July 27, 2015 § 2 Comments
We’ve reached our last week of internal medicine practice and I’m looking forward to the change of pace that awaits us from next week. It’s been a rich learning experience and I feel so much more secure now that I have some hospital experience here in Norway.
From next week, Skjalg and I will be working in “hjemmetjeneste”. This is a government service that provides home care for patients, such as giving medication, making food or aiding with personal care. The number of visits a day for a single patient varies depending on their needs. In addition to the shifts in hjemmetjeneste, we will be working at the restaurant. Skjalg’s stepmom will be heading back to Thailand to visit her mom, so it is likely that we will need to pick up some more shifts. It’s going to be a tough month for us, but it will be really nice to fill in the financial hole created by the exchange rate this past year (we have to pay our tuition in dollar and our rent in euro and were hit quite hard this past semester).
Our schedule – without the extra restaurant shifts – for the next 5 weeks! Day shifts go from 7:30-15:00 and evening shifts from 15:00-22:45.
Our time here at the hospital has been nice but we’re ready for a change. Since the first week, things have become quite monotonous. We start every morning in the large conference room where all of the doctors from the different departments meet and discuss new patients. Depending on the number of patients and associated discussions, this can last anywhere from 20 minutes to an hour, though usually closer to 20 minutes. After this, we head to our respective departments and sit down for more meetings.
The first is a meeting with all the doctors on the shift to discuss the patients. I find this really interesting (what I’m able to follow at least). A large projector displays all the necessary patient information, including lab values and any notes/referrals. There is also a program that shows any imaging results, CT scans, MRIs, X-rays, etc. One of the doctors told me that they like to be at least two when making a decision about a patient and prefer if they are three, with the third coming from a different department. I have to say that I am really impressed by the level of communication here.
During this meeting, the names of different medications are constantly brought up and discussed. We haven’t taken pharmacology yet, but I still want to get something out of it. My solution? I downloaded an app for felleskatalogen (catalog of pharmaceuticals in Norway) and look-up the various medications as they discuss them. I can also save the ones I look up to a list so that they are easier to find. The profile of each medication is extremely thorough and there is even an option to check the effect of medications on each other.
Following the doctor’s meeting, the doctors for each group (patients are divided into two groups by color, i.e. red and blue) meet with the corresponding nurse. During this time, they discuss the patients in more detail. The doctor usually asks how the patient has been doing, how they have been interacting with the nurses and if there is anything that stands out. Then they update the nurse on what was discussed at the earlier meeting and begin to discuss further treatment. This is usually over by 11:00/11:30 (depending on the doctor and cases) and after that, the doctors go to visit each of the patients.
After spending an hour or so visiting the 5-6 patients in the group, it’s time for lunch. At this point, I head up to grab my lunch from my locker in the medical student room. Well, sometimes. Usually I stay in the department until it’s time for me to go home, just so I don’t miss out on anything. The reason for this is that after lunch, the doctors sit down to paperwork. This is the time during which I can get lost in the shuffle. If there is something happening, you can bet I’m there! Otherwise, the doctors don’t seem to enjoy having a medical student staring over their shoulder….
One day, Skjalg and I took a patient for an echocardiogram. The doctor was in training, so she was good about describing the whole process for us. When she was done and the head doctor came in to check the results with her, Skjalg and I were allowed to continue examining the patient for our own benefit. The patient had chronic kidney failure and the doctors in my department suspected him/her of having amyloidosis. They were doing the echo to see if they could find any morphological changes in the heart. Amyloidosis is a disease where protein is deposited outside the cells in various organs/tissues. There are several types depending on the type of protein and this patient was suspected of having the age-associated type, senile systemic amyloidosis. When it was time for us to take the patient back to our department, the doctors actually thanked us for showing interest. I found this so surprising because to me it’s obvious that we are interested – we should be! It also made me wonder about what other students are like…
On another day, I got to see a kidney biopsy. I’ve never seen one before and am still so in awe about how it was done. For some reason, I had it in my head that it was more invasive and the sample much larger than it actually is. The patient lay on his/her back and the doctor visualized his/her anatomy via ultrasound. Then, once all the necessary sterile preparations were in place, the doctor attached a spring-loaded needle to the transducer and located the ideal point for the biopsy.
The patient was instructed to hold his/her breath (to stop the organs from moving with respiration) and the needle was engaged and in and out within a second or two. The sample was washed out of the needle with saline solution and then quickly examined by another doctor using a light microscope to ensure that the sample was sufficient (in the case of a kidney biopsy, they had to ensure that there were enough glomeruli to perform an accurate diagnosis). Meanwhile, 2 or 3 more samples were taken from the patient.
Once the samples were confirmed, we ran them over to the pathology lab for further processing.
To maximize this last week, our plan is to spend at least two days in the emergency room, if they’ll have us. I regret that I haven’t spent more time there because it seems like there is so much more to do. Since I’m assigned to the kidney department, it hasn’t felt right to run off to the ER if there is something that I could there. But knowing if there is going to be something to do or not has been challenging! Instead, my days have been: attending four or so hours of meetings, going on rounds and then joining anything possible in the afternoon. By the time I’m done there, it’s almost a bit too late to head down to the ER (we’re supposed to finish around 15:00/15:30).
Now that I’m 3 weeks in and feel more comfortable here, I realize how little of an issue it would have been to just go whenever I want. There isn’t really any structure here, at least in my personal experience. I’m assigned to a department and I follow around whichever doctor will have me (usually the most senior doctor) and if I’m not told that I can join anything that day, I’m kind of on my own. I’m at a level of my education where I’m just not very useful. Once we have taken pharmacology (4th year) and have more clinical practice (4th and 5th year), we’ll be able to do a lot more. As I wrote to a friend earlier today, I’ve learned two things during this past month: (1) we know a lot, (2) we know nothing.
As you can probably tell, I’m currently in a mixed state of satisfied and disappointed. I wish there had been a bit more structure and guidance, but at the same time understand that this is not always possible in this environment. There have been good teaching moments sprinkled throughout the practice, for which I am very grateful:
- One of the doctors, Dr. J, was a great teacher when he wasn’t busy. He taught me about different types of dialysis and even sat down with me for 20 minutes to explain the exact mechanism behind peritoneal dialysis – with drawings and everything. Despite his many years as a doctor, he’d retained his ability to think like a student and would often explain things in list form with plenty of theoretical details. Unfortunately he went on vacation after the second week, so I didn’t have much time with him.
- Another doctor, Dr. T, was in a teaching-mood one morning and explained the importance of each of the lab values as we went through them. I furiously wrote these down and then properly answered a question when I was pimped by Dr. J a few days later. The question was, “What is the reason behind the increased leukocyte count?”, to which I answered, “Treatment with steroids”. I didn’t execute my answer very well though. I wasn’t sure that I had the right answer and mentioned that I thought I’d heard Dr. T say it earlier that week. Dr. J said I was right but joked that I’d cheated. Another doctor, Dr. Q, then asked if I knew the mechanism behind it. When I shook my head, he explained that steroids decrease the expression of the adhesion molecules that enable leukocytes to exit the blood into the interstitial space. So, there are technically the same number of leukocytes in the body, but more in the blood because they are stuck there. Pretty cool!
- Last week, we had a doctor in (for just the day) who constantly asked me if I had any questions. This was really nice because I tend to write down things I am curious about, look them up later and then if I don’t find anything I ask. While we were waiting for the nurse to come for the doctor-nurse meeting, he pulled up a random patient’s EKG on the projector screen and told me to diagnose it. I was a bit flustered, since we’ve learned everything in English, but was pleasantly surprised at how quickly it all came back. My analysis was a bit bumpy – mainly because the speed is different (Norway uses 50 mm/min, whereas the rest of Europe 25 mm/min) – but I got it right in the end: acute right myocardial infarction.
A last experience – and an extremely valuable one at that – came with yet another new doctor, Dr. P. (Since it is summer and most Norwegians take their vacations during summer (Norwegians have the right to 3 weeks of vacation during the summer and 2 weeks outside of the summer), the doctors in the department have changed almost every week). One of the patients in our department is terminal and Dr. P had to set up a meeting with his/her significant other and sons to inform them there are no more options for treatment. The patient, whom we can call Blue, suffered for a long time with chronic kidney failure and received a kidney transplant last year, which unfortunately didn’t go well. Blue ended up with an infection and has been on a downward spiral since then.
The meeting ended up being three: one with Blue’s significant other, one with the most involved sons and one with the others (who were on vacation during the first two meetings). Each of these meetings lasted at least an hour long – which left me pleasantly surprised! I was present for the first two so that I could witness first-hand what it is like to deliver bad news to a patient’s family. I feel so lucky to have had that opportunity, as Dr. P has an especially good bedside manner. I’ve been on several rounds with him now and really admire the way he talks to the patients. He’s the kind of doctor that I hope to be one day.
That’s enough for today! Hoping the rest of the week goes smoothly, maybe with a few bumps for learning’s sake 😉
P.S. My stats page shows me which posts are read that day (not who or when). Someone looked at this one today – Perpetual fluctuation is the essence of the perpetual universe – and I’m so happy they did because it was just what I needed to “hear”. Such a treat to be able to look back like this! More than two years ago…so much has happened since then!
July 19, 2015 § 7 Comments
This month (so far) in pictures.
Grandma’s homemade whole grain bread!
July 6th – Signed up at the new StaminaHot gym. They are remodeling the whole area and the gym is now up on the 4th floor. It has stunning views!
Post-workout sushi made by Skjalg’s stepbrother Pai – such a treat!
This random photo represents one of my “I love Norway” moments. The receptionist at the gym is only there for a few hours a day during the summer, so the rest of the time, the gym is unmanned. There is a little kitchen area with coffee mugs and a coffee pot. I watched one guy walk over, wash some dishes and put on a fresh pot of coffee. Then he poured himself a cup and walked back to the training room to continue training. This is something I feel could never happen in the US because of the liability. Here it just seemed so natural…and homey.
July 11th – Skjalg and I started the day with a hike up to the top of Keiservarden
That night, Skjalg had his shift at the restaurant (we’ve been working a couple shifts at Skjalg’s dad’s restaurant; I have mine on Fridays). He ordered some chicken satay to go, picked me up and we headed up to turisthytta (a sort of lookout point) to eat dinner and enjoy the midnight sun.
After last weekend, this has been the weather pretty much every day 😦 Trying to make the best of it and appreciate the coziness… but it’s hard!
July 16, 2015 § 4 Comments
Time flies when you’re having fun… and when you’re exhausted! It’s been a bit of a challenge transitioning from student life to being at the hospital. Sometimes during our time off, I’ll catch Skjalg just staring out the window with his hands in his pockets. After 5 minutes or so, he always turns around and says, “It’s so weird having free time”.
Last I wrote, I had just experienced something that I will remember forever: my first ever patient! I do want to clarify that this is not the first patient I’ve seen as a medical student, just the first one for whom I was responsible (at least for the physical evaluation, history and admittance paperwork). Our first clinical class is internal medicine, of which we have completed 2 of 5 semesters. During the first semester, we visited the hospital twice a week and learned how to properly examine patients and take a patient history. This continued into the second semester, but we only had “class” once a week and three of the sessions were seminars covering endocrinological diseases. In internal medicine, we are assigned to a patient as a pair, one with whom our doctor is already familiar, and afterwards we present our findings. Since it is a teaching hospital, the patients are quite used to students examining them and are fully aware that the examination is practice. The experience last Wednesday was different because the patient was essentially my patient.
So, jumping back to last Wednesday. All I knew in the hour before was that I would be getting a patient with erysipelas, that he/she spoke English and that the resident would be there to help me if I needed it. I didn’t really know what to expect or what I would have to do, so I didn’t prepare anything. I simply followed the resident while she checked in with her patients and when I was alone, I browsed through some physical exam techniques. Suddenly, it was time.
A few long, quick steps brought us over to a separate area of the emergency room with two doors. A nurse was there dressing himself in a yellow gown and putting on a mask and gloves. As he snuck into the room, it hit me: the patient was in isolation. All of a sudden, things became really fast paced. The resident told me that I would be going in alone and that, in addition to doing the full physical and history, I had to take samples for MRSA (a highly resistant bacteria that is strictly monitored in Norway and many other countries). It really wasn’t a big deal in the end, and definitely not complicated, but this was my first time and I had to do it sterile! I had to wear a special sterile gown, mask and gloves, use a special stethoscope and couldn’t touch my notes or pens. It felt like I had to do everything without touching anything, or at least be extremely aware of every single movement I made.
In those minutes outside the room while I was getting dressed, I felt like I was getting ready to jump out of a plane and the resident was telling me everything I needed to do to deploy my parachute and survive. A little dramatic, I know, but that is really what it felt like. Luckily, it usually doesn’t show when I am nervous. My confusion/anxiety somehow translates to confidence when I need it most. Fake it till you make it, right?
When dealing with patients, there is so much to remember! You have to remember what questions to ask, in which order to ask them and how to ask them. You have to make sure you ask the right questions and there are so many questions you can’t forget to ask (i.e. do you have any chest/abdominal pain?). For the physical examination, you have to have a system. Otherwise, you’ll have the patient moving up and down, back and forth – and most likely wondering if you know what you’re doing! There are so many details you need to cover and it needs to be done in a timely manner – but must also be thorough and correct! And this all needs to be done in a way that still makes the patient feel comfortable, that makes them feel heard and their thoughts/feelings respected and that makes them feel like they are in good hands. All of this was swirling around in my head. Add on the fact that this was only my second day of practice – and in a foreign country! – and I had to remember to keep it sterile!
I did everything I could to maintain a facade of confidence, competence and caring. That didn’t stop me from feeling like a little girl with no business being there… but no one – especially the patient – needed to know that. The MRSA samples had to be done right away. This was required for this patient, who we can call Rio, because Rio was a tourist and protocol dictates that they be screened. I had to take samples of Rio’s nose, pharynx (back of his/her throat) and lastly, perineum. For this one, I gave Rio the choice of either me or him/her doing it, for obvious reasons. After I’d collected the samples, I clicked the call button for the nurse and then met him outside to deliver them. I don’t think he ever picked up on the fact that I was just a medical student because at this moment and for the rest of the examination, he talked to me like I was a doctor. He asked me if I wanted to run an EKG and I told him that I wanted to wait until the resident came back to confirm whether or not that was necessary.
Back in the room I jumped into my examination routine. For this part, I was so, so, so unbelievably happy that this was all in English! It was so nice to have one thing that I could be 100% confident about. Rio was patient (hehe) and cooperative, which was helpful when the resident finally came in and then suddenly left again – for an hour and a half. I’d finished with my examination, but had no idea what to do after. Since I didn’t know how long the resident would be, I just stayed there and tried not to touch anything. It was a bit uncomfortable keeping the conversation going for so long, but Rio was luckily enough pretty easy to talk to. Finally, the nurse came in with an infusion bag with penicillin and the resident swooped in to explain the treatment.
I was buzzing quite a bit afterwards. I felt a little helpless and didn’t really know what to do with myself. The resident told me that I would need to write the admittance report – in Norwegian – and that gave me enough anxiety to keep my mind busy for the next 4 hours. Yes, 4 hours. It got so busy in the emergency room that I just stood around trying to not be in the way until finally, at around 18:00, the resident showed me to a room where I could sit down to write it. The hospital uses a program called DIPS for all patient information. Skjalg and I were both given usernames and passwords, but our access is limited (since we’re not doctors yet…). Without this access, I wasn’t able to do any of the things that she’d told me to do. I didn’t want to go back to the ER and bother her more than I already had, so I decided to write up everything in a Word file and then just transfer it over into her DIPS account when she got back. At this point, I had had no food or water since 6:30 in the morning and was feeling absolutely exhausted. When she came back, I was pleasantly surprised as she sat down next to me and read through the entire report, giving me feedback. It was such an important learning experience and I am so grateful that she took the time to help me.
At 20:00, I was free. I made my way up to the medical student office, fueled by the thought of coming home to eat and crash. When I entered the office I heard Skjalg’s voice. I peeked around the corner and there he was, sitting in the small meeting room with takeout from his dad’s restaurant.
At that moment, I felt so acutely aware of everything that had happened, that was happening and that will happen. I saw us as young, exhausted medical students at our first job in a hospital in Northern Norway, me having just experienced something that felt so huge for the first time… something that will never feel that huge again. We’ve come so far and yet this still feels like the beginning! There is so much more to learn and so many more experiences to be had and I feel so lucky that we are doing it together 🙂
July 8, 2015 § 2 Comments
12 hours with no food or water and one bathroom break (which was at that point already 6 hours overdue) and I am about to crash. Today I had my first ever patient and wrote my first ever report. Was I ready for it? It certainly didn’t feel like it, but maybe it’s something you’re never really ready for.
July 5, 2015 § 10 Comments
It’s been a while since my last post and I’m starting to feel way too anxious about all the things I have yet to document. I want to write posts about my last exams and the weeks that followed, but that’s quite the project! Before that, I want to finish answering emails/comments from you – I’m working my way through them all, I promise! That’s been my plan and I will most likely get through it this week. However, life does go on and that too needs to be documented. For now I will just say that exams went well, we’re both done and so, so unbelievably happy about it!
We arrived in Bodø yesterday after a completely exhausting trip that included an 8-hour layover from midnight to 8:00 am in Copenhagen and the airline losing our bags on our stop-over in Trondheim. After lunch at Skjalg’s dad’s restaurant and dinner at Skjalg’s mom’s (grill food – perfect for 4th of July!) we crashed and ended up sleeping for almost 12 hours.
Today has been lazy and perfect. Skjalg and I both got sunburns from coffee on the patio this morning, working on the lawn in the afternoon and a fully sunny evening hike with Skjalg’s dad. I hope it doesn’t take me too long to get used to the light here (it is light 24 hours of the day!).
Tomorrow we start our practice in internal medicine at the local hospital. I’m extremely nervous and extremely excited at the same time. Hopefully it will go smoothly!