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.