Archives

Grands Rounds 2.19

Grand Rounds 2.19 is up at Barbados Butterfly, a surgical registrar (resident) in Australia. Check it out!

The Year of the Dog

(The Fire Dog, specifically) — Happy Chinese New Year! I miss being in Houston where I could take part in festivities (usually that means just eating amidst deafening firecrackers in the street, seeing a dragon dance or two), but I’ll deal, especially with an ethics exam tomorrow.

I was actually born in the Year of the Dog, and here are some characteristics (as well as my year) as per the Chinese Zodiac:

The Dog is a giving, compassionate personality. He offers kind words, support and advice to friends and family. He is a listener, always available to lend an ear or a shoulder to a friend in need. They have extremely high standards and expect a lot of themselves and of others. They are loyal and hold a strong outlook about the direction they want their life to take. Once they have committed themselves, there is little to no turning back. They are bold, unafraid to disagree out loud about anything they feel is unjust or unfair. They are easily stressed if a plan does not go accordingly. They find it difficult to relax when there are things to be done.

Guilty as charged! Have a prosperous new year!

Community Medicine: My First House Call

As part of our community medicine assignment for the semester (apart from our crazy-long complete patient histories–I swear they want us to ask about their dog’s illnesses during childhood), are two home patient visits that we’re required to do. Usually, these wind up being for the elderly or those that couldn’t make it to the clinic for whatever reason. In an otherwise uneventful first day at the clinic, a patient having her own minor problems started asking for some help for a neighbor of hers that couldn’t leave the house. The doctor appropriately responded that there was nothing he could do without establishing a chart there, but [gesturing to me] offered that I could go and do the history and physical exam, report back to him and from there see how to proceed further. I was happy I had an opportunity to clear 2 maybe 3 things (SOAP notes included) off my semester’s “to-do” list in one shot on the first day.

When I got to the patient’s house, I was surprised to find a relatively young woman. I had it in my head from the beginning I’d be getting a little old lady; instead, here was this 37-year-old woman with her feet up on a foam wedge and her left leg in a compression stocking. I suspected peripheral vascular problems immediately, but I had no idea why or how. I was still reeling from the fact that the woman was not all that much older than I am.

I explained that I was there to do a history, a basic physical exam, and most of all act as liaison between her and the clinic until she can make it in. She had a pending appt with a doc at the hospital the next day, but she needed consistent outpatient management, which is what I was trying to help facilitate.

Proceeding with the history, she said her chief complaint was “pain from her thrombophlebitis.” I swallowed hard. I knew what thrombophlebitis was, but I was surprised that she put it in those terms. [read: she was well versed in her illness, something you don’t find a lot here, and the implications of the disease] She said she was in the hospital for a few days and they sent her home a day or two ago. She showed me contrast CT angiogram films they took from her legs, along with what looked like a computer image reconstruction of her leg vasculature, clearly showing several points of stenosis in her left thigh and popliteal area. Still reeling from information overload having expected grandma’s easy 1-2-3 history/physical, she starts recounting something about a clot last year in her groin and [greater] saphenous vein the time before this last time she was hospitalized…

I started having a mild panic attack. I felt like a complete fraud, alone and exposed. Mind you–I explained I wasn’t there here to treat her, but it didn’t matter: she looked to me for help. I was in way over my head, like I couldn’t even see the surface of the water much less try to reach up to gasp for air. All I could think about was how clueless I must have seemed trying to take everything in during this exhaustive and complex history, trying to keep track of everything and their implications, like a baboon trying to make sense of differential equations. While I do know some clinical aspects of her problems, I obviously have no experience to place a clinical context to that limited knowledge, much less help the patient. I didn’t know if she was a pulmonary embolism waiting to happen or a well-managed patient who was just overly worried, who got the neighbor worried, who got me there, etc.

To add insult to injury to this poor lady, she had a son born with cerebral palsy, and much of her quality of life is suffering because of extreme stress having to care for him while sick herself. Her husband works and provides money but is emotionally abusive to her because 1) he can’t bear having a disabled son so he takes it out on her verbally and emotionally, and 2) since she is sick and can’t do as much housework, he constantly calls her “lazy” and “good for nothing,” since all this “is in [your] head.” Oh yeah, and while I’m wondering if there are dormant clots waiting to be dislodged, she referred chest pain, deep and intense with radiation to the left side, with numbness in her arms and fingers. Great–I think at this point I started having chest pain of my own…

I had to field innumerable questions about her problems, her CP child, her depression–you name it. I had to balance my desire to help with what I could answer with what I SHOULD be answering, all with some semblance of time management because she could have had me there all day. I continued the history, got vitals, did a basic physical exam, talked a bit more and then as I was getting ready to leave, she said, “How much do I owe you?” Stunned, I said, “No, you don’t owe me anything; this is part of my responsibilities at the clinic,” to which she replied, “But you came all the way out here, I need to give you something.” I reassured her and she kept thanking me over and over. Maybe I wasn’t so obviously clueless after all. Honestly, I think no one has ever talked to her that long about her problems, and if so, certainly not in the relaxed atmosphere of her home. As a patient myself, there’s something different about a doctor’s office, a sense of urgency and business that gets erased when visiting at a home–the patient’s home–that allows more peace of mind. I got a glimpse of the time-honored “house call” of days past (unless you are in the growing concierge medicine business, in which case, that’s part of your job).

Remember, all this was for an assignment, and under normal circumstances, all the writeups wouldn’t be rushed since they’re spaced out over the semester; however, the patient was wanting to come into the clinic ASAP, so I was also freaking out about having to get this done to start the chart. Frantic, I stopped by the clinic on my way home to talk the attending. He reassured me to take my time, get it all written up well and that if they come in, he’ll get the basic data and add my information after-the-fact. He assured me that my helplessness was normal and that I WAS helping the patient just by being there, acting as an advocate on her behalf since she didn’t have a PCP or a “home base” to coordinate everything. He was so interested in the case, that he said if she didn’t come in before next week when I am there next, that we’d both go together to her house for a follow up.

I was full of conflicted feelings: helplessness, a desire to help yet not overstep my bounds, to reassure yet not give false hope, and feeling upset to have to hurry up and get this done at the expense of immediate exams/assignments when I should have weeks to do it because the patient needs it. I know that in the future, many sacrifices will have to be made of my time and energy to do what’s right for a patient, but I didn’t expect to feel the beginnings of these things this early, even in my own little way given my limited experience and responsibility. Perhaps that’s part of the greater plan, having us do more and more every semester. All I know is that more than ever, in spite of all the conflicting feelings, this is definitely what I want to be doing.

Great Mexican Smokeout

Started community medicine again today, but this time, I have a little bit all semester rather than a concentrated dose. I’ll write more about it later (pretty exhausted right now and have to get up at 5:30 tomorrow AM), but I had to share this one absolutely true story:

(patient comes in for asthma/asthma-like symptoms, wheezing present)
“So how long have you had this problem?”
“Off and on for a while, but it’s been worse the last two weeks”
“Do you smoke?”
(look of horror) “Oh no! I actually was a regular smoker, but I stopped smoking already–too many problems.”
“Excellent!” I say. “How long has it been since you quit?”
“One week.”

Well that takes care of that! Now to find the hidden cause that is exacerbating her bronchoconstriction… *eyeroll*

Update: see comments for explanation of boldface above

New Semester Apathy, Ethics

A new semester of school is usually met with the highest level of interest and productivity before the procrastination and rationalization of “later” sets in, right? I don’t know what’s wrong with me, but I can’t seem to get it together to get studying done. Granted it’s only been a week, but I can already feel the tug of distractions with the simplest of study tasks not being done. To be fair, we came back from our first vacation to the states and moved into a new house all at the same time, so there was quite a bit of work pending when the semester began last week. Perhaps future breaks when I don’t go very far or for as long will keep me focused on restarting.

Right now we have bioethics, which is a serious, important subject, but taught with the so much open-ended flexibility, I have no idea what’s up or down. “The AMA suggests…” is about all we get from this prof, who is a visiting prof from a Texas med school. I know ethics doesn’t have a “right” answer, but some answers are more right/wrong than others, and we should be focusing on those. Just as there is no one or absolute way to treat a patient/disease, there are certainly things to do that are better than others, and that is part of our training. We read case studies with thought-provoking questions at the end, but no follow-up to say, “Here would be a couple of responses that would be consistent with core ethical principles…1)…2)…” Of course, I wouldn’t mind the thought-provoking discussion except that we have an objective, multiple-choice exam soon, so a sense of what’s right and wrong has short-term practical considerations, too.

Histology is certainly the most dense course right now, but physiology will begin soon, too. Like anatomy, I have a harder time with histology and classes which depend on more visual and rote memorization than concept-oriented ones. There’s not much “concept” in histology. The meatier the courses get (path, immunology, etc.) this semester, the more I think I’ll enjoy them at the expense of their being damn difficult. I can’t wait until then to get out of my study slump, however.

The times, they are a changin’

So my semester already began, and thankfully it’s been a whole lot of “ho hum.” I shouldn’t say that entirely, but in contrast to how the last semester started (probably intended to be a boot camp ground-you-into-the-dirt-like-maggots-style “Welcome!”), I can get used to this lighter load while it lasts.

My original goal was to switch to WordPress for this blog before school started, but as usual, life–particularly Bob Vila-style domestic chores got in the way. So, I’ll be doing that this week, most likely.

FOR THOSE WITH USERNAMES/PASSWORDS TO THIS SITE:
Sorry, but no usernames will be available for general registration anymore. I did this because I wanted to encourage those that knew me in real life to follow more private details that were not super-secret but not necessarily information I’d want to share with the entirety of the Internet. I’ve decided to devote this blog entirely with what I want to write publicly and nothing more — I’ll have another solution when the time comes for more private writing, but of course, that information would be private.
So again, thanks to all for reading and I hope to make your experience here better really soon.

Grand Rounds and MedBlog Awards

This week’s Grand Rounds is up at GruntDoc, the veteran (literally) blogger in my home country state of Texas. Go and enjoy the choice cuts of the medical blogosphere.

Speaking of choice–or in this case, prime–cuts, the MedBlog awards have been finalized! Congrats to all who won! And you thought the Golden Globes was the only awards going on…

Gee, you think?

I normally don’t post links for health news and events straight from a news feed, but this latest study does kinda have me scratching my head:

NEW YORK (Reuters Health) - Though countless fad diets promise a trimmer physique, the old-fashioned route of portion control and calorie consciousness may be the way to go after all, a new study suggests.

“May” be the way to go? You think? Wow! As the dearly departed Scotty poignigantly said, “You cannot change the laws of physics,” and while weight loss/management is much more than managing energy equations (see below), all programs/plans/etc. will all come down to tipping the energy balance in a negative state whether they do it via intake restriction, attempts at fine-tuning the body’s metabolic cycles by certain types of foods to have/not have, and/or increasing physical activity. Yes, I know the point of the report also seems to be about modest cuts, but that’s also a “duh” conclusion since hardly anybody (except that whacko Jared) will tolerate radical changes for long.

The reason people don’t lose weight/keep it off isn’t because they don’t understand (although some are in denial about) energetics, it’s because weight loss is such a multi-factorial problem dealing with such deep emotional, environmental and social factors. More studies need to address these aspects rather than constantly reiterating that which is obvious.

Best of Medical Weblog Polls Open

Actually, they’ve been open for a while, but I’ve been too busy traveling and moving, being away from a computer to really put 2+2 together. If inclined, go vote here; I’m in the “Best New Medical Weblog” category, but it’s really about whomever you want to vote for. Again, visit the sites on the list–they all deserve to be there.

I find the whole voting/nomination/etc. to be really neat as you can see people you otherwise might not known about, but I write mainly to keep a journal for myself and perhaps by making it public, find other people who expand my experience. I have to say that I really think commercial or business-focused sites should have their own category, as should perhaps nursing and/or students.

Anyway, give the love, and vote only once!

Pensively unpacking

We finally got here! YAY! Actually, we got here earlier in the week, but the computer, etc. was not set up yet, so finally after a couple of days of unpacking–and yes, things like curtains, kitchen items (utensils, pots/pans, coffee maker), unpacking towels, etc. actually do take priority over computer room setup, alas–I finally feel like life is getting back on track again. I had a vacation from school and it definitely feels like it, but there was no vacation from family and life responsibilities. There never is, I suppose.

I usually enjoy unpacking and setting up anew in spite of my absolute hate for the moving process. Uprooting, and the packaging of your life into boxes, bags and what not, is traumatic while laying down new roots brings the feeling of a new beginning. This time is no exception, but so much has happened (part of that will be shared in the next few days when I have more time) in the last 6 months that makes this more than just a move across town. To say we left a cramped, shithole of an apartment is no overstatement. I don’t know much about feng shui, but the amount of space we have in our new place is so mentally freeing and gives such a sense of relaxation to me. Some people will see empty space and need to fill it; right now, space is a luxury in which we are basking. (We’ll fill it eventually I’m sure )

As I organize my stuff into my new space, I am thinking what changes I want to make in my life too. What mistakes did I make last semester academically that I want to change? Am I going to make the hard changes and sacrifices necessary to excel to that next level, not getting behind in any of my classes? Is it more of a hardship to be iron-disciplined about time management so that I don’t get too far behind or is it more stressful to let things get away from me because I wanted more time for personal things and then scramble? My tendency is to wait and work under time pressure, but often I wonder how much pressure is healthy, especially since this kind of studying has not had its match in my past.

I also think of the changes I need to make personally, such as continuing to get healthier, lose more weight, and making time for myself and Claudia (see above about time management). Perhaps being iron-willed about time management when dealing with school is what will allow me to relax when I want to knowing a job has been done, rather than space it out over a long time and always having something over my head. I also think that there will always be something over my head, and to stop trying to wipe the slate clean all the time–that the measure of success is not necessarily having to have done everything.

Anyway, I’m just rambling. Moving always makes me think about new beginnings, and I think that the previous big move to Mexico really was overshadowed by so many overwhelming things (dealing with a non-functional apartment, getting ready for school, learning a new country, etc.) that I really didn’t have time to think. I guess it’s a luxury, but I thought I’d write now that I had it.