A busy day in the emergency room

I had a great time in the emergency rooms around Vancouver when I went through my third year rotations. I guess I liked the variety of cases that come through the door, and doing what I think is one of the most fun parts of medicine: diagnosing and stabilizing all sorts of patients until the right experts can take over.

But my 4 weeks of emergency in Vancouver was nothing compared to what I did in a rural rotation during my fourth year. In a small town emergency manned by just one doctor, I suddenly became a useful member on the team. The nurses look to me to take on patients so that I can help with the workflow, seek me out to do procedures “because the student should learn this”, and the doctor place me up front and center for my first cardiac arrest code…

During the day, I sutured a few lacerated fingers (I love suturing no matter how many times I do it… I think it has to do with liking to do small arts and crafts that are fun but not overwhelming), examined a few patients with various ailments, pushed the shock button and zapped a patient out of her multifocal atrial tachycardia, all in a day’s work.

But in the evening, things got more interesting. While I was talking to the ER doc about anaphylaxis, a family member suddenly called out: “we need some help!” I jumped up and rushed to the bedside; I interviewed the frail lady just several minutes ago and thought she just had a partial bowel obstruction, and ordered the standard set of workup.

She looked very different now. Her eyes rolled back, and her muscles started to spasm. Her false teeth came loose and was about to fall into the back of the throat when I threw on a pair of gloves and grabbed it.

“Open her airway,” the ER doc said. “Start bagging her. Call a code!” He turned and called out to the nurses.

I grabbed the bag-valve-mask and the thing fell apart. I clumsily put it back together and starting bagging (providing artificial respiration by pressing air into the lungs with the bag) the patient. I was so focused on my task that when I finally looked up, the family member has been gone, a team is already around the patient, and an ECG was showing ventricular tachycardia (and she is pulseless)- one of the most deadly heart rhythms that means certain death if not corrected in minutes.

“All clear!”

The patient jerked while the shock was delivered. I resumed bagging the patient right away, but almost immediately she started showing signs of life, moving her limbs and spitting out her oral airway. I pulled out the airway and the doctor told me to keep bagging her. After a minute or two, she started breathing on her own and I just held the mask delivering 15L/minute of oxygen over her face, and took in the scene.

A nurse was having difficulty with placing the oxygen pulsimeter, another nurse is placing a large-bore IV, and someone else is fitting a bag of fluids into a pressure cuff. The ER doc was giving orders for interventions and investigations. The patient continued to stabilize, and things finally settled. She was saved from death, for now, but we haven’t figured out what she was dying from.

As a part of tests to find out, we ordered an arterial blood gas. This requires puncturing the artery with a needle to draw arterial blood, to find out about the gases and pH values of blood that the body sees. I had practiced on a classmate more than a year ago, so I was poking my head over a nurse’s shoulder to get a look.

She suddenly asked, “where’s the student?”

“I’m right here behind you.” I said.

“You should be doing this.” She said, matter-of-factly.

“I was thinking ‘I wish I could be doing this'”, I said, which was the truth.

So we switched spots. I struggled at first, but another nurse holding the patient’s hand was steady and patient, and the ER doc gave me some directions, and I got a steady stream of arterial blood from the radial artery. First ABG, success.

The ABG later showed that the patient had plenty of oxygen in her blood, and no other abnormalities. “You bagged her well,” the ER doc said. First time bagging a coding patient, success.

Later on that evening, just as everyone felt they’ve put in a good day, a call came in notifying us that there’s a cardiac arrest patient being rushed in by ambulance.

A team of nurses that make up the trauma team got ready in the trauma bay, and I volunteered to do chest compressions. But the ER doc had something else in mind.

“You will intubate the patient.” He said.

“Alright!” I said, excited.

“Have you intubated before?”

“Only in very controlled settings (in the operating room).” I said

“Well, there will be nothing controlled about this,” he said.

We checked the intubation equipment, and someone pulled up the glidescope. The guidescope is basically a camera that shows the patient’s airway on a screen, which often helps visualizing the trachea into which the tube has to be inserted.

After a few minutes of calm when the whole team waited, the ambulance arrived. A nurse closest to the door took a look, and said quietly: “god, he is 400lb.”

The ambulance crew flew in with the morbidly obese patient, and somehow managed to drag him over to our stretcher. The continued to pound away on his chest until our nurses took over. The team got to work, placing IV’s, defibrillator pads, and I pulled over the glidescope.

“Go?” I asked.

“Go.” The ER doc said. “And 1mg of epinephrine!” He said to the medication nurse.

I opened the man’s mouth. His neck is massive, and his tongue seemed as big as my palm. I couldn’t even fit the glidescope into his mouth, and I think it is at least 2 inches too short for him.

“Let’s use the traditional way,” the ER doc said after he couldn’t get a view either.

I pulled up the laryngoscope, and naturally used my right hand to put his head (which must weigh 8kg) into the sniffing position. I saw the epiglottis, and it was impossible to see the vocal cords.

Thankfully I learned how to use a flick motion with the tube in this suboptimal situation, and I got it in one go.

Unfortunately, despite our best efforts, the patient was too far gone. The ambulance crew has been doing CPR for about 30 minutes before arriving to the emergency, and he was in asystole on arrival. The most likely cause of death is a massive MI, and there is little CPR can do in this situation.

The ER doc called it, and commended on everyone’s efforts. He was especially impressed with my intubation.

“Truly a great job. Things were chaotic, the nurses were doing chest compressions, the man is so obese that even anesthetists would have to try hard.” He said. “You won’t have to do a harder intubation in your life.”

Although the outcome of my first case of cardiac arrest was not successful, I left the emergency room at 2am knowing that I have done as well as what anyone in my situation could have, and that was a good feeling for a medical newbie like me.

And I realized: the more I do in the emergency, the more I like it.


A few days before MCAT

I feel good about it. From the practice exams on AAMC (yup, practice tests from the agency that writes these MCAT exams itself), I’ve written 4 full length exams.

And I did well.

To be more specific, I don’t know how I did on the essays, but the other three sections (physical sciences, verbal reasoning, and biological sciences) were marked out of a percentage, then a standardized scale score out of 15 is estimated for these practice tests. “Standardized scale score” means they have a fixed mean and standard deviation (which means if you happen to write the exam at the time when thousands of crazy keeners, you will probably end up with a low mark).

And what scale score is considered good on MCAT?

Here’s some data. I couldn’t find what the score on this website is (maximum? minimum? mean? median?), but I think it’s the mean of MCAT scores of the entering class

For the Canadian schools, MCAT scores rank from Queen’s @ 33 -> McGill’s & UT @ 32 ->  and UBC comes in at a humble 29.

And the American schools (deng deng deng!): Washington University @ a staggering 38, followed by Duke’s @ 36, and across the board, Stanford, Johns Hopkins, and most Ivy leagues come in at 35. Some Ivies trail slightly behind @ 34.

I don’t know what is up with Washington University; a MCAT score of 38 is probably something like 13:13:12 (physical:biological:verbal).

It’s madness!

And even Sparta will think it’s madness!

In the wake of this madness, I humbly compiled a list of realizations that may prove boring for some, and more boring for others.

If you are at UBC and you want to go to med school, what courses should you take?

A solid background in 1st year physics and 1st and 2nd year chemistry (take chem 205 if you are at UBC and you want to go to med school, boys and girls) will put you at around 12-13 in the physical sciences section.

A solid background in o-chem (chem 233 at UBC), physiology (phyl 301 helped big time), biology (cellular bio would be most important, followed by really basic genetics. biol 200, biol 201, bioc 303 and the like) will put you around 12-13 in the biological sciences section too. On a lucky day, maybe 14. On a bad day, 10.

And verbal? You are on your own. Maybe if you read 100+ passages religiously under the intense supervision of a MCAT reading coach (if there is such a person), you can improve your score on this section. Maybe. But no matter what I did, I always hover between 10 and 11.

Disclaimer: having a solid background is awesome and all, but you still need to spend a good chunk of time reviewing your stuff. This raises another question:

When should I write the MCAT?

Many people write it after they finish 2nd year university, when o-chem and other 1st year sciences are still hot and fresh in their young heads. This way they can also start applying to Med school in 3rd year and get the experience when they get rejected. They can come back stronger and more prepared than most in 4th year.

But taking 3rd year courses like physiology and biochemistry really helps with MCAT preparation. It’s fair to say that I’m really glad I held off MCAT until I have a solid grasp on the different systems in the human body. If I took the test last summer, I would have needed to take a MCAT prep course for 2 months and a half, and cram the heck out of myself because of the inadequate time to properly digest this knowledge.

The down side of taking the MCAT after 3rd year is you start to feel old and your time’s running out; if you do badly on your MCAT, you would have left school when the next application cycle comes around. By then, your mind is probably not set on school (assuming you started working or feeling like a full time bum at home).

A quick solution: stay in school longer 😄 I’m taking 5 years with my undergrad, and I don’t feel some of the pressure my friends who are graduating feel.

What else should I do to prepare for my med school application?

Find your passions, devote time to them, and back them up with references!

It is no good to say: “I like cycling”. It’s pretty awesome to say: “I started a cycling club/I was the captain of this cycling team which competed in this race/I spent 100 hours on the track with this coach”.

It’s pretty frustrating to be unable to show yourself off because of a lack of reference; not every activity has a reference. But you gotta keep an eye out and collect contacts wherever possible if you are serious about med school. Unlike a job interview, where experience and passion in a particular field would suffice, the med schools seem to look for super-human well-roundedness — and they want this peer reviewed.

Oh, spending 150+ hours on a blog doesn’t count as a referenceable activity unless your blog wins some kind of blog award or such? Oops me.

That’s it for today. Wish me luck.

Med or no med

Med school is on the minds of many. Mine included.

If I think about it, I can come up with the following reasons  right off the bat:

  1. Personally, morally, and emotionally rewarding. There are very few jobs that offer the same level of “feel-good factor” as a doctor helping a patient regain health. Sure Steve Jobs can make the sexiest computers in the world, but he is helping the affluent get more gadgets. Perhaps working in social services that aim at helping the populations in need – such as alleviating children stricken with poverty and disease – would have the similar “feel-good factor” to helping patients regain joy of health.
  2. Stable income. Docs aren’t the richest people around, but they do well.
  3. Family expectation. Many of us grow up under the constant influence of our families who view raising children to be docs to be the ultimate achievement. When the people dearest to you all think that way, it’s quite impossible to put it off completely.
  4. Social status. It’s not some non-sense pride; it’s very much a real thing: how good do you feel doing what you do? How good do you feel when you tell people what you do? I think feeling good is important for most people.

Why is med school just “on my mind”, and not “all I can see”? Here are some reasons right off the bat again (meaning this post is much open to discussion and expansion):

  1. Crazy hours. I have lots of wild ideas that I’d love to pursue, and if my job occupies me 7 days a week, then bye-bye my ideas.
  2. Idealist bubble burst. Perhaps I fear the vision of coming out of med school for all the feel-good factor in the world, and realize I’m just becoming a soldier of a corporation built on exploiting the suffering.
  3. Somehow being a doc seems less colorful and intellectually exciting than being, say, a Google engineer working on world-domination. Being a doc requires doing the same things over and over, to build up the experience, expertise, and efficiency. Being an innovator requires constant learning, new ideas, and breaking new grounds.