Stars in Brooklyn

Did you know you can still see the stars in Brooklyn?

In other news, I saw an Argyll Robertson pupil today, the so called prostitute’s pupil.

End of life

Yesterday I teared up on rounds as we were discussing end-of-life care.

We were talking about the end of life and how the caring for the person at that point changes when you are balancing quality and quantity of life. More specifically, we were discussing people who are imminently dying and whether or not they feel thirsty or hungry, and whether feeding them and providing fluids for them was doing more harm than good. My attending was telling us that feeling thirst at the end of life isn’t correlated with the amount of fluid the person needs, and that the thirst can often be alleviated by swabbing the person’s lips and mouth with a moist sponge. Over time, people tend to stop feeling thirsty or hungry at all. She described a common scenario where the family of the dying patient are alarmed that their loved one isn’t being fed or given fluids anymore, even if the family understands that the patient is imminently terminal. There’s an instinctive cross-cultural urge to continue feeding the loved one, thinking that it’s needed to be kept comfortable and alive. I was trying to focus on her point which was that when it comes to people who are that far gone, feeding them can lead to more discomfort with increased salivation and GI secretions that can predispose them to choking, infections, increased interventions and potentially a more drawn-out and painful death.

But I was just picturing my grandma in the hospital bed asking over and over for hot water. But she was NPO because they were worried she’d aspirate. I finally wet a gauze and put it in her mouth. She sucked on it and didn’t ask for water any more. A few days later she died, they said it was because of aspiration pneumonia. I cried because I thought I had contributed to that since I had given her a bit of water when she was thirsty. Even though people told me the small bit of moisture in her mouth couldn’t have caused her aspiration, that she already had food remnants in her esophagus before coming to the hospital, and even after hearing from my attending on rounds that providing a swab of water helps relieve the thirsty suffering without risking them aspirating, I still felt sad and teared up.

Funny experience, standing on the ward floor in our white coats and steths around our necks, discussing studies and evidence for this or that medicine or treatment or intervention, while feeling such dramatic emotions inside. We talk about these things without talking about how it makes us feel. It’s ok to bring up previous experiences with patients, but we don’t bring up personal experiences with our own family or friends. Even though I think one of the most important things is to be able to feel what you’re talking about, to be emotional, to empathize, I still struggled hard to dissociate any feelings from what we were talking about, and to look at it as just facts.

New new

When I was in Surgery I would see the kids in internal medicine rotation and think “Weenies.”

They were laughing, happy, so young and free. At least, that’s how it seemed through my eyes, burning from weeks of waking up at 4:30am to stay at the hospital until 6pm.

Now I’m in medicine myself and I don’t feel bad at all. I like IM.

Start.

Day one of clerkship tomorrow. Surgery. I feel ill but that may be my flying and little eating today. Excited, open, tired, unprepared, bit nervous. I say 5:30am start isn’t so bad. At least I won’t be jumping into a frigid pool. Good luck to me and all the other new 3rd years.

Dr. cures hangovers in Las Vegas

One of my friends in a different medical school back home told me how students would hook themselves up to IVs after a night out partying.  Sounded pretty shady to me.

I guess it’s not so uncommon though.  In fact, one doctor has made a business out of it.  His company drives a bus up and down the Las Vegas strip, offering hangover cures in 45 minutes.  Clients are hooked up to an IV, offered iPads and coffee while they rest on the bus’ bunkbeds.  There’s the Redemption package (basics), and the Salvation package (plus some vitamins).  They also sell t-shirts.  There’s “Now If I could Just Find Herpes Heaven” and “I Feel Like Jesus on Easter Morning”.

Hangover heaven.

Psych! week

It’s Psychiatry week in Pathophysiology.

In honour of this week of self-analysis and labeling everyone you know with a psychiatric condition, here is nice gem from my prof:

It’s SPEAK.  It’s what he counsels his patients with depression to do.

S – Schedule daily (this is important)

P – Pleasant activities (we really don’t get enough)

E – Exercise (get that blood flowin’!)

A – Assertiveness (express those emotions and feelings!)

K – Kind thoughts (kindness starts with being kind to yourself).

He said that med students especially need to look after themselves.  I’m not sure about especially, but looking around at students, there is a definite tend to letting yourself go – physically, emotionally, creatively, and socially (myself included).  On the one hand I feel one-dimensional if I spend my days only studying.  On the other hand if I don’t spend all my time studying I feel behind and like I am not living up to my potential.

In the end, it’s this: we are living now, not just working and preparing for the future – future career, future location, future life.  We keep ourselves going by focusing on our goals but it’s still worth living a good life now.  Besides, it’s only going to get harder to figure this balance out; may as well figure it out now.

 

P.S.  I’m cyclothymic.

Something to keep going on

It’s been tough to concentrate these days.  The material doesn’t seem as exciting as it did in first year and, just to be dramatic, I’m finding myself forgetting why I’m doing this.  It’s normal and happens to all second years, especially in the lead-up to the step 1.  But it does make me appreciate reading things like this post, reblogged from a 3rd year medical student:

I’m not taking this for granted – from Notes from spice island

“This” being medicine.”This” being a chance to be a medical student. Which if you really think about it, is a pretty awesome job. I get to spend my days learning about things I find interesting. I’m on my feet, talking to patients and practicing skills I hope to spend the rest of my life doing. I am not really responsible for anything. Nothing is expected of me beyond being interested and showing up.”This” being a part of patients’ lives when they are at their most vulnerable. As a medical student I have time so I can spend an hour talking to and educating my patient about whatever disease and treatment is relevant. I have time so I can talk about life or anything really… and I like this time.I can spend half the day in the library reading. Or I can spend it in the cath lab, or GI suite or wherever else my patient may need to go. I get to see medicine from the perspective of someone who knows a little but has the time to absorb it all.I’m only 10 days in but so far I’ve see the textbook come to life.
Ascites with a fluid wave. Gout with tophus nodules. Stephenson-Johnson Syndrome. Hypertensive retinopathy complete with arteriovenous nicking, cotton-wool spots and flame-shaped hemorrhages.

This is medicine and this me getting to do it.

I love this time in medical school. Third year is nearly over and I’m just happy to be here. This is good.

Gastrointestinal truths

I have female patients who try to convince me that they don’t pass gas.  I tell them, “Well I know you pass gas every day, and I know how much you pass every day!”

– GI Pathophysiology prof

For the record: 7-8 times a day.  Males do it twice as much.

Gems from First Aid

There’s a study book to use for the Step 1 called First Aid, and you’ll see pretty much every med student on campus (and on any campus) carrying it around wherever they go.

Here are some of the gems it has:

How to remember that the nipple is at the level of the T4 dermatome?  T4 for the teat pore.

How to remember that Gardnerella vaginalis is one of the bacteria causing bacterial vaginosis, which produces discharge with a fishy smell and white blood cells covered in bacteria (clue cells)?  I have no clue why there’s a fishy smell in my vagina garden.

Please avoid the nipple

It’s back to school and that means back to more awkward clinical examinations.

Last week, we had our last practice session with a simulated patient.  From here on out we’ll be going to the General Hospital with only real patients.

Our simulated patient was a 70 year old man, who worked as a gardener.  We decided to practice going over the examination for the central nervous system.  We started with the mini-mental state exam, which is what it sounds like.  One of the questions to test higher functioning is to ask to hear “world” spelled backwards.   Our patient hesitated for a long while but couldn’t do it.   We tried the other test, which is to count down from 100 by 7.  He said “100.. 97…”, he had memorized the answer to the other version of the test, which was to count down by 3.   Some of the people in my group felt uncomfortable and laughed to cover it up, which stirred something in the patient.  To his credit, my group member who was actually doing the test didn’t laugh and just waited patiently for his answer.  The patient had been sitting quietly during the entire exam, but spoke up to say, “Let me tell you something.  My mother abandoned me when I was three weeks old.  I was raised by an adoptive family.  So they didn’t teach me to spell such words.”  The room was quieter after that.

We moved on to testing the sensory system, and the tutor reminded us to test dermatomes T4 and T10, which are at the level of the nipple and umbilicus, respectively.  My group member doing the test opened up the gown and picked up the opened up paperclip that we use to test the pain and crude touch sensations.  He told the patient to let him know if he felt a sharp touch (end of the paperclip) or a dull touch (the bent end of the paperclip) and went ahead and poked the patient with the sharp end right on the patient’s areola.  “Sharp or dull?”   He went on to poke the other nipple with the bent end.  Our tutor told us that we should try to avoid the nipple.   This poor 70 year old man.  My group member went on to test for fine touch, which is done with a cotton wisp.  Again, he went right for the nipple and brushed it with the cotton wisp.  “Do you feel anything?”  My tutor said, “Again, please try to avoid the nipple.”

Sometimes when you’re doing an exam it’s hard to keep things straight.  You’re taught to do things that you’d think would hurt (sticking your fingers way into someone’s neck to feel their thyroid, tugging hard at someone’s knee to test their cruciate ligaments), and common sense easily goes out the window for things you clearly shouldn’t be doing (tickling someone’s nipple with a piece of cotton).