Make Way For Ducklings, part two

There is a specific order in which medical students follow around other members on their team.  This is based on the hierarchical nature of medicine.  Some rotations follow this more strictly than others.  This is also very implicit.  No one tells you in what order you should walk in/out of a patient's room, through a doorway, or down the hall during rounds.  You just pick this up and start realizing that you are the bottom of the hierarchy in every sense, which is physically represented as being the last in line. 

1. Attending
2. Chief Resident
3. Mid-level residents
4. Intern
5. Sub-Intern/4th Year Med Student
6. 3rd Year Med Students

Make Way For Ducklings

There are many times when I feel that the multiple 3rd year students on any given service look like ducklings as they trail behind an intern, resident, or attending.  There are several reasons why this occurs.  3rd years, just like young ducklings, must face many dangers in their new environment.  Some of the perils that await the 3rd year during his or her first days in the hospital:

1. Hospitals are mazes.  They are like casinos in their ability to disorient you to direction and time.  3rd years are used to the safety of the lecture hall and the library, the domains of the preclinical years.  The bright lights, identical hallways, and multitude of oddly named buildings of the hospital take some getting used to.  
2. People will ask you for directions.  You are wearing a white coat and/or scrubs.  You have a badge. You look like you belong.  Well, that's a joke.  You are barely able to find your own locker let alone the radiology residents' reading room (bam, alliteration!) that you were asked to find.
3. Some people have looks of horror on their faces when they enter an elevator full of White Coats. Just be aware of this and don't take it personally.
4. You will lose your attending.  He or she will momentarily duck into a patient room or go to talk to a nurse and you will have absolutely no idea where he or she went.  You will look like a lost puppy.
5. At 6am (or some other absurdly early time), all of the ducklings will enter a patient room with the Mother Duck for rounds.  I can only imagine that many patients have nightmares about how a room full of doctors is going to interrogate them in the dark when they are barely awake.
6. You are not sure of your role in the hospital.  Hence you attach yourself to people who look like they know what they are doing and wait to be asked to do something.  Yes, it is as vague as it sounds.
7. Finally, just try to keep up, no matter the length of your stride in relation to that of the resident.

Superlatives

Working in a hospital is a little bit like high school.  The cliques (or professions) are very clearly defined and seem to represent certain personalities and attributes.  These are just some stereotypes that I have observed.  I realize that these are huge generalizations, but I think that there is some truth behind them.  Let me know what you think.

Best dressed: Female surgeons

Worst dressed: ER docs

Best looking male residents: Anesthesia

Most use of foul language: Orthopedic residents

Nicest people: Pediatricians

Most fun to joke around with: General surgeons

I'm not the only one who has thought about these stereotypes.  See the Scrubs link below for how ob/gyn is like a sorority:

Less Is More but sometimes More Is Good

I feel like I have a very cynical attitude towards medicine.  I'm often surprised by how little we can do to help some patients.  There are even times when I feel that we do too much and are too invasive.  I want to scream that "less is more".  I want to tell the patient to leave the hospital or to refuse treatment.  But occasionally, my faith in medicine is actually restored and there comes a scenario or two when a life is actually saved.

A little boy with a severe asthma exaacerbation and possible anaphylactic reaction was in acute respiratory distress...  It is scary to watch a young child struggle for air with complete panic in his eyes.  The parents are crying and do not know how to help their son.  Life or death really does lie in the hands of the physician at this point.

This situation occurred last night when I was on call in the Emergency Department.  Although my shift was over at 11pm, I stayed until 2am just to make sure that this kid was still breathing.  I listened to his lungs and have never heard a more severe exam.  There were no normal breath sounds.  The space between his ribs was visible as his work of breathing increased.  This is what I call Stress.

Thankfully, a barrage of medications, including an EpiPen, nebulizer treatments, and several IV meds, calmed his breathing.  He was eventually able to fall asleep.  On exam, I was amazed to hear that his lungs were completely clear.  It was as though this episode had never even happened.

In this acute case, it was necessary to use as many medications that could possibly help.  The stakes were so high.  And despite the vomiting and shakiness and headaches that followed some of the medications, this boy was able to breathe deeply once again.

Thus, my rule in life is that "Less is More but sometimes More is Good".  I think that it is our job as future physicians to learn this distinction.  We need to determine when we have done enough, when the body is better off healing without our help, and when we have pushed the limits of our knowledge.  But we also need to determine the situations in which a well-orchestrated intervention can mean the difference between life and death.

Post Call Disorientation Syndrome

I propose that Post Call Disorientation Syndrome should be a new category in the upcoming DSM-V.  You can identify this syndrome if you meet the following criteria:

1.   When asked a question during morning rounds (24+ hours after you first entered the hospital), you just start laughing at the fact that they actually expect you to know the answer and to speak intelligently.  You know that your central nervous system lost these capabilities previously in the night and cannot recover them so easily.

2.   Eating, showering, and sleeping are all equally urgent priorities.  It can be difficult to know which one to do first.  Like the Sims.

3.   When you wake up and don’t know the day, time, or place, and yet you must still assess the mental status of your patients.  This can lead to awkward questions such as “Is today really Friday?” and “Wow, it’s November already?”.

4.   You start getting hungry at random times and Pop-Tarts seem like a good idea for a meal at 2 am.

5.   Your scrubs definitely smell weird, whether you are aware of this or not.

6.   When post-call conversations with parents are initiated by incomprehensible blabber and usually followed by the subsequent questions: 1) did you eat; and 2) is the patient alive?

7.   You appear slighlty manic when you leave the hospital and really, really hope that you don't see people you know on the way home.

8.   You notice that you hold your hands in a neutral position above the waist at all times, even when not scrubbed in to a surgery.  You start to wonder about classical conditioning…and if you will ever be free again.

9.   You leave the OR after x number of hours and are blinded by sunlight.  This is equivalent to a vampire being burned by the sun.  Or a newborn animal just entering the world for the first time.  Or a blind person that can miraculously see again.

10. Post-call sleep transcends space and time.  You go off the grid for several hours, ignore phone calls and text messages, and have strange dreams that involve the hospital.  


Post Call Disorientation Syndrome is aptly demonstrated by this gem:
http://whatshouldwecallmedschool.tumblr.com/post/29683353941/leaving-the-hospital-after-a-24-hour-im-call

Meet the Newborns

The Newborns (neonates, if we are going to get technical) are interesting creatures in medicine.  Having spent all of my previous rotations dealing with adults, it was surprising to find out that newborns' heart rates normally approach values that I've only ever seen on my elliptical's heart rate monitor (when I was really, really in shape) and that premies can commonly forget that they are supposed to breathe.  Yup.

Breathing is something that we take for granted, but when you are born into this world that first breath is hard.  Watching a newly delivered baby turn from blue to pink is really an amazing experience.  You want them to cry and scream and fight against you.  You want them to be severely pissed off that you have taken them from their mother's warm tummy and thrust them into this world with its Air and Light and Noise.

It is common among students to refer to newborns as little aliens.  I even heard one person refer to them as "gerbils" because they are kept in plastic cribs and incubators.  But if you pause to think about it, we must seem like the actual aliens.  Existence in the womb is based on the sounds of your mother's heartbeat and voice.  Breathing is not necessary.  You are floating in fluid, feeling the weightlessness associated with buoyancy and the security that comes with confinement.  At some point, you are forcefully expelled from an overstretched uterus, pass through a bony canal (watch out for that pubic bone!), and are held, blue and writhing, in some physician's gloved hands.

Today I watched a woman deliver her baby while she watched the process in the mirror.  The mirror was positioned between her legs at an angle so that she could see her baby's head emerge.  This was a little too much for me.  I pretend to be all about this sort of thing, but in reality, I think that I would faint if I saw the damage being done, you know, "down there" while I was giving birth.  

Also, if you ever have some extra time in clinic, take the time to peruse the What to Expect books.  Mostly this is for the entertainment factor (they are wildly outdated).  For example, I learned that chicken soup is actually good for a cold, but it can't be the Campbell's kind.  If you actually decide to boil some chicken parts and vegetables and make your own chicken stock, then you can feed this to the infant.  Don't forget to skim the fat.  I'm not sure what you are supposed to do with the crying, sick infant while you are homemaking some chicken soup.  The book failed to provide any strategies for this conundrum.

I looked up the meaning of my name in a baby name book (ok, so I had a lot of time waiting for patients to show up to clinic) and it said: "from Greek mythology, goddess of the moon, hunting, and fertility".  That's an interesting combo and I'm not sure how to interpret this, but I do like the part about being a Greek goddess.  Let's just say though that this goddess of fertility will not be holding up a mirror to watch her little alien be born anytime soon.