My first BIG miss

One of my sicker kids came up to me in the middle of the day yesterday while I was sitting at the nurses station writing a note. He looked pretty relaxed and like he was doing ok, so I talked to him for a bit while I was writing. Then out of the blue he said "My tounge feels funny. Kind of tingly. It just started a little while ago."

OK I thought, probably not a big deal. So I ask him all of the questions that I can think of relating to electrolyte abnormalities, and it doesn't really sound like a big deal to me. So I tell him so and put it in the back of my mind. Well about an hour later, he's told my resident, the nurses and anyone that would listen that he's feeling tingly all over his body and his hands are getting crampy, and it feels like when his K gets lower. Ok not really a big deal, but this is not good!!! Resident orders a BMP and CXR, and we go to sign out for the night.

In the middle of signout the lab calls back with a STAT BMP showing a K+ in the 7's. STAT EKG is showing PVC's. Insulin + Glucose, CaGluconate and Kaoxalte go in and he's transferred to the PICU...OH SHIT THIS IS NOT GOOD. Long story short, he ended up being completely fine once his K+ was brought down to normal levels and he'll be back on the floors tomorrow.

However, the scary thing is that this kid came up to me and directly presented me with a problem. I brushed it off as something not serious...it didn't sound like Ca+ or high K+ to me...but there he is. I could have nipped the issue in the bud and looked like a superstar, but instead I was a space cadet and blew off someone who was SEVERELY sick. We're not talking "ooops, I missed something"...we're talking OOOPS I could have killed a kid by not saying anything. He could have flipped over into VTach or VFib and collapsed infront of me and I wouldn't have known what happened.

I know that I'm a third year student and that seeing the manefestations of disease are what this year is all about. I know there's a saftey net of 10 physicians, nurses, techs and janitors behind me to pick up what I miss. I know this one turned out to be OK...but what about when it isn't OK?

Great article!

Sorry I haven't posted in a while....just haven't been inspired to write and haven't really had anything interesting.

Just to update, the remainder of neuro went well and I had one excellent preceptor and one medicore preceptor. The excellent doc was one of the best educators that I have ever met. He cared about us learning more than the neuro exam...he wanted to be a role model for us and to educate our entire person...what a breath of fresh air. The other guy just didn't want to do work and blew us off...which was good for studying but bad for learning practically. The shelf sucked, but that's what I expected. Now it's onto peds.

Anyway, I was sent this article by a classmate and wanted to post a link to it: Medical Student Burnout

I'm pretty sure this will be me in about 10 years sitting around with my classmate recalling how miserable I was. The years of my life spent isolated from the real world, real people is starting to wear on me. The single persuit of nothing but medical knowledge is eroding who I am...but I'm too in debt now to back out. Today for instance, I finished my work by 4:30 PM and had to sit around waiting to sign out until nearly 7 PM. In that time I wrote 1 note, discharged 1 patient, attended 4 hours of lecture, and 2 sets of teaching rounds.

Was it a fulfilling day? NO!!!
Did anyone get better because of what I did today??? NO!!!
Did anyone get worse because of what I did today??? I certainly hope not, but I'll find out in the morning I guess.

I've said it a few times in the past, but I had no idea what I was getting myself into. I niavely just convinced myself that I would have no problem being a great doctor because I'm a pretty smart guy who listens and cares a whole bunch. HA...if I had only known. Anyway take a gander at the article, it's interesting to see this doc's look back at medical school. I found it to reflect my feelings many times.


Follow the leader

I'm getting kind of sick of this neurology rotation, but it is providing some valuable insight into the nature of what I want to do with my life. Here's today's episode of frustration:

Yestederday, 4:30 PM: Attending says "I'll see you in the morning. I have a meeting that will be over at 10, give me a call after that"

8:30 AM- Morning report...2 of our patients are presented by the medical residents, I learn a little bit
9:15 AM- Report ends, go to coffee shop to blow off 45 minutes waiting for attending
10:00- Call attending, who doesn't answer, leave voicemail
10:30: Call attending, who still doesn't answer, leave voicemail with pager number because I know he doesn't remember it
Noon: Attending pages and asks us to meet him in Radiology in 5
12:04: medical students and NP arrive at radiology ready to start the day
12:10: No sign of attending
12:15: Attending shows up, talks to radiologist about golf for 5 minutes, radiologist says the patient's scans are fine
12:20: Go to noontime conference
1:15: call attending to meet, he's still eating lunch...call back at 2
2:00: call attending to meet, says to meet at this patient in 5, head up and print out everything needed for a consult and play 'find the chart'
2:30: Attending strolls onto the floor, sees the patient and dictates his note
3:00: Another consult, med students play 'find the chart' for 10 minutes and then attending does the neuro exam
3:30: Another consult, another game of 'find the chart' but we can't find the patient either...he gives a brief lecture on MG and then we BS about the stock market, iPhones, his kids.
4:00: Patient arrives, he does the consult while we watch
4:30: Called for a frequent flier in the ED...he whines about having to go there, we talk him into going to see her, he says that he'd like to keep it less than 20 minutes if possible
4:52: Finishes dictating his note on a silly CYA consult...
4:53: As we walk out of the ED, "Well that wasn't so bad, I'm glad we decided to go see her. Have a nice evening"

Total time in the hospital: 8.5 hours
Total time doing anything productive: 30 minutes playing 'find the chart', 10 minute lecture on MG, 2 minutes removing socks and performing babinski's= 42 minutes of actual educational time towards the specialty of Neurology.

So I think I've made the 'doing' vs 'thinking' decision in my career decision tree. Thinking sucks...I really don't think I could take 30 years of sitting around and hypothesizing what the hell is wrong with patients...I need to have something going on, I need some sort of end-goal directed activity to get through...not just a bunch of people chilling in beds waiting to get better. I need a stack of charts, or an OR schedule, or a patient schedule...this in-hospital endless rounding thing just isn't my cup of tea.



There are just certain times when a neuro exam just isn't going to go smoothly and won't be of much value...I was lucky enough to have TWO of those situations today pawned off on me by my attending. Consequently, as of this morning I had done 1 independant neuro exam...so as you can imagine, it went smoothly.

1) A lovely, demented, non-english speaking Pakistani woman presents to the clinic with her son who claims initially that she can not speak, form new memories or remember much from the distant past. Ok...I'm a fairly bright and patient guy, but patience and creativity have their limits. Son acting as translator, I manage to get about 40% of the neuro exam done and have a slight clue that she does have some functional capability. I go back and give my very disorganized, half completed report to the attending who then feels the need reward my performance by mercilessly pimping me on all of the causes of dementia. Anyway, he gets frustrated while repeating the exam and gets frustrated after extracting about half as much as I did out of the lady and gives up...I felt a little bit satisfied, but only a little.

2) There are two consults on the psych ward that the attending wants to avoid: I'm assigned the chronic schitzophrenic found wandering the streets and my classmate gets the lovely, cognitively intact gentleman that's getting discharged in about 10 minutes with a clean bill of health. I'm sort of getting the feeling that I'm not the favorite student on this rotation. My patient's HPI is completely disjointed, his MSE is literally the most painful exercise in futilty that I have every striven to complete...fortunately the rest of the exam was less than painful.

Again...I don't see myself doing this EVER.


I'm about 2 weeks into Neuro at this point and I have to honestly say that I could NEVER consider this as a career path. I will admit that my opinion is colored by the service that I'm on (consult based in a private community hospital) and that the two of us on the service have been left waiting for HOURS for the damned attending to show up and pay some attention to us and maybe let us do a consult or two.

I think the most frustrating thing is the thought processes of a neurology attending since the advent of the MRI. In one hand you have the bread and butter Neurological exam: Someone's brain is potentially (whether in reality or not) different from baseline, so you call the neurologist to find out what is functionally wrong with this person's neuraxis, localize the lesion to a level/side/location if possible and then try to figure out what can cause that and devise your treatment plan. On the other hand...you could get an MRI and be done with the logical part.

The scary thing is that the neuro exam can be very wrong...and I've seen it in my short time on the service. We had a lady that came into the ED with what seemed to be unequivocally radiculopathic pain on exam. It looked like classic root compression with some pain and loss of sensory modalities...thanks for the $500 ED copay, do some PT for 6 wks and follow up. Well, within 24 hours she was a paraplegic without control of her bowel or bladder without sensation below the waist, enhancing lesions in the spine consistent with transverse myelitis. What causes it? We don't know 50% of the time. What's the prognosis? We don't know most of the time, but we're hopeful. What are the chances that I won't be bed ridden and incontinent? 60% that you'll improve, we're hopeful. It's tough to sit infront of a family and tell them that you're completely out of control of what is happening to them and you don't exactly know what will happen. I guess this is the most humble and useless that I've felt in a long time.

I don't think that I could walk into the hospital every day for the next 30 years to localize the leison, check to make sure I was right on the MRI and then have a role of the dice as to whether I can affect any change in the patient. Not to take anything away from them, neurologists are some of the most brilliant and logical physicians in the hospital dealing with a very complex system. I just couldn't see myself in their shoes.