Clinical Medicine Module: Surgery Rotation

So last Thursday was my Surgery rotation as part of the Bute's new Clinical Medicine Module. We're basically the guinea pigs for this, but at least most of the kinks from last year's class had already been worked out. It was basically what I imagine an Introduction to Clinical Medicine class would be like if I were back home. There were 6 of us, and one Consultant (an Attending, back home), and we basically just went on a small Ward Round. He would explain to us basic things, do a lot of basic science pimping, as well as explaining some more of the semantic things about patient care (DVT prophylaxis with LMWH and stockings, etc).

For those of our class who have no/little hospital experience from a patient carer standpoint (eg doctor/nurse, as opposed to clerk), I think it was very beneficial. I'm not trying to sound cocky, but most of the stuff he told me I learned this past summer with the Hospitalists. However, he did show me how much basic anatomy I had forgotten over the summer/past year.

Overall I think it was pretty good, and while I was really looking forward to my A&E day next sememster, it turns out that it's just a ortho fracture review...but the Consultant offered everyone some Saturday night shifts in the A&E doing proper work, so I might just...pretend I have already met him and take him up on the offer :-)

In other news, I am very behind in my work. We have mainly only had Anatomy lectures so far (Head & Neck, and CNS), with a little bit of Pharm (General Anaesthetics, etc) thrown in for fun. I have written up 3 of the 15 lectures we've had, and more start tomorrow....*sigh*. That's med school for you...


-AMiB

"Code Blue, 6West, Back Hallway"

So last night I was doing an overnight in the ER, and I had my first code of this summer. I've seen 5 or 6 in the past, and participated in 3 or 4, but this is the first one since I started at the hospital this June.

Dr. M (ER doc), the ER tech, and I, all head out of the ER and towards the elevators. We are met there by 2 ICU nurses and 2 Respiratory Therapists. We get up to the 6th floor, and head to the 'back hallway'. As we walk through the nurses station, I'm completely surprised as to how empty it was. They must all be with the Code, I figured. And I was right. As we enter the hallway, I see a scramble of nurses, frantically doing things to save the old man on the floor. I ask for the story, and try and see his face to see if he was one of ours (on the Hospitalist service - he wasn't). He's had had a couple stents placed this morning, and had seemed to be doing fine. He was taking a walk (who goes for a walk at 3.15am?!) with his nurse, when he started to feel faint, brady'd down, and collapsed. No pulse, no respirations - so the Code was called. After a couple rounds of CPR and drugs, we get him onto a bed and into a room. It was then that I realized how many people respond to a code. Roughly 30 nurses, techs, CNAs, 1 doc (which should've been 3 - the ER, the Intesivist, and the patient's Cardiologist), and a handful of Respiratory Techs.
I was standing outside at this point, and couldn't see much of what was going on. I did hear the patient, however: "GET OFF ME! YOU'RE KILLING ME! LET ME GO! LET ME GO!" (we were holding him still while trying to start an IV). These words were masking those of the Respiratory Tech: "Calm down, sir. Your heart stopped and we've had to CPR on you!"

Eventually, he stabilized, and Dr. M went off to talk to the patient's Cardiologist. He didn't feel much like coming in to write orders, and wanted to send his NP to do it. Now, I have nothing against NPs, but if you're a Cardiologist, and you cath'd someone this morning, and they Code: come in. What about the patients family? It's your responsibility to let them know what happened. But anyway, I digress.

By now, he's lost his pulse again. On with the compressions. We secure the airway with endotrachial intubation. The patient kept fluctuating between PEA, Asystole, and Brady, all the way down to the ICU. We get down there and continue compressions. Dr. M puts in a femoral arterial line to see if the compressions are working, as well as if the patient's heart is beating on its own.

At 4.116am, roughly an hour after the Code was called, Dr. M pronounces the patient. The monitor is turned off, and everyone stops what they're doing. We look down at him, and see that his larynx is moving. Either he's trying to breathe on his own, or he's swallowing. Either way, that's not what a dead person does. We feel for pulses: one on each fem, one on each carotid. One of the ICU nurses swears she feels a pulse. Other people feel it as well, so we turn the monitor back on - but they don't match. It's much faster than what is on the monitor. I tell them to feel their own pulse while they're feeling the patients. Yep, those match. I guess it kind of goes to show how much health care professionals want to save their patients. We listen for heart sounds, check reflexes - nothing. His throat was probably just agonal breathing (last breaths).

Time of Death, 4.20am.

Quote of the Day, August 23rd, 2007

So there's this Infections Disease doc, Dr. C. The Hospitalists hate the ID guys, cuz they interfere with our antibiotic treatment and blocking discharges of patients who really should be going home. Anyway, I've NEVER seen Dr. C, but I always see her notes in our charts. For a while, I didn't believe she actually existed. Figment of our imagination, I believed. In reality, she rounds late at night, because her notes are always timed no earlier than 2200 (once, she had put 2430 - because they have to see each patient and write a note each day).

Anyway, today I actually met her. She looks up at me and asks me to question I get so many times -

Dr. C: "So, are you a new Hospitalist?"
Me: "No, I'm just a Medical Student"
Dr. C: "Oh...you're awfully big for a medical student"

wtf?!

Peds (Paeds) Trick

Learned a little trick in the ER for when you have 3 year olds whose eyes you need to look into:
Make them watch you do it to their parent, who is holding them. Do exactly what you are about to do to them, then say "OK, now its your turn!" Seemed to work out fine for the 2 young patients we had today (thankfully one did not have the head bleed we were worried about).

-AMiB

Time of Death, 11:36am

So Dr. M had to call a patient today. This is the first time I've seen someone die on the floor (seen 3 or 4 in the ER). Was an 90something year old woman, DNR, had a mid-brain bleed while in a nursing home, was admitted officially for the bleed, but really so that she could die peacefully.

I never realized how much you have to do to pronounce someone. Pupils have to be fixed and dilated, no gag reflex, listen for 1 minute for absent heartbeat, absent Babinski's sign. Then there's the paperwork...don't get me started on that.

It was humbling, to say the least.

There is treason afoot...

There seems to be a lot of secrecy, treachery, vying for power and spying going among amongst some of the Hospitalists. It's kind of funny to me as an outsider, but it'll be interesting to see how this pans out...

I learn so much in 8 hours with Dr. A (medical director), it's kind of ridiculous.

-AMiB

Week 1, Part 2

Thursday:
8.30am - Arrived on 7W
8.35am - Dr. S arrives on 7W (first time I have arrived before a Hospitalist :-P); Rounding begins. This time, was equipped with my Sanford Guide (2003, need to get a new one), my PIMP Protector, and my sister's Oxford Clinical Handbook. All of which came in useful. We saw quite a number of patients, some of which who were very nice and polite, and others who were, as Dr. S put it, "bitches". I just smiled like a good little medical student :-). Let's see...notable cases: a lady with a new onset of back pain from an old L1 compression fracture, as well as an unkown pain in the mesogastric area of her abdomen. History of shingles (Herpes Zoster), coronary artery disease s/p 3 stents placed about 5 years ago, renolithiasis stuck in renal pelvis (but asymptomatic), an ovarian cyst, and rheumatoid arthritis. Dr. S orders a test for rheumatoid factor, ANA & ESR to see if abd. pain might be rheumatoid in origin; MRI of back to look for any possible new fractures leading to her back pain; MRA of abdomen to look for atherosclerosis of mesenteric arteries, possibly leading to abdominal pain. Was quite the interesting case. Dr. S called her a bitch. :-P
Saw a 90 year old lady with Alzheimer's, who had been prescribed sleeping medication q4hrs PRN. Nurse (at care facility) had given it q4hrs instead, as well as ativan (wtf, why?), and patient sort of just nodded off...for a few days. Was starting to wake up today, A&Ox1(name)
We were called for a consult on a young lady who had had gastric bypass surgery 3.5 years ago, and now is having abdominal pain. Bariatric surgeon went in, lysed some adhesions, but didn't find anything else that could be causing the pain. So called for a Med consult. We (and when I keep saying 'we', I mean Dr. S, with me following like a sheep...or a shadow :-P) figure it's an infected blind loop, and call for a GI consult to do endoscopy so we can biopsy the sac.

Finally asked Dr. A and Dr. S what they do after rounds, while waiting for consults. They say mostly the admits/consults pile up, so they don't really get a break. Usually lunch is their first stop, though.

Am looking forward to working with Dr. C tomorrow (she's the same race as me...always fun lol)

Friday:
8am - Working with Dr. C today. She only had 5 or so patients, but was on call. I just realized that me describing my day week after week will get boring after a while, so maybe I'll continue, maybe I won't. Saw some diverticulitis patients, lobar pneumonia (possibly community-acquired, possibly aspiration). Had my first (well, first with the Hospitalists) drug rep visit. Some nice ladies from the companies that make Lovenox (enoxaparin, a LMWH - low molecular weight heparin) and Lantus (insuline glargine) came in and brought us lunch (Sanofi Aventis, I believe). Apparently, Lovenox is now approved for STEMI patients. Fancy that. I got a free lunch and a pen and a clickie-sharpie, both with LOVENOX written on them. Awesome.

Got the weekend off (err...will take the weekend off?), and am working with Dr. C again on Monday, 8am.

Week 1, Part 1

Monday:
8.15am - Start 'rounding' with Dr. R, Hospitalist. See a number of patients she already had from previous days, so no full workups. Some interesting cases, including Acute Renal Failure secondary to Rhabdomyalosis after running a marathon. And a homeless patient who had been in hospital for several months (since February), who tried to drink his own urine. Twice. While IN hospital.
Only saw a handful of patients. Dr. R assured me that this is not the normal case, and she normally has twice as many.
Side note: She kept introducing me in this manner: "This is Dr. AMiB (well, my last name), he's actually a medical student who's shadowing me today." This got me confused, because didn't someone who went through a normal US school and residency have students with them on rounds, and know how to introduce them? I tried correcting her every time, but she kept doing it...i dunno.
11am - 'Grand Rounds' is what I'll call it, it was more a meeting, really. Went down to the Hospitalists office, met with the 2 other docs who were in hospital at the time, the Medical Director (also a Hospitalist), and the Case Managers from the different floors. Went over all the patients they had, and let the case managers know what is going on and what the plan of action and time frame would be. (Heard of a case of Necrotizing Fasciitis!)
After GR, saw a couple more patients, then Dr. R...left, the hospital. I was quite confused, really. I understand that being on call means coming in and admitting any Medical patient the ER decides to admit, but after rounds, what is there really to do? (At the time of this writing [Tuesday night], I have no idea what Hospitalists do for the majority of the day. I plan to ask tomorrow.) Hopefully I will find out or find something to do, because leaving at 12 after a few hours of seeing patients is kind of boring, really. Don't get me wrong, I enjoy the patients I see, but because I'm not allowed to go see patients by myself, should I just literally follow the doc wherever they go?! Most of them take care of personal things, or work on charting. This is time that could be spent wisely seeing interesting patients, but guess what?! Can't do that. (I'm not still bitter - I promise! :-P)


Tuesday:
7.15am - Arive in OR
7.30am - Dr. C, Neurosurgeon, arrives in OR
9.35am - After 2 hours or prepping the patient, first incision is made. The patient was an elderly gentleman, struck by an auto. He had a mechanical heart valve, and was on Plavix (clopidogrel), a commonly used anticoagulant. He had a broken shoulder, open tib-fib fracture, as well as pretty severe head bleeding (due to the Plavix). Also, he has a Type 2 odontoid fracture. His C1/C2 joint is unstable, and his C3/C4 joint has rotatory dislocation. Also, the facet joints all the way down his C-spine are opened/problematic. At the C6/C7 joint, there is subluxation and the thecal sac is endangered. He is 10 days post-incident, and Dr. C believes he is ready to have surgery. An Occipitocervical Fusion is performed, fusing the occiput of the skull all the way down through C7. Graft taken from the right iliac crest, as well as allograft bone marrow was put near the rods to hopefully fuse them. The patient will have absolutely ZERO range of motion in his neck, as if he were permanantely in a halo. I really hope they caught the guy who did this.
3.15pm - After nearly 6 hours in open surgery, and 8 hours in the OR, Dr. C starts closing and I head out. I had had an amazing vantage point, standing at the head of the patient, looking straight into the posterior cervical incision. Dr. C was to my right, and a Trauma NP was to my left, assisting. I didn't even have to scrub in, since I was on the non-sterile side (I hate being sterile, and would've died if I had to have been standing there for this long). All in all, was an amazing day. Not many people my age or in my class can say they've seen what I've seen, and while I bitch and moan about what I don't get to do, sometimes (like these), I realize how lucky I have been.

Wednesday:
8am - Started rounds with Dr. A, the Director of the Hospitalists group that does the Internal Medicine call for out hospital (the guys I'll spend most of the summer shadowing). Saw a number of interesting patients, most of which I can't remember at this time, except Necrotizing Fasciitis! Dr. Adrian says he hates that diagnosis, since it grosses him out, but as a student, I can't help but find it cool. So sue me (no seriously though, don't - I have no money, being just a lowly student! :-P)
Dr. A was an Attending at the same teaching hospital where he did his residency, and is very skilled in the way of Academic Medicine. He introduced me properly, as "AMiB, one of my medical students", and gave me my first real dose of PIMPing. For those of you not from the medical profession, here is a definition of pimping:

The term pimping is common slang in medical education to describe the process of attending physicians asking physicians-in-training (i.e. resident physicians or medical students) difficult questions — some would say just questions in general. This is usually used in a derogatory fashion by those being on the receiving end of questions, as in, "I got so nervous when Dr. Smith pimped me about the causes of pancreatitis!" According to The Art of Pimping by Brancati, German surgeon Walter Karl Koch first recorded "Puempfrage" questions in 1889 to be used while seeing patients with his students in Heidelberg. In America, Abraham Flexner noted on his visit to Johns Hopkins in 1916 that Osler (likely William Osler) used rapid-fire questions on his students.

And let me tell you - it sucked. I'm taking this as a sign of how little I know, although I believe Dr. A was asking me questions that I wasn't really supposed to know the answer to (the only one I got right was looking for splinter haemorrhages in cases of Infective Endocarditis). Wow, I just realized how overboard I'm going with these links. Oh well.
We had a few admits in the ER, including a homeless man in alcohol withdrawal and associated seizures, who chose to use the ER bathroom floor instead of the toilet to take a dump. How nice of him!
Also, a patient with renal failure, probably due to an unknown obstructive uropathy (wheee I love big words :-D), and a really nice lady with cellulitis of the arm.

Near 1ish, Dr. A told me he was going to step out for a bit, and to go grab lunch. He said he'd call me when the next admit came in. So I went to the Physician's Lounge, grabbed some of the free pastries and coffee they had there, and just sat and watched TV while I waited for a phone call. Eventually it came in, and we met up again in the ER. We admitted the cellulitis lady, went up and saw a patient who had been in surgery during morning rounds, and then that was essentially it. He said I didn't have to stay till 6, as I had probably seen plenty of good patients. I agreed, and said I would head home. But I kind of wanted to see what he would have said if I had wanted to stay the whole shift. Would I have just sat in the Physician's Lounge again? Maybe done nothing in their windowless office (it's in the basement, definitely not their fault lol)? I dunno. Will see when I go with Dr. S tomorrow. Apparently, Dr. A says that if I thought his pimping was bad, I just have to wait until Dr. S's. I'm a bit scared. Will bring my PIMP Protector with me!


OK, so I've decided to post this first half of the week, just to see if you guys like it, and just so you don't think HIPAA has dragged me off the face of the earth (which they may well do after this post! :-/) Please leave feedback in the comments, lettering me know if the style of the post is good. I thought that small, daily posts would have been too annoying, so decided to go for a Weekly one. If y'all think it's cool, I will probably continue like that for the summer. So...yeah. Here goes!

And so it begins...

Medical Student Observer forms filled out...check!
Immunization Records up to date...check!
PPD Tuberculosis skin test...negative! (that's a good thing)
Doctor(s) who are willing to let me shadow them...check!
Hospital badge so I don't get kicked out of the hospital...check!

So, looks like I'm all set! Once I get the go-ahead email, I'll head in on Monday for my first day. The shifts are 6am-6pm, but it doesn't seem like any of the docs start before 7 or 7:30. We'll see how long I actually last on the shifts, but I'm gonna try and stick em out.

Also, Dr. C is doing a surgery Tuesday morning that he's willing to let me watch, so I'll probably be in for that too.

We'll see how this all goes, I'm pretty much playing by ear as it is.

A Ray of Hope...

Looks like there may be some opportunities for me after all...not as much 'doing' as I'd like (or any at all), but I think at this point, having sat at home doing nothing for so long, I'll just be glad to get back into the hospital...

Wish me luck, have a couple meetings tomorrow to sort it all out!

-AMiB

The Quest for Summer Medical Education

So, since I have 4 months of summer vacation, I decided I should do something more productive with my time than sit here and do nothing all day. Last summer I was taking a class to get my EMT-B license (Emergency Medical Technician – Basic; the lowest level of Ambulance training there is), shadowing an ER doc, let's call him Dr. M, at my local ER, as well as shadowing a neurosurgeon (actually, the Head of Neurosurgical Trauma), Dr. C (who should really be called Dr. Ridiculously Smart & Awesome…or something along those lines).

First, a bit of history:

Dr. M was the doc who was always on at the ER when I was doing my Volunteer shifts. When it came time to do my preceptorship in the summer before first year, I chose Dr. E (another ER doc), because he seemed 'cooler'. Bad choice. He is an amazing doctor and gets the job done, but I felt he could be quite rude, at points, and had a bit of a short fuse. To be honest, I'm kind of like that too, at times, which may be why when Dr. E went on vacation, I asked Dr. M if I could shadow him. Dr. M has been doing practicing Emergency Medicine for 30 years. He's a Navy guy, but is very relaxed and laid back, and tends to let the younger docs pick up more shifts, so he can have more vacation time (after 30 years, I'm sure I'd be doing the same). So I started shadowing Dr. M on most of his shifts, and he never seemed to mind. When I left, he said I could come back whenever, and I took him up on that when I returned last summer. The Medical Staff office has a short form you can fill out, defining yourself as a medical student, and allowing you to "Observe" a physician – essentially a shadowing position, exactly what I was looking for.

I was introduced to Dr. C by the Volunteer Coordinator, a nice lady who looks after the Volunteers. She felt that this would be a good fit, as Dr. C was new to the hospital, but was very eager to teach students. I started shadowing Dr. C in his office, which is in a Medical Office building on the hospital campus, and once I got the "Observer" status, I was allowed in the OR as well – he even taught me how to scrub in. He also said that I could come back this summer, but we'll get to that later. Funny story about my first day with Dr. C: I was going to his office straight from EMT class (class ends at 12, first patient is at 12.45). The hospital was only 20 minutes or so away, so I figured I had plenty of time. I threw my volunteer outfit in my backpack to get changed in the Volunteer office. All was going well until I was about to turn into the hospital campus, when I realized I was wearing my flip-flops, and didn't have any shoes. What was I to do? So I start going as fast as I can towards my house, obeying all speed limits, of course, but every single thing that goes wrong can. The exit for my house off the freeway is blocked. One street from my house, there is a large forklift in the middle of the road, suspending a large amount of wood in the air. There doesn't seem to be much movement, the forklift operator seems to be staring off into nowhere. Of course, I encounter this on the way back to the hospital as well. Overall, I was maybe 30 minutes late, gave a fake excuse of traffic and an accident on the freeway, and all was well. I tell them of this story now, and they love it – but it was way too nerve-wracking for my first day.

So, back to the real reason for this post: This summer. Having shadowed physicians for 2 summers now, I'd like to try and practice my skills (see my previous post). The first thing I did was write a letter to a family friend, who is a Family Practice doctor in a private office:

"Dear Dr. B,

My name is AMiB; I believe you know my parents D & D of [our Pharmacy]. I have recently completed my second preclinical year at the Bute Medical School, University of St. Andrews, UK, and am looking to spend my summer developing clinical aptitude in preparation for my clinical years to come. As part of our curriculum at the Bute, I have completed my theoretical studies of the Cardiovascular, Respiratory, Gastrointestinal, Renal, and Reproductive Systems; studying, in turn, the Anatomical, Physiological, Pathological, and Pharmacological aspects of each. As well as these, we have learned basic clinical and communication skills (see attached sheet of Scope of Practice). I feel that I must disclose, however, that both the Central Nervous and Endocrine Systems will be covered next year (our final preclinical year), and as such my knowledge of these fields is lacking.

My ideal situation for this summer would be that of a medical student, seeing patients, presenting to an attending Physician (preferably you or one of your partners, if willing), and learning about necessary treatments. I believe that learning by doing is a method that has been tried and tested in the medical education tradition for years, and I would like to continue that this summer. The knowledge I would gain, and the communication skills I would develop would be an invaluable addition to my medical education, and I would be deeply grateful.

If you are unable to have me for too long or feel that I am asking too much, I would still be honored if you would let me shadow you for a few days to get a feel for what Family Practice is like. Also, if you know of any clinics in the area that accept medical students in this role, or know of any other physicians, in any specialty, which might be willing to have me around, please put them in contact with me.

Attached, you will find my Scope of Practice, letter of indemnity coverage from the MDU (Medical Defense Union), and a letter from the Dean of my medical school approving my work for this summer."

I haven't yet received a response, but am hopeful. I also wrote a letter to an Internal Medicine doc that I met in the ER last summer. He is from India, and I'm hoping I might be able to pull the "we Indians got to stick together" card. But we'll see.

So yesterday I went to the hospital to see what I could do. Dr. C's office was all out to lunch, so I went and said hi to the Volunteer office. They offered me a Volunteer position, but there are a few people ahead of me to get set up with doc's, and I'd rather give that opportunity to a high schooler looking for something to put on their college app – after all, that's what I did. I went to the ER, and it turns out Dr. M is on vacation for all of June. I went to the Medical Staff office, and all but pleaded with them to give me privileges. Nothing. All I can do is Observe. They mentioned something about California State law and not being able to practice medicine without a license. They made it sound like I was trying to open up my own hospital – all I want to do is a simple H&P! Maybe start an IV or two, CVS exam…anything? Jeez…

Today I went back, said hi to Dr. C's office. This is why I think he is Dr. Amazing – he is going to ask around with some of his colleagues, Internists, Family Practice, and see if anyone is willing to take me on for the summer. He said he'll get in contact with me, so I'm anticipating an email from his office manager. While I'm not too hopeful, I'm really wishing something will come of it.

So I left my hospital, and went to another hospital down the street – they're all owned by the same overall organization/corporation (non-profit), but this was a different hospital campus altogether, and hopefully I might be able to find something here. Nope. Their office gave me the same deal – actually, their "no way" was much more enthusiastic than I got at my hospital. They told me that the law prohibits any patient contact from someone who is not licensed to practice medicine in the State of California. However they do have clerkships for final year students, but it is very difficult for International students to get approved for this.

I left very frustrated with the whole system. Honestly, why is it such a big deal? I'll sign your HIPAA forms, I won't give out medical advice, but let me do something! Sometimes, part of me wishes that I stuck with it and went through the American medical education system. I guess all I have to do is wait one more year until my clinical years start, but I tend to be a bit impatient sometimes.

If anyone out there has any advice, any connections, or any loopholes they know about, please, share them with me, either in the comments, or at veerthetiguy –AT- sbcglobal –DOT- net.

I'll be sure to keep everyone updated about the situation, but it looks like it'll be Observation only once again…

Until later,

-AMiB

Manchester Hospital Allocations

Today was the last day to fill out the form for our Hospital Choices for our clinical years in Manchester. So obviously, I filled them in yesterday :-P

My choices were in the following order:
1. South (Wythenshawe)
2. Preston
3. Central (Manchester Royal Infirmary - MRI)
4. Salford (Hope)

Will elaborate further after exams (Short Answer Questions on the 14th, Multiple Choice on the 16th, and OSPE [Objective Structured Practical Exam] on the 18th)

-AMiB