If there's one thing that every medical student knows, its that medical school is really just a bunch of humbling experiences all strewn together under the ruse of "education." Most people out there know that doctors are smart. And that they know lots of stuff. But I don't think anyone can truly realize how much there is to know and how much practicing physicians DO know as part of their daily functioning. I have studied day and night for 8 straight months and still am barely able to interact on a fairly elementary level. And just when you start to forget that and start to think you might actually be making progress on this whole doctor thing, bam, along come some attending wielding his massive sword of knowledge, striking you down from your high horse to go mingle again with the peasants.
Take for example today in clinic. I was talking with a pediatric hematologist about an interesting patient I was about to see with him - a 17 year old patient with Blackfan-Diamond Anemia. The typical first line of treatment for this disease (a erythroid progenitor disease that prevents red blood cells from properly maturing) is steroids in hopes of resuscitating the patient's own marrow's ability to pump out those cute little RBCs. So the physician was discussing the various steroid treatments they have tried on this patient and asks me "do you know what some common clinically pertinent adverse effects to steroids?" I proceeded to stare at him like a stoned pufferfish.
Now, deep in my brain somewhere, I actually know some "common clinically pertinent adverse effects of steroids." They include weight gain, hypertension, osteopenia, and psychosis. But like 99.9% of the things I've learned this year, they were stuffed into my tired and overfilled brain and subsequently left to dissolve back into this bizarre long term memory twilight zone where they come back to me during weird moments like when I'm watching Futurama on a Monday night (read: now), but never when I actually need them.
Massive Sword of Knowledge: 1
Me: 0
Of course, I currently hold the ultimate wild card: the totally awesome "I'm a first year" card. Play this card in any situation and the attending will smile with a fond reminiscence at you, reward you for demonstrating any shred of medical knowledge whatsoever, and then proceed to explain things to you at the level of a first grader. If you've been there, you know what its like, and its truly hilarious.
But like all good things, the totally awesome "I'm a first year" card will come to an end. In exactly 10 weeks (not like I'm counting) I will graduate from a cute little first year to a second year. And then I might be actually expected to know something.
Uh oh.
The first reaction most people have when I tell them I'm working pediatric oncology right now is: "Wow, that must be tough."
And you know what, it is.
Cancer is a nasty and tragic disease, and is particularly evil when it exerts it ravages on the young and innocent. So when I started my term through pediatric hematology/oncology, I was really curious to observe how the various docs went about dealing with such heart-wrenching tragedy in this unique field. Yet, so far I've found there's no secret formula used here. Physicians treat children's cancer the same way most physicians in any area of medicine do: by separating the patient from their disease, and going like hell after the disease. By looking at outcomes and odds instead of any patient's individual fortitude or attitude. By using established regimens instead of letting bias of how well they think one patient may tolerate a specific treatment cloud their judgment. But, just like other areas of medicine, it doesn't protect you from the real tragedies - the patients who fight like hell, who beat the odds. The patients who are a true joy to work with, but who ultimately succumb to the very odds they have proven wrong for so long.
The entire clinic loves this one patient - I'll call him Ricky. Ricky is a hilarious, upbeat, smiling 11 year old boy. Who has had acute lymphoblastic leukemia 3 times. His latest relapse came last year and he had a successful 3rd bone marrow transplant about 150 days ago with successful engraftment. Odds for kids with relapsed ALL aren't good. We have about an 80% cure rate right now if it's your first bout with the disease. But for the 20% with a first relapse, their odds of a second relapse skyrocket to nearly 80%, and each ensuing relapse it more difficult to treat as the toxic effects of chemotherapy ravage the body and as each generation of cancer cells grows more and more resistant to typical therapies.
Still, Ricky was looking to beat the odds again. His 3rd bone marrow transplant had established well and they were working on getting Ricky to taper off his immunosuppressive drugs. Everything was going great, and about 2 weeks ago the mom brought in Ricky cause he was feeling a little under the weather and his sister had recently had bronchitis. Since Ricky was still on immunosuppression, we did an xray (which came back negative) and told mom to come back in 3 days if he didn't start feeling better.
Sure enough, that next Monday, Ricky and his mom were back, and Ricky wasn't feeling any better. A second xray was ordered, and bad news: something was definitely growing in Ricky's lungs.
They immediately admitted him, but this sort of thing happens a lot with immunosupressed post-transplant kids (especially if they are back to school (a.k.a germ factories) while they are on them), and it would be expected he would be home within a week after a round of our big gun antibiotics.
I saw Ricky the Monday when his mom brought him in the second time.
And I saw Ricky in the PICU a week later, being intubated because the infection has steadily progressed. The last thing I heard him say before I left the room was "I'm going to die."
In normal people who get sick with community-acquired pneumonia, the culprit is a soft gram positive little bug called streptococcus. And most immunosupressed kids who catch an infection while out and about in the world catch your garden variety strep (or one of the several other common bugs you yourself are very familiar with from every time you get a cold or a cough). We got lots of different guns (drugs) to kick their butts. Streptococcus has a characteristic way of showing up on the xray, building up down in the base of your alveoli of your lungs.
But that's not what Ricky's xray looked like. Whatever was growing in Ricky's lungs grew is a diffuse, wispy, spider-web like pattern on both sides of his lungs. Not good. Ricky had pneumocystis carinii pneumonia (PCP).
It's very rare for healthy people to get PCP, as our immune system is pretty adept at targeting and attacking it. But in the immunocompromised and immunosupressed, its a nasty, nasty fungus that is incredibly hard to treat. It was one of the biggest killers of AIDS patients early in the epidemic before we had good prophylactic and anti-viral therapies.
Yesterday, Ricky passed away. It's tough when a kid succumbs to a disease, but especially a kid who has fought so hard his entire life and was doing so well, who finally lost to the odds he had beat for so long.
But if there's a silver lining to tragedy, its that it lets us appreciate the blessings we have in our own lives. And the reason people keep fighting to beat the odds is because people have fought before them. Ricky is an inspiration, even if the end of his story didn't go as we all would have hoped for him. So we keep fighting.
Good news for me: Goodbye kidney. I have now put in my requisite time for the year learning about pee. Yippee.
Leading up to this last exam, I've noticed a trend that's been developing over the last few months. See graph:
The funny thing about burnout is how it sneaks up on you. Time starts to slip away from you, the days start to blend together, and before you know it you're sitting in starbucks with 3 empty venti cups strewn about you staring bleary eyed at the same page of notes you've been looking at for the last 1/2 hour, listening to the crazy woman in the corner talk on her corded phone thats not hooked up to anything, then getting a free 4th coffee from the barista who looks at you with a sad sympathetic look in her eyes as she says "you're always here."
Thanks for the free coffee.
Luckily, I have two of the most potent drugs possible for combating the dreaded burnoutosis (its not quite developed into a full blown -itis yet). The two magical medicines are:
-SevenDaysOfDrunkenessonix (generic name: spingbreakatol)
-Guinnessium (generic name: stpatraxia)
Applying my mad pharmacokinetics skillz obtained over this last block, I had my proper loading dose of stpatraxia on Saturday and now plan to work my way into therapeutic levels tomorrow, March 17th, the greatest day of the year. Hopefully this can help keep off some of the more severe symptoms of burnoutosis until I had get onto a steady regimen of sprinbreakatol on Friday. And yes, my life has now degenerated to the point where making lame jokes turning fun things in my life into fake drugs is highly amusing to me.
I have a couple cool stories from clinic to share sometime soon (one thing I've learned about pediatric oncology - there's always stories), but given my current level of motivation (read: none) it will have to wait. Maybe when I'm sufficiently medicated with springbreakatol (I'm so funny!)
They say in medicine everyone has their favorite organ. I think that's true (mine's the heart). Even my preceptor, who as an oncologist deals every day with a multi-system approach in her practice, didn't even have to think about hers and rattled off the thymus right after I asked. The human body is a beautiful and awe inspiring thing, and everyone eventually finds some particular facet especially elegant and thought provoking. Personally, I love the heart for its power and its simplicity - the way it utilizes electrical and fluid dynamic principles to amazingly fine tune such a critical and demanding aspect of our daily functioning as circulation. The dramatic way disease manifests itself when things go wrong. The way, in a congenitally deformed heart, things can go from horribly awry to just fine within minutes by simply moving some pipes (vessels) around and taping (suturing) everything in place.
But I'd like to counter that point with another point. Everyone also finds an organ they hate.
Mine's the kidney.
Now I am a very fun loving and agreeable guy. I have a great sense of humor and make an easy friend. So I don't throw around the word "hate" very often. I have only used the word hate in a few sorts of circumstances in my life. I hate Paris Hilton. I hate steamed squash. I hate the Santa Clara Broncos men's basketball team (sorry guys). I hate people who try to merge onto I-5 at 35mph.
And I hate the kidney. I have since the very first day I attempted to learn about it, back in high school. I hated studying it for the MCAT. I hated questions about it on said MCAT. I hated it in anatomy. In histology. In biochemistry. In physiology.
Needless to say, we're studying the kidney right now, which puts my effective motivation to study at about... 0%. My dreams are haunted by podocytes, GFR, aquaporins, and that douchebag Henle.
Why do I hate the kidney, you ask? Well, like anything involving hate in this world, I don't really have a good reason. It's a completely irrational and unfounded hate. Maybe because it makes pee. Maybe because its involved in the renin/angiotensin system (does anyone actually enjoy learning about that?). I can appreciate how important the kidney is. I can appreciate what it does is impressive. But its not fun or exciting.
One day, I may have it in my heart to forgive the kidney. Make up with it. We can be friends. But not today. Today, and for the next two weeks, you will officially be number one of my hate list, Kidney. Lock your doors.
They say if you want to go into surgery you have to love the OR. I've always said yeah... that makes sense. You don't become a professional baseball player if you're allergic to grass.
Which brings me to one of the most disconcerting experiences of my life. From a very young age, I was fascinated by surgery. I watched operations on the Discovery Health Channel, the UW Medical Channel (which conveniently got pumped through the cable into my dorm room in college!). I've always envisioned myself as a surgeon. Told people I wanted to be a surgeon. People always told me I looked and acted like a surgeon. Hell even my Meyers-Briggs test matched me as a best fit into... surgery. Which brings me to my first OR experience in medical school.
After the initial thrill and the incredible sight of the surgeons disassembling someone's body (dramatic embellishment) and the OH MY GOD I'M IN SURGERY! ... I was bored. I'm almost ashamed to type it, but I was. My legs ached from standing, my goggles kept fogging up, and I couldn't follow what was going on. It was horrible.
The good news: things got better. The surgeons let me do a couple menial things a few times, which helped keep my attention better. But it still felt boring. And it scared me, because I almost felt like my visions of my future self were slipping away, and needless to say that was a bit frightening.
At the beginning of our Systems Processes and Homeostasis block, we got to sign up for a variety of labs which helped reinforce a variety of the concepts we were taught in class. One of the labs was a controversial lab where we worked with anesthetized live pigs, learned how to put in central lines, and observed various effects of the cardiovascular system with some manipulation.
I signed up for it, mainly because it sounded like a cool experience. I arrived in the lab this week and found our team's pig on the table, quietly unconscious and on a ventilator. Our team divvied up tasks and the task of cutting into and exposing the internal jugular vein in order to insert the central venous line landed on me (with a little bit of coaxing by myself).
Now, I've been through 12 weeks of anatomy and dissected and studied the entire human body (which was equally thrilling and boring). Any medical student can attest to the fact that working on a cadaver is both an exciting and frustrating experience. Things adhere to each other, vessels and nerves snap if you don't meticulously search them out beforehand.
With that in mind, I made my very first incision into live tissue. Unlike preserved tissue, the scalpel glided through the dermis as smooth as silk. The capillary beds bled then closed off as the body's clotting mechanisms kicked in. I found the fascial layer beneath the dermis and slowly dissected to open the incision. Unlike in a human, where the jugular is conveniently located in the easily exposed neck, in a pig it is buried down beneath layers of muscle and connective tissue. I delve deeper, finding an experience completely contrary to that of anatomy.
And it all clicked. I saw the thyroid gland, sitting with its glistening arteries wrapping themselves around the enclosed clusters of thyroglobulin. I saw the recurrent laryngeal nerve looping back up supply CNS control. I found the carotid, briskly pulsing with the powerful pressures of the heart. The vagus running down along as its mate to its destination on the heart. And I found the jugular, slowly pulling it out of its enclosing carotid sheath.
I finally understand and appreciate surgery. The elegance of it, the concentration needed during it. The care and the meticulous nature of it. I can understand why it can seem boring if you're not locked into the moment of it, but when you're involved in it, when you're focused so intensely on what you're doing, focused so intensely on what you're planning next, its like being in 'the zone.' If I end up in surgery (and I'm keeping an open mind throughout medical school) I think this will be the experience that I can look back and point to that sold me on it. Which is funny. Because if that's the case, I didn't decide on surgery because of some dramatic and amazing experience in the OR with a human. It will have been because of a pig.
Jesus, my future professional career can theoretically now be traced all the way back to Babe. But you know what, I think I'm cool with that. Word pig, ya did good.
BTW... Props to the 480, Arizona. The land of desert, desert, concrete, and more desert. If I was a rattlesnake, or dating a professional ice skater, I'd live there.
It's amazing how thing's in life come full circle. While in college, I was a 'child life' volunteer during the summer at Doernbecher Children's Hospital in Portland. We really didn't do much of anything clinical, but it was a great opportunity to get to know and connect with a great number of brave and incredible children (and families). I operated mainly on the 9th floor acute card ward, but would occasionally float up to the 10th floor cancer ward. Needless to say, the kids I met up on the 10th floor provided me with some of the most inspirational encounters of my life, and ultimately shaped my decision that no matter what area of medicine I went into, I wanted to subspecialize into pediatrics (screw the lower reimbursement!).
Well, I'm back. For the next 13 weeks, my clinical preceptorship will be on Doernbecher's 10th floor following and learning from a pediatric hematologist/oncologist. Nearly 3 years ago, I roamed the halls with a bright blue volunteer polo with a big red wagon in tow. Now I'll be roaming those very same halls with my white coat in tow. Besides the obvious opportunity for my own personal reflection on how far I've come in those past 3 years (and even past 6 months), it gives me a great opporunity to integrate those incredible experiences which made me want to be a physician in the first place into my current medical education and growth.
Cancer is tough. When kids get cancer its really heartbreaking, on an indeterminable number of levels. But the kids in pediatric oncology also showed me one of the greatest aspects of working with children in medicine: kids fight. They fight so damn hard. It's what makes pediatric oncology one of those most interesting areas of medicine in my eyes. The failures are that much more gut-wrenching. But the success is even more rewarding.
I think this is a great way for me to round off my preceptorship experience for the year. I got to work with an orthopaedic trauma surgeon... and learned that really wasn't for me. I got to work with a cardiology specializing in congenital heart disease... and learned that right now my passion still lies along those lines. And I get to work with a pediatric oncologist... which means I finally start to get to see and work with kids again.
That's my update for now. We just finished a particularly brutal stretch of the curriculum, 3 exams and 2 quizzes in 4 weeks. One more exam next week and I'm back to normalcy. And on that note, I'm out.
As a first year medical student, they don't trust you to do a whole lot around the clinic or on the wards (and frankly, I don't blame them). So we make do by finding excitement in the little things. "Dude, you got to TAKE OUR SUTURES today? Awesome!" "I can't believe they let you disempact the patient's bowel!" "Whoa, they actually let you CUT the tendon?! NO WAY!" This week, I got thrown a bone of my own.
I got to push a button.
Now, I know what you're saying. But this wasn't just any button. This button was hooked up to a machine. A defibrillator more specifically. And pushing that button delivered 250 joules of energy through a man's chest, lifting him several feet off the bed and returning his heart from abnormal atrial flutter to boring sinus rhythm. Ah, cardioversion.
It went down like this. It was my last week in cardiology clinic and we had a whole 
two patients to fill the next four hours of time. So my preceptor, bless his soul, decided to send me up on the hill to follow a patient from earlier who was being admitted to observe his cardioversion. Y'know, last week in cardiology, might as well see the cool stuff. So I find the appropriate room, give the fellow the rundown, and we go in and meet the patient. Really nice guy, with a great attitude and sense of humor. And as I introduce myself, I say "Hi, my name is MedZag, I'm a medical student who is going to be observing your cardioversion. Don't worry, they won't let me push any buttons or anything. Ha. Ha. Ha." Wow, either I'm a horrible psychic or have an incredible sense for irony. We get the pads all hooked up, get him sedated, and page the attending. The attending arrives (*dramatic music*), checks all the numbers, and gets ready to give the go ahead. Just as the moment arrives, he turns to me, standing in the corner (oh my god! he noticed me!), and says the words that made my week:
"You want to do it?"
Now the appropriate response would have been something along the lines of "Yes, sir, I would appreciate the opportunity to further expand my medical experience." Instead, all I was able to mutter was a highly confident and assured... "Sure." So the attending shows me how to set the appropriate knobs and dohickeys on the defib (yes, $40,000 a year towards my education and I still use the word 'dohickey'), shows me the charge button and the big red discharge button, and makes very damn well that I "hold down the button" when I press it. Then the time comes. The countdown... 3... 2... 1... and BAM! I press that button better than any first year medical student has ever pressed a button, held it down TWICE as long as needed to prove that I'm a good listener, and watched as the patient's back arches and his body rises two feet off the bed. The EKG goes crazy then slowly settles down and... normal sinus rhythm. Damn, he's good.
The attending says "good job," I reply with an equally confident "thank you," while my brain is screaming "OH MY GOD! That was freaking AWESOME! OH MY GOD! WOW! JUST WOW! OH MY GOD!"
It's the little victories that get me through the day. Soon enough, I'll yawn at such experiences as I move on to bigger and grander things in my medical career. But I'm really just trying to enjoy the journey along the way (said after a long weekend slaving over autonomic physiology and pharmacology which has subsequently leeched all the joy out of this week). And damn, it's never been so much fun to push a button before.
BTW... 1000 visitors. CHEYYYAAAAA!!!! Visitors from Libya, Nigeria, Pakistan, and the Netherlands. New Hampshire, Minnesota, Tennessee, and Nevada. Very cool stuff.
Take for example today in clinic. I was talking with a pediatric hematologist about an interesting patient I was about to see with him - a 17 year old patient with Blackfan-Diamond Anemia. The typical first line of treatment for this disease (a erythroid progenitor disease that prevents red blood cells from properly maturing) is steroids in hopes of resuscitating the patient's own marrow's ability to pump out those cute little RBCs. So the physician was discussing the various steroid treatments they have tried on this patient and asks me "do you know what some common clinically pertinent adverse effects to steroids?" I proceeded to stare at him like a stoned pufferfish.
