The One With the Bag Full of Pills

“Well, let me tackle the most important thing first. Dr. Family really wants me to figure out what medications you’re on, Ms. Smith, since we weren’t so sure during your last visit,” I explain, settling into a Lazy-Boy recliner situated near the 89 year old woman’s end of the couch. My preceptor had asked me to focus my mandatory geriatric home visit on reconciling the medication regimen of this patient.

Overhearing me, Ms. Smith’s 63 year old daughter emerges from the kitchen to drop two gallon-sized Ziplocs and a weekly pill organizer into my lap before immersing herself back into baking what smells to be apple pie.

I glance down at the bags and struggle to hold in my reaction. One bag is simply a collection of appropriately labeled prescription bottles. The other, however, looks similar to this:“Ms. Smith, do you know what these pills are?” I ask, holding up the bag. Please tell me you don’t take anything out of this mess, I think to myself. My mind wanders to a story my preceptor told me of a woman who would toss all of her medications into one bag and take a handful each morning.

Her blue eyes, blurred by a recent stroke, squint to make out what I’m holding. “Oh, no, dear. That’s why they’re all in there. I don’t think I take any of those.”

“You don’t think you take them?” I prompt.

“No. But my daughter puts my meds out for me. I can’t see all those tiny little pills.” There’s a touch of frustration in her voice. Eighty-nine years of life and several mini strokes had robbed the frail woman of her strength and independence.

I make a mental note to ask the daughter about the hodgepodge of pills and shift my attention to the prescription bottles. I pull them out one-by-one, each time looking to Ms. Smith for confirmation that she takes this medication as prescribed, and she responds each time with a nod.

“How about aspirin? It’s the one to help keep your blood from clotting up and giving you another stroke.” I hold up the bottle.

“Oh, no, I don’t take that stuff. I don’t need thin blood!” Her arms fold across her tiny chest; an act of defiance that exerts some control over her life.

“I see. But what if it’s just thin enough to help you avoid strokes?”

She gazes back at me unconvinced. “I think I’d rather have a stroke.”

“Can we compromise? These are big aspirins, but maybe you can try just a baby aspirin?” I’m tossing out a lifeline. Changing medication doses isn’t exactly within my job description, but I figure my preceptor will agree that any aspirin is better than none in this patient.

She allows me a slight smile. “Okay. I guess that would be all right.”

I smile back, satisfied with my small victory. “What about your sleeping pill? Are you using that each night?”

Ms. Smith shakes her head. “Oh, no. I never take my sleeping pills these days. I’m always sleepy enough.”

I decide to open the bottle to take a look at the pills inside and compare them to the pills sorted into her weekly medication box. I immediately discover a matching white tab in one of the PM slots, but subsequently locate it in almost every AM box as well.

“Ms. Smith, you’re taking these twice a day every day! No wonder you’re sleepy!”

She shrugs her shoulders and laughs. “Oh. How silly. I guess that explains things.”

I start opening the other bottles and comparing the placement of the pills into the pill box with the prescribed dosing. In each bottle, I notice a few rogue pills hiding among the uniformed tabs that I assume are meant to be in that bottle. Where do these other pills come from? I debate.

And then I open her hydralazine bottle. Though I know this to be a blood pressure medication, I find a bottle stuffed with the exact same white pills I’d found in the sleeping pill bottle.

Crap. This cannot be good.

Thankfully, I’m learning to practice in the age of Google, and what would once have required scouring a thick text full of pages and pages of pill images now required simply locating a website on which I could type in “white” “circular” and choose the pill code stamped on top to discover the true identity of the pills.

They are, in fact, hydralazine. Ms. Smith is consuming twice the dose prescribed for her on this medication. Suddenly, her recent history of dizziness makes so much more sense.

“Ms. Smith, I think I know one way to make you better,” I declare, beginning the arduous task of returning the medications to the appropriate bottles.

“Good,” Ms. Smith replies. “Next, I’d really like to be able to see my TV again, okay?”

The One With the Thorax

He peers up at me through crystal blue eyes, hands folded over the posey vest he continues to wear so he can be restrained if he gets agitated like he did last night.

“How are you today, sir?” I begin, pulling up a nearby chair and nodding to his 1:1 sitter that it’s okay to sneak out for some breakfast.

“Pretty good,” he nods, just as he has every other day I’ve asked.

“Can you tell me where we are?” This question is standard in psychiatry, especially when following a patient for delirium.

“Correct City Hospital.”

“Great! And what town is that in?” I add, just to be sure.

“Incorrect City.”

I pause and look at him, waiting to see if he’ll correct himself. He doesn’t.

“No, Correct City Hospital is in Correct City.”

“They’re all the same in a snowstorm,” he declares, tossing up his hands. “You just see if you care which one you’re in in six feet of snow.”

Well, hard to argue with that, I guess.

“Do you know what the date is today?”

“Aww man…” he groans, wrinkling his nose.

“I know, you hate this part. But it’s really important for me to track how you’re doing!”

“I think it’s November. Maybe the 2nd?” he says, mostly questioning.

“Not quite. It’s actually still only October. It’s the 10th.”

“Ugh. I swear the government keeps sneaking in extra days.” He shoots a glare at the presidential election coverage on television.

“I think it’s more that staying in the hospital this long is pretty confusing.” I offer.

At this point, I reach for a paper in my pocket; it’s a cognitive exam known as the MoCA: the Montreal Cognitive Assessment. I decide to start easy and direct his attention to three cartoon drawings on the center of the page.

I point to the first one:

*All of the next three photos are directly from the MoCA and link directly to the assessment

“Camel!” he correctly exclaims.

“Great! And this one?”

“Hippo!”

“I would say rhino, but that’s close. And this last one?”

“That’s a thorax.”

“A what?” I inquire, thinking I must have heard him incorrectly.

“A thorax.”

“A thorax?”

“Yes.”

Pause. “Sir, I think that’s a lion.”

He glares at me, and we argue for a moment before he agrees that it’s a lion and we move through the rest of the assessment. He continues to do incredibly well at some parts and poorly at others. The brain, especially the hospitalized, recovering-from-surgery-and-infection-and-sedation brain, does some pretty incredible things.

————————-

“Hi! How are you?” I begin again the following morning.

“Pretty good. Hey, did you bring that animal sheet back? Or a new one with a dragon or a deer?”

“Not today, sir. Do you remember what was on it?”

“Yep. There was a camel. And maybe a rabbit and a frog.”

“You got one of them right.”

“Oh, and a lion. We fought about that. I thought it was a sign of the Florentine Zodiac.”

I stop, willing myself not to let my jaw drop, shocked that he remembers our argument. I’m suddenly hopeful that he’s turned the corner into recovery.

“Sir, how was your night last night?”

“Good. Except for when I tripped over lawn chairs and the painters woke me up.”

I sighed. It was going to be another few days.

Top Ten Things That Have Helped Me Survive Psychiatry

Because honestly, psychiatry really doesn’t seem to be my thing (and I have nothing but respect for the people that take it on).

1. Tea
What I’m about to reveal may shock you: I have survived medical school on little to no caffeine.
I never even touched coffee or tea through first year. My maximum caffeine consumption was when I drank one iced french vanilla coffee each morning during intensive study period for Step 1. Since third year has started, I’ve had the occasional coffee here and there, but it wasn’t until I felt the beginnings of a cold that I began to truly appreciate tea. And now, “running the list” would not be the same without my morning tea.
2. Spaghetti Squash

Mmmmm!

I’m pretty much the ONLY medical student who managed to gain weight on OB/GYN and Pediatrics rotations. I blame “second breakfast,” a phenomenon in which a medical student eats at 4 AM upon awakening and is therefore ravenous by 9 AM. In an attempt to maintain a frame that fits into my dress clothes (because student loans simply do not cover new ones), I’ve taken to “eating healthy.” Nothing crazy or super specific, just less dessert and bread and more fruits and vegetables, including substituting the typical quick pasta meal with spaghetti squash. This week, I’m planning to make it with pesto. Win.
 
3. The New Normal
This new NBC comedy is basically the first show since Modern Family to make me laugh out loud. It’s about a gay couple, their surrogate mother, and her racist, homophobic grandmother. It’s absolutely hilarious (minus part of one episode in which the couple deals with getting insulted in public, which made me really want to hug my gay best friend).  I burned through all six episodes in a matter of two evenings, though had I started them earlier on the first evening, they wouldn’t have even lasted that long.
 
4. Apple picking. And copious apple consumption thereafter. 
Okay, so really, this one’s all about the apple cider donuts. It’s tied with “all things pumpkin” for “Highlight of Fall.”
 
5. Liver Rounds. 
I recently ran into some classmates on the opposite rotation schedule and was invited to join them for “Liver Rounds” on Fridays; basically the nerdy medical student version of Happy Hour. It’s been so nice to catch up with old friends, exchange stories from the ward, and collect advice on how to approach the ever-intimidating Medicine and Surgery blocks.
 
6. College Hockey.
In an NHL-lockout world, a hockey fan’s gotta take what she can gets.
 
7. Murder Mystery Birthday Parties.

Solving Murders at the Juice Joint!

I’ve had the honor of attending a string of birthday parties in the past couple weeks, but my favorite by far was a murder mystery party with friends from college. It was set in a 1920’s Speakeasy, and I got to dress up like a flapper and play the bold, catty cigarette girl and trade insults with my character’s arch-nemesis. I must admit, I failed at solving the crime (though I would argue it was due to some excellent framing on the part of the guilty party), but it was so much fun and so different from the standard house party.
 
8. Frozen Yogurt.

Pumpkin Pie Froyo with Graham Cracker, Cinnamon Pecans, and Coconut. SO. MUCH. WIN.

This is my indulgence among my “healthy eating,” partially because I absolutely love it, and partially because I typically use it as a means to catch up with one of my closest friends in my class. We’ve gotten pretty good at knowing what flavors are available and planning our trips to coincide with our favorites.
 
9. Great colleagues. 
I lucked out in that I have some awesome classmates on my rotation with me that help to keep me sane and help me to make the most of the rotation. My personal favorite moment, however, had to be on rounds one day when the attending was speaking in a hushed voice to the nurse, and “Call Me Maybe” was playing in the nurses’ station. Without a word, three of us started an impromptu dance party.
Okay, so maybe that story is a had-to-be-there moment, but it’s hands down the best moment I’ve ever had on rounds.
 
10. Amazing friends.
I’m so lucky to have the support of so many amazing people that make the insanities of medical school (and psychiatry rotation) bearable. This past week, I got to catch up with an old friend who I haven’t heard from in a year, my roommate’s birthday served as a reunion with my closest friends’ from school, and I got to spend time with several other friends from college.

The One with the Important Lesson from Psych Orientation

Psych’s been a whirlwind so far. I’m adjusting to life without three day weekends, as well as life on a consult service at a busy urban hospital. I’m not sure a career in psychiatry is in my future, but it’s been a good lesson in understanding how to approach different types of people.

Orientation for this rotation was a brief two hour session that featured a lot of role-play to help my classmates and me prepare for interactions with patients that are flirtatious or psychotic or suicidal.

The most memorable line?

“Sir, I’m sorry, but in our society, you just can’t run around naked in the streets. Because if you do, a little kid might see you, and well… you can… RUIN HIS LIFE!”

The One with the Family Med Recap

The past six weeks have absolutely flown by, though arguably not as quickly as my recent three day “golden weekend,” which included catching up on television, exchanging stories with classmates on other rotations, and apple picking with friends from college. Regardless, I am finished with family medicine, and for my sake (and yours), it’s time to summarize my thoughts on the rotation (even though I still have a few family med stories to blog about in days to come).

First things first: I loved this rotation. But I suppose there’s a caveat to that: I had the best preceptor I could possibly ask for, and she really felt like she could be me in twenty years. She graduated from the same med school, shares my love for ice hockey and trying new recipes, juggles ridiculous numbers of side projects that include medical advocacy (one of my passions), and even shares my lightning multiple choice test taking speed. We occasionally would stay later than we intended, just chatting about life. As a former educator, she was a fantastic teacher of medicine, but she also taught me lifestyle tips, both for my career and life in general (like putting your kids to sleep in their clothes to save the morning battles… brilliant!).

Add in the fact that I never had to work Fridays and I felt like I had won the family medicine lottery. So, of course I loved this rotation. How could I not?

The question becomes: “Could I do family medicine as a career?”

My immediate answer? Maybe.

I always knew I liked working with kids. But this rotation, I realized I really enjoy working with the adult and geriatric populations as well. At this point, I can’t imagine not seeing one of those populations for the rest of my career, so FM is a logical choice to provide balance.

But realistically, the things that draw me to family medicine would be factors of primary care in general:

-I’m good at planning and coordinating; primary care physicians are often the quarterbacks of a patient’s medical team, making sure consults communicate appropriately and that all bases are covered.

-I enjoy the breadth of diagnoses that walk through the door; in one day of Family Med, you can see prenatal care, followed by hypertension follow-up, followed by a well child check, followed by new onset chest pain.

-Primary care docs are constantly being challenged by a new presentation, but if it’s really complicated, they can phone friends from any number of medical specialties.

-Primary care allows you to get to know your patients (and potentially their families) really well. (If my patients love me half as much as my preceptor’s love her, I’ll call that a success.) These relationships potentially will facilitate medical advocacy work, which I would really like to incorporate in my career.

-At this point in my short clinical career, acutely/severely ill patients make me REALLY nervous. I’m sure this will improve as time goes on, but for now, I feel much more at home in an outpatient setting.

But Family Med has its cons as well. One of the biggest for me is that it’s very limited in terms of specialties, and it’s really easy to burn out in primary care. It’s frustrating to see a patient with a BMI of 70 and know that they’re slowly killing themselves, but they won’t take their medications or change their diets.  That fact pushes me away from family medicine and more towards Medicine/Pediatrics solely because you can subsequently specialize; I really would like to know I have an out if I need a change.

It also has the potential to get boring. One day, I saw about 10 follow-up appointments for hypertension. Sure, I enjoyed interacting with the patients, but by the end of the day, I didn’t care if I ever had to take another blood pressure again.

At the end of the day, this rotation has done one thing: taken a career pathway that was not even on my radar and placed it at the top of my mind.

And now I’m on to psych. Which is also not on my radar, but talk to me in a couple weeks and see where I stand. Most likely, I’ll be the one hovering outside the patient’s door, reminding myself that they’re “crazy”, not me.

The One with the Catch-22

“It’s child abuse!” one of my classmates declared, tossing his hands up in the air.

I winced.

“I disagree,” I insisted, gently rocking the baby who’d been wailing inconsolably for the past ten minutes.

The beautiful, redheaded baby girl was detoxing from methadone, a medication used to wean opiate addicts away from their addiction. Her mother, a former heroin addict, had switched to methadone the moment she learned she was pregnant.

———–

Methadone is a narcotic, but it simultaneously prevents opiate withdrawal symptoms and blocks the euphoric effects of other narcotics, like heroin or morphine. It’s a prescribed, controlled substance given to patients who need to be weaned away from an opiate addiction. Though my patient’s mother was addicted to illegal drugs, it’s not uncommon to find patients who require methadone for something like an addiction to Percocet taken for chronic back pain. Regardless of the addiction source, a prescription for methadone is like the promise of a new horizon. It’s a medication sought by individuals who want to change their ways.

As a student at an urban hospital, I saw a fair number of pregnant former drug addicts who had sought out a methadone prescription, intending to straighten their lives out for the new babies. There is not a whole lot of data on using narcotics in pregnancy, but one of my preceptors reasoned that it’s preferable to keep the mother on a controlled, monitored dose while keeping a close eye on baby’s progress than to have her shooting up heroin in a back alley.

However, methadone use is still controversial. The babies are still born addicted to narcotics, and spend their first few weeks having withdrawal symptoms. They’re fussy and inconsolable. They have tremors and diarrhea. They’re easily startled and basically miserable.

So why not have mom go cold turkey and prevent all of this? Because if she cuts off the opiates completely, the baby will withdraw in utero, and we’d have no way to monitor it. Instead, at least, at my hospital, the mother is followed by a special clinic that monitors the methadone dose and obtains frequent urine toxicology screens to ensure compliance.

A common sentiment, however, is that expressed by my classmate: the belief that these women are clearly abusing their child via the narcotics they’re taking in during pregnancy. Child Services inevitably get involved with these cases, and this article details a situation in which a woman is denigrated by her surgeons and her child is eventually placed in foster case. Essentially, she is punished for seeking treatment for her problem.

While I absolutely do not condone drug use in pregnancy (or ever), I absolutely support any woman who seeks to make the right choices and get help for her addiction in light of her new pregnancy. Though I acknowledge there is a risk for relapse, I would argue that one of the most important factors in the mother’s success will be the support of her health care provider and the responsibility of caring for a newborn.

Here’s hoping physicians will learn to support and encourage these mothers as they endeavor to fight addiction AND raise a new child.

———-

I stepped into the hallway and raised one fist, poised to knock on an exam room door.

“Hey, I remember you. You’re from the hospital!”

I paused and looked down the hall. It was the mother and redheaded baby girl who I had taken care of during my pediatrics rotation.

“How ARE you?!” I gushed, taking that beautiful baby into my arms.

Her precious smile said it all.

20 Ways to Know You’re a Medical Student

It’s October. I can’t believe how quickly time flies. But it’s also Monday, which means it’s time for another Medical Monday Bloghop! For those of you who found me on the bloghop, welcome! To those of you interested in listing your own blog or exploring other medical blogs, hop on over to From a Doctor’s Wife or Your Doctor’s Wife to join in the fun!

In the spirit of Medical Mondays and exploring medical blogs, I thought it fitting to compile a list (likely the first of many installations) of ways to know you’re a medical student. Without further ado, you know you’re a medical student when…

1. You celebrate the one day a week when you get to “sleep in” until 6:30 AM.

2. You’ve turned down invitations to go out on the weekend with your “real people with real job” friends, but party on Monday after your anatomy exam.

3. You struggle to smalltalk with your friends of friends but have no trouble asking a total stranger about their bowel habits.

4. You automatically tell your young adult male friend that his chronic lower back pain must be ankylosing spondylitis.

5. You find out you were right.

6. People have switched tables at a coffee shop after overhearing your discussion with a classmate about the concept of using Vitamin C and parsley to terminate a pregnancy.

7. You anxiously await your “Golden Weekend,” which you spend sleeping, exercising, and doing the dishes and laundry that have piled up in the last week.

8. You wake up with a crick in your neck and immediately convince yourself it’s the beginnings of nuchal rigidity because you clearly have meningitis.

9. You willingly volunteer to let a classmate attempt his first ever IV placement on you solely because you want to do it on him afterward.

Oooh! Oooh! Oooh! ME ME ME!

10. Roast beef will never look the same after anatomy. Neither will cheese.

11. You’ve spent the entirety of a very awkward manicure discussing your experiences dissecting a dead body with the Asian man who can’t seem to understand how you tolerated the experience.

12. You carry Tupperware in your bag, “just in case” you come across any free food.

13. You spend hours counseling your patients on the importance of a healthy diet, and then scurry off to purchase your chicken fingers and french fries in the few minutes between AM and PM clinic.

14. You pay a ridiculously high tuition to have the opportunity to wake up at all hours of the morning and spend 14 hour days on your feet getting yelled at and puked on.

15. Strangers on the bus have used your Netter’s flashcards to start conversations with you.

16. You have a pager. And it’s not even a text pager. Welcome to the 90’s.

17. You’ve nearly been bitten by an overdramatic “psychotic” classmate during a demonstration on using four point restraints.

18. You get ridiculously excited when you realize that you can eat all of the hospital vanilla ice cream cups you want.

19. You’re super pumped when you receive a 71% on your exam. P = MD!

Thanks for the tip, Amazon, I think I will.

20. You pull your first all-nighter. The result? You deliver 4 babies. Win.

Happy Monday, everyone!