My new toy and clerkship

I decided not to get an iPhone for clerkship. It was going to be too expensive to pay for a data plan that would let me surf as much as I knew I would want to plus let me keep the couples plan I have. Instead, I went with an iTouch, 1st generation, 16G. I got it second hand from a class mate at a great price. It's beat up but works very well and I love it.


I've added a lot of programs to it, which means I've also spent a lot of money on the resources. I still think it was a good idea. There isn't a lot of practical info on which programs work best for med students doing their clerkship. I'm going to throw my opinion into the mix.

The 3 apps I used most often on CTU were Diagnosaurus, 5 Minute Clinical Consult and Dr. Drugs.

Scenario, my Senior Medical Resident pages me with the following..."Hi Imposter, I have a 58 year old female in emerg with hyponatremia and decreased level of consciousness. Please come down and do the admission to your team."

I'd start with my Diagnosaurus app and look up the Differentials for hyponatremia and decreased LoC. I used those lists to direct my questions, physical and investigations. Diagnosaurus lets you look things up according to symptoms (like hyponatremia) or disease (like renal tubular acidosis. It also has things divided by organ system which I didn't use at all.

If there were conditions on the differential I wasn't familiar with - err, WHEN things showed up I waasn't familiar with, I'd look them up on 5MCC. 5MCC has the disease described by the Basics (description, epidemiology, risk factors, general prevention, pathophys, etiology, associated conditions), Diagnosis (signs and symptoms, diagnostic tests & interpretations, differential diagnosis), Treatment (meds, additional treatment, in patient considerations), Ongoing Care (follow up, patient education, prognosis, complications) and references for the material given.

The diagnosis section was especially helpful in directing my investigations and the ongoing care was useful once the patients hit the wards. Reading through the basics made me look like less of an idiot before going to the morning report and being pimped by the consultants.

Patients come in on a huge list of medications sometimes, often ones I've never heard of. I used Dr. Drugs to help me figure out what the heck was going on. It's on the Skyscape app as well (pay extra for it though) so it's in one place and links to 5MCC. Very useful. The information is given in terms of Indications, Contraindications/Precautions, Adverse Reactions/Side Effects, Interactions (drug/drug, drug/natural products), Availability (tablets etc.), Dose (adult, paeds, geriatric, etc.), US Brand Names, Classifications (therapeutic and pharmacologic), Pregnancy Category, Pharmacokinetics (absorption, distribution, protein binding, metabolism/excretion, half-life), Canadian Brand name, Time/Action Profile (onset, peak, duration), Patient/Family teaching, pronunciation.

Interactions came in handy quite a few times when trying to sort out why a patient was having problems with their new meds, the dose is priceless for obvious reasons, and the time/action profile made it possible to predict when to check back on a patient to see how the meds were working.

I love clerkship. I have so many stories to tell. As soon as I get more time, I promise to update!

Why I'm not much of a drinker anymore

During my 2 week elective in geriatrics I had a few patients who were in the rough situation they are in because of their drinking habits/addictions.

One is thought to have Korsakoff encephalopathy from years of drinking. It took doctors a while to figure out what was going on with this man and really shows the importance of a good social/addictions history when taking people in. It also shows the importance of getting a collateral histroy from family. One or two drinks a day (that the patient said he was drinking) would not cost the thousand dollars his daughter said he was spending monthly. He has tremors and no short term memory. His family is dissapointed with how things have turned out, not surprisingly.

Another has chronic pancreatitis, after acute pancreatitis and years of abuse (Scorpion stings are my class's favourite cause of acute pancreatitis). Her digestive system is blooey (technical term). Bingeing on alcohol = a bad idea.

My usual glass or 2 of wine every night have turned into none - 1/2 a glass.

Here's an article on how to determine if your loved one has an alcohol problem. Or, I guess, you.

What is going on in Montreal??

Another father has delivered his baby at the Royal Vic because the staff weren't available. At least the last one delivered a live baby.

The latest couple was sent home from emerg the night before after being told that their fetus had died. What a long night they must have had after hearing this bad news, worrying about what would come next. They ended up back in emerg again the next day. Apparently, the department was busy and when the baby was delivered, no staff was around.

Losing a pregnancy, especially one this far along can be the worst day someone has. It bothers me that the people who work at the hospital, presumably the ones who went into health care because they wanted to help people, didn't seem to care that this couple was having a terrible day.

Simple goals aren't always that easy to reach

I've been working at our Geriatric Rehab Unit this week. It's been a great experience and I've been learning so much. Patients are complicated but motivated to get better. It's a treat.

Their goals are mostly attainable. They want to be able to walk again, with or without a gait aid. They want to be continent of bladder and bowel. They want to remember how to make dinner. It takes a lot for some of these folks to literally get back on their feet. They've been in hospital dealing with a fractured hip or MI and become 'deconditioned' and need to rebuild their atrophied muscles, deal with the increase in dementia from inactivity and retrain their bladders to do what they used to know before they were catheterized for week.

Their families are heavily invested in their loved one's health.

Our patients spend a few hours a day in PT and OT, working with social workers and volunteers. When I do their admission interviews they tell me that they are here to work and excited to do so.

Unreal.

Emerg!!

I think I'm in love with Emergency medicine. It's easy to jump back and forth between patients and see many different things. I got to spend the last 2 nights hanging out with my preceptor for clinical. She's wonderful and I'd consider her to be a mentor.

A list of the things I can now say I've done:

• sutured a finger and put in a nerve block (grab the other end higher HIGHER, little bit of lidocaine just under the skin before going deeper, watch for tenting on the other side)
• performed several neuro, msk, cranial nerve exams
• diagnosed cataracts
• helped reduce a displaced wrist fracture
• used a silver nitrate stick to stop bleeding (use water if not currently bleeding!)

Not as many things as I wish I could have done, but still a good couple of nights!

A series of updates

First things first, I passed my classes. Some by the skin of my teeth, others by the whole tooth.

Second, I've survived H1N1. Hopefully I'm now immune and won't get sick again this fallwith it when it morphs into the superflu everyone keeps warning me about.

Third, there are only 3 bugs that I actively kill; fruit flies, mosquitoes and earwigs.

Fourth, I spent last week in Edmonton doing a week of geriatrics. Edmonton is a fabulous city. I was shocked. It's well planned, very green, has a great night life and terrific restaurants and has an amazing amount of money in the health care system. We were given tours of the various facilities and were surprised by the quality and amount of resources available. The docs and staff were all incredibly passionate about the care of the elderly. It was inspiring, though to be honest, I don't see a future for myself in geriatrics.

In Alberta, it seems that the Care of the Elderly diploma (a 6 month fellowship following a Family Med degree) is highly valued. These docs are considered geriatricians and work with the elderly full time. I don't think that the same education in Ontario is as well respected, but I don't really know.

Given that we have a shortage of geriatricians in Ontario, it seems that the short cut in training would be popular but it doesn't seem to be. Part of the concern is that the first baby boomer turns 65 in 2011. They won't be needed the service of a geriatrician for several years following that but the cohort before them will need the specialized attention. Despite the supposed raucous that the boomers are able to raise, no one seems to be championing the need for geriatricians.

Few med students choose to enter geriatrics. As far as I can tell, it's not necessarily because they don't like the idea of working with the old folks, it's that something else is just much more interesting. It's hard to see what the point is in specializing in the care of the elderly when you're planning on doing your residency in internal medicine since the majority of your patients are geriatric. Also, it's hard to see geriatrics as anything but a dead end. Geriatricians across Canada are trying to figure out how to woo medical students to join their ranks.

I mentioned that I don't see myself going into geriatrics. This is for a couple of reasons. For starters, I don't really see myself dealing with just one population forever. It's why pediatrics and obstetrics are not that appealing to me. While it's true that geriatrics is not a dead end, you still spend a short amount of time with your patients, either doing their assessment and sending them back to their primary care provider or because their life expectancy at that point is nearing its due date.

Fifth, my cat is really sick again. We've taken to calling him the million dollar cat. This vet bill ran $800 with the possibility of surgery and more imaging still to come.

Ironically, he is a geriatric cat.

The health care system is broken?

This story of a man delivering his own baby gathered many comments about how broken our health care system is. I'm not sure it is though.

In this case, it seems like the delivery went significantly faster than expected. People are also making a big deal about the fact that the doctor wasn't in the room. My experience last summer was that the doctor doesn't necessarily need to be there for the actual delivery. The first hour post birth is the most important one for him/her to be there.

I'm just surprised at how much anger there is about our health care system. I'm also very disillusioned. And studying seems even more important if I need to prove to my patients that I'm not the fool they seem to think doctors are.

It's exam week

I'm disappointed with how little actual school work/learning I've had time to do this year. It's clear that when I have the time to study and stay on top of the work load (eat all those pancakes) I can do very well.

We had a one week course in Emerg/ICU care this semester. I stayed on top of the material and feel like I killed the exam. Yes it's just one week, but that just meant I was able to stay on top of the work. What makes this win extra scary though is that the rest of the class seems to feel that they did not do well on the exam.

The other three courses this semester though, will not go as well. I'm desperately choosing which weeks I will study. Weeks! Not just lectures or parts of lectures I feel are less important, entire weeks!

We had our OSCE last week and despite studying for the past 2 years and feeling pretty prepared for it, I was knocked off my game a couple of times. It was fun but also, as I said to the examiner for the ankle exam, fully humiliating.

Our school has a pass/fail system so that as long as I make my 60%, I'll make it through to clerkship. For the OSCE, we just need 60% of 60% of the stations. But, I don't want to be the doctor that barely made it through med school. I don't want some doc in administrivia hell looking for the last 1/2 % so that no one has to hold my hand through remediation in the summer. I want to do well in clerkship and need to start making studying a priority in my life. Starting.....NOW.

Footprints in our hearts

Our school community said good bye to a friend today. He was someone that everyone is happy for having known. He and his partner taught me wonderful lessons about love, about giving with everything you can, about being a friend and about living life on purpose.

During the memorial speeches made by his family, friends and co-workers, I was overwhelmed with a desire to make sure that when I pass, these beautiful things could be said about me. I know it's a bit selfish, but I hope that he would forgive me for wanting to learn from his successes and challenges.

I've learned that I need to treat everyone well. To reach out when someone asks for help and to feel comfortable reaching out myself. I need to pay attention to life. It's happening now, I should be taking advantage of it rather than whiling my hours away watching streaming TV (the studying I find acceptable though). I learned to love completely, fully and not worry about other people's prejudices.

I need to travel. I need to respect my family and encourage their respect of me. Chocolate is a perfectly acceptable way to buy friends, and it's OK to insist that people smile when they take any that I offer. One can live elegantly and fully on a modest salary. Making one's home means making it feel like home for everyone you love.

Admit when I make a mistake. Eat well but never too much. Drink well but never too much. Our time is not our own. Our friends' time is not their own either. Except lunch time.

Lunch time should never be messed with. It is a precious, recharging and essential part of everyone's day.

Footprints In Our Hearts Some people come into our lives and quickly go.

Some people move our souls to dance.

They awaken us to new understanding with the passing whisper of their wisdom.

Some people make the sky more beautiful to gaze upon.

They stay in our lives for awhile, leave footprints in our hearts, and we are never, ever the same again.


Author Unknown


In case you're thinking that there has been a lot of talk of death, funerals and the like in here lately, you're right. It's also why I haven't been posting much lately. My thoughts have been too big to put into blog form.

Don't throw stones

We're coming up to our last week of psych. It has been a relaxing block so far. I was able to get through one week of notes in an afternoon. That never happens for me. I've spent an afternoon on 3 renal lectures.

This is when MedStudent-itis has shown up. I have gone through notes diagnosing my classmates, my family, my partner, my past partners and me. It's shocking how much mental illness there is near me.

This block has been eye opening as far as how my classmates view mental illness. It's clear that the stigma attached to it is alive an well in our ranks. I hope to continue to advocate for those with mental illness.

During our CBL session last week, I made a comment to the effect that patients who don't take their meds are much less likely to get my sympathy than those who do. I was shot down by the other members of my group. I can't remember what their argument was, I'm sure it was brilliant.

What I did think about for a while after was that I am just as guilty of not taking care of myself. Despite counselling patients and family to eat well, I still eat donuts, drink too much coffee. I haven't been to the gym in a couple of months.

I was comfortable throwing stones in this glass house of mine. And very glad I've recognized yet another prejudice I hold.

Respect the Jinx!!

It's been a rough year for people I love. I've been refusing to say or think anything that might tempt fate into slapping me in the face. A favourite relative died last night. When I told my partner this morning, he said "so do you think that means it's over for a while?".

Augh!!

You've got to respect the jinx! I try not to be superstitious, but at the same time I'm not taking any chances.

Synesthesia

"Live music is better; bumper stickers should be issued"
Neil Young

Very little affects me more than music. I can laugh, cry and get angry within an afternoon with the right mix of music. Live music sends me to another planet. When the right group of local musicians get together, the result is undeniably brilliant. They play better with each other than any of them could separately. Awe inspiring solos are released from their fingers as though they were always waiting there for the right moment to be let out.

Some songs remind me of events and emotions. One lick and I'm back to the crowded bar when I first knew I just had to kiss that guy or a sunny patio at a summer festival or a cozy hug or a ridiculous political argument.

Hearing those licks played by someone replacing a friend who has recently passed though, is absolutely heart breaking. The notes are right, the groove is great, but it clangs in my head. My late friend's soul is woven into the notes and I can't tell the music apart from him.

And I cry.

We'll miss you Mel.

To Do List

I slept in today. A weekday. Until I woke up.

It was brilliant.

I've been working on my To-Do list. It includes only extra-curricular things today. There's such a sense of accomplishment crossing things off a list. I add things that I started on before making the list just for the joy of crossing them off.

I'm looking forward to going to Starbucks tonight to study neuro for a few hours away from all my other responsibilities. No one ever sees me there because I go to the shop far away from campus. It's fantastic. Although not just a little pathetic that I need to isolate myself to get work done.

How NOT to talk to patients, as tempting as it is

Cyanide & Happiness @ Explosm.net

Random facts about The Impostor - Med School edition

1. I often bath rather than shower before an exam. This is so I can study in the tub.

2. Even though almost everyone in my class thinks I'm intelligent, I'm barely making it through my exams.

3. Anatomy lab makes me HUNGRY. Which really grosses me out.

4. I'm addicted to having textbooks but rarely use them (though the Case Files series may convert me).

5. When my class chatters while we should be listening to a lecture, I'm ashamed of them.

6. I have consistently done poorer than the class average on all my exams and assignments but one.

7. I crave the approval of those around me. I worry what will happy when I move into my own practice and need to encourage myself - this is when the impostor part of me takes over.

8. I'm terrible at completing projects - I can have several going at once and never truly finish one of them.

9. Even though I know my school has a pass/fail system and that my potential residency programs won't see those marks, I worry that they will somehow find out that my marks aren't brilliant.

10. Drinking herbal tea with fun sounding names makes it easier to study for exams.

11. I watch TV while I'm studying. That likely explains my poor marks.

12. Every now and then I get these moments when I realise that I'm going to be a doctor - soonish. At first I go into this sense of awe and happiness, that is later replaced by abject terror. While I feel I can talk the talk, I'm not sure I'll be able to walk the walk. Maybe dermatology is the thing for me? I like raspberries in my water.

13. I want to specialize in everything.

14. Our class is incredibly charitable. We spend a great deal of time raising money for people overseas, kids who are chronically ill and friends who are fighting great battles. It makes me very proud of them.

15. My favourite block so far has been MSK. I like diseases and body systems that I can see.

16. I was drinking 8 cups of coffee a day. I'm down to 2 now because the hypertension and tachycardia caught up with me.

All talk no action?

One of the first 'touchy feely' things we talked about in med school was how to doctor the doctor. That is, how to treat a colleague in need of medical attention.

I've been thinking a bit about that discussion and how applicable it really could be.

There's something terribly abstract about a lot of the discussions we have in our weekly groups. We talk big, things we would do in certain situations, but will we actually act this way?

I spent a large part of the last three weeks in the hospital with my parent who was having heart surgery. This was unexpected and very scary. My family was kept in the dark quite often about what was going on. Doctors would talk to the stoned patient who would then pass on incredibly strange interpretations of what was going to happen next/what had already happened. At one point, the staff had Dad wrapped up and ready to ship to another hospital while my mother and I were worried in the waiting room, oblivious to why the procedure had taken so long and wondering if anyone was going to come and talk to us. Apparently, they weren't.

Patient centred my large white bum.

Losing control of something as simple as how information is passed on to us was incredibly upsetting, especially for me. I had no idea I was such a control freak, but apparently no one else was surprised.

My father is now home and doing well and doesn't remember much of his hospital stay. All the more reason that his medical decisions and information should have been considered with a family member present. I'm glad he's doing well, but confused about how others dealt with the situation.

Apparently my entire family but one is afraid of hospitals and illness. They choose to ignore it and hope for the best. The one exception is overseas - I can't imagine how stressful that can be.

What bothers me about everyone being afraid of hospitals is the assumption that I will just take care of everything. I get that I'm in med school and can handle a bunch more and understand what's going on. I worry that when my parents are old and in need of help that I will be expected to be the one to take care of them. That worries me. A lot.

I was also thrown by classmates' reaction to me while this was going on. I am currently the epitome of depression. It's from being emotionally and physically exhausted and just so far behind in everything that I need to do. I know it will go away, but I really need support now while I deal with it.

One classmate who I consider a friend but wouldn't think of asking for help emailed me her notes to keep me in the loop on days I missed. I was surprised and very very happy that she cared that much and recognized that I needed a hand. A few others in the class have been very supportive. Ones I would and would not have expected. They noticed I was missing and wanted to know if I needed help. So fantastic.

Others that I consider to be friends are completely ignoring me. I guess they're waiting for the non-depressed me to show her face before trying to engage in conversation again.

This makes me worry about 'the person in our class who will develop mental illness during our 4 years here'. Apparently there's one in every class. I hope the person who notices the out of character behaviour is able to help and can act in the idealized way we discuss in our groups.

Apropos of nothing

Best death scene ever.

Lemming

Apple Introduces Revolutionary New Laptop With No Keyboard

We've been looking at getting me a smart phone so I'm ready for clerkship. I'm really drawn to the the iPhone because the screen is a good size. There is a similarly sized screen for a PC smart phone but after getting many many demonstrations over the holidays, it really seems like this is the way to go. But I still feel like I'm jumping on a bandwagon and going for something I think is sexy not something that is perfect for my needs as a clinical clerk.

And yes, 2 posts, one day. I decided that I needed to take tonight off. I've been watching Buffy and generally doing nothing. It's glorious.

How could anyone possibly study?

There is simply far too much to snuggle, far too little motivation and far too many calories consumed over the holidays. How could I possibly study repro? I'm excited to learn more about the reproductive bits of us humans, but it involves holding still and not playing. I like playing.

Repro certainly has it's moments. The erectile dysfunction talk was the most exciting of my med school experience. My favourite quote (with respect to the male arousal cycle)
"A few years ago I asked the class what the difference is between the arousal cycle in males and females. One student put up her hand and replied 'women don't have orgasms'. While this is my personal experience, the literature tends to disagree."