Cross posting...

Two things that I put on my facebook page today that I'm cross posting...

1) the above picture
2) this link: Suck it up, America (via DocShazam)


Now it's time to watch some TV and pack for the drive back to Massachusetts tomorrow...huzzah

FML...AGAIN

Lappy is expired again...t-3 days until exam...FML. Looks like I'm sitting in the library for the next few days.

I'm pretty sure that the poor innocent Dell tech support guys had no idea what to do with the irrational, angry, over-caffeinated, sleep deprived medical student on the other end of the phone blabbering on about some sort of "medical licensing exam" with "major career implications" threatening to buy a Mac and trying to get a free windows 7 upgrade out of the whole thing me.

3.5 days left...AAAAAH

Lappy is now back and fully functional thanks to its third motherboard and the nice technician that came out to install it! I spent most of Saturday on campus using the computers there (shudder) and had some serious flashbacks to my first two years of med school. Luckily one of my friends let me borrow one of his 3 computers and I managed to get by alright.

I had been thinking about postponing my CK for a week and Saturday's little FML incident nearly pushed me over the edge. The constant 5 week beating from USMLE World had completely eroded my confidence, and I have been watching my average slowly decline over the past week. So I took one of the NBME exams just to see how I did, and it was in the acceptable range...so I'm sticking with my date this Friday. I'm self-imposing a blogging ban since I have like 3.5 days of studying left, but I'll put something up afterwards.

GAAAAAAAAAAAAH...FML

Not sure if everyone's seen this website but it's called F my life, pretty classic stuff on there. If there is such a thing, I had the med school equivalent of that today.

I'm taking Step 2CK in 6 days and I woke up to find my computer dead with 30% of USMLEworld to go. FML.

Welcome to Neurosis...

In behavioral health/psych, we learn about obsessive-compulsive disorder which is mainly characterized by intrusive thoughts that cause anxiety and compulsive behaviors that alleviate the anxiety. (DSMIV criteria can be found here.) Whenever OCD comes up, there's always the half-joking/half-serious tag added on that "a little bit of this isn't a bad thing in medical school," and we all nervously chuckle and look around at all of the other medical students sitting around the lecture hall.

Well, my fourth year is begining to feel a little bit like that. My brain is entirely somewhere else during the day and I can't stop thinking about the match, interviewing, my step 2 exams or other asinine med-school related stuff for more than a few minutes to pay attention to the docs patients. One of the caveats is that the worries can't be about real life concerns...so I think I'm pretty safe there, but I'm still absolutely unable to concentrate because of this chronic, baseline anxiety. The only thing that makes it better is checking my email to see if the programs I applied to are offering interviews yet...and I know that there won't be very much movement this week due to the ACEP meeting in Boston, but I keep on checking anyway! It's totally inappropriate, but I'll slink away to a computer between patients and pull up my email to check. Fortunately, I see other fourth years going through the same motions on the wards and pulling out their iPhone's every few minutes to peak at the inbox...

It doesn't help that I'm on my mandatory PM&R rotation this week. The requirements of the rotation are to sit in a little exam room with a PM&R attending (who looks amazingly well rested, in shape, and happy by the way) and struggle with the patients through her Russian accent and brusk mannerisms. Between her and the tales of woeful chronic back back pain it takes me about 2.4 seconds to zone out wondering when I'll finally get home to start mowing down USMLE world questions or get my next interview (up to 3 now!). I can't muster the energy to care. However she does manage to drop some randomly awesome physical diagnosis knowledge from time to time, but I have to cut through the fog of aweful surrounding the rest of the day...

55% of USMLE World questions down and 10 days to go...I figure 3 blocks of questions plus review should get me done by the middle of next week before my exam. Still getting smacked down by the occasional section, but there's a steady average trend...

USMLE World...

Is slowly killing me. Although, it is GREAAAAT at exposing the weaknesses in my fund of knowledge: Apparently I suck at peds and psych. And the roller-coaster of performance isn't very confidence inspiriting either.

I've also noticed a disturbing trend in reviewing questions: the longer I go with questions during the day, the worse I do. The earlier in the day and the more awake I am, the better at thinking I am...but after a long day on the wards when I come home and try to get through my questions, I can get through a section alright, but the second section of the day tends to be worse every time.

Oh well...14 more days of this stuff until the real thing!

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

Whiplash

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.

Teamwork

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.

less aweful reading

b-9

Radgirl's path was benign!!! Best of luck with recovery

And now for some aweful reading...

One of my more faithful readers Radioactive Girl was just diagnosed with cervical cancer following her recent surgery and had the courage to write about her surgery on her blog.

My heart goes out to her and her family. Please send her your positive vibes as she's waiting for the path results. I can't even begin to imagine the horribleness of having to wait for these things.

Some good reading lately

Since I've been taking a little bit of a break from writing, I've had some more time to keep up with my blog reading list between my shifts and studying to get up to speed. Here are some of the highlights:

White Coat's Trial- this has been a phenomenal series to follow. It highlights some of WC's thoughts going through the trial, the process of being sued as a physician and how malpractice attorneys exploit documentation to build their case. Very insightful!

Ed Leap has a great post about why EM is hard written in his wonderfully insightful manner

The Central Line is the new ACEP blog tackling all sorts of EM-related issues from policy to practice. Grahm from Over!My!Med!Body! is one of the contributing authors with guest posts from Shadowfax.

The ever-cantankerous Panda Bear has been back with some good stuff over on his blog.

ABB is starting to make her transition from the world or EM nursing to Medical School at the RCSI...I'll bet she'll have some good stuff about her transition. One of the best recent posts was about running a code on a neonate and the aftermath.

Finally, the fake doctor is back from his year long hiatus and has a new Healtcare policy blog that he's using to explore the new US health care quagmire. White Coat and The Central Line also have alot of policy content these days...each with a slightly different angle.

Back where I belong

For the past month I've been the Bostonian in Boston. My natural habitat!!! I've been hanging out in some of the Hub's better emergency departments and I'll be spending August in another cool Boston-area program. I can't tell you how nice it has been work in the field that I want to match into in the city I want to live in. I finally feel like the past 3 years of pain and suffering are coming to an end and that there is a light at the end of the tunnel. I feel like I can finally be what I want to be and do what I want to do. Best of all, I leave my shifts exhausted and happy, which hasn't happened very often in medical school.

One thing that is nice about doing an emergency medicine clerkship is that you have freedom to see the patient, evaluate them and put your own plan into action with the approval of the attending. Something that I hadn't really appreciated until these rotations are how awesome ED nurses are. At the first program that I worked at, the nurses and physicians had an amazing collaborative relationship...no one was above anyone else and everyone worked hard to "move the meat".

One of the murses (yes...murse) adopted me during one of my first shifts and made sure that I knew where everything was. He'd save procedures for me, grease the wheels to make me look good, (knew what tests were going to be sent before I asked for them and usually what meds should be hanging)...and would gently remind me if I forgot something in the orders. Absolutely stellar (!), as were most of the other nurses. It was probably one of my favorite settings to work in...ever!

In the new department that I've started in, there's a physical divide between the physicians and everyone else. The department, designed by a trauma surgeon, is divided into two pods. Each pod has a large rectangular nurses station in the center surrounding an enclosed physician's charting area, a med room and a nutrition center. This doesn't lend itself to the most collaborative environment, and as such it's not easy to keep track of who has who. Fortunately, I'm pretty low-key and have managed to get along with most of the nurses pretty well without them rolling their eyes or yelling at me...so that makes me feel good.

Anyway, I've had alot of shifts and a good amount of reading to keep up on amongst living at home with the parents and siblings wanting to hang out in my free time...so the blogging will be thin this month, but I'm sure that I'll have some more stories to share...

T-minus 1 year...

July 1st...the worst day to be a patient in the United States.

One year from today, I'm going to be licensed to kill. Reminders of that were everywhere:

1) ERAS went active today...
2) My friends who are interns all had Facebook statuses with something like "I hope I don't kill anyone today..."
3) There were a couple blog posts about it...like here

Scaaaary stuff my friends, scary stuff

My buddy the heroin addict

We're standing on rounds and the resident presents the following patient that was admitted to our team over-night:

John Doe is a 25 year old male presents with left sided facial/anterior neck swelling, left shoulder soreness and pain/parestheisas over the left buttock/thigh. He was skin popping heroin the night before last and woke up yesterday morning with these symptoms and presented to the ED…Febrile to 102 in the ED…cough, hoarse voice, a couple ulcers over his chest…CXR shows scattered infiltrate, cultures and some labs are cooking but he's got a white count and a CK>16,000. Yadda yadda yadda. This is a good case, why don't you cover him Bostonian??

I hate those words..."this is a good case" usually means that the patient will have a mildly interesting work-up but is such a pain in the ass that the residents didn't want to deal with him...

My prediction was right...he's cursed and swore through the H&P that morning. He kept telling us that he just woke up that way and was in alot of pain. He was even courteous enough to remind us that he has a tolerance to opiates. So my attending decided to throw me under the bus: "Alrighty, well we'll do our best to make your pain more tolerable and then Bostonian will be back in to talk a little later on". Thanks doc...I can't wait to work with this little ray of sunshine for the next 2 weeks.

So I come back later in the day and he's passed out, snoring away with a half finished breakfast tray in front of him...guess that extra dilaudid helped with the pain. I woke him up and got the whole story from his side of what happened. He ended up being a pretty nice guy underneath the gruff exterior and the pain was controlled. He had gone to a decent college was trying to keep his own business afloat, but he got mixed up with the wrong crowd and started using the hard stuff. I ended up having to do the patient education since I was covering him.

John: So this was pretty serious huh? I could have died from this, right?
Bostonian: Yep, if you had waited to come in, you might have been much worse off.
John: Hey, how old are you man??
Bostonian: 25
John: That sucks. We're the same age and you're here being a doctor and I could have died from heroin. That's scary man!
Bostonian: Yeah, we've had different lives. My parents were on my ass for the first 20 years of my life and your dad was an alcoholic who and won't even visit you 3 miles from home in the hospital. But the good thing is that you're young and still have your health and a business and a talent. You can change your life before the drugs kill you...alot of people don't get the wake-up call until it's too late.
John: You know I've been thinking about going back to school once I get clean. You've inspired me man, I want to do something with my life. I mean seeing you here making a difference, it's amazing. I don't want to waste my life any more.
Bostonian: I'm glad, I'll have the case manager give you some numbers for rehab programs.

Getting over your cynical preconceived notions of someone is a good thing sometimes. It gave me one of the more rewarding patient interactions in my career, but I'll always wonder how much of that was him blowing smoke up my ass to get his dilaudid and how much was genuine. I'm hoping that he's clean and back in school!

I guess you gotta wear the rose-colored glasses sometimes to hope for the best, because reality sucks sometimes.

EM in the Village

My school is affiliated with a hospital in New York's Grenwich Village and they saw fit to send me there for a few weeks of EM. For those of you unaware, the Village houses some of the more interesting people in the City living alternative lifestyles. I don't mean "alternative" in the GLBT alternative...I mean the homeless, the drug abusing, and the clueless. Here's a few of my favorite chief complaints and quotes:

29 yo F with chest pain-
Had a history of panic attacks with chest pain when riding the subway. She started having a panic attack when I was on the subway and had some chest pain...wanted to make sure it wasn't a heart attack. Her panic disorder remains untreated.

34 yo M with fever and L testicle pain/swelling-
Bostonian: Do you use any drugs?
Dude: Officially, no. This isn't going in my medical record is it?
Bostonian: I need to know because certain drugs can cause fevers and infections. Unofficially?
Dude: I dunno, just little bit of Meth.
Bostonian: What happened on your arms there? (Pointing to the relatively fresh track marks)
Dude: Ok, I use a little bit of heroin too. But only a couple times.

25 yo F with BRBPR-
Bostonian: Any change in bowel habits?
Chick: Well...not really. I just moved in with my boyfriend a few weeks ago and I can poop with him in the apartment. I hold it, sometimes all weekend.
Bostonian: Honestly, I didn't know that girls poop until medical school.
Preparing for DRE
Chick: I usually don't let guys get to this point unless there are dinner and drinks first...
Me: Um...does that mean I owe you a drink?

23 yo F- with classical migrane and possible seizure D/O
Her- OH MY GAWD...I THINK I'M GOING TO HAVE A SEIZURE!!!!!
Me- Do you always have seizures when you feel like this?
Her- No
Me- So why do you think you're going to have a seizure?
Her- Because I have a headache!!!
Me- How many seizures have you had?
Her- Like 15 since 2006. But no one believes me.
Me- Have you seen a doctor for them?
Her- I just started seeing one last month. He didn't believe me until my roomate yelled at him and made him order an MRI. He started me on Keppra a month ago which I didn't start until 3 days ago. And he gave me perscriptions for an MRI, EEG and CT scan, but I missed them all so they have to reschedule them.
Me- So you had 15 seizures and didn't see a doctor for 3 years and then you didn't follow up with your appointments or take your medication. Did you tell your neurologist about your headaches?
Her- No.

Cutting back on the drink...

A fairly put-together 30 year-old lady came in with some moderate epigastric pain and nausea for a few days. She said she over did it over the weekend before at a bachelorette party but no real other medical history besides some poorly controlled hypertension and a rapid tremor that she claimed had been there since birth. Oh...and by the way she drank about a bottle and a half of wine most nights. Labs showed elevated amylase and lipase, so we went with acute pancreatitis (alcoholic vs. gall stone). The enzymes came down after a few days of NPO and hydration and the GB U/S was clean, so we decided to send her home after she tolerated PO without pain or nausea and we were able to send her home with her tremor and hypertension. Well, the whole HTN and tremor history sounded pretty funny to me...but my attending brushed it off, so I did too...who am I to question the attending? I rotated onto the CCU team the following Monday thinking that she was doing well.

About a day after discharge, the poor girl has a seizure and spends 2 days in the ICU where she was suddenly hypotensive and dyspneic, placed on BIPAP. She got an ECHO that showed an EF around 20% due to alcoholic cardiomyopathy. Suddenly that hypertension and tremor looked a bit more noteworthy than before...I saw my attending rounding and all I could ask is "WHAT'D YOU DO???".

She ended up doing pretty well, fortunately. But missing a girl in alcohol withdrawl is kind of a big deal in my book and I hope the attending knew it. I felt aweful that I hadn't spoken up about my tingling spidey sense...not that my attending would have paid attention to me anyway.

Suck it third year

Sorry for the long lapse between posts...I was studying for my medicine exams, planning fourth year and moving, etc.

Finished my medicine shelf last friday and OSCE last Sunday...so I'm essentially onto 4th year of med school!!!!

Since then I've been couch-surfing down in Brooklyn while working in one of our affiliated ED's in Manhattan...more on that later though. For now I'm going for a nice long run in Prospect park, and I'm going to catch up on some of the non-medical parts of life...which involves a decent amount of driving around in circles up and down the east coast...I've got another week here in the ED then home for a few days next weekend, then down to see the GF down in DC for a few days. Then I've been conned into helping out with orientation for the rising third years...so it's back to NY for a few days and then my last few days of freedom before I spend the summer in some of the busier EDs in Massachusetts doing what I love to do!!! Oughtta be fun...

I'll try to get some of my better post ideas up before I'm stuck studying my face off for the summer and hanging out with my fam and the Boston crew.