Hello, Darlin'

"Hello, Darlin'

Nice to see you.

It's been a long, long time..."

As Conway Twitty's voice rang out from the patient's buzzing cell phone, the very focused intern began inserting a catheter through the abdominal wall where it would drain almost 4 liters of fluid from Mr. X's very distended abdomen.

Just as the catheter tip was reaching our fluid filled money spot, I thought about all the other times that song may have been the soundtrack to moments in this patient's life. Driving a date to the movies. Playing to an empty house after his kids went off to college. Serenading him now when he goes to his favorite local diner for pie. And then I thought about this moment. The one we all found ourselves starring in. The setting: a quiet ICU. The supporting characters: a seasoned attending, a couple of nervous interns, and one third year medical student, trying desperately not to contaminate my sterile gloves. The leading role: a man in his early seventies, currently grappling with the harsh reality of decompensated heart failure.

I originally began this post during my last week of internal medicine. And while there were moments that I absolutely loved working on the floor, there were also many that left me disillusioned. There have been stories that I've wanted to share on this blog, but ultimately chose not to. Mostly because I felt that my writing was inadequate. But also because coming home after ten-plus hours surrounded by sickness, the last thing I wanted to do was write about it.

A lot of those posts, like this one, would start off with a person, their story eventually interrupted rudely by an illness. And that's where it would stop. Because as much as I tried I couldn't find a nice way to wrap it up. A final point or "Scrubs-like" realization to conclude those posts would elude me. It just wasn't there. And I guess that's what made those moments in the hospital, like the one above, so heavy. Those moments remained absent in my writing because they did not exist in real life. Sickness is cruel like that. It so rarely provides the luxury of a satisfactory conclusion.

It is the singular commonality I've found in all the really sick patients I've seen. That no matter how many pack years they've smoked, how severe their coronary artery disease is, or how much their cancer has metastasized, no one ever imagines the hospital is how or where they will end. And when they do find themselves in those moments, faced with the end of it all, it just doesn't seem to fit. Kind of like Conway Twitty in the ICU.

"Thank you, darlin'

May God bless you

And may each step you take

Bring you closer

To the things you seem to find."

Dear med school newbie...

A couple weeks ago I posted an open-ended letter to a future patient. A couple days ago one of my dear friends, who I've known forever, started medical school. I like the idea of writing to people I know, but writing to people I don't know is just so fun too. It's in that spirit I give some advice to the brand new med school newbies out there.

Dear med school newbie,

First off, congratulations! Not just for getting accepted to medical school, but for accomplishing the goals that mark that journey. The pre-requisites, and letters of recommendation, and community service projects alone are usually enough to scare the faint of heart from ever even thinking of applying to medical school. (Do I dare even mention the MCAT? Ok, I won't.) But not you, friend. You stuck it out. You figured out exactly how much caffeine precipitates palpitations and walked that fine line like an olympic gymnast. You passed organic chemistry - even if it was with a C. You volunteered your time and parts of yourself and hopefully along the way you realized that helping people is really one of the greatest things ever. Which only made your nerdy little heart chase after a career in medicine that much faster. Go you. :)

Right now I wish I could give you a hug and a high five through the internet (get with it, technology!) I also wish I could tell you that the hard part is over. That once you get that life changing letter cementing your white-coated dreams into reality you can take a breath and relax. (Ok, I guess on the actual day that letter arrives you can chill for a bit.) But if I said the rest of this crazy ride was all downhill after getting accepted, I would be a big fat liar. Which is generally something I try not to be. (People like you more and your scrubs fit better. :) )

The reality is that medical school is like a roller coaster. And some days -- like when you pass an exam you were sure you failed, or you manage not to make an ass out of yourself in front of a faculty member -- you are going to feel so confident and sure of your decision to practice medicine. But other days are going to be low. And the stress and workload and never ending list of things to know and study and review will be overwhelming. You may find yourself questioning this particular life choice and doubting your ability to do this whole med school thing.

I wish I had some advice on how to get through the tough days. All I can say is lean into the people who supported you this far. They're still there. Seek comfort and encouragement in your new med school friends - they're in the academic trenches with you! And remember why you wanted to become a doctor in the first place.  Set goals for yourself and chase after them, just like you did when you were still a puny "pre-med." Acknowledge and appreciate your strengths. Work on your weaknesses, but don't beat yourself up over them. And just a couple of med school myth busters for you: Every one struggles with something. No one "barely studies." And no person in a white coat, yes even your esteemed faculty members and attending physicians, will ever know it all.

It's also important to know that medical school is finite. It's not gonna last forever. And, even though I'm only 2 months into clinical rotations, they are so so so much better than the first 2 years. Because those years suck! There really is not use telling you they don't. But again, they only last 2 years. And then they're gone. So learn as much as you can. Say goodbye to the outside world (and your tan. Libraries generally don't have UV lights.), and work your tail off. Because one day you'll walk into a patient's room and lying before you on a hospital bed will be that random disease you read about manifested in a living, breathing person and you will be able to help them. Which is really what all of this med school stuff is about in the first place.

And, when all else fails, and on those days when you "literally can't even," remember PASS = MD/DO.

Now, go put your smarty pants on. We've got some studying to do. :)

Morgan

P.S. This week I really did walk into a room where a patient had one of those "random diseases" we're told as students we'll "hardly ever see." When you get a chance, check out neurofibromatosis. Gotta love those neurocutaneous disorders. :)

Time Machine

I looked down at my watch and felt a small surge of panic rise in my chest. 6:42am. 18 minutes until morning report. 18 minutes to talk to my patient and examine her before I had to be sitting in a conference room on the other side of the hospital.

Mrs. X, can you tell me how your night went?

Mrs. X, did you get some sleep?

Mrs. X, have you had any headaches? 

I began asking my usual battery of questions to a sleepy, semi confused elderly female patient. She interrupted me to say that she needed some water. I hurriedly explained that I would have the nurse bring some in once we were done.

6:47am. 13 minutes.

Any nausea?

Any vomiting?

Again, she asked me for some water.

"I know your throat is dry Mrs. X. We have you on NPO in case we need to do any procedures. I'll have the nurse get you a small cup of water as soon as we finish up here. "

6:51am. 9 minutes.

That time when I looked up from my watch, I noticed Mrs. X gently rubbing her throat, eyes closed. I stopped. I felt like someone had smacked me in the face. Here was an 88 year old female patient, a patient who I had been assigned to follow. A patient who looked remarkably like my grandmother. A patient who was sick and tired and scared. And she was asking me for water. Water.  And all I could focus on was getting the information I needed so I wouldn't make an ass out of my self in front of my attending. Here I was behaving exactly like the type of doctor I had sworn to never become.

I paused. Grabbed her hand and said that I was sorry she was so thirsty. I filled up her cup with a little bit of water (NPO is the worst) and patiently waited while she slowly took a few sips. After she was done I took the cup from her and started over.

I was 6 minutes late to morning report that morning. And I though I can't say that I didn't care -- the watchful eyes of my resident stung a little as I took my seat,  I was more grateful for a lesson learned.  I realized just how easy it is to give in to the endless demands placed on pretty much everyone working in a hospital. I also realized that the choice of giving in to the ever present tick-tock of an over-packed schedule, or taking the time to truly care for the living, breathing human being in front of me will always be just that -- a choice.

Realistically, as a third year medical student, my choices don't impact much right now. Mrs. X would have eventually gotten her water at 7:00am anyways when her nurse came in to administer morning meds. But one day, my choices will have more lasting consequences. And I want them to be positive ones.

Dear Future Patient...

Dear future patient,

First off, let me say that it will be a privilege to take care of you. There are a lot of folks in long white coats out there with a jumble of letters after their names, and I am honored that you will one day allow me the privilege of being your doctor. It's something that I am working very hard at, and will continue to do so for the rest of my career.

Because this relationship you and I will have, of patient and physician, is based on honesty, there is something you should know. I did not score exceptionally well on my licensing exams. In fact, like 50% of the other physicians out there, I did not even score in the top 50th percentile. So, if you're looking for that doc who knocked their licensing exams out of the park, I know several and I will get you their contact information and a referral, no charge. :)

You see, reading information out of a medical text book and regurgitating it onto a scantron is not my forte, and never has been. Those questions are two dimensional and more often than not, all they really test is a person's ability to recognize a word they've seen before and match it with another word they've seen before. The exams don't always test how well the examinee understands a concept, just how good they are at a matching game with really big science words. Your disease process, like you, is a multi-dimensional ever-changing entity. So when it comes time to treat you and tailor your care to the unique and complex individual you are, the ability to correctly pick "B" on a multiple choice test doesn't really seem all that helpful, don't you agree?

So, yes, knowing the science behind your ailments and injuries is the foundation of this thing we call medicine. And as I move forward in my training I will continue to learn and strengthen my understanding of the diseases that will one day bring you into my office. But, there is more to providing good quality patient centered care than high exam scores. For example...

While I'm learning about the various kinds of anemias and how they will make you feel like crap, I'm also learning to put you at ease when you tell me about what hurts. And while I need to know what neurological exams to perform if you present to me with stroke-like symptoms, I'm also learning to make asking questions about your bowel movements more funny and less awkward. Should you get admitted to the hospital for acute atrial fibrillation, I'm learning about the medications  I need to give you to make your heart stop racing like its chasing after the Sprint Cup. I am also learning how to keep you in the discussion and remember that you are the center of treatment, not your disease. When your concerned wife drags you into my office because you've been coughing up blood for the past week and have a history of unintentional weight loss, I'm learning how to explain the diagnostic exams I want to run to see if it is cancer in a way that empowers and not terrifies you. And one day, when you aren't really you anymore and your body is old and simply no longer capable of doing this "life thing," I am learning how to prepare the people you love and walk them through the difficult process of letting you go.

So no, I did not pass my board exams with flying rainbow colors. I passed them and moved on to learning how to practice medicine. I scored what I needed to so that I could continue to learn how take the very best care of you.  Because that has always been my goal - to be an amazing doctor, not an amazing test taker.

Thanks for letting me be honest with you, dear patient. It will still be a few years before we meet, and I promise until we do to continue to to bust my butt and learn the things I need to know to provide you with phenomenal care, the same kind of care I would wish for myself, and those that I love.

See you soon,
Future Dr. Day

P.S. Stop smoking, try to get 30 minutes of exercise at least three times a week, and don't be afraid of those leafy greens. :)

Lo siento

"Hey, have you ever heard of benzos causing GI bleeding?" I quietly asked one of the first year interns on my team during rounds this morning.

"No. Why?"

"Dr. X. just said patients on ativan are at high risk for GI bleeds."

"Are you sure he didn't say aspirin?"

"Yeah, he definitely said ativan."

"Hm. Yeah I've never heard of that. He really didn't say aspirin? He has a pretty thick accent. Maybe you misunderstood him."

"Oh no, I'm from AZ and am totally used to listening to people with thick accents," I said, half joking.

Full of third year confidence, I grabbed my phone and opened epocrates to check the adverse effects of ativan.

Later, during a lull in the morning activities, I mustered the courage to ask the attending about this baffling correlation between ativan and GI bleeds. He looked at me, puzzled and said, "no, aspirin. Aspirin causes GI bleeds."

Blank stare. Internal scream. Morgan, you arrogant ass.

"Oh. I must have misunderstood."

I caught a smile creep across the intern's face out of the the corner of my eye, just as our attending began pimping me on aspirin, and other drug classes, that are known to cause GI bleeds. Woo.

Happy Monday, folks! And, if you too were served a tasty slice of humble pie today, I hope you at least learned something from it. :)

Then Came the Morning

My flight had been postponed for the following morning and I was riding in a shuttle to some crappy hotel in Atlanta. In between small talk with the driver and an 18-year old newly enlisted soldier on his way to boot camp, I managed to catch bits of the talk radio program playing in the background. The speaker, an older man with a voice that could have given Morgan Freeman a run for his money, was speaking about the journeys this life takes us on. The quote that resonated with me, at that time just a med school hopeful fresh out of a medical school interview, was this:

"If we knew how hard the journey was going to be, we would never take the first step."

And I think most of us, regardless of what life paths we're cruising along, would agree with that statement. Because goals are great, and dreams are...well, fun to dream about. But when you're in the thick of things it can be easy to forget why you started in the first place.

Now that I have taken survived boards, the real "school" portion of my life has pretty much come to a close. No more entire days spent studying in the library. No more case reading lists and PBL exams and flash cards filled with "high yield" facts. There were times during these past two years when I doubted this path I worked so hard to get on. And from time to time, those words I randomly heard on a rainy night in Georgia, when I was exhausted and far from home, come back to me. And I am glad there was no way I could have known then what the first two years of medical school would hold for me.  Because I know now what I might not have believed then. That though stressful times would come, I would not only get through them, but be strengthened by them. And with every passing exam, I would grow more confident in myself as a future physician and as a person.

One week from today I officially start my third year in a hospital seeing patients every day. After two years of burying my head in books, I am so excited to be back among the living. And while I am sure there will be tough times in the next two years, for now I remain blissfully, and thankfully, unaware.

The Final Countdown

"No. When the sternocleidomastoid contracts, your head looks to the opposite side of the contracting muscle."

The EM intern stared incredulously at the GIANT man nurse (seriously, this guy was a huge dude) who was schooling him on neck anatomy. While Dr. Shaky-Hands (a nickname I secretly gave him after watching him butcher a central line) timidly tried to figure out the mysteries of the SCM, his attending walked by and barked an order at him, which sent him running, and that was that.

The entire interaction lasted all of 5 seconds. And because of it I will always remember that when the SCM contracts unilaterally, the head turns to the opposite side of the activated muscle. One tiny factoid I randomly learned years ago that still helps me on OMM/Anatomy questions.

One week from tomorrow I'll take the first of my two board exams. Which is kind of a big deal. Any medical student will tell you, starting with the very first day of medical school, everything is about boards. Boards boards boards. They determine a lot. What specialties you're competitive for, what residencies you have a shot at matching to, etc. Like I said, kind of a big deal. As you can imagine, this weekend I've been doing my best to keep the panic at bay.

I haven't studied enough! 

I should probably post-pone my exam... 

There is no way I know everything I need to know for this thing. 

I'm out of coffee. Nooooooo!!!

Earlier today, I had a practice question about the SCM, and was reminded that I have been preparing for this exam for years. I have studied enough. I am not going to post-pone my exam (not gonna lie, a pretty big factor in this decision is that I wouldn't get to go home and drink margaritas by my pool before I start rotations, but whatever). And no, I won't know everything I "need to know." There is simply too much.

But in the next seven days, in addition to making one last pass through First-Aid and replenishing my coffee supply, I am going to to trust that I know more than I think I know. And keep my fingers crossed for at least one question about the SCM. ;)