Zebras and Death: my experiences this week in IM

While searching for an article to present at my next didactics day, I came across one titled “My Hidden VA List” by Dr. Dena Rifkin. I had to open it because I’m currently doing an internal medicine rotation at the Phoenix VA. In the article, the doctor writes about how the Phoenix VA national scandal does not line up with his personal experience as a VA physician. He says he keeps a hidden list of patients that he has had the pleasure of helping, the fortunate ones who walked out and the ones that weren’t so lucky. One quote in particular stood out to me. He states:

“My hidden list reminds me of some of my most difficult days as a doctor. It reminds me that shortness of breath can be a sign of acute myocardial infarction, that renal-cell cancer can recur years after the initial diagnosis, that men can get invasive breast cancer. Sometimes, I feel, I may sink under the weight of these names. As time passes, though, the weight of the list balances me. It prevents me from being too sure of anything, yet it also keeps me from hesitating to trust my instincts.”

This quote struck me for several reasons. We are taught as medical students to look for horses, not zebras- meaning that common things are common. If someone comes in with the signs and symptoms of pneumonia, it is most likely pneumonia and not some rare respiratory disease that we learned for our board exams. However, there is the rare occurrence of a “zebra,” a once-in-a-career disease that happens to show up on your doorstep. Or, rather, your ward. It is these experiences that shock, terrify, surprise, and delight physicians and med students alike. For me, it was meningitis from coccidiomycosis (Valley Fever). We have to keep our eyes open and not get anchored in the same 5-10 diagnoses we see day in and day out. We have to be prepared for zebras so we can catch them early and treat them and hopefully succeed at sending the patient home.

Another reason the quote stood out to me was because I saw my first death this week. A rapid response was called on the patient and my Attending and I happened to be getting coffee near the patient’s ward. We raced over to the patient’s room only to watch ACLS fail to revive the patient. Afterwards I didn’t know how to react or deal with the emotions I felt. To be honest, I came home and snapped at my hubby who finally asked what was wrong, and I broke down. Was it better for the patient to have not made it? Would they have had to live with the sequelae of oxygen deprivation if they had lived? What would his quality of life had been? What else could we have done? It just made me reflect on why I am so uncomfortable with death. In medical school, we never learn about death. Just that we should avoid it at all costs, including quality of life. We are there to SAVE the patient, are we not? Why would we ALLOW death to ‘win’ when that is our sole reason of existing, to prevent it? The Palliative Care team at the VA has repeatedly told us that death is as natural as birth. But for some reason, it frightens me. It makes me feel as if medicine failed. As if all of our extraordinary measures just weren’t enough.

A quote from “Scrubs” sums it up pretty nicely:
Dr. Cox says, “Pumpkin, that’s modern medicine. Advances that keep people alive that should have died a long time ago, back when they lost what made them people. Now your job is to stay sane enough so that when someone does come in that you actually can help, you’re not so brain dead that you can’t function.”

It is so sad but so true. Many times medicine is a necessary evil that prolongs life without prolonging any semblance of a QUALITY of life. We do help people- lots of people. Or I wouldn’t be doing this. But the bare naked truth of it all is that sometimes we do more harm than good. Sometimes we do all we can and people don’t survive. Sometimes they shouldn’t. I have to find a way to be ok with that and not see it as a failure. Because it isn’t. It’s as natural as any other life process and it can be a comfortable and painless process if we allow it.

My point in this post is simply to remind everyone to keep their eyes open. You never know what you’re going to see. You never know when you’ll see a zebra. But in the meantime, keep treating those horses. And if they don’t make it, try again. And remember, not everyone is intended to live longer. And that’s ok. It’s not a failure. It’s a natural part of life.


Internal Medicine: life lessons forged on the frontier of the Wards

Internal medicine. I wasn’t really sure what I was getting into with this new rotation. I was so sad to leave surgery because I loved it so much, so I was admittedly setting unrealistic expectations for my medicine rotation. (Oh, that’s another thing this clueless third year didn’t realize: it’s not “internal medicine.” The cool kids just call it “medicine” and you’re supposed to know what they mean.) Anyway, I started my ‘medicine’ rotation and was assigned a team. Orange team. If you know anything about my undergraduate experience, you know I hate all things orange- University of Oklahoma alums are trained to cringe at the sight of orange d/t (due to. medicine shorthand) Oklahoma State being bright halloween orange and University of Texas being burnt orange. So basically any shade I’m against.

So I started thinking it was a bad omen, that I was assigned orange team because it was bound to be horrible.

I walked into our little team room- that’s another thing, we are assigned teams made up of an Attending Physician, senior resident, 2 interns, 2 med students, and a pharmacist.

*Attending Physician= GOD
*senior resident= in their 2nd or 3rd year of residency. Also godlike. They know everything it seems!
*interns= bright eyed and bushy tailed in their first year of residency. i.e. just graduated from med school in May. i.e. they are as clueless as me, but have way more at stake because they can prescribe medications and make orders
*med students= lost and confused but know just enough “boards relevant” stuff to be dangerous. Think they understand things. Often mistaken.
*pharmacist= drug lords. They know every cross reaction, side effect, dosage, and alternative to every drug and what conditions they work for. It’s a respectable and incredible amount of knowledge and expertise.

I am working at the Phoenix VA- Yes, THAT VA. As in the one making national headlines for being utterly horrible- only it isn’t. All of the ‘conflict’ is administrative- the docs are just doing their thang, not being bothered by the bad press. Which I love.

Being at the VA and on federal government property means a lot of things, but mainly that I can’t take any selfies or pics of anything on the property, and I can’t get on Facebook. Not too many restrictions.

So in the team room, we each have our own computer which is nice. The other med student and I get along surprisingly well- so much so that I believe we will stay friends after our short spat of time together is up! We are learning a lot from each other too! I’ve even been able to teach her some OMM! 🙂

The flow of the day is this: I get there at 6am. The other med student and I both have 2-3 patients each. I check my patients’ records for any lab results or updates from the night before, then I go see my patients. You’d think this was the fun part of medicine- and it is in so many ways! But it’s also 6 am. At the VA. These are old veterans who just want to sleep in. And I’m the first face nudging them every AM asking to listen to their heart, shine my penlight in their eyes, and interrogate them about their bowel movements (regular? loose? frequent? constipated?). It’s ridiculous. But luckily they are mostly polite and understanding that it is a teaching hospital so I have to poke and prod them to develop my physical exam skills.

So after I see my patients, I update the interns and senior resident and they check anything that I missed (even if I’m sure I did everything, there’s always some small detail I forget!). Then our Attending Physician/god comes in around 8am and we ‘present’ the patients to him. You basically sum up the entire history and physical (a good 15-20 minute interrogation of every detail of a person’s current and past medical conditions) in 2 minutes or less. It must be concise yet thorough, detailed but to the point. These presentations are the bread and butter of med school- if you can get good at presenting patients, you’ve learned a lot! So that’s what I’ve been working on polishing up. I think I’m on the right track because I passed what my Attending calls the “real test of presentation skills”: presenting in front of the patient. If you can do that and not have the patient correct you, you know you’ve made it! And apparently I have! Yippee!

Most of what I have learned can be detailed in one-liners. They’re better left to your own interpretation. Some are funny, some are tragic. Enjoy the list I’ve created below:
Vets love 2 things: their freedom. And their privacy.
If you’re nice, the prognosis is bad. (The mean ones have more of a fight in ’em).
Everyone steals your pens. Always carry crappy ones you don’t care about.
No one knows their antibiotics well… and that’s ok. (except the pharmacists!)
You just can’t make this stuff up.
There is not a single presentation that goes by where 5 pagers don’t go off.
GOMERs never die.
There is something called a Bed Czar. Look it up.
65 hour weeks are doable. Difficult, yes. But satisfying.
The patient is the one with the disease.
Everyone who smokes doesn’t inhale. Just ask them. It’s ok if you don’t inhale.
Meth addicts and HIV+ patients can surprise you. Not everyone is a stereotype.
Sometimes silence is best.
Sometimes they just don’t wake up.
Just because you know you can doesn’t mean you should.
CPR in an inpatient hospital setting only works 1/6 of the time.
Wording is everything- Do Not Resuscitate vs. Allow Natural Death.
Lastly, we are not here for our own health. We are providers. And that is a privilege.

I am so excited to learn more in my remaining short 2 weeks at the VA. It’s truly a wonderful experience. Don’t take one single minute with a patient for granted. In the words of my surgeon from last month, “See every patient. Listen to them. You can learn something from everyone, no matter the simplicity of the case.”