Sirens awail

This is what I do in my spare time.  I am a volunteer EMT with the local fire department's ambulance company. 

Let me just say that the folks I work with in the company are an inspiration to me and have been a very strong influence on why I want to practice medicine.  They work hard and are available 24/7 to help those who are in need of medical assistance.  The kicker: nobody gets paid a dime.  Their sacrifice embodies the Christian principle of, "My life for yours," and reminds me every time I run a call with them why the calling of medicine is so great.  For another perspective, go here and click on the video at the bottom labeled, "Moscow."

More transitions

This week I began a stint with the government.  I'm working in general internal medicine, which has been quite the culture shock.  I see patients with no fewer than five concurrent medical problems, and during the visits I generally manage to elicit at least two additional medical complaints from side pain to, "Oh yah... I've got this thing on my toe..."  This rotation is intimidating beyond what I had initially anticipated, but the biggest challenge for me has been the adjustment from the fast paced and well delineated world of general surgery to the much more relaxed paced (yet still incredibly busy) and nebulous world of internal medicine. 

A week ago I was doing rounds on a number of patients each with a clearly defined medical history and all of the necessary diagnostic testing at our fingertips.  We would be sent a patient complaining of right upper quadrant pain, for example, and they would have blood chemistries and blood cell counts already done or available within the hour.  They would have CT scans already performed and the scan would be accessible to us within two minutes. 

But this week I am working in a governmental systems with more "i's" to dot and "t's" to cross than I can keep straight.  When the patient comes in with a complaint, we are the ones trying to coordinate the labs and imaging which we won't see for at least a week.  We have records dating back YEARS that we must pore through to get to the bottom of the issue.  The conversation often goes, "I was seen by a doctor... whatshisname... over there at that one clinic?  Yeah, that guy.  Anyway, he saw me and ordered all sorts of tests.  He called my condition "somerandomname" and gave me these pills.  Itinilol or something like that.  Can't you just look at the records on your computer?"  Of course we do our due diligence and track down all of the records, complete and incomplete alike, and piece together the progress of the problem at hand.  It takes an experienced provider at least 20 minutes to get it all together, and it takes me easily three times as long.  It is frustrating, but rewarding.  I put together the pieces of the puzzle and get to the bottom of the problem, find a solution, and get the patient sent on his merry way.  My biggest challenge now has become determining which pieces play a large part in making the diagnosis and which ones are less important.  For example, a patient with unexplained weight loss, restlessness, insomnia, and excessively active reflexes doesn't necessarily have a thyroid condition as one would suspect based upon the textbooks. 

I think the issue that has come up is that as a student I don't have enough snapshots of what hyperthyroidism, renal artery stenosis, autonomic orthostatic hypotension, etc. look like.  I have pre-conceived notions of how these things might present, but these don't match with reality well because of my lack of experience.  My hope is that this will come to me quickly and that each time I see something new I will take a good mental "snapshot" of that condition and store it away for benefit to my patients in the future.  In the meantime, I need to be wary of trying to shoe-horn symptoms into a pre-conceived mold of what condition a person with mild peripheral nerve problems and large red blood cells has. 

What an exciting time!

Interesting experiences...

So today marks the first day that I have been lied to by a patient.  Short version: there was a car accident.  The patient denied using any "substances" prior to the incident.  Toxicology disagreed. 

I was notably chagrined to find out that I had not done my best to get an honest and complete history from the patient.  But I learned that there are situations that are not acceptable - having a patient's family in the room will not work.  I understand that in situations like today, it is not good medicine to have family in the room. 

And I have taken another step on the path to good judgment.  As they say, good judgment comes from experience, and experiences are gained by having bad judgment.  I deemed the patient a reliable source, and my poor judgment on that gave me some more good experience.  Experience I hope I won't soon forget. 

All good things

As I come to the end of my surgical rotation I note that all good things must come to an end.  This has been a fantastic rotation for me.  I have learned quite a lot about the practice of medicine both from the medical knowledge standpoint and from the practical application standpoint.  One of the biggest take home points is that my academic knowledge translates well into real world scenarios, but not always the way that I had expected.  For example - a patient with intractable nausea and vomiting whose CT scan shows gallstones doesn't necessarily have cholecystitis and should not necessarily be taken to surgery right away. 

That said, I leave this rotation feeling as if there is so much that I don't know that it is frightening.  I recognize and fully admit that I don't know everything about medicine, but at the moment I am feeling the weight of precisely how much I don't know.  From what I've been told, this is a natural feeling.  It's still uncomfortable, and I am even more aware that by the end of the clinical year I will still not know all there is to know.  My prayer is that I will know enough, and more importantly that I will recognize when I don't know what I need to know.  I think that the latter is the most important thing and I hope that I get a chance to develop that skill in the coming week. 

Surgical self-reflection

As I muddle my way through the surgical clerkship I am reminded that continuous self reflection and precise revision of ideas, thought processes, and methods for carrying out tasks are skills that are developed alongside clinical acumen that comes with experience. 

As we worked through the didactic year, we all had to develop our own studying styles and methods for parsing out the critical information from all of the LOADS of information we were presented.  We had to continually monitor the way we learned to get to the key features of what we needed to learn.  After each exam we needed to evaluate how we had studied to determine if it was the right way to do it - did we get the result that we'd wanted? 

After each surgery and each patient encounter, I have been evaluating the way that things have gone.  Did I ask all the right questions?  Did I anticipate the surgeon's movements well enough?  The most interesting aspect of this has been that the surgeon I've been working with does this, too.  After every case he goes through the steps of the case no matter how routine to make sure that it went as well as it possibly could.  If something wasn't right, he has to figure out why.  This is a skill we could all benefit from developing and one that I know we as students have to work through.  But the challenge and the charge is to continue to self-reflect and develop new ways (better ways) of practicing medicine. 

It's not that I think this is news to anyone - rather it is probably mundane by the end of your didactic year.  But it should not be mundane or taken for granted.  We should all work to analyze each suture, each H&P, each patient encounter - and make the most of our experiences so our patients will benefit in the end. 

Social ettiquette

I have to write about this as a bit of a pointer to those who will come along behind me.  In a way it's kind of humorous because most who know me in a professional setting probably understand that I am fairly particular about rules of social behavior.  I like my personal bubble and I try to respect other peoples' personal space.  "Please," and, "thank you," are common words in my vocabulary (though not common enough to some).

But the world of surgery is different, and I am having some trouble adjusting to it.  The other day I asked for, "Scissors, please."  When I received them, I said, "Thank you."  The surgeon stopped what he was doing and stared at me.  His words were, "you need to stop that right now.  Stop being so polite."  He was half joking, of course, but he had a point.  That is that we must be as polite as is feasible but as direct as is required to get our job done.  Extra words are, in a pinch, unnecessary.  And today I was having some difficulty visualizing the surgical field because of where I was standing - to the right of the patient across from the surgeon.  The surgeon was working deep in the abdomen and I could not see what she was working on in order to keep the field clear.  But I couldn't see because I was trying to keep my head a reasonable distance from hers (personal bubble).  It was frustrating for her that I couldn't do my job, and unacceptable in my opinion.  The tech explained that the sense of personal space is modified in the OR and the surgeon explained later on that I have to do whatever is necessary to see the field in order to help her do her job.  This might include being nearly ear-to-ear so that I can see what I need to.

So another lesson from the surgical ward: get over being polite... sort of.