New content... but not here

As I mentioned before, I'm going to be guest authoring over at headmirror.com with articles talking about my experiences pursuing an ENT residency, and hopefully offering some good advice and useful information along the way. Sort of like Dear Abby, but without the botox or perm.

Anyways, my first post is up. You can check it out here (navigate to the Medical Students section), if you're feeling whimsical.

And now... a picture of a kitten.

The Mind Is A Beautiful Thing To Waste

So I am in the midst of my 3rd week on psychiatry, and I would be remiss if I didn't at least talk about it a bit. My duties are relegated to the locked ward in the VAMC of my city (or the "Vah" as its affectionately referred to here), which means more substance abuse, PTSD, and homelessness than you can shake a stick at. I can confidently say that I could never be a psychiatrist. I have a great deal of respect for those that enter the field, and find many of the conditions patients carry very interesting (I was a philosophy major in undergrad, what can I say?) but the pace of the field is maddening to say the least. I'm the type of person who likes to have my work and get it done in an expedient manner, but often find my days filled with dawdling waiting for x to happen. "In 15 minutes" can mean up to an hour and a half later. Especially coming off of general surgery, the adjustment has been... interesting to say the least.

Alas, I do not have any amusing psych stories yet. Just a lot of sad ones. Between the limited resources social work has to deal with, the intractable condition of many of the patient's disorders, and the high relapse rate on substance abuse, there just aren't many warm fuzzies to come about. I've been experiencing a pretty good amount of countertransference while on service, and many of the days can feel emotionally exhausting. Plus the nature of the physician-patient relationship carries a very different flavor. Sure, the hours are nice, but I just do not feel the same get-up-and-go in the morning I've felt on other services.

Unfortunately, that's about all I can say about the matter. Such is the life of the third year med student. You do some things because you like to, and you do a lot of things because you have to. 2 1/2 more weeks until I'm on family medicine, and definitely looking forward to getting back in clinic and interacting with patients on a normal playing field again.

MedZag Picks A Specialty.

There are few decisions more consternating to a medical student that choosing their eventual field. Sure, there's a few students born to be pediatricians or neurosurgeons or ED docs out there who know it, but the gross majority of us go through a great deal of waffling and procrastinating when it comes to deciding what more we want to be when we grow up besides the esoteric "I wanna be a doctor! Cause its cool!" Even those who were convinced they were going to go into x when they entered med school often do a complete 180 once they rotate through the clinical aspects and their face is to the table saw as they hover over the "submit" button on their ERAS residency application.

There's a certain progression to the process:
(1) Panic: The Lifestyle Specialties
When you first come into medical school, you have these idealistic views of what being a physician entails. Then you actually get into medical school, and a disenfranchised attending comes along, convinced the entire field of medicine now sucks, and blows that idealism into tiny, sparkly little pieces. You begin to become convinced that the only way you could possibly be happy is if you find your way into one of the highly-touted ROAD specialties: Radiology, Ophthalmology, Anesthesiology, or Dermatology. You begin to become convinced you could be happy staring at a computer screen all day, or rashes for that matter. After a while, you realize that all rashes look the same to you anyways, and you move on to...

(2) Resolve: Screw What Everyone Thinks
You encounter a doc who absolutely flippin' loves what they do. They tell you that it doesn't matter what area of medicine you go into, as long as you love what you do. You begin to convince yourself the same. You tell yourself that the disenfranchised attending from step 1 can go to hell, and you're going to go work for Doctors Without Borders as a surgically trained general practitioner. As medical school and the ongoing debate about healthcare reform progresses, you begin to notice that little "Total:" line on your student loans climbing at a otherworldly pace. You then move on to...

(3) Hopelessness: It All Sucks Anyways
Why does it matter anyways? In a few years, you're either going to be a government employee, and make peanuts, or privately employed, and make peanuts. Either way, you'll be working your glueteals off the rest of your life. You'll never pay off your loans. You're going to be driving that 1995 sentra for another 20 years. Your daughter is going to grow up with daddy issues because you'll never be home. You procrastinate thinking about what you want to do, because its no longer fun to think about it. Some stay in this stage perpetually, and become the attending referenced in Stage 1. If you're lucky you get to move on to...

(4) Chance: Your Specialty Picks You
The residents and attendings I've talked to who really enjoy what they do, and are pleasant people in turn, almost universally give the same advice about picking a specialty: get rid of your preconceptions, analyze your strengths and weaknesses, the things about practice which are important and unimportant to you, prune your list, then go out there and experience as many areas as you can. When you come across your specialty... you'll know. It'll be the one where you don't want to go home at the end of the day. Where you'll look and read about things not because you have to, but because you want to.

I came into medical school convinced I was going to be a surgeon. My friends told me as much, I told everyone as much, my ESTJ Meyers-Briggs personality evaluation told me as much. Now granted, my concept of "being a surgeon" wasn't all candycanes and lollipops - I had shadowed enough in undergrad to have a general idea - but I will be first to admit I had a very naive and limited view on the scope of medical practice and the proverbial "potpourri" of options afforded to me early in medical school. I found out in a hurry that telling people in the Real World™ that you want to go into surgery evokes an entirely different response to telling people in the medical field that you want to go into surgery. Namely, that instead of eliciting the token "Ooooo! Like Gray's Anatomy!" response, they instead try to scare you the hell out of considering the field. And granted, much of that behavior is grounded in either reality or stereotype of the field. And so began my progression of through the steps.

First was "what have I gotten myself into? I don't want to work 120 hour weeks for the rest of my life!" Followed "I'm going to do it anyways! It'll be fine!" I eventually just resigned to telling myself "you'll know when you rotate through surgery if its for you." But alas, my surgery rotation came and went, and by the end I was still just as on the fence about the whole surgery conundrum as before. So I began to break it down. I knew that there was nothing like being in the OR for me. That time flew when I was in it, and I missed it when I was out of it. But surgical clinic also left a bad taste in my mouth. I found myself enjoying the clinical aspect of medicine more than I anticipated, and I found clinic in general surgery too fixated on "to operate or not to operate?" Yet after leaving surgery and venturing into the realm of psychiatry, I found myself missing the faster paced lifestyle of the specialty.

ENT was a specialty that first caught my eye during second year. I had a small group doc who specialized in laryngeal surgery and speech therapy, and he really tried pushing us to take a look at the field. But at the time, I was too hung up on the "to surgery or to medicine?" that I never stopped and said to myself "self? how about both?" It was a field I kept on my list but never really investigated... namely, because I had no idea what in the hell an "otolaryngologist" was or did. With no frame of reference, I wasn't in a position to realistically examine the field. But the seed was there, and as third year started and I began to have more interaction with various specialties, I began to notice that I was really digging this ENT stuff. The more I read about the field, the more it seemed to jive with my expectations and desires for how I wanted to practice medicine. There was a monday morning report I went to that was presented by the ENT department... and instead of sleeping through it I found myself taking notes. I scrubbed on a pharyngolaryngectomy with a free jejunal transplant and even though I was on the colorectal service and was parked by the abdomen, supposed to be focused on the jejunal resection, I found myself fixated instead on the bilateral neck dissection. It was the small things that slowly roped me in, and after extensive email conversations and a few tall coffees with a couple members of the faculty, I've finally come to a decision. I said to myself: "Self, you're going to match into otolaryngology."

Along those lines, I'm going to be guest-posting about my experiences in discovering ENT, rotating through ENT, applying, and such over at headmirror.com (see the new side banner). If you're considering ENT, I suggest you check it out - there's a lot of great info on the site. All I can say is that its incredibly exciting to find that niche of medicine which really vibes with your persona. When I decided to commit myself to the field and really get after it, all I felt was this overwhelming sense of relief. I think that was really telling.

Till next time.

Friday Night Lights

So I happen to be attending med school in the same city I grew up in. There's a lot of advantages to the situation: I know the area really well, the city "feels" like home, I'm close to friends and family, in-state tuition, etc. There's also the annoyances that come from returning to your hometown. Namely, running into old acquaintances, especially high school classmates, everywhere from the deodorant aisle at Safeway to the self-help section at Borders (you to!?!). Now, these aren't the good friends from the old days - those I've actually kept in touch with over the years and still make plans with from time to time. These are the people you see in a crowd, recognize the face and try to place their name, and before you can think of it they jump you with with the "Heeeeyyyy how are yoooouuuuu? What are you uppppp to? *awkward pause*" before you can make a quick getaway. At first these spontaneous encounters were kind of fun, namely because my younger self got to pull the "I'm in medical school card" (Yeah. I know. You don't have to tell me.) But after a while it becomes an annoyance more than anything. That being said, there's one place I never expected to bump into an old high school friend.

I was on trauma call on Friday night and going through my usual routine. Which means I was in the cafeteria at 10 at night, justifying to myself that I should get the ham and cheese sandwich and fries instead of the halibut and grilled veggies because "You deserve it. You're on call." Before I could contribute to my future coronary artery disease, the trauma pager goes off and I hand the delicious ham and cheese sandwich back to the cook and shrug, mumbling "Sorry. Trauma." I do my best doctor walk (you know, the walk where you don't look like you're running but you're tearing down the hallway on pace for a 4.0 40) down to the ER and work my way over to Trauma Bay 3. Ten minutes later the action starts as the paramedics wheel in the patient in a c-collar. My role is the lower extremity exam so I work on peeling away the patient's trauma-sheered pant legs, feeling for pulses, checking capillary refill, etc. The presentation of the patient begins.

"25 year old male was swimming with friends in the river. Dove off a rock and misjudged the depth of the water. Landed head first into shallow depth and immediately lost use of all extremities."

I examine the legs in front of me for lacerations, abrasions and such. The ED resident begins to talk to the patient.

"Sir, can you hear me?"

"Yeah," the patient replies.

"Can you tell me your name?"

"Mike." The appointed scribe sets out her form and begins to write in the elucidated info. "What's your last name, Mike?"

"Jergens."

Mike Jergens*. The two names snap together in my mind and I immediately glance up to the patient's face poking out above the c-collar. He had a beard now, but there was no mistaking his face. This was the same Mike I sweat and bled with during countless hours of football practice back in high school. He was a linebacker, I was a cornerback, and we spent more than a few hours shooting the sh*t in the huddle back in the day. I think back to my last vivid memory of him - also a Friday night, 7 years ago. We were walking off the football field my senior year, knocked out of the state playoffs in the quarterfinals in a royal butt-kicking from our local rival. He had cried that night in the locker room. I suddenly had the urge to cry myself.

I somehow pull myself together enough to help finish the triage and he is sent off to imaging. It would find that he had a C6-7 fracture dislocation. His cord was compromised. He was taken to the OR the next day.

Mike would eventually regain some motor use of his upper extremities. He had a long hospital stay with a rocky course including a ventilator-associated pneumonia. He was eventually discharged home 4 weeks later with a trach, facing a long road ahead I cannot even begin to fathom.

I never let him know I was there in that trauma bay. I tried to muster the courage several times to go visit him in his ICU bed, but the best I could do was to post a message on the website that had been erected for friends to send well-wishes and prayers. I still don't know what kept me from stepping into that room, but I carry a certain amount of guilt knowing that we now face such divergent paths in life. If anything, it has certainly helped me to gain perspective on how precipitous our lives can be and how quickly they can change. The minor annoyances in life, such as being "forced" to make small talk with an old acquaintance, are suddenly seen as blessings instead. An opportunity to see and know that that person is well. It's a strange world we live in.

As if to emphasize this point, the next night on trauma a patient in his early twenties was life-flighted in with nearly the exact same injury. He had dove into the river off a large boulder. Misjudged the depth. Landed head first in shallow water. But he escaped with only a hairline skull fracture.

It's a strange, strange world we live in.

* = Name obviously changed to protect his identity.

MedZag's First Night on Surgery

If there's one thing you can count on during your surgery rotation, it's that you'll have at least one occurrence a week where you will stop, survey what is going on in the room, and think in your head "what the f**k is going on in this room?!?" The residents take a certain amount of glee in finding ways to induce nausea and/or vomiting in the new, cute and cuddly little medical students on service. So of course on the first day of our rotation, with the knowledge they will be soon gaining some fledgling MS3s on service, the residents on my team saved all their *ahem* hands-on *ahem* floor work for the day for evening rounds when we would be joining them.

Case #1 was a patient we called Boss. Ms. Boss was the first patient I saw on my surgery service. Now keep in mind, I had just rotated off pediatrics, where I was used to seeing adorable kids all day. Sure, they may have been covered in poop, or really sick, or doing their due vigilance to prevent atelectasis by screaming for 23 hours a day, but they were still kids, and I freakin love kids. So we roll into The Boss' hospital room here I am confronted with a 350 pound elderly woman lying in her bed as Jerry Springer blasted from her television set. Our resident instructs myself and my fellow med student to glove up as it was time to change The Boss' wound. He peels back the dressing to reveal no wound but rather a massive gaping hole. You see, Ms. Boss had had a previous ventral hernia repair with a mesh. She got discharged to her nursing facility and the mesh subsequently got infected - necessitating removal of said mesh and all surrounding infected tissue. What was left was a 14" crater in her abdomen, with loops of bowel showing through a thin layer of tissue at the base. The tissue was still infected and I was immediately struck with the smell of... sherbert ice cream. Needless to say no sherbert ice cream was consumed this past month. So we get the supplies together and the resident gets to packing the "wound" with xeroform and two packs of kerlex. As I watch the resident place gauze on the exposed bowel, I step back for just long enough to think to myself: "what the f**k is going on in this room?!?"

Later on in rounds we come to a patient who the team had come to call Mr. Rabbit, for reasons which HIPAA will not allow me to explain but unfortunately not due to resembling a rabbit in appearance or size. Mr. Rabbit has originally presented to the ER with what was originally diagnosed as a rip-roaring case of panniculitis. As Mr. Rabbit was homeless and weighed in at a hefty 628 lbs, there was obviously quite a bit of pannus to become infected. He was taken to the OR where they found that while yes, his pannus was infected, it was actually due to a large sack of herniated bowel which was eroding into the skin. His hernia was reduced and he got a non-cosmetic panniculectomy (aka tummy tuck). The weight of his excised pannus: 78 lbs. So we reach Mr. Rabbit on rounds, now a svelte 550 lbs, who was beginning to show signs of a wound infection: rubor, dolor, calor, tumor (you have to say these in as dramatic a voice as possible). The team decides its time to open the wound to let it drain, a staple of proper wound care on surgery. The protocol for opening an infected wound is to (1) open, (2) assess drainage, then (3) follow the pocket of infection to get a sense of how large it is and where it tracts. For small wounds, this can be done with a wooden q-tip. For larger wounds, a gloved finger is often necessary. Our resident gloves up, removes the necessary staples, and begins to follow the pocket of infection. More and more pus begins to pour out of his abdomen. Despite his newfound surgically-enhanced physique, Mr. Rabbit still had quite a bit of subcutaneous fat, and before we know it, the resident has his entire hand, up past the wrist, inside the patient's infected incision. I stand back, take the scene in, and think... well you already know what I think.

Surgery... Is Exciting

So I took my surgery shelf exam yesterday. It's hard to believe that the rotation is already over and done with. I guess the true gauge of how much you're really interested in the field is how much you miss it when you move on, and - well - I already miss it. Yes, the hours can be exhausting, but the human body has an amazing ability to adapt to even the most extreme conditions and once you get used to the lack of sleep, you begin to enjoy what happens when you're awake a lot more. And boy, does a lot happen when you're awake. Nearly every day something would happen which would make me stop, if only for a second, and think "I can't believe we're allowed to DO this." And then I'd grin a little bit.

The great thing about surgery is that its a field ripe with ingredients for stories, and I have plenty from the past 5 weeks. The unfortunate thing is you often don't have the time to digest and tell those stories. So that's my project for the next few weeks, just bear with me.

Starting on psych on Tuesday - which is about as black and white a field from surgery as you an get. I think I'm going to be bored, but I'm trying to not carry any preconceived notions into the rotation.