Saturday, December 01, 2007

Surgical notes: Bleeding always stops eventually

It was Wednesday night last week that I had my first night of trauma call. Instead of my normal quota of one pager going off no less than once per day (usually with breaking news on our lecture schedule, but often to find my team or receive tasks), I was carrying a second: the trauma pager. It's not so much a pager to answer as it is an alert to begin making your way to the ER to admit an incoming trauma patient.

I paged the resident on call for trauma service, and gave him my own personal pager number as well in case he needed to reach me for anything else. That was at 5 pm. It was almost 6 pm when I was paged and informed there was an in-house patient headed to the OR with an upper GI bleed. The surgical team was informed I would be on my way to help out, and I was to head to suite 15. I hung up and left the lounge to head towards the OR.

I scrubbed before I walked into the OR suite, hat and mask in place as well, and was greeted by the scrub nurse who asked for my glove size as she gowned me, and once all was in place I stepped up beside the patient with the attending just as the incision was being made vertically down the abdominal wall. The abdomen was already beginning to look distended, and after cutting through the muscle fascia the small bowel swelled into view.

I realize most people have never seen the site of a human's intestines laid open, much less know the site of intestines that are swollen like a water balloon with blood, but that was the situation presenting to us. On top of the large amount of distended bowel to deal with, the abdominal cavity was a basin full of blood. Multiple suction tubes were prepped and inserted to drain the abdomen so that the anatomy could be visualized. As the resident and attending discussed the patient I learned he was having an upper GI bleed, somewhere around the duodenum (the first part of the small intestine just as you exit the stomach). After much of the blood in the abdomen was drained away, the surgeons cut through the stomach and duodenum in an attempt to find the bleed. Blood continued to pour from the bowel, and no definite site of bleeding (at least not in proportion to the amount of bleeding occuring) was found. Blood continued to pool in the abdomen faster than I was able to clear it with the suction tubes, and many times I had to resort to using my hands to scoop large preformed clot from the cavity.

Eventially the bleeding was enough of a problem with working that a vascular clamp was placed across the aorta, above the celiac trunk. For those who aren't familiar with anatomy, the celiac trunk is the first artery to come off the aorta after it enters the abdomen from the heart. The celiac trunk and every subsequent artery provides every organ and limb below the lungs with blood. Essentially, we cut off the blood to half his body.

Monday, November 19, 2007

Visiting Edward

I'm just about ready to put a bullet in my Jeep after the recent headaches it's putting me through. First the whole brake system needed replacement, then a belt pulley all but broke, and in the last few days I am hearing a new noise under the hood. I'll be very frustrated if I have to pay for much more here lately to repair my Jeep.

Last Wednesday I had a special opportunity to visit someone. Classmate Janette McVey, currently on pediatrics, informed me that Edward, the African refuge child I cared for during my inpatient month, had a well child visit on November 14th. She told me he and his family would really like me to stop in and pay a visit. After clearing it with my chief resident last week while on inpatient, I was able to drive over to Green Meadows post-call and surprise Edward by walking into his exam room.

Edward greeted me by walking! He is completely without need of a walker or cane now, and easily sauntered to me and hugged me as I knelt to grab him in a big embrace. His mom quickly jumped up with her digital camera and snapped a few photos of us. As I stood up Edward continued to simply lean his body against mine while I rested my arm around him. "So this is the beloved physician," their refuge case worker commented, saying that Edward has been expecting me to show up at clinic. Few things have been as wonderful to hear as that.

Edward got his exam, and had his vaccinations administered while I held his hand. I sat on the floor beside him while his sister had her checkup, letting him embrace my arm while holding my hand. Occasionally he would test his strength by trying to wrestle my arm, and occasionally I'd let him win. His mom showed me some pictures from Halloween, and of family activities, and snapped a few more of us. I gave her my email so she could send me some pictures soon. After an hour I reluctantly said my goodbyes and hugged Edward once more, and promised to keep up with them. I still don't speak French, and Edward manages only a handful of animal names and some numbers and abc's, but we understand each other when we touch. Touch is good medicine.

Wednesday, November 07, 2007

The world on foot

Recently I've run into some serious problems with my brakes on my Jeep, that forced me into taking it to a garage last Saturday to be inspected. I was expecting a minor problem; my friend Adam had helped me look at it and thought the problem was only a leaky rear wheel cylinder, letting air into the brake lines and lowering the braking pressure. When I got an estimate from the mechanic it was around $350, and consisted of replacing both rear wheel cylinders, both rear wheel brakes, and new wheel drums.
After talking with my father and then calling Adam again I decided to get a second opinion and new estimate. In between patient visits I called around a few recommended mechanics and found a second one I felt comfortable going to. After taking my Jeep to them yesterday, though, they found that all breaks needed to be replaced, and the front rotors and rear cylinders, but the drums could be spared. It would actually cost me almost $500 to repair.

Since Saturday I have had to rely on the generosity of a few wonderful people to receive transportation for work and necessary errands. I'm finding I'm not the kind of person that likes to be dependent on others. With transportation especially, being without a vehicle is a new kind of helpless. No longer do I have the power to go where I want exactly when I want. I have to plan ahead my transportation and be more strategic about where and when I go places.

Being without a car is as good an excuse as any to do more walking, and I have used walking to get myself to Eastgate for groceries or even as far as the downtown for coffee and escape. I walk or run to Stephen's Lake Park already, so that is nothing new. Yesterday I walked from Panera at Nifong to the Green Meadows clinic after lunch, which opened my eyes to how much I take for granted driving; there are no crosswalks or sidewalks within the Nifong-Green Meadows stretch of Providence, so I need to watch traffic far more. Crossing Nifong alone felt like an adventure, with cars flying around the corner near Gerbes.

Walking last night to Lakota took at least 20 minutes. Twenty minutes is generally a drop in the bucket, but when walking and with nothing else to do I was able to appreciate just how much time 20 minutes really is. I prayed. I contemplated things going on right now in my life. I thought about my friends and family, missing them, loving them, and worrying for them. I was grateful for those who have given me rides up to this point. I'm trying to think of what kind of help or assistance I can be to them and others with the talents and resources I have available. Most of all, I try not to feel guilty for being dependent.

Perhaps this is a result of living in a culture where the ideal is complete independance, strength, and the ability to provide for yourself. The American Dream. Financial brokerages advertising for "security in your future". The predominace of advertising geared towards "YOU" in all aspects of life. I wonder if it has anything to do with the depression of older life, when we are forced to be dependent on others. Maybe we are innundating ourselves so much with the need to not rely on anyone else that we are guilty for it, when Biblically speaking humility and a sense of dependence should characterize our walk with Christ. And, if that is true, why should it be odd that dependence on each other should be expected? Still, why is it a hard thing to accept? I guess that's just the problem with humility's antithesis: pride.

Tuesday, October 02, 2007

The boy from Africa

Edward is 9, and when he first came in to he ER he was in terrible shape. His dad was with him, and both were falling asleep they was so exhausted. Edward has two siblings and he's the oldest. They all speak French, because that's spoken along the Ivory Coast. I have been thinking of going for two months to Africa during the spring of my 4th year, and this really made me want to even more.

Edward was rather depressed and rather in pain for most of the first of the week he stayed with us. He had his knees retapped and his hip tapped to draw off some of the fluid of the effusion that was causing the pain and swelling. That helped with some pain, and we eventually had him on opiate painkillers as well as super high strength NSAIDs. We drew blood for so many labs, and the anemia he already had got worse and we transfused him by the time he left. We did a chest x-ray to screen him for Tb and that resulted in his getting a CT that found a big lung cyst we feared was an infection called pneumocystis, that would indicate he had AIDS. He got a bronchoscopy of his lungs that I got to assist on as his 'doctor', and it was hard when he came out of anesthesia because he was screaming and terrified.

After almost a week we had Edward on IV fluids part time and his pain was a whole lot better, but he was still not too happy. He hadn't been outside since arriving, and had been wheeled around the hospital only a little. Mostly he was confined to his room, and the shades were almost always draw. So, one afternoon when I was free of work, I had the intern, my friend David, write an order to allow him a 1 hour leave to go outside and have a break. Edward told the translator that she and his mom were not allowed to go; he just wanted it to be me and him. His student nurse had to go though to keep an eye on him. We had a syringe squirt gun fight and I got soaked. I raced him down the hospital lobby hallway in his wheelchair. We went outside and did some off road wheelchairing, then played catch, soccer, stickball, and dodgeball in the grass. I worked real hard and eventually got Edward throwing his hands up and giving a big man yell as loud as he could. That was one of the most awesome things I've ever seen. Then we went and bought a chocolate bar and some juice. Later that evening he was voluntarily leaving his bed to show one of the peds residents he could use his walker and take a few steps (he had been getting PT and OT to help him increase his range of motion and his strength). That resident, Kelly, was one of the first to notice what a change he had taken.

The next couple days he was so much happier. He was chatty, and even a little pouty in a little kid way. The former somberness was mostly all gone. We had a wrestling match where he tried to break my arm and a game of catch with the whole care team of doctors with him after that. He also had really caught on to the secret hand shake I had been working on teaching him. I had an action figure named after me.

I never really learned any French beyond "bonjour" and "Salut" and "Sefe fe mal?" (supposed to be "does it hurt?", though I'm sure I wrote that wrong). We didn't need to speak the same language though. We spoke boy.

Friday, September 28, 2007

Healing Children in Pediatrics

Since the beginning of August I've been working on my pediatrics rotation. It started mundanely enough with 8 am - 5 pm clinic hours, and by the beginning of September picked up in worktime, with 6 am - 5 pm the norm for a day's work, Monday through Saturday. Still, despite peaking with 75 - 80 hours each week not including time spent studying, pediatrics is the most enjoyable thing I have encountered in medicine thus far, and the largest reason for that is the children.

Early on in the first week of the rotation Dr. Groshong, the head of the pediatrics department, spoke to us about what he wanted us to get out of the next two months. He said the primary goal is for us to enjoy learning to care for children and have fun doing the work we do at the same time. That I enjoyed working in pediatrics is an understatement; there was no house officer or attending physician who was ever unpleasant to be around or ever was in so poor a mood it was intolerable.

Clinic duties consisted of me seeing a patient first, followed by a senior resident. It was through this process that I honed my skills in interviewing and examing patients. It was also through this process that I learned how fun it is to engage children. One very memorable moment was when a 6 year old girl with a rash hopped off the exam table, pulled up her shirt to show off her belly and yelled "Wanna see it?!" Children are so excited to have an adult's attention, and I was perpetually eager to dispense as much attention that was needed to make the visit pleasant for the kid.

A few times in clinic there were patients that elicited fear of serious concern from me as a budding clinician. The time I was most concerned was when I approached the exam room to see a 2 month old boy and read the nurses note on the chart stating "coughing up blood" as the reason for visiting. My first concern was whether it truly was blood, or something less serious, and I truly hoped in my mind it was a mistake. The family was young; the mother only 17 at best and a father who was of similar age, living with the mom's grandparents. The father described that the child had started to cough, began to be frothy at the mouth, and when he wiped away the spit noted that it was tinged with blood about an hour earlier. Later during my exam, with the baby on his back on the table, he began to cough and gurgle again. I grabbed a few paper towels and stopped my exam and just waited. I waited long enough until I noticed pinkish frothy sputum at the child's mouth, and wiped a large portion away only to see it was thick with blood. I set it aside as my evidence for true hemoptysis (coughing up blood) and began meticulously inspecting the inside of the child's nose and mouth for a source of the bleed other than the lungs. There was no discernable source, and a more ominous sign was the sound of wet crackles coming from the child's lungs through my stethescope. A chest x-ray performed in the clinic showed a diffuse clouding of the lower right lung, and the 2 month old was rapidly admitted and treated with antibiotics for a possible unknown infection. Other concerns were a possible tumor or foreign object in the lung.

I finished my outpatient weeks at the Green Meadows General Pediatrics clinic and moved on to inpatient pediatrics service. It was an adjustment to have to start the day before sunrise, but the plus side was there was little to any traffic to deal with on the drive to the hospital. The atmosphere of the ward was one of running an efficient machine; a day consisted of a systematic hand-off of information on patients from the night float physicians to the day team, a pre-rounding and data calculating period, determining the quantity of fluid and caloric intake versus fluid output a patient had, the days and dose of antibiotics or medications, lab results as well as those pending, attending rounds with the head physician where the treatment plan was discussed and adjusted, afternoon "power hours" where all the work needed was done for the day and progress notes were recorded. Phone calls would be made to receive lab results or schedule consults or follow up appointments, follow up visits with the patients would be performed, reporting to the intern or resident about changes in patients occurred, and new patients would be admitted by the intern and student on call that day. At the end of the regular work day the night float team would arrive, and the info on patients would be relayed systematically to the physicians and hand-off would once again occur. Patient management was, in short, a careful process of adjusting the vital signs and symptoms of a patient to a point of better health, be it by symptom control until the illness passed or disease process control to provide better baseline health.

Despite the many similarities to auto mechanics inpatient medicine had in my head, it was not without attention to the psychosocial aspects of the care of the patient. One patient who taught me a great deal about the importance of caring for non-medical needs was my little refuge from Gabon, Africa, who I will call Edward (not his real name, though). Edward was a 9 year old boy who came to the US with his family as refugees and spoke only French. I admitted Edward on a Tuesday evening in the ER, at the end of what had been a rather blue day as I ruminated over several things that had been on my mind as of late. For the past 4 days his knees and ankles had begun to swell and become painful, and a day after arriving in the US was so painful and weak he could not support his own weight. He was accompanied in the ER by his father and the refuge service case worker of the Jefferson City Diocese.

Edward was scared, quiet, and in obvious pain and discomfort. He was a very slender 9 year old child with little muscle mass, and although not emaciated, did not have much cutaneous fat. He and his father had arrived in the US the day before and had not slept since the previous morning. They were exhausted and earnestly desired to go home, however the father wanted to do whatever the doctors deemed necessary for the child's health. A tap of the left knee joint to draw off fluid showed a large amount of white blood cells and a lot of inflammation. It was also learned that the boy was HIV positive, and being highly concerned about the possibility of joint infection that could devastate the child's knees, we admitted him to begin treatment that would last 18 days. In those 18 days Edward and I would develop a patient-physician connection that demonstrated love and hope in a way that surpassed the language and cultural barriers present between us.

To be continued...

Wednesday, August 29, 2007

Being afraid

She was a 4 year old girl lying wrapped in a blanket on the exam table, eyes red from tears. I was going through my usual routine; I started with an interview of the parent asking about the course of the current illness. I systematically asked the when, how long, is it improving or getting worse, what have you given her to help with the pain and vomiting, etc.

After gathering the story from the girl's mom, I approached the girl on the exam bed and began my exam. She was in clear distress, but it wasn't until I began my abdominal exam that I became really concerned. As I uncovered her and began to feel her abdomen, she began to cry and wail even more. I felt as deep as I could and she continued to be more distressed. Possible diagnoses were coming into my mind; acute gastroenteritis, appendicitis, sepsis, others. I was beginning to be more concerned that she may have need for surgery. I ended my exam and went to present to my resident.

The resident came and did the exam as well, and when she was done she came and presented to our attending. The resident did not at first expect the girl to be in such distress, and after her exam was still unsure whether she had appendicitis or not. Our attending then did an exam, the third time the girl was examined, and decided to do an ultrasound of the girl's abdomen.

Today the resident informed me that the girl's ultrasound did not show any appendicitis or any need for surgery. I was relieved. I haven't had many (or any, really) patients in such acute distress that I was concerned something may be seriously wrong. A little bit of fear like that can make you a bit more alert and mindful of all the details, but it can also fluster you and cause you to lose your focus. I turned into the latter. I'm sure in the future with more experience and seeing more patients, the occasional serious patient will not shake my focus so easily. It was never a matter of not having the medical knowledge for the situation, but having the experience in dealing with these situations without letting the excitement overtake you. I guess that's just part of the process in learning the art of medicine.

Sunday, August 12, 2007

How to Shower: Women vs. Men

What's one of the most defining differences between men and women? How we do personal hygiene.

Saturday, July 14, 2007

Neurology: Consult service as a brain and nervous system "expert"

This past week was my first of two weeks on neurology service. I am working on the consult team, meaning that I am with the neurology resident called by other medical services when their patients' have a neurological problem they cannot solve or don't know how to best manage. Two other medical students are with me, and we all three work under our resident's tutilage. I'll outline a typical day:

At 7 a.m. I arrive at the neurology swamp (where the residents have their desks and a couple computers for work) and start running through the day's patient list with Scott, who often gets there just before I do. We add current medications to the table with patient info on it, as well as their location, age, medical record numbers, and so on. Any medication that has an effect on the nervous system is also listed with dosages. The third medical student, Mackenzie, often arrives shortly after I do, and our resident Aarti arrives just after 7. Aarti acts as the quarterback of our crew, making the decision on which patients we will see that day.

We run through the patient list for the day over the next hour, checking the medical records for any pertinent labs or progress notes, MRI's and CT's, and discuss any patients that we saw the previous day. By 8 a.m. we are ready to start rounds.

Oftentimes this week we start from the top down, taking the west elevators straight to the 6th floor and checking on any patients on the medical service there. Then we take the stairs to the 5th floor medical service, and round on patients there. We continue in this fashion, also rounding on patients in the medical-neurosurgical ICU, the surgical ICU, and the cardiac ICU. Sometimes our patients are in a coma (often those in the ICU). Others may be conscious but have a trach (a tube in their neck to help them breath) and they cannot speak. After checking on all our patients with Aarti, and sometimes doing part of the physical exam, the attending (a physician who has completed residency and trains other residents) arrives and makes rounds with us over the patients we have just seen, and the resident presents each patient and the treatment plan. During this time us students are more so observers than active workers. The afternoon may be filled with research on the conditions our patients have and how to treat them, or clinic duties, or more consults as they are called in throughout the day. Sometimes it's a time to follow up on work that we couldn't finish in the morning.

Occasionally as a medical student, you get to actually feel as though you've contributed significantly to the care of a medical patient. I had that experience this week. One of the patients on our consult service, I'll call him Mr. Brooke, a chronic COPD'er who presented to us with muscle weakness that was more pronounced in the shoulders and hips than at the ends of his arms and legs. I was instructed by my resident to go examine him one afternoon this week before she would go see him. I went and introduced myself to the patient as a member of the neurology team that would be assessing him and trying to help determine why he was experiencing weakness. I moved through the neurological exam with less grace and efficiency than my resident Aarti, but effective nonetheless. After gaining a medical history on my patient and documenting all my findings I left to organize my information to present in the morning.

On the next morning I presented my patient to Aarti in the typical structured fashion we have been trained in as student-physicians. I was interrupted occasionally as she smoothed out my delivery, and questioned me on certain aspects of the history and exam. After presenting my patient she asked me for my differential (a list of possible diagnoses that would explain the symtomatology of your patient). My top diagnosis was ankylosing spondylitis, an inflammatory disease of the spine that can cause weakness, pain and stiffness. I came to this conclusion based on my patient telling he he had a "spondylitis" that had affected him since high school. My resident disagreed, considering glucocorticoid myopathy as a more likely choice, given his history of lung disease and high doses of steroids. A quick look at his chart and his lab levels showed that steroid myopathy couldn't be right, and we were still considering what could be the case. The next day, when revisiting his chart and reading a pulmonary consult note, we discovered that he had a restrictive lung process, something that can coincide with a diagnosis of ankylosing spondylitis.

It turned out I was right on with my diagnosis the first time, and with further reading was able to justify my diagnosis. It also earned me a high five from my resident. Despite being right, however, I was easily swayed around towards other possibilities once I found my resident disagreeing with me. It's a common thing to second guess yourself when you are the student working under the expert, but sometimes you just might be right. With a little bit of time and a lot more experience in seeing patients, it'll be much easier to hold fast to my convictions and not question my gut-instincts.

Monday, June 18, 2007

My First Week: 2 South psych ward

Monday last week was orientation for clinical rotation on the psychiatry ward. It was exciting and intimidating all at the same time, especially the part about getting security keys, fingerprinted, and having to provide a urine sample for drug screening. It was a calm day regardless though, and there was no work with actual patients until Tuesday.

Tuesday morning I made my way through the string of locked doors at Mid-Missouri Mental Health Center (hereout referred to as Mid-MO), the mental health hospital. I am assigned to the ward on 2 south. I met the psych resident assigned to the floor, Dr. Johnson (not his real name of course), and discovered I and the other two medical students assigned to the floor would accompany him to the county courthouse to start the day. Dr. Johnson had to take the stand to testify to the need for inpatient treatment for a number of mentally ill individuals who were picked up by the law. It was an interesting start to the day.

After court hearings we hurried back to the ward on 2 south to attend rounds at 9 am. Rounds are a meeting with all the members of the ward's care team, and are lead by the attending physician. The other individuals include several social workers, the chief nurse, the medical students, and the resident Dr. Johnson. At rounds every day each patient on the ward is briefly discussed and the plan of care is modified based on the most recent assessment of the individual. Those who interact with the patient discuss their impression of the patient's situation and their thoughts on treatment.

After rounds we have staffing. Staffing is when a new patient gets to meet with the care team and have a conference on the care plan, with all members of the team able to ask questions of the patient, and the patient has the opportunity to ask any questions they want about their care as well. These have been emotionally charged so far.

When those meetings are finished, I take time to round about the ward seeking out the patients I follow, and sit down to discuss how they are doing with them. The first time I went around to meet the patients I am following, I was threatened by one man, eyed suspiciously and avoided by another, treated ambivalently by a third and fourth, and sort of welcomed by another. Some of the patients have sort of warmed up to me, and I'm glad for that.

One thing that wasn't expected was the emotional burden of caring for the people on the psych ward. Not everyone is completely out of touch with reality. Those that are still able to know what is going on are the ones who are most heartbreaking. I've met individuals with hardcore substance abuse on multiple street drugs who have depression, sit and contemplate suicide, get so emotionally overwhelmed with stress and anger that they slam their head into the table during their staffing meeting, patients who's arms have more scarring than normal skin, patients who emotionlessly describe how they took a kitchen knife to their arms to see them bleed, and later break down over the misery of the emptiness they feel. Even harder than all of that is knowing that I cannot simply break out and share the gospel with them, being in the position of a health care provider. At least, it is rather taboo and would likely result in me running into some sort of trouble. There may be some point when I do at least mention it, simply because I can't not want to, but I have to be careful. I am praying for them nontheless. It is perhaps harder having had a friend who was in an inpatient mental health setting and eventually committed suicide, and seeing several people who are experiencing similar problems. The worst is just not knowing what you are supposed to say.

Sunday, June 10, 2007

My first place, technology and humanity

This past Friday I signed the lease on my own apartment. No roommates, just myself. It is both exciting and scary at the same time. It feels grown up to do the signing myself, and being the one person responsible for everything. In any case, it is a milestone in my life to have my first place.

Being a type of person that enjoys having a peaceful repose to retreat to when I need recharging, it was overwhelmingly calming to wake up this morning to the sound of rain and rolling thunder, and to sit on the couch with a bowl of cereal after a time of quiet devotion and journaling. It is highly rewarding to now be sitting here publicly journaling while some relaxing music plays from my office. I look forward to slowly building a home out of my apartment, through decorating and spreading out of my belongings, and that will be a great feeling of comfort to come to after a hard day's work or to end a good evening.

If there's any one thing I am nervous about in my own place, it is dealing with the inevitable sense of loneliness that will hit at times. So far I have been fine with that, as I have seen people each day in the past couple of days. Since I will be less busy during the first rotation of the year I will have many opportunities to spend time with people, and hope plenty of people will drop by to see the new place and also just to check it out. I think however, that having a private retreat to return to when I want will in some ways make me more purposeful about reaching out to other people.

Some time last week the History Channel was running a program on the future of technology. Several examples had to deal with the merger of technology with the human body. One example was the potential to place a piece of technology into the retina of someone's eye, enabling them to perhaps watch television without having to have an outside box. They showed a 'simulation' of a man seemingly listening to a woman talking and then from his eye view having a video screen partially obscuring her face. Oh, and in order to exaggerate the annoyance of her talking, she was being played in something of a fast-forward, high-pitched voice. In reality, the use of optics in the eye is more for the purpose of finding a potential cure for blindness, which is a far more worthwhile cause if you ask me.
Another example of technology was the program that could interpret brain waves as someone thought them and be programmed to perform certain computer functions based off of what the person 'thought'. Some of the actions however were also programmed via an eyebrow raise, a jaw clench, and so forth. The purpose was to provide quadriplegics who were paralyzed with a more sophisticated means of communicating beyond the current technology in place, which utilizes eye-blinking alone.

As a future doctor, I am more than excited to see technological advances that can restore any measure of function to the disabled. It does however make me thankful for my own feelings of wholeness. I have two arms and two legs that function, I have a heart with natural valves and no need for stents to hold open my arteries. I have hearing that does not require a hearing aid. I do require glasses for seeing things sharply at a distance, and it is at times a frustration to have to acknowledge that there is something about my body that does not work perfectly. As each day goes by however, I know that I only get older, and progress more towards the end result of the Curse: death. Thank God that someday an imperishable body awaits me.

I am disturbed by some showcased technology that this show had on. One example was the insertion of video/television media wherever you would like it, even rolling it up and taking it with you. It may only have made up a small amount of the whole hour, but to me it seemed to take up quite a bit of the programming. There were examples of fabric-thickness televisions hanging on a wall, in massive size using up the sides of skyscrapers, digital screens built into the counter and tabletops of living spaces. Eugene Peterson, the author of the Bible paraphrase The Message, mentions in an interview I read recently that he feels television has done more than anything else to degrade society. John Patrick, an English physician I heard speak at a medical missions conference in November, spoke about the lack of true learning that occurs via visual media, and that the deepest knowledge and learning comes through reading and the written word.

I enjoy some television, and I enjoy going to a movie as well. Those things are good, and it is beautiful a lot of times to see a story depicted through the eyes of someone's imagination. The Lord of the Rings, Braveheart, Rudy, Finding Neverland most especially, are great stories that lose nothing by being put to film. I think what I really dislike is when television or movies become an escape from being able to interact with others, or tell the stories to others, or if there is a lack of imagination involved in the telling of any story in what is being watched. "Couch Potato" evokes a rather undesireable state of being in my mind, and I would much rather be engaged with people than be a numb consumer of visual imagery.

Right now, I do not own a television in my new apartment, and I have considered what it would be like to simply not own a television at all. Of course, that would mean being unable to watch my favorite show Scrubs, or watch what I consider good programming like HGTV or the History Channel or Discovery, but it would challenge me to do more engaging activities with my time. If it came to watching movies, I could easily watch them on my computer's DVD system. I have a couple seasons of Scrubs on DVD, and then there's always the opportunity to reach out and spend time with people in order to watch a movie with them. I could also simply catch up on all the reading I say I intend to do. I could write far more as I say I will. I could start that book I have always told myself I want to write. Or, if I end up with a TV, lose sight of those interests.

Monday, May 14, 2007

Just an ordinary hero

I'm thankful that I'm about to start the part of my medical career where I can interact with people regularly, and more than just seeing people, but seeing the same people more than once and getting to develop a relationship with them. Studying, for all it's worth, can only bring so much gratification (if much at all, most times). The real payoff in studying is when it is finally put to use in helping someone. Every once in a while, I get those little moments here and there, and I can remember why I'm pushing down this hard road of medical training.

My younger cousin has systemic lupus erythematosus (SLE) or "lupus" as most people have heard it called. She's only 17. I think most people have at least heard of lupus but few seem to know what it is. Lupus is an autoimmune disorder, where your body creates antibodies that bind proteins in your blood, and they get stuck in the blood vessels and cause damage when immune cells react with them. It can cause lung, kidney, skin, heart, and joint disease, and at one time was a very serious disease. Now it is very treatable, with most people living perfectly normal lives, to some extent.

My cousin got in touch with me because she had recently seen her doctor and was getting a couple of new medications, and knowing her older cousin James was going to be a doctor, decided that I would be able to answer her questions. Questions aside, she told me she was glad I was her cousin who she could talk to about medical issues. Soon the conversation turned away from the medications and on to how living with lupus has affected her life. She's frustrated and upset that she tires easily, and can't play soccer or softball like she used to. She told me she wishes she didn't have lupus and could go back to life without it. It breaks my heart hearing those things, but it makes me so happy to hear her tell me that she loves me and loves to be able to talk to me because I can understand what she's going through. Perhaps it's a little more rewarding because she's family, but you see, she thinks I'm a hero.

I have a friend who is sold out to be the best doctor he can be. He took the MCAT this spring while also taking Histology, a traditionally demanding class from what I hear. I frequently see him out studying when I visit the Artisan, and oftentimes he has stopped me to ask questions on things he's unsure about. Pretending to actually know more biomedical science than I perhaps really do, I answer him to the best of my ability. He also oftentimes asks me questions about the process of getting into medical school, why I want to be a doctor, and so on. One day, while checking my email, I received a letter from him thanking me for being an excellent role model and something of a mentor to him. I'm just doing my best to give of what I know.

My pastor gave a brief dissertation over a passage from the book of Phillipians on Saturday night. Really, it was a random, obscure passage that didn't have much of a "traditional" lesson in it; there was no parable, no sage words of wisdom, but only some personal comments from Paul to the Philippians. In a table with observation and interpretation notes was one section with a phrase "Care so much that it hurts!" This can be all too easy, mostly because it is hard to love others deeply without desiring some kind of feedback. A "thank you" here and there, someone's praise in front of others, others returning the love to you. It's easy to get let down when you realize that most of the time you're giving upwards of ten-times the love as most people return to you. It's wearisome, you get tired, you get bitter and feel jaded and the world is no longer beautiful, but rather a harsh take-without-give reality. I know that feeling pretty well.

The biggest reason I get so tired is because of the above mentioned reasons, or to state it differently, because I am seeking the return love of other people, when I should be seeking it from God. Studying Romans 5:5 today a book mentioned the signifigance of the phrase "poured out his love for us", and that in the Greek "poured out" signifies a gushing source that doesn't end. God's love doesn't end. It was a rather good lesson to turn to this morning, at a rather useful time.

So that's a little sidetracked maybe, but here's how for me I tie it together: I am going to be constantly giving and loving from everything I have (and as a Christian, I'm called all the more to love others with everything I have), and if I don't have some source to refresh from, those stores of love and caring will get taxed and eventually dry. I have to pray quite often, and quite pleadingly to God, that I be restored and renewed with his love so that I can love others. Today as I was walking the street by my house I was praying that, and I felt like there was a pouring into my heart of something refreshing, something filling me back up to be ready to pour out on others. It's rather profound, perhaps, but at the same time simple. So long as I am diligent about going back to the source of love, it'll be rather easy to be a hero when I need to be. And maybe, even when I'm not trying to be because it'll be such a natural extension of the love God's shown me already.

No matter the reasons for it, I know one thing is certain, that I love people and caring for them, and to find myself pursuing a career where I am paid to do it? That's priceless.

Saturday, May 05, 2007

My last day in the classroom

Today was a very special occasion. I am officially done with classroom-based schoolwork. I will occasionally have a lecture to go to, but my day-to-day routine will not be lecture/classroom based. From here on out, I will be working directly with the patients, and I can't wait.

It was also the last day that Docapella, as it is this year, would likely ever perform together. As is customary we sang on the last day of lecture for both the M1's and M2's, first in the morning (for the M1's) and then the afternoon (for the M2's). Singing Billy Joel's "Longest Time", I felt we sounded the best we have ever sounded, which made the occasion even more memorable. Our voices harmonized, our fingers snapped in rhythm, and we had our audience completely captivated. Even this evening studying at Lakota, a classmate said that our performances will be the most missed thing about the first two years lectures. That's a huge reward to hear.

After my exams next Wednesday - Friday, I will kick studying into an even higher gear as I make a final 3-week push to prepare for the boards on June 2nd. This is the first and often mentioned most important of the boards, as it is the test score residency programs look at the most, and can influence how much of a chance you have to get into a competitive field. A week after that I will start my psychiatry rotation.

I am really excited about doing the psychiatry rotation, even though right now I am not considering it as a specialty. I think that I am somewhat nervous about talking to people with mental disorders, but at the same time am in no way intimidated. I have always felt a great fulfillment in listening and talking to and caring for someone through the giving of my time and my heart, and I think that psychiatry is the best example of a medical field where that can be most explemplified.

I don't think I can in any way promise to have as great an influence on a mental patient's outcome in 6 weeks as a physician can over the course of an ongoing relationship, but I care for the patient as one person to another. I sincerely hope that after six weeks the patients I have been able to see will say that they felt sincerely cared for and listened to, and if I can help better their life by that alone, I think I'll feel I was effective.

Wednesday, May 02, 2007

My Homeless Friend

If any of you who bother to read this have talked to me at any point this year, you know that this is a very grueling school year. Lately especially, with block exams and board exams looming, I have been even more pressured by school. However, Sunday was a very good day. The whole town of Columbia seemed to be on pause; while downtown standing outside the Artisan talking with my mom on the phone I noticed only two cars driving in any direction from where I could see. There wasn't but a couple people now and again walking through the district, and the air was still. The Artisan was equally peaceful being about a quarter full at best, with low-playing Beatles music and the sound of milk steamers and coffee grinders occasionally interrupting. I was studying for block exams while being kept company by a friend analyzed a research article and proofread a report. I was already feeling blessed and in a good mood by the time I met Jeff, who taught me what I believe God had in mind to say to me that good day.

I was using the restroom and had just discovered that the soap dispenser was empty, when Jeff offered me some of his own liquid soap. He was at the other sink at the counter brushing his teeth. On the counter was his styrofoam cup holding water, a pocket bible open to a much-highlighted page of Psalms, and a cloth tote bag that contained shampoo, liquid soap, and other necessities.

Jeff and I began to talk, and he confided to me that he was currently homeless but had complete faith that God would care for and provide for him. He wasn't always homeless, and had even been in college and considered a health care profession. He demonstrated a still-keen memory of medical terminology by discussing the various terms used to describe stroke, cerebrovascular accidents, QRS-T EKG complexes, and so forth. He married however and settled down, although a habit of giving more time to friends and drinking lead to an unhappy wife, and though he didn't specifically mention it he is no longer with her. A friend convinced him to come to Missouri, where life was slower and he would find it easier to get along.

Now in Missouri, he has the next two months to wait to find out whether he will receive disabilities pay and potentially be able to live in Paquin tower or another similar housing situation. Despite many hardships he shared, he continually repeated the joy and reliance he has on God for his needs, and the thankfulness he has for even the smallest pleasures. It shames me to think how often I have taken for granted something so simple as being able to get a meal out at a restaurant, or a warm bed, or email, or a hot shower, when this man lives from what he can carry on his shoulders. That alone is perhaps the only telling sign he is currently living homeless. He criticized other homeless individuals for shooting themselves in the foot by not keeping good hygiene, or by their disrespectful attitudes and rudeness that prevents them from having the same welcomeness Jeff has in establishments such as the Artisan or Panera.

Jeff praised the simple joy of seeing the fireflies, even if he doesn't have a roof. He told of his overwhelming joy in the Artisan's Gourmet Grilled Cheeze, simply because it is not familiar enough to be mundane to his senses. He spoke earnestly about his desire to "break bread" with me sometime, just to enjoy that pleasure. Jeff amazed me with his utter hope and reliance on God. He did not deny that he desired a safe home, with a shelter, and bed, and human comforts, but despite his lack he would not be bitter. He was even more thankful than some of the most wealthy people I have ever met for the little things. I believe he prays in earnest:

" But as for me, I will always have hope;
I will praise you more and more.
My mouth will tell of your righteousness,

of your salvation all day long,
though I know not its measure."

Psalms 71:14 - 15

Friday, April 06, 2007

Letters from Mexico: Excerpts from my journal

Saturday, March 24th, 2007
We leave for Cancun today, and since Thursday I have felt rushed from one place to the next. MUlation was Thursday, then I picked up some of the medical equipment that John told me was available. Friday morning I received a vision exam by a retinal specialist, and now have visual field testing scheduled for just after Step 1 to absolutely rule out the possibility of a nerve cell tumor or impingement of my optic nerve from drusen deposited around the cup.

Friday night I packed, and my tension continued. Packing and laundry interspersed with phoning family engrossed my evening until 11 p.m., at which point I felt I might truly rest. I was in bed by 1 a.m.

I awoke at 6:45 a.m., none too rested. With two hours to spare I still felt stressed and rushed...My general lack of control of the trip leaves me feeling inadequate...

Sunday, March 25th, 2007
The night passed harshly, as the sound of the air conditioner kept me up much of the night.

Our morning meeting was at 7:30 a.m., although our breakfast was at 9 a.m. Prior to 7:30 Bret and I went for a walk, and we came across the large cathedral at the square. Going closer we could listen to the hymns in Spanish, and the poetry of the responsive chant. The haunting sound was beautiful, and the sound of it all will be etched into my mind.

We went to see some Mayan ruins after a brief Sunday service by Doug Hornok, our leader. It was a relatively recently uncovered site, Ek Balam...

After that we went to a swimming hole in a cavern. It was a very refreshing reprieve from the hot weather. The lighting came from a large hole in the ceiling, which now has the roots of a tree descending to the rock island in the center....

"We're all important in God's eyes," was Doug's words this morning. But I want to feel valuable to people. I want people to be invested in me. I want people to think I am special, too...

Tuesday, March 27th, 2007
...Yesterday we worked in a clinic, and the system of seeing people was rather hodgepodge...The whole operation was somewhat organized except for the area where the doctors were gathered. It was something of a catch basket.

My first patient was a woman with eye problems, and I expected it to be a great opportunity to do a fundoscopic exam, until I ran into her bilateral cataracts. Several patients I saw on my own, only consulting a doctor when I had taken a history and physical. I find my increased depth of knowledge is profound compared to last year....

Friday, March 16, 2007

Match Day, the medical student "draft"

Perhaps the biggest event in all of medical education outside of graduation itself is match day. Match day is the day during fourth year when medical students across the country find out where they have been accepted for residency. In many ways, it is like a professional sports draft; students file past a large table of envelops to receive theirs, not knowing what residency program they've matched to until they open that powerful letter. A little background on the match process...

Students initially register for the match process in their fourth years with the Electronic Residency Application Service (ERAP), and through the fall and early winter of fourth year interview with the residency programs in the specialty field of their choice/interest. By early January, students begin to submit a rank list of the programs they are interested in, in order of interest. The programs that they interviewed with then submit a rank list of students they wish to accept as new medical interns. A computer then "matches" each student with the program that is the closest match in terms of ranking. For example, if the program you rank #1 also ranks you at the top, or at least closer than the program you ranked #2 ranked you, then you match there (i.e. - ranks of 1 and 2, or 1 and 3, are closer matches than 2 and 6, for example). On Match Day, the third Thursday in March, students receive their envelops which inform them of their residency placement.

It was exciting to stand atop a bench in the Atrium of the medical school and gaze out on all the familiar faces I have seen and people I've known in the last almost two years. First through fourth years were present, along with families, friends, husbands and wives, doctors, residents, mentors, and many more as well. Many hugged, some kissed, some screamed for joy, some cried tears of happiness, some of sorrow. To think that I will be one of the many students receiving their match in the next two years suddenly seems so very close and near. It is not far in the future that I will be transitioning from student to working physician. It's a little scary, in many ways.

As I see more and more patients through APD, I am feeling more and more comfortable with doing a history and physical exam (although I still have far to go before I can be considered expert in proficiency or efficiency). My depth of knowledge is gradually growing, almost it seems on it's own. My ability to learn seems to be getting better as well, as I become better at determining what is most important to remember, and being able to put what I know with what I observe clinically. Still, the idea of being the person who will make the call on how to treat a patient is something that strikes a chord of fear in me. What if the patient asks me a question I can't answer? What if I don't know what to do? What if I make a mistake? What if I have to tell them I messed up? What if I can't, because they died from my mistake? Those questions, if you could tell, gradiate the level of fear that comes with being autonomous in the care of your patients. For the time being at least, even through residency, I will have the safety net of an attending supervising me. It will thankfully be a good five years or more before I remove the training wheels.

Thursday, February 22, 2007

My First Time, IVs, and Less Than Bulletproof

Monday evening this week my lab was required to do our GTA teaching session. GTA stands for Gynecologic Teaching Associate, which is the title of the women who are paid to be teaching assistants for students learning how to do the breast and pelvic exam. The role of the GTA is not just to teach how to do the breast and pelvic exam, but to allow the students to learn the exam by performing it on them while they teach. Now, it's one thing to do a prostate exam (a requirement to fulfill before entering our third year, for whatever reason), but the awkwardness of inserting your first digit in a man's rectum pales in comparison to the awkwardness of performing your first pelvic exam. One thing's certain; you never forget your first time.

I was one of two guys in a group of four students, with two GTAs who work as nurses in the OB/Gyn department at Columbia Regional. The nurses gratefully understood the nervousness of performing a pelvic exam, especially for us guys who don't routinely have pelvic exams ourselves and are unfamiliar with the whole process. Their friendliness and openness made performing the exam far less awkward, and there was a lot of friendly chatter with no lack of humor surrounding the circumstances. The ability to laugh without fear helped ease tensions, and we talked openly about how not to say or phrase things during an actual exam. For instance, you never tell a patient that her anatomy "looks good"; instead, you would tell the patient that everything "looks normal". It may even be uncalled for to say vagina; instead you might say "bottom".


Starting an IV

Wednesday we have IV lab. One of the best things about this block is learning how to do procedures. Last week we did intubation on dummies with inflatable lungs. Once we got the hang of the procedure, we began competing for time. Amanda was hands down the fastest with a time of less than 15 seconds to getting a patent airway. I digress...

I've often paired up with James Alaly for lab activities, and so we did again on this occasion. He went first, attempting to insert the IV into my left hand. Unfortunately, with a little misguidance from the anesthesiology resident, he instead had a good inch and a half of 22 gauge cathether needle inserted between the knuckles of my first two fingers inside my hand underneath the vein he was trying to stick. Repeated efforts to hit the vein by retracting and readvancing, angling up and to either side, and starting all over only managed to dig around my flesh without hitting a vein. Don't worry, I was given anesthetic beforehand, and he eventually found the vein. I got my revenge when, after getting venous access on him, removed the needle and opened the catheter port without holding the vein closed, allowing him to start an open bleed all over the table.



"Only three other people know this; I may not be coming back after this year."

It was almost painful to hear a friend of mine mention this to me recently. Something that has become even more apparent to me, especially this late in the second year, is how much of a toll the stress of medical education places on each one of us. It's not so much that the stress isn't manageable, because it is. I think more than anything its that so many of us have not learned how to or understand how best to deal with the stress of our environment. After all, most of us are very driven, type A, highly successful individuals who are unfamiliar with being merely average. After being in the upper echelon of most undergraduate courses, it comes as a shock to find yourself working as hard as you can to at best make a mid to upper 70's test score. It also doesn't help that learning in medical school can be like drinking from an open fire hydrant (in fact, I rarely feel as though I've covered everything adequately before exams). Seeing scores like that triggers an almost fight-or-flight response in most medical students. Our instinct is, after all, that if we aren't at the top, near-perfect, we're not adequate. Compounding that drive to be flawless is the pressure to be a doctor who will never be stumped, who always knows the diagnosis, the correct treatment regimen, and never harms a patient. The hard truth of imperfection becomes an overwhelming burden many try to deny or simply cover up.

Maybe a part of this has been trained in us early on. Starting as early as childhood, kids who excel in the classroom are first identified as being "gifted". By high school this continues with our placement on the honor roll. Not that any of this is bad, but it definitely begins to create a behavioral reward thinking paradigm. In college we learn that in order to be doctors we need to excel in the classroom, be leaders of organizations, involved in the community, and so forth. We learn that in order to stand a chance of admission compared to the other many hundreds of applicants, we need to be better than almost 90% of all other applicants. For comparison, the University of Missouri - School of Medicine had 916 applicants for the 2006 entering class. 298 applicants were invited to interviews, and from that group 95 applicants matriculated, or only 10% of all applicants (see link for statistics on the class of 2009). Understanding this creates an intrinsic instinct to attempt to succeed at all costs, and then when we enter medical school and are faced with an even more difficult academic challenge, for which most of us will at best be average, we continue to push ourselves like a high performance machine needing to operate at high production without taking time to rest and do personal maintenance.

It's somewhat a rarity for anyone to ever admit what they scored on an exam beyond mentioning they received a passing grade. Maybe people are trying to hide behind that bulletproof shell of perfection, not admitting that they were merely average. Or maybe it's more of a "strongest shall survive" attitude. Whatever it is, it's a heavy facade to hold up without getting worn down, and the thicker your bulletproof cover is, the more and more distance you create between yourself and others. Pretty soon everyone is walking around and feeling as though they are strangers. You can see the strain in everyone's faces as they struggle to maintain that spark of early inspiration that drove them to want to care for people. Some people have lost most of it, and what remains is a jaded shell that's been sucked dry by the system.

I'm glad that a few cracks have shown up in my own cover. Without them, I may not have had the courage to simply let the facade fall and be seen as a struggling individual who needs others to help him along. I love learning medicine, and I just can't wait to be able to see real patients and put all of this pent up desire to help others to real and active use. I can't do it alone though, and I can't pretend that I can or I'm going to become so bitter, so depressed, so hopeless that I end up as just another drone in the system, where everyone is like a beaten dog out for themselves. Or, I'll continue to let the stress rise as I strain for a greater sense of perfection, until it reaches a breaking point and a simple mistake causes a total system meltdown. I've got to let people know that I'm not perfect, and that it's ok. I need to let others know I need them, just as much as they need me to tell them I'm there for them.

So a lot of other things have been going on with my friend outside of school as well, involving family, personal health, and other things. In fact, it isn't a consideration of not being able to pass tests, but rather a loss of interest in medicine. The stress has taken it's toll physically and emotionally. I'm glad I'm trusted with a secret, but I'm terribly sad to hear that medicine might not be what they want to do. Out of our entire class, they're easily one of the few I see as being a great doctor. Not because they are an excellent academic, but because they care for people in a way that just can't be taught, and seeing someone so instinctually compassionate leave is hard. More than that, it's going to be a little bit harder without such a good friend around for the next two years.

Wednesday, January 31, 2007

Pediatrics clinic and becoming compassionate

On Tuesday I had my third day in the pediatrics pulmonary clinic. I am grateful for the experience I have had there. I have been given a lot of practice in interviewing and examining patients that I would not normally have in my APD class. The first time there, I was nervous and avoidant of seeing any patients by myself. This Tuesday, however, I saw several alone before they were seen by the doctor, and prior to being seen by the doctor would return and give him the rundown, a.k.a. presenting the patient. I was getting better even as the morning wore on. One thing challenging about pediatrics is that your patient is often only a third your size with a will and defiance five times your own, making for a formidable adversary. When you ask an adult patient to comply with a request, generally they will without much hesitation. When you ask a child, you are first faced with putting the request in a manner they will understand. Second, you must ask it in a way that they will comply with. That's the real challenge. I have grown far better with this, and also in my ability to be relaxed in seeing patients and in conducting a clinic visit. I know what use certain questions have, I know how to lead an interview, and I am becoming more and more comfortable with conducting a physical exam. Of course, it becomes far more complicated when you meet that child who won't have anything to do with you, and will let the whole clinic know with a blood curdling scream.

I've noticed in the last year that I react very differently to hearing news that a family member, friend, or friend's family member is sick. When I first started medical school I was more concerned about the disease. Now, having amassed far more medical knowledge, I find that what the disease is and how it is progressing is far less interesting than how the person who's sick and their friends and family are doing. It's not something explicitly taught in medical school, but compassion is something continually alluded to and described. It's not really something that can be taught so much as it's already there inside us, waiting for the right moment when, like the sun rising, everything is illuminated.

I've realized I've come to that point. After having a cousin diagnosed with systemic lupus erythematosus and a brother diagnosed with panic disorder, my first concern was for how they are managing personally. Was there any comfort I could offer out of my fund of knowledge, and as a loving caring family member? Recently a friend's mother was diagnosed with ovarian cancer, and is receiving treatment in St. Louis. Although I am curious about the details, they are of lesser concern to me than the way she and her mom are doing, and how I can show my support.

I don't think I was ever without a sense of human compassion. I guess what has happened is that I am comfortable with disease and suffering. Where once the disease was foreign and terrifying, it is now familiar to a point that I can concentrate more on the person and how it is affecting them and the family. There's also a new boldness I have found myself having with patients. In the pediatric pulmonary clinic this past Tuesday, I was interviewing a mother who was accompanied by her two boys and daughter, the oldest of which was four. The three children were running around the exam room, fighting, getting into things, and the mother was clearly exacerbated. I stopped my interview to put down the patient's (her 4 year old son) file and addressed the kids, focused on them, and was able to gain their attention and cooperation while I conducted the rest of the interview and physical exam. It was a huge reward to be able to feel as though I made a connection with the family, and the mother especially. Because, when all is done in medicine, it's not just how much better you feel after seeing the doctor, but how comfortable it was to get to that better place.

Thursday, January 25, 2007

The Yellow Man and Facing Mortality

Yesterday in Advanced Physical Diagnosis my classmate Blair and I met a man who was nearing end-stage liver disease. In the book The House of God, there is a patient with hepatitis who is named the Yellow Man, and the description fit well for this patient. My Yellow Man was a lanky gentleman with short messy brown-black hair, with a complexion that could be considered olive under normal circumstances, but was now a sickly yellow tint. All of the waste products from broken down red blood cells that couldn't be cleared through his diseased liver were built up in his blood to the point of making him yellow. Yellow Man said that he had been having nosebleeds for the past two months without relief. In interviewing him it became apparent that he had hepatitis C, a liver infection that eventually leads to scarring and liver failure. It was difficult to determine how he had gotten hepatitis, but he was under the impression it was from a blood transfusion. As his liver became more and more scarred and cirrhotic, it failed to produce the clotting factors needed to stop small bleeding, which resulted in the nosebleeds. The scarred liver also blocked bloodflow back to the heart, leading to distended esophageal varices (veins) as the blood sought to return by another route.

As we started our physical, one of the first things I got a closer look at was the Yellow Man's eyes. As I shined my penlight on them, the white of his eye was completely replaced with a sickly yellow tint. Feeling his abdomen, I could feel his massive liver moving with every breath.

I went to Ed and Beth Courtney's house for a church leaders appreciation dinner, and got to talk with my pastor John Drage. As I told him about the Yellow Man, he asked me how long he had to live. I couldn't say, but said that he is likely nearing the end-stage of disease, as he is losing all normal liver function. I told John he would probably die by bleeding out from a ruptured vein in his esophagus or bowels, or maybe he might succumb to a toxic death as his liver fails to process his body's waste, or maybe he'll die from multiple drug interactions, or something else. John asked me how hard it is to face the reality of working with dying people....

As I was climbing the steps of the parking garage this evening I noticed the hearse parked along the side drive, and then spotted the covered gurney being wheeled to the hearse. It is a scene that most people never see, but happens all the time. It isn't the first time I have ever seen a draped gurney wheeled from the hospital complex, but I've been thinking about mortality since seeing these latest two.

The medical examiner's office is in the same hallway as the anatomy lab in the medical school. It is actually a reasonable distance from the rest of the main hospital building, as though some distance can separate the healthy from the deceased (I'm not certain where the morgue is, but imagine it is likely in the basement, also out of sight). Many people have heard the stories of the false-bottom beds being used to transport dead patients out of sight of everyone else, in an attempt to hide death. Doing everything possible to remove a sense of death from the hospital, I imagine, attempts to convey a sense of health and life. Even in posters and brochures for hospice and end-of-life care the patients look vibrant and lively. Heaven forbid those who walk through the hospital doors never leave breathing.

I've also heard many times how hard it is when your first patient dies. It seems counter to what the doctor is fighting against with his entire existance, yet at some point everone dies. Perhaps it is more comforting for the patient to die outside the hospital, either at home or en route or anywhere else but here, in the house of health and healing. At least then I think I wouldn't have to play the what-if game of what I could have done differently, because I was not able to get to the patient. But once the patient is in the hospital and under my care, the failure to reverse the progression of disease lends to self-doubt. What we all need then is the courage to face the reality that everyone who enters the hospital, from those who work for health and those who seek it, will someday die, and it may just happen while they are trying not to.

Saturday, January 20, 2007

How not to do a physical exam

Yesterday I had APD and was with my classmate/partner and our instructor Dr. Phillips. He introduced us to a woman in the VA who had severe right lower abdominal pain who was admitted Thursday. She was on a morphine drip, and reported that the pain was so terrible she was passing out when she was admitted. Since APD is essentially a class on doing patient histories and physical exams, this was "practice" for us. We spent a good hour asking every question we could, exhausting our minds for medically relevant topics, and only then did a complete physical exam (almost a complete physical).

By the time we reached the physical exam, Dr. Phillips had left to go to the swamp (the residents' workstation room) and said he'd wait for us. As my classmate and I moved through the physical, we reached the abdomen. I gently examined the lady's abdomen, noting that she flinched and guarded when I began to press firmly. I moved back and Blair repeated, with questions in between. As Blair asked the woman a question, I was running in my mind the steps of the physical exam, and realized I needed to determine the woman's liver size. You determine this by lightly tapping the abdomen and listening for the difference in resonance. Something that didn't cross my mind was that this woman was in the hospital with severe abdominal pain, and as soon as i made my first tap (which she was not expecting) she grimaced and groaned in pain, doubling up on her bed.

The moral of the story is, don't do anything on a physical that you haven't informed/warned the patient you are about to do.

Wednesday, January 17, 2007

Drawing first blood, finding a purpose

It's the third week of class for me now (all those undergrads who started today have it way too easy), and the year is out of the gates and running. It's incredible that a half month has already flown by. Time is so short when you stop to think about it. Maybe it's no wonder why so many people these days get so busy; they've learned that there's only so much time they have on this earth to accomplish something, and they're working hard to get what it is they're trying to do, done. It seems though that the ability to stop and smell the roses is still eluding most of us. As the wise philosopher Bueller once said, "Life moves pretty fast. If you don't stop and look around once in a while, you could miss it." All too true. I missed a lot of the last six months because in trying so hard to get from A to Z, I missed B - Y. Worse yet, getting to point Z results in a new point A altogether. Now that I've lost everyone...

In the first two weeks of class we've been addressing endocrine pathology. I don't get especially excited about hormones, which is why lectures on procedures is so much more interesting. With third year rotations starting in only 6 months, I'm drooling to get my hands dirty. So, a recap of procedures learned in the last two weeks:

We've been getting a primer in how to draw blood. First week was venous access, and we drew blood into lab vials. The unsuspecting "patients" who got to be our first needle stick was our very own classmates. It's good to know that the Office of Medical Education likes to protect the hospital patients by making us first stick each other. The blood draw lab was no worries though, and I stuck the median antecubital vein of my partner's inside arm with no sweat. Just for practice, I stuck him again on the back of the hand with a butterfly needle. Even easier the second time. Practice really does make perfect.

Week two we had another blood draw lab, only we were going to be drawing arterial blood. Arterial blood is commonly drawn for arterial blood gas measurement (carbon dioxide, oxygen, pH, and bicarbonate). The artery that is stuck is the radial artery. It's the artery you take your pulse at on your wrist. One slight difference with arteries compared to veins is that they are deeper, and are higher pressure. For this lab, we used manequin arms. Also, to get deep enough to access the artery, the syringe is held like a dart and is taken almost straight down, as opposed to a low angle into a vein. It's a good thing we used manequins; I almost hemorrhaged the arm by leaving the needle in so long the stopper was almost pressed off the top. This week we're supposed to do pulmonary artery catheterization (read: thread a cathether to the heart....on a manequin).

Advanced Physical Diagnosis class could be renamed "Give your teacher a physical" class. I discovered I need some practice at giving physicals.

Following the inspiration of a talk given at church before New Years, I wrote up a personal purpose and mission statement. It was the result of a whole day's work on January 1st. I thought I'd share it for the opportunity to get feedback if anyone wanted to.

Personal Mission Statement

Purpose

I exist to glorify God and love Him with all my heart, all my soul, and all my mind by:

  • Living out the character of Christ at home, at school, in my church, in my community, and across the world
  • Pursuing professional excellence through committed ongoing learning, wise management of my time, and empathic relationship building with peers and patients
  • Influencing my family, friends, peers, patients, and others I may meet towards a right relationship with Jesus Christ
  • Championing Biblical principles in bioethics and health care provision

To accomplish my purpose, I intend to:

  • Pursue a right relationship with Jesus Christ through regular and frequent prayer, confession, silence, and solitude
  • Consistently spend time studying the Bible according to a pre-determined plan of study
  • Set aside time at the beginning of each week for introspection and assessment
  • Set aside time daily and weekly to assess my time management and plan ahead for the next day/week
  • Create an organized approach to studying and learning the medical knowledge necessary to achieve my mission
  • Commit to investing in people and scheduling time to do so

Mission

My mission is to love, serve, and heal others as an empathic physician exemplifying the character of Christ with my life; to commit my life to providing morally sound health care to others regardless of age, race, creed, or status; to be devoted to lifelong learning and understanding; to be committed to advancing the kingdom of Christ in my community and internationally; and to be a loving and loyal son, brother, and friend.