Friendly Reminders

One of the nice things about traveling so much is it has afforded me the opportunity to read-for-pleasure for the first time in several years. I just finished digesting this 500 page behemoth:

A fictional tale of twins born to a disgraced nun slash scrub nurse in Ethiopia, the tale follows the narrative of one of the boys as he grew up in Ethiopia to two physician parents working in a small mission hospital. The protagonist follows in his parents footsteps of medicine, ultimately coming to America to train as a general surgeon.

The novel is penned by Dr. Verghese, an infectious disease doctor at Stanford who, like his characters, was also born in Ethiopia. A powerful read, with an very engaging plot and many poignant moments intertwined into the story.

Perhaps the most interesting parts of the story for me where when the main character was himself on the path of medical training, both in his youth and then in medical school proper. There were some very profound statements Verghese used to describe the "transformation into a physician" and his own personal viewpoint on care of the patient. I found most of them surprisingly on-point despite the fact that the author is not a surgeon himself.

To be a good surgeon, you need to commit to being a good surgeon. It's as simple as that. You need to be meticulous in the small things, not just in the operating room, but outside. A good surgeon would want to redo this knot. You're going to tie thousands of knots in your lifetime. If you tie each one as well as humanly possible, you'll experience fewer complications. The big things in surgery depend on the little things.

I take heart from my fellow physicians who come to me when they themselves must suffer the knife. They know that Marion Stone will be as involved after the surgery as before and during. They know I have no use for surgical euphamisms such as "When in doubt, cut it out" or "Why wait when you can operate" other than for how reliably they reveal the shallowest intellects in our field. My father says "The operation with the best outcome is the one you decide not to do." Knowing when not to operate, knowing when I am in over my head-that kind of talent, that kind of "brilliance," goes unheralded.

I found the read quite inspiring as times. Too often in medical training, we get caught up in the drudgery of the day to day. Wake up, drink coffee, round, do work, go home, read, sleep. It's refreshing to feel inspired, because I can admit it is not often enough that I feel such as I trudge through my days.

Interviews are going well. Done with three, with four and five to come this week. My traveling karma has been good so far. No missed connections, flights on time. It's great to travel and experience new cities I haven't visited before. Gives me an appreciation for the vastness of America, but also for how similar we all are in ways that are not readily apparent. I'm also getting a better sense for what I am looking for in a program, but know that when it comes time to form a rank list, it's going to be insanely difficult.

That's it for now, off at the airport at 4:30am again tomorrow. Wake up, drink coffee, don suit, board plane... but then, luckily, I get a chance to reflect on where I am and what has brought me to this point. In the words of Dr. Verghese Life is like that. You live it forward, but understand it backward.

Leaving On A Jetplane

Last night, got to say adios to my plastics "sub-i" and scurry home to pack my belongings.

Today, I embarked on the interview trail that will take me (as of now) to 11 different states and several thousand miles. I won't see another patient until February of 2011 (which is weird to think about... 2 months in medical school without medicine?) Over the next 30 days, I'll spend 18 of them away from home. Then in January another 4 interviews. Whew.

I'm sure there will be some things learned the hard way along the way... I'll be sure to chronicle the foibles and follies here.

Sid Meier's Hospital

So I'm on Plastic Surgery this month. Excuse me, Plastic & RECONSTRUCTIVE Surgery. Though I think it's fair to say the department here earns that title as they do a fair bit of reconstruction amongst the stripperplasties and wrinkles-be-gonesies. It's strange being back on an academic surgical service after a break of over 3 months, but refreshing at the same time as the duties of the medical student on said services of academia (list updating, prerounding, hastily presenting, obscure pimping) are warm and familiar to me. Like a well worn sweatshirt or something. But the hours still suck.

We had a really interesting person on the census the past while - the whole package, interesting medical case and interesting personality. The guy was tackled by a buddy of his and broke a rib. Being the regular dust-on-the-boots American that he is, he didn't come to the ED but rather was just going to deal with the pain. Problem was, he was a nice guy, and since bad things only happen to nice guys, the rib pierced his pleura and soon enough he was in the hospital whether he liked it or not with a rip roaring empyema. One lobectomy, a lat flap, and a couple chest tubes later, he found himself parked on the floor slowly biding his time until he was given the blessings of the great doctors to go home. The healing was slow and he was nearing 2 months on service when I rotated on.

Of course he felt well enough, and rather than bore himself with watching his chest tube output, every day when we rolled through the room in the clusterfuck that is surgery rounds, he would be clicking away on his laptop, engrossed in a computer game. Now despite my rugged and masculine exterior, I am quite the computer nerd. Growing up in the glory days of DOS, I spent many an hour of my youth tinkering away at the computer keyboard with classics such as X-Wing, Doom, and Mechwarrior. Like like many things of youth, these hobbies have slowly been eroded away by the responsibilities of growing up. So on rounds we were much more focused on said chest tubes than what was on the computer screen.

Finally, after a few days on service, the chief resident glances up from the patient's incision and asks "Are you playing Civilization???"

The junior looks up from the chart to add "Hey, I love Civilization."

Intern: "What version? I haven't played 5 yet."

From my n=1 experience, I can now say that all medical students and residents have played Civilization. I'm not sure what that says about our demographic, but the computer nerd in me grinned internally.

Sure enough, this past weekend we were rounding with the attending on call, and our fearless world leader slash conquerer was getting ready to be discharged home. We roll into the room and there he is, clicking away at his laptop like always. He's excited to go home. We make small talk. Finally, the attending was bent over glancing at the site of the last chest tube, when she comments "Is that Civilization? I love that game!"

Somewhere, Sid Meier is smiling.

These Healing Hands

It's a reality in medicine that sometimes your patients die, and patients generally do not take exception to this fact if they happen to be cared for by a medical student. Some deaths can be more difficult than others as a student, depending on how well you got to know the patient beforehand or the circumstances of their death. Throughout my third year of medical school, I had several patients who I was caring for pass away while I was on service. Generally, these deaths were of one of two varieties:
(1) A healthy individual crashes and burns, a code is called, and we try our damndest for hours to fight the inevitable tide of death. Eventually the code is called, the team collapses in exhaustion, but there is a certain amount of solace to be taken in knowing that we tried everything.

(2) An individual with end stage x disease, who has been playing ding-dong-ditch at Death's front door for far to long, finally catches Death as he/she is walking by the front door in a bath robe and passes quietly in the night. News of these deaths comes during the AM handoffs and is generally met with a general sense of "Damn." but part of your psyche had already begun stacking the sandbags, knowing full well that your dying patient was, well, dying.

I had another, unique experience with death while on my neurology rotation. We had been consulted on an elderly woman admitted with altered mental status, in the classic CYA consult "rule/out stroke" that elderly patients with AMS tend to collect as they pass through the ED. I originally went to examine her with my attending in the AM, to find a frail looking woman, eyes open staring directly at the ceiling, unresponsive to anything in the room around her. She was altered (frankly, encephalopathic), but we did a full exam anyways and determined that she most likely did not have a stroke. Her breathing was shallow, raspy, and moist, a death gurgle of sorts as she was having difficulty handling her secretions. Labs would show a CO2 of >150... the likely culprit of her current stuporous state.

We weighed in our opinion and were off to clinic for the day. When the late afternoon rolled around, I decided to check back up on her, anticipating that after the requisite therapy for her COPD exacerbation, she would be doing much better. Luckily, I decided to glance at the chart before entering the room, and found a note from the medicine team "Discussed situation and prognosis with family. Family wishes DNR/DNI, palliative care consult."

I enter to find her much as she was that morning. Eyes open, staring blankly at the ceiling, still unresponsive. The late afternoon tends to be quiet in this wing of the hospital, and it was just her and I and the setting sun through the hospital window. Her raspy breathing penetrated harshly through the serenity of the moment. Like a good medical student, I set to task repeating the neurological exam, looking for any differences from the morning. Dolls eye test. Corneal reflex. Tap on the tendons. Check tone. It is just as I remove her sock to perform a babinski exam that I notice a subtle change in the room. It takes me a moment to realize that the throaty death rattle, my patient's weakened attempts at oxygen exchange... had stopped.

The first thought to race across my mind was "Oh shit!" I don't know how, but I remembered at that moment her do-not-resuscitate status, which fortunately prevented me from running into the hallways like an idiot yelling "Call a code!!!!" I watched as the color rapidly drained from her face, and stepped out of the room to talk to the nurse. "Ms. R just passed away. I don't know the protocol for the hospital, do you need to page the attending? I'm just a medical student." She replies that it is ok, as the patient was on comfort care. "Just go listen to the heart and lungs to confirm."

As a medical student, you are not trusted to do a whole lot. In today's chaotic environment of CYA-medicine and medical malpractice, we mainly pretend we can do things while someone holds our hand, until intern year rolls around. And a task as simple as listening to a patient's heart & lungs and feeling for a pulse should be elementary for a fourth year medical student, who has felt hundreds of pulses and listened to hundreds if not thousands of hearts. Regardless, there was a certain amount of anxiety involved in confirming a patient's death. Placing a finality on a life, even a life known to be near it's end, felt like a heavy responsibility. "I'm just a medical student."

"Time of death 18:21."

There would be no code, no crowd of people in the room, no blood staining the gown from STAT blood draws. Just myself, and my patient - a patient I had never even talked to. This was a different death than what I was used to. Some would say a good death. But the intimacy of the moment, especially considering it happened while I was performing the physical exam, struck me.

I page my neuro attending to tell him the news. He breaks the mood with some levity: "Well don't go see of the other patients now... I thought they were supposed to be healing hands!"

I looked down at those healing hands.

Onwards and Upwards

Jeesh, I've been really slacking on this blogging thing. Probably because my life has been incredibly uninteresting the past month slaving away in honor to the boards gods. So I successfully (I think) navigated the travails of Step 2 and its assorted clinical vignettes and fake patients. The second romp with the Step exam was not nearly as stressful or interesting as the first go. More a matter of knowing what you have to do, then going and doing it. And yes, Step 2 CS is as big of a joke as everyone makes it out to be.

This month is neurology, which has turned out to be a quite the neurocation. Which means I've replaced qbank and first aid with monday night football and hulu. I'm already starting to feel that 4th year senioritis sink in.

First residency interview invite finally trickled in today. The residents warned me that in ENT things happen late, so while my classmates have been racking in the interviews I've been obsessively checking MyERAS to see "Available, but not yet retrieved" over and over again. After a month of hearing only crickets, it's nice to finally start getting some movement. So it's back to twiddling my thumbs and hitting refresh on my cell phone email every 30 minutes.

Btw, blog crossed 50,000 visitors this week. Pretty freaking surreal if you ask me. Thanks to all who follow this site and pretend to enjoy the content. Never thought when I started this thing it would generate such attention. Y'all are great!

Retro

So this month has been a blast from the past. Like all fourth year medical students in our fine nation, I've been spending the past week buffing, fluffing, proofreading, and shining my residency application. It brought back many a "fond" memory of 2006 when I was going through a similar process applying to medical school. And just like before, I'm stuck in that weird limbo now where everything is submitted, there's nothing left to do, and now it's a matter of waiting, and waiting, and waiting. As someone whose past four years have been filled with things to plan, things to do, things to prepare for... it's a strange feeling.

"Fortunately" I have Step 2 to keep me busy this month, which involves plenty of QBank and First Aid. It brings back many a "fond" memory of 2009 and preparing for Step 1. Luckily, none of the same anxieties this time around. But I'm back to my favorite spot at my favorite Starbucks, highlighters in hand. God knows how I did this for two whole years.

Luckily, only another 10 days of this then I'll literally be out of things to do. Who knows what I'll do then, I sure don't.

Empathy, Tragedy, and Progress

She was 28 years old when she first noticed the spot on her tongue.

Red and bleeding, it resembled a pinpoint ulcer along the left lateral border. She went to her doctor, with understandable concern. And he reassured her it looked like a small aphthous ulcer. He told her if it did not get better, or got larger, to come back and see him.

Shortly after that, she became pregnant with her third child. And as anyone would in that situation would likely do, concerns of small aphthous ulcers were placed into the back of her mind as her and her husband went about planning the new addition to their family. Months went by, until one day in her third trimester, she was brushing her teeth and noticed blood on the toothbrush. She took a look at her tongue again, only this time to find a large hard mass in place of the small red spot from before.

What followed was more doctors visits, biopsies, referrals, and a diagnosis... squamous cell carcinoma of the left lateral tongue. She was told there would need to be surgery, but not for another few weeks until her baby was safely delivered.

The baby was safely delivered.

It was the morning of her operation when our paths first crossed. I introduced myself to her, and the entirety of her large, supportive family in the pre-op room. I made small talk, and she spoke in articulate words with a slight British accent. I asked if she had any questions, and she shook her head no.

Back in the operating room, it was business as usual. Help transfer the patient to the OR table. SCDs on. Bovie pad on. Extra blanket on. Warm air circulating. She succumbs to the general anesthetic. Intubation successful. Rotate table 180 degrees. I go out to scrub with the attending and resident, yellow iodine dripping down my forearms into the sink. Sterile towel. Sterile gown. Gloves. Spin. Prep the operative field.

We are finally ready to begin, and we finally get a good look at the tumor. It it large, extending from the lateral edge nearly to the tip. Fingers of white parasite extending deeper into the tissue.

Calmly, the operation commences. According to the pre-operative MRI, it looked like the tumor did not creep too deep. The hope was to get in, get clean margins, and close primarily, leaving her enough residual tissue that her speech and swallowing would be largely unaffected. The dissection proceeds around the mass, and finally the bovie tip penetrates out the opposite side. Frozen sections are sent off to pathology, and we breathe a sigh of relief for the moment. We sit and absorb ourselves in the BB King playing from the iPod. We have a discussion about how much we enjoy the blues.

The phone rings, pathology on the other end. "Frozen sections show margin passing through tumor." In the passing 3 hours, more tissue was taken, more sections were sent, more phones ring, and more swear words penetrate the soft, solemn blues of BB King wafting through the air. The partial glossectomy transforms itself into a hemoglossectomy, which creeps towards a near total glossectomy with each positive margin. Finally, margins are clear and we close, folding the thin strip of remaining tongue over onto itself and securing it with the appropriate number of half hitches.

I am reminded on my last question to her before the operation, when she simply shook her head and smiled. What brings me back to that moment is that for the next few days, her sole mode of communication involves those same left-right, upwards-downwards motions. Any pain? Shake no. Comfortable? Shake yes. Ok, more of the same today. Try to get out of the bed. She turns out to be quite lucky in some ways. Her swallowing was intact. And she will eventually speak again, though not without a heavy lisp and not until the burns of the radiation therapy subside and many months of speech therapy are completed.

There were two things that stuck out to me as particularly profound about this case, about this mother of three.

First occurred during those nauseating hours in the OR as frozen section after frozen section returned with tumor as we burrowed deeper into tongue tissue. With each subsequent resection, I could not shake the feeling of how horribly I felt for the patient, that we were slowly robbing her of her chance at a normal life. Part of that is good, I think. It means these past four years of medical school have not robbed me of those intimate emotions, of the ability to feel empathy for the person prepped and draped in front of me. But I was also struck by how calmly and confidently the attending surgeon, a man I greatly respect and admire, went back to work with each setback... steadfastly marching with tenacity towards negative margins. He knew the data, but more importantly he had lived the data in his many years of practice. He knew that if we did not get clear margins, this woman in front of us would be robbed of her chance to see her children grow old. So he could bury those emotions in order to do what is necessary. Me, I could not yet detach myself from those feelings of horror, because I was not yet convinced it was necessary. Quite bluntly, I have not seen enough people die to be convinced.

It reminded me how much time and space still yet separate myself, inquisitive pitiful fourth year medical student, from the title of surgeon. Because in that situation, I'm not sure I could have done what was necessary. That was humbling to realize.

The second profound moment came the next week in clinic when the attending, chief resident, and myself saw the name of a 32 year of woman on the schedule for follow-up. She too had developed a tongue cancer noticed after becoming pregnant. She too required an operation and radiation. We got to talking, and the chief resident remembered another young woman from her second year of residency who had a tongue squamous cell. We look at her chart and notice she was pregnant. "Interesting," the attending states, and we go to see our follow-up patient. Somehow the conversation turned to what we were discussing earlier, and the patient states she also knew another young woman in the south part of the state who had tongue squamous cell. The momentum of the conversation between the three of us accelerated throughout the day. By the end of clinic, we had assembled a list of 9 young pregnant women with tongue cancer who had been operated on in the past several years. Questions floated about to the tune of the scientific method. Why pregnancy? Why are we seeing more of these tumors? What's different about these tumors? Are there unique ways of approaching treating them?

And so a hypothesis was born. And a plan. There would be a study. IRB protocols and special stains and information databases and eventually a publication. And hopefully... progress. And I thought that all is not so horrible after all.

She's high maintenance.

There's a dangerous new mistress in my life that's been sucking up all my time I would have been writing on here, and her name is "ERAS". I know, sexy.

Anyways, promise more stuff is coming soon.

Sub-I... Check.

Man, time flies when you're having fun, I guess. My four weeks on my otolaryngology sub-i were over in a flash. I have to admit, I was a bit nervous coming into the rotation. I felt like I had a fair amount of exposure to the field of otolaryngology, but any time you're making a decision to enter a field when you haven't spent dedicated time rotating through the specialty, you have to wonder if you'll end up enjoying it as much as you think you will. Luckily, I found a great experience during my rotation that reaffirmed rather than undermined my decision.

That being said, talk about a crash course of an experience. Doing a sub-i in a field that is only peripherally covered by the third year rotations, I found myself having to read quite a bit every night just to stay on top of the topics I may see in the clinic or OR the next day. Luckily, I got to rotate through a different service each week, so I could focus each week on learning one specific aspect of the field, be it head & neck, rhinology, peds, or facial plastics. That being said, I felt like the rotation was much less about showing what I knew and much more about showing my willingness to learn. Definitely a different experience than some of my friends who were doing sub-i's in general surgery, internal medicine, etc where you're expected to have mastered basic principles as a third year and graduated on to more patient management.

That being said, being a sub-i kicks butt compared to being a third year. The attendings know you are entering their field, and are much more willing to tolerate your presence and teach. You're given more hands-on opportunities. You're seen more as part of the team and less as a stranger passing through for a few weeks. Good times abound.

Some highlights from the four weeks:
- First assisting an entire anterior lateral thigh free flap
- Getting to perform a trachesotomy on my own
- Pulling a popcorn kernel out of a 3 year old kiddo's ear
- Draining 350cc's of pus out of a patient's neck who has a post-op infection (I'm afraid to admit... I love I&D's)
- Becoming known as "the PEG man" on service, and being paged specifically to come put one in
- First assisting an entire rhinoplasty with rib cartilage harvest
- First time getting to use the microdebrider
- First time getting to play with the DaVinci robot
- First time getting to shoot the laser

But, all good things must come to an end. My sub-i wrapped up and now I'm off on an away rotation. Living in a different, large city with only a small furniture-less room and a twin sized bed to call home. But still otolaryngology, so I can't complain. Grin.

Reflections on Third Year

So third year ended 2 weeks ago for me, and I've yet to write about it. You think after an "accomplishment" such a surviving third year I'd be bursting with feeeeeelings about the matter. After all, I briefly delved into the realm of the introspective when I finished first year, and I got damn near teary-eyed after taking down Step 1. After third year, I don't know. I don't have that same sense of accomplishment, and the same sense of transitioning onto something new. Am I glad I no longer have to rotate through specialties I have no interest in showing faux-interest along the way? You betcha. But I didn't wake up the day after my OB/Gyn shelf feeling any older or wiser. I think part of that is because the transition to the next level of competency tends to come throughout third year rather than after it. Before my last shelf exam, I was thinking a lot about my first rotation on peds and the student I was then was very different from the student I am now. But that change was a slow process that had little to do with the MS label after my name. Basically, I can see the progress I made this year, but don't really feel like I "survived" anything. Maybe it's because I really enjoyed third year and the things that are historically dreaded about it weren't that big of a deal to me. Maybe it's because I'm going into a surgical field and I know my days of sleep deprivation, early mornings, and busy days are far from over. And you know what, I'm cool with that.

That being said, good riddance to the third year label. It'll be nice to not have people automatically assume you know nothing and can do nothing just because you're a third year medical student.

Anyways, it was a good week off, and now I'm on to the greener pastures of fourth year, the "best year of medical school."

Normalizing.

I had an interesting conversation with a friend in the military the other day about the things we do for work and how they become so mundane to us, that we lose sense of what's normal. As third year draws to a close and I look back at the experiences of the past 12 months, I realize how much I have seen and experienced that to many (or most) people would be vasovagal-inducing, nauseating, disturbing, masochistic, macabre, or just plain strange which has simply become... normal, to me. It is normal to be covered in blood or various other bodily fluids. It is normal for the workplace to smell of feces and urine. It is normal to work 15 hours a day. It is normal to stick your hand into various bodily orifices, natural or artificial. It is normal to disassemble the human body, intervene in a problem, then reassemble using silk, nylon, and stainless steel. It is normal to discuss bowel habits, suicidal thoughts, and sexual activity the first time you meet a person.

Back when I was in undergrad, I remember some of the jokes about certain medical specialties. Proctology. Who would want to deal with butts all day? Urology. Who would want to touch penises all day? Gynecology. Who would want to stare down vaginas all day? C'mon man, that's gross. Seriously, who would want to do that for a living? Especially a guy.

Well, after two weeks on OB/Gyn and numerous sterile speculum exams, the field has become... normalized. And really, once the pelvic exam stops being weird and starts being just one more physical exam you "do" to get information, you begin to see what's cool about the field. It's fast paced and busy, where things can go from reassuring to tenuous quickly. A good balance of medicine and surgery. Good outcomes for the patient in most circumstances, and a chance to significantly improve outcomes in cases where things are more dire. A sense of participating in an important moment in the patient's life.

But yes, all "that" stuff about OB/Gyn is now nothing unusual. So much so that when I do a pelvic exam now, all the anxieties I felt before about an exam that seemed so "gross" and inappropriate before just seems like another part of my job. My main concerns are more for the patient and how she may feel about a baby-faced male doctor-to-be performing an exam that is uncomfortable and in principle socially taboo. I am still very much in tune with that, and still struggle with balancing patient discomfort with my own education. But as far as it seeming gross, or unusual, those feelings are gone. I already find myself forgetting what it was like to know nothing about obstetrics. The 17 year old nulliparous patient who has no idea it is normal to defecate the bed during delivery. The couple who just welcomed their first child into the world who have a brief look of horror when the resident says she is now "using suture to reapproximate the vaginal wall." The 28 year old new mother who glances down in horror after we "remove" 300cc's of clot from her uterus post-partum. I forget how strange these things must seem.

During a c-section earlier in the week, the anesthesiology resident was comforting the patient during the procedure, talking her through the steps of the procedure. We had just finished closing the hysterotomy, and the resident says flatly "they just finished closing the uterus, you may feel some discomfort as they return the uterus to inside the body." I can imagine the patient's eyes growing wide, but all I hear over the drape is "WHAT!?!???" A large part of me cannot find fault in his faux pas, as these things seem routine to us. There is nothing strange about removing the uterus and placing it on the stomach to better sew the incision.

Just a few things that are now normal to me.

Ironically, 3 of the first 8 image results for the keyword "normal" in google images are of genitalia.

Livin' in a woman's world.

So I'm a week into OB/Gyn, which has traditionally been labeled as the estrogen-charged girls club of the third year rotations. I've heard some horror stories from a few members of my class of the male gender, so I had a few trepidations heading into the rotation.

I was standing in the workroom doing board rounds last week when the conversation of the room turned to hair straighteners. Believe me when I tell you I now know more about hair straighteners than I ever cared to know. My intern turned to me and mouths "sor-ry", and someone makes a comment about how I was the only guy in a room of 9 women. The funny thing is, I didn't even bat an eye at the entire situation. Hell, I didn't even notice the female predominance of the room until someone pointed it out. It seems like I've been working on female dominated teams more of the year, so I decided to do a formal count.

And of the 40 residents and attendings I've worked under this year... 33 have been women.

Maybe this has conferred some inherent advantage on this rotation, because things have gone swimmingly well so far. After all, we're all just living in a woman's world.

4 weeks left in third year.

Character approved.

So one of the fun things of this rural rotation is that I get to know a lot of the docs in the hospital, just by virtue of its small size (40 beds). I've been scrubbing a couple cases with "the" general surgeon on staff who's a real character. Pushing 70 years old, 5 ft and change, originally from Brooklyn. Which means he's a little ADD, a little senile, lacks any sort of social filter, and is a helluva surgeon. Kinda like Tommy DeVito from Goodfellas, except Jewish, and minus the mean streak.

Example of an exchange we had:

"So its my 40th wedding anniversary this weekend"
"Congratulations! That's quite the accomplishment! Any big plans?"
"Well, it's actually our 39th. But I'm telling the wife its the 40th so I can take her to Switzerland at the end of the month. That way we get to do it twice. The broad doesn't have a fuckin' clue how long its been, but god do I love 'er."
"Haha, that's brilliant."

Anyways, earlier this week I scrubbed on a "soft tissue mass excision", which was basically excising an abscess. The thing had been I&D'd a couple times and always recurred, and since it sat squarely in the patient's perineum (3 cm or so lateral to the anal triangle, almost right over his ischial tuberosity... yeowch), it was a painful sucker.

So we're about to start the case and Dr. DeVito turns to me and says "I was gonna let you cut, but I'm gonna try to get this sucker out without piercing the abscess. Y'know, keep the pus out of the wound and we might be able to close him up and save him a lot of trouble." We get the site draped, eyeball/palpate the abscess, and draw a nice clear margin on the skin. I'm ready with suction in hand, Dr. DeVito makes the first cut, and... almost immediately pus pours out of the incision all over the surgical site, sprung free from a pocket of the abscess that was tracking laterally under the skin.

"Well, shit. Might as well let you take over."

He turns, hands me the 10 blade, and grins.

"The Look."

As part of our internal medicine rotation, we were required to spend 5 weeks at a hospital out in the community. The hospital I was sent to was a fairly large medical center with close to 500 licensed beds, and part of my hospital was a large tower of a structure dedicated as the "cancer center". The problem with the cancer center is that it was built as an addition to the hospital, which meant to get access to the beds within the tower, you had to go up to the 3rd floor of the regular hospital, through this back hallway attached to the corner stairwell, go through a tiny side door, which brought you to a back elevator shaft. You then went up the curiously slow elevator, through a set of double doors, then up another set of stairs, just to get to the beds in the tower. As a result, the tower had been nicknamed the "Death Star", because every time a code or rapid response was called in the tower it took several minutes to respond simply by virtue of its reclusive location. While rotating at the site, I worked with a senior resident who took the code pager very, very seriously. Whether it was a code blue or a rapid response, we. were. running.

One day on short call, we had an afternoon where the code pager would not shut up. As a result, we were running all over the hospital to various locations within the hospital, always at an aggressive jog with my 30 pound white coat flapping around me and sweat beading on my forehead. All the codes that morning ended up being fairly well controlled situations... a patient in the post-op area of the day surgery who got too much narcotic, a code blue called on a patient already in the cath lab, a patient who had an an RRT called simply because the attending wanted a stat ECG. We had just finished up our 5th code of the morning when the code pager started blaring again, this time for a patient in the Death Star. "Crap." my senior muttered, and off we took, up to corner stairwell, down the back hallway, through the tiny side door, to the elevator. Wait for it. Wait for it. Wait for it. Up the elevator. Through the double doors. Up the stairwell. Down another hallway.

When we arrived the scene was fairly chaotic. An elderly woman was sitting tensely up in bed. Nursing staff was trying, quite unsuccessfully, to get an ABG, and blood was spotted all over her arm and hospital gown. The ECG showed new-onset a-fib and the patient was satting 70% on 12 liters of oxygen through a rebreather mask. But what struck me most profoundly was the look on the poor woman's face. She had what we called "the look": sitting rigidly upright, arms locked with hands grasping onto her sheets, desperately trying to breath with eyes wide and an expression of impending doom on her face.

There's only a few things that give someone "the look," and in an elderly bed-ridden hospital patient, we knew even before the labs came back that she had thrown a clot to her lungs. She was wheeled down the hallway, down the elevator, through the lobby, up another set of elevators, and into the ICU. Luckily, she did quite well and survived her PE with only a scare. The Death Star had been defeated that day. But I'll forever be imprinted with that look she had the moment we walked through the door. It's one of those indelible moments that are sprinkled throughout the third year of medical school - when what you learn in textbooks manifests itself in a living, breathing human being tenuously placed in front of you.

The unrelenting March of time.

Apologies for the lack of posts recently. Spent the last weeks of my internal med rotation scrambling to study for the shelf exam, which definitely lived up to it's billing as a ridiculous exam. That was followed by a week of continuity curriculum, with The Greatest Day of the Year thrown in mid-week (and copious consumption of Guinness in celebration). Followed by The Greatest Weekend of the Year (aka March Madness). Little time for frivolous things like blogging, you know.

Anyways, just started on my rural medicine clerkship. I'm nestled in a small coastal town, living in a small loft apartment without television. Should be interesting. I'll keep the updates coming more frequently. Got some good stories from the end of medicine, including a couple dramatic codes and my first intubation! Stay tuned.

ADD stands for Attention Deficit.. LET'S GO RIDE BIKES!

Well that was fun while it lasted. I was really in a groove there for a while, but alas, no good thing in medicine lasts long. I'm going into my 9th week of internal medicine now... and I'm sick of it. Sick of detailed assessments and plans, sick of "rule out MI", sick of pontificating on the various minutiae of pathophysiology. Granted 9 weeks in any discipline can get tiresome, I imagine. Couple that with being sorely behind in my review for the massive "you will FAIL this shelf!" shelf exam bearing down in 11 days, and a new senior who believes "you can't learn if you aren't in the hospital, so I'm going to keep you here forever muahahaha" and well, you get the idea.

But if there's one thing you learn as a third year, its how to grin and bear it.

11 more days.

Grin.

In the meantime, if you're looking for some good reading, don't look here. But look here:
Great story about the hidden lives of our patients, by Aggravated DocSurg. This story really encapsulates where I was at with my last post.

If you're a pre-med or just someone considering going to medical school, don't do it for the money, or the so-called "prestige", or the babes, because such things are slowly being eroded away (well, except the babes... I think?). But there are still plenty of great reasons to go into medicine, and Dr. Parks over at Buckeye Surgeon states it absolutely eloquently.

And, and your homework for next time... read up on Throckmorton's Sign.

'Till next time.

Happily exhausted.

There's a lot of mystique surrounding the internal medicine rotation in the third year of medical school. Besides the fact that your IM core clerkship grade is considered one of those "important things" for residency, its also the rotation that best integrates the various informations you crammed into your head during the pre-clinical years. Some say its where you learn to "think like a doctor" or "be a doctor." While my IM clerkship has not turned out to be nearly as dramatic as some would make it out to be, I have seen myself making small but significant strides on being able to capably diagnose and manage patients in the acute setting. I'm on week 6 of 10, and so far it's been exhausting, but incredibly rewarding.

It's amazing how many different experiences you can pick up in a short period of time, and how patient's stories are intertwined within all of it. Some are humorous, some are sad, some are powerful.
The little old lady found wandering the streets at 3am looking for her favorite starbucks, pleasantly delirious due to a UTI.
The woman admitted with herpes zoster ophthalmicus, who always wants you to linger just a little longer when pre-rounding, and you can tell she is lonely.
The patient who has a syncopal episode while masturbating.
The woman who has never smoked a single cigarette in her life, who dies from lung cancer.
The woman with sickle cell who is allergic to opiates, forced to endure the pain of her acute crises with only tylenol, who handles herself with awe-inspiring stoicism.
The 22 year old asthmatic, who can't afford an inhaler because he spends all his money on heroin.
The man with end-stage liver disease who can't get a transplant because he can't kick the bottle.
The 600 lb man, bed-ridden for over a year, who stands for the first time, and the attending shakes your hand and says "strong work, without your help, I don't think he would have ever left the hospital."
The patient with a-fib who passes suddenly in the middle of the night.
The woman who comes in with difficulty swallowing and leaves with a terminal cancer diagnosis.

It's humbling that these experiences are considered my "education." But I don't think I've ever appreciated or enjoyed medical school more than now. Its funny that it happened on this rotation, because internal medicine can sometimes (often) be much too rhetorical and slow paced for me. But there's something to be said about the principles of internal medicine being the foundation of how medicine is practiced, regardless of specialty. And I think my experiences on this rotation have allowed me to cross another one of those thresholds of clinical competency. I found as I was getting my feet wet in third year, I was often so concerned with not screwing up that the nuances of clinical medicine whisked right by me. I was so concerned with not missing anything in my history, I missed connecting with my patient. I was so concerned with my notes being perfect, I didn't stop and think about what I was looking for in my physical exam, or why certain things were in the plan. But as you gain competency in those skills, you learn to enjoy the process as much as the result. Medicine becomes less of a checklist and more of a visceral experience. And it becomes much more fun in the process.

So tomorrow, my alarm will go off at 4:30am. And I'll groan, because I'm exhausted. But then, I'll get up, and I'll smile. Because I get to do this for a living. How awesome is that?

o hai

Yup, still alive. Been taking a ton of call, essentially q3, and service has been slammed. I will update soon when I become AAOx3 again.

You know you're in med school when... (VI)

Was riding up the hospital elevator up from the Starbucks in the lobby this morning with a classmate of mine. We were both clutching venti size coffees, and I turn to him and go:

"How much sleep did you get last night?"
"2 hours. You?"
"3, I was lucky."

A lady in the elevator with us suddenly laughs and says: "It builds character."

NEW. MOTTO.

Have to be up in 4 hours.

First day on IM and I'm just finishing up my H&P at 1:45am. Ooof, and a full day tomorrow.

Anyways, to celebrate the joyous state of sleep-deprivation, enjoy a new post of mine over at Headmirror.com.

Check it out here: So You Wanna Do Research, Eh Tough Guy? (navigate to Medical Students -> Big Blogger Symbol, you know what to do.)

I think I'll be exceeding my daily coffee allotment tomorrow.

Onward and Upwards

2010. Has a nice ring to it - I'm a big fan on even numbers. It will be interesting to see how people abbreviate it. "Oh-Ten" is inaccurate but it sounds silly to just call it "Ten". But I digress.

I'm not normally a big fan on new years resolutions, but I've been trying to integrate more mindfulness into my life and resolutions seem like a good assess-and-change exercise, so here's my top 4 for the new year:
1. Take Better Advantage of Learning Opportunities
I've found myself too often getting caught up in the drudgery of third year. When you're tired, it's easy to check out mentally at the end of a long day, post up on the couch, and drown your sorrows in a big glass of reality television. And with medical school costing me $115 a day (and that's in-state tuition!) it'd be really stupid to waste the opportunity to maximize my education. So, in a small-changes-leading-to-sustainable-change sort of way, my goal is to read at least one article/subject/etc related to a learning issue from the day each day. I can polish off a good review article in 15-30 minutes, so there's really no excuse to not be able to go this... except laziness.

2. Get More Procedures!
The first part of third year, I've been pretty timid about standing up for myself and taking advantage of opportunities to get my hands dirty. Part of it was probably the shock of jumping into the deep end of clinical medicine - I think a certain part of me didn't believe I deserved to do s**t to real live people yet. And with residents abound in the hospital, its been easy to defer to them when chances do come up because they "need" it more than me, for accreditation issues, etc. But with fourth year and graduation barreling towards me, I'm starting to realize I'm going to NEED those skills faster than I realized, and I better get to work gaining competence in those skills I'll need as an intern sooner rather than later.

3. More Self Care
I got an hour long massage the other day (my first in 6 years) and quite plainly, it was probably the one thing I've needed most for quite a while. I tend to hold my stress in my neck and back, and both were starting to resemble cargo netting with the number of knots I was accruing on a daily basis. Along the same lines, I've gotten lazy when it comes to eating, and have found it easier to whip up some ready-made meal rather than deal with cooking/cleaning the various dishes and pans required to cook a real meal of food. So, goals for the new year are to: a. Get one massage a month - all that loan money has to be good for something, right! b. Cook at least one real meal of food per week.

4. Socialize
I've found myself falling into a trap the first half of third year. If there's one word to describe the clinical years of med school, it's: tired. Always tired. So when those few daybreaks of free time do pop up, I found myself staying in to sleep, waking up afterwards to find myself... still tired. So I waste all my free time trying unsuccessfully to become untired, and miss out on opportunities to, you know, be a normal human being for a couple hours. So the goal for the new year: at least 3 social events a month, where I engage in activities such as imbibing delicious deverages and debate the psychological intricacies of Jersey Shore. You know, stuff a normal 24 year old should be doing. Who cares if it means I'll be tired? I'd be that way anyways.

Onwards to 10 weeks of internal medicine starting tomorrow. On call this week, and I haven't taken call since October, so it'll be another "0-to-60" adjustment. But I'm looking forward to rejoining the clinical world. I feel like my medical brain has atrophied over the past month, so it's time to start practicing the mental gymnastics again. Hooah!