Daylight

A few months ago I had been under the impression that I was busy.  I realize now what busy really means but what gets me is that I am still probably wrong about what I consider busy.  At any rate...

The past week has been rather intense.  We have seen 80+ patients over three days and performed 14 operations.  Each day has been longer than 12 hours for the surgeon and myself.  Of course, this week is offset by the prior week in which we only had 60 patients and 9 surgeries.  I understand that not all weeks are like this one, but it's still to the point that I have to ask myself - how do they do it?  I am thankful that I don't have a residency waiting for me in which these hours would be pretty much normal.  I don't envy anyone that mental stress but I also am thankful that I will not subject my family to that.  Not seeing the daylight for four straight days (literally) definitely has an adverse effect on me but also for my family. 

An important part of all of this is that we all (my family and I) will have to understand that there will be weeks like this one - there will be weeks when I need to work a lot of extra hours because there is a lot of work to be done.  We can handle that.  But we also need to understand that when the weeks are a bit slower, we need to recharge the batteries a bit - we need to let things be a little slower and spend some extra time doing family centered things.  I guess I need to point out that I need to learn to take it a little slower on the slow weeks - and it's something that everyone coming after me should take into account. 

My advice: as students, take the slow weeks to tend to the family/friends. 

Now, if only I could take my own advice. 

Orthopedic surgery

This past week has been spent learning the ropes of a local orthopedic surgery practice.  To say that we have been busy is an understatement.  We have had over seventy patients in the office (on the three days that we saw patients in the office) and have performed twelve surgeries.  It has been a whirlwind and I have tried my hardest to keep up.  Whether or not I have done that well is up in the air.  Regardless, I have enjoyed the ride. 

We began on Monday in the clinic doing some pre-op and follow-up appointments.  We had a few new patients, so in all it was a well-rounded day.  On Tuesday it was all OR - seven cases in total.  And we began the day with a procedure I had never seen before - a total knee replacement.  It was an eye opening day and I was reminded of how much I enjoyed the OR during general surgery some months ago.  More clinic and surgery on Wednesday, then Thursday just clinic.  Friday was another day of surgery in which we performed a meniscus transplant.  What an experience!  The surgeon took a piece of donor meniscus (knee cartilage) and sewed it into a patient whose knee cartilage was pretty much plum worn out. 

The emotional ride has been a little less extreme, but I am still humbled by all that I am doing now as a student.  The job that we have as medical providers is, in a word, huge.  I am enjoying learning that job and I am truly awestruck by the extent of what we need to know and be able to do.  At this moment, I feel very tiny in the world of medicine - as if I am too small to be able to do my job.  Yet in eight short months (ok - seven and a half, but who's counting?) I will need to be a functional part of this system.  I know I will get there, but it still seems so far away. 

Funny pictures

As anyone else, I enjoy a humorous picture every now and again.  This picture isn't quite as funny as the story behind the employees reaction when I took it.  First, the picture:

Then the story:
We were out at some establishment (I don't want to name any names, of course) and I happened to be wearing a jacket that identified me as a local ambulance company member (a Christmas gift from the company).  An employee had noticed my coat and wished us all a quiet evening (which didn't happen by the way).  As we were going about our business, we noticed that there was conspicuously no fire extinguisher on the wall and, what with the big sign and an arrow pointing to where it should be, we got a good laugh and I decided to snap a picture for giggles.  Well, the employee took note that an ambulance company member was snapping a picture of a place where a fire extinguisher is supposed to be and got just a little worked up -

"Wait, wait...  We have a fire extinguisher right here!"  She dutifully pulled one out from behind the counter.  "It just fell down and we haven't had a chance to put it back up yet," the look on her face a mixture of "got caught with a hand in the cookie jar" and "please don't tell anyone... it was an accident, honest."

I reassured the kind employee that I was snapping the picture for my own personal amusement and that I really do not care about the fact that the fire extinguisher is not exactly where the sign on the wall says that it should be.  I tried to convey that I was confident that they had everyone's safety well taken care of and that there was really nothing to worry about.  But I don't think I succeeded.  

In the end I got more of a chuckle out of the employee's reaction than I did over the photo itself.  And I realize that this means I am a horrible person. 

Oh, the possibilities...

Once again I am in the unfamiliar waters of not having a solid answer at my fingertips.  So much in medicine is evidence based - we know that if we give you antibiotics (the right ones) you will be cured of your pneumonia.  We know that if we sew your wound closed within 6 hours (newer studies are saying 24 hours for clean wounds), your chance of infection is only about 5%.  These are facts as far as we're concerned.  No more debating to be done.  As students, we learn myriads of these facts and are armed with solid answers for a multitude of medical complaints.  And then comes clinical year and we realize that so much of actual medicine is far less certain than we were initially taught.  Does this wound need a two layer closure, or will just one do?  How many sutures does it need?  Is this viral, or bacterial?  Will chronic tonsillitis cause a child to have paroxysmal nausea with vomiting?  Is this patient septic?  Does an elevated carboxyhemoglobin explain all of these symptoms, or just a few?  Should this patient be admitted, or not?  Many of the questions that we have can only be answered after a lab has had a chance to run certain tests, which often take a day or two.  Thus we make treatment decisions based on probability, or more plainly put uncertainty.  This is medicine, take it or leave it.

I have spent much effort getting comfortable with this.  As a clinical student, it is my job to learn to operate in this world of incomplete certainty - "Mrs. Smith - you most likely have a viral bronchitis and will not need antibiotics for this condition.  Use symptomatic treatments like cough syrup and throat losenges.  If you're not better in a week, come back and see me and we'll see if we need to do something different."  In this case, the most likely diagnosis is a viral illness, but it could be bacterial.  We can't be certain without expensive and, sometimes, inaccurate tests.  This case is a simple one but they can be much more complex and serious such that if we don't have a grasp of operating in uncertainty then we may end up contributing to a patient's demise.

In the ER it comes down to a relatively simple problem - what could this be that might kill the patient?  If we can rule all of those out, but still don't find an answer to exactly what's causing the symptoms, then so be it.  We'll have them follow up with their primary care provider later.  But when I was working in internal medicine, we were the primary care providers.  Here's an example: "I went to the emergency room over the weekend because I was having a lot of trouble with pain in my legs - so bad I couldn't walk.  What do you think it is?"  In this case, the ER has ruled out the "Big Bads" - things like PE, cancer (sometimes), fractures, and the nasty bacterial infections.  But they didn't give the patient an answer - they were only able to treat the symptoms (make the patient functional again, which is always a win in my book), made sure it wasn't anything "serious" and let him go on his merry way.  But then in internal medicine we were expected to come up with the answer - this is our job, so I'm not complaining.  Yet the patient sits in the examining room and we, without certainty, begin the workup again (usually we don't get the results of all of the tests done in the ER).  So from an uncertain footing we begin and we do all the same stuff as the ER docs/PAs/NPs perhaps with the exception of x-rays at first (though, of course, repeating an x-ray after a week can show occult fractures - something to keep in mind).  We repeat the physical exam, trying to be perhaps more thorough than the previous provider, and hope to come up with some more clues.  Sometimes we get the answer from a test or a physical exam maneuver, but sometimes not.  In that case, we have to say something along the lines of, "This is most likely [you fill in the blank].  We'll treat you much as they did in the ER, but we'll try something new that will cure it if it is what we think it is."  Talk about uncertainty...

This is generally not how we are taught to practice medicine.  In classrooms, we are taught the typical prodromes and clinical pictures of disease - a patient comes in with chest pain when taking a deep breath and his EKG shows a deep S wave in lead I, a pathologic Q wave and a flipped T wave in lead III - what is it?  This would be a "classic" presentation of pulmonary embolus (PE) but truth be told, it is nearly never that clear cut.  One preceptor notes that in all his years of practice, he has never looked for that classic "S in lead I, Q and flipped T in lead III" pattern for PE.  Thus classroom learning, though undoubtedly beneficial, does not reflect real world situations as well as we would like.  In my recent (though short) experiences, I would have to say that probably 1/5 or even 1/4 of the patients I have seen have not had "classic" symptoms of the conditions with which they end up being diagnosed.  Though this is not news to anyone, I think it highlights the value of clinical experience - both before PA school and our clinical year.  In some ways, I believe this year is my true medical education because I not only learn the facts of disease but I learn the uncertainty of medicine as well.

Perhaps if we designed a new curriculum to address uncertainty a bit better, we would all be better off.  Of course, whoever can figure out how to do that will be a millionaire and won't ever have to work again.  Where would be the fun in that?

"Lost to follow-up"

This phrase is one that is often used in scientific literature to describe members of a longitudinal experiment who cannot be contacted after a certain period of time following the initiation of the research project.  They have been lost as far as the researchers are concerned.

I have titled this post as such because this phrase keeps running through my mind as I consider some of the patients I have seen and treated in the ER.  A vast majority have been treated and discharged, some have been treated and admitted only to be discharged a day or two later by their hospitalists.  I don't consider these patients "lost to follow-up" because there is, essentially, no follow-up required.  We have provided definitive care either in our ER or within our hospital system and these patients leave my care in stable condition.  However, I carry the cases of a select few patients who did not receive definitive care while I was rotating through the ER.  Over my month-long clerkship, there were just a few patients who were so ill as to warrant admission, but who did not receive a cure while within our system.  These few are lost to follow-up for me, and it occurs to me that I am somewhat saddened by the fact that I couldn't have a hand in "fixing" them - making them free of their illness as I was able to with so many others.

This is part of being a student - involved in a certain population for a while, then off to the next rotation and everyone you had previously cared for is lost to follow-up.  

The worst day

Putting this one into words may be a little bit difficult.  My aim is to convey a couple of ideas and I need to do it while preserving plenty of anonymity.  On top of this restriction, it's a bit of an emotional issue - so please bear with me as I stumble through this topic.

A number of days ago, we had a remarkably sick patient come through the ER.  Not knowing how sick this person was, I was initially a little unimpressed by the presenting illness - nothing seemed too amiss.  As I presented to my Attending and proposed a workup and treatment plan, I was educated in just how to treat someone with these co-occurring symptoms.  Through this process I realized how ill our patient was (or had the potential to become) and thereafter kept a keener eye on how things progressed.  I was humbled by the experience of having initially assumed our patient was not sick when in fact the opposite was true. 

This brings to mind another point: we have had drilled into us the idea that we need to be able to differentiate sick from not-sick.  Sometimes this is referred to as a doorway assessment or a ten-foot assessment.  One of our instructors would show us pictures of patients and quiz us: "Sick or not-sick?" he would say...  Sometimes it was obvious, others not so much.  Admittedly it was difficult to tell especially for a new student.  I still have a ways to go, naturally.  But it's an important skill and this case illustrates that well.

At any rate, this patient was definitely sick and my doorway assessment was inaccurate.  Our patient became a bit more ill in our department so we got an admission to the hospital set up.  The patient got worse and ended up in the ICU (intensive care unit).

This is where the main point of this post comes in.  One aspect of emergency medicine that is incredibly rewarding is the fact that we often take care of people on their worst day.  Something has brought them to see us that is worse than any other illness or event in their life - something like a heart attack, brain attack, or major accident.  We have the opportunity to make a horrendous event just a little less miserable, sometimes make it resolve altogether.  What a great thing to be able to do.

On this particular day, our patient's worst day, I had the opportunity participate in the care that made it a little bit better.  We helped a family cope with difficult times and cared for a patient who, without good treatment, faced a terrible prognosis.  This is a part of the honor of practicing medicine.

Condensed down into a pithy saying: a patient's worst day brings the opportunity for us to have our best day.  I just hope that, with time and more training, I will be able to fulfill my end of the deal.

There'll be days like this....

As we all set about our medical careers we understand that there are going to be certain days that stick in our memories for a lifetime.  There will be days when the events that unfold make an impression upon us - days from which we learn volumes yet feel as if we have fallen flat on our faces.  These days are difficult to bear, but strike so well at our weaknesses that they are essential to becoming proficient medical providers.  Today was such a day for me.

Without going into too much detail, we had a number of pretty sick folks come through the ER today.  As a student, I was unfortunately a bit hamstrung in what I could do to help in these cases - the bustle of activity surrounding me included skills that I do not possess and skills that are not easily acquired in just a month of emergency medicine.  This experience was intensely frustrating in some ways and incredibly valuable in others - frustrating because the skills are ones that I need to know to practice medicine well, yet valuable in that essentially I was allowed to be a fly on the wall observing some talented providers work together to provide good medical care.  In my case, the frustration overshadows the value a bit.

But to make good use of the time I spent in the ER today, it is my job to see to it that the value is evident in the end.  Our clinical experiences will be what we make them to be, not more and not less.  With this in mind, I can let the memories of the events that unfolded today sink in and stay with me so that when I am in practice and begin taking care of patients as sick as those that I saw today, I will at least understand the sequence of the things that need to occur.

As it turns out, I don't think I have a choice about whether or not the events that transpired will stick with me - some things we don't tend to forget. 

SCUT Monkey

Many books have been written on this topic and every medical provider has had to perform this role at some point in his or her career.  The role of the "Scut Monkey" is one that some do not desire for, to be honest, it can be an undesireable job.  But this work has to be done.  I have learned to fulfill this role mainly in the form of taking care of our "frequent fliers."  It has been challenging, but interesting, and up to this point I don't mind the job too much.

The situation is usually the same - the doctor (my preceptor) will say, "I think you should go see Mrs. Smith," usually with a sly glint in his eye.  The PA working in the department will say, "Ooooh, yeah!  Mrs. Smith will be a good patient for you to see," with a wicked grin.  Of course the PA really means, "This is going to be a challenging and potentially annoying case that will probably end with the patient making inane requests or having a laundry list of complaints a mile long that we have already worked up literally twenty times without any new results... so let's see if you can get all the right answers."  I try to dutifully march off to see the patient, but often I say to myself, "Not another one!"

It is here that I must take pause and mention something that my preceptor and the PAs in the department have already taught me - even frequent fliers get sick sometimes.  The same things that can afflict John Doe can effect Mrs. Smith, and it is in this type of patient that we will most likely miss a major medical problem, because we've heard it all before.  We have heard the complaints of abdominal pain, or back pain, or headaches a hundred times (sometimes literally) and there is never anything to point to an actual cause of the symptoms, so we think, "Why should this time be any different?"  Isn't the definition of insanity something along the lines of repeating the same exact activity a number of times and expecting a different result?  Admittedly, it takes a bit of a naive mind to subject oneself to the difficulties of getting an H&P on this type of patient, but that is exactly what I am - a naive mind.  I need to fill it with something, right?  Who better for a naive mind to see than someone who has a number of complaints without corresponding physical findings?  It is this patient who will challenge my diagnostic abilities the most - and one that I have the luxury of time to examine.  Will I be allowed to assess a patient in flash pulmonary edema?  Not likely - this patient's respiratory compromise warrants more urgency than a PA student in his second week of emergency medicine can provide, especially since this particular PA student has only seen one or two of these types of patients in his entire life.  But the frequent flier...  This is a patient that the doctor already knows and someone that will allow the PA student the time to perform a solid H&P and the appropriate tests in the hope that this naive mind might give them whatever it is that they seek.  And this is why it is a good experience for me to see our frequent fliers.

Interestingly, in one book on the topic of "Scut Monkeys" the charge was given to think of SCUT as an acronym for Some Clinically Useful Training.  My charge to those that come after me is to adopt a constructive view of scut work for we will all have to perform these tasks - but they are what you will make of them.

Thrill ride

I have been having some trouble coming up with an update about where I am and what I'm doing.  I think this is mostly because I've been having too much fun doing it. 

Thus the update of the day is that I am currently doing an ER rotation at the largest regional medical center in our area.  It is so enjoyable that I hardly feel I am at school.  My preceptor has an amazing amount of knowledge to share and has been pretty willing to have me experience new things first hand - like suturing.  On my first day a patient came in needing a number of stitches... my preceptor said, essentially, "Go for it," and with the appropriate supervision (he looked over my shoulder the whole time) I closed the patient's wound with no trouble.  It was a good experience.  I have had many others already, and I've only worked 2.5 shifts (30 hours) so far. 

One dilemma I have faced so far - and one that hit a little too close to home - was that of how far we as providers should go for patients in a permanent vegetative state.  This came up in my last rotation as my preceptor and I listened to a radio news broadcast on the subject.  We discussed this and the question that arises is this: should we do absolutely everything for everyone?  Of course, if we say that we should not provide life support for people in permanent vegetative states then at what point will we draw the line?  Will we begin to draw it further and further down the line?  Will we start withholding medical care from the frail elderly or those who are simply so ill that they have no change of a meaningful recovery?  Truth be told, this decision does not lie with us (the medical providers) but often times families ask us what we think - what we would do.  It is their decision, but they seek affirmation of their choice and support for whatever they elect to do.  The weight of the situation is such that it warrants a great deal of forethought. 

One discussion point that I think helps me the most is this: perhaps we should draw the line between prolonging death and preserving quality of life.  If a patient is in end stage lung cancer with multiple metastatic lesions to their bones and in excruciating pain all day, every day then perhaps we should not seek to blast them with all sorts of chemotherapy and make them endure their pain longer by only slowing the progression of their disease without hope of a cure (aside from a miracle direct from the hand of God).  Perhaps in this situation we should simply help them be comfortable - not hastening or prolonging death, but providing comfort and care for the ill in their final days.  And I think that most reasonable medical providers can see the logic and compassion in this situation. 

But how does it change in a pediatric patient?  Perhaps there is more hope for a cure and long years of a high quality of life, or perhaps a child is so ill that he cannot be saved.  This is a huge dilemma for all of us, and the answers are not so clear cut.  I have struggled with this recently and will no doubt revisit it.  But my preliminary thought is that if, for example, a child has an injury that has left them without higher brain function such that they have a steady heartbeat and steady respiration we should do nothing to prolong their entrapment in that tomb made of flesh and bone.  We should not hasten death, but I have to ask a question: what good does it do a person to be trapped without hope of recovery inside a body that itches, that hurts, that will become ill over the years?  In this situation there is no expressive faculty left for the patient and no ability to move - in my opinion this would be more like torture than life. 

So where should we come down on this issue as medical providers?  Well, I have my opinion, and others will have their own.  And, to be honest, it is unlikely that all of us will ever agree.  But we should all give it a great deal of thought and we should all do it early in our careers so as to be ready for these situation because, as I have seen, they come up often. 

PA school interviews

Taking part in an interview for PA school is quite an adventure in and of itself - I should know: I did it twice.  The day begins as any other with an alarm clock blaring.  The first difference is that the candidate is most likely already awake and just waiting for the alarm clock to go off.  The morning routine progresses with more intensity, more enthusiasm, more attention to detail, and often more quickly than usual.  The trip to the interview site goes more quickly than ever before, too.  It is filled with thoughts about how to answer the questions, about what the future might hold, and often about how much the interview itself means to the candidate.  One question that comes up often is, "Why do I want to be a PA, anyway?"  Everyone's answer is different, but this is the central question that interviewers want to get at.  The interviewers want an answer and then they have to judge whether a person's motives are adequate.  This is the tricky part. 

It is this last part that I want to comment on today.  I have now had the experience of interviewing the next round of candidates to come through my school's PA program.  It was my task to assess whether or not the candidate's motives are right, whether they are at the right depth and maturity, and whether or not the candidate really knows what lies ahead - what a PA is and does, what it means to be in PA school, and what taking sips from a firehose is all about.  In the end, it comes down to one decision: accept or reject.  This was the hardest part for me.  Having been in their shoes so recently, I could see the future they were hoping for and that this interview was their first step.  I could still see it from their perspective very freshly.  Thus it was difficult to weed out those who just didn't have it - I wanted them all to succeed because they all brought some sort of promising characteristics to the table.  Some not as much, and these were the ones that I could not decide upon.  But weighing these things - desire, motivation, knowledge, maturity, motives - was done well and a good class is coming up for next year. 

I was honored to help select them and humbled by those that I did not select.  Afterall, I did not get selected once and I remember how it feels.  My hope is that all those who didn't make it will show their true character by keeping their chins up, setting goals to improve themselves over the coming year, meeting those goals and re-applying next year.  If they do these things, they will shine brighter among a group of bright young people next year and will, in the end, make a fine PA someday.