Saturday, October 1, 2011

Fair's Fair

"Fair" is an important part of "fair warning". Yelling "Fore!" as your Titleist 3 ricochets off an unsuspecting golfer's head doesn't qualify. That would seem to be too late to aid anyone and, while the "warning" portion still applies, you lose the implied utility of providing not only helpful information but also a chance to make use of it. You are giving the warned party time to react, and that's important. Imagine what Abe Lincoln could have done with fair warning. Probably retained a good bit of his brain matter, would be my guess. And so it was that on my first overnight call on Labor and Delivery, the nurse midwife pulled me into one of the labor rooms the moment I set foot on the floor. Knowing my past predilection for wooziness in such situations and this being the first time I would view childbirth, I gave the midwife fair warning as I donned sterile attire. "You told us during orientation that usually one student in every OB/Gyn rotation group faints during a delivery. I'm Aron." I also told her it was more a possibility than a certainty, but that's less fun. We covered proper protocol should such a thing happen and off we went as the patient was fully dilated and starting to push. This week on Flash Gordon: Can our intrepid hero overcome the threat of vasovagal response and stay on his feet during the live birth of a human child? Yup. Shoot I blew the suspense so I guess I wasn't made to write old timey radio drama after all. Objectively, the proces of childbirth is disgusting and I'm fairly certain I don't need to explain in detail the reasons why. Yeah, I've heard the fluffy arguments about how The Miracle of Life trumps the rest of that stuff, like the smell. There is a distinct smell that goes along with childbirth that isn't so much offensive as it is the smell of someone caramelizing the top of a creme brulee but utilizing a pile of old car tires instead of a ramekin. It turns out, though, that there is actually something slightly magical about the whole process though and it does indeed trump the various offenses. So the midwife delivered the baby, I delivered the placenta (gross!), and no one got hurt or wound up face down unconscious in birth materials. I can't say I was looking forward to OB/Gyn. In fact, of all the rotations lined up for the year, OB/Gyn was the only one I approached with apprehension. Six weeks later and it turns out I rather enjoyed the rotation, enough that I'd almost consider OB/Gyn as a career choice. The chance to do both clinical work and surgery is enticing and women's health is a neat field. Consider one particular case I participated in on an overnight call. Retained placental tissue caused bleeding in a mother As the 71-year-old attending continued working to remove the offending tissue, he recognized the need for more serious action and ordered blood and blood products as well as paging the surgical team in. By the time the operating room was assembled and the patient prepped, an hour and a half had passed with the patient missing well over a liter of blood. The attending decided that it was too late to do anything but an emergency hysterectomy and since he's old school, he did so without electric cautery, opting instead to ligate everything with suture material. By 2:45am, surgery was over. Because the attending ordered blood early, the patient got necessary transfusions in a timely manner during surgery. What was a perilous situation for the patient resolved successfully due to the calm anticipation and diligence of the attending after midnight. Cool stuff, OB.

Sunday, August 14, 2011

One Flew East, One Flew West

As the counselor unlocked the door to the unit to give us a quick tour, I got nervous. I’m certainly no stranger to hospitals at this point between growing up with my parents, volunteering, completing a senior design project at Children’s Memorial, working at Cedars Sinai and so on. I’m quite comfortable walking around inpatient units. I ‘ve experienced high-tension environments shadowing an ER doc through some overnight shifts, spending time in the ICU and OR at Children’s, and of course cholera care in Haiti. Why then was I suddenly quite uncomfortable and apprehensive about how I’d make it through the next six weeks? The opening sentence to the paragraph holds the answer. Of course I withheld information, as the counselor’s title is Mental Health Counselor, but the locked door is a clue that the unit is the inpatient psychiatric floor and this experience was straight out of One Flew Over the Cuckoo’s Nest. My six colleagues and I were led onto the unit in the early afternoon, where patients are at their most active. Several manic patients were out in the hall acting boisterously, one rapping loudly and walking around aggressively. Seven white coats in a tight bunch drew plenty of attention from manic and schizophrenic patients alike, drawing bizarre questions or simply attracting attention. Dark-blue-scrub-clad nurses and mental health counselors in burgundy were trying to get patients back into their rooms, social workers worked furiously in the nurses station, all while environmental services folks ran the floor polisher and swapped out linens. Chaos. The other med students and I shot each other grimaces, conveying with clenched teeth the same feeling you would experience while paying for groceries in pennies with Ron Artest in line behind you. Day one.

It turns out that inpatient psychiatry from a medical perspective looks nothing like the image of Freud psychoanalyzing patients. Getting hospitalized for psychiatric reasons requires pretty severe impairment in overall function or risk of harm to yourself or others. As such, most of our patients were schizophrenics with acute exacerbations, bipolar patients in manic phase, patients suffering from episodes of Major Depression, or substance abusers with an underlying psychiatric diagnosis. The role of our attending focuses more on pharmacotherapy and social work than I would have guessed. For someone with debilitating schizophrenia, there just isn’t much to do until the patient has the right mix of medications to keep their thoughts more organized and psychosis at bay. Imagine conducting an interview where the response to your question, “Does anyone in your family have a psychiatric illness?” with the response, “You know when you hear music, like a Pink Floyd album, it really takes you back?”. The effects of antipsychotic medications are incredible. The police brought one of my patients in after bizarre behavior in the streets. The patient responded to all questioning in the ER and on our floor by grunting or mumbling incoherently. After trials of several antipsychotic medications, we found one that worked. A patient who remained in bed for most of the day previously now spoke in short sentences, was dressed and walking around, and no longer had hallucinations; the difference was night and day. Of course after discharge he stopped taking his meds and was back in the same condition soon enough, but that’s a different matter.

Part of our rotation was just learning the ins and outs of being an M3 in the hospital. How do I interact with my attending? How do I write notes? What exactly am I responsible for? Getting those questions answered within the first few days made things a lot easier. We got a feel for what drug seeking looks like and how system abusers behave. The law passed in Florida that requires drug testing for Medicare recipients makes a lot of sense. We’d have patients who blew their check on drugs and then didn’t have a place to stay so they’d get themselves admitted to the psych ward. Housing for free, on the government’s tab so who needs a job? As long as this country is reforming healthcare and trying to cut down on costs, Medicare deserves a look too. Overall, though, a great experience. It sure beats seclusion in a library.

For the last two years, I’ve been waiting. Sitting down and studying for hours on end does not provide any enjoyment. I love learning, but man is the process agonizing. Learning through doing? I’ll take it. So that’s what this year is about, and I’m already enjoying it. The benefit of this rotation is that there are no residents or interns on the psych ward so I was responsible directly to our attending and responsible for two or three patients at a time. My fellow M3s and I got to do the psychiatric evaluations on new patients and then write progress notes daily. Our attending trusted us to help make medication and discharge decisions, which was clearly neat. There were times there when, just for a moment, I felt like a doctor.
OB/Gyn is next and has the reputation as the most difficult rotation in terms of hours and intensity. Catch.