Reflections on Third Year

"So what should I know for third year?" someone asked me recently.

Whoa. Wow. Um. Where to begin?

Undoubtedly, the third year of medical school has been the most memorable experience thus far in my life, and even now when I reflect on all the crazy and outrageous and wonderful and awful things that I've seen, I can't even believe that it happened to me and not some 2D person on "Grey's Anatomy." In psychiatry, they might call that derealization.

Being a third year medical student is like being a guppy in the hospital ocean. You wander around helplessly, trying to learn how to coexist in a complex environment under some very talented and harried residents. It can be totally confusing and bewildering, but it also opens the door to levels of opportunity and privileged intimacy with strangers previously unheard of. Sometimes, third year feels like an apprenticeship where you learn things using your hands and watching others. Other times, it can feel like boot camp or pledging a fraternity. In many ways, you learn things about yourself and other people during your first year on the wards...and none of these lessons can be easily transmitted verbally...it's almost like everyone has to undergo a second awkward adolescent period as a rite of passage. Also, being a third year medical student was like regressing back into being a 4-year-old child, because the medical world is often alien to the newcomer and learning how to be a doctor is like learning how to be an adult all over again...how to speak medical jargon in surgery vs. psychiatry, how to be polite (pager etiquette), how to follow rules, how to learn what might be important (lab values, complaints) and what is unimportant when listening to a story -- simple things that seem obvious to the indoctrinated.

What also amazed me was how simply being a third year student opened doors in the hospital... From being a mere college graduate with an interest in medicine to someone invited to scrub in on surgeries, write notes, interview patients, perform IV insertions and intubations, and witness the miracle of birth...I learned halfway through third year that simply saying, "I'm a medical student, can I watch?" led me to opportunities beyond imagination.

Third year is hard, I definitely feel slightly burned out, but surprisingly my cynicism has not worsened. If anything, I've shed a little bit of my "beat around the bush" mentality. It was more difficult to blog about third year than anticipated, mostly because of time constraints but also because of privacy issues (HIPAA etc). If I had more time, I would write out paragraphs of my ten most memorable experiences this past year, but instead will list them in no particular order:

1) participating in a liver donor run to New Mexico over Thanksgiving
2) scrubbing in on liver transplants
3) befriending a boy with a giant retroperitoneal tumor in rad onc and crying outside the OR after hearing that it was wrapped around his aorta
4) taking care of little kids in peds urgent care
5) watching babies being born in fresno
6) inserting a 14-gauge IV into the dorsal hand vein of a patient under the curtain on anesthesia
7) chasing after a psychotic HIV+ transgendered patient at SF General on psychiatry
8) participating in my first code while scrubbed in on a vascular surgery in which the patient had an MI on the table...he was placed on ECMO
9) learning from medicine to "always do what's right for the patient" and to talk to unconscious patients as though they were awake, even though it seems strange, it's a sign of respect.
10) watching the work-up of a patient who turned out to have Q fever endocarditis

Philz Coffee

For the past few weeks, Paul and I have been addicted to Philz Coffee. Seriously addicted. My favorite is "Anesthesia to the Upside," because it's very mellow, sweet, and nutty. Other good ones are Ambrosia, Tesora, and Aromatic Arabic (dark roast).

http://www.philzcoffee.com/

At first sip, you will fall in love and get a huge caffeine rush. I've never had coffee that was so flavorful and well-blended, and they make each cup one at a time with heavy cream and brown sugar.

The mini donuts are also tasty, especially Meyer Lemon.

There's a new store in Palo Alto, too! :)

Go drink coffee now! And then eat BiRite ice cream! :)

Do Not Use Dirty Needles

My neuro ICU patient is currently suffering from MRSA bacteremia and endocarditis, with mycotic aneurysms in her brain causing intracranial hemorrhages. She is an IV drug user with hepatitis C and she's 30 years old.

After seeing many patients with a history of IV drug use, a staggering proportion of patients have hepatitis C, HIV, or both. Many patients have infections from dirty needles, like my patient.

Kids, just say no to drugs. But please, do NOT INJECT DRUGS. It's possibly the worst imaginable method of ingesting substances for tons of reasons (outlined below), but it also happens to give people the quickest and most intense effect (partly because it increases bioavailability by bypassing the gut). It's impressive to me that much of the morbidity arising from IV drug use (IVDU) arises from using dirty needles...
- Hepatitis C - very common
- HIV - pretty common
- MRSA, infections, etc
- higher risk of overdose
- nerve/artery damage

Never use needles. Stay away from drugs. Can you tell that I'm venting?

Psych!

"Third year sucks," an intern once told me in the middle of third year.

"Really? Why?" I said (wow, way to go, Stephanie).

"Because you're constantly changing into different clinics and doing different roles and working with new people with no idea how to think or what to expect until you get the hang of it after a few days and then you're shoved into a totally new setting with a different set of practices. And the whole time that you're struggling, everyone around you is critically judging you."

Never really considered that, but it's a good synopsis of why third year can be challenging. The other aspect not really mentioned is that third year can be hard because there is a huge lack of personal free time and a sense of social isolation compared to the first two years of medical school. But it's not all bad news, ladies and gents.

Once you get the hang of third year, however, it can be exciting and fun! Imagine going to a chocolate salon and sampling every bite of chocolate. That was fun last week, until I got really nauseous.

Third year is like a cultural safari where you can study different tribes, adopt their customs, and learn how they think and what their values are. For someone who is adventurous and flexible, resourceful and resilient, third year is like a grueling backpacking trip through the Amazon where the locals are concurrently evaluating whether or not you should be allowed to go traveling. But the best part is that you don't have to travel very far at all...in fact, you tend to stay in one building for 13 hours per day.

Another interesting group that you get enormous exposure to is your patients. I have always suspected this before, but the strength of any medical training (and thus medical school) is heavily based upon both the skills of the residents AND the diversity of your patient population. Pick a medical school based on geography and the patient population that you get exposure to, because that will shape your training as a doctor. At UCSF, we are enormously privileged to have several settings (VA, Moffitt, SFGH, CPMC, Fresno) that gives us a wide range of patients from all walks of life....young/old, rich/poor, urban/rural, etc/etc. Working at SFGH has been an amazing experience, because it is the only hospital in the city that serves the uninsured, the only trauma center in SF, and the cradle of HIV/AIDS healthcare. It is estimated that up to 25% of the patients at SFGH are HIV+ and SFGH is home to Ward 86, one of the most renowned HIV clinics in the country. Going to medical school in SF allows you the unbelievable privilege of working with a large HIV+ population in SF and gives you insight and medical training that cannot be replicated, and I never TRULY appreciated this until third year.

Okay, I've totally digressed again. All of this was a prelude to a short reflection on my time on inpatient psychiatry at SFGH. It was an excellent experience, and I learned so much about how to interview psychiatric patients (be nonjudgmental, ask questions like Columbo) and how to think/adminster psychiatric medications. In fact, the inspiration for this posting was a recent UCSF news tidbit on how the drug company Eli Lilly is trying to market a new combo drug (olanzapine and prozac) for treatment-resistant depression. Psych is so incredibly interesting, and I predict big advances in the next 50-100 years as we learn more about the pathophysiology of schizophrenia, bipolar, depression.

Oops, gotta go.

hey, i got my stuff back

Believe it or not...but I got a call from a medical classmate letting me know that my stolen tote bag was dropped off "by a homeless guy" at the Moffitt ED. Most of my stuff was still there (!) including:

- psychiatry case files book
- medical student ID
- stethoscope
- reflex hammer
- key
- pager
- two notebooks
- chapstick
- umbrella

The only things missing that i can tell so far were a cliff bar, the battery from my pager, and a pack of 50 cards for 1-800 quit tobacco. Found objects include a BART card and a flyer for a tattoo parlor.

Not sure what to make of this...maybe the man who smashed my car window realized that he stole a bag from a painfully dorky medical student and took pity on me?

boosts

Last night my car window was broken and my book bag taken as I was eating dinner in SOMA. Bummer. Like any curious medical student, I started almost compulsively googling some background reading and found that these car burglaries or "smash and grab" crimes (known as "boosts") are way too common in San Francisco, with an average of 41 incidents per day in the city!

Many medical students have experienced car burglaries even in the Sunset, which is relatively safe, and some have had their cars stolen. It's like owning a bicycle in college....it WILL get stolen! Accepting these crimes as a fact of life is frustrating.

Interestingly, after a campaign to crack down on car burglaries, the police reported that "the team has arrested 34 people, according to department spokesman Sgt. Steve Mannina, which has contributed to a 22 percent drop in incidents reported between October of this year and October 2006."

"By arresting one person, we prevent at least 10 to 20 [break-ins] per week,” Lazar said. “One person doesn’t break into just one car. They move on and target more.”

This week, my car window got broken and I lost all of my psychiatry materials.

Last week, a psychiatric patient escaped from the hospital under my supervision...but he came back six hours later to "get his stuff back"!

Sigh.

Mnemonic for EKG Lead Placement

Today in anesthesiology, I helped out with the setup for a patient undergoing a whipple procedure for pancreatic cancer. the surgery lasted all day (roughly 8-5pm) and was pretty complex, plus there was a really amazing resected specimen (part of the pancreas, duodenum, with a huge yellow globular tumor). slices of the tumor were sent to a tissue bank and the rest was sent to pathology. but i digress.

after the whipple man was well underway, i tagged along and observed four IVF procedures in which eggs were being harvested from hormonally primed women. then i bounced back to the OR to help set up 2 more patients for a D&C and TVH.

slowly, i am starting to learn how to think like an anesthesiologist. also, i am starting to figure out the myriad of procedures that have to be done in a hurry. during the IVF procedures, it was amazing to think about how marvelous noninvasive inventions like the EKG, pulse oximeter, and even an O2 nasal cannula with CO2 monitors can improve patient safety without harming the patient at all. anesthesia itself has always amazed me...how can a person go to sleep, have their abdomen exposed, have a tumor resected with their plumbing all reconnected...and wake up with minimal pain (thanks to an epidural), alive and kicking? the miracle of anesthesia. amen.

oh wait, i forgot about the title of this post.

so the EKG leads in the OR have 5 leads. on the left side, the resident taught me the mnemonic "smoke over fire," meaning that the red lead is below the black lead (and the brown lead is in between, pretend it's wood if it makes you feel better). on the right side, the green lead is below the white lead, so I have decided to make my own mnemonic: "snow falling on cedars." okay, okay, I know that the biggest criticism of my MSP lessons (based on comments in Evalue) was that I was heavy on the mnemonics, but there are oodles of things in medicine that don't have any intrinsic meaning...like why the white lead has to be white...and why i am spending time typing this ramble when I should be sleeping....zzzz...

anesthesiology

Currently on a 2-week anesthesiology rotation at mount zion, and it's pretty cool so far. During grand rounds this morning, I got the impression that anesthesiologists seem happier than surgeons...! There's a lot of cool procedures (i got to put in an LMA today) and different medications to use, and there's a great emphasis on thinking through the patient's physiology.

family planning

Visiting the Family Planning Clinic in Fresno, California, was an important part of our Ob/Gyn rotation and of our medical education. Although most students have mixed feelings about elective abortions, the general consensus appears to be that most students are pro-choice, but would never be able to personally perform abortions. How can there be such a contradiction? It is almost impossible to be neutral or apathetic about the issue of abortion, because everyone has deeply held personal beliefs, personal experiences, and cultural or religious backgrounds that influence how we feel and act.
The doctor working at the Family Planning Clinic was extremely cordial and eager to teach medical students. He encouraged us to ask questions and made efforts to have us observe several procedures. After the embryos were extracted, the doctor had the samples placed in dishes of saline so that we could observe the villi, gestational sac, and parts of a 14-week embryo.
There were several moments during the visit when I was very grateful for the opportunity to visit the Family Planning Clinic to observe an important process that even doctors and hospitals will not openly acknowledge. It also made me aware of how difficult it is to be a woman with an unwanted pregnancy with few options, and how the stigma of abortion can be still be so potent. Overall, the experience strengthened my conviction that legalizing abortions is crucial to women’s health and well-being, because so many women would lose their lives to infection, hemorrhage, and dangerous procedures if safe, effective, and confidential medical procedures were unavailable.
Admittedly, there were also a few moments when I experienced twinges of sadness. Gazing into the saline dish, we could see the gestational sac and 2-centimeter body of the 14-week embryo. The embryo’s head had been ripped apart during the vacuum process, but we could still discern the legs, spine, and arms down to the tiny fingers. When we found the embryo head, the two small eyes seemed to be staring at us with a sad confusion that mirrored my own unresolved feelings.

My intellectual mother, part 2

Chatting with my 13 y/o brother....

Jeremy: Mom is too mad to talk right now

me: whoa...why is she mad ?

Jeremy: The book she read was the worst book she ever read

me: HAHAHA

Jeremy: The series was called the dreamers
In the end, they went in the past and killed the enemy
Leaving all the books before useless

Tip #3: Pregnant? Go See a Doctor ASAP.

Pregnant women of the world, please see a doctor AS SOON AS you think that you might be pregnant. Not only can you get a second pregnancy test, but you can start your prenatal care early. Fetuses need healthcare too, but the most important thing might be the first sonogram to estimate the age of the fetus. Combined with knowledge of your exact LMP (the first day of your last period), doctors can make better decisions about your healthcare...everything from deciding when you might need an induction to whether your fetus is growing normally.

I always wondered by doctors get very persnickety and anal about "dating" the pregnancy, but now realize that it is a fundamental and often underestimated part of the process.

respect

I often enjoy David Brooks' columns in the NYT, here is a particular quote of a quote for today:

"In 2005, Ryne Sandberg was inducted into the baseball Hall of Fame. Heclo cites his speech as an example of how people talk when they are defined by their devotion to an institution:

'I was in awe every time I walked onto the field. That’s respect. I was taught you never, ever disrespect your opponents or your teammates or your organization or your manager and never, ever your uniform. You make a great play, act like you’ve done it before; get a big hit, look for the third base coach and get ready to run the bases.'”

However, I disagree with Brooks' assertion that we must return to a culture more reliant upon institutional thinking. I am still a big believer in the philosophy of a liberal education, as Brooks points out:

"A few years ago, a faculty committee at Harvard produced a report on the purpose of education. “The aim of a liberal education” the report declared, “is to unsettle presumptions, to defamiliarize the familiar, to reveal what is going on beneath and behind appearances, to disorient young people and to help them to find ways to reorient themselves.”
The report implied an entire way of living. Individuals should learn to think for themselves. They should be skeptical of pre-existing arrangements. They should break free from the way they were raised, examine life from the outside and discover their own values."

Whether we devote ourselves to individualistic "thinking" or institutional "thinking" is not even the point; both labels describe certain automatic behaviors. We need to be capable of thinking (and I say this in italics) in a consciously unbiased manner instead of blindly following our own needs or conforming to the demands of society.

Happy Chinese New Year!

Year of the Ox. :)

When I Grow Up

The favorite questions between classmates during this season are: 1) Are you taking a year off? and 2) Do you know what you might go into?

No. And no.

Throughout medical school, I always assumed that the right field would seem immediately and obviously perfect for me. Maybe it would be when I diagnosed my first ear infection in a 2-year-old in Pediatrics. Maybe it would be when I first saw an open abdomen under the bright lights in an OR during Surgery. But somehow, working on the theory that finding a medical profession can be as easy as love at first sight has...well...turned out to be harder than imagined.

Writing has always been a way for me to process emotions and explain decisions. But during third year, writing has been difficult due to time constraints, privacy issues, and my inability to sit down and ponder the journey that will be my life.

Stay tuned for future angst.

Fresno, CA

Fresno is an inland city located in California's Central Valley approximately midway between San Francisco and Los Angeles. In many ways, Fresno is very different from San Francisco...the median income for a household in Fresno is $32,236 vs. $57,833 in San Francisco according to wiki. There is a larger population of Hispanic and minority patients, and most of the Asian patients in Fresno are the legendary Hmong. (Legendary because Hmong culture is featured extensively in our required reading during medical school as part of lessons in cultural sensitivity, but rarely seen in San Francisco).

In Ob-Gyn, our female patients tend to be younger, healthier, poorer, and less educated than patients probably seen at other hospitals in the Bay Area. A fair amount of patients are illiterate. Many are immigrants from other countries. Learning medicine in a non-academic center has been new and refreshing for me, and I have been able to practice my medical Spanish. I had wanted to do obgyn in Fresno because 1) it seemed like a good idea to do an away rotation to see new settings; 2) Fresno has one of the highest birth rates in CA; 3) I've never been to Fresno; 4) I wanted to practice my Spanish.

I haven't spoken much Spanish since college, and have been amazed again at how beautiful the language can be. Honestly, Spanish is more expressive and beautiful than English or Mandarin...and this is coming from a pseudo-Asian American English major. There are so many shades of meaning, and interesting quirks to think about...like how the term for giving birth is "dar la luz" (literally: give light), or why someone can be "estar muerto" (dead) when the verb "estar" implies a temporary state. Or even why someone can be "ser joven" (young) when "ser" usually implies a permanent state. Don't get me wrong, my Spanish is still fairly poor.

Another interesting thing about Fresno is the lifestyle...the buildings are spread out, there are gazillions of chain stores like Target, Starbucks, Costco, and plenty of parking and free high quality food at the hospital. The people in Fresno tend to be more open, friendly, less pretentious and more humble. :)

Tip #2: Wipe from Front to Back

Ladies, avoid getting UTI's by wiping from front to back (if you know what I mean).

Interesting NYT article on abortions in the NYC Dominican community: http://www.nytimes.com/2009/01/05/nyregion/05abortion.html?pagewanted=2&fta=y

ObGyn is fun! I enjoy working in the clinic and seeing different aspects of female reproductive health. Today I saw a few colposcopies for cervical dysplasia and worked up a case of bilateral breast pain. In the past week, there have been a few endometrial biopsies, some PID, a MRSA abscess, lots of prenatal appointments, and lots of birth control appointments. :)

Ladies, Keep Track of Your Period

Current in Fresno on my ob-gyn rotation. Fresno is a cool town, and medical students get free housing! So far, I like how ob-gyn is such a great mix of medicine and surgery.

Public Service Announcement: Ladies, PLEASE KEEP TRACK OF THE FIRST DAY OF YOUR PERIOD. In clinic, less than 25% of women know the date of their last menstrual period (LMP). This is just sad and pathetic, because obviously it's not hard to keep track of your period using a calendar, but rather indicates that medical professionals suck at teaching patients how take charge of their health. This will also come in handy not only if you're pregnant, but also if you show up at the Emergency Room with appendicitis...they will want to know your LMP.

Don't worry about anything more than the FIRST DAY of your period.

Raise Your Kids in Arcadia, CA

Sorry again for the lack of posts...surgery was busy and full of dramatic stories to be related soon. A belated Merry Christmas and Happy New Year! :)

Also just wanted to let everyone know that my hometown of Arcadia, CA was named the best place in California to raise your kids in 2009 accordinging to Business Week magazine! And the Rose Queen in the 2009 Pasadena Rose Parade is an Arcadia High School student! :)

See links: http://images.businessweek.com/ss/08/11/1110_best_places_for_kids/6.htm

Kid-Friendly and Cost-Friendly

By Prashant Gopal

Welcome to BusinessWeek's second annual roundup of the best places to raise your kids.
This year we are going state by state. Once again working with OnBoard Informatics, a New York-based provider of real estate analysis, we selected towns with at least 50,000 residents and a median family income between $40,000 and $100,000. We then narrowed the list of towns using the following weighted criteria: school performance; number of schools; household expenditures; crime rates; air quality; job growth; family income; museums, parks, theaters, and other amenities; and diversity. We weighted school performance and safety most heavily, but also gave strong weight to amenities and affordability.

Bear in mind with this list, the organizing principle was affordability. While the median household income varies by state, we purposely weighted the results to prevent pricing out most readers. That's why, for example, Greenwich, Conn., with its good private schools, low crime, and abundance of cultural amenities, was left out. It simply costs too much to live there.
Of course, there are other places that are great for kids which did not make this list. In many states the competition was extremely close. Moreover, we looked for communities that scored well across the board. So, while there might be places that offer more culture, better schools, etc., other factors such as crime or a high cost of living knocked them down.

Surgery. 'Nuff Said.

Sorry for the lack of posts...I fell off the blogging bandwagon for a few weeks.  

Currently, I just finished week 3/8 of Surgery at Mt. Zion/Parnassus.  MZ is UCSF's cancer center, and I love being on the surgical oncology White service (the Gold service at MZ does colorectal cases).  White surgeries include GI malignancies (whipple's, etc), liver resections, and melanoma.  

Surgical oncology seems like a great field, there's a lot of satisfaction to be gained from whacking out a tumor.  

P.S. It seems like a bad dream...how did Prop 8 AND Prop 2 BOTH pass?  Since when do chickens enjoy advances in rights...while humans do not?

SAVE GENERAL HOSPITAL

http://www.savesfgeneral.com/

San Francisco voters, please vote YES on Prop A to make San Francisco General Hospital earthquake-friendly.

SELECT trial halted!

As a prostate cancer/oncology geek, I have to let you know that the huge trial examining whether selenium + Vitamin E prevents prostate cancer (results were due in 2013) was closed permanently yesterday!

Researchers found that there was a small but significant increase among vitamin E users to develop prostate cancer, and a small but significant increase in the incidence of diabetes among selenium users.

Juicy oncology gossip!

Discuss.

Intersession 2 and a Really Nice Weekend

Big Sur from the Lucia Lodge restaurant porch

best fish and chips ever

The MS3's are midway through Intersession 2, a week-long break between 3rd and 4th block. It's interesting that even though I had more free time during Family Medicine, I actually ended up blogging less. During Intersession, the students engage in a variety of touchy-feely small groups and lectures about medical ethics and professionalism. It's actually a good time to unwind and reflect on how we are changing on our journey to becoming doctors.

Last weekend after the Family Medicine exam was also extremely nice. To start, I spent an hour walking around Lake Merced by myself before sunset, which is something that I wanted to do for six weeks after glimpsing the beautiful lake through a window at the Janet Pomeroy Center (a fantastic center for children and adults with disabilities that FCM introduced me to via a community project). Lake Merced is beautiful; there are so many areas of the city that I haven't explored yet (the SF Zoo is nearby too).

Gingivostomatitis

I diagnosed my first case of gingivostomatitis this morning in a 2-year-old girl who had reported to the ED 5 days ago with a fever of 104 degrees. The ED thought thought that she had OM, and gave her amoxicillin. The next day, the patient presented with mouth sores and continued running a fever. Her gums were swollen and purplish, and she had oral lesions in her buccal mucosa, on her tongue, and soft palate.

After checking her normal TM's b/l and ruling out HFMD (oh, Coxsackie, I know you well after catching you during my peds rotation) and chicken pox (vaccinations UTD, no rash), the leading diagnosis was herpetic stomatitis caused by HSV-1.

Even though it was a relatively simple case, it feels good to have a solid differential and coming up with a diagnosis. One of the things that I enjoy most about the outpatient clinic is seeing new patients with fresh eyes, being the first person to examine a patient and figure out what's going on. For instance, last week, I saw a 3 y/o boy with a 6 cm cervical LN. I find myself enjoying acute/urgent care more than routine physicals/WCC/healthcare maintenance (but predictably enjoy the Pap smears, FOBT, PSA, and other cancer screenings).

In family medicine, I have also found myself having an irrational fear of pregnant women (having not yet done OB-GYN, pregnant women are a black box to me), and an extreme fondness for taking care of children who are acutely ill.

Wish List: paJAMAs

When they start making flannel JAMA PAJAMAS, please tell me so I can get me one'a'those. Brillz.

Welcome, MS1's!

Orientation for the youngsters started last week, but I just wanted to say "HI" on my blog to the fresh-faced med students who will be having their white coat ceremony tomorrow. Sorry for being a deadbeat MS3, you will probably never see me unless you like to shadow doctors at Moffitt (you eager beaver you).

Ironically, as a first year, I always wondered why we didn't meet any MS3's or MS4's, apparently they were too busy to mingle with the first and second years. Also, we never get to attend any UCSF graduations, so there is a particular divide between MS1/2 and MS 3/4, that UCSF could probably remedy to some degree. Anyway, it's just funny that now I AM the shadowy MS3 whom you will never meet, and therefore assume that I am aloof and a little bit eccentric (ah, first non-impressions).

Enjoy medical school, and for goodness' sake, HAVE FUN this year and next year. Enjoy the pass/fail system and relax (you won't listen to me, but i'll say it anyway). Try to go to class. Eat the hashbrowns in the Moffiteria. Avoid the hospital. Do what you love. Hang out with friends and family. Don't worry about the Boards until perhaps Nov.-Dec. of your second year. Be nice to the MSP teachers and don't be (too) mean to the small group leaders. DON'T BUY ANY OF THE TEXTBOOKS ON THE LIST!! (except for Netter's and Blumenfeld, which you can buy in May). YOU NEVER USE THE TEXTBOOKS.

Good luck, medlings!

Family Medicine

My family medicine rotation started yesterday, and it's been nice so far. The rotation is entirely outpatient, with no call nights and every weekend free...which is great because i never had a "golden weekend" for 8 weeks on medicine. In many ways, the family medicine rotation is different from other rotations, and not just because it's entirely outpatient, but also in terms of philosophy and mindset. There's an emphasis on continuity of care, being the medical "home" for a patient, and doctors can care for entire families throughout the generations. The "bread and butter" conditions for family medicine are chronic -- HTN, COPD/asthma, HL, CAD, DM. Psychosocial issues like substance abuse, domestic violence, or homelessness -- which can be swept under the rug by time constraints in an inpatient ward -- become more important during family medicine.

During orientation, the clerkship director asked us how patients have already been affected medically even before we see them during the first new patient visit. It was a confusing question, but it's not just past surgeries or vaccinations, etc. that affect a patient...other factors such as environmental pollution, McDonald's, and rising gas prices can affect someone's health. I never appreciated how family medicine can be a vehicle for advocacy for many different things in the "real world" that impact health and well-being.

On another (non med) note, the media has exploded recently with the debut of Sarah Palin -- i've never seen so much press on one person in one week. She has made the news interesting lately, to say the least.

Home Conversations

Home in Arcadia before starting Family Medicine.

After passing by Jeremy's old preschool, my siblings and I started talking about how we used to eat dirt, grass, and insects when we were in preschool.

"My friends and I ate ants," Jeremy said, "They were spicy."

"At least you ate them with friends," Samantha retorted, "I ate grass ALONE."

Love my family. :)

the case of the bloody poo

Mike and I were trading stories about medical cases that we've seen recently. My fault, really, since I'm obsessed with medicine and can't stop talking about work (since that's all I do anymore, anyway). After I told Mike about my current patient with weight loss of unknown origin and a recent case of Q fever endocarditis, Mike told me the following pediatrics case that he saw today:

"Six-year-old boy, the story is that he took a dump this morning and it was bright red. No stomach pain, might have had a similar poop last night, no vomiting, heart rate is stable, no signs of dehydration or shock, kid is in no apparent distress."

"INTUSSUCEPTION!" I yell.

"No. So the resident does a digital rectal exam, and his glove comes out bright red and covered in poo. The resident smears his glove on a FOBT (a strip of paper that turns color when poo with blood gets smeared on it, even if the blood is not visible to the naked eye), and the strip never changes color."

"The strip should change color," I said, "so either the strip is defective or it's not really blood."

"Right, but what is it?"

"Meckel's?" I said.

"No. Then we asked the boy to pee in a cup. Why?"

"To check for hematuria or proteinuria?"

"No, even simpler."

"To see if his pee is red too?"

"Yes! Because eating too many beets can color your poop and your pee."

"Was it red?" I asked.

"No, his urine was not red."

"GI bleed?" I said, "he doesn't seem to be in distress. He's too young for colon cancer, diverticulitis, or ulcers.

"No. Give up?" Mike asked.

Yes.

"So the resident is totally clueless. We talk to the attending, and the attending laughs. He says that a couple years ago, when RED HOT CHEETOS hit the market, there was a huge outbreak of kids with bright red poo. And this was the case."

"that's all i can do"

Mr. D suffered from the lung disease that killed Evel Knievel -- idiopathic pulmonary fibrosis (IPF). The word "idiopathic" in medicine is a code word that means "doctors have no clue what the cause of the disease can be." As a result, Mr. D couldn't breathe anymore -- his lungs were like a pair of old dishwashing sponges left in the sun to dry. Needless to say, there wasn't much oxygen exchange happening. So Mr. D got a lung transplant -- just one lung because organs are in short supply and that's actually sufficient for someone to live. When you have a new organ, you have to take lots of drugs to keep your immune system down so that it doesn't reject the new heart/lung/kidney, but that also renders you susceptible to millions of germs and bacteria that would otherwise be harmless. So Mr. D came down with a fungal infection -- Aspergillus -- and a bacterial infection -- Pseudomonas.

When Mr. D came to the hospital for a short procedure, he seemed okay. It was interesting listening to his lungs, because his right lung (the "native" one with IPF), sounded like tissue paper crackling. His left lung had normal breath sounds. It was listening to two different lungs in one person. I was immediately struck by how equanimous Mr. D was, especially when I asked him if it was okay for a group of medical students to come by and listen to his interesting physical exam. He was a quiet, scholarly guy in his 50s with graying hair -- the type of patient with glasses and a copy of the New York Times on his bed.

After I switched services, Mr. D was ready to go home when something nearly catastrophic happened. He developed a massive bleed into the space behind his back -- his retroperitoneal space. The bleed was idiopathic. Mr. D landed in the ICU and suffered from acute renal failure --- his kidneys were in trouble.

A few days ago, I saw Mr. D while walking through the ICU and dropped by to say hello. Mr. D looked pale and sick, his head was tilted to one side, but he was still conversant. I nervously eyed a length of tubing filled with blood emerging from his body -- he was on CVVH, which filters the blood and helps out by mimicking the kidney. The doctors were thinking that he might need to go on dialysis for the rest of his life.

"Hang in there, Mr. D," I chirped.

He looked at me with tired eyes filled with weary, stubborn resignation.

"That's all I can do," he said softly.

satire on intellectual pretension

NYT yesterday, the most amusing, hilarious, mockingly pseudo-intellectual satire that I've read in a while. There are some valid points...have we become a society that values the aggregator over the creator? Is the mode of information delivery more important or prestigious than the information itself?


Lord of the Memes

By DAVID BROOKS
Published: August 7, 2008

Dear Dr. Kierkegaard,

All my life I’ve been a successful pseudo-intellectual, sprinkling quotations from Kafka, Epictetus and Derrida into my conversations, impressing dates and making my friends feel mentally inferior. But over the last few years, it’s stopped working. People just look at me blankly. My artificially inflated self-esteem is on the wane. What happened?

Existential in Exeter



Dear Existential,

It pains me to see so many people being pseudo-intellectual in the wrong way. It desecrates the memory of the great poseurs of the past. And it is all the more frustrating because your error is so simple and yet so fundamental.

You have failed to keep pace with the current code of intellectual one-upsmanship. You have failed to appreciate that over the past few years, there has been a tectonic shift in the basis of good taste.

You must remember that there have been three epochs of intellectual affectation. The first, lasting from approximately 1400 to 1965, was the great age of snobbery. Cultural artifacts existed in a hierarchy, with opera and fine art at the top, and stripping at the bottom. The social climbing pseud merely had to familiarize himself with the forms at the top of the hierarchy and febrile acolytes would perch at his feet.

In 1960, for example, he merely had to follow the code of high modernism. He would master some impenetrably difficult work of art from T.S. Eliot or Ezra Pound and then brood contemplatively at parties about Lionel Trilling’s misinterpretation of it. A successful date might consist of going to a reading of “The Waste Land,” contemplating the hollowness of the human condition and then going home to drink Russian vodka and suck on the gas pipe.

This code died sometime in the late 1960s and was replaced by the code of the Higher Eclectica. The old hierarchy of the arts was dismissed as hopelessly reactionary. Instead, any cultural artifact produced by a member of a colonially oppressed out-group was deemed artistically and intellectually superior.

During this period, status rewards went to the ostentatious cultural omnivores — those who could publicly savor an infinite range of historically hegemonized cultural products. It was necessary to have a record collection that contained “a little bit of everything” (except heavy metal): bluegrass, rap, world music, salsa and Gregorian chant. It was useful to decorate one’s living room with African or Thai religious totems — any religion so long as it was one you could not conceivably believe in.

But on or about June 29, 2007, human character changed. That, of course, was the release date of the first iPhone.

On that date, media displaced culture. As commenters on The American Scene blog have pointed out, the means of transmission replaced the content of culture as the center of historical excitement and as the marker of social status.

Now the global thought-leader is defined less by what culture he enjoys than by the smartphone, social bookmarking site, social network and e-mail provider he uses to store and transmit it. (In this era, MySpace is the new leisure suit and an AOL e-mail address is a scarlet letter of techno-shame.)

Today, Kindle can change the world, but nobody expects much from a mere novel. The brain overshadows the mind. Design overshadows art.

This transition has produced some new status rules. In the first place, prestige has shifted from the producer of art to the aggregator and the appraiser. Inventors, artists and writers come and go, but buzz is forever. Maximum status goes to the Gladwellian heroes who occupy the convergence points of the Internet infosystem — Web sites like Pitchfork for music, Gizmodo for gadgets, Bookforum for ideas, etc.

These tastemakers surf the obscure niches of the culture market bringing back fashion-forward nuggets of coolness for their throngs of grateful disciples.

Second, in order to cement your status in the cultural elite, you want to be already sick of everything no one else has even heard of.

When you first come across some obscure cultural artifact — an unknown indie band, organic skate sneakers or wireless headphones from Finland — you will want to erupt with ecstatic enthusiasm. This will highlight the importance of your cultural discovery, the fineness of your discerning taste, and your early adopter insiderness for having found it before anyone else.
Then, a few weeks later, after the object is slightly better known, you will dismiss all the hype with a gesture of putrid disgust. This will demonstrate your lofty superiority to the sluggish masses. It will show how far ahead of the crowd you are and how distantly you have already ventured into the future.

If you can do this, becoming not only an early adopter, but an early discarder, you will realize greater status rewards than you ever imagined. Remember, cultural epochs come and go, but one-upsmanship is forever.

Heart Attack? Do This Now.

Working on the cardiology service, here is my public service announcement on heart attacks adapted from http://www.health.com/health/condition-article/0,,20188758,00.html

"If you are having chest pain and you do not have nitroglycerin:
1) Call 911 or other emergency services now. Describe your symptoms, and say that you could be having a heart attack.
2) Stay on the phone. The emergency operator will tell you what to do.
3) After you call for help, chew one regular-strength uncoated aspirin. Aspirin helps keep blood from clotting, so it may help you survive a heart attack.

The best choice is to go to the hospital in an ambulance. The paramedics can begin lifesaving treatments even before you arrive at the hospital. If you cannot reach emergency services, have someone drive you to the hospital right away. Do not drive yourself unless you have absolutely no other choice."

the.most.awesome.bedroom.ever.

from BIDMC CEO Paul Levy's blog

Boston's Fenway Park on a bedroom mural! Can I get one for my future kid?? This mural is so awesome! You could get little sox player dolls and stick them on the bases -- too bad the Manny doll was lost. At least he went to my hometown Dodgers...

garp quote

just started reading for fun, from irving's the world according to garp:

"She felt if she ever had children she would love them no less when they were twenty than when they were two; they might need you more at twenty, she thought. What do you really need when you're two?

In the hospital, the babies were the easiest patients. The older they got, the more they needed; and the less anyone wanted or loved them."

q2 and randy pausch

Post-call from medicine service, starting cardiology tomorrow and guess what? I'm on call! I'm going to sit and vegetate at home today.

In other news, Randy Pausch passed away on Friday, 7/25. Sad sad news. :(

http://www.cmu.edu/homepage/beyond/2008/summer/an-enduring-legacy.shtml

Med Culture: Phrases I Hate

Phrases That Annoy Me (used by med folks among themselves):
- "touch base" with med onc/neuro/etc.
- "teaching point"
- "common things being common"

Phrases I Like:
- "our service"
- "patient census"

"only at Moffitt"

Since my first two blocks have been at Moffitt -- UCSF's fancy shmancy ivory tower tertiary medical center -- I'm starting to realize that my view of medicine can be a bit skewed. Someone observed that yes, we can get regular bread-and-butter medical cases like pneumonia or heart disease, but there's usually some exotic past medical history (a transplant, a rare genetic disorder) or some unusual aspect of the case (patient has PCP pneumonia). We see patients that can be very sick, and an attending warned us that it is not uncommon for a fair number of patients to pass away at Moffitt.

Some people have jokingly dubbed Moffitt "the Death Star," partly because of the complexity/severity of the cases, but also because there appears to be this consensus that the medical culture at Moffitt is highly intense, demanding, and academic.

From my perspective, there appears to be some truth to the rumors, but I wouldn't have ranked Moffitt so highly on my list if I wasn't interested in seeing rare medical cases (nicknamed "zebras" in medical slang, as opposed to the more common afflictions called "horses" ). I have always had a soft spot for academic medicine, and it's interesting seeing how different specialists work together to unravel or treat challenging medical conditions. Later this year, I will be doing family medicine in the Bay area, ob-gyn in "rural" Fresno, and neuro-psych at the General (SFGH), so there will be an interesting mixture of sites and practices to experience.

However, I am enjoying my time at the medical Ivory Tower with the aforementioned zebra folks. In pediatrics, I saw a patient with a disorder so rare that it affects 1 in 2 million people and there are only 230 cases in the U.S. It was also fairly common to see kids with fetal or neonatal abdominal surgeries, 2 babies with short gut syndrome who are on Hospital Day #301, kids with rare genetic mitochondrial disorders, a 14-year-old with a stroke who left AMA, a teenage boy with lupus (SLE), and a 12-year-old boy with anorexia. Kawasaki syndrome was not an outrageous differential when a child had a fever for over 3 days.

Adult medicine at Moffitt has been similarly intense and interesting. During our last intersession, Dr. Don Ganem told us anecdotes from his days as an infectious disease fellow at UCSF in the 1980s during the HIV/AIDS era, and how bizarre infections like PCP pneumonia, cryptococcal meningitis, and Kaposi's sarcoma became "bread and butter" cases at SF General Hospital and Moffitt. When he asked a third-year med student what the most common cause of community-acquired pneumonia was, the MS3 answered, "PCP." Dr. Ganem continued by saying, "I was going to whale on the student, until I realized that that was really all that he ever actually saw in the hospital." Sometimes, I can sympathize with the situation of Dr. Ganem's hapless student -- all zebras and no horses.

Our medicine service had 11 patients, three of which were double-lung transplants. We usually have at least 1 lung transplant patient, sometimes a kidney transplant or a patient with a rare cancer (adult rhabdomyosarcoma of the cervix, primary CNS lymphoma and HIV negative, a metastatic paraganglioma presenting like pheochromocytoma). Many of our patients have serious bacterial infections, and some have end-stage liver or renal disease.

Whenever a resident or attending hears a fantastically unusual medical case -- say, a 22-year-old with a STEMI, intermittent fevers, acute renal failure, bilateral PE's, and a violaceous vesicular rash on the left side of the body -- there is a classic reaction: the doctor's eyes widen slightly, the eyes roll up to the ceiling, there is a deep sigh, and finally exhalation of the ritualistic phrase, "Only at Moffitt."


Lunchtime conversation with a fellow med student at Moffitt:
A: "My vision has been blurry and my head hurts lately...I think I have a brain tumor."
B: "Are you sure it's not a vasculitis...or a demyelinating disorder?"

Troponin Leak?!?

Doctors keep throwing around the phrase "troponin leak," and I came across this doozy paper while reading up on the mysterious term:

CASE REPORT

Cardiac Troponin I Elevation After Orogenital Sex During Pregnancy

José Mauricio Sánchez, MD1, Michael R. Milam, MD, MPH2, Tracy M. Tomlinson, MD3 and Michael A. Beardslee, MD1

From 1Washington University School of Medicine, Division of Cardiology, St. Louis, Missouri; 2Department of Gynecologic Oncology, M. D. Anderson Cancer Center, Houston, Texas; 3Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri.

ABSTRACT

BACKGROUND: Venous air embolism due to orogenital sex in pregnancy is an uncommon clinical event.

CASE: A previously healthy, 29-week pregnant woman presented to the emergency room unconscious 1 hour after engaging in orogenital sex with her partner. The cardiology service was consulted due to troponin elevation. Assessment was that the patient had likely suffered an air embolism with associated troponin leak.

CONCLUSION: Although a rare clinical event, air embolism from air insufflation of the vagina can result in troponin elevation and should be considered in the differential diagnosis in pregnant patients with a history of orogenital sex.

Obstetrics & Gynecology 2008;111:487-489 © 2008 by The American College of Obstetricians and Gynecologists

edward hopper in vietnam

Sent to me by Kim, traveler/dreamer/medical student extraordinaire. Recalling my love of Hopper's paintings, she took this photos that looks strikingly Hopperesque with solid blocks of light, neutral color, stark shadows, and straight lines. Her poetic emails remind me that there is life and literature and adventure outside of the medical ivory tower -- I can't help feeling a bit like a pale imitation of Rapunzel or the Lady of Shalott.

a leaf falls

Medicine has been great so far, it is almost the end of my third week and we are on-call tomorrow. What impresses me is that almost everything can fall within the umbrella of internal medicine -- the heart, the lung, the brain, the GI tract, and infections of every kind.

What also impresses me is how the doctors at UCSF in the dept. of medicine are so devoted to educating the medical students and taking the extra time to teach us when they could easily ignore us or make us do scutwork (KIDDING). in fact, the culture of the medicine dept. at Moffitt has been so welcoming and comfortable. As a third year medical student, it's easy to feel like the smallest kid in the medicine family, and the residents and attendings recognize this and take the time to truly nurture us.

Medicine has also been extremely busy, and 8 weeks of inpatient care with call every 4 days (we don't usually stay overnight, but sometimes we can be home from 3-6 a.m.) can be a marathon. One thing that I've noticed and somewhat expected (now that there's time to be contemplative and write long blog entries) is that third year can feel rather isolating. There's not much time to do things beyond shower, eat dinner, and maybe clean the kitchen and I've been trying unsuccessfully to sleep at 10 pm. Although it's nice to see my classmates in the hospital and build relationships with patients and my team, I miss feeling connected to people outside of the hospital and having leisure time without all the weekends blurring away into a 4-day cycle of work-work-work-sleep. Watching my interns and residents, it seems like there will be at least several more years of sleepless, blurry weeks before I can be a craggy old attending who doesn't carry a pager and makes tennis dates with his colleagues (for reals).

Bad Puns

Resident: "IR can be very picky (PICCy)"

Me: "I don't have any patients (patience)!"



No pun intended (really):

Intern: "She's radioactive....and disobedient."
Day float: "I don't like disobedient radioactive patients...[looks down at paper]...who have anxiety."

Things Learned in Medicine (so far)

1) 80% of the time, when a doctor asks you how to initially treat a patient's condition, "IV fluids" is correct. This does not work for CHF. It does work for pancreatitis.

2) Our attending teaches us to -- above all -- "do what's right for the patient." I have found that this mantra can rarely lead you astray.

3) In terms of H&P presentations, accuracy > speed > thoroughness.

4) Food is good for the soul

Lost in Medicine Land

Sorry for the paucity of postings...I've been spending 70% of my time at the hospital learning how to think about sick grown-ups. Medicine has been great so far; the culture is definitely different from peds, but I feel more comfortable in medicine than expected. In peds, the residents almost never wore white coats and had silly colorful toys. In medicine, everyone wears a white coat and the whole setting is slightly more formal, but still comfortable and very dedicated towards nurturing the med students. :-)

This morning, I got a numeric page on the 14th floor of Moffitt, so I called back saying, "this is Stephanie returning a page."

"Stephanie? Stephanie Chang?" the voice said on the other line.

"Yes."

"This is the ICU attending," the voice continued, "and I have to say that I am very disappointed..."

at that point I started experiencing dyspnea...

..."your progress note this morning was horrible..."

...my vitals were HR 99, BP 150/90, RR 22

..."JUST KIDDING, STEPH!"

It was a classmate of mine playing a prank on me. In the hospital.

If I wasn't the victim, I would say that it was genius....

Great Weekend

One of my best friends from high school came to visit me in SF last weekend, and we drove to check out Stanford Business School for him before going to an 80s cover band concert on Friday night. The next morning, we biked around the perimeter of Angel Island, which was reachable by ferry and surprisingly lovely. The bike ride took about 1.5 hours, and the best part was how you could get a 360 degree view of San Francisco bay and how each part of the path gave you a slightly different by no less breathtaking view of the colorful houses, blue water, and white sailboats. I liked how the scenic view changed as you labored around the island, the changing nature was perhaps one of my favorite parts. It's weird, I told Leo, how after we visited Alcatraz 2 years ago, that I would not visit Alcatraz more than once, but I would definitely visit Angel Island again.

On Sunday, we visited Napa and tasted wine at Freemark Abbey, Louis Martini (hands down the best cabs in terms of taste & value, all 5 wines were amazing and I couldn't dump a single drop), V Sattui, Mondavi, and Opus One (ridiculous and excellent $30 tasting of one extremely hyped- up wine). We also saw the view from Artesa.

Today in medicine, it made me happy to think that only yesterday I was in Napa. :-)

Gone Baby Gone II

Learned from a fellow medical student that the baby from my first delivery ever died a few weeks ago. It was a huge jolt, because I never expected the baby to die, even though his Apgars (assigned by me after some review with the peds team) were 3, 4, and 6. I assumed that he was going to make it after watching him for almost 10 hours after he was born, and now he has become my first peds patient to pass away.

Peds vs. Surgery

Notable quotes

...from peds: a boy in clinic with penis pain says that his "peanuts" hurts...Awww!

...from a friend in surgery: a resident who barks, "THERE'S NO TIME FOR TEACHING, ONLY LEARNING."

Pausch's Last Lecture

Four days of fever, 1 day of sore throat, and 1 day of recovery (6 days total) and I'm back to baseline....wow, that took way longer than expected. :( I'm a little bummed that my 2-week summer vacation was cut in half by a pediatric viral illness, but I'm glad that it happened at a "convenient" time (so to speak) when there was not much going on and no patients to see.

Talking to my roommate made me realize that there are different senses of the word "sick," there's the conversational "sick" when you have sniffles or a mild URI. Then there's the second-level "sick," when you can't get out of bed and feel truly miserable and incapacitated for a short while and remember how much it sucks to not be healthy. There's also "sick" in the sense of mental illness, which is chronic and difficult to describe and quantify, and there's also the profound sense of "sick," usually earning you that "coveted" admission to the hospital because one of your organs is failing, or you need surgery with dorky UC med students watching, or sometimes because you are dying.

Most people on the web have heard of Randy Pausch, PhD, the professor at Carnegie Mellon University dying from pancreatic cancer who gave a stirring "Last Lecture" about life lessons. A few months ago, I learned about him from an interview in Time magazine, but didn't bother to Google his lecture until a friend in pharmacy school told me about it in the laundry room today. You can watch it on Google videos, it's a bit long (76 minutes), but worth the investment.

Naturally, I was interested because Randy is a pancreatic cancer patient, and if you don't read my blog that often, I am interested in pancreatic cancer research. Different cancers have different mortality rates, but pancreatic cancer remains a fearsome predator among cancers with a median survival of 6 months depending on how far the tumor spreads.

Oncology keeps drawing me closer, but still no idea. I told my friend in the laundry room that I'm interested in oncology because it's work that continually reminds me by its very nature why I am working and what really matters in this life. Somehow, by working with pancreatic cancer patients who continually face this duel with death, I feel like oncology motivates me to work even harder and with more purpose. Paradoxically and more importantly, oncology also simultaneously inspires me to appreciate everything non-work related in life -- family, friends, food, food, creature comforts, beautiful moments, holidays, and the ease of health. How can anything else teach me so elegantly to value both work and everything non-work?

Dr. Pausch's video: http://video.google.com/videoplay?docid=-5700431505846055184
Dr. Pausch's homepage: http://download.srv.cs.cmu.edu/~pausch/

Happy Graduation, Matthew!

My little brother Matthew is graduating from Arcadia High School today!

Congratulations, Matthew!

Pictured with his prom date, but don't worry ladies, he's single! (as far as we know)

Coxsuckie

Did you know...?

From Wiki: "The Coxsackie viruses were discovered in 1948-49 by Gilbert Dalldorf, a scientist working at the New York State Department of Health in Albany, New York. Dr. Dalldorf, in collaboration with Grace Sickles, had been searching for a cure for the dreaded disease polio. Earlier work Dalldorf had done in monkeys suggested that fluid collected from a non-polio virus preparation could protect against the crippling effects of polio. Using newborn mice as a vehicle, Dalldorf attempted to isolate such protective viruses from the feces of polio patients. In carrying out these experiments, he discovered viruses that often mimicked mild or nonparalytic polio. The virus family he discovered was eventually given the name Coxsackie, for the town of Coxsackie, New York, a small town on the Hudson River where Dalldorf had obtained the first fecal specimens."

There's also a good Wiki clinical description:
"The most well known Coxsackie A disease is hand, foot and mouth disease (unrelated to foot and mouth disease), a common childhood illness which affect mostly children aged 10 or under[1], often produced by Coxsackie A16. In most cases infection is asymptomatic or causes only mild symptoms. In others, infection produces short-lived (7-10 days) fever and painful blisters in the mouth (a condition known as herpangina), on the palms and fingers of the hand, or on the soles of the feet. There can also be blisters in the throat, or on or above the tonsils. Adults can also be affected. The rash, which can appear several days after high temperature and painful sore throat, can be itchy and painful, especially on the hands/fingers and bottom of feet."

It should really be called Coxsuckie!!

The Other Foot-in-Mouth Disease

First day of my 2-week vacation and I come down with a 101.8 degree fever, mouth sore, and sore throat.

Today I woke up hoping it would be better, but I'm still sweating enough to fill a small swimming pool, must have caught something from the kiddos in pediatrics. Couldn't make it to my longitudinal clerkship in radiation oncology, but it's probably better not to give a virus to cancer patients getting chemotherapy. Stumbled into Student Health Services (SHS) this afternoon with a fever of 102.6 F, sore throat, apthous ulcer, and slightly bleeding gums. Since I just completed my pediatrics clerkship, my differential included strep throat and hand-foot-and-mouth disease (Coxsackie virus A).

As a kid, I remember getting HFMD with my siblings, and how I thought that it was called "Foot in Mouth Disease," and felt confused because that was supposed to mean something else...

Rapid strep test was negative (but you would still order a culture if your suspicions were strong), and the doctor said it was probably HFMD. The disease lasts 7-10 days (good use of vacation, eh?), and includes fever, sore throat, oral ulcers, and itchy vesicles on your hands and feet. Not all presentations have the full hand-foot-mouth thing.

My fever has been running pretty high these past 3 days, and i've been doing some reading on the internet to see if tylenol vs. motrin (ibuprofen) is better as a fever reducers. Some studies say ibuprofen, some say alternating both drugs works best.

Heal Thyself

Came down with a 101.7 F fever last night...must have caught something from the kiddos. I sat on the couch for a good 20 minutes before I realized, "Hey, I could be taking an antipyretic right now." So I took Tylenol, but at the clinic we always give feverish kids ibuprofen, I wonder which one works better for fevers. Another useful thing that I learned in peds is that fevers burn off a lot of water, so you have to rehydrate mucho -- and that dehydrated kids will decompensate a lot faster and with less warning than adults do.

Woke up this morning with a fever of 101.8 F...Arghhh.

My First Peds Patient in WBN

Baby Sierra (with permission)

Cancer Stem Cell Symposium

Recently found out that I missed a cancer stem cell symposium at UCSF...bummer.

http://cancer.ucsf.edu/symposium2008/

Education > Contraception

On adolescents: "An increase in the number of years of schooling for a woman delays the age at which a woman marries and has her first child."

Seriously?

What about men?

Smegma

Attendings throw around the word "smegma" occasionally in clinic, and I assumed that it was a slang term for secretory accumulations of "schtuff," but apparently it's an actual scientific term. Mmm, gross!

From Wikipedia:
"Smegma, a transliteration of the Greek word σμήγμα for sebum, is a combination of exfoliated (shed) epithelial cells, transudated skin oils, and moisture, and can accumulate under the foreskin of males and within the vulva of females. It has a characteristic strong odor. Smegma is common to all mammals, male and female. Mycobacterium smegmatis is the characteristic bacterium involved in smegma production, and is generally thought to form smegma from epidermal secretions."

Anti-Babies

Intern: "Baby M and Baby M2 are the anti-babies...don't put them together or they'll explode."

Bye Bye Baby

Babies are born into this world into different situations, and while most babies are born into loving families, the range of parents is amazing. Some parents have special "birth plans" and pediatrician appointments already established before the baby even leaves the hospital, while other babies need Child Protective Services (CPS) because the mom's living situation is unsafe or unstable.

Baby M was a small baby girl born during my second day of service in the newborn nursery, the daughter of a mom who told Jim, the intern, that she had used drugs, smoked a pack a day, and injected an IV "speedball" (cocaine and heroine) during her pregnancy. The situation was not unusual, but it naturally made the hospital staff a little concerned. Dad was in prison, mom was acting a little strange, and it was unclear whether mom would be able to take care of Baby M.

CPS offered to check mom into a residential rehab facility so that she could live with her baby, but mom was upset about not being able to take care of a dog at home. Since mom's urine tox tested positive for methamphetamines, and so did Baby M's, the staff decided to keep the baby in the nursery until mom detoxed a little. Usually, babies stay with their moms in the hospital rooms in order to promote bonding. Gone are the days when u see babies lined up in little rows behind a glass window, the newborn nursery is usually a quiet place when no circumcisions are occurring (just kidding).

Jim, the compassionate intern, urged that Baby M stay with mom to encourage bonding. Maybe spending time with her baby would convince mom to take CPS's offer of a second chance. Disappointingly, mom didn't seem to be interested in taking care of Baby M...who spent the same amount of time in the nursery as before.

Whenever we saw Baby M -- small, quiet, with a rounded nose -- sleeping in her crib alone in the newborn nursery -- I would look at Jim with a funny expression and he would shrug his shoulders at me with an air of disappointment. Jim really cared about Baby M.

On Friday, Baby M's mom was discharged from the hospital. CPS informed her that Baby M was going to be taken into foster care, but the full impact of the news seemed to escape her and she left.

It was quiet in the nursery that Friday afternoon. It was getting late -- 5 p.m. -- and people were leaving for home and the weekend. The sun was growing dimmer over a spectacular 15th floor view of San Francisco and the only occupant in the newborn nursery was quiet little Baby M waiting to be picked up by the foster care program at 6 p.m. Her eyes were open, but she was silent, so I picked her up and rocked Baby M in my arms for a few minutes to say good-bye. As I thought about how all of the other babies in the ward had gone home with happy families and all of the love and opportunity that awaited these other babies -- tears started coming to my eyes thinking about how Baby M was left behind in the hands of strangers.

When Baby M's mom dramatically returned to the newborn nursery the next afternoon -- glassy tears streaming down her face because she couldn't find her baby in the Well Baby Nursery or anywhere in the hospital -- it was hard not to feel sorry for a mom wearing dirty tennis shoes with rolled down socks and a red sweatshirt who didn't realize -- like many of us -- what she had lost until it was truly gone.

My First C-Section (as a med student)

The pager beeped and we dropped everything and ran to the labor and delivery room.

After a week of waiting, I finally witnessed my first newborn delivery. The mom was Rh negative and sensitized to Rh factor (which is sort of like seeing an ivory-billed woodpecker because everyone has read about it, but few people have seen such a case in the U.S. now that we are so meticulous about managing pregnant moms), and the baby was Rh positive.

The Ob-Gyn docs tried to pull the baby out using forceps, but baby wasn't coming out...so they took mom to the OR to do a C-section. I saw my first C-section, which was eerily how I imagined it. Save your romantic notions that surgery is a delicate scientific process...they made a transverse incision across mom's lower belly and reached in to grab the baby. There was a fair amount of blood, but it was fascinating how much of the blood was collected by a plastic bag around the incision (will learn more about this later, hopefully), and the tough Ob-Gyn ladies were pulling and rummaging around mom's belly looking for the blue baby. The pediatrics team generously allowed me to hold a blue sterile towel so that I could "catch" the baby. Soon we could see the head, and the Ob-Gyn attending reached in and pulled the baby out of the womb by its head. I held my arms outstretched, holding the blue cloth, ready to receive the baby from the Ob-Gyn docs, and the baby landed in my arms, newly severed from mom -- a big blue baby that was sort of floppy and doll-like. I carried the baby 3 feet to a warmer and we began warming, drying, and vigorously stimulating the baby with towels...he had Apgar scores of 3, 4, and 6.

The baby was taken to the ICN and I watched as the residents put in a central line. I mentioned that it was my first delivery, and one of the residents asked if I was keeping a journal of my third year of medical school. I told him no, but I do keep a blog...

Working in the Well Baby Nursery this week (or Hell Baby Nursery according to some interns who dislike the loads of paperwork, the MS3's LOVE the nursery) was a lot of fun. It was very pleasurable playing with newborns, they are so different from any other patients and a pleasure to care for. The parents are always very excited and grateful, and the dads are amusingly awkward and sort of dazed and eager to help. I learned how to perform a newborn exam, and what things to look out for and what findings are normal in a newborn.

Medicine and Domestic Violence

Sent by a JMP student today...

May 20, 2008

Screening for Abuse May Be Key to Ending It

By ERIN N. MARCUS, M.D.

The silver-haired woman greeted me at the clinic door, one arm suspended in a bright blue sling.
This wasn’t her first visit. In the preceding few months, she had come to the clinic twice with assorted aches and inexplicable pains. Now her husband had broken her arm, and the reason for those visits had become glaringly obvious: he had been hitting her.

And the domestic violence screening question I’d asked months before — nestled between queries about smoking and seat belts — seemed to have been spectacularly ineffective, since she’d answered “no.”

When I had asked about violence at home, I had been following guidelines set by the surgeon general and many professional groups, including the American Medical Association. Those who support routine questioning say domestic violence is as or more common in women than many diseases for which doctors regularly check, including breast and colon cancer, and its health risks are well documented.

Despite these recommendations, screening for domestic abuse in seemingly healthy women is nowhere near as widespread among doctors as testing for breast cancer or high cholesterol.
Some physicians see domestic violence primarily as a criminal justice issue, and take umbrage at being expected to delve into a difficult, messy topic when they already have to screen for many other conditions and diagnose complicated diseases in the span of an ever-shorter visit.
In a recent nationwide study of nearly 5,000 women, only 7 percent said a health professional had ever asked them about domestic or family violence. When surveyed, doctors often respond that they don’t ask such questions because of a lack of time, training and easy access to services that help these patients.

Some have reported that they worry about offending patients and believe asking won’t make any difference.

“Just like anybody else, doctors avoid things they may have discomfort doing,” said Dr. Michael Rodriguez, a researcher and family practitioner at the University of California, Los Angeles.

“There’s also an expectation on the part of some folks that once we identify abuse she should just walk away, and frustration when she doesn’t.”

Dr. Rodriguez and other experts say that urging an abused patient simply to leave may not be realistic or safe, for several reasons: The risk of being murdered is highest at the time one leaves, the woman may depend on her partner for food and shelter, and patients may not respond well to a doctor who dictates what to do.

They also say the best way to ask about such abuse is in a private place, with no family members present, as part of the routine patient history. If the patient says she has been battered or threatened at home, experts recommend that the doctor offer empathy, tell her what’s happening is wrong, document her story in the medical record and provide her with information on places to go or refer her to someone who may be able to help, like a social worker.
Barbara Gerbert, director of the Center for Health Improvement and Prevention Studies at the University of California, San Francisco, said that while some women might deny domestic violence at first, the question itself could have a profound effect: many women remember that their doctor asked and eventually, even years later, reveal their secret.

“Just by asking, you may be planting a seed for change,” she said.

Numerous studies indicate that doctors ask about domestic violence poorly, however, and don’t handle it well when they do get a yes answer.

Felicia M. Frezell, 34, an office manager in Omaha, told me recently that she visited her doctor’s office many times with her five children during the 15 years she lived with her ex-husband, who was convicted in 2005 of raping her. She said that even though she often had bruises, no one ever asked her why — until she asked her doctor to look at her swollen black eye and told him her husband had hit her.

“He just said, ‘You’d better get out of that situation’ and left it at that,” Ms. Frezell said, and added: “Looking back, I didn’t know the resources that were out there. The doctor’s office is a good place to go because it’s neutral and it’s confidential. It’s not like telling your husband you’re going to the police department.”

According to the Bureau of Justice Statistics, from 2001 to 2005 (the last year for which statistics are available) there was an annual average of nearly 511,000 violent assaults against women — and 105,000 against men — by a spouse or intimate partner, about half resulting in physical injury.

Despite such numbers, the United States Preventive Services Task Force concluded in 2004 that although clinicians should “be alert” for signs of violence, there was insufficient evidence to recommend for or against screening asymptomatic patients for domestic abuse — mainly because of a dearth of large-scale scientific studies looking at this question.
While many researchers say more money is needed to pay for such studies, some say the analogy to routine screening misses the point.

“Trying to equate it to a Pap smear is the wrong paradigm, and it’s just irrelevant,” said Dr. Christina Nicolaidis, a general internist and researcher at Oregon Health and Science University. “It’s not a test you can just check off.”

“The reasons to ask,” she continued, “are to educate a patient and to open the door so that the patient knows she can come to you. It’s part of developing a real relationship with your patient. Over time, you might be able to uncover the abuse and improve her safety, but you also might better understand why she’s having her symptoms and how to better approach her self-management of her illness.”

Abused women are at increased risk of chronic pain, depression, anxiety and alcohol and substance abuse, and they can have problems taking their medication correctly and getting to appointments. In one recent study, women who said they had been abused within the past year were more likely to have partners who interfered with their medical care.

Seven years ago, the Institute of Medicine, which advises the federal government, issued a major report on the training of health workers on family violence. The report concluded that such violence “was not a consistent priority” in health workers’ education and recommended that the Department of Health and Human Services establish education and research centers in family violence.

By unhappy coincidence, the report was unveiled at a news conference on Sept. 11, 2001, and has since “collected dust,” said one of the authors, Felicia Cohn, who now directs medical ethics at the University of California, Irvine.

“Certainly other issues took precedence at the time,” Dr. Cohn added, “but the continuing inattention is both inexcusable and embarrassing. This is a public health pandemic with immense health care implications.”

For my silver-haired patient — and other women I see at the clinic where I work — there have been no simple answers. I keep the telephone numbers for a local women’s shelter and the police department’s domestic violence unit in my lab coat pocket. And I keep asking the question, so my patients know there’s a place they can turn.

Erin N. Marcus is a general internist and associate medical director of the Institute for Women’s Health at the University of Miami Miller School of Medicine.

Finger to Nose

Just got back from the ED (for some reason, the med community calls it the ED, while the public calls it the ER or emergency room).

Pediatric urgent care was crazy busy today (everyone waits until Monday over the weekend), was there until 8 p.m. Then went over to the ED and saw the cutest 4 y/o boy with an eyelid laceration because his friend hit him in the eye with a rusty pole this afternoon (me: "it doesn't sound like he's a very good friend").

The cutest thing was when I was doing the neuro exam to make sure that his brain was intact after getting whacked in the head, and I asked him to do finger-to-nose to test his coordination.

Me: "Okay, I want you to touch your nose and then touch the tip of my finger."
Boy: [Sticks his index finger up his nostril to the first knuckle and withdraws a snot-covered finger]
Me: [Collective "Eew" arises from adults watching. Me pulling finger away quickly while parents burst out laughing] "Heh...okay...um, let's test your other finger..."

Wow, I never expected that from a pediatric finger-to-nose exam!

On another note, I am so far removed from current events...Robert Mondavi passed away and apparently there was this big earthquack in China. For a great blog posting on Anderson Cooper 360, please refer to a posting written by the sister of my former housemate: http://ac360.blogs.cnn.com/2008/05/19/china-children-searching-for-their-parents/#comments

Shit, did I just say "earthquack"?

Thoughts on Parents

In college, I was most interested in pediatrics because a) I like kids; b) I have 3 younger siblings whose ages range over a 12-year span; and c) most of my community service in high school and college reflected working with little kids or mentoring adolescents.

Feeling comfortable with babies, toddlers, preteens, teenagers has helped me enjoy my pediatric rotation, so it's funny how by the end of my year finishing clinical research at Stanford, my career interests had changed course and my interest in oncology grew. As a patient population, I really enjoyed working with an older age group of patients who had pancreatic cancer -- they had diverse backgrounds, interests, and personalities tied together by an unfortunate and often tragic illness.

One thing that worried me about pediatrics was the hearsay that it's not just the patient whom you have to worry about...but often their neurotic and demanding parents who are understandably worried about their most precious charges. Hearing that argument, I was turned off by the idea that maybe I could not treat the patient directly, but would spend much of my time negotiating diagnoses and treatments by proxy. Another common argument one often hears is that pediatrics can sometimes be "veterinary medicine" (I don't like this phrase), since nonverbal children cannot articulate their symptoms or discomfort.

During my pediatrics rotation, I have found that my worries about Parents (with a capital P) have been exaggerated. Although some Parents can be bossy, demanding, and overly histrionic, I have more often found myself touched by the love, dedication, and sacrifice that each parent demonstrates for his or her child. An infant who received a liver transplant practically lives in our inpatient ward with his parents and older brother, who spend every hour with him, sleeping on chairs and air mattresses every night and never leaving his side for days without a word of complaint or resentment. A mom who cries because her son has anorexia and will not eat anything she offers. Another mom asking about the cognitive effects of whole brain irradiation on her 10 y/o son with Down's syndrome and ALL. Parents who take showers in the hospital, sleep on chairs every night, pour every ounce of energy into supporting their children, no matter how sick the child is or how hopeless the situation may be.

So now I find that Parents tug at my heartstrings as much as their children do, and everything that I have always loved about kids remains the same. Children perceive the world differently, they are more pure of heart and have cute miniature body parts.

Adolescents are an interesting age group, too, they have such a unique set of concerns, risk factors, and half-formed perceptions of the world and how it should be. At best, their preoccupations and insecurities amuse and touch me, at worst, their teenage angst and myopic, self-conscious and self-centered views of the world impede effective medical care.

Overall, however, both pediatric patient groups demonstrate an acute vulnerability that makes me want to take care of them, and their little Parents too.

Pediatric Urgent Care

Today, I diagnosed a 16-month-old girl with acute otitis media. I am proud of this because a) the baby couldn't tell me what was hurting her and b) i've never seen an inflamed TM before. This makes me feel like maybe someday I can be a semi-competent doctor.

I also helped take care of a 10 y/o boy today who fell on his head and had a 2.5 cm. forehead laceration that was so deep it was down to the bone. It was a really wicked cool laceration, and the poor boy took it like a champ. Watching the suturing was so cool!

There was also a 4 y/o girl who also fell on the pavement, but she presented with waxing and waning mental status and 3 bouts of emesis in the exam room. We rushed her to the CT scanner in the emergency department to check her head.

Random Peds Quotes

Intern: "Can't trust a four-year-old."

Intern: "Why don't we do pregnancy tests on all of our male adolescents, too? It would be more thorough and less discriminatory."

"The longer you stay...the longer you stay." (this makes so much more sense now that I'm in the hospital than it did before)

Senior: "She's afebrile and non-edematous, which is...weird."

Senior: "She's going to barf on you."

Moffiteers

Moffiteer = pediatric patient who spends more than 50% of their time in the hospital

My service is the Blue team (adolescent med/eating disorders, GI, neurology) and I love our patient cases. We've had a incredibly busy service this week with over 20 patients this morning!

Other teams are Green (renal, psych, and endocrine) and Gold (pulmonary and gen. peds).

Only in Peds

Senior: "Cinderella is walking down the hallway!"
Me: "She is very convincing."

Woody from Toy Story was here too! :)

What I Have Learned So Far on the Wards

Four days of working at the inpatient pediatric ward at Parnassus (someone who works here a lot would be called "Little Miss Moffitt"!) and it feels like I've been here for TWO months!

Lessons learned from the wards so far:

1) Medical school may possibly be detrimental to your own health. A classmate observed that doctors spend so much time obsessing about other people (the patients) by talking about them for hours, measuring every mL of fluid that enters and leaves their bodies, writing about them, visiting them, that it's ironic how healthcare workers forgo the basic building blocks of life: eat, sleep, exercise, go outside for fresh air and sunlight.

2) Abbreviations are extremely annoying and yet irresistibly convenient. New one: EOMI. Still don't know what c/c/r means.

3) Patients complain that they never see the doctor, but the doctor spends 10 hours everyday thinking about the patient, talking about the patient during rounds, making phone calls about the patient, writing orders for the patient, and writing progress notes for the patient...and then they spend 10 minutes interviewing and examining the patient!

4) Doctors can lose perspective by working the hospital everyday. Last night, we admitted a patient at 8 p.m., and after working for more than 12 hours...it didn't seem like anything new or exciting. But the family was really anxious because the patient was spending the night and it was all so unfamiliar and scary for them. Working in a hospital can give you a strange sort of myopia about what is normal and what is not...because everything normal at Moffitt is abnormal in the "real world."


I am loving my pediatrics rotation so far. Pediatricians are perhaps one of the nicest species of doctors, they are usually very happy and nurturing with a good sense of humor. I think it's impossible to be angry or bitter when you are surrounded by little children and adorable babies sitting in red plastic wagons pulled around the hallways or sitting at the nurses' station. Seriously, where else am I going to find a ward filled with red plastic wagons bearing adorable smiling kids (err...hooked up to IV's).

Yesterday, we had a talk on sickle cell anemia given by Dr. Mentzer (of Mentzer Index fame!). He is a professor emeritus at UCSF, and he talked about how he just grafted his pinot noir plants in the backyard.


Random Amusing Quotes:

Me: I don't even know how UCare works!
Intern: It barely does.

Me: [An 11 year-old boy] urinated on himself this morning and he became really embarassed and started to cry.
Attending: Happens to the best of us.
[Really?]

The First Day of a Long Year

I just wanted to commemorate my FIRST day in the wards with a special post. Today marks the first time that I have:

1) written an order
2) written an H&P that will actually go into a patient's file
3) been paged regarding an order


The transition from the classroom to the clinic is jarring no matter how wonderfully UCSF tries to soften the blow through FPC and Transitional Clerkship (which was excellent). I remember that right after a brief morning session, I began to follow Blue Team around on Rounds and they began discussing this baby with hyperbilirubinemia and debating things like hereditary spherocytosis, osmotic fragility test, Coombs test, etc. Suddenly, I had a moment of clarity lined slightly by surprise, delight, and terror. My first thought was, "Oh shit, this stuff actually matters." Two years of medical school have already passed, may they stand me in good stead.

Craig, you stole my post!

Lying awake this morning, I was thinking about writing the same thing as Craig....about the balance of power between nurses and doctors and how doctors can only write orders and are not allowed to touch the medications, while nurses are the only ones who can "push" the meds.

Moreover, nurses usually perform phlebotomies (blood draw from veins), but if the patient is a "hard stick," the butterfly needle may end up in the doctor's hands (MD's are also the least experienced phlebotomists!). What's even more interesting is that only doctors are allowed to draw blood from arteries...why is that?

if I don't return your calls

Third year is starting! Please forgive me if I don't return your calls/emails/smoke signals/pigeons...I will be in the hospital...a guppy in the healthcare ocean learning how to survive. This is your warning!

Block 1: Pediatrics
Block 2: Medicine
Block 3: Family Medicine
Block 4: Surgery
Block 5: Ob-Gyn
Block 6: Psych/Neurology

I will continue to blog, worry not. See you next May! =p

Chagrin

Funny thing: the closer we get to starting third year...the less sure I am about what I'm interested in. Suddenly everything feels more like an open book than ever before, and I don't know what I want to do or even where I'm going to live!