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?