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 2916: Señor Fixity-Fix-It

Above: Miami traffic to Key Biscayne was a pain this weekend due to the Sony Ericsson Tennis Open.

On the way down, somewhere in the swampy regions of southern Georgia along southbound Interstate 75, I was driving while bopping along to the groovy tunes of Spyro Gyra when....

SSSNNAAPPPP!

... as I looked around the car to see if anything went wrong, I noticed a white streak from the passenger-side pillar of the windshield beginning to crawl across until it gradually came to a stop, forming a discrete line across my windshield. Now, noticing that the line was 1) horizontal, 2) not moving toward the roof of my car as my car was moving at highway speeds, and 3) not disappearing with the truckloads of windshield wiper fluid I poured on it, I figured it was a crack caused by some random piece of debris on the road. Since it didn't grow initially, I drove down to Miami thinking nothing would happen, but by the third day in town, the crack grew up the pillar of my car and towards the center of the glass.

Fortunately, my insurance covers windshield replacements, so I had it fixed just in case it'd get worse.

They sent a repairman over to my apartment in Miami to fix the glass. I met him in the parking lot outside my garage. The man was middle age, but built, clearly a working blue-collar man. He had drips of sweat coming down as he spent the moments outside preparing his tools while waiting for me to come out in the Miami sun that was gradually intensifying. As I looked inside his van, a picture of his kin and a glimmering cross was hanging from the rearview mirror of his van.

I walked up to him and said, Are you here to repair my glass?

The first thing he said to me was, I can't speak mucho English.

I replied to him with a rather nervous smile: Puedo hablar un poco español. He smiled back at me, with a slight chuckle, and he got to work. As the work went on, here we were, both of us trying to speak each one's first language, and using different hand motions, synonyms (oh, my spanglish was on a roll!), and broken english/spanish, yet we were getting what each other's message. I'll have to say that the man had mad repair skills: the windshield repair didn't appear to be fácil (easy), but he was able to pay attention to the details to get the work done, and yet focus on our conversation quite well.

As the work came to completion, he said to me, grateful for our ability to communicate, Puedes hablar como mi en ingles (You can talk just like me in English), and I replied back to him, Solomente con practica. With a smile, we wished each other a good day, I gave him a small tip for his buen trabajo (good work), and were off on our separate ways.

---

This is the thing. After meeting the repairman, I thought about the term language barrier. But is language really a barrier if both parties try to understand one another? It's only a barrier if the two parties don't try hard enough to understand each other. I thought it was really cool how we figured our way around where possible misunderstandings could occur. I'm going to encounter people either in the hospital or in my practice that aren't going to speak my language, and I see how creativity in communication can go a long way to understanding where another person is coming from.

I've said before, I'm an optimist. Although, I can see how people still see this situation as a language barrier, I still prefer to look at it as a language opportunity.

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.

---

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.

Edutainment

Above: The Wonders of Life Pavilion in Walt Disney World, Florida, August 2007.

EXPERIENCE THE JOY OF LIFE.

August 2007. I'm here at EPCOT staring at a huge golden geodesic dome. Unlike the pavilion to my left that is shaped like a mirrored box (Universe of Energy) and the granite colored space-themed pavilion to my right (Mission: Space), there's something different about this dome.

NOBODY'S WALKING INTO IT.

Nope, instead a sign saying "Wonders of Life is Currently Closed" is placed in front of the entry walkway, with bushes surrounding the sign to prevent curious people (such as myself) from entering the closed pavilion.

If you know me well enough, you'll know that one of my great hobbies is the Disney theme park EPCOT Center (now known as Epcot). However, the common misconception that's made along with that hobby is that I'm in it simply to feel like a kid. The truth actually encompasses Epcot's original vision, a center standing for world diversity and peace (through the showcase of nations in the World Showcase) and a display of progress through our scientific discoveries (Future World) to millions every year.

Wonders of Life was not one of the original pavilions of Epcot when it opened in 1982. With the sponsor Metropolitan Life (most of you know it as MetLife, the snoopy sponsored insurance company), the golden geodesic dome, featuring the words listed above, in FutureWorld West opened in 1989. The outside mounted a tall DNA spire (not shown in picture above, as it was removed by this time). To demonstrate the progress and technology of medicine that was to be approaching in the 21st century in addition to spreading good words about medicine, various instruments from interactive exhibits to a serous simulator ride were erected. In 2007, the health pavilion in epcot closed after years of sponsorship under MetLife came to an end.

At Wonders, one of the attractions that struck home with me was an experience called "Cranium Command."In my opinion, the brain is one of the most complex parts of the body. It is the control center of the human, the centers of our thoughts, the processor our senses, and even unconscious actions of the body, heartbeat, breathing, and reproductive cycles. But yet, with Disney magic with imagineers (the guys who create the experience for us in an engineering standpoint) and the actors provided (stars like Charles Grodin, Dana Carvey, Jon Lovitz, Charles Wendt, and more), the general gist of the functions of the most critical parts of the brain (right side, left side, hypothalamus, etc.) can be made sensible to even someone in 2nd grade.

The other significant exhibit of the Wonders of Life pavilion was the Frontiers exhibit, oddly placed at the rear of the building for introducing to everyone the forward-thinking that was going on with engineering & health. You'd walk up to a station with a picture and a short description of that technology, and if you wanted to learn more, you'd pick up the handset and listen for more. If you think it sounds very 80s, I definitely agree with you (Handsets... come on!).

AND it is for this I call medicine an art... One of the most important devices to being in the profession is an essence of educating the patient to understand his/her condition. In this day and age, information is one of the best ways to arm the patient to win against what might be plaguing them. And to me, through creativity, doctors can avoid that medical "scientific lingo" to teach the common person effectively, potentially help their patients strive to do better to improve their health, and make that information reach as many people as possible.

Quite Frenchy

Above: A typical morning out on the streets waiting for my bus to Roseau (Taken: Aug 2007)

YEARS OF HIGH SCHOOL SPANISH...

THREE HOURS OF COMMUNICATING

IN THE YEAR 1996, I remember sitting in a room with a bunch of my sixth grade peers taking some type of language aptitude exam. Being in Spanish class and getting a head start on the four years in high school was absolutely the chic thing to do. We sat there and all we did was listen to some unknown (and rather obsolete) foreign language come off of the record player, and figure out if we could understand it. OH YEAH, WE WERE KINDA FIBBING WHEN WE MARKED A BUBBLE SAYING WE KNEW WHAT WAS GOING ON...

FROM THE YEARS 1997-2003, I spent 6 years learning Spanish in middle and high school, learning everything from nouns to verbs to conjunctive forms to attempting to learning how to swear (which apparently is hard to do without a student from a truly Hispanic background in your class to whisper it to you behind the teacher's back, as I learned years later).

And then afterwards... I thought it was all downhill... I thought I would never use Spanish practically again!

That is, UNTIL THE YEAR 2009. Week 7 in Semester 5 brings along the OBGYN (babies & female reproductive) rotations for two weeks. Today, we interviewed a patient who had trouble speaking and understanding English & spoke French creole... We knew we had a challenge on our hands. Fortunately, I was on rotations with a pair of Dominicans, and they really pulled out their trump card. Turns out that they're bilingual. However, there's a bug in all of that... I don't speak French Creole (which actually is quite a common finding in Dominica with its French origins), so I found myself always tapping one of them on the shoulder or shouting across the bed to another one of them to ask...

"Can you translate that response back to me again?"

After about 20 minutes of asking that with literally every other question (sometimes a bit of English would actually paid off), I had our patient laughing on her bed. She looked me right in the eye and then told me:

I speaks Spanish...

Now, why would she finally come up with that idea? Is it my hispanic-derived good looks? And my brain went into double-overdrive... I had to start yanking out Spanish from my left and right. Although my spanish was broken at times (putting together a bit of English with a slice of Creole which I learned from the last hour would crack in), I sometimes was able to help get out questions to the patient and our history taking was underway. I would never think I'd be pulling out words like dolor, cabeza, and even conjugate a word into the command form ever again. But I was doing it as it turned out the skills were still there... OKAY, SOME OF THEM. :P

Walking out of that room three hours later (a normal work-up of history and examination of a patient usually undertakes 1 hour), we were tired, but we learned a lot (another one of my colleagues wasn't exactly hot with her creole, but she did a great job as she realized). Not to mention, we all had a good time... our patient was an absolute fan of our looks of flabbergasted-ness (not a word, but you get the point :P). You know, sometimes those semesters or years in foreign language may actually play a key in skill in the future. Also knowing how to handle issues like that with your team can make a big difference in helping out patients who come to your office feel more like they're getting taken care of appropriately.

If I have an opportunity to go out and refresh my Spanish, you know what: I'm going to go do it. No voy a hacer más combinaciónes de "Spanglish." No más.

Horn Honking

"YOU'RE IN... SCRUB UP!"

One of the best most memorable parts about driving to Roseau is the way that drivers love to use their horns on the road. I don’t know about you, but I am not afraid to use my horn whenever a driver passes me on the road back in the states, as the driver decides to almost slice the front bumper off my car with a not-so-slick pass on the expressway. However, in Dominica, although this can happen (Now, I’m thinking that being horn happy came as an after effect of the invention of the automobile), I’ve seen Dominican drivers use their horns for many reasons, such as:

1. It could be social: some bus drivers, when passing through the smaller towns, honk their horns and then wave to the people on the streets.

2. It could be out of courtesy: I’ve seen some bus drivers decide to use their horn to let someone know they could pass.

3. It could be for business: If I'm walking down the street by the bus depot in Roseau. Every single van's horn starts honking for me, to win me over in the bus-filling race that occurs there. (Although I'm flattered, I still pick the nicest looking van... I like the one with tiger-skinned upholstery. :P)

4. Most importantly... It sometimes could be attraction: like the Dominican driver that honks at women while he’s waiting to “pick them up” to take them back to Portsmouth... :D.

IT JUST SEEMS sometimes it seems that these customs are crazy to us in America. But what matters the people in Dominica have it work for them, and it works (yes, even purpose number 4... sometimes.)

How the heck does this relate to medicine?

Like I said in my last entry, one of my good colleagues, Alex, jumped in on a herniaplasty a few weeks ago in the Operating Room (actually, in Dominica its termed the Operating Theatre). Six of us med students were standing in our wide spectrum of scrubs - anywhere from "poop-like" brown (me) to a torquoise green (him). All of a sudden, the surgeon comes out and points at Alex and says, "You're in... scrub up!"

Bada bing and bada boom... He's ready to go. There he was standing in an operating room gown, with long latex gloves, pumping his hands in the air as if he was ready to take on a patient. And, he was in...

But there's a caveat... As soon as he had the handles on the tools, there was the doctor tapping Alex's hands on the forceps, and there my colleague was... caught completely off guard, semi-frozen. I really understand how he felt, because although the surgeon was telling him something, he had no idea what the surgeon meant by his friendly gesture. The surgeon then took my friends hands and placed them in the right position with the forceps around the suture in the right position. The doctor went over to the nurse, and also did the same tapping motion, and bam!, she was out there with the right suture string and placed it into the hands of the doctor, and I wondered how they figured it out so quickly...

It seemed that after many hours of working together, the nurse and the doctor somehow knew what every single gesture meant. Instead of taking precious seconds off of the clock to verbalize their intentions, those seconds went to use more efficiently ( a good case especially when circulation to a limb is cut off - precious seconds that could mean the difference between recovery to normal use of an arm or necessary amputation). That seems to be part to the art of medicine... finding ways to communicate make procedures more efficient and effective, using our creativity to its potential... and they're definitely not textbook, and even may seem crazy, by all means.

But remember: It got the job done.