Evidence-Less Medicine

"The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head."
-William Osler

It's common to hear physicians say that medicine is an art and not a science.  In spite of evidence-based medicine (EBM) being all the rage these days, a whole lot of what we do is based on expert opinion, what we think should theoretically work, anecdotal experience, and unabashed personal preference.  Most laymen don't realize just how unscientific medicine really is, and sometimes that leads to a huge disconnect between patient expectations and physician expectations.

I struggled with a great example of this phenomenon while on my OB rotation.  During the first stage of labor, the mother's cervix dilates from somewhere between 0-2 cm up to 10 centimeters.  This is a process that takes several hours, and sometimes even a day or two.  As you might expect from the name, being in labor for so many hours is exhausting for the patients, both physically and emotionally.  It also gets more painful as the fetus descends lower into the mother's pelvis and the contractions get stronger.  Most of the patients understandably want to be reassured that things are progressing well and that there is an end in sight.  The way we assess labor progress is by performing cervical checks on a scheduled basis.

To perform a labor check, the examiner (generally a resident, attending, or nurse) puts on sterile gloves and inserts two fingers into the patient's vagina.  The examiner then measures the width of the cervical opening based on how far he or she can spread the two fingers apart.  This is a highly subjective and imprecise process.  We don't all have fingers that are the same size, and it's not uncommon for two experienced examiners to differ by up to a centimeter in their measurements, especially when the cervix is over halfway dilated.  Throw an inexperienced examiner like me in the mix, and the lack of precision becomes even greater.

Because of this imprecision, we sometimes ran into a situation where the second examiner told the patient that she was less dilated than the previous examiner said.  The patients would understandably get very upset by this, as it seemed to imply that not only was their labor not progressing, but it was even going backward.  After the first time I accidentally did this to a patient, I always asked the patient how far the previous examiner had said she was dilated before I did my exam, and I never said she was less dilated than that.  Sometimes I'd tell the patient that her cervix was a centimeter more dilated than what the previous examiner had said, even though I wasn't totally sure if it had actually changed.

The problem was that many patients thought our labor checks were precise measurements of cervical dilation.  But the more dilated the patient's cervix got, the harder it became to know what the actual measurement was.  As I already said, even experienced examiners can differ by a centimeter or so in the later part of Stage 1 labor, and I was sometimes off by two or three centimeters.  I didn't want to give a patient the wrong impression that her cervix was contracting instead of dilating.  To add to the confusion, sometimes the size of the cervical opening really did change during the period of time between two examinations.  And even if I had wanted to explain why examiner #2 gave a smaller measurement than examiner #1, a woman in active labor is not usually up for having a philosophical discussion about why different examiners might tell her different numbers.

I never really learned the finer points of cervical measurement late in the first stage of labor, and it ultimately doesn't matter to me if a patient's cervical dilation is eight centimeters versus nine centimeters anyway.  I realized partway through the rotation that what I really need to know as an emergency physician is how imminent the delivery is.  If I do my exam and find that the cervix is only partially dilated, that means I probably have enough time to get the patient up to the L&D floor before she delivers.  But if I feel caput and hair, that means I'd better gown and glove up pronto.  Telling partially dilated cervix apart from caput and hair is very easy and completely objective.  There is no such thing as a hairy cervix!

It's a Beautiful Noise

"An ugly baby is a very nasty object - and the prettiest is frightful."
-Queen Victoria

I'm working nights now, and it seems like what I had heard about more babies being born at night versus during the day is true.  This week alone, I have participated in almost as many deliveries as I did during the first two weeks combined.  I'm also well over the minimum fifteen deliveries that we are required to do during the rotation, which prompted me to ask the chief if that meant I could have next week off.  She rolled her eyes at me and said, "I don't think so."  Well, I thought it was funny, anyway.

As interns, we are only involved with the low risk deliveries, while the junior and senior residents take on the higher risk patients.  There was one night where we had four low risk patients in labor all at the same time, and my med student and I were running from room to room like crazy checking on them all.  Of course, they all delivered at almost the same time too, which was around 4 AM.

Maybe it was the time of night, and maybe it was just the timing, period.  But I was a little freaked out by how much deja vu I seemed to be experiencing.  Patient #1 delivers first, and the baby is in the warmer, crying.  (You'd be crying too if someone just smeared erythromycin ointment in your eyes, and then stabbed you in the thigh with a gigantic needle to give you a shot of vitamin K.)  We were congratulating the parents, and the mother says, "Is it weird that I love hearing her cry?"

Now, you have to understand that to me, a crying newborn sounds kind of like a lamb bleating, and it's not an especially pleasant sound at all.  The worst is when one of them starts crying in the nursery, and then the whole nursery-full starts wailing.  That is a grating, nails-on-chalkboard kind of sound.  But by this point, I've heard enough newborn bleating that I can kind of tune it out.  I can even tune screaming women in labor out.  So I said, "No, it's not weird at all.  Though you may not feel this way in a few weeks!"  She and the father laughed and agreed.  I filled out the paperwork, and just then, a nurse poked her head in to tell me that my patient in the room next door was also pushing and the baby's head was starting to crown.

I ran next door, gowned and gloved, and there was delivery #2 for that night.  The baby was in the warmer, crying, and the mother turns to me and says, "Is it weird that I love hearing her cry?"  What I wanted to say was, "Yes, it's weird, and what weirds me out the most about it is that the lady next door asked me the exact same question half an hour ago!"  But I didn't.  Instead, I smiled at her and said, "No, it's not weird at all.  Though you may not feel this way in a few weeks!"  She and the father laughed and agreed.  I filled out the paperwork, and just then, a nurse poked her head in to tell me that my patient in the room next door was also pushing and the baby's head was starting to crown.

I made a hasty exit to room #3, vowing to avoid discussions about the auditory aesthetics of babies crying at all costs....

Medicine Is Disgusting

"Watching a baby being born is a little like watching a wet St. Bernard coming in through the cat door."
-Jeff Foxworthy

I'm now halfway done with my OB rotation.  Our schedule in EM is a week off from the OB residents' schedule, so my entire team changed over from the week before.  The other intern who worked with me this week was the same OB intern who was working in the ED with me last month as an off-service intern, and it was nice to see her again.  It also made for the rather odd situation where she was showing me how to use the electronic medical record and charts on my first day in the ED, and I was showing her how to do the same thing on her first day in OB.

Some of the OB residents and I had an interesting discussion at one point about which field is more disgusting: EM or OB.  I argued that there is nothing more disgusting than delivering a baby: you always have some combination of blood, mucus, amniotic fluid, urine, and feces (both the mother's and the baby's) covering you from head to toe after each delivery.  Plus, the infant is born covered with vernix, and its skin is gray, both of which conspire to make it look like some kind of creature from Gremlins.  And the mother is often screaming  the whole time, which makes for a less than pleasant backdrop to this ghastly scene of childbirth.  What do we do in the ED that could possibly beat a delivery in terms of sheer disgustingness?

One of the OB residents countered with abscesses.  Abscesses?  Come on!  Incision and drainage of pus from abscesses is THE best procedure to do in the ED.  You can literally cure a patient in about ten minutes.  They come in with a lot of pain and swelling; you numb them up, cut the abscess open, and poof, all better.  Plus, an abscess only contains one body fluid (or maybe two if you count some bleeding), neither of which includes feces.  She pointed out that abscesses can smell pretty bad too, which I had to concede.  I have opened up some abscesses that smelled bad enough to make my eyes water.  But worse than feces?  You've got to be kidding.

It occurred to me later that what it comes down to is that all fields of clinical medicine are disgusting.  Really, what body fluid is there that is beautiful, pleasant smelling, and nice to have all over you?  I guess if I had to pick the least offensive body fluid, I'd go with urine.  Assuming the patient doesn't have a urinary tract infection, at least urine is relatively sterile.

Starting OB

"Anyone who hates children and animals can't be all bad."
-W.C. Fields

When I was in medical school, there were a few rotations I really liked and several that I thought were ok, but only one that still makes the hair stand up on the back of my neck whenever I think about it.  That would be obstetrics and gynecology.  Part of what I disliked about obstetrics (OB) was the medicine itself, and part was the malignancy of the environment.  So you can understand why I had some trepidation about being an off-service intern on OB.  (An off-service intern is an intern from one specialty who is doing a rotation in another specialty.)

Now that I have finished my first week of OB as a resident, I'm relieved that so far it hasn't been nearly as bad as I expected.  (Of course, my expectations were so low that it would have been hard for the rotation to be worse than I was expecting.)  The biggest thing that has made my residency OB experience better is that I like the people I'm working with.  The residents have been very helpful and understanding, especially on the first day when I had no idea what to do.  We also have two third year medical students rotating with us, and they showed me where to find supplies and helped me write notes as well.

Another major reason is that my being there has a purpose.  There is a job that the team needs me to do, and I am there to do it.  This was not the case when I was a medical student; the work went on just as well without my presence as with it, and probably more efficiently without me. It's easy to feel like you're in the way as a student, especially when the residents are busy and not really thinking about giving you a job to do.  I don't have that feeling as a resident.  Feeling useful, feeling like a part of the team, makes a big difference in terms of how important the work seems.

I still don't enjoy the medicine part of OB.  I sometimes joke that I don't like women, don't like babies, and don't like women having babies.  But I don't hate OB either, and I feel like what I'm getting out of the rotation is worthwhile, even though it isn't always fun while I'm going through it.

A Normal Day

“The trouble with normal is it always gets worse.”

-Bruce Cockburn 

I'm officially done with my first rotation, and every shift has been just as crazy and hectic as the first one.  I'm not sure if it has really gotten any easier.  Sometimes it seems like the only difference is that now I'm a little better mentally prepared for the organized chaos I encounter every time I go through the revolving door into the ED waiting room.  Several people have told me that this is not what the ED is normally like, but I already know better than to believe that.  It's like when a doctor tells a patient that this won't hurt, right before stabbing them with a syringe of lidocaine.  Of course it hurts, at least until the numbing effect of the lidocaine kicks in.

When I press people to explain what the normal ED shift is like, I can't really get a good answer except for something along the lines of, "not like this."  Presumably, normal means that there are fewer patients.  Not only that, but fewer patients with non-urgent complaints.  I can identify with wishing there were fewer patients.  There is just a feeling of desperation that I get every time I look at the growing list of patients in the triage area when I'm already stretched thin in too many directions as it is.  As for too few urgent patients, that doesn't seem like a problem to me at all.  I have already helped care for patients who were sick enough to be admitted directly to the intensive care unit (ICU), and also patients who were sick enough that they didn't make it to the ICU.  Spending every shift caring only for these high acuity patients would be more than I could cope with, at least right now.

So the main issue seems to be one of patient volume.  But what does it even mean to say that the ED volume is above normal, anyway?  It's not like the number of annual visits to the ED is a static number.  In fact, we know that the number of yearly ED visits in Massachusetts has continued to increase even though a state health care reform plan was enacted in 2006.  In other words, this increased volume isn't some kind of aberration.  It's now the new normal.

The Flying Ambulance

“...The helicopter symbolize(s) the victory of ingenuity over common sense.” 
~Montross, Lyn and Prouty, Ray, U.S. Marine Corps Helicopter Experience, p. 20.

You may recall that a few weeks ago, I was half drowned to death and the other half scared to death while going through dunker training.  (Click here to read about it.)  This week, I had my first LifeFlight shift and went on three helicopter flights.  LifeFlight is the UMass emergency medical helicopter program.  Each flight has a three-person crew consisting of a pilot, a flight nurse, and a resident.  I was a fourth person going along mainly to observe.

I will admit to being skeptical about the value of the emergency medical helicopter experience for residents in general, and even more skeptical about the wisdom of my physical presence on a helicopter.  UMass is one of the few EM residency programs in the country that requires residents to serve as flight physicians.  So I think it's fair to ask why, if being a flight physician is such a valuable experience for residents, more programs don't require it.  Not only that, why are some programs eliminating resident helicopter flying altogether?  The answer to the second question is because of the large number of emergency medical helicopter crashes that have occurred over the past several years.  (For example, click on the Program Highlights tab to see Indiana University's statement about why EM resident involvement in their air ambulance program was suspended.)

All of that being said, I came to this program knowing that flying on the helicopter was required, and it's obviously a bit late to back out now.  But as I strapped myself in for the first flight, I took the time to study how to open the emergency window exit.  Just a precaution, you know, in case I had to put my dunker training to use.

The flight itself was completely uneventful, and surprisingly enjoyable.  I had been worried about getting motion sick, but this was not an issue.  Our first transport was from an outside hospital (OSH) that had its own landing pad.  The patient was being transferred to UMass for more advanced treatment of a serious medical condition.  The resident and flight nurse helped the hospital staff prepare the patient, who was unresponsive, for transport.  We took the patient outside, loaded everything (patient plus equipment) onto the helicopter, and took off.  I went on two other flights, one for a patient who suffered trauma in a car accident, and the other a hospital-to-hospital transfer like the first flight.

Wherever we went, a crowd of onlookers gathered.  It amused me every time to see them shielding themselves from the wind created by the rotor downwash, which is a lot more powerful than I (and evidently they) had realized.  In addition, watching the upper level resident, I was able to appreciate why there could be some value in residents participating in LifeFlight.  When you're at a scene, there is no attending standing there telling you what to do; there is no team of nurses and techs to back you up; and you do not have the luxury of using much of the advanced equipment that is available in the ED.  Several of the program graduates have told me that participating in LifeFlight gave them tremendous confidence in their ability to handle emergency situations.

I still don't think that my education would suffer greatly if the residents were suddenly pulled out of the LifeFlight program.  However, I don't see the time spent working on LifeFlight as something that detracts from my education any more either.  I also have a better understanding of why the opportunity to fly is such a huge draw for many applicants to this program.

These Dreams Go On

"All the things one has forgotten scream for help in dreams."
-Elias Canetti 

A friend of mine who spent a year studying abroad once told me that the way you know when you've become fluent in another language is when you start dreaming in that language.  I only wish that this could be the criterion for fluency in the duties of internship, because I have been having all kinds of crazy emergency medicine dreams.

First, there are the "left the house without any underwear on" dreams.  Only for me, the issue is always that I have forgotten to show up for a shift.  Every day upon awakening, I have this brief period of disorientation when I'm wondering where I am supposed to be right now.  Even on my days off, my first panicky thought as soon as I wake up is, "What time is it?  Did I oversleep?"  The fact that my shifts constantly change times (overnights last week, afternoons this week, days next week) does not help things.  Neither does the fact that the summer days in Massachusetts are so long that it's just as light out at 5 AM as it is at 5 PM.  It also doesn't matter in the slightest that in real life, I have not ever forgotten about an upcoming shift, or even been late for a shift.

Next, there are the "scary monster" dreams.  Only in my case, the monster comes in the form of a grotesque patient encounter.  Sometimes it's the patients themselves that are grotesque.  In one version, I walk into the room, only to find that the patient's limbs have fallen off.  I start frantically trying to put them back on again before the attending finds out that I have let the patient fall apart.  Other times, I am the grotesque one.  I catch my reflection as I walk by the window, and I have no face.  (Don't ask how I can see myself when I don't have a face--no one ever said that dreams were rational.)  Then there are the attendings, who can easily be transformed to gremlins, goblins, and trolls of all kinds.  Some of these transformations require less imagination than others.

Finally, there are the "trapped inside and can't get out" dreams.  I'm wandering around the ED, which has turned into a gigantic warehouse filled with screaming, crying, cursing people in johnnies.  It's time for me to go home, but I can't find the exit.  Nothing I see looks familiar, and the more I walk around, the more lost I get.  (That one is actually not so far from reality, because I have gotten lost in the hospital several times in the last few weeks, including twice within the Emergency Medicine administrative suite.)

I'm not sure if the reason why my dreams are so vivid and detailed is because I'm writing them down.  But anecdotally, having dreams about residency seems to be fairly common.  I overheard another resident complaining about how she hates that even when she is away from work, it's like she didn't leave, because she still dreams about being in the hospital.  The resident she was telling this to agreed, saying that the same thing happened to him.

Hopefully, all of this dreaming means that I'm learning something.