My last post got all
by fiona
My last post got all sad and reflective, but I forgot to write about one of the funny things about working in an ENT clinic. In addition to seeing people with tumors and swallowing problems, you get the occasional speech therapy patient. People who have some kind of trouble with their vocal cords come to get evaluated and hopefully rehabilitated. As part of the evaluation, these patients undergo an electrical measurement of their vocal cord activity while they are making a variety of sounds. Often these are very loud sounds.
Yesterday, soon after I arrived in clinic, someone started this test. All of a sudden I heard this "aaaaaaaaaaaaaaaaaaaaaaaaaaahhhhhh..." Really loud, same note. It seemed to go on for minutes. Could this really be just one breath? Then they went up in pitch: "AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAHHHHHHH..." So loud! It was like somebody was just sitting in a room, yelling. They probably didn't realize, of course, that literally everyone in the whole clinic can hear them.
Then they started saying phrases, again in the same loud, deliberate tone. "HELLO. HELLO." "BLUE." "WALK IN THE PARK." These phrases are just wafting down the hallway, in and out of exam rooms. Its hard to imagine the actual scene: someone sitting on a chair with electrodes hanging off them, getting prompted by a quiet, mild mannered technician to repeat after them. It's much easier to picture someone just sitting in there having an extremely loud conversation about very weird things while occasionally yelling for no reason. And this, of course, makes it impossible to concentrate on anything else. "WHAT'S FOR DINNER?" "HELLO."
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Posted on April 22, 2004 | Comments (0)
I currently working with a
by fiona
I currently working with a ENT (ear nose and throat) doc once a week. He is actually a surgeon, who specializes in head and neck cancer, so I have gotten to see some pretty cool things. Actually, I hung out with him in surgery a few weeks ago, and saw a sub-sternal goiter removal, a laryngectomy, and the beginning of a thymectomy (where they used this weird little crane to hoist up the sternum of a 15 year old girl in order to gain access to her thymus, located just above her heart). Surgery was a really rewarding experience, and my pervious night's review of neck anatomy definitely paid off- I was able to make myself look good by correctly naming a couple of muscles and nerves. Though I think I need to learn to be a bit more assertive with what I know - "Is that the omohyoid?" Doesn't sound as good as just saying it confidently, even if I was wrong. "Omohyoid." I also did not know which animal was famed for having the largest omohyoid muscle of all animals (Dr. Andersen was either trying to be funny or look smart). Turns out, its the badger.
A lot of the folks I see in clinic are there for post-op visits, after Dr. Andersen has removed part of their head or neck. Yesterday I saw I guy whose ear had been replaced by a flap of thigh skin (he had had a skin cancer in his ear canal). I see tons and tons of people with tongue, mouth, and throat cancer, the vast majority of whom were long time smokers, and some of whom, in some inexplicable feat of either masochism or stupidy, are still smoking. I think all kids who are caught smoking should be required to do volunteer work in an ENT clinic or a VA hospital, where practically everyone is dying of lung cancer or emphysema.
Some of these patients, though, are the exception. Yesterday I also saw a guy, a young guy, maybe he was 29 or 30, who got a throat cancer in his early teens. He wasn't a smoker, he didn't do anything wrong, he just got cancer. He eventually ended up with a laryngectomy, where the entire larynx (voicebox) is removed, and the trachea is reconnected to the skin at the base of the neck. He is now like one of those old guys you occasionally see with the horrible growling voices who breathe out of a hole in their necks. He talks by way of a small voice prosthesis that funnels air into his esophagus, allowing him to use the flappy walls of his esophagus as vocal cords. But because there is no muscular control over this tube, his voice has no tone, no inflection, and no variation in volume. In addition, every time he wants to say anything, he has to lift is hand to the gaping hole in his neck to cover the opening of the prosthesis.
He also must undergo frequent painful dilations of his esophagus, and the changing of his voice prosthesis every 8 weeks or so. I was there for that yesterday, and it looked very unpleasant. He recently had to get a feeding tube reinserted because he couldn't get enough food down his damaged esophagus to keep him going.
It seems so cruel, such an incredibly harsh blow to this man's life, especially his social life. He told me that because of multiple treatments and difficulties, he went a period of three years without talking - as a teenager. Imagine how that would change your life. He is in architecture school now, and says that people treat him really weirdly because his voice is so, well, grotesque. He told me of a time when he was working on a small group project, and one of the girls in his group was literally scared of him. Looked terrified and grossed out every time he said anything. How awful. It weird, but it seems like this kind of outcome is easier for us to accept if it happens to someone whose actions have caused it (aka by smoking). Not that their suffering is any less, or they deserve it more, especially considering how difficult it is to master a nicotine addiction. But somehow we think, reasoning with our child-like sense of fairness, they brought in on themselves. Seeing it in an "innocent" person is much harder, especially if they are just at the beginning of their life. Nothing about it is fair.
It was really cool to get to talk to this guy. We ended up walking out of the clinic at the same time and i got to chat with him a little more. He told me how he was getting ready to climb mount St. Helen's, which he does every year. He told me that biking up the hill to OHSU wasn't that hard and I should just do it. He was just this cool guy. I couldn't help but wonder about how difficult it must be to meet people and to make new friends, much less go on dates or find someone to love him. I hope he does.
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Posted on April 22, 2004 | Comments (0)
Last Tuesday I went through
by fiona
Last Tuesday I went through a classic medical school rite of passage. Everybody's favorite... the pelvic/rectal exam! And because everybody loves getting them so much, people are usually really excited to have inexperienced medical students practice on them. In fact, patients often request specifically that a medical student (preferably one in their first or second year) perform their pap smear, testicular exam, or rectal exam. They just can't get enough!
However, it occasionally happens that people find these exams uncomfortable, invasive, and emabarrasing, and if avoiding them at all costs isn't an option, they sometimes prefer that the person performing them has actually done it before. Go figure. Patients are weird. So, to deal with these ornery folks, it is nice as a medical student to get the chance to practice doing things like this in a neutral, educational environment. I have heard stories of some medical schools (hopefully in the distant past) encouraging their students to practice doing pelvic exams on uninformed women who are under general anesthetic for surgical procedures. OHSU takes a different approach. They pay people big bucks to be our guniea pigs.
It went down on a tuesday evening. Because I forgot to sign up for a time, one was appointed to me, and it happened to be the evening before a test (that's what you get for not being proactive about your education). I showed up with a group of students, and we divided ourselves into pairs. Interestingly, we self-divided along gender lines - every single pair was either 2 girls or 2 guys. I don't know why. Maybe that highlights how subconsiously uncomfortable everyone was. I paired up with this girl Sarah, who's in my Medical Students for Choice group. Turns out she's really good at it. Turns out, I'm not so good.
We are guided to a room with a man in a suit and a man in a gown. The man in the suit is a urologist, and he procedes to guide us through how he does a male genital and rectal exam. The man in the gown is the lucky recipient of three of the aforementioned exams. He is really nice and patient. Sarah goes first. She does a good job. Then I go. First you ask the man to stand and hold up his gown, as you are sitting on a stool in front of him. You look first, assessing the distribuition of pubic hair, and the general size and symmetry of all involved structures. Then you procede to squeeze and pull all of said structures, pausing to check for any unusual ulceration, fibrosis, discharge, or asymmetry.
As I don't possess any of these structures myself, it was tough to know just how much pressure I could exert. I think I might have been a bit on the cautious side. Then the whole "turn your head and cough" test. Who knew you could stick your finger so far up there? Man. That was really suprising to me. I guess it shouldn't be, since i knew that the layers of the scrotal wall were contiguous with the abdominal wall, but still.
Then came the rectal and prostate exam. I started by lubing up the wrong finger - see, you do the hernia exam with your middle finger, but the rectal exam with your index finger. You want maximal length for the rectal because that prostate is pretty far up there, and you need to get a good sense of its contours on all sides. As the urologist instructed, I pushed in "to the hilt." This is perhaps unneccessarily graphic, sorry. I then displayed my inexperience by using two hands to fumble with the fecal occult blood card (Sarah only used one). But Sarah and I were even because she inadvertenly pushed the poor guy's testicle up into his abdominal cavity when attempting a hernia exam.
However, she quickly surpassed me after I botched the pelvic exam. This, of course, was done on a different patient. Sarah and I were guided to another room with a woman in a gown, and a woman in some clothes. The woman in the clothes demonstrated her methods of doing a breast exam, followed by speculum exam, pap smear, and bimanual exam. Then I went. I think I may have lost points for failing to check for nipple discharge and for opting to only examine one breast in the interest of time. I also created an akward moment while explaining to the patient that I was "looking at her breasts to make sure everything was symmetrical." Turns out, she had one inverted nipple, so her breasts were clearly not symmetrical. I made some sort of incoherent joke, and moved on.
Then came the speculum exam, something I have both experienced and witnessed, on multiple occasions. Because of this, I assumed it would go smoothly. There's where I was wrong. Dead wrong. The speculum went in without a hitch, but then when I went to open it to look at the cervix... where was it? Just mile after mile of pink vaginal wall, caving in and dead ending, taunting me, hiding from me the object of my pursuit. I instantly panicked and forgot how to manipulate the speculum, that pesky instrument of screws and levers. I followed my instructor's advice to "just relax the speculum," which induced a cry of pain from my poor patient. I had pinched something. It might have been the cervix. I removed the speculum.
Second try. Even less successfull. Still no sign of the elusive cervix, but this time when I was searching around for it I managed to get some of that damn vaginal wall stuck between the beaks of the speculum. Literally stuck! This produced more pain, and requests to have the speculum removed. I complied. By this time I was getting really flustered. I was regressing to my elementary school years, when not being good at something would make me burst into tears of frustration, and then keep crying out of embarassment for crying in the first place (ok, so maybe that lasted into my college years, but I thought I was over it). I was seriously almost to that point. Fortunately, the woman was being kind and patient and said that I could go again. They must have been paying her like thousands of dollars.
"Maybe its the speculum," my guide says. "Sure," I think. Blame in on the piece of metal. She gets out a longer one. Third try. Speculum in. Speculum open. Nothing. NOOOO! What kind of a doctor am I going to be, if I can't even find a fricking cervix! The thoughts are racing through my head. My face is turning hot and bright red. I'm considering dropping out of school. Then the doctor leans over my shoulder and says, "Look, there it is!" And its there, barely. Its like hanging off the wall way to the left, facing down - it doesn't even look like a cervix. Some sort of stupid, gimp cervix that's in the wrong place. I don't think it would even be possible to do a pap smear on that. But I feel triumphant. I decide to stay in school.
Of course, Sarah gets in there, and sees it right away. The cervix just pops right into view. Great. Every other person on earth is good at it. But I don't feel so bad because during the bimanual exam I felt her left ovary when no one else was able to, not even the doctor. I'm sure that some day I will look back on that experience with a happy sigh and a far-off look in my eyes. I will remember what it was like to try this akward thing for the first time. I will probably wish I was back in medical school, practicing pelvic exams and studying for tests because those were probably the best damn years of my life. Hopefully by that time I will be able to find a cervix.
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Posted on April 14, 2004 | Comments (0)
It is a glorious day.
by fiona
It is a glorious day. It is perfectly warm and sunny, and the construction has momentarily halted across the street, returning me to the welcome sounds of the city on Saturday. Oh. They just started again.
I am sitting on my balcony with the final act of Wagner's "Ride of the Valkeries" cascading dramatically through the kitchen window, battling with the incessant metallic buzzing from the construction site. There. I just gave Brunhilda a volume boost. Take that, you saturday-workers, you!
The sun is steadily creeping towards me as I sit at my newly acquired faux marble-topped balcony table. Now I can sit out here on a warm weekend morning, drinking earl gray tea and reading the Annals of Emergency Medicine in total comfort. Yesterday I rigged up a long extension cord from the kitchen to supply the white christmas lights that I wove between the railings of the balcony. Not only will I get light at night, but I can now plug in a laptop out here, with full internet access (courtesy of our friends upstairs).
The Admiral is sleeping in the sun, the pink-blossomed tree just below the balcony is swaying in the breeze, the construction has halted again, and Brunhilda is lamenting her fate. I's time to get dressed and go out in the world!
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Posted on April 3, 2004 | Comments (0)