Nothing Crazy today...just reset a drunk drivers dislocated elbow, talked to a screaming (but thankfully restrained) woman who had become violent and psychotic after taking an overdose of xanax, did a few blood draws, placed an IV, and did a few dopplers and ultrasounds

Actually more than a few...it was like national bilateral leg edema/ rule out pulmonary embolism day

and got to watch and assist on a lumbar puncture...though i was not the one who put the spinal tap in...this time, anyway.

And now for a week of night shifts. Hello vampire sleeping schedule.

Still having fun, but i will be glad when i can finally relax for a bit in family med

SO yesterday was my first day of Emergency Medicine, henceforth ED or ER for those of you inundated by pop culture. The morning started off with an orientation at the not-quite-inner city hospital i will be spending the next month at, where the concluding part of orientating was a suture clinic on pigs feet.

Now let me tell you, at the end of that clinic i was thoroughly convinced that If my pig had been alive, he would have been screaming and trying to run away, and failing from the gaping wound in his foot caused by my open sutures.

And yet a mere 12 hours later, I was suturing on a real person who would do neither. But let's back up a tad, shall we?

ED is on a shift schedule, meaning you work 8 hour shifts which are pretty much assigned at random. My first shift was the 10pm to 6am, of which I have another tonite, causing me to switch to a vampire like sleeping schedule. SO lets break it down by hour, shall we?

10pm: Arrive work. Think this doesnt look at all like the TV show. Introduce myself to the attending for the night and a few of the staff, get sent to see first patient, a chronic schizophreniz with a colostomy bag. Do you know what a colostomy bag is? It is a bag placed outside your body to act as your colon...basically a balloon of poo on the outside. Gross? Funny? You decide...i couldnt, because professionalism requires me to keep a straight face. Decide the schizophrenic has nothing immediately wrong with her and she is on her way to discharge

11pm: Next patient is a little kid with croup. Pretty simple, just learning to manhandle children for the physical exam, that things go easiest when you sit them on their mothers lap, that you can look into their mouth from above instead of below, and making goofy noises during your entire exam will be much more comforting to the child then the mother.

12am: Down time since there are 2 other students working on the trauma side of the ER who I have to share patients with. Write some notes, look over and notice a bottle of irish rose whisky and colt 45 on ice. Wonder aloud what they are doing there...informed that they were confiscated from a patient and are being kept cold. Next wonder for whom...

1am: Look up at list of incoming patients...one chief complaint is the patient "drank pine sol" Why? Because it smelled so lemony fresh he thought it would go down that way just as easy? Maybe he had a problem with streaking and mistook it for the windex? WHo knows, not I

2am: Patient comes in with huge laceration on his arm from several glass cuts. After a soccer match, he went to his sisters and knocked on the window "a little too hard" Too hard being a 6 inch long laceration down his forearm exposing the muscle, though not down to the bone. First things first, we do a bbi on him...meaning place ultrasound gel on his wrist, and the PA (physicians assistant) moves the speaker around til we hear his pulse, and then I inflate the blood pressure cuff to listen to the numbers at which it dissapears and reappears. This is done for each arm, and the numbers are compared to see if the ratio is an acceptable limit...it isnt so trauma from surgery is called down to evaluate

3am: Following the surgical eval, it is time to suture the lacerations up...and guess which med student gets to do it? YEP. The one who at 10am this morning was having trouble suturing a pigs foot. Not that the patient was going to be informed of this. Thats what you get for going to a teaching hospital folks. So first things first, we irrigate the wound with sterile saline to wash out a bunch of blood and debris. This is followed by a lidocaine injection performed by yours truly...around each of the corners of the wound, a constant stream to make sure the entire area is numbed enough for a med student to suture. Thank goodness, because if i had to do it without him anesthetized it might have turned out like the pigs foot

3:15am: look at gaping wound in pts hand, idly wonder about zombie bite. SHake head, realize I am tired.

3:30 finally its time to start throwing sutures. First things first...the resident sutures closed the muscle tear, because that is a little too important to leave to a med student whose first patient it is suturing. Then the fascia layer is closed by both myself and the PA, with a tie known as a vertical mattress tie to place less tension on the wound. Takes longer to do, especially since neither of us knew this tie before tonite, but he is numbed up enough to not notice. Then the resident leaves us to close up the most superficial layer of skin because he can see we are capable of handling it.

4am: So the first couple of instrument tie sutures i throw to close the skin are not pretty...but the patient was told that given the size of the cut, he is going to have a scar anyway, and its on his forearm not his face, and he has no clue of my relative inexperience and i am certainly not going to tell him

JOSH'S RULE #176: ACT LIKE YOU BELONG, AND PEOPLE WILL ASSUME YOU DO

The initial laceration required about 9 stitches to close and by the end i was doing just fine with tying, and spacing, though still leaving a little too much cord at the tail end to get cut off...oh well that will come with experience. And there was no screaming by the patient, no doubtful questioning by the family member present, no sniggering by the PA, and no wtf by the attending and resident who came back in to check the sutures...just a good job, next time try and place them a little further from the wound.

5am: Place the last few stitches in the gentleman, a total of 9 in the largest cut, with another 6 underneath those, then 4 in the next largest cut, and 2 in some minor cuts. I am a suturing machine with a sore back.

5:30am...avoiding all patients, finishing up paperwork

6am: leave the hospital after first overnight call

7am:arrive home, fall asleep

1:10am: wake up, have breakfast, go to xanga so you could all share my story.

And remember, if anything goes wrong during the next month...

-J

After 2 months rotating in internal medicine, I am finally beginning to feel like I have a handle on things. My History taking skills are pretty solid, my physical exam could still use some work, but what i do, i do well, even my assessment and plans resemble the ones actually decided upon by the residents. I also can totally relate to the characters in scrubs.

The other day I was percussing a patients liver span, basically going through the motions like I had been taught in school, since I still had no real idea what the change was supposed to be, when all of a sudden, the percussion sounds changed. As in, I realized that without realizing it, i had actually begun to perform the exam correctly, and what's more, I realized I was doing it correctly. I continued to percuss the patients liver and then spleen amazed at my newfound ability. A piece of the puzzle had finally dropped into place.

Of course, being the mature young future physician that I am, in my head was playing on repeat Queen and David Bowies "under pressure" while i was percussing the abdomen to the bassline. "Doo Doo Doo Doo Doo Doo Doo Doo. Doo Doo Doo (tap tap) Pressure! pushing down on you, pushing down on me no man ask for"

Any pain when i press sir? No?

"Under Pressure-burns a building down, puts people on streets um ba ba dey"

I think he can be discharged tomorrow after a scope

"Its the terror of knowing what the world is about, watching some good friends scream 'let me out'"

Patient needs a colonoscopy, is declining, and requesting to sign out AMA (against medical advice)

But yeah you get the idea. My life the scrubs episode.

Another great moment I should share happened not to me, but my friend. He was taking a sexual history on an teenage adolescent and asked about partners, activities habits and the like. He then had to come back and mention to the patient on a completely unrelated note that she had a flare up of herpes type 1 (for those of you wondering, this is the one which give you cold or canker sores, occasionally vesicles on your lip, and is NOT sexually transmitted). Of course, when he delivered the news that she just had an outbreak of Herpes type 1, or oral herpes, the patient got quite offended and yelled back,

"That's impossible! I don't suck dick!"

*chuckles* oh, those patients.

So my medicine rotation comes to an end this friday, and looking back, I would say I have enjoyed it greatly, both the experience itself, and those I interacted with during the rotation. As I make and update the list of fields I may want to go into this year, here is how things currently stand

Josh's Career-O-Meter

Internal Medicine- Absolutely stays on the chart...about 60% of medical students go into IM out of med school, and it looks like I may not be different. In terms of specialties within IM

Infectious Disease: Who Knew? I love seeing ulcers, abcesses, draining pus, and figuring out what exactly is going on with the patient. The more disgusting the better, and once you do know the disease, you immediately have an idea what antibiotic to start. This one stays on the radar, and it only has a 2 year fellowship! bonus!

GI: How best to describe what I enjoyed about GI?

that ought to do it well. And believe me, it is true true true

Cardio: meh. Not super excited about it, but neither am I repulsed. It stays on the mind for the moment
Nephrology: Same as Cardio, though I dont get excited about the kidneys the way I do about the intestinal tract

Lets watch as the career o meter advances through the year, shall we?

My new favorite webcomic (i am up to reading 8 on a regular basis now), as introduced by my good friend uclari

-J

Because poop is funny to me, as should be patently obvious by now

It had to be said. Also, in another brief intro for you all into med student life and the ways it warps your thinking...

I had to perform 4 rectal exams today. My previous number of exams performed before today was 4. I actually performed as many rectals in one day as i did all last month. During one of the rectals, I am pretty sure that somebody's poop got onto my white coat. Now blood on my coat...understandable...I totally signed up for that when i got into med school...heck its even a little cool, like a tacit affirmation that you were saving someone's life and too busy to pay attention to what was splattering where.

But poop on your coat...not so much. And in spite of all that, I still consider today a GOOD day at work. Not like a well it was okay, or could have been worse, or just run of the mill day. It was actually a good day, as in days that reaffirm my decision to go into medicine. And when i realized that, I both laughed and cried a little inside. My thinking has been so twisted that poop on my coat is not even high enough up on the irritation meter to register.

2 weeks left of medicine, then I start ER for 4 weeks. Ooh the anticipation

-J

-J