Moving Right Along

As promised, albeit a little later than I planned, another post this millennium from yours truly.

Where to begin, I suppose an update of sorts is in order. I have just under 2 weeks left of medical school. My official last day of this rotation is December 25th but with the holiday, and missing a day for an interview- I have only 8 more days at the hospital until I am finished with the whole ball of wax. It still doesn't feel completely real just yet.

I are gonna be a doktor soon!

The interview season is in full swing and I have just returned from a trip down to Florida for an interview. The weather was amazing, the city was very cool, and the program was pretty impressive. The interviews there went well and I received a great deal of positive feedback, for what that is worth. A few more of these interviews and I can put this whole process behind me.

We are going to be moving back to the Philadelphia / So. Jersey area at the end of the month since there is no longer any reason to stay in New York and we want to be close to family for a while until I find out where I will be doing my residency in March. New York is a great place to visit and I suppose it is not too horrible to live here for a while, but I am ready to leave.

All that remains is finding a job for Kathy and a place to live.........details!

Until next time

Uno Mas!

Earlier this week I began what will be my final rotation of medical school.

It sounds weird. My LAST rotation! Yes, in just a few short weeks I will finish medical school. The reality hasn't fully set in yet.

For those who are following along at home, when last we left our hero he was up to his pons in reflex hammers and MRI scans during the Neurology rotation. After 4 weeks of diseases of the brain and nervous system, I began Hematology/Oncology.

This was not a very enjoyable rotation for a few reasons, not least among these was the rather depressing nature of seeing patient after patient in the throes of their terminal illness. It becomes almost surreal after a while. It was interesting to observe how different physicians interacted with the patients. Styles varied but most seemed to deal with the death issue very well. One can learn a great deal just being around people I suppose. From a medical student perspective, the rotation was fairly educational and the attendings were laid-back and focused on teaching. The schedule was rather long and most nights I was there way longer than any self-respecting 4th year with senioritis should have been.

Anyway, that is all behind us now and this week I began ...I'll say it again...my final rotation of medical school- Endocrinology.

So far it is completely enjoyable. There are only a few disorders that make up the lion's share of the patients we see- Diabetes, Thyroid derangements, the occasional pituitary abnormality nothing too exotic so far. The management is pretty straight forward and not too mentally exhausting, even for a medical student. Our attending is quite personable and has an excellent rapport with both his patients and his students. He seems never to be at a loss for a story, ready at a moment's notice, to illustrate a point, or teach a lesson. Most are pretty amusing . Tuesdays are spent at his private office in the heart of Brooklyn- quite an interesting experience.

Each of his patients seemed to come straight out of Central Casting. More caricatures than actual people, I half expected to hear a laugh track begin playing after each question and answer exchange, or perhaps a rimshot.

Some of the actual exchanges between our attending and his patients :

So what brought you in today?
"The bus"

And how do you take your metformin? ( a diabetes pill)
"Orally"

You have diabetes, high cholesterol and high blood pressure; is that right?
"No I don't HAVE high blood pressure- I GIVE high blood pressure, I'm a carrier [points to his wife]

...and so it went.

Each patient seemingly trying to outdo the last in this Vaudevillian banter. I'm not sure if it was just the patient's personalities, or the fact that they had an audience in us [the medical students], but I suspect that this was part of the normal relationship our attending has with his patients. It was nice to see. Quite a refreshing change compared to my last rotation.

I realize I haven't posted in a while and have yet to mention anything about the whole applications/interview process- stay tuned. I apologize to the 3 of you who actually read this and may be interested in such things.

More posts are coming soon. Really. I mean it this time.

Trust me, I'm almost a doctor!

Halloween Pics

As requested, some Halloween pictures:

One Cute Little Pirate

One Not-So-Amused Elephant

In Search of: Candy

This year: (click the play button to see video)

Quite a difference from last year:

Okay..New Plan

I'll stop promising to blog more frequently and you'll stop pretending to believe me.

John Lennon said, "Life is what happens when you're busy making other plans."

I truly understand what he meant.

On the medical school front, I have just started my antepenultimate rotation: Neurology. ( ok fine- look it up, ye non Lovers-of-Latin)
Ailments of the brain and nervous system are what my world will be about for the next 4 weeks. So far the rotation started out very disorganized but when we finally got around to rounding it was rather good. My only complaint would be the hours, since I barely made it home in time for Kathy to hand-off the kids to me and head to work.

I finally completed the application process for residency and currently I am in sit-around-and-wait-mode. I have heard from only one of the programs that I applied to with a nice little email letting me know they are reviewing all the applications and will not be offering interview invitations until the first week of November. From what I hear this seems to be the modus operandi of many of the programs in Emergency Medicine, so I have not begun to worry yet.

The family is doing great and I am enjoying all the extra time being with them since my schedule has been a little easier (up until today anyway).

Kids update:

• After quite possibly the longest ping pong losing streak in history (151 games- just ask him) Johnny's systematic trouncing of the old man came to an end! I was finally able to beat him. I promptly decided to retire from play and go out on top;-) [update: My retirement was short-lived and a week later I was back to "coming in second" ]
  
• Meagan is being inducted into the National Honor Society this Wednesday, we are all very proud of her. As several people were quick to point out, she must get her brains from her mother.
  
• Kaitlyn is also doing very well in school, this is no small feat- considering that she spends almost every waking moment trying to become the world's greatest Flyers fan. Apparently she is in "Daddy, you just don't understand" kind of LOVE with several of the players and has even roped me into taking her to a Flyers practice. Not sure how I should feel that my daughter is all starry-eyed smitten with someone who is missing his front teeth.... I suppose it could be worse.
  
• Rileigh is doing quite well with the potty-training and aside from the occasional mishap, I believe that we are just about home-free. From the most recent entry in her Toddler Tricks to Horrify, Frighten, and Annoy your Parents playbook, our little darling painted her face with White-out (don't ask) and then got a hold of Dylan's tub of formula powder and decided to eat some with the convenient little scoop provided and as I was running from the other side of the room screaming attempting to redirect her, it must have sounded to her like "dump all the powder on the floor just before Daddy gets there, sweetie!" because ...yeah that is just what she did.
  
• Dylan is growing like a weed and at this rate will be as big as Rileigh any day now.

That's it for now.

Tune in soon.

I'm not dead...

Much has happened since my last posting.

I received the results of my USMLE Step 2 exam and I couldn't be happier. All the studying paid off!

I finished my GI rotation and now in the second week of Cardiology.

My oldest daughter, Meagan turned 17, passed her driver's license exam, and bought her first car- all in the same day!

Meanwhile I have been busy working on my application for residency- I am happy to say the process is just about complete and all that is left for me to do is sit around and wait for interview invitations. Hopefully some will come!

That's all for now- I hope to post more frequently now that I have a little more free time.

And When I Get That Feeling....

This week in GI, I am doing consults. It is a nice change of pace from the non-stop onslaught of colonoscopies and esophagogastroduodenoscopies. Basically, whenever one of the managing medical teams decides that their patient has a problem that may benefit from the GI service they request a consult. It is the medical world's equivalent to "Hey take a look at this and tell me what you think". There is a fair amount of consults that come into the GI service everyday so they are only too happy to let the medical students "help them out". Anyway, during a lull in the consult action I was asked to head back to the endoscopy suite to lend a hand. I was soon joined by another medical student and after taking some H&Ps we were observing a fairly routine colonoscopy.

The endoscopy suite resembles a small operating room. There is a large video monitor on the wall, a stretcher in the middle of the room, the endoscopy machine is stacked neatly on the counter, and a full array of tools, wires, hoses, and scopes are hanging neatly on the wall. The thing that makes the endoscopy room a bit different is once the procedure begins the lights are all turned down really low. I made a joke my first day there that at least they provided a little mood lighting before impaling you with large medical instruments.

Having music playing in the operating room is a fairly common thing. Many surgeons have their "pet music" that they need playing in the background while they snip and hack through tissue practice their healing arts. The endo suite is no different. Most of the doctors there are content to leave the radio on; tuned to some "office-appropriate" adult contemporary station.

The low lights, the music playing in the background, and my somewhat twisted sense of humor came together in a perfect storm today that almost had me laughing out loud.

In the middle of a procedure that involves passing anywhere between 4 and 6 feet of unfriendly colonoscope into your "Holyiest of Holyies", I happen to catch the song that was playing on the radio. I tried to stifle a giggle as I looked over at the other student and told her to listen. As luck would have it, Marvin Gaye was crooning on about his need for Sexual Healing.

And then came this lyric:

"You're my medicine. Open up and let me in.
Darling you're so great, I can't wait for you to operate.
I can't wait for you to operate. Baby, I can't wait for you to operate."


I guess you had to be there.....

The Word of the Day

You hear about in throughout medical school: The medical student closet hypochondriac who, upon learning about a disease, is JUST CONVINCED that he has said affliction. I have witnessed this phenomenon to a mild degree with a couple of my classmates. You know what they say, "a little knowledge is a dangerous thing."

But after spending the last week watching enough colonoscopies to last several lifetimes, I got really concerned. Seeing countless diverticula, polyps, hemorrhoids, and abnormal mucosa, well, it was enough to scare the sh...well you get the idea ;-)

Anyway, the word of the day is :



Do you and your colon a favor and jam your face full of oat bran, vegetables, fruits, beans, tree bark- whatever. Just be sure to shoot for 30-40 grams per day.

This Public Service Announcement brought to you by concerned colons everywhere.


Picture Credit

The Weight of the World

I woke up this morning and something was different. I actually got a decent night's rest, something I sorely missed.

After what seems like an eternity of endless studying, I finally have come to the day where I no longer have to worry about the USMLE step 2 exam*. What a relief!

The exam yesterday went pretty much according to plan- after over a thousand practice questions, the test seemed to go by pretty quick. There was however, a series of about 5 questions near the beginning of my first block that felt like a stiff boot to the pills. They asked some off-the-wall curve-ball questions that were more of the Step 1 variety. Aside from that I felt pretty comfortable with the material and I didn't think it was too horrible.

I suppose I will know for sure in about 3 weeks when I get my results.

My son John picked me up after the exam and we met up with Jersey Pete to did a little post-exam celebrating over a few beers and the Yankee game at Brother Jimmy's.

Up next, I am reunited with my friends in GI starting Monday.


* assuming I passed

Is that The Eye of The Tiger playing behind me?

If my life were a movie, this is where the Big Training Montage scene would go.

With only 6 more studying days until my big fight test, the studying has been in high gear for a while.

Actually, it is almost around the clock, literally. Between my usual dose of insomnia and Dylan's 2 middle-of-the-god-damned-night-feedings while Kathy is at work, I find myself watching review videos or reading by computer light while the little guy hungrily chows down a bottle. Afterwards, as I toss and turn, trying to fall asleep, I will inevitably think of something I wanted to look up or a practice question I got wrong. It will fester until I eventually give in to my compulsion and... out come the books.

I have been at this pace for a good while now and I seriously can't wait until this particular test is in my rearview mirror.

You always hear about the Herculean effort and multiple sacrifices that are needed to get through medical school. I wasn't naive. I understood what kind of work it was going to take. I knew what I was getting into. I entered into this journey eager, and with eyes wide open. Don't get me wrong, there have been a bunch of sacrifices and our road was not without its share of bumps, but frankly, I never felt like this whole thing was that bad . I'm not sure if it is because I have a supportive family around, or because I had a good bit of clinical experience before starting, or just that I am too damned old to get flustered about things. Whatever the reason, I had it all under control. Things, they are starting to change.

I am sure this is a very common feeling for most students around this time in their careers. So close to the end (or beginning, actually) and each next step is a bit harder to take. The feeling like it is NEVER going to end, and the mountains of tasks- still left to be done.

Yes, I am so ready to get this test over with and reclaim just a small part of my life.

So, if you are in the neighborhood of the Prometric Testing Center in Manhattan next week, and you spot a man with blood-shot eyes, sporting a "playoff beard", who smells of regurgitant breast milk and baby powder, mumbling to himself manicaly, "Yo, Adrian!", as he walks out of the building- just smile and nod and let me have my moment- I've earned it!

Weekend Update # 716....

This past weekend Kathy, Rileigh, Dylan, and I drove down to spend a few days at Chateau de Exwife . As usual we had a great time. We got to spend some time with the whole family before Susie, Bruce, and the girls head off for their annual vacation- this time it is Mexico for 10 days. Color me jealous.

Friday I spent the day at my mother's house taking care of a list of things she needed me to do: running some new pipes for a water spigot in her garage, repairing her kitchen faucet, replacing a dimmer switch in her dining room, replacing the toilet flange and re-mounting her toilet, and some other manual labor type things. Thankfully Bruce had the day off and offered to come along and help me get things done quicker. Everything got fixed and nary a trip to an ER- it was a good day.


Speaking of my mother... Let this be fair warning to all:

It now may be unsafe to drive (or walk, for that matter) about the streets of Philadelphia.

It seems those wacky, fun-loving pranksters over at the PA Department of Transportation thought it would be a good idea to issue her her first Driver's License! Congratulations, mom!


Because of an upcoming change to the test format, begining on August 10th, people who take Step 2 will experience a significant delay in score reporting. I wanted to avoid this and so I have re-scheduled my Step 2 exam for Thursday, July August 6th. Hopefully the 4 days of forsaken last-minute studying won't have an impact on my score. I can't wait for this to be over!

Lastly, file this under "David Hasselhoff, I ain't!"

While enjoying some barbecue yesterday in the back yard at Chateau de Exwife, Rileigh somehow managed to crawl underneath the ad hoc security gate at the bottom of the steps that lead up to the pool deck. She was up just about at the topmost step when we noticed her. My dad instincts took over and I lept up from the table stepping over a Sleeping Dylan in his carrier seat, and sprinted across the lawn to the steps. I'm not sure what exactly possessed me, but I hurdled over the gate at the bottom of the steps and nearly tackled poor Rileigh up on the deck. She was quite startled because she was only headed up the steps to retrieve a toy and here comes her dad barrling down on her like she stole something. After catching my breath for a second I recieved a strange message from my lower back.

It said, "You idiot! Apparently, you think you are some sort of athlete who can sprint off and go hurdling over things. You are so wrong. You will pay."

Almost immediately, I felt the wonderful searing hot pain of old age and deconditioning racing across the right side of my lower back. So today I am hobbling around half-crippled and hoping this goes away soon.

The safety gate has been repositioned and she can no longer get by it (for now). Sadly, I imagine my lower back will take a bit more effort to get back in shape.

Lessoned learned.

On losing one's mind...

Friday night was my last shift of my Emergency Medicine rotation. Unfortunately, it went out with a whimper and not a bang. My last 2 shifts there were uncharacteristically slow. I suppose that is a good thing for the citizens surrounding the hospital, but not necessarily how you want your shifts to go when you are an eager medical student. (paying not a small sum of money to 'get your learn on') The whole rotation went really well however, and it has been the most enjoyable rotation by far. I am looking forward to another ER rotation assuming I can successfully schedule one.

With only 5 months of rotations left, I am starting to see the light at the end of this tunnel. It is a pretty exciting time. I must admit my excitement is tempered a bit by the stress of all that remains left to do. There are personal statements to write, lists of residency programs to weed through, letters of recommendations to secure, applications to fill out etc. The seemingly endless administrative tasks are the bane of my existence, but a necessary evil so I'll stop whining now.

Before I can dedicate the time needed to get my applications in order, I have to tackle the USMLE Step 2. August 10th is my test date. I have been trying to study as much as I can and have been doing practice questions for almost 2 months now- squeezing in a block of questions whenever I could. Since I am rotation-free for the next 3 weeks, my studying will ratchet up to a full-time job (in addition to my Mr. Mom duties while Kathy is at work) so this should be a very interesting few weeks. I have been doing pretty well so far on the practice questions and I did well on the sample exam that you can download from the USMLE site; so far so good.

While I am fairly confident going into this exam, everyday it seems I uncover yet another piece of medical knowledge that yours truly has simply... forgotten. The information is gone and all that remains is the phantom of a memory, mocking you, like a dream you can barely remember. The harder I try to recall, the fuzzier the details get until I find myself at my desk drooling on myself and realize half an hour has passed. I realize that no one is expected to remeber everything, and I'm sure everyone has moments like these, but it is of little consulation when you feel the cruel grip of senility taking hold. Studying for an exam like this is quite the gut-check. I think half the battle is hanging on to your sanity.

I have a particular mental block when it comes to a few topics, try as I might they slide through the steel trap sieve that is my mind:

The glycogen storage diseases- once upon a time I could prattle on about them, now... nada.

The serological markers and the auto immune diseases they are associated with- anit-dna, ana, anti-centromere, smith, rho, jo, anca...calgon take me away!

The congenital adrenal hyperplasia enzyme deficiencies- 11, 17, 21...22 23 whatever it takes. ( I have drawn the chart about a bajillion times over the last 4 years- you think I would remeber... any of it!

The relationship of gnrh, fsh, lh, estrogen and progesterone in the menstural cycle/pregnancy. This one I can usually recall after a mini "drooling session" but it seems that my lack of understanding of women doesn't end with The Mystery of the toilet seat left in the UP position and the psychotic break it precipitates in those afflicted with 2 X chromosomes.

By no means is this list complete, the sheer weight of what I don't remember would sink the QE2.

Despite my selective amnesia, I push on, ego in tatters, and like Sisyphus, I am condmened to watch the boulder of my memory roll back down the hill. Maybe today some of it will stick.

Maybe.

X-Ray From Last Week

Things have been a bit on the busy side. I have switched to night shift in the ER for the next 2 weeks and have been struggling to get used to being awake all night again. Things are going really well on this rotation and time is flying by- as I imagined it would.

This was a case I had last week. I saw a gentleman with a bad venous stasis ulcer who had just been discharged from the hospital. He was returning because the ulcer had just started to drain some rather purulent material despite being on some antibiotics. After taking his history and doing a physical I went and looked in the computer system for a x-ray of his leg- since he had an old distal femur fracture that he chose not to have repaired for some reason. I saw the x-ray and it was quite an impressive fracture but other than that, the area of his leg where the ulcer was looked pretty good. When I presented the case to the attending I mentioned that I would like to get another x-ray even though the one on file was less than a week ago. He agreed, and I ordered the films. A little while later I went to pull up the x-rays and this is what I saw:




Click on the images to enlarge them, if you are having trouble seeing, there is subcutaneous air in the soft tissue.

Diagnosis: Gas Gangrene. Pt was scheduled for amputation of the leg above the knee for the morning.

Reason # 419 to keep your diabetes under control.

EM week 2 begins...

Today I began my 2nd week of Emergency Medicine with an all-day student lecture marathon. They rotated in several of the residents/attendings in throughout the day and each one conducted a lecture. The topics were pretty good for the most part, but sitting a very warm and stuffy room for 8 hours is not my idea of a good time. Tomorrow I am scheduled for the 7am-7pm shift I suppose it will go by much faster than today did.

Tonight is Kathy's first night back at work since having Dylan; and we have recruited Kaitlyn to come up and lend a hand watching the kids in the overlap between when I leave for work in the morning and when Kathy gets home. Rileigh is thrilled to have her big sister here to torment  play with! So far Dylan seems to be cooperating, and hopefully we will all get some sleep tonight.

Speaking of sleep...

Thumbs Up!

Last night I spent my shift in the "Urgent Care" area. Every hospital has its own nomenclature- but this falls somewhere between the "Fast Track" and the "Acute area"(where I spent my first shift) in terms of acuity. The Urgent Care area is where patients with a low likelihood of admission are seen- but who still may require some type of work-up / intervention. I was stationed there with one other student, a resident, and of course, the attending physician.

It wasn't incredibly busy, and my first impression was that my evening would be spent with a lot of down time; and not much in the way of learning on this particular night. So, I decided to make the most of things and grabbed a copy of Blueprints in Emergency Medicine, 2nd edition and proceeded to do all the questions at the end of the book in between evaluating patients*.

There was a fairly steady flow of patients and I was able to see my share throughout the night. Granted, they had nowhere near the acuity of the previous nights' patients, but that is the nature of the beast. Fortunately, the attending physician was into teaching and began early-on with the interactive teaching sessions.

Several topics were covered including the management of the acutely intoxicated patient( and legal ramifications thereof), the differential for invasive diarrhea, and the evaluation of shoulder injuries. Since I am the whipping boy sub-intern, most of the questions were directed straight at me. I was feeling pretty confident since I was fielding them without any trouble at all. This of course was about to come to an abrupt end.

The patient in question was a female in her 30's who sustained a small laceration to the tip of her thumb 4 days ago. She was prescribed an antibiotic by her primary care doctor 2 days ago, when the thumb began to swell and became more painful. I conducted a brief history and exam. The thumb did not look that bad, there was no local collection of pus, and there was only minimal restriction of her range of motion while sensation in her thumb was not grossly affected. I was working on a diagnosis of local cellulitis. After quickly confirming the absence of any fevers or drug allergies(I was anticipating a change in antibiotics) I was on my way back to the attending to present the case to him. [Cue Chopin]

After what I thought was a rather complete and concise presentation, the attending said, "Let's go see her." I thought I detected a certain glisten in his eye.

The attending introduced himself to the patient and proceeded to put her through a very similar physical exam that I had just conducted. After which, we went back to the witness stand desk where the questions began:

Attending: So, what is your diagnosis?

Me: It doesn't look like an abscess, I think it is just a mild localized cellulitus**.

Attending: Mmm Hmm... [this is never good] So, what would you be concerned about given the location of the injury?

Me: umm...err...duh....I suppose It could to progress to a Felon ?

Attending: OK fine, that is right it could, but what would be a serious complication of her wound? [holding back frustration in a not-so-subtle-way]

Me: I suppose it is unlikely, but perhaps osteomyelitis would be fairly serious.

Attending: [doing his best to fight the overwhelming urge to call my lineage into question] That would be "rare". Have you ever heard of Tenosynovitis?

Me: [cue crickets chirping... as I desperately apply my "conversational Latin skills" to the problem] That is inflammation of the..uh.. tendon..[trailing off] and the... synovial space?

Attending: [wearing the look of a chess grandmaster who sees imminent victory] Close-But. Why dont you go ahead and look that up for me- and tell me Kanavel's 4 Cardinal Signs of Tenosynovitis, why it is important, and the management. I'll give you 5 minutes, then you will tell me. And then you'll teach the 3rd year when he comes back from seeing his patient.

Me: Uh, Sure. [I like this guy]

Needless to say, I looked up all there is to know about Tenosynovitis and was able to sucessfully answer the question, and proceeded to teach my fellow student about the diagnosis and management of the dreaded, Tenosynovitis. Thankfully there was a 5-Minute Consult on the bookshelf.

I have to say, I think it will be a good long while before I ever forget to consider that diagnosis again.

Tuiton for clincial roatations: ~$1000.00 per week
Cost of Dansko Clogs (inserted firmly in the mouth): ~ $90.00
Having your ego kicked in the nuts- but actually learning something that may save a finger or a hand someday: Pricelesss.



*If you are interested, there is a typo in the answer key- answers #33 and #34 are transposed.

** For the record, my diagnosis was correct; but I was wrong not to consider( or even know about) the more serious differential.

Picture credit: Wikipedia

LUCY...............I"M......HOME!

At long last, my Emergency Medicine sub-internship has started. Last night was my first shift and despite what Tom Wolfe said, it was EXACTLY like going home again!

Home- assuming your home was a chaotic, loud, disorganized, subterranean outpost of the hospital where the teeming masses of the sick and injured (and not-so-sick-or-injured) are congregated on stretchers that appear to be engaging in some constant breeding program and occupying just about every square inch of real estate. If your home is filled with the cacophony of ringing phones, beeping monitors, wailing patients, colorful language and smells like a cross between a Calcutta sewer and a North Philadelphia manhole cover, then yeah- it is just like home.

I can't believe how much I have missed this!

My shift started at 3pm. There were several students there some 3rd years and some 4th years. We met with the attending who was working that evening and since he is also the administrator in charge of the medical students, he gave us a brief orientation. It was your basic "Welcome to the ED" kind of orientation, but he did tell us that they expected a bit more from the 4th year students doing the sub-internship. They expect us to be completely be involved in all aspects of our patient's care. They made a big emphasis on procedures as well. The 4th year students are supposed to get the first shot at any procedure that their patient may need, central lines, intubation, sutures, etc. More important than this in my opinion, is that we really are expected to function at the intern level. We see patients independently, come up with a differential, formulate a plan and then present directly to the attendings. We then go back and "do" all of the things in our plan: if the patient needs an IV we insert one, if they need blood-work, we do it, ditto Foley catheters, NG tubes et cetera, et cetera. This is probably done just as much out of necessity as it is for educational value. There is a high volume of patients and there is only a finite number of nurses. So I suppose it works out for everyone.

After our brief orientation I was handed a chart and told to see my first patient. A patient that the test writers at Step 2 CS would love! ( I promise I will post about my CS experience very soon) She had symptoms that easily covered about 5 diagnoses. A great medical student case.

My next patient was a woman who elderely woman who only complained about "not feeling well". She was not the most easy pateint to get info out of and kept saying very ambiguous things like "I am just not feeling up to par". After a long list of questions from me including her opinion on East coast versus West coast Rap, I was only able to get her to admit to slight shortness of breath. OK on to the exam. Lungs: rales at the bases..hmmm. Heart: systoloic murmur, irregular and kinda quick...the plot thickens. Of course she was in a A-fib with rapid ventriclular response with a rate of about 160. Interestingly enough, after some rate control with cardizem her CHF got worse and she teetered on the intubate/no intubate fence for a while before she finally started to improve.

Not to be outdone, my very next patient was an 80ish year old man sent from a nursing home for evaluation of an isolated extremity injury, seemingly a pretty mundane case except when his EKG printed out:



The patient was asymptomatic (as much as an 80 year old demented man can be asymptomatic).


Not a bad way to start a shift. I got to do a bunch and saw some pretty high acuity for my first night there.

I entered med school with the idea that I wanted to do Emergency Medicine. I did try to keep an open mind and stay receptive to the possibility of another specialty, but nothing is as satisfying to me as EM. For me, I suppose the choice was made long ago. But if I was on the fence about what to do, last night would have sealed the deal- not because I saw some interesting patients or the 'excitement' of treating a high acuity case. For me the thing that stood out was how comfortable I felt to be back in an ED doing what I think I am meant to do. It was like putting on a very comfortable broken-in pair of jeans.

To the uninitiated, the ED must appear simply chaotic where there is no chance of anyone receiving anything even approaching decent medical care. With stretchers packed in one practically right on top of the next and only a thin curtain to distinguish where one patient's "room" ends and the next one begins it must look more like some makeshift M*A*S*H unit from days gone by, than a modern American hospital. Despite all of this, if you watch closely enough you start to see some order in the chaos, and somehow, however unlikely, people are cared for and the staff seems to have a handle on what is going on. Make no mistake, the ED is not without its share of problems and given the current state of health care in this country is likely to be one of the targets for any real reform.

Emergency medicine is not perfect, far from it, I know; but somehow (perhaps because I am so very far from perfect) I feel like we are perfect for each other.

I am actually looking forward to my shift tonight. Sick, I know.

Pee Pee in the Potty Conga

They say it is the little things in life that are to be treasured. I suppose that is true.

Lately we have been encouraging Rileigh to sit on her potty everyday once or twice, in an effort to transition her into some serious potty training down the road. Well, tonight during such an attempt she sat on the potty and made her customary "psssssss" sound to signify her peeing (this is ALL she usually does- is make the sound) and then demanded toilet paper and washed her hands- I suppose, at least, we are ingraining hygienic habits.

Anyway after this little mock micturition she gathered herself and made her way back to playing with her 7,149 toys that lay strewn about the living room. Several minutes later I was in the bedroom when I heard my wife shreik er...mention that there was indeed some of the golden fruits of our little darling's hard working nephrons sparkling at the bottom of the pint sized potty. She had somehow managed to run back into the bathroom and conduct a covert urination operation while Kathy was preparing dinner.

As is the custom in my household, whenever one of our clan overcomes the genetic boundaries, acheives expert marksmanship, and actually deposits urine in the receptacle designed with the expressed purpose of containing it- it is cause for much celebration. I for one like to celebrate our successes and not dwell on any of the shortfalls (unlike my wife and her inability to forget the infamous 3am drunken livingroom accident or the dreaded toilet seat faux paus of 2006) Anyway, this was clearly a time to rejoice.

I took the lead during an un-precedented rendition of the "Pee Pee in the Potty Conga" song complete with rolling hand motions and gesticulating dance moves. I would love to post a video of the aformentioned spectacle, but we were so caught up in the peeing pandemonium that it slipped my mind to capture the event on film. Trust me when I tell you it was quite the sight to behold!

I smiled broad and long.

Who knew urine could bring such happiness?

It really is the little things.

So much to say..so little energy...

I had intended on posting a pretty long narrative about my ordeal taking Step 2 CS - but I am dog-tired. My flight got in rather late last night and after an awful night sleep I was scheduled for 12 hours in the Peds ER today. Thankfully I was in a familiar and comfortable environment and was able to get through the day while still appearing to have my head in the game. The reality is Vince is just about approching the red line on the old stress-o-meter.

There has been a perfect storm of circumstances conspiring to have me loose my shit in an epic way.

Perhaps I'll feel better after a couple hours of sleep.

Relay for Life Pictures

Better late than never I suppose; here are some pictures from last week's Relay for Life Event.

Soon after setting up our tents and getting our gear unpacked it poured off-and-on for a few hours but it didn't seem to dampen anyone's fun. Relay was a good time despite the rain and it raises a bunch of money for a good cause. Thanks again to everyone who donated to our team!

Meagan even convinced me to sign up for the CP3 Cancer prevention study and have some blood drawn. CP3 hopes to enroll 1/2 a million people from ages 30-65 and follow them for 20 years (Nothing like a 20 year commitment!) looking for incidences of cancer and associated blood markers, lifestyle and dietary habits, and other factors to establish links and subsequently prevention of cancer. Previous CP studies, for instance, were responsible for linking smoking to cancer. It is supposed to take only about 45 mins every 2 years to fill out a mailed survey so we will see how it goes.

Meagan and Autumn:




Susie and Bruce:




Kaitlyn and her old man:



Silly Face Brigade:




Rileigh doing her first of many laps:




Rileigh getting a ride around the track:



Fashion provided courtesy of Megg and Kait:



Meagan and her aunt Michele, a cancer survivor:



Bruce manning the (unforgiving) cotton candy machine:




Selling cotton candy - we raised over $220.00 $248.00- not bad at only $2 each (the ADA was protesting outside of the event !)




Middle of the night shots:





Waking up isn't so pleasant for everyone:



Made it to the morning:

Freaky....

I was taking a break from studying, sitting at my computer and listening to Pandora Radio (which is cooler than a box of frozen cucumbers) and enjoying my custom radio station- featuring various Blues greats.

Anyway, I was checking my news feeds on Thunderbird and read this story : Koko Taylor died today at age 80. I was about 2 paragraphs into the story, when I realized that at that very moment, Koko was playing over my computer speakers wailing out one of her hits, Evil:

"Long way from home
Can't sleep at all
'Cause there's another
Mule kickin' in your stall" (they don't write 'em like this any more!)

Weird coincidence.

Meanwhile, back in the land of the living, I am doing a fair bit of studying lately for my upcoming test in Chicago next Wednesday. Posting will be a bit light but I am working on putting up some pictures and a video or two from last weekends Relay for Life event.

Stay Tuned.

Friday Randomosity

Today is the end of my 3rd week of my Pediatrics rotation- halfway done! So far it is very laid-back and pretty enjoyable. My first 2 weeks I have been on the pediatric in-patient unit doing pretty much the same thing that is done on the adult medicine floors. Seeing patients, writing notes, following up labs etc. This week I was in the Neonatal intensive care nursery as well as the regular newborn nursery. We practice doing a complete examination on the babies which is markedly different from how we examine adults. Some of the babies are so small, that with my adult-sized stethoscope I can almost simultaneously auscultate heart sounds, lung sounds, bowel sounds, and listen for renal and carotid bruits all from the same position. Most of the babies are pretty cute and even the ones that are pretty sick are still kind of enjoyable. There was one baby in the NICU who was wearing the staff out- He was born to a mother who was on horse dosages of Methadone during her pregnancy and so the baby was born addicted to opiates and was pretty much inconsolably crying aorund the clock while his medication dosages were being adjusted. Kind of sad.

I got to witness a circumcision. This was the first one I had ever seen. Um......OUCH! This practice seems just a tad on the brutal side. I know the babies don't "remember" the pain, but I imagine it isn'tmuch of a consolation at the time to the little fellas.

Tonight we are headed to the Relay for Life event at Meagan and Kaitlyn's high school and hopefully the weather will hold off or else I will be sleepy, grumpy, and wet come tomorrow morning. Thank you to everyone who has donated. You guys rock!

One last thing I have been driving by this barber shop every day for a while now and finally took the time to pull over and snap a quick picture. The sign cracks me up!



"We Specialize In All Cuts"

"What kind of haircut do you want sir, because whatever style you want- it happens to be our speacialty"

To steal from a great movie, "You keep using that word, I do not think it means what you think it means"

Weekend Roundup (Late Edition)

John Lennon wrote the lyric, "Life is what happens while you are busy making other plans." Lately I feel like I truly understand what he meant.

Much has happened since my last post, I'll try to recap the highlights.

My daughter Kaitlyn turned 15 Friday and to celebrate, Kathy, Rileigh, Dylan and I drove down and spent a very nice extended weekend at Susie and Bruce's. For those who don't know, Susie is my ex-wife and the mother of my 3 oldest children and Bruce is her husband. We wind up spending many weekends at their house where all the kids are together and we have a great time. I suppose it seems weird to most people, but I am really glad we all get along and get to spend so much time together with the kids. So, anyway, Friday we all went out to a pretty good cheeseburger place and followed it up with a barbecue and swimming in their pool. Here are some pictures from this weekend:

Cheeburger-Cheeburger is over-run by our not so little clan:



Johnny STUNS us all by whipping out his card and offering to pay:



Kaitlyn opening presents:



The birthday girl and her mommy. (mommy is the shorter one..hehehehe)



Kaitlyn and Meagan



Kathy and Dylan enjoying the weather



Our little camera-shy monster



One of my favorite pics: Rileigh donning protective glasses to counteract the glare bouncing off the top of my bald head!





Meanwhile, I have scheduled both of the next "big" exams for finishing medical school. I was originally slotted for mid-September, but got lucky and was able to switch to a spot in Chicago on June 10th for my USMLE Step 2 CS exam. This is a practical exam that consists of 12 patient encounters with professional actor patients where we are graded on things like communication skills, clinical examination skills, our ability to formulate a differential diagnosis, and writing a note documenting our findings and ordering the next set of labwork/imaging studies/diagnositic studies etc.. (and yes, there is a whole module dedicated to making patients wait 45 minutes in an uncomfortable paper gown while we sit in an office and surf the internet- in case you were wondering) I finalized my travel and hotel arrangements just a few minutes ago , so we are all set.

Also scheduled is the "written" part of my Step 2 board exam. It is actually computer based, consists of 400 questions, and takes about 9 hours. D-Day is August 10th. Yay!


Peds is going along okay and I will save some material for an upcoming post.... stay tuned.

Dog-gone Stupid

I am convinced that I am in the wrong business.

I took this picture while in a book store last week:




I apologize for the crappy picture, in case you can't read what it says,

Zen Dog

Music and Massage for a Stress-Free Pet

Enlightened Advice for Nurturing a Happy, Healthy Dog

The kit consists of a music CD , a plastic little palm-brush (to facilitate the Massage) and of course a book chock-full of 'Enlightened' advice. All for $12.95 What a bargain!

In case you are interested you can pick up your very own Zen Dog kit here.

From the product Synopsis on the Barnes & Noble site:

"De-stress Your Dog with Music and Touch. Tap into the power of music to calm your dog and learn the art of gentle massage to improve your pal’s mental and physical well-being!"

If I sat around the house all day licking my own balls, could be entertained for all of eternity by chasing my own tail, and was perfectly content to drink water directly from a toilet bowl- what kind of stress could I possibly have?

Im just sayin'.

Blogmnesia

I have been so busy lately, that I have forgotten to post any of my inane ramblings for some time now. My apologies to the 2 of you who read this regularly. Anyway...



After doing only a week of GI, I have started my Pediatrics rotation last week. Apparently there was a major scheduling SNAFU between the hospital and the hallowed halls of my school's clinical affairs office.

:-0

See that? That was my shocked face.

Tentatively, I am scheduled to return to the GI Department at the end of these 6 weeks and finish my rotation there.

As for Pediatrics, so far so good. Because of the scheduling, I am the only medical student on the rotation for the next couple of weeks, which has both pluses and minuses. I suppose this arrangement would be ideal for someone with an interest in Peds as a career, given the "spotlight" of being the only student. For me, I never heard the crying calling to become a Pediatrician; although I'm sure that most of what I learn here will be valuable in my upcoming life as an ER doc.

I have only been here just over a week but I have made some observations.

For instance:

• The stereotype seems to be true- Pediatricians really are Shiny Happy People. I guess working with the Cute and Cuddlies attracts happy people to begin with, and the enviornment seems to keep them happy. I wont make any obvious comparisons here because I don't want to get anyone's scrubs panties in a bunch. ;-)
• Perhaps it is because I am a father, or getting older, or perhaps it is just something that we are all evolutionarily predisposed to, but I really do understand the attraction to treating children exclusively. First, they are all so damn, ..well....cute. Aside from this, they are pound-for-pound the most honest, brave, optimistic, and loveable little creatures you'll ever come across. Not to mention entertaining- nothing will snap you from your "rambling attending daze" than watching a 2 year old sneeze into the (open mouthed) face of her examiner.
  
• The flip side of this coin, of course, is the agony that comes with the territory. When all the medicine in the world won't make a difference; and you are forced to helplessly sit by and watch the light fade from the Cute and Cuddlies as they die. There are fewer things that are sadder than to look into the eyes of a suffering child. It must be like falling in love and having your hear broken for the first time- over, and over, and over again. Fortunately, this doesn't occur as often as it does at the other end of the age spectrum, or there would be considerably less Shiny or Happy to go around.
  
• And finally, this is something I learned long ago, but was recently reminded. There are some people who are so shockingly ill-prepared to be human beings themselves, that the idea of their being entrusted with the life of a helpless child is figuratively and literally, criminal.

Relay For Life

It is that time of year again.

My oldest daughter, Meagan is once again captaining a Relay for Life team and this year has recruited her sister Kaitlyn to share the captaining duties.

For those who do not know, the Relay for Life event is a 24hr walking marathon around the high school's track. At all times someone from each team has someone walking around...and around...and around...and.... More info about the event here.

Last year yours truly made it to the event and despite being extremely sleep deprived, I had a great time. This year I look forward to again walking around aimlessly- a skill I have significantly mastered over the last year!

Last year her team raised $2300.00 $2500.00* for the American Cancer Society and this year they are looking to do the same.

This is where you guys come in.

I don't ask for much on this blog, but this is a worthwhile cause; so if you can find it in your hearts to click on their team's page and make a donation, however small, I would be terribly obliged. Thanks.





*which earned the team the Bronze team title. Thanks for correcting me Meg!

Cinco de Hellmann's

Tody is Cinco de mayo, which is of course, Spanish for, "must do Tequila shots!"

To all my liver-exercising brethern..."Uno mas, por favor"

For those that do not know, my Pediatrics rotation has been delayed by a few weeks; so in the meanwhile ,I was able to secure a spot doing a GI elective. The GI stands for Gastro-Intestinal, if you were wondering.

So far it is a very laid-back rotation. I show up in the afternoon! (9 am actually..although it feels like the afternoon after doing Surgery) I am given a few patients to see and write consults on, I meet with the Fellow and discuss the cases, and he signs off on my consult. No muss. No fuss.

These people (if you will excuse the very obvious pun) have their shit together!

Terrible Twos

We knew it wouldn't last forever.

I am not sure if it is her way of adjusting to her baby brother invading her well-marked space or just the age, but our little princess has officially entered the Monster stage of her development. I hope I live through it.

Over the last couple of weeks Rileigh has taken to letting us know she is "all-finished" eating by launching her plate (behind her head, or across the room, or simply tossing it over the side of her chair) and having it crash down splattering food all about the room. Joy.

We have tried several methods of dealing with this- all with less than effective results:

• A serious look and a stern "NO" in my most intimidating "dad" voice- usually met with the "cute doe-eyed face" and the phrase "I dropped, I dropped" ( as if to blame it all on gravity) This method was modified from the previous one that consisted of me yelling an assortment of expletives- Kathy informed me that this was not going to enrich her development and may only serve to expand her vocabulary- good point.
  
• A brief trial of not yelling at her, but "explaining" that it is not nice to hurl plates of food about also failed miserably. She would usually stare at us intently and nod her head in complete agreement and say, "I know". Still the plates flew.
• Even a little spank on the offending hand was only met with a pitiful confused look and continued aerodynamic testing of our dinner wear.
• My lovely wife even advocated a trial of "ignoring" the dish as it flew past. This plan never got off the ground- the other day Kathy was in the middle of trying to calm down a screaming Dylan while Rileigh was having lunch. I was in the back room reading , when I heard my wife yell in frustration.

Lately we have decided to be more pro-active and employ what I call the "microwave popcorn" approach. This consists of being vigilant during meals and snatching the plate from her whenever the popping eating slows down and there is more than several seconds between bites and she gets that "I'm finished" look in her eyes. So far it has worked pretty well. Until tonight.

Apparently we had let our guard slip down just enough and.... oh look, it's raining rice, corn, peas, and chicken cutlet!



I went back to my stern-face-"NO"-routine and put her in her crib for a brief "time-out". She has recently learned to say, "I'm sorry" and after a few minutes I got her out. I was about to clean up the mess when she walked over and looked down at her handiwork and employed her latest tactic:

Plead ignorance, blame it on someone else, and when all else fails, dazzle them with cuteness.

A Beautiful Tuesday

Today I forced myself to take a break from some incredibly painful phone calls (trying to straighten out some student loan issues) and go for a walk to the playground with Kathy Rileigh and Dylan. The weather has been exceptionally gorgeous lately and it felt great to get outside.

Some pictures from today:

Rileigh taking a break during our walk to hop up on a bench and demand, "Cheeeeeese", which is of course Rileigh for "Father, would you please take a photo of me"



Such a ham!




Rileigh enjoying the swings:






Meanwhile Dylan napped:

Free Hugs...Almost

Came across this video and it made me giggle... a lot.

Kinkos, Eat Your Heart Out!

Today was the last day of my surgery rotation!

At the hospital today we had to "sign-out", a process that involved an oral exam with one of the attending physicians, a review of our case logs, a card where we had the procedures that we performed signed-off and turning in our pagers, keys, evaluation forms etc.

Several of us had our oral exam yesterday and it wasn't as bad as we had heard. Anyway, a few students and I were in the library where I was completing my patient logs (a requirement for school) when fellow student and friend Jersey Pete walked in.

Me: Hey Pete

JP: What are you doing? Oh, patient logs huh.

Me: Do you need any blank ones or are you finished?

JP: Nah, I'm gonna print mine out- I did them in Excel.

Now, for those of you who don't know Jersey Pete: this last sentence was the mental equivalent of hearing Snoop Dogg covering a Puccini aria! Whiskey Tango Foxtrot indeed!

He walked away and headed toward the back of the library toward the printers.

JP is not exactly what I would call, the most" tech-savy" guy I know. As a matter of fact, he was notorious for only checking his email account once a semester or so. Rumor had it that it took his computer that long to log in. And recently when I was at his apartment his "laptop" was the computing equivalent of a rust-eaten 1974 Ford Maverick. He asked me to take a look at it because in his words it was "running a little slow". While the full extent of his computer problems probably deserve their own post, suffice it to say that I half expected to open up the case and find either a small Asian boy with an abacus or a gerbil furiously running on an excercise wheel about to give up the ghost.

Anyway, after a few minutes, Pete returned form the printer area and sat down next to us- but it was no longer the same friend I had met 3 years ago. He was somehow...different- the flicker of light that lived behind his eyes had dimmed ever so slightly- but noticably. He was no longer "good old Jersey Pete".

The pressures of medical school it seems has claimned another victim. Some people turn to violence as in the alleged "CraigsList Killer" and others are so radically transformed that they are barely recognizable as the people they once were. Allow me to explain...

When Pete came back from the printer he wasn't carrying a standard stack of 8x11 printed pages, no this was something alltogther different. When he sat down what he placed on the desk in front of him was thing that Legends are made of. It was a binder, nay , a bound masterpiece that any OCD patient would be proud to call his own. Pete had somehow printed and compiled not only his Patient log, but his Surgery Case Log, his Patient Case Write-Ups, and a List of ALL the cases that were discussed during our "morning report", the hospital's version of grand rounds. Not only this- but each section was separated with neon-brightly colored tabbed dividers and he EVEN INCLUDED A TABLE OF BLOODY CONTENTS on the first page!!! But my meager descriptions fail to do this epic tome justice; so allow me to present:

The Jersey Pete Complete Surgery Rotation Compendium and Reference Manual Vol 1
(Click on the pictures to enlarge)

(drum roll..........)



Notice the glossy polyvinyl cover, and that personal touch of orange highlighter on the spine!



No longer do you have to aimlessly flip pages (all 30 of them) to find what you need! This semi-automatic Table of Contents will guide you there in a jiffy!



Is that 100% Naugahyde© ?



It certainly makes a handsome addition to any bookshelf. A treasure to be cherished for generations!

My fellow students were excited beyond words to be photographed with this Masterpiece:






The Creator and his MASTERPIECE:



Now, to fully understand the transformation that this represents, consider the following facts:

• For 11 of the last 12 weeks, Jersey Pete's lab coat has resembled a Jackson Pollack masterpiece of stains. I often joked- that to find out what the cafeteria has for lunch, I just look at JP's coat. He has had a series of coffee stains so absolutely prominent I thought he would be mistaken for a Holstein cow. The man walked around with a soy sauce stain in the shape of Africa on his sleeve for 3 weeks! I bet that one could culture his lab coat and produce a whole new species of life never before encountered on this planet.
• One morning Pete showed up to rounds late, and without pants- well, to be fair- without SCRUB pants. He decided to "borrow" a pair of white Tyvek pants from someone in the maintenance department and walked around proudly all day in his (see-through) white disposable pants.
• At any given time during our rotation Pete had the equivalent of the entire New York Metropolitan Area Phone Book jammed, stuffed, folded, wedged, and hidden in his various pockets. Every time he tried to pull something out of a pocket, the ensuing eruption resembled a bulimic Pica patient who had been locked in a paper factory.
• Through no fault of his own, for the last month, JP has been living in an apartment with no electricity. An ongoing dispute with his landlord and the electric company has left our poor hero, literally, in the dark. Despite several offers by yours truly to come stay with us, he has been living by candlelight- which makes the above book even more impressive!

Please, don't get me wrong... Pete is an incredibly bright and knowledgeable guy who I would feel safe having treat my family, but to say that a color-coded, Table-of Context-ed, neatly printed and bound complete collection of all pertinent data is a tad "out of character" would be quite the understatement.

Clearly, his were balls that needed to be broken.

Mission accomplished!