You win this time, baby.

"Syncopal Event" So a couple of nights ago I ended up unconscious, on the floor, dreaming about a duck and a witch debating over who should mow their lawn. Incredibly unprofessional. But apparently these things are common on Ob-Gyn rotations. But I don't understand why these things have to be common for me. Here's my track record so far: In a week of working pure shifts I observed a c-section and helped out with a normal spontaneous vaginal delivery (NSVD). I nearly passed out in one, and definitively passed out in the other--I was on the floor dreaming about ducks. That means right now the score is: seven pound neonates 2, Elora 0.

When the scrub nurse told me I needed to leave the table during the c-section because I was leaning on the patient and I was passively crossing my eyes, I gave my retractor up and I had at the time told myself my blood sugar was probably low. Type 1 Diabetes fail! I sulked out of the room--very slowly so that I wouldn't fall onto any of the nurses standing cautiously around me. And then I had found my way to a patient fridge which are really just stock piles of assorted milks, jellos, and juice cups. One chocolate milk and one orange juice down, I found a dark, quiet unused part of the family waiting room and slowly collected the sweat pooling off of my face onto the collar of my oversized, hospital recycled scrubs. Excellent example of an acute hypoglycemic event--so perfect I didn't even think about checking my blood sugar. And then I actually passed out for real during a NSVD and upon regaining consciousness enough to check my blood glucose, I was perfectly normal--better than normal… 176 mg/dl. So now everything is in question!

DID I REALLY ALMOST PASS OUT DURING THAT C-SECTION? Even my potential as a future family practitioner should be questioned. If I can't handle pregnant people and kids, then I will have to become a… oh god… an internist? I would rather die than do something that boring. I HAD SUCH HIGH HOPES FOR OB-GYN. I've more or less "mastered" (for a third year medical student) the pelvic exam (I can find your cervix! If you have one). Vaginas don't creep me out at all! Vaginal products don't really creep me out either. Senior year of high school, as a swim team captain, I had picked up, with my bare hands, a bloodied feminine napkin that some noob had left on our locker room floor. This merited me a great gag gift at the end of the season. But it also kind of made me think that I could handle a large amount of grossness associated with the female reproductive tract. I still don't think vaginas or uteruses are my problem.

Which is why I think my real problem is… babies. When I had returned to the floor station after passing out during the NSVD, and the nurse wheeled the less than one hour old baby past me, I pointed at it and declared: "You made me pass out, baby!" What the hell is wrong with me? THEY BARELY MOVE! They are pathetic. Me and a baby in an actual fight? I would probably win, right? Gah. Maybe not.

This is the bruise left from my syncopal event.

 The midwife, the residents, and a ton of nurses have been very supportive of the fact that I am not, in fact, a very imposing six foot tall woman, but rather a pathetic, spineless, inexperienced medical student. Every one has stories of passing out and watching other people pass out. It makes me feel better to know that this isn't rare. But I don't want to feel normal. I want to actually be good at maintaining consciousness in unpleasant situations.

Talking with my friend, Cindy, who was also on shift with me, who had also watched this baby emerge into the world, who had also, like me, held the mom's legs back to flatten the pelvic floor and increase the size of the pelvic outlet, and who is a very small five feet tall, but who had NOT passed out, suggested something like, maybe it's not the actual sight of a baby entering the world--because they are pretty ugly looking in an adorable way--but maybe it's the smells of deliveries that really knock me out. Possible. The c-section lady had smelled pretty gross before the operation, and during it, she hadn't smelled that much better. And during the NSVD, I was literally holding up a thigh as the woman kept exhaling directly into my face. I shouldn't say anything. If I had been in labor for the last thirteen hours, yea… I probably wouldn't have spent time brushing my teeth, either. But then it was all I could smell and I felt like vomiting. And when the baby came out I kind of stepped out into the corner, leaning against the window sill. I was thinking to myself "hypoacousis: the thing that happens to me when I'm really happy/manic when driving and I have to turn up the radio all the way because everything sounds so quiet" because that's what was happening to me at the time. Everything was incredibly muffled. There was no longer blood in my ears, apparently. Nor was their blood in the rest of my body, because my arms and legs were moving very slowly. I managed to make it to the window sill and was just kind of waiting for the aura to subside. But it was a prodrome. And the next time I opened my eyes, I was staring at the ground and a nurse was propping me up against the wall with a blanket, and another was going out to get me orange juice. "I don't know what just happened," was my response to "Are you alright?" And Cindy was giving me a pity smile. The patient's family members were mildly freaking out, and I wondered if when the kid asked about her birth they'd tell her that she made a medical student pass out.

Later I would have to fill out an employee injury report, and although I had a small, 1-2 cm laceration ion the lateral aspect of my forearm, and my hand was really sore, I was tempted to write "ego" in the head of the anatomical model of the human body, and circle it to show where I was in fact, most hurt.

What's Death Got to Do With It?

I realized something today while I was hypoglycemic at 63 mg/dL and more susceptible to fear: I am absolutely terrified of death. Not that that is something new. When I was nine I watched a movie about time travel while vacationing around Mesa Verde, and I realized, at nine, that one day I would die and all my accomplishments would account for naught. More than that, I realized that an eternity of total, unyielding unconsciousness was something I never wanted to experience but something I one day would. I, personally, do not want to die. Besides the fact that I engage in a lot of moderate risk behaviors, I do not want to die. I have been suicidal twice in my life, and those events were partially fueled by untreated depression, but they were mostly fueled by my previous realization that one day I will die and everything about me will mean nothing. 

Besides the soul-crushing nihilism surrounding my personal future death, I am also reaching the age where the people I know and love are starting to die. Yet still these deaths are mostly accidental… I feel a great amount of guilt for the deaths of people close to me… those that have stolen people who are related to me by blood in particular… but I cannot change what I did, and ultimately, even though I failed to do things that may have prevented their deaths, their lives were not my responsibility*. 

Now that I am in medicine, lives are very much my responsibility. I have a feeling that this is the source of my fear. I have always been a very good liar. I sometimes attribute this to the fact that I am a natural fiction writer, and therefore I am more readily capable of producing fictional realities in my mind. But the reason why I lied when I was little, and the reason why I occasionally lie now at the age of 24 is because I do not want to let someone down… I do not want to fail.

As a result, when I encounter a patient-doctor situation where the patient might be dead, I run back to my resident and make up reasons for not seeing the patient. I have two examples of this behavior:

The first example occurred when I was asked by my team to inform a suicidal patient that he wouldn't be able to leave the hospital until he was admitted by psych and evaluated for several days. I went to the patient's room and found it empty… But all suicidal ideationists have to have a 1 to 1 sitter, someone with them at all times…. yet here was a hospital room completely devoid of people…. although the bathroom light was on… and it occurred to me that this patient of ours may have hung himself on the water line that connects to the shower head… or cut open his veins, letting the blood pool out from around his wrists, only to let is fall on the brown tiles that constitute our hospitals bathroom floors. WHAT I WISH I COULD HAVE DONE would have involved knocking on the door, and upon not hearing a response from its occupant, opening the bathroom door to see if any dead bodies were mucking around. If a dead person had been found, I surmise I would have run out into the hallway and yelled "HELP", forgetting how to present patients to healthcare professionals.

The second occasion involved a patient with chronic hypotension. My intern instructed that I run to check the patient out--ask about dizziness, measure blood pressure, assess any changes in mental status--but when I got to the room the patient was fairly unarousable… he was asleep. I knocked several times on the door to this room and on the walls containing him. I even yelled out his name. Yet he did not even twitch underneath his sheets. The next step in arousing a patient would be to apply a sternal rub--basically pounding on somebody's chest with your fingertips. But I couldn't bring myself to touch this patient… what if he was really dead? He wouldn't respond to my tapping. He wouldn't be saved no matter what medical interventions were applied to him.

In both of these situations, the patient was found to be very much alive. I was acting inefficiently when I decided to enter the patient's room only to promptly leave it when I didn't get the response I wanted. 

The death of a patient seems like the greatest insult to a physician, even scoring above having your medical license removed. It tells you that you missed something. Hell, we have M&M's specifically designed to analyzed where you as a physician failed the patient.

I don't want to tell someone a patient died because we didn't check their blood pressures often enough. I would rather lie than experience that shame and guilt.

Rules and Regulations: Is Cover-Your-Ass Medicine Devaluing Healthcare?

Today was the day I realized I will have to go into family medicine. Not because I loathe internal medicine (quite the opposite--I have loved almost every day of this clerkship) but because I cannot work inside a hospital. There are many terrible things about hospitals. They are full of sick people. And because they are full of sick people they are always full of the things that accompany sick people in societies both full of resources and those that reside in the third world: the smell of disinfectant mixed with the odor of bodily excrement--almost unavoidable if you spend a day walking around on the floors; the screams... the tortured moans of patient's suffering either from a psychiatric issue (although who wouldn't be driven insane by being locked up in a hospital room for days?) or a pressing physical complaint? (I don't imagine a leg ulcer infested with maggots* can be purified without any amount of pain).

But, unfortunately... well, unfortunate for those people who find themselves confined to hospitals, and also for those people like me who have the option of working in one... the worst thing about hospitals isn't the patients or their illnesses. The worst thing about hospitals are their dumb-@$% rules.

I have a patient. He is my only patient. He is my favorite patient. He is super old and he has borderline dementia.... he reminds me of my father and so I try to be super nice to him because he, like my father in about a decade, deserves the best.

One of the things that is really hard to deal with while working as a pretend internist is how old and close to death so many of our patients are. In surgery, all of our patients had to be surgical candidates, and to be a surgical candidate you have to be able to withstand general anesthesia and someone poking around your insides. This is not so with internal medicine. Hell... one of our team's patients died the other day.

SIDE NOTE: I think surgeon's fear death way more than other physicians. While m&m's (morbidity and mortality) presentations for internal medicine (IM) are relatively tame and emotionally controlled, surgery m&m's seem to be intensely discussed, with the accusations of "who-to-blame" are hotly debated. I think this is a result of surgeon's wanting to, one some level, think of themselves as able to prevent death in their patients. I think this also makes much more timid, surprisingly, when it comes to patient care. I called both of my parents today (remember: both of my parents are surgeons) to ask them what they would have done with one of our patients: patient is an 84 year old man, with a past medical history significant for hypertension, diabetes, and two previous strokes, who was admitted to the hospital 7 days ago with slurred speech and left sided facial weakness suggestive of acute, focal cerebral ischemia, with brain CT and MRI also suggesting stroke, who know, the day before being cleared for discharge, has spiked a WBC count. Both of my parents said he should stay in the hospital. True, you should find the source of his infection. But we could almost be sure what the infection was... couldn't we just treat him for that and send him on his way? The extra care my parents seemed willing to offer might have simply been an artifact from how much more surgeons have to pay in medical malpractice. OR, they could simply hate seeing patients die from something so insidious and so simple as an infection. 

Where was I...? Yes, the incredibly stupid rules. And I'm not complaining about stupid seeming rules that are set up for the purpose of patient safety. For example, this patient, with his borderline dementia, was put on high fall precautions... essentially, he was strapped to his bed by soft handcuffs, which are called "soft restraints" in medical jargon. I understand this rule--if he falls out of bed he could easily die--although it is terrifying to think of fading in and out of orientation to a world in which you are permanently tied up against your will. No. I hate rules like the one that requires the next of kin to physically enter the hospital to sign cover-your-ass paperwork when the patient isn't at full decisional capacity. And even though a lot of terrible malpractice cases, a lot of morbidity, and a lot of mortality have arisen from the fact that things weren't explained well enough to the patient, there are some procedures that are so non-lethal it really doesn't make sense to require the patient's family member(s) to come in. Some people are busy. Most people are busy. Even I never get a weekday off work... if I was told I had to go to the hospital on a Wednesday to fill something out so that my parents could get discharged... I'd probably still take until the weekend to scrounge up enough time to liberate my parents. Doctors know what's best for the patient. We shouldn't have to explain to the patient how the procedure is done, what risks are involved... if the risks are minimal enough.

I know, I know: that wreaks of paternalism. But in all honesty, what we do now is highly inefficient. If I become an internal medicine resident, I'm going to spend my intern year writing down all the times money and/or time was wasted because we had to get paperwork down before patients could get what they needed and leave the hospital as soon as possible. Some patients love staying in the hospital... most patients don't. All doctors want to see their patients get back to baseline so that they can be discharged. But I don't think enough doctors want to put in the time necessary for analyzing why these rules and regulations are often detrimental.

Or maybe we just don't have the time. After all, I rarely see doctors taking off weekdays.

*yes. there were actual maggots in this patient's room. there were actual maggots under her skin. however, when they were finally discovered and the wound care nurse and her assistants were telling everyone outside the room about their findings within, I did not--in that moment--have enough courage to walk inside and look that hollering woman in her face while examining her wounds. I was not brave enough to examine and deduce what exact parts of her scabbed up wounds were flesh and blood and what were maggots.

So this is emergent care?

My teammate and I were sitting on the plethora of abandoned chairs in the emergency room. It was an odd time of the day for people to show up--right around lunch time--and it wasn't the right weather: too cold to be outside and accidentally or intentionally get hurt. Yet there were still patients in about half of the rooms, and because we were on call, all those patients who could be deemed fit for admission had to be processed by us. While we had been interviewing a man with suprapubic pain suspicious for bladder cancer, nearly continuous screams were emanating from a female patient nearby, drowning out the sounds of televisions, beeping monitors, and phone calls. I've been getting better and better at ignoring people screaming in hospitals. But this woman was loud and persistent and every once in a while I could hear the crashing of equipment or cheap furniture, and I'd wonder why a code hadn't been called yet or why nobody had tried to administer drugs.

I was incredibly saddened that the screaming had stopped--it is secretly my dream to rush in to help with a "Paging Dr. Strong" or "Code Grey" (combative patient/person). Alas, today was not going to be that day. Our intern had disappeared again so we had little to do except periodically check up on our patients through their electronic medical records. And then... an Emergency Medicine resident swept by and without hardly stopping asked: "You medical students?" "Yea," we both answered. "I need one of you to follow me." I started asking why as my friend was already standing up to follow him--she is way more instinctively helpful than I am. "To chaperone." Only as they were entering one of the private rooms did I kind of understand. Female patient. Delicate issues. Male doctors needed a female in the room. How obnoxious and unnecessary. So this is where politically correctness was taking us, that male doctors were no longer trusted enough to perform gyne check-ups without female supervision. 

Shortly thereafter, I was pulled away by one of the resident's on my internal medicine team to help out with ABG draws and paper work and phone calls. Eventually my teammate pages me.

"Hi Elora. It's Rebecca. Where are you?"

"The residence room. Why?"

"Okay. I need to tell you something. Will you be in the residence room for long?"

I looked at my computer screen, at the list of patients who were awaiting results of labs and imaging.

"Yea I'll be here."

to be continued. 

Internal Medicine Clerkship (Entry 1: First Impression)

So now I'm starting the third week of my internal medicine rotation, and I am loving it. These residents are significantly nicer than the surgery ones (although most of the surgery residents were definitely good human beings), and because of that, I feel like I'm getting more out of the rotation. Basically, I feel forced to learn and study on my own because not looking something up would make my residents disappointed in me and that would break my heart.
Speaking of hearts, and as an example of the previous statement made above, I finally understand EKGs. It's still very difficult for me to determine what the exact diagnosis is, but considering before I could only get rate, I think it's a step in the right direction. Maybe by the end of this rotation I'll feel and sound intelligent! The only drawback--but it's not that bad--is there's a lot of scut work. A lot of using pagers and calling people and talking to nurses, or social workers, or consultation services.
Speaking of scut work, today I was trying to decipher a note, but it was using an abbreviation I didn't know so I sent an e-mail to my surgeon dad to see if he knew what it was (I could of more easily used dr. google, but I like to keep my dad informed of my learning).

ELORA: "Hey dad! Does PCI stand for percutaneous catheter intervention? Thanks!"
FATHER: "I am not sure. That is why acronyms are not welcome in medical practice. It does make sense that PCI stands for percutaneous catheter insertion. It could also stand for pulmonary catheter insertion or pulsatile cardiac imaging. The message is TRY NOT TO USE ACRONYMS unless you are with friends, who cannot judge you. Dad."

Clerkship

I hate my life.

But first, let's focus on the positives:

• During my last entry, I had decided (although not revealed) that I was going to push my step one test date back 10 days to June 11th. Good news, I passed. 
• I am now almost entirely moved into my downtown apartment. My room is still full of random stuff and I still don't have a well stocked fridge, but I know the area pretty well now and every weekend I go to the beach (within walking distance) with my friends. 

Okay, now on to clerkships.

I started with Surgery. At Lutheran. Widely rumored to be the toughest place to do a surgery rotation. Results are in: I hate it even though I love how much I'm learning and how much I'm doing everyday. In the last two-and-a-half weeks I have cried six times, every single time because of surgery. I am a mess. And I finally know exactly why so I'll tell you:

Being a third year medical student on rotations is like being a middle child: no one likes you and no one pays attention to you so you might as well die. 

If we were to compare the classical hierarchy of teaching hospitals to a nuclear American family circa 1950, the Attendings would be your parents, your older sibling is the residents, medical students are the middle child, and depending on group dynamics, the role of younger sibling is played by either medical students who are great at sucking up and being professional or interns. 

Attendings are the people you want to be like. They are your role models. Sometimes you hate them, but most of the time you love/respect them. They may make you upset because they yell at you and occasionally call you dumb, but eventually you realize they are right about almost everything. 

Residents are your older sibling. But there are a lot of different ways older siblings can act:

-We're in this together: Life is hard. But with any luck, your older sibling likes you and wants you to succeed. This sibling gets extra points if they know how to succeed. Residents can be good role models, just like attendings, but they can also be terrible influences. And as a young med student, you can't really know what's right or what's wrong yet. So you just pray these people are good influences.

-Too cool for you: Okay, you can't really blame someone for this, and to be honest, medical students are dorks. So...

-Constantly antagonistic: For some unknown reason, most likely being they are still bitter about that you took attention away from them (i.e., your birth), they hate you. They would never say that. But if they can, they will make you look bad. For fun. Because, to sum it all up, the world is cruel and if seeing someone else suffers helps you get through your shift, then someone's going to suffer. 

Essentially, residents will determine how you feel about yourself day after day. Your parents may be important to you, but sometimes, they just don't understand. If a resident physician tells you that you did something well, then you feel pretty cool and competent. Otherwise you're just a useless person who know one pays any attention to.

Finally, there are the suck-up med students, the little sibling who really just makes you feel worthless. Everyone is so much nicer to them for reasons you cannot completely elucidate. They are even nice to you--but only some times. At other times they are totally working the angle so they get more assignments. Everyone wants to be around them... nobody wants to be around you. 

Anyway, I'll probably post up something less... emotional, more analytical later. But right now, an hour past my bedtime, I'm genuinely shocked that I haven't quit yet. 

More good news I guess.