Medical School Mythbusters: The One about Peds in the Summer

THE STORY:

Pediatrics is known to be a very germy rotation. Somehow, those irresistibly adorable mini hands and feet are gateways to cesspools swirling with bacteria and viruses just itching to make a home in your nice, warm, moist oral mucosa. In a lot of ways, Pixar said it best:

However, they say that the brunt of the force can be avoided if you are lucky enough to complete this clerkship during the summer.  After all, most illnesses are not as prevalent during the summer, and there’s no school to facilitate germ swaps. I was assured that most of the patients I’d be seeing would have asthma or broken bones… ailments that are not contagious.

And let’s be serious: I’m a terrible sick person (read: incessantly whiny, yet still insistant on carrying out all of my daily activities) and I really don’t care to have my education mottled by nasty GI symptoms. So at the end of the day, I was grateful to be assigned to Peds for July/August.

The Experiment

I spent my first week of clerkship in the pediatric emergency department, spending 8 hours a day each weekday seeing patients since last Wednesday. Sure, I saw my fair share of crooked arms and motor vehicle accidents. But no asthma, and plenty of stomach bugs, fevers of unknown origins, and Coxsackievirus with its skin rash and throat lesions and vomiting. But I carried out my physical exams and then drowned my hands in Purell every single time, sometimes more than once. Surely, these viruses would be no match for my decades-old trained immune system AND obsessive-compulsive handwashing, right?

Wrong.

The Evidence:

Woke up yesterday with a mild sore throat. Shrugged it off. Probably just dry; it’s hard to stay hydrated when you’re on your feet all day running in and out of the various rooms in the ED.

But when I got home, I had that hot-and-sweaty-but-cold, all-over-achy feeling. And my throat felt like tiny evil pixies with daggers were stabbing it with every single swallow, regardless of my combination dose of 800 mg ibuprofen and 625 mg tylenol. Not to mention, it looked like this:

Tonsils are absolutely NOT supposed to look like this.

Yes, I did photograph my own tonsils. Is anyone actually surprised?

Between my inability to hydrate (swallowing legitimately brought tears to my eyes for a while), fever, sleepless night, and blatant need for a rapid strep test, I moved my final ED shift to this weekend and spent my day resting and seeing my own doctor (though realistically I could have written my own history and I’d basically done my own physical…). And, because I couldn’t resist, studying. No amount of gross goopy whiteness in my throat can knock the medical student out of me (a friend had to argue with me before I agreed to ask for the day off).

Regardless, one thing is clear: completing your pediatrics clerkship in the summer absolutely DOES NOT save you from the small child plague. Even if you only see bike accidents and dog bites, those tiny sticky hands and smile-inducing mini shoes and snot-dripping noses will hunt you down and attack every time.

MYTH BUSTED.

Actual blog post to come when I’m feeling more myself. Although I kind of like the concept of medical school mythbusters. Anyone have another one they’d like me to tackle? Let me know!

K

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The One After OB/GYN

Third year of medical school is kind of like getting thrown into a pool. Only you’ve spent two years memorizing every single method that you could use to swim, and all the things that could go wrong when you try to swim, and all the chemicals you could add to the water, and all the approaches you can use to jump.

Except that all of the memorizing and analyzing and studying in the world can’t possibly prepare you for that moment you hit the water, when the cold makes your breath stop and your limbs flail wildly just for a split second until you’ve righted yourself in the water and your body acknowledges that it did not just die. But I guess that’s what third year’s all about: jumping into the pool, over and over and over, and they’re just watching to see how well you sink or swim.

And of course, I was convinced that my efforts were going to result in something along these lines:

Third year requires being prepared to do this on a daily basis

But somehow, I survived OB/GYN, and my first rotation is under my belt. It’s actually kind of crazy how quickly you learn to adapt. And admittedly, there were nights were I came home and pulled one of these:

…sometimes, if I was lucky, I’d manage to scarf down about 5 Oreos for dinner before my head hit the pillow.

Anyway, basic final thoughts on OB/GYN:

-Thought I would hate it. Couldn’t imagine possibly dedicating six weeks to lady parts. But I loved it. I loved working with women; I loved participating in delivering new life; I love that it’s a doctor’s appointment that most women will attend consistently so that it builds continuity.

-I’m recognizing that I want a specialty with a lot of patient interaction. I want to know my patients, I want to be there with them through the course of an entire problem. I’d LOVE to follow through with my depressed patient from a few weeks ago; I wish I was in a position where I could.

-Third year is SO much better than second year. I’m not meant to be trapped at a desk all day, although time management skills are a must, because the SHELF exam was scary. Although there’s a part of me that’s convinced I would not have ever studied the topics on the exam even if I had spent more time, so maybe it’s just a product of lacking the knowledge base from other blocks.

-OB/GYN is a really awesome mix of medicine and surgery, but a very specialized knowledge base, which is what makes it a stellar first block and an attractive career option. You learn some medicine and surgical skills, but you’re not cramming endless amounts of information into your brain.

-My vasovagal response is still in tact: managed to ALMOST pass out in my first Caesarian section, but I did the responsible thing and stepped out and discovered I really do get THAT pale when it happens. The bright side? It only happened that once, so maybe I can be a surgeon. Maybe.

-Newsflash: working in OB does NOT necessarily mean your life is controlled by unborn children. You just have to be okay with letting your partners deliver your patients when you’re not on scheduled call.

-I managed to gain weight on this rotation. That’s what happens when you have second breakfast because you woke up at 4 AM but can’t survive your morning clinic without something extra, and you get home so tired you can’t exercise. Diet and exercise in medical school is an art form.

-OB/GYNs have a terrible reputation. I must say, at my hospital, I did not meet a single doctor who fit the total Type A super-bitch mold.

Top Five Things I Never Said/Heard Until OB/GYN:

  1. I get to sleep in until 6 AM tomorrow!
  2. My shoulder is killing me from driving that uterus all day.
  3. I’m about to scrub in on a vaginal hysterectomy. Except she had a total abdominal hysterectomy in 2010.
  4. Ugh, I hate when there are no patients; why are there not more vaginas to examine?
  5. Okay, so now that you’re on two step stools, reach over and hold this retractor with your third hand.

And with that, on to Pediatrics!

K

The One with the Rule Out Ectopic

I’d never seen a patient in that much pain.  Not even in labor and delivery.

And though I’m a little ashamed to admit it, my initial reaction was to hug the wall, allowing the fully trained physicians and nurses attend her needs while I watched the shaking, the sweating, the whimpering from the periphery, the typical home of a clueless third year medical student.

I guess I need to recap a little.

I wasn’t there when she initially came in to the emergency department with lower abdominal pain and a positive pregnancy test, the kind of patient considered  an ectopic pregnancy until proven otherwise, solely because the danger of leaving a pregnancy in the Fallopian tube is so incredibly high. Unfortunately, at just a few weeks along, it was too early to observe any signs of pregnancy in her uterus on ultrasound, but there are a few other methods for diagnosis. One sounds a little bit bizarre: in women with unwanted pregnancies, one option is to carry out a dilation and curettage, the procedure used for surgical terminations. The pathologists examine the collected tissue, and if they can find the products of conception, the tissue from the fetus, then you can rest assured the pregnancy was not ectopic.

Ultimately, at that time, it was decided that this was the best option for her, and she was scheduled to come back in the morning.

The next morning, she was having doubts. One of the residents and I trekked up to the procedure unit to chat, my resident reminding me that if there is any doubt about wanting the pregnancy, then we should not do the procedure.

We explained the risks of an ectopic pregnancy. We explained the concept of the D&C and how it was absolutely NOT the only option. We re-explained everything to her worried husband. We left the room while they tearfully discussed their options.

When we re-entered, he spoke first: “She wants the procedure.”

Eyes locked on him, she nodded slowly, tentatively, assuring us she was 100% sure when prompted. I wasn’t convinced, but the consents were signed.

Later, at her scheduled procedure, her little discomfort had blossomed into full blown pain attacks. The doctors tried once more to locate the pregnancy on ultrasound; she wailed and writhed in pain, begging for medication. By this time, I’ve jumped in to grab her hand and encourage her to take deep breaths

They gave her the usual sedation for the procedure. Anesthesia’s a funny thing sometimes, and this time, it opened the floodgates.  She started bawling, telling me how she’s so upset that her husband talked her into this procedure and she’s going to be such a terrible mother because she couldn’t even risk her own life to try and save the child. Tears and words and sobs poured out, and I tried desperately to console her, completely ignoring the procedure happening toward the other end of the bed.

At one point, I even stopped and asked the attending if it was okay to proceed with everything when she so clearly didn’t want to, but unfortunately, informed consent does not extend to patients under sedation, so we had to follow her previously stated wishes.

However, her pain intensified to the point we were concerned for rupture, so we rushed to the emergency room for exploratory surgery, where we inserted the laparoscopic camera to find… nothing. No rupture. No inflamed tube. No blood. Nothing.

I figured that was it; I was a little taken aback when they then proceeded with the D&C anyway. She had been coherent in the interim between procedures; I’d had extensive conversation with her to calm her down and encourage her not to let this horrible experience ruin her whole summer. I didn’t quite understand why no one had double-checked that she still wanted the procedure if we didn’t find clear evidence of ectopic, but again, the physicians proceeded with previously stated wishes.

She woke up asking for her baby, over and over. It was easily the most heartbreaking moment I have ever seen in my entire life.

*************

The intern on this case with me actually went and told the clerkship director she was impressed with the way I stepped in to be the patient’s support. That she didn’t think she could have done that as a third year medical student. That it was exactly what the patient needed, and I did it without hesitation.

While I’m incredibly grateful for the recognition and assurance that I’m doing my job well, it’s a little unsettling to me that this isn’t the norm.

Why is it commendable to see a patient on the worst day of her life and hold her hand and listen to her? I don’t think it even crossed my mind to do anything otherwise… it just makes me a little uneasy that it was such a big deal, that perhaps others wouldn’t do the same.

I guess the oath tells us to “do no harm.” Maybe we all just need a reminder that we should also strive to be there for our patients, and to do good.

The One with the USMLE Results

You’d think after 6 weeks on the wards, it’d take a whole lot more than a slowly loading website to bring my heart into my throat.

And any other day, that’d be true. But today? Today is July 11, 2012: the day I finally received my long awaited USMLE (read: boards) score after nearly two months of anxious anticipation.

For those who haven’t kept up with me in the past couple of months, the month of intensive boards study period was by far my least favorite few weeks of medical school. The preceding few months I’d been tried with a variety of personal life stressors that certainly did nothing to help matters, but I honestly think I would have hated that month regardless. I holed myself up in a study room for 12 hours at a time day after day for a month, working through hundreds of multiple choice questions and poring over thousands of pages of text in preparation for what basically amounts to an eight hour final examination for the first two years of medical school. I’d be lying if I said I never had days where I wondered why I thought medicine was a good idea in the first place, and I was convinced that if I failed I’d just self implode. Except in reality, I’d do it all again without hesitation to get to third year… I’m totally enamored with life as a third year medical student.

Anyway, to any of you who’ve come across my blog hoping for guidance in your own Step 1 endeavors, I’m not sure I’m one to be trusted in terms of how to prepare. I can tell you I dedicated most of my time to USMLE World QBank questions; I found I learned best by using tutor mode to do questions sorted into categorical blocks and annotating the answers in my First Aid, and that’s pretty much all I did. Occasionally I supplemented with another book or two (like Clinical Microbio Made Ridiciulously Simple… because it made me laugh), and my iPod was set to play nothing but Goljan audio pathology lectures for a solid three months before the exam. And well, I guess it all worked out just fine.

Because this morning, I joined nearly every rising third year medical student in the nation in incessantly pressing the refresh button for hours, groaning as time after time these efforts were answered with error messages. Until suddenly, it loaded, and out came the breath I had no idea I was holding.

I passed.

…I passed! It’s over! I never have to take that god awful exam EVER again. And while I’m no shoe-in for the #1 dermatology residency program in the country (which is perfectly fine by me), it’s over.

See ya never, USMLE Step 1. It’s onward and upward for this girl.

Until then,

K

The One Where Antibiotics Weren’t Enough

Looking for a narrative today? I can do that. For you.

*********

            She looks less than thrilled to see me when I enter the room, and begins to stammer when I ask why she’s here.  I’m immediately concerned that this is going to be a difficult interview, with confusing information and an uncooperative patient.

“I’m not sure how I’m supposed to say this,” she tells me flatly. “It’s hard to tell people all your business.”

“Honestly, I’ve heard it all at this point,” I assure her. “Just get it out however is easiest for you.”

For a second, her flat affect lifts as she lets out a nervous giggle that folds her small frame in half. She slowly begins to describe her symptoms. Nothing out of the ordinary, really, just your run-of-the-mill urinary tract infection symptoms.  I proceed through my usual string of questions, teasing out her current symptoms and past medical history and medications.

“Oh,” she adds quietly at the end. “I think I smell. Everyone notices. It’s embarrassing.”

This takes minute to register. Mostly because, well, she doesn’t smell, and as she elaborates, I begin to realize that antibiotics won’t even begin to get to the root of this woman’s real problems.

“It’s okay, though,” she assures me. “I’m a big girl.”

I ask her to explain. And then, I listen. I listen about how she isn’t sure what smell they’re talking about, but she lost all of her friends. No, really, she just lives alone and doesn’t leave the house unless she absolutely has to. No, there’s no family or friends in this area and there’s no one she calls for support. She doesn’t pursue any hobbies she enjoys anymore. She’s stopped going to church because she’s self-conscious, even though she’s devoutly Christian. She’s afraid to go to the grocery store because she feels judged, so sometimes she just doesn’t eat. In fact, she’s lost 20 pounds these days, but maybe it’s just because she’s been walking a lot.

Her eyes get misty at this point. “I don’t want to cry,” she insists. “I’m a big girl.”

“It’s okay,” I tell her, softly resting my hand on her arm. “Sometimes it takes a stronger girl to recognize when it’s time to get some help.”

*******

In the end, I spend nearly an hour listening to this woman in what was meant to be an acute care appointment. I make her a referral to primary care and beg her to attend in hopes that they would refer her to mental health, a referral that I can’t make directly from my clinic because of insurance mumbo-jumbo.

“Please go. You don’t have to deal with this by yourself. And you shouldn’t. You deserve so much better than this,” I plead.

Her brown eyes gleam with tears once more. “Okay,” she concedes. “I’ll go. I promise. You’ve been such a good listener. Thank you so much for caring.”

Content with my small victory, I offer her one last treatment: “Would it be okay if I gave you a hug?”

For the first time, her face lights up.

And for the first time since starting this rotation, I recognize the importance of just listening, and enjoy the unbelievable feeling of knowing I may have actually made a difference.

The One with OB/GYN

I’ve been on OB/GYN for five weeks now. It feels like I’ve been doing this forever, but at the same time, like it’s barely been a day and I haven’t possibly learned enough to be one week from done.

I think that’s par for the course on this one though, because if I could describe OB/GYN in one word, it’s contrast.

It’s the silent tears of joy on a mother’s face as her newborn lets out his first cry, and it’s the wails of despair of the mother who came in for her scheduled C section to discover her baby no longer had a heart beat.

It’s holding a mother’s hand as she gives that final push, and it’s holding the sobbing teenager’s hand as she prepares to terminate her pregnancy.

It’s counseling a young woman about her birth control options, and it’s explaining to the newlywed couple how to prepare for pregnancy.

It’s the gross smells and excruciating pain and bloody vaginal lacerations of labor, and it’s the beauty of new life entering the world.

It’s pointing out her baby’s wildly beating heart on prenatal ultrasound, and it’s showing her the scan that shows the ovarian tumor that will probably kill her.

From a more medical perspective, it’s the medicine of evaluating vaginitis and screening for cervical cancer, and it’s the careful surgery of a laparoscopic hysterectomy or tubal ligation.

It’s acute care for vaginitis, and it’s chronic care for ongoing pelvic pain.

Perhaps the biggest contrast of all: it’s entering the rotation convinced that you’ll never live a life looking into vaginas and allowing unborn children to make your schedule, and it’s finishing the rotation realizing that so many things about OB/GYN are exactly what you want from your career.

The One with the Intro

So… you found my blog. And I’m guessing you’ve got a few questions. Well, turns out, I’ve got a few answers.

1. Who are you anyway?

Well, I’m K. I am a third year medical student as of June working in an urban hospital in the USA and absolutely loving it. I also happen to have a soft spot for the Pittsburgh Penguins, Modern Family, frozen yogurt, having solo dance parties to 90’s music, and getting absurdly excited over the concept of glowing green kittens.

No, but really. Isn’t this adorable? (From Google Images)

2. Why are you writing this blog anyway?

My reasons are twofold: first, to keep up with family and friends, who have been amazingly supportive and who have every right to know what I’ve been up to while their emails, voice mails, and texts have accumulated unanswered. Second, I’ve found I have a lot to say about medicine, about patient encounters, and about life in general. If this serves any purpose to anyone else, whether it be entertainment, food for thought, or help navigating medical school, I’m so excited to have it do so. In the meantime, I get to combine two of the things I love: writing and medicine/helping people.

3. Why is this anonymous? Why can’t I know your name or where you are?

Because I’m a ninja.

Okay, so that and two other reasons. First is for the privacy of all involved. We all know about HIPAA, and though I don’t plan on saying anything that would violate any patient, provider, or otherwise, I would like to maintain as much distance from myself and my hospital as possible. Second, I want to remind everyone that medicine is universal. My experiences could happen anywhere, to anyone.

4. What’s your favorite ice cream flavor?

Hah, now that’s a more complicated question than you would think. I’m always down for a soft-serve twist with rainbow sprinkles. But if we’re talking hard ice cream? Mint Oreo.

5. Can I ask you questions about medical school? Or life?

I can’t profess to know everything about life, so it’s your prerogative to trust me on that front. But med school… that I can help with. Get at me at: isandosblog@gmail.com

6. What’s your blog name about?

Well, I/O stands for Ins and Outs, which is one of the most important factors to consider in a postoperative patient. Now, I have no real emotional tie to urine output, but I wanted a simple name that tied into medicine but also to the concept of this blog. Thus, I’s & O’s: The Ins and Outs of Life, Medicine, and This Girl’s Wandering Mind.

7. Wait… I’ve seen your title format before…

Yes. Yes, you have. All my thanks and love to the creators of Friends, the television show that’s been my procrastination tool of choice for much of my short medical career.

8. My sister/brother/cousin/mother/lawyer/neighbor has this weird pain on the left side of the elbow, but only on Tuesdays after eating tacos. Can you help me?

Oh, honey. Take two pills and call a REAL doctor.

And that’s that. Got more questions? Comment away!

Until then,

K