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: