Mile 24417 + 2710: Different Mindsets

Above: I ate this food 2 hours after taking this picture when the food was fresh. Oh ER...

"YOU AND I HAVE
DIFFERENT MINDSETS."

A seventeen hour drive was completed about two weeks ago. It brings me to the sunny shores of St. Petersburg, Florida. I am enjoying my time here so far as the mentality of the people of the city definitely feels midwestern, but of course, the weather is a side benefit to living here too. We're less than 7 weeks away from graduation...

During my days in the Emergency Room to date, I'll have to say that no day is ever the same. There are some shifts that'll have me waiting for a good case, other days I'll have loads of good cases. There are days that there will be no procedures, and other days where I'll be doing a million. There are days when my days are filled with a bunch of chest pain due to a cardiac cause, and other days where I get a bunch of chest pain from drug seekers.

I had an opportunity to work on a patient who came in with abdominal pain and urinary incontinence over several weeks, but was soon discovered to be pregnant via a urine screen. When presenting to my attending, my assessment started with the important stuff, the abdominal pain probably secondary to being pregnant, and then when I started on the urinary incontinence, my attending stopped me in a friendly manner, saying we're going to take care of the pregnancy first. However, although I knew that was very important, I thought that addressing the patient's concerns about her frequent urination and peeing would be important.

That's when my attending told me that we have different mindsets. I wanted to take care of the whole patient, or at least address everything, but the emergency room doctor needed to prioritize. I agree there should be priorities, but it seemed the patient's urinary complaints would go by the wayside if they weren't addressed further in the visit for follow-up.

I love taking care of the whole person as much as possible. It's a hard habit to break.

However, that doesn't mean Emergency Medicine has been a bust. It's been anything but. I've had opportunities to put stitches in people coming in from accidents (20 in one patient, and even learning the technique of the vertical mattress to add on to my skills), taking care of abscesses, and even yanking back dislocated hips (which taught me that I need to go to the gym). These types of procedures are seen frequently in the emergency room, but if I have my own practice, it's possible I'll be doing these same procedures too, so I'm glad that I have an opportunity to do these now.

Emergency Medicine at Bayfront here in St. Petersburg has also brought me to work along with the armed forces, as the ER here is a site of training for them. I had an opportunity to meet some of our folks who are learning to work on the field as medics, and some of them have taught me a pearl here or there. As tough as our armed forces are, they are real people and great at teamwork. Many of them are blunt and honest with each other, but each member took it on as constructive criticism. I really enjoyed working with them as they had a very good model for camaraderie.

Mile 24417 + 1204: Shortie: The Final Leg

Above: Oddly found a four-leaf clover in front of the cath lab this month.

I MIGHT HAVE TO BRING
THE WHOLE HOSPITAL WITH ME.

That's what I said when everyone reacted with interest when I mentioned that I was heading south, with fall right behind me.

I'm about to head off to bed, but I just wanted to log that we're 1204 miles in. Tomorrow begins the trip to St. Petersburg, Florida, where my final rotations in Emergency Medicine and Obstetrics & Gynecology will take place. I'm looking forward to it. But first, time to rest, there's 17 hours of traveling ahead. I'll update you on some of my final adventures in Columbus soon, when I get an opportunity to stop on the road.

Mile 24417 + 847: Pull Up a Chair...

Above: The Cath Lab has a wonderful Digital LED clock emitting the tone, "Pressure."

"IT WAS
SNOWING..."

... was what the patient said to me as I listened to him/her give their story about their current issue in the hospital today. The patient was on the elderly side, but I found it amusing. I played along with it to see where the patient was going with it. However, just to make sure I didn't mislead anyone, I told that patient that it was 70 degrees outside and warmer. Patient's response: "I hope it stays this way."

----

After three weeks of Cardiology (and 847 miles into my second cross-country trip), I'll admit that the group I am working with has me truly enlightened on a huge concept in medicine. It's more than diagnosis and treatment... it's also risk management. Measure the costs and benefits of each treatment and see how that works well for the patient. Mnemonics like CHADS and TIMI sound pretty silly when you're not in the medical world, but to us clinicians, they mean the difference between whether or not we're going to thin someone's blood for possible clots or whether or not a person had a heart attack or not.

On another note, going into primary care and providing excellent bedside manner is something that I am looking forward to doing when I become a doctor. And, I'll say that the last place I expected someone to pull up a chair and have a solid conversation with a patient was on a consult service. However, each one of the doctors I've seen, provided there's an open chair or a ledge around, will sit down to have a face-to-face conversation with the patient.

When I was in Decatur, IL, I remember sitting in front of a news article stating the benefits of sitting down. It makes so much sense though, as it makes the visit much more personable for the patient, and instead of seeming like a commander, it makes the doctor seem like more of a role model or counselor. I think that can go yards to helping a patient feel like he/she can participate more in what is going on, and feel more comfortable with all that is going on around them.

And that also goes for the physical exam. I don't know if I have posted it before, but this article from the New York Times, mentions how Stanford plans to revive the Physical Exam. I've mentioned before how numbers and labs are important, but the context to which they are all interpreted are covered in the history and physical. But there's more to it than that... utilizing the stethoscope and interacting with the patient, seem to give the patients a feeling that the doctor is truly participating in their care. As much as numbers are accurate, numbers can only do so much.

So, next time your doctor takes some time to sit down next to you, it's no longer only in times of bad news, it's always for the best.

Mile 24318: Call me Erwin

Above: Graham crackers are in ready supply on the surgery floor.

"ERWIN... JOHNNY...

ALMOST."

- My attending on a fellow medical student calling me by the wrong name.

Last year, during my Internal Medicine Rotation, I found myself eating a horrible breakfast a lot of mornings when arriving at the hospital.   However, it was the most easily accessible: potato chips and cups of juice (that in truth were only 10% juice) stared right at me in the resident's lounge.  It was a terrible combination. Well, during my Anesthesia Rotation, I've gotta say that I worked on it. I'm getting more nutritious by keeping my energy levels high through Graham crackers. These wonderfully available packets (above), kept me going through taking patient histories, inserting LMAs, and following through with patients in the post-op room.  Pretty potent for a small packet, I may say.

And here I am, after a full sixteen weeks of Surgery, currently in a 2 week break before hitting the road to Columbus.  As much as I'm not going to go into Surgery, the folks at St. Anthony have really taught me an appreciation for it (with or without the graham crackers).  I'm not going to forget how the masks and scrub uniforms on the nursing staff made people look completely different than when seeing them outside of the hospital.  That perhaps led to my last nickname, Erwin, when a fellow medical student couldn't come up with my name.

Erwin... It works.

However, my last four weeks in anesthesiology were quite interesting.  Originally, my perception of a day in the specialty consisted of placing some tubes and watching the patient as they fall asleep, then waking them up, and you're pretty much done for the day.  I ended up seeing their jobs are much more important then orignally thought, making me appreciate the rotation much more.  If you think about it, just a couple ounces of anesthesia, if placed into the wrong part of the body or if dosed wrongly could put the patient in danger.

I've talked about the "art of medicine" before from my perspective, as much more of a clinical thinking concept, but the "art of medicine" in Anesthesia I saw was one of procedure.  Many of the procedures, such as spinal or nerve blocks, or even the classic intubation require a lot of muscle memory and hours of practice.  Everything they do needs to be accurate and precise, or a lot of wrong could happen.  But it doesn't.  The doctors and nurses in the anesthesia department at St. Anthony were pros at their jobs.

And with that, I'm entering back into the realm of medicine, and taking a Cardiology elective at Grant Medical Center in Columbus, OH.  This is the start of the last big road trip I will make during my medical school career, and the start of the last three rotations ever.  My journey through medical school has been amazing so far, it can only get better toward the end.

Mile 23611: Books Were Here

Above: My Local Borders Bookstore Is Closing.

READING KINDA MAKES ME FEEL
LIKE A KID AGAIN.

Flash back to 1993. Imagine a pony-tailed me (I think the 1980s lived on to the early 1990s for me) in the face of a book about 500 pages thick (the pages weren't that wide, so don't think I spent a year to get through it). One of the things that I always looked forward to doing in elementary school was reading through a book, and then taking a comprehensive quiz to garner points as part of the Accelerated Reader system. It was a good program, as it made me work on recalling what I read, and better yet, made me enjoy a whole breadth of books.

2011. I now own a kindle. With the breadth of free classic books on it, it's been a great add-on. I could access tales of Jack London that I read when I was younger, or even classics I have never touched such as Jules Verne's "The Time Machine." However, with the attack of information I've gotten from aspects of medicine all-over, I haven't had as much time to read. There's something about reading a book from front to back in a good setting.

However, with the recent announcement of the closure of Borders' Bookstores, I decided to stop in. Borders was always my favorite of the two big boxers. For some odd reason, it didn't feel as pretentious, and their staff was always nice and courteous. I liked their pricing compared to other big B down the street too. But with the recent sales, I thought I'd get my hands on a couple of books I've been meaning to read. I'll admit that holding a paper book gets me kinda nostalgic. Here's a couple of classic books I got from Borders' this week:

George Orwell's 1984
Craig Ferguson's American On Purpose
John Steinbeck's Travels With Charlie
Ken Keysey's One Flew Over the Cuckoo's Nest

It's been a odd past couple of years for big bookstores in my area... the closest bookstore to my house where I studied for Step 1 closed suddenly (the other B- store), and then the Borders I prefer to go to is now going to shut their doors. Libraries were great to study at, but there was only one problem, I needed my coffee. And then coffeeshops were also great too, but they had a little too much conversation going on. And no better invention was made by man to get the best of both worlds by combining both... a bookstore cafe.

After I finish my boards for med school and my applications for matching, I look forward to reading all these books straight through. It's certainly been a while since literature and I have spent some quality time together.

Borders Books & Music, you will be missed.

Mile 23344: Shortie: A Steaming Summer

Above: I get double dared both on paper and in person on the surgical ward. This is the paper version.

I'M 8/10 IN USING MOTOR SOUNDS
TO KEEP BABIES HAPPY.

Well we jumped the 20000 mile mark just about a month ago, during surgery. However, studying for the big Step 2 CK exam which is coming up this month, so time has been limited to write. That doesn't mean that the writing is over. I finished my surgery rotation a month ago, took 4 weeks off to study, and right now am back in business with doing an anesthesia rotaiton here at Saint Anthony Hospital in Chicago, IL.

This is just a quick note to say I'm alive and I'm still counting miles (we're quite up there right now).

The summer has also brought some unexpected surprises.
- I'm now a Godfather to a beautiful baby boy, Joshua. I attended his baptism in June. He loves motor sounds. However, little did I know they only work on most babies. I learned that fact quite quickly at the baptism.
- Old Silver is now New Blue... Long story put short, my old 2002 Ford Focus needed to be retired, so a 2012 is now my new mode of transportation. However, my mile counting still sticks dead on the dot accurate mile for mile.
- It's match season, so applying to residencies is in play currently.

Another surprise: this summer has just been plain hot. And I'll be honest, with all this work to do, it's tough to get out there and enjoy it. However, I believe that work will pay off. And I certainly hope it does. More soon.

Mile 19314: Chasing the Smoke

Above: I really pride my hometown. It's quite a beauty, no? September 2010.

HERE...
HOLD IT!

Last week, my surgery partner and I are putting together a presentation for journal club on the Nissen Fundoplication we did earlier in the rotation. It was really cool to have an opportunity to present the case & the operation in front of the surgical nurses / assistants of the hospital. A really rad case the Nissen was, but I've been learning over the last few weeks that even the basic of the basic surgeries (I would assume that a surgeon would call them "easy cases") would teach someone going into primary care some of the easiest tricks up the sleeve for being a team player in the operating room.

I had written in one of my blog entries in Dominica, about the excellent communication I saw between nurses and the attending doctors. It's just awesome to see the voiceless transactions that occur here in the operating room at the hospital. But with the opportunity to scrub in with several surgeons, it's interesting to see how different attendings have different expectations on communication.

For some, they're pretty vocal. One of the surgeons I work with during Lapascopic procedures communicates well, and I kinda plug in extra judgment with my experience with him to get the camera angle right for him to use the "Bovie" with precision. (It's so weird, because you're acting as someone else's eyes). Some are a little less vocal, using one to three words to describe how to assist, such as the command that started this blog entry, "Here, Hold it!" Another one of the surgeons is a lot more silent, but with more experience with him, I'm able to figure out if he really wants me to chase the smoke or drain out the blood. And somehow, we get it to work.

In addition to learning more on how communication can go about in the operating room, I'll have to say that I'm happy that I was able to pull off my first suture in the OR... actually 2 small ones. We have an awesome set of nurses, attendings, and surgical assistants, and it's great to have an excellent support group (which I wasn't expecting in the first place from such a stressful environment in the OR). Also, as of this week, I'm learning how to throw in IVs... a couple of us get together around a table and basically spend the time to practice on ourselves, before going out in the "real world" and practicing on the patients. I'll admit, that it is touching to see that all of us are willing to risk potential hematomas or blown veins for each other's learning benefit.

This week, I started Orthopedic Clinic which I'll be doing for the next four weeks, and I'll update more on that in the next entry.