent the remainder of my shift trying to find resources for the patient. Her daughter and her mother had been in the room with her. I couldn't believe the attendings all sounded so jaded. Or maybe I'm just naive.
Whatever the case, I learned something important about emergency medicine which will keep me from considering it as my profession. As an EMED doctor, I would be in charge of processing huge numbers of patients, finding out where they needed to go--surgery, floors, or home. You run tests, you look at scans. You figure out where they're going (hopefully not down) and you get them to go there. Simple stuff (insofar as anything in medicine can be simple). All pathologies can be thought of as puzzles, and it seems like in EMED, you kind of lay down a few tiles and get the gist of what you're looking at (e.g.: in puzzles, a horse running across a beach; in pathologies, appendicitis.) But at the end of the day, or at the end of my shift, I won't be satisfied looking at a nearly finished puzzle and admiring it. I'll be searching for the person who scattered the tiles in the first place.
Whatever the case, I learned something important about emergency medicine which will keep me from considering it as my profession. As an EMED doctor, I would be in charge of processing huge numbers of patients, finding out where they needed to go--surgery, floors, or home. You run tests, you look at scans. You figure out where they're going (hopefully not down) and you get them to go there. Simple stuff (insofar as anything in medicine can be simple). All pathologies can be thought of as puzzles, and it seems like in EMED, you kind of lay down a few tiles and get the gist of what you're looking at (e.g.: in puzzles, a horse running across a beach; in pathologies, appendicitis.) But at the end of the day, or at the end of my shift, I won't be satisfied looking at a nearly finished puzzle and admiring it. I'll be searching for the person who scattered the tiles in the first place.
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