The Funny Current

is actually a current controlling heart rate.

Category: Work

The Tapeworm and Magician

So I think the last 2 notable encounters I had in Tucson were with a boy who apparently had a tapeworm and a couple who were…”practitioners of magic”.

The little boy was probably around 7 years old. He’s such a sad case because it highlighted how long things take. His mother had come to the van almost a month ago, looking for help, but we couldn’t do anything because we needed to get his old hospital records. For some reason, that took forever and there was a bit of push-and-pull between the staff to actually look for the tapeworm or not. Finally, they came back with a stack of papers detailing his history and hopefully, they’ve given him some anti-parasitic like praziquantel.

Both the mother and son are super sweet, and you could tell he was almost lethargic and just too thin. How strange is it that after all the workup from the hospitals, they didn’t discharge him with the medication? It looks pretty cheap…

The day before I left, we had Tucson House which is a slow site, but it was topped off with the last people of the day. This couple comes in and I strike up a conversation with the husband who’s waiting outside. I mention his shirt, which I’ve seen on Threadless (or is it Woot?), a puppy Cerberus. He gets really excited and just starts talking about how he’s a “death-head” and schools me on all mythology, Greek, Roman, Norse.

What started it all

His wife’s name is Freya (Of course), and he starts telling me about the Ring Cycle, and I’m totally overwhelmed. He says some odd things about how he believes in magic, and I get the feeling that he’s something related to a Wiccan, where it’s almost a religion/way of life, but I really can’t tell. His wife is actually getting a bit antsy since they have an appointment to make and doesn’t let him go on too much.

He did give me something valuable though…

He had his and his wife’s bikes strung up on the sidewalk, and I asked him where he had started out from. He said a place that would have easily been 15 miles away, and I gave him a look of “wow, that was a workout”, and say it must have taken a long time.

He’s a bit of a smart alec, and smirks at me then says, “yeah well, we rode for a few blocks then took the bus.” To my expression, he supplies, “I only implied that we rode here, I never said I did. You made the assumption yourself. That’s what magic’s about– illusions”.

Push It

It seems like everyone has gone through really rough times in their life. But you’d never suspect a complex story when you first look at someone. If they’re relaxed enough, you assume things have gone more or less OK.

When I first met Edgar, he was introduced simply as the MA and truck driver. But this guy has traveled and lived all over the US. He had grown up around mechanics and had a familiarity for automobiles, and naturally got into trucking. That alone is a job I can’t even imagine properly. Being given a few days to cross multiple state lines in this huge semi. Alone. Bored. Maybe sleepy. I’d love to stop and take pictures on the side of the road, but that really isn’t an option when it’s your job to get to your destination fast and you could be carrying perishables.

It kind of explains Edgar’s fixation with the phone and texting. I mean, what else can you do while you’re driving than have a long conversation with someone?

It makes me think of the Transformers when he told me and Betty about how he and his buddies would resolve road issues. On a 2 lane road, if someone wouldn’t let him pass, he’d radio in his friends to cut ahead and block the other truck off, then they’d have words with him.

For a few years, he also did some oil rigging in I think Wyoming, the details are a bit fuzzy now. Wyoming?! Another state that I know exists but I don’t ever think of. Being on 24 hour call to drive and separated from his wife and kids must have been torment. It makes me think how petty it is when college kids tell each other they “can’t do long distance”.

Somehow Edgar got into health care and was working as an in-home care assistant before he came to the Mobile. I guess these instances stuck out in his mind as particularly disturbing: a naked old woman who always got up to smear her stool on the walls, and an elderly man who was sexually flamboyant and would always be masturbating.

Then there’s Ryan, the new MA, completing his hours on the van. He’s obviously going to school and also has a part-time job driving the Green Cab in town. I don’t know if he ever sleeps. Driving a cab (just like taking out loans for medical school with 8% interest) sounds a lot like indentured servitude. He starts with -$114, so he has to make back that amount and then some for it to matter any.

I feel pretty high-brow saying that I’ve done part-time work tutoring. It’s a clean, painless, high-paying, cash job. Money is money in the end, but the work you do to get it makes you appreciate it in more ways. I’m thankful that my family is financially stable and in the middle-class. That I could make some pocket money to spend on whatever I wanted instead of having to put it to never-ending rent or car payments.

Betty of course has her own story. She started nursing school later in life and had to literally go to extreme lengths to attend school, driving some 150 miles one-way in another town. With husband and kids too? I just can’t believe how much one person can handle and then push themselves to do more. Willpower is amazing.

I had originally had this draft with notes on how inadequate I felt compared to these people, but I’ve changed my mind about it. It’s not productive to compare and then lament. It should stand as an inspiration for your capacity to do more. It’s too easy to get stuck in this downward rut and I’m actively trying to lift myself out of thinking that way.

Note On Organizing

Keep 1 planner…for everything. Just 1, I don’t care if it’s paper or digital. But you best make sure you write everything in it.

The Future

Got up early to do some dental varnishings, so it was a pretty laid back day. Hopefully I didn’t irritate Edgar by constantly talking to fill the empty space as we were going to the school and back.

I was saying how I would really strongly consider becoming a national park ranger/medic in a place like this when I’m older, and just embrace the wilderness. (What is this? Am I saying I’d be interested in rural family medicine??) I can have some cowboy coffee and beans. Hilarious considering I scream when I see insects. Arizona’s been pretty life-altering.

Me from just a few months ago would have never said this.

Pinch-hitting and Tears

Today’s lessons: be prepared for everything, including all the “pertinent negatives”.

                               -Always carry tissues for patients

                                -Tell patients they can cry when you’re with them…because they won’t
otherwise, and they really want to.

I keep getting hung up when a doc asks a question like: “have you heard anything from X?”

Well… no, or else I would have put something on there. And then I start thinking, “well what if they did call, what if something happened…” I think I think too much. Conclusion, just assertively say yes or no. No no no.

Ended up pinch-hitting for Lorenia, and it’s a good thing to know everyone’s skills. Just in case something happens, you can fill in for them without falling apart. Note to self if I start my own practice.

Gosh… It’s so personal for me when I meet people who are depressed. I really feel like there’s no way for someone to resolve it for you. They can only be vaguely supportive, but you really need to dig yourself out of the hole. Today I was speaking to an LPNurse who was unloading all her troubles. She’s lost her job, forced to move in with her parents, taking care of her father who is a recovering alcoholic and sounds verbally abusive, she had a broken leg which she never got examined/put into a cast, is overweight, has COPD, still smokes because she’s under so much stress.

When you’re seeing someone in this context, there’s just an emotional gulf between you and the patient. You don’t know them very well and they’re reaching out to you because you’re a stranger but are in a position of authority.
You feel sympathy but it’s not like you’re really there with them. You don’t feel that sad. It’s the kind of sad you feel when you watch something on television. Because if you were that affected, you’d be crying with them. The crying is an important part I think. Shedding tears in public is pretty taboo. It’s a symbol of weakness and irrationality. But it’s also this very physical release for your mounting anxiety. It’s weird to “give permission” to someone to let it out, but I’m putting that in my book of good things to do. Because it was so clear she was keeping it in just for posterity but needed to get it out to someone.

Cherry Picking Skills

I’m watching everyone really carefully and picking out things I like. Betty is super analytical, and if she’s not sure about something, she’ll just go ahead and do all the background labs to check. In this world, better safe than sorry, but she strikes a good balance where she’s not overly conservative.  Edgar is oddly really collected, and so polite. When we were down a person, no one else really formally announced it, but he came in and just clasped his hands to tell the doctor, you know, we’re really sorry but bear with us because we just lost so-and-so. That totally changed the atmosphere from crackly-annoyed to on-alert and how can I help.

Maria, the MA student now volunteer, is keyed into something I have the most trouble getting down. She has this silver tongue that just chats people up and makes the donations flow. Our cash jar was so dry when I was around, and I admit I could have been more proactive about that. But I had conflicting interests, you can be at the front office and with a patient at the same time. But I just watch Maria and she really steps it up by using her own initiative to make payment plans and find companies willing to donate money or supplies. It easy to talk about this stuff but someone actually needs to do the legwork, and she loves doing it.

I’ve been able to work with and shadow several of the Family Medicine residents and there are a few I really like. Paul got to come on the van just the week before and I’ve always been struck by how level-headed he is.

I think because I’ve been in a small school for so long, just fighting other people to secure a spot, I’ve forgotten to think about just me instead of me relative to others. He stands up straight and tall and when he puts on his white coat, I get the distinct feeling of his pride. He’s a sharp guy and remembers details of the papers he reads, and is nice about bringing them up as conversation points during the residents’ teaching day. I had no idea he was bilingual, and he just goes smoothly to seeing his patient on the Mobile and seamlessly starts speaking Spanish, at a slow pace, clearly, and it’s nothing too high-tech. In fact, I could do it easily myself but I always find myself giving myself a prep talk before I go into an exam room. Why the hell am I so nervous? The patient feels at ease because they feel confident they can convey what they need to and it goes so much smoother than when a nervous wreck of a resident starts off with “hi, I’m doctor ____ and I’m sorry but my Spanish is not so good”.

So I’ve been channeling some Swenson. I just tell myself to be confident (not overconfident) and just take it as it comes. Spanish isn’t hard, it’s just there and I can reach into it whenever I want.

He was also able to reset the Babbling Brook’s attention by touching his knee, and has this great sense of empathy. Smoking cessation talks are canned. Both patient and doctor know what the script is and both know that unless the patient is in a life-threatening situation or really emotional, nothing’s going to happen. The way Paul was looking at this young guy, asking him, “Don’t you know what happens when you smoke? You should really think about quitting. What’s stopping you?” I realize now, the approach was different because he was using a bit of Cognitive Behavioral Therapy, he wasn’t just lecturing, he was really trying to give some psychological counseling. And you could tell the guy was a little spooked and was starting to actually get introspective.

As a person, he’s a great conversationalist. He’s actually the first resident I spoke to and had closer contact with. It was funny…he invited me to a potluck with the other members of his year, and I thought I’d be there at a good time by arriving an hour in. No, all the residents have children and are working so they came early and left early. He had the grace to let me stay for an hour and entertain me before turning in to bed.

So you can tell he is a great teacher. But now it’s firmly stamped in my head, you can’t ever hope to be a good teacher if you don’t know it all. He has a mastery over physiology and explains to patients a disease process so that they’re not just following doctor’s orders, but are able to take control of their own health. I guess on a certain level, health care providers are afraid of it because it means less authority for them, less of a blind following of directions and challenge, “are you sure this is the right medication for me?”

Med students complain (and that’s a recurring theme, med students complain, a lot), that they have to go through so much theory that just isn’t useful clinically. It can be. If you have a good understanding of something, even Biochem, it makes you that much more powerful and effective as a provider. If you can’t explain why something is wrong with someone, how can you expect these people to trust you with their health? He really inspires me to remember mechanisms behind things and not act like other people, tossing the process away and just thinking of the end results.

So how did I use this.

I remember this woman as a super black-haired lady. It was obvious she had dyed it, it had such a luster and intense black almost blue tone to it. Small Hispanic woman, hair in a thick braid down to the small of her back. I go in with her and introduce myself real casually, I’m Chelsea, a medical student, I want to ask you a few questions before I had the nurse come in and see you. And she’s pretty impressed, some of her anxiety is loosened as her face relaxes.

“Oh, you speak Spanish?” and I tell her yes, I learned in high school, and it’s just going along swimmingly. She tells me she’s worried she has something wrong with her heart because of a pain in her arm. Ok, so it’s muscular or maybe she does have some kind of blockage and stress on the myocardium. I try to have her characterize the pain, and it’s not radiating anywhere, kind of dull, more in the arm than anywhere else. I have her do some movements to test the rotator cuff, and palpate her back. She has no contributory history and is in overall good health. She actually seems more on top of her diet than I am! So I think I’m feeling very tight muscles and just strain. I tell her this and have Betty come in and verify since anyone having heart issues is automatically a big deal. She agrees and I think we decide to give her some ibuprofen and flexeril at night.

A “boring” encounter, sure, but it ranked as one of my best. I was so in control of the situation, I knew what I was looking for, and the patient was at ease and willing to tell me more about her condition. What I’ve noticed happening with the Spanish-speaking patients is that they clam up when they realize the provider can’t speak Spanish to them. But I went calmly, slowly, not trying to prove my fluency and it was awesome.

Speaking of smoking cessation, afterwards we had a woman who wanted to refill her bipolar medication before going on a long trip. You would think that was the big deal, but it was her lungs. I haven’t had anyone with appreciable sounds until her, and there was wheezing. I asked if she had asthma. Yes. Smoking? Yes. Quitting? Ehh… not really, will think about it? I probably would have pushed more if she wasn’t so obviously closed to the idea of quitting. How do you get someone to the point of just starting to think about quitting? Hm… guess I’m googling that and some psych material.

The Swan Neck, the Babbling Brook, and the Burning Ball of Styrofoam

What an atypical week. We had off for nearly 7 days, so it was a flood of patients today. I didn’t bear the brunt of it since I was with the Ob residents, but I got to see a few of the Family Med patients once those doctors were done.

Maria, our now volunteer MA, is chatting with the next patient and taking her blood pressure. When she asks her to rise so she can stand on the scale for her weight, the woman just can’t get up. She’s wincing and struggling to get a grip on the table and use it as leverage to hoist herself upright. Betty and I are looking at her– if you can imagine dogs suddenly turning their heads to a noise–and we watch as Maria helps her onto the scale. The pain isn’t new to the patient, she said she’s had it for the past 3 years. But she’s only 44.

She has her little kid with her who keeps mimicking what Paul, our resident for the day, does– pressing on her joints and squeezing them. Paul shows me her index finger and how it curves into a swan-neck.

We find out that there is a history of lupus in her family, so we’re fairly sure that it’s RA.

The next guy is someone who came in last minute before. Maybe I just look very approachable but he kept looking at me and giving this very long convoluted history. I felt like I was reliving my clinical skill exam…I had the talkative patient and I bombed the first time as she went on and on about her husband’s eating habits and her Air Force uncle. It was a little more awkward since I wasn’t the one handling the case. Paul was doing it so I didn’t want to steal the show from him. I picked up some more things from him (I love watching him), he touches the side of the Brook’s knee to get his attention and that seems to bring him back to Earth.

Last girl was …classic. She’s a little thing and has a big scab on the side of her face. We find the story is that she was with her friends at the river and had burning balls of styrofoam on sticks. Of course, you can imagine what would happen to a bunch of kids whirling around flaming balls of burning plastic. She got hit with a gob of it on the face, and it actually looked to be healing pretty well. Something that irks me is how people never use any medicine before coming to see us. Isn’t that common sense?

Physical Exam Obsolete?

Before I had my physical exam class, I was really excited to be the best House-like med student ever. I thought, if I can master this, I can be with a person for 15 minutes and tell what they have without needing to order any imaging.

It still amazes me how stupidly idealistic I can be.

The practicals for that class were probably the most irritating ones I’ve ever had, and then getting a glimpse of how patients are seem in the hospital showed me that a lot of the maneuvers are useless. For one, you need to get good documentation of everything and double check your work (mostly in case you get sued), so you can’t just rely on physical exam techniques. They’re more to just give you a sense of security in your guess of what’s going on.

So things like whispered petrioloqy, fremitus, jugular venous pulse, estimating diaphragm descent (written in Bates as extremely inaccurate compared to an x-ray) etc, etc, seem like silly things to be teaching students.

In this day and age, I’d say that a person extremely skilled in physical exam would only be used to their full capacity in a place with almost no medical equipment. I’m talking about a place with a stethoscope, bandages, and just a pharmacy.

 

Self-Medicating

I have a theory that nearly everyone has tried an illicit drug. The category doesn’t just have marijuana and cocaine, but also the grey-area items like bath salts, K2/spice, and salvia. People usually just don’t admit it during an interview, or they don’t think it’s relevant to their illness.

Granted, there are a lot of people who just like it for the cheap thrills the drug brings. And to a certain degree, you can’t blame them, these agents are hitting the best pleasure receptors in the brain that we’re hard-wired to love. But I’ve met several people who are using to self-medicate.

Does marijuana use cause depression or does depression cause marijuana use?

Do people with undiagnosed anxiety use marijuana to help them?

AM: Identifiers

It was an Ob clinic day, so we started off early to do a pre-conference before all the patients came. We’re a little undermanned, and as much as I’d like/need to see the clinical side of things, I was off being a team player and directing patients, getting them to do the fluoride varnishings, dipping urine, that’s the life!

I feel like I spend 50% of my time handling urine.

I am so bad with names. I feel like I need to do a Phil Dunphy and rhyme names with silly items to remember them. If I have the time, I make a little cartoon of their defining facial features. I’m almost done in AZ, but I feel like starting a reporter’s notebook with everyone names and cartoons so that I can just catch them at the door and say hello without referring to their chart.

That’s another thing– people are concerned that medical students/professionals are becoming desensitized to their patients being people. I think it’s because of the nature of the work. You are constantly looking at their chart and thinking of the disease process, you end up identifying people as “Mrs. X with an amputated arm” which in short-hand becomes “no-arm-lady”, no wonder it gets offensive and scary. The only solution I can see for that is having a more “wholesome” relationship with your patient, but that’s something that requires more time and less patients, not something that can be done in most work environments.

I wonder if anyone has suggested making a cap of  universal maximum number of patients every few months. It could distribute the patient load across the board and that would mean you could also tailor your services to everyone much like a private or concierge healthcare. It would also eventually mean that the imbalanced ratio of specialists to GPs would have be equalized by supply and demand, not by money made.