Flow Riders

Third year of a medical school is a weird thing.

We bounce from place to place, speciality to speciality.

It's like having to move, learning to work at a new full time job every 6 weeks, new responsibilities, new people, new policies,

and go to school at the same time.

So we definitely have to go with the flow.

The flow has taken me to South Florida this time,

a GLORIOUS step up from Connecticut.

But still not somewhere that necessarily jives with my lifestyle.

So,

we're just going with it and soaking up the good stuff.

 The good stuff includes beautiful, beautiful beaches.

Hello sunshine!  Where have you been all my life?

 

Long lunch break walk on the beach?  Don't mind if I do!

 

I felt like such a rebel back at the office with sand still in my shoes.

 South Florida is a weird mix extreme luxury, emphasis on appearances, and lots of people struggling with addiction.

We checked out the extreme luxury at the Breakers hotel.

 And courtesy of my dad, pretended we weren't struggling medical students for a night.

 It was decadently wonderful.

 We even made up new identities of being an artist, owning a dance studio, and being a recent divorcee from a professional cyclist.

 Unfortunately nobody asked.

 But it was fun to pretend for a night.

 Pretty gorgeous no?

 This past weekend my roommate Mayo and I decided to explore some of the less manicured parts of Florida:

The Everglades

&

Key West

 I had a liter of blood sucked out of me by mosquitoes while jumping out of the car for 5 seconds to take this picture.  

I have never seen such swarms, (swarms I tell you!), of mosquitoes.

Made it feel like much more of an adventure though, 

especially since we were sleeping here:

More proof:  Mayo RUNNING on one of the paths to the mosquitoes at bay.

Vicious.

We made it to the bay at the end of the park and jumped on a boat ride.

We saw manatees (or at least their tails) before we even left the marina!

AND we were surrounded by a bunch of dolphins!

Magical.

The captain turned off the engine and we just floated out in the bay with the dolphin fins cutting through the water and the only sound coming from the dolphin blowholes.

Absolutely magical.

Cielo, our potbellied naturalist guide, also pointed out all kinds of birds.

Rainstorms come every afternoon in Florida in August.

And you can usually see them a coming.

We took advantage of some real Mexican food just outside of the Everglades park,

before we return to the Mexican-food-less North!

The next morning we went to walk the Anahinga path which we were told would be the best place to see alligators.

(Mayo's biggest Florida wish.)

I was pretty sure we'd already cashed in all our wildlife-spotting luck the previous day.

But about 50 yards from the trailhead, I heard Mayo gasp "Oh god!"

"What?" I asked whipping my head around to see that I'd just walked past a 11 foot alligator on the side of the path.

Dear god!
I was convinced there was no way it could be real.

Must be planted there to please the tourists, right??

So we squatted down to get a better look (and you know, get closer to the 11 foot alligator) and sure enough, 

it was breathing.

Oh hey, Mr. Alligator.

  We saw so many alligators on that walk.
Like 9 of them!
Can you spot the alligator in this picture?

 We also saw this adorably ugly turtle. Ackkk! Cuteness.

 More blog photo hunt:

Can you spot where the alligator is in this one??

 Photo shoots aren't harassment right??

 The mangroves were pretty spectacular too.

 But I know you really want to see that 11 foot alligator again don't you?

It was still there on the way out.

And this time started opening its mouth.

We took that as our sign to leave.

 

Then, we stopped by a local joint and ATE some alligator.

It was delicious, and I imagine you can get a lot of meat from one alligator (see above photo).

 We also stopped at this fruit stand.

I got an amazing mango smoothie and Mayo got a dragon fruit.

Have you ever tried a dragon fruit?

You should because they're delicious and hot pink!

Oh, and in case you were wondering...

Robert was there.

Next stop:  Key West

Where we immediately discovered what we want our mailboxes to look like when we're grown ups.

We made it to the Southern most point in the United States.

 Cooled off with some pineapple shaved ice.

 Marveled at the beautiful houses.

 And rampant flowers (compared to the square hedges of Palm Beach).

We ate delicious seafood while contemplating living on boat.

 Then we drank like pirates with bikers and tourists and rugby players.

 It's been a good ride, Florida.

You're a funny place, but it's been real.

Sunday, I'm moving to Florida's polar opposite:  Maine,

to start my new job as a Family Medicine medical student.

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Flow with whatever may happen and let your mind be free. 

Stay centered by accepting whatever you are doing. This is the ultimate.
-Zhuangzi

MEDICINE/Quote of the Week

Mandy* (a 24-year-old woman in a manic state): So you're a medical student? Where do you go to school?

Me: Yeah, I go to University of Vermont.

Mandy: Are you a working girl?

Me: No, I'm a medical student.

Mandy: Were you ever a working girl?

Me: No, why?

Mandy: You look like you could be.

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"Other elements of mania may include delusions (of grandeur, potential, or otherwise), hypersensitivity, hypersexuality, hyper-religiosity, hyperactivity, talkativeness, an internal pressure to keep talking (over-explanation) or rapid speech, grandiose ideas and plans, and decreased need for sleep (e.g. feeling rested after 3 or 4 hours of sleep)."
-Wikipedia, my favorite med school reference

Quote of the Week

Ella (another elderly, confused patient): Excuse me, where am I?

(Note: She has been admitted for a few weeks and was talking to me 2 minutes before that.)

Me: You're at St. Mary's Hospital.

Ella: The hospital? Why am I in the hospital?

Me: Well, you were confused. Do you remember who I am?

Ella: Yeah, you're my earth angel. [Smiling up her wrinkled face.]

Me: That's right.

The previous day she had told me she had 100 earth angels, and I was one of them.
Definitely a step up from having the devil on my body.

Why, what was your day like??

Quote of the Week

Me: Mary*, you seem happier today. How are you?

Mary (smiling toothlessly) : Oh, I am better. I see the devil on your body.

Me: Excuse me? You see the devil on me?

Mary: Oh yes. I see the devil on your body.

[Pause]

Me: I like your new sweater.

Mary: Oh thank you!

*Patient name changed.
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If you're going to be crazy, you have to get paid for it or else you're going to be locked up.
Hunter S. Thompson

We are the Storykeepers

Photo credit: Mayo Fujji, my classmate, on her trip to Montana

I don't think I knew how much of medicine was storytelling.

The majority of time is spent gathering people's stories,
"taking a history".
And people tell you everything.
They will tell you about the aches in their little toe, their great aunt's hernia repair, the time of their last bowel movement, that they're having sex with someone who isn't their wife, all the drugs they've done, and they'll tell you their fears.
Fears about cancer, about heart attacks, about death.

Then we keep these stories.

We can't share them with many people,
only those involved in their care.

But we write them down in H&P's (History & Physical)
or we present the story to our attending physician.
And we keep them inside of us.

When we see that patient again,
this time for high blood pressure,
the history of their divorce and their family history of diabetes
comes tumbling out of our story chest also,
like a pulling a piece of tangled string and realizing that it's connected to everything.

And these stories become a part of us.
We know someone who is a recovering heroin addict.
We grieve the loss of people with stage 4 lung cancer.
We struggle with the knowledge that COPD (emphysema) patients are out there still smoking slowly causing themselves to drown in their own lungs.

Today I started my psychiatry rotation.
I have a feeling that the stories are about to get more harrowing,
and that they may haunt me.
But I feel like these might be the most important stories to hear,
because there are no dressings to be changed,
no stitches needed,
listening might just be one of the best medicines we have.
And there are no side effects for the patient,
only the care giver.

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Eventually, all things merge into one, and a river runs through it. The river was cut by the world's great flood and runs over rocks from the basement of time. On some of those rocks are timeless raindrops. Under the rocks are the words, and some of the words are theirs. I am haunted by waters.
-Norman Maclean, A River Runs Through It

Questionable

This is a practice question I did the other day.

A 19-year-old man is evaluated for depression of 6 weeks duration. He enrolled in college as a freshman 5 months ago and began participating in intramural basketball, football, and soccer in addition to carrying a full academic load and having a part-time job. He smokes cigarettes and marijuana and consumes more than 12 alcoholic drinks on the weekends at parties. He is sexually active with four different partners. However, during the last 6 weeks he has seldom left his room and has stopped attending classes because he cannot concentrate; he is in danger of failing all of his classes. He feels restless, cannot sleep, has a poor appetite, and feels depressed. He can identify no precipitating event related to his change in mood, although he had a similar episode once before at age 16 years. There is no family history of mood disorders.

Which of the following is the most likely diagnosis?

(a) Bipolar disorder
(b) Dysthymia
(c) Major depressive disorder
(d) Seasonal affective disorder
(e) Situational adjustment reaction with depressed mood

(Question from MKSAP for students 4, American College of Physicians)

The answer I gave: Major Depressive Disorder
The one they said was right: Bipolar Disorder

They thought his behavior when starting college was "hypomanic".
Seriously??
I would just label that at "college freshman". No??

Interesting how much depends on your perspective.

So I've been studying lately, and sweating, and packing up my car wearing a dress, and sweating through the dress, and planning stuff for this weekend.
Fun things to post about coming up ...
a 30th birthday, a wedding, time in Vermont, and Buckfest.
And that's just the next 4 days!

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"A question that sometimes drives me hazy: am I or are the others crazy? "
-Albert Einstein

eeks, I don't know where I got these images.

I heard a cardiologist
talking to a group of residents
about treating patients with congestive heart failure,
and she talked about how
sometimes even when we try all the treatments and drugs we have in modern medicine
some people
are at a stage beyond our help.

With congestive heart failure,
you get fatigue, swelling in your legs, and fluid starts to back up into your lungs making you short of breath.
It's also usually found with a constellation of
other health problems.

"I have one patient,"
the cardiologist, a doctor of the heart, said,
"We'd tried all the drugs, and she would still come in crying about her symptoms every time.
Then she discovered this "healer".
And let me tell you, we're in the wrong business,
because this guy does "ceremonies"
with her
and he charges hundreds of dollars a session!"
She cackled at the absurdity.

"But," she continued, "the patient has never been happier. Nothing has changed in her physiology, but she claims she feels a lot better."

And all I could think,
as the residents laughed at this woman gaining some peace from a "placebo effect", was

"Aren't we supposed to be healers??"

We've been told over and over again in medical school to treat the person, not just the disease.

And yet,
the prevailing culture in medicine is still
treat the physiology.
It doesn't matter if the patient is crying in your office every visit.

Don't get me wrong.
I'm not saying I'm there.
My "practicing of medicine" in this clerkship year of medical school,
mostly just involves
trying to remember the right questions to ask so my attending won't yell at me when I tell them about the patient.
But I hope one day
to be more like that "healer"
and less like that cardiologist.

-----------------------------------------------------------
"It's not one thing that takes away pain.
Sometimes it's herbs. Sometimes it is having someone take your hand.
Sometimes it is telling somebody something wrong you have done and letting them take the weight of it away from you."
-Juniper, Monica Furlong

"The fact that people were attentive to his body
does not compensate for their ignoring his being."
-Cutting for Stone, Abraham Verghese

More than a Doctor?

Photo source

We have a patient* right now that is dying.

He's a 77 year old man from India who came in with sudden onset severe dementia.
We tried all the drugs we could think of for that.
Nothing has changed.
He couldn't swallow on his own without risking him getting pneumonia from inhaling his food.
So we placed a nasogastric tube to feed him through.
He pulled it out.
We put it back and put mitts on his hands.
He pulled it out again.
He also pulled out his IV.
Three times.
He spits at the healthcare workers sometimes because of his confusion and agitation. He mumbles in Hindi and his glazed eyes will look right at you, but you know they aren't seeing you.
His 90lb frame is stiffly curled up in the fetal position dwarfed by the white sheets and blankets of the hospital bed.

He's been placed on comfort care now, which means hydration, pain management, and waiting.

He will probably be the first patient I have that will pass away on my watch.
And it bothers me for 2 reasons.

1) This is not a good death.
Confused, in a hospital where people don't speak his language, hooked up to IVs.
The real shame is he comes from a culture and a family that would normally take him home, feed him and keep him until it was his time to go, at home, comfortable, surrounded by family.
However,
since they live in the US now, they all have to work to afford to live and so there is no one at home to take care of him.
That's a real shame that that part of our culture, not taking care of the elderly, is eroding another culture's desire to do so.

2) I want to be more than a doctor.
In these situations, we've done all we can medically, and my team still rounds on him every day, just to make sure he's medically stable and to adjust his Ativan so that he is not so agitated for the nurses.
But it's times like this that I want to do things that go beyond the realm of medicine and would be considered highly unprofessional.
I want to climb in the hospital bed and cradle his frail body.
I wish I knew his language and would tell him stories,
beautiful stories of creation and and myths of the afterlife.
But in this age of modern medicine, even hugging your patients is frowned upon.

And so I wonder, is it really a doctor I want to be?
And if not, what would qualify me to care for people like that? A nurse? A chaplain? A mother?
And where does one train for that?

------------------------------------------

There has never been a time when you and I have not existed, nor will there be a time when we will cease to exist. As the same person inhabits the body through childhood, youth, and old age, so too at the time of death he attains another body. The wise are not deluded by these changes.
Bhagavad Gita

*some details have been changed to protect anonymity.

Clinical Pearl

This photo has nothing to do with this post but is a teaser for my Vermont weekends post.

And then sometimes, there were amazing shining examples, veritable beacons of hope in a medical wasteland.

Dr. Awesome: What do you think the most important thing on this sheet is?

He was waving the sheet of paper that nurses put outside your exam room when you go to see the doctor. I had often grabbed that sheet looking for information about the patient before going into see them, but found that it didn't have any health information or even why they were here to see the doctor; it only contained insurance information and was really for the patient to check out with at the end of the visit.

Me: To see whether the patient has insurance or not?

Dr. Awesome: Wow, is that really the kind of doctor you think I am?

I want to eat my words.
No, not at all!, I want to say, I think you're Dr. Awesome. I've just apparently let myself become jaded in 3 short weeks.
Nice.

Dr. Awesome: It's to see when their birthday is. Because if their birthday is coming up I like to wish them Happy Birthday.

And that is why he is Dr. Awesome.

Ways in which Surgery is like Star Wars

In the many, many hours I've spent standing and observing surgeries over the last several weeks,
I've come to notice how much we are living in what I imagined to be the future and how much that reminds me of Star Wars.

Star Wars had R2D2.

The hospital has "TUG", a robot that delivers lab results and supplies all over the hospital.
He has his own elevator and he talks to you when he's arrived at his destination.
He's adorable and I want to hug him sometimes.
I feel the same way about R2D2.

Star Wars has battle droids.

The hospital has Artis Zeego (even sounds like a Star Wars name!), a machine that takes real time video pictures of the blood vessels during vascular surgery.
He moves by remote control and lets you see what you're doing inside the body.
Totally the future.

Star Wars has Darth Vader.

Surgery also has men in masks that I would be devastated to find out were my father.

We had our oral exam today.
I have my last 4:30am morning tomorrow (at least until Ob/Gyn),
and our Shelf Exam (standardized test) on Friday.

Then hopefully I'll have more time to tell you about the AMAZING wedding I went to in Northern Ireland and all the beautiful Vermont weekends I had during this clerkship.