Archive for May, 2009

Unpredictability in Medicine

May 28, 2009

If there are any generalizations I can make during my four week long dabble in pediatrics, it is that in medicine, things are never certain, and that those things can change really fast.

It is sorta unspoken wisdom during your third year, that when your intern excuses you or tells you to go home, you say thank you and then haul ass outta there as fast as you can make yourself go, because no one knows what might happen next that could keep you in the hospital, turning your free afternoon into a late night.  A classic example of this is the hypothetical last minute admission (it has yet to happen to me in it’s full-on glory, but the scenario is not uncommon).  You and your team are puttering away in a Doc Box (apparently medical slang for “the room in which the doctors hang out and do their work when they’re not seeing patients”) taking care of little odds and ends on a quiet day, and then all of a sudden two kids are admitted from the emergency room, another is admitted straight to the floor and one of the patients already on the ward decides to get sicker.  And so, the slow day is quickly dashed.

Another example of unpredictability in medicine applies to diseases in individuals as well.  About a week and a half ago, I had just ended my two weeks on the Heme-Onc service, and was just starting my first day on the general peds wards.  My team and I were sitting in a corner, doing sitting rounds on our patients before we got up to see them.  It seemed like a rather routine morning (with no more than the usual amount of stress that comes from presenting in front of smart people who really don’t need you).  But then the interns’, the resident’s and the attending’s pagers all went off at once.  Trouble.  They snatched the pagers off their hips, looked at them, and without a word to each other they all jumped up and ran off in the same direction, with a terse call over a shoulder to follow them.  Big Trouble.  Us medical students could sense the electric tension in the air, and we fumbled with our knick knacks as we took off after the rest of the team.  We joined a growing stream of nurses, med students, house officers and attendings hurrying towards a single room, and heard the PA mechanically vocalize “Code Blue, (insert location here), Code Blue . . .” and it then dawned on us what was happening.

For the medically uninitiated, and those who have never seen an episode of Gray’s Anatomy, House, ER, or just about any other TV show or movie that involves a hospital, a code describes a set protocol that medical personnel follow when a patient, usually suddenly, develops a condition that is either imminently incompatible with life, or is a large shift in a negative direction from their baseline.  When someone calls a code, it is an all-hands on deck sort of operation, (theoretically) with a single person in charge, and a zillion other people trying to put in IVs, give drugs, administer chest compressions, setup defibrillators, check pulses and vital signs, fetch additional supplies, call for emergency imaging, and do whatever else someone more senior to you tells you to do.

Codes are hectic, scary, adrenaline drenched affairs.  Because just about the entire staff of the floor is attending the code, as a med student everyone else present is more clinically useful than you.  And so when someone calls out to go get more saline, or syringes, or make a call to radiology or fetch a portable computer, like three or four of us scatter off in all directions because we want to be of some help in this incredibly intense process.  In the end, for this particular code, it went on long enough that the residents and nurses were tiring from doing chest compressions, and so two or three medical students rotated in to take over.  Sadly, I remember this distinctly, for I was standing almost next to the doctor in charge, gloved up and with a face shield on getting ready to rotate in on the chest compressions, when he turned to the clock and said “Alright, I’m calling it now, at 10:10 am,” and all the frenetic activity in the room stopped.  People took off their protective masks and gloves and gowns, and started cleaning up.

And just like that, the entire floor of the hospital had gone from a quiet morning, to a full-on code for an emotional, time-bending two hours, and thence to a full stop.  My team and I were to be taking on care of this girl, and my intern had actually gone to see her early that morning.  But things change fast in medicine.

But not all the unpredictability in medicine is bad.  Just as patients can suddenly get worse, they can suddenly get better too. And I think that there are a lot of quiet random acts of kindness that slip in under the radar.  I started writing this last night but ran out of time (gotta get to bed by 10:30!) and sadly, I’m outta the verve that might have added another paragraph or two about some other unpredictable things that have transpired in those four weeks.  But it’s gonna be a long third year, so don’t worry.  I am sure there are going to be more stories.

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This is Ourselves, Under Pressure (or First Week of Third Year)

May 9, 2009

Well, third year officially started about a week ago, and by all apperances it seems I am still here to tell the tale.  But no lie, this week feels like it could fill a month.  Last Friday we began orientation to third year, and Monday I had my pediatrics clerkship orientation (it’s my first rotation).  I am assigned to the team taking care of the pediatric hematology-oncology ward (read: kids with cancer) with (in rough order of seniority) another fellow third year, an exchange student from Japan, a fourth year, an intern, a second year resident and an attending.  There are only 8 or 10 patients on our service, so the Japanese medical student, and us two third years are responsible for ‘only’ one patient.

I use the quotation marks there because even now, a week later, we are still struggling to figure out such simple things as how to access the appropriate records and how to present in a manner that doesn’t provoke the wrath of our attending.  Needless to say, it’s a good day when, between my third year colleauge and I, we can find the elevator to get from one floor of the hospital to another (I’ve given up on finding the stairs).  And to make it all worse, our utter ineptitude slows the work of the team down to a pace cold molasses might surpass.  In the colorful words of my old high school soccer coach, we’re “as useless as tits on a bull” and for someone who desparately wants to be of use to those around him, it’s kina irksome.

But yeah, I think I’ll just tell you guys about what an average day looks like on our peds heme-onc service.

The day starts at 4:45am when my alarm goes off, so I can get to the hospital a little before 6 to pre-round (check up on, in medical-ese) on my single patient.  For the next hour or so, I check her labs, speak to her nurse, slip in quietly to actually see her and do a brief physical exam, then settle down to try and hammer out a progress note summarizing my physical, any new labs, the pertinent events from the last 24 hours and so on.  Taking that, I am theoretically then supposed to formulate a plan for my patient for the day . . . which usually turns into the clinical equivalent of a five year old’s attempt to design the Lourvre.  After that we meet with the night float team and hear their quick summary of the patients on our service.  Then at around 7:30 we practice our presentations with our intern, scurry off to Morning Report, where one of the pediatrics residents presents an interesting case seen recently in the hospital.  At 8 or 8:30 the attending arrives, and we round on our patients, updating him on the events of the last 24 hours for each of the patients.  These labs came back, patient X developed a fever, patient Y was admitted, patient Z seems to be tolerating her chemo well, etc etc.  Then we explain to him the treatment plan we’d like to institute for the day, and go visit each of the patients again with the attending.

It is here during rounds that we get pimped (so far pretty gently), reprimanded for not presenting data correctly, or chucked at for suggesting outlandish or grossly inappropriate treatments for our patients.  (By the way, ‘pimping’ in medicine describes the ritual of the attending asking questions of med students or other members of the team.  “Why did we order the magnesium levels on patient z?” “How much would you expect the hemoglobin of patient x to change if we transfused him with 2 units of blood?” etc etc.  Not the other thing.).  Because of our painful deficit in clinical knowleage, presenting skill and general medical know-how, rounds usually drag on until 12 or later, until we zoom off for (what has lately been) a ten minute lunch and return to sit for a Journal Club or some other noon-time conference that usually has materiel waaaaay over my medical student head.  Then the afternoon is spent ‘making things happen,’ calling consults, ordering labs and meds, and so on.  If we are lucky and do our work quickly, we update the attending again in the later afternoon regarding any changes . . . or we keep on taking care of the work we were suppposed to do, but because of the medical student dead weight, is still being worked on.  Then at around 5 or so the intern and resident excuse us to head home to study about the 10,000 things we didn’t understand, eat, maybe watch a Scrubs episode, then to bed to repeat the next day.  This goes on for six days a week.

I promise there is a lot more to all of these things than I am writing here.  Sick, sad children with cancer being pretty high on the list, as well as what it feels like to ostenibly take care of them, and to finally be in the hosptial.  I promise there is more to come in the future, but I think that’s all I can muster for now.  More to come.