Made a Fool

Today was the first day of Psychiatry block. One day’s impression: engrossing, perplexing, and not like anything I’ve done before.

This afternoon we broke into small groups to practice the psychiatric interview. It took place at the hospital. After greater than an hour of conversation with a woman who was describing significant symptoms of depression, I felt quite involved in her story. I was disquieted by her lack of self-worth. Pangs of empathy welled up when she began to cry, and the urge to hug required active suppression. What a wretched affliction this poor woman is enduring, I thought.

It wasn’t until after the interview that I found out from my colleagues that she was acting. She was not a patient! Rather, she was a ‘Standardized Patient’, performing a role written for her by our psychiatrist instructors! What a fool ! I feel completely taken-in! She sure did her job well.

ER Observership: My First Stitches!

I’m racing to keep up, both on my feet and mentally. The Charge Nurse gives the doctor a quick run-down of the patient being brought in by the paramedics. While we wait for the ambulance to arrive, the ER Resident comes over, gives a quick but thorough description of her patient, and asks the doctor for guidance. One of the Nurses interrupts, and asks for clarification on an order. There are three patient areas to monitor. The waiting room is filling, and the Triage Nurse has been separating those out with Flu-like symptoms for segregation to a private H1N1-designated area. The doctor I’m observing with turns to me and, to my amazement, apologizes because of how slow an evening it has been! I suppose ER Docs like it chaotic.

Observerships are an incredible opportunity for us students. Meeting a real patient is incomparably more impacting (and more memorable) than anything we can learn in the classroom. They are the best chance for us to practice our skills at taking histories, examining patients, and using problem-solving clinical reasoning. Depending on your preceptor, they may also be your first chance to learn a new skill! Such was the case this past Wednesday, when the ER Resident was generous enough to teach me how to suture – first time on a real patient! The experience was exhilerating. Particularly as, the laceration was to the patient’s face, and so an aesthetic result was paramount.

Observerships also give a window into the lives of various specialities. My superficial observations of the ER team, are that they are generally fun-loving, easy-going, and active people. They’re also super friendly! After our shift, the entire doc team went for beers together (and invited me!); I understand they do this regularly! Seems like a fun group of people.

Week in the Country

“Welcome to Lanark – Population 800″; I spun my head around to read the sign as we drove by. I had not previously appreciated that when my preceptor referred to Lanark as “the village”, this was not merely a metaphor of endearment – she had meant it quite literally.

“Week in the Country” is a program sponsored by the government of Canada to entice medical students towards rural family practice. Every medical student is required to spend at least one week shadowing a rural Family Doctor. Almost all expenses are covered, as our government is desperate to meet the growing need for doctors in under-serviced rural areas.

Lanark has one major road running through town. We were lodged extravagantly at a bed & breakfast (see photo above) on one side of town, and walked into the Community Health Centre on the directly opposite edge. The walk across all of Lanark took no more than 20 mins.

4 year-old male presents with left ear pain lasting five days, and other non-specific symptoms of an upper respiratory tract infection – our first patient. It is surprisingly difficult to look into a squirmy child’s ear! Otitis media; Amoxicillin 50mg/kg/day TID x 10 days. After Week in the Country, I can now write that with some confidence! In fact, the week was extremely valuable for gaining some proficiency at triaging common complaints, and I am now more confident in differentiating sore throats, sinus infections, headaches, and common skin rashes.

Perhaps the most memorable patient, for me, was an admirable young man trying to quit smoking. He had impressive resolve, but was profoundly impeded by addiction. I cannot imagine the frustration of fighting a war with your own brain. I learned about the arsenal of medical tools available to help. More powerful, however, was when my preceptor offered to make an appointment with this patient every other day on his way to work for the next month – a brief check-up, so that every two days there would be someone asking “Have you had a smoke?”, and “How is it going?”. What a privilege to be that source of accountability and motivation in a person’s life.

In Lanark this week I didn’t get into the OR, or the ER. We didn’t see anybody who was mortally ill. We didn’t perform any cowboy, daring, rescue procedures. But I’m not in the least disappointed. I learned how to swab a throat, how to give a vaccination, and how to detect pneumonia without the luxury of an x-ray. Less romantic perhaps, but unaccountably more useful.

 

Copious Documentation

On Thursday I had my first full history and physical examination with a standardized patient! This proved a really great way to learn. The standardized patients are trained to present with a particular disease, and so the elements of the history and physical all match up to point towards a diagnosis that we have studied, and should know. Our patient (we worked in pairs) likely had angina.

Anyway, the whole experience on Thursday lasted about 40 mins. What blows me away today, is that I’ve just spent more than three hours writing up the case report! Granted that I am an amateur, it is still unbelievable how much documentation is required after every clinical encounter. The results of all questions and tests are recorded, and any that were missed are noted as not having been assessed. Some of my slowness may have been due to that our tutors require us to write out the case reports by hand, as this is more comparable to how they would be done in a hospital.

Cardiovascular Exam

I’ve realized that I probably give a rather skewed impression of medical school through what I’ve been posting to these pages. Not everything that we learn is clinical skills! In fact, most of the time we’re sitting in our dungeon classroom for hours on end just trying desperately to stay awake. That’s what medical school is really about. Or, at least the first phase.

But of course, that brief Thursday afternoon when we dress up all fancy and head down to the Clinical Education Centre to play doctor is the absolute high of the week. Thus it is also mostly what I blog about! This post will be no exception.

Today we learned the cardiovascular exam, with the help of both volunteer patients and standardized patients (actors/actresses who have been trained to present like a patient with a particular condition). I’m glad that we had patients helping us, because the cardiovascular exam requires quite a bit of disrobing, and would have been awkward to perform on classmates to say the least. 

The basics of a cardiovascular exam are visual inspection, palpation, and finally auscultation. That is: you look at the superficial anatomy of the heart and the great vessels; you feel for pulses, heaves, lifts, or thrills; and finally you listen for the heart sounds, murmurs, or bruits. I found it surprising just how much information can be gleaned about the heart without any more equipment than your hands and a stethoscope.

Of course, mostly what we learned today was the motions of executing the rituals of a cardiovascular exam -where to palpate, where to listen, and how to communicate effectively with the patient. What’s still lacking, I feel, is a good appreciation of the findings! I’m probably not going to be able to hear and identify a carotid bruit, until I’ve actually met and examined a patient with a carotid bruit! Seems obvious eh?

Eyes Wide Open

So a couple days ago I sat down to my computer to write a blog post about learning the retina exam. It was only to discover that I couldn’t read the words on the screen… and well, that was the end of that. You see, my pupils were still dilated because in the course of learning the exam, we had been practising on each other. The retina exam becomes vastly easier if you use eyedrops to dilate the pupils, so a few of us had to take a hit for the team.

The screening retina exam is actually way cool ! It’s got to be one of the most exciting moments during a general physical. Using a tool called an ophthalmoscope, you peer through the pupil (like looking through a keyhole) to the retina in the back of the eye. What you’re hoping to see is a nice pink looking retina, a yellow circle called the optic disk at the fundus of the eye, which is where the nerves bundle together to go back into the brain, and arteries coursing peripherally. Here’s what a normal looking retina looks like:

Perhaps the most interesting part of a retinal exam is considering the path of the light. To achieve the above view, light travels from the lamp in the ophthalmoscope, through the lens of the patient’s eye, bounces off their retina, passes through the patient’s lens again, passes through your own lens, and finally hits your own retina. Amazing!

If anybody reading this wants an eye exam, I’m just dying to get some practice ! Do let me know,

My First Stitches

I had hoped that a post titled ‘My First Stitches’ would describe the first sutures knotted by my own hand, probably on a raw chicken breast or a banana for practice. Fortunately, life has a sense of humour! So – you guessed it – the title of this post refers to my first stitches received, not given.

While volunteering at a kids camp near Sauble Beach this week, I was helping in the kitchen when I slipped with a pizza cutter and gave myself a nice gash at the base of my left thumb. It was really exceedingly brilliant on my part to be cutting towards my own hand! But that is a realization that can only be made in hindsight. Of course, the accident occurred while making the final cut to the final tray of peanut crunch bars.

Although thin and clean, the cut was deep and refused to stay closed. So, we took a trip to the ER in Owen Sound. On this particular day another patient had been brought in with spinal injuries after being trapped under a hay bale. Understandably, the ER docs were thus occupied until the patient was flown to London for treatment by a trauma team.

When finally reached, my turn was largely anticlimactic. The numbing needle wasn’t very painful, only four stitches were needed, and the cut is already neatly closed and healing (see picture). I did get to watch closely, and ask a few questions about the suturing! One surprise was the amount of blood involved – each suture drew two new flowers of blood from the poke holes. Now with the cut almost completely healed over, I can have the stitches out on Friday.

Taking Vaccinations For Granted

You consider it given that a vaccination will render you immune. Not always true. After receiving back my initial bloodwork for the screening that I am required to do, I discovered that I lack immunity to measles, hepatitis A, and hepatitis B. As a child, I completed standard vaccinations for each of these.

What does this mean for me? Mostly, more needles! And a warning against blindly trusting any vaccine to accomplish it’s work. I’m hoping to learn more about why vaccines work, and sometimes don’t.

The upshot is, my nurse has been giving me some wonderful tips on how to administer injections! She’s quite a pro. Now, if only I wasn’t the demonstration patient too !