1. Don't cut in line (especially for senior schedule appointments...not nice)
2. Don't be afraid to ask for help (for that IV on the Hepatitis C dude that you can't seem to get)
3. Be careful with sharp objects (like your suture-cutting scissors during a surgery)
4. Listen when others are talking to you (comes in handy with taking a history from a patient)
5. Tuck in your shirt (and don't have an attending have to tell you this)
6. Take turns (don't answer every.single.question that the attending asks, you just look like a smartypants)
7. Don't take things that belong to others (don't be jacking my gel pens! they are the best for charting)
8. Don't hit people...especially patients, even when they are annoying you. Although I must say my patients never annoy me the way my classmates do.
9. Wash your hands before you eat. And after you do a pap smear. Among other times.
10. Put things away when you're finished with them (don't leave your sponges and needles in anyone's abdomen)
Tuesday, April 14, 2009
Wednesday, April 1, 2009
Patient Autonomy
I have a patient on my current service who desperately needs a blood transfusion. For her own reasons which she has not disclosed to anyone, she refuses. Iron, Procrit, folate - she'll take these willingly and eagerly. But mention a blood transfusion and she shuts down totally. It's not to the point yet where she is going to deprive her organs of oxygen at rest, but she's bed-bound and any time she gets up she's short of breath because she has too few red blood cells in her vessels to pick up oxygen, so her body reacts by making her breathe at a faster rate.
The situation is complicated by the patient's psychiatric issues, which are incidentally not her primary reason for the current hospitalization. She has a health care proxy who has consented for blood transfusions, but the medical team is reluctant to infuse an uncooperative patient who could lash out at the nursing staff during the transfusion. Though we have orders from Psych to sedate the patient if necessary, no one wants to do that yet due to some other complicating issues pertaining to her care.
I told my fellow (doctor superior to a resident but not as senior as the attending) today that I thought I could convince the patient to accept the transfusion. She seems to like me, and I've cared for her every day for two weeks now. As the medical student I have more time than anyone else to hang around her room and chat, and in the mean time investigate her motivations and fears about her transfusion. Technically we already have a consent form in the chart for a transfusion, but if someone could get the patient on board it would be better all around.
When I mentioned this on rounds, the resident scoffed and reported that it was not our job to "babysit crazy patients" and insisted she had already tried to talk to the patient about the transfusion and she refused.
I was really irritated because the resident is lazy (the service has 6 patients under the care of 4 residents and 4 students; we have plenty of time to deal with these kinds of issues that go unattended on a busier week) and because she's writing off this patient as "crazy" because of her psychiatric issues.
This is a patient who is dealing not only with psychosocial issues and psychiatric problems, but is being worked up for a potentially life-threatening condition. She may be facing multiple rounds of chemotherapy. It is in the best interest of the patient to get her blood counts up to normal levels before the treatment begins. In this situation, the patient has been deemed incapable of making her own decisions medically, but that doesn't mean we can't try our best to get her on board with the best measures of care.
I get really irritated when I see this crap happening. Lazy residents are annoying. Dumb residents are frustrating. But lazy, dumb residents are a danger.
At least now I have extra motivation to convince this patient to accept a transfusion tomorrow.
It would look awesome on rounds to prove that resident wrong!
The situation is complicated by the patient's psychiatric issues, which are incidentally not her primary reason for the current hospitalization. She has a health care proxy who has consented for blood transfusions, but the medical team is reluctant to infuse an uncooperative patient who could lash out at the nursing staff during the transfusion. Though we have orders from Psych to sedate the patient if necessary, no one wants to do that yet due to some other complicating issues pertaining to her care.
I told my fellow (doctor superior to a resident but not as senior as the attending) today that I thought I could convince the patient to accept the transfusion. She seems to like me, and I've cared for her every day for two weeks now. As the medical student I have more time than anyone else to hang around her room and chat, and in the mean time investigate her motivations and fears about her transfusion. Technically we already have a consent form in the chart for a transfusion, but if someone could get the patient on board it would be better all around.
When I mentioned this on rounds, the resident scoffed and reported that it was not our job to "babysit crazy patients" and insisted she had already tried to talk to the patient about the transfusion and she refused.
I was really irritated because the resident is lazy (the service has 6 patients under the care of 4 residents and 4 students; we have plenty of time to deal with these kinds of issues that go unattended on a busier week) and because she's writing off this patient as "crazy" because of her psychiatric issues.
This is a patient who is dealing not only with psychosocial issues and psychiatric problems, but is being worked up for a potentially life-threatening condition. She may be facing multiple rounds of chemotherapy. It is in the best interest of the patient to get her blood counts up to normal levels before the treatment begins. In this situation, the patient has been deemed incapable of making her own decisions medically, but that doesn't mean we can't try our best to get her on board with the best measures of care.
I get really irritated when I see this crap happening. Lazy residents are annoying. Dumb residents are frustrating. But lazy, dumb residents are a danger.
At least now I have extra motivation to convince this patient to accept a transfusion tomorrow.
It would look awesome on rounds to prove that resident wrong!
Thursday, March 12, 2009
Play nice.
There's nothing better on a crappy rotation than having good residents, or even better, good fellow students on your team. The benefits of good residents are obvious; it's akin to having a cool boss that you really like. You don't get screamed at when you mess something up, the rules are reasonable, and they let you go home when your work is done.
The benefits of good student teammates are a little harder to understand. It's similar to having good coworkers, I guess. It's always better to work with people who don't annoy the shit out of you. But there's this extra layer of competition on medical school (that I tolerate because I'm too far in debt to drop out, but it is so annoying to deal with) that turns some students who seem normal into these crazy, achievement-hungry brownnosers who will throw you under the bus in the blink of an eye if it means making themselves look good.
There are a few breeds of medical student that make me groan when I see their name next to mine on the rotation assignment sheet.
1. The Scut-Seeker: These students are generally pleasant and helpful. The problem is when they don't know how to say no. Pair this student up with a lazy resident or intern and you have disaster. The resident instantly recognizes the doormat potential in this student and puts him or her (usually her; why can't women say no!??!) to work doing pointless tasks, which we call "scut". These tasks usually are unrelated to patient care and involve things like making copies, fetching coffee, running prescription pads down to the ER to another resident who ran out (this really happened and I could not believe it...the student was being scutted out by some resident on another service who paged our resident asking for scripts!!). Usually the Scut-Seeker is too nice, too spineless or too fearful of a bad evaluation from the resident to say no. This makes the rest of the students on the team who refuse to be scutted out look lazy, uncaring and unhelpful. Not good.
2. The Closet Gunner: In med school, the term "gunner" refers to a student who is so hell-bent on getting the top score that he or she (usually a he, in my experience) will stop at nothing to tear other students down in order to get to the top. The Gunners are easily recognizable and although they're awful, their motives are transparent and everyone usually agrees that they suck. The Closet Gunner is a different animal. This student is one who pretends to not care about grades or evaluations, is generally "too cool" to stress out over something, and appears to be a pretty normal, harmless teammate. Their true colors are revealed on attending rounds, which consist of walking around the hospital to visit the bedside of interesting patients, then discussing the case in the hallway. These discussions usually involve the attending asking lots of questions and students racking their brains to come up with an answer. The unspoken rules of attending rounds state that if the patient being discussed belongs to a particular student, then that student gets a few seconds to answer the questions before other students start chiming in. Closet Gunners will not abide by these rules. They will usually talk over another student, or answer all of the attending's questions without allowing other students time to think. They'll make other students look bad by answer questions about their patients, and are generally so busy kissing the ass of the attending that they don't notice the rest of the team rolling their eyes at him all morning.
3. The Frat Brother: This student can be good or bad. Usually these students are fun-loving, pleasant, and hardworking, if a bit annoying when they talk about how many beers they drank last weekend or how their "boys" are going to come visit this weekend and he can't wait to "pick up some chicks" with them. The trouble starts when The Frat Brother is placed on a team with a Frat Brother Attending or Frat Brother Resident. Then they spend all of their time talking about college, beer, "chicks", "bitches", and how much they can bench press. The rest of the students are marginalized and forgotten about because they are unable to forge such connections as are seen between Frat Brothers. The Frat Brother will get the best evaluation from the Frat Attending and Frat Resident, because Brothers look out for each other. Ugh. Annoying.
On this last rotation, I was paired with a Closet Gunner and a Scut-Seeker. Thankfully I also had a Hilarious Person and a Friend on the team with me, so the three of us yukked it up on the sidelines and let the other clowns run themselves ragged trying to impress people. Thank god this rotation is over!
The benefits of good student teammates are a little harder to understand. It's similar to having good coworkers, I guess. It's always better to work with people who don't annoy the shit out of you. But there's this extra layer of competition on medical school (that I tolerate because I'm too far in debt to drop out, but it is so annoying to deal with) that turns some students who seem normal into these crazy, achievement-hungry brownnosers who will throw you under the bus in the blink of an eye if it means making themselves look good.
There are a few breeds of medical student that make me groan when I see their name next to mine on the rotation assignment sheet.
1. The Scut-Seeker: These students are generally pleasant and helpful. The problem is when they don't know how to say no. Pair this student up with a lazy resident or intern and you have disaster. The resident instantly recognizes the doormat potential in this student and puts him or her (usually her; why can't women say no!??!) to work doing pointless tasks, which we call "scut". These tasks usually are unrelated to patient care and involve things like making copies, fetching coffee, running prescription pads down to the ER to another resident who ran out (this really happened and I could not believe it...the student was being scutted out by some resident on another service who paged our resident asking for scripts!!). Usually the Scut-Seeker is too nice, too spineless or too fearful of a bad evaluation from the resident to say no. This makes the rest of the students on the team who refuse to be scutted out look lazy, uncaring and unhelpful. Not good.
2. The Closet Gunner: In med school, the term "gunner" refers to a student who is so hell-bent on getting the top score that he or she (usually a he, in my experience) will stop at nothing to tear other students down in order to get to the top. The Gunners are easily recognizable and although they're awful, their motives are transparent and everyone usually agrees that they suck. The Closet Gunner is a different animal. This student is one who pretends to not care about grades or evaluations, is generally "too cool" to stress out over something, and appears to be a pretty normal, harmless teammate. Their true colors are revealed on attending rounds, which consist of walking around the hospital to visit the bedside of interesting patients, then discussing the case in the hallway. These discussions usually involve the attending asking lots of questions and students racking their brains to come up with an answer. The unspoken rules of attending rounds state that if the patient being discussed belongs to a particular student, then that student gets a few seconds to answer the questions before other students start chiming in. Closet Gunners will not abide by these rules. They will usually talk over another student, or answer all of the attending's questions without allowing other students time to think. They'll make other students look bad by answer questions about their patients, and are generally so busy kissing the ass of the attending that they don't notice the rest of the team rolling their eyes at him all morning.
3. The Frat Brother: This student can be good or bad. Usually these students are fun-loving, pleasant, and hardworking, if a bit annoying when they talk about how many beers they drank last weekend or how their "boys" are going to come visit this weekend and he can't wait to "pick up some chicks" with them. The trouble starts when The Frat Brother is placed on a team with a Frat Brother Attending or Frat Brother Resident. Then they spend all of their time talking about college, beer, "chicks", "bitches", and how much they can bench press. The rest of the students are marginalized and forgotten about because they are unable to forge such connections as are seen between Frat Brothers. The Frat Brother will get the best evaluation from the Frat Attending and Frat Resident, because Brothers look out for each other. Ugh. Annoying.
On this last rotation, I was paired with a Closet Gunner and a Scut-Seeker. Thankfully I also had a Hilarious Person and a Friend on the team with me, so the three of us yukked it up on the sidelines and let the other clowns run themselves ragged trying to impress people. Thank god this rotation is over!
Tuesday, March 3, 2009
Hiatus
I think I know why I can't keep a blog going...I think my frequency of posting is directly related to my degree of excitement about my current rotation, and indirectly related to the amount of time I have on my hands to blog.
Right now I am on a rotation that I loathe. With the fire of a thousand suns. Thus, no updates.
It's not so much the rotation itself (pediatrics) but the residents and interns who make it so intolerable. The rotation director has also put into place some ridiculous policies that make it very difficult to not hate every second I spend at the hospital these days. For example:
1. Students take call Q4 (every fourth day) until 10 PM. This means students admit any patients that come in between 4 PM (end of our official shift) and 10 PM. Most students are released by their residents by 8 PM if they haven't admitted a patient, since admitting a patient and running through orders and the presentation with your resident takes for-e-ver, and students (unlike the intern and resident on call) are NOT allowed to leave after rounds the day after taking call. Which is all fine until you get the resident who makes you stay and admit a patient at 9:30 and then you're there until after midnight and back less than 6 hours later and have to stay until 5 PM the following day while your intern and resident sleep in their nice warm beds.
2. Students have to be present any time the residents "run the list". This entails going over every patient's to-do list for that day: follow up on labs, schedule/order/followup on MRI/CT/Xrays, whatever. A necessary evil. The trouble comes when this running of the list happens FIFTY THOUSAND TIMES because the interns are painfully inefficient and the resident is a crazy control freak. And students have to listen to this at least 4-5 times a day.
Ugh. I'm getting all annoyed just thinking about this nonsense. I can't wait to be a resident to PUT AN END to the NONSENSE. Holy jesus people. Please have mercy on your medical students.
Right now I am on a rotation that I loathe. With the fire of a thousand suns. Thus, no updates.
It's not so much the rotation itself (pediatrics) but the residents and interns who make it so intolerable. The rotation director has also put into place some ridiculous policies that make it very difficult to not hate every second I spend at the hospital these days. For example:
1. Students take call Q4 (every fourth day) until 10 PM. This means students admit any patients that come in between 4 PM (end of our official shift) and 10 PM. Most students are released by their residents by 8 PM if they haven't admitted a patient, since admitting a patient and running through orders and the presentation with your resident takes for-e-ver, and students (unlike the intern and resident on call) are NOT allowed to leave after rounds the day after taking call. Which is all fine until you get the resident who makes you stay and admit a patient at 9:30 and then you're there until after midnight and back less than 6 hours later and have to stay until 5 PM the following day while your intern and resident sleep in their nice warm beds.
2. Students have to be present any time the residents "run the list". This entails going over every patient's to-do list for that day: follow up on labs, schedule/order/followup on MRI/CT/Xrays, whatever. A necessary evil. The trouble comes when this running of the list happens FIFTY THOUSAND TIMES because the interns are painfully inefficient and the resident is a crazy control freak. And students have to listen to this at least 4-5 times a day.
Ugh. I'm getting all annoyed just thinking about this nonsense. I can't wait to be a resident to PUT AN END to the NONSENSE. Holy jesus people. Please have mercy on your medical students.
Monday, December 15, 2008
Scary
There have been a couple of times I've felt scared in the hospital as a medical student. Some of the times where I anticipated feeling terror were surprisingly un-terrifying. For example, being in the trauma bay when an ambulance comes screaming in with motorcycle crash victims or gunshot wounds is not nearly as scary as I thought it would be. Maybe it's because the environment is one in which the patients are expected to be in critical condition on arrival (we have a trauma center in addition to our ED, so the super critical patients with bloody gorey stuff end up in trauma). Maybe when you expect a patient with body parts falling off and a blood pressure of 70/40, and you get...a patient with body parts falling off and a blood pressure of 70/40, you're par for the course.
One incident that terrified me was recently when I was in the ED evaluating a patient in Bed 4. She was a woman with end-stage liver disease who was yellower than a highlighter thanks to her bilirubin of 45. She was critically ill but able to relate her history. I was busy scribbling notes when I heard a most horrible retching sound from behind the curtain next to us. I tried to ignore it and continue listening to my patient. Noises like coughing, retching, moaning, and screaming are the background noise of a busy ED and nothing to get terribly excited about. The third round of retching sounded especially disgusting. Something about it did not sound like normal vomiting to me. I peeked behind the curtain to see what the hell was going on and saw a frail man in his 60s staring into his lap, which was saturated with what appeared to be pure blood. I saw him retch again and bring up a large volume of bright red blood with huge clots, some the size of golf balls.
In medical school, when you learn about gastrointestinal bleeds, they tell you to always quantify the amount of blood. I always wondered how much "a lot" is. One person's "a lot" could be very different than another person's. My professor told me at the time that when we saw a big upper GI bleed, there would be no question about it. "A lot" is any amount large enough to result in you soiling your drawers when you see it.
The poor man was shaking and absolutely white as the sheets he was sweating through. His nurse ran over right as I was reaching down to elevate the head of his bed (to prevent him from choking on his vomit/blood and aspirating it into his lungs). When she saw him covered in his vomited blood, she hollered for the ED attending, who flew over and started yelling orders to IV fluids and blood products to be hung STAT!
I'm not sure why this incident was so horrifying for me. Maybe because it caught me off guard...I expect the ED to have crazy stuff going on when a patient arrives and is unstable, but not after the patient is settled in and awaiting a bed on the medical floor. It's all about your expectations, I think.
One incident that terrified me was recently when I was in the ED evaluating a patient in Bed 4. She was a woman with end-stage liver disease who was yellower than a highlighter thanks to her bilirubin of 45. She was critically ill but able to relate her history. I was busy scribbling notes when I heard a most horrible retching sound from behind the curtain next to us. I tried to ignore it and continue listening to my patient. Noises like coughing, retching, moaning, and screaming are the background noise of a busy ED and nothing to get terribly excited about. The third round of retching sounded especially disgusting. Something about it did not sound like normal vomiting to me. I peeked behind the curtain to see what the hell was going on and saw a frail man in his 60s staring into his lap, which was saturated with what appeared to be pure blood. I saw him retch again and bring up a large volume of bright red blood with huge clots, some the size of golf balls.
In medical school, when you learn about gastrointestinal bleeds, they tell you to always quantify the amount of blood. I always wondered how much "a lot" is. One person's "a lot" could be very different than another person's. My professor told me at the time that when we saw a big upper GI bleed, there would be no question about it. "A lot" is any amount large enough to result in you soiling your drawers when you see it.
The poor man was shaking and absolutely white as the sheets he was sweating through. His nurse ran over right as I was reaching down to elevate the head of his bed (to prevent him from choking on his vomit/blood and aspirating it into his lungs). When she saw him covered in his vomited blood, she hollered for the ED attending, who flew over and started yelling orders to IV fluids and blood products to be hung STAT!
I'm not sure why this incident was so horrifying for me. Maybe because it caught me off guard...I expect the ED to have crazy stuff going on when a patient arrives and is unstable, but not after the patient is settled in and awaiting a bed on the medical floor. It's all about your expectations, I think.
Wednesday, November 12, 2008
One Liners
Patient: "I used to smoke crack every day. Now I only smoke three times a week!"
Resident: "Well sir, if there's one thing we like here in internal medicine, it's progress."
Patient: "Baby girl, you need a boyfriend to give you kisses and caresses."
Me: "Okay, sure. I'll look into that."
Patient: "How old you are, girl? Why ain't you married? You a playa?"
Me: "Enough about me, are you currently sexually active?"
Patient: (calling out from her stretcher in the ER hallway to a 3rd-generation Vietnamese American intern): "Chinese, chinese, chinese! Chinky!"
Intern: "Um, I was born in Atlanta."
Me: "Sir, do you use any drugs?"
Patient: "Drug-free, sweetheart. One hundred percent drug-free. Drugs kill girl, you know?"
(urine tox screen positive for cocaine, cannabinoids, amphetamines)
Resident: "Well sir, if there's one thing we like here in internal medicine, it's progress."
Patient: "Baby girl, you need a boyfriend to give you kisses and caresses."
Me: "Okay, sure. I'll look into that."
Patient: "How old you are, girl? Why ain't you married? You a playa?"
Me: "Enough about me, are you currently sexually active?"
Patient: (calling out from her stretcher in the ER hallway to a 3rd-generation Vietnamese American intern): "Chinese, chinese, chinese! Chinky!"
Intern: "Um, I was born in Atlanta."
Me: "Sir, do you use any drugs?"
Patient: "Drug-free, sweetheart. One hundred percent drug-free. Drugs kill girl, you know?"
(urine tox screen positive for cocaine, cannabinoids, amphetamines)
Wednesday, October 22, 2008
Food Chain
Medical student : plankton :: attending physician : Great White shark
And I guess resident physicians would be...barracudas?
Medical school is 4 years. You get your M.D. and then train some more in residency, where you are called a resident. Your first year in residency is called your intern year, and you are called an intern. All interns do the same thing no matter what field you want to go into. They take care of the patients in the hospital, making phone calls, calling consults, nagging the nurses, and writing notes in the charts. Sometimes they have to go to clinic to see patients, which they hate (especially the surgery interns, who prefer their patients anesthetized).
When you are a third year medical student as I am, you are the bottom of the totem pole. Nobody is below you on the ladder. Even the lady sweeping the floors knows more about the hospital than you do, at least geographically. The nurses know the protocols better than you. The attendings know the medicine better than you, and half the time you are terrified of them. The interns are so damn happy to not be at the bottom (though they are only one rung up) and are generally kind to the students.
The residents are the wild cards on the medical team. Some residents love to teach and help students learn. We looove this kind of resident.
Other residents are like the overlords. They feel they are getting some knowledge under their belts, and love bossing the interns around. They also love to lecture medical students in the most irritating pedantic fashion. This is my new resident, and needless to say, he sucks.
Yesterday we saw a patient together--a new medical admission from the clinics downstairs. He told me before we went in that he had only 20 minutes to talk to the patient and do the physical exam, and that he wanted me to do it. Fine, although 20 minutes is not really sufficient, but I get it, he's busy. I went along and asked the man the typical questions--where does it hurt? when did it start? how did it feel? how long did it last? have you had this before? did you take anything for it? what makes it better/worse? I also asked him questions about his past medical history and family history, since this patient was new to me and I didn't know anything about him yet.
After we took the history, my resident was checking his watch and looking annoyed, so instead of completing the physical head-to-toe as I normally would, I just rolled up the guy's pants leg to look at his leg (he had a possible blood clot). I figured the resident could get the info he needed to start his admission note and that I would come back later and get a more detailed physical and history.
Later my resident took me aside and the lecturing began. "Your history was a little too detailed; you don't need to ask too many questions here. We know what's going on, so don't bother asking about family history right now. We don't care about that." Hmm. News to me. I read that 80% of medical diagnoses can be made from history alone. And many important medical problems are related to family history. Since when is that unimportant?
"And furthermore, your physical exam should be more systematic. You need to go head-to-toe. Don't just jump to the leg right away." Ok dude. If you weren't breathing down my neck, glancing at your watch and shifting your weight from foot to foot for the last 10 minutes I wouldn't have felt pressured to skip half the exam. "And I didn't see you check for Homan's sign, so go back and do that later."
In patients with blood clots in the calf, they can have pain when you push their foot up towards their knee (so their toes point to the ceiling). This is called a positive Homan's sign. Unfortunately the sign is practically meaningless; you can have a clot and not have the sign, and you can have the sign and have no clot, and it doesn't help at all.
So I went back and did the Homan's sign, being an obedient medical student. I reported a positive Homan's sign this morning to my attending physician, to whom I must present the new admissions during rounds with the team. "You did a Homan's?! You know you can dislodge the clot by doing that maneuver..." Dislodging a leg clot can cause it to float through the veins back into the right side of the heart and into the lungs, meaning pulmonary embolism and possible death for the patient.
Thanks, resident!
And I guess resident physicians would be...barracudas?
Medical school is 4 years. You get your M.D. and then train some more in residency, where you are called a resident. Your first year in residency is called your intern year, and you are called an intern. All interns do the same thing no matter what field you want to go into. They take care of the patients in the hospital, making phone calls, calling consults, nagging the nurses, and writing notes in the charts. Sometimes they have to go to clinic to see patients, which they hate (especially the surgery interns, who prefer their patients anesthetized).
When you are a third year medical student as I am, you are the bottom of the totem pole. Nobody is below you on the ladder. Even the lady sweeping the floors knows more about the hospital than you do, at least geographically. The nurses know the protocols better than you. The attendings know the medicine better than you, and half the time you are terrified of them. The interns are so damn happy to not be at the bottom (though they are only one rung up) and are generally kind to the students.
The residents are the wild cards on the medical team. Some residents love to teach and help students learn. We looove this kind of resident.
Other residents are like the overlords. They feel they are getting some knowledge under their belts, and love bossing the interns around. They also love to lecture medical students in the most irritating pedantic fashion. This is my new resident, and needless to say, he sucks.
Yesterday we saw a patient together--a new medical admission from the clinics downstairs. He told me before we went in that he had only 20 minutes to talk to the patient and do the physical exam, and that he wanted me to do it. Fine, although 20 minutes is not really sufficient, but I get it, he's busy. I went along and asked the man the typical questions--where does it hurt? when did it start? how did it feel? how long did it last? have you had this before? did you take anything for it? what makes it better/worse? I also asked him questions about his past medical history and family history, since this patient was new to me and I didn't know anything about him yet.
After we took the history, my resident was checking his watch and looking annoyed, so instead of completing the physical head-to-toe as I normally would, I just rolled up the guy's pants leg to look at his leg (he had a possible blood clot). I figured the resident could get the info he needed to start his admission note and that I would come back later and get a more detailed physical and history.
Later my resident took me aside and the lecturing began. "Your history was a little too detailed; you don't need to ask too many questions here. We know what's going on, so don't bother asking about family history right now. We don't care about that." Hmm. News to me. I read that 80% of medical diagnoses can be made from history alone. And many important medical problems are related to family history. Since when is that unimportant?
"And furthermore, your physical exam should be more systematic. You need to go head-to-toe. Don't just jump to the leg right away." Ok dude. If you weren't breathing down my neck, glancing at your watch and shifting your weight from foot to foot for the last 10 minutes I wouldn't have felt pressured to skip half the exam. "And I didn't see you check for Homan's sign, so go back and do that later."
In patients with blood clots in the calf, they can have pain when you push their foot up towards their knee (so their toes point to the ceiling). This is called a positive Homan's sign. Unfortunately the sign is practically meaningless; you can have a clot and not have the sign, and you can have the sign and have no clot, and it doesn't help at all.
So I went back and did the Homan's sign, being an obedient medical student. I reported a positive Homan's sign this morning to my attending physician, to whom I must present the new admissions during rounds with the team. "You did a Homan's?! You know you can dislodge the clot by doing that maneuver..." Dislodging a leg clot can cause it to float through the veins back into the right side of the heart and into the lungs, meaning pulmonary embolism and possible death for the patient.
Thanks, resident!
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