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 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 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 + 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.

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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.

Mile 13624: Final Push

Above: Team "Kentucky Fried" takes one final shot. December 2010.

PUUSSHHH!!!!

Being on call has become a routine for me. Every fifth day during my rotation, my partner and I end up staying 24 hours at the hospital "on call" in the Labor & Delivery Ward. We're responsible for admitting patients in labor, writing their history & physicals and to observe / assist with deliveries. Sounds hectic, but yet over the 6 1/2 calls I have had over the last 6 weeks, there was none more busy than my final day. However, that doesn't mean that the night was tiring beyond measure, as I found the pace of this call exhilarating. I found myself in synchronization with three other nurses saying "push!" to get a mom to finish her delivery and even was treated to a "fourthmeal" along with the nursing staff underneath our attending doctor's tab.

I'll be honest, a quarter pound burger along with a frozen non-alcoholic lemonade sits pretty well when being on call.

However, even after not having busy calls, that night was our "test" to see how much we learned through the deliveries that we had over the calls in the past weeks. And that's something both my partner and I both noticed: we learned a lot simply by observation (and much more than we give our eyes credit for). With the help of our attendings and our past memory, we were able to position the baby's head on its exit from the vaginal canal, deliver placentas, and even coach the mom through her contractions.

I'll admit that it is really invigorating and exciting to do the coaching. I've always seen it on telemagazines and on TV shows, but when actually doing it, it feels quite different. Coaching seems to be one of the most important parts of delivery, as I see how good coaching can result in much more efficient pushing and quick delivery of the baby.

Okay... 10 seconds... Let's go!.... Come on back into it, take a deep breath, give me 10 more seconds... you can do it!

I really loved the OB portion of my rotation. There's always some type of joy associated with delivery, and it brings a type of doctoring where instead of dealing with something that holds back our own lives (the loss of health), OB most of the time brings happiness and its not just to the mother but to the baby's family. This was best seen midday, when one of the nurses yanked my partner and I out of the nursing station simply to do "rounds" consisting of delivering a muffin-top birthday cake and 2 glasses of "fake champagne" (aka sparkling grape juice) to each mom with a newborn that day and singing "Happy Birthday" to each new baby boy and girl. We did 9 newborns that day, and it felt very rewarding.

Even in a world where malpractice could be scary, I can definitely see the light that OBGYN doctors see that motivates them to do their work everyday.

---

Forgive me for not writing for the last month. I'll admit the hectic schedule of OB has held back my ability to stop and think and write. However, I was able to see a side of my OBGYN rotation that is more applicable to anyone in every field, and I'm thankful to have an attending that was inspirational as the one I had to show me it. More on that in the next entry.

Mile 12056: First On-Call

Above: Almost a perfect shot on my "adopted sister's" final night in town. Replace that lightbulb, Chicago! November 2010.

SOMETIMES THE UNEXPECTED
JUST HAPPENS.

This week, I began my OBGYN rotation at St. Anthony Hospital in Chicago, IL. There's a group of 10 students working what has been nomered as a q5 schedule. A typical stretch of days include clinic, surgery, more clinic, call, and post-call. Call and Post-Call add up together for a 24 hour time shift from 6:30 AM - 6:30 AM the next day.

And that's exactly what I just went through.

I'll admit that call does have its pros and cons. Let's start with the cons first, because I personally think they won't outweigh the pros. There's less sleep (and odd patterns of it) and an acquired horrible diet (100% fresh pure high-fructose corn syrup in my Crush Orange Soda to start off my day and a nurse offered me chili cheese fries for the night).

Then there's the pros that make call kinda cool: A nifty on-call room (with a comfy bed and a small flat-screen TV). My crush soda (along with the rest of my on-call meals) were taken care of with meal cards. Hanging out with a cool nursing, midwife, and medical staff when there was a long period of downtime. An awesome resident who took the downtime to teach us.

However, the big win of the night occurred early in the morning almost 24 hours after my first call, when my partner shot me a call on my cell phone that woke me out of my trance of sleep in the on-call room. "The doc's here, just wanted to let you know so you won't miss the delivery." So within 10 minutes I was upstairs. I had taken the patient's H&P earlier that night (looked like labor was going to move on smoothly), and hit the sack rather worried about not getting to see a birth that night.

And here I was scrubbed up with the doctor, and the whole experience just went by so quickly. For me as a new medical student, the novelty was definitely there and made every single moment from scrubbing up to catching the baby to waiting for the placenta to come out post-partum exciting. I was glad I had an attending who was willing to trust me to guide me throughout the process. It felt really awesome to participate in the joy with the family & parents that were there.

So here I am, typing up this entry after just ending my shift (a little of editing at home led to a later release). In a discussion I had with my partner in the elevator post-call, we came to an agreement saying that although call is so tiring, a call experience is very rewarding and very cool (although doing too many calls I think makes the novelty wear off). Both my partner and I delivered for the first time today. It totally takes technique and practice, but with the joy brought of making a new boy or girl make it into the world, to me, there can be nothing more motivating to perfect my delivery skills & knowledge as much as I can in the next 6 weeks.

Mile 11942: Exploration - A Prelude to Part III

Above: Michigan Avenue in Chicago has to be one of my favorite streets of all time. September 2010.

IN JANUARY 2011,
WE'RE TRULY HITTING THE ROAD.

Is this something I'm truly excited about? Yes.

With me finishing up psychiatry (roundup ahead), I have two big cores left, OB/GYN and Surgery. Both are at St. Anthony Hospital in Chicago and I begin the OB half this upcoming Monday.

Now that all the bugs have been smoothed out (they were kinked for a little bit), I can tell you that I'm going on an amazing road trip. In May of this year, I went on a road trip that was independent of medicine, just to explore life without limits, and not to be a medical student for a little while. However, beginning in January, I'll be going on the road to do several rotations away from home. It's my time to explore where I might do residencies, different places to work, and even experience what it is to live in a city that's not my own.

(Please don't get me wrong, I love my hometown, the Windy City, to death. I'm just an explorer at heart.)

My current remaining schedule looks like this:
November 2010 - Obstetrics & Gynecology Core at St. Anthony Hospital, Chicago, IL
January 2011 - Family Practice Sub-Internship at Decatur Memorial Hospital, Decatur, IL.
February 2011 - Internal Medicine Sub-Internship at Wilson Medical Center, Johnson City, NY.
March 2011 - Intensive Care Unit at Grant Medical Center, Columbus, OH.
1 week break to take the ever-so-important Step 2 CS on April 1, 2011.
April 2011 - Surgery Core at St. Anthony Hospital, Chicago, IL
Planning 4 week break to take the also very-important Step 2 CK in July 2011.

After then, we're back to an abyss as to what to expect after then. I have about 16 weeks of electives remaining to schedule, as to what they are, we'll see as I have a series of sites I'm looking into and will be putting in my reservations for them soon...

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And now approaching 12,000 miles, I have ended psych. The doctor I round with in the morning and I have seen many things we never have expected to see, everything from people saying that they were "poisoned" to people who have ended up with more money in their pocket after dying. I even met someone from Bedrock (ever Meet the Flinstones?). And as crazy as these stories may seem to some people, doing a psych rotation really has put new perspective on how to look at these patients. To me, with each interview, I was getting onto a roll of taking each interview as a conversation I'd have with someone over breakfast or a cup of coffee. Each patient (from the elderly with dementia to the teenager with schizophrenia) presented with a new challenge, which was something I always welcomed. That's the way I learn: through my challenges.

Although my career interests currently don't involve psychiatry, I value now being able to see how the skills that psychiatric interviewers use to talk to their patients can be used in any setting, and it certainly helps in making any doctor's job easier. Thanks psych for a wonderful six weeks, I loved every moment of it.

So now I'm now a Fourth-Year student (by numbers of weeks of rotations)... If this past year came that fast, well... the next year is going to fly.

Mile 10121: Now You See It

Above: Jack Narz was the host of the 1970s edition of the great game show "Now You See It."

SOMETIMES YOU JUST HAVE TO
SEE THINGS FOR YOURSELF.

As Dr. Psychobabble said, "Psychology is the bestest." Even though, yes, it is a biased opinion (she said so!), this week on the wards, I started seeing how it was the "bestest", exactly as I told you in my last entry. So far, my schedule on the wards has been pretty consistent. Each of my days are faced with an interesting juxtaposition: earlier in my day, I round with a Psychiatrist who is a consultant on the medicine floors, while later in my day I round with a Family Physician who is a consultant on the psychiatric floors. It provides two different perspectives on how to look at a psych patient.

However, to date five things have stood out about psychiatry that have made my first two weeks on the floors enjoyable:

1. Au contraire: psychiatry doesn't just deal with the extremes.
In my last entry, I described some of the more severe cases where my friends were physically "harmed" by a psych patient. However, although there's a chunk of patients that do present with danger, a majority of patients are not like that. Many of the medicine floor patients talk just like their non-psychiatric consult counterparts on the floor. The patients on the psychiatric floor have very cool personalities and backgrounds. Many of them are quite easy to talk to, which leads me to point two.

2. A psych patient is still a person.
During lecture last week, I heard in lecture that the best way to interact with a psychiatric patient is by starting a conversation just like any other in one's non-medical life. I totally enjoy getting away from the standard "conversation conformed to standard history taking" format, and being able to use the interview in another dimension to assess mental function is pretty cool. It was a concept I finally got a hang of this week and am trying to tweak.

3. Sometimes your imagination itself just has to fly.
A few days ago, I heard a patient down the hallway start to sing. Mind you, it wasn't emmy quality, but the few simple notes that the patient was singing were pretty catchy. I ended up looking out the room and saw the patient dancing a semi-two step to the same song. I was very tempted to go out there and dance with him, but I was still getting used to the psych ward. However, that moment really brought a smile to my face.

4. Psychiatry offers some really unique situations.
If I went to a cocktail party, I could actually ask the question, "How many med students does it take to cut a person's ring off?" and answer truthfully six. Our group spent 2 hours switching between each other with a manual ring cutter to cut this patient's ring off. It was grueling, but it was good to see our team pull together with each twist and grip of the ring cutter.

Although this situation could be seen in some other fields (ER for instance), I'll be honest, it was fun to hear our patient sing "Free at Last" when the ring finally came off.

5. A psych rotation offers skills to both future psychiatrists and non-psychiatrists combined.
Every doctor is going to run into psychiatric patients of different sorts throughout their career. Getting an opportunity to see how to interview these patients has been, so far, a great learning experience. To recognize different psychiatric conditions and how to handle them can help aid with not only treatments of the mental conditions but improved understanding of the patient and increased compliance with treatments for their own medical conditions.

I love having an open mind... it makes me enjoy more of what life has to offer. That's what has made me get through 10,000 miles... Here's to 10,000 more!

Mile 9714: Get Psyched!

Above: Meadowbrook Park in Urbana, IL gives visitors a glimpse of the original praries that covered Illinois.

NEVER EVER ASSOCIATE PSYCH WARDS
WITH STRAITJACKETS.

This week, I've started a new round and a new rotation at Jackson Park Hospital in Chicago for Psychiatry. My friends love to tell me stories about things that have happened on the wards when they did their psych rotations. Their stories weren't exactly the most amusing... one got coffee thrown in her face while another put up pictures on Facebook of arm bruises from of a friendly tap from a patient that was all but well... friendly.

Oddly enough, using psych terminology, I think I have a psych ward phobia to get over.

I'm personally determined to use systemic desensitization to getting over it. My first day on the rotation was on Monday, and I'll admit that the adventure was filled with just about every anxiety-producing moment I wanted to just avoid. I kept my eye on the doorway while interviewing patients, I made sure that the door was locked behind me to the nursing station, and I even watched my back to make sure that nobody tried to make a move on me. However, the only way I'll learn and the only way that I face what might happen head on.

After taking on weekend call today, I'm starting to see how Psychiatry, like Peds, takes the concept of medicine and adds its own interesting twist. There's an increased reliance on other people's histories (police, family, nurses), some treatments involve a huge amount of trust in psychology, and blood tests and lab values don't carry as much importance as they do in medicine in pulling a diagnosis (but still can be helpful). And it is for this, just like my previous adventures, I am looking forward to my adventure in psychiatry. There's a reason why psychiatrists enjoy what they do, and I've read about them. However, the only way I'll completely learn and understand is if I see these reasons for myself.

And, that's exactly why I'm keeping my eyes open.

Mile 8895: Keep on Moving

Above: I do miss the 6 AM rush hour.

ALTHOUGH I MISS INTERNAL MEDICINE,
THE ADVENTURE MUST CONTINUE.

And just like that... it's over. One of the odd ways I've thought about the last 16 weeks is, I've been at the hospital 4 weeks longer than the current interns.

My last 16 weeks at Westlake Hospital were absolutely amazing.

Some of the biggest lessons that I learned during my time in Infectious Disease weren't even in infection (although, with the amount of cellulitis cases that we got called for, I would almost consider myself an expert in cellulitis now). When comparing my 12 weeks on the floors, where we took care of just about every single aspect of our patients, my 4 weeks on infectious disease were simply focused on that. I still remember the first day when I was on "floor mode" - as I liked to term it - and wrote just about every single assessment and plan on the patient I could in my note. I quickly learned that was quite inefficient considering I was on a consulting service. But this is one reason that I couldn't see myself - at this moment - going into a subspecialty; I feel odd treating only one aspect of a patient.

One thing that I really enjoyed was that my Infectious Disease rotation came right after my Internal Medicine rotation and at exactly the same hospital. I knew how the teams worked along with who worked the teams, which not only made the transition easy, but I appreciated how the tables turned. On the floors, my intern would let me know what consults I need to pull, but now the interns were coming to my doctor and me with new consults. I'm going to miss the rhythm I started putting together with the interns, seniors, and students, but I must keep moving...

It was with this program that I appreciated some of the aspects of smaller community programs, getting to know everyone's face, seeing common cases repetitively (i.e. like the cellulitis above), working with tight knit teams, and sometimes seeing patients over and over again. I've been a big fan of the "make a big world a small one" concept, and community-type residency programs attract me in that manner.

For the next 3 weeks, I have them off, but starting in late September begins my Psychiatry rotation at Jackson Park Hospital. But I tell you, I surely am going to miss running up and down those floors.

A huge thank you goes out to the attendings, residents, and students at Westlake.

Mile 8652: (Cue Marching Band)

Above: Rush University Medical Center's new Advanced Center for Emergency Response. From Rush News.

I FELT LIKE I WAS IN AN
AIRPORT TERMINAL...

I learned this week a situation where clear, accurate documentation is critical for monitoring a situation. Let's just say this, figuring out whether or not someone has a "critically morbid chronic condition" from hearsay isn't the best way to handle it. With medicine, a certain line of things need to be done to confirm or rule-out whether someone has a condition. If those tests aren't done in order, it breaks the chain, and a degree of uncertainty (which is never good) hinders the line of treatment for the patient. Nobody wins if things are not documented and tracked appropriately.

----

A few weeks ago, the Infectious Disease team that I am a part of goes to the Infectious Disease grand rounds that go on at Rush University near the heart of Chicago. My attending picked me up from the hospital and we soon walked into a series of tall buildings, a facade of steel and glass. We soon were walking down a hallway with large directional signs and a walkway that could support a flow of a huge crowd (making me feel like I was about to catch my 9 AM flight). After going up to the fourth floor of the building we were in in the middle of a slightly crowded conference room that holds about 50-75 people, I watched several presentations from residents of some fairly interesting cases that they ran into. As the attendings, fellows, residents, and students chatted amongst themselves (and myself with my attending) to discuss each case, I felt that the openness to discusssion I observed to encourage each other's understanding of the concept was amazing. When I look back to my several hours there, I honestly saw myself as a kid in awe at a candy store.

And that's what is really attracting me about university programs when I'll match (next year). The variety of cases that you get to see there, their reputation for being at the forefront of medicine and research, the resources that are available, and not to mention the aura of academia (which I enjoyed after my 1.5 years in a Masters program at the University of Illinois) are just astounding. I really feel that a university program would easily satisfy me academically and open me up to even more new opportunities in medicine. However, aspects of community programs also reach out to me, and I'll tell you more about what attracts me to them in the next post.

Mile 8246: To Tell the Truth

Above: A depiction of the electronic medical records system from Upstream.

WHO CAN I TRUST MORE:
THE PATIENT OR THE CHART?

Infectious Diseases has been a great rotation thus far. Although I'm still at the same hospital as my previous rotation, the days feel a lot different as a consultant than as someone who's working the floors. Maybe its that the subject matter is much more specialized, or its probably also not having to deal with as many folks left and right when managing patients (on the floors for the last twelve weeks, everything from nurses to consultants and even writing notes would slow down a day's efficiency dramatically). However, I'll be honest that after 12 weeks of intensely working the floors, 4 weeks of consulting is a breath of fresh air.

Don't get me wrong, I've learned a lot about management of infectious disease simply from my first week on the post. I've at least had some slight refining with my knowledge of antibiotic spectra, common sense on when to appropriately check for blood cultures, and even evaluating if a "fever" is truly a fever. For some odd reason the "card-playing" game with empiric and more targeted antibiotics is something that intrigued me. I'm looking forward to learning more about that in the near future.

1:30 PM Friday. My attending and I are in the room of a patient along with their family. However, when my attending was further questioning a part of the patient's family history, we basically got a irate response of, "Go look in the chart!" from the family (I'm guessing that getting asked the same questions multiple times by multiple people finally go to them). My attending handled the situation calmly and well and explained to them that it is better to get the information from the patient rather than from the chart, because the chart has the higher chance for errors. Only when the patient couldn't recall the information would my attending refer to the chart. My attending further mentioned that the patient was someone that could be trusted more. With that, the patient, along with the family, had smiles of confidence and breaths of relief.

The point makes much sense though. If you've ever seen people try to spread news from one person to another, it never comes out straight after being handed down several people. The chart is like that, especially exaggerated when trying to interpret someone else's words when someone is not there to clarify or answer any of the doctor's questions. The bottom line from this lesson is that the purpose of the chart is to document what was done, but not to be used to substitute for a proper history taking or physical examination.

A simple, but very useful lesson.