Wednesday, March 31, 2010

Yes, it's that bad.

My schedule + personal items requiring a lot of attention=very short blog post.

Today, as it is early in the block and I am well-fed and rested, I actually talked to a nurse about showing compassion.

Picture it: Two patients in the ED. Both are going to be admitted. Both probably should have been at a clinic (but I can't go into ER misuse right now). Both probably contributed to their illness by ignorance/non-compliance.

There is one nurse to take care of those two patients. One stopped taking his medications b/c they "cost too much and weren't working". I'm not really sure why the other one was there except I'm sure it had something to do with his morbid obesity.

On a related note, why is it that when my hunger is at a fever pitch do I get a train wreck patient who is Obese with a capital "Oh."?

Patient #1 was one of those that answered "Well, yeah, I think I have that" to every question. And obviously had different ideas about how medical care worked. Patient #2 was just obnoxious. Now, I might have mentioned before that I don't care to be whistled at, hooted at, or called "NURSE". This guy did all three to me because his actual nurse (who was wearing pink scrubs compared to my professional dress) was too busy taking care of a stroke patient to attend to all 650 lbs of need.

Nurse Bitterface had had it up to her angry forehead lines by then. She started making under-the-breath comments that so loud she had to be a. deaf or b. close to retirement. When patient #1's family accidentally used the word "thyroid" instead of "fibroid" (totally wrong part of the body), she rudely corrected them, saying, "You said thyroid! That's wrong! It's a totally different thing!" I could hear patient #1's family member say, "You're right, I'm sorry. I messed up the words again," with clear embarrassment in her voice. I know it was a difficult patient, and I know that nurse is probably tired of dealing with people who misuse the system. But I know deep down that the patient's family meant the best for her. And a good doctor or nurse will dig deep down enough to pull out some compassion. Besides, at that point it's not our jobs to judge (if at all possible. It's hard sometimes.) to approach that without making her feel like an asshole...

I decided to take a tactic from my usually very well-spoken husband. When she came back to the desk after harassing patient #2 (who quite frankly could stand to wait around a little bit. Maybe he'll learn the ER isn't a 4 star hotel) I said, "you have some tough cases today." "Sure do" she replied. "The hard part for me is making sure that I don't get so frustrated with one patient's rudeness that I punish another patient's ignorance. I know they mean well, they just don't seem to know any better," I offered. "Yeah, I think they really do want to take care of her, but why would you go off meds?" "I don't know," I said, "but I assume I won't know everything about a situation."

After that she at least toned her 'tude down with the patients a little. I would not want her job, but knowing I was coming home to my husband, who didn't deserve a bad attitude (yet), made me want to work a little harder at controlling my thoughts concerning difficult patients.

Wednesday, March 24, 2010

The Animal Continued.

As we went along in anatomy, we worked our way from the neck down (you didn't do the head until you'd been properly desensitized). We did everything except for the leg. The embittered anatomy department had an ongoing feud with the Office of Medical Education. The OME thought traditional anatomy shouldn't take up so much of our time considering we didn't have any strictly anatomy questions on our boards. The anatomy department wasn't having it. In my first year, they got so mad they told the OME they just weren't going to teach us the lower limb. "They were just not given enough time." So we didn't learn the leg. Way to put the students over politics, anatomy department. Not that I expected you to particularly care about students who aren't going into your field and snicker when you insist on being called, "Dr."

For three years, any time an attending asked me an anatomy question about the nerves in the lower limb, I just said, "We didn't learn that." Kind of a cop-out considering I actually still had to learn it on my own.

I could tell you about the things you'd expect to hear in an anatomy blog, like how you had to squeeze all the stool into one spot in the colon, then tie it off above and below so you didn't get it all over yourself when you remove the colon. Ugh. I'd forgotten about that.

When it came time to do the pelvis, we'd join groups so we had one male and one female cadaver. Then we had to cut. Of course none of the guys wanted to cut one of their own, so I said, "scalpel please."

Yes, we found a penis pump or two. My favorite quote of the day was when we were on the female cadaver. As we were going down our checklist, we hit "clitoris." A male student working with my group leaned over and said quietly, "I don't actually know where the clitoris is." "I'm about to change your life" I said.

Monday I start my last real rotation. Internal Medicine. I expect to have many more stories.

Sunday, March 14, 2010

The Animal, Part Two

As promised, I have more to tell about anatomy lab. Ready?

I believe I left off after describing some unsavory realities of the actual lab. Now I'll talk about what we actually had to do in there.

I was not particularly looking forward to this. I had never seen a dead body before and I was about to see a bunch of them. They were all under sheets but it was an unmistakable form, one you see all the time in movies and TV but these were real and I was going to have to touch one. My group and I gathered around our cadaver, an elderly lady, and pulled back the sheet. The head of the cadaver is covered by a bag so you don't see the face at first. It helped a little. We had to flip her over because we were learning about the muscles of the back and the upper limb. In a word, awkward. I remember the moment I made my first cut so clearly. It was one of those "Take a deep breath and just do it" moments. "Now you're real medical students." the instructor boomed.

Once that was finished, so was the short list of things we knew how to do. As I mentioned last time, our "instructor" didn't really give us any clue about what we were doing in his pre-lab lecture. I assumed the long list of ridges and bumps he was rattling off were meant to point us in the general direction. So there we were, a bunch of mouth-breathers with scalpels, one group member reading from the dedicated anatomy and dissection book, trying to take apart skin and muscles we didn't know the names of.

The revered anatomist marched around the room, not really answering questions (or even being visible when you had one), but always managing to show up just as you cut too deep and ruined what you were looking for the whole time. "Ahhh you totally messed this up! You're going to have to walk around and find someone who didn't butcher their cadaver." "You just bluntly probe around until you--Ah well you already mutilated the ligament." "Jeez, don't you people know how to do this?" I think his one pleasure in life was to walk around observing all of us who hadn't and couldn't dissect a cadaver as well as he could (after his many lonely years in the lab) and make sure we knew it. It was almost as if none of us scrubs were worthy of his knowledge.

We were specifically lectured on what not to do in the lab--for example, move a cadaver's mouth to "make it talk" or generally disrespect the cadaver in any way other than cutting it's flesh of its bones, gutting it, and sawing off limbs as the instructor saw fit. He, however, had the bizarre habit of, when he got around to teaching, coming over to your table, leaning an arm on the cadaver's shrouded face (and we're talking leaning on it), and referring to it (the cadaver) as "The Animal". As in "The Animal's trapezius should be dissected away to reveal the small muscles of the upper back." or "The Animal's heart has been surrounded by blood trapped in the pericardial sac." or "The Animal needs to be flipped over now to allow access to its thorax."

That never failed to bother me.

"Who you calling an animal?"

On that note, I will leave again. More to come; this is turning out to be a series!

Friday, March 12, 2010

The Animal

Since I'm once again on vacation (I DO love fourth year), I think it's time to talk a little about the first two years of medical school.

One of the things that truly distinguishes your transition from hopeful pre-med to "why-am-I-doing this?" medical student is anatomy. Shudder.

I know some freaks like anatomy lab. I liked anatomy as much as I'd like being drowned in a bucket of vomit.

Did that gross you out? Good, because that's how I feel every time I think about anatomy class and it's fearsome fearless leader, a man who wore shorts to every single anatomy session, a man who'd spent his life studying what had already been taken apart and put back together. And documented. Really, I don't see what there is left to do regarding anatomy. But there he was, crusty old weirdo, happily hoarding his knowledge while leaving us utterly adrift in a sea of skin and muscles.

He gave a lecture right before each anatomy lab session, but honest to God I have no idea if he ever actually intended those lectures to help us. To start with, they were early. It feels like they started at 7am, though that would have been weird. Probably they started at eight, but I as a first year student I was blissfully unaware of what 5:30 looked like and thought 8am was painfully early. Also, they were as boring as watching a bitter old man mumble aimlessly in front of a projector. Because that's what we were doing.

At the start of the 8 week academic block we were given a multiple page list of anatomy we were to have learned by the end of the block. This list ranged from the doable "humerus" to the ridiculous "coracobrachialis". We were supposed to know every bump on every bone. From what I gather we were supposed to know a certain amount of them before each lecture too. I think I tried really hard the first week, but still ended up banging my head on the desk after his "lecture", so after that I just flew by the seat of my pants. Excuse me, by the gluteus maximus of my pants.

Next up was actual anatomy lab. We trudged back to our classrooms and changed into our dedicated anatomy scrubs. I say dedicated because once you stepped into the anatomy lab wearing something, it would never be the same. So we wore the same set of scrubs, shoes, and for me, lab coat, undershirt, shorts, and old sports bra (you could never have too many layers) for the first 3/4 of our M1 year. Some groups rotated every week on who would take everyone's scrubs home to wash them. Some people washed their scrubs after every block. Some reasoned that they wouldn't want to put whatever had splashed onto their scrubs into their home washing machine and just sent the lab coat, scrubs, undershirt, shorts and old sports bra to the incinerator at the end of anatomy.

Oh Lord. They smelled. The whole hallway with the lockers where we kept our scrubs smelled. Any hallway we walked through to get to and from the lab smelled. And the lab itself? Shudder. One friend wore a surgical mask that she either sprayed perfume onto or stapled a dryer sheet into it to mask the smell of formaldehyde. Brilliant.

You may ask, if the chemicals smelled so bad, how was it safe to be in the room? Actually, that is a great question. Our anatomy lab was usually kept ice cold (for good reason), and was in the lowest level of the building. The windows were occasionally cracked open, but not at any degree as to actually give us fresh air. There's a group that goes around monitoring the air quality in medical school anatomy labs. A few years before I started, one M1 class just didn't have anatomy because the lab had failed the standards. So they were off the hook while the lab was fixed. If ours was that rank after it was refurbished, I don't even want to imagine the headaches the class before it had.

After a few months of anatomy, certain areas of the lab started to take on a slightly different even more terrible smell. Inevitably, some of the cadavers are not as well preserved as the others. We rotated cadavers every eight weeks, and you just prayed that you wouldn't transfer to a rotting one.

Another fun-killer in anatomy was the obese cadaver. We had a set amount of things to dissect and see per session, and I felt terrible for the groups who would spend the first hour or two dissecting down layer after layer of adipose tissue before they could even start to see muscle.

I have so much more to say on this topic (more than I thought when I started this!) that I'm going to post this now and finish later. And my title will make more sense. I feel bad because posts have been slow since I got off vagina-detail.

But don't worry. Next month I'm on Internal Medicine again.

Wednesday, March 10, 2010

Here's Your One Chance...

I continue to be fascinated by babies having babies.

As I've said before, some are whiners, some are idiots, some were trying, some just got caught. Some though, you just can't figure out.

One 17-year old having her first baby was completely calm and collected. She was doing her Lamaze breathing through the contractions, with a mom-aged lady on either side of her. I couldn't figure out which one was the mom. One of the women seemed to be much more helpful and generally pulled-together. The kid was listening to her more than the other, but you can never assume. Sure enough, that lady was a friend of the family; the real mom was the not-so-pulled together one in sweatpants sneaking out to smoke. Her name was the title to a country song. I've never actually met a real person with that name before.

That girl ended up with a C-section. "She's always been so grown-up" the real mom said after I commented on how well her daughter was handling everything. "Agree to disagree," I thought.

Now, every time the parent of a teenager about to birth said something like that (and I kid you not, it happened more than once), a little part of me started seizing. I have to concentrate so hard on keeping a straight face that I'm surprised my nose doesn't start bleeding. How grown up is it to have sex without birth control? How grown up is it to intentionally get knocked up at 15 because you think you really love him! I grew up in a small town, so I thought I'd understand it. But I don't. While I was thinking about getting my act together in high school so I could go to medical school (no, I didn't date much), some of those girls don't have anything to think about after high school.

What about adoption? Oh no. OH no. You don't understand. Out of that entire month, every day of which at least two unmarried teenagers gave birth, only 1 woman gave her baby up for adoption. The other patients and their families were all excited about the new arrival.

It's a difficult situation. On the one hand, at this point the baby will be born so you might as well be excited about it. It's not like I think everyone should wear black to the birth and sit around talking about how the girl is probably never going to finish school or make more than minimum wage. But these patient's mothers, many of whom were teenage parents themselves, act as if she's going to bring home a new doll for everyone in the family to play with. As if things will magically be better, despite the fact that they already can't afford health care or rent for a big enough apartment to house the expanding family.

There has been a little research showing that a religion-free abstinence education program might delay teen sex better than religion-based abstinence only (might as well rent the kids hotel rooms for how successful that is) and comprehensive sex-ed. Honestly, at this point, after that month, I don't care if you send in fire-breathing nuns that do balloon animals out of condoms. If it would convince these women that there are more possibilities in life, I'd blow them up myself.

Friday, March 5, 2010

Cancer! CANCER!!!

One day while hanging around with the on-call OB (I lived away from my husband during the week, what did I have to go home to?) we got a call from the ER. Actually, every day we got calls from the ER, but this one was about a post-menopausal (early 70's) lady who had massive amounts of vaginal bleeding.

That's never good. Besides being unexpected and pain to clean up, post-menopausal bleeding is cancer until proven otherwise.

Not that it's always cancer-actually, only about 10% of that post-menopausal bleeding will be diagnosed as cancer. There are several other reasons it could happen, fibroids being one common harmless example. But you have to prove it isn't cancer. And with the amount of blood the patient described that was our first suspicion. Not to mention the patient had a pelvic ultrasound that showed a 17cm uterus (normal for a post-menopausal lady is around 8x5 cm) with a thick shaggy endometrial strip measured in centimeters--the endometrium should be no bigger than 4-5millimeters, and her was in centimeters.

Well that was bad news. We saw all this before we went to go see the patient. She was a very pleasant lady who brought her daughter along. It's very odd to interview patients in the ER because they are often laid out in a bed scrunched in a tiny room. So you are standing at the foot of the bed and they are laying down straining to see you. Sounds weird that this would matter, but people just look different like that. And you have to remember that until they got to the ER, they were perfectly upright and mostly-normal looking (i.e., not sick and in a hospital gown).

Anyway, this lady knew she'd bled a lot, but I don't think it sank in how bad that was. The attending asked her the whole gamut of normal questions like family history and previous symptoms and allergies because she knew the patient would be admitted to our service that night. The lady just talked and talked, telling us about her aunt's history of diabetes or her father's father's heart attack and not really getting that we're trying to find out if there's anything other than cancer that could be happening. I could barely concentrate on her answers because my mind was screaming "CANCER! YOU PROBABLY HAVE CANCER! I DON'T WANT TO KNOW THAT YOU'RE ALLERGIC TO STRAWBERRIES--CANCERCANCERCANCER!!" Her daughter looked a little more worried--I tried to see if she understood what was probably happening. Maybe that's why the doctor wrote things down; otherwise she'd be like me unable to remember anything but how the lady looked and wondering how long she had left. The attending told her how vaginal bleeding, especially her amount, was abnormal and that it could be fibroids but we needed to get a tissue sample. "What else could it be?" She knew and we knew what else it could be. "Well, I'm concerned about cancer." "Oh."

Endometrial adenocarcinoma is usually found early, at stage I the 5-year survival rate is 85-95%. But something about the size of her uterus and endometrium made us think it was more serious. And even if you know that statistic, it's still cancer. It's still scary.

We scheduled this lady for a D&C (dilation and curettage-basically a cleaning out of the uterus) so we could send tissue to pathology. "When would we go to surgery?" she asked. "Tonight" my surgeon replied. "Oh."

Once back in the OR, we started cleaning out bloody necrotic material with black and yellow blobs. "This makes me lean toward cancer unfortunately," the attending said.

After we were done we went out to see the patient's daughter (husband still wasn't there for some reason). "We should have pathology results by Wednesday. Make sure someone is here with her." Meaning, "It's probably bad news."

Later that week the doctor relayed what had happened. The path report came back as cancer, specifically a type of sarcoma, which has a much lower 5-year survival rate than adenocarcinoma. She said the patient's daughter was with her again, and the patient said she couldn't rely on her husband for support; she did everything for him and he couldn't handle the idea of cancer. So he wouldn't come to the doctor's with her.

It seemed like the lady and her daughter handled the news well, and she was sent to the city where a gyn oncologist could do her hysterectomy and look for cancer elsewhere in the pelvis. I hope this lady's husband comes around and decides to be with her as all of this is happening.

Wednesday, March 3, 2010

Hysterectomies all around!!

Apparently, in that small town, uteri were no longer cool.

Women not much older than me were having them yanked right and left for things like "menorrhagia" and "dysmenorrhea" (heavy bleeding and difficult periods, respectively). Even when they were offered endometrial ablation, which is totally awesome and involves knocking the patient out, sticking a tube up in the uterus, and to grossly simplify it, push a button so that the end of it shoots out and opens up like an uterine cavity-shaped umbrella. Then you press another button and it sizzles the endometrium. Sure, it eventually grows back, but not for a while. And it sure as hell beats losing an organ.

I don't think I can impress upon you enough how much I dislike surgery. Not just because of those bowel-goblins who tortured me for four weeks last year either. It is not natural. Having seen what I have seen now, I would not do it unless it were impressed upon me that I would die without it. Appendix? Yeah that'll kill you, take it. Gall Bladder? Hmm...that can still be fatal, and any idiot can take out a gall bladder. But hysterectomy? I better have cancer, or fibroids the size of fists. And not just one fibroid. I better have enough that if I cough my uterus falls out on its own. Then the surgery will be more like a wart removal I imagine.

Picture it: 325lb, 5'3" woman who thinks her uterus is what she needs to lose. The preferred way for someone to let go of her uterus is through her "natural orifice". Women who have it out like that usually get to go home the next day. Unfortunately, things are so padded down there that despite the fact that you have the lady in "dorsal lithotomy position" aka. "The Baby Maker" (sorry if you clicked the link already) the 5 inch long deep weighted speculum couldn't hold its ground.

I thought you needed a picture.

Soooo if you can't spelunk the lady-cave, there are other options. One is a laparoscopic-assisted vaginal hysterectomy, where you go in with a camera through her abdomen and loosen things up. Then you finish the job through the vagina.

With this lady though, we elected to do an open hysterectomy. These are the old-school surgeries everyone used to get. For this one we cut a Pfannenstiel incision and went right for it. This particular patient had a few pieces of fantastic that made the surgery something to look forward to:

A. Morbid obesity. Like, Tim Burton morbid.
B. Panic attacks at the thought of anesthesia-specifically the Happy Mask going over her mouth and nose.
C. How did we find this out? Because she flipped s#$@ ON THE TABLE at her last surgery and canceled. Do you know how frustrated an OR team gets when a patient does that (besides the fact that you're all dressed up for a party that just got canceled, another customer could have had the spot. And you knew she'd come back when she calmed down.)
D. She has a coagulation disorder. So now you have 4 inches of fat to cut through, which loves to ooze, and the lady has a bleeding problem (due to meds that she has to take to prevent clotting all around her body). That's before you start the real cutting.
E. She smokes. Grrrrr.

In short, this was a very difficult surgery. Before we even went in I noticed several circular bruises on her abdomen from heparin shots in the days leading to the surgery. My job, per usual, was to keep the tidal-pannus from lapping over the surgery site. It took a long time because the attending was fastidious about stopping any and all bleeders. After it was done and the uterus was in the bucket, I actually thought things had gone well.

Unfortunately, the next day, her hemoglobin dropped. Several points. CCRRRrraaaaaappp. She had to get transfusions and stay in the hospital several days because after each transfusion (sometimes 2 units), her hemoglobin would keep drifting down. She had a bleeder somewhere, probably something arterial with how fast things dropped that first day. I was really surprised. My attending had been so careful; nothing, I mean NOTHING, was bleeding when we got out of that abdomen. Did a stitch slip? Did we not notice something? Did something else rip when she sat up, coughed, went to the bathroom? I don't want to blame her, but her obesity and coagulation problem did not help.

We were left with several decisions: Should we restart anticoagulation? It seems like a no-brainer NOT to start anti-coagulation when a woman is actively bleeding, but during this time she also developed a DVT in her arm at her IV site, probably due to poor IV care by the nursing staff. So now what?

Do we go back in and try to stop whatever is bleeding? Then we run the risk of making something else bleed.

We started with an ultrasound to look for blood, which is usually a crap study on someone so heavy-sound does not penetrate obesity. We finally had a CT scan done, and in a disappointing show from the radiology department, two different doctors were told two somewhat different results. The hematologist got a phone call that there was an abdominal wall hematoma. That is something that does not require surgery, as the pressure in an enclosed space will likely cause hemostasis.

My attending was not called, and instead read the dictated report, which mentioned "some free fluid in the abdomen" (at least attempt to quantify, please), and had absolutely nothing about the hematoma.

Those are two vastly different interpretations with vastly different treatments. A patient can bleed out into her abdomen. Luckily the hematologist talked to the gyn surgeon and they eventually cleared things up. Not before the surgeon talked to the patient and looked like an ass, unfortunately, but she covered very well.

So we didn't have to go back and do surgery. Thank GOODNESS. But I do wonder-when we inspected her abdomen, there was new bruising. My pannus-retraction, while definitely not anything you could call "eager", probably did that to her. Her hematoma could have been caused by several parts of the surgery, but what if the big one was my fault? What if this lady had 4 blood transfusions and a week in the hospital because I was focused on wrangling her wayward belly and forgot that she bruised so easily? Could I have been gentler? Was there another way to fat-smash without actually smashing? During the surgery, all I thought about was clearing the way so we could see and reach what needed to be done. I guess I have some things to learn about holding each patient's special circumstances in my head instead of approaching each like they are the same problem with the same rote solution.

Tuesday, March 2, 2010

Follow Up

I still have stories to tell about last month, so don't worry. My blog won't get boring just yet.

Before I forget though, remember the strung out woman who didn't know that the kicking lump in her abdomen was a baby?

The baby tested positive for HIV. Mom tested positive for opiates (heroin?) among other things. I hope she never gets that baby back.