Neuroradiology Rotation

Neuroradiology is just radiology of the brain and spine. Now that we're all on the same page ... what's up with this field?

I have been on this rotation for 5 days and have worked a total of 8 hours ... and by "worked" I mean sat in a chair and listened to the radiologists talk to each other. I show up (although I guarantee they wouldn't notice if I was absent) and listen to the attending and resident read films. All I do is I sit behind them and try to stay awake. Every once in awhile I provide my two cents, but only on non-medical topics (e.g. the war in Iraq, the Daily Show, or combinations of the two). I feel like I'm in high school again, shadowing doctors and contributing nothing.

With that said, I love this rotation! In case you missed it, I've been on this rotation for 5 days and have only worked 8 hours! That's less than 2 hours a day. I don't know if my interactions with these radiologists are representative of their profession, but if so, I'm entering the wrong field. Why work 10 hours a day when you can work 2 (and make more money too)? Working 2 hours per day is something with which I have absolutely no problem. I am really curious what the radiologists do the rest of their day, though ... procedures? scans? Either brain and spine scans are easy to read or there aren't that many performed each day.

Either way, I don't know ... and for once, I don't care. I'm enjoying my free time.

Thanksgiving Travel

It being Thanksgiving and all, I have come home to Northern California for several days. Normally I drive, but since I will only be gone for 3 nights I decided instead to fly here. (Yes, I was just here last week for my sub-I.)

My flight was scheduled for 9pm, and I figured I should be at the airport at 8pm. But after hearing about a big-rig flipping over on the 405 freeway and clogging up traffic for miles, and also every news station reporting unusually long lines at airports, I chose to leave for the airport even earlier ... as in, I left for the airport at 6pm (and it normally takes about 30 minutes to reach the airport).

Not only did I not hit traffic, but I flew through the security line. It also helped that I wasn't checking in luggage and that I printed my boarding pass at home. So I ended up at my gate at 6:45pm. For a 9pm flight. Talk about unnecessary precautions.

To top things off, I was also an idiot. I sat in line at Gate 7 (since Southwest seats on a first-come-first-served basis) until 9pm, reading, staring, twiddling my thumbs, when I realized how strange it was that we hadn't boarded yet. I then heard an announcement overhead saying, "Passenger Axis, please come to the counter". Not sure if that was really my name I heard (even though I have a distinctive last name) I waited, and sure enough they announced it again. I went to the counter and the woman said that I should board the plane at Gate 7 now, as my flight was about to take off. I looked up and noticed that I was actually at Gate 6. I had been sitting for 2 hours in front of Gate 6!

I rushed onto the plane and noticed the plane was full of passengers ... with luggage packed away, seated, and listening to the flight attendant explain where the exit rows were. So apparently I single-handedly held up the entire flight for a few minutes. How many people can do that (non-violently, at least)?

Anyway, I'm home for Thanksgiving now. Will be flying back to Southern California in a few days. Enjoy your turkeys everybody!

Next Rotation

Tomorrow will be the start of my next rotation: neuroradiology. As far as I can tell, this simply means radiology of the head.

I (as well as many other students) schedule this rotation during the winter months in anticipation of being absent during interview season, since this rotation is supposed to be very easy and not at all time-consuming. Regular radiology is supposed to be an easy rotation, where you work only several hours per day ... and neuroradiology supposedly makes radiology look like hard work.

I am definitely looking forward to the free time, to say the least ...

Back to SoCal

Subject says it all.

The sub-I is over (it actually ended Saturday when I was post-call) and I am driving back to southern California tomorrow. The month went very quickly, and I cannot believe I am heading back already. Now let's see if this month of work has gained me anything ... in terms of earning me an interview at this program (I doubt it).

In any case, will be writing next from sunny southern California ... till then.

Call Room Funk

I'm on call right now. It's 1:30 in the morning, and I'm about to take a little nap in this call room. All I want is some sleep, but unfortunately this call room smells like ass. Seriously, no seriously. It smells like a homeless person lived here for a week and left. Either that or someone took a piss in here.

This ain't fair ...

Random Thoughts

• Residency interview offers are finally starting to trickle in. I have a few offers from some of the programs I have slightly less interest in, but they are interviews nonetheless. I'm still waiting around for some of the big guns to get back to me (with good news, I hope).


• I'm quickly getting tired of people who only talk about their kids. I completely understand the excitement of fatherhood and motherhood, and I fully expect to have kids in the future myself, but the behavior of these new parents is just irritating. As long as a topic relates remotely to their kids or children in general (e.g. Halloween) they jump at the opportunity to bring up pictures and stories of their children. So now, to prevent them from dominating conversations, I have started showing pictures of my dog to everyone.


• Being on call q4 (medical speak for "every 4 nights") is not as bad as I thought it would be. Granted it's no breeze either, since there are only 2 days where I am neither on- or post-call, but I'm holding up better than I expected. I have been lucky, however, to get about 2 hours of sleep per call night. It is also easier knowing that this schedule will end soon ... which scares me a little since I know fully well that the bulk of next year will involve such a call schedule.


• On a related note, my time here is almost up. Three weeks down, one to go. Funny how my first week here seemed to drag on, as I was learning the ins and outs of this new hospital and system, and now all of a sudden I have only one week to go before I return to Southern California.


• In other news: being up here is definitely clearing my head of the friend situation from back home. The flip side is that whenever I receive a phone call or text message from friend I get even more excited than normal, which I'll admit is probably not a healthy sign. Case in point: I woke up at 3am recently to the sound of my phone receiving a text message -- from her -- which made me so excited I couldn't fall asleep afterwards.


• P.S. Go see Borat!

The Drip

I got the drip.

I've actually had it for about a month now, and I am upset because it's been a LONG time since I've had it. It is really starting to irritate me now, too ... I wake up and the drip is there, during the day it's there, and it's actually the worst at nighttime. Its green color doesn't excite me much, either.

I don't know where I got it from, but it probably doesn't help that I work in the hospital. I was borderline sick before, but since starting this rotation it's become full-blown ... so I probably picked it up from someone here. If only I knew who ...

Anyway, I finally decided to stop with the over-the-counter stuff and go to the doctor today, who prescribed some sprays and such. I expect results by tomorrow morning!

(By the way, I'm referring to the post-nasal drip.)

Drowning in Estrogen

Attending: female.
Resident: female.
Intern: female.
Me: not so much.

This is a first for me, where my entire team is composed of girls (women?) I have been on many teams where the majority of the team was female, but never where I am the only guy.

I definitely have no problem with this, it is just new for me. The team is just as efficient and competent as any team I've ever been on, but it definitely has a different air to it than when guys are the majority. Everyone instinctively responds with "ohhh" (with sympathetic tone) when a patient says something touching. They all bust out with "he's so cuuuuuute!" after interacting with our little old man patient. And they all show pictures of their children to each other.

Luckily the fellow that rounds with us for our unit (ICU) patients is a guy, so there is a little burst of testosterone for a few minutes each morning. (The interesting thing is that I did not even notice this all-female aspect of my team until he brought it up one morning!)

Anyway, not complaining ... just reporting.

Grey's Anatomy

I have been watching a lot of the TV show Grey's Anatomy on DVD here since I don't have television (but luckily I do have internet).

But what is up with this show? These "general surgery" residents do everything ... they're not just general surgeons, but they deliver babies, they do prostatectomies, they do it all. The cardiothoracic surgeons remove abdominal tumors, the neurosurgeons do heart surgery ... what don't they do?

Well for one, they don't listen to DNR/DNI orders (such as the Asian girl intern who goes about coding a DNR patient like there was no tomorrow), as well as many other orders from their attendings. What kind of intern goes behind their attending's back and second guesses their clinical decisions? I cannot even imagine in real life what would happen to that lowly intern if they were to defy an attending in that way.

Also, at what program do most interns sleep with their attendings? Perhaps I should go there for training ... I do like Seattle, afterall.

And finally, come to think of it, this show is on its 3rd season ... and what kind of interns remain interns for 3 years?

Anyway, time for the next episode.

(I know these post-call posts are lame, but in my delirious state of mind they're pretty damn entertaining.)

50 Posts

I am post-call and thus a little tired right now, but I just realized that my weblog just broke 50 posts! Might not sound like much, but when I first started this little endeavor -- while I was hoping for many and frequent posts -- I was afraid it would fizzle out after a few posts. But surprisingly I have found enough time, motivation, and topics to write about.

So thank you to everyone who reads this blog, and the few of you who have even linked to it -- I really appreciate it and am flattered.

Time to sleep ...

Updates from the Subinternship

Hello from Northern California.

Well this rotation is keeping me a lot busier than I expected! Apparently it is a subinternship, which means I am being treated as if I'm an intern ... meaning that I have (near) complete control of my patients, I take overnight call with the team and admit about several new patients, and I am also the first one that's paged in the middle of the night when there is a problem with the patient. Some of these are responsibilities I'm used to, but others are completely new duties for me (such as putting myself down for first page on the admission orders).

Plus, they hit me hard and they hit me fast ... I was on call my second day, as I was still slightly shaken up over struggling to learn my way around the hospital, learn their electronic medical system, and just get a feel for the overall culture. (At least I got to sleep for about 1 1/2 hours.)

Anyway, I am pulling pretty long hours so I have very little time for leisure activities. So much for going to the gym and hanging out with family/friends for the remainder of this rotation. My schedule consists of going to work at 6am, coming home, eating, squeezing in some reading, and then going to sleep. Repeat x 28 days. On the bright side, the residents and faculty here are extremely sharp and knowledgeable, and I am learning a lot. I am also getting an appreciation for what next year (i.e. internship) will feel like.

This is a program I really would like to go to for residency, so I'm willing to endure all of this ... but I get a total of 4 days off (today being one of them), so I won't complain too much.

In the meantime, expect posts and comment replies only on my days off ... so until then, goodbye.

P.S. There are noontime talks here nearly everyday, and the first one I attended was one about the influence of the pharmaceutical industry on medical industry. A very interesting talk ... and very timely!

Away Rotation

I leave today for a month-long rotation in northern California. I will be at a fairly top-notch medical center, working with their housestaff and students, which is a slightly intimidating thought. Then again I will be working in the CCU (Cardiac Care Unit), and when it comes to cardiology I am rock solid ... so I don't worry much.

Northern California is home for me, so I look forward to spending the little free time I have with family and friends. It should be a good month, especially since I think I need to get away from this area to get me away from a certain distraction that has been clouding my thoughts (and sleep) for the past several weeks. Maybe the physical distance will help clear my head.

Anyway, stay tuned for posting from the Bay Area!

Pharmaceutical Sales Reps

I just came across an interesting article in the New York Times entitled Drug Makers Pay for Lunch as They Pitch, describing how pharmaceutical sales reps frequently bring lunch and other meals to doctors' offices in a not-so-subtle effort to pitch their drugs. They resort to providing meals because recent laws have restricted them from offering the fancy gifts that they used to give in the past, such as free vacations, golfing trips, or tickets to sports events.

Anyone that has spent at least a full day in a hospital or doctor's office knows just how true this article rings. You cannot go one day without having a drug rep -- usually an attractive (or wannabe attractive) woman -- prance in with several large containers of food and plenty of drug-related information. Their objective is straightforward: soften you up with goodies and simultaneously slip in information about their drug. They are the missionaries of the medical world ... but instead of "Here, take some Bible with your hot meal" it's more like "As long as you’re eating, let me tell you about this drug.” Their hope, obviously, is that their drug will be the only one you consider if and when you need it at some point in the future.

Careful observation of these reps will often reveal some pathetic behavior. Since drug reps often come in pairs, one will do the talking, schmoozing, and chat-chitting with the doctors; meanwhile their partner is at your disposal, slaving away by preparing fresh food in front of you: Belgian waffles, ice cream sundaes, fresh fruit smoothies, you name it. It is a little sad seeing a grown man or woman in a fancy suit serving milk shakes in Dixie cups. Silly as their behavior is, however, their goal of the bottom line is serious.

Even more amusing is when they refer to a published study that touts their drug's efficacy over a rival drug (conveniently, they are usually pulling out a hard copy of the article and handing it to you.) I don't think they are fooling many people, since most people know these studies were funded by the drug maker, and the results are necessarily skewed. The frightening part is that many people are probably not aware of this financial connection.

The only reason drug reps and their tactics continue to exist is that drug makers have done studies showing the powerful impact of surrounding doctors by simple items that bear the drug names (some people say the only true science that drug companies study is marketing.) They conclude that if even one in every X people (5, 10, 100, etc.) remembers their drug name, it’s a success.

Attending physicians or those with private practices aren't the only targets, but so are the doctors of tomorrow: residents. It is a genius strategy … bombard them with your drug while they are still impressionable and they will likely remember your product once they are practicing on their own. What hungry overworked resident wouldn't pick a fresh hot meal over a repulsive cafeteria meal, even if it means tolerating a short blurb about the latest anti-hypertensive

My personal opinion is that reps should be forbidden from giving any sort of free gifts to doctors ... or if that isn't possible, doctors should not be allowed to accept such items. It was refreshing to hear that Stanford University recently instituted such a rule for its medical centers, by forbidding any of their doctors from accepting even the simplest of free gifts from reps.

Some people claim that drug reps do some good by bringing free samples for doctors to give out to their patients, which is particularly helpful for poorer patients. But the very reason medications have such high prices in the first place is because they include the costs of marketing, including drug rep salaries. So it's kind of like a drug rep bringing a few free paper towels to clean up spilled milk … but only after they had intentionally knocked over the cup of milk themselves.

In the end, as tough as it might be, I hope more medical centers will follow in Stanford’s footsteps. (Until then, you can find me writing with my Zoloft pen on my Rocephin notepad while I drink from my Prevacid cup).

Randoms

Random thoughts ... some related to medicine, some not.

• I just ate spinach -- not raw spinach, but spinach that was on a frozen pizza. If a week goes by and I still haven't written, consider me dead. (Actually let's make it two weeks ... I'm feeling a little lazy these days.) I am also a few big steps closer to colon cancer. A friend recently brought over a huge 2-pound log of meat to my place to BBQ, and we ended finishing it all off. Not bad for two skinny people. Unfortunately, I'm still suffering from too much meat in my system.
  


• Costco sent me a free Gilette Fusion razor in the mail. In case you haven't seen its TV commercials, the Fusion is the monster razor with 5 blades (for the bulk of your shaving) as well as a single blade on the other side (for tricky areas) . I had a pretty good shave with it -- but nothing better than my previous Mach 3 -- but I have to say, the attachment that holds the 5 blades in place is pretty damn big. I feel like I'm running a vaccuum cleaner across my face.
  
  (Relatedly, I just got myself another one too. On our apartment complex's mailbox there was a free blade (again, from Costco) addressed to a former tenant, and the new tenant scribbed "Does Not Live Here, Return to Sender" on it. So I felt free to take it for myself, since these blades are so expensive.


• I had a scotch neat this weekend ... my first "neat" drink. Not so neat considering my throat was burning the entire 2 hours it took me to finish it. I guess this really is an adult drink. I'll try again in 10 years.


• I am suffering from a nasty cold right now. I don't know whether I picked up from "the community" or from the doc that I'm working with right now, one who coughs so violently and frequently, I swear I think I see alveoli shooting out of his mouth every few minutes. That plague is the last thing I need right now, especially since psychologically I don't handle getting sick well.
  


• In other news: I went to a dinner at someone's place last night, and the friend was there. We ended up hanging out together till well past midnight, which was really enjoyable. But then when I went to bed I couldn't sleep at all during the night, as I was thinking about her. My mind is a mess now ... this ain't healthy.
  

Advice for USMLE Step 2 CS

I just took the USMLE Step 2 CS today (see previous post). It was a long and tiring day going from station to station and putting on the same enthusiastic act ... 12 times over.

So, dear readers, for your benefit I have put together a list of how to prepare for the Step 2 CS. Read on ...

STANDARD ADVICE:

Get First Aid
If you've dealt with standardized patients before for school, the test is not very difficult. However, you should be familiar with the large variety of possible chief complaints the patients will present with and the possible diagnoses you could give them. I recommend getting First Aid for the USMLE Step 2 CS to prepare; it is a thin book and has many practice cases to review for the appropriate questions to ask, the physicals to perform, and sample patient notes. Just spend four or five days reading through this book and you'll likely do well.


WHAT THEY DON'T TELL YOU:

Take the 405
(This is specifically for the LA testing center.) To reach the center, I had to drive on the (in)famous 405 freeway. I never take this freeway, and so with everything people have told me about the horrendously slow traffic, to arrive there at 8am I decided to leave home at 7am. I don't know if these aforementioned people were hallucinating, but there was no traffic on this freeway. None! I got to the center at 7:20am, and spent the remainder of the time sitting in my car, in the dark, 2 stories underground, counting down the minutes. Do yourself a favor and don't arrive too early.

Bring your own food
(I'm kind of a picky eater, so this might be particular just to me.) The testing center does provide you with "lunch", but in reality what they provide are some gross looking pre-made sandwiches. I swear, they must have spent only $50 total on that meal ... for all 24 people. Do yourself another favor and bring your own lunch.

Beta-block with bananas
While I don't get full-blown test anxiety, on big test days my stomach usually does some pretty crazy internal gymnastics. I heard that eating bananas helps musicians with performance anxiety. I thought it might be an old-wives tale, but they followed up by saying bananas have beta-blockers. Hm, now that's something I could get behind. So I went and bought bananas last night, and ate a boatload of them throughout today. I don't know if it was the bananas or the placebo effect, but I actually didn't feel too bad. (Note: after searching the web, there seems to be confusion as to whether this effect is due to beta-blockade or high amounts of potassium.) Either way, I ate so much potassium, it was coming outta my assium ...

Bring parking money
The cheap USMLE bastards have no problem charging you $1000 for this test (not to mention the airfare and hotel costs some poor people have to pay to travel cross-country to reach the testing center). Then, they stick it to you again and make you pay $8.75 for parking. Come on, that's just low. I'd rather they simply make the test fee $1009 and let us have "free" parking. Keep the change.


INSIDER TIPS:

Don't eat Thai food the night before
I love Thai food. I eat lots of it. I've even been to Thailand and tolerated the food just fine. But, there's something about eating Thai food the night before important events that makes me regret it. I thought my system could easily handle the Thai noodles I ate last night, but I was mistaken. The moment I came within eyeshot of the testing center, I experienced some ... um, unusual ... "GI symptoms". I don't know what it is about Thai food, but somehow it's spicier on the way out than on the way in. This made for a stressful morning, as a few times I had to cut in front of people in line for the bathroom in order to make it.

Lock the bathroom door
Continuing with the bathroom theme, please lock the door to the bathroom when you use it. While we were all sitting quietly in the waiting room before the test began, a woman went into one of the bathrooms. Maybe it was because she was foreign, but for some reason she forgot to lock the bathroom door. A few minutes later another guy got up to use the bathroom. He walked to the same bathroom door, opened it, and then jumped back yelling "I'm sorry!" It was great! But the reason I bring this up is because I replayed this scene in my head during one of my patient encounters, making me laugh at an inappropriate time. So spare your fellow examinees potential embarassment and lock your bathroom door.

Go easy on the tongue depressor.
I suppose this one was my fault. I was doing a physical exam on a patient who was supposedly in lots of pain, making her very subdued and quiet. At one point I used a tongue depressor to push down her tongue. I guess I pushed down a little too hard, because she then gagged, started laughing, and worked quickly to correct her behavior. I really don't think I pushed down that hard, but whatever its cause, it was funny watching her break out of her role for a minute.

If all else fails ...
If for some reason you completely forget what to ask or do next, rest assured you can’t go wrong if you do one of the following: 1) wash your hands, 2) drape the patient, or 3) ask “Do you have any questions?” I feel the only thing the USMLE people care about is the patient and their safety, modesty, and input. So, if you’re hot on the trail of asking the patient about hematuria and you freeze up ... simply drape them (if they are already draped, take off the sheet and just re-drape them). If you’re auscultating the heart and forget the next heart sound location ... just walk over the sink and wash your hands. Don’t know how to respond to a patient who says, “Doc I’m scared, what do I have?” ... just say “I see. So do you have any questions?” What you lack in content will be more than made up by professionalism.

That's it. If even one of these suggestions helps you, I'll consider them a success.

Oh Yeah, Step 2 CS

If it's not one thing, it's another ...

Just when I thought I would have nothing to do the next few weeks, I realized I have the next part of my board exams coming up on Monday. It's the USMLE Step 2 CS, which is a day-long clinical exam where there are 12 encounters with standardized patients. You have to take a focused history, do the appropriate physical exams, tell the patient your impression, and then write a progress note on them. (You also have to drape the patients and wash your hands a lot.)

This exam is a recently added component to the Step 2, originally for foreign medical graduates only, but apparently various people complained and now all of us have to take it.

Apparently this is an easy exam for American students, and my medical school has been teaching and reinforcing these clinical skills non-stop over the past 3 years, so I really have nothing to worry about. However, I still don't like walking into any sort of test unprepared, so I am spending an hour or two per day with a review book familiarizing myself with the type of cases commonly encountered ... nothing intense like the Step 1, though.

Anyway, I never have as much free time as I think I do ...

Neurology Notes

Some neuro-related thoughts collected over the past four weeks:

• On the very first day of our neuro unit, I counted down exactly how many days of the 4-week clerkship I would have to work (taking into account weekends, lecture days, and a few school functions). The final count: 12. Only 12 working days out of 4 weeks! Most people in the "real world" would laugh at such a schedule. I, however, barely lasted those 12.
  


• We had a random lecture one day about neuroimmunology ... 2 topics I couldn't despise more. I don't even know what neuroimmunology. I really do not know what puts me to sleep quicker, talking about the cerebral cortex or T-cells. Actually, a topic that does put me to sleep even quicker is anything related to a uterus. There's the triple threat: a lecture on gynecologic neuroimmunology.


• My dog doesn't have reflexes. I tried tapping her knees with my reflex hammer to elicit a response, but I didn't see any movement. Who knows if I was doing it correctly, though, since she kept trying to sniff the hammer. Come to think of it ... I don't know if she even has knees.


• Speaking of reflexes, I need some better ones for myself. I just learned the hard way why one should load silverware into the dishwasher with the sharp sides pointed down. As I was emptying the dishwasher, I was stabbed by a fork ... and I now have 4 holes in my thumb. All in a straight line.


• Neurology rounds are possibly the most boring event ever ... and not just in a hospital, either. One day our attending, while we all stood around and observed, interrogated an obstinate patient for over 30 minutes about a seizure he had had ... it was unbelievably painful since there are only so many ways to ask "what happened during the seizure?". And he ended the whole encounter by pleading with the patient to tell a dirty joke (to evaluate a part of the brain involved with the sense of humor), which the patient refused to do. I wanted to kick both my attending and the patient.


• No more left-sided weakness, right-sided weakness, dysarthria, fasciculations, fibrillations, nerve conduction studies, EMGs, pain and temperature sensation, or two-point discrimination!
  

Neurology is Over!

I just took the neuro exam (aka, the shelf exam. or is it Shelf? SHELF?), which signifies the much-awaited end to my monthlong neurology clerkship. The shelf went as smoothly as all other shelfs (i.e. it didn't), but that is OK as long as I don't have to retake that exam.

I did learn a few things in this rotation:

1. There are rounds more boring than medicine rounds.
2. We still can't do much for stroke patients, despite advances in medicine and technology. Unfortunately if you get a (ischemic) stroke, much of what we can offer is supportive care and rehab.
   
3. There is a good chance I might have MS (multiple sclerosis). But I'd rather not think about that too much.

Anyway, with luck I can retire my tuning fork and reflex hammer for good now.

And actually, now that I think about it, this test was also the last exam I will ever have to take in medical school. Nice.

Neuro Exam

Much as I despite this rotation, I still have to take this Friday's test seriously ... and being forced to work until Thursday doesn't leave me much free time. So posting will resume then. Hopefully.

Nurse Power

I am always on the lookout for tips and tricks to make my intern year -- next year -- easier and less stressful. I am observing others around me, trying to learn how to deal with commonly-encountered problems (e.g. a patient's middle-of-the-night temperature spike) so that when I face these same problems as an intern, I'll be ready.

I am also learning how to treat (and not treat) nurses.

As the ones that maintain true continuity of patient care, nurses have the power to make doctors' lives very easy, but just as easily can make their lives miserable. I got a rare and behind-the-scenes glimpse into the mindset of a nurse who was exercising this power. I was chatting with one of the nurses on our floor -- a nurse who is very feisty but stubborn -- and she began telling me her views on all the interns. The conversation then turned to one specific intern who this nurse hated. I admit, from my limited interactions with this intern, that she was not entirely pleasant to work with, but I learned from the nurse that the intern was particularly rude to her recently.

In fact, the incident she described was one when the intern was on call and began barking out orders in a condescending manner at one point in the night. After that encounter, and for the rest of the entire night, the nurse made a point of paging the intern with every order that was written in order to "double check" them. Needless to say the intern didn't get much sleep, much to the nurse's amusement.

I haven't taken many overnight calls (only ~10) in my brief medical career, but I quickly learned to appreciate sleep the few moments I did get ... and after this conversation, I definitely don't want a vengeful nurse ruining those few minutes of shut-eye.

So, yes, lesson learned. I will not be rude to you nurses.

The Natural History of Blogs

It never fails. I had to stop reading yet another blog because it became lame.

I am not going to get into a deep discussion about blogs and their impact (since I swear, there have more articles written analyzing blogs than there were analyzing 9/11), but in my experience most blogs have the same natural history. It starts with me somehow discovering a blog I find interesting and then reading it conscientiously. This lasts a few weeks or months until some dramatic event occurs in the blogger's life ... something major with either their job, health, social situation, or whatever.

At that point the blog degenerates. The collection of well-written posts revolving around a single theme turns into a bunch of entries describing random events in the blogger's personal life. The focus of the blog is nearly always lost, because that dramatic event usually disrupted the original motivation for the blog. Then the blog starts to suck.

The most prominent example I can think of is Opinionistas, a blog written by a young New York attorney who was highly dissatisfied with her job in a big city law firm. Her blog did an entertaining job of describing the ridiculousness of life inside a large law firm. She eventually "outted" herself, and once her anonymity was lost so was her ability to write posts with any unified topic. Now -- or rather, last time I checked -- she just writes about whatever crosses her mind, and it is not that interesting.

Anyway, the reason I discuss any of this is because I just had to yank two blogs from my "Medical Blogs I Read" (since you know, making it onto my blogroll is so competitive.) I don't read that many blogs in the first place, medical or otherwise, so whenever one fizzles out, my online reading list takes a big hit.

This fate befalls all blogs I encounter, so I hope it doesn't happen to mine. But don't worry ... as long as I don't get kicked out of med school, Axis will be here for you.

West Coast - East Coast

Many months ago I sent in applications to two different medical schools to do a month-long visiting rotation at each (one for his month and next month). While both are prestigious schools, one is in California and one on the east coast ... and what a difference a coast makes.

The California school informed within a week that they scheduled me in to the block I wanted.

Snooty East Coast School didn't get back to me after one month, two months, or even four months. I sent countless emails and made many phone calls to their registrar's office, all of which yielded no response. I even had an old advisor of mine (who is faculty there) send personal emails to the clerkship director, which, again, was fruitless.

After another month I finally got in touch with their registrar ... who not only acted like she had no idea who I was (despite my 5+ voicemails), but who still didn't know if they could accomodate me. It turned out that she had been unable to get in touch with the clerkship director (or his secretary). She certainly didn't feel the same sense of urgency I did, as this month was quickly approaching and I still didn't know if I needed to buy a $500 cross-country plane ticket.

The week before my theoretical start date arrived I gave them one last call, only to get lip from the registrar herself, saying how she had no idea how to get in touch with the clerkship director and that he was probably on summer vacation for all she knew. I was shocked to hear her getting angry with me ... and then she had the f'ing nerve to shrug me off with a "you might have better luck in the spring"!

So I was stuck with an empty month-long block that I need to fill, simply because of a sketchy clerkship director who didn't realize that students' schedules are on the line.

Topping off this story, the California school just recently contacted me, asking if I had a preference as to what attending I would like to be on a team with. What love!

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In other news: I went out with some people last night, including the friend from the previous post. This situation is getting a little torturous for me, since nothing can happen because it would set up a triangle.

To sum up: California is great, and I'm a little conflicted.

Power Walking

It is always amazing what a little confidence can do. A few days ago I dropped by our university hospital -- aka, the fancy, uppity hospital -- to visit a friend who is doing research there. I had never stepped foot inside that hospital before, and so when I walked hoping to find the elevators to the third floor, I realized didn't know exactly where they were.

The front desk people immediately sensed my confusion and asked if they could be of assistance. I mistakenly asked them to direct me to the elevators, because I was immediately directed to several different security guards, each asking what room I was going (no idea), why I was going there (to visit an employee), and how long I would be there (again, no idea). I then was forced to sign in and slap on a tacky "VISITOR" sticker to my white coat ... yes, I was wearing my white coat and was still was put through this unnecessary hassle.

So today I went to visit her again, and this time I headed straight for the elevator as if I had walked it a thousand times. Surprise surprise, no one even bothered questioning me.

And I was wearing neither my white coat nor my ID badge ... there's the humor of it.

And My ERAS is Off!

After two months of working on my personal statement and entering my CV into the system, my residency application has been submitted. Today was the first day applicants are able submit their ERAS (Electronic Residency Application System) so that programs directors can view them.

I am happy -- and slightly surprised -- that I was able to make it on opening day since last night I was a mess. In anticipation of submitting today, I read and re-read my application literally dozens of times despite having reviewed and edited all my documents countless times throughout the past few months. As the night went on, I re-read my application with increasing frequency per hour ... in the afternoon I would look over everything about once an hour, and by the time I went to bed, I would fill up entire hour reading everything back to back ... once I finished reading it, I'd start all over and read it again. I couldn't put my application down, and yet I wasn't changing anything with each additional read. I was definitely driving myself crazy.

I woke up extra early this morning, ready to submit at last, but was prompted by numerous dialog boxes asking questions like "Are you sure you want to submit", followed by "You cannot change your application after you submit", to "Your application will be locked now", to "This is an irrevocable step" ... with each additional click, my anxiety levels rose further and my stomach twisted even more around itself. I'm surprised the final box didn't ask "Did you get your mother's permission to submit?"

I felt sick for about an hours after I submitted, but luckily that subsided. Only then was I happy and relieved. Thinking about it, a few days doesn't matter much, but at least now I do not have to worry about it during this long weekend)

Anyway, nothing to do now but wait for interviews ... I hope.

(How did I write so many words on such a simple event?)

First Day of Neurology

It's been four weeks, so it's time for another rotation: neurology. I can't say I am looking forward to this rotation since I do not find neurology -- or even neuroscience -- fascinating. Any time I hear words like "thalamus" or "amygdala" I seem to zone out of the conversation, so I have to watch myself for the next month.

Neurology might be particularly agonizing because one of my surgical subspecialty electives was neurosurgery, and so I had first-hand experience (and enjoyment) with the surgical side of solving neurologic problems. Unfortunately, the medical side of neuro problems is essentially limited to diagnosis, since not much can be done medically for neurologic problems.

I am also a little worried, since I tend to be susceptible to neurologic conditions when it comes to my hypochondria. After meeting our three myasthenia gravis patients today, I am already a little self-conscious about my possibly drooping eyelids.

This will be a long 4 weeks, now for more than one reason.

Residency Applications

The time has come to apply for residency. Which means I will soon be graduating medical school ... and soon be "a doctor". I have to say this moment crept up on me a little quicker than expected. It is now time to write another personal statement, harass more faculty for letters of recommendation, and make a laundry list of my accomplishments. I am starting to depise this process since I feel like I've been doing it non-stop year for the past several years.

Back to residency applications, since the process is a little different from college or medical school applications, I shall describe the steps here in brief:

Step 1: You first submit your filled-out application to a centralized service, who then sends it to all the residency programs you've selected. The earliest you can submit is September 1, and as usual, the earlier the better (I just realized Sept 1 is quickly approaching).

Step 2: Programs may then choose to interview you, and interview season usually runs November to February. Only if you get interviews, may you proceed to the next step. If not, please start over -- next year.

Step 3: This is when it gets a little hairy for most people (at least non-medical people). At this point in the process, applicants rank the programs they interviewed at; in other words, they state that their #1 choice is Program X, #2 is Program Y, etc. Similarly, the programs go through and rank all the applicants they interviewed.

Both of these lists are then submitted to that same centralized service again and are run through a computer, which takes the lists and matches every applicant with a program. Theoretically it creates an optimal list of matches (matching applicants and programs), whereby no two people could be happier if they were to switch with each other.

Match Day: This is the day when people find out where they've matched. It takes place in March, and it is a significant day in the lives of every medical students, since it is when they find out where they've been assigned for the next several years. For most people it is a day of happiness. On the other hand, don't like where you're going? Tough.

. . .

Anyway, September 1st is quickly approaching, which really means I should finish preparing my application.

TB for all

One of our patients was just diagnosed with tuberculosis.

It's not a big deal, except that TB is a serious public health concern. Since this disease is essentially non-existent in most industrialized countries (we see it because there is a large immigrant and Mexican population at our hospital), public health officials want to ensure that all TB patients are being actively treated. In an effort to further minimize its spread to others, they also try to make sure people in close proximity to the patient are protected from the disease.

Specifically this means that when a patient with TB is discharged home, they will be visited weekly by nurses who force them to take their medications, and the patient's family will have to take TB medications too.

So when we were ready to discharge home our patient, we had the TB Control people get in touch with her family to get them involved with the plan ... only to find out the entire family already has TB!

It doesn't get easier than that! That's certainly one way to avoid dealing with the TB Control people. And what do you know ... a county patient made things easy for once!

Struggling with the Dead

We already have a huge patient census (9 ICU patients!), which is miserable enough on its own. But who would have thought that out of all our patients, it's our brain dead patients that cause the most trouble. You would think these two patients -- these two motionless bodies that, for all intents and purposes, are dead -- would be the easiest to take care of. But no.

As each patient has family that will not accept the fact that these patients' brains are technically dead (perfusion studies have shown that their brains are not receiving blood flow), they refuse to allow us to perform a "terminal extubation" ... meaning they won't let us disconnect the ventilator from the patient so that the patient may die.

At first we thought we could invoke California state law, which mandates that once a patient is declared brain dead, terminal extubation must be performed within 12 hours. Unfortunately we couldn't take advantage of that law because we could not just yet declare them brain dead. And what was the reason for that? Because a patient cannot be declared brain dead until all of their electrolyte abnormalities are normalized.

So ... in an effort to declare these patients brain dead, we are busy correcting their low sodium, elevated blood sugars, and elevated creatinine. Which means we are giving our dead patients saline, insulin, and (get this) dialysis. Even better, one of them has an anemia, so he is about to be transfused with some red cells.

I don't want to come off as insensitive, since I know this must be a hard situation for any family, but there comes a point when evidence makes it clear the patient will never recover. I guess it's easy for me to think like this, since it isn't my loved one that is affected.

In any case, it's quite a hassle taking care of our dead patients.

(With all that said, I hope someone from above doesn't strike down upon me with great vengeance and furious anger.)

More Interactions with ENT

One of our patients who was recently trached started bleeding from her trach site. We thus called back ENT -- who placed the trach and wants responsibility for making any adjustments to it -- to investigate the bleeding, identify its source, and fix it. Eager to get involved with any procedure (I swear, surgery is my true calling) I offered to help them, and they gladly accepted.

So for more than an hour I worked with the two ENT residents at the bedside, as they cauterized the hell out of one fat goiter (large thyroid gland) that was causing all the bleeding. Assisting them was interesting, and at the end they asked if I would help clean up. I had no problem helping them clean up the large mess that they had created, which entailed bloody 4x4's, empty suture packages, and dirty surgical towels scattered on and around the patient's bed, as long as it was just that -- helping.

Once I agreed they promptly walked out of the room and left me to clean up the mess alone ... but not without first making me aware of a "sharp" (needle) they had lost somewhere on the bed!

Thanks asshole! First, didn't your momma teach you to clean your own fucking mess? Next, if you are going to make a medical student clean up your crap, at least ask your own medical student to clean up your crap -- not one from another service. And finally, you're an even bigger asshole for making me clean up your mess after you conveniently lost a sharp that I will probably "find" by accidentally sticking my finger into.

I've gotta say, after my last encounter, my track record with ENT is 0 and 2.

Grand Rounds

It's that time again. You can find them at Inside Surgery this week.

This is a Spinal Tap

Meningitis patients beware. I am no longer afraid of lumbar punctures, as I performed my first one today.

(Actually I am still afraid of getting one, but at least now I know they don't necessarily have to be painful.)

We had to get an lumbar puncture from a paralyzed patient of ours today in order to help diagnose whatever bizarre illness she contracted that made her become, in a matter of days, "locked-in" -- meaning that she is nearly completely paralyzed, except for her eyes, which she can move up and down. Since I had seen one performed on her earlier in the week, and abiding by the "see one, do one, teach one" principle, my resident let me perform it.

It's amazing how far into the back the needle can be pushed. I plunged in that long needle, expecting it to hit subarachnoid space or bone at any minute, but it kept going. After about 3 inches, I finally felt it pierce through something (I assume dura) and then CSF started dripping out!

A successful LP on my first try ... talk about beginner's luck.

Latest Grand Rounds

Sorry, I know it's been awhile, but the latest Grand Rounds is up at donorcycle.

Two Tubes and an Idiot

A few days ago my ICU patient had his endotracheal tube removed and replaced with a tracheostomy, aka a "trach". At the same time he had a NG tube (a tube that enters the stomach via the nose) placed to facilitate suctioning secretions from his stomach, but because his NG tube was severely irritating his nose, ENT -- the team who performed these procedures -- recommended that it be removed and replaced with an OG tube (a tube that enters the stomach via the mouth).

I brought this up on morning rounds with my team, and my fellow was confused how an OG tube could be used with a trach in place. I honestly had no idea why he felt there would be an issue, but he really wanted to know if was ok to have both of these tubes at the same time ... so he told me to call the ENT resident and ask. Being an obedient medical student I agreed to call ENT, knowing this would be viewed as an idiotic question. My fellow realized it too and said just to act like a clueless med student to get the answer.

So I called up the ENT resident -- who was no longer at the hospital at this point, but at home -- and asked "Is it ok to have an OG tube in this patient, who also has a trach?" Then, in a slow voice that's usually reserved for talking to a 6-year-old, she said "Um, you realize the trach is in the trachea, and the OG tube is in the esophagus?"

I replied with "I understand", although really I wanted to say "Thanks, but I took gross anatomy too." Her response caught me off guard, and so the rest of the phone call involved me stuttering away trying to ask if it was ok to have these two tubes in place -- without coming across even dumber than before.

I got off the phone as quickly as possible, feeling like an idiot, and relayed the news to my fellow, who thought it was amusing.

Thanks a lot, fellow. There, you got your answer ... and also made me look like an idiot at the same time. I hate hierarchy.

New Interns

The new interns arrived at the hospital this week, and they're quite amusing to watch. They are very easy to spot, not only because they walk around with a slightly lost look on their faces as they try to find various wards in the hospital (in their defense, our hospital is huge), but also because their name badges are white, while everyone else's is blue.

It is also nice, for once, to feel like I'm not the least experienced member of the team. While the interns technically do have more medical training than I do -- by just one year -- most of them are from other medical schools and are thus new to our hospital. As a result, they need a little hand-holding on what are typically straightforward tasks, like finding lab results.

For example, the new intern on our team, after admitting his first patient, quietly pulled me aside and asked me to look through his admission orders to make sure he did them properly. I helped him out, flattered that he, someone higher in rank than me, turned to me for guidance. I didn't want to get too cocky, however, knowing fully well that this will be me in one year.

But still, quite amusing.

Fourth Year Focus

I feel that every year of medical school has a different focus. The goal of first year is simply to adjust to medical school and get used to memorizing huge volumes of new information. Second year, having had survived one year of med school, we were able to relax a bit more although the dark cloud of the boards was constantly looming overhead; even if school wasn't very demanding at a given time, you knew you should be devoting some time to boards studying. Third year you are thrust into the hospital, full of book knowledge, but absolutely clueless how to perform on the wards -- and pretty damn scared because of it.

Here I am now at the start of fourth year, wondering what my priorities are.

I am no longer scared of the hospital, as I have enough experience with clinical rotations to feel comfortable with patient care and the workings of the hospital. The motivation of before is also gone. With no more required rotations (which is what third year was filled with) the grading scale is now simply pass/fail -- no more honors, high pass, pass, or fail. This is a huge relief. Now there is no more struggle to out brown-nose the other medical students in order to appear more eager than them. This grading scale is also the reason why, when your resident tells you, "You can go home, or stay if you want to", you have no problem saying "see ya", instead of forcing out a "OK I'll stay".

With all that in mind, I realized the goal for this year really is not just to get by, but to prepare myself for internship. This is my chance to learn about true patient care, which, thus far, I have left to the responsibility of my interns and residents. Seeing how I'll be in that position in less than a year, I should start getting used to performing all these things myself.

And now with that in mind, I am more serious about fourth year. I am trying to learn the boring details of patient care that interns are typically responsible for, such as writing orders, learning medication dosages, following up abnormal lab values, etc. When a Mg returns at 1.8, I now know to write an order for Mg Oxide 400mg PO x 3, instead of running immediately to my resident. Hopefully this mindset will prepare me better for internship, and make the inevitable shock next year a little less overwhelming.

Standardized Patients

I just got through a monster afternoon dealing with a seemingly non-stop series of standardized patients -- actors trained to behave as patients and then interact with us as we practice various clinical skills (e.g. bedside manner, clinical reasoning, ability to take a good history and physical exam, etc.) Being required to make special efforts to teach their students good clinical skills, most medical schools now incorporate standardized patients into their curriculum.

But having performed dozens of encounters with standardized patients during the past few years, including today's exam that consisted of 8 back-to-back standardized patient encounters, I am officially sick of them.

It takes a lot of energy walking into each room putting on an extra fat grin, being extra verbose as you talk to the patient, and then remembering to perform every aspect of the physical exam (especially the ones you don't normally perform) on these people who are obviously tired. Furthermore, I treat them differently that I do my real patients, as I'm sure most people do. I seriously doubt there are students who take the time to inspect, palpate, percuss, and only then auscultate.

Although I'm sure the feeling is reciprocal. It must be hard putting on the same act 16 times a day for an entire month, complaining over and over to a new student how suddenly this morning they started having abdominal pain ... or how their poop has been discolored for awhile.

Latest Grand Rounds

Grand Rounds is up at the Medical Blog Network. The page is a little busy up top, but scroll down a little for the individual entries.

First Day in the CCU

Welcome to hell.

Today was the first day of my cardiology rotation, based entirely out of the cardiac care unit, which is an ICU only for heart patients. Patients with the most urgent or serious heart diseases come here and stay until they're stable enough to be transferred to the regular cardiology floor ... or until they die. (Or so I hear, that is; I have yet to witness a patient dying anywhere.)

I was also on call today and thus had to stick around until I admitted at least one patient. Used to long and uneventful hours of waiting while on call during other rotations, I was not looking forward to today's call. Lucky for me -- but not so much for our patients -- the events of the day were far from boring.

The first patient to usher in the day was my patient, a very young man with an acute MI -- heart attack. Not only had he just suffered a heart attack, but it was the second heart attack of his life. All my years of reading about nitrates and morphine and beta-blockers and interventional procedures were being put into play in front of me, and in overdrive. And this was for our most stable patient, too.

Some of our other patients we admitted -- ALL of which were acute MI's -- were a man who suffered an MI and whose condition went downhill fast (so much so that within a few minutes there were miles of wires and tubing leaving his body and connecting to life support machines and medicine drips), and another who had his MI while getting a CT scan for an entirely unrelated reason.

Quite an exciting day (at least for me, no my patients). Never before had I had an acute MI patient on a rotation, and now all of a sudden we were hit with five.

Happy 6/6/6, everyone.

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On a related note, this is my first clinical rotation of 4th year in the hospital, so I got to sign my notes as MS4 today. Pretty exciting, although I first wrote MS3 and then had to cross it out.

Mealside Consult

Getting some lunch at the bagel place today, I stood in line behind one of the vascular surgeons who lectured us during my surgery rotation. His lecture topic, specifically, was on abdominal aortic aneurysms (AAA), which is when the aorta balloons out because of extra thin walls ... and, if you're very unlucky, ruptures. It's not very common, and it most often occurs in patients over 50 years old.

One of the symptoms of an AAA -- before it ruptures, of course -- is that if you press down on your abdomen you can feel the pulsating blood. And I've felt my abdomen pulsate in the past, mostly at the gym when I'm working out.

So back in line, I thought this was my chance to confront an AAA specialist and see what he thought. I politely introduced myself, let him know how his lecture has been weighing on my mind, and then asked about my problem (or is it my "problem"? See here.) Immediately he shot it down with a quick "of course you feel a pulsation, you should, since you're skinny".

Oh.

He then let me know of some things to look for in the event it truly was an AAA, so you can be sure I'll be examing my abdomen in more detail tonight.

So much for that.

(However, I'll admit I was slightly relieved to hear what he said.)

Weird Habit

I have many weird habits, ask anyone that even slightly knows me. But if you ask me, none of them are weird ... in fact they are all done for a practical purpose.

One of these habits involves the bathroom here at the hospital and what I do as I enter one. Whenever I open the door to the bathroom -- and only those that are single-occupancy, not the ones that accomodate many people -- I open it slowly, very slowly. I do this just in case there is someone in there, so as to give them a chance to yell out in case they forgot to lock the door. As reasonable as it seems to me, people always give me a hard time about this, saying no one forgets to lock the bathroom door.

Well just a few days ago I went to the bathroom in clinic and started opening the door slowly ... and then heard something like a moan or a yell. Turns out a man was in there, and, that's right, he forgot to lock the door. I quickly apologized (or mumbled something) and shut the door.

And now I have no qualms about continuing this habit in the future. A 1 in 100 hit rate ain't bad!

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Oops, a little late, but you can find the latest Grand Rounds up at KidneyNotes.

Gotta Watch Yourself

There are certain people in this world, who, by virtue of their job or profession, are untouchable. And by untouchable I mean you can't treat them how you truly want or how they deserve to be treated. Examples include waiters, executive assistants, babysitters, and more. It's not worth it to be rude to a waiter if it means your sandwich will arrive with spit (or worse) hidden inside, or if your pancakes will arrive on a plate after having been sitting inside the chef's sweaty underwear as he did jumping jacks. Conversely, it is in your best interest to be a little more polite than usual if it means your resume for a job application will not "accidentally" be thrown into the trash. You get the point.

I have two specific people to add to this list, both recently involved with the same endeavor of mine. I am busy preparing the paperwork to send away my applications for rotations at other hospitals, and this, in turn, requires me to deal with our Student Affairs office. For the most part it is staffed by kind and friendly people, except the one woman in charge who is quite the rude and unrefined b****. I apologize for the demeaning comment, except that this woman is horrible and barks at people like she has never had any politeness instilled into her. She yells at you if you stand more than 3 feet away, and you can't ask her to repeat something unless you want an earful of loud "WHAT DID I JUST TELL YOU?" Unfortunately I can't speak my mind, lest I want my transcript and letters conveniently misplaced ... so damn you, you win this round.

Next up is the a-hole mother****** guy who works in a mailbox store near me (not the US Post Office, but some private mailbox store that is a pick-up station for FedEx, UPS, USPS, etc.) This guy, who I've interacted many times with before, is among the most terse, rude, and irritable POS's I've ever encountered. Ask for help and he gets visibly irritated because he has to interrupt whatever he's doing (often just text messaging) to help you. Or ask him how much it costs to send something overnight and he'll bark back "How do I know?". Someone needs to walk in, smash his hands with a baseball bat, and then tell him to treat customers.

That's all. (It's loosely related to medicine, no?)

A Tale of 2 Hospitals

Like most medical schools, our university is associated with two hospitals: the university hospital and a large county hospital. They sit on opposite sides of both our campus and the spectrum of luxury.

The university hospital is the nicer, more luxurious private hospital while the county hospital is a large, crowded, and understaffed monster of an institution that serves anyone who walks through the doors. The large county hospital is where we do nearly all our clinical rotations, but occasionally, for certain rotations or events, we get to work in the university hospital. Being used to the county hospital, most of us students get used to its inefficiency and dark, depressing corridors; but when you come over to the university hospital you immediately realize what the outside world is like.

Even though this is our hospital, and it's a great place to get trained as a medical student, you can't help but wish the county hospital was a little more like the other. Exactly how are they different?

• That hospital has way too much money; there are new fancy buildings being erected every year. This hospital has has government money ... which ends up meaning no extra money.


• Patients of that hospital have tens of millions of dollars to spare and then donate. Patients of this hospital can barely find two nickels to rub together.


• Patients of that hospital include prominent celebrities like athletes, actors, and government officials. Patients of this hospital are homeless.


• In that hospital halls are brightly lit, and rooms are spacious and single. In this hospital, the lights are orange and dim, and rooms are packed with 8 patients.


• That hospital has 2 CT scanners for its 300 patients. This hospital has 4 scanners for approximately 800 patients -- and 3 of the scanners don't work (no joke).
  


• In that hospital, ordering a test as "STAT" gets it performed immediately; in this hospital, STAT ends up meaning do it in a few hours -- unless, of course, the nurses don't feel like it.


• In that hospital has air-conditioning; this hospital does too -- except it doesn't work, it isn't repaired, and it makes the summer months sweaty and miserable.


• The cafeteria staff at that hospital learns your name and makes dishes according to your preferences. The staff at this hospital will never admit to recognizing you if you forget your name badge, and they make you swipe your badge twice if you want extra portions of food.


• That cafeteria is well-lit and lively. This cafeteria keeps the lights dim so you don't see the mice running around.


• Those patients, when discharged home, invite you to Pebble Beach to play golf, and sometimes they offer you a new car. The patients here, when discharged "home", go sit on the stairs just outside the hospital because that is their home.

This listing isn't meant to be scathing or bitter; it's merely a factual comparison between two hospitals separated by one physical block but by worlds of money.

Luxurious as the university hospital may seem, you can't beat the training you receive at the county hospital -- in terms of patient load, exposure to obscure diseases, and responsibility. And believe it or not, if you spend enough time at this hospital you might even begin to enjoy all its "features".

Grand Rounds 235

The latest Grand Rounds is up at Parellel Universe. I'm pretty excited because it features one of my posts. Be sure to check it out!

Hypochondria

Medical school is harmful to your health -- or, at least, it's harmful to my health. Thankful as I am to be in med school, this same education that is teaching me about the body and how to treat sick patients is, unknowingly, also teaching me the many ways in which my body can go wrong.

I can no longer experience even a simple ache or pain without thinking about the worst-case scenarios. I can't help but analyze my occasional random symptoms, and I usually misinterpret them as signs of an unlikely, horrible disease process. As an example, my hand occasionally shakes slightly. The moment I am aware of it my mind instantly shoots to Parkinson's disease, the neurodegenerative disorder characterized by a tremor, which actor Michael J. Fox has.

I know it's almost unheard of in someone as young as I am, but once the thought is in my head, obsessive behaviors begin. I once pulled a neurologist professor aside to ask her what she thought of my tremor; I had her attention initially, but then she thought was joking when I asked her if it was Parkinson's. This was years ago, and so I've forgotten about it for the time being. However, I ran across a brief mention of the disease online a few days ago, and I immediately reverted to my obsessive ways. Sneak up behind me and you'll find me staring at my hand in midair, trying to look for any microscopic movement.

That was by no means an isolated incident. Last year, early one morning about an hour before I was to wake up, I had to get up to pee. Seeing how that was not normal for me, I concluded that I must have new-onset diabetes. The next few days I was convinced that my vision was blurring and my feet tingling (which, by the way, are only long-term complications of diabetes), and so I sought advice from a diabetes expert (we were "coincidentally" learning about diabetes in the classroom). He said I had nothing to worry about, but was I calmed? Not really. Luckily in a few weeks, I had forgotten about it.

It's the classic medical student syndrome, I've been told, whereby we learn about diseases, and our vivid imaginations convince us we have them. Being a medical student, with our unrefined diagnosing skills, also predisposes us to conclude the worst, most rare diagnoses when evaluating a symptom ... as opposed to thinking of more common explanations first. As I sat in class one day my neck started to ache. Uh oh, is this nuchal rigidity? I must have meningitis, so I inched my way to the aisle in case I needed treatement quickly. Meningitis could have been the culprit, but so could those hard and uncomfortable lecture seats. Brushing my teeth one morning before school, I spit into the sink and noticed little reddish-browning clumps of stuff -- which I assumed to be blood. Coughed-up blood only happens with lung cancer, and so as I drove to school that morning, I tried sorting out what I wanted to do in the remaining 5 years of my life, before the lung cancer killed me ... me, a 20-something-year-old non-smoker. It turns out the Oreos I ate the night before caused the discolored sputum. Finally, I was sure I had an abdominal aortic aneurysm (aka, AAA, where the aorta, the largest artery in your body, balloons out and pulsates throughout your abdomen) because I felt abdominal pulsations the night before ... after I had finished a strenous workout at the gym.

As if all these incorrect interpretations of normal bodily functions weren't causing enough misery and distress, I've been known to start worrying even if I feel too "fine". Many diseases start out completely asymptomatic, I argued in my head, so why couldn't I have one of those diseases? Aortic regurgitation, where one of the heart valves doesn't shut tightly, is one of these diseases, and thus feeling fine doesn't rule out me having AR. Again, it was a "coincidence" I was in the company of a heart specialist, who examined my heart with genuine efforts and told me I was fine.

The only thing that comforts me is the fact that some of the diseases I'm convinced I have usually coincide with the topics of our classroom lectures. I had Parkinson's disease during our Neuroscience unit, diabetes during our Endocrine unit, and my aortic regurgitation surfaced during a rotation in cardiac surgery where I saw AR patients on a daily basis. Everyday a trip to the classroom revealed some new ailment I could have. At the end of lecture, most students lined up for the professor to clarify a confusing point; I got in line to ask if I had the disease they just taught us.

I don't know when this will stop, but I hope it's soon. So do many others, including friends, family, and roommates. It's one thing when I obsess in my head; it's another when I harass people I know and ask what they think. They always reply, "How do I know, you're the one in med school." Medical school, right. What can I say? Med school --- it's my gift and my curse.

Grand Rounds 234

This week Grand Rounds is being hosted by Doc Around the Clock. Go take a look.

First Penis in Awhile

With ob/gyn (my final 3rd year rotation) done, I am now doing an elective research block with an advisor I've been working with for several years, conducting research in the field in which I hope to end up.

Today I had the opportunity to scrub into a surgical case where the patient was a man. He was put on the table, the staff started to prep him ... and then I noticed he had a penis! No, it wasn't that it was deformed or that it was big or small, just that he had one. That's it.

This would have been a non-issue for nearly anyone else, but you have to understand ... I hadn't seen a patient with a penis in a long time. After 6 weeks of being up to my neck in vagina -- diseased vaginas and ones with baby heads prodding through them -- it was refreshing to see a robe pulled off to reveal male parts.

Once this hit me, I was pretty excited ... in a non-homosexual way, if that's even possible given the fascination with which I've written.

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With Ob/Gyn done, I also suppose I'm in my 4th year now. Fourth year med student. MS4. One more year to go ... exciting, yeah?

Super Nurses

What is up with the nurses that work on this floor? I ask because they eat -- a lot. Work isn't their job, but rather something to do to pass time between feedings. There is no simple breakfast and lunch ... but rather breakfast, mid-morning snack, late-morning snack, and then lunch, lunch #2, and lunch #3. Breakfast and lunch are what you would consider reasonable, while their "snacks" are bigger, heartier, and even fattier than the main courses. Lunch can be a burrito, but not to be outdone, the snack might be a bucket of KFC chicken, or a big styrofoam container of fried zucchini sticks, or a mound of thumb-sized french fries.

Obviously, the food has taken its toll on their bodies. When one takes in 4000+ calories per day but doesn't exercise, one should expect to grow; one should expect their fat cells to become happy; one should realize they are bigger than two.

And that's just the start. These nurses are so gigantic that they can no longer even walk by themselves. Seriously, no seriously. The rare occasions that one of these nurses needs to get up either to go to the bathroom or leave for the day, what I assumed was a normal chair magically turns into a modified wheelchair/walker that they depend upon to be mobile. They rest their weight on this thing, then push. Rest and push. It's a very slow process -- and an even more frustrating one to watch -- but I doubt they are in a rush.

It's really quite sad, but it's also beyond sad at this point. These nurses must believe that their obesity, like an advanced disease (many even argue it is a disease), is at a point beyond which any treatment can help ... and it's just a matter of palliative care. Why bother losing weight when you can eat all your favorite foods, and walk with this walker? (To make it clear, their situation is not beyond treatment; no amount of obesity is, and I hope they've been told this by someone. With motivation, even they can lose weight).

Final words: don't get near their food -- lest you get chewed out how the food brought in by the pharmaceutical rep is their food.

Grand Rounds 233

This week, Aetiology is hosting Grand Rounds.

Bye Bye Ob/Gyn

If I play my cards right, I may never see a uterus again. Today was the last day of my Ob/Gyn clerkship, and not a day too soon. Ob/Gyn felt like the longest rotation despite being 6 weeks like all others, and I never felt less interested in a specialty. I wasn't a fan of the patients, the residents, or the nature of their work. The moment the words uterus, vagina, or cervix were mentioned, my mind zoned out and all I heard was "blah blah blah blah" . . . until I heard "you can go home now."

With plans to go into medicine or surgery (yes, a pretty non-specific plan), I hope never to deal with girl parts again.

Abortion Clinic

As one of the requirements of this clerkship, I spent the morning in our hospital's abortion clinic, amusingly dubbed the "Reproduction Clinic", which is ironic considering it's more along the lines of an "anti-reproduction" clinic. We were given a quick tour of the "facilities" (a big clinic room with 3 chair/beds, separated by curtains) by one of the family planning fellows and then participated in several cases.

The process begins with a patient coming in desiring to terminate their pregancy; most of the pregnancies are in their first trimester. The patient is then counseled to ensure that she is certain of her decision, and once she is, she sets up an appointment in the near future.

One of the most interesting things was learning that patients don't need to provide a reason why they want to end their pregnancy. Initially this seemed odd, but after considering that certain reasons offered by patients might lead to ethically difficult situations, I realized this was the best approach.

On the morning of the big day, the patient arrives, is put on the table, examined, and given a mild sedative (usually a benzodiazepine). An ultrasound is then performed to establish the status of the pregnancy. One of our patients was unknowingly carrying twins, one of whom was already demised.

The termination itself is performed with a procedure known as a D&C, aka "dilation and curettage". Dilation refers to the enlarging of the cervix (the opening into the uterus); curettage is the scraping of the insides of the uterus with either a large syringe or vaccuum pump.

What occurred next was both the most fascinating and eerie part of the procedure. The products of conception (POC), meaning the pregnancy itself, was run through a strainer and then dumped onto a lighted surface. Then, like anthropologists trying to reconstruct an old fossil, all the tissue were examined in search of identifiable parts. In what initially looked like a soggy, watery mess of shredded red tissue paper, with some probing, little fetal parts were soon surfacing and being identified.

Watching this part of the procedure, while interesting because I felt like a crime scene investigator, was also slightly disturbing because the parts being separating out in front of us were the same ones that, just minutes earlier, were seen moving around inside the patient's uterus. It's saddening if you think about it too much. This wasn't a high school biology dissection, it was a tiny human being.

This might seem as if I'm siding with the pro-lifers, but I am most definitely not. I'm merely conceding that the procedure is one that undoubtedly carries much impact on the patient, and having participated in this clinic's activities made it even clearer why this is such a controversial topic across the country. With that said, I still hold that it's better to terminate a pregnancy than to carry it to term and provide the child with a sub-standard quality of life.