Pediatrics
has been a blast so far. I’ve found myself paying more attention to
minute detail with infant and small children, as they are not able to describe
the extent of their illness. This forces me to consider more options, and
really become a better diagnostician, as the differentials aren’t eliminated by
the patients’ narrative as they tend to be with adults. The harder part
can be the physical exam with a fussy patient.
What
used to be a routine procedure, has suddenly become more complex. The general
physical exam with adults follows a pattern that becomes routine, however
with the children, the order varies with each patient. There are the
children who have no problem being placed on the exam table and being poked and
prodded in the ear canal and nose. Then there are those who are a ticking
time bomb. They are placed on the examination table and give that look of
concern as the stethoscope touches their chest. They then glance at the
mother then back at me with that “stranger danger” look quickly followed by a
trembling of the lower lip. Sometimes a sticker is enough to console
them. Other times, they have had enough and and are hungry, tired,
constipated, and/or have had enough of my face. They let out a scream
that lets me know I am a nuisance and then I proceed to the more invasive parts
of the exam: looking into the mouth. Then proceed to look into the ears
with the parent/s holding their arms as I stabilize the head and look into the
ears and nose. Then the hard part is over, they hold their parents and
look at me with a piercing glance. One 3 year old patient then proceeded
to tell me to “go away.”
5:00 Exercise
6:25
drive to hospital
6:
45 head to rounding room
7:00
night shift gives updates on patients
7:30-11:
Round on patients, individually and with resident/ Finish SOAP notes
11:-12:
Round with attending physician
12-12:45:
discuss plan and updates with patients
12:45-1:15:
lunch
1:15-1:45:
Update SOAP notes
1:45-7
(Options): 1) One of the three students goes to the FM clinic 10 min away
2)
One student can go home
3)
One student stays until 7 PM to study/ wait for another patient admit
and complete an
H&P/ Follow up with to-do items for patients
7-10:
??? Eat, study, read, piano, social activity, sleep
There
is no set schedule, really everything varies depending on how many patients we
have and how many complications they have, and which resident we’re working
with, some will keep us at the hospital longer than others. Also, each
student has a week of nights from 7pm-7am and a week at the clinic from 8-5pm.
Sometimes
I try to make the posts flow with a topic, I think I’ll now just go into a
random flow, if you hate it let me know. So much goes into rotations.
The other day one of my classmates was making a joke about how the other
students were sounding. A very knowledgeable yet pompous doctor, just ask
him and he’ll tell you his accomplishments, was passing through the hall and
the other students were hanging on to his other word and you could just tell
they were feigning interest. My collegaue was like I know I sound like
that too, trust me espeicially with the surgeon. He was like I’ll be “yes
sir that is the most amazing story ever, so extraordinary” lol. I know i
some of that, laughing a little too hard at the doctors’ jokes that aren’t that
funny, and just trying to be likeable, but when I notice I try to stop.
For the most part, I think i just try to do teh best for the patient, and
try not to care about what grade I’ll get at the end. Then there’s the
dilemma of studying to get a good grade on the shelf exam vs. studying the
disease of a patient and studying the disease of the patient that will not be
on the test. Then there’s the feeling that you’re not responsible for the
patient, because you’re not the doctor, you just gotta go home and study.
Feeling like you don’t really know enough to really make a difference,
but then realize that this is probably the most time you’ll ever be able
to spend with the patients. You are able to do more educating and more
thorough physical exam that the docs simply don’t have the time to do.
You’ll see the residents stressed from all the documentation, and you’ll also
be doing alot of the same documention thinking you’d rather be spending time
with the patient or looking up the pathophysiology of their disease, and get
disheartened because alot of medicine these days is simply that, documentation.
Then I spend time thinking about maybe I should just go into a concierge
practice or other priate practice and not have to worry about insurance, but
then realize that that will likely alienate the same underserved medicare
population that was part of the reason you went into medicne.
Then you look at the schedule and realized that you won’t be able to have
months off for vaction to travel or otehrwise like in undergrad, but then you
realie that you’re actually looking forward to going to work and that you’re
amking a difference in that patients life and that makes it all worth it.
Then the next day you don’t remember which types of bacteria are gram
positive rods when you just spent months studying for a test that covered all
that, and feel like stupid.n… Then you run up and down flight of stairs just to
get a hold of medical records of another hospital to get the records of another
hospital. Then get placed on hold, then find out that they never received
the fax. Then you wonder why in 2015 you can’t just send a picture of the
document or why there still isn’t a central database where all hospitals
can access a patients info. Then after many calls back and forth and
holds, you realize that the other hospitals’ records don’t match this
hospitals’ so the patient was given a higher dose of pain meds than necessary,
causing the patient to be somnolent and barely responsive. Then
you worry about whether or not someone will take you for residency and
after that how long it was pay off these pesky loans. Then you have the
nurses who treat you choose to be less than helpful, but you can’t blame
them cuz it because being nice probably leads to being overworked and over
questioned by these pesky students who don’t know much. But we’re still a
part of the medical team and want to be respected as such.
But we’re the bottom of the bottom because we’re paying to be here and
everyone else, including the janitor, is being paid to be here. Then you
think how great it is to be learning about the human body and get to see God’s
intricacies everyday, and find peace in the fact that you’re making subtle
differences in people’s lifes
Sometimes
medicine is like putting together the pieces of a puzzle. We had a
patient who has been in and out of the clinic and hospital, depressed from not
being able to determine the cause of his chronic illness. Over the years,
doctors had run multiple tests to determine the cause of his systemic skin
problems and lung problems. It got the point where we couldn’t provide
any answers, so we had to release him. Then suddenly an obscure lab
result led to further investigation and the eventual confirmation of a
suspected diagnosis. The patient was elated and for the first time, eager
to come back to the hospital. Now we can finally begin treatment with prednisone.
It is important to have a diagnosis, because steroids can cause multiple
adverse effects such as impairing wound healing or worsening osteoporosis,
but with a diagnosis you have studies that can confirm that the benefits
outweigh the risks.
The
night shift hasn’t been so bad so far. Initially I was thinking that
I would have to stay up the whole time (7pm-7am), but I’ve been able to get
more sleep then expected if it’s a slow day. Yesterday, we only had
three patients, so I got a full night’s rest. The call room for the
students is pretty nice, with a computer, desk, bed, and bathroom.
Tonight
will be the first day of my week on the night shift. I’ll be working 7-7,
should be fun! There is a room for medical students to sleep in with a
desk for studying, but I guess it will depend on how busy we are to see if I’ll
be using that room or not.
I
always assumed that residency is when it would be really difficult to sustain a
relationship (especially a new one), as the partner realizes how little they
will see the resident who is usually studying, in the hospital, or too tired to
function. Boy was I wrong.
Today
I learned the formula to relationships during residency from a resident at the
clinic who is an expert on the topic. Apparently, the number of
girlfriends you should have during residency should increase linearly in
proportion to your year of residency. During year 1, you’re still trying
to figure things out with the hospital system, having increased workload,
complicated and chronic pain patients that get passed down from more senior
residents, and the other “hazing” that accompanies first year of residency.
Therefore, you can only handle one woman at a time. Then you
gradually get more and more accustomed to the processes, get better with time
management, and get faster with seeing patients, procedures, and paperwork. Naturally,
you use the extra free time to add another girlfriend to the roster.
By third year of residency, you’re pretty much a full fledged
physician, and you have more autonomy and ability to trickle tasks down to the
interns and 2nd year residents. Of course you then add the last
girlfriend to the roster. Today was the first time I heard of this,
but it’s common sense, I’m surprised they didn’t mention this during
orientation. It’s definitely something that needs to be addressed in the
future.
A constant
fluctuation of emotions, whether revealed or concealed, accompany the practice
of medicine. Death is one of these unavoidable triggers of emotions.
I experienced the death of a patient for the first time this week.
The art of being a physician is more than just knowledge of how to
diagnose and treat the disease, but also how to manage the expectations and
emotions of a patient and their families. When diagnosing a terminal
disease, whether it be pancreatic cancer, advanced heart failure, or chronic
organ failure, the hardest part is often breaking the news to the patient and
families. As difficult as this can be on the family, sometimes dealing
with sudden, unexpected deaths can be even harder. As doctors, we can
estimate, but we are never certain of when a patients life will end. You
can image the agony of a family who had no idea that a disease of a
relative would progress more quickly than expected. Words that will
forever remain unspoken, grudges that can no longer be rectified, or
expectations that will go unfulfilled. Sometimes the anger of a sudden
death or quick change from a stable to unstable patient, will leave the physician
as the blunt of the blame, whether justifiable or not. We are taught to
discuss the code status of the patient during the first visit, but it is often
a question that goes overlooked. Questions for the physician begin such
as when will be a good time to talk to the angry family about options for
resuscitation? How would the family react to 20 people in a room crushing
the ribs of an old man or woman in attempts for revival? Is the patient
competent to make their own decision? Which family member should have the
ultimate say? Is there a chance for this patient to regain
normal mental capacity?
Throughout
all this, the physician is required to maintain composure, suppress their
emotions, and address the family and develop a plan on how to proceed next.
Then go on to address other patients that have been squeezed into a
tight schedule without a moment to fully process the moment.
I
had a chance to witness residents an attending physician address this situation
with a level of empathy that cannot be feigned. They addressed the
families concerns and explained the disease, while walking a tightrope in
the middle of being too reassuring or too insensitive.
Family
med so far has been interesting. I split my time between the hospital and
a clinic nearby. According to the residents, these last few days have
been unusually slow, as we have only had one or two patients come in to the
hospital per day. However, the patients we did have were pretty complex.
I had the day off yesterday, but apparently one of the patients screamed
that she didn’t want to see another med student, but this morning she was in a
pleasant mood. The beauty of the rotations is that now I am able to make
connections between the information I learned in the textbooks and finally
apply it to a patient, it makes the studying and learning much more fun.
There is a steep learning curve when it comes to learning the electronic
medical records, drug names and dosages, questions to ask of the nurse, fax
numbers, interpreting lab values, and coming up with an assessment and plan to
present to the residents and attending physician.
It’s
starting to get real now. I begin my family med rotation tomorrow. I never
thought I’d be this excited to receive a pager, but they used to be so cool
when I saw the older people with one when I was just a young lad.
No comments:
Post a Comment