Green Binder

Above: Jeeps at the off-road exhibit at the Chicago Auto Show. Now look at the Jeep on the incline, and paint yourself a picture, putting the car on a small concrete road, surrounded by tropical flora. Now, that describes some of those roads around Ross.

IN THE UNITED STATES,
A RAINBOW EXISTS TOO.

I love the nurses at the Jackson Park neonatal ward. They have been very helpful to me and my medical education. I feel very comfortable asking them questions about the patients, and they're always willing to help when my attending doctor is elsewhere. A few days ago, I was heading out the door, and I said "Have a good one!" to both of the nurses at the nurses' desk.

"Hey, Wait!" one of them then shouted.

We then had one of those exchanges solely in body language. I looked at the nurses with one of those What did I do? facial expressions. They both then pointed at my chest... I looked down, and instead of my clipboard, they caught a green binder that was a patient chart, instead of my clipboard. Whoops... that gave me another reason to be appreciative to have the nursing staff around. After a nervous laugh and apology, I walked to return the binder where it belonged.

That, my friends, is my embarrassing medical student mistake #1.

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A few months ago, I wrote an article about how primitive record keeping in Dominica was. In each record, a multitude of colors for different types of documentation could be found, pink, yellow, and green. But now I face a new dilemma, as colors aren't exactly as helpful in the states as it was in Dominica. I've noticed two issues with paper record systems in America, to my current experience.

1. Forms, Forms, Forms - The one advantage to Dominica's record system was that at least I just needed to keep track of a couple of colors, and I knew what the colors and sheets were going to present to me (although, the standard as to what information needed to be put on the page wasn't exactly the same from doctor/staffer to doctor/staffer). In the American hospitals, there's loads and loads of forms, making it easy for someone who knows what's where to find the info they need, but to a medical student like me, a pain in the butt, when finding out that different hospitals have different standards.

2. Reading the Doctor's handwriting - This is a problem anywhere, but at least in Dominica, only a few doctors and staffers wrote information in each record, so I got to know their handwriting patterns well. However, in America I've noticed that several doctors can contribute to a patient's record, making me feel I'm in a game show where in order to win (the prize: getting the diagnosis), I have to be able to skillfully read paragraphs of information. Well, I guess I'm slowly getting the hang of it - I figured that if I can't read the word, its like trying to figure out the definition to the word I've never heard of before: try to guess out of context. But whenever it's possible, it's always better to ask when the doctor or staffer's available.

As much as during my lifetime, I'll probably get to see electronic record keeping, I can say that I still need to get used to the plethora of forms and handwriting styles known to man. Record keeping is really important in medicine: the ability to communicate and understand communication is important to appropriately manage our patients. This is just another one of those "unwritten skills" that I need to learn during my clerkships.

Mile 377: Distortions of Proportions

Above: Sky high in 2007 on my first trip to Dominica. Note the turboprop propeller.

I LIVED THE REAL LIFE VERSION OF
LOOK WHO'S TALKING.

7:10 AM - One of the babies starts to cry. Like I said in the previous entry, I talk and bargain with the little kid. Okay, let's make a deal. I'll cover you up if you're going to cooperate with me when I listen to your heart.

Back up a step...

7:08 AM - I'm practicing a head to toe physical exam on one of the kids in the ward. Now, one of the greatest tools that us doctors have is the stethoscope, designed to amplify sounds within the body wherever it is placed. I'm about to auscultate the baby's chest for lung sounds and heart sounds. However, once placed the flat face of the stethoscope on the newborn, he/she started to shiver. I notice:

Oh shoot... My steth is cold!

I start to rub the base of the stethoscope to warm it up... but it was too late... by the time I was listening to another area of the chest for heart sounds, the baby started to cry loudly. Do the math: Crying + Sound transmission to the chest + Loud + Amplifying stethoscope = "Ouch to my ears!"

7:11 AM - As the baby was crying, I decide to go ahead and carry the baby in my arms to the nearby window to see the snow that was falling down. My "magic touch" includes a series of clicks and gooing sounds I make with my mouth (some of my group mates have called it pretty entertaining). I know the baby can't exactly see out there, but as he/she looked out, the crying slowly came to a stop and the eyes opened. And for odd reasons, that brought a smile to my face.

For some odd reason, I could see this happen over and over again, and I could not imagine myself not smiling at that sight.

And it was then, the babies in the ward started to cry one after another... I felt they honestly were communicating to each other (take that, John Travolta and Kirstie Alley!).

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When I enter through the huge door to the lobby of the hospital every morning, it's like a whole new world. No, we aren't talking about entering some newfound medical discovery, or even into a hospital cafeteria, where - for some - describing it as a "new world" isn't exactly a good thing.

Think about this. Let's say that the prevalence of some disease or condition - and this could go for any of the thousands of them - was 1 per 100,000 in the whole United States (not just the contiguous 48, but also Alaska, Hawaii, and just for kicks, throw in Puerto Rico). That doesn't sound too bad, does it? That's a 0.001% chance of running into someone who has that condition. Well, there's a lot of factors that affect my chances of running into it, but I've already noticed two that have increased my chances of running into them:

1. The Hospital Setting - Think about it, I'm always running into sick people... sick people concentrate in hospitals. Thus, due to a less of a chance of running into someone who's not sick, this could make some uncommon condition much more common to hospital staff.

2. Local Prevalence - Depending on where you are, risk factors for conditions are more prominent in one region of the world than the other. One good example was there used to be a higher incidence of goiter in the midwest than by the east and west coast. Why? We just weren't eating enough fish (a source of iodine, a nutrient that prevents goiters). So for many cases, me being in Chicago and in a specific location of the city may increase my risk into running into some special cases. I'd say what I've seen, but I'd probably break HIPAA confidentiality if I did.

So, that's what I mean by walking into a "whole new world." Even in just my first week, I've run into stuff I don't run into where I live (suburbia) but I get to see within the city limits of Chicago. I just find an opportunity to see rare things often very cool.

Mile 253: Newborns of Wonder

Above: If you come at the right time, Chicago will welcome you along with many, many others.

WE JUST CAN'T KEEP SAYING
BABIES ARE OH, SO CUTE!

6:15 AM - Stuck between two trucks in the middle lane of the Stevenson expressway, I'm glad I have my music lineup ready to stay entertained for my drive to the hospital. I've got my Spyro Gyra, David Benoit, and Phish albums (one of these things is not like the other?) queued for the morning drive. I've now become a member of what used to be called the "rat race" - nowadays it's "commuting," or the "morning rush." We're required to be at the hospital at 7:15 AM, and I live out in the suburbs. So, I could either risk hitting a traffic jam but get some more sleep, or just take it easy on the drive and start the trek early. For the past week, I've been waking up at 4:45 AM to prepare to do the latter...

The group of students that I rotate with has come to a great conclusion: we love babies. Our attending expects us to know how to examine a newborn by the end of 3 weeks, and with lots of opportunities to practice, I've learned that I actually love interacting with them. I'll be honest, I didn't think babies and me went together, but with the several that I've interacted so far, my confidence with working with them has increased. I've learned that I have this tendency to have an imaginary conversation with the baby, sometimes late-night-talk-show-host style.

(But... one problem I gotta fix: I keep referring to the babies as "hombres" or "bros." Yes, even if it's a girl. As much as I'm into bro-hood, I gotta respect the female gender.)

A Try This at Home Moment.
Some of my favorite facts I've learned have come from the neurological exam of a newborn. If you know someone who has an infant within 12 months of age, you might want to try these reflexes on them. It's just really cool how these behaviors are instilled and can be triggered by simple stimuli from you. Many of these reflexes occur due to portions of the brain still in development at their age. In case you were asking: Yes, you can have someone attempt to trigger these reflexes in you (but if you notice you're pulling off these reactions involuntarily... that's not exactly a good thing!).

Just note: 1) that the sooner the better if you have a newborn (most of these reflexes will disappear within the range of 4-9 months of age, with the exception of the Babinski below) and 2) these reflexes are best shown when the baby's awake and alert.

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1. Palmar Reflex - If you place an object or a stimulus in the palm of their hand, the newborn will go ahead and grab it, no matter what it is.

2. Glabellar Tap - Go ahead and tap the area right above the space in between the eyes. Initially, adults blink and then will stop blinking as the tapping continues. For newborns, they will keep on blinking no matter how long you keep tapping.

3. Babinski - Your turn. Take off your shoes and socks, sit down on a chair where your feet just dangle and close your eyes. Now have the person trace the sole of your foot from heel to toe, following the outside edge of the sole (it should be somewhat like a C shape). Note which way your foot points (it should go down). Now pull it off on an infant or a newborn (their feet should point up). What's really cool is that development of just a tract that controls the foot (which isn't developed in infants until 12 months of age), is what causes a simple difference in the reaction to this stimulus.

4. Rooting Reflex - Newborns love their moms. They love 'em so much that they have a reflex to be nurtured. Stroke the newborn's cheek with their finger. The baby should move their head to the side where the cheek was stroked. From what I've read, this reflex works to help the baby find the mom when they are breast fed. This reflex works best if the baby hasn't been fed in the past hour or two.

5. Suckling Reflex - Touch the newborn/infant by the upper lip with your finger (or slightly insert it into the mouth - wash your hands!). The baby should start sucking on your finger.

6. The Moro (Startle) Reflex - I've saved the best for last! Three ways to pull this off. There's a mild, medium, and a risky way to do this.

- The mild way is to simply startle the baby with a clap right above their head or surprise them with a loud pre-recorded sound.
- The medium way is to take the newborn/infant and pull them up by the arms, until sitting up and then let go to have them fall back.
- The risky way is to support the baby by the head neck and back and pull them away from where they were lying down. Next, simulate a drop by keeping support and lowering the baby quickly about 2 feet. It's fun, but one needs to be careful here and support the baby properly.

In both cases, the baby should extend their arms and legs outward (looking somewhat like an X) in response to the startle (as if they're looking for something to grab on). The baby may then pull back their arms/legs (flexing them) and perhaps they cry. They're just so adorable when they pull this off!

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And with that evidence, the intellectually derived conclusion is: I think babies are cool. Not just because they're cute, but there's a lot more to them than most people think.

Shortie: Mile Zero

Above: My odometer start mark for my journey. Forgive the 0.1 on the trip counter - that was from the gas station. As for the seatbelt light - Contrary to the indicator, I do wear a seat belt regularly.

O' MEDICINE,
HERE IS WHAT I EXPECT O' THEE.

As I'm embarking on this second half of medical school, I've given great thought as hwo to approach the clinical side of medicine. I'm going to be expected to do things underneath objectives, rubrics, and my attending doctor's expectations. Well, I'm going to turn it around and put down here what my current expectations are for my next 2 years of medical school and residency. I understand that sometimes these expectations may not be met, but I want the best out of my education and want to be worked to my fullest potential.

Here they are (in short):
1. I want to be challenged (Please, no cakewalks!).
2. I want to experience the roller-coaster of emotions that doctors face day-to-day.
3. I want to interact with patients and staff first-hand.
4. I want to experience a variety of cases, from the most common to the most rare.
5. I want my experiences in medicine to be enjoyable.

Many of my following blog entries may deal with these expectations (and others I might come up with in the future too). And with that, the second half begins. My first stop for three weeks: Jackson Park Hospital in Chicago, Illinois for the first half of my Pediatrics Core rotation.

May the adventure continue... and start that odometer.

Retrospective: Behind the Scenes

Above: The food service staff hidden in this shot from Scrubs. (ABC)

"OUT ON THE EDGE YOU CAN SEE ALL THE THINGS
YOU CAN'T SEE FROM THE CENTER."
- Kurt Vonnegut (Novelist)

I’m practically hooked on medical shows like Doogie Howser, M.D., St. Elsewhere, or even comedic favorite Scrubs (if you haven't noticed already). However, I notice that many times the focus is on the clinical (what I think many people interpret as the most interesting), and not so much on what’s supporting the medical staff. It reminded me of an experience I had back before college...

2003. My final summer in Chicago before I set off for the University of Illinois. I’ll be honest, I wanted to do something that summer, and I considered working at Eagle Country Market (It was an easy job because nobody went to the one near my house) and Best Buy (I thought it was so cool to sell computers back then). However, my mom had a better idea: why don’t I get to work at a hospital? I already wanted to become a doctor – although my reasons weren’t as defined as they are now – so I thought this was a great opportunity.

Just to let you know, I don’t come from a family of doctors. My dad has been focused on business, although my mom is my closest link to anything medically related by working in food service. Although she helped land me my first job in a hospital, my role wasn't anywhere close to being related to medicine...

My job was to work the storeroom at a food service department of a hospital on Chicago's north side. Day in and day out that summer, I took care of deliveries coming into the hospital and stacked the shelves. I was held to the same standards as everyone else in the department (including the cooks and the dishwashers), wore the same uniforms, and paid exactly the same too. I realized the latter when I got a check, and for all that work and expectation, I didn’t think I could support my education – and even my life – with that amount. I now understood that “labored work” actually made handling my finances a quite "labored" too.

But I met some amazing people from within the staff, who have worked at the hospital through many years, some at a dish machine, those at a steel boiler, and some at the tray line. They’ve been supportive of me to this day of my medical journey. I also had the pleasure of working with those outside of the staff, such as the delivery men who came in everyday. I remember one man from a local meat supplier who always wanted me to wear a jacket as I was packing the meat freezer. He said that he ended up having joint problems after years of working in them. As much as I loved his advice, I still went in without the extra layer: sometimes, I just needed the cold to refresh myself from a day's work.

At the hospital, my job duties did vary. Sometimes, I was pulled in for secretarial duties, when they were available. Some of the stuff I created still stands today, seven years later, such as the menu for the coffee shop in the adjacent retirement home and a few signs in the storeroom I got to put up reminding people to always take the stuff off the shelf date first. Other times, I was called to help out for special occasions, such as an employee barbecue, where I had to help drag a large steel grill piece by piece out to the courtyard and then flip burgers for hundreds of employees. It felt good that I was able to help out the hospital by being able to branch off from the store room. I think it was for that reason people just started call me the "floater."

I look back upon the job now, and my mom really taught me a lot of plethora of lessons that summer through helping me get that job, and I really appreciated it. These people - everyone from the people running the food service, the volunteers assisting the patients, the maintenance people making sure everything is in order – are hard-working people that are people who should be truly appreciated for making such a big operation run as smoothly as it possibly can. Doctors and nurses not the only ones working hard and breaking sweats: there’s others behind the scenes also contributing toward a hospital’s mission to care for those who need it.

When I become a doctor, I hope to be as appreciative as possible of the work that these men and women do. So the next time you turn on the TV, take a moment and focus on the people that are around the doctors and the nurses… without them the hospital setting would not be successful enough to create a full-fledged comedy or drama in a prime timeslot around it.

Retrospective: Red No. 40

Above: Robert Moore, Director of Patient Simulation, Ross University School of Medicine - Bahamas campus demonstrates use of a patient simulator. (From Derek Caroll, BahamaIslandsInfo.com)

IN MY DAY,
WE CALLED HIM STAN.

2008. I remember during fourth semester in Dominica, I was ready to draw blood for a blood test on the patient. My proctor was watching me as I went for the median cubital vein for the draw, and I only pulled out air. He said, try again, and as this was my first shot at drawing blood, I mistakenly pushed the syringe in the wrong direction, pushing the air into the patient.

STOP! WHAT DID YOU DO!?
He shouted.

Back then, I didn't know. He told me I almost triggered an air embolus in a patient. Fortunately, I never harmed the patient. After a second try, I hit the median cubital vein, and I drew blood properly using the syringe method. Okay, I fibbed, it wasn't blood... more like a watery substance colored with loads of Red #40 food coloring.

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If you didn't catch it by now, I was working on a full-blown human simulator.

I'll admit that it wasn't exactly like working on a real patient: the simulator couldn't give feedback (only through what our proctor interpreting as the patient), techniques that require fine hand skills (e.g. placement of IVs or drawing blood) could only be coarsely worked upon, and we always had a second chance if one of us did something wrong. In the case of the failed blood draw on my part, I was glad I did: an air embolus might have killed the patient.

However, it was different in years past. From a recent New York Times article by Pauline W. Chen, much of her clinical experiences on patients was done directly to real patients with that risk, and teams reviewed their cases on videotape. Now, patient simulators can be used for full clinical situations, putting away that risk that lies with working with patients needing critical care. It seems to be the answer to the ethical dilemma of if its acceptable to use patients as "airplanes or machines" (according to Dr. David M. Gaba from Stanford University School of Medicine) to test on.

With the simulators at Ross University in Dominica, we were able to work in teams of eight directly on a simulator with a professor as a proctor. And if a group of eight of us, for the first time, had issues with figuring what to do in such a critical situation, imagine us doing the same with a real patient. We'd definitely scare them, and not to mention put them at harm. The simulator room gave us a "safe zone" where we could try our best to develop a team dynamic so we could work efficiently towards the patient. Seconds count with the simulator, but fortunately running out of them doesn't mean life or death (in real terms, anyway).

The one thing I found initially annoying though was how easily the program running the patient could be manipulated. Sometimes our proctor would go right to the controlling computer and click a button, and all of a sudden the patient would be undergoing a deadly arrhythmia. However, I responded exactly as I would have with a real patients, with greater alertness toward the situation, and our team made the appropriate actions. This flexibility enhanced the realism and educational benefit of a simulator session, and in the end, I actually appreciated the switcheroo.

I really hope that simulator technology improves for the next generation of doctors, as I found it very valuable in my medical education. Thanks for the memories, Stan.

Sources: BahamaIslandsInfo.com & The New York Times

The Times, They are A'Changin'

Above: Movie poster to the 2004 film Super Size Me.

1995. The summer of McDonald's was the way I named it. Every Monday to Friday for lunch, my dad and I would go. I think we made a multi Mickey-D's trip, with one of them with the classic red/brown roof, one of them inside a Wal-Mart, and another with modern - and quite hip - styling. My menu looked like this:

A Daily Double (think Mickey D's version of the Whopper, Jr.)
A Small French Fry
A 16 oz Hi-C or Coke/Sprite Mix, with another refill.

Mind you I also was a growing 10-year-old boy with metabolism as fierce as a tiger. So, even after a full summer, before going back to school, I didn't gain many pounds. Oh I forgot, I was also totally a fan of those 7-eleven Super Slurpees (40 ounces of Brain Freeze goodness) too.

Every time my mom would come home and ask where my dad and I ate, she'd always say, "Again?"

2010. My dad and I have spent the time I've been home going to Mickey-D's once again, but this time around, especially with a metabolism more like that of a slug, traditional fast food doesn't go down well with me, so my ordering off the menu has changed:

A Wrap (either Mac, or a Grilled Chicken Chipotle)
A Side Salad
A Fruit & Yogurt parfait
A Water or a 16-oz Diet Coke, with refills

Ever since the movie with the quite appropriate name came out, McDonald's has impressed me with its healthy options. I've done the calorie calculations and the above meal calculates in at about 550-700 calories/kcals (depends on my wrap, dressing, and crouton preferences), and doesn't really blow me out of the water in terms of fat content or cholesterol. It's a pretty balanced meal.

So, nowadays, this goes to show that going to Mickey-D's isn't synonymous with bad food anymore, provided the right choices off the menu are made. And that's why Americans are getting larger and acquiring health problems as portrayed (sometimes exaggerated) in Super Size Me, some people just make the wrong choices and say those three deadly words at the counter when ordering.

However, don't get me wrong: although times have changed in the way I eat, my mom still says "Again?" when she comes home from work. I'm used to it... so is my dad.