Pediatrics, Week 1

Well, I have started pediatrics.  It is generally not the most interesting rotation, but there is a lot of stuff to memorize and it requires more participation.  Also, since it is a regular schedule, where I have to leave at 8:15 and end up back here around 6pm, I am finding my energy levels waning quite noticeably.  I've decided I'm just going to have to bring an energy drink every day to drink between 8 and 12, and that'll keep me going decently well for the whole day.  Luckily they don't cost much more than a cup of coffee, so it won't break my bank.  

As far as pediatrics goes, the most common visits involve a kid with a bad cold - usually with "sinusitis" or a possible ear infection associated with it.  If it's more than 2 weeks or the kid has strong symptoms, we prescribe antibiotics.  Personally, I think we are prescribing antibiotics too much and if it were me then I would not prescribe them, but right now I'm the student and I don't want to rock the boat.  We also see a bunch of kids for their ADHD, or monitoring their doses.  I still don't quite know what to make of it yet, as I've never attended a group session where the kids are seen interacting with each other and I don't know from experience what "normal" child behavior is.  Then there are the endless well-child checks, at 2 months, 4 or 5 or 6 months, 9 months, 12 months, etc.  We check their developmental milestones, answer parental questions, prepare the parent for the next stage of development and what to expect.  We haven't had any crying kids yet, so I'm kind of surprised - they are all really compliant with the exam, especially with the ear exam.  They've also let me examine them without much problem, they're all pretty nice.  I'm sure we'll have some combative screamers eventually, but so far so good.  

In other news, I finally got my isotretinoin medications today - better known as Accutane, though I have the generic version.  The process is extremely involved, especially if you are a female.  First you consult with a qualified physician who is familiar with isotretinoin, the indications, etc. and you discuss whether it is the right option - you are supposed to have exhausted every other treatment first.  Next, you get this packet for "females who have the potential to become pregnant."  You are required to read through everything, sign and initial tons of papers, and register and answer questions online swearing that you will use two forms of birth control (primary method such as hormones, an implantable device, or injections, and a secondary barrier method like a condom).  You must then wait for 30 days, and get a blood test within 7 days of your next appointment.  At that appointment the doctor makes sure you've done everything you're supposed to and that your blood tests check out, and they give you the prescription.  Once you have that, you have to take your special ID card, after having filled out the questionnaire online and registered, and go to your pharmacy to fill the prescription - if they do not have the medication on hand, then you have to wait until the next day when they will have it.  So...today was that day, and I now have it.  Side effects (aside from pregnancy) include skin sensitivity, depression, stomach upset, liver problems, skin dryness.  

I have seen some uncommon things though, which is cool - like Henoch-Schonlein Purpura and Roseola.  Also saw a case of Fetal Alcohol Syndrome, which is horribly tragic.  

Last Week of OB/GYN

Here I am, in my final week of OB/GYN.  Surprisingly little has happened between my last post and now.  There have been very few deliveries that I have been around to see.  I didn't do any 24 hour shifts last week because I was studying for my USMLE Step 1 exam (Feb 4).  I am also not doing any 24 hour shifts this week because I have my COMAT exam this Friday, which I take at the end of a block of rotations (e.g. OB/GYN, pediatrics).  As far as the USMLE goes, I think it went well, I am pretty confident I passed, and fairly confident I got around an average score.  It's hard for me to gauge because I took only one practice assessment and a lot of the questions that were on that test weren't very representative of the most commonly tested items.  Also, unlike practice questions, this test did not have very many of my weak spots on there; so, there were very few questions about CV/Respiratory physiology, elaborate equations, or complicated mechanisms about adrenergic receptors and drug combinations.  There were some endocrine questions which I may or may not have gotten right, and a few complicated ethical questions, but aside from those, I think I did decently well.  Only one or two questions were asking me about things I had no idea about.

Now onto this week - the most interesting thing that has happened was a woman in her mid-30s came in (she is in her late 2nd or early 3rd trimester) and she has profuse sweating, 102 degree fever, mild chest congestion, tachycardia, very fatigued.  She was kicked out of her house by the baby's father (likely because of her drug problems) and she was brought to the hospital by the homeless shelter people.  One of the more perplexing things about this case was that her white blood cell count was within normal range, and the ratios of cells was all practically normal - only up or down in a couple areas by 1 percentage point.  Also, her chest x-ray did not look very concerning - only some mild opacities along the central portion of her thorax and slightly on the left (mediastinum).  Her lung sounded pretty clear.  We also got a report from her past medical history that she has no asthma history, but she was diagnosed with hyperthyroidism back in the year 2000 and she said she hasn't taken any medications.  So of course the first thing I'm thinking is exacerbation of her thyroid disorder, possibly thyroid storm, because hyperthyroidism can cause all of her symptoms.  So my preceptor thought I might be onto something and ordered a stat TSH - it came back < 0.01 - in other words, something is suppressing her thyroid stimulating hormone production, this is most commonly caused by an excess amount of thyroid hormone causing feedback inhibition.  We ordered free T4 and free T3, as well as a thyroid hormone receptor antibody test to see if she has an autoimmune cause of hyperthyroidism (common in women 20-40) called Grave's disease.  My preceptor was very excited about me making a call she probably wouldn't have thought of - so hopefully that will reflect in my evaluation a bit - I haven't had any reviews yet that were particularly complimentary about my medical knowledge.  

At the moment I am keeping an eye on that patient from yesterday - her fever has resolved somewhat since starting the antibiotics for possible pneumonia, so maybe we just caught a really early pneumonia and the hyperthyroidism is just a longstanding comorbid condition.  Either way, hyperthyroidism is something really important to deal with in general, and in pregnancy especially.  I also have a presentation tomorrow about intrapartum anesthesia - emphasis on some of the lesser used modalities, such as nitrous oxide (commonly used outside the US), acupressure, and osteopathic medicine (mostly because my preceptor expressed interest).  I'll work on that when I get home probably, it's a little hard to focus here - I kinda need a break but I'm gonna stay at least a couple more hours.  My preceptor isn't here and we only have the one patient who probably isn't due for several weeks - and who knows if any other pregnant women will be coming in within the next few hours.  Even if they do, the odds that they will be imminently entering active labor are slim.

After my COMAT exam on Friday, I get to enjoy Valentine's Day weekend and then Monday I start Pediatrics after my Accutane appointment.  Wooh, fun times.

3rd and 4th Weeks of OBGYN

Phew, it has been an intense couple weeks.  Have barely had time to think.  I'll start with my 3rd week (last with Preceptor #1).  As far as the clinic days went, we had some interesting cases - an IUD expulsion, a retained tampon, trichomoniasis, and lots of pregnant women with whom I got to practice finding fetal heart sounds.  The most recent thing I can remember is my last day there - Thursday which lasted 24 hours.  We had clinic during the day, then that evening we had an overnight call shift from 6:30pm-6:30am.  I think it was that night that at the start I joined the doctor for a laparoscopic ectopic pregnancy removal.  She was somewhere between 12-20 weeks.  Apparently it is rather rare for an ectopic to get as far as surgery because they usually catch it early enough to use medical interventions.  Anyhow, that was interesting.  Then I slept for a while and got woken up for the delivery at the end of the shift.  My preceptor let me sit in the front seat for this one and I delivered the baby, handed it to the mother, clamped the cord for the dad to cut, and delivered the placenta.  My preceptor sutured up the tears, of which there weren't very many, and we took care of that.  There was some retained placenta (I think because he was trying to get it out before it was fully detached, I would have given it more time but that's my side of things), but he got it out with a loop scraper. 

A few other things of note - I was following a patient who I had assisted on a delivery for.  She was a caesarean section because of a placenta previa.  As a result of excessive bleeding that was suspicious for retained placenta or at least failure to clot, we took her back to the OR but in the room the uterus had essentially stopped bleeding so we inserted a 'balloon' to help plug the bleeding via compression.  We took that out the next day.  There was another patient for who had a urethral sling, vaginal/cervical suspension and anterior and posterior repairs done on the pelvic floor.  Her posterior repair (the easy part at the end) wouldn't stop bleeding and she developed a painful hematoma so an hour after taking her out we had to bring her back into the OR to redo the stitching.  That was a bit of a pain.

Now onto my 4th week (1st week with Preceptor #2).  My new preceptor is very nice, a bit more 'preceptor-like' than my previous ones - a lot more teaching, more presenting, more following patients, more is expected of me but I am rising to the challenge without much problem.  It's more mentally stimulating and it's nice to have a little autonomy.  The first day I saw one delivery that went well, and then there was another one that ended up being a shoulder dystocia.  Shoulder dystocias are one of the most scary complications in obstetrics because a healthy baby manages to get it's head out of the vaginal canal, but one of the shoulders gets caught beneath the woman's pelvic bone.  This causes compression of the cord, and compression of the baby - so the baby is getting less oxygenation from the mother, and is doubly unable to expand its lungs to breathe air from the outside.  At this point the team starts a timer and begins various maneuvers to free up the shoulder - including hyperflexion of the mother's legs at the hip, suprapubic compression, reaching into the uterus and trying to free up the arm, and various clockwise/counterclockwise rotations.  Last resort includes breaking the collarbone and/or humerus.  Many complications can occur as a result, one of the most notable ones is a brachial plexus injury which results in nerve damage to the impinged shoulder.  The baby comes out with an arm that doesn't rise, it is pinned to the baby's side and it's hand is facing behind it - Erb-Duchenne Palsy (or "Waiter's Tip" palsy).  Anyhow...this baby they got out and it ended up having decreased arm movement, it looked like it had some nerve damage.  Luckily, even when these signs are present at birth, 85-90% of the time the baby recovers in the first 2 months.  By the second day after the delivery, the baby was starting to move its hand and shoulder. 

Now onto today - a nice long 24 hour shift from 7am to 7pm.  This L&D floor is a lot smaller than the previous department that I was in so there aren't too many active patients, and there's a bit more down time.  However, as luck would have it, we had ANOTHER baby with shoulder dystocia today. The first baby ended up being 9 pounds 11 oz, and this one was 10 pounds 1 oz.  Needless to say, it is well documented in the literature that large "macrosomic" babies have a higher incidence of shoulder dystocia.  This one didn't have any real nerve damage though.  The mom was pushing for a good 2.5 hours, it was a little challenging with language barriers but it worked out okay.  From what I can tell, shoulder dystocias are not very common occurrences - some previous students haven't even seen a delivery period, so for me to see two dystocias is pretty crazy.  I'm glad the outcomes have been relatively good.

We also had an interesting ED consult for gynecology - a woman with a 14cm possible tubo-ovarian abscess.  We have started her on empiric antibiotic therapy while we wait for GC/Chlamydia results.  There is some concern that it may be a tumor, or have some tumor involvement because she has had significant unintentional weight loss over the past 6 months.  No way to know at the moment - just gotta treat.  I'm gonna nap now, I'll be woken up if we have any new admits - on the plus side, I get the day off tomorrow.  More studying, wooh!

Call Night and Week 2

OB-GYN is coming along without much of a problem.  I had my on-call night, and I thought I had been warming up to the whole baby thing, but I think the first vaginal delivery was kind of the ideal situation, along with ideal family responses, and environment.  The call night started out with figuring out logistics essentially - talked to the doctor for the evening, and it was my preceptor and this other female doctor on call that evening.  They divide the night into shifts, and so my preceptor slept from 9pm-2am, and the other doctor got to sleep from 2am-7am.  Like all medical students, I wanted to show my enthusiasm, so I decided to spend as much time with the other doctor before caving into sleep.  We had a couple interesting cases.

First case - fetal demise in an orthodox Jewish woman, 3rd pregnancy (has two living children).  A couple things are wrong with this case.  First, she was inconsistent with her prenatal care and was taking a lay midwife's advice over going to prenatal checks with her physician.  The doctors that I work with at the hospital have made a distinction between the midwife nurses at their hospitals and the lay midwives who are not affiliated - that in the hospital, their threshold for thinking a baby is in trouble (and thus, needing to interfere with the 'natural' progression of a gestation and vaginal birth) is a lot lower.  As a result, the hospital midwives are more willing to consult a doctor about a baby's status, or suggest a C-section.  Anyway, the woman stopped feeling any fetal movement around 23 weeks and the lay midwife said that was "normal".  The woman finally comes into the hospital after a WEEK of her baby not moving and there are no fetal heart tones of course, so it's dead.  The second problem is that a lack of prenatal screens/ultrasounds didn't catch what is most likely an anencephaly (or lack of a head) on the baby.  It could have been caught a couple weeks earlier, but no.  People like to talk up natural traditional methods of health care, but there's a reason we have these tests.  The third problem with this case is the orthodox religion - mostly it just makes patient care more difficult, but they need to consult another rabbi (even though her husband is a rabbi) to determine if they can test the placenta (dead baby is definitely off-limits) for chromosomal abnormalities.  Often when a woman has a fetal death, it is reassuring and relieves guilt to know that the baby had a chromosomal abnormality or other problems inherent in the baby that would have made it nonviable no matter what.  

Next case of the night... this really pretty Asian girl, possibly Filipina, late twenties, on her third child.  Her husband was with her, kinda ugly, but I gave him the benefit that maybe he's just a really sweet supportive guy to win a gal like her.  She decided to go through the vaginal delivery without any epidural anesthesia, and she barely made a peep - she did a great job, trembled a lot, but delivered the baby pretty quickly.  Right after this, the husband essentially ditches his shaking wife and stands with his back to her filming the baby in the warmer with his phone.  Once or twice the wife seemed to try to get his attention but he either glanced briefly or didn't respond.  This went on for at least 10 minutes, the whole time I was in the room anyway.  There also wasn't anyone else in the room, no other family.  I never saw him go over and ask her how she was feeling, or tell her she did a great job - made my blood boil.  

Next case before I went to bed - 21year old girl, second pregnancy, husband was this short kinda meek white guy - she delivered like a pro too - she did have an epidural, but she basically had no problems.  The husband on the other hand just about passed out when he saw the baby crowning - he wasn't intending to look, he was walking around where we were to the other side of her and his face just went white and he just about fell to the ground right there.  It was kinda funny, but at least all the family were supportive, smiling, and the husband stayed next to his wife this time.  

After that I went to sleep and my preceptor called me when he had a new case - we did a few checks to see if any girls' water was breaking, interesting stuff.  Around 8am I was done and in the car.  

That was it for that week - yesterday we started in the clinic and I got to do some Pap smears and some prenatal checks where I measured the uterus size (to see if it was consistent with the gestational age) and checked fetal orientation and heart rate.  The first one or two were a little challenging to find the heart beat for me, but I think I've started figuring out where the baby's body is oriented, so I was spot on the last 3 heart rate checks.  We saw a woman with an expelled IUD - usually that doesn't happen to women who have had pregnancies, but apparently she was told she has a short cervix.  

Today had two surgeries - one was a mid-urethral sling insertion, which is to help with incontinence.  The woman was awesome - she was a feisty, energetic, humourous elderly woman.  It's always reassuring to see older people with such vitality!  So that surgery took 35 minutes, no problem.  The next one was significantly longer, a laparoscopic vaginal hysterectomy, on a woman with an enlarged uterus and multiple fibroids - had to cut it up a lot and bring it out piece by piece.  The doctor my preceptor was assisting actually thanked me at the end for my help because the extra pair of hands made it go a lot better than they were expecting.  Yay!  

Tomorrow is a morning/afternoon of surgeries, and then another evening of call duty - I think I will try to sleep when my preceptor does this time, since I will not have had all day to relax.

Week 2, and Week 3 of Orthopedic Surgery

Orthopedic surgery is continuing to do well.  Since those two hip replacement revision surgeries, which apparently are only done once a year or so, I have assisted on several arthroscopic procedures and today we had 9 hours of surgery - no waiting around - two total knee replacements and two total hip replacements.   Apparently I am getting a lot of good experiences, since some of these procedures are not done all that often during a single 4 week rotation period.  I definitely feel privileged to be able to handle shards of bone and help drill into patients' dislocated hips.  

One of the patients today had had a hip fracture a long time ago and was immobile at his hip joint because his bones had not set properly and had accessory bone growth within the joint socket and around it, essentially cementing his femur into his pelvis.  It would be neat to see him in post-op after he realizes he can move his hip again on that side.  

Something interesting I found was how the procedures are very step-by-step - everything is cut based on relative positioning and they have a ton of pre-made accessories that they attach to the bone to help guide their cuts.  Also, when boring into the shaft of the femur to place the metal rod, they first make a small hole, then start with the smallest metal rod, and then build up incrementally to the size they wish and it is all very precise.  It is quite neat.  

My preceptor also seems to think I am coming along fine - he and the PA both think I pick up things fast and my preceptor was pleased with my more recent patient presentations and assessments.  He is also very relaxed - the PA as well.  They both have similar political/religious/cultural views (which I of course let them voice first before chiming in at all - I'd rather not take the risk of striking a bad chord) so that helps make for good conversation in the OR.  I have also been allowed to help put respiratory equipment into patients with the anesthesiologists - just the throat dam (not sure the name), but it's still useful to get a little familiarity with the oropharynx.

Infectious Disease, Last Week

Things are going well with Infectious Disease still.  We've had a few interesting developments.  One of our patients, the homeless young female patient who has had altered mental status and been in full restraints for the past week and has systemic Methicillin-Resistant Staphylococcus Aureus infection has actually started to come out of it.  From the start she had altered mental status and we haven't been able to get an MRI to see how her brain is functioning, so we have had no way to know how her brain was doing.  Through this we were speculating that she had bacterial vegetations forming throughout her body that could be throwing clots to her brain, and she even grew MRSA in her spinal fluid, so it could have been forming microabscesses in her brain as well.  Not to mention the huge abscesses in her iliacus and piriformis muscles (anterior to the spine in the lower back, behind the abdominal viscera) that started the whole deal.  I think none of us were really expecting her to ever come back to mental awareness, and we had not seen her in anything resembling a lucid state since we started treating her.  

Today she woke up.  

For her it almost seemed like nothing ever happened - just saying "I'm hungry," and "I feel tired," like she'd had a really long nap.  Calm and tired, not thrashing about or pulling at her tubes or anything like that.  No alarm yet, maybe has a little bit of a drugged look (understandably), and we still don't know the extent of the damage of this week of MRSA sepsis, but she's lucky she had my preceptor on the case for her infection and such a good team of ICU specialists.  It's amazing - there are some patients who you really don't know if they will recover who somehow bounce back, and then there are others who look fine and are ready for discharge and they die that evening.  Definitely drives home how unpredictable medicine can be.  

That's not to say that I think we should do everything in our power to keep a human body running when it is beyond what a clinician would estimate is "the point of no return".  Some absolutely septic patients, with multi-organ failure, and other comorbidities like diabetes and obesity are still getting specialty bone scans and send out labs even when their lactic acid level is at 14, they are on 5 different pressor medications and their blood pressure is still not in control, their stats are steadily dropping, and they're on a ventilator.  There is a time and place for hospice and palliative care.  Some points that indicated that perhaps our homeless young woman might recover were the following: she was never on a ventilator, her laboratory values were never all that particularly horrible, she was young, AND she wasn't obese, diabetic, or suffering any other comorbidities that we knew of (aside from drug abuse).  It's amazing what diabetes and obesity will do to your survival rates in a hospital.

Week 2 Infectious Disease

Well this week is off to a good start - we had a nice morning where he let me be to look up information on all our patients.  I reported sufficient information to him, so that's always good - I hate to come up short.  One of our patients who has a history of Chronic Lymphocytic Leukemia has upper lung lobe pneumonia of some kind and when I looked up his information I didn't see the positive quantiferon gold test for tuberculosis (he comes from an endemic region).  When I went to check in on him he hadn't yet been transferred to isolation, so then when I learned about the test then 10 minutes later when we went in to see him together he was in isolation and we were wearing our face masks.  

My preceptor told a funny-creepy story today.  When we were discussing antibiotic therapies with the pharmacists, a patient came up who was 100 years old and in a persistent vegetative state, and the daughter is refusing to let up on aggressive treatment.  It reminded my preceptor of a patient he saw some time ago who was brain dead, and had been for months, and the son refused to let them stop treatment, despite the man's mother being on a ventilator, and essentially brain dead.  The difference between persistent vegetative state and brain dead is that the former is specifically nonfunctioning of the cerebral hemispheres (higher thinking), while the latter includes the brainstem (basic respiration, reflexes).  So one day he was doing a status check on the brain dead patient and saw something on the patient's earlobe - it was a maggot.  Apparently somehow a fly had gotten into the mouth and/or ear and laid eggs and there were maggots in the throat/mouth and ear.  Kinda adds new meaning to someone being 'brain dead'.  

I also had a mini-victory today - we were talking about one patient who had a few trichomonads on her urine analysis and he asked me what the treatment is for that, and as he was adding, "do you have your Sanford guide on you?" (which is our booklet for antimicrobial therapy) I just answered without skipping a beat the first line and second line treatments.  I guess he didn't expect me to know off the top of my head, so I was pleased with myself, even if it was a super easy question for me.  

FM 2 Week 4

This is my last week of Family Medicine, only a couple more days.  Thursday is my Family Medicine COMAT exam, so hopefully I'm ready for it - I've been listening to prep lectures.  Yesterday we went to a nursing home for my preceptor to catch up on his nursing home patients.  It was interesting, though mostly depressing.  A good number of the patients are unaware of things, and most have those childlike empty grins of Alzheimers, the nonverbal combativeness of Alzheimers, slow fogginess of normal dementia, shaking and mental confusion of Parkinson's, or if they're lucky a semi-lucid awareness of what is going on.  One lady/man (I couldn't tell what gender the patient was, to be quite honest) kept following us down the corridors in his/her wheelchair, calling after the doctor who examined his/her friend asking why we didn't examine him/her.  He/she kept grabbing my arm and trying to talk to me, but the person was partly deaf so it was hard to even talk to him/her.  The doctor and the chief nurse tried ignoring the person, but he/she was very persistent.  Eventually they talked the person down, but it was awkward for a little while there.  We also saw one lady who has a big fall risk who feels trapped at the nursing home, because she cannot go out unaccompanied and has no family nearby.  That was rather depressing also.

I start Infectious Disease at Fairfield next week, so that should be neat.  I checked my rotation schedule again and my second elective is still not arranged, so I re-emailed our coordinator and I guess she just hadn't noticed that I had attached two different forms when I emailed her a month or so ago, and so she tried to blame the IT department on it.  She better not cost me a rotation...it'll be a big headache to have to find another place.  

FM2 Week 3

I'm in my second to last week of  Family Medicine - things have gotten even more routine feeling, especially since my current preceptor is a little more relaxed even than the first one.  He's great, just very chill, so he doesn't really pressure me to make SOAP notes and such.  I'm glad all the doctors have such good bedside manner, except that one that I mentioned before who had the difficulty communicating.  There was also this other doctor I was with one day who sounded tired/bored the whole time, no real emotional changes in his voice, but that's beside the point.  

This week there have been a few interesting cases - we saw a woman who had a gastric bypass who "felt like she had something stuck in her throat" and was feeling nauseous and unable to drink liquids.  She ended up having to be sent to the ER to get her esophagus checked and sure enough she had a bolus of food stuck in her lower esophagus.  I feel like most of the presentations I am seeing in the office are familiar to me now and I have a pretty good idea of what medications and treatment plans to use.  

Today I was with the sports medicine doctor again and confirmed that he will write me a letter of recommendation - I just need to email him my stuff.  It had been a while since I saw him (2 weeks), so I was glad our previous dynamic was still intact.  This afternoon my current preceptor and I went to do a home visit for a patient we saw previously in the office who is now on hospice care for his metastatic melanoma.  As far as terminal patients go, this one is rather fortunate - he is 86 years old, has two great-grandchildren, his wife of 66 years is still mobile and caring for him, and his daughter is helping as well, and he doesn't live in a nursing facility, he is at the home of he and his wife.  My preceptor essentially went over the basics for hospice - making sure he's eating and drinking, that he doesn't have any pain, and managing side effects of pain medications (constipation, which can cause secondary pain).  The wife talked to me a fair amount, and we did a check up with the patient, who has had a lot of family visits and support.  It would be horrible to know you only have a month or two left at best, but if that were the case, his situation is probably one of the more fortunate.  At the end they gave my preceptor two bottles of wine (it's Napa) and he ended up giving me one of them - a 2009 Rose Syrah.  I imagine as a doctor in Napa he gets a lot of gifts of wine from patients - and for good reason, he's a very nice and thorough physician.  

I have finished all the "modules" for my Family Medicine rotation, so now I need to finish the last two quizzes and start reading/preparing for my end of rotation exam.  Sometime next week I will ask Dr. Cotter if he is willing to write me a letter of recommendation - I feel like it will be odd having all my recommendations from Kaiser Family Medicine doctors, but since I am considering family medicine and have gotten along great at Kaiser, this will be very helpful.  The sports medicine doctor (the associate dean of our clinical education) may also be the one who writes my Dean's letter, which would be good since I actually know him - versus the main dean of clinical education is not very well known to me, aside from his bad advice regarding USMLE vs COMLEX for those on the border.   Time to get some light exercise in and eat and study...

Zoster Presentation

Well today was my presentation, and it went pretty well.  My previous preceptor told me just beforehand that we had a really good turnout, that usually not many doctors don't come to the student lectures, and both my preceptors (last one and current one) were sitting to my right as I went through the slides.  I got maybe 2-3 questions, 1-2 comments, and my preceptors chimed in when I was asked questions that I couldn't answer, so it was nice having backup.  Also there were three fellow students in the audience, so that was nice.  Afterwards I got a lot of compliments from them, my preceptors, and the doctor I was with that afternoon - that she learned a lot and that it looked like I had put a lot of time and research into it.  

Didn't see too many interesting patients today, as it was a slightly later start and I had my presentation.  In the latter half, the doctor I was with today went in with me to see a diabetes patient, and she was kind of stressed because she was getting behind and so she was lapsing into a lot of doctor speak that I had to explain to the patients.  I felt kind of bad because it seemed like the doctor and the patients were both having a lot of trouble getting their points across.  The doctor was talking too fast and repeating herself a lot, and not answering the questions as the patients intended (as in they would ask something and the doctor would think they were asking something else and answer that other thing).  I think I am pretty good at speaking with patients, and my last couple preceptors were pretty good too, so it's interesting to see when a doctor has some trouble.

After that, ran off to didactics to see a student lecture on coronary artery disease.  Also handed in the cover letter for my previous preceptor to write a recommendation.

First Day of FM2

Since I have been with this doctor before, there is not too much more to report.  He's a friendly guy, very open to discussing cases and instructing.  We saw a lot of patients today, and it seems like he takes a while with them so I have a feeling we will be running late a lot of the time.  Of notable cases, there was a patient with cerebral palsy since he was an infant in for trigger point injections, and a 3 year old boy with recurrent episodes of croup, which had been diagnosed as asthma - it is likely some kind of structural problem so we referred him to a specialist.  

In other news, I am still working on my herpes zoster presentation - I just need to hammer out the details, it is essentially organized, and provided that my preceptor approves, it will work out pretty well.  There are also online cases to do, quizzes, and plenty of studying - I have to take my family medicine end-of-rotation exam in 4 weeks.  Not looking forward to it.  

Thursday I will be going to a regional conference in Vallejo (the first 2 hours of it) with my preceptor, there are some lectures on chronic pain management and migraines, so that should be interesting.  On Friday I will be assisting him after work at a high school football game.  Managing to fit in exercise in my schedule is still a challenge - at least I'm eating healthy.  The weekends feel much shorter.

Difficult Patients

It is interesting seeing some doctor reactions to difficult patients.  Yesterday I was with the sports medicine doctor in the morning, he treated me to Starbucks (I just got some tea) and got some cookies for the medical assistants and receptionists.  We saw a few patients, but none were particularly vexing diagnoses as I recall.  Kind of a slow morning.  I'll probably ask him for a recommendation near the end of family medicine, but I'll be asking my main family medicine doctor for one sooner.

With the afternoon doctor, it started out with him relating a difficult patient he had had that day.  A middle aged lady had emailed him asking for a refill on her Valium, which he doesn't like to prescribe and it had been a long time since he saw her, so he asked for her to come in to discuss prescriptions.  He ended up prescribing it to her since she has been on it for a while and has no history of abuse.  He also ordered a thyroid panel because she was obese, and he had told her this, but perhaps not in the clearest phrasing.  When we put in a prescription or lab order, we have to also plug in a diagnosis to justify it, and in this case the thyroid was justified with a diagnosis of obesity, which is technically true.  The woman called later that day furious that he had written 'obesity' as a diagnosis on her chart - as if this was news to her, and was insulting and she just went ballistic.  The doctor of course tried to explain that it is medically true, and it isn't a judgement in any way, but merely an assessment based on BMI, and that Kaiser can offer weight loss classes and counseling.  This did nothing to placate her and she just kept going on and shouting she expects someone to come out to her place to bring her healthy meals similar to a Jenny Craig program or something similar - and that she's so angry she might just leave Kaiser (which the doctor would not have a problem with - in private practice, physicians can much more easily drop difficult patients).  Because he was so frustrated with it he put something about her being a difficult patient in her chart, but later he knew that'd be just starting a war and added an addendum to change it (sort of like writing an angry letter and then fishing it out of the mailbox).  

We also saw a patient with "dizziness" following a fall from a roof, which ended up being benign paroxysmal positional vertigo.  We did the dix-hallpike maneuver where you turn a patient's head to one side as they lie back on the table and when you turn their head in the direction of the affected ear, it produces uncontrolled eye movements.  It was a pretty positive test with this patient, and so there are Epley maneuvers where you have them roll back on the opposite side to try to dislodge the piece of debris in their inner ear which is causing all the problem.  It's a benign condition that usually self-resolves in 2-3 weeks, so that was a relief considering there was concern about concussion in this man initially.

Slow Day

Today was rather slow by comparison - only saw two patients.  In the morning there were lots of quickies here for some injections (either Supartz or corticosteroids) and one or two who didn't want a student.  Spent a lot of time sitting around reading JAMA articles.  I came across a few interesting tidbits.

1. Onchocerca and Dranunculus, both parasitic roundworms, are in the process of being essentially eliminated from the human population by the World Health Programme.  Onchocerca causes river blindness in South America, and Dranunculus is also known as the Guinea Fire Worm, and if you don't remove it slowly from a person's arteries then it will die and cause a reaction that will kill the person.  You hear about viruses like polio or smallpox being eliminated, or maybe malaria, but rarely about parasitic worms.     

2. Bladder cancer is higher in men than in women - I hadn't really thought about this before now.  Bladder cancer is strongly linked to cigarette smoking, particularly to a chemical in cigarette smoke: naphthylamine, which  is also found in certain textile dyes.  However, it was previously thought one of the reasons men were more susceptible was because men were more likely to be smokers, have unhealthy lifestyles, and work in environments that expose them to carcinogens.  Now that women are working in a lot of the same fields as men, the incidence has not increased an equivalent amount.  A study in 2007 showed that mice without the testosterone/androgen receptors who were exposed to chemicals linked to bladder cancer did not get any bladder cancer, compared to mice with the receptors who nearly all got bladder cancer (~90%).  It would seem that the same mechanism behind prostate cancer may be involved in development of bladder cancer in men.

3. JAMA includes a previous JAMA article from 100 years ago to the day at the end of each issue.  One of the old articles about digitalis/foxglove and its use as a medication for arrhythmias and other heart problems had a very interesting line in it.  After going at length about the benefits of high doses of digitalis, the author writes: "For that reason, a daily large dose of digitalis is advocated indefinitely to keep the weary heart a-going on its rapid journey to an eternal standstill."  That article was written in 1911, and the last part of that line has a very poetic, almost morbid sound to it.  Rather unexpected when I was reading the article.

At the end of the day I had to go to didactics, where a guy who reminded me a lot of Jim Carrey was telling us about Clopidogrel, and how it compares to Aspirin - his main argument was that Clopidogrel (Plavix) is treated like a substitute or necessary adjunct therapy for Aspirin, but in reality there is little evidence it is more efficacious than Aspirin, or that dual therapy would benefit anyone besides those with cardiac vessel stents or in an acute cardiac event.  It was interesting, he was going on a bit about drug reps and such - since I studied a lot of that in undergrad for my medical history classes, it wasn't anything that new to me.  Anyhow, time to get some reading done and try to recharge for tomorrow.

More Family Medicine

Family Medicine is still going pretty well - the patients all seem to like me, and I have gotten to see a good range of ages, from kids 3 years old to adults 91 years old.  I have spent time with two general family medicine physicians and one sports medicine doctor (who also happens to be associate dean of clinical education at our school).  I've been trying to do readings on the stuff I see in the clinic, and stay engaging with the physicians.  I get along with all three of them really well, and I get the sense they do not mind having me around.  We had a little snag up with the scheduling so the dean was not quite expecting to see me today, but it worked out fine.  I talked to him a little more about some stuff, and near the end he said he was glad that I'm going to be with him two days a week instead of just one.  I also asked him if my timing on patient interviews was okay and he said that he would have let me know if I was going too fast or too slow, so I'll take that as a good sign.

Yesterday was good as far as patient interactions - a middle aged man came in yesterday and we diagnosed him with an inguinal hernia, and I was able to palpate bilaterally and up the inguinal canal - first time on an actual patient and not an actor.  Also one of the patients, a real talker who probably held me up a bit longer than I'd have liked, complimented me to the physician that day, saying that I was going to be a great doctor and was really good at talking to patients.  The more positive things said, the better - I just have to keep doing well and not let anything negative creep up.  I still feel pretty tired at the end of each day, and it's looking more and more like my drive is an hour each day - I have started listening to German audio lessons in the car.  Today I got off earlier than usual because the doctor I was going to be with this afternoon was not around and most of the other doctors in the office were not there this afternoon.  Time to catch up on my studies!

One more week to go...

One more week until I take COMLEX, going to have to step up and really study. Took a break the last day or two, just been stressed out. Plus after I take the test it is off to Oregon, then the day after I get back it's time to jump into the general surgery rotation and patient interviews and scrubbing-in and all that fun stuff. I've gotten my badges for the two hospitals I'll be at for now, and have a surgery rotations book to review while I'm in Oregon. It's getting really hot now in the bay area, so it's getting harder to focus. Must stay strong! Time to do some practice questions...

Finished BLS and ACLS

Since I shall soon be starting rotations in hospitals, I had to go through BLS (Basic Life Support) and ACLS (Advanced Cardiac Life Support) training and certification. Didn't take too long, and BLS was a recertification so that was no challenge - ACLS was a lot of new material and new sequences of information, along with a refresher course on EKG reading so that was fun! I particularly liked the instructor, as he had 42 years of experience as a paramedic and emergency department (ED) technician so he had lots of case examples to share with us.

Some take-away points for normal people which I feel I should mention - as it may save you or a loved one one day:

3 main things to know for CPR

1. Are they breathing? Do they have a pulse? (if no...)

2. Have someone call 911 and tell them to try to find an AED (often in hospitals, schools, major office buildings, gymnasiums) - no use doing CPR if no one is coming to help.

3. Chest compressions - fast and hard - at a rate of at LEAST 100/minute, so we're talking about 2 compressions per second. When you do compressions, middle of the chest (approximately between where the nipples are), compress about 2 inches into the chest. On kids, 1/3 of the way. *FYI: If you are doing compressions properly, you may very well end up breaking their ribs - don't let that stop you - keeping heart circulation going is much more important than a broken rib or two*

If you are comfortable doing mouth-to-mouth on this person (child, husband, etc.) do only 2 breaths, head tilted back, covering nose, and then go straight back to compressions -compressions are WAY more important, so alternate 30 compressions then 2 breaths.

Another take-away note about Strokes...

If you or someone else starts having signs of a stroke (one sided muscle weakness, face drooping on one side, difficulty speaking) - CALL 911 - DO NOT DRIVE THE PERSON OR YOURSELF (unless you are less than a block from a hospital MAYBE). Reason? You may feel well enough to drive yourself, or you may think you can drive your family member, but if an ambulance picks them up, then not only will they get en-route care, the hospital they deliver the person to will be completely prepared, with the neurologist, cardiologists, etc. all notified and ready to take care of the patient. It can take 45 minutes of assessment and evaluation once you get to the hospital before they decide it's a stroke and can do any therapy - by then, it may be too late.

Why is this so important? Fibrinolytics - you basically have a 3 hour window where you can be given a medicine that will essentially dissolve the clot in your brain. I have known people who drove themselves while having a stroke, or who started having a stroke in the middle of a golf course and played through to the end before going to the hospital - if you want that shot at a Fibrinolytic, which will GREATLY INCREASE your chance of restoring brain circulation, get to the hospital ASAP.

Bottom line: If you have a loved one, pass on this information so they get the fastest possible care, or so they know what to do if this happens to you. Time makes a MAJOR difference when it comes to blood not getting to your brain.

Enough with the public service announcements though - time to get back to studying for board exams! Wooh! Diuretic medications.

Nearing the End of 2nd Year

Well, in a few short weeks my core classes will be finished and I will be mostly studying for Board Exams (USMLE, COMLEX) and gearing up for rotations. My third year rotations will mostly be taking place around Fairfield and Napa, with two rotations out in Stockton (psychiatry and hospital-internal medicine). That isn't until the end of year 3. My schedule only permits one month of vacation, which I intend to take right at the beginning so I can extend the time that Itake USMLE and COMLEX by a month - an extra month of studying will make a big difference, especially since that is ALL I will be doing. I am leaving a week between the COMLEX and the start of rotations to go on a vacation though - it's my only vacation, I should try to do something!

The unfortunate thing about Touro University is they do not let us finish school very early. We are in actual classes up to April/May, many mandatory, while other schools have already finished second year to give students time to study for boards! No wonder Touro students perform more poorly on boards. It's hard to keep up with boards and classes at the same time. Luckily a lot of the boards review is starting to overlap with what we are currently studying, so hopefully that'll help out a bit.

I also had an interesting extra-clinical experience - we are required to do a visit and then 6 month follow-up with a geriatric patient at a nearby retirement community. When I went to visit, it so happened that my patient had fallen in a parking lot that day and did not feel up to visiting the clinic, so the head nurse told me to make a house call. In a way, it's kind of ironic that my first "house call," once a traditional type of doctor visit, is probably the only one I shall make in my career. It was a little awkward, but kind of cool to examine a patient with an acute injury in the comfort of her home (in case you were concerned, she was barely injured - extremely lucky considering she is an 83 year old female with history of osteoporosis and is on anti-coagulation medications - she could have easily broken her hip, leg, or wrist, or ended up bleeding a ton).

On another "fun" note, we get to do rectal, breast, and vaginal exams on paid "patients" this week...not particularly looking forward to it, but at least I have experienced all three, so it's not an entirely foreign concept. We are getting into the genitourinary and pediatrics sections now so ... time to race to the finish line. I still have some fun stuff planned - next week double date to Sattui Winery for complimentary tastings, thanks to being wine club members. Anyhow, back to boards review...

Fourth Week In...

Posting has been lacking due to the insane amount of stuff I have been up to - being a second year is no simple matter. Nor is moving. Anyhow, I am finally settled in the new place - which has a gorgeous view and is pretty darn spacious and awesome - because it is "technically" within Vallejo's city limits, it makes the property values a lot lower, so the rent is surprisingly affordable.

The start of this year has been centered on Neurohistology, Psychiatry, Cranial OMM stuff, and learning how to do more focused Physical Exams. We will be also doing an extra clinical experience at a retirement home to learn more about geriatrics and the problems that face that particular demographic. Neurophysiology is very detailed, so that has been taking up most of my time. Money is also super tight. However, our living area is great, my friends are close enough for us to visit regularly and for us to host things every so often, and school is closer, and I have a lot of time to study in the evenings. Not to mention the occasional social events like LAN parties or themed parties. Still have time to do a half-hour or hour of games a day - I need a nice way to de-stress, and the latest one, plants vs zombies, can be played with just a mouse, leaving my other hand free.

First Week in Bolivia

I would have written sooner but it's a little difficult to find time among all the things we are doing. We got in on Sunday morning at about 6am after flying to Miami and then La Paz. A lot of flying. Very long flights. We were met by Mr. Gonzalo who is our liason/coordinator for the volunteering we are doing. He helped us get a taxi which took us to our homestay. We are on the fifth floor of an apartment complex and staying with a woman named Olga. She speaks essentially no English but among our group of three (Nourah, Me, and John), Nourah and I usually are able to make sense of things. We were considering taking Spanish lessons, but we placed as intermediate/advanced so we weren't sure it'd be worth our money. Anyway, we napped that first day, then met Nathalie, one of our professors, at a coffee place in one of the plazas. We then explored the area a bit, did some shopping, that sort of thing.

The next two days were kind of a blur of meeting with Gonzalo to discuss the cultural and social climate here in Bolivia, discuss our role in the hospital, how we can contribute, that sort of thing. We also were joined by a physician from Touro, Dr. Mokari, who is hanging out at the hospital with us. We visited the hospital and were introduced to people but didn't stay long enough to do much else. Then we returned, have been eating out a lot and getting drinks, that sort of thing. We saw Prince of Persia the other day in Spanish, have gone on two bus tours, and the like. We're starting to get a pretty good feel of the city, including which taxis and minibuses are sketchy.

First day in the hospital I chose to follow an infectious disease epidemiology specialist - of course - and we saw four cases of Dengue fever (apparently really unusual for this time of year), a case of gallbladder stones, and then discussed the etiology, causes, diagnostics, treatments, etc. Today I saw a patient with tuberculosis, got to look at his X-Rays and auscultate his chest. It was really interesting. I was also shown around the SUMI office, which is insurance for low income individuals and they keep tabs on the most significant infectious diseases or conditions including yellow fever, leishmaniasis, rabies, influenza, tuberculosis, dengue, AIDS, hanta virus, polio, rubella, measles, etc. We're going to do a survey on Monday, and this weekend our group is going to do a biking trip to the rainforest, hopefully! Until then!

Bolivia and Research

Things are progressing as usual at school. We're studying drugs for treating hypertension, dyslipidemias, arrhythmias, angina, etc. Essentially this is the phase where we learn how to treat the diseases in the renal, cardiac, and respiratory systems, which we learned about last block.

In the meantime, I've gotten started on some research, fortunately with the same professor who is going to Bolivia with us. I'm glad I am on good terms with all the faculty so far - I have heard of a few students who think certain professors dislike them, and I haven't gotten that vibe from anyone yet, so hopefully I won't. The research is related to bacteriophages, as I mentioned before, and we will be growing bacteria (Salmonella) and determining under what conditions their bacteriophages become most activated to the lytic phase (where they reproduce themselves and lyse their host cell, looking for more hosts, compared to the lyosgenic phase where they lay dormant in the host cell's DNA). The professor I am working with, as well as others in the lab, seem to be really laid back, It's kind of a "when you can help out, come on in - put your studies first" situation. After the high-stress environment of working in a hospital laboratory, and even the strict environment at UCSD, this is a welcome change.

Also, the Bolivia trip is beginning to materialize more. We are about ready to book our flight to La Paz, are going to put together a presentation of pre-research about Bolivia, and are getting materials ready for the trip. I'm very much looking forward to the experience - Spanish immersion, health education, learning how to diagnose and possibly treat diseases we rarely will see here in the US. Anyhow, back to studying.