moving!

America's interstates really do all look the same. Mom and Dad driving ahead of me.

...2 days of driving later. One hand/eye on the wheel, the other trying to capture this moment at 85 mph.

Downstairs.

View from the loft upstairs.

It's been a whirlwind week of packing, driving, unpacking, furnishing the new place, and getting settled in while exploring the city. Everything happened so fast after match, but I guess it's time to get to work now.

we MaDe it!

Green for medicine, orange for Texas.

The last thing I ever made in my Dallas kitchen.

Graduation Cupcakes

What you need:
-4 years that fly by
-the perfect ballpoint pen
-countless hours in the carrels, library, Starbucks, and hospital hallways
-smiles, laughter, hugs, tears
-births, deaths, weddings, breakups
-lives saved, lives lost, patients and families of all ages, race, and walks of life
-humility and wonderment at being blessed with this opportunity at all
-amazing friends and loved ones to travel the journey with you

What you do:
1. Begin medical school in a strange new city with absolutely no idea what you're getting yourself into.
2. Be lucky enough to meet the most generous, strong, beautiful, intelligent, and loving people along the way.
3. Find yourself --- in the midst of zero hours of sleep, at 4am on call, with people dying all around.
4. Have faith that beginning residency --- in a strange new city with only a vague idea of what you're getting yourself into --- will bring just as much adventure and growth.
5. Bake bittersweet cupcakes. Frost, then top with an upside-down mini-Reese's peanut butter cup, a Ghirardelli chocolate square, and an M&M. Anchor with frosting.
6. Share with friends, and know that this isn't "goodbye," it's "see you later."

back to the P-M-H

On call tomorrow at Parkland; it'll be the first since... oh wow, last November. Craziness.

-Scrubs and toothbrush? Check.
-New pager battery? Check.
-Snacks? Check.
-Stash of preferred brand of fine-tipped pens? Check.
-Paperback book to read on call now that I don't have to study? Yessss!

Bring it.

why are you asking me this?

I have never in my life been asked, so often and so frequently, the question that seems to bombard me from every angle these days.

Point blank: "Are you single?"

And it's not even coming from guys trying to hit on me. It's from deans and attendings and chief residents and residency advisors trying to help me assess how best to proceed with my career. I get that it impacts tons of people's decisions on a specialty choice, lifestyle, geographic constraints for a wife's career, kids in school, family in the area, whatever. I get that part of it, I really do. But it still shocks me a little each time someone asks me so bluntly.

I've tried to address the whole personal life issue by saying, "I have no geographic constraints and would not hesitate to move anywhere for a great residency program." Then, for good measure, I wave my unadorned left hand around. No, I'm just kidding. I honestly did not expect the whole personal life vs. career balance issue to come up so early - I'm having a hard time even imagining myself married - but apparently my superiors expect someone at my life stage to take these things into consideration.

So... the answer is yes. And as one attending said to me today with a huge smile, "Good for you! That's great, you're so free to do as you please!"

lost in thought

Is it incredibly morbid that I feel most alive when my patients' lives hang by a thread? I've come to realize that what inspires me most in medicine is life and death, quick decisiveness, saving lives. In all my current apathy, it's almost like I need the intense (melo)drama and adrenaline that comes with caring for a patient who is literally fighting for each minute of his/her life. It makes me think. It makes me care. It makes me appreciate.

And when they often die, it makes me incredibly sad.

I often joke that I don't believe in moderation, but it's mostly true: I will work out either every day or not at all. I often binge eat. I won't study at all for 7 weeks, then cram like a maniac for a week straight. My emotions have always been rather extreme as well, and recently have become closely linked to the work I do. I don't know what's the lesser of two evils: being so apathetic in life as to mimic melancholic depression, or feeling alive only because of a constant melodramatic reminder of how fragile we all are.

I don't know what I want to do with my career. I fear that following my passion for life/death will lead to throwing my entire emotional reserve into my work with nothing left for myself and/or relationships. On the other hand, the daily grind of boredom, apathy, and leaden paralysis is getting me nowhere either.

intent

A few days ago I performed my first D&C. Granted, it was an incomplete abortion (a miscarriage in which products of conception are not completely expelled and require evacuation) and was not done expressly for the purpose of aborting a fetus. Like any other surgical procedure, it felt oddly impersonal and detached. The patient, draped in sterile fashion with only the surgical site exposed, appears merely as a body part. All members of the surgical team, covered in hats, masks, long sterile gowns, gloves and shoe covers, appear mostly anonymous. The procedure itself - simple enough that I was allowed to perform much of it - is a series of well-rehearsed steps. We were in the OR probably less than 30 minutes.

I couldn't help thinking the whole time, though, that this D&C wasn't done any differently than when performed specifically to abort a pregnancy. Clearly, medical abortion is a giant ethical and moral debate with infinite arguments about what constitutes a "life"; however, from a strictly surgical perspective, it really doesn't feel any different. Like law and murder/manslaughter, it all seems to fall back on intent. Parsing out intent vaguely intellectualizes the whole situation in the first place, yet abortion draws fervently emotional responses. It's easy to debate medicolegal issues like euthanasia and abortion in the intellectual sense, but in person (in hospital?) nothing is black and white. If everyone could see things like this, I wonder if there would be more open-minded, gray people.

On that note, I leave you with this article published yesterday in the Times, written by an retired OB/Gyn discussing his experience before Roe v. Wade.

awkward: defined

Awkward = talking to someone my own age about erectile dysfunction and his inability to, you know, keep things up long enough in order to get his wife pregnant.

Thoughts:
1) My own age. ED with probing discussion of sexual practices and specific difficulties. Gah. Almost as awkward as doing a hernia exam on that college-aged kid.
2) My own age. Wife! Pregnant! Good Lord! Earlier this year, my bamboo plant died of blatant neglect, and those things literally live forever.
3) Why is he unable to maintain any sort of eye contact with me? And nervously laughing? Hey dude, I'm using clinical terminology, calm the f* down.

Oh right, so... I'm back from Thailand! And back at work after my glorious international jetsetting/month off. Next post on Thailand. Stay tuned.

pharmaceutakeover

I came home to my parents' house in Houston, only to find Crestor tissues in my bathroom, Synthroid and Aranesp sticky notepads by every computer, and all kinds of random drug pens scattered randomly throughout the house. Creepy.

the lingo

Every field has it: the insider culture, jokes, language. Since being introduced to the financially-ubiquitous use of "aggressive," I've been singlehandedly trying to start a wave in the medical culture. I'm confident it'll catch on soon. For example, "Mr. X, you have a form of cancer that's particularly aggressive." Except that we already use "aggressive" in that sense. Shit.

In the meantime, here are a few gems that I think might translate well. Go forth and globalize your office or firm! Or wherever else it is you spend your day - your mom's basement, that's cool too.

Badness (n). A general term for "this does not look good." Often used by interns and med students when asked to specifically interpret radiographic studies. Used in combination with generalized sweeping motion of the hand in generalized area of CT or X-ray.

Churn and burn. A phrase used to describe the act of discharging a patient as soon as humanly (healthily?) possible after admitting him, in order to pare down the service. Heard almost constantly on call nights.

Gunner (n). An overly competitive and ambitious (some might say, "aggressive") med student. Likely to backstab fellow students. Always used in derogatory fashion. BIG potential for this one to spread into other fields.

Pimp (v). To ask spontaneous, often random and trivial, questions in order to test the knowledge of your underlings or simply to create anxiety and feelings of inadequacy. Performed under the guise of the Socratic method.

Rock (n). The patient that has been sitting on your internal medicine service for several weeks and doesn't seem to be getting any better, no matter what you do. A problem that will not be leaving in any foreseeable future. This term does not exist in surgery, where patients are discharged home as soon as they are able to fart. You think I'm kidding.

Strong work. A phrase of congratulations exchanged between medicine team members for, you guessed it, a job well done. Often means getting a patient back to his baseline barely-healthy-enough-to-avoid-hospitalization state to discharge him. See: churn and burn.

death defying!

Today I placed a PPD on my HIV+ patient. It was completely benign, just three little 27-gauge needles and three little syringes of tuberculin, candida, and aspergillus. But still. Needles! with HIV! and his blood!

My homeless HIV+ patient was so dirty that the alcohol swab I used to clean the area actually rubbed off brown dirt. Then he hacked and coughed so hard that he threw up. Awesome. Despite my little microfilter-isolation-mask, I held my breath and tried not to imagine the aerosolized particles of DISEASE floating in the air.

things learned on surgery clerkship

I could say, I now know how to perform a running subcuticular with Monocryl. Or how to handle a gunshot wound trauma. Or how to diagnose, work up, and perform a Kasai portoenterostomy for a baby with biliary atresia. But the real lessons are as follows.

In the OR:
1) Pee before scrubbing in.
2) Pinch the nose of your mask to avoid fogging up the entire faceshield. Fog on faceshield = the mark of an amateur.
3) Speak when pimped. Shut up otherwise. Especially when things are not going well.
4) Never contaminate yourself or the sterile field. This is a one-way ticket to OR blacklist hell.
5) Remain perfectly still while retracting. Even when you haven't moved in 4 hours and you can't feel your hands anymore.
6) You will get yelled at. All the time. For things beyond your control. This is okay.

On the wards:
1) It is indeed possible to stay awake for 34 hours straight. And, surprisingly, possible to think on your feet at the 30th hour.
2) Scut is a real phenomenon. Order and pick up Chinese food for both the Trauma and Emergency General teams on my first night on call? Yes sir.
3) It is possible to survive on vending machine food for 34 hours.
4) Get used to the smell of vomit, blood, urine, feces, and sweat.
5) You will ask complete strangers about the quality, color, and odor of their vomit and feces. And then stick your finger up their asses.
6) You will get yelled at. Luckily this is within your control. Don't be dumb.

the ultimate scut

Jo (on phone to OR9)

Hi, I was paged to this number.

Fellow

Yes. What are you doing right now?

Jo

I'm in clinic. Is there something I can do for you?

(Surgery follow-up clinic is in the outpatient building - an entirely separate building from the ORs in the main hospital).

Fellow

Oh. Nevermind then.

Jo

No, really, it's okay. We don't have any patients just yet. How can I help?

Fellow

Well, I left my pen in one of the patient's rooms this morning. I was going to ask you to go track it down. But I guess you're away in clinic. (hangs up.)

a day in the life

...of an MS3 on pediatric surgery:

-Arrive at 5am to pre-round on patients
-Round at 6am. Keeping it concise, I report that my post-appy pt is afebrile, making good UOP, and now eating well with no nausea/vomiting. Proceed to get yelled at for not reporting that he ate "tacos."
-Be intern's bitch and do discharge paperwork all morning on pts I've never even seen before and thus have to read the entire chart to do said paperwork. Finish approx one patient per 5 min but get yelled at anyway. "Are you STILL working? God!!"
-Fellow mumbles to me about how it's his wife's birthday and he's on call tonight and he forgot to reset the alarm for her this morning, thus making her late for work on her birthday, and also leaving their two small children with her tonight. Alone. On her birthday. Then realizes he's talking to a (idiotic, subhuman, truly worthless) med student and stops talking.
-Find out about interesting case in the afternoon and actually manage to scrub in.
-So interesting in fact that TWO attendings, a fellow, and a surgery intern also scrub in, thus leaving me an amazing view of the back of someone else's head as I am elbowed out of the way. This is also poor sterile technique, but who am I to say anything?
-Wanted to at least suture the trochar sites, but since an intern is here, she gets to do this instead. Stand there uselessly and fog up my mask due to my hasty/poor tying prior to scrubbing in.
-Begin pimptastic teaching rounds at 5pm. On a Friday. Don't you people have families to go home to?
-Before leaving, am reminded that students are "encouraged, but not required" to round on weekends. This is so freaking passive-aggressive, and I refuse to buy into it. Also I have not had a weekend off in over a month. When I receive poor evaluations I guess I'll know why.

down

Death happens. No big deal. Even this early in our medical careers, it's unnervingly easy to shrug it off when trauma patients die right in front of you, when you discuss patients in Morbidity & Mortality conferences, when geriatric patients pass away. As inhumane as it sounds, there were definitely times when it was like - oh that Level I patient was DOA. Oh, my DNR patient coded. Now then, who's up for coffee?

Somehow it's different in young patients, though I know it's technically not any different. Somehow it's more tragic when teens end up paralyzed in MVCs. Somehow it's more heartbreaking when children die before organ donors become available. Today I found out one of my old patients was sent to hospice. Later today my school-aged, previously healthy, now quadriplegic and vent-dependent, patient looked me straight in the eye and said "Please kill me. I want to die."

God. How do you forget something like that?

real quotes, part 2

Jo (to patient with suspected small bowel obstruction)

So when was the last time you passed gas?

Patient, writhing and moaning inconsolably

I'm not. I dunno. A week maybe. Ohhhhhh my stomach!!

Jo

A WEEK?? (Mind reels frantically. This is a surgical emergency!) Are you sure??

Patient

Yeessss!! Ohhhhhh!!

*proceeds to rip one loudly*

**********************

Fast forward: Jo presents patient to third year resident. R3 and Jo re-enter room.

R3

I hear you're having some abdominal pain.

Patient

*rips another one*

R3 shoots Jo an amused look. Jo almost falls over laughing on the spot and nearly suffocates while choking back laughter.

R3

So, uh, you said you don't think you're passing any gas? When do you think the last time was?

Patient, with "duh" expression

Just now.

real quotes

Two 100% real conversations with patients on trauma surgery:

Jo (to drunk injured driver brought in after motor vehicle collision)

Is there anyone we can call right now to let them know you're here?

Patient

Yeah, uh, I got a woman.

Jo

Sure, what's her name and a number where I can reach her?

Patient

[gives first name and number]

Jo

And her last name?

Patient

Uhh... I dunno. It don't matter anyway, we getting married soon and it's gonna be MY last name.

****************

Jo (to drunk combative patient, who will be a convicted felon upon release from hospital, with gunshot wound to upper thigh)

Sir, I'm going to need you to lay still so I can examine this wound.

Patient

No!! Stop touching me!! That hurts, b****!! [thrashes around wildly]

Jo (yelling)

Be still! I need to stop this bleeding. I'm going to lift up your gown and look at your thigh now, okay? [looking around desperately for his accompanying police to restrain him]

Patient concedes, lifts his entire gown, and exposes his genitalia and anus with legs splayed

How's that? You like THAT, b****?

Jo

Sir, please just lay still. There is no need for you to do that.

Patient

Shieeeet, I ain't just putting on a free show here!

my new home

Today is Tuesday, 5pm. Since Sunday I have spent 45 hours at the hospital. This is somewhat absurd. Please direct all mail to my new home at Parkland Memorial Hospital ER, Trauma Hall.

My last call was Sunday before Labor Day... trauma call is always worse on weekends or holidays when people are out drinking, boating, firing guns, etc. This ended up being 33 straight hours of being awake and running around, barely sitting down for 20 min to eat dinner. It drove me beyond the point of utter exhaustion and took everything out of me physically and mentally. It's so surreal... your entire body and head hurt, you can barely see or think straight, and you hope the adrenaline of life-and-death will get you through the night. Two Level I traumas were pronounced on the spot late in the night; by that point I just felt empty, emotionless, and numb to the smells of blood and sweat and death. After the patient was pronounced and the time called out, we all robotically returned to our work - peeling off bloody gowns and masks, returning to paperwork, and dreading the sound of our pagers going off signaling the next case on its way to our ER.

By the time a drunk, psychotic, frighteningly combative patient rolled in at 3am - physically restrained by 5 policemen on capital felony charges - I was shocked by how weary and unemotional I felt. This guy was seriously scary: he was foaming at the mouth, eyes rolling back in his head, bleeding profusely and flinging blood everywhere, spitting, reeking of urine and vomit, speech barely intelligible, cursing and lashing out at anyone nearby, violently jerking at his handcuff restraints. Even now the thought of him scares me, but I guess the weariness took over at the time; I just yelled at him to lay down and hold still while I dressed his gunshot wounds. One of his policemen pulled me aside later in wonder to comment how much it looked like I totally had my shit together. Yeah right. More like I was too tired and my brain too slow to be scared. When I finally went home at 1pm the next day, laying down and feeling the blood rush back into my legs was literally orgasmic.

Is this what the culture of medicine does to us? Belittles weakness and demands superhuman concentration after over 30 hours of being awake? Makes us feel indifferent to human suffering and death? People dying right in front of us, their relatives screaming in agony, patients in excruciating pain, and we're too tired to care? I don't want to become callous by disconnecting mentally, but at some point it's the only way to get through the night.

this time it's personal

Peds is over. I want more. It's not just the kids - the whole family gets involved and it's all such a warm fuzzy feeling. When kids get better, it feels like you're releasing such potential back into the world.

I had been following one notoriously difficult patient for several weeks on two different services (my team jokes that she "followed" me to my new service). She was constantly surly, listless, bitter, uncooperative with all of the nurses/doctors, her parents were impossible to track down to obtain consent, and to top it off, she was a medical enigma.

After 3 straight weeks of seeing her, barely making any progress (medically or otherwise), she was finally scheduled for a procedure on a day when her parents couldn't be there. She looked up at me, confessed she was scared, and shyly asked if I could go to the procedure with her and stay at her side until she "fell asleep" (from the anesthesia). I began to visit her more and more often outside of my required morning rounds. Our team ended up diagnosing her definitively, and I discharged her on the very last day of my peds clerkship. She was a completely changed person - smiling, energetic, relieved to know "what was wrong with her"... and thanked me for listening and being nice when no one else did.

I know it's cheesy, but I'm convinced there was some element of fate there... how else to explain her being on both of my services AND leaving exactly when I did? I'd like to think I made a difference in her life (and I do hope I did), but she definitely made a lasting impression on me. It's all too easy to become impersonal in this line of work.

Tomorrow I begin my first day of trauma surgery. On call, no less. So really it's my first two days, all wrapped up into one very long day-to-night-to-day.

scut

Today was a big day for procedures. I got to remove the staples from my patient's liver transplant incision. And then I went in on my other patient's EGD/colonoscopy. It's like a video game - or the Magic School Bus. But on a real person!

Then I spent a few hours writing up admit/discharge orders like the little bottom-of-the-totem-pole-bitch that I am. Do endless amounts of redundant paperwork? Yes sir. Right away. I ENJOY meaningless scutwork and 13-hr work days. It's not like I have, you know, a shelf exam to study for this week. Shall I also lick the bottom of your shoe while I'm at it?

On an unrelated note: I somehow manage to injure myself constantly. Bumps, bruises, lacerations, you name it. If I were under 18, CPS would have removed me from parental custody already.

pedi GI

Q&A with an MS3 (me!) on pediatric GI service.

What does a typical day smell like?
Well, pretty much like poop. Kidding. A lot of patients are actually here for liver transplant, malabsorption, or pancreatic disease.

So... GI docs don't work with poop?
Don't get me wrong, I've done my share of "cleaning out" kids with fecal impaction. Medically, this involves infusing Golytely* (osmotically active PEG, combined with electrolytes) down a nasogastric tube and waiting until the kid is dripping clear out the other end. Practically, this translates to several days' worth - literally a shitload - of stale, built-up, previously rock-hard fecal matter. We actually put adult diapers on my little 2-year-old when he finally (and explosively) began stooling after 2 days of continuous Golytely.
*Har har. So punny, those drug companies!

Ew, diapers filled with poop.
Yes. And then they send in the third year medical student to pry open the dirty diapers to document texture, color, presence of blood/mucus, odors, etc. Believe it or not, some GI diseases are described in textbooks as producing "foul-smelling stools." Who is writing these textbooks???

What about buttholes?
Yes, we do that too. Sometimes this just means looking for anal fissures. Other times I have to insert a finger. All in a good morning's work before lunch!

Is it true that GI doctors use food descriptions for poop textures?
Yes. Two notable examples are "banana" and "Wolf Brand Chili."

I've heard you enjoy humorous poop stories. Is poop still funny?
Definitely.