Blood.  BLOOD EVERYWHERE.

Usually for no discernible reason, because the uterus is a pear-shaped bundle of nothing but capillaries and spite.

I was supposed to see a patient with Common Thing.  But I came away suspecting it was actually Uncommon Thing.  So, with the patient’s permission, I called one of their family members to confirm that the patient actually had symptoms consistent with Uncommon Thing.  And I presented my case to the preceptor, and he said, “I agree”, and he changed the course of the patient’s management, and then I died of shock, the end.

(To be fair, this was not a difficult diagnosis.  But people were nice enough to make me feel good about it because I called family members when no one else had the time to do so.  Because they were all busy doing actual work.
…  turns out my lack of any meaningful purpose is an attribute!  I’ll take it.)

Also, there’s a lot of psychiatry involved.  In one week, I’ve seen more Axis I disorders than I did in a whole semester of psychiatry proper – and I’m not sure there’s anything in life more satisfying than working up an undiagnosed Axis I disorder.

In conclusion, 1) Neurology is the most intellectual fun I’ve had in years, and 2) I am clearly getting cocky about it.

Even though 75% of the consult cases are requested in the spirit of “Hey, you know that WE know this isn’t neurological, but we want to cover our collective asses legally” – to me, each consult sounds more like “We have summoned you from afar to solve an intractable clinical problem with your wise neurological wizardry.”

… which I don’t actually, you know, have.  At all.  I have the opposite of that.

But I work for a doctor who does, and I’m armed with a tuning fork.

So, you know.  Samesies.

Actually Doing The History & Physical:

When Trying to Figure Out the Neuroanatomy of a Lesion that causes Vertical Diplopia and Nystagmus with Maybe Some Weird Disconjugate Gaze Shit As Well, And God Only Knows If I Actually Assessed Any of The Visual Field Correctly:

When My Preceptor Asks Me To Present My Findings:

And When He Asks For My Plan:

(Here’s to tomorrow, when I will bring a very thick neurology book and MY GAME FACE.

Grrrrr.)

I felt a little blind-sided by this conversation, but I chalked it up to my preceptor’s med school just being weird (and also possibly a totalitarian dystopia where people are failed for standing wrong) – at least, until I remembered an encounter I once had with my family physician.

Years ago, on an exceptionally busy day, her nurse had me wait in a different provider’s exam room.  So my doctor walked in, started to greet me – then stopped mid-sentence and physically rearranged the damn furniture so she would have room to examine me from the right side.

She had me hop off the exam table so she could pull the table away from the wall and everything.

At the time I thought she was crazy, but now I’m realizing that it’s more likely that it’s Medicine as a field that’s crazy and in dire need of loosening up a bit but DING DING command “LoosenUp.exe” not recognized by server:medicine.

Maybe I’m paranoid, but I’m beginning to suspect that it’s actually my school that’s weird for not requiring students to learn the physical exam exclusively from one singular, easily obstructed position with no versatility whatsoever.

Do you examine patients only from the right?  Did your med school tell you that’s the tradition?  Does your med school care about this tradition to the point where they’d actually make it a policy?  Do you want to fight?

I’m kidding.  Of course you do.  We have a difference of opinion here, and – as a med student – I know of no other way to solve it.  (Besides maybe just having an extended passive-aggressive Letters to The Editor war about it in a major scientific journal.  Also an option!)

“I’m so bored I nearly stole a mop from the cleaning closet.”

“… so no pediatrics for you, then?”

“I mean, it’s just boring right now because it’s all well newborn checks.”

“I thought you loved newborns!”

“Well, if the job involved holding newborns all day, it’d be awesome!  I’d sign right up!  But it doesn’t.  It involves consulting ortho for breech births and telling the moms about the new car seat law.”

“You’d get bored of holding them all day too, though.”

“I would not.  The fact that you’re even saying that means you’re seriously over-estimating my mental maturity.  THEY HAVE TINY TOES.”

“Uh, honey, if you wanted to be a daycare worker you were supposed to check the OTHER box on your college application.”

“Goddamnit, you’re right.”

Since this conversation, I’ve realized I would be a pretty lousy daycare worker, for a multitude of reasons (most of which involve Being Responsible and Not Letting Kids Play “Hunger Games” To Determine Who Gets The Last Graham Cracker), but mostly because as near as I can figure it wouldn’t involve obsessing about the kids’ electrolyte panels.

A day without a serious conversation about potassium is NOT A DAY AT ALL,

1.  Drinking From The Firehouse – Are you following this blog?  You are probably not yet following this blog.  You should follow this blog.

(3rd year medical student at University Medical School.  Check out his/her post on Clinical Medicine Rules - it’s gold.)

2.  Would you like to bake an egg in an avacado?

3.  I may be in “slight-to-moderate” trouble.  I like to walk the fine-line between “doing as little busy work as possible” and “not getting kicked out of school”, so I only realized yesterday that the “2 required formal write-ups, corrected by your preceptor, then turned into Metropolis Med” were actually for-real required, instead of just.. you know, suggestions.

(I’ve been through 18 years of formal schooling.  That’s 17 more years than it takes to learn to differentiate “work that will be checked up on and/or useful” from “work no one actually care about”.  This is news to me.)

… It’s gonna be news to my preceptor, too.

Maybe I can just have him wave a red pen around in the general direction of some computer paper.

4.  I’m gonna go to work now.  That lecture on hemolytic anemia isn’t gonna present itself.

You stay with the patient.  It’s not a hard choice. You’re the only person in the room they know.  The patient is looking at you, bewildered.  You squeeze their hand while they’re sedated and paralyzed.  You are leaving for a new rotation, so you will probably never find out what went wrong.  Or if it’ll really be as okay as you’re promising.

You get an e-mail reprimanding you for not attending the mandatory lecture.  You now have to write an essay about your thoughts on the subject of the lecture:

The High Rate of Suicide in The Medical Profession.

You look up the statistics.

You read a depressing article.

You pour yourself a drink.

You decide this essay is a random decision that will never be checked by anyone of any importance, you say “screw it”, and you go to bed at 7.

Residents: … No.  Why?

Attending:  In 1976, there was a meeting of the American Legion in a Phildadelphia hotel, and everyone contracted a mystery illness.  The CDC got involved, they found a brand new gram negative bacteria in the hotel’s air filtering system, and called it “Legionnaire’s disease”.

Resident:  Ah, very interesting.

Attending:  How about Nystatin?  Anyone know how Nystatin got its name?

Residents:  Er, no.  Why?

Attending:  It was discovered in upstate New York!  N-y!  Nystatin.  Boy, you’re all learning a lot today!

Residents:  *murmurs of agreement*

Attending:  Now that you know that, you should be able to figure out how Coxsackie virus was named!  Anyone know how Coxsackie got it’s name?

Residents:  ….

Foreign Resident:  It was found in… cock.. sack?

Ten minutes of silence.

A pin drops.

Yes, I think we all learned a lot today.

Attendings rarely ever ask about 50/50 things – they’re asking you because the number is either unexpectedly large or small – so guessing 20% or 80% is almost guaranteed to put you within 10% of the right answer.

(Not that it matters how you answer, since the attending is only asking so he can give you a short speech about [random test] or [Disease X] – but it’s a cool trick.  Works 80% of the time.)

2.  One excellent presentation can make up for at least 5 days of looking like an idiot.

3.   Pulmonary Embolism should be on your differential diagnosis if your patient has any of the following risk factors:
* any symptom above the diaphragm.
* any symptom below the diaphragm.
* lungs.

Also, a really nice stock phrase for your patient presentation is “We could order a D-dimer, but we essentially know it’s going to be positive in this patient – so we may as well save time and just do a V/Q scan.”

(The D-dimer test will be positive if the patient has any of the following:
* heart problems.
* lung problems.
* cancer problems.
* any problems that could possibly be causing some stress, such as “is currently hospitalized.”)

Enters patient room with an obnoxious excess of enthusiasm.

Me:  Excuse me – sir?  Hi!  I’m Action Potential, a 3rd year medical student from Metropolis Med.  Can I ask you some questions and do a quick physical exam?
Patient:  *nods*
Me:  Great.  Can you tell me why you came to the hospital?
Patient:  *nods*
Me: … Oh.  Okay.  Why did you come to the hospital?
Patient:  *nods*
Two Nurses Standing Outside:  *snickering*
Me: …  Sir?  … Can you speak?
Patient:  PTHTHTHB.
Two Nurses Standing Outside:  *outright laughter*
Patient:  *falls asleep, drooling slightly*
Me:  … soooo, can the patient talk?
Nurse:  Well, if you’d read his chart, you’d know he doesn’t talk.
Me:  … I see.
Nurse:  You finished?  I need to change the IV.
Me: … Apparently.  *leaves*

I didn’t think it was a very funny joke.

This story has an even more unfortunate ending, though, which is that “But I thought you were joking” is not a good excuse when the resident asks you to give a full presentation and plan for that patient.

Stop shaking your head at me.  I thought it was a mean joke!  I know full well that some patients in the hospital can’t talk!  I just.. you know…?  They have…

… I mean…

… shutup.