From the Waiting Room, Post Set

A new documentary was released in 2012 called "The Waiting Room" depicting life in the emergency department at Highland Hospital in Oakland. While I wasn't on the set at the time of the filming, I came afterward to experience the waiting room live for my emergency medicine rotation. I haven't seen "The Waiting Room" yet, but from its trailor, Highland is made out to depict the modern state of health care for the underserved. Meaning this group of impoverished beings must secure all their health care needs -- from dental work to cancer screening -- at the emergency department. Not the ideal place for treating chronic conditions.

As its name implies, the emergency department is meant to treat emergencies. But that's not the reality of emergency medicine -- at least from what I saw during my 4 weeks there. Sure I saw gunshot victims, knife wounds, and pneumonias, but for the most part, I saw more chronic pathologies manifested into a state of personal torture for the eventual triaged patient.

Here were a sampling of my cases:

1. 59 y/o Chinese F with PMHx of hysterectomy presenting with over a year of weight loss, abdominal distention, fullness, early satiety, bloating, and pelvic suprapubic pain. Pt recently visited China, where a CT showed a unilateral ovarian mass. Pt put off seeking medical help for 3 months after returning from China because she was scared. Outcome: Unknown. This is a chronic condition, so we referred the patient to the OB/Gyn clinic at Highland. This was likely ovarian cancer.

2. 64 y/o Arabic-speaking female with PMHx of chronic back pain presented with near-syncopal episode. She was getting up from couch, saw stars, got lightheaded, then caught herself on couch. Afterward, she felt tachycardic and SOB. I was scared this woman had a TIA, even though she didn't c/o any weakness, etc. EKG was normal. Essentially, this was a case of lightheadedness but described in other terms, which threw me. I wanted to do a CT scan because the woman was stilll c/o of headache. But my attending said to look at the sequence of events, which was important. We pretty much ruled out cardiac cause, so yeah, this came down to case of dizziness, likely from orthostatic hypotension. OH occurs in the elderly, due to a pooling of blood in the legs and a decreased cardiac output in response. There's usually an underlying etiology like hypovolemia, drugs, or other diseases because the baroreceptors should kick in to compensate for decreased CO. How to dx? Systolic BP decreases by 20 or diastolic BP drops by 10 mmHg from supine to standing position.

3. 28 y/o M with PMHx of diabetes and frequent ED visits for gastroparesis presents with unrelenting vomiting and stomach pain x several days. He's been waiting for gastric pacemaker at UCSF, but unable to be put on list. His chart listed him as drug-seeking in the past, although he didn't ask for any opioids at the time. We referred him to GI, and he's still on wait for gastric pacemaker. I saw him return twice for same complaint during my visit in ED.

4. Multiple vaginal bleeding -- pregnant and not. One of the women (black female) saw some spotting when she wiped. And she was just scared in general from pain in abdomen. Pelvic exam showed closed cervix and b-HCG was positive. She was referred to OB outpatient. The other woman was older (52) with dysmenorragia and hx of fibroids. We deferred pelvic exam and referred to outpatient OB with high suspicion for fibroid flare.

5. 32 y/o M with pleuritic like CP after lifting rock from neighbor's yard, hemoptysis, and myalgias/chills. Chest Xray positive for Pneumonia. Did case report on this patient. He was admitted for CAP, although he should have be treated as outpatient based on his PSI and Curb-65 scores.

6. Stitched up a woman's hand s/p knife fight with "baby daddy." We had to do 2 nerve blocks -- median and ulnar -- plus lidocaine injection. Learned that after nerve blocks, it's just as effective to run hand under warm water as it is to perform saline flush. Gave 9 stitches to hand, and placed in orthopedic cast.

ICU

I came to the ICU after a 2-month long maternity leave. And in that time I felt like I forgot all of medicine. The vocabulary and memory came trickling back, although a bit slowly. Dr. Ahmed was patient to my baby brain. Top cases to reflect on in the future:

1. 42 yo female s/p intracranial bleed and renal failure from severe preeclampsia. She came to ICU after suffering MI with no electrical activity for over 20 minutes. Diagnosed with anoxic brain damage. While in the ICU, she suffered from what might have been red man's syndrome from quick infusion of Vancomycin. She also had myoclonic jerks, which suggests a very poor prognosis. Husband let her go after a week, although her parents fought him over it.

2. 18 yo male with PMHx of ornithine transcarbamylase deficiency came in with delirium s/p vomiting episode. Any type of stress to the body can cause urea cycle buildup which sends patients with this deficiency into hyperuremic state. Treated with fluids and anti-nausea. Patient supposed to return to normal after 4-5 days.

3. 68 yo indian female with chylothorax from Gorham's syndrome. Gorham's syndrome is a uncontrolled proliferation of vascular channels or lymphatic channels in the bone which leads to resorption of bone. Patients often present with chylothorax which shows up with high TGs on throracentesis. No treatment other than avoiding high protein diet and preventitive strategies.

4. 58 yo Asian female presented in septic shock of unknown cause, likely from skin infiltrate. Gram cultures came back positive for cocci in clusters and chains. Treatment of vasopressors (dopamine), fluid, and antibiotics. Patient developed lower extremity ischemia due to poor circulation. Vascular surgeon called in to discuss possible amputation. Also developed renal failure and put on dialysis.

Themes:
- Get them hemodynamically stable --> pressors, fluids, HTN control, pH, and airway
- Almost everyone is on anticoagulants
- Start on diet (tube or TPN) within 24-48 hours
-  CPAP trial prior to extubation
- ABGs run regularly
- GI prophylaxis with PPIs or H2 blockers
- Pneumonia prophylaxis
- PICCs preferred over central lines to decrease infection (due to drier lines and less chance of infection). CVP measured via PICC or central lines
- IJ over Femoral for decreased infection 

What It’s like to be an Older Medical Student

According to CNN, more and more people are making a career change to medicine later in life. I’m one of them.  And although I’m only 36---which is smack dab in the middle on the older student age range – I still feel a little out of my element. What follows is a top 5 list of what it’s like to be in medical school a little older in life.

#5: You’re in age purgatory.

Like I said, I’m 36. Still fairly young by society’s standards. I’m not partying every night like I was in my 20s, but I’m still young enough to be found drinking at the bar. But for medical school, 36 is like 36 was in the stone age. Freaking old.

I feel this on a daily basis. During my first and second years, I’d glance around the lecture hall and see reflections of 20-something faces, soft, round, and line-free. Which can be terribly confusing by the way. Because looking at people 10 years junior on a daily basis can stimulate deceptive neurological age pathways in the brain that make YOU believe that you’re actually in your 20s too. Ever hear of the mirror pathways in the brain? The ones where you reflect in your expression someone else’s reflection? Well, that’s what it’s like to be older amongst a bunch of youngins. It makes you think that you look young, when in fact you don’t.

Which brings me to the material of the real mirror – the one I look upon on a daily basis. My real reflection tells me I look pretty damn good for my age. I’m still lean with just a few more eye wrinkles. I maybe look 32/33. Still damn old for medical school.

Where does that lead me? In a state of in-betweenism. In between a previous world of expensive restaurants, interesting adult conversations, life enrichment and the current world of ketchup condiments for your potato, youth colloquialisms, and deep insecurities about grades and studying. According to Erik Erikson, 20th century philosopher who came up with the stages of psychosocial development, my age puts me in the middle adulthood stage of life. But my environment puts me in the young adulthood one. Each age group struggles with different aspects of ego development. I’m in age purgatory.

#4: Who you were before seems totally lost.

On a daily basis, I ask why? Why am I torturing myself and my husband going back to medical school – laboring through the material, exams, boards, cost? I was doing just fine in my previous career. However, the question of why put me here in the first place. I asked why too much in my previous career to the point of a major life upheaval. Now I’m in the land of the lost.  (For the majority of you who didn’t grow up in the 80s to watch that show, it was about a group of modern day homo sapiens who got stuck in the dinosaur age. Totally lost.)

But my world is not fictional. It is, though, confusing. Instead of enjoying good literature, going out to shows, and drinking at dinner parties, I’m laboring over various pathologies and working as an officer for student clubs.

And then there’s the friend element. Do you know how difficult it is to explain the trajectory of medical school? My husband doesn’t even get it. Explaining this concept to friends – friends who graciously try to understand and sympathize with my scenario – halts conversations into blank stares. It’s downright boring. My husband is a CPA, and medical jargon is just one notch above tax jargon on the boring scale.

So I juggle my worlds. I see my old friends on the weekends, and leave medicine behind. During the week, I engage in medical speak with my current medical school friends, talk about their struggling relationships, where we’re going to apply for residency, and get my nerves tangled up in things like grades, clubs, future endeavors. 

In the process, I’ve lost the old me. It’s impossible to be regained. Right now I just feel like a bag of cerebral worms in an older body with life experience. Which in medical school just means you’re past your prime.

#3. Money becomes scarce again.

Summer before starting medical school, my husband and I bought a house in the Berkeley, California, area. So along with going into debt $40K-plus a year in medical school, we decided to take out a $500K-plus loan from the bank. And with just my husband now employed, we were quivering with debt fear.

Turns out we float pretty well. During that first year, we really watched our pennies, but we loosened up quite a bit after that. Or I should say, my husband loosened up. He kept up his $100 martini lunches, while I kept to a strict Clif-bar-and-water one.

Even though I worked all those years before med school, there’s something us older medical students deal with on a daily basis: guilt. Our spouses, even though they won’t say it, come to resent us a little. Here I am living out my life dream and you, husband, have to work for it. No way. I’ll deny myself other things to show you how much it means to me. Like eating out, going out, having any kind of fun necessary. That’s the gut-wrenching, self-deprecating guilt we’re talking about here. It’s downright masochistic.

However, even if the guilt factor didn’t play a role, there’s the fact that you’re going to school with other broke-as-a-joke comrades, who also know how to survive on ketchup packets and Clif bars. And every dinner party is pot-luck style. You bring the bean salad, I’ll bring the vinegary wine.

Then there’s the other half of friends, the pre-med school ones. They’re still spending money in earnest – on expensive dinners, good plays, quality booze. And when you come around asking for the 2-star instead of 4-star restaurant, your friends begin to resent you.

What happens when we graduate? When we become doctors? I get paid half what I would in my other job, get a huge mound of student loans, and pay annually into malpractice insurance. Whoever said medical school is about the money?

#2: Your preceptors will be confused by you.

The same thing is on the mind of your instructors, preceptors, mentors. How old is she really? Cause she sure as hell acts like a medical student – unsure and unknowledgeable. It’s true. I no longer carry the certainty I did in the past. In fact, I feel pretty inadequate. How do I use this speculum? Sorry I just touched you with my super icy hands. No, I have no idea what the risk factors for placenta previa are.

Do I tell my preceptors that I used to work?  That I am in fact 36? Let ‘em know that hey man, I got life experience. I’ve traveled. I’ve sweated. I’ve received paychecks in the past. I’m whole! I so desperately want to connect with my preceptors in this way – mano a mano. During my family practice rotation, I even out-aged my preceptor.  She and I connected when she bluntly asked, “How old are you anyway?” She actually started talking to me differently once I told her. Almost like a real person, connecting on politics and life events.

For the most part, I keep my mouth shut and try not to act stupid. Challenge failed. I act like an idiot most of the time.  My past is completely irrelevant to preceptors. I guess that’s for the best, because in the end, I want to be treated like a medical student. But I also want to be treated like a whole person too.

#1: You’ll grow apart from your husband.

It’s inevitable. You’ll be sitting across from your husband at the dinner table with flat conversation, maybe even nothing to say at all. ‘Cause face it, you’ve transformed into a somewhat different person. This really doesn’t have anything to do with age. It has everything to do with being in medical school.
 

Medical students become saturated in medical material that completely re-compartmentalizes old brain space to make room for this new information. Meaning that the old information, the information you used to connect about with your husband, is gone. In its place is that dry, boring stuff I talked about before. The stuff no one wants to hear unless you’re a medical student. Yeah sure my husband is a CPA, but he doesn’t talk about that stuff with me. It’s boring! Plus he’s a whole person, remember? With other interesting activities and thoughts to engage in. But not me. My thoughts are consumed by medicine. it’s impossible for me to keep my flap shut about the subject. I’m not a whole person anymore, so it’s almost all I’ve got up my conversation sleeve these days.

“Did you read the news today?” is a common question from my husband. “Have you followed so and so?” Uhh, no. I did learn about the importance of the gallbladder, though. Wanna hear? No. He doesn’t. Ohh. Then tell me about that news thing, as I sit there dumbfounded searching my old brain compartments for the location of the Balkans.

And so you and your mate grow apart. Before medical school, this was my biggest fear. While contested, many studies pit divorce rates for medical students and doctors about 10-20% higher than the average population. Luckily my husband and I fit into the category of the percentage who stay together. Even though he’s essentially putting me through medical school – even though it’s “our money,” let’s get real, it’s really his working that keeps me afloat – he supports me emotionally too. I can’t talk at length about the upcoming presidential campaign like I used to, but at least I’ve learned to shut my trap about medicine and discuss the greater world around me. That’s the only way to keep it going, friends.
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Yeah, I think It's Medicine I want

Internal medicine is what I mean. But am I cut out?

That was a recent topic of discussion when I went back to Texas over Thanksgiving, the place where I was raised. My aunt asked, "Are you a good diagnostician?" somewhat too candidly. The question floored me because she really hit the heart of the matter. Becoming an internist takes a great deal of analysis and diagnosis. In honesty, I couldn't answer unequivocally "yes." I have no idea if I'm a good diagnostician. How would I know right now as a third year medical student? I know I'm logical, thorough, and resourceful. But plenty of times during my medicine rotation, I was astounded by the doctor's diagnostic skills.

For example, one evening in the ER, one of Dr. Afsari's patients (Dr. Afsari being my preceptor) came in with an acute abdomen. She was vomiting coffee-bean-like substance, had an acute, diffusely tender abdomen, and leukocytosis. Dr. Afsari said "Looks like ischemic bowel." Huh? I really had no idea. Yeah, she was in the age range, but I was thinking PUD or diverticulitis. Those were on the differentials, but guess what? A few days later, she was diagnosed with acute bowel. Damn. I was slackjawed.

What does it take to be a strong internist? If I were commissioned to write this story, I'd probably research this topic. But I'm not. So I'm moving on to my next, most internally (get it?) pressing issue during this rotation...the experience.

Fantastically mesmerizing. Buoyantly intriguing. Deeply haunting. Mindblowing. No, I'm not giving a movie review. This is what medicine with Dr. Afsari was like. He's an infectious disease specialist and an incredibly straightforward teacher and stable, understanding, and thinking doctor. Most days, we rotated with him for 3-4 hours, then researched the cases, visited our own patients, prepared for our presentations, and caught up on school work.

Most of the patients were really sick or had chronic illnesses. And many, many of our patients died. Not because Dr. Afsari is a poor physician, but because Doctors Medical Center serves a destitute, underserved patient population. Examples: the IV drug user with cirrhosis. The obese male with ischemic bowel. The handyman with pancreatic cancer. The rheumatoid arthritis patient with rheumatoid lung. Death to many of these individuals was unwelcome and shocking. Many weren't ready. And many finished out their lives on the gurney in Doctors, some alone, some with loved ones, and some with loved ones ready for their death.

I bring up the subject of patients who died because it pained me to watch. And I keep those feelings close to me. I want those feelings to stay close to me, to live with me, and to be uprooted again and again during patient encounters.

There's so much to say about internal medicine. Dr. Afsari methodically works up each patient, spending hours reviewing patients' charts, consulting with other practioners, and talking to the patient. His way is thorough and thinking, heartfelt, and real.

On my last day, I nearly buckled. I wanted to stay with Dr. Afsari and continue to learn from my patients. He said his farewell over a glass of champagne, calling us his colleagues, and the future of medicine. I'm humbled by this thought.

A Family Medicine Epitaph

If I could write my farewells to family medicine, it would have to start with Dr. Mahoney at Brookside. A man of many talents, Dr. Mahoney is a boisterous, larger-than-life man frequently spewing one-up knock-knock jokes, talking about pretty ladies, jostling poor time management skills, and most importantly, engaging and meeting his patients at their level. Family medicine at Brookside is how I envision practicing medicine. The patients are diverse, the staff is friendly, and everyone shows passion and flexibility for their work. I didn't encounter negativity as I did at other sites. Between Dr. Mahoney, who laughs more easily than any other doc I've worked with, and Dr. Villanuevo, who smoothly jumps from task to patient, I learned and loved a lot. It was easy to go in and hard to leave everyday.

Brookside specializes in adult, underserved care, especially for a hispanic culture. Mostly, we encountered diabetics and hypertensive patients. But there was also the guy with the skin tag, the young man who went through a slew of tests before finding a pancreatic mass, the hispanic elder who lost a ton of weight in mexico because he became insulin-intolerant, the female with PID who got three speculum exams that day, the IV drug user with a new-onset stroke, two or three PPD-positive patients, two patients with toenail removals, and the young lady with heavy periods and 6.0 Hb.

Looking back, I realize that Brookside was a special place where the right patient population meets the right doctors. For Brookside, your memory uproots feelings of warmth, spirit, care, and diversity.

I finish my FM rotation at the Touro Medical clinic, a more structured, stuffy facility that still maintains hand-written charts. Structure hasn't been a bad thing. I go in, see a few patients, present the patients, then write 4 SOAP notes daily. Weekly, I given presentations -- from topics to journal presentations. My professors expect technical perfection in physical exams and SOAP note linguistics. I've risen to the challenge, and although somewhat gruelling, my note taking ability and neuro exam have seen vast improvements. And I can finally explain relative risk, odds ratios, and the number-needed-to-treat like a pro.

There were also, of course, the patients. Vastly different setting than Brookside, Touro Medical Clinic serves a mostly Caucasian population. Also underserved and mostly medical. What is it with osteopaths and the underserved? not that I'm complaining. That's the population I strive to work with. We saw plenty of interesting cases, along with the normal hypertensives and Diabetics. There was the young woman with Turner's syndrome and menorrhagia. The 48-year-old male with corneal ulcerations, back pain, and GI upset (AI infection perhaps?), the COPD patient who just wanted to be "fixed," the teenagers who wanted to know everything about the male genital anatomy (including the color of a testes), and the cases of lower back pain which required four injections by yours truly.

Between Brookside, my love, and Touro, my challenger, I've thrived in Family Medicine. Probably because I like the world of variety and diversity. A much needed break from the rigors and monotony of surgery.

Acute Abdomen, Farewell

I finished my last day of general surgery yesterday. Kind of sad to say goodbye to Dr. Gourlay and Julie, his secretary. Gourlay has a great way of putting people at ease and anticipating questions. Key takeaways:

- Always maintain a sense of humor, even if you're about to drain someone's abscess by sticking a knife in 'em.
- Talk kindly of other docs, even if you don't agree with their decisions. This is a Gourlayism, and I like it.
- Lead the conversation and don't let the patient lead you, such as if they're about to tell you a story about being in the roller derby.
- Say yes to anything a preceptor asks you to do even if you don't want to.
- Know more about the patient than the preceptor knows.
- Follow your attending's lead
- Stay human, even if that means you gotta cry every once in a while.
- People are tough. Take the 49-year old obese male who had perianal abscess. When the doctor said, "I'm just gonna knife you and drain it" the patient replied, "did you say knife me, Doc?" To which the doctor said with a smile, "Yes, because I think a local would be just as painful as just sticking a knife in it," the patient said, "OK. Do it doc." The knife went in, pus and blood emerged, and it was done that fast. The patient left smiling and thanking the doctor. What!? Like I said, people are tough.

In the last two weeks, I scrubbed in to see:
- 1 partial mastectomy
- 1 lumpectomy and sentinel node biopsy
- 2 ventral hernia repairs
- a few more cholecystectomies
- 2 colonectomies

I also saw several hemorrhoid cases, 1 abscess drainage, generalized lymphadenopathy, sebaceous cyst, inguinal hernia, and lots of post-op follow-ups.

I'm constantly learning about the doctor-patient relationship, how bad docs can make a patient feel like a specimen, and how good docs can make her feel like a human again. For example, I helped one of the ICU doctors put in a central line (on the same patient I helped put in a trachea tube). The doctor didn't explain shit. He didn't consider any opioid until the nurse suggested it. I felt sick for the patient who took the procedure without any conception of what was happening.

Mr. Aldea, an 81-year old Asian man, underwent a colonectomy for stage III colon cancer. The surgery went successfully but the patient slipped into SIRS (systemic inflammatory response syndrome). He already suffered from kidney failure and several other complications. After 7 days in the ICU and many docs trying to figure out how to treat him, his end prognosis didn't look good.

Then there was the 82-year old man with parkinson's, CABG, and a large inguinal hernia. His wife, a recovered colon cancer patient, was his sole support and only learned of his growing testicle a few days ago.

Those patients and all the interactions did me in. I had a good cry and felt human again. It's easy to forget that the patients in the hospital and in the clinics are suffering human beings, scared and desparate for life. I hope I never forget.

General Surgery Rotation

On my way home after observing and partially assisting a tracheostomy this morning, I felt an incredible sense of honor for the ability to view the human body in this way. I got to insert my finger into the patient's trachea, feel the isthums of her thyroid, view the pulsation of her internal thyroid artery, and suction the little blood that escaped from the incisions. Anatomy books don't cover this stuff. A living, breathing human being with bubbling fat, warm tissue, and throbbing vasculature dwarfs the cartoon drawings in Netter.

Like my preceptor of 30 years in the surgery business said, "It's still an honor and privilege to perform my job every day."

I started general surgery two weeks ago. Since then, I've seen:
- 4 cholecystectomies
- 1 hemmorhoidectomy
- 1 bennett's fracture
- 1 basal cell carcinoma and benign nodule removal
- 1 umbilical hernia
- 1 tracheostomy (today)

Next week, we're scheduled for a mastectomy, colostomy, inguinal hernia, and hemmoroidectomy.

What's general surgery like? Thrilling. Humiliating. Humbling. Scary. Being a medical student in general surgery is like being a videographer filming a lion attacking its prey. You keep pretty quiet, try to stay out of the way of the techs and nurses, and take in everything that's going on around you. And it's almost deathly when you mess up. First day, I put my mask on backwards AND nearly passed out. Addressing the first mistake, my glasses kept clouding up like I was in a dishwasher. Couldn't see a lot. As to the passing out, I asked to sit down (luckily) before I took a nose dive onto the ground, or worse, into the sterile field. The nurses hate that.

Since then, I've been pretty unassuming. Just slip in and out, say lots of "thank yous," "sorries," and "oh, wows." I only blew my scrub-in once, when I starting tying my gown before putting on the gloves. Oops.

Other than the nurses scowling at you at all times, and realizing that you're the lowest man on the totem poll, being a medical student is surgery has its definite advantages. For one, you get to suture. My step-in preceptor let me suture the entire bennett fracture incision from the lateral thumb to the scaphoid. You also get to stand right next to or across from the surgeon so you can see every bit of anatomy, incision, and probing. Other than that, you sit around a lot, try to make small talk, and formulate good questions and answers to pimping.

How about the preceptor I'm following? Best description for him: knowledgeable, charismatic old kook. He's a character. Always talking, sharing some story about the past or the current, remembering every little detail from names and dates to history and circumstances. He can tell you why every instrument is named like it is. The pathophysiology of most diseases, and even give you a blow by blow of the American Civil War, recounting the Battle of Gettsyburg to the Second Battle of Bull Run. Night time remains difficult for me. When we stop seeing patients at night, he wants to talk politics, NPR news, and the history of medicine for hours. How do you leave that?

Over these past few weeks, I've also had the opportunity to be self-reflective. I'm strong enough for this profession, but it takes some serious self confidence and guidance. I feel like I know jack right now, my information tied up somewhere in different brain compartments. I'm learning how to retrieve the information, but I'm dealing with an antiquated system here. Everyone says H&Ps, Dx, and understanding comes after the third year.

Right now, I'm just putting things together like a puzzle.