Mile 8246: To Tell the Truth

Above: A depiction of the electronic medical records system from Upstream.

WHO CAN I TRUST MORE:
THE PATIENT OR THE CHART?

Infectious Diseases has been a great rotation thus far. Although I'm still at the same hospital as my previous rotation, the days feel a lot different as a consultant than as someone who's working the floors. Maybe its that the subject matter is much more specialized, or its probably also not having to deal with as many folks left and right when managing patients (on the floors for the last twelve weeks, everything from nurses to consultants and even writing notes would slow down a day's efficiency dramatically). However, I'll be honest that after 12 weeks of intensely working the floors, 4 weeks of consulting is a breath of fresh air.

Don't get me wrong, I've learned a lot about management of infectious disease simply from my first week on the post. I've at least had some slight refining with my knowledge of antibiotic spectra, common sense on when to appropriately check for blood cultures, and even evaluating if a "fever" is truly a fever. For some odd reason the "card-playing" game with empiric and more targeted antibiotics is something that intrigued me. I'm looking forward to learning more about that in the near future.

1:30 PM Friday. My attending and I are in the room of a patient along with their family. However, when my attending was further questioning a part of the patient's family history, we basically got a irate response of, "Go look in the chart!" from the family (I'm guessing that getting asked the same questions multiple times by multiple people finally go to them). My attending handled the situation calmly and well and explained to them that it is better to get the information from the patient rather than from the chart, because the chart has the higher chance for errors. Only when the patient couldn't recall the information would my attending refer to the chart. My attending further mentioned that the patient was someone that could be trusted more. With that, the patient, along with the family, had smiles of confidence and breaths of relief.

The point makes much sense though. If you've ever seen people try to spread news from one person to another, it never comes out straight after being handed down several people. The chart is like that, especially exaggerated when trying to interpret someone else's words when someone is not there to clarify or answer any of the doctor's questions. The bottom line from this lesson is that the purpose of the chart is to document what was done, but not to be used to substitute for a proper history taking or physical examination.

A simple, but very useful lesson.

Mile 1036: Games People Play

Above: My high score at Buzz Lightyear's Space Ranger Spin at Walt Disney World, FL. May 2009.

"SEEING IT FROM WHERE I STAND
NOTHING COMES EASY."
From the theme song to the 1990s sitcom Just the Ten of Us.

2008. A group of 10 of us students sits in a small room on our first day of the Behavioral Sciences Lab. There's a huge table in the middle of the room which we all are sitting around. We're staring at each other, probably making small talk... but we're waiting. A Dominican lady walks in, along with one of our faculty, and they sit at the table. I find myself in the chair directly to the right of them, as they prepare the class. And when they asked for a volunteer to interview the Dominican lady (a patient, standardized most of the time, if not always), I had raised my hand. A form with questions to ask was handed to me, and soon I found myself going through the form to take the Dominican's history.

However, I knew that soon enough - just like the training wheels on the bicycle - I needed to be free of support to know I could really do this on my own.

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We're finished with the babies, at least in terms of a full-time sense. As I've crossed the 1000 mile mark on this part of the adventure, we've moved from the hospital setting to a private practice in Buffalo Grove. Here's the dilemma I'm facing - how to take a history from a pediatric patient. Even though I've been through many experiences with history taking - starting with standardized days of yore - it feels different when I'm in with real patients with real health issues. I just don't want to mess up.

I'll admit during my first few days, I've felt nervous about taking histories and physical exams, but when I had talked to my attending doctor, he said that experience comes with practice. From what I've seen so far, I think there's three hoops to leap through to get an accurate history and physical exam in pediatrics:
1. The Kid's Trust
2. The Parents Trust
3. The Kid's Communication

One of my group mates brought up an excellent idea on why I might be having trouble: why don't I try playing a few games to start to earn some of the kid's trust. No, I didn't pull any of the following things on 19-year-olds but I did try them on some of my younger patients. For instance, with an infant, I soon made my hand into an airplane to try to make the kid smile. The benefits were enormous though as the kid showed teeth! I knew I had made the little one comfortable for the ride.

However, it's not over yet, as many kids come in with concerned parents. And I've seen them all, from the laid back, leave the son/daughter in control mom/dad to the stern, "I don't any students in the room" mom/dad. Parents are an important part of the health of the kid, and from what I've learned so far, as physicians, we're not here to override what parents are thinking, but to help and assist them with their children. The cool part is that pediatric histories may include a combination of information from the mom/dad and the patient himself/herself (both will answer your questions). It's up to the clinician on how to interpret any differences (which occur often!) between the two.

I also am learning how kids love to term how they feel. Some instances were an unending "stream" of yes's to a line of questions I asked one patient. Other times, I found myself trying to interpret what "weird" or "tickle" meant. The words are cute, but in order to help out the kid, I had to probe what exactly those words meant. I'd love it when a kid would clear up how "weird" something was by saying, it was just "weird." It's just another piece to try to put into the puzzle.

I guess jumping through hoops may be right up my alley.

The Mind of an Examining Med Student

One of the biggest things I've learned in medical school is that my perception of time is absolutely messed up...

At the end of fifth semester in Dominica, we have our Final Physical Exam Practical. This is where we're tested on our "Doctor Skills", but with horrendously strict time limits. For instance, we have to question the patient on his/her condition (a.k.a. Taking a History) or perform a physical examination on some organ system of the patient (i.e. heart, lungs, stomach) in a less than comfortable 10 minutes.

And there I was... one of those medical students about to take on that exam. I was dressed up in my white coat - with the great honorable Ross emblem patched above the right pocket - and my reliable blue shirt / dark blue tie combo. My white coat was loaded with the appropriate exam tools - an ophthalmoscope/otoscope, a reflex hammer, a cotton-ball, and of course, Doctor's Best Friend, the stethoscope.

As a side note: never ever underestimte the power of the hammer that your doctor uses to make you kick involuntarily with your knee. (That brown or orange rubber hammer isn't there just for show.) It could be very helpful to detecting more serious neurological issues, such as a stroke or a spinal cord injury.

There are three rooms of 10 minute tasks a piece. I had gotten through the first two rooms and barely survived, but then I came to the third room. I enter the room, greet the doctors that are proctoring the room, and then the doctors proctoring my room say to me:

"Make sure you manage your time wisely to examine your patient."

They had given us a paper before entering the room that said what the patient had. If you've heard about schools using standardized (acting) patients in their programs, well, in fifth semester at Ross University in Dominica, we use real patients in our examinations. The patient in front of me, as described by the paper, was complaining of weakness on the left side of his whole body.

The proctors told me that the time on the clock started with me pressing the start button on the kitchen counter timer that was about to being used to time it. I knew that when I clicked the start button... it would just be between the patient, the clock, and me.

... And, CLICK!.

10' 00"... 9' 59"... 9' 58"...

At Ross, we've been taught a script that we would digest to every patient we'd work with in an examination case, everything from introducing ourselves to mentioning things would be confidential to whether or not we've washed our hands (in that case we hope that the former was the case). As I was doing my examination, I started to notice that upon movement of the patient's arms, his arms were tough to move, with rigidity upon movement (med lingo: hypertonia).

When we're practicing for these examinations in small groups, we try our best to simulate our standardized patients: well get one of our group members to either falling asleep, act with minimal compliance, or pretend that he or she have no idea what the student is saying. However, we never really knew how to practice for real patients, because the scenarios aren't known until the day of the exam.

I then worked on the man's reflexes in his arm and leg carefully, and then I looked at the clock...

3' 22"... 3' 31"... 3' 20"...

At this point I realized I still over half the examination to go. I said to myself, "Clock it!" Which is my lingo for saying "Speed it up!" My heart started to enter a rush and I started racing through various sensational exams on our patient (i.e. testing whether the patient could feel vibration, feel a pin or a cotton ball, or know the position of their fingers). When I finished that, I started to examine the head, I started asking the patient questions about vision or loss of smell... but then I looked at the clock again...

0' 23"... 0' 22"... 0' 21"...

I clenched my teeth as I started checking out the patient's face to see if the patient could feel me touch his face. However, I still looked back at the clock...

0' 10"... 0' 09"... 0' 08"...

"Come on, let's really clock it..." At this point, I think I was basically speed-blabbering instructions... but after testing the patient's jaw movements, I looked again...

0' 02"... 0' 01"...

Now, if you would have seen the look on my face at that point, you would have probably described it as the "Oh, Shit" look. Forgive my language.

BEEP. BEEP. BEEP. BEEP....

After the proctors told me to write my findings outside, I thanked them and the patient for their time, but I had left a couple facial neurological exams on the table, which were quintessential to evaluating the patient. I guess for some people "That's life," but that's also a couple of points off my full exam. It was then that I walked into the library room and sat down with a pencil and paper and wrote up the cases that we just investigated in each of the exam rooms.

But that's my story about how my perception of time is messed up... Sometimes medical school can be tough, but it teaches you one thing: not all the time can we take our time to exam our patients and make sure we can do everything properly. There's going to be times when time is going to be of the essence. And it is then, I'll realize that only through practice are we able to do everything a doctor can possibly do properly in an efficient amount of time.

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And today was the "last" official day of classes I had here during my time at Ross. Next week, we'll be doing our BLS (Basic Life Support) and ACLS (Advanced Cardiac Life Support) training. On April 12 next week, I'll be on my last plane flight home from the Nature Island. So here's what to expect on the blog: over the next couple of weeks you'll see some retrospective entries on some of the greatest lessons and moments I've had during my 20 months here in Dominica.

Remember: If you have any prompts or questions about Life in Dominica or at Ross, let me know. I'm always looking for something new to write about.