So third year ended 2 weeks ago for me, and I've yet to write about it. You think after an "accomplishment" such a surviving third year I'd be bursting with feeeeeelings about the matter. After all, I briefly delved into the realm of the introspective when I finished first year, and I got damn near teary-eyed after taking down Step 1. After third year, I don't know. I don't have that same sense of accomplishment, and the same sense of transitioning onto something new. Am I glad I no longer have to rotate through specialties I have no interest in showing faux-interest along the way? You betcha. But I didn't wake up the day after my OB/Gyn shelf feeling any older or wiser. I think part of that is because the transition to the next level of competency tends to come throughout third year rather than after it. Before my last shelf exam, I was thinking a lot about my first rotation on peds and the student I was then was very different from the student I am now. But that change was a slow process that had little to do with the MS label after my name. Basically, I can see the progress I made this year, but don't really feel like I "survived" anything. Maybe it's because I really enjoyed third year and the things that are historically dreaded about it weren't that big of a deal to me. Maybe it's because I'm going into a surgical field and I know my days of sleep deprivation, early mornings, and busy days are far from over. And you know what, I'm cool with that.
That being said, good riddance to the third year label. It'll be nice to not have people automatically assume you know nothing and can do nothing just because you're a third year medical student.
Anyways, it was a good week off, and now I'm on to the greener pastures of fourth year, the "best year of medical school."
Normalizing.
I had an interesting conversation with a friend in the military the other day about the things we do for work and how they become so mundane to us, that we lose sense of what's normal. As third year draws to a close and I look back at the experiences of the past 12 months, I realize how much I have seen and experienced that to many (or most) people would be vasovagal-inducing, nauseating, disturbing, masochistic, macabre, or just plain strange which has simply become... normal, to me. It is normal to be covered in blood or various other bodily fluids. It is normal for the workplace to smell of feces and urine. It is normal to work 15 hours a day. It is normal to stick your hand into various bodily orifices, natural or artificial. It is normal to disassemble the human body, intervene in a problem, then reassemble using silk, nylon, and stainless steel. It is normal to discuss bowel habits, suicidal thoughts, and sexual activity the first time you meet a person.
Back when I was in undergrad, I remember some of the jokes about certain medical specialties. Proctology. Who would want to deal with butts all day? Urology. Who would want to touch penises all day? Gynecology. Who would want to stare down vaginas all day? C'mon man, that's gross. Seriously, who would want to do that for a living? Especially a guy.
Well, after two weeks on OB/Gyn and numerous sterile speculum exams, the field has become... normalized. And really, once the pelvic exam stops being weird and starts being just one more physical exam you "do" to get information, you begin to see what's cool about the field. It's fast paced and busy, where things can go from reassuring to tenuous quickly. A good balance of medicine and surgery. Good outcomes for the patient in most circumstances, and a chance to significantly improve outcomes in cases where things are more dire. A sense of participating in an important moment in the patient's life.
But yes, all "that" stuff about OB/Gyn is now nothing unusual. So much so that when I do a pelvic exam now, all the anxieties I felt before about an exam that seemed so "gross" and inappropriate before just seems like another part of my job. My main concerns are more for the patient and how she may feel about a baby-faced male doctor-to-be performing an exam that is uncomfortable and in principle socially taboo. I am still very much in tune with that, and still struggle with balancing patient discomfort with my own education. But as far as it seeming gross, or unusual, those feelings are gone. I already find myself forgetting what it was like to know nothing about obstetrics. The 17 year old nulliparous patient who has no idea it is normal to defecate the bed during delivery. The couple who just welcomed their first child into the world who have a brief look of horror when the resident says she is now "using suture to reapproximate the vaginal wall." The 28 year old new mother who glances down in horror after we "remove" 300cc's of clot from her uterus post-partum. I forget how strange these things must seem.
During a c-section earlier in the week, the anesthesiology resident was comforting the patient during the procedure, talking her through the steps of the procedure. We had just finished closing the hysterotomy, and the resident says flatly "they just finished closing the uterus, you may feel some discomfort as they return the uterus to inside the body." I can imagine the patient's eyes growing wide, but all I hear over the drape is "WHAT!?!???" A large part of me cannot find fault in his faux pas, as these things seem routine to us. There is nothing strange about removing the uterus and placing it on the stomach to better sew the incision.
Just a few things that are now normal to me.
Ironically, 3 of the first 8 image results for the keyword "normal" in google images are of genitalia.
"The Look."
As part of our internal medicine rotation, we were required to spend 5 weeks at a hospital out in the community. The hospital I was sent to was a fairly large medical center with close to 500 licensed beds, and part of my hospital was a large tower of a structure dedicated as the "cancer center". The problem with the cancer center is that it was built as an addition to the hospital, which meant to get access to the beds within the tower, you had to go up to the 3rd floor of the regular hospital, through this back hallway attached to the corner stairwell, go through a tiny side door, which brought you to a back elevator shaft. You then went up the curiously slow elevator, through a set of double doors, then up another set of stairs, just to get to the beds in the tower. As a result, the tower had been nicknamed the "Death Star", because every time a code or rapid response was called in the tower it took several minutes to respond simply by virtue of its reclusive location. While rotating at the site, I worked with a senior resident who took the code pager very, very seriously. Whether it was a code blue or a rapid response, we. were. running.
One day on short call, we had an afternoon where the code pager would not shut up. As a result, we were running all over the hospital to various locations within the hospital, always at an aggressive jog with my 30 pound white coat flapping around me and sweat beading on my forehead. All the codes that morning ended up being fairly well controlled situations... a patient in the post-op area of the day surgery who got too much narcotic, a code blue called on a patient already in the cath lab, a patient who had an an RRT called simply because the attending wanted a stat ECG. We had just finished up our 5th code of the morning when the code pager started blaring again, this time for a patient in the Death Star. "Crap." my senior muttered, and off we took, up to corner stairwell, down the back hallway, through the tiny side door, to the elevator. Wait for it. Wait for it. Wait for it. Up the elevator. Through the double doors. Up the stairwell. Down another hallway.
When we arrived the scene was fairly chaotic. An elderly woman was sitting tensely up in bed. Nursing staff was trying, quite unsuccessfully, to get an ABG, and blood was spotted all over her arm and hospital gown. The ECG showed new-onset a-fib and the patient was satting 70% on 12 liters of oxygen through a rebreather mask. But what struck me most profoundly was the look on the poor woman's face. She had what we called "the look": sitting rigidly upright, arms locked with hands grasping onto her sheets, desperately trying to breath with eyes wide and an expression of impending doom on her face.
There's only a few things that give someone "the look," and in an elderly bed-ridden hospital patient, we knew even before the labs came back that she had thrown a clot to her lungs. She was wheeled down the hallway, down the elevator, through the lobby, up another set of elevators, and into the ICU. Luckily, she did quite well and survived her PE with only a scare. The Death Star had been defeated that day. But I'll forever be imprinted with that look she had the moment we walked through the door. It's one of those indelible moments that are sprinkled throughout the third year of medical school - when what you learn in textbooks manifests itself in a living, breathing human being tenuously placed in front of you.
Happily exhausted.
There's a lot of mystique surrounding the internal medicine rotation in the third year of medical school. Besides the fact that your IM core clerkship grade is considered one of those "important things" for residency, its also the rotation that best integrates the various informations you crammed into your head during the pre-clinical years. Some say its where you learn to "think like a doctor" or "be a doctor." While my IM clerkship has not turned out to be nearly as dramatic as some would make it out to be, I have seen myself making small but significant strides on being able to capably diagnose and manage patients in the acute setting. I'm on week 6 of 10, and so far it's been exhausting, but incredibly rewarding.
It's amazing how many different experiences you can pick up in a short period of time, and how patient's stories are intertwined within all of it. Some are humorous, some are sad, some are powerful.
The little old lady found wandering the streets at 3am looking for her favorite starbucks, pleasantly delirious due to a UTI.
The woman admitted with herpes zoster ophthalmicus, who always wants you to linger just a little longer when pre-rounding, and you can tell she is lonely.
The patient who has a syncopal episode while masturbating.
The woman who has never smoked a single cigarette in her life, who dies from lung cancer.
The woman with sickle cell who is allergic to opiates, forced to endure the pain of her acute crises with only tylenol, who handles herself with awe-inspiring stoicism.
The 22 year old asthmatic, who can't afford an inhaler because he spends all his money on heroin.
The man with end-stage liver disease who can't get a transplant because he can't kick the bottle.
The 600 lb man, bed-ridden for over a year, who stands for the first time, and the attending shakes your hand and says "strong work, without your help, I don't think he would have ever left the hospital."
The patient with a-fib who passes suddenly in the middle of the night.
The woman who comes in with difficulty swallowing and leaves with a terminal cancer diagnosis.
It's humbling that these experiences are considered my "education." But I don't think I've ever appreciated or enjoyed medical school more than now. Its funny that it happened on this rotation, because internal medicine can sometimes (often) be much too rhetorical and slow paced for me. But there's something to be said about the principles of internal medicine being the foundation of how medicine is practiced, regardless of specialty. And I think my experiences on this rotation have allowed me to cross another one of those thresholds of clinical competency. I found as I was getting my feet wet in third year, I was often so concerned with not screwing up that the nuances of clinical medicine whisked right by me. I was so concerned with not missing anything in my history, I missed connecting with my patient. I was so concerned with my notes being perfect, I didn't stop and think about what I was looking for in my physical exam, or why certain things were in the plan. But as you gain competency in those skills, you learn to enjoy the process as much as the result. Medicine becomes less of a checklist and more of a visceral experience. And it becomes much more fun in the process.
So tomorrow, my alarm will go off at 4:30am. And I'll groan, because I'm exhausted. But then, I'll get up, and I'll smile. Because I get to do this for a living. How awesome is that?
So you wanna do research huh?
So I recently somewhat stumbled onto two research projects, which are currently eating up a lot of my free time, and thought to myself “Self, this would be a good topic for a post.” So here we are.
When applying to medical school, many students become adept at “fluffing” up their CV on their AMCAS application. So what if you only went to the Save Ugandan Tortoises Interest Group meeting once? It looks great to application committees; add it to your activities! Luckily (or unfortunately, depending on your fluffing skills), residency programs are much less interested in having you fill up your ERAS application with BS and are much more interested in firmer aspects of your resume, such as board scores, clinical grades, and letters of recommendation. Research is one piece of the puzzle whose importance is highly debated among medical students. One of the first questions out of the mouth of more ambitious freshly minted MS1s, still dripping with the sweet dew of the World Outside Medicine, is “How can I get involved in some research? I need it to get into a good residency.”
There are a myriad of opinions on the necessity of doing research in medical school, whether it is more fluff or substance. There is plenty of n=1 evidence of individuals able to land top spots in tough fields without it, as well as evidence to the contrary. Like most things in life, the truth likely lies somewhere in the middle, and how much you “need” research on your resume when applying for residency is highly program and field dependent. Unfortunately, I have yet to find a good website or book with that kind of information. The best approach I’ve found is simply asking around amongst individuals further up the food chain. Residency directors in particular are invaluable resources for giving you a good sense of what you do and do not need to do during your first 3 years to make yourself into a solid applicant, as well as the tastes and preferences of various programs. That being said, the NRMP website has a plethora of data available about characteristics of applicants who successfully match into each specific field, broken up by board score, state, amount of publications, shoe size, hair color, etc. One thing to keep in mind when viewing the data is that variables such as total number of publications tend to be skewed upwards in the more competitive specialties, as they tend to attract a greater proportion of the “super applicants” with pub lists larger that the US National Debt. For example, the mean number of abstracts/presentations/etc for ENT last year for successfully matched applicants was 4.1. But the mode of the pool of successfully matched applicants is lower than the mean due to the “drag effect” of the upper crust, so it does not necessarily mean you are “below average” if you are applying into ENT with less than 4.1 pubs. However, the NRMP data is useful for broadly comparative purposes, where you can construe that research is more important to match into ENT than family medicine (avg 2.8) but less important than rad onc (avg 8.2).
So where does ENT sit on the spectrum on research-loving/research-hating? The consensus I’ve received after talking to various faculty is: research isn’t essential for matching into ENT, but it’s pretty important. The field as a whole tends to highly value research. Part of that is due to the smaller size of the specialty – it is much more reliant on broad participation in clinical research to contribute to the common knowledge of the field. Part of it is the rapidly evolving nature of the field. Part of it is that residency programs pride themselves in being academic pipelines and being responsible for training the future department chairs of the world. The simple fact is that nearly all ENT residencies offer some form of dedicated research time in their residency track, and most require their residents to be working on at least one study while in training. It is an asset when a resident has sufficient experience from medical school to be able to jump in and tackle a solid research project while at said residency’s program, rather than having to learn the ropes on the fly. Can you match into ENT without any research experience? Sure, and many have, but it requires having something else to compensate (be it above stellar board scores, above stellar letters of recommendation, etc).
So, you’re sold, you want to do research. What does that even mean? How does one even begin to “do research?” That’s the situation I found myself in my first two years of med school. My experience with research prior to med school consisted of running PCR gels in a lab, and unfortunately my school did not do much in terms of educating us of our options during the pre-clinical years, besides telling us to “get involved!” and spamming our inboxes with a bunch of vague emails. So I floated through my preclinical years, feeling slightly guilty I wasn’t in on this “research” bit but having no idea where to start. When I became pretty sure I wanted to go into ENT, I knew getting involved in some research would probably be a good idea, but wasn’t sure where to begin. Luckily, I found out it can really be as simple as sending an email. Most faculty in an academic setting have a project or two going at any given time, and at least a couple questions they would like to investigate. And if they don’t, they tend to know who in the department does and are looking for medical students to help. The main thing is to just be proactive; there’s a wide myriad of opportunities, but you need to find that point of first contact. Your “in”, so to say. Whether that is replying to a “research opportunity” email, talking to a contact in the dean’s office, or an un-solicited message to an attending you may know in a department you may be interested in, I’ve heard of successes with any and all of the above strategies. You don’t even have to commit to a project, but once you open the dialog there is often a great deal of flexibility in how much time and energy they will let you contribute. But no one is going to give you research opportunities if you don’t ask, so the onus is really on you as the student in the beginning. If you’re not sure where to start with research, the Medical Student Research FAQ over at Student Doctor Network is a good place to start.
I was chatting with the ENT program director at my school the other day and I asked how he was able to differentiate between such a large pool of highly qualified applicants, all with research on their CVs. Here were a few of the things he told me they look for:
1. The more responsibility you have over the study, the better
The ideal, of course, is that you started with a question, formulated that into a hypothesis, structured a research design to answer that question, got the protocol approved through IRB, collected and crunched all the data, worked with a statistician, wrote your article, and got it published. Of course, with both the time and resource constraints of medical school, and the limited timeline we are on to score a publication, such a scenario can be largely unrealistic. But what it comes down to is: what you end up researching is less important than the experience you gain during the process. Are you familiar with all the steps that are involved with taking research from idea-to-publication? Can you create a solid study design? Are you experienced in writing publications? The most obvious way you can demonstrate these qualities on a residency application is to be either first or second author on a publication. But first and second author opportunities are few and far between for students, and often more a consequence of luck. That being said, you will be asked about your research during your interviews, and being able to speak intelligibly about your project(s) will go a long ways towards demonstrating that you would be a competent researcher.
2. Get some funding
There’s a surprising amount of money out they for medical students doing research who are up to the task of writing an application for the award. It doesn’t even have to be a large sum, a couple thousand dollars is sufficient. But the nice thing that a grant or award demonstrates is an additional level to the vetting process of your study. It shows that an independent body evaluated your study and decided it was a worthwhile enterprise. This does a lot towards legitimizing your work in the eyes of program directors. Your dean’s office is likely your best bet if you’re looking for a few leads on some awards you can apply for.
3. Sell your experience
Like I said before, what you end up studying is much less important than your experience in doing research. PDs want to see not only that you’re competent, but that you’re excited and engaged in the research process. Being able to discuss both the skills you’ve gained through the process and what about doing research intellectually challenges and stimulates you demonstrates an additional aspect of what would make you an asset to their program.
As for my own personal experience – I got my “in” by emailing an younger attending in my department who I had gotten to know through our clinical skills class during the pre-clinical years. We set up a meeting and he laid out a few study questions he had been considering and let me pick up a project I’d like to take up. I ended up taking on two different studies (that have now evolved into three studies) and have been the point man as far as getting IRB approval, writing consent forms and proposed project protocols, collecting data, and such. Let me say, if you can snag yourself a similar experience, it’s a lot of fun. Being the person in charge of the nitty-gritty details gives you a large appreciation for the research process and causes you to ask yourself a lot of the questions that differentiate a well-designed study from a haphazard one. Plus in medical school, where you often find yourself busy with tasks that feel mundane or pointless, it’s a pleasant experience to be involved with something that feels meaningful. You get to be the master of a small subject, and you’d be surprised the many ways you can spin that into talks, posters, and papers along the way. I wasn’t particularly enthused with research before getting involved with all of this, but since then have found my clinical curiosity kick up a few notches and encountering all sorts of questions in the clinical world that would make for interesting studies.
Well, that’s it for now. Until next time!
Flying Solo
Few things represent the hierarchical and tradition-seeped natures of medicine better than the operating room. As many med students will attest, half of the battle of the general surgery rotation isn't learning the post-operative management of surgical patients or how to properly manage a wound infection - it's learning the ebb and flow of the operating room. Tales abound which serve to strike fear and trepidation into subsequent generations of medical students of students being yelled at for touching something, looking at something, breathing improperly, blinking improperly, etc, etc. There's a procedure and tradition for every minute detail of the choreography of the OR, and you are expected to know it all before you learn it all, which contributes to awkward or embarrassing moments aplenty for medical students as they rotate through. I remember when I got yelled at while participating in a patient transfer off the operating table. I was the one pulling the majority of the weight on the rollerboard, and assumed it was my responsibility to do the countdown. 3... 2... 1... I get glares. I'm told to step away from the patient and not touch anything anymore. Turns out it's always Anesthesia which does the countdown, which is logical as they are overseeing/moving the airway, everything that happens in the OR is logical, but how in the hell was I supposed to know that beforehand? Such is life sometimes for a medical student in the OR - expected to know these things, before anyone tells them. In my own limited time in the OR, I have collected a small bundle of mortifying anecdotes. The time I almost desterilized the entire instrument table with a sneeze, the time I put the SCDs on upside down, the time I almost face-planted into the operative field when I slipped on some sigmoidoscope-associated KY jelly which had dribbled onto the floor... the list goes on.
But this post isn't about embarrassment; it's about hierarchy. When standing around the surgical field, there's also a rigid structure to where one must place one's feet. Traditionally, to the upper right of the patient, by the patient's right armpit, stands the lead surgeon. The lead surgeon is, by virtue of the position, the individual in charge of directing and performing the majority of the operation. To the left of the lead surgeon stands the scrub nurse or scrub tech, whose job is to, among other things, maintain sterile technique during the operation, pass instruments to surgeon during procedure, and help perform counts of surgical instruments throughout the procedure. To the upper left of the patient resides the individual providing first assist to the operation - who, among other things, uses the bovie to cut vessels and tissues at the lead surgeon's discretion, helps provide traction to tissue planes to aid in dissection, etc. And to the right of the first assist lies the domain of the medical student: the position of second assist. Here one typically aids in the operation by holding retractors to open the operative view, use suction to remove smoke, fluid, and blood from the operative plane, and tightly covet the Mayo scissors that one uses to cut suture ties. But with the myriad of surgeries and surgical approaches out there, there's also a wide variety of places where the surgeon and assistants stand to get the best exposure into the surgical field. And just likes plays on a football field, its up to the medical student to learn where to proverbially 'line up' for the snap. In an academic institution like my own base of operations, typically a resident provides first assist during the operation and the medical student stands beside as second assist for the operation. But during chance opportunities, such as when the resident is taking the lead on a case, med students are given the opportunity to run first assist, which is infinitely more fun for obvious reasons - namely, being able to more actively participate in the case. Rarely, a med student is offered to take the lead on simple cases (appendectomies, cholecystectomies, etc), which is always something worthy of writing home about, no matter how mundane the case may be for everyone else in the OR.
So a couple weeks ago I was spending a day in the OR with the ENT surgeon who I'm doing research with and a third year resident. We were powering through several of the half dozen cases on the docket for the day and next up on the case list was a simple tonsillectomy. The resident gets called down to the ED for a consult, and suddenly the attending turns to me and says:
"Want to take a whack at it?"
The third year of med school is a lot like the game of golf. All too often, you find yourself feeling incompetent, frustrated, disheartened, or some combination of the three. As your shot out of the shrub grass careens off the tree and lands in the water hazard you didn't take into account, you begin to ask yourself why you even play this stupid game to begin with. But a handful of times during a round, the balls rises gracefully into the air and plops, like it should, down onto the green within spitting distance of that birdie. And before you know it, you're paying another set of green fees and are back for more. Likewise, third year is full of foibles and f*ckups, sometimes asking yourself why you're doing this for the rest of your life. But every once and a while, you get to see or do something incredibly cool that reminds you why you're in it in the first place. And you come back for more.
Well this moment was my proverbial 240 yard approach shot plopped down 6 inches from the pin. The first time I get to take the lead during an operation. I step into position above the patient's head and gaze down at the base of the mouth. Just as I get bovie in hand, the attending laughs and says: "Don't worry... the first tonsillectomy I ever scrubbed on, the patient lost 1800ml of blood. The bar's set pretty low." Great. My resting tremor kicks up a couple notches.
But before I know it, we're off. I go in alongside the anterior tonsillar pillar, find the capsule, and before I know it, the procedure is over. Less nervous than I thought I'd be, but still trying to contain the 8 year old inside of me jumping off the walls going "WOW! That was COOL! Let's do it AGAIN! WHEEEE!"
Yup, back for more.
Respect Mah Authoritah
Wow, has it really been a month since I've posted? Apologies, my loyal reader(s) (hi mom!). I successfully survived my family medicine clerkship and sat through long hours of lecture during our "continuity curriculum" week (sidenote: how in the hell did I ever survive the first two years of medical school? I can barely sit and listen to a presentation for an hour now; I can't believe I used to do it for 4-8 hours straight every day).
Which brings me to my current location within the lands of an "Elective Block". Unlike some of my classmates who decided to do something clinical with that time, I decided to pursue a research elective, which I have concluded (as I sit in Starbucks and sip on my delicious holiday drink) was quite possibly the most awesome decision I've made this year.
The original plan was to have one study I was going to pound out in this 4-6 week period. Well, that 1 study turned into 2, and the 2 turned into 3 (well, more 2 1/2) and suddenly I am growing research protocols out of my ears and dreaming of HIPAA waivers of authorization. Yet despite all the madness, the simple fact that I get to set my own schedule has been incredibly refreshing. No sitting around in the afternoons on the wards bored out of my mind, no scut work, no asking permission to leave, no early mornings unless I am feeling particularly motivated. Ahhhhhh.
There is one thing that has been particularly maddening though; it's $%#@$%ing impossible to get anyone to do something for you if you're "only" a "medical student." It's the sad reality of the authority purgatory we reside in. On the wards, we can make treatment recommendations but can't prescribe medications. We can place orders but they have to be co-signed. Our notes are part of the medical record but residents must write separate notes for billing purposes. Because there is so little we can actually accomplish independently, we exist in this strange limbo where we can do a lot but there's very little we can actually "do." So it's understandable that there tends to be this dismissive attitude towards med students in the hospital, and I'm cool with that. But the reverse is also true - it often seems impossible to get anyone to do anything for you as a med student. On the wards, I've learned to stop signing my pages with "MS3" because if I do it'll be over an hour until I get a call back. I always go back to a moment on my psych rotation when one of my fellow students on the team slammed down the phone and yelled "Do they REALLY think its only the med student who wants this CT? Just for sh*ts and giggles?!? I'm CALLING because my ATTENDING wants the damn CT scan! RESPECT MAH AUTHORITAH!"
Yup, been there before.
Well, I've found that the research realm is not exempt from this phenomenon. Every email I send needs at least one follow-up before I get an answer. Every voicemail I leave requires at least one call-back before I get a reply. Being that I have precious few weeks where I can devote all my focus and time to this, I'm trying to get things done in an expedient manner, but too often it's like trying to work in quicksand where every action requires twice the normal effort. It's almost a daily occurrence where I want to have a cow and just yell "I'm CALLING because my PI wants the damn form signed!"
So, if there is anyone from the IRB reading this: Please. If a medical student is asking for help in getting something done, try to help the first time. We are not rogue anarchists set loose in the hospital to do what we want all willy nilly. If we're trying to get something done, there's typically a damn good reason why we are.
Now, back to my delicious holiday drink.
Snap, Crackle, Pop.
One of the difficult things about learning the art of the physical exam early in medical school is learning to differentiate pathology from normal. I remember when we first were instructed on the lung exam. We learned about these ambiguous terms... rales, rhonchi, egophony, stridor, tactile fremitus. I learned that you could have crackles in your lungs, and set about listening to the lungs on all my patients very closely. And I discovered a funny thing. Vesicular (aka normal) breath sounds can sound kinda-crackley if you listen close enough. All my patients started having crackles. I asked a doc I was working with one day "What do crackles sound like? Because it sounds to me like all my damn patients have crackles."
Eventually, I had a patient with real crackles, and like anything else with the physical exam, once you listen and touch enough normal patients the pathology begins to jump out at you. But this story isn't about that patient. It's about a patient I saw earlier this week, a 65 year old man with chronic kidney disease and congestive heart failure who presented with shortness of breath. He was actually my first patient I've seen with 3+ pitting edema, I damn near lost the entirety of my index finger into his left shin. But this story is about crackles, and I noticed a certain quality to his voice as I was talking to him in the exam room. No hoarseness or changes in phonation. But it sounded like someone had just poured themselves a bowl of rice krispies and set it in the corner. The snap, crackle, pop became more audible with each labored breath he took. For some reason, the moment brought me back to my early days of listening to the lungs, waiting for total silence and listening intently, hoping to catch a crackle or two in passing. And here I had a patient sitting in front of me with so much fluid brimming out of his lungs that I didn't even have to place a stethoscope on him to hear the crackles.
Sadly, in this economy, I'm not sure Kelloggs is looking for any new spokespersons anytime soon.