The best analogy I can offer for the third year of medical school is that it's a roller coaster ride. It has ups, it has downs, and it has parts where your knuckles turn white as you hold on because you're 90% sure you're about to fall off. Both my parents are physicians, and I've heard (horror) stories about clinical rotations since I was in diapers (AKA high school). Nothing I heard, either from parents or professors, could have prepared me for the most strange and interesting ten months of my life. Looking back, there are so many moments I feel should be recorded, if not for entertainment value, then for posterity. Below you will find all my stories that I think are at least a little bit interesting. Some are happy, some sad, some just plain weird. Some stories have a point or a lesson, some just exist. Interpret their meanings as you wish.
I spent my two weeks of general neurology as part of a consult service. One of the patients we were called in for had developed what appeared to be bilateral sixth nerve palsy. For those of you who haven't memorized your cranial nerves, the sixth nerve helps move the eye outwards (ie the left nerve moves the left eye left). This patient, upon looking in one direction, found himself becoming crosseyed. This is highly unusual (and slightly disconcerting); most conditions cause disruption of nerve function on only one side, not both. The most likely cause was something raising the intracranial pressure, as these nerves are small and sensitive to those sorts of changes. It turns out he had developed a headache months ago, but had ignored it until his crosseyedness appeared. We suggested a thorough workup; there had to be an underlying cause...and there was. Upon obtaining a lumbar puncture (inserting a needle in the spinal canal to drain cerebrospinal fluid for analysis), it seems our patient had cryptococcal (a type of fungus) meningitis. Well, that's awfully strange, because healthy people don't usually get this sort of illness, and when they do, they show signs of infection (fever, chills, etc). The only plausible explanation was that his immune system wasn't working. Further testing showed he had an extremely active HIV infection, which he had never been previously diagnosed with. Needless to say, he was not in the best of moods. Fortunately he received care for his infections and his nerve palsy resolved. Months later, I learned that his struggles had not ended there; he developed IRIS, which occurs when the immune system bounces back with full force once HAART treatment is started. This can often be as devastating to the patient's wellbeing as the AIDS infection itself. Fortunately he did receive treatment for this as well.
One of the most interesting experiences was spending a day with the adult muscular dystrophy clinic. I had the opportunity to meet patients with the sorts of disorders that you only read about in textbooks: Fascioscapulohumeral disorder, Kennedy disorder, and others I'd never heard of. I was most impressed by how amicable the patients were. They were more than happy to explain their medical history, describe the struggles they dealt with before being diagnosed, and demonstrated which muscle groups were atrophied. I was impressed by their willigness to teach, in the hopes that they could inspire the next generation of medical professionals. At the end of my third year I was able to see one of these patients in surgery clinic. We chatted about his hobbies he had told me about at our first encounter, and I was delighted that my experiences with patient care had come full circle.
I also had the chance to go to the pediatric muscular dystrophy clinic. Whereas in the adult side, there was only one patient at each appointment, this clinic had appointments for the whole family. At one meeting, there was a mother with her kids, all with different degrees of Charcot-Marie-Tooth. Fortunately they all had mild cases, so we chatted about their classes and how the daughter couldn't dance ballet due to her disorder. In another room, I met an Amish family with four sons, all with Duchenne's muscular dystrophy. Duchenne's is a lethal disorder caused by fibrofatty replacement of muscle tissue. The only current treatment is steroids, which prolongs life but results in countless side effects. When I walked in the room, there was a child in a wheelchair who looked to be only ten. I was shocked to find he was eighteen; his growth stunted by years of steroid use. His brother was four or five, but was already exhibiting early signs of Duchenne's. I listened as the doctor discussed with his parents whether steroids should be started; whether the benefits outweighed the likelihood of a life full of side effects when the ultimate outcome is already known.
Twice a week, kids would come into the cerebral palsy clinic for treatment. Cerebral palsy is really a catch-all diagnosis for children who had abnormal motor development from birth for any number of reasons. Many of them have spastic paralysis, meaning their arms and legs are constantly held in a certain position. They come to clinic to receive botox injections or refills for their subcutaneous baclofen pumps, with the result being muscle relaxation. One girl I met was eighteen years old, a quadriplegic. She had difficulty speaking and her caretaker occasionally had to wipe drool from her mouth. The only difference between her and the other kids? She wasn't born with cerebral palsy. When she was thirteen, a stray bullet entered her home while she was doing homework and penetrated her brain. She spent months in the hospital, dealing with multiple surgeries and numerous complications. Some of the bullet fragments are still embedded in her brain. Even after all she had been through, she was one of the most optimistic people I have ever met. She told me how she had just graduated high school and was hoping to go on to get her college degree. I hope she follows her dreams, wherever they lead.
Many of the kids coming to neurology clinic were there for quick checkups. They often had ADHD, which required an appointment before refilling medications. At one visit, the doctor discussed updates with the mother. Her son, six years old, sat in the corner quietly staring at his shoes. I asked him if he was excited for summer vacation. He avoided my eye contact but quietly said "yes." I asked more questions about his summer plans. He told me his class was taking a field trip to "the Honey Hut." "Honey Hut? What's that?" Honestly it sounded like a name for a rural strip club, but he told me it was an ice cream parlor in his hometown. I agreed that it sounded like a pretty fun field trip, and I told him to have a good time. A few weeks later, I was sent to suburban Ohio for my outpatient pediatric experience. On my daily drive, I passed a Honey Hut. I stopped by after work once. The ice cream was good. He had good taste in ice cream.
One of my favorite patients on the inpatient psychiatry floor was a floridly schizophrenic patient brought in from her assisted living home for increasingly psychotic behavior. She was middle aged, obese, and unkempt, as if she'd just wandered in off the street. However, I enjoyed talking with her because she was always friendly and enjoyed having someone to talk to. Each day brought new delusions (beliefs running contrary to the facts); she told me she was a different species, sent here to protect us humans from "sitting ducks," among many others. One recurring delusion was that she had "a coumadin (warfarin) virus in her eye." According to her records, she had been treated with coumadin years ago for a deep vein thrombosis but was not currently taking any. Finally, I asked her if anything would help with this "coumadin virus." She flatly informed me, "broccoli." "Broccoli," I repeated? She stated again, "broccoli." Every day, I asked her the same question, and every day, received the same answer. I asked the staff if we could give her broccoli with her meals; they agreed, but broccoli was never served. Finally, on the last day of my rotation, I went down to the cafeteria at 7AM and asked for some broccoli. The servers gave me a weird look, but I obtained the broccoli. After confirming with my attending that this wouldn't mess with her medications, I brought the broccoli to her room. When she saw the broccoli, her eyes grew wide and she said, "it's beautiful!" I'll never forget the look of joy on her face as she ate the broccoli. I only hope I can bring the same joy to the rest of my patients.
Another patient who I met during my inpatient experience was a young man with a long history of schizophrenia admitted after possible suicidal behavior and being unable to take care of himself. He would spend almost the entire day pacing around the circular unit while constantly talking to himself. Not just talking, but often laughing at jokes only he had heard. However, any time any of us stopped him in the hall to chat, we would nonchalantly ask who he was talking to. He was give us an incredulous look and say "Talking to myself? Now that's crazy!" He would promptly walk away...and resume his internal conversation.
We admitted a man in his thirties for suicidal behavior. He had been diagnosed with schizoaffective disorder (schizophrenia plus occasional mood symptoms) in the past. During the interview, he was an extremely friendly individual. He explained that he had been admitted before, where he would be given prescriptions for antipsychotics which he would faithfully take after discharge. However, once he started feeling well, he would stop the antipsychotics, start using cocaine, the voices would return, and he would end up back in the inpatient unit. He realized this obviously wasn't working, and his wife had even threatened to take his children away if this behavior continued. I spent time talking to him about ways to break this cycle, the importance of his medication, and the dangers of drug usage. We even held family meetings with his wife, where he promised to alter his behaviors. He was discharged after a couple days, and I was hopeful that this time he was going to change, we had made a difference. However, I also wondered how many times this had already happened, how many promises, how many hopeful medical students trying to make a difference? I only hope he meant what he said, and he's being the father he needs to be for his children.
Not all moments in the hospital are child-friendly. We had to assess a patient's capacity to refuse transfer to a nursing home after she repeatedly fell at home and was not taking care of herself. I went to see her with the resident, and we found this small, shriveled elderly woman glaring at us. "Cut the bullshit and just go home, I don't want your help!" she kept saying. My resident was polite but persistent and continued to ask her questions. "Look lady," the patient would say to my resident, "leave me alone!" Midway through the questions, the patient stopped, looked at us, and shouted, "Lady, get ma' nurse; I'm shittin'!" She then let out a grunt that can only be described as "EUNGHHHHHHHH." I stopped, ran out of the room (not my finest moment), and found the nearest nurse. "I'm not sure who's taking care of this patient, but she went to the bathroom in the bed and needs help and I don't know what to do." I looked over as my resident walked out of the room, shrugged, and said "we'll come back later."
As part of my psychiatry rotation, I had to stay late on two evenings and help with inpatient admissions. My first night, a middle aged woman came in after a suicide attempt; she supposedly took over fifty quetiapine (brand name Seroquel, a type of atypical antipsychotic). I remember seeing this broken woman, sitting emotionless, as the intake nurse asked her a series of questions. I didn't think much of her until two weeks later on my first day of inpatient psychiatry when I found she was still admitted to the unit. I volunteered to be her medical student as I already "knew" her. She quickly bonded with me, as I would come in every morning and ask about her mood and any other concerns. She quickly opened up, telling me about the issues in her life as well as the different physical ailments bothering her. I expressed my concerns, although I quickly realized many of these were psychosomatic. Each day brought a new malady which she spent much of the day complaining about, though the next morning it had disappeared, replaced by an entirely new concern. One day she looked at me and said, "You've been nice to me while I'm here, will you be my doctor when I leave?" It was difficult to draw the line, providing adequate care while maintaining boundaries, especially when she felt I was the only one who genuinely cared about her. When it came time for discharge, suddenly her personality changed; she became manipulative and melodramatic. She had spent much of her life sitting at home and watching TV and her husband had recently divorced her, kicking her out of the house. She was frightened for what might become of her; she had no interest in going to a shelter after seeing what they're like in TV shows. Fortunately, with much dedication on her daughter's part (she was a social worker), we came up with a compromise for long-term housing, the possibility of work, and the promise for psychiatric follow-up. It was the perfect example of the social aspects of a patient's life affecting their care, but I think we were able to treat both her medical and social issues during her stay.
One patient was sent to us from the rehab facility down the street. He had been in a car accident, causing a neck and ankle fractures, but was not the most compliant patient. His girlfriend would visit, and after one visit he was found with his cervical collar off and crawling under his bed "looking for his dog." He was promptly sent to psychiatry to deal with his drug and other previously diagnosed psychiatric issues...although the inpatient unit had no capacity for the rehab he needed. Our daily interviews were cut short as he told us to go away and demanded pain medications. Although we reminded him to keep the C-collar on and remain in his wheelchair, we would often find him hobbling around the hall on his casts with his collar off, screaming "NURSE! WHERE'S MY ***** PAIN MEDS?" He did calm down occasionally after his requests were met, so at least that was a victory.
NKX2 is a gene which acts in the brain and thyroid. It also acts to produce lung surfactant, without which the lungs would be unable to expand and act in gas exchange. We had a two month old girl on my inpatient service who had a NKX2 mutation, which are exceedingly rare. She was unable to produce surfactant from birth, and could only survive with supplemental oxygen given through a nasal cannula. Even wtih this she was tachypneic (she breathed faster than normal). She also had a nasogastric (NG) tube placed to feed her, since she was unable to breastfeed and breathe at the same time. Her mother was with her constantly, always concerned for her daughter's health. However, she was also in denial of her daughter's condition. Since this is a rare genetic condition, she was initially told her daughter had pneumonia, and still believed this was the cause of her daughter's condition. She would also ask if this was caused by amniotic fluid aspiration, among other causes. She continued to deny that this was caused by a genetic mutation, even demanding that her daughter be retested and that there must have been a screw-up (even though only one lab in the country runs this test, and they would be the ones to re-run the test). No matter what the residents discussed or how much she seemed to understand, the next day she would be back at the starting point. To make matters worse, she refused to learn how to place the NG tube, insisting that if it fell out, she would bring her daughter to the Emergency Department and have it placed there. Finally, her daughter was discharged with all the necessary precautions (and plenty of oxygen). Unfortunately, a few weeks after I left my team, one of the residents informed me that the girl had to be readmitted because the mother, refusing to believe her daughter required the oxygen, had removed the nasal cannula. I'm not sure what happened to the little girl (sadly these patients have extremely short life-spans) but I hope her mother was able to accept the situation and come to terms with her daughter's health.
Another patient on the inpatient service was an infant born with a giant omphalocele. An omphalocele occurs when the intestines (and sometimes other abdominal organs) bulge into the umbilical cord. This normally occurs during weeks 8-10 of development, but the contents are supposed to return to the abdomen instead of remaining outside. Most omphaloceles are small, on the scale of a few inches and are compressed to return everything to the abdomen. However, her omphalocele was larger than her head; it was the size of a medium canteloupe. To make matters worse, since she had few organs within her abdomen, it had not grown to an adequate size to return the omphalocele contents to the abdomen. Any overly vigorous attempt to compress the omphalocele, and her respiratory functions would be compromised. In fact, to prevent this, she had received placement of a tracheostomy. It was a struggle between repairing her abdominal defect and preventing respiratory compromise. A condition like this can take over a year to treat, and may even require surgery for final repair.
One of the requirements for my inpatient pediatrics rotation was doing a "full" history and physical exam. "Full" can mean "ask every question you learned in the first two years of medical school" or it can mean "ask every question that is pertinent to this patient." It is often unclear which one is desired. I repeatedly asked which one was intended, and I was repeatedly told to do a "full" H&P. So I did. My patient was a young girl with cystic fibrosis requiring treatment for a nasty Pseudomonal (a strain of bacteria) infection in her lungs before she went off to college. The treatment was prophylactic, meaning that she didn't feel sick or have symptoms, but we were treating her before she developed any symptoms. I proceeded to ask her every question I could think of, then performed the most thorough physical exam seen on the pediatrics floor in a while. I even included a detailed neurologic exam, as I had just finished my month of neurology. The entire time, she was cooperative and never complained. After I left the room, the resident looked at me and said "you know you didn't have to do a full H&P, right?" I think I may have thrown my hands up in exasperation. She remained on the floor for the next week. Every morning I would check in before rounds, wearing my medical student white coat, a shirt, and tie. One morning, she looked at me and asked, "what year of nursing school are you?" I guess it's not just female doctors in scrubs that get asked the question. I will admit I was flattered, the pediatric nurses were extremely hard working, and I'm sure I could find much worse occupations to be mistaken for.
A young boy came in to clinic for a sports physical, I don't think he had any relevant medical history. The doctor was working through her exam when she paused, looked at me, and said "why don't you examine his abdomen?" Usually this is some sort of test for a subtle finding, so I was slightly apprehensive. However, when I palpated (AKA felt) his abdomen, I felt an ENORMOUS midline mass present in his lower abdomen. I pushed a little harder and asked "does this hurt?" He said no, it didn't. Had he noticed it before? No, and neither had his mother. The doctor left the room and brought back one of the other pediatricians, who confirmed the finding. Without raising too much concern, the doctor sent him for an abdominal X-ray, with a possible CT scan for follow-up. She told me the next day that the X-ray had been inconclusive, possibly showing constipation but other causes couldn't be ruled out. I never found out what happened to him; I really hope he was just constipated.
I'm not sure if this happens every summer (I think it does) but there was an outbreak of hand, foot, and mouth (HFM) disease during my outpatient experience. Children present with rashes on the palms and soles (one of the few diseases that causes this) as well as painful white lesions on the palate and oral cavity. Oftentimes, it is difficult to tell if the marks on the palms or soles is a rash or just marks from running around with bare feet. The key is getting a good look at the back of a child's throat, to see the white lesions. However, kids are less than agreeable to a strange gangly man looking in their throat. I became relatively adept at doing ear and mouth exams, because I wouldn't give up until I'd made a reasonable effort to examine the tympanic membranes and the back of the throat. Every once in a while, I would be rewarded with the victory of seeing the pearly white spots on the palate. I would turn to the mother and say (in my head), "ma'am, your child's got the HFM."
We had a patient come into the pediatric ED with a cough, fatigue, and hoarse voice. The first thing to pop into my head when she spoke was "hot potato voice." Oh geez, she's got a peritonsillar abscess. But the story didn't really fit completely. The attending was going to order a CT with contrast, but I begged her to run a monospot test. It really sounded like mono. I came back the next day, boom, mono. CALLED IT. But they also ran bloodwork and she had some abnormal white blood cells (totally seen in mono)...BUT it could be leukemia. So we couldn't let her leave until the pathologist confirmed it wasn't leukemia. Fortunately it wasn't. Then, 5 months later, I got mono. It sucked.
I was on inpatient peds the same time as one of my good friends. One morning during handoff, he came up to me with a concerned look and gestured for me to come with him. We went to a room, there was a ~6 month old in the crib. Supposedly he had some sort of neurologic disorder and was there for further tests. But my friend was concerned, the baby's pupils were pretty dilated, and one looked bigger than the other. What if he had a cerebral herniation? I was getting worried, and although the baby wasn't acting differently than other days, Isuggested he talk to his resident. Before we left, we noticed a bottle of drops on the table containing a drug we'd never heard of. About an hour later, I saw him in the hallway laughing. Turns out ophtho was going to examine the baby's retinas later, so they had pre-emptively dilated the pupils. Nothing wrong with being overly cautious.
I did a week in the newborn nursery. It was pretty chill, but we did go to any high-risk deliveries that occurred. One delivery I attended was for triplets. Unfortunately, two of the twins were identical and had twin-twin transfusion syndrome. This means one twin "donates" its blood to the "recipient" twin through the shared placental supply. Unfortunately, the donor twin was already deceased prior to delivery, but there was concern for the health of the recipient, as the increased blood flow can cause heart failure and other issues. The two babies were delivered without issue and given to the nursing staff for neonatal care. The deceased infant was placed in a separate area. I asked to see the baby, and the attending said okay. It was strange to see the baby; its blood supply donated to its sibling, it appeared a deflated tiny human, practically two-dimensional. The father was there, conflicting emotions of joy and loss on his face. It was probably one of the most difficult interactions I had dealt with up to that point in my third year.
I saw a late-term abortion during my OB/GYN rotation. They don't normally do them at the hospital, but this was an unusual circumstance. The patient had two previous children, had never received medical prenatal care. She preferred to use a "midwife" who provided more "natural" births. However, she was ~25 weeks along and started having some vaginal bleeding. An ultrasound quickly confirmed placenta previa (placenta growing over the cervical os and causing bleeding), but it also confirmed something worse. The fetus had major malformations; even if it survived to term, it wouldn't be able to survive outside the womb. Unfortunately something had to be done soon or else the mother would bleed to death, the only option being a late-term abortion. It was heartbreaking for the family, if they had received regular prenatal visits this could have been diagnosed and "treated" sooner with less distress. I went to the operating room after going with the resident to obtain potassium chloride (KCl) from the pharmacy. In the OR, the physician injected the KCl into the fetus, stopping its heart. Then, the real procedure began, known as a dilation and evacuation. First, her cervix was dilated. Then, the fetus and placenta had to be removed extremely quickly, as the mother was going to be bleeding if there was any placental tissue left. It's not a pretty procedure. Although everything went well, I wish that she had received care sooner and this situation wouldn't have happened.
Continuing the trend of depressing stories, we had to go to the ED a few times for patients with incomplete miscarriages. I can't imagine how hard it is for someone to already know they've lost their child, then need medical care to finish the process. One patient had started passing "products of conception," but the amniotic sac was still intact and wouldn't come out. The resident had to rupture the sac to remove it. I'm not sure how to describe that, so I'll leave it up to your imagination.
One patient had an interesting hospital course, with a happier ending. While on GYN surgery, we had a consult for a pediatric patient with a supposed ovarian cyst. We looked at the scans, this cyst was huge, and very torsed. She was 15 years old, so we had to confirm it with her mother. As a side note, the doctors tried discussing intra-operative IUD placement...but it turns out the daughter was conceived while the mother had an IUD, so they were less than interested in that idea. OB/GYN doesn't normally operate in the pediatric ORs, so it took some getting used to at first. But she did just fine.
One time on night shift we had two ectopic pregnancies in an hour. One of them had an abdomen full of clotted blood because she had waited a couple days before seeking medical attention for her abdominal pain. Sometimes it's okay to seek medical attention.
One of my most embarassing med student moments was when a patient came into OB triage complaining of painful vaginal bleeding during her 3rd trimester. Normally it was my job to obtain a good history, so I started asking her the usual questions. But she kept screaming and squirming. Finally, a resident came in and took charge. Turns out she was relatively well known, it wasn't her first baby. Also, she had abruptio placenta...because she was a cocaine user. Exactly like the vignette on exams. She delivered that night, the baby was just fine. Later, I came in to check on her (like a good med student should) and asked her how the baby was doing. She started ranting and whatnot, so I decided we had chatted enough and left the room. The resident saw me and said "you didn't mention her baby, did you? They're revoking custody because child protective services says she's unfit to be a mother. She doesn't have custody of her other kids either." Welp, I wish I'd known that before I went in the room. Not my finest moment.
Moms with who are Rh- can produce antibodies to the Rh antigen if exposed to an Rh+ fetus. This can happen during labor for their first child. If subsequent children are also Rh+, the antibodies can cause fetal hemolysis, known as erythroblastosis fetalis, which can be fatal. However, we had a patient found to be producing Rh antibodies...even though it was her first child. This is extremely rare; I couldn't even find a case report about it. She worked in the medical field, so it's entirely possible she'd somehow been exposed to blood from a patient. Still, quite unusual. She received RhoGam and delivered the baby without issue.
Once, I accidentally asked to observe a patient at the beginning of her labor. She labored for 3 hours before delivery. You don't realize how much awkward silence there is during the birth process until you've stood there awkwardly for 3 hours, interspersed with the patients screams, grunts, pants, crying, and pooping. Yes, ladies, you will likely poop while giving birth. And this was in front of her mother and husband. Props to you ladies for doing this, because there's no way I'd sign up for that.
One day, I was discussing with my friend how labor and delivery was the farthest thing from trauma. By a stroke of coincidence, the next day I found myself in the trauma unit, as an 8-month pregnant woman had been shot in the abdomen. Fortunately, she delivered the baby by C-section and both patients were okay. But it's not every day you get to round on a new mother in the trauma ICU.
My first patient of my medicine rotation was quite the adventure. He initially presented months earlier with ataxia, incontinence, and memory issues - the classic Normal Pressure Hydrocephalus triad. Neurosurg put a VP shunt in and thought nothing else of it. Months later, he came back, still confused. Neurosurg checked their shunt and were so sure it was working fine that they offered to write an "official letter" of proof. Well, labs came back, and he had a calcium level of 14. 14! I think they ran some further labs and gave high dose bisphosphonates. Labs showed low PTH, normal PTHrP, and elevated Vitamin D. He was an old white guy, was it myeloma? Sarcoidosis? I joined the team when he was readmitted for a renal biopsy; he had already received skin biopsies for a strange rash and bone marrow biopsies to look for myeloma. We ran every lab imaginable: ANCA, Strongyloides, PPD, HTLV, complement, ACE, and K/L light chain ratios. It was the craziest workup I had ever seen. Finally, the renal biopsy came back: it showed "granulomatous interstitial nephritis," which is often seen in the context of sarcoidosis. He was treated with steroids, his calcium levels returned to normal. A job well done by the medicine team!
I actually spent the first three weeks of medicine on the nephrology service. It should have been called the dialysis service, because 90% of patients came in for dialysis or dialysis-related complications. One patient was admitted for an infection, her labs showed her to have a bicarb level in the 50s-60s. I was a little worried, what if she had some crazy acidosis or alkalosis going on? However, my wise resident asked a few important questions and the whole story cleared up. She had a stomachache and ate a bunch of baking soda to soothe her stomach. Her body absorbed the bicarb, but couldn't excrete it because her kidneys were shot. Fortunately, a round of dialysis cleared everything up. The day was saved.
A less ending was the patient with calciphylaxis. It's a condition where calcium gets deposited in vessel walls and causes extremely poor wound healing, way worse than seen in diabetes or venous stasis. This patient already had her fair share of medical issues: diabetes, hypertension, and morbid obesity. She had fallen a couple times and the combination of diagnoses meant the wounds on her feet weren't going to heal for a long time. I remember feeling helpless; I didn't even know where to start with this patient, was she even going to get better? Eventually she was discharged, but she came back pretty much the next day. Some of her toes had become necrotic. I'll never forget feeling like a failure, unable to steer this patient away from the path she was headed down. Calciphylaxis has an extremely poor prognosis.
Sometimes going the extra mile pays off. Some days on medicine you have to work long shifts to pick up new patients. I had to stay late but it was a quiet day, so my resident said I could leave at 6PM if no one new was admitted. Of course, at 5:55, a new patient came in. My resident said "just go home," but it was my duty to meet the new patient and make sure she was okay. She was an older woman, 70s-ish, who had a few episodes of diarrhea in her nursing home and was admitted to our hospital. It seemed like the diarrhea had resolved and she seemed like she'd be ready to go home in the next day or two. Her daughter was on the phone, they lived an hour away and couldn't drive in that night but I promised we'd take excellent care of her mother and call with any updates. My visit was almost over, but I was a little concerned. I noticed she was breathing heavily, as if she couldn't catch her breath. She hadn't even noticed. I listened to her lungs anteriorly, as she didn't have the energy to sit up. They sounded clear. However, I was still a little worried, so I called the night resident covering our team to let him know about my concerns, although I was probably just a med student overreacting. The next morning, I found out the patient desatted overnight and had to be put on supplemental oxygen. The residents thanked me for the good warning, but I hadn't gotten the whole picture. A CT scan showed enormous bilateral pleural effusions, most likely caused by her history of rheumatoid arthritis and the source of her dyspnea. Fortunately, one diuretic drip later and she was ready to go home.
Another crazy patient situation was an Amish man with portal hypertension. I don't remember why he presented (probably GI bleeding), but CT imaging showed one of the biggest portal vein thromboses many of the resident had ever seen. It extended into the superior mesenteric and splenic veins! The scan also appeared to demonstrate a cirrhotic liver. This raised many questions: were the issues related? Did he have cancer causing the thrombosis? What caused his cirrhosis? How were we going to treat him? We started him on heparin and drew a plethora of labs. We ruled out alcoholism, infectious hepatitis, PBC, genetic causes, and anything else we could think of. We also ruled out 99% of neoplasms that could cause massive clotting. It seemed like a simple case of NASH cirrhosis, and he just had the bad luck to get it. He was one of my favorite patients; he and his family members would always have new questions to ask and would listen patiently as I explained liver physiology, anticoagulant mechanics, and other aspects of his medical care. However, one day his platelets were lower. Not margin-of-error lower, actually lower. That's not good... The next day they were lower still. I told my attending, we ordered a Serotonin Release Assay. It came back positive. My patient had HIT. He wasn't showing any symptoms, so we quickly switched him to enoxaparin and bridged to warfarin. That was close.
A middle-aged patient with severe developmental delay was admitted for what seemed like pancreatitis. CT scan didn't demonstrate obvious pancreatitis, but it did demonstrate a massive growth from the gallbladder taking up much of the right abdomen and growing into the liver. This was extremely bad. I can't even imagine what the discussion was like with his family; his elderly mother in her 80s still took care of him at home. I never found out what happened with him in the end, but I hope the medical staff did whatever they could to make him comfortable in the end.
Sometimes it's hard to help patients when they don't help themselves. A woman came in after fainting at her friend's house. She was visiting from Florida, and she "just happened" to bring all her medical records from the past three years. She was young, in her thirties, and had a history of syncope and bradycardia which had been treated with a pacemaker. I sifted through the paperwork, there was some concern for autonomic insufficiency (AI) but she hadn't been able to get a full workup yet. She had an interesting presentation which could fit (AI), but it didn't totally fit together. It was possible she had conversion disorder, or maybe even some malingering. Who brings their medical records to visit a friend in a different state? But I wanted to give her the benefit of the doubt. I showed the paperwork to the neurology team, and I tried calling the autonomic evaluation lab. But most people just wrote it off as conversion disorder and moved on. She was stabilized and discharged. There's a good chance I had the diagnosis wrong and it was conversion disorder, but I hope she finds whatever help she's looking for, for whatever diagnoses she has.
There's quite a variety of older people, and I had a chance to meet a few during my week on geriatrics. One woman had emergency glaucoma surgery, and all she wanted to do was curl up on the side of her bed. I'd help her up, tuck all her blankets in, and as soon as I'd walk away she'd roll right back to her spot. Another woman was there with concern for mild dementia. She told me she liked to travel, and her favorite place was "The Holy Land." She said she saw the Dead Sea, and "the place where Cain slew Abel." I ask if she had the chance to see the Western Wall. Her eyes widened and she exclaimed "Oh Lordy Jesus YES!" We were best buds after that.
I did a week of night float the same week as the presidential election. But I won't talk about how I had to watch the election slowly progress, the results coming out, and watch as the incredulous news articles trickled in until 7AM. My highlights were learning how to place IVs from the nursing staff. I didn't have much to do, so I went around to each floor and asked the charge nurse to page me if she had patients needing IVs. Soon the pages rolled in. Most of the IVs were way too difficult for me, but a few kind patients let me give it a shot. One nurse joked that she had a patient who needed a suppository, and wanted to know if the "med student" would do it. I looked her in the eye and said completely serious, "what time and when." That night, I put in my first suppository. Maybe my last, but who knows? I also saw my first real code, but what I didn't find out until later was that it was one of my patients from my day team who had to be readmitted and eventually passed away the next day. (Un)Fortunately, there were so many people in the room that I was only able to see from afar.
My resident was running behind with patients, so I offered to talk to one of them in the meantime. As soon as I walked in, the patient started yelling at me about everything. She shouted about how she'd been waiting forever, how she was in horrible pain, and how she could barely leave her house. She sounded like a mess, and she looked like one too. I had scanned her medical chart minutes before, she had every comorbidity imaginable and had to get around in a wheelchair. I apologized profusely and asked what I could do for her, but she kept shouting. I wasn't going to give up, and I kept patiently asking her to tell me more about why she seemed so angry. Bits and pieces began coming out, how she felt sad all the time, how she wouldn't go spend time with her family, and how she wanted to stop being so sick. As I asked her more questions, she calmed down. She'd complain less and less about how much pain she was in, or how no one would help her. All she really wanted was someone to talk to. Finally, I suggested she might benefit from talking to someone slightly more professional than me, but she wasn't having any of it. She rejected any suggestion of speaking to a therapist, but she did agree that maybe she should spend a little more time with her family. A small victory, but a victory nonetheless.
Another woman came in with the complaint of abdominal pain. I interviewed her but she barely made eye contact and appeared extremely sad. Thankfully the attending came in and knew exactly what to ask. Soon, the woman was crying, telling us how she was a single mother working two jobs, and although her family lives nearby, they had made no effort to help her at all. She couldn't remember the last time she felt happy, and hadn't been taking her psych meds or seeing a therapist. It was powerful to see this woman open up to us and talk about her extremely personal issues. The attending spent a lot of the visit either quietly listening or sitting in silence. It was powerful. Finally, she discussed the importance staying on the medication and starting a relationship with a therapist. She provided information and phone numbers, and promised that she was always there if the patient needed her.
One patient came in for follow-up after having three necrotic toes removed. He used to sell drugs on the street (literally), and one time he stood outside for waaaaaaay too long in the cold so he ended up with frostbite. He also told me he once cheated on his wife because "the chick was hot and how could I not." I dunno man, I dunno.
I had to come in on a Saturday to round with my Gen Surg team. I figured that I'd get to go home after rounds, but little did I know that I was in for a day full of ADVENTURE. It started with a patient who needed an emergency exam under anesthesia for multiple perianal abscesses. Watching the surgeon drain a bunch of butt-pus is the best way to start the Saturday. After that, a female patient had what appeared to be appendicitis...but after a diagnostic laparoscopy and a OB/GYN consult, it turned out she just had a really big tubo-ovarian abscess. Then a patient was transferred with a globe rupture. He had went to the bathroom at 2AM but fallen asleep on the can, falling face-first into the bathroom door. Not often you get to see an ophthamologist come into work on a Saturday! Right after that, I was able to assist with placement of a femoral rod for a midshaft fracture (I think he'd been shot, don't remember). It's amazing how much bone marrow oozes out when you drill right through it. I finished off the day with a patient who had his hand "degloved" in an industrial accident. All the skin on his hand had been stripped off, only attached at the fingertips. Quite the variety of patient presentation.
I found myself in the plastic surgery OR one day, they were wiring a jaw shut. The patient had been assaulted by group of people, and it was fractured in a couple different spots.
Here's how to wire a jaw shut: First, put the patient to sleep (duh). It's gonna hurt. Then, bolt a piece of metal to the gum line of both the upper and lower jaws, with little hooks over the teeth. Don't place the screws too deep, otherwise the metal will wear into the gums. Next, place loops of wire around the hooks and tighten down to hold the jaw in place. Now you can wake the patient up, but don't forget to give him a wire cutter. If he's going to vomit, he needs to cut the wires. Otherwise he might breathe in his own vomit...not good.
One of my favorite patients from my surgery rotation was a 30s-ish Spanish-speaking woman who was found to have colon cancer and required a sigmoidectomy. They had only moved to this country recently when she began having symptoms and was eventually diagnosed. No idea how she developed colon cancer at such a young age. Every morning I would try to greet her with what little Spanish I know, and her husband was there to suggest new phrases to add to my repitoire. Seeing her daily improvement was one of the highlights of my day. After she was discharged, I was able to see her come to clinic for a follow-up visit, she was doing great!
I spent some time on urology during my rotation, and had a few days in clinic. And by clinic, I mean seeing ~100 patients in a day. We moved FAST. One patient came to the office with difficulty urinating and other symptoms of BPH. I told the resident, so he came in, quickly told the patient he had BPH, prescribed Flomax, then told him to follow-up. Before I walked out of the room, I mentioned to the patient that "BPH" stands for "Benign Prostatic Hyperplasia." He said "okay, but what's a prostate." It was hard not to stop and stare. I sat back down and drew him a picture of his anatomy, explaining where the prostate was and what it does. Sometimes in medicine, we have so many things on our mind that we forget what the patient is there for and how best to treat him or her. It's hard to treat a patient for BPH when he doesn't even know what his prostate is.
A little girl accompanied her mom to the clinic one morning. While her mom and the doctor discussed medical issues, the little girl looked at me and said "draw me a duck." What could I do? I drew her a duck. It was a damn good duck. I even signed it. Someday when I'm super famous, that piece of art hanging on her fridge will be worth millions of dollars.
We had a really sick patient in the ICU. They had done a colectomy and weren't even sure if he was going to make it. He was intubated, full of edema, with poor kidney function. We would visit him every day, but his prognosis seemed pretty poor, even if he improved a little bit. Then one day I showed up and he wasn't in the ICU anymore. He was on a regular nursing floor. We went to see him; he was sitting there eating a cheeseburger. I'll never forget watching this guy, who had been completely sedated the previous day, just chillin' there eating a cheeseburger like it was no big deal. Medicine can do some crazy stuff.
A older woman was admitted for diverticulitis, she had been living in a shelter for some time and hadn't been taking proper care of her colostomy bag. The procedure was prolonged; her stoma site was herniated and necrotic, the surgeon was unable to primarily reconnect the colon after resection, and she was found to incidentally have a mass in her stomach, which was removed. She was admitted to the ICU for issues with maintaining oxygen saturations, where she was restrained for becoming combative and agitated. Every time I talked to her she was pretty calm, I think part of the isue was that no one explained her situation to her. She knew where/when she was, what was going on, and would even crack jokes. One time, as I was leaving her room, she told me "I'm gonna rip this shit up tonight!" then cackled to herself. She was a weird old lady, but probably not crazy. Her stomach mass was diagnosed as a variant of a GIST tumor, so she was cured via the resection.
I did one overnight trauma shift during my surgery rotation. It started off with a 10 year old boy who only spoke Romanian who had punched through a plate glass window, slicing his arm open almost to the shoulder. We took him to the operating room and although his major blood vessels survived undamaged, it took over an hour to suture up his entire arm in a tight baseball stitch. Later, EMS brought in a man who had gotten drunk (and possibly high) and crashed his car into a parked car. He called multiple residents (male and female) "sweetheart" and when the cops tried to calm him down, he'd shout "you're killin' me smalls!" I was able to bond with a drunk college student who had somehow fallen and hit his head, with an active bleeding vessel. After controlling the bleeding, I sutured up his scalp laceration. It made it much easier that he fell asleep in the midle of suturing.
If you ever get the chance to see a CABG, take that chance. CABG stands for "Coronary Artery Bypass Grafting," it's what people mean when they say "bypass surgery." One day I didn't have any cases so I thought I'd check one out. It's probably one of the coolest procedures I've ever seen. The surgeon sawed the sternum in half, isolated the internal thoracic artery from within the pleural cavity, then got ready to hook up the heart to the bypass pump. Watching him cut and saw through the layers appeared extremely unrefined, but then again this was only the prelude to the actual surgery. It was unbelievable to watch the lungs inflate, the heart pumping right in front of me. Then, they stopped the heart and the real surgery began. The surgeon was meticulous, carefully suturing each vessel graft to its rightful place on the heart. He then brought the chest wall back together with some well-placed extremely large wires. Although I have no interest in CT surgery, I have a new appreciation for heart surgery and what it entails.
Medical TV shows glorify medical codes and CPR. An elderly woman was in the ED for respiratory failure when she lost her pulse. The residents and nurses ran into the room, and I jumped in line to perform compressions. It's strange, pushing on a stranger's chest, not knowing if your efforts are in vain. She regained a heart rhythm, so the residents prepared to place a subclavian central line. She coded twice more during the process but was brought back each time. Sadly, she passed the next day after being admitted to the hospital.
My ED resident sent me into a patient's room, all we knew was that she felt there were "bugs" in her skin. I entered the room to find a large, disheveled woman with numerous scabs on her arms and legs and a slightly confused look in her eyes. She launched into a story about bugs and worms coming out of her skin. She pointed out a paper towel with bugs on it (there was nothing there) and showed me a pill container turned into a bug container (containing only bits of scab). When asked where else she had these scabs with bugs, she whipped off her gown, sitting naked to point out scabs on her breasts and buttocks. I quickly and politely asked her to re-gown. At first it appeared to be a psychosis, but the more I asked, it appeared that she was just picking bits of scab and believed it to be bugs and worms. I reassured her multiple times, and dermatology had already taken biopsies of the scabs. At least she left with the knowledge that she was neither crazy nor growing bugs in her skin.
A Spanish-speaking woman was brought in by her sons after stating repeatedly that she was having abdominal pain...which was caused by her neighbor zapping her with laser beams. At first I tried getting history from her sons, but then I realized I would need privacy, so I obtained the translator phone. However, as soon as I started asking the important questions, the phone cut out and I couldn't get the translator back on the line. I don't speak much spanish, but in the little that I know, I explained that I needed to perform a physical exam. Upon examining her abdomen, I found it covered in bruises; had she falled, was it abuse, or something worse? She kept pointing to her groin and complaining of pain as well. However, I also noticed that she was sometimes having difficulty answering basic questions in Spanish; did she have some delirium? The sons confirmed that their mother was acting a little stranger than normal. Unfortunately I left before the workup was completed, but I believe the consensus was that she had developed a UTI and it led to delirium.
A patient came in from the womens' prison with what appeared to be tonic-clonic seizures. She was loaded with benzodiazepines and phenytoin. However, upon examination of her records at another hospital, it appeared that she already had an extensive seizure workup and she'd been diagnosed with pseudoseizures. She would use the seizures to get out of prison, although she'd usually go right back. Well, this time she just went right back.
Most patients with alcoholism complications are pretty old. Not this patient. She was 35 and was in the ED for drainage of fluid from her abdomen (ascites), a common complication of alcoholic cirrhosis. When I walked in the room, the first thing I thought was "wow, she's super yellow." She was ridiculously yellow. She had super yellow eyes, and even though I think she had an olive skin tone, her skin definitely had a yellow coloration to it. The good news was, the fluid wasn't infected. The bad news was, her liver was probably permanently screwed.
This was one of the worst things I've witnessed in medicine so far. I showed up one morning and went to find my resident. I found him in one of the acute medical bays with and intubated patient laying there, all the monitors beeping. I asked him, "what's going on with her?" He responded, "she's dead, she coded and we just stopped CPR a minute ago." Wow. This was the first newly dead person I'd ever seen. We left the room to go take care of other patients.
A couple hours later, the social worker came up to my resident to let him know the family was in the meeting room, and that they didn't know their family member was dead. I walked with him to the room and entered. There were 5-6 women of different ages and a young girl playing on the floor. I avoided eye contact as I didn't want to make it obvious that I already knew what was going on. One woman asked for an explanation, and the doctor said "I'm sorry, she was found near her car, EMS picked her up, we performed CPR but it wasn't successful, she's dead." The room exploded.
You know those families on "The Price is Right" that jump around all excited when someone gets picked to be a contestant? Picture that, but with sadness and anger instead of joy. One woman slid off her chair and into a heap on the floor. Another let out the loudest ear-splitting scream I have ever heard. Some of them just kept shouting "I can't believe she's dead! Dead!" I didn't know what to do, so I just froze and stood their. The social worker comforted some of them, providing tissues. Finally, our resident quietly said "let's go" and we walked out of the room. Everyone deals with death in different ways, it's our job to comfort them when they need it, and to provide space when they need that too.
A patient came to the ED after having blurry vision for a few days. He said he woke up one morning and just noticed that his vision was blurry in both eyes, bad enough that his glasses didn't work properly anymore. He didn't have any loss of vision in either eye or in any of the vision fields. It happened when he woke up, and wasn't a gradual change. He denied eye pain and floaters. He hadn't noticed any other neurologic symptoms. His only medical history included chronic back pain, for which he took narcotics (and occasionally self-treated with heroin). What are you thinking? Personally I had no idea. I tried looking up "acute blurry vision bilaterally" but nothing appeared in the search. One resource "possibly" suggested it could be some sort of stroke, so I asked the attending if we could get a CT as a long shot. Upon return of the images, it turned out he had multiple tiny infarcts in the occipital regions, likely the cause of his blurred vision. Sometimes, a lucky (educated) guess is all it takes.
I did 3 months of urology rotations back-to-back. Here are just a few of the many things I saw during my rotations:
I spent a month on trauma, including 15 days straight on night shift during one of the busiest times for trauma. I definitely got the chance to improve my suturing skills, and to see a whole variety of patients: