sometimes there is nothing to say...

I have not blogged in a while, and in truth the only reason is laziness over the last few weeks. I finished up my family medicine rotation, where my preceptor clearly did not like me much. The last day the staff said goodbye the two other doctors told me to contact them if i needed anything and my preceptor simply left the office without a word. I did not even realize she had left. Glad its over!! the very last day of the rotation, i spent the majority of the day seeing her appointments and walk-in patients and not even a goodbye!! The day started off wrong, and my hopes of improvement were slim. At 7:30am i show up pour some coffee (like i do everyday) and take a look at the census for the day. I see the first 3 patients before the Doctor even shows up, and i wait patiently for her to start since all the rooms are full. So i am standing at the lab with my coffee, she comes in demanding to know about the 3 patients, but before we go into a room (its about 8:45am at this point) she looks me in the face and says, "you look really tired this morning." In case you were not aware, this is the equivalent of a nurse in the hospital asking if you are "post call," its the polite/not so nice way of saying you look like crap! That is how the day started and it didnt get any better until 3:30pm when she left, i could finally take a lunch break and enjoy the afternoon with another doctor. So glad that rotation is over!! Family medicine is not for me at all.





My rotation ended on a thursday, I had my shelf exam on friday, and i started my new rotation on saturday. My most dreaded rotation of medical school.....ambulatory pediatrics! My goals for this rotation are easy: first, dont get sick (everybody gets sick on this rotation), second, try and learn as much as I can about peds since i never plan on doing it again, lastly, try to have some fun.

after finishing a week of peds my attitude has changed, Peds isnt that bad! i dont think i could do it everyday for the rest of my life, because i dont think its that much fun either. Overall its not as bad as i thought it was going to be......they are kinda cute, even with the snot coming out the nose....

I have been able to see some pretty interesting things so far.....but my first day i missed a diagnosis and i am still kicking myself for it.....

a 3year old girl comes in because she been developing a rash. they look like pimples, and she has 3 of them total on her entire body. one of them popped this morning and had pus, another one scarred, and another one is just developing with redness and swelling...

I really was not sure what it was, and i when i asked the doctor he said its 'chicken pox!' Now i have seen chicken pox, and this didnt look like chicken pox. I had them all over the place, scratched at them, picked at them, had a fever and looked horrible. This girl didnt even seem to notice she had them. So really easy mistake. Especially because all children get routinely vaccinated against chicken pox, that those who develop the rash, have a very mild case.....but seriously all i can think is man....i missed chicken pox!!!

luckily while i was on family medicine, i did not miss a single diagnosis of herpes zoster (ie shingles - caused by the same virus)...seriously i missed chicken pox!!

On the other hand i have correctly diagnosed several other rashes - molluscum, roseola and fifth's disease, candidiasis. Rashes are a common problem in peds, so hopefully i will not miss another case of chicken pox!!







The other great thing about peds is the repetition....on a normal day, the types of chief complaints i see are:
- rash
-runny nose, congestion and cough
-fever
-wheezing
-diarrhea


thats about it, i see over 30 patients a day....mostly sick kids with upper respiratory infections and low grade fevers, or kids with eczema and diaper rash.

I am actually starting to look forward to inpatient pediatrics in march. Maybe it wont be as horrible as i was anticipating.

In reference to my non medical student life, its pretty status quo....i go on a series of not so great first dates....and realize that dating is horrible and awkward, and most of the people who are still single, have good reasons for that! So luckily i have some awesome girlfriends who keep me sane and a schedule that keeps me busy. I am loving my life right now, even on pediatrics. Especially because i am taking some trauma calls this month when the trauma team is down students.....

and of course i am being the good jew and working Christmas....cause really trauma patients or Chinese and movies??? the choice is so easy, chest tubes for everyone!!!

I really will try and update more often, but some days are boring and i feel there isnt anything to say about my life on clinical rotations, especially when i am in an office and not a hospital...all the drama and good stories come from the hospital...

for instance my roommate who is on trauma surgery this month, is starting a photo collection of foreign objects she has removed from a patients anus. usually the patients are male (cause clearly men are stupid and instead of putting things where they belong, they put them in their butt). So far she removed a 16inch double sided dildo that had "slipped in" so far that you could not see it, she had to reach into the rectum up to the sigmoid to get a hold of it.....awesome! the other was a foreign object resembling the male anatomy of the vibrating type. also sufficiently stuck in the man's rectum. If she didnt have pictures, i would believe the stories....but really they are funny!!

Colorado is a little crazy!

So for those that dont read the NY Times on a daily basis, or decide to read some other paper like USA today, i have decided to spotlight an interesting article from the Nov 18th paper, "Proposed Colorado Measure on Rights for Human Eggs" please enjoy!

DENVER, Nov. 16 -- A proposed amendment to the Colorado Constitution that would give legal rights to fertilized human eggs may be headed for the ballot next year, raising the prospect of a heated local debate over abortion at the same time that Democrats are gathering here for their
national convention.



The ballot measure, which passed a legal hurdle this week when the Colorado Supreme Court upheld an administrative panel's ruling about its wording, would give Colorado perhaps the most sweeping language in the nation about the rights of the unborn, legal experts said.




The proposal must go through several other steps between now and Election Day 2008, including gathering of enough signatures to qualify for the ballot.



But both sides agreed that the measure, if it passed, would have immense ripple effects. The measure, just one paragraph long, would ask voters whether inalienable rights, due process rights and equality of justice rights as defined in the state Constitution should be extended to "any human being from the moment of fertilization."



The deputy director of Naral Pro-Choice Colorado, Toni Panetta, said state courts could be swamped by suits claiming specific rights for a fertilized egg that the broad language of the ballot measure did not clarify.



"All fertilized eggs could use the courts, and that lays the foundation for a potential onslaught," she said. She said the language would open up challenges to birth control, including oral contraception and intrauterine devices, which make the uterine wall inhospitable to the developing egg.



A lawyer who represented supporters of the proposal, Michael J. Norton, said the real impact of the proposal would be in its simplicity, asking a profound philosophical and moral question.



"The whole issue centers on when does life begin," Mr. Norton said. He said that though the word "abortion" would not appear in the language of the proposal, it would effectively make an abortion "the destruction of a person" and therefore illegal.



"Whatever rights and liberties and duties and responsibilities are guaranteed under the Constitution or other state laws would flow to that life," Mr. Norton said.



A spokesman for the Colorado Democratic Party, Matt Sugar, said he thought the measure was perhaps timed in an effort to highlight divisions over abortion in Colorado at a time when much attention will be focused here. But he said he thought it could play into the United States Senate race even more than the convention in August, by forcing candidates to talk about the subject. Senator Wayne Allard, a Republican, is not seeking re-election, creating an open seat.



Dale Schowengerdt, a lawyer for the Alliance Defense Fund, a legal organization based in Arizona that supported the ballot measure before the Colorado Supreme Court, said the timing of the proposal was "pure coincidence," to next year's elections.



"It's an important debate that people ought to have, and Colorado ought to have, about when does life begin," Mr. Schowengerdt said.




So, in going along with the argument that fertilized eggs will have right to due process and equality of justice and therefore be able to have appointed legal representation, will a woman be charged with manslaughter if she has a spontaneous abortion and in doing so kills the fertilized egg? Could a women be charged if through no fault or planning of her own, be charged for killing a "fertilized human egg" if her own body rejects the zygote that results in a miscarriage???

I think this is def going to spark some interesting discussion on the origins of life, and the implications of defining those origins in a constitution and therefore granting equal rights and protection under the constitution, esp because at the present time women still do not have equal rights under the federal Constitution??? but the possible future offspring will be able to have lawyer represent in a court of law.....really?? are they serious?? I know this is just semantics, but come on is this really necessary to define when life begins?


My personal thoughts on the subject of when life begins.....i like to call it viability. When the fetus can survive outside the womb in the most basic sense, able to breath, circulate blood. That is as simple as i can make it, and this is what i believe. if you chose to believe something else congratulations that is your right as an American living in a democracy where we can debate all viewpoints

Sometimes you just have to yell!

Just another day in primary care, trying to get patients to actually care about their health. I have finally found an aspect of primary care that I enjoy, in essence its something i have enjoyed for a long time, arguing. In the office today (and pretty much everyday) are patients that are not following the guidelines and suggestions given by the doctor, they inevitable feel bad and come back, and when asked why they didnt do what they were supposed to in order to feel better come up with ridiculous excuses.
"I just didnt feel like taking a pill in the morning"
"I am single, and do a lot of heavy lifting, so i cant diet"
" I started feeling better so i stopped taking my blood pressure medication"
" exercise is too time consuming, cant you just give me a pill?"
" both of my parents died of heart attacks, but i dont want to take medication"

So today, i tried to educate patients about the importance of their health with a little bit of yelling. When someone has triglycerides in the 800's and tells me he cant diet because he is single, i get to explain what will happen to him if he continues to let this go unchecked. For males the consequences of poor cardiovascular health is evident by the inability to maintain an erection or even have one at all. Sometimes a little scare tactic is what it takes to get through. He decided to try and stop eating fried foods, start taking fish oil supplements in addition to medication.

Another man comes in, with a diastolic blood pressure over 100. He has chosen to stop taking his blood pressure medication 3 weeks ago, because he said it may him pee too often, and he had been feeling better. Now he has constant headaches, his vision is getting blurry and he has sever neck pain. When i tried to explain how not treating his BP and allowing it to continue at the current state, he could have a stroke at any moment. He didnt really seem phased by any of this, but did mention how both parents died of massive heart attacks. We tried to explain that if he didnt start taking care of his BP then he would end up the same way, and his kids would be without a father. Still not fully understanding the gravity of the situation, instead his main concern is the pain in the neck and head, so he demanded to be placed on percocet and valium since it helps with the pain and relaxes him (ie lowers his BP in his mind). I am nearly shocked to see a man be more concerned with scoring some drugs to treat the symptom instead of treating the cause of the pain by lowering his medication. Once we made some calls, we realized he has been filling pain medication prescriptions all over town from 12 different doctors in the last month. He ended up walking out of the clinic with no meds, not even for his BP. He became agitated and irate with us for accusing him of doctor shopping and drug seeking. Seriously....drug seekers come in all forms.

But at least today went a little better, i am starting to think my doctor doesnt hate me, and instead is just harsh by nature. My mantra, "i can do anything for a month" is working really well, and so is blanking out when she yells and talks to me in a degrading manner in front of patients. I just sit there quietly with a smile, suck it up, write some notes down and go home and look up the info, so the next day she cant yell at me for the same reason. Unfortunately, i feel she looks for minor details to pick out and tell me where i am wrong....i wonder if she had a bad experience as a medical student?? hopefully i will not treat my medical students this way.

on a side note, i got to drain an abscess on a breast today and it was AWESOME!!! hope i see more pus tomorrow....

number of strep throat cases seen so far in 3 days at a family med office = 12 and counting

Sorry I dont speak Spanish

So i started my family medicine rotation on thursday and so far its been a nightmare. I am convinced the doctor hates me, and wont give me straight answers about anything.

i show up the first day and ask the doctor what she expects of me, what my hours will be etc. She mentioned that i am to get there first thing in the morning and work until i am done. What does that mean?? could she possibly be more vague?? So i am still not sure what hours i am going to have while on this rotation, there are 3 doctors in the office, all with different schedules, and they see an average 75 patients a day (thats a ton!!, they see peds - geriatrics)....

then yesterday i showed up to the office at 8:30am, and worked with a different until 2pm when my doctor finally showed up. I saw patients all morning, and when i came out of a patient room and my doctor sees me, i get yelled at for not seeing her patients.

Then when she asked me to go and see the patient in room 4 i mentioned that i dont speak Spanish and the patient is Spanish only, so i could see the patient in room 3. I then got a speech (in front of patients, other doctors and the office staff), "you have lived here for over a year, what do you mean you cant speak Spanish?? Its a disgrace and I need to learn Spanish if i plan on living in south florida."

----seriously, I need to learn Spanish, to accommodate people who moved to this country?? I can learn Spanish and i am practicing, but my vocab is not nearly good enough to see patients on my own because i have a hard time understanding what they say in response to my questions.

but really, these people have moved to America, why are they not expected to learn English?? i have lived here a year and should speak Spanish, some of the patients have lived here over 20 years and speak NO English! why is that fair, and why am i the one who gets yelled at for it...It probably sounds really bad, but i am not against immigration, i am just not sure why we need to make it so easy for them to not assimilate to the new country they live in...if i moved to Spain, i am expected to learn Spanish i do not expect people to speak to me in English. I think we may it too easy for people to get away with not having to speak English.

enough of my rant.....there will be more i am sure in the coming weeks.....

"i can do anything for a month!" this is my new mantra....


i am going to DC for the next few days and will be back monday evening.

just call me Surgeon!

I know i havent updated in a long time end of the rotation got a little crazy, a little busy and full of evening activities for the trauma team (visiting professors, journal club, happy hour etc). The last month of my surgical rotation included critical care management. Each day i spent in the ICU managing neurosurgical patients and other trauma patients, and LOVED it more than i ever thought i would, the patients were complicated, interesting and involved lots of procedures!!

We had a patient who decided to get drunk and drive a boat into an overpass, smashing his head. The NS team declared his injuries incompatible with life, on his license he identified himself as an organ donor, so the transplant team went into full speed. The night before the harvest i had been on call, and around 2am rounded through the ICU and it turned out the patient needed to have 2 central lines put in for IV access for the harvest. I asked if i could do them, thinking they would say no, and to my surprise they said, "sure, get all the supplies and be in the room in 10min." That night i put into two subclavian central lines, without causing a pneumothorax and did it on the first stick! After those two lines, they let me put in any central line i asked to do...

The last month had some interesting cases come through the door, and most of them involved interesting lessons:

1. dont break up fights
2. dont sleep with another mans wife
3. dont drink and __________.
- ride a motorcycle, lift weights, work construction, drive a car, ride a scooter
4. dont rush to the IKEA grand opening on a scooter on I95
5. dont drink red bull while doing cocaine
6. dont misuse hardware
7. if you are going to try and kill yourself, at least know where the arteries are located
8. dont fight with your little brother around glass doors
9. "never sit on the stoop of church reading a bible minding your own business, you may get shot." - trauma patient


Some of the other things i have learned on my surgery rotation:

- only go into a patient room if you have to
- if you can smell the patient down the hall, dont go into the room alone
- ALWAYS double glove!
- surgeons are not doctors, so call medicine!
- ICU nurses are the backbone, dont piss them off
- cover your own ass at all times, because someone will always be there to make you look bad
- know everything about your patient!
- take some time for yourself
- keep a change of clothes in your car at all times
- smile, laugh and keep it fun or else you will go nuts
- call the attending only when you have too
- know when to use lidocaine with epi
- be nice to the triage nurses in the ER they can make or break your night call


At the end of the rotation, the chief of surgery called me into his office, and told me he sees me as a surgeon. He also mentioned that he would be willing to make some calls, and write me a rec letter for residency. Every student coming out of this rotation that wanted a spot in surgery got a spot in surgery. The chief knows people everywhere and is a big name in the world of trauma and surgery...AWESOME!!!

just glad i have found an area of medicine that i loved and could see doing every day for the rest of my life....not sleeping and living life in a chronic state of fatigue is awesome! currently i am on family med and my hours are so boring, 8:30-5 monday -fri...i have so much free time i am not sure what to do with it...

anyways family med is another post entirely!

Amazing and exhausting

So i know that i have not posted anything new in a long time. I am sorry about that, my surgery rotation is two rotations in one, trauma surgery and gen surgery. My hours are long, and exhausting, i have been averaging about 120 hours a week, and LOVE IT!!! i never thought i would ever say that working a 36 hour shift is actually something i enjoy, but as long as we are busy, its fast, interesting and strange enough fun....so i am starting to think i have a future in surgery, esp because i dont drink coffee (except for one cup in the morning around 5am) and i am able to stay awake and energized for the entire shift until i get home and sit down...then its GAME OVER!

here is how a normal day runs....
-get to hospital by 5am, see patients (either on the floors or in the ICU) write notes, check labs/imaging, exam the patient.
- 7:30am walking rounds
- 9am-2pm surgeries/ scut work/ procedures
-2pm sign out rounds to the on call people
- 3:30 till you finish scut work, post op notes, procedures---then you can go home, unless you are on call.

there are also days were we have morning lec from 7am-8am, sit down rounds 2x week 8-9 followed by walking rounds, we also have noon lecture 2x week, and clinic hours 3x wk from 10-1pm

for the on-call days we are able to go home after we finish rounding the following day. For example, if you are on-call wed, then you get to the hosp at 5am wed and will go home when we finish walking rounds on thursday, roughly 12...

my usually schedule resembles the daily habits of a newborn. I eat, sleep, work, poop, repeat.

i will get home take a nap for a few hours, wake up to read/study, eat dinner, shower, bedtime is usually around 9pm sometimes earlier. Then i repeat. Since i basically work 7days a week, all of my spare time is spent sleeping, doing laundry or trying to study.

Luckily for me, i have done well during my first month, made a good impression with the attending's and have been made chief medical student for my second month. This is a HUGE DEAL!! besides the obvious, good recommendation, more experience.....i am the one who makes the call schedule! so next month i will not be working every single weekend, and unlike this month where there were multiple occasions when my schedule had been q2 (every other day i am on call) next month i have a total of 6 calls, and work only 1 weekend. Ah the perks of leadership....


I have been meaning to post for weeks, since there are a lot of interesting cases/ stories that occur when you work trauma call/gen sx....here are some highlights of the cases

- psych patient who put a drill in his ass
- psych patient who liked to unhook his colostomy and play with his poop
- too many MCC's to count (MCC = motorcycle collision), if i have learned nothing else on this rotation, i have learned never to ride a motorcycle, and even helmets dont help that much!
- road rash of the scrotum
- man with metal nut around his penis (came to ER after been there for 2 days)
- man who worked construction, and fell 30ft after cutting a hole around himself...yep its as ridiculous as it sounds, we think about it like a cartoon. The only regret the pt has is 'maybe i should not have gone to work after drinking'
- the bigger the man the more they cry
- sometimes when you fall and hit your head and you think its nothing 2 days later you can be dead..... we had a lady who fell off a chair trying to get a lizard out of her house, and now she is going to die from a major bleed in her head that we cannot stop.
- stupidity keeps trauma surgeons in business, so thats good news!
- if you shoot yourself in the head with a .40caliber weapon, there is no reason to bring the body in via ambulance. you are going to be declared dead.
- regardless of injury two things can be certain if you come in via trauma alert - you will get a Foley and a rectal exam (and it will be done by a student!)

Funny story about the first Foley Catheter i tried to put in....the chief of surgery is running the trauma and tells me to put the Foley in, so i am trying, and all of sudden i hear..."Markle! you have to choke it, like you own it!" i will admit this is probably the best advice anyone can be given in the trauma bay. esp since i have not missed a Foley since then.

Other words of wisdom.....
-never break up a fight! if you need to just spray the people with a hose. We have a kid (17yr) who broke up a fight between 2 people at a party and ended up getting shot, and now is paralyzed from the waist down.
- Do not sleep with a married woman. Another pt we have decided to have an affair with a married woman, while having sex, the husband came home (in florida its legal to carry a concealed weapon), the husband shot the wife 3x in the chest, and shot the man in the ass. I am glad because it ended up perforating the rectum and we got to operate that night, but the man got a colostomy and had a lot of explaining to do when his wife and daughter came to visit him in the ICU
- dont ride a scooter. We have a pt who was hit by a car while on a scooter with no helmet (he was the passenger), they removed half his skull and part of his brain and now is in a vegetative state.
- Ritalin has multiple uses. We use Ritalin in head injuries, and i have seen patients that seem to be in a vegetative state start to wake up thanks to Ritalin. Its pretty amazing, so i am thinking about writing a research proposal about the use in the trauma patient to help stimulate brain function. Its pretty interesting.

I have learned a lot and seen a lot, and there are tons of stories, some from the patients and some more from the hilarious moments in the OR...the surgeons i am working with are awesome and keep the laughter a constant fixture. It helps since we see patients die on a near daily basis.

well its getting to bedtime, almost 9pm....so i need to get some sleep so i can wake up and do this all again tomorrow. I am going to try and post more in the next few weeks when i actually get a day off to sleep in, ie wake up at 7am and work out (thats a 3 hour sleep in!!! ) i never thought waking up at 7 is like a vacation...Similar to how i feel when i finally get to work a 40hr work week, its going to feel like i am on vacation/bored....

best week ever!

Basically the last week of my OB/GYN rotation is what i am calling the best week ever. The dr i love got back from africa, and the hands on experience starting racking up...they managed to let me do entire procedures on my own (under supervision), when i basically stood there with a blank face mumbling, "are you serious right now?" they would simply look at me and say, "there is nothing you can do, i cant fix". In my opinion i could def do something that is un-fixable, but i have learned to never tell a surgeon he/ she cannot do something. Instead you want to continue to make them feel as if they walk on water, so in following with this credo, i preceded to do the procedure and allow them to think they could be god like and fix anything i screw up...

so by the end of the week, i had delivered a baby (vaginal ) - this is really more like playing catch with a greased watermelon than really doing anything special. The placenta was def the harder part, this is where i did screw up a little and the dr came to the rescue. (he later told me it wasnt my fault, it had to do with the patients high blood pressure, than my med student skills, or lack there of). Next was a D & C, this is def the easiest of the procedures, followed by a cone biopsy and another D & C. At this point i am starting to get more confident, and the next case is for a bartholin gland marsupialization.

just as a side note this is a procedure we have been talking about since i learned about it a year ago, first it just sounds really cool (actually very simple) and its incredibly disgusting. So clearly a job i am looking forward to...i have not seen the follow up care for the patient since the rotation ended, but i hope the sutures look good, since i put in a lot, and it was on her labia....oh well, the doc didnt make a comment about it, so hopefully it looked good. I was pretty nervous on this one only because its on the outside, and on her vagina so you know, i dont want to be the one who makes it look ugly....

the climax of the week culminates with a series of hysterectomies. unfortunately one of the women decided not to show up for her pre-op clearance and the surgery had to be canceled. because the next day is my exam, and i am not going to be able to scrub in on the procedure and make it to my exam at 10am, i thought all had been lost. then the greatest page ever came in, the OR scheduling nurse wanted to add on another surgery to her schedule for friday and asked if she would be willing to start her first case at 7am in order to squeeze in the new case right after. she agreed, then asked me if i would be willing to be there at 6:15 to prep the patient. I told her i would be ready, but reminded her i would have to leave since missing my exam, and therefore failing my rotation is not an option. She assured me i would be out in time to make it to my exam. the next morning i am there bright and early, ready to see the patient and scrub in, i reviewed the anatomy the night before and new the procedure cold. i have even been practicing my knot tying with dental floss i carry with me at all times. we get into the OR and the doc asks the surgical assist to leave, and has me assist. when the scrub nurse handed me the scalpel i just stared at it for a few seconds, i knew i was going to help - retract, suction and maybe cut a suture. So when the scalpel is now in my hand and the surgeon is telling me to cut, i had a temp blackout or absence seizure if you will. once the scalpel hit the skin, a calming sensation came over, and it was def GAME ON! for the rest of the procedure, she simply said, watch me and repeat everything on your side. I ended up doing the entire left side of the procedure. i even tied off a vessel that the doc cut because my angle had been better. let me just say leaving that OR and for the rest of the day if felt awesome!!

today i started trauma surgery and i am really excited, nervous and very anxious to start to routine....my hours basically suck, and i will work more in the next two months than i have ever worked in my life...esp because there is someone who is supposed to be working with us who decided not to show up, so the rest of us have to pick up the slack....so that means someone was getting screwed with the schedule, thanks to murphy's law, that someone is me....so for the next two weeks i will work a 40hr shift every other day. yes that is like working 3 full time jobs in a week....or roughly 120hr work week....but it will probably be longer, i am guessing after seeing the amount of patients and the responsibilities of the on call student....its going to be closer to 140...yes, there are 168 hours in a week, so i am guessing the 28 hours left over i am going to spend asleep! so if there are no posts, its that i have nothing to say, its probably because i am so tired i have lost the capability to communicate/type/ stand up/ think. On a bright side, i will probably lose those last 10lbs i have been trying to drop because i dont know if i will have time to eat. The other piece of info that i think is particularly funny, is that when you are an intern its technically (people dont always follow this rule, but its really bad it you dont) illegal to work more than 80hr in a week (averaged over 4wk). But dont worry, the med student doesnt fall into those regulations since we tech do not get paid and are not employees! yay for semantics :)

A full moon and no prenatal care!

The doctor i admire most on my rotation just got back from a two week trip to Ghana where she performed all types of surgeries/ deliveries. On her first night back i decided to stay and hang out while she was on call (i am not required to take call because they have no beds for students, so i decided to stay around and see what happens). The whole day seemed to be very busy, and full of crazy people. esp crazy people who obviously think that prenatal care is an optional method of care.

So I am sitting with the doc looking at her pictures from her trip to Africa, listening to the interesting cases and crazy debauchery that happened and a page comes in from the ER. There is a 17yr old pregnant women seizing. So we basically run down to the ER, and find a 17yr old seizing, intubated, a crowd of people in the ER room, and no where to stand....

withing 10 minutes we had an ultra sound done, a vaginal exam, and she is being prep'ed for the OR for a stat cesearen. During this i am trying to talk to the family to get some history information since the patient is sedated, intubated and currently unable to communicate herself. The only information i am able to ascertain from the family is she is due on sept 3rd, and has not seen a dr yet, she lives with her mother and brother, dropped out of high school, the father of the baby is not in the picture, and she is only been taking prenatal vitamins for the last 2 months. This is not a really good state for the patient and the only thing running through my mind is, THIS IS AWESOME!!! i have just seen an ecclamptic seizing patient, and now i am going to learn how to manage someone with untreated pre-ecclampsia....

unfortunately this happens to me a lot, where my thought process is opposite of normal. As a med student, when a patient is in bad shape/ sick, i get excited and get even more excited when the patient gets worse! its slightly disturbing to say, but its def true. there is always a part of me that hopes that the patient gets worse. When i sent off labs i secretly wished the labs came back with elevated LFT's, low Platelets and hematuria, high uric acid and possible mag toxicity. I know that i should want the patient to get better, but i learn by seeing, and if i dont see a patient with a certain problem than my only experience is what i learn from a book. And lets face it, treating people is not as simple as the book makes it seem, so having some hands on experience is better than reading it from a book. But in order to learn from those rare, and difficult cases there has to be a patient on the other side actually experiencing disease process.

Then there is another part of me who thinks, if this person had been seen by a physician on a regular basis for prenatal care, the likelyhood of seeing a patient like this is low. Similar to another patient i saw who is from Haiti. Speaks no english (typical) and doesnt speak Spanish (which is getting soooo much better since starting rotations)...she is postmenopausal and has had vaginal bleeding for the past 3 months. Well, lets just say you could diagnose the cancer from outside the room due to the smell of necrotic tissue. She has a stage III cervical cancer, than is non-operable. She also has kidney failure are a result and is basically not doing well....the family wants everything done, so we will spend a lot of $$$$ trying to prolong her life a few months.

I have a friend who had been diagnosed with cancer halfway through our second year of medical school, tried treatment, got sicker from the treatment, treatment is not working, so he decided to stop the treatment and just live his life (whats left of it) as he wants, with his friends. Here is a man who is 23 with an entire life ahead of him, who has accepted that nothing can be done. And has put quality of life ahead of quantity of life. Juxtapose to the women who is 76, weak, dying and is going to have difficult aggressive treatment with lots of side effects to prolong a life that has already been lived a few more months. I think my friend is handling his life/death with such dignity and positivity that i truly admire him. Its really sad, esp when you hear him talk about knowing he is going to die, but there is still that same life spark in his eye, that just makes you smile and keep going.

those rumors are true....

Before starting medical school, i heard the stories about attending physicians grilling med students, the sexual harassment that goes down in the OR, and the caddy drama that goes on around the nurses station. In the world of hospital medicine there are two different worlds, and one of them has nothing at all to do with patient care...

For the past few weeks i have been speaking to some fellow female classmates also on rotations in different hospitals to find out what types of experiences they are having working with their male attendings....and it definitely has been getting a little interesting.

Here are just a few of the stories that i have heard in the last week...

- my attending while in the OR mentioned to me, that "because you are a smart, bright and driven woman, you are going to have a hard time getting married. But on the bright side, you will never get divorced" its nice that a surgeon has taken the time to find a silver lining in my love life.... he also mentioned that in order for me to find a man i should try and dumb myself down....instead i am hoping to find a man that isn't so insecure about his position in life...if i don't find one, than i will be glad i decided not settle for less than i deserve...

- a friend while on a peds rotation at a childrens hospital, was standing at the nurses station with another med student, when her attending comes up from behind..smacks her ass and gives her an order to complete in the same breath..."we need to cancel the clindamycin and start on PO antibiotics" ...i am sure that there are better ways of getting a students attention without subjecting her to sexual harassment. Esp because the student was caught so off guard she completely forgot to write the order in the first place...so here is an example of how sexual harassment can directly affect patient care...

- another friend of mine happened to be wearing a button down shirt, and about halfway through the day noticed that a lot of the male attendings were paying more attention to her than normal, and even smiling at her in the halls, and elevator....finally she ran into another classmate who told her that the top 3 buttons had come undone on her shirt!! she figured it had been about 3 hours before someone had told her about the fact her shirt was totally open, and she had no camisole on that day either...


- unfortunately there is a classmate of ours giving the rest of the women in the class a bad reputation....there is a girl who has decided to cross the line of appropriate behavior with her attending....lets just say the story line for McDreamy and Meredith didn't come from thin air....

Anyways, still loving rotation, and still making a fool of myself on a daily basis, but i think i am learning and getting better too. In the last few days, there have been over a dozen babies born, and about 5 ectopic pregnancies....so do the ectopic cancel out the new babies and make the net total for the week 7 babies??? or does baby math not work the same way....more questions to ponder....

my attending also used an old joke the other day during morning sign out.....the night before we had delivered a baby that had a fetal anomaly, and had been born with a short femur on one side.....so in morning sign out he mentioned that the parents should probably name the baby girl, Ilene!! (pronounced I - Lean) for about the next 20 minutes we could barely contain the laughter. For some reason at the time i had never heard that joke be so amusing....

not sure if i mentioned earlier how the service OB always gets the crazy patients....well yesterday was no exception....we had a G7 P6016 give birth vaginally to a 9lb 7oz baby...here is the interesting twist to the story, we were given explicit instruction not to tell the husband about the other pregnancies because he thinks its her first baby.....she married a man and he doesn't know that she has 5 other children in another country (only in south florida), so she ended up pushing a 9lb baby out of her vagina in just 2 pushes, not to mention there was no vaginal tearing.....that is def what happens in a nulliparous women (first pregnancy) JUST KIDDING, plus if anyone actually looked at her vagina can see that she has pushed multiple children out of her vagina...maybe he is truly living up to the stereotype about black guys, and he actually could not feel the difference....

well those are all the stories i have for you tonight!! more next week!

there is no way that is going to fit through that small hole......

As most of you know, i am half way through my OB/GYN rotation... during the course of this rotation so far my amazement of the how the human body can tolerate stress is absolutely ridiculous. Today is no exception. While rounding on one of our consults who has been in the hospital for the past 4 days with abdominal pain without alleviation, medicine has consulted everyone from surgery, to gastro to gyn to determine the cause of the pain that doesn't get better even pain meds only reduce the pain. Anyways, this is a process we like to call the TURF. A friend of mine is currently rotating on internal medicine, and has been trying to TURF the patient for 4 days. She is a handful and difficult to examine and a pain for the nursing staff. First medicine TURFED to surgery, surgery did not accept and attempted the TURF to gastro who sent back to medicine. Medicine tried for two days unsuccessful to TURF to gyn, and today we decided this is getting annoying so let's just poke a hole, stick a camera in the belly and find out what is causing the pain. Before starting surgery my attending secretly hoped to find an inflamed appendix so he could call surgery and give them the TURF. Unfortunately for us, its a gyn issue. She has an ovary attached to the abdominal wall, its oozing brown pussy fluid into the pelvis....she is now our patient....the successful TURF!


The highlight of my day is the surgery itself, i got to handle the laparoscope, i got to irrigate and suction (its kinda a big deal for me as a third year student) and I LOVED IT!!! i knew playing video games would pay off....so tell your kids to play their video games because it makes operating with a laparoscope a lot easier. (you get to watch it on TV while using your hands....so fun!! and to think one day i may actually get paid for this :) ) While washing the cavity the dr warned me to be careful because i could potentially perforate the bowel, bladder or something else...for a moment during surgery i forgot that its a patient and not a computer or something...a little strange, but since only a tinny bit of skin is actually visible it makes sense that you don't realize its a person under the blue drape. The coolest part is when we removed the ovary..i always wondered how they got an organ out one of those tiny little holes..and now i feel like i am in on the secret...they put the ovary in a little bag they placed through the hole. Then pulled the bag (like an empty balloon) through the hole....the ovary did get stuck, but with a little maneuvering we managed to pull it through the belly button!!! it was awesome!! who ever would have thought that an ovary can fit through a hole in your belly button...

well another day down....only a few weeks left :(

Day 3 and 3 babies!!

Finally...today i saw my first vaginal delivery, and 2 c-sections (now on referred to c/s). The group of doctors i am rotating with has 5 Dr's in the group so each day i spend time with a different. I think its great because i am learning to adjust on the fly, each has a different personality and different way of handling patients, charts, calls and each other.

While one of the Dr's is on a medical mission trip to Africa, they have a Dr from Canada come down to cover. He takes 2, 24 calls back to back with a 8 hr day in between...its absolutely absurd in my opinion. The day started off with tumor board at 7am, and a lecture at 9am. After that i saw service patients, and wrote discharge orders on all of them. Now its only 1pm and i have no patients. So i decide to call the OR and see who is working and whats going on....

Turns out the Canadian has scheduled a suction D/C and a c/s in the afternoon. So i decided to find him and ask if i could scrub in....Jackpot.

Since i still had 2 hours to kill before the OR is ready, i went by L+D to see if any babies were being delivered....right place right time, the only midwife that doesn't hate me is on today, and saw me in the hall, grabbed me to help with a delivery. This was a woman's 3rd vaginal delivery so the midwife said it will be an easy uncomplicated delivery and i can help. It was awesome, kinda gross, and a little intense. The husband and her 2 other children were in the room at the time, i thought having the kids in the room was a little odd, but they were well behaved and sat on the couch, didn't even make noise. The husband stood on the opposite of the room, and i was the one who held her hand, and leg back as she pushed a 7lb baby out....its pretty amazing to see how much the vagina actually stretches, but the amount of fluid, blood and poop that comes out is a bit much for me, and the baby comes out looking kinda gross....like a wet puppy or something....in the end, i still believe that natural childbirth is the most unnatural natural process i have ever seen.

After the delivery was over, i made it over to the OR to find my Dr a little lost, he couldn't find pre-op holding...luckily i have worked at the hospital for 2 days, so i showed him were to find the patient, the chart and the scrub nurse. after seeing the patient, he got lost again trying to find the OR....luckily i was there, or he would have just wondered the halls....i show him what OR we are in, go in to the OR to set up my gloves and gown before the patient is brought into the room. I come out and the Dr is gone, missing and cannot be found anywhere. I grab the scrub nurse and we start the Doc Hunt...we have a Canadian in blue scrubs on the loose. (everyone else has green scrubs on, so he is easy to spot) After we page him and find out way back to the OR, he is there scrubbin in....lets just say this D/C didn't have my soaked in blood like the one yesterday....

my first scrubbed procedure was yesterday, an easy missed abortion D/C on a 14 wk preg. I got squirted and covered in blood projecting from the patients cervix......it was a very strange feeling, imagine a cervix or vagina projectile vomiting blood on you...that was me yesterday...Carrie had nothing, this is what true horror movies are made of my friends.


I then got to see my first c/s. They anticipated the baby being large roughly 10lbs so they opted at the last minute for the c/s instead of trying a vaginal delivery and running the risk of getting the baby stuck. All i have to say, bloody bloody mess, with a side of hot warm amniotic fluid....

those were some of the highlights.....cant wait for round 2 on Monday, hopefully we will have some more patients come in this weekend since i discharged all the service patients, including the 4 consults we had today.....

but on the bright side....i still LOVE this rotation, and think that i am going to end up in ob/gyn

seriously.

Today was my first day working in the labor and delivery at the hospital. A little disappointed because i happened to just miss all 3 of the vaginal deliveries, because i had to deal with a group of post-op and gyn patients. Overall today was interesting....

started off rounding a group of post-op patients, nothing too exciting. no complications, healthy babies. easy patients.

then things started getting interesting. We saw a patient with a nasty, disgusting, dry heaving infection. She is in quarantine, so we had to put gowns, masks and sterile gloves on before entering to change the dressing on her wound. It was my job to remove the existing covering and expose the wound. My jaw nearly hit the floor when i saw what we were dealing with (thank god for the mask). She has a MRSA infection of her c-section scar, that started to become necrotic and form a fistula. (describing this is tough....imagine a c-section scar across the lower pelvis, now imagine a circular HOLE above this open scar the size of a silver dollar that actually connects with the original scar. And then envision black/dying tissue inside this hole, deep enough to stick your hand up to your knuckles). basically a horrible looking wound with an even worse smell.

Even when i did autopsies i had never smelled anything this horrific. I wanted to dry heave each time we removed more dead tissue from the wound. We finally got finished, it was one of the most horrible experiences of my day. usually my stomach is pretty solid, but the smell alone nearly killed me.

another patient disturbed me today. This one is actually famous on the service.....she came in last week for abd pain, she thought she was about 20wk pregnant.

here is what actually happened......24yr old, 43 wks gestation, 12lb baby (overcooked, dead). She also weighed 580lbs, is diabetic, hypertensive and by definition severely morbidly obese.

its strange but the only part of that i found disturbing....is that someone actually had sex with her to get her pregnant! I had a hard enough time removing the Foley catheter and all i had to do is follow the tube to the vagina!! cleaning the incision was a team effort as well, esp because the pt stated that she is unable to wipe herself so you can imagine how much skin had to be held up to clean and bandage the incision.

one of the last patients gave me practice in giving information to the patient.....we had to tell a patient that she had a severe gonorrhea and chlamydia infection that has spread to the abdominal cavity....not to mention she is pregnant so clearly my treatment plan of choice is no good unless i want her kid to be deformed.

anyways.....things are still going well and i still love OB/GYN even if things are quite gross at the moment.....no OR yet, but maybe tomorrow i will get to see a delivery or be in the OR..i will keep you posted.

Down the Rabbit Hole...

before we get started I just want to say, I'm sorry for not giving daily updates, or even weekly updates. I will try to do better, but sometimes (gasp) i don't have much to say. usually i have already ranted, vented and told about 5 people what happened, so i have no more need to speak about it in blogger world. If you know me, than you are fully aware of my need to constantly share my opinion and tell others what i am thinking. Currenly on my Ob/Gyn rotation the doctors are AWESOME, and i rarely have something to get off my chest at the end of the day. Fortunately i am going to be starting a 2 month rotation on trauma surgery, i have a feeling there will be lots more to discuss in the next few months. there is no need to be at a loss for postings...and now onto what i like to call, a trip down the rabbit hole..

in my opinion life starts out as a trip down the rabbit hole, and there are times when the patients that i am in contact cause me to question the reality of my existence. sometimes i think i may be in an alternate universe that is guided by some other force different and very backwards to the one we all think is true. let me give you a quick glance of what i have seen in the past week..


- 15 year old girl 38 weeks pregnant who walks in sucking a lollipop and twiddling her hair. My take on her is a mix of pros and cons. At least she is smart enough to seek prenatal care, understanding she will qualify for medicaid and welfare. What about the fact the state of Florida doesn't think this girl is mature enough to operate a motor vehicle but at the same time is capable of taking care of a child. I guess the school system has failed this child. unfortunately there are handfuls of girls just like her.

- 37 year old 3 weeks post-partum. She is a christian scientist who doesn't believe in modern medicine. She ended up going into labor at 42 weeks after refusing to be induced. She delivered a beautifully healthy baby despite there being no heart beat. the only thing that killed this baby is that it wasn't delivered on time. While talking to her, she told me that her baby was doing well, and that she has even started walking. At this time i thought i was talking to the wrong patient because i knew that her baby had died. Nope i had the correct patient, she was just a little off center and she felt her baby was with her spiritually.

- 42 year old G8 P0080 (that means she was pregnant 8 times, and had 8 terminations). Now she is sitting in the room crying because she wants to get pregnant. She recently got married, thinks her husband may be cheating on her, but wants to get pregnant anyway. This would be what my attending calls, 'making a bad choice'.

- 25 year old, primagravid (first pregnancy) who is 498lbs, and thought she was only 14 weeks pregnant. In reality she was closer to 43 weeks pregnant. The baby was slightly overcooked, meaning it was 11lbs and had no skin (the skin had pooled around the wrists and ankles). It took over 4 doctors to pull the baby out. Not to mention that OR tables are only approved for up to 350lbs, so they had to bring in a special bariatric bed for the patient, who had a plethora of medical issues to deal with post-op.

well that is a nice sampling of what i deal with on a daily basis. And even after all that, i still want to do this everyday for the rest of my life. I love gyn, not so sure about the OB part but i def want to do the gyn part.

i start in the OR on wed, i have been practicing tying knots so hopefully they will let me close on one of the surgeries.

So in the end i am still not convinced that i have not accidentally slipped down a rabbit hole into a world very similar to our own, but with a slight twist on the morality scale.

Things your doctor doesnt even want to see

Today was my first day of OB/GYN. For the first half i work in a gyn clinic adjacent to the health department, so you can already guess the fantastic crowd i have the pleasure of seeing each and every day. As my first day, they took no time in throwing me directly into a room with a patient i like to call, "the train wreck"

to clarify - you know the feeling, when you are driving along and happen to come across a railroad crossing, just as pass the last possible turn before crossing the tracks, the lights flash and the gate comes down. You have now reached the point of no return. You can do nothing at this point except wait for the long, slow moving, boring train to pass. As you sit there patiently, you begin to notice the train slowing down, and then realize that it has stopped. This is the point where you know you are screwed and you cannot get out. All you can do is sit back and wait.

I had a patient like this today, i had no idea what i was getting myself in for when i first knocked on room 3. As i entered the room, i noticed she brought a shopping bag with her. Normally patients are helpful and bring in their medication bottles, this way they wont have to worry about messing them up when the question arises, "what meds are you currently taking?"

Sometimes you dont want to know what patients bring in those bags...today was that day. I have been used to internal medicine, where patients are sick, and usually complicated sick. Today i had just sick....

when i asked the first question, "why are you here today?" i got a response i wont forget.
"i want you to remove my uterus because i am sick and tired of bleeding."
I only wish i could provide you with the irate, demanding and angry tone the woman had with me, as she preceded to open her bag, take out a Ziploc filled with used tampons and pads, to fully illustrate the point of how much she was bleeding.

(and really, she had about the same amount i go through in a normal period, nothing more)

Instead of gaining the sympathy she wanted from me, all i could think of is how crazy it is to save a weeks worth of tampons and pads, to complain about heavy bleeding. You can tell me how many you go through without the visual. Really i know how to count. After discussing with her the results of her pelvic MRI, pelvic U/S and CT of the pelvis (all demanded by her), telling her that her uterus was normal without any evidence of fibroid or tumors and that she should try the oral contraceptives that had been prescribed to her upon each visit she made over the past year. Her only response is, "just please take it out, i am in pain every time i have my period, and i bleed so much that i am in pain." This woman was more than a little irate, and even when told she could have a referral to another gyn for a second opinion because the dr i work with refuses to perform an elective hysterectomy. She just yelled at the doctor and demanded pain medication....

what a drug seeker, a woman that is willing to have a part of her body removed to score drugs...

Another day, another crazy patient

Everyday starts out the same, a list of 20 patients to see before lunch. The fun part of internal medicine is that you have no idea what kind of crazy is going to walk through the door. I enjoy knocking on the door of the exam room and having no idea what i am in store for until i ask my favorite question, "what brings you into the office today?" the next few words uttered from the patient are no longer a shock to me...here are a few highlights from the last few days-

- it burns when i pee
- i have a pain in my right testicle
- i burned the lower half of my face with hot wax
- my husband is leaving me for a woman younger than my children
- i was a witness to a bank robbery and cant sleep
- i drink 9 beers a day, smoke 2 packs a day and need a physical for a discount on my car insurance
- my wife made me come
- i have had bloody diarrhea for the last 3 days (go to ER not the Dr office!)
- i have trouble breathing and have been having chest pain (also, go to the ER!!)

those were just a few of the fun ones.....of course there are the normal, i am here for my normal 3 month check up, i need refills, i have a runny nose, a cough, a headache....

The range of patients and range of complaints is fun, not knowing what is going to happen before going into the room is a blast!

A few days ago I experienced my first awkward moment with a patient. I performed a urethral swab (Dr was present) on a patient I suspected of having chlamydia...(btw i was correct) the male patient presented with pain at the end of urination, has been having unprotected sex with a partner who has not been screened for STI's, and he had never been screened for an STI...seriously, not a tough diagnosis. Unfortunately in order to confirm the dx I had to place a small swab into the urethra and hold it there for 30 seconds. This had to have been the longest 30sec of my life. (i imagine the patient did not enjoy the 30sec either, but maybe from now on he will learn to wear a condom!)

it seemed to be the day for urology complaints...that is possible another field that could see myself doing.....so far i am interested in GI, urology, infectious disease. I guess the nice part is i am starting to enjoy contact with patients...even the patients that are totally crazy are in their own way a little amusing....

speaking of crazy patients, there was another patient that came in because of anxiety. She seemed very overwhelmed and anxious, and shaking periodically during the H+P. Even while i performed an EKG, her body would shake. I spent a lot of time talking to her, trying to calm her down, keep the environment friendly and comfortable. after discussing some options with the doctor she left with a plan, and a follow up appointment. The next day i came into the office, and she had left a message for the Doc, mentioning how comfortable she was by the time she left, and how distressed she felt on arrival. She wanted the dr to know i did a great job making her feel calm and comfortable.

A lot of patients have mentioned to him, that they enjoyed talking with me, and that i make them feel comfortable and at ease. Seriously, i hope my attending doesnt think i am paying people to say nice comments about my patient/bedside manner....but either way, its nice to hear :)

I guess i cant cross psychiatry off the list....

well i need to finish reading Harry Potter, since my attending finished it on sunday is planning on questioning about it tomorrow since he cant believe i have not finished reading it yet.

will try and post again in a few days, tomorrow is my scrub class for OB/Gyn and Surgery...that should be interesting...

one more week...

So i know that some of you are missing my posts. I want to apologize its been a little bit of a crazy week and i think that this next week will be just as bad. Part of me is actually a little sad since think i am being spoiled on my current rotation, the nurses are wonderful, the other doctors are usually smiling and willing to answer questions, case managers, social workers pretty much the entire hospital staff GREAT. Then i go to the other hospital (the main hospital) and nurses are rude, nobody gives you the time of day, and really they could care less if you have a question. Some of the nurses were given attitude to my attending. I really could not believe how she treated him...We walked away, and as we approached the elevators i mentioned that the nurses on that floor had some major chutzpa. My doc agreed, he said the nursing staff is just rude at this hospital.

So I think next month my life is going to have a rude awakening when i realize exactly how spoiled i have been. I normally average 35 patients a day, with an average of 10 in the hospital the rest in office. Some of my peers see only 2 or 3 patients. Soon i may actually have some free time in the hospital to learn my way around, and get some more hands on experience with procedures. Nothing to exciting has happened in the last few days, i am spending my time reading about patients and working on AMSA stuff.

Speaking of AMSA stuff, i am getting ready to launch a new campaign on sept 17th titled, Not My Property, an attempt to bring common sense and science back to reproductive health policy at the local and federal level. This is a grassroots campaign, focusing on local direct action projects connected to a central information center. We are setting up a website where people will be able to download information, share information, post video/ photo clips and have discussion about the current state and how to change reproductive policy at both the local and federal level. So be on the look out for a posting with a link to the website officially to be launched on sept 17.

Nothing else to report, so i am going to get back to Harry Potter!!! its sad this is the last book i will be reading about Potter :( good thing i can always read them again :) i am def under the spell of potter!!!

Update on SCHIP expansion - veto

President objects to SCHIP expansion "on philosophical grounds."

In continuing coverage on proposed increases to expand the State Children's Health Insurance Program (SCHIP), the Washington Post (7/19, A3, Lee) reports that "President Bush yesterday rejected entreaties by his Republican allies that he compromise with Democrats on legislation to renew" SCHIP, saying that expanding the program "would enlarge the role of the federal government at the expense of private insurance." The president said he "objects on philosophical grounds to a bipartisan Senate proposal to boost the SCHIP by $35 billion over five years. Bush has proposed $5 billion in increased funding and has threatened to veto the Senate compromise and a more costly expansion being contemplated in the House." Bush said in an interview with the Washington Post, "My concern is that when you expand eligibility...you're really beginning to open up an avenue for people to switch from private insurance to the government." Recently, the American Medical Association voted in favor of!
strengthening SCHIP

Just trying to get a leg up!

Medical School is about trying to get a leg up on the competition. Each step of the way to become a Doctor, you must be better than someone to achieve the next step. Let me quickly sum up the steps to becoming a great doctor...

1. Be an member of the OAC (over achiever club)
2. Be willing at each and every moment to benefit from the failures of those around you (undergrad)
- in reality its not as bad as it sounds. In undergrad there are more people that want to get into medical school than there are spots in first year classes. To boil that down, only about 60% of your pre-med friends that actually apply to med school will get in. The rest will pick a better career to pursue with the knowledge you get in college in pre med.
3. Work hard, and at the very least work harder than at least 30% of your class, that way you will never end up in the bottom third of your class.
4. Be sure to renew your membership in the OAC
5. Understand that being a medical student in the hospitals is like being the new kid in high school again....ie, you are the butt of all jokes, and people think you don't your butt from head.
- most of the time its not that bad, i completely understand i don't know everything, and people above me will sometimes point out how much smarter and better they are than me, and for i just take my personality, check it at the door, suck it up and take it.
6. Don't take anything personally
7. Take constructive criticism, as constructive - Not personally
8. Be sure when criticism is personally to deal with it properly (there are going to be cases, when a comment is directed in a personal manner, if necessary these are the ones, that may require some added action)

ok, so now that we are all on the same level, let me share with you a story. I had a discussion with my attending about my progress, and how i was doing halfway through the rotation. He spoke to me as an equal and just told me exactly what I should do differently, some areas that are strong and what i need to work on. He also told me that I remind him of when he was a student and gave me some additional advice about how to approach other rotations.

After the short discussion, he told to go into room 2 and take my time, go through a complete physical. He also gave me a small warning, "she has a lot of pathology, and try to remember Ockham's razor, good luck!"

When he wished me good luck is when i started to wonder what kind of trap i am walking into. I decided not to worry, i know i have some skill when it comes to physical diagnosis. I trust my skills, and m knowledge and just knocked and entered the room. In the room is a nice older women sitting in a wheelchair, and another women sitting in a chair across from her. She didn't speak any English, and my Spanish is not that good, so luckily the daughter can translate.

I got through the HPI pretty quick with a little help, if only i had been a little more thorough the joke my have not been on me.
Starting on the physical,
-HEENT (head, eye, ear, nose, throat) all relatively normal. Moving onto chest, her lungs sounded like there was wet carpet inside, pathology.
-Heart, placed the stethoscope and heard a loud blowing sound, she has severe insufficiency from her aortic valve, pathology. She also has a prosthetic mitral valve, pathology.
- abdomen, relatively normal. PEG tube (feeding tube) in place but not infected.
now is when I became the butt of the joke. I was going to check peripheral pulses but couldn't find them. I thought that her legs felt a little funny, then i noticed both patients laughing and looking at me funny. Then she told me, which i also noticed...

She had no legs.

yep, sometimes the most obvious is not obvious, even when you are being observant and trying to pay attention to physical exam...you can miss something. But really, she has no legs, i have to admit i laughed a little too. Why? Because it was funny, i am doing a physical exam to pick up subtle changes to detect underlying pathology, and i miss the big obvious things...SHE HAS NO LEGS. She had bilateral below the knee amputation due to diabetes. So she has two prosthetic legs, she is able to walk around and be relatively independent.

She had some severe consequences of untreated diabetes, not to mention some problems due to her smoking. She had developed mild COPD, DVT's in legs and arms, PE and even had a stroke while on coumadin. She has been more compliant with her current medication/ treatment plan. So thankfully she is doing well and is in good spirits.

The Doc finally came in, laughing a little and wanted to know what i found, I said, she has no legs! and he said good, glad you noticed!


I still think its funny.

Also, my patient that i thought may have Dengue fever, does actually have Dengue fever. I was really excited about that...unfortunately there is a part of me that hopes his platelet count continues downward and that he develops hemorrhagic dengue (i know that sounds bad, but the curious med student sometimes wants patients to get worse so we can see more disease process.) But I am also glad his platelet numbers are climbing and he is getting better.

(hemorrhagic dengue has a 30% mortality, dengue fever has no treatment and is symptom based, making the patient comfortable and giving fluids)

other than that i feel i am seeing and learning a lot...between two hospitals and two offices every day i get in a lot of patient contact.

roughly 20 office patients/ day and so far we have followed 20 different patients in the hospital in my first 2 weeks, at one point we had 14 patients in the hospital at once, that was crazy since on my internal med rotation its just me, i have no team....i wish i did, so when i get 'pimped' and don't know the answer someone else can answer.

Stop Bush Veto of S-CHIP

July 15, 2007 - NYT
Bush Is Prepared to Veto Bill to Expand Child Insurance
By ROBERT PEAR

WASHINGTON, July 14 — The White House said on Saturday that President Bush would veto a bipartisan plan to expand the Children's Health Insurance Program, drafted over the last six months by senior members of the Senate Finance Committee.

The vow puts Mr. Bush at odds with the Democratic majority in Congress, with a substantial number of Republican lawmakers and with many governors of both parties, who want to expand the popular program to cover some of the nation's eight million uninsured children.

Tony Fratto, a White House spokesman, said: "The president's senior advisers will certainly recommend a veto of this proposal. And there is no question that the president would veto it."

The program, which insured 7.4 million people at some time in the last year, is set to expire Sept. 30.

The Finance Committee is expected to approve the Senate plan next week, sending it to the full Senate for action later this month.

Senator Max Baucus, the Montana Democrat who is chairman of the committee, said he would move ahead despite the veto threat.

"The Senate will not be deterred from helping more kids in need," Mr. Baucus said. "The president should stop playing politics and start working with Congress to help kids, through renewal of this program."

The proposal would increase current levels of spending by $35 billion over the next five years, bringing the total to $60 billion. The Congressional Budget Office says the plan would reduce the number of uninsured children by 4.1 million.

The new spending would be financed by an increase in the federal excise tax on tobacco products. The tax on cigarettes would rise to $1 a pack, from the current 39 cents.

Mr. Fratto, the White House spokesman, said, "Tax increases are neither necessary nor advisable to fund the program appropriately."

Democrats in the House would go much further than the bipartisan Senate plan. They would add $50 billion to the program over five years, bringing the total to $75 billion. By contrast, in his latest budget request, Mr. Bush proposed an increase of $5 billion over five years, which would bring the total to $30 billion.

White House officials said the president had several other reasons to veto the bipartisan Senate plan.

"The proposal would dramatically expand the Children's Health Insurance Program, adding nonpoor children to the program, and more than doubling the level of spending," Mr. Fratto said. "This will have the effect of encouraging many to drop private coverage, to go on the government-subsidized program"

In addition, Mr. Fratto said, the Senate plan does not include any of Mr Bush's proposals to change the tax treatment of health insurance, in an effort to make it more affordable for millions of Americans.

Senator Charles E. Grassley of Iowa, the senior Republican on the Finance Committee, said he would like to consider such tax proposals. But, he said, "it's not realistic — given the lack of bipartisan support for the president's plan — to think that can be accomplished before the current children's health care program runs out in September."



Can someone please explain to me why Bush of all people would want to keep children uninsured....isn't he pro-life because he values every child, and the children are the future of our country. I guess he just wants those children to die. I think that in his ideal future the only children to survive are those from wealthy families who would vote for him...clearly the world would be a very different place if only the rich survived. By keeping the poor, in poverty and enslaving them to a life where they are unable to raise themselves up, we are behaving in a similar manner in this respect as some of the third world countries treat their citizens...some of these very countries we are currently occupying in order to bring them the American sense of freedom. If we can not take care of those that cannot take care of themselves in our own country, then we need to stop focusing elsewhere and put the focus back on the home front. Diversions of rhetoric and political ploy should be saved by those with the educational merit to join the debate.


if you agree....please call your senator and tell him what you think...

the link is on the side if you dont who they are, although you should because you voted for them (or maybe you voted for the other guy, but regardless they still represent you, tell them what you think! )

And Balls make four.....

Another day, another patient, another diagnosis....

Each day of the rotation starts out very similar....see about 15 patients in the office, go to the hospital and round on as many patients as i can until 2pm, go to the other office and see patients until 4pm, then head back to the hospital to see the patients i did not get a chance to see during my lunch break...

And when i say lunch break, the hours between 12-2pm (when i thought my doctor took a 2 hour lunch....) is when we see patients, and try and eat lunch....the more i can get done between these hours the earlier i go home at the end of the day...


today, was long.....but i don't have to work this weekend because my doctor is not on call (YAY!) I think i am going to stop in anyway because i want to check up on my patients that i have been following, but anything i do is my own time, my doctor is not responsible.


We had 15 patients in the hospital to see, so the best method is to divide and conquer (even though i still have to present to him and have the Dr sign all my orders)... i started off seeing a women with HTN, Bells palsy and Zoster....next, we have Fever of unknown origin, suspecting infectious waiting for Dengue fever Ab's to come back. Moving to a different floor I go and see a patient who is a known drug seeker with Crohn's disease, nothing new there just wants dalaudid refuses to be seen by pain management, the last patient i got the pleasure of seeing before leaving at 2pm is a man with a testicle swollen to the size of a softball. The swelling came down and the man with swollen balls actually thanks the doctor and asks for his card to bring the rest of the gang to see him. So when my doctor asks how many patients i have seen...i list through them and basically say, say "and balls makes four."

After my attending had a good laugh, i realized how horrible that sounded and made sure to apologize since i had no intention of mocking my patient....but it does help break some tension and keep things in perspective..

After lunch i saw some more crazy patients in the office and had a moment of truth...

I saw another example of how insurance companies dictate care instead of doctors. The doctor i am working with is trying to have approval for a service for his 3yr old daughter and had been denied...the reason was ludicrous i could not believe what they told him....he got mad, up until this point i have not seen the man raise his voice, or even get slightly frustrated with anything...but now he is clearly frustrated and upset. But i notice that he channeled his energy to a more productive manner.

here are some helpful hints i learned about dealing with insurance companies...even some items that they probably don't want you to know...

1) be sure to ask that the medical director of the insurance company that denied the claim is actually licensed to practice medicine in your state.
- in the state of Florida, if the medical director that denied the claim is not licensed to practice medicine in the state of Florida, notify the Florida medical board, and the insurance commission. Charges can be brought for malpractice, "practicing medicine without a license" and in FL this carries a 7yr prison sentence. Its illegal in this state.
- i spoke with a case worker at the hospital, she mentioned this trick to me, she helped a friend who had $42,000 medical bill the insurance company refused to pay...she called and asked about the license of the medical director, threatened to press charges for malpractice..after 4 years of fighting the company, the $42,000 bill was erased within 48hours.

2) have your doctor write a letter to insurance company (using his own letter head, nothing from the insurance company) stating that it is his/her legal and medical decision that the following treatment is necessary and the best course for treatment. Because the letter is not on insurance paperwork, and is a personal communication it is filed as a grievance. In the state of FL, the insurance co by law has 30 days to respond. If they deny the claim (legal document), and something happens as a result, they can be held liable....
- because every insurance company has a risk management department, they will flag the letter, and have push the approval through because denying the claim will open the co. to liability. Settling the claim is easier and potentially less risky for the insurance co.

there are more, but these were some of the methods used and i thought they were great....the one case worker i have been working with has nearly a zero denial rate with insurance companies. She is awesome.....finally a lawyer who is advocating for the patient!

basically more reasons why we have to get rid of the profit driving environment in order to advocate for the patient.

ahhh business, politics, and medicine.....i have finally found a great balance....not to mention some interesting cases..

here are a few more of the highlights from the afternoon...

female with meningioma and neurosyphilis, man with dengue fever, woman with NSTEMI developing retroperitoneal bleed....

these are the types of cases where i feel bad, because part of me hopes the patient actually gets worse....so i can see what happens....its kinda bad to think that, but i cant help but have it run through my head at the same time as how to fix it.

......another pearl from the day....i got to the floor where my patient was the night before, he is scheduled to be back from surgery, and i am there to check in on him....for some reason i cant find his chart, his name is no longer on the board.,....

i asked a nurse, "have you seen Patient X"

her reply, "he went for surgery and just never came back"


i later discovered that there were complications and they put him in the ICU.......but after nearly ending up in the ICU myself after thinking my patient died on the table from a routine procedure, she could have simply mentioned that he got transferred...seriously...

no seriously...that was a bit much....i thought i had a patient die on me....

not yet, that bridge has not been crossed yet, but soon enough.....i have 4 patients in the ICU....the post about breaking the news is coming soon....

for some reason i don't think its going to go nearly as well as when i watched my attending tell a patient he has cancer......my smooth talking doctor nearly had the patient thank him....i hope i am around to hear my attending deliver the bad news about death to a family...that will be a great learning experience...(i hope that doesn't sound as bad i think it may come across....but really we are all going at some point, so learning how to deliver the bad news will be an invaluable experience)

CALL YOUR SENATOR!!!

President bush nominated a behind-the-times bigot for top doc, join us
in stopping his disastrous confirmation

Holsinger*s Bias Threatens the Health of Americans

Washington, DC * The American Medical Student Association today urged
the US Senate to reject the nomination of Dr. James Holsinger to be US
Surgeon General.

Dr. Holsinger*s *The Pathophysiology of Male Homosexuality,*
prepared in January 1991, regards the sexual practices of homosexual men
as biologically unnatural and pathological - inherently leading to, *a
diverse and expanded concept of sexually transmitted disease and
associated trauma.* The paper continues to state that men and women
have a sexual *complementarity* that speaks for itself, comparing
male and female reproductive organs to pipe fittings.

*The Office of the Surgeon General has a superb history of combating
threats to public health, including smoking, obesity, and HIV/AIDS,*
states Dr. Michael Ehlert, President of the American Medical Student
Association. *To name a Surgeon General with an obvious ideological
bias is insulting to the very purpose of the office and threatens its
capacity to serve all Americans.*

The American Medical Student Association advocates for reducing the
health disparities faced by Lesbian, Gay, Bisexual and Transgender
people, and opposes policies that discriminate against patients based on
their sexual orientation and gender identity as well as policies that
inhibit any population*s access to quality care.

*The United States Senate should reject Dr. Holsinger*s
nomination,* urged Daniel Murphy, AMSA Legislative Affairs Director.
*We need a Surgeon General committed to the well-being of all *
including Lesbian Gay Bisexual and Transgender * Americans.*


use some of the highlighted points as talking points....for those who just want to call, be sure to let them know you are a voting constituent and strongly oppose the nominations, and would like the senator to oppose the nomination.

for those that do not know/ have their senators and representatives on speed dial , feel free to use the link i have posted to find the numbers necessary to call....

if you live in michigan i know levin and stabenow's phone numbers so here they are....and call call call.....you vote and these people represent you! they dont know how you feel about an issue unless you tell them.....so do just that...CALL!!!!

carl levin = 202-224-6221
debbie stabenow = 202-224-4822

have a great day!