Possibilities

I found my wedding dress! And it's gorgeous...now I just need to figure out the rest of the wedding. The whole decision making process in dress shopping feels similar to figuring out residency rankings. There are tons of beautiful dresses out there so it becomes all about finding the one that fits your style and your dreams best. I can see myself at almost any of the 12 pediatrics residencies where I interviewed...they're all great programs and theoretically I would have a similar experience at any of them. So where should I go? How do quality of global health and Hem/Onc programs factor in? Are you a lace or satin bride? How much does size matter? One thing I did figure out somewhere in all the interview madness is that I do want a Children's Hospital or something very closely approximating that environment.

Outside opinions are not terribly helpful in either decision. The most commonly offered piece of advice in both is to "go with your gut". No matter how valid that is as an answer, it's very difficult to use actively, and it's a little bit terrifying because what if you never get that feeling? Much to my surprise, I did get a little choked up when I finally said yes to the dress, but it wasn't like I had transcendent moment the second I put it on. Similarly, I agree that my general gestalt of a program at the end of the interview day is a more valuable tool than any excel sheet I might make trying to rank different aspects of the program. It's important to feel like you could actually fit into a place and play well with the people around you. Unfortunately, the few people you meet throughout your interview day can really color your feelings about the program and it's impossible to know if they are truly a representative sample. I was really not a fan of my Columbia College tour guide way back in the day, but my other knowledge of the school made me confident that it could be the place for me.

I chose my interview thank you notes based on an Emily Dickinson quote on the cover of the Memento Box, "Dwell in possibility". That's exactly the feeling I'm trying to cultivate right now. 2011 is overflowing with major events...going to Kenya, graduating for med school, getting married, starting residency, hopefully going to the Greek Islands for my honeymoon (damn you Bar Exam)...and it's all incredibly exhilarating. But at some point the myriad possibilities must give way to choices, which will hopefully open doors to even more possibilities. Of course, when it comes to the Match, what I want only goes so far at the end of the day. The programs have to like you too and who knows what else could influence the final outcome. The Match is still kind of a black box to me and there's that element of randomness (or computer algorithm or something) that makes you surrender a lot of control. Stay tuned...all will be answered on St. Patrick's Day...

Just Breathe

Bronchoscopies are cool because you can visualize the insides of people's airways and go "Oh crap, no wonder you can't breathe, your bronchi are completely filled with mucus." Very interesting for the doctor, not so great for the patient. What did I learn during my peds pulmonary rotation? Please, everyone, be tested to see if you carry the Cystic Fibrosis gene. Although treatments are improving they are still only supportive, not curative. It only takes one encounter with a 17 year old girl slowly dying after her third lung transplant to convince you that this is not a disease you want to mess with. 1 in 29 caucasians carry the recessive trait which is pretty high in the scheme of things. And if both parents are carriers...do you really want to have a 1 in 4 chance that your child's life expectancy is around 30? If you're informed you can explore all options...if you don't know until you find out you have a salty baby, I hope you like regularly spending 2 weeks in the hospital for IV antibiotics.

I also saw a lot of kids with asthma which is not at all surprising since I'm in the prime neighborhood for it. It's gotta be incredibly scary not to be able to breathe, but at least doctors should be able to control asthma...it's not Ondine's Curse. I've gotta remember to breathe over the next couple weeks too. So far I've had two pediatric residency interviews (CHOP and Columbia) and loved both places. Next up, 10 interviews, 3 weeks, 7 states (and 2 coasts)...craziness. Hope for the best! So thankful for my wonderful family and friends...and we can all be thankful for oxygen.

Food Matters

About a year ago I swore off Ramen Noodles because as tempting as they seem I started feeling sick after eating them and they weren't doing my blood pressure any favors. Sure they had gotten me through many a long train ride in China, but my long term health matters. So how did I get here, sitting in a rundown dorm room in Washington Heights about to eat some Hot & Spicy Bowl Noodles (one bowl=76% daily sodium requirement)? Let's just say the one kitchen in the building is ten floors up and my brand new Hot Pot is wonderful but still somewhat limited in what it can cook. I really can't complain though, I've had some wonderful meals during my past week in New York including a delicious brunch with an amazing view and wonderful Pizzoccheri, which for all my love of pasta I'd somehow never eaten before. But sadly my bank account can't handle many more fabulous meals and my current living situation does not exactly make cooking easy (I'd like to go all zenhabits and simplify my eating...but I don't even have a refrigerator) so it's Ramen or bust.

Since my own diet is going down the drain it got me thinking about the struggle to get the general population to eat healthfully. Back in the neighborhood were I was once involved with the Project Health Girls Fitness and Nutrition Program, I'm reminded of how far there is to go. Sure, we may have the first lady on our side, but when certain people treat eating junk food as an inalienable right, you know you're in trouble. Coincidentally, the Rally to Restore Sanity and/or Fear is going on today and I wish I was there!

I actually applaud Major Bloomberg for the steps he's taken to make New York a healthier (and much more smoke free) place. Honestly, I don't think it's unreasonable to prevent people from buying soda with food stamps. If you absolutely must have soda, buy it yourself! Then there are programs with good intentions that get all messed up in the execution. Let kids eat what they grow! One of the reasons I want to be a pediatrician is to get started early helping kids to make healthy life choices. Of course, all physicians must talk to patients about obesity and apparently the way they do it counts for a lot. If only we learned more about nutrition in med school!

I'm nervous about starting my away rotation at Columbia on Monday...despite the stress of Step II and my crazy research project I've enjoyed the past two months of setting my own schedule...but Pediatric Pulmonology here I come. Wish me luck!

Three Cups of Tea

So what have I been up to all September? Trying to finish up my research project, study for Step 2, and get all my peds residency application stuff together. Exciting. It's the longest "break" I've had since before third year started, but really it hasn't been vacation at all...I've been working pretty much all day every day...just not in the hospital. Still there's been more time for reflection, more time to watch my cats fight with each other and talk to Monkey, and more time to sit on my new balcony and drink tea. I've never been a coffee person (even with my time in Costa Rica), the caffeine and all the sugar I put in to make it palatable just make me to jittery, but I love all the wonderful possibilities of tea.

Earlier this week I started off my day with Twinings new Chai Spiced Apple. Some might say it's trying to hard, but it's perfect for a brisk autumn morning (when did summer end? seriously). Now that I've completed that wonderful hurdle known as the Step 2CS test in all its standardized patient glory (though I did have a fabulous trip to Chicago so it wasn't all bad), I'm in full on Step 2 CK study mode. Which means many many hours doing QBank questions. With less than 2 weeks to go I should probably be more nervous, but I actually like studying sometimes and wish I had done more of it over the past year.

Later that day I met up with Dr. S at Starbucks to talk about my pediatric thrombosis study which is still making me tear my hair out but is also finally coming together. I actually had a Pumpkin Spice Latte instead of tea (also recommend the carmel apple cider). For the life of me I've never been able to study in coffee shops. I agree with this guy that they are a place where ideas go to have sex, but they are not a place for silent studying. They are, however, a wonderful place to meet up and compare demographics on DVT patients and controls. With any luck our data analysis will actually yield something interesting.

That evening I was thrilled to hear Greg Mortenson give a talk while sipping a lovely cup of organic rose tea. You really don't get much more inspiring than that. The underlying idea is so simple, educated girls in Afghanistan and Pakistan, build communities, stop this ridiculous cycle of violence. Of course, as demonstrated in his books implementing that idea is anything but simple. And sadly, it's still something only a man could do. There is no way in hell those cultures would be receptive to a woman going in there and attempting to do what he's done, but at least maybe what he's doing could change all that. I would love to integrate better education into any future global health pursuits of mine (and here's another TED talk about one way it could be done). Shouldn't education and health be human rights? Maybe not at a survival level, but the world is sure as hell not going to become a better place without them. And Greg was so open and kind and funny. He really comes across as this normal guy who saw an opportunity where he could be of use and ran with it to the ends of the world. Just what I needed to remind me of what I really care about and keep me motivated when I'm stuck inside studying all day.

The God Delusion

Last time I was on call at the VA, we were called at 5:30am for a rapid response on a patient with lymphoma that had compressed his spinal cord and made him a paraplegic in a matter of weeks. Just that morning his family had made him a DNR. When we saw him he was relatively unresponsive but would respond to touch and shake his head when we asked if he was in pain. The nurse told me that his wife was coming back soon with other family members and that after 58 years she had finally convinced her husband to be baptized that morning. We stabilized his blood pressure and went to rounds. Later that morning I found out the patient had died, but first he had woken up just long enough to be baptized.

I'm glad for the patient's wife and family that they can get comfort from the thought that he was saved in his last moments of life. I wonder how the patient himself felt and if he got any comfort thinking he was going to God. At least he was surrounded by his family. Not that there's any harm in a little water splashed on your head if you don't believe it's anything but water...though some people could certain take offense, and with good reason. It reminded me of a recent interview I saw with Christopher Hitchens where he says that any future remarks that make it sound as though he had found religion would not truly be from him, but would rather represent the ravings of a dying man. Stick with your principles to the end. I'm hoping to finish reading "The God Delusion" as soon as I have a little free time (you know, when I've finished my sub-I, pediatric residency applications, research project, and "The Girl Who Played With Fire").

I've never been quite as militantly atheistic as Christopher Hitchens, I belong more to the school of everyone's free to believe whatever they want. Having said that (which I can't say without thinking of Curb Your Enthusiasm), I find it impossible to relate to anyone with strong religious beliefs. I certainly respect faith and think that good things can come out of it, but at some underlying level our world views are just completely irreconcilable. I'm not going to go out and name the second chapter of a book "Religion Kills", but at least from my observations in the hospital, may be in can. We had one patient who had been in the hospital for about a week with meningitis and thrombocytopenia. His platelet level was 4000 (anything under 150,000 is too low). With platelets that low if you hit your head on a cabinet or trip and fall you have going to bleed into you brain and die, no question. He was in the middle of his treatment but just got fed up with being in the hospital and decided to leave against medical advice. Our attending did everything he could to talk him in to staying, but the patient had decided that he was in God's hands and through the power of prayer he would be healed and if not then it was meant to be. He left. We've tried to follow-up with him since, but he lives alone and no one picked up the phone at his house. Hopefully he's still alive. He was deemed competent so he's allowed to make all his own medical decisions, even if they are delusional. Of course, in psychiatry delusions are defined as fixed beliefs that are certainly and definitely false, but not beliefs that are ordinarily accepted by other members of the person's culture or subculture. Any way of thinking that needs a qualification like that should give one pause.

Enough, Really

I hate to say that I became jaded with the ER over the course of the month, but I really did. Maybe it was the lady who came in with allergic conjunctivitis. Her eyes had been kind of itchy for three days, no vision changes, no pain. She was using visine and it seemed to help. Not quite an emergency and nothing we can really do. Next. Or maybe it was the guy I saw at 2 am a few days ago who said his car had been side swiped and his right hand crushed because he had been sticking it out the window. He had wrist drop, radial nerve injury findings, and a little swelling, but the hand didn't look that hurt. The mystery deepened when X-rays didn't show any fractures or dislocations or anything. It took an orthopedics consult going back and grilling him twice for him to admit that he just fell asleep in his car with his arm out the window and when he woke up he couldn't use his wrist. Classic case of Saturday Night Palsy. I felt a little bad I didn't pick up on it earlier, but when a patient is blatantly lying to you, what are you going to do? I think the last straw was the woman who came in with bruising on her hand and said she had dropped a cabinet on it. I was super sympathetic, she had a definite injury, but then my attending was like, "oh, I know that lady". Apparently she was a frequent customer and judging from her INSPECT report she got several prescriptions for narcotics from different ERs around the area every month for back strain, neck strain, bruising, etc. etc. Sigh. I just want to go back to peds where I can deal with pushy parents and not worry about patients seeking drugs at least until they are teenagers.

Of course, there were some interesting patients too. The schizophrenic patient who said a demon named "Terry" had taken his finger and twisted it around three times. Sure enough, he had a spiral fracture of his third digit. He was off his meds so I think the world will never know whether he did it to himself, someone else assaulted him, or it really was "Terry". I also had a really sweet, old, confused lady with metastatic lung cancer and a giant plural effusion making it hard for her to breathe. I got to do a thoracentesis and drain all the fluid off her lung which was fun for me and a big help to her. Score. Then there was the other sad patient who had a 75 pound unintentional weight loss over the past 7 months. Totally emaciated, easy bruising, feeling horrible, and he just didn't want to go to the doctor. I had to leave before I got to see his lab results, but I think he most likely has cancer till proven otherwise. Really nice guy, and really sad. That's another thing I like about peds...I feel like even the most negligent parents would bring their kid in to a doctor well before they lost a third of their body weight. Please, if you have sudden weight loss for no apparent reason, go see your doctor!

I think this video says it best. Goodbye ER. Good short term experience. Not for me.

ER

I keep having dreams that I'm in the ER rushing to take care of another patient. This has happened to me on other rotations but never to this extent...it's like something out of Inception...in the dream I can't tell it's not reality and I definitely have a physical response to the stress. Regardless, I've enjoyed my month of ER more than I thought I would. Sure it hasn't been as relaxing as I'd hoped...working 15 9 hour shifts in one month doesn't sound too strenuous, but you never stop moving the whole 9 hours and with the constantly changing schedule my body doesn't ever really know what time it is. 6 more shifts to go...

There are good days and bad days...I really like the pretty clear cut diagnoses where if you pick the right study you can verify and then treat a disease. 3 year old with fever of unknown origin...she has a UTI. Guy writhing in pain? Definitely a kidney stone. Guy with a week of fatigue...hmm, kind of a vague complaint, but whoa...turns out his glucose was 1200, hello new onset diabetes. Lady coughing her guts out with a clear pneumonia on chest X-ray. That can be treated, no problem. I also like sewing up lacerations...nice, definitive fix.

The diagnostic mysteries are a little more frustrating because in the ER you only really have one chance. Sure I got to do an LP on a guy who may have been having a subarachnoid hemorrhage, but turns out he wasn't. When patients are having bad abdominal pain it's not terribly satisfying to give them some pain meds, anti-nausea medication, and a liter of fluids, run a few tests then tell them you have no idea why they're in pain and come back if it gets worse. I wish I could pull a Dr. House and come up with some really crazy diagnosis, but the ER is not really the setting for that.

Then there are the patients who have no business being in the ER in the first place . Chronic pain patients, an old lady who had been sitting at home worrying about her blood pressure, a teenage guy who had come to the ER (and called an ambulance!) literally every other day for the past 2 weeks for complaints from impotence to coughing up blood. What are you doing here? The county hospital where I'm doing my rotation has on average a 2-3 hour wait...even at midnight. I think the wait actually goes a long way in cutting down on some of the more pointless visits...at the other hospital where I work in the ER as an extern there's usually no wait at all and then we really see a lot of patients with completely non-emergent complaints.

The ER definitely plays an important role in the healthcare system. Even in our fractured non-system it's good to know that there's a place where anyone can get health care. We've had illegal immigrants getting dialysis and, I'm sure, tons of patients who will never pay their bills. Apparently even with healthcare reform the ER crunch is not going away any time soon. Fair enough. Most patients we refer to physicians for non-urgent follow-up won't be able to get an appointment for 3+ months. Sometimes that's just not good enough...and finding a good solution is rough.

I haven't gotten to work in the Shock/OBS unit yet where they get the critical cases, gun shot wounds, MVAs, heart attacks, etc. After watching 8+ seasons of ER I feel like I'm ready. I can always use a little drama...just no more mass shootings of teenagers downtown please.

New Year

All the new 3rd year med students started today and it helped me realize just how far I've come. Though I've had my doubts, I did learn a lot over the past year, mainly about functioning as part of the hospital team and caring for patients. If I had to take Step 1 right now it would be bad news (and I have Step 2 fast approaching...). Anyways, it felt good being able to help oriented the 3rd year students and it definitely helped that I've been on the pediatric cardiology rotation since the beginning of June. It's been good...lots of babies with congenital heart disease including way more hypoplastic left heart disease then seems statistically possible (though I think they just need such complex surgeries--imagine basically completely reconfiguring a heart the size of a small strawberry in the Norwood procedure--that they need to spend more time in the hospital than most kids). I also took care of a girl with rheumatic heart disease which apparently is good preparation for my trip to Kenya. I'm maybe getting better at reading EKGs and listening to heart sounds, though I have a long way to go. I really like my team and I feel I can actually be useful which is always nice.

I had a few crazy days last week with little sleep. I've started working as an extern in the St. Francis ER so Thursday I did my full day of peds cardiology starting at 7am (including a presentation to high school students about med school)...then right after work I drove to St. Francis and worked over night in the ER (fortunately they let me go to sleep at 2 am and just sleep the rest of my time there-nice to make $15 an hour not doing anything). Then I had to come back and work all day Friday since technically I wasn't post call, it just felt that way. The next morning I got up at volunteered at this PBS Kids in the Park event where we helped preschoolers do check-ups on stuffed animals. Good times. Thinking about intern year and keeping that schedule all the time is a little scary. I took pediatrics call yesterday though I couldn't stay over night. This year my goal is really to focus on preparing myself to feel semi-competent as an intern. Scary. We'll see how it goes...

Med Students Anonymous

2.5 days left till my psych rotation (and 3rd year!) is over! It can't come soon enough...I think I'm about to become a basket case...most likely I'm experiencing Generalized Anxiety Disorder or Psychosis NOS. Just kidding...I think. It's definitely time for a vacation. A road trip to Yellowstone is exactly what I need right now.

Still, I've enjoyed psych (though I won't miss having to use a key to get through every single door...the joys of a locked ward). It has unquestionably produced some of the best stories of the year and I've seen people come in completely unhinged and pull it together over night with the help of some meds (or maybe they're just sobering up). I also got to see Electroconvulsive Therapy which was nothing like One Flew Over the Cuckoo's Nest since the patients were anesthetized and none were as energetic as Jack Nicholson to begin with. There have been a few patients who are severely over medicated but that's way more reversible than a lobotomy.

Substance abuse has been a major issue with a lot of the patients and from the way they talk it seems like you can find heroin on every street corner. Procuring drugs is definitely outside my skill set but I don't think it would be professional for me to ask them for details. As part of the rotation we had to attend both an AA Meeting (yes they really did say the serenity prayer and recite the 12 steps...plus I got to say "Hi, my name is Lianna and I'm a medical student"). People's willingness to discuss their problems openly was incredibly impressive and I can definitely understand how hearing stories from people who are going through the same thing can be really beneficial. Having some goody two shoes doctor tell you to quit smoking crack probably doesn't cut it. Unfortunately only 30% of people maintain sobriety through AA, but it's still better than 5% of people who try to quit drinking by themselves. Bad news. I think med students could benefit from frequent meetings to share our horror stories and stresses. I can't believe the school year is almost over. In less than a year I'll be a doctor!

It's All In Your Head Part 2

Stomping out mental illness has been quite the trip. The past week on the psych ward has been a lot more work than I imagined, but at least it's engaging and I actually feel like I'm part of the team. The patients keep things interesting...the guy who collects dead squirrels (and carries their rotting corpses around with him) because he thinks they're talking to him), the guy who thinks he's Satan, the lady who stabbed herself with a kitchen knife when her boyfriend said he was leaving her (she was actually the normal one of the bunch). I actually enjoy talking to them, trying to figure out how they ended up in this position, trying to get them back on track.

Of course that raises the question of what is crazy anyway. I mean, in some of the patients you instantly know they're out of whack, but in the majority they actually seem pretty normal until you ask them if they've heard any voices recently. I got to go to court to watch a commitment hearing and our patient really came across as totally sane on the stand, it was only testimony from her mom about her hoarding tendencies that got her committed. Then there's the idealistic kid who recently dropped out of college, smokes pot, and thinks that there's a government conspiracy supporting the corn industry resulting in high fructose corn syrup in all of our food products. Not wanting to participate in a dysfunctional society is not necessarily crazy. Plus, most of his views are pretty much identical to those of some of my friends. Go figure.

I've always been leery of psych meds...but they definitely get results. If you've got mild depression a little psychotherapy might go a long way, but for bipolar mania or schizophrenia it's hard to argue that just talking about it will make everything better. Still just talking about things can be incredibly beneficial and perhaps it doesn't happen enough. What about Mind Over Meds?

It's All In Your Head

Somehow my neuro rotation is already over. In theory neurology is really cool...but in practice it's one of the last things I would want to do. I love neuroscience. I love the brain. While I'm not wild about dissecting mouse neurons (and killing mama rats), figuring out how the mind works is the next frontier. So cool. I would love to stick people in fMRI machines all day and see what happens (aside from them getting really claustrophobic) just like in Why We Love.

So what don't I love about neuro? For the interesting diseases such as ALS, Muscular Dystrophy, Alzheimer's and Parkinson's there's only so much (or nothing at all) we can do to treat patients right now. While the doctors can provide support and guidance, really they're just there to watch you slowly die. You can give people who have strokes TPA if they get to the hospital in time, but if they don't you just verify that they had a stroke and send them off to rehab. And don't get me started with all of the chronic pain/headache patients. I have total respect for doctors who manage that sort of amorphous complaint, because the pain certainly can be real, but not necessarily physiologic. Sure there are some great seizure medications out there, but then you have to differentiate the real from the "ma'am, that was not a seizure, that was a dance move". Oh how I love pseudoseizures, excuse me, "non-epileptic seizures". Every day of the past two weeks I kind of felt like I would have one myself if I didn't get out soon.

In other words, I hope to continue learning as much as I can about the brain for my own enlightenment. What's not to love about Oliver Sacks and "The Man Who Mistook His Wife for a Hat"? Plus Eric Kandel's amazing autobiography "In Search of Memory", apparently now also a documentary, was one of the most inspiring books about research I've ever read. And then we have the story of our very own Jill Bolte Taylor...check out her priceless "Brain Bank Song" she sang on Oprah's Soul Series (Part 4 Minute 25:15). I could sure use some inner peace right now, but I'd like to pass on the hemorrhage.

Salvage

Generally speaking it's never a good sign if the word salvage is associated with your medical treatment. Whether salvaging a limb, salvaging heart muscle, or using salvage chemotherapy, things can only be kind of desperate and the outlook can only go from bad to worse. In hematology, salvage chemo is usually not well established, there aren't many controlled trials and even fewer good outcomes. Not saying it never works...just that working is usually defined in terms of extra months or weeks of life, rarely anything close to a cure. And sometimes just stopping and making the most of what's left is the best move. Our patient with fungal sepsis decided to marry her boyfriend and spend the last weeks of her life at home. I find it hard to fathom that turning point, where you're ready to give up on life, but at the same time rationally I think it's a completely reasonable decision when all remotely useful treatments have been exhausted. Grey's Anatomy actually had a really moving scene in the most recent episode, Suicide is Painless. A patient with terminal lung cancer describes how hope can be extremely damaging when you are ready to die. She's living in pain and there's no chance of a good treatment or cure...she wants physician assisted suicide and is happy with that choice. However, the thought of what if (what if there was a new cure, what if something had been missed and she's not really terminal) keeps her from being completely at peace with her decision, even when there really, truly is no hope. Insightful. There was also some annoying talk about Whoville...which as much as I love the Grinch Who Stole Christmas seems like a desperate attempt to start a catch phrase. I mean, SERIOUSLY. I miss the glory days of Grey's.

Speaking of salvaging. I spent the past week trying to salvage what remained of my medicine rotation. I definitely suffered for serious burnout right around the time I would normally be having spring break instead of working 13 days in a row. Now it's on to neurology which has it's own depressing set of problems and even less effective treatments. But at least it's spring!

Healing Hands

Hematology has been a different world from life at the VA. The new cancer center is amazingly nice...big, well decorated rooms, floor to ceiling windows, fake hard wood floors, a meditation room, a courtyard with a giant sculpture, bamboo, a staff sanctuary...it really does create a good atmosphere. Never underestimate the importance of beautiful pictures when you feel like hell. The rotation itself has been a little awkward, even the resident doesn't really operate with anything like autonomy, which I guess is how it has to be in a super subspecialized acute care setting. In one week I've seen lots of AML and multiple myeloma...along with ALL, CLL, ITP and some lymphoma. It's been interesting to see how adult oncology differs from pediatric oncology...different diseases (I'm actually glad I'm doing hematology not oncology since most pediatric cancers are leukemias), slightly different chemo regimens, and those poor adults have to be awake during bone marrow biopsies (I don't think I truly appreciated how painful they are). The tranquil setting definitely helps.

Today was an interesting day. I was grilled by my attending, Dr. F, over pulmonary and cardiovascular physical exam findings. Scary but actually super helpful...when I can get over feeling like an idiot, I definitely learn the most when doctors ask questions and really teach. I could use more of it. Then I got to observe Dr. F in his bone marrow transplant clinic and see him grilled by a similarly type-A patient who wanted to know his prognosis...not just statistics but a specific number of years...an impossible question. Dr. F's response "Only God really knows, and he hasn't told me". I could do without the God part, but I think it captures the degree to which outcomes can be very patient specific and hard to pin down despite all the risk stratification. Control what you can control because so much is out of your hands. One of our patients, a woman in her 20s with refractory AML, has been growing fungus in her blood and now it's spread to her skin despite anti-fungal therapy. She has no white count and she can't fight the infection until she has a white count which probably won't happen for several weeks, if she even lasts that long. No one has told her yet.

Speaking of God, today the director of palliative care and a hospital chaplain performed a blessing of the hands ceremony for all the doctors and nurses caring for cancer patients. It was very symbolic and beautiful...they personally washed each of our hands and anointed them with oil (?!?). I love the idea of the ceremony, "blessed be these hands that have touched life, and felt pain, and embraced with compassion" but it was also way too non-secular/O Holy God, for me. I'll happily swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, but I'm not about to join STO.

Good Medicine

Every morning this past month on the way to the VA I walked past the remains of an old hospital being torn down. Quite impressive actually, watching a building get ripped apart (though who knows how many toxins I inhaled), but also kind of depressing. And that's how I felt with my month at the VA...one chronic health problem after another slowly destroying these patients until something like cancer or an MI comes along and really knocks them down. There's not really a good endpoint...sure you can try to fix the acute situation, but death is always there somewhere. Plus I felt like every single patient had diabetes, hypertension, chronic kidney disease, hyperlipidemia and BPH. Good grief! They could be my dad!

Don't get me wrong, I actually really enjoyed the month...I liked talking to the veterans, I liked having a little more autonomy (or at least the illusion that I could make some of my own treatment decisions), and the hours were quite nice. I'd gladly do my sub-internship there next year (hopefully this calendar year) since I know how to work the system now. But so many patients just waiting for placement in nursing homes? So many patients coming in for altered mental status due to alcohol or drugs? So many patients in for COPD exacerbations with 150 pack year histories of smoking? Give me peds any day. Though I have to say I'm now a little torn on whether I'd want to do a Med-Peds residency instead of just a straight up peds residency. When I think of the quintessential doctor, it really is an internist. There is a huge array of medical problems you'd just never see in a peds setting (though apparently diabetes, obesity etc. are becoming bigger peds issues...yay), and I feel like for my own knowledge I want to know how to properly manage those diseases. Especially if I end up doing anything global health related...I've got to be ready for anything.

Today was my first day on the Hematology service at University...back into the world of chemotherapy, ANCs, and lots of things that are totally over my head. So much to do this month...hopefully I'll keep it all together.

Pediatric Cancer Genome Project

How cool is this? St. Jude Children's Hospital and the University of Washington School of Medicine in St. Louis have teamed up for the Pediatric Cancer Genome Project, an attempt to map out the genomes of 600 pediatric cancer patients. The more I learn about chemotherapy protocols and all the toxicities that come with them, the more I can't wait for a future where specific tumor mutations or cancer genes can be targeted to treat the disease without causing infertility, cardiomyopathy, immunosupression, extreme nausea, hair loss, etc. Yay!

It'd be great if the cute little 16 month old boy I did a bone marrow aspiration on last week had a better than 25% chance of survival with his Stage 4 Hepatoblastoma. It'd be great if our 19 year old girl just recovering from sepsis and trying to survive her third relapse of ALL could go have fun in college with her boyfriend. It'd be great if our 6 year old boy with Hodgkin's Lymphoma didn't need radiation and could still have kids when he grows up. The future can't get here soon enough!

Haiti

As things continue to fall apart in Haiti post-earthquake, the stark inequalities in health care (and building practices) are painfully obvious. I think I'm particularly sensitive to this right now since I'm in the world of Peds Hem/Onc and the NICU where it is not at all abnormal to spend upwards of a million dollars trying to save one child. I'm not implying that shouldn't be done, how on earth can you deny available treatment to a kid when it might save their life? But just think what that money could do in Haiti...save 10,000 kids or 100,000 kids by giving them vaccines, anti-virals, food. In third world environments, actual health care is only part of the problem...sure you can give people antibiotics, but if they don't have clean water to take them with, you're doomed. The resident on hem/onc is from Pakistan and he was telling us about the one Peds Hem/Onc clinic at their main teaching hospital. They have most of the necessary drugs and can follow the recommended treating protocols, but when the kids are immunosuppressed at all they must keep them in the hospital or the infection rate is just astronomical due to general unsanitary conditions. Health care inequalities are really just one manifestation of overall inequality.

Today was rough...one of the patients I saw on my first day who had a lytic lesion in her leg which we hoped was just a brodie's abscess got her pathology back today and it turns out the lesion is a high grade osteoblastic osteosarcoma. Not good. Then we were consulted on a 5 month old in the NICU with end stage liver failure. She has major coagulopathies since her liver is pretty much nonfunctional and because she's not a candidate for a liver transplant there's really nothing that can be done. Maybe someday soon we'll be able to create new livers in a lab, no problem, but that might just widen the health care gap. At least in the U.S. most kids won't be denied treatment from inability to pay...but sadly for this little girl science just isn't there yet. Then we have our patient who might be a vampire...

I wish I had the training to go and help in Haiti. At least Partners in Health is still relatively intact since it was based in rural areas. I've been rereading Paul Farmer's "Aids and Accusation"...health disasters in Haiti are hardly new, how much can one country take?

What Now?

How do you decide what you want to do for the rest of your life? I know you can change your mind about residency programs (even after you start them, if you must) and certainly any fellowship decisions are still a few years away, but I'm really starting to feel the pressure to make up my mind. This month I'm on my pediatric hematology/oncology ambulatory elective, and it definitely is something I can see myself doing in the future. Not that the elective is everything I hoped it would be...there are three students instead of just one (though they're both friends so it's fun) and there's not all that much for us to do most days. A lot of patients are in the process of being treated so it's hard for students to just jump in and, of course, the chemo protocols are ridiculously complex.

Nevertheless, while I may feel out of place as a student, when I think about what the doctors do all day, their ongoing interactions with patients, their procedures, their research, etc., it certainly seems like something I'd like to be doing long term once I actually know what I'm doing. Fortunately I can still keep my options open...but every day I'm a little more confident in the decision to do a pediatrics residency.

I've certainly seen a range of patients in the last week...from the four month old with the atypical teratoid rhabdoid tumor with an abysmal prognosis (brain tumor + brain surgery + no proven chemo or radiation treatment + young age = bad news) to the 19 year old 3 years out from completion of treatment for Hodgkin's Lymphoma who's doing great. The doctors and nurses are a great support system for patients and families facing a scary treatment and rocky road for the next few years...they offer hope and reassurance. I want to do that. Now if only I could figure out my next few years...