The Long Road Ahead

Fun on the Outer Banks

2005-11-06T22:23:00.000-05:00

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

2005-08-31T18:13:00.000-04:00

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

2005-08-11T22:48:00.000-04:00

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

2005-08-09T23:10:00.000-04:00

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

2005-08-03T20:11:00.000-04:00

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 ;-)

Template help

2005-08-02T23:29:00.000-04:00

Any expert bloggers out there (*cough* Josh) know how to play around with the blogger settings? Mainly I'm interesting in getting rid of the pink text. Aside from chipping away at my masculinity, it's a little rough on the eyes. Also I'd like to use my own banner image. The current image is the one that most closely approximates the theme "The Long Road Ahead." I'm sure the metaphor inherent to this theme is pretty clear, but I plan to explain it a bit more in a future entry.

On the possible function of dreams

2005-08-02T01:23:00.000-04:00

Today we began our second week of orientation, and the faculty are priming us for the mental and physical challenges that will crop up next year. In terms of mental preparedness, we had a few lectures on the practical points of arterial blood gases, pulmonary function testing, and acute renal failure. We then had an interesting lecture on sleep deprivation, certainly a dominant theme for us next year. Interestingly, REM (rapid eye movement) sleep, the period of sleep during which story-like dreams occur, is essential to our perception of reality. The lecturer mentioned a study (I wish I had the reference) in which volunteers were hooked up to an EEG (“brain wave recorder”), which could help differentiate the different stages of sleep. Using the EEG as an indicator for sleep stage, the researchers allowed the volunteers all stages of sleep except for REM sleep. Within 72 hours, the volunteers were psychotic. That is, their perception of reality did not agree with the general perception of reality (seeing dragons emerging from the wall, for example). Fortunately, this was easily reversible with REM sleep. I just thought I’d mention this study since it sheds some light on the possible function of dreams. Perhaps we all need these abstract excursions of the mind in order to handle the restrictive truth of reality (or what we perceive to be reality).

On a less philosophical note, we got toys today! Everyone was playing with their pagers (self included), scrolling through the annoying rings, those piercing tones which we will all grow to loathe. We also were issued Palm Tungsten C’s, loaded with useful software such as Palm EKG, Shots 2005 (immunization schedules), and equipped with wireless capabilities to allow us to access resources on the Duke network. No Tetris… yet.

Orientation week 1

2005-07-29T01:56:00.000-04:00

Today we continued orientation, which we started on Monday. We started off by learning a few abnormal heart sounds, using our simulation dummy HARVEY. In addition to emitting heart sounds from his chest, HARVEY simulates pulses and I’m sure does some other stuff. The instructor was able to place the stethoscope on HARVEY and we all listened in using wireless headphone “stethoscopes.” Hopefully if I encounter any abnormal heart sounds on the wards, they’ll be that obvious, and I’ll be able to catch them.

Later in the day we went over the history and physical exams (H&P’s) we did yesterday on random patients. Though we were assigned to a ward, most of the patients understandably refused an H&P that would take up 90 minutes of their time and have no impact whatsoever on their medical care. Since it was the neuro floor, the rest of the patients had neurological deficits that would impede a nice history (unconscious, speech difficulties, dementia, etc.). I went to another ward, where four patients understandably turned me away. So then I walked over to the VA, where the patients are almost always willing to be poked and prodded by budding medical students. I’ve also found that the veterans are quite pleasant and friendly. Of course, I hate putting these patients through a completely unnecessary history and physical, though it is a pleasure getting to know them. I think once I start my rotations, I’ll be glad to actually have my H&P’s have an effect on the patients’ care.

The end of the day was interesting. Some of us, including yours truly, had male genitourinary and rectal/prostate exam training. It wasn’t as unsettling as you might imagine. Just like when I first put in a foley catheter (to drain urine), when you have a job to do, you tend to block out the apparent awkwardness of the situation.

I'm back!

2005-07-27T20:46:00.000-04:00

I’m back! For some reason, I decided to bring this back, but I’m using Blogger on the advice of an expert in the field.

I say “some reason,” but when I visited some undergrad friends over the summer, I realized how out of touch I’ve been, and it’s only going to get worse. Yes, my friends, at DukeMed, the 2nd year is the clinical year, so I decided to restart the blog to let you all know how it goes (and also as a little journal for myself). Of course, updating will be tough given the general lack of time, but I would be more encouraged if comments were left. ;-)

There were a few reasons I abandoned my old blog, and I’ll be sure to avoid those pitfalls this time around:
1. Nothing interesting to write about. This is a likely problem during the first year of medical school, which consists of a steady diet of lecture and studying. Combine that with my normally humdrum life, and it doesn’t make much for blog material. This year will be much more exciting due to the changing nature of what I’m doing each day, and also due to the interaction with actual people!
2. Self-consciousness about blog entries. If you look at my old entries, it’s kind of ridiculous. I tried to infuse as much complex language as possible in order to look smart. I think in doing so, my entries were shorter and less frequent than if I just wrote in a stream-of-consciousness fashion. Also, I avoided the more mundane topics in favor of the occasional intelligent thought. Well, from now on, I’ll just write from the heart, no matter how clichéd (like that last phrase) or cheesy.

So stay tuned, and hope for some interesting stories (I have psych rotation in April).