Tag Archives: Rotations

The real “ER”

When I think about my childhood and what I imagined I’d be doing when I get older–Dr. Mark Green from the series “ER” comes to mind. I grew up every Thursday night watching the show with my mom. I loved everything about the gritty, fast-paced drama. When some gruesome scene of a thoracotomy came on, my mom, turning away from the screen with a look of horror and disgust, would say, “you really want to do this in life?!” And I would sit there grinning, wide-eyed…and nod my head, yes, I can’t wait.

I’m very much still the same person who turns towards the terrible things in life. Twenty years later, it is in the Emergency Department where I feel most comfortable in the vastness that is medicine. It is unpolished, unapologetic, rough around the edges, a meeting ground of people from all walks of life. It takes a certain personality to want to spend time there. I am privileged and humbled to be there to help.

The heart of emergency medicine is what we call the “undifferentiated patient”–in layman’s terms, a patient with a complaint but no diagnosis–it is up to us–the Emergency Medicine folks to try to figure out what is causing your chest pain, stomach pain or swollen calf. We hone in on your story, symptoms, vital signs and labs to begin to narrow down from the hundreds of possible diagnoses the two or three life-threatening ones. It is our job to make sure you don’t have them and treat if you do.

Every patient is a mystery diagnosis. We don’t know you. Many times we’ve never met you or have the luxury of previous notes from your regular physicians. Yet we get to figure out what is wrong with you. Our job has been described as the most exciting 60 minutes of every speciality. And it is true. We get to see almost every diagnosis in medicine.  

Unlike the TV shows, our job is not always full-throttle, chest tubes flying, ribs cracking, shocking people (we don’t even use those paddles any more). It is some combination of charting, bedside procedures, discussions with patients, discussions with consultants and juggling a million and one tasks at once. I will say, twelve hours in the ED can fly by in a blink.

As I finish up my second month rotating in the speciality, here are the most exciting, the most typical and the most unusual things I’ve come across:

  • The normal stuff-Charting: No TV show ever shows just how much time we spend documenting. It would bore most viewers to death if they had to sit through our clicking. But that is a huge part of what we do. We pick up patients when they turn “red” on our screen (that is, the patient is finally in a bed after waiting for a very long time for that bed to become available) and after our 10 minute conversation and physical exam, we spend often double that time making sure we meticulously document our encounter. In today’s age of complicated medical coding systems and reimbursement it is just part of the job.
  • The normal stuff-Placing orders, waiting for results: After we meet you, our investigation begins. Even before we set foot in your room we begin critically thinking about the potential causes of your complaint and what path we’ll need to go down. Emergency medicine is very chief complaint driven. That is, whatever symptom is bringing you here must have a cause and in our department we love ruling things in and out-specifically the scary stuff. We geek out on pre-test probabilities, most likely scenarios, typical presentations and making sure we never ever miss anything that can kill you. That is our job in a nutshell. We place orders to relieve your symptoms and investigate the cause. Often this means juggling multiple patients and checking back on our results, re-accessing, going down a different path based on what we find. TV shows never show just how calculated our job is. Emergency Medicine doesn’t exactly have the best reputation of being the “thinking” speciality, but I beg to differ that we actually ponder and digest just as much if not more than the internal medicine folks–for us things are just done at a faster pace. Things can change in an instant and we are constantly on guard, re-prioritizing, changing course and staying on top of the very dynamic place we call the ED.
  • The exciting stuff: Yes, Emergency Departments get the sickest patients. We have to move quickly when things are going terribly wrong. We get to put in airways when you are about to stop breathing; chest tubes when you collapsed your lung or have a pleural cavity filled with blood; we place central lines when your blood pressure is low and your body is in septic shock; we even put needles into the sac around your heart when there is blood constricting it from beating; we stich up foreheads after bar fights and reduce shoulders that have popped out of their socket. We pretty much get to do lots and lots of amazing, adrenaline inducing procedures. But those are the sorts of things that break up your shift, most of the time we are just seeing patients, thinking about them and charting.
  • The abnormal but normal to us stuff: We get to see some of the oddest things that can happen to a person. Some visits are heartbreaking. Some are humorous. Some are really annoying. Others catch you off guard. We see the best and worst of humanity. You absolutely never know what is about to walk through the door and that makes our job so unique.

The past two months have been the best. I love all the mundane, the exciting, the normal and the difficult parts of my future career. Each of my rotations has been very different, building on my skill set and continuing to add to it. I’m so excited about the career path I have chosen and very proud to call myself a future ED physician. I have one more EM rotation ahead of me and then the process of applying for residency!

 

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I’m Back, Let’s Recap (Step 2 board stuff)

To my amazing readers:

We really need to catch up! My last post left you somewhere near the end of third year. I was grinding out my last two rotations and feeling fairly uninspired. You see, it took all the reserve I had left to keep coming into clinic just as excited as my first day of rotations. I ended the year with ambulatory and family medicine. Two rotations that are classically considered “easy.” Working less than 40 hours a week, having weekends off and getting home by 5 pm was so foreign to me. Paradoxically, I tend to be less productive the more free time I have. A combination of a really long year and a lack of stress propelling me forward left me struggling internally to maintain my tireless enthusiasm. There was no sense of urgency. Even the medical cases were non-emergent. Well, I did have one blood glucose stick of 38 we had to call an ambulance for–and that was the most exciting thing that happened.  Needless to say, those two months dragged. I reconfirmed that my type of medicine is the worrisome kind–at least ruling it out.

I moved from one day being the last day of my rotation to the next day starting 4th year. I began the year with a Step 2 study block.

Board exams are basically the worst thing you ever have to do in medical school. Period. No matter how prepared you are, they are always terrible.  I tried to take away some lessons from my Step 1 experience–mainly that I needed to calm down, so I approached the 4 weeks I had to study much more relaxed this time. I was surprised I didn’t freak out once. Probably because I spent the last two days before the exam dancing around my living room. Doing the Dougie, even terribly, will kill all last minute nerves. Try it.

My study schedule consisted of waking up at 8 am, doing question blocks in Uworld, taking notes, reading my notes, and doing more questions, then going to bed around midnight just to wake up and do it all over again. I kept an excel spreadsheet and ended up doing about 2,900 practice questions. I also took three practice NBME exams. NBME number 4, 6 and 7. My actual score was within 2 points of NBME 4 and 6 and 18 points higher than NBME 7. (Don’t waste your time taking NBME 7 unless you are doing it just for additional practice questions.)

The exam itself was just as terrible as Step 1. 9 hours of answering questions leaves you feeling miserable and delirious. Even though I felt I totally failed, I did not sit and cry in my car this time, instead I took a celebratory selfie and moved on. I purposefully didn’t allow myself to think about the exam at all. If I felt my mind slipping back there I immediately redirected my thinking. This was because I actually thought I failed the exam. Only to find I did incredibly well. So just remember, feeling like you failed is inversely related to your score. The worse you feel, the better you did!

With that monstrosity behind me I FINALLY began what I have been waiting for: my Emergency Medicine rotations!!

Since I will be matching into EM, the beginning of my 4th year is filled with three, 1 month EM rotations: my home institution, a Kaiser hospital and a county program. Because EM deserves its very own blog post I will leave you here. All I will say is Emergency Medicine is awesome and any feeling of lassitude immediately dissipated the second I saw that neon Emergency Room sign. It is perfect for me.

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Photo I took during my away EM rotation. Southern California.

 

 

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1st Break

I’ve been on vacation for exactly 14 days now. It’s amazing how quickly I’ve made the transformation from over-worked, dark-under-eye-circle concealing, one-track mind, med student zombie to a life of carefree leisure. I’ve been wearing make-up, blow drying my hair, going to the movies, not setting an alarm clock, seeing friends, spending precious time with my family, updating my closet and decorating our house. All things I forgot I seriously enjoyed. One could get used to this. For those of you not in medicine, the list above, taken for granted by most people reading this blog, are actually a rare luxury during medical training. Luckily, I have 4 more weeks before I start my next rotation. Sometimes working hard until an overdue, extra-long break is worth the sacrifice.

To catch my readers up on my life: Since I last wrote, I finished my pediatrics rotation. Tiny people patients are awesome. They are guaranteed to make you smile no matter what type of day you are having. I definitely enjoyed inpatient pediatrics more than clinic, but that is because I prefer acute medicine. Case in point, the time I enjoyed clinic the most was when we had to send one of our patients to the ED because they were too sick to be in our office. Identifying critical situations is kind of my thing…the thing I hope to do as a specialty.

I’ve completed 5 out of 8 rotations, with just a few more months of third year left. When I look back I can’t help but feel happy that I can put all that hard work behind me. It’s kind of like getting to mile 19 of a marathon, you’d be feeling pretty good you are there, but if someone told you there was a mistake and you need to re-run that distance–well you’d probably feel devastated to do it again.

After all that running, it feels great to hit pause. I need this time to soak in what I’ve learned and let my brain compartmentalize. To enjoy medicine. Funny enough, I still want to read, to do practice questions, even more than when I had to do them for the shelf exams. What can I say? Medicine is a deep-seated passion, even while on vacation.

Because I am not the type of person who can just leisure for too long, January is filled with exciting projects, including a research elective, supporting a dear friend’s campaign to provide girls education in the developing world, photography and spending a few days here and there in the emergency department. Not a bad way to start off the year!

I also turn 30 this month. So there is that. I’ll be celebrating with my best girlfriends of almost 20 years, doing a mini-road trip in Northern California.

Stay tuned. This month should be a good one.

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Ob/Gyn Life

To my neglected blog and readers, let’s catch up!

I successfully finished my psychiatry rotation with a clear understanding that psychiatry is not for me. It was the first rotation I’ve been on, where I wasn’t excited to go to the hospital. Work actually felt like work. The hours were wonderfully short in comparison to hospital life yet the days dragged on. I can’t put my finger on exactly what it was that didn’t appeal to me–in theory, psychiatry is fascinating– but it just didn’t grab me. Feeling ambivalent about your day is the surest way to cross a specialty off your consideration list. Done and done forever.

In comparison, this past week has been invigorating. I started my obstetrics and gynecology rotation and I am loving life. Driving in when it’s still dark out, seeing the sun rise above the hospital and knowing that I’ll be scrubbing in on gyn surgery, while the rest of the world is just waking up makes me feel alive. I love when things are happening–the busier the better. I like the fact my patient progress note is due by 6:20 am because we have a full day of surgery ahead and who has time for rounding. I love how hands-on everything is. It’s true, my back is killing me from standing and I arrive home too exhausted to cook dinner. Somedays, the thought of going upstairs is too much to bear and I end up falling asleep on the couch. The physicality of it is tough. It’s also tough to imagine going through life being this tired. But despite how draining the day is, I feel so incredibly fulfilled by what I am doing. I think that in a nut-shell is the dichotomy of medicine.

This past week, I’ve had time for exactly one thing–surgery. Unfortunately, that means my singular interest consumes my life. For two weeks, my marriage can easily handle that but much longer and I can see why doctors have such high divorce rates. I have a great husband who’s picked up dinner, vacuumed the house and even woke me up with Starbucks this week. But eventually, he’ll want a wife again. But this is the point of 3rd year of medical school– you get to put yourself in the life of various specialties and try on that life. Spend a few weeks walking in their proverbial shoes and see if you can handle it. We’re all looking for that perfect pair that fits just right. So far, I’ve felt most comfortable in my Emergency Room sneakers 🙂

In any case, I digress, I have 5 more weeks of ob/gyn which will include two weeks of clinic and two weeks of nights/days on Labor and Delivery service. What makes the rotation manageable are 4/6 weekends off and a dedicated lecture/study day on Fridays. This is the first rotation where I’ll be graded not only on my medical knowledge and interaction with patients but my (limited) technical surgical skills. Perfecting various suturing and knot tying techniques is certainly a new challenge for me–but it’s also really fun!

That’s it for now. I am quite literally too tired to write more. Until next time!

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Kids as Patients vs Brain Surgery

I’m wrapping up my Neurology rotation with 2 weeks at a children’s hospital–aside from having (mainly) adorable patients here is a list of things that have made this service particularly awesome. If you go to my school this list of “perks” may help you decide when picking between peds neuro, neuro surgery or ICU care.

  1. The hospital is colorful. Like seriously, there is a theme to every floor. You can’t help but smile when even the architecture of the building has color in mind. It is also a brand new hospital so everything is very modern.
  2. Parking is free. FREE!
  3. Parking is close! (when you savor every minute of sleep you can get, saving yourself 5 minutes of walk time is worth its weight in gold).
  4. Breakfast is free! The food is amazing with fresh fruit, pastries, yogurt parfaits, bagels, coffee. When you are a poor med student you can be easily swayed by the little things in life like starting your day with a full-healthyish- stomach.
  5. Lunch is free! I can’t rave as much about the lunch, but I will say it is 100% better than any of the other free lunches at other hospitals. It is always catered, so if you are not a vegetarian like me, you’ll probably love it.
  6. The electronic medical record is easily one of the best choices around. Super easy to look up stuff.
  7. The residents are super nice.
  8. The attendings are super nice.
  9. The patients are hilarious. Case in point, I was trying to examine my first little patient of the day and he looks at me and says “excuse me, you are interrupting my cartoons.” Absolutely the cutest.
  10. You have NICU patients. The tiniest, sweetest, humans around.
  11. The hours are very tolerable. Typically I start my day around 7:20 am so I have time to see my old patients and read briefly about any new ones I will be picking up. You have morning report (free breakfast!) at 8 am, which includes an hour discussion about one particularly interesting case and the teaching points involved. Followed by time to see and examine your new patient before rounds start around 9:45am. Rounds typically wrap up by noon lecture (free lunch!) followed by time to write your notes, check in on your patients before you head over to the main medical center for afternoon lecture at 4pm. You are free to go home after that, which is usually either 5pm or 6pm.
  12. Being able to put parents at ease is very gratifying. It feels tremendous when you can send a child home and they are all better.
  13. This hospital sees some of the rarest childhood illnesses you’ll come across. In one week I’ve already seen two cases of Guillane-Barre (overall incidence of 1 to 2 per 100,000 per year). You are guaranteed to learn a tremendous amount. The cases are all very interesting.

Now to the alternative….instead of peds neuro you have the choice of picking either neuro surgery or neuro ICU care. I was able to get a glimpse of the high of neurosurgery while on-call one night. This was the first time I’ve ever scrubbed for a case and it will easily be a memory that stays with me for a lifetime. The excitement of being in an OR is hard to describe. Furthermore, being in the OR when emergency neurosurgery is involved is like putting that excitement on steroids. Few things in life are as surreal as looking down on a human brain. The whole time I was standing in that OR I just kept thinking to myself how lucky I am that I am in this profession and have the absolute privilege of being in this room right now. The whole world disappears when you have surgical tools in your hands and get to watch someone literally fixing the human body. Of course, as thrilling as that experience is, picking neuro surgery as your elective comes with a price. You will have exhausting hours (think 5am start times), high stress, high pressure–yet all that comes with the prize of being in the OR. So choose carefully.

My favorite part of my neurology experience has been the camaraderie with my team. Everyone has been so eager to teach and learn. I’ve enjoyed all my co-workers. Actually, maybe I just miss having co-workers. Being in school full time was certainly an adjustment. Now I get to have a little bit of that feeling back of what it’s like to be around people you work with! Although I don’t get a paycheck, and the teams change all the time, it is nice to feel like I am working again.

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Inpatient Medicine: A Review and Survival Guide

I just wrapped up my first rotation of my MS3 year–8 weeks of inpatient medicine! Now that I’ve had the weekend to de-stress, enjoy some quality time vegging out with good movies, take-out and my very handsome husband who I’ve missed–I wanted to devote this post to a run-down of the rotation and my hints for success. Think of it as one med students’ mistakes are another one’s treasure?

What is it: Inpatient medicine covers almost every aspect of medicine. If you get “admitted” to the hospital and you are not critically ill enough to be in the ICU, the inpatient medicine team will be the ones taking care of you. For details about how it all works see my previous posts. (Daily run down) (Inpatient medicine post)

Typical day: This rotation is one of the brutal ones–so just be prepared to be tired all the time and go in knowing that you won’t see your friends. You may not even see your cat, but you’ll learn a whole hell of a lot. There will be days you will get home and you will be unable to do anything except plop down on the couch and nap until the following morning–yes, skipping dinner and all because it’s almost 9 pm anyways and you need to be up soon. But don’t let me scare you. This will be one of those good types of tired, where your body and mind are exhausted, but your heart is happy. It is the type of tired you only get when you are chasing after something you truly care about. It is the tired of medicine. The one that makes you feel alive. Welcome friend. Yes, my feet were sore but my heart was happy.

Schedule: The schedule is 6 days on, 1 day off per week of your choosing. The hours were something between 6:30 am and 8:30pm, although depending on your senior Resident you may be going home at 5pm. My advice, don’t schedule your day off on a no call day because you are wasting a valuable shortened day. Depending on your location you will be long call (meaning you admit patients until 7:30pm), short call (meaning you admit until 6:30pm) or no call meaning you don’t take any new patients after 5:30pm (woo hoo!). If you take off a week-day as your scheduled day off then you may miss out on some lectures/didactics, but that also means you are working during the weekend, and the weekends are much chiller and they usually let the med students off earlier than usual. So just see which you prefer. Don’t make any grand plans for your day off, you will want to sleep. And to be honest, you’ll need to recharge. Rest– a lot. Also, you’ll have to study.

Studying:  Now that I just told you all about how tired you’ll be, well, dig deep and carve out 30 minutes each night to do some questions. Trust me, it will save you in the end if you can do even a handful of questions each night. The options are either MKSAP (now called IM Essentials) or UWorld. I am on the fence about which one is better for the shelf. The shelf exam questions were much shorter than MKSAP but MKSAP covered most of the topics you will need for the shelf. If you do all 500 MKSAP questions and maybe another 200-300 Uworld questions you should be in fairly good shape. The key is that you actually understand the answers. The shelf, as well as the oral exam are testing key concepts. Bread and butter medicine like chest pain, AKI, COPD, shortness of breath, asthma, edema, GI bleed, thyroid disorders, neoplasms, etc.

What to know:
-You should aim to know differential diagnoses for the main chief complaints people get admitted for
-Presenting symptoms and
-What differentiates one diagnosis from another based either on symptoms or labs
-Key labs and any work up that will need to be done
-And then of course treatment plan

If it seems overwhelming at first, it is. For the first 2 weeks or so I felt like a real idiot. But eventually, as you begin to see cases these “symptoms” start to come to life in the form of real patients. You will easily be able to recall what your team did for Mr. Johnson, the GI bleeder in bed 8. The best advice I received was to read up on my patients’ conditions. You will always have 10-15 minutes of down time so spend that time reading UptoDate or Step Up to Medicine and getting some background information on the condition you are treating. This is seriously golden. Several things may happen as a result: 1) you will actually understand what is happening to your patients and why you are implementing the treatment plan you’ve outlined 2) you will understand critical things to look out for or complications you are working hard to avoid 3) in going to UptoDate or a similar source you may find that there are new guidelines/recommendations and you can share those with your team 4) even if you have nothing “new” to share, you can always help your team understand a medical topic in more depth by putting together a short little memo or presentation.

How to Be a Rockstar MS3: This brings me to the most important information. If you want to succeed on your rotation my advice is simply this: don’t be lazy. Don’t cut corners. Be eager. Be passionate. Show up with 2 missions–1) you are there to learn and 2) you are there to be an advocate for your patients. If you show up early, volunteer to stay late so you can see that late night lumbar puncture or the new interesting case that just got admitted at 7:30pm– people will notice. If you see your resident isn’t sure what the dosage adjustment is for renal impairment go to UptoDate and find out for them.  If you get a Turner’s syndrome patient and the team isn’t sure if renal anomalies are part of the syndrome, look it up for everyone and present to your team. Learn your patients really well. No one should know your patient better than you. Go see them in the afternoon, even when you don’t have to. Go check on them after they get a CT and keep checking the computer until the results are read. Explain your patients condition to them–this is the best way for you to check if you truly understand it. Make yourself available to your patient’s families. Be confident. Believe in the skills you’ve amassed up to this point. Don’t start your rotation feeling like you are “just” a student. You are part of the team and depending on your own outlook, desire and work ethic, you can become an essential part of the team.

Below is a list of things you can do on your rotation as the “student”:

1. Learn your patients’ condition and treatment

2. Talk with your patient and their families about their condition and treatment plan

3. Examine your patient thoroughly, doing the complete physical exam, even if others on your team skipped it

4. Page consults and explain what we need from them

5. Observe procedures and ask to assist or learn to perform things like arterial blood gas, lumbar puncture, wound dressing, I&D, etc.

6. Call the lab for critical lab values

7. Go down to radiology and look at scans with the Radiologist

8. Call the pathologist and discuss results of a new biopsy with them.

9. Call down to radiology to see when your patient will get their MRI, CT scan, etc.

10. Check labs throughout the day and inform your resident with your recommendations for corrections, new treatment plans.

You will learn a tremendous amount on this rotation. Prepare yourself for hard work and you may actually enjoy it quite a bit. Spend time with your patients, make them feel cared for and take in as much knowledge as you can. Just like before, the best way to learn is through repetition. So do questions, read a ton and have fun!

Final words: inpatient medicine is challenging yet rewarding–make the most of it and it will be a great foundational rotation that all the others build from.

 

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