Rural Rounds

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 ou...

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 hurr...

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...

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,...

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 Wednesd...

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 t...

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 a...

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 c...

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...

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. Tha...

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...

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. ...

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...

The year began wonderfully and quietly, and I believed it would turn to be an excellent year. Then on January 10th, or 11th, Pam Miller committed suicide. I received a phone call from John Drage informing me of what had happened. We hadn't been very close for quite some time, but Pam Miller is possibly the person most responsible for who I am now today. I believe there are God-ordained moments in time that influence our entire lives, and for me one of those moments came in the winter of 2002, the second semester of my freshman year at MU. I had grown apart from the friends on my floor I had initially made when their desire to go party and drink and my desire to stay sober led to our no longer hanging out quite so often. On a Saturday night I sat in the 4th floor lounge of Hatch Hall playing old school Nintendo alone, and most of the floor was gone doing other things. Pam Miller suddenly appeared passing through, and having met before she saw me and came and said hello. She invited ...

Last weekend I was able to attend the Global Missions Health Conference in Louisville, Kentucky. The conference is on Christian missions-field medical and health care work, both nationally and internationally (although international medical missions is overwhelmingly represented). I attended the conference with one other person, Halley, a nursing student I am friends with who heard of the conference through the Nursing Christian Fellowship group. We left town together on Thursday night last week to be able to attend the whole day's sessions on Friday. Being a six-and-a-half hour drive from Columbia (seven and a half when factoring in the time I drove in the wrong direction), we arrived in Louisville at 3 a.m. central time. Louisville unfortunately is on eastern time. After a two hour nap on Friday morning I awoke shortly after six to get over to the conference. The church that it is held at is so big you could fit my entire hometown's population inside the building (West Plains...

I apologize in advance for the length of this post, but it will likely be a week before writing again due to a busy schedule at the moment. So sit back and digest this in pieces if you like (although, if you want to know when you can see Dr. Peppers in action, scroll down to the last heading). I've provided some headings for breaking it up a little bit. Today was the second time my APD (read: advanced physical diagnosis) group met over at the VA hospital. This time however we were actually able to see patients, thanks to Dr. K, who is the resident paired with the attending in charge of our APD group. Dr. K had a talk with us about how she understood we needed to see patients in order for this to be a learning experience at all, and we proceeded to the second floor wards. Today we saw three cases. This week's cases: VA Hospital Mr. H was an elderly man who had developed pneumonia and a pleural effusion in his left lung. He was cooperative with allowing student doctors to exami...

Today was the Rock Equippers retreat. Basically, the equippers retreat is a day long getaway out of town somewhere where the small group leaders can gather together, be encouraged, share stories, and have John Drage remind us of what we have committed to as leaders and renew our commitments to ministry. One of the verses John shared in his introduction of our time together was 1 Peter 2:9. It says: But you are a chosen people, a royal priesthood, a holy nation, a people belonging to God, that you may declare the praises of him who called you out of darkness into his wonderful light. - 1 Peter 2:9 The verse is exceptionally powerful. I was reminded of the following quote: "It is a serious thing to live in a society of possible gods and goddesses, to remember that the dullest and most uninteresting person you talk to may one day be a creature which, if you saw it now, you would be strongly tempted to worship....There are no ordinary people. You have never talked to a mere mortal....

***Note, some of this material may not be suitable for those sensitive to squeemish topics. Those sections will be starred for your own warning*** Last night was my first day of ACE (Ambulatory Care Experience, basically a glorified shadowing patient-seeing experience before your clinical years) and this block I am doing my ACE in the Emergency Department. I was apprehensive at first, not because of what I might see, but because having volunteered there as an undergrad I was not given much to do in terms of volunteer service. In fact, they acted like they didn't know what to do with me. I called the ER to get the passcode for entry shortly before 4 p.m., and then, donning my white coat, proceeded down the hallway leading towards the west elevators and turned the corner towards the ER door. I let myself in, walked confidently up to the first person manning a desk station, and asked for the attending. There were two that night, and I was recommended to go to Dr. D. Introducing myself...

In psychiatry, there's a set of three patterns of thought that are observed in depression known as the cognitive triad. The cognitive triad consists of the following: A negative view of oneself A negative interpretation of experience A negative view of the future Outside of clinical depression syndromes, I feel it adequately describes the pattern of thinking in any episode of depressed mood. Having tried to think through my own periods of moodiness and depression, I've found that the mood often exists and persists only when all three patterns of thought are present. More on this later, but first a breakdown of how the triad has occured in my own thought process. To start, I've had a decent amount of difficulty with self-esteem, and with large groups of people social anxiety as well. When I begin to start feeling depressed, it will often start with "a negative interpretation of experience". Usually with people this manifests as an anxiety that the person or people ...

Last week was the end of block test week, and at the very end of the week, on Friday, I left for Mexico, Missouri for my church's annual 22-hour retreat. For the last two years it has been perfectly scheduled to coincide with the very end of test week and the beginning of break week, and both times so far has been an incredibly refreshing way to escape the world of academic medicine and the bustle of the city. "Cell phones don't work out here," I mused on the drive out to the camp. The camp where we hold our retreat is several small buildings owned by a Baptist church group out that way that allows us to use it each year. The property is the size of several football fields, with a creative array of fields, wooded hollows, remnants of a creek and some runoff lanes between rises in the ground. There's a lake with a dock that is the perennial wilderness baptismal. There's also a barn-like building that now serves as a chapel. A firepit next to an outdoor ampithea...