more dermy derm

Lets see today at peds clinic say 1)little cutie with eczema  2) and 3) two teen guys with honestly, not that bad of acne  4) girl with seb derm aka dandruff and keratosis pilaris, which are these hereditary little bumps on your skin, i guess plugged up hair follicles, totally benign.  Hopefully won't forget that.  And that was it. Tomorrow more VA outpt.  lots of toe fungus and athletes foot.  Just two more days and I'm done.

being told what to do

If anything medical school has prepared me to follow set guidelines, think in  a certain line of thought, check labs and facts, double check labs and facts, ask questions, and most importantly do as I am told.  I see patients all day long take their histories, examine their bodies, document the information and present it to a senior either a resident or attending.  Most commonly said senior will say mmhmm ok lets do xyz, give them this, and see them back in x months.  Occasionally they may ask well what do you think they have? and even then I may guess correctly but still they will proceed to say give them this and do that etc.  In theory I am supposed to internalize and process this information about treatment for said condition - but usually happens is that i write it down, document it in the chart, explain it to the patient. and poof its gone outta my head.  So i n SUm what I learned from a day of seeing patients is how to  follow directions.  I fear for myself as I enter intern year as I am expected to not only do the bidding of all senior residents and attendings but make decisions on my own about treatment for my patients.  Granted there will still be some presentations and modification and for the sake of my patients and myself I hope that it is not more of the same sort of "do what I tell you" learning.

perspective

Being on dermatology i've been dealing with lot of little rashes, itchiness of an  unknown cause, anxiety provoking moles, spots, dots, and the like.  And for some of the more chronic things like eczema and psoriasis, I feel like patients are never satisfied.  Some have only the mildest form and yet they always ask - can i get rid of this? do i have to use these meds forever?  is there anything else you can do?  and By this point they've got big gun steroids and creams being thrown at them.  And they're skin is truly not that bad.  Now I realize if it was my skin I may feel like them, I realize that.  But also I wish some of these patients could see the more moderate or severe cases and see that theirs isn't that bad.  Right?  There are people with worse problems if that makes anyone feel any better.
  On a brighter note it is exciting that as a family med practitioner  I can easily treat the things the derm docs do.
  Today I watched Mohs surgery.  Its quite a detailed procedure for a very small area of of the face.  All to protect from a benign cancer - basal cell and a more malignant but not usually a cause of death squamous cell carcinoma, from causing a cosmetic scar to the face.  I appreciated the time and care the docs put into making sure the patients eye lid wasn't puckered after the suturing but wow it took so long.  I guess in the end the pt will have a very minimal scar on her cheek, but she certainly had to be very patient to attain it.

senioritis?

Maybe cuz we are nearing the end of "medical school" the formal education = these last three weeks are just dragging. i have no desire to see patients, write notes, ask questions, scut around for residents etc. I am weary as I know I will begin seeing pts yet again in June - am I ready?

*image from http://blog.timesunion.com/breakfastclub/senioritis-already-but-its-only-december/1244/

some guate musings

Sometime in between:
I worked with a general physician who practices both psych and essentially family med (minus ob and gyn) . He had a unique perspective on his patients and esp psychosomatic presentations. A young man came in brought in by his mom and aunt after he received the news that his brother was killed. The kid was catatonic. Dr. Llamas checked him out, then took two plastic chairs to a small corner of the hospital, his "office," and as he says, "le di un sacudo" (i gave him agood shake) essentially a mini therapy session. the kid came out a whole new person. it was amazing.

later a woman who was their for gallstones and I suppose you could say intractable pain was just laying in the ER, moaning and groaning - obv. pain. Dr. Llamas went to her and of course she asked for something for her pain, yet again. And he said,(in spanish)"I could give you all the pain medicine in the world, and i have already given you a lot. But you know this will only work if you have a positive attitude and believe it will work." after that we didn't hear a peep from her and she went home. who knows.

more guatemala emails

Feb 7 2010:
MOst recently on Saturday we went to the Volcan pacaya. we all went with another family friend and his famly, short of julio roberto who had to go to work. we went in the back of the pick up and the weather changed so much in that short distance. it got more fresh. i took some video leaving town and on the volcano. we rode up on horses and walked the rest of the way with our young uide, of 15, elder. we maneuvered over hardened molten lava until we reached the top. where others were roasting marshmallows from the fresh lava. it was crazy being so close to it, as if any second we may be in the way of upcoming lava. we put a quarter in the hot lava and took it home as a recuerdo. it rained on the way bck but fortunatly we were not too wet. ana was cold! and it was not even cold at all i assure you. she´s just so used to warm wather. we take it with a grain of salt when they say it is going to be ´cold. haha. today we grilled some lomito marinatd in garlic and salt, ate some corn, and made some salsa with roasted tomatos, cilantro and onion. i made some salsa with the chiles chaltepos )piquines) and cilantro. i had shannon finish it off by putting lemon ' but she put way to much, and then the famly blammed me for putting too much lemon! who knew that girl needed so much supervision. i was mad that she didn´t speak up and say sorry my fault. brat. today we are just resting and tomorrow we start pediatrics

Feb 16 2010:
hey guys, chugging along over here. thigns are better. i am working er and they are atually letting me see patients by myself, super scary esp since i do´nt konw the names of meds here and stuff. today my patient this little old woman with light eyes siaid eres extranjera i said yes and she said ah por su accneto y por que estas muy amable it being nice is strange this world is twised. but its very hot and sweaty in the place., the docs are really nie. i helped to manually ventialte a woman today as well. she was very sick. what lelse oh i can now use a glucometer, do blood gases from the radial artery its good. timne is flying. and there is not enough time for everything. yesterday we made pizza for the fmaily. a bag of cheese was 14 dollars crazy

Feb 20 2010:
family came over and one of the wifes, here name is lady, took us out for a spin on her moto. she showed us all her favorite discotecs. she is this tiny little woman too. and then we took a series of pics on her scooter. everyone said how coool that papi had a vespa. it was a hard last day in the ER. three real emergencies. one of which died in front of everyone, she had an incarcerated hernia of her intestine that caused her to vomit blood and feces. it was petrifiying and absoluely gross they offered me the chnce to practice intubating on her afterwards, now that she was deceased, but i declined. and then our two favoirte little babies in the peds intensive care also died. i took a pic with the >Er team on my last day. they said my despedida was all the action in the ER today. ha.

guatemala emails

Feb 2 2010:
so far i have tried two new food. unos chuchitos which is tiny but masa filled tamale with a lump of pork very delicious and atol not atole which is like atole but made with rice and tastes like rice milk and its warm interesting. it so hot and humid i don´t know why they like to eat such warm foods. we never eat vegetables here etiehr. iam going to get fat. and tortillas, not skiinyy ones, but fat ones that the native women make in their puestos. that go with every meal even pasta. and ofcourse tons of black beans. the family is impressed by my ability to eat chile. they hvae chile piqines that i have been devouring with each meal. thaknfully sinec the food is not very spicy


Feb 3 2010:
i got to deliver a baby today, and we watched three c sections. two were due to emergencies, one of th ebabies was being born with one foot out, another the cord was coming out before the baby which is a major emergency. today we ate chicken homado? it tasted like ham. i am very unimpressed by the food. i miss leafy greens. also we ate some papaya and sandia,

derm

don't even need my stethoscope. lots of punch biopsies and excisions. very quick and dirty. just gotta learn the common stuff and ur good.