Month: April 2015

Categories
Clinical Reflection

Chronic Fatigue Syndrome

The year was 2011 and I was an undergraduate student at Weber State University in Ogden, Utah. I was on the premed track and looking for doctors to shadow and research to participate in. I was also working part time at a physical therapy clinic and one day I started a conversation with one of the patients. After hearing a little about my interests and career goals, she became enthusiastic about introducing me to her doctor who was conducting research on chronic fatigue syndrome.   I had never heard of the syndrome, but I was eager to take on any new medical experience and jumped at the opportunity. One week later I found myself at the clinic of Dr. Lucinda Bateman in Salt Lake City.

After meeting with Dr. Bateman and discussing chronic fatigue syndrome, I followed her throughout her day and sat in on several appointments. Because chronic fatigue syndrome is a relatively unknown condition, Dr. Bateman and her patients were strong advocates of educating as many people as possible about the condition, including me.

Many of the patients shared their stories with me. One woman I remember vividly: she was quite thin with short cropped hair and wore a smart business suit and trendy glasses. The immediate impression I had when I saw her was that she was someone who got things done. Her story was heartbreaking. I listened as she described her life before chronic fatigue syndrome and how she was a “go, go, go” person. She worked full time, ran long distance races, and was active in every sense of the word. Then, one day, she could not get out of bed. Her muscles ached intensely despite the fact that she had not exercised the day before. She was debilitated by an intense fatigue she could not overcome. These symptoms lasted for days before she scheduled an appointment with her primary care doctor. All the tests came back negative and she was prescribed bed rest, which did not resolve any of the fatigue or pain.

I could tell as she was recounting her story that she was trying not to become emotional. She was still experiencing the fatigue and recalling the activities she used to enjoy was difficult for her. I felt I could begin to understand some of what she was going through, because I could remember how cripplingly fatigued I had been when I had contracted infectious mononucleosis as a teenager.   I could not imagine having to deal with that kind of fatigue for months or years on end.

After shadowing Dr. Bateman, I went on to finish my undergraduate degree and was accepted into medical school. I heard nothing of chronic fatigue syndrome for years. In February, 2015 I was surprised to see that NPR had published an article on the syndrome. The article was written to cover a new report published by the Institute of Medicine. The report legitimizes chronic fatigue syndrome (known as myalgic encephalomyelitis in Europe), establishes  new diagnostic criteria  , encourages more research into pathophysiology and treatment, and recommends that the name of the disease be changed to Systemic Exertion Intolerance Disease (SEID).

According to the report, “between 836,000 and 2.5 million Americans suffer from myalgic encephalitis/chronic fatigue syndrome,” and the hallmark of the disease is “a substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social, or personal activities, that persists for more than 6 months and is accompanied by fatigue, which is often profound, is of new or definite onset (not lifelong), is not the result of ongoing excessive exertion, and is not substantially alleviated by rest.”

As we go through medical school and enter practice, I think it is a good idea to be on the lookout for these patients. I highly recommend reading the report for educational purposes, especially since, according to the report, less than one-third of medical schools educate their students about chronic fatigue syndrome and fewer than half of medical texts mention it. The disease is poorly understood, but increased awareness and future research may help fill in our knowledge gaps and assist in finding effective treatments for those who suffer from chronic fatigue syndrome.

Read the NPR article: “Panel Says Chronic Fatigue Syndrome Is A Disease, And Renames It”

Read the Institute of Medicine report “Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness”

Featured Image:
cfs by Jem Yoshioka

Categories
General

Call For Medical Student Writers

The Medical Student Press invites all current medical students to apply to join the MSPress Blog team. The MSPress Blog is a weekly publication featuring humorous, instructive, creative, and opinionated pieces.

Regular writers are required to submit one piece a month. To join the collaborative and expressive MSPress Blog team, visit our application site. CV and writing sample are required. For further information, feel free to contact the current MSPress Blog Associate Editor, Marija Kusulja (blog@themspress.org).

Categories
General Lifestyle Opinion

Staying Alive

https://www.youtube.com/watch?v=n5hP4DIBCEE

https://www.youtube.com/watch?v=ILxjxfB4zNk

Have you seen these videos that promote hands-only cardiopulmonary resuscitation (CPR)? Unfortunately, they don’t appear to be as popular and catchy as the song they feature.

CPR is a basic life supporting activity that literally saves lives. Even though the majority of the public is familiar with the concept or CPR, most don’t feel confident in executing it when the need arises. This could be because there are not enough first aid courses. However, I think there is another important factor for consideration.

Media and the entertainment industry, especially films and TV shows, portray physicians performing CPR as a miracle. The setting usually includes a gasping patient whose ECG suddenly flat-lines; then the doctors run in, yelling ‘blue code’, and immediately applies defibrillator pads on the patient’s chest. There may be sparks, and the patient is usually shown to give a jolt, often waking up and becoming completely alert and fully recovered.

Following this highly romanticized portrayal of CPR, it’s not a surprise if non-health professionals decide to merely wait for heroic EMTs, paramedics or physicians. In fact, some may view CPR as a seemingly complicated procedure that requires special equipment with the ability to bring a dead person back to life.

I don’t expect medical TV shows to be completely accurate or to portray entirely realistic situations; nevertheless, the repetitiveness of this false portrayal of resuscitation sticks in the minds of viewers. The entertainment industry is not responsible for educating the general public, but even if they don’t portray CPR entirely accurately, they shouldn’t lead their viewers astray. Repetitively being exposed to on-screen resuscitation, people can come to believe that defibrillators are an essential piece of equipment, without which resuscitation isn’t possible and the best approach is to leave it up to health professionals. Furthermore, showing conversion of flat-line ECG into sinus rhythm implies that electricity can restart a human heart. With the amazing automated external defibrillators becoming more widely used, a non-health professional can use them without knowing which rhythms are convertible, but I still believe they need to be aware that flat-line ECG means there is no electric activity in the heart, and that electricity cannot reinstate it; all a defibrillator can do is give a jolt to an irregularly paced heart which will hopefully terminate the irregular rhythm, allowing the natural pacemaker to take over and reinstate sinus rhythm.

The media has a strong influence on all of us. While attempting to amuse the audience and gain financial reward, the media should still impart important and accurate life lessons.  Thanks to TV series and films, I don’t expect anyone would struggle to remember the emergency telephone number. Yet, because of the same media influences, many people would wait for an ambulance and their magical defibrillator instead of starting CPR themselves. Instead of giving false impressions about resuscitation, the media could play a large role in popularizing CPR as a simple, but vital action that can be performed by anyone, anywhere. Even though it is not the point nor purpose of the entertainment industry, this is an important message that can be relayed without requiring producers and actors going out of their way.

Featured image:
cpr mother & child by zen Sutherland

Categories
Clinical Humour Lifestyle

A Guide to the Operating Room for Medical Students Or How I Learned to Stop Worrying and Love the Sterile Field

The summer between MS1 and MS2 I did a research project with an orthopedic surgeon at my school.  Part of the project had me observing in the operating room (OR) a few days a week, watching procedures and helping with any tasks that came up.  This experience was actually my first time being in an OR, and I was pretty nervous leading up to it.  I had heard horror stories about students breaking sterility, knocking over solution bottles, and generally making fools of themselves in front of important people.  While I tried my best not to do anything foolish or embarrassing, it was oftentimes very hard to avoid.  Slowly, I become more confident in the OR, and the blunders came further and further apart.  As a service to all the pre-meds and un-initiated med students, I now present a short list of important things to know before your first OR experience.

  1. Figure out the rules.  Surgeons love rules, and at times it seems as if they have a weird fascination with them.  If you don’t ask then the rules are never really explained to you, and you will be in big trouble when you break one.  Consequently, I think it’s prudent to ask someone what the rules are.  Considering your fear of talking to the surgeon, he or she isn’t the best option.  The resident or intern is probably too sleep-deprived and hopped-up on caffeine to notice you.  Your best bet is to ask one of the circulating nurses or other students who have been on the service for a while.  Believe me, it will save you a lot of trouble later on.
  2. Make sure you’re dressed appropriately.  Make sure everything you’re supposed to wear is on correctly.  Make a mental note of scrubs, cap, mask, and boots.  Aside from actually wearing the right attire, please make sure you are wearing it correctly.  You’re going to feel really stupid when someone points out that your cap is on crooked, or that you forgot to tie half of your mask.  You will also be the butt of many jokes over the next few days when you aren’t there.  In addition to knowing what to wear, it is also important to know what not to wear.  Don’t wear shoes that you actually like, unless you think it’s cool to have fecal matter on your $100 Sperry’s.  Also, leave the personal items and accessories at home.  While that puka shell necklace you made in 10th grade art class may be “totally rad, bro,” it is definitely a sterility hazard and you definitely shouldn’t bring it into the OR.  Also, if you’re still wearing puka shell necklaces in your mid-20s you should probably re-evaluate your life choices.
  3. Know where the sterile field is and how to avoid it.  This rule only applies if you’re not scrubbed in, and the decision of whether or not you get to scrub should have decided before you show up.  Anyway, just remember that the sterile field should be avoided like the plague.  Any blue towel or covering should send off warning signals in your head.  Don’t get close to it, don’t breathe on it, and don’t even really look at it if you don’t have to.  Don’t try to be cute either and inch your way as close as possible, because the scrub nurse will call you out and you will be embarrassed.
  4. Try to look interested even when you’re not.  After the 5th time seeing the same surgery, it’s only human nature to get a little disinterested.  There are only so many times you can be mystified by a hernia repair, and you’ve probably passed that threshold long ago.  It is imperative, however, that you look interested at all times.  Surgeons have an innate ability, almost like boredom-radar, to tell when you are dozing off or doing something else.  These situations usually end up in you getting pimped mercilessly in front of everyone.  To make matters worse, you don’t come off looking like a shining star when your response to the first question is “Huh?”  You can typically avoid these situations by employing certain maneuvers that indicate “interest.”  My go-to method was switching sides of the OR every 20 minutes to get a new “viewing-angle.”  Another tried and tested one is intently looking at the monitors or camera.  Find what method works for you, and stick to it.
  5. If you’re not scrubbed in, find yourself a role.  Surgeons dislike idle people.  There’s nothing worse you can do than to just stand in the same place in the OR doing nothing.  Find a job you can do, and be amazing at it.  Like to record information?  Write down the incision and closing times.  Like to clean?  Become the best darn disinfectant wipe user ever.  Like to retrieve things?  Be the person who looks up and prints all the obscure research papers the surgeon even tangentially mentions during the procedure.  Note:  If you choose the last one, be prepared for incessant pimping later.  Remember folks, nothing is without consequence, so choose your punishment wisely.
  6. Prepare yourself for the spectacle that is a patient waking-up post-op.  This is the part that you never hear about or even see on those dramatized TV shows about surgery.  A patient waking up from anesthesia is most definitely not pleasant.  Prepare yourselves for all sorts of near disasters.  Patients will try to pull out breathing tubes, or roll over onto joints that have just been operated on.  Some will even try to get out of the bed, as they don’t realize where they are for the first few minutes.  People will often kick out their arms and legs, and if they aren’t stabilized someone on the team is bound to get a black eye.  The best thing you can do is to be aware of the possibilities, and find out how the team handles such situations.
  7. Find a place to store food for post-op consumption.  We have finally reached the pinnacle, the crown jewel of my OR guide.  Don’t pay attention to the fact that this rule actually doesn’t correspond to anything taking place in the OR.  After spending countless hours in the OR, the first thing on your mind will be food.  No matter how mundane or exciting the procedure was, human need for nutritional sustenance will take over.  Make sure you have a safe storage spot for food, whether it is in the clinical workroom or in the students’ lounge.  Also, considering that everyone you will be working with (read: vultures) will also be voraciously hungry and will have no problem eating anything lying around, make sure you keep your food in a place only you can find it.  Invest in a locker and a lock if your facilities have them.  You’ll thank me for this advice later.  You’re welcome, by the way.

Featured image:
CPMC Surgery by Artur Bergman

Categories
Literature

Ishmael’s narrative: an emotional response

“Call me Ishmael” is the first line in Moby Dick and probably the most famous opening line in all of American Renaissance era literature. Taken in a different context: “Call me Ishmael,” or perhaps: “My name is Ishmael,” could also be a first exchange between a doctor and patient. Coincidentally, our Ishmael in Moby Dick tells readers something that resembles what a patient might say to a doctor following initial greetings:

moby dick
Photo courtesy of Tony Sun

[So doc,] Some years ago—never mind how long precisely—having little or no money in my purse, and nothing particular to interest me on shore, I thought I would sail about a little and see the watery part of the world. It is a way I have of driving off the spleen, and regulating the circulation…whenever my hypos get   such an upper hand of me, that it requires a strong moral principle to prevent me from deliberately stepping into the street, and methodically knocking people’s hats off—then, I account it high time to get to sea as soon as I can.

So, translation? That is to say, can a physician translate Ishmael’s opening account into a chief complaint and past medical history? Here is my attempt: Ishmael is a middle-aged male (his age is not given) who complains about feelings of boredom and tiredness. He also describes a history of behavioral symptoms that suggest underlying feelings of anger. Ishmael mentions he looks for ways of “driving off the spleen”—the most fitting definition of “spleen” given by the Oxford English Dictionary is: “irritable or peevish temper.” Imagine now, if a patient used that exact phrase, “driving off the spleen,” to describe his anger and how he tries to rid it. As a student, I encountered patients during my preceptorships that mentioned similar behavioral symptoms including becoming “more irritable” and “losing their temper.” I found it challenging but helpful to imagine such feelings and consider them in the context of the patient’s chief complaint and past medical history. This allowed me to move with the patient’s sorry and avoid awkward moments and responses. As an exaggerated example, responding with a huge smile to a patient saying they’re “irritable” is not an ideal reaction and creates a difficult situation. Many times, these problems may not even be apparent until later reflection. To give students more chances to reflect, some medical schools such as Weill Cornell Medical College offer students recorded sessions of them interviewing mock patients. As a student, taking complete patient histories is not an easy task, and we can use all the practice we can get.

To wrap the above discussion into the ongoing theme of my posts—how reading imaginative literature is useful to doctors and scientists—I would suggest that my classmates, and also upper years and residents, make time to read poems and imaginative fiction that elicit a wide range of emotions. To this end, I can give the example that reading Othello and King Lear elicits very different emotional responses than reading, say, A Midsummer Night’s Dream and As You Like It. Yes, readers should read deeply into the variety of emotions in these plays, but they must remember to feel those emotions within the characters of Othello and Lear, or in our case, Ishmael and Ahab. This reading followed by feeling is a practice that physicians can use while taking a patient history: read and hear the patients’ situation, and then feel with the patient. Importantly, students and doctors can practice this even outside the clinic, while reading a poem, play, or novel.

Coming back to Melville’s novel, Ishmael announces his decision to go on a whaling journey at the end of Chapter 1: “By reason of these things, then, the whaling voyage was welcome; the great flood-gates of the wonder-world swung open.” Ishmael’s decision to “get to sea” then brings readers into Ahab’s infamously mad pursuit of the white whale.

My future posts will follow Ishmael’s narrative and bring to light elements that relate to medicine and science.

 

Featuring image:
Sea and sky by Theophilos Papadopoulos