Category: Medical School

Wildflower Willow after our pediatrics exam. “I loved my OB/Gyn rotation–actually doing something instead of just talking for hours about a patient on internal medicine. We would be relaxing in the resident lounge area and then hear a yell for BRT — that’s the Birth Response Team — and we would run.” She continued, “I am pretty bummed that I didn’t get to deliver a baby. I wasn’t proactive my first week. My second week I had four perfect multips [multiparous mothers, i.e., those who have previously delivered a baby] but each of them had a complication requiring either a CS or an operative vaginal delivery [vacuum delivery assistance].”

OB/Gyn orientation starts at 8:00 am Monday morning. The clerkship director, an attending obstetrician, provides a well-organized pamphlet with details about each component of the block, one week each: Labor and Delivery (“L&D”) days, L&D nights, outpatient gynecology, outpatient obstetrics, surgical oncology, and either Maternal Fetal Medicine (MFM) or Reproductive Endocrinology and Infertility (REI). She picks Device Denise, a short, cheerful 27-year-old who worked for two years in medical device engineering, as a schedule example. Denise comments, half sucking up (she wants to go into Ob/Gyn), half truthful: “This is by far the most organized clerkship we’ve had.” The clerkship director responds: “Well, it is the most complicated schedule. A lot of students complain about moving around among locations and specialties. You run around because we do so many different things in OB/Gyn.” My individually printed schedule shows that I will start with L&D nights.

At 9:00, we head over for a 30-minute tour of the hospital and end at the simulation center to practice suture technique and delivery of a baby on a $60,000 model. The simulation technician: “This isn’t even one of the more expensive ones. We have a $110,000 model of a kid the EM residents practice on.” Half of us have already done surgery so we are quite proficient in scrubbing in and sutring. The simulation model is a plastic female with her legs spread. Southern Steve comments: “Her feet look quite manly. Are they interchangeable with some other models?” Technician: “No that’s just the way she’s built.” She then presses start on a computer and a motor pushes a rubber doll out of the model’s vagina. This is followed by a rubber pancake connected to rubber tubing, representing the placenta and umbilical cord. The attending goes through correct technique to deliver a baby. When the technician and attendings leave the room, I ask, “Do you think this was a worthwhile investment?” Device Denise: “It’s better than not knowing what is going on with a real patient.” Lanky Luke: “It was helpful but it could have just as easily be done by observing a real patient.” 

Orientation ends at 11:00 am, and I head home to take a quick nap. I come back in to meet the night team at 5:00 pm for the handoff from the day team. The team consists of an attending, the senior PGY4 High-Horse Haley, a mid-level (PGY2 or PGY3), a OB/Gyn intern Teacher Tom, a Family Medicine intern Tangled Tiffany, and myself. Despite having been an intern for only a couple of months, Teacher Tom has already been recognized with a teaching award due to great medical student evaluations in the preceding two blocks. Tangled Tiffany has long tangled red hair and an open personality. She is a great teacher, her patients love her, but she clashes with High-Horse Haley. If she were a man, Tiffany might not survive in a #MeToo world. When I ask her the brand of neck heating pad she recommended, she responds, “Well, I could look through the texts with my ex-boyfriend, but no… I shouldn’t. Nobody wants to see those.”

Tiffany asks if I want to interview her patient in Triage. I lead the interview by asking questions (how frequent are your contractions, any bleeding, prenatal care history, etc.), while Tiffany fills in the numerous gaps. She then performs a cervical exam to measure cervical dilation, effacement, and station (position of baby relative to hips). We then report to our mid-level and senior resident in the resident computer area. After 10 minutes, High-Horse Haley scolds Tiffany  for performing a cervical exam without supervision. Apparently, a family medicine intern was not supposed to do this without either an upper level or the OB intern. She explains: “I was worried she was about to push the baby out any second.”

I scrub into a Cesarean section. The patient is a 26-year-old inmate at a nearby prison and suffers from Hepatitis B and C. She had been arrested for shoplifting and was then convicted of being a meth dealer. There are two armed guards looking through the OR door. (I asked them later how frequently they’re at the hospital. One responds “I’m here almost every day. I think I might have learned enough to work as a nurse.”)

It is unnerving that the patient is awake throughout the entire procedure talking to her sister behind the drape as the PGY2 makes the initial midline transverse incision. They bluntly dissect down to the abdominal fascial layer. The attending pimps me on the layers of the abdomen. Attending: “You speak like internal medicine doc — I would know, I’m married to one. Not a bad thing. You’ll find most OB/Gyn give short answers but we do have a few deep divers.” The resident makes a small cut with scissors into the fascia, then the attending and resident yank laterally ripping the fascia — it’s pretty violent. They then pull the uterus through the fascial opening — it looks like a turkey! The resident makes a small inferior transverse incision into the uterus. Membranes rupture with a gush of amniotic fluid and then the resident pulls the baby out. Whole process takes about 10 minutes. We suction the baby, clamp the cord after 1 minute, and then hand the baby to the neonatologist in the room. We don’t know what’s happening with the baby after that. 

Haley then proceeds to suture the uterus as the attending guides through. They talk about different suture technique among attendings. After they place the uterus back into position, the PGY2 closes the fascia with help from the attending. The attending allows me to do a running subcuticular to close the initial incision. They were impressed because most of the students this year have not done their surgical rotation yet. 

I ask the attending if she operates on patients with Hep C frequently? “Yes all the time. Also HIV. Some of my partners get tested every six months and I probably should start too.” 

Around 10:00 pm, everything slows down. No triage patients, no one close to delivery. I go with the OB resident to watch him do two cervical checks for actively laboring. No one is past 5 cm dilation. Both the FM and OB resident know how to speak Spanish fairly well and could get their interpreter licenses. The FM resident asked the OB resident: “What do you think about the Spanish license and phone interpreters?” “The phone interpreters are terrible. I asked a patient if they were soaking more than three pads per day. They asked do you need three pads? I do not get certified because of the liability. If something happened to a Spanish-speaking patient, they will grill me on my Spanish. Even if you did nothing wrong, they’ll blame the language barrier due to not using an interpreter and cross examine you to see how well you speak Spanish. You will be made to look like an idiot on the stand.”

Tiffany: “My patient is 29 years old with six kids, soon to be seven, who doesn’t speak a word of English after living in the US for over 10 years.  I have nothing against refugees or old people who are not going to be able to learn a new language. But she has been here for over 10 years and doesn’t work. I did my training in Miami and I use Spanish here more than there. Everyone speaks English [in our city]. How does she take care of her kids?” She added: “Geez, I’m sounding Republican now that I make money. Mom always said I would become one. But I’m not, I am a hardcore Democrat. Weird. I just can’t stand lazy people.” Teacher Tom: “Better get used to it.”

[Editor: She doesn’t like lazy people, but votes to give anyone who doesn’t work a free house, free health care, free food, and a free smartphone?]

Our team has very little patience for non-laboring patients. The surgery service “made us take care” of a multip at 24 weeks who underwent hemorrhoid surgery. The surgery service threw the patient on our service because of an unequivocal fetal heart rate test (Non Stress test) requiring a more expensive rule-out test (BPP). Surgery is consult, OB is primary even though the only reason she is in the hospital is for recovery from the hemorrhoid surgery.  She was told this is an excruciatingly painful surgery that will take two days to be bearable. The surgery resident went into the wolfden. “She is a weiner, very low pain tolerance.”  The resident came to us afterwards to say nothing is wrong with postoperative course, and no more pain meds can be given. “This is a direct quote from the surgeon, ‘I don’t see them for two weeks because they will chew me out.” 

We read the operative note for the surgery. High-Horse Haley comments: “You see everyone says OB is disgusting. Look at this. During the surgery they dilated anus to get access. Babies are meant to come out of the vagina. Anuses not meant to be dilated.”

The mid-level explains that there is no medical necessity to be in the hospital and we are just giving you meds that can be given at home. You’ll recover better at home. The husband responded that they won’t leave because it would be difficult to get into the car and get her up the stairs to their bedroom. “Sleep on the damn floor. We’re not keeping them because he doesn’t want to deal with her at home.” Are they private or Medicaid? Private. “There is no way that Anthem is going to pay for this hospital stay. It’ll be out of pocket. Most expensive hotel stay ever. $4,000 just for the night, not including outpatient med costs.”

After they are informed about cost, they leave within 30 minutes.

Around 2:00 am, Tiffany delivers her patient’s baby with the attending and Haley and myself in the room. I get to deliver the placenta and perform a uterine massage. Haley: “Tomorrow we’ll try to get you a baby to deliver. Good job.”

Things become dead at 4:00 am. We don’t have any patients to report to the morning team so we make up names to put on the sign out sheet. We come up with: Bree, Frank; Rea, Gunner. Tom: “Let’s see how long until they notice they’re all fake.”

Wednesday night starts off with a few rule-out ROM (rupture of membrane) ferning tests. Tangled Tiffany swabs the vagina and wipes the swab on a glass slide. If the amniotic fluid has ruptured, the salts will crystalize into snowflakes at 40x magnification.

My patient for the night is a 24-year-old pregnant with her first child. I walk into her room at 6:30 pm to introduce myself. The similar-age father is snuggling on the pull-out bed with the patient’s sister. The expectant mother is concerned about pain. “I was promised I wouldn’t feel anything. Is this true?” There were enough similar questions that her day nurse requested reassignment. The epidural is in and we know that it’s working because she can’t move her legs, but the new mom continues to complain about pain. Haley joins five minutes later: “You are going to feel some pain. Delivering a baby is painful. Pressure is okay.” As delivery gets closer we finally acquiesce

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The last week of inpatient pediatrics is shortened by Thursday’s Shelf exam. I am woefully unprepared, having completed only 100 of the 400 pediatrics UWorld questions. Gentle Greg, a soft-spoken classmate: “No one has figured out a good balance between clerkship and studying.There is just no time.”. His father is a critical care hospitalist who trained as a physician in his native India and practiced in both India and England before emigrating to the US.

A new team of residents and attending start on Monday. I introduce myself and take on two overnight admissions, both asthmatics. Our hospital has had two deaths from asthma attacks the past year. The pharmacist who joins us on morning rounds comments: “There is no excuse for kids dying from asthma. It’s a completely controllable disease. More so than even T1D [Type 1 Diabetic]. The best insulin  control and medical communication can still sometimes not be enough to control hyperglycemia. The five-month-old who died from status asthmaticus is tragic but can be justified as unavoidable. There was no prior history. But that 16-year-old who died at her Subway job should have been flagged by her family and physician for using a rescue inhaler [albuterol] every few hours rather than taking her [steroid] controller medication daily as instructed.”

I take care of a 13-year-old T1D admitted for DKA [diabetic ketoacidosis]. We were taught about different types of insulin, but we were never taught practical lessons, for example, the three types of standard sugar control regimens, how to administer the insulin, how an insulin pump works. I ask my resident to go through the basics before I go into the room and make a fool of myself and the team. Most diabetics take daily or twice daily long-acting insulin (Lantus or Levemir)  to act as the foundation. In addition, after every meal they do a carbohydrate correction (e.g., 1 unit for 15g carbs for lunch and 1 unit per 30g carbs for dinner). Lastly, they do a sliding-scale adjustment every 2 or 3 hours, where they administer 1 unit for every 30 mg/dL glucose above 130 mg/dL. She has been hospitalized six times in the past 2 years for DKA after relatively good glycemic control since the diagnosis at age 3. We are not exactly sure what happened. The residents suspect that, given her age, she is refusing to take insulin as prescribed as a weight loss strategy (“diabetic anorexia”).

[Editor:A friend who has managed Type 1 Diabetes since childhood wrote the following private message: “I always see people posting on Facebook how they go to CVS to buy insulin and it is $500 a bottle (lasts me a month but lasts fat people 2 weeks) and they are so mad that companies are ‘allowed’ to charge this. I ask them why they go to CVS and pay retail when the same insulin is $40 a bottle mail order from Canada, including shipping. And the older kind is $29 a bottle at Walmart. Almost no one in the UK has insulin pumps because their health system doesn’t provide them for free. Pumps are $6000 here new, but I got two for free on Facebook and you can buy them on Craigslist for $300 except do-gooders report the listings and get the listing taken down as Facebook, eBay, and Craigslist don’t allow them to be resold.”]

An 8-year-old is admitted for poor weight gain (4th percentile for weight and BMI) and acute episodes of diarrhea. We need to get his charts from an outside institution also on Epic to determine when he fell off the growth chart. In theory this should be easy with Epic’s “Care Everywhere” reconciliation. However, we spelled his last name wrong in our system, causing a failure to synchronize with the outside institution. IT informs us we that it is impossible to correct this error until after the patient is discharged.

Part of the medical student’s role is to get medical records from outside institutions. How does this work, nearly 10 years after the American Reinvestment & Recovery Act, which included the “Health Information Technology for Economic and Clinical Health (HITECH) Act” that provided taxpayer funds for computerization of medical records? The core technologies are the telephone and a FAX machine. Here are the steps:

1. 20 minutes on hold
2. speak to the medical record department
3. get their institution-specific medical request form faxed to us
4. fill out the form with help from the family, e.g., to learn the Social Security number
5. fax the request form back
6. wait 30 minutes for the requested documents to appear on our fax machine

This is not to say that the electronic medical record (EMR) has had no effect on the process. EMRs may automatically add vitals at 15-minute intervals to the record and therefore even the simplest data request usually results in at least 10 pages of irrelevant notes before you get to the information that is sought. I learned that it is more efficient to ask the patient to call the institution and speak with a nurse who can relay relevant labs over the phone. I then type them into our Epic system. Even triple-checking the values on a voice call, the total time and effort is much less than using EMR+fax.

I say farewell to my team and head off Wednesday afternoon for a lecture on childhood GI bleeding. The lecturer speaks in a monotone, reading verbatim off the slides of a presentation that someone else created. I ask classmates if it was obvious that I was dozing off. Anki Alex, a class gunner who does 300 Anki cards daily on rotation: “Big Dawg, every person was dozing off. There was a wave of head bobbing. The few times that I myself wasn’t sleeping it was hilarious to watch.”

We take our exam Friday morning. Crisis ensues at the exam. The hospital WIFi is intermittent so every 10 minutes the private secure browser in which we take the NBME Shelf exam shuts down. Nervous Nancy’s computer works fine and she is taking her exam while the other 25 students shriek and hollar. Exams are typically proctored by two people: a clerkship administrator and someone from IT. Today, the IT proctor is sweating and scrambling. His best theory is restarting each computer after every shutdown, but today this is providing only another 10 minutes before the next shutdown. After 30 minutes, the clerkship coordinator kicks everyone out to give Nancy some quiet. We are then called in one at a time to log on and restart the exam. This process of getting people restarted for the 2-hour, 45-minute exam takes about 2 hours.

The exam is probably the hardest exam I have taken throughout medical school.The average is low enough the passing score is rumored to be 60 percent correct.  The pediatrics shelf includes questions on childhood skin lesions, upper airway versus lower airway disorders the amoxicillin drug reaction from mononucleosis, several challenging autoimmune disorders (e.g., compare Bruton-K agammaglobulinemia versus Common Variable Immunodeficiency), and an annoying nephrology biopsy image (Pinterest Penelope: “blast from Step 1 past”).

Type-A Anita complains to the administration that the disruptions affected her exam performance after we finished the exam. We got an email on Saturday:

We apologize for any added stress caused by the technology issues during testing this week. Thanks to the determination of our IT professionals, we understand now that the issue was beyond our control and that it has been resolved with the necessary groups.  … Although we will not receive results from the NBME until this weekend, please understand that all contextual factors will be considered in the case of any undesirable outcomes.

Statistics for the week… Study: 15 hours. Sleep: 7 hours/night; Fun: 1 night. We grab burgers and beer with Mischievous Mary who just finished her OB rotation. “You hear the most ridiculous stories. The residents and students sit in an alcove that is obscured by walls from the patient hallways. An African-American in his late 20s came up to the nurses and said: ‘Ma’am, my wife and girlfriend are in rooms next to each other. Could we move them so they are not near each other.'” She continues: “You’ll also hear the worst baby name choices. I asked the attending if she ever tries to change their minds? The attending responded: “Only once: the patient wanted to name their daughter Chlamydia. I talked them out of that.” She concluded: “I never appreciate how obstetrics is such a surgical field. I am actually considering OB now instead of CT surgery.”

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First week of inpatient pediatrics starts at 7:00 am. The team consists of a PGY3 (“senior resident”), a PGY2 (“the mid-level”), two interns (would be “PGY1”), an M4 in the role of an intern (“Acting Internship”  or “AI”), and two M3s, including me. The PGY3 pediatrics resident is a short quiet 31-year-old. He looks at the floor and around when he speaks to someone. He took several years off after college to live in NYC with his librarian girlfriend. The idea was to work as a researcher to improve his medical school application, but working as a “manny” for wealthy Upper West Side families turned out to be the job that paid enough to afford an apartment. The PGY2 is a 29-year-old Oregonian native who loves her three cats and is married to a tenuously employed man back home. Rockstar Rita is the attendings’ favorite intern. Her girlfriend is a resident in a city that is a four-hour drive away so they rarely see each other.

After meeting the team, I shadow the interns and residents on Monday while getting accustomed to the basic structure of the day. First, we preround on each intern’s 3-4 patients. The interns plus the “AI” write notes at the resident station until morning handoff at 8:00 am, packed into a 10-person conference room attended by the residents, interns, medical students, our pediatric hospitalist attending, and the hematology/oncology attending and/or fellow as well. We first go over the oncology kids. Rockstar Rita has all of these notoriously complicated cancer kids. She presents a patient summary for each of the four “regulars”: two acute myelocytic leukemia (“AML kids just get sick” [from the drugs used to destroy their white blood cells]), a rhabdomyosarcoma, and a Ewing’s Sarcoma. She highlights actionable items such as thresholds to transfuse platelets or red blood cells, when to draw another blood culture if they have a fever after 24 hours, and pain medication regimens. The night team then presents the new patients admitted overnight. Finally, we leave the conference room to round on each others’ patients in our pack of 8 and finish at the resident station for everyone to write notes.

The resident station is a short hallway outfitted with five computers that connect the nurses station with the snack room in the middle of floor. It is hidden from patient’s view but clearly not out of range from the loud conversations going on. “Alright, team lets get em out,” as he whistles. “The Discharge train begins.” Rockstar Rita complains that her “T1D” [12-year-old type 1 diabetic admitted for diabetic ketoacidosis] should be ready to leave the hospital, but is acting lazy: “She just won’t get up. She is lying in bed, not drinking or walking. This is a perfect job for a medical student [looks at me], Go get her up. I don’t care how you do it but get her to chug a glass of water.” What do we do if a patient doesn’t want to leave?” The senior resident chimes in: “Same exact thing with gastroenteritis girl. Vomiting is not a reason to be admitted to a hospital. They were admitted for concern of an appendicitis, which we have now ruled out. Go have diarrhea at home like everyone else.” The AI chimes in: “We ask him if he wants to go home and he replied, ‘No, let’s stay, it’s fun.’ Could we take the TV cord? (Oh no, cord broke what happened?)”

The senior resident added afterwards: “It sounds heartless, but we need to get these patients out of the hospital. The PICU is completely full so when we don’t have a room patients may have to be transferred to a less capable hospital. Also, the best thing for these patients is to get home and back to a normal schedule.”

I wake up our T1D, walk her to the water station for a drink, then drop her off with the video games in the Teen room. 

I then sit down with my classmate Diva Dorothy, one of the younger class members at 24. She’s a great resource now that our class has dispersed because she keeps up with gossip from every year within our school. She started a week earlier and gives me some advice about Inpatient Peds. “Unlike with adult medicine, pediatric patients recover so quickly that it’s tough to do any patient presentations. Grab any patient who will be here for a few days. Also, bring your own laptop because there won’t be room at the resident station.”

She confides her struggle during the previous week. “They think I’m lazy or not interested and ignore me. I’m sitting in the next room over and they’ll just leave and go to the consult without me. No one gave me any orientation, each medical student has had to rely on the previous medical student to get situated. We have no idea what note templates to use [within Epic]. No one gives me the AM rounding sheet showing new patients that they print out for everyone else. How did you get one?” (me: “I try to get in at least 15 minutes before the official 7:00 am start time. Then I can ask the night team resident for a printout.”) 

Dorothy: “I’m sad about this whole experience because I loved outpatient pediatrics. I’ve had such a bad time here that it’s making me question doing pediatrics.” I agreed that it is a shame that an unapproachable team during a clerkship can discourage someone from pursuing a residency. She complained last week to the clerkship director. Apparently this was conveyed to the pediatric hospitalist attendings because Dorothy remarked that this week’s orientation was substantially improved.

[Discussion with Jane that night: “all of the rotations are poorly organized.” By Wednesday, Diva Dorothy is absent. Our team is told that she is sick with a stomach bug, but she texts me to say that she has been moved to hematology/oncology clinic at a different location.]

After rounds we sit at the residents’ station. I am surprised at how little we actually see patients. After the initial morning round, most patients do not get seen by a physician until the next day. The night team does not go in unless a nurse asks them to. Residents during the day spend most of their time writing notes, ordering labs, and finishing discharge summaries. The senior resident mentioned that one thing a medical student can do to help the team is check periodically on patients. [Editor: Doctors are so busy typing at computers that the medical students have to do the actual doctoring.]

We get two new admits from the ED at 4:00 and 4:30 pm. Diva Dorothy was packing her stuff. The attending had to convince her to stay later than the normal 4:00 pm sign out. The attending: “You can go, but it would be good practice to admit a patient.” She responds: “Okay, I’ll stay.” (We are only supposed to do one late sign out per week). The residents/interns regularly stay late. 

Tuesday is a typical day. I get in at 6:45 am for prerounding on my one patient. At 8:00 am, I head to the conference room for morning handoff. Diva Dorothy is complimenting Rockstar Rita on her new short haircut. “I love short hair, but I never know if I should get it. My parents are Sikh so they frown when I cut my hair.” (She references a tattoo, though, but I have never seen it.) Once everyone is present, we hear about the cancer patients. Rita is doing a fabulous job despite constant interruptions from the PGY2. The Attendings are chatting with each other, oblivious to this rivalry between the two young women. I pick up a new patient who was admitted by the night team.

The medical student or intern present the patient to the patient and the whole team in the room. We are instructed to use “layman’s terms” or explain the term if you use it to a patient: e.g., “afebrile means no fever overnight”; “leukocytosis with bandemia means high white blood cells with markers suggestive of immune response”. The quality of our presentation is a big part of how we’re evaluating, but it is challenging to select the right amount of information for the team and the desired level of detail will vary considerably depending on whether we’re ahead of or behind schedule. One attending later complimented me after I brought up a potentially disturbing question with him privately before we entered a patient’s room. I didn’t tell him that it was Rita’s whispered idea.

I struggle to present my patient in the clear “SOAP” format [Subjective, Objective, Assessment, Plan], forgetting a few lab values and symptoms that I mention in the wrong section. I need to work on this. Much different that presenting a surgery patient. 

She’s six months old and was taken to her pediatrician for a three-day history of diarrhea, nbnb (non-bilious, non-bloody) vomiting, and lethargy. The pediatrician gave the baby some Pedialyte and sent her to an outside ED, which administered a fluid bolus (20 mL/kg). and took an x-ray to look for possible obstruction. The extra hydration led to rapid improvement in her symptoms. The x-ray did not show any signs of obstruction, but there is a concerning left upper quadrant opacification suggestive of a mass. An abdominal ultrasound showed a large, heterogeneous mass separated from the kidney and spleen. The outside hospital did not feel prepared to evaluate this patient, so an 80-mile helicopter transfer to our tertiary hospital was ordered.

[Editor: Yay! Creating jobs for East Coast Aero Club graduates and Eurocopter mechanics.]

The baby arrived looking well and entertained the residents as the cutest kid on the floor.  Morning report from a night intern: “Given the location of the mass, our differential needs to remain wide. This includes: Wilm’s tumor, nephroblastoma, neuroblastoma, lymphoma, and other neoplasms of the adrenal gland, kidney, stomach cancer, etc.” PGY2 chimes in with statistics about the most common pediatric malignancies. Our Attending: “I called down to radiology and our pediatric radiologist is not convinced this is a mass. He wants us to insert a NG [nasogastric] tube to better visualize the stomach.” The heme/onc noted that the abdominal ultrasound did not show much vascularization of the unknown mass. We need to CT before we can have a definite plan. I’d like to CT before we biopsy.” The hematologist/oncologist attending goes in and tells the parents that there is a concerning mass that may be a tumor. The parents start crying.

A few hours later, after we get through our critical note-typing, I am tapped to insert the NG tube under Rita’s guidance. Every NG tube must have a x-ray to confirm correct placement, i.e., not in the lung or perforating the stomach into the peritoneal cavity. The baby gets her second x-ray.. We send the baby down to get another abdominal ultrasound while water is poured into the NG tube for better visualization of the stomach. 

I look at the NG tube-confirmation x-ray and notice that the mass is gone. I bring this up to the resident. “Hmmm that is very interesting.” A few minutes pass and the ultrasound tech calls to say that she cannot locate the mass. We go down to the radiologist who believes this “mass” was just a distended stomach. “Look at the air-fluid levels on the ultrasound. It’s just a really distended stomach from a large feed.” We learn that mom is feeding the child 9 oz of formula every 2-3 hours, about 3 times the recommended amount.” The senior resident jokes: “We just discovered a new disease: malignant constipation.”

We have two boys on our floor for constipation requiring manual disimpaction. The senior resident: “This would be a perfect job for our medical student. Ask the nurse to supervise.” The nurse explains how to do the procedure before we go in. I perform the digital disimpaction and insert an NG tube hooked up

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Day shift at the neonatal intensive care unit (NICU) begins at 7:00 am. The night shift neonatologist is finishing her notes in the physician lounge before the 7:30 am handoff. I asked why she isn’t using the hospital’s Epic system. She explains, “We are part of Pediatrix, a MEDNAX subsidiary. Forty percent of neonatologists are part of this group.” (When she’s finished with her note it will be exported to Epic as a picture, thus resulting in a hard-to-use chart for the patient. The Pediatrix system is problem-oriented and, though less flashy than the Epic screens, is superior in terms of information presentation and productivity.)

My attending, a 50-year-old who speaks softly in a thick Indian accent, arrives at 7:15 am, and opens a discussion regarding the consolidation of physicians (Pediatrix employs more than 1,750 doctors). The night neonatologist: “We have no one to blame but ourselves. Physicians want to only focus on patients and do not want to deal with billing so we just handed it to administrators who took over. We don’t get paid if we don’t bill.” He responds: “It just seems that the administrators took the power and have made it so complicated it is impossible for any physician to understand it. Every year they change the reporting requirements, change the codes. They purposefully make it such that you need an army of administrators behind the scenes.”

“The administrators think we are naive to their little ploys,” she added. “They make a big deal that they sent us a link to a live feed of the 9:00 am annual shareholder meeting. Are you freaking kidding!?! We have babies to take care of in the morning. They have no idea what we do.  They are just profiteers. Our company will never raise our salaries. New hires get paid more than we do. Instead of raises they’ll give us bonuses from the profit, but of course they take the first 50 percent.”

After the night neonatologist left, my attending summarized: “People remember the $500,000 per year salary from the good old days, but they forget that they had to work every single day, no weekends off, to earn that.”

We proceed to the actual NICU, double-washing our hands and sterilizing our phones and badges with UV light. We then take turns listening to the neonates from the individual child stethoscope hung on each pod (to avoid cross-contamination). I am assigned two babies. I try to conduct a full physical exam on them but the nurses shoo me away because it is outside of scheduled “Care Time”. Neonates are given four hours of undisturbed nap time in between medical interventions.

The attending heads off to the physician lounge to write notes while I set up in the respiratory supply closet, which doubles as a respiratory therapist (RT) station with three computers. I finish my note and then study UpToDate on various neonatology topics, e.g., respiratory interventions and feeding regimens.

Around 12:00 pm, a nurse pops her head in and asks if I want to “join for stairs.” I agree, despite not knowing what is involved. The 30-year-old nurse, my attending, a 60-year-old RT and I walk up and down the hospital stairs (13 floors) three times before we head to a meeting on provider well-being. The RT keeps going. We all get pretty sweaty and the nurse says, “We better not show up at the same time to the meeting. Could be questions.” Despite carrying 20 extra pounds, the attending is able to smile: “Yes, yes, I’ll show an hour later.”

[Editor: How long would a male nurse last after making a sex-related joke?]

The meeting regards the emotional fallout from caring for a particular baby, in his seventh week in the NICU, with skeletal dysplasia, a fatal disease with numerous bony deformities and cardiac anomalies. One nurse confides: “It’s just hard to go to work seeing this baby in pain day after day.” The child has a gastrostomy tube that has had two episodes of cellulitis. The infection is cured, but there continues to be wound breakdown. “No matter what position he is placed in he squirms.” Two nurses have refused to care for the child. The nurses have to suction out the tracheostomy tube to prevent the child from desaturating due to mucous plugs. The nurses thanked both physicians for their clarity to the family. “I think the family had different impressions from the beginning compared to what you two have conveyed.” The attending said that the family is slowly coming around to the idea of letting nature take its course.

We slip out of the meeting for a Caesarian section. A neonatologist is present at every vaginal delivery of a pre-37-week infant and at every Caesarian section regardless of gestational age. I get permission to watch from behind the surgical tech’s Mayo Stand (stainless steel table near the surgical field, holding commonly required instruments) the Ob/Gyn team performs a laparotomy (opening of the abdominal cavity). After they reach the anterior abdominal fascial sheath, the resident makes a small incision with her dissecting scissors. They widen the hole until the attending and resident can each fit one of their hands into the peritoneal cavity. “Lots of pressure,” announces the attending as she pulls laterally to tear open the fascial sheath. They’re casually chatting about a recently retired physician during this 8-minute procedure.

Once they’re inside the peritoneal cavity, I can’t see anything more so I head back to the baby response team (nurse plus neonatologist). The surgical team announces uterine incision time, then membrane rupture time. The baby response team doesn’t even look at the mother or surgical site until the surgical team announces membranes are ruptured. The nurse hangs a large blanket on my shoulder and demonstrates how to carry the baby. After a 15-second struggle, the resident pulls the baby out of the uterus, cuts the cord, and passes the baby to me. I wrap the baby in the blanket, take two awkward steps, and place the baby down on the warming bed for the neonatologist to evaluate.

The baby has a low blood oxygen saturation so we begin BIPAP (bilevel positive airway pressure). The neonatologist grabs an oxygen mask from the nurse and places it on the newborn. There is a small hole in the mask out of which the 44-percent oxygen mixture escapes until the attending places his index finger on the hole, at which point positive pressure is applied to the lungs. The neonatologist demonstrates how to deliver the pressure by toggling the pressure every two seconds. I take over and watch the oxygen saturation go from 80 percent to 86 percent. 

The neonatologist whispers, “Does this look like a funny baby?” I look for classic syndrome characteristics: he has a smooth philtrum (groove between mouth and noise; bad), macrosomia (bad), low set ears (bad). I open his hands: two palmar creases (good). My attending points out sandal gap toes (wide-space between big toe and the 2nd toe). The neonatologist admits the baby for respiratory distress and further evaluation of syndromic characteristics.

The nurses 10 feet away: “How does she think she’ll get to keep this baby?” The other nurse: “She doesn’t think we know about her other kids. She keeps having more kids thinking CPS won’t be notified and she’ll get to keep this one. Maybe stop doing drugs and be a mother.”

The nurses see me listening in and comment, “Welcome to the NICU. Not your Cinderella stories.” The notion that NICU care would be heroic work saving premature babies, a completely clean slate, from certain death to bring them to adulthood and productivity is typically wrong. Similar to my trauma experience, these patients are “high risk”. Unfortunately, a majority of the babies are in the NICU because of terrible mothers. And business is booming. They just doubled the NICU beds in a large renovation. 

I dig through the mother’s chart. She’s a 38-year-old Hispanic and this is her ninth child. She does not have custody of any of the previous eight, three of whom have Down Syndrome. (She likely has a Robertsonian translocation, which means each child has a 50 percent chance of Down Syndrome.) She admitted throughout this pregnancy to using crack and other narcotics, but did stop using meth at 14 weeks into the pregnancy. The neonatologist and I interview the mother. It is taboo to ask about who the father might be so the discussion centers on CPS and the likelihood of them taking over custody of this child.

We get called down for a 34-week vaginal delivery. Fetal ultrasound at 20 weeks showed excess amniotic fluid, but no renal abnormalities or tracheoesophageal atresia. The patient is only 7 cm dilated. We ask the Ob/Gyn resident if she needs our help. “No, I think it’ll be awhile.” Why did she page us? My attending: “OBs have no sense of time. Do they think we just sit up there twiddling our thumbs waiting for them to call? We have an entire NICU to run upstairs.” The baby is born two hours later, and nephrology is consulted for a rare inherited kidney disorder from a genetic defect in a kidney channel furosemide or hydrochlorothiazide use leading excess diuresis. (There are only an estimated 8,000 people in the world with this disorder. Prognosis: there is relatively good prognosis for the child if treated consistently with nonsteroidal antiinflammatory drugs and electroylte monitoring)

While finishing the day’s notes my attending says, “Look at this. A 34-weeker was given a portable warmer. This costs $600. A 34-weeker does not need this warmer. Under 28 okay, but 34-weeker. I don’t even know why I try to save money. It’s all Medicaid money. No one cares.”

Friday afternoon is our clerkship director leads a lecture from 1 to 6, ostensibly on the topic of Failure to Thrive. Looking at the weight charts, however, spawns a tangent on the subject of obesity. “Weight percentiles on growth charts are calculated off of the 1960s and 1970s NHANES [National Health and Nutrition Examination Survey] data. Over half the country are above the 75th percentile.” Pinterest Penelope asked when we would update them to reflect our actual population. “I don’t think we want to lower our standards.” Our clerkship director shared her personal secret for motivating children to lose weight: “You have to frame it as a personal problem. I tell the mom: ‘You unfortunately are an easy weight gainer, and you will have to work extra hard to get it off.’ The parents and child all have to lose weight together.”

She covered familiar ground about kids playing indoors with electronics rather than outdoors with neighborhood friends: “I flip out when I see a one-year-old swipe at a Fisher-Price iPad App before he can run. It’s scary, right? I can’t even do that.”

She concluded this topic: “Positive thoughts lead to positive feelings that lead to positive actions and positive results! Repeat after me.” We all repeat in unison.

[Editor: From Life of Brian… “You’re all individuals”; (in unison) Yes! We’re all individuals! “You’re all different!”; (in unison) “Yes, we are all different!”]

She talks about acetaminophen overdoses. Two classmates report seeing two acetaminophen overdoses each during their inpatient pediatrics rotations. She explains: “The parents a lot of time don’t think it is serious. They want to take their daughter home, but it hits them when we put one-one suicide precautions: minder in the room at all times, take their phone, place them in paper gowns. Parents think it is situational. Their teenage daughter is temporarily depressed after a break-up, so there is no need for treatment. Do the parents think there won’t be another boyfriend and another breakup? I had to get a restraining order to prevent a mother from taking her daughter home.”

She attributes the bulk of the problem to glorification of suicide in our culture. Pinterest Penelope responds by mentioning Amy Winehouse and the Netflix show 13 Reasons Why.

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My week in the nursery starts at 7:45 am. My attending, a specialist in NAS clinic (babies born addicted to opioids from addicted mothers), strolls in at 8:15 am. After residency two years ago, she did a fellowship in pediatric palliative care, and took the job at our institution expecting to be mentored by the palliative care team. However, the position evaporated, and she took the job in the nursery instead. “I needed a job,” she explained. “The goal of this week is for you to become comfortable being around a baby.” She goes over a basic newborn exam on newborn baby in the nursery receiving phototherapy for jaundice. “Tomorrow we’ll give you a newborn for you to follow. Today just follow me around.”

Afterwards, she catches up on the computer while I configure my Epic with all the best screens to view weight changes, bilirubin values, feeding schedules, and diaper changes. The 35-year-old PA student training with us arrives around 10:00 am, and I help set up his account. We then go into a conference room. She hands us a folder that every mother gets when she arrives on the floor. It includes information on breastfeeding and postpartum blues information. She also hands us a H&P (history and physical) form where we record all the patient’s information for handoff to the night team. She asks us to introduce ourselves. 

The attending does newborn checks on the four babies born overnight and this morning. Around 11:30 am, she sends us over to work with the lactation consultants. They instruct us to read a packet, titled “Breastfeeding for Dummies”, describing good breastfeeding technique and detailing the number of times a baby should feed in the first week of life. After 30 minutes, we each follow one lactation consultant. “No, no, no. That must be painful.” she explains to a mother, showing her how to get a good latch. “If it hurts at all, you need to start over. Babies are lazy, you need to teach them good habits from the beginning or it will be harder to breastfeed.” She breaks the latch with her finger, and then grasps the areola with her palm, opens the baby’s mouth and shoves the breast into the babies mouth. The mom exclaims, “Wow much better.” Are there any male lactation consultants? “I’ve been doing this a long time and have never worked with one, I think I saw one at a conference, but he may have been a doctor.” [Editor: Perhaps this male-appearing individual identified as a woman?]

The next patient is a baby who is not gaining enough weight. The pediatrician put in an order for formula, but the mom wants to breastfeed exclusively. The lactation consultant disagrees with the order, but shows the parents how to feed with a syringe and tube on which the baby will have to suck. “If you start the bottle this early, the baby will start to only want to use the bottle. You’ll have to pump all the time, but your supply will slowly go down. You need those hormones to kick in to keep the supply going.”

Our attending is trying to work her way down from 180 lbs. with salad and sends me out to grab lunch with Jane at the hospital outside the coffee shop. Jane is on her orthopaedic elective. She was in clinic this morning, and arrived at the hospital two hours early for her first OR case. Jane hasn’t done surgery yet, so I give her the basic tour of the OR, the various staff members in the operating room, where to get gloves, and how to help the nurses. “Make sure you wear a mask into the OR!”

After lunch, I watch the attending perform two circumcisions. The nurse grabs a chair and puts it behind me. “If you feel queasy, sit down.” A medical student last year passed out during the procedure. I give the baby sucrose (“Toot Sweet”) drops which help the baby ignore the pain. “It distracts them.” I squeeze the sucrose tube so hard that the entire tube is emptied by the end of the procedure. The nurse laughed: “That usually lasts their entire hospital stay!” The attending does one later in the afternoon demonstrating the World Health Organization technique to the residents. It’s definitely less efficient. I learned that a circumcised infant has a 1 in 1000 chance of a UTI in the first year of life compared to a 1:100 chance for an uncircumcised boy.

The PA and I leave at 1:00 pm for lectures in a nearby outpatient clinic lecture room. We have students present a 10-minute topic of interest followed by a 3-hour discussion on failure to thrive (“FTT”) led by the clerkship director, an 50-year-old pediatrician. She talks at the speed of light. We learn that she lives with her mom in a small apartment complex next to campus known to us graduate students as the party apartment. She tells us about yelling through the window at kids swimming in the pool without a parent present. “My mom tells me to stop, but I can’t help myself. I just can’t. What parent would leave their kid alone in a pool? Right, Right?” Southern Steve counts the number of times she says “Right” — 54 times in 3 hours of lectures.

Pinterest Penelope presents on the causes of hypoglycemia (low blood sugar). The clerkship director interjects: “What is the number one cause of hypoglycemia around Christmas time or New Years?” Blank stares. “Alcohol ingestion.The kids get up early and drink all the eggnog left over. [excess alcohol consumption increases insulin secretion, decreasing blood glucose levels.] We have lots of these patterns. Halloween is DKA season [diabetics eating too much sugar]. Halloween is also costume dermatitis season.”

Our clerkship director strays from the advertised topic of FTT. “We are so spoiled with vaccines. I’ve been in practice for 18 years. My mentor would tell me how they used to go into the hospital with 100 kids, and leave with only 30 on some days. That’s how bad HiB [the Haemophilus influenzae type B bacterium] was. It would decimate entire counties. The medical community worked hard to develop HiB vaccine. I was around when Prevnar 13 was developed from Prevnar 7. I had babies die from Strep meningitis.”

A student asks: “How do you deal with parents that refuse vaccines?” She explains: “Being a doctor means dealing with difficult decisions. Get used to it. Some practices refuse to see patients that do not get vaccines. If you see a nonvaccer baby, you’ll get sued by another patient who catches measles in the waiting room or if the child dies from a vaccine-preventable disease you’ll be sued cause every dead baby is a lawsuit. We have a large refugee population here. [Editor: Maybe the next caravan from Honduras will take refuge around the pool in mom’s apartment complex?] We need to take care of them, but they are all not vaccinated. Do we just refuse to see them? Where do they go? Well they come to us, we take everyone in the community. Everyone is different, but I love this part of our job.”

Wednesday starts with patients at 8:00 am and then presenting three babies to the attending. The first baby was found to have agenesis of the right kidney on prenatal ultrasound and, during the newborn exam, was found to have a sacral dimple. We take the baby down to get an ultrasound of her spine and her abdomen.

The PA asks why? I respond: “I think it is because of the VACTERL association (Vertebral abnormalities, Anal agenesis, Cardiac abnormalities, TracheoEsophageal fistula, Renal agenesis, and Limb defects). A baby with one of these anomalies has a much higher risk of another congenital defect.” We order a genetics consult to help us rule out any syndrome. The nursery turns out to be mostly a filter for identifying complicated babies that are sent for further evaluation.

The ultrasound exam takes about 30 minutes because of the newborn’s difficulty.

Several hours earlier, the mom had asked that the baby be moved to the nursery so that she could get some sleep. I go to ask if she would like the baby returned to her room for phototherapy. “Yes, please.” No one had been to see her for hours, so she’d never had a chance to ask for the baby back. I’m surprised how docile patients can be, afraid to ask for more information from the nurses and doctors. I ask, “Has anyone explained the ultrasound results?” She responds, “No.”

“Well as you were told a few months ago [at the 20-week anatomy scan],” I begin, “your baby doesn’t have her right kidney. We want to make sure she doesn’t have some other anomalies that can occur with this. It is possible this is an isolated finding. We are getting a genetics consult to rule out any syndrome.” She was really calm and relaxed about the whole ordeal.

After lunch, the attending invites us to go home, but I decide to wait around for the genetics consult. I fill the hours until 5:00 pm by taking notes on “High Yield Pediatrics” by Emma Holliday Ramahi, a slide deck of everything relevant to a pediatrics clerk. I shared the link on our Peds clerkship GroupMe, receiving six hearts. The geneticist still hadn’t show up, so I went home.

[The geneticist ultimately arrived at 7:30 pm and ordered genetic testing to rule out some rare syndromes. I opened the check a week later and found that the patient was discharged without any further abnormal findings.]

Jane is not enjoying the first week of her orthopaedic surgery elective. She is working with a new spine surgeon. “All he wants to do is operate so he is quite brisk with the patients in the office. He’s probably a great surgeon, but I am not in the OR until next week.” What does the surgeon do if they’re not in the OR? “He has clinic three days per week and sees 50 patients per day, including post-op follow-ups. Out of roughly 25 evaluations, he might select 5 to have surgery.”

She describes the orthopaedic lounge: “They talk about sports all the time. And the female pediatric orthopedist leads the conversation. She would’ve been the center of every fraternity party doing keg stands back in her day.” Jane is frustrated about the uncertain schedule. “We have no scheduled free time that we could use for studying, but a lot of time is wasted waiting around.”

I attend dumpling-making night with a few Asian classmates. Our vice president, Sleek Sylvester recounts his experience on OB/Gyn, specifically Maternal Fetal Medicine [MFM] service. “MFM has a pretty sick gig. They just consult for the obstetricians— confirm normal fetal growth or diagnose weird condition. They have no patients they are on call for. He described his week: “I work with the ultrasound techs a lot. We noticed this one kid… ” Ditzy Daphne, a classmate who can regurgitate Anki decks, but is slow at applying the information to a patient case, interrupts: “careful what you call the fetus.” Sylvester continues: “fetus sorry. Anyways, I know nothing about reading an anatomy ultrasound. But even I could see that this fetus did not have a normal arm. The tech zoomed in on the extremity. I suddenly realized that the extremity ended at the olecranon [elbow] and it had one small digit coming off of it. We could clearly see the fully formed single finger — with the MCP, PIP and DIP. It was moving! I looked at the tech, and wanted to say, ‘What the Hell?!?” The tech just nodded her head. When we left, I was like what the hell was that. She replied, ‘That was an elbow finger. I’ve only seen one other in my career.'”

Sylvester explained that the MFM attendings receive a live feed from the ultrasound machines. “We were doing an ultrasound on

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Second week of outpatient pediatrics. My job for 80 percent of the visits is to differentiate between viral and bacterial upper respiratory infections (“URIs”). I take the history and physical for each cold and respond to questions about medication dosing. Then it is time to present the patient for two minutes while the attending fills out a SmartText in the clinic’s Epic system. Mother Mabel: “Once we realize you know how to conduct a basic exam, we want to see if you can parse the relevant findings from the ordinary.”

We see an 5-year-old who has red macules and patches all over her body. She’s not scratching and doesn’t even notice them. The rash started on her leg, and spread over her entire body. I have no idea what the rash is because it does not fit the standard viral exanthems (rashes) of childhood that we learned in medical school. As I am describing the case to Mother Mabel, she starts smiling. “I know exactly what this is.” Pityriasis Rosea. We tell the patient there is nothing to do but wait. “We believe it is caused by the immune system’s reaction to various viruses.”

We see a 13-year-old patient with Addison’s disease for a URI and dizziness. She and her mother knew a huge amount about managing her disease, including about the need to take extra stress dosing. Addison’s disease is an autoimmune attack destroying the adrenal glands. Without any cortisol, the body can become hypoglycemic in times of stress. During an infection, the patient is instructed to take an additional “stress” dose over her daily hydrocortisone level.

Mabel also gets excited by this one. We check her blood glucose to rule out hypoglycemia and prescribe antibiotics for a sinus infection: high dose amoxicillin. I talk to Busy Belle, the patient’s regular pediatrician, about management of Addison’s disease such as stress dosing and risk of other endocrine gland destruction. “I’m not sure, my N is 1.” Last year, Busy Belle saw the patient at the office in hypoglycemic shock. Her blood sugar was in the 30s, blood pressure was 80/35. She gave her some pedialyte solution and sent her to the hospital in an ambulance where she was diagnosed with Addison’s disease. Her most recent labs in the chart show a slightly elevated TSH (thyroid stimulating hormone) at her last visit with the pediatric endocrinologist, with whom she has an appointment next week. It seems that all the exciting management is done by the specialist.

A similar experience occurred on Wednesday with Mercedes Mike. He has accumulated several patients with congenital heart defects. I see an adorable 4-year-old with hypoplastic left heart syndrome who came down with the sniffles. The mother brought her in to ensure she didn’t need immediate intervention. Her oxygen saturations were fine, so we sent her home until her F/U (“follow up”) with the cardiologist in a week. We talked afterwards about the various surgical management of hypoplastic left heart syndrome. Once again, all the interesting management, e.g., echocardiograms, CT surgery referrals, EKG evaluation, etc., is performed by the specialist.

Patterns emerge around risk factors by age group. Every girl with a chief complaint of back pain is going to be either a dancer or cheerleader. An 8-year-old who presented for a typical URI tells us that she dances competitively five days a week. I asked if she has back pain. The mother lights up: “Oh yes, tell him honey.” The expected five minute visit, turns into a complicated 20 minute neurological exam. Afterwards, Mercedes Mike asks: “What’s the elephant in the room you have to rule out in these patients?” I don’t know. I look it up and get back to him. Spondylolisthesis, where one vertebra slips forward from the one below. This can cause serious spinal cord injury if not treated.

My next patient stumbled and hit her head on the gym floor during cheer practice. My presentation: “A CT is not indicated. She has a benign neurological exam, no LOC [loss of consciousness], and only mild headaches. My assessment is she has a mild concussion from the fall and should return to practice only after she feels comfortable at school for a few days.” He responds: “I agree with you, but it’s better to not use your gut when there are evidence-based protocols. Look up the indications for a CT scan.” After 10 minutes of googling I find the PECARN (Pediatric Head/Injuries Trauma Algorithm) guidelines and summarize: “As long as there is not prolonged LOC, signs of basilar skull fracture and no altered mental status, it is unlikely to have a significant TBI requiring further intervention.” Mike responds, “Yep, look above your screen.” Taped to the wall above the nurse’s station is the algorithm figure from the original PECARN paper. According to the these guidelines, there is less than a one percent chance of a clinically-important TBI as long as there are no signs of LOC > 5s, Glascow Coma Score < 14 (GCS, standard metric to assess neurological status) or palpable non-frontal skull fracture. Mercedes Mike: “I’m a new attending, so if I were talking with a more experienced doctor about a patient with suspected TBI, I would definitely mention PECARN just so they know that I am familiar with the guidelines. As a new attending, you need to build trust with other doctors.”

[Later, to Jane: “If we ever have kids, they are not doing dance or cheer.”]

A middle-class white 16-year-old girl is next. Mom wants to increase her ADHD medication dose because of bad behavior at home. Instead of acquiescing, Mercedes Mike asked, “Why are you poorly behaved at home?” Teenager mumbles: “I just get mad when my mom and sister ask me to repeat myself.” Mike: “Well neither of you are perfect, but she’s in charge right now until you pay the bills. So try not to mumble” Teen: “I’m going to be working at Taco Bell soon.” Mike: “You’re not paying the bills yet.” Decision: no change in meds.

[Busy Belle suggests skepticism regarding schools’ recommendations for ADHD evaluation. “We always get teacher and coach evaluations as well as a parent evaluation of each kid. The symptoms need to be occurring in at least two different environments. I started to notice a lot of kids at one school were being recommended for ADHD medication. It turned out that the evaluations were the exact same letter with the names substituted. Boy, did they regret that. I contacted the county superintendent and the principal’s secretary was fired with a stern warning to the principal.” (Editor: the stern warning to the bureaucrat was softened only by a monthly paycheck, lifetime health insurance, and lifetime pension.)]

Outpatient pediatrics is helpful for understanding why diagnoses take a long time. A common reason for patients to come in is non-specific abdominal pain without any diarrhea, constipation, or vomiting. It’s not reasonable to get a full work up (CT, CBC, CMP, inflammatory markers) for a one-week history of GI pain. Patients arrive with only a vague story of off-and-on symptoms rather than a precise timeline. One of our common responses is handing out a symptom diary. Mother Mabel: “As a new attending I keep a slightly closer eye on my patients. Instead of telling them to come back in a month with a symptom diary, I’ll have them come back in two weeks for a follow up visit.”

The best part so far is playing with the adorable 4-8 month olds. However, most of what a pediatrician does is educate parents or tell students to get their act together and listen to mom (our typical patient lives primarily with a “single mom” and is well-behaved every other weekend with dad, but out of control in the mom’s house). Should seven years of training be required for this? A successful parent of four could do most of this job. A pediatrician is involved in the “interesting” kids only to manage common illnesses that pop up in between their visits to specialists.

Mike delivers a mid-clinic eval. “You’re doing fine. Use a template when you interview patients to not forget anything, but overall good job.”

Jane on pediatric hematology/oncology, an elective rotation, and has been bored because one of the hematologists is on vacation. Jane’s typical day: arrives at 8:30 am, her first two patients are (Medicaid) no-shows so her attending fills out paperwork in the office. She sits around waiting until her lecture at 12:30 for a journal club on the use of antibiotics and reflux medications in childhood leading to allergies. She waits all day to see two patients at 3 and 4:30 pm. She returns home: “I wanted to strangle a 7 year old today.” Strangle a kid with cancer? “He wouldn’t shut up, and he was in remission.” 

Statistics for the week… Study: 8 hours. Sleep: 8 hours/night; Fun: 1 night. Meet classmates downtown for happy hour margaritas. Pinterest Penelope, also in pediatrics but in a different clinic: :”What I hate about third year so far is that you cannot plan anything. I rescheduled my own doctor’s appointment today so that I could be there for all the patients. The last two were no-shows. It’s just so much waiting, yet no free time.” (Penelope’s clinic serves an all-Medicaid population and there are no charges for failing to show up.)

The rest of the book: http://fifthchance.com/MedicalSchool2020

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Work starts at 8:00 am at an outpatient pediatric clinic that is a one-hour drive from the hospital. I’m the only student in the clinic. I meet the three attendings, one advanced care provider (“ACP,” typically a PA or NP), and lactation consultant) before the first scheduled office visits at 8:30 am. Two of the attendings are hot off the press, having finished their residencies a year ago. Momma Mabel had a baby in December and is back after three months off [Editor: fully paid thanks to the extra work put in by the childless.]. Her husband is a stay-at-home dad who brings the baby in during lunch. Mercedes Mike, the other new attending who drives a new SLC Roadster, and Busy Belle, a divorced pediatrician in her 50s who is booked weeks out except for two unscheduled daily sick slots. 

They have fifteen 15-minute well-child-checks (“WCC”) scheduled each day, thirteen 10-minute scheduled sick visits, and two open 10-minute sick-visit slots at the end of the day. A complicated patient, e.g., chronic headache, may be allocated two 10-minute slots. Five minutes out of the 15 are allotted for rooming. The nurse will get vitals while the physician writes up notes from the previous encounter. The physician then has either 5 or 10 minutes to see the patient without falling behind. I go in with Mabel for a 4-month-old WCC. Mabel invites me to listen to the patient’s heart and I hear an early systolic murmur. When I tell Mabel about that, after the encounter, she says “Yep, good job. That’s called a Still’s murmur. It classically is described as having a musical quality. I didn’t tell the parents because it is a benign murmur of childhood.” Mabel pumps during the one-hour lunch break as I head over to the other side of the office for lunch with Busy Belle.

Belle explains the different pay structures for primary care. Some health systems use a flat salary. “You are required to see a minimum number of patients.” Many health systems are transitioning to a relative value unit (RVU) reimbursement structure. Mercedes Mike stops by and adds: “I  considered working for another system that is completely based on RVUs. I’d get paid more per patient, but if I decided to go on vacation for two, I would get nothing. I felt this was a little nerve-wracking for me just starting out with a young family.” Another factor emerging is scorecard evaluation. “We get evaluated based upon peer performance across selected metrics, e.g., smoking cessation, weight loss.”

I shadow Belle for the remainder of the day and we’re done with patients at 4:30 and out the door at 5.

Tuesday I graduate from mere shadowing and begin to interview patients alone prior to the attending coming in. My first  interview is with the mother of a 2-year-old presenting for a two-day history of sore throat, fever, and runny nose.The kid just started daycare, and the parents took an ear temperature at 100 degrees, which means she’s technically afebrile because fever starts at 100.4. I complete a physical exam before presenting the findings to Mabel while she fills out an Epic SmartText template. Students are allowed to write notes for surgery, but not for pediatrics due to concerns about insurance reimbursement. We then both go into the room. Either I got the history wrong or the mother has changed her story. The sore throat began three days ago, not two and nasal saline rinse has been used, contradicting my report of no medications. Afterwards, Mabel completes her own physical. We send them home and recommend symptomatic management with Tylenol and ibuprofen if needed.

Our next four patients come in with sniffles or sore throat. I can’t find signs of bacterial infection. “What is your assessment?” asks Mabel.  “She has a viral pharyngitis that can be managed symptomatically. Let’s tell them to keep hydrated and make sure there are 3 or 4 wet diapers per day. Return in case of fever.” In the afternoon, I see a 6-month-old with conjunctivitis, bilateral otitis media, and pharyngitis caused by a suspected adenovirus infection. Mabel: “Notice the difference? Treatment is symptomatic, but these kids can get really sick. Tell me the serious complications of adenovirus?” She goes into the next patient while I look at UpToDate. I report that the main complication of adenovirus is pneumonia. Fifteen percent of childhood pneumonias are caused by adenovirus and myocarditis (a rare heart infection) is usually caused by certain strains of adenovirus. Finally, I report an outbreak of serotype 7 that caused a serious outbreak in 2014 with 136 (69 percent) of 198 persons with adenovirus-positive respiratory tract specimens were hospitalized, out of which 18 percent required mechanical ventilation, and 5 patients died (“Human Adenovirus Associated with Severe Respiratory Infection, Oregon, USA, 2013-2014”, Emerg Infect Dis. 2016)

After I finish a 17 year-old WCC and sports physical, my attending grabs me to come take a listen to 9-month-old twins with bronchiolitis. “Could my medical student listen?” she asks the parents. These are the sickest patients I’ve seen today and show classic signs of adenovirus: conjunctivitis, runny nose, cough and pharyngitis. I listen to their lungs and hear inspiratory crackles with an expiratory wheeze. There are no signs of dehydration, such as lack of tears while crying, poor capillary refill, poor urine output. They are not in respiratory distress, e.g., nose flaring, intercostal retractions, abdominal muscle use. We sent the family home with instructions regarding what would merit a follow-up visit.

I’m learning that most of a pediatrician’s job is educating parents on the basics: when to brush teeth, how often to breastfeed, what car seat should the child be in, how much should the baby drink, when to stop using the bottle. The format of a well child check is standardized for each age. Despite the hundreds of millions of dollars spent to install Epic, it doesn’t default to the practice’s preferred form for, e.g., a 10-year-old, when a 10-year-old patient is being seen. The efficient physician populates a custom-made SmartText for a 10 year old, and then fills out certain milestones that were filled out by the parents on paper.

Statistics for the week… Study: 5 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: best friend from college visits this weekend. He is an M3 at a different school who has already been on rotations for six months: “Third year sucks. Physicians claim that they remember third year as the best. Bullshit. It is mostly waiting around doing nothing, and yet you have no free time.” He adds: “Scary to think this is all the training we have in some areas. For example, if you don’t want to be a surgeon, you will be a practicing physician with only a few weeks of surgery experience. It wouldn’t surprise me if some physicians don’t even know how to start an IV anymore.” He is looking forward to psychiatry: “You talk to each patient for 30 minutes, chart a note during the interview. Pay for psychiatrists grew 15 percent last year. If this continues for 5 years, a psychiatrist will get paid as much as an orthopedist and get out every day at 2:00 pm.”

The rest of the book: http://fifthchance.com/MedicalSchool2020

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Sunday and Monday with the trauma service team. They don’t expect much from students this week because they know that we’re thinking about the exams that start on Tuesday. Ted, my chief, tells instructs me, “You can go study in the student lounge. We’ll let you know if anything interesting pops up.”

There are only 183 UWorld surgery questions. It takes about five minutes per question, each of which has five possible answers, to pick an answer and then read the explanations associated with each possible answer. I have studied all but 44. M4s and previous clases recommended getting through the Internal Medicine gastrointestinal and pulmonology questions as well because they all overlap with the Surgery SHELF exam. Surgeon Sally and Christian Charlie both finished the 113 GI and 123 pulmonology questions on top of the surgery questions.

In the ED, we have a skinny 26-year-old patient who was in a head-on collision. He is in no apparent distress, with some minor hip pain that is well controlled on 5 micrograms fentanyl. An x-ray shows a femoral head (top of femur) fracture extending into the acetabulum (hip bone). Was he drinking? He replies in a muted, monotone voice: “No.” Use any drugs? “I’ve used meth and heroin in the past. I wasn’t using anything.” Nurses keep telling him how amazing it is he came out with only minor injuries after a 65 mph crash, but he doesn’t perk up.

What do you do for a living? “I worked in a mechanic shop, but I’m between jobs. I lost my job two weeks ago.” He shrugs. “It’s whatever.” Ted joins me in the ED, recognizes the last name, and we admit the patient to our service (“trauma”), and consult orthopaedic trauma service. Our job is mostly coordination with more specialized services.

We are placing orders in the ED when the patient’s father and mother arrive. The father is a well-respected doctor in the hospital. Out in the hallway, the parents report that their sonhas been diagnosed with schizophrenia and major depressive disorder, but refuses to seek help for the past two years. “He’ll live with us for a few weeks, then we won’t see him for moths. He currently lives out of his car.. He’ll keep a job for a few weeks to get money for drugs, then quit.” We go back in and ask about his psychiatric history. He admits that he purposefully drove across the yellow lines into traffic. (The mother and back-seat child in the other car were not seriously injured and had been taken to a hospital without Level 1 Trauma certification.)

We place him on suicide precautions (1-1 sitter, paper gowns) and consult psychiatry. A classmate on the psychiatry service shows up. We interview the patient together. He reports that he has no active suicidal ideation since he drove into the oncoming car. The job of an inpatient psychiatrist is to determine whether the patient needs to be admitted to the psych after being medically cleared by the primary team. Even a patient who tried to kill himself 24 hours prior does not meet criteria without active suicidal ideation. Therefore, he will be referred to follow up with a different psychiatrist in an outpatient clinic two weeks later. It is the patient’s responsibility to call and make the appointment and then show up. Everyone knows that this won’t happen, but nobody takes ownership of the patient’s mental health and, even if the patient did take the necessary initiative there would be no continuity of care.

He undergoes surgery that evening for his hip. We also get a consult for radiation oncology. Why? Fractures that involve the acetabulum have a high risk of developing impingement as remodeling creates spurs into the hip joint. To prevent this, there are two options, a two week course of strong NSAID, or radiation to the hip joint to stop remodeling. He undergoes radiation the following day.

Tuesday is the simulated patient exam, starting with with mesenteric ischemia (poor circulation to the small bowel). I walk in to a screaming 60-year-old. The challenge is to perform a physical exam while she is squirming on the bed in pain. After the encounter, I’m writing a note and able to view the PMHx (medical history). The diagnosis becomes clear after reading about the two previous heart attacks and paroxysmal atrial fibrillation. The second patient has classic cholecystitis (inflammation of the gallbladder). The patient reports nausea, vomiting and RUQ abdominal pain. When I ask her to take a deep breath while applying pressure under her right ribs, she jumps off the table (positive Murphy’s sign). She also fits the “Fat, forty, female and fertile” saying for gallbladder pathology. 

The SHELF exam consisted of 110 questions over 2.5 hours. Questions were mostly second order. They would present a patient, and you would have to determine the initial management step for this diagnosis. Examples:

1. A patient with sudden onset of abdominal pain and vomiting presents to the ED. Pain localized midway between umbilicus and RLQ. Should the patient under surgery, CT scan or ultrasound? (Older docs would be content with a clinical diagnosis of appendicitis, but the board wants CT confirmation.)
2. What is the work up of an elderly patient with painless jaundice? CT scan or an endoscopic retrograde cholangio-pancreatography (ERCP, a procedure where a scope is placed down the esophagus into the stomach and duodenum; contrast dye is injected into the biliary tree under live x-ray to evaluate for any stricture or gallstone obstruction)?
3. Should you give antibiotics or undergo surgery for uncomplicated diverticulitis?
4. Patient with air-fluid levels on abdominal x-ray. Surgery or aggressive bowel prep?
5. What is the most likely loss of function for a midshaft humeral fracture? Axillary or Median nerve palsy?

I got 79 percent right. The mean across all medical schools is 74 (standard deviation: 8), but these are averaged without regard to rotation order. Surgery, Pediatrics, and Internal Medicine are known as the most challenging SHELF exams. Studying more wouldn’t have helped much. Recommendation: study the indications for exploratory laparotomy, management of appendicitis, and cholecystitis.

My Step 1 score is back. As the exam questions are changed, it takes a few months before any scores can be calculated. I get 237, disappointing because my last two practice scores were 245 and 252. (Passing is 194, mean across all medical schools is 229 with a standard deviation of 20.) Starting with the questions and practice exams earlier in the year would have helped. The best strategy seems to have been starting the UWorld questions in August and resetting the program to go through them again during the study period. Jane didn’t do that, but she made it through all of the UWorld questions and snagged a dermatology-worthy 249. Our Dean of Student Affairs is ecstatic with the class average score of 239.

[Editor: The 237 should be fine for dermatology if our author/hero checks the “Related to Elizabeth Warren in the Remnant DNA Tribe” box!]

Statistics for the week… Study: hours. Sleep: 6 hours/night; Fun: 1 night. Burger and beers with Mischievous Mary, Lanky Luke and Geezer George.

The rest of the book: http://fifthchance.com/MedicalSchool2020

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After a Sunday reprieve, Monday begins two back-to-back trauma alerts that force us to cut rounds short.

A 16-year-old 220 lb. 6’6″ African American high school football star flipped an ATV during a morning ride. As he is transported onto the trauma bed, he repeatedly screams, “I can’t move my legs!”. He has no movement or sensation in either of his legs. A CT shows numerous vertebral fractures. Most likely complete transection of thoracic spinal cord. Neurosurgery is consulted. Nothing to do now but wait. The attending: “We won’t know final outcome until about 48 hours when spinal shock resolves.”

He spends two weeks in the hospital working with physical and occupational therapy. He is paralyzed in both legs. He becomes agitated and aggressive with the therapists, calming down only when his mother and brother are present (there is never a visit from the father and we are trained not to ask). His football team visits after one week in the hospital. After one week, he is ready for rehabilitation, but the social worker struggles to find a good child rehab facility that will accept our state’s Medicaid insurance. My attending: “He would be a fantastic candidate for a few out-of-state adolescent rehab facilities, but I doubt this state’s Medicaid will cover them.” I am reminded by the young paraplegic who was admitted last week for a Stage IV decubitus ulcer (to soft tissue or bone) and sepsis rule out. If he does not take care of himself, this will also be his eventual fate. 

The next trauma alert arrives while the 16-year-old is in the CT scanner. An 18-year-old presents with a gunshot wound to the right leg. He appears stable, with intact pulses and sensation in the lower extremity. EMS reports that he was running away from a gang shootout (our patient is African American; perhaps he got on the wrong side of our active Hispanic gang, MS-13). Somehow the bullet missed all vital structures, just piercing muscle and fat. The attending comments: “The cardinal rule of trauma is that only the good die. If you are a productive member of society, paying taxes, a respectable member in the community, father of three, then that bullet will have bounced off the femur into the abdomen ripping up the pancreas, and piercing the lung. If the patient is a gangbanger, then it’ll just miss everything. The good die young.” I throw a suture in the entry wound, and we admit the patient to the floor. (I heard a news story about the gang battle during the drive home.)

We continue rounds where I meet an overnight MVC admission from yesterday. He is a suboxone clinic patient (monthly group therapy for opioid abusers ending in the dispensing of opioids) and is anxious to avoid being stereotyped as an addict. His trauma from the car accident was not severe, but the ED gave him tons of pain meds to overcome his years of tolerance for opioids.

He has not had a bowel movement in three days so we explain we need to transition him from scheduled Q6H (every six hours) to “as needed” narcotics. We propose scheduled acetaminophen and NSAIDs (e.g., Advil) with breakthrough Toradol for pain control. “Oh I don’t want that stuff. NSAIDs are bad for you.”

The rest of the week is uneventful except for another ATV accident, this time in a 14-year-old. She has a Colles fracture (fracture of distal radius from falling onto outstretched hand), and a few abrasions. We also have two elderly ground falls requiring hip surgery: trochanteric fracture requiring pin, and femoral neck fracture requiring hip replacement. 

I had expected two weeks of running all around the hospital in response to urgent pages and watching dramatic life-saving surgeries. Instead, despite the best efforts of our local gangs, drug abusers, seat belt scoffers, ATV enthusiasts, and motorcycle riders, it was mostly waiting around. We had more “trauma” during the week of nights (Year 3, Week 3). Much of “trauma” turned out to be social work, e.g., predicting who would be a motivated candidate for inpatient rehab and persuading insurance companies that OT/PT will be effective. Patients may occupy a bed for a week receiving no significant care while the social worker enrolls the patient in Medicaid and then negotiates with Medicaid regarding the new beneficiary.

Summary of two weeks of trauma: I learned the ABCs (Airway, Breathing, Circulation) for initial trauma evaluation and some fracture management. Work started just after 6:00 am and I was usually gone by 4:30 pm. The emergency surgery service option probably would have been more educational due to its higher caseload.

Saturday: Jane’s sister is at the hospital until 10:00 pm, well past her 7:30 pm scheduled shift conclusion, and stops by our house on her way home. “An 18-wheeler going 65 mph hit three highway workers, father, his son, and the son’s best friend. The father dies on impact, the 30-year-old son is medevaced to our hospital, and the best friend is medevaced to an outside facility because our ICU is full. Now, keep in mind about 30 minutes before he shows up, we get a self-inflicted GSW [gunshot wound] to the chest resulting in a massive pulmonary contusion and injury to the IMA [inferior mesenteric artery, supplying the colon]. He had shot his girlfriend who had died in the trauma bay. So we have one patient who is bleeding out into his chest and abdomen, and [Dr. Cruella] comes running in and performs a bedside thoracotomy [opening of the sternum and ribs] and x-lap [exploratory laparotomy] on the GSW. Meanwhile, we are coding the 30-year-old as he goes in and out for 30 minutes of VFib [ventricular fibrillation, serious cardiac arrhythmia]. His wife is crying holding their one-year-old daughter. Dr. Cruella is running between the GSW and the highway worker. We finally get both patients stabilized. He is brain-dead, but everyone except Dr. Cruella is in denial. We perform two nuclear perfusion scans before the wife accepts.

“Time of death is called. My CNA [certified nurse assistant] and I then have to deal with post-mortem poops before the family comes in. And let me tell you, post-mortem poops are the worst. Everything comes out. Worse than C diff [clostridium difficile infection of colon]. I tell my CNA to watch out as we turn him. As we’re dealing with this, three gigantic birds, maybe vultures or something, fly right up to the window. It was the freakiest out-of-this-world experience ever, like a sign from God. [coworker nurse]’s jaw dropped. Was that the three souls leaving this world?

“After we cleaned the room and changed the sheets, my coworker and I offer to get a handprint for the daughter. The wife thanks us. We then realize he has a huge cast on his hand. We try prying it off, then ask if a footprint would suffice. We then don’t have enough ink in the ICU so we’re struggling to just get a toe print. We eventually find some from upstairs. The family comes in to say their farewell before we remove him from life support. They stay in the room for more than an hour.”

Statistics for the week… Study: 12 hours. Sleep: 6 hours/night; Fun: 0 nights. Jane and I grab a beer Friday evening, and then study the weekend away before exams.

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After sleeping all day Friday and Saturday, I am nearly recovered from a week of night surgery and it is time to start a two-week trauma rotation. Morning report starts at 6:30 am with M&M (morbidity and mortality).

“Ted,” a burly, soft-spoken 6’4″ 32-year-old PGY4 resident described by Surgeon Sara as a teddy bear, is presenting a trauma case on a MVC (motor vehicle collision) patient in hemorrhagic shock from abdominal bleeding. The case was chosen because the team deployed an aortic balloon to maintain blood flow to the brain before exploratory laparotomy. Ted wants the entire surgery team to be familiar with the proper uses and indications for an aortic balloon. The attendings reduce Teddy to blubbering as they grill him on management of this patient. My former chief comments as we walk up the stairs: “[Teddy] was stumbling, but he was answering all questions right.” After M&M, we head up to the floor to round on our twenty trauma patients, fifteen of which are fractures following falls, ten from alcohol and five from old age.

I am assigned a 21-year-old patient beginning her second in the hospital following an MVC that resulted in an epidural hematoma (bleeding in the skull) and multiple fractures. She was driving back from work at Subway when a drunk driver hit her head-on at about 45 miles per hour. She was ejected from the car. Most of the ICU team did not expect her to recover any brain function. She has become somewhat of a miracle on the floor as she has regained consciousness, primitive motor function, but is cognitively at the level of a 5-year-old. She underwent emergent craniotomy by neurosurgery to release intracranial pressure from the epidural hematoma. She has a wound vac (sponge-packed wound hooked up to a continuous vacuum) on her scalp from the craniotomy site and a tracheostomy tube that can be capped to allow her to speak. The trach does not bother her as much as the spine brace that is needed for several weeks due to her cervical and thoracic vertebra fractures. Her 45-year-old mother stays quiet in the back as we pile into the room.

(The drunk driver was placed in the ICU bed next to her and passed away a few weeks ago.)

Rounds last about two hours as we go room to room for each trauma patient. I meet my 38-year-old attending. At barely 5’4″ she is known to put chills in medical students and residents alike. She is also Jane’s role model in surgery.

(We met her in Year 1, Week 17, starting a meeting of a “women in surgery” interest group:

There is no such thing as work-life balance. Anything not work becomes a distraction against surgery… Getting married, distraction. Having children, distraction. I was in surgery on my son’s birthday. He waited until 10:00 pm to give me a slice of his birthday cake. His birthday was a distraction.

)

Dr. Cruella says that we deal with “bullshit” faux trauma (e.g., drunk person falls and is screened for head injury) rather than transfer patients to the internal medicine service or orthopedic service, as was conventional at the hospital where she trained. Her theory is that this relates to enhanced revenue if a trauma note is dropped into Epic. After rounds, we head to the OR for a rib plating (one plate per broken rib) on a 60-year-old alcoholic who was run over by a car after he passed out in the middle of a road. Eleven ribs were broken, but miraculously he suffered only a mild lung contusion. 

Dr. Cruella hasn’t used this brand of rib plates, so the manufacturer’s rep is here to teach her how to use the drill and deploy the plate. After she gets the hang of the equipment, she asks about my background. She describes her experience as a resident. “This old guy in the ‘golden age of surgery’ used to sexually harass every female — med student, intern, resident, nurse, you name it — except the surgical techs. He would never mess with a surgical tech. I was writing a note as a second-year resident and he pulled down my scrub pants in front of the entire OR.” 

Had she ever been written up for unprofessional behavior? “I got written up for intimidating the blood bank personnel. I was doing a splenectomy and we needed blood urgently. We kept calling the blood bank and they said they would bring it down. I called two more times, and finally they tell me they need a form, which they could have told me right at the beginning. I had to speak with the Chair and attend anger management.” Like the movie?!? “No, it’s on the phone. Most surgeons have a monthly session.”

What’s the worst thing you’ve seen in the OR? “Well besides getting pantsed by my attending, watching a hotshot surgeon throw a spleen full force at the wall. It exploded with blood everywhere and on everyone’s face. That was pretty bad.” She jokes, “I’ve never done that, but I’ve wanted to!”

Has any surgeon gotten written up by a medical student? “At least once every year. Last year,  a medical student wrote a surgeon up for ‘throwing a scalpel at me’. There was no blade on it. Not sure what was going on, but it could have been just him tossing the scalpel to the student.”

The rib plating takes about 2 hours. I assist in retraction of the skin folds while the attending and chief attach the plates between the fractured rib fragments. At the end they allow me to place a chest tube on each side (it will be removed three days later after testing for leaks). Ted patiently teaches me his special “D” suture technique to anchor the tubes in place.

While rolling the patient back to the ICU, a nurse says, “Natural selection, it’s a real thing. You get drunk and pass out in a road, Nature is coming for you.”

The rib plating ends at 1:00 pm. I wait in the medical student lounge for gold alerts, but there aren’t any, and get sent home around 4:00 pm.

The next days are similar. I round on my 21-year-old MVC recovering patient. I also check in on the rib plating, although there is a different service and attending that covers the ICU patients. This can be quite frustrating as many patients that we may do the initial trauma evaluation, and possible surgical intervention, will be transferred to the ICU team for further management until they are ready for downgrade to the PCU (progressive care unit) or “floor” (the most basic level of inpatient care).

Thursday morning: trauma alert for an overweight 28-year-old who fell while running from U.S. Marshalls. He was cornered on top of a two-story building, and decided to jump. Why is he not in handcuffs? “He wasn’t arrested,” explains the EMT. “That’s pretty common. Law enforcement will arrest him after he’s out of the hospital so that the Department of Corrections doesn’t have to pay for the trauma care.”

He arrives on a stretcher. We transfer him to a trauma bay bed, and begin the initial assessment. About 10 people are around him: three trauma nurses, a respiratory therapist, a scribe, an EM resident, a general surgery resident and intern. I grab my valuable trauma shears and cut off his clothes, while the intern evaluates for airway (he can speak), breathing (good air entry into both lungs), and circulation (good peripheral pulses). He has severe pain in both arms. Vitals are stable. We get a chest x-ray to ensure no rib fractures, and a mid humerus x-ray showing a closed, displaced fracture. His right arm has a mid-humerus fracture, and his left shoulder is anteriorly displaced. He also has an anteriorly dislocated shoulder. Ortho tells us via text they will put him on the case list for tomorrow.

Friday morning I pre-round on the patient. He is pensive. He asks, “How old are you?” and then shares some hard-earned lessons. “Make sure you choose the right woman, man. I got two baby girls, and their mom doesn’t care about them or me. But I am going to be a man and take care of them.” It seems that the drug dealing that led to the encounter with U.S. Marshals was motivated by a need to pay court-ordered child support in excess of his legitimately earned income. The orthopedics PGY2 comes into the room and I stay to see his examination. He tries to “reduce” (put back into place) his left dislocated shoulder. After three failed attempts with just a 50 microgram dose of fentanyl, he decides to just do the reduction during the operation while he is sedated. Orthopaedics take him for open reduction, internal fixation. He stays for seven more days working with PT/OT until he has some movement restored in both arms. Arguably disproving his theory that baby mama doesn’t care about him, she was his only visitor during this week.

Statistics for the week… Study: 8 hours. Sleep: 6 hours/night; Fun: 1 night. Dinner party with Lanky Luke, Sarcastic Samantha, Jane and me at Put-Together Pete’s apartment. Jane and I successfully made Tres Leche cake.

The rest of the book: http://fifthchance.com/MedicalSchool2020

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