Saturday, February 24, 2007

Neuro stuff

Yesterday I was on call (although we were sent home at about nine which was quite nice). Not much happened during the day, but we saw 3 or 4 consults in the ER that evening.

One was an alcoholic who complained of having about 5 seizures an hour for the last day. He didn’t have any while we were in the ER, and his exam was not particularly convincing. He got admitted for seizure monitoring. The next was a woman who has had weakness for the last seven months. She was hospitalized last July for two months then sent to rehab for another two months after some improvement. Her neurologist diagnosed her with Guillain Barre (an autoimmune disorder that usually resolves with time), but now questioning his diagnosis and referrred her to the chairman of neurology at my school. She has an appointment in March, but her husband (who has been her caretaker) had gotten to the point where he didn’t think she was safe in the house. He couldn’t get her into a rehab facility, so he brought her here thinking that the chairman would be able to see her sooner (not correct unfortunately). There was really absolutely nothing we could offer them that she hadn’t received in the last seven months. The resident told them that if they didn’t feel she was safe at home he could admit her and after the weekend have the social workers try to find a facility for her, and the woman flipped out. She started screaming at her husband that she wanted to go home, and that she would die if she stayed at the hospital that night. When the husband tried to tell her that he didn’t want her to fall and hurt herself at home, she started screaming and kicking like a three year old having a temper tantrum. We excused ourselves to let them sort it out. He ended up calming her down and she was admitted. When we left for the night we passed by her room and she was much calmer and apologized for freaking out.

The last patient was a woman with a numb foot for the last day. The ER did a CT scan and chest x-ray (not clear on why the CXR—our resident on being asked made a joke about its being because she walked through the door of the ER), both of which were normal as was expected. The resident thought she had somehow injured her peroneal nerve peripherally.

One of the problems with this rotation is that there are a lot of fakers. The clerkship director told us that half of neurology is weeding out the fakers from the patients with genuine conditions. We’ve already had a couple on our service, it’s making me very cynical.

Wednesday, February 21, 2007


OB is over. I now have two weeks of neuro, then four of psychiatry.

Today I had the best drug rep lunch I have ever had--he brought beef tenderloin, two types of fried catfish, really good cajun shrimp, really good bread, seafood salad, Asian salad, pasta salad, and a variety of desserts from a gourmet bakery. Afterwards, I stopped by the hospital coffee shop, and the lady gave me free coffee because I had to wait two minutes for her to brew a fresh batch. On the way home, it was warm enough that I cracked my car window (as opposed to the minus 10 that it was last week). Very good day.

Thursday, February 08, 2007

Call, call, call

Last night I was on call again—one more call night to go. In the afternoon I was in clinic. The most interesting (and saddest) case was a 30 year old woman with seven children (from four or five different fathers) who had an abortion in December with her eighth pregnancy. Ever since she has had cramping, and she never passed blood or tissue. She was diagnosed with an incomplete abortion, meaning that the fetus is dead but still in her uterus. She will get an ultrasound today or tomorrow and likely will have a D&C done to remove the dead fetal tissue. She had no suspicions coming in that she had retained the fetus, and was interested in birth control—but she wanted us to be sure to do a pregnancy test first because she thought it was fairly likely she was pregnant again.

In the evening, I was in on one delivery with a family practice resident and attending. The patient pushed for about 45 minutes without anything happening, and the resident failed in two attempts to attach a scalp electrode to the baby to monitor its heart rate. I do not have anywhere near enough experience to know if they were doing something wrong, but it was definitely not going smoothly. The two nurses (L&D nurses tend to be very good at what they do) were very calm, but were clearly getting very antsy. Finally, they started making very neutral comments asking the attending if he wanted an OB doctor to come in, and at one point telling him straight out that he needed to make a decision (over whether to do a C-section). One of the nurses quietly stepped out and came back in, a minute later the attending told her to call the OB doctor and she told him that she already had. Naturally, at this point the baby decided it wanted out and three minutes later it was delivered. When I left the room the other medical student on call told me that all the nurses in the workroom had been freaking out.

At ten a woman came into the ER with left lower quadrant pain, an ultrasound showed that she had a dermoid cyst (aka teratoma, a benign tumor that contains many types of tissue, sometimes even teeth and hair) on her left ovary with possible torsion. She went to the OR, we found a massive tumor (and torsion) and removed her ovary. I got the honors of cutting it open, it was quite possible the most disgusting thing I’ve seen in medical school. There were no teeth, but there was a lot of sickly yellow goo.

Right afterwards, another lady came into the ER with vaginal bleeding. She was diagnosed with a miscarriage. When we were done seeing her, I went back to L&D just in time to make it to a delivery. It was one of the resident clinic patients, usually the student gets to catch the baby—something I’ve not yet done. When we got there the intern took over and I didn’t touch it. She spent the rest of the night apologizing for stealing the delivery.

After that, I slept from 1:15 to 4:45, and was home by 8:00. Unfortunately I will be on call again on Saturday, which is by far the worst day to be on call.

Saturday, February 03, 2007

OB: The ongoing saga

OB is slowly growing on me, though I still would not consider it a career option. Last week I saw a couple more deliveries, though was not able to help much as they were somewhat complicated. One was going to be delivered by forceps but at the last minute things started going smoothly and the forceps were not necessary.

The patient population at this hospital is mostly inner city black, most of the mothers are younger than I am and either have no man in the picture or have an immature adolescent who laughs and makes jokes as the baby is being delivered. There have been a couple 24 year old G10P6046s (pregnant ten times, 4 miscarriages/abortions, 6 living children). It can be very discouraging at times. On Thursday I saw a married couple who were having their first child, and the husband stood and held his wife’s hand the whole time—it was a very nice change.

This rotation has brought up the subject of contraceptives. Obviously, anything that causes the death of an embryo I would consider wrong, but I have very mixed feelings about contraceptives that just stop ovulation. I have no problem with their being used by married couples, but at the beginning of the rotation I would have tended to not be comfortable with giving them to unmarried people because I felt like it would be facilitating a sinful and dangerous lifestyle. Now, I am not quite so sure—I am tending to think that they are going to live that lifestyle regardless of whether or not I give them contraceptives, but by giving them contraceptives I can at least stop them from conceiving a baby then having it aborted. I was talking about it to some of my Christian friends last night (one of who interestingly had no problem with contraceptives before, but now after being on Ob/Gyn does) and we came to the conclusion that if we were to give contraceptives out when we were doctors it would not be at all for the patient’s benefit because the only way the patient would be benefited would be to stop living a lifestyle of harmful and broken relationships. The only benefit is for society. Temporarily sterilizing these women prevents them from having babies for whom they do not have the resources (monetary and nurture-wise) to care for, and prevents the single mother/no family structure environment in which the children will inevitably be raised from being perpetuated. Having said that, isn’t the job of a doctor to care for the patient, not for society in general? And, I’m not sure that I will ever be able to comfortably sit down with an unmarried sixteen year old who has more sexual partners than she has fingers and discuss how she can continue this life but not get pregnant.

Mildly funny story: I had dinner at a hamburger joint with some classmates a couple weeks ago—our waiter who was very gay in the modern sense of the word but definitely not in the old gave us one bill, so the seven of us had to calculate out exactly how much each of us owed, write down the amounts with our names, then give him the list with five credit cards and a handful of cash—this is the conversation that ensued:

Gay waiter (annoyed at the prospect of 30 extra seconds of work): I need to know how much to charge each card.
Friend #1: We calculated the amounts and wrote down our names next to the amounts on this slip of paper. (and I'm deducting the time we spent on it from your tip)
GW (exasperated at the idiot medical student): That doesn’t help me, I need to know which card to use for each amount.
Friend #1 (wondering if he's serious): Our names are on the cards…
GW: Silence
Friend #2: grinding teeth shut and looking straight ahead to prevent herself from falling out of her chair laughing