Mile 24417 + 2710: Different Mindsets

Above: I ate this food 2 hours after taking this picture when the food was fresh. Oh ER...

"YOU AND I HAVE
DIFFERENT MINDSETS."

A seventeen hour drive was completed about two weeks ago. It brings me to the sunny shores of St. Petersburg, Florida. I am enjoying my time here so far as the mentality of the people of the city definitely feels midwestern, but of course, the weather is a side benefit to living here too. We're less than 7 weeks away from graduation...

During my days in the Emergency Room to date, I'll have to say that no day is ever the same. There are some shifts that'll have me waiting for a good case, other days I'll have loads of good cases. There are days that there will be no procedures, and other days where I'll be doing a million. There are days when my days are filled with a bunch of chest pain due to a cardiac cause, and other days where I get a bunch of chest pain from drug seekers.

I had an opportunity to work on a patient who came in with abdominal pain and urinary incontinence over several weeks, but was soon discovered to be pregnant via a urine screen. When presenting to my attending, my assessment started with the important stuff, the abdominal pain probably secondary to being pregnant, and then when I started on the urinary incontinence, my attending stopped me in a friendly manner, saying we're going to take care of the pregnancy first. However, although I knew that was very important, I thought that addressing the patient's concerns about her frequent urination and peeing would be important.

That's when my attending told me that we have different mindsets. I wanted to take care of the whole patient, or at least address everything, but the emergency room doctor needed to prioritize. I agree there should be priorities, but it seemed the patient's urinary complaints would go by the wayside if they weren't addressed further in the visit for follow-up.

I love taking care of the whole person as much as possible. It's a hard habit to break.

However, that doesn't mean Emergency Medicine has been a bust. It's been anything but. I've had opportunities to put stitches in people coming in from accidents (20 in one patient, and even learning the technique of the vertical mattress to add on to my skills), taking care of abscesses, and even yanking back dislocated hips (which taught me that I need to go to the gym). These types of procedures are seen frequently in the emergency room, but if I have my own practice, it's possible I'll be doing these same procedures too, so I'm glad that I have an opportunity to do these now.

Emergency Medicine at Bayfront here in St. Petersburg has also brought me to work along with the armed forces, as the ER here is a site of training for them. I had an opportunity to meet some of our folks who are learning to work on the field as medics, and some of them have taught me a pearl here or there. As tough as our armed forces are, they are real people and great at teamwork. Many of them are blunt and honest with each other, but each member took it on as constructive criticism. I really enjoyed working with them as they had a very good model for camaraderie.

Mile 24417 + 1204: Shortie: The Final Leg

Above: Oddly found a four-leaf clover in front of the cath lab this month.

I MIGHT HAVE TO BRING
THE WHOLE HOSPITAL WITH ME.

That's what I said when everyone reacted with interest when I mentioned that I was heading south, with fall right behind me.

I'm about to head off to bed, but I just wanted to log that we're 1204 miles in. Tomorrow begins the trip to St. Petersburg, Florida, where my final rotations in Emergency Medicine and Obstetrics & Gynecology will take place. I'm looking forward to it. But first, time to rest, there's 17 hours of traveling ahead. I'll update you on some of my final adventures in Columbus soon, when I get an opportunity to stop on the road.

Mile 24417 + 847: Pull Up a Chair...

Above: The Cath Lab has a wonderful Digital LED clock emitting the tone, "Pressure."

"IT WAS
SNOWING..."

... was what the patient said to me as I listened to him/her give their story about their current issue in the hospital today. The patient was on the elderly side, but I found it amusing. I played along with it to see where the patient was going with it. However, just to make sure I didn't mislead anyone, I told that patient that it was 70 degrees outside and warmer. Patient's response: "I hope it stays this way."

----

After three weeks of Cardiology (and 847 miles into my second cross-country trip), I'll admit that the group I am working with has me truly enlightened on a huge concept in medicine. It's more than diagnosis and treatment... it's also risk management. Measure the costs and benefits of each treatment and see how that works well for the patient. Mnemonics like CHADS and TIMI sound pretty silly when you're not in the medical world, but to us clinicians, they mean the difference between whether or not we're going to thin someone's blood for possible clots or whether or not a person had a heart attack or not.

On another note, going into primary care and providing excellent bedside manner is something that I am looking forward to doing when I become a doctor. And, I'll say that the last place I expected someone to pull up a chair and have a solid conversation with a patient was on a consult service. However, each one of the doctors I've seen, provided there's an open chair or a ledge around, will sit down to have a face-to-face conversation with the patient.

When I was in Decatur, IL, I remember sitting in front of a news article stating the benefits of sitting down. It makes so much sense though, as it makes the visit much more personable for the patient, and instead of seeming like a commander, it makes the doctor seem like more of a role model or counselor. I think that can go yards to helping a patient feel like he/she can participate more in what is going on, and feel more comfortable with all that is going on around them.

And that also goes for the physical exam. I don't know if I have posted it before, but this article from the New York Times, mentions how Stanford plans to revive the Physical Exam. I've mentioned before how numbers and labs are important, but the context to which they are all interpreted are covered in the history and physical. But there's more to it than that... utilizing the stethoscope and interacting with the patient, seem to give the patients a feeling that the doctor is truly participating in their care. As much as numbers are accurate, numbers can only do so much.

So, next time your doctor takes some time to sit down next to you, it's no longer only in times of bad news, it's always for the best.

Mile 24318: Call me Erwin

Above: Graham crackers are in ready supply on the surgery floor.

"ERWIN... JOHNNY...

ALMOST."

- My attending on a fellow medical student calling me by the wrong name.

Last year, during my Internal Medicine Rotation, I found myself eating a horrible breakfast a lot of mornings when arriving at the hospital.   However, it was the most easily accessible: potato chips and cups of juice (that in truth were only 10% juice) stared right at me in the resident's lounge.  It was a terrible combination. Well, during my Anesthesia Rotation, I've gotta say that I worked on it. I'm getting more nutritious by keeping my energy levels high through Graham crackers. These wonderfully available packets (above), kept me going through taking patient histories, inserting LMAs, and following through with patients in the post-op room.  Pretty potent for a small packet, I may say.

And here I am, after a full sixteen weeks of Surgery, currently in a 2 week break before hitting the road to Columbus.  As much as I'm not going to go into Surgery, the folks at St. Anthony have really taught me an appreciation for it (with or without the graham crackers).  I'm not going to forget how the masks and scrub uniforms on the nursing staff made people look completely different than when seeing them outside of the hospital.  That perhaps led to my last nickname, Erwin, when a fellow medical student couldn't come up with my name.

Erwin... It works.

However, my last four weeks in anesthesiology were quite interesting.  Originally, my perception of a day in the specialty consisted of placing some tubes and watching the patient as they fall asleep, then waking them up, and you're pretty much done for the day.  I ended up seeing their jobs are much more important then orignally thought, making me appreciate the rotation much more.  If you think about it, just a couple ounces of anesthesia, if placed into the wrong part of the body or if dosed wrongly could put the patient in danger.

I've talked about the "art of medicine" before from my perspective, as much more of a clinical thinking concept, but the "art of medicine" in Anesthesia I saw was one of procedure.  Many of the procedures, such as spinal or nerve blocks, or even the classic intubation require a lot of muscle memory and hours of practice.  Everything they do needs to be accurate and precise, or a lot of wrong could happen.  But it doesn't.  The doctors and nurses in the anesthesia department at St. Anthony were pros at their jobs.

And with that, I'm entering back into the realm of medicine, and taking a Cardiology elective at Grant Medical Center in Columbus, OH.  This is the start of the last big road trip I will make during my medical school career, and the start of the last three rotations ever.  My journey through medical school has been amazing so far, it can only get better toward the end.

Mile 23611: Books Were Here

Above: My Local Borders Bookstore Is Closing.

READING KINDA MAKES ME FEEL
LIKE A KID AGAIN.

Flash back to 1993. Imagine a pony-tailed me (I think the 1980s lived on to the early 1990s for me) in the face of a book about 500 pages thick (the pages weren't that wide, so don't think I spent a year to get through it). One of the things that I always looked forward to doing in elementary school was reading through a book, and then taking a comprehensive quiz to garner points as part of the Accelerated Reader system. It was a good program, as it made me work on recalling what I read, and better yet, made me enjoy a whole breadth of books.

2011. I now own a kindle. With the breadth of free classic books on it, it's been a great add-on. I could access tales of Jack London that I read when I was younger, or even classics I have never touched such as Jules Verne's "The Time Machine." However, with the attack of information I've gotten from aspects of medicine all-over, I haven't had as much time to read. There's something about reading a book from front to back in a good setting.

However, with the recent announcement of the closure of Borders' Bookstores, I decided to stop in. Borders was always my favorite of the two big boxers. For some odd reason, it didn't feel as pretentious, and their staff was always nice and courteous. I liked their pricing compared to other big B down the street too. But with the recent sales, I thought I'd get my hands on a couple of books I've been meaning to read. I'll admit that holding a paper book gets me kinda nostalgic. Here's a couple of classic books I got from Borders' this week:

George Orwell's 1984
Craig Ferguson's American On Purpose
John Steinbeck's Travels With Charlie
Ken Keysey's One Flew Over the Cuckoo's Nest

It's been a odd past couple of years for big bookstores in my area... the closest bookstore to my house where I studied for Step 1 closed suddenly (the other B- store), and then the Borders I prefer to go to is now going to shut their doors. Libraries were great to study at, but there was only one problem, I needed my coffee. And then coffeeshops were also great too, but they had a little too much conversation going on. And no better invention was made by man to get the best of both worlds by combining both... a bookstore cafe.

After I finish my boards for med school and my applications for matching, I look forward to reading all these books straight through. It's certainly been a while since literature and I have spent some quality time together.

Borders Books & Music, you will be missed.

Mile 23344: Shortie: A Steaming Summer

Above: I get double dared both on paper and in person on the surgical ward. This is the paper version.

I'M 8/10 IN USING MOTOR SOUNDS
TO KEEP BABIES HAPPY.

Well we jumped the 20000 mile mark just about a month ago, during surgery. However, studying for the big Step 2 CK exam which is coming up this month, so time has been limited to write. That doesn't mean that the writing is over. I finished my surgery rotation a month ago, took 4 weeks off to study, and right now am back in business with doing an anesthesia rotaiton here at Saint Anthony Hospital in Chicago, IL.

This is just a quick note to say I'm alive and I'm still counting miles (we're quite up there right now).

The summer has also brought some unexpected surprises.
- I'm now a Godfather to a beautiful baby boy, Joshua. I attended his baptism in June. He loves motor sounds. However, little did I know they only work on most babies. I learned that fact quite quickly at the baptism.
- Old Silver is now New Blue... Long story put short, my old 2002 Ford Focus needed to be retired, so a 2012 is now my new mode of transportation. However, my mile counting still sticks dead on the dot accurate mile for mile.
- It's match season, so applying to residencies is in play currently.

Another surprise: this summer has just been plain hot. And I'll be honest, with all this work to do, it's tough to get out there and enjoy it. However, I believe that work will pay off. And I certainly hope it does. More soon.

Mile 19314: Chasing the Smoke

Above: I really pride my hometown. It's quite a beauty, no? September 2010.

HERE...
HOLD IT!

Last week, my surgery partner and I are putting together a presentation for journal club on the Nissen Fundoplication we did earlier in the rotation. It was really cool to have an opportunity to present the case & the operation in front of the surgical nurses / assistants of the hospital. A really rad case the Nissen was, but I've been learning over the last few weeks that even the basic of the basic surgeries (I would assume that a surgeon would call them "easy cases") would teach someone going into primary care some of the easiest tricks up the sleeve for being a team player in the operating room.

I had written in one of my blog entries in Dominica, about the excellent communication I saw between nurses and the attending doctors. It's just awesome to see the voiceless transactions that occur here in the operating room at the hospital. But with the opportunity to scrub in with several surgeons, it's interesting to see how different attendings have different expectations on communication.

For some, they're pretty vocal. One of the surgeons I work with during Lapascopic procedures communicates well, and I kinda plug in extra judgment with my experience with him to get the camera angle right for him to use the "Bovie" with precision. (It's so weird, because you're acting as someone else's eyes). Some are a little less vocal, using one to three words to describe how to assist, such as the command that started this blog entry, "Here, Hold it!" Another one of the surgeons is a lot more silent, but with more experience with him, I'm able to figure out if he really wants me to chase the smoke or drain out the blood. And somehow, we get it to work.

In addition to learning more on how communication can go about in the operating room, I'll have to say that I'm happy that I was able to pull off my first suture in the OR... actually 2 small ones. We have an awesome set of nurses, attendings, and surgical assistants, and it's great to have an excellent support group (which I wasn't expecting in the first place from such a stressful environment in the OR). Also, as of this week, I'm learning how to throw in IVs... a couple of us get together around a table and basically spend the time to practice on ourselves, before going out in the "real world" and practicing on the patients. I'll admit, that it is touching to see that all of us are willing to risk potential hematomas or blown veins for each other's learning benefit.

This week, I started Orthopedic Clinic which I'll be doing for the next four weeks, and I'll update more on that in the next entry.

Mile 18039: Candid Camera

Above: Streaks of sky light up Covington, Ohio during a brisk March sunset.

I LOVE SEEING LESSONS COME
FULL-CIRCLE.

This week, I had an opportunity to guide the camera behind a laparascopic procedure. I enjoyed being behind it for once, pulling in and swiping across the abdomen to make sure the surgeon covered all the ground he needed to cover. When I was in Dominica, I had written about how surgeons and their assistants start to have this way of "hidden" communication. I've worked with one surgeon for the past week, and I'll admit the first time I assisted, it was like trying to teach a kid to bike without training wheels. Fortunately, I had a patient attending, so by the second time around, I started to get some of the gist of what the surgeon was going for.

For those of you not familiar with laparoscopy, the jist of it basically comes down to a fiber-optic camera (don't think of a lens-faced camera, but a camera in the a shape of a long-thin pole). Many surgical procedures in the abdomen in the past used to be conducted by cutting through the front part of the stomach wall, and when the surgery was over, a big scar would be left across the abdomen. Things are different with laparoscopy, a couple of port holes for instruments and the camera itself are poked in, leaving only a few small scars after surgery. It's much more cosmetically beneficial.

And here I was, keeping my eye on the plasma screens, on the scope, being the surgeon's eyes, and kinda like his brain (most of the time). And soon, the surgery was over. I was soon assisting in my first sutures, and I'll admit that its gonna take practice to get the art down of beating the "anesthesia clock." Basically, suturing up surgical openings is harder when the patient starts to breathe on their own and get active as they wake up from being asleep during the surgery. However, the thrill of jumping in to try things out is definitely there.

And, although my primary intention is still to go into primary care, I'll admit, Surgery so far has been a blast.

Mile 17935: Surgical Adventures of Dr. Shortcoat

Above: I was living "on the air" in Cincinnati. At the Cleopatra exhibit. March 2011.

SURGERY IS AN EXPERIENCE THAT CAN BE LEARNED

THROUGH EXPERIENCES.

On Monday, I began my 12 week adventure into Surgery. Operating room observation, follow-ups on patients on the floors, going to clinics to do more follow-ups and consults, and the list keeps going, but its something I'm looking forward to. I had talked about the operating room in Dominica when I first came onto the island, but I'm glad to be finally writing about it again.

This week, I experienced the longest of surgeries (at least according to one of the nurses) that I'll be experiencing. It was the Laparascopic Nissen Fundoplication procedure (basically wrapping a portion of the stomach around the esophagus as one of the treatments for GERD - layman, acid reflux - not responding to medication). Five hours standing, and assisting by basically handling instruments in an upright position for multiple hours. I'm a bit sore, admittedly, after holding up some of the instruments after a while. However, it felt good to scrub in and afterwards getting my first shot of real stitching after the surgery was over. I used to complain about my ability to scrub into a gown, but with this rotation, I feel I'm getting better.

The operation was rather interesting, as at a point during the operation, there were multiple plasma screens that I could look at, with one camera looking down the esophagus from the mouth and the laparascopic scope looking at the stomach from inside the abdomen. I'll have to say that doing surgery is sometimes like a concert... the lights are on, you have the best view when scrubbed in, and your attention is definitely on the person in the spotlight. Now I know where the term "Operating Theater" came from in Dominica.

My first real scrubbed in surgery was quite an experience. I'm looking forward to the next 12 weeks not just to experience what the profession can offer, but also to learn a few tricks from surgeons that may be applicable to my life in primary care (we still have to do procedures!). Over the next few weeks, I may be also reflecting a little bit more on my last roadtrip... as much as I'm missed Chicago, I'm now missing the road.

Dr. Shortcoat was a name I had earned from one of the nurses when I was in Decatur. More about how I got the name later.

Mile 14020 + 3797.7: An Amazing Roadtrip

Above: Snuck onto OSUs campus during their Spring Break. Here's the Thompson Main Library from the Oval.

SO MUCH TRUTH WITH OHIO'S SLOGAN:
SO MUCH TO DISCOVER!

So we're now at a grand total of 17817 miles, with 2 board exams on the table (one later this week) and the last day of rotations creeping closer and closer each day...

After a six-hour trip beginning with breakfast at Tim Horton's (we don't have one in Chicago), lunch at a Bob Evans in Indy (we have one in Chicago, but I haven't been to one in a while), and ending with me breaking a $20 bill to pay $1.60 in tolls, I'm quite tired. However, I'll have to say that I just had the roadtrip of a lifetime. It wasn't just fun, but I learned a lot about myself, different aspects of medicine, American culture, and enjoyed every moment of it. When I started medical school, I did not imagine myself doing something like this.

If you're from Ross or another school (Caribbean or not) that has the opportunity to travel to do rotations, I highly recommend it. I know that many people like to stay in one place to do rotations to save on money and limit travel, but there's just so much out there to discover. I've always loved traveling (the roadtrip has always been a staple of bonding for my family) and I thought that this would be an excellent opportunity to combine what I love to do along with my love for medicine. I saw some of the benefits of hitting the road when I had my May roadtrip last year. However, unlike then, this road trip still had aspects of personal exploration, but also now combined learning more about my field and where I may want to go in the future.

In terms of learning, one of the peeves that I had with traveling was that every four weeks I would have to change up my routine as each hospital had their own way of doing things. And it wasn't just in terms of attendings, but each hospital had a different set of protocols or ways of handling situations (i.e. one hospital had a "electrolyte protocol" to automatically replace low levels of electrolytes like sodium or potassium, while another hospital needed specific instructions from the doctor to do so). Some hospitals were almost completely had full electronic medical records, while other hospitals were still primarily chart based. Every four weeks, just about when I was ready to finally adapt to the new system, I was about to start packing to head to the next site on my trip.

However, that in itself is one of the beauties of traveling. I think that learning different ways that hospitals work can help in the long run of adapting where ever one ends up to be. It also gives a wide-perspective on how different attendings from different locations have different approaches. It turns out that everyone has different ideas on how to do things, but for the most part end up with the same endgame. I took what I liked from each region and attending and took mental note so I could develop my own clinical style when I start operating autonomously as a resident (provided I match first!).

On the traveling end, I was so glad to visit 3 places I have never been before. The beauty of the hills of Binghamton, the charm of the people in Decatur, and the educational pride seen in Columbus have positively added to my experience. I perhaps have a better hold of what types of cities I'll be looking for when I start my residency search this fall. A good lifestyle to balance the stresses of residency, charming people, a unique city personality are some of the criteria I'll be looking for.

So there it is, after miles (and hours of driving), I am quite tired, but I have my Step 2 CS examination to take later this week. And then, Surgery... and then Step 2 CK... and then more electives... The train of tests, requirements, and rotations never ends, but with each mile I travel, there is always a new sense of adventure. I really thank my university, Ross, for giving me the ability to put a trip like this together. Traveling has definitely been one of the defining points of my medical school experience.

For now, though, I am glad to be home.

Mile 14020 + 2980.5 - Medicine By The Numbers

Above: My lone welcome into Ohio. February 2011.

TAKING ON THE ICU
ONE NUMBER AT A TIME.

Well it’s week 2 here for me in the ICU and CCU at Grant Medical Center here in Columbus, Ohio. I’m getting used to the big city rhythm again, by taking my 15 minute commute everyday down Interstate 71 to get to the centrally-located hospital. Could you say my rush-minute days are over? Well, not certainly so, as traffic moves, for the most part, well in Columbus, in comparison to Chicago.

During my past year of clinicals, this is my first real exposure into the world of critical care medicine. When I did my Internal Medicine Core, I remember simply seeing these huge plasma-screened machines sitting next to patients that were dependent on these machines to live. Well, now I know what those machines are saying to me. Welcome to the world of the mechanical ventilator, where with the simple touch of a button, I could change any aspect of the patient’s breathing. You name it, it probably can do it (make it longer, make the patient take deeper breaths, even set them to breathe at a minimal rate). There's other machines, such as ones that are able to give dialysis 24 hours a day and even those that dose IV medications and fluids precisely.

Critical care medicine has also been interesting, as they take a different approach (at least in my perspective) to gathering information than I’ve seen in my other rotations. History-taking is very important to a patient on the medicine floors or a family physician at the office, but as many of the patients entering the ICU are sedated and most probably intubated, much of the history and decision making has to come from other sources, mainly the charts and labs. For the hospitalists on the medicine floors, it’s an information gathering game (most diagnoses can be concluded simply from the history itself), while I see that critical care physicians play the numbers game (I’ve never seen evidence based-medicine play such a dominant role until now).

One thing can be truly daunting about the ICU: there is always at least one machine, TV, or monitor in a room. I think I saw at least one room this past week with a dialysis machine, mechanical ventilator, vitals monitor, and multiple digital IV infusion pumps. I’ll be honest, if it wasn’t for these machines, many of the patients in the ICU/CCU would not survive. I find it odd that we always make fun that someday computers and machines will take over the world, well if one looked at the ICU, machines were definitely taking over one patient at a time.

The outcomes from the machines differed from patient to patient. Sometimes the machine was able to assist someone who had an acute exacerbation of their COPD to get through a day of respiratory distress. And others… well, are best demonstrated by the code I experienced last week. As I’ve been hearing, coding is no joking matter. With each minute that a person goes through CPR, I’ve heard the survival chances of that patient decrease by 10%. And with the code that I experienced, it lasted quite a while. When one loses the game, its rather difficult to see, as one by one, each of the screens and monitors takes their turn to turn off. It’s as if they are giving up, but in truth, the machines get to be shipped off to the next room to work on a new patient.

However, as dark as this may seem, there are wins that definitely occur on the floor. I feel a genuine feeling of good whenever I see a patient start to wake up on a ventilator, and move their way to a much less invasive nasal cannula to assist with getting oxygenation to them (basically a plastic tube that shoots oxygen up your nose). I had a patient this week smile after her week on the ventilator. She sounded like she faced a tough battle with that machine, looking fatigued, having a rough, raspy voice, but she did well. Each time we're able to pull out a tube, I feel like the ICU/CCU team definitely had the machines on their side.

---

This past weekend I spent in my friend Neal's small town of Clarksville, OH with his family. It was a great experience experiencing the real small-town first hand. More on that next time.

Mile 14020 + 2482.6: Main Street

Above: Americana at its best. The aluminum-sided diner on a business-lined Main Street. Red Robin Diner, Johnson City, NY.

BACK TO THE
BIG CITY LIFE.

... more on that in a bit.

My four weeks in February were my first four weeks ever in New York. And to many people, when I mentioned that I was in New York, the first thing they ever thought was "New York City." And I was like no, there's more to New York than NYC. But I can understand, with NYC's metro area being almost twice the size of Illinois as a state itself in terms of population, there can't be much more. But to me, a traveling Midwesterner, I had to explore the world of upstate NY for myself.

So after four-weeks in the flat-land of Decatur, I found myself in Johnson City, New York. It was quite a change, being amongst the hills of the Appalachians, but I found it quite enjoyable. A part of me wished I could ski, so I could go up and take advantage of the hills, but I'll be honest, the beauty of the area was just awe inspiring. It was my first time to the Northeast ever, but the hospitality of New York State made my stay quite memorable (not to mention having someone at church giving me a genuine hug before a week before I hit the road!). Binghamton was one of the cities that had a culture and identity of its own while combining a small-town feel into the variety of things to do in a bigger town.

However, I wasn't there to simply enjoy myself. I had an Internal Medicine Subinternship to accomplish. A new routine had to be learned, but I was pleased I got to work with two groups I had limited interactions with in my past: 1) U.S. medical students - I had some experience with them in OB, but not as closely as I did here. 2) Osteopathic medical students and residents. As for the latter, I took advantage of my four weeks, and got to watch what made them exactly "different."

And to be truthfully, during rounds and having discussions, there wasn't much different there. So I asked one of the residents that I worked with, "What makes osteopathic medicine, osteopathic?" And all of a sudden, I found myself doing a process called "rib raising" on a patient with a ventilator. The philosophy (and forgive me if I get it wrong me being an allopathic student) is to give more room for the lungs to breathe air by increasing the space between the scapula and the spine. A very cool thought. I saw other osteopathic manipulations that involved very fine finger dexterity and sensation that I could only see years of practice mastering. I really enjoyed I could learn something new over the last 4 weeks, as I don't think there's only one right way to master the art of medicine. Somehow we all have an approach that works, and as doctors, we stick to it.

But one thing that I noticed about my 8 weeks on the road, was the value of overnight call. Yes, I would end up tired and pooped after 24-30 hours on board, but then I would realized the value of staying up. To interview patients and get those History & Physicals of unique in-the-middle-of-the-night cases was amazing. I remember in both the ERs of Decatur and Binghamton, I'd stand there at 3 AM figuring out how I should attack the history of a patient. Perhaps it was the novelty or even the academic satisfaction of getting my brain to work at such an early time in the morning. I learned a lot during those hours in the morning, and that's something I'm thankful for.

Now, my drive has brought me to the world of Columbus, Ohio. Where I'm doing ICU. More on how this rotation has a different way of looking at patients in my next entry.

Mile 14020 + 1804.2: Catching-Up

Above: A shot from one of the overpasses at UHS Wilson Medical Center in Johnson City, NY.

The whole last four weeks were both absolutely busy and awesome. So, here's a retrospective entry on a lot I haven't talked about, and we'll get caught up this week (hopefully). Due to the above, I left the odometer at the mileage before hitting the road today.

THE ROADS WEREN'T EXACTLY
FRIENDLY.

My last night in Decatur wasn't exactly just spent packing. I actually went to a journal club that night with a couple of the residents. A few of the discussions that they had really got me thinking. Now, I think that the current debate on how effective kyphoplasty and vertebroplasty actually are on curing pain for spinal fractures is a good one to look at (and right now the best study shows that it isn't). However, the whole time I was thinking... evidence-based medicine (EBM) against basic-science-based medicine. A lot can be explained with pathophysiology, but theoretical doesn't mean its proven. And that's where evidence-based medicine comes in, the proof that theory works (or doesn't). However, a lot of the ideas where studies for EBM come from either come from basic-sciences or practicality. So, in short, they both go hand in hand.

And 36 hours later after I finished in Decatur, I found myself amongst the Appalachian hills of Upstate New York. The trip wasn't exactly the friendliest, as snow dominated my trip on I-86 in Western New York. Some of the roads I passed only had one lane plowed, and I had to make the ultimate winter road trip decision... Take the plowed lane with potholes the size of montana, or the unplowed lane without them. But I ended up in Johnson City, NY safely. My four weeks on the wards of Internal Medicine for my Subinternship were quite intense, but very enjoyable. One of the things I liked about both of my Internal Med rotations (Core & Sub-I) was teamwork that's necessary to keep things running on the floors and in the hospitals. Somehow different combinations of residents, students, and attendings seem to always work out. But as I may have written before, every time I get into a rhythm of things, I have to move on for my next rotation. I can't wait for residency, as I finally can get into a rhythm with my colleagues for a good three years.

Well, I'm tired after a long day of driving... So, more thoughts on my last four weeks on Internal Medicine and on what's going on with my stop in Columbus tomorrow.

Mile 14020 + 667.4: Shortie: New York Bound

Above: Sometimes on the road, if you pick the right one, you'll be the only one on it. Indiana Route 63, May 2010.

ANOTHER ROTATION,
ANOTHER LOCATION.

Sitting in a Panera Bread after checking-out after what I called the longest time I ever spent in a hotel room, I felt compelled to mark the beginning of the next leg of my medical adventure. I've enjoyed my time here in Decatur and I have a few more things to reflect on the area by the time I get to Binghamton, NY (provided the snow doesn't lock me out)! By this time tomorrow, I should be on the road, and 36 hours from now, instead of seeing the flat plains of the midwest, I'll be amidst the snowy hills of Appalachia.

On deck to reflect: journal clubs and being on call. Cya on the east coast!

Mile 14020 + 638.1: Countrified Conversation

Above: Traffic in today's Decatur Rush-Minute.

YOU NEVER KNOW WHO YOU'LL MEET
AT A COFFEEHOUSE.

Ever since I started writing in this blog, I have always written about what I like about smaller communities. My stay in Decatur (about a medium size city) has been defined by amazing patients, great faculty, and a very intensive learning experience. The city perplexed me with not only having two Starbucks locations, but both locations are within 200 feet of each other (one is located within a Target, and there's a freestanding Starbucks right in front).

As I was studying in the freestanding Starbucks this week, I noticed one of the people that walked through the door looked familiar. That person came to sit down at the table next to me. It was then that everything clicked. I saw that person at the hospital and she was in the family of one of the patients that I saw during rounds. I ended up extending my hand out to that person and introducing myself...

"I don't know if you remember me, but I was at the hospital when..."

Her eyes lit up, and one of those looks where everything clicked appeared on her face. Another person related to my patient in the hospital also sat down with her. He shook my hand. Little did I know that just opening up to them would result in a hour in conversation about health care, patient education, and even stories about health care that either discouraged us or inspired us about the field.

Let me tell you, hearing about the healthcare shortage in rural areas meant so much more from people from the areas themselves than the media. I was hearing stories about how much family physicians were critical for care here in Central Illinois, stories about doctors moving out to urban areas for better support, and how much family practice meant a lot to this family. I really appreciated the open honesty and conversation we had.

They asked me what specialty I was considering to go into. When I told them I was strongly considering Family Medicine, the man held out his hand, and as I grabbed it to shake it, he said, "We need people like you here." The woman then said, "Are you coming back here?" I explained my love for Central Illinois (being a part of the alma mater) and told them that I would gladly come back if they let me back in. We all laughed.

Small / Medium sized cities have always caught my interest. Yes, Decatur may not have everything that Chicago has in terms of lifestyle, but the people are who make the difference in experience. It's not every day that one can run into patients at the store or in a coffeehouse, but its a part of the continuum of care: knowing that one can talk to his/her doctor even outside of the hospital is reassuring to our patients and helps build that patient-doctor trust.

(It was awesome to see that my Iced Coffee Property has some actual basis.)

Mile 14020 + 236.4: The Superdoctor

Above: January 2011. With winter approaching, borrowing our AWD Ford Freestyle was appropriate.

ALWAYS GIVE
150%.

With this entry being halfway-written during my time in OB, this entry will have a first-day feel, but it easily relates to my intial experiences in Family Practice.

All first days of my rotations seem to be just about the same. A bunch of students sitting around a room, some knowing one student more than others, with an aura of silence that surrounds the room. A man in a sturdy, well-pressed blue suit walks in. Wearing glasses, and sporting fine (but well groomed) gray hair, the man definitely has a presence. As he looks around at us, we all fall into a bout of silence. As we look up, a friendly smile develops across his face and he welcomed us into OB.

We then knew we would have nothing to worry about.

During that first day, he was an example of a model teacher. Some of the most inspiring doctors that I have observed during my time in clinicals have a degree of charisma, passion, and love for what they do that really inspire me. One of the most inspiring things about him was his concept of the "Superdoctor." A terrific doctor, to him, is a doctor which can only diagnose & treat conditions after they've occurred. However a "Superdoctor" is able to prevent those conditions from occurring in addition to being excellent at diagnosis and treatment. Education of patients and anticipation of sequelae of diseases are absolutely necessary to pull this off (and something that I hope to learn. He said to always give "150%" to your patients; I most certainly believed him.

And this is one of the places I've seen this has been at my Family Medicine Sub-Internship. This is one of the things I really admire about Family Medicine, the time taken to know the patients and where they come from and their lifestyles. I've seen how knowing a patient can contribute to better anticipation of how a disease may progress (i.e. how to adjust a treatment plan for a patient who has been non-compliant int he past). I've also seen attending physicians and doctors set good examples for educating their patients, spending the time to advise them on what else they can do (than just the medication) to help out with their health.

----

So, I'm sure you've noticed the mile formatting change above. Well due to winter, I ended up in a more "wintry" car for taking this cross country trip, so while my dad uses my car, I get to use an all-wheel drive car to make sure I stick to the road. So, after 14,020 miles in my Focus, it's time to pull these miles on the Ford Freestyle (the +236.4 and counting miles).

Living in Decatur has actually been pretty cool. With the wide range of patients that come to Decatur as a health center, I've met many patients from kids to adults and the stereotypical Midwestern family to the Amish. However, the patient population has been really receptive to the teaching environment, and not to mention patient. I really, really respect and appreciate that. This week, I participated in the resident clinic seeing patients. Next week, I get to spend some time with the interns on the inpatient floors.