Where's the awesome???

Fourth year of medical school is supposed to be the promised land after years of slogging through the pre-reqs, the pre-clinicals and the core clinical rotations. My EM rotations over the summer were PHENOMENAL and I will share my stories when they're not subject to search and seizure by the programs that I've applied to...not that I'm paranoid much in due time.

However, Geri put the brakes on the momentum of the year, subsequently derailed by the neurosis of residency applications, Step 2CK studying and the onset of acute lack-of-time-and-money-itis. So instead of being that cool and confident 4th year who's partying and putting his ducks in a row, I'm just that mildly out-of-shape dude in scrubs who looks perpetually over-caffeinated and sleep deprived from checking his email constantly and only talks about USMLE World (TM) questions and interviews. (Maybe they'll give me some cash for dropping their name???).

I stuck out the rest of Geri without very much effort difficulty but managed a generally positive performance review from the course director and attendings. I think the most educational part of the rotation was a peek of what a visit from the medical marijuana associates JCHAO does to the flow of a hospital. I think the floor of my unit was buffed twice daily for 2 weeks straight (so much that I got to know the guys by name), the patient's call bells were answered in a timely manner, the residents washed their hands obsessively, the food in the cafeteria was markedly better and the demented old people who were usually restrained were all magically on 1-to-1. Oh, and everyone was on edge...for like 2 weeks straight. I thought the unit clerk was going to lose it when she found out that the hospital started spreading rumors that JCHAO was in house when they really weren't coming until the following week...it was a pretty slick move by the admins.

So now I'm slacking my way through a week of Anesthesia (actually lot of fun!) and a week of Rehabilitation (Physiatry) before my Step 2CK exam in the middle of October. If you remember, I'm a big fan of preparing for standardized exams. Fortunately, I have a couple of hours to distract myself in the clinic before pounding out 2 hours of questions every night. I'm about 1/2 way through my prep and my scores are pretty much all over the place still...depending on how tired I am while taking it...but I'm consistently sucking in Peds and Psych. My current plan is to focus my studying on the weaker stuff in hopes of picking up easy points, but we'll see how that goes.

Anyway, I'll continue my infrequent and vague postings as my life rolls along, I hit the interview trail and tick off the days left in medical school. I'm sure there will be some fun stories to share...


Positive physical exam findings

After examining hundreds of normal people finding something on physical exam that isn't right is sort of a novelty. Today I had a couple of them in one poor old guy who had a problem list extending to number 18:

1) AAA actually does feel like a pulsitile mass in the abdomen...but I knew about that one
2) Bruits in almost every large vessel...knew about the PVD and carotid stenosis too
3) I definitely hear crackles in the RLL...you didn't hear those medicine resident? Never mind...you wrote the worst admitting H&P ever! Lemme go read the official CXR report...he's got an infiltrate to match his findings...maybe there's something to the physical exam crap.
4) Stage 1 decubitus ulcers look like some redness that doesn't blanch...noted.
5) Contracture vs lead-pipe rigidity...I couldn't tell the difference, but he's on cimetedine so he has Parkinsons in someones mind.

It really helped that I was on the Geri floor and had time to mess around with this poor demented old fellow...some cool findings that I might not ever see again.


An indecent proposal

I'm drawing some blood from one of my little old ladies today...actually my own patient...bent over her bedside palpating her contracted, cachetic little arms to try and find ANY vessel that I can stick a 22 guage into.

LOL: Tell me that you love me...
Bostonian: Ok...Berta, do you even know who I am?
LOL: No...I thought you were my man.
Bostonian: Well we just met this morning, I think we're moving a little bit fast here.
LOL: (getting tearful) But I love you. Why won't you say that you love me?
Bostonian: Ok Berta, I love you.
LOL: Why won't you take me like you used to
Bostonian: Berta...do you even know who I am?
LOL: No...I thought you were my man...I love you
Bostonian: Sweetie, I'm just your doctor, you're going to feel a little pinch in your arm.
LOL: Ouch...why do you treat me so bad. Won't you take me like you used to???
Bostonian: I'm just here to get some blood...I'll see you tomorrow Berta.

Whiplash and Teamwork

After finishing up a wonderful couple of months in the ED's of Massachusetts, I headed back down for my September Geriatrics rotation in the Bronx. One of my EM attendings predicted it would feel like whiplash...and it has!

Talk about polar opposites of the health care spectrum...I went from managing 7-8 patients per shift from presentation to managing 1-2 patients at a time...without the ability to do ANYTHING. Not look at labs, not order tests/meds/care, nothing. I stand on rounds for 2-3 hours per day, drop my notes and suffer through the seemingly endless didactics (over 12 hours per week). Not only that, but I am the only student in the Medicine Department right now because the third years just finished their medicine rotations. I looked around the room the other day during grand rounds and I was one of three native English speakers in the room...great.

Ok so it wouldn't be aweful if I didn't deal so poorly with being scutted in it's most evil form. I don't really mind doing blood draws, IV's and rectals on other people's patients, but most of the patients I've been assigned have come from the interns on their last day of hospitalization...so guess who gets to do the discharge paperwork. Yeah...that's right...me! Here's the kicker: I'm not technically allowed to sign the discharge papers or fill them out.

Well that caveat came back to bite the entire service in the arse. I picked up a patient for maybe 3 hours, presented on rounds and took care of the last minute social work, got the discharge meds from the resident and put the discharge summary in the chart. I notified the intern that the papers were finished and in the chart. Well, she never signed them, the resident never signed them, the fellow never signed them, the attending never signed them and the charge nurse made sure the patient was on his way out the door. Well the nursing home was a little bit upset when they didn't see anything signed and that there was a little bit of a heftier dose of ampicillin than usual...so they called to double check on that. And so my team proceeded to throw me under the bus...yes it was my fault for not double checking the resident's dosing, not waiving the discharge papers in front of everyone to sign and not signing the document that I'm not even supposed to fill out.

There's my other scut. Working in NYC exposes you to all sorts of races, languages, beliefs and sexual practices. We were rounding the other day and one of the Spanish speaking patients is screaming that he wants a sleeping pill because he hasn't slept in like 3 days due to his pain...en Espanol of course. So forgetting that I was the only one with any sort of western language skillz, I accidentally translated what he was saying...my big secret came out. Yes, I can understand and speak some limited Spanish. All of a sudden, I am translating for EVERYONE.

Ever tried to get a history from a demented old man with an old stroke in a language that you only sort of understand? Ever tried to take a history in a language that is not your own for a hematologist? Ever tried to explain an AV-fistula surgery in Spanish?

Only one week of this left...I've never been so happy to leave a service.

Insurance = Care???

I started writing a post sometime back in August about the health care debate and sooo many of my gripes with both sides and how stupid the whole process was...and then it sat as a draft because it was pretty much unreadable and full of half-formed ideas and grossly stated opinion...but it started something like this:

Putting aside all of the death pannels, town-hall screaming matches, etc. here's my bottom line: you cannot equate health insurance and health care.

And then I read an amazing article that included my point in a rationally stated, down to-earth manner. So here's the link from Atlantic Monthly. Hopefully it saves you from my awful writing.