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My first day as a doctor

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Panda Bear, MD (a feisty young blogger) gives some advice to
new medical interns in his recent post.
Internship, for those of you who may not know, is the first year of
residency training.  It is the first time
that a doctor, fresh out of medical school, has responsibility for patient
care.  The intern prescribes medications,
performs procedures, writes notes that are part of the medical record, and
generally learns the art of medicine under the careful watch of more senior
physicians.

Internship is a frightening time for all of us.  We’ve studied medicine for 4 years, memorized
ungodly amounts of largely irrelevant material, played “doctor” in third and
fourth year clerkships, but never before have lives actually been put in our hands.  We know the expression, “never get sick in
July” because that’s when all the well-intentioned, but generally incompetent
new interns start caring for patients. And so, as Panda describes the experience,
we tremble as we begin the new stage in our careers – applying our medical knowledge
to real life situations, and praying that we don’t kill anybody.

I’ll never forget my first day of internship.  I must have drawn the short straw, because
not only was I assigned to the busiest, sickest ward in my hospital (the HIV
and infectious disease unit), but I was on call that day (so I’d be working for
24 hours straight) with the most hated resident in the program (he had a
reputation for treating interns poorly and being arrogant to the nurses).  As I reviewed my patient list, I noticed that
the sign out sheet (the paper “baton” of information handed to you by the last
intern who cared for the patients – meant to give you a synopsis of what they
needed) was supremely unhelpful.  Chicken
scratch with diagnoses and little check boxes of “to do’s” for me.  I was really nervous.

So I began to round on my patients – introducing myself to
each of them, letting them know that I was their new doctor.  I figured that even if I couldn’t completely
understand the sign out notes, at least by eye-balling them I’d have an idea of
whether or not they were in imminent danger of coding or some other awful thing
that I figured they’d be trying to do.

My third patient (of 15) was a thin, elderly Hispanic man,
Mr. Santos.  He smiled at me when I came
in the door – the kind of lecherous smile that a certain type of man gives to
all women of child bearing age.  I
ignored it and introduced myself in a professional manner and began to check
his vital signs.  I was listening to his
heart, and I honestly couldn’t hear much of anything.  There was a weird very distant beat –
something I wouldn’t expect for such a thin chest.  The man himself looked awful, but I really
wasn’t sure why – he just seemed really, really ill.

My pager was going off mercilessly all night.  I wondered if this was how the nurses got to
know the characters of their new interns – to test them by paging them for
anything under the sun, tempting us to tip our hand if we had tendencies to be
impatient or disrespectful.  But in the
midst of all the “we need you to sign this Tylenol order” pages, there came a
concerning one: “Hey, Mr. Santos doesn’t look good.  Better get up here.”

My heart raced as I rushed to his bedside.  Yup, he sure didn’t look too good.  He was breathing heavily, and had some kind
of fearful expression on his face.  I
didn’t really know what to do, so I decided to call the resident in charge
(much as I was loathe to do so, since I knew he would humiliate me for bothering
him).

The resident appeared in a froth – “why are you paging
me?  What’s wrong with the patient?  Why do you need me here?  This better be good!”

“Um… Mr. Santos doesn’t look too good.” I said, frightened
to death.

“What do you mean ‘he doesn’t look too good?’  Can you be a little bit more specific” he
said, sarcasm dripping from his tongue.

“Well, I can’t hear his heart and he’s breathing hard.”

“I see,” said the resident, rolling his eyes.  He marched off towards the patient’s room,
certain to make an example of me and this case.

I trotted along behind him, hoping I hadn’t been wrong in
paging him – trying to remember the ACLS
protocol from 2 weeks prior.

The resident drew back the curtain around the man’s bed with
one grand sweep of the arm.  “Mr. Santos,
how are you doing?” he shouted, as if the man were deaf.

The man was staring at the wall, taking in deep, labored
breaths of air.  I saw that the resident
immediately realized that this was serious, and he placed his stethoscope on
the man’s chest.

I approached on the other side of the bed and held his
hand.  “Mr. Santos, I’m back, remember
me?”  He smiled and looked me straight in
the eye.

He replied, “Angel.” (in Spanish)  Then he let out a deep breath and all was
silent.

The resident shook the man, “Mr. Santos?  Mr. Santos?!”
There was no response.

“Should I call a code?” I asked sheepishly.

“Nope, he’s DNR,” said the resident.

I was flabbergasted.

“Yep, you just killed your first patient.  Welcome to intern year.”

As I thought about his cruel accusation, I was comforted by
the fact that at least, as Mr. Santos released his final breath, he thought he
had seen an angel.  Maybe my presence
with him that night did something good… even though I was only a lowly intern.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

More than skin deep

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A few weeks ago I tripped and fell on the sidewalk.  I went down on hands and knees and scraped my left knee pretty badly.  The onlookers pretended not to notice, I suppose sparing me the embarrassment of asking if I was ok.  I dusted myself off and bled down my leg en route to work.

Since then I kept the wound moist with neosporin and band aids, allowing the skin to heal with minimal scarring.  But as I marveled at how painful this little patch of road burn is, I remembered a young girl I met about a decade ago who had a much more serious burn.

Inga was camping with her parents in a synthetic tent.  They had spent the day fishing and canoing near a campground somewhere in Eastern Europe.  They were huddled together inside the tent in the cool of the evening, speaking animatedly about the day’s events and the beauty of nature when Inga accidentally knocked over the kerosene lamp situated near the exit flap.  The kerosene spilled out onto the tent and the fire ignited immediately.  The tent began to melt in the fire and the zipper got stuck in the hot plastic material.  The unimaginable screams of her dying parents as they burned alive, trapped in this tent, brought help just in time to save Inga’s life.

But Inga was horribly disfigured by the fire.  She spent nearly a year in the hospital, receiving skin grafts and fighting off infections.  She was eventually able to return to school, but was treated like an outcast.  Her former friends were too horrified by her appearance to welcome her back and she spent most of her days sitting alone in the corner, covering her face with a scarf, blaming herself for the death of her own parents.

Her story reached the compassionate ears of a plastic surgeon friend of mine.  He traveled to Eastern Europe to meet Inga and see if he could help her.  As it turns out, she had no living relatives and was dirt poor.  He could see that the medical team taking care of her had carefully covered the defects in her skin, but had not attempted to restore a normal appearance with modern plastic surgery techniques.

The surgeon knew that it would take many surgeries over many years to give her the best result possible.  After some debate and soul searching, he decided to sponsor Inga to come to America where he committed to taking care of her financial needs and to giving her a new life.

I first met Inga after she had been in the states for several years.  She looked like a burn victim, with tight facial skin and abnormal contours – but compared to how she appeared in the photos of when she first arrived (with no nose or cheek flesh at all) this was a huge improvement.  She was meeting with the surgeon to have a seroma evacuated from under her left cheek.  He had to remove the extra fluid with a large syringe.

As I watched him numb the area and sink a deep, large bore needle into this young girl’s face, I cringed internally but tried to appear unphased for her sake.  She didn’t flinch, but sat staring forward bravely, her grey eyes fixed on the wall in front of her.  I saw a tear well up and trickle down her disfigured cheek during the procedure and I instinctively reached for her hand.  The tears continued in silence.  This burn had penetrated so much deeper than the skin.

I haven’t seen Inga since, though I’ve heard that she’s doing well in school, has made some good friends, and is planning to become a nurse one day.  Her decision to devote her life to caring for others is a beautiful example of “paying it forward.”This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Smelling the flowers

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There are cherry trees just outside my patio and 2 days ago
they decided to drop the majority of their pink petals on the ground.  It created a luxurious, 2 inch deep floral
carpet that surrounded my home.  It was so
beautiful and soft in appearance that I couldn’t resist scooping up fist fulls
of the flower bits and holding them out to my husband.  It was a sunny blue day and I giggled as I
asked him to join me in my child like glee.

“I’m not touching them,” he said, “It will make my nose
itch.”

“Aw, come on honey,” I cajoled him, “these petals won’t be
here like this again for another year!
Touch them, they’re so soft!”

He glanced at me sideways.
“No, I don’t want to touch them.
They’re dirty.”

I was crest fallen at first, but then I started thinking
about how something so beautiful to one person, can look entirely different to
someone with allergies.  What a sad thing
to have taken away – the ability to truly stop and smell the flowers.  I count my blessings that I have no allergies
to anything.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The great unveiling

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A psychiatric nurse once relayed an observation to me that I
have been pondering for the last decade.
We were working together in an inner city “dementia unit,” populated
with patients with end stage Alzheimer’s, vascular dementias, and brain
disorders of unclear etiology.
Individuals were parked in geri-chairs in institutional hallways, others
were in bed in 4 point restraints for their own protection, still others were
muttering to themselves in wheelchairs.

We were discussing the case of a particularly unpleasant
patient
– he would swing at people as they got near him, trying to hurt them –
scratching, punching, even biting if you got close enough.  His favorite thing was to grab nurses’, or
other female staff’s, breasts or crotches.  He rarely succeeded at this, since most staff
were aware of his tactics, though he sat in his chair nearly motionless, like a
Moray eel in a reef cave, small eyes and snaggle teeth, mouth open slightly at
all times, taking slow deliberate breaths as he waited for an unsuspecting ocean
dweller to wander inadvertently into his reach.

I asked the nurse how she thought he had gotten to be so
rotten.  She replied simply, “When people
get older they become more like themselves.”

That one sentence has fascinated me ever since.  Could it be that as we age (and our minds
lose their ability to maintain the social graces we were taught), we slip into saying
things in an uncensored manner, and behaving the way we truly want to?  Or is the difference between “sweet little
old ladies
” and “mean old biddies” a matter of how much damage there has been
to their frontal lobes?

The scientist in me would like to explain away all agitation
as an organic brain disorder.  But I just
don’t think we can reduce human behavior to neuroanatomy.  The complexity of a lifetime of circumstances
and individual choices – and their interaction with personality – are soul-defining.

Perhaps age brings wisdom and life experience… or maybe it
unveils the truth about who we’ve been all along.  Either way I have a feeling that when the time
draws near for our bodies to give up our souls, we can catch a glimpse of what people
are “made of” in their final words and deeds.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Baking cookies, Part 2

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One day I was consulted on a patient in the surgical
ICU. It is uncommon for rehab physicians
to be called to the SICU, and so en route, I pondered what I might find. Maybe a multiple trauma patient who needs a
walker or chest PT?

As it happened, the patient was a 21 year old male who had
gotten into a fight in the West Village. He was hit on the head with a blunt object, resulting
in a subdural hematoma and severe brain injury.
He was intubated, sedated, and expressing decerebrate posturing (a
really bad sign).

The surgeons had called me because they were concerned about
pressure ulcers and contractures. They
wanted to initiate physical therapy and stretching exercises to make sure that
his Achilles tendons didn’t shorten irreparably as his feet were pointing
downward in the bed. Although I thought
it was great that the surgeons were planning ahead like that, truthfully I didn’t
think the patient would ever walk again, or perhaps even survive the SICU. The level of brain injury was just too
severe.

I wrote orders for daily physical therapy, got him some Multi Podus Boots, and recommended frequent turns in bed.
I figured I’d never see him again as I was scheduled to change rotations
and transfer follow up of this consult to another resident. It was a tragic case.

About 2 months later I began an inpatient rotation and was
listening to the story of several patients whose care was being transferred to
me. As the resident presented the final
one, I thought the story sounded familiar.
A young man out partying with his friends, got into a fight, sustained a
severe brain injury after being hit in the head…

“This isn’t the guy I saw in the SICU 2 months ago, is it?” I asked the resident.

“Yeah, that’s the one!
I remember seeing your note in the chart. The PTs did a great job with his ankles – he could
stand on them just fine when he got up.”

“Dude, no way! When I
saw him he was posturing in the SICU… this guy actually recovered?!”

“Yeah, I know… he’s the first one I’ve ever seen like this. Do you wanna see him?”

“Heck yeah,” I said, “I’ve got to see this with my own eyes.”

My colleague led me down the hallway to the occupational
therapy kitchen. As we got closer, a
wonderful chocolatey smell filled the air.

“What smells so good?” I asked.

“Oh, the patient is making cookies with the occupational
therapists. He’s learning how to cook
and take care of himself.”

I rounded the corner into the kitchen and there was a young
man, handsome and healthy, pulling a tray of cookies from an oven – I could barely believe it was the same
person.

“Hey doc,” he said to me – not recognizing me of course, but
friendly nonetheless. “You want a
cookie?”

“I’d love a cookie,” I said, remembering the last time I had baked them.

“I believe that this is the best cookie I’ve ever tasted,” I
said, looking at the man with tears in my eyes.

He grinned from ear to ear.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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