Sinking Fast

Medicine Clerkship Day 4: Still overwhelmed and now seriously questioning whether I have what it takes to be in medicine.

It's amazing how much I don't know. Actually, maybe it's not so amazing. I don't know. That's another thing I don't know. The list keeps growing. Here is a list of topics that I wrote down just from clinic today - all of which need serious review on my part (in order of when I discovered that I knew way too little about each):

• How to present my patients during rounds
• Fanconi's syndrome
• hypomagnesemia
• hyperkalemia
• β agonists
• acidosis
• alkalosis
• homocysteine
• homocysteine and its association with cardiovascular disease
• homocysteine and its association with peripheral vascular disease
• homocysteine and its association with vitamin B₁₂ deficiency
• diuretics
• the renal system
  
• electrolytes (yes, all of them)
  
• portal hypertension
• metabolic acidosis caused by ethylene glycol and the fact that calcium oxalate crystals appear in the urine because of the aforementioned ethylene glycol
• anion gap
• the thoracic duct

You see, I think building that medical 'fund of knowledge' is like building a dam. Um, like, the water is the knowledge, and...uh...the bricks are like the - hmm - and I don't have any mortar...well, you know what I mean, I think. I'd carry on with this analogy but I really don't know how (add yet another item to the ever-growing list). Plus I have way too much reading to do.

My Medicine Clerkship: First Impressions

Day 3: Still feeling overwhelmed.

I'm spending the first four weeks of the clerkship doing "inpatient" at a Veterans Administration (VA) hospital in the suburbs. A brief description of the way this hospital works:

• There are four 'general medical wards' teams (Teams A, B, C, or D) and two 'CV med' teams (Cards 1 and Cards 2). I'm on Team A.
  
• Each ward team is comprised of an attending, a resident, two interns, and one or two medical students.
• Call is taken as a team q4 ('q4' means every 4 days).
• 'Short Call' means that the team admits new patients until 12:00 pm. It caps at four patients or up to 6 night float admissions on a busy night.
• 'Long Call' means that the team admits from noon until 10:00 pm. Long Call caps at 10 patients. The Long Call team must remain in house until 10:00 pm, except on Fridays, during which the team admits overnight until 8:00 am Saturday morning.
• The pour souls on the CV med teams are on call q2 (every other day). Ouch.

An intern is someone who just graduated medical school, Post-Grad Year 1 (PGY-1). After that year, in internal medicine, they're referred to as residents: junior resident (PGY-2) or senior resident (PGY-3). Once the residency is completed, the physician can then be referred to as the attending physician. I think. These things aren't very clear to me.

Anyway, I meet with my team for Morning Rounds. Basically, the intern (or medical student) presents in about 2 minutes or less any updates regarding each patient and it sounds something like:
"Mr. Smith is a 76-year old was admitted to the emergency room at 11pm last night complaining of shortness of breath. He was first diagnosed with COPD 10 years ago. His history also includes Obstructive Sleep Apnea (OSA) and seizures. The symptoms of dyspnea improve when the patient sits up and breathes through pursed lips. The patient is compliant with his medications, but not compliant with his C-PAP device. His hematocrit this morning is 58.1, his blood pressure is 98/57, his pulse is 85, respiratory rate 20, and O₂ sat is 92%."
The team then agrees on a plan.

What's striking to me is how young the team is. The resident leading the team is only starting her third year after graduating medical school. The people doing most of the scutwork are the interns (with some help from the medical students, who - between you and me - are still pretty freaking clueless at this point). Remember, like 6 months ago, the interns were still in medical school. Does this scare you? It really shouldn't - every case is overseen by the attending physician, who has tons more experience.

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I spent five years in graduate school, so much of the material I learned in Biology of Disease is a distant memory. It's starting to show. I was asked several questions today by the attending physician, and I think I fell short of satisfactory. Some questions regarding the incidence, presentation, and prognosis of cancer of the esophagus.
Incidence is about 1 per 20,000 people. Usually, when esophageal cancer presents in the clinic, it's in its later stages, so the prognosis is relatively poor: 5-year survival rate is between 5 and 14%. With metastasis, it's around 2%.

Another question probing whether I understood the mechanism behind the hyponatremia of one of the team's diabetic patients. I couldn't remember.
Our patient's blood glucose levels were beyond the range of the instrumentation, above 600 mg/dl. To put it simply, if you remember your high school chemistry, the increased sugar concentration in the serum results in hyperosmolarity, causing water to be drawn out from within cells. This dehydrates cells and also dilutes serum sodium.

I think the attending gave up asking me questions at this point. Boy...I've got some serious catching-up to do in the next few weeks.

This is cool

Some Japanese marine biologists caught the giant squid (Architeuthis) on film. Some pictures can be seen here. Look at those tentacles! That reminds me - I had the BEST calamari the other day at the Cottonwood Cafe. Lightly breaded served over a sundried-tomato vinaigrette....Mmmmmmmmmmmmmmm.

Drinking Water from a Firehose

I attended the orientation session for the Internal Medicine Clerkship this morning.

First, the bad news: I felt overwhelmed after only 3 hours of the director telling us what was expected of us.
The good news: Everyone else feels the exact same way.

The medical students' day begins around 6:30 am, pre-rounding on patients. Afterwards there are Morning Rounds, seminars, Attending Rounds, presentations, and more seminars. Plus there's this long-call/short-call thing that nobody understands - yet. Depending on whether the student's team is on call, the day could end at 5pm, or 7pm, or 10pm, or midnight. Plus the clerkship director estimates that we need to do about 10-15 hours of reading every week to keep up. Looks like I'll need at least that to take in all the material that we're expected to know. Here's a picture of all the reference books that I'll have my nose buried in for the next 11 weeks:

Yep. Should be a party.

Shelved

No updates this week. My psychiatry clerkship is coming to an end, and that means I'm taking my final exam this Friday. Later!

Images: September 16, 2005

The first thing I notice when I walk into the ward is the fact that the walls are nearly entirely windows. The drywall has been cut off approximately four feet from the ground and everything above that line is all clear so the staff can keep an eye on the residents. The ward is horseshoe-shaped, with the Nursing Station in the center, the patients' rooms lining the perimeter of the horseshoe. I see several elderly patients sitting in the common room, which has a television, several couches, and several dining tables. And I hear screaming.

The Screamer¹
The Screamer is sitting in what is supposed to be a second common room, perhaps a space reserved for group therapy sessions. The Screamer has earned this space all to herself, as the noise probably drives the other patients into agitated states. The Screamer is an elderly woman with late-stage dementia, probably Alzheimer's, and during the times that she is lucid, she is able to describe the auditory and visual hallucinations that she experiences. The rest of the time, she is yelling at the top of her lungs. The screams make no sense - rarely there is word formation, so for example, one could hear:
"AAAAAAAAAAAAAAAWHYYYYYDIIIIIDYOOOOOUUUUAAAAAAAAAAA"
but most of the time it's merely babble. Babble at a really loud volume.

Earlier this week, The Screamer was agitated, and the babble was especially loud. Apparently, during one of her lucid states, one of the other patients had gone up to her and told her that she had been "molested" by several men earlier (but not in those words). This upset her, as it would anyone, and it manifested in a particularly disturbing screaming fit. You ask yourself what kind of person would walk up to someone else and say something like that, which brings us to...

The Shark²
The Shark is an elderly man who is confined to a wheelchair because his right leg was amputated above the knee sometime during World War II. He also is suffering from dementia. The Shark likes to prowl around in his wheelchair all around the floor. One morning during rounds, we heard someone fiddling with the door handle. I turned to look, and saw the top half of The Shark's head cutting across the base of the windows as he made his "escape". The image reminded me of the shark fin cutting through the water in Jaws - explaining the 'dah-dum...dah-dum...dah-dum-buhm-buhm...dah-dum-buhm-buhm...' as The Shark wheeled himself by the windows.

The Zombie
Imagine walking down a street and seeing a complete stranger who absolutely needed a hug. Multiply that by a factor of 20 and you have The Zombie. The Zombie, to me, defines the image of depression. Every symptom of SPACE GAS is there. His depression is so profound that he has tremor in his right arm which worsens when he gets upset; the length of his stride is about 8 inches max. He can't eat, can't sleep, has no energy, has no interest in life - we're watching someone die extremely slowly. To me, the most striking element is the level of guilt this man carries. Being a Conservative Baptist, he believes he's being punished for his sins. He's even fabricating guilt: yesterday The Zombie saw a pair of pants on his bed - these pants belonged to his roommate, and The Zombie, rather than thinking that these pants had been mistakenly placed on his bed, believed that he had stolen them and placed them on his own bed.

What hurts is that The Zombie has not shown very much improvement at all. There is not enough staff around to give him adequate psychotherapy, and his depression has so far been resistant to antidepressant medication. He is a superb candidate for electroconvulsive therapy (ECT), but he and his family have so far refused the treatment, most probably because of the the negative images it conjures up in the imagination. We're planning a group meeting with The Zombie and his family - hopefully, we'll be able to educate them on the benefits of ECT. Otherwise, we fear The Zombie will never feel happiness again.

¹ I've given the patients nicknames, which are for descriptive purposes only. Not that I don't trust everyone's reading comprehension abilities, but I think it needs to be stated that I intend nothing derogatory.

² The Shark broke his hip a while ago and still had staples in his leg from the surgery. The resident let me take them out. It wasn't that exciting, but I noticed that my hands were shaking throughout the procedure. I wasn't especially nervous, and I'm hoping that the shakes were from the caffeine I'd taken in earlier. If not, it doesn't look like I'll be following my father's footsteps into surgery.

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Right now I'm listening to: (What's the Story) Morning Glory?, Oasis

The Shakes

The last half of my Psychiatry Clerkship is at a local community hospital in suburban Boston. The biggest difference is that we spend the bulk of our time in an inpatient geriatric psychiatry ward. This is in stark contrast to the Psychiatry Consult Service I was on earlier, in which the patients were hospitalized primarily for a medical or surgical reason. The patients at the community hospital have serious psychiatric problems. My first patient, Leroy, is an elderly African-American man with schizophrenia. To be diagnosed with schizophrenia, a person needs two or more of the following symptoms present for one month:

• Delusions
• Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behavior
• Negative symptoms (like a flat affect, alogia, or avolition)

You'll recall that one of my previous patients, Clive, had what we thought was schizoaffective disorder, which is schizophrenia with the presence of mood symptoms (depression, mania, hypomania).

I perform the chart biopsy on Leroy and it looks as if he's the chronic paranoid type of schizophrenic. He's been admitted to the geriatric psych ward because of a "change in mental status." I'm not sure what that means, but most probably it refers to him becoming difficult in whatever setting he was in previously (nursing home, assisted living, etc), they got tired of it, and booted him into the hospital. He's homeless, though, and has no close family. The internist has noted that Leroy has a fungal infection on his right hand. Currently, he's on fifteen different medications that treat a number of issues, ranging from the infection to psychotic symptoms.

I stride (yeah, right)....nay, I step with trepidation into the ward (it's a 'locked-in' unit, so the patients can't elope) and look for Leroy. One of the nurses points him out to me - Leroy is sitting in the corner, isolating himself from the rest of the patients. I walk up to him and introduce myself, offering my hand. Leroy just looks at me with suspicion, then ten seconds later, offers his hand. The fungal infection is HYOOGE. The skin is flaky white up to his wrist. Every fingernail is discolored (note: that link is unsafe for the queasy and those eating lunch).

To shake or not to shake? In the next 5 milliseconds during which I reach to grasp his hand, I'm thinking to myself: "I can't renege on the handshake, can I? Oh, great, Mike. Way to go." Leroy and I shake hands.

The interview is rather uneventful. Leroy's thought process and speech are highly disorganized, so he perseverates on random topics that have nothing to do with the questions I ask him. Some of his answers are tangential and just take off and float away into the ether. He's hard to follow because he speaks in a monotone mumble, and all I can think at this time is to not touch anything on my person - not my notes, not my pen, not my pants, not anything. I'm holding my hand at my side awkwardly, I'm sure, as it seems to be pining for a scrubbing with soap and hot water.

The goal for Leroy while he's in the ward is to get him to a point where the social worker can find a nursing home that will accept him. He seems to have calmed down, and he seems quite friendly, as schizophrenics go. In the psychiatry texts, schizophrenia is described as an illness that demonstrates the downward drift hypothesis, in which schizophrenics are unable to function in society and hence sink to lower socioeconomic groups. While Clive and Leroy are certainly noticeably different than us "normal people", I can see that they would be able to fend for themselves independently at some level, despite what the textbooks say.

I end the interview, perhaps a little flustered by Leroy's lack of coherence. Perhaps our interaction, though, has stirred him a little, because, as I turn to leave, Leroy calls after me: "Don't forget to wash your hands."

Depressed Mnemonic

Mnemonics have usually failed me miserably during the course of my medical school education. There are so many things to remember, and people just make up these things to help squeeze it all in. Some mnemonics make total sense. To remember the symptoms of mania, just imagine a hyper person that has to DIG FAST:

Distractibility
Insomnia
Grandiosity

Flight of ideas
Activity/agitation
Speech (pressured)
Thoughtlessness

That works pretty well. However, I'm having trouble remembering the mnemonic for symptoms of major depression, because, frankly, the mnemonic stinks. Here's what years and years of brilliant minds could come up with for depression: SIG E CAPS. WTF?!?! What the hell does that mean? Here's what the letters stand for:

Sleep (too much or too little)
Interest (loss thereof in pleasurable activities, aka anhedonia)
Guilt

Energy (lack thereof)

Concentration (lack thereof)
Appetite (increased or decreased)
Psychomotor activity (restlessness or slowness)
Suicidal ideation

All of these symptoms make sense, but couldn't someone have come up with something better? It's not that hard. Look: just read it in reverse, and we get SPACE GIS. That is so much cooler, and at least it's a word and an abbreviation. Or PISS CAGE. Now that's a depressing image. I think I'm going with that. Spread the word and turn the health care world on its ear.

Good News

I got my mid-clerkship evaluation on Thursday. Apparently I made a good impression on the Psychiatry Consult staff. I definitely feel more confident about things now, and I feel like I belong here. Of course, just as I'm getting comfortable, I'm saying farewell to these people, so no more Mitch, Dr. Berg, et al. for a while. Perhaps I'll run into them again, perhaps not. I'm moving on to another hospital and a whole new population of patients. We'll see how that goes.

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In even better news, our blog friend Kat has made it through Katrina. We hadn't heard from her in several days, so we were getting worried. She's posted on her blog, here. Glad to see you're okay!!!

*****

I'm off to Canton, OH to see Terry and Melissa get married. Have a nice Labor Day, everyone.