A construction worker came into our primary care clinic complaining of left elbow pain that was worse with activity. Based on his description, the location of his pain, and my exam, I thought it was lateral epicondylitis ("tennis elbow"). I couldn't remember the best physical exam maneuvers for lateral epicondylitis, so I excused myself from the room and opened up my physical examination textbook. The book described a simple maneuver called the "Handshake Test."
I went back in and shook the patient's right hand. Then I asked to shake his left hand. The next moment, he was doubled over in pain.
Diagnosis made. Sometimes it can be that simple.
09 May 2014
07 May 2014
Death by paperwork
A patient was admitted to our hospital service with a large mass that had been growing for months, as well as significant weight loss. When I examined him, it was obvious that he had an aggressive form of cancer. But had it metastasized?
With this particular type of cancer, the prognosis is fairly good if the primary mass is removed and there is no evidence of metastasis. But the prognosis is bleak if the cancer has spread. This patient was lucky, because there was no evidence of spread.
This patient was uninsured, which is why he had put off seeing the doctor for so long. But he was eligible for Medicaid and had never bothered to apply. After getting a tissue sample, we discharged him home, and advised him to get insurance as quickly as possible, so that the surgeons could remove the mass immediately. I figured it would take a few days for the state to process his insurance forms.
I turned out to be dead wrong. Processing the patient's insurance application apparently took months. By the time the patient came back, the mass had grown nearly 20 times bigger, and it had metastasized. His prognosis had gone from optimistic to terrible.
People get sick, and some inevitably die. Yet some die needlessly, and for the stupidest of reasons.
With this particular type of cancer, the prognosis is fairly good if the primary mass is removed and there is no evidence of metastasis. But the prognosis is bleak if the cancer has spread. This patient was lucky, because there was no evidence of spread.
This patient was uninsured, which is why he had put off seeing the doctor for so long. But he was eligible for Medicaid and had never bothered to apply. After getting a tissue sample, we discharged him home, and advised him to get insurance as quickly as possible, so that the surgeons could remove the mass immediately. I figured it would take a few days for the state to process his insurance forms.
I turned out to be dead wrong. Processing the patient's insurance application apparently took months. By the time the patient came back, the mass had grown nearly 20 times bigger, and it had metastasized. His prognosis had gone from optimistic to terrible.
People get sick, and some inevitably die. Yet some die needlessly, and for the stupidest of reasons.
02 May 2014
The siesta method
On the trauma surgery rotation, rounds start early. At 6:00 AM, to be exact (and medical students had best be exact, lest they show up late and incur the attending physician's scorn).
But when I was on the rotation, the workday also ended mercifully early. Often, we finished before noon. Some of the medical students would go home straight away. Others would hang around, studying for the upcoming surgery exam and waiting for trauma cases to roll in. But by the time evening fell, all of the students would have already filtered out of the hospital.
That is, except for me. Almost by accident, I was on a different schedule from my classmates. I have named it "the siesta method," and it is a true winner.
To make sure I had time to see my patients before rounds and prepare my presentations to the wards team, some days I would set my alarm for 3:50 AM. By the end of the workday, I was knackered. Too spent to study or hang around, I would grab lunch and then head straight to the medical student call room to nap. Several hours later, I would wake up to find that nightfall had descended. I would groggily grab dinner and shuffle to a classroom where I could study for my upcoming surgery exam.
Sometimes, though, the wail of an ambulance or the distant chop of a helicopter would shatter the nighttime silence. A trauma case! Trauma cases excited me much more than studying. I would sprint to the emergency room to see what new case had been brought in. Indeed, most trauma cases come in at night, in large part because night is when people most commonly consume alcohol.
During the day, as many as six medical students would arrive at a trauma case. But at night, I was the only medical student there. I got to stand near the patient and even participate in the resuscitation efforts. The residents took notice. They were impressed that a medical student had decided to stay so late, when they could be at home. I got a reputation as "that med student who's always here." The attendings noticed as well. They encouraged me to "scrub in" to (i.e. participate in) their surgeries. "We've never seen a medical student here this late," one explained. "We really appreciate it, because it gives us more opportunities to teach."
Some nights were quiet. On these nights, I would go home and catch up on sleep until my 3:50 AM alarm. Other nights, when the trauma bay was buzzing, I would stay up all night, enjoying a ring-side view of the fascinating cases that came in.
By sleeping twice a day, I ensured I was getting sufficient sleep. If I pulled an all-nighter, I would simply sleep for longer the following afternoon.
Eventually I finished the trauma rotation, and went back to sleeping only once a day, at night. But I miss the excitement of the trauma cases, and look back fondly on my siesta system. It ended up being a fantastic way to learn surgery.
But when I was on the rotation, the workday also ended mercifully early. Often, we finished before noon. Some of the medical students would go home straight away. Others would hang around, studying for the upcoming surgery exam and waiting for trauma cases to roll in. But by the time evening fell, all of the students would have already filtered out of the hospital.
That is, except for me. Almost by accident, I was on a different schedule from my classmates. I have named it "the siesta method," and it is a true winner.
To make sure I had time to see my patients before rounds and prepare my presentations to the wards team, some days I would set my alarm for 3:50 AM. By the end of the workday, I was knackered. Too spent to study or hang around, I would grab lunch and then head straight to the medical student call room to nap. Several hours later, I would wake up to find that nightfall had descended. I would groggily grab dinner and shuffle to a classroom where I could study for my upcoming surgery exam.
Sometimes, though, the wail of an ambulance or the distant chop of a helicopter would shatter the nighttime silence. A trauma case! Trauma cases excited me much more than studying. I would sprint to the emergency room to see what new case had been brought in. Indeed, most trauma cases come in at night, in large part because night is when people most commonly consume alcohol.
During the day, as many as six medical students would arrive at a trauma case. But at night, I was the only medical student there. I got to stand near the patient and even participate in the resuscitation efforts. The residents took notice. They were impressed that a medical student had decided to stay so late, when they could be at home. I got a reputation as "that med student who's always here." The attendings noticed as well. They encouraged me to "scrub in" to (i.e. participate in) their surgeries. "We've never seen a medical student here this late," one explained. "We really appreciate it, because it gives us more opportunities to teach."
Some nights were quiet. On these nights, I would go home and catch up on sleep until my 3:50 AM alarm. Other nights, when the trauma bay was buzzing, I would stay up all night, enjoying a ring-side view of the fascinating cases that came in.
By sleeping twice a day, I ensured I was getting sufficient sleep. If I pulled an all-nighter, I would simply sleep for longer the following afternoon.
Eventually I finished the trauma rotation, and went back to sleeping only once a day, at night. But I miss the excitement of the trauma cases, and look back fondly on my siesta system. It ended up being a fantastic way to learn surgery.
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