Literalism

For those of you who've read this blog for a while, you may have noticed a sort of hyperbole and psychotic flowery quality to my language.  I'm also a bit of a philosophical hedonist, if you haven't picked up on that.

This is by no means limited to the written word and is actually quite a bit worse in person since I can't backspace over terrible things and it's how I both entertain myself and cope with stressful situations.  Also why it's great to be in a profession populated by people who can handle me.

I'm telling you this to tell you about a birthday present.  Several months ago, I was wine tasting with my roommate and her boyfriend in one of those cute types of shops with wine and wine accessories and lots of sort of expensive things that allow you to say "I enjoy drinking".  And I do.  My roommate is a type that tailors things to herself and her interests quite well and brings it all together in a way that is fashionable, individual, and fun.  This is less how I roll.  So when we got on the topic of wine glasses, I said something along the lines of "I'd love to have a wine glass that really says *me* all over it, but they don't make them with naked werewolves on them", then promptly forgot the comment.

Flash forward:

Speechless.  I mean.  It's a wine glass of shirtless Alcides.  No one else on earth has a wine glass of shirtless Alcides.  She and her boyfriend conspired to create something so perfect for me that if I left it in a cafe in Bali, weeks later I would get an email saying "We found your glass."  If archeologists dig this glass up in a thousand years, they will be able to perfectly derive everything about my personality from this single artifact.  They'll probably even be able to guess that I was a pathologist.

This brings me to a few conclusions.  One, the idea that all my glib comments can be brought to life is both wonderous and terrifying, because while it does mean I will indeed die as I am buried alive under a mountain of double chocolate porter, Butter Lane cupcakes and shirtless dudes, it *also* means that a seven foot palmetto bug will, at some point, pin me against a wall and take my purse.

Other conclusions... I have heard a lot of roommate bitching from the masses since living alone is something only the 1% can continue to do, but I have been blessed by the great roommate god on high because I have lucked out every single frigging time.

Grenada:  First roommate, from the islands, shows me around, makes kingfish curry, is generally cool despite me living in a phobia clad sleep deprived geek cloud.
Prague:  Find roommate from lower term off facebook within about 24 hours.  Wind up with roommate who makes coffee every morning and saves it for me and who speaks (and is) Russian so can translate.  Also introduces me to Hoegaarden, because she wasn't being great enough.
New York:  I live with the cooking, cleaning, decorating oracle of party finding awesomeness and spend two years in a cloud of burlesque and happy hours.  Started learning about fashion.
Fire house: two roommates.  One can cook everything from scratch and is eager to teach the same.  The other is a die hard Star Wars aficionado with an awesome dog who finds chicken and waffle diners and likes to have bonfires in the back yard and play Mario Kart.
Current house: Makes me wine glasses with naked werewolves on them.

I'm holding out that my fellowship roommate will carry me on his/her shoulders at all times while making horsey noises, but that could be asking a bit much.

The holiday tweener

I'm not a huge Thanksgiving person.  I think it's because I like neither turkey or pilgrims a whole lot.  I generally only whine about Christmas stuff before Thanksgiving because that's about the level of Jingle Bells I can take without shooting mall Santas.

So roomie and I found ourself in the odd predicament of having our apartment fully decked out for Halloween, but then she and I are taking turns leaving through November, and her boyfriend (re: manual labor) was visiting last weekend, so for practicality's sake, we took down the vampires and tombstones and bloodstained "help" messages on the mirrors and replaced them with a fake Christmas tree, glowing lit up presents, and santas.

I'm oddly okay with it.  As long as there's no music.  It's an odd nostalgia.  I know I said I wouldn't talk about the fire anymore (mentirosa!!), but this was post fire.  I've mentioned before that due to the loving embrace of my colleagues and friends, it took at least a week for the whole business to even sink in, and this is part of why.  I got back home, I believe on the 29th, and new roomie picked me up from the airport and I moved straight in with her.  When I got to her house, not only did I have unexpected furniture, unexpected linens, and unexpected scrubs, but my new abode was completely decked out for Christmas, and these are all the same decorations that greeted me when I first arrived.

So I'm degrinched... but one too many Jingle Bells, and I'll snap.

Speaking of holiday stuff, I carved this pumpkin, and while likely inebriated, sent a picture of it to Poe's Tavern with the message "You make good burgers so I made you a pumpkin", not realizing they have an annual Poe themed pumpkin carving contest which I would have been able to enter had I waited until Thursday.  Ah well.

Halloween was on a Wednesday mid surgical pathology this year, so I did my festivities on Saturday, which included a joint work party/Skinful festival.  I was initially worried my costume was going to be inappropriate for the first, but arrived to the new chief's house to find the entire dining room done up as Dexter's kill room complete with a plastic wrapped blow up doll and her husband, convincingly dressed in the apron and holding a butcher knife, so I worried less about being family friendly.

I was initially going to go as one of four birds, others represented were a flamingo, a peacock, and a bjork-swan, and I had the brilliant plan of being a parrot with a pirate strapped to my shoulder, but upon further evaluation, since I can't sew, this plan was looking at costing me over 200 dollars, but this get up:

was 40.  I am so very cheap.

I got my fall cooking on.  I discovered how to make pumpkin cheesecake, which is the best trick ever, and then followed it up with some pork and squash and a pumpkin risotto.

October was also breast cancer awareness month, otherwise known as "the worst month to be on surgical pathology".  It also was "surgical chiefs go out of town leaving their underlings to attempt horrendous resections that involve five thousand frozens for no specific reason.  But I'm still getting a better hang of it from last year.  I'm starting to get comfortable with my own language on reports rather than desperately grasping for others over the course of hours "how do I phrase 'benign skin and granulation tissue with hemorrhage, acute inflammation, and edema'??"  I'm getting the hang of our very own Halloween trick, the introduction of a new and likely evil computer system, and the rest of it.  I finally found the answer to the question "what if a biopsy shows cancer, and you take the specimen, and you can't find any cancer, but you also can't find the clip or biopsy changes?"  The answer is "first, take all the wax filled cassettes you've put samples into and x-ray all of them at a less-than-thrilled cancer center.  Then, when you can't find it, take the formalin soaked remainder of the specimen, in small color coded pieces back to the even less thrilled cancer center, take countless x-rays of that until you find a clip the size of the head of a pin, and then resample that.

Oh, making friends.  And apparently when we're on surgical pathology, our specimens and us have such a combined aroma that we can be detected through the funk we leave on *other* people's clothing.  I've personally gotten so used to formalin that I don't really perceive the smell unless it's up against my face making my eyes water (it burns!!!) and a vague sense of hunger since it has that disturbing side effect, so no early med students, being hungry after anatomy lab does not make you a cannibal.

Still, clinical chemistry this month is providing a nice break and one that allows me to defect up to Virginia for a hiking trip for my birthday since Christmas will be at the beck and call of my pager.  I'm then going to turn around and go back for that Thanksgiving day and hopefully con some fondue out of the situation because blah, turkey.

Clinical chemistry involves relearning some chem, which is always a treat for me, but my daily activities consist of answering calls, mostly that involve mislabeling or not labeling specimens and I get the daily sob story for why I should allow blood that I don't know came from the patient to be assigned for the patient, and I get to read electrophoresis gels and calculate hemoglobin percentages to catch various hemoglobinopathies (sickle cell, thalassemia, SC disease, etc).  The gels are for a lot of things, but mostly I'm trying to find bands that could correspond with multiple myeloma or any other monoclonal blood cell proliferation that isn't supposed to be there.  It involves peering at a light board and interpreting a wavy graph and tables and then writing a series of important looking codes while signing it all illegibly with my doctor scrawl signature, so it feels very professional.

My lecture attendance is getting better; always a plus, despite having a series of 28 Days Later dread dreams where un-fun zombies chased me through the New York City subway system while killing all my friends.  I'm not exactly sure who did what to my subconscious, but it gets temperamental this way.  It's that thing where you show up at work either mad at your friends for dream-slights or panicked for your friends because you had a dream where they were standing drunk in a black evening dress and then they fell down the stairs and twisted their head all the way around like in Death Becomes Her.  Thanks brain, you sick freak.

I do love October

It's such a great month, that awesome combination of spookiness, good weather, fall, cooking stuff with pumpkin and cinnamon in it.  That's why I skipped blogging in September, you see, just because why?  It's not October, so I kept you on edge.  That, plus I'm lazy.  And was busy while work itself was not blog-interesting.

I'm making a pizza right now, because apparently that's something I can do now.  Mad props to my current roommate, my past two roommates, and the Smitten Kitchen for getting me beyond the scrambled eggs, steak, and ramen stage of my life.  So last effort with the pizza stone was this:

Not bad, eh?

What's awesome about both having a roommate and being an adult and no longer having all your stuff in a flaming pile is you start to accumulate kitchen stuff.  So today, making a pizza consists of throwing the ingredients together that I already have (including honey and white wine) rather than running out and spending more on ingredients than it would have cost to order a pizza.

This is also an awesome effect with the liquor cabinet.  As you gradually accumulate different kinds, you can start making impressive swanky cocktails and improvising new ones.  But it takes time to build without noticing, and once you get there, you feel awesome about it.

Or maybe I do.  I don't live places long.

Reminding me, since I mentioned the fire (when don't I), September brought about the last chapter in you or I ever having to hear about it again, and let me be the first to say "At fucking last" because good lord.

So here's that story.  Right after I returned from the conference (more on that in a bit), I'm back at work for like... three days, when I get a phone call that evening, a missed call from 3 PM that afternoon.  It was the victim's advocate saying the sentencing hearing that would be at 1:30 PM the next day (less than 24 hours notice), and oh, they wouldn't be seeking restitution because the "defense wouldn't go for it."

A long time ago on this blog, I described completely losing my shit and it was in Grenada at Air Jamaica on day 10 or something of aggressively denying me my bags when my loans simultaneously hadn't processed so I had no belongings and no money, so I finally just starting banging my fist on the ticket counter like Nikita frikking Khrushchev until they got tired enough of my yelling that I followed them back into security.  (Cautionary note: Do not do this at American airports for any reason.  You'll get tazed.)  So that's me flipping out.  It's pretty uncommon.  That may have been the last time it happened.  Now I've been overemotional and cried and self destructed and been bitchy, that's normal course.  But unleashing rage?  I hate confrontation.

So yeah, I flipped out.  Since it was after hours at the solicitor's office, I left a pretty choice voicemail, got home rage-addled and sent the advocate an email, cc'd to the solicitor (our DA), etc that was about two pages of my rights, and having to deal with this constantly, and make their case for them and I was tired of it.  That I have student loans and if I call their offices and say the "defense won't go for it", they won't just wipe my records clean and asked them why a convicted felon gets more rights than anyone with a car payment.  That sort of thing.  My big thing was that I haven't gotten anyone associated with the state or with this perp or his family appearing to give half a crap about any of this, and it's galling.

The solicitor responded with wanting to meet with me a half hour before, which kind of ignored my "short notice" point, but whatever.  I spent that morning with one of my seniors aggressively researching victims rights laws and trial stuff in South Carolina, which renewed my hatred of law which is both confusing and tedious.  I never understand "Doctor or lawyer?" versus "Doctor or biological scientist" since they're really different professions.

So I head to the hearing again with an armful of manilla folders full of printed stuff and a bad attitude, and so they spend a half hour talking me down.  Say they can't force the kid to work in prison, but they can make restitution a condition of his parole.  So essentially, once he's out, if he's not actively seeking (legal) work to help pay back his debts, it's a parole violation and he gets thrown back in jail.  And I'm like "Uh yeah, that's all I asked for."

So we wait for another hearing... the LAST hearing.  At first there's some like "Oh, they may postpone it again" which pissed me off again.  But then I overhear the family's attorney saying that they have the "nice judge".  I'm like "Not the nice judge!!  Give them the judge me that gave me the speeding ticket 2 weeks after the fire.  The mean judge."

We get in, same stuff... I have the opportunity to speak first, and choke/chicken, so the only other victim to show up goes first, thank goodness.  The girl that helped me research the law stuff kept saying "No crying, no cursing, no gesticulating", so I kept reciting in my head as the closest thing I get to a prayer.

I'm introduced as "Ms. Sancho" so we're off to a super start, though the victim's advocate corrected and stood up and said "This is DOCTOR Sancho" and I'm like "That's right."  I usually don't play the D card, but this is the occasion.

So my voice shakes a little, but then I speak a bit, and I'm already charged up by the night's crap.  I talk about my stethoscope, my car, my pictures, the dog, the dead cat.  I talk about medical textbooks.  I say I've heard neither a "sorry" or a "guilty" but have to come back again and again to hear the mother wail about what a good boy he is, but that he's not.  That he's demonstrated no regret or remorse whatsoever through any of his actions, without a care for people's rights or property.

The whole time the judge is looking at me and nodding sympathetically, which helped.  It felt empowering.  She asked me if I thought our lives would have been in danger if we'd been home and I tell her absolutely yes.  That boy-roomie might have gotten out by being on the first floor but that the two girls were on the rooms off the porch and the porch caught first.  That I came back to Houston with nothing but my bags.

I think my statement made the kid's mom cry, and I can't lie; I'm kinda proud of that.  Needless to say, she didn't stand up to give the "my boy's a good boy" talk for the thousandth time.  The father stood up and said "First off, I'm sorry" to me.  Which he derailed after that about fighting for his son, and accidents and bad kids and being the fall guy, but I was like "first time anyone has apologized to me since all this started."  After this statement, the solicitor merely says that the reason the boy is "taking the fall" is because he was bragging about it all at school.  How he did it.  So much for "accident".

At that point the judge starts talking and she is not happy.  The VA leans over to me and says "The judge lives downtown".  Downtown Charleston, for what it's worth, is exquisitely flammable.  All the houses are made of heartwood pine and crammed together.  And a few years ago, there was a massive factory fire that killed a bunch of people.  So the "oops, didn't mean it" factor found *no* love.  She kept on about how lucky the defendant was that people weren't killed because he'd be tried as an adult and no one would even think about seeing him before he turned 40, and that the only reason people weren't killed was luck.  So max sentencing.  With restitution assigned on release.  No recommended camps for troubled boys or the like.

So that's it.  We won.  No more last minute hearings.  No more delays.  No more "re-victimization" as the solicitor was putting it as I kept saying I just wanted to get on with my life.  This kid got what he deserved and I even got a half assed apology out of someone related to it.

I've never felt so relieved.  I went back to work on a song, hypercharged with the conclusion of it all and went out to have oyster shooters (my first!) with some celebrants.  I cannot say how good it is, after NINE MONTHS to have this all behind me.

I'm even starting to work on a future apartment, maybe fellowship, by having handy roommate teach me how to redo furniture from craigslist and garage sales and such.  So that in the future, I can really build a home.  I also now have renters insurance along with my (now cheaper) car insurance.

Good times.

This is getting long.  And I haven't started on San Diego.  But no more fire drama right?  Hooray!!!

All right, the conference was awesome.  Naturally, we engaged in scholarly studies for the entire five days so didn't really do much outside of mingle.

 

Well, I mean you have to have some fun, right?  The conference itself was good.  I went to some awesome hematopathology lectures, schmoozed a bit with future fellowship programs, and though people weren't really much stopping for my poster, I felt like it looked really good and like we did a good job, so that was great.

The hotel was gorgeous.  The Grand Hyatt is the one that dominates a great deal of the classic San Diego skyline, and the rooms were jawdropping.  I split one with two other colleagues.

The day I got there, one of my other colleagues and my attending were already there, so we registered, grabbed lunch, and headed to a brewery on Coronado Island via ferry.  The brewery was just aiight but great view, great time.  Met up with the girls as they arrived and went barhopping through the gaslamp district.  The next day, there was a big resident mingling thing, but a friend from my school was in town, so we headed out to the beach and drank in a bunch of the Pacific.  That night our attending took a huge crowd of us (including med school friend) out to a fancy pants restaurant where I stuffed myself full of good wine and scallops because life is good.  We hit a rooftop soon after.

Sunday was quite scholarly.  I had my poster in the mid morning-afternoon session so I hit a pretty solid peripheral blood smear conference in the morning.  There was a good bone marrow lecture on in the afternoon post-poster.  I was craving good Mexican food because I haven't had any in at least five years, so yelp helped me find a decent dive with amazing burritos so we hit it for lunch on Monday between conferences.  Tuesday, we hit a morning conference and a couple of us headed for the zoo, because come on, it's San Diego.  Apparently not only can you drink around the zoo, but they have microbrews because California is awesome.  Californian microbrews usually aren't awesome, but these weren't local.  Sorry Cali; your wine's still good.  At some point we ended up back on Coronado Island having strangely authentic NYC pizza despite looking like "Sbarros by the sea" but apparently they import their water.  Hooray snobbiness!

Wednesday was check out, so the entire trip was just a funly educational whirlwind, but what a great time.  Gotta do the conference thing more often.

What else?  I'm back on surgical pathology.  This may be where some of you recall my having a nervous breakdown last year and contemplating quitting everything because I felt unbelievably stupid.

I feel much more confident this time around, which is fortunate, because we've had a whole new software implemented to control everything and it is working *terribly*.  It's eliminating all of our paperwork, so now slides are going to the wrong people, slides are coming out super late, we're having to stalk specimens, and getting reports dropped.  So the last week has been hideous, busy, and stressful, but now that it's do to external sources than my own crushing insecurity, I feel okay with myself and my lot.  I'm getting interested in my specimens now that I understand more about them and feel like I might be a good pathologist.  Which is a great feeling.  We'll see if that dissolves into existential angst in the next couple of weeks.  Heh.

Well, welcome back readers.  Hope you're having an amazing October. :)

I'm not quite dead...

That's a topic I've undoubtedly used before, but despite buying an Autopsy Scully action figure *and* inexplicably watching episodes of My Little Pony: Friendship is Magic, I need the nerd street cred that quoting Monty Python affords me.

Why haven't I blogged?  July was full of autopsy, so again, full of mystery, intrigue, but I can't share any of them with you because nyah nyah, I know something you don't.

Seriously though guys... don't wear ironic t-shirts if you're about to embark on something stupid and dangerous.  The emotion between "that's tragic" and "that's hilarious" is like "smelling purple" or "hearing cinnamon" and it's uncomfortable to experience since they don't let us drop acid.  On the plus side, if hell exists, I'm reserved for the VIP lounge.

August has just been full.  I've been on blood bank, which is usually a good opportunity to catch up on back projects and read webcomics, but it's decided to envy autopsy's weirdness and just stepped up the game this month so I've been putting out fires every day.

Speaking of which... if you're not actively in surgery, and I page you, call me the frick back.  I went to medical school, I have your status, and I'm getting ticked.  If I need to clear something with you, and I need your authorization, you have made me a servant to my phone, requiring me to ask someone to babysit it if I use the restroom, and makes me paranoid about having to use it to call the other four clinicians that are ignoring me later.

So because I'm a bastard, I tuck in my heels.  Here's the story, ladies.  If you need authorization that requires special attention, your patient isn't actively bleeding to death, and you need product, and you haven't called me back yet to explain WHY you need product despite your patient's numbers being adequate, NO.  I don't care how many times your nurses have called in the order to the blood bank despite providing no further information, the answer is no.  Now, you can repeat page other residents into relenting because they're sick of getting paged for authorization, but I'm not one of them.  Oh yeah, and I will *keep* paging you.  And I'll call the department you're in, talk to your staff, and confirm whether you're in the OR.  And depending on the rarity of the order, I may speakerphone you in there.  And if you're not in the OR, NO.

Usually, the matter can be cleared up in under three minutes.  "Oh, you want the platelets above 100 before you discharge the pati... NO."  "Oh, the patient is going in for neurosurgery today?  Useful information, fellow doctor!  Absolutely yes!  Wouldn't that have been easier to tell me three hours ago?  Because you know giving people useless blood products causes them to develop antibodies that make them hard to transfuse later right?  And although rare, transfusions expose them to infectious disease risk?  Which is why we're being obnoxious about this?  You didn't??  Wow, guess you should have called me back.  I'm full of useful information.  Ask me about how useless it is to dump platelets into uremic patients.  Addendum, I'm not authorizing more platelets for your uremic patient.  Dialysis is your friend."

Addendum in chemistry:  If you call me at two in the morning because you don't want to retake a patient's blood sample, and you got a specimen kicked back because it has the wrong label on the tube in a bag with the right labels, ABSOLUTELY NO.  For two reasons: One- the petulant, I can't believe you're waking me up with this.  Two- the 'this is my patient too', new studies have shown that 30% of relabeled specimens do not match the DNA of the patient you super pinky best friend swore to me is the right patient.

And so help me, if I found out you restuck them after saying "Sorry we have to do this: Pathology lost the specimen", I will hunt you down and make you spectate a decomp autopsy.  And there ain't no Vicks up in our house.

So that's the fun work stuff... now some play...

A few weeks back, our knowledge of meteorology and sailing were both tested heavily.  As Roommate, Friend We Drag Into This Weekly, and I were having a pretty solid run around the harbor, we saw two other hobie cats hauling ass back towards us, and more critically, to the launch site.  This would be a clue to most people but we were like "Hmm.  Curious."

A quick word about our launch site.  Despite our miles of beaches around here, we can only find one rocky, heavy ship traffic site where we're allowed to launch for less than 2000 dollars a year (literal number).  This site is extremely susceptible to tides so we are in a perpetual balance between "three girls drag the boat and trailer over a hundred yards of beach" to having just the dirt parking lot, rocks, and *no beach*.  At the time all this was going down, we were at *no beach".  Our plan, since we got out late, was to wait out the tide, and head back with a nice strip of beach but not a long one.  Brilliant, right?  Work smart, not hard.

Unfortunately, as we obliviously sailed onward that day, we saw lightning streak down over the city.  And then another.  And another.

"Rut roh," we thought calmly, realizing we were now the sole 20 foot lightning rod in the middle of angry seas, as we spun the boat around and ran screaming back to shore with the ever increasing wind coming up.  Since the wind was now gusting, we had to continuously kill our momentum to prevent "pitch poling", which is a cute name for what happens when the front of your boat starts to dip down and then that's the last thing you see before being catapulted at launch speed into your mast like Wile E. Coyote.  Not good.

We get to the rocks and since we do not want to punch a hole in our boat (as the people did the week before), we are attempting to drop the sails in the water before we get it on the trailer on the back of the car because it is one hundred percent possible to capsize on land.  And so while "Why did I sign up for this?" girl is desperately holding onto the front of the boat while simultaneously getting beaten up by it and the ocean, Roomie is running to bring the car, and I am clinging to the trampoline (the 'deck' of a catamaran) mid motion sick trying to yank down the sails.  A few other guys who were in line to get out of the water helped us and we were able to push the boat onto the trailer after a near catastrophe, pull it out, and drop the mast about 10 minutes before the storm hit us.

We kind of skulked home broken and drank beer.  Sailor fail.

So that was that.  I decided to take a break from near death weekend leisure so spent the next two weekends traveling.

First stop, final farewell to one of my closest friends up in Charlotte as she departs Americaland for the great uncharted northern region known to some as "French Canada (is the best Canada)".  She gave me many things, among which was a collection of X-Files DVDs (woot!), a Jagger shirt, and the chair for my fabulous new Ikea desk, since Charlotte contains that sweet sweet piece of Swedish ingenuity that Charleston still lacks.  And Waffle House breakfast because it's the cure for beer all night.

Took a two day vacay from blood bank over the next weekend and headed back up to NYC for an impromptu class reunion, and got to stay with my wonderful NY-roommate.

While there, I had a rather odd request.  You see after that way back fire, everyone really came together for me, but one attending in particular totally blew my mind.  This attending also comes through for everyone, to extremes.  You become afraid to ask him for help because if you accidentally page him at home (which he's never at home), if you ask him to look at something with you casually, he will drive to the hospital and help you until you're helped.  He's that guy.

So tech and I were trying to figure out to do for this man since it's impossible to give him anything because he'll give it away.  He likes a textbook that happened to be written by a man who is still alive and practices at Bellevue.  Which is coincidentally, about three blocks away from my favorite Indian restaurant.

So roomie and I, and roomie has never met this attending, navigate the... interesting corridors that comprise Bellevue's emergency room as I clutch my book to get signed.

Lemme tell you... it's a close call, but I think dodging a "Code Brown" to ask a physician for a picture and autograph may even be geekier than the time I asked Mitch Pileggi to hug me, but it's a close call.

The author was an exceptionally good sport, and we put a chuck on a flat surface so he could sign the book without getting it coated in partially dried blood.

The follow up to this was on Monday, I also smuggled back some Russ and Daughters bagels since this guy likes NY bagels/pizza (who doesn't??) too.  I like to multitask my vacations.

The rest of the weekend, which included a trip to the Jersey shore (not that one) to see even more friends from NY years was kind of an indulgent blur of massive quantities of excellent wine, excellent food, excellent entertainment, half a glass of gin spilled over the top of my head, and about ten seconds where I thought a burlesque dancer's albino burmese python (not a euphemism) was going to bite me in the face.

Me: "Gods, I need to wash up before I go to bed."
Roomie: "Do you?  You still look fine."
Me: "I have simple syrup in my hair."

But we got this sunset!!

So yes.  Need to get up to NYC more often.

Speaking of travel, I'm also heading to San Diego in the near future, which is a work thing, but come on, San Diego.  And airfare/hotel covered.  I'll take more pictures there.  I've been terrible about photos lately, and managed to escape from NYC with two.  Literally.

What else.  Another fire update!  This freaking thing has more parts than the USMLE, and the USMLE is 2.5 steps too long.

Anooother call with little notice from the victim's advocate office!  And it'd be super helpful for me to be there!  So more time off work!  And boy-roomie would be coming, and he totally didn't!  So I got to sit for an hour hoping he would!  And then got to go into court again and talk about how much it sucked which totally makes it hard to *move on* despite it having been months!  And his brother (who was involved but they can't prove it) smirked at me the whole time I was talking!  And he pleaded no contest which means "I'm guilty but I'm not going to say it!" followed by his mom standing up and talking about how he's a good boy who fell in with the wrong crowd, and (drumroll) learned his lesson!  This boy's lesson is so unlearned he won't even say the word "guilty" or "I'm sorry" or "I'm a terrible human being that is going to wound up doubtlessly being shot by someone in self defense" but he's certainly learned it!  So his mom's asking for leniency!

Now I'm not certain what the actual leniency could be because there's another sentencing hearing (which it would be super helpful if I showed up for!) 45 more days after that.

I feel like I'm trapped in a Mystery Science Theater 3000 episode screaming "End.  End!  END!!!!!" at the screen.  I want this boy to be punished strongly, particularly since he's an unrepentant, life-endangering, cat murdering repeat offender, but I'd also like to never hear about him or the fire ever again.  I pretty much never thought about it these days and then that popped up and now it's not that it's dragging me down, it's just always on my mind again.  I get telling me what's happening because I have a right to know, but why is my input needed every other month and why always with like a week's notice maybe?  I was never asked for a formal "please read this in court" victim's statement though I am now still being asked for faxed copies of GAP insurance payoffs and such for restitution which should be to my insurance company (the uninsured stuff was what he owes *me*) which even so, they keep assuring me "I probably won't see that money", which I know well, so why are you asking me for anything and dredging this up again?  Go away.  Do your job.  Make that boy print license plates and quietly deposit the money split among all the victims for the next 300 years.  Or don't.  I don't care.

I super duper hate the term "victim's responsibilities".  Remember in school or the military or whatever and some kid was screwing off, and *everyone* got punished for it?  Fifty push ups, pop quiz, whatever?  Now imagine that guy punched you in the face... but then you still had to do fifty push ups.  And only you.  The rest of the class watches and talks about how you should have ducked faster.  It's like that.

Ugh, but that shit's depressing.  Let's talk about something else.

Ooh!  I made this tonight:

There's this awesome trend lately... I'm not sure if it's a local southern thing or a nationwide thing, but you go to a studio with an appetizer and a bottle of wine and they teach you how to paint something while you drink wine and giggle about not knowing how to paint.  You get to wear the apron and everything.  The results tend to be pretty cool.  Roomie did an octopus and I fell in love with the Burton style adaptation of the Sullivan's Island Lighthouse so went with a colleague, had an amazing time, and will go back again and again, possibly sans the amped up girl next to me that kept nudging my painting arm and saying "A girl's half inch ain't a guy's half inch, amiright????"  Oh, it never gets old!

But Pinot Noir and I made the chocolate boozy cupcakes again because I am a one trick pony.

Amiright?

NO MORE USMLE EVER

There are not enough emoticons, anigifs, or any other advanced mid 90s technology sufficient to express the joy I field.

Oh, I'll do the path thing.  How many points did you drop?  I dropped 22!!  LOL!  I dropped 30!  So I dropped quite a bit but within a safe margin, considering my study strategy only got going during the end.

So fare thee well clinical medicine.  Nice knowing you.  I may see you sometime in the future when someone goes "IS THERE A DOCTOR ON THIS PLANE??!!!!" and I turn my headphones up cuz NOT MY JOB babies!

Noooooo more step.  Gods, half the stress of the whole process revolves around those bloody tests.  And now all my tests will be path.

Wait... all my tests will be path????  Oh god, to the textbooks!!!!

I no longer have my "intern" excuse

For I now rank among the second year residents.

This is a bit of a mixed bag.  I don't feel completely "NO MORE INTERN YEAR!!!" because we're relatively unabused pathology residents and I've been on clinical pathology rotations for the past few months so I've been particularly unabused.

We had a couple parties today: one a path party at one of our seniors' houses to celebrate the new residents/fellows and say bye to the remaining ones, and the other was the same awesome mixer at the marina, which we showed up at the end.  We made friends with two fellow SGU grads (one med; one vet) and upon leaving they were like "You're path people!  Why are you bailing at 9 PM?" and we had to very honestly say "We have to get up early tomorrow.  We're going sailing."

Yeah.  Hard times.

Because of the ACGME (residency police) regulations set in place last year, first year pathology residents don't tend to take any call.  Essentially, they made it so that newbies would no longer work 24 hour shifts, which is critical when you're a surgery resident trying to not develop a meth habit, but less critical when your call consists of going home and maybe answering your phone a few times.  What does this mean?  It means welcome to taking call, mofo.  I drew the straw of being the first resident on Anatomic Pathology call this year, so Monday to Monday, I'm the late night frozen section and weekend/4th of July autopsy girl.  It's mildly intimidating, but we have a decent support network.  I will at this point reiterate the advice of "try to avoid going to teaching hospitals as a patient the first week of July".

I will be back on autopsy next month, which critically means getting to wear nice breezy scrubs instead of people clothes during the 100 degree month, which, hooray.

Last few weeks... hmm... due to Step 3 and my Journal Club and my CP talk melting my brain, I had forgotten that as part of my last month's rotation in molecular pathology, I had to give a talk at what they call the Big Meeting.

So about ten days before that, our attending mentions it offhand, and I'm like "Uh oh", and casually ask him to *remind* me how long this thing is supposed to be.  Apparently like 20 minutes.  The two talks a year that we spend weeks preparing for is 30 minutes.  I spend 8 hours at the hospital over 5 minutes.  So I'm like "No problem!  (AHHH)"

A short time after that, at our afternoon meeting about Extremely Difficult Things, he's like "Oh, apparently I have to go to a meeting at 5 to discuss a new machine with the heme onc docs.  Wanna come?" and I'm like "N... sure!" because I am spineless enough to barely qualify as a vertebrate.

This impromptu meeting turned out to be incredibly cool.  It was all new technology-esque with abilities to sequence hundreds of genes for the same cost as five, and then they were getting into interpretation and marketing and it was all very Future of Medicine like and I got super excited about it.  Unfortunately for me.

I expressed my enthusiasm to my attending and he thought it was great and suggested I present it as my topic at the Big Meeting since the techs would love getting a look at a machine that might be implemented over the next year or so.  I wholeheartedly agreed.  Heck, half the work had been done for me and it all seemed really cool anyway.

Holy crap.  This stuff is HARD.  The difference between briefly explaining the implications of a new technology to doctors that don't work with it and explaining how the machine that uses it works when you don't even know is just wow...

Even the company website was taunting me.  "It's simple!  It works just like any other microchip!"

OH DOES IT REALLY?  Dude, I still think my iPhone runs on elf blood.

Wikipedia took an absolute beating.  "The technology uses next generation PCR".  (sigh)  Wiki.  "next generation PCR."  (sigh)  Wiki "DNA beads".  Wiki "Emulsion PCR"  Wiki. "PCR".  Wiki "DNA Sequencing".  Wiki "DNA".

"The DNA beads are then loaded onto the chip, which is made out of a silicon boule."

(sigh)  Wiki.  "Boule".

The whole thing gradually built into this mental house of cards on which my entire understanding of this technology rested.  I was thinking so hard that I felt like I was working out.  When roommate's boyfriend came home, I was squint-glaring at my computer screen and wouldn't greet him because I was afraid the fragile base of my knowledge would crumble into dust if I deviated my glance for a second.

So the presentation comes, and I was told the meeting was very casual and no big deal, which is what is colloquially referred to as a complete lie.  Fellow resident and I actually showed up at the wrong conference room because we thought it would be our three attendings and a couple lab people and some sandwiches, and everyone would probably be eating and doze.

Wrong.  We end up at our morning conference room, and it is *packed*.  We don't have that many people for the real morning conference.  I've met about half the people.  It ranges from the general techs, that do sciencey stuff all day long and work with the type of machines I'm about to try to explain to different types of techs to doctors to god knows who.  There's also some PhDs thrown in for fun.  Ya know, those people that were learning this subject specifically and writing papers on it while I was screwing up IVs and taking blood pressure.  I mentioned very recently that I don't tend to get stage fright for this stuff, and this proved a notable exception.  This was more like that dream where you have to take a calculus exam in your underpants.

I was in such a hurry to unload the giant ball of painful information in my head that I even forgot to introduce myself.  Possibly as an unconscious defense mechanism in case I screwed up.

It actually went really well.  In jamming the data into my limited capacity to understand it, I had inadvertently created a presentation that was apparently easy to follow while getting deep into the subject since it was the only way I could create a presentation on it in the first place.

I would say this taught me an important lesson about how to do this in the future and how to pick topics that I find extremely challenging, but hell no.  Brain drain.

So happy July to all of you, and congratulations to all my fellow travelers at your various stages of progress.  May your powerpoints never crash.

The halfway point!!

Geeze these exams are long.  By the end you're just skimming questions because you're like "This isn't the Hunger Games!  Why am I here?"

Step 3, as mentioned, is two glorious days of overpriced MCQ (and case scenario) pwnage.  Ostensibly, I could be using this time to review notes and antibiotics and such, so instead, I'm blogging while my powder-pink toenail polish dries, cuz priorities.

The stress level has significantly decreased over the course of the exams, as, weirdly, my distance from the exam center.  This feature is unrelated, but just kind of nifty.

Step 1:  As an IMG (also AMGs, but not half as much), this exam makes or breaks you.  It is stressed again and again how well you need to do, and specifically how well you need to do relative to your AMG cousins.  It was a nightmare to study for.  My hours were long but poorly planned, spent frequently skipping from reading textbook to textbook over the course of about three months during which I was not tasked with doing much else.  I had the all important "unintentional weight loss", the anhedonia, the overwhelming stress, the blood pressures that jumped to about 160/105 regularly toward the end.  I was crashed out in North Carolina, far from fellow sufferers. Dressed in whatever filthy rags I scraped together, drove an hour and a half to Greenville to the exam, and sleepwalked through it while running to my locker at every break, trying to eat something, and cramming Red Bull.  Got my foam earplugs taken away and got distracted by my heartbeat for the whole thing.  Walked out feeling numb and apathetic.  Did well.

Step 2 CS: Not so stressed about this one, since... pathology.  Also, no score other than P/F.  I don't really count it among the classic Steps, since it's not the standard "Prometric" center.  If it didn't cost as much as a 60" LCD TV, it could be fun.  Practiced for a week with hilarious results, flew to Houston, stayed with my lovely family, had my uncle iron my white coat because I'm useless at household anything, wore nice clothes because it's required, saw fake patients, had a nice lunch, saw more fake patients, and hung out in Spring, TX.  Groovy.

Step 2 CK:  Important, yet somewhat less so unless you have to compensate for Step 1.  An hour longer so you really reach the "hit the wall" feeling.  Living up my little hedonistic lifestyle in New York with my similarly hedonistic med student roommate.  Took about seven weeks off rotations to study, which later translated into a long loan-check-less summer.  Studied alternately at home and at the new Brooklyn Bridge park.

Studied a reasonable number of hours a day, did not obsess over tons of textbooks, and pretty much just stuck to UWorld while making sure to rush downstairs to Maria's with regularity to get my evening cocktail.  Finally moved the exam up about a week and a half because I was tired of studying for it.  Took the subway and strolled to the exam at lunch time.  Jeans and a (probably) clean t-shirt with a (maybe clean?) sweater.  Due to the nature of the testing center, had to sneak food into the bathroom and hastily consume sandwiches and Red Bull.  Walked out feeling numb.  Did well.

Step 3:  Seriously.  If you're not trying to get a competitive IM fellowship, just pass the stupid thing.  You have a job.  If you're a pathology resident, try to not be stupid and take it early in your first year.  If you're a path resident and your program doesn't force you to take it your first year, for gods sake man, take it early in your first year.  The stories I've heard.  Took a week off (paid!!!) during which I also worked on presentations that are moderately more stressful since I actually have to impress my colleagues.  On other weeks, did quite a bit of studying in the form of QBank on my iPhone and perusing flashcards by the pool.  Made time last week for this:

And no, that's not me, though I certainly wish it were.  You can't let studying interfere with the *annual* southeastern beard and mustache festival.

Half through so far.  At the testing center, they were super friendly, encouraged me to bring my foam earplugs (WAHOO), and were like "Oh, have a cup of coffee", and referred to me as "Doctor" or "Doc" about fifty kajillion times, which, kinda awesome.  Didn't feel rushed on breaks.  Had lunch at a normal hour, no Red Bull (wha?), and ate it out in the sunshine.  Walked out feeling.. fine?  Staff encouraged me to come back nearly an hour early tomorrow so I'm out sooner.  Can't lie, I don't miss the stress.

Not that this means I'm doing well.  It could mean quite the opposite.  Especially since it's soooo long.  I think it's so long that you don't dedicate as much mental energy to it because you're just "blah blah blah... uhh.. C.  Sure."

But the constant crushing career-rides-on-this, every day you take is money lost feeling is gone and good frigging riddance to it for three more wonderful years until the monster that is the double day dual certification AP/CP path board exams that our glorious leaders are currently suffering through.

But tomorrow... tomorrow.... the end of the USMLE cycle for EVER tomorrow.

Step 3 starts tomorrow

As a great man once said: "All right, brain, I don't like you and you don't like me - so let's just do this and I'll get back to killing you with beer."

One woman.  Two days.  Some number of questions.  Some other number of patient care scenarios.  750 dollars.  Can she do it?  Time will tell.

Monday, talk.  Wednesday, longer talk.  Then?  Bender.  I'm definitely thinking bender.

I have finally adopted the schedule I planned on for Step 1.  Get up.  Go to work despite being on vacation.  Do questions and work on projects.  Work out at the gym.  Eat healthy dinner.  Watch an episode of Archer.  Go to sleep.  Repeat.

See, with hard work and dedication, you too can be responsible... for like, a couple of weeks, a year plus after you graduated medical school, but still

Another frigging USMLE, really?

So, in my program, you have to take the USMLE Step 3 by June 30th of your first year because they realize path residents are going to forget all their clinical medicine.  The plus side is we don't technically have to *pass* it until June 30th of your second year.  But since "Step 3: Electric Boogaloo: MCQs in Space" is two days of work-day length misery instead of one, I really don't want to do it twice.

Being a responsible person, I'm taking it June 8-9, which is about three weeks before when normal me would take it, but about nine months past when a reasonable person would take it.

Being a SUPER responsible person, I decided to make use of all resources that would really help me study for this exam.

Yeah, roomie and I got a boat.

How do you study?

Roomie mostly got a boat, particularly since she has a car that can tow it without invalidating the warranty and I don't, but damn.  I'm now officially a disgustingly rich boat owning doctor, except I'm poor and part-owner of a hobie cat we got off craigslist, but the potential is there!  All that's left is to stuff it full of golf clubs and caviar and butlers and such.  Posh people do that, right?

Posh people also go to Kiawah Island.  As part of my program being incredibly awesome, they sent us to attend at least one day of a conference out in rich people land.  This was my first for-real conference, and I was sufficiently blown away.  The lecturers were actually pretty damn amazing; notes came with bling and a preprogramed flash drive with the power points, and then the spread required a lot of extra treadmill/swimming/weights time particularly since it all concluded with an oyster roast/food orgy/open bar out in a beautific location.  I thought when they saw my handbag lacked either a "Coach" or "Louis Vuitton" logo on it, they'd throw me out, but security must have been lax.

So yeah, perhaps I'm in an upswing that will terminate with my telling all you fine people to run screaming from the profession (again), but life is currently making all the Step 3 UWorld pwnage worth it.  Despite the fact that palmetto bug season is starting to bloom, or "Satan Death by Aerial Insect Assault" season as it's known by those who can interpret the screaming.  For you lucky uninitiated, palmetto bugs are roaches that are pumped up on steroids, aggressive, and fly.  You're welcome.  Pleasant dreams.

Back in heme, I was required to do a five minute presentation at conference on something I'd learned that month.  Since I'd had a quasi argument/discussion/I know this topic talk with my attending on thalassemias, we jointly decided I would do that since I'm lazy and he wants to focus on a topic where there aren't a lot of cases here.

For some reason, this five minute topic on a disease my mother is carrying a trait for had me up until 2 AM.  Personally, I blame powerpoint for being a horrendously inefficient way to present information that isn't a picture of something.  So I did the thing this morning to a fading audience, but my attending had left, so I did it again at the beginning of sign out, and he approved, so I may be doing it again to all the heme onc people because I like boring diverse groups of people.

Since I'm pathologically addicted to Game of Thrones, this does allow me to make the most specific geekiest, least funny reference in history by saying "Hemoglobin Constant Spring is a deletion in the alpha gene stop codon which leads to a long alpha globin chain, contrasted to Hemoglobin Winter is Coming which causes the gene to make progressively stupider decisions until someone kills it."  [Crickets chirp, awkward silence ensues]  "Thank you!  You've been a wonderful audience!"

I get nervous about presentations until the time where I actually have to give them and then I don't care.  You'd think this not caring would carry over to the presentation effort so that it doesn't take me 7 hours to hack together a 5 minute presentation, but it doesn't.  I also never do a practice run, usually because it's 2 in the morning.  I attribute this all to being 11 years old, with my precision team, opening the Ice Capades (yes, really) and falling directly on my ass during a simple maneuver in front of at least a couple thousand people.  Given that, scrambling some medical terms to a group of thirty people who know me just doesn't matter.

That being said, if I give a presentation and you ask me to do the same presentation an hour later (today), you will get two entirely different presentations.  And despite all the care and effort I put into making a stupid powerpoint presentation, I rarely reference anything but the pictures.  "Behind me, you'll see a list of bullet points that constitute my midnight stream of consciousness and have nothing to do with what I'm talking about.  Enjoy."

I also over research and under reference.  This has been something I've literally done since high school.

"Oh, I have a paper due on Shakespeare?  Okay!"  [Read all of Shakespeare's works.  Read several biographies on Shakespeare.  Pull up lots of webpages that recount the same information.  Do this for several weeks.  Write entire paper in a single run beginning at 10 PM the night before it's due with no rough draft.  Sprinkle arbitrary references in among facts that may or not be where you got the original information, but by then it's amalgamated into your "common knowledge" and you have no idea where it came from.  Hope like hell they won't fact check you or that you've inadvertently plagiarized someone.  Swear you won't space your time like this next time.  Repeat pattern for next fifteen years.]

What else?  Oh, we did the Residents In Service Exam, which for first years, as I mentioned, has no real significance other than telling you what you need to learn.  What did I learn?  I'm good at microbiology.  I don't really know why I'm good at microbiology since we haven't rotated in it yet.  I'm not good at surgical pathology even though I spent most of my time in it and stresses related to it nearly sent me fleeing to Mexico despite an exquisitely poor command of Spanish for a native Californian.  Baby steps.

I blame the media for my current career path.  I wanted to be a virologist initially because I thought Outbreak was a good movie and I was, like, 12.  I downplayed this during my "Why did you get into pathology" interviews because I wanted to eventually get work.  I'd like to say X-Files hasn't played a role in my current course, but I'm suspicious.  Now I'm weirdly good at microbiology, and the most logical reason I can come up with is that Dustin Hoffman is remotely beaming the information into my mind.  That's reasonable, right?

Background noise

(Resident comes from other rotation, speaks to fellow)

Resident: Teach me something.

Fellow: (sums up case) So CD30 is all you need.

Me:  I thought love was all you need.

Resident: Is she always like this?

Fellow: Yes.

The Economy Car Blues

I finally got my wonderful guitar gift fixed up for the low low price of 10 dollars, so I can put this to music:

9 AM, the flames are lickin'
10 AM, the porch ain't there
At noon, I'm getting that call saying, girl you're gonna stay where?
And you got no way to get going now,
Naw, they burned up your ride too,
Now I'm sitting in the ruins singing the economy car blues, baby...

Can't get to work
Can't get to church
I'm in the lurch
Can't head to the Red Cross
Can't get to tell my boss
Can't get to the downtown, feeling lowdown blues...
No, I've got the economy car blues.

Where's your bed baby?
That futon? It's gone
Your tv and vodka bottles?
Just pieces on the lawn
But I'm sleeping out here barefoot; yeah they got my pretty shoes,
And now all I got are these economy car blues, yeah
Those subcompact blues,
Those window-crank blues.

 When you're missing your stride, you got no ride
Want your stereo, want those sexy pleather seats back
A three quarter spare, smells like burning hair,
and the paint job's turned smoky black
That's just the economy car blues, yeah it is
That's just the economy car blues.

Can't get to work
Can't get to church
I'm in the lurch
Can't get to the mall, not the justice hall
Not the clinic, I can't win it blues
I got these economy car blues. Yeah yeahhhhhhh CHA.
(guitar slide)

---
See, this is what happens when I don't get enough sleep and get called out in derm lecture.

Meanwhile, in hemelandia

I don't even watch Portlandia much, but I really like adding "ia" onto everything. And putting a bird on it (Okay, I watch Portlandia a little).

Anyhoo: Dear Clinicians, we do actually read your notes. And you are hilarious. "The patient is obese, and extra personnel will be needed in the OR to deal with the obesity of the patient, who I may have mentioned, is obese."

Also, all notes begin "The patient is a pleasant blah blah blah. And all the referrals begin with "Thank you Dr. ScaryName for referring your patient, who is a pleasant blah blah blah". Sometimes, they're "very pleasant". Which of course, is meaningless to us, and after reading thirty notes that begin that way, is either a complete lie, or we have the most pleasant group of in-pain people ever. "The patient, Ms. Jones, is a demanding chore of a woman who has threatened to sue me five times. By referring her to me, I can only guess I have grievously wronged you in some way, and for that, I do apologize."

I know as a medical student, I got some unpleasants. One wanted to be her doctor, which is a story for later and helped me run screaming into my field just in case she ever found me. "My patient, Ms. Really?, said she threatened to slap a nun. I feel no further history is needed."

That's not really heme though. That's everything, including autopsy, though in the latter they tend to add, "In this unfortunate case", which is weird because no death note is going to begin with "Well obviously..." The unfortunate part seems implied.

Heme. Things are difficult. Good difficult, but difficult. I'm starting to absorb the immunostains, which is extremely important in heme. CD20 and CD3 in particular are becoming my bestest friends.

My attending freaks me out a little bit, so I'm just as pleasant (see what I did there) as possible while remaining self deprecating enough to not be aggressively pimped. For instance...

Attending to other resident: Go slowly through this; Ishie won't mind. She's very patient.

Me: It's one of exceedingly few virtues, sir.

Fellow: (chokes)

An interesting thing... I'm either "The Quiet One" (go figure) or "The Extremely Inappropriate One". The former is usually to avoid the latter when I'm around people that I'm not sure will appreciate it, which to be fair, is most people. This occurred in my surgery rotation, which is the only way I made it through the rotation alive. This confused a friend of mine, because the secretary specifically referred to me as the Quiet One, which sparked "Wha??"

The fellow seems to be around me enough to know I'm secretly a horrible person. He hasn't told anyone at this point, so I think we're cool.

Other heme stuff... we work much closer with clinicians, which is cool in a sense, but sucks in a sense, because it means we have to talk directly with people who talk to our patients and they say stuff like "Awww, that's a shame. This kid's so sweet and is such a fighter", and that personal touch is honestly really deflating. Not in a "grave detriment to my work" way by any means, and I do like giving good news on any front, but surgical pathology is quite hands off when people aren't hounding you for frozen sections, and you can be like "Oooh, weird melanoma!", whereas when you see someone's repeat-after-chemo bone marrow packed with Unspeakable Evil and you have to immediately call the clinician, who at times comes down and looks through the scope with you, there's no real excitement to it. "These stain really weird!!!" just doesn't cut it. The heme/onc people are great though. I suppose you'd have to be.

In other news, my mom's coming down to visit for her birthday, so I get to show off Charleston in a hopefully non-murdery, good food sort of way, which contrasts sharply to her last visit which was to a Motel 6 in the hood where someone immediately got killed outside the freeway exit the night we'd gone to a Denny's for dinner. I seem to attract trouble.

Attempting to be Southern...

Attending: I'm not going to tell you anything about this patient's history; I'm just going to show you the slide. Tell me what you're seeing.

Me: Sickle cell patient

Attending: What cells are you seeing?

Me: Uh... target cells, fragments, reticulocytes, lots of polychromatic forms, SICKLE CELLS

Attending: What cells are these? (points at sickled cells)

Me: Sickle cells

Colleague: Elliptocytes?

Attending: No, not quite elliptocytes. These are sickle cells.

Me: ...

Attending, to me: See right here, this group? (points with scope arrow), they don't look like typical sickle cells, but that's what they are.

Me, flatly: I know.

(pause)

Me: I mean, yes sir.

Surprisingly, the conversation went perfectly normally after that even as my brain was screaming "I SAID SICKLE CELL LIKE FOUR TIMESSSSS IT'S THE ONLY THING I KNOW ASIDE FROM PROSTATE. ACKNOWLEDGE MY GREATNESSSSSS AAAAHHHHH must have theee PREEECCCCIIIOOUUUSSS"

Yeah, I say sir and ma'am now. I pick up strange idiosyncrasies but without the accent or upbringing to back it up. One of my attendings may well be called "Dr. Bless his heart" because he's so damn nice to everyone all the time. "Bless his heart" is a phrase I *NEVER* used before I moved here, and certainly not said in its original intention, but today, while talking to my mom on the phone, I uttered "And Dr. C, bless his heart, actually ordered in bagels from New York for us."

I blame my former roommate for my calling people "doll", "dollface", "baby", and "babycakes" though. People may think I picked them up here, but they were instilled by an exuberant roommate and a lot of burlesque announcers in New York.

The sir thing is weird though. I've never been a sir person, but now it's just part of how I talk to my attendings. "No sir, I'm pulling the patient's history up right now, I apologize for that sir". Every time I do it, in my head, I sound like Bill from True Blood, which eventually means that by the end of my residency, I'm going to have the voice and accent down. Ishie! Did you check the trends on this guy's urine proteins? Sir, I must regret to inform you that those files remain untouched by my hands. Now, if you'll excuse me, sir, I will escort Miss Stackhouse out of the hospital before she surely incites trouble in these halls. Where is that girl... SOOKIE.

Happy Easter!

Dinner will be courtesy of Trader Joe's. I actually googled to see whether there was a TJ's in Charleston when I was moving here, and was bummed that there wasn't, though there's a Whole Foods, and then a month or two after I moved here, they opened one, which makes me way happier than it should since I can't really afford to shop at Whole Foods until I'm an attending.

I'm not sure why I'm expounding on my favorite grocery store. Because I can, I suppose. Anyway, I had aspirations of baking my own ham (for two people) and all sorts of fanciness, then went to the store, saw they had some cheap awesome looking precooked and figured making potato salad and asparagus is enough cooking for a holiday I really only celebrate to score Cadbury eggs.

Speaking of cooking, I literally can't remember the last time I got take out or fast food. That doesn't mean I'm eating healthy or anything (since I learned how to make cupcakes out of alcohol), but it's a huge financial boon, so I took all that newly uneaten money to buy clothes-that-are-not-scrubs because new month new rotation. Since I don't have creepy crawlies, bowel contents, and blood (weirdly) to contend with, I no longer have an excuse to spend all day in my pajamas. Yes hemepath, a field oddly lacking in fresh blood.

See, I took it from grocery stores back to medicine. I'm a jedi. I'm in hematopathology now, which is a field that's in my "maybe I'll do that when I grow up" box without the financial apocalypse that is forensic pathology, which is also interesting, but does not promise to pay off my loans. Also, I hate courtrooms, and considering I just had to rush out to go shopping due to being in another flavor of path, I definitely don't want a closet full of jury fodder to worry about.

ANYway, I initially developed a crush on hemepath when I did pediatric hematology/oncology as my pediatric elective.

For the uninitiated, hematopathology deals with blood (duh) and has a pretty large focus on leukemias, lymphomas, and hemoglobinopathies (like sickle cell), though the former two much more than the latter. Hemepath is much more diagnostic contrasted to blood bank which deals more with obtaining and matching blood, though I actually like both.

Essentially, in hemepath, someone comes in with a blood problem, and we do science at it until we arrive at an answer. We also evaluate treatment, so if someone's been on chemo for a while and their bone marrow is still packed with evil, that's bad. Other stuff. We mostly look at peripheral blood, bone marrow aspirates, bone marrow biopsies, and lymph nodes if they are suspicious for lymphoma. If there are weird blood cells in other body fluids like cerebrospinal fluid or belly juice (usually cytology's turf), we look at that too.

Blood is tricky, because while it may be kind of obvious about being "BAD" or "probably not bad", the different categories of badness look very similar, and knowing whether you have promyelocytic leukemia versus lymphoblastic leukemia versus etc is extremely important for treatment, so we do all sorts of voodoo to these cells and get way more money allocated to play with them. This is in contrast to autopsy where you do not order special stains EVER. "What kind of cancer did they die of? Fatal cancer. Next case."

I'll take a minute to sideline on a couple perception pet peeves here. Cancer is a fantastically expensive set of diseases. It's not anyone's fault. I'd love to blame drug companies and corrupt doctors and government, but cancers are extremely specific self made little assholes, and it takes thousands of hours of manpower and chemical warfare to get into it. A whole spectrum of specialists needs to find out what it is, where it came from, what broke, and then either a magic bullet for it (there are a couple of cancer types that produce a specifically combined gene product that doesn't normally occur and we can target it and kill the cells that make it, but that's unfortunately not many of them) or the specific combination of horrible chemicals that will target the cancer first. A lot of promise in treatment is coming along the way of the understanding of the genome but things like targeted antibodies and the whole new wave thing is outrageously expensive.

I say this to make two points. One. No one can privately afford this. I'm glad that back in someone's grandpa's day, health care was simple and affordable, but if grandpa's sister got leukemia, she'd have died. Two, anyone that says "Sure, we can _____________, but we can't cure cancer!" needs to shut up. Seriously, anything they have to say after that is irrelevant. Most things that can be murdered with a single inexpensive drug (looking at you, syphilis) have been.

I'll also bring up another point, more as an education thing. Since cancer is *not* one disease, approach to treatment is extremely specialized, so anyone thinking "If I got diagnosed with cancer, I wouldn't go through ______", not a good way to look at it. There are pediatric leukemias that have an 80-90% ten year survival rate. The kids lose all their hair, turn white, look like death, get scary pneumonias where they're on a ventilator and you're absolutely certain they're done, and two years later, boom. Hair back, rallied, good grades in school, no cancer. Breast cancer? Runs everything from "not a big deal" to "death sentence". If you ever get cancer, talk extensively with your doctor, look up articles, etc. Also, don't wait because you don't want to deal with it or you don't have the money. Often the only difference between outpatient surgery and stage four metastatic disease is time. Keep in mind, I am *not* saying cling onto the promise of life by your fingernails in the face of everything or that I should manage your individual situation. Believe me, I have a list of cancers and progressive diseases that are in my "Give up and run up all my credit cards in Thailand" category, but I'll be damned if "breast lump" will be one of them.

And please listen to your doctors once you have a diagnosis. If you don't like yours, get a new one, but absolutely consult people with peer reviewed literature on their side *before* and possibly as an adjunct to the other stuff you try. As far as all natural goes, cancer is all natural, which is why you really have to go unnatural to kill it. Lest you think I'm MD patronizing all of you, my grandfather died because of prostate cancer that remained quite treatable until quite late, thus leaving me at 13 with *no* grandparents (last man standing) so it's a topic I care about.

But soapbox off. Where was I? Oh yes, the battery of heme tests. For the most part, heme feels approachable, memorizable. There are nuances to the cells I'm learning to appreciate on morphology, but a lot of it is memorizing which markers correspond to which cells and which markers are likely to go screwy first when the cells they're sitting on go bad.

Unfortunately, one test they run is flow cytometry. Part of tomorrow is going to be spent trying to make heads or tails of it. It's super duper important, and unfortunately, looks like this:

Yeah. When I encountered flow on my first day, a little avatar-Ishie from college calculus popped up, had a seizure, and dropped dead. Lest you think that little graph up there could be comprehended, most flows are about six-ten pages of that run against different parameters and cluster differentiations. So the heme path fellow is flipping through it realllly quickly considering it's full of math and says something to the effect of:

"Okay, it does look like we're dealing with an M4 type acute myelogenous leukemia."

Noooo... it doesn't look anything like acute myelogenous leukemia. AML looks like this:

Whereas that looks like this:

But I'm going to try to get it, so I can pwn hemepath and show it the love I think it deserves.

In the meantime, as your Easter/Game of Thrones Episode 2 present, here's Joffrey getting slapped.

Wahoooooooooooooo

So what, I have a GME presentation and an abstract due because it's SUNDAY SUNDAY SUNDAY...

It's been what... nine months?? I'm all "Dun dun daddda dum, da dum dum daadda dum."



SO freaking excited. Particularly with True Blood and Dexter both being poor showings this last year, I've needed this.

I am being responsible by not going to see Hunger Games with some of the other first years though. Gotta get some work done.

Addendum: Since I haven't geeked out over this show enough, here's some amazing dude playing the opening against multiple copies of himself.

Surprised by progressive people...

I wear my scrubs home from work a lot because I'm lazy and never sterile anyway. I'm a short female frequently wearing a backpack, so General-Populationville usually thinks I'm a nursing student, which I've stopped really giving half a crap about since it's easier than explaining what I actually do.

The CSI watchers jump to autopsy (Yes, I carry a gun and chase criminals around crime scenes. In heels. I'm badass that way. I also used my kelp knife to fight great white sharks rather than using it to avoid being murdered by algae), and any further explanation of what pathologists do, ie, most of our job, is lost on people.

I would say that etiquette would dictate erring on the side of highest education/deepest loan burden, thus I insist all people noticing my scrubs address me as "You must be the program director of neurosurgery at Johns Hopkins!" else be branded as sexist pigs. On the other hand, I'd note that my hospital is one of the biggest employers in this city, as well as being a medical school, so seeing someone in scrubs should usually prompt people to not guess what you do, since they have as much chance of getting your profession correct as you do seeing someone in a suit.

Still, imagine my surprise:

Rite Aid cashier: "Oh, are you a doctor?"

Me (shocked stutter): "Yes!"

Rite Aid cashier: "Surgeon?"

Me (double shocked stutter for the double un-sexism): "No, uh.. pathologist."

Rite Aid cashier: "Ah! Heh. 'Are the margins clear?? Are the margins clear??' "

Me: "You appear to know more about pathology than most doctors."

It's true too. In med school, I had a frigging anesthesiologist hear my interest and go "Oh, but don't you mostly deal with dead people?" Dude, you're in the OR when they send specimens. You have to sit there and wait for the phone to ring so the operation can proceed. How do you not know what we do?

Then I remember I've been on autopsy for two months and feel like I'm fulfilling some sort of stereotype, like if I'd been caught painting my toenails and watching Fried Green Tomatoes while crying into a kitten's fur and asking a man what he's thinking.

And now for something completely different

I had a request for a new blog post today, and responded with something to the effect of "I'm in the middle of trying to get an abstract accepted and everything I'm doing at work right now is confidential", so I came across a colleague's link of facebook which led to a post that really moved me a lot, while also reminding me that I became a pathologist to help with situations like this while not having to directly deal with situations like this:

An Ode to a Patient

There's a bunch of fighting about health care currently, and if I were a truly good politically aware doc, I'd be paying more attention, but honestly, this whole health care legislation/insurance company screwage is so confusing that it's honestly not because we don't care. We don't get it either.

This doesn't really relate to the current bill either. It's just a general observation.

Common situation even as a medical student:

Patient: I have insurance. I have a complaint. Please address my complaint.

Doctor: I am a doctor, thus interested in your complaint. Let me examine you and run tests and get images.

Patient's insurance company: We're going to cover 60% of this and some of this, but this image you ordered we aren't going to cover because... blahblahblahfishcakes. So you're not going to really get paid much, but the patient's general expenses are going to still be life altering, and patient still isn't going to be able to afford the MRI, and if you want the MRI, you're going to have to cough the two grand out of your bank account, since while you can comp your services, you don't own an MRI or an MRI technician, or a radiologist. Addendum, we're adjusting our provider options, so the specialty treatment your patient requires is going to be at a hospital across town. Double addendum. Those lab tests got sent out to a lab that wasn't covered, so the patient's getting charged four hundred dollars she's going to blame you for. Meanwhile, people are just going to keep thinking you're a Mercedes driving golf club swinging douchebag while you drive your used jetta to work and pay off a quarter million in loans, cool?

Doctor: Super.

Patient: Why can't YOU treat me???

Doctor: I genuinely don't know.

This is why the boys don't call me

Financial advisor: Is there a time you can talk tomorrow morning?

Me: Uhhh... I don't know yet.

Financial advisor: You don't know?

Me: Well... I'm on autopsy this month, so it kinda depends on.. ya know, who dies.

Financial advisor: "..."

Happy St. Patrick's Day!!

I'm pilgrimming to Savannah tomorrow for what I'm told is an incredible celebration, and most importantly, I made these:

I got the recipe from here which is an adaptation off the Smitten Kitchen.

Pretty much it's an Irish car bomb shot that's been made into a cupcake. More significantly, *I* cooked. Which I can't generally, but I've been on phase 45 of trying to become a grown up at the tender age of 31 and eat something that hasn't come out of the hands of a delivery boy or out of a microwave or through my car's window.

And I get to see New York friends again! Which is super awesome.

Other news:

The fire: I replaced my fabulous alligator head purse which I loved so much and feel a little more complete.

I attended another hearing for the little shit that started all this and this time got to see him, look him in the eye, and tell him what he did. Heard his mother talk about his neighborhood and how he wasn't a bad child even though he's already committed a decent smattering of felonies and misdemeanors without being beaten to death. I love my mom, but somewhere between larceny and assault, I would have concerned myself with finding and recovering tooth fragments rather than progressing to arson. Not that she beat me, because I didn't give her a compelling enough reason to do so, because I knew better. Anyhoo, the next hearing was waved and next step is a trial, so I don't have to worry about it for a while and getting to say "This is what you did" in a court and have people listen to me for a change felt a lot like closure.

I feel comfortably settled into my new life. My roommate's dog is hating me me less. My car is awesome, shuttled me to and from Maryland last weekend without incident, and tempts me every time I shift into first gear to really rev the engines and let it run, but I'm trying to behave myself for the sake of my greatly inflated insurance rates.

Work: Pretty not bad. Autopsy is calming; I like the attendings, and I'm beginning to not feel like a complete idiot. The heart used to panic me since there's a whole process for it and it's usually what kills someone, and now I can teach it to med students so they can cut it shakingly while I watch. I can toss stuff off while I'm dissecting. Here's the conduction system; here's the substantia nigra; what's the significance of it? Why don't you see it in babies? This is a pulmonary embolism. This is a postmortem blood clot. This is how you can tell. Do you remember the liens of Zahn?

I still feel an odd sense of fascination about the snapshot of a person we get from their personal effects. Especially since the police usually take wallet and phone (and guns and such) so no picture, no identification, just.. cough drop wrappers. A crack pipe. A penny. A photo. Fifty dollars and a gap coupon. A handful of tree leaves and branches from where they died. When someone's tried to help, the sequella of events is extremely clear, the laryngeal edema from the endotracheal tube, bruises on the chest, the rib and sternal fractures, the punctures all over from rapid indelicate IV attempts. The battle scars of the good Samaritan.

A word of advice though, which I reserve for myself a lot. It's never as bad as you think it is. Tomorrow will always be better when you've had time to process it. The idea that you're going to "show someone" you're fighting with and teach them a lesson either leads to you hurting someone who cares about you or killing yourself over someone who doesn't. Just sleep on it. The bridge or the gun or the chainsaw or the pills will always be there tomorrow, so why be hasty about it? No one will ever find you? Of course they will. And it won't be as bones or a memory. It'll be bloated and stinking and that's the legacy you'll leave to a room full of people that refer to you by a number. So therapy and some perspective guys; just saying.

My handwriting...

Forensic fellow: "Oh! I've been looking for you. Did you add an addendum on to an older case but crossed out some stuff, because it's a different case number?"

Me: "Uhh... I have the attention span of a goldfish, thus no idea what you're talking about if it doesn't relate to a case I've been doing in the last day."

Forensic fellow: "It's a girl's handwriting."

Me: "Oh, then it's not mine."

Forensic fellow: "Oh, do you write like a boy?"

Me: "I write like someone in the middle of a seizure."
-----------

Follow up: Yeah, I did it. Apparently, my handwriting is 'curvy', thus I write like a girl. I defended myself by saying that I can't write like a girl because I don't dot my i's with little hearts. He wasn't buying it.

More than you wanted to know about autopsies

Hola amigos. Autopsy's been pretty crazy this last week. There's an interesting split in pathology because there's more than one type of autopsy. There are baby autopsies, forensic autopsies, and medical autopsies. The babies tend to involve perinatal circumstances so more to find out why something went down either before birth but after 20 weeks gestation, or right after birth, and hopefully find something to give the parents some idea of how likely it is to happen again.

Forensic autopsies are what everyone things pathologists exclusively do, and also, people think they encompass way less than they do. Essentially, if you don't die in the hospital, you get a forensic autopsy. Homicides, the famous one, but suicides, car accidents, bike accidents, pedestrian accidents, old people found at home, boaters found in rivers, etc. Full spectrum. When you're not the lead on these cases, they're actually less of a pain in the butt then people would expect since mail off labs are the ones that have to do the extremely slow version of all that CSI stuff.

Medical autopsies are the ones that are most important to the residents, and constitute the most paperwork. They give you a benefit over forensic autopsies because you have all the hospital paperwork at your disposal. Unlike most forensic autopsies though, this complicates the course because people in hospitals don't tend to die of really straightforward things. So... what killed this person? Cardiac arrhythmias are a particular headache. If it's not caught on a monitor, we can't demonstrate it happened. An MI will leave evidence (sometimes) but the arrhythmia it triggers? Not so much. We were given a handout describing death not as a loss of structure, but of function, and since we get them after the cease of function, it can be something of a mystery.

An added aspect to medicals is unlike with forensics, unless the forensic has a really medical-ly component to it, is we have to explain it to their clinicians AND families in a write up. This is difficult. Laymen understand why getting crushed by a truck causes death. They do not generally know what an amniotic fluid embolism is, why their mortality rate is so high, why doctors couldn't really do anything about it, and what the mechanism of death is, all without using words like "disseminated intravascular coagulopathy", and I have to explain it without being callous. And cite references.

But it's all good, and ultimately, way less stressful than surgical pathology. My attendings are super cool, and one of them caused me to discover an autopsy scully doll that I didn't know existed, and sparked my long dormant desire (coupled with Slappy mailing me a Scully action figure to replace the one burned by a fire, and yes I am a complete dork) to collect X-Files things. I'm trying to temper it with a more normal grown up habit like buying nice shoes or purses, but damn that stuff is expensive. I feel like a yuppie tool every time I pay 80 bucks for running shoes (worth it) but I saw a pair of Gucci boots that I liked decently online and they were 1100 dollars. Noooooo.

What else... Oh! People have been sending me pictures! See???

My nudibranch from Monterey!

Grenada hash!

The Alps!!!

Soooo awesome. Great to have memories back.