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Drainage of clotted blood from the Knee joint! 

WARNING: Graphic Surgical Content!! 

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New video blog is up! 

“Do you even understand medicine?”  The words landed like a punch in the stomach.  It was 3:30 AM and I had taken my 4th admit while also managing a patient with SVT and one who was rapidly decompensating.  My senior was visibly stressed and I was the target that happened to be standing in front of her.

We had disagreed on the plan of care for one patient.  And then I had wanted to increase a patient’s pain meds, but apparently my proposal would have been too much.  It was clear that with all that was going on she needed the help of a fully functional resident, not just me, the lowly intern.

Welcome to night float.

They say that night float is where you “earn your stripes.”  In essence, few good things happen at night and the bad things happen quickly.  It is your job to answer pages, triaging what is important and what can wait until the day, and take admits from outside hospitals and the ER.  It is a time where you learn a lot about medicine and yourself as a physician.

I felt tired and worthless.  With each mistake I made my self-esteem spiraled and I became more distracted, making more mistakes.  I started to put orders in on the wrong patient.  I added admit orders that were already done.  I lost a note that I didn’t save.  The night was cascading into an internal chaos, where self-doubt and fatigue brought me to a point of being unable to make decisions.  But I pushed through, despite being reamed by my senior resident.  And somehow I survived.

I went home as the sun rose.  I felt defeated, on the verge of tears.  Was I cut out to be a doctor?  Did I make a bad choice in doing medicine?  Is everyone going to know me as the weak intern?  I slept that day and returned as the sun was setting, the questions still percolating internally.

But that night was better.  As was the night after.  My senior resident apologized.  Life went on and my reviews on the next rotations were extremely positive.  

Being a doctor is not anything like what I expected.  There are so many things they cannot teach you in medical school, the least of which is that you are fallible.  You are going to make mistakes and people are going to be upset about that.  To my knowledge I have never made a mistake that made it to the patient, but one day I know that will happen.  But if you let those small mistakes affect you it will quickly spiral out of control, which is what happened to me.  

Sir William Osler, possibly the most notable figure in American Medicine, spoke about the idea of living in “day-tight compartments.”  He advised to avoid reflecting too greatly on the past and to keep your mind from wandering to the future.  Always keep your focus on the task at hand.  His words echoed in my mind as I attempted to put that night out my thoughts.  We all have bad days, and we must move forward without allowing those days to weigh heavy on our thoughts. 

A fellow that I knew as a medical student ran into me the other day and asked how I was doing as an intern.  I explained that some days were tough and that I sometimes doubted if I was cut out for this.  “The long white coat is a lot heavier than it looks,” he responded.  In so many ways that is true.  But by living in my day-tight compartments I am not going to make it heavier than it needs to be. 

Ankylosing Spondylitis

Ankylosing spondylitis is an inflammatory disorder of the axial skeleton, peripheral joints, and extraarticular structures. Over 90% of pts have HLA-B27, a protein on the surface of WBCs in the presence of infection. It is 2-5 times more common in males, and onset is typically in the 2nd or 3rd generation. 

Pathogenesis

  • Occurs at entheses (attachment points between tendon, ligament, or capsule and bone) 
  • Inflammation
  • Bone erosion
  • Syndesmophyte (spur) formation

Clinical Manifestations

  • Vague low back pain radiating to buttocks
  • Bony tenderness
  • Enthesopathy
  • Constitutional symptoms - photophobia, blurred vision
  • Extraarticular symptoms 
  • Morning stiffness

Physical Examination

  • Spinal stiffness
  • Loss of lumbar lordosis
  • Increase of thoracic kyphosis
  • Stooped posture
  • Decreased chest wall expansion
  • Schober test: detects limitation of forward flexion and hyperextension of lumbar spine

Diagnosis/Lab

  • No direct serum marker
  • Elevated ESR, CRP, Alk. Phos
  • Radiographic: “bamboo spine”, sacroilitis, pseudowidening of SI joint, sclerosis/fusion
  • Diagnosis at early stage is important to limit irreversible deformity

Treatment

  • Physical therapy - exercise is the best treatment!
  • NSAIDs
  • Anti-TNF
  • DMARDs
  • Referral to rheumatologist

Complications

  • Spondylitic heart disease
    • Aortic/mitral regurgitation
Medblr Question: Patient Histories

I just started my first year of Medical School and we are learning how to take patient histories. I noticed that doctors tend to have certain lines or go-to phrases they say when they address different issues in the conversation, so I’m wondering if medblrs can reblog this and add some of the things they like to say when taking a history.

(Nurblr responses are welcome too, as are signal boosts, thanks! 😊)

I like those medicated and mighty posts, I’m really proud people are taking care of their health physical and mental. I’d like to see lots of fellow Catholics/Christians post some, there’s a pretty big stigma regarding needing medication because some people are misinformed or ignorant and believe it to be some sort of “weakness” of the faith. It’s a really amazing act of humility, trust, and strength to take care of your physical and mental health when it is out of your hands. Allowing God to work through physicians and medication is Holy work, and I hope people post more of those. I really like to see them in my feed. So if you were wondering if you should I’m cheering you on!

Sara Josephine Baker, or “Dr. Joe” to her friends, was a groundbreaking physician in the fields of public health and preventative medicine. After working for several years as a medical examiner and private physician in New York City, she became assistant to the commissioner of health in 1907. A year later, she was made director of the Bureau of Child Hygiene, where she implemented a number of programs aimed at reducing mortality rates among infants and children living in poor environments.

And behind the camera is Jessie Tarbox Beals, the country’s first female photojournalist, who kept a studio for many years in New York City. 

Jessie Tarbox Beals. Sara Josephine Baker. undated (circa 1910-1920). New-York Historical Society.

If you think the details are not important, then leave the profession now. Our job is saving lives, a most ancient and honorable profession. If we have a bad day, someone will pay for our mistakes with suffering or even death. Since the early beginnings of EMS, patients and even rescuers have lost their lives because attention was not paid to the details. Many of us can recall patients that we might have saved if we had been a little smarter, a little faster, or a little better organized. Make no mistake, there is no “high” like saving a life, but we carry the scars of our failures all our lives.

Your mind-set and attitude are very important. You must be concerned but not emotional, alert but not excited, quick but not hasty. Above all, you must continuously strive for what is best for your patient. When your training has not prepared you for a situation, always fall back on the question: “What is best for my patient?”

When you no longer care, burnout has set in, and your effectiveness is severely limited. When this happens, seek help. (Yes, all of us need help when the stress overcomes us.) or seek an alternative profession.

—  John E. Campbell, MD, FACEP