Practice makes Perfect

Today was my first day at Baptist hospital. It's only a mile from Vanderbilt. I'm on my OB/GYN rotation, and I get to spend 2 weeks there.

During a complicated operation:
The attending tells me to cut about 15 sutures exactly 1.5 centimeters from the knot. I proceed to do so, one at a time.

Dr.: Too long.Me: Ok

Dr.: Too short

Me: Ok

Dr.: Too short.

Me.: Ok.

Dr. Too long.

This continued until all were cut. He asked both my medical student partner and me, "why did I do that?"

My partner's response was, "Hazing???" The resident on the case gave her a funny look.

"No," he said.

"Perfection," I answered.

Surgery is a technical as well as academic skill. Perfection is an unatainable goal that surgeons strive for. So even after a lifetime of practice, one is always still improving, striving toward that goal of perfection. That's why they call it the "practice" of medicine.

It's just like rowing. I've rowed for many years, and taken litterally millions of strokes with the oar. As of late, I've been watching training videos made by an olympic gold and silver medalist, Xeno Muller. He's reached the very top of his profession, yet every day he continually tries to improve his stroke, reaching for that unatainable goal. And that's what makes an excellent oarsman, as well as an excellent surgeon. And I look forward to a lifetime of trying to hone my skills.

My first patient to die

I knew it would happen sooner or later. Everyone eventually has a patient die. I'm sure other patients of mine had died before, but this is the first one I knew about. She had serious emphysema. You get that from smoking.

Anyways, she came in for an exacerbation of her emphysema. She could hardly breathe. And she was only 50 years old. We gave her breathing treatments. A chest X-ray suggested pneumonia. That would explain why she suddenly had trouble breathing. We treated her with antibiotics. She got better for a while.


The trouble with antibiotics is this: They wipe out ALL bacteria. This leaves room for bad ones to grow in the place of good ones. We all have C. difficile in our colons, but when you wipe out all of your normal bacteria, C. difficile can overrun everything. And the result is horrible diarrhea. Most people get over it.

But in some peple, this diarrhea progresses to something worse. She developed "Toxic Megacolon," where the gut simply is overwhealmed with the bacteria and ceases to function. This bacteria got into her bloodstream. The only option was to surgically remove part of her colon. However, she was in such bad shape that her mortality from this procedure was 100%. And without the procedure, it was 100%. There was nothing we could do, except let her die. And that is what she did, after a few hours.

I plan on going to the autopsy tomorrow. It seems right to see everything through till the last steps. The permanence of it all is stifling. From joking about her kids just a few days ago.... to this. I hope she did not suffer too much through it all.

My Backpack

I'm going to Portugal in about a month. I always travel with my large camping backpack, a trusty REI Valhalla. I first got it in the 8th grade, when I figured it would be easier to carry everything with me rather than keep going to my locker. Other kids called it my "body bag" and suspected that there might be some dead person deep in there. After all, it was about as big as I was at the time.
However, after 12 years of service, it didn't look quite up to the trip. The stitching on the bottom was starting to come apart, and the waterproofing on the inside was flaking everywhere.
I remembered that REI has a 100% satisfaction guarantee. So I put it in the car and drove to a nearby store. I went to the customer service counter. The man was very nice, but he couldn't find the bag in his computer system (it was too old). So after a bit of discussion, he offered me a $60.00 credit. Sounded fair to me.
Then I went backpack shopping in the store. The salesman was very helpful, but when I inquired about one of the packs, he said, "Oh, no way. If you think a 12 year old bag is returnable, that won't be nearly tough enough for you!" Point taken.
So I shelled out a hundred bucks on a Kelty Coyote 4900. Hopefully it will last me many more years. And it too has a lifetime warranty! I'm keeping the receipt though.
But right now I'm really missing that purple REI bag. It went to school with me for years. Countless camping trips. Probably 10 times across the Atlantic. London, Paris, Rome, Nice, Naples, Avignon, Cambridge, Frankfurt, Montreal..... I kind of want to drive back to the store right now and get it back. Maybe I can sew it back together.

I become the patient

I came out of the shower and dried myself with a huge white towel. Something caught my eye. What was that on my back? It was dark, but I couldn't get a good look at it, even with all the mirrors in my bathroom. I'd never noticed it before.

A few days later, I became more worried. Could it be the dreaded melanoma? I had recently seen several patients die of metastatic melanoma in the hospital, and they were terrible, slow, painful deaths. I was rather young for such a thing, and I tend to wear sunscreen and keep out of the sun when I can. But there was still a chance. And if it was the real deal, catching it early was my only hope. If it invades more than 1 millimeter into my skin, my five year survival (the odds that I would live longer than five years) drops off a cliff. I couldn't let this go.

Since I couldn't see it well, I took pictures of it with my digital camera. I saw that it met all the ABCD's of melanoma. It was Asymmetric. Its Border was ragged. It was comprised of two or more different Colors. And its Diameter was greater than a pencil eraser. Shit. This could be bad. Should have used more sunscreen. I suddenly remembered the blistering sunburns of my youth. That time in Saudi Arabia when my skin was peeling right off my back. All those times I went water-skiing without sunscreen. Those blistering sunburn drastically increase your odds of skin cancer.

So I went to the Dermatology department to try to make an appointment. They asked to see my insurance card. Then they told me that the first available appointment was in late November. Really? I'm supposed to wait more than two months with a time bomb on my back?

That afternoon, I decided to take matters into my own hands. I would not wait that long if I could help it. I left the pediatric neurology clinic in which I was working, and headed towards the derm clinic. I tracked down the doctor I was after, and introduced myself. "Hi Dr. B! I'm me. You worked with my dad a while back. I have this thing on my back, and I think it might be a melanoma."

He was so nice. He immediately took me into a room so he could look at it. He thought it was suspicious, so a few minutes later, he took a biopsy of it. He asked for my pager number so he could give me the results as soon as he read the slides (he's also a dermatopathologist). Now I have quite a few stitches in my back, but at least I know that I, and the little piece of my back, are in good hands.

The Nile

A patient comes in today. Middle-aged man, slightly balding. He had headaches that just wouldn't go away. So we got a MRI of his brain. The official report hadn't come in yet, but the images were on the computer. So I glanced through them.

MRI is an amazing thing. With the click of my mouse, I can fly through cross sections of a person's brain, seeing it in exquisite detail. I can see, millimeter by millimeter, what makes you who you are.

As I flew through the cross sections, I started to see bright spots at the junction of the gray and white matter. There were ar least four to my untrained eye. I called over the resident (a junior doctor). He agreed. Lesions at the gray-white interface are pathognomonic for metastatic cancer. The patient's prognosis was dismal.

The resident and I went into the patient's room to tell him the news. His wife was there.

"The results of the MRI are not good," the resident told him. "We think you have cancer in your brain. The prognosis is not good."

He looked at us for a while, not showing much emotion. I tried to picture myself in his position, but couldn't. I had no idea what I would do or say or think.

He said, "Jesus will heal me!" "I'll be fine, 'cause Jesus will heal me!"



Denial ain't just a river in Egypt.
-Mark Twain

Crazy People

Mr. T came to the hospital to detox for his sixth time, and he was only 25 years old. He was taking large amounts of Valium, booze, and opiates, as usual. So we detoxed him, giving him meds that would make him more comfortable while he withdrew from the drugs.

He would come up to me, seemingly from nowhere, and beg for more. He said the withdrawl was unbearable. He hadn't slept for days. He was anxious. He was sweating. He felt like he was crawling out of his skin.

And then he started to pee blood. A lot of blood. Oh shit. And on top of that, he had a urinary tract infection. He had a history of kidney stones, which can cause bloody urine as they pass through. And he described in perfect detail the exact location and excrutiating pain a kidney stone can cause.

He wanted opiates for his pain. If it were anyone else, we would have given it to him.

So we got a consult from Nephrology. They said that the bacterium cultured from his urine usually didn't cause UTI's. We started him on antibiotics. A CT scan confirmed that there were stones in his kidneys, but unless the stones actually pass through, they shouldn't cause any pain.

Then we got a Urology consult. They said his bloody urine was almost certainly due to "self manipulation." This translates to him shoving a coat hanger into his penis, all the way through his urethra, and then into his bladder, and then whirling it around. All to get opiates.

We discharged him a few days later. He was supposed to go to an inpatient drug treatment program the very next day (we had set up everything for him). But he relapsed, again, and nearly died, again. So now he's detoxing at yet another hospital.

At first I was furious. Furious that he had misled us. That we had wasted thousands of dollars for needless tests and consults. Money that could have probably saved several lives elsewhere in the world. All because this idiot was a druggie.

And then I felt sorry for him. Genuinely sorry. I wondered how a person would have to feel to do such a thing. To fake kidney stones with a coat hanger just to get some drugs. Never before had I realized the power of addiction could be so strong. So strong as to take over everything that you have been, or ever will be.

Death

The thought of death is terrifying to me. You would think, being a medical student, that it would be natural... In some ways it is. But in almost all ways it's not. The permanance. The feeling of never feeling anything ever again. The emptyness. The abscence of anything. That scares me. I will be zero. Just a memory in someone's mind.
It really came home today when one of my professors, in Neurology, said it quite plainly: We are only future cadavers.
In many ways, I had only dealt with death superficially. It happened to other people. My job is to help prevent it, or if I can't, I am to make it as comfortable and palatable as possible.
Now I understand why people want children so badly. It is their way of cheating death. The one way of outliving one's self.
But still I can hardly imagine myself dead. The stagnation of it all. I would think it boring, but that implies consciousness. I can only hope that the purpose of my life is to provide comfort to those who need it the most. To those who have nothing else. To those who know the end is near.

Coxing while intoxicated?

So this saturday, I got up at 6 in the morning so I could be rowing at 7. The only problem is that our coxswain was half an hour late. Her mom dropped her off at the lake. She said she was really sorry, and that she had had a late night (going to bed at 5 in the morning to be exact). She said she was still drunk from the night before, after having quite a few drinks with her friends. And from the way she coxed the boat, she still clearly was. The smell of vodka on her breath was still strong. We joked weather she could get in trouble for coxing while drunk. But all was good, and we had a good row, even if I got quite sunburned in the process.

I spent most of last night and this morning figuring out how to replace the battery in the cox box (the thing that amplifys the coxsain's voice). I went to wal mart and found some RC car batteries, which were perfect (600 Mah NI-CD's). After a lot of soldering, the cox box is working again. Yay for saving a few hundred bucks.

So much has happened

So I spent this summer in England, studying for Step I of the NBME examination (the first step to becoming a licensed physician). This was probably not the best decision I've ever made, since there were plenty of distractions and other stuff to do.

We went to the Isle of Man for a vacation. This cost a fortune (as everything does when the dollar is so weak) but it was well worth it. We stayed at the Wicklow Hills hotel, which is within a half hour walk of the ferry terminal. A guy was waiting outside, and greeted us as we walked up to the place (at 1 in the morning). "Mr. and Mrs. XXXXXX? Welcome to the wicklow hills!" He showed us to our room, and told us that we could arrange payment the next day. Fucking amazing service.

Wow, so much has happened since I last posted. I went to England to study for my step I board exams, and that seemed to go fairly well. While in England, I went to the Isle of Man, went to the Cambridge Beer festival, got chased down an alley by a drunk guy bent on hurting me, and had a jolly good time overall.

I got back to the US. I studied a lot. I took the boards exam, and think I did ok. And now I'm starting the third year of med school.

Wow, I'm half of a doctor already. Who would have known?