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.

Surgery... Is Tough

The general consensus of the third year rotations is that surgery is the toughest rotation to get through. I didn't necessarily pooh-pooh this assertion, but I said to myself: "Self, you enjoy surgery. How bad can it really be?" After the first week of 3:30am mornings, walking home at 8pm realizing I need to be awake in 7 1/2 hours, still have to eat (since I haven't all day), and read up on my cases the next day, I have come to the conclusion that surgery... is tough.

This definitely creates a tension for me regarding my future. Surgery has been at the top of my list since the start of med school, and I've really enjoyed the rotation. I love being in the OR and time generally flies by while I'm in the hospital. But the moment you step outside those hospital doors, you realize just how tired you are and just how much your life sucks. There's been a lot of criticism of med school graduates choosing "lifestyle" as one of the major determining factors in choosing their future medical specialty. But when you're in the middle of a 96 hour week (sssshhhhh, we're only supposed to be working 80), watching the attendings crawl home at 7 or 8pm daily just as you are, you start to realize in a hurry just how much lifestyle can bolster or sink your happiness.

I'm on the colorectal surgery service. Which means obesity, obesity, and morbid obesity. I'm hoping to post some stories soon, because I've seen some crazy sh*t (no pun intended). But tomorrow is my birthday, so I plan to spend it how anyone would hope to spend it: On call on trauma service on a Friday night. Woooooo surgery!

The Bee Gees, Storage Closets, and Medical Education: A Thursday

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

It was my last day in the PICU and last day on pediatrics. I had come in at my usual time of 5:30 to pre-round on my patients. One I had carried for a week and was very familiar with and the other was a little boy with an epidural for who most of the heavy lifting had been done overnight. 7:30 came, I presented my last 2 patients, and rounds flew by, finishing ahead of time mostly due to our light census. It was looking like it was going to be a light last day, and that I would have time to fit in some much-needed studying for my shelf exam the next day. It was 8:30am and I had just settled down with a paper on PRVC ventilation when the voice on the overhead speaker system chimed on: "Code 99, 9th floor, room 4. Code 99, 9th floor, room 4."

The PICU chief takes off running down the hallway, the team a few meters behind. We arrive up at the code in under a minute, finding ourselves the first responders due to the fact that most of the attendings and residents in the hospital were a building over in morning report. Our team would be running this code.

A code in real life is nothing like in the television shows (big surprise). It is a much more controlled chaos. There isn't any yelling, pounding on chests, doctors screaming "don't quit on me! DON'T QUIT ON ME!," or any of the other stereotypes that people think of when you say the words "code blue." We had actually had a mock code for the residents and students with a sim-patient the week before - our institution is big on assigned roles and closed loop communication. So I settled into my role of information gatherer and runner: finding the patient's most recent labs in her chart, getting ice to cool the patient's body, running blood gases down to the PICU, etc.

The patient was a 3 year old little girl who was actually set to be discharged later in the day. She had nephrotic syndrome and had spent half a day in the PICU earlier in the week with some mild pulmonary edema. Her labs looked completely normal and she hadn't had any issues besides intermittent hypertension. While her parents were showering her that morning in her hospital room, getting her clean for the ride home, she suddenly collapsed and became unresponsive. Within 4 minutes of that moment she was receiving chest compressions from the PICU chief.

137 minutes of chest compressions, 8 boluses of epinepherine, 4 boluses of atropine, 4 boluses of bicarbonate, 3 doses of calcium, 3 cardioversions, 2 boluses of ibutilide, 2 IO lines, and a bolus of insulin later, there still wasn't a pulse. Since she was a previously healthy child and was remarkably stable during the course of her hospital stay and had started getting chest compressions so soon after her event, the decision was made to get her down to the PICU and put her on ECMO (cardiopulmonary bypass) in hopes that giving the heart a break would allow it to snap back into rhythm. She was wheeled down the hallway with my resident straddling her on the bed, continuing to give compressions.

Down in the PICU, her room was converted into a field OR, and the cardiothoracic surgeons arrive to prepare to get her on ECMO. I am standing outside the room, looking for more opportunities to help and absorbing the controlled chaos, when the chief turns to me and says:

"MedZag, why don't you relieve David from compressions. He needs a break and I think it would be a good experience for you."

My adrenals dump a massive load of catecholamines into my system. I somehow find a way to utter "Yes, sir."

During our "Transition to Clerkship Week" at the beginning of MS3, we were forced to re-certify in our healthcare provider BLS (basic life support) training. Which basically entailed kneeing on the hard ground in dress clothes for 2 hours doing practice compressions on blue plastic mannequins which looked like they got misplaced from the set of I, Robot. There was no way I could predict that in 6 short weeks, my mannequin would suddenly morph into this brown-haired little girl.

I gown and glove up and go and relieve the fellow doing compressions. I was determined to do everything exactly correct - probably a delusional desire in the given circumstances, but I became fixated on a study I remember reading where residents and medical students who were instructed to do chest compressions to the beat of the Bee Gee's "Stayin' Alive" were much more likely to hit to target heart rate.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

The surgeons incise in her neck and begin to dissect down to the carotid artery, a difficult prospect as with every thrust of my palm down into the little girl's ribcage, her neck jerks and blood flies into the air.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

I become fascinated by how strong her ribcage is. Sweat begins to bead on my forehead, my respirations steadily quicken, and my arms begin to burn as the lactate accumulates in my muscle tissues.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

This little girl was going to make it. She was supposed to go home today. This will be a fantastic experience to look back upon. I had images of the thank you card the PICU will receive when she starts first grade - the little girl grinning in a photo, missing her front baby teeth. The little girl who nearly died but now has her entire life, a full and rich life, to look forward to.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

Bypass in on. Her body is once again receiving fully oxygenated blood. Chest x-ray shows everything is properly in place. Her heart regains a rhythm. Sinus. But 45 seconds later it fades. Asystole.

A repeat echocardiogram would eventually show a massive saddle embolus in her pulmonary arteries. You can't get blood to the body if blood can't get to the left heart. MRI and clinical exam showed absence of all reflexes and fixed, dilated pupils. There would be no first grade photograph.

I was in the room for the conference with the patients. Our chief explained what had happened. The scene felt surreal.

When stepping out of the room, one of the residents broke down in tears. The chief stares off into space. His words resonate in my head.

"Hope and pray that you never have to do that enough in your career that you get as good at it as I have."

Bypass was stopped 2 hours later. Within minutes, the brown-haired little girl, who should have been home watching cartoons, had passed on.

I was sent home to study for my shelf exam. I sat starting at my question book, but no studying would be happening that night. I logged onto the EMR and looked at her chart again. I looked at her echo again. I read the note I had written on her earlier in the week when she had been in the PICU. We had been instilled with the proper fear of a saddle embolus during our first two years of med school, but this was the first time I had seen one clinically and wanted to make sure all the information about the situation was seared into my brain. But mostly I simply sat there. And thought. I couldn't shake the feeling of guilt clawing at my stomach. This will be one of those centennial moments of my medical training: the first time I actively participated in a code, the first time I performed CPR on a patient, the first time I witnessed a truly horrific conference with parents, the first time I saw a member of the team collapse in tears, the first time I watched a patient die without forewarning. This was an important day in my medical career. But it is a sadistic reality that my education requires bad things to happen to good people.

So, to the patients of that little brown-haired girl: Thank you. Through your tragedy, I gained valuable experience that one day may perhaps enable me to save someone else's life. And know that I would gladly exchange all that experience for a picture of your daughter, clutching her pink backpack, grinning with her missing front teeth, on her way to start the first grade.