My last day of medical school

I got to the hospital at about 6:00 am in the morning and none of the other doctors / team members were there yet. I decided to round on all of our patients that we were caring for and treating. I would enter the room of each patient and ask them how there night was and perform a focused physical exam depending on their pathology and also look for any new problems. I would then check with the overnight nurse and document any overnight complaints or problems. For example one of my patients had tried to escape and was found outside having a cigarette. Noted. I really did not mind this as this patient has terminal cancer that has metastasized throughout his entire body and his days are numbered. I had to tell the patient this was not wise and that he could not just leave and smoke. In my mind I was thinking "smoke 'em if you got 'em" at this point.

Another goal of pre-rounding on the patients is to followup on all of the consults, and procedures we had ordered from the day before to see what kind of progress had been made. Did hospice come and see patient #1? Did social work find a nursing home placement for patient #2? Did anesthesia do the epidural for patient #3? Did the infectious disease doctors see patient #4 and make their antibiotic recommendations? Did ortho come by and evaluate patient #5 who is recovering from the total hip replacement they did several days ago and have still not followed up, despite numerous calls and begging attempts. The answer to all of these follow up questions at the government hospital is unfortunately no.

This makes the day's work frustrating and stressful as I need to followup with the various specialties and needed services and kindly beg to get the work accomplished. I was all over it and started making my calls to there various doctors and one by one started to get the list taken care of and checked off. While doing all of this I have to document everything and of course deal with new situations that pop up. The nurse will come in and exclaim "Patient #2 has low blood pressure, what should we do?" I would respond accordingly and make the orders and run them by my senior to verify that he agreed and we would move forward.

The day was busy and there was not a lot of time to think about how this was my last day of medical school. Finally at around 6:00pm my senior looked at me and said "isn't this your last day?" and I replied triumphantly: "Yes" and he said "go home already!" I quickly grabbed my stuff and made a dash for the exit before I could get pulled into another crisis. I walked out the front door of the hospital and walked toward my car. I was dumbfounded and even emotional but it still had not sunk in that I was done.

I am done....

Sub Intern in a Socialized medicine hospital

Here I am finishing up my last rotation as a medical student and I chose to do this part of my training at a government hospital. This is socialized medicine. All the patients are seen free of charge and all the doctors, nurses and ancillary staff are paid by the government. The doctors do not have to carry the same type of malpractice insurance because they do not get sued and if they do the US government steps in as the one being sued so the doctor faces a different form of liability than a private doctor would face in a regular private practice.

The first thing I have notice is that no one really wants to work. Everyone spends a lot of time trying to avoid work. If the emergency doctor can refer the patient to the medical floor he/ she will and if the medical floor doctors can get the patient admitted to the ICU or surgical floor or somewhere else they will do it. There is a ton of pass the responsibility at all levels of care. Often the patients are left confused and wondering what is going on because no one takes the time to communicate the plan to the patient.

I am not saying that nothing gets done or accomplished because we are treating lots of patients but we are very inefficient and slow. Often our hands are tied because the CT scanner is backed up or ekg tech has exceeded the government allowed number of ekgs so they have to stop doing ekgs for the day. There is red tape and paper work which makes doing very simple tasks like taking the patient's temperature a 7-10 page document that multiple people have to sign off on each step of the way. This creates many opportunities for error and many bottle necks in the process.

A patient that would be in a private hospital for 23 observation gets trapped in this government hospital for 3 - 5 days and have multiple tests and unnecessary things done or necessary things not done because of all the red tape and confusion. Imagine the DMV. It is a lot like the DMV and there is almost zero customer support. No one looks at the patients as customers but rather the patients represent more work. It is really sad.

On the good side, because I am motivated and want to learn a lot I am able to get procedures and do things that I might not get to do at a private hospital. The patients are very grateful for even the smallest acts of kindest. They are not used to being talked to in a nice manner, so when I say "Hi Mrs. y, how is your morning?" She grins and appreciates the gesture.

More stories to follow. I have seen a bunch of complicated late stage cancer this past week and some other crazy illnesses.

jack of all master of none

I pose this post as a question to readers of this blog or those who stumble across it by accident. Please feel free to comment and add your thoughts or opinions.

As I finish up medical school and get ready to start residency I have found myself in many conversations with friends, family and others where medical topics are discussed. Often a question will be directed at me directly. Sometimes it is a group discussion and I may give an opinion or a thought regarding a medical topic within the conversation.

I am a little sensitive to the idea that I amy come across as pretentious "know it all" large ego pride filled "doctor" when discussing medical topics. Sometime I have caught myself starting a comment with the words "I tell patients......." or "Often I explain ..... to my patients ......" For example, the other day a group of my friends and some family members where sitting around the table and discussing life when one friend brought up the subject of headaches. Everyone was talking about different things they have heard or have read about different types of headaches. Some shared their own experiences with their headaches and everyone was casually discussing the topic.

In this particular group I was the only person who works in the healthcare field. At some point in the conversation I made a comment that started with "I like to tell my patients, ....... about their headache and ..... about their treatment options." I was asked a couple of medical questions about headaches and the conversation continued with others sharing their knowledge or comments about headaches. Eventually we moved onto a different non-medical discussion about something else.

Ok, so where am I going with this and what am I babbling about, what is my point? I do not want to come across to people as a pretentious egomaniac. I was not making comments out of turn or interrupting the discussion or correcting anyone and maybe I am worrying too much about it but this is my question.

Do you think it sounds pretentious to start a comment or statement when discussing a medical topic or even a medical question directed to me by non-medical people if I start the comment or response with "I tell my patients......"?

I have not had any bad reactions from anyone or looks from people that would suggest that they think I am acting high and mighty but I want to avoid sounding like a egotistical know it all. On one hand I think when I start a statement with "I tell patients ......" it may sound like or come across like I am saying I have treated thousands of patients with (fill in the blank), when in fact I am trying to say "with the patients I have seen or treated with (fill in the blank), I have found..." In some cases it may have been several patients, in other cases it may have been only a small number of patients that I have seen thus far in my training.

Feel free to share your thoughts and comments and suggestions. I have been seeing and treating (under supervision) patients on some level / degree for the past 2.5 years across nearly every field of medicine in 2 week to 8 week blocks and have directly or indirectly worked with 1000's of patients on some level with lots of different diseases. For example when I did my neurology rotation I worked with at least 100 patients on some level with headaches.

You kind of get to see a little bit of everything on some level during your rotations but are not an "expert" on any of it. It is like being a jack of all trades and master of none as you wrap up your medical school training and get ready for residency.

I am "wet behind the ears" and I am very young in my career / life long training. I have a long way to go and I am certainly not an "expert" on headaches or any other illnesses at this point. The nice part about medical school is that during your clinical training year you get to see a little of everything as you rotate through all the different specialties but you really start honing in on your "expert" level training during residency which I will begin shortly.

I do not want people thinking "he thinks he is hot stuff and is in the beginning of his training and talks like he has seen thousands of patients with (fill in the blank)." I never want to be one of those doctors that thinks he / she is a god and then end all be all expert. I certainly do not want to come across as a pretentious, pompous "know it all" either.

Let me have it and give me your thoughts. Should I stop saying "I tell patients ......" or am I overly sensitive? If you think I should avoid saying, "I tell patients ......" what would be a better way to convey a response or comment regarding a given medical topic?

Thanks.

Research and Waiting

Currently I am doing 2 week elective and senior independent research paper. In other words I have 2 weeks to write a paper on a topic of my choice that will be a learning experience for me and possibly a document that my school could use to help medical students as they start their clinical rotations.

My topic = The most common chief complaints (CC) at emergency departments and the differential diagnosis (DDx) for these ailments. While researching this topic it was easy to see what I already knew that if you approach it from the "most common" you quickly see that the most common are not necessarily what an Emergency Physician needs to master. Many of the most common complaints / presenting patients to the ED are not true emergencies but rather primary care type chief complaints and they seem to always occur at 3:00 am.

For example. At 3:00 am on one shift a patient comes in and says hey I am constipated. After examine the patient and doing a thorough physical exam and realize that this is not an emergency. He had been battling with the constipation on and off for 6 months but for some reason at 3:00 am on this thursday night he decided it had become an emergency. He did have a good case of constipation but no primary care physician and did not have insurance. He was intoxicated and rather belligerent. So I decided that I take care of the patient. Ultimately after some enemas I digitally disimpacted the harden fecal mater in his bowel and this relieved his issues. I started him on a regimen and treatment plan to improve his diet and cut back on the drinking and smoking and sent the happy patient on his way. Not really an emergency. It could have possibly developed into an emergency but when I saw him at 3:00 am it was not an emergency.

I decided to change the topic of my paper the 10 most important chief complaints in the emergency department and the to DDx for each. One would be a chief complaint of chest pain and I wrote out in detail all the possible different diagnosis that it could be and how you would narrow it down to make an accurate diagnosis. Just to name a few it could be a myocardial infarction, pneumothorax, pneumonia, fractured rib / flail chest, mallory-weis tear, pancreatitis and etc, etc the list goes on and on. No need to bore you here.

Part of being a good / great emergency physician is being able to quickly and accurately diagnose and treat many different life threatening illnesses. However you get your fair share of non-emergant pathologies as well and you have to be able to manage these illnesses and manage all the different colorful personalities that may show up on a given night. No one said it was not interesting and I happen to love the chaos and the never ending unbelievable stories that show up as patients to be treated and helped to heal. There is a saying in medicine that says Emergency Doctors always have the best stories to share at social gatherings.

I have to finish up this project this week and then I start a month long rotation doing internal medicine at a VA hospital. Government medicine at its finest. I will have some great stories for sure so you may want to stay tuned.

Age of the younger Tox Patients

There is a general rule regarding toxicology patients. Generally fro age 0 - 3 we see lots of accidental exposures to toxic substances. This is the toddler that gets his / her hands on mom's or grandpa's medications and gobbles them down or the kid that drinks bleach or some other substance. These are usually accidental exposures.

Children at the ages 4 or 5 - 12 this is a relatively a calm period for accidental exposures or intentional poisonings. Any of exposures in this age group the physician must consider medical conditions that require medications and possible interactions of the medications or too much of a given medication or possibly child abuse, either by neglect or by munchausen by proxy.

Children at ages from 12 or 13 and older and above have toxic exposures by suicide attempts or accidental overdoses in drug abuse. Teens start experimenting with drugs at these ages and also some teens attempt suicide by pills. The physician has to be aware of these trends and make sure to fully investigate all of these possibilities when the patient presents to the emergency department.

This is toxicology!

What is Toxicology?

I completed a 1 month rotation in clinical Toxicology. So what is toxicology? Like everything else in medicine it is a complicated question. A clinical toxicologist usually completes medical school and then completes a residency in emergency medicine (3-4 years) followed by a 2 year fellowship in toxicology.

A clinical toxicologist will usually work as an emergency medicine physician part time and then work as a consultant in toxicology where they get consulted on cases where a patient has overdosed or taken a poison (intentionally or accidentally). The toxicologist will come in and see the patient and make recommendations on how to treat the poisoned patient. These consultations usually come from emergency medicine doctors or the poison control.

The clinical toxicologist will also usually be professor tied to an academic teaching hospital and will spend some of their time teaching about various toxic exposures that occur to patients. Their job includes several different roles which makes it an interesting field.

As one toxicologist told me; "Everything in medicine is tox related"

I matched at my #1 spot

In order to keep some anonymity I will not post my actual place of residency. Those who know me like friends, family and others will already know the location.

However, I am very excited and will say that I did match at my #1 choice. That is great and I feel blessed as there are many this year who did not match and some of the program directors of the residency programs were saying that this was the most competitive year they have seen, meaning that they received many more applications for the spots this year than they had in prior years.

I feel like everything lined up and I was fortunate enough to not only match but get my top choice. Like I said, I was blessed.