Saturday night and my excuse to stay in is that I'm being "responsible."

I haven't had any good blogging ideas for a while.  But since I've posted all of my rotation writings this year, I had been expecting to post my upcoming medicine paper.  Thing is I haven't made it yet- but its only supposed to be a page long (double spaced of course...), and sure enough keeping reflective writing that short will easily be the hardest part.  So I'm going to write one freely here- then edit for submission.

My assignment-

Reflective writing differs from other kinds of writing in that it allows the writer to express his or her thoughts and feelings about something (an experience, a text, a film, etc).  By the time I finish your paper, I should have a good idea of what your experience with one of your patients was like, how it impacted the care of the patient, and what it taught you about your future work as a physician.  Remember the goal of this writing is reflection and the subject is one specific, meaningful patient experience you had while on the Medicine Clerkship.  I want to know what you are thinking!

There are 3 parts to this paper:

1. Summary of the specific doctor-patient experience/encounter.  Tell the story.  Do not interpret here. 
2. Exploration/interpretation of the possible meanings of the event.  For example, how did this event contribute to your understanding of the patient?  What did you actually experience, feel or observe?
3. Description/prediction of how the knowledge you gained from this encounter can be used in the future for your profession.  For example, what implications are there from this experience that will impact your work as a physician in the future?  What did the experience teach you?  How will it make you a better physician?

 I believe the description of the assignment itself is about 2 pages double spaced.

It doesn't say in this description, but it is suggested in other course documents that this paper is supposed to reflect on a palliative experience, but not necessarily one from my palliative med week.  So as I try to recall patients I could potentially use, there are plenty that come to mind, most of them actually from my last couple weeks of the rotation.  It's hard to pick one, but I will probably pick the one I followed the longest...

The patients that I find the most interesting from a learning standpoint were those which were delirious, demented.  I had three that I would like to choose from... JW, PW, RG.

JW

61 woman who had a kidney transplant something like 15 years ago.  She came in because of confusion, or altered mental status, and kidney injury.  We did the full work up for all typical causes of delirium in a patient like this, but all work up was negative.  No infections, tumors, strokes. Discontinuing many of her meds did not do the trick to clear her up.  So in the hospital she stayed for 4 weeks, the exact 4 weeks I was at this hospital.  She waxed and waned in her confusion, a quality typical for delirium.  At her worst she was calling out, saying that she was trapped in her car and somewhere in Lexington.  In reality, she was dangling her legs off the side of the bed, tangling them in the bed rails, staring off into the air.  She was given antipsychotics for a week or so, but they seemed to only knock her out and not improve her confusion.  She did improve the most in the last week, but only to about the level she was at admission.  My attending decided in the end that it must be a psych issue that she has just kept masked well for a long period of time. 

We decided to consult palliative medicine at the beginning of the last week.  Largely because she was not eating or drinking hardly at all due to refusal, and she had made it clear in the past that she would never take a feeding tube.  Consulting palliative for a patient in her situation was very baffling for me.  You consult palliative usually when you know someone is dying.  We had no idea what was wrong with her, we just knew that she had already denied the types of care she needed to get better (feeding tube, dialysis for her worsening kidney function due to dehydration, blood transfusion for her worsening kidney-faulted anemia).  It was one of those end of life care situations that should make someone paranoid to make those life-prolonging-care decisions: a patient unable to make her own decisions during a hospital course that should be totally fixable, but previous refusals of care wishes prevent someone for bouncing back.  If she dies as a result of this condition, her cause of death will be something like renal failure due to dehydration secondary to altered mental status.

PW
88 year old woman.  My experience with this woman was brief, but I did learn some new things from her.  She was a patient of mine during my palliative week, and she was consulted due to "terminal agitation."  Agitation can kill you, huh?  That's not something we've ever learned for step 1 boards...  In more understandable terms for me, her diagnosis was "end stage dementia."  She was sleeping more, eating less, and had become combative in her confusion around others. During psychiatry, I heard for the first time that dementia is actually a terminal disease.  I hadn't known that previously, but those who get it usually die within 5 years or so.  I learned during this rotation that dementia has 3 types, two that are neurological, and the third is simple Alzheimer's.  And most people who have dementia don't just have dementia, they have Alzheimer's dementia.  The word is just cut short.  There is no such thing as plain dementia.

Everyone with delirium/dementia thinks the year is in the 1990s.  At least that was my experience.

RG

92 year old woman.  It may not be easily assumed, but dementia and delirium is all over the hospital.  Hold for Peds I've probably had dozens of patients in these states.  You get used to them though.  Every morning you see them, you go ahead and assess whether they are still confused, then you tell them you are going to take a listen to them and move on.  So when we visited RG on Wednesday, it didn't feel overly imposing that the fellow, my classmate, and I all did focused physical exams on this woman.  She was awake and responsive to stimuli, moving slowly and deliberately, but was not following commands, acknowledging our presence, or speaking.  When I first walked into the room during the fellows exam, he was working to have her release a tight grip on his index finger, before moving on to look at her feet.  My classmate and I both did exams on her because we needed a patient to demonstrate a physical exam on so the fellow could fill out eval forms for us.  We could not do very good ones without her cooperation, but we went through the motions anyway. 

The next day a code was called on her during our morning rounds, and I was the one that went to the unit to see if it was her.  As she was the day before, she appeared to have no visitors, but instead the typical 15 or so response staff surrounding her, attempting to intubate, doing compressions, on her plank-like, exposed and bony frame.  We were a consult team for her, so I am not certain of her complete course, but my attending said she was likely septic all along.  I feel bad about doing the physical exam.  But maybe I feel worse that she was not DNR.

I know I didn't address all three criteria for reflection in each of the patient stories... but I probably could once I pick which one I decide to use... obviously RG or JW, probably JW.  I'll take thoughts if anyone wants to give.  I'm supposed to submit by March 19 I think.

Nails [Love]

LOVE this new color I got last time.  I like most colors- except red and pink haha.  I've done grey, whites, golds, silver.  For most situations, I feel the need to stick to the whites/pale colors so I feel less obnoxious at work.

A genius realization struck me in the past year.  Artificial nails.

Those who know me most definitely know about my shameless nail-biting habit.  I was one of those people that biting until I bled was not uncommon.  Typically at least one of my fingers would be throbbing any given week.  That part didn't bother me really- it was the conscious thought that even though no one ever said anything- my hands made me look like a nastier person.

I was very specifically enlightened to this during one of our intro to clinical years sessions-  According to our lecturer, the number one thing patients notice regarding the hygiene of their physician is their nails.  Really??

So during the summer, I took myself to my first gel nails appointments.  And then soon after my Mom started inviting me to join her.  One of the best things we've probably done for our relationship, actually.

 Am I actually cured of the bite?  Not exactly.  If anything happens to the perfect smooth curve of one of my nails, the whole thing is inevitably removed then the shaved down flimsy remnant of the original nail is soon after back to its state of neglect.

"Pearl of Wisdom"

Career Exploration – Gynecologic Oncology

Another reflective piece I needed to write for school below.  It's talking about my week elective I did in gyn onc back in early November.  It was fun.  But not for me I think.  I'm taking picking my specialty more serious all of the time.  I spent a day of break focusing on looking into specialties.  Right now my tops are Urology and ENT.  And if I decide against those (#1 negatives- Urology- working with all those darn genitals. and I was thinking I'd like to avoid the pelvis period, ENT- bitches too competitive! :( ), you can bet I'll just do general.  But surgery, I'm coming for you, baby!

            The nature of gynecologic oncology consists of working with women who are either diagnosed with female cancer or suspected of a diagnosis.  One of the most important things I learned with this broad description is that the Gyn Onc surgeons are truly primary caretakers of their cancer patients.  Aside from radiation oncology, gynecological oncology surgeons are not just surgeons.  They are diagnosticians, surgeons, and chemotherapy caretakers.

gyn surgery = watching a boob tube for a few hours.  that's an ovary getting bovied off a ligament...

             The training involves the Ob/Gyn 4-year residency plus a two-plus year fellowship focusing on oncology.  I only spent a week in the exploration, but a typical academic gyn onc surgeon would operate 2-3 days a week, have 2 days a week for clinic, and an administrative day.  Hours seemed very comparable to typical general surgeons, with early mornings starting at 5 for residents and days ending with the ending of procedures, which could vary from 5pm to 8pm on any particular day of procedures.  Many of the surgeons seemed to like having marathon surgery days, consisting of 3 or more surgeries one after the next.  None of this was overwhelming after just having completed my surgery rotation.   In fact I enjoyed the similarity.

            I mentioned that understanding the composition of gyn onc work was one of the most important things I learned in my week of exploration.  I did not know that gyn onc spent so much time in clinic following up with long term patients and making major treatment plans beyond surgery.  I had spent a 3-4 weeks before this exploration following surgical oncologists, and had always enjoyed their clinic.  In Surg onc, clinic usually consisted of new patients looking for a positive or negative diagnosis, patients ready to undergo surgical treatment decisions, patients coming to hear their pathology results, and beyond that, long term follow-up of already “cured” surgical patients.  In gyn onc clinic, I was distressed at the amount of bad news and difficult decision-making advice I watched the surgeons give.  These solemn encounters were oddly out of proportion to what I had considered routine in cancer surgery work.  I couldn’t help but get the impression from this that it meant that gyn onc’s had to deal with some of the worst and most incurable cancer seen in medicine.  But I knew that this assumption couldn’t be correct.  

Da Vinci! concept kind of cool.  but laparascopy in general can't ever seriously be fun unless your behind the electronic arms :)  Not to mention pretty much 80% of the surgeries I saw were hysterectomies.  shoo.

            It didn’t take me long to realize that the lack of comparison to surg onc was due to the fact that surgical oncologists have the convenience of turning away cases that are inoperable, and thus are able to turn away situations doomed for bad outcomes.

            I have long thought to myself that I like sick patients.  But I have also thought that I like sick patients that can and are going to get better with a physician.  The typical excuse some people use when they go into surgery comes to my mind: a desire to cure patients in a expeditious fashion [with surgery]. 

            I know I want to work with cancer.  This may sound counterintuitive in the opinion of the typical person, but those who go into cancer work dooming themselves to the struggle of dealing with failure and death (and likely desensitizing themselves to death in the meantime)…. are the medical oncologists.  I want to go into a field of oncology that has been shown to be capable of truly curing cancer patients.  Surgeons may not cure all, but the rate of disappointment is statistically much better than those who have to depend on chemotherapy.

            After getting my peak into gyn onc, I do wonder if I still may like regular OB/GYN.  But I am running out of time to decide, and after my experiences in my surgery rotation and my enjoyment of my cancer research, I like the path I’ve already started trailing down.  Cancer surgery!

christmas gift projects

We've been very broke this fall.  It's been a constant struggle, month to month, and I owe lots of money to my Dad.  Loan check should be here in next week or so though, and with Saia likely starting public preschool, we should be able to exhale for at least a little bit.  Anyway, it's been the first holiday season that I had to have serious budget planning. In the past, I always thought it totally reasonable to do $40-50 per family member. I mean, what can you really get for less than that these days? crap is what.  Interestingly I read an article that suggested a lot of people just do not spend money on Christmas.  News to me.  But this year I wanted to try to spend $200 on everyone.  That's for eight family members on my side, eight on Jeff's side, and four friends.  Final total $314...

A lot of how I made it stay relatively cheap was making things.  I got ideas from random places I found through google and I got some of the best ideas from Martha Stewart's website (haha).


Handwarmers
from this website. All you do is make 4 inch bean bags with fabric then fill them with ceramic.  Specifically, the instructions were to use ceramic pie weights (something people use to make pies), but that would've made them like $8 a set! No thanks.  You know what else is made of ceramic?  Tiles.  $0.57 foot square tiles, that is.

I made 4 pairs, most for friends.  Pop them in the microwave for 90 seconds or so and you've got something that feels great against your face/hands/wherever when you are out in the cold or come in from it.  My dad and friend Alex have requested I make them some.

Charm bracelet

Momma's love their babies.  And my mom's got her own new collection this last few years.  She's a typical older woman, likes those goofy charm bracelets, "pandora" ones in particular.  But those lousy things are $30 a charm! I don't think so. You can't deny something custom though- with charms that really are unique to your own babies.  This was Martha Stewart's idea.  I couldn't find everything on the supply list though.  So I had to improvise.  And I chose against the sepia photo thing. But I like the bracelet...

Baby-girl-to-come, Isaiah, Me, Julia, Calvin, Jenn

Cardinal hats

This season they have been selling these cute Cardinal hats for kids in the authentic store.  I found them online for $23 but they are probably $30 at the Yum center. The idea looked simple to me I guess.  I originally thought it would be fun to make for Isaiah, but then realized I also needed gifts for Isaiah's cousins.  So I'm making three.  One down, still two to go.

the model from the store

I don't know why I can't get this right side up

I've never made a hat before.  To get an idea of how I'd do this I found a tutorial online on how to make a simple tobaggan kid hat online, which gave me some idea of how templates and sewing work... then I just had to wing it.  I used the picture above to sketch my own template.  I think the hats I made were a bit smaller, but they turned out well proportioned.  Pretty happy with it.


No knit Rosette scarf

My other idea taken from Martha Stewart.  She said to use a tool called a knit-wit, but it would've been $20 online and I couldn't find it in a store.  So this other website told me how to make my own tool.  This No-knit thing looks pretty lame in its traditional usage (70s trend stuff), but Martha recommended using a fancier type of yarn that makes a scarf look "decidedly modern," as she puts it.  Mohair yarn.  I'm liking it! I've got lots of yarn.  I'll probably make a scarf for myself as well.

[No pic right now, will update later.]

String Art name plates

In an old post on art club, I showed a string art project I did of an owl.  Since it was a project I shared with my art club, I had google imaged string art looking for ideas for other clubbers.  One thing I saw was an example of where someone had used string art for words.  I decided to use that idea for my last DIY Christmas gift idea.  It was an ungodly long endeavor for each of the three name plates... First I would come up with what I wanted on the plate using Word, print it out at the right size, affix it, then cut the wood to fit.  Then I sanded the edges and stained the wood. Then with the paper template taped on the wood, I hammered all of the nails down.  Then after removing the paper template, I'd tie on the string.  Vomit.  I won't be doing another one of these until I have a good reason.  I like them.  But probably not enough for the time I put into it.

This is the last one I did.  I knew that fleur de li would turn out good.

I messed up the staining on this one and the one above.  It's not dark enough to keep the text legible :(

Looking for the link to the string art words I linked above, I found some other new examples.  People use bright string.  I just worked with what I already had, which was mostly dull.

While I'm posting about DIY endeavors- Saia's bday party was yesterday and I made my own angry bird cake.  :)

my model

the facial features are all cookies.  Including the ears which are hanging on with toothpicks.

Reflective Writing Experience – Psychiatry, Fall 2011

I had to write a reflective piece on a patient encounter for psychiatry, and I had a great subject to work with.  So I enjoyed the patient, enjoyed writing the paper, and wanted to share.  I probably could've gone on and on about the patient story and my thoughts, but we had a 3 page limit.  And yeah I know the ending isn't good.  I've never been good at concluding summaries.

                My first week on inpatient psychiatry, I anxiously awaited my first intimidating experiences with the mentally ill.  One morning later in the week, I thought I’d finally get that perfect opportunity to practice keeping myself between the patient and the door.  My resident had taken assignment of AB, a 23-year old white male, with a past diagnosis of paranoid schizophrenia.

                An MIW had been filed by his mother for bizarre behavior after he had neglected his medications for 9 months.  He had been making threats regarding his mother, sister and self. Specifically, he threatened to hang himself, his mother, or make bombs and blow up their house. In the EPS report at admission, it was noted that he had over “10 hospitalizations” in the past 2 years including at Central state. In addition, as a minor he had hospitalizations in OLOP, and a facility in Florida.

                On our first visit to him, he was non-threatening but somewhat agitated, denying cooperating with the interview, and criticizing his mandatory hold in the unit.  He was often sarcastic and scrutinizing.  On questioning of his homicidal threats, he denied, calling himself a “prince of peace.”

                His toxicology screen was negative, but he claimed that he had used cocaine, marijuana, and hallucinogens in the past.  He stated that he had “tried it all.”  He claimed to use marijuana and alcohol both “once in a blue moon,” with last uses within the past month.  He claimed that he had tried unheard-of hallucinogenic drugs around the time of his first hospitalizations.

                On further questioning of how he got his schizophrenia diagnosis, he denied memory of the events which led up to it, other than the drug use.  He also claimed to have little memory of the sequence and timing of his past hospitalizations.  AB denied he had schizophrenia.  He denied experiencing auditory or visual hallucinations, suicidal ideations, homicidal ideations, and past suicide attempts.  We did not have any documentation from previous hospitalizations to support his diagnosis.

                He had held a job as a waiter for 7 months, which he lost a month before because he decided to “no call no show” and stop going after getting involved romantically with a girlfriend.  He lived at home.  He claimed to have an active social life, involving music, dancing, and bar scenes.  When not living at home, he stayed with friends for days at a time.  On questioning about his relationship with his mother, he said they do not get along because she “pushes her beliefs on me.”  His family is Jehovah’s Witness.

                He frequently referred to his distrust of doctors, including us, calling them “representatives of the pharmaceutical industry.”  On questioning of his orientation to location, he stated he was “in a restricted area.”  He cooperated with a urine tox screen taken in EPS but refused further labs.  When asked about his mood, he stated it was “like Thomas Jefferson,” with a blunted affect.

                During his admission, AB appeared slightly disorganized.  He was unkempt with long hair, and his body odor was noticeable on occasion.  He refused to take a shower because he only used organic soaps.  His excuse was the same whenever he denied food and medicine.  He did eat vegetarian diet foods when offered.  He never took his scheduled Seroquel in his 5 days inpatient.  During the day, he would often stand in hallways, looking around at the other patients, occasionally laughing at the bizarre behaviors of other patients.  On one occasion, AB was given an intramuscular dose of Geodon because he would not remove himself from an area where another patient was displaying aggressive behavior.  

                 AB often stood facing the nursing station, staring off but doing rhythmic movements, especially hand gestures.  When asked about his movements, he responded about his interest in magnetic healing powers, and also that they were movements he enjoyed for raving and glow stick dancing.  He would say that he was “magnetizing the air.”

                Even with his slight disorganization, bizarre and magical beliefs, he was able to give a clear, concise, goal-directed, and daresay convincing argument about his current situation at his mental inquest hearing.  His mother attended the hearing, but was unable to provide testimony due to English language struggles without an interpreter.  Regardless, the judge determined that a de novo would be needed to begin forced medications.  This could only be done at Central state hospital, leading to his transfer out of the unit on day 5.

                In the 6 weeks on psychiatry, it did become very clear to me how common it is for schizophrenics to deny their diagnosis.  I noticed this early on, but even in the end I still wish I understood more about why this is the case.  Most of the patients who exhibited this seemed to be aware that they were not being honest.  I also got the impression that those that denied their diagnosis were more at threat for future suicide, which worries me about patients like AB.

                I had a lot of doubts about AB and his diagnosis while he was in the hospital.  Compared to the other schizophrenics I had the chance to observe, he seemed so calm and aware of reality.  He was never caught talking to himself or responding to other internal stimuli.  Most of his out-of-the-ordinary beliefs were not unheard of.  He agreed in one conversation that he was definitely anti-establishment.  He seemed immature for his age, and not well educated… but I would argue that if he was schizophrenic, he was in a residual state.  I know that as a student, I am inexperienced and probably naïve in regards to psych, but as an attending I will hope to maintain an open mind with every patient.

                If I hadn’t felt as limited by my role as a student, I would have wanted to interview him more to gain more insight about his thought processes, and to look for clear signs of positive or negative symptoms.  I did get the opportunity to have a last conversation with him on his last day.  I knew I wasn’t going to see him again.  I wanted to tell him that I thought he seemed fine, but of course I couldn’t.  Instead, I warned him that if he wanted to stay out of the hospital, he needed to avoid arguments with his family.  And that when does argue, he could never threaten, or he would be back.

2011 fam Xmas card

There was a "vistaprint" daily deal recently that I took advantage of- $15 for 30 cardstock personalized Christmas cards.  Goody!  I've always wanted to make some. I've thought of 25 households to send them to, and still trying to decide what to do with the last few.

 
The cards look good- but I'll go ahead and warn you that vistaprint itself sucked.  Probably one of the cheapest options out there.... but a huge hassle going through the designing and purchasing process.

Enjoying the season!!!!!! I am.  Can't wait to share all the Christmas projects I've been working on.  I have to wait til after Christmas day (hint to anyone out there expecting a gift).

Xmas List Eye Candy...