Sunday, May 29, 2011

The Human Tune-up

I had just finished the last suture on a young child only nights ago when I had an epiphany. He walked out sewn accordingly and feeling better than when he walked in.

Time for a Fix

Being a human mechanic definitely has it's perks. The object of our profession can actually express gratitude for the help received. People of all backgrounds come see us for a tune-up of body, mind and spirit. We are in the business of repairs; diagnosing problems and giving appropriate treatment.

It's not always easy to make patients feel at ease when their mechanism malfunctions. Jokes seem out of place, time is precious and pain is very subjective. I suppose that is why so many refer to medicine as an art. Balancing these things is a skill obtained over time and one in which students definitely need experience. So my epiphany was part realization and part appreciation. People get broken and we fix them, what an awesome responsibility.

Question of the Week
A 25 year old female presents to the emergency department with right sided flank pain, nausea and vomiting since this morning. She denies frank hematuria but urinalysis is positive for occult blood. Her CT scan is pictured above. Which of the following medications would be most appropriate for this patient?

A. Tamsulosin
B. Verapamil
C. Gabapentin
D. Calcitonin
E. Metronidazole

Answer & Explanation

Sunday, May 22, 2011

High Speed Medicine

As a kid, one of the best parts of the parade was the emergency vehicles blaring their horns and flashing their wild strobes. Sometimes though, lights and sirens just never get old. Since I am currently rotating in emergency medicine, it seemed fitting that I would get my share of prehospital care on the city streets.

Prehospital Medicine

The high pitched tones squealed over the radios and we were all out the door in a matter of seconds. With the lights flashing in a wild furry and the siren blaring, we flew down the city streets on our way to the injured and ill. For any who have never gone "Code 3" in a vehicle, it is like the best commute ever; no red lights, stop signs or question of who has the right of way. We were parting the sea of vehicles all the way to our destination. The little information dispatch provided was all we had to prepare for the call. Once on scene, we could size up the patient and events that had transpired only minutes earlier. The few things we carried were usually sufficient to get our patients from home to hospital.

Countless times in the hospital, I have heard the Emergency Medical Services (EMS) get a bad wrap. Perhaps we are all jealous they get to ride around city streets at high speeds and make loud noises in the process with all those attractive lights. In reality, I think there is a disconnect between the providers in the field and those in the hospital. We are on the same team looking out for the patients that so desperately need our help, but unfortunately forget that all too often. I feel bad when doctors don't take the time to listen to EMS. They have spent the first moments of patient interaction building a relationship that will ultimately be transferred to the hospital personnel. Without their efforts, it would be a disaster getting people to the hospitals. In a sense EMS is bringing medicine to the people.

Although my time with EMS was limited and not required of me, I had a blast being among men and women who save lives on the run. I was welcomed into their department/home and to dine at their dinner table. They let me get my hands dirty and shared how they wished more would learn what they do. If you ever get the chance, I would highly recommend spending a day on the crew, they have plenty to teach. To those at San Bernardino County Fire Station 71, thank you.

Question of the Week
A 56 year old homeless male is brought in by ambulance to the emergency department after being found on the ground with what appeared to be hematemesis. He is now alert with mild confusion. His blood pressure is 86/48, heart rate 124 bpm and respirations 28 bpm. He is afebrile and weak. It is initially thought that he has a gastrointestinal bleed. What is the first step in management of this patient?

A. Normal saline to replace lost fluids
B. IV Octreotide to slow bleeding
C. Ensure a patent airway
D. Blood transfusion to replace lost blood
E. Guaiac testing of vomitus

Answer & Explanation

Monday, May 16, 2011

Experiencing Out-of-State Rotations

Being away on rotation definitely changes the pace during the clinical years. Living in a new place forces one to adjust rapidly, but getting there is half the battle. [Pictured: Huntington Botanical Gardens, San Marino, CA]

New Sights, New Places

This month I have chosen to do a clinical rotation out of state at a facility I am interested in applying to for residency. It makes for a good opportunity to learn the computer system, get to know the people I would be working with, and decide if this is a good fit for me. I have been happily impressed with things for the most part. Despite the great onsite rotation, moving from my home with a well-established comfort zone to a rented room in someone's home for a short period with roommates is quite the opposite. I feel like I am back in college with so many people on different schedules all doing their own thing to succeed. It's just a change I am going to have to deal with as it's helping me achieve my goals too.

Some thoughts for those looking to do away rotations that I have found useful:
  • Stay organized - Make a spreadsheet for contact and program names, numbers, emails, addresses, dates etc for easy referencing
  • Apply to programs six months in advance or earlier - If it is a program you are interested in, there is good chance others are too and positions will fill quickly if you don't have time on your side
  • Double book - There is nothing wrong with double booking rotations and politely declining one as time approaches to ensure you have a position somewhere
  • Be seen - If you can't get the specialty you want at the site you are visiting, pick one that will permit face-time in the department you are interested in or request a different month
  • Make lodging arrangements early - Ask student coordinators for a list of available renters, visit craigslist for local postings, and check nearby university classifieds for shared housing
  • Save money on flights - Use airfarewatchdog for updates on the best flight prices to your destinations
  • Be a tourist - Plan a day to visit and explore your new surroundings. It may prove helpful when deciding where to apply for residency. Get groupons to local restaurants and activities
  • Show appreciation - Send a note of appreciation to the program, it only takes a minute and will be one more way for them to remember you
If you have other helpful pointers that you would like to share, please leave them in the comments below. 

Question of the Week
A 23 year old obese appearing female presents to the emergency department complaining of headache, nausea, photophobia and tinnitus for 3 days. This is the first time she has experienced a headache like this. She denies recent fevers, loss of consciousness, or a significant past medical history. Her last menstrual period was 5 days ago. Her vital signs are stable and your physical exam is benign. Computed tomography of the head and lumbar puncture are normal.What is the most likely diagnosis?

A. Normal Pregnancy
B. Dehydration
C. Idiopathic Intracranial Hypertension
D. Subarachnoid Hemorrhage
E. Meningitis

Answer & Explanation

Sunday, May 8, 2011

The Moment Has Finally Come

It was not long ago that I had hoped for more aha moments to clarify what to do with my career. Now on rotation out of state, it didn't take long for me to realize that I felt right at home. Perhaps not in relation to my living arrangement, but at least along the lines of a specialty, I know what I want to do. [Pictured: Arrowhead Regional Medical Center, Colton, CA]

My Aha!

I had prepared well in advance for this rotation and anticipated it with great excitement. Everyone with whom I spoke had positive things to say which only fueled the fire. All year I have been craving that feeling that told me this is the right specialty for me. Despite previous experience in emergency medicine, I left room for any specialty that could woo me throughout the year. Although some came close, none were successful. My first shift this week was late into the night and twelve hours long. Only a couple hours into the shift and I was hooked...again. Emergency medicine feels right and holds my interest, even at 3 o'clock in the morning when the conditions may be less than favorable.

It is one of the more exciting events of my third year, to walk to my car after a long day of work and feel just as enthusiastic to return the following day. There is a sense of fulfillment and accomplishment which are perhaps afforded by the instant gratification that the treatment of acute conditions can offer. It is fast paced, full of variety, and there is room to really make a difference. If you don't believe me, ask the patient we coded last night whose heart started again after CPR and a few medications. In only a couple of nights I have been exposed to horrific cancers, multiple stab wounds, and minor illnesses alike. Somewhere between the medicine and procedures the coolness of it all sinks in. How reassuring to have finally figured out my specialty, because I was starting to worry that nothing would stand out.

Question of the Week
A 28-year-old HIV-positive male complains of pain on swallowing. Physical examination is remarkable for white plaque-like material on his tongue and buccal mucosa, which is scraped and sent to the laboratory. Based on these findings, and on the laboratory results, the man is diagnosed with acquired immunodeficiency syndrome (AIDS). With which of the following agents is the man most likely infected?

A. Candida albicans
B. Cytomegalovirus
C. Herpes simplex I
D. Human herpesvirus 8
E. Human papilloma virus

Answer & Explanation

Monday, May 2, 2011

Conquering the COMLEX PE

What seemed like an exam that would suck the life out of me actually turned into something memorable. The COMLEX Level 2 PE was no slice of cake, but it is finally over and behind me.

Visiting Philadelphia

I've been feeling a sense of hostility towards this exam for some time now. It just had to be done and put to rest however. Last week I made the trip, racking up miles and spending lots of cash to see it put to rest. The best part of it all was the Philly Cheese Steak sandwiches. Although my classmates and I were only in Philadelphia for a 24 hour period, we couldn't stop at one sandwich and filled our glutinous desires with a couple. I never would have thought Cheese Whiz on steak could taste so good.

Although I am not allowed to share information about the test in particular since it would violate the policies and jeopardize my grade, I will say it was quite unique moving from room to room in so short a time frame. If that was any indication of what clinical practice will be like, I had better get used to things soon. I don't know if anybody walks out of that exam feeling confident that they solidified a passing grade. All we can do is hope that we put our best foot forward and let our experience do the talking. The rest is in the hands of the graders to determine our fate. So begins the long wait in agony for a pass/fail test result. At least I have a 50% chance of doing well.  

Question of the Week
During a bitterly cold winter, an elderly couple is found dead in
their apartment. All of their windows are closed and their leaky old
furnace is on full. Which of the following is the primary mechanism
by which the toxin involved led to the death of this couple?

A. Decreasing intracellular calcium
B. Inhibition of cytochrome oxidase
C. Inhibition of Na+/K+ ATPase
D. Irreversibly binding to hemoglobin
E. Stimulation of cellular apoptosis

Answer & Explanation

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