On Friday my new consultant (MNC) gathered together myself and the other doclings to do some bedside teaching. Normally I try to slink between the folds of curtain during these sessions as I really don't want to be pimped on differentials for pseudopseudohypoparathyroidism or some other disease dredged up from the Annals of Obscure Internal Medicine. But since MNC hasn't seen me examine / present yet he asked the handful of final meds to step away from the morbidly obese no-necked man who was sleeping with his feet at the head of the bed, and told me to conduct a complete cardiac exam and report my findings.
Yeah. It was sub-awesome.
First of all, I could hardly feel his radial pulse and my racing thoughts kept forgetting where I was in my count...was I at 14 or 24 when I had counted 15 seconds...wait...did I start counting when my seconds hand was at the 12 or the 1 position...where DID his radial pulse go--GAH!
Then I attempted to feel his carotid pulse which should have been located somewhere between his clavicle and angle of jaw (which were, in his case, resting comfortably on each other, heavily padded by folds of flesh). No luck, despite the patient kindly allowing me to dig around there for a while.
JVP? No. Bueno.
Ok, and on to the apex beat. Not so much. Heart sounds?? Is this stethoscope on?? Tap. Tap. Tap. I can't actually even hear his heart beating--hark?! Is that it?? No, that is the sound of my own blood rushing through my ears...
And now to my dazzling presentation. Sure, I'll just neglect to mention that he was hooked up to telemetry, and that he had cardiac meds at the bedside...even though MNC kept asking me, "is there anything else you'd like to comment on??"
"Er...he has a midline abdominal incision??"
"No, he's on telemetry."
"Oh, right." Yeah, the device you hooked cardiac patients up to everyday in the emergency department. The painfully obvious tangle of colorful wires stuck to his chest. Yes, those.
Surprisingly MNC did not shred me into tiny bite sized pieces. I suppose he just assumes that 3rd years are clueless. The major bummer was when he turned to the final meds and asked them how to manage the patient. I had to fight hard to not pull a "Summer" from School of Rock...
But, no. My medical self had failed and my nursing self couldn't help me now.
Ah well, maybe my extremely low bar setting means I will appear to shine upon my next opportunity to examine and present.
Maybe.
:)
Yeah. It was sub-awesome.
First of all, I could hardly feel his radial pulse and my racing thoughts kept forgetting where I was in my count...was I at 14 or 24 when I had counted 15 seconds...wait...did I start counting when my seconds hand was at the 12 or the 1 position...where DID his radial pulse go--GAH!
Then I attempted to feel his carotid pulse which should have been located somewhere between his clavicle and angle of jaw (which were, in his case, resting comfortably on each other, heavily padded by folds of flesh). No luck, despite the patient kindly allowing me to dig around there for a while.
JVP? No. Bueno.
Ok, and on to the apex beat. Not so much. Heart sounds?? Is this stethoscope on?? Tap. Tap. Tap. I can't actually even hear his heart beating--hark?! Is that it?? No, that is the sound of my own blood rushing through my ears...
And now to my dazzling presentation. Sure, I'll just neglect to mention that he was hooked up to telemetry, and that he had cardiac meds at the bedside...even though MNC kept asking me, "is there anything else you'd like to comment on??"
"Er...he has a midline abdominal incision??"
"No, he's on telemetry."
"Oh, right." Yeah, the device you hooked cardiac patients up to everyday in the emergency department. The painfully obvious tangle of colorful wires stuck to his chest. Yes, those.
Surprisingly MNC did not shred me into tiny bite sized pieces. I suppose he just assumes that 3rd years are clueless. The major bummer was when he turned to the final meds and asked them how to manage the patient. I had to fight hard to not pull a "Summer" from School of Rock...
 |
| "Oooh! Ooooh!! ASK ME!! I know how to MANAGE a CCF patient!!! Really!!! YES!!" |
Ah well, maybe my extremely low bar setting means I will appear to shine upon my next opportunity to examine and present.
Maybe.
:)
9 comments:
Gee. My zeal to go to medical just shriveled up and died.
Haha, oh noooo!
This little anecdote was simply to illustrate how one's brain is capable of major flatlining when under duress! :) It wasn't meant to kill MD school dreams! hahah
Dont know if it helps, but I was used as one of those guess whats up with the patient type of people for new doctors a couple of weeks ago.
They had to asses my cardiac system. Out of 12 people, only one person managed to find my radial. The big boss doctor had a go and also could not feel it, as I have had a lot of arterial lines its hard to find. But the boss like to keep asking to see how they went about the exam.
So with a bit of luck you will still get a good report and such.
Yes, well I hope so!
I guess my hard stance at not pretending to hear/find something that wasn't there is what saved me. After some of the final meds claimed they could hear heart sounds the consultant tried and said, "well I actually can't hear them at all". So I felt slightly relieved and less like a moron. :)
Yeah, it's impossible to hear heart sounds in a surprisingly large # of patients. Body habitus maybe? Anyway, it's remarkable how many people make up a normal cardiac exam anyway. Good on you for not doing that.
"Exam is difficult due to body habitus" is a phrase that will save your ass time and again.
At least in North America.
Oh my, did this bring back some memories from my younger days.
***We now interrupt this comment for a few moments of nostalgic shoulders-to-the-ears cringing.***
But "sub-awesome" is my new favorite word.
wv = yedis. Sounds like it should be joke worthy, but I can't think of anything. Because I am old, no doubt.
I've learned not to second guess myself. Many times pts will have normal exams documented by prior providers. When I listen I hear either something totally different or can't hear sh*t. I agree that 'exam limited by body habitus' is a useful phrase, I frequently will say heart sounds are distant and only document that rate is regular based on radial pulse or listening at the apex (which is where I can usually hear better in obese patients).
I can totally relate and it is so frustrating, isn't it? Especially as then the follow-up which you could ace is then given to someone else!
Good to hear that medicine isn't completely destroying your will to live, though ;)
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