I saw a patient in the Emergency Department last night (while working with my Foundations of Doctoring preceptor Dr. Browne) who hit his head while falling due to a witnessed tonic-clonic seizure.
It came out in the interview that he has been homeless for 2 months, has been abusing alcohol and marijuana for the same amount of time, and had been sober from both for 5 years before that. In addition to hitting his head, he was complaining of left shoulder pain, right wrist pain, and right knee pain such that he couldn't bear any weight on that leg. His past medical history was also significant for a very serious car accident a few years ago that required surgery on his left eye and left leg.
On physical exam, I didn't notice any head lacerations or bruising (around the eyes or behind the ears) that would have indicated a more serious problem. I noticed that his left eyelid was drooping noticeably (ptosis). Both pupils reacted appropriately when I shone a light in his eyes, but I couldn't reliably compare the size of one pupil to the other. I could passively move his left arm only slightly before causing him pain; he could turn his head to the left and right against resistance, but he couldn't shrug his left shoulder.
During the course of the interview and physical exam, I noticed that my patient became less responsive to my questions. He could hardly keep his eyes open, but he was also not confused, and he was able to follow commands. I became very concerned when he asked me if it was alright if he went to sleep. "Try to keep your eyes open," I said, and after thinking about it for a moment, I decided to go get help.
I interrupted two residents who were talking about another patient and very succinctly described my patient and concerns. They rushed into my patient's room, talked with him briefly, and decided to order a head CT.
The CT came back negative, and the toxicology screen came back positive. The bump on his head wasn't serious; he just needed to sober up. The drooping left eyelid was most likely caused by the car accident a few years ago.
After the excitement was over, I asked my resident if he thought it was appropriate that I asked for his help in this situation. "Absolutely, you did the right thing," he said. The patient didn't smell like alcohol, so in the absence of the toxicology screen we had no way to know what was causing his neurological changes. It's better to err on the side of safety, he said, than to let something important slip by us unheeded.
What I've heard many times over is that the good third-year medical student is a strong advocate for his or her patients and will be appropriately aggressive in that advocacy when it's necessary. It was difficult to interrupt those residents, but I felt that it was necessary to ask their opinion in this case. It was also pretty neat to see how my input directly impacted this patient's care.
I expect that third year will hold many more situations similar to this one.
Showing posts with label Preceptor. Show all posts
Showing posts with label Preceptor. Show all posts
Sunday, April 24, 2011
Saturday, January 30, 2010
A word on switching preceptors
Last semester, I found myself in the unfortunate position of not being satisfied with my preceptorship experience. We were semi-randomly matched to a physician, either associated with the University or out in the community, usually in a specialty that would afford us opportunities to practice general patient interaction skills and be exposed to a range of different patients (Family, OB/Gyn, Peds, Emergency, Internal).
I matched with a doctor practicing occupational medicine, which basically involves seeing patients who were injured on the job. There's also usually some sort of legal involvement: a lawsuit against the employer, requiring the doctor's signature to allow the patient to return to work, or something along those lines.
Being at the nexus of medicine and two arcane systems of law (Federal and State), there were many aspects of occupational medicine that I frankly found distasteful. First, in some circumstances, doctor-patient confidentiality does not exist. My preceptor sometimes had to preface a question by saying, "Now you don't have to answer this because my records are not confidential..." To me, taking away that privileged relationship between doctor and patient subtly shifts the role of the doctor away from first and foremost caring for the patient's health. The societal role that my old preceptor filled is a necessary one, but I didn't have any interest in spending the next two years of my preceptorship in that environment.
There were other consequences of being caught in middle of a tug-of-war between medicine and law. My old preceptor counseled some of his patients that they may be followed or videotaped by their employers who hope to prove that their injuries were not as severe as they claimed. Also, in order to determine how much worker's compensation should be given to a man with a rotator cuff injury, the deficit in the shoulder's range of motion was measured and applied to arbitrary guidelines imposed by the State and Federal governments. Again, I just didn't have any interest in gaining more exposure to that kind of medicine.
I feel it's important to emphasize that, personally, I very much liked my old preceptor. He seemed to enjoy his role as mentor, and I learned a lot from him. I felt bad telling him that I would no longer be coming in; it was like a break-up conversation. But at the end of the day, this is my medical education, and I need to do whatever is in my power to make the most out of it.
Finding a new preceptor
Finding a new preceptor on my own was a lot more difficult than I thought it would be. My strong preference was to work in the emergency room environment, but I kept an open mind to other possibilities, as well. After striking out with several promising leads, I began to grow discouraged about my prospects of finding a new preceptor.
Then, at the end of last semester, I attended a sonography workshop hosted through the Emergency Medicine Interest Group. Afterward, I approached the doctor who ran the workshop, explained that I was looking for a new preceptor, and asked if he knew if any of his colleagues might be interested. "I'll take you," he said, and that is how I met my new preceptor.
I feel very fortunate to be working with Dr. Browne.
I matched with a doctor practicing occupational medicine, which basically involves seeing patients who were injured on the job. There's also usually some sort of legal involvement: a lawsuit against the employer, requiring the doctor's signature to allow the patient to return to work, or something along those lines.
Being at the nexus of medicine and two arcane systems of law (Federal and State), there were many aspects of occupational medicine that I frankly found distasteful. First, in some circumstances, doctor-patient confidentiality does not exist. My preceptor sometimes had to preface a question by saying, "Now you don't have to answer this because my records are not confidential..." To me, taking away that privileged relationship between doctor and patient subtly shifts the role of the doctor away from first and foremost caring for the patient's health. The societal role that my old preceptor filled is a necessary one, but I didn't have any interest in spending the next two years of my preceptorship in that environment.
There were other consequences of being caught in middle of a tug-of-war between medicine and law. My old preceptor counseled some of his patients that they may be followed or videotaped by their employers who hope to prove that their injuries were not as severe as they claimed. Also, in order to determine how much worker's compensation should be given to a man with a rotator cuff injury, the deficit in the shoulder's range of motion was measured and applied to arbitrary guidelines imposed by the State and Federal governments. Again, I just didn't have any interest in gaining more exposure to that kind of medicine.
I feel it's important to emphasize that, personally, I very much liked my old preceptor. He seemed to enjoy his role as mentor, and I learned a lot from him. I felt bad telling him that I would no longer be coming in; it was like a break-up conversation. But at the end of the day, this is my medical education, and I need to do whatever is in my power to make the most out of it.
Finding a new preceptor
Finding a new preceptor on my own was a lot more difficult than I thought it would be. My strong preference was to work in the emergency room environment, but I kept an open mind to other possibilities, as well. After striking out with several promising leads, I began to grow discouraged about my prospects of finding a new preceptor.
Then, at the end of last semester, I attended a sonography workshop hosted through the Emergency Medicine Interest Group. Afterward, I approached the doctor who ran the workshop, explained that I was looking for a new preceptor, and asked if he knew if any of his colleagues might be interested. "I'll take you," he said, and that is how I met my new preceptor.
I feel very fortunate to be working with Dr. Browne.
Sunday, January 24, 2010
Crazy Saturday night in the ER
I went into the ER yesterday for my second preceptor session with Dr. Vaughn Browne. It started off rather slow in the afternoon but turned into quite the night.
There was the guy who came in with possible neck and intracranial injuries after he was hit repeatedly with a blunt object in a drunken fight. It took four security guards and a team of doctors just to keep this guy down, he was thrashing around so bad. "I'm a human being, not an animal!" The decision was finally made to intubate him (sedate him with assisted breathing) in order to protect his neck and head injuries. During all of this, I stood by as a passive observer, shocked.
Then there was the Pentacostal preacher who prophesied the night before that God would inflict him with pain so that his congregation would Believe. He came in with ambiguous chest and flank pain and brought with him half his congregation camped out in the waiting area. The whole work-up was done on him, just in case there was actually a medical basis for his pain, but I'm not sure how that turned out.
Learning how to insert an IV line
Toward the end of the night, I spent some time with Vicky, a nurse who taught me how to insert an IV line. After all of the passive observing I had done so far, I was eager to actually do something and to pick up a new skill. My first patient was a sweet old man who called himself a "professional patient." He was having a tough time of it with kidney problems. His veins were particularly difficult because of his chronic illness, but I was able to get the line in on my second try with minimal fumbling.
My last case of the night was a drunk driver who got in a minor accident that didn't involve anyone else. This guy was very, very drunk. "I'm not sure if this is the best person to practice on," I told Vicky, wary of him becoming belligerent and uncooperative in the middle of my novice attempt to stick him with an IV. Two security guards were in his room, and two more were hanging out outside in case he got out of control. "Come on, he's the perfect person for you to practice on!" Vicky replied with a twinkle in her eye.
At this point, the two security guards were arguing with the patient, trying to get him to lie down. "Watch this," Vicky whispered, "I'm gonna sweet talk him. I'll put on my mommy-face, and he's gonna give us his veins." Vicky has been doing this whole nursing thing for quite some time, and she's good. She calmed the man down in no time, introduced him to me, and before I knew it, I was this guy's best friend. Of course I could take some blood, no problem! In the middle of the procedure, my best friend started thrashing around. All four security guards descended on him, but I had already lost the vein. "That was his fault, not yours," Vicky reassured me. With security holding him down, I got it on the next try. Adrenaline was pumping when I left the room, and I didn't really calm down until I got home.
"Now try doing that in the back of a speeding ambulance."
There was the guy who came in with possible neck and intracranial injuries after he was hit repeatedly with a blunt object in a drunken fight. It took four security guards and a team of doctors just to keep this guy down, he was thrashing around so bad. "I'm a human being, not an animal!" The decision was finally made to intubate him (sedate him with assisted breathing) in order to protect his neck and head injuries. During all of this, I stood by as a passive observer, shocked.
Then there was the Pentacostal preacher who prophesied the night before that God would inflict him with pain so that his congregation would Believe. He came in with ambiguous chest and flank pain and brought with him half his congregation camped out in the waiting area. The whole work-up was done on him, just in case there was actually a medical basis for his pain, but I'm not sure how that turned out.
Learning how to insert an IV line
Toward the end of the night, I spent some time with Vicky, a nurse who taught me how to insert an IV line. After all of the passive observing I had done so far, I was eager to actually do something and to pick up a new skill. My first patient was a sweet old man who called himself a "professional patient." He was having a tough time of it with kidney problems. His veins were particularly difficult because of his chronic illness, but I was able to get the line in on my second try with minimal fumbling.
My last case of the night was a drunk driver who got in a minor accident that didn't involve anyone else. This guy was very, very drunk. "I'm not sure if this is the best person to practice on," I told Vicky, wary of him becoming belligerent and uncooperative in the middle of my novice attempt to stick him with an IV. Two security guards were in his room, and two more were hanging out outside in case he got out of control. "Come on, he's the perfect person for you to practice on!" Vicky replied with a twinkle in her eye.
At this point, the two security guards were arguing with the patient, trying to get him to lie down. "Watch this," Vicky whispered, "I'm gonna sweet talk him. I'll put on my mommy-face, and he's gonna give us his veins." Vicky has been doing this whole nursing thing for quite some time, and she's good. She calmed the man down in no time, introduced him to me, and before I knew it, I was this guy's best friend. Of course I could take some blood, no problem! In the middle of the procedure, my best friend started thrashing around. All four security guards descended on him, but I had already lost the vein. "That was his fault, not yours," Vicky reassured me. With security holding him down, I got it on the next try. Adrenaline was pumping when I left the room, and I didn't really calm down until I got home.
"Now try doing that in the back of a speeding ambulance."
Witnessing death
During my preceptor experience yesterday, I watched for the first time as someone died in front of me. A man in his mid-50's had a heart attack. He got CPR right away, even before the paramedics arrived at the scene, but he flat-lined soon after arriving at the ER 20-30 minutes later.
In these situations, the medical students are usually told to stand by in case the team needs CPR relief. This man didn't make it that far, though. I watched as the emergency team did their thing, trying my best not to get in the way. Then, before I knew it, the attending physician called time of death, and the entire operation was shut down.
I looked at the man on the table, who was now just a body to all the doctors and nurses and techs in the room. His eyes were partly open, and he still wore a bling watch on his left wrist, as if time still mattered to him. I wondered what he experienced, if anything, in those last few moments before the doctors decided that he could not be saved. If he had survived, would he have reported some sort of near-death experience like walking toward a bright light or talking to a dead relative? That would be too Hollywood.
I asked another doctor, after all the excitement had passed, why his death was so quickly called. Her answer was that we have to weigh the morbidities for someone who has been down for almost a half-hour. Even if they had been able to re-establish a heartbeat, it's likely that this man would have suffered severe brain damage, possibly to the point of persisting in a vegetative state.
In my training to become a doctor, I am certain to witness death again. It is inescapable, because Life is the currency of the profession that I chose.
In these situations, the medical students are usually told to stand by in case the team needs CPR relief. This man didn't make it that far, though. I watched as the emergency team did their thing, trying my best not to get in the way. Then, before I knew it, the attending physician called time of death, and the entire operation was shut down.
I looked at the man on the table, who was now just a body to all the doctors and nurses and techs in the room. His eyes were partly open, and he still wore a bling watch on his left wrist, as if time still mattered to him. I wondered what he experienced, if anything, in those last few moments before the doctors decided that he could not be saved. If he had survived, would he have reported some sort of near-death experience like walking toward a bright light or talking to a dead relative? That would be too Hollywood.
I asked another doctor, after all the excitement had passed, why his death was so quickly called. Her answer was that we have to weigh the morbidities for someone who has been down for almost a half-hour. Even if they had been able to re-establish a heartbeat, it's likely that this man would have suffered severe brain damage, possibly to the point of persisting in a vegetative state.
In my training to become a doctor, I am certain to witness death again. It is inescapable, because Life is the currency of the profession that I chose.
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