The Final Exam

After the second year of medical school, students take the first of their board examinations, then a second board exam during the third year. A clinical patient encounter accompanies the second exam and fourth year is full of interviews which prove test enough to not need another board exam. One would think that post-medical school, the examination process ends and life returns to normal ebb and flow sans souci. Sadly, this is not the case. Enter residency...

Oiling the Rusty Mind

Months into residency and things are going great. Strolling wards, seeing patients and watching therapies take effect is a reward that hard work is paying off. But in order to pass intern year, the final round of board exams looms overhead holding in its death-grip the ability to moonlight in our post-graduate year II. This is where the intensive subject review satisfies the gap of knowledge from match day to test day. While passing scores are not required to be as high the third time around, we all want to perform well and put this exam behind us forever. It is said one needs to study two months for Level 1, two weeks for Level 2 and bring a #2 pencil for Level 3. Fortunately, many board exam resources are available so we don't have to rely on sheer luck.

With this third and final board exam I chose to prepare with the COMQUEST question bank for about one month in addition to my reading materials. One clear benefit that usually appeals to (over-worked and under-paid) residents is cost, which is generally lower than other question sets on the market. For those who might be curious what this Qbank has to offer, I have made some comments below highlighting both pros and cons. 

Pros

• Reasoning - Each question has a detailed but brief explanation of the correct answer including information as to why the wrong answers are incorrect.
• Comparison - Each question provides a percentage of users who chose the correct answer, thus providing you with an idea of what you should already know.
• Suggestions - Many of the Osteopathic Manipulative Medicine questions provide special algorithms to work through confusing scenarios.
• Images - Pathology is explained and shown to assimilate exam-like experiences.
• Representative - These questions are very similar to actual exam questions, thus better preparing the student for exam day.

Cons

• Calculations - Some questions use numbers that are hard to manipulate and explain that the boards will use simplified values, why not use simpler values in the questions too?
• Video - New examination format is implementing the use of video to portray questions which could be helpful in practice questions.
• Goal - It would be nice to know what most passing test-takers are achieving overall in the Qbank to give an idea of how prepared we are before sitting for an 8-hour exam.
• Scores - Currently, scores are reported in small font making them hard to stand out. It would be nice if they were larger and if you could select the last 5-10 tests to see recent percentages that don't include poor scores from the beginning of practice.
• Devices - Making a smartphone or tablet app to do questions on the go, would be really helpful.

Per the folks at COMQUEST, audio and video style questions are soon to be added to the question bank. As a gift to dedicated readers and those interested in using this resource in their board exam preparations, when purchasing your subscription, enter the COMQUEST discount code CQMED10 for 10% off until 2/28/13. Please leave comments below with your feedback! 

Medical Student No More!

That bitter-sweet time came at three o'clock in the morning. I had finished my last shift in the emergency department, in medical school, and in Las Vegas. My last official function as a medical student had officially come to an end. (This might be a good time to celebrate.)

The Knell of Medical School

The walk in solitude to my car in the cool calm of the morning hours was much more subdued than my nervous entry to the classroom on day one. From the first week of school, to my first exam and first patient encounter I have really enjoyed the ride getting to the final destination. With any luck, my medical knowledge has increased and I have learned how to study more effectively. Thankfully, my level of confidence continues to develop and I'm starting to get preceptor questions right...it's about time!

I finally feel like I have something to contribute to the medical community. In due time, that feeling will be validated with my diploma. The dream of a lifetime will be a reality and yet it feels like the time went by so quickly. Residency will be a completely different animal, but at least I won't have to take out more loans to participate there. For now, I am reconnecting with my lost weekends, sleep and play time. This is the breath of fresh air I've been waiting to experience for a long time.

Question of the week

What looks like a doctor, works like a doctor and is shortly going to be a doctor?

Answer

Chasing Zebras

This week I became fascinated again with the basic sciences, this time through physics and chemistry. The department had a Wood's lamp easily accessible and I had a urine specimen readied for testing. A patient with dermatological manifestations of a diseased state presented and according to my research, this simple bedside test would demonstrate fluorescence if positive. Shown here is my wishful attempt at something out of the ordinary, which to my dismay was negative.

Trial by Experimentation

Sometimes going out on a limb to explore a part of the differential can be illuminating to the disease process. In this case, it was more educative. Should I have a patient in the future with similar symptoms, this test will more likely come to mind than having to research it. After discussing the out-of-the-ordinary, potential diagnosis with my attending, he encouraged my investigation rather than laugh me to scorn. They told me that medical students, even in their limited knowledge can actually have a significant contribution to the patient's care. Even though we may come up with a "zebra" or two, if we didn't consider them as part of the diagnosis perhaps nobody would.

For those not familiar with the term zebra, although they appear similar and may even audibly sound similar, it is more common to come across a horse than a zebra. In medicine we use this idea to relate to diseases wherein the common things are common. We look for the obvious and common problems while considering that there may be a zebra in front of us. If we don't look for the zebras, then we will effectively miss them and erroneously treat the "horse" disease states, thus leaving the patient inadequately treated.

This little exercise was a reminder to me of how many varied sciences are included in the art of medicine. The fact that many professionals with educated backgrounds come together adding their piece of the puzzle to bring understanding to the whole picture. Whether a bioscientist, chemist, physicist, or technologist it is a team effort in creating the best outcome for a patient. On this particular day, I got to venture a little off the beaten path and was enlightened by my exploration.

Question of the Week

A 57 year old homeless male presents after a night of alcoholic binge drinking complaining of new blisters forming on his forearms. You notice that his skin appears tanned and consider the diagnosis of Porphyria Cutanea Tarda. The uroporphyrins in his urine sample appear to fluoresce under the Wood's lamp. What other finding would you expect to see in this patient?

A. Hypertrichosis
B. Melena
C. Telangectasias
D. Nail pitting
E. Cotton-wool spots

Answer & Explanation

Trading Scrubs for Camouflage

Having spent most of my time in civilian hospitals and clinical settings, it was quite the change this month when I started my last medical school rotation in a military-run facility. Government issued footwear, camouflaged vestments and unique insignia delineating the pecking order of those in uniform.

Regimented Medicine

Hospital security started well beyond the doors of the building proper and required adequate identification through background checks and documentation. On the premise, it seems a little more like medical centers I have known with the exception of the foreign jargon and dress codes. I might add that I was happily surprised that many of the employees and patients seemed to be physically fit or at least once enjoyed a life of good health -- something that would be nice to see as the new American trend. Courtesy and manners are expressed more openly than elsewhere, likely a result of the regimented training military personnel receive.

My limited exposure to such an environment has its awkward moments. For example, the time I walked into a room and addressed the patient by a formal Mister/Missess to be quickly corrected by the patient of their notably high military ranking title. As a civilian, I had no way of knowing, nor did it change my approach to that particular patient's care. It was simply an unsettling feeling that somehow the career title with which I was unfamiliar, was expected to modify my view of that interaction. I am waiting for the time when I receive a demerit for a rule I never knew existed. Despite this unexpected occurrence, I sincerely honor and respect the service that these men and women provide or have provided to our country. It is fascinating to hear their stories and see their determination to succeed. While I may not have my stripes, I can appreciate the family bond they have created. If only more workplaces could emulate their approach, I postulate that outcomes would be favorable. Thank you troops for a job well done.

Question of the Week

A 17 year old male presents to your clinic with an apparent case of streptococcal pharyngitis by exam. You treat the patient with antibiotics and he returns a week later complaining of a diffuse erythematous rash. What is the most likely cause of your patient's rash?

A. Allergic response
B. Azithromycin
C. Amoxicillin
D. Contact dermatitis
E. Post-streptococcal dermatitis

Answer & Explanation

Textbook Diagnosis

It's in the books. There is something fascinating when you actually get to see a "textbook" case in the clinic. Before medical school, I would have thought disease states followed some text written description or at least would present as we are taught. They don't and that is what makes medicine a "practice". Diseases don't do a whole lot of reading in their spare time.

Learning from the Patient

Earlier this month, a young child was brought to the clinic with decreased appetite and oral sores that the mother had noticed for a couple days. My initial exam suggested this was more than oral ulcers. Thinking back to the diseases with oral lesions I was excited to look for more skin changes on other parts of the child's body. One small vesicle on the palm and one on the foot confirmed my suspicion of hand, foot, mouth disease (HFMD). It was exciting to see what the books had described, albeit a mild case. On follow-up examination days later, I reached for the child's hands to see what changes could be seen, there were none. Mimicking my examination, the child's sibling did a self-exam and quickly realized he too was affected. Once a family supporter and now a patient, the sibling actually had a worse case of HFMD that would have gone undiagnosed if he wasn't present.

In a sense, the diagnosis was rewarding knowing that somewhere in my mind was stored the details to help my patient. With the vast amounts of knowledge we are expected to retain and the impossibility of doing so, I am willing to celebrate the small successes. Seeing textbook cases helps confirm my understanding of the many documented pathologies we are expected to understand. Written details are reinforced by touching, seeing and hearing the real thing in person. At least I am making progress in the right direction...and washing my hands a lot more frequently.

Question of the Week

A parent brings in their 4 year old child with what appears to be hand, foot and mouth disease. You know this is commonly associated with the Coxsackie A virus and want the parents to be aware of possible complications that may arise including which of the following?

A. Encephalitis
B. Renal Failure
C. Cardiac arrhythmias
D. Myalgias
E. Vision impairment

Answer & Explanations

Pediatric Medicine

Likely due to language disparities, my less-than-five-year-old patient sat quietly on the examination table patiently waiting for me to start. She was smart and well-versed in the way of the doctor's office. As I approached, she knew when to open her mouth, brush her hair back for access to her ears and when to take deep breaths for adequate pulmonary auscultation. Finally finished with my exam, I returned to my documentation and in her best thespian performance let out a wee little, "a-choo," followed by a finger to the nose for good measure. [Picture: Before The Shot, by Norman Rockwell]

Child's Play

This month on pediatrics I am observing all kinds of lost treasures from childhood. From true emotions that come out in smiles, laughter and screams which somehow get tucked away when we grow older to naive playing with other people never met, ringing bells just because they are there and making sounds for no other reason than to entertain the thoughts floating inside one's head. It brings thoughts of Patch Adams gallivanting through a pediatric unit striving to see just a glimpse of a smile.

I had to laugh a little when another patient in the middle of their numerous vaccinations screamed in horror, their mother encouraging manners and to say thank you. What child wants to show appreciation for a shot and multiple at that?! Nevertheless, it brought a smile to my face when the little voice, through tears, cried out a profound, "thank you!"

Children are trying to be good even though their world revolves around them sometimes. It bothers me when their parents get cloudy vision and choose to refuse care that would easily remedy problems because they lack time or money. Taking your child to the emergency department is not just a suggestion by your doctor, it is sound medical advice that merits following. It makes me wonder why they brought the child in the first place if all they are going to do is ignore our recommendations. So who is the egocentric one now? Clearly, parents are responsible for their child's well-being. Maybe it's time for parents to have their own time out and come to their senses.

While I observe their behavior and character, I wonder what has happened to the child in me. Have I suppressed it so much that it can no longer come out to play or do I encourage its development in the hopes of a happier, healthier me?

Question of the Week

While doing a routine well-child exam you notice your 7 year-old male patient has freckles in his axilla and multiple café-au-lait spots on his torso; 3 anteriorly and 4 posteriorly. There is mild genu varus, no scoliosis and no vision abnormalities. What is the most likely condition this patient has?

A. Lesch–Nyhan syndrome
B. Henoch–Schönlein
C. von Recklinghausen disease
D. Chediak Higashi syndrome
E. Tuberous sclerosis

Answer & Explanation

Medical Coding

Guest post from Deanne Hicks, Medical Billing and Coding Instructor

Greetings! My name is Deanne Hicks and I have worked in the Health Information Technology field as a certified coder for the past ten years. So, what is coding? The greatest analogy I can use to describe coding is to compare it to learning a new language. Essentially, it is the art of storytelling. A coder abstracts information from the patient's medical chart and translates that medical information into alpha or numeric codes that are up to five characters in length. There are several uses for codes, with the most common usage to drive reimbursement for providers. The other uses are for statistic collection, vital records for cause of death, public safety for communicable disease reporting, epidemic/pandemic reporting from hospital records in certain geographic areas and a host of other topics.

You may wonder how someone becomes a coder. For me, I needed a life change and decided to go back to school. Having just gone through a fairly difficult pregnancy, undergoing several encounters with a myriad of different providers over a course of almost two years, medical terminology and anatomy became fascinating to me. I wanted to learn more! I signed up for a diploma program as a medical office assistant and away I went, on a journey from which I have never turned back. I learned more about the human anatomy than I ever thought possible. When I took my medical terminology course, I was completely hooked! Once I got to the medical billing and coding portion of my program, I was on cloud nine. Although medical billing an insurance didn't interest me, I still persevered onward, patiently awaiting this thing called medical coding. Once I learned how to code, it was as if I had found my passion. For the first time in my life I knew what I wanted to be when I grew up...a Coder.

Earlier, I mentioned that coding is first and foremost, utilized in order to get the provider paid. As young medical students who dream of becoming a physician someday, wouldn't you eventually like to get paid for your time? I realize you will most likely have a hefty student loan to repay, so I suspect you will appreciate getting maximum reimbursement for services rendered. Yes, your practice will have a coder to assist you in this effort, but what you need to keep in mind is this; coders code from the medical record so the more complete and specific the documentation is, the more specific the code choice will be. In turn, the higher the reimbursement might be!

Here is a great example, hypertension. In the coding manual, hypertension is divided into three types, those being malignant hypertension, benign hypertension and unspecified hypertension. Malignant hypertension (ICD-9 code 401.0) is defined as very high blood pressure that comes on suddenly and quickly, with the diastolic reading above 130mmHg. With malignant hypertension, complications could arise with kidneys, blindness or an increased risk of stroke or myocardial infarction. If a patient exhibits symptoms such as blurred vision, confusion, anxiety, chest pain, nausea, vomiting, shortness of breath, or weakness in the limbs with a high diastolic reading, malignant hypertension needs to be considered. However, more often than not, the treating physician will simply enter the abbreviation of "HTN" on the encounter form. Because coders code from the medical documentation given, the only code choice would be unspecified hypertension (ICD-9 code 401.9). Also, benign hypertension's (ICD-9 code 401.1) definition describes this type of hypertension as slightly elevated blood pressure which, if left untreated, could cause cardiovascular and central nervous system complications.

If a physician were to document and diagnose the specific type of hypertension, this would open up the opportunity to allow a deeper evaluation of the patient with blood work, ECG if warranted, additional body systems to examine and evaluate as well. In order to code the encounter in the outpatient setting, the more body systems examined and the more test results to review on subsequent visits, the higher the level of coding for the physician's cognitive skills. All things considered, the reimbursement level for the provider will increase over a period of time, which will certainly help to make the practice thrive and in turn give the patient a higher level of care.

Everyone is a winner! Here is the successful chain of events:

1. Medical students learn to give greater detail in medical documentation in preparation for future billing
2. Coders and billers can code more specifically from detailed documentation
3. Greater reimbursement can be obtained
4. Patient's, doctors and coders are happy

So, physicians-in-training, add one more thing to your to-do list. Take a coding course offered at your local community college. Arm yourself with coding knowledge. I realize your brains are constantly being stuffed like a turkey with all that medical info, but as you know, we only use a small portion of brain power anyways. Cramming a little more knowledge into that head of yours will pay off for you big time!

Good luck!

Deanne works with Lincoln Group of Schools, a group of career training schools. She is a medical billing and coding training instructor, which is one of the various Lincoln programs available.

Question of the Week

While attending the cardiology clinic, the staff nurse measures the blood pressure of a 61 year-old man and finds that it is 182/100 mmHg sitting and 190/104 standing. He has a heart rate of 82/minute, with an irregularly irregular rhythm. On auscultation of the heart, there are no murmurs, but he has bibasilar crackles on chest examination. Which of the following pathological findings is most likely to be present?

A. Left ventricular hypertrophy
B. Left atrial myxoma
C. Occlusive coronary atherosclerosis
D. Cor pulmonale
E. Mitral regurgitation

Answer & Explanation

The Ultimate Upgrade

This appears to be a very clean and tidy hospital room, ready for the next patient to fill its bed and utilize its healing equipment. I happened to come across it in the early morning hours on my way to see a patient assigned to my service, a patient who had occupied this bed less than 24 hours earlier.

The Morning After

I knew from the previous day that my patient was struggling to survive his declining medical condition and that it would only be a matter of time before his body decompensated. It just didn't occur to me that this particular morning would be the one I found his room void of active recovery. I was rather surprised when I passed the door mentally preparing myself to review his chart for daily rounds. This was not a novel experience for me, yet it was reason for pause in reflection of a life ended, that taught me in during his struggle to survive. Despite the frequency with which this happens, it resonates as a moment of appreciation for the health that I currently possess.

In medicine, we grapple to preserve life and health. Death is not failure in that equation, yet it is the antithesis of our goal. In fact, it may be the expectant end to the story, but our attempts at prolonging its arrival are the reason we prepare for years to work in healthcare. Sadly, it is something we have to accept as an outcome and become comfortable with despite our best efforts to thwart its occurrence. It happens and the morning I stopped in to see my patient, I could not think of a better scene than his empty bed with the light of the sun filling the corners of his room. It was serenely peaceful and appropriate. 

Question of the Week

An elderly woman, diagnosed with Parkinson's Disease, is very combative with hospital staff, refusing treatment except from her own family physician. Which of the following stages of death is she most likely experiencing?

A. Denial
B. Anger
C. Bargaining
D. Depression
E. Acceptance

Answer & Explanation

Infectious Disease

One of the perks of emergency medicine, OBGYN and surgical rotations is wearing scrubs to work. Between these specialties and vacation it has been a year since I last wore a dress shirt and tie on my rotations. Despite being a little less comfortable, it brings a different sense of professionalism to the game.

Avoiding Disease

Currently rotating on a medicine specialty, infectious disease, I am learning more than ever before, the importance of antibacterial, antifungal, antiviral and antiparasitic medications. I knew there was a lot to know before, but I am now reminded of that fact where it counts, at the bedside. Every day we round on patients who have serious infections including tuberculosis, HIV, meningitis and more. When the patient's infection fighting army can no longer handle the battle, we are called in to bring the reserve armory. Donning special masks, gowns and gloves protects both the patient and ourselves from the exchange of harmful bugs during discussion and examination.

Washing hands is a necessity and stethoscopes are cleaned routinely on this service. If we are not careful, we can be the source of somebody's newest infection at which point it doesn't matter what your tie looks like -- keeping it secured is not a bad idea so it's not dragging through the patient's wounds and dressings. Medicine is a lot like figuring out a good puzzle, both in making a diagnosis and providing the right treatment regimen. Infectious disease aims to find the perfect medication for the job so we are not firing shotguns at thumbtacks every time building resistance to the arsenal we have available. It is a thought provoking field that can have a significant impact on patient outcomes as long as we don't let the disease bug them too much.

Question of the Week

Which of the following drug classes is responsible for both nephrotoxicity and ototoxicity?

A. Carbapenems
B. Penicillins
C. Tetracyclines
D. Aminoglycosides
E. Quinolones

Answer & Explanation

Medical Sub-Specialization

Returning home to Las Vegas after touring the country means it's time to go back to rotations as usual. Fully expecting to hit some of the core specialties, I was surprised when I was assigned to urogynecology as an OB/GYN rotation.

Urogynecology

Initially, I expected to be listening for fetal heart tones, delivering babies and controlling irregular menstrual cycles. When first learned of the specialty, there was not much guesswork as to the line of work we would be dealing with: incontinent women and prolapsed organs. It is so specialized, that it would be similar to finding a surgeon that only operates on right hands. The patients we see are generally very satisfied with their outcomes after surgery, probably because it changes their lives significantly.

It's exciting to think these last few rotations will move faster than any before as things are rolling downhill with great momentum. Experiencing sub-specialized medicine definitely keeps the study topics to a minimum when all I can focus on is the rank list and match. At least there are some aspects in every field of medicine that can be used in emergency medicine. So I am looking for opportunities to gain from this rotation those things that will be pertinent to my future specialty. Needless to say, but this has been a uniquely educational month with far fewer babies than I had imagined.

Question of the Week

What are the symptoms of urinary incontinence?

Answer & Explanation

Education Beyond the Classroom

Learning the tricks of the medical trade comes from lots of exposure to lectures, books and hands-on experience. Initially we are expected to be attentive to professors who create a basic foundation and then pick up the rest on our own time through personal study and discussion with colleagues. When it comes to the clinical setting, the direct form of teaching dissipates and we carry more of the responsibility to be self taught. Yet there remains plenty of room for a student-teacher relationship. [Classroom at the Washington University School of Medicine 1943]

Learning Through Respect

In speaking with one of the residents at the program I am visiting, he reminded me that not all physicians remember what it is like to be a student. They have forgotten the basics and want to be identified as one who no longer has to be "at that level" of training. In doing so they often seem to have a chip on their shoulder, teach very little to students and ignore even the existence of students trying to be friendly. So doctor, my morning greeting was not an attempt to waste a breath of air, it was intended to be pleasant and acknowledge your existence in hopes that perhaps you would acknowledge mine. Little things like that are what really set a tone in my opinion. It standardizes a sense of mutual respect and understanding allowing for potential growth beyond that point. Maybe it is perceived as a "brown-nosing" tactic wherein I am gunning for a response. Whatever the case, I thought it was a simple common gesture in human interaction. What do I know, I am just a medical student.

Medical students just learn to grow thick skin. Patients give you grief because you are the first person willing to listen to their complaints and desires. After hearing out the patient, the student finally presents to the residents who are the first to think you have set them back because "you must have been delivering a baby in there." If you are not thinking what they are thinking, they will let you know without hesitation that you are wrong. But this mode of action comes from their superiors too. The attendings are looking at them in a similar light but may not always say so out loud. So it only makes sense that the residents become calloused and project their troubles onto the medical student who will smile, be pleasant and always take a verbal lashing for the ever coveted passing grade. All the while the student is thinking, "why do I pay good money to be demoralized in front of patients and coworkers?" We know our end goal and will walk through the gauntlet to get there, even if that means we will be red in the face a few times.

Once in a while, however, there are those who will remember the emotional strain medical students experience. In their wisdom, the residents will slow down and teach or maybe even learn something because we are all in this together. What one person may have recently studied, the other has not heard in a while. This resident remembers the efforts students are making to impress and succeed even if they fall short once in a while. The effects of the classroom extend beyond those four walls into the community and clinics. It has the potential to reside within each relationship we have for better or for worse. I refuse to let my education be compromised by those who have forgotten how a patient teacher can influence an eager student.

Question of the Week

A 24 year old medical student admires and begins to pattern her life after her surgical mentor. Which one of the following defense mechanisms does she exhibit?

A. Introjection
B. Projection
C. Rationalization
D. Identification
E. Conscious Control

Answer & Explanation

Digital Medical Instruments for Your Phone

The effect of the smartphone on technological advances is undeniable. With apps for everything these days people are expanding to a peripheral market to expand the functionality of smartphone products. If you are in medicine, there are some fun gadgets you might consider adding to your black bag arsenal of portable instruments.

Smartphone Adjuncts

Of course you could use your phone as a reflex hammer, but that is just not as exciting as having a few gadgets and gizmos on hand. So if you are looking for a medical gift or something to put on your wish list you might consider some of these ideas that are sure to draw some attention from your coworkers. Many of these have either received FDA approval or are in the process of doing so and will be available for purchase soon. The majority of these devices are expanding use beyond the Apple operating system so keep an eye out for developments if you do not already use the iPhone.

Stethoscope

• Price - $90
• Designed for iPhone/iPod but it looks like it would function in any headphone jack
• App not needed
• Other - iStethoscope Pro app ($0.99), Does not require attachment

Pulse Oximeter

• Price - Unknown
• Designed for iPhone and works with Android, Windows etc
• App required

 Blood Pressure Monitor

• Price - $130
• Designed for iPhone, iPad and iPod
• App required

Electrocardiogram (ECG)

• Price - Less than $100
• Designed for iPhone and iPod Touch, plans to be available for other operating systems
• App required

Blood Glucose Monitor

• Price - $80
• Designed for iPhone and iPod Touch
• App required (Free)

Dermatoscope

• Price - $1,200
• Designed for iPhone 4
• App required ($5.00) Compatible on iPhone, iPad and iPod Touch. Can be used without the attachment.

Ultrasound

• Price - $7,500
• Not currently available on a smartphone but expected to integrate that function eventually
• Available only to medical professionals and comes with visualization device

The practicality of some of these devices is obvious. When traveling or doing house calls to friends and family they could definitely be useful to have on hand. If you are aware of any similar products, I would love to add them to the list. Please take a minute to comment on them below with any information you have found.

Question of the Week

A mother brings in her 3 year old child for a well-baby office visit. She is concerned her child is not progressing normally because he has not memorized his own name, address and phone number? You explain that children are expected to obtain these skills at which of the following ages?

A. 12 months
B. 3 years
C. 5 years
D. 7 years
E. 9 years

Answer & Explanation

The Doctor Behind the Curtain

As the month comes quickly to a close, I reflect on the time I had in the operating room that was definitely an enjoyable experience. At first glance it looks overwhelming, but in time the buttons and monitors have started to make sense. It is no wonder that there is a dedicated individual at the head of any operating table managing a patient's life.

Sweet Dreams

There is much more to anesthesia than putting tubes here and wires there. As the photo demonstrates, there is one tower for monitoring the patient while providing life support and another for the medications that assist in that effort. Poles for fluid resuscitation, suctioning for secretions and gizmos for I don't know what that keep a patient happily asleep. It is amazing that so many tools, gadgets and devices can be crammed into such a small space and have such a large impact. There is barely enough room back there for the physician let alone a student to participate and learn. Despite the lack of space, the attendings continually let me interact with intubations, monitoring and interventional  procedures to get the full experience. These docs run a great one-man show and are so full of knowledge that I often could not keep up.

This niche in medicine will apparently have a 15,000 physician shortage in the year 2020. I hear medical students clamoring to get on board and it seems that the doors may be opening for them. From the physicians who tout the profession, they share their opinion as though it is medicine's best kept secret. They manage only one patient at a time who they rarely seen again, earn a significantly comfortable salary, and between the induction/emergence phases of anesthesia have few complications. On more than one occasion I have noted the relaxed and stressless demeanor of these specialists to be common for the profession. But when patients are in distress, these doctors are collected enough to help carry a patient through more often than not. It has been a good month with plenty to learn.

Question of the Week

A 30 year old male presents to the emergency department with muscle rigidity and dyskinesias. You notice he is mute, incontinent, in and out of consciousness, and febrile. He is diagnosed with neuroleptic malignant syndrome. Which of the following would be least useful in the treatment of this patient's symptoms?

A. Admission to the hospital
B. Replenishment of IV fluids
C. Administration of bromocriptine
D. Administration of dantrolene sodium
E. Administration of haloperidol

Answer & Explanation

The Art of an Operating Room

For whatever reason, I missed out on a general surgery rotation in my third year of medical school. It was replaced by random surgical specialties which were educational, but did not cover the basics of surgery. Now that I am rotating with anesthesia, I am seeing a larger variety of surgery than I could have imagined.

Effects of Cold Steel

In only a week's time I have observed surgeries from head to toe and everything in between. Some abbreviated and others extensive. All bring their own sense of fascination as they are usually a definitive treatment for the patient's particular condition. On numerous occasions I was able to witness cases that I thought were simply for the textbooks; in other words, those that rarely make their way into the operating room. Skin grafting, thyroglossal duct cyst removal, gangrenous cholecystectomy, thoracotomy, colectomy, craniotomy to name some that have stood out. After meeting up with the anesthesiologist and putting the patient to sleep, I stick around if the case has some educational appeal. Since I never had the traditional general surgery rotation, I am doubling up this month to get the most possible from this experience.

Life in the O.R. is an array of medical art. Everyone has a role and moves to fill it with precision. The colors of contrasting sterile blue against blood red seem to glow under the lights while everyone mysteriously peers over their masks. Instruments shimmer in cleanliness as they move to and from the operating field. The sounds of monitors keeping pace, instruments doing their job and personnel collaborating fills the silence creating an ambient effect. In concert everyone works together to see that the patient has a positive outcome. It's a beautiful place to observe and learn, it's a place where things get done. 

Question of the Week

A febrile 12-year-old child presents with severe right lower quadrant
pain that is interpreted by the attending physician as acute appendicitis.
The patient has also been complaining of joint pain. At laparotomy, the
surgeon notes that the appendix is normal; however, the mesenteric lymph
nodes are markedly enlarged and contain focal areas of microabscess
formation on cut section. This patient is most likely

A. An asthmatic
B. Deficient in C1 esterase inhibitor activity
C. HLA-B27 positive
D. Leukopenic
E. Serologically positive for toxoplasmosis

Answer & Explanation

Anesthesia 101

After introducing myself to the anesthesiologist I would be working with for the day he quipped, "I'm not an intubation monkey, you are going to learn something this month." With many years under his belt and all the students he has seen, I had a feeling he was speaking from experience. He taught and I learned from the best writing space available, his knee.

Moving Forward

Some have said that fourth year is the apology for the first three years of medical school. We get more freedom to explore our interests and roam about the country finding residency programs worth our time. At last we get a little autonomy and it was for this reason I chose to do anesthesia early in my fourth year. Since I plan to go into emergency medicine, it will help me with sedations, analgesia, medications and airway management via intubations. (Apparently, Dr. Anesthesiologist saw right through that one.) Fortunately, I had no problem with the first tube of the day and we were rather productive as far as teacher and student are concerned.

It seems that for the most part, anesthesia is a calm environment at the head of the table hidden behind the sterile drapes. It consists of mostly monitors, charting and pharmacologic management of the surgical patient. On rare occasions things get a little hairy and I was fortunate enough to experience one such event on the first day. Fortunate because it brings a new understanding to the profession. The patient was dying and the anxious surgeon was eager to start the case. But before anything could happen the patient needed to be resuscitated or the surgery would be futile. Tensions ran high for a short time, but through focused efforts the patient responded to treatment and the surgery was performed as planned with no complications.

Every rotation seems to have significant learning potential and I doubt this one will be any different. I look forward to a busy and productive fourth year. It also happens to be my last year as a tuition paying student which is quite a happy thought.

Question of the Week

A patient becomes cyanotic, has profuse sweating, an unstable blood pressure, and a temperature of 106°F two to three minutes after induction of general anesthesia with halothane. Appropriate intervention would consist of respiratory support and the administration of which of the following?

A. Succinylcholine
B. Dantrolene
C. Acetominophen
D. Hydrocortisone
E. Epinephrine

Answer & Explanation

Things I Wish I Knew - Third Year

And now for one of my favorite posts of the year; taking a look back at everything I have experienced and attempting to come up with a few things that helped me succeed. I would like to invite you to share your input as I may have overlooked a number of useful ideas. As in years past, I am including my weekly intensity chart.

The Year Reviewed

I will be the first to admit that this year's intensity chart has little benefit to anyone but myself. Everyone experiences rotations in different orders and each has a varied feel depending on site, preceptor and specialty. For the most part it was on a steady continuum. The occasional peaks and troughs were likely tests or vacations respectively. The large dip representing my vacation month when I was recovering from surgery and the recent peaks reflecting weeks that I left nothing to chance on elective rotations in emergency medicine. These later markings also show stress that has been mounting in anticipation for board examinations. Without further delay, below are those things which I wish I knew coming into third year.

1. Maintain an open mind - Every specialty has something to offer, even if you are not enthusiastically interested in the field. You never know when a lesson learned from a particular patient will come in handy on another rotation or even later in your career. There is always something to be learned, even if you are not fascinated by the work before you.
2. Participate actively - It is easy to observe and nod your head when preceptors carry about their normal activities. Encourage them to teach by asking thoughtful questions or volunteering to participate in procedures. One night during my studies I watched how to place a central line only to be asked the following day if I knew the steps. Because I was familiar with the procedure I was given the opportunity to place the line and have been entrusted numerous times since then. Always be ready to step in to answer questions or use your hands and actively learn.
3. Avoid easy rotations - Every now and then it is nice to have a rotation that demands less, but too many of these can be detrimental. This is the best time to interact with patients, perform procedures and learn from attendings. We pay good money to be in clinics and hospitals, why read about the diseases when they are in the room next door ready to be seen first hand. Even if you are on an "easy" rotation, push yourself to take advantage of the little time you are there, you can read later when you get home.
4. Pace yourself - There is more information than you can possibly consume in a few short weeks about any one subject. Start studying the specialty early on in the rotation and regularly review the "bread and butter" topics. By the end of your time there you may become exhausted when shelf exams are just around the corner. Cramming for the end of rotation exams is not going to help you in your career as much as regular study.
5. Enjoy your time off - It is really easy to get swamped by the books, board exams and stress of preparing for residency. There is a little more time in third year to break away from school and it can be a perfect therapy for all the stress that will inevitably mount. Be sure to have regular time set aside for exercise and breaks. Work hard, play hard.

Question of the Week

A 67 year old male patient presents with mild confusion, diarrhea, and a new skin rash. These symptoms have been present for 1 week according to the patient's wife. What is the most likely nutritional deficiency that this patient is experiencing?

A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B5
E. Vitamin B6


Answer & Explanation

Providing Fresh Air

I have yet another first to add to my list of many as I trudge along the med student life. Like many, this one is procedural. In emergency medicine the procedures continue to accumulate the longer you are there. I think it falls into the "see one, do one, teach one" mantra.

Rapid Sequence Intubation

With little success at my previous attempts, intubations were starting to concern me when I could only see the epiglottis and no vocal cords. That was the closest I came before patients would start to lose oxygen and the attending moved in to finish the job. After wondering why I was going to an extra shift last week, I was glad it fit into my schedule. We had a patient with respiratory distress needing rapid intubation. Despite their predetermined status as a "difficult" airway, my attending gave me the opportunity to perform the skill. Focused and determined to finally have a successful intubation, I meticulously placed the endotracheal tube on my first attempt...in the right place! In a specialty where airway management is critical and a career of it ahead of me, it is nice to see where my first success actually occurred.

The physician with whom I was working mentioned the day before, "you have to respect the difficult airway." Although I may not completely understand that statement at this point in my career, I know that the skill is important enough to appreciate pitfalls and workarounds. My extra shift turned out to be rewarding on this particular occasion. A simple procedure to some happened to be another milestone in my book.

Question of the Week

A dialysis patient has missed their routine treatment and is now currently in respiratory distress as a result. You choose to intubate the patient. In preparation for this procedure, the use of which of the following paralytic medications would be discouraged?

A. Succinylcholine
B. Rocuronium
C. Vecuronium
D. Pancuronium
E. Rapacuronium

Answer & Explanation

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

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

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