Surgery... Is Tough

The general consensus of the third year rotations is that surgery is the toughest rotation to get through. I didn't necessarily pooh-pooh this assertion, but I said to myself: "Self, you enjoy surgery. How bad can it really be?" After the first week of 3:30am mornings, walking home at 8pm realizing I need to be awake in 7 1/2 hours, still have to eat (since I haven't all day), and read up on my cases the next day, I have come to the conclusion that surgery... is tough.

This definitely creates a tension for me regarding my future. Surgery has been at the top of my list since the start of med school, and I've really enjoyed the rotation. I love being in the OR and time generally flies by while I'm in the hospital. But the moment you step outside those hospital doors, you realize just how tired you are and just how much your life sucks. There's been a lot of criticism of med school graduates choosing "lifestyle" as one of the major determining factors in choosing their future medical specialty. But when you're in the middle of a 96 hour week (sssshhhhh, we're only supposed to be working 80), watching the attendings crawl home at 7 or 8pm daily just as you are, you start to realize in a hurry just how much lifestyle can bolster or sink your happiness.

I'm on the colorectal surgery service. Which means obesity, obesity, and morbid obesity. I'm hoping to post some stories soon, because I've seen some crazy sh*t (no pun intended). But tomorrow is my birthday, so I plan to spend it how anyone would hope to spend it: On call on trauma service on a Friday night. Woooooo surgery!

The Bee Gees, Storage Closets, and Medical Education: A Thursday

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

It was my last day in the PICU and last day on pediatrics. I had come in at my usual time of 5:30 to pre-round on my patients. One I had carried for a week and was very familiar with and the other was a little boy with an epidural for who most of the heavy lifting had been done overnight. 7:30 came, I presented my last 2 patients, and rounds flew by, finishing ahead of time mostly due to our light census. It was looking like it was going to be a light last day, and that I would have time to fit in some much-needed studying for my shelf exam the next day. It was 8:30am and I had just settled down with a paper on PRVC ventilation when the voice on the overhead speaker system chimed on: "Code 99, 9th floor, room 4. Code 99, 9th floor, room 4."

The PICU chief takes off running down the hallway, the team a few meters behind. We arrive up at the code in under a minute, finding ourselves the first responders due to the fact that most of the attendings and residents in the hospital were a building over in morning report. Our team would be running this code.

A code in real life is nothing like in the television shows (big surprise). It is a much more controlled chaos. There isn't any yelling, pounding on chests, doctors screaming "don't quit on me! DON'T QUIT ON ME!," or any of the other stereotypes that people think of when you say the words "code blue." We had actually had a mock code for the residents and students with a sim-patient the week before - our institution is big on assigned roles and closed loop communication. So I settled into my role of information gatherer and runner: finding the patient's most recent labs in her chart, getting ice to cool the patient's body, running blood gases down to the PICU, etc.

The patient was a 3 year old little girl who was actually set to be discharged later in the day. She had nephrotic syndrome and had spent half a day in the PICU earlier in the week with some mild pulmonary edema. Her labs looked completely normal and she hadn't had any issues besides intermittent hypertension. While her parents were showering her that morning in her hospital room, getting her clean for the ride home, she suddenly collapsed and became unresponsive. Within 4 minutes of that moment she was receiving chest compressions from the PICU chief.

137 minutes of chest compressions, 8 boluses of epinepherine, 4 boluses of atropine, 4 boluses of bicarbonate, 3 doses of calcium, 3 cardioversions, 2 boluses of ibutilide, 2 IO lines, and a bolus of insulin later, there still wasn't a pulse. Since she was a previously healthy child and was remarkably stable during the course of her hospital stay and had started getting chest compressions so soon after her event, the decision was made to get her down to the PICU and put her on ECMO (cardiopulmonary bypass) in hopes that giving the heart a break would allow it to snap back into rhythm. She was wheeled down the hallway with my resident straddling her on the bed, continuing to give compressions.

Down in the PICU, her room was converted into a field OR, and the cardiothoracic surgeons arrive to prepare to get her on ECMO. I am standing outside the room, looking for more opportunities to help and absorbing the controlled chaos, when the chief turns to me and says:

"MedZag, why don't you relieve David from compressions. He needs a break and I think it would be a good experience for you."

My adrenals dump a massive load of catecholamines into my system. I somehow find a way to utter "Yes, sir."

During our "Transition to Clerkship Week" at the beginning of MS3, we were forced to re-certify in our healthcare provider BLS (basic life support) training. Which basically entailed kneeing on the hard ground in dress clothes for 2 hours doing practice compressions on blue plastic mannequins which looked like they got misplaced from the set of I, Robot. There was no way I could predict that in 6 short weeks, my mannequin would suddenly morph into this brown-haired little girl.

I gown and glove up and go and relieve the fellow doing compressions. I was determined to do everything exactly correct - probably a delusional desire in the given circumstances, but I became fixated on a study I remember reading where residents and medical students who were instructed to do chest compressions to the beat of the Bee Gee's "Stayin' Alive" were much more likely to hit to target heart rate.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

The surgeons incise in her neck and begin to dissect down to the carotid artery, a difficult prospect as with every thrust of my palm down into the little girl's ribcage, her neck jerks and blood flies into the air.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

I become fascinated by how strong her ribcage is. Sweat begins to bead on my forehead, my respirations steadily quicken, and my arms begin to burn as the lactate accumulates in my muscle tissues.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

This little girl was going to make it. She was supposed to go home today. This will be a fantastic experience to look back upon. I had images of the thank you card the PICU will receive when she starts first grade - the little girl grinning in a photo, missing her front baby teeth. The little girl who nearly died but now has her entire life, a full and rich life, to look forward to.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

Bypass in on. Her body is once again receiving fully oxygenated blood. Chest x-ray shows everything is properly in place. Her heart regains a rhythm. Sinus. But 45 seconds later it fades. Asystole.

A repeat echocardiogram would eventually show a massive saddle embolus in her pulmonary arteries. You can't get blood to the body if blood can't get to the left heart. MRI and clinical exam showed absence of all reflexes and fixed, dilated pupils. There would be no first grade photograph.

I was in the room for the conference with the patients. Our chief explained what had happened. The scene felt surreal.

When stepping out of the room, one of the residents broke down in tears. The chief stares off into space. His words resonate in my head.

"Hope and pray that you never have to do that enough in your career that you get as good at it as I have."

Bypass was stopped 2 hours later. Within minutes, the brown-haired little girl, who should have been home watching cartoons, had passed on.

I was sent home to study for my shelf exam. I sat starting at my question book, but no studying would be happening that night. I logged onto the EMR and looked at her chart again. I looked at her echo again. I read the note I had written on her earlier in the week when she had been in the PICU. We had been instilled with the proper fear of a saddle embolus during our first two years of med school, but this was the first time I had seen one clinically and wanted to make sure all the information about the situation was seared into my brain. But mostly I simply sat there. And thought. I couldn't shake the feeling of guilt clawing at my stomach. This will be one of those centennial moments of my medical training: the first time I actively participated in a code, the first time I performed CPR on a patient, the first time I witnessed a truly horrific conference with parents, the first time I saw a member of the team collapse in tears, the first time I watched a patient die without forewarning. This was an important day in my medical career. But it is a sadistic reality that my education requires bad things to happen to good people.

So, to the patients of that little brown-haired girl: Thank you. Through your tragedy, I gained valuable experience that one day may perhaps enable me to save someone else's life. And know that I would gladly exchange all that experience for a picture of your daughter, clutching her pink backpack, grinning with her missing front teeth, on her way to start the first grade.

Tough week.

Death count for my PICU rotation: 4 and climbing...

Worst by far was the mother who found her 15 year old daughter down in her room. EMS resuscitated but her pupils became fixed during transport and she was brain dead by the time she got to the PICU. Her cerebral perfusion scan was eerie for the complete and total absence of all blood flow. It was like someone went in and performed a total lobectomy, the cutoff was so precise. Tox screen negative, all lab work negative, no signs of trauma, asphyxiation, etc. We have no idea why this perfectly healthy girl was suddenly found essentially dead.

There are true tragedies in this world.

Balls.

So during our pre-clinical years we had this wonderful class called "Principles of Clinical Medicine" which was "designed" to impart onto us all the skills we need to survive in the clinical world that you don't learn out of a basic science textbook. We had lectures on giving bad news. Lectures on disaster preparedness. Lectures on healthcare reform. Lectures on "adapting to a chronic illness." The culmination of the class was something called the (Group) Objective Standardized Clinical Examination (GOSCE if as a group, OSCE if solo), where you had to perform a history/physical exam on fake patients often with one of the "difficult" issues lectured on, such as substance abuse, non-compliance, divulging a medical error, etc and graded in checkbox style on whether you washed your hands, shed appropriate tears, preserved modesty whilst sticking a finger up a man's inguinal canal, and such. Did it help me prepare for my clinical years? Yeah, I think so. But as far as preparing me for what I do 75% of my day, it didn't help squat. So instead, in order to better prepare MS1s and MS2s for what the wards are actually like, I propose the OSCE be replaced with... the SACK (Subjectively Arbitrary Clinical Klusterf*ck - with a K 'cause SACK is a way cooler acronym than SACC)

Here is how it would be conducted. 10 students would be unleashed into a mock ward with 1 patient assigned to each of them. There is a workroom with computers. The student must:
(1) Log onto the records system on a computer terminal to read up on the full H&P, course, vitals, labs, and imaging of their patient and commit them in some form to memory
(2) Go see their patient and get overnight updates/perform a physical exam
(3) Go talk to the nurse for the patient to find out what really happened overnight
(4) Come back to computer terminal and write a progress note complete with assessment and plan with a "well thought out and thorough" differential and relatively accurate plan
Now the rules of the exam:
--The student must perform all of the above tasks on a timer of 120 minutes. At the end of the 120 minutes, the student must present their patient while individuals in long white coats stand around, shuffle their feet, and clear their throats
--Even though there are 10 students and 10 patients, there are 8 computers in the work room. Additionally, throughout the course of the 60 minutes, 8 individuals in long coats representing consults, attendings, and residents will come in and sit at terminals to check their google mail and book airline tickets to exotic tropical places. The students have no choice but to defer to hierarchy and rescind a computer terminal if needed by said individuals. Said individuals can sit at any station as long as they want, and if all 8 individuals decide to use computers, students have no choice but to stand there wasting precious time
--There will be 5 nurses for the 10 patients. At any moment 2 of the 5 nurses will be missing and no one knows where they are.
--60 minutes into the exam, the students will all be herded into a room and forced to listen to "morning report" for 30 minutes, denying them access to patient, work room, or computer terminal and cutting their effective work time down to 90 minutes
--Patients will either be too tired to give a good history of last nights events or physical exam, too cranky to give a good history of last nights events or physical exam, or too drugged to give a good history of last nights events or physical exam.
--You are allowed to print your notes for aid in your presentation at the end, but only 2 of the 8 computers will send to the printer

Now that's real wards experience.

BTW... saw my first code today. A parent of a patient seized and collapsed in the hallway right outside our workroom. He hit his head on a counter, cracked his skull open, and went apneic. I stayed out of the way, since simply observing the carts and the medical supplies and the pooled blood on the floor was way too much for me. But good lord, within minutes of the code being called there were 50 docs and nurses all in that narrow little hallway while people tried to get supplies and a stretcher to the patient. It was like pigeons at a bird feed sale.

Cryptococcus!
(You might be a med student if you get that joke.)

The Big Leagues

I was a big baseball player growing up. T-ball, coach pitch, Little League, American League, all the way up through high school ball. The developmental leagues in the American ball system have a very specific method to their madness. Each level has its own set of skills it develops. T-ball is all about learning the rules of the game and the fundamentals - how to field a ball, how to throw a ball, etc. Little League is all about proper technique, learning how to turn a double play, who to hit as your relay man, and such. By college ball/minor leagues, the fundamentals are all supposed to be in place, and you focus on refining technique and maximizing talent. Then you reach the big leagues and its all about delivering on your talent.

Academia is a similar sort of setup, especially when it comes to medicine. High school is your t-ball. Developing study skills, learning the fundamentals of each subject, starting on your critical reasoning. College is your little league. Experimenting how to efficiently learn, developing your reasoning and communication (and drinking) skills. The pre-clinical years of med school are the minors where you are working on adding the necessary information to your cranium to step up to the top level.

Lame analogy? Super lame. But the nickname around here for the clinical years is the "Big Leagues" and after a week of getting my feet wet I can see where it comes from. No more syllabus to hold your hand and feed your orange slices between innings. No more cute little "classic presentation" clinical vignettes to tell you to lower your elbow on your swing. Just you, the patient history, the physical exam, some lab tests, and a team of individuals grossly more experienced and knowledgeable than you waiting impatiently for your assessment and plan. It's terrifying but infinitely more fun.

Anyways, enough melodramatics. I think the rub is that third year is an entirely different beast. Peds has been a great rotation to start on. By its very nature it tends to accumulate more nurturing personalities and its been a good atmosphere to hopelessly stumble around in during the first few days. From the intern to the attending, everyone has been great at understanding and helping me with my incompetence. Kids are definitely my fave patient population and we've had some real cute ones on the floor this past week. I'm glad my first H&P was with a mother concerned about her adorable little daughter instead who was previously healthy and not on a 47 year old chronic patient with a PMHx and a Meds list the size of the US deficit. So I'm having a blast so far. Some moments from my first week:
--10 year old little boy who presented with focal hemiparesis. Was originally given diagnosis of acute disseminated encephalomyelitis, until the CSF came back with oligoclonal bands and tests showed myelin basic protein antibodies. Diagnosis of Multiple Sclerosis, that was a real heartbreaker.
--Little 2 month old baby admitted with poor feeding and failure to thrive. MRI showed diffuse hypomyelination of the CNS. In medicine, generally the more names in a condition, the worse it is. Especially if they're German names. This baby was suspected of having a condition consisting of 3 German names. Such a bummer, and the worst part was that he was perfectly healthy at delivery and until 8 weeks of life.
--On call when the intern gets a page that a patient admitted the night before for UTI was "turning blue." We run down to the room and see a poor child who was inconsolable in her mothers arms, had just had an impressive bout of diarrhea, and who had purple extremities with cap refill of 4-5 sec. Luckily everything turned out alright and she was discharged today.
--The family practice intern walked in on two cystic fibrosis patients doing the horizontal handshake. Yes, we all know the hospital is a boring place when you're a patient, especially when you're there 1/4 of the year, but probably not the best way to exchange nosocomial organisms.
--Poor 8 year old girl who presented with a history of 3 days of fever including a fever of 105.7! I can't even imagine how miserable she must have felt. Blood culture grew Streptococcus. Thanks to the miracles of medicine, her stuffed Tigger and she were discharged today.

That's it for now. I'm post-call and it's time for bed.

Post Call Delirium

Had my first night on call last night. Lot of fun!
Time really flew by, even though of the 31 hours in the hospital, I was working for 29 of them.

3 admits. Asthma exacerbation, viral tracheolaryngitis (croup), and cellulitis.
1 PICU tranfer. DKA.
0 emergencies.
2 Starbucks venti coffees.
1 presentation of childhood nephrotic syndrome prepared.
2 H&Ps completed.
2 bloodshot eyes.
1 pair of dirty scrubs.

We're on holiday this Friday so I'll try to update with some thoughts of my first week in The Big Time aka the wards at that time.

So, Third Year.

So tomorrow marks the end of our "Transition to Clerkship" week, which means at this point I'm supposed to be pretty much transitioned to whatever this "clerkship" thing is supposed to be.

In the past I had (arguably) witty food analogies for the first two years of medical school. First year is like a hot dog eating contest. Second year is like trying to polish off that 72oz steak at Billy Joe's Steak Emporium. If I had to come up with an analogy for what transitioning to MS3 would be like... it'd probably be analogous to that NBA commercial involving Yao Ming (still one of my faves):

Yes, third year is like trying to eat a live crustacean. It's new, it's exciting, it's exotic, and you have no idea what the f*ck you're supposed to be doing. You can google how to eat a live crustacean, people can tell you how to eat a live crustacean, but until you've actually gotten out there and done it, you really have no sense of what its like. And when you try for the first time, its awkward, you fumble around, and you generally look like an idiot.

Our week started off with a morning full of "talks" from the big wigs in the School of Medicine who never appear unless something "important" is going on, which basically consisted of them reminiscing to us about their own days at the beginning of their clinical days. Luckily things picked up at that, and the rest of the week has been very fun. Finally had my first quasi-patient which I had to do a full H&P on and present the next morning. The rest of our time has been filled with workshops filled with how to scrub for the OR, knot tying and suturing, intubation, accessing/reading/interpreting path reports, how to place an IV, managing acute patients, etc, etc. The material has varied from interesting to repetitive, but the best thing is that is have all been HANDS ON. It's all been simulated, but actually getting your hands dirty and having things be interactive beats the hell out of sitting in lecture all morning and then hurrying up to sit in front of your syllabus the rest of the day.

Start peds on Monday. 2 weeks on the general wards then 3 weeks in the PICU. Hoorah.

Step Prep: The Aftermatch

I survived Step 1.

It still seems surreal to say it. That the seemingly insurmountable task that has been hovering over my head for such a long time is now over and done. In the past.

All that remains is the aftermath. My First Aid binder with pages ripped through their 3 hole punches, hanging out like a dog's tongue after chasing one too many frisbees. Dead highlighters on my desk. Sheets full of self-made diagrams and flowcharts. Sentences underlined in red with "QUESTION!" written next to them. My Goljan book, with its binding cracked down the middle and the second half of the "Hepatobiliary and Pancreatic Disorders" chapter hastily scotch taped back in. 3,400 QBank questions tucked somewhere in my cranium. 2,400 notecards sitting no longer of use on my laptop.

I'll post more about my experiences with my progress doing questions, taking NBMEs, and the like when I get my actual score back and know how accurately it actually projected how I'd do. But I thought I'd talk a bit about the experience of the test. My actual test day went pretty well. My immune system made one last rally and with my prophylactic DayQuil in hand I kept the congestion and runny nose at bay throughout the day. I arrived for the test a half hour early, and found myself starting the exam early at 7:40am. All those hours doing questions paid off and I found my stamina was good enough that I could bang out two hours of question blocks at a time between breaks. Time goes VERY quickly while you're taking the test. You find yourself so focused on each question that blocks can seem to fly by, and hours of the day silently tick away. Before I knew it, block 7 rolled around and I clicked that final "End Block" button and half-assed my way through the survey at the end.

What does it feel like when you step out of the testing center? It's a strange combination of exhaustion, exhilaration, and denial. It didn't sink in for almost two days that I was done. That there was no more studying to do. The day itself almost felt like just a long day of doing USMLEWorld, as the interface, pacing, and question prompts were all so similar.

But it does finally sink in. And its a great feeling when its over. The sheer amount of concentrated will it takes to study endlessly, day after day without reprieve, was honestly something I wasn't sure I had in me. Its a time filled with highs and lows. Lots of lows. Frustrations, and sometimes despair. You realize you have gone days without talking to another human being, and find yourself unable to engage in normal conversation when you do. You become robotic in your routine. Wake up, study. Eat only because you have to. Study. Sleep. Repeat.

I think if I had to sum up the entire experience it would be: I would never want to repeat it. But I'm damn glad I went through it. And now its time to sleep.