July 30th, 2013

There is a patient on my team’s service who tried to kill himself with alcohol and drugs.  He is now sitting in the Intensive Care Unit on sedation with a tube down his throat bringing oxygen to his lungs and brain. I measure his reflexes day-by-day and his prognosis is looking more grim with each passing day.  The longer he is here, the more problems arise and there are infections and hematomas to add to the severity of his situation.

At first it was hard for me to wrap my mind around this case.  If the man wanted to die, why are we working so hard to keep him alive?  It is apparent that he is a chore for all involved with his care.   It’s difficult to take a person from the brink of death and find a way to bring them back to life, and even if we are successful, will he even be able to live an independent and meaningful life? I can't help but be sad for him, as the condition is self-inflicted, but my sympathy is hard-bought (more so than I care to admit).

Today on rounds I was bored; he was not my patient.  I was also hungry and we had not been given the chance to sit since 7am and it was now around 1pm (I’m still getting my legs trained for the long days on rounds.  Some days they last 40 minutes, but most days they last upwards to 5 hours! My greatest priority now is getting comfortable shoes...) I was ready for it all to be over, and another comatose patient was not going to help me pass my shelf exam. 

While discussing this patient, the resident said it best: “Even if he is a suicidal, alcohol-abusing patient with a multitude of problems, we, as his doctors, owe him the best medical care we can give.”  It might be cliché and pithy, but today it was the message I needed to hear.  At the moment I don’t get to choose my patients.  The past years I’ve travelled the world to help impoverished Africans and Belizeans, and spoiled myself looking at cute babies at the pediatric hospital.   But not all the world is cute or exotic.  Sometimes the people that need the most love are right in front of us in our own communities and are the least cute, the least friendly, and the least interesting cases.  I had forgotten that in my hunger and apathy and boredom.  I’m afraid I’ll only grow more bored and tired and apathetic about what is going on around me as the year goes on.  It is the inevitable fate of most medical students.   My hope that even in the midst of unavoidable apathy and exhaustion, I will still keep my eyes peeled for the important lessons that camouflage themselves in the midst of hungry stomachs and tired feet.  

The Mental Status Exam

            As we all know, strokes are no laughing matter, nor is ending up in the emergency room. 

            It was my first call on my neurology rotation.  Being on call as a medical student means very little, at least on this service.  You work 4 extra hours, from 4-8pm, and you follow around a very frazzled-looking intern as he checks up on all the different patients from the different teams.  My biggest challenge of the night was simply finding the guy with whom I was assigned to follow.  After going to all the usual places, I finally found him in the Emergency Department.  After a brief introduction, he sent my off on my first task of the night—to do a Mini Mental Status Exam on a patient who came in for a stroke. 

            Among the organized chaos of the ED I found the patient in room 7, lying quietly in his bed.  I approach and introduce myself (Introducing yourself as medical student is tricky business.  You can say, ‘I’m just a medical student’ and risk losing all credibility [not that I really have much at this point].  Or you can say ‘I’m student-doctor Katie,’ and hope that gives you a little more credence without the responsibility.) and then began the assessment. 

                        What is your name?

                        What is the day?

                        Spell WORLD backwards

                        Make up a sentence. 

                        Draw these two blocks intersecting…?  ( I didn’t make this up)

            It all seems rather basic, but it does give you a good picture about the possible damage you might be dealing with.  Luckily this guy did pretty well and I had good news to report back to the attendee.  Apparently there is quite a bit more to the assessment, so back we went for round two, except this time asking much more detailed questions as well as examining strength and reflexes.  He was answering some questions right, and some questions wrong, but that was to be expected.

 At one point in the conversation, the resident asked what seemed to be a pretty straight-forward inquiry.  “Sir, what color is the sky?”

The patient looked up at him, a smile slowly creeping onto his face, as he answered, “Well to be honest, doctor, it all depends on the weather.”

I tried with all my might not to laugh too loudly while the resident suppressed a smile with his best effort.  It was definitely not the answer he was looking for, but at least his wit and humor were fully intact. 

It’s difficult to find anything to laugh about in the hospital sometimes.  When people are sick, usually they are really sick.  The rare light-hearted moment amidst all the somber ones can really brighten a day!

July 27, 2013

The 180

You came in for a virus;

A fever,

Some pain in your legs.

There were mosquitos on vacation—

Could that be the reason?

The story was that you were a happy kid;

Excited to play baseball and start first grade.

But your body had other plans.

It turned on you.

There were blasts and there shouldn’t be.

Biopsies.

Blood panels.

Lumbar punctures and ports.

            And suddenly a mother’s worst nightmare was born.

What do you do when the world completely flips?

The only wars you wage now are against yourself.

It’s you against you, but not you. 

The sick kid, the sad parents,

They’re just stories on the radio, the TV.

              The people you see, but won’t be—

Can’t be.

The truth is, Even when,

Poison is the hero and you fight against yourself,

The world is still turning.

Little boys will dream of baseball,

First grade and Spring.

If all goes right, the 180 will become 360,

And nightmares become sweet dreams again.

This is a poem I wrote in honor of my first patient as a third year student. 

It was weird to think that after two years of literally cramming my brain with thousands upon thousands of words and facts and associations and medications, I would suddenly walk into the hospital and be on the care team.  Don’t get me wrong.  I know a lot of things.  Ask me the genetic chromosomal translocation of Acute Pro-Myelocytic Leukemia and I can pull that from its tidy file, but if that patient comes to see me, I’m not going to know what to do about it.  There are just too many dimensions of knowledge in medicine.  I now fully understand why there are so many years of training.   

In the classroom, we would look at the disease and deconstruct it.  What caused it?  What does it look like?  What does it make the patient look like?  How would you treat it? What are the risk factors?  All these random little details that you assemble into a Lego structure and then you have the problem solved and the answer right.  There was a point in my studying where I became so fixated on the facts of the case and the symptoms, I would literally skip the first sentence that described the actual patient being discussed.  He was just a name and an age, what was more important was the disease he had.  That’s all that really mattered.   

In the story of my first patient, I knew the facts, and I knew them well.  I could tell you about the genetics of the disease.  I knew what the peripheral smear would look like that would diagnose him, as well what the mechanism of action of the drugs that would treat him.  But what they just can’t teach you is the way a parent looks at you when they’ve just received some of the scariest news of their life.  They don’t teach you that in the course of one hour a little boy goes from a kid who maybe got a tick bite on vacation to a little boy on the cancer floor of the hospital getting prodded with needles and nurses.  A little boy who now will be at the mercy of poison for years to come.  When you are in the classroom, you have the distance between you and the disease.  You have the safety of pages and pictures that you can simply glance at and dismiss at your leisure.   Now you can’t separate yourself from the patient; glaze over him as unimportant detail.  Because his face, or the face of their spouse, or child, or parent, is the face that is looking right back at you and listening to every word from your mouth as you describe a small detail that could alter their lives forever. 

When you finally reach the hospital as a medical student, you reach the heart of medicine and that is where you will learn the most important details about what this all really means.

Africa 1

“Medicine is all about story-telling.  The patient tells the story of their symptoms, and the doctor tells the story of their disease and cure.”   -Suddarth     "The Emperor of all Maladies"

                I read this quote in the book I was reading as we were leaving Kitale.  It seemed almost too fitting for the situation, like it was written to commemorate the entirety of my experience in Kenya.  Before we left for Africa, someone warned us to be patient with our patients.  “You will ask them what their symptoms are,” they said, “but instead of getting a short in direct answer, the patient will go on and on about their lives and family.  They will tell their entire life story, ending it with ‘and then I came to the clinic.’  They are sharing their story with you, and you have now become part of their story.”

                There were so many stories involved with our trip—stories from Wesley Korir, the elite marathon runner who just happened to be in the right place at the right time to have our group relocated to the town he grew up in to open the hospital that he has been pouring his winnings into for years.  Stories from the interpreters, the pastors, the Kenyan doctors and nurses and most importantly the patient that reverberated in the halls of a bare hospital throughout the week and gave it life.  And as we said our final farewells to Kitale and the people there, we realized that these stories were now our own, and our presence in Biribiriet is now a part of it's history. 

                Kenya is a difficult country to explain.  People keep asking me “how was it?” and honestly, I don’t even know where to start.  There are so many things I want to say, but no words seem to be enough to fill the epic grandeur of the landscape and its inhabitants.  There are so many facets, and only by being among it, holding it in your hand, can you see how the light shines among it, like a diamond or any other precious stone.  No picture can quite do it justice.  It is only when you have the stone in your hand that you can see all of the different dimensions.  Such is Africa.  I have read books, seen pictures in magazines, and watched movies that all try to capture the epic scope of the people there but none can do it justice.  You have to be there, see it with your own eyes, and be fully immersed in it all to truly understand.  And even then, our time in Africa was just too limited—so much was left undiscovered.  It would take a lot more than just three weeks to see and experience everything to satisfaction.  My next few entries will be my humble attempt to tell the story of how 8 medical students, two nurses, two water engineers from EDGE Outreach, and one ER doctor from Louisville all found ourselves serving the people of Biribiriet and bringing what was once only a distant dream to life.

June 22, 2012

        By the end of the second week the stream of patients had been so vast, varied and extensive that I could hardly place a name to the diagnosis.  It’s making me wonder how I will ever keep up with all the patients once I am more than just an observer.  That’s a lot of medicines, lab results, allergies, and social histories to keep straight. 

Rounds have been by far the most interesting time of the day.  We go as a team to meet new patients or give progress reports on others.  It’s not really that interesting to go stand in a room to listen to other people talk, but it is interesting to watch the interaction between the families and doctors, and doctors and patients.  Most often the room is dark and we wake our patients and families up with a mass movement of yellow-gowned people of indiscernible origin crowding around a sick bed. These moments have taught me lessons that classrooms cannot.  How to deal with pained patients and frustrated parents.  How to communicate with people in the midst of language and social barriers, and mostly to put all of the pieces of the puzzle together to see the patient, disease, and cure all in the same place. 

As a student, it is sometimes difficult to see past the disease itself.  That is something that I need to work on.  You see the situation more as a case study and less like you trying to end some pain and worry.  I think about the right questions to ask and the meaning behind the labs, and not about the effect these have on the patient.  From observing the attendees and residents, it seems like this comes with time, but I still have a long time until I become comfortable enough in my role to see more than just the means of health care.  Now, don’t think me callous.  I walk into the rooms and, as an observer, hear the stories with compassion and empathy.  Not every case is interesting, I can’t help but admit, but every case is of utter importance to the people involved, and that has to be the one thing I remember, no matter my role in the case. 

When the time comes, however, for me to play doctor, I begin to see the task at hand and not so much the patient.  I enter the room and play a film strip in my head of all the chores that have to be checked off the list.  Introduce myself.  Ask question A and question B.  And don’t forget question C.  Keep eye contact, and allow the patient or the family to talk, but don’t let them talk too much.  You do have other things to do and people to see.  And then comes the physical exam.  Is the patient breathing? Check.  Can you hear a heartbeat? Is the stethoscope on correctly? Lung sounds? Is that sound my shirt or a lung crackle? Pupils? Reflexes?  There’s a lot to remember and even now I can’t recall all the components.  Then there are the labs.  A lot of numbers that can tell me so much about a patient.  The blood cultures.  The stool samples.  The myriad of facts that tell me everything I need to know about a patients true health form a mask in front of the true face of the patient.  And as these numbers increase and these histories and physical findings become more extensive, the faces behind the sickness begin to blend together and I can hardly find the patient in the hospital, let alone remember why they came. 

But how can I forget the people that have been so formative in the beginnings of my medical education?  The boy with salmonella meningitis whose family could not take him home for fear of reinfection has taught me that every family has its own cross to bear.   The 4-year-old girl with diGeorge’s syndrome who taught me to recognize the different degrees of heart murmurs (6 degrees, who knew?).  And I’ll never forget the weary faces of mothers who were wishing that they could ease their children’s pain or simply find a way to take their babies home. They remind me of the reasons to keep on learning, so that one day I could be a source of comfort.  Not that I will not have the answers all the time, but I will know enough that the faces will begin to reemerge from the facts and I will be able to play the small and vital role in giving some sort of ease and comfort.    

June 15, 2012

It’s been over a week in the hospital and I am finally learning the ropes of the place.  I can find my way around at least (and all the places that have free food!) and beginning to feel more a part of the team.  There have been a great variety of cases, from the mundane to the interesting to the downright mysterious.  And each day I learn and see something new.  Here are just a few things I have learned about life in a hospital. 

-          It is never a good thing to be interesting to doctors.  Doctors, residents, and medical students all love medicine, and the more interesting case, the better.  We like to see what we have read about. But you don’t want to be what we have read about, because it’s probably rare, dangerous, and involves an difficult procedure.

-          There can never be enough caffeine.  Coffee, cola, and tea is everywhere, and it is put to good use. 

-          Doctors are still able to keep their humor.  From the quote boards in the physicians’ offices to the sporadic games of jeopardy and resident roasts, doctors aren’t as serious as they could be.  It’s good to keep a sense of humor. It makes the exhaustion and somewhat serious work-load seem a little more tolerable.

-          Doctors ask questions without shame.  I thought that the best doctor would be the one who knows all the answers, but really, the best doctor is the one that asks questions, does research, and is not afraid to put their pride aside and make sure that what they are thinking is correct. They work in teams because, lets face it, the more brains, the better.  It gives me hope that I’m going to be a good doctor even without knowing all of the enzymes of the Krebs Cycle. 

Look, ma, I’m learning so much!  And in the end, I think learning how to be in the hospital and not look silly is, in the beginning, almost as important as knowing how to help patients.  That comes with time, and I have a lot of time to go.     

First Day

My white coat is a little big for me.  When I look at myself in the mirror, I can’t help but think that I look like one of those high school kids in those 80’s sitcoms. The sleeves are too long and must be rolled, the shoulders are big and boxy, and it really doesn’t quite hug the silhouette like a girl nowadays would like.   But still I like the crisp whiteness and all that it symbolizes in my life.  It has these silly pins that highlight my ‘newness’ to the profession, and even sports a tacky sign that merely says ‘observer, just because I know if I remove it, I will surely lose it and lose access to hospital shadowing privilege.  And the pockets are all filled to the brim with things that make me look like I’m actually doing something, like a stethoscope, a pen-light, blank H&P forms, and rubber gloves.  I walk out of my apartment with my coat on, and for a few, fleeting moments I feel like I’m someone important;  but I can’t fool people for long. 

 I have just finished the first year of medical school, and though I learned so much, I still don’t think I know anything.  Silly words like the Islets of Langherhan, and ketoacidosis, gracilis, medial lemiscus, MCAD and neuropathy all hold a glimmering significance in my mind, but ask me about BUN/creatine ratios and I just stammer and mumble excuses about renal physiology just being my weak spot. (It is. I hate the kidneys.)   With the first year being complete, I decided it would be fun to spend my summer pretending to be a doctor and getting as much clinical experience as possible.  The month of June is filled with a pediatric externship (Externship: noun: a required period of supervised practice done off campus or away from one's affiliated institution.)  and a trip to Kenya to work in a medical clinic there.  Part of my hope in make my summer so full of clinical experiences was not just to get experience, but to see the light at the end of the tunnel.  It’s very dark in the library, and most time you lose sight of the forest in the midst of graphs and facts that promise to be useful someday but really you can’t imagine how and you just stuff them in your brain anyway. 

My first day of externship at Kosairs Children’s Hospital was just, well, awkward. (You want to see everything, but at the same time, you want to stay as out of the way as possible.  "Do I sit in the trashcan or just as close to it as possible?")  My first assignment was to go to an educational conference, where all the residents, interns, and attendees sit and talk and listen to different cases and presentations.  As I looked around, I was a little intimidated with all the long white coats in the room and all the confidence.  These people were not just scared little plebian doctor wanna-bes; no sir, these people had run the gauntlet and had conquered it.  I’m sure they didn’t even notice me sitting there bambi-eyed and scared.  The first presentation was a pediatric neurosurgeon.  In the middle of his talk about the neuro exam, he casually exclaims ‘Oh hey! There are medical students in this room too!’  Indeed there were.  As I was sitting directly in front of him, I became the target for my first pimp (the medical pop quiz, to test you on your preparedness of your future profession. I knew my first pimp would come, but never thought it would happen in a room full of already accomplished doctors). 

“Since you were bold enough to sit in front of me, what is the evaluation scale we use to measure patients who are unconscious?”

I racked my brain for any clue, but not even the remotest sliver of the answer appeared.

“I’ll give you a hint, it’s named after a town in Scotland”

Edinburgh?  Brigadoon?  I didn’t know I would have to know geography too to be a doctor.

“Glagscow Coma Scale,” was the final answer.  I wasn’t the only person to miss an answer, but it would have been nice to know that one simple fact.  I’ll never forget it now, that’s for certain. 

Before I knew it, the presentation was over and there was a mad rush of people shuffling out the door to go about their business of rounds and reporting.  And there I was, without much knowledge of where to go from there.  Luckily there was a doctor who kindly gave up the run-down and introduced us to the teams we would be shadowing.  I was given to the Blue team. 

                An attendee, 4 residents, 3 3^rd year medical students, and a lowly rising 2^nd year make up team blue.  We travel in a flock for the most part.  We round together, and give report together.  We make quite a crowd, and I can only wonder what patients and their families are thinking when we herd into their room and talk about the number of bowel movements the patient had in the past night.  They were so welcoming, and eager to teach me all that they know.  I still felt in the way, as you do shadowing anyone, but it wasn't as bad as it could be. They had all been there before, they understand my situation and are more than willing to help.  At times there is nothing else to do but merely stand around and wait and that is just the reality of my position.  Thank goodness for the iphone (never in a million years did I think I would ever say that, but there it is.) that I can use to look up facts and distract myself with in those moments of waiting around for something to happen. These next few weeks will prove to be quite the learning experience for me as I see things, learn things, and do things that I have only seen and heard about in the classroom.