Discussion of the rest of the abdominal organs, spine, and pelvis. Also a short discussion of what doctors can do at scenes to help expedite care once the patient reaches the hospital. Thanks.
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Archive for category Hospital
Trauma Primer Part 2
Dec 7
Trauma Surgery Primer #1
Nov 27
This is a primer on Traumatology starting with pre-hospital and moving through the small intestine (no pun intended). At the beginning and the end is a recording I found of when I played baritone sax with the McDonald’s Tri-State Jazz Ensemble in 1979. Not bad for a bunch of high school kids.
JY
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I discuss a typical severe GSW to the abdomen and chest. This is part 1 describing the actions during the initial surgery where damage control is necessary. Part 2 next week will describe what to do during the second operation. Also a tune from the CD I made with Tom Jolly in the 90’s. Thanks for listening. JY
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A discussion of patients who present with hyperurgent head and hyperurgent abdominal injuries. I discuss my decision tree and algorithm for care. Thanks for listening. JY.
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Hypotension
Oct 23
We discuss hypotension. Recognition, therapy, decision making, and some new developments in fluids and goals of resuscitation. A little original music I wrote for my daughters at the beginning and end. Thanks for listening. JY
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So…if you’ve got a GPA over 3.8 and MCATs in the top 5 percent, you don’t really need to read this. As long as you don’t come across as a shut-in or an axe murderer, you will probably be accepted to at least a few, if not all of the medical schools you apply to. But for the rest of you, let’s talk about the other parts of the application, namely what you did with your spare time in college.
First thing, no one cares what you did in high school. Eagle scout, all-county football, whatever don’t embarrass yourself by putting that on your med school application. They don’t care what you did when you were 16. Now as far as what you did (or should do) in college to prepare yourself, and make yourself attractive to medical schools, here’s my take on it. I gave you my qualifications to make these opinions in my previous post.
Clinical experience: I think it is vital that you touch patients enough to know whether being a doctor is the right thing for you. Even if you think you are going to be a pathologist, you are going to spend a whole lot of time with patients in med school, and you better at least tolerate it. Volunteering in the hospital is more of a high school thing, and is not looked upon with favor.
The choices are: follow a doc around (maybe your parent if you’re lucky) enough to be able to write in your essay how much you feel medicine is a “wonderful mix of science and art where I get to combine my love of the scientific world with my humanistic nature”. Don’t copy that, but I must have seen it on 75% of the applications I reviewed.
Next: be a scribe. This is something that was not around when I was in college and is an interesting choice if you don’t want to expend the effort to become an EMT, or an ER tech, or something else more hands on. You get paid, and you get to be a transcriptionist. Don’t mean to belittle this experience, but you are not making medical decisions, you are not examining patients and synthesizing their history, physical, and lab data into a diagnosis and formulating a treatment plan. It does demonstrate that you went to the effort to actually work in the hospital, and you get to hang around with docs and residents and maybe get invited to a few parties. Many people do this, and a lot of them get into medical school, but I’m not sure if that’s true, true, and unrelated.
Next: be a lab tech, ED tech, burn tech, etc. These jobs require some training, and you are actually working on the front lines, touching patients, drawing blood, changing dressings, etc. There is a possibility this will turn you off from being a doctor, but better to find out now than when you start your third year. This is impressive because you were willing to get your hands dirty and get in the fight.
Next: be an EMT, Medic, and/or firefighter. This is what my wife and I did, and it pretty much changed our lives for the better. We met people who are our friends after 30 years, it gets you around great guys and gals that you wouldn’t normally be with in college, and it gives you the best possible clinical experience. This experience is that you get medical training, you apply it through direct patient interactions where you actually have to make critical clinical decisions, and most importantly you are exposed to medical error and corrective actions, which are very important to see. It requires you to take time to get trained, to study, take tests, demonstrate your competence, and run shifts. Needless to say, this is my recommendation.
Finally, to make yourself the ultimate triple threat, you need research (grades, clinical experience, and research is the triple threat). It is not hard to find research opportunities if you go to school near an academic medical center, but it takes effort to get something worthwhile out of the experience. I have been the “mentor” for quite a few college students who didn’t do squat, and a few that worked their butts off. It is pretty much up to you. When I did this, I just looked in the back of the scientific journals, and wrote letters to people I wanted to work with. Usually they know people where you are and can hook you up. Also, many colleges have summer and school year research programs that are easy to get into. Research is also interesting. It is important to learn the scientific method, and how to design and interpret an experiment. My research experience has made me a better doctor by teaching me how to evaluate scientific evidence. I think if you can do it, research is very important. You probably will not get to publish anything unless you get real lucky, but the letter of recommendation from the research mentor will be helpful.
Well that’s it. Hope this was helpful. Don’t hesitate to contact me if I can help.
JY
Sepsis
Oct 13
A discussion of sepsis for pre-hospital and hospital providers. I go over the causes, signs, symptoms, and emergency treatment of sepsis and septic shock. A little original gospel sax at the beginning and end. Thanks, JY
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Calling for help…
Sep 27
A discussion of when to call for help, and how to respond. Also, what we need to do in medicine to better define our core competencies and abilities. A little of my sax playing at the beginning and end. Be safe, JY
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Learning..
Sep 25
In many academic medicine situations (and others in Fire and EMS) the immediate supervisor, or slightly more senior provider is often the one teaching the novice something. This is often a matter of expediency since in the middle of the night, the attending, Chief, etc is not there to teach. But I worry that in many disciplines, learners never see a real expert do something. An example is in some mid-level operating room procedures. In many of these the senior resident is taking the junior resident through the case with the attending watching. In those cases, it is likely that the junior resident’s only experience with the procedure is having watched another junior resident taken through the case by another senior resident.
Thus, that junior resident, and possibly the senior resident, have never watched someone who has done 100 of these cases perform the case. There are a lot of things that can be learned by watching an expert do something. I remember my experience from a rotation at a private hospital during my residency. At this hospital, the residents were often first assistants to the attending surgeons. It was the first time I first assisted in my residence on major operations (since usually the attending first assists the senior resident in major cases in academics). It was very eye opening. Expert surgeons have a different way of proceeding through a case, it appears more like a task than an adventure. They go from task A to task B to task C with little wasted motion. They know the next step and they anticipate it, sometimes moving my hands so I could begin to expose for the next step, since they didnt need the exposure for the step they were on. Anticipation and pre-planning were evident and really moved the cases along. Also since they knew the anatomy, and how to separate structures, there was less bleeding. If theres less bleeding you can see better, and the case moves quicker.
I have told my senior residents that you don’t operate fast by operating fast. You operate fast by knowing what comes next and making sure you’re prepared for the next step, and by taking your time during the critical steps to make sure you get it right the first time. There is a great phrase “there is never enough time to do it right, but always enough time to do it over” that applies. Doing something quickly and wrong takes far more time than doing something slow and correctly.
If you have the opportunity to be with someone with a great deal of experience, watch the way that they do things, not just with their hands, but how they think, how they anticipate, and how they plan the next step. Sometimes great commanders do this in such a way that it is transparent (going to get a stretcher, a piece of equipment, making a radio call for more help before needing it , etc.). Taking the time to talk to experienced people, understanding why they do things the way they do, and taking their path through a problem can enhance your education in any field.
So now that we’ve talked about the basic premise behind recognition primed decision making, lets go to step 2 – how do you train people when good decisions are based on experience?
If you don’t have experience, then you won’t have a database of cases and scenes in your head to compare to new situations and past plans to choose from to create new plans. If all you need is experience, why spend all the time learning fundamentals, biochemistry, flow dynamics, etc.?
First, in complex situations, you probably could be an adequate practitioner if you just went through 1,000 simulated or real life situations, critically looked at what went on, threw away the bad ideas and kept the good ones, and then moved forward. Unfortunately all your acumen would be based on previous situations and how they came out, you would not have the background to adapt to alterations in new situations, and it would be harder for you to remember what to do under pressure, without some fundamental knowledge of how things work. If you wanted me to be a fire ground commander, or you wanted a master sergeant in the army to be a surgical intern, you could probably accomplish both goals by giving both of us tons of situations, describing the presentations, going through the decisions, and what cues were used to make them, and then go over the action plans, what worked and what didn’t, and putting us both under and apprentice period of close observation. We both would probably not absolutely need the background knowledge, and we would be able to handle most simple situations, but we would have little capability to react to new situations. So our eventual competence would be limited by only what we’d been taught, and what we experienced personally.
So you need some background fundamental knowledge, and real cases, carefully presented and taught. But I believe a training program where you present 90% background scientific fundamentals and 10% demonstration of real life decision making is a lot less effective than 25% background and 75% real life cases, simulation, and apprenticeship.
So when you’re trying to teach new people, or trying to improve the performance of experienced people, it is ESSENTIAL that you focus on those aspects of the call, case, or fire that would have prompted you to move in a different direction than the other person did. Did you see something they didn’t see? Did you put more emphasis on one piece of data? Did they they not recognize the importance of a group of data? If you dont dissect out those issues, then they will not know where their mental model went wrong and they will just make the same mistake again.
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