Half-way through

I am now half-way done with third year! In less than a year and a half I will be a doctor. My last day of inpatient peds was yesterday and the shelf exam was today. It didn’t seem horrible, definitely not as bad as the medicine shelf, but it is one of those exams from which you leave having no clue whatsoever as to how you did.

This last week there has really been nothing worth posting. Lots of sick babies—I can at least now say that I feel very comfortable coming up with a plan for infants with bronchiolitis. My intern the ER resident did extremely well this month—our senior resident was very impressed with how quickly she caught on.

Now I get ten beautiful days off. The day after I come back we have a class “intersession” that will consist of eight hours of lectures and small groups about professionalism and “patient centered care”. Yippee. Woohoo. Save me a seat in the front row. They actually emailed us five articles on these topics that they expect us to read over Christmas. Yeah, that’s going to happen. I don’t fully understand why we have so much touchy-feely stuff in medical school—the vast majority of people I know in medical school tend (like I do—can you tell?) toward the cynical side—maybe it’s the more sensitive ones who go into the education side of medicine?

My next rotation will be OB/GYN—I’ll be at a community hospital that is known as the “baby factory”. It will be the first rotation I’ll have been on with overnight call. I’ve not particularly been looking forward to this rotation, but I suppose it will be good. It will definitely come in handy for the next time I get stuck on an elevator with a woman in active labor.

More peds

This week has been fairly busy—nothing particularly exciting has occurred. I was on call Friday so had to go back in yesterday. I feel really bad for my intern—she had seven admissions and was basically running around all night long. Fortunately I was able to help her at least a little by talking to the radiologists, calling medical records, etc., but there is only so much one is able to do as a student—for some reason on this rotation interns have to write notes even on patients that students write notes on, as opposed to the typical “agree with above” addendum on most other rotations, so my seeing patients didn’t particularly help her any. Today is my last day off before Christmas break—I am becoming more and more glad that I did CT surgery, because now there is pretty much no schedule that I am intimidated by. Even though I have been working 60-70 hours a week this month, I am the most relaxed I have been in two and a half years. I think part of it is that since one doesn’t have to go to the OR, there is a lot more time to get floor work done thus one does not feel quite as pressed for time.

Wednesday we had a class meeting to talk a little about getting ready for fourth year, we’ll have another in February to actually schedule it. However, we have to pick an advisor in the beginning of January to help us make plans. One of the trauma surgeons spoke about things to do/not to do in fourth year for students interested in surgery. She recommended taking as few surgery rotations and as many medicine rotations as possible. Essentially she said the primary goal of surgery rotations should be to get letters of recommendation from the biggest names possible, while the primary goal of the medicine rotations should be to learn (likewise the medicine doctor who spoke said that students interested in medicine should do as few medicine and as many surgery rotations as possible), the idea being that surgery residents have their entire lives to learn about surgery, but not much time to learn about medicine. One of the things she was adamant about was that one should never do an away rotation at a place one is interested in doing a residency (again, the opposite of what the medicine doctor recommended). Apparently, only one visiting student to my school has been accepted to our program in the last seven years (my intern from CT surgery). I think that I am going to ask her to be my advisor—from what I hear she is super intense, but does take time to teach students. I think she would make things happen and would be able to help me figure out where to apply/what rotations to take that I could get good letters from. The only mildly scary thing is that picking an advisor, while not completely commiting one to going into a certain specialty, is certainly a big step in that direction. I’m pretty sure I want to do surgery, but I do like to have room to change my mind.

Bitter

I had the weekend off—didn’t really do anything fun or productive, although I did manage to write up a couple H&Ps—we have to turn in four which wouldn’t be a problem except that we need to write up an extra discussion about the differential diagnosis. It’s not really hard, but it does suck up time.

Yesterday I was on call, it was busier than Friday which was nice—also, I got to leave at nine instead of ten since I had helped admit two patients by then. The first patient was a 13 month old boy with a five day history of forceful cough, posttussive emesis (throwing up due to coughing so hard), diarrhea, and low grade fever. His pediatrician had taken a chest xray, but they didn’t bring it—all we had was a sheet of paper from the radiologist that said “bilateral pneumonia”. We started him on IV fluids and an antibiotic (even though this is most likely viral). His lungs sounded good to me, but he got an albuterol treatment as well. Overnight though, he did start having lower oxygen saturations, so his pediatrician started him on steroids.

The other patient was a 5.5 month old girl with a two day history of diarrhea (16 watery stools/day), vomiting, and fever. She was admitted to the hospital because her bicarbonate was 11 (normal about 24) at her pediatrician’s office, signifying dehydration. Most likely viral gastroenteritis, probably rotavirus. She got IV fluids and an electrolyte recheck this morning which showed bicarbonate <5. So, we started replacing volume lost in stool in addition to maintenance fluids. I had to call the community hospital lab to get the results of her stool culture (she had gone to the ER on Saturday)—all that had been ordered though was a gram stain and culture—no viral tests were done, so of course all the results were negative.

I talked to my intern from the first couple days last night and it turns out the kid that we admitted to the other team (that she is actually on now) ended up having Kawasaki disease—we had initially been suspicious of it, but thought it unlikely after exam since the kid only met a couple of the criteria for it—lymphadenopathy and a rash, and since the rash started the day after taking amoxicillin we thought it was probably a side effect of the medication. Apparently though, over the last few days he developed the other classic signs: fever >5 days, bilateral conjunctivitis, and palmar desquamation. I kind of wish he had been admitted to my team as that would have been very interesting to see.

I got my surgery grades today—I did fine, but I am fuming right now. My first month of surgery I was on a team with two other students, an intern, two senior residents, and four attendings. I ended up getting evaluations from (drumroll) the intern and one of the attendings (the one I had virtually no contact with). The evaluation forms essentially give several categories in which the evaluator ranks the student 1-9, and then there is a space for comments. The attending gave me all sevens and wrote no comments, and he did the exact same thing for the other two students. Given the fact that neither of the two attendings I had more contact with bothered to fill out an eval, I’ve got to give the one attending credit for filling one out, cursory, mechanical, and essentially meaningless as it may have been. What really ticks me off is that neither of the senior residents, the two people who were in the best position to accurately rate my performance, filled one out either. The other two students weren’t evaluated by them either, so it’s not just me. Incredibly frustrating—I’m supposed to pick an advisor out of the faculty over the next month—I have medicine doctors I can go to, but since none of the surgeons I have worked with are apparently even aware that students exist I’m not quite sure how that’s going to work out. Guess who I won’t be requesting letters of recommendation from? /end of bitter mini-rant—at least no evals are better than bad evals.

This afternoon we had to go to an hour-long ethics discussion—quite possibly the most worthless hour of the week, and that’s counting the hour I spent on the weekend going back and forth between the basement and my room to see if my clothes were dry because I really wanted to go to bed but had to have clothes for the next morning. I can’t really explain what was discussed because really nothing was. Fortunately we only have one more session and we’ll be discussing an actual case so I might be able to at least feign interest. On the plus side, our interns told us we didn’t have to go back to the floor, so we got to go home at 2:30.

Inpatient Peds

I can’t believe it’s already December. I started pediatric inpatient on Tuesday—usually we would switch rotations at the first of the month, but with Christmas things got shaken up a bit. On peds each student is paired up with an intern, but the interns all switched on the first. The intern I had the first couple days is going to go into dermatology, but she is doing a pediatric internship. She was very nice and extremely smart and competent and it turns out we went to the same undergrad in California. The intern I just got yesterday is also very nice, but she is an ER resident who hasn’t done inpatient pediatrics since her third year of medical school (ER residents rotate through a bunch of different specialties in their intern year). One of the first things she told me was that she hates kids. I likely won’t learn as much (at least about pediatrics) from her, but the good thing is that I know I’m going to get a great evaluation from her—after we spent two hours going over a chart to transfer a patient to our floor she told me that anyone who has to deal with that [garbage] deserves a good eval. Since yesterday was her first day, she had no idea about how rounds/presentations work; one of the other students on the team told me it was the first time he felt like we knew more about what was going on than the intern did. I think she’ll be fine in a couple days, though she has not been shy about making it clear she really doesn’t care what any of the supervising residents think about her since she has no intention of having anything to do with kids after this month.

One of the first patients I saw on this floor was a 5 month old girl with mild holoprosencephaly, a cleft lip/palate, seizures, and central diabetes insipidus. She had been there for two weeks and will hopefully go home on Monday. The main problem is the dosing of her ddAVP—too much and her sodium drops, too little and it shoots up.

I was on call Thursday, and helped admit two kids. One was a 2 year old with a 4 day history of fever who developed a rash the day after being started on an antibiotic. The other was a 19 month old with a two week history of vomiting and diarrhea who presented to the ER with severe dehydration and hypoglycemia. The two year old we admitted for another team, so I don’t know what happened with him; but the 19 month old (after getting a lot of IV fluids) was feeling better yesterday and probably went home this morning.

The way this rotation works is that we are on call every four days (intern stays overnight, students leave at ten, then the next day the intern has to leave by noon [though they usually don’t] and the student stays to take care of loose ends). Weekends we have off unless we are on call or post call. Essentially, that means that I have three days off this month, and two of them are this weekend. Next week I will be on call Friday, so will have to be there on Saturday, then the next week I will be on call Saturday so will have to be there Sunday. Even given this, I still prefer inpatient to outpatient. I wouldn’t mind having an outpatient month once every six months or so though.