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Breakfast with the stars... - Nobody wears a white coat any more... — LiveJournal
...a tribute to becoming a doctor.
Breakfast with the stars...
Pager went off at 0655 this morning. Angel brought it to me; I'd left it downstairs but you can hear it beep almost anywhere in the house. I was too busy completely panicking to do much of anything. I looked at the screen: 0700. Breakfast call, not a patient. I could breathe again.

Working 2pm-2am today. Medicine Day Off tomorrow and Sunday. ALSO (Advanced Life Support in Obstetrics) from 0730-1700 Monday and Tuesday, and then on call for the Medicine Service on Wednesday. Next clinic next Friday.

Yesterday's clinic was a triumph and a reminder of how stupid I get when people ask me questions. I had a patient - she was on someone else's schedule, but I was in clinic, so he thought he'd see if I could see her and I said yes, of course, I was actually done with my paperwork for the other two people earlier than anticipated. She had what was bordering on a pilonidal abscess, but that we finally decided was just a skin abscess. I looked at it. It looked inflamed and red, and the skin around it was firm, but it didn't feel like it was still the giant sac of icky stuff that it must have been before it burst (two days earlier). But I am not always certain of my skills, and I got one of the staff. We were walking to the room and he said "So what are you thinking you'll do?"
I panicked. I tend to. I'm terrified I'll be wrong and look stupid and get yelled at and be a disappointment. I blithered a bit about how it could go antibiotics + warm compresses vs. I&D, how it'd drained some already. And he looked at me. What do you want to do?
What did I want to do? I wanted a real doctor to look at it and tell me what to do so that I could nod and agree. I opened my mouth. It looks like it's drained well, I'm leaning toward not doing the I&D. He nodded. "I just wanted you to call the shots, make a decision." He knows. They all know what it's like, being young and inexperienced and afraid you're wrong.
In this case, I wasn't - he agreed with me, I said we would do antibiotics and then I got the list of allergies, including penicillins and cephalosporins. I went back out, different staff this time. "I have this lady with a skin abscess, it's draining, it looks a little red still, she's allergic to penicillin and cephalosporin and I'm not sure what to use to treat." He looks at me. "Tell me what you're thinking. What are you worried about?"
Panic. "Um..." This particular staff is a man I am quite fond of, but who is very smart and fast on his feet. I am not, I am slow, I have to be told multiple times before the lightbulb goes off. "It's a skin infection...so..." A little nod. "Staph." Something had clicked. I was mentally congratulating myself on remembering anything regarding antibiotics and microbes when he nodded again. "And?"
"And...um..." There are two schools of thought regarding what to do when you have been lobbed a question that you are certain you are supposed to know the answer to. One of them is to be quiet before you make yourself look stupid. The other is to talk through it, out loud, so that if you look stupid at least you'll learn where your error was. I started talking. "And...given its location, I suppose enterococci might be a concern." He fixed me with a look that said Okay, not wrong, but not what I wanted. I thought, and then a moment later something blinding went off in my brain. "Strep!" I did my best not to articulate the exclamation point. He nodded, approvingly. And then came the next question.
So what do you treat staph and strep with?
The first-line answer is penicillins, the second-line cephalosporins. Both of which she was allergic to. He nodded as I explained all that to him. "So what are you thinking?" And I started racking my brain for other drug classes. Something inside me danced around "tetracycline" but for some reason I ignored it, considered erythromycin out loud, got no flicker of approval, discarded it, and then the card flipped over and I remembered what tetracyclines were used for in teenagers: acne and skin infections. "Tetracyclines, that would work." Another nod. Now which one? Which one? Which-what, there's more than just "tetracycline"? And I know there are more drugs in the class, I know that now, sitting here at my computer, and I can even name some of them easy as thought. "I think...there's no reason not to just use tetracycline proper, is there?" He smiled, shook his head. No, there's not. Trick question. I looked up the dose, suggested 250 mg four times a day for seven days, he said that sounded quite reasonable, and then we were on to being quizzed over antibiotic warnings. What should you tell your patient?
The answer, after I admitted defeat and he baby-stepped me through the process, is thus: Take tetracyclines on an empty stomach and especially no milk or calcium-containing products within half an hour of taking it. Drink lots of fluids to avoid getting pill esophagitis (did you know that tetracycline is used as a sclerosing agent in recurrent pneumothoraces?). Don't get pregnant.
There was a little smile on his face; the process hadn't taken long but fear had dragged it out forever. He hadn't been cruel - cruelty does not come with soft and gentle words, with the slow prompting for me to think through what I was saying - but the faculty here are not cruel people; they simply want us to become the best that we can become. I am glad I was not given the answers; I think I am a little bit better for the ordeal, as much as it pains me to go through it, and I have a memory of success at the end.

Medicine is going to be a very long block.

now feeling:: sleepy sleepy

4 whispers echo . o O ( ... ) O o . whisper a word
attickah From: attickah Date: August 26th, 2005 07:23 pm (UTC) (etched in stone)


Take tetracyclines on an empty stomach and especially no milk or calcium-containing products within half an hour of taking it. Drink lots of fluids to avoid getting pill esophagitis (did you know that tetracycline is used as a sclerosing agent in recurrent pneumothoraces?). Don't get pregnant.

Why the no-calcium thing--because it interferes with the drug's function/absorption? And why no pregnancy--because it's a teratogen?

< /curiosity >
ayradyss From: ayradyss Date: August 26th, 2005 09:11 pm (UTC) (etched in stone)

Re: Questions....

Tetracyclines bind to everything, especially calcium. Especially bone calcium, especially fetal and child bones. You can actually see it in children who've been treated, bone samples fluoresce and you can see discolored teeth.
They're also feto-toxic.
jays_princess From: jays_princess Date: August 26th, 2005 09:46 pm (UTC) (etched in stone)

Re: Questions....

the only thing i ever remember about tetras is that they cause teeth discoloration in kids...and that they're fetotoxic.

other than that, i totally forget EVERYTHING!

i'm like you...i usually stay quiet so as not to look completely retarded, but i'm trying out the talking-aloud thing. so far so good. my resident yesterday was walking us through an ACLS game and the situation was a young girl with a trach collar and a GT that was vomiting blood. she asked what labs i wanted...um, i don't know for sure what would help in an acute situation like that. so i stumbled through asking for an ABG, a CBC with diff...and completely forgot that it may be possible to aspirate through the GT with a foley to see if there is still bleeding going on. this girl also has liver disease (she's not my patient, per se, so how am i supposed to know?) so i didn't even think of varices being a potential cause. that's one of those things they teach you in med school that only happens to alcoholics and people with hepatitis. gah!

i don't feel like i'll ever know all the answers...which no doctor ever does...what scares me the most is that i'll never know even half the answers.
tablecolor From: tablecolor Date: August 27th, 2005 01:32 pm (UTC) (etched in stone)
somewhat relieved to know that i'm not the only one who gets confused over antibiotics...
4 whispers echo . o O ( ... ) O o . whisper a word