Three Cups of Tea

So what have I been up to all September? Trying to finish up my research project, study for Step 2, and get all my peds residency application stuff together. Exciting. It's the longest "break" I've had since before third year started, but really it hasn't been vacation at all...I've been working pretty much all day every day...just not in the hospital. Still there's been more time for reflection, more time to watch my cats fight with each other and talk to Monkey, and more time to sit on my new balcony and drink tea. I've never been a coffee person (even with my time in Costa Rica), the caffeine and all the sugar I put in to make it palatable just make me to jittery, but I love all the wonderful possibilities of tea.

Earlier this week I started off my day with Twinings new Chai Spiced Apple. Some might say it's trying to hard, but it's perfect for a brisk autumn morning (when did summer end? seriously). Now that I've completed that wonderful hurdle known as the Step 2CS test in all its standardized patient glory (though I did have a fabulous trip to Chicago so it wasn't all bad), I'm in full on Step 2 CK study mode. Which means many many hours doing QBank questions. With less than 2 weeks to go I should probably be more nervous, but I actually like studying sometimes and wish I had done more of it over the past year.

Later that day I met up with Dr. S at Starbucks to talk about my pediatric thrombosis study which is still making me tear my hair out but is also finally coming together. I actually had a Pumpkin Spice Latte instead of tea (also recommend the carmel apple cider). For the life of me I've never been able to study in coffee shops. I agree with this guy that they are a place where ideas go to have sex, but they are not a place for silent studying. They are, however, a wonderful place to meet up and compare demographics on DVT patients and controls. With any luck our data analysis will actually yield something interesting.

That evening I was thrilled to hear Greg Mortenson give a talk while sipping a lovely cup of organic rose tea. You really don't get much more inspiring than that. The underlying idea is so simple, educated girls in Afghanistan and Pakistan, build communities, stop this ridiculous cycle of violence. Of course, as demonstrated in his books implementing that idea is anything but simple. And sadly, it's still something only a man could do. There is no way in hell those cultures would be receptive to a woman going in there and attempting to do what he's done, but at least maybe what he's doing could change all that. I would love to integrate better education into any future global health pursuits of mine (and here's another TED talk about one way it could be done). Shouldn't education and health be human rights? Maybe not at a survival level, but the world is sure as hell not going to become a better place without them. And Greg was so open and kind and funny. He really comes across as this normal guy who saw an opportunity where he could be of use and ran with it to the ends of the world. Just what I needed to remind me of what I really care about and keep me motivated when I'm stuck inside studying all day.

The God Delusion

Last time I was on call at the VA, we were called at 5:30am for a rapid response on a patient with lymphoma that had compressed his spinal cord and made him a paraplegic in a matter of weeks. Just that morning his family had made him a DNR. When we saw him he was relatively unresponsive but would respond to touch and shake his head when we asked if he was in pain. The nurse told me that his wife was coming back soon with other family members and that after 58 years she had finally convinced her husband to be baptized that morning. We stabilized his blood pressure and went to rounds. Later that morning I found out the patient had died, but first he had woken up just long enough to be baptized.

I'm glad for the patient's wife and family that they can get comfort from the thought that he was saved in his last moments of life. I wonder how the patient himself felt and if he got any comfort thinking he was going to God. At least he was surrounded by his family. Not that there's any harm in a little water splashed on your head if you don't believe it's anything but water...though some people could certain take offense, and with good reason. It reminded me of a recent interview I saw with Christopher Hitchens where he says that any future remarks that make it sound as though he had found religion would not truly be from him, but would rather represent the ravings of a dying man. Stick with your principles to the end. I'm hoping to finish reading "The God Delusion" as soon as I have a little free time (you know, when I've finished my sub-I, pediatric residency applications, research project, and "The Girl Who Played With Fire").

I've never been quite as militantly atheistic as Christopher Hitchens, I belong more to the school of everyone's free to believe whatever they want. Having said that (which I can't say without thinking of Curb Your Enthusiasm), I find it impossible to relate to anyone with strong religious beliefs. I certainly respect faith and think that good things can come out of it, but at some underlying level our world views are just completely irreconcilable. I'm not going to go out and name the second chapter of a book "Religion Kills", but at least from my observations in the hospital, may be in can. We had one patient who had been in the hospital for about a week with meningitis and thrombocytopenia. His platelet level was 4000 (anything under 150,000 is too low). With platelets that low if you hit your head on a cabinet or trip and fall you have going to bleed into you brain and die, no question. He was in the middle of his treatment but just got fed up with being in the hospital and decided to leave against medical advice. Our attending did everything he could to talk him in to staying, but the patient had decided that he was in God's hands and through the power of prayer he would be healed and if not then it was meant to be. He left. We've tried to follow-up with him since, but he lives alone and no one picked up the phone at his house. Hopefully he's still alive. He was deemed competent so he's allowed to make all his own medical decisions, even if they are delusional. Of course, in psychiatry delusions are defined as fixed beliefs that are certainly and definitely false, but not beliefs that are ordinarily accepted by other members of the person's culture or subculture. Any way of thinking that needs a qualification like that should give one pause.

Enough, Really

I hate to say that I became jaded with the ER over the course of the month, but I really did. Maybe it was the lady who came in with allergic conjunctivitis. Her eyes had been kind of itchy for three days, no vision changes, no pain. She was using visine and it seemed to help. Not quite an emergency and nothing we can really do. Next. Or maybe it was the guy I saw at 2 am a few days ago who said his car had been side swiped and his right hand crushed because he had been sticking it out the window. He had wrist drop, radial nerve injury findings, and a little swelling, but the hand didn't look that hurt. The mystery deepened when X-rays didn't show any fractures or dislocations or anything. It took an orthopedics consult going back and grilling him twice for him to admit that he just fell asleep in his car with his arm out the window and when he woke up he couldn't use his wrist. Classic case of Saturday Night Palsy. I felt a little bad I didn't pick up on it earlier, but when a patient is blatantly lying to you, what are you going to do? I think the last straw was the woman who came in with bruising on her hand and said she had dropped a cabinet on it. I was super sympathetic, she had a definite injury, but then my attending was like, "oh, I know that lady". Apparently she was a frequent customer and judging from her INSPECT report she got several prescriptions for narcotics from different ERs around the area every month for back strain, neck strain, bruising, etc. etc. Sigh. I just want to go back to peds where I can deal with pushy parents and not worry about patients seeking drugs at least until they are teenagers.

Of course, there were some interesting patients too. The schizophrenic patient who said a demon named "Terry" had taken his finger and twisted it around three times. Sure enough, he had a spiral fracture of his third digit. He was off his meds so I think the world will never know whether he did it to himself, someone else assaulted him, or it really was "Terry". I also had a really sweet, old, confused lady with metastatic lung cancer and a giant plural effusion making it hard for her to breathe. I got to do a thoracentesis and drain all the fluid off her lung which was fun for me and a big help to her. Score. Then there was the other sad patient who had a 75 pound unintentional weight loss over the past 7 months. Totally emaciated, easy bruising, feeling horrible, and he just didn't want to go to the doctor. I had to leave before I got to see his lab results, but I think he most likely has cancer till proven otherwise. Really nice guy, and really sad. That's another thing I like about peds...I feel like even the most negligent parents would bring their kid in to a doctor well before they lost a third of their body weight. Please, if you have sudden weight loss for no apparent reason, go see your doctor!

I think this video says it best. Goodbye ER. Good short term experience. Not for me.

ER

I keep having dreams that I'm in the ER rushing to take care of another patient. This has happened to me on other rotations but never to this extent...it's like something out of Inception...in the dream I can't tell it's not reality and I definitely have a physical response to the stress. Regardless, I've enjoyed my month of ER more than I thought I would. Sure it hasn't been as relaxing as I'd hoped...working 15 9 hour shifts in one month doesn't sound too strenuous, but you never stop moving the whole 9 hours and with the constantly changing schedule my body doesn't ever really know what time it is. 6 more shifts to go...

There are good days and bad days...I really like the pretty clear cut diagnoses where if you pick the right study you can verify and then treat a disease. 3 year old with fever of unknown origin...she has a UTI. Guy writhing in pain? Definitely a kidney stone. Guy with a week of fatigue...hmm, kind of a vague complaint, but whoa...turns out his glucose was 1200, hello new onset diabetes. Lady coughing her guts out with a clear pneumonia on chest X-ray. That can be treated, no problem. I also like sewing up lacerations...nice, definitive fix.

The diagnostic mysteries are a little more frustrating because in the ER you only really have one chance. Sure I got to do an LP on a guy who may have been having a subarachnoid hemorrhage, but turns out he wasn't. When patients are having bad abdominal pain it's not terribly satisfying to give them some pain meds, anti-nausea medication, and a liter of fluids, run a few tests then tell them you have no idea why they're in pain and come back if it gets worse. I wish I could pull a Dr. House and come up with some really crazy diagnosis, but the ER is not really the setting for that.

Then there are the patients who have no business being in the ER in the first place . Chronic pain patients, an old lady who had been sitting at home worrying about her blood pressure, a teenage guy who had come to the ER (and called an ambulance!) literally every other day for the past 2 weeks for complaints from impotence to coughing up blood. What are you doing here? The county hospital where I'm doing my rotation has on average a 2-3 hour wait...even at midnight. I think the wait actually goes a long way in cutting down on some of the more pointless visits...at the other hospital where I work in the ER as an extern there's usually no wait at all and then we really see a lot of patients with completely non-emergent complaints.

The ER definitely plays an important role in the healthcare system. Even in our fractured non-system it's good to know that there's a place where anyone can get health care. We've had illegal immigrants getting dialysis and, I'm sure, tons of patients who will never pay their bills. Apparently even with healthcare reform the ER crunch is not going away any time soon. Fair enough. Most patients we refer to physicians for non-urgent follow-up won't be able to get an appointment for 3+ months. Sometimes that's just not good enough...and finding a good solution is rough.

I haven't gotten to work in the Shock/OBS unit yet where they get the critical cases, gun shot wounds, MVAs, heart attacks, etc. After watching 8+ seasons of ER I feel like I'm ready. I can always use a little drama...just no more mass shootings of teenagers downtown please.

New Year

All the new 3rd year med students started today and it helped me realize just how far I've come. Though I've had my doubts, I did learn a lot over the past year, mainly about functioning as part of the hospital team and caring for patients. If I had to take Step 1 right now it would be bad news (and I have Step 2 fast approaching...). Anyways, it felt good being able to help oriented the 3rd year students and it definitely helped that I've been on the pediatric cardiology rotation since the beginning of June. It's been good...lots of babies with congenital heart disease including way more hypoplastic left heart disease then seems statistically possible (though I think they just need such complex surgeries--imagine basically completely reconfiguring a heart the size of a small strawberry in the Norwood procedure--that they need to spend more time in the hospital than most kids). I also took care of a girl with rheumatic heart disease which apparently is good preparation for my trip to Kenya. I'm maybe getting better at reading EKGs and listening to heart sounds, though I have a long way to go. I really like my team and I feel I can actually be useful which is always nice.

I had a few crazy days last week with little sleep. I've started working as an extern in the St. Francis ER so Thursday I did my full day of peds cardiology starting at 7am (including a presentation to high school students about med school)...then right after work I drove to St. Francis and worked over night in the ER (fortunately they let me go to sleep at 2 am and just sleep the rest of my time there-nice to make $15 an hour not doing anything). Then I had to come back and work all day Friday since technically I wasn't post call, it just felt that way. The next morning I got up at volunteered at this PBS Kids in the Park event where we helped preschoolers do check-ups on stuffed animals. Good times. Thinking about intern year and keeping that schedule all the time is a little scary. I took pediatrics call yesterday though I couldn't stay over night. This year my goal is really to focus on preparing myself to feel semi-competent as an intern. Scary. We'll see how it goes...

Med Students Anonymous

2.5 days left till my psych rotation (and 3rd year!) is over! It can't come soon enough...I think I'm about to become a basket case...most likely I'm experiencing Generalized Anxiety Disorder or Psychosis NOS. Just kidding...I think. It's definitely time for a vacation. A road trip to Yellowstone is exactly what I need right now.

Still, I've enjoyed psych (though I won't miss having to use a key to get through every single door...the joys of a locked ward). It has unquestionably produced some of the best stories of the year and I've seen people come in completely unhinged and pull it together over night with the help of some meds (or maybe they're just sobering up). I also got to see Electroconvulsive Therapy which was nothing like One Flew Over the Cuckoo's Nest since the patients were anesthetized and none were as energetic as Jack Nicholson to begin with. There have been a few patients who are severely over medicated but that's way more reversible than a lobotomy.

Substance abuse has been a major issue with a lot of the patients and from the way they talk it seems like you can find heroin on every street corner. Procuring drugs is definitely outside my skill set but I don't think it would be professional for me to ask them for details. As part of the rotation we had to attend both an AA Meeting (yes they really did say the serenity prayer and recite the 12 steps...plus I got to say "Hi, my name is Lianna and I'm a medical student"). People's willingness to discuss their problems openly was incredibly impressive and I can definitely understand how hearing stories from people who are going through the same thing can be really beneficial. Having some goody two shoes doctor tell you to quit smoking crack probably doesn't cut it. Unfortunately only 30% of people maintain sobriety through AA, but it's still better than 5% of people who try to quit drinking by themselves. Bad news. I think med students could benefit from frequent meetings to share our horror stories and stresses. I can't believe the school year is almost over. In less than a year I'll be a doctor!

It's All In Your Head Part 2

Stomping out mental illness has been quite the trip. The past week on the psych ward has been a lot more work than I imagined, but at least it's engaging and I actually feel like I'm part of the team. The patients keep things interesting...the guy who collects dead squirrels (and carries their rotting corpses around with him) because he thinks they're talking to him), the guy who thinks he's Satan, the lady who stabbed herself with a kitchen knife when her boyfriend said he was leaving her (she was actually the normal one of the bunch). I actually enjoy talking to them, trying to figure out how they ended up in this position, trying to get them back on track.

Of course that raises the question of what is crazy anyway. I mean, in some of the patients you instantly know they're out of whack, but in the majority they actually seem pretty normal until you ask them if they've heard any voices recently. I got to go to court to watch a commitment hearing and our patient really came across as totally sane on the stand, it was only testimony from her mom about her hoarding tendencies that got her committed. Then there's the idealistic kid who recently dropped out of college, smokes pot, and thinks that there's a government conspiracy supporting the corn industry resulting in high fructose corn syrup in all of our food products. Not wanting to participate in a dysfunctional society is not necessarily crazy. Plus, most of his views are pretty much identical to those of some of my friends. Go figure.

I've always been leery of psych meds...but they definitely get results. If you've got mild depression a little psychotherapy might go a long way, but for bipolar mania or schizophrenia it's hard to argue that just talking about it will make everything better. Still just talking about things can be incredibly beneficial and perhaps it doesn't happen enough. What about Mind Over Meds?