It’s Monday morning. My first day on my new rotation, Neurology. Neurology is the study of the Nervous system, for example, the brain, the spinal cord, and nerves. It’s one of those things that I think is really interesting and fascinating… but really hate to study. It’s really a complicated mess trying to understand how everything works.
So I’m not exactly EXCITED to start Neurology. But I know that the hours are better and I’m looking forward to having a little bit of a break in terms of workload.
We start off the day with Orientation. It’s really quite painfully boring. We get handed about 20 sheets of paper. And the girl that is leading our orientation is somewhat new. So she doesn’t really seem to know what she’s talking about.
We then have one of the Residents come in and talk to us about a typical neurological exam. It is awful. She is describing every single step of it in boring, monotone detail. And I want to stab myself. It is a struggle to stay awake. Even with 20 oz of Starbucks coursing through my vein. I think I may have to upgrade to crack.
When we are done with orientation, we get 3 hours off until we have to report to our service! Okay. So maybe I’m kind of liking Neurology at this point. It’s funny to see the faces of people just coming off of surgery. The minute they get anything resembling a break, they get giddy. We were walking around looking at each just grinning from ear to ear.
At
It’s really interesting. We are seeing a patient who has been admitted to the psychology floor. We are examining her for possible seizures. She tells her story… and there’s just something not right about it. And it doesn’t fit what others are saying about it either. She also tells us that she has a disorder called acute intermittent porphyria (AIP), which is a disorder of the blood, where your body is missing certain enzymes for producing hemoglobin. This disorder can actually cause some psychiatric issues. The problem is… she has several other psychiatric problems… including hallucinations. Apparently she goes into these spells where she is going into a deep hallucination… but she also continuous hallucinations throughout the day. So it’s really hard to figure out what exactly is going on with her. If this sounds confusing, it’s because it really really is. I am trying really hard to figure out some idea of how this story fits… and I am completely at a loss.
When we are done with taking the history and the physical exam, we walk outside and our AI asks me what I think. And I tell him, I don’t know… but I kept having the feeling that she was faking at least part of the story or the symptoms. My AI says, yup. And he tells me about different parts of the exam that he did to kind of see if she were faking. There are some things that she said she felt during the physical exam that just aren’t possible. I thought that was pretty cool. We find out later that she doesn’t even have AIP. We also find out that the nurse saw her during her so-called seizure… and says it was nothing like a seizure at all. Plus, in addition to her so-called seizures… she also sees people around her all of the time. Imaginary people. These people, she says, will walk through walls or will be cutting up other people. She also says, she sees the floor opening up and sees herself getting sucked into it. Pretty interesting. We still have to go through an entire physical workup just to make sure. But after ordering all of the tests, they let us go home. Not a bad first day.
My morning starts off interesting. In the middle of rounds, we get a page for a possible stroke patient in the ER. I go down with one of the senior residents to see
He also has some serious problems with his kidneys. I kind of feel like we’re trying to untangle a big mess of Christmas lights…. It’s just so hard to figure out where to start.
Working
I’m home by
During rounds today, I witnessed an interesting thing. We were going to see a 54 year old man named Mr. JA. Mr. JA was celebrating his birthday in the typical way… party, cake, booze, pot, and cocaine. At some point, he became confused and appeared to have what we describe as “altered mental status.” This means that there appears to be something not right about him from a mental standpoint. It can be due to a lot of things, but they usually call in a neurology consult for these things. He had a history of strokes in the past, so the ER docs were worried that he might have had a small stroke. I’m thinking it might have had a lot to do with the booze, pot, and cocaine. But I’m just a medical student. What do I know. When we go to check on him during rounds, we see this old frail looking man. I can’t imagine him doing pot and coke. He starts talking about when he had a spinal tap. And he says that he is still traumatized by it to this day. And as he talks about it, he asks our attending, why the doctor who did his spinal tap did that to him. And things start getting really weird. He starts asking the attending over and over again, “why did that doc do me like that?” And an interesting thing happened. This frail old man, started getting kind of fierce… and intense… and all of a sudden… I found myself kind of afraid of him… it was unreal. Our attending does a great job of playing all of this off in a nice easy going way… but things have taken a weird turn, and there’s no going back. During the neuro exam, one of the things that we check for is muscle strength. And when our attending asks Mr. JA to put his arms up, Mr. JA asks him, “you sure you ready for that?” and gives him one of the scariest looks I’ve ever seen. As our attending tests his strength, Mr. JA takes a swing at him. It’s not a very good swing, and our attending doesn’t have to do much to avoid getting hit. But he immediately says, “okay, we’re done,” and we leave.
Later that day, we get a request for a consult and it’s my turn to do one on my own. My patient is a Mr. JK who was in his house and collapsed. No one knows exactly what happened. He’s not really fully conscious, but he’s also not really with it either. I go to the ICU to examine him. This is really the first time I have ever gone in to see a patient who I couldn’t talk to. It’s… a challenge… I didn’t think it was a big deal when I went down… and in some ways you would think that the physical exam is easier, because they can’t see you mess up or be clumsy. But it’s actually really awkward trying to move around all of the tubing and stuff. It’s hard to really know if you’re doing the right thing. And when I’m done… I have no idea what the heck is wrong with him.
As I sit at the nurse’s station trying to figure out what the heck I saw, his nurse comes up to me and we talk… and she asks me what I think… I laugh and I say, “You’re kidding, right?” But she says I look like I know what I’m doing. It’s flattering… but pretty misguided. The interesting thing is when I examine his chest, I see old surgical scars… and I recognize the scars right away… he had a CABG! I tell my intern that and he asks me how I know it wasn’t just some heart surgery and I point to some different scars on his chest and then I show him the scars on his thigh. There’s just no substitute for actually having been involved in one of these surgeries.
I start to just think of all of the possible scenarios. One of the tricky things about Mr. JK’s exam is that he is on some medication that puts your nervous system to sleep. So I can’t tell if he has some problems with his nervous system or if it’s the medication. The nurse asks me if I want her to stop the IV for a little while. I’m amazed at how much this scares the crap out of me. I laugh and I tell her that it’s probably a really good idea that she has, but that as a student, I am way too scared out of my mind to decide that. She laughs with me, and I tell her I’ll check with my chief.
When I present the patient to my chief, I am surprised at how confident I sound. It’s weird how just being in the hospital for a few months starts changing the way you carry yourself. You almost become smarter in ways that you can’t begin to see or feel. He agrees with me and we tell the nurse to hold his IV medication for a little bit. We then go down together and do a full exam on him. He teaches me a ton about how to describe what I am seeing. It’s really refreshing having a Chief that is actually interested in teaching. When I show him how I know he had a CABG, he seems really impressed.
I go home at
Before rounds get started, I go to see Mr. JK. It’s cool, because I walk into the ICU and he has the same nurse. She comes up to me and we start talking about him. It’s so weird to be in this position, where an ICU nurse with all of this experience is deferring to my knowledge and asking me my opinion. I’m not used to being in this position. I try not to act like a tool. I also try not to act like a total idiot either. I know more than I think. I am aware of this.
Mr. JK is definitely more awake. I’m able to talk to him a little bit. As I try to find out more of his story, I find that it’s tricky… because he really fades in and out. As I’m checking whether or not he has feeling at different parts of his body, I get the feeling that he may not be answering completely honestly… not that I think he’s lying… I just think he’s still too groggy to give me real answers. So I do some stuff where I’m not really touching him, but I ask him if he can feel me touching him. He says he can… So I know he can’t really tell… I feel a little devious… but I also feel really clever.
I present him on rounds and I go through my assessment and plan… which is where we say what we think is going on and what we want to do. Basically, I want to do several tests on him to rule out some simple stuff that we might be able to fix quickly, but I’m leaning more towards, some sort of fainting spell because of his cardiac issues, a seizure, or a mini-stroke. When we go see Mr. JK, our attending does a full exam. And he agrees with my assessment and plan. He also adds a couple more while we’re there. It’s a great feeling. His nurse comes up to me and we’re chatting and I let her know what we’re going to do. I guess I have to start getting used to being the one that gets asked about the plan… it’s an interesting feeling. Honestly, it’s incredibly flattering… and yet… it’s really scary. It’s a lot like the first time you ride a roller coaster… you’re scared the entire time, but you’re also really excited. I wonder if every 3rd year medical student feels like this or if this is just my own special kind of goofiness…
After lunch, we don’t have much going on, so I go to study at the Medical Student Study/Computer Lounge called CBIL. While I’m there, I see a girl making photocopies. And I see the stuff she’s copying… and I recognize the material as being the graduate school stuff I had to do to get into medical school. So I ask her if she’s in the certificate program. She laughs and says, yes! I talk to her a little bit about the certificate program and the pros and cons. And I offer up some words of advice and some words of encouragement. It’s a little thing… but I love the feeling you get when you are able to help someone who is walking through a patch that you have walked before.
I’m on call tonight. I’m not really sure what to expect. So after studying at CBIL, I change into scrubs and then go up to the Team Room. I run into one of the residents on call and he tells us to go to the ER because there is a lady that we were just called about with ALS. ALS stands for Amyotrophic Lateral Sclerosis and is also known as Lou Gehrig’s Disease. It is a disease where your nerves that control muscle movement start to die. It’s one of those diseases that you hear about in medicine all of the time, but I have never seen a patient with it. As I go down to the ER with the other student on call, I get pretty excited to think I’m going to get to see this disease in an actual person.
When I get to the ER, the patient is a 79 year old woman named
We spend some time talking with them. And I can’t help but just hold her hand. What an awful disease for anyone to have. And the thing is… there is NOTHING we can do about it.
When our Resident comes down to talk to them, it is painful to watch. He is a really nice guy and he is incredibly smart. But he is from a different country and he doesn’t really know how to ask questions in a way that a non-medical person can answer. For example, he asks her if she’s noticed any fasciculations. ????? He asks her if she’s noticed any wasting. ????? He asks her if she’s noticed herself laughing or crying inappropriately. ???????????? How does someone answer a question like that? The whole time, she looks at me (because even though she can’t talk, she can hear perfectly well) and has this expression on her face like, what the hell did he ask? I do my best to translate. It’s not easy.
When our resident does the physical exam, he shows us a lot of the specific physical findings that are unique to someone with ALS. It’s a really good learning experience. But I still feel guilty about learning it at the expense of
When we’re done, we decide to put a tube down her nose, down her throat, and into her stomach, so that we can start some nutrition on her. Later on, she will get a feeding placed surgically. Her case makes me incredibly sad and I have a hard time shaking it.
I go to the call room. When we’re on call, we’re not alone. We’re usually on call with people who are on other rotations. Two of my friends on Psych rotations are on call. We decide to go to McDonald’s and get ice cream before they close. On our way down there, we get in line and all of a sudden their pagers go off… but not mine. I wave goodbye to them… and very happily order my Oreo McFlurry. It’s the best tasting McFlurry I’ve had in a long time. Why does it taste so sweet when others get paged and I don’t? I guess I’ll never know.
I don’t get paged at all over night. My other Neuro friend gets paged at
After waking up from being on call, I get some breakfast and go to evaluate Mr. JK. He’s been moved out of the ICU which is a good thing. He’s on a regular medical floor. I go to see him… and I am amazed at how good he looks. He is much more alert and he remembers me and he remembers that I have been coming in to see him. For the first time, he knows the date correctly. I get a little bit more detail about what happened to him. And it sounds like he fainted and/or had a little seizure. This would explain why he was so confused for 2 days. He’s doing a ton better and I am very happy.
At rounds, our attending looks at me and asks me if I was on call. I tell him yes. He tells me to present my patients and present whatever topic I was supposed to teach everyone about and then go home. I’m out of there by
So I’ve finished my first week of Neurology. The hours are a million times better than anything I had on surgery. It’s a little boring at this point. But I love the fact that I go to work like everyone else in the world, I eat lunch at lunch time every day, and I get home before normal dinner time.
Seeing that girl in the Certificate program was good for me. It was another reminder of where I was… and made me appreciate where I am now…
I kind of feel like I was in an episode of “House” this week. Only, the ending wasn’t as satisfying as the TV show. Plus… and this is important… the diseases suck a lot more and in reality… there’s so much less that we can actually do for people.
