When you haven’t seen kids in awhile, it’s always nice to have a review of the anatomy and pictures of normals and abnormals . Big help.

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Found this “Guide to Being an Intern” online –it’s for UMich residents, but has some good little tips that I’ll definitely be referring back to when I hit my SubI and finally graduate.

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Doctors, nurses, med students, patients, we should be embarrassed.

Welcome 2007. You can email , send instant messages , order airline tickets in seconds , track that airplane as it flies across the globe , manage your calendar , work on documents and spreadsheets in real time with your friends and colleagues , even read newspapers from around the freaking globe . But our computerized medical records (or whatever you want to call them) can’t even print out labs in the right order. This is, in a word, ridonkulous. Hospitals and clinics should demand more. The big medical record makers should provide more. Their interfaces, truly, look like they’re from 1990.

I have spent a little over a year in hospitals, working as an upcoming doctor, and I’ve seen 8 completely different electronic medical records. (This is working at only 4 different hospitals.) Some are better than others, some are definitely worse than others. The government’s own Veterans’ Hospital’s CPRS software is probably the best, and honestly leaves much to be desired. ( This is what it looks like. )

Over the year I’ve tried to collect ideas about the best features (and worst) of these different systems, and I’ve put them all together in something I call (for lack of better): the GMR (Grahamazon Medical Record) . It’s an interface only–doesn’t actually save patient data (yet!)–but sadly, I think it’s lightyears ahead of what I’ve seen (and I live in Silicon Valley). It’s mainly a proof of concept–that this could be done, and can be done. (Note: It works in all modern browsers: IE7, Firefox, Safari.)

I’ve put together a screencast that walks you through some of the features . Watch it, and then play around with the interface . My goals, basically:

1. Make the software work for you, not the other way around. I see many of my attendings bewildered when trying to figure out basic tasks on current systems.
2. Make it make sense. Chemistry panels should come out in the right order. Information should be easy to find and accessible. Information that needs to be known quickly in an emergency should be easily displayed.
3. Don’t act like a medical record. Act like a one-stop shop for getting hospital work done . Be context sensitive. Don’t make me call the operator to find out who’s on call. If a lab isn’t being processed, show me who to call for that lab.
4. Be legible, and easy to process. I see too many people having to squint and strain to read their monitor.

Note: This is obviously not optimized code for efficiency, it’s my hacking-so-it-works Web 2.0 interface. It could definitely be improved, but it’s a start.

Feedback, as always, is appreciated. (Oh–forgot to mention in the video–you can easily access any of the tabs by doing “Ctrl+letter” on a Mac or “Alt+Letter” on a PC, using the underlined letter.)

(Special thanks to Maria and Nick for their feedback!)

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First time seeing one of these, two weeks ago. Off to the cath lab for him!

(For the non-medical, that’s an acute MI–active heart attack–in progress. The big rounded convex lines look like tombstones for a reason.)

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I can’t believe I haven’t written about one of the most evil, most frustrating things about being a med student: the dreaded Attending Effect(tm).

The Attending Effect, by definition, is the magical, mystical powers that the presence of an attending has on your patient’s history. The mere sight of an attending will transform the words that come from your patient’s mouth from those he or she told you to a different story entirely.

You’ll get the story from your patient, “Okay, so it’s been 3 days of vomitting, but you’ve been keeping liquids down fine, and there’s no blood in your stool, or black, tarry stools.”

You go tell this fascinating story to your attending, give your assessment and plan, they agree, and you feel good–“The attending said I’m doing the right things! Yes!”

Then, you either go back with your attending to examine the patient again–or worse, your attending sees the patient without you–and the story the attending gets is totally different. Your attending tells you, “She told me it’s been a week and a half of diarrhea, sometimes bloody, and she can barely drink anything.”

The first few times this happens, your eyes bulge out, your jaw drops. You sweat, your heart races, you panic. You are convinced that the attending thinks you totally lied to him or her, or that you weren’t listened to the patient, or that you’re just a total dumbass. You quickly re-tell the story the patient gave you, and you swear you didn’t make it up. You are so totally pissed at this patient.

Once this has happened a dozen times or so, you just kind of shrug it off. You’re annoyed, wonder what the patient was thinking. But you know it’s just the Attending Effect at work, there’s nothing you can do about it, so you just adjust your assessment/plan and keep on moving. There’s more patients to see.

(Reminded of this by Flea , whose stories are totally depressing lately and really getting to me, and making me wonder “Is this really what being an attending is like?)

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I guess this post has been a long time coming, and probably why I haven’t written for awhile. It’s a culmination of a year of clinical training, and what effects it has had on me, from the good, to the bad, to the ugly. I think I’ll start with the bad and the ugly, because that’s what’s really been bothering me for awhile now.

Medicine has made me into a shitty person. Or, maybe more appropriately, the shitty-person side of me was always there, but the stress of medicine brought him out. Many of the problems, I believe, stem from behaviors in medicine that I can’t shake from my person when I’m not in my medical role. Shitty Graham takes several forms:

• Impatience. Often you’re sitting around waiting for a lab result, or a patient to go to x-ray, or waiting for a patient to get his new medication. Or you have a patient that talks on and on about unrelated things, when you know you have many more patients to see and you don’t want to get behind. But this attitude comes home with me. I want this now, I need to hurry to finish that, why are these other people besides me taking so damn long? I’ve lost the ability to live in the moment.
• No tolerance for incompetence. (It dawned on me yesterday why this one has happened.) The transformation from preclinical student to clinical student is a miraculous one, and the amount of knowledge learned is mind-boggling. But with this comes another step: beginning to feel like one understands medicine–and even if you don’t, patients ask you questions as if you do. When strangers ask you questions about medical stuff and you know the answer, it feels great. It feels like you went through all this training for a reason. But at least for me, it’s been a terrible boon for my ego. I really think it’s made me feel like a total know-it-all, even in the non-medical world. It’s weird. I’m incredibly guilty of “always having to be right” in the non-medical world, and honestly trying to fight this and tell myself I’m not always right and that I don’t always have to be. But at the same time, I’ve probably become much more confident and sure of myself (read: cocky), so that I don’t even question whether I’m right or not. Now granted, this never applies to medicine and rarely applies to anything of importance in my life, but it does impact my interactions with others, and how I probably make others feel.

I don’t want to make this sound like I’ve become some sort of terrible monster, but it’s just the little occasioal interactions and thoughts that run through my head that didn’t used to be there.

I haven’t really talked about this at all with any classmates, probably mostly out of shame and the fear that no one will feel the same way, and it’s just me that’s a terrible person. But somehow the pseudo-anonymity of the web and the written word makes it easier to type the words than to say them. I’m just trying to be honest with myself and figure out what I’d really like to focus on in the coming year–mainly why I went into medicine and how I can rediscover some of my humanity and virtue, because the path I’m taking right now won’t lead me anywhere I want to be.

The Good I referred to above will, I guess, be left for another post. Believe me, there’s plenty of it, but I’m just not feeling it right now.

As for this blog–what will I write about since I’ll be doing a year of research and not seeing patients? Several people have asked. I think I’ll spend more time reflecting on the year as a whole (I love reflecting, if you can’t tell), and then who knows, probably some thoughts on research, being a teaching assistant, and then of course my 2 month jaunt to Guatemala next year.

(And welcome back to MedPundit , who thought she was giving up blogging but it’s reeled her back in.)

(Editted, I total was unclear by what I meant by incompetence.)

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The end of clinics, year one, is now complete, and was completely anti-climactic to boot. It’s off to a family vacationn, some rest and relaxation, before I begin my research year that I don’t think I ever announced. (I guess that last sentence was the announcement.) More on that, as well as a wrap up of clerkships year one, when I return. Ciao!

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Some of these are inherent to going to an Emergency Department; others are just the difficulties of clinical medicine.

• Your doctor will assume the worst. This is something patient’s really don’t get, and only recently have I started to get myself. Emergency medicine trains a person to rule out the really deadly, nasty stuff. We treat, we diagnose when we can, but above all, we make sure you’re not having a heart attack or any other potentially deadly disease. Let’s remember, of course, that you the patient, have generally gotten yourself to an emergency department for some reason–and we’d like to figure out if it really is an emergency. For this reason, my lists of possible diagnoses have changed.
  I saw 5 kids a day with nausea and vomitting on my Peds rotation, and we primarily made the diagnosis of acute gastroenteritis and sent them on their way with fluids and education. But in the ED, it’s not just the stomach flu. It’s an appendicitis, or an incarcerated hernia. (I realize I should have been considering this more often in the outpatient clinics, but my awareness is definitely more heightened.)
  The correlate of this emergency paranoia is that you, the patient, will get poked and prodded much more than you would if you just went to your outpatient doctor. Your stomach ache isn’t just a stomach ache in the ED; it could be a heart attack, an aortic dissection, pancreatitis, a kidney stone, or an early appendicitis. (And this isn’t just exaggeration on the part of the ED–there’s many people who have heart attacks who don’t have the classic “crushing chest pain.”) It’s almost like once you’ve got a bed in the ED, you’re stuck there until we’re done with you. I know this sounds terrible. It probably is. But think of the physician’s responsibility for his or her patients: you’ve gone to an Emergency Department and want his or her help. Is it worth drawing blood and urine on patients who might have a heart attack (but might not) if you catch more heart attacks, or other deadly conditions? I’m inclined to say yes. I’ve been in the ED two weeks and I’ve already had at least one patient with a heart attack that I never would have suspected. She had no chest pain, but had a very significant history of heart problems. (Note: this does not mean go to the ER for a heart attack every time you have a stomach ache! Do not tell them I sent you!)
• On to number 2: You will wait. And wait, and wait, and wait. We don’t see people in the order they came in, like they do in your doctor’s office. We see them by seriousness of illness, and then by when they came in. If you’re next up to get a bed, and then a guy comes in with left-sided weakness, and another comes in with a broken arm, and then the clerk announces that a 3-person trauma from Life Flight is on its way, you’ve just been bumped. Again, emergencies go first.
  And even if you’ve got a bed, if someone more sick comes in and requires your doctor’s attention, that patient’s care goes first. Your labs may be done and your CT scans and drugs may be finished, but your doctor’s busy managing someone that’s not breathing. You wait. Is this suboptimal? Yes, but if you were the patient that wasn’t breathing, you’d want it that way, too. Have your partner or spouse or friend bring a book or magazine for you.
• If you don’t speak English, you’ll likely wait longer on average. I can’t imagine what it’s like in an area of the country that’s pretty homogenous. Even in central California, which has an enormous immigrant population, translation is a problem . Even at one of the many hospitals we rotate through, which has 24-hour, live and breathing translators, they still have to be paged, or they’re currently seeing another patient. I had several non-English speaking patients, both in pain, but without knowing what their problems were, we had a difficult time treating their pain adequately. I’m heading to Guatemala next year to get my Spanish up to fluency standards, but still most doctors only speak two languages: English and medicalese. (There are many problems with using kids as translators as well–if they speak one language at home and English at school, they may have never learned medical words like pancreas or palsy or gall bladder, for example.)
• You don’t get much privacy. Your neighbor can probably hear you when you tell the doctor you’ve had STDs in the past, or abortions, or use drugs, or whatever else you’re supposed to be ashamed of. They can probably hear your diagnosis, your intimate, private details. And it’s probably safe to say that the ED isn’t the best for grieving, or talking about death, or anything solemn and serious. There’s no peace, nor quiet, in the ED.

For next time: the great things about the ED, of which there are many.

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These are the words that start to change my diagnosis from “kidney stone” to “drug-seeking.”

Two weeks ago, I pull back the curtain, introduce myself, and see a woman writhing around in (supposed) pain, tears in her eyes. She tells me she’s had 4 kidney stones previously. They’re all uric acid stones, which are generally undetectable on X-ray. That she went to a urologist, was on allopurinol, but stopped it two months ago. This all happened in Texas. She tells me where her pain is, and that it radiates to her back and down to her groin. “Kidney stone! It’s a kidney stone!” I tell myself. I am brilliant. I examine her, find some tenderness on her right flank. Her urine has already been sent to the lab. I tell her I’m going to go talk to the doctors to discuss what we can use for pain control. She warns me that she is allergic to aspirin and Tordol–a strong pain reliever but not a narcotic. (Think super-Advil.) Her mouth swells up when she takes either of these. “What terrible luck, a woman with chronic, painful kidney stones and allergies to common pain relievers!” I think. She then finishes her pain medication story: “Whenever this happens, I usually get dilaudid and phenergan, and sometimes ativan because I have anxiety attacks.” And it all goes downhill from there.

I pause, skepticism and cynicism running through my mind, but I give her the benefit of the doubt. Assume nothing , I remind myself. Moments later, the patient’s nurse chases after me in the hallway. “She’s a frequent flyer here, you know. She was just here 2 weeks asking for the same thing. And I guarantee you next she’ll ask for Fentanyl.” Add more skepticism to the pot.

So we check her name–first time she’s been at the hospital. Maybe she’s using an assumed name? We check her urine, and it’s strongly positive for both blood (going along with the stone story) and white cells, indicating an infection. We’re stuck–her story and labs say maybe she’s telling the truth, but everything else is leaning toward malingering. So we start antibiotics for her infection, give her yes, some dilaudid and phenergan for pain control, and I tell her she’s going to need a CT scan. We get the scan setup, and she continues to ask for more pain medication–“It helps for like 2 seconds and then goes away!” Just when she’s ready to go to the scan, she starts asking for some ativan (similar to valium) for anxiety, because she gets claustrophobic in the scanner. We point out her head won’t be in the scanner, just her abdomen and pelvis. She continues. We tell her she’s already had a good deal of pain medication, and we don’t want to continue giving medications that could suppress her respiratory rate. She starts crying, and starts loudly asking, “Why can’t you just help me?? I’m in pain here, I’ve never been treated like this before.”

My resident pops into the room and helps with the authority bit, and later tells me she recognizes the woman too.

She misses her chance in the CT scanner, so we wait. She, as the nurse predicts, starts asking for Fentanyl, a very strong narcotic. She then starts cycling–“I’m in pain,” then “I’m nauseous!” then “I have a headache,” then “I have a sore throat,” then “I’m anxious,” each time asking for a different medication for her symptoms. She finally just goes to the CT scanner, but leaves the scanner with an anxiety attack.

If the woman does have a stone plus an infection, the infection could start climbing up toward her kidney. She could get an infected kidney, could get septic, could die. I discuss this at length with her. I tell her we believe she needs this scan to make sure she doesn’t have such an infection. She gets upset again and says she wants to leave. (I’m leaving out plenty of copious details, as this dragged on for hours.) We talk about why this is a terrible idea, but she wants to leave anyway. I go get the paperwork for her to sign to leave Against Medical Advice. I come back and note 2 things: her hand is down near her genitalia, under the blanket. (This was the case the last time she was here.) She’s either masterbating or giving herself an infection. I try my best to ignore this, which is totally disgusting, and hand her the paperwork to sign. She can barely grab the pen, she’s so sleepy and out of it from the narcotics. She’s still complaining of pain. She signs and initials here and there, and finally leaves. (I throw away the pen.)

Meanwhile, we have 10 other patients that have been waiting to be seen by a doctor; she’s wasted a bed for at least 4 hours. I’m angry, frustrated, and annoyed–and the rest of the nurses and doctors are, too. I sigh, quickly eat a granola bar for dinner, and pick up my next chart: a woman that’s been waiting 6 hours in the lobby to be seen for a simple clogged NG tube.

Update: I forgot to mention the final kicker–the woman asked for “Vicoprofen,” which is like Vicodin, but has ibuprofen in it instead of Tylenol, which is in vicodin. (She says the Vicodin makes her throw up.) My attending was smart, and realized the real reason she asked for the vicoprofen: it has a larger amount of narcotic in it per pill than the vicodin. Another trick of the trade, apparently.

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I have a habit (don’t we all?) of walking around the ER (especially in the trauma bay) to see what’s happening with patients. It’s all the rubbernecking goodness without wasting any gasoline. You see someone with some big gashes in his forearm, or an arm that’s totally deformed, and you think to yourself, “Man, that must hurt like hell. That sucks. Glad that’s not me.”

This same sick curiosity happened last week with a jaundiced patient. This guy was the brightest yellow I’ve ever seen in my life. The whites of his eyes were fluorescent-highlighter yellow. I had just caught him out of the corner of my eye, and the “Oh man, that really sucks” thoughts came flowing right in.

But then I did a double-take–I knew the guy. He was actually one of my favorite patients that I had taken care of back in February. And I felt really sick for giving him such a cursory thought–and one of pity at that. I went over and we talked for a few minutes–that I was sorry to bump into him in such circumstances, how his kids were doing, how he was feeling.

And then the conversation quickly went from superficial to serious, confiding in me that he didn’t want to be one of those poor guys that dies on the transplant list. His eyes filled with tears, and a lump grew in the back of my throat. I touched his forearm, and said I didn’t want that to happen, either. Right after that the transporter came in to take him to his bed in the hospital, and I said goodbye for the time being.

While I don’t know if I’ll ever be able to get the rubbernecking thoughts from my head, I know I’ll be less superficial with their impact–it’s not just that an arm is broken–it’s that the person’s arm is broken.

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