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 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.

Mile 18039: Candid Camera

Above: Streaks of sky light up Covington, Ohio during a brisk March sunset.

I LOVE SEEING LESSONS COME
FULL-CIRCLE.

This week, I had an opportunity to guide the camera behind a laparascopic procedure. I enjoyed being behind it for once, pulling in and swiping across the abdomen to make sure the surgeon covered all the ground he needed to cover. When I was in Dominica, I had written about how surgeons and their assistants start to have this way of "hidden" communication. I've worked with one surgeon for the past week, and I'll admit the first time I assisted, it was like trying to teach a kid to bike without training wheels. Fortunately, I had a patient attending, so by the second time around, I started to get some of the gist of what the surgeon was going for.

For those of you not familiar with laparoscopy, the jist of it basically comes down to a fiber-optic camera (don't think of a lens-faced camera, but a camera in the a shape of a long-thin pole). Many surgical procedures in the abdomen in the past used to be conducted by cutting through the front part of the stomach wall, and when the surgery was over, a big scar would be left across the abdomen. Things are different with laparoscopy, a couple of port holes for instruments and the camera itself are poked in, leaving only a few small scars after surgery. It's much more cosmetically beneficial.

And here I was, keeping my eye on the plasma screens, on the scope, being the surgeon's eyes, and kinda like his brain (most of the time). And soon, the surgery was over. I was soon assisting in my first sutures, and I'll admit that its gonna take practice to get the art down of beating the "anesthesia clock." Basically, suturing up surgical openings is harder when the patient starts to breathe on their own and get active as they wake up from being asleep during the surgery. However, the thrill of jumping in to try things out is definitely there.

And, although my primary intention is still to go into primary care, I'll admit, Surgery so far has been a blast.

A Matter of Trust

Above: A view of Dominica just from above the Justin Fadipe center, one of our training sites.

"THIS TIME YOU'VE GOT

NOTHING TO LOSE." - Billy Joel, A Matter of Trust, 1986.

I'm tired. It's 4;25 pm and I'm riding back on a local bus from Roseau to campus. (I'm going to blame Jamina for us taking the bus we never vowed to take again). But the tired that's going through me comes after a day of the ER... it's one of those "motivated tired" episodes. It's only day 2 and I'm already finding myself blogging about my episodes in the ER.

What makes the ER (I mean... A&E) so great? First, as simple as it seems to an experienced doctor, having the ability to do sutures or putting on a plaster of paris (layman's terms: a cast) can be quite amusing to a naive medical student such as myself. From the doctors we've had, we've learned a lot about practicality (i.e. how to make use of what you have). And they've utilized a quality that makes the hospital environment work efficiently... It's called... Trust.

[ Go figure, I'm talking about A&E and there's an ambulance viewable in my rear-view monitor (remember what I said: the bus I'm on won't move for it at all... so it just passed). Okay, gotta quit the addiction to watching ambulances... ]

Yep... TRUST. And the coolest part is that it came in three dimensions today:

1. TRUSTING MYSELF.

Within 30 minutes of arriving at the ward, I already had found myself in gloves with a pair of forceps in one hand, and a suture needle in the other. Mind you, I have had only practiced suturing once in my life (about 5 weeks ago). Our doctor had placed us with a patient with a deep slice on his finger, and with an urgent case coming in, he told us to get started with the patient as he handled this new case. One of my colleagues, Jamina, decided to take help us and say, "He knows what he's doing." Shivers were sent down my spine. However, it was at that moment that I said to myself, I needed to use the knowledge I already had...

In, Out, Loop... Loop... In, Out, Loop... Loop... In, Out, Loop... Loop...

Before you know it... the doctor was in the room approving of my sutures and we had sent off our patient. If I hadn't trusted myself, I don't think I would have made it all the way through, mind you making some pretty hot sutures, if I don't say so myself... :P

2. TRUSTING TEAMMATES

It can be tough sometime, especially if in you're group, you're neck-to-neck vying to perform the next procedure. However, it was done. With one person in the lead of the next procedure, we put our trust in the other person (i.e. Jamina and my suturing, above), it's supportive for the student and not to mention, definitely reassures the patient that everyone's on the same page. Another way that the trust came into play is using them as your "assistants", as Robert took on another incident of drainage of pus from the knee (we get a lot of these... the Dominicans love their cricket and basketball). Before you know it, we all were working on assisting him based on his direction due this previous experience working as a Nurse. With that trust, we learned we could all work as a team effectively to provide proper procedures in addition to making the patient comfortable (I'll admit, I loved giving out my hand to the patient who needed to squeeze to take on the pain of a brutal procedure).

3. TRUSTING STUDENTS

What our attending doctor did was pretty gutsy. Just leaving a bunch of medical students at the start of their career in front of a patient. However, you don't see me complaining or saying that our doctor didn't care. In fact, doing so, I respected him so much more. Why? His trust gave the ER the best learning environment that I have had learning medicine not only at PMH, but also in Dominica. We acted like real doctors, and mind you, doing the history, the physical exam... then writing up the referrals and prescriptions, before having our attending come in and verify our work along with our impressions completed. With that trust, I learned a lot of practicality, because there wasn't guidance around most of the time, but our doctor would always recap the case with us afterwards, so any of our mistakes or issues, would be addressed.

I'll admit, with those three degrees of trust, I felt completely engaged in the hospital environment, and not another one of those silly medical students left to do random, kinda pointless work.

[ Did I tell you about this darn bus... at this point I think that the springs in the back of my seat have gathered a liking for my lower back (and I think they're getting involved in a one-way relationship)... ]

Anyway, you'll hear at least one more day about A&E... this day sets a pretty high standard for the remaining days in rotations at PMH. So far, it's been absolutely rewarding.

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NOTE: ENTRY EDITED FOR CONTENT & FORMATTING AFTER THE BUS RIDE.