Rural Rounds

It was Wednesday night last week that I had my first night of trauma call. Instead of my normal quota of one pager going off no less than once per day (usually with breaking news on our lecture schedule, but often to find my team or receive tasks), I was carrying a second: the trauma pager. It's not so much a pager to answer as it is an alert to begin making your way to the ER to admit an incoming trauma patient. I paged the resident on call for trauma service, and gave him my own personal pager number as well in case he needed to reach me for anything else. That was at 5 pm. It was almost 6 pm when I was paged and informed there was an in-house patient headed to the OR with an upper GI bleed. The surgical team was informed I would be on my way to help out, and I was to head to suite 15. I hung up and left the lounge to head towards the OR. I scrubbed before I walked into the OR suite, hat and mask in place as well, and was greeted by the scrub nurse who asked for my glove size...

I'm just about ready to put a bullet in my Jeep after the recent headaches it's putting me through. First the whole brake system needed replacement, then a belt pulley all but broke, and in the last few days I am hearing a new noise under the hood. I'll be very frustrated if I have to pay for much more here lately to repair my Jeep. Last Wednesday I had a special opportunity to visit someone. Classmate Janette McVey, currently on pediatrics, informed me that Edward, the African refuge child I cared for during my inpatient month, had a well child visit on November 14th. She told me he and his family would really like me to stop in and pay a visit. After clearing it with my chief resident last week while on inpatient, I was able to drive over to Green Meadows post-call and surprise Edward by walking into his exam room. Edward greeted me by walking! He is completely without need of a walker or cane now, and easily sauntered to me and hugged me as I knelt to grab him in a big e...

Recently I've run into some serious problems with my brakes on my Jeep, that forced me into taking it to a garage last Saturday to be inspected. I was expecting a minor problem; my friend Adam had helped me look at it and thought the problem was only a leaky rear wheel cylinder, letting air into the brake lines and lowering the braking pressure. When I got an estimate from the mechanic it was around $350, and consisted of replacing both rear wheel cylinders, both rear wheel brakes, and new wheel drums. After talking with my father and then calling Adam again I decided to get a second opinion and new estimate. In between patient visits I called around a few recommended mechanics and found a second one I felt comfortable going to. After taking my Jeep to them yesterday, though, they found that all breaks needed to be replaced, and the front rotors and rear cylinders, but the drums could be spared. It would actually cost me almost $500 to repair. Since Saturday I have had to rely on t...

Edward is 9, and when he first came in to he ER he was in terrible shape. His dad was with him, and both were falling asleep they was so exhausted. Edward has two siblings and he's the oldest. They all speak French, because that's spoken along the Ivory Coast. I have been thinking of going for two months to Africa during the spring of my 4th year, and this really made me want to even more. Edward was rather depressed and rather in pain for most of the first of the week he stayed with us. He had his knees retapped and his hip tapped to draw off some of the fluid of the effusion that was causing the pain and swelling. That helped with some pain, and we eventually had him on opiate painkillers as well as super high strength NSAIDs. We drew blood for so many labs, and the anemia he already had got worse and we transfused him by the time he left. We did a chest x-ray to screen him for Tb and that resulted in his getting a CT that found a big lung cyst we feared was an infection call...

Since the beginning of August I've been working on my pediatrics rotation. It started mundanely enough with 8 am - 5 pm clinic hours, and by the beginning of September picked up in worktime, with 6 am - 5 pm the norm for a day's work, Monday through Saturday. Still, despite peaking with 75 - 80 hours each week not including time spent studying, pediatrics is the most enjoyable thing I have encountered in medicine thus far, and the largest reason for that is the children. Early on in the first week of the rotation Dr. Groshong, the head of the pediatrics department, spoke to us about what he wanted us to get out of the next two months. He said the primary goal is for us to enjoy learning to care for children and have fun doing the work we do at the same time. That I enjoyed working in pediatrics is an understatement; there was no house officer or attending physician who was ever unpleasant to be around or ever was in so poor a mood it was intolerable. Clinic duties consisted of ...

She was a 4 year old girl lying wrapped in a blanket on the exam table, eyes red from tears. I was going through my usual routine; I started with an interview of the parent asking about the course of the current illness. I systematically asked the when, how long, is it improving or getting worse, what have you given her to help with the pain and vomiting, etc. After gathering the story from the girl's mom, I approached the girl on the exam bed and began my exam. She was in clear distress, but it wasn't until I began my abdominal exam that I became really concerned. As I uncovered her and began to feel her abdomen, she began to cry and wail even more. I felt as deep as I could and she continued to be more distressed. Possible diagnoses were coming into my mind; acute gastroenteritis, appendicitis, sepsis, others. I was beginning to be more concerned that she may have need for surgery. I ended my exam and went to present to my resident. The resident came and did the exam as well,...

What's one of the most defining differences between men and women? How we do personal hygiene.

This past week was my first of two weeks on neurology service. I am working on the consult team, meaning that I am with the neurology resident called by other medical services when their patients' have a neurological problem they cannot solve or don't know how to best manage. Two other medical students are with me, and we all three work under our resident's tutilage. I'll outline a typical day: At 7 a.m. I arrive at the neurology swamp (where the residents have their desks and a couple computers for work) and start running through the day's patient list with Scott, who often gets there just before I do. We add current medications to the table with patient info on it, as well as their location, age, medical record numbers, and so on. Any medication that has an effect on the nervous system is also listed with dosages. The third medical student, Mackenzie, often arrives shortly after I do, and our resident Aarti arrives just after 7. Aarti acts as the quarterback of ou...

Monday last week was orientation for clinical rotation on the psychiatry ward. It was exciting and intimidating all at the same time, especially the part about getting security keys, fingerprinted, and having to provide a urine sample for drug screening. It was a calm day regardless though, and there was no work with actual patients until Tuesday. Tuesday morning I made my way through the string of locked doors at Mid-Missouri Mental Health Center (hereout referred to as Mid-MO), the mental health hospital. I am assigned to the ward on 2 south. I met the psych resident assigned to the floor, Dr. Johnson (not his real name of course), and discovered I and the other two medical students assigned to the floor would accompany him to the county courthouse to start the day. Dr. Johnson had to take the stand to testify to the need for inpatient treatment for a number of mentally ill individuals who were picked up by the law. It was an interesting start to the day. After court hearings we hurr...

This past Friday I signed the lease on my own apartment. No roommates, just myself. It is both exciting and scary at the same time. It feels grown up to do the signing myself, and being the one person responsible for everything. In any case, it is a milestone in my life to have my first place. Being a type of person that enjoys having a peaceful repose to retreat to when I need recharging, it was overwhelmingly calming to wake up this morning to the sound of rain and rolling thunder, and to sit on the couch with a bowl of cereal after a time of quiet devotion and journaling. It is highly rewarding to now be sitting here publicly journaling while some relaxing music plays from my office. I look forward to slowly building a home out of my apartment, through decorating and spreading out of my belongings, and that will be a great feeling of comfort to come to after a hard day's work or to end a good evening. If there's any one thing I am nervous about in my own place, it is dealing...

I'm thankful that I'm about to start the part of my medical career where I can interact with people regularly, and more than just seeing people, but seeing the same people more than once and getting to develop a relationship with them. Studying, for all it's worth, can only bring so much gratification (if much at all, most times). The real payoff in studying is when it is finally put to use in helping someone. Every once in a while, I get those little moments here and there, and I can remember why I'm pushing down this hard road of medical training. My younger cousin has systemic lupus erythematosus (SLE) or "lupus" as most people have heard it called. She's only 17. I think most people have at least heard of lupus but few seem to know what it is. Lupus is an autoimmune disorder, where your body creates antibodies that bind proteins in your blood, and they get stuck in the blood vessels and cause damage when immune cells react with them. It can cause lung,...

Today was a very special occasion. I am officially done with classroom-based schoolwork. I will occasionally have a lecture to go to, but my day-to-day routine will not be lecture/classroom based. From here on out, I will be working directly with the patients, and I can't wait. It was also the last day that Docapella, as it is this year, would likely ever perform together. As is customary we sang on the last day of lecture for both the M1's and M2's, first in the morning (for the M1's) and then the afternoon (for the M2's). Singing Billy Joel's "Longest Time", I felt we sounded the best we have ever sounded, which made the occasion even more memorable. Our voices harmonized, our fingers snapped in rhythm, and we had our audience completely captivated. Even this evening studying at Lakota, a classmate said that our performances will be the most missed thing about the first two years lectures. That's a huge reward to hear. After my exams next Wednesd...

If any of you who bother to read this have talked to me at any point this year, you know that this is a very grueling school year. Lately especially, with block exams and board exams looming, I have been even more pressured by school. However, Sunday was a very good day. The whole town of Columbia seemed to be on pause; while downtown standing outside the Artisan talking with my mom on the phone I noticed only two cars driving in any direction from where I could see. There wasn't but a couple people now and again walking through the district, and the air was still. The Artisan was equally peaceful being about a quarter full at best, with low-playing Beatles music and the sound of milk steamers and coffee grinders occasionally interrupting. I was studying for block exams while being kept company by a friend analyzed a research article and proofread a report. I was already feeling blessed and in a good mood by the time I met Jeff, who taught me what I believe God had in mind to say t...

Saturday, March 24th, 2007 We leave for Cancun today, and since Thursday I have felt rushed from one place to the next. MUlation was Thursday, then I picked up some of the medical equipment that John told me was available. Friday morning I received a vision exam by a retinal specialist, and now have visual field testing scheduled for just after Step 1 to absolutely rule out the possibility of a nerve cell tumor or impingement of my optic nerve from drusen deposited around the cup. Friday night I packed, and my tension continued. Packing and laundry interspersed with phoning family engrossed my evening until 11 p.m., at which point I felt I might truly rest. I was in bed by 1 a.m. I awoke at 6:45 a.m., none too rested. With two hours to spare I still felt stressed and rushed...My general lack of control of the trip leaves me feeling inadequate... Sunday, March 25th, 2007 The night passed harshly, as the sound of the air conditioner kept me up much of the night. Our morning meeting was a...

Perhaps the biggest event in all of medical education outside of graduation itself is match day. Match day is the day during fourth year when medical students across the country find out where they have been accepted for residency. In many ways, it is like a professional sports draft; students file past a large table of envelops to receive theirs, not knowing what residency program they've matched to until they open that powerful letter. A little background on the match process... Students initially register for the match process in their fourth years with the Electronic Residency Application Service (ERAP), and through the fall and early winter of fourth year interview with the residency programs in the specialty field of their choice/interest. By early January, students begin to submit a rank list of the programs they are interested in, in order of interest. The programs that they interviewed with then submit a rank list of students they wish to accept as new medical interns. A c...

Monday evening this week my lab was required to do our GTA teaching session. GTA stands for Gynecologic Teaching Associate, which is the title of the women who are paid to be teaching assistants for students learning how to do the breast and pelvic exam. The role of the GTA is not just to teach how to do the breast and pelvic exam, but to allow the students to learn the exam by performing it on them while they teach. Now, it's one thing to do a prostate exam (a requirement to fulfill before entering our third year, for whatever reason), but the awkwardness of inserting your first digit in a man's rectum pales in comparison to the awkwardness of performing your first pelvic exam. One thing's certain; you never forget your first time. I was one of two guys in a group of four students, with two GTAs who work as nurses in the OB/Gyn department at Columbia Regional. The nurses gratefully understood the nervousness of performing a pelvic exam, especially for us guys who don't...

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. Tha...

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...

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. ...

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...