Friday, September 5, 2014

Caitlin's in...residency??

Okay.

As a friend recently pointed out (hi Amanda!) the title of my blog is now wildly inaccurate. I am no longer in medical school. I have closed the door on that part of my life and am pretty securely settled into the three years that will be known as my residency years.

The last few months of medical school were kind of a blur. We were looking for a new apartment and packing for that move, planning a rapid-fire Europe trip, making graduation plans, and actually finishing my last few rotations.

Cardiology: The heart! So cool. Amazing organ. I got to see an ablation for atrial fibrillation which was super cool in the first 45 minutes and then interesting in concept, but super boring in execution for the next 4 hours. Over all in the rotation, what did I learn? Lots of medications and treatment plans, of course, but then also a general piece of advice from the cardiologist to a future family doctor: don't send someone to a cardiologist unless you want them to get a full cardiologist work-up.This sounds silly, but you'd be surprised with how many primary care physicians aren't really sure what will happen when they send their patients to a specialist. They're not just going to double check all the meds you have them on and send them out the door. They're going to get an EKG, an echocardiogram, a stress test if necessary and then completely change up the medication regimen you started the patient on. That's okay! They're the specialists, they know what they're doing - you should just be ready for that and warn your patients about it.

Neurology: A short rotation. Two weeks with a couple of neurologists, mostly seeing patients with MS (multiple sclerosis). Now there's an unfair disease. Unknown underlying cause, but a relatively simple disease process (the insulating covers over nerves in the brain and spinal cord are slowly destroyed causing nerve communication problems) that leads to an insanely wide range of symptoms. One patient has some balance issues and feels more steady using a cane when walking outside. The next patient is severely disabled and in a wheelchair. No cure, but some exciting new drugs being worked on. One notable patient rolled in one day on a segway! It's his normal, everyday mode of transportation. He uses the term "Stand-up Wheelchair" to be allowed into more places that usually wouldn't let a segway.

Trauma ICU: Crazy last rotation to have. Long hours, lots of insane traumas. Mostly broken heads and broken bones. No one in my family please ever ride motorcycles, okay? One guy with at least one bone broken in literally all 4 of his limbs. I got to set a severely displaced tibia fracture (lower leg bone) one day and got pretty good at doing a quick, emergency room level assessment for major and minor trauma when a person first comes in unconscious. I'm really fast at cutting people's pants off - probably my most valuable contribution as a med student. One of my favorite patients was a gentleman with healing head trauma who was always a day or two ahead of where we thought he was. By this I mean that he kept pulling things out of himself before we could decide to do it for him. He "extubated" himself (pulled his own breathing tube out), pulled out his IVs multiple times, pulled his own urinary catheter out, and (my personal favorite) pulled out the wires that were going through his skull to his brain, monitoring his intracranial pressure. Luckily, the neurosugeon was cool with that one - "Well, I guess we don't need to be monitoring his pressures anymore, do we?"

I had a week and half off after my last block and then it was down to Arizona for graduation!



Proof:

We took pictures under this sign with every possible permutation of supporters

(in order) Dr., Dr., Mr. and Mrs. Karplus

My mom made this! Amazingly accurate portrayal.

This guy, though. Couldn't have done it without him.

So, the empty diploma holder looked and felt exactly like a relay baton
An impromptu support-whiteboard created at my impromptu graduation party. How could I have NOT succeeded with these awesome folks behind  me?



Friday, April 25, 2014

Emergency Medicine Ahoy!


Here's a theory I developed during my ER rotation. The emergency room and emergency medicine is the exact opposite of surgery.

When the surgeon walks in and sees the patient, they (the patient) are completely draped except for the surgical site, rendering them totally antonymous to the doctor. They are as pristine clean as a person can be made (at least at the surgical site). They are anesthetized and silent. They operating room is run very efficiently and we know as much as possible about the problem before the surgeon starts his work. The surgeon is able to walk out at the end of a procedure with a pretty good idea about what was going on and that he was able to help fix it (ideally). They have very little freedom with their schedule. The surgery starts at a certain time, but after that it takes as long as it takes.

In contrast, the patients in the ER are dirty, close, loud, and personal. They are very talkative and often give you much more information than you need. They come with multiple family members, with varying levels of helpfulness. They come straight in from the outside world, often in bad shape. There is dirt and blood and smells. Nothing is sterile, even after you sterilize something. Things move quickly sometimes, but drag other times, taking hours for a lab report, far from efficient. When an ER doctor signs off a patient to either the hospitalist or to go home, they often are as similarly perplexed about the patient's condition as when they walked in. They kind of have to just deal with this uncertainty every day. However, when their shift is over for the day, they get to go home, trusting the care of the patients to their colleagues. 

Nothing extremely profound here, just something I would muse about during my shifts. 

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I really loved my ER rotation. I suspected this might be the case before even starting because I enjoyed the ER/urgent care side of things when I was up in Alaska. I'm good at multi-tasking, I like having a set shift, and I like doing procedures.
Here's a fun what-if scenario: I think I would really enjoy working in an ER for about 5 years and then would get super burned out. I would start to hate the uncertainty of my job (how many patients will I have tonight?). I would slowly grow extremely jaded about people (everyone is a stinking, lying, drug-seeker). I would come to resent my colleagues (of course the cardiologist won't come down and see this patient having a heart attack). I saw all these attitudes (and more!) in some of the ER docs I worked with. Mostly these were on bad days and at the ends of long shifts, but it definitely made me think that the rush and excitement of this job wears off after awhile.

I think one reason some ER docs might not like their job as much after awhile is because they do very little emergency medicine. Here's a concept: ER vs. Urgent Care vs. Primary Care. ER stands for Emergency Room. I never heard anyone define it, but to me an emergency means if you are not here, being taken care of right now you will die or be permanently damaged in the very near future. Or there's enough of a chance that this could happen that we need to do a complete workup just in case. Examples: major trauma, heart attack, stroke. Urgent care is the next step down. You do, in fact, need to be cared for urgently, but death is not looming in the room waiting to take you down. Examples: arm laceration needing stitches, chest pain that isn't a heart attack, fever and vomiting in a baby. Finally, we have primary care issues. These are things that, yes, you need to have taken care of, but in no kind of an urgent or emergent timeline. It would be perfectly fine if you stayed home and came into a doctor's office with an appointment in the near future. Examples: dizziness, mild abdominal pain, or cough in an otherwise healthy person.
Mostly, I saw patients in an urgent care situation. Of the 15-20 patients I saw per night, maybe two per shift on average were true emergencies and about five had primary care issues. I liked this set-up just fine: the real emergencies were scary and moved much too fast for me to keep up and the primary care visits were nice boring breaks in the shift. The urgent care visits were where I got to do the most: putting in stitches, setting dislocations, reading EKGs and chest x-rays, etc.
Notably, my ER rotation was the best so far for stories. Every day coming home I would have another awesome story to tell Tim (all while maintaining strict patient confidentiality, of course).
Here are a couple of quick ones:
  • A lady who called the emergency hotline about her schizophrenic delusions. The operator, used to taking calls about actual emergencies handled her very well. She validated the patient's concerns about her roommates talking about her behind her back, "even when they aren't around I can still hear them talking and I think they all are connected to the Asian man that brainwashed me 30 years ago down in California who I'm pretty sure followed me up here" etc, etc. and convinced her to go the ER where they could maybe help her with her roommate issue. 
  • A pleasant, but stubborn intoxicated young man who refused to tell us what happened to him. He was covered in scrapes and bruises with a cut on the back of his head. All he wanted was some staples in his head and to go home. Because we couldn't rule out internal injuries based on his (non-existent) story and his denial of pain, we had to do a complete work-up with head-to-toe imaging of his head, neck, spine, chest, abdomen, and pelvis. Of course, he ended up having nothing wrong with him. 
  • I got to put most of 40 stitches put in a young man's arm covered with lacerations. He had accidentally put it through a window while running through the school gym in the dark trying to beat the lights' motion sensor. 
  • A complicated situation that needed some sort of chart to keep straight: There are patients in two separate rooms: room A held a mildly beat up guy. Room B held a severely beat up guy. Both were mildly intoxicated. Before coming to the ER, room B had been harassing room A (mildly beat up). Room A called the cops. Room B pulled a gun on the cops (severely beat up). 


Pop quiz: what is the most commonly missed injury in the ER?


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Answer: the second injury. 

Classic med school/residency question and it totally happened to me! We were focused a bunch on this patient's very obviously dislocated ankle. It was really impressive looking and I got to set it and splint it. It took a while, we had to do it more than once and it wasn't until awhile later that we learned he also had a dislocated hip! The "leg pain" he was complaining of we kept attributing to us messing with his ankle so much and didn't check it out until he kept complaining of it after the ankle was set. Don't tell anyone, but it turns out doctors are, in fact, human.


Stay tuned for a cardiology post including very professionally drawn homemade diagrams of the heart!

Sunday, March 2, 2014

The Big Reveal...

Most of you have already heard the news, but here it is! The biggest moment in a medical student's career! Residency match day!

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(are you ready?)

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(are you at the edge of your seat?)

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(are you, in fact, a family member or friend who already knows the news because it happened almost a month ago and those are the only people who read my blog?)

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Okay, enough of that: we're staying in Portland! I got my first choice, the Wright Center Family Medicine Residency Program based here in Portland. We use two of the hospitals in town and a clinic a little out of town in Hillsboro. The program is interesting - the Wright Center is based out of Pennsylvania, but they have a national (as well as a regional) residency program that has several branches all over the country, including in Portland. Sound familiar? It's actually a residency program that's partnered with and somewhat based on my school's system of a central program with multiple satellite campuses.

I think it'll be great. Here's what I like:

  • D.O. program
  • Family medicine program, unopposed
  • Small, community-based program with people who are super excited about serving under-served communities
  • Uses a FQCHC for a continuity clinic
  • In Portland! Close to family, Tim gets to keep up his music career here, we can finally get around to seeing a Timber's game
  • Awesome program directors, clinic faculty, and current residents. It was probably my second favorite interview of the 10 I ended up doing and definitely the most casual and comfortable. 
  • Partners with a big, fancy residency program in the hospitals for our hospital rotations. We get the resources of the large program and fantastic hospitals without having to be a part of the huge, impersonal system. I already sound like I'm on the marketing team for the program, don't I?
Here's what I don't love:
  • How tiny the resident class is. There are only two current first-year residents (will become 2nd years when I start) and then me and another future intern.
  • The drive to Hillsboro. Once a week (in my intern year) I'll be driving out to Hillsboro for clinic (20-30 minute drive, much worse with traffic).
  • The extended orientation. We'll have to have orientation for the overall program in Pennsylvania and then for the local hospitals here in Portland. We're planning a trip to England and Denmark (!!!) in between graduation and starting work that has been cut a little short by my orientation dates. Is that just the most "white people problems" you've ever heard? Oh, our trip to Europe is only going to get to be 9 days instead of 2-3 weeks!
Overall, the pros far outweigh the cons and we're both totally happy with the choice and excited about the future! Next comes contract-signing, finishing up my last few 4th-year rotations, moving a few miles south, graduation, vacation, orientation, then the start of intern year!

I might need to change the name of my blog soon. 


Thursday, January 30, 2014

Happy New Year! (it still counts since it's still January)

The last semester of medical school is upon us!

Semesters mean very little in the last 2 years of med school since we just have these month long rotations all year, but still. It's the last one!

I completely missed Thanksgiving and Christmas and New Year's out here in the blog-o-sphere (rest assured I did not miss them in the real world), so here is a picture recap of the holiday season. It was pretty much wonderful and filled with family and fun and food and a couple more last interviews.

These pictures are in the wrong order, but it's possible I don't really care. Here's a quick guide: we spent Thanksgiving with Tim's family in the bay area (those pictures are in the middle), Christmas with my family in Philomath (those pictures are at the start) and then New Years back in California (those are at the end).

Collecting holly for above the doors and windows

Cora and Nana being entertained by our resident guitar hero

The traditional Christmas sky lanterns!

Hard at work on the Thanksgiving feast

Turkey baby! (The baby did not, in fact, actually get any turkey)

Our gingerbread houses!

Kayaking in discovery bay! 

Love these girls (and the baby)!

We built a bridge! Did we miss our calling in civil engineering?? Um, no. I don't think we did. 



The whole Thanksgiving crew

Tim is Vulcan and I have only one leg. 
The Krazy Karplus New Year's Theme Dinner! The theme this year was "Oceans". These are the Polynesians coming over to Hawaii on their canoes. On the right you can spy a sea monster.


A very appreciative audience


New Year's also included this little munchkin's 3rd birthday.

Tuesday, November 19, 2013

Welcome Home! Your car window is now smashed.

You know what's a really bad idea? Getting your car broken into and having just So Much stuff stolen while you're in the middle of the stress of residency interviewing/planning/traveling.

Bad idea.

Don't worry (any of you that were). Everything's okay and most of the important things are replaced. In fact, I'm currently typing this blog post on my fancy-pants new laptop. Spoiler alert: Windows 8 isn't as bad as people say.

What have I been up to other than getting my stuff stolen? Well, like we talked about a couple of posts ago, we're in the middle of residency search season. I've been doing audition rotations, interviews, and making long lists of program attributes that I'm trying to compare.

Here are some things I look at when I'm considering a program (they are in no particular order):
  • Location
  • Opportunities for Tim's life (music, teaching, grad school, etc.)
  • Allopathic (MD world) vs. Osteopathic (DO world) vs. combined 
  • Age of program
  • Number of residents per year
  • Number of preceptors working with residents
  • Hospital-based vs. community-based
  • Travel required (clinics and hospitals in one town or spread across the state)
  • Curriculum
    • how much in-patient vs out-patient
    • how many days per week in the continuity clinic
    • how much OMM training
    • how they incorporate mental health training
    • what electives are available
    • who sets up the curriculum and how much input the residents have
  • How close the residents are with each other
  • How the residents feel about the program
  • How "family friendly" is the program 
  • Hospital affiliations
    • are there other residency programs using that hospital (we call it opposed vs. unopposed)?
    • are there any fellows in those hospitals (this generally means less one-on-one time with the attendings)?
    • are we working with the same preceptors in the hospital and clinic?
  • How easy was the interview process (contacting folks, driving up, parking, etc.)
  • General vibe from interview day (this sounds silly, but it is pretty much how I decided what medical school to go to...)
  • Length of orientation in June/July
  • Amount of night call
  • How the clinic folks feel about the residents and/or treat the interviewees on our tours
A lot of things are the same from program to program. There are, of course, requirements that all programs have to meet in order to stay in business. However, as you can see from my far from exhaustive list, there are plenty of factors that can differ and what might be a major deal-breaker for me might be just what another candidate is looking for. 

In other words, it turns out there isn't a perfect residency program and my final "rank list" is going to take me a heck of a long time to perfect.

I've had 5 interviews so far, all in Washington and Oregon. I have 5 more scheduled. Some days I think this is way too many for someone going into a super non-competitive field like family medicine, but other days I imagine not matching on that big day in February and I stop myself from canceling any interviews. 

I originally had four audition rotations scheduled. After two of them (and two months away from home) I decided that four was probably too many so I scrambled to get a Portland elective rotation in the place of one. It was a little tricky, but I managed to get a pretty awesome rotation in "community mental health". That's what I'm doing now. It's kind of perfect for during interview season. It's challenging, but I get to be home by 5pm most days and they have no problem with me taking a day off here and there for an interview.

Besides just being convenient, however, the experience in this rotation is going to seriously come in handy in the future. Do you know what primary care is full of? People with mental health problems. Do you know where resources are severely limited and where primary care docs have to take up a lot of the slack? Mental health services. Do you know where lots of primary care docs are terrified of making any medication/therapy decisions? You get one guess and it rhymes with "schmental schmealth". Obviously, this is not a great setup. I'm hoping to not be one of those terrified family doctors in the future who refers their depressed and anxious patients with a history of substance abuse even when they know it will take months for them to see anyone. 

A drug rep came to the office one day and set up this thing where you could "experience what a psychotic break is really like". Okay, so it wasn't as immersive and crazy-disturbing as the rep described it being, but it was still pretty interesting and not a bad way to start to get a feeling for what it might be like living with schizophrenia.

Here's a similar video. It's not the same one I saw, but I think it's made by the same company and meant to be educational:

Tuesday, October 1, 2013

Just so you know...



...this post is going to be a little bit about poop

I’m just warning you.

The thing is, poop is a part of life. We don’t talk about it much and that’s Totally Okay. I’m fine with not talking about poop in my everyday life. However, the doctor’s office is the place where we can talk about all those things that make us super uncomfortable. It’s this sort of social contract that we all agree to when we go to a doctor’s office: Patients promise to be honest about things that they might normally lie about to a stranger and doctors promise to be professional and compassionate and not make the patient feel funny about talking about super personal stuff.

Incidentally, this social contract gets broken from both sides all the time. 

Just saying.

Ideally, however, we should be able to talk about anything in a doctor’s office, including poop.

This brings me to my rotation following ICU: Pediatric Gastroenterology. Working with kids is super fun; working with parents is not always great. Overall, though, the rotation was good and I learned a lot about both simple and complicated problems in kids’ GI tracts.

The complicated problems were very interesting to learn about, but to be perfectly honest, I didn’t try to become an expert about them. As a primary care doctor, when I know my patient has a super complicated disease, I’m going to depending on the specialists to know their stuff and take care of my patients.

The vast majority of patients I saw in this (very specialized) specialist’s office, however, were very simple cases that could have been taken care of by their PCP. Have you ever heard of a “functional” disorder? I saw a lot of this: functional abdominal pain, functional constipation, functional dyspepsia, etc. This basically means that nothing is anatomically or physiologically wrong with you, but something else isn’t quite right. It’s a fine line you walk with patients (and parents): you don’t want them walking away thinking we’re saying “nothing’s wrong, it’s all in your head”, but you want to reassure them that there’s no big scary disease process happening.

Let’s look at functional abdominal pain as an example. The GI tract has a separate nervous system than the rest of your body. It's called the enteric nervous system and it moves and writhes your intestines around getting the food down through your insides. There are connections between these two systems so that your brain know when you’re hungry, full, gassy, etc. Sometimes, however, these connections get a little revved up and normal movement from your stomach or intestines sends signals up that your brain interprets as “pain”. Ta da! Functional abdominal pain.

Another intriguing problem is functional constipation. Imagine you’re a little kid who is still figuring out most everything about the world and your body. You’ve started using the toilet and boy are mom and dad excited about that. Maybe one day however, because you ate too much cheese or too many bananas, it hurts a little to go poop. You do not like this. Maybe it happens once more - you really don’t like it and decide that you’re done. No more pooping for you. You hold it for a few days and then when you finally go, it REALLY hurts. This pattern continues for a while until your parents take you to a specialist convinced that there’s something terribly wrong with your insides that are keeping you from pooping and making it really painful. Nope! Just functional constipation. I seriously heard this story and this conversation dozens of times. It might take a little while, but it really will get better with enough days of regular stool softeners and scheduled bathroom visits. No, your kid does not need a colonoscopy, promise. 

When you think about it, pooping is kind of a complicated process and it’s amazing that a little kid that can’t even talk right can learn to do it. You have to simultaneously tighten some muscles while relaxing others. You also have to get the timing right and figure out how to communicate when you need to go. It’s completely understandable for them to have problems sometimes. Also, because it’s become routine for us grownups, it’s understandable for a parent to freak out a little when their kid seems to have something wrong with them. I’m perfectly happy to reassure parents about kid-pooping-problems for many years to come as a family doc. 

Okay, I'm done with the bathroom talk! You may now get on with the rest of your life.

Wednesday, September 18, 2013

ICU was over a month ago

ICU was interesting for several reasons. First of all, the illnesses are much more acute and the medicine is very cool and intense (hence the name of the unit). By definition, the sickest patients are in the ICU and (in my opinion) the doctors are the best of the best. They have to know the most, be the most up-to-date about the widest range of the most acute patients, illnesses, and treatments. The only further step I think you could take would be Pediatric ICU where all those things are true, but then the physiology is all crazy compared to adults and everyone is way more sad and scared because oh my gosh kids are sick. Basically I'm saying that I was impressed everyday by the ICU doctors (and nurses). They're just simply the best that I've met.
 
The other cool thing about my ICU rotation was that it was at a teaching hospital. I'll take a second here to define some terms:
 
Medical student: me and my peeps. We come in the 3rd year and 4th year varieties.

Intern: your first year of residency. You just graduated from medical school and the concept that you're a real doctor hasn't quite sunk in yet. TV reference: first season of Grey's Anatomy.
 
Resident: years 2 through whatever of residency. Skills, knowledge, confidence, cynicism, jadedness, and more are gained as you move from R2 to R3 to R4 and beyond. TV reference: the rest of Grey's Anatomy. Also, all of Scrubs.

Fellow: kind of like a specialty resident. They've finished their residency in something general (Internal Medicine, Pediatrics, Family Medicine, etc) and now are back to do more training in something more specialized (Intensive care, Pediatric Cardiology, Geriatrics, etc.). TV reference: House (all the doctors working under Dr. House)
 
Attending: the "attending physician" is the doctor (usually with many years of experience, but it's possible for them to be just out of residency) that is officially in charge of everyone. It's their name on the chart and their license on the line. Yes, the residents have THEIR patients that they are totally responsible for, but we're all officially overseen by an attending. 
 
Rounds: this is when the team (students, residents, fellows, attendings) walk from room to room and discuss the patients of the day. One person (student or resident) "presents" the patient ("Mr. Smith is a 35 year old male here with pancreatitis" etc, etc.) and then the attending guides the assessment and plan for the day.
 
My medical school is kind of non-traditional in the sense that we're not connected to a teaching hospital or residency program. Most of my rotations have been at community clinics and hospitals where I'm working directly with the attending, no residents involved. 
 
There are definite advantages to this (no competing for procedures or the attending doc's attention, usually a more chill atmosphere, smaller and more navigable hospitals), but you lose something here too. The first time we were on rounds and the attending took 20 minutes to give a little mini-lecture on ventilators, I was totally thrown off. Don't we need to get going on rounds? He's got way more important things to do than this, doesn't he? Nope, he doesn't. This is a teaching hospital. His role is to teach us, not just to see patients and allow us to trail after him as he does his "real job". I quickly learned to love this open, questions-welcomed, teaching atmosphere. It makes me excited for residency.
 
For some reason I used to be super intimidated by residents. There was something about being so close to where I was (we're only a year or two apart), but also being so far ahead that was very daunting. Not only did they know more than me about medicine, but they also knew more about where they were going in their lives and how to navigate the big scary hospital system. I am very overwhelmed by hospitals when they're new and (of course) a resident always knows where to find stuff, what the cafeteria hours are, and where the attending hangs out.  
 
Working with them for a month, however, fixed that. It turns out that (most) resdients are just super nice people who are really smart, happy to help students, and not afraid to ask questions and let the attending know when they don't know what they're doing. 
 
I also got to work with about 3 interns and 5 residents throughout the month and am starting to get an idea about what kind of intern and resident I want to be someday. Although overall my experience with them was great, they were not all equal in their skills, knowledge, willingness to teach, willingness to admit when they're wrong, ability to ask for help, speed with picking new things up, enthusiasm, cheerfulness in the early morning, etc.
 
I got to do one major procedure in the ICU: putting in an arterial line. This is like an IV, except it goes into an arterial rather than a venous vessel. A-lines almost always go into the radial pulse: the one on your wrist right below your thumb. These are put in for a couple of reasons. First, you can get a much more accurate blood pressure with a little catheter line right in an artery rather than depending on an arm cuff. If we're concerned about someone's blood pressure and there's a reason to believe the cuff measurements aren't accurate, we use an A-line. Second, an A-line is useful if you're needing to get frequent samples of arterial blood (the usual blood draws from IVs are venous blood). We do "blood gases" (measurements of the pH, C02, and 02 levels in the blood) from arterial blood and it's nice to have a line in to draw from rather than sticking them all the time if you're getting multiple in a day. It was quite exciting. I got it on the "first stick" without even having to use an ultrasound for guidance. Yay, procedures!
 
Here's a pretty good YouTube video with a fuller explanation: