Peds ED week has the weirdest hours.

Today I saw a questionable supraclavicular lymph node, definite scleral icterus, contagious conversion disorder, several dangerously cute babies and one MVA with three perfectly healthy, perfectly giggly victims.

Yesterday I got so bored of taking medical HPIs (please don’t make me ask one more person “okay but exactly when did your symptoms start” *snore*). Today was scarier for a few patients, but I definitely got the chance to stretch my brain a bit more.

No fear

"You really don’t have to be afraid to touch the babies. Like, not that long ago, a bunch of them were squeezed out a vagina, so your physical exam is not the worst thing that has ever happened to them, ok? Just don’t drop them and you will be fine."
- peds orientation

pediatrics final: real-world edition

This had to happen eventually.

I was getting into my truck after having lunch with a friend, and I heard this blood-curdling screaming behind me. On the other side of the intersection from where I was parked, a little kid had just been run over by a car. I had this absolutely sickening flash of realization that I might be the best person in the immediate vicinity to help. 

The source of the blood-curdling screaming, the kid’s dad, had taken him into a store to call 911. I ran over there hoping like hell that I was just going to find a kid with a broken arm. He did seem to have that, but he was also bleeding from his ears and mouth. Reassuringly, he was also screaming at the top of his little lungs. Airway/breathing/circulation: check, check, check. 

The short version is, we were in an area where I knew an ambulance would be there really quickly, and while I had big concerns about head and abdominal injuries, there wasn’t a lot for me to do besides try to calm him down and keep him still (not easy). Dad wasn’t in a state to help much with those things, but there was another woman there who seemed to have some kind of first-aid training and who also seemed to think that calm-and-still was a good goal…I very much appreciated her. And yeah, the ambulance was really fast. Mercifully fast. 

I really wish I could say that the little boy is ok. I have no idea. I’ll see if I can find out later tonight (edit: obviously I couldn’t, because HIPAA, but I tried). 

Here’s the actual point of this post right now: medblrs, this is going to happen to you too, and I have some advice that was probably not included in your training. 

What I did after the ambulance took him — think of this as “the wrong thing” — is I went into the store’s restroom and washed his blood off of my hands, and then I went back to my truck, and I sat and took a few deep breaths and decided that I was still feeling reasonably calm…and then went and got on the freeway to drive home. I spent the first ten minutes of the drive in this very academic headspace, thinking about what his injuries might have been, what I did, what I could have done better, what I would have done in a more rural setting…that sort of thing. And then my normal-human-ness started to come back, and the horror landed, and I realized that I was gripping the steering wheel so hard that my hands were white, I was paying no attention to the road, and I was fighting the urge to both puke and cry. I absolutely should not have been driving.

So, when this happens to you? Please go get a cup of coffee or something. Don’t drive. The ambulances are busy taking care of injured children…be safe. 

kintsugi heart

My current rotation is psychiatry, and the full six weeks are spent on the inpatient psych service at a large county hospital. The unit I’m working on is about 75% involuntary, and most people have multiple diagnoses. The most common seem to be depression, schizophrenia, borderline personality disorder, and bipolar disorder. With a thick frosting of substance abuse spread over the top of all of it, of course. 

I like psychiatry, and I think I’d be good at it. These diseases, for all of the tragedy and suffering associated with them, are interesting to me. But I don’t know if I am a tough enough person to live in this world full-time.

Walking into a locked psych ward is uncomfortable at first. I think it’s because you can’t count on people adhering to any sort of social norms. I don’t think I’ve ever quite appreciated before just how much comfort we all take in knowing roughly how the vast majority of people are going to behave at any given moment. At this point, though, I really love being there. People tend to be in for long stays, so I know almost everybody at least a little bit, and I know what to expect from them. I also like most of them, and in most cases they’re trying really hard. I guess it seems like just seeing these people as human beings helps them, and that’s a thing I can do.

It’s all terribly sad. Most of my patients are too impaired to engage much in therapies, so treatment usually focuses on medication, and a lot of the drugs are pretty intense. Baselines are mostly terrible. Almost everybody is homeless. A significant proportion have absolutely nobody looking out for them outside of the hospital — no family or friends who haven’t already been worn out or alienated. Some of them have lives that seem worth living, but an awful lot of them don’t. It’s very hard to blame them for their recreational drug use, or for their frequent attempts to game the system in order to hang on to the safe shelter and companionship that hospitalization provides. 

For the second time since starting medical school, I’m having an experience that makes me feel deeply changed. Broken, even. The first such experience was cadaver lab. After the first day of cadaver lab, I walked out into the sunshine and looked at the other people on campus and felt like I was from a different species. I went home and sat in my bathtub and cried. And then I went back and spent hundreds of hours disassembling dead bodies over the course of the year, and it became easier…became almost normal. 

I don’t come home from psych and cry, but I do have a harder time leaving the work at the hospital than I usually do, and I feel like my humanity is distorted by the things that I’m seeing. I try to distract myself (thanks, internet!). I’m eating either too much or not enough on any given day. I feel like I’m being picked up and shaken until something inside cracks, and then put back down and expected to walk around the world like a normal person again, and I’m not sure how that’s supposed to work. 

There is a Japanese art form called kintsugi. It is a method of repairing broken pottery with a resin which contains gold dust. After repair, the item is considered more beautiful than it was before it was broken. There is an associated philosophy of wabi-sabi which reveres the organically imperfect, the lovingly handmade, and the things that have been worn and mended or broken and repaired. My best hope right now is that the med-student heart ends up being kintsugi. 

So you're off to the wards

Congrats! The moment you’ve been waiting for since you started med school (or even sooner than that) is upon you. But what is it really going to be like? How do you prepare? 

After 6 months on the wards, here are some tips I think are pretty important:

1) Read.

You will hear this on any rotation, but it really is important. UpToDate is your new best friend. Hear about an interesting patient? Read about on UpToDate. About to go interview to a patient? Skim through UpToDate on your way. Prepping for a presentation on a topic? UpToDate. You can even download the app straight to your phone. 

Case Files is a fantastic series. I read it cover to cover for every rotation. It is a great introduction to each rotation. The cases are really quick, very high-yield informative reads. 

2)  It can be really stressful starting a new rotation, especially if you’re at a new hospital. 

Spend the first half your rotation getting used to the rotation. Read about your patients, learn the terminology and figure out what’s expected of you. 

Then spend the 2nd half preparing for the shelf. It is sort of pointless to try and study for the shelf in the beginning anyways. Sure, the weekends are a perfect time to whip out Blue Prints or First Aid, but where you really learn is on the wards. Once you see a patient, reading about them in the textbook helps you reinforce the material. 

3. Do practice questions.

For shelf prep, UWorld Step 2 is amazing. You can have it on your computer, your phone and your tablet/iPad. It’s definitely pricery ($400 for a year) but completely worth it. Not only does it help you get used to the format of the Shelf exams, but each question has a lengthy explanation and it basically serves as another source of information. 

4. Dress professionally.

This is a tough area because the residents and attendings might dress a little more casual, but as a rule of thumb, you should always dress more professional than your seniors.

For guys, its pretty strait forward. For ladies, it can get a little more complicated. There are so many combinations! Dress pants and a nice shirt are always a safe bet. I think skirts and dresses at or a little above the knee are totally appropriate. You can never go wrong with tights. Boots in the winter/rain are ok as long as they are in good condition. 

I basically paid attention to what the residents were wearing and tried to dress as professionally, if not more professionally, as they were on a day to day basis.

5. Get used to not knowing the answer.

It’s okay. That’s the point of this year. Attendings and residents don’t expect you to know the answer to every question. The questions they ask you are meant to teach you and guide your learning.

It’s also important not to lie. If you don’t know an answer to their question, tell them you don’t know but you’ll look it up! 

6. Try not to take things too personally, especially in the OR!

The attendings/residents will get upset and they will inevitably get mad at you for holding the camera wrong or not retracting the right way, but don’t take it personally. 

This also applies to patients. Not every patient is going to love med students. There will be patients who don’t want you in their deliveries or their surgeries, but don’t let that get to you. You’re awesome and it’s their loss!

7. Be honest.

I know I mentioned this already, but it needs its own category because its so important.  Rounds are stressful, you will inevitably have forgotten to look something up before hand, but if you do, don’t lie about it! Even if you are pretty sure there sodium was okay, just tell your team you aren’t sure and you’ll get back to them. No one will fault you for that (unless you are consistently forgetting, that’s another story).  

8. Work hard, play hard.

Good work-life balance is essential. A happy person is a better student.

Seriously. Exercise, paint, take pictures, go to happy hour with classmates, whatever floats your boat, but make time for things besides studying and work. 

9. Be enthusiastic. You are living the dream.

Even if this is the 10th cholecystectomy you’ve seen, go to the surgery. Is there another med student scrubbed in the case and you have nothing to do? Go to the case.  A lot of my feedback so far has focused on my enthusiasm. It’s easy to get caught up in the scut work or trying to study for the shelf, but remember, this is what you’ve always dreamed of! 

As a side note, while it’s important to be enthusiastic, it’s also important to be genuine. The residents and attendings don’t expect you to want go into their field and you don’t need to feel pressured to tell them you want to go into their field just because you think that’s what they want to hear. Most of the time they see through people that are being insincere anyways.

Stay true to yourself and you’ll rock this year!

Oh and most importantly, 

10. The wise words of Elle Woods: