The Little Beating Hearts

I listened to a baby's heart for the first time today. The bell of my stethoscope was humongous on the baby's small chest. I could hear the pounding and rapid heart rate of our six-month year old patient. I could also hear an amplified inspiratory stridor, every time he took a deep breath in. As I listened to the heart, the beeping monitors over his head registered his heart rate, pulse, and oxygen saturation.

Later on, I got to see a beating heart of a baby that had just undergone cardiac surgery to repair a congenital abnormality that required reconstructing the vasculature of the heart. The little heart was pounding.

Today was our first day of pediatric preceptorship. I spent my day at the Children's Hospital in Oakland in the Pediatric Intensive Care Unit. Within the PICU, there was a number of young patients of all ages with a spectrum of medical conditions. In our shift, we saw everything from newborns with congenital abnormalities to young children with lung problems to teenage victims of trauma.

"Pediatrics is about observation and integration," our preceptor said. For this reason, we first observe our patients before moving towards any examination. We started by standing at the foot of our first baby's crib and watched him breathe, observing him and noting any abnormal physical findings.

The 23-bed PICU was a bustling area. Some patients were asleep or sedated, while others were being attended to by family members or health care workers. In a corner bed, family members read letters aloud to a young girl, who was unresponsive.

The site of children in hospital beds attached to tubes and monitors was surreal. I am not used to seeing children in the hospital and it was difficult to take the entire site in. Listening to the cries of patients and watching family members circle over their loved one's bed was heart wrenching. I can not even imagine how families cope with critically ill children.

Today's shift in the PICU was an eye-opening experience. I look forward to our return visits to the PICU.

Farewell Bugz

The fog settled in yesterday, blanketing the city; I got a glimpse of the speckles of the city lights, as I made by my way home late at night after a day of filling every crevice of my brain with details relating to the microorganisms that invade our world and our bodies, everything from bacteria to viruses to fungi to protozoa.

Friday marked the last day of I3 (the microbiology block). In lab, we got to see real life Schistosomes, organisms that are transmitted by snails and can penetrate through the skin of hosts and reek havoc in the veins of the bladder, colon or liver. (Another reason why you should be careful in fresh water). So, needless to say- we kept our fingers to ourselves while observing the cercaria (worm-like creatures) that were swarming in the water.

With our final tomorrow, I am amazed at how six weeks of infectious diseases has impacted my differential diagnosis for fever, chills, diarrhea and rash. I went from thinking about a handful of things to now making an endless list of possibilities. Such an expansion will invariably contract, so I've been warned by my seasoned resident friends.

For now, I bask in the joy of knowing that I have learned about so many rare diseases and organisms (some pretty crazy bugs), which I may or may not encounter in the years to come. They do exist out there. And I am little more obsessive about washing my hands and properly preparing my food.



Aside from extending my intellectual bounds as far as they can, like a rubber band that has been stretched to capacity, I am really exhausted and looking forward to the end of infectious diseases. We'll finally get a much-needed interblock break from all the bug madness.

Cheers to the end (it's almost here!)

Diagnosis

With a diagnosis of sinusitis in a 43 year old man complaining about congestion and coughing, we completed our adult preceptorship. We walked into our preceptor's office just a year ago.

While spending time in an Allergist's office, I have seen my share of inflamed noses, heard all sorts of wheezes in lungs of patients with asthma, seen all shades of prurulent discharge on the back of patient's mouths and observed the prednisone injections. And I have met real patients from the community, so different from the standardized patients we are accustomed to seeing in the clinical skills center.

I have learned to take a full history and perform a directed physical exam (mostly for an upper respiratory infection). I have become versed in the language of immunology as it relates to asthma and allergies. I know to check for nystagmus anytime I suspect a eustachian tube obstruction.

I appreciate the time my preceptor took to teach me and for allowing me to enter his office.

Making a final diagnosis was a great culmination of preceptorship and a nice preview of what awaits us in the spring, when we venture into the wards.

From here, we move to working with "little people," as we soon start our pediatrics preceptorship. I am looking forward to the adventures that await us in the next phase of our medical training.

The 10 P's of Success

A Department of Surgery chair, from a well-known medical school, shared some pearls with a crowd of 250 eager medical students at the American College of Surgeons Clinical Congress, Division of Education Medical Student Program, which is being held in San Francisco this year.

She listed the 10 P's of Success in Leadership in Academic Medicine.
1. Plan
2. Be Prepared
3. Pay Attention
4. Look at the Process
5. Be Persistent
6. Demonstrate Power
7. Find a Partner
8. Be Pleasant
9. Pace yourself
10. Don't take it Personally

She asked the audience members to add any additional P's. I volunteered the following- finding inner peace, especially in difficult situations and as a general rule to balance one's life.

Other P's audience members provided included the following:
-Pride
-Politics
-Passion
-Proactive
-Productive
-Appreciation
-Potluck?
-Perseverance
-Prayer
-Patience
-Pure
-Possibilities
-Play
-Perform (under pressure)
-Push (your personal boundaries)

I'll try to attend more of the ACS sessions to learn more about a field that had continuously intrigued me and remains an evolving interest.

Exam 1

We clustered in front of Cole Hall, with our baked and store-bought goods in hand. Once everyone appeared, we slowly made our way to the lecture hall. I entered first, carrying a plate of home-made brownies (triple chocolate) and placed the plate in the front of the lecture hall. After me, another 30 or so classmates streamed down the stairs of the lecture hall with their desserts.

It was so heartwarming to bake for the first year medical students. Today was their first exam of medical school, a milestone for many students. I remember how nervous and anxious we all were, huddled in front of Cole Hall. And how refreshing it was to see the former second years bring baked goods for us.

I made sure to schedule time for baking yesterday. Lately, my life has become before PDA and schedule-centric (story of my life). I usually get the store-bought desserts, but I wanted to put some effort in this little project. I know how hard the first years have been working in anticipation for this exam; I have been helping teach anatomy during MSP and answering questions (content and non-content based).

In the end, I hope everyone does not get too caught up in the score on the exam. And just remember that it's "pass now or pass later," the mantra I recite to myself a lot more now.

With the exam almost done for most of the first years, I wanted to wish them all a hearty congratulations on completing your first exam--one of many more to come!

No Surprises

"No Surprises." That was the lesson of today's lesson.

Last week was the female pelvic exam and today was the male pelvic exam. Our educator, reminded us that the the pelvic exam is not as simple as asking someone to "stick out their tongue." Like the female pelvic exam, there are many parts to the exam that take us to an entirely new physical exam territory.

Our educator emphasized the importance of remaining "nonjudgmental," when we start dealing with real patients from the real world, including real human sexual behaviors that may not seem normal to us. We gain to learn from our patients and in doing so, we must pay attention to our facial expressions, verbal and body language.

There were three main parts to the exam: the breast exam, pelvic exam and rectal exam.

Although breast cancer is most common in women, men can develop breast cancer. For this reason, it is important to perform the breast exam and teach patients to perform self-exams. The cases of breast cancer in males generally is more severe, because cancer often goes undetected.

The pelvic exam was not nearly as complicated as the female pelvic exam (there was no metal instruments). Most of the exam was external, involving visual inspection and palpation, with the exception of the classic hernia exam (turn your head and cough test). As our educator walked us through the motions, he explained how to be sensitive to our patients, including the golden rule of "no surprises," to stress the importance of open communication and clear explanations.

The last part of the exam is the dreaded rectal exam (uncomfortable for the patient and the examiner). Our educators had some great tips to help patients relax (because no one really relaxes if you tell them to "relax.") Lubrication and deep breathing exercises combined with Kegels may do the trick to help patients relax (or to help the examiner relax, at least).

As I mentally prepared myself for the rectal exam (specifically thinking about where my finger was to go), I realized how we have learned to palpate and navigate every corner of the body, including orifices, such as the anus. Using a wind-shield motion, I could feel the surface of the prostate gland and with a 360 degree rotation, I could feel the rectal wall (the anatomy can only be appreciated your finger has made it's way far enough up, in case your are interested in knowing).

The last exam will be the breast exam. After that, I will have learned the full head-to-toe physical.

We come a long way. It will be interesting when we start performing full physical exams on our patients. Hopefully, we'll remember the lessons our educators have taught us and have too many surprises.