Windmill somewhere in Kansas. 

Back in McPherson

I am rounding out my third week back in McPherson, Kansas. This is the small Kansas town where I spent January of this year doing 4 weeks of my surgery rotation. During our 4th year of school, we are required to spend 4 weeks in a rural location for our "Rural Health Month." Knowing this would be a requirement, and knowing how great a time I had in McP earlier this year, I quickly asked to be reassigned to this quiet little town.
I have been with the surgeons again since I got here, but this time we have had quite a bit more action. We have had unscheduled surgeries on the past 14 of 18 days. This has meant being in the operating room well into the evening most nights, even well into the next day on a couple of occasions.
Of note, I got to see my first amputation. It was bloody and bony and physically demanding on everyone involved. My job was holding the thigh up while the surgeon cut off the leg below the knee.
There have, of course, been plenty of colonoscopies. We also had a run on appendicitis and and gallstones, getting to take out at least one of the two every day in the past week.
Yesterday I worked with an Ob-Gyn who comes to McPherson once a week. She was helping out a little old lady whose vagina had decided to fall out, bringing along the uterus and part of the bladder and rectum with it. It was to the point that she had to wear a catheter because she wasn't able to go pee. Since this little old lady was quite frail, it was thought she wouldn't be able to tolerate general anesthesia or a long procedure. So, the ob-gyn did something that is rarely done in the age of hysterectomies...she got an epidural. and then, after tucking everything back into place, the vagina got sewn shut.
This may sound like a great idea for some people...many of the nurses invovled in the case asked when they could have theirs done.
What I thought about, though, was that somewhere in the past, some poor woman had to be the first to endure this. And she probably did it with little in the way of sedation or analgesia.
In fact, when I thought about it, I realized that most surgeries are fairly barbaric, specifically gynecologic surgeries. And what is most frightening is that sometime, someone had to INVENT these procedures.
I have tried to rationalize that most of these things were probably first done on animals in barns and fields in order to meet the demands of necessity.
You have a cow and her vagina is falling out? Well, just stuff it back in there and sew the damn hole shut. Problem solved.
None of these rationalizations give me a great deal of peace, though. It just makes me really grateful to live in a time of really nice drugs that can make us fall asleep and other really nice drugs that can help take away pain.
My time with surgery is drawing to an end, though, for my last week I will be working with a family practice doctor. I don't think we'll sewing any holes shut in her office.

Three Down...

I am only 16 hours from completing my third year of medical school. That means just one more year to go, or 332 days until the official graduation day, or 372 days until I begin my residency training.
Has the last year gone quite fast for you, too?
It hit me this afternoon while riding the elevtaor at the Barnes & Noble on the Plaza, heading up to the Starbucks Cafe where I sometimes go to study when I am going out of my skin in my own house. Actually, I haven't been there for over a year, since I had my last afternoon of studying for Step One of the boards on June 14 of last year. Riding the escalator, I kept thinking, "Has it been a year since I last took this ride?" It seems like it might have been just last week or maybe last month, but to think that it has been an entire year, and that I have just one more year left to go, feels a bit strange.
This time last summer, there were so mant things I was dreading about my upcoming semesters. I was dreading finding out of I passed or failed Step One. I was dreading the idea of spending the night in the hospital on call. I was dreading the eight weeks of my surgery rotation. I had so much trepidation mixed with so much anticipation. Having come through this year, a part of me looks back and thinks, "Who was that person?"
All of the things I feared or worried about now look like the molehill rather than the mountain I saw at first. It seems that what I feel most of all is a sense of being able to trust myself.
For a long time, whenever I was nervous about a new situation, I would remind myself that I figured out how to master the subway system in Paris, and it would help calm me down. That is how I am starting to feel about the last 12 months.
It is my latest Parisian Metro.
So, which route am I going to take?
I have looked at the map for a long time now, and I have had a chance to ride on each of the lines trying to find the one that suits me best. Certain of them I expected to love, but turned out to find the ride a bit bumpy. With others I expected an unpleasant ride and ended up having a smooth trip. Each of them eventually brought me to a point that I thought I could be happy staying at for my life.
Now, though, finally, I think I might be able to say which direction I'm going to head.
It is kind of a surprise to me, as it wasn't a direction I ever expected to choose to head, but in my gut I have a feeling it is the right way.
Ready?
Want to hear?
This really is a big deal to be making this type of "announcement," having danced aorund the issue for so long and having actually gotten a bit comfortable with the words, "I don't know what I'm going to do."
So, I better just say it.
I am going to pursue a combined residency in the areas of internal medicine and pediatrics, aka, med-peds.
One of the beauties of this choice is that it still allows me not to choose just one area, but instead I get to have two.
The reason this choice surprises me is that at the beginning of this year, I had no desire to become neither an internist nor a pediatrician.
And here it looks like they are just what I am going to be.
I am going to get to treat adults and kids, but not deliver babies. I will be able to spend all of my time working as a hospitalist or I will be able to have the traditional doctor's office. I can stay general, or I can do a fellowship after residency. In short, I am setting myself up here to have a lot more options.
Do I still have an affinity for women's health? Yes, absolutely. The thought of becoming an ob-gyn still lingers in my mind, and I will add the disclaimer that it may still happen.
I feel pretty confident in med-peds, though. I have been saying, "I am going to do med-peds" in my mind now for several weeks, and something about it just feels right. Today one of my classmates said, "I think you just have to kind of try something on and see if it fits and feels comfortable," and I feel like that is what I have been doing here lately.
Phew.
So, there it is, in public, on the record. Like the first time wearing a new dress out, thinking it looks and feels good, but still feeling nervous about putting it on display.

Exit Stage

A thought occurred to me today that I know has been hashed out by cultures, religions, and societies for thousands of years, but that for the first time really made sense on a practical level. Death is almost exactly like birth, but instead is the opposite.
This month on the oncology service has been among the most remarkable thus far. In a way, it has been so remarkable that I have had a difficult time remarking on it. I have seen how precariously life can hang in the balance, how fiercely it can be fought for, and how easily it can be let to fade away. All of the patients I have seen this month are sick. This sounds a bit silly, given that I have been seeing sick people for almost a year now, but this month the patients are sick. They do not simply have a sickness. They, in a sense, are their sickness, because cancer, no matter how valiantly it is fought, will, at a minimum, take over a life, and when fulminant will simply take the life.
The patients that we see range from those who are admitted for "routine" chemotherapy to those whose bodies are losing their last battle. For the most part, every patient we have seen has been nothing but wonderfully kind and thoughtful and a true joy to know. We don't just get to know the patients, we get to know their families, and we get to know their stories. This makes it all the more difficult when they leave the hospital, all of us knowing that they are going home to die. This event of dying is one that I have feared witnessing. Every doctor has their story of their first patient that died. It is just one of those touchstones along our path. I haven't yet made that part of my journey, but today I came very close.
We have a lovely older woman in her late 70s who has widely metastatic breast cancer, including metastases to her liver, lungs, and brain. She came to us having seizures and extreme shortness of breath. For the past two weeks, we have been working on getting her to a point of having her pain managed well enough for her to be able to leave the hospital. Her family has decided that she should receive only comfort care, and that we should not make attempts to resuscitate her or intubate her should her heart stop or should she stop breathing (doctor lingo: do not resuscitate, do not intubate, or DNR/DNI). She has made steady improvement, but there have been several setbacks along the way, including her becoming delirious and needing to be sedated because she was taking swings at every one who came into her room, and a run in with pneumonia. Over the last few days she has seemed to become a bit more coherent, but still confused, and plans were in the works for her to go home with her family on Friday.
This morning the other medical student on service with me commented that this patient seemed a bit more confused and lethargic. Later in the morning, our senior resident rushed into the resident room where we all do our work, asking, "Mrs. E is a DNR/DNI, right?"
"Yes," several of us said in unison.
"Okay. She's dying."
The three of us who were in the room jumped up from our chairs and walked across the hall, following our senior resident into the patient's room. Her nurse and the nurse's aide were with her. Her eyes were closed, she was breathing very rapidly, her heart rate was less than half the normal, and she was unresponsive to us, but seemed to be trying to utter something. The four of us who had just entered the room gathered around her bed, and watched.
The thought kept going through my head, "This is death. This is the last battle for her." It felt like some kind of out of body experience, just too surreal to actually be taking place in front of me, with all of us just standing around watching it happen. There were questions flying around the room about calling her daughters to let them know what was going on, paging our attending and updating him, running checks of her vital signs to see if this would somehow pass, theories about what might be happening other than simply death. At that point, the four of us all had a task to accomplish to make sure things went smoothly and that all the proper people were called.
We left the room, did our tasks, and by the time we got back, she seemed to be improving. Her breathing was slowing, but still irregular. Her heart rate was approaching normal, and her blood oxygen level had started to creep back up from the depths. Then she started whimpering, "It hurts. It hurts." Again, a flurry of activity. When was her last chest x-ray and what did it show? Could she have just had another seizure? Is this something that actually could be easily treated? So again, we left the room.
After a few more gatherings around the bed, we drifted back into our resident room, and waited. We soon realized that she had, indeed, faked us out, and that although her death would likely be soon, it was not imminent.
It all reminded me so much of the nights on the labor and delivery floor, the waiting, the checking, the watching, the progressing of labor and the failure to progress. The knowledge that a life changing event was about to take place, and that it could be neither hurried nor delayed. Life, it seems, comes and goes as it pleases despite our best efforts to command it.
In experiencing these moments, I have noticed the division beginning to develop within me. There is the side that must think, "What do I do now with my knowledge and my skills to help this person medically," and the side that thinks, "Given my lack of real knowledge or experience, what can I do to make up for my lack of skills?" This is the same side that wonders, "Do I pray now?" and "Do I try and say something soothing or calming."
Not exactly being a churchly person, ahem ahem, I find the idea of actually praying a bit awkward, but for some reason, I find myself hardly being able to keep myself from simply thinking, "God please help this person and help us help them." Not having ever been in the position of having my legs in stirrups with all my goods showing while a small human is ejected from my body, I have an equally hard time mustering up the courage to say something as ridiculous as, "Keep pushing." Or even being able to imagine the feeling of hearing that first cry, that first breath.
And, not having ever been in the process of dying, it seems grotesquely inadequate to try and think of anything at all to comfort someone who is about to breathe their last, or to their families watching the last breath be drawn.
In both of these moments, I feel so small.

Four More Weeks

after this week, i will have only four more weeks left of my third year of medical school.
i still do not know what i want to go into after all this is over, and i have really just stopped trying to figure it out.
as has now happened 6 times previous, i am finding that i unexpectedly enjoy this rotation. i had really convinced myself that i would hate everything about internal medicine, from the hours to the patient population to the subject matter. i kept thinking," this rotation is going to make me learn about all that stuff i hate, like the kidneys." when i shared this thought aloud, the reactions i got were along the lines of, "well, i hope a doctor would know something about the kidneys..."
um, true.
so, here i am, finally actually understanding material that has evaded me for so long. i am not sure if it is because i can think, "oh, mr. so and so has kidney failure, and this is what happened to him, let me read about it so i understand more." maybe it is because my brain just needs to read about kidney failure 28 times in three years to finally get it, in which case, i will be about 78 before i am able to understand every organ in the body.
the other thing i feel i need to share right now is actually an answer to a question that has recently been asked of me several times.
the question is, "have you been watching that new show 'grey's anatomy?'"
answer: no.
i was intitally intrigued by it, and i watched a short part of maybe the second episode. it had to do with some guy dying and the interns deciding to try and get his organs or something. what i remember most are things like, " we're doctors, aren't we supposed to save lives?" delivered with such emotion that i nearly gagged on the puke welling up in my throat.
i have been warned that any form of entertainment involoving the medical world would one day be ruined for, and i think it now finally is. the thought, "that could never actually happen," has gone through my head several times, each time annoying me because i do not want to be "that girl" who always says things like, "oh, that would never really happen because blah blah blah," thereby ruining the show or movie for all the other people who are just trying to be entertained. so, i have now started avoiding any medico-fiction-drama in order not to have to see myself as "that girl."
and, since i am married to an attorney who has a very difficult time watching any legal fiction-drama, and since 90% of television shows have something to do with medicine or law, we have no choice BUT to watch intellectually stimulating shows like "America's Next Top Model" and "Showdog Moms and Dads." i suppose the one exception to my rule is "dr. 90210," a show on E! that i fond very amusing because, unfortunately, it is a pretty accurate portrayal of the kinds of personalities that flock to surgery as a career.
thank you for excusing the lack of proper capitalization.

Two Months?

Has it really been two months since I have written anything for this. Yikes.
I do have a lovely set of excuses prepared, though...

1. Upon my return from McPherson, I was assigned to the neurosurgery service at KU Med. Although I enjoyed parts of it, the hours did begin to suck my will to live. Although I often thought about writing about seeing a skull sawed open, or drilling pieces of skull back together, it just never happened.
2. For some reason my computer stopped letting me log into my account, so I wasn't able to post anything even if I'd had the time to sit down and write it. Last night I did some computer wizardry, though, and ta-da, here I am again.
3. Now that I have had a bit of experience with the psychiatry, I have a label for the constant worrying and thinking and talking about what to do with my future. Perseverating. I have been spending all my free time perseverating about what the heck I am going to do for the next 30 years.

So, now that the excuses are all there, and now that I can access my account, and now that I am about to do a 4 week stint on the inpatient psych ward, I ought to have plenty to share. I think.

Freaking Me Out

The powers that be at my school held a class meeting today to freak me and the rest of my classmates out.
Phrases like "graduation," and "getting your lives together," and "plan ahead," were uttered several times.
Apparently, we are reaching that time in medical school when we actually have to face the reality of being shoved out of the shelter of school and into the real world. with our third year barely halfway over, it is time for us to start planning and scheduling our fourth year.
The beauty of the fourth year of school is that it is basically a "do it yourself" year. We get to choose the rotations we want to do, and to a certain extent we choose when and where we want to do them. There are three rotations and one class that we are required to complete, but they exist in the sense of categories, meaning that we have to do a months of Critical Care, but it can be in the medical intensive care unit, the neonatal intensive care unit, the surgical intensive care unit, the emergency room, or some other types of intensive care units.
The problem is that the rotations we choose and when we do them and where we do them are actually going to be of importance. No longer can I say, "oh, that sounds cool." Instead, I have to actually think in terms of "oh, that sounds cool, AND it is something I am interested in doing for the rest of my life, and therefore I need to take that rotation in Septmeber because I want to impress these doctors and be able to get a letter of recommendation for residency, and those are due in October."

Somehow I ended up with this afternoon off, so ever since the meeting I have been looking through the catalog of electives, looking at the possible schedules, making lists, drawing arrows, circling things, crossing things out, and in general, the longer I do this,
the
more
I
freak
out.

People have started asking me when I have to decide what kind of doctor I will be, and when I say "in the next 8 months," the response has been, "Oh, well that is plenty of time."
Uh.
No.
Not for me.
I have spent the last 26 years avoiding deciding on a specific profession. I have carefully shrouded myself in the dream world of academia and school. And now they want me to dacide on one thing to do for the rest of my working life?

As Tommy will attest, even the daily decision of what to have for dinner is gut wrenching for me. "Do I really want spaghetti tonight? Maybe I would have spaghetti tomorrow night, and should have grilled cheese tonight. But if I have grilled cheese tonight, then I might not want to have pizze tomorrow, and pizza might be the only decent thing available in the cafeteria at lunch tomorrow. I did just have spaghetti two days ago, though, maybe I should have pizza tonight..."

I have started trying to look for signs as to what I should go into. I have tried to close my eyes and imagine myself as a doctor, and what kind of doctor I see in my mind's eye. I have tried to find things that I know I definitely would never want to do with my life. The only things I can rule out for sure are anything that has to do with poop and most things that would have to do with the penis. I like kids. I like old people. I like being in outpatient clinics, and I like being on the inpatient service. I like the medicine side and I like the surgery side.
So, here I sit, writing this in order to both avoid actually making any decisions and hoping that by getting my thoughts on the screen, I will maybe see some kind of clue. Then I glance to my left and sitting on the table is the calendar they gave us, and my own notes and scratch marks and highlighting and general insanity.

The only things I know for sure are that I am going to New Zealand in February of 2006 and that I graduate on May 20, 2006.

Other than that, I am clueless.