Emergency Room TROLLS

Category: Clinical Rotations

"28 year old male with possible seizure activity..."
crackled the voice over the radio. The paramedic giving report then proceeded to dutifully give history and vital signs and such, but nobody heard it. All we heard was the first line. We knew who it was.

A troll was coming in to waste our time.

In the brief time I've spent in the ER so far, this made the 2nd or 3rd time this guy came in on my shift, and the regular ER staff sees much more of him..much MUCH more.

He comes in several times a month having "seizures" that are only relieved by Xanax or sometimes Ativan - IV, always IV. Lately he's taken to being nauseated as well, because then he gets to have some Phenergan as a super fun bonus.

Seizure guy has been dealt with in various ways here, from being taken seriously and completely worked up to being pretty much brushed off. One time he was discharged without any of his goodies and he literally threw himself down on the ground, wrapped both arms around a nurse's legs and begged for drugs. "You've been discharged," the nurse had told him. "There's nothing I can give you now. Go on home."

So what did he do? He stormed out of the ER treatment area and into the waiting area, flopped down in a wheelchair, and had a "seizure." He was re-triaged, re-registered, and got his kicks.

So back to today. "He can go to triage," the triage nurse said in a bored voice as the paramedics wheeled him in. It hadn't gotten very busy yet and there were plenty of beds available, but to triage he went. Trolls often use the poor ambulance services just because they know they'll usually go straight to a treatment room instead of the waiting room.

Troll (whining): Don't you have a room open? I don't think I can walk!
Triage nurse: Oh you don't have to walk. We'll take you in a wheelchair.
Troll (whining more): But I might have a seizure, and if I do a wheelchair won't hold me.
Another nurse (curtly): You'll be all right.

Cold, aren't they? Rotten, cynical, hateful nurses! Don't they know they're supposed to be filled with compassion, dripping with sweetness, and always wear ridiculous white hats?

Trolls like that guy make everyone more tired, less loving, less patient, and a lot grouchier. We have some patients that come to the ER with a migraine, for example. And because they know that "chest pain" are the magic words that will move them to the front of the line and perhaps get them some morphine, they claim chest pain, causing us to spend money on a bogus cardiac workup based on a lie.

And what about the prison inmate who bashes his head agains the bars until it splits open, just so he can get out of jail for awhile and come waste our pefectly good oxygen with his presence?

What about the "kidney stone" patient who cuts herself and drips blood into the urine sample she's been asked to give so we'll all be convinced of the excruciating pain she's in? And let's not forget that she's "allergic" to every non-narcotic painkiller ever made.

The list goes on, each example more pathetic and ridiculous than the one before. But while the nurses in this ER may be jaded and tired of playing ames, they still manage to somehow muster up compassion and kind words for the truly sick. They still manage to at least sometimes give people the benefit of the doubt. I'd like to think I'm like that as well: somewhat suspcious, taking no crap, but being careful not to jump to wrong conclusions or be negligent. Concerning a different troll a couple of weeks ago, one of the ER docs said this: "You know you're wasting your time with this person. But you have to take this seriously as much as is reasonable. They very day you brush off someone as crying wolf or drug seeking will be the very day something really is wrong with them. Don't let that happen to you."

Hitting the Wall

Category: Clinical Rotations

Around midway through my third year, I hit a wall. I had made a mistake and it was all very unfair. I did not want to do medicine anymore. It was a bad decision. Wrong career choice.

I believe part of it was because my Family Practice and Internal Medicine rotations were all globbed together and there was almost 4 months straight of getting up too early to see hospital patients and dictating large numbers of charts and keeping up with all kinds of details about patients and their lives and their diseases and being on call a lot. Family Practice and Internal Medicine are very broad specialties - there's a lot of information to try to remember. I decided if I had to walk through those hospital doors one more day I would go insane, and do something like poison all my patients, or start rapping over the hospital PA system.

Another factor in my newfound disgust, fatigue, and boredom with the profession I hadn't even begun yet was that I still hadn't found "the love of my life." That's part of the reason we do third and fourth year clinical rotations - to help us figure out what we want to be when we grow up. Several of my friends had already found their niche and were all glowing and in love with some specialty. I suppose it was silly to compare myself with my chums. Just because they had found the love of their lives before I did shouldn't mean I would never find it? Right?

Thankfully I was cured. The following rotation after all that Family Practice and Internal Medicine was Psychiatry. It was a nice change and it was at a different hospital. The psych hospital was 1.5 hours away and I drove it. The driving was tiring but it also gave me some nice down time and I was able to decompress. And then about two months later, I found Pediatrics, which clicked with me like no other rotation had.

So...problem solved, and I was/am grateful. But it left me wondering how long I would have felt all hopeless and whiny and miserable if things hadn't fallen into place the way they did.

Flashback: Anatomy

Category: Classroom Years

Medical school Anatomy class is a direct creation of Satan - at least it seems that way to the majority of first year students. It takes up an enormous amount of time, effort, energy, blood, guts, sweat, and tears. The volume of material to be learned can be very overwhelming. Anatomy has contributed to students' fatigue, worry, depression, and nervous breakdowns. Below is a list of things I've learned (almost too late) on how to survive.

1. Find a good study method quickly. I nearly flunked the class because my study technique was terrible. I kept trying to re-adjust and re-do my little methods and they all kept failing because they were all far too detailed, tedious, and time-consuming - which brings me to #2.
2. Try not to study in a way that involves a lot of re-writing and forced memorization. I tried to do this a lot. It didn't work - there was simply way too much information. Lots of reading and re-reading over and over and drawing out a few things - when I started doing that is when my scores started (finally) going up.
3. Visit the Anatomy Lab often to review structures. Even if it's a relatively "easy" day in the lab you only have to unearth a few structures, go back and review by the next day at the latest. It's very surprising how much one can forget about those flimsy, tiny, barely-identifable little nerves after just a few hours. Be sure and visit your classmates' cadavars as well as your own; Anatomy practical exams usually make use of every cadavar in the lab. Try to be familiar with them.
4. Try reading other sources. An old anatomy book from undergad, a hand-me-down anatomy board review book from a 2nd year, your little sister's anatomy coloring book - whatever works. Often a fresh, different approach to the same material can go a long way in making the information stick.
5. Don't skim over the clinical stuff. This tip is probably way obvious to some of you normal people, but I was exceedingly stupid and did skim over the clinical stuff thinking, "Yeah that's interesting, but I need to focus more on these other million details." Dumb, dumb, dumb. Questions about Colles' fracture, the anatomical snuffbox, and brachial plexus injuries were all over my exams in that class and they popped back up to make an appearance in Part 1 Boards too. Don't ignore it.
6. Don't neglect your other subjects. However tempting it might be to let your "easier" subjects go abandoned in order to spend more precious time and energy with precious Anatomy - don't do it. Being frustrated and guilt-ridden about forsaking your other classes will just hasten your impending mental collapse. Take a break from Anatomy sometimes. Give the other stuff you're supposed to be learning due attention.

Of course, not everyone gets buried under the Anatomy Avalanche. There's some who do great in Anatomy from Day #1 and really enjoy it. I never was able to figure out if I liked or disliked Anatomy - I was too busy trying to work out how to study effectively for it. I figured out what worked best for me just in time, and I scraped by, but to this day I'm terrible at Anatomy. I hate pimp questions that require me to know much more than "The heart is the chest," and "The brain is in the head." It's a classic case of "If I knew then what I know now."

The Twelve Types of Medical Students

Category: Clinical Rotations

This is a comic-strip sort of illustration that shows the twelve types of medical students. Funny and accurate. Follow the link.

The Six Types of Attending Physician

Category: Clinical Rotations

1. The Mean Attending. This is the constant berater, the one who changes the rules on you daily, the one who expects the most mind-reading from you, the one who expects perfection in all minutia, and whose greatest joy and delight in life is to see you fail. Thank God I have yet to meet Mean Attending. Doctors like that don't exactly create an atmosphere of learning.
2. The Vague Attending. As nice as these docs can be, they are infuriatingly vague when it comes to their expectations of students. I have worked with the Vague Attending on a few occasions, and while the rotations weren't too bad, my days were filled with: "Oh you know, whenever you want to be done for the day, just leave." and "You can write directly on the charts or make your own notes - doesn't matter to me." and (after asking if there was anything specific I needed to be studying) "Oh, yes, well - just read about whatever interests you."
3. The Busy Attending. While you may not learn much content, you'll certainly learn how to effectively see 20 clinic patients in 15 minutes, right after rounding on 1000 hospital patients beginning at 4:30 a.m.
4. The Buddy. Most of your time is spent shooting the breeze in your doc's office while the patient charts pile up and then you finally follow your attending in to see the patients (since the time you would have taken to see them yourself was spent talking about your attending's children's newest school project). This is fun for about 2 days. Then it gets old.
5. The Teacher. You will learn. You will have a 15 minute teaching/pimping session after every patient. You will read up-t0-date, hot-off-the-press articles about exciting new breakthroughs in otitis media. You will organize presentations on journal articles to present to your fellow medical students/residents/attendings.
6. The User. Cinderelly, Cinderelly - all you have to do is make sure all charts are dictated, all forms filled out, all tests ordered, all prescriptions written, all visits coded, while ensuring your attending is well stocked with pens and prescription pads...and by the way, do you have a penlight I could use for awhile? Never mind if you've learned anything.

In reality most attendings are some combination of these. And I'm sure there's a lot more categories that other students can think of. I do appreciate the attendings I've had so far - most of them have been smart, likeable, laid back doctors who did a pretty decent job at teaching. But it's still fun to make fun! I encourage related comments and trackbacks on this entry. I find this type of thing very entertaining.

Flashback: Radiology

Category: Clinical Rotations

Toward the beginning of my third year, I did 2 weeks of radiology. Even though I have no desire to be a radiologist, I still found the experience useful. The radiology department here acts like it wishes medical students didn't exist, but sometimes I caught a radiologist on a good day and actually learned some things. And I studied quite a bit on my own. For people that don't care anything about radiology, I still semi-recommend it. A broad and basic knowledge of plain x-ray films is useful and necessary, especially in the Emergency Department. With this in mind, I tried to pay a lot of attention to chest x-rays. A good working knowledge of chest x-rays can be important in primary care, and after my rotation, I felt a lot more comfortable about reading them. I looked at other plain films too, but I didn't seem to retain that information as well. Now, in the ER, I'm only slightly less pathetic at "find the fracture" than I would have been if I hadn't done those two weeks.

Here are some quick tidbits on radiology:

• Annual Salary: $276,684
• Work hours: 7AM or 8AM to 4PM or 5PM
• Call: Radiologists do take call, but often from home. X-rays that have to interpreted quickly can be transmitted from the hospital to the radiologist's house and he/she can give the reading over the phone.
• Residency Length: 5 years
• Duties: reading lots of films (obviously), taking numerous calls from other physicians with questions, concerns, (or demands) about x-rays they ordered, and doing procedures such as ultrasound-guided biopsies, GU and GI studies, and angiograms.

I could never do radiology because a radiologist's knowledge of anatomy has to be fantabulous and the residencies are very competitive. They get to hang out in darkish rooms and look at pictures all day and they don't have to fool with silly old patients too much. However, they have to hang out in darkish rooms and look at pictures all day and don't get to fool with patients much.

I admire people that can do radiology. I'm glad I'm not one of them.

I'm So Glad You're Sick

Category: Clinical Rotations

Never forget that it is not a pneumonia, but a pneumonic man who is your patient.
- William Withey Gull

An odd and slightly disconcerting aspect of the clinical 3rd and 4th years is how excited we can get over people's illnesses. And the sicker the better - I don't get terribly excited over "routine" illnesses and I can do those history and physicals or admission orders or whatever while stifling a yawn and wishing I was working on someone with a much more fun disease. Warped, isn't it?

It does feel weird at first when we start drooling over the stories other doctors or fellow medical students tell - stories about a septic patient with ARDS or the OB patient about to give birth to octuplets and so forth. But medical students aren't really sick, sadistic creatures who draw pleasure and energy from the pain of others.

As in all things, there must be a balance. In this case, it's a balance between being compassionate toward our patient and trying to cure him/her, and being secretly pleased that their disease process is severe or unusual and we have the chance to learn to manage them and grow that much more into doctorhood.

Health News: Cleanliness is Next to Godliness?

Category: Health News

WASHINGTON (AP) — Gritty rats and mice living in sewers and farms seem to have healthier immune systems than their squeaky clean cousins that frolic in cushy antiseptic labs, two studies indicate.

The lesson for humans: Clean living may make us sick.

The studies give more weight to a 17-year-old theory that the sanitized Western world may be partly to blame for soaring rates of human allergy and asthma cases and some autoimmune diseases, such as Type I diabetes and rheumatoid arthritis. The theory, called the hygiene hypothesis, figures that people's immune systems aren't being challenged by disease and dirt early in life, so the body's natural defenses overreact to small irritants such as pollen.

Click here for the full article.

I always did think our society went a little overboard on cleanliness. I'm not saying we should raise our children to eat dead bugs and make pretty sculptures out of animal excrement, but I agree with a little less Clorox and a little more dog hair. As an animal lover, I kind of like the theory that people in developing countries have fewer problems with allergies because they live in such close contact with their animals. I'm all for that.




This nifty picture was swiped from a blog called A Shepherd's Voice. It's a blog totally devoted to sheep. Bet this kid doesn't have any allergies!

Emergency Room

Category: Clinical Rotations

I'm doing my ER rotation till the end of July. It's going to be one of those rotations where it'll be "what I make of it." I suppose technically all 3rd and 4th year rotations are what you make of them, but it seems like some require more effort than others to get anything out of them.

I've ended up working way too much with a doctor who used to do surgery. And he mined coal. And he was in the army. And he had a degree in engineering. And I'm sure he's probably the inventor of plastic or something. I have to sit through endless stories about his adventures in vascular surgery and how brilliant he was/is.

Another doctor I work with doesn't care if you learn at all, as long as you do his paperwork. Still another stares at God-knows-what on Google and grunts and mutters while I try to present patients to him.

There is a really good one, though. This guy listens to my whole presentation, asks what I'd like to do, often listens to my suggestions, asks good pimp questions, teaches me stuff, and then I get to follow the patient all the way to discharge or admission. That's become kind of important to me. There was a couple of days when I was trying to be a hotshot machine and see patient after patient. I really was just trying to be efficient, but it ended up being a stupid thing to do. I was so busy trying to hurry and see patients that I never followed the patients I'd already seen to conclusion and I might have missed something cool.

It's a small hospital with a lack of many specialties, and a small ER, so I'm not working in a knife and gun club. Instead, I'm seeing a bunch of patients who use the ER as their primary care. Here's a few things I've gotten to see so far:

• A guy who waited to till 1:00 a.m. to come get treated for his poison ivy
• Several minor injuries
• People with migraine headaches who just so happen to be allergic to every non-narcotic pain medicine on the market
• Large numbers of complaints of chest pain and shortness of breath (there's lots of coronary artery disease and COPD in this area)
• Several pukers - there's been a GI virus going around.
• A really good case of rhabdomylosis, complete with acute renal failure. He also had a nasty UTI, was septic, dehydrated, and had mental status changes. He was admitted to the ICU.
• An idiot mother who brought her 14 year old to the ER over a zit. I'm not kidding.
• A possible real trauma - she was in a 4-wheeler accident. All her plain x-rays were negative at cursory glance. Her lab work showed blood in the urine and slightly elevated liver enzymes. She was pretty tender and hard the left upper quadrant of her abdomen, where the spleen is. Unfortunately my shift ended before she had her CT of the abdomen and pelvis. I was tempted to stay and follow her some more, but I was dog tired. I hate night shift.

One good thing about night shift in this ER is that sometimes things do eventually slow down enough to where I can get some reading in or kick back for a few minutes.

So until the end of July I'll be griping about the trolls that come in wasting my time, and glowing over the truly sick patients that make me think. I'll put up with a variety of ER doctors and their stupid quirks and pet peeves and pet lab tests and pet medications. I will then periodically chide myself for being such a whiny baby and go back to "making the best of it."

All We Ever Talk About

Category: General

It usually happens just a few weeks into the first year of medical school. You begin discussing religion, politics, and the after-exam party while cheerfully (or angrily) hacking away at your poor cadavar in Anatomy Lab. You use the words "medial," "lateral," "distal," and "proximal" when you're giving directions to your house. You understand stupid medical jokes that normal people don't get - and what's worse is that you think they're funny.

Medicine takes us over, and finds its way into our everyday lives to take a firm hold. And to the distress of many, nearly every conversation is dominated by medicine and we say, "Good grief! All we ever talk about is medicine! This is ridiculous!!" And there's truth to this. For the first two years we commiserate about classes and exams. And for the next year we commiserate about call schedules and mean residents, and swap stories and patient anecdotes.

But is it really ridiculous? Why do we act like we're the only group of people to whom this happens? Take your average stay-at-home mom raising 3 little kids. Surely she says to herself, "All I talk about is my kids! My non-parent friends must hate me!" Even people with "regular" jobs talk about their work a lot. Why? Because our work/school is such a large part of our lives, it's only natural that it become a large part of our conversation. Whether you work at Wal-Mart or go to medical school or raise a bunch of kids, you're going to have a lot to say about the thing you do the most.

I believe if we would take a closer look at our conversations, we would probably find that we really do talk about other things, even if it's only here and there. I've decided that if I'm in a conversation and it happens to be about medicine, I'm not to going to kill myself trying to change the subject just because medicine is "all I ever talk about."

Mind Reading

Category: Clinical Rotations

When interacting with physicians as a 3rd and 4th year medical student, there's a degree of mind reading that is expected. Here's a scenario experienced by one of my friends on her OB/Gyn rotation:

Doctor: So, how's our post-op hysterectomy doing?
Student: Um, fine I guess - you mean this morning before her surgery?
Doctor: No, I don't mean this morning before her surgery. I mean this afternoon after her surgery. You didn't go check on her?
Student: No, I didn't know you wanted me to.
Doctor: (sighing hugely and rolling her eyes): You have to always remember to go back and check on your patients as soon as possible after surgery. Patient care doesn't end with morning rounds.

Now that probably doesn't seem like such a huge deal but conversations like that can go a long way in making you feel stupid and lazy and incompetent. Wouldn't it have been nice if someone would have told her about that expectation at the beginning of the rotation? Or at least at the beginning of rounds that morning? There are tons more examples I could write about, and I've experienced quite a few myself. Ideally, the attending physician should spend a few minutes (and a few minutes is all it would take - it's not like it would eat hours out of the day) talking to the student at the beginning of the rotation, telling him/her what the expectations and requirements are. Good luck finding an attending who will do that. Before starting 3rd year, it might be best to brush up on your hidden magical psychic powers of mindreading.

Flashback: Study Habits

Category: Classroom Years

During the first two years of medical school, I was something of a misfit where study habits were concerned. I studied a little differently than most of my other classmates in two ways:

Number 1: I slept

I rarely went without a decent night's sleep (6-10 hours) in years one and two. Why should I deprive myself when all I do all night is panic, stare at the clock and panic some more, wonder if I could just go to sleep and get up really early instead of staying up really late, and read the same paragraph 10 million times and never know what it says? I tried this method in college. Useless.

Number 2: The closer exams came, the less I studied.

This was completely backwards in comparison with my friends. We had exams about every four weeks. For the first two weeks of a block, while everyone else caught up on sleep, drank too much alcohol, visited family, and cleaned their houses/apartments, I was already studying for the next exams. About the time I started slowing down is when everyone else was just getting into the study groove. And then by the time exams were a day or two away, I had pretty much quit studying and most of my friends had pretty much quit eating and sleeping.

The bottom line is that different methods work for different people. It's easy to let yourself feel guilty if you're not a person who can study for 12 hours straight without taking a bathroom break, or one of those nuts who can pull frequent all-nighters. But it's important to let yourself have guilt-free study time, regardless of how backwards, bizarre, or different your study habits may be from everyone else's. If your methods get you the grade you want, then stick with your methods.

One of my friends spent his afternoons after lecture piddling around, and then sleeping. He'd wake up and get started studying at 10:30 or 11:00 p.m. It worked great for him. Another friend re-wrote all her lecture notes - I tried that and it ended in tragedy, but she really benefited from it. Still another was a hard-core marathoner - it irritated her when she had to stop and do ridiculous things like shower, eat, and pee. I figured out that what worked best for me was a lot reading and re-reading over and over again, jotting a few notes here and there, and consulting various textbooks if I needed clarification. I usually couldn't bear to study for more than four hours a day (the exception was Anatomy in my first year). It took me awhile to get over feeling like I should be making better use of my study time. Sometimes I ended up spending all my study time feeling guilty and panicky that I wasn't studying enough. At some point in my second year, I just got it over it. My grades were fine. I accepted the fact that I didn't have to study and learn like everyone else.

I believe there's a right study technique and a right study schedule for everybody. It's just a matter of finding it.

About On Doctoring

Category: About

The On Doctoring blog will journey through my life in medicine. It begins with the fourth and final year of medical school, but many entries will flash back and include scenes from the first three years as well. The story then continues through residency and beyond.