I remember writing about how medicine and becomeing a doctor is discouraging. It's like your goal is journeying to the moon and you are so far away and every day is only a single step, it seems unobtainable. My thoughts concerning that goal over a year of being a "doctor" hasn't changed...you still take it a step at a time, each achievement you pat yourself on the back for and each failure you close your eyes and recite your mantra, "I'll do better next time". You keep telling yourself that every failure and every success just moves you one step closure to that goal that is so far away.
For the past 3 years I've been practicing my eye exam. To me it's a very hard thing to do, use that opthalmoscope. I've been using it almost daily for the past 3 years and I've finally gotten to a place where I can routinly see the vessels in the back of the eye. Some patients I still have a problem with and can't for some reason. Many of my collegues when I question about it say they don't even try...I myself have wondered why I keep it up. Well several months ago now I got a 14 year old male in the hospital with a horrible headache, he'd been into several emergency departments and urgent cares, all of which had treated him as a migraine and sent him home. I met him early in the morning, he had continued 10 out of 10 pain despite adequate pain management (which honestly is pretty typical of most teen migraines), however some things struck me different about this patient. His mom was histerical and insisting something was wrong with her son. Most mothers of teen migraines have seen it before and in the back of their mind, either know that the child is just having a migraine or in the case of most female teenage migraines know that the child is faking it (evidenced by the 17 year old female text messaging her boyfriend with a smile on her face saying that her headache is a 10 out of 10 pain level). What added to that was this was a stable family, I notice most males with migraines either have a strong family history or an unstable family/social environment. On top of that, he was complaining of symptoms that were very un-migraine, he said that his hands were balling up involuntarily.
When you suspect brain pathology (a mass or increased pressure) there are only a couple of things you can do. You can do a neuro exam, look at the backs of the eyes, and take picture of the brain with an MRI or CT. By far the quickest check is to look in the back of the eyes with the opthalmoscope, but I'm convinced not many doctors (even the experienced ones) can do this...(I've seen most just defer it and do one of the other tests or order an optho consult). But, I've been diligently practicing, so I dim the lights, focus the scope, and tell him to pick a point in the room and focus on it. I pull the scope up so we are centimeters from each other. My light coarses through his pupils and I see the back of his eye clear as day. I focus a bit more until the vessels are crisp in my vision and then I follow them to the source, the enterence of the vessels into the eye...I'm shocked...I see a glimpse of white...it's ussually red/pink/orange. I peer closer, he must feel like I'm going to jump inside his skull. There surounding the enterence of the eyes is a white puffy donut...papilledema, wow, after years of practicing it's finally paid off! In a second for free, I've identified the cause of this kids headache. He has increased pressure on his brain that is pushing on the backs of his eyes. I've done what a CT and MRI couldn't, I send him for an STAT opthomology consult to confirm my findings (Come on I'm practiced but I'm not at all confident)...they confirm my findings and he's sent for a lumbar puncture which removes the excess brain fluid, his headache is cured. Although time has passed from that moment, days have turned to weeks, and weeks to months, and during that time I've found myself still on that long journey still millions of miles away from my goal, in that one moment I was standing on the moon.
Newbie Doc
