The Emergency Department

I am currently on my Medicine rotation at one of the Boston area hospitals.  I was in the ED when the first ambulances pulled up after the Boston Marathon explosions.  The doors opened from the back of the trucks and stretchers were wheeled out.

As medical students, we participate in "mock codes" and learn the basics of urgent care.  We are trained how to deal with traumas.  In the hospital, we run to the bedside every time there is a "code blue" just so we can be there - to help, to watch, and to learn.  But it was unreal to watch ambulance after ambulance pull up to the ED.  We had no idea how many people were injured or in what condition they were.  I did a trauma surgery rotation earlier in the year and never saw anything of this magnitude.

I have found in my rotations that physicians, especially surgeons, have a "let's go to work" mentality. We are here to do this job.  We have to be able to handle whatever the ambulance brings us.  At the end of the day, a patient is a patient, no matter the cause of the injury.

I am so proud of my colleagues who were directly involved with patient care and all of the medical personnel who helped during this tragedy.

Near and Dear to my Heart

First of all, Happy Valentine's Day!!

Second, keep your heart happy and healthy.

Third, let's talk about how dark chocolate is good for your heart.

50 Shades Of Grey

"When looking at an image, there are different shades of grey..." said the radiology resident.

"Fifty shades, perhaps?" I wanted to reply.  I know....  Bad joke.

Despite my inane thoughts, there really are MANY shades of grey in radiology, or so I have learned during my current radiology elective.  Bone, water, air, and fat all have different shades of grey depending on which type of imaging is being used.  Moreover, radiologists constantly change the contrast of an image in order to detect any changes in density, which could indicate the presence of some sort of pathology.

I was amazed to watch one resident scan for lung nodules in a CT scan (like the image shown below) and he picked out tiny little grey spots that seemed to me to be very much like other grey spots on the image.  Nope.  He could tell the difference between which grey spot was likely a cancer and which one was just lung tissue.  I sort of laughed when he pointed to these spots because, to me, there was no way to see the difference between them.

Hence, I guess that's why radiology is a 5-year residency.  It takes a long time to "see" the right things.

On an interesting tangent, see if you can find the image of a gorilla in the CT scan to the right.  I DID NOT SEE IT!!  But...apparently 83% of radiologists missed it too, so maybe I shouldn't feel so bad.

And read the article below (side note: I've actually watched the gorilla video that they talk about during a college class and totally did not see the gorilla either).  Apparently, I should stay away from radiology as a career choice.

NPR: Why Even Radiologist Can Miss a Gorilla Hiding in Plain Sight

Ascending and Descending

So the cover of JAMA this past week showed a picture based on M.C. Escher's Ascending and Descending drawing (which made me super happy because I really like Escher's work!).  More importantly, however, the topic of the journal this week was about hospital readmissions.

This isn't really a topic that I had really thought about before, but I have to say that the people in Escher's drawing, traveling either up or down (or simultaneously both), seem to capture the paradoxes of hospital admissions/readmissions.  It seems like hospitals are always playing a numbers game: cutting down on ER wait times, increasing admissions numbers, increasing discharges, and decreasing the number of days in the hospital.  If all of these factors were satisfied at the same time, I'm assuming there would be some sort of math error (like when zero is in the denominator).  It seems highly unlikely that hospitals could simultaneously shorten hospital stays while then reducing readmissions.  In fact, shortening hospital stays may be the reason that more and more readmissions are occurring.  Sometimes the disease process needs longer than a few days to enfold, and sometimes people need to come back to the hospital for treatment.

The bottom line of most of these articles is how to make medicine more efficient.  Granted, this is a very important goal, but sometimes I wonder if we need to change our expectations about health care outcomes so that we don't end up going in circles like the people in Escher's drawing.

Gunner vs. Nerd

So I took a Gunner vs. Nerd quiz today.  After answering a variety of questions based on my procrastination skills, social life, and unease about surgery/anatomy lab, it turns out that I am just a Normal, Average Medical Student.  Funny that I think that none of my answers to these questions are actually normal, but then again med school normal tends to be quite different from normal normal.  

Normal, Average Medical Student
(From doccartoon.blogspot.com)

I was not hoping to be either a gunner or a nerd, so at least there's some compensation in that.  I would have liked if Super Amazing Medical Student was an option, but that would undermine the fact that if you make it through medical school without being a gunner or nerd, you are inherently Super Amazing.

Take the quiz and find out for yourself:   http://doccartoon.blogspot.com/p/are-you-gunner-or-nerd.html

To Sit or Not to Sit

Found this on A Cartoon Guide to Becoming a Doctor: Seating Rank Order and thought it was really similar to my post on the order in which medical students, residents, and attendings walk on rounds. (See Medical Student Survival Guide: Make Way For Ducklings, part two).

Also, today I had a very awkward "No, you can sit here"/ "No I'm fine, you take the chair" debate with my resident while there was one chair for two computers.

The Inpatient Psych Ward

Let me describe a scenario of inpatient psychiatry rounds:

Bring the patient to a conference room, in front of an entire team of health professionals, and ask the patient to describe his/her innermost thoughts.  I imagine the patient feels something like this:

The differences between the patient and the health care team in this type of setting are important to recognize.  First, in terms of dress, the patient is often wearing a hospital gown while the team members are wearing white coats and professional dress.  Second, in terms of spatial arrangement, the patient is placed at the head of the table (which is often a position of power), but here serves the purpose as a seat of distinction.  All eyes look towards the patient, the patient is asked questions, and the answers are deemed appropriate or not.  Third, there is an assumed knowledge gap between the side of the professionals and the side of the patient (i.e. there is the assumption that the doctors know more than the patient about his/her own illness).  I think this is especially prevalent in psychiatry when the patient may be seen as unreliable in providing accurate details about their illness.  Hallucinations, delusions, paranoia, personality disorders, and phobias all play into this assumption; it as though the illness is distorting the motives of the patient.

All of these differences contribute to a profound sense of power.  The power clearly lies in the hands of the health care members.  Is power taken away from the patient in this setting?  Is the patient powerless to change the shape of their own illness?  In some extreme cases, power is more literally taken away from the patient in terms of legally stating that the patient no longer has the right to make their own health care decisions.  On the other hand, therapeutic treatment of a psychiatric disorder often rests on the ability of a patient to change behaviors and thought patterns.  I guess that I am struggling with the concept of how we can empower patients to be agents of change and to be accountable for their illnesses despite an inpatient setting that strips them of power and autonomy.

As a quick aside, I am fully aware that there are often necessary reasons to take away a person's power, such as if the person has expressed a wish to hurt themselves or others.  However, I do think that this is not the case in many situations, and it is still a useful exercise to draw out a power landscape.  Awareness of our own assumptions (as well as the implications of how we spatially arrange ourselves in relation to patients) is always an important goal in medicine.

New Year's Resolutions

So I'm not usually the sort of person who makes New Year's Resolutions.  I think that if I have low expectations of success, then I won't feel like a failure.  Case in point, I had wanted to do yoga today but felt too tired from the night before...hence, I've already failed and it is only Jan 1st.

However, I did want to make some resolutions related to health care and this blog.  Thinking about the upcoming year, I will decide what sort of specialty I want to do and apply to residency programs.  It seems like there are a lot of big decisions ahead and I want to try to get the most out of this year.  So I have come up with a few resolutions that I can hopefully work on throughout the year:

1. Learn about health care policy and debate.  Ok, so this is a huge topic, but I feel like a poor excuse for a medical student when people ask me about how healthcare reform is going to affect doctors.  Also, I know very little about health insurance.  And I've been ignoring the news for way too long, but I think I am reaching the point where these things are going to start to matter much more in my daily life.
2. Fight the urge to be lazy.  Sometimes on rotations I have opted to sit out on a clinical experience because I was too tired or I wanted to study instead.  This sounds like I am a horrible person, but I think that most med students face a point when they are overtired, overworked, and stressed and they don't put in as much of an effort as they could.
3. Enjoy the process.  I only have one and a half rotations left in third year!  It is kind of scary that this could be the last time that I see a surgery, deliver a baby, or work with adults (if I do Peds).  I need to just try to learn and see as much as I can. 
4. Remember why I went to medical school.  It's a long road and I'm in the middle of it now.  It's important to keep the end goal in mind to remember why I started on this crazy journey in the first place.
5. Keep posting to this blog.  So it can be hard to write posts after coming home from the hospital, but I want to be a bit more consistent in posting.  

Happy New Year!!

One Eye Open, One Eye Shut

I need to delve into a little theory (sorry!) but I think this is my most important post yet:

Pablo Picasso painted a picture called the Head of a Medical Student in 1907.  Famously known for his abstract style, Picasso portrays the medical student with one eye opened and one eye closed.  To a large extent, medical school training involves desensitization to the body and trauma.  This happens from the very first semester during anatomy as one begins the process of dissecting a human into a series of body parts.  The process of desensitization continues as one watches a trauma response to a car accident victim, a neonate who is not breathing, a psychiatric patient with hallucinations, and a surgery with unexpected complications.  We are taught that desensitization is a good thing, that it is something essential to our ability to practice as physicians.  We need to be desensitized, to keep our emotions in check, in order to do our jobs.

But at the same time, we are taught to empathize with our patients.  We try to learn their life stories and listen to the very intimate details of their lives.  We are taught to pay attention to body language, draping, positioning of chairs, and the way we ask questions in order to make patients more comfortable.  We learn to be aware of social disparities in health care, access to insurance, and different cultural beliefs in medicine.  Yet, I still feel that there is an "us" versus "them" mentality between doctors and patients.  So I need to ask the question, are we doing enough?

I propose that physicians learn to see the world with two eyes open.  Why do we actually need to be desensitized?  I have yet to be in a surgery or dissection in which I was not aware of the fact that I was cutting into a human body.  I can remember several experiences in which I was fully aware of the emotional and moral consequences of a procedure.  Basically, it is the understanding of "what is at stake" for the patient.

For example, when I was on my surgery rotation, I had a patient with pancreatic cancer who was brought to the OR to attempt a risky procedure to remove the tumor.  Due to the extensive nature of the cancer, which was unexpected, we had to stop the surgery and close up her abdomen.  I remember physically feeling the hard tumor on her pancreas with my own gloved hands.  I was aware of more than just the fact that I wasn't going to see a Whipple procedure.  In actuality, I was consumed with the concept that as soon as we closed her abdomen, we were going to have to deliver some devastating news.  It was like looking death straight in the face and feeling utterly unable to do anything to prevent it.  I even remember feeling so sad about this that I was near tears.  As I continue to follow this patient post-op, I remember being a little wary of what I was going to say.  What could I, as a medical student, offer to this patient?

Rather than shy away from her room (as it is so easy to do while on the wards), I tried to bring myself into her room at least once every afternoon to sit down with her and have a conversation.  I did not talk about disease or treatment, but I just listened to her voice her concerns and tried to answer her questions if I could.  Some time later, I realized that these were the most valuable things that I could offer to her: my time and my ability to listen.  In this way, I gave her a chance to emotionally react to her illness and I hopefully allowed her to diffuse some of her burden. According to medical anthropologist and psychiatrist Arthur Kleinman, when a caregiver shares in someone's suffering, "The caregiver becomes a sufferer as well, who first acknowledges and then intimately experiences what is at stake for the other person" (2006).  I was attempting to see this situation with "two eyes open", to explore what was really "at stake" for this patient, rather than medicalize her as just another patient with cancer.

Doctors often forget that we are not immune to disease.  The "doctor" versus "patient" delineation is false, considering that we are all people on a varying continuum of health and illness at any given point in time.  The "two eyes open" analysis allows us to interact as people with other people.  Perhaps this will enable us to better understand the consequences of the illness experience for any of the individuals under our care.





Reference: (A MUST-read article if you are in medicine)
Kleinman, A. & Benson, P. (2006). Culture, Moral Experience and Medicine. The Mount Sinai Journal of Medicine, 73(6), 834-839.

My Week in the Psych ED

I spent this past week working in the Psych ED.  My week basically went like this:

Methamphetamine Monday
Suicidal Ideation Tuesday
Crack Party Wednesday
Hallucination Thursday
Living Life Friday (since I had zero patients this Friday, I can only assume that they are doing things that will land them in the ED later on in the night)


Puts new meaning to the song Manic Monday: