Happy Day!

Every medical student has his or her own unique challenges as they progress through training. For some, its social anxieties fostered by years of seclusion in the library. Others its the constant berating by superiors. Fear of needles. Aversion to blood. Painful memories of gurneys. Dislike of the color white. Latex allergy. For me, I've had my own Everest I've had to climb.

I have a baby face.

Now I know. I'll be laughing when I'm 40. I'll miss the days when I get carded by Brutus on Monday $1 pint night (or carded for rated R movies... still happens!). But unfortunately I kind of need to learn this medicine thing now not later, and getting a 45 year old man to talk to me about his sexual history or confide possibly socially taboo behavior when I look like I should be playing on his 12 year old son's little league team just doesn't seem to fly.

There has been several (unsuccessful) attempts at growing a beard, but the battle against genetics has proven a futile one. Wearing glasses helps a little. Then patients just ask what college I go to instead of what high school (no exaggeration). White coat or not, patients are always observing "So you're following this doctor around today? How fun! Well do well in college and maybe you'll get into medical school!" Sorry lady. Jumped the gun on that one. Let me just put away your chart with your full medical history in it and go work on my English homework.

The best? A patient who told me I look just like Richie from Happy days (see above).

Maybe I should embrace it. It'll only take a couple months before I could grow a mean comb-over.

And change my name to Doogie.

Anyone got any good ideas on how to look older? That doesn't involve illicit drug use or alternative medicine?

Top 3's From Summer Medicine

So after taking a couple weeks off from medicine completely, drinking my weight in beer, and catching up on all my trashy reality television (seriously, its the closest thing to crack you can dig up without having to talk to a large man named Bubba) I've finally started seeing patients again and dusting the cobwebs off the old hippocampus (see left). Medical school has taught me that its awe-inspiring how much you can learn in a couple weeks. Summer break has taught me that you can forget all that information plus tons more in a couple weeks more. But I'm starting to get back into the swing of things. This summer I am doing a preceptorship with a cardiothoracic surgeon (my 13 year old self would have wet himself at this sentence), and picking up a few shifts down at the free clinic. I'll muse on the deeper ruminations of each opportunity later, but for now I'll just present my top 3 experiences from each so far.

THE OR:
|| My First Cabbage ||
The coronary artery bypass graft (or CABG... or "cabbage") is the most common procedure in CT surgery. Layman's terms the "x bypass" surgery. For most CT surgeons, this procedure is as mundane as the morning coffee, but for a medical student seeing the procedure for the first time, it's pretty f'n cool. This one was cool because it was a throwback to my wide-eyed "this is super awesome" pre-med days. It was also cool because it really shows some of the ingenuity employed in surgical techniques. I've known that the internal thoracic artery (or internal mammary artery) is the most common graft harvested for use during the bypass due to the dual-circulatory blood supply to the anterior thoracic wall. But I always assumed you simply cut out a length of the artery necessary for the bypass and suture in one end to the appropriate coronary artery and the other end into the root of the aorta. In actuality, in most cases things are done slightly differently, with the surgeon dissecting the artery away from the sternal wall, ligating it at its distal point, and redirecting only the distal end to the point past the coronary artery stenosis. This allows the natural circulation of the IMA to supply blood to the coronary artery and has the advantage of removing the need to incise into the aorta, which is one of the most post-op complications-wrought steps of a CABG. Small difference technically which has big implications for post-op prognosis.

|| The Bi-Polar Heart ||
Saw an atrial septal defect (ASD) repair, a procedure that is common and straightforward in pediatric cardiac surgery. Most ASDs are found and repaired within the first few years of life. The difference in this case was that the patient was a 71 year old man, who has lived his entire life with a 3cm hole between the atria of his heart and a significant left-to-right shunt of his circulatory system. With so many years living with his condition, his right atrium had dilated to 60cm in circumference (when normal is under 20cm). Yeah, this guy's right atrium was almost as large as the rest of his heart. Besides making for one strange looking heart, the large floppy atrium allowed a big window to look into the heart during the ASD repair so I got a good look to see how the pericardium patch was applied to the atrial septum.

|| The "Holy Crap That's A Big Surgery" Woman ||
This one was a 5 hour surgery on a woman in severe end-stage heart failure. The patient underwent a two-vessel CABG followed by an atrial valve annuloplastyand a tricuspid valve annuloplasty. Layman's terms: a double-bypass heart surgery with two valve reconstructions. Essentially got to see three different surgeries all wrapped into a nice little wrapper. The most important thing I learned from it: I need more comfortable shoes. And never forget coffee is a diuretic.

THE CLINIC:
|| Love The Thyroid ||
Saw a patient with Graves' Disease who had been upping her carbimazole dose (an anti-TSH drug) to try to get her TSH levels back into normal range. She came in complaining of fatigue and irritability, two common symptoms of hypothyroidism, but also common symptoms of many other diseases. If it wasn't for her Grave's Disease I'd have had to idea to think "thyroid" in the diagnosis. This one stuck out to me because I have had a handout on hypothyroidism sitting on my coffee table for the past 8 months that I still have not gotten around to reading. And after a significantly humbling experience pow-wowing with the attending where I practiced my favorite "stoned pufferfish" expression as I had not a single answer to any of her questions, I found the patient had a laundry-list of all the other symptoms associated with hypothyroidism (hot/cold sensitivity, dry patches of skin, weight gain, depression, hair loss, constipation), which would have been readily available to me if I had had my coffee table with me in clinic. Note to self: coffee table fits in back seat of car.

|| I Do Not Speak Hausa ||
Second patient is a diabetic Nigerian who spoke minimal english, and to further compound issues, had significant hearing loss in his left ear. To further compound issues he came in reeking of alcohol, and had admitted to alcoholic habits in the past that would be characterized as addiction. To further compound issues I had a reasonable amount of clinical suspicion he was suffering from severe depression. So I had a drunk, depressed patient with wildly uncontrolled diabetes who I had to talk to through his one good ear while he comprehended maybe every 5th word out of my mouth. A complicated clinical situation in general, but especially difficult when you cannot express the nuances and expansiveness of the english language to the patient. A frustrating situation, because there was a great deal of good we could have done for this patient if not for the lost-in-translation issues. But we made sure he had access to his insulin and was scheduled for a follow-up, so there's always hope for the future.

|| Future Rap Video Girl ||
15 year old girl comes in, leaving mom to wait in the hallway. Had started birth control a month ago in order to control her periods. Stopped after 3 weeks due to nausea. Only, after stopping birth control, the nausea continued. (*red lights and alarms* All hands to battle stations!) One pregnancy test later, I'm talking to a visibly shaking pregnant 15 year old girl. On counseling, found out she has had 12 sexual partners in the past year, and uses a condom "pretty much always." Hot damn, that's a more extensive resume than I have accumulated in the past 22 years of my life. Counsel her on the importance of ALWAYS using a condom, the dangers of the money-shot (ok, maybe not), and sent her on her way clutching a pamphlet with the phone numbers of various teen pregnancy resources in the area. On the way out, the mother comes up to me and talks to me about her daughter's nausea. Asks if her daughter should keep taking her vitamins. I tell her, yes, her daughter should take her multivitamin every day, to follow her weight at home, and to make sure she gets her protein. HEYO! I'm going to hell.

Ok, that's way too much writing for having to be up at 5am tomorrow. Ah, medicine.

Tom Hanks will kill you.

An article on CNN.com caught my eye the other day:

Man designing Camry hybrid works self to death

One of the main highlights of the short article is the following blurb:

"The man who died was aged 45 and had been under severe pressure as the lead engineer in developing a hybrid version of Toyota's blockbuster Camry line, said Mikio Mizuno, the lawyer representing his wife. The man's identity is being withheld at the request of his family, who continue to live in Toyota City where the company is based.

In the two months up to his death, the man averaged more than 80 hours of overtime per month, according to Mizuno."

This is not a unique occurrence in Japan. It happens with enough frequency that they actually have a term for it: Karōshi... occupational sudden death from overworking.

Now time for some basic arithmetic. Assuming they are talking about 80 hours of overtime a month in accordance with the Japanese work week (46 hours per week, thank you wikipedia), that means that the unfortunate Toyota employee from the article worked (46/7)*30 + 80 hours a month... ~277 hours.

Now take your average US resident. Under the new work week restrictions, US residents are "limited" to 80 hours per week (though many work more secretly to gain more experience or due to underlying program expectations... SSSSSHHHHHHH). (80/7)*30 hours a month... ~343 hours.

Note this post is in no way meant to belittle the unfortunate tragedy of this man's death. But it does offer a unique insight into the under-the-radar life that people in medicine live. Everyone I talk to outside of medicine understands and sympathizes on some level with the long hours of the field and realizes that a 36 hour shift is not good for the decision making processes. But if a resident were to die from overworking, I don't think it would illicit more than a curious yawn from the general public. Everyone I talk to outside of medicine also expects perfection from their doctors. At first glance these two things, sympathy to mistakes and expectations of perfection, seem utterly incompatible.  

Of course the conundrum is that residents do not work so many hours simply as some form of primitive medicinal hazing ritual. Residents work so much because they have to. The Medical Knowledge Ocean is vast, and a single resident but a small speck upon a life raft on it (Wilson sometimes accompanying). Even cutting resident hours down to 80 hours per week, which some professions would be considered ridiculous, we have already seen a greater amount of graduating residents seeking fellowship feeling that they have not had enough training to enter individual practice on their own. With talk of a further reduced 56 hour work week for residents, the debate between the "enough hours to stay sane" vs. "enough hours to not become Dr. Death" debate has gained even further ammunition. The benefits of work hour restriction are obvious. More balanced and well adjusted residents. Less medical mistakes due to sleep deprivation. Candy canes and bubbles and rainbows and shit. The drawbacks are perhaps less obvious but just as important. Necessary longer periods of training on an already exhausting path. Losing the lessons learned from being in the hospital to follow patients from admission all the way through the course of treatment. More time with that "interest" ticker steadily clicking away on student loans.

Personally, since I am firmly plopped on the "baby" end of the medical student age spectrum, the idea of extending residency another 1-2 years in favor of more sane working hours appeals to a certain side of me. After all, whether I am 29 or 31 when I leave residency is apples and apples to me. But the path of medical training is a long and arduous path, and I can certainly sympathize with my older classmates who find the idea of even 12 more months of residency truly gross. And 56 hours doesn't seem like enough time a week to learn what you need to in medicine.

Of course, its easy to spin the wheels in the ol' noggin about this topic when my days still consist of a schedule largely under my own control. It will be interesting to see how my opinions change as I'm thrown into said Medical Knowledge Ocean and told to survive, with the nearest island far enough away it will take 80 hours of paddling a day to reach it in 5 years.

But the idea of residents dropping dead in the hallways, being picked off like flies, in an epidemic of karōshi is a funny image to think of. In a morbid, real kind of way.

Pop.

So I was running on a nature trail by my place last week. About 1.5 miles in on a particularly brutal downhill stretch, I roll my left foot underneath me. I catch myself and stop, thinking "Oh. Man, that'd really suck to sprain an ankle out here." Run about 50 more feet, and sure enough, roll my RIGHT ankle underneath me, only this time its accompanied with a wonderful 'pop'. I hopped around in circles for a good minute or two and was able to walk it off, and ran the remainder of my 4 miles. Still, a pop is never good, so when I got home I crashed on the couch and kept my leg elevated. Sure enough, by that night it had tightened up considerably and by the next morning I couldn't put my full weight on it.

Of course, my natural curiosity gets the best of me. I hobble over to my bookshelf. Open up Netter's Plate 527. "Ligaments and Tendons of Ankle".

Looking at the mechanism of injury, my foot was plantarflexed and inverted at the time of the pop. Physical exam reveals mild non-pitting edema of the lateral side of the ankle. Palpation produces pain between the lateral maleolus and the calcaneous. No significant loss of range of motion or pain on dorsiflexion. No significant loss of range of motion but pain on plantarflexion. Pain on eversion and inversion of the foot with limited range of motion.

Diagnosis: Likely grade II strain of the calcaneofibular or anterior talofibular ligaments. The pop is worrisome and a less likely but more serious diagnosis of grade III strain is plausible. The fact I can still dorsi and plantarflex my foot and that I was able to continue running post-injury is a good indicator of a less severe injury.

Treatment: The RICE protocol. Rest, Ice, Compression, and Elevation.

... This is what happens when a medical student has nothing to do. I think I need help.

Annnnnnd.... Cut.

I am now officially a MS2.

Pretty wild.

Game. Set. Match.

No med school blog would be complete without a requisite end-of-first-year sappy reflective post. Since I know my friends love reading my entries where I get all gushy and sentimental (Hi Kate!) I figured it would be a disservice to not add my 2 cents to the plethora of bad advice on the internet. With my final exam lurking in 5 days, I figured now would be a great opportunity to procrastinate, put on some Coldplay, mix up a cosmo, and look back at myself 10 months ago (and laugh).

So, without further ago, I now present my 5 pearls of wisdom garnered along the way of the past 290 day endeavor in masochism known endearingly as MS1 (© 2008 for a future book deal, of course):

1. You will fail.
Maybe not literally, if you successfully claw above that 70% line every test, but you will fail. You will study your ass off for an exam and do significantly worse then you expected. You will make an idiot of yourself in front of a patient. You will inevitably do something that makes you turn a color of red so bright it has not existed in the world outside of a Crayola crayon box (see Torch Red).  

But there is hope. Luckily, the admissions departments at medical schools do a superb job of selecting perfectionists with abnormally tight external rectal spincters and the moments of failure will become your moments of greatest insight and learning as you sadistically mull over your mess ups. Some of things that I will never forget from MS1 due to my own incompetence include how to feel for the PMI on a well endowed woman (BACK of the hand, do not cup the breast!), the many ways that steroids will destroy your body (that you don't hear about on ESPN), and the fact that the femoral nerve is lateral to the artery (stuttering is not a recommended method of answering a question when pimped). Love the failure, it's good for you.
 

2. You will have doubts.
Everybody is a happy, fluffy cloud of optimism when they start medical school. Unfortunately, fluffy clouds can quickly become rain clouds (wow, did I really just type that?) There are times when medical school sucks. But it's important to realize that everything in life sucks sometimes and you are not experiencing a phenomenon unique to medical school. Everyone does it differently, but one of the most important things you can do in your medical career has absolutely nothing to do with studying tip & tricks or learning to differentiate rales and ronchi or buying out the pigs feet at Fred Meyer to practice your running line stitch. The most important thing you can do to get ahead is to find something that keeps you happy. Join a pottery group. Train for a half marathon. Go to a strip club. It is those things that will make you a better medical student, since no one likes interacting with a thorny burnt out wad of pessimism all the time.

Best advice I got from a physician this year: "Make sure at least one good thing happens to you every day."
 

3. You will complain.
Unfortunately, medical students come off as very negative people at times to our friends and loved ones, since one of the most effective and easy ways to let out your stresses involving school is to bitch and complain. I was catching up with a friend the other day and explaining my 10 year roadmap, stating quite truthfully and rather sarcastically that I have 3 more years of medical school where I'm "everyone's bitch," following by 1 year of internship where I am "everyone's bitch... but the medical student," following by x years of residency where I am "everyone's bitch... but the medical student and intern." After finishing all he says to me is "so you wish you didn't go to medical school?" I've loved medical school so far, and don't regret my decision for a second, but can see how that can be lost on others behind the Wall of Bitch.

So, learn the art of complaining. Embrace it as a part of you. But remember when you're done complaining that you are going into a career thats pretty sweet too.
 

4. Make friends not enemies.
Your classmates are pretty cool people. And thankfully we are kind of self-selecting to be generous and helpful. Same goes for most people you interact with in health care. Your life can either be miserable or awesome depending on how you choose to interact with others. Sure there are bitter and evil classmates, nurses, attendings, information desk receptionists, and patients lurking out there in the shadows, but if you let them make you miserable, they win. [Insert corny Star Wars analogy about the dark side here]. Be nice, it pays off way better then being an asshole.
 

5. You will love it.
Medical school is really cool. You get to see and do things 95% of the population would never dream of. You get to visualize the human body in ways you never would think possible (tangent: people watching becomes really fascinating when you play the What Disease Do I Have? game). You will be continually challenged and rewarded for your efforts. Yup, most of that crap you rambled on about in your AMCAS personal statement is true.

It even has my skin tone.

I am a medical student. A big, bad learning machine. Well adapted to its environment, with skills honed at survival. That is, until the end of the year workload comes, and bites my fucking head off.

***This post in tribute to the infectious disease block we are currently slogging through, aka "101 things you do not want growing in your body" aka "I am never traveling to anywhere outside of my apartment again"

***This post also in tribute to the 5000 visitor milestone I just passed. That's cool. So are people who visit this lame blog.

***This post also in tribute to the 4 other posts I have started but not finished. I look forward to the day when I have sufficient motivation to finish them. That day is June 14th, or the mythical "summer vacation" I have heard about but lost hope in long ago.

Super Hyphy

So we just started our micro/infectious disease block, and blew through all the fungal infections in 3 lecture hours. Which included such vividly lovely descriptors such as "grainy exudate," "cauliflower-like," and "versicolor lesions."

These lectures are mind-numbingly boring, especially right after an exam. Yet, even in my fungally induced coma, I noticed there seemed to be an unwritten law amongst mycologists. For every disease of the fungus, thou must havest four slides:

Firsteth, thou must haveth a slide that talks about how common this fungal infection is and how important it is that you learn it. (BS)

Secondly, thou must haveth a slide showing a highly advanced form of the fungal infection in attempts to gross out the students. (BS)

Thirdly, thou must haveth a slide talking about Amphotericin B. Complete with requisite "Amphoterrible" joke. And a tiny aside about the azoles and how they are actually the mainstay of treatment. (Not really BS, but redundant)

And fourthly, thou must haveth a slide showing a KOH prep or biopsy slide. (see right)

Now along with every microscopy slide must come the following remark: "If you were a good mycologist, you could differentiate the species based on this slide." There are two things wrong with this statement (I'm big into lists today). One, I am not a good mycologist. Two, I have no desire to ever become a good mycologist. In fact, the odds of even one person from our class of 126 becoming a "good mycologist" are well below .500.

But I digress. Maybe we should be more appreciative of our mycologists. After all, when it comes to deadly systemic fungal infections, there isn't mushroom for error

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...

I'm sorry that was in spore taste.