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!

What I did on my summer vacation

I still owe you a list of the loveliness that I witnessed during my elective.

• breast reduction surgery - this was one of the most amazing things I've ever seen. The tissue went from looking like a train wreck to a perfectly shaped breast. Wow.
• removal of a congenital defect from someone's tendon, a huge connective tissue chunk. Again, wow. Plastic surgery is looking less like something ridiculous
• colonoscopy - ew
• emergency ectopic pregnancy surgery - so much blood
  
• 2 deliveries, both were natural and no tearing on either
• I presented 2 cases to the internal medicine preceptor
• witnessed a respiratory code
• saw a passionate doctor calm the coding patient down with only a few words
• saw an amputated toe
• listened to a billion hearts and lungs, give or take a million
• surgically assisted on a vasectomy
• saw toe nails removed **always cut your toe nails straight across**
• heard a patient scream at an emergency physician because she wanted to be treated immediately. She went on to compare the US EDs to Canadian "over there you're served in 29 minutes or it's free, they're proud of it", "like a pizza?" " ya". Witnessed Doc storming from room. What drama.
• was asked by a 4 year old if I would give his mom a foot massage too when I dropped off a warm blanket
  

Bone Tired

I get that a lot of docs feel a strong need to let lesser people (aka nurses, med students, patients) know that they are not as worthy of oxygen as they are. It's absolutely exhausting though. I was yelled at by a surgeon the other day, in front of the patient and his family, which was humiliating for me and uncomfortable for them. I can appreciate that she was having a rough day and knows a million more things than I do, but it's hard to remember that when I'm too busy looking for a hole to crawl into.

I can't wait for clerkship when I have to deal with this all the time. Yay.

Pessaries and Circumcision

This week was a bit more dull than last - probably because I wasn't in the OR at all. I spent most of the week with family docs plus some time in the ER and with an internist at the hospital. My list for this week:

• performed a 6 month well baby check up with the cutest baby ever
• met a born again Christian/recovering alcoholic
• danced with a delirious geriatric patient to try to keep her in her room in the ED
• heard the distinctive tinkling of someone with a bowel obstruction
• met someone who had been hit by a train and survived
• learned what shifting dullness was and how to properly check for pitting edema
• saw a stress test in action
• heard COPD, emphysema and chronic bronchitis
• saw a woman with shifting pain that the doc didn't know what to do with - not sure why she wasn't referred to rheumatology, even though it wasn't in the joints, it may have been fibromyalgia
  
• speaking of rheumatology, why are none of these docs on top of management??? Tylenol for RA?? wtf?
• was lectured endlessly on the woes of the Canadian family doctor and how we'll never make any money
• saw a woman with scleroderma and pronounced sclerodactyly
• she was happy to let me feel her fingers and skin to get an idea of what to expect
• there are support groups for those with scleroderma
• I think the doc was dissapointed - I'm pretty sure he was hoping to stump me with that one ;)
• watched moles and skin tags be burned off
• closely followed with the first time I've almost fainted (no lunch + burning flesh = syncope)
• saw a circumcision - uck - how can you do that to your baby??
• met a man who takes 72 pain pills a day for his chronic pain
• my first question - do you still have room to eat food? Apparently his appetite is still strong
• heard a pan systolic murmur
• found a melanoma spot in an elderly woman's mouth
• wrote the admission notes for a patient who was unconscious - or at least attempted to, I wasn't that great at it - this is how we learn though
• saw a uterine prolapse and a pessary insertion
• examined a few pregnant bellies
• saw several cervixes (cervi?)
• met "that guy", the one who thinks that because he's on lipid lowering meds that he can eat whatever he wants and as a result his blood sample was 1/2 fat so the lab couldn't do cardiac enzymes - those guys actually exist!
  

Still freaking out a bit about finals but I this week has been busy enough that I haven't really noticed. I'm doing a 5 week "elective" at a large centre away from med schools. It means I get to see a lot and I'm the first in line to watch it all happen/learn how to do it myself.

It's been great to see a team of doctors, nurses and nurse practitioners that work together so well. It makes me want to work at least part of the time in a hospital. So far this week I have seen:

• carpal tunnel release surgery
• the suturing was so neat and close to invisible I'd be surprised if there was any scarring
  
• laparoscopic cholecystectomy
• I will never consider eating beluga caviar again

• C section, double ovary removal, tubal ligation
• aortic aneurysm
• cranial fracture
• very sick people
• drug seeking people
• intubated 2 people
• put a peripheral IV line in one
  
• took close to 20 histories
• did abdominal, respiratory, cardio and MSK exams
• missed a fracture
• got to hang out in the OR, ER, family doc's office

All together, it was a great experience for a first week!!

Oops.

I've gotten myself so far behind with 6 projects that I can barely breath. How did I let this happen? Too much T.V. probably. Stupid T.V. Plus I've definitely stretched myself beyond the real capacity I have for working.

Very little real work got done this weekend, but I did get into the habit of going to the gym every day, so I suppose that's something. I ended up counselling a couple people too - how is that possible? I'm on break fer cryin' out loud!

After doing 2 years residency in Family Medicine, we have the option of adding on a third year in whatever we'd like. I spent quite a bit of time looking at my options this week and am quite confused about what to do. Palliative care has been calling to me, so has psychotherapy, obstetrics and paeds.

Thank goodness I've got another 5 years before I need to make that decision.

Palliative care seems a bit out there right? It's not. One of the things that really drew me to medicine was the way my uncle was treated by the docs caring for him during end stage pancreatic cancer. They were patient and compassionate with his family as they explained the options and what quality of life he could expect if they continued treatment. They allowed us to have a mini - family reunion/going away party for him in his hospital room. To me, they gave him a good death. There's something really noble about giving people a good death.

To me a good death is on the terms of the patient. They deserve to spend their last days in the way that their well - self would have liked. Their family also deserves to spend time with their loved one in a way that is hopefully not entirely clouded by pain meds/end of life delerium. The family and patient need to be heard. This is a pivotal moment in their lives and they deserve to be able to talk about it and celebrate/mourn.

I was lucky enough to get to hang out with a palliative care doc a month ago. In the hospitals here, there's a palliative team working with the docs to provide a comfortable end of life experience. Social workers in particular are available to the patients and their family as they work through what will be happening next. Tests and medications that don't have short term effects are discontinued so that the last moments aren't spent being poked and prodded.

Maybe when I hang out with a psychotherapist though, I'll feel just as passionate.

Shoulda' bought shares in Starbucks

We bit the bullet and bought me a car. I think it's about time since it was taking an extra-ordinary amount of time to take the bus to school and every person who comes to visit my home feels they've left the county. But I think they may be slightly exaggerating.

The car has been lovely, I can make it to meetings and observerships without any worries. I can stay late at night and study with my colleagues. I can get tasty Starbucks whenever I like.

Have I defined observership yet? Partner o'mine hates it when I use words he doesn't understand. An observership is when a kind doc lets me come and watch what he/she does. These are usually a few hours long, and aren't repeated unless I'm very lucky. I've seen an osteoporosis clinic, a rehab ward in a hospital and an outreach program between a psychiatrist and community GPs. Pretty cool.

But about this car. It means that I'm suddenly spending a lot of money on gas (well, not a lot I guess relatively speaking since it's such a tiny car), but it's not cheap. Plus there's insurance and maintenance etc, and my sudden car induced craving for Starbucks.

I'm pretty sure that where ever I decide to practise, there needs to be a Starbucks nearby.

Waffles; they're not just for breakfast anymore!

I keep waffling back and forth between feeling as though I am going to be the best doctor ever and expecting the big Gong Show cane t.m. to pull me off the stage. My class nominated me for an award. I'm in awe - partly because I'm pretty sure other people deserve it more, partly because I didn't think anyone noticed that I was there. There's a dollar amount attached to the award, so it would be fantastic if I actually win the thing.

I've decided that observerships are the best thing a med student can possibly do. I arranged to shadow a rheumatologist this week for an afternoon in her Osteoarthritis clinic. Her nurse was confused about my qualifications (thought I was a resident i.e. already an MD) and started barking orders at me about what I was to be doing all day. Given that I've covered OA in school already and feel comfortable taking patient histories from all the clinical methods training I've had (6 weeks) I was OK with it. When the doc showed up, she knew I was still in first year and didn't give me anything I couldn't handle. I was essentially catching patients' files up since their last visit by getting their histories (solo), interpreting x rays and learning a heck of a lot. Don't worry, the patients all knew that I'm just a student.

I left the OA clinic feeling like I could be a doctor right then and there!

Then I started studying again.

How is it possible that I can be so far behind when I work so much? I think I set my expectations for studying way too high. Re-writing every single lecture is too far. Ignoring weeks of material because I had the prof isn't far enough. Where is the balance they talked about in our first week?

Something I haven't mentioned yet is what I have going on in the background. I find it to be a struggle to keep up with what is going on in my home life and my school life. My partner has bipolar disorder. It's type II which means it's a mild version of the disorder, but that's not reassuring when I never know what to expect when I come home. I don't have the support here that I wish I did. It's not something that I advertise either, I don't want people to know what I'm dealing with. I'm not sure why I think it matters - probably just that I'm not ready to expose my weaknesses until I really get to know my classmates. He's on meds which is fantastic and tries really hard to be stable for me. No extra pressure at all. But if I can get through med school while dealing with his insanity (literally) I deserve then M.D. I'm given.

I guess I'll just keep trudging through until the cane pulls me off the stage.

Lots of information, not enough neurons

AHHHHHHHHHHHHHHHHHHH!!!!

Midterm is next Monday, Finals start the week before Christmas. The first final will be fine but the next 3 I haven't begun to prepare for.

I'm still going to do observerships because that's where I feel I learn more about medicine than I ever do in lecture.

My last was with a hospitalist who let me do rounds with his residents. I was taught to do some tests and was included in conversations about the patients' care. I can't believe it's taken me so long to do these!

My next is a psych observership which I'm really looking forward to. I'm not sure if I want to be a psychiatrist - in fact I'm not at all sure I know what I want to be, but it will be great to learn what they do. I think that no matter what practice I end up taking up, there will be a psych component to it. Same as regardless of which practice we choose, we're all going to be geriatritians. As I go through my class material, I try to think about how what I'm learning is different if the patient is old. Should be good practice right?

One of my finals is MSK (musculoskeletal) so I've arranged for my observership before finals to be in the osteoporosis clinic. It'll be like review for the final right??

The more I think about finals, the more I freak out. It's a lot of information for me to have in my head and be able to apply clinically. Clinical application is fun but requires that I really own the material.

Which means I better get back to work and stop watching Bones.