Family Medicine

I know, I know, I still never told you my interesting psychiatry stories. I PROMISE I will, sometime. I also promise I'll do that "how to use OTC meds properly" post before next cold-and-flu season, too.

But now I'm on family medicine, and I have to document these events while they're still fresh.

So here I am in Whitesburg, a teeny tiny little town in southeastern Kentucky, on my family medicine rotation. My preceptor is a born-and-bred Whitesburg-ian who sees patients in his clinic on Monday, Wednesday, and Friday, and works in the ER on Tuesday and Thursday. Awesome for me, because I do, deep down, like the ER. So here are some notes from the last week:

*My preceptor normally works with beginning-of-the-year third-year med students, whereas I'm an end-of-the-year third-year med student. That means I'm more independent, and know, as he puts it, "enough not to kill anyone," which means he gives me free reign to see and treat patients however I want in the ER. In clinic, I still run things by him, since they're his regular patients. He really has given me a lot of free reign, allowing me to re-attach a JP drain all by myself (I used sterile technique and the thing won't come out again, but I definitely didn't use the proper sewing technique from a surgeon's perspective. Oh well.).

*He was delighted on Day 1 to discover that I have, indeed, read House of God. I am, apparently, the only med student he has ever had who has read that book, and I agree, that's pretty upsetting. The only problem with that book is that there is a very small window of opportunity to read it. If you read it in your first year, you won't understand any of the clinical stuff. If you read it second year, you'll understand more of the clinical stuff but get depressed because you're not on the wards yet. Third year, you'll get even more depressed because you realize the no-win situation you've gotten yourself into. Fourth year, even more depressed at the thought of being about to enter intern year. Intern year, you might actually kill yourself, because it's just documenting the hell you're going through. After intern year, you'll wonder why you didn't read it earlier, because it would have helped you a lot. What to do? Personally, I read it during grad school, after having worked in an ER for 3 years, so I had an OK mix of clinical experience and optimism about the future. Maybe I'll try reading it again this month since I have some free time and am already plenty cynical enough about medicine that the book shouldn't depress me too much.

*He loves my car. And has informed the powers that be that it is OK for me to park in the doctors' spaces (woohoo!):


*On my second day in the ER, I pulled a fishing hook out of a guy's scalp. It. Was. Awesome. He had hooked himself by accident, and had brought a duplicate hook into the ER so we could see what we were dealing with. Since the tip was barbed, I couldn't just pull it back out, so I numbed him up, shoved the tip through the scalp with a pair of needle holders, clipped the barb off with wire cutters, and pulled the rest of the hook back out entrance wound. Of course, AFTER I did all that, I realized I had my camera with me, so instead of taking a picture of a fishhook sticking out of a guy's scalp, I just took a picture of the duplicate:
Next to a bag of tongue depressors for size comparison. I pulled one of these out of a guy's scalp, you HAVE TO BELIEVE ME!!!

*One night last week my preceptor was on call, and got an admission around 8:30 at night. He actually called me at the motel and told me to go admit the patient and write whatever orders I thought were necessary, and he would call the nurses and tell them to do whatever I wrote. That completely freaked me out, because I've never worked that independently before. It was just a simple case of gout, but I was seriously worked up. Do I order IV fluids? Can I justify ordering morning labs? Am I supposed to take the patient's health insurance into account? Can I order something stronger for pain when the patient is in such obvious discomfort? Do I dare order NARCOTICS all by myself? It was stressful. But I survived (and so did the patient. see? won't kill anyone.). Also, I should mention that it's technically illegal, but he did call and have the nurses tell him my orders, and verbally OK-ed them, which is legal. Still, yet another reason to not go to a teaching hospital unless your life is in imminent danger, in my opinion.

*We had a woman with an active MI in the ER last week as well. First of all, she was like 330 pounds, which made caring for her difficult. Second of all, her legs looked like she had elephantiasis. She said she had gotten bitten by a spider 5 years ago and her legs had started to look like that afterward, but who knows. Third of all, she was having an active MI, so we had to helicopter her to Lexington to get cardiac cathed. Now the bad part about small-town medicine is that you have a tendency to get stuck in a learning rut. In an academic medical center, you are constantly staying up to date on medical issues. In a small town? Not so much. Standard protocol these days for anyone having an acute ST-elevation MI is to give oxygen, morphine, and a beta blocker. Oxygen? Check. Morphine? Check, but not enough, in my opinion, especially since she was 330 pounds. Beta blocker? Nowhere in sight. And dammit if my preceptor didn't give me a lot of push back as to why we didn't need to give one while we were waiting for the helicopter to arrive. But I kept pushing, and he relented. I mean, it's standard protocol, there is NO reason not to give it! So there you go, not only do I not kill people, but I actually do things to save them also. I am an ambassador of modern medicine. And I will get him to stop saying "insulin-dependent and non-insulin-dependent diabetes" and start saying "Type I and Type II diabetes" if it's the last thing I do this month!

*I got to do CPR for the first time on a real person. This is good, because I am a certified BLS instructor, and I've always felt rather foolish teaching people to do chest compressions when I've never done them myself. Not-so-luckily for the patient, but luckily for me, the opportunity presented itself on Thursday. The patient died (he was a lost cause from the start), but I gave great chest compressions that created a femoral pulse, which is what you're looking for. So now I feel legit as a BLS instructor, and it was a great workout (crass, I know, but I was sore for 2 days).

*I already dislike small-town medicine, and possibly all primary care. My preceptor knows all of his patients WAAAY too well. Their past medical histories, their personalities, everything. I guess it's nice to know your patients that well, but the downside, from my perspective, is that he views everything they say through glasses tinted by their pasts. So I don't think he provides care as objectively as he should be. I'm sure it's common to most small-town primary care doctors, not unique to him. But it's just another reason I doubt I'll be setting up shop in an area like this.

*There are SO MANY drug seekers around here. You can't take anyone's pain seriously, and everyone wants to be a wuss and get opioids immediately. First of all, suck it up, people! Second of all, it's really scary that it's so prevalent and the drugs have such a street value that you really need to be careful. You don't prescribe pain meds without proper documentation and knowing the patient fairly well, and patients with any sense don't let it get out that they are on opioids, because they will get them stolen from them. I may have been conned by a drug seeker today; I won't know for another week. I hope I wasn't, because that guy was really really nice and I really thought I was helping him fix a real problem. Luckily, all the blame isn't on me if I did get conned (I don't sign prescriptions, remember), so I won't feel too guilty. We'll see.

*Tomorrow's another ER day, and the Ob/Gyn in town has told me to feel free to pop into his Gyn surgeries if I don't feel like staying in the ER. My preceptor is totally amenable to it, so it might be an OR day tomorrow!