Wrestling With a Patient


image credit from jesuslivesinmyheart.tumblr.com


“Lord, I pray that you would help me see my patients the way you see them.” This is a prayer that I prayed from time to time during my junior year. Just recently, I have been reminded of this prayer by a friend and it turned out to be tremendously helpful in processing one of my more difficult patient encounters.

A patient with a genetic disease presented to the ED with pain, which is a fairly common symptom of her disease. She frequently visits the ED requesting IV analgesics and would attempt to leave with IVs in place. This time, she did the same thing again. There was concern that she may be addicted to opiates and intended to keep her IV for drug administration, so I went to her bedside and tried to understand her thoughts. After I listened to her thoughts, I explained the causes of her pain, the need to learn ways to manage and prevent pain, and the importance of following up with her primary physician. She became less guarded and tearfully shared that she felt no one really cared about her. She eventually agreed to have her IV taken out and go to follow up visits. With satisfaction, I gave the attending the good news and brought back the discharge papers. However, the patient changed her mind and refused to have her IV taken out again. She insisted that her pain is not better and if she was not going to get IV morphine, she would re-admit herself or go to a different ED. I explained we could not give her what she requested and she could not keep her IV, so she said she was going to pull out the IV herself. She had an external jugular IV placed because she was a hard stick, so out of concern for an air embolus, albeit most likely harmless in this situation, I recommended that she lay down. However, she refused to lay down, and would not let me place gauze over the IV site. She shoved my hands away every time I tried to place gauze over her IV and we were essentially wrestling back and forth for minutes. Right before the IV tip was pulled out, I was able to put gauze over it and tape it in place.

As I reflected upon this encounter at home, I realized that I really cared about this patient and wanted the best for her. I felt disappointed that she did not take my well-intentioned advice that was meant to help her. Then I realized how heartbroken God must feel when His children whom he cares and loves deeply disobey His commands that were meant for their good. I was not angry at her, but sad that she was too fixated on what she wanted in that moment and could not see a better alternative. Perhaps in many ways, I am like her in God’s eyes. I have desires that I am fixated on. I also have disobeyed God despite His wholehearted intention for me to do what is righteous. I have broken God’s heart many times. Despite my ways, God is gracious to those who repent and promises eternal life, delivery from sins, and refuge for the broken.

This patient encounter started out disheartening but I definitely learned from it. Now, if I see the same patient again in the ED for another pain crisis, my prayer would be “Lord, I pray that you would help me to treat this patient with the same kind of grace and forgiveness that you demonstrated to me.”

My Waiting Game

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One Day. Ever since beginning medical school, “Match Day” felt like more a myth than reality, an elusive goal that never seemed to get any closer. And now finally, FINALLY, it’s only one short day away. We haven’t graduated yet, but for the first time, we are being told all our efforts are worthy of being a doctor. After all the time we put into the books, the clinics, the call nights… someone out there wants us to be a doctor! Match Day is the realization of a dream. Only. One. More. Day.

Keep Calm

Ok, boring stuff first (skip ahead if you want to read about my experience!): this is how “The Match” works! A big part of the 4th year of medical school is dedicated to finding a job. Graduating from medical school is not enough to practice medicine in the United States; one still needs to complete additional training after graduation to become certified in a specialty. This process begins when 4th year students submit applications in September to residency programs of his or her choice. The next few months are a blur of interviewing, trying to impress programs all while searching for the perfect place to train.

Next comes the tricky part. Each applicant makes a preference list of where they would like to work for residency, the “rank list.” Likewise, each program makes a list of applicants, ranking the interviewees in the order of its preference. All these lists are thrown into a huge algorithm, and when the switch is thrown, it tries to match each applicant as high up on his or her rank list as it possibly can.

So for example, lets say my rank list has 3 programs: Awesome is at the top of my rank list, followed by programs Spectacular, then Fantastic. If Awesome still has one open spot left when the computer reaches my rank list, it will put me there tentatively. If the algorithm later finds another applicant who is higher up than me on program Awesome’s list (boo!), because there are no more spots left, I will get bumped out in favor of that other applicant. The algorithm will then try to put me in Spectacular. This process continues until I am permanently put in a program, or the algorithm has exhausted my list of potential programs. Because of that possibility, applicants typically have a lot more than 3 programs ranked!

Hard Work

Ranking Programs Is Hard Work!

Back to my story. In my last blog post, I was finishing up interviews and ready to start creating my rank list. That was a whole lot harder than I thought it would be! Fortunately, that was because I liked most of the programs at which I interviewed, and not because I hated them all. It was a nice problem to have! I knew where my first two or three programs would fall on the list, but after that, it was pretty tricky.

After submitting my rank list toward the end of February, there was nothing I could do but wait. And it’s been the hardest waiting game I’ve ever had to play! I’ll be 100% candid with you, this whole process of applying for residency has been pretty stressful. Emergency medicine has a firm grasp on my heart, but it’s a tough specialty to get into. And even though it’s where I know I belong, lingering doubts about my application kept trying to get me down: Are my grades good enough? Did I say anything dumb during interviews? Is my repeat year of medical school going to hold me back? How do I stack up next to other applicants?

The Monday before Match Day, all applicants are sent an email letting them know if they matched or not. Those that don’t match usually have to try for a spot in any remaining programs that didn’t fill up (which usually means having to change specialties). Needless to say, this past Sunday night was a long one for me. I tried sleeping, but about two hours before the expected email arrived, I just couldn’t keep my eyes shut anymore. I rolled over in bed to see my wife, wide awake.

“You can’t sleep either?” to which she replied with an anxious, “Is it time yet?!” Those two hours crawled ever so slowly, and I was reminded of being an elementary student, staring at the clock and watching the seconds tick down to the end of a Friday afternoon. But then it happened. At exactly 8:56 AM, my phone gave off it’s recognizable notification ding, and this is what I saw:

Matched!

Next thing I know, my wife is sobbing, I’m doing this crazy happy dance, and my son is squealing with delight. I did it!! I’m going to be a Doctor of Emergency Medicine! So now here I am, with one day left to go, a guaranteed match in hand,but no clue where I’m headed. Tomorrow (Friday) at 9 AM, my classmates & I will gather in a big celebration to find out the results of the Match… To be continued…

class of 2015 GalaThe Class of 2015, Ready to Match!

 

My 4th Year

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Fourth year. I’ve made it! Well, technically I made it last June, but I’ve been taking a hiatus from blogging to prioritize 4th year responsibilities. When I last logged in, I was enjoying my OBGYN rotation with its many deliveries, surgeries, and clinic hours. The following six months have been a whirlwind of USMLEs, emergency medicine rotations, interviews and life events (the birth of my son!). I’ve been a tad bit busy! Nevertheless, I am back on the grid and ready to present my fourth and final season here on the student blog!

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First Day of School Door Shot!

Ah, Emergency Medicine, the Lewis to my Clark, the Abbott to my Costello, the Andy Richter to my Conan O’Brian. It’s what got me excited about medical school in the first place! As I wrapped up the requirements of third year and moved on to my fourth and final year of medical school, the excitement of upcoming emergency medicine rotations built. Excitement… and a little bit of anxiety. What if I decided EM wasn’t all I thought it would be? Most medical students have a good idea of their desired medical specialty by the beginning of 4th year; what if I suddenly didn’t? Fortunately for me, even though I got very distracted with the excitement of other specialties during 3rd year rotations, I definitely remembered why emergency medicine was my first love the moment I set foot in a busy emergency department (ED).

For those of you who may not know exactly what Emergency Medicine is, these are the doctors at the doorways of the hospital. They are the one’s who stabilize life threatening emergencies and sort out acute problems that need immediate treatment from those that may have a little more time. They could see anything from a stabbing victim to a common cold to the guy that ate too much for Thanksgiving dinner and is now having belly pain.

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Practicing Casting with Classmate Claudia

Because I plan to go into Emergency Medicine, I spent a couple of months at the beginning of my fourth year rotating through different ED’s, evaluating my desires and learning all I could for my future career. I went from LLUMC to Riverside County Hospital, then Kettering Medical Center in Ohio to Borgess Medical Center in Kalamazoo, Michigan. Here are a couple of highlights:

  1. I’m thinking I’m going to be the only medical student who graduates having never done chest compressions. I’ve been CPR certified since I was 14, yet never needed to use the skills, which is a good thing, I guess! Yet all it takes is for me to state that fact out loud in the middle of a busy shift… I proceed to participate in 6 or 7 codes (basically what they call CPR in the hospital) over the next 3 weeks.
  1. Guy comes in to the community ED with back pain in his left shoulder blade, and is triaged as low acuity (which means he probably wasn’t an emergency, per se). He had been laying floor tiles the previous day and is now feeling sore, so he wants to get checked out. His EKG (heart rhythm) looks ok at first, but while talking to him, he begins saying the pain has come on over the last hour and is now shooting down his left arm. Not only that, but he’s feeling pretty anxious and nauseous. The story sounds too familiar to something I’ve seen before, so I leave to get the attending physician. He agrees we should check his EKG again and get some cardiac labs drawn. Sure enough, he is having much more than a simple muscle strain; it’s a massive heart attack, and treatment is needed right away. I’m sure someone would have caught that pretty quickly without me there, but I pat myself on the back anyways. Sometimes the story given in triage is not enough!
  1. Sutures, sutures, sutures. Cleaning up a jagged wound can really get the dopamine going! I’ve gone from taking an hour to sew up a 4 cm laceration (they call them “patients” for a reason), to finishing before the attending is ready to check out the wound. I’ve still got a ways to go, but it’s nice to see progress!
  1. I enter the jail ward to see a patient who is having auditory hallucinations (hearing voices). As I enter, a patient in the adjacent secure holding cell is having a shouting match with one of the security officers. I’m looking at the large chart I’m holding to see if I’ve missed anything about my patient, when I suddenly notice it’s become very quiet. I look up, and that loud patient is now silently staring at me dead on, head down, eyes rolled up, like little lasers that could have pierced into me. I’m thoroughly creeped out. After returning the stare for a moment, he suddenly bursts into the “Macarena,” singing and dancing, all while holding his glare of death.
  1. An elderly lady comes in after a fall, and her chart says she has a pretty nasty cut on the back of her head. I go to say hi, and see if this “nasty cut” is something that needs stitches or if a staple or two would do the job. Walking into the room, I first notice a very pleasant lady, despite the fact it’s 4:30 in the morning. The second thing I notice is her head looks perfectly normal. I look all around her scalp, but no cut. I take a step back and say, “Are you sure you slipped and fell, I don’t see any cuts!” The patient smiles, reaches up, and pulls off her very convincing wig. There’s a large bandage on her now bald head.

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Finishing up an EM shift at Kettering Medical Center in Ohio

I love Emergency Medicine. These are just a couple random stories I pulled off the top of my head, and there are SO many more. I love that I can interact with tons of different people, from all walks of life. I love that someone can come in with a life-threatening problem and I can help him or her begin to heal within 20 minutes. I love that on any given shift, anything could walk through those double doors, and I have no idea what it’s going to be. It’s not all sexy, adrenaline rush-a-minute action like the TV would have you believe, but it sure is a lot of fun.

Right now, I’m sitting in an airplane, on my way to an interview on the East Coast. The road to apply for emergency medicine training has been daunting for sure, but it’s something I’m excited to be doing, and I’m blessed to have the opportunity. There’s so much more I’d like to write about (that’s what happens when you don’t blog for awhile!) but I’ll save that for a future update. For now, please keep my fellow classmates and I in your thoughts and prayers as we wrap up interview season and begin to mull over where we want to spend the next couple of years training. See you next time!

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Me with My Newborn Son, Clarkston!

Learnings

Leanna, Fourth Year Medical Student

In the past several weeks I’ve matched to USC’s internal medicine program, graduated medical school, and now am preparing for residency (i.e. filled out 100+ pages of paperwork and bought Pocket Medicine and new shoes). The things I learned about medicine, becoming a doctor, myself, and life during these last four years of medical school are far too many to confine to a blog post, but I’ll note some of the more entertaining and blog-able ones here.

MSI: First year – year of the basic sciences:

I learned that my new best friends would likely be the ones who made art projects with me, art projects with the titles of “Cell Lineage Cupcakes” and “Sandcastle Nephron: a beach study in the functional unit of the kidney”.

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I learned that in order to get decent grades in medical school you had to make huge sacrifices in all other realms of life, sacrifices that I did not have to make in undergrad and at first had a hard time making during this transition.

I learned that from the moment you tell someone, I’m studying to be a doctor, inevitably one of the next questions would be – Oh good, can you check this out for me and tell me if it’s anything serious? Or, sometimes his or her next odd question was, You mean, like a nurse?

Conclusion: I had no life, and far fewer friends than I was used to, but I was okay with it.

MSII: Second year – year of pathology/pathophysiology

I learned all the different ways a person can die (there are a lot).

I learned that pathophysiology is best studied as a group, with cookies.

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I learned that when a professor says, “This concept will be on Step 1”, the entire class wakes up and poises ready with their pencils/iPad note-taking software.

I learned that I could walk around the Drayson Center track for up to three hours at a time while listening to audio lectures.

I learned that while listening to audio lectures at Drayson Center track I ran the risk of getting hit in the head by a stray soccer ball [I learned this lesson twice].

I learned that some of the Step 1 study books had the stupidest study tips, such as, “Just remember the simple acronym AINBIBYXDYAHTGUVI for all the causes of liver failure and you’ll never forget ‘em!”

I learned that the best friends I made in first year were indeed still my best friends and fellow soldiers in the war against overwhelming exams and boards.

MSIII: Third year – year of clinical rotations and the beginning of the hospital hierarchy

I learned that all residents can be bribed, whether they are conscious of it or not – sometimes with food, sometimes with compliments.

I learned that the diseases that in prior years were confined to pages and chapters were infinitely more fascinating when seen up close in a living, hopefully breathing human being.

I learned to act quickly and seriously with the pregnant woman with a life-threatening lupus flare and for the man with a rupturing abdominal aneurysm, and how to lean towards empathy instead of apathy for the patient complaining of non-descript fatigue.

I learned that I loved internal medicine and family medicine and neurology and wilderness medicine and psychiatry and endocrinology and emergency medicine and cardiology and gynecology and critical care and pediatrics.

I learned that Hour #1 of a hernia repair and abdominal adhesion lysis surgery is fascinating, but Hour #9 is not (note that surgery did not make my aforementioned list of rotations and specialties that I love).

I learned that surgeons, upon finding out that I was moderately intelligent and strongly considering primary care as a career, had no inhibition when it came to constantly telling me that it would be a waste of my mind to go into primary care. And this was discouraging.

I learned that there was no possible way to describe my joy and relief with ending my surgery rotation other than this picture:

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I learned that a benevolent neurologist who lets multiple students practice the opthalmoscopic exam (imagine the Death Star killer beam that destroyed Alderaan in a single blast being emblazoned onto your retinas) on her, is a saint and I hope the Vatican City or the Catholic Church or whatever recognizes her as such eventually.

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I learned that as much as I liked doing rotations at White Memorial Medical Center, doing several months’ of rotations there instead of in Loma Linda distanced me from my fellow classmates and disintegrated what little social life I had.

Without a doubt I learned the most during third year. And as I looked back at the beginning of third year compared to the end of third year, I realized that maybe, just maybe, I was actually getting the hang of this doctor thing.

MSIV: Fourth year – year of marketing yourself to residencies and awkward spare time.

I learned that I would have a very hard time choosing between internal medicine and family medicine.

I learned that I loved diversity, puzzle-solving, variety, primary care, and hospitalist medicine, and because of that finally chose internal medicine as my residency path.

I learned that I would have A LOT of time off. What is time off? What do I do with it? Should I study? Should I sleep? Should I go to a pound and adopt another rabbit? Should I read War and Peace? I’ll bake some cupcakes.

I learned how to better practice grace and patience when a family member or friend tells me that they don’t “believe” in Western medicine and prefer only “natural” routes [Hint: arsenic, cyanide, and a variety of lethal mushroom are all “natural”…this could be a topic for a whole different post].

I learned how to be a wife, and in that taking on my husband’s last name of Wise, being called “Dr. Wise” sets quite a high threshold of excellence to which I will be held. Sometimes I wish his last name was Dumb, so that I could be Dr. Dumb and not too much would be expected of me.

I learned on the residency trail that an emphatic “Nope!” is a perfectly acceptable answer when asked if I have plans for specializing after residency.

I learned that Match Day is like a combination of eHarmony, the football draft, the Harry Potter sorting hat, and that part of the Hunger Games when teenagers are chosen to go fight to the death. The last comparison is the most accurate.

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I learned that I liked sushi.

I learned that graduation and all the festivities involved was going to feel extraordinarily surreal, almost joke-like. I’m – graduating? What?

I learned that graduation would be horribly bittersweet as the incredible people I’ve met over the last four years would be leaving to go their separate ways around the country.

In retrospect, I learned that all our well-meaning deans and administrators were morbidly incorrect when they told us during first year, Before you know it, the next four years will fly by and you’ll be graduating! No no no, the years creeped by like a elderly arthritic sloth pulling a wagon full of turtles. With slugs and snails and all other slow things cheering him on.

I learned of all the beautiful hiking trails in the immediate LA area and experienced many of them for myself, some of which for the first time.

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On May 22rd, 2014, I learned that I had officially completed all the requirements for my M.D., and May 25th, I walked with my best friends to receive my doctorate of medicine.

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I learned that the most fierce and profound last four years of academics have brought me to a point where I am entrusted with the well-being of others.

I learned that as a doctor, I am swearing to be a life-long observer, innovator, and of course, insatiable learner. My future patients are my new teachers, the exams will be based on the degree of my patients’ health and wellness, and the hospital and clinics are my full-time classrooms.

A deep gratitude to Loma Linda University for setting me on this path of learning, and to my God for sustaining me with so many blessings, and His promises for my future.

[For any folks who are interested, I plan to be blogging at wisemd.wordpress.com during residency]

Outgrowing My Short White Coat

Ryan, Fourth Year Medical StudentMy white coat doesn’t seem to fit anymore.  I haven’t gotten any larger through medical school, so it’s not that.  My wrists stick out at the sleeves, the hem rests roughly at my hip bones, and the pockets are up so high that putting my hands in them makes me look like I’m doing the Chicken Dance.  But it’s always been that way, and that’s not what I’m referring to.

I know what orders I should write, but I can’t write them.  I can write a fantastic progress note, but it doesn’t go in the chart.  Nurses ask me management questions and I know the answer, but I have no authority to give the answer.  I can form an air-tight assessment and plan, but no one can bill for it.

It seems I have outgrown my short white coat.

It didn’t used to be this way. I remember trying on my first white coat, on the first day of medical school, in that little room underneath the Dean’s Office. It was perfect, a pristine symbol of learning, of caring, of healing. And it didn’t fade for awhile. I loved physical diagnosis labs, freshman ward experience, and continuity clinic during first and second year. I looked up to the third and fourth year students in their white coats, which were actually embroidered with their names. They would come in to Centennial Complex for their OCSE practical exams, and I knew that they were stepping back into the simulator from the real thing, the opposite of what I was doing.

And at the end of second year I picked up my two brand new, pressed, embroidered, personalized white coats, ready to start clinical rotations. That was an even more meaningful symbol for me than the original white coat. I had arrived. After two years of basic science study, I was actually learning how to take care of patients. It felt good to put on that white coat and to wear it around. It meant something.

Now, that symbol is old. I don’t like wearing my short white coat anymore. I feel like it’s holding me back. I’ve done all of my clinical rotations, been in the surgeries, learned the operative indications, repaired the lacerations, counseled the patients, and passed the exams. I’ve matched into an orthopedic surgery residency. Now when I put on my white coat, it feels way too short.

It’s not that it’s bad to be a student; I couldn’t have gotten to this point without going through it. And it’s not that it’s bad to have a short white coat; I could only learn how to be a resident by being a student. It’s just that I’ve outgrown it.

And that’s the way it should be.