EKG Basics

You give me premature ventricular contractions – Emma, No Strings Attached (film)

I was never really confident reading EKGs. But after one week and 300+ EKGs later, I can finally say, without a doubt, that I can read an EKG on my own! One small step as med student in training, one big step for future Dr. Jenny!

Most of you are probably much better at reading EKGs than I am, but I just wanted to make this video as a short refresher. Plus I might need to look back on it some time in the future … I regret not making a radiology video when the material was still fresh. So I always have to go back and read Priya’s blog post. Hope you all enjoy!

Short overview incase you couldn’t catch it in the video:

1. Is the patient in Sinus Rhythm? – Check for positive P waves in leads II, III, aVF
2. Heart Rate
3. Axis deviation – Check leads I & aVF
4. Left Anterior Fascicular Block? – Check lead II
5. P wave + PR intervals – are they long? are they short?
6. QRS complex – are they wide? more than 3 small boxes?
7. ST/T wave changes

I hope that helps. I wanted to read more samples of EKGs but then this video would be a bajillion hours long.

Burn Injuries

HI EDC!

We are so close to being finished with medical school – I am finally feeling the weight of that thought and getting excited about graduation. 🙂

My final surgical elective was in the Burn Unit at a local hospital. It was a very busy rotation; from pre-rounding at 5am, rounding at 6am, a very full panel of patients, and surgery MWF, there was a lot going on. Overall, I really enjoyed this rotation. I am fairly non-surgical, but having the opportunity to observe application of various skin grafts to 50% total body surface areas (TBSA) burns was pretty cool. I will not miss the 90 deg temps in the OR though. Burn surgery ORs are kept at least 85 deg F for patients with large burns because of the tremendous loss of heat from the absence of skin. It gets gross under surgical gowns quite quickly.

Some highlights of this rotation:

  • Working with a large team of residents: 4 Interns (1 ortho, 2 gen surg, 1 EM), 1 gen surg pgy-3, and 2 fellows. Plus me, tagging along. We were a big group and everyone’s roles changed weekly.
  • Surgery on Monday, Wednesday, Friday: burn cases would take up to 4 hours depending on the extent of the burn injury
  • Clinical rehab psychologist on site. Many burn injuries result in PTSD from the injury or may be the consequence of behavioral issues (drug use, violence/abuse). Rehab psychologists are quite rare in hospital settings, but essential – especially in the burn unit. The majority of the cases were tragic and having a resource for patients coping with serious life changes was instrumental for their treatment and long-term prognosis. Patients that believe that life can get better, after severe tragedy, are ones that will do better with their burn/wound care and have the best outcomes.
  • Patient cases were complex and a many of them were the result of homes catching fire. When your home is destroyed… what do you do after? These are really unfortunate cases and many times patients live in transitional housing or if they’re lucky will live with friends/family until they can obtain stable housing.
  • Patients were very sick, and not necessarily because of their burns. So much of how well someone does is based on their health status prior to hospital admission. If someone has chronic peripheral vascular disease, poorly controlled diabetes or regular diabetes, meth use (this one’s huge), poor nutritional status (alcoholism, Crohn’s disease), or any autoimmune process then the ability for wounds to heal is significantly impaired.

I am really glad to have had the opportunity to participate on this service as I think this is a really unique surgical specialty and one in which more attention should be paid. But I’m biased now. 🙂

Until Match Day,

N

DO vs MD: Residency Programs

Hi All,

There are currently 2 different MATCHes you can participate in: the DO match and the MD match. The DO match is about 1 month before the MD match (and if you match into a DO program, you are locked in and cannot participate in the MD match).

Soon, none of this will matter as all programs will become ACGME (MD) accredited. However, there are a few things to be aware of:

DO programs: Do audition rotations! I didn’t get interviews at places I didn’t rotate at! Much of this process is based on how well programs know you/networking. Get letters of rec from former residents at the programs you want to go to or from known physicians in the osteopathic community. Also, go to osteopathic conferences (like the ACOOG conference held twice a year) to meet program directors. Make a portfolio and pass it out at said conferences. DO programs look at your holistically and try to get a good fit for their program. To be honest, my DO audition rotations (I had 2) were very challenging. At one rotation, there were 5 other students on service with me. At the other, there were 2 others. And because DO students tend to be super nice, helpful, smart people, it’s hard to compete with them. Everyone has a great personality. Everyone is a hard worker. Everyone is knowledgeable. Everyone knows everyone (especially on the East coast were a lot of DO residency programs are). I found that it helped if you knew one of the residents at the program (and had someone to vouch for you). Some programs really take the residents’ opinion into account when finalizing their rank list, others don’t. Also, some programs will require you to do a presentation – so be ready!

MD programs: Very much merit based – you’ll get an interview invite with high scores and grades. Many programs will not keep in touch with you after your interview so that all applicants have an equal playing field. My MD audition rotations were tricky because some programs don’t offer you an interview, even if you rotated there. Regardless, I think it’s really important to try for auditions. In the MD world, many people don’t do audition rotations, so when you show up with your DO, can-do, friendly, hard-working attitude, it makes a huge difference in the eyes of  the program. One of the DO programs I interviewed at had an MD program director (who is awesome!) and she used to work for an MD program as the assistant program director. She actually stated that at her MD program (and as an MD), she preferred all the DO applicants! She said that they brought something more to the table and that they wanted to be there. I’ll also say this-one interview I got was because I sent an email to an MD program expressing my interest in it- so that (can) DO attitude really does go a long way.

I hope this helps you as make your decision on which programs to apply to and which programs to do auditions at!

-P

 

How to ICU

Nearly 4 weeks into ICU and I am still uncertain as to what is going on. On a regular basis. It’s been a strange rotation. Partly because I have missed an inordinate amount of time on this rotation combined with having patients that are extremely complicated. Luckily, much of the ICU is managed by a team of  really good RNs, Respiratory therapy, social work, and solid pharmacists. And of course your Pulmonologists/Critical care doctor. It really takes a team to manage one patient.

Overall, I have enjoyed the freedom provided on this rotation as I am able to pre-round independently, write my own notes, and present my patients to the team. Being able to do your own thing is really nice. But fear not! – a Resident is always around in case I have lingering Q’s. Something that I found to be immensely useful is chatting with the nurses before ICU rounds. These nurses know their medicine and are some of your best allies when training and beyond.

Before I started ICU, I didn’t really know what to expect and relied on the google machine to help me out. I stumbled upon these resources and reviewed them throughout the rotation:

I guess that’s not too many. I also relied on good ol’ fashioned uptodate and Medscape app.

The majority of your time will be spent reviewing drips and vent settings. Having a good understanding of pharmacological sedatives and vasopressors will serve you well. Additionally, knowing how vent settings work is helpful; at the bare minimum you should know how to interpret them. Jenny did a great job detailing this in her ICU video, so give that a listen for more info.

Everyone that warns you that ICU will be depressing was right. I had a patient die each day. Not fun stuff. Plus your patients are either intubated on a ventilator or altered or sedated so you can’t interview them. You end up relying on their vitals, PE, labs, and imaging to communicate with you their progression. Some of the more interesting cases included:

  • Meth user with valvular vegetations and septic emboli to the pleura causing pneumothorax requiring multiple chest tubes.
  • Former meth user found down in his trailer found to be in DKA and septic shock with a necrotic right foot that underwent emergent guillotine below knee amputation (BKA).
  • Diffuse scleroderma in a young adult resulting in advanced interstitial lung disease complicated by pneumomediastinum.
  • Lung metastases secondary to advanced ovarian cancer, undetected until admission.

Image result for ICU medical school memes

Of course, we also had a lot of the bread & butter cases like COPD exacerbation, isolated DKA, toxic vs metabolic encephalopathy, acute respiratory failure, and septic shock. I also was able to get in a couple of procedures: intubation and placing chest tubes. Nothing too crazy. Oh, and in case you’re wondering, I only missed time because of residency interviews – those wait lists are no joke – if you pop off of one, you find out last minute!

By the way… anyone notice the fog after January 20th? I think the Dementors were let loose from Azkaban.

Nari

Ophthalmology Rotation

The eye does not see what the mind does not know – Anonymous

I sat on a bench waiting for the ophthalmologist.

Lately, I’ve been doing rotations with physicians who own their own practice. This particular preceptor built the whole building! (He was actually most proud of his doors which were perfectly balanced and could be closed with a touch of a finger).

A gentle older man, with many laugh lines and tanned skinned walked up to me (he was the ophthalmologist) – and asked me the dreaded question “So you want to go into ophthalmology?” This far in my medical career my answer had to be “No …. I am applying to family medicine residency. But I am still very interested in ophthalmology.” Maybe it is just my own insecurities, but I feel like some preceptors are disappointed by my answer. Maybe they think I wouldn’t be as engaging or eager to learn as someone who is interested in their particular specialty. Luckily, this particular preceptor was an excellent teacher – rather he geared his teachings to particular things that I would find useful in my primary care practice.

Psychiatric Emergency Services elective

Hello EDC!

I recently completed 4 weeks at the county hospital in a dedicated psych ER and I feel like I saw another side to this city that I live in and I ended up loving this rotation. This psych ER unit, of 10 beds, was instrumental in getting patients access to either inpatient psychiatric hospitalization, connection with outpatient mental health or chemical dependency resources, or setting them up with housing options. On staff are social workers, ARNPs, mental health specialists, RNs, ER and Psych Residents, and of course the Attending Psychiatrist. We worked as a team making decisions and determining, with limited resources, the best outcome for our patients. This was hard. On one occasion, I spent the majority of my day trying to set a patient up with housing only to have him tell us that this was inadequate and threaten suicide if he wasn’t admitted to the hospital. I won’t lie, these patients were difficult. Coming up with a plan for safe dispo was sometimes impossible and we were left escorting them out of the hospital with security’s help.

The weather made things even more challenging as many of the local shelters often kick people out at 7am, patients would show up to the hospital claiming that they were suicidal and be provided with a warm bed, breakfast, and a clean bathroom.

What I loved about this rotation was how immensely challenging and gratifying it could be. When a patient arrived with first-break psychosis and their family was concerned, or the pt was brought in by police because of drug abuse 2/2 underlying mental health disorder, or pt was suicidal because life dealt them a bad hand, these were the patient cases I really enjoyed and feel like I could provide the most help. I truly believe that each time they came into our unit, it was a step closer to getting better and realizing the weight of their problems.

Some of my favorite patient cases included:

  • Capgras Syndrome (Impostor syndrome)
  • Narcissistic & Borderline Personality d/o rolled into one person
  • New-onset schizophrenia vs. bipolar w/ mania
  • Paranoid schizophrenia resulting in fear of food/sleep
  • Major depressive d/o with psychotic features & substance use
  • Chronic, untreated schizophrenia in decompensated state

In Washington State, doctors are not permitted by law to declare whether a patient requires hospitalization. Instead, county-appointed designated mental health professionals (DMHPs) fill this role. When patients come into the psych ER and are clearly suicidal, homicidal, or gravely disabled (unable to care for self), the DMHP is contacted to assess the patient. If the DMHP agrees the patient meets one of these safety concerns, they are detained and involuntarily admitted to the hospital or to another facility. We spent a lot of time working with patients that qualified.

The best advice I received on this rotation was to do the best you can with the resources available to you and no more. I loved working with these patients, but they could be difficult and in the emergency setting it is easy to feel like you are not doing enough for your patients and that they are not grateful. But the reality is that if someone wants help, then this was the place where people had the opportunity to start getting their lives back on track.

Image result for happy holidays meme penguin

Count down to graduation begins January 1 2017. 🙂

PM&R Rotation

Vodka does not ease back pain. But it does get your mind off it. – Fuzzy Zoeller

Besides the craziness of audition rotations and interview – I would have to say that fourth year is much more fun. I just finished PM&R and I must say I rather enjoyed it.

I don’t know if any of you have felt this but I guess I can describe it as sense of fear. Fear that I have not experienced everything and that there is something out there like PMR residency that I should be going to instead of FM. I personally feel that because I was never exposed to these different specialties, it never crossed my mind that it would be something I would want a career in. I’m currently doing an ophthalmology rotation and I love that too! Don’t get me wrong, I don’t regret choosing FM at all. I know I will be very happy. I just wish that there was a better way to expose people to these specialties earlier on in our medical career.

Even though I am not going into PMR and a Pain Fellowship is not in the books on my current rout, I still learned some interesting things that I could incorporate into my family practice like injections. Made a short video reviewing and explaining some of these. I miss you all. I look forward to our gossip frenzy after Match day.