my night stand

I have begun to notice a trend. At the start of any new rotation I'm usually ready and anxious to learn all I could possibly need to know about that speciality. It often starts with checking out a book from the library or finding a book I already own and making plans to read it during the month. Inevitably the book never or rarely gets cracked open.

I'm starting to compile a collection of books on my nightstand from my latest rotations. I've got a really short book on primary care ENT which I've left on my nightstand because surely I'll make time to read it sometime! There are some packets of practice board questions under that. The latest is an EKG book, which I have actually read about 20 pages of this month! (it must be a record! I'll not be discouraged that this particular book has tons of pictures and very large print!). The derm, acute care medicine, and gyn books have already made it back to my bookshelf or to the library.

And my nightstand only one of several places in my home where medical knowledge and study material is available! Doctor magazines are scattered about in the bathroom and on the coffee table just waiting for me. When I sit down at the computer my homepage offers me dozens of important articles, not to mention my e-mail which is filled with links to case studies.

I keep telling myself that if I don't develop some good study habits now I'm going to be a "bad doctor". But I seam to be making it along okay without the vigorous study that I have the good intentions of doing. There is always room for improvement and always things to learn or review, so I'll keep those books and articles on my nightstand and just keep trying.

Susto

I saw a Spanish speaking patient the other day that was a new patient visit. I asked about her past medical history and her family history. I usually ask specifically about diabetes in the patient or their family, especially in any patient with risk factors for diabetes. This patient denied any health problems at all, but told me that they had a sister with diabetes.

"She had a susto and her sugar went high and the diabetes hit her and she's had diabetes ever since then" the patient explained to me.

(for the non-Spanish speaker- susto is a scare, or an emotional stress, perhaps what we would call an anxiety attack)

Wow... I've done some research in diabetes and Hispanics, and I had actually read about this notion that some believe that diabetes can be caused by susto. But reading about it and hearing it first hand are different indeed. So, I can now testify that there are (still) people out there that blame a metabolic / genetic disorder on susto! So watch out for anything too scary, you don't want diabetes to get you.

Anything else can be fixed!

My first delivery was in the fall of my third year of medical school. The second year family practice resident I was working with had just joined our team after being out of town for the first week of my rotation. He was surprised that I had been through a whole week of the rotation and not had my first delivery yet. 'Let's get you a delivery!' he said, and proceeded to find a patient on our board that would be an appropriate first delivery. In my case that meant a G7P6 who had a teenage daughter in the room cheering her on.

I had delivered a plastic baby from a plastic model before but felt confused about the right hand position... should my right hand go on top or the left? what do I do to minimize a tear? which way do I flip the baby onto it's back after it's out? so I asked my resident. 'However you're comfortable' he says, I must have still looked concerned about doing it wrong, because he continued 'Look, whatever you do, just don't drop the baby. Anything else can be fixed'

As I caught the slippery neonate that came flying out of my experienced patient, that turned out to have been the best advice he could have given me! I remember focusing hard on 'not dropping the baby', which I didn't think would be necessary, but those things are pretty dang slippery. I kept less than a foot between me and the patient and remember at one point almost leaning against the patient to give myself leverage to support the baby and ensure that it didn't slip away. Concern for a tear was silly as her vagina was a wide cavernous opening with room for baby and then some. I have since more or less mastered the art of 'not dropping' slippery little ones!

Dedicated to anyone named Rodriguez

So the other day I saw a patient named Rodriguez. As you may be aware it is a somewhat common name. Well I have many in my clinic and I had two scheduled on the same day.

I went in to see my next patient (Rodriguez) and recognized the patient as someone I had met one month earlier and started on insulin. I began by asking how things were going with the daily insulin injection. "everything is fine" was the reply

I opened my chart to the medication list and found that not only was Lantus (bedtime insulin) on the list, but Novolog was too (mealtime insulin). I felt puzzed, sure that I had started only Lantus, but now unsure that I remembered the patient in front of me. I started to update the medicine list. Then I thought 'am I confusing this patient with someone else?' so I turned back to the last clinic visit and read over my last note which made me feel even more confused, I must have the wrong patient, I though.

So, naturally I look at the name 'Rodriguez' and verify that this is my patient's name, 'yes, that's me' (At this point I had not realized or remembered that I had two Rodriguezes scheduled on the same day)

Well luckily I wasn't convinced I asked my patient a couple of details about the last visit like "didn't we start you on Lantus 10 Units last month?" The patient confirmed my memory and also confirmed that I had the wrong chart in front of me. I also asked for the Date of Birth which was incorrect. I excused myself from the room and let my nurse know that I had the wrong chart and we found the second chart labeled Rodriguez (these patients had the same first name too, by the way!) It was nice to know that I had the right patient, and identified the wrong chart before doing anything crazy like sending the patient home with prescriptions for the wrong person. Ironically the other Rodriguez never showed up!

my first viagra prescriptions (PG-13)

So a group of colgueges were discusing the fact that viagra (sildenafil) is used to treat not only erectile dysfuction, but also pulmonary hypertension. In order to avoid the stigma of taking viagra, the same medicine has a different name when it is prescribed for pulmonary hypertension. Someone wondered outloud if the latter is cheaper. He said that he had a lot of diabetic patients with ED that have trouble affording ED meds. I thought to myself - wow, I've never even written a prescription for viagra... and I have plenty of middle age and older diabetic males that I see in clinic. I never ask about it, perhaps I should ask more often, or perhaps my being a female makes my patients less likely to bring up the topic themselves.

Well... within one week of that conversation I wrote my first 3 prescriptions for viagra (without changing any of my history taking habits).

On gentelman, ironically was sitting on an exam table that had 'viagra' paper roll covering the table. This is very uncommon in my clinic, in fact that was the first and last time I've seen that. Usually it's the generic white exam paper roll, and on very rare occasions a pediatric print with animals or something. Now whether or not the advertisement prompted the request or whether it was already on his agenda is anyone's guess.

Another gentelman was preparing to marry a woman he described as 20 years his junior and "frisky", he actually asked me if he could have and unlimited supply of viagra. I also had the pleasure of teaching him proper sexual terms. When I asked if his problem was getting an erection, he asked 'is that when that stuff come out?' .. no sir, that's called ejaculation. 'oh so you talking about when the dick get hard' .. yes, that's called an erection. He thanked me for teaching him the right words.

My third encounter was in Spanish, and while I know a lot of words in Spanish and pride myself on being fairly fluent, erection is not in my Spanish vocab. So the ED discussion consisted of me talking about the pene duro or the hard penis. I was hoping the patient could enlighten me on how to say erection in Spanish, but he either didn't understand what I was asking him or did not know the word himself (errecion - should have guessed!). So perhaps pene duro was better understood anyway as had been the case with the 2nd man!

I haven't seen any of these gentelmen back since ... I guess they got what they wanted ;)

feeding the babies

so I keep telling myself when I'm on my newborn nursery rotation that 'when I finish my work' or 'when things slow down a little' that I'm going to sit in a rocking chair and just feed a baby - gosh dang it! It just looks so relaxing.

For the babies that are in the nursery the nurses and sometimes volunteers take that job, and I'm always stuck doing exam after exam, checking bilirubin and other labs, doing paperwork. And of course there is never a 'when I'm finished' or 'when things slow down' (or if there is I'm on call and that's when I'm sleeping!)

some of my collegues make time to feed babies because they want to. a couple even swing by the nursery when they aren't on that rotation, but they'er nearby and want to feed/hold a baby.

so perhaps I'm just not the type that feeds babies... I have yet to make time for it. Though I'm sure I'd make time for it if it were my own baby!

Seriously....

So the other day I had a patient who complained of headache. Here is how part of the conversation went (and might I mention that this is an adult patient):

Dr: Do you have any problems with your vision?

Pt: What's that?

Dr: When you see is it blurry or is it normal?

Pt: Oh, I don't know.

Dr: When you look at things, can you see them ok?

Pt: Yea, I can.

So either the education gap between me and this patient was large, or I really need to work on my communication skills...! I was having a hard time thinking of any other way to ask the question or be more clear. Really more a sad story than I funny one.