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.

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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.