Mile 1036: Games People Play

Above: My high score at Buzz Lightyear's Space Ranger Spin at Walt Disney World, FL. May 2009.

"SEEING IT FROM WHERE I STAND
NOTHING COMES EASY."
From the theme song to the 1990s sitcom Just the Ten of Us.

2008. A group of 10 of us students sits in a small room on our first day of the Behavioral Sciences Lab. There's a huge table in the middle of the room which we all are sitting around. We're staring at each other, probably making small talk... but we're waiting. A Dominican lady walks in, along with one of our faculty, and they sit at the table. I find myself in the chair directly to the right of them, as they prepare the class. And when they asked for a volunteer to interview the Dominican lady (a patient, standardized most of the time, if not always), I had raised my hand. A form with questions to ask was handed to me, and soon I found myself going through the form to take the Dominican's history.

However, I knew that soon enough - just like the training wheels on the bicycle - I needed to be free of support to know I could really do this on my own.

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We're finished with the babies, at least in terms of a full-time sense. As I've crossed the 1000 mile mark on this part of the adventure, we've moved from the hospital setting to a private practice in Buffalo Grove. Here's the dilemma I'm facing - how to take a history from a pediatric patient. Even though I've been through many experiences with history taking - starting with standardized days of yore - it feels different when I'm in with real patients with real health issues. I just don't want to mess up.

I'll admit during my first few days, I've felt nervous about taking histories and physical exams, but when I had talked to my attending doctor, he said that experience comes with practice. From what I've seen so far, I think there's three hoops to leap through to get an accurate history and physical exam in pediatrics:
1. The Kid's Trust
2. The Parents Trust
3. The Kid's Communication

One of my group mates brought up an excellent idea on why I might be having trouble: why don't I try playing a few games to start to earn some of the kid's trust. No, I didn't pull any of the following things on 19-year-olds but I did try them on some of my younger patients. For instance, with an infant, I soon made my hand into an airplane to try to make the kid smile. The benefits were enormous though as the kid showed teeth! I knew I had made the little one comfortable for the ride.

However, it's not over yet, as many kids come in with concerned parents. And I've seen them all, from the laid back, leave the son/daughter in control mom/dad to the stern, "I don't any students in the room" mom/dad. Parents are an important part of the health of the kid, and from what I've learned so far, as physicians, we're not here to override what parents are thinking, but to help and assist them with their children. The cool part is that pediatric histories may include a combination of information from the mom/dad and the patient himself/herself (both will answer your questions). It's up to the clinician on how to interpret any differences (which occur often!) between the two.

I also am learning how kids love to term how they feel. Some instances were an unending "stream" of yes's to a line of questions I asked one patient. Other times, I found myself trying to interpret what "weird" or "tickle" meant. The words are cute, but in order to help out the kid, I had to probe what exactly those words meant. I'd love it when a kid would clear up how "weird" something was by saying, it was just "weird." It's just another piece to try to put into the puzzle.

I guess jumping through hoops may be right up my alley.

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.

What's Next?

Above: A Med Student's Bible, First Aid (2006, 7, 8, or 9). I have the odd -numbered years in that aforementioned set :P.

"IF WE CAN DREAM IT
WE CAN DO IT."

-- From EPCOT Center's Horizons (1982-1999)

I really enjoyed that I took some time off for R&R after the COMP. Spending some time at Epcot to refresh myself on the promises of the future, and now on the shores of Daytona Beach to relax, I'm back to get into the grind of studying (I miss my coffeehouses).

I talked a few entries ago about where I want to go as a doctor. Well, it's time to take that issue head on. For every medical student, the boards (a more lax term for the three "steps" of the United States Medical Licensing Exams - USMLE) are fate-determining for medical students. Many studies show that the First Board Exam will almost absolutely determine what type of doctor I'll become. So, I'm about to head onto the fog once again, and its time to start thinking who, or what I want to go with medicine. And, here's three prospects...

1. Pediatrics. I have always loved kids... they're the hope of the future. Hence, I've always dreamed of working in a pediatric hospital, treating some of the worse of diseases. Sometimes it may seem that diseases are simply spontaneous, but for many kids they're born with them. Chromosomal abnormalities, physical deformations, immune system and even tumors present at birth plague these kids. And for some odd reason that pulls me that some of the pride of the future is affected from the beginning.

On my flight to take the COMP, I had an opportunity to meet a Canadian resident currently doing pediatrics. She caught me carrying two of my step books with me. However, as we were talking about our medical experiences, she mentioned one thing that stoked me... pediatrics encompassess a lot of embryology. I see embryology as one of the most intriguing parts of medicine, and it focuses a lot on the origins of the different parts of the body from the start of the merging of a male sperm and female egg cell. I'll be honest, that with the complexity of the way cells develop in a baby during pregnancy, I feel that embryology albeit interesting, is neglected in today's medical education: I felt it was something we had to simply memorize instead of understand.

2. Pathologist and potentially as an educator. I bet you're thinking: You're crazy... from kids to dead people. I'm not. Pathology was one of my favorite subjects in medical school. Opening up bodies, with the pursuit of mystery and problem solving, in addition to mastering the visual art to realize minute differences in the appearance of pathologic organs, makes pathology a quite interesting field (if you don't believe me, watch Dr. G: Medical Examiner on Discovery Health). Yes, interacting with people isn't involved, but I figured I would make that up if I would become a medical educator. With inspiration from my favorite(and in my opinion best) professor, Dr. C, back in dominica, along with my aspirations to teach others, this has appeared as a great option. Because pathology is a subject in medical school, my clinical and educational aspirations have found a great partnership.

3. Anthropologic medicine. I have always been interested in behaviors and culture. And we know that both of these options affect the ways that people treat themselves. Looking at the Wikipedia entry on Medical Anthropology:

In general, we may consider the following five basic fields:

• the development of systems of medical knowledge and medical care
• the doctor and patient relationship
• the integration of alternative medical systems in culturally diverse environments
• the interaction of social, environmental and biological factors which influence health and illness both in the individual and the community as a whole
• the impact of biomedicine and biomedical technologies in non-Western settings

I honestly believe that understanding patient behaviors and the rationale behind them can improve healthcare. And, with my likening for research, I can see how this might be a field for me in the future. Along with the pathology field, I can see how this may get me re-involved with becoming an educator (via academia), along with participating as a clinician. The disadvantage is that this may involve additional education: a PhD may be in the works here, perhaps in Anthropology or Psychology, but those are definitely other interests down my alley.

A recent AMSA The New Physician article is what started me on this idea. These people do cool things, see great places, and get to interact with people the average clinician won't see on a daily basis. A little adventure to make things exciting, right?

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SO...With these options: Perhaps there'll be a research component? Like I said, I love the clinician aspect, but i always wanted to do more with the job. Perhaps I'll need extra education? I love academia, so I wouldn't mind. Perhaps I need to do more research on my future? Yes. Perhaps I need to have a back-up plan in case things don't work out? Obviously. Perhaps I'll change my mind? Who knows.

My options are open... the higher my score on the boards, the more options I can keep. Well, all of us med students value options... Therefore, we value this exam. Along with my friends who have/will take(n) this exam too, this is a time we all need to put our best foot forward. Good words from the king, Elvis, put our situation well: It's now or never.

However, I prefer to look at the situation using the words that started this entry... :D