Category Archives: Medicine

Passing Time

It never feels like that much time has passed between posts..and then I look at the date. Despite being on a “year off,” times seems to pass by extremely quickly.  I suppose that is what happens when every weekend is excellent. A few months ago, I spent an awesome, sleep-less 3 days in NYC with some good friends from California. Not only did I spend time with amazing people, I also spent the weekend doing touristy things intermixed with things that could only happen in NYC.

While we were there, we had the opportunity to tour Donna Karan’s Urban Zen Foundation (THANKS DHRUMIL!). As I understand it, the Urban Zen Foundation is inspired by Donna Karan’s husband Stephen and his battle with lung cancer. Having first hand experience with patient care, Donna focuses on the fusion of western and eastern medicine. While we were touring the center, the foundation was hosting a large training session for yoga instructors involved in patient care. Because of Dhrumil’s natural charms, we had the opportunity to sit down with Rabbi  Stephen Robbins, a kabbalist and psychologist.

Sitting down with him, he recounted numerous encounters with patients dealing with emotional and psychological barriers. While medical school makes me very skeptical of non-traditional, little researched forms of “medicine,” I do believe attitude and mood play a significant role in patient outcomes. After all, we are often told about the importance of hope and having the will to live.

The half hour to forty-five minutes we spent with the Rabbi were incredibly interesting. While I am still skeptical at his ability to improve outcomes for concrete diseases with a known pathophysiology, I do see how his work could benefit people whose state of mind affects their disease. On my psychiatry rotation, it was pretty clear that there was a fine line between sane and crazy. In many cases, there was some significant trauma or a sustained external factor that would often push an individual in one direction versus another. As one of my preceptors would say, “we all have the potential for crazy, we just need the push.”

If I had one patient that I could send to the Rabbi for treatment, I would have to pick a patient that was on my service on medicine. Having to switch to a new team in the middle of a rotation was always difficult. New attending, new residents, new interns and new patients with their own set of problems. This particular patient on our service stuck out…in a good way. He was incredibly nice. He was understanding of delays. And, he was constantly showering our team with unnecessary praise.  As a recovering addict, he had been on long-term methadone treatment. He was admitted for palpitations and EKG changes that were side effects of his treatment. Our plan for him was to wean him off Methadone and switch him to another form of treatment. On his last day in the hospital, he thanked our entire team for our hard work. He even left with the name and business contact information for the intern taking care of him, vowing to return to clinic to see her.

A few days later, while rounding, we saw him again. He was in a hospital gown being followed by a nurse.  As he walked by us, he started at us as if he had never seen us before. It was almost eerie to see the lack of recognition in his eyes. While we wondered why he wasn’t bounced back to our team for treatment, an interesting story  emerged. He had been taken to the emergency room after dunking his head into a fish tank in an Asian restaurant and spitting water at the diners. Upon arriving at the hospital, he was admitted under a different name….one that was in the system….one that he had used in the past. He had no recollection of his previous hospital stay or even the person he was just a few days earlier. After several attempts to escape the 6th floor through a small open window, he was transferred to a psychiatric hospital.

It’s one thing to hear about “Multiple Personality Disorder” aka Dissociative Identity Disorder (DID) but another thing to meet someone who has it. To have no recollection of an alternate life you have created for yourself is really an amazing and scary thing. Genetic predisposition aside, I’ve often wondered how jarring the inciting event would have to be to result in the development of multiple personas.  Considering that DID is thought to be caused by physical/sexual abuse during childhood, it’s no surprise that this disorder predominately occurs in women. As you can imagine, therapy is critical in merging the different “alters” that are created to process the trauma.

So while I don’t ALWAYS see a place for “eastern medicine” in daily practice, meeting patients like this one is a reminder that western medicine doesn’t always offer concrete solutions for the complete spectrum of human disease. In many cases, alternative treatment strategies can complement traditional western medicine in providing patient care. Perhaps there is a greater place for those lessons in medicine that have been passed down from generation to generation (hardar nu dood anyone?).

On a side note, I’ve become obsessed with this song. Hope you enjoy it as well!

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Backlog

Its funny to know who read this blog.  I guess this has always been my secret passion – writing.  While I love that YOU are reading this, I find this blog is more for me. Really, just a log of all the crazy experiences that I hope to remember when I am old and gray and still some sort of doctor.  But still, you secret reader you, I appreciate it.

The last few months have been so busy that I have a backlog of all these patients that I need to write about.  Bear with me – I’m on surgery now and sadly have little free time. When I am on Vacation Rotation aka Radiology, I’ll have time to catch up.

One of the best things that happened during my medicine block was the new team that I got at the end of my month at the VA.  The team I started with was amazing and my resident at the time is still the best resident I have had thus far, but as a team, my last one at the VA was the best.  We picked up one new resident (K), one Brigham intern (S) and one BU intern (W).  We also picked up another medical student from Harvard (D).  I’ll leave D out of my stories since we seemed to work independently of each other.  It was during this part of the rotation that I was really challenged to be a better student and more importantly a better future doctor.  After I was done with my short time with them, I was ready to treat patients on my own.

One of my triumphs of my medicine block was a result of all the time the team had invested in me.  Mr. R walked in the ED with complaints of back pain.  On a whim, a chest xray was ordered which showed multiple pulmonary nodules.  Since very few things present at multiple pulmonary nodules, it was known to all – Mr. R had lung cancer.  As he made his way to our team, he came with a battery of tests.  He had a CT scan that confirmed that the nodules were well-circumscribed.  It also showed that he had 1 metastasis to the bone – the likely cause of this back pain.

It was my last day on the service and I had one appointment: to pick up Ronak at the airport by 11 PM.  At 8 PM, I started talking to Mr. R.  The first thing that struck me was how incredibly nice Mr. R was.  He was the ideal med student patient.  He answered all my questions in full the first time around.  Within 10 minutes I had his full story – the back pain had started after lifting a heavy machinery into the back of his truck.  After talking to Mr. R for a half hour to iron out his story, past medical history, ect., I started the physical exam.  He was grossly normal until I hit the neurologic exam.  I started with the head which was normal.  Then, the arms and trunk which were also normal.  I moved onto the legs.  Everything was normal once again.  Remembering that I should be thorough when there is question of nervous system involvement, I started on a better neuro exam (including those things that we normally skip).

I had gotten through most of the exam when it was time to test Mr. R’s response to sharp and dull.  Mr. R did well – he did better than well, he was great.  Well great, except for the defecits on the later part of both his legs.  To me, there was something wrong – he answered correctly maybe 60% of the time.  While that can be normal in some patients – what whas thowing me off was how quick he was to answer normally, but in this particular region of the body, he deliberated for several seconds.  I finished the exam and went to report the results to the intern.

As I walked away, I thought that maybe I was mistaken…I should probably repeat that portion of the exam.  I went back in the room 2 more times with various tool.  Each time, Mr. R was trying so hard to give me the right answers.  I couldn’t tell if it was because he wanted to be as helpful as possible or if it was because he knew that his problem might be bigger than just lung cancer.  After another half hour – I called the intern.  I was instructed to but in a STAT MRI and to call neurology to repeat the exam.  The neurologist came back to us to report that the exam was normal.

There was a predicament – was I right or was the neurologist…did we need to make a move on what might be acute cord compression?  I went back in with S.  He noticed what I noticed – Mr. R was trying really hard to give us the right answers when it came to that one region of the body.

We went for it – Mr. R was in MRI when I called the BU radiologists to give them the story.  At 1 AM, I got my read – there were multiple spinal cord lesions but there was one specifically in the part of the spinal cord that distributed to the lateral legs.  Mr. R was started on steroids that night.

From what I heard after I left, Mr. R was doing well and was discharged from the hospital.  His legs “felt more alive” when he started the steroids.

I think that is another point for me.


Dirty White Coat

So we had to write a reflection for our clerkship – I figured I’d post it here:

As third year medical students we are often told that when we hit the wards, we will know the most about the basic sciences – that will be our niche. While our first two years of education prepare us for discussions of various diseases and syndromes, we are provided with little idea of how to diagnose and treat these diseases. The majority of us can easily regurgitate the content of our First Aid books, but we are lost when it comes to deciding what test to order or which medications are most appropriate. What becomes painfully obvious on the first day is that we are the conspicuous bottom feeders of physician food chain, most easily identified by our one defining feature – a pristine, short white coat.

At the beginning of my medicine rotation, my first rotation of the year, I had no idea what to expect. Would I like my teams? Would I be a terrible medical student? Would I fail out of medical school? Would I learn something? Anything? After only a few days of being “on the job,” all of my fears disappeared. I loved my team. I was not a terrible medical student. I probably would not fail out of medical school, (but maybe I spoke too soon). Most importantly, I learned a lot – not from my typical teachers, the attending, resident and interns, but from the people that I was visiting daily, the patients.

Not all of my patient experiences have been particularly positive. I have had my share of patients unwilling to speak to the lowly medical student, patients too tired to hold a conversation, patients unable to speak English and my favorite, patients with mental status changes, barely able to tell me their names let alone the nature of their disease. While these patients are painful challenges for fresh students, they provide the greatest opportunities for learning. They add the valuable experience needed to transform great clinicians into great doctors. In my first 6 weeks of 3rd year, I have encountered one particularly challenging patient, who was frustrating enough to make me scream into a pillow. Fortunately, following him also provided incredible learning experiences.

Mr. E was an OCD schizophrenic who had spent much of the last decade residing in an inpatient psych ward. During his time there, he had been prescribed over 20 different psychiatric medications in various combinations. He was also noted to be “dangerous” from previous psychiatric reports. He had come to us overnight for evaluation of new onset drooling and ataxia. In the ED, it became clear that he was in acute renal failure and rhabdomyolysis – most likely the result of the medications he had been taking. In retrospect, Mr. E should not have been admitted to any of the ward teams, let alone my team, but when I left the conference room that morning – it was decided. He was my patient.

When I first saw Mr. E, he was pleasant. I wouldn’t call him conversant, but he could answer all of my questions and follow all of my commands. We made a plan to pump him full of fluids until his kidney were back to normal and to stopped all of his medications until this happened. We got Mr. E on a Friday. Saturday was my day off and I was rested on Sunday, ready to revisit my model patient. Overnight, no events were reports – he was the same as he had been when we left for the weekend. When I walked into his room, it was clear; this was not the same Mr. E I had seen on Friday.

On that Sunday morning, I walk into Mr. E’s room to wake him up. He silently rose to his bed, looked at me and headed straight for the door, dragging a bag of urine behind him. I followed him in fear as we slowly approached the hallway. Just outside of the door, Mr. E turned around, scurried into his room and slammed the door in my face. I returned 10 minutes later with the resident to find Mr. E naked smearing urine and feces on the floor. For the rest of the day Mr. E would wander in and out of his room without saying a single word to anyone. Sometimes he would be disrobed, heading toward the patient with C. Diff precautions. He would become aggressive and swing at the staff trying to redirect him. I was horrified – every time Mr. E came out of his room, I found myself frozen, unable to help redirect him. All I could do was wonder how fast he could be sedated with Ativan.

That afternoon, Mr. E was placed on restraints and given a one-to-one sitter. Over the next few days, he spent much of his time silent, thrashing around in his bed. He would chew on the restraints, pull out his IV’s and disconnect the Foley. He would become so restless overnight that he would be given the maximum doses of Ativan. In the mornings, he would be so sedated that he would be unable to open his eyes. On hospital day 8 or so, I entered Mr. E’s room, prepared to hear about his eventful nights. A new sitter named Teddy was there to greet me. I had been in the habit of thanking the overnight nurse for looking after Mr. E, but this was the first time I felt it was fitting to tell the nurse that he was magical. Overnight, the old Mr. E had returned. He was able to talk and take care of himself. He had quickly gone back to being one of my favorite patients.

I turned to Teddy and said, “You are a miracle worker. What’s your secret?” He simply replied back, “All I do is treat him like a human being, with respect and dignity. That is all.” I felt ashamed. I like most of the people, scared by Mr. E’s behavior, felt the best treatment was to pump him full of benzos until his kidney function had improved and he could be restarted on his psychiatric medications. I had almost forgotten that Mr. E was once a proud soldier, serving our country in Vietnam. He had been trapped in his own mind as a result of his experiences abroad. Within 3 days, Mr. E had improved so much that we were able to return him to his former residence, in perfect condition.

I had walked into medical school with the intention to uphold my Hippocratic Oath “to do no harm.” With a sense of nativity and innocence, I started rotations believing that I would be guided by that principle. While good doctors practice medicine with the intention to uphold the Oath that they took their first year of medical school, real medicine rarely conforms to the principles by which they were taught. In what is now a little over 6 weeks, I have learned a tremendous amount about the number of ethical dilemmas that interfere with medical management. Although I am still a conspicuous bottom feeder on the physician food chain, it seems that I have already got a little dirt on my pristine white coat.


Hospital = Circus

The ups and downs post was definitely too soon. Literally the day after that post, everything simmered down at the hospital and things were back to normal. Woohoo.

The most painful part of the medicine rotation is call. When you are short call, you only admit patients until a certain time in the day. Normally, these people came in overnight and the night team (night float) assigns them to your team. Normally, this is pretty good because night float has already done a lot to work up the patient. Long call means when short call caps, you start admitting all the new patients. The worst part is that you have to actually go and get all the information from the patients. You wouldn’t think it’s that bad but sometimes everything just PILES UP and then you look up and it’s 9 PM and you still have to put everything into the computer. Man, it’s rough.

Of course you are thinking – “what is worse than that?” Nothing? WRONG. New interns. I love the interns on my team (by far the best team) but they are a little slow. That plus a new resident means rounds that should have taken an hour actually take 4-5 hours. AND then you finish everything on top of that. I do have to give them all a break though – our service has literally become the service of the crazy house. The majority of our patients have some huge unresolved psych problems and really no amount of knowledge in medicine would help us treat these patients. Its all about calling the consults and waiting for them to respond to us…then trying to figure out how to translate what they said into the online computer system.

On Saturday night, a bunch of us got together to celebrate the birthday of a friends. Because I was on call on Sunday, this was an early night. The one thing that I seemed to get out of all the hospital talk was that every hospital is a circus. I must say that Jim wins for the best story – life would be more amusing if we all had patients that called us vampires every day – you can deny the resemblance can you?

student doctor signing out.


Ups and Downs

Maybe its too soon to be talking about ups and downs but here I go anyways. Being a medical student means you are the most useless member of a team of doctors…real doctors. You are the person that no one notices. The one with the least amount of clinical knowledge and limited contributions. Why does this come up? Well many reasons. As I am realizing there is little continuity with the new BU schedule change. Instead of being the same team for 2-4 weeks, everyone keeps leaving at random intervals. The team I started with had 1 HMS student, 2 veteran interns, 1 veteran resident and 1 attending. After my 3rd day, one of the interns finished and we got a new one. One day after that we lost the HMS student. Today was the other veteran intern’s last day. 1 week from now the resident is gone and so is the attending and so is that intern that we just picked up.

Every new member significantly changes the dynamics of team. The older interns are experienced, overworked and lacking motivation. New interns are just out of medical school and learning to adjust to not being constantly evaluated and actually being responsible for a number of patients. It hard to constantly find your place on a team when the people and the overall work experience of the team is also changing.

On the POSITIVE, the resident is awesome and because of that I have gotten to do some things that I never imagined doing on my first week on the job. Not only have I been juggling multiple patients, but I got to drain an abscess! Ok. Maybe that sounds more gross than cool but it was awesome. There was lidocaine, scalpels, gauze, sterile gloves and wicks. Oh yes, and MRSA. It was lovely. The patient was a 50 something male that worked as a nurse and has a history of caring MRSA as part of his normal flora. I guess he got a really bad haircut and somehow MRSA started growing there making painful nodules on the back of his neck. The area was so tender and painful. At first I thought the whole experience was so cool. The intern had already done 3 of these on the same guy earlier so he was tired of doing it. Once we finished cutting open the abcess, we packed the wound with sterile cotton. Then came the traumatizing part – changing the old cotton. It really shook me up to see some one wince and scream like that. I had literally just cut the guy’s head open and he didn’t say a thing – now I see him screaming from pain. I was hit with shock.

Tomorrow is scrub day…my favorite day ever!


So, I have patients

So, there is a running joke about how the HMS med student on the team should refer to himself as the World Renowned Student Doctor when he picks up the phone or returns a page. We have patients…we don’t know anything and we have patients – that is kind of scary. Granted, we are always followed by interns/residents/attendings at this stage in the game so we never actually run free in the hospital (what a scary thought). Let me tell you about my patients…doctor-style.

Patient 1.

76 yo male with a history of millions of ophthalmic problems and coronary artery disease (heart problems) comes in after nearly fainting during an ophtho exam. If you ask the resident playing with the eye what happened you get some story about no pulse for a ridiculous period of time. If you ask the patient – he remembers everything. Too bad the patient wouldn’t tell me that.

Yes yes, I started out my first rotation ever with the ominous “Difficult patient.” The kind of person you try so hard to get information from only to find out he hates you because 6 other people entered the room to ask the same things and you happened to be the last one. Initially I was bummed – unlike other clinical experiences, I didnt just get to talk to another patient instead. I was stuck. After seeing what other people got out of him plus what I managed to get, I made my way through my first diagnosis. One point Jainy. (For those that care, we think the oculocardiac reflex kicked in, although the patient had a history of these kind of episodes when he was younger so maybe vasovagal).

With diagnosis one out of the way, I figured my next patient would be that bad. We were on short call meaning we were getting new patients from the team that in overnight. What did I get, a class case of alcohol abuse and withdrawal…or I thought it was classic. Here comes the story of “difficult patient #2.”

63 yo male with an extensive history of chronic alcohol abuse, depression, Hepatitis C and cirrhosis presents with symptoms of withdrawal and intoxication. Something about having money stolen and an account frozen…then a lot of drinking…then eventually coming to the hospital. The patient has come to the hospital like this 9 times in the past year – just one year alone – for the same problems. I got my brief on the patient..I thought this would be so easy – he’s already experienced but boy, was I wrong. Difficult patient number 2 is the patient that really can get to the point of his story. If I were to ask “Do you have pain?” I would get back a convoluted story about nothing related to anything we have talked about. It would semi-answer my question but it really should have been a simple/sweet yes or no. What makes this better is that I was being watched during this whole interview. I just felt myself drowning the whole time. Eventually we uncovered a crazy past medical history of gender identity disorder for which he got implants (yes, breast implants) and a lot of cocaine/crack use.

Who ever thought that I would get slightly attached to these patients – but after the first day passed that I would grow to really like these people. Its true what they say about mean patients – most of the time they are normal, nice people dealing with the huge stress of being admitted to the hospital. All I can say is that I’m glad both of the patients are back to their lives with the second actually checking into a detox program for help. 2 points me? I think so.


Learning Medicine?

Before the start of 3rd year, I spent a few hours at a Borders near my house looking for medical books with tips and trick for surviving 3rd year rotations. Instead of finding what I was looking for, I found a slew of “personal narratives” about the torturous years known as medical school and residency. I’m not going to lie. I’ve read some of these books. While it is extremely interesting to hear cases that challenge both medical limits and personal limits, it is hard not to notice that the majority of these writers are somehow affiliated with Harvard. They seem to have a culture of writing (a rare skill among doctors).

Though there is not Ivy League attached to my name, this is my attempt to write about the patients that will help me become a real doctor.

Less than 2 weeks ago, I took my boards and here I am trying to diagnose and care for patients. In two weeks, we have all gone from near experts in the basic sciences relevant to medical school (AKA the nearest First Aid book) to clinicians. Since this is the beginning of rotations and I am starting with Medicine, its been a big adjustment. Its funny how much the schedule change wears you down. Let me tell you, I do not like waking up at 5:30 AM.

For the last year, we have been told that when we hit the hospitals, we, as medical students, will know the most about the basic sciences. We know so much yet none of it actually helps treat a patients. At the most, we can describe what is happening and sound intelligent doing it. The last two years were spent learning the spectrum of diseases, the next two years will be spent learning how to be doctors.

Yes! I am excited.