What you don't know. . .

The promised article:
Do you know who's been in your vagina recently?


This is a tough one for me.

Because if I dig deep down in my heart and soul, I have no problem, whatsoever, with students practicing exams on unconscious patients. None at all.

It's not something we do here in Israel as far as I know. But, we did learn how to draw blood and insert IVs during our internal medicine rotation, and if we were feeling nervous we were often directed to the intensive care room to practice on the most sedated, senile, and least-likely-to-feel-and/or-respond-unfavorably patients. It makes sense. We're inevitably going to cause pain with our first clumsy attempts to insert needle into vein. Practice on those who aren't going to scream, refuse, or suffer the mental anguish of my 20 minutes of blood-drawing ineptitude. (I was shaking so much the first few times I couldn't unwrap the needle without getting the wrapper stuck to my glove, tearing my glove in the process of removing wrapper, and then knocking something over, such as a lamp or a wandering patient.) It's best to spare patients the mental anguish of an encounter with untrained, terrified, needle-wielding me.

And now, during surgery, I touch people's intestines without consent, I learned how to do stitches yesterday on a real patient without his consent. (Big busy surgeon demonstrated one stitch, handed me the needle, said "do the rest," and left. I couldn't leave the poor guy open!)

But of course I see the other side. I understand patients' wierdness about having a bunch of students up in there. I agree 100% that patients should be informed about everything that is going to happen to them.

A pelvic exam just seem so benign to me. No pain, no lasting damage, really just sticking a light in and looking. Especially compared to leaving a permanent scar on someone with my first-ever stitching attempt, or the trauma of my first attempt to localize the radial artery with yet another shaking needle.

So I would love to obtain every patient's consent for every little thing we do to them in the name of learning. And I would love it if patients would offer up their bodies on the altar of our education. I would love it if they understood that they have found themselves in a teaching hospital and part of the game is to let blossoming little student doctors practice doctor things until one night (May 19th for me) they go to sleep caterpillars, melt into a little puddle of goo, and reemerge as full-fledged MD butterflies.

So this is a tough one for me.

What do you think?

Assorted anecdotes from surgery day 1

This entry brought to you courtesy of "the ex knife set."

No comments. Too tired to comment. Just stories.

First patient of the day. 64ish year old man, hospitalized for renal failure. During his hospital stay, the internal medicine staff began to suspect that he perhaps had some sort of psychiatric issues of an unspecified nature. They ordered a psych consult. Psychiatrist ruled that the patient posed no threat to himself or others and sent him back to the ward. A few hours later, he went missing from his bed. He was found shortly thereafter at the triage desk of the ER complaining of "chest pain." The cause of this chest pain?
A scalpel protruding from his right ventricle. Apparently he wandered into the hallway, grabbed the sharpest object he could find in the ward, and stuck it into his heart.

This prompted one of my favorite student-attending dialogues of all time:

Student: What is the prognosis after being stabbed in the right ventricle?
Doctor: About the same as being stabbed in the left ventricle.
::Walks away::

Patient two 30sish. Admitted due to multiple stab wounds to the . . . guess. .. yup! Right ventricle. The best part of his medical records: "Medical history significant for inspiring multiple homicide attempts." I did not realize until today that people wanting to kill you was a medical condition.

This was in fact, not the first time he had been stabbed in the heart. Handled it like a pro too. He was nearly discharged the day after surgery for stealing cigarettes from the nurses and smoking in his bed. With his oxygen connected and flowing.

The rest of the day was mostly spent taking out staples and sutures in the outpatient clinic. One of the good things about learning medicine in Israel is that there is much less bureaucracy surrounding what medical students can and cannot do. We've been sticking needles, fingers, and catheters in and taking blood, urine, and poo (<--technical medical term) out of patients since we first started on the wards. If the attending is comfortable with us and we're super confident we do just about any procedure we're moved to.

There's something amazing about the fact that the first time I take a scalpel or needle and thread to a person's skin will leave a mark that they'll carry around with them for the rest of their life.

That's inspiration to practice, I suppose. Off I go.



Tomorrow: A short news story and ramble on the ethics of medical education.

Typo of the day

I'm all out of love I'm soooooo looooost without yooouuuu

This post will work much better if you pick your favorite mid 80s lite rock song and sing it over and over in your head while you read.


Two days pre-pediatrics exam. I am sitting in my new favorite study haunt. An often-empty, well-lit cafe with decent to very good coffee depending on the day, the mood of the barrista, and the phase of the moon. They play the same 15 easy listening songs over and over again in a loop. This should bother me but I actually find it oddly comforting. I monitor my time by Take That, Sting, and Elton John. Second "I want you back," Coffee break! "Don't Let the Sun go Down on Me" means it's snack time. "Shape of my heart" generally signals a bathroom trip.



Ahhhh. . . Take that. ::sigh::

Studying pediatrics in a cafe offers a unique challenge. Namely, that much of my studying involves looking at pictures of rashes, birth defects, broken limbs, and genital malformations that I surmise most of this cafe's patrons would not be too delighted to accidentally catch glimpse of as they walk by my table.

I also tend to feel when I'm reading something naughty like I have a big cartoon thought bubble over my head and everyone around can tell I'm looking at something not fit for public consumption.

This results in me awkwardly arranging my book with my cell phone, sugar packets, and other books strategically covering the offending images. Which probably makes me look even more sketchy and just generally unusual.

The couple next to me today, however, erased any fears I may have had about inappropriate cafe behavior. They were in their mid 50s, on some kind of strange awkward adulterous vacation date. The woman was American, here visiting her daughter, the man Israeli. They were speaking English making it of course 100% impossible for me not to eavesdrop.

I suppose they figured that no one else in the cafe understood English because after 30 minutes or so of exchanging pleasantries and basic personal information, they launched into the most graphic, detailed discussion of their sexual likes and dislikes and lack of satisfaction in their marriages. And I mean graphic. And loud. Full voice, like they were talking about coffee or the weather. This included an enlightening 15 minute monologue from the woman about how comforting she finds it to perform oral sex (with vast amounts of detail on exactly how she enjoys performing it) and how disappointing it is that her husband doesn't like to receive.

And here I am carefully examining images of various infants' scrotums (scrota? scroti?) trying to identify the ones with hernias or fluid accumulation. It felt like this tremendously inappropriate moment.

And I'm trying so very hard to turn into a serious professional grown-up who doesn't giggle every time she opens a diaper and discovers that the newborn baby boy she's checking was literally "born ready".
Surprise!













In happy unrelated news- I present you with my favorite medically relevant cartoon of all time, courtesy of Nataliedee.com:


Happy bacteria!

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?