Liz's Medical School Journey

I am entering my final week of pediatrics, so the rotation is nearly over.  These last weeks on outpatient are going by the fastest because every other day I switch to something new; first, sick visits, then well child checks, next pediatric emergency shifts, and now newborn nursery.  Next week I have specialty clinics, like pediatric nephrology, “ENT” (ear, nose and throat) and surgery.   To put it simply, I am having a great time now, which is why it will end (as soon as I get comfortable).  Since so many different things have happened, I’ll recount the highlights from each place I’ve been.

First, I rotated in the clinic where I did sick and well child checks.  My roll was to introduce myself to the family as a third-year medical student, and ask if it was ok if I took the history and did a short physical exam before speaking with the doctor.  After I did my history and exam, I would report to the doctor, and we would go back and see the patient together, and perform a complete exam.

I saw 1-week olds to 14-year-olds.  I learned a lot about immunizations, and how to approach the sensitive parts of the visit (for example, how to examine genitalia professionally without making kids or parents too nervous, and when/ how to interview teens by themselves).  I also learned a lot about what it means to be a healthy baby or child, since we were encouraged to ask many general questions about diet, transportation (car seat and helmet use), smoking and safety at home, discipline, bowel and urinary habits, etc.

I was so impressed by the format of the pediatric visits.  Adult primary care has a lot to learn from pediatrics!  For example, a common format for interviewing teens is called “HEEADSS:” Home, Education/ Employment, Eating, Activities, Drugs, Sex, Suicide.  There are target questions to ask about each topic, for example, “Home” includes questions like: “Do you get along with your family?” and “Who do you talk to?”  I think most adults would also benefit if their doctor  asked these questions at physical exams.  Adult medicine as we know it focuses much less on prevention than pediatrics.  I didn’t realize the difference until this week.

Working in the emergency room was totally different from the clinic.  My roll on the ER team was not well-defined.  What I did varied depending which physicians were there with me.  The things that surprised me the most were the multitude of non-emergencies in the emergency department, and the procedures I saw.  Finally, I was able to overcome my anxiety about passing out again.  I stapled a boy’s scalp, which was surprisingly easy and gratifying.  He even came over to thank me.  Then I assisted with a toddler with a deep facial laceration, and another girl who had an abscess on her toe (which ended up draining about 3 tablespoons of puss from her tiny toe).

Today I was in the newborn nursery.  Just 8 hours ago, I was surrounded by 6 newborns <72 hours-old.  Each baby was swaddled in his or her own clear basket.  I helped with the discharge exams.  We undressed each baby, examined them from head sutures to capillary toe refill.  We tested their reflexes, listened carefully for murmurs, tested for hip dislocations, palpated for broken clavicles, and looked for red-reflexes in their small eyes.  This is a precious job, despite the babies being appropriately angry at times (I’m sorry, babies).  I was hoping to see a delivery, but nobody was in active labor today, so  maybe Monday.

Now it’s time to start getting serious about studying for my first shelf exam, which is a week away.

This week I reached the half-way point of my pediatric rotation, which marks a switch from inpatient service to outpatient ambulatory care.  I felt reluctant about this change, since I was just starting to feel comfortable with my role with the inpatient team.  I had a good experience, besides fainting on the floor (even that turned out to be not SO bad).

My memories from the inpatient weeks revolve mostly around the people. Medical students who begin 3rd year especially remember their first patients.  It wasn’t until my second day working with the pediatrics inpatient team that I was assigned to a new admission.  I felt excited and nervous as I went to meet him.

He was a toddler “with history of CHF (Chronic Heart Failure), admitted for 2 days of worsening fever and respiratory distress.”  What I wasn’t prepared for was that mom spoke only a little English.  She understood Spanish, but spoke primarily Portuguese.  Along with an intern and the head resident, we took a history of his illness from mom, asking questions in Spanish and deciphering answers in Portuguese and English.

I was expecting him to cry when we examined him, but he was quiet and still.  I moved my stethoscope along his torso, listening to his heart, lungs and abdomen while he was quiet.  Then, I examined his ears, eyes, head and throat.  We determined he probably had a viral infection, most likely to be “RSV” (Respiratory Syncitial Virus).  This case was “bread and butter” (common) for pediatrics.  In fact, there was not much we could do for him besides monitor his respiratory and cardiovascular status and treat his symptoms.

I wanted to do more.  I came home and read journal articles on RSV treatments.  Asthma medications weren’t recommended because the respiratory obstruction was due to mucus, not inflamed airways.  Saline nebulizers could be used to reduce the mucus, but the evidence was still “inconclusive.”  Heliox (helium and oxygen) was useful in extreme cases, but it is extremely expensive.  There weren’t any easy solutions, and this is the case with many patients.

As the week went on, his story blended with others.  Coincidentally my second patient was another boy with a probable RSV infection and a history of heart problems.  This time I learned about WPW (Wolff-Parkinson-White Syndrome), a type of “SVT,” (Supraventricular Tachycardia), especially common in children.

As the days passed, my patients’ diagnoses broadened to include asthma, cellulitis, dacryocystocele and febrile seizures.  During rounds, I heard the stories of other patients: dermatitis herpeticus, functional constipation with encopresis, bilious vomiting, bloody diarrhea, accidentally cut gastric-tube, fever of unknown origin, mysterious ALTE’s (Apparent Life Threatening Events), and a child who had been in a mysterious coma for a month.

Everyday we discussed the “assessment and plan,” how we would care for each patient.  I felt my medical knowledge, the roughly piled structure of facts, start to form itself into something more concrete.  It was like I had been studying another language, and suddenly I was in the country, surrounded by people who spoke only that language.  I was overwhelmed, clueless at times.  I started scribbling words that I heard often, like: MRCP, VCUG, KUB, NCAT.  The everyday language was different from what I had studied.

From my first patient to my second, third and fourth, I already started to feel a huge difference.  I learned the order of notes and presentations.  I used some of those previously foreign acronyms myself, and I entered patients’ rooms with more joy and less trepidation.  My performance has been far from perfect, but these first patient memories are the best learning experiences in medicine that I have had so far.

This week started off backwards. One moment I was the “doctor,” standing over a patient for a procedure. And the next moment I was on the ground with doctors and nurses surrounding ME.  I fainted, known in the medical world as “vasovagal syncope,” an autonomic reaction stimulated by stress that drops blood pressure and causes temporary loss of consciousness.

I wasn’t prepared for this episode at all.  I was looking forward to the hospital for my call shift on Sunday.  I woke up before my alarm and got there 30 minutes early. I finished morning rounds, and was preparing to admit a transfer patient with a possible history of seizures.

Then, I stopped to help one of the interns replace a G-tube (gastric feeding tube) on a baby.  The baby was uncomfortable, and I was helping to keep him still.  Suddenly I started to feel light-headed…BAM!

My mind became totally empty, and oddly peaceful.  I’m not sure what happened, but I awoke and was surrounded.  The nurse was saying something about a code.  Suddenly I realized… I had fainted and the code was for me.  Panic!  What a great way to begin my second week.

Then I was taken to the ER… in a wheelchair.  Apparently I hit my head on the way down, was unresponsive for over a minute and didn’t have a pulse.  I had never fainted like this before in my life.  While being wheeled down the hallway, all the pediatric residents were running to the “pediatric code.”  They were relieved that no baby was dying.  It was just me, the medical student.

From the moment I gained consciousness, my mouth was dry.  I wanted a glass of water and to pee.  However, I got an authentic patient experience of not feeling in control.  I was attached to a heart rate monitor, then an ECG, and finally a glowing oxygen saturation clip on my finger.  I had to put on a hospital gown.  Despite being thirsty and having to pee, nobody would detach me or bring me water.

Different people asked me the same questions: name, date of birth, etc.  The billing lady came in 3 times because she couldn’t find me (my name was spelled wrong) and then I wasn’t listed as an employee (because I’m a student)  Then, she informed me that I probably wasn’t eligible for any compensation for the ER costs. Fine.*

Everybody wanted to know how I hit my head, but I didn’t know.  How was I supposed to know what happened if I was unconscious?  I waited in a curtained compartment under the bright fluorescent lights, feeling pretty agitated (full of hypochondriac medical student thoughts).  Finally, the doctor came in.

He was my Physical Diagnosis professor. He did a thorough exam on me, even borrowing my light to check my pupils.  Then, he said I could go back to my shift.  Finally, after an hour I got to pee, and then headed back to my ward.

Everyone was kind.  They said this happens a lot, and they were glad I was ok. They sent me home early to rest, eat, drink fluids, etc.  I wasn’t sure if I should stay or go, and maybe I’ll regret going later.  But, I did feel pretty shaken up, so I went.  First, I sat in the hallway and drank a huge glass of water and inhaled my lunch.

On the bright side, I have a personal experience of my hospital’s emergency department, and a print-out of my very own ECG and hospital note (which I later used to design a nifty banner for the top of this website).  The nurse handed copies to me, and said, “Here’s for your studying pleasure.”  She knows medical students well.

I feel almost 100% now.  I just find myself feeling anxious that it will happen again, and I’m not sure I can prevent or predict it.  I have seen much grosser things than G-tubes, so I’m not sure why I reacted that way.  I figure I just need more sleep, food and fluids.  This week is going well… thankfully no more codes.

*As of September 9, I received an bill for my brief ER visit, which mistakingly did not include my insurance information and included a $200 “pulmonary func,” which was not performed.  Although I was ashamed by the errors and cost of my own university hospital, I was not surprised and am negotiating via snail-mail letters.  Nevertheless, reading “You owe: $1,500″ reminded me the aftermath that my patients must go through.

I just finished my first week of clinical rotations, and there is so much to report!

The first thing on my mind after such an exciting and full week is… SLEEP.  Between jet-lag and excitement, it was impossible to go to bed early, which made waking up at 5:15am pretty painful.  My new schedule requires me to be at the hospital 6:30am-5:45pm Monday-Friday, and stay 6:30am-10pm one weekday and one weekend day.  That’s a lot of hours at the hospital.  It’s still under the 80-hour limit for medical students and residents, but for a rookie who doesn’t quite know my way around yet, it was a LONG week.

Despite being exhausted, I’m thrilled to begin my clinical journey.  The doctors and residents are surprisingly kind and friendly, not to mention encouraging teachers.  The program is well-organized, so everybody has clear responsibilities.  My goals are to get-to-know my assigned patients well; build rapport with the patient, family, nurse and social worker; examine and interview them; write progress notes; and present them at “rounds.”  Pediatrics rounds are in the morning from 9-11am when everybody on our ward’s medical team gathers to visit and speak about every patient in our care.

In every teaching hospital there are a lot of doctors and students working on the medical team.  The highest member is the “Attending,” then the “Head Resident” (a 3rd-year resident), followed by the “Interns” (1st year residents), and finally the medical students (like me).  Residents are new doctors who train for 3-5 years after graduating from medical school to become fully licensed, so all residents are MD’s.  Every patient to whom I am assigned is also assigned to an Intern, the Head Resident, AND the Attending (and of course we can’t leave out all the amazing nurses too).  This is the system of care in  teaching hospital.

Our goal is to work together to provide the best care.  Considering there are many brains involved, this type of care is great for detailed learning, especially when patients have complicated conditions.  The drawbacks are that the patient might feel overwhelmed by the number of doctors, or frustrated that they have to keep repeating their story to different people.  But, patients get more medical attention and often this results in a higher level of care.

I was assigned to two patients this week.  This doesn’t sound like much, but it was enough to overwhelm me.  At first, I felt totally incompetent.  I felt like I’d forgotten so many facts, and was making a lot of mistakes.  For example, I confused dermatitis herpetiformis with dermatitis herpeticum.  Then during my first presentation at rounds, I announced that my patient had received 7,000 mL (7 Liters, or about 3.5 gallons) of IV fluids during the night. Oops!

But then, I started feeling slightly better by the end of the week.  I wrote my first “SOAP” note that was added to my patient’s chart.  A “SOAP” note is a progress note written in this order: S=subjective, O=objective, A=assessment, and P=plan.  I made my first oral presentations during rounds.  I helped complete electronic medical records, and write new orders for my patients.  I consulted a cardiologist.  Most importantly, I spent time with my patients and their parents, and started feeling more fulfilled by my presence on the ward.

Tomorrow I’m on call 6:30am-10pm, so I better go finish up all the things I have to do… and then get ready for bed, STAT!

Here is a link to my rotation schedule, if you’re curious:  Pediatrics Schedule