On Tuesday I had my third day in the pediatrics pulmonary clinic. I am grateful for the experience I have had there. I have been given a lot of practice in interviewing and examining patients that I would not normally have in my APD class. The first time there, I was nervous and avoidant of seeing any patients by myself. This Tuesday, however, I saw several alone before they were seen by the doctor, and prior to being seen by the doctor would return and give him the rundown, a.k.a. presenting the patient. I was getting better even as the morning wore on. One thing challenging about pediatrics is that your patient is often only a third your size with a will and defiance five times your own, making for a formidable adversary. When you ask an adult patient to comply with a request, generally they will without much hesitation. When you ask a child, you are first faced with putting the request in a manner they will understand. Second, you must ask it in a way that they will comply with. That's the real challenge. I have grown far better with this, and also in my ability to be relaxed in seeing patients and in conducting a clinic visit. I know what use certain questions have, I know how to lead an interview, and I am becoming more and more comfortable with conducting a physical exam. Of course, it becomes far more complicated when you meet that child who won't have anything to do with you, and will let the whole clinic know with a blood curdling scream.
I've noticed in the last year that I react very differently to hearing news that a family member, friend, or friend's family member is sick. When I first started medical school I was more concerned about the disease. Now, having amassed far more medical knowledge, I find that what the disease is and how it is progressing is far less interesting than how the person who's sick and their friends and family are doing. It's not something explicitly taught in medical school, but compassion is something continually alluded to and described. It's not really something that can be taught so much as it's already there inside us, waiting for the right moment when, like the sun rising, everything is illuminated.
I've realized I've come to that point. After having a cousin diagnosed with systemic lupus erythematosus and a brother diagnosed with panic disorder, my first concern was for how they are managing personally. Was there any comfort I could offer out of my fund of knowledge, and as a loving caring family member? Recently a friend's mother was diagnosed with ovarian cancer, and is receiving treatment in St. Louis. Although I am curious about the details, they are of lesser concern to me than the way she and her mom are doing, and how I can show my support.
I don't think I was ever without a sense of human compassion. I guess what has happened is that I am comfortable with disease and suffering. Where once the disease was foreign and terrifying, it is now familiar to a point that I can concentrate more on the person and how it is affecting them and the family. There's also a new boldness I have found myself having with patients. In the pediatric pulmonary clinic this past Tuesday, I was interviewing a mother who was accompanied by her two boys and daughter, the oldest of which was four. The three children were running around the exam room, fighting, getting into things, and the mother was clearly exacerbated. I stopped my interview to put down the patient's (her 4 year old son) file and addressed the kids, focused on them, and was able to gain their attention and cooperation while I conducted the rest of the interview and physical exam. It was a huge reward to be able to feel as though I made a connection with the family, and the mother especially. Because, when all is done in medicine, it's not just how much better you feel after seeing the doctor, but how comfortable it was to get to that better place.
Wednesday, January 31, 2007
Thursday, January 25, 2007
The Yellow Man and Facing Mortality
Yesterday in Advanced Physical Diagnosis my classmate Blair and I met a man who was nearing end-stage liver disease. In the book The House of God, there is a patient with hepatitis who is named the Yellow Man, and the description fit well for this patient. My Yellow Man was a lanky gentleman with short messy brown-black hair, with a complexion that could be considered olive under normal circumstances, but was now a sickly yellow tint. All of the waste products from broken down red blood cells that couldn't be cleared through his diseased liver were built up in his blood to the point of making him yellow. Yellow Man said that he had been having nosebleeds for the past two months without relief. In interviewing him it became apparent that he had hepatitis C, a liver infection that eventually leads to scarring and liver failure. It was difficult to determine how he had gotten hepatitis, but he was under the impression it was from a blood transfusion. As his liver became more and more scarred and cirrhotic, it failed to produce the clotting factors needed to stop small bleeding, which resulted in the nosebleeds. The scarred liver also blocked bloodflow back to the heart, leading to distended esophageal varices (veins) as the blood sought to return by another route.
As we started our physical, one of the first things I got a closer look at was the Yellow Man's eyes. As I shined my penlight on them, the white of his eye was completely replaced with a sickly yellow tint. Feeling his abdomen, I could feel his massive liver moving with every breath.
I went to Ed and Beth Courtney's house for a church leaders appreciation dinner, and got to talk with my pastor John Drage. As I told him about the Yellow Man, he asked me how long he had to live. I couldn't say, but said that he is likely nearing the end-stage of disease, as he is losing all normal liver function. I told John he would probably die by bleeding out from a ruptured vein in his esophagus or bowels, or maybe he might succumb to a toxic death as his liver fails to process his body's waste, or maybe he'll die from multiple drug interactions, or something else. John asked me how hard it is to face the reality of working with dying people....
As I was climbing the steps of the parking garage this evening I noticed the hearse parked along the side drive, and then spotted the covered gurney being wheeled to the hearse. It is a scene that most people never see, but happens all the time. It isn't the first time I have ever seen a draped gurney wheeled from the hospital complex, but I've been thinking about mortality since seeing these latest two.
The medical examiner's office is in the same hallway as the anatomy lab in the medical school. It is actually a reasonable distance from the rest of the main hospital building, as though some distance can separate the healthy from the deceased (I'm not certain where the morgue is, but imagine it is likely in the basement, also out of sight). Many people have heard the stories of the false-bottom beds being used to transport dead patients out of sight of everyone else, in an attempt to hide death. Doing everything possible to remove a sense of death from the hospital, I imagine, attempts to convey a sense of health and life. Even in posters and brochures for hospice and end-of-life care the patients look vibrant and lively. Heaven forbid those who walk through the hospital doors never leave breathing.
I've also heard many times how hard it is when your first patient dies. It seems counter to what the doctor is fighting against with his entire existance, yet at some point everone dies. Perhaps it is more comforting for the patient to die outside the hospital, either at home or en route or anywhere else but here, in the house of health and healing. At least then I think I wouldn't have to play the what-if game of what I could have done differently, because I was not able to get to the patient. But once the patient is in the hospital and under my care, the failure to reverse the progression of disease lends to self-doubt. What we all need then is the courage to face the reality that everyone who enters the hospital, from those who work for health and those who seek it, will someday die, and it may just happen while they are trying not to.
As we started our physical, one of the first things I got a closer look at was the Yellow Man's eyes. As I shined my penlight on them, the white of his eye was completely replaced with a sickly yellow tint. Feeling his abdomen, I could feel his massive liver moving with every breath.
I went to Ed and Beth Courtney's house for a church leaders appreciation dinner, and got to talk with my pastor John Drage. As I told him about the Yellow Man, he asked me how long he had to live. I couldn't say, but said that he is likely nearing the end-stage of disease, as he is losing all normal liver function. I told John he would probably die by bleeding out from a ruptured vein in his esophagus or bowels, or maybe he might succumb to a toxic death as his liver fails to process his body's waste, or maybe he'll die from multiple drug interactions, or something else. John asked me how hard it is to face the reality of working with dying people....
As I was climbing the steps of the parking garage this evening I noticed the hearse parked along the side drive, and then spotted the covered gurney being wheeled to the hearse. It is a scene that most people never see, but happens all the time. It isn't the first time I have ever seen a draped gurney wheeled from the hospital complex, but I've been thinking about mortality since seeing these latest two.
The medical examiner's office is in the same hallway as the anatomy lab in the medical school. It is actually a reasonable distance from the rest of the main hospital building, as though some distance can separate the healthy from the deceased (I'm not certain where the morgue is, but imagine it is likely in the basement, also out of sight). Many people have heard the stories of the false-bottom beds being used to transport dead patients out of sight of everyone else, in an attempt to hide death. Doing everything possible to remove a sense of death from the hospital, I imagine, attempts to convey a sense of health and life. Even in posters and brochures for hospice and end-of-life care the patients look vibrant and lively. Heaven forbid those who walk through the hospital doors never leave breathing.
I've also heard many times how hard it is when your first patient dies. It seems counter to what the doctor is fighting against with his entire existance, yet at some point everone dies. Perhaps it is more comforting for the patient to die outside the hospital, either at home or en route or anywhere else but here, in the house of health and healing. At least then I think I wouldn't have to play the what-if game of what I could have done differently, because I was not able to get to the patient. But once the patient is in the hospital and under my care, the failure to reverse the progression of disease lends to self-doubt. What we all need then is the courage to face the reality that everyone who enters the hospital, from those who work for health and those who seek it, will someday die, and it may just happen while they are trying not to.
Saturday, January 20, 2007
How not to do a physical exam
Yesterday I had APD and was with my classmate/partner and our instructor Dr. Phillips. He introduced us to a woman in the VA who had severe right lower abdominal pain who was admitted Thursday. She was on a morphine drip, and reported that the pain was so terrible she was passing out when she was admitted. Since APD is essentially a class on doing patient histories and physical exams, this was "practice" for us. We spent a good hour asking every question we could, exhausting our minds for medically relevant topics, and only then did a complete physical exam (almost a complete physical).
By the time we reached the physical exam, Dr. Phillips had left to go to the swamp (the residents' workstation room) and said he'd wait for us. As my classmate and I moved through the physical, we reached the abdomen. I gently examined the lady's abdomen, noting that she flinched and guarded when I began to press firmly. I moved back and Blair repeated, with questions in between. As Blair asked the woman a question, I was running in my mind the steps of the physical exam, and realized I needed to determine the woman's liver size. You determine this by lightly tapping the abdomen and listening for the difference in resonance. Something that didn't cross my mind was that this woman was in the hospital with severe abdominal pain, and as soon as i made my first tap (which she was not expecting) she grimaced and groaned in pain, doubling up on her bed.
The moral of the story is, don't do anything on a physical that you haven't informed/warned the patient you are about to do.
By the time we reached the physical exam, Dr. Phillips had left to go to the swamp (the residents' workstation room) and said he'd wait for us. As my classmate and I moved through the physical, we reached the abdomen. I gently examined the lady's abdomen, noting that she flinched and guarded when I began to press firmly. I moved back and Blair repeated, with questions in between. As Blair asked the woman a question, I was running in my mind the steps of the physical exam, and realized I needed to determine the woman's liver size. You determine this by lightly tapping the abdomen and listening for the difference in resonance. Something that didn't cross my mind was that this woman was in the hospital with severe abdominal pain, and as soon as i made my first tap (which she was not expecting) she grimaced and groaned in pain, doubling up on her bed.
The moral of the story is, don't do anything on a physical that you haven't informed/warned the patient you are about to do.
Wednesday, January 17, 2007
Drawing first blood, finding a purpose
It's the third week of class for me now (all those undergrads who started today have it way too easy), and the year is out of the gates and running. It's incredible that a half month has already flown by. Time is so short when you stop to think about it. Maybe it's no wonder why so many people these days get so busy; they've learned that there's only so much time they have on this earth to accomplish something, and they're working hard to get what it is they're trying to do, done. It seems though that the ability to stop and smell the roses is still eluding most of us. As the wise philosopher Bueller once said, "Life moves pretty fast. If you don't stop and look around once in a while, you could miss it." All too true. I missed a lot of the last six months because in trying so hard to get from A to Z, I missed B - Y. Worse yet, getting to point Z results in a new point A altogether. Now that I've lost everyone...
In the first two weeks of class we've been addressing endocrine pathology. I don't get especially excited about hormones, which is why lectures on procedures is so much more interesting. With third year rotations starting in only 6 months, I'm drooling to get my hands dirty. So, a recap of procedures learned in the last two weeks:
We've been getting a primer in how to draw blood. First week was venous access, and we drew blood into lab vials. The unsuspecting "patients" who got to be our first needle stick was our very own classmates. It's good to know that the Office of Medical Education likes to protect the hospital patients by making us first stick each other. The blood draw lab was no worries though, and I stuck the median antecubital vein of my partner's inside arm with no sweat. Just for practice, I stuck him again on the back of the hand with a butterfly needle. Even easier the second time. Practice really does make perfect.
Week two we had another blood draw lab, only we were going to be drawing arterial blood. Arterial blood is commonly drawn for arterial blood gas measurement (carbon dioxide, oxygen, pH, and bicarbonate). The artery that is stuck is the radial artery. It's the artery you take your pulse at on your wrist. One slight difference with arteries compared to veins is that they are deeper, and are higher pressure. For this lab, we used manequin arms. Also, to get deep enough to access the artery, the syringe is held like a dart and is taken almost straight down, as opposed to a low angle into a vein. It's a good thing we used manequins; I almost hemorrhaged the arm by leaving the needle in so long the stopper was almost pressed off the top. This week we're supposed to do pulmonary artery catheterization (read: thread a cathether to the heart....on a manequin).
Advanced Physical Diagnosis class could be renamed "Give your teacher a physical" class. I discovered I need some practice at giving physicals.
Following the inspiration of a talk given at church before New Years, I wrote up a personal purpose and mission statement. It was the result of a whole day's work on January 1st. I thought I'd share it for the opportunity to get feedback if anyone wanted to.
Personal Mission Statement
In the first two weeks of class we've been addressing endocrine pathology. I don't get especially excited about hormones, which is why lectures on procedures is so much more interesting. With third year rotations starting in only 6 months, I'm drooling to get my hands dirty. So, a recap of procedures learned in the last two weeks:
We've been getting a primer in how to draw blood. First week was venous access, and we drew blood into lab vials. The unsuspecting "patients" who got to be our first needle stick was our very own classmates. It's good to know that the Office of Medical Education likes to protect the hospital patients by making us first stick each other. The blood draw lab was no worries though, and I stuck the median antecubital vein of my partner's inside arm with no sweat. Just for practice, I stuck him again on the back of the hand with a butterfly needle. Even easier the second time. Practice really does make perfect.
Week two we had another blood draw lab, only we were going to be drawing arterial blood. Arterial blood is commonly drawn for arterial blood gas measurement (carbon dioxide, oxygen, pH, and bicarbonate). The artery that is stuck is the radial artery. It's the artery you take your pulse at on your wrist. One slight difference with arteries compared to veins is that they are deeper, and are higher pressure. For this lab, we used manequin arms. Also, to get deep enough to access the artery, the syringe is held like a dart and is taken almost straight down, as opposed to a low angle into a vein. It's a good thing we used manequins; I almost hemorrhaged the arm by leaving the needle in so long the stopper was almost pressed off the top. This week we're supposed to do pulmonary artery catheterization (read: thread a cathether to the heart....on a manequin).
Advanced Physical Diagnosis class could be renamed "Give your teacher a physical" class. I discovered I need some practice at giving physicals.
Following the inspiration of a talk given at church before New Years, I wrote up a personal purpose and mission statement. It was the result of a whole day's work on January 1st. I thought I'd share it for the opportunity to get feedback if anyone wanted to.
Personal Mission Statement
Purpose
I exist to glorify God and love Him with all my heart, all my soul, and all my mind by:
- Living out the character of Christ at home, at school, in my church, in my community, and across the world
- Pursuing professional excellence through committed ongoing learning, wise management of my time, and empathic relationship building with peers and patients
- Influencing my family, friends, peers, patients, and others I may meet towards a right relationship with Jesus Christ
- Championing Biblical principles in bioethics and health care provision
To accomplish my purpose, I intend to:
- Pursue a right relationship with Jesus Christ through regular and frequent prayer, confession, silence, and solitude
- Consistently spend time studying the Bible according to a pre-determined plan of study
- Set aside time at the beginning of each week for introspection and assessment
- Set aside time daily and weekly to assess my time management and plan ahead for the next day/week
- Create an organized approach to studying and learning the medical knowledge necessary to achieve my mission
- Commit to investing in people and scheduling time to do so
Mission
My mission is to love, serve, and heal others as an empathic physician exemplifying the character of Christ with my life; to commit my life to providing morally sound health care to others regardless of age, race, creed, or status; to be devoted to lifelong learning and understanding; to be committed to advancing the kingdom of Christ in my community and internationally; and to be a loving and loyal son, brother, and friend.
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