Everything I Learned in Medical School: Besides All the Book Stuff (3 page)

Chapter 5

The Pressure’s On

Halfway through medical school, life as a student takes an abrupt turn. In most medical schools, the first two years consist of sitting in a large, rather unstimulating classroom, hearing lectures for hours on end. Some pay attention, while others chat online or daydream. For the most part, it’s a rather comfortable, undemanding environment. But as the third year of medical school starts (or in our case, the second year), we’re suddenly plucked out of our classroom seats that have become so cozy, and dropped into a whole new world. This is when we start learning in a different environment -- inside the hospital. Our medical school had only one year of classroom lectures, and we spent our second and fourth years working in the hospital. The third year we will talk about later. So, one year into medical school, we are thrown into the thick of it. Most of our time is spent on the inpatient side of the hospital (aka, the wards) as opposed to working in clinics where people come in for regular appointments. Here is how the wards work… students are assigned to a particular field of medicine for one or two months, such as pediatrics, internal medicine, surgery, obstetrics and gynecology, etc. Each of these fields has a number of teams, and each team consists of an attending, resident, a few interns, and the patients they take care of. As a medical student, you are part of a particular team and follow two to three patients. You aren’t truly taking care of them, but it’s mostly a way to pretend you are, in order to learn how medicine is practiced. The typical day consists of the students, interns, and residents getting there early, seeing all of the patients and collecting information from overnight, such as whether the patient had a fever, laboratory results, interpretation of x-rays, etc. Then, later in the morning, the attending shows up and the entire team goes to each patient’s room (or sits down in a conference room) and talks about everyone under their care. This is known as “rounds”.

Any student that has been through rounds for the first time can tell you this is when it becomes blatantly clear that the comfortable days of sinking into your classroom chair and daydreaming are very much over. You are now constantly asked to perform in front of a crowd of doctors. When it’s time to talk about your patient, you discuss how the patient did overnight, how the patient feels that morning, vital signs, new lab results, physical exam, and a plan for the day. It sounds fairly straightforward, but when you’re in front of the entire team, it’s not that easy. Plus, this is one of the few times a student actually interacts with the attending physician, so your grade is often influenced by how calmly, comfortably, and succinctly you can give the presentation.

I consider myself a pretty calm guy. Public speaking was never really a problem for me, and I felt comfortable in front of a crowd. But this was a totally different feeling. Not only are you in front of a crowd, but this crowd knows a lot more than you do about your topic. I think of it as trying to give a physics presentation in front of Einstein or Stephen Hawking. Well, maybe not that bad, but you get the point. So, one Saturday during my surgery rotation, I was rounding with the team. So far, I had been incredibly composed during rounds. But today, the senior resident made it a point to say we were going to try to move fast through the patients so we could get home. After all, it was the weekend. No problem, I thought to myself, I’ll present my patients quickly and succinctly.

We were walking around fast, from room to room. My patients were coming up, and I felt the rush of nervousness, knowing I had to impress the team. We rushed up and down flights of stairs to get to patients on other floors. My heart started racing and I was a little out of breath from all the moving around. And before I knew it, we were at the door of my first patient. I started the presentation, and it came out in chunks in between the breaths I was taking. There was this feeling of discomfort, as if my heart was beating so hard that it was pressing against my wind pipe. I tried to go on with the presentation as if I was merely catching my breath, but it soon became obvious to me, and to the team, that there was more going on. “Man, I can’t catch my breath,” I said, trying to hide my obvious discomfort. “Calm down, you’re doing fine,” the resident said, not fooled by my cover-up. I couldn’t believe it, this had never happened to me before. I was hyperventilating! “Oh, no, I’m just short of breath,” I said, trying to save face. Eventually calming down, I proceeded with the rest of the presentation. As we walked around that morning, I occasionally threw in comments on how out of shape I was, hoping the team would buy it. But I think we all knew what had happened. How embarrassing.

The presentation itself can be tough, but there is yet another part of rounding that can increase sphincter tone, and that’s having the whole team go in and talk with the patient. You’ve just stood outside the door with the entire team telling them how the patient is doing that morning, and everything you thought was relevant. Then, you pray that the patient doesn’t say something contradictory, making you look like a liar, or add something new to the story, making you look incompetent. It’s probably not that difficult to believe that the patient’s story changes all the time. For example, the patient tells you they are having sharp, stabbing belly pain, which you tell the team, but when you go in the room and ask the patient, they say it is dull, crushing chest pain. The student stands there, turning slightly red, wanting to cry out, “BUT YOU TOLD ME EARLIER THAT…,” but usually the doctor just keeps talking without even giving the student a look. Meanwhile, the student is wondering whether the doctor even caught on to the discrepancy, and if they are going to mention it after walking out of the room. Nine times out of ten, the doctor doesn’t mention anything, either because they expect students to mess up, because they know that the patient’s story changes all the time, or the most likely reason, they weren’t listening to the student’s presentation in the first place.

One of the more entertaining presentation experiences happened to a fellow medical student while on the neurology service. On this rotation, students are expected to do neurologic physical exams on patients in the morning to assess if there are any changes. The majority of patients on the neurology service have had strokes, so any changes in the exam, like new areas of weakness, could indicate a worsening stroke. This exam includes a “Cranial Nerve” exam, which tests the important nerves of the head, neck and shoulders. These are the nerves that are important in sight, taste, touch, hearing, movement, etc. The second cranial nerve is called the optic nerve, and it is responsible for vision. To test a patient’s peripheral vision, an examiner will often have the patient stare straight ahead and have them report how many fingers the examiner is holding up on the sides. Likewise, there are ways to test the function of the other cranial nerves. When the entire cranial nerve exam is finished, and if everything is normal, doctors typically report, “Cranial Nerves 2 through 12 are intact.” Cranial nerve 1 is the olfactory nerve, responsible for smell, which we don’t typically check unless the patient complains about problems smelling. So, on rounds, it’s typical for a student to start the physical exam presentation by stating, “For the neuro exam, cranial nerves 2 through 12 are intact.” Well, this particular day was the student’s first day on the rotation, and he had to pick up patients that had been in the hospital for a few days. So, the other members of the team were already familiar with the patients. That morning, the student had rounded on his patients bright and early. When rounding began with the team, they eventually got to his patient and stood outside of the room to discuss the case. So, he began his presentation. When he got to the physical exam portion, he calmly told the team,

“Cranial Nerves 2 through 12 intact.”

Before he could go on with the rest of his exam findings, the attending interrupted,

“What did you say?”

“Cranial Nerves 2 through 12 intact,” the student repeated, this time somewhat more hesitant.

“That’s not possible,” the resident said.

The student stood there, confused at where he went wrong. The attending, at this point somewhat perturbed, asked,

“Did you actually go in to examine this patient?”

“Yes, of course.”

“Well, his cranial nerves can’t all be intact, because the patient is blind!”

The student looked shocked at this, and explained to the team that he even tested his peripheral vision, and everything seemed fine. So, the team walked into the room, intent on resolving the two discrepant stories. The attending went up to the patient, and asked simply,

“Sir, can you see my hand waving in front of you?”

“No, I’ve been blind for years.”

At this point, the student had to speak up.

“But sir, when I came in this morning, and tested your vision, you kept telling me how many fingers I was holding up.”

To which the patient calmly replied, “Oh, I was just guessing.”

Turns out this patient was a great guesser, and the team ended up having a good laugh.

In any given day, there are multiple pressure-filled situations in the hospital or any other work place that can get you upset or test your composure. Sometimes, you have to take a step back and just laugh at yourself. For a student, it can make the difference between being constantly stressed in a new, challenging environment and truly being able to relax and enjoy the new learning experience.

Chapter 6

“Nursing” Homes

One of the most difficult groups of patients to treat in the hospital are those that come from nursing homes. These are the patients that are either too sick to be cared for at home, or those whose families simply don’t have the time to care for. Although one would hope that the money families put into nursing homes would ensure their loved ones are looked after, this sadly is sometimes not the case.

One particular patient stands out vividly. It was during my Internal Medicine rotation that this African American man in his 50s was admitted for worsening of his congestive heart failure (CHF). CHF starts when, for one reason or another, a person’s heart isn’t able to work well enough to pump blood to their organs. Blood starts backing up in the veins, and fluid begins to leak out because of the pressure. This causes swelling all over, most commonly in the legs. Well, this unfortunate man had swelling in only one leg. His other leg had been amputated long ago from gangrene, which happens when blood stops flowing in an extremity. Despite having a prosthetic leg, he couldn’t stand up, because his heart wasn’t able to keep up with the stress of pumping blood all the way up to his head against gravity. If he tried to stand, he would pass out. Truly unfortunate. But to make matters worse, his wife no longer wanted him living at home because taking care of him was such a huge burden. You can imagine how difficult it would be to bathe and change a 300 pound man on a daily basis. So he spent his time in a nursing home.

While in the hospital, the team took good care of him. We gave him furosemide, which is a drug that helped him urinate the extra fluid that had built up. We even got him a new prosthetic leg, which fit much better than his old one. He was in remarkably good spirits through all of this, despite his illness. After nearly a week, his swelling had improved, and he was ready to leave the hospital. I walked in early that morning to share the good news.

“You’re all set. Looks like you’ve lost a bunch of that fluid. We should have you back to the nursing home this afternoon.”

I was expecting a smile, and a sigh of relief, but he gave me neither.

“Please don’t send me back there.”

He explained how each morning, he would wake up around 8AM. For the next few hours, he would simply lay there. The staff would argue about whose turn it was to lift him to sit him up. This was all done within earshot. It wasn’t until lunch time on most days that he would be helped into a sitting position, where he could finally look out the window, eat, or watch TV. “People just shouldn’t be treated like that,” he told me. I truly felt sorry for him, wishing we could just keep him in the hospital with us. But as a resident once told me, the hospital is no hotel. Patients have to leave. I told him I would check to see if we could get him into another nursing home, and he was grateful.

So off I went to the social worker’s office, with my hopes high. One look at his insurance, and the social worker explained that there was no other place that would accept him. He was stuck. It was truly unfortunate when he had to leave, knowing that he would return to the same miserable conditions, trapped within his own body, unable to care for himself. Each day he would face the same humiliation and inconsiderate disregard by the staff. It was disturbing. It was inhumane.

Later during that month, an old lady in her 80s was admitted, virtually comatose. She was incredibly dehydrated, and looked shriveled up. The lady was slightly demented, and for some reason, she stopped drinking and eating in her nursing home. When she got dehydrated, she started losing consciousness. But that didn’t stop the nursing home staff from bringing out her juice bottles with her meals, and watching them pile up on her desk. Apparently, it wasn’t their job to make sure she drank them, just so long as she got them. When her daughter arrived to visit a few days later, she was rightfully horrified, and brought her to the hospital. When an elderly person doesn’t drink for 2-3 days, the body starts shutting down. To make matters worse, when we went into her room to examine her and turned her to one side, her hip had a bed sore that had torn through her skin and eroded all the way to her hip bone! This is what happens to the skin when someone is bed ridden and unable to change positions (or in this case, when no one helps you change positions). The hole was oozing yellow, foul smelling pus. This was a human being, very much alive, but rotting to death.

All it took were a few bags of saline into her veins, and she was up and talking again, asking for hotdogs and juice. And off she went, back to her nursing home. It would be only a matter of time until she returned again.

This is not to say that all nursing homes are negligent. To the contrary, there are no doubt some that take very good care of their inhabitants. There is also little doubt that the amount these particular homes charge will cause you to have a heart attack and die before you can truly enjoy their services. Either way, I hope that my children continue in the tradition that is a big part of my culture. That is, to have the parents take care of the children while they are young, and then the children take care of the parents when they get old. It’s a beautiful system, because in the end, when you’re old and gray, if your family won’t look after you, I learned it’s hard to count on anyone else.