Everything I Learned in Medical School: Besides All the Book Stuff (6 page)

Chapter 14

The Explosion

During our first year on the wards, we go through what is known as the “core” rotations. These allow us to work in the various fields of medicine that are the basics of general care. The core rotations at most schools include surgery, internal medicine, pediatrics, obstetrics/ gynecology, psychiatry, family medicine, and neurology. Each rotation typically lasts between one and two months. During our surgery rotation, we spent two days in the ER, working alongside the surgery resident who was called whenever an ER case came in that could require surgical intervention. These were always the most interesting cases in the ER. The first case I saw was a hunter who had been shot by a rifle from very close range. His side had been towards the gunman, and the bullet went into his upper back, tunneled under the skin of his back, and left a large exit crater behind his shoulder. By the time we got to him, he was loaded up with morphine, and requesting a Snickers
^®
bar. Amazing stuff, that morphine. The surgery resident proceeded to shove gauze dressing down into the tunnel the bullet had left. This served to put some pressure on the bleeding areas to prevent him from losing too much blood. Lucky for this guy, the bullet completely missed his spinal cord and most of the vital structures in his body. It had mostly just torn through the fat on his back, of which he had a pretty good supply. He was very lucky that night.

The second case was one I will never forget, or at least my nose will never forget. I was asked to go see this patient on my own initially, then discuss him with the resident. Entering the room, I saw a couple that was probably in their mid 50s. The husband was laying on the table, not appearing to be in any distress.

“What brings you in today, sir.”

“I have this large mass on my belly, and it’s been getting larger for a few weeks now. I figured it was time to get it looked at.”

If there is one thing I’ve learned, it’s that some people wait inordinately large amounts of time with seemingly awful states of health, knowing full well that something is wrong, but just assuming that if they wait long enough, it’ll go away. Well, the mass on his stomach was now the size of a grapefruit, and it had become quite obvious that it wasn’t going away. To make matters worse, the mass was exquisitely painful, severely limiting his activity.

I continued to get his story, including his past medical history. Apparently, he had a small area like this come up in the same place many years ago, but it seemed to go away on its own (which probably helped him take the “watch and wait” approach). After getting the story, it was time to take a look at his belly. Sure enough, there was this large, elevated mass on his right lower abdomen, with an area in the middle that looked as if it had a very thin layer of skin, with blood pooling underneath. I pressed on the mass gently, and in the middle, there was an area that felt…well… squishy, which was an indication that he likely had a big pool of pus sitting underneath. I left the room, and told the resident the story.

“It’s probably an abscess,” he told me. “We will have to open it up.”

The resident was still busy tending to the gunshot victim, so I went back to the room to share our plan with the patient. As I entered, there was an unusual smell that was initially faint, but began getting stronger as the seconds went by. It smelled like rotten eggs.

“Do you smell that,” I asked.

The man took a deep breath. “Yeh, what is that?”

I looked down at the man’s stomach and noticed that his gown had become slightly wet in the area of his right lower abdomen. I put on gloves, and carefully lifted his gown. Sure enough, the ball of pus finally could not hold itself, and had started to ooze out from the center.

“Oh my!” His wife looked a little scared.

“Well, looks like it popped. We’re going to have to give it a good squeeze to get this pus out,” I told him.

All this while, the smell kept getting stronger and stronger. It was the worst thing I had smelled in my entire life. In fact, the smell was leaking out of the room and into the rest of the ER.

I stepped out to get some more gauze, ready to get as much pus out of this thing as possible. The nurses outside had begun noticing the odor, and asked me what was going on.

“His big ball of pus just exploded.”

His nurse walked into his room, and a few seconds later, had to walk out. The smell was just too much. She had to leave the ER and walk outside for a while, sure she was about to vomit. ER nurses have seen it all, and if they can’t handle a smell, you better believe it’s bad.

I tried to be brave and walked back in. The only way to do this was to breathe through my mouth, in hopes of avoiding the unpleasantness. I went to work, pressing firmly on the sides of the mass, as the pus and blood began pouring through the top. With each push, the patient grimaced in obvious pain, and more yellow liquid came seeping out. I wiped it as quickly as I could with the gauze, and soon realized I was running out and would need to go get even more. Good thing, as the stench was beginning to seep into my nose regardless of how hard I tried to breathe through my mouth. It was again becoming unbearable. My words came out extra breathy, trying hard not to let any air flow through the nostrils.

“Ahh’ll be bhack in just a sec.”

I got outside, and it was obvious that the smell had now seeped into half of the ER, as everyone was standing around, holding their noses, wondering what was happening. There were a few patients that were in the hallways (which is where they’re kept if all the rooms are full). The poor woman who was assigned the spot outside of this particular room was losing it as well. The only saving grace was a small bottle of wintergreen scented liquid that the nurses were passing around. This was super-concentrated stuff, which I assume was used by putting a few drops into bad smelling stuff. This poor patient squeezed multiple drops onto her fingers and then proceeded to smear it right onto her upper lip.

Overuse of this scented liquid had left the area smelling of wintergreen pus. It was horrendous. The nurse that had to walk out earlier came back and told me how I was her hero for actually going into the war zone. Another medical student that was working with me walked up, and offered to help. I let him go back in there to squeeze the rest of the juice out of the grapefruit. The smell had become unbearable for me, and I couldn’t go back in.

Turns out, the man had his appendix removed when he was younger, and the stitches they used to sew up his skin had been metal ones that never dissolved. Any foreign object in the body is bad news, as it can serve as a place for bacteria to hold on to and set up camp, allowing them to multiply within the body. Unfortunately for this man, the surgeons decided that they would not be able to remove all the stitches for reasons that are still unclear to me. Although they were able to fully drain his abscess, it would likely happen to him again at some point. I’m assuming he won’t wait as long to seek help next time.

As for me and the other student that helped drain the abscess, we could smell the odor on our white coats that entire night. As soon as I arrived home, I threw everything in the washer, and as I was about to enter the shower, I could still distinctly smell the abscess. Maybe it was just in my head I thought, but then raised my arm and took a good whiff of my forearm. The scent had actually gotten into my skin!!! I must have scrubbed myself down for an hour. For months after this incident, I would see my fellow medical student every now and then, and our conversation would consist of the same two lines:

“Man, that thing was nasty.”

“Dude, so nasty.”

There is little delay in seeking medical attention when your problem is as dramatic as a gunshot wound. But there are problems just as life-threatening that come on so slowly, we are able to keep convincing ourselves that everything is okay. Lives would be saved for cancer patients and infections could be treated before they rage out of control, simply by getting help sooner rather than later. Therefore, I have developed a simple system to determine when it is time to seek medical help. Just ask yourself, “If I went up to a complete stranger and told them about my medical problem, would they think everything is alright?” If the answer is “no”, go see a doctor. I guarantee a stranger will never give you an “all-clear” when you’ve got a grapefruit-sized ball of pus in your belly.

Chapter 15

The Medical Student

A young couple sits outside of a corner coffee shop. It’s early, and cars busily hustle by, carrying people to their places of work. About half an hour into their morning coffee, the observant woman sees a familiar car pass by. “I think that’s the third time that guy has passed this corner,” she says to her husband. The husband barely looks over his morning newspaper, and with a casual glance, is back into the sports section. “Maybe he’s lost,” he replies, settling further into his chair.

But for the man in this car, his morning is not so relaxing. And no, it’s not his third time driving by the same corner, it’s his twelfth. He is not lost. On the contrary, he knows these roads better than perhaps anyone in his town. He is late for work once again, but continues circling around the block. The reason is simple -- he can’t stop.

This is a typical morning for our troubled driver. Every morning he comes down this road. Right before reaching the coffee shop, he runs over a patch of uneven road. He knows it’s coming, he passes it every day. But no matter how hard he tries, the minute his car runs over this patch of road, the same thought comes barreling through, knocking away anything else in his mind.

“Did I just run somebody over?”

The rational mind says it’s very unlikely. After all, he looked in his rearview mirror and saw no one laying in the road, just the familiar uneven pavement. He runs over the same pavement each day, and today was no different. There is no look of panic on the pedestrians walking by as if an accident just happened. But another voice in his head thunders over rationality, and convinces him that anything is possible. So, around the block he circles, and passes the same road again. His anxiety is relieved when he sees no one laying in the street, no terrified pedestrians calling 911 frantically. But he again drives over the same rough patch, and again thoughts of ambulances and an injured man are back, so he circles again, just to be sure.

This is the mind of someone who suffers from obsessive-compulsive disorder (OCD), one of the most fascinating and devastating conditions in psychiatry. I saw a number of patients with this disease during my psychiatry rotation. There are two distinct parts to this disorder. The first is the obsession, which is an irrational, intruding thought. For our driver, it’s the thought that he may have run someone over. For others, it can be worries about germs, constant fear that the stove was left on, or an irrational belief that something bad will happen if their sock drawer is disheveled. Interestingly, these people often realize their thoughts are irrational, but these thoughts continue to dominate their day. This obsession is followed by a compulsion, which is a physical action that relieves the stress brought about by the obsession. In our examples, that would be constantly circling the block, washing your hands 100 times a day, constantly checking and rechecking the stove, or making sure your socks are perfectly arranged. However, in order for these thoughts and actions to be considered a disorder, it has to adversely affect the person’s ability to function. Whether it be trouble at work, difficulty in personal relationships, or trouble with the law, it has to negatively impact one’s life. Unfortunately, these people are labeled as “crazy” for their affliction. They are treated by psychiatrists and medications.

There is a very similar type of person in society, but instead of facing psychiatrists and prescriptions, they are awarded with accolades and high paying salaries. These are people who are obsessed with success, or with the fear of failure, leading them to work compulsively. It may be the basketball player that has to make 20 free throws in a row before he can rest, or the investment banker that works through the night learning the minute details of a company’s balance sheet. In my case, and the case of countless colleagues, it was an obsession with getting into medical school. After all, a large number of students enter college with the aspirations of becoming a doctor. It takes someone with the constant thoughts of being rejected from medical school and the need to succeed (the obsession), to motivate them enough to complete countless prerequisite courses, study for hours and hours for the MCAT, and meticulously complete countless, flawless applications for school (the compulsions). And even then, only a small fraction are accepted. This is the group that was the most compulsive. I remember taking a bathroom break in between sections during the MCAT, and in the bathroom was an Asian student holding some notes in one hand to cram before the next section, while urinating with the other hand. This is the world of the pre-med student. So it comes as no surprise that once you get to medical school and look around at your fellow classmates, you see people that were just as obsessed as you were about success. I will admit to locking myself in a library with lunch in hand and studying physiology for 18 straight hours. The scary thing is, I don’t consider myself nearly as obsessive as many of my other classmates. One can only imagine what they put themselves through when it comes to studying.

I’ve learned that we all are obsessive-compulsive beings. It is merely the nature of our obsessions that separate the successful from the pathologic. Perhaps it’s true when the famous composer and author Oscar Levant said, “There’s a fine line between genius and insanity.” I hope I’ve convinced you that this line may not even exist. And if you still aren’t convinced we all have a bit of OCD, perhaps you missed something and should read this chapter again.