Family

Sigh...my dad was just diagnosed with diabetes. A fitting end to my family medicine rotation. After treating 50,000 patients a day with diabetes it seems kind of routine, but he's helped me remember that for each individual patient it's not necessarily routine at all (especially the initial diagnosis) and he's really depressed about it. Not that he's totally turned his diet around, but he's trying.

Seeing all my relatives over winter break (and just having any break at all) has been great. Here's hoping for the best in the new year!!!

Every Day Low Prices

Say what you will about Wal-Mart, it definitely serves a purpose. So much convenience, so many low prices...I do most of my grocery shopping there now and the selection is pretty good, even the produce. Plus, the prices are pretty damn good. Don't take my word for it...this study showed that in poor communities Wal-Mart actually improved customer health. In other health news, the price wars between pharmacies Wal-Mart started by offering so many generics at $4 for a month supply has immeasureably helped patients bear the cost of their endless medication lists. Seriously, check it out...you can control high blood pressure for $40 a year. As much as I loved living in New York City, the one thing I missed (and this may sound sacreligious) was a big Wal-Mart where I could buy basic supplies, yarn, really anything, at a reasonable price all in one store. For better or worse this may soon become a possibility.

I agree with a recent poll that found that Wal-Mart Best Symbolizes America. A little scary, yes, but when I think of America, as vast and diverse as it is, one unmistakable feature is the big shopping complexes located near highways that are the same anywhere you go and usually include a Wal-Mart. Wal-Mart is super sized...convenient, generic, but when it uses it's power for good maybe it could even save the environment. Of course, Wal-Mart also has its huge share of problems. Yes, it employs a lot of people (yay!), but it sure could treat them better (boo). Then there's always the question of what means Wal-Mart uses to keep its prices quite so low, and the damage it causes to local businesses.

And let's not forget the breathtaking creatures on display at your local store. What could possibly be more American?

Stories

My first day of family medicine I saw a 2 week old and a 99 year old. That pretty much sums up what makes it cool...the range of what you get to see is, well, everything! Still, I can't get away from the fact that dealing with diabetes and hypertension in non-compliant, obese patients would frustrate me over time. At least in theory. In the room, with the patient, you really just want to help and encourage and hope the best for them. But what most of the patients need isn't a doctor...it's a lifestyle overhaul...and probably a doctor too. You can manage the problems, but you can't cure most of them...at least not until the singularity. Following patients and families through the years would be wonderful. Really knowing the patient's life, their history and social situation, and having the skills to treat most of their problems is how I always pictured a good family doctor...and just a good doctor period. I love stories. More than any other doctors I've worked with, the family practitioners seem interested in the med student's back stories and the stories of their patients. One of the books I read for my medical anthropology class long ago, "A Fortune Man: The Story of a Country Doctor" about John Sassall, a general practitioner working in rural England, completely captivated me...the compassion and solidarity he showed with his patients is remarkable. If only being a doctor was like that now...though maybe you can get too close...he ultimately committed suicide.

"The human condition is not curable." -Our family medicine preceptor

While I've been all broken up about genocide and kids with cancer, family medicine has made me realize how much depression so many people are dealing with on a regular basis. A series of unfortunate events. Being laid off, kids who won't graduate for high school, abuse, obesity, retirement, death, realizing your life hasn't turned out the way you wanted...it's not that I'm completely naive and refuse to acknowledge all of these things exist...I've just been fortunate to not have to confront them head on on a regular basis. Yet, this seems to be the majority of what we see in family practice (and the physical manifestations of these problems). If you've got tons of fungus growing in your fat folds, you know you have a problem. I get depressed just thinking about it...but that's life. And if a doctor can try to help with pills, or encouragement, or anything that's great. Of course, the people who make regular trips to the doctor aren't really a random sampling of humanity either. I really like the doctor I'm working with, she's about my mom's age and just totally competent and spot on with most things. But my favorite patients are still the few kids we get to see. I like to dream that with the right influence from their pediatrician, kids can fulfill their potential and avoid a life plagued by regrets.

An Imperfect Offering

Physicians for Human Rights is finally starting to establish itself here on campus. So far this year we've had journal club meetings, a documentary showing and a World AIDS Day quasi-event. While I got into the group mainly due to my interest in global health I'm slowly getting drawn into the more activist side of things. It's a little rough sometimes...I'm not one to force ideas on people or even argue all that much and I'm not wild about petition signing (except for the 10,000 in 10 days campaign for women's rights) but I'm getting there. And it's a way to stand up and rant again and fight for something. Perhaps it's even an outlet for the lack of drama in my personal life...which is a completely wonderful thing...it just could use the occassional shot of chaos. Gossip Girl helps with that too (especially with it's Thanksgiving episode) but it's not always the most fulfilling endeavor. I can't wait to go to Kenya for 2 months in early 2011 for the OB/GYN elective...it just seems so far away...

Before running away to China for the summer, Andrei gave me three books..."Becoming a Doctor" (a biographical book by an anthropologist who went back to med school), "The Knot Book of Wedding Lists" (pretty self explanatory), and "An Imperfect Offering: Humanitarian Action for the Twenty-First Century" (by Dr. James Orbinski, a former president of Doctors Without Borders, who has done some crazy stuff in his time like working in Rwanda during the genocide in 1994). Guess which one captivated me? I may not be destined for war zones, but it's hard not to respond to the book. While his eye witness account contains some of the most horrifying stories I've ever heard (how can people just start slaughtering their neighbors?), his intelligent, compassionate response is ultimately hopeful. He's a realistic optimist! We decided to show the companion documentary, "Triage: Dr. James Orbinski's Humanitarian Dilemma", for a PHR event (with Noodles!). The book and the documentary cover similar territory and Dr. Orbinski is shown trying to write the book in the documentary as he revisits Rwanda and Somalia. Intense. But I held it together. What finally made me lose it was watching "Hotel Rwanda". After studying the genocide but thinking about it as something that happened 15 years ago, watching a movie that put you right there was just too much. I was sobbing uncontrollably the majority of the time...between all the little kids with cancer and being confronted with the fact of genocide, the pain and senselessness in the world seemed overwhelming. And now I can say something about how Thanksgiving with my wonderful family restored my faith in humanity...but that doesn't really solve anything.

Pain Control

So much for a daily blog...inpatient pediatrics on the hem/onc team has come and gone in a blur. And I enjoyed it...in a "I could see doing this for the rest of my life" kind of way. What did I like? I liked the kids...though they weren't always warm and fuzzy (but who could blame them?). One little 2 year old girl I took care of with Burkitt's Lymphoma was so adorable...she would brighten up my morning being super cute and playful (and she liked my hummingbird stethoscope!). I also took care of another 2 year old girl for almost the whole 3 weeks I was there and she never really opened up at all. She was in the hospital for her second autologous peripheral blood stem cell transplant where they give intense chemo and totally wipe out your bone marrow and then give you some stem cells back. That can't be any fun. I think she's understandably warry of doctors. You just want to take away her pain. Then there's the 17 year old who had just been diagnosed with Diffuse Large B-Cell Lymphoma but still seemed like your typical teenage boy (just a little skinny and bald) who'd stay up all night playing video games. For some reason, the kids with recent diagnoses get to me the most because you can so easily imagine them going about their normal lives and then suddenly getting steamrolled with this news. But you adjust. Getting to follow kids over the course of their treatment and beyond and be there to support them through an incredibly rough part of their life seems to be a really rewarding path.

Though you also have to torture them. Cancer's not exactly a picinic but often times the chemo makes them feel much much worse. Mucositis, nausea, crazy infections, spinal taps...honestly. While the cure rates for cancers such as Acute Lymphoblastic Leukemia are now quite impressive and inspiring, there has to be a better way. As much as I thought I was sick of lab work, I like that a big part of a career in hematology/oncology is research oriented. A big part of the patient management also involves pain control. Both the sickle cell kids with vaso occlusive pain crises and many of the oncology patients are candidates for patient controlled analgesia...in other words, lots of morphine or dilaudid at the push of a button. No reason for people to suffer unneccessarily. Probably the most intense thing I witnessed on the rotation occured with a little five year old girl with an unresectable recurrent Wilm's Tumor who was in pain over night. She had just had surgery and her parents had just received the dismal prognosis and the resident on call did everything he could think of to help with her pain, but it wasn't enough. The next morning the mother was livid and came in to rounds screaming at the resident with more hatred in her voice then I think I have ever witnessed in person. Why didn't he call someone to ask for help? How could he make her daughter suffer? Who did he think he was? Unfortunately this was all directed at one of the nicest residents in the world, but he probably should have sought help. And not all of the anger was due to the mismanagement of the pain, there was also the despair of a mother coming to terms with her daughter's impending death.

Sometimes there's only so much you can do. One five year old boy was diagnosed with an untreatable tumor on his brain stem a year ago. It couldn't even be biopsied. Then when it grew to the point where it could be safely biopsied, they discovered it was treatable...but by then it had also compressed his spinal cord to the point where he was paralyzed. Now he's super cushingoid from tons of steroids and he got a decubitus ulcer from being immobile. Then he developed a clot around his PICC line when broke off and caused a pulmonary embolism. Then when he was given heparin he developed an active brain bleed...so he was taken off heparin and now he's just kind of hanging out, waiting for something to happen . We're not really doing anything for him, but we can't really send him home in this condition. How do you deal with that?

Most of the kids are only in for a few days at a time, for scheduled chemo or acute fever and neutropenia. Some kids with Acute Myelogenous Leukemia pretty much just hang out at the hospital while waiting for their white counts to recover (though we discovered just how important it is for them to be nearby when one girl who had been happily running around the halls suddenly developed acute appendicitis). Then there are the kids who get sent home for hospice care...as a parent and a doctor where do you draw the line in pumping kids full of chemo when there's really no hope left? No easy answers...but that keeps it interesting. Unlike endless well-child checks, hem/onc presents seemingly continuous problems that are challenging and thought provoking.

On our second day we were faced with the classic ethical dilemma of a Jehovah's Witness whose 3 year old daughter with sickle cell was admitted for splenic sequestration and required a packed red blood cell transfusion. The parents absolutely did not want it, though there was some discussion that maybe they really did, they just couldn't allow it and go against the church. As we were watching her hemoglobin drop the attending decided that she absolutely had to get the transfusion and we'd just have to circumvent the parent's wishes with a court order or the girl was going to die. It was all very dramatic, but when the parents witnessed the improvement following the transfusion I think they decided not to sue the hospital. I understand respecting religious beliefs...but how could you actually watch your child die? Is thinking your child is possessed by witches and performing elaborate and dangerous exorcisims that much more crazy then denying them a life saving treatment because of a few random passages in the bible?

I'm a little sad the rotation is over...I wish we had another week since this was one of the rotations I wanted to do most. But I've also been stressed out precisely because this is something I'm interested in and want to pursue and therefore I really want to do well in it. And I feel like I did ok, I can present patients, suggest changes in pain control and IV management, maybe even which antibiotics to use, but I was just never the amazing wonderful student I wanted to be. I like working with the parents and the kids and I think I did that well. Our residents were all great (we went out to a Peruvian restaurant together) and the fellow and attendings were nice, but it's nerve racking when their evaluations are such a big part of your grade. And then I feel guilty because I'm surrounded by people with real problems and I'm worrying about grades. Why can't our school just be pass/fail?

Halloweeeeeen

Cardiac Arrest! Very scary.

Preventative Medicine

I just got told off by a guitar repairman who was not so pleased that I didn't use a guitar stand and hadn't brought in my mom's guitar to the store in a case. It's true...if the guitar had been on a stand Catastrophe wouldn't have been able to knock it over, breaking the head. Sure he can fix it, but the repair will be expensive, it won't be good as new and the whole incident could have been prevented if we had taken better care of the guitar from the beginning. He sure made me feel like an idiot...it's just a guitar!!!!! I know a mechanic would probably have similarly harsh words about the condition of my car.

Oh preventative medicine...it makes such intuitive sense. Why not prevent a problem instead of finding elaborate, expensive, painful ways to fix it. Sure habits are hard to change, but why not have a healthy diet and exercise a little instead of getting type II diabetes. And once you have diabetes why not take your medication and avoid eating tons of donuts instead of requiring expensive hospital admissions for foot ulcers, kidney damage, amputations, etc. that eventually lead to an early death. Seriously. Health care just needs a change of focus as described in the article "Making Health Care About Health". We'd be a lot healthier as a nation. While I fully believe in preventative medicine, maybe I don't believe enough in people. One of the reasons I'm drawn to pediatrics is that kids are kids, they shouldn't yet know better and they are totally dependent on others so they need all the understanding help they can get. I do not want to deal with adults who won't follow medical advice, won't stop smoking or eating triple cheeseburgers even when it's obviously killing them (of course I've gained 5 pounds in the past month due to being sick, never exercising and eating all my mom home cooked meals). Issues such as access to healthy foods and safe places to exercise are understandble and most definitely need to be addressed, nothing is ever as simple as it sounds. That's why public health initiatives are incredibly important. It would be the general unwillingness of a patient to take on an active role in their health that I know would drive me crazy pretty quickly.

I've discovered that while I think patients need to be told about the importance of preventative medicine, I don't necessarily want to be the person doing it. All of the well child exams I've seen in general pediatrics have been fun due to the kids, but at the end of the day most don't serve much of a purpose beyond reassurance and occasionally some education. If we didn't do well child exams, 95% of the kids we see would be just fine regardless. Still it's that remaining 5% that it's important to catch...just like in prenatal care. However, as I'm encouraging kids to eat more fruits and vegetables, exercise more and wear their bicycle helmet I wonder if I really need 7 plus years of education to dispense this common sense. Of course, maybe it means more coming from a doctor, and if it actually inspires people to follow the advice that's great. Long term I think I'd rather deal with the kids with more serious problems, but we'll see how this all plays out.

Vaccines are an important part of preventative medicine too. Just look at polio. The number of vaccines given to kids has skyrocketed even since I was little and it's done a lot of good. And inspired some unfounded fear. Pediatricians (or their nurses) are at the frontlines of most vaccination campaigns. The flu clinics have been crazy with everyone scrambling for the H1N1 or seasonal flu vaccine (though some parents are afraid, there is still way more demand than supply). I'm fortunate the varicella vaccination came a long right when it did so hopefully I'll never get chicken pox. And it looks like an HIV vaccine is slowly becoming more than just a dream. Still vaccines can't fix everything...as the director of trauma surgery said, "Unfortunately there's no vaccine for bullets".

Where the Wild Things Are

Two weeks into my pediatrics rotation and I've embraced my inner child. Saturday I went to see "Where the Wild Things Are" in all its dappled golden sunlight glory. It's a beautifully filmed movie, but I honestly think I preferred the trailer to the full length film...it captures all the sweeping emotion and magical creatures and the nonexistent plot isn't really an issue. I spent Sunday at the Children's Museum of Indianapolis visiting the King Tut exhibit on its last day...most recent theory is that he died of an infection after breaking his femur right above the knee...who knew? Also played with the dinosaurs, trains, water clock, glass fireworks, dollhouses, mirror maze, etc. So much fun!

Outpatient peds has been fun too. I'm down in Bloomington working with all the doctors at Southern Indiana Pediatrics including my own pediatrician! Of course, due to H1N1, my very first week here was apparently the craziest week they've seen in 10 years. Great. Plus I was sick even before I started so it was a little rough getting through the days without coughing on the kids (generally bad form). It feels like half the kids in town have fever, chills, cough and runny nose and I've seen most of them. At least I finally got my H1N1 vaccine (and I got to administer the nasal mist to myself). It's been a good experience working with a different doctor every day because you get to see different styles and figure out what works best for you. Love the bird sounds and handouts (and Dr. McDaniel referring to everyone as "little buddy" which is my nickname for Catastrophe), not so wild about the doctor who put all kids in a death grip in order to see their ears. I also get to see the newborns at Bloomington Hospital...right back where I was born! There have been some interesting patients along with all the flu and otitis media...a toddler recovering from neuroblastoma, a kid hospitalized with cystic fibrosis, and a sixth grader with albinism, a concussion, and sorta freaky congenital nystagmus.

With general pediatrics so much is about the interaction with the kids and their families. Our clerkship director told us today that in order to be a primary care pediatrician you need to get joy out of reassuring the family that their child will be just fine and it's just the flu, or contact dermatitis, or an ear infection. At the same time you need to be prepared in the rare case it is something more serious. I've enjoyed every one of the 200+ kids I've seen in the past two weeks, even the fussy ones. It's just more fun working with kids and it's nice to see reasonably healthy kids after all of the pediatric surgery patients I encountered at Riley. Next up I have my inpatient pediatrics rotation with Hematology/Oncology at Riley so it will be back to the seriously ill kiddos. I can definitely envision a pediatrics residency in my future...

Suddenly I See...or not

Good grief...I'm already a third of the way done with third year! Normally I would be ecstatic, but for the first time in my life I'm feeling that just knowing enough to get through the days and get through the tests is not sufficient. Not all that long from now my knowledge (or lack thereof) could really make a difference in someone's life. Sure there should always be some doctor around I can ask for help throughout residency, but a good part of the responsibility lies with me...and I just don't know how I can learn all I need to know in the time I have left. Perhaps I'm prematurely freaking out (that's what I do), but it has inspired me to focus on the most practical skills that can make a huge difference in a crunch...you can always stop and look up a biochemical pathway, but if someone has a tension pneumothorax they need it fixed NOW.

It's a relief to be done with my surgical rotation (assuming I passed that damn test) and move on from ophthalmology. I learned quite a bit in that month...but I wasn't really inspired to pursue it further. Incredible things are being done in ophthalmology (Burst of Technology Helps Blind To See) but the only other surgery I saw on my rotation was a medial wall orbital fracture repair where the patient went in with fine vision and extraocular motion and post-op he couldn't move his eye properly. That's not cool. Sometimes doctors must inflict a little pain to solve a problem, but it's generally not great when we take an almost non-issue and make the problem much worse.

I'm super excited about my peds rotation! I'm down in Bloomington for the rest of the month and I'll even be working with my pediatrician part of the time (hope that's not too weird). Here's hoping I avoid this whole H1N1 mess.

"Lasers"

"I have one simple request. And that is to have sharks with frickin' laser beams attached to their heads!" -Dr. Evil

You'd think that shining lasers in peoples' eyes isn't the best medical therapy. Surprisingly ophthalmologists use it for all sorts of treatments from diabetic retinopathy to retinal edema. And you wear the laser as head gear, how cool (or scary) is that! If you just kill off some of the retinal cells you can reduce oxygen demand and cut down on the amount of out of control arteriole growth in the back of the eye. Still, I'd rather avoid a laser in the eye if at all possible, that you very much.

Despite all my complaining, I have seen a bunch of eye pathology and other cool diseases that frequently have eye related problems...sarcoidosis, Wegner's granulomatosis, HLA-B27 ankylosing spondylitis, retinopathy of prematurity, lots of glaucoma, and a guy whose blood sugar was 1663. Talk about off the charts. Plus, unless I decide to become an ophtalmologist (not looking so good right now) this may be my one and only chance to learn about eye problems. It's true ophthalmologists get to do cool things...like transplanting a tooth into an eye to restore sight, I just never get to see them! However, I did observe two cataract surgeries last week which were pretty interesting and relatively non-invasive. With ultrasound and a 2.4 mm incision in the eye you can mix up the lens, extract it from the eyeball and put in a replacement. Way more high-tech than the surgery I saw in Guatemala where you had to make an almost 180 degree incision and then suture the eye back together. Ouch. Still it was a pretty impressive surgery to see in the middle of nowhere. I imagine cataract sugeries must feel pretty rewarding...with a half hour surgery and minimal complications you can reliably restore vision and really improve people's quality of life. You can't say that about many medical interventions.

Sadly, I'm trying to deal my own ophthalmology problem right now (and I don't mean preparing for that test). My wonderfully kitty, Katsumoto (above right), has been scratched in the eye my my devilish little kitty, Catastrophe, and has been all watery discharge and winky, blinky eye pain for the past two days. Hopefully it will improve on its own because my limited eye knowledge definitely does not extend to cats. Though Katsumoto loves to chase the laser pointer around, I don't think shining it in her eye is going to help in this situation.

Furthur

Is LSD Good for You? Oh the possibilities! I was just finishing up Tom Wolfe's trippy "The Electric Kool-Aid Acid Test" when I ran into this article on the renewed interest in the therapeutic potential of LSD. Fun stuff. Sure Lysergic Acid Diethylamide started out in the 1940s as a drug under investigation for specific psychiatric uses, but it quickly took on a psychedelic life of its own...good for you in the mind expanding, horizon broadening sense. Oh to be on the bus! If medical marijuana is controversial, I don't really see this going over well. But if it treats really bad cluster headaches better than anything else, how can you deny someone? On an ophthalmology related note... marijuana can lower intraocular pressure and therefore be used to help treat glaucoma. Plus, cocaine has long been used (though I don't think anymore) as a topical anesthetic for eye surgeries. Who says recreational drugs aren't useful?!?

Last night I saw a dance performance that absolutely blew my mind (and I wasn't on any drugs). It was amazing....like laugh out loud, speechless, crazy amazing. The work was called "Caught", by the Parsons Dance Company, and it featured a male dancer who essentially seemed to levitate due to extraordinary skill and the use of strobe lights. Strobe lights! Just like they used with the Grateful Dead at Ken Kesey's Acid Tests with his Merry Pranksters. Awesome! There was some other really great dancing, but nothing else quite as innovative (of course the dance was first choreographed in 1982, so I'm a little late to the party). Sadly the youtube video just doesn't do it justice at all. I mean, that's what it looks like, but you've gotta see it live. It reminded me of this equally jaw dropping exhibit I saw at the Guggenheim, "I Want to Believe" by Cai Guo-Qiang. The main work "Inopportune: Stage One" depicted a car bomb explosion created by nine cars somersaulting up the atrium with lights radiating out in every direction. Insane. Images suspended in time...just as if they were viewed under a strobe light...or maybe on an acid trip. Turn on, tune in, heal?

Abre los Ojos

It's been an interesting week in Ophthalmology...not exactly exciting, but, well...eye opening. I just finished seeing a guy with a corneal ulcer, that's gotten worse. Because he doesn't have the money to buy the antibiotics he needs. Because he can't work until his vision improves. Catch-22. Excellent. I'm working in an eye clinic that's essentially free to the patients, but we still can't cover all medication costs. Health care reform is in the air and can't get here soon enough...what form it takes, we'll just have to see. If nothing else, isn't there an economic imperative to keep healthy young people in working condition so they can contribute to society?

I digress...so far my ophthalmology experience has been pretty chill. All clinic, no surgery...so much for my surgical subspecialty rotation. I can't really complain because the hours are great and it was my top choice. Ophthalmology is the first thing I've done all of third year that I'm actually considering as a career. Which is why it's kind of a bummer that so far it's been a non-event. Essentially the other med student and I are work horses that do the patient work-up and vision exam, a job several rungs below the techs. I don't even do any actual eye exams which is the one thing I really wanted to learn since I thought it'd be useful in future practice no matter what.

The residents are nice and when you have the time to follow them you can learn something, but since most of them don't have teaching scopes, even that is limited. The indirect ophthalmoscopes are pretty awesome, I had the best view of the retina I've ever seen in my life. Unfortunately, unless I actually become an ophthalmologist (we'll see how the rest of this rotation goes) that's one gadget I'll probably never use. This weekend I desperately need to review some of my Español because at least a third of our patients speak nothing but Spanish. One woman didn't even know the alphabet...we had to use pictures. I can muddle through an exam ok, but I need to use the interpreter phone to be sure I'm not missing out on any critical history stuff. I've got a lot of studying to do in general between the ophthalmology test and our general surgery test. Gah. But enough complaining, I think I just have to be proactive about this experience...shadow residents as much as possible and do my own covert eye exams.

Every passing minute is a another chance to turn it all around.

Be Still My Heart

What's the difference between a cardiothoracic surgeon and God?
God doesn't think he's a cardiothoracic surgeon.

Love it.

The coolest part of anesthesia (besides intubating people...4 for 4, yay!) has been seeing all the different surgeries. Today I saw the beginnings of a lobe resection for lung cancer (a live view of a disgusting, black, cancerous lung would probably help people quit smoking) which involved preferentially ventilating the healthy lung and collapsing the one to be resected. Very cool. And yesterday I got to see a mitral valve replacement involving cardiopulmonary bypass. Modern medicine is pretty amazing. First we got to do a tracheoesophageal echo and get a really clear view of the heart in action, dysfunctional valves and all. Then I got to watch the surgeon cut open the guy's chest. It kind of freaked me out to see all the monitors flatline when the patient was switched over to the bypass machine, but obviously everything was very controlled. All I could think was...VAMPIRES!!! All that bright red blood going through the machine, being oxygenated and pumped back in...even Angel might not be able to control himself. Fortunately the patient made it through with flying colors.

I also saw a supraclavicular regional block for an arterio-venous fistula surgery (type I diabetes sucks). It was cool to see the brachial plexus on ultrasound but even though everything seemed to go smoothly, obviously the block wasn't effective enough because once the surgeon cut into the patient's arm he started moaning. Yikes! I mean not screaming bloodly murder like someone was cutting into his arm, but he was definitely feeling sharp pain. Awkwardly, the resident I was with didn't seem to want to admit that the block wasn't everything it should be. Every time the patient let out a moan he would lean in and ask "is the pain tolerable?". Okay, it's nice that he's inquiring...but pain is a relative thing and tolerable can mean many things to many people. I can certainly imagine that an old military veteran might not want to complain about being in a lot of pain. Man up. But there's no reason he should have to suffer when he's surrounded by pain killers. The surgeons kept injecting him with local anesthetics, but eventually the attending anesthesiologist came in and knocked him out. Not ideal, but it was probably best for the patient at that point.

Sadly I'm now done with my anesthesia rotation/amazing vacation. Next up: Ophtalmology!

Time to Sleep

I've now been fingerprinted by the Federal government so I should probably rethink all my big bank robbery plans. Working at the VA hospital for my anesthesia rotation has definitely been a change of scenery. Out with the young pregnant ladies and in with the rough old veterans. But it's been good so far. And the hours have been heavenly.

One of my friends really wants to be an anesthesiologist. I can see the appeal but I don't really think it's for me. A lot of hurry up and wait...a lot of repeating the same exact thing over and over. I know anesthesiologists have to be ready for anything if something goes wrong, and it can all go horribly wrong, but mainly there's a lot of monitoring ("you've wired me for sound" as one patient put it), mixing and pushing drugs, and airway protecting. I did get to watch a carotid endarterectomy from a distance and today I saw a guy with a very large umbilical hernia. The anesthesiologist is important...but in many ways they play second fiddle to the surgeon.

It seems only fair that since I mentioned Michael Jackson's death in my very first post, I should follow up on the fact that it's now been ruled a homicide. What drugs were in his system? Propofol, diazepam, lorazepam, midazolam, lidocaine and ephedrine. I saw every single one of those administered today to prepare someone for surgery. In a controlled environment...when we were going to breath for them. It's like his doctor broke into the OR and sifted through the anesthesiologist's drawers of drugs. Scary. Once you're knocked out you do want a trained professional watching over you. Or else...

A Miscarriage of Justice

Every year around 300,000 women worldwide die from cervical cancer. In the U.S. it's closer to 3,000 and that number should soon decrease due to the new Gardasil vaccine. What makes the difference? Pap smears...one the most effective screening tests for cancer. If you catch it early, which is totally possible with annual pap smears, then a straight forward colposcopy and possibly a LEEP can basically take care of the problem. However, once cervical cancer spreads things become much more complex. In much of the developing world annual pap smears simply aren't possible (food and water may be a higher priority) and so many cases are caught when they are much more advanced and the options are limited. Although Gardasil is great and could soon almost eradicate HPV in the U.S. (as long as we start vaccinating boys too) it will never have that much of an impact on our cervical cancer numbers because they are already low due to all the pap smears (maybe too many pap smears...apparently with the liquid prep that is more accurate and now most frequently used you only need to be screened every other year meaning that at the clinic where I was working and most everywhere else women are actually being over tested, not that there's any downside...just a little more cramping...but it could be seen as an unnecessary waste of resources). Where Gardasil could have a major impact is if it was available to women around the world at a reasonable price. Now that would really be something.

I've just finished up my OB/GYN rotation, survived (hopefully) the NBME test and the OSCE and sat through another meeting on ethics, one of our competencies for this rotation. The core ethical principles are all important...Beneficence, Nonmaleficience (hopefully most doctors aren't setting out to do harm) and Autonomy (I think this is a much bigger deal in the U.S. then elsewhere). Those are all well and good and you constantly deal with them on a case to case basis, but the one I think really deserves more attention is Justice. Treating individuals according to what is fair, due, or owed to them. And this is where the whole conversation explodes. I would argue that everyone in this country is entitled...yes, ENTITLED...to a certain basic level of health care. It sure seems self evident to me...but obviously there's a very vocal group who disagree. On a related note, rest in peace Ted Kennedy, I wish you could have stuck around to finish the fight. But health care reform is a topic for another day, what I really want to talk about is Women's Rights.

So yesterday I had my annual gynecologic exam which seemed a fitting way to end the rotation. Doctors in general might be better informed if they had to go through all the things they do to their patients (not that they should undergo needless operations, but being a patient gives you a whole new perspective). For convenience I went to the clinic where many of the patients we had seen at Methodist get their care...it's open to people without health insurance and serves a different population than the private clinic where I worked the past two weeks. You can definitely tell the difference. I mean, it was totally adequate, I got my pap smear and my birth control prescription which was all I needed anyway, but that was really it. No comprehensive physical exam or extended chat about how life's going. Which is fine, I didn't want that anyway. But it would have been nice to get a proper blood pressure reading (if only my BP was 100/61, but I guarantee it isn't, not by a long shot). And no pelvic exam? No breast exam? I don't mind that it was a midwife and not a doctor, but I started to mind the wait. Still I was receiving care and that's a vast improvement over much of the world.

On my half hour drive to the clinic I've been listening to "A Thousand Splendid Suns" by Khaled Hosseini and it really got to me...in a driving down the highway with tears streaming down my face kind of way. Not that I thought things were rosy in Afghanistan (we'll see what happens with the recent undecided election), but seriously. Women have no where to turn for help if they are stuck in an abusive relationship. Hell, they can't even walk outside alone. Unfathomable. In one of the most wrenching scenes the main character has to have a C-Section without anesthesia because there's none in the women's hospital where she's forced to go. That's just crazy. CRAZY. I saw 11 C-Sections in my month on OB/GYN and trust me, when someone yanks your uterus out of your body and sews it back together you don't want to feel it.

The New York Times recently ran and article, "The Women's Crusade", which touched on many of these issues and some of the ways change might be possible. Maternal morbidity and mortality around the world, especially in Africa, is out of control. No one should have a one in ten chance of dying during child birth in their life time. That has serious ramifications for the economic prosperity of a country...and it's just ridiculous. Of course, many of these countries have horrible things going on beyond the disgusting treatment of women...but implementing programs for proper health care for women and children seems like a sensible place to start. Last summer when I was working with Mayan Medical Aid in Santa Cruz La Laguna, a Mayan village in Guatemala, we were all about prenatal care and women's health. It gives you the best chance to start out little children on the right foot and hopefully bring about transformation of a community. Give mothers protein and proper baby brain myelination will follow. Provide education for children with well myelinated neurons and you can change the world!

Beta Alpha Beta Iota Epsilon Sigma

OB/GYN really is kind of like a sorority. First of all there's only one male resident left in the entire residency program and only one male attending at Methodist. Secondly, we spend portions of the day sitting around in the resident room watch Good Morning America and Oprah, reading People and US Weekly, knitting, shopping for handbags online, and talking about relationships. That's all well and good...it just feels weird when it's a big part of your work day! Still, I'm enjoying all the girl power! And I think that for the most part it's a really good thing that women are taking over the field...there are just some things it's better to talk to about with someone who can directly relate.

It's the same with the doctor I've been shadowing for the past week and a half. A large part of the day is spent counseling people on diminished libido or heavy menstrual periods. Dr. Lee is focused and descriptive but also reassuring and understanding. I just don't think male doctors can make the same connection with their patients. Not to say that some women wouldn't prefer a male doctor in this situation...but for the most part the girls club seems to work well. It kind of makes me feel bad for all the guys in my class who have to go through this rotation.

Working at this new hospital has definitely been a different experience. The building itself is only 5 years old so everything is sparkly and super nice. It's also outside of the resident education system so it's just me and Dr. Lee which is both a good and bad thing. I've learned a lot just from shadowing her and watching how she interacts with patients, but most of what I've done has been observation since these are her private patients and I don't think she's quite sure what to do with me. We see patients in clinic all day most days...though starting at 7 or 8...not 4:30! At least a third of the patients are routine OB visits leading up to delivery so lots of listening to heart tones (something I actually get to do!) and measuring bellies. There's also the annual exams (yay pap smears!) and random visits for STDs, colposcopy, etc. We do surgery on Tuesdays and Fridays...though I'm not convinced surgical options are really the best for treating chronic pelvic pain. I really like the continuity of care, but I don't think I want to be talking about periods all day, every day for the rest of my life!

My Birth Day!

That's a quarter of a century! Makes a girl think...

Wish I had delivered a baby today, how awesome would that be?!?

26

So I just survived my last OB/GYN call and it was a doosie. Not quite Jack Bauer, end of the world stuff, but 5 C-Sections, 4 of them emergent, and lots of running around. No missing nuclear warheads, government conspiracies or biological warfare, but lots of fetal heart decelerations, arrested labor (not as entertaining as Arrested Development), and pre-eclampsia. But it was fun in a weird, med school kind of way.

A break down of my long day:

6:30 am: Rounding on postpartum patients, are they breast or bottle feeding? do they want contraception? how's their incision? nausea/vomiting? vaginal bleeding? ambulating? eating? flatus? fun stuff

7:45 am: Breakfast! My amazing resident buys me some fresh fruit from the cafeteria (not from the horrendously expensive Au Bon Pain which has taken over the hospital)

8:00 am: Changeover with the people from the night before. Gotta love running the list.

8:30 am: Cervical check on a HIV+ lady. She hasn't told her family her HIV status. Fortunately she has a low viral load. I'll cross my fingers for the baby.

8:45 am: Update records for some of the patients.

9:00 am: C-Section #1...this one was planned...it was the lady's 5th section! Crazy. Wisely, this time around she's also getting a bilateral tubal ligation...I get to cut the fallopian tube. Yay!

11:00 am: Watch the swearing in of Sonya Sotomayor...all goes smoothly, no jumbled lines. Try to study Case Files.

12:00 pm: Lunch! I eat the lunch I packed the day before and never ate since I went out to Clarian West to see the uterine septum removal. That day I ended up eating a chocolate pop-tart for lunch. Not the best.

12:15 pm: Check the Amniotic Fluid Index on a lady at term who may or may not have ruptured. It still looks good...she goes home...no baby today.

12:30 pm: Recheck the lady with HIV. Slowly progressing. I secretly hope she'll deliver vaginally and not tear. There's so much blood and blades and scissors flying around during a C-Section it'd make me a little paranoid to participate in that surgery. I trust universal precautions...but still...

1:30 pm: The lady in Room 5 isn't progressing...we're going to do a C-Section but then the nurse suggests we give her an epidural and see if things change. So we wait.

2:00 pm: Back in the break room watching Runaway Bride. I prefer Pretty Woman.

2:15 pm: Write a bunch of B9 discharge papers. Hopefully some women can go home soon.

3:00 pm: Watch Sex and the City! It's the one where Miranda moves and is afraid she'll die and the cat will eat her face, Carrie gets back together with Big and they go bowling, Charlotte dates the widowed guy, and Samantha becomes a social outcast only to be saved by Leonardo DiCaprio ex machina. Why do I so clearly remember all the episodes? Why can't medical knowledge stick so well? At this point I do the smartest thing I did all day and eat some of the pesto pasta I brought for dinner. Even though it's early I'm hungry and you never know what's going to happen...

3:30 pm: Go to check on the lady in Room 5 and discover that the baby in Room 9 is crashing and needs a C-Section first. I get to retract, sponge, sew up fat and staple. It's a boy! Hurray! Get reports that the baby in Room 3 is crashing. Great.

5:00 pm: Room 3 gets a C-Section...the little boy is all tangled in his umbilical cord but does fine.

6:00 pm: Now it's Room 5's turn for a C-Section. Haven't I done this before? She's quite large and has about 6 inches of fat over her uterus. Challenging surgery. Get reports that a 430 pound lady just came into triage and the baby does not look good.

7:30 pm: Call Monkey via Skype on my phone! So glad he'll be back in a week and I'll be done with this craziness.

7:40pm: The staff physician is ordering Jimmy Johns and gets a #5 Vito for me. Awesome. Write Op Note from the last surgery.

8:00 pm: The super size lady is brought back to the OR but the spinal anesthesia is taking a while because, well, her spine sure as hell can't be palpated or visualized and she can't bend forward at all. Also can't monitor the baby properly through all the extra tissue. Yet another reason not to get fat. But seriously...this lady is almost 4 times as big as I am!

8:30 pm: Spinal still not in...go eat Jimmy Johns. Everything looks better after eating.

9:00 pm: Back to OR. Help position patient which requires about 8 people, table extenders, tape, and lots of rolling and pushing. Definitely the largest person I've seen in an operation...of course I've been working on little babies in the past rotation which are challenging in their own way. Scary moment when we take out the baby and there's lots of meconium in the amniotic fluid and she's totally blue and not moving. Hand her over to peds and she eventually gets apgars of 3/8/8. So glad the baby survived!

10:30 pm: Out of surgery. The lady with HIV delivered while I was in one of the C-Sections. Yay!

11:00 pm: Amazingly the resident sends me to bed. Fabulous!

5:00 am: Wake up for morning rounds. See our three antepartum patients. Pre-eclampsia, IUGR, and an MVA with a pelvic fracture...very not cool during pregnancy.

6:30 am: Meet my friend who's just starting her rotation here and has to be on call and see all the postpartum patients we delivered yesterday. Plus her resident isn't there. Help her see patients, it's nice to check in on all the ladies we delivered yesterday not that I'm not delirious.

8:00 am: Change over

8:30 am: Stumble out into the sun and humidity. Good bye Methodist!