Tales from the ER

I ended my one and only rotation in the emergency department today. I learned two valuable things:

1. It is correct when doctors tell you that the emergency room is 90% boredom, 8% interesting, and 2% terror.

2. I cope well with true emergencies, making fast and accurate decisions...but I don't like them.

Here are some stories from the ER:

Boredom

• A woman comes in for hand pain. Further elucidation reveals that she "slept on it wrong."

• Countless drug seekers, with some nonspecific abdominal pain complaint, who have had so many CT scans that you expect their belly to light up from the inside. They will moan and writhe so much that you finally cave and write the script just to get them to shut the hell up and get out of there.

• A kid with a rash x 3 weeks, which has been evaluated by numerous primary care providers. What makes you think that at 10 pm with a busy ER, I will be able to accurately diagnose and treat your rash any better than the other doctors you have seen?

• Colds and viruses. Please, go see your primary care doctor.

• Anxiety. Anxiety. Anxiety. You would not believe how often this diagnosis came up and how many insidious ways it can present. And how even thought you are 99% sure it is anxiety, they need a full, expensive, cardiac workup for you to be able to discharge them since they came in complaining of chest pain and/or shortness of breath. These typically present between 10 pm and 7 am.

• A parent wondering if permanent marker was toxic if absorbed through the skin (kid had done some "face-painting"). Definitely a firstborn child. Subsequent kids would walk around for months with marker on their faces.

Interesting/Funny

• A woman came in with numbness and tingling down her right thigh. She was dressed very nicely, and told me that she had just come from a wedding. The (male) attending wanted an MRI. I asked if she was wearing anything new. Turns out she had worn Spanx for the first time under her nice dress, and it had compressed her lateral femoral cutaneous nerve. She took off the Spanx, and the numbness and tingling went away.

• A poor ninety year-old woman came in after tripping and falling on her carpet. The carpet ripped away her paper-thin skin, leaving her patella and a good part of her lower leg tissue exposed. I spent an hour and a half putting in fifty stitches, and had a wonderful conversation with her while doing so, learning all about her long life. She loves to needlepoint, and asked how I did the stitches, and if sewing people was similar to sewing upholstery.

• A man came in under arrest after attempting burglary. He had fallen on glass while robbing someone's home and was brought in by the police to get his knee sewn up prior to going to jail. As per usual, I asked him what happened to his knee. He told me he fell on a rock while playing basketball. I commented that the rock must have been pretty sharp, given the perfectly clean laceration he had (a confidence afforded by the fact that he was handcuffed to the bed).

• A kid who had eaten a scorpion. Is it toxic if the venom is ingested?

• An old Hispanic man, yellow as a canary, coming in with abdominal pain and a big stone in his bile duct.

• A four year-old girl with a cut deep into her foot from a rotary blade. I made a game of wrapping her up in a sheet like a burrito, which she liked, and then cringed as I began to inject lidocaine and start suturing while she screamed and tried to flail the arms and legs that I had wrapped up so tightly.

• People on/withdrawing from drugs. Always interesting to watch.

• A heroin user with a kidney stone who begged for pain medication. Nothing worked. He was furious when I told him that since he had developed so much tolerance to narcotics, they weren't effective for him anymore.

• A heroin user who unscrewed his IV and left AMA ("against medical advice"), then used the line to inject mass amounts of heroin and ended up right back in his old exam room, now unconscious and apprehended by the police.

• A heroin user who had multiple abscesses from skin popping, each filled with several CCs of pus. They needed to be drained (fun to do). She had a lot of anxiety over the needle with the numbing medicine. I tried to refrain from pointing out that she put needles in her skin several times a day anyways, so what was the big deal?

• A woman complaining of vaginal bleeding during pregnancy. Normally this would fall under the "boredom" heading, but what made this unique was that this individual was transgender, and I was greeted by a penis and testes when I lifted up the gown for the pelvic exam. He/she was so desperate to identify as female that she had sought medical attention for a "female" problem. Definitely a psychosomatic diagnosis.

Terror

• Multiple trauma victims of a multi-vehicle crash, all coming in at once.

• A child bleeding to death internally after sustaining blunt abdominal trauma from a trampoline fall.

• A man with an eyeball hanging out of his socket after an injury.

• A drunk driver laying in the trauma bay next to the man he killed, separated only by a curtain.

• A ten year-old who successfully hung himself.

I'm glad I'm going into Ob/Gyn. There is some inherent terror in that specialty as well, and the emergencies affect two people, not one...but thankfully, they are few and far between. In the meantime, I can enjoy an overall healthy population and followup with the same patients for a long time. I missed that in the ER...I wonder about some of these patients and don't like that I will never find out how their story ends. It was a good rotation for me to do. And good that it's over.

Dr. Jekyll and Ms. Hyde

I am not a mean person. I think I am generally good-natured, thoughtful, reasonably patient, and kind. I am not unreasonable unless my blood sugar dips too low. I try not to sweat the small stuff, try to take good care of myself and others.

But everyone has a breaking point.

Mine seems to come after about being awake over thirty hours. If I have worked all night and sometimes the day before, I leave my house Dr. Jekyll and return as Ms. Hyde.

Dr. Anne Jekyll knows she is just tired. She can look at dishes in the sink and know that they can be done later, after a long nap. Email can wait. She knows she doesn't need to run with the dog right now, even though it is cool and light outside- a rarity in the Phoenix sun. She can recognize that even though she was up working all night, it is okay for others to be sleeping, doing nothing productive except restoring themselves.

Ms. Anne Hyde is unglued about dirty dishes in the sink. She thinks, "if I have been awake and working for the last umpteenth-and-a-half hours, at LEAST have the kitchen clean before I get home." She feels like she needs to immediately start her daily duties and rest later. She scowls at those that have been sleeping all night, expecting others to at least achieve partial productivity in the many hours that she has been gone. She has no patience for hearing that someone hasn't slept well, and even less patience for hearing that someone has.

Dr. Jekyll and Ms. Hyde are both predictably, undoubtably me. These characters of duality persist across level of training, rotation assignment, and seasons. And I have medicine to thank for introducing me to Ms. Hyde...I don't know if I ever would have experienced such impatience, discompassion, and crabbiness if left on a normal schedule. I don't think I would have believed that I could feel this way, that these emotions and thoughts could come from the person I thought myself to be.

I think many doctors struggle with this, and it partially fuels the burnout of medicine. Like Mr. Hyde in Robert Louis Stevenson's original novella, our meaner selves can grow from a part-time appearance to an ever-present alter ego. Dr. Jekyll saw the transformation too late, and lost himself to Mr. Hyde. Doctors enter medicine for all the right reasons, and, sensing their bitter change too late, leave for all the wrong ones.

They say recognition is the first step to recovery. Well, I don't know if I can ever completely recover. But I can recognize Ms. Anne Hyde, acknowledge her for who she is and the place of exhaustion that she comes from, and choose to go to sleep. I can wake up as Dr. Anne Jekyll, kindness and patience restored, ready to see another patient.

The Match, Part I

The Match. Not the match. It gets it's own capital letter, like God. It's that important.

I've been keeping busy all weekend...cleaning, farmer's market, baking cookies, a ten mile hike, trying not to mentally count down the seconds until finding out at 9 am Monday morning. I haven't pooped for five days. This last week has been like a sucktastic Advent season for residency, with excitement for Christmas replaced by anxious anticipation for the Match.

Today, I woke up with a surgery to do before the Match results posted. I was in the operating room at 7 am, doing a c-section with a kind preceptor who knew Match anxiety well, who told me at 9:01 just to leave and go find out the results, that he would finish the suturing and paperwork. I stopped in the operating room hallway, mask still on, feet stuffed into surgical booties, and opened my email on my phone.

From: NRMP (National Ranking Match Program)

Subject: Did I Match?

Message: "Congratulations! You have Matched."

And that was it. A short email that left me elated and tired. I didn't know how worried I was about not Matching until I actually Matched. I expected to Match, but this is the kind of thing you can't be sure about, and the intense physical letdown I felt let me know how much I had worried unconsciously about today. I didn't expect to feel exhausted or achy. It felt as if my body started to relax, as if months of tension were evaporating out of my muscles.

Today, I only found out whether or not I Matched. I don't find out which program I'm going to until this Thursday (Match Part II). This lapse in information gives time for those who have not Matched to enter the "Scramble." The Scramble is the only thing besides God and the Match to command it's own capital letter. This is where an unmatched student applies for an open residency position, a spot that went unfilled in the first draft. You scramble for 72 hours to find an available spot, and find out where you are going on Thursday along with everyone else. Trouble is, it might not be in the location or the specialty that you wanted. I wouldn't wish the Scramble on anybody. Truth is, this is all quite complex and you don't totally understand it until you have gone through it. And since you only go through it once, the information you learn is really of no use to anyone at the point that you have acquired it.

I still have a lot of anticipatory anxiety over where I'll be going, but knowing that I'm going somewhere, that some program out there liked me enough to want me to be their resident physician, makes me feel safer than I did this morning. Somewhere, very soon, I'll be a doctor. And this thought gives me a sense of quiet relief, enough to feel sleepy and relaxed.

56 hours and 41 min left...3401 minutes...204,060 seconds...204,059...58...57....56...zzzzzzz .

The Interview Experience

Now that I am done with my applications, interviews, and rank lists, I am just waiting for the Match results to post in twelve days, fifteem hours, and twelve minutes. I wanted to share a little of the interview experience, which I thought was special at first and subsequently realized is the same everywhere. It doesn't give me a lot of joy to recall this, but its probably worth remembering and will be funny at some point to look back on.

Optional dinner night before: A mid-priced restaurant that can accomodate a large party but not hot food. Drinks offered; applicants decline, residents eagerly accept. Applicants practice lines they will use following day, residents ask if you have any questions.

INTERVIEW, MORNING:

-Walk into nondescript door, wondering if in the right place.

-Find other lost people in suits, decide we are in right place.

-Program coordinator appears, "Good morning! Here are your packets! Sign here, and here."

-Applicants sit nervously.

-Program Coordinator: Help yourselves to some food.

*strawberries, grapes, and pineapple disappear. Water bottles taken. All donuts/wrapped pastries/candy/melon left on table.

-Female applicants: "blah blah blah your nails i like your purse blah blah omigod i love your necklace."

-Male applicants: silent.

-Paw through goody bag with the program materials in it, find hand sanitizer/lip balm/sunscreen/cheesy bag/bottle opener/flash drive/some combination of the above. Mentally compare to other programs' goody bags.

-Program director appears. Goody bags dropped, fake smiles and assertive handshakes all around.

INTERVIEW, MID-MORNING:

-Technical difficulties with laptop/powerpoint. Applicants wonder if there are any more strawberries.

-Laptop finally works, powerpoint projected onto wall for program director's presentation.

-Program director: "this is why [insert program name here] is THE BEST program ever in like the entire world according to NIH/US News and World Report/Yahoo News/your mom."

-Program director: "this is why [insert your city here] is an awesome place to live." Show pictures of breathtaking scenery.

-Program director: "these are our healthy, happy residents" [insert group picture here].

-"Any questions?"

-Applicants ask pre-practiced questions. Student glares at other student who stole "their" question and frantically tries to think of another well thought-out, intelligent, enlightening question.

INTERVIEWS, LATER MID-MORNING

-Program coordinator: "time for interviews!" Splits group so three students go with three different faculty members/program coordinator/other important person, one "chats" with resident, and one is left sitting at the table staring at the now-blank powerpoint screen.

Interview #1: The Faculty Member

-Faculty: "tell me what interested you in our program."

-Student: recite information gleaned from website, say why they are perfect fit for program and program perfect fit for them. Bonus points if specifically mention interest in the concentration in which said faculty member specialized.

-Faculty: any questions?

-Student: asks pre-meditated questions

-Assertively shake hand, exit

Interview #2: "The Associate Program Director/Faculty Member/Important Person

-Important Person: "tell me what interested you in our program"
-Student: recite information gleaned from website, say why they are perfect fit for program and program perfect fit for them. Now mention former research/extra talents/skills/bilingual ability/other personal selling points

-Important Person: any questions?
-Student: asks pre-meditated questions

-Assertively shake hand, exit

Interview #3: "The Resident"

-Male resident: "It's nice to meet you"

-or-

-Female resident: "omigod i love your boots/necklace/toenail polish/insert personal item of choice here"

-Chat about leisure activities in the area (like they would know...I saw the call schedule), pets, families, etc while stealthily working in my baking prowess/why I would be the best coworker ever

Interview #4" "The Break"

-Sit and stare at table during "off" interview. Wonder if I have enough time to eat protein bar in my purse before next interview. Glare at melon/lack of strawberries.

Interview #5: "The Program Director" aka Big Cheese/Big Guns/Top Dog/God

-Director: "tell me what interested you in our program"

-Student: recite information gleaned from website, say why they are perfect fit for program and program perfect fit for them. Now mention former research/extra talents/skills/bilingual ability/other personal selling points. Just with more enthusiasm than prior interviews.
-Director: any questions?

-Student: realizes I've already asked all my questions. Shit.

-Assertively shake hand, exit

LUNCHTIME/NOON CONFERENCE, AT ONE O'CLOCK

The program thinks that combining resident noon conference and interview lunch is a splendid idea of efficiency and example of the program. The student thinks it is a horrifying opportunity to have to ask intelligent questions and make smart comments. The residents eat and sleep, as per usual.

I make my way to the lunch table. Salad? No. Might stick in my teeth. Chips? Too loud to eat. Must not draw attention to self. Spaghetti? Too messy. Danger to suit. Soda? Don't want to burp. I end up eating a pickle slice.

TOUR OF HOSPITAL/CLINIC, MID-AFTERNOON

-Resident: These are our amazing patient rooms

*note: they look like every other hospital

-Resident: These are our amazing call rooms

*note: they are tiny with bunk beds and no pillows

-Resident: We are so lucky to have a workout room!

*note: it looks like a dungeon and is in the basement

-Resident: It takes awhile to find your way around

*note: my toes are now bleeding from the approximately eighteen flights of stairs we have climbed and I have no idea which way points north. If I were to be left alone I would just have to live in the stairwell and accept that there is no way out.

FAREWELL, LATER-AFTERNOON

Program Director: Thank you for joining us. You don't need to send thank you notes. Please let us know if you would like a second look at our program.

*All students write down name/address to mail thank you notes.

Program Coordinator: Please sign here, and here, and here....

Firm handshakes and thank yous all around.

THE AFTERMATH, EVENING

Get in car. Exhale.

Take 800 mg ibuprofen.

Get home, eat entire contents of refrigerator.

Sleep.

Shake the headache within 48 hours, just in time for the next interview.

Namaste

I love yoga. I was twenty years old when I first tried it, and it was joy. I loved how strong I felt, how my muscles looked long and lean in the poses, and mostly I loved the self-acceptance that it brought. The lesson that you accept your body for what it can do that day, you acknowledge your distractions and then let them go, the requirement of accepting and thanking the body for the work it does for you, and honoring those who have practiced with you. Each practice was closed with a bow and a repeat of "Namaste", which means "the spirit in me recognizes and honors the spirit in you."

"Namaste" is a phrase that I felt applied to the study of human anatomy. I spent hundreds of hours in the anatomy lab, looking at cadavers, memorizing each bony prominence and tiny vessel and nerve. It was arduous, and even though a lot of times I would rather not have been there, I felt a connection with the cadavers. Their bodies gave me clues to their life and possibly their death, and I felt like I knew them and a little of their story even though we had never met. I could recognize how my own body worked by viewing theirs. I could profoundly accept that human anatomy is essentially universal, that we are much the same.

I saw "Body Worlds" recently, which is an exhibit of human anatomy with preserved specimens. Many bodies were placed in positions of movement, like dance, running, or hitting a baseball. While it is a controversial exhibit for some, I loved the celebration of movement in the bodies. It reminded me of yoga, how much joy could come out of one's anatomy and movement. And I loved how it brought the amazement that I was privileged to have in the anatomy lab to millions of people who otherwise wouldn't experience human anatomy. It shows the universality of the human condition, how we recognize and honor others through the study of anatomy.

So as I cover my cadaver gently with formaldehyde-soaked towels, zip up the body bag, and return him to the refrigerator, I almost want to bow to him, saying "Namaste." The spirit in me recognizes and honors the spirit in you.

In nature we never see anything isolated, but everything in connection with something else which is before it, beside it, under it and over it.

-Philosopher Johann van Goethe

Top 10 Study Spots

A list of the top 10 most interesting/unusual/weird places I have studied medicine (none include a desk):

10. At the summit of a ten mile hike (the EKG book fit nicely into my Camelbak).

9. In the middle seat of an airplane. Not too original except for the fact that the seatmates on either side were looking over my shoulder and commenting on the subject material. Topic: platelets. Window seat guy: "I'm on Plavix." Aisle seat guy: "What are platelets? Is that a disease?"

8. On a ski lift. But it was hard to turn the notecards with my ski gloves on. And even harder to stuff the notecards back in my pocket, get a pole in each hand, and scoot to the front of the seat in time for the lift to end.

7. In the bathtub. But the water made the ink run on the notecards.

6. On the toilet. (Sorry).

5. At the pool, both in a chaise lounge and on a floaty in the pool, but ran into same problem as #7.

4. In my kayak, floating in the middle of the back bay, toes dipped over either side into the water.

3. Sweet Tomatoes (a soup/salad buffet restaurant). If I came for a late lunch and studied long enough, I could dish up dinner before leaving!

2. On my cat. Not with my cat, on my cat. He made an excellent bookstand...the reading angle was perfect. And he didn't even seem to mind.

1. On a date. With my (very) patient husband.

The Day That Wrote Itself

There are days that it takes me a while to formulate what I want to write. I think about it while I run, feet in rhythmic movement, a moving meditation of words. Other days are easier; I sit down and words flow.

Today, this blog wrote itself.

I saw fifteen cardiology patients today. Here are eight of them:

Patient #1: Denial

Me: "Do you have trouble sleeping at night?"

Patient: "No. I've taken Xanax at night to sleep for years. I'm not addicted, just used to it."

Patient #2: The Generous Risk-taker

Doctor: "Your stress test and angiogram showed that four of your bypass grafts are blocked and your heart is severely damaged. You need to be very careful or you will need a heart transplant."

Patient (reeks of smoke): "Well, can I go up in a hot air balloon to 4000 feet?"

Doctor: "You really want to go up there and do a self-induced stress test in a basket 4000 feet up with no medical personnel to help you?"

Patient (thinking): "That's a good point. Would you like to come?"

Patient #3: The Medicaid Fraudster

Patient (with $400 purse, BMW keys, and 3 pack-per-day cigarette habit): "Doctor, I know my cholesterol is worse than before since I stopped taking my meds. I can't afford my medication and Medicaid doesn't cover it for me. I need a generic."

Doctor: "Oh?"

Patient: "Yeah. That reminds me, my boyfriend and I are buying a hot air balloon. Would you like to come for a ride sometime?"

*note: I do not know what is up with hot air balloons today. Apparently they are the thing to do for cardiac patients in Arizona.

Patient #4: The Undersharer

Patient: "I have chest pain."

Doctor: Asks all manner of questions related to chest pain symptoms

Patient (20 minutes later): "I work for a company that transports museum exhibits. A few weeks ago, I was at work and was pinned between a wall and a 1200 lb crate that rolled into my chest."

Me: "Is that when the chest pain started?"

Patient: "I think so."

Later X-Ray showed 4 broken ribs

Patient #5: Another Undersharer

Me (taking history): "Have you ever had any heart problems?"

Patient: "No."

Me: "Any murmurs, stents, valve replacements, high cholesterol, high blood pressure, or chest pain?"

Patient: "No."

Me: "Have you had any surgeries?"

Patient: "No."

Me: "Any problems with your lungs or breathing?"

Patient: "Well, I had pneumonia after my quadruple bypass three years ago."

WTF?

Patient #6: The Neurotic Oversharer

*contrast this to patients #s 4 and 5.

Patient: "Doctor, I know you told me to to worry about my myocardial bridge, but I am concerned."

Doctor: "The myocardial bridge is nothing to worry about. Your angiogram showed that it is not significantly occluding your coronary artery, and since it is a congenital condition, it will not get worse."

Patient: "Well, I've been looking into research to get it fixed. There are all kinds of new experimental procedures."

Doctor: "You don't need it fixed."

Patient: Produces 6 page, typed, single-spaced paper detailing his research on the subject, complete with references in parentheses and a works cited page.

Doctor: "This research is for bridges that cause artery blockages. You don't need any intervention. And, this experimental procedure is only done in New Zealand."

Patient: And while I'm here, I want to talk about my blood pressure."

Doctor: "O-kay..."

Patient: "It's just out of control. I take my medications, but every time I put my cuff on, I get so anxious and just watch the numbers creep up and up."

Doctor: "How often are you taking your blood pressure?"

Patient: "Roughly, um, (thinks)....maybe 25 times a day?"

Doctor: "I think you should do it just a few times a week, when you are relaxed and not stressed."

Patient: "I also think my blood pressure is causing me to have erectile dysfunction."

*note: by now I am zoning out and am as bored by the patient as you probably are at this point.

Doctor (later, to me): "That guy is really annoying. I think I'm going to fire him from my practice."

I don't blame him.

Patient #7: The Surgical Clearance Patient

Patient: "I need cardiac clearance for a surgery that I'm supposed to have on Thursday."

Doctor: "That's in two days! I'm not sure we can clear you that quickly, especially if you've had any heart problems in the past."

Patient: "Please, doc. I really need this surgery ASAP."

Doctor: "Well, what is it for?"

Patient: "It's with an ENT doctor."

Doctor: "For what?"

Patient: silent

Patient's wife: "Well, I bought him a nose hair trimmer for an early Valentine's gift. But he had so much darn hair that I guess it wrapped around the attachment and...."

Patient: "It's stuck up there."

Doctor: "What's stuck up where?"

Patient: "You know. The nose trimmer attachment. It's stuck way up there and I need the surgery to remove it."

Doctor: "We'll do your cardiac clearance as soon as possible."

Patient #8: The Med Student Abuser

Me: "Can I listen to your heart and lungs?"

Patient: "Sure. I'm all for helping students learn."

Me: "Sounds good." (Listens and then puts stethescope down on the exam table next to patient).

Patient: "So you're learning how to use this thing, huh?" Picks up stethescpe and whirls it around, just as I lean into check his pulses.

Stethescope bell hits me in the temple.

Me: "I'll just go get the doctor for you."

Ow.

10 Things

Here is a list of 10 things I wish I had known upon entering medical school:

10. Eat, sleep, shower, and poop when you can. Cuz you never know when the next time you can is.

9. It IS possible to have a life during medical school. Many of my friends were able to get married, have babies, adopt a dog....BUT...

8. Realize that medical school will not always allow you to spend time with them, or even to live with them.

7. Patients die. It's (probably) not your fault.

6. Sleep is not necessary to live; nor is it required to make life and death decisions.

5. You'll learn to study all the time. Examples include, but are not limited to: notes wrapped in a baggie in the shower, EKG book while at summit of ten mile hike, flash cards while at the DMV/hair salon/post office/public transit/red lights/bathroom/other "unavoidable delay."

4. Shoe requirements: 1) Really, really comfortable. 2) Blood/other body fluids wipe off easily.

3. You'll get sick. A lot.

2. Many days you'll wonder why you went into medicine. And then you meet a patient that reminds you that...

1. Medicine= love. Love your patients. Love yourself.

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.