Two Hundred and Sixteen, Carburetors

     Puttering along. No, that would imply I work in a factory or office setting. Unfortunately the profession I'm in is increasingly being run like a factory improving efficiency however the acceptable losses is still considered to be zero. Unlike carburetors–of which the worst case scenario is a flawed shipment costing $$$–people are not expendable. When a carburetor isn't functioning properly the usual treatment is to replace it.  Not so with human beings. There is no reason for a mechanic to be on call to fix a car emergently in a night.
     It is enjoyable though and satisfying. That little part that glorifies in fixing problems while interacting with people burns brightly every day for me. Although every now and then I fix a problem or two and then my patient happens to pass away from something else despite the improvement he or she had shown.
     But those thoughts are for another day.

Two Hundred, Another List of Memories

• First season of Cylons with a friend
  
• Hearing the tuba again
  
• Spontaneous late-night table discussions with new people and old people
  
• Couch-crashing
  
• Baseball games
  
• Guacamole and taco salad
  
• Brownies
  
• Baking a cake
• Jesus loves this guy!
• A cave
  
• A museum and a shut-down factory
  
• Local eats
  
• Southern drawls
  
• A splinter in a little girl's hand
  
• Extremely thankful patients
  
• Gangrene
  
• Exploration of an old but new town
  
• One skittish dog
  
• One wonderful vegetarian restaurant
  
• Being reminded that time doesn't stop
• Writing that reminds me of my friend
  

One Hundred and Ninety-four, Cardiac Arrest

I have been remiss from this forum for quite a while mainly because I did forget about it in the jumble known as life.  This entry doesn't herald my sudden return to all things blog but it is to point out a small event that occurred earlier today.

A patient in the hospital for whatever reason stopped breathing and pumping his own blood.  Doctors rushed in along with nurses, I stood outside the room with my three colleagues.  I hear different orders being shouted through the air, "Get the crash cart!" "You start compressions!" "I'll get the kit" "Push another atropine!" "Stop! Does he have a pulse?" "Rotate on compressions" "We have a pulse!" "Ok, he's stable" "I lost the pulse!" "Quick, start compressions again!" and on and on.

At one point, one of the residents turns to me, points, and beckons.  As I near him, he tells me to leave my white coat outside the room.  I hurriedly rush in sans white coat and grab the gloves he gives me.  

"You're going to relieve the guy giving compressions."

My mind's jaw drops.  My physical body continues as directed to the side of the room where the folks giving compressions are standing and doing their job.  As I stand behind the fellow whose shoulders are heaving as he pushes heavily onto the old gentleman's sternum, someone tells him to pause to check pulses.  They find one!  Everyone relaxes (again) as the people in the room prepare to move the bed to the ICU.  As the connections are dropped, they notice his pulse is gone again.  Matt, my resident, turns to me and points me in.  I step up, place my hands as taught and practiced on rubber dummies, and start counting while doing my job.  I count ~50 compressions when the lady next to me says, "I can feel your compressions, stop so I can see if he's beating on his own."  I halt.  She still has a pulse.  I step back after glancing at Matt as the bed is wheeled off.  As I exit slowly behind the bed and its horde of people, my two colleagues come up to me and congratulate me on saving a life.  I stutter like I always do when I get a compliment.  Jokes continue into the night about using the story to score chicks at the bar.  I'm just happy he lived.  And constantly reminding myself in my mind about how oddly the feel of the elderly gentleman's chest felt just like the mannequins we practice on.  The only odd part was the face staring up at me slowly turning first purple, then pink with compressions, and with a mouth slightly parted in the agony of the situation...

One Hundred and Eighty-six, Patient Continuity

So this daily blogging isn't going to work as is apparent to all who read my last one and then glanced at the date on this one.  Ohwell, ONWARDS!  

Continuity of Care is important in medicine for particular doctors.  Mainly Family medicine, Ob/Gyns, Psychiatry, and Pediatrics.  You see the same patients regularly either for checkups or for sick visits.  Hopefully the former, but the world isn't perfect.  Friday closed a chain of events in which I had interacted with a particular patient through three separate events, as opposed to following a patient stuck in a hospital during my rotation.  The first encounter was during my Ob/Gyn month during clinic where she came in for a 28 week checkup.  I can recall the exacts of her circumstances, older mom, excited that she quit smoking during the pregnancy, and with a particular medical condition which required some vigilance on our part when delivery-time came but was not a major worry.After her checkup that day, I placed her out of mind and figured, like the rest of the patients I had seen during those months, that I would let her melt into the pool of faces and names and diagnoses that collects all the patients I see.

Ten days ago during Newborn nursery my fellow classmate was examining a baby who had just come from the OR where mom had just had an emergency Caesarian section.  I didn' think much of it as I was writing my note on another baby while listening to them talk about a medical condition plaguing some mothers when I happened to hear the baby's last name.  I glanced up and without thinking uttered a first name.  The attending glanced down and read the mother's name.  Perfect match.  Mom was not exactly with it since she was recovering from her operation so I didn't get a chance to congratulate her then.  I felt a little warm inside with this patient continuity but again I figured that this was it, the end of the line.  I was prepared to let her and her child melt into the pool of patients although I figured it would take a little longer due to this second interaction, however remote it was.

Two days ago in my pediatric outpatient clinic, again I found myself sitting writing up a note on a patient I had seen while listening to the residents and attendings interacting and teaching/learning.  This time I heard about how this newborn's mother had a particular medical condition but it had been handled properly and there was no sign of damage to the baby due to it.  This time I glanced over at the folder the resident was working on.  There was the last name again.  This time I did go in to say hi.  

I don't know what I want to do yet, but I do want continuity.

One Hundred and Eighty-four, Diapers

I started Newborn Nursery on Tuesday.  I changed my first diaper then.  It was goopy.  But I did a good job!

One Hundred and Eighty-three, Two Days

I joked with my friends before starting the Pediatric rotation on how long I'd go before I came down with something.  The results are in!  I went a paltry two days before getting feverish, having extreme cold chills, a headache, and some muscle aches.  In my defense, I do believe this is related not to the kids I saw yesterday as much as to the flu vaccine I received yesterday at noon.

One Hundred and Eighty-one, Everyday Doctoring Stuff

Last week Wednesday I received an email from the Beatnik.  He'd recently done 129 questions to see what Dungeons and Dragons character build he would be and was curious what our friend circle would get.  This was in the morning.  I set aside this task since I was heading into the hospital and decided to confront this monster of a quiz later on that day.

Wednesday continued and I learned that I would be participating in a big surgery starting at 2 PM called a "free fibula flap" surgery.  If you Google it, the second hit that comes up does a good succint job of describing it.  I describe it below in brief.  Anyway, we didn't finish the surgery and I didn't get back to the apartment until 1:00 AM Thursday morning from the hospital.  I had a pounding headache from lack of food and liquids but I had just seen an amazing surgery.  I saw a slew of emails from all of my friends who had replied their character builds throughout the day as they completed the 129 question quiz.  The last one was from the Beatnik again, addressing all of us.  Here it is, and pardon any language that might be offensive to you.

The Beatnik's question to the world:

"Well our party is pretty varied.  We have Drock as the all powerful wizard.  I'm the tree hugging hippy druid.  Crazy Blonde is the know it all Wizard.  Woodwind is the touchy feely Cleric and Lord Chaos is our soul devouring Fighter/sorcerer.  The Engineer is our totally not gay Bard.  And I know you are all wondering the same question I am,

 

WHAT THE FUCK IS DAVE!?!? TAKE THE GOD DAMN TEST!

 

Our group make up would put Lord Chaos in the front.  Me and Woodwind in the middle with the Engineer close behind (Dancing or doing whatever the fuck bards do), Crazy Blonde and Drock as our artillery in the rear (tee hee).  And I know you are all curious about one thing,

 

WHERE THE FUCK IS DAVE?

 

I know me too.  Kinda fun, maybe we should all cosplay sometime (shudder) 

love,

The Beatnik 

p.s.  TAKING THE FUCKING TEST DAVE! "

Reading this at 1:00 AM, I quickly sent out a reply to everyone:

"I just saw a guy’s left jaw taken out, then a bone from his leg taken and put in with a metal bracket to work as a jaw, then his pec from his left chest pasted over the bone, and then multiple skin grafts.  This morning I briefly read your email at 6:00 AM before running off to the hospital.  There I have been until 1 AM right now.  I don’t think I need a test to tell everyone that I’m some type of good cleric

I’ll take it one day. 

-Dave"

I felt that while this might be harsh, it helped explain why I hadn't replied and that I'd get to it when I had a chance.  Little did I realize but in the couple of hours of sleep I got, the Beatnik had responded:

"Lol, now was that so hard?  I kind of realized your crazy schedule after a little while.  You're doing something right now that I could never do.  I know that you're in a world of doctors and people who do this shit all the time.  But, those of us who don't have MD in front of our names are pretty impressed by what you're doing right now.  Just thought you should know. 

Keep up the good work Cleric Dave,

The Beatnik"

This was 6 AM Thursday morning after a 4 hour nap.  I paused.  

and continued to pause.

I have become so inundated with cholecystectomies (gallbladder removals) and hernia repairs (fixing weak areas of bellies and groins) and other surgical terms that I was missing out on the simple fact that the majority of humanity never sees the things surgeons and the OR staff do.  Yeah, during the surgery I wondered who the hell thought up taking someone's bone from a leg to rebuild a jaw, but the actual procedure never amazed me because it made sense.  To laypeople though, it's practically magic.  The patient sees the difference between what they used to look and feel like compared to how everything is after a surgery and it's amazing.  

That's what my two months on Surgery have boiled down to: Amazing.

One Hundred and Seventy-five, The Elderly

I went into a room to check on an 83 year-old man's progress that day.  "Good morning sir." I said clearly as I turned on the light and approached his bed.  His eyes perked up and his head tilted slightly towards my voice.  In the corner the television was blaring away on some news channel some family member or nurse had put on for him.  I realized as his eyes stared at the ceiling that he would not be focusing directly on me.  I involuntarily speak louder asking him how his night was.  In reply, a slew of noises issued from his toothless mouth.  I put my ear close to him to hear him better.  No avail.  How was I supposed to gather information from this fellow?!  I stood at the side of his bed despairing that this man with a rich history (all 83 year-old people have a rich history) couldn't communicate what he was trying so hard to tell.  I continued explaining my exam steps as I checked his heart and lungs and operative site and legs.  He never stopped with his trail of words.  In fact, I couldn't hear clearly at all in his chest due to his larynx sending sound waves down through his body into my stethoscope.  As I said goodbye and left, he quieted down in what I imagine was frustration.  He might have had a stroke, but he obviously was aware of people.  He just couldn't communicate effectively and that is what made me saddest.

In opposition to that experience, I met a nurse later on that day who was from the Philippines.  She had immigrated 58 years ago.  At the spry age of 79, she worked regularly in the operating room as a circulating nurse--the nurse who makes sure everything runs smoothly in the OR and gets stuff we don't have in there.  She was telling us stories about her younger days and stuff about her husband.  Her husband is Japanese and apparently when she married him, the Philippine government took away her Filipino citizenship.  She told an elaborate story about how she eventually kept from being deported to Japan through friends in high places and even getting her name on a bill that Lyndon Johnson signed.  And then there was the story about her husband who was to be deployed in the war "in just a few days when the war ended."  At one point a newer worker in the area, some nurse or tech, came by asking if she would help move the patient back to the ready OR.  The 79 year-old fixed a look on the intruder which clearly meant, "Let me finish my story, then I'll take care of it!"  She picked up where she was decribing a kamikaze's underwater counterpart, a Kaiten.  Her husband had been training as a pilot for one of these and was scheduled to be deployed a couple days after Nagasaki.  Her wrinkled face was animated throughout the storytelling.  Deep furrows appearing in her brow when reciting the parts regarding her possible deportment and the fact that her husband was a Kaiten pilot.  Wrinkles clearing out with her smiles when she reached the happy conclusions of remaining in the States and her husband not being deployed incidentally.

In one day I encountered two people who showed me the wide variability in human function and communication.  I also grew to appreciate different qualities in each.  From the gentleman patient, I had a glimpse of future disability that is more likely to strike than sudden death and the possibility of unheard stories.  From the nurse, I learned the richness of a life and the joy of knowing the lives others have lived.  In fact, it gave me hope hearing her realizing that the gentleman probably had regaled other people with his own stories prior to his mishap.  I hope those people take those stories and remember them time to time.  

What are we but the sum of our experiences and knowledge? 

One Hundred and Seventy-one, Dr. Horrible

I finally watched Dr. Horrible's Sing-Along-Blog. Doogie Howser (yeah yeah, Neil Patrick Harris) can SING! Go watch it. Pretty please.

One Hundred and Seventy, Being Chiseled Away

While I am enjoying myself (I started Surgery on Monday), I am tired, and eagerly awaiting the rotation where I will be allowed to sleep more. Alas, they are all far away next Spring. I've slowly been refining what kind of doctor I want to be not by selecting and excluding specific positions like obstetrician or surgeon but by selecting and excluding doctor qualities and types of patient interactions I enjoy and dislike.

One Hundred and Sixty-nine, Start of a Queen's Reign

"Go on, get in there!"

As I stepped forward, a fleeting moment of nervousness and panic entered me and left as I strengthened my resolve. I was ready for this. I'd seen it done many times by now and felt comfortable with the process along with the doctors there. I held the little girl's head as it came at me. I moved the head and the shoulders downward until the top shoulder came free. Then, before I could blink, she popped out! I wasn't prepared for the speedy exit she made so I was holding her with both hands as she started crying (the practiced physicians develop a one-handed safe baby-holding technique). The resident put the clamps on the cord and Papa leaned in to cut it with the scissors. Finally I handed the little girl off to the pediatric crew ready to assess her health.

Later on I asked the resident, "Does it ever get old?"

"No."

One Hundred and Sixty-seven, Deliveries and Home

My days this past week included two Cesarean sections, one normal delivery, and one ectopic pregnancy. I've managed to find many babies' heartbeats while they're inside mommy using Doppler devices. I've met a woman who is pregnant for the third time after having lost her first pregnancy because the baby developed no brain and lost the second in a miscarriage. She and the doctor are ecstatic that this third pregnancy is going well and she's getting really close to term with a healthy baby growing inside her.
This past weekend I saw the Engineer and some other friends. I came to realize that while I had become slightly desensitized to bar smoke in the past, my year or so of abstinence from smoke-ridden air caused my throat to heal up and feel Friday night stronger than usual. My grandmother's birthday was on Saturday. And Valiben showed up just before I ate dinner and then drove off to my schooltown. Sunday I managed to get laundry done and I had some good chats with a couple friends.

One Hundred and Sixty-four, Wrinkles

It's both amazing and freaky to watch a baby come out of a woman's uterus. More to come later this week!

One Hundred and Fifty-nine, Gyn/Onc

[Disclaimer: Medical terminology and surgeries are described here. No "graphic violence" or descriptions about how bloody it was or bodily juices, but relevant surgical terms are used]

Ok, where to start...[ponders]

Gynecology - the branch of medical science that deals with the health maintenance and diseases of women, esp. of the reproductive organs. (definition from here)

Oncology - the branch of medical science dealing with tumors, including the origin, development, diagnosis, and treatment of malignant neoplasms. (definition from here)

July 7th, 4:30 AM I met with my classmates in a dark parking garage. We walked to the hospital and changed into scrubs nervously. We learned.

That early in the morning we wake up old ladies and ask them whether their pain is controlled. Whether they are feeling nausea or have vomited overnight. Did they have any bowel movements or did they pass any gas (I always want to say fart but I have to sound proper even though the patients can say whatever they want). One lady talked about popping a kid off on July 4th and another mentioned she'd let rip a big fart just the past night. We proceed on with our exam.

The exam isn't anything horrific. I just listen to lungs to make sure there's no fluid buildup and listen to the heart. This is where I start practicing listening to normal stuff and might hear abnormal stuff time to time. Then I check the abdomen. There's a variety of abdomens. Some are pale and doughy, others are pinker and more rigid. I always get nervous poking near the site of the wound.

After all that, we sit and write our progress notes. Basically a distillation of all we learned from the patient and writing down all the pertinent lab information from the computer and from the nurses' vitals' sheets. We try to finish before the residents come in--I still find this morning deadline challenging. The residents then repeat everything we did except they go much faster and they have an idea about what treatments to follow for the day. The Attending doctor arrives at some point and we proceed to summarize all the patients for him (or her) and then go to each patient as a large horde. We talk to each patient and sometimes re-examine them telling them what we have planned for them and listening to their concerns.

One day a week I have clinic. This is akin to a doctors office and deals mainly with pregnant women coming in for regular checkups or post-operative patients coming in for 3 or 6 week followups. Women seeking contraceptive help can also come into the clinic. Here I brush up on interviewing skills and practice my physical exams steps of listening to heart/lungs, and checking the abdomen as well.

I have to dress up for this day. I still find jeans and a t-shirt more comfortable.

Outside of that routine, we get to scrub into surgeries our doctors perform. My first surgery was a 3 hour hysterectomy and bilateral salpingo-oopherectomy. Those are fancy words for "We took her ovaries, tubes, and uterus out of her." It was a surreal experience putting my hands inside her belly. I've been following her since her surgery and she's been doing alright. We're waiting for her to have a bowel movement. Yup, surgery is grand!

I enjoyed laprascopic surgery. I play video games. Controlling the camera felt quite natural. I was also controlling the lady's uterus so it stayed up and out of our way. The tension in my arms from these two actions used a lot of oxygen. I almost fainted. I'm glad I spoke up and sat down at that time. Falling down on a sterile field is definitely frowned upon in surgery.

Yesterday's surgery was to investigate a pelvic mass in a dear old lady who wasn't able to keep anything down. This was a neat surgery because as we delved down into her bowels, it was clear why she couldn't eat anything. A huge cyst had adhered to her intestines and then grew big enough to pressure the gut to close. We took out the cyst--it quivered as it came into the cold OR. It was black and blue and slowly dying (the cyst, not the lady). We're hoping she'll heal just fine now!

Today I will go to bed two hours ago. I will wake up tomorrow dark and early to go back to the hospital!

One Hundred and Eleven, Juno

"Doctors are sadists; who like to play God and watch lesser people scream."

Ninety-six, Prostate

I just felt a prostate a half hour ago. Felt like a bump on the inside of the fleshy tube. Nothing that gross, nothing that amazing. Just was.

Eighty, Toasted Cheese Sandwiches

I woke up today and throughout today so far have had that heavy sinus-filled feeling of doom which in my world means a judgment of a cold is about to fall upon me. Doesn't necessarily mean it's going to be a really bad one, but it's going to be one. The "filled-head" feeling (yes, that's doctor for the lay folk out there), the slight skull ache (specifically my maxilla!), and the low fever I've developed plus my loss of normal taste sense.

Mmmmm, soup and toasted cheese sandwiches (lazy man's grilled cheese).

Fourty-one, Humanism in Medicine

There's a reason why the number one complaint by patients about their doctors is not that they don't know what they're talking about. Rather the biggest complaint is that their doctor isn't treating them like a person. They barely spend time with the patient; they just don't get to know him/her; the doctors' abrupt manners affect their patients.

My thinking is that over the past 60 years, medical education has evolved in its ability to pass vast amounts of scientific knowledge to the learners which, unfortunately, has moved hours from the bedside to hours in a lecture hall. This lack of bedside hours equals directly into lack of communication skills with patients. And that's what doctors do. Anybody can make the diagnoses doctors can make as long as they learn the language which is vast. So the doctors have to take the knowledge they hear/see/feel and convert it into English. While I do think it's important to be able to build the knowledge base so that everything you hear/see/feel means something to you, I don't think one should neglect the ability to talk to the patient. After all, if you know everything wrong with a person you see, what's the good of not being able to inform them?

Our Dean recognizes this and is willing to stumble along in trying to find a solution. I'm just sad that I'll be missing out on his changes.

Thirty-nine, Compassion Overload

In my lifetime, many times have I been approached on streets by barely dressed 4 and 5 year-olds asking for money. Mothers holding babies begging for a few cents. In all these years I have never given them anything. Yet yesterday I gave some money to, not an individual or two, but an organization that specializes in feeding and caring for kids around the world. How can I condone giving to an organization and not an individual? For me, it has always been easy. I don't believe that anything going wrong can be fixed simply by throwing money at it. Rather, money works better if it's decided how to spend it first so instead of showering the destitute with colored paper with deceased people's portraits on them, it is used to pay for the creation of homes, for the purchase of foodstuffs and medicines, and hopefully on education for everyone--especially the children.

I don't deny that there are barely dressed children running around in American streets. But I guarantee that the number in this country is much lower than in most developing nations. The question then crops up: Do I support a National initiative to help people or a World-wide one? And this is where your individual ideals come into play. For me, the whole has always been very important to me. In classes, the learning occurs at the pace of the slowest learner to make sure no one gets left behind. Granted, this has changed in the past year and a half with the advent of Medical School but overall, the idea remains.

The Numbers. Percentage-wise, the US and India aren't at opposite ends of the scale in their poverty numbers: 12% and 27.5% respectively. But when I take into account the population, the US has ~36.4 million people under the poverty line while India has 321.5 million under the poverty line. For comparison, the total population of the United states is just over 300 million strong. This makes it harder for me to spend on people and organizations that service just the United States.

I do hope I have the nerve to offer up my services to groups like Doctors without Borders or go and provide free clinic care annually to areas that receive no care usually unless they travel hundreds of miles to the nearest hospitals which are too expensive for them and have overcrowding issues. That would be the best thing that I could accomplish to serve my fellow suffering human beings.

Twenty-seven, Heartbeat

She came in asking for a pregnancy test. The clinic director figured it would show up negative since all the previous ones requesting the test weren't really pregnant. The student assigned to work with her rushed back to the doctor with the news that she was. The doctor just took it in stride, possibly because it was her first day at the free clinic too. She came in to talk to the woman, who was obviously happy at her news. God knows enough young women in the same condition, finding out that they are pregnant at a free medical clinic run by students, would freeze and wonder what will happen to their lives. The volunteering doctor then rummaged around the clinic. She knew what she was looking for but wasn't sure if they had one. After scrounging through many cabinets, one yielded the medical equipment she was looking for. Going back to the pregnant lady, the doctor applied some gel to her and then gently placed the equipment's sensor rod against her belly. Suddenly, loud sounds began emanating from the box connected to the sensor rod. Oddly enough, it sounded just like what we hear in a set of stethoscopes except faster, much faster.

As I listened to this sound, I stood in awe. Here was the sound of something new, something untouched by the world I have come to call home in my twenty-five years. Its life could go anywhere, or nowhere. This holiday season, it will bring joy to its family. But as I stood there, I could think of little beyond how cool it was.

Here were the heartbeats of an unborn baby