A middle-aged man came into the Emergency Department awhile ago complaining of confusion and somnolence. He was brought in from the waiting room after falling out of his chair. A resident and I interviewed him together, and during the interview he drifted off mid-sentence. Because he was so incoherent, getting a reliable history from him was rather difficult. However, we did get that he was taking a combination of narcotics and benzodiazepines to control his back pain.
On exam his O2 saturation was 88% on room air (this is a measure of lung function and corresponds roughly to breathing air at 14,000 feet altitude; normal is >96%), and he had pinpoint pupils.
When we left the patient's room, the resident with whom I was working asked me what I thought it was and what I wanted to do. We both agreed that this patient's confusion and sleepiness was most likely caused by taking too many narcotics (one of the most dangerous side-effects of narcotics is suppression of respiratory drive). Other possibilities included stroke, cerebral hemorrhage, or infection, which were all indications to get a CT scan of the head.
I asked her if we could just give him Narcan and see if his symptoms resolved to spare the patient the cost and radiation exposure of the CT scan. Narcan is a drug used to reverse narcotics overdose and is typically reserved for emergencies or if a patient shows signs of difficulty breathing. When the resident presented this patient's case to the Attending Physician, he agreed that a low dose of Narcan was reasonable given the patient's respiratory and mental status and the need to quickly differentiate between narcotics overdose and other causes such as a brain infection, bleeding, or stroke.
----
We rechecked the patient about an hour after this all happened, but he was still very sleepy but arousable. The Attending Physician asked the nurse if she had given him Narcan yet. She had gotten 3 or 4 new patients at the same time and had not yet given the Narcan. The Attending pointed out that the patient was still very altered and asked the nurse again to give the patient the Narcan that he had ordered more than an hour before.
We came back about 15 minutes later, and our patient was still very sleepy. The Attending again asked the nurse if she had given our patient the Narcan he had ordered, and she again said that she hadn't. He said more directly: "I want you to give the patient Narcan, please." The nurse replied, "Are you even the patient's doctor?"
This doctor in general is a very nice and happy man, and he chose to laugh off this insult and insubordination. "Yes I am! Can't you see my name right here next to these orders? Have you not read my Attending Note?" At this point in the afternoon, a new shift of doctors had already come into the ED, and care of patients was being transferred from one set of doctors to the next. The nurse was suggesting that she did not carry out his orders because she didn't know who was taking primary responsibility for this patient.
When the Attending Physician told the nurse, "I want you to give him the Narcan I ordered, now," the nurse replied that she didn't feel comfortable doing that because in her opinion the patient didn't need Narcan.
Rather than engaging in open confrontation, this prompted the Attending to re-evaluate the patient and his history, together with the resident and the other doctor who was taking over this patient's care. Over the 2 hours that elapsed since the patient arrived, his O2 saturation was up from 88% to 93%; he was much more coherent and able to answer questions but was still falling asleep in the middle of the interview. The on-coming physician who was relieving the first Attending Physician agreed that Narcan should have been given when it was first ordered but that at this point the patient did not need it because his confusion was resolving.
----
My overall impression of this interaction is that the nurse compromised this patient's care by neglecting to carry out the Attending Physician's order for low-dose Narcan. When I talked with him about this, he emphasized that nurses do provide a vital layer of security in caring for patients; oftentimes, nurses recheck medication orders to make sure that the correct medication and doses are given and that there are no allergies. Nurses often spend more time with patients than do physicians and can readily observe changes in the patient's condition that may necessitate a change in the treatment plan.
The problem I saw, though, was that this nurse didn't voice her concerns to the Attending Physician when he first put in the order for low-dose Narcan but instead acted in a passive-aggressive manner by simply ignoring the order. The purpose of the Narcan was to quickly assess whether this patient's symptoms were due to a narcotic overdose or to another more emergent condition such as infection of the brain, stroke, or bleeding. The nurse's behavior undercut the value of this diagnostic approach.
Moreover, this nurse was being less than honest by suggesting that she didn't administer the medication because she didn't know which doctor was taking responsibility for this patient. Shift changes in the Emergency Department are typically seamless: all the doctors meet for rounds, and the first shift of doctors stick around until the outstanding questions or problems with patients are resolved. This was the first time I saw a nurse express confusion about continuity of care across shifts.
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How will this situation be resolved? Has this nurse had problems interacting with other doctors? The Attending Physician said that this was his third or fourth incident with this nurse over the past week alone. The second-shift doctor and a resident listening to the conversation both confirmed that they, too, had had similar problems with this nurse.
The Attending Physician's immediate response to this situation was to speak privately with this nurse, express his concerns to her, and attempt to fix the working dynamic so that patient care is not compromised in the future. The long-term response is to establish a paper trail documenting these incidences. The second-shift doctor stressed that this nurse is by all appearances very smart and capable but perhaps needs an environment in which she has more control over patient care.
While this is not the first time I have observed tensions between different members of a health-care team, I feel it's necessary to say that this is the first time I have felt that patient care has been compromised as a result of those tensions.
Monday, May 30, 2011
Saturday, May 28, 2011
Rural accommodations: Living on a ranch
I spent the past week living in an apartment above Kremmling Memorial Hospital. I had my own room and bathroom with a shared living room, dining room, and kitchen. There are two other bedrooms up there for various doctors rotating through the hospital, staying for one or two nights to avoid a long commute. There was usually only one doctor staying there at a time.
These accommodations worked just fine, except for the fact that Kremmling is 30 miles away from Granby where I work. I was placed in housing so far away from work because of the short notice due to some technology and communication snafus. AHEC typically tries to place students in rural housing such that their commute is no farther than 30 miles, so I was right at the upper limit. Over this past week, the AHEC coordinator bent over backwards to find me housing closer to Granby.
My new home for the next few weeks is a mountain paradise. I get to wake up to this idyllic view every morning:
I’m living on a working ranch, and the family who’s hosting me is incredibly nice. As a housewarming present, the mother gave me a dozen eggs fresh from her hens. The rooster crows in the morning just like in the children’s books, the donkeys look at me indifferently when I drive past them on my way to work, and a pair of farm dogs welcome me back to the ranch in the evening.
I’m situated in an apartment above the garage. It has a full kitchen (including a dishwasher), bathroom, washer/dryer, plenty of drawer and closet space, and a private entrance so I don’t have to bother my hosts when I come and go.
I know how fortunate I am. Can I stay here forever?
These accommodations worked just fine, except for the fact that Kremmling is 30 miles away from Granby where I work. I was placed in housing so far away from work because of the short notice due to some technology and communication snafus. AHEC typically tries to place students in rural housing such that their commute is no farther than 30 miles, so I was right at the upper limit. Over this past week, the AHEC coordinator bent over backwards to find me housing closer to Granby.
My new home for the next few weeks is a mountain paradise. I get to wake up to this idyllic view every morning:
I’m living on a working ranch, and the family who’s hosting me is incredibly nice. As a housewarming present, the mother gave me a dozen eggs fresh from her hens. The rooster crows in the morning just like in the children’s books, the donkeys look at me indifferently when I drive past them on my way to work, and a pair of farm dogs welcome me back to the ranch in the evening.
I’m situated in an apartment above the garage. It has a full kitchen (including a dishwasher), bathroom, washer/dryer, plenty of drawer and closet space, and a private entrance so I don’t have to bother my hosts when I come and go.
I know how fortunate I am. Can I stay here forever?
Off-roading accident in a rural emergency room
Living in an apartment above Kremmling Memorial Hospital (KMH), just shy of 30 miles away from where I'm working this month, did have its silver linings. I met several doctors who rotate through KMH; they alternate covering emergency room shifts and making rounds on the long-term-care patients. All of them were very nice, talked a lot about their experiences as rural physicians, and asked me if I wanted to be called if an interesting case came in downstairs. Yes, of course!
This only happened a few times. The most exciting case was a young guy who had an accident while off-roading. He caught some air when going over the top of a hill, landed the wrong way, and was thrown from his vehicle with it rolling over him.
He had hit his head but was helmeted and never lost consciousness. There were no signs of head trauma, and there were no neurological deficits. He denied neck pain and was taken out of the C-collar after physical exam and x-rays showed no damage to his cervical spine. He was taken off the backboard after physical exam showed no injury to the rest of his spine.
He denied any shortness of breath and lung sounds were normal. He did not have any abdominal complaints, and abdominal exam was normal. Interestingly, an ultrasound FAST exam was not done because KMH does not have a portable ultrasound machine.
The major problem was a deep wound in the medial aspect of his right lower leg that extended down to the tibia. He was able to wiggle his toes but could not plantarflex (like stepping on the gas pedal). The wound was full of dirt and gravel. We were able to stop the bleeding with gauze and pressure. X-ray showed that the bone was not broken. He was given Dilaudid to manage the pain of his leg injury and clavicle fracture.
The doctor explained to me that he had to assess whether there was tendon involvement because that would dictate whether he should send this patient to a higher level of care or just close the wound. We numbed the wound with injections of lidocaine/epinephrine and cleaned it thoroughly. The whole time, his off-roading buddies were taking pictures and video on their iPhones. With the wound all numbed and cleaned out, I could see his extensor digitorum longus tendon move back and forth when he wiggled his toes.
The doctor decided that it would be best to send this patient to a higher level of care because the patient still could not plantarflex. The two options for higher-level care from Kremmling are Steamboat Springs and Denver.
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This case was interesting to me for two main reasons, aside from the excitement of trauma. First, this trauma was the result of an off-roading accident, something that I would be much less likely to see in the city. Second, I got to see how this rural doctor, covering the emergency department of a small hospital, first assessed the seriousness of the injury and then negotiated the system in order to figure out the appropriate transfer of care. Events would have unfolded slightly differently if this were at University Hospital Emergency Department.
This only happened a few times. The most exciting case was a young guy who had an accident while off-roading. He caught some air when going over the top of a hill, landed the wrong way, and was thrown from his vehicle with it rolling over him.
He had hit his head but was helmeted and never lost consciousness. There were no signs of head trauma, and there were no neurological deficits. He denied neck pain and was taken out of the C-collar after physical exam and x-rays showed no damage to his cervical spine. He was taken off the backboard after physical exam showed no injury to the rest of his spine.
He denied any shortness of breath and lung sounds were normal. He did not have any abdominal complaints, and abdominal exam was normal. Interestingly, an ultrasound FAST exam was not done because KMH does not have a portable ultrasound machine.
The major problem was a deep wound in the medial aspect of his right lower leg that extended down to the tibia. He was able to wiggle his toes but could not plantarflex (like stepping on the gas pedal). The wound was full of dirt and gravel. We were able to stop the bleeding with gauze and pressure. X-ray showed that the bone was not broken. He was given Dilaudid to manage the pain of his leg injury and clavicle fracture.
The doctor explained to me that he had to assess whether there was tendon involvement because that would dictate whether he should send this patient to a higher level of care or just close the wound. We numbed the wound with injections of lidocaine/epinephrine and cleaned it thoroughly. The whole time, his off-roading buddies were taking pictures and video on their iPhones. With the wound all numbed and cleaned out, I could see his extensor digitorum longus tendon move back and forth when he wiggled his toes.
The doctor decided that it would be best to send this patient to a higher level of care because the patient still could not plantarflex. The two options for higher-level care from Kremmling are Steamboat Springs and Denver.
----
This case was interesting to me for two main reasons, aside from the excitement of trauma. First, this trauma was the result of an off-roading accident, something that I would be much less likely to see in the city. Second, I got to see how this rural doctor, covering the emergency department of a small hospital, first assessed the seriousness of the injury and then negotiated the system in order to figure out the appropriate transfer of care. Events would have unfolded slightly differently if this were at University Hospital Emergency Department.
Friday, May 27, 2011
Heuristic trap
Since starting third-year, I've noticed that sometimes I form preconceptions of what a patient's diagnosis will be before I have examined that patient or even gathered a full history. My preceptor picked up on this when he observed me interviewing a patient this afternoon, and he talked to me about it. He calls it the "heuristic trap." To avoid the heuristic trap is to think as a physician.
Later on in the afternoon, a patient came in complaining of a dry cough that she has had for 8 months. She was also taking a blood pressure medication that can cause a chronic dry cough. The heuristic trap would have been to think that this patient's cough was caused by that medication but fail to fully think of other possible causes.
Instead, I went into the interview armed with this information but pushed myself to think of other causes of her cough. My patient told me that she also gets heartburn everyday, that it's worse when she's bending over to clean the floors, and that it gets better when she eats food, drinks water, and puts milk in her coffee instead of drinking it black. Also, she always sleeps on her side but never on her back. She denied that her cough got worse with exercise or with cold air. This history is very suggestive of gastroesophageal reflux disease (GERD), which can cause a chronic cough due to inflammation of the esophagus.
On exam, her lung sounds were clear making a chronic lung infection and asthma less likely.
Now I could give a proper differential diagnosis and plan when presenting to my attending:
1. GERD - strongly suggested by history
2. Side effect from blood pressure medication
3. Asthma - less likely; not suggested by history, no wheezes on exam
4. Chronic lung infection - less likely; not suggested by history, normal lung exam
We decided to give her a diagnostic treatment of a proton pump inhibitor (which decreases stomach acidity) and follow up in 2 weeks to see if her cough symptoms have improved. If her cough does not resolve, we will consider measuring the pH level in her esophagus to rule out GERD; we would also consider switching her blood pressure medication to one that does not cause cough to rule that out as a possibility.
My mentor says that most physicians must constantly train their minds to avoid the heuristic trap, to think broadly about what might cause a particular set of symptoms. That is, after all, part of a doctor's job description. The third year medical student is at the beginning of that mental training.
Later on in the afternoon, a patient came in complaining of a dry cough that she has had for 8 months. She was also taking a blood pressure medication that can cause a chronic dry cough. The heuristic trap would have been to think that this patient's cough was caused by that medication but fail to fully think of other possible causes.
Instead, I went into the interview armed with this information but pushed myself to think of other causes of her cough. My patient told me that she also gets heartburn everyday, that it's worse when she's bending over to clean the floors, and that it gets better when she eats food, drinks water, and puts milk in her coffee instead of drinking it black. Also, she always sleeps on her side but never on her back. She denied that her cough got worse with exercise or with cold air. This history is very suggestive of gastroesophageal reflux disease (GERD), which can cause a chronic cough due to inflammation of the esophagus.
On exam, her lung sounds were clear making a chronic lung infection and asthma less likely.
Now I could give a proper differential diagnosis and plan when presenting to my attending:
1. GERD - strongly suggested by history
2. Side effect from blood pressure medication
3. Asthma - less likely; not suggested by history, no wheezes on exam
4. Chronic lung infection - less likely; not suggested by history, normal lung exam
We decided to give her a diagnostic treatment of a proton pump inhibitor (which decreases stomach acidity) and follow up in 2 weeks to see if her cough symptoms have improved. If her cough does not resolve, we will consider measuring the pH level in her esophagus to rule out GERD; we would also consider switching her blood pressure medication to one that does not cause cough to rule that out as a possibility.
My mentor says that most physicians must constantly train their minds to avoid the heuristic trap, to think broadly about what might cause a particular set of symptoms. That is, after all, part of a doctor's job description. The third year medical student is at the beginning of that mental training.
Thursday, May 26, 2011
The pace of rural life
It turns out that my mentor does not work on Thursdays. So when Wednesday rolled around, I asked him, "What would you like me to be doing tomorrow?" His reply was that the purpose of me being out here is to experience the life of a country doc and that I should take the day off. Can't argue with that!
I studied in the morning then headed out to Steamboat to meet up with one of the ER doctors at Kremmling who I made friends with. He took me to the Mad Creek trailhead for a "hike" (I ran, he rode his mountain bike) that ended up at Strawberry Springs. We soaked for a little while, ran/rode back down, then I grabbed some dinner at a local diner.
Not a bad way to spend a Thursday afternoon as a third-year medical student!
I studied in the morning then headed out to Steamboat to meet up with one of the ER doctors at Kremmling who I made friends with. He took me to the Mad Creek trailhead for a "hike" (I ran, he rode his mountain bike) that ended up at Strawberry Springs. We soaked for a little while, ran/rode back down, then I grabbed some dinner at a local diner.
Not a bad way to spend a Thursday afternoon as a third-year medical student!
Saturday, May 21, 2011
Geriatric medicine in a nutshell
For the past month, I spent Thursday afternoons at the VA Geriatrics clinic as part of my sub-specialty requirement for Adult Ambulatory Care. My mentor was fantastic. About half of the patients I saw at some point during the interview said of him, "That man walks on water!" For his part, my geriatrics preceptor brushed that off and laid all the credit at his patients' feet for doing the hard work.
From my perspective, there's some truth to both my mentor's story and his patients' claims. He has a special way with his patients, and I tried to glean as much wisdom as possible in my 16 hours with him. The following are some nuggets of wisdom that come either from my observations of his practice or directly from him. They summarize fairly well the practice of geriatric medicine:
From my perspective, there's some truth to both my mentor's story and his patients' claims. He has a special way with his patients, and I tried to glean as much wisdom as possible in my 16 hours with him. The following are some nuggets of wisdom that come either from my observations of his practice or directly from him. They summarize fairly well the practice of geriatric medicine:
- There are three diseases that you need to avoid in order to make it to your 90's: 1) Heart disease, 2) Cancer, and 3) Dementia.
- Likewise, there are three diseases that you will almost certainly have if you are lucky enough to make it to your 90's: 1) Arthritis, 2) Vision loss, and 3) Hearing loss. If you had a practice purely of 90-year-olds, you would likely be focused on those issues.
- In an elderly patient, prevention measures may be less useful in long-term processes such as high blood pressure or cholesterol. When a patient's life expectancy is short (recognizing that we are not very good at predicting it), the benefits of getting their blood pressure or lipids at goal might be outweighed by harmful side effects of medications.
- Avoiding polypharmacy is a big challenge. Always consider whether a drug is truly needed, how it will interact with drugs that the patient is already taking, and the impact of its side-effects on the patient's overall health. This should be true for all patients but particularly so for the elderly who are more vulnerable.
- Improving the quality of life is sometimes more important than extending life.
- Speak loudly and slowly to your elderly patients, smile a lot, ask them about their lives, and listen to their stories with genuine interest.
Friday, May 20, 2011
Housing accommodations for my rural rotation
I finally got my housing situation figured out for my rural rotation, sort of. There was some sort of glitch with the online registration on the AHEC website and because of that the housing coordinators were not aware that I needed housing until last week. Moreover, because Kremmling is a new site, they didn't have a list of potential hosts to draw from. To complicate matters even further, it appears that my mentor's practice is in fact not located in Kremmling but instead in Granby, a town about a half-hour to the east.
Long story short: I will stay for the first few days of my rural rotation in an apartment at Kremmling Memorial Hospital and commute the 30 miles each day to my mentor's practice in Granby. In the meantime, the housing coordinators at AHEC will try to locate better accommodations for me a little closer to work.
It has been kind of strange for the past few days knowing that I will be heading off to the mountains but not having in my mind a clear idea of what to expect. I like a little adventure. I have no doubt that everything will work itself out, especially after talking with the housing coordinator at AHEC who feels so bad about my situation and is working hard to help me.
Long story short: I will stay for the first few days of my rural rotation in an apartment at Kremmling Memorial Hospital and commute the 30 miles each day to my mentor's practice in Granby. In the meantime, the housing coordinators at AHEC will try to locate better accommodations for me a little closer to work.
It has been kind of strange for the past few days knowing that I will be heading off to the mountains but not having in my mind a clear idea of what to expect. I like a little adventure. I have no doubt that everything will work itself out, especially after talking with the housing coordinator at AHEC who feels so bad about my situation and is working hard to help me.
Saturday, May 14, 2011
Good Samaritan
I was getting some work done at St. Mark’s café this afternoon when out of the corner of my eye I saw someone fall over and hit their head on the back of a chair a few feet away. I immediately rushed over to help.
He was a kid in his early 20’s, and he had a laceration over the medial part of his left eyebrow; he was awake and never lost consciousness.
He said that he felt lightheaded when he stood up after tying his shoe. The poor kid felt embarrassed and tried to get up, but I asked him to lie back so I could make sure he was not seriously injured. He was able to tell me his name; his pupils were of equal size, and he could track my finger with his eyes. The eye itself didn’t appear to be damaged. He denied any change of vision and denied feeling tired or nauseous. He denied neck pain and had full range of motion in his neck.
We got him sitting up in a chair, and the barista brought him some water, soup, and a cookie. He was still white as a ghost but was feeling better. I told him to get himself to a hospital right away if he felt drowsy or had any changes in his vision.
Afterward, someone asked me if I am a doctor. “No! I’m just a medical student,” I replied, and it occurred to me for the first time that perhaps I shouldn’t have rushed over to help. I had acted automatically and without thinking. Now that I have had a bit more time to reflect on what happened, I think that I did act appropriately.
Out of curiosity, I looked up Colorado’s Good Samaritan law (CRS §13-21-108):
I am definitely not a licensed physician or surgeon, but I'm pretty sure that I do meet qualifying criteria for "any other person."
He was a kid in his early 20’s, and he had a laceration over the medial part of his left eyebrow; he was awake and never lost consciousness.
He said that he felt lightheaded when he stood up after tying his shoe. The poor kid felt embarrassed and tried to get up, but I asked him to lie back so I could make sure he was not seriously injured. He was able to tell me his name; his pupils were of equal size, and he could track my finger with his eyes. The eye itself didn’t appear to be damaged. He denied any change of vision and denied feeling tired or nauseous. He denied neck pain and had full range of motion in his neck.
We got him sitting up in a chair, and the barista brought him some water, soup, and a cookie. He was still white as a ghost but was feeling better. I told him to get himself to a hospital right away if he felt drowsy or had any changes in his vision.
Afterward, someone asked me if I am a doctor. “No! I’m just a medical student,” I replied, and it occurred to me for the first time that perhaps I shouldn’t have rushed over to help. I had acted automatically and without thinking. Now that I have had a bit more time to reflect on what happened, I think that I did act appropriately.
Out of curiosity, I looked up Colorado’s Good Samaritan law (CRS §13-21-108):
Any person licensed as a physician and surgeon under the laws of the state of Colorado, or any other person, who in good faith renders emergency care or emergency assistance to a person not presently his patient without compensation at the place of an emergency or accident, including a health care institution as defined in section 13-64-202 (3), shall not be liable for any civil damages for acts or omissions made in good faith as a result of the rendering of such emergency care or emergency assistance during the emergency, unless the acts or omissions were grossly negligent or willful and wanton. This section shall not apply to any person who renders such emergency care or emergency assistance to a patient he is otherwise obligated to cover.
I am definitely not a licensed physician or surgeon, but I'm pretty sure that I do meet qualifying criteria for "any other person."
Interviewing patients who only speak Spanish
The patient population of Westside Clinic is 75% Hispanic, a large portion of whom speak only Spanish. This presents the particular challenge of learning how to effectively interview these patients either by using the Denver Health translator service or by trying to interview them myself in Spanish.
I started studying Spanish in middle school, took it all throughout high school, and earned a minor in Spanish in college. I traveled for long periods of time in Spanish-speaking countries, and I grew up in Southern California. Even with all of that Spanish under my belt, I'm still not proficient enough in Spanish to feel like I can effectively interview a patient who only speaks Spanish, without possibly missing something that I wouldn't have missed with an English-speaker.
In fact, studies have shown that there is an increased incidence of medical errors when there is a language barrier. Because of this, a doctor at Denver Health who wishes to provide care in a second language must demonstrate proficiency in that language and be certified as "interpreter status." At least 4 of the attending physicians with whom I have worked these past few weeks have interpreter status for Spanish.
This offers me the opportunity to practice my Spanish in the clinical setting, since my Spanish-speaking supervisors provide quality control. I was very rusty during my first week. Given that I was green as grass my first week, too, I was pretty much a disaster that first week when I was put in with a Spanish-speaking patient.
Since then, though, my Spanish has improved as much as my clinical skills. I'd estimate that I understand about 80-90% of what my patients say and that I'm able to communicate about 70-80% of what I want to say. Those numbers go up if the patient understands even a minimal amount of English. Still, it's not enough for me to feel comfortable that I wouldn't be missing something important that would impact my ability to effectively care for my Spanish-speaking patients.
I have enough of a foothold, though, to justify practicing my Spanish. This past week, I was seeing a Spanish-speaking woman in her 60's who had wildly uncontrolled blood sugars. As I was gathering her history, I got the feeling that she was having a very difficult time emotionally dealing with her diabetes and that she was possibly depressed. I decided to administer the PHQ-9, a questionnaire that screens for depression, and found that she was indeed severely impaired by depression. This was all in Spanish. My attending hadn't picked up the depression during her prior visits, and he ended up deciding to treat her with fluoxetine.
This patient interaction emphasized to me how important it is to be able to communicate with my Spanish-speaking patients in their own language. A good goal for me is to achieve interpreter status in Spanish.
I started studying Spanish in middle school, took it all throughout high school, and earned a minor in Spanish in college. I traveled for long periods of time in Spanish-speaking countries, and I grew up in Southern California. Even with all of that Spanish under my belt, I'm still not proficient enough in Spanish to feel like I can effectively interview a patient who only speaks Spanish, without possibly missing something that I wouldn't have missed with an English-speaker.
In fact, studies have shown that there is an increased incidence of medical errors when there is a language barrier. Because of this, a doctor at Denver Health who wishes to provide care in a second language must demonstrate proficiency in that language and be certified as "interpreter status." At least 4 of the attending physicians with whom I have worked these past few weeks have interpreter status for Spanish.
This offers me the opportunity to practice my Spanish in the clinical setting, since my Spanish-speaking supervisors provide quality control. I was very rusty during my first week. Given that I was green as grass my first week, too, I was pretty much a disaster that first week when I was put in with a Spanish-speaking patient.
Since then, though, my Spanish has improved as much as my clinical skills. I'd estimate that I understand about 80-90% of what my patients say and that I'm able to communicate about 70-80% of what I want to say. Those numbers go up if the patient understands even a minimal amount of English. Still, it's not enough for me to feel comfortable that I wouldn't be missing something important that would impact my ability to effectively care for my Spanish-speaking patients.
I have enough of a foothold, though, to justify practicing my Spanish. This past week, I was seeing a Spanish-speaking woman in her 60's who had wildly uncontrolled blood sugars. As I was gathering her history, I got the feeling that she was having a very difficult time emotionally dealing with her diabetes and that she was possibly depressed. I decided to administer the PHQ-9, a questionnaire that screens for depression, and found that she was indeed severely impaired by depression. This was all in Spanish. My attending hadn't picked up the depression during her prior visits, and he ended up deciding to treat her with fluoxetine.
This patient interaction emphasized to me how important it is to be able to communicate with my Spanish-speaking patients in their own language. A good goal for me is to achieve interpreter status in Spanish.
Wednesday, May 11, 2011
The importance of reading patient charts
A patient came in today complaining of stomach pain and alternating constipation and diarrhea over the last 1-2 months. She wanted a referral for a colonoscopy.
She said that she has had stomach pains since childhood (likely related to abuse that she suffered) but that her stomach got much worse over the past year to the point that she hasn't been able to eat without feeling nauseous and sometimes throwing up. She denied blood in her stool, denied black stools, but said that here stools were "greasy." Moreover, she said that she lost about 50 pounds in the last year without trying to lose weight, going from a waist size 44 to a 34. She denied fevers and chills but said that she sometimes woke up in the middle of the night with the bed drenched in sweat.
She has a 100 pack-year smoking history under her belt as well as a substantial history of drug abuse of many drugs. Her family history is significant for her mother who died of colorectal cancer when she was 60 years old.
I was obviously very concerned about possible colorectal cancer with this history. As I presented the case to my attending, though, she didn't seem to share my concerns. Why not?
My attending had provided me with limited background to this patient's case but threw me in the room without giving me time to review the patient's chart. After I had finished the interview and exam, I didn't have any time to look into the chart before my attending wanted to hear about our patient.
My patient did in fact unintentionally lose 50 pounds in less than a year, but that was two years ago; her weight has been stable since then at a healthy BMI of 24.0. When her weight was in a free-fall, my attending was justifiably very concerned about possible cancer.
My attending tried at the time to convince our patient to get a colonoscopy, but the patient refused. Now she came back a year-and-a-half later because her symptoms got worse, and she was requesting the colonoscopy.
All of this underscores the importance of reviewing the patient's chart and corroborating the patient's story with objective evidence or documentation whenever possible. This patient was unable to provide critical details of her illness that shifted concern away from the possibility of colorectal cancer.
It would be very easy for me to jump to the conclusion: Don't trust patients. It's more complicated than that, though. I think that a large portion of patients are unfortunately poor historians, but it's also true that doctors often rely on patients' subjective experiences in deciding on a course of treatment. My job, then, is to make a judgment call of how much I can rely on the unsubstantiated "testimony" of my patients and to seek objective corroborating evidence whenever possible. That's what a physical exam is for, and that's what chart review is for.
Thankfully, my attending acknowledged that she hadn't given me time to review the chart and that I couldn't have known these pertinent facts that conflicted with the patient's story.
She said that she has had stomach pains since childhood (likely related to abuse that she suffered) but that her stomach got much worse over the past year to the point that she hasn't been able to eat without feeling nauseous and sometimes throwing up. She denied blood in her stool, denied black stools, but said that here stools were "greasy." Moreover, she said that she lost about 50 pounds in the last year without trying to lose weight, going from a waist size 44 to a 34. She denied fevers and chills but said that she sometimes woke up in the middle of the night with the bed drenched in sweat.
She has a 100 pack-year smoking history under her belt as well as a substantial history of drug abuse of many drugs. Her family history is significant for her mother who died of colorectal cancer when she was 60 years old.
I was obviously very concerned about possible colorectal cancer with this history. As I presented the case to my attending, though, she didn't seem to share my concerns. Why not?
My attending had provided me with limited background to this patient's case but threw me in the room without giving me time to review the patient's chart. After I had finished the interview and exam, I didn't have any time to look into the chart before my attending wanted to hear about our patient.
My patient did in fact unintentionally lose 50 pounds in less than a year, but that was two years ago; her weight has been stable since then at a healthy BMI of 24.0. When her weight was in a free-fall, my attending was justifiably very concerned about possible cancer.
My attending tried at the time to convince our patient to get a colonoscopy, but the patient refused. Now she came back a year-and-a-half later because her symptoms got worse, and she was requesting the colonoscopy.
All of this underscores the importance of reviewing the patient's chart and corroborating the patient's story with objective evidence or documentation whenever possible. This patient was unable to provide critical details of her illness that shifted concern away from the possibility of colorectal cancer.
It would be very easy for me to jump to the conclusion: Don't trust patients. It's more complicated than that, though. I think that a large portion of patients are unfortunately poor historians, but it's also true that doctors often rely on patients' subjective experiences in deciding on a course of treatment. My job, then, is to make a judgment call of how much I can rely on the unsubstantiated "testimony" of my patients and to seek objective corroborating evidence whenever possible. That's what a physical exam is for, and that's what chart review is for.
Thankfully, my attending acknowledged that she hadn't given me time to review the chart and that I couldn't have known these pertinent facts that conflicted with the patient's story.
Monday, May 9, 2011
Adult Urgent Care Center: Learning to widen my differential
I had the opportunity this afternoon to accompany one of my attendings during her shift at the Denver Health Adult Urgent Care Center. This is like one step down from the Emergency Room, taking patients who are acutely ill but not necessarily a medical emergency.
One patient I saw was an elderly woman who came in with a subjective fever, chills, sore throat, cough productive of green sputum, and shortness of breath. She had these symptoms for 1 week, but she came in today because her shortness of breath got worse and because her throat hurt so bad she could hardly even drink water let alone eat. She has a 50 pack-year smoking history, and she denied any recent sick contacts or travel.
I could hear her wheezing from across the room. On exam I found an inflamed throat coated with a thick white mucus. Listening to her lungs I heard expiratory wheezes but no signs that there might be a fluid buildup.
When we sent her for a chest x-ray, I was thinking mostly about a possible atypical pneumonia or upper respiratory infection. Her presentation was screaming of an infectious cause so much that I didn't really think much of other possible causes of her symptoms.
On further questioning by my attending physician, my patient reported pain in her back, swelling in her ankles, and sleeping propped up on 3 pillows at night. These together raise red flags for congestive heart failure. Her heart sounded great, though, and I only found a trace amount of fluid accumulation in her lower legs. We ran an EKG on her just in case, and it was unchanged from an EKG done a few months earlier when she didn't have these symptoms. This all pointed away from CHF as the culprit.
My attending also drew my attention to chronic obstructive pulmonary disease (COPD) as a possible cause of her symptoms. However, she had recently done pulmonary function tests that were normal, lowering COPD on the differential.
Her chest x-ray came back with no consolidations making pneumonia much less likely. It turns out that she had reactive airway disease from an acute asthma exacerbation likely caused by a viral upper respiratory infection. We treated her asthma with an oral steroid and an albuterol nebulizer, and we treated her cough with cheratussin.
Even though I was partly right about her illness being infectious in nature, and that it was likely viral, I didn’t pick up that her viral infection was causing an acute asthma exacerbation. The expiratory wheezes should have given it away. More frustrating, I zeroed in too quickly on the infectious nature of her illness to the exclusion of other possibilities such as COPD or CHF exacerbation, which were perfectly reasonable to include in the differential given her past medical history.
This is a typical mistake for a third-year medical student to make – and I learned a lot from it.
One patient I saw was an elderly woman who came in with a subjective fever, chills, sore throat, cough productive of green sputum, and shortness of breath. She had these symptoms for 1 week, but she came in today because her shortness of breath got worse and because her throat hurt so bad she could hardly even drink water let alone eat. She has a 50 pack-year smoking history, and she denied any recent sick contacts or travel.
I could hear her wheezing from across the room. On exam I found an inflamed throat coated with a thick white mucus. Listening to her lungs I heard expiratory wheezes but no signs that there might be a fluid buildup.
When we sent her for a chest x-ray, I was thinking mostly about a possible atypical pneumonia or upper respiratory infection. Her presentation was screaming of an infectious cause so much that I didn't really think much of other possible causes of her symptoms.
On further questioning by my attending physician, my patient reported pain in her back, swelling in her ankles, and sleeping propped up on 3 pillows at night. These together raise red flags for congestive heart failure. Her heart sounded great, though, and I only found a trace amount of fluid accumulation in her lower legs. We ran an EKG on her just in case, and it was unchanged from an EKG done a few months earlier when she didn't have these symptoms. This all pointed away from CHF as the culprit.
My attending also drew my attention to chronic obstructive pulmonary disease (COPD) as a possible cause of her symptoms. However, she had recently done pulmonary function tests that were normal, lowering COPD on the differential.
Her chest x-ray came back with no consolidations making pneumonia much less likely. It turns out that she had reactive airway disease from an acute asthma exacerbation likely caused by a viral upper respiratory infection. We treated her asthma with an oral steroid and an albuterol nebulizer, and we treated her cough with cheratussin.
Even though I was partly right about her illness being infectious in nature, and that it was likely viral, I didn’t pick up that her viral infection was causing an acute asthma exacerbation. The expiratory wheezes should have given it away. More frustrating, I zeroed in too quickly on the infectious nature of her illness to the exclusion of other possibilities such as COPD or CHF exacerbation, which were perfectly reasonable to include in the differential given her past medical history.
This is a typical mistake for a third-year medical student to make – and I learned a lot from it.
Saturday, May 7, 2011
That's a whole lotta burritos
I lived on Chipotle burritos during the first two years of medical school. One of those suckers could get me through 4 hours of straight studying, easy. I started to wonder, as my second year was wrapping up, exactly how many Chipotle burritos I had eaten during those first two years. So I looked back at my bank statements and came up with this chart:
That's 104 Chipotle burritos from August 2009 through April 2011, or an average of 5 burritos per month. I was guessing I would average more like 8 per month. At $6.86 per burrito, that's a grand total of $713.44 spent on Chipotle burritos. Money well spent.
That's 104 Chipotle burritos from August 2009 through April 2011, or an average of 5 burritos per month. I was guessing I would average more like 8 per month. At $6.86 per burrito, that's a grand total of $713.44 spent on Chipotle burritos. Money well spent.
Rural Community: Kremmling, CO
I finally got my placement for Rural Community Care: Kremmling, CO!
Naturally I had never heard of this town, before, so I spent a good amount of time researching it. Kremmling has its own Wikipedia page. I was also able to find their Chamber of Commerce website, which provides a lot of insight into the character of the town and what it has to offer. Aside from being situated a stone's throw away from three national parks, I'm particularly excited that the Quarter Circle Saloon has a pool tournament every Tuesday night!
I contacted the doctor with whom I will be working. He told me that his clinic days are four days a week with Thursdays off, and that he works one weekend per month at Kremmling Memorial Hospital. He also invited me to work with him covering the Triple DHip downhill dirt-bike race in the nearby town of Granby!
I think this is going to be a great experience.
Naturally I had never heard of this town, before, so I spent a good amount of time researching it. Kremmling has its own Wikipedia page. I was also able to find their Chamber of Commerce website, which provides a lot of insight into the character of the town and what it has to offer. Aside from being situated a stone's throw away from three national parks, I'm particularly excited that the Quarter Circle Saloon has a pool tournament every Tuesday night!
I contacted the doctor with whom I will be working. He told me that his clinic days are four days a week with Thursdays off, and that he works one weekend per month at Kremmling Memorial Hospital. He also invited me to work with him covering the Triple DHip downhill dirt-bike race in the nearby town of Granby!
I think this is going to be a great experience.
Adult Ambulatory: Halfway through my first clerkship
Time flies when you're having fun. It's hard to believe that I'm already halfway through my first clinical rotation, Adult Ambulatory Care (AAC). A lot of people have asked me, "What does Adult Ambulatory mean, anyways?" I confess that I wasn't exactly sure, myself, before this clerkship began. Adult Ambulatory is outpatient doctor's office care.
Fourteen of my classmates are in AAC with me. Everyone is placed at their own site, and each site has its own character. A friend of mine was placed with a solo-practice physician where it's just the doctor, one nurse, and my medical student friend. Another classmate of mine was placed at an outpatient clinic in the VA hospital, which has a much more hectic atmosphere.
I was placed at Westside Clinic, which is a satellite clinic of Denver Health. It serves a socioeconomically disadvantaged population, and a large percentage of patients only speak Spanish.
Because of the nature of the doctors' schedules, I don't have one specific doctor who is mentoring me throughout this one-month rotation but instead follow whichever doctor is covering triage for a given shift. This is a stark contrast from my friend's solo-practice experience. So far, I have followed around about a half-dozen doctors, most of them for several shifts. All of my attending physicians are very nice, fun to work with, and invested in helping me improve my clinical skills.
At first, I was uncertain how I would be evaluated by so many mentors. One doctor is primarily responsible for overseeing my education at Westside; all the other doctors provide feedback to that primary mentor, and they synthesize that feedback into a single evaluation. This has meant a little bit of extra work and stress on my part forging good working relationships with many different attendings, but in the end I'm glad for the experience. Each one of them has their own particular style of interacting with patients and preferences of how they want me to present patients to them. I think that this has given me more versatility in the way I communicate with my supervisors.
My schedule is much more luxurious than I could have hoped for. I was expecting to work crazy 'round-the-clock hours, but it turns out that I am essentially working 8am-5pm. When I show up earlier than 8am, the building is locked, and I wait around like a fool for someone with a badge to open the door. I do often stay later than 5pm to read or catch up on my notes, but most of the doctors are gone by 5:30.
I am very aware that my schedule will change dramatically when I start my Internal Medicine rotation in June. But for now, I'm going to have fun and enjoy it while I can!
Fourteen of my classmates are in AAC with me. Everyone is placed at their own site, and each site has its own character. A friend of mine was placed with a solo-practice physician where it's just the doctor, one nurse, and my medical student friend. Another classmate of mine was placed at an outpatient clinic in the VA hospital, which has a much more hectic atmosphere.
I was placed at Westside Clinic, which is a satellite clinic of Denver Health. It serves a socioeconomically disadvantaged population, and a large percentage of patients only speak Spanish.
Because of the nature of the doctors' schedules, I don't have one specific doctor who is mentoring me throughout this one-month rotation but instead follow whichever doctor is covering triage for a given shift. This is a stark contrast from my friend's solo-practice experience. So far, I have followed around about a half-dozen doctors, most of them for several shifts. All of my attending physicians are very nice, fun to work with, and invested in helping me improve my clinical skills.
At first, I was uncertain how I would be evaluated by so many mentors. One doctor is primarily responsible for overseeing my education at Westside; all the other doctors provide feedback to that primary mentor, and they synthesize that feedback into a single evaluation. This has meant a little bit of extra work and stress on my part forging good working relationships with many different attendings, but in the end I'm glad for the experience. Each one of them has their own particular style of interacting with patients and preferences of how they want me to present patients to them. I think that this has given me more versatility in the way I communicate with my supervisors.
My schedule is much more luxurious than I could have hoped for. I was expecting to work crazy 'round-the-clock hours, but it turns out that I am essentially working 8am-5pm. When I show up earlier than 8am, the building is locked, and I wait around like a fool for someone with a badge to open the door. I do often stay later than 5pm to read or catch up on my notes, but most of the doctors are gone by 5:30.
I am very aware that my schedule will change dramatically when I start my Internal Medicine rotation in June. But for now, I'm going to have fun and enjoy it while I can!
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