« June 2008 | Main | August 2008 »

Medical Monikers

NewannaAnna Burkhead -- Recently, two of the biggest movie stars in US pop culture celebrated the birth of their twins. Angelina Jolie and Brad Pitt added to their brood of children (twins make six!) with the delivery of a boy and a girl over the weekend in France. Their newborns' names: Knox Leon and Vivienne Marcheline.

Knox and Vivi join the cadres of celebrity babies with unusual names. But this trend is not limited to the rich and famous. When I was on my 3rd year OB/GYN clerkship, I witnessed and participated in many deliveries. Most of the names given to these precious newborns were unremarkable. However, of note, I did witness the christening of twins Mi'Angel and Mi'Joy, as well as a beautiful baby girl Taryntulla (you may need to say it out loud).

It made me wonder about the babies born every day with unusual monikers. Well, I did some scrounging around on the miracle that is the internet, and found more than a few names that are sure to make you furrow your brow. I was particularly fascinated with the medical-themed handles that have been reported on birth certificates.

First, two disclaimers: 1. Some of this is probably folklore. 2. Every baby is a precious gift, and even if the baby's name is Plantar Wart, Jr. he can still grow up to be a fine upstanding person.

Here are some gems I came across.

Enamel (pronounced EE-na-mul, like animal with a long 'e')

Urea (pronounced YUR-ee-ah, emphasis on first syllable)

Syphilis (pronounced suh-PHYL-us, like Phyllis with a –suh)

Eczema (pronounced as usual)

Ovary (pronounced oh-VAR-ee)

I'm not sure what the procedure of signing a birth certificate entails. However, I would think that a doctor, nurse, or other medical professional would be somewhere nearby and could potentially intervene, or at least verify, that parents know the meanings of these words, before they're inked in legal print.

Perhaps these words have ancestral or cultural meanings in particular families' cases. But in other situations, I could imagine these medical terms being chosen for baby names because they sound pretty, without actually knowing their meanings.

I'm sure there are some Labor & Delivery folks out there who keep lists of their favorites, either because they truly love the name, or they're truly fascinated by it. Let's hear 'em!

July 17, 2008 in Anna Burkhead | Permalink | Comments (24)

A Thank You Note

JeffJeff Wonoprabowo -- Dear Professor,

Medical school is filled with plenty of defining moments. During my first year, one of those moments was meeting you. I’m not quite sure what word I’d use to describe that time I first met you. Odd? Eerie? Creepy? Awesome? Inspiring? Solemn?

I remember looking at you, a little intimidated. You were the expert in what you were going to teach me. I was a little lost as to what I needed to do. I noticed your wrinkled skin. You could probably tell me a whole bunch of fascinating stories from your lifetime.

A classmate mumbled that you were old. But you looked calm and composed –- not at all like a rookie teacher. It was reassuring. I knew I’d learn a lot from you during the course of my first year.

I remember staring at the muscles of the neck in Anatomy lab. I was confused about which muscles were which. Was this the anterior scalene? Or was that the anterior scalene? If this one is the anterior, then that must be the middle. But wait, what the heck is this muscle here? Staring into a human neck for the first time can be disorienting. And it often only barely resembles the drawings in Netter’s Atlas. I lamented, but you offered no answer. Instead, you remained silent, forcing me to figure it out on my own. And when I finally figured it out, I thought I could make out the beginnings of a smile on your face.

Because I struggled, I remembered. And I did well on that first anatomy lab practical.

The rest of the year followed in similar fashion. I was stuck and confused. You stuck to your teaching method. At least you were consistent. Regardless, you stayed right beside me all along.

I came to accept your method of teaching and even found your silent presence calming -– even if I often wished for you to just speak up and point out what I was looking for.

I just wanted to write this note to say thank you. I’m sorry you will never get to read this. At the memorial service we held for all those who had donated their bodies to our Anatomy program, I sat quietly and looked around. There were plenty of family members there to remember and celebrate their loved ones. I couldn’t help but wonder if your family was there.

Was it that old lady wiping away tears? Was it the young lady who sat proudly as her loved one was appreciated by so many students? I don’t know; I’ll never know.

I never knew your name. But I knew your face. I knew your arms, your hands, and your legs. I knew you inside and out. And I know that you have give 100% of yourself so that I could be a better doctor. Thank you, Professor.

July 17, 2008 in Jeff Wonoprabowo | Permalink | Comments (28)

All Because of a Cat

Benferguson72x722Ben Ferguson -- My fiancee and I had this cat once, probably the coolest cat I or she or anyone else who visited us had ever seen. He was so hairy, so cuddly, and so strangely human, as if he could communicate with us and understand what we were feeling (with the slight exception of all those nights from 2-5am when he just would not shut up). Ringo was surely one of the greatest pets ever.

He often slept so soundly that practically no amount of rousing or kitty versions of sternal rubs would wake him. Lucky for us, this allowed for at least a few minutes of unobstructed access to his gloriously soft paws, of lifting his feet up and letting them fall to the ground, and, thankfully, of freedom from the extreme heat he generated while sitting on your lap.

Then one day I came home and he was dead. He looked asleep, but no amount of shaking or sternal rubs could wake him. It was probably one of the worst days my fiancee or I have ever had, but it also has had lingering effects.

It set into place an emotional connection I’ve developed between deep sleep and death, so much so that I cannot look away from someone or something who’s asleep until they’ve moved, until I know for sure that they’ve not also died. Several mornings a week now, I have a brief, intense fear that my fiancee has died in her sleep while I go to kiss her goodbye. My dog often has bouts of apnea while he sleeps, and if I come upon him during one of them, I think that surely he’s dead. I do this with homeless people sleeping in the park, fellow bus riders who’ve dozed off, and our other cat, too.

I’ve never been happier than I am these days to see the smallest of movements in someone’s chest, but I’m really hoping this goes away before it has a chance to haunt my life on the wards like it is now in the lab.

July 16, 2008 in Ben Ferguson | Permalink | Comments (2)

Mistakes in Medical School

Thomasrobey72x721Thomas Robey -- How many times in medical school have you thought, “Wait a minute, was that right?” Sometimes we students question statements made from classroom podiums. Other times it’s a policy made by school administration. Maybe a classmate’s behavior raises concern. The further along I get in my medical education, the more I notice myself asking that question of my own clinical decisions.

My first week in the county hospital’s emergency room has prompted a spike in moments of post facto doubt that I did the right thing for a patient. Addressing mistakes in medicine is an important skill –- and it’s one that I feel I am not yet prepared for. All I know now is that I’m painfully aware of both the potential for and reality of medical mistakes.

As far as I can gather, this sort of introspection occurs when providers take on new and increased responsibility, are in the process of learning from experiences, and find themselves in a new environment. For me, the longish transits to and from work permit additional opportunities for reflection.

Students on my emergency medicine clerkship are given responsibility unrivaled by any other rotation in our training. We are expected to carry 3-5 charts at a time and take initiative for patients’ care from the moment they are put in a bed until their discharge or admission. There are caveats, of course. This doesn’t apply to trauma patients: students participate in care, but certainly do not call the shots! Also, attending physicians chart a complete note in addition to the student’s record, must co-sign orders and expect to receive regular updates. But the basic decisions are the student’s to make. Due to the busy nature of the ER, and the throughput, a faulty action may not be realized until the patient is out the door.

Take for example the injection drug user I cared for this week. She came in with a deep deltoid abscess in her shoulder. Why so deep? She had run out of veins so was now muscling heroin. I did a thorough exam of her lesion, determined there was no subcutaneous gas and used ultrasound imaging to identify the depth and size of the abscess. I was able to get a little bit of blood for labs and found her white count was 14,000 but her sodium level was normal. (Potentially systemic infection, but probably not necrotizing fasciitis.) Knowing that muscle abscesses cannot be drained in the ER, I referred her to the general surgery service. I was caught up on the logistics of her transfer; for example, no one could get satisfactory venous access, even with ultrasound guidance. I didn’t realize until after she was admitted to the operating room that I’d not listened closely to her heart. Yes, cellulitis can kill people, but the more fatal consequence of IV drug use is endocarditis and septic emboli to the brain. I was so caught up in doing the right thing for her wound that I lost track of the big picture.

It’s a good thing that my attending listened to her heart, and the anesthesiologist, and surgeons and... but in the end I am left with the truth that I let her down. I suppose that’s why experiential learning works. You can bet on my listening to every injection drug user’s heart from this point forward.

July 15, 2008 in Thomas Robey | Permalink | Comments (40)

Nobody’s Favorite Exam

Colin_son_144x144Colin Son -- I don’t know what your hospital is like, but the patient room we walk into is one of those unique ones crammed into an obscure corner. It is tucked away next to a utility closet and behind a team room. It screws up the numbering for every other patient room down the hall. An oddity of the multiple disorganized architectural revisions this hospital floor has no doubt gone through.

In one of those mysteries of modern life, the automatic door senses when we’re in front of it and slides open. I always expect it to do so with a hiss but that never seems to happen. Through the door I’m asked to practice that saturnine but all important final physical exam. I imagine, when it actually counts, there is nothing too unique about performing an exam to document brain death except in its requirement to be methodological and highly attentive. As I walk myself through the exam this day, in this room, I wonder if that is ever difficult; if bias ever hampers the whole thing. I mean, I had seen this gentleman’s CT scan. Maybe not. Certainly not during my first time through it, even if my exam doesn’t contribute anything to the outcome.

Brain death is something that deserves and has legal definitions. While the specifics of some of the laws vary by locale, in general the physical exam to document brain death is pretty standardized.

Foremost you need to rule out anything, other than permanent loss of function, which could be depressing the brainstem. Things to think about include:

- Intoxication or other depressants

- Hypoglycemia or other metabolic problems

- Hypothermia

- Paralytic agents

With those met, the physical exam can be performed. The standard of care through most places is an exam by two experienced physicians with each exam spaced by at least half an hour. In the U.S. some states require an EEG (or two separated by some time period). Some places even use radionuclide scans to document brainstem metabolism.

As for the physical exam itself, you’re testing brainstem function:

- Gag reflex

- Pupillary reaction to light

- Corneal reflex

- Oculocephalic reflex

- Vestibuloocular reflex

- Cranial nerve response to painful stimuli

- Apnea challenge

All of the above have to be negative.

The gag, pupillary light, and corneal reflexes are pretty typical. I’ll just clarify the others for completeness sake. The oculocephalic reflex is the doll’s eyes reflex. With an intact brainstem the eyes should fixate on a point. With their eyes open you take the patient’s head and turn it back and forth. If the eyes remain unchanging in their gaze then the reflex is absent. The vestibuloocular reflex is also known as the caloric test. For this test you typically use cold water. Inserted into the external auditory canal, the water should elicit eye movement if the reflex is present. The old mnemonic COWS (Cold Opposite, Warm Same), which refers to the direction of the primary movement based on the temperature of the water inserted into the canal, really isn’t important in a brain death exam. Any eye movement during caloric testing is enough to preclude a declaration of brain death. Finally, the apnea challenge just refers to disconnecting the patient from their ventilator and allowing the pCO2 to rise. If the hypercapnia will not evoke respiratory efforts in the patient, then the test is negative.

With all of those reflexes run through I follow my team out and up to the call room. I’d bet not the last time I’ll make that walk.

July 14, 2008 in Colin Son | Permalink | Comments (4)

Med Student "Personality Disorders"

Kendra_new_headshotKendra Campbell -- As part of my psych rotation, we have lectures once a week on various psychiatric disorders. The most recent lecture was on personality disorders. In the beginning of the lecture, the psychiatrist warned us that we’d find certain characteristics of the disorders to be ones that we actually possess. However, she reminded us that this doesn’t necessarily mean that we have the disorder, because we don’t have the traits to the point of pathology. Of course, even with that disclaimer, I noted traits that I display, and it caused me to pause! I also realized that many of the traits are ones that are particularly applicable to medical students. So, I’ll list the disorders, and note the specific relevance to med students.

Paranoid Personality Disorder – Reluctant to confide in others due to unwarranted fears that the information will be used against him/her.

Med Student Disorder – Sometimes, we hide things from others because we fear that people will think we are incapable!

Schizoid Personality Disorder – Shows emotional coldness, detachment or flattened affectivity.

Med Student Disorder – While we’re supposed to display compassion, aren’t we frequently supposed to hide our true emotions to patients?

Schizotypal Personality Disorder – Displays odd thinking and speech.

Med Student Disorder – The relevance here is profound! With all of our medical jargon, and the way we have to think about the world, who out there can’t admit to having this one?!

Borderline Personality Disorder – Has an unstable sense of self.

Med Student Disorder – We endure all the trials and tribulations of med school and continue having to live up to ever-changing expectations.

Narcissistic Personality Disorder – Has a grandiose sense of self-importance, believes that he or she is special and unique, and can only be understood by, or associate with, other special people or institutions.

Med Student Disorder – I don’t even think this one needs an explanation.

Histrionic Personality Disorder – Displays rapidly shifting and shallow expressions of emotion.

Med Student Disorder – Isn’t this necessary in order to see twenty different patients with serious illnesses in a short period of time?

Antisocial Personality Disorder – Irritability and failure to plan ahead.

Med Student Disorder – Hopefully, this one only applies during times of stress.

Avoidant Personality Disorder – Avoids activities that involve significant interpersonal contact.

Med Student Disorder – Ummm, hello?! Have you ever spent three days with only your books and loads of caffeine?!

Dependent Personality Disorder – Has difficulty making decisions without an excessive amount of advice and reassurance from others.

Med Student Disorder – How much do we look to our residents and attendings for direction and advice?

Obsessive-Compulsive Personality Disorder – Has a preoccupation with details, rules, and lists, and is devoted to perfectionism and work, to the exclusion of leisure activities and friendships.

Med Student Disorder - Another one that doesn’t need an explanation! I must admit, that I might be the queen of lists.

So, there you are! Which personality disorder fits YOU?

Disclaimer: I am not implying that med students actually have all these traits, or the disorders! Rather, I'm attempting (perhaps poorly) to point out the humorous parallels between our lives, and the disorders' traits.

July 11, 2008 in Kendra Campbell | Permalink | Comments (11)

Don't Get Sick in July

Thomasrobey72x721Thomas Robey -- There's a proverb often spoken around academic medical centers this time of year: "Don't get sick in July."

Why? July is when the medical new year occurs. It's when interns appear on the scene. Young attendings often take their first jobs at this time. Chief residents are getting used to their new digs. Third year students are deer in the headlights; fourth years feel invincible. At every rung of the medical hierarchy, there's a new guy. The surgery R2 is running her first trauma code in the ER. The senior resident all of a sudden has 2-5 other people reporting to him. There's new paperwork, there are hundreds of new phone numbers –- even new sleep schedules. Not to mention the responsibility.

The theory behind the July warning is that with the guard changing, also goes the skill of care. More mistakes are made, diagnosis takes longer, healthcare is a little less... careful. Last year, as one of the deer-in-the-headlights students, I bought into this idea: I told family to stay away from procedures in July.

But things have changed. I think there's another story here.

That R2 leading the trauma code? She just helped teach the interns the ATLS course, she participated in 200 codes last year, she even practiced barking orders to her dog last month to develop that voice of confidence. Sure, she's scared... but she read the manual 23 times. She's terrified of making a mistake, but that fear heightens her observational skill, and polishes her decision-making process.

And the new senior resident on the ward team? Last year he worked under nine different R2s and R3s. He's been making mental notes. "I like how Dr. Schroff involved the medical students in care." "Dr. Wright had an efficient system of collecting information for discharge summaries." "Dr. Miller was intolerable on rounds because of her endless questions (but they helped in the team room)." This new senior may not have his system quite in place, but he makes up for it with his freshness and enthusiasm.

And what about the deer-in-the-headlights category? (Interns and third year students: that's you!) It will take longer to make the diagnosis, you will carry fewer patients, and you will get things wrong. After I realized as an M3 that the work gets done without me there, it helped me fit into the team better. The intern had already figured out what to write and sometimes took care of it before I could come up with a differential or treatment plan, and that was for the good of the patient. Early on, you hope for an intern who helps you figure it out with her; you won't learn by being told the answer! Likewise, every intern has that superstar of a senior backing her up. Even higher on the rung is the attentive attending. In times of transition, the medical hierarchy pays off.

So is it safe to be a patient in an academic medical center in July? I think it's safer than in June... I'd rather have a little extra adrenaline pumping through my team's blood than the residue of burnout and the debris of casual care.

July 10, 2008 in Thomas Robey | Permalink | Comments (4)

It's High School -- With Scalpels

JeffglassesJeff Wonoprabowo -- It’s lunchtime at the hospital cafeteria. Patients stand in line, their IV stands in tow. Children from the pediatrics hospital sit in pillow-lined wagons while their parents pick out food. Doctors, nurses, and other staff members file through the cashier, scanning their cards so as to avoid the hassle of carrying cash. The first year medical students eat and talk about their morning experiences on the wards, some more excitedly than others.

A phone vibrates and its owner chuckles as he reads the text message. And that’s how the lunchtime gossip starts. Or maybe that’s just how the morning gossip transforms into lunchtime gossip. He leans over to his neighbor, who then gladly moves the info down the line. A first year fainted during rounds that morning. Everyone smiles, then desperately tries to find out which one of their classmates fainted and on which service.

A character from Grey’s Anatomy said that the hospital is “high school with scalpels.” That could probably be said about medical school, too.

Watching at least one of the medical dramas on television seems to be a requisite for every medical student -– regardless of how little medicine is actually on the show. When the new season of Grey’s was starting, there were a bunch of my classmates who got together to have Grey’s Anatomy nights. (For the record: I don’t care for E.R., I have no comment on Grey’s Anatomy, Dr. Gregory House fascinates me, and Turk and J.D. never fail to, in the very least, put a grin on my face.)

In medical school you can find the nerds, the jocks, the popular kids, and the bullies. They’re just called by different names. For example, bullies have graduated to being called gunners. The really mean ones have an even cooler name: snipers (as previously written about by Anna here on The Differential). Even the class elections, where interesting promises and platforms can be found aplenty, seem like popularity contests. It’s just tough to grow up.

On the other hand, I’ve heard plenty of stories about the workplace being so much like high school, too. Maybe it isn’t adults acting like teenagers, but teenagers acting like adults. And then we just have a bunch of really mature teenagers in high school. But this is a topic of a whole ’nother post.

The difference between medical school and high school, though, is more than just scalpels. It’s, uh, about… Well, it's like… It’s about learning to save lives!

Wow. Now I’m even writing like a high schooler.

July 9, 2008 in Jeff Wonoprabowo | Permalink | Comments (2)

Horses, Zebras, Ninjas

Ben_3Ben Bryner -- I was reading this story the other day, in which a camp counselor was mistaken for a ninja, which then prompted a school lockdown. It reminded me of the old medical adage, "when you hear hoofbeats, think horses, not zebras." Briefly, if you’re in an area where horses are more common, when you hear hoofbeats outside, it's much more likely to be the sound of horses, not zebras. The idea is that when a patient presents with symptoms that are consistent with a common disease, but are also consistent with a much less common disease, you work under the assumption that it is the more common disease until you can confirm it. In other words, if you’re in New Jersey, a person dressed in a ninja getup is more likely to be a regular person who’s just into karate or dress-up than an actual ninja.

The saying is usually used to correct a student or resident’s differential diagnosis. When you’re on rounds and presenting a new patient with an unknown or not-quite-certain diagnosis, when you get to the end of your presentation, your attending will generally expect you to list the “horses” (the more common diseases) first and the “zebras” second. If you don’t, the attending may request that you do so by saying “Horses, not zebras,” or by the less-conventional technique of whinnying while slapping his or her legs to simulate hoofbeats.

So you should follow what I like to call the “Family Feud” strategy of presentations, based on the game show of the same name. (If you are wondering whether I think all of medical school can be reduced to elements of game shows, the answer is: No, only 80%.) The point of this show was to guess the most popular answers to open-ended questions, with one team trying to list off the top answers to build up points, and the other team waiting for their chance to pounce and steal the points by giving an answer the other team neglected. In a presentation, if you go through the most common possible diagnoses and then get down to the more obscure ones, it’s less likely that someone else on your team will steal the diagnosis you’re waiting to reveal, or that you’ll get interrupted before listing the most important diagnosis. Also, if you’re on a surgical rotation, you should look around after listing off more than two or three potential diagnoses, as your team has probably already moved on to the next patient.

This is not to say that you can ignore the zebras. You try to confirm the presence of a horse before moving on to investigate the presence of a zebra. And you do this mindful of the setting. If you are in feudal-era Japan and you see a shadowy masked figure running around outside, then “Ninja!” is a pretty good theory. By the same token, identical symptoms in a newborn, a teenager, and an adult may prompt very different diagnoses.

As long as you’re not in a true emergency situation, in which you have to try to rule out even uncommon diagnoses if they could cause death rapidly, taking the Family Feud approach to diagnosis has its advantages. Less money is wasted on low-yield tests and evidence-based medicine has a better chance of being followed. When you jump straight to the weird diagnoses, patients get scared, easy fixes get missed and everyone gets confused. Think of the kids in that school who are probably less likely to take a future lockdown seriously. They’ll laugh -- “What is it this time, a pirate in the cafeteria?” And then when ninjas really do attack, they won’t be ready.


And if you’re not ready for a ninja, you don’t have a chance.

July 8, 2008 in Ben Bryner | Permalink | Comments (15)

Will I Be Ready?

NewannaAnna Burkhead -- Folks, it’s time. Prepare yourselves. The final frontier is upon us.

Well, the final frontier is upon me really, not all of y'all. And not really a final frontier actually, just the beginning of my last year in medical school. Forgive me, for I’m prone to hyperbole.

On Monday I will commence the first rotation of 4th year. It is an away, “audition” rotation, and will surely be the topic of a later blog. The fact that the rotation is entirely across the country, at a school I’ve never visited, with people I’ve never met, none of that scares me. What scares me is that a year from now, I (and every other newbie 4th year out there) won’t be starting a rotation, but instead starting work as a new doctor.

Our orders will matter! Our progress notes will be read and taken seriously! Our pagers will go off first! We will be the ones on call! We will be the ones making decisions at 3am! We will be the ones who are responsible when things don’t get done! We will….

Good gracious. We’re in for it, aren’t we?

I know that all doctors start off as interns, and that nearly all of them survive it. I know that I still have another year of learning before I will be expected to do the job myself. But I also know that I’m already thinking and worrying about what it’s going to be like. Is that normal?

I know that several residents and medical students out there have revealed their secret question, “When is someone going to realize that I don’t belong here / that I’m not smart enough / that I am never sure of my decisions?” It’s my secret question too. (I need to know… seriously… when’s it going to happen?)

Maybe I’m getting a little ahead of myself. It certainly wouldn’t be the first time. I’m a bit of a worrier. I still have a whole year to get more comfortable with medicine.

A whole year. The last year of this chapter of learning!

July 7, 2008 in Anna Burkhead | Permalink | Comments (61)