Getting The Hang Of Treating Patients In Rural Kansas

Aug 30, 2016

Former KCUR intern Stefani Fontana, now a fourth-year medical student at the University of Kansas School of Medicine, spent last summer doing a clinical rotation in western Kansas. We asked her to keep a journal of her experiences. We’ve edited out actual names of people and places to protect privacy, but otherwise present her journals as she wrote them. 

Part 2 of 4: From nerves to needles

By Friday, I’d gotten the hang of shadowing the family medicine doctor from room to room, smiling at the patients and asking what I hoped were intelligent questions.  It sounds silly to be worried about how to “follow the doctor” correctly, but if you ask too many questions at the wrong times, the shadowing experience can easily turn from professional to painful.

Dr. O and I had developed a good rapport. She seemed to genuinely like me, and her personality was so big I felt free to let my own light shine instead of struggling to hide it in the name of “professionalism,” as I’d tried, and been told to do, in so many other situations in medicine and in life.

I would follow Dr. O from room to room, she would introduce me and then work with the patient, pausing every now and then to point out something or tell me about the guidelines for screening patients of that age, demographic group and disease risk. This was teaching . These guidelines are what I would be tested over, and we never had this kind of one-on-one teaching in medical school.

On Friday we were back at the hospital, working the walk-in clinic. It was basic family medicine: a kid with strep throat who needed antibiotics, another who needed a sports physical, a woman with a urinary tract infection. Late in the day, the doctor went home and left the PA (physician’s assistant) with me and the pre-med student. 

One of our patients was an elderly patient who spoke only Spanish. She had emigrated to Kansas from Mexico a week before. She was complaining of periodic vomiting, an occasional stomach ache when she ate meat and cheese, and generalized pain all over. She’d come in with her two daughters and 12-year-old granddaughter. The granddaughter was the only one who spoke English.  The 40-something daughters were dressed for work, red uniform shirts and black visors. The patient wore a black sweater and floor-length skirt.  Her long, straight, salt-and-pepper hair was parted down the middle. She had a tired, wizened gaze.

Although we usually had a Spanish-to-English medical interpreter at the clinic, it was after-hours, so the translator had left for the day. Because I was feeling more confident of my family medicine skills, I invited the pre-med student to see the patient with me.  He spoke a little bit of Spanish but proved to be helpful for only a few words.

“How long have you been feeling pain?” I asked. I looked at her when I spoke, even though I knew she didn’t understand me, because that’s what the instructors always told us to do when working with an interpreter. 

We’re told never to let a family member translate. But we were in a pinch here, so the granddaughter would have to do. Then the two daughters repeated the question, as though translating for the granddaughter. I recognized it as something that often happened in my family, where my grandmother doesn’t speak English and my mom will often repeat things to her.  The elderly lady finally responded and the granddaughter translated: “She doesn’t hurt, she feels nauseated.”

The entire history taking went like that: I said something to her, the 12-year-old translated, then the older women re-translated. After an hour of repeating back what they had translated to me to clarify the story they were telling, I gave up and spoke directly to the 12-year-old.  

I gathered that the grandmother had felt nauseated for the past three months. It started after she’d eaten some cheese, making me think listeria. She’d thrown up twice during this period, once within an hour of eating beef and the second the morning after she’d eaten pork. She sometimes had diarrhea, but other times she was constipated. There was never any blood in her stool. She was fatigued, had night sweats, and her back and right knee hurt. Sometimes she coughed, but there was no blood in the sputum.

The knee pain sounded like osteoarthritis. The night sweats and back pain concerned me a little for multiple myeloma, which would require a few lab tests to confirm. As for the nausea, given that she’d been in Mexico until recently, it could have been a whole slew of infectious bacteria, viruses and parasites.  I was not equipped to differentiate which one it might be. It would take a lot of laboratory tests to do that.

I had her sit up on the exam bench and listened to her heart and lungs. Nothing sounded wrong. I looked at her eyes and tested for focal neurological defects. Nothing wrong there either.  I had her lie down and listened to her belly. She had normal active bowel sounds. I pressed around on her belly and she indicated pain when I pressed on her liver. But I couldn’t feel any masses. I did a few physical exam maneuvers on her back to rule out a herniated disc. At that point, I’d exhausted my knowledge and excused myself from the room to get the attending physician.

I told the attending about the case, what I’d found on the physical exam and the tests I thought we needed to run. The attending added a CT scan to my list, and we went to see the patient together. We talked to the family for about 10 minutes and finally one of the daughters said, “Can’t you just give her a medicine to make her feel better?” No, we can’t! I thought. We need to do tests. How are we supposed to give medications without knowing what illness we’re talking about?

We tried to explain this, but it was clear they had neither the financial means nor the desire to let us do any diagnostic tests on the patient. So we gave her a prescription and gave them directions to the free clinic in a nearby city. I hoped she went to the free clinic, but I wasn’t optimistic that they would follow up.

Building and earning trust

Just as I was heading out the door, Dr. S grabbed me and said he had a knee injection to do, both knees, and asked if I’d like to do one. Heck yeah, I wanted to do a knee injection! I followed him to the nurses' station, where he’d gathered the lidocaine to numb each knee and the steroids to inject. He then turned to me and said, “Talk me through a knee injection. What are you going to do?”

That caught me off guard. I’d never done a knee injection before. There are so many things going on in the knee! There’s the top of the tibia, the bottom of the femur, the knee cap, not to mention all of the tendons ... I didn’t know where to start.  While I was concerned that not knowing how to inject a knee could make me look like an unprepared medical student, I decided it was still best to be honest about my lack of knowledge.

Dr. S explained how to palpate the landmarks between the tibia and fibula, which helps you find the tibiopatellar tendon, and this lets you know where to inject the lidocaine and steroid.

Adding to my anxiety, I’d heard our patient was a farmer, so if I damaged his knee by hurting one of the tendons with the needle while injecting, he wouldn’t be able to work anymore.  I could accidentally destroy his livelihood. But I told myself there’s only one way to learn, and that’s to do it. The attending wouldn’t put me in a position to do something he wasn’t comfortable with me doing, I reminded myself.

We walked into the patient room and I found myself facing a very tall and heavy man. Overweight and obese patients tend to get bad osteoarthritis in their knees and generally are the ones who get the steroid shots.

“Would you like a gown to change into?” Dr. S asked.

“Why, is this girl shy or something?” the patient said with a large belly laugh.

“No, no, it’s for your comfort,” Dr. S said, chuckling. “J is my brother in law,” he said to me. That made me feel a little less awkward. Since he was family, he’d be more forgiving if I caused pain during the procedure.

The patient was wearing a large red shirt and classic blue overalls, clean and new-looking. He stood up in front of the exam table, turned and unhooked the straps of the overalls, so they dropped to the floor. He sat down on the exam table and Dr. S began palpating his sausage-shaped knees, then invited me to palpate for the landmarks he had described to me.

It was like pressing down on top of a pot roast and hoping to feel the bone.  I couldn’t even see where the knee was supposed to be, let alone feel the bones. I pressed into his leg with the full force of my body, but simply could not compress enough tissue to feel the bones. That’s when I began to worry. I don’t think I can do this. If it was a fit person and I could see all the landmarks, then that would be a different story, but this? If I can’t find the landmarks, how do I know I’m even in the joint capsule and not shooting steroids into a blood vessel somewhere else in the leg?

I considered pulling Dr. S out of the room to tell him I was not comfortable doing this procedure. Then something inside of me spoke up. No, it’s time for you to woman-up.

Dr. S pulled out a pen and drew the landmarks. Then he handed me a needle loaded with lidocaine. I took a deep breath and tried to go through the steps. I slid the needle in at an angle and, to my consternation, Dr. S started talking to the patient. Doesn’t he realize I have no experience? He shouldn’t be talking, he should be hovering over my shoulder, breathing down my neck, making sure I don’t mess up! I made a bubble of lidocaine under the skin, satisfied that it looked right. 

Then I grabbed the bigger syringe, which was loaded with steroids. Dr. S continued to talk and I placed the needle next to the knee, where I wanted to insert it, and looked up at him. He was still talking, but glanced down and nodded, telling me I was pointing the needle in the right place.  The needle slid through the skin without resistance and I watched about two inches of the needle disappear into his knee. Then I hit something hard. I knew it wasn’t bone, Dr. S had told me bone would feel gritty. The way the resistance felt made me think I had hit either tendon (bad) or the joint capsule (good).

I looked up to catch Dr. S’s attention, genuinely worried I was on tendon or some structure I didn’t even know. He placed his hand over mine, felt the resistance for himself and said, “You’re at the joint capsule. Push through that and inject the remainder of the lidocaine, then follow that exact path with the needle with steroid in it.”

I did as he said, and took the needle with the steroid, following the same path into the knee. I felt the same resistance when I got to the joint capsule and still felt hesitant.  I glanced up at the patient to see if he was in pain. Perhaps if I was hitting something bad, he’d react. The patient was chatting with Dr. S about their kids and didn’t even seem to notice I had a needle buried three inches deep into his knee. 

I guess the lidocaine worked, I thought.  I wanted to ask Dr. S to place his hand on the needle, feel the firmness I was pressing against and tell me if it was the joint capsule and I should push the needle through it. The problem was I knew interrupting their conversation would reduce the patient’s confidence in me, expose me as never having done this before.

Nobody wants to know that you’re doing a procedure for the first time on them.  Everyone just wants to be reassured you know what you’re doing.  Of course if the patient had asked, I would have been honest about this being my first time, but I still wanted to appear confident.

I looked hard at Dr. S, telepathing to him with all my might that I needed help, all the while trying to hold my needle as still as possible. After the longest minute of my life, Dr. S looked down where I was kneeling at the foot of the exam table. Without a word he placed his hand on mine, gently pressed and through my hand was able to appreciate the firm anatomic landmark the needle was pressing against.

“Yup, that’s the joint capsule,” he said reassuringly. “We’ve gotta penetrate this to get into the joint space, that’s where you want to inject the steroids.” Then, a little louder to signify it was directed to the patient, he said, “You’re gonna feel a little pressure here,” while simultaneously pressing my hand and the syringe forward. I felt the firmness of the joint capsule, a little resistance, then the needle gliding smoothly forward, without any resistance at all. I had pushed the needle into the joint capsule.

“Go ahead,” Dr. S said, indicating it was time to push the plunger of the syringe down and empty the steroids into his brother-in-law’s joint space. Relief spread over me. I’d successfully injected someone’s knee with steroids!

I learned not only how important an in-depth knowledge of anatomy is, I also discovered that I had a pretty good knowledge of anatomy.  I learned that I could have confidence in myself, recognizing, for instance, that I hadn’t hit bone based solely on the feel of the needle in my hand.  I also learned to trust the doctors I worked with, trust that they knew what I was capable of and that they would never put me in a position where I could hurt a patient.

This is an example of what I know to be one of my weaknesses: how much I question myself in these situations. I’m worried my superiors overestimate me and believe I can do things simply because I’ve scored well on tests, but I think I’m actually not as smart as they think and can’t do the things they think I can. 

I’ve been told it’s called “imposter syndrome,” and many women in science and medicine suffer from this.  It’s the notion that we aren’t as smart as everyone thinks we are and that we’ve fooled them into thinking we’re smart.  And with my type of work, that fear comes with the fear that a patient will pay with his life or limb. Oftentimes, women with imposter syndrome are driven by this insecurity to work even harder, which can worsen their feelings of having “fooled” everyone into thinking they’re smart. In this instance, I learned that those self-doubts weren’t justified.

That day I also began to understand the gravity of the work we do, and why everyone takes every little step of medicine as seriously as they do. I thought residents were being dramatic when they made me rewrite a prescription because the 1 wasn’t clear enough. But they’re right; people’s lives are in our hands.

These doctors have seen people die because they weren’t meticulous enough, and they were training me not only to fully appreciate the gravity of our jobs but to act accordingly. And now I was learning to trust them to ask of me only what I was capable of, not more. This was a new type of trust for me. But in it I found a new self-confidence. I could inject a knee! I know it’s a minor procedure, but for me that baby step, that first step, was the biggest one I’d taken in years.

Talking and listening

Monday morning I woke up, ran five miles, then cleaned up and went to the hospital. I was working with a different doctor this week, Dr. F. 

That afternoon we went to the outreach clinic in a nearby town of around 300 people. I didn’t know such small towns existed, but I climbed into Dr. F’s car and we drove half an hour, past a dead golf course, to a place that had one grocery store and a row of nondescript buildings on a short, two-block-long main street.

We parked in front of an abandoned storefront and Dr. F pulled out some keys. This was the clinic. It was a small building with three exam rooms and a bathroom. People started coming in and we did the same thing we’d been doing at the hospital clinic: I’d go see a patient, do the exam and then report back to Dr. F. Afterward we’d go see the patient together and I’d mentally chastise myself for not asking or noticing something Dr. F did during his exam.

One of the patients who came in brought his dog, a fat, little bichon mix, with him. The man was wearing a straw hat, the kind Van Gogh wears in his self-portraits. The dog waddled next to him without a leash.

“Mr. M is an artist. He does these really amazing sculptures,” Dr. F told me. “His wife died a couple years ago, and he’s been really struggling with depression since then. I have him see me once a month. Mostly we just do talk therapy.” I was surprised. I’d always assumed family medicine had more to do with managing diabetes. I never realized that it entailed such holistic patient care.

These cases made my heart hurt. Scientifically, I understand that your heart can’t actually hurt because it doesn’t have the right kind of nerves, but I still feel a thud and tightness in my chest when elderly patients come in with depression after losing their life partner. The kind of invisible, inorganic pain and depth of loneliness that medicine can’t fix. It made me feel helpless.

I knocked twice, then turned the knob and walked into the room. “Hi, I’m Stefani, a third-year medical student working with Dr. F,” I said, extending my hand.  He had hooded eyes and the irises were very dark, almost black. The combination made him look hollow inside somehow.

We talked for a long time, mostly him telling me about his son, about the new paint he just bought. I listened, unsure if I was just supposed to listen or try to do a physical exam. We have these exercises in medical school where we practice working with patients who are excessively talkative. The goal is to learn how to let them know we’re listening, but also to take control of the situation so we can complete a thorough physical exam in a timely manner. It’s hard to do this without the patient feeling like you cut them off or aren’t interested in their lives. I’m not that good at it, to be honest.

But this was particularly challenging. He clearly just needed someone to talk to, and we’re taught that sometimes just listening is the best treatment we can provide. Moreover, Dr. F had sort of implied that this was the best thing to do for this patient. So I listened and asked questions about his son and his sculptures. Then he said his wife’s favorite cat had gone missing. This, I imagined, was what was upsetting him the most right now.  I delved deeper and tried to reassure him the cat would come back, but I really had no basis to think so.

I finally managed to listen to his heart and lungs, and when I reported back to Dr. F (what’s called “presenting the patient”), I made sure to mention that his wife’s favorite cat had gone missing, deciding this was the most pertinent finding in my patient exam. We went back into the patient’s room together. Mr. M talked to Dr. F, who just listened. We covered many of the same topics, and Dr. F gently asked about his wife’s cat. Mr. M revealed that he was concerned the cat had died and became tearful.

We didn’t give him any medication, but he seemed happier when he left. He even smiled. Letting him talk, listening and providing some caring turned out to be the best medicine for him.

Later in the week, I had an encounter with a patient whose blood pressures varied by the widest degree I’d ever seen. She would have normal blood pressures early in the day but later in the day they’d be so high that if I read them on a test question, the correct answer would have been to send her to the emergency room. As we continued to chat, I asked how she was taking her blood pressure.

“I’ve got one of those machines that takes it,” she said. Oh, I thought, I’ve heard that they’re often not accurate and should always be double-checked manually if you’re suspicious.

“Can I ask when’s the last time you calibrated the blood-pressure machine?” I asked. I was feeling quite proud of myself, sure I’d identified the problem.

“We don’t do that here, this is Kansas,” her son said. “Are you one of those city girls? Where are you from?”

I tried to stop blushing. “I’m from Johnson County,” I said, chagrined, although I wasn’t sure  why.

“Yup, a city girl,” he said. At that point I went to grab the real doctor, as I’d clearly proven myself to be useless. 

Read the rest of the series.