A Doctor's Christmas Dinner

I'm stuffed. Christmas dinner with my family, a happy time spending time with grandparents, cousins, aunt and uncles, and all the good Swedish food I remember having as a kid. It's bittersweet; I'm worried that next year I'll be an intern and won't get to be home for Christmas. It's my last year on an academic schedule, the last year that I can depend on someone to protect my time. And as I was thinking about being a doctor during Christmas, my mind drifted to the many foods I learned about in medical school. Not really foods exactly; doctors seem to like to name various pathologies after the dishes they abstractly resemble. So here is my idea of a Christmas dinner for doctors, a menu of pathology.

To drink:

Port-wine

Coffee-ground

Cafe-au-lait

Rice water

Appetizers:

Anchovy paste

bread and butter with red currant jelly

caseous (cheese) necrosis

Grape clusters

Olive sign

Main dish:

Pizza pie with onion skin

Hamburger sign

Millet

Dessert:

Red cherry

Strawberry tongue

sugar coated spleen

chocolate cyst

Apple core

Banana sign with nutmeg

Here is what we are really serving:

To drink:

Port-wine stain: hemangioblastoma

Coffee-grounds: upper GI bleed emesis

Cafe-au-lait spots: neurofibromatosis

Rice water: cholera diarrhea

Appetizers:

Anchovy paste liver: amebic liver abscess

bread and butter with red currant jelly: pericarditis, klebsiella pneumonia

caseous (cheese) necrosis: tuberculosis

Grape clusters: hydatidiform mole

Olive sign: pyloric stenosis

Main dish:

Pizza pie with onion skin: cytomegalovirus retinitis and hypertensive arteriosclerosis

Hamburger sign: uncovered vertebral articular facet

Millet: spread of tuberculosis

Dessert:

Red cherry: Tay-Sachs disease

Strawberry tongue: Kawasaki disease

Sugar coated spleen: chronic spleen serositis

Chocolate cyst: hemorrhagic ovarian cyst

Apple core: colon tumor

Banana sign with nutmeg: hypertrophic cardiomyopathy and alcoholic hepatitis

These are all signs and symptoms that are clinical language to describe the diseases mentioned. Doctors just seem to describe these clinical signs in terms of a better known entity: food. Everyone knows what bread on butter looks like. So when you see a heart with pericarditis, it's a frame of reference for something you see. But it is an unappetizing way to characterize disease.

My advice: don't have holiday dinner in the doctor's lounge.

It's Not Easy Being Green

No, I’m not talking about Kermit the Frog or even about the environment. I’m talking about medical school. Now that I am a few months from graduating (after nearly four years) I have decided that it’s never easy to be the "greenest" person in one’s profession with little knowledge and a lot of demands. The following account is really true; it is way too bizarre to have been made up.

Month 1: A group of medical students listens to a robot simulation-patient with a heart murmur. It's the same murmur for every student. We must describe said murmur to teacher. Each student proceeds to listen to the patient with their brand new stethescope and echoes the previous student's assessment. In my anxiety and eagerness, I press my stethescope bell to his chest and repeat the same findings. Teacher points out stethescope is hung around my neck and not in my ears.

Month 3: We study anatomy of the lower extremity, and find a cadaver leg with painted toenails. Group of students abandons study and instead discusses whether the person the leg belonged to painted her toenails then died, or if sick student painted them postmortem. Argue about whether formaldehyde would act as nail polish remover or preserver. Never reach conclusion. I still kind of wonder about it.

Month 5: Study the thorax and abdomen. Work hard to learn muscles of chest wall and back. Anatomy professor (retired surgeon) points to a muscle and asks what it is. I blurt out "pec major! its pectoralis major!" He looks at me and says "that would be true...if he were laying on his BACK!" It was the trapezius (similar looking muscle, opposite side of body)! He took the opportunity, not unkindly, to remind us to first orient ourselves to the patient's position and anatomy in all visits and operations. Very sound advice indeed.

Month 10: School pays unfortunate woman to serve as a "standardized" patient for the purposes of us learning to do a well-woman exam. We take turns examining her breasts and learning to do a pelvic exam. As it turns out, opening the speculum is nearly impossible and requires at least three hands. Who knew?

Also Month 10: Same patient is exposed to little docs learning how to professionally communicate. A male classmate completes the breast exam, looks at her and says, "Your breasts feel great to me!" I think what he meant to say was, "Your breast exam is normal." It just came out wrong.

Month 13: I rotate through my first half day in clinic doing pediatrics. Secretly think newborns look like little aliens. Am horrified when little one cries when I touch him because my hands are so cold. I want to cry too.

Month 15: Man comes under my care after cardiac arrest. I ask how he was resuscitated. Wife cuts in and says she punched him in the chest, saying "You're not going to die on me, you son of a bitch!" The punch restarted his heart into sinus rhythm.

Month 16: Watch attending (physician) distract hospitalized patients and then eat food off of their trays.

Month 17: Watch a classmate diagnose twins based on fetal doppler tones. Laugh when attending tells him he did indeed find two heartbeats: Mom's and Baby's.

Month 21: Write out a prescription and attending signs it. Spend entire lunch staring at it, admiring my handwriting on prescription pad.

Month 24: Halfway through medical school, and still have to imagine myself sitting as the patient to know which side is their left and right.

Month 25: See infertility consult with attending. Assist with intrauterine insemination procedure. Attending approves my work by saying, "Between you and me, we should be able to get this lady pregnant."

Month 26: Greeted by new rotation attending: "Do you know how many millequivalents per hour to raise a hyponatremic patient's sodium level to prevent central pontine myelinolysis?" Um, no. I think I just forgot what sodium is.

Month 27: Greeted by new rotation attending: "Who the hell are you?"

Month 30: Greeted by new rotation attending: "The s*** has hit the fan!" Um, am I the s*** on your fan? Or is it something else? In any case, can I please, please run away?

Month 31: Realize between my tuition and my husband's salary (we work at the same place), we owe the health center eight thousand dollars for us to both work there full time.

Month 33: See patient with the back of my skirt tucked into my underwear.

Month 34: Do hernia exam on old, fat, hairy, bald man. He jovially warns me to be careful, don't get turned on. Realize, almost too late, that it is not professional to say "Ewwww!"

Month 35: Wear new dress. Attending asks if I am pregnant. Never wear dress again.

Month 36: Must get size medium scrubs from scrub machine at hospital as smalls do not fit over my hips. Mediums huge on bottom, even bigger on top. Curse misogynist freak that designed machine to only dispense atomic booger-colored men's scrubs in sets, not separates.

Also Month 36: Examine patient who has a toddler in tow. Toddler pulls on the drawstring of my too-big scrub pants while I am examining mother. Pants fall down. Complete examination in pink polka-dot panties.

Month 37: Eat at doctor's lounge with attending. Take last turkey sandwich. Attending gets ham, wants turkey. Takes my turkey sandwich. Opens both sandwiches. Removes cheese, changes his swiss for my cheddar. Proceeds to enjoy turkey and cheddar sandwich.

Month 38: Do rotation at a new hospital. Get slapped on the hand (literally) for harmless mistake. Watch another student get grabbed by the back of the scrubs and thrown across the OR. Fondly miss my sandwich-stealing attending.

Month 40: Almost seize with happiness when patient argues with reception that she wants to make her follow-up appointment with me instead of the real doctor.

Month 42: Realize I am graduating in 6 months. Start reflecting on stories. Decide some are pretty funny, and almost certainly universal for medical students.

Month 43: Write them down. More to come.

Board and Restless

I switch my computer on, open up a webpage, stare at it blankly, and shut my laptop. I go unload the dishwasher, clean the catbox, and put away my shoes. I return to the computer, mindlessly opening it back up. With a frown, I shut it again. I open a book, then shut it. I stare at my dog. He stares back. I'm not sure what to do now.

I took my boards yesterday. I am so used to doing practice tests online, to using every spare moment to open a book and do a practice question, that I forgot what it's like to not do that. It's become a habit, a compulsion, to take free moments and turn them into study time. Now the test is over, but I feel no different than I was day before yesterday. I have to adjust to the new, test-free me. It's very disorienting.

I remember this sensation after I took my Step 1 board exams. I wandered around the house restlessly for a few days, turning my computer on and off, cleaning, hovering around my husband until he finally suggested that I go to the gym (a good idea). Eventually I settled down, into a new routine that didn't include 200 daily practice questions, each with a 2 paragraph question stem and answer choices a through j. But now I'm back to this post-board restlessness after Step 2. You think it would be relieving, to have the test over with. But with the test's completion, a significant effort in your life is over. And you are left with the residual habits and anxiety that have unknowingly become part of your daily routine, without anywhere to direct them.

I think anyone in intense academia can relate. I remember the end of my dad's dissertation, when he would dazedly relinquish the Apple Mac (high tech with a 7" screen) to a six year-old me to play Shuffle Puck and McGee. Even though he had a diploma on the wall and cap on the desk, it didn't feel right that he didn't need the computer anymore. Even to me, the house was strangely quiet without the sound of the dot-matrix printer. It had been my bedtime lullaby for as long as I could remember.

I imagine this will happen in the days following my Step 3 boards and written/oral specialty boards. Each time I'm a little more prepared for this strange inner restlessness. It's something that was new for me in medical school, yet another course in the unwritten curriculum. And on many levels it tests doctors in other ways than the questions. It asks you to devote your entire thought process to something, then leave it and be able to shift focus. The test demands all your effort, with no immediate result to show for it. It makes you think quickly, so you have time for every problem. It doesn't take excuses, only answers.

Such is the daily practice of medicine. And these lessons are probably even more valuable information than the actual questions asked.

Metamorphosis

I interviewed for medical school just about four years ago. It was my first (and only) interview, and I was desperate to get in after the long, somewhat traumatic, experience of the application process. My mom came with me, and she and my sister helped pick out my outfit. Pretty black skirt suit, pumps, white blouse, generic black briefcase, hair down, fingernails and toes painted a safe pale pink, eyeshadow carefully applied. I interviewed well, feeling like I needed to be everything they wanted. Want primary care docs? Family practice it is! Want someone bilingual? Yo Hablo! Rural, underserved medicine? Why, I wouldn't do anything different. Need someone taller? I can order heel lifts! I'll be just what you want and do anything it takes.

Everything was external to me, a force dictating my future that I had no control over. I wanted desperately to be a medical student, but didn't seem to know how to make admissions committees pay attention to me, see past my white skin and nontraditional science major and frustratingly low MCAT score to my strengths of empathy and love of medicine. My workouts during those months were hours of kickboxing, my muscles toned and body thin with the effort of trying to punch and kick myself out of this box of uncertainty and desperation.

Fast forward four years. I'm graduating from medical school in a few months, and on the interview trail for a residency position. In many respects, it's similar to applying to medical school. You prepare written statements, an online application, and visit for an interview. But for me, it was all different. I didn't fit into my old suit, my body no longer skinny from unhappy workouts stemming from a lack of contentment and control. I bought a skirt suit that skimmed my new curves, strong legs and hips from hours of happy, thoughtful running and hiking with my new dog and husband. The new suit, a dark gray with a collar that cascaded down in a gentle ruffle, felt to me to represent a little of my personality- polished, yet fun with some unexpected detail. My formerly nude nail polish was replaced by a cheerful pink plaid on my toes, peeking out from those same pumps, and my nondescript white blouse replaced by a bright blue top that turned my hair auburn and showed my personality a little bit more. The generic black briefcase wasn't there; I opted for my pink, blue, and tan patchwork Coach tote. I don't like wearing my hair down or eyeshadow, and this interview sported a dressy ponytail and clean eyes. I wasn't going into the interview as a blank slate, available to be designed into anything they wanted. I was going in dressed in things that I liked, knowing things I liked about the program and things I like about myself. The balance shifted between me needing to be a good fit for them to needing to be a good fit for each other.

So, it was a much happier interview than a few years ago. I've gained a little more style, power, knowledge, and a lot more confidence. The transformation from wanna-be student to almost-doctor was evident in these similar, but very different encounters. There's a change from a frozen, headache-inducing smile to an easy, genuine one. This is a happy metamorphosis, and one that I am proud of, for the health of both my patients and myself.

Strong Candidate!

Residency

I thought you became a doctor after graduating from medical school.

Whoops. My bad.

I think a lot of people have this misconception. It turns out that while you graduate with a medical doctorate after four years, it's actually a sham. You can't practice anything. You have to go through a residency and become trained in a specific specialty, which can take anywhere from 3-7 additional years.

I just hit "submit" on my residency applications. It is a process akin to, but worse than, applying to medical school, with complicated essays, letters of recommendation, resume information, letters from the dean of your medical school, and lots of fees. Most people apply to between 15 and 50 programs. You put your applications in, hope for interviews, and then submit a list of your "rank" preferences of programs. The programs do the same for applicants, and a computer forms a "match" between students and programs. The Match results post the third thursday of March. If you don't match, you go into "The Scramble", which is the process of finding an open residency position and applying for that spot, and is as stressful and disorganized as it sounds.

I had a few programs that I was really interested in, and one in particular, but ended up submitting extra applications at the last minute, petrified that I would end up as an unwanted egg in the student scramble. Better to send more applications and get into less than my first choice than to end up thousands of miles from my husband in a specialty and program I didn't want to go to in the first place, is what I figured. So I made a list, checked it twice (thrice? Ten times?), made sure my information was not wrong but right...for each of the eighteen programs I selected. And finally hit the "submit" button with a relieved sigh.

And a happy smile crept into my heart and onto my face. It's really happening. I will be a doctor, a resident physician somewhere. A program will rank me because they want to train me, to have me to be one of their graduates. I will have a long white coat, instead of the short student coat I have now (which I thought was cool when I got it but now realize it only denotes me as an underling wanna-be doctor who doesn't actually know anything). This time next year, I will already be a few months into my residency. YAY! I'll be a resident!

Hopefully....somewhere....

Oh God. Self-doubt creeps in. The life of the medical student is wrought with emotional lability and doubt, and residency hunting season is the pinnacle of it. You compare yourself to others (how many interviews has she gotten already? Should I have submitted my application earlier? What is his class rank? Will my nice personality outrank that guy's jerk demeanor and high board score? Am I as helpful as she is? Do they care if I'm pretty?). You compare yourself to the expectation you have for yourself (Did I do as well as I thought I would? Will I match to one of my top choices? Did I do the application as well as possible? Am I as competitive as I hoped to be?). You worry about letting your friends and family down with a poor test score, low evaluation, or unmatched residency status, because they're the ones that believed in you all along, who thought you could be a good doctor even before you did.

Would anyone do it if they really knew? If they knew that the application to medical school, the acceptance to doctorhood was only the beginning? If they knew there wasn't one board exam but six, if they knew that medical school is only the first part in the process of becoming a doctor?

Would I do it again? Yeah. As stupid as that feels at the moment. It's probably a good thing that I didn't realize all of this at the time of my application and acceptance to medical school, because that only would have given me more to worry about. But ultimately it's a good thing, the path I want to be on. I love medicine. I just hope a program loves me back.

Life and Death

There are two givens about life. You are born, and you die. And medicine intersects these points. I prefer to be on the birth end of the graph. Being part of the process of a new life in this world is joyous and rewarding, and preferable to me over caring for the end. But obstetrics is the only specialty that traverses these two givens, that can unite them in a matter of minutes rather than years. We hear about life and death situations a lot, in terms of making a decision to save someone's life. But what if you have two lives to save?

Babies are born, and some babies die. It's terribly sad, but not unexpected. With what needs to happen for any baby to born healthy, it is truly a miracle that it ever happens. And it isn't surprising that sometimes things don't go right. More precarious is the balance of a healthy baby and unhealthy mama. I've only seen this a few times. One instance that sticks in my memory is of a young woman, twenty-five weeks pregnant, unconscious as an oscillating ventilator forced air into her swine flu-filled lungs. She couldn't get well with a parasite (baby) grabbing every extra molecule of oxygen she had. And so the decision became- do you deliver her for the possibility of saving this mom of a three year old, this wife and daughter, and risk a probable death of her baby? Do you watch her oxygen saturation decline in the presence of a happy, reactive fetal monitoring strip? Do you keep her alive for a few more weeks, using her body as a physiologic NICU incubator for her baby, and see what happens? This is what was opted for, and she was delivered two weeks later. Last I heard, her baby was doing well and she was newly pregnant again- a good ending for a tough call.

I saw another instance of this today. A young woman, exactly my age, came in to have her prenatal ultrasound. We looked at her uterus, measured her little boy, watched the happy flutter of his heart and his kicking feet. Swinging the ultrasound around for a cursory quick glance of a normal ovary revealed a large, nodular mass lined by enlarged lymph nodes. Most certainly an ovarian tumor, a highly malignant mass nestled against her growing child. Life and death, adjacent, growing silently together. Would this tumor be all this baby knew of his mother, both in the womb and growing up in her absence? Would the mother watch her baby's fluttering heart grow still as she underwent treatment in hopes of removing the cancer? Is there a chance of them both being okay, a chance for her existing daughter to keep her mother and gain a brother?

Medicine is imprecise, a collection of educated guesses from educated people, and that's the best you can do. And somewhere amid these calculated thoughts, there is a person. The nature of medicine is caring for fellow humans in times of difficulty, and it seems reasonable that the physician would grieve along with their patients. But they also need to learn to let go of the summation of patient pain to preserve themselves and their practice of medicine. It seems to be an unspoken competency in medical school, a skill untaught and hard-learned for most. A skill I am still learning, and expect to learn better in any field of medicine, especially obstetrics.

My First Baby

Here is the (long overdue) account of my first baby. Not one that I carried in my own body, but one that I cared for and delivered. The baby that changed my career as a doctor.

I thought I wanted to be a gastroenterologist. My background in clinical nutrition led me to an interest in the GI tract and how nutrients were absorbed and how nutrition affected health. Throughout my first two years of medical school I planned on become an internist and subspecializing.

And then I delivered this baby.

I was poised at the woman's vagina, easing the head, one shoulder, two shoulders, a body, and feet out of her body, clutching the newborn tightly against my too-big surgical gown. And my first, illogical, thought was "wow, this baby is really warm." Which was really stupid. Of course the baby was warm- he came out of a toasty uterus, insulated by his mother. But the first thought of a student doctor is often an expression of something that should be obvious, but just has not yet been experienced. It was a surprise to me when I first held him.

This has been kind of a funny story to friends, family, other patients, myself...I think in part because it illustrates that doctors start as children in medicine. We have these first experiences and have normal human reactions to them, instead of calculated medical answers. I think being a student gives you a unique perspective too, for your first delivery to coincide with a mother's first birth, where you share in the newness of this experience together. After that point, you are on unequal footing; the doctor and the patient, but as a student, you appreciate things along with the patient.

And I loved it. That feeling of cradling the warm, slippery baby and the happiness of laying the infant on his mother's belly was one of the greatest joys I had ever known, and ultimately changed my career in medicine.

It's a Man's, Man's World

My pants fell down today.

I was listening to the lungs of a patient, and she had a toddler, about waist high, who tugged on the drawstring of my scrub pants to tell me something. They puddled on the floor, leaving me to examine my patient in my pink polka-dot panties.

How professional.

Nobody wants to be caught with their pants down. Particularly not in an audition rotation where you are trying to prove competence and professionalism to possible future colleagues. Given that I look young to begin with, a look exacerbated by no makeup and a daily ponytail, I try to make sure that I give a professional presentation in both a tailored dress and manner. Pink polka-dots were not the look I was going for.

I dropped my stethescope and snatched up my pants, silently cursing the bastard that invented "unisex" scrubs. They are the suggested uniform of the wards, and required to enter any surgical procedure. They are an ugly green two-piece set freely dispensed from the ScrubX machine in the hall. They say "unisex" but are clearly designed by a man for a man. First of all, no woman would pick that atomic booger color. Secondly, they don't fit.

I have the option of scanning my badge and pressing "10" for a size small uniform, and "12" for a medium. I can press "10" and get pants that are huge on the waist, yet hug my hips so tight that it brings the rise and hem of the pants four inches above my socks. I can press "10" and recieve a shirt that is so big that when I bend over, you can see my belly button through the v-neck. Or, I can press "12" and get a pair of pants that easily slides over my hips but has twenty extra inches around the drawstring waist and a rise halfway down to my knees. You can see my toes through the v-neck in that shirt. Usually I opt for the "12" since I don't like things tight on my hips nor unintended capri pants, but this choice leaves me vulnerable to rogue toddler pantsings.

Men do not have these problems. They walk around confident, broad-shouldered and tall, scrubs draped gently over their physician physiques. They look like doctors, not girls wearing their father's scrubs.

I do have some scrubs that fit me. I spent about $100 a pair, and they were worth it. Designed for a female doctor, they look like clinician scrubs, not nursing scrubs, and fit every curve and height. I look like a well-polished version of myself; the tailored female equivalent to the uniforms my male colleagues wear so easily and for free.

But I can't wear them in outside of ambulatory care. Any procedure requires a hospital-issued uniform where its sterility can be verified. With almost half of new doctors being female, this "unisex" policy is dysfunctional for nearly a majority of physicians. In ob/gyn, there were only 7% female physicians in 1970; today females make up 80% of incoming obstetricians. Yet most women look like I do, uncomfortably sandwiched or swimming in an ill-fitting professional uniform.

Medicine is still a man's world. Scrubs designed for a man's form are issued to women. I've sat in many doctors lounges filled with only males, making women driver/shopper/insert your stereotype here jokes over lunch, seemingly oblivious to the fact that I was there. Ugly, fat men that I have done hernia assessments on pull down the underwear and tell me to be careful, don't get turned on during your exam down there. Surgical instruments fit in a man's hand, not my small fingers. If a toddler pulled on a man's drawstring, their pants would stay up.

Aside from offensive jokes and patients with too much self-esteem, I genuinely think that our male counterparts are oblivious to the day-to-day difficulties that face a female physician. I'm sure they don't think how uncomfortable it is for pants to pull around your widest part all day, or for a male patient to leer down a gaping top. The tide of medicine is still changing; since older physicians are still in practice, females make up only 30% of doctors despite nearly equivalent numbers of males to females in medical school. And perhaps some of these challenges will change when the gender of the work force evens out. In the meantime, I think of James Brown's 1966 song...

This is a man's world

This is a man's world

But it wouldn't be nothing, nothing

Without a woman or a girl

Disorientated

I don't know what day it is. Hell, I don't even know what time it is. I was driving around at 7 today, genuinely wondering if it was 7 am or pm. The sky is a mellow blue at both instances of seven o'clock and either way the moon is up, so I just wasn't sure. Even though I have been driving to this hospital for two weeks now, I still turn my GPS on to get there from my motel. Normally I'm good with directions, but this rotation has turned my head around.

I get there before it is light. Sometimes I leave after dark. Sometimes I sleep during the day and go in at night. I am so beyond tired that I don't even feel tired; instead it manifests in a mild nausea and progressive confusion. This experience reminds me of training for deep diving, to prepare for the nitrogen narcosis that occurs at depth. With many extra atmospheres of external pressure, nitrogen solubilizes in the blood and decreases oxygen supply to the brain, and tasks that you could do at surface in 9 seconds now takes 14 at depth. A divemaster will show you this deficit and prepare you that even though you feel completely normal, your capabilities are affected by the external pressures.

Even though I feel okay, I am aware by objective measures that my cognition is not sound. My GPS tells me to turn right, and I turn left, and then am surprised when it says "recalculating" because I think I've gone the correct way. I do a patient's history and physical in Spanish, and then come out and write parts of the note in Spanish, because the conversation is in my head that way. I don't seem to realize that the English-speaking chief resident isn't going to know what I mean when I write "no tiene sangrado" on the intake form. My dad thinks he's been disconnected from me on the phone when he asks a simple question, because it takes awhile for me to formulate an answer. I'm making up words that make sense, such as the neologism of being "disorientated."

A lot of these skills are tested in what's called a Mini Mental Status Exam, or MMSE. We give to patients who are elderly, confused, psychotic, or otherwise just not making sense. It's a baseline measure of basic orientation and cognitive skills.

I'm sure I have a much better chance of failing it than whomever I am giving it to.

These external pressures are real, and even if I don't feel them consciously, I am narcosed by the environment, just like diving. I'm sure this is not the best idea for patient care. Would you want someone operating on you that had been working the last 84 hours with irregular sleep? Probably not. But it's an hazing of doctors into the fraternity of medicine, a tradition of each generation of doctors initiating the next. It's traditionally thought that this creates a stronger doctor that is capable of practicing good medicine despite all circumstances, but I have to doubt that. And I question the role of the older physician in this process. A divemaster demonstrates human deficit in the face of uncontrollable external pressure and teaches each student to recognize it and compensate for it. The doctor-divemaster takes young physicians to depths to try to prove that skills can overcome human reality. My sense is that this is not good for the new doctor, and certainly not in the patient's best interest.

Que hora es?

(Not) Paging Dr. Nobody

I'm starting the first rotation of my fourth year tomorrow. The night before a new rotation, I always have jitters. It's like the first day of school rolls around every four weeks- new teacher (doctor), new classroom (office), new classmates (office staff, nurses, etc), new location. But this one is different. It's my first "audition" rotation, which means it is an out-of-town rotation at a place that I hope to do residency. There are only two for ob/gyn in Phoenix, where we'll be living because of my husband's doctoral program, so I really need it to go well. I always have "sunday-night" anxiety before a new rotation, but this time I am alone in an unfamiliar hotel room, white coat pressed and stethescope polished, counting down the hours until 8 am.

I wasn't sure why this one bothered me more than others. Obviously the stakes are high- I desperately want this program to like me, and for me to like them, since since there are only two residencies in Phoenix. But I think it's more than that. In this hospital, there are attendings, fellows, residents, interns, other students. It's associated with a large academic university. It's planned down to the last four page memo emailed to me last night, with a reminder to bring fifty bucks with me to pay for my badge so I can work. In my hospital- wait. I don't have a hospital. I have a collection of low-income clinics that serves high volumes of underserved patients. My school is a thousand miles away. Planning is scant, since I am part of the school's first class and the rotations are arranged the month, week, day before they start. And I'm intimidated that I am finally going to a "real" medical school hospital, where I perceive other students to be better trained than me. I'm nervous about being in a place where there are tiers of doctors to be hard on me, and to prove myself to.

For most students, this is a standard experience. And every time I wish my school was "regular", that I had gone somewhere else where I would be more used to a traditional, well-planned curriculum, I think about what I got to do in my second and third year. The feel of a warm, slippery baby that I eased out of a mother's body, instead of a handful of paperwork. The unique pressure to make a clean abdominal incision, instead of peering over some other student's head. I wrote prescriptions, chart notes, did patient visits and counseling on my own, made changes in meds. I put in IUDs and did pap smears and colposcopies, rather than just being responsible for cleaning the sticky mess at the end. I told a mother her baby had died. It was an underserved area with too much work, and I was given responsibility beyond my formal education level, with the expectation that I would grow exponentially in skills and knowledge.

My school says this is the benefit of their new, unique curriculum- that students will really be used to care for patients, and will learn more as a result. There weren't other students or residents- just me and the doctor- which is a much different relationship than the model I will be entering tomorrow. I worry that the doctors above me will see it as their right and duty to humiliate me, be hard on me, and overwork me with busy work that they don't want to do, but I more worry about opportunities that will pass me by as a senior student. I don't get to deliver the baby, because that's the privilege of the second-year resident. I get to scrub in on a surgery, but not touch. Now that I've had a taste of these things, I think it might be frustrating and boring to be sidelined. At this hospital, I'll be a nobody, a not-even doctor.

I'm hoping despite these probable outcomes that I will like the program and make a good impression. Despite the usual anxieties- I hope I find the place, can I bring a lunch? will I get to eat it? What time do I go home? Will they like me? Will they give me good patient opportunities? How can I be a good student for this rotation?- there are new ones, more permanent and worrying ones. Will they like me enough to offer me a position for four years of training? Can I compete in an MD residency as a DO student? What are they looking for in a potential resident? What if I don't like them?- a horrifying thought since that eliminates half of the local programs. How can I show them that I will be a good doctor, that in some situations I have already been a good doctor?

T- 12 hours and counting...

Patients(ce)

Patients take patience. On any day, interaction with a high number of people can be trying, especially for an introverted personality like myself. But patients are uniquely frustrating in that many of their disease processes are self-induced. This becomes difficult to manage in an outpatient setting, where patients have the capability of making lifestyle choices. By the time they reach inpatient status, the problems are sometimes beyond repair. I've had many such cases this week in the ICU, and have been struck by how preventable they all could have been.

Besides the typical obesity/hypertension leading to heart disease, and smoking leading to pneumonia and pulmonary complications, there has been some interesting cases of causality casualties. Here are a few examples from my last couple days:

• A young man so obese that the weight of his chest wall compressed his own lungs to where he couldn't properly oxygenate his blood. He needed a tracheostomy and a gastric tube and placement in a long-term care facility to lose enough weight to be weaned off of the trach.

• Two teenagers with multiple gunshot wounds to the chest following a gang fight.

• A Jehovah's Witness dying from complications of low hemoglobin post-surgery. She would walk out of the ICU if given a few units of blood, but instead will die within a day or so from heart failure from her steadily dropping hemoglobin.

• A patient with severe aortic stenosis who declined a valve replacement for years. Now she has consented to the surgery, but her heart is four times a normal size from the pressure exerted on it from the stenosed valve, which makes her a poor surgical candidate. Even if she were to survive the operation, her heart is too badly damaged to expect any change in prognosis.

• A young mother, brain-dead from an overdose of cocaine, meth, marijuana, and other drugs. She was brought in after crashing her car with her baby daughter in the backseat.

• A woman who wrote an alternative-medicine book on radiation poisoning, who failed to follow up with her doctor after he told her the treatment for her lung mass was radiation therapy. Now she is in the ICU with a lung completely filled with tumor and metastases to the liver and brain, causing intracranial bleeding. She didn't even want the CT scan that yielded that information. She died a few hours later, only 58 years old.

It takes a lot of patience to manage these situations; to explain to a family member that choices their loved one has made has caused irreversible damage. Families sometimes displace anger over the uncontrollable nature of the situation onto the doctor, and that takes a lot of patience to work through. You force yourself to be patient and thoughtful with the treatment, because it is unmotivating to try to heal someone who made such damaging decisions. You try to be patient and kind with yourself, acknowledging the frustration and discouragement that comes with an easily preventable death.

One thing I am learning quickly upon entering doctorhood...patients require patience.

Intensive Care

For the past 2 1/2 weeks, I've been working in the intensive care unit. I love it- each case is interesting, there is a lot to think about in terms of medical management of multiple organ systems, the nurses are very knowledgeable, there is a wide array of procedures to perform, and the hours are good. One of the things I've particularly liked about it is the communication skills that it takes to do the job well. I hadn't thought of this as an important requirement for this specialty; after all, a lot of the patients are completely unresponsive. What I forgot about was the families.

Communicating with families is probably the most important thing the intensivist does each day. The doctor has to manage patient care, in some cases making them well enough to walk out of the unit, in others, providing a comfortable death. He does a variety of bedside procedures and stays on top of every electrolyte and troponin and ventilator setting. But that's not really the intensive care. Intensive care is for the family, not the patient. Intensive care is a clear and detailed explanation of their loved one's disease, treatments, changes in status, and prognosis. It's obtaining a compassionate and clear do not resuscitate order. It's putting a dying patient on morphine so the only discomfort in their death is felt by the family, not the patient. It's being willing to be the only doctor in the hospital to recognize when medical management has failed, and to make the judgement to decline further treatments that have little chance to improve prognosis.

This is a very unique role for a doctor. Our job is to fight death by treating the entities that lead to it. Acceptance of death equivocates failure. After all, many other professions are measured by outcome. Teachers are graded on how many of their students pass exams, retailers by how much they sell, lawyers on how many cases they win, preachers on how many souls they save. Doctors are assessed by how many of their patients live. This places far too much responsibility on the doctor for patient outcome, rather than a recognition of human mortality. It's true that some physicians are better than others, but none of us can alter or reverse all disease processes. This outcome-based measurement doesn't allow for a practice that by it's nature cares for those with poor prognoses.

Many beds in the ICU are occupied by dead people. The only thing separating them from the morgue in the basement is a ventilator, balloon pumps, medications to keep blood pressure up, dialysis machines, defibrillators, fluids, blood products, and a crash cart. The thing is, death is temporarily optional in most situations. If your heart stops, we can start it. Lungs don't work? No problem. I can keep a body warm and a heart beating until family comes to discuss end of life care, but I have I saved them? No. Dead but with a living body, patients are suspended in a sort of physiologic purgatory until families indicate their last wishes.

And this is where the intensive care really happens. You place a patient on "comfort care" measures- morphine so they don't feel shortness of breath or pain. You take out the uncomfortable endotracheal tube and allow them to breathe on their own. Dialysis stops, feedings stop, medications are withdrawn. They die within minutes, hours, or days, with no discomfort. The loved ones are the people experiencing pain, not the patient. They are the ones that need to be updated daily on patient status, repeatedly explained prognosis and options to, and reassured that their loved one is not in pain and no, they couldn't have prevented it. Comfort care is for the patient. Intensive care is for the family.

Thus was my situation this afternoon. A patient brought in this morning, down for hours at home following a cardiac arrest. Minimally responsive, with a poor prognosis, the attending had a conference with the family to explain these things and let them know that we would watch him for 72 hours to get a better idea of his neurological status and possibility of recovery. That afternoon, the attending left to place a difficult central line, and the patient's oxygen dropped from 96 to 30, pressure dropped, pupils were dilated and nonreactive, no response to sternal rub- all signs of neurologic death and rapidly approaching cardiopulmonary death as well. Since he didn't have an end of life directive (at age 44, who would?), it needed to be ascertained quickly from his wife and daughter what their wishes were. And there was no other physician there. So, I put my big-girl coat on and was the physician, kneeling next to his wife, explaining his new signs and that a decision was needed more prematurely than we had anticipated. It was my first time explaining an impending death in order to get a DNR status, and it was an intensive experience for me to explain his deterioration, to say that the prognosis wouldn't change much despite more aggressive life support, and to try to help the family believe that his death wouldn't be their fault, even if they elected to turn off the ventilator. It was an intensive experience to look into this patient's eyes- glassy, fixed, and dilated, and know that even though I was watching his heartbeat on EKG, he wasn't alive.

No matter what I go into, this rotation has great value not only in learning to think critically about many organ systems at once, but in developing finesse for talking with patients and their families about sensitive topics, including end of life care. It's good for me to see that a good outcome doesn't necessarily equal life. I am grateful to see that just because another treatment is out there doesn't mean it should be initiated. It's good for me to know that I am capable of having difficult conversations. I'm glad to be more exposed to and comfortable with death, accepting that it's a universal truth and that I as a physician can't change that truth. I know these realizations from the intensive care unit are reflective of the intensive process of becoming a doctor.

Dress Shopping

In high school, I loved to shop for dresses. Prom, homecoming, winter formal, Sadie's....my mom and I would head out to Macy's or Jessica McClintock to pick out something really special. Often this would happen before I even had a date to these dances. The date was negotiable; the dress was not. We'd spend the day checking out the racks of dresses and even though the styles and materials changed over the years, the dresses always fell into the same categories:

Category 1: The dress looked great on the rack, but not on me

Category 2: The dress was neither attractive on the rack or on me

Category 3: The dress looked good, my mom liked it, but I wasn't in love with it

Category 4: The dress didn't stand out on the rack, but looked fantastic on me

Sometimes I walked in thinking I knew what I wanted, and left with something completely different that I loved. Other times I left with what I thought I was looking for. Each time, it was a fun adventure.

It's the end of my third year of medical school. I'm starting to ask for letters of recommendation for residency, set up "audition" rotations, and look at programs. I'm setting up all these things like I know what I'm doing, but I don't. I have to figure it out soon, though. It's almost time to pick a specialty. Rotations are set up so students can "try out" all the different disciplines of medicine, and see what they want to do. And strangely enough, it reminds me of dress shopping.

I knew some disciplines were not for me. They were a category 2 dress, a specialty that I knew wouldn't fit and it didn't. I never had aspirations to be a general surgeon, and I would have rather done just about anything than stand next to the OR table for a seven hour abdominal surgery. Radiology is a wonderful diagnostic tool, but the darkroom put me to sleep. Neurology was painstakingly meticulous and gave me a headache.

Category 3: I did wonderfully in family medicine. The attending physicians and patients loved me, and I scored the highest score in my class on the family medicine board exam. The high score actually created some anxiety, because I wondered if I was so clearly dispositioned to this specialty, shouldn't I go into it? I did like it, but I didn't love it.

Category 1: Internal medicine was like one of those dresses that looks fab on the rack and then adds fifteen pounds to your hips. You had high hopes for it, but then can't peel it off fast enough. I was sure this was going to be my specialty; a springboard for internal subspecialties like oncology and gastroenterology. Instead, addressing multiple chronic (and often preventable) diseases in medically complex patients became a draining task, bringing me a sense of weariness instead of the reward of knowing I helped someone. It is an important specialty, one of the backbones of medicine, but I was ready to unzip it and move on.

Category 4: Pediatrics and ob/gyn were time-consuming specialties that I thought I might enjoy, but would certainly not pick as a career. Crying kids held little appeal to me, and I was not particularly interested in women's health. But trying them on was like slipping into a great dress- curves in all the right places without being too tight, a gorgeous color and on sale. I felt like I easily molded into the role of obstetrician, into a kind pediatrician talking with a scared mom. It wasn't a tense stretch, it was just a gentle extension of my own personality, of my own strengths and skills.

So I'm left with two dresses that fit well, a scenario that often happened in the shopping trips with my mom. Sometimes we bought both, if I had occasion to wear them; perhaps perinatology, a mix of obstetrics and newborn care, would be a good choice. Other times we put them on hold and went out for lunch, returning to buy the one that stuck the most in my head. That's another option- just finish up my rotations now, and return to my thoughts in August, assessing which specialty has persisted out of all the disciplines.

I'm don't know yet. I'm still out to lunch. Hopefully it will be become clear soon, or maybe there is nothing to become clear. Either specialty fit well, and I could be a good doctor either way. I need to let go of the idea that there is only one "right" choice. I'm just not sure yet.

For now, I think I'll order dessert.

The Oranges of Wrath

I grew up in Orange County, CA. Back in the 1980s, it lived up to its name. Every spring, my life was punctuated by the sweet smell of orange blossoms that heralded summer fun. By the time I was eight or so, that smell was gone, replaced by the smell of multimillion-dollar new construction. That orange scent always stayed with me though, bringing forth happy memories of my childhood.

Fifteen years later, both the orange blossoms and I have been transplanted to the Central Valley, and that smell is just as good as I remember. However, the scent of oranges now brings a reminder of the long work of harvest. Before living here, I never had an appreciation for the human demands of orange picking. It's expected that delicate fruits such as peaches and strawberries have to be carefully handpicked, often justifying their high prices. But oranges are hardy and plentiful- couldn't they be shaken from the tree like their neighboring crops of walnuts? No. This Valley is covered in thousands of acres of orange groves, each tree bringing forth a harvest of hundreds of oranges...and they all have to be laboriously picked, one by one.

The ladders lean precariously against the leaves of the tree, wide at the base and narrow at the top, and the workers wear a sack that will eventually be filled with about one hundred pounds of oranges. They advance up the ladder, filling the sack, reaching for the oranges in the middle of the tree, and then come down the ladder to place the fruit in crates that hold 400 pounds apiece. Too many times I've seen a worker that's been left hanging by his arms as the ladder slipped, with 80 or so pounds on his back. Fascia tears, creating hernias, shoulders dislocate, rotator cuffs strain, vertebrae compress as the picker falls and his sack falls on top of him. But the fruit needs to remain clean and the day finished for the worker to receive their pay, so back up the ladder he goes. I see him several days later in the clinic or ER, when he has a day off, after his hernia has strangulated, his arm hangs limply at his side, and he can't walk.

John Steinbeck wrote about this same ordeal in his 1939 book, the Grapes of Wrath. He writes about pickers who are starving, who work for almost nothing because its still better than the alternative, which is nothing. The Dust Bowl has abated, but the premise has not. Despite the establishment of a minimum wage, workers (especially illegal ones) have pay that is contingent on productivity and doesn't reflect the overtime worked. The creation of food stamps relieved hunger, but I wonder if it galls the pickers to pay at the store for the all-too-familiar fruit. Maybe available healthcare is better, but mass amounts of toxic pesticides used create high rates of cancers, lung problems, and birth defects. I should see only a few cases of DiGeorge syndrome, a rare type of immunodeficiency, in my entire clinical career. Instead, I've seen six cases in four months.

I still love the pungent, spring smell of orange blossoms. But now the happy memories of early childhood comes with an awareness of the effort and sacrifices made for these fruits. In saying grace, I used to thank God for our food, and the hands that prepared it. Now, I thank Him for the hands that picked it.

Role Models

The job of the physician is to promote health. Whether it be in treatment of disease, palliative care, mental well-being, or health promotion advice, patients look to doctors for answers. They really want to know how they can become or remain healthy. Part of the unspoken advice to the patient is in the physician's own appearance, the choices they enact in their own lives. After all, they are the ones with the wealth of knowledge; they beyond all others are enabled to maintain a healthy lifestyle.

I was in the hospital cafeteria the other day, chatting with a group of local physicians. Here's what I observed:

The cardiologist was holding a plate of fried beef chimichangas, french fries, and ranch dip

The pulmonologist was smoking

The gastroenterologist was eating meats loaded with nitrites

The internist was morbidly obese

Looking at this group of well-educated people, I sarcastically wondered where the dermatologist was? In the tanning bed? I mean, come on. Not only were these poor choices for anybody, but the infraction was directly related to the physician's line of work! Of all specialists, the pulmonologist knows the detrimental effects of smoking, the internist sees the ramifications of obesity, and so on.

I think physicians have a higher obligation to care for ourselves, not only for our own health but as an example to the patients we care for. The "do as I say, not as I do" philosophy is a contradictory and ineffective message to patients. After all, if doctors are making these choices with the knowledge and resources they have been afforded, why should a patient be motivated to make a change? The first line in the Hippocratic Oath is "first, do no harm." But being a poor example of health not only harms physicians, it has the potential to harm patients as well. Making lifestyle changes is hard. It's even more difficult with the professional demands of physicianship. However, I see this as an opportunity to serve patients; a demonstration that healthy choices can be made despite long hours, mentally-draining work, and personal obligations. The physician can be a role model in not only their treatments and advice, but in their own life.

Amputations

I never thought much about amputations. They are common surgeries, most often related to uncontrolled diabetes, and seemed routine and unremarkable to me.

I've had the experience of witnessing several amputations while in my surgical service, all diabetes-related. Each time it surprises me with the sense of loss that comes with the amputation of a toe, a foot, a leg. I had never really considered the emotional impact of losing a limb. To be honest, I sort of thought that amputation resulted from a lack of self-control; the inability of the patient to monitor their glucose levels and make changes. Not to say that anyone deserves this sort of pain, but it seemed like a correlation between sugar and limb loss equaled a well-documented and preventable consequence. And then I had a black foot staring at me from a sterile blue-shrouded operating table.

I looked at it, and it looked at me, and I thought about all the things it had done for that person over the course of their life, how it was part of the patient. Bodies last longer than people, and it's natural to think that the body remains intact throughout ones' life. The operation to remove it reflects the difficulty, the tense dichotomy of this separation. It is a very physical removal- powered bone saws, strong manual bone cutters, and large scissors coarsely separate the limb from the proximal tissues. Nothing is pretty, edges are not delicately sewn. The necrotic tissue is essentially ripped from the living person.

And then you are left with a toe sitting on the OR table; a foot without an owner. You look at it and think "that was just attached a moment ago. Now it's just sitting there." You think about the extension of the person that it was- a baby's tiny toe, taking a first step, running, stubbed, swimming, carefully painted- and the gaping hole that is left from the amputation reflects the loss of something that helped shape a life. It always seems wrong to me to bandage up the stump without the limb, like the surgeon forgot something.

Even as these surgeries seem in contradiction with life, they are performed so people may live. A missing foot is a small price to pay for the excision of gangrene. There is a picture of me (on my second birthday) and my grandfather, who looks absolutely enamored with his granddaughter. He died a few months after this picture was taken. After hearing about my emotional reaction to the excision of a limb, my dad sent this picture to me. He gently reminded me that this precious moment with his granddaughter would not have been possible if he hadn't had the operations to remove a diabetic gangrenous foot and leg.

This is the glory and curse of the surgeon: you either cure or kill. The operating room is the fastest place in the hospital to make a difference in the long term prognosis of a patient. It's not for me- I like ongoing relationships with (awake) patients- but I can appreciate the meaningful work of the surgeon.

Grandpa Irv and a (very) Little Doc, May 15, 1986

Slice n' Dice

I am lame.

On the first surgery of my first day in the OR, I got faint and had to sit down. I am so embarrassed even to write that here. And it was on a simple tumor excision- no big deal! This wooziness from a girl that was a phlebotomist in college, thinks emergencies are interesting, had a relationship with a cadaver (named Phyllis!), and enjoys nothing more than the gory display of childbirth. Granted, I had just recovered from a pneumonia, and have a propensity towards hypoglycemia if I don't eat every two hours, but I don't think that was it. I think it triggers something in me when I see a sign of life in the patient on the table. When they become a person, and not a body, it freaks me out.

Normally I am okay with surgery. I stand there, assist, do what I need to do, and have lunch afterwards. In fact, I'm usually hungry in the operating room. As far as I can tell, the only times I have gotten woozy is when I connect the parts to a whole. I was fine with c-sections, except one time when the patient began complaining of pain. The thought that she could feel the pain of my knife instantly made me anxious and dizzy. A hysterectomy is a removal of a part, akin to replacing the air filter in a car. That's the level of attachment that I have towards the body. But one time, I was assisting on an open hysterectomy and saw the iliac artery, pulsing just beneath my tools, and right away I was nauseated. Of course I know that the person on the table is alive, and this is normal anatomy. However, I think that a sign of life- pain, a pulsating artery, the woman today who was talking to me about western movies- these force the connection for me between patient and body, person and pain.

Surgery is a different mindset than medicine. As my attending said today: "In medicine, you help people live with their disease. In surgery, you either cure or kill." The more I thought about it, the more I thought he was right. There is something to be said for being a mechanic, for leaving everything you got on the table, and walking away. It's not for me though. Those signs of life that make me dizzy- I think that happens because I love patients, because I connect and empathize with them. I don't think I'd ever feel fulfilled having a practice where the patients were primarily unconscious. Plus, its hard on you physically- to stand that long, under those bright lights, with your bladder exploding and stomach grumbling. I'm kind of dreading the next month. And I'm hoping that I can breathe my way through those moments where I catch a glimpse of human pain, and maybe even learn something about being a good surgeon.

California Dreamin'

I had a young patient in the hospital last week that I went to round on, and met her mother. She was a young Hispanic woman, anxious and obviously trying to do the best she could for her daughter. She said that she had recently moved here, and I asked where from? She said Arizona. Making conversation while I examined her baby, I said my school was out by Phoenix, and what brought her to Visalia? She said "I can get much more assistance programs for my kids here- it doesn't make sense for me to live anywhere else. My whole family moved here because in California, we can get so much free stuff."

Her honesty took me aback. I've said before that I can't judge anything as right or wrong, black or white. To an honest and educated person, things are always shades of gray. I cannot- and will not- comment on what my thoughts were at that moment, because what I truly think is that things are much more complex than they may seem. And my opinion is not really relevant anyway. This was just a conversation that surprised me, and demanded some thought. And I wanted to record it here because I thought it might provoke some thought in others.

Soldiers: The Silent Underserved

I loved my elective rotation in a family practice in Orange County. The office was decorated nicely, the exam rooms had winged armchairs instead of standard-issue medical office chairs, the office staff was a close-knit group, and the temp was a cool 67 degrees. It was exactly the kind of practice I'd like to have in the future. I saw many patients there, ranging from newborn to elderly, and enjoyed the various presentations of illness unique to a diverse family practice. One patient in particular was memorable, a young man serving in the Army.

The first thing I noticed about this guy was that he called me "Ma'am." It almost made me giggle- he was about my same age, maybe a few years younger, and I wasn't even the real doctor. He was clean-cut, polite, and respectful, wearing a t-shirt that I recognized as military fabric, similar to the ones my husband wears that are leftover from his years in the Air Force. I asked him what brought him in, and he held up his pointer finger, which was an ominous black color with red marks streaking up his forearm. He said a black widow had bitten it five days prior, and he had tried to lance the bite to relieve some of the pus, but it was getting worse. I asked him what he used to try to drain the area, and he replied "a steak knife, ma'am." Ouch.

I called in the doctor I was working for (clearly this was over my head), and she told me she had never seen a black widow bite before. Unfortunately (or fortunately?) I had already seen many, because in the community I serve, grape-pickers come in after a full-day's work with several bites on their fingers and back from the spiders falling down their shirts from the tall grape arbors. I had seen this because I work with underserved pickers. I never expected this active-duty military member to be more medically underserved than the illegal farmworkers.

The best idea was to refer him urgently over to the orthopedic clinic, given the likely systemic manifestations of the bite and the underperfused finger, but he couldn't go over there due to insurance limits. (When telling this story to my husband, he stopped me here and said, "TriCare" and rolled his eyes). Apparently the military insurance, TriCare, denies unapproved specialist/emergency visits, unless there is an "impending loss of limb, sight, or life." This was getting close enough to loss of limb that the doctor was uncomfortable, but couldn't get the visit approved. He had only come to the office today under direct order from his sergeant.

We gave him antibiotics, and she let me drain the pus using a scalpel (not a steak knife). He was a tough guy, but I knew it was hurting him. He left with strict instructions to come back in the morning to have it looked at again (Yes, Ma'am).

I was appalled. Here was this young man, putting his life on the line, and he was in danger of sepsis and loss of a finger because of insurance regulations? He should have absolutely the best insurance available, able to show his military ID card at any medical facility and receive care, no questions asked. Antivenom should have been given on day one, not palliative care on day six. This doesn't seem to be a topic civilians know much about, but I believe that if a feature article was run about it in a prominent newspaper, taxpayers would demand better medical care of our military personnel. I think this system compromises the medical well-being of the thousands of people that are responsible for protecting our country's safety. My own husband cites it as the main reason that he chose to leave the Air Force and reenter society as a civilian.

I don't know what happened to this guy. I wasn't in the office the following day (another doctor was on call), but I still wonder about him, and hope that everything healed well with no loss of function. Especially since the affected finger was his trigger finger- important for an Army man. I hope everything is okay, but I'm doubtful. If it did heal, it's because of his staff sergeant's orders and his own immune system, not because of care provided by the military. And that's a shame.

Babyfinder.com

I adopted all my animals. Either they were from the pound, browsed for on petfinder.com, or someone didn't want them anymore. In any event, they joined the family. While I know babies are a lot different than dogs or cats, this was my only personal exposure to adoption.

A few weeks ago, while attending to the NICU babies, I noticed one that didn't seems sick and wasn't getting visitors. She was labeled a "boarder baby" on my rounds report. I asked the attending what that meant. He said "it means that she was born and her mom gave her up for adoption. She's just staying here until we can find a home for her." He turned away, and then turned back suddenly. "Hey, do you want her? She's really cute. She has a little heart murmur, but that will probably close within the first year."

I was surprised. I thought that finding a baby to adopt was a huge, prolonged process, and maybe it is. But they were looking for a home for this little one right away. What struck me as funny was the way the baby was presented. All of the animals I adopted had a similar advertisement. The only thing missing for the baby was the "free to a good home" sign, a cardboard box replacing the isolette, and maybe a listing on a website like babyfinder.com.

I told the doctor I wasn't really looking for a baby right now, but I hoped she finds a good home. The doctor looked disappointed and said he understood. And then he turned to one of the nurses and said, "Hey. Do you know if Susie's still looking to adopt? We've got a cute one here." She must have been adopted, heart murmur and all, because when I came back a few days later, she was gone.

Then I started working in pediatric gastroenterology, and saw the most medically fragile kids I've ever seen. I loved it- the challenge of keeping these kids thriving, comfortable, and developing as normally as possible. I loved the challenge of talking with the parents about every aspect of their complicated kid's medical health, and enjoyed the rapport that was built between the patient, parent, and physician of this pediatric subspecialty. I marveled at these young parents' ability to care for their kid and be so knowledgeable about the multiple medical problems they had. They knew much more about their child's care than I did as the medical student. Premature crack babies with a short gut due to resection of necrotizing enterocolitis, feeding tubes, Down syndrome, epidermolysis bullosae (where the kid was wrapped in head-to-toe sterile gauze because of the deep blistering), kids in strollers with oxygen and parenteral nutrition on board, little girls with Crohn's disease, rare metabolic defects, and everything else- these kids needed care. I would sit there and observe, wondering, how do these moms do it? They are happy, invested and knowledgeable about their complicated child's care. Every minute of their lives is consumed with this kid, and they accept it as a part of a full life.

What ultimately came to amaze me was that the most complex kids invariably came with an adoptive parent. The crack kid? The nice lady in front of me wasn't the one who had smoked crack while pregnant. She was the one that accepted the kid after the prenatal damage was done. The kid with cystic fibrosis? She sat breathing noisily on her adopted mom's lap as her adopted grandma fussed over her. It was absolutely amazing- the unquestioned commitment that these parents had to their kids, kids that sometimes had preventable problems due to another adult's irresponsibility.

I think when most people look for a pet, they want to adopt a young, healthy animal. But these moms had committed to kids with disabilities, with lifelong special needs. How much of a commitment is a dog, really? Fifteen years? Compared to a lifetime commitment for a child. It was one of the best lessons that I got out of the rotation. And I hope that the little boarder baby, wherever she is, was adopted by a mom such as this.

My Drowning

Today is Tuesday. It happened on Friday. Usually I use writing as a tool to think about what I've seen, make sense of problems, and move on. I am writing today because it has taken me this long just to sort out this situation well enough to write about it.

A four year old boy drowned. In a pool, in the middle of winter. He had been dead, was resuscitated by the paramedics, and was brought to meet me and the attending pediatrician in the ER. As I put the bagged oxygen mask over his mouth, I wondered if he had been eating a blue popsicle before drowning? No, I realized, his tongue was that color because he was so cold. Reaching out to touch his baby hand was like holding a refrigerated chicken wing. His eyes were brown, dull and unseeing, under his closed eyelids. His temperature was 85 degrees, and his lungs were filled with water. Listening to them was like ascultating an aquarium. He wasn't getting enough oxygen, even with the bagged oxygen mask, so we needed to intubate him. The ER doc tried first, pushing the tube down his throat. As the ventilator was turned on, his stomach distended with air. His heart rate dropped down into the 30s, and bagging was resumed. However, the bagged oxygen mask was now cracked, and he was losing oxygen and his heart rate was falling. The doctor gave the laryngoscope to me to try, and I opened his mouth, visualized two tiny vocal cords, and pushed the tube in. Pool water sprayed out, soaking my shirt and face, and the monitor alarms went off. In the few moments it had taken me to intubate, he had gone into asystole.

Asystole. Pulse zero. Respirations zero. These are all medical terms to describe death. The death of a kid that had been a normal little boy a few hours ago, and was now cold and lifeless under my shaking hands. The doctor shouted, "He's going to die!" and my stupid brain wondered "Isn't he already dead?"

The attending and I talked with his parents, explaining what had happened, and invited them to come see their son. As I watched mom kiss around the intubation tube, and dad touch his son's cold, dusky feet, my heart broke for these parents that turned away from their child for a minute and will now live with a lifetime of guilt. A couple of tears slid down my face as I watched these parents desperately try to reach their son, and grapple with the realization that he was not there.

My lungs were clear, but my heart was drowning. How long would it be before I forgot the sweet detail of this child's face? How could I not wonder if I could have done something better? When would I see other children as they are, rather than thinking about how they would look drowned like this little one? After all, he was a healthy boy a few hours ago, with a chest that heaved with exuberant play instead of the force of a ventilator. Why was I the only one that seemed to be bereaved by the loss of this child?

My friend June, who has been a wonderful nurse for longer than I've been alive, offered some perspective. Some doctors build protective clamshells around themselves, shielding them from experiencing patient pain. Sometimes this dissociation is necessary in order to care for someone in great distress. But to be too far removed is a disservice to patients and their families; patients need doctors who are there for them in the most difficult of times. She also reminded me to be gentle with myself. All of the distress and grief I experienced over the loss of this child are some of my best attributes; they indicate a caring and empathetic nature that ultimately will benefit my patients. It also indicates that my self-awareness is set correctly, because questioning and analyzing situations like this is the way to maintain a humble and teachable spirit. However, that does not mean that these situations are easy on me.

This is not an easy job. I never want to wear those chlorine-soaked scrubs again. Suddenly I don't like my stethescope, because it allows the amplification of human suffering into my ears. I don't know how to move on and forget about this kid that was the most awful situation I've ever seen.

All of these events form a collage of who I will be as a physician. With experience, I'll learn how to reach an equilibrium where the pain and triumphs of my profession are balanced with the rest of my life. And I'll know that while this experience will stay with me the rest of my life, there is a new patient outside my door that deserves every bit of the best care that I tried to give this little boy. It's not right for grief to cloud my focus on the next patient, because there is always more need to be met.

People say medical school is hard. What they don't say is that the academics are extensive, but attainable. What you really wrestle with is the ability to develop meaningful doctor-patient relationships. To emotionally engage with someone that is in pain is burdensome, but a privilege. Doctors have the unique opportunity to be part of peoples' lives in exquisitely intimate moments. I think most people would say that they go to medical school to "help people." This is probably partially true, but I think it goes beyond this. I think the desire to become a doctor stems from a deep yearning to offer people a part of us; the ability to treat illness but also relate to them in a time of difficulty, to meet needs that are seen and unseen. And I think if you do it right, you come away with more than you ever gave.