Day 2 After day 3 (day 2 of actual work) I can say I'm having a lot of fun. My team is pretty crazy - made up of an upper level medicine resident (pgy-2, I think) and two interns - one of which is an EM intern (the one with which I'm working) and another medicine intern (the one with which my girlfriend is working). So far, as I said, everyone has been really cool - we all get along famously - joking and laughing until we almost don't get anything else done.

Medicine, overall, is pretty boring. You go to work in the morning (about 0700 here, which isn't too bad) and you see your patients. Then you call your intern (if you're a student. If you're an intern, you call your upper-level) and round again, evaluate their status and write orders for the day. After you're done, your intern calls the chief (upper level) and says you're ready to round with the chief and the attending (the boss who oversees the care and is responsible for the patients on the team). Then, you round again. Finally, after you round with the attending and chief, you go back around and make sure everything is taken care of for your patients, await consults, and lab/test results that you ordered earlier in the day.

At this program, there is a lecture/presentation series almost everyday at noon, so you have to finish rounding before then. Also, mondays and thursdays, there are lectures for the students by the director of medical student education and the chief Medicine resident. These are over various topics. Yesterday (we had the lecture on tuesday since everyone arrived a little late on monday) we talked about pulmonary function tests (PFTs) and ventilators, which was pretty nice, since ventilator settings are important to know for any physician.

So, that's how we've begun this new month. I'm on call saturday for the first time. Of course, we're changing teams on saturday as well, so I don't know how the new team will be. Hopefully as cool as this one. I have my fingers crossed.  ¶ 7:03:00 PM 0 comments

  In Bethlehem No, I haven't taken a trip to the middle east - I don't see the Tigris or the Euphrates anywhere nearby. I'm in Pennsylvania. Although Bethlehem, Pa touts itself as the "Christmas City" of the west, so far I have seen no children in mangers or wise men (crazy men talking to themselves I have seen, however).

Why am I way up here, so far from home? Well, I'm doing a rotation in Internal Medicine at St. Luke's Hospital, that's why! I wanted a rotation in the ICU, but I didn't get it - the best they could offer is IM, so I took it. Also while I'm up here, I'm interviewing at a few programs in the area (which is almost all of the ones I've applied to).

St. Luke's is a medium sized hospital (Link here) in, as I said above, Bethlehem, Pennsylvania. There is a smaller sister hospital in nearby Allentown, Pa that is practically a separate entity. There are several residency programs at St. Luke's, including an Osteopathic Internship, for which I am applying. There are also Internal medicine, Emergency Medicine, Surgery, and Ob/Gyn, among others.

I was kind-of nervous when I first arrived here; I'm always nervous when starting something where I am going to be constantly watched. That is exactly what I am walking into: Since I am applying at this program, this rotation becomes like a month-long job interview, which increases the stress tenfold. Of course, first off I meet the program director for the internship, unexpectedly, and I'm wearing comfortable clothes I'd been driving in for almost 4 hours from Washington D.C., so I look like I've been on the road, I'm sure. Not a wonderful first impression... strike one...

No stress here at all, right? No worries, though. I get moved in to the dormitory (!!) where they have all medical students staying. What they don't tell you, though, is that the dorm also houses the resident nursing students who are quite hostile toward the medical students, for some reason, and treat us all as third-rate citizens.

But I've made friends already, which is nice. A couple of students from Temple (one of the medical schools in Philadelphia) were also checking in at the same time as me and we were talking and stuff. They seem pretty ok, even if a little overexhuberant.

I'm hoping for a great month. So far, I'm just really nervous since I don't know where anything is - in the hospital AND in the city in which I find myself.  ¶ 7:44:00 PM 0 comments

  Another one bites the dust! Well, I finished my final shift in the ED today... I'm sad, but happy in another way. I had a lot of fun on this rotation, even if there isn't a residency program there. I saw a lot of people I hadn't seen in several years - which was nice - and met a lot of really cool people. That means the staff, not the patients.. Just kidding. The patients were typical ED patients: Some real patients with real problems, others real patients with what they think are real problems, and the others that are fake patients that make up problems to get something that they want.

Saw some really interesting stuff tonight, though. When I first arrived at the ED, the trauma team was working over this patient who had come in "all swollen up" after a fall a couple of days ago. I was working with GruntDoc tonight, and I'm sure he'll have pictures of the CT (cat scan for you non-medically savvy people) on his site in the next couple of days. Check it out - it was really cool. Basically, this guy had air under his skin all the way from his neck, down past his pelvis. Not a good thing!

Another cool patient I saw was a 40-something hispanic male who came in complaining of nausea, vomiting, and upper abdominal pain. That's not the cool part - what was so weird is that on his chest x-ray, his entire left lung is a series of bullae - bubbles formed (usually from emphysema or other lung pathology) within the lung tissue and surrounded by very thin walls of lung. Typically, you'll see a few of these in the lung. This guy, however, had his entire lung replaced by bullae, which was pushing his heart and other central vessels over into the other side of the chest. Strangely, this guy wasn't having difficulty breathing - especially since the other lung was full of bullae.

Ok.. I'm tired now. I'm going to bed so I can get up tomorrow and get ready to go to Pennsylvania for a month. I have a lot to do!  ¶ 5:29:00 AM 1 comments

  The Dean's Letter The Dean's Letter is something medical students bemoan. Many think they are form letters - some I've seen or heard about have seemed to be that exactly - others think they are useless because what dean is going to say something bad about a student their institution has trained? That would make for bad press all around - "this is a poor student" or something similar begs the question from residency committees "Well why did you accept them to your program or not terminate them when you discovered they are a poor student?" This only causes a loss of faith in that school's students overall. Of course, if the dean extolls the student to high heavens, they are hired into a residency program and then suck - that's even worse... like I said - bad press.

This year, the Dean's Letter has been renamed the "Medical Student Performance Examination," or MSPE for short. I don't know why, it still serves the same purpose - to tell the residency director what the dean thinks of that student and allow the residency committee to have a "sneak peek" into that student's performance evaluations. Some postulate there is a "code" used by deans to secretly tell a residency director/committee what kind of candidate the student will be. Personally (and from the research I've seen showing how insignificant a factor Dean's letters are in the residency selection process), I think the code does not exist, or if it does, it is not widely attended to. Most articles I've seen place the Dean's letter lower than the top 5 priorities for residency selection. One of the highest is the interview or an "audition rotation" at the site or a letter from a person on an "audition" somewhere else. That means when you go on a rotation somewhere, you'd better lay it all out on the table. Same goes for the interview.

That said, below is the "evaluation copy" of my MSPE sent to me yesterday. I'll make comments in italics where appropriate:

-------------------------------------------------

September 20, 2005

Medical Student Performance Evaluation


JONETHAN DeLAUGHTER


IDENTIFYING INFORMATION

Prior to matriculation at UNTHSC, Mr. DeLaughter graduated from Angelo State University with an AAS degree in Nursing. While enrolled he was named to the University Dean’s List. Upon graduation Mr. DeLaughter worked as an RN for the next several years prior to his admission to medical school and also during his first two years. He is currently a fourth year student at the University of North Texas Health Science Center/Texas College of Osteopathic Medicine.

UNIQUE CHARACTERISTICS

After entering medical school, Mr. DeLaughter enriched his educational experience through participation in a wide variety of activities. He worked as a medical team member during the annual Cowtown Marathon and also a spent spring break working in Mexico providing healthcare to the indigent population of that region.

Nevermind all the other things I did in medical school - such as running EM related clinics every other month or attending numerous state and national meetings, volunteering with a sports medicine doc for a professional women's football team, etc.

While at the health science center Mr. DeLaughter maintained high academic standards. He has been named to the Dean’s List each semester. He has also been actively involved in leadership, serving as first year representative and later President of the Emergency Medicine Club. He was the Medical Student Section Student Coordinator for the Emergency Medicine Resident’s Association and is currently serving as Regional Coordinator for Region W3 of the EMRA’s Medical Student Governing Council. He is also a member of the following student organizations: American Osteopathic Association; American Medical Association; American College of Osteopathic Family Physicians; American Medical Student Association; Emergency Medicine Club; Emergency Medicine Resident’s Association; American College of Osteopathic Emergency Physicians – Student Chapter; American College of Emergency Physicians; Texas College of Emergency Physicians, American Academy of Emergency Medicine – Student Member.

ACADEMIC HISTORY

Expected date of graduation from Medical School:
May 20, 2006
Date of matriculation into Medical School:
August 5, 2002
Please explain any extensions, leave(s) of absence, gap(s), or break(s) in the student’s education program.
N/A

ACADEMIC PROGRESS

Preclinical/basic science curriculum:
The first year of the preclinical curriculum includes 80 percent basic science and 20 percent clinical science instruction and is devoted to learning the preclinical sciences in the context of patients’ clinical problems. Students move through a sequence of seven organ system courses designed around normal human structure, finishing the first year curriculum with the study of the mechanisms of disease. The second year includes 80 percent clinical and 20 percent basic science instruction and is devoted to learning the clinical sciences and osteopathic manipulative medicine and their relationship to basic science. This time the focus is on abnormal structure and functions in each of nine organ systems. At the completion of the basic science portion of the curriculum, Mr. DeLaughter’s cumulative weighted average was 94.34, which placed him 6 in a class of 123. His current cumulative weighted average is 94.27, placing him 3 in a class of 114.

The following are a sampling of grades from completed clinical clerkships. Core clerkships are reported in the order in which they were completed. All clerkships are completed with health science center faculty unless otherwise specified. When available, verbatim comments made by clinical faculty during the clinical experience are included.

MEDICINE: 97 John Peter Smith Hospital
This clerkship is eight weeks in duration. Comments were provided by two preceptors.
Excellent student
Good student

I think I can guess who made the second comment - a doctor with whom I had a severe personality conflict. He seemed to think that medical student = attending slave and also tried to make me break the law by giving orders to nurses over the phone. His rationale: "Well, you are a nurse, aren't you? You can relay an order from a physician to another nurse!" My response: "Sure, I'm a nurse, but I am not functioning as such in this setting, so it would be illegal for me (a medical student) to issue a medical order and have it followed without a physician signing off on it." He didn't like that at all and began yelling at me, saying he was going to have me failed.. yeah. See where that got him :)

CLINICS: 93
This clerkship is twelve weeks in duration.
Admissions committee scored 10/10 in accepting Jonethan to ROM. His previous life experiences as a nurse has aided in his clinical development and performance. Jonethan will make an Excellent clinician and will be an asset to the community he serves and to our profession.

I have no idea what "ROM" is. Family Medicine was a great rotation. I really enjoyed my time there and would highly recommend everyone I can to take a rotation with Dr. U.

SURGERY: 95 John Peter Smith Hospital
This clerkship is eight weeks in duration. Comments were provided by three preceptors.
A very good student and excellent bedside manner. He’ll be a good doctor.
Excellent knowledge site. Could use improvement in inter-personal skills. Patients have commented – “very distant”.
Hardworking in clinic and on call, very good at completing assigned tasks in a timely fashion. Good Attitude. Good clinical knowledge.

I found it funny how one comment was "excellent bedside manner" and the next says I have poor interpersonal skills. This is the anomaly I think every Dean's letter has - overall glowing comments and that one that just makes you say "huh?" Funny thing is, I never heard any complaints from patients, nor was I EVER reprimanded by a physician while on this rotation.

PEDIATRICS: 93
This clerkship is six weeks in duration. Comments were provided by three preceptors.
Excellent, knowledgeable student.
Sound clinical skills and effective communication.
Excellent Pe’s; Very good Hx’s; competent progress notes; excellent management plans; professional interactions with patients.

Pediatrics was fun. Kids are great, so long as you can give them back ot their parents when you're finished playing with them! I really enjoyed my time at the Peds clinic, though. The teachers are first-rate, even though the clinic is constantly swamped and usually 1-2 hours behind schedule.

OB/GYN: 92 Texas Tech University HSC-Odessa
This clerkship is six weeks in duration. Comments were provided by three preceptors.
Very helpful, eager to learn.
Eager to learn, well prepared, self-motivated. Great to work with.
Good knowledge. Pleasant, enthusiastic – Loves ER!

OB/Gyn was an interesting rotation, to say the least. This rotation was out in waaaaaaayyy West Texas. If you've seen the movie "Friday Night Lights" this is that town. Everyone is psycho about football. That and sex. There were so many pregnant teenagers out there, it was uncanny. I guess when your town doesn't even have a movie theatre you have to do something to keep yourself occupied. The residents out there were very interesting - most of them were foreign grads, as were most of the residents in all their programs. Nothing wrong with that - apparently this program is one of the most FMG friendly places in the state. It made for some interesting patient-physician dynamics, though.

PSYCHIATRY: 94 John Peter Smith Hospital
The clerkship is four weeks in duration.
Basic knowledge of psychiatry was excellent. He did readings/computer research on issues appropriate to the patient. He was very respectful of staff and patients which was reciprocated. He did an excellent job in obtaining detailed histories from families.

PRIMARY CARE PARTNERSHIP (FM): 100 Robert Sparks, D.O.
This four week clinical clerkship is performed in the office of a private practice physician.
This young man has rotated with me for the last 3 years and I have had students since 1978 – he is the best I’ve ever had. He may return anytime

Dr. Sparks ROCKS!!! I had a blast with him. He is really freaking hilarious and we had a great time and we still got a lot done. Spending time with him during the first 3 years of medical school helped me realize and understand that not all physicians have to be stuffy and boring. Thank you Dr. Sparks!!

MANIPULATIVE MEDICINE: 93
The clerkship is four weeks in duration.
S/D DeLaughter far exceeded expectations on this rotation. His knowledge, skills and attitude surpassed that of his classmates and he was a delight to work with.

My preceptor for OMM was great. Dr. G was super-cool. He was incredibly laid back and wonderful with his patients. No matter if the manipulations we provided changed a darn thing, every patient left feeling like a million bucks because of the way he interacts with them. Mucho kudos to you, Dr. G!

SUMMARY:
It is a pleasure to write a Deans letter for a top student. This is the case for student doctor Jonethan Delaughter. Jonethan has been a top performer here at the University of North Texas Health Science Center - Texas College of Osteopathic Medicine since day one. He has mastered his studies; giving him an overall GPA of 94.27 and a score of 735 on his COMLEX I National Board examination. This score placed Jonethan in the top 1% nationally of all examinees!!! Jonethan is a pleasure in the classroom, wards and in the clinics. He has been named to the TCOM Deans List because of his excellent performance.

Clinical evaluations all report Jonethan to be an excellent student with excellent diagnostic acumen and sound treatment plans. Jonethan performs way above expectations for a medical student and frequently outperforms residents at a higher level. Jonathan’s shelf exam scores on his NBME subject examinations were 100 in Family Practice, Internal Medicine, Pediatrics, and Surgery!! In Obstetrics he received a 96 and in Psychiatry it was a 94!! This is all quite an accomplishment.

I'm not so sure about "outperforms residents at a higher level..." I'm still just a student and am shielded from a lot of the crap residents have to deal with - and from my last couple of rotations, I've come to realize I have a lot to learn before I am a solid physician. I still tend to oversimplify things - when I think I've found the diagnosis (or something similar) I like to put on the blinders and go at it full force. Fortunately, the attendings I've worked with have always caught my mistakes and showed me where I went wrong. I need to stop doing that before I'll consider myself as good as a resident. I need to take a step-wise approach and make sure I have a good differential that I can work through before I plunge in. I've worked on that a lot this month in EM, and I'm getting better. Now, a lot of the time when I miss something, it's because I didn't see the connection at all (or forgot something very basic and completely screwed the pooch, so to speak). I'm still working on it, but it's a work in progress.

Jonethan exhibits natural leadership ability along with his excellent knowledgebase. He has been both a leader and member of a variety of student organizations and provided many hours of community service.

In summary, student doctor Jonethan Delaughter is an excellent student with exceptional potential. He has all the qualities for great success as a resident and beyond.

Ok, so here we go with the code: is "excellent potential" code for "ok, but needs work?" If so, I'd agree with that. I'm nowhere near as wonderful as this letter tends to make me sound. I'm slow, I am iffy on which studies to order a lot of the time, and sometimes I forget things. The last is what pisses me off the most: I'll know I know something, but I just can't connect A and B to make a coherent thought.. like a short circuit in my brain. Really gets my goat!!


Sincerely,

Bruce Dubin, D.O., J.D., FCLM
Associate Dean for Academic Affairs

After writing all this, I just hope a residency director/committee doesn't read it and get second thoughts. I really do work hard, and my head is in the right place. I'm just not done learning - no student is. If any tells you so, they're lying through their teeth. In fact, no physician should EVER stop learning. Medicine is an ever-changing field. If you stand still, you will be left far, far behind. I was told something the other day, and I'd heard it before:

A speaker at a medical school graduation said this to the graduating class, "If you're worried at all you've forgotten over the past four years, don't fret - studies show that half of what you've learned in medical school is wrong, and the other half will be outdated or proven wrong in the next 5 years. The problem is, we don't know which half is wrong now!"

See the point?
  ¶ 12:15:00 AM 0 comments

  A couple of days later Well, it's been a couple of days and I've received a couple more interview offers: One from Reading Hospital in Reading, Pa and another that I received today from Wilson Memorial Hospital in Johnson City, NY. So, in one week of certifying my application I have 3 interviews out of a total 12 programs to which I applied.

Now I just need to figure out how the whole interview system works. I'd like to take care of as many of these as I can while I am up in Penna next month, but I don't want to miss my entire rotation for interviews. I also don't want to have to keep going back and forth between Texas and New England for interviews. People that apply locally have it easy! If only I were interested in staying here :)

I'm really excited about interviews, though. A little nervous nonetheless, but excited. I've never been one to try to sell myself to a company or program. I like to go in, talk a bit, and get to know everyone. I always feel like interviews are about selling yourself, and that makes me feel like a used-car salesman. I know it is expected of applicants to be bouncy and overzealous. I just wonder how they will view a down-to-earth, low key guy. I hope it's not bad. I have great numbers and a solid app, so maybe that will give me the opportunity to be a little more low-key than some.  ¶ 11:37:00 PM 0 comments

  What a relief! Well, I just had a huge weight lifted off of my shoulders - I received my Step II USMLE scores in the mail today. I knew they were out, since my ERAS profile had been updated 3 or 4 days ago.. it was just a matter of time.

Why the huge relief? Because I did well - using the z-score conversion site at MedFriendly to determine my actual percentile shows that my score is in the 94th percentile nationally for this test administration.

How did I determine the percentile when it is not given on my score report? Easy, I calculated the z-score (a score that tells you how many standard deviations away from the mean your score is) with the following formula:

z = (x - mean)/sd

where x = YOUR SCORE, mean = TEST MEAN, and sd = STANDARD DEVIATION as provided by the test administrators. After the z-score is calculated, look at the table on the above page and voila! Your standardized test score calculated to a percentile!

Anyway, if I didn't have to work at 1700, I'd go out and drink tonite! What a relief!  ¶ 3:39:00 PM 0 comments

  First Interview invitation 9/14/2005
Dear Mr. DeLaughter,
Thank you for your interest in the Internal Medicine Residency/Traditional Rotating Internship Program here at St. Luke's Hospital-Bethlehem. It is my pleasure to offer you an interview for a position in our internship class for the 2006-07 academic year. If you are interested in scheduling an interview, please contact our administrative assistant, Ms. J.B., at 555-555-5555, or e-mail at changed-email@slhn.org

Once again, thank you for your interest, and we hope to see you soon.

Sincerely,

J. E. P., D.O.
Internal Medicine Faculty
St. Luke's Hospital-Bethlehem

---------------------------------------------------------------------------------------

I received this email today (without the alterations). I was freaking stoked! I looked at the email, and then looked at it again to make sure I had read it correctly. Then I checked to make sure I was logged in to my email account, and then I looked at it again. Not that I'm paranoid or anything.

After the initial shock/surprise wore off, I was able to actually comprehend what it said and I became worried. I applied for an internship position, not a position in an Internal Medicine residency. So I emailed the person indicated in the email to clarify before I take the interview. I'd be unhappy if the internship tracked directly into the residency, because nowhere on their website or on the ERAS application does it say it does so - and also this hospital is one of the one's I'm really interested in for my internship.

We'll see, I suppose.
  ¶ 8:23:00 PM 0 comments

  ERAS completed Well, I finally finished my ERAS application, submitted it, and applied to 12 programs. Currently, I am waiting on the school to upload my letters of recommendation and the NBOME to upload my COMLEX scores so my file will be complete. I am also lacking a letter of recommendation or two before I am done.

I plan on asking a couple of the docs in the ED where I am currently rotating to write me letters. I don't think they will refuse, I just hope they can write them quickly so my file will be completed. My biggest problem was that I never worked with one doctor in IM (one month I did, but shortly after that month, he disappeared after the hospital he worked at closed), so I was unable to get a letter from a Medicine attending. I got a letter from a Family Med and Surgery attending. As I said, I'm planning on 1 or 2 from this EM rotation, and maybe one from my IM rotation next month - which may be too late for residency interviews.

Anyway - the waiting game has begun. The quest for an internship continues. I hope the result is satisfactory. I am a great candidate, even if I say so myself! :)  ¶ 6:41:00 AM 0 comments

  "Holiday Heart" makes national news headlines Heavy Drinking Linked to Heart Rhythm Problem in Men from Yahoo! News.

Ever heard of "Holiday Heart?" The story goes something like this: A young man, typically college age (18-24) comes in to the Emergency department or his PCPs office (more likely the ED though) after a night of heavy drinking because his "heart is beating irregularly" or is "beating out of his chest." He has no significant cardiovascular history or other medical problems.

When the patient is placed on the cardiac monitor, he is noticed to be in atrial fibrillation and everyone freaks out because a young man should not have A-fib. What they don't know is why he is in A-fib. The answer is simple: Ethanol (the alcohol in beer and other commonly imbibed liquors) is cardiotoxic, as well as being toxic pretty much every other body system. In high enough doses, it interferes with the electrical conduction of the myocardium, resulting in a-fib and sometimes other fun arrhythmias. The cure? Stop drinking and study so you don't have to work at McDonald's flipping burgers.

Exactly why this is a national news story, I don't know. People have known about this for years. I guess every now and then we have to be reminded of how stupid people really are.

The really ironic thing is that while heavy drinking may result in arrhythmias like a-fib (which, as pointed out in the article, may cause a blood clot to form in the atria), it also results in cirrhosis and liver damage, which paradoxically causes a coagulopathy - so, if you drink long enough and heavily enough you might have a-fib, but you won't have to worry about clotting your blood!

Funny, eh?  ¶ 6:18:00 AM 0 comments

  Kharma? Baby Born to Brain-Dead Virginia Woman Dies

I love technology, I really do. I install new software, re-install operating systems, and upgrade the things all the time it seems (probably more than I really should). I really love it. However, especially when dealing with medicine and nuclear weapons technology, I realize one thing: Just because we CAN do something, doe not necessarily mean we SHOULD.

Here's the scenario - this woman in Virginia was diagnosed with malignant melanoma with metastases to the brain. As if this wasn't bad enough, her metastases caused her to have a stroke and become essentially brain dead. I'm thinking, "Oh no. Not another Terry Shiavo case!!" as I tear my hair out. Of course, she's pregnant and of course her family decides to keep her alive, not because they believe she will recover, but because they want to use her body to carry the baby until it can be delivered.

It was at this point that I got pissed.

First of all, the lady is dead. Let her die in peace. Just because she is pregnant, it doesn't give you the right to use her body as an incubator to hatch your eggs, only to be tossed aside after you get what you want.

Does noone see anything wrong with this? A woman is 15 weeks pregnant, 25 (!!!!) weeks pre-term, when she has a stroke, and we keep her "alive" for 3 months, at which time the baby is 27 weeks along - still very very very very preterm. So, at what point did we think this was a good idea? The mother is dead, the baby has about a 50% chance of dying, and still we provide millions of dollars of medical care to make this happen. Jesus Christ. What a waste of precious resources!

From the wording of the story, it sounds as though the kid got NEC - necrotizing enterocolitis, a condition common in extremely premature infants/fetuses. This is a condition where the childs' intestines begin to rot away in situ. It is very frequently fatal, regardless of treatment - but it can be treated with emergent surgery.

Anyway, the kiddo dies today, and I'm left to wonder; even after millions of dollars worth of care given to the mother, then another million spent on the kids' care, has the universe righted itself and taken back into itself what we tried to keep for ourselves?

I'm also left to wonder who is going to pick up the tab? I never agreed to keep this woman alive - I shouldn't have to pay for it.  ¶ 12:24:00 AM 0 comments

  Been busy I haven't updated here in a few days, I see. I've been busy updating all my other blog pages - see the links on the side bar. I've completely moved my old blog entries here, so now the past year of blathering is available all in a one-stop-shop of hell :)

Ok, ok.. enough.  ¶ 12:18:00 AM 0 comments

  An update Well, I'm almost 2 weeks into my EM rotation, and it seems I've lost count of all the procedures I've done. At first, it was easy - a LP here, I &D there, suture that patient's lac over there - but after everyone gets used to you being around (and willing to help), they start handing you procedures like crazy. Not that I mind - I like doing procedures, and I need the practice so I can get better at them.

Anyway, I've worked nine shifts now (I think) and I'm getting more comfortable with how things are flowing. I'm still not nearly as fast as the physicians, but I don't have nearly as much practice as they do (and I don't have a scribe following me around to write everything down, either), so I'm not sweating it. I still see patients in between 5 and 10 minutes, which I think is pretty good timing for an ED visit. I'm also able to come up with a pretty good differential and tell the attending the plan I'd recommend for evaluation and treatment of the patient.

Needless to say, I've gotten better at all the procedures they've let me do - suturing, central lines, I&Ds, etc. I'm not perfect (and I'm still pretty slow), but I'm improving and I'm gaining confidence. All the physicians have been very complimentary of my abilities so far. I've not had any discouraging remarks from anyone.

Maybe I'm doing the right thing after all.  ¶ 6:09:00 PM 0 comments

  My night at the shelter I spent last night in one of the local shelters here in North Texas working in the medical area along with another medical student, a physician, and a nurse. Our purpose was to medically clear any new evacuees coming to the shelter as well as tend to the medical needs of the 400 or so people already staying at the shelter. As it would turn out, most of our aid went to the latter group, as we saw only 2 new evacuees come in to the shelter all night long, despite rumors of several more buses coming overnight.

About the shelter: One of the local auditoriums was converted into a makeshift shelter, with televisions, basketball goals, and tables/chairs as a makeshift dining area on one side and hundreds of mattresses on the other side to make a large communal bedroom. Apparently, the day I arrived (Labor day), volunteers had been busy getting children registered for school the next day, as there were signs everywhere.

Overnight, things were pretty quiet. The two new evacuees arrived several hours apart, an aside from being travel-weary, hungry, and dehydrated, were in pretty good shape. Then, there were the evacuees already residing at the shelter.

Most, I think, wanted someone to talk to more than medical care, as they all seemed desperate for attention. The longer you were willing to sit and talk with them, the happier they became and they seemed more at ease. Many had difficulty sleeping, a few had other medical problems that needed tending to. Others only needed reassurance - all, in fact, needed reassurance that they were safe and help is available.

So, that was my night at the evacuee shelter. Nothing too exciting - just trying to do my part to ease the suffering of the thousands displaced from their homes. Hopefully I accomplished something there.
  ¶ 9:09:00 AM 0 comments

  Helping Katrina's Lost As everyone knows, hurricane Katrina hit the gulf coast this past week, causing billions in estimated damage and an unknown number of deaths. In addition, thousands of people were stranded in Louisiana and Mississippi during the storm. Afterwards, it has become a nightmare situation over there. For the past three to four days, helicopters and buses have been taking people out of the hurricane-ravaged areas to nearby states. Living in northeast Texas, we have been getting plane- and busloads of refugees for the past 3 days: all hungry, dehydrated, and with various physical and mental ailments.

Physician and humanitarian groups in the area have been called to help with the displaced citizens of Louisiana, and my medical school has put out a distress call to its students as well asking for volunteers. As a result, I will probably spend tomorrow night doing whatever it is that I can to help those whose lives have been ravaged by mother nature's last assault.

Afterwards, I will leave an account of all I see and experience; both for my remembrance and as a testament to those who have never seen the toll a disaster can take on a life.  ¶ 4:21:00 PM 0 comments

  Pelvic night I worked with Dr. R again last night. Again, had a good night - was pretty busy, but that makes the night go faster, so it was enjoyable all the same. I just think I really like being back in the Emergency Department. I didn't realize how much I'd missed it until now. Ah, fate.

As you can see from the title of the page, last night was pelvic night. I saw 2 patients that I know had pelvic inflammatory disease (PID), and a couple others that probably do. What fun, eh? What is PID? Bad, that's what. Basically, it is when you have an STD (usually chlamydia or gonorrhea) that travels up the uterus and fallopian tubes growing and causing inflammation the whole way up. Sometimes it is generalized, involving both the uterus, fallopian tubes, and sometimes the abdominal cavity, sometimes it is localized, involving only one of these structures. Never is it good, however. PID can cause bad things like infertility, increased risk of ectopic pregnancy, and sometimes death if it's bad enough. Check out the link to the right (emedicine) for more information. Fortunately, PID can be treated, fairly effectively if caught early enough.

Bottom line: Remember that whoever you are having sex with - you're having sex with them, and everyone they've ever had sex with IN THEIR ENTIRE LIFE! It might be more prudent to just keep your legs closed until you're sure you and your partner are clean. This isn't the time to be messing around with sex. What you don't know can most definitely hurt you!  ¶ 11:40:00 AM 0 comments

  Emergency Medicine: Days 3 and 4 Well, I missed posting yesterday - by the time I got off at 0500, I was really tired and I knew I would need to get to sleep pretty quickly, since I had to go to work today at 1700. Yes, that means I was off only 12 hours today. Not so bad, actually... I only slept about 5 hours and then was up again.

Last night (8/31-9/1/05) was pretty cool. I saw a bunch of patients and also had a couple of new procedures. I promise I'll explain these procedures and stuff someday soon. I was working with the same physician that I worked with the first 2 days - Dr. K. I really like working with him, except that he is psycho fast when seeing patients. He would see about 10 patients to my 1. It makes me feel really freaking inadequate and stupid; or maybe he is just really wicked-freaking fast, since it only takes me 10-15 minutes to see a patient as it is. I"ve been told he is just really wicked-fast. At the end of the night, he asked me if I was working with him again, and I told him I had two more shifts with him this month. He was very complimentary, which is awesome! At least it seems I am doing something right. So, the night was cool - I did 2 more LPs, an I&D, and sutured a simple lac on a patient's forehead. Not too bad; no central lines, chest tubes or reductions though. Hopefully, I'll get to do some of those before the month is over. I'm thinking of taking an extra shift on Labor day - I'm sure there will be plenty of trauma THAT night!

Procedure List (Day 3):
- I&D: 2
- Central Line: 1
- Simple Lac repair: 1
- Lumbar Puncture: 5
- Staple Application: 1

So, today I went in at 1700 and worked with another physician, Dr. R. I was a little nervous working with a new physician, but it turns out I needed not be worried. I was actually given more autonomy than I had with Dr. K; so, in a way, I had a better time, since I had some followup on my patients and I wasn't a complete procedure-bitch today. Not to say I didn't have some procedures, just not 5 hours worth :)

I saw a really freaking sick guy today. He was diagnosed with HIV 12 years ago and never really took any antiviral medications since then - he would go one week on or so and then take a couple of months off. His last viral load and CD4 count were about 1 year ago and he thought his counts were 150,000 and 101, respectively. Anyway, he came in yesterday evening with a fever, productive cough, and progressive dyspnea for the past two weeks. He also had extensive oropharyngeal thrush for the past 2 - 3 weeks, which has been progressing. Pretty sick fella. On exam, he was tachycardic with rales and rhonchi in bilateral lungs. He also had horrid thrush in his oropharynx and leukoplakia on his tongue. We worked him up: CBC, Chem7, blood and sputum cultures, and chest x-ray, and started him on some antibiotics. When everything came back, his CXR showed bilateral lower lobe infiltrates and peribronchial edema. His labs weren't overly impressive, but his neutrophil count was elevated, his lymphocyte count was depressed (not surprising, considering he has HIV). He was admitted to medicine for treatment. I feel kind of sorry for him - but then again, he did make the decision to forego treatment.

Today I did a complex repair of a guy's arm - he had an accident with a bush trimmer. Oops. So, I did a 3 layer closure - first I repaired the fascial covering of his extensor muscles, then a deep subcutaneous/dermal closure and finally a skin closure. Not too bad - it even looks like it will heal nicely. Not too bad for my first major lac repair.

What else did I do? I drained a dental abscess - possibly the most disgusting thing I've seen in awhile. Something about pus draining into someone's mouth... yummy! I also did an I&D on the leg - a "spider bite," which is only very infrequently actually a spider bite. Usually it is in fact a folliculitis - an infection in a hair follicle, that is often caused by S. aureus - a bacterium that normally grows on your skin and in your nose.

I'm really loving EM, as I suspected I would. Career decision confirmed.

Procedure List (as of Day 4):
- I&D: 4
- Central Line: 1
- Simple Lac repair: 1
- Complex Lac repair: 1
- Lumbar Puncture: 5
- Staple Application: 1  ¶ 1:18:00 AM 0 comments