The "Audience response questions" did not work very well. No one responded! haha
Truthfully, it's not fair of me to ask people what they would have done... it's a hard topic and it would not have been anonymous. In class, we voted with clickers and there was no way to tell who said what. But I'll tell you how I voted, and then what actually happened in these two real cases.
In the case of the newborn Down syndrome whose parents refuse the life saving surgery, I would
b. Apply for court appointed guardianship so that an operation can be performed to save the child’s life.
I think this would cover the legal aspect of going against the wishes of the parents and give the child a chance at life. What actually happened was:
e. Leave the child at hospital B to die under the care of the house staff and nurses
It was explained that this was the decision of the medical team involved. They felt this was the most ethical choice. It makes me really sad.
In the case of the 25 year old severely burned in a motor vehicle accident and wanted his doctors and nurses to end his life, I would
d. Request psychiatric consultation to declare the patient incompetent to make decisions regarding his own care
... with the caveat that I wouldn't be pushing for the consultation to automatically declare the patient incompetent, rather be trying to determine if the patent was competent enough to make the decision to end his life. My feelings are that I would want to be able to make my own decisions about my life and care if ever in such a painful, devastating and unbearable situation. Therefore, this man should be allowed to make his own decisions if he was competent enough to do so.
What actually happened was the b. Consider the patient incapable of requesting withdrawal of care and continue regardless of patient wishes. The patient, Dax Cowart, is famous in the medical ethics world. Should the patient have the right to die? Dax subsequently went on to get married, go to law school and fight for the rights of patients to choose their fate.
Monday, November 22, 2010
Tuesday, November 16, 2010
What would you do?
From Dr. M's lecture today on Medical Ethics:
Case 1: Audience response question
Newborn with Trisomy 21(Down syndrome) transferred from hospital A to hospital B. Unable to keep food down, vomiting solid and liquid foods. Duodenal atresia (small intestine malformation), complete blockage beyond stomach. Surgical recommendation to relieve obstruction.
Parents refuse, citing:
• poor future quality of life for child
• additional drain on family’s resources away from other children
• the child is “as God made him” and it is God’s will that the child should be allowed to die on its own without intervention
What would you do?
a. Refuse to accept the parents wishes: repair the small intestine
b. Apply for court appointed guardianship so that an operation can be performed to save the child’s life.
c. Send the child to die at home with its parents
d. Transfer the child back to die in the initial hospital (hospital A)
e. Leave the child at hospital B to die under the care of the house staff and nurses
f. Administer lethal doses of medication to the child to end its life quickly as an alternative to starvation and dehydration.
Case 2: Audience response question
25 year old military pilot involved in motor vehicle accident with father, both engulfed by flames. His memory of scene of accident:
"I was burned so severely and in so much pain that I did not want to live even in the early moments following the explosion. A man who heard my shouts for help came running down the road, I asked him for a gun. He said, 'Why?' I said, 'Canʼt you see I am a dead man? I am going to die anyway. I have got to put myself out of this misery.' In a very kind and compassionate caring way, he said, 'I canʼt do that.”
Patientʼs father dies en route to hospital. Throughout his hospitalization and rehabilitation, he asks his doctors and nurses to end his life because he is in unbearable pain and knows that he is blind and deformed.
What would you do?
a. Respect the patient’s wishes and administer a lethal dose of morphine and barbiturates
b. Consider the patient incapable of requesting withdrawal of care and continue regardless of patient wishes
c. Consider the patient incapable of making informed decisions and defer to closest relative: his mother
d. Request psychiatric consultation to declare the patient incompetent to make decisions regarding his own care
e. Transfer the patient to another burn treatment facility
Please include your reasoning for your answer(s).
Case 1: Audience response question
Newborn with Trisomy 21(Down syndrome) transferred from hospital A to hospital B. Unable to keep food down, vomiting solid and liquid foods. Duodenal atresia (small intestine malformation), complete blockage beyond stomach. Surgical recommendation to relieve obstruction.
Parents refuse, citing:
• poor future quality of life for child
• additional drain on family’s resources away from other children
• the child is “as God made him” and it is God’s will that the child should be allowed to die on its own without intervention
What would you do?
a. Refuse to accept the parents wishes: repair the small intestine
b. Apply for court appointed guardianship so that an operation can be performed to save the child’s life.
c. Send the child to die at home with its parents
d. Transfer the child back to die in the initial hospital (hospital A)
e. Leave the child at hospital B to die under the care of the house staff and nurses
f. Administer lethal doses of medication to the child to end its life quickly as an alternative to starvation and dehydration.
Case 2: Audience response question
25 year old military pilot involved in motor vehicle accident with father, both engulfed by flames. His memory of scene of accident:
"I was burned so severely and in so much pain that I did not want to live even in the early moments following the explosion. A man who heard my shouts for help came running down the road, I asked him for a gun. He said, 'Why?' I said, 'Canʼt you see I am a dead man? I am going to die anyway. I have got to put myself out of this misery.' In a very kind and compassionate caring way, he said, 'I canʼt do that.”
Patientʼs father dies en route to hospital. Throughout his hospitalization and rehabilitation, he asks his doctors and nurses to end his life because he is in unbearable pain and knows that he is blind and deformed.
What would you do?
a. Respect the patient’s wishes and administer a lethal dose of morphine and barbiturates
b. Consider the patient incapable of requesting withdrawal of care and continue regardless of patient wishes
c. Consider the patient incapable of making informed decisions and defer to closest relative: his mother
d. Request psychiatric consultation to declare the patient incompetent to make decisions regarding his own care
e. Transfer the patient to another burn treatment facility
Please include your reasoning for your answer(s).
Thursday, November 11, 2010
It's Fall!
They told me these 4 years will fly by. I won't believe it when I'm finally graduating with my M.D. After only 3 months, I fully realize the truth in that statement. I can't believe we're already into November! I LOVE the fall! While growing up, the fall = a new school year. In Olean, NY September meant leaves changing colors, crisp breezes and back-to-school shopping at the Outlets or in Buffalo with my mom and sisters. (which begs the question: if I'm still starting a new school year in the fall, why no back-to-school shopping with my mom and sisters?!?!)
Anyway... here in Baltimore it doesn't seem like fall until well into November. So here we are! Finally. Last night, while studying for my metabolism exam (read: boring), I made (homemade!) hot chocolate, lit the Yankee candle that smells like apples and put on my favorite slippers. It was awesome!
Shout-Out to Kristen and Kathy for getting me addicted to the homemade hot chocolate they give out at Christmas:
Much of the reason my life is flying by can be attributed to the pace of the curriculum. Our "blocks" are 5-8 days long. Meaning a new topic, new teachers, new section leaders, and a new style every week or two. Today we had a metabolism exam (a block I wasn't particularly fond of, mostly due to the lack of organization of the faculty... how can posting powerpoint slides be that difficult!?), and tomorrow we start genetics. Then next Friday, a week from tomorrow, we have our genetics test. WOW.
In addition to that science-y curriculum, we are at the climax of our clinical skills curriculum. The day after my Thanksgiving Break I will perform a head-to-toe physical evaluation on a standardized patient. Get ready! To prepare for this we went to the hospital this past Monday to interview an inpatient and do an abbreviated physical exam. This patient has lupus, an autoimmune disease where the body attacks it's own cells and tissues. The patient had severe connective tissue disorders that caused hardening of the skin and bones and kidney failure among other things. He was so wonderful to interview. He was patient, kind, and understanding of our inexperience. When we asked him to let us know if he felt uncomfortable while we were examining him, his quote was, "You're probably more uncomfortable doing this than I am." Check.
Anyway... here in Baltimore it doesn't seem like fall until well into November. So here we are! Finally. Last night, while studying for my metabolism exam (read: boring), I made (homemade!) hot chocolate, lit the Yankee candle that smells like apples and put on my favorite slippers. It was awesome!
Shout-Out to Kristen and Kathy for getting me addicted to the homemade hot chocolate they give out at Christmas:
Homemade Hot Chocolate Mix
Ingredients:
1 large can of Nestle Quick Choc. Mix (32 oz?)
1/2 bag confectioners sugar
11 oz container of non-dairy coffee creamer
8-10 qt. box dry milk (Sanalac brand is best)
Combine all ingredients together in LARGE bowl. Blend well.
Much of the reason my life is flying by can be attributed to the pace of the curriculum. Our "blocks" are 5-8 days long. Meaning a new topic, new teachers, new section leaders, and a new style every week or two. Today we had a metabolism exam (a block I wasn't particularly fond of, mostly due to the lack of organization of the faculty... how can posting powerpoint slides be that difficult!?), and tomorrow we start genetics. Then next Friday, a week from tomorrow, we have our genetics test. WOW.
In addition to that science-y curriculum, we are at the climax of our clinical skills curriculum. The day after my Thanksgiving Break I will perform a head-to-toe physical evaluation on a standardized patient. Get ready! To prepare for this we went to the hospital this past Monday to interview an inpatient and do an abbreviated physical exam. This patient has lupus, an autoimmune disease where the body attacks it's own cells and tissues. The patient had severe connective tissue disorders that caused hardening of the skin and bones and kidney failure among other things. He was so wonderful to interview. He was patient, kind, and understanding of our inexperience. When we asked him to let us know if he felt uncomfortable while we were examining him, his quote was, "You're probably more uncomfortable doing this than I am." Check.
Wednesday, November 3, 2010
Dia de los Muertos
Today we finally honored the contributions of the donors that so selflessly gave their bodies. Some of my classmates put together a wonderful celebration that allowed us to reflect on death, healing and learning. A few people read poems, there was a violin performance, and two of my classmates sang The Only Exception by Paramore. I was truly touched by the offers of others, and finally had the opportunity and venue to say "Thank you" to the person I got to know so well. A moment of silence gave us the opportunity to write down a reflection and drop it in a bowl of water on a Dia de los Muertos altar.Thank you for being the most amazing teacher, for letting me discover the details, and for giving me a completely new appreciation for life and the role of a physician.
Thursday, October 28, 2010
PETAs!!!
The week after Thanksgiving break will be exciting! We are going to take our practical clinical exam, including a full patient interview and a full physical exam (on a standardized patient actor). To prepare for this grand event, we've been learning the physical exam in sections: head and neck, lung, cardiovascular, abdominal, musculoskeletal, and neurologic exams.
There is a total of 104 things we must to during the 40 minutes we will have with the patient. Some will be ridiculously easy: wash hands, observe patient's general appearance... And most will be really interesting and fun: Inspect ear canals and tympanic membranes using otoscope... the problem is there are 104 of them that need to be done in order and properly.
The Physical Exam Teaching Associate program allows us to practice all aspects of the physical exam on real live people. Today I spend 1.5 hours with another student practicing the Neurological Exam on a PETA. It was fabulous! Below is the checklist for this portion of the exam.
So! If you would like to receive a FREE physical exam from someone who may or may not be able to identify findings, and almost certainly won't be able to explain why you have a bump there or can't follow my finger with your eyes or don't have a Babinski Reflex... please let me know! I'm willing to make house calls. :-) But seriously, I need to practice! This is only 38 of the 104 things I need to be able to do!
H. Psychiatric and Neurologic Mental Status Exam (9 items)
___ Observe level of consciousness: Awake and Alert?
Consciousness and Orientation:
___ Assess orientation: Asks patient: name, day, date, time, place and situation
___ Assess attention: Asks patient to recite days of week forward and backwards
Speech
___ Ask patient to name three objects :
___ Ask patient to repeat, “The sky is blue in Baltimore”.
___ Ask patient to point to the ceiling and point to the way out of the room.
___ Notes speech quality (e.g. clear/coherent; slurred, rambling)
___ Assess mood (predominant emotional state) and affect (emotional expression)
Mood and Thought:
___ Assess thought content and behavior.
J. Neurologic Exam (29 items)
Cranial nerves (10 items)
___ Check pupils and assesses for consensual response-bilaterally
___ Test visual fields; ask how many fingers are seen on each side (not total of both hands)
___ Extra-ocular: Ask to follow finger from center to left to right to center to up and to down.
___ Sensation: Touch quickly V1, V2, and V3 on each side
___ Ask patient to close eyes tightly, then open widely (observe forehead wrinkling). of face
___ Ask patient to show teeth
___ Rub fingers in each ear to assess hearing
___ Observe elevation of palate
___ Ask patient to protrude tongue
___ Test shoulder shrug strength bilaterally
Motor (5 items) - All are bilateral assessments
___ Check for pronator drift bilaterally
___ Check proximal arm strength at deltoid: arms in ‘chicken wing position- test one side at a time
___ Check finger extensor strength bilaterally
___ Check hip flexor strength bilaterally
___ Check dorsiflexion of foot strength bilaterally
Sensation (4 items) - All bilateral assessments
___ Fine touch: Use cotton tip on mid-arm, distal phalanx of index finger, mid-thigh, distal phalanx of great toe- (ask patient to close eyes)
___ Pain: use point of broken wooden shaft of cotton swab for pin-prick on mid-arm, distal phalanx of index finger, mid-thigh and distal phalanx of great toe
___ Vibration- use 128 or 256 Hz tuning fork on PIP joint of great toe bilaterally, counting to 10
___ Proprioception- moving great toe up or down
Reflexes (3 items) - All bilateral assessments
___ Strike tendon on one of biceps or brachioradialis bilaterally
___ Strike tendon on one of patella or ankle tendon bilaterally
___ Assess Babinski reflex, warning patient first of possible discomfort.
Coordination/Gait (7 items)
___ Perform finger to nose testing both sides using two points for each side- bilateral
___ Rapidly tap 5 times on thigh with each hand (rhythm and regularity)-bilateral
___ Ask patient to stand and walk distance of 10 feet (if possible)
___ Ask patient to stand with feet together, then close eyes (provide contact guard)
___ Ask patient to walk with one foot in front of the other (tandem walk).
___ Ask patient to stand on heels then stand on toes.
___ Alternate: heel to shin test-bilateral (may omit if performs all of walking/gait tasks)
There is a total of 104 things we must to during the 40 minutes we will have with the patient. Some will be ridiculously easy: wash hands, observe patient's general appearance... And most will be really interesting and fun: Inspect ear canals and tympanic membranes using otoscope... the problem is there are 104 of them that need to be done in order and properly.
The Physical Exam Teaching Associate program allows us to practice all aspects of the physical exam on real live people. Today I spend 1.5 hours with another student practicing the Neurological Exam on a PETA. It was fabulous! Below is the checklist for this portion of the exam.
So! If you would like to receive a FREE physical exam from someone who may or may not be able to identify findings, and almost certainly won't be able to explain why you have a bump there or can't follow my finger with your eyes or don't have a Babinski Reflex... please let me know! I'm willing to make house calls. :-) But seriously, I need to practice! This is only 38 of the 104 things I need to be able to do!
H. Psychiatric and Neurologic Mental Status Exam (9 items)
___ Observe level of consciousness: Awake and Alert?
Consciousness and Orientation:
___ Assess orientation: Asks patient: name, day, date, time, place and situation
___ Assess attention: Asks patient to recite days of week forward and backwards
Speech
___ Ask patient to name three objects :
___ Ask patient to repeat, “The sky is blue in Baltimore”.
___ Ask patient to point to the ceiling and point to the way out of the room.
___ Notes speech quality (e.g. clear/coherent; slurred, rambling)
___ Assess mood (predominant emotional state) and affect (emotional expression)
Mood and Thought:
___ Assess thought content and behavior.
J. Neurologic Exam (29 items)
Cranial nerves (10 items)
___ Check pupils and assesses for consensual response-bilaterally
___ Test visual fields; ask how many fingers are seen on each side (not total of both hands)
___ Extra-ocular: Ask to follow finger from center to left to right to center to up and to down.
___ Sensation: Touch quickly V1, V2, and V3 on each side
___ Ask patient to close eyes tightly, then open widely (observe forehead wrinkling). of face
___ Ask patient to show teeth
___ Rub fingers in each ear to assess hearing
___ Observe elevation of palate
___ Ask patient to protrude tongue
___ Test shoulder shrug strength bilaterally
Motor (5 items) - All are bilateral assessments
___ Check for pronator drift bilaterally
___ Check proximal arm strength at deltoid: arms in ‘chicken wing position- test one side at a time
___ Check finger extensor strength bilaterally
___ Check hip flexor strength bilaterally
___ Check dorsiflexion of foot strength bilaterally
Sensation (4 items) - All bilateral assessments
___ Fine touch: Use cotton tip on mid-arm, distal phalanx of index finger, mid-thigh, distal phalanx of great toe- (ask patient to close eyes)
___ Pain: use point of broken wooden shaft of cotton swab for pin-prick on mid-arm, distal phalanx of index finger, mid-thigh and distal phalanx of great toe
___ Vibration- use 128 or 256 Hz tuning fork on PIP joint of great toe bilaterally, counting to 10
___ Proprioception- moving great toe up or down
Reflexes (3 items) - All bilateral assessments
___ Strike tendon on one of biceps or brachioradialis bilaterally
___ Strike tendon on one of patella or ankle tendon bilaterally
___ Assess Babinski reflex, warning patient first of possible discomfort.
Coordination/Gait (7 items)
___ Perform finger to nose testing both sides using two points for each side- bilateral
___ Rapidly tap 5 times on thigh with each hand (rhythm and regularity)-bilateral
___ Ask patient to stand and walk distance of 10 feet (if possible)
___ Ask patient to stand with feet together, then close eyes (provide contact guard)
___ Ask patient to walk with one foot in front of the other (tandem walk).
___ Ask patient to stand on heels then stand on toes.
___ Alternate: heel to shin test-bilateral (may omit if performs all of walking/gait tasks)
Wednesday, October 27, 2010
Thank you Fourth Year!
Dear Amazing Fourth Year,
Thank you. Thank you for sitting me down and telling me what I need to know... what I need to know today, for this semester, for this year, and for this summer. And thank you for telling me that I don't need to worry about anything beyond that time frame right now.
Thank you for telling me that it's just safer to say "52 year old woman" rather than just "52 year old female" because an attending might ask, "Female person? Female dog?"
Thank you for offering to let me practice a head-to-toe physical exam on you (or a friend you beg to help us) so I can be ready for my practical exam in early December. I really can't do any of the systems without looking at the sheet (Heart rate then respiratory rate? The other way around? When do I listen to the lungs? When is the patient laying down, but elevated 30 degrees? What is jugular venous pressure and where do I look to see that it's normal?.... ya got me!)
Thank you for setting up times for me to go to the hospital and round with the attendings, residents and 4th years. I think it will be really helpful to see it all in action! And I can't imagine a better motivator than wearing my white coat in front of real live patients :)
Most of all, thank you for going through med school, even though none of your family went through it and you didn't know what to do or what to expect, because by watching and listening to you - I KNOW that it will all come together! Instead of having a list or 2 or 3 differentials or possible causes of the illness, I'll be able to list off 15 things when an attending or resident asks me for a differential diagnosis. And I'll be able to defend why each one might be the cause... and I'll know which tests, observations or questions about the patient's history would eliminate things from my list.
It's ok to be at the "one day at a time" phase right now. And I am suddenly really excited to learn this stuff about how cells work! I need to know how ion channels in cell membranes work... so I can understand how they make muscles contract... because certain drugs will alter these ion channels to increase heart rate or decrease heart rate. And I need to know that - because eventually I'll see a patient who is having a problem with her heart and I'll have to give her a drug. And I better know what drug will help her because then she might give me a hug and say thank you. And that will be a good day.
So thank you.
Sincerely,
Melissa
Thank you. Thank you for sitting me down and telling me what I need to know... what I need to know today, for this semester, for this year, and for this summer. And thank you for telling me that I don't need to worry about anything beyond that time frame right now.
Thank you for telling me that it's just safer to say "52 year old woman" rather than just "52 year old female" because an attending might ask, "Female person? Female dog?"
Thank you for offering to let me practice a head-to-toe physical exam on you (or a friend you beg to help us) so I can be ready for my practical exam in early December. I really can't do any of the systems without looking at the sheet (Heart rate then respiratory rate? The other way around? When do I listen to the lungs? When is the patient laying down, but elevated 30 degrees? What is jugular venous pressure and where do I look to see that it's normal?.... ya got me!)
Thank you for setting up times for me to go to the hospital and round with the attendings, residents and 4th years. I think it will be really helpful to see it all in action! And I can't imagine a better motivator than wearing my white coat in front of real live patients :)
Most of all, thank you for going through med school, even though none of your family went through it and you didn't know what to do or what to expect, because by watching and listening to you - I KNOW that it will all come together! Instead of having a list or 2 or 3 differentials or possible causes of the illness, I'll be able to list off 15 things when an attending or resident asks me for a differential diagnosis. And I'll be able to defend why each one might be the cause... and I'll know which tests, observations or questions about the patient's history would eliminate things from my list.
It's ok to be at the "one day at a time" phase right now. And I am suddenly really excited to learn this stuff about how cells work! I need to know how ion channels in cell membranes work... so I can understand how they make muscles contract... because certain drugs will alter these ion channels to increase heart rate or decrease heart rate. And I need to know that - because eventually I'll see a patient who is having a problem with her heart and I'll have to give her a drug. And I better know what drug will help her because then she might give me a hug and say thank you. And that will be a good day.
So thank you.
Sincerely,
Melissa
Monday, October 25, 2010
I whip my hair...
Sike naw.
Actually this is the version that plays in my house... for reasons you should probably know.
Awesome weekend:
Fri: dinner and drink out at a cute new bar: Diablita plus movie night with the hubby
Sat: school work then TWO parties: Amy's housewarming and Ryan's 30th Birthday
Sun: IMP Mentoring program football game - ending with kids vs. mentors... which we lost :(
Monday:
Ugh... I'm feeling more and more overwhelmed. It's not hard, it's just A LOT (see last post). In college or during TFA I was stretched, just as I am now. But, I didn't have a husband to come home to... and I really hate studying or doing cell physiology problem sets at night when we should be going for a walk, making dinner or just relaxing together.
I need to:
- Prioritize
- Be efficient
- Realize that I don't need to do everything or understand everything in the crazy amount of detail that is presented in class... I need to understand the big concepts... the forest, not the individual trees
- Call my mom (but remember not to make her worry that I'm eating or something crazy like that (I mean, come on, if there's one thing that I do very well every day... that's it, just get her to tell me it'll be ok!)
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