Time

Rush, rush, rush. My life as a medical student hoping to go into emergency medicine meant I must see more patients per hour! Churn , churn, churn them through the ER. Which was why I was in agony at first, in what felt like the longest patient interview. I found myself impatient at my partner, at the world, at the clock for faltering so long with each step.

 “I don’t know when I am going to die. I don’t care. I am just here.” Suddenly time stood still as everything clicked together. My hilarious patient who used humor as a coping mechanism was imprisoned at the VA. Although he was my father’s age, a hard life had worn down his exterior while a liver cancer was bubbling away his interior. An unusual familial breakdown as well as a bitter casting away of his treatment team led to this sad situation. There was literally no one left who cared about this patient except for the palliative care team. My fellow medical student and I took in his joking and his life story, and tried our best to be there for him.

 It is interesting that I was scheduled to come back to the VA for my palliative care assignment. My first patient at the VA as a student died before he could be transferred into the hospice unit here. Etiology, diagnosis, prognosis, treatment, follow up. Everything about that particular disease I learned in basic sciences twisted into grotesque reality as my first patient with intractable cancer passed away before my eyes before we could even place a consult. Time passed too quickly.

 Then, while on the psychiatry consult service, I met every patient who entered the hospice unit for their final days. Time passed too slowly then, as I tried to pry reason into my hours-long interview with demented patients trying to die in peace.

Fast forward to 1 week before my palliative care visit. The pinnacle of surgical technique rested in my trembling hands as I held a donor liver while transplant surgeon/gods quickly sealed it into a recipient. A once incurable cancer, stopped dead in its tracks with new life. Fast forward to my current patient- one who refused such a transplant. I tried to make sense of this decision. “They want me to be this perfect patient, to stop drinking and smoking, to take all these drugs. I don’t have time man! I want to do things my way, on my own clock. I want to live my own life.”

At the end of the interview, we thanked him for his time.

Time

Rush, rush, rush. My life as a medical student hoping to go into emergency medicine meant I must see more patients per hour! Churn , churn, churn them through the ER. Which was why I was in agony at first, in what felt like the longest patient interview. I found myself impatient at my partner, at the world, at the clock for faltering so long with each step. “I don’t know when I am going to die. I don’t care. I am just here.” Suddenly time stood still as everything clicked together. My hilarious patient who used humor as a coping mechanism was imprisoned at the VA. Although he was my father’s age, a hard life had worn down his exterior while a liver cancer was bubbling away his interior. An unusual familial breakdown as well as a bitter casting away of his treatment team led to this sad situation. There was literally no one left who cared about this patient except for the palliative care team. My fellow medical student and I took in his joking and his life story, and tried our best to be there for him. It is interesting that I was scheduled to come back to the VA for my palliative care assignment. My first patient at the VA as a student died before he could be transferred into the hospice unit here. Etiology, diagnosis, prognosis, treatment, follow up. Everything about that particular disease I learned in basic sciences twisted into grotesque reality as my first patient with intractable cancer passed away before my eyes before we could even place a consult. Time passed too quickly. Then, while on the psychiatry consult service, I met every patient who entered the hospice unit for their final days. Time passed too slowly then, as I tried to pry reason into my hours-long interview with demented patients trying to die in peace. Fast forward to 1 week before my palliative care visit. The pinnacle of surgical technique rested in my trembling hands as I held a donor liver while transplant surgeon/gods quickly sealed it into a recipient. A once incurable cancer, stopped dead in its tracks with new life. Fast forward to my current patient- one who refused such a transplant. I tried to make sense of this decision. “They want me to be this perfect patient, to stop drinking and smoking, to take all these drugs. I don’t have time man! I want to do things my way, on my own clock. I want to live my own life.” At the end of the interview, we thanked him for his time.

Time

Rush, rush, rush. My life as a medical student hoping to go into emergency medicine meant I must see more patients per hour! Churn , churn, churn them through the ER. Which was why I was in agony at first, in what felt like the longest patient interview. I found myself impatient at my partner, at the world, at the clock for faltering so long with each step. “I don’t know when I am going to die. I don’t care. I am just here.” Suddenly time stood still as everything clicked together. My hilarious patient who used humor as a coping mechanism was imprisoned at the VA. Although he was my father’s age, a hard life had worn down his exterior while a liver cancer was bubbling away his interior. An unusual familial breakdown as well as a bitter casting away of his treatment team led to this sad situation. There was literally no one left who cared about this patient except for the palliative care team. My fellow medical student and I took in his joking and his life story, and tried our best to be there for him. It is interesting that I was scheduled to come back to the VA for my palliative care assignment. My first patient at the VA as a student died before he could be transferred into the hospice unit here. Etiology, diagnosis, prognosis, treatment, follow up. Everything about that particular disease I learned in basic sciences twisted into grotesque reality as my first patient with intractable cancer passed away before my eyes before we could even place a consult. Time passed too quickly. Then, while on the psychiatry consult service, I met every patient who entered the hospice unit for their final days. Time passed too slowly then, as I tried to pry reason into my hours-long interview with demented patients trying to die in peace. Fast forward to 1 week before my palliative care visit. The pinnacle of surgical technique rested in my trembling hands as I held a donor liver while transplant surgeon/gods quickly sealed it into a recipient. A once incurable cancer, stopped dead in its tracks with new life. Fast forward to my current patient- one who refused such a transplant. I tried to make sense of this decision. “They want me to be this perfect patient, to stop drinking and smoking, to take all these drugs. I don’t have time man! I want to do things my way, on my own clock. I want to live my own life.” At the end of the interview, we thanked him for his time.

Interesting patients from the psych locked unit

"Well sir, if I were you I would not call the police on your brother just because he would not let you smoke crack in his house."

"Ma'am I must confess when I heard you were caught running naked in the grocery store with a bag of fry sticks, I thought 'yes fries are indeed delicious.'" (Fry sticks= actually joints dipped in formaldehyde aka embalming fluid with some PCP sprinkled in)

"Yes ma'am, I understand that you think you are Jesus." x2 with women and x1 with a dude.

"Is it me, or is it me?" (Every day for the first week I had patients "terminate the interview" with me either by running away from me, refusing to talk, or getting so agitated I needed to leave before things got out of hand.)

"Why are you afraid of the police?" Insert reasonable answer here. Then insert comment about FBI tapping his phone lines.

Apparently bath salts are the big new drug. That is all. I'm not even halfway through the rotation. More fun later.

Done. Libyan refugees are happy.

Done. Done done done! Done with pediatrics. And there goes my first clinical rotation.

The national shelf exam at the end of the rotation destroyed me and left nothing behind. I needed to go home, attend a massive birthday party for my niece, and then take a 7 hour nap just to recover from it.

Thankfully that test was the only bad part of the rotation. I loved playing with kids for 2 months. They come to you without any baggage. No drug dealers or depression- my patients were still...pure and ready to take on the world. Some were really sick, others were just fine and dandy for their well child check ups. Universally, it just feels so good to make a kid feel better.

Now I've still had my fair share of crazy stories. My very last patient for the rotation was a Libyan refugee. Her parents had gotten out a day or so after the protests had started, just in time before the government had started to knock off civilians. The parents were amazing and coping well for what was going on. Skype was their main line back home- but it was hard to work around the communications blackout.

They were also doing well with their daughter, who had a rare genetic condition that I had never encountered before. The moment I looked over her charts and saw what condition she had, I could think back to the very lecture that was supposed to cover it. Our professor was notoriously slow and his last words for that class: "Sorry for not getting to this condition. Please cover it on your own, but I'll be nice and not put it on the test." So of course I never studied it then. And of course I mastered that material at home later that day. But guess what. It never showed up on the exam. Not a single genetic condition showed up on the exam. Gosh I love medical school right now.

Onward to psychiatry! Two months total, with my first at the Veterans Affairs Medical Center, and the next at the local county hospital. Should be interesting. I am ready for the war stories.

A wall.

My intern was calm, always calm.

The patient's mother on the other hand was unsettlingly still, watching her daughter with distant eyes. Moving her pediatric stethoscope across our patient's heaving chest, my intern closed her eyes in order to focus. Feeling uneasy about what was happening, I stared at my watch and started to count. Twenty shallow yet labored breaths in 15 seconds. Shit.

"She always goes straight to the ICU when I bring her to the hospital," the mother commented. This scene was unfolding about 11 floors too far from the ICU I thought, and tried to mentally urge my intern to pull the alarm. "Come ON Tina! She's in respiratory failure! I do NOT want to do CPR on my last day here..."

We excused ourselves as the respiratory tech came in to administer a scheduled breathing treatment. Outside the room at the nursing station our upper level resident raced over while my intern was on the phone with our attending. She opened the vitals sheet and cursed silently, then dialed in the Rapid Response Team.

If someone's heart stops, a team descends upon the "code" in order to perform CPR. At the children's hospital I was rotation at, a Rapid Response Team could be called whenever a patient is at the brink of disaster. Hopefully the RRT could avert the disaster and prevent patients from coding via timely intervention.

Timely indeed was the intervention. First 3 upper level residents arrived immediately, then a couple of cardiac fellows swung by because we were on the cardiac floor. My intern's calm presence was replaced by a orchestrated chaos, dancing around our patient with the heaving chest.

In the frenetic activity swirling around the patient, the mother was strangely calm, sitting still while observing the action. What kind of emotions were bottled up inside? Was she now simply used to the idea of death's hand constantly on her daughter's shoulder?

My attending was the last to arrive, and avoided everyone in order to walk to then squat next to the mother. He made sure to be at her level, and spoke in a slow and reassuring manner, an anchor while waves rocked the patient's bed. Soon the wires and tubing was disconnected from the walls, and the bed carrying our patient was wheeled out of the room, and to the direct elevators to the ICU. My attending remained by the mother's side, and continued his conversation with her.

When it was time to go, the mother simply squeezed my attending's hand, then shifted her gaze back to the empty space where her daughter's bed had been.

Open your mouth and say ahhhhhh- oh crap!

I can make kids vomit on cue.

That is all.

Intensity

I think I've figured out why my posts dried up this past year. I like to tell stories, of people I've met and of the strange or crazy situations we've been in. For the past year and a half my routine steadily became sleep-shower-study in isolation as I grudgingly converted to the cult of lecture streamers. Why bother spending 5-6 hours at school everyday when I can speed through all of my lectures at 2.5x fast-forward in just three hours in my pj's? Nothing blog-worthy there.

If this is my last post, then you will know it was because I caught some bug from the scores of kids coughing into my face as I try to listen to their breath sounds. I've started my clinical rotations with pediatrics, and I absolutely love it. Today was my first day in the pediatric ER at the local children's hospital. I have been thinking of going into emergency medicine (just skim through some of my previous posts), but now that I am on pediatrics I'm not so sure I could go back into the adult world. Perhaps pediatric emergency medicine?


Lumbar punctures.

The pediatric ER attending delicately unwrapped a sterile tray that held the needle as wide as my clipboard. I looked at the pudgy preteen boy curled up into a soccer ball on the stretcher, then back to the needle. There was no way this was going to end well, I thought.

Instead of finding the landmarks for the needle, the attending started to screw together a strange contraption that resembled a chemistry set. The entire time the attending gave a steady running commentary of everything he was doing to keep the patient relaxed as possible. He promised to notify the patient every time any needles were involved- and to his credit he did so- all except when the humongous one finally went in. Kinda like ripping off the Bandaid at 2 instead of 3 I suppose. Anything to minimize the agony of having the contents of your spinal canal poked around.

Now I am not squeamish but I found myself holding my breath as the needle went in all directions in search of the elusive cerebral spinal fluid. Seconds slipped by and still nothing. What started as a low moan steadily grew as the poor kid's pain tolerance slowly broke down. The attending moved the needle in and out faster and faster as he checked for the clear drop of liquid that would indicate success.

Nothing. For now. Later that afternoon:

"I want you to burn this picture into your head, and never forget it." The strange wailing cry, the mottled purple of the tiny infant, and the sheer rigidness of her back was nothing like what a normal healthy baby should look or sound like. "She's getting the full sepsis work up," another attending explained to the gaggle of medical students in short white coats.

Do you remember the first time you saw an ultra-violent movie in the theaters? For me it was Saving Private Ryan. You aren't the same afterwards. Sure it is fake, but the constant exposure wears you down little by little almost imperceptibly.

I've already seen too much out on my ambulance, so for this little infant girl to give me chills, I knew something was extremely wrong. Microscopic invaders had so thoroughly conquered this tiny body that her organs were starting to give up. Starting to was the key word. If this lumbar puncture could work, our team could speed drugs through her system to combat this deadly intrusion. We were at a critical window however, and this stick needed to work.

A experienced nurse held the tiny baby in a firm motherly grip that forced the tiny torso to lean forward. She put a towel over the infant's head, then put her chin over the baby's head while holding the rest of the extremities with her hands. This must have caused explosions of pain as the diseased spinal cord and brain covering stretched out so that the attending could take a sample of the fluid that bathed the tiny brain. If I had cried as hard as the infant did I would have blown out my eyes.

Seconds turned into minutes as the needle poked around the spine, searching for an entrance into the spinal canal. Suddenly blood appeared and the doctor scrambled to hold a test tube to the open needle as precious drops of clear cerebral spinal fluid reluctantly left the body. I found myself exhaling slowly finally, and my train of thoughts picked up speed again. Okay little kids. Time to show me what you are made of. Cough all you want all over me, but I'm going to figure out how to fix you up right.

So close I can taste the double rainbow.

Hi there.

No, I'm not dead. Just learning stuff.

Lots of stuff. You know, so I can be a doctor.

Sometimes my brain wants to take a vacation, but I won't let it.

Not for another month at least. Then I will be done with basic sciences.

That means I probably know all of medicine, right? Right.

Movie Trailer life

If my life were to be made into a quick montage for a movie trailer, this would be the background music to it: