The Medical Apprentice

The start of a new month brings about another new rotation.  Just as Toledo seems to be a battleground in the Michigan/Ohio State rivalry, my away rotations are equally split.  After a month at the University of Michigan I am heading down to Ohio State.  For November I will be completing an elective in Pediatric Emergency Medicine at Nationwide Children’s Hospital in Columbus.  I really enjoyed my time in the ED at UTMC during my third year clerkship, so I’m looking forward to this upcoming month.  I have heard that Nationwide Children’s is always quite busy, and with H1N1 there will certainly be no shortage of patients. 

I enjoyed last month’s rotation in Pediatric GI at Michigan.  Even though it was a subspecialty month, I saw a great deal of general pediatrics.  I think being able to manage the common complaints is just as important as caring for the rare “zebras” that are found at large tertiary care centers.  I gained a lot of experience in evaluating the “bread and butter” of pediatrics, from growth and nutrition to constipation and vomiting.    

Stories from the pediatric ED coming soon!

Hot chocolate made with butter and heavy cream

A bowl of cereal with whole milk

Mayonnaise as a dip for raw vegetables

Extra eggs and powdered milk for pancake batter

Gravy for just about any dish

No, these aren’t tidbits from Paula Deen’s latest cookbook.  Nor were they used by the child-devouring witch to fatten up Hansel and Gretel.  They’re actually some of the suggestions given by nutritionists for children who need to increase their caloric intake.  While a high calorie diet is the last thing the average American might need, I’ve encountered many children on my GI rotation that are benefiting from this change in diet.  Our body digests food and absorbs nutrients through the GI tract.  Therefore any disorder disrupting the function of this system has the potential to cause malnutrition.  Adequate nutrition is crucial for child growth and development, so early intervention in this area is extremely important. 

During this month I’ve had the opportunity to rotate through a number of interdisciplinary clinics.  These bring together healthcare workers from a variety of fields that work together to care for patients with complex medical issues (such as the Intestinal Rehabilitation or Liver Transplant clinic).  Instead of making appointments and tromping around the hospital to see multiple people, patients and their families come to one clinic.  Families set up shop in a single exam room to be seen by multiple healthcare professionals.  In addition to the physician, a nurse might assess medication compliance or recent health issues.  A dietician will monitor weight gain and ensure the child is receiving adequate carbohydrates, fats, and protein.   A PharmD looks at medication dosages, efficacy and monitors for side effects.  A social worker helps families adjust to caring for a sick child and advocates for whatever help they might need (financial assistance, medical leave, or special accommodations at school).

As a student in these clinics I often get assigned to one family.  I then go in with each member of the team for their assessments.  It’s been interesting to witness each person’s role.  The teaching has been great too (i.e. calorie counts or updating TPN orders with a nutritionist).  It’s nice to see folks from many different fields taking an active role in clinical education.  After all, there are many people in the hospital that med students can learn from, other than physicians.  Interdisciplinary clinics have plenty to teach students (including the decadent new places to add butter on the menu!)

The physical exam is an important part of any clinical evaluation. For a child, getting poked and prodded by a complete stranger can be quite scary. Throughout my rotations I have discovered that pediatricians have quite the arsenal of games and tricks to help get what they require from an exam while keeping the child as comfortable as possible. Ears can be examined while the child is in their parent’s arms.  A fun sticker or penlight can keep an infant quiet long enough to listen to their heart and lungs. Having a child talk about this year’s Halloween costume helps them relax their tummy and allow for an abdominal exam.

Fun games and distractions can help disguise a physical exam. In a similar way, sometimes a disease can present appearing to be something else. For example, in the Peds GI clinic they commonly evaluate children who have symptoms of gastroesophageal reflux but have not found relief with diet changes and commonly used medications. Luckily there are plenty of tests available to help clinicians sort through all the potential causes. In this case, one such test in an esophagogastroduodenoscopy (EGD). It looks down the throat with a tiny camera to visualize the esophagus, stomach, and first part of the small intestine. Biopsies can be taken, and these little pieces of tissue can provide clues that point to the underlying cause of a patient’s symptoms.

Each week the Pediatric GI team at U of M has a pathology conference. The team meets with a pathologist to look at biopsies from the previous week. We gather around an elaborate microscope that allows everyone to look at the same slide. In this way the team is able to correlate a patient’s clinical presentation to findings on the histologic (tissue) and cellular level. These conferences are a great refresher of classes from my pre-clinical years, and we’ve seen some interesting cases. It is pretty amazing how quickly the pathologists can pick out seemingly subtle changes under a microscope.

Though more invasive means are required to obtain them, biopsies can provide a more definitive idea of what process is causing a patient’s symptoms. That case of gastroesophageal reflux actually turned out to be eosinophillic esophagitis, a disorder that can present the same way but require different treatment.  It seems that it can sometimes take months to find the true cause of a little guy’s discomfort, so it’s a big relief to families to finally get the right diagnosis.

“Hi, my name is Pat Clements, and I’m a medical student.  I know we just met, but I’m going to take a seat and ask you thirty questions or so about your bowel habits.”

This month I am doing an “away” elective.  Fourth-year med students can apply for electives at other medical schools, adding to their clinical experiences and allowing them to visit residency programs in their field of interest.  I’m up at Mott Children’s Hospital at the University of Michigan.  I am rotating in Pediatric Gastroenterology, the specialty that deals with the digestive system.  Disorders of these organs impair the ability to eat, digest food, absorb nutrients, and excrete waste.

U of M has a pretty big pediatric referral base, so plenty of interesting cases come their way.  I’ve already seen a couple of “mythical” diseases (ones that I thought existed only in textbooks).  At the same time, the majority of my days in clinic I see the “bread and butter” of Pediatric Gastroenterology.  These are patients referred for evaluation of constipation/diarrhea, vomiting, and failure to adequately grow.

When interviewing a patient and their family, particular questions are asked during the review of systems.  For GI, the questions are focused heavily on diet and bowel habits.  As you can imagine, these areas are sometimes a bit strange to talk about.  There’s even a standardized scale to help move the conversation along.  The little guys look back with wide eyes to their parents.  Does he really want me to talk about my poop?  On the other end of the spectrum are the young adults, often mortified to have to talk about their sometimes embarrassing problems.  Issues with the GI system can cause a lot of frustration and discomfort for children and parents alike.  Hopefully in the end the solution makes the child healthier and gives them a better quality of life, making the awkward “GI interrogation” well worth it.

This month will hopefully give me a good exposure to patients with the spectrum of gastrointestinal illnesses, plus increase my experience in evaluating growth and nutrition.  I’ll try not to mention bowel movements in every blog, but no guarantees!

My four weeks in the Pediatric Intensive Care Unit flew by, and once again I find myself on a new rotation.  I had an amazing time in the PICU at Toledo Children’s, so I’m a bit bummed to be leaving.  This month I am doing pediatric GI, working mainly in outpatient clinics.

One big difference about working in the outpatient setting is that I won’t be on-call.  I definitely enjoyed taking call, despite the havoc it sometimes wreaked on my sleep cycle.  It seems that my best “lightbulb” learning moments and most interesting patients from my clinical rotations have always came in the middle of the night.  The hospital is definitely a different world after dark.  The wards seem deserted and are eerily quiet.  My fellow acting intern Dusty and I were on-call together a few nights.  It was cool to be able to bounce ideas off one another regarding our patients or partake in the cafeteria’s amazing late-night taco bar. 

Almost every night I took call the unit received a patient with a familiar story.  While in high school, I remember helping to fill up my grandmother’s pill containers each week.  It had seven compartments marked Sunday through Saturday to help her keep track of her medicines.  While this is a great organizing tool, there were quite a few nights when I saw the potentially devastating effects when children got ahold of them.  We saw little guys admitted for suspected drug overdoses, and their stories were similar.  A parent walked back into a room to find a chair pushed over to the kitchen counter, half-empty bottles of medication on the floor, or a child who simply said “I ate the purple ones”. 

The thought of two-year-olds consuming large amounts of multiple medicines is certainly a scary one.  However, strictly from an academic standpoint, working up patients for drug overdoses is pretty interesting.  The pills in question treated some of the most common “American” medical problems (pain, hypertension, diabetes, anxiety).  Each one tweaked the body’s physiology to provide its effect.  When evaluating an overdose you have to look at each medicine and understand how it works.  What is the mechanism of action?  What is the drug’s half-life? (aka how long will the drug be in the body?)  What organ systems will be affected by toxicity, and how should we monitor for adverse effects?  These impromptu pharmacology reviews were really important to deciding a plan of care.  I made plenty of late-night calls to poison control to ensure that we were covering all our bases.

Luckily the kids I saw those nights had good outcomes.  Most of them stayed in the unit for observation and were sent home the next day.  With these cases I saw firsthand the importance of keeping medicines and other chemicals locked and stowed away from kids.  The average family medicine cabinet can provide remedies to almost every illness under the sun.  For little guys this stockpile might look like a colorful mix of Jelly Belly’s, but accidental overdoses can have disastrous consequences (not to mention the purple ones don’t taste like grape!)

Yesterday I had the chance to participate in the Komen Northwest Ohio Race for the Cure.  The program promotes breast cancer awareness and raises money for expanded access to screening and research.  Most importantly, it is a chance for our community to come together and recognize those affected by breast cancer.  I imagine that almost all of us have family or friends who have faced this disease.  My friends and I were part of Team Barb, walking in memory of our friend Megan’s mother who died of breast cancer this past spring.       

In the past I’ve been active in Relay for Life, but this was my first Race for the Cure.  I was amazed by how many people participated!  Over 18,000 ran or walked the 5K course downtown.  Toledo’s is actually one of the largest Race for the Cure events in the country!

It was really cool to see so many people unite with a common goal, and there was a lot of positive energy.  Along the route they had live music and plenty of folks cheering you on.  I’ll have to admit there was one moment that cast a bit of a shadow on the day.  Towards the end we were walking behind a group of people who were smoking cigarettes (my friend Jon nicknamed them the menthols for mammograms team!).  It was odd to see folks actively increasing their risk of getting cancer at a cancer awareness event!  But luckily they didn’t put a damper on our day.  Though we had only walked it, we took a chance at the end to get an exaggerated exhaustion picture. 

It seemed like everyone had a great time.  In the sea of thousands I’m sure there were many from the UT community that participated.  Share your story!  How did the event go for you?  Who were you honoring as you ran or walked?

The phlebotomists did not know what they had coming.  He was small but feisty.  My little brother Mike and I (5 and 7 years old at the time) had just visited our pediatrician for a check-up.  My brother unfortunately had to get a blood test.  Since needles and five-year-olds don’t generally mix well, there wasn’t anything quick or easy about it.

We walked over to the lab. My mom led my anxious brother back to the room, leaving me in the lobby to catch up on the latest edition of Ranger Rick.  I barely made it through the first pages when I heard my little brother’s disapproval.  There was loud screaming and crying followed by a burst of commotion.  My determined little bro had somehow evaded the needle’s poke and made a break for it!  His escape took him as far as the front desk before he was scooped up and carried back into the room.  The cavalry was called, and it took three nurses to hold him steady.  The screams echoed through the lobby.  The waiting patients had wide eyes and nervous smiles as they undoubtedly wondered what torture was taking place down the hall.  Finally they were able to successfully draw the blood they needed.  My brother emerged with a taped piece of gauze as the only evidence of the struggle.  His face was bright pink and puffy from all the crying.  Going to the doctor traditionally earned you a sucker, and that day my little bro came out clutching the entire bag!

When caring for adults on the hospital wards, daily labs are quite common.  They can be useful in tracking a patient’s anemia, electrolyte balance, or kidney function.  It seems a bit easier to convince adults of the importance of the occasional unpleasant hospital experiences, like blood draws or diagnostic scans.  The hospital experience for a child can be incredibly scary.   There are beeping machines, medical instruments, and strangers wearing gloves and masks.  For little ones this can be a living nightmare, so it’s no wonder why kids get frightened (and occasionally run away from phlebotomists!)

What strikes me most about the pediatric hospital experience is the commitment to keeping kids safe, relaxed, and entertained.  From doctors and nurses to social workers and therapists, it seems that everyone is focused on ensuring children and their families are comfortable.  In the Pediatric ICU all the scary medical equipment is still there.  But you’ll also find plenty of toys, movies, and videogames.  This commitment to comfort also means diligent efforts to minimize needle sticks and other scary moments.  Obviously some of these are necessarily evils (like lumbar punctures to evaluate for meningitis).  However, it has been refreshing during rounds to think about exactly which tests are necessary for determining the plan of care, helping to minimize discomfort.  From Sponge Bob to chocolate ice cream, little things can go a long way in making the hospital less frightening for little guys. 

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Speaking of needle pokes, I got my flu shot this past week.  Remember that this year there are two shots, the seasonal flu and upcoming H1N1 vaccinations.  Flu shots are important, especially for healthcare workers.  An infection that might give me relatively mild symptoms could cause a potentially devastating illness for others I come in contact with.  If you haven’t had the chance, be sure to check out the university’s H1N1 influenza website.  It has a great deal of information on what you can do to stay healthy this flu season.

Growing up, my street was on a bit of a hill.  It was annoying to lose a ball into the road and have it stop rolling a dozen houses down.  Learning to ride a bike was especially challenging.  During the training wheel transition I had plenty of near misses (and full-blown crashes) with trees, fire hydrants, and mailboxes.  Though I got plenty of scrapes and bruises along the way, in the end I somehow managed to master the two-wheel art. 

This week I’ve felt my educational “training wheels” begin to loosen.  My classmates and I submitted our applications for residency, and some have already started to receive invitations to interview.  This month I am doing an acting internship (AI) in the Pediatric Intensive Care Unit (PICU).  AI’s are chances for 4^th year students to assume the roles and responsibilities of 1^st year residents (aka interns).  We have the opportunity to manage a larger number of patients and be more involved in the day-to-day plan of care than a student normally would. 

I’m working in the PICU at Toledo Children’s Hospital.  At first I was a bit nervous about starting in an area that took care of the most critically ill little ones in the hospital.  It certainly felt like I was jumping into the deep end of the pool.  However I’ve managed to stay afloat so far and learn a great deal.  The majority of the kids I saw this week had respiratory problems including pertussis, croup, and status asthmaticus.  Fortunately I was able to see most of the little whoopers, croupers, and wheezers improve enough to leave the unit.

As a student it seems I am constantly reminded of how “green” I remain in many areas.  I wrote almost all the orders for my patients this week, with an attending physician co-signing them.  While there are plenty of equations and protocols for calculating fluids and medication doses, so much of practicing medicine is based on experience and that clinical “gut” instinct.  Is this child ready to be taken off continuous aerosol treatments?  Should I recheck his potassium level in 6 or 12 hours?  Do the steroids alone account for this high blood sugar?  Luckily I have gotten some great practical advice from my preceptors and some tremendous nurses.  Perhaps realizing just how much there is to learn is the most authentic “intern” experience one can have.

I’m glad to have this acting internship to give me a preview of what residency will be like.  There’s a mix of exhilaration and a bit of terror that comes with removing training wheels.  I look forward to what this month has in store for me (while hopefully avoiding wayward trees or fire hydrants in the process!)

Well tomorrow is the big day.  I’m taking the next part of my medical boards, known as the USMLE Step 2 CK.  The computer-based exam covers pretty much all of med school so far.  It’s quite the marathon with 368 questions over 8 hours, plus an hour of break time.  All the questions are based around patient cases with x-rays, labs, and plenty of pictures to complete the story. 

Students taking their medical boards are fortunate enough to have a testing center right on campus.  The Academic Testing Center is located in the Center for Creative Education on the HSC.  It’s great that students don’t have to worry about traveling out of town and can sleep in their own bed the night before the big test.  The proctors for boards are the same folks who proctor all med school exams, so it’s nice to see some familiar faces.  They do their best to ensure that everything runs smoothly and the environment is as relaxing as can be.  If it wasn’t for the mental bombardment it wouldn’t be such a bad place to hang out!

This is one of the last tests I’ll have to take before I graduate.  I look forward to a time when I won’t have the dark cloud of an exam constantly hanging over me.  But such is the life of any student; we are chronic test takers.  When it comes to exams, it’s obviously helpful to crack the books beforehand.  Yet attitude on the big day also plays a huge role.  Even if your palms are sweaty and your belly is producing sounds you’ve never heard before, you have to stay positive and take your seat with confidence.  Whether you call it moxie, mojo, or swagger, I think the best way to give yourself a boost before a big test is with music.  Here are some of songs I’ll have on my iPod before the exam.

Europe – “The Final Countdown”

Muse – “Time is Running Out”

One Block Radius – “Loud and Clear”

MGMT – “Kids”

The Killers – “All These Things that I’ve Done”

So what are some of your favorite pre-exam swagger songs???

August has turned out to be quite the busy month!  In a little over a week I’ll be taking the USMLE Step 2.  It’s a daylong national licensing exam that students take before finishing medical school.  I’ll be happy to get it over with.  There’s nothing more frustrating than spending a beautiful summer’s day stuck studying at the library.  As if getting ready for boards wasn’t fun enough, my classmates and I will be starting to submit our applications for residency at the beginning of next month.  This is the first step in the process that will ultimately lead us to our specialty training that begins after graduation next June.  Like all senior years seem to be, it’s an exciting but stressful time. 

This week the newest medical students are going through orientation.  Welcome to UTCOM!   You have quite the journey ahead of you, but I think you’ll really enjoy it.  Just watch out for wayward cement trunks as you navigate your way around the HSC!

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Perhaps the quintessential American vacation is the summer RV road trip.  Over the past month I’ve been able to spend some nights in an RV of sorts, except this one is designed to provide healthcare almost anywhere you can pull over and park.  St. Charles Mercy Hospital operates a mobile health van.  Throughout the year the unit provides health screenings, educational programs, and medical care throughout northwest Ohio. Working in conjunction with FLOC (Farm Labor Organizing Committee, AFL-CIO), the mobile health van has been offering free medical care to migrant workers in our area.  Given the nature of migrant work, it’s often difficult for folks to receive medical care (especially preventative care at well-visits).  The unit had been spending an evening each week at a different camp in our region.  Staffing the unit were physicians and nurses, including quite a few from UTMC.  I helped out with other medical student volunteers from the Community Care Clinic.

Inside the van were two exam rooms and an area for medicines and supplies.  It was tight maneuvering as the patients had their vitals checked, were examined by the medical team, and then picked up their prescriptions.  Not all the volunteers spoke Spanish, but our close quarters meant that an interpreter was always nearby.    

We would set up shortly after dinner and saw patients until well after dark.  A majority of them were young men who arrived after a long day of working the fields.  There were also a fair number of women with their children.  Many were there for basic well-checks.  Others had concerns related to their work, including lower back and knee pain, eye irritation from the sun and dust, and respiratory problems.  Many of the kiddos were seen for upper respiratory and ear infections.  Some patients required tests beyond our capabilities (say, at a clinic or hospital not on wheels), and were referred accordingly. 

On one of our busier evenings we had three doctors working.  Since there were only two exam rooms inside the van, we decided to set up a station outside.  After popping open the rear door of a minivan we were good to go!  It was a pleasant view as the sun set over the cornfields.  That night we saw plenty of kids, including a child with a burn.  He reminded me of the little girl I saw in Tanzania who had a severe burn, but luckily his wasn’t too bad.  We sent the little guy on his way with a clean dressing.  The sun went down and we enlisted the local kids to hold flashlights so we could finish up.  One of our last patients that evening was a preschooler who was having difficulty breathing.  We sat him on the bumper of our minivan clinic for an aerosol treatment.    

It was fun brushing up on some medical Spanish, though it was a little painful getting that part of my brain working again.  Christy (the other fourth year student) and I tried our best to take the “senior” role, teaching the other students a few things as we went along.  We certainly learned a lot from the upperclassmen when we were in their shoes, so it was important to pass on as much as we could.  It was nice to take a break from studying to do a little teaching.

In a single night the clinic would see between thirty and sixty patients.  It reminded me a lot of mission work, but this time it was in our own backyards.  We met some kind people who were leading some pretty tough lives.  While we couldn’t move mountains, there were always little things to be done that could make big difference for those we served.