There is laughter in Medicine too; what about the Stethoscope sign?

I started a couple of months to post quotes that I wanted to remember some years from now and this's just a continuation of that:

-so we're in morning report and the next patient is an HIV +ve male who was admitted for Epididymitis (he had swollen testis). Then immediately after the resident calls the patient's name and gets ready to present him, here goes the attending "so how does his balls looks today?" The pharmacists who sits in on rounds burst out laughing but in a discrete way and I couldn't help either.

-"The stethoscope sign?"
so I had seen a patient earlier and was presenting the abdominal findings to the resident, who had also seen the patient after me. My abdominal exam was impressive in that it was tender to palpation but the resident want impressed with the abdominal exam. So she said "have you ever heard of the stethoscope sign?" I was like "no". So she said "when you palpate on the patients abdomen and they act like they're in pain and you want to validate your exam in suspicious cases, just place your stethoscope on their abdomen as if you're listening to their bowel sounds but apply pressure equal to that which you used during bare hand palpation and if the patient doesn't act like they're in pain, then the stethoscope sign is +ve" which means patient is just feigning.

- The cry for "vigina"
So this woman in her 40s comes in with chief complain of vertigo (felt as if she was spinning while in reality she was still) and had unstable gait. So we decided to r/o any Cerebro Spinal Fluid (CSF )infection etiology. She had earned a Lumbar puncture (which is where you basically insert a needle into some one's spinal canal -while avoiding the spinal cord and nerves) in order to collect some CSF for testing. Usually the area of needle penetration is numbed by injecting Lidocaine. So as the resident penetrates the spinal canal, the patient starts to really becomes anxious and I calmly talk her into being as calm as she can but she was still a little anxious. Then all of a sudden she says "awww, I can feel it going down me." "Do you feel pain or pressure? the resident asks" patient replies " I feel presssuuurreee" then a couple of seconds goes by and patient shouts " awwwww my viiiiigiiiiinnaaa; a sharp pain just went down my viigiinaa" and at this point we're looking at each other is dismay and thinking what's possibly happening here. Not to mention that the LP ended up being unsuccessful i.e no CSF could be obtained.

Thanks for reading,
Later.

You must be really good then if you're still in trianing...

As I mentioned in my last posting, I spent this entire month doing my Internal Medicine rotation. I have a short story to share about what happen during one of my patient encouters.
So my team (which I really really enjoyed working with) was on call. The day had been going slow so I decided to go through some questions and readings. All of a sudden I heard "BEEP" "BEEP" that was my pager going off. I instantaneously called back and the resident said "Anselm, we've an admission here. Wanna take it?" I was like "Sure, of course". With my long legs, I was in the ER within the next 2-3 mins, ready to get an History, do a Physical and discuss about the work up plan with the resident and go from there. As I arrived at the ER, the met the resident who told me that ... "so your pt is a 49y/o African American female who has Abdominal pain and was has been admitted at an Outside hospital twice in the last 2 months for thesame complain. I really don't have much on her, go see her and see what you come up with." I said sure and was gone.

So I met the pt, introduced myself and began to talk with her. She initally gives me a very scanty history in the sense that she didn't want to give me much about her past history regarding her abdominal pain. Rather she wanted to focus on the present episode. I told her that obviously there must be something wrong going on, since she's had this same quality of pain for a couple of yrs with the severity getting worse. I pulled a chair and sat right across from her as she laid in bed on her right side with hips flexed. I asked her to take me back to the first episode and walk her way from there to where we are today. I was interrupting at times of course to guide her towards waht I thought was pertinent. From the look on her face, I could infer that she couldn't believe that I wanted to spend all this time with her and listen to what has happened to date. Well, she was a descent historian and even kept some discharge summaries from the OSH with her. I collected them, quickly glanced through some and read some, copying what I thought was pertinent to her presentation ( I guess as a med student you have more time to go through stuff like this). She described her pain as starting from the Right upper and lower quadrants and radiating to the Left quadrants then to her entire lower back; the pain was sharp, throbbing and aching with a severity of 10/10. She had an extensive history and throughout our conversation, she didn't request for any pain medicine but prior to that, she was getting Dilaudid quite often and had just received Toradol IV prior to me entering her room. The Toradol must have been doing a fine job. So as I was getting ready to do my Physical Exam, a nurse came in and said there was a bed ready on one of the floors and she needed to be transported to her room where she'll be during her admission. I told her that I'll meet her in her room.

A couple a minutes later, I was in her room ready to do the Physical Exam (PE) and the Husband walked in. He was a little helpful as he was able to tell me some results of imaging done at outside hospitals. I proceeded to do the PE and when I got to the Abd (where the money is), her Abdomen was diffusely tender but moreso on the lateral aspects. Both flank regions were tender to palpation (with the patient retracting herself from my hands) but the Left was more than the Right. Her labs were remarkable for a microscopic hematuria for which she said she has had a history of that.

From my exam, I was convinced that the kidneys were involved (the impressive flank tenderness) plus hematuria. This would explain the back pain but what about the abdominal pain - maybe it was radiating to her abd especially given that the lateral aspects were more tender. I did some search and reading and came up with a theory of my own: Was it a possible case of - Loin pain humaturia Syndrome (LPHS)?
Briefly, LPHS, is when the glomerular basement membrane (in your kidney) is very thin such that the normal pressure from blood supplying (perfusing) your kidney causes micro damage and bleeding hence the Pain and blood in urine. Classic presentation is unilateral flank pain and blood in urine (either microscopic or frank blood in the urine).

Well, the resident was quite interested in the case and asked my to present it at the morning report the following day but she cautioned me that students do NOT usually present and she'll be on the podium with me in case I needed any assistance. Well I did and she was wonderful in chipping in here and there and it went great. My attending congratulated me after the presentation. More tests and imaging studies will be done to workup the possible etiology of her pain. Too bad I wasn't going to be there any longer to see how it turns our. Usually the LPHS is a diagnosis of exclusion and if the w/u came back negative for the suspects then it makes my theory more credible.

Well, so back to my patient. Later that night I stopped by her room and she asked if I was going to be her doctor the entire time while she was at hospital. "I'm a medical student that is, I'm still in training, your doctor will be doctor P. But I'll be following you and working together with Dr. P" I replied. She then stated "You must be really good then if you're still in training. I was talking with my husband about how you really cared about asking me all the questions. About how you wanted to know everything about my pain and what I've been taking for it. Usually other doctors are just like okay we'll give you pain medicine and then they get me out of the hospital but no one has ever showed that they really care about my pain as you did." At this point my heart was racing and she continued "so I was telling my husband that I think this time, they gonna find what's wrong with me because someone's acting like they really wanna get to the bottom of this pain." Then I gave my little reason of why I went to medicine "b/c I really like to do my best to help people feel better and if there's anything possible that I can, I will which is why I was going through all what I did earlier and I also appreciate you being open to willing to discuss your history with us because it'll help us take good care of you" and also added that "the doctors that I work with here all care too and we'll do our best to get to the bottom of it." Then she said "well if they all care like you then I'm glad because I just wanna get this pain away, it's been bothering me for too long now and all I do is just pop pain pills which don't really help me."

I wish I could see how this case ends. Just one of those things that really gets me thinking even as I drove on my way home from the hospital.

Thanks for reading/visiting. Will be sure to write sooner.

Then end of third year and a look ahead

Ladies and gentlemen, it has been a good while since my last post. I've spent the last month at Union Memorial Hospital (a community hospital in Baltimore City) doing my Internal medicine rotation which is my last third year rotation. I just took the shelf exams (a National Medical exam for 3rd yr medical students to access their competency at the end of each rotation). The shelf exam is not obligatory and as such, only certain schools subscribe for their students to take it and in each school some rotations don't offer shelf exams. For instance at the University of Maryland SOM, Family Medicine and Neurology do not offer Shelf exams. They have an "in-house" exam instead.

With that said, the Medicine Shelf exam went really well and I expect to perform well. Eventhough I'll be going into Surgery, I'm a strong believer that a solid foundation in Medicine sets the stage for whatever field you're interested in. I'll be managing patients on the floor pre- and post op moreso as an intern than ever and these medicine skills will come in very handy. I'll be called for consults to the ER or to see pts admitted by the medicine service and in order to rule in any case as a surgery case, I'll need to r/o potential issues that could be managed by medicine first because Surgery is usually called in, most of the times, when medical management fails or isn't the best route to take in a particular situation.

I really enjoyed my last month of third year and will as of July 6, be a 4th year, officially! I'm excited to take on my new role as a Sub-Intern in Cardiothoracic Surgery. I KNOW that it'll be hard work. It'll require getting up really early in the morning, 5AM or so, and getting to the hospital early to have an early start. I feel like my background has really set the stage for me as far as having work ethics, being hard working, resilient and a "no whinner" which are definite qualities expected of a student of Surgery. As young as I can remember, where I grew up in Cameroon, W. Africa, I and the rest of my family would get very early not later than 5Am and get ready to start treking to far away bushes and farms. We would trake at times for over an hour to get to the farm and then start working. I and my brother would clear the bush while my sisters and mom would tilt the soil. Once in a while I would visit my uncle in the village during summer vacations (in Lewoh) where we'll build fences out of sticks that we would cut from the forests. We would go to far away farms and carry cocoyams on our barehead and trake hours upon hours to get home. Well, Surgery doesn't require any building fences, no treking for long distances, no clearing of bushes BUT it DOES require you to stand for long hours, use your hands all day long and above all, you have to be READY AT ALL TIMES to GET THE JOB DONE. My background sets my ready for this already. I do not have to force myself, push myself, set my mind ready for this since it's more or less part of me and I just need to be a student of surgery and learn from many wonderful surgeons on how to be the best surgeon. All what I want from any surgery program that I end up with is that I be thought EVERYTHING that the surgeons know so that in the future, whenever I decide on "cutting" on someone I will know without any doubt that the patient is getting the best care.

For the couple of days that I have left to begin 4th year, I have a couple of things to complete.
1- I'm currently working with Dr. Turner, the Program Director for Surgery at the University of Maryland on a research project. Our abstract was appected for presentation at the National Medical Association annual meeting. I should complete my poster for that presentation in a couple of days; already started on that.
2- I'll tie the loose ends that I have on another manuscript that we're working on.
3- Reading towards my Sub-internship. I've got to read up on Anatomy especially pulmonary and Cardiac, different types of Ventilation machines and their settings, LVAD (Left Ventricular Assisted Device) which are machines that help the Left Ventricle pump blood to the Aorta - it's used in End Stage heart Failure and for some, it helps "buy time" while they're waiting for a heart transplantation. Also I'll have to look at Chest tubes and Cardiac drips (medicines given to patients who undergo cardiac surgeries).

and then in August I'll be doing an away rotation at Mayo clinic. I'm so excited about the opportunity to spend a month in a world class institution of medicine. Can't wait!

I'll keep you posted and thanks for visiting the site. Again, feel free to share your experiences be it in 1st, 2nd or any other year of medical school. Together, we can learn from each other, make ourselves better and subsequently make the people around us feel better and thus the world.

There's that place deep within each and everyone of us that we may never discover. You do not want to leave this earth without reaching deep down within you, deep in that place to pull out what you can offer to your patients (neighbors, strangers, community and friends). You will know it when you are close or deep in that place ... but you must make allowance for challenges and criticisms from within and without because it is only through pushing yourself beyond your domain, beyond what makes you cozy that you will be able to reach that place; deep within and you'll know it.

Mother Africa - half a loaf is better than none

It's been a while since I posted. It has been busy at school/clinic and can't wait for the last month of my Junior year to be over! I got this interesting article in my inbox from the surgery group of the American Medical Association: http://www.plosmedicine.org/article/info:doi%2F10.1371%2Fjournal.pmed.1000078. It touches on how non medical staffs have been trained in courses as short as 6 months in order to carry out simple surgical procedures in some African countries. While the surgical residency in the United States takes 5yrs, and I recognize the fact that surgery is a highly specialized art and needs lots of training, I also sympathize with pts in Africa who don't have enough doctors, let alone specialists (surgeons). So I would rather have a well trained non medical personnel perform a simple procedure to prevent a life long deformity or death than nothing.

My hope is that clear boundaries and good supervision be put in place so that these non medical professionals don't attempt at doing what is beyond their very short training and knowledge. There's no way that one of these professionals will match a well trained doctor b/c there's a vast difference in their knowledge of Anatomy and Physiology and in situations where surgoens could use this knowledge to their advantage to "troubleshoot" a challenging/difficult case, these trained non medical professionals would probably be baffled at what to do since they're more or less taught to "just do it" without a deep understanding of the physiology that underlies the human body. As I work towards obtaining a residency in General Surgery at a wonderful institution in the US, my long term goal is to give back to Africa. I recognize and understand how much they don't have in terms of medical professionals and especially specialist. I pray that God grant me the strength to carry out my heart's desire by providing surgical services to Africa.

On another note, I was very excited last week when Mayo clinic came through and accepted my application to do my subinternship Surgery rotation with them. It's a world-class institution and can't wait to suck, live and breath Mayo i.e surgical knowledge and experience during my month there.

I'll be sure to keep in touch.

A reminder of my drive to becoming a doctor

During the recent papal visit to Cameroon earlier this year, he made a speech at a Rehabilitation Center in the Capital city of Cameroon, Yaounde. Here is an extract from his speech which sent chills down my spine and reminded me of why I wake up every day wanting so bad to be a doctor and set on the trail of helping my fellow people around the world. Pope Benedict said, Doctors “are called, in the first place, to protect human life” because they “are the defenders of life from conception to natural death.” May God “graciously grant the prayers of all who turn to him. He answers our call and our prayer, as and when he wishes, for our good and not according to our desires,”

Basic health care is not common. Is it really basic?

Greetings to everyone visiting this block. I must welcome the newest follower, Linda, to the blog! Feel free to add to the discussion and air your experiences and visions.

So I'm a day shy of being 2 wks into my Internal Medicine rotation and I'm at the Veterans Administration well known for its acronym "VA". My classmate was taking care of this patient, an AA in his 50's, who has chronic lung disease, diabetes and schizophrenia. As part of assessing the patient's oxygen saturation, we usually check patient's oxygen saturation using a machine called a pulse oximeter "pulse ox" before, during and after walking the patient. So my classmate approached the aforementioned gentleman and explained that in order to give him appropriate treatment he'll have to walk so that we can get a good sense of his oxygen saturation level. He blatantly refused to walk saying at first that he was tired then later that he didn't feel like walking and "no one is gonna make me do what I don't feel like doing." So at this juncture, the chief resident got involved and explained to him that he will let him go it he didn't want to cooperate with his care. He was so ready to sign the damn - Leaving Against Medical Advice form, what is generally referred to as "AMA". While in the midst of all these, we (the medical students) had to leave for a noon conference, which we have every day. The guy was out by the time we returned to the Unit about an a hour later.

This serves like a very good base, I think, of what I'm going to talk about next. My parents are from a small village in South West province of Cameroon called Lewoh. In Lewoh, there is a health care center which is not currently staffed by a doctor. There is a nurse and and some nurse assistants and that's about it! So you have all these villagers who flock in every day with various types of complaints and illnesses. Some may need something as simple as an anti-pyretic to antibiotics or as complicated as needing surgery. As you can imagine a health care center without a doctor, all these poor villagers just have to do with what is available to them... and guess what? At the end of the day, the are very grateful that someone is even at the health care center to consult, talk and prescribe them some medicine. The credentials are really not the first thing that comes to mind.

The VA patient who didn't even want to walk so that we could better assess him and take care of him has all the doctors and specialists at his disposal. Yet, he's not compliant and won't make good use of his available resources. Only if some of these patients knew how well they got it going. Ask one of the Lewoh villagers who's sick and can't even get out of bed to walk and if he/she knows that it will contribute in some manner to the improvement of his/her health, I bet you, he/she will somehow by some means walk! Access to health care is a word we use quite often these days. Quality health care is another word. When I think of the Lewoh villagers, I think of these two words. Yes, there is a problem of access to health care in the US but it's a whole different entity when you think of poor access to health care in Lewoh; Quality of care is just far and deep in the trenches. We're just thinking access and praying that Quality will sometime come in the future. I guess Lewoh is in a developing country but then humans are humans and they all hurt the same. Appendicitis or malaria in any part of the world is the same thing but some have access to medical personnel and facilities to help take care of these same problems while others don't. God, bless your people. This's really not a problem in Cameroon but many developing countries.

I really don't want to make this block political but I can't refrain from saying that the big names in Cameroon government just keep getting richer and richer while their people's suffering increase exponentially day after day. People think that Cameroon is peaceful just because there
isn't war. But if we look at peace as the absence of justice then there ain't no peace in Cameroon, which is how I see it.

In order to promote better health care in the Lewoh village, it's Cultural Organization known as Lewoh Cultural and Development Organization (LECUDEM) is launching a fund raiser so as to renovate the lewoh healthcare center. These villagers need a chance to receive health care, I mean basic health care. Nothing but Basic. These villagers need basic things as:
-Pregnant women go through their entire pregnancies without ever getting an Ultrasound. Imagine how un comforting that can be. Their lives and that of their fetus are at the mercy of good luck.
-Children have to be sent to hospitals that are thousand of miles away b/c they are too sick to be taken care of at the health center with nothing besides BP cuffs, thermometer and a stethoscope. At times, they end up dieing b/c parents can't afford to take them any where else.
-Patients routinely come to the hospital just because they are given only medications that are available even when it's not the best/right agent for their illness. As a result, they have to stay away from their farm which is basically the only means of living for most families.
- There aren't even enough beds and those that are available have nothing but a few inches of mattress that your back hurts like crazy when you lie on it. How uncomfortable can you get at a hospital??
- Imagine having palpitations and feeling like your heart is about to jump off your chest just to go to the hospital and there's no mere EKG to check your heart? This's what has become common to these people.

So attached is more information about the fund raiser and if, please, anyone is willing to help the people of Lewoh village, don't hesitate to contact me. Your help will prevent a tragedy in a family, prevent a child from staying away from school b/c of illness or just bring smile to a woman's face because they can be sure of a healthy baby at delivery. see more about the fund raiser at the following website: LECUDEM.ORG
_________________________________________________________________________________
LECUDEM-USA ANNOUNCES A SUMMER FUNDRAISER FOR ATLANTA, GA.

The Lewoh Cultural and Development Meeting in the United States (LECUDEM-USA) has announced a June 2009 meeting in Atlanta, Georgia to help raise funds for the up-grading of the Lewoh Health Center at Anya. The fundraiser is aimed at raising some $50,000 for the project. The not-for-profit organization has already raised $10,000 here in the U.S. and the Cameroon government, in its 2009/2010 budget, has earmarked ($50,000) as an initial amount for the up-grading efforts. The government allocation is already at divisional level in Menji awaiting the award of a contract for work to begin.

In a conference call last Sunday night with some of his executive members and a development think tank the President of LECUDEM-USA, Mr. Michael Fondungallah, who has just returned from Cameroon, reported that on-going efforts to partner with the Cameroon government to up-grade the Lewoh Health Center are well underway. He noted that during his trip to Cameroon he visited Anya (Lewoh), Yaounde, and Limbe where he held working sessions with staff of the health center, and home-based members and executives of the mother branch of LECUDEM. The up-grading will raise the health center to a divisional hospital with the following features: a neonatal ward, an obstetric and gynecological ward, an emergency and trauma unit, and an infectious disease unit.

The Minnesota-based Attorney said that up-grading the health center remains LECUDEM-USA’s priority project for the 2009/2010 development year. Mr. Fondungallah said that he also met with staff of the health center and noted the absence of a resident medical officer at the facility. He discussed the needs of the health center with staff and LECUDEM members in Limbe and Yaounde and the Lewoh traditional Council before meeting with His Majesty Fotabong Lekelefac I, the Atemangwat of Lewoh. He also met with the organization’s international relations officer HRH Fuafe’eh (Prof. Leke Tambo).

LECUDEM-U.S.A is a non-profit organization certified by the IRS service code 501 (c) 3 to procure tax-deductible donations. The mother organization, LECUDEM, brings together both the home-based and Lewoh sons and daughters in the Diaspora with the purpose of harnessing their energies toward coordinated, meaningful, and planned development initiatives that uplift the human person by improving on the quality of life of the people of Lewoh. The organization has built a portable water project in the Fondom, a trans-Lewoh road that needs funding to surface and build bridges and culverts, and supported educational projects. Story by Asonglefac Nkemleke, PRO.

{ a picture of Lewoh health care center was here - unable to download for some reason]

LECUDEM-USA PRESIDENT, MICHAEL FONDUNGALLAH Esq. with staff of the Lewoh Health Center (April 2009)

Omega-3 is beneficial to the Heart

Just adding a link to a paper which I co-authored entitled:
"Fish oil, but not flaxseed oil, decreases inflammation and prevents pressure overload-induced cardiac dysfunction". It's a cardiovascular research. We found the benefits of omega-3 polyunsaturated fatty acids are cardio-protective and decrease incidence of Left Ventricular Hypertrophy and subsequent heart failure. Here's a link to the abstract and entire paper. My mentor in this research project, Dr. William Stanley is excellent and has been very supportive. He's just plain awesome and down to earth as it gets. Enjoy browsing through or reading! :-)

The picture on top left is of myself in the Lab. Taken during the research. I'm measuring and analyzing BP measurements on rats using a computer software. Dr. Brian, one of the great post docs, was so kind to get the pic for me.

The pic bottom left: presenting the preliminary results of the research at the Annual Medical Student Research Forum at my school (University of Maryland School of Medicine). Much thanks to Dr. Stanley's Lab - Cardiovascular Research.

http://cardiovascres.oxfordjournals.org/cgi/content/short/81/2/319