Head .S p a c e

Slow cooker beef barley soup

2012-01-25T20:06:00.003-05:00

Yes, yes y'all! I broke out my newly acquired slow cooker to make some yummy winter soup. I couldn't find the perfect recipe so I decided to wing it and hope for the best. It turned out quite tasty, if I do say so myself.

Want to try? Throw the following things into a slow cooker: 1 lb cubed stewing beef, 1 sweet potato (diced), 1 onion (diced), 1 cup celery, 1 tomato (diced), 4-6 mushrooms, 2 tsp Worcestershire sauce, garlic and black pepper to taste, and 5 cups beef broth. Cook on low for 7.5 hours. 1 hour prior to finish, add 3/4 cup barley and one bay leaf. Serve with a dollop of sour cream.

Next time I might add some carrots as well, a second onion, and possibly one more cup of broth.

Next idea: split pea soup. But first, I have to eat my way through the leftovers. It's a tough life.

Overheard in Ann Arbor

2012-01-24T15:42:00.002-05:00

Worked-up guy in coffeeshop: You can kill two birds with one stone. If you lose weight, you live longer, it's good for your health. But if you lose weight, you also make yourself more attractive. You kill two birds with one stone.

Gosh darnit, they like you!

2012-01-23T22:34:00.004-05:00

On Jan 21st I was part of a team of finalists representing Ross
business school in the Kellogg biotech and healthcare case competition. One week prior we had been given a dilemma
surrounding the issue of infant HIV diagnosis in a poor African nation. We had to come up with a pilot program for a new point-of-care testing method and justify our strategy. There were thirty-six entrants, of which 11 finalists were chosen. Each finalist team had 1/2 hour to present their solution.

We won. Felt awesome.

If you can believe it, I did power calculations and threshold sensitivity analysis. I used formulas in excel. I could feel the rust falling off the mental gears I used 10 years ago in my undergrad business degree. It felt really good to be doing something a little different than the past 3.5 years.

It was so much fun, in fact, that I am pursuing the idea of doing a three month project with one of the professors in the Ross business school as an interdisciplinary elective. I'll know more next week on how feasible that is.

Dr. G has a sense of humor

2012-01-15T12:11:00.002-05:00

While studying a module on asthma, the following practice question came up:

Q. Which of the following issues are concerns for the athlete with asthma?

A. Cold air

B. Exercise

C. Restrictions on drug use

D. Brent Musberger

The correct answer, for those non-medigeeks, is all of the above.

For those whose knowledge of athletics is limited (as is mine), Musberger has been quoted stating, " While anabolic steroids have no place in high school athletics, I think under the proper care and doctor's advice, they could be used at the professional level."

Life after medical school

2012-01-12T16:19:00.000-05:00

It occurs to me that most people outside of medicine don't really know how the medical education system works after medical school. So here is a combined primer/update.

Upon completing medical school, you are an MD, however you cannot practice clinical medicine without supervision until you complete a minimum of one post-graduate year. Typically, this is accomplished by entering into a residency program. The vast majority of people complete a full residency, upon completion of which you sit the board exams in a particular specialty (or specialties). If you pass that exam, you are then "board-licensed" in that area of medicine. You can further specialize within that category of medicine by completing a fellowship and sitting sub-specialty boards.

Example: You could complete an internal medicine residency to become a board-licensed internist and subsequently complete an endocrine fellowship to become a licensed endocrinologist.

You cannot complete a fellowship without first completing a residency. Theoretically you can practice medicine without board licensure, however you would never get the malpractice insurance required and no hospital would hire you/give you privileges.

Okay, so how does a medical school graduate get into a residency program? The answer is the national residency match process. In your final year of medical school you apply to residency programs at a variety of hospitals using a central database called the ERAS. You fill the application out once and select the programs at which you would like to be considered (and pay $$). Generally, people apply to only one type of residency (ie anesthesia, pediatrics, ob/gyn), however occasionally people will apply to a less competitive option in case they do not get a spot in something coveted (ie, someone applying for dermatology may also apply to internal medicine).

Programs that found your application compelling will invite you to interview with them. An interview involves flying out to the hospital the day prior, attending a dinner with current residents the evening prior, followed by a full day of interviews/presentations/tours. You pay for this yourself, so you can imagine that a person who interviews with 10-12 programs will burn though a chunk of change accomplishing this. Interview season is November-January.

In February, the applicants submit a ranked list of places they interviewed at. The list does not have to include all the programs, however, not ranking a program means you would refuse to work there even if given an offer. Applicants cannot rank programs at which they did not interview. Simultaneously, each program ranks the applicants they interviewed. Again, they do not have to list all the people they interviewed, but they cannot list someone who did not interview.

In March a computer goes through and attempts to create the optimal pairing of applicants to programs. If multiple programs rank an applicant, the applicant is generally assigned to the program they preferred. If no programs rank an applicant high enough, that applicant will not get a residency placement (ie they will not have a job). On March 16th, 2012, all applicants will get an email telling them where they have been assigned. If an applicant did not match, they are generally notified the Monday prior and they go through something called the scramble.

So, where am I in all of this? Well, I'm applying to a combined residency program, called medicine-pediatrics. It's four years in length. At it's conclusion, I will sit both the internal medicine and pediatrics board examinations (ie I will be double-boarded). I applied to 19 programs and was offered interviews at 14 of them. I completed 11 interviews, but have not yet settled on what order to rank them.

Places I interviewed: UPenn/CHOP, Univ. Minnesota, Univ. Maryland, Univ. Michigan, Georgetown, Brown, Baystate (Tufts), UCLA, USC, UNC, Univ. Rochester

Places I declined to interview: UCSD, Vanderbilt, Univ. Chicago

Places I was rejected: Brigham & Women's, Mass Gen, Yale, Duke

Places I never heard anything from: Univ. Pittsburgh

Free time

2012-01-05T18:37:00.000-05:00

For those of you not in medical school, it's residency interview season. My particular medical school gives me two months off (read: vacation) in order to travel and complete interviews. Two months is more free time than I have head since, well, since I went to Thailand. So what did I do with this precious time? I intended to learn Spanish. That did not happen. Instead, I:

- traveled to 11 interviews (and saw friends!)

- took Step 2 CS

- visited my parents for two weeks

- met my boyfriend's parents (I took them to the anatomy lab)

- did crossword puzzles

- baked (a lot)

- tasted several varieties of gourmet cupcakes

- improved my skills at Burnout 3 on the PS2

- played Betrayal: House on Haunted Hill (board game)

- watched The Lives of Others and Lawrence of Arabia

- trained new SPIs at school

- taught the M2s pulmonary classics

- slept. slept more.

All in all, it was quite nice to live life at a reduced pace, however I don't think it really generated any interesting or funny stories for blogging. Except for that time I found $20.

Holiday update

2011-12-28T20:04:00.000-05:00

The highlight of the holidays was a lovely little Christmas dinner. We had Geoff's desert island meal: lasagna, cheesecake and wine. The cheesecake (left) was Geoff's signature triple layered carrot cake cheesecake. Add to that the cardiac anatomy jigsaw puzzle he gave me and it was perfect.

Also, a big thanks to the parentals for the slow-cooker; I may now be able to avoid scurvy in residency. And to my brother for the madeline pan and appropriately geeky cookbook.

Contrast

2011-12-20T14:13:00.001-05:00

What he does...

What I do...

Dutch Thanksgiving

2011-11-24T22:43:00.001-05:00

Reasons I don't generally go home for Thanksgiving:

1. It's six hours and three time zones away by plane

2. We're European, it's not really a family tradition

3. Most of the food is not on mom's Atkins diet

Lucky for me I have generous friends and am usually adopted by someone else's family on a temporary basis. For the past two years, it has been by AH, a classmate. Her family, back in the day, were Dutch and oma (grandma) in particular finds my authentic Dutch self charming. Last year she had me read a Dutch cookbook and indicate which foods were familiar. So this year I baked some Boterkoek and brought it with me. It's super simple and looks fairly plain, but let's face it, anything that's 25% butter is going to be tasty. I like mine with a hint of almond flavouring.

Try something Dutch:

1 cup butter, softened

1.5 cups granulated sugar

2 eggs

1 tablespoon almond extract

2.5 cups all-purpose flour

1.5 teaspoons baking powder

Mix butter and sugar. Add eggs, 1 at a time. Add remaining ingredients. Press into two 8" pie or tart tins. Bake for 30 minutes at 350 degrees Fahrenheit. For best texture, leave uncovered for 12-24 hours. Thereafter, store in an airtight container.

Emergency Dept: week 4

2011-10-21T18:42:00.001-04:00

Monday: chest compressions and a resident too busy to staff with me
Tuesday: no cath for you, more abdominal pain
Wednesday: just had his nose done and now it's broken, back pain, allergic reaction
Thursday: it's not your shunt but we'll scan you anyway, can't stop pooping
Friday: exam (that doesn't count)

Emergency Department: Week 3

2011-10-19T14:49:00.002-04:00

Monday: name that heart rhythm...
Tuesday: just plain crazy x2, abdominal pain
Wednesday: off! pumpkin surgery.
Thursday: immunosuppressed and febrile, attending gave me homework?!
Friday: chest compressions, large bore IVs and a bladder scan
Saturday: mr anxious, mrs crazy and the guy smoking though lung cancer
Sunday: off (again)

Emergency Dept: week 2

2011-10-09T14:08:00.000-04:00

Monday: Lupus, vomiting blood, strep throat, passing out.
Tuesday: Multiple orbital fractures, pelvic exam and a cheerleader with the flu.
Wednesday: Tech shift - peripheral IVs, appendicitis.
Thursday: Splints x3. Asthma. Oops, the baby ate mommy's pills.
Friday: Stitched up a chin, a forehead and an ear.
Saturday: Biliary colic, drunk, drunker and drunkest.
Sunday: off

Emergency Dept: week 1

2011-10-02T21:20:00.004-04:00

Monday: orientation. started an IV on a classmate.

Tuesday: orientation. splinted a classmate.

Wednesday: abdominal pain x2, chest pain and hypoglycemia. started an IV.

Thursday: seizure, abdominal pain x2, chest pain. did an NG lavage and placed an a-line.

Friday (peds): poison ivy, lip abrasion, abnormal labs, abdominal pain, seizure

Funny thing about that poison ivy... the little boy had a small patch of it on his hand and a big patch of it in his groin area...

really?!

2011-09-30T21:16:00.000-04:00

Me: What illnesses run in your family?

Patient's mother: My high blood pressure was giving me seizures so they took out my spleen.

Emergency Medicine orientation

2011-09-26T21:20:00.002-04:00

"Sometimes the facial structures are traumatized, complicating the intubation. Although, it is a lot easier to get the jaw and tongue out of the way when they are disconnected."

"You want to make sure the NG tube is not in the lungs; it can't really decompress the stomach from there."

"He came in with a skeleton of a finger, no flesh, and said 'fix me.' Well, sorry dude, you're f*cked. There's no saving that finger. Degloving injuries require amputation."

"In Europe, not everyone who goes into a trauma bay gets a rectal, but here we log roll everyone and do a rectal exam. The surgeons love it."

it shouldn't bother me, but it does

2011-09-05T13:30:00.003-04:00

I'm talking about medical inaccuracies on television. We won't even get into the inaccurate representation of resuscitation, which is so egregious that there is published research on it. Recent errors I've noted:

1. Nurses, unless they are CRNAs, don't intubate patients.

2. There is no such thing as part-time medical school.

3. You don't get a long white coat at the white coat ceremony, you get the short one.

4. Diabetics requiring insulin do not leave needle impressions on their hip bones.

5. Hospitals cannot turn away acutely ill patients because they don't have insurance.

6. You are not forbidden from speaking with a person after neurosurgery because getting them emotional could cause their brain edema to worsen.

7. If you coded, you would be moved to an ICU, not put on a stretcher along the hallway. And a lot of people would show up, not just one nurse.

8. I don't care if there's a killing spree, a random nurse would not be authorized to read confidential patient data (about a potential victim) over the phone to a police officer. She would be fired.

9. If a trauma victim is talking, they don't go straight to the OR. They go to the ER to be stabilized or for images. There is no magic hallway connecting the outside door to the OR.

10. If you sprained your pinkie finger, you would not have a hard cast placed on your hand.

Another time I'll let loose on the absolutely ridiculous depictions of medical school. I have yet to see anything that remotely resembles actual medical training on television.

Quatrains

2011-09-02T21:11:00.003-04:00

I'm apparently late to the party, but I just stumbled across the poet Rumi. Some favourites:

You think you are alive
because you breathe air?
Shame on you,
that you are alive in such a limited way.
Don't be without Love,
so you won't feel dead.
Die in Love
and stay alive forever.

It is your turn now,
you waited, you were patient.
The time has come,
for us to polish you.
We will transform your inner pearl
into a house of fire.
You're a gold mine.
Did you know that,
hidden in the dirt of the earth?
It is your turn now,
to be placed in fire.
Let us cremate your impurities.

I am so drunk
I have lost the way in
and the way out.
I have lost the earth, the moon, and the sky.
Don't put another cup of wine in my hand,
pour it in my mouth,
for I have lost the way to my mouth.

More at http://www.rumi.net/rumi_poems_main.htm

Little m, big P

2011-08-20T21:17:00.002-04:00

It occurs to me that I haven't really talked about residency applications, which actually comprise a lot of time and mental energy during the beginning of M4 year. I'm applying for a medicine-pediatrics residency. It's a four year program, at the end of which you sit the boards for both internal medicine and pediatrics. You are then eligible for any fellowship in either medicine or pediatrics, though 60% of graduates go into primary care. Not me - of course - I will be headed to fellowship.

There aren't very many med-peds residency programs, and each one takes very few candidates. Thus, this residency is competitive because demand outstrips supply. Nevertheless, my advisors tell me I will match.

For those of you who don't have relatives in medicine, I will briefly mention what "the match" is. Basically, as a 4th year you apply to some residencies. The ones interested in you will invite you to interview. You rank all the places you interviewed. The hospitals rank all the people they interviewed. It goes into a big computer program called the NRMP. In March you get an email telling you where you matched - not all the places, just the one place you will go to. It's not a choice and you are not guaranteed to be chosen anywhere. Rather appropriately, this process causes a tremendous amount of anxiety - will I match at all? Will I match somewhere I actually want to go?

Right, so I've been told I will match, it's just a question of where. My current list of programs is 19 deep and I hope to get 10 interviews. I've had to get four letters of recommendation, two of which must come from the chair of the peds dept. and the chair of the internal medicine dept. I have to get a letter of endorsement from the dean of the medical school as well. I have to put my CV and all my publications into the online program (one item at a time). I have to provide transcripts and copies of my USMLE step 1 and 2 scores. I have to write a personal statement and include a photo. I have to pay money (of course). All of this gets submitted September 1st, so you can imagine the past three months have been spent getting all of this together. But soon - so soon - I hit submit and then... I wait. Wait and hope. Hope for interviews.

I will keep you updated.

Heartbreak cardiomyopathy

2011-08-10T21:02:00.000-04:00

This month I had a patient with an interesting and rare condition called TakoTsubo Cardiomyopathy, also known as "broken heart syndrome." It involves myocardial stunning after a highly stressful event such as the death of a spouse or a natural disaster. Basically, you are so overwhelmed that you literally go into heart failure. The physiologic mechanism is incompletely understood, but leading theories revolve around catecholamine release. Thankfully, the significant majority of people recover their full heart function in days to weeks. It is most commonly seen in Japanese post-menopausal women, however it has been described in the US and Europe as well. It can be accompanied by an NSTEMI (heart attack) and frequently QT prolongation (repolarization abnormality - sorry, I don't know how to translate that better without a tutorial on EKGs).

It gets its name from Japanese octopus traps. Why? Because this particular heart failure displays what we call "apical ballooning." Basically, the upper and middle parts of the ventricle contract, but the apex (the point) of the heart does not. That means that blood, which is ordinarily squeezed from the bottom of the heart towards the top, is now being simultaneously pushed up and down. the down-going blood has nowhere to go so the tip of the heart balloons out (see diagram).

My patient began recovering heart function very quickly, but her QT prolongation was impressive. Almost write-it-up-in-a-journal impressive. Thankfully, that also resolved quickly. We never got a good sense of what her precipitating event was, but I suppose all stress is relative.

Welcome to M4!

2011-05-09T11:04:00.002-04:00

One whole week into my fourth year you may be wondering, what have I done with myself? Well, I am starting the fourth year much the same way I started the third year: studying for a USMLE exam.

This week I have covered cardiology, dermatology, GI, endocrine, biostatistics and some infectious disease. I am reading, highlighting, making flashcards and doing lots of practice questions. Fun fun.

However, life is not all work. I had a lovely day and night out (we started a little early) after completing third year: there was sangria, there was gin, there were pancakes the next morning.

I've also been helping to orient the rising M3s, which is a nostalgia-inducing process. It really makes me realise how far I've come in the last year in terms of my comfort in talking to and evaluating patients. It also points out how different the focus in teaching is now - I spend much more time thinking about details: drug choice, dosing, treatment length, etc - whereas before it was about having a workable list of potential diagnoses. A lot of what I struggled with at the beginning of my third year is assumed knowledge in the fourth. My review books don't even bother to classify antibiotic types, for example, it's assumed I know azithromycin is a macrolide that acts on the 50S ribosomal subunit and has good efficacy against gram positives and atypicals. The new questions is: how much and how many days worth for a patient with strep pharyngitis in a COPD patient?

In an effort to stay balanced while studying, I've joined a tennis clinic. I had my first practice yesterday and got a little sun (oops) as well as losing half a toenail jamming my foot in my shoe on some abrupt directional change. Worth it. I'm horrendously inconsistent at the moment, but I hit a few aces and a couple of solid put-away shots. I'm considering joining a USTA team this summer, but I'm not sure I'll have time with the sub-i's etc.

Motorcycle lessons start next week and I'm now involved with admissions for the medical school too - so hopefully those will yield some good stories for a post. In the meantime... nose to the grindstone to (hopefully) pull out a good Step 2 score.

?! #492

2011-04-26T20:16:00.002-04:00

I was reading a NYT article on hospital compliance with hand-washing when I came across this gem of a comment:

"I'm confused. I thought the only way hand washing would kill bacteria is if the water was boiling hot."

Um, have you heard of SOAP?

Little old man

2011-04-25T21:08:00.002-04:00

I had a cute four year old patient today with two old-man problems: a bald spot and urinary hesitancy. His mother brought him in because of the bald spot: an oval stripe towards the front-top of his head roughly the size of a kiwi. It first appeared a month ago as a painless, small spot the size of a dime and it had steadily grown. He was otherwise well.

While the attending conferenced with his mother, he came up to me and announced "I have to go potty!" I took him by the hand and we walked to the clinic bathroom. I waited outside the door. Thirty seconds go by and I hear "Mr. doctor. Mr. doctor!" I crack the door and he's standing there with his pants around his ankles. "I want to use the giant bathroom!" I pull his pants up, take him by the hand and walk him to the other end of clinic where a more spacious bathroom is located. Again, I wait outside the door and soon hear "Mr. doctor, mr. doctor!" I crack the door. "I'm scared!" I enter the bathroom, kneel and say "How can I help you? Do you want me to lift you up or get you a stool to stand on?" He replies "I just kidding. I don't have to go potty!"

The question everyone in the office is asking me all day: what happened to that little kid's head? The answer: he's pulling his hair out.

Maybe the grown-up sized toilet at home is freaking him out.

PIckled penis

2011-04-18T21:24:00.000-04:00

One of my preceptors recently taught me about a physical exam that was commonly done in the late 1980s: androscopy. It's an exam aimed at finding and treating HPV warts on the male genitalia. It is analogous to a (cervical) colposcopy in women.

The male is undressed from the waist down and lies on the exam table with feet in stirrups - similar to a woman undergoing a pelvic exam. The genitals (penis, scrotum, perineum) are wrapped gauze soaked with vinegar for five minutes and then inspected with the naked eye and with the colposcope (a special microscope). Lesions, if present, may be excised, cauterized (acid or freezing), or laser vapourized.

Interestingly, a pub med search has revealed that 51-65% of men who were clinically asymptomatic had lesions on their genitals when viewed under the microscope. However, up to 20% would continue to be seropositive for HPV even with negative follow-up colposcope exams; suggesting that androscopy was not eradicating the disease from the male population. For that reason, and because penile cancer is a very rare complication of male HPV, the exam was largely abandoned as routine practice.

It may come back into favour for the rectum, however, as anal cancer rates increase. Just as we now recommend screening anal pap smears for persons practicing anal intercourse, a vinegar anoscopy of the anus would be a logical follow up exam for a positive result.

For the men out there - yes, they put vinegar on the cervix for a colposcopy.

Let's talk about sex, baby

2011-04-15T11:31:00.003-04:00

Lately, there has been a lot of talk about sex. From the lecture I had today on contraceptive counseling to the recent public debate over federal funding for Planned Parenthood to the omnipresent national abortion conversation. For some reason, I thought that people had at least some basic knowledge about sex and contraception from either their parents or their junior high health classes or, hey, the internet. Apparently this is not the case, so let's clear a few things up.

1. “The fact is that 95 percent of the contraceptives on the market kill the baby in the womb,” said Jim Sedlak of the American Life League.

INCORRECT. The American College of Obstetricians and Gynecologists defines pregnancy as beginning with the fertilized egg’s implantation. Even if you believe that life begins prior to that - at the joining of sperm and egg - the majority of contraceptive measures intervene BEFORE the sperm and the egg meet. Let's review:

a. Hormones (aka the pill) - birth control pills prevent a woman from ovulating. If there is no egg, there is nothing for the sperm to fertilize and thus no baby is formed. The pill also has the happy side effects of decreasing the risk of ovarian cancer, reducing acne, and decreasing period-related pain. There are plenty of reasons women take the pill that have nothing to do with sex; it is a first line treatment for dysmenorrhea, endometriosis, ovarian cysts and fibroids.

b. Intra-uterine device (aka IUD) - One form of IUD, the Mirena, contains hormones and thus partially acts via the same mechanism as the pill. All IUDs also cause alterations in cervical mucus, which prevent sperm from being able to fuse with an egg. There are enzymes in cervical mucus that aide the sperm in 1) getting to the egg and 2) penetrating it. Without these cervical enzymes, fertilization does not occur.

c. Condoms - okay, I should hope this is self-explanatory. If the sperm is in a wrapper and not in the vagina, it's not going to make contact with an egg and create a baby.

2. If I have anal or oral sex then I won't get STDs.

INCORRECT. In fact, if you are having anal sex you should be getting regular anal pap smears. A cotton q-tip is swabbed in the anus and the cells analysed the same way they are for a cervical pap smear. HPV will do the same thing to the cells in the anus as it does to the cervix: cause cancer. Recall that some strains of HPV do not cause symptoms so you're not safe just because you don't have warts. Famous case: Farrah Fawcett died of anal cancer. HPV has also caused a rise in mouth and throat cancers, however we do not routinely swab for oral HPV at this time.

3. Guardasil (the HPV vaccine) is only for girls.

INCORRECT. It has been FDA approved for men as well. Men can transmit HPV to their sexual partners and, when infected, HPV causes an increased risk for penile cancer (still rare though). HPV will cause anal and oral cancers just as effectively in men as women.

4. “Fertility and babies are not diseases,” said Jeanne Monahan of the Family Research Council’s Center for Human Dignity

SORT OF. Many physicians consider pregnancy a natural and healthy state; however it does have a diagnosis code (an ICD-9) and it does dramatically and sometimes permanently alter the physiology of the mother. If it were totally benign we wouldn't require so many pre-natal visits, lab tests, ultrasounds and testing. There are diseases a woman can have that make pregnancy a clear and present danger to her health, even potentially fatal. There is also the issue of implantation in an abnormal part of the body (ectopic) which is also extremely dangerous to mom.

Public debate is healthy and I don't expect everyone to hold the same opinions as me; however I think is important that we are at least factual and informed about the topic. Let's not pass laws in ignorance.

Extra-curriculars

2011-04-12T08:00:00.000-04:00

A friend recently made me aware of the BANF film festival, which had a showing in town over the weekend. Talk about inspiring! It's essentially all movies about extreme athletes of some kind: mountain biking, whitewater kyaking, speed freeclimbing, etc. Two movies stuck out for me at the showing for both their striking visual content as well as their kick-butt soundtrack choices:

LifeCycles

Song: Saskatoon by Data Romance (this is a remix of Levee Camp Holler)

The Swiss Machine

Song: Welcome Home by Radical Face

I called it!

2011-04-05T17:45:00.001-04:00

Warning: this post involves some bragging. Let me state that I frequently get things wrong (thus, still in training), but that's not as fun to write about.

How clinic works: The attending sends me in to each room ahead of her to get a history and perform a physical exam. I then briefly present the patient to her as well as any recommendations I have. She then finishes the appointment with the patient (I'm in the room too).

I go in to see patient X who is supposedly here for a routine physical. I ask her how she's been feeling lately and she says "my optometrist said it was important I keep this appointment." On questioning I discover that she is having positional headaches and some intermittent nausea, but otherwise feels well. She denies any vision changes.

On physical exam, patient X had bilaterally blurred optic disc margins (papilledema), full visual fields to confrontation, but otherwise appeared well.

If you're in medical school, make your diagnosis now...

During my presentation I state that idiopathic intracranial hypertension is at the top of my differential, but that a mass lesion should be ruled out. I state that papilledema merits an MRI but that ultimately a lumbar puncture should be performed. My attending smiles at me, pats my hand and says, "please don't be offended if I disagree with you, that's a pretty rare thing to find."

We go in together to see patient X. My attending examines her and begins counseling her. Guess what turns out to be at the top of her differential? Guess what test she wants first? Yup. I may have given myself a mental pat on the back.

you know you're in medicine when #253

2011-04-05T08:43:00.002-04:00

You're watching a television show and during a scene in which a character is getting blood drawn you look at the syringe and remark "that's not what blood looks like."

When I grow up...

2011-04-03T23:59:00.003-04:00

A big focus in life at the moment is answering the question: What kind of doctor do I want to be? Unfortunately for me, I am currently undecided. Here's where I am:

Internal Medicine (likely fellowship in cardiology or critical care)

Pro: Some patient continuity, variety, acute care, flexible lifestyle

Con: Not heavily procedural unless I go into the cath lab

Total time: 3 years residency + 3 years fellowship

General Surgery (likely critical care fellowship)

Pro: Very procedural, the OR is fun, prestige, variety, some patient continuity

Con: Not sure I love GI problems, tough lifestyle, required lab year

Total time: 7 years residency, with fellowship as one of my research years

Pediatrics (likely fellowship in cardiology or critical care)

Pro: love the patient population, patient continuity, flexible lifestyle

Con: not procedural (again, unless cath lab), limited places to practice

Total time: 3 years residency + 3 years fellowship

I've ruled out anesthesiology for lack of patient continuity. Plus, if I'm going to be in the OR, it's going to be my OR. I would likely match in any of these, though surgery would be toughest. Current plan: subi in each, await my surgery grade and see where we stand.

ps note the M4 schedule has been posted on the sidebar, for those who are curious.

Overdue Update

2011-04-02T20:36:00.000-04:00

I apologise for my absence. I was on rotation in downtown Detroit and the temporary crash-pad did not have internet (?!). I was on neurology, which is not at the top of my super-interesting-material list, but I did get to spend two weeks in the neuro-ICU and I do so love any kind of ICU. Bring me your super-sick, your actively dying and I will go to work with enthusiasm and diligence.

One of the wonderful things about this new hospital was the white chocolate macadamia cookies. And the Monday schwarma lunches. Yummy. Also interesting was editing my fellow's notes for proper English grammar and spelling (yes, I was called upon for spelling).

There was one very sad case: a patient who had a stroke at the young age of 41. We don't know why. He's now densely hemiplegic (can't move half of his body) and non-verbal. While under our care his wife found out she's pregnant. She's going to have a new baby and a husband in inpatient rehab who also needs her care. While rounding each morning he would start crying; he is cognitively intact and aware of his prognosis: he will likely not get much movement back.

In personal life news (yes, neurology is one of the rotations in which a life is possible), I've taken up P90X, which is quite challenging, but awesome. I finally had a good night out dancing, which I sorely needed. Sometimes there's just nothing like a cocktail and a good song to dance too. I even made some friends in Detroit, so hopefully I'll spend some more time exploring the city. Oh, and I signed up for motorcycle classes... shhh... don't tell my parents. It's going to be awesome when I visit them in May and hop on dad's Ducati! I'm working on signing up for tennis clinic, but it might be full. Boo.

Tomorrow morning is the beginning of Family Medicine... in Toledo. Also, the ramp up for studying for Step 2 (the second board exam, scheduled for June 2nd). Nevertheless, weekends off for another month so hopefully I'll be able to continue this whole "balance" thing.

I feel dirty

2011-03-09T17:20:00.002-05:00

I am on rotation at another hospital at the moment and one of our lecturers failed to show. Instead, I got to bond with some of my fellow students (for whom this hospital is home). One of them had a great horror story...

She was evaluating a patient in the ER who came in with priapism (a prolonged erection). Draining the organ was attempted, with no success. The student's attending then told her to "milk it." After some hesitation, she did as she was told. Another attending came by and asked her what on earth she was doing?! Turns out the first attending had been joking. The patient went on to surgery.

take it where you find it

2011-03-05T11:56:00.001-05:00

Is it sad that I feel validated when I correctly diagnose tv characters before the tv doctors?

Stating the obvious

2011-03-03T14:27:00.003-05:00

According to my textbook, "the basic principles of hepatic resection are complete removal of the lesion without patient death."

Don't want to set the bar too high there...

MIS: the last surgery

2011-03-02T20:35:00.000-05:00

Ok, so it was technically the second to last surgery, but the true last one wasn't nearly as unique.

The picture is not my patient, but the operation was the same: repair of a rather large primary umbilical hernia. He literally had a basketball-sized hernia filled with bowel and omentum hanging off of a 8cm x 8cm fascial defect. We managed to reduce the hernia completely, placed some synthetic mesh to bridge the defect, covered it with some muscle flaps, then closed fascia, deep dermis and skin. For those of you up on your hernia repairs, he did not require separation of parts to achieve repair nor did he necessitate a full laparotomy. We only extended our incision 2 inches above the hernia sack (the defect in the picture must be larger since his sack extends to the xiphoid). We did remove quite a bit of skin, as you can imagine.

The operation was complicated by a difficult foley placement. I thought it was just my technical error... but I was vindicated when my chief couldn't pass the catheter either and we had to call urology. They managed a foley with the assistance of a flexible scope, which revealed a significant stricture in the urethra.

In slightly less medical terms: a hernia is a weakness or hole in one of the connective tissue layers separating two compartments in your body. In this case, the hole was in the abdominal wall where your belly button is. It was about 8cm in diameter. The man's intestines had crept out of the hole and were right below his skin in the big ball hanging off of his belly. We cut open the skin, pushed his intestines back into his belly and put some mesh over the hole to prevent his intestines from getting out again. We then pulled his abdominal muscles over the mesh to strengthen the repair. Sometimes when we pull the muscles, they don't close properly because they can't reach each other. If that's the case, we cut them free from other muscles on your sides (separation of parts) so that they can move more centrally and cover the hole. Since the hernia stretched the skin, we cut off some of the extra skin and stapled the incision closed.

Rule of Threes: Music

2011-02-25T20:00:00.004-05:00

Three recent albums you should already own:

1. Mumford and Sons - Sigh No More

2. The Black Keys - Brothers

3. Adele - 21

Great line from #2: "I wanted love/but not for myself/but for the girl/so she could love herself."

Three songs with attitude, on heavy rotation:

1. When I Get you Alone - Glee Cast version

2. Forget You - Cee Lo Green

3. Feel Good Drag - Anberlin

Great line from #1 "baby girl, you da shit/that makes you my equivalent."

Three songs recently rediscovered:

1. Tangled Up in Blue - Bob Dylan

2. Crush on Everyone - Jonah Matranga

3. She's not There - The Zombies

Great line from #2 "if you like large intestines/please let me find out."

Three songs I deny are on my Ipod:

1. Represent, Cuba - Studio Sound Ensemble

2. Tonight (I'm loving you) - Enrique Inglesias

3. Haunted - Taylor Swift

Dumbest line from #2: "If I never lied then/baby you'd be the truth."

Fabulous gift

2011-02-25T19:53:00.002-05:00

This was given to me today by a friend. It's a plate from Gray's anatomy (the book, not the tv show) with the cardiac anatomy labeled in latin. I absolutely love it.

Inguinal hernia

2011-02-19T22:56:00.003-05:00

On Friday I assisted a laparoscopic bilateral inguinal hernia repair. For those of you uncertain where the inguinal area is, feel your hip bones at the bottom of your stomach. Draw a line from each hipbone to where your pubic hair starts. That's roughly the location of your inguinal ligament.

The surgery provided the best view of that anatomy of the lower anterior abdominal wall I have seen to date. Better than anatomy lab without question. I can't find a phenomenal photo of it, but this one isn't bad. There is a normal weak point in the abdominal wall in that region, called Hesselbach's triangle (the HT in the picture). The vessel that borders it is called the inferior epigastric (not labeled) and a hernia medial (in HT) is called a direct inguinal hernia whereas a hernia lateral to the vessel is called indirect (through the internal inguinal ring, labeled IIR in the picture). Two important anatomic regions lie near Hesselbach's triangle, making the surgery technically quite challenging. My attending affectionally refers to these as the triangle of doom (inferior, where the femoral vessels run) and the triangle of pain (lateral, where the genitofemoral nerve runs). During the surgery he would constantly yell out which triangle we were near when our instruments got too close (which was often, it's a tiny space). "Watch out for DOOM!" "Beware PAIN!"

It was a quick, interesting case to observe; a good start to the morning. It was followed by (yet another) anterior abdominal wall reconstrution.

Professionalism

2011-02-18T17:30:00.000-05:00

We has a small group lecture on Friday to discuss professionalism. Our facilitator was supposed to have us discuss what professionalism means to us and how we think we learn it, but instead the conversation became a reflection on the tenor of the interactions we have witnessed over the last year in the hospital. We all agreed that by-and-large the demeanor displayed towards patients was very professional. Not always warm and fuzzy, but at a minimum, respectful. The few occasions we witnessed something less were generally in the context of extreme burn out.

What was more interesting is that we witness a lot of unprofessional interaction between medical professionals. The doctor-nurse relationship has been beaten to death in many forums, but it also exists between consulting and primary teams, between different specialties and between levels in the hierarchy. In particular, medical students can be the target of unprofessional, disrespectful behavior; most commonly from non-physicians on the care team. There is something about wearing a short white coat instead of a long one that signals to nurses and scrub techs that it's ok to abuse you or ignore you at will. Maybe it's because in a few months when we graduate we will be their bosses. Maybe it's because we have zero power to retaliate. Maybe it's because we're new and young. Whatever it is, we have all experienced it.

In the end, having a collective bitch session was very therapeutic. We are at a stage in training in which we have no autonomy, no choices, long hours and constant evaluation. Being able to complain to others who understand and don't recoil with a look of disgust at our temporary lack of compassion and empathy was very freeing. And the truth is, everyone else in the world complains about their job, their coworkers and their customers at times. Is it so surprising that we, as (future) physicians, would need to as well?

Vascular: the final surgery

2011-02-04T19:07:00.001-05:00

My last day on the vascular surgery service was spent in the OR on an exceptionally engrossing case. It was a thoracic aorta to celiac/SMA bypass. Basically, we anastamose (attach) a bifurcated graft (tube that splits in two) proximally to the thoracic aorta (above the diaphragm) and distally to the celiac trunk and the superior mesenteric arteries (one leg of the graft to each artery. This means it's attached once to the aorta, splits, and then each leg attaches to one of the arteries). The patient was suffering from mesenteric ischemia (bowel that wasn't getting enough oxygen) due to atherosclerosis. Two of the three arteries supplying the gut were completly occluded, so those are the two we bypassed, improving blood flow to the gut and hopefully reduing his pain.

The attending was Dr. C, an eccentric Spaniard who is both an exceptional technical surgeon and an enthusiastic teacher. He would step back every 10 minutes or so during the dissection to describe the planes of anatomy he was crossing, ask a few reasonable questions and then have everyone stick their hand in and feel for key structures. The incision was along the ninth rib space in the retroperitoneum, just below the diaphragm. We dissected through the diaphragm to access the thoracic aorta; then through the pleural space while strategically collapsing the lung. This provided a beautiful view of the heart contracting, which is really quite captivating. This lateral incision also allowed us to leave the kidney alone, though we did have to mobilze the pancreas. Once the graft had been sewn in and we were closing, we reinflated the lung. It was pretty nifty to see the lung inflating and deflating with each breath while we closed the diaphragm. Dr. C let me close the skin, which involved no small number of subcuticular stitches (yay).

In the end, I really enjoyed my month on vascular. It almost makes me think I would enjoy being a surgeon, so we'll have to see how MIS goes. I wonder if the novelty of being inside someone would wear off and it would become tedious? You don't really follow your patients and you take care of such a compartmentalized portion of their health. On the other hand, you get to operate. The trouble with liking everything is that it becomes awfully hard to choose.

180 degrees

2011-02-02T21:31:00.002-05:00

I had an amazing day on surgery, which is unexpected but welcome. There was a blizzard overnight, the new interns were starting and I was on call so I was geared up for a long, rough day. Instead...

1. I presented patients on rounds and the fellow liked my plans

2. I pulled drains and changed dressings before the OR (it's fun to do things)

3. I did the electrocautery to open the patient's groin (in the OR)

4. I got to close the groin alone

5. The uptight fellow looked at my closure and said "you've got skills."

6. I actually had a 45 minute lunch

7. We did a helpful teaching session on trauma and I managed to not interrupt

8. I was sent to consult a patient because I knew more about the procedure than the intern

9. The uptight fellow had me do the entire add-on I&D while she supervised

10. The uptight fellow gave me unexpectedly positive feedback

11. I was paged while in the OR by another attending

12. I was sent home at 8pm on a call night

I should probably stop calling her the uptight fellow since I actually sort of like her now. Since I'm less scared and we've both gotten used to each other, I feel like I can relate to her somewhat. I feel like I've seen a little of her human/personal side rather than just her all-business/work side.

Medical funfact #249

2011-02-01T18:40:00.002-05:00

We use protamine sulfate to reverse the effects of the blood thinner heparin. One potential side effect exists for males who have undergone vasectomy...

Protamine is made from salmon sperm. Usually, the (human) testicles reside across a special barrier from the rest of the body, much like the brain. If this barrier was damaged during a vasectomy, some of the protamine could cross it. The human immune system would then mount an allergic reaction to the non-human sperm proteins.

And for the beauty pageant contestants out there: no, protamine cannot get you pregnant.

Sunday call

2011-01-30T14:28:00.004-05:00

There is nothing quite like a morning amputation to make your day feel productive. By lunchtime you have already rounded on all the patients, redressed the wounds, updated the orders, written progress notes and removed a person's limb. Call it macabre, but that's a lot of to-do list items checked off.

Amputations feel so satisfying because you can physically see the work (unlike a stent or graft where all the work is interior). They are also extremely quick surgeries; you bove through the skin/muscle, saw through the bone, clean up the edges and sew a skin flap. Done and done. From induction to reversal, taking off this guy's forefoot took one hour. And yes, they let me cut through some bone. There was a lot more spatter than with the above-the-knee I did last week. This time I had blood spray on my goggles and mask (cool).

The picture is an x-ray s/p (after) a transmetatarsal amputation. People lose their forefoot and have special shoe inserts that help them with ambulation.

There is another guy on the floor at the moment who had a bypass graft done earlier this week. It's a high risk graft, which means there is a strong likelihood the graft will clot off. More of a when than if. To extend the life of the graft we put the patients on coumadin. Well, this guy really doesn't want to take it in case it causes some nausea. SERIOUSLY? How is this a decision? Take the coumadin +/- a anti-emetic and keep the leg for a few years vs. don't take coumadin and lose the leg in weeks. He has to think about this?

Tidbits

2011-01-28T16:16:00.002-05:00

1. Standing in the OR holding a freshly amputated leg (above the knee) and putting it in the disposal bag. When you take something off the table, you have to call out. Examples include: knife down, needle back, etc. Handing off the leg, I stated "one partially used limb for pathology."

2. Putting stitches into a femoral artery graft. They have to be perfect because you don't want the patient bleeding from the graft-artery junction (anastamosis). The attending let me throw the last 4 to close the anastamosis. The needle we use is less than a millimeter thick and 1cm long. We took the clamp off and... my sutures held!

3. A patient on the thoracic service was bleeding through his dressings after having an emergent bilateral fasciotomy (two big incisions in each leg, left open) earlier that morning. The interns were busy dealing with a patient having a heart attack so they sent me down to do the consult. The fellow and attending agreed with my plan and had me present to the primary team. The nurse didn't want to touch the dressings so I redid the surgical bandages (more complicated than just some gauze), stitched his central lines in place, then answered the wife's questions. Basically, I acted as the consulting resident from vascular (quite a promotion).

4. Putting a Foley in a man with a penis that is permanently fibrosed in the erect position.

bad days

2011-01-27T15:54:00.000-05:00

I'm coming to the conclusion that when choosing a specialty, you need to choose the one where even the bad days are somewhat fun. I don't mean bad as in the previous post where you're emotionally drained; I mean bad as in technically the sh*t is hitting the fan. An example of one of these painful days...

I got to the unit at 5:30am for pre-rounds, as usual. I checked in on my patients and took down the dressings, as usual. We rounded as a team and I re-dressed the wounds, as usual. There was no morning conference so I headed down to the OR early to put in the patient's Foley and watch anesthesia place the central lines. The planned surgery was an open (cut the abdomen open, rather than inserting a catheter though the vessels) abdominal aortic aneurysm repair. It should take 4-5 hours. I was scrubbing with the uptight fellow and one of the old Spaniards.

The case began and he was a little wetter (oozing blood) than expected, but otherwise the dissection to the retroperitoneum was uneventful. We were able to clamp infra-renally (good) and got proximal and distal control of the arteries near our anastamosis sites. We began grafting to the aorta, but the clamp appeared through the posterior wall. This means the aorta had torn, so we had to reclamp, higher, and get control of the bleeding. We managed to get the graft on, but the patient was still bleeding. We discovered the aorta had torn proximal to the clamp. We attempted to mobilize the aorta and sew the tear closed, but it continued extending. It look 3-4 hours and a supra-renal clamp to repair the tear. We turned our attention to the iliac anastamoses, and one of these also proved problematic with excess bleeding. We finally closed the belly to find he had stopped urinating and had stooled all over the OR table. At this point he had lost just over 13L of blood.

We did dopplers of his feet to check for pulses and found one limb to have absent pulses and pallor. We prepped for a thrombectomy, to extract the presumed clot released when we came off the aortic clamp. Once in his groin, we found very calcified arteries and insufficient forward flow to float a catheter down the leg. We immediately converted to a femoral to femoral bypass graft. We opened the other groin and reheparinised him. The bypass was completed uneventfully and his groins were closed. At this point, he had another 2L of blood loss.

The whole operation took 14 hours (I was allowed to leave at hour 12) and ended up being really rough on his kidneys (suprarenal clamp) and having a very long aortic clamp time (no fresh blood to the legs -> tissue loss -> also bad for kidneys). He's stable (for now) in the ICU. The point (long-winded, yes) is that this was a tough case where everything was going wrong. This is a painful surgery, even for a surgeon. In fact, the attending that started the case was not the one who finished it. If you can still find some fun in this kind of day, then maybe the OR is the place for you. Me, well, I did not find so much fun in this. But there are rough days in the ICU I get some rush from. Where the fight is energizing as well as draining. So I don't think I'm a future surgeon, but I think I earned some respect from them for standing in that OR for 12 hours with no food/water/peeing/sitting.

We all fall down

2011-01-24T20:37:00.002-05:00

Well, I suspected it would happen, but surgery broke me. On Friday night I was reduce to tears. Or more accurately, collapsed sobbing on my bedroom floor. It was, in all honesty, a pathetic sight and a definite low-point. How did this happen? Well... Friday actually started out quite well. Rounds went relatively smoothly since we had the relaxed fellow. Then it was off to clinic with the nice attending. The first two patients didn't show so I was able to grab a coffee and tend to some email. I managed to see six patients and write their notes before leaving for seminar, prompting Dr. E to tell me I was "ready to be a fourth year." So yeah, the day started out fairly well. Seminar should have been a hint. It was about our future, a topic that always give me a little spasm of fear: will I be able to match to geography I like given my Step 1 score? Am I going to get stuck doing primary care in Idaho? A classmate approached me during seminar to tell me that the uptight fellow had scrubbed on some cases at the VA with him and spent the time in the OR asking my fellow student pointed questions about ME (unprofessional!). He couldn't say anything nice (what?) so he lied and said he had never been on service with me (thanks). I got back to the conference room after seminar in time for afternoon rounds. When the other students on vascular got back they made it clear I shouldn't have left without them (they left without me last week). Off to teaching rounds with the over-enthusiastic attending who pimped JUST ME on surgical abdomens, but felt the need to stop halfway through to tell the whole room that I was defensive and arrogant and should get that under control (unprofessional!). After teaching rounds the two medical students on vascular cornered me to have a frank talk about how I interrupt too much. I then took some staples out of a woman's abdominal wound and was allowed to leave. I got out of the hospital into the freezing air and tears started sprouting. Trouble is, they started freezing in my eyelashes as I walked. Yes, I froze my eyes shut crying on the walk home.

So let's reflect: yes, the "constructive" criticism I received is grounded in truth. My board scores are my fault. I am defensive, but not out of arrogance. I hate getting things wrong because I'm terrified. I probably do interrupt too much, but could that conversation possibly have waited until the next day given they had just watched me get humiliated by an attending? Not to mention that I have not committed the cardinal sins of throwing another student under the bus or claiming all the good surgeries?

End result: I don't have skin thick enough to be a surgeon. Nor do I want to. I do take it personally when people criticize me; because I care. I care that I'm good at this and that I am respected. I don't want to become the kind of person who can humiliate another person in public just because they can't talk back for fear of their grade. It does not help my learning. Being a good teacher is about motivating and empowering, not belittling and intimidating. Surgeons seem to confuse fear with respect.

A clue, sherlock?

2011-01-17T20:02:00.003-05:00

The big decision: internal medicine vs. pediatrics.

While on call on Friday I was with my team (vascular surgery, at the moment) on evening rounds checking on patients before we more or less leave them alone for the night. One of our patients was a young boy, so we had to trek over to the children's hospital to check on him. On entering the pediatric intensive care unit, I got this little stomach flip-flop. That little bubble of abdominal excitement you get when you're about to open a present or buckle yourself into the rollercoaster with 7 loop-de-loops. I wonder if that fleeting visceral excitement is a signal from my subconscious telling me to be a pediatrician?

Surgery begins

2011-01-12T21:46:00.002-05:00

On Monday I began my vascular surgery month. It's now Wednesday night and I have already worked 31.25 hours. They have us track because we aren't supposed to go over 80 in a week. Legally we can, but they don't want us to have it worse than the interns. How generous. Not that they would actually send us home if we hit 80; they just want to know.

Regardless, I spent day 1 in lectures and the simulation center; days 2 and 3 involved rounding and then hitting the OR. The OR is an interesting mix of incredibly cool and unbelievably boring. There are moments when you are helping, being quizzed (or taught) or watching something insane. Those are the cool parts. Then there are long stretches of time when you are largely ignored, uninvolved and staring obliquely at something which is probably an organ or blood vessel. You try your best to stay out of the way, remain sterile and ignore the aching in your back and feet. And the fact that you are hungry. And need to pee. Those would be the boring bits. Thankfully, the vascular attendings are somewhat more enthusiastic about teaching than reputation would have you believe and they like playing music and cracking jokes in the OR. This helps the time move more quickly.

In fact, one of the patients today was under sedation (rather than anesthesia and thus is partially awake) and requested Barry White be played. We complied and he sang along! This while we were debriding his horrendous foot ulcer and stenting open his right leg arteries by sending a catheter down his left arm. Bonus, one of the nurses showed me where she keeps her stash of peanutbutter Dove chocolates... score!

them apples!

2011-01-09T21:18:00.000-05:00

Is it just me, or have apples become ginormous?

Hace calor. Hace sol.

2011-01-08T21:20:00.000-05:00

I have returned from a two week trip to Argentina. Amazingly, this is the only true vacation I get between May 2010-Dec 2011. Yay medical school. Anyway, I returned from a trip to El Calafate and Buenos Aires. Unfortunately time did not allow me to see Torres Del Pine and circumstances prevented a side trip to Colonia, Uruguay, so those will have to be accomplished in a subsequent trip.

In El Calafate we hiked the Perito Moreno glacier; first an hour along the lateral moraine, then four hours on the accumulation zone (complete with crampons) before hiking back out along the lateral moraine again. It's impossible to capture the scale of the glacier with photographs. The weather was fantastic; I did the second half of the hike in just a long-sleeved t-shirt.

We also hopped onto some horses to see the surrounding countryside, which is practically an iridescent shade of green. It's complete with wild llamas and plenty of space for a good gallop or a cozy lunch of steak, onions, wine and havanas.

Back in Buenos Aires we did a little going out, a little cultural enrichment and a lot of reading and relaxing. And eating. There is a lot of great food (especially ice cream), but interestingly, no peanutbutter to be found. Anywhere. There might have been a little shopping in there too.

Going out in Argentina is a bit crazy because, in general, dinner is between 9-11pm. No one arrives at the bars or clubs until 2-2:30am and then people stay out until sunrise. Needless to say, that's not my usual schedule so it took a little adjusting too. As did coming back (to surgery and 5:15am pre-rounds). We went to a local, unmarked bar to shoot some pool, a swanky foreign bar, spent a night learning to tango and hit up a hip-hop club, complete with break dancing and dance crews.

Overall, I was surprised by how European the city is and how good the English is (although a friend who was also there said he had more trouble with the level of English). It's definitely a place I would enjoy returning too and there are plenty of stunning landmarks I missed: Mendoza (wine country), Iguazu Falls (natural wonder) and the previously mentioned Torres Del Pine. It also reinforced the fact that I absolutely must learn Spanish. It is an extremely useful second language in medicine and in travel.

Pediatric Cardiology

2010-12-08T20:43:00.000-05:00

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?

nom nom nom

2010-11-01T21:31:00.004-04:00

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

2010-10-07T20:56:00.002-04:00

On scrubbing

2010-10-07T20:19:00.002-04:00

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

2010-10-06T22:35:00.000-04:00

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

2010-09-14T21:57:00.002-04:00

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?!

2010-09-13T23:33:00.003-04:00

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

2010-09-12T15:22:00.002-04:00

On the wall of the VA.

Drug rash

2010-08-29T18:43:00.003-04:00

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

2010-08-21T00:09:00.001-04:00

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...

2010-08-05T23:00:00.002-04:00

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

2010-07-29T16:05:00.002-04:00

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

2010-07-24T18:30:00.003-04:00

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

2010-07-22T19:01:00.004-04:00

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

2010-07-14T22:49:00.002-04:00

hat tip: geekinheels blog.

And now for something completely different

2010-07-09T22:19:00.002-04:00

A little humour...

2010-07-08T22:13:00.002-04:00

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

2010-07-06T21:27:00.000-04:00

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

2010-06-22T17:50:00.002-04:00

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

2010-06-20T14:08:00.000-04:00

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"

2010-05-13T22:43:00.002-04:00

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

2010-04-15T20:53:00.005-04:00

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?

2010-04-08T18:33:00.003-04:00

The reservoir for leprosy in the USA is armadillos.

Scorpion stings can cause acute pancreatitis.

pls Reply: none

2010-04-08T17:30:00.002-04:00

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...

2010-04-07T14:51:00.003-04:00

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

2010-04-05T17:35:00.004-04:00

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?

2010-04-02T12:07:00.004-04:00

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

2010-03-25T19:35:00.003-04:00

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

2010-03-21T19:31:00.000-04:00

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?

2010-03-13T13:46:00.003-05:00

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...

2010-03-13T13:39:00.002-05:00

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

2010-03-11T22:45:00.002-05:00

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

2010-02-18T13:52:00.003-05:00

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

2010-01-28T06:56:00.000-05:00

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!

2010-01-24T23:46:00.002-05:00

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?

2010-01-15T16:22:00.002-05:00

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

2010-01-14T22:57:00.002-05:00

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

2010-01-08T00:41:00.002-05:00

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

2010-01-07T22:17:00.003-05:00

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

2010-01-06T00:34:00.001-05:00

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

2010-01-05T16:57:00.003-05:00

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

2010-01-04T09:36:00.002-05:00

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...

2010-01-03T18:06:00.003-05:00

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?!

2010-01-02T17:54:00.002-05:00

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.

Victory!

2009-12-10T16:25:00.004-05:00

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.

Joke's on me

2009-12-06T23:34:00.003-05:00

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 non-medicine side of medicine

2009-12-03T22:31:00.004-05:00

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:

Send in your license
Complete lifelong learning modules
Pass an exam
Complete an approved quality improvement project

An example of an improved quality improvement project is to plug data from 10 patients with asthma into some software which analyzes your management practices against accepted asthma guidelines. It will then suggest areas you could improve. You choose one, change your care appropriately and put the new data into the program. You can then look at how your patients are doing based on the change in your practice. The idea is to continually be evaluating your quality as a practitioner and actively identify and implement potential improvements.

My issue is this: it seems a lot like research without informed consent. The patient does not know they are part of this quality initiative. Their management is not being changed based on an individualized assessment by the physician, but by a national guideline or software program.

Apparently, if the intent is not publishing, it's not "research". I think this is an ethical gray area. Comparing your practices in a systematic way against the national guidelines is a good thing - it can help you identify ways to improve. But altering the treatment of your patients then merits thought about their individual case. I would like to believe that when my doctor makes a decision about my care, he has done so because he thinks it's best for me, not because he needs to meet his re-certification requirements. And as far as I'm concerned, if you run a systematic intervention with the intent of producing altered outcomes - that's research, published or not.

Lastly, patient outcomes are reliant on two (controllable) factors: the ability of the physician and the compliance of the patient. The physician can follow all the guidelines, run the right tests and prescribe the right meds, but if the patient doesn't take responsibility, the outcomes are still going to be poor. We should absolutely measure and track physicians performance, but we have to remember that the doctor cannot be there every day to put a pill in your mouth, put the ice cream away and get you out the door for a run.

For example, the pediatricians were discussing how they are held accountable for vaccination rates in their practices. Some parents simply don't make appointments and don't bring their kids in, so those kids hurt the physician's numbers (which hurts their reimbursement). The docs were seriously considering renting a van and going to the local school, rounding up the kids who hadn't shown for the vaccinations and vaccinating them. Are you kidding? In order to get paid for the services they provide the kids who do show up they have to track down all the rest and accost them at school? I'd rather fine the non-compliant parents. The money would help pay for child health insurance, incentivize care and remind the parents of a little thing called personal responsibility.

Wednesday night procrastination

2009-12-02T20:49:00.005-05:00

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.

Sounds like...

2009-11-30T18:27:00.002-05:00

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.

Why I never call anymore

2009-11-29T17:55:00.000-05:00

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?

Body Surface Area

2009-11-24T00:46:00.004-05:00

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

Vocab lessons

2009-11-22T21:16:00.005-05:00

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.