A Hundred Words for “Tired”

Posted on March 1, 2023 by marylbrandt

It has been said that the Inuit people have a hundred words for snow. When you live in a dangerous environment, it’s important to learn the variations of snow to survive. But, when you look into the origin of the “hundred words for snow”, it turns out it’s not exactly true – Inuits don’t have more words for snow than other languages…Their detailed understanding of snow is a lived, not spoken vocabulary.

The same is true for those who spend nights awake working in a hospital. We, too, have a lived vocabulary that includes hundreds of subtle variations of fatigue, even though we don’t have words to describe them. (The closest I’ve come to being able to describe this fatigue is in “sleep equivalents”, specific events or things that makes you feel like you have had more sleep than you actually did. For example, a shower after being up all night can give you the equivalent of anywhere from 20 to 60 minutes of sleep depending on how tired you are. Brushing your teeth after a hard night of call is usually 5-10 minute sleep equivalent. A good strong cup of coffee can be as much as 45 minutes of sleep equivalent – although it’s important to titrate it so you don’t end up with anxious jitters instead of just being awake.)

Knowing how to manage this level of fatigue it is part of medical training. (Don’t get me wrong… I’m not advocating that trainees must get tired on a regular basis to “learn how to manage it”) Learning to successfully manage the fatigue of long days and nights on call hinges on two things and both have to do with deliberate choices.

Learning not to trust your first instinct if you are sleep deprived is the first important lesson. Even if it’s a drug you know well, or the chest x-ray looks ok, stop and be deliberate. Consciously review the data, look at the options and, for really important decisions, ask someone to look at the situation with you.

The second lesson in managing fatigue is maybe even more important. The bone deep fatigue of medical training is not solely the result of sleep deprivation. When you stay up all night you also lose the liminal spaces of waking and falling asleep, the threshold between night and day. In scientific terms, this means there is a major disruption of your circadian rhythms. But it’s more than just physiology. The drowsy moments between sleep and being awake take place in the liminal spaces of dawn and dusk. We lose more than orientation to daylight when we lose this liminal space. The Irish poet and priest John O’Donoghue, teaches that liminal spaces are moments and places where the spiritual touches the finite. By losing the profoundly important rhythm of rest – including these liminal spaces – we end up physiologically, psychologically, and spiritually unmoored.

You have to be deliberate here, too. By trial-and-error work to find the things that ground you, the things that help you recover in a deeper way than just catching up on the sleep. Make lists of anything and everything that helps you recover from call for the times you are too tired to remember or choose. Look at those lists before you leave for your call day and choose something to do for yourself when you leave the hospital the next day. It might be going to the gym for a light workout, having a great cup of coffee in a cafe, a slow, grateful walk outside, playing with a pet, a hug from a loved one…or finding a way to “play” outside.

May the sacrifice of time and sleep you make for others come back to you as joy … and may you find deep rest in knowing you make a difference in so many lives.

Learning Medicine #SmartNotes

Posted on July 18, 2022 by marylbrandt

What if I told you there’s a system that makes it easy to remember the things that you need to remember for exams, but also creates links that make it easy to study and understand the network of knowledge that you really need to learn to heal?

And what if you could start using this system beginning on the first day of medical school…or at the beginning of your PGY2 year… or wherever you are on this journey now?

Here’s how:

Step 1. Create a folder in Google Drive*

Step 2. Take notes. About everything.

Step 3. Put the notes in your digital folder, filed by date and time, identified by hashtags and keywords.

Step 4. Synthesize, summarize, and link.

Step 1: Create a folder in Google Drive*

Don’t panic. Yes… just one folder.

Mine is labeled “card file”. You can always rename it. Maybe start with “My digital brain”?

If you just can’t stand it, you can create sub folders based on an anatomic filing system (e.g. Appendix, Colon, Heart, etc) but trust me – no sub-sub folders!

*I like Google Drive because it’s very flexible and you can access it from any computer and your phone. There are other ways to store digital data that can work as well, like Evernote, OneNote, etc.

Step 2: Take notes. About everything.

Keep a notebook in your pocket, use paper out of the printer, use a white board, or dictate directly into Google drive… but just take notes!

This practice is a leap for most of us, but it not only leads to phenomenal learning, it fundamentally transforms how you interact with your day. There is power in a practice that makes you more present in your day. Every encounter, every lecture, every article you read becomes a potential adventure, a source for new insight and growth.

There are only two rules

Rule 1: One concept per note.

Rule 2: Write the note only one time – don’t rewrite or retype notes. (If its’ a paper note, take a photo, or create a pdf to file in your google drive.)

What kind of notes will go into this system?

Lectures. You know how to do this from other classes! Just because we call it “Grand Rounds” or “Path-Rad conference” doesn’t mean it’s not a class. Take notes!

Notes from Reading. Textbook chapters, articles, handouts…

SOP (Standard Operating Procedure). This one is key if you are in a procedural specialty. Keep a single “note” for each procedure and update it with new information as you scrub with new attendings. Put in links to good videos, photos from textbooks and anatomy books. Anything that will help you review what you know and have learned before you do the procedure again.

Milestones. The first time you….listened to a murmur, talked to a patient about their prognosis, did a Whipple.

Questions, thoughts… “Why isn’t there a way to diagnose malrotation that needs surgery (vs.nonrotation) with diagnostic imaging?”

What you learned from patients. Make it your goal to learn something from every patient you take care of. Write it down. Make sure it’s HIPAA compliant – no patient identifiers that someone else could decipher.

Sounds. Yes, you can digitally store recordings!

Summary Notes. One page summaries of complex ideas

Unanswered questions. Ideas for possible publications, future investigations, etc.

Step 3. Put the notes in your digital folder, filed by date and time, identified by hashtags and keywords.

File the notes by date and time + description e.g. 2022-07-18 1645 Creating a filing system for studying medicine.

Why?

Imagine… It’s the last year of your residency, it’s 2am, and you are admitting a patient with Hemophilia A who needs emergency surgery.

You open your phone, go to your folder and search for #Hemophilia… and you find these notes:

First year lecture on coagulation

Second year lecture on disorders of coagulation

Second year lecture on the pharmacology of factors given for the different types of hemophilia

Your summary notes on coagulation, coagulation disorders, and the meds used to treat them

Notes from a review article on caring for patients with hemophilia

Notes about that really cute 6 year old on your pediatric rotation who had hemarthrosis

Notes from Grand Rounds on your medicine rotation about disorders of coagulation

A lecture during your surgery rotation on pre-op preparation of patients with clotting disorders.

Notes from Sabiston’s Textbook of surgery on patients with Hemophilia

What you learned taking care of the diabetic hemophiliac who needed an amputation when you were an intern

Last years’ conference with the visiting professor who was an expert on Hemophilia B

Step 4. Synthesize, summarize, and link.

There are so many details in medicine that we often lose track of the big picture. That takes thinking, creating one page summaries of complex topics, and noticing connections.

Maybe it would be easier to show you rather than tell you. Let’s say you are in a lecture about how to read a chest x-ray. In your notebook (or on your computer) you are taking notes… lots of notes… how to tell what’s a pneumonia vs atelectasis, what different lung tumors look like, how to tell if the mediastinum is too wide. As a result, 2 years from now when you see a patient with a lung mass, you will be able to search your drive for “lung cancer” and these specific notes will come up.

But as you sit and think about this lecture, you’ll realize that in addition to the details, there were more general concepts that were important, too. For example, how important it is to systematically review every diagnostic image so you don’t miss the lytic lesion in the bone that was behind the big mass in the chest. (Link to my favorite study describing how this happens)

So you create a digital note that describes, in your words, how important it is to have a system to look at images. Which makes you remember that this is very similar to how we always follow a system to do a history and physical. So you search in your drive for the card you made about how to do an H&P and you link them, using the “insert link” command. And, as you look at your H&P card, you notice that you had already linked it to cards you made about Basic Life Support (BLS) and ACLS (Advanced Cardiac Life Support), two certificates you were required to obtain, both based on a system to not miss important steps in resuscitating patients. And suddenly you are interested in why systems like this make it so much easier, so you do a quick search and find a fascinating article on memory and learning (as opposed to memorizing).

This post represents a modification of the amazing Smart Notes system described by Sönke Ahrens in his book How to Take Smart Notes: One Simple Technique to Boost Writing, Learning and Thinking. I highly recommend it, especially if you are considering an academic career!

Other things I’ve written about studying in medical school and residency:

Studying for the In-Training Exam 2022-01-30

Study Tips for First Year Medical Students 2018-08-11

How to Succeed in Clinical Rotations (and residency, too) 2018-01-09

Top Ten Tips on Starting Medical School 2022-06-18

How to Ace the NBME Shelf Exams, In-Training Exams and Your Boards 2017-04-14

Things I Wish I’d Known From the Beginning: OR Lights

Posted on March 29, 2022 by marylbrandt

One of my residents this morning thanked me for teaching her how to adjust the lights in the OR before a case. In fact, she said that since she had started this new practice that she hasn’t had to re-position the lights once while operating. There are so many minor details about the art of medicine that aren’t in books, so many things that make our lives easier…and that we wish someone had taught us earlier!

Operating Room Lights 101

Both lights should be positioned in the mid-line of the operative field – which means usually the mid-line of the table.

One of them should point straight down into the operative field. The second light should be either at the head or foot of the bed pointing into the field at an angle. If there are more than two, use them however it seems best.

Most importantly – You should position the lights BEFORE the procedure. Adjusting them after you start is always more difficult.

Operating Room Lights… Down the Historical Rabbit Hole

4500 BCE – Oil lamps

3000 BCE – Candles

1802 – Incandescent light invented by Humphrey Davy.

1850s – Operating rooms were built in the southeast corner on the top floor of hospitals to take advantage of natural sunlight. There were also four mirrors in the corners of the operating room to reflect sunlight toward the operating room table. (Wikipedia, Surgical Lighting).

1880s – Incandescent bulbs commercially available.

1920 – The scialytic (which means “dispersing or dispelling shadows”) light invented by Professor Verain in 1920 was the first design to direct light around the head of the surgeon. This allowed operating rooms to be moved from the top floor of hospitals. (Ersek, 1972)

1930s – Fluorescent lights commercially available

1962 – First LED light developed

“The light must be sufficient in quantity, must be directed into the proper places, and must be of such a quality that the pathological conditions are recognizable. Also the light cannot produce glare, which will serve to blind the surgeon, just as the high headlights of an oncoming automobile may incapacitate an automobile operator; and it is just as dangerous.” (Beck, 1971)

There are four factors to consider in optimizing illumination (reference)

Luminance = reflected light. Too much = glare = eye strain.

Volume. This refers to the need to have light in more than one plane, which is important because we operate in three dimensions (which is why there are always two lights). This is also why surgeons wear headlights or use lighted retractors.

Shadow management. This is why the position of the lights is important!

Temperature. Was much more of an issue before LED lights.

Setting the lights to set your intention

Positioning the lights before an operation will help you see more clearly. This simple act can also become a ritual and a reminder of why you are there… to heal.