That’s even more “M”s in one title than last time!

Since my primary field and time investment is the medical field, it’s natural that I’d derive some motivational moments from my work. Without such moments of fulfillment, it would be difficult to keep going with the intensity and time commitment that’s required. While these are quite far and few between the daily nonsense that goes on during this portion of my training (internal medicine residency), I hope that writing about these moments will put them to the forefront of my mind and remind me of the diamonds that can be found only by working within this field.

A New Heart Murmur

I once used my stethoscope to great effect. Although using it is a basic skill, being able to identify and grade murmurs, and understand their differential diagnoses and potential risks is important. While my skills have certainly improved, I noticed that I may sometimes over-grade a murmur because it sounds rather prominent to me. Over-grading can lead to a different level of concern (and workup) than accurate grading.

On to the story of the murmur itself: this was a just barely-elderly woman (65 years old) without any known heart or cardiovascular problems, with no previously documented heart murmur. She had no prior problems or symptoms associated with her heart, and no known infections that could lead to heart problems. Yet, naturally, it’s still important to listen to the heart as part of a basic physical exam.

I managed to hear what sounded like a 3-4/6 crescendo-decrescendo systolic heart murmur. This means that between the two heart sounds (thump-thump; this section is called systolic), I heard an ongoing sound that became louder than softer (crescendo-decrescendo) that was moderately loud (3-4 out of 6 in loudness). Due to this, I also decided to listen to the neck veins, which sometimes carry a murmur in certain conditions that involves the vessels leaving or entering the heart, and I heard the same sound in both veins in the neck.

This type of murmur is normally concerning for what is called aortic stenosis. The aorta is a large vessel that comes out of the heart and provides blood to other organs within the body, some of the closest of which go to the head and neck. Aortic stenosis means that the aorta is constricted in expanding (either due to plaque, which is commonly in people with poor lifestyles) or due to a problem with the smooth muscle tissue in the walls of the aorta. The blood flowing from the heart through the constricted space of the aorta creates the sounds that are heard in aortic stenosis. Blood coming towards the area of the stethoscope becomes louder (crescendo), then going away becomes softer (decrescendo). This happens while the heart pumps blood out (systolic portion of the heartbeat).

My attending physician / boss, once again, was the same who hired me to this residency program. Yet again, she applauded me for being able to catch what she called a rather subtle heart sound (she graded it as 2-3/6 loudness).

I had suggested obtaining an Echocardiogram to determine whether the aortic stenosis was, indeed, present, and to assess the degree to which blood flow from the heart could be compromised. That’s usually standard procedure for a newly found heart murmur.

My attending, aware of the tremendous backlog of Echocardiograms in the hospital, and also pointing out that the murmur was asymptomatic, plus not too loud and (in the case of this particular murmur) thus not too severe, suggested starting off with an outpatient EKG and progressing from there.

A Successful Midline Placement

A midline is a line placed into a vein that’s deeper in the body than a regular peripheral line (IV line), and done so with strict sterile technique to avoid infections. These types of lines are used for long-term antibiotics that have to be delivered directly into the bloodstream, when a patient has difficulty maintaining a regular peripheral line, for continued nutritional purposes (when a patient can’t eat for the long term), and sometimes for rapid access to give medications that support blood pressure (pressors). They’re done using an ultrasound to see the tip of the line’s wire within the blood vessel.

I had done these a couple of times before, all successfully under the guidance of more experienced resident doctors. However, my technique was not initially great – yet, improving with practice.

This time around, under the guidance of another experienced resident (who happened to be one year younger than me in his overall training, but was extremely adept at procedures!), I had improved upon a point which had eluded me for a long time: seeing and following the tip of the line’s wire with the ultrasound so that I could ensure it’s going exactly where I want it to go. Certainly, I made some inaccuracies during the process, from which I learned, but they were smaller than previously, and I had a better flow to my approach. It’s great to see my own progression in technique for such procedures.

Several days later… in fact, just yesterday… I attempted to put a regular peripheral line for a patient. I had a lot of difficulty finding and keeping the tip of the line’s wire. It’s possible that I had to play around with the settings of the ultrasound to enhance my view, but it was a rather disappointing moment, since I thought I had improved this aspect of my technique significantly.

No matter! The only solution is to practice more and to remember the lessons from your errors. That’s how you’ll improve over time. Nothing worth having comes quick and easy; the most meaningful rewards come from a labor of love.

Conclusion

Some more successful moments in my budding medical career! During more difficult times, it’s useful to reflect upon and write about these little moments of victory. Now that I recalled these successes, I’m feeling a touch more confident again. It’s fuel for further self-improvement. 😁

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Disclaimer: FreeCompliments will be a beneficiary for this post, and I will attempt to boost it via Ecency points as well. Since this post is heavily medicine-based, I am also adding @stemsocial as a 5% beneficiary.