BEEPER DOC

Scutmonkey with a beeper

Look ma, no hands

This is my first post since starting residency exactly 1 month ago and so I did some spring cleaning around this blog. (Read as: googling myself recently was creepy, now proceeding with damage control.)

Doubtfire.gif

“Beeper doc” seemed an appropriate title because as the resident scutmonkey uniquely qualified by virtue of a medical degree and opposable thumbs refined over millions of years to silence the shrill cry of a pager, interns need not go by any other name.

Here is the abridged version of what happened during orientation:

Get sleep, they said.
Eat food, they said.
See your doctors, they said.
Exercise, they said.
Report harassment, they said.
Call an uber, they said.
Don’t yell at uber drivers, they said.
Be mindful, they said.
Wash your hands, they said.
Report your hours, they said.

Where, exactly, the entrance portal to this imaginary time-space dimension exists is still unclear. Maybe Niantic® can help us out with an augmented reality app for that.

BlackHole

The attendings and seniors in our residency program have been nothing short of fantastic doing the grown up version of hand-holding and spoon-feeding while we interns spit up our sloppy mess of ignorance. We just feel badly at this point.

Repeatthepart

We are now certified in advanced cardiac life support (ACLS) as witnessed by EMS and have supreme confidence in our ability to constructively participate in a code. Balloon animal codes, that is.

OxygenStat.jpg

We are already brainstorming measures to further maximize resident efficiency.

FullSizeRender 10

We are highly competent at navigating not one but TWO electronic medical record (EMR) systems, one for the hospital and another for the clinic. Our technical finesse is ESPECIALLY enhanced with the patient, patient’s family, or medical student in the room, hawkishly watching our every move/itch/twitch.

Computer animal

And that’s just about all to report for now. On the floors tomorrow with our dear senior lost to night float last week.

By the way, if you’ve made it this far to the bottom of this post (may God bless you), there’s an excellent article in the today’s Sunday Times about immunotherapy for cancer treatment. I love this topic, and it’s a very informative read.

Beeperdoc signing out.

Confusion in the midwest: Tales from an ethnic yankee

NYMapofUSA

I feel like an anthropologist in Ohio. This is my first experience in the midwest and was initially enraptured with childlike excitement. I’m sure this is exactly how Christopher Columbus felt when he discovered The Americas and found the (non-bobbling) Indians to be comical and naive, that is, before they started chanting “hubba hubba hubba” in the bushes and blowing darts into his forehead.

I would also like to acknowledge that what I just wrote was a VERY ABOVE AVERAGE American understanding of world history. Did you know that 42% of high school seniors in the US can’t identify an Asian country on a map? I have no idea if that statistic is true but, honestly, if someone started singing, “In 1492, Trump sailed the ocean blue” I’d start singing it too because in this day and age you can literally make up any random fact and it will be true, simply because you thought it and because you’re no dum dum!

I actually haven’t been able to formulate a coherent opinion about the midwest, other than jotting down these few observations. I urge my friends and family to forgive what will probably sound like “racist” banter. I certainly don’t mean it as a personal attack, and have always believed that having roots in the USA is its own unique cultural experience akin to hailing from any other country on this planet. I am inherently an outsider looking in to an experience that I will never claim to understand, because I’m too self-obsessed and in search of unattainable solace in my own utterly confused and fractured personal identity. But that’s a hilarious (to be read as: hilÁHR-iyus!) topic for another day.

There are a lot of white men named “Brian”

Initially I found it odd that there were so many men introducing themselves as “Brian”. I started to believe that maybe all the white guys in Ohio made a secret pact to introduce themselves to the lost indian yankee speaking surfer ebonics as “Brian” because that would be funny, and when things are funny you laugh, and when you’re laughing you’re not crying about how we’re all actually just still in the midwest.

Brian

I don’t know. I guess I’ve grown fond of the name Brian. I think statistically, of all male names, I know the most Brians. And if you’re unsure of the name of the person you’re speaking to, you can just blurt out the word “Brian”. This is advantageous in either one of four ways: Either his name actually is Brian, you will catch the attention of some other Brian who is coincidentally passing in the periphery, his name is Ryan which sounds like Brian, or nothing will happen at all because in some parts of the state it can be construed as normal to stare off blankly into space and whisper the name “Brian” to yourself at abrupt and unexpected moments in time because the midwestern “spirit of Brian” will have possessed you–something that probably decimated the indigenous peoples of Ohio centuries ago.

Listen, I’m ignorant, so I don’t know what the name Brian actually means. I’ll have to do some reading about it, or please feel free to edjucate me. But like most common names, I’m going to assume that it has something important to do with the history of the Western identity. It will be very confusing for my brain if this were not true. (Which reminds me, if you’ve ever misspelt the word “brain” by writing “brian”, I believe it to be a sign that you’ve been possessed by the spirit. It was not an accident.)

Every farmhouse has a shimmering temple

Silo & Barn

A writer from the midwest once said grain silos were like shining, shimmering, splendid temples on the horizon. This man wasn’t Aladdin, but he did show me the world, and it was true! I had no idea that the name for the towering, oddly phallic-shaped buildings which were adjacent to rural homes but which I deduced could neither be an actual house nor a water reservoir was called a “silo”. I am not being facetious when I say that they seem like powerful and symbolic artifacts of wealth and sustenance. It is a uniquely American structure that inspires great awe within me. I feel like part of the reason may be because they are roughly the shape of Hindu lingams blown grossly out of proportion, and that if I were ever close to one, I probably should start walking in circles around it. I’ve never been close enough to touch a silo, but I imagine the following scenario in which I’m standing with a farmer, beside the farm’s silo, looking upwards with my eyes filling with tears and my hands trembling:

Me: “Farmer, let us pray, to the lord Shiva.”
Farmer: “Get off my farm, before I call the police.”

Stuck behind a freight train in Tinkerdink, for eternity

It turns out that in the middle of America there are tons of mysterious goods to shlep around in freight trains across counties with uniquely American names like “Coleslaw” and “Tinkerdink”. In fact, one of the most exciting things to look forward to when rolling along the Great Plains (read as: clipping my cat’s toenails in the backseat with cruise control on) is arriving at the little green signs that say “NOW ENTERING [X] COUNTY”:

X =

SHMUCKADUNK
DUNGAREE
SALAUMEE
YAWNSVILLE
etc.

The fact that there was not one distinguishing feature between County A and County B–not even a piece of roadkill, or a location-orienting water tower, was baffling to me. What was it that gave each county a sense of identity, or even history? It felt like the entire midwest was the same patch of wilting corn field that God had copy & pasted and had fallen asleep holding “cntrl + v” because he was so bored with creating the midwest.

Anyway, what I had truly underestimated was the ancient american railway system whose freight trains of the 1800’s are still tooting around the open country with the speed of molasses, burping soot of death. They passed at any time of day which was pretty eerie especially in the dead of night when the entire town echoed with the screech of these derelect trains, apparently manned by no human other than the ghost of a probable local legend, Capt’n Dungaree. Both the sound and the site were enough to give me goosebumps. What the hell was moving these trains? White walkers??

Freight train

Noooooooooooo

Getting stuck behind trains was a comical site for the locals, who either whipped their pick-ups around and darted off leaving a trail of dust towards some magical portal back to civilization or entirely avoided this situation with the pride of exclusively knowing the important goings-on of the bumpkin backroads. Usually my GPS signal was out of range. Anticipating the timing of my actions was the most stressful. Would it have already moved in the time it would take to figure out how to get around it? For how long would I be stranded? I couldn’t even urinate into some godforsaken Nalgene bottle thinking that someone or something in that train was watching me. I’d have to start drinking windshield wiper fluid to survive and then just lay sprawled out on the dirt beside my car and await my natural death.

Knowing that these county roads are predictably shaped in giant, endless grids, I often tried to outsmart the train by trying to calculate the general N/S/E/W directions I could speed through to get to the opposite side. So then I, too, would whip my car around and speed off turning aggressively into every permutation of direction, dreaming the American dream of driving away with that demonic 19th century train receding in the mirror, crying joyful expletives. 100% of the time that dream never came true and either resulted in turning onto an interstate that was rapidly siphoning me off towards the state of Indiana or ending up right back in front of that same godawful train, banging the steering wheel and crying joyless expletives.

RoadSign

Terrible drivers who haven’t earned their terrible personalities

Most people who claim that “drivers in NYC are atrocious” are missing the very obvious fact that people who are capable of traversing that finite and hostile terrain are basically the olympic athletes of driving in public. It’s like training and then performing at Juilliard. If you can’t keep up, then either quit driving or go back to driving your Tonka truck in circles in your driveway. They may be unfriendly but that is because they are fighting to claim their very limited space. It comes with an incredibly adept intuition as to the size and capacity of their car, as well as near-perfect timing of sudden movements without actually killing anybody. The middle fingers, flying expletives, honking, and arm farting is basically a romance language between two city drivers displaying mutual appreciation.

On the contrary, midwesterners were born and raised in a big, bloated land mass where it is never required to be possessive nor even at least minimally conscious of what may be happening within a 1 mile radius of their trucks. Instead of being humbled by the small bit of land that they tenuously hold on to, they feel entitled to claim vast quantities of nothingness. They bluster around, the Tom Buchanans of the world, not only unwilling to let you into a lane, but entirely likely to smash into your car due to the collectively sluggish reflex of the midwestern spinal cord. Every road is an eight lane expressway in which you are perpetually in the lane furtherest from the one you should actually be in. You are constantly missing turns and trying to navigate cryptic arrows painted on the road. Then in order to make the next U-turn, you must traverse an endless strip of road spotted with motels, Red Robins, Speedways and absolutely nothing that resembled my false idea of a ‘quaint’ midwest.

Megamarts

Meijer

It seems that everyone in the midwest exclusively does all their shopping in some type of “megamart” establishment. The one closest to me was called “Meijer”, which I never actually learned how to pronounce, largely out of resignation that most places are never pronounced properly out here (eg, Toledo is pronounced tol-EE-do; Lima is pronounced as LYE-ma). Well I guess that since American states are quite literally as large as moderately-sized european countries, it would make sense to amass all commercial goods under the roof of one centrally located space.

But good Lord. These stores where so colossal, I thought that all the frail old people who wandered in there had accepted the fact that Meijer would likely be their final resting place. Do they gift them LifeAlerts at the door?? I literally had to start doing burpees in my apartment just to muster then thigh strength necessary to spend an entire Saturday propelling both my body and cow-sized cart up and down the aisles.

Screen Shot 2016-03-12 at 5.35.20 PM

A charming place to [have your friends] be from

I’m not going to lie. It’s a love-hate relationship with this place, most especially after realizing that even doctors with over 10+ years of graduate level education (usually the community paragons of rational thinking) were staunch Trump supporters. It was particularly deflating as students who had to silently endure poisonous ideology disguised behind a midwestern smile long enough to get out before making a scene, which, in theory, could delay our graduation.

Um. Can I get a heeeeeyyyyylllllll nawwwwwww!

KevinHartNo

But some things I did love: Q95 country radio, camo everything, driving fast, cheap gas, incredible star gazing, massive sunrises/sets, wine sold everywhere at any hour (all these people must be functional drunks), the fact that one dollar goes a hell of a long way, and of course, all the exceptional attendings, residents, students, and patients who have helped me learn the universal language of medicine, regardless of where I was on planet earth. Because everyone, at the end of the day, is simply a human being. (At the beginning of the day they are robots.)

On the meaning of diagnosis.

So I haven’t written in a while. To be honest, I lost a lot of my mojo between my internal & family medicine rotations during which I saw a PCP for the first time and somehow ended up diagnosed with three different autoimmune diseases, one being quite rare. (I mean, what the heck? Who has time for this??)

It was all a pretty classic case of “20-whatever y/o female c/o [list of non-specific sx] with abnormal ___ on initial blood work…” You know the rest. I’m still a little shell-shocked and frankly I don’t even want to talk about it for fear of being known as “[may name] with ____” instead of just “[my name]”. So this is probably the only time I’ll address it, that is, if I don’t delete it later.

At first I couldn’t help but laugh at the irony that at the same time that I was teaching immunology, my own body was waging war on itself. It really only showed itself this past year in which every day became an exercise in waking in misery, cheering myself up in the mirror, and running over to the hospital to function (quite cheerfully) in a way that I otherwise would not.

Diagnosis itself is as stressful as it is cathartic. Suddenly you have an explanation as to why you feel or act the way that you do, and you are empowered to create what I think is the most important thing in medicine: a plan of action. So in that regard, it was nice.

What continues to not be so nice is to work amongst the chronically ill and to silently wonder what will become of my own life. I feel overwhelmed by the intrusion of thoughts that I never expected to have to think before:

How many meds will I take, for how long?
Will I need surgery?
Will I get insurance with “pre-existing conditions”?
Would I be able to have children, if I wanted to?
Will I inconvenience the people that I care about?
How do I not feel so worthless, even though I know it’s unreasonable?
How do I handle not being as spontaneous, athletic, and care-free as I used to be?
…and the most obvious,
Is my lifespan compromised?

I feel humbled to have joined the ranks of the millions of young adults who quietly interact with the world in the context of their own health, and regard the health of others with uncommon respect and clarity.

Truly the point of this post is not to be dramatic, and not even to talk about myself. For the record, writing about myself is one of the most exquisitely uncomfortable things to have to do. But I wanted to share an awareness I’ve gained about what happens the moment in which your day-to-day life suddenly becomes lists of words forever stamped into your chart’s “PMHx” (past medical history).

I realize now that a diagnosis is:

  • More than just an ICD code in a computer; it is a state of existence that may define a person forever.
  • A succinct articulation that a person’s experience is justified in the eyes of contemporary science, and that this experience has been lived by other people who came before them.
  • A practical way to organize sickness into a house in which it belongs, to become the domain of the specialists of which they are the master.
  • An agreement, a formal pact between doctor and patient, that even if I am not caring for you, somebody else in my position will pick up where I left off and will not abandon you.
  • An unpredictable storm of emotion that whispers at times and howls at others. It has the power to bring together or destroy families by nature of giving an experience a lexical form that may be misunderstood by the uninformed, or far worse, mistreated by the uneducated.

I will forever remember this past one year of my life as something of a purgatory. (I’m referring to things beyond the scope of this blog.) But if the crucible of this year has crystallized anything in my mind, it is how to be dignified in this profession with curiosity and patience for every complaint. Every leaf should be turned over, as if looking for something small and hidden underneath, which may alter the course of a person’s life. I know that as a physician I will never have the time to follow up with every diagnosis that I make, but I must never forget the infinite and lifelong complexity that other people experience from having had the power to do just that.

A quiet saturday morning

Another day on medicine.

Today I decided to bring my gargantuan reflex hammer. The thing actually looks like a sledgehammer. I don’t even know why I did–my only patient is a GI bleed. Lately I’ve been voraciously reading Sapira and my most recent topic was reflex techniques on the supine patient. Ever since then I’ve been performing a type of self-instructed “didactic assault” by slamming this thing into every tendon in my path. So far, so good.

The team is scattered doing random things before sign out to Moonlight Doc. I cross a crazy-eyed gomer in the hallway. She implores me to help her escape. I implore her to help me escape, too. She says she’s confused. I say I’m confused.

I go see my guy, Mr. Black. I’m following him through our ED admission last night. CC: Vomiting blood. I cover the essentials, orthostatics/NV/ABP/stool/etc, following the sacred advice of Dr. P, “Essentials first, sight-see later.” I spare bashing him with my hammer, for no good reason. He seems sad.

We sit in the dark and talk for an hour. He speaks the way reticent men finally talk, eight decades after when they were supposed to start talking: full of fear and regret. He praises his wife and grandchildren. He admits to mistakes. He spends an inordinate amount of time talking about a male best friend who recently passed, a frequent vacation companion whose ghost haunts him at the kitchen table. He cries in silence. Tears dribble down his face, diverting randomly into the creases of his skin like plinko chips. He says, “I’m not like the others. I’m a good guy. I really care. I’m not ready to die. Don’t tell my granddaughter that I’m here.” It’s quiet. On the other side of the curtain heroin-withdrawal-guy is flopping around, doing something weird, ruining the moment. Mr. Black’s jello arrives. His phone rings. I go find my team.

I don’t know.

I’ll spend my whole life talking to “Mr. Blacks”. But I know that when I’m his age, I too will be lying in a hospital bed, dancing with death, conversing with a blurry voice by the bedside, desperately trying to convince myself that whatever decisions I had made in my life were truly the right ones to have made.

No regrets?

Yeah,

right.

Surgery Clerkship: “We accidentally replaced your heart with a baked potato.”

Three months have come to an end of playing dress-up in the cult of surgery, manipulating the open human body as did our ancient predecessors, performing the (now legal) act of therapeutic assault & battery. It was awesome.

SPHeart

Each morning we’d awake at 4 AM and mobilize on the floors by 5 like green berets, doing important surgical things and asking important surgical questions, like:

“Mr. Jones, have you passed any gas since yesterday?”

Sometimes, it becomes apparent that Mr. Jones is either deaf and/or demented, in which case we must rephrase the question to a more intelligible form:

“MISTER, JONES, HAVE, YOU, PASSED, ANY, GAS?”

Sometimes, Mr. Jones does not understand what is meant by “gas”, so we clarify with important surgical vernacular:

“HAAAAAAAAVE
YYYYYYOOOUUUUUU
FFFAAARRRTTEEDD???!!”

On the rare occasion, the room lights are turned on and it becomes apparent that the patient is both intubated and sedated. This is a very stressful situation for the team, not because of the circumstances that may have required intubation and sedation, but because the status of this man’s flatus may never be known. Senior stabby (senior surgical resident) asks baby stabby (MS3) if she would sit in the dark and maintain utmost vigilance over the sedated man’s anus, and to notify junior stabby (surgical intern) immediately upon its passage. Baby stabby does not fully comprehend this request, but agrees anyway, blaming the lack of comprehension on her own presumed incompetence.

TheFirstSurgery

The First Surgery

The OR is a sacred temple with its own rituals (scrubbing, gowning, draping) and professional requirements that are necessarily strict lest kill grandpa for preventable reasons. OR etiquette is perhaps the single most important thing a med student could know on surgery. As is oft said, if you want to ask a question, don’t, or ask if you can ask a question. The question better not be something you could look up in a book, and definitely must not expose a mid-level, senior, or king/queen stabby’s (attending’s) ignorance. During particularly long and complex procedures, for example during a Whipple or hernia repair with poor visualization, it is advisable to avoid asking any questions at all, as doing so can only back-fire in either one of two ways:

#1. The attending will turn your question into a question:

Medical student: “I’m unclear as to what’s happening Dr. Stabby…If we’ve identified the lacunar ligament, does that mean that this is actually a femoral and not an inguinal hernia?”
Dr. Stabby: “What do you think?”
Medical student: “Umm. I don’t know. That is why I asked.”
Dr. Stabby: “Why don’t you take some time to think about it.”
*silence*

#2. The attending will make you question your (actually) correct knowledge:

Medical student: “Dr. Stabby, are you isolating the IVC?”
Dr. Stabby: “Well, let’s see. How does the IVC lie in relation to the pancreas?”
Medical student: “Posterior to the head of the panceas.”
Dr. Stabby: “Are you sure?”
Medical student: “…Yes…No…”
Dr. Stabby: “Really?”
Medical student: “Am I wrong??”
Dr. Stabby: “Why don’t you take some time to think about it.”
*silence*

Anesthesia

The “abuse” hardly matters (perhaps is even comforting to those of us sufficiently disturbed) given how extraordinarily privileged we are to have our buffoonery permitted in this space. As my skills improved, my privileges were raised. I was privileged to hold suction. Privileged to tie knots. Privileged to suspend grandma’s gargantuous, saggy, old breasts straight in the air indefinitely. Privileged to close port sites. To make open incisions. To cut an appendix. To close an abdomen. To run the bowel. To close a leg.

But alas, leave it to GI surgery to keep our passions in check. All it takes is one 2 AM stat ostomy repair, an unexpected geyser of warm diarrhea, and watching your mid-level stabby vomit himself and be carted off to the ER to start pivoting your career in another direction.

But God bless these surgeons! No week can parallel working with the greatest colorectal surgeon in all the land. He was, quite simply, the Gandhi of the bowels. I became utterly and inexplicably fascinated by his fascination with the rectal exam. He eloquently equated it to “reading braille” that’s written inside our bodies. Intoxicated by his passion, I too wanted to be the Hellen Keller of the rectum! I wanted to close my eyes, caress their hemorrhoids, and prophesy their visceral horoscope! Feel the “kiss” of normal sphincter tone! Tickle the prostate! In fact I got jealous of the junior stabby who was so uncommonly enthusiastic about our Trauma cases rectums, she could have hoisted them off the gurney with her index finger alone and spun them like a pizza pie. Then I realized…I had spent too much time with the colorectal service.

RemoveHand

All in all, I will deeply miss my rite of passage through surgery. I loved the ability to “fix”, to be action-oriented, to reason logically from one finding to the next, and the duality of gravity and hilarity. I’ll never forget my patients and perhaps even more, my mentors.

Onwards to medicine.

Diary of a Colostomy Bag

I am bag. I collect all the poops. Fast poops, slow poops, green poops, gold poops.

I love my human. She is warm.

I feel bad. I collect the nectar. Nectar of the bowels. She gets none. I feel bad.

Sometimes I share. I hug less hard. I give her nectar too. She doesn’t like this. I don’t know why.

Toilet is mad. He gets no nectar. Toilet is sad. He is cold and lonely.

I feel bad for toilet. He wasn’t always cold and lonely. He gets yellow spray. No nectar. I don’t know where yellow spray comes from. Yellow spray looks hectic and stupid.

I feel bad for toilet. He doesn’t believe in god. He hates god. God is “bowel surgeon”. Bowel surgeon created me. He created the universe.

I love my human. We do everything together. We swim, we run, we dance with stoma.

Do you know stoma? Stoma is my friend. Stoma likes to dance. He dances every 20 minutes.

Sometimes it is annoying. I try to sleep. But stoma dances. He has no rhythm.

I love my human. But does she love me? She hides me, like a lover.

Sometimes love hurts. Like when I get stuck in belt. Belt is confusing.

Sometimes love hurts. Like when we see Ostomy Nurse.

I hate Ostomy Nurse. She is evil. She tears me from human. She throws me in trash.

Trash is cold and dark. I yearn for human. If I had eyes like human, I would make water from them, too.

I have no purpose. I am old bag in trash. I wish I were new bag.

New bag hugs human. New bag gets nectar. I don’t know new bag. But I hate new bag.

Wound vac is in trash with me. He says “think of memories”. So I think of memories with human.

They are nice. We went to IMAX. We saw the hobbits. It was long and confusing. It was okay though, because human was happy. And I slept on human. And it was nice.

Maybe new bag is nice. I don’t know.

I hope new bag hugs less hard. And shares lots of nectar with human. And makes her mad. Then human will miss me. And then find me in trash. And pull me out. And we will be together again.

Just me, human, and stoma. Happily ever after.

Colostomy

Surgery In Letters

s
l
i
c
e

Burn.
Stare.
Burn.
Stare.
Burn.

[dab]  [dab]  [dab]  [dab]

slice
slic
sli
sl–

Suction [blood].

Clink. Crank.

Suction [smoke].

Clink. Crank.

[—————-RETRACT—————-]

DRILLLLLLLLLLLLLLLLLL.

[—————-RETRACT—————-]

Hold this. Like THIS.                          until thursday.

INTERRUPTION: Dr. Hangry’s sterile field rant

rant
rant
rant
                                                                RESUME.

L          e          a            k.

L      e       a       k.

L   e   a   k.

LEAK!!!

Kidney pan.

[TUBING]

DigDigTieDigDigTieDigDigTieDigDigTie. Snip.
[–retract–]  
DigDigTieDigDigTieDigDigTieDigDigTie. Snip.
                      [–retract–]  
DigDigTieDigDigTieDigDigTieDigDigTie. Snip.
                         
                   [–retract–]

T  | T | T | T
A | A | A | A
P | P | P | P
E | E | E | E

HELLO
SIR
I
MEAN
MA’AM
YOU
ARE
JUST
WAKING
UP
FROM
SURGERY.

Vulvectomy

I’m scrubbed in and standing in the OR in front of Bertha, the circulating nurse, holding two plastic cups with specimens for labeling. I am silently shocked and delighted that I am participating in a procedure so bizarrely archaic. I imagine myself as Cleopatra of ancient Egypt (if she were a trailblazing female medical apprentice instead of a psycho killer), ready to go light an oil lamp and chisel the OR report in hieroglyphics.

“What’s the first one?” she asks, holding her pen.

“Uh. Left labia minora.”

“The other?”

“Right labia majora.”

“Jesus.”

The indication for surgery? Recurring genital warts. Under the OR lights the topography of this patient’s vulva is so complex and variegated that it looks like a city of exophytic masses. Maybe even the thirteen original American colonies, each with its own politics and inter-wart bickering and adamance to exist. One wart wants to secede, others are drawing the Mason-Dixon Line. Anyway, studies show that these masses are generally benign and are removed for cosmetic purposes. So here we are, the vaginal beautification squad, ready to alter the course of history.

The patient is shrouded in sterile drapes. For now, who she is as a person is entirely irrelevant to the anatomy that is exposed. I try to think that having memorized her chart would make the encounter (that is to say, pelvic exams under general anesthesia) seem less like ‘assault and battery’.

We’re about to go bombs away with a military-grade arsenal: scalpels, cautery, lasers. Standard protocol for a woman of this age with unabating condyloma acuminata. It’s been a few hours now and I’ve had the highly honorable MS III (third year medical student) task of standing on a step-stool, retracting her lady parts with my hands. (I am also not kidding; people are treating me like royalty for this service that clearly only one person in the OR is going be providing.) I silently coach myself into keeping my digits flexed to ensure that it is still smiling the joyless smile that only a retracted, condylomatous vagina can make.

Soon a nurse notices that I’m not wearing the laser-specific protective lenses. She asks why. I politely say because my hands have been full and that when we decided to use the laser, no one put them on my face. She instructs me to not look directly at the laser. So, I look directly at the laser. I look away, and then with senseless irony, my eyes crawl back to the laser. I find her comment a cruel joke. I begin to believe that once upon a time she was pimped by another nurse who told her ‘not to look at the laser’. She is now avenging her memory from behind prosthetic eyeballs full of hatred. I  imagine that my last visual memory will be of me scorching out my own eyeballs, retracting an infected vagina on a step-stool. I smile at the poeticism. This is the gyne version of Oedipus Rex.

I try to distract myself from the laser by thinking about something else. I dig into the recesses of my mind to recall my First Aid notes on condyloma acuminata. I fixate on a picmonic I drew: Condaleeza Rice in a field of cauliflower. She is very happy in the cauliflower. She is smiling with that type of giant, buck-toothed smile that just makes you want to have giant, bucked-teeth too. Good work, I say to myself. We have accomplished much with this exercise. The attending asks why I am talking to myself. I respond with an unusual silence.

Eventually the attending leaves and I am helping the resident close the lacerated vulva. I am first confused and then later impressed by her near-maniacal devotion to saving the clitoris. She says, “If you think about it, this is it. This is all she has to live for.” What a strange and powerful thing to have said. But mostly strange. It appears she has transformed herself into the mother teresa of clitori, as if she had watched many die unceremoniously under her watch and has now dedicated her life to their preservation.  Two hours later, she asks me if I think it has been saved.

I say, “no ma’am.”

I feel bad for saying no. I ultimately feel good for having helped restore human anatomy. I am elated. I begin to believe that the impossible is possible. I believe that we can save all the vulvas of the world, one papillomatous mass at a time.

I scrub out last and make a cool sprint for potato chips. The next case has already begun. I file through my mind to recall this next patient’s history. I meet her, meet the attending, and review anatomy with the resident. I’m hoping that my mind will do less ridiculous mental gymnastics in the OR. But as an MS III comically placed in unusual circumstances that may never be seen again, every thought is memorable.

Pediatrics rotation: “She’s got a terminal diagnosis of cute.”

I made my first mistake in pediatrics before my rotation even began; I never watched the movie Frozen. So obviously I was ill-prepared to handle the onslaught of patients with “Let-It-Go-itis” (a term I didn’t coin), a highly contagious disease known to compromise voluntary motor function with the repetitive singing of “let it goooooo!” Every girl and their primordial follicles wanted to dress up as Elsa for halloween, and one even started to cry when I said that ‘we ran out of Elsa stickers’.

Walking out of the shelf exam.

But you live and you learn! I only managed to get sick twice on peds (aka, all 5 out of 6 weeks). I had a wonderful time on my rotation which opened my mind to the possibility of Pediatric Cardiology, a combination of being cool with kids + a focused sub-speciality. I wanted to jot down a few things worth sharing from the past month.

Firstly, pediatricians are the nicest people on earth. It’s basically a prerequisite to be fun, personable, and irrationally happy in pediatrics. For medical students who endure a lot of abuse, their niceness is initially weird and confusing. (Why is that attending smiling so much? Am I allowed to smile? Should I be smiling with my weight on my left leg, standing by the door, or on my right leg, standing by the window??) Eventually, I learned to let my guard down and enjoy a 6-week vacation back to normalcy.

Who are these people??

To be honest, I initially had no intention of going into peds. I am one of the youngest people in my family, so I never spent much time around people younger than me. I started med school intending to specialize in a rare field of medicine. I almost started to get defensive when parents would say, “He [my baby] loves you!” or “Are you going to be a pediatrician?” or “You have to go where you gifts are!” as if to say that just because I was a girl, or because I was friendly and non-threatening, that I should practice friendly and non-threatening medicine. I wanted to say, “No! Be scared of me! BOO!!!”

BOO.

Obviously I scared no one except the infants and toddlers I had to wrestle into a headlock for their physical exams, and I don’t blame them (it was as traumatizing for me as it was for them).

But as time passed, and as I found myself looking forward to every morning and every patient encounter, the emotional satisfaction of peds became obvious. There is unparalleled autonomy in pediatrics, and the pediatrician-child relationship is tremendously meaningful. In what other specialty does your patient immediately worship you for simply being 3 feet taller and for concocting games out of the lights on exam tools? Or engage in play to assess their developmental milestones? Or intervene as a role model to prevent a lifetime of illness before it even happens? Or watch a human (literally) ascend through the world and be there for every major life event? Kids aren’t jaded, rude, and complicated as the people you find on adult wards. And as is often said–there’s a pretty big difference between having to spend your day elbow-deep in adult poop, instead of baby poop.

I was also amazed by the simple things. Like the trust that’s gifted after simply kneeling down to a child’s eye level, or what teenagers opened up about once I asked their parents to leave the room. All I wanted to do was take these kids and cryogenically freeze them as prophylaxis from the damage of time.

First time on ice.

Children always wanna act like they’re at a cocktail party. They wanna walk around and eat. That’s a choking hazard. Sit, down! (Peds foriegn body lecture)

But just as there is the good in peds, there is also the bad and the ugly. There were many patients who were inexplicably broken from the start: premies born to drug-addicted mothers born missing crucial elements of their brain, girls impregnated by their own family members and seeking abortion, children physically broken and branded with cigarette burns, etc. As time went on I learned the art of performing histories and physicals with an attitude that’s tacitly learned in medicine, “feigned ambivalence”. It’s a type of emotional auto-pilot that numbs you from all that is disturbing.

What I’d like to do to some parents.

I learned hands-on medicine in the medicaid clinics, and I learned how to treat medicine as a business in the upscale practices. Our hospital is located at the epicenter of a hispanic, portuguese, and brazilian community. When I showed up on my first day at the medicaid clinic and responded in spanish to my preceptor’s question as to whether or not I spoke spanish, she blinked and then slowly cracked a smile. She then insanely entrusted me with a stack of charts and a morningful of histories and physicals to perform on my own–each with an oral presentation and her stamp of approval. Even though I felt like I was juggling more than what I was qualified for, and even though I felt that there were significant gaps in their histories that I couldn’t properly communicate, it was my first feeling as a medical student that I could be a person of value. Especially when my mind started to bounce with the nerdy excitement of catching pathological clues, like exfoliation of the hands and soles, periodic breathing, inguinal herniation, herald patches, or my favorite catch–a VACTERL congenital anomaly.

Trying to communicate in Spanish, to toddlers.

It was also fantastic to work with pediatric specialists who, just as the general pediatricians, were truly excellent at what they do. There were opportunities to see rare diseases that I may not see again for a long time, like palpating and auscultating bruits over a goiter, duchenne muscular dystrophy, growth hormone deficiency, wolff-parkinson-white syndrome, etc.

Onwards to OB/GYN tomorrow! This hospital is notorious for its excellent yet demanding OB/GYN team. Can’t wait to begin.

 

Now some boring MS3 advice:

Wards/Outpatient. In my (humble) experience I’d recommend being an expert on:

  • Developmental milestones, monthly from birth to  age 5. Particularly how to observe the child in silence, ask a parent in lay terms, and report back to the preceptor (bonus points for spanish).
  • Asthma and diabetes. Particularly diagnosis criteria, pharmacology, and the protocols for status asthmaticus and DKA. A useful MS3 thing to do is teach a parent or child the proper use of a nebulizer or spacer.
  • Differentials for wheezing and cough.
  • Calculating fluid replacement!!
  • Growth charts.
  • Vaccination schedules. Particularly what a child should be expected to receive during their visit.
  • Neurocutaneous disorders, differentials for rash, and kawasaki’s disease–classic pimping questions.
  • NICU–differentials for elevated bilirubin, Rh/ABO incompatibility, normal neonatal values, the newborn exam, APGAR scoring, CPAP, respiratory distress, VSDs, and newborn hematomas.

Shelf

  • A very tricky exam, as expected. I can almost guarantee that whatever you see on the wards or in outpatient will be irrelevant to the test. Mine in particular didn’t have a single question on milestones, asthma, or diabetes. I can’t recommend doing the entire Pre-Test book enough (this is really gold), especially the infectious disease/immunology chapter which seemed to be 50% of my exam. My roommate and I agreed that the UWorld questions were too easy so I ended up getting fed up and only did half of them. Let BRS be your peds bible–I literally looked up every single thing in this book and continue to worship BRS’ near-perfect organization. Case Files was a fairly good review to breeze through at the very end, but if I could go back in time, I probably wouldn’t have bought it (it’s missing way too much info).

Enjoy the week!!

A few facts on Ebola

As per my advisor, a CDC trained ID specialist currently en route to Liberia:

1. Ebola is not an airborne virus.

  • Examples of airborne viruses include small pox and measles. It is only transmitted through physical contact with the blood or bodily fluids of infected individuals (semen, vaginal secretions, breast milk).

2. All cases of Ebola in the U.S. were due to contact with patients known to have Ebola. I.e., medical staff who were treating Ebola patients.

  • Unless you are a nurse treating an Ebola patient, you have virtually no chance of becoming infected.

3. A person with Ebola cannot infect other people unless they are quite obviously symptomatic.

  • If a person is infected with Ebola on Day 0 and receives absolutely no treatment, they can be expected to demonstrate the most severe symptoms of disease roughly by Day 10. (The incubation period is 2-21 days, usually 8-10.) It is only towards the tail end of the disease, for example when the patient is most likely to be vomiting during intubation, that others exposed to their fluid will likely be infected. These symptoms may include a spiking fever, muscle soreness, vomiting, diarrhea, headache, severe soft tissue infection, and passive behavior.
  • Unlike its name (“hemorrhagic fever”), massive hemorrhage (or bleeding) has not been common in the current epidemic.
  • Ebola has been hypothesized to hide in the CNS (brain and spinal cord) and appear in the blood only after the onset of fever. Even on Day 1 or Day 2 of the initial fever, the patient is generally still not infectious until Days 4 or 5.
    • It may take up to 4+ days after the fever onset for an Ebola PCR to be positive. This is therefore not a good screening tool and we currently need a more rapid and less hazardous diagnostic test. The Ebola PCR test identifies the genes for a polymerase and a nucleoprotein. Note that PCR may also be responsible for false positives or false negative results.

4. Most cases of Ebola are highly treatable as long as IV fluids are provided early.

  • All cases of health care workers infected with Ebola in the U.S. were successfully treated with supportive therapy alone. This is called “oral rehydration”. Unless immunosuppressed, most people will survive from early fluid resuscitation. Wealthy countries can easily provide this. Poorer countries cannot.

5. Those who’ve recovered from Ebola can be potential “carriers” up to 3 months after recovery.

  • These people are obviously advised to avoid sex, blood donation, providing breast milk, etc. for at least 3 months following infection.

6. The vaccine for Ebola is a fairly “easy” concept.

  • It is made from a chimpanzee adenovirus. This virus is made non-immunogenic (the genes that made it infective are removed), and replaced with a gene segment from the current Ebola strain. This gene segment taken from the Ebola virus is not infectious because it is not the ‘whole’ Ebola virus! The modified adenovirus is then injected into a human, whose cellular machinery will produce proteins (antibodies) against this piece of Ebola virus. So far this method has been extremely successful.
  • Note that the talk about “treatment” will not do anything to change the course of the epidemic. Changing the epidemic means identifying “patient zeros”, i.e. those who were the first to be infected, and isolating those who came in contact with them. Vaccines are not a solution to the epidemic–they rather provide a sense of hope.

7. Research on Ebola is not new.

  • In 2007, up to 270 research papers on Ebola were already published. You can imagine why acting on this information has only become significant now…

8. Once the epidemic is over, Ebola and the “filoviruses” are likely to go away, forever.

  • Now that strict protocols regarding Ebola infection control are being implemented worldwide, there is little chance that the virus will ever make a come back.

***Please note***: My only agenda is to combat ignorance and misinformation. I do not claim to be an expert. I am merely a medical student with an interest in infectious diseases, relaying the words of a credible source to my lay-friends and readers. I encourage you to turn off the news, read the literature, and to learn from physicians and scientists who have been educated on the current epidemic. I feel embarrassed for my country and disgusted that politicians would use the upcoming elections to fear-monger and punish some of its citizens for entirely unscientific reasons.

http://www.washingtonpost.com/blogs/worldviews/wp/2014/11/03/map-the-africa-without-ebola/
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Yikes. All that aside, hope y’all enjoy the rest of your week!!