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!

Flying Solo

Few things represent the hierarchical and tradition-seeped natures of medicine better than the operating room. As many med students will attest, half of the battle of the general surgery rotation isn't learning the post-operative management of surgical patients or how to properly manage a wound infection - it's learning the ebb and flow of the operating room. Tales abound which serve to strike fear and trepidation into subsequent generations of medical students of students being yelled at for touching something, looking at something, breathing improperly, blinking improperly, etc, etc. There's a procedure and tradition for every minute detail of the choreography of the OR, and you are expected to know it all before you learn it all, which contributes to awkward or embarrassing moments aplenty for medical students as they rotate through. I remember when I got yelled at while participating in a patient transfer off the operating table. I was the one pulling the majority of the weight on the rollerboard, and assumed it was my responsibility to do the countdown. 3... 2... 1... I get glares. I'm told to step away from the patient and not touch anything anymore. Turns out it's always Anesthesia which does the countdown, which is logical as they are overseeing/moving the airway, everything that happens in the OR is logical, but how in the hell was I supposed to know that beforehand? Such is life sometimes for a medical student in the OR - expected to know these things, before anyone tells them. In my own limited time in the OR, I have collected a small bundle of mortifying anecdotes. The time I almost desterilized the entire instrument table with a sneeze, the time I put the SCDs on upside down, the time I almost face-planted into the operative field when I slipped on some sigmoidoscope-associated KY jelly which had dribbled onto the floor... the list goes on.

But this post isn't about embarrassment; it's about hierarchy. When standing around the surgical field, there's also a rigid structure to where one must place one's feet. Traditionally, to the upper right of the patient, by the patient's right armpit, stands the lead surgeon. The lead surgeon is, by virtue of the position, the individual in charge of directing and performing the majority of the operation. To the left of the lead surgeon stands the scrub nurse or scrub tech, whose job is to, among other things, maintain sterile technique during the operation, pass instruments to surgeon during procedure, and help perform counts of surgical instruments throughout the procedure. To the upper left of the patient resides the individual providing first assist to the operation - who, among other things, uses the bovie to cut vessels and tissues at the lead surgeon's discretion, helps provide traction to tissue planes to aid in dissection, etc. And to the right of the first assist lies the domain of the medical student: the position of second assist. Here one typically aids in the operation by holding retractors to open the operative view, use suction to remove smoke, fluid, and blood from the operative plane, and tightly covet the Mayo scissors that one uses to cut suture ties. But with the myriad of surgeries and surgical approaches out there, there's also a wide variety of places where the surgeon and assistants stand to get the best exposure into the surgical field. And just likes plays on a football field, its up to the medical student to learn where to proverbially 'line up' for the snap. In an academic institution like my own base of operations, typically a resident provides first assist during the operation and the medical student stands beside as second assist for the operation. But during chance opportunities, such as when the resident is taking the lead on a case, med students are given the opportunity to run first assist, which is infinitely more fun for obvious reasons - namely, being able to more actively participate in the case. Rarely, a med student is offered to take the lead on simple cases (appendectomies, cholecystectomies, etc), which is always something worthy of writing home about, no matter how mundane the case may be for everyone else in the OR.

So a couple weeks ago I was spending a day in the OR with the ENT surgeon who I'm doing research with and a third year resident. We were powering through several of the half dozen cases on the docket for the day and next up on the case list was a simple tonsillectomy. The resident gets called down to the ED for a consult, and suddenly the attending turns to me and says:

"Want to take a whack at it?"

The third year of med school is a lot like the game of golf. All too often, you find yourself feeling incompetent, frustrated, disheartened, or some combination of the three. As your shot out of the shrub grass careens off the tree and lands in the water hazard you didn't take into account, you begin to ask yourself why you even play this stupid game to begin with. But a handful of times during a round, the balls rises gracefully into the air and plops, like it should, down onto the green within spitting distance of that birdie. And before you know it, you're paying another set of green fees and are back for more. Likewise, third year is full of foibles and f*ckups, sometimes asking yourself why you're doing this for the rest of your life. But every once and a while, you get to see or do something incredibly cool that reminds you why you're in it in the first place. And you come back for more.

Well this moment was my proverbial 240 yard approach shot plopped down 6 inches from the pin. The first time I get to take the lead during an operation. I step into position above the patient's head and gaze down at the base of the mouth. Just as I get bovie in hand, the attending laughs and says: "Don't worry... the first tonsillectomy I ever scrubbed on, the patient lost 1800ml of blood. The bar's set pretty low." Great. My resting tremor kicks up a couple notches.

But before I know it, we're off. I go in alongside the anterior tonsillar pillar, find the capsule, and before I know it, the procedure is over. Less nervous than I thought I'd be, but still trying to contain the 8 year old inside of me jumping off the walls going "WOW! That was COOL! Let's do it AGAIN! WHEEEE!"

Yup, back for more.