As of May 2010, Michigan will go smoke-free. That means when I go out to restaurants, bars and clubs my hair and clothes will no longer reek of cigarettes! Even better, I won't be increasing my risk of practically every medical ailment for the sake of being social.
I went on a date with a MBA student this weekend and during our conversation he asked how our classes work (since we don't really get electives or any control over our schedule at all). I honestly had never looked at how many credit hours we take because it never seemed relevant. So I looked it up. I also looked up the requirements for the MBAs for comparison.
Total credit hours in 2 years for b-school: 57
Total credit hours in 2 yrs (pre-clinical) for med school: 97
Years it takes an MBA to earn back the debt and lost salary: 5
Years it takes an MD to earn back the debt and lost salary: 20-40
The MI chapter of the American Academy of Pediatrics had an open forum meeting tonight, which I attended. It was interesting to attend a meeting of physicians that really had nothing to do with medicine or providing care. The two hours were spend discussing Medicaid reimbursement, disproportionate share payments and the requirements for re-certification; specifically the quality initiative requirement. I have strong opinions on all of these issues, but the one I will disucss now is re-certification.
Re-certification, which must be done every 10 years, requires four things:
My much-anticipated new shoes came - limited edition pinstripe Jack Purcells. I love them. Super preppy with a twist. So perfect. They took their inaugural walk to get me to IV clinic and back.
IV clinic is where the emergency department docs teach us how to place IVs and subsequently give us equipment to practice on each other. My friend J and I stuck each other three times. It turns out placing IVs in the hand is both more difficult and more painful than in the arm.
I watched the premiere of Scrubs season 9 and was disappointed. What the hell were all the first year medical students doing on rounds, in scrubs and working with patients? Your first two years (until you take and pass the boards) you are lucky if you shadow rounds - you are definitely not let loose in the hospital. Not to mention you would definitely not have a class called internal medicine before you've completed something as basic as anatomy. C'mon writers. Seriously.
Speaking of boards, I've turned in my registration for mine. I'm aiming for April 26... USMLE step 1 is officially on my radar.
I haven't been in the OR since Oct 14th, but I'm on call this Thurs-Sun. Here's hoping for a liver. Except maybe not Sat night (day is fine) because I have a date and I would kinda like to make it. Even if I have to show up with a pager and track marks (from IV clinic). Actually, Sat would be a good time to get my autopsy requirement out of the way. So here's hoping for a dead body and a life-saving liver, all in one weekend.
One of the blogs I read recently had a patient come in with Flea-bitis. It reminded me of a mother who brought her son in to neurology clinic for a second opinion. Apparently he had been diagnosed with something that sounded like Gardenias. The neurologist and the NP threw out a series of potential neurologic conditions... Guillian-Barre, maybe? After a quiet moment, I volunteered, do you mean Myasthenia Gravis? Yes, she did.
Recently, characters on tv have taken to enrolling in medical school. For example, the revamped Scrubs show will be set in medical school (the original started in residency). I'm actually quite curious to see what Scrubs does with this as the first few seasons were a fairly realistic portrayal of life as a resident.
On Brothers & Sisters, the youngest son and war vet, Justin, started medical school this season. His classes don't really seem anything like mine, but that could simply be a curricular difference. Medical schools all teach the same facts the first two years, but the approach to disseminating the information is quite varied. What was interesting though, it that they wrote him as a stressed out character that became removed from everyone else in his life. He lost track of much of the family gossip and was not there to support his girlfriend during his midterms; even telling her "there are going to be times when I'm not there for you."
I actually really appreciated this portrayal because honestly, that's how it happens. Like it or not, everything else comes second to medical school. Right before a final exam, your laundry, the dishes, phone calls to parents, gchat - everything is put on hold. If you're dating a medical student and you have bad news - hold on to it until the exams are done. Think of it as a preview for life to come: if you marry a doctor you will always come second to whatever patient is on the other end of that beeper. My 10 year anniversary? My daughter's first ballet recital? Your father's funeral? If I'm on call and that pager goes off... I have to go.
We joke about it sometimes, but I'm a little scared. In not too long I will be responsible for people's lives. I am leaning towards pediatric subspecialties; that could be your child. And if it was your child - consider - aren't you glad that I put everything else second to my education?
While gchatting (ostensibly studying neurology) a friend sent me a news story (from the science section?!) detailing how much skin a woman should show to maximize attractiveness to nearby men.
Methods: This was an observational study in which the authors used percentages of the body to determine the amount of exposed skin. Each arm was 10%, each leg 15% and the torso 50%. They they counted how many times each woman was approached. Neither the men or the women knew they were being studied.
Results: Women showing more or less than 40% exposed skin were approached less frequently.
Conclusion: Women showing less than 40% sent "prude" signals and women showing more sent "whore, adulteress" signals.
My immediate reaction was not "what a stupid thing to study" or "how can they claim to know what the men were thinking" or even "how does the methodology account for the possibility that the 40% women just happened to be the hottest regardless of clothing".
No, my reaction was: they got the body percentages wrong! Commonly used body surface area percentages for estimating burn injury are shown in the picture.
picture from UofM burn website: http://www.traumaburn.org/referring/fluid.shtml
Thanks to medical school I now know:
- The annoying twitching that my left deltoid has been doing all day is called a fasciculation.
- My myopia will likely mean a later onset of presbyopia (compared to non-myopes).
- When I was a child I had a form of parasomnia (I sleep-talked; c'mon, who's surprised?).
- Neurologists like disorders with either 1) long names or 2) eponyms 3) both for the same syndrome (ex. acute demylinating polyradiculoneuropathy aka Guillian-Barre)
- Ophthalmologists also like long names, but prefer they end in "-ia" (ex. internuclear opthalmoplegia)
- If you eat contaminated pork, you can get pork tapeworm (T. solium), but if you eat a carrot contaminated by someone with pork tapeworm you get neurocysticercosis so cook those carrots good (see picture above).
- Laser Assisted Subepithelial Keratomileusis (LASEK) surgery involves shearing a flap into your cornea, while you are awake (with analgesic eye drops, picture).
- Anesthesia is technically only central nervous system depression. When you are put under you also get neuromuscular blockade (paralysis), analgesia (pain control) and amnesia (no memories).
- A symptom of hepatic (liver) failure or renal (kidney) failure is asterixis (characteristic hand flapping). It is likely accompanied by encephalopathy (altered mental status). Oh, and you're in danger of dying, soon.
Recent quotes from lecture:
"Our country handles schizoid personalities very well. That's why we have software engineers, pathologists and Montana." -Dr. J
"Biopsying an aneurysm is not a successful procedure." -Dr. G
"If someone's head is cut completely off, that's not an emergency - that's a tragedy." - Dr. G
Medicine is full of big words with very specific meanings. Here is a fun paragraph from today:
Internuclear ophthalmoplegia (INO) is indicative of a particular opthalmoparesis. It is a disorder of conjugate lateral gaze in which the affected eye shows impairment of adduction. When the partner eye is abducted, it diverges from the affected eye. This produces horizontal diplopia. During extreme abduction, compensatory nystagmus can be seen in the partner eye. Convergence is generally preserved.
You realise you washed suture with your white coat.
AND you're excited it's still in tact so you can practice.
I felt a certain pressure to match last year's pumpkin. I fear I did not manage it.
Last year:
This year:
I'm pretty sure I just heard Chase, on the show House, order Streptokinase and heparin. That would be a no-no. You can use tPa with heparin, but not streptokinase.
The environment of medicine is all wrong on the show, but usually the medicine (diagnostically) is accurate. Where was your physician-fact checker? Tsk tsk. I'm disappointed.
Time I got paged this morning: 5am
Hours of sleep I got: 3.25
Time I waited for my patient to pee: 8hr 37min
# 12oz coffees I drank in that time: 2
# times I peed in that time: 3
A recent assignment for school caused me to recollect a patient from my previous hospital. An excerpt (the original essay is several paragraphs longer) from my assignment summarizes the story...
The patient, an 8-year-old boy, was the elder of two sons of a recently immigrated family. He had been admitted for status epilepticus, which proved to be refractory. He was ultimately placed in a medically induced coma (which he continued to seize through for a month) and the parents were asked whom else they would like present for a discussion of his prognosis.
The family requested that a doctor from their home country be involved and so a teleconference was established. Various members of the care staff reported their opinions and summarized the boy’s course to date. There was almost as much silence as there was talking and each person was careful to solicit and answer questions. The questions themselves guided the discussion. The parents really needed to believe that every option had been exhausted. They believed that because we had been able to find an etiology, we should be able to find a cure.
From a physician’s perspective, after a month of seizing and coma there was likely to be little brain function left. A multitude of testing revealed a genetic defect in a sodium channel, which was blamed for the seizure activity. The boy was not a surgical candidate because the seizures were multi-focal and originated from both hemispheres. Everything had been tried and nothing would break the seizures, which were still occurring roughly every three minutes. There was nothing more that could be done.
Most of the conversation centered on the futility of our treatments. That we, as doctors, could not even promise he would wake up if we took away the sedatives. Eventually the parents chose to withdraw support. I think they knew their decision from the moment they sat down; they just couldn’t say it out loud. I didn’t get the sense we had persuaded them; more that we gave them a safe and justified way of letting go and not feeling as if they were bad parents, that they were simply giving up because it was hard.
It was then, when they stated their decision, that I was so thankful for the private room (not a patient room) the whole conversation took place in. The family had somewhere they could be where they wouldn’t be disturbed or overheard. Not by a nurse who needed to take vitals, not by a doctor checking on another patient. They couldn’t hear the business of medicine still working around them, healing some of the other children who would eventually be able to go home to their parents. But the room also allowed us, as the medical staff, to separate the conversation we just had from the rest of our work. When you walk out the door and back onto the ward, you leave the heaviness in that room and focus on health and healing on the floor. The spatial separation aids the mental and emotional one.
That separation is not learned with one conversation. Or maybe it’s always imperfect. But I do know that I was unusually quiet the rest of the day. When a friend needed sympathy later that night, I just couldn’t muster any. His problems seemed so petty. The boy was only eight and he was dead. Dead because of a sodium channel, which seems like such a insufficient and small reason. He had a little brother who clearly didn’t understand what had happened. He had a mom and dad that somehow had to keep going. And while I wasn’t consciously dwelling on it, something in me didn’t let it go immediately. Within the week though, the petty problems regained their gravity and the pressing concerns of work and medical school applications took over.
- * - * - * - * - * -
I have to admit that delivering bad news became easier. Maybe not in the moment, but my recovery got much faster.
With regard to the family in the story, the little brother had ongoing issues coping with his brother's death. I personally think some of this had to do with the fact that the parents never allowed the younger son to visit the older one (they didn't want him to see his brother sick or in pain). Then again, I am neither a parent nor a psychologist, so I am not at all qualified on the subject.
Today at noon the National Physicians Alliance Foundation and the American Medical Students Association held a National Grand Rounds policy panel discussion on the current legislation on health care reform. There were three panelists: one from the House, one from the Senate and one from Health and Human Services. The questions were relatively predictable, centering on access to primary care, the public option, tort reform and quality of care. The answers were similarly predictable: sound bites encapsulating pretty much what we want to hear and how historic this whole endeavor is. Pleasantly vague and bland, with little actual substance.
I would really like to see some of the legislators being honest about some of the real, and short-term unsolvable problems we're facing. How do we increase the number of primary care physicians to what we need when there aren't enough doctors going through school? How are we going to decide what medications and procedures are covered under the new insurance? How are we going to reduce the paperwork burden? How are we going to pay to insure/care for all these new people - most of whom cannot pay themselves? Because let's be honest, there will be a physician shortage in the short term and ERs will get even more crowded. We won't be able to cover everything for everyone. All these new committees and program will produce bureaucracy and without some planning, that will fall on docs and hospitals. And we don't have the money to cover all this new healthcare - either taxes will need to go up or spending will need to be cut. Public hospitals will need cash from the government to cover the services they have to provide to the population. Those are just realities.
The panelists all indicated in their introductions that their comments were off the record for any press attending, so it would have been nice if they had actually said something.
Interesting fact: Identical twin transplant recipients do not need immunosuppression.
Another interesting fact: The first dialysis machine was made out of sausage casings and a bathtub. (picture)
Health disparities fact: While ethnicity is not a match criteria for organ transplant, blood type is. Caucasians (who form the majority of donors) tend to be O & A blood types. African Americans, who have the highest need (for kidneys) have a much higher incidence of type B blood. (source: http://www.bloodbook.com/world-abo.html)
abscess
arrhythmia
component
dilated
epididymis
etiology
exercise
fourchette
gynecomastia
immunoflorescence
staphylococcus
wenckebach
I made an appearance at a local bar's grad night last night. None of my friends would go, but I met up with some classmates and made an appearance anyway. I was hoping at least one of the two cute guys I notice would be there. Neither was. A friend introduced me to his friend, an attractive German who was doing two months of research here. The German and I chatted for 30 minutes or so. Today I find out the German thinks my classmate is the most beautiful thing he's seen and that I was supposed to introduce them.
This comes after last weekend's fantastic ego boost of being told that I don't seem to know how to have fun. Not only did I let that slide, I was supposed to meet up with that guy later in the evening. He never showed.
FML.
Old woman to doc: Dr, When I arrived at the hospital I had one leg and now I have two!
Doc: Well, there is a war on, is it possible you miscounted?
-Dr. Who [episode 10 season 1]
I was in the hemodialysis unit recently, chatting with a patient about how his life had been affected by HD and how he generally feels. As corny as it may sound, I find these touchy-feely encounters with patients to be incredibly rewarding and informative. I think those of us who are healthy underestimate the impact of chronic disease, but simaltaneouly underestimate people's adaptive resiliance. This summer I have been fortunate to have several one-on-one opportunities, but group interactions of this kind are a regular part of our medical school curriculum.
Anway, this one was especially awkward because the patient proposed to me several times and repeatedly offered to have my children. He was neither demeted nor joking. He wanted to take me out to dinner that night and put a ring on my finger. He thought it was a genetic imperitive that I breed because I (apparently) am "drop-dead gorgeous and a genius." Just about every question I asked was answered with some variation on this theme (along with some genuine insight into renal failure) for almost two hours.
An example interaction:
Me: Do you have other health problems too?
Him: I'm healthy enough, if you know what I mean; no disrespect.
Me: How about high blood pressure or high cholesterol?
Him: Yes, I got both of those, lady.
Me: Are you on medications for them?
Him: Yes, but I don't take em. I don't believe in pills. I seen to many people die from pills.
Me: I suspect those were different kinds of pills. It's important that you take your medicines.
Him: I feel fine. I'll take them if you hand them out though.
Me: Your health could get a lot worse if you don't control your blood pressure and cholesterol. You want to make it to transplant don't you?
Him: I would take them if I had you to come home to, lady.
Me: Do you live with anyone now?
Him: No, you can move right in. I'll take you out to dinner tonight and put a ring on your finger.
I went to bed excited because we had consented another patient for our liver transplant study. The OR schedule said they would induce the anesthesia at 10:30am, so I hit the sack just before 2 with my alarm set for 9. At 4:46 my pager goes off. They are inducing now. I head straight to the OR where I find out that this is expected to be a tricky case. I have had 3 hours of sleep and haven't eaten since 8:30pm the previous night. I emerge from the OR at 10:30am, put the samples on ice and head straight to Einsteins for a large coffee and a honey wheat bagel with honey almond smear. Never tasted so amazing.
The surgery itself was longer than the last one I observed, but they didn't have to use any blood products and were able to extubate before sending the patient to the SICU. It speaks to the skills of the surgeons and anesthesiologists in managing the anatomy (surgeons, no blood) and physiology (anesthesiologists, not acidotic).
The patient was awake when I went up to the SICU for the 2 hour post-op samples; the family was there too. It's really kind of fun when you can say you were in there with the patient the whole surgery.
I left the hospital around 2:45pm and was kind of dragging this afternoon, but I just had some coffee and a chocolate chip cookie. Nothing like caffiene and glucose to keep yourself on point.
There's another harvest this afternoon. If they keep the liver in house there's a chance I'll have another surgery this evening, although it looks like the graft is of poor quality, so I may get some sleep instead.
Before medical school I took a quiz to see which medical specialty I should be. Those answers are here. I retook it now (beginning of M2 year) to see if it's changed at all. Apparently, the new list is:
1. Thoracic surgery
2. Urology
3. Plastic surgery
4. Orthopaedic surgery
5. Ob/Gyn
6. Nephrology
7. Neurosurgery
8. Infectious disease
9. Cardiology
10. Nuclear Medicine
Apparently I am straying farther into surgery and surgical subspecialties. It is worth noting that the quiz does not separate pediatric specialties from adult. If I remember, we'll try again after third year and see if I'm any different then.
(18:21) I get the email that there is to be a liver transplant at 20:30.
(20:07) I get the page that says the transplant will begin 21:00.
(20:14) I get the page that says the transplant has been canceled.
(22:00) I go out dancing instead.
Turns out carrying a pager in a club makes you attractive. A law student asked for my phone number.
Cirrhotic liver. The kind you take out, not put in.
A class one rolled in with the survival flight paramedics; he had been broad-sided in a MVC. He looked to be in surprising good shape: unstable pelvis and dehydrated, but good vitals, responsive pupils and moving all four extremities. The CT scan, however, told a different story and he went up to the OR emergently: 3 perforations in his bowels, multiple pelvic fractures (with bleeding) and an aortic dissection. He went straight from OR to IR to BICU... we'll see how he does.
It started off well. I was studying in a coffeeshop when my trauma pager went off. It's silly, but I felt a little cool reading the page out to my friend and booking it out of there.
"Class 2 M, Go cart vs truck, blunt, 115/78, not intubated, unk GCS, ETA 8 min"
It turned out the patient was pretty much ok - just a closed tib/fib fracture. He had been transferred to our hospital mostly because of questionable change in mental status, which it became quickly clear was not the case.
On my way back to my car to drive home and contine studying (well, doing write-ups on clinic patients) the pager goes off again (in front of more people!).
"Class 1, M, ATV vs tree, blunt, 123/80, intubated, GCS 3, ETA 10 mins."
It turned out ATV vs tree was actually fell-off-the-back-of-moving-pickup-truck. For those non-medical folk, GCS of 3 is very bad. It's a scale of 3-15 based on eye opening, movement and vocalization. A 3 means you have none of the above. He displayed from priapism (look it up if you don't know), indicating decreased sympathetic tone. On CT he had an impressive skull fracture and significant uncal herniation.
While eating a delayed dinner, the pager again beeps.
"Class 2, M, dirt bike accident, GCS 15, not int, in ER"
Five minutes later...
"Adult, class 2, motorcycle accident, left ankle lac, 148/68, HR 118, GCS 15, ETA 5mins"
The trauma pager has beeped a few more times and I've seen multiple bike vs. car and a falling off a 30 foot ladder. Think chest tubes, intubation, consults with a neurosurgeon and lot of leg fractures. Any thoughts I had of becoming a bicyclist are definitely out. Mostly I just watch the trauma team in action, but occasionally I get to do things like put a gown on the person, stabilize the neck while rolling him.. small things of that nature.
I've also had two more gen med clinics. Yesterday's was particularly cool because Dr. K went in and did the appointment (without me), then sent me in to try my hand (observed by Dr. P). I asked my questions, did a limited physical exam and then explained what I thought it was and attempted to address the patients concerns and questions. Upon debrief with Dr. K and Dr. P... I got it RIGHT! I successfully diagnosed a real patient based only on information I gathered myself in real time. I have to admit, that felt really really good.
There was a second ego boost later in the day when the M4 on trauma rotation was quizzing the M3s on surgery about thoracotomy and pneumothorax. M3s didn't have a clue (and I knew all the answers, but kept my mouth shut because no one likes a show off). The current M3 class has been running around patting themselves on the back for their record-breaking board scores (their average was the highest at UofM ever), but they are being outdone by lowly little M2s in the trauma bay.
Rounds just ended. I did fine on the first half where we are walking from room to room. Even saw a man with 27% of his body surface burned by a bbq. Also saw a compartment syndrome fasciotomy on the anteriolateral lower leg. THEN we went to the conference room and went through another hour of patients just talking.... talking in a dim room... sitting down... after I'd been up all night... I REALLY tried to hold it together.
The trauma surgeon who was in the trauma bay over the weekend walks out of the room with me.
"Looks like your coffee is wearing off. Fighting a losing battle there."
And now I'm completely ashamed. Ashamed and embarrassed. And still really sleepy.
It's the morning of my first overnight in the hospital. I was here from 10am-4pm on Sunday getting samples for anesthesia and working on charts for cardiology. When I checked my email on arrival at home, I found out there was going to be a liver transplant that evening. I took a quick nap, ate some food and headed back to the hospital. I spent the night in the OR, pestering the anesthesiologists with questions and asking for samples. Did you know that post liver transplant the person will have no gallbladder? I spent the wee hours of the morning processing the blood and urine. I just returned from putting it in the -20/-70 freezers. In less than two hours I have trauma/burn rounds, after which I will run home to shower/change into professional dress and return to the hospital for noon conference and trauma clinic. At about 6pm I will be able to go home and crash. And you know what? It's fantastic fun!
I was getting some ice to prepare for the samples I am getting today when two doctors approached me. Keep in mind I am standing at an ice machine in an otherwise empty pre-op unit (non-emergent surgeries are not scheduled for weekends, especially not holiday weekends).
Doctor: Have you seen a big fat man?
Me: Excuse me?
Doctor: We're looking for a patient, Mr. L. He's ginormous, you couldn't miss him.
Me: I'm sorry, I haven't seen anyone like that.
Doctor: If someone was going to have surgery, where would they be pre-op?
Me: Here, but it's a weekend.
Doctor: Yes, I know, but we've lost him you see. He's missing.
Me: Sorry.
I'm not sure what's more concerning: that fact that they have managed to lose a huge fat patient or that the doctors had to ask the medical student where patients go pre-op.
This weekend brought the first liver transplant since I started taking anesthesia call and the first trauma page on my trauma block.
For anesthesia, my friend J was on call of the intra-op samples (I'm jealous) but I've been going in to the surgical ICU every day to take blood from the arterial line and urine from the Foley for processing. I'm sure there will eventually be a liver on my watch and I'll get to go into the OR.
For trauma, I booked it down to the trauma bays to watch the team take care of a young adult with an open tib-fib fracture from a motorcycle accident. I was hoping July 4th would be a heavy trauma weekend, but so far - not so much. Let's hope it gets busier over the next two weeks.
Ok, so I realise that my hoping for livers and trauma requires that people get sick and that it makes me a tad bit of a bad person. But really, these things are going to happen; I just want them to happen here (as opposed to in OH or some other place that I am not).
Dr: A man came into clinic yesterday with pelvic pain. This was his x-ray. What do you think is wrong?
Me: There is a flashlight up his rectum.
Dr: Exactly.
A 33yo woman comes to your clinic with bilateral cervical lymph node swelling and fatigue.
Examination: Afebrile. Several bilateral 1-2cm cervial lymph nodes that were soft, non-tender and freely movable. No other lymphadenopathy. Her chest was clear, heart sounds normal, but she had mild tenderness at the right costal margin on deep inspiration.
Lab studies: Hct 37% WBC 5,200/uL, ALT 75 units, AST 70 units, AlkPhos 140 units. UA nml.
What is the (infectious) differential? What testing do you want?
Hypoplastic Left Heart Syndrome (HLHS).
HLHS is a congenital cardiac malformation that falls under the heading of "single ventricle" defects. Essentially, the baby is born with only one functioning ventricle that must supply (actively or passively) both the body and the lungs. They also fall under the coloquial heading of "blue babies."
Typically HLHS babies will have a poorly formed left ventricle, mitral valve, aortic valve and proximal aorta. In order to promote delivery of blood to the body, the ductus is kept open by administering prostaglandins and in some cases the foramen ovale will be enlarged (in the cath lab or the OR).
Surgical repair for this condition is done in three stages: a Norwood procedure (with central shunt) shortly after birth, a hemi-fontan or bi-direction Glenn a few months later and eventually a full fontan at 2-3 years. Pictures and explanations of those in a later post. Sometimes the right heart cannot cope with the strain and transplantation needs to be considered.
HLHS occurs more frequently in boys than girls and has an overall prevelence of roughly 4 in 10,000 live births.
On a more personal note, a child I visited often in the hospital made it to her hemi-fontan, but her heart couldn't cope with the stress. She was on the transplant list for months and recently received her new heart. I was able to watch them close her chest three days post-op (in major cardiac surgery on infants they generally delay sternal closure) and she is growing stronger daily.
I have been cramming physiology, anatomy, histology, pathology, biochemistry and pharmacology into my head since August 4th 2008 and I am not one tangible iota closer to being able to effectively treat patients. It's not that I haven't learned anything, it's just that most of what I've learned is foundational. It's like building a house: when you drive by a newly laid foundation it doesn't look like much progress despite a terrific amount of work.
Yesterday I shadowed on the pediatric cardiology ward. This is a leading candidate for the kind of physician I want to be in the future and a field in which I have been published for clinical research. I didn't expect to keep up with the residents and fellows, but I thought I'd get some of it... maybe 10%?
Try less than 1%. About the best I could manage was knowing what the acronyms stood for. I knew why they wanted albumin levels and I correctly identified respiratory acidosis. But I couldn't tell you that the pleural effusion was protein or why, what the difference between a surgical and pigtail chest tube was, why you would withhold anti-fungals on the febrile baby with mediasteinitis, why a triple lumen catheter was better than a double, which port you put the guide wire through when changing a central line or what a 3/4 Fontan was. It was intense, thrilling and terrifying. How am I supposed to get from what I know now to being responsible for a pod full of patients like that?
Plenty of people dumber than me have become good physicians. I find myself repeating that a lot lately. I too will learn it and master it. But it was certainly a hip check to see just how long the road ahead is.
To end on a high note... I loved the day on the PTCU anyway. Despite feeling cluess most of the time, I loved it there. It's a great mix of medicine and procedures, acute care with repeat patients, interesting problems and enough good outcomes. One day my life is going to be amazing.
We recently had a lecture on bioterrorism within our infectious diseases sequence. One of the potential diseases that could be used as a weapon is Tularemia, a not-too-deadily infection caused by Francisella tularensis. It has a low infective dose, does not spread human-human, but you would feel like crap for a while. The Soviets were accused of using it and the US even researched its use as a weapon in the '50s.
Anyway, what I think is much more interesting is the outbreak that occurred in Martha's Vineyard in 2000. The CDC documented cases of people getting sick from lawn-mowing. Apparently, they mowed over nests of infected rabbits, aerosolizing the infected rabbits and inhaling the bug. That's right. The people of Martha's vineyard got sick from aerosolized bunnies.
It was then published in the Journal of Clinical Microbiology.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1233993
My professor sang this to us in lab. Then he played a CD of his son's band performing it. It was originally printed in JAMA on Jan 31, 1942. Can you guess the disease?
There was a young man of Black Bay
Who thought syphilis just went away,
And felt that a chancre
Was merely a canker
Acquired in lascivious play.
Now first he got acne vulgaris,
The kind that is rampant in Paris,
It covered his skin
From forehead to shin,
And now people ask where his hair is.
With symptoms increasing in number,
His aorta's in need of a plumber,
His heart is cavorting,
His wife is aborting,
And now he's acquired a gumma.
Consider his terrible plight--
His eyes won't react to to the light
His hands are apraxic,
His gait is ataxic,
He's developing gun-barrel sight.
His passions are strong, as before,
But his penis is flaccid, and sore,
His wife now has tabes
And sabre-shinned babies--
She's really worse off than a whore.
He aches from his head to his toes,
His sphincters have gone where who knows,
Paroxysmal incontinence
With all its concomitants,
Brings forth unpredictable flows.
Though treated in every known way,
His spirochetes grow day by day,
He's developed paresis
Converses with Jesus
And thinks he's the Queen of the May.
I've alluded to the idea that the last month hasn't been the happiest in my personal life, which is true. And while I'm now managing to be honestly happy most of the time, I still have hours/days when I just feel achingly sad. I have found though, that when I get into one of those moods that stepping back a bit helps. Yes, it is appropriate and natural that I am sad, but the man I met who lost his arm, his son and his wife in the same week has much more to bear. The parents who had to withdraw care on their 3.5 year old son have lost so much more than me. It doesn't invalidate my own grief, but it certainly puts it in perspective for me.
One of the curricular elements here involves students visiting a family with a chronic illness several times over the course of two years. We then form small groups and create an interpretive multi-media project expressing common themes in chronic illness (as well as writing a series of reflective essays). While the visits are enjoyable and certainly lead to reflection on what it must be like to live with a chronic health issue, this is medical school not art school. During the most difficult sequence of the M1 year I am expected to come up with an interpretive art project?!
My two partners and I have decided to create artwork using the board game Life. We are going to remake the game board and glue it and other related game pieces to a giant posterboard. It's supposed to represent that illness is not really in one's control and that it affects all facets of life on a longitudinal scale. Or something like that.
When we proposed the idea to our class there was a certain amount of horror: you are going to make a game out of chronic illness? Crap. We hadn't really thought that through.
The best projects are then chosen to be displayed at a reception that all the families (and medical students) attend. I'll put up $20 that our remake of Life is not chosen.
I would like to take a moment to honour the memory of a 3 year old boy I knew in Philadelphia. He recently passed away due to GI complications and a genetic illness. I met him several times over the two years I was there and his whole family were warm and wonderful people.
We had our anatomy closing ceremony today. After seven months and 32 labs of dissection, we have completed the anatomy curriculum. The occasion was marked by a series of awards, given out by the legend himself, Dr. Burkel, for the best anatomy students. I received recognition for setting up the practice exams for every sequence (with my colleague Zach).
One of the body donors had written a letter to the students who would be dissecting him and it was read to the whole class. It was a poignant and appropriate moment, but it was nevertheless awkward. While I try to be respectful of the body I worked on (I never cut of random body parts for fun or put him in strange poses), I simply cannot think of him as a living, breathing man while I'm sawing off his cheekbone or cutting his genitals in half.
Anatomy was a rite of passage, but I'm not unhappy it's over. It's important and valuable material, but it's simply not my favorite subject. I will miss the anatomy faculty, they are truly great teachers and interesting people.
Histology is also over, but that seems less momentous. Onwards to histopath! Only two sequences left... infectious diseases and development (and some clinical weeks in between). Two more months, then I'm an M2!
My dad likes to send me links to interesting articles he finds online. Recently I received one about Japan's health care problems (which I didn't read) in a journal that also had an article on characteristics of successful women (which I did read). Apparently these women exhibited something called "positive framing."
"Positive framing and positive thinking... are two different notions. The latter tries to replace adversity with positive beliefs. The former accepts the facts of adversity and counters them with action."
This, I think, sums up my last few weeks very well. They have been extremely turbulent and somehow, three days ago, my mind pulled the plug on the purely emotional reactions and kicked me into action-mode. It's not that everything is suddenly okay, but that I have accepted what is and decided on actions that will eventually result in a restoration of my usual level of happiness.
And I have to say, when I dried my eyes and took stock of the life I have, I was really grateful. I have wonderful, supportive friends who were there for me, the respect of my peers and professors and lots of interesting opportunities ahead of me.
I'm certain I didn't choose the easiest road, but I (still) think it's the best one for me. Besides, you can't "live to the point of tears (Albert Camus)" without actually crying once and a while.
I recently began working in clinical research again; with the Congenital Heart outcomes group. The study I'm working on has a much wider ranger of diagnoses that my previous work so I'm brushing up on my pediatric cardiology (in all that spare time medical school leaves). I thought it might be an interesting topic to share here, so this post is a primer on normal functioning (I did the drawings).
Unfortunately, most of the diagrams you see in books are functionally correct (ex. above), but not anatomically helpful. If you open up someone's chest (from the front, ie anterior or ventral) you do not see two ventricles sitting side by side. Instead, you see something more like...
You can see immediately that rather than a right-left orientation, the heart is really more front-back (anterior-posterior). Also, the ventricles are not so much "on top" as they are to the right. Which brings me to another point, we name everything by the patient's orientation. Thus, the right ventricle is the patient's right side, not yours. The whole heart sits slightly to the left of midline in the chest and its apex (point) is roughly beneath the left nipple.
The way blood flows through the two interconnected circuits - systemic (body) and pulmonary (lungs) - is frequently disrupted in congenital heart disorders. Normally, blood returns from the body through the superior vena cava (SVC) and inferior vena cava (IVC) into the right atrium (RA). As the right ventricle relaxes (diastole) it fills with blood from the right atrium. This is accomplished through a pressure difference between the ventricle (low) and the atrium (high), which opens the tricuspid valve. When the ventricle is full, the pressure will be higher than the atrium, pushing the valve closed (creating unidirectional flow). The ventricle contracts (systole) and blood enters the pulmonary trunk (through the pulmonary valve). The pulmonary trunk divides into a right and left branch to the right and left lungs. Each of these eventually becomes a capillary bed, which drains into small veins, which drain in to the 4 pulmonary veins. The pulmonary veins drain into the left atrium. As the left ventricle relaxes it fills with blood from the left atrium (same process as right ventricle, except the valve is called the mitral valve). When the left ventricle contracts it sends blood into the aorta (through the aortic valve). From the aorta blood goes all over the body and returns to the heart via the SVC/IVC.
There are two structures unique to babies' hearts: the foramen ovale and the ductus arteriosus. The foramen is a hole in the wall (septum) between the two atria. It's open and birth and normally closes in the first few days of life. Failure to close is called a patent foramen ovale (PFO) and can ultimately lead to congestive heart failure. The ductus is a vessel connecting the pulmonary trunk to the aorta. In fetal life it's used to bypass the lungs and it too usually closes soon after birth. Both of these conduits allow for mixing of blue (deoxygenated) blood and red (oxygenated) blood (which is a normal person is bad).
Summary: SVC/IVC -> R atrium -> (tricuspid) R ventricle -> (pulmonary valve) Pulmonary system -> L atrium (mitral) -> L ventricle -> (aortic valve) Aorta -> systemic circulation -> SVC/IVC
Key Points:
1. Ventricular filling is accomplished (almost entirely) through pressure differentials
2. The valves closing properly is important for unidirectional flow
3. There are two conduits for shunting blood from the right heart to the left: the foramen ovale and the ductus arteriosis
4. The pressures in the right heart are normally much lower than those in the left
If there are any questions, let me know and I will attempt to clarify. I only gets more complex from here!
I went to a classical concert last Saturday of the Silk Road Project. It was absolutely phenomenal. It's a company founded by YoYo Ma (yes, he and his cello were there) that incorporates instruments and musicals styles from all over the world and across many periods in time. It's a sort of classical-jazz-world-improvisation type of fusion that's unlike anything else I've heard. They've recorded a few albums that are on itunes (audio on their website too); I recommend giving it a glance and if they come to your city, go and watch it live.
I also got to hear YoYo Ma say the phrase "Go Blue!"
Medicine is an interesting career in that it has very specific points at which you are forced to make a choice about what you want. The quintessential one is match day; there is a specific date on which everyone finds out what residency (and where) they will complete. For the current M4s, match day is this week. Medicine is also unique in that you are told where you will go - you don't get to weigh offers and choose one. You interview, you state your preference, and you hope to god you get what you want.
I have a lot of friends outside medicine right now trying to change jobs or get into graduate school and many of them have mentioned they envy the structure medicine provides. The next few years of my life are basically planned for me, but I find that terrifying. What if I can't make myself attractive to a residency program I want? What if I get stuck in a city I hate? What if I choose the wrong residency type (ie peds vs. surgery)?
I feel as if I have given up so much to do this, to be a doctor, and it doesn't end. I gave up a financially better career (banking) in a phenomenal city (NYC) to spend two years in night school just to apply to medical school. Now I'm living in a place I don't really like that's far from family and friends because it will give me the best chance at one of my top residency choices. I don't have the time (or energy) to play tennis or read books anymore and I can't keep a relationship together. I can't even make it to a friend's wedding or my 5-year college reunion. What do I have to give up next?
I know that what I'm doing is the best investment for my future and that I truly want to be a physician and yes, I am aware that eventually, when this is all done, I will have job security and a decent income (well... that depends a little on Obama...). I guess I just wish I was a little happier now. It's all well and good to plan for your future, but I seem to forget that I have to live in the present.
I know it's been a while since I've posted regularly. I can give you all kinds of excuses (medical school is a lot of work, I've been traveling a lot), but honestly it doesn't mean much unless you see me post regularly again... so let's see if I can manage that.
The first year of medical school (to date) has been a little different than expected - there is a lot less patient interaction than I was accustomed to while being in the hospital. It's a lot more social than you think - we work really hard but we go out a lot too. On the other hand, it's also cost me more than I expected and I don't likemy geography at all. I love my school and my classmates, but I don't like living in Michigan (too far from friends/family/big cities). Some notes:
1. I hate anatomy. It takes up a lot of time and it's not that interesting. Apparently this means I am unlikely to become a surgeon.
2. I love video-taped lectures and flex-time quizzes. It gives me autonomy and allows me to pursue activities outside of class.
3. I was in a swing dance performance
4. I am doing clinical research again (on HLHS). I didn't realise how much I would miss it, so it's really nice to be able to work that into my schedule.
5. I am a MedBuddy coordinator - we pair medical and nursing students with children in the hospital for extended stays. The students visit the kids 3-4 times a week. I also have a MedBuddy - cutest little girl ever!
6. Two of the papers I was co-author on have been published!
7. During an a series of alternative medicine lectures I received a massage and had an acupuncture needle put in my hand (it feels weird).
8. I went to the inauguration
9. I went to Rome, Florence and Paris for spring break
Ok - I think that covers some of the cooler tidbits. I will keep you updated!
