put your back into it

a dirty song becomes applicable.  while on call for family medicine, i spent a decent amount of time hanging out with my former senior surgical resident.  while i didn’t enjoy most of surgery, the one area i did truly appreciate was vascular surgery.  i don’t know what it is about it.  regardless, the resident mentions that there is a ruptured, descending aortic dissection.  this is pretty much a big deal.  conveniently, sophie, one of my best friends is on call for surgery, and i meet her down there. 

quick aside to explain aortic dissections. 

• the aorta is the biggest artery in your body.  most peeps know this. 
• blood pressure is determined by the pressure in the aorta when the heart is pumping into it, and when the heart is closed - hence 120/80.
• when you have high blood pressure or hypertension or htn - you can damage basically everything in your body, but in this guy’s case, you can get an aortic dissection
• an artery is composed of three layers.  in a dissection, you have a separation of these layers forming a flap.  you end up having two lumens. 
• it’s a big deal when 1 ruptures

normally a descending dissection is treated medically - you just control their blood pressure to keep it from worsening.  so what if it ruptures?  emergent surgery fool! that means blood is emptying into your body at a pretty fast rate because the aorta is packed with pressure.  and boy they don’t fool around.   they made a huge “L” cut into his sternum and along his ribs and opened his chest.  and there it is…you couldn’t miss it.  the aorta was humongous and bruised…just plain old ugly. 

they put the guy on bypass - from his left atrium to his common femoral artery - also nuts to see.  regular bypass consists of vena cava to aorta.  then i actually get to see the aorta cut open.  unfortunately the surgery didn’t get to far because the guy ended up dying on the table because of a complication (the dissection started to ascend - about the worst thing possible).  it was an amazing surgery nevertheless.  it’s not often you get to see the chest wide open with a clear view of the aorta in your chest…abdominal aorta? maybe, but in the chest?  very rare.

if it weren’t for general surgery being a 5 year bane to get to vascular surgery, i might actually consider it.  but gen surg is just too boring and painful. 

the disney disappointment syndrome

i really didn’t consider the possibility that watching disney movies could have any negative effect on my psyche until recently.  for christmas, one of the gifts i consider the best was a 5 cd set of disney songs.  since receiving this gift, very rarely has one of those cds not been occupying the space of my player. 

as i listen to them more and more, i feel like i begin to be brainwashed.  here i am, listening to song after song about the perfect romances that occur between a man and a woman (or beast and a woman, depending on the movie).  it’s really draining - because my practical side wants to me say - no that’s ridiculous.  those types of fairytales don’t exist.  but why can’t they?  why can’t i have everything?  i have always thought, that if someone could imagine it, it could exist.  i have been raised since i was a little girl to believe that life may be hard, but when you wish upon a star, your dreams come true and those evil stepmothers don’t exist.  

 i think the biggest culprit of all these movies is probably snow white.  at least with newer disney movies, there is that initial conflict.  in aladin, he’s a ’street rat’.  in beauty and the beast (my personal fav of the princess movies), he’s a jerk…and super hairy.  in snow white, they meet for all of 2 seconds and bam - it’s love.  i don’t expect such an ending or beginning for that matter…but shouldn’t i hope for everything?  is it settling when my expectations aren’t met?

 really, it comes down to the idea - are you really ever content with what you have?  i continually have that fear that i’m giving something up.  how do you know when you’re settling? 

pap smear…no wait, colp…no wait, i&d…no wait, all three

that title, right there, describes family medicine to a tee.

i have been on the rotation for just barely a week, and mostly it confirms my desire to never do outpt medicine.  outpt medicine is torture, especially as a student.  even if a patient comes in for nothing, i still have to do a full onslaught of questioning and write-ups.  plus, you can’t focus on a patient’s one problem for that day.  since they’re there, let’s also ask about when their last _____ was (fill in blank with: mammography, pap, fobt, etc).  most of family is pretty boring to - it’s all run of the mill.  however, it’s early yet.  one of the pulls to fp is the variety, though.  for instance, they can do minor surgical procedures - sutures, wart removal, incision and drainage (i&d), etc.  today was sort of an example of such a day.

 as i waited around for my resident, the clerkship director came by because she would be seeing patients this am.   she sees me and tells me to work with her for the day (she’s a really good clerkship director because she’s always so involved).  the last patient of our afternoon is listed to be a basic pap smear.   this pap smear was actually due to be a colposcopy, which i had never seen before… this may not seem like much, but it’s pretty random that on day 3 i’m already seeing procedures like this.  (not to mention that on day 1 i got to swab for stds and do a pelvic on a woman [this involves putting fingers in a woman's vajay]).  before we start the colpo, the doc notices a nodule on the labia and basically it turns out to likely be an abscess, which the treatment of choice is i&d.  so, in addition to seeing a pap and colpo on this woman, i got to do the incision and draining, not something i expected for a routine pap.  but that’s family medicine, you really don’t ever know what a patient is gonna surprise you with.

the resident also pulled me aside today to show me some scabies.  scabies are often an std, and people often know them for this, but a young girl came in with them.  it was a pretty clear cut case, but as the mom is asking about a note for her daughter, she asks that the reason not be put (the stigma as her reason).   this resident totally blunders and is like, no it has to be on there.  which isn’t the blunder, because the school may need to be aware of the severity of why she is missing class - what he didn’t explain is that while if other students knew, sure they would make fun of her, but then that means the school has broken hippa laws.  while the reason will be listed on the note, the school can’t share that kind of information.  instead he’s like - nope we’re writing it down.  dios mios.

 i also might add that i feel completely overwhelmed this week.  i am, as usual, completely overloaded.  i give myself way too many responsibilities, but they’re all things i want to get done.  sometimes i feel like a bipolar, starting a million projects and being unable to complete them.  i just need to take a step back and just knock these down.  it’s exhausting when i do this to myself.  my goal is to knock one out completely, one major one that has dragged out. we’ll see.

devil incarnate

third post.

last night, dede would not stop crying.  i left my door slightly ajar so she would hopefully stop crying.  and you know what happened? exactly what i expected.  bailey shat in my room.

i hate that dog.

and you know what else?  she’s two for two on my morning good byes.  for several weeks i have only said bye to delilah.  yesterday, i decided to start saying by to all of them.  what did bailey do? snarled viciously at me even when i tried every trick in the book to be nice.  i talked in a high pitch voice, i didn’t stand over her, i tapped the couch to see if she would come closer. nothing.  it’s all good though. i got my revenge.  she happened to be laying on a blanket yesterday, so i just tugged the blanket up to throw her off a little (no, rach, she barely moved), and of course, she tried to bite me.

nasty bitch.

igor

i really don’t need to be posting today, but due to my supreme desire to not study, this is now my second post.  i have worked hard this rotation, and hopefully i can honor a test, but it’s not the end of the world.  i rocked the boards and in the end, that’s the most important thing for residency. 

i walked onto 6400, looking ahead to my game of chess.  i went and saw my three patients - two of which are familiar to the people on this blog: the “mohawk indian” and the chess player, henceforth dubbed ‘the rook’.  they were all in the day hall eating breakfast, so rather than peruse the charts first, i just asked them the routine questions.  as i sat at one of the tables, which held two of my patients (sans mohawk), and spoke with the rook, he was like another person.  i was estatic to see him come so far.  he then proceeded to do an incredible dracula and igor impersonations.  he could even contort his face like igor might. 

i brought him back to the ‘music room’ and while we waited the 5 minutes for the psychiatrist, i asked him to play the piano for me.  he had mentioned before that he had been taught at a young age, and while he wasn’t gonna go out and be a concert pianist, he was certainly talented.  the psychiatrist had the opportunity to see the rook in this state and he showed the doc his igor impression. 

this side of the rook impressed the doc so much that he’ll probably get to go home tomorrow.  and i can’t lie, i feel like i helped him down that road by being there to talk with him, play chess, etc.   we played our chess game, too.  he quickly won the first, so quickly that we decided to play another, which i won.  our last game was all his, leaving him the reigning champion.  as we played, he asked me my name again.  after telling him, he asked my middle name.  “ashley.”  he then decided he liked this name better, and told me he would call me that.  and let me tell you, he did.  he gave me a picture he made during art and wrote “to ashley”. 

psych was a really unique experience.  on internal medicine, i remember walking away with around 4 patients that will really stick with me.

1.  the parkinson’s pt i wrote about

2.  a 78 yo dwarf with nf1 (neurofibromatosis)

3.  the alcoholic

4.  the elderly man in the icu who developed rhabomyolysis.  (when asked if he remembered me, when he was no longer intubated and sedated? “i could never forget those eyes”)

 leaving psych, i will have at least double that:

1.  the one who called me the cheap slut

2.  the rook

3.  the mohawk

4.  the patient who called me gorgeous (i’m so vain)

5.  the suicidal depressive

6.  the mlk defender (attacked people for standing in front of mlk’s pic)

7.  the geriatric theif

i could prob name more, but those were the big dogs.

it broke my heart saying good bye to the rook.  before i left, he told me he felt like he actually loved me more than he loved his wife, because i accepted him for who he was.  do i think he meant he was in love with me?  no, i don’t.  but i do understand what he means. 

they don’t teach common sense

when you have two diet cokes sitting on your desk (because to hell with giving up soda when you’re this close to that special time of the month), and you’re not sure which one is the one you brought home today, you have several options to discover which one is the pop you want. 

1.  taste both

2.  shake them and see which fizzes the most

i tried both.  i opened bottle one, tasted it, and it seemed flat.  still unconvinced, i took bottle two and shook it.  ‘well that seems fizzy’ i think to myself.  to be sure, let’s taste it.  right after i shook it.  i think we can all guess what happened.

chess

one way to make a psych patient’s day?  send them to 6400.  instant cooperation.  with my favorite patient, all i had to do was suggest a game of chess.  from 8 in the morning when i mentioned it until we managed to sit down and play (11), all he did was prepare for the game.  when i walked into 6100, he had the game already set up perfectly.

the key to psych patients is not to go around thinking they’re “crazy”.  i’m not going to say something stupid like “they just like us” or something lame like that.  but i will say that it is easy to underestimate the intelligence of someone who says they’re 100% mohawk indian or that the aryans are after them when they themselves are aryan, and aryans to them are black people. 

my patient gave me great tips and refreshed my memory for our first game.  unfortunately for him, because i’m a quick learner, i beat him at the first game.  we started the second game and it was a ’stalemate’ aka i basically kicked his butt.  the third game, he won, but barely.  tomorrow is to be our tie-breaker and sadly it’s my last day of psych.

we ended up playing for about 2-3 hours.  it was entertaining through much of it, and it was so much fun getting to know my patient better.  honestly i wish studying were less important because i am really not ever going to have this kind of time later.  

there are downfalls to playing with an impulsive/paranoid patient however.  when other people would come up to talk, and he got irritated, he yelled at them.  then, when his arch nemesis was sitting nearby, the man said something to my patient, and my patient’s response?  he flipped him the bird.  but not just any bird - it was accompanied by the kind of glare only a person with schizophrenia can give.  an absolute dead stare, like he could see into your soul and rip it to shreds just with a gaze.   it was a great time.

 overall, psych has been a great run.  i doubt i will have more fun on my other rotations.  nevertheless there are many reasons i wouldn’t do psych.  it will never be the experience i’ve had.  if my job could be what i have done for 4 of my 6 weeks, then heck yes.  i would love to spend my time just hanging out with patients all day.  but no doctor will have the time (again unfortunately) to play chess for 3 hours with one patient.

i’ll let you know how the tie-breaker goes.  i anticipate it being a great game.  (we’ve also attracted quite a crowd.)

ideally…

i have recently decided that while my doctor interviews psych patients, i am just going to start writing their quotes.  The most recent one from the 100% american indian:

pt:  I need a breath of fresh air and a cigarette.

doc:  See, in my mind, those two things are diametrically opposed. 

(this pt is smart, so he can say words like diametrically)

pt: that’s because you are a victim of propaganda.  tobacco is a holy substance. especially for american indians.  5 cigarettes a day is ideal.

doc:  how do you come by this kind of information?

pt: it’s common knowledge.

 apparently, the physicians of the world have missed this boat of information.

didn’t know where to start

the past week or so has been rough.  for a multitude of reasons, i have been severely sad.  i think a lot of it has to do with the stress my brother causes me.  his continual inconsideracy has, on more than one occasion, pushed me to looking up alternative places to live. 

how has he been inconsiderate?  it’s been a bunch of little things that have added up.  one little one might not have bothered me, but when you stack them up, the load breaks my strength.  i have spent 2.5 years in medical school, and i question that there has been a time that i have been more stressed out.  i have managed every year with ease.  i know it’s not a matter of being this year either.  before my mother left, i was doing just fine.  during surgery when i was rarely home, i was just fine.  now, on the easiest rotation of the year, i am breaking down.   the amount of stress and responsibility put on me is overwhelming.

i am notoriously matt’s “second mom”, which is always a good joke, but when push comes to shove - i am not actually his second mother, nor have i ever wanted that responsibility.  i don’t want to tell him to clean, i don’t want to tell him to pay people back, i don’t want to check to make sure he’s awake in the morning, i don’t want to worry about him going to court.  this f-ing ridiculous.  i don’t want to answer calls from my father regarding matt not answering his telephone.

what i want, is to spend my time studying when i am home, and studying in peace - apparently another luxury in this household.  The day brandon moves out, that tv is going downstairs, because i cannot stand the congregation of people in the living room, right outside the room i study.  i have told my mother that i will not tolerate having a fourth roommate who i don’t know.  i know cougar steve a little, but that’s about it.  i have reports that he’s clean, which for me, would be a miracle.  however, i would rather pay extra rent than take on another person, which i definitely explained to my mother.

 my concern for her is the continued unreliability of these guys.  all i can ask of her is to put her house on the market, put in laminate floors in the common rooms, fresh carpetting in the bedrooms, and hope the house sells.  she could pay matt and i to repaint neutral colors.  i have no doubt of my ability to handle an apartment on my own, and at this point, i don’t really give a rats ass what matt does.  i know of some new apartments that take dogs (aka delilah) and i’ll peace out.

i have only reassured my mom that i’m not going to bail on her and put her in a lurch.  i will have to talk more formally with her regarding putting the house on the market.  i don’t know what’s involved in selling a house, but if she’s willing to put it up now, by the time summer rolls around she might have  sale.  hopefully, she’ll just read this blog and i can save myself a phone call.

why i loved IM

this is a letter i wrote to my internal medicine clerkship director.  you can figure out the jist of the situation from the letter.  it’s hard to convey just how incredible of a clerkship director this man was. 

Hi _______,

I was writing to let you know I got my eval today, and to thank you on so many different levels.  I have become very cynical with regards to the way _______ is handling things this year with regards to grading (i.e. the returned influence to test scores and not performance on the floors), especially after receiving my surgery clerkship evaluation. 

When I was on surgery, I worked the way I usually do.  I continued studying as much as I could, and my studying become even more efficient than I was on medicine.  I really felt like I would do well on the test.  All this time I continued to work hard on the rotation, and while I knew surgery wasn’t for me, I could always put a positive spin on it, by enjoying the residents and attendings I worked with.  In the end, I again recieved good evaluations from my attendings and residents.  I took the shelf, and I walked out feeling like I could have really honored it.  Unfortunately, I barely missed making the required percent. 

I will be honest and say of course I was disappointed, but I am always able to remind myself how unimportant these tests are.  I am able to remind myself that ultimately I am studying this hard because some day, patients will assume I have done that and I want to be worthy of their trust.  However, I was more disappointed by the lack of comments by my clerkship director and the manner in which he made me appear mediocre, which was completely contradictory to everything I had been told on that rotation.  I became jaded knowing that because I didn’t “honor” the shelf, I received a uninspired evaluation.  I didn’t expect glowing remarks, but I was expected something like… “She did well at this, she could improve here.”  Anything, but instead, the comments were, “the student is clearly progressing appropriately.”  He didn’t even use my name.  (This was the evaluation I at first thought came from IM, which is why I mentioned in that previous email my confusion).

My whole point to that story is to tell you how much I appreciate the time you take filling out everyone’s evaluation, even when your site takes the most students year after year.  Additionally, I can’t thank you enough for not just giving me an average recommendation just because I botched the shelf.  I know I didn’t do terrible, but I know I could have done better.  I appreciate that you didn’t make my evaluation a mediocre one when I know student’s report so many other clerkship directors doing such (and I have at least had one say verbatim, she will not honor someone who honors the shelf).  I just feel like this is a poor out look.  Sure it doesn’t mean anything towards the honors grade if the student couldn’t manage on the shelf, but it means a lot when the student gets their review in the mail.

Anyway, I apologize for the absurdly long e-mail, but I have always made a point to let you know this kind of stuff.  And just like the 100 points, the 13 or some weeks were worth the wait.  Even had I had a lesser eval, I would have appreciated all of the effort and time you so clearly put into our evaluations.

Thanks you as always, _______.  I will continue to tell students about _____ IM, and hopefully, the 100 pts will continue to ensure you get a great crop year after year. I’m sure I’ll be making many more trips to the office this year (I have OB at ______).

Paula