Pastors informing on death

I think the first death of a patient is something that a first year medical student views with dreaded anticipation (although I guess I'm a second year now? A rising second year?). It's frightening to think about, mainly because of the unknown -- in my first year, I had patients that I knew were going to die (and soon), but I was never there for it. There were patients who used to be in the ICU...and weren't anymore. I probably should have looked up what happened to them, but I didn't. Too scary. And somehow still feels like none of my business. Like I'm still an intruder, because I'm still just learning and not really helping.

In anticipation of second year, where the anticipation will likely finally come to an end, I found this article oddly comforting.

Some thoughts

Interesting article that's worth a read on a topic completely and utterly frightening to medical students (and medical professionals, I'm sure): http://well.blogs.nytimes.com/2011/07/06/when-nurses-make-mistakes/?hp#

[For what it's worth, the title may as well be "When Doctors Or Nurses Make Mistakes"]

Orange Sweaters and Purple DNRs

Is that part of an oncologist's job description? I wondered. Dressing in fiercely optimistic clothing? Or is that just the only way they can get out of bed some days? She was a stout lady, probably barely coming up to my ears, but with quite a few pounds on me. Curly dark hair, and an almost traceable accent. Italian perhaps. She waved the DNR sheet around nonchalantly as she talked to my Longitudinal Clerkship preceptor. Tragic, yes. Maybe not the worst thing if she, the patient, didn't come out of this. She didn't have much time as it was. Add in the current systemic inflammatory response syndrome (SIRS) and you weren't left with much. Especially since we couldn't trace the SIRS to a source. Frustrating really. It could be some sort of damage in the bowel....leaking somewhere. Perhaps. Maybe the blood cultures were bad. Unlikely. Could be in her lungs? Hard to say.

And yet, also hard to just accept death at this point. Even with that purple DNR sheet being waved around like a flag. Quicker, sometimes, when the oncologist really got thinking. And then slow again. Barely a tick. Like a cool spring breeze that might whip the Stars and Stripes up into a frenzy for a few seconds and then die off. And just flutter. But yes, the patient. 44 years old. Seems much too young. In this day and age. Much too young to have your insides invaded by your own cells, choking the life out of your every organ. Metastatic cancer from the breast had invaded her ovaries, her liver, pushed her kidneys to the point of exhaustion. Dialysis buys her some time, but...it's really only a matter of time. Time. Funny thing at the end. How it lengthens and slips away all at the same time. And all the while the pale purple DNR flag waving around between me and the bright bright BRIGHT orange sweater of the oncologist. Above the bright bright BRIGHT floral skirt. A skirt of the flowing variety. An outfit they no doubt put together on some mannequin in Macy's to announce the spring arrivals. Do oncologists have time to go to the store? Especially oncologists with 44 year old dying women on their hands? Or are they strictly an order-by-mail consumer? Internet must make that much easier these days.

44, sighed my preceptor. I hadn't seen him so upset and so resigned before. A man who, as an intensivist, must see a lot of death. But this case was bothering him. Especially bothering him. Disturbing to be at a loss like this. Unable to explain her newest symptoms. Vanquished by the cancerous adversary. And mystified by it as well. He'd entertained even the most absurd theories earlier from the nursing staff and PA's surrounding the screen of the patient's CT scans. Considered them, tried to reason an answer out of even the most unlikely of possibilities. And still, nothing. Annoying, but not annoying in the "my problems aren't problems" way that sometime captures us. This is a problem. A real problem. A problem problem. And there was no solution in sight. The battle was over. And so was the war.

I was distracted by the oncologist again and couldn't focus on what they were saying. The orange was just so so orange. Would it distract our patient's family like it was distracting me now? Would they be able to understand and listen when the "do not resuscitate" living will was explained to them and to the patient? Or would they be like me, thinking of nothing but a pale purple flag in the gentle spring breeze, framed by the bright orange sky of a setting sun.....and wish they could just curl up in the flower below. Or by a peaceful lake. Or....anywhere but here, really.

And then, just like that, there was no time to dwell. My next patient was waiting. I straightened my white coat, took a deep breath, and left the orange orange oncologist and her pale pale purple DNR sheet to her duties. I stepped into the next patient's room, washed my hands of any bacteria and of all the thoughts that had been racing through my mind, and dove into yet someone else's life.

An Immodest Proposal

[Warning: PG-13 material. Actually, let’s be honest, they would never cover this stuff in a movie.]

In what I’m sure will be my most celebrated blog post yet, I will now turn my attention to the recent opportunity (and by recent I mean, in November. I recognize it’s been a dry spell for the blogosphere. My apologies) medical school provided us with – learning the genitourinary exam. To lay the groundwork for this experience: we’ve been learning the physical exam in pieces every week with our Clinical Foundations of Medicine exam (same small 5-student group of pancreatic cancer/Sharon-induced tears previously addressed). Each week we’re responsible for reading about and learning a portion of the complete physical exam, to include the pulmonary, cardiovascular, neurological, musculoskeletal, etc. We then meet in our groups in the Simulation Center in “fake” exam rooms and practice….on each other. It’s actually not as uncomfortable as it sounds and the males in the group are “voluntold” that they’ll be the guinea pigs for the abdominal, cardio, and pulmonary exams, thus eliminating the potential awkwardness of female students taking their shirts off….

As weird as practicing on each other sounded when we were first told about, I actually think it’s a great idea. And understand why a survey at the University of Minnesota medical school revealed that 95% of students also thought it was a great idea. From a learning perspective, you get the dual experience of both practicing on your classmates and getting practiced on, which only enhances your understanding. From a learning environment perspective, it’s pretty easy to quickly understand how practicing on your classmates is actually much more comfortable than practicing on “real people.” Practice is the way to eliminate the fumbling awkwardness of putting your hands all over someone else’s body; you are very fumbling and awkward when you haven’t figured out where on someone’s chest to listen for a S1-S2 split or how to use the otoscope without slapping someone in the face with the cord. Practicing on another medical student, who understands this learning curve and is patient with your fumbles, is much better than practicing on someone else. Additionally, medical students are a very healthy (and thin!) group of individuals. While any group of young adults is probably riddled with body image issues and I assume the first year medical school class is no different, the fact that basically no one is overweight (and many are probably underweight) relieves what could likely be the most uncomfortable issue. (However, it did not prepare me for my grossly overweight GU exam, but more on that to come. )

Obviously, however, practicing the GU exam on a fellow medical student would be vastly inappropriate. And uncomfortable. And so, the medical school gods, in their infinite wisdom, have created a solution – the GUTA.

GUTA stands for Genitourinary Teaching Associate; these are individuals who have been trained in the GU exam. They then teach medical students the exam…by demonstrating on themselves. And allowing us to practice on them. How you get into such a job…or would want some novice medical students touch you in all the most personal of places…. is beyond my wildest imagination. It surely must take a special individual. Or a crazy one..but again, more on that later.

So there we were – 24 intrepid medical students, sitting around the Simulation Center one morning, ready to spend the better part of our Saturday shoving metal pieces into vaginal canals and testing cremaster reflexes. Sounds delightful, right? It was probably not helped by the fact that the day before had been an exam day and, instead of catching up on the sleep lost to cramming, most of the first year class hit the town the night before. Needless to say, everyone was looking a little rough at 8:30am.

I was fortunate enough to be paired up with two friends of mine, both of whom have been out of college for a few years and who I assumed had achieved the maturity that experience confers. We gamely braced ourselves and headed towards the exam room for our first exam – the male exam.

I’m not sure how to say this, or what this says about me, but I was much more concerned about the female exam than the male exam, so I was happy to get “warmed up” with the delightful and elderly male GUTA whom we will call Mr. Brown. I think relative lack of apprehension had to do with a few things, namely, the relative simplicity (straightforwardness?) of male genital anatomy (dear readers -- uncomfortable yet?) and the fact that I wouldn’t be shoving implements into someone’s body as you do with the female exam. Just my fingers. Hooray?

It was impressively less awkward than it might sound, and I think that is a credit to the calm and reassuring nature of Mr. Brown. He was compassionate and understanding of our unease, while also being mostly matter-of-fact. I gamely volunteered to go first for the first few procedures, in an attempt to a) get it over with quickly, b) have the lower standard of being the first one out of the gate and c) try to pretend like it was no big deal to stroke this man’s testicles. Among other things. All in all, it was over before I knew it and I had successfully, if not mastered, at least performed, all the wonderful series of tests that take place, including everyone’s favorite, the prostate exam. Thanks, Mr. Brown, that wasn’t has bad as I might have imagined it would be.

Little did we know what awaited us in the next room.

Our next GUTA was the female GUTA, who we’ll call Ms. Devil, because I’m fairly confident that she is related to the little red man who carries a pitchfork and delights in uncomfortably high temperatures. To begin with, she was morbidly morbidly obese. And smelled bad. Really bad. Although I suppose those two things are good preparatory experiences for taking care of sick Americans for the rest of my life. I was willing to look past her enormous mass of body and unfortunate odor because, well, she's a person too. Until she started talking. And I began to question that single simple fact.

Basically she had none of the warm, comforting, reassuring charm that Mr. Brown possessed. Or even the small bit that even the most reticent of teachers possesses. So there was that. She began by berating us for not introducing ourselves as “Student Doctor [last name here].” One, that’s a dumb term and sounds as dumb as it is. Two, we’ve been told explicitly since coming to medical school to always introduce ourselves by full name and then state that we are first year medical students. But no matter. To hell with that. Student Doctors it is!

The first part of the female GUTA exam is the breast exam, which includes palpating the breast for masses, as well as palpating the lymph nodes in the axillary – basically beneath the arm pit. I went first (game face?) and essentially just got yelled at for 10 minutes. So that was fun. But not constructive yelling. Yelling more along the lines of – “why did you move your hand there?!?” Me: “uh….” Her: “put your hand back where it was! What ARE you doing? Why did you move your hand! PUT. IT. BACK.” It was awesome.

Palpating the lymph nodes was no better. She insisted we contort our arms in a completely comical way that involved sticking your fingers between the muscles below her armpit and was somehow was supposed to end with us putting our thumb on her scapula (that triangular flat bone on your back, right beneath your shoulder). But....upside-down. There were a couple of problems with this – she was so overweight that palpating her scapula, even with your entire hand, was somewhat of a challenge. Her excessive weight also meant that even if my hands were the size of Shaq’s, I’m not sure I could have reached her scapula with my thumb if my life depended on it. And finally, the absurd position she had us twist our arm into cannot possibly be the correct technique. There’s no way. Maybe she should try right side-up?

I somehow got out of that relatively unscathed, but one of my fellow “student doctors” simply could not satisfy her demands. She kept yelling “put your thumb on my scapula” and he tried the very best he could to no avail. It got so bad that we all seriously started to wonder if we were doomed to spend the rest of our days camped out in that exam room as she continued to berate him for the rest of eternity. It was almost comical. And then it was comical. The third of us started laughing. And couldn’t stop. And then the student with his poor fingers still in the GUTA’s axillary started laughing too. And I looked around for the candid camera crew to jump out.

They didn’t.

Somehow we moved on to the real substance of the female GUTA exam, examining the genital area, including palpating the ovaries, and visualizing the cervix. Shoving a large metal speculum into someone’s vagina is not exactly my favorite way to spend a Saturday morning. But at least now I’ve done it?

The remainder of the exam was just as bad as the beginning, especially in terms of the vague but demanding yelling and generally hostile learning environment. Thanks, Ms. Devil, you got the worst evaluation I've ever given in my entire life. In spite of all that, I could still see myself going into ob-gyn (whaaaaaat?). I’m certainly more interested in the obstetrics component of that specialty, but I realized that I, if not “get into” the rest of the residency, I could at least tolerate it, and probably even enjoy it. It’s a special kind of responsibility (and scary "power") for someone to place the health and protection of their genitals into your hands.

I also think this experience drove home the point that we’re very much in medical school. One fellow student commented that this experience is the start of differentiation between us and the graduate students. There are many biomedical engineering students, medical illustration students, or genetics graduate students, in most of our classes. But obviously, not this class. This is a doctoring class, in the most essential way. There’s something special about that. And I wouldn't trade where I am for anything in the world.