Mile 14020 + 3797.7: An Amazing Roadtrip

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

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

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

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

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

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

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

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

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

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

Mile 14020 + 2980.5 - Medicine By The Numbers

Above: My lone welcome into Ohio. February 2011.

TAKING ON THE ICU
ONE NUMBER AT A TIME.

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

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

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

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

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

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

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

Mile 14020 + 2482.6: Main Street

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

BACK TO THE
BIG CITY LIFE.

... more on that in a bit.

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

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

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

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

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

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

Mile 14020 + 1804.2: Catching-Up

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

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

THE ROADS WEREN'T EXACTLY
FRIENDLY.

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

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

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

Mile 14020 + 667.4: Shortie: New York Bound

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

ANOTHER ROTATION,
ANOTHER LOCATION.

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

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

Mile 14020 + 638.1: Countrified Conversation

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

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

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

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

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

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

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

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

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

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

Mile 14020 + 236.4: The Superdoctor

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

ALWAYS GIVE
150%.

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

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

We then knew we would have nothing to worry about.

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

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

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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.