Sick professors and endless didactics

So, it's been awhile since my last post... sorry. There's just not a lot going on in Dodd Hall.

I had a couple of new patients yesterday--a man who was ejected from a single-car crash on Jan. 31 and a woman who had had a burst aneurysm in her head after being pushed against a wall at work (a center for "troubled" teens). The woman is rather easy and probably won't be at Dodd for very long, but the man has quite a few problems, including a broken pelvis (surgically fixed but still healing) and several other surgical sites. He also has quite a lot of pain in his foot due to nerve damage. The hospital where he was staying since the accident (not OSU) had him on all sorts of narcotics, which aren't that great for nerve pain, so we're working on changing him over to better medications. It'll be a long process, but on the plus side, his brain injury isn't too bad, so he might actually get to return to a somewhat-normal life, unlike many of the patient on the traumatic brain injury service.

This morning I saw these patients, then headed over to Children's for didactics and a quiz this afternoon. The topic this week was domestic violence and children with complicated cases (either medically or developmentally). Not too thrilling, and none of us really wanted to be there--tomorrow is match day for most of my classmates (the military matches in December, but civilians match tomorrow), so nobody was thinking about didactics anyway. As one of my residents put it, match day is one of the three important days that dictates the path of your life; marriage and birth of a child are the other two. So it's a really big deal, and I'm looking forward to celebrating with my classmates tomorrow.

My first day as a "resident"

One of our vice deans gave us an interesting proposition: a half day off of being a fourth year medical student a week in exchange for a half day of being a resident for a week. It was an interesting offer; five of us on PM&R took him up on it.

So after a morning of being a fourth year (on PM&R, the translation there is, standing around looking like you're doing something while, well, not), we grabbed lunch and came back for our first afternoon as "residents". Near the end of second year, students take a course to teach how to take histories and perform physicals. Usually, these are facilitated by residents, but our students get, well, us.

It was a rather enlightening experience. For one, it forced me to remember how to do a complete history from scratch. Usually, we start by looking the patient up on the computer, and then talking to the patient to fill in the gaps, but the students are taught to start knowing nothing about the patient, which is much harder, and kinda pointless. Talk about reinventing the wheel.

The second thing that was enlightening was how much we've learned in two years. These kids know, well, nothing about how to take a history. They've practiced on each other and standardized patients, but everything there is scripted. These are real patients. So while they know the right questions to ask, they don't really know how to ask them. It was quite entertaining, actually. More so (and a bit painful) when they were presenting these histories to said vice-dean. Fortunately, Dr. Clinchot is probably the most laid-back vice dean in existence. He spent as much making fun of the fourth years for being mentally checked out pre-match (civilian match is on March 19; that's all my classmates think about) as he did correcting the students. Most of their mistakes came from being nervous about presenting to attendings, and the only way to get over that is to practice presenting to attendings.

Oh, and my med student did a good job, which makes me look good :) As a med student, the most valuable lesson learned is that your primary job is to make your residents look good. My med student will go far.

Objectives and evaluations

Tomorrow is my exam for my clinical skills immersion experience (this week and a half course with the procedures and whatnot). To study for the test, I figured I'd go through the objectives that they have on-line for each of the procedures, since I hadn't been doing my reading every day like I should have (the first two years of medical school took away my old habits of keeping up with all the reading--there's just too much of it, so we learn to be selective about our reading). Unfortunately, I've been a bit too selective--I haven't read anything. I figured going through the objectives would be a good, quick study technique, but that was definitely not the case! I didn't realize how detailed some of these objectives could be. For example, on the lecture about reading CT and MRI, one of the objectives is "Explain T1, T2, PDW, FLAIR, and diffusion weighted MRI". I actually paid attention to that lecture and I still have no idea what that question is asking. For the chest tube procedure, one of the questions was "What is the pathophysiology of a tension pneumothorax? Know the physiologic changes regarding inspiratory and expiratory pressures." On paracentesis (drawing fluid from the abdomen): "What are the pathophysiologic classifications of ascites, and what are the major etiologies of each?" If I had realized that I would have to know the physics of CT, MRI, and ultrasound, the anatomy the neck muscles, the physiology of fluid shifts, and the stages of wound healing--in addition to the steps of each of forty or so procedures--I probably would have studied a little bit more.

Playing Army

Today I took a brief break from practicing procedures on cadavers and played Army for a couple of hours. After putting a chest tube and interosseous line (like an IV, but directly into the bone) into someone who really isn't going to benefit from either, I changed out of my scrubs and into dress clothes to meet with Major General Bostick, the Commanding General of the US Army Recruiting Command, and his entire entourage. I, along with Dr. Hitchcock, the Military Medicine Interest Group advisor and retired Air Force major, showed them around the medical center and all the cool things we have there. In the process, I got coins.

The one on the left is from MG Bostick, the one on the right is from LTC Rice, the commanding officer of the 3rd Medical Recruiting Battalion. And the backs:

After the tour, I ran home to change into my class B uniform (green skirt, green short sleeved shirt with 2LT bars on the shoulders) and headed for the restaurant to socialize with people with much higher ranks than my own. Fortunately, there were a couple of dental students there, too, so I wasn't alone in my second lieutenant-ness. After that, it was running home again, changing back into my scrubs, and heading back to school to do a kidney biopsy on someone with much larger issues than that (another cadaver). All of the running around made me a bit tired, but they're paying for my education, so it's the least I could do. Besides, it got me coins :)

Back to the "grind"

Well, it was a nice and relaxing weekend, but like all weekends, had to end. After Adrienne and I went on our usual Saturday morning long run (nine miles this time), I threw some clothes in a bag and headed over to Dayton to spend some time with the McNachtans before I head out to Washington for a couple of months. It was good to spend time with Ed and Tina and the kids and just relax. Saturday was mostly just lounging around the house and somewhat trying to convince myself to at least do some practice questions for the boards (I think I did 25...). On Sunday we went out to John Bryan State Park and went "hiking". I just the quotation marks because going on a 2.6 mile loop with a seven-year-old and five-year-old hardly constitutes hiking in my mind, but it was on real trails, and the kids seemed somewhat tired when we were done (Paige was getting rather fussy), so I guess it qualifies. Then we went out to a late lunch, I threw my bag back in my car, and after a brief detour to the Air Force base to pick up a wireless router and fill up on gas that was less than $4 a gallon (I think it was $3.95), it was back to Columbus to discover that I can't even manage to set up a wireless network properly. I'll give it another shot later tonight after Adrienne gets home. Until then, it's stealing the neighbor's unsecured wireless for me.

So today I was obviously back at school. We had another lengthly session of procedures this morning, with incision and drainage of abscesses, ventilator management (complete waste of half an hour; that's what respiratory techs are for), intubation, central lines, and more practice running a code. Then we had journal club in the afternoon, and were off at two. If it weren't for the fact that the pool at the gym is closed until 6:30 this evening, it would have been a perfect day all around.

End of rotation celebration

Well, the written exam for OB was yesterday afternoon, so I'm now completely done with OB/GYN (assuming I passed, of course, which hasn't been a problem yet). My oral exam score was posted, and I got a 95%, so I guess Suchi and Adrienne were right when they told me I have nothing to worry about. I won't get my written exam score for another week or so, and it'll probably be two months before all my evaluations get in and I get an official final grade for the rotation. Grading is a little bit different here at OSU College of Medicine. There are no A's, B's, etc. Instead, the top 10% in each rotation get honors, the next 15% get letters of commendation, and the remaining 75% who pass (which is almost everyone) get satisfactory. So, whether you are the 76th percentile or the 1st percentile of the rotation, you get the same grade. Needless to say, I've earned satisfactory in most of my rotations (I did get honors in my research elective :)). Each rotation has slightly different criteria for grading, but for all of them, evaluations carry the most weight, then the written exam, and then for the rotations with other tests, like the oral exam in OB or quizzes in Internal Medicine, those carry the least weight.

So after we all finished the exam, we celebrated in typical medical student fashion. We got cleaned up (that was a big deal after rarely wearing anything but scrubs for six and a half weeks) and went out to a bar for dinner, drinks, and sitting around decompressing for a few hours. I have pictures.

That's me and Adrienne.

There was pool being played--Erin, Madhu, and Adrienne (Erin was at Grant Hospital, Madhu was at OSU but on a different team, and Adrienne and I were on the same team).

Sam was obviously happy to be done with OB, and Sunny was either so exhausted from the last six weeks that he fell asleep at the bar, or was so relieved that he couldn't stop laughing. I think he was laughing.

So that' s what we do when we're done with a rotation. Unfortunately, we had class today (we have a week and a half of clinical skills immersion), which was a flashback to the first two years of medical school--we just sat around in the classroom for 8 hours while people lectured to us. It was kinda nice not to have to think, though, and I'll never complain about two extra hours of sleep.

Aloha!

As I'm sure you can guess from the title, I'm going to Hawaii! It's not until November, and I'll be spending most of my time inside the hospital, but Hawaii is Hawaii. I just got approved to do an Army rotation in outpatient allergy and immunology at Tripler Army Medical Center. The only problem is, I had to change most of my plan for fourth year to do it. I was originally scheduled to do my active duty training at Madigan in August and Walter Reed in September. Now, it's Walter Reed in September and Tripler in November, which meant I had to ask for my orders to report to Madigan be revoked, make a request for orders for Tripler in November, notify Madigan that I'll be doing the rotation without orders, get a memorandum of agreement to be made between OSU and Madigan, and let my vice dean of academic affairs aware of the change. Oh, and I'm dealing with a total time zone difference of six hours. No, dealing with the government isn't complicated at all.

Onto other happy news... today was our last day of OB/GYN! Well, we still have the exam tomorrow, but we don't have to get up early to round and we don't have see laboring patients, so as far as I'm concerned, it's over. And what a way to end the rotation! I think the diabetes clinic was giving us a special deal on patients with pre-eclampsia... they sent us four or five, all of which had to be admitted for induction or c-section. Throughout the day, all of the L&D rooms and all the triage rooms were full. At one point, we had to put a pre-eclampic patient in the c-section recovery area because there was no where else to put her, and she had to be admitted. And then there was the Spanish-speaking only woman who was pregnant with twins--that was a fun discovery. It took about five minutes of the husband's rudimentary English and the total of ten words of Spanish tht Suchi and I knew to find out that there were two babies in there, not just one. The only break I had all day was the lunch break Suchi let me take and the half an hour for my oral exam. I don't think that went all that well, but both Suchi and Adrienne (my roommate and also on this rotation) told me that it's going to be okay, so I have to believe them. Guess we'll find out soon enough.

Birth plans and other strange things

As I'm sure you can guess from the title, it was another day on the labor and delivery floor. Fortunately, it was a very light day--there was only one woman in labor, and she was a private patient (there are two classes of patients: private and clinic. Residents and med students deliver clinic patients. Private patients are the ones who pay money to see a real OB/GYN). Anyway, said private patient came in with a birth plan which somehow involved one of those birthing balls. Also in her birth plan was no internal fetal monitoring. Fortunately, this particular private patient was reasonable enough that when the baby didn't look so good on external monitoring, she agreed to internal monitors. That's not really the point of this story, though. As soon as the night team said the words "birth plan", that prompted all the residents to start telling their own stories of patients arriving with birth plans. The one that took the cake was a couple who had a six page plan, the last step of which was to give the mom a plate and utensils after birthing was complete so she could eat the placenta. Ewww. I still get grossed out thinking about it. (It didn't happen--placentas are considered biological waste, so patients who deliver in the hospital aren't allowed to eat them).

The only other patient who did anything was a woman at 29 weeks gestation who came in complaining that she hadn't felt the baby move in the last two days. When they took her blood pressure, it was about 210/120 (normal is 120/80), and when they put external monitors on her, they found the baby's heartbeat, but the tracing was not very reassuring--there was almost no variability to the baby's pulse, which should be seen. So, she went from presenting to triage to the OR for a c-section within an hour. Baby is now in the NICU.

And speaking of the NICU, I got a little scare this morning when I checked the NICU census out of curiosity and didn't see the baby from the c-section Friday night (the one with a hemoglobin of 1.5). So I looked him up and read the notes. He was transferred to the NICU at Nationwide Children's early this morning. By that point, his hemoglobin was about 7.8--not normal, but much better. Lots of baby blood transfusions will do that. So since he's at the children's hospital, I can't check up on him anymore, so all that's left is to pray for him and his family.

After we signed out to the night team, I headed for the pool for my weekly 2 mile swim, then the smoothie place for my weekly "you went swimming today, good job" smoothie. Dinner was a bowl of cereal, and now it's time for a shower and getting to bed to do it all again tomorrow.

Let's give this a try

Just for the record, I find the whole idea of blogging a little bit silly, and I'm a little bit embarrassed that I resorted to starting one. However, when I was way too tired this morning at some ungodly hour after being awake for far too long, I thought it would be a good idea. Fortunately for everyone involved, I didn't start it then. I don't think it would have been all that coherent.

Okay, now that that's out of the way... for those of you who don't know what I'm up to these days (which is most people... my level of communication has really declined recently), I am two weeks away from the end of my third year of medical school at The Ohio State University College of Medicine, and four days away from the end of my OB/GYN rotation, and I am thrilled with the idea of being done with OB. I don't think words could adequately express how much I dislike this rotation--some of that comes from the fact that I'm post-call and my brain isn't very good at coming up with words right now, and some of that is that I just find it that horrible. I have about a million reasons for why that is, but I'll sum it up by saying the hours are really long and the residents are really stressed most of the time, and for good reason. There's a lot that can go wrong in the whole pregnancy/labor and delivery thing, and it's their job to keep those bad things to a minimum. That, and they work even longer hours than I do. The difference is, they're doing what they want to be doing for the rest of their lives. I am not.

Call last night was, as far as call nights go (at least my call nights) not too bad. I was working in the low-risk OB clinic during the day, and there is no Friday afternoon clinic, which meant I had a few hours off before beginning my overnight stretch on the labor and delivery floor. A few hours off means a pre-call nap, which is just about essential for surviving the night. I did get scolded by a roommate for coming home to take a nap instead of staying at the hospital, but I wasn't too worried about that. She seemed to be the only one who thought I shouldn't have done that.

So I returned to the hospital at 5:20, which, as it turns out, was 20 minutes late--I didn't realize the night team started at 5 on Fridays (they start at 5:30 Sunday-Thursday). So I was late for a c-section and didn't scrub in for that, but to me, most c-sections are the same, so I don't feel that I missed anything. There were two others last night, run in staggered ORs, so I only helped with one, a woman who was 27 weeks and six days pregnant (for non-medical people, pregnancy is 40 weeks. 37-42 weeks is considered full-term, 42+ is past-term, 24-37 is pre-term, and 24 and less is not viable). So even just from the dates standpoint, this was not going to be a happy baby, but to add to it (and the reason why we were doing the cesarean), the baby had fetal hydrops, which is severe anemia of the fetus. This baby was so anemic that when he was delivered, he was white. Not white like Caucasian (which he was), but white like a piece of paper. The maternal-fetal medicine specialist estimated his hemoglobin at 3 (normal for a newborn is 14-20). As it turned out, it was 1.5, the lowest the neonatologist has ever seen. When I left L&D this morning, he was still alive and in the NICU at OSU. If he makes it the next couple of days, they might transfer him to the NICU at Nationwide Children's. Sad situation, but the parents are hopeful.

The rest of the night was fairly mundane. While in that c-section, I missed a delivery of a woman I had been following for the first few hours of the night, so there really wasn't much to do other than writing notes on the patients receiving magnesium for pre-eclampsia every two hours. Then a woman came into the ER "in labor" (as I'm being to discover, many pregnant women think they are in labor up to weeks before they actually deliver. The OB residents are pretty good at figuring out which are really about to deliver and which are not). Anyway, we get a call from the ER saying that she is crowning and they're bringing her up. So we're confused about why they're bringing her up, because they should know how to deliver babies in the ER (ER docs do a couple of months on L&D during residency), and crowning isn't exactly a controlled situation that you would risk an elevator ride with. Well, she gets to the floor, and there is no crowning going on--she's about 4 cm dilated (have to be 10 to deliver), and it was her first pregnancy. Things usually present a little slower for the first one. That gave us a good laugh for the rest of the night, though. She did end up delivering before I went home in the morning, but the resident I was with seemed to think that I couldn't handle it (despite having delivered three babies already), so I didn't really do anything. And then it was back to the magnesium checks until the Saturday team arrived at 8, at which point I stumbled back home and slept until noon, then got some studying done. I have to go back tomorrow for the Sunday day shift (fortunately, it's short--only ten hours as opposed to the 12.5 during the week or 26 when on call). So I have to live through Sunday, Monday, Tuesday, and the exam on Wednesday, and I'll be able to put OB behind me forever.

Anyway, that's my life right now. Hopefully I'll be in a better mood and writing about something happier in the future.