on the theme of "patients lie"

A book I clearly need to read!

I had a lovely older lady the other day. She was slightly confused but I was able to get her to answer direct questions if I tried a few times. During the personal history I asked her how many children she has, what ages, where they live etc. She told me she has 11 children, told me all their names, where they live, what they're doing.

I picked up her chart late. She has. . . three children.

Hmmm.

In an even better example, my friend S was interviewing a fascinating middle aged man who was admitted for knee pain. He spoke in elaborate detail about his service as a high-ranking official in the Russian army, including his experience serving in Afghanistan, during which time he was captured and held as a prisoner of war for five years. She spoke to him about this for nearly two hours, thinking maybe he'd sustained a relevant injury, or PTSD, something like that.

When she returned to the doctors' lounge and looked at his file, she was mildly confused. His personal history mentioned nothing about his military service, no mention of malnutrition, broken bones. Nothing.

Then she flipped the page to "medical history." His medical history: "Sociopath. Long history of manipulation of hospital personnel, pathological lying."

The doctors almost fell over laughing when S presented the history she had collected from him.

The above is a picture of the major highway leading into Jerusalem on Yom Kippur. It's a really impressive, kind of delightful thing.

But of course there's a flip side.

The hematologist we were shadowing on Tuesday was on call over the holidays. On Yom Kippur day one of his lymphoma patients had an emergency. He got in his car and made his way towards the hospital, a 20 minute drive from his house. Unfortunately, exiting his neighborhood requires driving down the street on which his synagogue is located. As he attempted to drive through, a mob of people surrounded his car. He rolled down the window and calmly explained that he was a doctor on his way to handle a life-and-death emergency involving one of his patients at the hospital. The crowd began to throw rocks at his car and continue to block the road. Eventually he turned around and went home.

Apparently they do the same thing to ambulances.

And these aren't even the super-religious, it happens here in Beer Sheva which barely has a chasidic community.

I can't even describe how personally insulting I find this.
I understand believing strongly that everyone should respect the high holidays. I understand the government closing all the stores. I understand buses and trains and taxis not running. I understand roping off the streets near synagogues.

But I cannot think of anything more contra to the spirit of the holiday than going out of your way to cause harm to others who just don't happen to share the same belief as you. And an ambulance? I mean, come on.

A car driving through your neighborhood does absolutely nothing to ruin your Yom Kippur. It means nothing to you. Yet instead of focusing on, I don't know, prayer maybe, your own spiritual journey, you're seriously going to leave your home or synagogue to break the windows of ambulances and try to injure the people who are on their way to save the lives of a member of your community.

Another interesting holiday occurrence is a slight peak of premature deliveries. Pregnant religious women are emphatically forbidden to fast because of the risk of the stress causing early labor. Some of them do anyway. A lot of them will go into labor and try to wait until the end of the holiday to go to the hospital.

There's also always a major blood shortage over the holidays. The blood collection centers are shut down by law (all government organizations close except the hospital itself) and by the 4th or 5th day there's a major blood shortage.

According to our chief doctor, the government won't allow anyone to do a study on a possible increase in preventable deaths around the time of the holidays because the government needs the vote of the religious community and would clearly lose it if they sponsored a study proving that religious observance causes death. (in the doctor's words, "the religious people don't want to hear that religion causes death").

What an interesting universe it is.

We pass numerous "beware of camels by the road" signs, and several actual camels, during the 40 minutes drive to the hospital. It's easy, having lived here for three years, to forget how so very different everything is from where I grew up.

It's Yom Kippur here, which means that the entire country is shut down. No flights, no traffic lights, no traffic. It's pretty stunning. Cliche to talk about, but it's a pretty powerful thing to see the center of Jerusalem just absolutely dead, to be able to walk in the middle of the street. And it's sooo quiet.

The quiet is much needed, to be honest. It's been an unbelievably long week full of sleep-deprivation, patient after patient after patient, being yelled at by nurses, doctors, and patients alike.

We have a not-surprising amount of patients from Sderot who end up in the internal medicine ward and turn out to be more post-traumatic-stress-disordered than anything else. Our hospital is where all the kazaam rocket victims end up, and fortunately there are happily few physical injuries- but we get all sorts of anxiety disorders, depression, eating disorders etc. from that area. I understand being attached to where you live but it's hard for me to understand why so many people are still living there. Especially families with children. We saw a 14 year old boy last week who stopped eating after a rocket fell near his house. We kept him for a few days to rehydrate him, but what he needs isn't exactly a hospital, really.

The rest of our patients have been an interesting mix. The usual 70-80 year youngs with heart disease, dementia, anemia etc., a bunch of fevers of unknown origin. It's been more difficult than I expected. An endless stream of new patients to admit, needles to stick in people, 10 page reports to write, 30 minute presentations. I wake up at 6am, get to the hospital at 7:15, get home at 5pm, with only a 40 minute lunch break in between. I literally don't sit down the entire day except for morning meeting and lunch. I also made the mistake last week of doing on-call on Sunday night this week, which means that I started the week with a 20 hour day and really never recovered.

For those who are unfamiliar with the middle-eastern idea of hospitality, I'll explain. You cannot enter someone's home here without being offered a hot drink, a cold drink, cookies/cake, and fruit. And it's not something you can say no to. The same atmosphere carries over into the hospital. There are constantly cookies in the on-call room, and someone makes coffee for everyone on a half-hourly basis. And not normal coffee. Turkish coffee. Which is basically tar and tree bark in a cup with a lot of sugar in it. They actually use the sludge that stays in the bottom of the cup to read the future, like tea leaves. I attempt this from time to time during the morning meetings in a vague attempt to amuse myself. I'm doing my best to de-caffeinate, it's a losing battle. I try to take only a sip or two and then discretely dispose of the rest, but still I feel like a permanent hole has been burned through my stomach.

it's official

I can tell I'm spending a little too much time at the hospital. Every time I meet someone new I find my eyes immediately traveling down to their arm and trying to find a good vein. It has been a long three days full of doctor-y goodness, including my first on-call night and my first unsupervised needle-sticks. I still can't quite believe they even let me talk to patients alone, much less stick needles in them.

Now I have a 30 minute presentation to write on one of our patients with an unexplained fever that spikes two times every two days.

Anyone want to venture a diagnosis?

corrections and clarifications

So, I've been informed by a savvy commenter re: my earwig post that the picture of an earwig given to me by google images is actually a tick! Which is an equally disturbing thing to have in an ear, for sure. But I do believe in accuracy (and reliability and reproducibility) so above is a picture of an actual earwig, courtesy of Wikipedia. Enjoy!

I'm spending this hot desert afternoon watching videos of physical exams conducted by a tremendously uncharismatic doctor and a patient who is very very obviously an actress and does not seem all that pleased with this gig she's landed.

In fun blog-related news, I was camera-less for the past few weeks, but we're now reunited so I hope to start posting some fun desert/hospital/falafel related pictures in the near future.

Back to the proper examination of cranial nerves. . .

The above image came up on google images under the heading "women's role in the workplace."

My group on the wards yesterday turned out to be 8 women and one guy, due to the usual scheduling confusions which led half our group to not be able to find our assigned ward.

When our doctor arrived he asked what percentage of our class is female (56ish%) and then launched into a speech about how the fact that medical school classes are now predominantly female signifies the decline of the status of the profession of medicine.

After a moment of silence, in which I suspect most of us were trying to decide whether to be offended or not, we asked him to clarify/expound, here were his examples:

1. Most investment bankers are men.
2. Most first-grade teachers are female.
3. Most neurosurgeons are men. (neurosurgery is an 8 year residency, the female predominance in medical school has happened within the past 10 years, the XX chromosome neurosurgeons are just still in school!)

His logic: Men are drawn to higher status professions so the fact that there are now less men in the medical force is a sign that the status of the field of medicine is declining.

Now I never speak in class unless absolutely supremely necessary. But, after listening to about 5.5 minutes of this, I heard a voice.

I strongly disagree. Said the voice.

I looked around. Oh my goodness, it was my voice.

Just for argument's sake, my voice continued without my approval, couldn't you argue just as validly that the status of women is increasing or that women are now increasingly drawn to traditionally male and "higher status" career choices?

To which he sniffed disdainfully and replied that it's simply a fact that the amount of males in a given profession is an indicator of that profession's status. "I don't necessarily agree with it," he shrugged, "it's just true."

I can't explain why this is making me so angry. Maybe he's right. I don't even care about that. But why would he enter a classroom full of women and say that?

Anyway, what do you all think? Would you find neurosurgery less impressive if most neurosurgeons were women? Would you look down on a man if he were a first-grade teacher? Does the "status" of the medical profession even matter?

And why does this bother me so much?

dreams of ships and sealing-wax

So I've been having a series of really odd dreams.
And by odd I mean mind-numbingly mundane.

Wednesday night: I was in the student book center looking for a calendar/day planner. They didn't have one I wanted. I called my friend for emergency calendar-buying assistance. She came and helped me look. We couldn't find a good one. I woke up.

How is that a dream???? Medical school has made me so boring that my deepest darkest fantasy life involves shopping for school supplies.

The strange part is that I don't even use a calendar or a planner. Since my life at this point consists of wake up, go to hospital, wander around hospital looking for the doctor who's supposed to be supervising, convince nurse on duty that said doctor does in fact exist and work in her ward, find doctor who was unaware that we were coming and taking a coffee break, convince doctor to briefly abandon coffee and teach us something, poke patients, go to gym, study, sleep- there doesn't seem much point in writing it all down.

The rest of my dreams this week have been about the same: one involved grocery shopping and looking for purple grapes, one involved studying, one involved mopping my apartment.

And class is provided plenty of fodder for interesting dreams. We spent hours yesterday looking at pictures of spiders stuck in ears, fractured eye sockets, missing noses, face-eating tumors. So much material there brain!



Our rounds in the wards continue to be a little upsetting. This is even more striking since we had an absolutely incredible doctor on Tuesday. She made sure to give each patient some kind of reassurance, to rub their back, to take a look at their bruises. . . I can't even figure out how she did it, but she managed to include the patients in her presentation on them. So instead of standing and taking notes on the patients as though they're some exotic zoo animals, it felt like a conversation. She introduced us by name, and then she'd say "tell us about your surgery" or "do you mind showing them your scar?" and when she did give us mini-lectures she'd make sure to stop and ask the patient if she was getting it right or if they had anything to add and the patients just lit up and were so eager to answer our questions and to tell us about their interesting heart sounds. It was really lovely. It made us feel like even as we were learning we were caring for the patients at the same time. And wow, what a different experience from the rest of these two weeks.


Then on Wednesday we were back to normal. We started calling our doctor "living-dead-doctor" I'm not sure why other than the fact that he is in fact the living dead. He has one of those limps where one leg drags behind him. He speaks in a monotone so monotone that I'm not even sure it can be called a monotone. More of a notone, perhaps. He displays no facial expressions ever except one that vaguely looks like anger or disgust when patients speak or when we answer a question right.

None of that would matter except that I have never seen anybody who was such a champion of ignoring people's pain. First of all, he's supposed to let us do the exams and just supervise. Instead, we follow him around as he looks for patients with "interesting" findings. Then we stood around as he, without any prelude, without bothering to even look at the chart and find out what's wrong and what parts of them might hurt, would pull the patient's robe aside and start aggressively pointing out scars, skin markings, fat, bruises etc. Then he would do the most violent exam I have ever seen, often repeating maneuvers that caused the patient pain to make sure we could all see that the patients abdomen was tender, for example.

The last patient was a senile or delirious older woman in the intensive care unit. She was moaning and yelling in a language that none of us could understand and she kept batting away LDD's hands as he tried to show us her stomach mass. Which isn't surprising since he didn't even say hi, just went over, opened up her robe, pulled down her adult diaper and started prodding her. After about three minutes of wrestling a sick 90 year old so he could show us an "interesting" stomach mass (which he was unable to locate), he stopped and said, with a trace of his one facial expression (it was fleeting, but I do believe I saw it): "the patient is non-compliant so it is impossible to collect any physical findings."

At that point we had a moment of group ESP and even though it was an hour early, we told LDD that we felt we had learned enough for the day. And we left.

So clearly, there are plenty of interesting things for me to dream about. I mean, my professor is an actual zombie! Yet I dream about sharpening pencils and highlighting textbooks.

Makes sense.

An actual earwig:

delightful side note!

So as of the week after next, due to a scheduling problem at the hospital I was supposed to go to in Jerusalem, I will be moving away from my safe and cozy desert hideaway and moving just a tidge closer to, well, Gaza.

Now I've lived there before it's a perfectly nice place to live. There's a beach and a cute little marina and my favorite pizza place "pizzameter," where you do indeed order pizza by the meter. I quickly adapted to the nightly fighter jets and the kazaam rockets and didn't feel all too terribly unsafe, although I was upset when my favorite beach and the water park were both hit within a week (the rocket that hit the water park just narrowly missed the Carlsburg beer factory, so it certainly could have been worse).

Well, our morning lecturer is the owner of the hospital I'll be working at, and he divulged some interesting information. (Oh, how much better life is without knowing too many facts!). Namely, that over 5,000 Kazaam rockets have fallen in that immediate region in the past year. He insists that they're not too much of a risk since they won't hurt you unless they land pretty much on top of your head. Which is true.

However, within the past 6 months a Kenyan bat and a French seagull both managed to poo directly onto the top of my head. So my head is either friggin gigantic, or has acquired its own magnetic field. I sincerely hope that this strange force attracts only exotic animal poo and not umm missiles, but I might invest in a sturdy hat.

Our morning lecture was about the health care system here. Among the interesting points.

1. All doctors are on a set salary. This explains a lot. Because there is no reward, well no financial reward, for quality work. You get paid the same if you take 17 coffee breaks, keep all your patients waiting, and never look up from you desk as if you work nonstop, give each patients your full attention, and spend your breaks researching new treatments. So umm. . . if you're a little tired on a given day (or most days) and you know your paycheck is coming no matter what, which doctor are you going to be?

2. To compound the above problem, there is basically no punishment for malpractice. Unless you literally murder or rape a patient, the most you're likely to get is a 3 - 4 month suspension. While I think it's terrible the way doctors are paralyzed by malpractice fears in America- I do believe doctors should be terrified to misdiagnose , mistreat, or harm their patients. Basically we have this tremendous socialist system where everyone gets healthcare. But with no incentives in place- it's basically mediocre healthcare for everyone. And of course you get self-motivated doctors who do extraordinary work all the time, and I would hope the majority of doctors do care a tremendous amount about their patients and the quality of their care. I'm sure many/most of them do. But it does explain a lot of the laissez-faire-ness that seems pervasive around here.

3. The ministry of health both sets health care standards and pays for those changes to be made. Which means that, for example, the ministry of health decides that every hospital must have functioning sprinkler systems. Then the ministry of health realizes that it is socialized health care and that they are responsible for giving the hospitals the money to install aforementioned sprinklers. Then the ministry of health realizes that will cost 400 million shekels and they can't afford it. So the ministry of health decides that all hospitals do not need to have functioning sprinklers.

Right. So the organization that is supposed to set the standards of health care in this country voluntarily lowers its own standards so that it can afford to meet them.

Confused? Concerned, perhaps? Yeah me too.


Ahhh, middle east. Sometimes I enjoy the contradictions. For example, the only gym /health club in my city has . . . a bar in it. I should clarify. The gym is actually in the bar, you have to walk through the bar to enter the gym. And there are windows so that bar patrons can peek into the spinning studio or weight room as you work out. There is nothing stranger than walking out in my sweaty gym clothes at as the bar is opening and having to squeeze out through a room of smoking, drunk, dressed up people. The fun part is that the DJ will usually come in and spin in the gym for a bit before the bar opens and occasionally they move the gym stuff aside and have actual parties inside the gym. It's special.

But what's amusing and fun and different out in daily life is significantly less funny in the hospital. Well, it's kind of funny, but in a "are you serious?" kind of way. The patients smoking out on the balconies with the nurses with their oxygen and IVs still attached. Or the way the AC rarely works on the wards so you have really sick old people lying in beds next to windows wide open (as though that helps anything when its 120 outside)with dust and smoke and germs from the other wards blowing right on in. Or the way the nurses don't ever seem to know where the patients in their own ward are. Or the way there are cats wandering about the high-risk pregnancy ward. And the hospital is really quite clean and modern and professional and there are just little carelessnesses that drive me crazy.

Of hearts and heartlessness and Henry the happy hand

<---- A heart nebula. Much prettier than the actual thing. Yet unlikely to fit inside my chest and circulate essential nutrients to my tissues. Alas.

Today, as you might have guessed, was cardiology day. Wards were unpleasant as usual. The doctors here have a brusqueness to them which comes off as callousness to me, although I suppose it's their form of professionalism. It makes them excellent teachers because they are more than willing to poke and prod and undress and make completely sure that we have seen every single feature of illness on our patient. But when our patients are these adorable old ladies who can't breathe it just feels cruel.

We had one patient today who started crying in the middle of our exam when we asked her about a scar on her chest. It turned out that she had had a breast removed unnecessarily when her doctors mistook a bruise for cancer. (!) Which is clearly upsetting. One of my classmates asked the doctor in charge if we should maybe cut the examination short since she was upset. The doctor says, without even looking at the woman, "Oh, she suffers from depressive disorder, many patients with chronic diseases do- she's not crying because you're hurting her. Continue." And I'm thinking are you kidding me? She's not depressed, she's sad because she's in the hospital and you've just reminded her in front of a group of 10 students that she only has one breast because of a doctor's oversight. Of course she's upset. And maybe we could show her a little compassion instead of lining up and poking at her scars and then leaving and talking about her.

The next woman also got upset halfway through and asked us to stop. And our doctor told us to keep going. Now it's one thing for us to continue when the patient is a little uncomfortable. It's another thing entirely when a patient explicitly asks us to stop. In my mind, that's it. We're here to learn. But a hospital's main responsibility is to care for patients. If our education is going to harm a patient, the patient comes first. Period. And that didn't exactly happen today.

And again, our physician went from patient to patient to patient without washing her hands. I managed to rally our group and we all made a big show of washing our hands and stethoscopes in between each exam- but the doctor was not inspired to follow suit. I can already tell that I'm going to become that annoying obsessive hand-washer on the wards- but if something that simple can prevent more than 50% of hospital-acquired infections, how dare I not be obsessive about it? I guess as I get busy and tired I'll start forgetting and start caring less- but if I start out psycho about it maybe it'll become a habit and stick.

Perhaps if the hospital tried these posters. . .

So I want to talk about . . .

sacrifice.

Because I realized that starting this magical journey called medical school was going to mean giving some things up.

Sleep, for example. Free time. Decaf.

But it's been so much more than that. Because while you're a medical student, at some point realize you don't have the time or energy to be anything but a medical student. Of course you're still a mother, sister, lover, brother, friend-all those things you inherently are. And inside you might remember that you used to be a whole lot of fun on weekends, or a jazz singer, or a high-school basketball champion- but one by one those hobbies start to take second place to the endless stream of lectures and clinical vignettes and shelf exams and patient interviews and licensing exams and rounds and. . .

whoa. Every few weeks I stop and look around and just wonder where I went to. For the past two years I've spent day after day doing none of the things that I love doing, doing none of the things that I'm great at doing.

And I do this because I suspect that one day in the not-too-distant future I will love my job and I sincerely hope and believe that one day I will be great at it.

But today is one of those days. When I look back at my summer, which was eaten alive by studying for the USMLE, when I look back at the past two weeks when I have done nothing but sit in class, interview and poke at patients (still working on my physical exam skills), and lie on my floor studying. And I know it's temporary, but I just look at myself from my imaginary video camera on the ceiling and see. . . a medical student.

Hmm.

"Please gather around the giant penis"

These were our professor's opening words this afternoon. The penis in question turned out not to be giant after all, but it did have a giant hole in it for catheterization practice.

The rest of the day proved equal parts exciting and uncomfortable. We spent a few squeamish hours practicing IV insertion and blood-drawing on each other. My partner managed not to punch all the way through my vein this year, but it definitely took her a few more pokes than I would have preferred.

We also did more MEGACODE DRILLS!!!!!!!!!!!!!! with "simulation man." Simulation man is the ultimate CPR dummy. He "talks" and "breathes" and you can feel his pulse. The TA couldn't quite figure out how to make him speak coherently, so a typical drill would start out with us entering the room to hear him coughing or making throwing up noises. Then he would say "I'm feeling really bad" or "Go away." Then we would examine him and find out that he was in Vfib, not breathing, and had no pulse (which probably explained why he was feeling really bad).

I managed to make an already uncomfortable day even more special when I attempted to find a femoral pulse down in the crease of Sim man's hip, and realized that he was very anatomically correct. I recognized this when I realized that what I had thought was the edge of Sim man's leg was . . umm. . not his leg at all. The entire rest of the class, of course, knew exactly what body part I was prodding a good three minutes before I did. I actually felt embarrassed for Sim man- I didn't mean to get so personal so fast.

Sim man, I'm very sorry. And I believe I owe you dinner.

"You did some things that were good. . .

I will talk about the things that were not good."

Our professor today? Not the most supportive and loving.

After three days of classroom preparation, and vague attempts at studying, today was megacode drill day.

And wow- it was intensely. . . disturbing. First of all, our "patient" was the oldest CPR dummy I have ever seen. His mouth was cracked at one side so all rescue breaths sort of slipped out his cheek. His legs and arms refused to stay attached to his body.

Then somehow, throughout the day, he became oddly life like. He's the kind of dummy you can shock, and intubate, and pretend to put drugs into, and he reacts accordingly. He "breathes" and "throws up" and he has a heart rhythm that you can pick up with a monitor. So there was a little tension in the room every time we finished a set of CPR or injected a new drug and were waiting to see if it had worked. It started to feel almost real.

And we killed him over and over and over.

I had the honor of killing him by failing to diagnose his hyperkalemia. I was however, the first team leader to get through the entire protocol without having the professor stop us in disgust.

I also managed to intubate properly on my first try. You only have 30 seconds per attempt to squeeze the little plastic tube down the patient's throat, making sure to push it up through the vocal cords into the trachea instead of down into the esophagus. And it's hard. And the dummy makes this terrible cracking sound if you push to hard with the flashlight that means that you've broken his teeth. I did not break any teeth and I just managed to find the vocal cords and get the tube into place on second 29. Talk about tension! And I have a nagging suspicion that actual patients are going to be just a tad more difficult that a CPR dummy.

Tomorrow, we have another 4 hours of Megacode drills and then a whole afternoon of skill stations: chest tube insertion, IV practice (on each other), drawing blood, nasogastric tube placement etc. Last time we practiced IVs, my very nervous partner punched all the way through my vein not once, but several times, and I ended up with a six inch bruise from my bicep to halfway down my forearm.

I should be excited that we're finally finally learning actual skills that we're going to use in the hospital, but it's less exciting, and more overwhelming. Running codes this morning made me all too aware, that within a few years, I will be running actual codes, and that peoples' lives will depend on the decisions I make based on the training I'm getting right now. That's a lot of pressure. And a whole lot of protocols to memorize.

I'm completely exhausted already (it's only been three days!)- but I guess that's a pretty good approximation of how I will feel for the next, oh, rest of my life.

On a creepy side note- here's what we get to play with tomorrow: