And so it ends

The next time I introduce myself to a patient, it will be as "doctor." Today was my last clinical day for the rest of my medical school career. And so Mr. Jefferson, who is in his 20s and just discovered he suffers from narcolepsy and sleep paralysis, will be the last patient to have heard me introduced as "a medical student in here today."

I was trying, on my drive home after my shift, to remember the first patient I saw in the hospital, just for comparison. But I can't remember him well. I do remember he was an elderly gentleman, with heart failure and a body suggesting no immediate danger of starvation, but I can't place his name.

More instructive, perhaps, is to try and remember how I interacted with him. I can recall my checklist, the 3x5 card crammed with obscure questions I generally forgot. And I also recollect that I had not yet learned the physical exam, so my three quarters of an hour in his room was solely to gather his story.

Most of what I've learned has been piecemeal, I think. Starting back in first year with interviews, progressing to the physical exam, learned in parts with a classmate first, then practiced as a whole on patients, trimmed under the influence of surgery attendings and residents mocking the "medical student exam" for its thoroughness to a cursory affair, lengthened during medicine, and focused when my knowledge expanded sufficiently. I remember first year, picking up a copy of the New England Journal of Medicine, forcing myself to read through an article, understanding half the the words at most. Now I can pick up that same article, and at least understand 95% of the words, usually I can follow the concept, and I'm beginning to think how I would apply that article to my own practice.

Though it is still scary to think of calling myself doctor, to think of being a doctor, to make life and death decisions, it is easier, thinking how far I've come.

The next two months are pretty laid back. A month of reading medical history, and a month of "transition to residency" classes. Then graduation, vacation, and the specter of July 1.

Amy Winehouse - Back to Black

There's a lot to be said for the beer test. As in, which of two people would you rather sit down over a beer with? Certainly this factor played some role in the last American presidential election, though whether of not that was good is completely inseparable from political presuppositions at this point.

But enough about politics. Here's the question for this review: given your choice between the following attractive, brunette, female, Jewish, pop musical stars, who would you rather have a beer with: a)Regina Spektor or b) Amy Winehouse? Now the smart money's on Spektor, because if the British tabloids are to be believed, Winehouse would probably finish off a case, and then belt you over the head with a bottle, just for the hell of it.

But to make judgements on such grounds is not always the best course of action. And just listening to this latest offering from Winehouse is enough to make me want to write a review of it. It's the sort of music that makes me want to use trite music review words, like "rollicking" and "infectious." But I'll refrain.

The music is obviously influenced by Ray Charles and his contemporaries, that era where jazz could still be heard beneath the rock. But there's a modern edge too. So yes, saxophones, piano, and a nod to Phil Spector on the production, but we've got drum loops too. And her voice is pure soul.

There are on iTunes the "Explicit" and the "Clean" versions of this record, which should tell you something about the lyrics. But either way, when the first words on the album are "they tried to make me go to rehab, an' I said no, no, no" you know this is probably not a girl you take home to mom, no matter how poetic she is. She is poetic though, and clever too, stating in the title track "we only said goodbye with words," implying the end of a relationship that was more. In "I'm no good" she is frank about infidelities of her own.

This is the blues, and Winehouse is writing what she lives. But it's hard not to hum along, and it's that invitation to share in her musical catharsis which makes this a great listen.

More from the ER

I've discovered that some traditional rumors are false. Surgeons are supposed to be very difficult to consult and intimidating to talk to. But I've found that if you know the basics of your patient, and have a legitimate question, they are fine. The tough ones to consult are neurologists, or cardiologists. Surgeons basically want to hear "belly pain, blood in rectum, pulse." Cardiologists want all sorts of labs, and an exquisitely detailed accounting of the nature of chest pain before they deign to descend to the ER. At least in my experience. And this is from someone who wants to do cardiology. And neurologists? Oh, boy.

About ten days ago I consulted neurology for the first time in this hospital. The patient in question was experiencing severe pain in her hands, in a median nerve distribution. The pain had come on quickly, with no inciting event, and my attending and I were at a loss to explain it. She was a bit hyperreflexic on one side, at least in the large tendons, though I didn't check the Babinski reflex. (more on that later) She had no surgeries, no neck pain, no trauma. X-rays showed no fracture. Lab values all normal, except for an elevated ESR. The pain was, in the patient's words, as bad as labor pain. As she was crying and rocking back and forth while cradling her arms, I believed her.

At this point, I wanted to call rheumatology. There was some distal clubbing, and I was ready to start a scleroderma workup, but my attending wanted a neurology consult first. So I called the neurologist, and gave him my presentation.

I got reamed. The neurologist was not, to put it mildly, having a good day. The first words out of his mouth were "tell me a story and get in line." And at every point in my presentation, he either swore under his breath, or rattled off lists of obscure eponymous neurological tests that I should have performed. When I stated that the patient was bit hyperreflexic, but that I hadn't checked her Babinski, he reached boiling point. He spat something about "this case being completely inappropriate for an ER consult," and then got very silent. I finished my presentation quickly and asked if he had any questions, and received the reply "nothing pertinent!" When he got into the ER (seven hours later), he didn't speak a word, even to the attending, saw the patient, wrote admission orders, and disappeared. I still have no idea what he thought the patient had, and I thought this was one point at which I probably ought not let curiosity guide my actions.

This is my chiefest frustration with emergency room medicine. The concern is, in the words of one of my attendings, "to make sure the patient doesn't have the five worst case scenarios possible with his symptoms." Often, it isn't even that many. Once we rule out the two or three quickly diagnosable possibilities, we move the patient either back to the street or upstairs, where the real problem solving begins.

Obviously, I'm not destined for the ER. Good thing I matched to internal medicine, eh?

Ah, yes, Match Day

I was hired by my first choice residency program. Much exultation occuring here today. Even the crazy patients in the ER can't dampen this mood.

The truth is out there

Tonight I had a patient who told us all he had Morgellons disease, a completely factitious disorder in which the patient has sores on his body from which he believes "fibers" can be extracted. These can vary in type, depending on the patient, with some believing they are organic fibre (cotton, etc) others believing they are actual worms. Apparently, some patients pull tiny bits of their own bodies out (muscle, nerve, connective tissue, etc.) in the desperate attempt to remove these foreign bodies. Some of the literature refers to a "positive matchbox sign," meaning the patient brings in a matchbox full of fibers he believes he has extracted from his body. Our patient believed he had worms in his body, and was very upset that we didn't believe him.

The difficulty with this disease is that these patients are undoubtably sick. Healthy, sane people, do not tear their own bodies to pieces seeking imaginary worms. There actually is a DSM-IV diagnosis which covers most these patients: under the delusional disorders is delusional parasitosis. Like any delusion, this is a powerfully fixed false belief, and patients refusing to believe they have a psychiatric diagnosis is probably the reason for another term for the condition. At least one article* (of the six total I could find in the medical literature) accepted the name Morgellons disease as a "a rapport-enhancing term for delusions of parasitosis." This article, in the finest rational skeptical language, mentions the fact that "Morgellons disease is not located in modern medical texts or online journals. But a Goggle search will produce approximately 15,400 hits." The author describes a patient he had claiming to have the disease, and mentions that he used the term with her to great effect. He also mentions the hub of the hype, a website which looks very scientific, but which is rather light on evidentiary support. His cautionary closing remarks: "we stress the importance of clarifying to all delusions of parasitosis patients that their condition is not a result of an infectious agent. However, we found the term to be of paramount importance in establishing patient confidence and in developing patient–physician rapport throughout this patient's care."

These patients need psychiatric care, and long term anti-psychotic therapy, but in our patient, we couldn't get him to understand this need. Since we lack inpatient psychiatric capability here, we transferred him to a larger, long term care facility.

So why the alien picture? There are some crazy, crazy theories out there regarding Morgellons disease, revolving around secret government labs and strange escaped biological experiments. And I can see an episode of the X-Files (back in the first few seasons, when it was good) with Scully insisting these patients are psychotic, while Mulder, playing fast and loose with the rules of evidence, agency conduct, etc, sneaks into some Area 51 clone in rural Tennesse, and is captured by a pair of unsmiling guards just short of opening a drawer marked "Top Secret: Morgellons." The truth is out there. Until we find it though, use risperidone.

*J Am Acad Dermatol. 2006 Nov;55(5):913-4.

Ugh...nurses

So today I had a rather poor experience with one of the ER nurses. I grabbed a patient's chart from the rack, headed into their room, and had started my history, when the new nurse coming on shift decided that was the best time to perform an assessment on that patient. Nevermind the fact that she had three other patients to see, and could certainly have waited on mine. So, in the middle of my history, this nurse comes in and starts rattling off unrelated questions, listening to the patient's heart and lungs, telling the patient to be quiet right after I asked a question, generally making a nuisance of herself. I finally had to leave, as it was impossible to continue the exam with the nurse in the way.

Now I will grant that I am only a medical student, but in 66 days I will be the doc, and I'm going to ask such interfering persons to kindly permit me to finish my exam before they get in the way. I'm not trying to be mean, we both have jobs to do, but since neither of them are emergencies, is it too much to ask that the nurse wait to perform her assessment until after I've finished with mine? I think not.

On the plus side, I had the opportunity to teach one of the techs a few things today as well. A patient of mine needed an EKG, and as I was in the room reevaluating her when the tech came in, I stayed to see the EKG when it was done. As it turned out, the tech had only done three EKGs before, and so I answered her questions on how to set up the leads, and then showed her some basics of reading the results as they were printed. I realized (again) that I love teaching, and I hope to make that a huge part of my practice in the future.

Stories

We are no other than a moving row
Of magic Shadow-shapes that come and go
Round with the Sun-illumin'd Lantern held
In Midnight by the Master of the Show.

The ER, on the last few busy days, has been much like any other rotation, but sped up. I imagine the kind of physician who is attracted to this specialty is the kind with a shorter attention span than most. No matter who it is, they certainly all have a healthy sense of defensive medicine. So for instance yesterday, a man and his son came in together. The dad was worried that they both had pneumonia, despite having no symptoms except those of a typical cold. The son, through this interview, was active enough to begin (like any good five year old) the destruction of the triage room. Obviously, he was oxygenating just fine. But my attending insisted on getting chest x-rays for both dad and son. His explanation was that, in the last conference he went to, there was a presentation on malpractice, and the speaker made the point that patients come to the doctor for the show, and if you can do something to make it look like you're doing something, even if they don't need it, they are less likely to sue you. Maybe that's smart, but I wouldn't have x-rayed them. Radiation isn't benign either.

The next patient was a little 2 year old who fell off something at his day care, landing on his arm, and was now complaining of elbow pain. We checked it out, felt a click when manipulating it, got some x-rays, and settled on a diagnosis of nursemaid's elbow. So we applied the textbook treatment for it, heard a click, and gave the kid five minutes to recover.

He didn't improve, and still held his arm like it hurt. We tried twice more to reduce the injury, with no more luck. We paged orthopedics. They tried four times. Finally, we decided to get full arm and shoulder x-rays, and discovered a Salter-Harris type IV fracture of the humeral head. Lesson learned? That back in second year clinical labs, when they told us to x-ray the joint above and below an orthopedic injury, they weren't kidding. Also, just because a two year old tells you his arm hurts while pointing to his elbow doesn't mean his elbow is what he means. The kid got a sling, a bunch of stickers, and congratulations from the ortho team for playing hard.

I also saw one patient who made me question my choice of specialty. A first time mother was concerned about a rash her one month old daughter had. The kid was fine, just a little baby acne, but kids are cute, and healthy ones more so. The mom was the second mother to look crestfallen when I told her I was not going into peds. But I steel my resolve with the memories of Sarah, the first peds patient I had on my inpatient rotation. For whatever reason, dealing with adults facing death is much easier on me.

And I'll close with a word of advice. If you come into the ER complaining of fever to 100.5 degrees, for which you have not taken Tylenol, and have no other complaints, you are not allowed to complain when you wait 4 hours to be seen. There are actual sick people in here.

The ER

I've begun a new rotation, the ER. As can probably be surmised from my lack of posting, it has not been eventful. I made the decision, a year back when my class went through the rotation-picking-lottery, to use the good number I got for this rotation to go to a small, community ER that is closer to my apartment than the inner city monstrosity where I did my SICU rotation.

This may have been a bad decision. Though I most decidedly have easy days, and I'm within cycling distance of the hospital, nothing happens.

Nothing.

I've spent hours at a time reading, waiting for a patient to show up. While this may help my book knowledge, I feel my physical exam and history taking skills are rotting through inactivity. About the most intense thing that happened today was a medicine resident getting paged out of the ER to a code. I wanted to go with him, because it was certainly going to be more entertaining than this.

So (despite my feeling bad for wishing pain and suffering on the world) hopefully this is just a slow few days, and things will pick up. But with the attending I've had for the last few days, that might not even make a difference. A lady came in today who needed sutures, and he did them rather than let me. *sigh* Only three more weeks.