The arrow sign

Clerkship is coming to a close… Last day is tomorrow (EEP!).

That means in just a couple short months, I will be an intern and a resident and then eventually (a long, long time from now) I will be an attending.  And with all this comes more responsibility.  Ack.

I love responsibility.  I thrive upon it in a sick sort of way.

Medicine has an interesting way of both shoving us in over our heads to make us learn and yet sheltering us because too much responsibility too soon can be a dangerous thing.  So, we basically do graduated on the job training.  Slowly build our confidence and the degree to which we manage and diagnose.  Sometimes, even when we feel hung out to dry, there seem to be hints of help, sometimes accidently left out there or bits that we learn to feed off of.

One of my favorite “hints” is the “arrow sign.”  This is the miraculous thing that appears on some x-rays and CT scans placed by some much wiser (though sometimes not) that generally points to the abnormality (or points to you looking like an idiot when you identify it as an abnormality).  Generally, the arrow sign is a partial get out of jail free card left there by someone.  It points to one or more of the findings on the scan and screams “look right here!”  Though it may not show everything, it at least points (ha ha) you in the right direction.

Arrow sign pointing out an epidural hematoma and a "swirl sign," which is a hypodense area representing actively extravasating unclotted blood. Image via

While on this radiology rotation, arrow signs are few and far between, because I am often one of the first ones to see the film.  I miss things.  More often than I would like to admit, though I am getting better.  I have left a few of my own arrow signs (some of which may inadvertently mislead other clerks… Whoops).  But this is how you learn.  Practice.  Even with the arrow signs.  Then, you get better and you learn where the arrows should go.  You can function without the arrows (even if you like them).

You don't really need the arrow sign to help you pick up on these fractures. Image via

Another good “hint” that becomes a bit of a survival mechanism for clerks is reading around your patient… In their old charts, the ER record (this doesn’t work as well when they are new and haven’t ben seen by anyone else).  There, you can sometimes find details that get missed/forgotten on history and also past physical exam findings and labs.  Sounds like common sense.  But, really, if you know the person has a grade I systolic ejection murmur (translation: super quiet murmur)… You can listen more closely for it.  I know, you should listen all the time.  But sometimes, the extra point of focus is useful.  Plus, then you can tell if it is unchanged from previous.  Or you can hear your first grade I murmur.  I think this is a valuable tactic, so long as you use discretion.  Old H&Ps can contain mistakes.  So, verify your info with the patient, confirm your own exam findings… Just plain do your work.  They are a resource, not a replacement.  When you see people with more undifferentiated problems, this is not always an option, but the practice with those who you have all kinds of information helps you to learn the process and be more cautious with it.

You may never hear a murmur in this guy... No matter how many of you try. Image via

My last “hint” that the world of medicine has fed me over the years is the “why don’t you examine this and tell me what you find.”  In a normal, healthy person, odds are its nothing.  But they aren’t the people you get told to do that to.  Usually, it is someone who is unwell and who has a finding.  And the person asking likely knows what it is.  So, go in expecting to find something.  Especially if you know they have a process that produces a finding.  Other side to that… If don’t note something abnormal… Don’t make it up.  Because they are probably testing to see if you will lie.  Just do a good exam.  Anticipate the common things.  Even while you are breaking out in a cold sweat because you don’t want to look stunned for the tenth time this week with everyone looking on expectantly.

I think sometimes in life, just like in medicine (because clearly medicine is not life), we get signs pointing us in the right direction.  Things just fall into place.  We know based on surrounding circumstances that we are supposed to take a designated action.  We quite literally get shoved that way.  The apartment that Patrick and I have been blessed with (blessed is used both literally and sarcastically… did I mention we are STILL under construction?) while living in here was one of two I went to see that day.  One was a hole.  This one was one of the only places that answered their phone and was in our price range.  It fell into our laps.

Other times, though, we go around searching for an arrow sign.  We just want God to draw a nice clear arrow in the sky pointing us in the direction He would like us to take.  A nice spiritual hint.  An obvious track to go on.  And we don’t get it.

Just like in medicine, we have graduated responsibility.  As kids, our parents make our decisions, but as we grow, we are left to make more of the choices.  They redirect us where appropriate and we learn.  God lets us make mistakes and if we really pay attention to Him, He gives us hints.  Maybe a specific system to examine.  We know the theory.  He gave us a whole textbook.  We just need to apply it.  We need to seek out the hints to help us along.  God gives arrow signs sometimes, or a specific system or at least a history… We just need to pay attention long enough to get the hint.  And apply what we have learned to do the right thing.  And it is tough.  But it is possible.

Sometimes, I feel like life (and medicine) would be easier if we always had arrow signs.  If we just knew where to look or what to do.  And sometimes we do.  Sometimes God slaps us in the face with how obvious what we should be doing truly is.  Not all of the time, but sometimes.    But really, if everything were dead obvious it would be boring.  It would be safe, but we wouldn’t have choice.  There wouldn’t be the rush of making the right call or the same commitment to God.  So, I am grateful that we need to learn to look for the signs without the obvious arrows.  Even if I don’t always like it so much.

2 thoughts on “The arrow sign

  1. From reading your blog, I think that I would have loved to have been a doctor — except for the fact that I have a sensitive gag reflex and cannot look at bloody yucky things. I oddly feel like I’m living vicariously through you, Trisha. Keep up the good work. And remember, we have “hints” in our Christian life as well. You and Patrick are in my prayers. Sandy

    • You might have loved it. The gag reflex and such might have been a struggle, but you would be amazed at what people can get past. I am glad you are living vicariously through me, though!
      We do get “hints” in our Christian life. I am glad. Otherwise things would be a lot more complicated.
      Thanks for the encouragement. I appreciate it always!

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