WILTIMS #505-7: Professional firsts and a pediatric homecoming

Continuing to catch up, this post is from about a week ago.

This was a very exciting week for me. For starters, it was the beginning of my infamous fourth-year sub-internship. This is a month during which I am treated like a somewhat inept first-year resident (they are also known as "interns," hence I am the sub-intern or "sub-I," for short). This mean I carry my own patients! I'm still supervised by a senior resident and all of my notes and orders must be co-signed before becoming official. But as far as the average patient is concerned, I am their doctor during their stay. This is a big step-up in responsibility and a terrifying reminder that I will be a real doctor in eight months.

I had a bunch of big firsts for my budding medical career, which are listed along with my learned factoids below. But the biggest first, was that this was the first time I've gotten to experience pediatrics since picking it as the specialty I'm planning to enter. In fact it has been nearly a year since my pediatrics clerkship at the very same hospital. For the past few months I had a nagging fear that I picked the wrong field and would only realize it on day-one of my sub-I rotation, two weeks before my residency application is due.

Turns out that that fear was totally unfounded. Even with the new level of responsibility and some emotionally difficult cases, this has easily been my happiest week of medical school so far. The residents were kind and inviting, most of the patients made me smile every time I entered their room, and I felt like I finally had moved past the busy-work to start actually helping real patients. I'm excited again to practice medicine and stoked that, through the chaos of third-year, I managed to find a field that I think will make me happy for a long time to come.

MondayILearned: Metronomic chemo = chemo given a lower more continuous doses to limit toxicity and tumor cell regrowth. Induction chemo = stage one of treatment that puts a patient into remission. Consolidation/adjuvant chemo = sometimes optional stage two of treatment that increases the odds that the cancer won't recur.

Monday 1st: I was assigned my first pager! This pinnacle of 1980s communication technology is the ball and chain around the ankle of every resident physician. It's weird to be excited to receive something you know you'll soon loath.

TuIL:  Make sure to keep patients NPO (no food by mouth) before an abdominal ultrasound, because food leads to gas and ultrasound doesn't penetrate gas well.

Also, it's very hard to get a young child to accurately describe the symptoms of paresthesias (pins and needles) and numbness. Kids don't have the experience and vocabulary to describe what their feeling and the questions we normally ask to get things rolling are rather cryptic ("If this feels like a ten, what number does this feel like?").

Tuesday 1sts: I received my first page on my nifty new (to me) pager! And far more significantly, I entered my first order. As a not-quite-doctor, all of my orders have to be signed off by an actual physician, but I now have access to the part of the awful electronic medical record software to put in orders to be followed by nursing.

WIL: Hemophagocytic lymphohistiocytosis (HLH) is a rare genetic disease where the immune system is over-reactive and starts to attack and eat the body's own cells.

Wednesday 1st: Due to a freak accident in patient assignments, a third-year med student wrote a patient note for my patient. This was the first time a subordinate med student has done work for me and I got to give him feedback. Not exactly the biggest milestone, but it sure felt weird at the time.

WILTIMS #502-4: The long-lost neuro conclusion!

The blog is still not dead! To sum up what's been going on: the final few days of neuro got left by the wayside, I was studying to take some big tests, and then the past couple weeks have been some of the busiest of all my time in med school. But I'm on nights right now, and some of the important things I need to work on are too important to work on while sleep deprived. Thankfully, I have still been stockpiling things that I've learned every day I'm in the hospital, so I have plenty to share, if I ever get around to sharing it!

~~~Now, we travel back in time to June and my final third-year clerkship, neurology. ~~~

One of the more subtle skills I've learned (but by no means mastered) during med school is figuring out the meaning of the innumerable acronyms that are used in medicine in general and each sub-specialty in particular. Some, everyone knows (e.g. EKG, IV, PO). Others are only commonly used by a select subset of medical professionals and are gibberish to everyone else (e.g G4P2010 of AMA w/ PMH of ASCUS s/p D+C desiring TOLAC p/w PPROM)*

A Monday several months ago, I started my few days in the neuro rehab unit of the hospital. Right away I was presented with the acronym CO, which I had never seen in this context. Carbon monoxide? Colorado? Unfortunately I didn't ask what this meant until so late that it felt awkward (kind of like asking what someones name is again 10 minutes into a conversation with them). But I did ask... and then promptly forgot again. I still can't figure out what it means. But as I haven't been in the neuro rehab unit in months and may never be there again, it can probably fade away in my memory dump, like of all those OBGYN abbreviations.

MondayIL: Strict bed rest causes a 1-3% loss of muscle mass per day. That adds up really fast, which is why there is such a big emphasis on getting patients up into a chair and then walking as soon as possible.

TuesdayIL: It's important to distinguish between crossed and uncrossed diplopia (double vision). When you ask someone if they are seeing double, odds are they don't know if their eyes are crossed or pointing away from each other; it would look pretty similar from their perspective. But to figure out what the problem is, you have to know which eye is moving normally and which isn't. That can be sorted out by looking at directed eye movements but knowing if the eyes are crossing is a good first step.

WednesdayIL: Occupational therapy was created in World War I to help wounded soldiers "occupy" their time. It has since evolved into a therapeutic discipline to help rehabilitate people to do the activities they need to live and work in society.

*Translates to: A woman of advanced maternal age who has been pregnant 4 times resulting in 2 births, an abortion and the current pregnancy, who has a past medical history of atypical cells of undetermined significance and a dilatation and curettage procedure and desires a trial of labor after having previously had a cesarean section presents with preterm premature rupture of membranes.