March 31, 2008

Med School Poker

If there's one thing that every medical student knows, its that medical school is really just a bunch of humbling experiences all strewn together under the ruse of "education." Most people out there know that doctors are smart. And that they know lots of stuff. But I don't think anyone can truly realize how much there is to know and how much practicing physicians DO know as part of their daily functioning. I have studied day and night for 8 straight months and still am barely able to interact on a fairly elementary level. And just when you start to forget that and start to think you might actually be making progress on this whole doctor thing, bam, along come some attending wielding his massive sword of knowledge, striking you down from your high horse to go mingle again with the peasants.

Take for example today in clinic. I was talking with a pediatric hematologist about an interesting patient I was about to see with him - a 17 year old patient with Blackfan-Diamond Anemia. The typical first line of treatment for this disease (a erythroid progenitor disease that prevents red blood cells from properly maturing) is steroids in hopes of resuscitating the patient's own marrow's ability to pump out those cute little RBCs. So the physician was discussing the various steroid treatments they have tried on this patient and asks me "do you know what some common clinically pertinent adverse effects to steroids?" I proceeded to stare at him like a stoned pufferfish.

Now, deep in my brain somewhere, I actually know some "common clinically pertinent adverse effects of steroids." They include weight gain, hypertension, osteopenia, and psychosis. But like 99.9% of the things I've learned this year, they were stuffed into my tired and overfilled brain and subsequently left to dissolve back into this bizarre long term memory twilight zone where they come back to me during weird moments like when I'm watching Futurama on a Monday night (read: now), but never when I actually need them.

Massive Sword of Knowledge: 1
Me: 0

Of course, I currently hold the ultimate wild card: the totally awesome "I'm a first year" card. Play this card in any situation and the attending will smile with a fond reminiscence at you, reward you for demonstrating any shred of medical knowledge whatsoever, and then proceed to explain things to you at the level of a first grader. If you've been there, you know what its like, and its truly hilarious.

But like all good things, the totally awesome "I'm a first year" card will come to an end. In exactly 10 weeks (not like I'm counting) I will graduate from a cute little first year to a second year. And then I might be actually expected to know something.

Uh oh.

March 22, 2008

Wow, That Must Be Tough

The first reaction most people have when I tell them I'm working pediatric oncology right now is: "Wow, that must be tough."

And you know what, it is.

Cancer is a nasty and tragic disease, and is particularly evil when it exerts it ravages on the young and innocent. So when I started my term through pediatric hematology/oncology, I was really curious to observe how the various docs went about dealing with such heart-wrenching tragedy in this unique field. Yet, so far I've found there's no secret formula used here. Physicians treat children's cancer the same way most physicians in any area of medicine do: by separating the patient from their disease, and going like hell after the disease. By looking at outcomes and odds instead of any patient's individual fortitude or attitude. By using established regimens instead of letting bias of how well they think one patient may tolerate a specific treatment cloud their judgment. But, just like other areas of medicine, it doesn't protect you from the real tragedies - the patients who fight like hell, who beat the odds. The patients who are a true joy to work with, but who ultimately succumb to the very odds they have proven wrong for so long.

The entire clinic loves this one patient - I'll call him Ricky. Ricky is a hilarious, upbeat, smiling 11 year old boy. Who has had acute lymphoblastic leukemia 3 times. His latest relapse came last year and he had a successful 3rd bone marrow transplant about 150 days ago with successful engraftment. Odds for kids with relapsed ALL aren't good. We have about an 80% cure rate right now if it's your first bout with the disease. But for the 20% with a first relapse, their odds of a second relapse skyrocket to nearly 80%, and each ensuing relapse it more difficult to treat as the toxic effects of chemotherapy ravage the body and as each generation of cancer cells grows more and more resistant to typical therapies.

Still, Ricky was looking to beat the odds again. His 3rd bone marrow transplant had established well and they were working on getting Ricky to taper off his immunosuppressive drugs. Everything was going great, and about 2 weeks ago the mom brought in Ricky cause he was feeling a little under the weather and his sister had recently had bronchitis. Since Ricky was still on immunosuppression, we did an xray (which came back negative) and told mom to come back in 3 days if he didn't start feeling better.

Sure enough, that next Monday, Ricky and his mom were back, and Ricky wasn't feeling any better. A second xray was ordered, and bad news: something was definitely growing in Ricky's lungs.

They immediately admitted him, but this sort of thing happens a lot with immunosupressed post-transplant kids (especially if they are back to school (a.k.a germ factories) while they are on them), and it would be expected he would be home within a week after a round of our big gun antibiotics.

I saw Ricky the Monday when his mom brought him in the second time.

And I saw Ricky in the PICU a week later, being intubated because the infection has steadily progressed. The last thing I heard him say before I left the room was "I'm going to die."

In normal people who get sick with community-acquired pneumonia, the culprit is a soft gram positive little bug called streptococcus. And most immunosupressed kids who catch an infection while out and about in the world catch your garden variety strep (or one of the several other common bugs you yourself are very familiar with from every time you get a cold or a cough). We got lots of different guns (drugs) to kick their butts. Streptococcus has a characteristic way of showing up on the xray, building up down in the base of your alveoli of your lungs.

But that's not what Ricky's xray looked like. Whatever was growing in Ricky's lungs grew is a diffuse, wispy, spider-web like pattern on both sides of his lungs. Not good. Ricky had pneumocystis carinii pneumonia (PCP).

It's very rare for healthy people to get PCP, as our immune system is pretty adept at targeting and attacking it. But in the immunocompromised and immunosupressed, its a nasty, nasty fungus that is incredibly hard to treat. It was one of the biggest killers of AIDS patients early in the epidemic before we had good prophylactic and anti-viral therapies.

Yesterday, Ricky passed away. It's tough when a kid succumbs to a disease, but especially a kid who has fought so hard his entire life and was doing so well, who finally lost to the odds he had beat for so long.

But if there's a silver lining to tragedy, its that it lets us appreciate the blessings we have in our own lives. And the reason people keep fighting to beat the odds is because people have fought before them. Ricky is an inspiration, even if the end of his story didn't go as we all would have hoped for him. So we keep fighting.

March 16, 2008

Venti Coffe, No Cream, Hold the Sympathy

Good news for me: Goodbye kidney. I have now put in my requisite time for the year learning about pee. Yippee.

Leading up to this last exam, I've noticed a trend that's been developing over the last few months. See graph:

The funny thing about burnout is how it sneaks up on you. Time starts to slip away from you, the days start to blend together, and before you know it you're sitting in starbucks with 3 empty venti cups strewn about you staring bleary eyed at the same page of notes you've been looking at for the last 1/2 hour, listening to the crazy woman in the corner talk on her corded phone thats not hooked up to anything, then getting a free 4th coffee from the barista who looks at you with a sad sympathetic look in her eyes as she says "you're always here."

Thanks for the free coffee.

Luckily, I have two of the most potent drugs possible for combating the dreaded burnoutosis (its not quite developed into a full blown -itis yet). The two magical medicines are:

-SevenDaysOfDrunkenessonix (generic name: spingbreakatol)

-Guinnessium (generic name: stpatraxia)

Applying my mad pharmacokinetics skillz obtained over this last block, I had my proper loading dose of stpatraxia on Saturday and now plan to work my way into therapeutic levels tomorrow, March 17th, the greatest day of the year. Hopefully this can help keep off some of the more severe symptoms of burnoutosis until I had get onto a steady regimen of sprinbreakatol on Friday. And yes, my life has now degenerated to the point where making lame jokes turning fun things in my life into fake drugs is highly amusing to me.

I have a couple cool stories from clinic to share sometime soon (one thing I've learned about pediatric oncology - there's always stories), but given my current level of motivation (read: none) it will have to wait. Maybe when I'm sufficiently medicated with springbreakatol (I'm so funny!)

March 4, 2008

The Macula Densa and Hollywood Socialites

They say in medicine everyone has their favorite organ. I think that's true (mine's the heart). Even my preceptor, who as an oncologist deals every day with a multi-system approach in her practice, didn't even have to think about hers and rattled off the thymus right after I asked. The human body is a beautiful and awe inspiring thing, and everyone eventually finds some particular facet especially elegant and thought provoking. Personally, I love the heart for its power and its simplicity - the way it utilizes electrical and fluid dynamic principles to amazingly fine tune such a critical and demanding aspect of our daily functioning as circulation. The dramatic way disease manifests itself when things go wrong. The way, in a congenitally deformed heart, things can go from horribly awry to just fine within minutes by simply moving some pipes (vessels) around and taping (suturing) everything in place.

But I'd like to counter that point with another point. Everyone also finds an organ they hate.

Mine's the kidney.

Now I am a very fun loving and agreeable guy. I have a great sense of humor and make an easy friend. So I don't throw around the word "hate" very often. I have only used the word hate in a few sorts of circumstances in my life. I hate Paris Hilton. I hate steamed squash. I hate the Santa Clara Broncos men's basketball team (sorry guys). I hate people who try to merge onto I-5 at 35mph.

And I hate the kidney. I have since the very first day I attempted to learn about it, back in high school. I hated studying it for the MCAT. I hated questions about it on said MCAT. I hated it in anatomy. In histology. In biochemistry. In physiology.
Needless to say, we're studying the kidney right now, which puts my effective motivation to study at about... 0%. My dreams are haunted by podocytes, GFR, aquaporins, and that douchebag Henle.

Why do I hate the kidney, you ask? Well, like anything involving hate in this world, I don't really have a good reason. It's a completely irrational and unfounded hate. Maybe because it makes pee. Maybe because its involved in the renin/angiotensin system (does anyone actually enjoy learning about that?). I can appreciate how important the kidney is. I can appreciate what it does is impressive. But its not fun or exciting.

One day, I may have it in my heart to forgive the kidney. Make up with it. We can be friends. But not today. Today, and for the next two weeks, you will officially be number one of my hate list, Kidney. Lock your doors.