24 December 2009

New Intern Practices (lists and listing)...

I am going to relate some of my practices as a new intern. I certainly learned from the best (my love and infinite respect to J-Ro wherever he is) and have generally kept up with the solid patient care practices that I learn from day one on the job.


Every good intern needs to have some kind of list procedure and I was no exception. Placing those little square boxes beside things to do and frequently checking my list became the "bane" of my existence on the wards. As a newly minted intern, my principle job was to make sure that every facet of patient care was done and assessed in a timely manner. I developed the practice of carrying both a clipboard (clip kept small pieces of paper from falling out) and blank sheets of paper. I would have a master list of patients that were under my care with Post-It sticky notes for things that I had to add to the lists in a hurry.

Daily Routine

When I first arrived in the morning, I pulled up my patient list and busied myself with checking the latest lab values. I scheduled my hospital arrival time based on service and the number of patients that I had signed out the night before. I knew that I would get at least one or more new patients and thus, on a service that contained a large number of patients with complicated diagnoses (or needs), I arrived earlier and on services with more long-term patients, I could arrive a bit later.

I would list my labs, check any imaging studies from the day before (or the middle of the night) and circle them in red (I always carried a 4-color pen or bright pink highlighter). I would want to make sure that the results and plans from these results were in my notes and orders for the day. Sometimes, lab results and imagining study results would indicate the need to change plans for the patients for the day. This is why these were the first things on my list.

My next tasks were generally to check with the night charge nurse for the things that needed immediate attention. Since the charge nurse knew that I was usually the first on the wards, he/she didn't have any problems letting me know anything that needed immediate intern attention from overnight. In general, the intern that was covering would also have reported to me but occasionally, there was a slight difference in the reports between these two people. I also make a concerted effort to get sign-out from the covering intern as soon as I could so that they could take care of their own patient load and I could get "cracking" on my daily duties. This is a good characteristic to have.

By the time my chief resident (and fellow on some services) arrived on the floor, I could hand them a patient list with the immediate problems (and my handling of them) circled in red. We could then start morning rounds with me (or a medical student) presenting the patient outside of the door, going inside for a look at the wound/incision, and any additional care options that the chief might want to add. These things were carefully noted and checked by me as I was responsible for everything aspect of bedside care on the service. A medical student could follow a patient or two but the intern has to be sure that everything is checked, double-checked and done.

Right after rounds

As soon as rounds were finished, I would quickly enter any orders that needed to be entered and head off to the OR for cases that had been assigned to me by the chief resident. Usually, unless there were loads of ward patient care duties, I could get to the operating room to do a case or two. I would check the schedule the night before to make sure that I had done my anatomy and surgical atlas work for any of the PGY-1 level cases. I didn't want to miss any of the "pimp" questions that I was bound to be asked over the incision during these cases.

If patients were likely to be discharged, I developed the habit of dictating a pre-discharge note that I only had to dictate an addendum to when the patient actually left. This meant that I could enter my discharge orders and scripts, pre-dictate the discharge and then release all of the information and scripts as the patient was leaving the hospital. Since these decisions were made during morning rounds or shortly after discussion with the attending, this turned out to be a great practice but one had to keep good records of patient numbers and what had been pre-written/dictated. There was nothing that prevented me from grabbing an order sheet, writing some discharge orders and keeping those orders on my clipboard (dating them when needed).

I also made it a point to go and observe any studies that were being carried out on my patients whenever possible. There were procedures like gastrografin swallow studies and upper gastrointestinal studies that were great to observe in "real time" along with the radiologist. I also made sure that I reviewed all of the CT Scans, cath reports, angiography studies and other studies of patients that were admitted the night before for surgery. I reviewed as much as possible in terms of their care in clinic and why the decisions had been made to take them to surgery. In short, I wanted to be there and get to the bottom of every patient detail as much as possible. Much of this type of investigation work was done on call based on my notes from clinic.

Do you actually know the most about your patients?

I have to say in all honesty, that my best skill as an intern was to know more about what was happening with my patients than anyone else on the service. Most of the time, the nursing staff would call me when a patient went to radiography so that I could slip over and look at their studies. The radiography techs and transporters were also happy to let me know when they had picked up a patient, especially at night. I always wanted to get in and see for myself, what the studies looked like even if it meant that I would lose some sleep. I knew that I would rest better when I had tracked down my studies; knew the results and had discussed them with the chief that was on call so that any plans could be done.

Sign Out

One of my colleagues replaced my folded paper system with an Excel system that I still use today. On this system, we kept a running log of patients, locations and things to do and check. An intern covering my system could easily check the sign-out sheet (done by printing out Excel sheet) or check our files on the service computer. I always kept this backed up on a jump drive too.

I never signed out anything that I could do or check before leaving. I knew that the night float intern would have a huge patient load ergo, I made sure that all admissions and post-operative checks were done by the time I left. Unless a patient was still in recovery (in which case, I checked on them anyway to fill anticipated needs), I didn't sign out discharges or new admissions. If I had to stay a bit longer, then I stayed a bit longer (signed out earlier) and updated the night float just as I left the hospital.

There is no substitute for making your own rounds and checks in the late morning between cases, in the afternoon to see that everyone got home OK and just before signing out to the night float (or receiving sign-out if you are on call). It is things that are signed out that are most often missed. On-call folks get busy and emergencies come in that will delay things. In short, I tried not to sign out anything that I could do by phone or that was routine (should have been done earlier in the day). My regular walking around solo rounds usually kept me on top of things.

Going off service

Another very nice thing that I always accomplished was an "off service" note that summarized the care of a long-term patient. There were many times when a patient (especially a burn patient) had been hospitalized for months. When I received such a patient, I wrote a summary of care up to when I started and a summary of the care while I was on service. If the patient died or was discharged a couple of days after I left the service, my "off service note" would assist the new intern in doing an accurate dictation on that patient. This type of note would also help them get up to speed when they came on too. I always appreciated when someone did this for me and readily returned the favor. An "off-service" note is one of the best things for good continuity of patient care.

21 December 2009

First Semester of Medical School (it's over and done)...

For many people, the first semester of medical school is complete. By today - barring being snowed in and delayed at one of the east coast airports - you are on your way or at home for the holiday break. Many folks worked harder this first semester than in any aspect of their previous academic endeavors only to find that they didn't do as well as they wanted or anticipated. The good news is that the semester is over and the bad news is that you have to go back and face second semester in a few short weeks.

My first piece of advice is to take a bit of time to assess what worked (and didn't work) in terms of getting the material mastered for this past semester. There is little use in anguishing over grades (you get what you get when you get it) or what you "could have done". You put everything regardless of good or bad, behind you and move into the next semester renewed. If you failed, it's behind you until you have to re-mediate. If you passed, it's behind you and you have to move forward. That's one of the great things about medical school in that it carries you along at a relentless pace.

As you take stock of the things that worked well for you, see if there is something that you can do to enhance your efficiency. You are going to have to be more efficient in the upcoming semester and into next year so why not take a look at what you can "tweak" to make better. If you are totally satisfied with your work, still look at adding some activities such as physical conditioning or stress relief. Trust me on this one, stress can come out at any time in medical school no matter how well you are doing. Having some kind of a stress relief plan is a good thing. Even if you walk around the block a couple of times, it will just relieve some of the stress.

Resist the urge to try to study for Boards during this holiday. You NEED rest and relaxation. If you feel that you must do something, then have a cursory look at First Aid for Step I but there is little that you can do that will make any meaningful "dent" in what you will have to review after next year is done. Your best prep now is rest and relaxation. Don't even try to use these next couple of weeks to "read ahead" for the next semester. Work on a plan for increased efficiency but you know that you will have ample time to study for the next semester of coursework.

Take this time to catch up with old college mates who have gone into something besides medical school. I found this practice most fulfilling because they wouldn't allow me to "talk shop" during our get-together. I could hoist a brew or enjoy the holiday lights without feeling compelled to study something or plan to study something. If you were fortunate enough to complete your Gross Anatomy course, relish in the fact that you can burn those formaldehyde-scented scrubs now. See, there is always something to put behind you. If you are not done with Gross Anatomy, well, you are at least further along that when you started.

I also used the holiday break to catch up on some of the latest movies, non-medical reading and other nice non-medical pursuits. Even today, as I have completed submitting grades and evaluations for the students that I teach, I am contemplating the movies that I will catch up on this week. I have some holiday clinical duties but as I have posted in past posts, I actually enjoy the hospital during the holidays. The patients are grateful that you are working in addition to the wonderful decorations everywhere. I love to take a couple of minutes to sniff the branches of the huge lobby Christmas tree just to get that holiday feeling. I also enjoy hearing the Christmas carolers strolling the halls to serenade the few patients who are left in the hospital.

In short, take the time to enjoy your time with your family and friends, to celebrate that you have gotten through your first semester and to face the upcoming semester with some anticipation. Try to remember that this whole "medical school thing" is a process and not a commentary on your worth as a human being. My bet is that you are far more complicated than your studies.

If you didn't get the grades you wanted or feel that everything you have learned has "leaked out of your brain" relax because that hasn't happened. You definitely know more than you think you know. Every medical student feels that they are forgetting everything that they have learned. You may not remember every tiny detail but the neural pattern is there and can be recovered with a bit of review. In short, relax, that knowledge is in there and will be there for you. Next semester will build upon what you went through this semester but isn't dependent upon you having done a "perfect" job with this semester's material. You will have another shot at anything presented this semester next year and for Step I study. Again, this is why you can relax right now.

Finally, to those who may have to re-mediate, put off the self-flagellation. You have learned what not to do so concentrate on thinking about what you will do differently. Assess what worked and resolve to hone that what worked for you. Don't be ashamed and don't keep running thoughts around in your mind that you have closed any doors to having a fine medical career. You haven't closed off anything. Remember that the vast majority of medical students will have something to face in the future that will cause a hiccup or a step-back. If you had your hiccup now, you are done. Put it behind you and know that you are going to move forward to enjoy a great career.

Happy Holidays!!!!!

03 July 2009

Doing Well in your Cardiothoracic Surgery Rotation

Many times, third-year medical students will have to spend a portion of their required surgical clinical clerkship on Cardiothoracic Surgery. This portion of your surgery clerkship can provide a good informational background for anyone going into medicine, pediatrics or surgery. For the medicine, emergency medicine and anesthesia folks, you get first hand experience with the actions of pressors such as dopamine and dobutamine and other cardio pharmaceuticals in the postop management of these patients. You see the real-time effects of agents like nipride and nitroglycerine because most cardiac surgery patient will have pulmonary artery catheters in place in the immediate post-operative period. For those anticipating entering pediatrics, you will get a chance to see some of the effects of the congenital heart disease entities and how repairs are undertaken. For those entering the surgical specialties, you can develop an understanding of some specialized surgical techniques in addition to becoming familiar with the surgical intensive care unit.
Approaching the Rotation
The first step in any clinical rotation is to have good reference materials so that you understand the language that these surgeons will be using. For cardiothoracic surgery, I strongly recommend the following: Essentials of the Surgical Subspecialties by Lawrence, Cardiac Surgery Secrets by Solotoski or Handbook of Patient Care in Cardiac Surgery by Vlahakes. Any of these books will provide a solid background into the types of pathology that you will encounter in your rotation. The Lawrence book includes good sections on the thoracic elements of this rotation which are not included in the other books. In addition, you need the usual pocket books such as the Pocket Pharmacopeia or Epocrates which may be used to look up dosages of medications and the Maxwell Book which outlines SOAP charting, brief operative notes and discharge summary writing.
The players on any cardiothoracic service are the Cardiothoracic attending surgeon, the resident or fellow surgeon, the intern and you the medical student. You need to understand your role as both a member of the team and as a student of medicine/surgery. This means that in many cases, this busy service will require that you become very proactive in terms of getting the information that you need. You should thoroughly understand the following for every case that you encounter on this service (or any service for that matter):

• The relevant pathology of the underlying disease entity
• The relevant anatomy of the underlying disease entity
• The “gold-standard” of diagnosing the disease entity
• The accepted treatment of the disease entity
• For surgery- the surgical approach and performance of the operative procedure
• For surgery – the postoperative disposition and management of the patient

In the case of a patient that is undergoing a coronary artery bypass graft procedure, you need to understand the indications for the procedure, how the diagnosis of coronary artery disease was obtained (how to read the cath report), where is the disease (in which arteries), the relevant surgical anatomy, how the case is done including the operative approach, how cardiopulmonary bypass works, the effects of the cardiopulmonary bypass pump on the patient and how these effects are managed in the postoperative period, how to read and interpret data from the pulmonary artery catheter, where the grafts for bypass were obtained and how they were utilized and the care of the patient both in the intensive care unit and on the postop ward before discharge home. You should also know why the patient is discharged on certain medications and what you may expect to see and evaluate in the clinic when the patient returns for postoperative care.

Armed with that knowledge, you should make sure that you observe (you probably won’t be actually scrubbing in these cases)the preparation for anesthesia, how the chest is opened and closed, that you see how the grafts are harvested (done by a surgical resident) and how that wound is closed, how the grafts are sewn I place (best to use the camera overhead for this observation rather than try to look over the shoulder of the surgeons, how the pacemaker wires are placed, how the patient is placed on and taken off the cardiopulmonary bypass pump, how the chest tubes are placed in the chest cavity and how blood is evacuated from the chest cavity when the sternal wires are placed. Placement of the sternal wires is also a good opportunity for you to observe an interesting procedure.

After the case, you should accompany the patient to the intensive care unit and you should carefully note and observe the data that is obtained from the pulmonary artery catheter, the arterial line and the 12-lead ECG. You should look at the pre-operative ECG and compare the two. Another good exercise is to note where the grafts were placed and the number of minutes of pump time and any circulatory arrest time. You thoroughly familiarize yourself with the preoperative workup and the postoperative course of every patient that is on your service. Look at things like electrolyte replacement, ventilator weaning, urine output and transfer from the intensive care unit. This is also a good time to learn how to remove chest tubes and arterial lines. You should observe the conversion of the pulmonary artery catheter to a central venous line but leave the rewiring duties to a resident. If you anticipate entering a surgical subspecialty, you might observe these procedures but you should never perform these procedures as a medical student.

In addition to the routine patients, you may get an opportunity to observe some trauma that involved the cardiothoracic service. You may see the repairs of lung lacerations, penetrating cardiac injuries and the relief of cardiac tamponade from a traumatic injury to the chest. It is always interesting to see a patient who is admitted to the emergency department with a stab wound to the chest, knife in placed, rushed off to the operating room where the object is removed and the repair completed with survival of the patient. These are some of the most interesting cases. You may also see how damaged cardiac valves are replaced and how congenital heart defects are repaired. All of these cases are under the practice of a cardiothoracic surgeon.

The thoracic cases may afford you an opportunity to scrub in on the procedures. In the case of the video-assisted thoracic (thorascopic) lung procedures, you will have a good view of lung pathology. You can follow the patient from biopsy (in the case of a tumor) or chest wall abnormalities/problems through the repair. These cases will have interesting anatomy and will have excellent postoperative observations and challenges that will teach you many good skills. You can learn about chest tube management and the physiology of the chest cavity. You will also learn about pain management and the prevention of major postoperative complications as these patients may often be a challenge in terms of pain relief. You may get a chance to observe a thoracentesis or placement of a chest tube.

This rotation can teach you many important skills and hone your ability to understand the critical care of patients. It is an excellent learning opportunity for you. You may not get much hands-op operative experience but you can be invaluable in the post-operative care of these patients.

25 May 2009

Memorial Day at the Veterans Hospital

Typical Wound Rounds

It was one of those typical wound rounds days at our VA Hospital. We made our (the complete vascular surgical team) over to the long-term care wing of the hospital to do our weekly check of patients who didn't have formal vascular clinic appointments or who were bedridden with chronic wounds. The mid-level practitioners would put names of patients on a list at the nurses station for us to check. The patients who were ambulatory or wheel-chair bound would return to their rooms so that we could check them as we made our way down a T-shaped hallway with two long wings. The entire process generally took from 2-4 hours depending on how many patients to see and how extensive the wounds were and what care was needed.

The hallways

Most of the rooms down these hallways were semi-private (2 vets to a room) with a ward (4 vets to a room) at the proximal ends. At the end of the hallway were the private rooms for those vets who were in isolation for infections or for those who were too loud or ventilated and would not be amenable to sharing a room with another vet. The rooms at the far end of the hallway, though private, had views from the window that rivaled any 4-star hotel. They overlooked the front grounds of the hospital and the baseball diamond. Flying in the breeze was the state flag, the POW-MIA flag and the flag of the United States. The entire VA complex sat upon a hill that overlooked the surrounding town and mountains in the distance. No matter what time of year, the views were spectacular and I always paused to admire nature's show for these men who had given so much.

Chronic Wounds

We made our way from room to room. Many of these patients were post toe amputations and needed wound checks. Others were diabetic with foot ulcers from poorly fitting shoes or injuries that they could not feel and thus the wounds had become infected. Many of the vets were long-time smokers and diabetics with peripheral vascular disease from smoking and neurovascular disease from their diabetes. Some were despirately trying to "keep their feet" while others had both lower extremities amputated starting with the toes, then the feet and finally the leg above the knee. With each room change, there came a new challenge or a new evaluation. We removed dressings, evaluated vascular supply and made recommendations for each patient. With each week, I grew to know these patients and to learn to predict whether the wounds would heal, or an intervention was needed, or progression to limb amputation. Sometimes it wasn't wonderful to tell a patient that he would lose his foot but a good amputation with a well-healed stump could mean a return to ambulation and increased freedom. It was the progression of things each week.

Moving toward the end of the hall

This week, we decided to divide the duties with the interns doing post op checks and the more senior residents examining those patients who needed evaluation for possible surgical interventions. I elected to see the last two patients who were bedridden and in isolation for MRSA (meth resistant stap aureus). I knew that these guys had extensive wounds that would take some time inspect, debride and re-dress. I loaded my pockets with enough bandages for the dressing change and left my coat on the cart outside of the door as I donned the yellow isolation gown, a mask , gloves and shoe covers. I greeted my first patient and set to work removing the old dressings. We had ordered that dressings be changed every six hours on this patient but it was clear that his dressings were being changed daily instead of three times daily. How was this wound going to heal? It's the wet to dry dressings that debride the wound and help to clear the necrotic tissue that would promote healing. I chatted with "George" as I completed the inspection and dressing change. I left my initials, the date and time on the outside of the dressing. If this was still here in the AM (I had planned to stop in early and check), I would be writing an incident report. If George was to keep his leg, this dressing needed to be changed. For George, a very pleasant gentleman who was post stroke, this was limb salvage.

The last room

I moved into Fred's room after I cleaned up and washed my hands from George's wounds. It was now well past dinner time and the sun was low in the sky. Fred's bed was facing the beautiful setting sun. Fred had congestive heart failure, diabetes and emphysema. He was a small thing gentleman with bright blue eyes that still held a twinkle when you greeted him with "Semper Fi". Fred had been a marine and by his looks, a real scrappy guy. I always chatted about baseball with him and he loved the company. Sometimes he sang "Take Me Out to the Ballgame" off key as I worked on his infected decubitus ulcers. Twice we had taken Fred to the OR for surgical debridement where we cleared away foul-smelling dead tissue down to the bone. Fred had little tissue left on any of his pressure points and had been failing rapidly.

Today, Fred appeared to be dozing quietly in the setting sun. I touched his hand which was wrinkled and warm. I noticed that Fred wasn't breathing and had likely died a few minutes earlier. He looked peaceful and happy as the sun's last rays of the day were settling on him. On the ball field, one of the local town teams was finishing up a game. Most likely, the last thing that Fred saw was his beloved baseball and a beautiful May sunset. To the man who had given so much so that I could come and dress his wounds, God had given one last baseball game in sunset.

There are thousands of veterans in hospitals around the country presently. They love company and they don't care if you are not related to them. They are very appreciative of everything that we do for them. Many times, the interns and medical students would complain about wound checks but for me, they are the highlight of my week. I might make a difference that will allow a vet to keep his feet or I might be reminded of how special these guys are and why I love what I do and have the opportunity to do it because of them

12 April 2009

Do I really NEED to take an MCAT Review Course?

You have completed your pre-med coursework with no grade less than B+ and a majority of A grades. You feel that you have a solid grasp of the material and the concepts presented in your pre-med courses. Do you really “need” to take a review course for the Medical College Admissions Test (MCAT)? The answer to that question depends on whether or not you are good at solving the types of problems that are presented on the MCAT. If your knowledge base is good, then taking a review course that emphasizes knowledge refreshment is largely going to be a waste of money for you. If it’s been a few years since your pre-med coursework, then getting your knowledge base up to speed is your first priority and thus a knowledge upgrade type of review course may be the key to a strong score on this very important admissions test.

How are your problem-solving skills?
You can quickly find out how well you solve MCAT-type problems by downloading one of the retired exams and working the problems under actual testing conditions. If you are finding that you are struggling with these types of problems, then try to find a review course that gives you plenty of strategy and experience with problem-solving. Problem-solving is often the main gap in the education of most pre-med students. With many undergraduate institutions placing more emphasis on “rote memorization” rather than application of knowledge to problem-solving, pre-med students may have earned high grades in science coursework with little training in how to apply those skills to new situations. Even the so-called “ranked” universities can be seriously lacking in terms of making sure that students have problem-solving skills. Many times these skills are utilized most in coursework like Calculus and applied Differential Equations; courses that many students avoid because of rigor or lack of math background.

How are your reading skills?
In this age of electronic media at every corner, many students have lost the ability to produce (and evaluate) good writing. Many students view the analysis of literature, primary resources and scientific papers as the torture of producing research papers and as a “necessary evil” of obtaining an education. Many professors routinely pass out PowerPoint lecture slides that contain the bare minimum of facts/information that students attempt to memorize verbatim without regard to analysis or research beyond what they have been handed. These processes have tended to rob many students of the skills needed to evaluate information sources and information. While Wikipedia may give starting points for a wide variety of subject matter, many students will often use the “cut and paste” function for research paper writing rather than spend some time evaluating a cross section of resources. Reliance on quick media resources is a great starting point but this reliance can’t be the end point of your information evaluation and gathering skills. Learning how to evaluate the primary literature is a valuable skill that you should have acquired in your undergraduate training regardless of major course of study.

The sections of the MCAT – Biological Sciences
This section will test and evaluate your mastery of General Biology with some Organic Chemistry thrown in. While it may seem strange to put these two subjects together, organic chemistry is largely the most concept application course that is taught in chemistry. Organic Chemistry relies on your understanding of the chemical properties of carbon as an element to solving problems across a wide variety of conditions. Many students hit a major roadblock with organic chemistry because there are many problems that can be created to test your knowledge of carbon chemistry. Trying to sit and memorize every problem that you were presented with in organic chemistry is not going to be very helpful but making sure that you know the concepts of carbon and its chemistry will enable you to solve any problem that you are presented with.
In addition, many student mistakenly believe that they must “take a course” in every type of subject matter that is covered on the MCAT. This could not be further from the truth. A good comprehensive General Biology course will give you the knowledge foundation to apply concepts to the problems that the MCAT will present in Biology. You don’t need specific coursework but you DO need to be able to do some creative thinking in the application of your concepts to novel experiences. A good comprehensive General Biology course will cover physiology, botany, zoology and ecology. Thus, you don’t HAVE to be a biology major to have exposure to the subject matter but you do need to have a grasp of the concepts of a good comprehensive General Biology course. Being able to synthesize and build upon a basic knowledge base are the types of skills that you will use in medicine thus your ability to do these types of problems will be measured by the Biological Sciences section of the MCAT.

The sections of the MCAT – Physical Sciences
This section tests your ability to solve quantitative problems using concepts that you learned in General Chemistry and General Physics. These types of problems are often answered by being able to apply order of magnitude type strategies rather than working though an entire problem. Students who thoroughly know quantitative relationships presented in their coursework will tend to do well on this section. Between General Chemistry and General Physics, the quantitative relationships of many concepts can be probed and tested. It is practically impossible to rote memorize every type of problem that can be presented in these courses but having a sound knowledge of quantitative relationships in addition to being able to apply those relationships can bring success in this section.

The sections of the MCAT – Verbal Reasoning
This section of the MCAT can often be very difficult to improve or prepare for. Being able to analyze critically the reading passages from a wide variety of sources and disciplines generally takes years of careful practice and skill building. Preparation for this section should have been occurring over students previous years of study in practically every subject. College coursework in the humanities with strong achievement can also hone these skills. In addition, good readers are always good writers and thus, the writing section of the MCAT is likely going to mirror the Verbal Reasoning section of this exam. Can you consistently read and learn from your text books and journals? This is a very valuable skill to take into medical school with you as medicine will require a lifetime of learning and the acquisition of new knowledge that will be outside of a classroom.

Some final thoughts…
Finally, the review courses are expensive and time-consuming. You have already paid thousands of dollars in tuition and book purchases in order to master your coursework. Do you actually NEED to pay a few thousand more for a review course of that work? If you didn’t master what you needed the first time around or if you find from doing a few practice retired MCAT exams, you are struggling with this test, and then perhaps a review course can make a difference for you. You should thoroughly investigate the materials offered and you should thoroughly understand what the courses are offering for the fees that they charge. You should also be prepared to master some of the material on your own as many of these courses are taught by people who have a variable ability to teach others. Doing well on the Medical College Admissions Test may not translate into being able to teach others to do well on this exam.
The Medical College Admissions Test is one aspect of your application to medical school. This test requires solid and thorough familiarity with the mode of testing and a solid knowledge base that must be applied to the problems asked on this test. Several retakes of this test do not bode well for medical school admissions. You want to be prepared and take this test one time. With this test being administered 22 times annually, you also have more options in terms of being able to time your preparation for this exam. The important thing to realize is that you don’t want to take this test unless you are thoroughly prepared at your own pace. This is not the time to listen to your peers tell you how much or how little time they needed but the time to set the study schedule that works for you.

11 April 2009

Burn Surgery

I was the resident in charge of the burn unit and working on my daily notes for the patients that were currently residing there. There was a 19-year-old who had suffered severe inhalational burns and brain damage after the carburetor that he was cleaning with gasoline caught fire from a static electricity spark. There was a 70-year-old who had fallen asleep with a lit cigarette and sustained 25% full thickness burns to his upper torso. There was a mother who had burned her hands and face when she opened the door to her house, smelled gas and pushed her children to safety just before her house exploded. All of these patients require intensive care, intensive wound management and attention to every detail of their progress and condition. Also, some of these patients were in the process of being grafted which required operative timing and preparation.

The call came in just before lunch that a 39-year-old highway construction worker was being flown in with 96% partial and full-thickness burns to his body. This man was working in a manhole when he accidently hit a steam pipe that ruptured. He was wearing steel-toed boots which kept his feet and lower legs from the burns but just about every place else on his body was burned. This would be a major trauma to this young man and this would predict months of recovery if he would be able to recover from such a traumatic blow. In the case of burns, the patient doesn’t stop in the Emergency Department but come immediately to the Burn Unit where the staff can start treatment as soon as possible. At stop in the Emergency Department would delay initiation of the treatment unnecessarily and would expose this patient to infection because the Burn Unit is far cleaner than an open Emergency Room. He would arrive in less than 30 minutes.

The nursing staff set up one of the evaluation rooms: scrubbed stainless steel tables lined with sterile liners and warm water for removal of any clothing that might be adherent to the skin. In the field, most paramedics know that burned clothing will hold heat and continue the burn process unless removed from the skin. They will make sure that any smoldering clothing is removed and will wrap the burns in sterile dressings and drapes. The patient’s airway will be protected and two large bore intravenous lines will be inserted so that fluids can be infused as quickly as possible. The paramedics had indicated that they had inserted three 16-guage lines into this patient and has already infused 1.5 liters of fluid. The patient was intubated, stripped of clothing and wrapped completely to prevent fluid and heat loss because of the burns. They had done an excellent job in the 15 minutes since the patient has been burned. They were 15 minutes out from the hospital.

The man arrived and we quickly set to work debriding any scorched skin and clothing from his wounds. I inserted a cordis intravenous line into his internal jugular vein for even more fluid infusion and extra IV access. We also induced a pharmacological coma for pain relief (about 60% or his burns were painful partial thickness and the other 30% were full-thickness (not painful but devastating). His face was swollen and red; his hair was gone; singed by the steam. It appeared that the pipe exploded, he inhaled the hot gas and turned to his left while covering his face. His left arm and back had the full thickness burns but his eyes were in good condition. I used an ultraviolet light with dye to assess corneal damage and found none. His ears were singed red with large blisters that wept fluid. His chest and legs had partial thickness burns that needed to be debrided too. Three nurses helped me start the initial debridement process while the respiratory therapist made sure that his ventilation was taken care of.

Full-thickness burns cause the skin to take on a leathery appearance. Since all layers of the skin are totally destroyed, this leathery eschar would need to be removed. Just under this layer would be a layer of ischemic damage that would be lost unless proper fluid resuscitation had been undertaken. Our patient had an IV rate of 1,950 ml/hr in the first 8 hours because of massive fluid loss. We didn’t want to get behind and cause further damage. After the first 8 hours, we cut the IV fluid rate back to 980 ml/hr for the next 16 hours. Overall, our estimate was that our patient was 31,000 ml of fluid down because of the extent of his burns. In addition, his body was massively stressed by the injury to his lungs and fluid loss from there. He was fortunate in that he had been in excellent health before this accident. We were able to hold blood pressure and urine output adequate in the first days after his accident.

My attending burn surgeon arrived after the patient had been in the unit for about 20 minutes. He helped with the debridement and wound evaluation. Our patient was fortunate that he didn’t need an escharotomy (incisions made to release burned skin so that the patient would be able to breathe/be ventilated). After 35-minutes, we had infused several liters of IV fluid, placed the patient in a pharmacological coma for pain relief, undertaken mechanical ventilation and cleaned/dressed his wounds. My preceptor surgeon and I sat down with the nurse assigned to the patient to plan for covering this patient beginning the next day. We also had antibiotics started and had placed a feeding tube for liquid nutrition which is so vitally important in burned patients. This young man would be in a hyperdynamic state with the ultimate demands on his body both physically and nutritionally. In addition, we would need to start to cover his burned skin as quickly as possible. Our first cover would be donated cadaver skin.

Cadaver skin would be a good cover to start with but the patient’s own skin would have to be harvested slowly as he healed. As soon as donor sites would become available, we would use them and would harvest. On our first assessment, the backs of both calves were not burned along with his right upper posterior thigh. These would be harvested first. We would start on hospital day 2, harvesting skin from the donor site and covering the full thickness burned areas with cadaver skin. The patient’s own skin would be meshed and would be used to cover the partial thickness areas. We would also perform a tracheostomy as he would require mechanical ventilation at least two week and possibly three or more. He had been fortunate in that he had not inhaled carbon monoxide but he did inhale heated gases which had caused some lung damage. We hoped that this would heal and we would come to see that this damage was minimal in the next week.

At the first surgery, our team consisted of seven people: the attending surgeon, the chief resident, an intern, a nurse practitioner and three medical students. Our attending surgeon set about further debriding the burned areas after anesthesia had been induced. I performed the tracheostomy creation while the intern and nurse practitioner harvested and meshed skin for beginning the coverage. Once the recipient sites had been properly debrided and prepared, the meshed skin was applied with everyone having an opportunity to do some suturing. In the coming weeks, he would undergo more of these coverage procedures as his body rejected the cadaver skin and the donor site would allow more harvest. In all, it took about three weeks to get his would covered with his skin and to keep the donor sites healthy and thriving.
In addition to coverage, keeping infection at bay and nutrition, we had the challenge of pain relief. At first, we kept the patient strongly sedated. As his lungs began to heal, we gradually cut back on the sedation to allow him to breathe on his own. After 2 ½ weeks, he was doing well and we removed mechanical ventilation. At this point, he was able to talk with his family by covering his tracheostomy tube. With is grafts and tubes, we could see that the greatest joy for this young man was having his family gathered round for encouragement. When he was pharmacologically comatose, his wife made tapes of their children singing for their father. The nurses would play these during the daily would care and dressing changes. Any person who entered his warm room (to prevent heat loss) would have to dress in sterile garb and wear a mask. In addition, the massive facial swelling started to resolve after about a week so that his children could see him from the door. His wife had carefully prepared them for the sight of seeing their father in bandages from head to toe.

When I left my burn rotation after two months, I would stop in to see him from time to time. He said some of his first memories had been of my voice and the staff speaking with him and encouraging him. During his dressing changes, we had sung (recommended by our music therapist) along with his children and that this had been of great comfort to him. He also said that he didn’t remember having a huge amount of pain until near the end of his recovery when he started to have difficulty with some mild contractures. He continued physical therapy and when I saw him one year later, he looked fantastic. One could tell that his arms and torso had been burned but the plastic and reconstructive work that had been done on his face and ears was very nice. He was upbeat and looking forward to changing careers. He had decided to go back to school to get a degree in counseling so that he could help other burned patients. The staff in the burn unit said that he would often visit young men who were burned to tell them his story as he was recovering. He said that he thought that recovery for a younger man was especially difficult.

I still remember what this gentleman looked like when he came in and often had to look at the portrait that his wife had supplied so that we knew what he had looked like before his accident. We also saw the incredible love and support that came from his family and parents. He had brothers and sisters who took turns sitting with him and reading to him while he was comatose. This was a very close-knit family who prays for and supports each other. We saw the incredible determination in this patient and in others that have undergone this type of extreme stress and life adjustment. All of these patients taught me the value of appreciating how easy it is for me to do something as simple as walk across a parking lot or sip a cup of coffee in the morning. Often it takes weeks and months for a burned patient to even get out of bed.

And finally, taking care of burned patients is the ultimate team effort. The surgical procedures take multiple hands and personnel who have the goal of getting the burned patients covered as soon as possible. In addition, the nurses, nursing assistants and environmental services personnel in the burn units are invaluable. They have some of the strongest work ethics of any area of the hospital. If the environmental services folks were not dedicated to their jobs and doing a job well, the infection rate in these units starts to climb. Every single person “counts” when it comes to getting this massively injured patients back to health.

29 March 2009

Working and attending college...

Potential lethal combination?
Many students find themselves in the unenviable position of HAVING to work and attend college at the same time. This a a potentially lethal combination in many ways. First of all, when something starts to suffer, it generally isn’t the job and second, burnout is a strong possibility. Both of these problems can be potentially avoided if you cut back on your coursework if you find that you must work full-time. If you are a full-time employee at most jobs, you have minimal time to study in between and thus, you can’t take on a full-time course load that includes pre-med lab courses. Decide that you are going to take your time and do well in your courses while leaving yourself plenty of time to rest from both coursework and employment. No medical school admissions committee is going to give you “brownie points” for trying to do a full-time course load along with full-time employment especially if your uGPA (or postbacc) work has suffered.

Recharging your batteries
You need time to digest and assimilate the material that you are learning in your pre-med coursework. Rushing through these classes with last minute “cramming” is not going to leave you with enough time to get the material in your long-term memory so that you can apply it on the Medical College Admissions Test. You need to be able to see the subtleties of what you are studying in addition to having some time to let your brain just rest. Again, rushing through your coursework makes MCAT review on the other end a total chore instead of a progressive process that will lead to success. Take your time, recharge your brain (even take a semester off if necessary) and then come back refreshed and ready to work at very high level.

Damage control
If you are retaking courses or attempting to take additional postbacc work to enhance your application, you need to do well without exception. You can’t keep posting mediocre grades and retaking courses with the expectation that eventually you will get that A and get into medical school. If you have significant prior poor coursework to overcome, take your time and remediate one course at at time. Pair a more demanding course like Physics with something less demanding like English/Psychology. Again, if you have prior poor coursework, you can’t afford to either do poorly in your recent coursework or drop courses because you have overloaded yourself. Slow, steady excellence will bring the success that you seek.

Keeping some perspective
If you have a family to support and take care of, be sure that you allow plenty of time for them. Working, attending class and then diving for a nap on the sofa or heading for bed is not going to do much for your relationship with your loved ones. They need your undivided attention and you need to interact with them for your sanity too. Let your loved ones be your much-needed and much-desired break from your schedule. They generally don’t expect your to be on your best behavior but only want you in your basic form. Allow them to see you, hang out with you and take you away from the grind of work/study on a regular basis. You grades will be better, you will be happier and you can keep yourself reminded of why you seek your goals in the first place.

Setting goals and achieving them
The whole key to finding success in the medical school application process is keeping your eye firmly on your long-term goals. I have stated in other posts that the process is like having 100 pounds of weight to lose. It isn’t going to happen overnight and you must take small steps on a daily basis to stay on track. It’s easy to get off track by the demands of work but you can’t achieve your goals by letting this happen. This means total organization and total commitment to the task at hand, be it work your studies. If you are at work, you give your work your full attention. When you attend class, you give your classwork the attention that it demands. It’s neat to be able to multi-task but most people are not able to work at a high level and achieve those A grades that you need for medical school admission at the same time. Again, if you work full-time, don’t expect to attend school full-time. If you attend school full-time, don’t expect to work full-time. The end result is that you wind up doing both things at a mediocre level which won’t allow you to achieve your goals.

There are no “points” for getting this process “almost” right. The level of academic achievement that is demanded of a potential medical student is getting higher every year. The MCAT is getting more competitive as many students are taking prep courses and spending more time preparing for this exam. You can’t expect to be competitive next year with this year’s work because the bar will move higher. If you are attempting to upgrade your credentials, then you need to do a complete overhaul and put up some good academics (even one course is better than nothing). Don’t expect to be the exception to any of the rules in this process. You are not generally in a position to be objective about yourself and your abilities. Make sure that you get some honest and objective advice. Trying to self-evaluate is like asking your Mum if you are a great kid. Of course, she’s going to answer in the affirmative but it’s far better to get someone who doesn’t know you, to look over your things (like a good academic adviser who knows the pre-med climate). Allow plenty of time for getting your work done at a high level and you will see movement toward your goals without sacrificing your employment records, your sanity or your soul.