The ICU continues to be frightening, but now not because it raises the questions of mortality or displays the prone bodies of the helplessly sick, but mostly because i still don't understand the vent settings.
All things can become conquerable, once they are named. Once they are named, divided, classified. Once they are named, translated and become a puzzle of cognition, technique, logical and mechanical resolution.
Grand Rounds today: surgical education. It began with a typical display of graphs. Outcomes, surveys, studies. Rigor was demanded, plus or minus p values. A new laparoscopy lab has been built, the bottom line, measured. Interns were made fun of. Papers were published. The last speaker (the one that i thought was smirky, that pimped us on Charcot's triad on day 1) ended with a discussion of his mother's death and the meaning of teaching: this [life] too shall pass. In teaching, the work caries on. We lift up others to see the future.
I got a bit teary.
Spock, 1. Kirk, 1.
Wednesday, June 3, 2009
Wednesday, May 27, 2009
Medical Student Presentation Guide
This is a rather amusing if not entirely didactic guide to patient presentations
A complete History and Physical must be obtained with the resident on the floor and written up for Dr. Miller and the teaching resident.
Presentation of morning rounds must be focused and concise. Specifically:
Give a one-line introduction with: age, sex, diagnosis(es)
Brief HPI with chief complaint, length and type of symptoms, medical interventions (if any)
ER course: Vital signs, exam in ER, interventions
Floor course: Exam if different from ER, interventions
Your plan: Medical management, studies required, etc.
Concise, effective presentations are very difficult to synthesize. To help you do this, use the intern who is assigned to the patient to figure out what information is pertinent, and give a trial run of your presentation to him or her.
You should practice your presentation and time yourself. The goal is less than two minutes! Remember to include what you feel are the PERTINENT positives and negatives. Your senior resident will ask specific focused questions if they require more information. Again, let me emphasize that we realize this is a difficult task. If you feel uncomfortable or unsure, talk to one of the seniors on your team and they can guide you through your specific areas of concern.
Examples:
Bad:
This is a three year old cute little girl who has been having a hard time breathing for awhile now. She has a doctor who manages her asthma with a bunch of different medicines but things weren't going so well, so she came to the ER with her Mother, sister, and baby doll, Mrs. Bigglesworth. Apparently, she has been in the hospital before with this and mom says she misses a lot of her preschool because of her wheezing. Mom things that she is worse in the spring but she was a little fuzzy on that point. So today after ballet class mom saw that Sissy was breathing hard and they decided to go to the ER after getting Mr. Misty at the DQ on the way, by the way Sissy got blueberry which worried the ER staff who initially thought she was cyanotic. Anyway, in the ER she was breathing fast and working hard so she was given Albuterol nebs and some prednisone which she vomited twice so she was enrolled in Steve Gordon's asthma study and given Dexamethasone. She was OK on q2 nebs so she came to the floor where she is still on q2 but looking a little better. Here on the floor, she was breathing around 68 breaths per minute and was having a hard time talking but she looked otherwise well and in no distress. Her immunizations are all current but mom is not sure if she should get the new heptavalent pneumovax. Currently, mom says that she can talk in five word phrases and she easily walks up and down stairs unassisted. Her exam on the floor is as follows. HR 118, RR 50, BP 111/68, head circumference 50 cm. Today, I think we should consider spacing her nebs to q3 hours in preparation for early morning discharge tomorrow since I know we are in a bed crunch.
Good:
This is a three year old moderate-severe asthmatic female who presented to the ER at 8 pm last night after having an increased work of breathing for one day that was refractory to Albuterol q3 at home. This is her fourth hospital admission, no PICU admissions, and no intubations. Her home regiment includes Albuterol nebs PRN, Flovent 44 mcg with spacer and mask BID and PO prednisone PRN severe exacerbation. Her triggers include cats, seasonal allergies and cold weather. Her mother and brother are also sever asthmatics.
In the ER, her respiratory rate was 68 and her O2 sat 90% on room air. Her exam revealed diffuse wheezing and pan retractions but was otherwise unremarkable. She was given IM Dexamethasone as per Dr. Gordon's protocol; Albuterol with Atrovent times three then two Albuterol nebs q2. Her respiratory distress improved significantly and she was admitted to 10 South for further management.
On the floor her respiratory rate was between 35-40, O2 sat greater than 98% with 1 liter nasal cannula O2, wt=14 kg (59th %). She continues to have diffuse wheezing but now has only a little nasal flaring. She continues on Albuterol q2 but appears to be in less distress this morning.
Today, I want to continue her nebs at q2, continue her steroid regimen and get Pulmonary to consult for asthma teaching.
A complete History and Physical must be obtained with the resident on the floor and written up for Dr. Miller and the teaching resident.
Presentation of morning rounds must be focused and concise. Specifically:
Give a one-line introduction with: age, sex, diagnosis(es)
Brief HPI with chief complaint, length and type of symptoms, medical interventions (if any)
ER course: Vital signs, exam in ER, interventions
Floor course: Exam if different from ER, interventions
Your plan: Medical management, studies required, etc.
Concise, effective presentations are very difficult to synthesize. To help you do this, use the intern who is assigned to the patient to figure out what information is pertinent, and give a trial run of your presentation to him or her.
You should practice your presentation and time yourself. The goal is less than two minutes! Remember to include what you feel are the PERTINENT positives and negatives. Your senior resident will ask specific focused questions if they require more information. Again, let me emphasize that we realize this is a difficult task. If you feel uncomfortable or unsure, talk to one of the seniors on your team and they can guide you through your specific areas of concern.
Examples:
Bad:
This is a three year old cute little girl who has been having a hard time breathing for awhile now. She has a doctor who manages her asthma with a bunch of different medicines but things weren't going so well, so she came to the ER with her Mother, sister, and baby doll, Mrs. Bigglesworth. Apparently, she has been in the hospital before with this and mom says she misses a lot of her preschool because of her wheezing. Mom things that she is worse in the spring but she was a little fuzzy on that point. So today after ballet class mom saw that Sissy was breathing hard and they decided to go to the ER after getting Mr. Misty at the DQ on the way, by the way Sissy got blueberry which worried the ER staff who initially thought she was cyanotic. Anyway, in the ER she was breathing fast and working hard so she was given Albuterol nebs and some prednisone which she vomited twice so she was enrolled in Steve Gordon's asthma study and given Dexamethasone. She was OK on q2 nebs so she came to the floor where she is still on q2 but looking a little better. Here on the floor, she was breathing around 68 breaths per minute and was having a hard time talking but she looked otherwise well and in no distress. Her immunizations are all current but mom is not sure if she should get the new heptavalent pneumovax. Currently, mom says that she can talk in five word phrases and she easily walks up and down stairs unassisted. Her exam on the floor is as follows. HR 118, RR 50, BP 111/68, head circumference 50 cm. Today, I think we should consider spacing her nebs to q3 hours in preparation for early morning discharge tomorrow since I know we are in a bed crunch.
Good:
This is a three year old moderate-severe asthmatic female who presented to the ER at 8 pm last night after having an increased work of breathing for one day that was refractory to Albuterol q3 at home. This is her fourth hospital admission, no PICU admissions, and no intubations. Her home regiment includes Albuterol nebs PRN, Flovent 44 mcg with spacer and mask BID and PO prednisone PRN severe exacerbation. Her triggers include cats, seasonal allergies and cold weather. Her mother and brother are also sever asthmatics.
In the ER, her respiratory rate was 68 and her O2 sat 90% on room air. Her exam revealed diffuse wheezing and pan retractions but was otherwise unremarkable. She was given IM Dexamethasone as per Dr. Gordon's protocol; Albuterol with Atrovent times three then two Albuterol nebs q2. Her respiratory distress improved significantly and she was admitted to 10 South for further management.
On the floor her respiratory rate was between 35-40, O2 sat greater than 98% with 1 liter nasal cannula O2, wt=14 kg (59th %). She continues to have diffuse wheezing but now has only a little nasal flaring. She continues on Albuterol q2 but appears to be in less distress this morning.
Today, I want to continue her nebs at q2, continue her steroid regimen and get Pulmonary to consult for asthma teaching.
Monday, May 4, 2009
Day 6 and 7
First call. probably good that i can't really twitter or fb in hospital. but many observations over 30 hours lost. maybe for better?
it was quiet for trauma. the ER was mostly full of non surgical stab wounds and DTs and the like. But after 8 pm two appendicitis cases. I scrubbed in on both.
I felt dorky for admitting it-these are bread and butter surgeries and laparascopies to boot--but how can i resist being insanely excited at my first OR experience? I wore gowns, double gloved, had a mask, got yelled at by the scrub nurse--everything i dreamed of! that beep beep of vital signs, the inappropriate jokes by the anesthesiologist. I even got to suture one of the ports. However i did a terrible job and we had to steristrip it (its only a 1 cm scar, i promise!)
tried not to be irritating to the residents, but they taught a lot. got to sleep 3 hours, more than most of the other medstudents this week
prepped for presentation at GI/surg conference but a surg resident did it instead, which is good bc his was much better. i got excited and spoke up, but it felt funny, a sense of breaching hierarchy. should make note of this in future--not so much to cease as to proceed with caution.
Felt pretty shitty and out of it for rest of day. Really tired, really hungry, feet hurt, back hurt, was kind of smelly, tried to speak coherently, but felt good in a deeper way, like i was doing something really tough like travelers and military and well, surgeons, do.
Biked home. took best shower in a long ass time.
it was quiet for trauma. the ER was mostly full of non surgical stab wounds and DTs and the like. But after 8 pm two appendicitis cases. I scrubbed in on both.
I felt dorky for admitting it-these are bread and butter surgeries and laparascopies to boot--but how can i resist being insanely excited at my first OR experience? I wore gowns, double gloved, had a mask, got yelled at by the scrub nurse--everything i dreamed of! that beep beep of vital signs, the inappropriate jokes by the anesthesiologist. I even got to suture one of the ports. However i did a terrible job and we had to steristrip it (its only a 1 cm scar, i promise!)
tried not to be irritating to the residents, but they taught a lot. got to sleep 3 hours, more than most of the other medstudents this week
prepped for presentation at GI/surg conference but a surg resident did it instead, which is good bc his was much better. i got excited and spoke up, but it felt funny, a sense of breaching hierarchy. should make note of this in future--not so much to cease as to proceed with caution.
Felt pretty shitty and out of it for rest of day. Really tired, really hungry, feet hurt, back hurt, was kind of smelly, tried to speak coherently, but felt good in a deeper way, like i was doing something really tough like travelers and military and well, surgeons, do.
Biked home. took best shower in a long ass time.
Saturday, May 2, 2009
Day 6
had day off. spent previous night with bf eating frozen pizza and salad.
Day 5 examined first prison patient. Remarkable for being unremarkable. Had a lump in his butt. Officer left the room during the butt exam, which caused some distress, but distress was unfounded. In general, first time examining a real patient's butt (although not a real rectal exam). Turns out to be equally weird as examining their chest, head, etc, but not weirder. Slightly weirder trying to remove someone's orange prison pants beneath their shackles, since they are handcuffed and can't remove their own pants. patient was regular, not weird or violent, and that was helpful. Two male genital exams have both been less weird than majority of female exams, but then also less invasive. I hate pelvic exams too.
afternoon spent suture workshop, practice sutures on decomposing pig feet. gross
Day 6 maybe have a cold. Went to capoeira anyway. still really out of shape, so weird to be desperately breathless--for some reason it is so beautiful and i love it, when i think about pts with COPD or intubators, and the reason i can't breathe is because i did 30 cartwheels, not because my lungs are not viable. It is frivolous and i am so grateful for the frivolity, for my health, for breath, which can leave us anytime. we all become patients one day.
Day 5 examined first prison patient. Remarkable for being unremarkable. Had a lump in his butt. Officer left the room during the butt exam, which caused some distress, but distress was unfounded. In general, first time examining a real patient's butt (although not a real rectal exam). Turns out to be equally weird as examining their chest, head, etc, but not weirder. Slightly weirder trying to remove someone's orange prison pants beneath their shackles, since they are handcuffed and can't remove their own pants. patient was regular, not weird or violent, and that was helpful. Two male genital exams have both been less weird than majority of female exams, but then also less invasive. I hate pelvic exams too.
afternoon spent suture workshop, practice sutures on decomposing pig feet. gross
Day 6 maybe have a cold. Went to capoeira anyway. still really out of shape, so weird to be desperately breathless--for some reason it is so beautiful and i love it, when i think about pts with COPD or intubators, and the reason i can't breathe is because i did 30 cartwheels, not because my lungs are not viable. It is frivolous and i am so grateful for the frivolity, for my health, for breath, which can leave us anytime. we all become patients one day.
Thursday, April 30, 2009
Day 4
First rounds this morning. Start at 6 am. The ICU is still a little bit scary. Doesn't end til 930 am. People seem disgruntled that the med students (us) are not doing what they are supposed to be doing, even though they realize we do not know what we are supposed to be doing.
We are supposed to be removing and replacing surgical dressings. We have to figure out how to do this by tomorrow at 6 am.
The rounds go until 930 am. The senior resident is dashing and charming and it is amazing how intimately he knows each of the 40 patients. The interns are post call and irate. We stay out of their way.
The clinic is over flowing. They are depending on us to keep the flow, even though at this point we cause more delay than speed. There is only one attending. Patients wait for 3 or 4 hours shivering in their gowns.
I examine a mans genitals with great authority. He has an enormous hernia and a painful swelling of his testicles. His penis is retracted. He is an ex-con, a "street warrior," his skin scarred and bruised from knife fights and heroin skin popping. He has an odd affect, a mood disorder. He follows my directions. I examine him with gloves. When i return the attending examines him without gloves and has me do the same.
I watch a pretty nurse practitioner who is about my age, expertly pull a drain from a man's stomach. She is someone like me--a normal person, a young person--but her hands and her brain are like magic. She helps me figure things out and i am grateful for her patience.
We do not end for several hours. At 2 i realize it has already been an 8 hour day.
I receive an email from a star graduating student who responds to my fretting about the future. She tells me not to fret. I believe her. She tells me to work really really hard. I believe her.
We are supposed to be removing and replacing surgical dressings. We have to figure out how to do this by tomorrow at 6 am.
The rounds go until 930 am. The senior resident is dashing and charming and it is amazing how intimately he knows each of the 40 patients. The interns are post call and irate. We stay out of their way.
The clinic is over flowing. They are depending on us to keep the flow, even though at this point we cause more delay than speed. There is only one attending. Patients wait for 3 or 4 hours shivering in their gowns.
I examine a mans genitals with great authority. He has an enormous hernia and a painful swelling of his testicles. His penis is retracted. He is an ex-con, a "street warrior," his skin scarred and bruised from knife fights and heroin skin popping. He has an odd affect, a mood disorder. He follows my directions. I examine him with gloves. When i return the attending examines him without gloves and has me do the same.
I watch a pretty nurse practitioner who is about my age, expertly pull a drain from a man's stomach. She is someone like me--a normal person, a young person--but her hands and her brain are like magic. She helps me figure things out and i am grateful for her patience.
We do not end for several hours. At 2 i realize it has already been an 8 hour day.
I receive an email from a star graduating student who responds to my fretting about the future. She tells me not to fret. I believe her. She tells me to work really really hard. I believe her.
Wednesday, April 29, 2009
Day 3
Grand rounds are boring
Found out board scores. Yay i passed. Sob, my score is lame.
Fret about future.
Thrown into clinic. Handed charts. Examine. Attending is mildly frightening. Patient gets off cell phone when i enter; "can't talk, the doctor is here." He meant me?! Attending turns out to be kind of really cool. Learn more in 2 hours then in 2 weeks. Survive.
Home. Fret about future. Decide to push on.
Found out board scores. Yay i passed. Sob, my score is lame.
Fret about future.
Thrown into clinic. Handed charts. Examine. Attending is mildly frightening. Patient gets off cell phone when i enter; "can't talk, the doctor is here." He meant me?! Attending turns out to be kind of really cool. Learn more in 2 hours then in 2 weeks. Survive.
Home. Fret about future. Decide to push on.
Tuesday, April 28, 2009
Day 2
More orientation. Does not begin till 10, even though i woke up at 6 and tomorrow i will wake up at 430.
there is still much hope in the air.
feel like the hardest part of med school is letting go of one's particularities of previous identities--namely, that of ditzy intellectual, which was a fun role to try to develope. its not as funny to have a ditzy doctor. its kind of scary. but changing such a thing brings up profound difficult questions of identity, habitus, and change. did i once develope such a role as one puts on garb, an arbitrary pair of pants found in the free bin--or did it seem a good way to deal with the fact that i have terrible short term memory? Is it essence or is it mere garb one puts on and off a deeper essence? is there no essence at all, this illusion of self?!
no time for difficult questions! have to review abdominal vasculature.
there is still much hope in the air.
feel like the hardest part of med school is letting go of one's particularities of previous identities--namely, that of ditzy intellectual, which was a fun role to try to develope. its not as funny to have a ditzy doctor. its kind of scary. but changing such a thing brings up profound difficult questions of identity, habitus, and change. did i once develope such a role as one puts on garb, an arbitrary pair of pants found in the free bin--or did it seem a good way to deal with the fact that i have terrible short term memory? Is it essence or is it mere garb one puts on and off a deeper essence? is there no essence at all, this illusion of self?!
no time for difficult questions! have to review abdominal vasculature.
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