Pediatric Cardiology

This was on the board of the pediatric cardiology staff room. It was one of the few clinics in which I largely shadowed as opposed to seeing patients independently. These drawings give an idea as to how complex the anatomy can be in these kids.

I actually really enjoyed pediatric clinics. I don't generally enjoy outpatient medicine; I much prefer the acuity of inpatient care. However, I loved my pediatric clinics. A hint, maybe?

two best to date

nom nom nom

Antibiotic tasting on the pediatric inpatient service. The pharmacists have us taste them so we know what we're force-feeding our patients.

I recommend the bactrim and amoxicillin. Beware the clindamycin and Flagyll!

LOL

On scrubbing

I have recently spent several weeks on surgical services within ob/gyn. It's been much more interesting and fun than I expected, however there were a few surgeries where the fellow or the attending told me *not* to scrub in. I was still in the OR, observing the surgery, being asked questions and being taught, but somehow, it's not the same. When you're scrubbed in two things happen: you have a much higher chance of participating in some way and you feel like part of the team.

The first point - participating - is exciting. Throwing stitches, retracting, using electrocautery and various scopes are skills that are difficult to learn well without practice. Truthfully, it makes the surgery a little less boring as well and keeps your attention on what is going on and not on what the anesthetist is doing, what time the clock reads, or the conversations of the circulating nurses. More importantly, it is usually impossible to get a good view of what is being done below the incision if you're not part of the sterile field. This means your ability to learn anatomy and technique are compromised when you're not scrubbed.

The second point - feeling like part of the team - is important in encouraging the morale of the medical student, something surgical fields traditionally struggle with. In general, as a medical student I aim to be useful or, at minimum, not be a drag on my team. Getting told not to scrub is like being put on time-out. Either you've done something wrong or there is no possible way in which you can contribute - not even to hold the skin open. Talk about feeling small and unwanted.

It takes very little to make a medical student feel good and we spend most of our time feeling tired, understudied and unhelpful. It takes time to teach us and we're aware of that. Residents and attendings frequently go home later when they spend time including and teaching us and we're grateful when they do. But it takes no extra time to let us scrub and observe from within the sterile field, so c'mon, throw us a friggin bone here.

subcuticular stitches

When closing the skin after abdominal surgery, one has two options: staples or subcuticular stitches. Staples are quicker, but subcuticular stitches leave a prettier scar. Subcuticular stitches are also one of the few things a medical student may be allowed to do in the OR causing an interesting phenomenon: the surgeons are artists within the body. They do an amazing job and while you may feel better, you will likely not be able to see their work. On the other hand, the medical student's skin stitches will be on display for you and others for the rest of your life. The least experienced person in the room is doing the most aesthetically relevant portion of the procedure (under supervision, of course).

I was recently allowed to do the subcuticular stitches on a women after her abdominal sacrocolpopexy and right-salpinooopherectomy. I am slow at them, but I do a decent enough job. The following morning when I went to pre-round on the patient, she told me she married her husband while he was in medical school. She looked straight at me and asked, "did they let you close?" I nodded. She replied "let's get this dressing off and see if you're any good." I convinced her to wait until the resident joined us for work rounds and he took the dressing off. As he peeled it off, she peered at her abdomen. "I approve." The resident looked puzzled and I was beaming. Excellent start to the day.

It's a little frosty in hell

I can't believe I'm about to say this, but after two days of orientation I am actually excited to begin Ob/Gyn. It seems like a really fun mix of procedure, continuity and okay, some clinic. We did some training on the laparoscopy instruments today and it was very cool. Holy crap. After two years of swearing up and down this is the last thing in the world I would ever do...

On the other hand, I still don't think I would be a psychiatrist, so they aren't ice skating in hell just yet.

An app that doesn't exist?!

I have done it. I have found the one app that had not yet been made for iphone. A surgical skills app that has demonstrations of knot tying, sutures, suture anchors, etc. It would be even better if they combined this with existing applications that have pictures of common surgical instruments, descriptions of suture/needle types and sample surgery note formats. There are fishing knot apps, climbing knot apps, menswear tie knot apps and chinese decorative knot apps - but no surgical knot apps.

If someone were really ambitious they would make an iphone case with a ring on the corner that students could hook suture through for mobile practice sessions. I'm just saying, people tie 'em to their scrub trouser ties at the moment and that goes bad one of two ways: you accidentally undo your pants while playing with the suture or 2) you can't get your pants off because you've sutured the knot fast.

Heartbreaking and true

On the wall of the VA.

Drug rash

For anyone who hasn't seen an allergic drug rash, this is what it looks like. Yes, that's my leg and yes, that's me having the allergic reaction. No, it wasn't confined to my right leg. It was, in fact, over my entire body, including my face.

This photo was snapped while I was in the urgent care waiting for steroids. I tried Benedryl and hoped it would do the trick. Nope. So off to urgent care for a shot of solumedrol to the hip and a prednisone taper as well as two varieties of antihistamine.

36 hours post solumedrol it covers the same area, but a much lighter shade of pink. Yes, I will go to work tomorrow and yes, I will be wearing concealer, long pants and long sleeves.

Tenants of surgery

1. Don't stand when you can sit

2. Don't sit when you can lie

3. Eat when you can

4. Sleep when you can

5. Don't mess with the pancreas

kiddies say the darndest...

16-year old boy I'm playing scrabble with on inpatient psych ward: You look like a fish.

Me: That's not very nice.

Boy: It's the eyes.

Me: I have poppy-buggy fish eyes?

Boy: No. They're just... like... fluorescent!

Me: Fluorescent? How is that fish like?

Boy: They just remind me of the Caribbean, okay?

shelf exams

At the end of each rotation in your third year of medical school, you sit a national exam called the "shelf". It's made up of questions very similar to what will be on the USMLE step 2 (which you sit during your fourth year). Unlike USMLE step 1, the shelf exams and the step 2 are more clinically oriented; however, they are no less frustrating. Step 1 was a pain because of questions like "what arm of what chromosome is implicated in ridiculously rare disease X?" Answer: No idea, not relevant, don't care. The medicine shelf exam, it seems, will be a pain for an entirely different, but equally irritating reason: apparently I'm supposed to be psychic. For example, one question was about a 10-week pregnant woman with a swollen leg and shortness of breath. I was apparently supposed to deduce that her main problem was vomiting, despite the fact that pregnancy is known to place an increased risk for DVT (which the swollen leg would fit with). Another example? A woman with arthritis symptoms comes back for a follow up visit with gastric discomfort. I was supposed to infer that she was having methotrexate side effects, despite the question never describing any treatments being started. This all brings to mind another, perplexing question. I'm not a stupid person and I struggle with these exams. I know some stupid people who are doctors... how the hell did they pass them all?!

I feel used

Me: Sir, I would like to do a rectal exam on you to be sure you're not bleeding before I give you a blood thinning medication.

Paranoid schizophrenic patient: As long as it's you and not that guy-doc

Me: Yes sir, it will be me doing the exam.

Patient: Do what you gotta.

[rectal exam]

Me: All done sir, I'll let you clean up now.

Patient: That was the best sex I've had in years.

alternative treatment

Man walking in the VA hallway: Are you a doctor here?

Me: Sort of, I'm a medical student here.

Man: Well, I really like the care I get here.

Me: That's good to hear, I'm glad.

Man: I come all the way from [some town in Ohio] because this is a good VA.

Me: Well, I'm glad we can help you.

Man: You know, if this doctor thing doesn't work out for you, you could be a model.

Me: Thank you, that's very kind.

Man: You got it going on. I'm serious. You could be a model.

Me: Thanks, but, I think I'm going to stick with the doctor thing.

Man: Looking at you done cured my cataracts. Damn.

Me: Thank you. Have a good afternoon, sir.

Man: You too, gorgeous.

LOL

hat tip: geekinheels blog.

And now for something completely different

A little humour...

I find my white coat heavy and it contains: a pager, tiny notebook, pens, penlight, reflex hammer, pocket medicine book, alcohol swabs, my cellphone and a near card. That's light compared to.... The Mr. Always Prepared For Everything Guy. And yes, these students really do exist.

Sad for me

My cardiology month is over. Sad for me. I think the heart is the most interesting organ in the body - it's both mechanical and electrical and just keeps going without any rest. Your brain needs sleep, but your heart just keeps beating minute after minute, day after day, year after year.

Cardiology highlights:

1. Man who did "only" 8 lines of cocaine before presenting with a "mysterious" BP of 200+ and no urine for three days.

2. Placing an arterial line and doing ABGs

3. Spending literally hours pouring over one man's EKGs to determine his AV nodal arryhthmia, which turned out to be... all of them

4. A patient who had a dream my attending was a rapper in a music video

5. Correctly identifying SVT with aberrancy at 3am when the telemetry monitor thought it was v-tac

6. Watching a man de-compensate into heart failure from a heart attack in front of me

7. Listening to a patient tell my attending about the "hind-lick" maneuver

8. Being the only person on the team who could draw the anatomy of a {I, D, D} congenital heart patient

9. Listening to an aortic stenosis murmur so severe you could hear it on her back - louder than her breath sounds

10. Being told by patient's and their family that my being on the team had made their stay better.

Now it's general medicine at the VA. Stories to come...

Long call

Intern year is infamous for the amount and frequency of long call (overnight) that must be done. While on internal medicine during third year, I have had to work the same schedule as the interns; thus also q4 long call (overnight every 4th night). It's busy, it's tiring, it's frustrating, but it's also when you bond the most with your team and with your patients.

This photo is an example of the night float bonding with an M4 over a shared love of high level mathematics. I was busy bonding with one of my interns over bento boxes and having grown up out west. Later that night I went to visit a patient and his wife, who declared they would be my surrogate grandparents since my family is so far away.

Long call is also exciting as an M3 because it's when you get to do the most. You can get a complete history for your busy intern and then write up the admission paperwork for them. You can follow up on orders to make sure tests and labs are done and interpreted, call consults and be the contact point for the nurses so that you are in the loop on the evolving treatment plans. On cardiology you carry the code pager so when anyone in the hospital goes into cardiac or respiratory arrest you have to drop what you're doing and respond. First person on scene starts chest compressions and let me tell you, a real chest feels nothing like those dummies you learn on.

I really like long call - I like being in the middle of it all. But I can see how 8 months of it would get tiring. Still, 6.5 weeks into 12 weeks of this I'm mostly just pumped. I'm finally in the hospital. Finally working with patients. The last two years I've been impatient to become an M3. Now that I'm finally there, I'm even more impatient to be an intern.

RN vs MD

There is a lot of literature and there are many studies assessing the relationship between doctors and nurses. As a medical student you are told often and early, "don't piss of the nurses." This is sound advice because honestly, you learn a lot from your nurses and they can make your life very frustrating if they so choose. On the other hand, I can already understand some of the frustration that doctors feel. There are those nurses who, for some reason or another, think their accumulated wisdom is more valuable and correct than what goes into the education of an MD. Two recent examples:

1. I was reviewing a rhythm strip on a patient who has an AV nodal arrhythmia. We were concerned the patient was intermittantly having 3rd degree heart block - a rhythm in which the atria no longer communicate with the ventricles, who begin to generate their own "escape/junctional" rhythm. The nurse told me that he couldn't possibly be having an arrhythmia because the interval between the beats was constant. I tried to explain that a junctional rhythm would, in fact, be regular, but would still be an arrhythmia. She proceeded to tell me that after all these years here she knew that, but it still couldn't be an arrhythmia. Um, yes, it could. She insisted it couldn't. I gave up because she clearly wasn't going to change her mind. But honestly... what does she think I've been studying for these last few years? Proper bleaching technique for my white coat?

2. Another patient of mine has been on the floor for two solid weeks getting antibiotics. He's going a little stir crazy and I wanted to let him walk around the hospital courtyard for some fresh air and sunshine. My attending agreed that he was safe to be off telemetry for an hour or so and a walk would be good for him. The nurses overruled us. Apparently, they decided he was too sick to be off telemetry. Excuse me? Since when did nurses get the right to veto physician orders?

Many kinds of "call"

I didn't realise until now that there are many kinds of call. It turns out, the overnight kind we all think of when we hear "on call" is more precisely long call. If you are on long call, it means your service is admitting patients. On my current service, the interns cap out at 4 patients each and the senior resident doesn't stay all night.

While on long call you also cross-cover the patients on other services. If something happens to a patient admitted to another service over the night, you will get the page instead of them. Of course, this also means that your patient's problems will be handled by others when you are not on call.

The day after overnight call you are post call. Interns usually leave by noon because they were working all night. The senior resident will finish any remaining management on the patients for that day. Unlucky for the medical students: afternoon conferences are still required even if you're post-call.

The second day after long call you are on short call. You admit one patient early in the day.

The day before your long call, you are pre-call. Your service doesn't admit any new patients in anticipation of the new load during long call.

Another good question: what does it actually mean - "admitting" a patient? Well, it means the ED or another hospital has determined a patient needs care in your hospital. When your service accepts the patient you get a one-liner about their major symptom (chief complaint). Then you go and examine the patient, ask lots of questions and come up with several possible reasons for their illness (differential diagnosis). You also come up with a plan of how to manage each of the patient's problems. Usually the intern will see the patient first, then the senior resident, then the attending. The intern writes up an admission note and the attending co-signs it.

Each day in the hospital the intern (and med students) will pre-round on the patient, then the interns, resident and attending all round on all the patients together. They discuss progress and complications that occurred overnight and how to continue or change the management plan. The intern and the senior then spend the day organising that care and documenting it.

That's life on general medicine, inpatient. I'll post some stories about my first patients soon.

Skeezy old man

My friend and I were sitting outside enjoying some frozen yogurt after a sushi dinner when we were approached by an elderly gentleman. Well, my friend was approached... he interrupted our conversation and completely ignored me while having the following conversation with my friend:

Old man: Excuse the interruption but you look familiar. Are you on the volleyball team?

My friend: No I'm not.

Old man: I'm retired so I have the time to keep up with the sports, you know. Are you a student here?

My friend: Yes.

Old man: What do you have... two years left?

My friend: Yes.

Old man: What are you studying?

My friend: I'm actually a graduate student.

Old man: In what?

My friend: Medicine.

Old man: That's a long and difficult road. What do you think of this healthcare bill Obama just passed? Do you think it will be good or bad for doctors?

My friend: My friend and I were just discussing that. We agree it will be bad.

Old man: Yes, you won't make the big bucks anymore. Probably doesn't make it worthwhile. Maybe you'll change fields now. Medicine is a long road.

My friend: I think I'll stick with it.

Old man: [gives his name, sticks out his hand to shake hers]

My friend: [gives her first name only]

Old man: [first name] what?

My friend: [gives her last name]

Old man: [mispronounces her last name], is that English or German?

My friend: German. I was actually in the middle of a conversation with my friend so if you'll excuse us...

Old man: Do you have a boyfriend?

My friend: Sir, I ...

Old man: Well now I was hoping to ask if you would like to get together for lunch some time so we could get better acquainted in a proper manner?

My friend: I don't think so...

Old man: Well if you don't ask, you'll never know. Take it as a compliment and have a nice evening.

Ok, so despite the veneer of politeness it was a decidedly skeezy conversation of the part of this AARP member. Let's not forget that when he approached her, he thought she was an undergrad with two years to go... that would make her 20, max. He looked an easy 70. Did he really think he was getting a yes? Delusions of Hefner much?

Who knew?

The reservoir for leprosy in the USA is armadillos.

Scorpion stings can cause acute pancreatitis.

pls Reply: none

A grad student sent out an email request today asking other grad students to take a short survey for her biostat final project. She sent it to all the grad students at UofM. One person, who took her survey, was appalled by the gender choices: male or female. Appalled enough to spam the entire list of grad students with a paragraph on social justice and acceptance.

That was a poor choice. Even poorer decision making was displayed by the 20 other people that then continued the discussion CCing ALL the grad student list-servs. The discussion expanded somewhat and the most recent email contained not just statements on social justice, but on manners, the phylogeny of the mango tree and the racial classifications on the US Census.

We've passed 40 emails and they still trickling in.... seriously people, don't you have something BETTER to do? Like, write your thesis?

Another fun fact...

Once upon a time in France, children born with cretinism were thought to be so mentally retarded that they were incapable of sinning. Thus the name cretinism, meaning Christlike.

Cretinism, for those not studying for the USMLEs, is endemic fetal hypothyroidism.

Alphabet Soup

Flash of brilliance: Immunology should be taught Sesame Street style.

This episode is brought to you by the letter C...

Big Bird: Hey Elmo, what are you doing with those big letters?

Elmo: I'm building the classic pathway of the complement cascade!

Big Bird: Gee Elmo, that sounds hard. Can I help?

Elmo: Sure! Why don't you hold these IgGs and C1s for me?

Elmo hangs IgGs and C1 on big bird like ornaments on a christmas tree.

Elmo: With the power of IgG/C1 you can split the C2 and C4!

Big Bird karate chops a C2, the halves come apart as C2a and C2b. He then chops a C4, creating a C4a and C4b.

Elmo: Yay! Hey, these two stick together!

Elmo stick the C2a and C4b together like magnets. A C3 floats onto the screen.

Big Bird: What's that?

Elmo: I can take care of it with this!

Elmo uses the C2a4b like a sword and slices the C2 into C3a and C3b, but the C3b sticks to the sword. C5 floats onto the screen...

Elmo: More of them! There are almost as many proteins in complement as there are in coagulation!

Elmo slices at the C5 with his C2a4b3b, splitting it into C5a and C5b. After a moment, cookie monster walks in sniffing the air...

Cookie Monster: Me smell... me smell C5a! Mmmm... cookie monster like C5a... nom nom nom

Elmo: Cookie Monster, what's that on your tummy?

Cookie Monster: Those are my lobar nuclei! Me hungry... me want to phagocytose!

Big Bird: This was fun Elmo! Next time we should try the alternate pathway!

WTF?

I was looking up information on intelligence tests (they constitute testable material on USMLE step 1) and I found a page about high IQ societies and their entrance requirements. Apparently many of them will accept high scores on the GRE or the LSAT, but not the MCAT. I'm not nearly as surprised that the GMAT doesn't count...

High IQ societies

X vs Y

According to my pathology review book, if you have an extra copy of the Y chromosome (male) you are more likely to have severe acne and be a violent criminal. If you have an extra copy of the X chromosome you are likely to have menstrual abnormalities.

If you have two extra copies of the female chromosome you will have mental deficiencies, but if you have two extra copies of the Y chromosome you will be dead.

One day of freedom

I officially passed and completed my M2 year! Pre-clinical medical school is over! My reward is a single day off before 4.5 weeks of intense boards studying.

I decided this was insufficient and so allowed myself the following two additional indulgences:

1.) Oreo milkshake from Potbelly's. Amazing and delicious.

2.) A new pair of shoes. They are completely impractical but utterly fabulous. Who doesn't feel sexy in red peep-toe heels?

I drove this car (Mustang Bullitt) last night. It started raining and I spun it out (without hitting anything or hurting anyone). The owner was sitting next to me, totally nonplussed. He's going to let me drive it again.

It's good to be a girl.

Happy thoughts...

Dr. V on maternal mortality:

" That's about 6 jumbo jets per day that crash full of pregnant women and they all die."

Yesterday afternoon's class consisted of watching a video of a cesarean section and a second video of a vaginal birth (all the funnier because it was filmed in the '70s). You may be surprised to learn that I would still prefer a cesarean. Neither looks like fun so maybe .... no kids. But, accidents happen and in that case... I'll take the surgery.

The Good and the Bad... an update

Thumbs Up:

• I found a new apartment - a one bedroom - and will move in July
• M3 rotations are out, I got my first choice track
• No cavities at the dentist
• Passed my physical with flying colours
• My car is fixed and looks/smells new again
• Love my gym, really enjoying PT

Bummer:

• Grandma may need surgery
• A friend is sick (with something chronic)
• Research projects are lagging a bit
• Um... boards?

I will try to post something more substantial soon.

Evil Email

When you go to visit a medical school, especially one with pass/fail pre-clinical years, you inevitably hear a lot about how collaborative the students are. How they all want to help each other and work together because ultimately, medicine is a team discipline.

Reality check: Type A's don't change their spots overnight.

Exhibit 1: An email from A--- to our entire class:

Subject: I'm tired of people wearing jeans to MDC's

Text: [insert classmate's name]. Done.

Exhibit 2: 20 minutes later a second email from A--- to the whole class:

Subject: Re: I'm tired of people wearing jeans to MDC's

Text: And now sleeping during the MDC. Not cool. Way to be respectful.

You might think this kind of behavior is limited to students.

Reality check: Once a gunner, always a gunner.

Exhibit 3: Last night the entire class (!!) was accidently cc'd (do people really not notice when they hit reply all?) on this email from a pathology faculty member to a senior administrator:

Subject: GI handout

Text: Are you serious? A synopsis of Robbins textbook? Are medical students now incapable of reading, even reading stuff that may be wrong?

Exhibit 4: And then we were CC'd on the reply (apparently no one over the age of 30 can tell the difference between reply and reply-all):

Subject: Re: GI handout

Text: As a faculty member we/I cannot control what he does -that is why I sent the e-mail - he does it on his own - not a team player or collegial - he will be retired in August - just a heads up

Despite these outliers, most people are actually very friendly and collaborative. And drama-prone. Does high school ever really end?

Live from the OR

Once upon a time I did a post composed of live blogging from the ER. I thought I would replicate the concept tonight by giving you an idea of what a transplant case looks like for me.

11:07 - consent is obtained and I receive an email. I am now aware that a donor liver is expected to arrive for a patient and the surgery should occur sometime today.

17:48 - I find out the donor liver is not expected to arrive until after 10pm, that means an overnight surgery is likely.

21:11 - I call the main OR desk and they indicate a lines-in time of 11:30pm. That means the incision won't happen before 00:30am.

23:50 - I arrive at the hospital to change into clean scrubs, prep some dry ice for samples and start the paperwork.

00:18 - I head down to the OR to check on the progress. They are just finishing the echo and still have to place the radial line.

00:37 - Incision. I draw two purple tops and collect 10cc of urine. I leave the OR and head to the lab to centrifuge the samples and put them on dry ice.

01:26 - Back in the OR to observe

02:51 - Anhepatic phase begins. This is when the patient is no longer connected to his old liver and not yet connected to the new one. I draw samples and put them on ice to process later.

03:29 - Reperfusion. This is when the new liver is connected and circulation through the liver is restored. All the preservatives and biochemical waste from the new liver cause the patients heart to struggle briefly. When well-managed and with a little luck this can be short-lived and uneventful. Tonight, reperfusion goes smoothly.

03:59 - I draw samples and bring them and the pre-reperfusion samples up to the lab to process. Sometimes I stay in the OR until close, but tonight I'm hoping to catch a few hours sleep before class. If the close is within two hours of my shift ending, I will be able to draw the closing samples and leave. If not, I will have to stay until 2 hours post-op.

04:40 - The surgeons have closed, the operation is complete. This was a very short surgery, which is good for the patient, but bad for me. I now have to stay until 6:40 to do the 2 hour post-op samples.

04:50 - Follow the patient up to the SICU to get immediate post-op samples. Run back to the lab to finish processing samples already collected.

05:30 - Email an update about the surgery and schedule for post-operative draws through POD4 to the research group.

06:30 - Head over to the SICU to check in with the nurse and get the 2 hour draw.

06:45 - Head back to the lab to leave the samples on ice (the girl coming in at 7 will process it), head home to catch a three hour nap before class at 11.

Swing performance!

Last night was the performance of the swing dance we've been working on for the last few months. We all landed our big breakout moves, which was awesome! Proof that med students do something other than study ;)

Smartest or Nicest?

The NYT ran an article recently on using personality tests as part of the criteria for medical school entrance. Apparently they gave personality tests to 600 students to look for which traits correlated with future success. Big surprise, those who stressed easily did poorly and those who were extroverted did well.

The thing is - I don't agree with their proposition that doctors all need to be super-nice people. Sure, a physician should treat you with respect and courtesy, but you're not there to make friends. When did it become an expectation that your doctor also be your confident and therapist?

Let's put this another way. If you found out tomorrow that you had cancer or HIV or needed a triple bypass - do you want the nicest kid in the class or the smartest?

I know what you're thinking, can't I have both? Sometimes yes. There are some very smart people who are also very friendly. But the traits that get you through training are not the traits that win friends. In medical school and residency you sacrifice a lot of your personal time to your training; thus your relationships are neglected. The divorce rate for doctors is above the national average. You have to be willing to study for hours alone - be independent and driven. The decisions you make and their consequences are weighty; they require detachment and objectivity.

Everyone's job has stress, but not everyone will find themselves leaving their son's baseball game because their pager went off. Your patient is in respiratory failure because they developed graft vs host disease after their bone marrow transplant, which you recommended and without which they would have died. And it's not just cancer doctors - it's the primary care physician whose patient has a hypertensive crisis or a stroke. It's the ER doctor that has to call the organ donation team when a 24 year old comes in from a motorcycle crash. It's the pediatrician who pronounces the unlucky child who got meningitis or the ob/gyn that tells a first-time mom that her baby has hydrocephalus. Every doctor sees these cases in training and no practice is immune from tragedy.

Why is the system built this way? Why do we make it such a stressful process to become a physician? Are we turning good people into bitter ones? I say no. I think we're pushed because there is a lot of medicine to learn and not enough time to learn it in. We spend two years in lecture halls learning biochemistry, anatomy, pharmacology and histology - no patients in sight - a lot of which we won't use in everyday practice. But those years are the difference between a doctor and everyone else on the medical team. They are they difference between memorizing a standard protocol to treat a disease and understanding on a molecular and cellular level how the disease and it's treatments work. You can't reassemble an engine if you don't understand how the parts work.

I promise that when I graduate and begin practicing that I will make every effort to treat you with respect. I will explain my reasoning and answer your questions. I will be professional and courteous. But I will not be your therapist or your best friend. I will not hold your hand or cry with you. It will have to be enough that you had the smartest kid in the class, trained in one of the best schools, using all of their intellect to save you.

Autologous surgery

Apparently, in 1961 a Russian surgeon did an appendectomy on himself in Antarctica. It's written up in the BMJ, complete with two intra-operative photos.

Thanks Andrew, for the link.

Pre-clinical years

I thought it would be interesting to total the number of exams I will take prior to my first clerkship in medical school.

M1 year: 37 written exams + 8 anatomy exams

M2: 15 written exams + Clinical Competency Exam (9 parts) + USMLE step 1

I've also had to write 15 essays and create an interpretive art project on chronic illness.

Hilarious

Those of you who read other medical blogs have probably see this, I know White Coat has re-posted this as well, but on Tales from Serenity Now there is a great story (with pictures) about a guy trying to escape the ED.

I can't wait for my fourth year ED rotation... I had a great time working in a PA ED during post-bacc and that was only 8 hours a week.

Best moment: my hand in an open chest.

Second: being barricaded in the ED because the gang fight followed the ambulance.

Being a positive deviant

I just finished writing a couple of essays for school. One of the assigned topics was on Atul Gawande's book Better. In the book, he lists his five suggestions for being a positive deviant; basically how to be Better.

1. Ask an unscripted question

2. Don't complain

3. Count something

4. Write

5. Change

I find it an intriguing list because it bears some similarity to the ideas I try to use to not just be better at what I do, but be a better person.

1. Ask more questions than you answer. I, like many extroverts, like to talk. It doesn't have to be about me, I like explaining things, I like reading out loud, I like debating - it's a hunger to participate. The risk, of course, is that with all the talking I find I've spent two hours with someone and I don't know their name, what they do or whether they've ever been West of the Mississippi. People have interesting stories and I can't hear them if I'm the one talking.

2. Don't whine. This is essentially the same as don't complain, but he's right.

Whining is not attractive and let's face it, everyone could come up with something to whine about. Interesting people find things to be happy about. Really interesting people can radiate their optimism to others.

3. Move the goal posts. Having a purpose is important. It creates focus, creativity and energy. They key is to be flexible about goals and to have them in multiple spheres of life. For example, one of my goals is to graduate medical school, but another (more fun) goal is to get stamps from every continent on one passport. Goals are personal - it's about what you are passionate about and should reflect who you are and who you want to be.

4. Choose. It's easy to follow orders and do what's expected. It's far more fun to go out on a limb and find your own path. It's harder, to be sure, but you learn much more. That's not to say you can't go with convention, just make sure you choose it, rather than letting life or others choose it for you.

5. Try everything once. Okay, within reason. But experience is a great way to learn things and fear is a poor excuse for ending up 75 with a bucketload of regrets. Trust your ingenuity, your resourcefulness and your survival instinct - you'll live through it and you might even like it.

Why is it that I feel slightly foolish publishing my philosophy and Gawande confidently makes a fortune off of his? Oh yes, because I'm not yet an accomplished surgeon at a world-renowned hospital. Still, I don't think it's a bad list. Plus, I'm wearing two pagers and he's only wearing one...

Law of unintended consequences

From the New York Times:

Britain was planning on using full body scanners at airports to enhance security after the Christmas Day bombing attempt in Michigan. Apparently, these scanners create an image of the body being scanned, which includes the genitals and any *ahem* enhancements.

Clearly, someone didn't think this through because now they will need to pass laws to exempt security personnel from child pornography laws. Britain also has some of the world's most aggressive paparazzi - images created of celebrities as they enter the country would be worth a fortune. I can see the US Weekly now: which of your favorite actresses really has fake boobs? See page 15!

I'm in favour of making our airports actually safer (take your shoes off? 30z of liquid? please...), but I'm not sure turning everyone into a porn star is a good solution. First, why are the images saved? Second, couldn't they be auto-analysed and then only exceptions reviewed manually?And third, do we have any evidence (say, in the form of controlled trials) that shows full body scanners catch more than metal detectors and pat downs?

Prion power

I have never been allowed to donate blood in the United States. Having lived in England during the "mad cow years", I'm permanently banned from donating for fear of spreading prion disease. I've never really understood this because in order to get Creutzfeldt-Jacob disease you need to ingest contaminated brain matter (since that's where the prions are located).

A quick aside for those unfamiliar with infectious particles: there are bacteria (alive), viruses (not alive) and prions (also not alive). Bacteria are whole cells, viruses are essentially a little pod of either DNA or RNA and prions are naked proteins. These proteins are misfolded, however, and have a knack for causing normal proteins to also misfold and create aggregates in central nervous system neurons. Since prions live only in neurons, they cannot be transmitted by blood or air or droplets (coughing) like viruses and bacteria.

So basically, the US government is concerned that I am contaminated from prions but haven't shown disease yet and that somehow I will spread this via blood donation. Recent research is now showing - lucky me - that prions may actually be adaptive and develop drug resistance. This is alarming (for the obvious reasons) although currently Creutzfeldt-Jacob is a death sentence (within months) and to my knowledge we didn't think we had effective drugs.

There are several human prion diseases (no, CJD is not the only one) and all are fatal. Worse, standard sterilization procedures do not eliminate prions so it's a good thing they aren't easily transmitted. Adding drug resistance to their virulence is almost superfluous.

Please excuse the girl moment...

I bought myself a little christmas present in the post-holiday sale... the Kate Spade Opus bag. Now if only I could justify a BCBG dress...

I graduated high school a DECADE ago?!

This is a photo of me getting dressed for new years this year. It was a low-key affair with low expectations so it turned out to be an okay night. I wasn't quite back to myself -I'm still not- having just been traveling internationally. I always get a bit brooding when I return home. I don't like giving up the freedom of traveling - life is a bit too tied down and restricting for my taste. I wonder if I should have taken more time off - a whole year of traveling instead of just a few months? I also miss the person I am when I'm not here - I'm more confident, easygoing, in-the-present when I'm away.

I'm not usually very big on new year's resolutions, but this year I have a few. They are more reflections on self-improvement that stem from travel, but new years is as good an excuse as any.

1. I choose confidence. I choose to be okay with who I am. I will own it.

2. I will read more non-medical non-fiction.

3. I will stop using medical school as an excuse.

I'm going to head back to California for a couple of weeks in early April and then hopefully off to Turkey the first week of May. Hopefully that will sate the nomad in me until next December.