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“Doctor! Heal thyself!”

 

Those were the words of the orthopedist as he entered my room in the Emergency Department.

 

Two weeks ago, while taking a break from working on residency applications, I decided to go ride one of my horses.  Alas, as I was leading him and his pasture-mate to the barn they spooked and one of them literally jumped on my foot.  I’ve been around horses for decades (eek!), and have had my toes crunched many times, but I immediately knew this time was different, not least because he had landed on the side of my foot not my toes.  The pain was instantaneous and overwhelming, I was doubled over and hyperventilating within seconds (at which point I realized that the horses hoof had actually torn my leather boots- let this be a lesson to ALWAYS wear boots around horses, a lesson I’ll admit that I haven’t always followed).  After taking a couple of minutes to catch my breath I hobbled to the barn, optimistically hoping I’d still be able to go for a ride.

 

Once in the barn, with the horses secured, I pulled my boot off and had a quick palpate. One good squeeze and I knew I needed to make a trip to the hospital for some X-rays. *Sigh*  This was NOT how I had planned to spend my evening!

 

A little later, at the community hospital, the X-ray tech snapped a few angles.  I asked if I could see the films before hobbling back the waiting area and immediately spotted two, slim, hypodensities in my 4th and 5th metatarsals.  With an expletive, I pointed to one of the lucencies. The tech tried to reassure me that it wasn’t anything significant: “just an artifact” because there was a similar line in the adjacent bone…

 

After the Physician’s Assistant examined me in fast track, he went to go check out the X-rays.  I asked if I could take another look, admitting that I was a med student (and currently on rotation in this community hospital for my sub-internship!). When he came back to pull the images up on the computer, he let me know that he and the ED doc agreed that I did, indeed, have non-displaced fractures of the 4th and 5th metatarsals.  There wasn’t really much they could do, but the orthopedist was coming into the hospital to see a couple other patients and if I was willing to hang out for half an hour he’d take a look at my images as well.

 

They don't look like much, but those two little lines are really cramping my style!

They don’t look like much, but those two little lines are really cramping my style!

 

Half an hour later, the cheery orthopedist came in, chatted with me about my future plans in medicine, and told me to follow up with him if things got worse instead of better.  I headed home with a walking cast, crutches, and a few Percocet.

 

This was two weeks ago, and while my foot is by no means “fixed” it is certainly getting better.  Hobbling around to take a shower the first morning was rather excruciating, but the walking cast was my saving grace in the hospital and I’ve been able to do more normal activities without the boot with time (though I think I may have pushed my limits last night heading into the city for a book release party and am paying for it today- on that note, definitely check out John Durant’s book The Paleo Manifesto).

 

So why am I writing this, other than catharsis? (It’s perfect fall hiking weather and I’m out of commission- boo.)

 

Healing takes time.

 

With things like a fractured bone people know this, but sometimes we (“we” the public, and “we” the medical community) seem to forget that healing takes time.

 

There’s no denying that I am “into” preventative medicine.  However, as much as we can try and prevent injury and illness- something is bound to happen.  In that vein, I don’t think preventative medicine is only about avoiding problems, but encouraging a physiology where healing is promoted.

 

I’ll admit that I’ve been frustrated at times in the hospital when my stable patients have complained to me on morning pre-rounds that they had a horrible nights sleep because someone was taking vital signs every couple hours, and the phlebotomist came for morning labs before 5.  Vital signs are vital for the management of some patients, but others would benefit much more from a good nights sleep. Of course, making the decision that your patient needs sleep more than monitoring is not an easy one- no one wants to find that their patient is hypotensive on morning rounds and not know when the problem occurred, but for some patients the risk seems quite low.  On my neurology clerkship I remember thinking that what many of our stroke patients needed most was a good night’s sleep.

 

I recently read, at the recommendation of my favorite cardiologist, the book Cutting for Stone.  It is amazing, in many ways. I particularly loved a short passage that talked about the success one person had in improving women’s recovery from fistula surgery.

 

Hema shared with us that she and Shiva had operated on fifteen successive fistula patients with not one recurrence.  ‘I owe this to Shiva,” she said. ‘He convinced me to take more time preparing the women for surgery. So now, we admit the patients and feed them eggs, meat, milk, and vitamins for two weeks…. We work on strengthening their legs, getting them moving.’…

 

‘Can’t get them to walk after surgery if they won’t walk before.’ Shiva said.

 

When I was on my anesthesia clerkship I saw how hard it is to manage a “sick” patient, and how easy it is to intubate and anesthetize a healthy one (a complicated cardiac patient vs a young ortho patient, for example).  On surgery, you see how well some people tolerate surgery and how poorly other do- how some heal quickly while other seem incapable of healing.  One’s underlying “health” certainly affects one’s ability to heal.

 

This is one of the many reasons I like primary care.  A good primary care doc makes everybody else’s job easier.  They can keep their patients healthy and out of the OR and specialist’s office, and if misfortune strikes, a patient in the best of health is almost always set up to fair better (the only example that I can think of where this is not the case is the pandemic flu of 1918, where the robust immune systems of young, healthy, adults was actually their demise).

 

Injury and illness, at some level, are inevitable.  A healthy lifestyle and good genetics can go a long way to keeping you out of the hospital, and they can also go a long way towards helping you heal if you do find yourself in harms way.  As the Dos Equis man might say “Stay healthy my friends.”.

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I have been a zombie today.

I’ve wanted to write this post all day, but I’ve been spinning my wheels, unable to find the focus to sit and write.

I know where my inability to focus comes from. It’s the same thing that’s been causing my insatiable hunger and serious sweet-tooth.

I had a night shift on Thursday night.

The health industry is notoriously unhealthy. Even during the best of times the medical community tends to get things wrong with seminars on preventative health being coupled with breakfasts that consist of pastries, margarine to schmear on bagels, and fat-free non-dairy creamer to opacify a foul smelling substance that masquerades as coffee.

Practicing medicine is not easy on the body.  Being a doctor is stressful and, of course, spending your days around people who are sick makes you prone to getting sick yourself.  Lack of sleep is another big problem.

Of all the clerkships that medical students rotate through, the surgical ones- surgery and obstetrics/gynecology- have the worst hours. Depending on a school’s program, this is where students first get to experience the joys (by which I mean terrors) of 24+ hour call and “night float”.

At my school, the surgery clerkship has maintained the traditional call schedule (you work a day and then when you’re on call you stay for the night and finally go home the next morning when you are “post call”), while the ob/gyn clerkship has adopted a “night float” schedule for students, where we switch from day service to night service for a few days running during the clerkship.  These two clerkships were separated by 8 months in my schedule, so it’s perhaps hard to accurately compare them.  Nonetheless, I’d like to write about my experience with these two notoriously rough clerkships.

Surgery…

My school still follows a traditional call schedule for students on the surgery clerkship: every 4th or 5th day we would be “on call” after our normal day in the hospital. For the first half of this clerkship I was at a hospital 45 minutes away from my apartment. I was up between 4:25 and 4:30 each morning to be in the hospital by 5:30 to round on my patients before we “ran the list” as a team shortly after 6 and then headed to the OR for the day.

My problems on this clerkship started early. I had just come off my psychiatry clerkship where I’d been enjoying the psyche hours of 9-4… surgery hours were a big change. I couldn’t convince myself to eat breakfast before 4:30 and instead started my mornings with 1 or 2 double-shot espressos before heading to the hospital. The hospital to which I was assigned doesn’t have great quarters for medical students on surgery, so I was left to share a miniscule locker with 3 other students.  We barely had space to store our clothes, let alone space for real food. While there was a residents’ lounge, it was adorned with a large sign warning “Med students- do not leave your shit here”, and we didn’t have access to a fridge or a microwave. Lunch was a hit-or-miss occurrence, and the general mantra for med students during a surgery rotation is “eat when you can, you don’t know when you’ll have the opportunity next.”

Here’s a classic from Whatshouldwecallmedschool

During that first month I subsisted on my morning espressos and my best attempts at healthy snacks- unsweetened banana chips, jerky, nuts, and 85% chocolate. In the evenings I’d eat a proper dinner before putting myself to bed before 9 on most nights. I occasionally managed to make it to the gym, but I tended to feel rather weak and pathetic when I managed to get in a workout. Every 4th or 5th night I was on call, and instead of heading home around 5pm as per usual, I would grab dinner in the hospital cafeteria and see patients in the emergency department and go to the OR for emergency cases.  At some point during the evening (usually between 11pm and 1am) the night resident would tell the med students to retreat to our on-call room for some sleep, promising to page us if anything interesting came through. For me, at that hospital, I was never paged during the night.

My second month of surgery was on the trauma team at our university hospital, which is a level 1 trauma center.  Start time was similar at this hospital, but I was now 25 minutes closer, giving me 25 more blissful minutes of sleep. Also, at school we have a students’ lounge with a fridge and microwave, and I was able to start eating real lunches again. I also had realized that going to the gym in my stressed and sleep-deprived state was doing me no favors so I put my gym membership on hold.  Our call schedule was similar on trauma service, but unlike the general surgery service at a community hospital, the trauma team at our inner-city hospital was constantly getting paged in the wee-hours of the morning. I don’t think I ever got more than 2 hours of sleep when I was on call, and was always woken by the screams of the pager rather than the dulcet tones of my cell phone’s alarm (I occasionally hear a pager with the same ring-tone as the trauma pager and it still sends chills down my spine).

At the first hospital, after being on call, we were usually dismissed after we “ran the list”- frequently being on the way home shortly after 7am. On trauma we would run the list, go to radiology rounds, and then physically round on our patients as a team before being sent home.  Alas, our list of patients grew malignantly during my month of trauma and at one point we had over 30 patients, with some on each floor of the hospital. After a night on trauma I would usually find myself driving home after over 30 hours in the hospital (sometimes with no sleep) willing myself to get home safely (I really didn’t want to end up in the trauma bay as a patient- nothing like the fear of having your classmates cut your clothes off with shears to keep you awake!).

It’s amazing what lack of sleep does… I remember being asked a simple question one post-call morning on rounds and completely drawing a total blank. The funny thing was, it was a simple question that I actually felt very strongly about (Why do so many of our hospitalized patients have messed up electrolyte levels? We do it to them by flooding them with fluids!). Also, despite eating a lot less than I usually do, I definitely put on weight during my surgery clerkship.

Eight months later, as I faced the prospect of another notoriously rough clerkship (ob/gyn), I prepared myself a bit better.  While I was again stationed at the hospital 45 minutes from my apartment, this time I made sure that I ate breakfast before starting each day. I had also weaned myself completely off coffee before the start of the clerkship and never drank more than a single double-shot espresso each morning. I also preemptively put my gym-membership on hold.

We didn’t have call on ob/gyn and instead had a brief stint of “night float”, where we were in the hospital from 7pm-9am for a number of days consecutively.  This is a more realistic experience of life as an intern (with current intern rules), and has the advantage of allowing you to “switch over” from days to nights. I did a bit of research and when I switched over to nights I did a combination of fasting and napping that saw me switch over easily.

During ob/gyn I didn’t have much of a social life- I was going to bed between 8:30 and 9:30 most nights and most of my time was spent in the hospital or sleeping, but all things considered I think I held up very well.  I’ve long liked ending showers with a brief cold-water rinse (I think of it as a healthy bit of hormesis), but during surgery I lost the ability to tolerate cold showers.  Actually the worst part of being “post call” was the dreadful, inescapable cold that would come over me early on the post-call morning.  I’ve always been a warm-handed person, but on surgery I developed cold hands on a regular basis. While my hands weren’t always warm, I didn’t develop terrible chills on ob/gyn.

Med school is, of course, a learning experience, and a big part of the experience is learning what your body can handle and what it can’t (and what you need to do to keep yourself healthy, happy, and sane).  I’m not looking forward to the rough hours of residency, but I know the importance of prioritizing sleep, food, and socialization and I’m learning how to balance these things to keep myself well.

Alas, just after celebrating my successful navigation of ob/gyn (at least on the “feeling good” front, I’m still waiting for grades to be posted), I was knocked almost flat by a night shift on my current EMS elective.  While a night shift is not *required* during this elective it is strongly recommended, and I went out with the night crew on Thursday night to get an idea of what night-life on an ambulance in a rough inner-city is like (short answer- it does not disappoint).  While I was out with a great team and saw some pretty interesting things, I’ve been suffering the consequences since.  On Friday morning I had an insatiable appetite and was battling sugar-cravings (something I don’t usually have) for the rest of the day. Even after getting 11 hours of sleep last night I was still pretty groggy and fairly useless most of today.

There are no more night-shift in my foreseeable future (though I know we’ll meet again during my Emergency Medicine clerkship) and I’m confident that with another good night’s sleep I’ll be back to normal, but this has been a good reminder of just how brutal sleep deprivation can be.  My time with EMS (though only brief) has also reminded me that being in the health profession is often not a healthy practice. The people I’ve been working with sometimes risk their lives to save a stranger, but they also risk their health on a daily basis by living a lifestyle for which our bodies are ill-suited.

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