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 these condensed journals largely as she wrote them.
Part 1 of 4: Go west, young doctor
“It was A-MAZING,” my friend Bridget had told me after she’d returned from her family medicine rotation, which she had done at a rural location. “There are no other medical students or residents around, so you’re the only person there for them to train … so you learn to do everything.”
This sounded good to me.
In Kansas City, I would have been shadowing primary care physicians, working 8 a.m. to 6 p.m., managing diabetes, high blood pressure, educating about diet and exercise and how to prevent other future ailments. While it’s a critical job, and frankly we need to give primary care doctors more credit as our first-line defense against illness, I wanted to have a broader, more traditional family-medicine experience. So I signed up to go west.
I packed up my Beetle and drove for four-and-a-half hours. As Siri told me I was nearing my destination, I saw I was driving directly toward an ominous-looking cloud. This can’t possibly be real, I thought, remembering all the times I’d been teased about Dorothy and tornadoes and the Wizard of Oz when I lived on the East Coast. So I’m seriously driving into a tornado in western Kansas. It was pouring rain and the wind was howling.
When I got into town, I realized I was utterly and hopelessly lost, and the rain and wind were starting to scare me. Siri told me that the address I was supposed to be at was in the midst of an intersection, but all I saw was a residential home and an elderly living center. I drove back and forth through the intersection half a dozen times.
But then I saw an elderly lady standing in her doorway watching me drive past. I shouldn’t worry her, I thought, I don’t want to scare her. Thinking of my own grandmother, who’s convinced evil spirits follow her throughout her apartment, I thought better of approaching her for directions.
The rain was getting heavier, and all I wanted to do was get myself and my possessions inside my apartment before the tornado hit. I can’t sleep in the car during the tornado, I thought to myself. Tornados blow little Beetles away. I’ll get hurt. I broke down and pulled into her driveway. I pressed the doorbell and squished myself under the awning to avoid the pelting rain.
The door opened, and a frail-looking woman in a blue dressing gown, probably all of 90 pounds and 5-foot 2, opened the door.
“Hi,” I said a bit self-consciously. “I’m so sorry to bother you, but I’m lost … I’m looking for 1001 S. Main Street?”
“Oh gosh come in! It’s raining!” she said sweetly.
“I’m Stefani," I said., "I’m a medical student at KU Med who will be working with Doctor O for the next few weeks."
“Oh yes, I know KU Med,” she said, ushering me into her home. “I’m Ruth. The place you’re looking for is right over there.”
She pointed to the senior living center catty-corner to her house. “Well what is your apartment number? I’ll bring you something next time I bake something, or do you like cucumbers? I just picked some from my garden. Any vegetable you want I have it in my garden you just let me know!” She smiled brightly.
My heart melted. Here I am, from East Baltimore, worried she was thinking I was trying to break in … and she invites me into her home and offers me baked goods and veggies from her garden.
I drove to the apartment she pointed me to, parked on the street and started unpacking my car in the pouring rain. Within minutes, the rain subsided. I looked up to see a clear, dusky evening sky. I could see the storm cell continuing its path southwest across the plains. The land was so flat I felt like I could see for miles.
It was truly beautiful.
'City girl' gets to work
Dr. O had asked me to meet her at the clinic at 8:45 a.m., though she said she might not be there until 9 a.m., as she had a toddler at home. I woke up at 7, showered, paired my white coat with a chambray shirt and the cowboy boots I’d stolen from my little sister, hoping this wouldn’t make me look like some “city girl."
The town was all of five blocks long. I pulled my little Beetle into the clinic's parking lot, paused Aziz Ansari’saudiobook and rolled up the top on my convertible. I really wanted to make a good impression on Dr. O. I took a deep breath. You can do this.
When I walked in, I immediately felt out of place. The chambray shirt and cowboy boots I’d picked out because I thought they looked rural made me look over-dressed and over-done. Everyone else was in scrub bottoms, a T-shirt and tennis shoes.
“Hi, I’m Stefani, the medical student working with Dr. O,” I said in my most confident voice. The nurse opened the door and pointed me back to Dr. O’s desk.
“Hi, I’m Chris,” a woman in purple said as she walked toward me. This was the nurse practitioner who worked with Dr. O. She walked straight toward me. I held out my right hand but she sidestepped it and grabbed me in a hug. “We are so glad to have you here!” she said. Wow, this is a huge invasion of personal space, I thought as I tried to get comfortable in a stranger’s embrace.
I waited there about 15 more minutes until Dr. O, who asked me to call her by her first name, walked in. Her personality was huge, bigger than mine. She was opinionated, smart and commanded respect without seeking it.
There’s a stereotype in medicine that if medicine is high school, then internal medicine is the chess club, surgery (especially orthopedics) the jocks, dermatology the pretty girls, and pathology the anti-social kids. Well, if that analogy holds up, Dr. O is the pep club. She walked into clinic, pulled her computer out of her bag and knocked on a numbered door. I guess we’re starting now! I shrugged on my white coat, with my pocket-sized books, stethoscope, clipboards and pen lights in the pockets, and scurried after her.
That morning we saw an 18-year-old girl who was eight months pregnant, an elderly couple in their 80s being seen for cancer and just about every type of patient in between.
Between patients, as I waited for Dr. O to write notes, I noticed an old shoebox full of crocheted items. There were socks and baby mittens and what you’d expect people to crochet, but there were also stuffed animals, a stuffed cupcake and a stuffed carrot.
When I started medical school, I’d picked up knitting as a hobby to keep my hands strong so I could go into surgery. (I did it on my own, but there’s actually a “Grey’s Anatomy” episode about this.) I had tried to teach myself to crochet but failed abysmally.
“Who made this cupcake?” I asked, holding up the crocheted cupcake.
“Oh, actually she’s our next patient,” Dr. O said. “She’s amazing. She crocheted my daughter a full tea set.”
She turned and knocked on the door and opened it to enter a patient room. In the corner was a woman I guessed was in her mid-80s. “Sandra, this is my medical student, Stefani. She wants to know if you’ll teach her how to crochet,” Dr. O said. The woman’s eyes brightened as she looked at me.
“Oh yes, I’ll give you my number. You just call me sometime this week and come over to my house. It’s just a block that way. I’ll show you how to crochet.” I was pleased, but quite surprised that an elderly woman would tell me exactly where her house was. I was still getting used to this small town thing, and how much people seemed to trust the town doctor.
A family feeling
“OK,” Dr. O said. “We’re done here, I’ll meet you at the P Clinic.”
Oh … I guess we’re changing clinics … and cities. I had passed the other clinic on the way into town, but I had only found my way to the emergency room. The building wasn’t that large, but I was still worried I wouldn’t be able to find the right entrance. She must have seen the confusion on my face. “Just follow me,” she said.
She walked me back to the conference room and introduced me in a meeting that involved the entire clinic staff. Then she introduced me to her husband, also a provider at the clinic.
He greeted me, then turned to his wife and said, “I almost offered to take your call for tonight, but I changed my mind.” She met him with a blank stare. “We had a 3-year-old girl come in here, and it was clear she was being neglected by her mother. I gave her a little bit of attention and she attached herself to my leg and would not let go after that … She’s been so neglected, that little bit of attention I gave her just fed her soul and she didn’t want to leave me. After seeing that little girl, I need to go home and spend some time with my daughter.”
Of course, because it was her husband, he was talking about their daughter. But I couldn’t help but be touched by how badly he wanted to see his child.
“OK, honey, don’t worry. I was prepared to work tonight. Besides, I’ve got Stefani with me,” she said, throwing me a smile. Is this when I should tell her this is my first overnight call … ever?
I was given time to go home and change out of my dress clothes into my scrubs. I returned to the hospital at 6 p.m. I found Dr. O’s husband and sat down with him. We chatted a little, then he got a call from the emergency room about a girl that had a near-drowning incident. He gave instructions, then I heard him say, “I have to go. This is a good teaching point.”
He hung up the phone, turned to me and said, “What am I looking for in this X-ray? Is the X-ray necessary? Why or why not?” Crap. Dear brain, you’re gonna have to go a little faster than this, ’cause we need to answer this question. After my few pathetic attempts to answer, he explained the guidelines and named the studies the guidelines were based on.
Then Dr. O came into the clinic with their daughter, who was carrying a toy doctor bag. She was adorable, with cheeks like tangerines and a sprout of curly blonde hair sticking off the crown of her head. I leaned forward and asked, “Is that a doctor bag?” Turning so that one eye was freed from her mother’s leg, she nodded. “Well what’s in the doctor’s bag?” I asked. She held it out and I took it, and slowly started taking things out of the bag. “What’s this?” I asked.
“Stefascope. Flex hammer. Otoscope,” she said, pointing to each item correctly. “But my otoscope doesn’t have a light,” she added, accurately identifying the difference between her toy and the tools her parents use. I was 29, and I didn’t know the word for otoscope until about a year ago.
After Dr. O’s husband took their daughter home, I followed Dr. O to the emergency room. We first checked on the girl who had the near-drowning incident that evening. While we were with her, a boy with a ruptured eardrum came in. Then a 23-year-old man who had broken his foot kicking a trailer arrived. I followed Dr. O from room to room. When the X-ray machine arrived for the 23-year-old, we went back to the nurses’ station and started writing notes on the patients. Dr. O was could remember every detail of every patient we’d seen; they were all a blur to me.
Losing the 'cool'
Later, we entered a patient room and there was a 5-year-old boy with hair buzzed close to his head and so blonde it was almost clear. He was lying on the table playing with an iPad. His mom sat in the corner.
“Well, hi bud!” Dr. O said to him as she walked into the room. “What did you do to your face? Were you trying to fly?” He smiled shyly and shrugged, as his mom got up and took away his iPad. Dr. O took his chin gently in her hands and tilted his head to reveal a cut about one centimeter long and half a centimeter wide just below the outer corner of his left eye. It was red but no longer bleeding.
“Hmm, yeah, I think that will need a few stitches.” she said. “We’ll go get the suture kit and we’ll be right back.” As soon as we left the room, she said to me, “Normally I would give you a chance to practice your sutures right now, but since it’s a child and on the face, I’ll do this one. You go get the kit and some 5.0 proline and I’ll grab the lidocaine.”
Since I didn’t know where anything was, I did what I do best: I asked a nurse for help. She helped me find the sterilized materials and sutures the doctor would need, along with the correct size of sterile gloves. I returned to the room with the treasures and found Dr. O sitting next to the little boy with a capped needle in her hand.
“OK, J, this is the stuff that will make it numb, so you won’t feel anything. You’ll feel this part, but afterwards you won’t feel a thing. I’ll tell you everything I’m going to do before I do it, OK?” He nodded.
I set the sterile materials down on the surgical tray next to Dr. O and unwrapped them so that I wouldn’t touch the parts that were sterile. It sounds silly, but I was proud of myself for knowing how to do this. There are so many details to every step of medicine, even unwrapping sterile items in a certain way, it takes all of third year, part of fourth year and some of residency to learn to do everything right.
“OK J, I’m going to use the numbing stuff now, OK?” The little boy kept his eyes cast downward and nodded without looking at Dr. O. Then she pushed the needle into the center of the wound – the center of the wound! Ouch! I thought, watching it. That fresh flesh is exquisitely tender, and there’s a needle in it now. Then, seven seconds after the needle had penetrated the exposed tissue, the little boy felt the burn of lidocaine.
“Aaaaaaahhhhhh!"
It was the loudest, most piercing shriek I’ve ever heard. He reached toward Dr. O to hit her, simultaneously rocking his body so that his head could pull as far away from her as possible. The EMT grabbed his head to hold it still, his mom grabbed his arms to hold him down. I thought about grabbing his legs, but didn’t want him to feel completely trapped. Dr. O smoothly moved her hands so that the needle didn’t budge one millimeter in depth or placement. She was perfectly calm. Finally the EMT and his mom had him restrained enough that Dr. O could continue with the procedure, despite his shrieks.
After she had injected the lidocaine, she took the time to help him calm down before proceeding with the stitches. “Are you ready to try? It’s numb now, so you won’t feel anything,” she said after he’d stopped crying. He sniffled to make sure we knew he was going through something hard, then nodded bravely.
J was calm until he caught the flash of steel out of the corner of his eye and realized there was a needle going into his face. “Aaaaahhhh!!” The shrieking started again. His mother and the EMT leapt into action, holding him still. As he screamed, I could see his face turning red, which revealed the wheal of white skin around his laceration. The white skin marked the area that had been affected by the numbing agent, and it extended about one centimeter in all directions from his laceration. He can’t feel this… he’s just reacting to the thought of the needle and feeling pressure, but he’s actually numb, I realized.
Then, out of the corner of my eye, I noticed one of the nurses sneak into the room. Since I was the closest to the door, she grabbed my arm. “We have a baby that asphyxiated on the way in the ambulance. She will be here in two minutes,” she whispered. Then she left the room.
This was the moment I finally lost the “cool” I’d been pretending to have and let myself panic.
I didn’t know if I was supposed to interrupt this procedure and tell Dr. O or if talking about it at all in front of this other family, particularly in a small town where everyone knew everyone, would violate HIPAA. I certainly didn’t want to interrupt Dr. O, because suturing right next to the eye is delicate on a stationary target, let alone a child who’s screaming. And Dr. O had already made it clear that I shouldn’t practice sutures on a child’s face, so I couldn’t take over. Furthermore there was not a single bone in my body that felt confident I could keep my needle out of that child’s eye if I were to take over so she could attend to the baby.
The best I could come up with was to leave the room, see what was going on with the baby and, if it truly was an emergency, go get Dr. O. So I followed the nurse into the trauma room. She was turning on the machine that measures pulse rate, blood pressure and oxygen saturation in the blood. The machine needed time to warm up.
Now what?
I was standing there with her, bumbling with wires trying to help her get the machine plugged in, when a young girl, maybe 22, wearing a pink tank top, soccer shorts, flip flops, glasses and smudged mascara, entered the room. She held a baby in her hands, wrapped in a blanket. She looked at me with the type of worry in her eyes that made me think the entire world was about to collapse. She held the baby out to me, arms stretched out, as though it were an offering to a god. I felt humbled. What do I know? I’m not a doctor, I’m a student.
My brain whirred. I had never faced this before. I was also conscious of trying not to look as if this were the first time someone handed me a baby that might be dying so that the mom wouldn’t get more worried. OK, brain, what do we do now? I looked at the baby; she was pink, not blue as I had expected based on what the nurse had told me. If she was no longer getting oxygen to her blood, she’d be blue. The pink skin was a good sign. She didn’t appear to be struggling to breathe, sticking her tongue out or flailing in panic. All good signs. All right, brain, what else should we do to see if the baby is breathing OK?
Then I remembered that the nurse had said the baby had choked on the mother’s breast milk. If she’d choked on milk, there could be fluid in her lungs. And when there’s fluid in the lungs, you can hear it with your stethoscope. I set the baby down on the exam table and looked at her chest as it expanded and contracted with each breath. I couldn’t see any of the muscles between her ribs contracting, so she was wasn't struggling to breathe. I set my stethoscope against the baby’s back and heard very clear, sharp breath noises. It was like one of the recordings we heard in class. It was clearer than that of any adult I had ever listened to, since there was no fat or muscle between the lungs and my stethoscope. From this, I could tell there was no fluid anywhere in her lungs.
“Can we put the pulse-ox on her?” I asked the nurse. I wasn’t used to giving orders to nurses. It felt weird that they were looking at me like an authority figure, doing what I asked them to do. We wrapped the pulse-ox band that usually goes on an adult’s finger around the baby’s foot. I worked my finger into the palm of the baby’s tiny hand, which she grasped. I looked at the pulse-ox screen, which read 100 percent oxygen saturation. The baby’s blood was carrying as much oxygen as it possibly could. She was breathing perfectly.
At that moment, Dr. O walked into the room. Little J had stopped screaming a while ago, but I hadn’t noticed because from the second the young mom walked in with her baby, all I had heard was the blood pounding in my ears.
“How’s she doing?” Dr. O asked.
“Her lungs sound clear and she’s sat'ing at 100 percent” I said, using a monotone voice to imitate the doctors I heard on “Grey’s Anatomy” to hide my own nerves. Dr. O quickly took in the pulse ox and the fact that the baby was pink, and walked over and listened to its breath with her stethoscope. I felt good that Dr. O’s first instinct was the same as mine. I wish I could say that having Dr. O present helped me relax, but my heart was still pounding.
“Do you want to hold your baby? Why don’t you have a seat here,” Dr. O said, facing the young mom and raising the back of the exam table so it would form a seat. The young mother took her baby and sat on the exam-table-turned-chair. Dr. O pulled over a stool and sat facing her, their knees touching, and placed a hand on the young mom’s knee. “Tell me what happened.”
It was at that point I realized how small the baby was. This was the tiniest baby I had ever seen in my life. We ended up seeing the baby the next day in a follow-up visit, when I learned she was 5 pounds, 3 ounces.
“I was feeding her and she just started coughing,” the young mom said, her eyes turning red. “She just started coughing and then she kept sticking her tongue out like she was trying to throw up … and I didn’t know what to do.” She started crying.
“Were you all alone?” Dr. O asked softly.
“Yes, my husband was out baling hay. He’s usually out till midnight … so I just called the ambulance.” She didn’t take her eyes off the sleeping baby the entire time.
Dr. O leaned forward to catch the mom’s eye. “I can’t see anything wrong with your baby right now,” she said. “She is breathing just fine, her lungs sound super. She is taking as much oxygen into her blood as you and me. Sometimes, babies just spit up and choke on it a little bit. Your baby is going to be fine.” Then she folded Mom into a hug.
A man walked into the room. He was exceedingly tall, broad enough to fill the entire door frame. He was wearing a blue plaid shirt, dirty jeans and a dirty blue baseball hat. He walked over to the foot of the bed and just stood there, crossing his arms, not saying a word. Dr. O turned to him. She obviously knew him.
I realized he was the dad. He must have been called in from the field where he was baling hay. He never uttered a word. I ultimately met him three times during my stay in that small town and never once heard his voice.
Our EMT meandered into the room. The nurses must have filled him in. “You know, if you’d wanted to show off your new baby, you could have just invited us over for dinner,” the EMT said to the dad. Everyone laughed and I followed Dr. O out of the room.
“I delivered that baby,” she said as we walked down the hallway. “She was early because the umbilical cord was too small to support her growth.”
We sat at the nurses’ station, Dr. O writing notes, and I pulled out a medical textbook on my iPad, but my mind was racing. Every now and then Dr. O would get up to check on the baby and I would follow her. Each time we entered the room, there were more people there. The in-laws, the young girl’s parents, aunts and uncles. Dr. O seemed to know them all, hugging each of them and giving a few more kisses to the baby’s head for good measure.
This was the beauty of rural medicine. Dr. O knew the entire family. She had been the primary care physician for all of them. She had been the obstetrician when the young mom was pregnant. She was the pediatrician when the baby was born. She’s the geriatrician for the grandparents and great-grandparents. And now she’s the emergency room doctor.
Patients continued to trickle in until about 2:30 a.m. I tried to suppress my yawns so I didn’t look like a total neophyte to the night shift. Dr. O didn’t yawn once. Finally, around 3:30 a.m., she picked up her computer and walked out of the nurses’ station. “You know where to find me if you need me,” she hollered over her shoulder to the nurses. I grabbed my overnight bag and scrambled after her. We went to the on-call room, where there were beds waiting for us.
