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.