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.

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.