Anne

I worked in a hospital for over a year on the Hem/Onc floor. We were the highest Onc floor, which meant we had the most terminal patients save for the ICU just above us. The night shift was a long shift, and we would pass it at the nurses’ station talking about nothing. The nurses would tell me about each patient or go through the charts with me (which might be against JCAHO, might not be) and I’d try to absorp what I could. When a patient needed to go for a CT scan, I would take him in his bed or wheelchair and sit behind the consoles watching the slices of their body on the screen.

 

After a year, even without any training in Anatomy, you get an idea of which cancers are the worst and what they look like on the CT. You know where each organ sits in the body and what it’s supposed to look like. And more than all of that, you can tell when the CT tech is holding her breath and the physician brings his hand to his mouth that this person is in some trouble.

 

So it was with Anne. She was a little younger than me, a year maybe. She went to a college that I knew well. We might have known some of the same people. She came to our floor with her parents and sister. I admitted her, went through my “this is everything” speech after I took her vitals, and let her family know that I was only a call-button away. She was beautiful and healthy and trying to make the best of it.

 

The admitting physician called me over with a wheelchair and I took her down to CT. She asked me where I went to school, if I was a nursing student or a med student (neither at the time, but hopeful), and my age. We had a lot in common. I helped her onto the table and then went in the back with the monitors. The Tech held her breath, the doctor covered his mouth. I saw what they saw: hundreds of tumors in her liver. “Poor girl. She’s so young.”

 

Everyone was speaking less as I took her upstairs and she knew. When we were alone in the elevator, she asked me, “So. What do I have?”

 

I didn’t say. “I’m just a tech; I can’t read a CT.” Again, she knew. I brought her back to her room and she said, “thank you.” My shift ended a few hours later, but not before every nurse on the floor knew about this girl.

 

I came back the next night and I could tell that the doctors hadn’t told the family. I came back the next night and off the elevator I could hear the papers moving at the secretary’s desk above the sounds of the nurses’ conversation. They had told her. I looked at the assignments and she was my patient that day. I rounded, got all my vitals and emptied urine and talked to families. Her room was the last. I came in ignorant and smiling because I’m not supposed to know what everyone knows. Her mother met me, told me it had been a hard day for the family, and that the nurse already got the vitals. “If you need anything, please…”

 

“We know. Thank you.”

 

She became sicker, friends started to visit, and then she left for a different hospital. I never found out what happened to her.

 

——-

 

Working in the hospital, that first week, you’re obsessed with knowing everything about the patients. You write their first and last names on your record sheet, you know what they did for a living, and you look at your insensitive coworkers that don’t know their patient’s names until they read their wristband. They have patients 3, 4, 5, 7, 9, 10, 14, and 15 instead of Mrs. Hayes, Mrs. Bopp, etc. You tell yourself that you’re going to remember the names of every person. You’re an idiot.

 

I’m no different. I tried it and slowly they slipped away. Then I started forgetting the names of people that had been on the floor for weeks at a time. Then I couldn’t remember the names of the people that had died on the floor, or the ones I had watched die. Then I couldn’t remember even 10 of them.

 

But I’ve always remembered Anne. Everytime I feel the year I spent in Hem/Onc slipping away and I can’t remember the nurses’ and the doctors’ and the patients’ names, so long as I remember Anne I feel like I haven’t lost it all. And I wonder how she’s doing. And I worry about her often.

Bet a Beer on It

I assume you want to do well in medical school. A trick I’ve learned since coming to Grenada is this: talking helps. After you’ve read about the sympathetics and the parasympathetics, spent some time in the library committing the topic to memory and worked through a handful of practice questions you start to feel comfortable with the material. Then you find yourself in a conversation with a classmate, trying to explain the concept to him when you realize: I don’t really know this. You stumble over your own explanation and a couple of excellent questions later you think about all the time your spent working on your wrong answers and you want to cry. At least I do.

That was my second week of class in Anatomy. Afterwards I started studying with the guy that asked the great questions and made sure that we talked through all the concepts every couple of days to keep each other on the ball. It shouldn’t surprise anyone to know that it works like gangbusters. After that we found another person that asked great questions and he was studying with us too.

We were lucky to find each other early on, stick to our schedule for covering each course, and to end up testing well. With the confidence of doing something correctly, you start to see the game emerge between the students and teachers. You begin to read the notes and see the test questions buried inside them. You start coming to group review with questions that you’ve created to stump your friends. They come with questions of their own and you fire back and forth. You bet a beer that such and such will be on the test. You bet three beers and four beers. You have to get out flash cards to keep track of all the bets. And at the end of it all, exhausted from the exam, you meet at the bottom of the hill in front of the D-store to tally-up and celebrate with your class. It’s intoxicating.

Remembering the thrill of learning and the excitement in the eyes of a person that “achieves understanding” of a difficult topic is what you cling to when two solid weeks of exams loom two weeks away and you’re holed up in the library hating the clock as it ticks past midnight. You remember that and then you see an interesting detail in the notes that you bet your friend doesn’t see. And you write it down. And you think about that beer you’re going to win.

Phlebotomists ‘R Us

I knew back in the hospital as a tech what all nurses and patients have known since time immemorial: doctors can’t draw blood. They’re horrible at it. Shouldn’t matter, right? Doctors have other much more important things to do like Chest tubes and Lumbar Punctures and all the other things that make an aspiring med student salivate. As an underling, I was almost grateful that I could be better at just this one stupid thing. What’s funny is that patients don’t think that way. When a physician walks in and starts stabbing and missing, they change in the eyes of their patient and become a little less Superman and a little more Clark Kent. Too bad that it happens over some stupid blood draws.

But here’s what really gets me: they get to pull ABGs! An Arterial Blood Gas is a collection of oxygenated blood from a pulsing tube in your wrist. It’s deeper than a vein, harder to draw correctly, and with more serious consequences. Patients wnjoy this even less than a vein puncture. So since my first days in the hospital, I’ve wanted to know exactly what kind of training future MDs get in the arts of nursing. Well guess what…

OUR CLASS JUST DREW BLOOD! That’s right, 300+ students that have never held a needle were shown a 10 minute instructional video explaining what happens when nothing goes wrong, and then they were given a tube, tourniquet, needle, cotton swab and bandaid! We were placing bets on how many students would pass out, vomit, or just walk out.

Guess what: THINGS WENT WRONG! Needles with vacutainers still attached were pulled, sucking tissue with them; veins were blown and swelling under the skin with tourniquets still tightly fastened; and hands were shaking so violently that the needle was scrapping back and forth before it had the chance to hit the target. There’s a rule among phlebotomists that it takes 100 draws to get comfortable and trully competent. With that math in mind, 3 people had correct draws today. Pretty respectable, I think.

Our group faired well: three shaky hands, two blown veins, only one blood spill onto the table and a lot to laugh about. Good day all around.

P.S. If you need a summer job that pays within reason: phlebotomy is the way to go.

The House Effect

It’s probably unfair to call this the “House effect” because this problem predates that show by a few decades, but I’m going to anyway.

House effect: obsession (of both teacher and student) to know (in detail) the aspects of a disease that you should never see in your entire life.

I learn that 95% of all tumors of the gallbladder are adenocarcinomas. Ok, I’m fine with that. What I’m not fine with is a page of notes then devoted to the minutiae of that remaining 5%. It’s not necessary. It wasn’t necessary after I learned that 90-95% of lobar pneumonias are caused by strep. pneumoniae, and it isn’t necessary after I learn that 98% of all peptic ulcers occur in the antrum of the stomach and in the duodenum. You can keep your 2%; I don’t want to know it.

Under the same logic, I should NEVER HAVE TO KNOW ABOUT ANTHRAX. I’m staring at two pages of Anthrax notes right now, and while I feel very prepared to hold my own against a talking head on FOX NEWS, I sure as hell know that I will never put this information to clinical use. And let’s say, for argument’s sake, that I did? Let’s say ten years from now I see a case of anthrax: I’m calling the CDC and letting them cough up their lung (which is what everyone should do, regardless).

The logic of the last 5% is pretty simple: if you treat 100 patients you’ll see it 5 times, so you need to know it. I understand and respect this. I also understand that all the truly useful things I ever learn will be on-the-job. So if during rotations my Resident decides that I really need to know the 5%, then I’ll know it. But just imagine how much more useful it would be if every medical student walked out of the first two years knowing 1) the top five causes of everything or 2) the causes that cover 95% of cases. Instead, I feel like I lose sight of the forest because the people writing my tests think the ant on that piece of bark on that rare tree is too interesting to skip. So I should probably know that instead.

Anatomy

For current, updated information about attending SGU, review of SGU textbooks, and access to more SGU resources, please visit the Welcome to Grenada site.

**************

So congratulations! If there’s any course that signifies medical school to the undergrad, it’s Human Anatomy. After this you should know every bone in the body, every muscle that moves them, and every nerve that orders them around. And I’m kidding. You will cover a fair bit of it, know some interesting clinical presentations, and be able to explain to your friends back home what “fight or flight” is all about. And isn’t that the goal? To sound impressive?

This course has changed a bit since I took it. Instead of having every student slave away in the lab cleaning fat for a grade, the department now pro-sects (a professional dissection) every structure of interest and then takes you through ID, relationships to neighboring structures, and pop quiz. I think you get to dissect the first day on a space that’s impossible to screw up too bad: the superficial back. Of course this didn’t stop me from cutting all the way to the ribs on that day. And yes, an announcement was made to the class that I was an idiot.

If you’ve taken the course already and want to freshen up or are taking it for the first time and want a heads up, this site is great. It shows the dissection of the entire human body in easy-to-download quicktime movies. Another great website is the University of Michigan site. Several classes have lived and died by their practice quizzes. Get a wrong answer: it tells you why you’re wrong. Most students click all the wrong answers anyway just to see what they might be missing. And for those of you with the free time to dream of overachieving, they have surgical videos as well.

Now for the books. The school gives you the combined oil paintings of Frank H. Netter, may he rest in peace, and the “Baby Moore” Clinical Anatomy book (make sure you read the Blue Boxes). For a book with a more gross approach to anatomy, the Color Atlas of Anatomy by Rohen is pretty clutch. Some students go so far as to buy Clemente’s but between you and me: that’s overkill. For those out there who like coloring books, they have those too.

The school produces their own Anatomy manual in binder format and all of the lectures are online as PowerPoints. Review at your leisure.

Strategy for covering all of this material? Who knows. The first week or two of classes is light, giving you every opportunity to study like an idiot and learn everything incorrectly. It happens, don’t sweat it. Instead, learn about the different ways to study and make a trip to the Department of Educational Services (DES) office and have a chat with them. I did both; both helped. Another thing you’ll probably due is attend too many DES sessions (tutored by students that are 4 months ahead of you), artificially boosting the confidence of said tutors until you cut back and find your rhythm. Best advice I received was 1) draw everything and 2) study with people smarter than you.

It’s going to be the first hard class of medical school, you will get through it, and look at it this way: by the final you will be able to write out all 208 bones of the human body on a table napkin and not bat an eyelash, and that’s what medical school is all about.

Black Belt in Notejitsu

My friends and I laugh at ourselves when we think back to undergraduate. Somehow, we were convinced that it was hard at the time. I remember talking to classmates after a test thinking, “Wow, I studied for six hours in the library for three straight days to prepare. I’m exhausted. I feel like I earned an A.” I wasn’t lying.

Well welcome to medical school. A friend of mine went out on a date with a med student who had to cut the date short so he could get back to the library, and he wasn’t blowing her off. I remember Uncle Neurophysiologist telling me that my life would be in a book, my weekends in a book, my nightlife in a book. I didn’t believe any of this. Well the rumors were true.

Medical school is the beginning of your life-long devotion to learning. You will spend the majority of your next two years (preclinical) in the library on a Friday night learning the morphological differences between Tropical Sprue and Whipple’s Disease. You will be a student of the 17th and 18th grades. And you had better be an expert at studying.

You will hear about the Cornell Method of note taking. You will flirt with concept mapping (CMap is the best program I’ve seen). You will swear by flash cards until the rubberband breaks sending your brain spilling across the floor. You will stick with the outline style of note-taking you learned in high school. You will see someone read the notes with a highlighter, achieve understanding, and then put it away until the test comes. You will hate that person. You will see someone that highlights too much, with too many colors, and has colored pens at the ready. You will see people with 3M sticky notes covering their cubicles, the organization making sense only to them. You will see people with too many other sources stacked around them, drowning in it.

Rarely will someone go to the student help center to learn about note taking styles and strategies. And that’s a shame. You’re going to study more and be tested more than any person that you know outside of this world. It makes too much sense to say that you should become an expert at what you do. So my advice to anyone in medical school or thinking about the plunge is to go to the bookstore, research studying methods, talk to an expert, and earn a black belt in note-jitsu. It’s going to be a long hard fight.

Public Speaker

In Pathology we have Clinicopathologic Cases. They’re cousin to the SOAP notes of Physio were a patient on paper presents with problems that neatly fit into that weeks’ lessons. In contrast to the SOAP note, the CPC is mildly terrifying. Our case this week is a 20 year old male that hit a pothole while drunk on his motorcycle and stopped at a tree, suffering serious trauma, a compound fracture with significant hemorrhage, and possible spinal injury. You’re working diagnosis at this point is “idiot”.

EMS arrives within the platinum ten minutes to deliver care. They get him to a hospital, work on his leg and get all of his vitals straight back to normal. He dies anyway from respiratory failure. Working diagnosis should now be “tree allergy.”

Everyone in my class of 350+ has this case, and while all of us think we know why he died, none of us wants to prove it. No matter, because our professor reaches into a bag with 350+ names and pulls one unlucky bastard to the front: not me. You can smell the collective exhale of that many students while they cheer the lottery winner to the front. He rereads the packet to kill time, asnwers what he can while getting a few things wrong, and is appropriately nervous. People like him and empathize, so he gets to avoid the tough questions.

Afterward I run into a few AAA-types saying how they wish they’d been called and were thinking about volunteering for the next CPC. I hope they let you; it’ll be a blood-bath.

This is what I think about when I think of doing clinicals in a year. Lay low, have the right answer if they ask you, but don’t be a dick about it.

Asthmatic Kite Runner

When I was kicking around the idea of being a doctor, my Neurophysiologist Uncle told me to read every book I ever wanted to read before going, because you wouldn’t ever read for pleasure again. I scoffed as I often do at such unbelievable things. Well, the rumor was true.

Today on Graham Azon’s blog (over my med body) he posted a pdf about a woman with perfect autobiographical memory for the past 26 years. I clicked it open and saw that it was 15 pages long. Well, I’ll never get to know about that lady becuase I don’t have 15 pages of free time.

And that’s the way I look at books now. A 350pg book isn’t some amazing journey through the life of such n such; it’s 4 days of waste with a 3rd place ribbon on my test (C). Nope, I’ll never know what it’s like to fly kites in Afghanistan. Too bad. Instead I’m learning about Asthma.

Though flying a kite would hit the spot right about now.

Should I Quit Medical School?

I remember the early days of first year when the work was hard and the labs were long and we had our hands in cadavers and our heads in biochemistry and we felt like some of the smartest people in the world. Everything is great, you’re dating new people and forming strong friendships and then BAM. The work is too much that week, that night, or that day and the peson next to you is getting it. They’re excited the way you used to be excited and life still feels easy to them the way you miss it. That feeling will hang around your neck as long as it needs to. It’ll keep hanging there until you have a conversation with yourself.

Why am I doing this? My friends back home are starting their jobs and making money and buying new things to make their apartments look nice so the people will want to sleep with them and I’m missing all of it. This is first year. It only gets harder. Why am I doing this? I could quit. I could quit right now and I’d only have $40,000 in debt to pay for my mistake. It might just be worth it. Maybe I should quit. Maybe this was a bad move.

And of course maybe it was a bad move for you. Maybe you shouldn’t be here and the smartest decision of your life would be leaving right now and cutting your losses. People stay though. They stay because they know a moron the year ahead of them, so figure it can’t be that bad if that guy made it. Some people stay because they don’t know what else they’d do with themselves. Some people stay because as much as it sucks, they can’t do anything else. The point is that the doubting doesn’t have to stop because you want it to.

I’m almost half way through 2nd year and I’m having a bad week. I don’t feel like I’m learning any of this Pathology and I’ve ignored Micro for three weeks now. It’s all going to catch up with me whether or not I catch up with it. And if I don’t suck it up and pull through then it’s going to sting real bad when I see my test. Feeling beat up and stupid is no fun, and it’s frequent enough that you often feel like quitting. But I remember exactly where I was standing on campus in first year where I had that important conversation with myself. And I remember my answer.

So I’m waiting for it to get better, plugging away while it isn’t and telling my problems to a stranger. All of it helps.

Everyone’s a Ken Doll

You’d think that at this point in our lives, as med students, that everyone would be comfortable with penises and vaginas. We are not. I remember as a first year in Anatomy lab there being seveal students that never laid a scalpel on the body and remained on the margins, their scrubs smelling just as bad as everyone else’s but missing the flecks of flesh. This would be laughable if it weren’t encouraged. Pick up a medical textbook and more often than not, instead of an anatomically correct drawing you get a Ken Doll, complete with nondescript genitalia and breasts that ride the border between overweight guy and underdeveloped girl.

So I was surprised today when I walked into Clinical Skills to see a video of a very curt Irish physician giving a full pelvic exam to a very hairy Jewish girl. I was more surprised than anyone, having heard so many stories about giving pelvic exams to manequins instead of prosititutes like the other medical schools get to do. I don’t know where I heard that, but I did.

So after a perfectly graphic demonstration of a female pelvic/anal/breast exam was an equally graphic male example. Checking for an inguinal hernia does not look fun.

“With your right index finger grab a section of free scrotal tissue and feed it up and into the inguinal ring, following the spermatic cord, where you may appreciate the internal inguinal ring.”

Now I applaud the folks that put the video together and the phsicians and patients that volunteered, but everything was still a little off. Hospital work, though repetitive and disgusting, does have a pot of gold at the end: you get comfortable. It took my around 11 months to get really comfortable to the point where I could talk to patients about their dying and regrets and family. Being able to speak frankly and honestly with a person that near death is special and should be mandatory. Imagine you’re dying slowly, having the chemo-book thrown at you, and everyone’s too busy being motivating and positive to say that, “Yeah, you’re dying. How do you feel about that? What are your biggest concerns and what do you want accomplished in the next few months?” Sure you throw a chaplain or two at them, but they aren’t part of the day to day care. That job should instead fall to the day-to-day staff: your oncologist and nurses and hell, even your techs.

My point about all this is that those physicians and patients were really off. The patients were too happy and compliant about their anuses and urethras and the physicians weren’t distracted enough. Your proctologist is bored with your anus. He’s seen thousands of them. Same goes for your OBGYN. The patients are not happy about your finger in their rectums. That hasn’t happened to them thousands of times and they want it to be over. They certainly don’t hop off the bed and shake your hand afterwards.

I’m not asking for much, just a doctor who’d prefer to do a quick exam and say your fine and a patient who can’t wait to hear it so that she can leave. They were all just too happy and it reminded me of the embarassed students in anatomy lab that didn’t want to see what a body really looked like, just like the video wasn’t showing us what a rectal exam is really like. I don’t blame the actors; I blame the director.

Soon, I hope, medical school will stop presenting the “Ken Doll” version of things and let Barbie know what she’s really in for.