So. I just came back from a lecture on menometorrhagia. It was a "lecture"... you know, where a big pharmaceutical pays a medical expert money to talk about a topic that interests them, and said doctor will genuinely believe and advocate for everything they tell you, including a plug for some drug or device that the pharmaceutical happens to supply, and we all get wined and dined as fancily as can be. I knew this is what they would do, so why did I go?
Multiple reasons. Firstly, I am a medical student away from home with long(ish) days who will take the nice free meal, thank you (shame on me, probably). Don't worry I felt a nice bout of guilt pretty much the whole time. Secondly, I'm all over the Ob/Gyn stuff, especially issues like menorrhagia which so many women live and suffer through and genuinely wanted to learn more about it. Thirdly, I mean, this was my big opportunity to see what all this "unethical pharmaceutical wooing" and "doctors getting sucked in" was all about. Now that, how could I pass up? We discuss the ethics and the awfulness of this kind of thing all the time since... pretty much high school, right through university undergrad and now in medical school. Really. Even an individual of the highest moral breed must be at least remotely curious about what that world is really all about, in terms of the very stereotypical medical marketing ploy experience, that, whether or not we like to admit, is incredibly successful at selling the good (ahem, this being the reason why they persist in their excellent sales strategy... no critical thinking can stop the wiley ways of our subconscious and all those positive associations with delicious food and other pleansantries like free samples, or that great conversation you had with that other doctor sitting next to you... am I wrong?)
So yes, I took the carrot. And like any other self-regarding medical student or resident or physician, I was so pleased with myself at taking careful and conscious note of that moment of recognition of the pharm plug exactly 2/3 of the way through the "lecture". And Intro to Clinical Sciences can give itself a pat on the back because when they said "this is not statistically significant" my first reaction (internally of course) was, "but is it clinically significant?" Of course, I will probably end up prescribing this intra-uterine device (IUD) at some point or another in my career. The question to ask is whether I would have prescribed it anyway, which I know is a resounding "Yes!" because we have been learning about this one by its trade name since our Basis of Medicine lectures as first year med students. Pharm is everywhere. You think you'll escape it by escaping a dinner?
Now, don't get me wrong, I do not think this means that one should just stop feeling guilty and attend all the dinners, stock up on freebees, melba toast packets and start binge drinking on pharma's dime (for the record, I did not touch a drop of alcohol... that would just feel too much like someone trying to get me drunk so they can take advantage of me... I know, I know, it's a total contradiction for me to feel this way about that, yet rationalize the rest, but just read me out, okay). I'm just saying that it's important to very realistically recognize that you will not get through medical school untainted by avoiding every luncheon and free pen available to you. Ideally, I would like to keep my distance from these as much as I can anyway. But recognizing that I've actually already come to think of trade names of a lot of different drugs as synonymous with the generic -I am already 'tainted' as it were -then the additional harm done by further exposing myself to more advertising is not as great (though probably still not negligable, so yes, be judicious if you decide to go down this path because it probably snowballs, etc).
But, so then if you genuinely think the topic is particularly interesting, and you don't think you know enough about a subject you would like to learn more about, and you're tired of searching PubMed and UpToDate to learn more about it because your eyes are tearing from doing this all day long, everyday, then why not. For example, today's lecture really was intersting. I didn't merely learn about the IUD being marketed, I also learned about the use of antifibrinolytics and specific oral contraceptive protocols for women with excessive blood loss during menstruation, surgical interventions and even what exactly some of the current definitions are -and all the wiggle-room within them -of 'irregularity' and 'too much blood loss', all of which are very practically, clinically useful... stuff that is always good to get exposed to multiple times if you ever want to actually remember it. Don't kid yourself -medicine itself is a brain-washing process, that's how we eventually come to remember so much stuff, only because we get exposed and re-exposed to variants of the same information enough times first theoretically and then in a clinical context, then get examined and re-examined on it... this is the reality of continuous education in medicine, especially early on! See at the end of the day, we all know Tylenol, Valium, Prozac, Pedialyte, Diabeta, Metformin, Micardis... trade names, trade names, trade names. How much do you think you'd be affected by going to a talk where there's a plug for Prozac? And what if you went to a talk about psychoactive drugs and that's where you got an 'aside' refresher on the use of chlorpromazine for intractable hiccups? Aren't you more likely to remember that than skimming past it in a 1000-page volume about all the antipsychotic drugs?
So you know, maybe ideally, we just need doctors to give lectures to other doctors without Big Pharma sponsorship... but what doctor do you know who can afford the time or lack of payment (especially in Quebec, let's be serious) to give the lecture, and how many less people would attend if there was no free food (free food, whether it is a lobster tail or McDonald's will always attract more people, no matter what the context and that is the cold, hard truth). Anyway. I know. This is a big bag of sweet and sour grapes, with a few rotten ones, no doubt. And I'm kind of tired of exploring the various arguments for and against all this.
But yes, for now, I'll say I felt guilty tonight, but did that guilt come from a real ethical place or from exposure to a lot of extreme opinions on both sides and the 'type' of person I want to associate myself with or emulate? Probably from both. Tricky (you can roll your eyes now because this is getting a bit too "meta" -I won't judge you for it). And I understand the whole ethical quandry. But I am also just putting it all into perspective -there are pros and cons and ignoring either is rather dangerous. Okay. Enough about that for now.
Changing topics, for the second half of my pediatrics rotation, I am currently "en régions" (i.e. other regions of Quebec, generally more remote / "rural", like some people here actually drink well-water and their kids get Giardia from it... I refuse to specify location / hospital details in a blog because my vagueries in these matters helps protect confidentiality and also maintains some anonymity of events, people, places, etc...) Today was Day 3 and I am liking it better everyday (I expected that I would, so of course, I was greatly disappointed with how I felt after Days 1 and 2... but let's be serious, I have hated the first few days of any rotation so far because that is when you're at your moron-est and then it gets better). For example, my first day was super depressing and I hated pediatrics that day; you would have too, and this classic moment is why:
I walk into this room of viral plague (well, not really, but it feels like it). I have to see this kid with runny eyes and nose, hacking away, while intermittently sucking intensely on this blue terry-cloth (or as I like to say, “towel-material”) teddy bear. I go to examine him, talk sweetly and lovingly and all that jazz (don’t worry, I was sincere at the time, and I am being sincere now too). What does he do? He “offers” me his sopping-wet, soaked-up-with-drool-and-infectious-secretions toy, and by “offer”, I mean thrusts it enthusiastically into my cowl-neck, bare arm and face. I, of course, thanked him for it (“Is this a present for me? Thank you!” Yes. This is exactly what I said. Verbatim. What else was I supposed to say –“hey, Terrible 2, stop contaminating me and coughing in my eye!”).
Yes, I realize that I am becoming a doctor and have thus conceded to spending the rest of my professional life in a cesspool of germs. But this kind of special treatment is very particular to pediatrics okay. I don't mind getting blood splattered all over me in a delivery or a surgery -that shit just happens sometimes. But this is just poor parenting and there is no medical or personal gain whatsoever in me getting yucked-up here -there is no benefit to this relative 'cost'. Anyway, I am not the callous physician nobody wants to have. I felt bad for the kid and wanted him to get better and mustered up all the maternal love I could to cope with the yuck factor (and successfully at the time, might I add), but honestly the only kid who's saliva I won't mind having all over my face will be my own, one day in the future. I have decided that I don't actually mind pediatrics... but that's exactly how I feel about it -I don't mind it. I don't love it either.
Now NICU (which is part of pediatrics) I loved. I mean they're too small and frail and sick and helpless to do anything, poor things (it's my favourite part of wards, even here). How can you not love them and want to sell bits of your own soul to save their lives if it was possible? Really, I could physically examine and write about those little bodies, and little hearts and open fontanelles and grasp reflexes all day long forever. But towel-material goopy wetness just for the sake of it? For now, I'll say no thanks to that.
Wednesday, October 27, 2010
Tuesday, October 5, 2010
Neonatal ICU: Thrown into the Rose
Today, I want this to be beautiful for you. It is intense and trying and miraculous and interesting for me, but for you it is intended straight for your heart (especially since I was planning on studying, but decided writing was more important for my mental health right now and honestly, the only place to which I can turn, really). I do begin with some frank explanations though -you will need them to be able to feel what I feel and hopefully, just know from feeling (oh, how very unscientific a statement that is!).
Honestly, I was quite apprehensive about pediatrics -after 4 half-days in family medicine about 8 months ago, I had decided that I particularly disliked dealing with sick children in a healthcare setting, with all their crying and squirming, etc. But so, I started my pediatrics rotation with two weeks in the Neonatal Intensive Care Unit (NICU) -this is week 2. And goodness, it is heart wrenching... though not only in the way you think.
This is the hardcore, stereotyped stuff of medical school: the typical making Rounds on all the patients every morning and evening, the "pimping" as they call it (i.e. getting constantly put on the spot with a zillion questions to which you mostly do not know the answer, often guess the answer and sometimes, miraculously and from God-knows-where, very certainly and quite confidently know both the answer and the answer behind the answer... of course, this gets better as you go along, so basically, we are all totally and utterly stupid the first few days and by the end we learn so very, very much that we can actually say that... well, we're still relatively pretty ignorant...), and of course the very intense call schedule.
For all the non-medical people (most of you), let me clarify what this "on-call" jargon is all about and how it works, because depending on who you are in the medical food-chain, call entails different things. In the NICU (as in some other specialties as well), med students and residents on-call keep a pager on them while they actually stay in the hospital for the duration of the shift. For med students, because of accreditation standards of the 21st century and the university trying to meet them, this means call until 11 pm on weekdays, but 24 hr call on weekends when you can get the post-call day "off", without the hospital actually giving you a real extra day off... oh those exploitive geniuses! Don't misunderstand me, I'm not complaining because I know how much worse it used to be, but it still could be better... like who wants someone cutting them open when they haven't slept in 24 hours, I ask you?
So what exactly happens when you're on call in the NICU? If you're not being paged for the caseroom (i.e. labour and delivery, who generally call if there's going to be a risky delivery, in terms of premature deliveries, fetal distress, other complications, etc... so they call up NICU, we run in there and prepare to resuscitate the neonate, sometimes just assess a healthy infant, decide whether the baby needs to be admitted to the NICU for observation / investigations / treatment, etc...), then you're rounding on the 20+ infants in the NICU, making sure to follow-up on labs / blood-work / microbiology, stabilizing babies on different forms of supportive ventilation, antibiotics, nutrition protocols, inserting or removing IV lines, etc... and there are bjillion monitors all beeping, all the time for various reasons.
In just little over 1 week, I have seen a few deliveries, assisted / tried to stay out of the way for a few resuscitations, examined a bunch of healthy and sick newborns, learned to juggle keeping up to date on labs and examining and writing up patients and trying to establish a good rapport with the nurses and administrators and my supervisors and colleagues all at the same time, have had 3 calls in 7 days (including one 24-hr call), assisted with 3 circumcisions and prepared and delivered a presentation. I have dealt with desperate parents, sometimes annoying parents who are really just scared to death about whether or not their baby will survive the great physical effort of living, overjoyed mothers, and even a mother who has been to Hell and back after delivering twins prematurely, losing one of them after a short while and now lives for every breath, test and feed of her remaining darling.
I have been deprived of sleep and rest and sometimes, of meals. I have become addicted to matcha green tea soy lattes at Second Cup. I have sneaked scrubs away from the surgery nurses who guard over blues (blues, greens = synonym for scrubs) like crows over cheese (Aesop anyone?)... I have felt privileged and grateful, angry and ashamedly, momentarily hateful. There has been joy and energy, and dragging lethargy. Sometimes, all of these, simultaneously (or at least variable from moment to moment). I have been thrilled with the vibrating of my pager, and also wanted to beat the pager to a pulp at 4:45 am.
Such is the emotional life of a medical student. We are veritably thrown into the rose -the spiral of fragrant petals, blood red, silky soft in its heart, and perilous anywhere else around it. It is beautiful and delicate and ethereal, blossoming and then drooping, perking up with a little nourishment, before wilting again and requiring the extremes of protection in order to survive the harsh weather. I nearly forget whether I am in the rose or whether I am the rose or whether the rose is me. But I know that I am thrown.
Today though, is the reason that I write to you. I assisted with the re-intubation of one of my patients, one of my babies in the NICU. The doctor was having a hard time getting the tube into the infant's tiny orifices (teeny, tiny nostrils and a mouth into which I could barely fit my pinky) -the goal of all this, of course, being to allow for proper and easier ventilation for respiration (ahem, sorry... the more jargon we learn, the harder it is to avoid using it... basically, breathing). Anyway, so doctor and respiratory therapist are failing miserably (before eventually succeeding, many an oxygen desaturation, bagging and suctioning episode later) at intubating this 600-gram baby, in the first few tries (hey, it's a complicated business for anyone, I can assure you!).
And what is my job? To hold baby down. This tiny little thing squirming and crying with its teeny-tiny limbs and tiny little rib cage moving up and down and baby abdomen twisting from side to side, writhing in distress. So I gently hold her limbs down and out of the way of the people who are trying to save her life, really. But I also profer my finger for her to hold onto in her delicate, miniscule hand. And she squeezes hard with all her might through the whole ordeal. I am there to hold her hand. That is all I can do for her right now. She is so small but in all her anguish, there is surprising strength in that grasp, and she squeezes till her fingers and toes are ghostly pale. Her oxygen saturation plummets down and then comes back up with every attempt to intubate and she cries and writhes and squeezes my finger. I tap her feet to help stimulate her and also to reassure her that here I am, baby, I am still here, I am right here, here. It is torture to watch this little thing fight for her life, struggling relentlessly with every effort. And the tears well up, threatening to spring from my eyes... twice. And I hold it together -of course I do, that's my job and my function here. And I pray and I pray and I do what I'm told, and I help suction and I hold baby's hand. And also I love her because everything we do in medicine is so vitally important, but love heals too and she needs my love in all that frenzy. So I just stand there and hold her hand and love her like she was a part of my soul. And then she is stable. She does not die in my arms as in the morbid image that flashed in my mind earlier that morning when I was on the metro. She is alive and more stable than she was before the intubation.
That's the rose. That's where I flew for a few eternal moments in a long and difficult day for many a baby in the NICU. It's true that you should not get too emotionally attached in some ways, but there is so much more to learn and to be gained and to be given if you do allow your heart to be opened. If you choose to go there, it is worth all the pieces of your soul and every breath of your life.
Honestly, I was quite apprehensive about pediatrics -after 4 half-days in family medicine about 8 months ago, I had decided that I particularly disliked dealing with sick children in a healthcare setting, with all their crying and squirming, etc. But so, I started my pediatrics rotation with two weeks in the Neonatal Intensive Care Unit (NICU) -this is week 2. And goodness, it is heart wrenching... though not only in the way you think.
This is the hardcore, stereotyped stuff of medical school: the typical making Rounds on all the patients every morning and evening, the "pimping" as they call it (i.e. getting constantly put on the spot with a zillion questions to which you mostly do not know the answer, often guess the answer and sometimes, miraculously and from God-knows-where, very certainly and quite confidently know both the answer and the answer behind the answer... of course, this gets better as you go along, so basically, we are all totally and utterly stupid the first few days and by the end we learn so very, very much that we can actually say that... well, we're still relatively pretty ignorant...), and of course the very intense call schedule.
For all the non-medical people (most of you), let me clarify what this "on-call" jargon is all about and how it works, because depending on who you are in the medical food-chain, call entails different things. In the NICU (as in some other specialties as well), med students and residents on-call keep a pager on them while they actually stay in the hospital for the duration of the shift. For med students, because of accreditation standards of the 21st century and the university trying to meet them, this means call until 11 pm on weekdays, but 24 hr call on weekends when you can get the post-call day "off", without the hospital actually giving you a real extra day off... oh those exploitive geniuses! Don't misunderstand me, I'm not complaining because I know how much worse it used to be, but it still could be better... like who wants someone cutting them open when they haven't slept in 24 hours, I ask you?
So what exactly happens when you're on call in the NICU? If you're not being paged for the caseroom (i.e. labour and delivery, who generally call if there's going to be a risky delivery, in terms of premature deliveries, fetal distress, other complications, etc... so they call up NICU, we run in there and prepare to resuscitate the neonate, sometimes just assess a healthy infant, decide whether the baby needs to be admitted to the NICU for observation / investigations / treatment, etc...), then you're rounding on the 20+ infants in the NICU, making sure to follow-up on labs / blood-work / microbiology, stabilizing babies on different forms of supportive ventilation, antibiotics, nutrition protocols, inserting or removing IV lines, etc... and there are bjillion monitors all beeping, all the time for various reasons.
In just little over 1 week, I have seen a few deliveries, assisted / tried to stay out of the way for a few resuscitations, examined a bunch of healthy and sick newborns, learned to juggle keeping up to date on labs and examining and writing up patients and trying to establish a good rapport with the nurses and administrators and my supervisors and colleagues all at the same time, have had 3 calls in 7 days (including one 24-hr call), assisted with 3 circumcisions and prepared and delivered a presentation. I have dealt with desperate parents, sometimes annoying parents who are really just scared to death about whether or not their baby will survive the great physical effort of living, overjoyed mothers, and even a mother who has been to Hell and back after delivering twins prematurely, losing one of them after a short while and now lives for every breath, test and feed of her remaining darling.
I have been deprived of sleep and rest and sometimes, of meals. I have become addicted to matcha green tea soy lattes at Second Cup. I have sneaked scrubs away from the surgery nurses who guard over blues (blues, greens = synonym for scrubs) like crows over cheese (Aesop anyone?)... I have felt privileged and grateful, angry and ashamedly, momentarily hateful. There has been joy and energy, and dragging lethargy. Sometimes, all of these, simultaneously (or at least variable from moment to moment). I have been thrilled with the vibrating of my pager, and also wanted to beat the pager to a pulp at 4:45 am.
Such is the emotional life of a medical student. We are veritably thrown into the rose -the spiral of fragrant petals, blood red, silky soft in its heart, and perilous anywhere else around it. It is beautiful and delicate and ethereal, blossoming and then drooping, perking up with a little nourishment, before wilting again and requiring the extremes of protection in order to survive the harsh weather. I nearly forget whether I am in the rose or whether I am the rose or whether the rose is me. But I know that I am thrown.
Today though, is the reason that I write to you. I assisted with the re-intubation of one of my patients, one of my babies in the NICU. The doctor was having a hard time getting the tube into the infant's tiny orifices (teeny, tiny nostrils and a mouth into which I could barely fit my pinky) -the goal of all this, of course, being to allow for proper and easier ventilation for respiration (ahem, sorry... the more jargon we learn, the harder it is to avoid using it... basically, breathing). Anyway, so doctor and respiratory therapist are failing miserably (before eventually succeeding, many an oxygen desaturation, bagging and suctioning episode later) at intubating this 600-gram baby, in the first few tries (hey, it's a complicated business for anyone, I can assure you!).
And what is my job? To hold baby down. This tiny little thing squirming and crying with its teeny-tiny limbs and tiny little rib cage moving up and down and baby abdomen twisting from side to side, writhing in distress. So I gently hold her limbs down and out of the way of the people who are trying to save her life, really. But I also profer my finger for her to hold onto in her delicate, miniscule hand. And she squeezes hard with all her might through the whole ordeal. I am there to hold her hand. That is all I can do for her right now. She is so small but in all her anguish, there is surprising strength in that grasp, and she squeezes till her fingers and toes are ghostly pale. Her oxygen saturation plummets down and then comes back up with every attempt to intubate and she cries and writhes and squeezes my finger. I tap her feet to help stimulate her and also to reassure her that here I am, baby, I am still here, I am right here, here. It is torture to watch this little thing fight for her life, struggling relentlessly with every effort. And the tears well up, threatening to spring from my eyes... twice. And I hold it together -of course I do, that's my job and my function here. And I pray and I pray and I do what I'm told, and I help suction and I hold baby's hand. And also I love her because everything we do in medicine is so vitally important, but love heals too and she needs my love in all that frenzy. So I just stand there and hold her hand and love her like she was a part of my soul. And then she is stable. She does not die in my arms as in the morbid image that flashed in my mind earlier that morning when I was on the metro. She is alive and more stable than she was before the intubation.
That's the rose. That's where I flew for a few eternal moments in a long and difficult day for many a baby in the NICU. It's true that you should not get too emotionally attached in some ways, but there is so much more to learn and to be gained and to be given if you do allow your heart to be opened. If you choose to go there, it is worth all the pieces of your soul and every breath of your life.
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