WILTIMS #305: Think twice

Today was a day of high soaring rhetoric and then a 3 hour lesson on child abuse. Since the former is far more fun to write/read about than the latter, I'll stick to that. 

As of this year we are, for all intents and purposes, doctors. The burden of doctorhood is, as of now, in effect. What burden you ask? When you go into medicine, you are given amazing privilege. You get to learn and do things very few people get to do and you get paid well to do it. The burden is that you are never not on the job. Compared to nearly every other profession (police are another good exception), when you clock out from doctoring, you are still expected to behave in a manner becoming of a doctor. This is because doctors' jobs are predicated on trust and actions off the clock can damage that trust just as much as actions while wearing that white coat.

In surgery, there is a saying: "Think twice; cut once." Now is the time to build the knowledge so that you can second guess yourself in the future and possibly save a life.

TIL: If a history of child abuse is discovered on a patient after that patient has already turned 18, it cannot be reported to child protective services... it can, however, be reported to the police.

Sorry it was a little uninteresting today; I promise tomorrow should make up for it.

WILTIMS #304: Stick it to 'em

Today we completed a right of passage in the medical field: we stabbed each other. Specifically, we stabbed each other in antecubital veins with a 23 gauge butterfly needle, i.e. practiced drawing blood from each other's arms.

It was a little nerve wracking to practice on an actual person, but as with the prostate and female pelvic exams, I am so grateful to get to practice this on a live person who is not my patient. And just like with those exams, we were given a mannequin-like piece of plastic and rubber to practice on first. You can see the quite literally disembodied arm that we had to practice on. It's about as high tech as it gets, but it was still nothing like practicing on another person, let alone a friend.

I love how everyone came together to support each other. Med students are often told they are many things: smart, dedicated, type-A, crazy. But sometimes I forget how kind they can be. We are all nervous about both today and the weeks to come as we finally put our studies to practice. We have been reminded repeatedly this week that we are both talented, for having made it this far, and human, as we will no doubt soon prove. So as we nervously stuck each other with needles, I loved to see this anxiety channeled into comfort and support for each other. A special thanks to my classmate Cyril for letting me photograph her as she voluntarily allowed a first-time phlebotomist wield a needle at her particularly shy veins. S'ok though, my old roommate Brian's got her back. We have scary things to come this year, but I think we'll be fine so long as we each watch each other's back.

TIL: A spiral CT is actually a misnomer. A spiral is two dimensional (think of those spinning hypnosis spirals you see on TV). A "spiral" CT is actually a helix - a three dimensional spring-like shape (à la the DNA double helix). A helical CT is done by continuously moving the patient through an x-ray machine that spins in a circle. This creates a ribbon-like helical image which can provide a much more rapid comprehensive scan that a conventional slice-based CT scan.

AP and PA chest x-rays are theoretically the same but different in practice. AP stands for anterior-posterior, and PA is posterior-anterior, each referring to the direction of travel of the x-rays through the body. There is a small difference in the size of the tissues in reference to each other due to the different angled paths the x-rays take through the body, but otherwise, as x-ray images are two-dimensional, the direction that you shoot them shouldn't matter. The actual difference is in the way that each is shot. A PA chest x-ray is taken with the patient standing against a detector with the x-ray at the other end of the room. An AP is often taken from a portable x-ray machine with the patient lying in bed. The decreased distance allows for more distortion of the image due to the less parallel paths of the electromagnetic waves. Thus, though they are very similar, PAs are usually preferable to APs.

WILTIMS #303: Now that's what I call soap!

Amusingly, the day after I whined about the basic nature of our hand washing instruction, we were taught how to scrub in for surgery. If you never thought someone could have an anxiety attack just practicing washing their hands, you'd be wrong.

TIL: The scrub procedure for our hospital:

• Wash your hands normally (wet, lather, apply friction for a good 30 seconds, rinse, dry with paper towel)
• Open your pre-soaped sponge and fingernail pick set
• Wet your hands
• Use the fingernail pick to clean under your fingernails
• Discard fingernail pick and pick up the pre-soaped sponge
• Quickly lather the soap and spread the suds from your hands to your elbows
• Now return to the fingers and, using the bristled side of the sponge, scrub ten times on each of the four sides of each finger, thumb, palm, lower arm and the two inches above the elbow
• Be sure to move distally to proximally from the fingers on both hands to the palms of both hands, etc
• This must take at least three full minutes or you will be asked to do it again
• Discard the sponge
• Rinse each arm, one at a time, starting from the fingers to the elbow making sure to always have the angle of the arm such that water only drops in the direction from the hands to the elbows
• Keep your arms in that same position and back into the OR, butt first, where a nurse will give you a sterile towel to dry first one hand and then the other, being sure to only use one side of the towel and not use the same area on that side

I never thought I'd need clarification on how to use a towel to dry my hands, but I actually needed it today. It's still seven months from when I start my surgery rotation, and there's no way I'm going to remember every part of this procedure. Thankfully surgical teams are known for their kindness and patience...

WILTIMS #302: Soap and SOAP

Today's theme works so well that I'm hoping it was actually a super subtle joke by our administration. We learned about infection control and patient progress notes - or as I would call them, soap and SOAP. For the latter, I'm not yelling; it's an acronym for the four sections that typically make up a progress note - Subjective, Objective, Assessment and Plan.

Regarding soap, we had an infection control lecture and "lab" that were brutally boring in the same way learning about empathy is - each is a vitally important aspect of patient care that is emphasized so strenuously and so often that it is quickly taken for granted. It must be so hard for the instructors to teach us. We're obviously an intelligent bunch. And when you break out the PowerPoint slides to teach us how to wash our hands, a task we've been able to handle albeit less expertly since preschool, we roll our eyes and sigh. But every study ever done on physicians and med students shows that we simply don't wash our hands properly or often enough. There's got to be a better way of reinforcing this because, though I may groan a bit when told not to forget the fingernails, I still try to take the message to heart. I worry that some of my classmates may actually have tuned out the more important message about saving lives and the negative impact health care workers can have on their patients.

Moving on to SOAP... a patient note is a fascinating document that's seems more art than science. The goal is to communicate all of the pertinent information about the patient's current problem and past history as efficiently as possible while still being easily understood.

There are many types of patient notes that vary by the stage of the patient's stay as well as the specialty doing the evaluation. There are admitting notes and daily notes and discharge notes. There are post-op notes and post-delivery notes and consult notes. Each follows the same general theme but, depending on the situation, different aspects of the patient's condition and treatment require highlighting or elaboration. The biggest variable is actually the resident or attending physician's personal preferences. We must quickly learn what the person overseeing us finds important or irrelevant when we begin writing notes on their/our patients.

TIL: One of the main benefits of washing your hands rather than using an alcohol-based sanitizer, is that sanitizers are ineffective against spores. By and large, this isn't a big deal as few common disease-causing bacteria have a spore form and the ones that due are rarely found in the hospital environment. The exception is C diff. This nasty bug causes a dangerous antibiotic associated diarrhea that is a rising cause of hospital infections and deaths. 

WILTIMS #301: Oh yeah, I remember this

Today was a day of revisiting things we should already know, but on which we likely need a refresher. We renewed our CPR certification and practiced writing patient notes after a patient interview. The former was made especially relevant as we will now be surrounding ourselves with sick people - making our chances of using CPR significantly greater than when we were in lecture halls all day.

One of the first things I noticed about our patient interview/note workshop was that everyone finally threw the VINDICATE mnemonic under the bus. It's joked that you learn everything you can from books by the end of second year and then are promptly told to forget it when you hit the wards. This is a giant exaggeration, but it was funny to me that the one mnemonic that epitomised good, misplaced educational intentions was the first to go.

VINDICATE is a system for remembering all the different areas of medicine to consider when coming up with the differential diagnosis. V stands for vascular, I stands for... one of the 4 things that the two I's in vindicate stand for. See? Not my favorite. But even though VINDICATE is the most liked system by our basic sciences faculty, there are several others that are a little more manageable. Two that were brought up today were organ systems and head to toe. Being a more visual learner, the head to toe method appeals to me: start at the top and quickly run through possible diagnoses as you make your way own the body. Simple and I don't have to remember how many I-words are in a mnemonic.

TIL: CPR loses about 10% of its success rate for every 1 minute that passes without CPR being initiated. So, if a person suddenly drops, the chance of reviving them falls to zero in about 10 minutes if no one starts CPR.

WILTIMS #300: T minus two years and counting!

Finally at the bottom of the totem pole!

In a traditional medical school curriculum, which my school vaguely follows, the first two years are annoyingly similar to the lecture-based experience that we seemingly left behind us in undergrad. That's not quite right... the first two years are a nightmarish phantasmagoria of insanely dense material presented as a twisted bastardization of the lecture-based undergraduate experience. Better.

But during the second half of med school, though still exhausting and more challenging than anything we've done before, we finally get to do what we've come so far to do: talk with real patients, who have real problems, and become part of the team that makes them better. Again, we're admittedly at the very bottom of the totem pole, but we are at least part of it now.

Fantastic joke stolen from a professor
who probably stole it from the internet

Being at the bottom is kinda weird in this field. We are admittedly useless: we know practically everything a book can teach you about the human body (and we all just proved it by taking our first board exams last week), but we are about as useful at saving lives as any random visitor to the hospital. However, even though we have the least responsibility and the fewest patients compared to our more qualified colleagues, we are far more likely spend time with and get to know our patients than any of the more overworked actual doctors above us. This gives us a unique ability to get to know the people we're "helping" take care of.

While I hope you've enjoyed the past two years of my blog, I'm really excited to start this new chapter. These are the experiences I've been waiting to share (while preserving total patient privacy, of course). I want to switch back to daily posts and the style may change yet again, but I'm not sure how yet. Hopefully I will be able to keep things a little more thoughtful and a whole lot less dry.

Even though we hit the hospital floor soon, we're not quite there yet. The next fortnight is our "transition to clerkship" program, which mainly consists of safety competencies and practice sessions - the general theme: now that we're letting you loose in hospitals, please don't kill anybody.

Day one was a fun one. It was nice to see all my classmates after six weeks of studying in isolation. Between all our mandatory sessions I got in some ping pong, billiards and frisbee... and the sessions had some highlights as well! Our new dean of medicine gave a surprisingly interesting talk on health policy in the US and Canada (he holds dual citizenship, so that wasn't totally random). And we got a great refresher on interpreting EKGs from a cardiologist.

Thank you, as always for reading my ramblings. I have missed this dearly and look forward to another great year of sharing what I learn with you.

What I Learned Today in Med School (WILTIMS): Treat hyperkalemia (high blood potassium levels) with calcium gluconate, insulin and glucose, and kexelate - in that order. The calcium gluconate stabilizes the conductive heart cells to minimize dangerous heart rhythms. Insulin drives potassium from the blood into cells throughout the body and glucose counters insulins other potential dangerous hypoglycemic effects. Lastly, Kexelate is a resin that trades sodium for potassium as it passes through the gut, so you can... pass it right on out of your body.