Fun on the Outer Banks
I think my life is so saturated by school that I'm not a fan of writing about such things, hence the long latency between posts. Put another way, I haven't done much else significant outside of school. And that's not to say I haven't had fun. I've certainly had time to play soccer, go running, hang out with friends, host a wine and cheese party, and even volunteer at Habitat. Those are all nice little distractions from school, but not really of any significant time period.
This weekend, though, a few of us visited a classmate who is doing his family medicine rotation in Eastern North Carolina. So we rented a little house on the beach of the Outer Banks and spent the weekend playing on the beach and soaking up the last of the autumn sun.
Things I did this weekend I've never done or haven't done since I was a kid:
- touched an Atlantic stingray and a horseshoe crab
- (attempted to) fly a kite, at night no less
- got pinched by a crab
- built a "sandcastle" and then a sand turtle
- climbed a huge sand dune and then rolled down (though not all the way)
- ran around on the beach without a care in the world :-)
Pretty awesome trip, but now back to the normal life. I start on inpatient pediatrics tomorrow. Probably not as fun as outpatient peds since the hours are longer and the kids are sicker, but likely more educational.
The blog is dead
My blog is dead. Good thing none of my patients are.
There's barely time to sleep, let alone update the blog. And I apologize for not keeping in touch otherwise - as a estimate of ability to contact others, I barely get a chance to call my parents once a week. But even though I'm busy, it's a good busy. I'm learning a lot, the only way 80+ hours of being at the hospital can teach you (the 80-hour maximum for work week doesn't apply to students - plus if I stick around, I can see/learn a lot more). If you're wondering how I'm doing, send me an email. Or better yet, VISIT! Renee's got the
right idea :-)
Signing off for now,
Ashish
DNR misconceptions
A few interesting things today. Those of us starting with internal medicine rotation brushed up on our sparse knowledge of heart sounds (murmurs, rubs, gallops), acid/base balance, and salt/water balance. Half of the group then did an EKG lab while my half of the group had a session on DNR/DNI orders (do not resuscitate, do not intubate).
Normally, when a patient’s heart stops (often a primary component of the legal definition of death), the medical team “runs a code” on the patient in an attempt to resuscitate the individual. This involves CPR, drugs, possibly a breathing tube, and the infamous defibrillation paddles as seen on ER. A DNR would allow a patient, typically a terminally-ill patient, to refuse such treatment in order to pass away peacefully. Similarly, a DNI would allow a patient to refuse intubation (having a breathing tube placed) since some patients understandably do not wish to live if it means being tethered to a machine that breathes for them.
There are many misconceptions about DNR/DNI and about resuscitation in general, some of which I believed until the session, so I thought I’d share those here. First of all, it’s important to note that patients who request a DNR typically do not do so because they are in physical and emotional pain and/or wish to die sooner rather than later. Rather, the primary reason behind seeking a DNR is to ensure their passing is peaceful and calm, surrounded by family and friends. The alternative, the seemingly frenzied chaos of resuscitation, is something they would wish to avoid. Another common misconception is that of the success rate of resuscitation. What percent of patients with cardiac arrest (heart stopping) would you say are successfully resuscitated? Look in the comments section for the answer. I found that quite surprising. It’s also important to note that that is the percentage that survived the resuscitation. Even fewer patients survived to discharge. The success rate is even lower for individuals over 70 (see comments). And of those individuals over 70 who are successfully resuscitated, half of them are left with permanent brain damage. The rate for patients with end-stage kidney disease and stage IV cancer are lowest of all (see comments). Given these abysmal success rates, it’s a little clearer why patients near the end of their life may opt for a DNR. Interestingly, an informal study found that the common misconceptions on the success of resuscitation may stem from TV shows. The investigators watched medical TV shows (watching TV – that’s my kind of research!) and found that on ER and Chicago Hope, the resuscitation success rate was around 67%. For Rescue 911, the success rate was 100% (it’s all success stories).
On Monday I start my medicine rotation. Having clinical rotations during the second year (as opposed to the third year) is a primary factor behind my decision to come to Duke. I know that many other programs may criticize this abbreviation of the basic science curriculum and early entry into the clinical world. However, as many former students have pointed out, the learning is so much easier when the condition of interest is not buried in the pages of some textbook but when it is conveyed to you by a person who lives with that condition every day. The internal medicine clerkship director gave us a great quote by Sir William Osler, a prominent figure in medicine and arguably the founder of American and Canadian medical education. He puts it a bit more eloquent than I can.
“My firm conviction is that we should start students beginning their clinical experience at once on their road of life. Ask any physician of twenty years standing how they have become proficient in their art, and they will reply, by constant contact with disease; and they will add that the medicine they learned in the schools was totally different from the medicine they learned at the bedside. In what may be called the natural method of teaching, students begin with the patient, continue with the patient, and end their studies with the patient, using books and lectures as tools, as means to an end. Students start, in fact, as practitioners, as observers of disordered machines, with the structure and orderly functions of which they are perfectly familiar. For beginning students in medicine and surgery it is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patients themselves. The whole art of medicine is in observation, as the old saying goes, but to educate the eye to see, the ear to hear, and the finger to feel takes time, and to make a beginning, to start a student on the right path, is all that we can do. We expect too much of students and we try to teach them too much. Give them good methods and a proper point of view, and all other things will be added, as their experience grows.”
- Adapted from William Osler: "The Hospital as College"
Patient safety from a systems perspective
After two weeks of OCY (Orientation to Clinical Year), we’re into our week of “intersession,” which attempts to prepare us for our specific upcoming rotation (medicine, surgery, ob/gyn, etc.) and also to explore topics not covered in the traditional medical curriculum. This week’s intersession theme is patient safety, quite appropriate for us naïve students. So we learned about infection control, scrubbing into surgeries, reporting medical errors and close-calls, and writing appropriate prescriptions to avoid mix-ups. As students, we are in charge of a few patients, including their initial evaluation and treatment plan, which we discuss with the supervising physicians (residents and attendings). Although we are not allowed to prescribe by ourselves, we write out the prescription and have the resident or attending approve and sign the script. Of course, in the hospital, this process is all done on computer, minimizing errors.
The issue of reporting medical errors and near-misses is an interesting one. A patient safety officer who spoke to us mentioned the shifting of procedure from “blame-and-shame” to a critical look at safety systems in place. In the past, an intern prescribing penicillin to a patient with an allergy would suffer a harsh trial by fire, including possible disciplinary action. The current system, at least at Duke, instead looks at the multiple safety checkpoints that failed and why they failed. Why did the computer allow the intern to order the drug despite the allergy? Why did the pharmacy not notice the error? Could there have been extra checks that would have prevented the mistake? And so forth. The essential message was that all humans are fallible, and therefore superior safety requires the use of multiple checkpoints in a system. I say superior safety because even 99.9% accuracy is not good enough. If the airlines accepted 99.9% accuracy, there would be a major plane crash every 3 days. If all the delivery wards in the US accepted 99.9% accuracy, 12 babies would be given to the wrong parents every day. (These figures from the Institute for Healthcare Improvement.) Since humans working in a complex system cannot be expected to consistently maintain such a high standard of accuracy, mistakes and mix-ups must be viewed from a systems perspective, and checks must be in place to provide additional barriers to error.
First site facelift
Thanks to Josh for the template settings advice. Please bear with me while I toy around with the settings over the next few days. If the site looks weird, I'm messing with the settings. Just check back later and it should be better. If it's not better after a while, then those are the final settings and I just have a horrible eye for design ;-)
