CAFFEINE, CURLY FRIES, AND MEDICINE

Attack the Day!!

2010-02-10T14:56:00.000-08:00

Steve left this for me one morning last week. It was great to wake up to, and is now posted right above my desk. The past few weeks I have been overwhelmed with work of a computer nature and it really, really!, kind of sucks. I guess I am thankful that I am headed down a road that will allow me to have a job "doing" something rather than just sitting on my ass all day long staring at a screen and being tempted by the mindsuck that is the internet (trolling random news stories, facebook...please. Like you all don't do the same. !!). God. Anyway, this note is pretty awesome, and was a good motivator on a day when I was feeling a bit overwhelmed and stressed....thinking "boy oh boy, what have I gotten myself into with this damn research??" But, onward I go! However, I am sorely missing scrubs, being in the hospital, instruments, and OR's, palpating abdomens and such...give me a stethescope, let me tie some knots! (Just another indicator that this sedentary life really is not my cup of tea...along with all the "practice" 2-0 silk surgical knots that are attached to stable points on my desk!) Anyway, I know I am sorely behind on stories and tales, and, believe me, they are still percolating away inside my brain. Soon to be typed out...at least before Mexico anyway. I am starting Geriatrics in a little over a week and I'm looking forward to it. I won't be in front of the computer so much, but also - we will be doing home visits and this sounds amazing to me - it totally appeals to my inner anthropologist....aka super nosy inner self! For now, I am going to get back to work, and try to attack my day as best as possible! Grrrrr!!

Coffee and Horchata

2010-01-27T08:09:00.000-08:00

This song, and a good cup of coffee, have really made my morning today...makes sitting in front of the computer for hours on end not so bad...

Organic

2010-01-26T16:51:00.000-08:00

On my last night on call in the SICU one of our patients died. This wasn't the first time I have had a patient on my service die, and not the first time one has died while I've been on call in the SICU. However, this death was such a long and drawn out process - he still made it onto our list for rounds in the morning as he teetered on the edge of death for hours...moving towards it and away, over and over again, but never far enough away from it not to make it inevitable.

His story was this; he was a 71 year old man, dialysis dependent as he had CRF (chronic renal failure). He also had significant liver disease, due to Hepatitis C, and a long history of alcohol abuse that had resulted in cirrhosis. He came into the ED complaining of severe belly pain x2 days - first noticed at his last dialysis appt. and which had only worsened since then. After exams and tests, he was quickly brought to the OR for an exploratory laparotomy, which revealed an extensive amount of necrotic bowel. Due to a number of variables, the surgery was difficult and lengthy. Eventually, the patient was found to be acidotic - a blood gas done by the anesthesiologist showed that his pH was 6.9 (we are all supposed to be happily churning along at a pH of 7.4 or so. Under 7.2 the proteins that your body needs to function don't work so well. They actually partially denature (think "human western blot", at least that's what I think about!) and obviously don't function in this state, i.e. all things start to go to shit. Fast.). We got news in the SICU that the surgery was being aborted, and that the patient was coming to us vac'd (meaning a wound vac had been put in place over his open abdomen), intubated, and sedated. We would be in charge of resuscitation.

It soon became clear that resuscitation was simply not going to happen. The patient received, innumerable liters of IV colloid solution, as well as 20 units of pRBC's (packed red blood cells), approximately 16 units of FFP (fresh frozen plasma), and also received multiple units of cryo (cryoprecipitate) and albumin. The dialysis unit was brought in and started. He was hooked up to an A-line (arterial line) for better BP monitoring, and a flotrac to monitor his CO (cardiac output) and his SVV (stroke volume variation), which is a good indicator of his volume status, as well as his responsiveness to fluids. A heating blanket was placed on him, and the temperature of the room was raised as his body temp continued to go down. He was given pain medication for comfort, and further medication to keep him sedated. The SICU team, especially the nurses, were all business - working together almost without the need to speak; they understood their roles in this critical situation so completely, as if they had done this hundreds of times, which - truth be told - they have. Everything was fast paced, but orderly, and my only role, really, was to stay out of the way.

We knew this man was going to die, and it became more evident, hour after hour, as blood was pumped into him and you could virtually see the line on the wound vac canister rise with a bright red fluid fluid we knew, almost certainly, was primarily arterial blood. His liver was so dysfunctional (it makes the majority of the clotting factors involved in the blood's clotting cascade) he was not able to clot or stop bleeding. His abdomen - which was distended with ascitic fluid on admit to the ED, had initially been flat when brought up to the SICU. It was packed tightly in the OR and sealed with a large dressing. But, over the course of the night it filled up again, and you could see his belly swelling underneath the pile of blankets he lay beneath. We knew that this was mostly blood, leaking from all the oozing areas that could not be cauterized or tied off during surgery. Additionally, we were pouring bicarb into him, yet he still remained acidotic, barely reaching 7.25 before his pH would drop down to 7.0. We tried to keep him above 7.25, a number we knew would allow for all of the other fluids filled with proteins to actually work inside his body, rather than just take up space...ironically, something he did actually need - volume resuscitation - however, that was just the tip of the ice berg.

What I found striking about this whole case was the fact that his fate - both his life and his death - depended solely on the basic function of his body on a cellular and microscopic level, which I know is not a new phenomenon (obviously!), but is something I have never thought about so distinctly when faced with a death of a patient. Now, I always marvel when I am able see organs working - the small bowel peristalsing, or the aorta pumping, the heart pumping! - during surgeries. I never get tired of it. Ever. It is mindboggling to think of the amount of things that have to come together to work in harmony inside our bodies in order for us to exist, and essentially so we don't even have to pay attention to our bodies on a day to day, or even minute to minute basis, i.e. if everything is working a-ok most people probably don't give too much thought to what is going on underneath their skin. But I have to admit, I do not always think so avidly about cellular mechanics, things like the krebs cycle, or glucose metabolism for example. And this guy...man! He was a perfect example - sadly - of the complexities of our existence, on a basic, and almost organic level, beyond all those organs I am entranced by. His cells in his liver and in his kidneys were broken, they didn't work....he couldn't clear ammonia, lactate, or clot his blood. As he lost blood, his BP went down and his cardiac output diminished - his brain began to receive less and less oxygen as the volume of blood it received decreased. There was nothing to do, short of receiving a liver transplant, something this gentleman most likely would not have been a candidate for, and we certainly couldn't go in and fix each cell one by one. So, all night we watched him, and we watched the monitors attached to him. His body was true and honest - it was broken, and it did not lie.

It was strange to drive home after this on call night and realize that - at least in terms of his death, or his loss of life - it didn't matter what type of person this patient was, that his wife was sitting at his bedside loving him and not wanting him to leave, that his son would not make it back from CA before he died; it didn't matter. What mattered was that - biologically and physiologically - he was beyond fixing, despite the life he led, the things he had accomplished and experienced, the people he loved, or who loved him. I thought about what this meant in terms of treating my body well, taking care of myself - realizing that the consequences of how we live are metered out at even the most minute and cellular level. I also thought about the idea of living life fully, to the best of my ability, and without as many regrets as possible, making each moment count; all of this because I realized that we cannot cheat biology, we cannot deny the "machines" that are chugging away inside each and every one of our cells. With hope, we exist in the state, most days, where things are working harmoniously, and we give very little thought to what is going on in our oh so complicated innards, but sometimes you just never know. I thought about death, and how it is a given, and about how, sometimes thinking about death, and feeling more connected to our bodies, can lend itself to better living, or maybe just living more completely within the moment.

Post Holiday Musings

2010-01-16T14:57:00.000-08:00

You know, I hate Christmas, I really do. I feel bad writing that statement out...am cringing a little seeing it sitting there in black and white; but it's the truth. When my sister and I were growing up and my parents divorce seemed to take center stage for so many years, or at least it's subsequent fall outs and aftermath did, many of our most painful moments were played out at this time of year. I actually was reminded of the Christmas season this year - not by my family, but by the Christmas decorations going up around the hospital, and the free candy canes at the starbucks counter where, admittedly, I did enjoy more than a month of their great holiday blend coffee. This holiday, for me, just brings up bad memories of fighting parents, crying parents, my sister and I crying, and then the holidays where we were shuttled back and forth from extraneous step-relative homes, where people tried, graciously...at least most of the time, to fit us into their already established holiday festivities. Those years put a big stop to the childlike happiness of decorating the Christmas tree, the delight in turning on the lights every night when it got dark, and spending a morning in pj's with family while opening presents and listening to Christmas music. This is further heightened by the fact that earlier and earlier each year Christmas decorations are present in stores, and everywhere I look there are ads pushing things to buy...useless things...a level of overt conspicuous consumption that I just find, well - GROSS. Every year, I try, in some small way, to feel what I felt as a child, to feel that happiness and joy in the season. But, really. This year I actually had the feeling, as I rushed to get coffee, calculating if I could actually afford to drink a whole cup because I would be in the OR for most of the day (i.e. sans bathroom breaks!), and looked at the giant dish of free candy canes at the starbuck's counter, that it really sucked that I am always going to have to deal with Christmas, or at least what it has turned into, every year! I probably was just exhausted, or having a rotten start to the day, who knows. I was in the midst of sub-I #1 and it vacillated between being pretty awesome to crap; even though the crap was very few and far between. I do know however, that despite having these feelings, I do try to take stock of my life at Christmas, mainly because the new year is looming, and I want, very much, to make my moments count.

Last year I wanted to be more present in my life, in everything I was experiencing, and that is a goal I will carry with me into 2010. I realized too, as I finish up these months and moths of surgical rotations, that I am heading in the right direction, albeit slowly. But as my aunt Janice always says, "slow and steady wins the race", and I try to remember that when I remind myself that I am making progress, despite a long road ahead, and that it is sometimes the journey that holds the biggest rewards. In 2010 I will spend months in Mexico, something I feel will be one of those "big" experiences in life. My research is moving along, and little by little I am enrolling patients, plus, hopefully!, I will have the papers, that have long been in the works, published. My friends will match on March 18th this year, and I am torn - excited for what I have planned for myself, excited for them, but sad to see them go, and sad to be separated from them in what has been an intense 4 year journey. But, I myself will have to embark on applications and interviews - all awaiting me on my return. Overall, exciting stuff, and a great deal to look forward to in 2010!

Candy Cane Cookies and Chest Tubes

2009-12-24T21:30:00.000-08:00

2+ months of surgery rotations and surgery sub-I's, and still counting. Too many stories to write now - I am hoping most of which I can recount. But tired and dehydrated as I may be, it has been exciting, and more than a little self informative. And here it is - Christmas Eve...with so much to be thankful for. I went from pulling chest tubes the other day, and extubating my septic shock patient yesterday, after treating her for 3 days in the SICU after her emergent surgery for a perforated colon - during which we found a softball sized mass attached to her transverse colon with leakage of pus and stool into her abdomen, and subsequent bacteremia - to drinking a gingerbread latte from starbucks, listening to a christmas music mix that Steve made, drinking some good spanish wine while baking candy cane cookies. I am lucky and thankful, and ready for all that the new year will bring. Stories to come - I promise!

Lost in translation.

2009-11-28T10:53:00.000-08:00

Don't even get me started on the language issue. The amount of times I have told attendings and residents that I don't feel comfortable translating for them with their spanish patients during critical visits, or when they are trying to consent them (kind of an important thing!! - consent for a surgery, a procedure of any sort, anesthesia...you name it!) is innumerable at this point. We are busy and pulled in many different directions and no one wants to waste precious time calling a translator, or even using the translator phones. I have really strong feelings about this. Some docs actually don't use these services for no other reason than an arrogant type of pride - thinking that their spanish skills, or portuguese, or french, what have you, is strong enough to convey the medical message they are trying to impart. It is one of the most frustrating aspects of this work that I see on a daily basis. One of my uncles and I were talking about this issue last Christmas, and he was telling me how the hospital that he is on the board of directors for is trying to spear-head this problem. One administrator had given him a list of problems that occur over and over - for example, in telling a patient to take a dose of their medication once a day, a provider had written out the word "once". The patient was spanish speaking and in spanish "once" is eleven (pronounced ON-say). So, the patient promptly went home and took his medication 11 times per day instead of one. The result is that his hospital seems to be making a big push for spanish speaking providers, over expanding their translator services. I think this is a really unrealistic goal, but then I don't know what else should be done. I mean, my hospital has one of the most extensive resources in terms of human translators, as well as translator phone services that can be plugged into any room, and we still do not, on a regular basis, take advantage of it. It is a shame, but also a kind of injustice in services as well. If a patient is at your hospital, and you are the care provider, I believe it is your responsibility to provide them with the same type of care and benefits that they would receive if they spoke english. Many times that is simply not the case. Patients are given instructions in some sort of half ass version of their language, along with miming and pantomiming on both the part of the doctor and the patient.

Just recently, I had a patient, Mr. M, a 76 year old Puerto Rican man, while I was on my anesthesia rotation. He was having surgery for his cataracts, and was awake during the entire procedure. The anesthesiologists said the same thing a lot of people say to me, "You speak spanish right? With that last name you should!, do you want to talk to Mr. M?" OK. Yes, I want to talk to Mr. M, but do I want to translate the consent for his surgery? Ummm. NO. But, Mr. M and I did talk a bit, and we had a great conversation - he was from the same neighborhood that my grandfather grew up in, and my father had lived in. After his surgery I saw him waiting for his daughter to come and pick him up. I went over to wish him good luck, and to tell him to stop touching his eye (it was covered, but his hand kept sliding up to the finger the tape and the dressing, over and over again). He talked with me again about Puerto Rico, and my spanish. I told him I needed to continue to practice, and that I was glad that he and I could talk for a moment. He stood up, and hugged me, kissed me on the cheek and patted my back, and told me in spanish that he wished me good luck, and that he was glad I was studying to be a doctor. Honestly, I love interactions like this, and I have had them time and time again with my hispanic patients. I have been hugged and thanked by first time mothers, and patients on my family medicine rotation. Grandmothers in various offices for follow up appointments with their own grown children because they needed a translator during their visit. A mom getting breast reduction surgery after losing 100 pounds, and visiting the office with her 10 year old daughter who speaks better english than she does. These are always the patients who see me, see my blue eyes, and then look at my name tag, look at my eyes, and then back at the name tag again. They ask me in spanish if I speak spanish. I speak back. The ask me about my name, my family, and I explain. More times than not, this familiar cultural background makes their tension ease, and they become relaxed and smile at me. But, the one caveat in all of this is that I say, right up front, that my spanish is not the best, and that translators are available if and when they want one because I want to make sure they understand everything I and the doctors have to say. Being able to establish this connection with this subset of patients is something that is really special to me; these interactions have been some of the most memorable I have had over the past few years. However, it makes me nervous to simply rely on language skills that are not as good as they can be, and I try always to be aware of that. Thus, my decision to make my trip to Mexico this spring. Tickets have been bought, and the classes and volunteer work is planned. I hope that after it, I can comfortably and honestly say that I speak spanish fluently, something I would never say now, because it is simply not the truth. After I return home, I can only imagine and hope that these interactions with my spanish speaking patients will be even better.

And another reason that this seems so pertinent now - just last week I was a patient myself. I was at a different hospital, and while waiting to register I saw a sign that said (in english) "If you need a translator, we will provide one. Simply take a pamphlet below that corresponds with the language you need. Thank you." Does anyone else find it ironic and totally stupid that this sign was written in english, and that none of the pamphlets below had any visible words on it in the language they were trying to advertise?? I was trying to take a picture of it with my phone, but the women at the registration desk were giving me the evil eye. Ironic, stupid, funny...but also a great example of how this problem is so poorly dealt with.

Edentulous

2009-11-16T17:33:00.000-08:00

Anesthesia has rolled into its second week. The people are nice, laid back, and some of them are just amazingly smart. It makes sense when you think about the fact that managing a person's "internal workings" - so to speak - during surgery, is essentially just being a superfreak master of all that is physiology. So, when someone is willing to teach during a complicated case it can be pretty interesting. Overall though, I am drawn time and time again, case after case, and day after day, to the other side of the curtain. I want to watch the surgeries...even the ones I have seen before, like hernia repairs (I watched a lap hernia repair, both ventral and inguinal, and it is crazy the amount of dexterity that is required in order to place the mesh, unroll it, and suture it in, all by only using long armed grasping devices!). And, by rotating through different OR rooms every day I am getting to see other types of surgeries that I have not yet been exposed to. Last Friday I watched a craniectomy, to remove a tumor from a 30 year old woman's brain...today I watched a CABG, and it was amazing to see the heart pumping right in front of me, to see the TEE (transesophageal ultrasound) (I have read about them, suggested ordering them for patients, but have never seen the real time picture of the valves working like that!), and to see how when the heart was stopped, the perfusionist ran the bypass system, all while the surgery team harvested a vein and used it as a graft for 3 different coronary vessels, and then restarted the heart and had it pacing back to normal. Needless to say, I recognize the value of knowing and understanding what the anesthesiologist does (especially as a future surgeon), but I am never as interested in what they are doing, as what is happening only a few feet away.

I do like intubating and placing oro-gastric tubes, and and other types of tubes and lines. Not that I am allowed to do anything as serious as say - a central line, but I am encouraged to do and try as much as possible. The first few people I tried to intubate were fairly easy, but one woman had the fattest tongue I had ever seen and I could not see my way around it! Even the resident and attending were saying how extraordinarily fat her tongue was. However, talking about her fat tongue or her mouth in general was just run of the mill for them, as discussing mouths and airways is just part of what they do. The next day that I attempted intubating it seemed fairly easy - a view of the cords, slide the tube in, insuflate the balloon, but something was off, I just couldn't figure out what it was. Finally I realized that all of the patients had teeth! (vs. all my patients the day before who had none, or who are called "edentulous"). So ridiculous. And so strange because that is not something I would ever really pay too much attention to. I was reminded of a case I scrubbed in on last year that was delayed because the anesthesiologists thought it would be too much of a risk to intubate the patient due to a loose tooth (it could fall completely out, and get lodged in his airway). So, they paged the dentists to come directly to the pre-op area to pull it out, after getting the "ok" from the patient. While we waited, the patient kept on shaking his head, and mumbling. I asked him if he was ok, and he said that he was, but he was just angry at himself. I asked him why, and he told me that he should have just pulled this tooth out with the rest of his teeth, which he had pulled out himself, only a few days before. Apparently, he had noticed that he had 3-4 loose teeth in his mouth, so he got his pliers and some beers, and pulled the teeth out, one by one. He left one lone tooth (the one that the dentists would now be pulling) because it did not seem as loose to him, and he thought he should have at least one tooth that was his own!

Imperfection.

2009-11-14T12:38:00.000-08:00

Lately I have been thinking about the field of medicine in general...how a lot of it does not meet up to the idealistic standards that many of us enter medical school with. There is a lot of talking, and a great deal of conversations are being generated about the state of the health care system in this country right now, and these conversations most definitely are happening within the hospital too. With all of this conversation in the forefront, it is hard not to notice how harried we are...how little time we have to spend with patients before moving on to the next, and the next, and the next...how sometimes it DOES feel really good when your list of patients diminishes instead of increases, even if it means you are effectively shoving people out of the door...how our overly litigious society is the elephant in the room on a daily basis. Sometimes, especially when I read back over some of my past blog entries, I feel so Pollyannaish - forever spewing out positives, and the "learning moments" I try to take away from whatever situation I find myself in. I am the type of person that tries to find a positive in everything, but sometimes the reality - whatever it is - far outweighs my positives...far outweighs my ideals. Here is just one example from the past couple of weeks:

One of the last surgeries I was scheduled to scrub into while on the Plastics service was a debridement and rotational "butt" flap repair of a chronic ischial pressure sore. The patient was a paraplegic man who had had multiple open sores in the past that had healed, leaving only the ischial sore which required the more complicated treatment of surgical flap repair. He was a complex patient, a past fall had caused his spinal damage, and he also presented with a large problem list, including many other basic health complaints, as well as a number of psychiatric issues and chronic substance abuse. For most of us within "the system", and especially at our hospital, that alone is a red flag as to what type of patient you would be dealing with (how's that for not pre-judging? Not great right? But, I am trying in this posting to be as honest and forthright as possible - and seeing this guy, seeing those problems in his file, your brain automatically starts to think about him in a certain way. It is your challenge to truly be impartial in how you treat him, and how you deal with his medical care. And there is the undying hope that most of us can succeed in this - and provide him with unfaltering, and unbiased care.) We roll him into the OR and the anesthesiologist anesthetizes him. I was pulling my gloves and handing them to the scrub nurse when I looked up and saw what everyone else in the room was looking at - his EKG tracings. He was in AFib. We looked into his pre-op anesthesia note - no mention of AFib. The plastics clinic also does a pre-op H and P (history and physical). Again, no mention of AFib. Was this new onset AFib? If so, we need to convert! What if it wasn't? We shouldn't convert. Is this new, is this old....if we convert he could throw a clot, if we operate as he is now, he could throw a clot. What should we do? We knew he was not taking a beta blocker for rate control, we also knew he wasn't anticoagulated. This means it was new, right?? The anesthesiologist said that he thought it was fine, and that he could manage it...the circulating nurse yelled for a crash cart....and then yelled again that this was not a code, just a conversion (i.e. please don't put on the loudspeaker that we are having a code!)...or is it a conversion? - she would let them know. The Fellow (yes, the dreaded Fellow) did not even know the patients name, and he scrambled to find out what it was as well as the contact phone number for the patients mom who might not have left the hospital yet...the intern looked confused...I looked confused...the attending was on the computer trying to load the electronic chart - always so slow when you need it the most. He scrolled...he scanned. The patient lay there, at this point anesthetized for 30 minutes. Still in AFib. Finally the attending finds a note listing an episode of AFib in 2006. I quietly note to self that if he had just clicked on the problem list in the patients chart, you could see "Fibrillation, Atrial" listed right at the top of the list. Needless to say, we still weren't sure. What about clots...rushing into his heart? So the decision was made to wake the patient and cancel the surgery. The whole time the nurses were in the background crankily citing the price for everything - even OR time, which one told me was $100/min. One sounded disgusted at all the resources we had used, for no reason. The patients mother was in tears in the PACU, the patient was confused, and when he finally woke up fully enough for us to ask him about AFib he said he did not even know what that meant. Instead, he would stay overnight at the hospital for 3 additional nights, until we figured it out, and he could potentially be put on the OR schedule again.

When I went back to take a look at his file I saw that his clinic pre-op note had been written by a 4th year medical student, just like me. Her cardiac exam was as follows, "RRR, No M/R/G", meaning regular rate and rhythm, no murmurs, rubs, or gallops, the standard line written for a normal cardiac exam. Despite "Fibrillation, Atrial" showing up in capital letters on his problem list, no one referred to this in the note, not her, not the multiple PA's who had seen him in the past, and not the attending who had signed off on all of it. This mistake had caused a chain reaction of so many things - the unnecessary exposure to anesthesia for this high risk patient, the cost to him or his insurance or even the state for all of the useless OR time, the nights spent in the hospital (and no one should be spending more nights in a hospital than they rightly need - given that it can cause more infection, more exposure to germs and nosocomial diseases, especially for a patient like him with multiple comorbidities), the extra time not only our team needed to devote to figuring out this mess (something that could arguably be said - occurred because not enough time was spent on him in the first place!), but also the time of the PACU nurses, the floor nurses, and the medicine and cardiology teams that were emergently paged to assess our patient, plus the heartache and worry of the patients mother, and the patient himself, especially as terms were being bandied around left and right that they did not seem to know or understand, as team after team came in to check on him. Craziness.

It turns out the patient spontaneously converted back to sinus rhythm all on his own, and spent 3 extra days sleeping on a state of the art air mattress and using facebook with his laptop in a single room on the surgical floor. He got his flap repair done, and will be seen by the cardiologist in clinic after he is discharged. I don't know if I am accurately imparting the true meaning of this story - essentially we were unprepared to take this patient to the OR, but it was something that was totally and completely avoidable. The patients information regarding his history of AFib was staring us right in the face as soon as we opened his chart; in capital letters no less! But, it had been missed in clinic, and when the attending reviewed the note. It had been missed by the pre-op anesthesia clinic. In those critical and frenetic moments when the team was trying to decide how to proceed - operate or not operate - the situation was muddled with how this would pan out legally, and how much all of this was costing - these concerns ever present in the room at the same time as the all important question of how to proceed in the best and safest interest of the patient.

Of course (and maybe in my forever Pollyannaish attitude!) I did take away some lessons in this. That - if information is availabe...readily available on a patient, it is my responsibility to not only learn about it, but take it into consideration when treating them. I mean, that is obvious - taking the information, past history, health status, into account for a patient - I am just emphasizing that I need to really be responsible for myself, no matter how much or little I interact with a patient. I cannot rely on someone else above me, or even beside or below me, to pick up the slack. Even if I am a 4th year medical student, even if I am the attending. If I am harried or rushed, or frustrated by a complicated patient who seems to be in the hospital day after day for multiple complaints, it is still MY responsibility to know about him, especially if I am one of his care providers, no matter how far down on the medical professional food chain I may fall.

Nip/Tuck

2009-11-07T08:25:00.000-08:00

I just finished my 2 weeks of plastic surgery. 2 weeks only, because it was half of my surgery subspecialty rotation; the other 2 weeks I will be doing anesthesia. I had been so looking forward to doing plastics, I know most of the attendings, and the practice is known as being very "med student friendly" - lots of suturing practice, and even some cutting (mostly of the parts of skin that will eventually be thrown away in an abdominoplasty or breast reduction, but still - time with a knife in your hand is still time with a knife in your hand - every little bit counts!). Of course, that always kind of blew my mind - a plastic surgeon letting an unpracticed medical student suture up some woman's breast? Maybe not the most aesthetic choice around, but it happens a lot. I also removed and replaced a lot of sutures, so at least they were paying attention to what I was doing, and demanding that it look good, that the two sides of skin that I was sewing together were "kissing". All good stuff, at least most of the time anyway.

The practice at our hospital is small, 4 attendings, 3 PA's, and one fellow, and one intern that rotates in every 4 weeks. I began my rotation really thrilled to be there - and happy to finally to be back in the OR after a 5 month hiatus! - but was quickly brought down to earth by my interactions with the Fellow. After the first day I actually came home and thought that I had unwittingly done something to personally offend him. There are lots of stories about frank, unfriendly personalities in surgery, and a lot of them can be true to some extent, and hey - I don't need someone to be my best friend, but someone that is outright malicious is a little unusual, and that is definitely what this guy was. He was belittling to the intern and I, loudly yelling at her and I on rounds - in front of the nurses station, or even in front of a patients open door. In the OR he ripped tools out of my hands, saying I was not fast enough, and that he could not stand to watch "so much fucking up", and that my time limit was up to say - put in a drain, and suture it in in 30 seconds, pull out staples with a clamp, or he would say that cutting out the extra fat and skin during the abdominoplasty with a scalpel (the first time I had used one on a live patient!) was not supposed to be the longest part of the surgery and I should "hurry the fuck up" because again, he could not stand watching me be so slow....basically anything and everything that I was told to do by him was - 30 seconds later - just used as an excuse to criticize me. He would go from a soft voice telling me that he really wanted me to have the opportunity to learn, and he was happy to have the opportunity to teach, so why didn't I take over suturing or cutting?, and then, within the minute, he would put his head close to mine and yell that I was not fast enough, I was a fuck up, that I had not practiced knots or sutures (when I had - this guy sent me home nightly within that first week asking for 100+ surgical knots on different types of sutures to be presented to him daily on rounds, and when he thought I had not done them double gloved at home (which I had) he would throw them out and ask again). He would grab the needle driver out of my hand, or the pick up, and push me, with his body, to the side, so that he could take over whatever I was doing. So confusing, and so surreal! He seriously seemed to be somewhat bipolar. It took one full day of being in the OR with him to put me on edge, and by Wednesday of my first week I was on a serious countdown for the whole experience to be over.

It turns out my experience was not abnormal, and one of the PA's informed me that he has been asked to leave, to put in his resignation within the next few weeks or he would be fired, all because of noxious and inappropriate interactions within the team, with students, and even with patients. Interesting - because on the surface it just seemed as if everyone was operating as if nothing was going on with this guy, or maybe - at the least - noticed something, but did not care to really delve into it, especially with me, who would only be working with them for a few weeks. But, it turns out I was wrong. A good lesson when dealing with a difficult personality, or maybe more of a lesson not to instantaneously judge a situation - especially one that you only get to work in for a few weeks. It can be tough though, always being the med student and worried about interactions with the team, grading, and overall "gelling" with everyone when - truth be told - you are in the door one minute and out the next, and on to something else. This is something I am definitely not going to miss once med school is over - the curse of the ever rotating med student - someone who starts and finishes a new job every 4 weeks! In the meantime I guess I just need to learn to take the most from each experience I can, even when some involve dealing with giant D-bags like the Plastics Fellow!!

Radiology rotation...aka Rads-a-cation

2009-10-11T07:28:00.001-07:00

2 weeks into my radiology rotation...2 more to go. I just had my mid-rotation eval with the preceptor, who told me she wishes this rotation was 6 weeks long...SIX! Ugh. I have to say I was excited for radiology...as a future surgeon I want to know how to approach a CT, or know the first imaging study, or the second, that is recommended for SBO or appendicitis, etc. and etc. But, sadly - minus our lectures in the mornings, we aren't really being taught too much. Needless to say, I can't wait for it to be over, and can certainly not imagine 6 weeks, instead of 4, of this mind numbing nothingness. Most people like it - calling it "Rads-a-cation"...which I guess would be nice for someone needing a break after a long string of sub-I's or someone needing time for ERAS apps or personal statements, but - due to my split 4th year schedule - I am not one of those, and spending time just lounging around the hospital, without any tangible thing to do is pretty tedious.

This is how things have gone so far:

- - We are a mix of 4th years and 3rd years...and it is interesting, as this is my first rotation back, after months of research, to observe some of the changes in the people around me. Some of my fourth year counterparts are now - s/p rotations away, sub-I's, applications submitted to ERAS - now strutting around, puffed up with their new purpose, and maybe the realization that they soon will be MD's...?? Who knows, I mean, I find arrogance to be such a gratingly annoying quality to have...but, at least for now, I am finding this strutting about fairly entertaining to watch, as none of them (at least the ones that are doing the strutting!) have really tapped into the realization that as soon as they gain that MD at the end of their name, they will also be shuttled back to the bottom of the pile as they begin their intern year...

- - A resident giving our morning lectures stopped after class to ask what I am interested in. When I told him I want to apply to general surgery residencies, he spent 20 minutes lecturing me about my life choices (and think - I just met this man, I don't even really know him!)...picking something that is more conducive to having a "real" life....how I couldn't possibly know at this time what gen surg would really be like for me....etc., etc....!! I say "etc." because this is not the first time - by far! - that I have been forced into having this conversation. This guy was actually phrasing it pretty kindly, but others have not. I don't know - maybe it is just me, but trashing the field a person wants to go into, labeling all who are in it as a certain "type" (and let's just say that a surgeon type is not usually described in the most positive way), trying to force a person to see the "error" of their choice - simply because that is not what THEY would choose...well, pretty pompous right? Or arrogant (there it is again!)...just overall offensive. Funny, because, I would never, ever! choose to be a radiologist - sit in a dark room day and night, staring at a giant computer screen...very little to no contact with patients, or even too many other doctors....definitely not for me. But you don't see me going around trying to force people to convert to my way of thinking! My theory is that everyone should pick the field they love, the field that makes them the happiest and most fulfilled...and you know what? That means we will have people who want to be radiologists being radiologists...people who want to be family med physicians running family med practices....and those who want to be surgeons in the operating room. Makes sense, right? I just never get this whole must preach and convert philosophy...to me it just indicates a giant unwillingness to see beyond your own personal constrictions - whatever they may be - to seeing someone elses point of view.

- - After morning lectures we are assigned to different reading rooms...those dark rooms where radiologists spend most of their time, "reading" CT's, CXR's, MRI's, etc. There is the "Body" room, the "Neuro" room, "Pedi" room. We all had to indicate our interests prior to starting the rotation, and then were assigned to the most relevant rooms. This would be great if someone would actually pay attention to us. What really happens is that we walk in, a few people glance up from dictating and looking at their screens, blink at us, and then continue to dictate without acknowledging our presence. We could (and actually have!) sit there for hours until someone speaks to us. Needless to say, this is the part of the rotation that most people end up skipping out of after a few days, me included, as - what type of educational purpose does it serve to be ignored for hours on end? I find this really strange as - on other rotations such as peds, medicine, and surgery, I have had a number of radiological images that I have had questions about or have needed assistance in interpreting, and have walked down to these rooms and have always been - not only acknowledged!, but helped.

- - Coffee. I am now back on my "in the hospital coffee regimen", and am back to being BFF's with the starbucks coffee girl who greets me every day by calling me "Princesa" - ha! I had to start something constructive to prepare for the 3 months of surgery I have coming up! Other than that I am working on finishing up another paper on an interesting surgical case of a patient with primary pancreatic CA and solitary lung mets without any liver mets - which is pretty unusual. Plus, my project protocol was conditionally approved by the IRB...so a few more changes, and then I guess we are officially enrolling patients! Also - I am finalizing plans for my spring trip to Mexico, and incorporating time to be there for my cousins wedding in Acapulco (!!). Well, I guess, in the end, it looks like I am trying to make the most of this Rads-a-cation that I can. Still, I can't wait to be busier, around patients again, in the OR...2 more weeks!!

Pauline Chen

2009-10-04T10:00:00.000-07:00

I love reading Pauline Chen's posts in the NY Times, she usually has one posted online every Thursday night, or Friday morning. This one titled, "When the Doctor is Distressed", is good...and relevant. I especially like when she writes in the second to last paragraph - in reference to dealing with the distress residents and physicians feel, "Many of these potential solutions are premised on two things: acknowledging the distress, then helping doctors find meaning in their work by supporting the ideals that inspired them to become doctors in the first place."

Dual Realities

2009-09-22T19:11:00.000-07:00

The other day I was walking from the T to the hospital for a meeting with the surgeon I am working for. I saw this woman with long, red, red, hair, in a braid down her back walking towards me with a man I did not know. I knew her, and I couldn't stop staring. I wanted very much for her to look at me...to recognize me. She was the mother who had been using the methadone clinic at our hospital, and whose baby was my patient on my peds rotation. The baby was being weaned off of the methadone that he had been born addicted to, and he and his mom, this woman, were living in the hospital the entire time I was on the inpatient service. But she was totally out of it, and brushed right past me. I am hoping this was simply due to a recent dose of methadone, rather than something else - which I am telling myself is an accurate guess, considering she was only one block from the hospital at the time I saw her.

Now, this woman, her baby, and even her partner - a giant woman who continuously asked me to call her "dad" (as in the babies dad), are forever stamped in a memory imprint within my brain. I will never forget them. I learned so much from working with them; from dosing for withdrawing babies sure, but also about babies themselves, about dealing with "difficult" patients - especially those that are camped out for long stays inside the hospital, about interactions that sometimes are necessary between the medical staff and state regulatory agencies, about drug dependency, and the list goes on and on. Having her son as my patient was a learning moment...a memorable moment for me, and it was just crazy that this woman - who I had seen in every state - sleep, awake, crying, happy, in her pj's, coming and going from the methadone clinic, worried about the DHS visits and assessment, who asked me if she could be my hair dresser (her occupation at one time), and who, with her partner, had asked me to be her son's doctor, and who I had to tell that I was not going to be a doctor for some time, and most likely not a pediatrician!...well, it was crazy that I could walk past her on the street, make eye contact, and even physical contact as she brushed past me, and she did not know me. Now, I guess I could contribute all of this to her most likely drugged state and move on, but the situation stuck with me, got me thinking, especially as I was on my way to upstate NY, and my aunt and uncle's farm where I had spent many childhood summers. My memories of my interactions with the red headed mom and her baby are so vivid that I know they are permanently affixed in my brain, just as are my happy memories of being on the farm as a young teenager. These visits were bright points of light filled with horses, nature, family, and a great deal of laughter, during a time in my life that was heavily marred by my parents nasty and drawn out divorce. While there, I brought up memory after memory...asking, "remember this, or remember that?" of my aunt and uncle. Some were easy memories for them to retrieve, yet some were small and deep, and barely there for them, not as vivid and alive as the ones I have carried and held onto for all these years.

As Steve and I drove back home I thought about it - how people can be part of the same experience, the same moment, but what each individual takes from it is, or can be, very different. Both experiences served as a good lesson - I mean, so many times we go through life and make the big mistake of assuming that, not only is our perspective the right one, but that it is mutually experienced and understood by all parties involved, which is almost always patently untrue. It is a simple thing to become more aware of, but being aware of this fact, the existence of these dual realities, can be quite profound. Each event, each moment, has multiple certainties and truths, and to find the common thread of understanding that lies between them is a formidable challenge, both with patients, but also within everyday life.

Step 2

2009-08-30T17:19:00.000-07:00

Today I took my Step 2 exam. There is no way around it, I just can't describe it as anything other than awful. I am not a fan of standardized tests - I mean, who is, right? But, I detest...DETEST!, these experiences. I will be totally honest, as much as I have been a good student throughout all of my academic pursuits, I have never been one to do well on standardized tests; routinely forcing out a performance that - no matter how much I sweat and grind away at studying prior to the actual test date - falls smack dab in the middle of the pack. "Average", I guess you could say. Yes, I wanted to get the super high SAT's, or stellar GRE's, or even better yet - a 35 or above on my MCAT's! It never happened, and there I sat, always in the middle. I never was concerned because my academic grades, and my overall "package" always stood out for other reasons - i.e. the positives not only outweighed the negatives, but some of them were just pretty unique and interesting. However, in med school, in terms of these crazy standardized tests anyway - shelf exams, step 1, step 2, step 2 cs - I feel like I am just trying to push through them, or more accurately, I feel like I am always racing the clock. Everything is timed, with paragraph after paragraph of information and lists of vitals and lab values. It's just exhausting (today was 8, one hour blocks of 44 questions), and I become so frustrated that my test results do not truly display my knowledge base, or how I would approach a problem. It does not help that today I was in a testing center packed with people taking their CPA exams, filing in and out of the test room, and that the testing area was freezing, and when I took a break the people monitoring the sign out did not know how to work the electronic finger printer device and made me do it over and over and over again (you have to sign in, get fingerprinted, show them that your pockets are empty, do a block or two...take a break...sign out, get fingerprinted - even if just for a bathroom break in between blocks, sign back in.....show them pockets again ("Oh Miss, are you really wearing pants with no pockets, we have to check, can you turn around please?")...fingerprint...show them ID...and, in my case! - reapply finger to finger printing device an average of 4 times every time I was required to be printed...sounds minor, but when you are dodging other test takers, and trying to get to the bathroom, shove a peanut butter jelly sandwich in your mouth...get back into the room in 5 - 10 min. or so, because there is only a total of 45 min. for breaks throughout the day, it can really add to the stress!)...

I know I am complaining. Today was just long and kind of miserable. I got there at a little before 8am, and did not leave until 6pm. It was a flashback to all my hated test taking moments in the past few years, and I don't think I really let myself think about it or get freaked out (too much!!) while I was in there. The funny thing is, I kind of liked studying for this exam, at least until the last few stress packed days. It was nice to revisit all of the things that were emphasized over this past year. However, in my war against the clock, and against the chill, the 10 hour day, and the mental fatigue, I know I made stupid mistakes, and yes - as any good anal retentive med student would, I am playing them over and over in my brain. I actually started as soon as I got to the car, and drove home. Funny how, once free of that dreaded test center, I can see clearly what would have been the right answer for a few different questions. Ugh. UGH!

Anyway. On a good note - yesterday was a great day spent in the North End for Steve's birthday, at one of the last feasts of the summer (St. Anthony's Feast). And my sister was amazing, and sent me flowers and a sweet card for encouragement; thank goodness for sisters!! (now if I can just stop thinking about that question I should have answered squamous cell carcinoma instead of basal cell carcinoma. Seriously!!)

Healthcare Reform - what do YOU think?

2009-08-27T09:21:00.000-07:00

I sometimes read the following blog, surgeonsblog, and peek into the list of blogs that he also follows (see his right handed side bar). Today he posted this video and I love it, so am re-posting it here (but giving him credit for finding it first!). I think he is right - the simplicity of cartoons is great. They are a frequent genre used to get the most complicated political opinions out there and understood...or at least healthily debated! Take a look.

Signs

2009-08-27T08:20:00.000-07:00

So, in studying for Step 2 I have come across so many references to medical "signs". Auenbrugger's Sign: epigastric bulge due to a massive pericardial effusion; Samter's Triad: nasal polyps, bronchial asthma, aspirin sensitivity; Riddoch's Sign: in cerebellar disease, with outstretched hands, the hand on the affected side begins to hyperpronate, so that the palm faces outward, and rises above the level of the other hand; Psoas Sign: pain elicited by extending the hip with the knee in full extension, seen with appendicitis and psoas inflammation; Kehr's Sign: pain in the left shoulder associated with splenic rupture; Pemberton's Sign: in SVC obstruction, development of facial plethora, inspiratory stridor, and non-pulsatile elevation of the JVP when patient lifts arms over head (that total thyroidectomy I saw a few weeks ago was for a woman with a crazily positive pemberton's sign due to the massive goiter in her neck); and there are a million more it seems like....Rovsing's Sign, Murphy's Sign, Battle's Sign, Tinel's Sign, etc. and etc.! Some of these are named after the nerves or muscles that are affected, but most are named after the physicians and/or scientists who discovered them (and I guess the signs that are named after nerves or muscles are secondarily named after an actual person, as, when different muscles, nerves, vessels, and anatomical structures were being discovered, they too were named after their founder, or at least the person claiming to be the founder!) This list, which I found on wikipedia, is interesting to read through. You can click on the name of the sign to read more about it; but I just think it is incredible that the list is so long! So many people laying claim to the body - it's many parts, the messages that it gives us when it's sick, and when things are just not working as they should - as the science of medicine was being discovered and recorded so many years ago. I even have an iphone app. that lists all the medical signs. Crazy!

I love history, I love old things, and I have always loved searching through antique stores and seeing things that used to be a part of someone's every day life. I guess it was not too surprising to find out that there are not only historians that focus only on medical history, but that there are antique dealers that only focus on medical antiquities. And now, in this day and age, when the internet is so heavily used, you can find a number of sites that are focused on medical history and medical antique paraphernalia. Just like this site called "antique scientifica" where I found this picture (you can buy the real deal from there, in addition to antique stethescopes, old original documents like Anatomy of the Arteries of the Human Body, by John Hatch Power, dated 1863, an antique lithotomy set from the early 1800's, antique forceps...and the list seemingly goes on and on and on!) Just looking at this picture (Jefferson Medical College c. 1900) is kind of crazy (if you click on it you can see a bigger version). First of all, this is how they used to teach students about surgery! Everyone is wearing a suit, and they all sat together and watched a surgery taking place in a giant ampitheater. Notice the fact that the only women in the room are the nurses, and that there are only white men present. They, apparently, were the face of medicine in the early 1900's.

I have also found this other interesting website called "Historical Anat omies on the Web", which is through the National Library of Medicine. It displays images from anatomical atlases, some dating back to the 1500's, like this picture here (Author: Brunshcwig, Hieronymus, (ca. 1450-1512), from the book titled: Liber de arte distillandi de compositis, published 1512). I also really like plates from William Cheselden's Osteographia (1733), such as the one pictured below.

Additionally, I have been reading about John Hunter, dubbed "The Father of Scientific Surgery", in this great book that Steve got me when I told him I wanted to read more about the history of surgery, and the history of medicine in general. More to come on him...I feel like John Hunter needs his own blog post!

I just think all of this history is fascinating, and I would be happy reading about it for days, but I also feel that it is a important subject to be aware of in general. In knowing our past, what mistakes and what accomplishments were made, we are then able to forge ahead - into the future!! - in the best way possible, or at least in the most educated way possible. To know our past means we are better able to create our future!!

Crush!!

2009-08-21T05:25:00.000-07:00

In the past few days I could really feel summer starting to slip away - time to put my nose to the grindstone again. I take my Step 2 boards in 10 days and have been trying to study for a good chunk of my day. The amount of resources out there is craziness - question banks and books with page after page of information. I finally resorted to borrowing "Crush Step 2 - The Ultimate USMLE Step 2 Review" - from a friend the other day (guaranteed to help you CRUSH the boards! - grrrrr!!). It is better than the books I have been reading through in my free time this summer. It is a great review without getting you bogged down in details; details in such volume that they can make you panic and turn mildly neurotic! I think it's much better to try to be able to reason your way to the answer rather then memorize loads of never ending "stuff". So, here I go - study, study, do practice questions, do more practice questions....fingers crossed for a good nights sleep the day before and a clear head during the test; two things that can really make all the difference.

As I write this I am looking out my window; it's definitely one of those hazy and muggy August mornings. I need to finish my coffee, my honey chobani (greek yogurt that is the bomb and so delish!), and try to go exercise before jumping into all this work. I always have this argument - always, and for years!! - exercise in the morning, or in the afternoon? I could give a list of pros and cons for each in seconds, but sadly, I never seem to be able to make up my mind one way or another, at least in terms of a program I can do every day. My body is not happy when I try to make it sweat and force it to raise it's heart rate excessively early in the morning (sometimes I feel like parts of my body aren't even awake enough to be connected to each other in the morning, so I am like a marionette, running in some herky jerky pattern down the street!), but there is something that is so great about knowing for the rest of the day that I have worked out, and checked one major thing off my to-do list. However, in the afternoon my workout is so much better, my body more relaxed, and ready to go (no herky jerky running - usually anyway!), but then, the fact that I have this major thing to DO just looms over my head, along with all the other work that I have to do, or could be doing. So, I am trying to make it my goal that it is not necessary to do the same schedule every day (Although that would be so great to just know that at 6am or 6pm I exercise, and that's it, and I don't have to think about it anymore. But, I am slowly realizing a schedule like that may be a fleeting memory of days past, and life before med school, when I didn't have endless lists of things I could be learning or doing, as well a schedule that is constantly shifting and changing from month to month.), it is just to be active, in some way, every day - hopefully in a good heart pounding, sweat provoking way, but even if my exercise ends up being only a long walk with the dogs, that is ok!

All of this coming from the fact that, yes - I know how to multi-task, but I have a really hard time sometimes when I set big goals for my day, and they do not get completed. I just can't stand it! It is as if I can't accept that I am not going to have time to go for a 3 mile run, and read 5 chapters, do 50 practice questions, and write 3 paragraphs of that paper I am working on, AND make dinner...AND...AND....AND! I become so pissed at myself when I can't do what I initially set out to do, and then I feel like I can never be satisfied with the outcome of what I actually end up doing - essentially, because I want to do it all!!! But. But! This summer has been really great at allowing me to take a step back, telling myself to chill out, accepting what happens, and knowing that - if I put my all into it, know that I worked my hardest, then it is ok, and I can re-group in order to tackle everything else. There is always tomorrow! (Of course that philosophy does not work if you are just a lazy slug who sits around watching The Real Housewives and reading novels, despite the large to-do list looming over your head. Tempting (at least those New Jersey Housewives are)! But always, always mind numbing! (well maybe not the novel...I can definitely justify time for a few pages of a good book at the end of the day!))

Now. Off to fight the humidity and get that run in. Even more of a reason to get my heart pumping is the giant peach, raspberry, and nectarine pie calling my name from the kitchen. Crush the boards, and crush the run! (grrrrrr!!)

Talk doesn't cook rice. ~ Chinese Proverb

2009-08-12T07:03:00.001-07:00

Yesterday was an interesting day for me. I have been doing research all summer long, and have been suspicious that this has allowed me to become lulled into some sort of false comfort zone...no real schedule, being allowed to actually do "real life" things on a regular basis like cook, and run, and lounge around lazily watching TV in the evenings (mainly So You Think You Can Dance, which I am totally addicted to!). Ohhhhh!! Back to reality Juliet! Not only was yesterday a flash into what I normally should be experiencing as a medical student, but it was a great snapshot into what I will be experiencing as a resident.

One of the most frustrating aspects of the research that I am doing is that it has been very difficult to meet with the surgeon I am working with. I email him, but he does not always email me back, and I have resorted to developing a relationship with his secretary so that she can squeeze me into his - extremely! - busy schedule. However, the last 3 or 4 times we were supposed to meet - actually sit down and go over one of the case reports I have written, and talk about the next one I am taking a stab at - he has had to cancel. The lack of feedback is a little discombobulating; on one hand having the freedom I have had this summer is nice, and I have tried, for the most part!, to use it wisely, but I would love a little constructive criticism every once in a while. I mean, everything I could have produced up to this point could be utter shit for all I know! Plus, as always - yes, yes, as always! - my concern is; how will I be graded for these two research blocks if this man has not even assessed the work I have done up to this point? - I want to do well, and obviously it is not too hot if you don't do a good job in research actually done within the genre of the field in which you hope to someday be in.

So, yesterday, I knew that my adviser would be in the OR all day, and I just thought - "this is it! This is becoming ridiculous! I need to meet with this man, if only for a few minutes, I have not seen him for over a month!" I put on some scrubs and basically "crashed" his surgery. Of course, I was nervous because I wondered if he would find this behavior slightly oppressive - he had a full OR schedule, booked well into the evening, and here I come, waltzing into the middle of his total thyroidectomy, demanding more of his time. (On the other hand, I can't tell you how great it felt to put on scrubs, and make my way into the OR. I have been in there so rarely since my surgery rotation, but whenever I am, I just feel...well, GOOD!) It turned out that, although I had sent him my draft of my first case report weeks ago, he had not even read it, let alone printed it out. So, I printed it then, in the OR, and after the first case he read it while surrounded by patients gowned and laying in beds, waiting for surgery in the holding area, and me just standing there waiting for his response (awkward!!). Then he rushed into the next case, still reading as he went, with me following him. While he scrubbed in, he told me that he thought I had written a good case report, that he liked my arguments, and how I continued to narrow the focus throughout - Yayayayayayayyyy!! That was a great feeling, even if I had to crash his surgeries and scuttle around behind him for hours in order to get it. But, then, reality really hit...!!

The next case was a lap chole (laparoscopic cholecystectomy). Now, normally in cases, at least in an academic teaching hospital, there is always the attending (in this case my adviser), the resident, and then a third year medical student doing their surgery rotation, and sometimes a fourth year medical student doing their Sub-I (sub-internship) (it was interesting for me to realize that not a lot of people know this, and they frequently express surprise that so many people were not only in, but actually a part, in some way, of their surgery). The resident was there, and the attending, but not the third year medical student. I had already watched the resident in the total thyroidectomy, and knew he was only a PGY3 (vs. a 4th or 5th year resident). His experience was more limited than what I had seen exhibited by the residents I had primarily worked with last year, but he seemed cool and collected, and overall dealt well with the verbal directions and corrections he was receiving from the attending. I stayed in the OR, but did not intend on scrubbing - I am technically not a sub-I at this point, and I did not want to take the place of a 3rd year, who was supposed to be the one at the table. But, as time progressed, and the incisions were made, ports were placed, no 3rd year was in sight. I was asked to scrub, and did so happily, as - weirdly! - this is only the 2nd lap chole I have seen and I was intending to stay throughout the surgery anyway in order to watch. I was getting gowned and gloved when it became a bit crazy. The third year showed up (finally!) and my adviser yelled "where were you? It is the responsibility of the 3rd years to cover all the surgeries; that can't be that hard, can it??! Now, we had to go and find a 4th year to cover your absence!" (which isn't technically true because I had already been in the OR suite, just standing about...) The student was a timid girl whose eyes grew wide and she kind of flailed around apologizing and asking if she could scrub, should she scrub...and once it was decided that wouldn't be worth it, I told her that she should still stay and watch, and she looked at me, in a semi-horrified way. I am not really sure why, I was not trying to be bossy, but I do know she would have been in more hot water if she had just left when it was determined she was not needed, instead of watching the surgery and trying to take something from it.

From there everything just flew along in a series of yelling from the attending to the resident: (who was holding the gallbladder with his grasping tool through one of the ports) "don't you see that you are causing the view to be shit? If the view is shit, it is all you! You are the only one holding that gallbladder! You need to understand the angle of where you are coming from!"..."Use that hook like a bovy, separate the bands holding the gallbladder to the liver, do NOT go into the gallbladder!!...How many times do I have to tell you NOT to do that!!...If bile is released into this abdomen I am going to be PISSED!"...The attending yelling at me: (I was supposed to be running the camera, through another port) "Keep it steady...STEADY!, the screen is jerking all over the place!"..."You are writing a paper on a laparoscopic surgery and you can't even drive the laparoscopic camera!??"...."Horizon, what is your horizon? Shouldn't the horizon be FLAT??"

You would think all of the yelling would make me nervous, and to be honest, it does a little; at first anyway. But, the thing is, you can't be sensitive about it, you just have to try to correct what you are doing, and do it right (theoretically!!). What makes me the most annoyed is that sometimes I say "sorry...sorry!". UGHH! I cannot tell you how pissed that makes me, at myself! No one wants to hear someone say I'm sorry every ten seconds that you are yelled at for not doing something right - the surgeons don't even acknowledge it, to be honest! I think they would rather you just pay attention, and try not to make the same mistake again. The thing is, the "sorry" is this horrible reaction I have to being told that I am doing something incorrectly or inefficiently, whether nicely, or in a yell (!!), and, if I am not thinking, I say or whisper,"sorry". It just slips out of my mouth, just like a big fat, slimy, slug of a word! This platitude, especially when it goes universally unacknowledged, just really makes me look like a giant pussy. I mean. SERIOUSLY! During that entire surgery I was being yelled at, sure, but that resident, man - he was being YELLED at. And the thing is...the reality is, that will be me someday. I don't mind the yelling, because really, the intent is not to belittle, it is simply to make you see your mistakes, correct them, and to ultimately direct you to learn the correct way of doing something rather than the incorrect way (which is something you then would have to unlearn, and subsequently relearn in the right manner). And, to be honest, I certainly don't think that a nice, placid voice is all that appropriate when there is concern that the common bile duct may be cut by accident, or if there is a vessel that needs to be visualized and the gallbladder is being mobilized in a shitty matter in order to see it (for example). These are important things! So. The yelling I don't mind. It is ME that I mind!! I want to be tougher, not so nervous, not so apologetic; I want to be able to think rationally (especially in times of higher stress..i.e. when someone is yelling at you!), to understand why it is that I am being corrected, and be able to reroute myself (so to speak) in that moment to doing - whatever it is I am doing! - better. A good example of the whole, "Your actions speak louder than words" philosophy; something to which I wholeheartedly subscribe, but need to get better at performing!!

When deeds speak, words are nothing. ~ African Proverb

PERSISTENCE

2009-08-07T05:50:00.000-07:00

As medical students we are frequently asked to think about how we would would describe ourselves, what characteristics we embody. We are constantly being warned that we should know these types of things about ourselves as we sit down to write personal statements for residencies, or prepare for future interviews. There are a lot of adjectives and descriptive phrases I can think of that I would apply to myself, but one of the first I always think of is *PERSISTENT*. I recently came upon this quote about persistence, and was struck at how accurately it describes one of the central beliefs with which I operate; in my personal life, as I approach my personal goals...in my pursuit of knowledge, and a career in medicine...and basically, just as I make my way in the world in general. Some good food for thought.

Nothing in the world can take the place of persistence. Talent will not; nothing is more common that unsuccessful men with talent. Genius will not; unrewarded genius is almost a proverb. Education will not; the world is full of educated derelicts. Persistence and determination alone are omnipotent. The slogan "press on" has solved, and always will solve, the problems of the human race.

- Calvin Coolidge, 30th President of the United States

Summer Plateau...

2009-08-05T22:00:00.000-07:00

This summer has been about relaxing, and about thinking. I feel like this is some sort of plateau I have reached - still with far reaching summits ahead of me, don’t get me wrong! (I can almost physically see my sub-I and the 3 months of surgical rotations I signed up for this winter looming ahead of me.) - but this moment is some sort of strange interlude, where I have had time, and time, and...well, TIME! I know this is because I am doing research, and the schedule, if there is one, is loose, and really just one of my own making. At first I felt that I would need to show up to school every day, all day, be physically present there...somewhere there on campus...but no one seems to notice what I do or where I am, and all that really seems to matter is that I get work done, that I produce, and - in doing so, that I learn. So, I have been reading page after page of academic papers in order to write even one sentence, let alone one paragraph!, of an intelligent sounding argument for my case reports...I have learned about writing and submitting a proposal to an IRB - tedious work, and something I know I need to learn, but which I want to just fast forward through at this point so we can get down to finally working on the project...enrolling patients and seeing if what we are proposing, is actually, in fact, true! Exciting stuff...seriously, you are going to have to trust me, but it really is!

However, in the meantime - wow. I just have been thinking and thinking and doing all sorts of things I can’t remember doing for a while...some since before med school. I think, because I am so frenetic, and in some ways always crave a fast, fly by the seat of your pants pace, in this somewhat lull I am experiencing, I have created a similar frenzy within my head. It is as if I have these big amorphous balls of ideas and thoughts all swishing and squashing, and flying around inside my brain, many times all at the same time (which I am beginning to finally realize is something I can’t help but do...I just can’t turn it off!)

Here are some highlights...

In the beginning of my summer Dr. George Tiller was gunned down while in his church by a pro-life, anti-choice, “activist”. I was horrified when this happened, and more horrified as I watched and read how so many people in our country had no idea what kind of work he actually did, or more accurately, what “late term abortion” actually means. I have thought of Dr. Tiller over the past few months, and the work he did - providing women’s health care and reproductive choices to women in desperate need - I have thought of how he not only had a belief and a conviction in what he did, but how he operated with both compassion towards his patients, and bravery as he faced everyone else...the law suits and the threats, not only to himself but to his staff, and his family. I think of him because I admired, and admire him still, but also because I hope to have just as much conviction and belief in the work I will someday do myself, no matter what it is, or how controversial it is or is not.

“Abortion is not a cerebral or a reproductive issue. Abortion is a matter of the heart. For until one understands the heart of a woman, nothing else about abortion makes any sense at all.”- Dr. George Tiller

More domestically...I have been thinking of recipes...the combinations of flavors...how different foods complement one another. Maybe a basic thing, but something I have not even had time to think about until now.

I have started calling this summer “The Summer of the Soups!!” because I really am a sucker for great soup...a spoonful of flavor in your mouth! The blender has become a great friend - especially the puree button. But breads and cakes, and delicious roasted vegetables are also making an appearance, along with fresh fruits in creamy ice creams...yummmmm....!! I mean, I am seriously enjoying things like - just the ESSENCE of a strawberry. Man, it’s a deep thing, it really is!

Michael Jackson passed away...and god! That was kind of a blow too! That man produced the soundtrack and the choreography to much of my childhood. I cried for his early death, for him being so misunderstood (will we really ever know everything? - probably not.), for his kids and his family...for myself even, because his music...well, let’s just say his music was there for me in so many circumstances and times during my life - good and bad. RIP MJ...

I have seen my sister twice - TWICE! Shocking....I know! We spent a great weekend in Dallas together with our Mexican cousins - we danced, and ate, and drank, and during the day lounged in the sun, and laughed and ate some more...with a little swimming in between. It was wonderful. Plus, I had a pair of the hottest shoes of all times to wear out - green snakeskin gladiators. Now, I think that wearing a pair of great high heels is a little like life...sometimes you have to take a chance, feel a little pain, but the pay off - man! Longer legs, calves that look gooo-oooo-ood!, I think they even made the dancing better...and you know what? - you really need that once in a while, a little spice. I live life 99% of the time in a pair of merrill shoes or dansko clogs, but sometimes, sometimes! - life just calls for a night in high heeled, green gladiator snakeskin shoes, with a great dress. Seriously!

Then we went to NY State for the other side of the family...interesting and funny revelry for my sister and I...and on that trip I thought about the places I enjoy (many!), the places I would want to live (maybe not so many...and even the proximity of my two weekends had me comparing sleek, sterile, and air conditioned Dallas, with the shabby chic of upstate NY with it’s meandering cows, wobbly red barns, and winding country roads, sometimes seemingly leading infinitely nowhere!), and the places I want to visit (man, that list is already long and only getting longer!).

I have been reading and reading and reading...books on glass blowing in venice, novels set on the beaches of nantucket, the history of surgery (trepanation/trephination (the drilling or cutting of a hole in the skull to relieve pressure)...cross culturally in prehistoric times - really fascinating - no joke!)...too many books to count. I read so fast it is probably a bad idea to buy as many books as I do, but someday I plan on having a big living room with floor to ceiling built in bookshelves...god, just even picturing that makes me smile. Owning books gives me serious pleasure.

OK...so there is lots of stuff. LOTS. Too much to recount here - and not the least of which is the crazy amount of random medical things I am learning while trying to pare down information to get to the “right” data for my cases...also - how I am now serious enemies with these dog owners in our neighborhood whose pack of dogs attacked Oscar and almost killed him a month ago...and who - just tonight! - attacked both Oscar and PB while we were walking them, leashed!, through the park (makes my blood boil!!!)...how I have been running and simultaneously bird watching - seeing swans swimming and diving in the reservoir, blue jays, orioles, and robins in the trees...how awesome it feels to be getting back into shape - slowly but surely...how I started using this crazy weight/cardio DVD that requires you to balance on a half ball type thing with the round side down - rockin’ and rockin’ away while liftin' and squattin' at the same time! - a good workout (despite the frantic creaking sounds that are produced, which, I swear, must sound like crazy sex to the downstairs neighbor!)....dinners with friends I have not seen for months...dinners with friends visiting from Australia, and Brazil!!...I mean, the past few months have been chock full of “stuff” that I have really been needing and missing (sometimes not even knowing that I have been needing or missing it until it happens!)...and it feels really good!!

I promise to write more...I will I will! There’s too many things going on in my brain not to (of course!)...I hope all of you are enjoying your summer as well...making every day count, even if it is only in the little things.

Financial Nauseation

2009-05-20T09:45:00.000-07:00

So, right after posting my "3/4" posting earlier today (below)...celebrating the great things of 3rd year, and of med school (which still hold true!) I spent some time on the phone with the registrar, and with the office of financial aid; both of which brought me crashing down to earth, hard. It is funny, that - even though I will be registered (technically) as a 1/2 time student for the next 2 academic years, the school still finds ways to charge me certain fees as a full time student. It doesn't seem fair to me...but neither does what I am asked to pay every year anyway. My tuition and fees are roughly $47,000 a year...this year! You also have to calculate that there has been a 5% tuition increase every year since I have been enrolled, and I was "advised" to plan for one for the 5th year I will be in school as well. If you add the calculated (i.e. calculated by the school and projected in order to predict the amount you are allowed to borrow every year) living expenses the amount tops out around $62,000/yr. Astounding. Even more astounding when they start reading off numbers to you in the hundreds of thousands...in terms of borrowed amounts...amounts possible to borrow in your lifetime...!! Additionally, the board exams we must take are $500 a pop, oh - except for the clinical skills exam which is $1000, plus the cost of flying to and staying in one of the 5 cities in the country where it is actually given at specific standardized test centers. And I won't even mention the amount I have spent, or will spend, on books and texts. Ugh. It just makes me sick, physically sick to my stomach. The issue for me is that I am not only putting myself into this large amount of debt for my education, but Steve is also involved as well, simply by being my husband! The amount of responsibility and concern I feel about this is overwhelming at times. I also worry - i.e. after my phone call a few minutes ago where they were spouting out loan limits and numbers so quickly I could barely keep up - that I won't be able to afford to finish med school, which is probably not a reality, instead - just one of those nightmares that can wake you up gasping in the middle of the night.

If asked, I would say this financial burden, this worry, is one of the biggest negatives of medical school. And, if you think about it, this also translates into our health care system now - I believe everyone in this country should have access to health care, but I also believe that doctors need to be compensated for all the money spent on their education, as well as all of their time. The reality is that I go to school with a large number of privileged people - many who do not even know, or even have the need to know, where the financial aid office is in our school, and have parents that write checks covering their tuition and fees in their entirety every year, in addition to either paying their rent or buying them a home in the city. But, there are also people like me - a friend that told me yesterday she will go home during one of her break months of 4th year to work for her father for 20 or so days, to make extra money; another that re-signed her lease for one more year here despite her noxious roommate - a girl who has recently been diagnosed with borderline personality disorder after her 2nd suicide attempt - yet my friend cannot afford an apartment on her own, let alone the simple cost of moving, if she will just be moving again, to her residency location, in a years time. The discrepancy between those who have a great deal of financial resources and those who don't, is simply "life", but I know for a fact that, for those of us who have to worry about the numbers of what this is all costing us, it can be pretty damn stressful at times.

3/4

2009-05-19T19:28:00.000-07:00

This past Friday was the end of my 3rd year, and the mark of 3/4 of the way to me becoming an MD. Well, I guess technically it is 3/5 of the way, as I am now graduating in 2011 instead of 2010, but the amount of classwork, despite the extended time, still remains the same. It has definitely been a strange journey, one I just remarked on yesterday to a friend; saying that it has been the most uncomfortable and unpleasant thing I have ever experienced while also being one of the best, and most exciting. The 3rd year of medical school is an interesting dichotomy, a mixture of finally being face to face with patients, patient care, and medical situations and problems that you are not just paging through in a text book, while constantly being faced with the issues of being graded, worrying how to stand out while not looking like or acting like a jack-ass, frustration with the fact that at the end of the day you are really not the primary caregiver, not yet anyway, and additionally - may work your ass off and do all and every kind of scut work for hours, and never get noticed by your ever rotating team of interns, residents, and attendings. The grading, the all encompassing desire for "honors" at all costs, and how this impacts your interactions with your superiors as well as your peers, makes this a very unpure process, at least in terms of learning. It really is a rare day in which you can head into the hospital as a 3rd year medical student and not be conscious of it; to try to learn and interact with everyone without being cognizant on some level that everyone is assessing you, and that, somehow, this assessment will play into whatever grade you will get at the end of that particular rotation...and how this could, further, impact the letters of recomendation you can or should ask for...and, even further, your future residency applications...and the list could go on and on and on. But, I have determined, if you want to get the most out of it, you just have to learn to deal with the competitiveness and constant concern about grades, stuff like that is just not going to go away - at least not for a while!

And so, my 3rd year of medical school, more than any other, taught me about medicine, but also taught me about myself. I was exhausted, but pushed to my max, and I kind of love learning like that, I was amused - many times when I was least expecting it, angered, embarrassed, enlightened, and more than anything, humbled. My father recently emailed me and said - what are the passions and positives? - and I think that, throughout this blog they are there, in my direct words, and as you read between the lines. However, to answer that more directly than just with reference to 20 or so blog posts, I can say that I think some of the best moments are when I have been the most humbled. By being in this position, a medical student, and ultimately someone who will be a doctor, you are given the most unfettered access into people's lives, their families, their sometimes tenuous connections, and the ones that are strong and sustain them. You see people in their most vulnerable state - many times they are naked or partially so, many are sick...very sick, and are worried and concerned - about their health yes, but sometimes about things you cannot even imagine until you ask, and you, and your white coat, open the door onto it all. When you are present in surgeries you are allowed access to a person's body in the most intimate ways - holding organs and vessels, removing cancers, and simply repairing what is not working or what has been damaged by trauma or disease, and that, in of itself, is truly, truly a privilege.

It may be the most obvious statement to make when I write - we are not all the same. Yet, many times we go through our lives, and operate in a comfort zone, working, living, socializing - all with those who are much more similar to us than different. This year I have met people from all sorts of cultures, and all walks of life, I have observed true relationships between parents and their children, grandparents and their grandkids, siblings, and even people without families that have found true friends who have essentially become their family. Having access to this is extraordinary, and I think makes me a lucky person - one who gets to see beyond my own life, my own culture, and my own social mores so to speak. Yes, this is definitely humbling, sometimes even uncomfortable as I am forced out of my own comfort zone on occasion, but it is also something that makes me a stronger person, a more aware person, and I love that. I wouldn't want it any other way.

Pet Peeve.

2009-04-30T18:26:00.000-07:00

OK. So, admittedly, I have a lot of pet peeves. People who post status updates on facebook and spell things wrong..."fowl" in stead of "foul" when they are trying to describe a bad odor...and on that note, people who put their health complaints or personal woes in their statuses...ugh. I hate when people spit in public, especially when prefaced with an especially long and growly attempt to dislodge whatever it is they are trying to spit out...I hate being around cigarette smoke, and I don't like looking at nasty snaggle teeth. I really dislike misbehaving children in public - even more so if they are dirty!, and I definitely don't like those guys that think they are so so great when they dance up behind you and try to worm their way into your evening by glomming onto your backside...hmmm - I also really hate the women that actually GO for that type of thing!

But, here's the thing - let me try to relate this back to medicine for a minute (please!). I have been in this psych rotation for 3 weeks, and there is just something about the mental health professional that I can't really put my finger on...in my less subtle moments I would say "preachy" - however I know that doesn't apply to the whole field. I think this is just coming from spending my time in this inpatient program and watching case managers shuttle these patients around, seemingly taking more pleasure in discussing how they regulated the behavior of a certain patient, or "set new boundaries" for them, rather than discussing the actual details of their treatment plans, and how - for gods sakes how! - these people are going to to integrate back into their lives, their jobs, their familes. Additionally, I have sat in on numerous groups - todays was regarding suicide - noticing the signs of it, and what to do, what resources are out there for these people. These groups are run by RN's and todays was a real doozy. I just don't know any other word for it! This woman stood and pranced in the middle of our circled chairs for close to an hour, seemingly more interested in hearing herself talk, rather than really listening to what these patients had to say. Even when one of the patients told her he was "tweaking out" by having to sit in on a discussion regarding suicide, she never really acknowledged him or his expressed fears, completely ironic since he was actually brought by ambulance to this program for attempted suicide! Rather, she simply said "let's alllll check in, make eye contact with me - let me see that you are ooooo kkkkk..." as she rotated around the room shimmying her hands and body in towards the patients and out - as if she was doing some weird voodoo dance. One man fell asleep, or at least chose to close his eyes and seperate himself from the lecture. He too had been admitted for attempted suicide. Then this woman proceeded to say that she was going to apologize on behalf of the country, the government, and the individuals in the room to a man who was a veteran because he said he had never truly received support for his suicidal ideations when he was in service. I mean.....really?? Really. This patronizing preachy behavior is intolerable to me. After an hour I cannot honestly say what was learned that was truly ground breaking for anyone there, let alone informative regarding suicide; at the most this lecture was anxiety provoking, at least for some of the patients. And that said, this is not something that is across the board in psych, it just seems to be the general theme or mood in terms of what these patients are experiencing during the majority of their days in this specific program - and I have to wonder how effective it is - who will be back for a return visit - at least to some treatment facility, if not this one?? Basically - it is just extremely frustrating to see good work muddled up with people who seem to take pleasure in listening to themselves preach on what is right and wrong, and are constantly confusing this with an actual attempt to provide treatment for some really ill people.

Now. That off my chest, my other pet peeve is obese people who use wheel chairs to get around, yet use their feet to crawl along, so their hands are totally free for cell phone use or eating, which is what I saw today - apparently giant plastic wrapped muffins seem to take two hands, but do not limit the feet, and legs, which are fully functioning and entirely without impairment of any kind! - from scampering along and carrying a person from room to room...ALL day long!! Not that this is too much better, but maybe a Rascal would be a more appropriate transportation tool.

Ms. D Update!

2009-04-23T19:03:00.000-07:00

Oh! and I keep forgetting to mention: During my spring break I was on campus doing errands and decided to stop in the ICU to check in Ms. D. She had been discharged to the floor, and then from there to a rehab facility - hazaaa!

Going Skinless

2009-04-23T18:18:00.001-07:00

Today I sat in on an intake interview done by one of the psychiatrists at our hospital that does not normally work with students. He was amazing to listen to - was able to elicit details from our patient in ways I did not even realize until we had moved on to the next thing and the next...it was over an hour long, and is still to be continued in the days to come. I had to continually focus on the doctor though, his techniques, how he organized his interview style, what information he asked for first, and how he started with many open ended questions, and got more information by just simply asking for more detail, and then staying quiet - something that is easy to think about, but actually really hard to do in practice. I needed to maintain this focus because the interview was really emotional to hear.

The patient was admitted to our program, directly from finishing treatment in acute care, where he had stayed in a lock down facility due to recent suicidal ideations, and a strong desire to follow through with them. He was a kind and quiet middle aged man, dressed neatly in well kept jeans and button up shirt, with white leather sneakers. He held his baseball hat in his hands when he sat down, and throughout our time in the office while he told us his story. I am reluctant to put the exact details of his life here, on the internet, but needless to say his story included physical and sexual abuse from a young age, and was overwhelmingly signifcant for sheer emotional neglect throughout his life from those who were supposed to be the closest to him. However, and surprisingly - especially given his horrifying upbring - he never resorted to drug or alcohol abuse, and tried and tried to live a good, successful, and purposeful life. There were times when his depression was hard to overcome, and the circumstances in which he found himself - jobless, a broken marriage - threatened to overwhelm him, yet he still persisted. He quietly described a life of working hard and just wanting to feel connected...feel as if he belonged - to someone, anyone. He never spoke of wanting a large house or fancy cars, so so different from many people that you meet now a days. He actually said how he was happy looking for a simple module home to live in with his girlfriend a few years ago, and even seemed embarassed when he told us how he spent a great deal of money on photography equipment and computers as his skills with both improved over time, yet was shocked when we asked him how much in debt this put him (assuming risk taking behaviors that involved excessive spending without thought to consequence) - saying that he was not in debt, it was just a great deal of money for one person to spend on themself.

There was just this persistent thread through the entire hour and a half that he spoke - that touched on belonging and connecting to others, and his quest for that throughout his life - even though he was rejected and pushed away time and time again, specifically by those that he was supposed to be able to rely on the most, rely on unquestionably. Yet, despite all of it, he still persevered in living within a moral code he had established for himself, in a truthful manner, and with purpose. And - isn't that what we all want, what sustains us all? Our connections with other human beings, our families, those we care for and who know us - our ups and downs, and ins and outs - that is what we have holding us on this planet, in this here and now, in this life.

No wonder he was depressed - dear god, I would be! He looked right at me and said, "I walk around, every day, I know I look normal, I know I pass for normal, and no one can see how I really am inside. No one can see it." And when asked to describe what his depression felt like he said, "it is as if someone has peeled off all my skin, my outer layer, and everything, every little thing that would be ok normally, makes you so upset, aggravated, anxious, you feel it all because your skin is not there anymore; there is no more protection."

Psychadelic

2009-04-22T18:34:00.000-07:00

I am currently on my psych rotation, which started with an orientation including lots and LOTS of role playing, which – thankfully! I did not have to take part in, but I did have to watch it all, and join in the commentary afterwards. After the role play we had discussions on the basic psych Dx’s we would or could see on this rotation – bipolar, schizophrenia, borderline, etc. and then – then! – we had many, many (!!) discussions on how to remove ourselves from dangerous situations, how and where to sit safely in a room with a patient, how to avoid getting hit…assaulted, attacked. Wonderful.

The site I am assigned to is a long drive away – 45 minutes to an hour depending on traffic. The patients I see are in a 3 week program trying to integrate back into the community, with coping skills, jobs, etc., and many have diagnoses like major depression, PTSD, and bipolar disorder, some even have schizophrenia. But I also see some patients with substance abuse problems, and patients in a lock down facility. Of course, as soon as I arrived on this new campus, I had a small orientation that involved another discussion about not being assaulted and how not to be in a dangerous situation with a patient. Nothing like really emphasizing a point to make it hit home…

It felt strange to begin there, there were no patient rooms, no schedule to really adhere to, except for the different group schedule the patients are signed up for every day (sharing, coping, etc.), which I can sit in on if I want to. My preceptor seemed to think it was really amusing when another student and I kept asking her, trying to nail down what exactly we would be doing here (??), what our schedule would be – smiling and half laughing as she said it is funny when people who are used to a great deal of structure are placed in an environment like this program, and that we would get the hang of it.

I was assigned a patient and decided to start interviewing him. However, however! I was, and still am, confused as to what I am actually going to offer this patient in terms of treatment. I received a big lecture on potentially “unraveling” this man at any moment, due to his extreme PTSD, and that this could be due to any thing – a noise, the way I looked at him, the way I approached him, what I started asking him about….and that his “unraveling” could involve anything from quietly sitting there and going someplace within himself to all of sudden turning violent. Again, great…great! So, the staff offered me an office – a fairly sound proof room (as this used to be the old lock down unit in this psych hospital) and shut me in there with him. Alone. Needless to say, I was, and continue to not be in danger around this man (I meet with him alone every day to determine his progress in the program). However – again, I wonder – I am not a therapist, nor a psychiatrist, and if everyone is so worried about this “unraveling”, his potential for instability, and maybe even violence, why are you sticking me in a room with him alone? Despite possible danger to myself – which I guess I would tend to minimize in the end, as – on medicine, surgery, pediatrics even, I have had or seen angry patients that have resorted to some level of violence with their care givers. But seriously – this man is so unfit to be in society he needs a 3 week intensive rehabilitation program, and I, me, am the one that is his primary contact and care giver to some extent? Boy oh boy…. Never, in any other rotation, have I been this unsupervised with someone who is ill, and in this case, psychiatrically ill.

Overall, my week has progressed with great frustrations at traffic on the multiple highways I have to take, daily wondering at what actually possesses people to live so far out of the city, so that they are forced to sit, absolutely still!, in traffic heading in the opposite direction from me – into the city, for over an hour each way, every day. I always think – no nice house is worth that – it is just not, I will take my apartment in the city any day! Once I get to the hospital I attend groups, or sit in the office of my preceptor as she talks to patients, and interviews day visiting patients (the other day we had a whole afternoon of schizophrenic patients bused in for their check ups with her….it was actually very interesting hearing about the voices that tell them to do things, and what those voices are actually saying…!!) I also spend time with my assigned patient – who at times frustrates me to no end…I am horrified by the things he has seen and experienced that have led to his PTSD, but he is a young man, who also has bipolar disorder, and the charismatic and charming personality that tends to come along with that. He told my preceptor that he only feels comfortable talking to a woman, which was why he was assigned to me – but I just can’t help feeling cynical…we have spent a few afternoons together while he has tried to flirt with me to avoid my questions, or even tried to turn the interview back on me – telling me that I was being unfair, and that I should have to answer the things I am asking him. Obviously I don’t (!), but the whole – “I need to talk to a woman” thing doesn’t really sit well with me…especially as I see him seeking out male companionship throughout the day from amongst the other patients, and even the other medical student that I am with. Additionally, he is a big veteran of the psychiatric health community and constantly tosses around lingo like “disassociating”, “unraveling”, “hypomanic”, etc. and peppers our conversations with discussions of more psych drugs than I even know myself off the top of my head. I feel, at times, that he is somewhat working the system, trying to work me even. However, I do vacillate daily, and tell myself not to be so jaded and cynical, to have more of an open mind. All in all I know (but I definitely think I already knew!) that psych is not for me, but, admittedly, there is always something so alluring, so interesting, about seeing the extremes in personalities and behaviors…seeing someone that fits the criteria for bipolar or schizophrenia to a T, for example. All in all, not a bad way to end my 3rd year, that’s for sure!

Freedom...

2009-04-01T21:41:00.000-07:00

I just had spring break – 3 weeks of unrelenting time off…almost too much – which initially sounds strange, but it is almost as if I do not know what to do with myself in a block of free time that large. Granted, if I had enough funds to actually travel somewhere, or do anything that might cost money - see shows, eat at all the restaurants in the city I am always drooling over…it might be different, but at this point that is just not a reality. So, at home I stayed, and in the first few days off I felt so antsy – almost as if I had stopped some really potent drug…I mean, I did not like internal medicine very much, but I was busy, and I was learning, and I definitely like the way that makes me feel; it is just really hard to know what to do with myself when I am not busy and adhering to some sort of intense schedule. I had all sorts of plans to study my Spanish, and read lots of books – for fun, and for learning. I got to some of it, but truthfully I spent a great deal of time frantically researching ideas for my fourth year of school. I have decided, after much, much! deliberation, to split my 4th year over two years. It will give me more time (vs. only the 2 weeks we are allotted) to study for my Step 2, which I really need to do well on, considering the utter shit-ness of my Step 1. Plus, I will have time to do some research with one of my attendings, and I will also have time to do some more extended international work vs. just a short block – hopefully somewhere where I am forced to use my Spanish night and day! All things I want to do, things that I think will make me more competitive while applying for residency, and things I know I will have little to no time to do during residency – as the protected time of being in school rarely ever comes again in the “real world”. All these things make sense to me…more time to study…doing things that makes me a more stand out candidate (i.e. avoiding a prelim year if at all possible!)…but wrapping my head around the idea that I will be graduating in 2011 vs. 2010, despite it being my own choice, was hard.

All of this came on the tail of many class meetings with Deans urging us to sign up for Step 2, our clinical skills assessment, doing sub-I’s, knowing where we want to do away rotations, etc. and etc., basically figuring out our lives asap (!), all coupled with many days of me driving home – exhausted – and arguing with myself, realizing that yes, yes – I did want to go into surgery, despite how much it scared me, despite how tired I know I will be, despite how much of my time it will demand, I don’t really know anywhere else I fit as well, and the bottom line is that I just can’t imagine not being in the OR for the rest of my life after med school. Things make sense to me in there, and yes, I am frightened – but that is coupled with excitement, and some weird sense of calm even…finally, finally I am deciding on something that is my real future. I mean, my entire 20’s were consumed with jobs that were never anything that I would do forever…they were all just things to get me somewhere, to move me along…get me here I guess, but god – how tedious! To always be the underling, never really thinking or synthesizing anything for myself, well, more accurately, just never really given too much of a chance to think or synthesize anything, just doing what others wanted and never really having too much of a say – think: superstar barista, slightly apathetic librarian, definitely apathetic tax firm secretary!, fish egg microinjector of biochem. dye, fluorimeter user, daily pipeter and cell culturer, oh – don’t forget, mass giant plasmid procurer, murine cancer giver, and mouse debrainer…all things that really, really, at the end of the day, don’t require much of you in terms of what your intellectual contributions could be (however, my work in forensic anthropology during this time was the one glaring stand out, as my teacher was a wonderful mentor - both in academics and in life, and I truly believe it was the catalyst for me somehow, someday, ending up in medical school). Of course, here I am picking the most stringently hierarchical branch of medicine – where the bottom is where I will be for a while, more than a while…but at least there is somewhat of a top to all of it, something definitive I will be working for – you know?

Ms. D

2009-03-14T10:04:00.000-07:00

Today I am sad. I was on long call last night, and our team got sign out from the CCU intern on a transfer patient. The intern was one of the interns from my old team, whom I absolutely love!, but who - when done with sign out - pulled me aside and told me that one of my patients that I had been following on the other campus, for weeks, and who was admitted for cholecystitis, C. dif. colitis, possible sepsis, but who improved monumentally during the time our team cared for her, and who - on my last day with them - was d/c'd to a rehab facility to get better prior to having surgery to remove her gall bladder, was now down in this CCU, intubated, and suffering from bacteremia due to the PICC line our team had ordered put in for her, and now they were also talking of possible endocarditis - Roth spots were visualized on her eye exam and she has a pretty significant murmur. I went down to see her but she was sedated and intubated.

I had just talked about her at our last preceptor meeting - when asked of moments that have been gratifying in medicine thus far, I talked about how I felt on the day she was d/c'd, how it was fitting that we both were leaving the east newton campus together in some way, and that I had seen her improve so drastically over the time I cared for her. I felt like I was not leaving any loose ends. Every morning I would go in and see her...wake her at 6:30 am, ask about her bowel movements, her abdominal pain, her mood...we grew to talk about her family, her fear that she would be hospitalized again (this was her 2nd hospitalization in 2 months for the same thing), how she needed more reading material to keep from being so bored in the hospital. Every morning she was sitting more upright, and on the last week her color came back, she started to worry about how her hair looked, and she began to wear this bright red velour shirt with pearl snaps over her johnny. On her last day she asked for me to write my name down so that she would not forget it, and also wanted my phone number, which I could not, and did not give her, but I told her I would be checking the records for when she would be scheduled for her cholecystectomy and would try to touch base with her when I knew she would be back in house. On her last day she sat at the edge of her bed with her belongings packed in the hospital bags, and a bright red knit hat sitting on top of her head, not pulled down tight, but covering her hair, and matching her velour shirt - she was ready to go. I wanted everyone to see her - she looked great, and the hat and shirt were amazing - when she came in and onto our service I could have never imagined or predicted that I would see her like that...and I remember thinking that to myself as I looked at her in that final moment actually, reminding myself how close she had been to going to the CCU...and how our care seemed to have made a difference.

But now she lays, intubated, in the CCU on the other side of the campus, and part of me feels that we failed her - I will go and see her tomorrow when I am back in the hospital again, but what can I say to her? She was so worried that she would have to come back to the hospital for another infection, that her surgery would continue to be delayed. I reassured her, I told her how great she was doing. And here she is. Again. And I know that she will constantly be in the back of my mind until I can get back in there tomorrow, and not only see her, but talk to my old intern, and read her chart, to find out how she is, what is going on...how she is progressing.

48 HOURS.

2009-03-12T19:23:00.000-07:00

Yesterday was short call…I admitted a man with an incredibly resistant strain of HIV with this horrible rash all over his body – peeling and scabbed. No one used gloves when we examined him – despite possible open wounds, I did the same, followed suit, yet felt the whole time I should glove up…wanted gloves…

Our team got a new attending – my 5th on this rotation, a Hispanic man, I like him, he seems kind and interested in teaching…but rounds were long and awkward – he is young and this is his first ward rotation…I have such a hard time paying attention for the hours and hours that we round… additionally I am counting down the days until this rotation is over…I am tired and bored and just ready to be done…at the same time worried that I have done very little studying for the shelf next week…

On rounds we see this man who has the most fetid breath – it actually reminds me of when my father used to make my sister and I clean out the algae from our pond in PA, so that the water did not become overgrown…when we ask him to “breath deep” for the lung exam I almost gag…

In the afternoon I troll the OR schedule to see what is going on…and when I leave I walk through the ER and past the trauma bays to see what is happening…wanting to be there, not wanting to be here…

I wonder about how long my patient will live…we talk about it amongst the students and with the attending…we talk about death with our medicine rotation preceptor…

I circulate between work rooms…trying to stay away from the new intern - the girl who keeps asking me if I am gay...so inappropriate and makes me so, so uncomfortable, constantly trying to find space to study, trying to find a computer to do work…hate the room with no windows, it is like a cave, you don’t know what time of day it is…whether it is day or night, but that is usually where we all sit to do work, to eat, to talk…

I meet with my clerkshop preceptor…I feel like I kind of hate him…he got in a fight with a fellow student about stem cell research, which he is against (!)…I think I just hate the fight…hate that he pushes his beliefs on us, on the patient (when he goes into rooms and introduces himself to new patients he says “God bless you, I am Dr. C”…) oh, I hate that I hate that!

5 out of 12 patients on our list are newly homeless…lost their homes to inability to pay for mortgages or rents…if I think about it too hard…I can’t, it makes me so sad, it makes my heart hurt…think about their HTN instead, their colitis…overwhelmed.

Look up the protective benefits of having an appendectomy on getting ulcerative colitis…look up the side effects of nivepine…try to understand the coagulopathies associated with chronic hep. C…why dapsone instead of bactrim for PCP?...what is “crack lung”?...try to remember to read about heparin induced thrombocytopenia regarding another patient…what is empiric tx for community acquired pneumonia – azithro and cetriaxone..ok, what doses?...

My grandfather emailed me...it makes me happy to see his email in my inbox...we will talk soon, we will talk of plans and of medicine...he can give me advice...some guidance...much appreciated as it is getting to that time in which I need to start making some critical decisions...

Note that patient’s RFP (syphilis test) is reactive…read ID fellow’s note in chart…in capital letters – “PLEASE USE GLOVES WHEN EXAMINING THIS PATIENT”…!!

Go home…feel stressed – feel like my teeth are permanently clenched, note that this is unique to this rotation…EAT!!....nap, 1 hr. (glorious, but why so tired??)…write H&P’s…need to present tomorrow to preceptor…go to gym…1 hour on weird elliptical machine…not convinced it is much of a work out…too much momentum carries you along…but too tired to run…go home…finish H&P’s, shower, go to bed. Get up. Do it again.

sitting and rounding, rounding and sitting

2009-02-12T19:08:00.001-08:00

So. I am sitting here, home early from a night that was supposed to be long call…an admitting night (i.e. our team admits for the medical service tonight), but my resident, kindly, sent us home early. Yet, I am exhausted and just antsy…and, most definitely, missing my days in surgery. I had been looking forward to internal medicine because there is so much still that I know I need to learn, or just be exposed to, or asked to critically think through – developing more thorough differential diagnoses for example. Yet, these days are really killing me. We round on our patients for hours – starting at 7:30 (I preround from 6:45 or 7 am to 7:30)…so, technically!, a pretty late start, in the land of medicince anyway, but the entire morning is filled with talking about patients, not even a huge list of patients…6-10 maybe?..until almost noon. Every day. Then we go to talks, about more patients, or about EKG’s, or kidney failure, etc., etc. or a patient vignette broken down, it doesn’t really matter. Unless we are actively rounding, we primarily rotate and sit amongst the various computer areas on the floors, or sit in meetings or lectures, and just get talked and talked and talked to…for hours and hours and hours… And, as much as people are friendlier and more open in internal medicine, I just can tell, COULD tell from day 1, that this is not where I can see myself in the future. At all.

It is really interesting what you can learn about yourself on all these different third year rotations. Each allows you to see into some aspect of the human condition/nature, whatever it is, so to speak – i.e. whatever is being treated – but each of these specialties and areas of focus really do attract a certain type of person, and have their own distinct culture. Surgery and ob/gyn can sometimes be lumped into a similar category – many times known for harsher residents (although I would rather just chalk that opinion up to individual experience, especially as I, personally, really appreciated the no bullshit, say it like it is, attitudes I many times encountered!), stronger opinions, and efficient and fast work, with little tolerance for anything else. Although I have liked, or at least appreciated, other rotations, I really have felt the most comfortable, the most MYSELF, in surgery, and definitely ob/gyn. I am sure that could take a psych consult or two to figure out – and, if I examined it closely enough myself! – could really help tease out a great deal about my personality and who I am.

Anyway, I am going to try to write more, but shorter postings…the long ones were maybe too long (at least my mom hinted at that), but allowed me to write less frequently. Let’s hope I can keep up, as there is always so much to say – more than I ever seem to get in here, unfortunately. And, in terms of this rotation, well – at least I can tell you I have had some interesting patients – one man with a 38 year history of IV heroin use..daily injections, suffering from osteomyelitis secondary to his IV drug use, another man admitted for a slow GI bleed and melanotic stool (black and tarry because it is basically composed from blood from an upper GI bleed that has been oxidized as it moves through the GI track turning black vs. lower GI bleed which would be bright red) with a hematocrit of 22 (low!) who sufferent a NSTMI (heart attack) on his first night in house – most likely secondary to the bleed and his severe blood loss – who never felt more than a little numbness running down his left arm for 2-3 hours (a great example of how not everything fits the text book version of a disease), another woman with a fever of unknown origin – interesting work up and findings….so, yeah – I guess I AM learning a lot, interspersed with some serious antsy-ness and boredom…but learning! – even though it would definitely be much, much! cooler to go to a surgery here and there, and every now and again!!

Surgery Finale

2009-01-28T19:53:00.001-08:00

So, my last day of surgery rotation was yesterday. My 8 week rotation finished off with my last day in trauma – 3 traumas came in during the day – 1 assault, 1 guy hit with falling ice, and another who fell off his bike without a helmet. My morning was filled with driving the 45 degree camera for a laproscopic bariatric surgery – being yelled at by the surgeon – “find the horizon damn it, find it!, you do know what center means don’t you?? Center does not mean left or right, it means CENTER!” while finding myself almost splayed over the patient – with a BMI of 60 or so – trying to avoid compressing the pneumoperitoneum as I struggled to focus and move the camera according to the instructions being shouted at me (in between the surgeon talking about himself in the 3rd person – “Dr. H is sewing, Dr. H would like the suction now”, etc. etc!). My afternoon was spent in trauma clinic seeing patients for f/u appts. – taking down dressings to see how stab wounds had healed, pulling cholecystostomy tubes, redressing incisions from ventral hernias, and checking out patients to determine if they would be ready for a surgery to reverse their ileostomy and regain bowel function. My last patient of the day, of the rotation!, was one of these, and as soon as he came in the room he lifted his shirt to show me how his ileostomy bag was leaking and fecal matter shot all over the room – all at the same time that I noticed that his computer file was tagged for VRE (vanco resistant enterococcus). Afternoon rounds were my final chore – and I was with a different chief, I had never worked with before, one who pimped the shit out of me for 30 minutes straight, before I could go home…relax, study (!!) for the 2 tests I have for the rotation this week. Just this past Sunday I was in the OR at 2am being pimped by my attending on the pathophysiology of a pneumothorax as he sat on a stool at the edge of the room and said “I am not leaving this room Juliet until you tell me WHY. THIS. MAN. WOULD. DIE!”

But today, as I sat at home trying to review all of the information for my tests tomorrow and Friday I thought a lot about what this 8 weeks has been for me. I have been tired – yes, getting up at 3 am is no fun, no matter how you look at it, I have been bone cold at 4am in the hospital on call as I tried to get some sleep in a discarded chair in the hallway, more than frustrated with peer dynamics on this rotation (think gunners extraordinaire!), I have felt nervous and foolish, and even stupid at times when asked questions, forced to answer questions under any and all circumstance….but I am going to miss it I think. I have learned so much, SEEN so much, and honestly – I NEED that pimping…those moments have made me a bit tougher, but more importantly, have forced me to think for myself rather than just regurgitating information over and over again. All I can think of is that there are more days than I can count that it was 1 in the afternoon or 3, and I was looking at the inside of someone’s neck, feeling their jugular with my finger, or seeing the inside of a person’s abdomen, their liver and gall bladder…and thinking – now, this is so damn cool! What is everyone else doing at 3pm on a Tuesday? Definitely not this!

Anyway, I have thoughts and opinions about this rotation – more than I can write here, or want to write right now, since I should be heading to bed b/c of my test tomorrow morning…but, as stated before, I have stories and things to write about all of this…with the hope that I only can portray or describe it all accurately…more to come….!

Surgery Teaser...

2009-01-11T13:50:00.001-08:00

Wow. I have not written in here for so long, and it is funny - it is not because I do not have anything to write, but because I am so, so, soooo tired during this surgery rotation….3 am wake up calls almost every day (a good day being when there is a 4 starting out the number that is my wake up time, man that IS glorious!) and sometimes 16 hour days or longer. I have a lot of thoughts on my experience, and a lot to write – and promise to do so soon…maybe this weekend, with my unexpected day off looming ahead of me; MLK Day. I want to have time to really express to you all what I am experiencing, seeing, going through – I promise it is interesting! More to come soon….!

Loss.

2008-11-12T09:48:00.000-08:00

For the past few days I, we, have been mourning the loss of our dog Osita. ½ black lab, ½ Samoyed, she was a presence that most people loved, if not remembered. She was the fluffiest dog around, almost all Samoyed in looks and behavior, except for her black color and completely lab ears. She smiled at everyone, and most people would say she licked everyone too, with her big Sammy tongue. She barked and squeaked to communicate with us, even up to the end. It was clear that Steve and I were her pack, along with Oscar, and nothing made her happier than being with us – whether it was at the beach, on a walk around the neighborhood, or even just lazing around watching TV. When I was alone at home she almost always moved with me from room to room – wherever I chose to settle down and study, she would be there too.

I had Osi for the past 10 ½ years, getting her just after I graduated college with my degree in Anthropology. I was working for one of my professors and her colleague had Osi’s father – a big black lab, and her neighbor owned the mother – the Samoyed. I had been hearing about the litter of puppies that were going to come for weeks, and it turned out that the litter was big – 8 puppies in all, with 3 that remained unclaimed. I went, with my boyfriend at the time, and we each picked out a pup. The whole litter was a hodge podge – some white and looking like labs with a little Samoyed curl to their tail, some looking like black labs entirely, some fully Samoyed looking, like little white cotton balls, and some with fuzzy black coats and curly tails, with white spots on their chests and toes. Osi was the blackest of the fuzzy puppies, and as I watched her she was the feistiest – sparring with her mother, and running around the yard with an old beer can clenched in her puppy teeth. From that moment on, she was mine. She accompanied me through thick and thin…through my life for the next 10 ½ years…through moves to Ohio, and then back to Maine, through the decision to go back to school, through bad boyfriends, interesting boyfriends, through strange jobs and tackling another degree. She was the one constant that I have had during a time in my life fraught with change. There have been many times – due to family dynamics and upheavals – that I have felt very alone, and my consolation and comfort was cuddling up with my big black dog. I remember just meeting and getting to know my husband, Steve, and how – when he first came to my apartment – I told him that we could not be friends if he did not like Osi, if Osi did not like him. Throughout the years she has always been there – living half her life in Maine, and half her life in Boston – adapting to it all, fine as long as she was with us. She was happy running through the woods behind the university, accompanying me on cross country ski afternoons, and was also happy prancing through the north end meeting tourists and happy…more than happy!, to pick up left behind pizza crusts and the bread and rolls that always seemed to be left out on the street there. I, always having problems sleeping at night, would frequently go and curl up with her on the floor or on the couch with my head on her chest – for comfort about my current worries or just the comfort of being with her…her and I.

I know that this may appear to bear no direct relation to my experience in medical school, but for me, in thinking of Osi, and remembering her, I cannot remember my trajectory through the past 10 ½ years to get to this point, where I am today, without her there as my constant…as a source of happiness for me during a time when all was, if not happy, then stressful, and a time when I questioned a great deal and did not always feel sure about where I was going or what I was doing. My life has always been marked with dogs…dog moments, but Osi was my first dog that was just mine, and I had her for my entire adult life. It feels strange to not get up and see her staring at me over the edge of the bed, wanting me to wake up, wake up!, or not having her there to greet me as I walk through the door, no matter what time of day or night. In every part of my life in the past 10 ½ years I have met and made friends, most of whom met Osi and loved her, and med school was no exception. I was asked about her frequently, because it is rare in med school that people – even if they want dogs, or are great dog people – have the time or the energy to have a dog. I was lucky, because Steve was able to take on most of the care of both Osi and Oscar, and in this way I was able to enjoy them both, despite being debilitatingly busy. I had people ask if they could meet her, or when they could come over to our apartment again and get a “dose of Osi”. She made not just me happy, but other people too.

What I can relate back to medicine, and med school however, were the moments we had with her at the end, those few hours that she was at Angell Memorial. Dogs are not much different than humans, and it came out in conversation with the vet that I was a third year medical student. She seemed relieved, saying that it made it that much easier for her to explain what was going on – and she began to share, in detail, all of Osi’s results…her lab work, and her x-rays. As I stood there staring at her films, lit up on the wall, it was horrifying because I knew that fluid filled lungs, so full in fact it was hard to even see her heart, were not a good prognosis. And when we were called back in the early morning, after the vet had tapped her abdomen and found blood, I felt sick with the knowledge that this was it. I could feel myself turning on my more clinical self…physically could feel myself clicking over to it almost…as we were led back to the ICU and found Osi lying in a cage with oxygen pumping in, and multiple lines inserted into her front leg for recent blood and fluid transfusions. Her chest was shaved and you could see the puncture marks where they had attempted to tap her lungs. Steve and I knew we had to make a decision, and we did so with the information the vet gave us about a probable burst hemangiocarcinoma, and after watching Osi and sitting with her for a few minutes, we could see that she was so clearly not herself, as she panted heavily and worked hard to breath. I could see that Steve struggled to hold back sobs and tears as we put her to sleep, but it was almost as if I shut that part of myself off, just letting myself hold her and pet her…watching the vet insert the needle, empty the syringe, and I waited for Osi’s last breath. I wanted to feel her fur, lay my face on her furry neck near her soft ears that I loved, but I did not really cry, or even let myself feel sadness…a fact that changed in the next hours and days as I woke up crying in the mornings, and cried myself to sleep at night. I can look back and very clearly see how I clinically turned my brain off in that moment, went to a very different place to deal with it all. Steve has said in the past few days how surprised he was, how hard it was to see her in that state, shaved, and with the lines in her leg…something I definitely registered, but more so after the fact. This made me think about how I have been learning, and have been trained to deal with seeing and experiencing traumatic events and moments– whether with humans OR an animal, it is very much the same I think – and how greatly that differs, in perception and impact, from someone who does not see these types of things day in and day out. It may be different…different than how I would have dealt with this a few years ago - most certainly, but I can say it does not at all dampen the feeling of loss or the heartache that comes with it.

I am heartbroken about the loss of Osi, and have been struggling over the past few days to re-adjust to my life without her in it, especially as she was such a constant force in it, and for me, for so long. I know all about the ideas and thoughts on dealing with loss and experiencing bereavement, but that does not make it any easier, or less of a burden to carry. I know that loss is very much a personal thing, and I am trying to comfort myself with great memories of a unique and very special dog. One of the reasons that I think this is so difficult is because pets, in my case dogs, and for me especially – Osita, provide you with joy and happiness that is complete and comes without any strings attached; it is a relationship that allows you to open your heart fully, truly, and without restriction – something that is, and has been for me, an anomaly in the world of human interaction. This is, at least, the way I felt about Osita, and I very much – more than I can truly express really – miss my furry smiling companion in life. I have felt, over and over in the past few days, that a large moment in my life has come to an end, and I guess that is true, as now she is gone – my most favorite canine companion, and a link to the past 10 ½ years of my life – my dog, whose presence is in the background and marks each memory in some way, of where I have come from, and how much I have grown and changed. I just miss her so very very much.

Dealin' with Feelin'

2008-10-31T11:03:00.000-07:00

I recently had dinner with a friend, who was – at the time – in the middle of her psych rotation. She told me of this patient – a girl who was 17 yo, and – while I had been on my pediatric inpatient service – had been diagnosed with stage 4 lupus nephritis, in addition to her already pre-existing diagnosis of sickle cell disease. Members of many different medical teams had collaborated on her care – peds, heme, renal – needless to say, her prognosis was, and is, pretty dire. My friend was telling me how this patient was now hospitalized again, this time under the ped psych team, as she had gone psychotic, and had become irrational and even, at points, physically abusive. After hearing this news I was just so sad – I mean, our team covered this girl the entire time I was on inpatient service…she has a huge burden to bear just medically alone, and it was projected that she most likely will not live past her 21st or 22nd year. Yet, she was also a foster child, trying to fit into her foster family, and also worried about starting her senior year of high school. She was not even my patient, yet the impact of this new news, in addition to what I already knew about her just made me feel…heavy. I guess I just don’t know any other way to describe it. I just felt heavy with emotion about her, about her life and her situation, and it raised the question for me about dealing with all of that emotion…that sense of feeling so much when dealing with patients, planning out their care.

We are constantly given lectures and readings, even forced to participate in numerous (ridiculous) role-playing exercises asking us to examine the idea of empathy and compassion in patient care. Recently there has been a huge surge of talk about burnout in the medical field, as a physician, and as a medical student, and how this translates into how we care for, treat, and deal with our patients (see the recent NYTimes article, “Medical Student Burnout and the Challenge to Patient Care”). As for myself, I can most certainly attest to the fact that the burnout is real – a huge issue, and one more related to the way of life you are forced to lead as a med student – tedious, but, at the same time, more stressful than can possibly be imagined, as you are forced to learn super human amounts of information at breakneck paces, deal with daily competition and peer over analysis as you worry constantly that you just don’t know enough, or even worse – may fail, and the lack of time to enjoy, or even on a much more basic level – deal with, anything else in your life that does not pertain to medical school. The first two years of med school fit this description to a T – creating a level of stress and unhappiness I can now only somewhat begin to identify and digest, coupled with the added realization that this training, and the feelings that come with it, is not something that those who have not experienced it themselves can truly ever really understand.

For me however, this has not impacted my thoughts and feelings on, or how I perceive my own empathy. During those first two years of schooling I constantly told myself – just wait, just wait until you get to 3rd and 4th year…your clinical experiences, then this whole experience, this process, will all finally start to make sense; and you know what? It has. Despite long hours, lack of sleep, interactions with “mean” and spiteful residents, things are finally falling into place for me – I am allowed a glimpse back at the reasons I truly wanted to head back to school to become a doctor in the first place. I do not feel burnt out as much as I feel like I am finally, finally!, heading somewhere, moving forward, despite – yes, still fully admitting to lack of sleep, feeling useless some days as the person who knows the least on the team, and wary of constantly having to re-prove myself on each new rotation. Yet this kind of tired, this kind of weariness, the physical, and huge amount of mental, exhaustion is something about this whole med school process that is finally making sense to me. Not only that – but I am, at last, allowed to deal with patients, to see them in the capacity of a provider, and to be a crucial component to their care. So, in being allowed this privilege, this access into these unguarded moments of peoples lives, I once again come upon that idea of empathy, feeling, and emotion…how to deal with it, how much to let into a patient encounter, how much to acknowledge internally, but set aside in the face of dealing with crucial clinical and medical information and results. And, in the face of all of these lectures, talks, role-playing exercises, and articles dealing with losing empathy – how does one strike that fine balance??

Maybe I ask this because – well, let’s just face it, I can be emotional…someone that, despite their best efforts, become emotionally involved in situations. The human element (god that sounds lame, but what else can I call it, that IS what it is!) has always interested me; people’s lives, how they live them, what they do, how they feel, their culture, their family, their circumstances – every detail…because every single person has a different story to tell. I am, essentially!, “nosy” about it all; an avid dissector and analyzer of human life. Maybe that is my inner anthropologist coming out…actually I know it is, and it is also one of the reasons I wanted to become a doctor. Yet, I have found, even in just the past 5 months, that sometimes what you learn about a person can leave you seeing them in their most basic and vulnerable state, and – for me at least – this can open up a flood gate of emotion that I don’t always know how best to deal with, and can sometimes just leave me feeling floored.

If you refer back to my story of Baby W you will remember that this is an issue I struggled with when caring for her. It was actually my time in the nursery that made me really feel that peds was not something I could specialize in. I mean yes – I am not thrilled about having exam rooms filled with screaming kids, but I did have a great time with my adolescent patients, and had encounters with them that definitively and positively mark that 6 week time period in my memory. However, when seeing those babies, the most helpless and defenseless human beings, who were put in such horrible positions at the very beginning moments of their lives – well, I just walked out of there every day thinking that yes – I was feeling so much, I needed to hold on to it…but how?? Years and years of seeing the type of situations I dealt with while caring for Baby W, feeling all that I felt…I just had a sense it could be too much, would just be overwhelming, and could change me – because in some ways, you have to harden yourself when seeing that kind of thing day in and day out, just in order to survive.

Don’t get me wrong, I love feeling the emotion that is generated in some patient visits, I just am interested to find how I will hold onto it – the right amount to keep me motivated and fired up…but with enough balance to not let it eat away and worry at me…take something away from who I am and how I act as a doctor. I had a moment a few weeks ago where a 22 yo came in for a broken toe, but when the doctor and I went to visit him together he said – you see Dr. C, I am still here, I made it to my 22nd birthday – with a shy smile on his face. When looking at his chart I saw that he had numerous past issues with suicide and depression, so many, that it was amazing that he was sitting in front of us, only concerned about a broken toe…..in the same office I also learned about a regular patient, a breast cancer survivor, who had come in at the beginning of the summer complaining of hip pain. Tests were done, and she was examined and determined to be in good health. Yet, in her follow up visit last month she provided the office with recent results from her oncologist which proved that her cancer had metastized everywhere – her long bones, skull, and to various organs – and was the reason for the hip pain and discomfort she had been feeling 3-4 months ago. She was a wife, and mother to young children, only in her mid-40’s, yet will most likely not live for very much longer…I also saw a 16 yo boy, a big football player who came in with his mom, and who was complaining of a headache that had lasted for 2 days. After performing a complete cranial nerve neuro exam (and finding him to be completely normal) the doctor, who was friends with their family, entered the room and began to discuss why he thought the headache was occurring. It turned out that the patient’s parents were recently going through a divorce, his father had left the house for good a few weeks prior, and this boy was devastated. His mom told me how he was the oldest, and was worried about his brother and sister, and also worried about her, but that he wasn’t paying much attention to himself…not sleeping at nights, and had quit playing football. All of this information, within 30 seconds, brought this big, and seemingly tough, guy to tears…he sat there, so obviously embarrassed to cry in front of me, but simply physically sagging under the weight of all that he and his family were going through, how responsible he felt he had to be for everyone...in the hospital, one of my main patients on the peds inservice was an 18 yo girl with HIV contracted en utero. She was hospitalized due to issues related to poor med compliance and resulting cryptococcal infections, and then, as we treated her, management of acute renal failure and other concerns related to her medication. I loved being the student assigned to working with her – it forced me to really think and learn as I had to understand daily lab values, and got the chance to work hand in hand with the pediatric infectious disease team. Yet, I also really liked her…she was a great teenager, and we talked about music and boys, her sisters, her friends at school, what she wanted to do when she “grew up”. We became friends, and many days the nurses would come to me when they needed help with her care. Yet, the reality of her situation was truly serious, and the ID fellow described to me, in great detail, how she had exhausted 10 different HIV med regimens, and they only had 2 more they could try. Her strain of HIV was incredibly resistant to treatment, due to past med noncompliance issues, and imparting all of this information to her, as well as to her mom was just so hard! She would tell me – I wish I never knew I had HIV! (it had been kept from her until she entered junior high) and I don’t LIKE taking all those pills – as she consistently refused either her medication or her daily potassium or magnesium supplement; even though I tried to explain to her again and again why they were so important. Her mom would laugh and say – I know she needs to take her meds, but she is a typical teenager, she does what she wants…which was oh so true, but it was also oh so true that her entire future really depended on her going home and staying compliant……while in the family planning clinic I met a great woman, who was fun, open, and talkative – essentially, the best kind of patient, one who does not mind that a med student is involved in their care, and one who has no problem talking about or sharing their information. She was there for a follow up appt. after placement of an IUD a month ago. She had had 2 abortions in the past, and told me how she was trying to get her life on track, with school and a job, and did not want to be in the place she was in currently a few years from now. She had finally decided on the IUD so she could “be in charge and responsible” for her contraception, something she said her boyfriends have not cared too much about in the past. She did not want to be pregnant, but additionally could not afford it financially OR in terms of her health, due to some serious pre-existing medical conditions. Yet, she said she was a bit worried – her breasts were tender and she was feeling “funny”. We did a pregnancy test, and also an ultrasound, which showed a small fetus, sitting right on top of the plastic T of the IUD in her uterus. When we told her that she was pregnant again she was inconsolable, crying and sobbing that she had tried and tried to be responsible, how could this be happening to her again, she was heartbroken and horrified that she had to undergo another D&C…

You see – all of these encounters, and more, too many more to write here, have impacted me, have made me feel so much…so much so that I truly would identify them as being huge moments in shaping me into the doctor I will be. I want to hold on to them, hold onto all the feelings associated with them – the humor, the sadness, the rage even, but I want to also learn how to keep this in check, establish a fine balance, something that really seems to be pretty tricky. I just never want to lose it, as so many people worry about and attribute to burn out, or becoming jaded, because I truly, truly think that would mean I would be losing a key component of who I am, doctor or not.

Snapshots

2008-10-22T21:11:00.000-07:00

Sometimes it is hard not to see this experience as a compilation of moments…some hilarious and ridiculous, others humbling and moving, and others disturbing or even startling. It is as if I am putting together a mental photo album of all of these bizarre events…bizarre because I really would not be privy to most of them if I was not heading into medicine…or there already, at least to some extent! Anyway here are a few “snapshots”, 5 at least…which are some of the more amusing events I have been a part of in the last few months.

…getting punched in the face by my attending during a vaginal hysterectomy (to be fair, he was removing one half of the hemi-sected uterus with tenaculums that…well, they just slipped!)

…during the same vag. hys. being told by my (very proper) attending: “retract Juliet, retract!! Juliet, when I was in internship we would rotate these procedures and would do up to 8 a day…a good work out, isn’t it?? We all knew to increase our gymnasium activities and prepare with 800 mg of motrin prior to surgery…come on Juliet, keep retracting!!” – all this while I pulled with all my might, using only one hand, on one side of a woman’s vagina with a giant metal retractor for hours and hours…the whole time imagining that if I did this day after day, I would look like those sailors who have one arm that is bigger than the other from pulling rope with the same arm over and over and over again….

…one night on call and checking in on my NAS baby (neonatal abstinence syndrome – a baby that had been exposed to methadone en utero and was weaning off of it…i.e. essentially detoxing after birth, so they, and their mom, stay in the hospital for up to a month or more while this process takes place) who just happened to have 2 moms. I knew that they, as a couple, had very limited financial resources, and I was always curious as to how they got pregnant – especially when reading through their chart and finding the notation – “they have been trying for 2 years”. I wondered how they could find the money for a sperm donor, what options they had pursued…well, no need to ask – they were happy to tell my intern, in GREAT detail, how they had enlisted all of their gay male friends, one after the other…gotten “samples” and a turkey baster…and a few dozen tries later…well, here they were…!!

…getting ready to d/c the same NAS baby….The moms and I have become friendly after all our time together; they had been there for a month, and their son was my patient for my entire inpatient peds experience…Anyway, NAS families frequently get roomed with other NAS families while on the ward. This, their long stay, the fact that many of them are very young, coupled with the issue of many of them knowing each other already from treatment clinics around the area, lends itself to much, MUCH drama – think: freshman girls dorm x10. As I was getting ready to say my goodbyes one of the moms decided to give me their “scoop” on the woman they had been sharing a room with, who had recently accused them of stealing an outfit from her baby, and some other things. The mom was livid – telling me why would she steal a thing from that (please fill in the blank…using many many expletives prefaced with crack or junkie…etc, etc.) as her brother was in a famous boy band and money was noooo object! She then proceeded to pull her credit card out of her wallet and wave it around while she stomped around pointing with it to objects saying “see that?, I could buy that, and that, and THAT!” (also interesting to note when picturing this scene is that she dressed - daily - as a white female version of flava flave, minus the clock around the neck of course, but coupled with a long, long mullet. This day was definitely not an exception)…needless to say it was a lengthy goodbye for all of us, a sticky mess to extricate myself from – and then the next day I found out they had stolen things from the patient kitchen on their way out for good. Go figure.

…Me quickly realizing in clinic, that – to treat children you are almost required, daily, at almost every visit, to act like a child – talking in baby voices, making ridiculous overly emotive faces, making funny sounds to get their attention, try to keep them from crying, moving away from you, biting you…the worst was a day when I had a child who came to see us for a follow up appt. regarding her ADHD meds…how well were they working, etc. She began to apply Disney princess stickers to her face…then to MY face…screaming every time I tried to move away from her…since she actually seemed to be focusing on something (anything!), I let her continue…all over my cheeks, my forehead, my chin…what else was there to do – right? The room was filled with her other 3 siblings, all younger than her, who were just feeding off her energy. So, there I am with Disney princesses. All over my face. All over. And I turn away for a second…she pulls all the tools off the wall…the BP cuff, the otoscope, the ophthalmoscope, flailing around…flailing and flailing…at this point (if you know me at all) I am freaking out and trying not to show it…I mean, small room, mom, 4 kids, me…disney princesses all over my face. Time to do the physical exam…it is TIME. At this point I realize that this girl, this 9 year old girl, has put all of the instruments in her mouth. Anything that could fit in her mouth had been in her mouth. So there I am, covered in Disney princesses, trying to maintain order, puffing balls of saliva out of the otoscope with the bulb to test the tympanic membrane in order to clean it out while she laughs and laughs. I mean…really…REALLY?! I told her that what she had just done was disgusting, unhygienic. In general – yes, but also because my last patient had an ear infection with green goo coming out of his ear and I had stuck that same otoscope, the one that she had sucked on, into his ear. Did she want green goo in her mouth, did she?! I knew I didn’t. Wow. I mean, the exchange with her wasn’t so, so bad…but it was one of those moments where I was just like – whoa. Whooooaaaa. This may just be what Oprah calls one of those ahh haaaa moments or whatever the hell it is, because I CANNOT do this. Cross this specialty off my list. Right. NOW.

Endless Hallway of Hypertension

2008-10-09T13:02:00.000-07:00

So, here it is – the end of week 5 of my family medicine clerkship. I have held off writing about this specific experience because, unlike other clerkships I have had so far, there was not much about this that initially jumped out at me, if anything I think I initially felt – despite rushing and rushing to see the huge amount of patients we schedule each day – that the whole process was slightly monotonous. To be honest, that alone really bothered me, because it was the idea of family medicine, healthcare for the community and all that jazz, that really appealed to me initially…on paper anyway.

So – where am I, what am I doing from day to day? Well, I am in a small family medicine practice north of the city, where our patient population is primarily white and middle class. I actually had my first black patient two days ago, a Haitian man, and my first, and only, Hispanic patient last week, a woman from the DR. I make this point because this is a huge…HUGE difference from what I was seeing at the hospital on a daily basis, and the lack of diversity was actually a bit disconcerting at the beginning of this rotation (mainly considering my overall preference to one day be practicing medicine in a more urban, culturally diverse setting). The practice is run by one doctor, who also has a nurse practitioner seeing patients a few days a week. It is in a small building, not attached to any hospital, with 3 adult exam rooms, and one pedi exam room available for him to see patients in. The equipment he has is all his own, as it is his own practice. It is functional and efficient, but definitely not as up to date as what is being used in a larger hospital based clinic (think EKG machine, UA machine (urine analysis), scales, etc.) I don’t know if it can be conveyed properly how small it is, but it is SMALL. Despite that, the doctor, Dr. C, has thousands, yes – there is an “s” at the end of that! – thousands of patients on his patient roster. Another thing that is different here is that drug reps are allowed. On our hospital and med school campus they are not allowed at all, and there are many physicians, students, and medical professionals in general who have very strong opinions about that, and the influence they can have on patient care and overall management, so it is interesting to actually see the converse of that picture. And what else?...well, another good point to make as I describe all of this is that there are many, many students here. There are 4 NP students and 3 med students rotating at the office now. Initially I had a huge issue with this – thinking that there would be a lot of down time, or less time spent with patients, but really, we are so crazy busy that it very quickly became apparent to me that Dr. C actually NEEDS that many students to help him run the practice day to day.

So. That all said – the stage is set so to speak – what is it like, what do I think of it?? Well. I really have come to believe that the idea…the ideal even, of family medicine is so much better than the reality. And this is a touchy issue as, anyone in health care now, or in medical school, can attest to, there is a huge shortage of primary care physicians out there, not just in MA, but nationally as well. We as students are constantly being barraged with emailed information about family medicine, primary care as an option, and in this rotation it is almost as if – if you don’t jump on the Fam. Med. Bandwagon, then you are pretty much dismissed – at least amongst the faculty that teach and run our weekly didactic sessions. And, it is true, when they talk to you and lecture on what family medicine can be like, how fulfilling it is to watch a family grow over time, and to forge lasting relationships with patients, and within a community – well, that sounds really wonderful, and I am actually able to see that from day to day between Dr. C and his patients. He knows and most likely treats a patient’s entire family, knows of births and deaths, family happiness’s and family stresses; and being allowed to be part of that via my experience with him has been a gift. Just by my association with him, I am trusted and confided in very quickly, and have developed relationships with patients I have seen multiple times already that would have maybe taken longer if I did not have him, in a sense, paving the way for me. Some of my favorite patients in this setting have been the women he cares for, and the geriatric patients he sees regularly. I have received a lot of hugs and kisses on the cheek lately, some even accompanied with a few pats of the cheek or shoulder for good measure, as they tell me I am going to make a very good doctor; and that truly has been one of the most rewarding aspects of this clerkship, no matter what else I think.

So, what else DO I think? Well, first – the infamous 15 minute visit. Now really…REALLY, how the hell are you going to treat, even see and address most patient’s issues in 15 minutes?? It is very, very difficult, and daily we get behind, sometimes up to 2 hours behind schedule, especially as there are many patients that get double booked, or added on as they call in for appts. that day. So, what do you do? You need to see all of your patients because you need to make money, but then you end up cramming them into a schedule that is already overflowing. The impacts on patient care are obvious, but there are impacts on providers too. The constant rush from room to room can be mind numbing and overwhelming, and you can begin to feel that the emphasis is to just “get it all done as fast as possible”. You need to chart everything as you go, which means typing while you are talking, and I have struggled with this every day…thank god I can type quickly and without looking at the computer, because I feel it is so inappropriate to have a patient trying to tell you their health concerns and you do not even look in their direction, let alone make eye contact. Additionally, we see patient after patient after patient with type II diabetes and/or hypertension…and there have been some days that I have felt I am endlessly running from room to room asking people what their home blood glucose readings have been, talking about diet and exercise, and examining feet for new lesions or neuropathy (the oh so fun diabetic foot exam). This can be frustrating because it is so much of the same, and there is also frustration that is generated from the fact that many of the patients I have seen are non-compliant in some way, whether it is with their actual medication, or with their diet and weight management. The reality is that much of health care now is management of these types of chronic diseases – DM II, hypertension, hyperlipidemia – that are actually preventable to a point with lifestyle changes, and maybe that is why I find it all so aggravating. I also, slowly, am beginning to realize the emphasis on billing and tracking these patients, in terms of a small family clinic, where getting paid for everything and anything counts. You tested someone’s urine, you did a pulse ox? You better make sure that is checked off on the billing sheet. You had also better make sure that you charted each exam under the correct heading – you get paid more and differently for a diabetic maintenance exam vs. a well child check or a sick visit for someone with sinusitis. I understand that there needs to be emphasis on this in order for everyone to get paid, and for the office to keep running, but as I have seen patients over the past 5 weeks I have wondered how accurately we have covered certain issues that are checked off in the patient’s note for that visit, rather than just checking them off in order to bill for them, or even further – so that it is logged for a better grade for the practice (DM II patients are tracked, and family practices that treat them are graded regularly – in terms of how well their patients are doing on weight, BP, cholesterol levels, sugar levels, hemoglobin A1C values, etc., and this grade impacts a number of things for the practice in terms of its relationships with other providers and affiliate hospitals under the same provider network). Additionally, there is no way, no possible way that this practice could run without the help of the students – the patient load is just too great. And, even with all of us there, there is very little to no time set aside for teaching, we simply run all day long from room to room to room.

And then finally – the drug reps. A different rep is scheduled to provide a free catered lunch every day, they all bring free pens and paper (I think I have enough pens now to last me until the end of time and beyond), and sometime bring us free coffee in the afternoons…lattes from starbucks or a giant vat of coffee from dunkin’ donuts, and of course they bring free drugs. The amount of free samples we give out is endless; we sometimes give patients plastic grocery store bags filled to the brim with boxes of drugs. This is the first time I have really been around anything like this, I mean – when I worked in the lab, we had free chocolates from perkin elmer or qiagen because they were trying to entice us to use their pipet tips or quick ligation or pcr kits, but that does not even compare to what is going on with these drug reps. The sheer amount of money that is spent every day, simply in order to feed an entire office, with the hopes of selling more of their products in the end, is just astounding. On one hand it could be argued that patients with no insurance or poor insurance coverage truly benefit from receiving samples rather than having to pay high prices for their every day medication. However, on the other hand, I wonder – are we just pushing drugs on patients, prescribing one thing over another, simply because of a contract with a certain company? It is a very fine line, and one I think about a great deal, as I see us prescribe a lot of the same brands or same drugs every day, knowing that they are effective, but not being able to take the time to really explore the alternatives. I don’t think that Dr. C would let this get in the way of ultimate patient care and management, but I can see, very clearly, how this has become a controversial issue in health care, as I am sure many non-discriminating physicians have been quick to prescribe things based on relationships and deals they have with various drug companies vs. taking the time to find something that is more suitable.

So – ultimately, how can a busy practice provide uncompromised care, while still being able to bill for all the services it provides so it can stay afloat? It seems like this is really the bottom line…and why we are seeing so many patients, all day, ever day, why all primary care providers seem to be doing the same, and why they need an influx of physicians into the field. Obviously there is a huge demand vs. available resources right now, but having this experience day after day – and only for 6 weeks total – and already feeling weary of going into to the same thing day after day, week after week, well, that pretty much tells me this is not for me. At least this setting – the small practice, the rushing, the lack of contact with other physicians, and the overall emphasis on charting and learning the ways of the computer system and billing over spending time with patients…I just can’t see myself here. I can’t even say, after experiencing all of this, that I feel that a huge influx of doctors into the field will fix all of the problems that we see with primary care. The health care system overall is just…well…it is just “off”…and I think some bigger changes, more than a few hundred doctors surging into one field is going to be needed to impact it in a positive way. But, that is just my humble opinion. However, this editorial expresses a lot of relevant issues in primary care right now, makes a lot of good points, and is definitely worth a read:

http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2008/05/29/the_crisis_of_primary_care_physicians/

And while your at it, this is pretty interesting too, and highlights some issues I have seen specific to MA, and the primary care problems out there today.

http://www.thehealthcareblog.com/the_health_care_blog/2008/07/primary-care-cr.html

Passion and Balance

2008-09-28T12:48:00.000-07:00

I have been thinking a lot about the idea of passion – passion about your career…about life….just having passion for anything! And I have also been thinking about the idea of balance. Two friends, one responding to this blog, and another responding to a recent email both wrote to me a few weeks ago, each mentioned one – passion and balance. And, just recently, a rather heated conversation with my father occurred, regarding much of the same thing. These are topics I don’t really think about in the direct sense – like daily listing out my passions, or worrying to myself as I drive to the hospital if my life is balanced, but I do think about them frequently as huge components in the larger picture - the sense of what they are, what their meanings truly encompass, and how that applies to me, my life, and my choices.

I cannot think of many other choices in my life that I have reassessed, reanalyzed, over-scrutinized; sometimes daily, sometimes even hourly it seems like, other than the choice to go to, and be in medical school. This involves a lot of thinking about – is this the right choice for me, will I be happy, is all of this going to be worth it in the end? And by “all of this” I mean…god! – I mean everything. I think it can be so easy to be swept up into the idea of a career or a life choice, the novelty of it all, its uniqueness, and sometimes even what the definition of it means to the world, how it will define you and how you will be perceived by society, those around you – and I can tell you, even just from the perspective of a person who is ambitious and self motivated, being defined by being “Dr. so and so”…well that has some weight on its own. But, really…can that sustain you?…and I think, for me anyway, the answer is no…the idea is really just that…just an idea, and until you start really living it, being a part of the experience yourself, you never really know what it is going to mean to and for you, and your life.

And so, to get back to the “all of this”. Well, hell. The “all of this” are the components of the equation that you can use to factor if you have balance in your life. And no, I am not going to, please excuse the phrase, blow smoke up everyone’s ass about how this process is the greatest thing ever, because in many ways it is not. And a lot of that boils down for me to the idea of how I feel, how I want my life to be balanced – I want to be physically fit –again!, be able to spend time with people I care about more than a cursory phone call or email, read books, see movies, have time to cook, etc AND etc. That said though, I think, the idea of a life in balance, is truly a very personal definition for everyone…something that is not standard or textbook. I constantly think how med school forces you to look at how people – patients – live their lives, how to counsel and teach them about what is healthy and not healthy, yet this whole situation, this training process in order to become a doctor, is not really that conducive to the person going through it being able to live a healthy lifestyle; in many different ways ranging from the physical to the emotional and psychological to even the financial (ohhhh a whole other topic – the financial burden of paying for a medical education).

So, do I think my life is balanced? No, honestly right now I don’t, although I can say it has changed even in the past 6 months, it feels a lot different now, in this 3rd year clinical setting, vs. the 1st two years of classroom learning, and the overwhelming amount of material we were forced to think about, learn, and memorize at an astounding, almost super human pace. Now that I am in the clinical setting, I can see glimpses and experience moments of what my life will be like in the future, in medicine – and that reality, well it can be pretty exciting, and, really, bring me back to the basic reasons I chose to go back to school to become a doctor in the first place. And – I guess that is where the idea of passion comes in – right? I mean, who does not want to be passionate about the things in their life? – and for me it is not just “nice”, but is necessary to be passionate about my career, especially when I have chosen one that has the potential to be so absorbing and life altering. So, because of this, almost every moment I have to myself, I think – can I see myself here, could I be doing this 10 years from now…20?? Will I be interested, involved, passionate about being in primary care, or being an internist, or working in ob/gyn, or peds…what will sustain my interest?? Do I like small clinics or the hustle and bustle of the hospital? Where will I be happy, where will I get the most satisfaction? Because – if I can’t maintain interest, or passion about what I do, then that impacts the balance of my life, how good I will or will not feel about myself, which then will ultimately translate, pretty strongly I think, into how I do my job as a physician, and how I deal with and treat my patients.

I have slowly come to understand and realize that this experience is a fluid thing, and that I just need to try to flow with it – at the same time recognizing what I want, what I am lacking, and where I want to be. The days of sitting at my desk for hours on end drinking endless cups of coffee and trying to memorize a list of 20 drugs, tumor markers for various types of cancers, and the coagulation pathway for tests the following week has mostly come to an end, although I remember feeling then like it never ever would. Each day is a work in process – to achieve my ideal balance, to find a genre of medicine that makes me feel impassioned, about it as a career choice – yes, but also how that will fit into and impact the rest of my life. I can equate all of this to how you can feel when you go for a great run on a beautiful day, and a good song comes on your ipod and you just want to run down the street, singing along and pumping your fist in the air…hellz yeah that’s what I want in my career...and in my life – I want to be singing along and pumping my fist to it ALL!! I am just trying to get there, not ignore the days on the way, and trying to understand what they mean in the larger picture. AND I am trying to get that run in too, damn it!

Baby W

2008-09-18T20:22:00.000-07:00

When I started my peds rotation I thought that I would like it, or even if I did not “like” it – i.e. think it was for me - that it would be fun, I mean, what isn’t fun about little kids – right? What I didn’t expect was how much of an emotional response I would have. It was actually during this rotation, when family and friends were asking me what I thought, what I liked or didn’t like, that I found that many times I still had not processed my day or even my whole week, and would not even be able to express properly what was going or how I was feeling, and so I decided to write this blog. I found that this “slow processing” mainly occurred for me during my last 4 weeks – the first of which was spent entirely in the newborn nursery, and the last 3 when I was on the inpatient portion of my rotation, and was responsible for following a number of patients during their stay at the hospital.
While in the nursery I was responsible for at least two babies every day – taking daily weights, monitoring their feeding – breast or bottle, making sure they got all labs they would need before heading home, keeping track of their output (stool and urine), doing newborn exams, were they jaundiced – what were their bili levels?, talking to the mom, giving them education about what to expect when going home – car seats, fevers, feeding times, etc. etc. This usually went smoothly, and – depending on whether the mom had a c-section or a vaginal delivery – she and the baby would head home in 2 days at the most, and, while in hospital, the babies always slept in the room with mom, so my contact and interaction with the baby was only when necessary. However, on my second day I arrived in the morning and found out that a woman had come in overnight and delivered. She was a drug user – had actually just used cocaine immediately before coming in to the hospital before delivery, and had been using during her entire pregnancy. Additionally, she had never received any prenatal care. She was a G9P5 – meaning that she had been pregnant 9 times, and had 5 living children. The other 4 living children were not in her custody, but did live all together with her parents - their grandparents, and she rarely saw them. This baby was initially going to be taken into DSS custody, while her grandparents went to court to get permanent custody of her. During all of this time the baby lived in the nursery, after the mother was discharged. So, almost the entire time I was rotating through the nursery I was in charge of this baby…Baby W. I fed her, carried her around and talked to her. Her mom came once to visit her, while supervised by nursery staff, but never came again while I was there. It was just so strange – I don’t want kids right now - at all!, have no idea when I will, or when I will be ready…yet, this baby….! She was adorable, big eyes, a full head of soft curly hair, and every day she responded to my voice and would open her eyes and stare and stare at me. As my week came to an end nothing was finalized for her - DSS was still taking over, and no one had actually heard about whether or not her grandparents were going to go to court to take her home. Each day I would go home and I could not stop thinking about her…how her life, at this point, was an unmapped series of moments and opportunities laying in front of her – technically she could or be anything – right? But, I just kept thinking about what her life would really be like – people fighting for her custody, knowing that she and her siblings were not with their mom because of her drug use, the fact that resources for the grandparents (I had met them a few times before the mother had been discharged) seemed scarce. I have to say I think I was a little obsessed with her. On my last day I left the nursery and left her there, knowing that nothing was resolved for her yet – she was still an indefinite “boarder” in the nursery. I thought about her all the way home, and for the rest of the weekend, even getting to the point of thinking – what if I had her…what would her life be like then?? Obviously I knew, distinctly!, that this was not a reality, but it was just so hard for me, knowing that she was in the hospital nursery – a newborn, whose first days of life were marked – not by a loving mother holding and feeding her, or a doting family getting to know and love her – but instead by living in a brightly 24hr. lit nursery, swaddled and laying in a plastic bin, touched only when the nurses were scheduled to feed her or if someone had a moment during their shift to spend holding her.
I kept telling myself that this is not unusual, and that I am going to have to toughen up, knowing that situations like this happen a lot…DSS is frequently involved with children that are using the services at our hospital, or there are families that come in and you find that the guardians of the kids are grandparents, aunts or uncles because the primary parent is not capable of providing the care they need, or is just not in the picture at all. This became more evident on the 1st day of my inpatient schedule, after I had finished my nurserly rotation, when – on my lunchbreak – I ran down a floor to the nursery in order to check on Baby W. Some of the nurses had told me that the grandparents were still undecided about whether or not they wanted to take her, and DSS was trying to push them for an answer, otherwise they would have to find placement for her in a foster home. I was frustrated because another medical student had said to me, “you know, doesn’t it suck, knowing that she will never know how nice you were to her? It doesn’t really matter since she is so young.” Now, I believe it does matter! Even though she was only in her first week of life, it had to have made a difference that I was carrying, feeding, and interacting with her, rather than leaving her in that plastic bin all week long. But, I knew that checking up on her when I was not assigned to the nursery anymore was going to elicit more comments from this same med student, and even from some of the more seasoned nurses and doctors that were there. They appreciated that I cared, I knew that, but they had learned an objectivity, that they were able to couple with a high level of caring, when dealing with these types of situations; something I knew that I still needed to work on. This was only made more evident when I went down to check up on Baby W and there next to her, in another plastic bin, was a little boy. The nurse on duty told me that his mother had come in that morning, gone into labor and would not even interact during the process, telling everyone that she was not really pregnant and that she was leaving….which she eventually did, against medical advice, and leaving her son in the nursery – as a “boader” – without any way to reach her. I checked on Baby W, but did not linger, realizing that it was not my place to be there any more. DSS was caring for her, and so were the doctors, nurses, and new med students now rotating through the nursery. I had to accept that…especially as the new baby next to her was a living example of how she was not the only baby that was, or would be, in the same type situation.
I realized that I definitely had a strong position in the large picture that would end up being her medical care after birth – I had to provide the care and follow up that Baby W needed in the nursery, and it was great that I was able to do more with her while I was there. My commitment to her was to do the best I could, in terms of the medical role that I was assigned to play, and, as hard as it was to wonder about her, wonder – what if? – by becoming more involved, and letting myself think too far beyond what my role and job was, I would be crossing lines and infiltrating other areas of care that were not my responsibility, and to some extent could detract from and impact the level of care I so strongly wanted to provide for her. I was the medical student, and someday will be a doctor, and what I needed to understand and learn, was how to provide care in the best way for Baby W, still be empathetic, caring, and compassionate, but also maintain objectivity and the ability to see the picture clearly, especially from a medical standpoint, and in a way that allowed me to interact with the social workers and other people from DSS so that I could inform and educate them to the best of my ability, while simultaneously getting information from them, recording it for her future care, and incorporating it into the care I was providing at the time – if applicable….definitely a tall order!
This said, I still wonder about her occasionally. I hope her brothers and sister love having a new baby in the house (her grandparents had finally gone to court that day I went to check up on her), and I hope her grandparents are able to do all they are able to for her future. I also hope her mom, who seems to be such a sad and lost component to all of this – a whole separate issue actually, would finally get the help that she needed. I hope…well, I hope a lot of things for Baby W…and I know I learned from that situation, something I will take with me when caring for patients in difficult familial and social situations in the future, but it was definitely a little bit of a heart wrenching lesson to learn.

Me and OB/GYN - who knew?

2008-09-11T13:11:00.000-07:00

So, today was the start to my family medicine experience, and I am sure I will have more to write about regarding that, once I have a few more days under my belt. So – what other rotations have I completed you ask (I know you all are, of course!, just DYING to know!)? Well, I just finished pediatrics, and my first rotation before that, to start off my 3rd year with bang – hazaa hazaaa!, was OB/GYN. I had interesting experiences in both, and have a lot to catch up on in terms of writing them all down. Both of them caught me off guard, in ways I did not expect.

When I filled out my form for the 3rd year schedule lottery I wanted to start with OB/GYN in my first block; I just wanted to get it done and out of the way. And PEDS, well…initially I was looking forward to that. And now, honestly, I don’t know how I came to either of my conclusions, about either field. Maybe part of me thought a while ago that I would want to be a pediatrician, but…dear god. Nothing can be further from the truth right now. And, I also initially thought, hellz no! – OB/GYN is not for me! Now, it is where I am, albeit tentatively (since I still have a few more rotations to go), seeing myself in the future. A little bit surprising eh? And then maybe not so much…I mean, I love women’s health, especially the way it was practiced in the huge underserved population that we see here; it seemed to be a great way to practice positive community health care in a very focused field, and to make a difference in a woman’s life. Also, I am a firm believer in a woman’s right to having a choice regarding her reproduction, whatever it may be; and believe that every health provider should at least be educated about abortion, choices and outcomes, even if they themselves do not choose to become an abortion provider at any point in their medical career. These things already being a good fit, I was surprised to really enjoy being on the labor and delivery floor…having to stop myself from crying at every birth (I think I was forgiven the first one, but at the 3rd or 4th or 10th!...come on!) The family dynamics, when they were present (and to be clear, not every laboring mother has a family, or anyone present during her delivery) were powerful, and, despite sounding cliché – beautiful. The first birth I saw was with a family who recently moved here from Colombia, a natural childbirth (rare to see). A small tight knit unit was there from the beginning – the woman’s husband, his sister, and her fiancée. They all lived together and had moved here at the same time, taking the “All American plunge” as a group. I have always appreciated the Latin family dynamic, loved the closeness, utter inclusiveness, and how everyone is able to rely on one another. I think it is something you notice more in families here in the US who are not as Americanized as the rest of us….something I have always enjoyed observing culturally and also experiencing on my family trips to Puerto Rico, or even here in Boston with some of the friends I have made over the past few years. This family was amazing, each person participating in every part of the birth, and when the baby came out their faces transformed in a way that is almost unexplainable…I mean, I can write that they were more than happy, that they were joyous…but that transformation, the look on their faces…well, it hard to explain just with words, but it was the best thing ever.

And C-sections…scrubbed in and ready to go, a few incisions later, and there is the baby, pulled right out of a giant uterus. Now, the med student never gets to cut…well, we do, but what we cut are the sutures after they have made the knots, no cutting of human flesh. Please! But we do get to put our hand inside the woman’s abdomen, on her fundus (top of the uterus) and massage it so that it firms up and tightens, in order to prevent hemorrhage. With your hand in there, in the midst of organs, blood, and warmth, you can feel the muscles of the uterus contract as you squeeze and push on it…and even though I was able to do this multiple times, I still think it is pretty damn cool.

Even when I did my three weeks of GYN I liked it – I mean, I did not even know what to expect (again!) I guess. And thus it was - surgeries, surgeries, surgeries…myomectomies, hysterectomies, colpopexies (I still do a bad job at pronouncing this), endometrial cancer stagings, laparoscopic procedures….it was kind of endless. But still some of the coolest stuff I have seen. In one of the myomectomies (a surgery to remove fibroids from the uterus) I saw, my first actually, the uterus was the size a 28 week pregnant uterus would be; the muscular walls were embedded with various sized fibroids that you could not initially see, but the largest, which was the size of a loaf of bread (!), extended off of the top of the uterus on a stalk (pedunculated). In order to prevent excessive bleeding, giant tourniquets were placed around the uterus itself, and also around the stalk to the larger fibroid, as it was highly vascularized. The attending and resident proceeded to remove all of them – a total of about 11 or 12, at least 10 lbs. of fibroids, and then reformed the uterus….I mean, at this point it was cut open and required multiple rows and various directions of sutures. It was just crazy though…at the end there was a uterus…again!, remade from the mess they had initially created with the removal of all the fibroids. Crazy shit, I am telling you!

In the clinics, prenatal care and lots of women’s health predominated. I had one day where I had to tell two women in a row that they had herpes, and two more that they had Chlamydia. They were young, and most of them cried…a few of them did not even understand what herpes (a virus) and Chlamydia (a bacteria) was…or how it actually got transmitted. One women, had just moved here from Germany to start college, and had come in to find out the test results from a herpes test she had come in for the week before. It was negative, and I was happy to report the news to her, she was even happier to receive it, but an exam was still needed to look at the ulcers and scabs she said she still had. She said she still could feel them a bit with her fingers, but they were less painful. When I examined her I was shocked by what I saw…her entire external vaginal area and labia were covered with large scabbed sores...I was glad she could not see my face at this point. A full vaginal exam could not even be completed, because it was too painful for her. It was hard for me to equate the calm and well-dressed woman I had been speaking with, to now knowing that she had been walking around with so many clearly painful, and almost obstructive, sores for the past week. I kept on wondering how she did not know, why did she not use a mirror? The doctor I was working with had to tell her that many times herpes tests can come back negative if the sample is taken after the vesicles burst, and that she actually had a classic first outbreak of herpes (when considered with her other symptoms of the past week that she reported – fever, aches, chills, more extreme vaginal discharge). I could not tell how she was taking the news, she just appeared stoic. But, the doctor then left the room and she started to cry and began asking me how this could happen, and then telling me it was simply not possible….she was in an 8 year relationship and she just knew, she KNEW it was not possible. It was definitely a hard moment for her, but hard for me too…in a day of breaking bad news, this was one of the worst, and I just wanted to make sure I was saying the right thing, acting the right way with her…for her. I know she was scared, but I was scared too…at not being “medical” enough, or not being as empathetic and comforting as she needed…was I striking the right balance?? I encountered many more situations like this – and although they remained hard – I think it always will be hard to see someone suffering – I felt, over and over again, that I was working in a field I really believed in, and in which I could make some sort of difference….and my constant weekly clinics were one of the best part of my rotation.

It is true that OB/GYN is famous, or more accurately - infamous, for its tough residents and attendings. It is a field populated 90% by women, who are many times referred to nicely as “mean”, and not so nicely as…well, I am sure you can fill in the blanks. My teaching was tough – no doubt about it, and sometimes almost militaristic in nature…they never really gave us an inch. I don’t know what it says about me that I almost preferred that at times, when compared to the “niceness” that peds is known for, or that I would even consider being part of that “tough, mean, and bitchy” culture for the rest of my life. But, I guess time will tell – right?

To Blog or Not to Blog...

2008-09-09T19:49:00.001-07:00

I have thought, for a while now, that writing down my thoughts and feelings during these medical rotations would be helpful to me – a way to process and really understand everything I am going through. But, I recently started thinking that it might be nice to make it all available to my friends and family (and I guess, now!, anyone else who may stumble upon this by accident) as a way to stay connected. I have found that there have been many days, more of them than not, that I think – Wow. no one in my “real” life really knows what I am doing today, what is going on – the rounds I am sitting through, the patient experiences I am having – the frustrating, the memorable, the laughable and the sad - how I am sometimes frantically trying to keep up with lab results and understand what they all mean, asking myself if I really got all the social history that was important, did that patient not really tell me everything?, should I be “stepping up” or “stepping down” on this kids asthma meds, can a benzo be mixed with that patients current med regimen?, did I really just see that mom smack her kid in the waiting room? etc. etc…the nitty gritty of a med student’s daily life in the hospital…sometimes it is great, sometimes it is definitely not so great, and there are many days that I don’t really understand what I think about it all until much later – because I have to go, go, go…and then get sleep when I can. Then there are the side effects….exhaustion, AND exhaustion!, eating whatever, whenever – but at least hoping to get to eat something green instead of giving in to those oh so delicious curly fries from the cafeteria, not having time to even get a haircut (the constant drama of a girl with short hair and dark roots!), let alone hem my new pants that I had to buy en masse to look “professional” (safety pinning and ironing in a new hem are skills I am now very adept at), driving every day through the city – fighting off a mix of fatigue and road rage (I definitely miss the T and walking everywhere), constantly being “on” – attentive, showing everyone that “counts” that you want to learn – all day, all the time, searching for the answer to all and every question and pimping moment a med student may receive, having to work with a bunch of people that are as, or more (!), type A than myself, the stereotypical “gunners”, your peers that end up being patient stealers – when you are the one that gets THE “interesting one”, working with people that are your peers in school and in terms of medical knowledge, but that are sometimes a decade younger than you, and interns and residents that fall in the same category, knowing you have to study for the shelf, but simply not being able to make yourself open the book on your one night off, not being able to spend time with your family, your friends, getting really sick but still having to work work work, wanting to exercise more – hell, at all would be nice!…and the list goes on and on, to the point where I have felt that this whole process can not only go from one extreme to the other, but it can also be a bit isolating at times, at least from the people who knew you in the “before” stage. Whether aggravating or exciting, mind numbing or hysterical, this process is something that changes you – the way you think, how you look at the world, at science, at people…you are on a path that takes you on the steepest and most challenging learning curve of your life, and sometimes it just seems so hard to convey all of that to the people that you would most want to know it.
So. Here I am. I have been, and I guess to some extent, still remain wary of the blogging world, first and foremost because I have, in the past, wondered if it just catered to those who are a little self obsessed – putting yourself out there like that, for all the world to see, and also because of the oh so many current litigious situations that the more extreme bloggers are finding themselves in. However, as a way to keep in touch with, and reach a larger group of people…well, I guess it cannot be beat. You can all tune in here for updates, when I have the time to write them, since I know, most certainly, that I have done a very poor job at keeping up with emails, letters, and phone calls. A lot of my current classmates have made the blogging plunge, and so…well…here I go!
I will, however, make a huge disclaimer here – this may not be for the faint of heart, discussion of blood, guts, and yes, *gasp* even penises and vaginas may follow. You have been so warned! So, keep checking in every once in a while, you never know what you will find…I have found that to be the one thing that remains a daily truth for me at least, no matter what rotation I find myself in!