Because... yeah

Progress?

Though hopefully enough progress to net me a decent grade on my Internal Medicine oral exam tomorrow.

IM is strange in that I'm learning medicine without really feeling like I'm learning medicine, and then the knowledge manifests itself in strange ways. It's also giving me odd moments of confidence when I get lists of lab values on UWorld before smacking me down by the fact that I'm still getting the wrong answers, just in a more efficient way. So far my most reliable sources of "WRONG" relate to picking antibiotics (there's a frigging billion of them!) and prioritizing diagnostic studies (Ohhhhh, abdominal CT before cholelithocystopancreatoduodenogenography, sucker! Your 'Gold Standard' is not welcome here!)."

I'll explain...

A great deal of time on pathology, pathophys, and USMLE questions was spent on getting a list of lab values, looking up the list of lab values (which are generally provided), figuring out which ones are buggy, separating those out, THEN coming up with a list of differential diagnoses for buggy lab values, THEN coming up with a definitive treatment or test. This understandably takes a lot of time.

Now, due to just random patient follow up in IM, when I see charts of lab values, I'm like "blah blah chloride giant who cares blah blah, hoo-damn that's some high calcium!!"

I'm also learning which abnormal lab values are associated with which chronic conditions and which abnormalities are not *that* abnormal, thus no longer look like such an idiot quite as often when I'm presenting to an attending with "OMG THE PLATELETS ARE 125K!!! GET THE CODE TEAM READY!!"

Which, I suppose, is the point.

Brief advertisement...

If you live in NYC, the Steampunk Haunted House is definitely worth checking out, and it's only ten bucks for students, apparently including medical students.

Sadly, I don't have pictures because they don't allow them, and I'm not affiliated with them in anyway, but dayam. Awesome!

Pause for Fall...

Or in my case, spend 7 hours in Brooklyn Hospital's library OCDing all over your presentation, come home, and hastily tap out a case report on yet another Patient Who Has Everything and Complains About Even More Things.

Oh, and realize that when you spend as much time attached to your computer as I do, even 20 gigs of music isn't enough and your old standbys are starting to wane. Right now, I'm trying to re-stimulate my urge to care by combining Pandora's "Turntabilism and Beat Science" with "Bluegrass Instrumental". Ohhhh yeah. I can be a dorkitron AND sell out at the same time! Take that!

Speaking of music, I finally got out to the Bowery Ballroom on Sunday to see Thursday with Midnight Masses and Some Other Band. Now *that* was an old school show. A mosh pit even I was afraid to venture into, stage diving, crowd surfing, and lead singer sweat spray that got further back into the audience than a show at Sea World. Lest anyone think I'm being irresponsible, doctoring is fully destroying my love of things that are bad for me as I was thinking "I would join in the closer-to-the-stage festivities, but I don't want a fatal brain injury." Plus, I'm pretty certain that at this stage, if I got hit hard enough in the head, USMLE World questions would leak out, and then I'd get busted for violating copyright.

Still freaking awesome though. Thanks Patrick!

ANYway, as I was hitting Stumble around the internet today to give my tired eyes a rest from uh... the computer screen, I found a webcomic near to my dorkly widdle heart, so I figured I'd share its Autumn sentiments with you.

IM starts to near to a close

Oh yeah, I did the whole start ICU thing... er... let's just say I long for the unbridled excitement of the floor.
My day:
Ishie: "So, what brought you into the hospital?"
Intubated patient: "..."
Ishie: "No problem! I'll read your chart!"
Chart: (Unintelligible scribbling)
Ishie: "No wonder everyone whines about my handwriting."

ICU is also revitalizing my desire to fill out a "DNR/DNI/DNfreaking touch me under the following conditions: ___________, ___________ etc etc" notification with detailed, fact-checked data points that have been looked over by a team of doctors and lawyers, notorized, and then forwarded to every hospital in the country plus a bonus copy in my wallet, and heck, possibly tattooed across my back. This is not to discourage or dehumanize anyone, but the amount of unending human tragedy that has come about with the misinterpretation of phrases like "Do everything" is staggering. And trying to interpret pre-condition patient wishes from a host of subjective third party accounts and opinions is about as useful as consulting a magic 8 ball. Just saying.

It's also annoying when the lack of communication leads to very well intentioned family members trying to do everything to respect the wishes of hospitalized party, but the original intentions get lost in the medical mumbo jumbo so you end up with incomplete documentation that allows you to do sort of half a revival.

Bah, but anyway. I've been learning a lot, and with oral and written exams pending as well as my first Halloween in NYC, I'm trying to cram in a whole lot of study and 11th hour case write ups in a very short period of time. Because once a procrastinator, always a.. well, I'll get back to you tomorrow. Except that I won't.

In the meantime, I'm trying to get some semblance of a direction to go career wise. My current struggle is with my unending love affair with pathology and pathology-like subject matter, but then I find myself caught up in the general arguments against pathology (and radiology, but I suck at reading X-rays, and that's apparently important) which is its general stigma of individuals within the profession as maladjusted sociopaths that aren't real doctors. Not that I believe these arguments, but the potential future of having to qualify my job to everyone I come across is annoying. Of course, if I went into Emergency Medicine, Internal Medicine, or Surgery, I would just have to continue my same explanation which is "I am not a nurse. I am not training to become a nurse. No, I'm not planning on going into OB/Gyn. No, not pediatrics either. Because I'm not overtly fond of children. Why not? Because I'm a maladjusted sociopath that's not a real... aw man!"

Also there is the patient contact issue. I like some patients, and I like to help people (at least that's what my personal statement said), but as I've also said, I don't like mean people, and I don't like hurting nice people. My job description as a "seeing patients" doctor would generally involve either sticking needles, catheters, or scalpels in nice people and getting yelled at by mean people (while also sticking needles, catheters, or scalpels in them).

I also like to either see something and diagnose it or have something diagnosed that I can then remove manually. This pretty much limits me to pathology or surgery.

But we'll see. You never know, and I'm still keeping my options open.

In the meantime, since I'm busy writing up three case reports and bleaching the nastiness out of my white coat (I wish I could be hardcore and claim it's blood, sweat and tears, but I think the majority of it is curry sauce and balsamic vinegar), here's a video that's not related to anything, but I thought it was hilarious. Enjoy!

ICU next week

And woo hoo for I dunno, sicker patients?

MICU/CSCU will mark my last three week stint of Internal Medicine, meaning I'm going to need to make sure that I spend some copious downtime learning everything there is to know about... uhhh... medicine. Pathology, here I come. On the long term patient management contact, there seem to be the "Mean/Stupid; sometimes both" patients and the "Nice so I feel bad sticking needles into them or giving them bad news" patients.

Also the whole teaching hospital thing still feels ridiculously strange every time there's a patient with an interesting disease or pathogonomic symptom and then we all wait in line to interview/prod that person. On the one hand, doctors need to learn and having the first case of MS we see either lucked into by drawing the patient or actually being responsible for an MS patient AS a doctor would be bad. On the other hand, it's kind of like a carnival side show for the unfortunate. "Hey, those intermittent neurological symptoms that your husband thinks you're making up sure must suck. Mind if I smack you with a reflex hammer for the sixth time?"

Some of them are pretty cool though. We saw a case of Stevens-Johnson Syndrome, aka "holy crap, those antibiotics made my skin fall off" and the patient who was pretty much letting us do whatever we wanted in the interest of learning. That one fell under the "Nice so I feel bad sticking needles into them or giving them bad news" category. Wasn't my patient though, so I didn't have to do either.

I'm looking forward to ICU. OB/Gyn will be my next rotation, which I've actually heard is very cool despite my general dislike of humans under the age of 2. Not considering it as a specialty or anything, but hey... I get to wear scrubs.

In other news, NYC had about a 2-3 week period of "Wow, what beautiful weather and such a nice change from the unrelenting heat" right into "HOLY HELL, it's cold outside!". I expected a little longer of "long sleeved shirts" rather than hopping right into gloves, two pairs of socks, a sweater, a jacket, and a hat. But that should mean the ice skating rinks open earlier.

Oh, happy early Diwali to my Hindu associates.

Zombie hiatus...

Yes, in the eternity of excitement that *IS* Internal Medicine, I took a minute to find out how kickass Zombieland is after the good part of a day was spent with the roommate scarfing Indian food, costume-shopping, tea-drinking, and Times-Square-smack-talking.

Friday was kind of a crappy day at work, made better by having Daniel come home about 30 minutes after I did and suggest Maria's Happy Hour. Hells yes.

Saturday was shopping day; I have new clothes, shoes, and smiles. Then Saturday night with the Maenad and her fair god of wine at the Slipper Room (hosted by a Sealboy) followed by a wine bar. Good times.

Sunday, hit a travel expo with my mom after taking her to an awesome lunch in Nolita. The distinguishing part of the day after that was trying to zipline while keeping my dress "family friendly". That took some doing, and I'm sure there's some youtube videos showing where I failed.

Now, to undo the debauchery of the weekend!

It would take less time to treat TB than present it

Hi again, I'd have updated before, but uh... well, IM is IM. About 20 minutes of patient contact to 5 hours of lecture, so it doesn't make for interesting reading. "Saw a guy I can't tell you too much about because of confidentiality. Fell asleep during morning report. Rounded and learned about biased studies. Fell asleep during noon conference. Learned about DKA. Went home. Did USMLE World questions. Engaged in either the activities of A: "Going out" or B: "Staying home, drinking a glass of wine, and watching the Big Bang Theory/True Blood."

Rinse, repeat.

But now, I've spent the better part of two days doing exactly what I did in college when I needed to write a paper, which is consult entirely too many references, read them, know the first halves so well that I could reproduce them from memory into machine language, and extensively work up the first part of the presentation/paper before getting bored with the topic, stay up too late, and ram all the conclusions together, which is where the punchline of the study usually is. Thank goodness for abstracts and Mountain Dew.

Pretty much, I want this presentation to go well so I can both avoid boring the living crap out of my colleagues (a tall order after an entire day of lecture) and more to the point, avoid continuing to present the impression that I am completely useless to our chief attending. Thing is, since he makes me nervous, I don't tend to screw up in front of anyone else, but the second I get within shot of this guy, my (on vibrate!) cell phone starts pumping out the MP3 player at full volume with no discernible motivation, I lock myself in or out of conference rooms, and drop things. Oh, do I drop things... papers, pens, stuff out of my pockets while picking up papers and pens, books; I'm just glad I haven't been around him while trying to transport a patient or there'd be someone with a fresh orthopedic consult thanks to me.

Not like I can say I'm having too rough a go of it. I'm still enjoying my life; I'm still enjoying this big wonderful city, and I am absolutely giddy over the notion that it's *actually getting cold*. Maybe I'll regret this come February, but four months of unrelenting un-airconditioned-above kitchen mugginess was enough and I am basking in the fact that last night I got to sleep under that Ikea comforter I bought back in May, rather than relying on ice packs and fans.

What else... the loan checks came in just in time for everyone, though I made the mistake of hauling ass to a nice Wachovia branch (couldn't find one in Brooklyn) while looking scruffy. So naturally this prompted a full jeans-t-shirt take and an evaluation of my check. For reference, this check looks like it was issued by the federal government. It's got freaking heat and fingerprint sensors on it.

"Have you deposited these checks before?"
"No, they were being sent to my father and he deposited them."
"Oh."
"There's no Wachovia branch in Grenada."
"Hmmm..."
"Is there a problem?"
"Well, does this check look different to you than before?"
"Ummm... I didn't see the previous ones, so no."
"Because they look completely different."
"It should be from St. George's University."
"No, it's from University Services LLC." (Oh, my frigging bad)
"Okay."
"When was the last check deposited?"
"One in May; one in December or November or something."
(Pause... she prints something out)
"You see? This is the one from May. It looks completely different."
"I don't know what to tell you. You can call them."

So she takes my driver's license, has a fairly hushed conversation on the phone to which I got hints of "No, she only wants to deposit it". At this point, I'm vaguely wondering if I'm going to have to explain myself to the police for daring to try to deposit a check of greater value than someone of my general appearance would get from a "Check into Cash" place.

All that and she got authorization, but then kindly but firmly tells me she's placing a hold on it until October 6th, which is one day after my rent's due, but whatever. I figure it's just the standard, but apparently the holds are determined by the branch, which meant after determining that I was not the world's most brilliantly stupid villain (I can create perfect heat sensor checks, but then choose to defraud banks by depositing them with no cash back to my verifiable bank account), she still thought I was so suspicious that we needed over a week to make sure I wasn't pretending to be an airline pilot from Pan-Am or something. So I'm gonna throw away those jeans, I think.

Uh oh; what's this? It's lecture time!

Bummer, dude

So a patient we saw a couple weeks ago died. He wasn't my patient or anything, but I did manage to botch his blood draw twice even though he had really awesome veins, and instead of being a whiny jerk about it like some people are on even the first stick when they're in the hospital primarily because they like dilaudid and would like more of it, instead he said it was no problem and asked if I wanted him to kick his family out if they were making me nervous.

Basically, the thing with him is he didn't seem very sick, and he was a nice guy. I mean, he had a lot of troubling symptoms, but he was a healthy guy, not a particularly old guy, and didn't have any risk factors. He didn't smoke, drink heavily, or have unprotected sex with IV drug abusing unimmunized bestiality-specializing prostitutes. He stayed in shape. He just got sick, got short of breath, and died extremely rapidly without much of anything medicine could do for him short of botch his blood draws while he was insisting he didn't have AIDS (he didn't). Weirdly, AIDS would have been a far better diagnosis. Weirdly as well, it was the one all the students were hoping he wouldn't have just before they discovered how much deadlier "idiopathic" is. If this were an episode of House, there'd just be some banter about how "idiopathic" means "f- if we know" and there'd be some miracle diagnosis at the 49 minute mark and this guy would go home to his wife. But, as mentioned, medicine is way more like Scrubs, so everything just carries along normally, and everyone's making jokes, and then they just cap someone in the last five minutes because it's sweeps week.

Weirdly, in this sort of thing, it's just a sort of depressing blip in your day before you go back to being told how unmotivated and incompetent you are before proving your maturity by framing one of your colleague's for stealing the other's reflex hammer. It's the way it goes. But it sucks sometimes.

So I did the whole 5K thing...

And woohoo, definitely a fan. Hooray for breast cancer research and running in Central Park. In celebration, our Heme/Onc lecture today was on breast cancer. I figured running in the 5K should make me exempt, but life isn't fair.

Speaking of life not being fair, this whole sickle cell/HIV combo everyone seems to have is a bitch. I feel genuinely bad for most of my patients, which should inspire me towards going into IM and helping them more, but more, it kind of inspires me to lean toward surgery since IM seems like a lot of playing with medications while watching people die. Not all of them, obviously. Oh, and lectures. Tons and tons and tons of lectures. I'm not knocking lectures, and more of them are clinically relevant than say, memorizing the essential amino acids, but it's SO much lecture. I attend way more lecture in clinicals than I ever did in basic sciences, not that that's saying much. I'm also doing more reading. I've already read enough of Blueprints that I'm searching for other books to buy because I need a more comprehensive coverage.

Oh yeah, the 5K (like I'm going to cover things in order?), over 25,000 people in Central Park. Very difficult to jog through unless you want to risk invoking the karma of pushing down breast cancer survivors, but still awesome, and still snagged a better time than usual for my 5K, helped by the fact that Central Park doesn't have the terminal hill of death that Prospect Park does.

My mom's moved to the city (upper east though; no Brooklyn for her!) so she came out to cheer, and I spent a good portion of the last weekend playing New York to New Jersey and back again Pong. Strangely, the forces of a GPS navigation system seemed hellbent on dumping me in Times Square as many times as possible, in one instance getting me there just in time to be caught in an angry 9/11 conspiracy theory mob. Oh joy. The other time, I just got the unprecedented joy of driving through it on a Friday night, which is surprisingly easier than walking through it.

Uhhh... this weekend, headed for the Jersey Shore with a bunch of H&Ps (History and Physicals) to write and relevant articles to read in the interim. IM is destroying a bit of my weekday hedonistic drives, but it shall not break the weekend!

Sometimes a favor isn't a favor...

Hi again... still here trying not to violate HIPAA or torch my evals.

There's a couple other third year students from another school rotating with us. We had the last two just rotate off and now we just got two more yesterday. I had two patients and didn't really get a chance to get much of a history/physical on one yesterday because rounds started early, so today, since one of the students had no patients and wanted to do something, I asked if she wanted the one I hadn't done much on, since the patient had been really nice yesterday.

The other student enthusiastically agreed, so I talked to my remaining patient, checked the new labs and vitals and got ready to write up my progress note. I wandered by the other patient's room only to hear LOUD profanity carrying from the room as the student tried to get a history from a woman that was cussing the hospital and everything in it up and down.

Whoopsie. It's a testament to other student that she doesn't hate me now. I swear I didn't know!

In related news, I'm still not great at dealing with hostile patients when I actually have to talk to them. In the ED it's easy because you just walk by hastily while looking at a chart because you aren't charged with getting a 40 minute history and several follow ups while the patient screams at you.

On an unrelated note, I've discovered that it's only taken a few short months for me to be completely desensitized to genitals in all forms. I was pretty blasé about them before, but now it's just ridiculous. Fortunately this has taken place at the hospital and not in the subway. As I saw a man wandering naked through the halls dragging his bedclothes, my first thought was "Oh crap; I hope he doesn't trip over his blanket" the second "Oh crap; that means a decline in his mental status" and third "Oh crap; I hope Dr. X doesn't make us list all the differentials for mental status change. Where the frig is my textbook? Rounds start in 15 minutes."

Other things I'm learning as a medical student:
-With a few exceptions, you are In The Way. You will be reminded of this frequently.

-The thrill of the white coat wears off really really fast. At first it's a "I'm gonna be a real doctor!" The next day it's "Oh god, people are calling me doc and expect me to do something". The day after it's, "Hey, I can store all my crap in these pockets!" After about a week, it's "My shoulders are killing me! Why do I have all this crap in my pockets?" Yes, that's right... you can actually shove enough seemingly necessary stuff into your coat to cause permanent orthopedic damage. And Batman does it all with a belt. Git.

-The stethoscope does not grant status. What grants status is being so high on the totem pole that you just miscellaneously grab other people's stethoscopes and use them.

-No matter how much you read, any answer you give is going to be met with rolled eyes and "Oh my god". Lest you think that means not reading, think again.

-During conference room lectures on any floor, there are two temperatures: Balls-Hot and Tomb-Cold. Dress in layers and don't be too proud to grab a blanket out of the storeroom.

-Ramadan affords the opportunity to score free lunch tickets from fellow students; however, caution should be taken when teasing these individuals. Fasting + Getting Pimped = Cranky. Love ya, J ;)

-Noon conference = Resident/student naptime. Do not disturb. Those unable to sleep during noon conference due to a Mountain Dew bolus during lunch can entertain yourselves by taking pictures of your sleeping colleagues and superiors. Just remember to turn the flash off.

-If you forget to bring a 4X4 gauze pad into a patient's room when you do a blood draw or give a shot, the patient WILL bleed from the site of a tiny little needle hole as if you've opened up their aorta with a chainsaw. Sleeves, the bedsheets, or the packaging to the needle are considered poor substitutions for gauze. Crying, praying, swearing, and fleeing the room are also considered unacceptable.

-Protonix, Lactulose, Motrin, and Heparin.

-Kerley B lines are a myth perpetuated by radiologists to see how many medical professionals they can get to claim they see them.

-No, no one actually believes you're allergic to tylenol, toradol, motrin, aspirin, and codeine.

-Know all the system passwords. Know them early.

-Yes, it's exactly like Scrubs. No, it's nothing like House.

Shamelessly stolen...

from someone's facebook comments list, but let's just say it rings pretty true after over a week of morning reports and noon conferences. Also after two years of basic sciences and four years of undergrad.



Enjoy!

Adios ER

Though thanks to being in the same hospital, I still get to see the residents around occasionally; even got a big hug from one I ran into in the stairwell.

The rotation itself was good, though as I mentioned before, I'm looking forward to seeing some of the end diagnoses for the more complicated cases, though half the patients still seem to walk out AMA, which I thought stopped down in the ED. The nice thing with the ED is you're pretty much allowed to do what you're willing and comfortable doing. The staff is pretty chill and I like the overall "ER personality". If you're at a hospital that has it as an additional third year requirement option, I'd definitely recommend it.

Now I'm onto Internal Medicine. It's much more lecture based now, which is both good and bad. Good because it keeps adding in new information, and it's important information, plus it breaks up the day. Bad because I'm still adjusting my schedule around, am chronically underslept, and having a conference right after lunch that involves the lights dimming is making for... difficult concentration, shall we say. But we're already seeing more diagnoses. Also difficult on IM is that due to the morning rounds involving a lot of people, the patients seem to grow frustrated quickly, with one walking out as he was sick of the "crew" and another ordering all "trainees" out of the room immediately.

But we're adjusting.

In other NYC news, it's been muggy and humid and nasty as all get out, which has some promise of relief next week. We had a really sudden storm blow through last night with high gusting winds that apparently took down a bunch of the trees in Central Park. It came through so fast that it went instantly from being nasty hot, then suddenly the wind blew through the windows, knocked everything off the refrigerator, and then started tossing the sign to the falafel stand under us around. Yikes!

But another day in IM tomorrow with bonus lectures, so we'll see how it goes.

Blair Witch Weekend

Another short post because I'm starting Internal Medicine in the precariously near future.

Speaking of precarious, never start hiking at 3 PM in a place called "Roaring Kill" that features a number of side trips the begin with the word "Devil's" lest you end up scrambling up boulders at 6:30 PM, realizing you're about to be in big trouble at 6:35 PM, hastily retracing your steps down the mountain so you can at least be on semi flat trail for when you are stumbling along in the dark using a broken digital camera as your sole source of light, and contemplating whether you're going to have to spend a hungry night sitting in mud while raccoons eat your face.

But we saw a porcupine!

Saturday night... well, I have rarely felt a relief and joy as pure and unadulterated as that which I found when we saw the car in the trailhead parking lot around 10 PM after finding the guest book we'd signed at the beginning of our adventure attached to a tree nearby. By that point, Stephanie's broken digital camera (whose cracked LCD had been shining a bright, trail marker finding light) was dead and my digital camera was out.

Sunday, we atoned for all of that by breezing through Woodstock for some tea and jam (the actual concert site is in Bethel, which was about 90 minutes away) and then went to a Bluegrass festival at the Saugerties lighthouse, which was awesome. Perfect way to celebrate the end of our respective rotations, complete with a bonus swim in the Hudson.

Now, though sad to see ED go, looking forward to the nitty gritty IM. Hopefully the enthusiasm lasts.

I love short notice...

We have our Emergency Medicine test on Friday, and got 4 of the 11 powerpoint lectures for it today, so that'll be some fun fast studying. Didn't get *any* of them until about two weeks ago, and it's like urgggh. One, would have liked to have more run time up to the test, but two, a lot of the stuff would have been useful for ER, specifically on splinting and wound management.

But no more EM as of Friday after the test, which is sad in a way, but I'm also looking forward to starting Internal Medicine, since that's the sort of bread and butter of things. It also might give me a shot at getting my schedule semi normal!

More info later; busy week.