Monday, November 29, 2010

Running Path


Tobie and I went for a chilly* Sunday walk yesterday on the path I usually run on. Isn't she a beaut?

*Chilly by Irish standards.

Sunday, November 28, 2010

The Only Accurate Thing About Grey's Anatomy

I used to watch Grey's about 3 years ago when I had gone back to do my pre-req courses for medical school. I'd spend a lot of time yelling at the screen when seriously inaccurate events were depicted (several times per episode) but yet I couldn't tear my eyes away. Yes, it was my television version of a train wreck.

The only thing they got right was the baking. Izzie used to bake when she was stressed and for me, that is bang on. Only I rarely bake, I cook.

action shot
Hence yesterday being rather therapeutic.

It was Ryan's birthday on Thursday so I offered him a birthday dinner as his present from me. I love cooking for people anyway, so it's like a double-edged gift sword of goodness (poor mixed metaphor? Whatever, I like it).

So out of the menu options he chose Hearty Wine and Beef Stew with Dumplings, I deviated slightly from the recipe because I loathe parsley, so the dumplings had green onion and basil in them instead. There was garlic bread and home made ceasar salad to start, and for dessert this berry custard and ginger cookie bowl of yumminess. And, naturally some mulled wine--hey, it is almost December. We have a farmers market here on campus I was able to get all organic veggies and even local organic meat (a.k.a happy meat) for a decent price.

Since I started making the stew at 1400h, it was great to study and breathe in the aromatherapy all afternoon. Somehow the different types of collagen and epithelial adhesion mechanisms just weren't that hard to bear.

By the time dinner was on the table I had been able to shake off the horrible feeling that had been churning my stomach all week. This was also in part due to the comments and emails of encouragement from the blogosphere---thank you! I definitely needed that pick-me-up.

School is hard, and most days yes, all encompassing. But somehow when there are people around that you love, delicious stew on the table, and mulled wine in your glass, life seems more than ok.

Caught with a mouthful of Ceasar. 

Friday, November 26, 2010

Medical School Makes You Haggard

I often end up turfing or just writing private posts about how much I loathe medical school somedays. I guess I don't want this blog to turn into a whiney drone about stress levels, lack of sleep, nil free time, and nostalgia for Canada. I am sure if I was back in my pre-med shoes again I and I came across posts like that I'd grind my teeth and think about how much I wanted to be in medical school while the world seemed full of undeserving, unappreciative little snots who did nothing but complain about being in medical school.

But let's be honest. I am not feeling the love right now.

I know that it is partly because finals are looming and that just brings my baseline cortisol levels up a notch, but it's also this sinking feeling that I made the wrong decision by quitting my life and coming here to do this.

I've been ruminating on the reasons I seem to have been hard-wired into pursuing medicine and wonder if there would have been any way I could have re-wired myself before I got tangled up in this.

I remember the exact moment that I decided I was going to be a doctor and after that, nothing else even seemed to be a possibility. The problem is that it was my complete awe and admiration for an astounding physician that made me want to pursue medicine. Where my reasoning may have been flawed is that it was the man (my grandfather) that was astounding, not the career. He would have touched hundreds of lives and made a positive impact on the plantet if he'd been a used book seller, or a languages professor, or a farmer, or a school janitor. When you are eight years old though you can't grasp that part of the equation. You just see a wonderful human and think the best way to somehow be like them is to do what they did with their life.

I should be feeling good, I did well on the anatomy spotter. But I just feel, obligated. Obligated to constantly study, review, test myself. Surely it is natural, when something seems to take up your entire existence, to feel resentful towards it from time to time?

I am actually grinding my teeth even when I am AWAKE these days. That is a new one. Can't sleep, can't eat, can't relax. Ugh.

So I apologize to the premeds that might stumble upon this post. But right now I'd rather be anywhere than here.

Wednesday, November 24, 2010

Engage with Grace

Things we are grateful for this year

For three years running now, many of us bloggers have participated in what we’ve called a “blog rally” to promote Engage With Grace – a movement aimed at making sure all of us understand, communicate, and have honored our end-of-life wishes.

The rally is timed to coincide with a weekend when most of us are with the very people with whom we should be having these unbelievably important conversations – our closest friends and family.

At the heart of Engage With Grace are five questions designed to get the conversation about end-of-life started. We’ve included them at the end of this post. They’re not easy questions, but they are important -- and believe it or not, most people find they actually enjoy discussing their answers with loved ones. The key is having the conversation before it’s too late.

This past year has done so much to support our mission to get more and more people talking about their end-of-life wishes. We’ve heard stories with happy endings … and stories with endings that could’ve (and should’ve) been better. We’ve stared down political opposition. We’ve supported each other’s efforts. And we’ve helped make this a topic of national importance.


So in the spirit of the upcoming Thanksgiving weekend, we’d like to highlight some things for which we’re grateful.


Thank you to Atul Gawande for writing such a fiercely intelligent and compelling piece on “letting go”– it is a work of art, and a must read.


Thank you to whomever perpetuated the myth of “death panels” for putting a fine point on all the things we don’t stand for, and in the process, shining a light on the right we all have to live our lives with intent – right through to the end.


Thank you to TEDMED for letting us share our story and our vision.


And of course, thank you to everyone who has taken this topic so seriously, and to all who have done so much to spread the word, including sharing The One Slide.



theoneslide




We share our thanks with you, and we ask that you share this slide with your family, friends, and followers. Know the answers for yourself, know the answers for your loved ones, and appoint an advocate who can make sure those wishes get honored – it’s something we think you’ll be thankful for when it matters most.


Here’s to a holiday filled with joy – and as we engage in conversation with the ones we love, we engage with grace.


To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team.

Tuesday, November 23, 2010

IV Starts

Today in clinical we are learning the fine art of I.V cannulation. 

This oughtta be interesting. 

Last year I had to just about bite my tongue off when we were taught to aspirate before injecting in IM and SC injections. When I was in nursing school *cough* 11 years ago that had already been turfed thanks to evidence based medicine that demonstrates the only area where this is indicated is in dorsogluteal IM's (even there it is debatable but certainly NOT indicated with SC injections). 

Ok well initially I didn't bite my tongue and said it to another student but the bat-like hearing of our clinical skills prof exposed me and I was told in no uncertain terms I would fail the OCASE if I didn't aspirate. Sigh. I muttered something about doing it for the exam and never again. (BAD medical student!! BAD!!!)

Anyway, I am interested to see how the IV starts are going to be taught. I wonder how many I may have done in my career as a nurse? Hard to calculate but based on rough figures...7 years, 200 shifts per year (with great variation in # of starts per shifts) maybe averaging 6 starts per shift...that comes out to 8400 starts. Okay even if that is a gross over-estimation, I am well past the 5000 mark. Hey! That is kinda cool. I never actually figured that out before. 

Below is a comment that I left on Rob's blog ages ago when he wrote about learning how to start IV's. They are some of the little tips/tricks I've gleaned mostly from other nurses, much more experienced than I. 

--

I love IV starts. These are some of the rituals I go through when I am starting an I.V. 

First off, most people believe that there is a metal needle in their arm. When people are really anxious about it (esp PEDS) I show them how it works with a demo needle that I chuck. It seems to really calm a lot of folks down. I only usually show adults if they are going to have the IV in for a long time, it makes them more relaxed about moving the tethered limb around. 

Some tricks I use for tough starts (I am sure you know these already but in case you don't):

-In the elderly with the feathery skin and veins don’t use a tourniquet as you are more likely to have it roll or blow with the induction. Just anchor the vein above the site with the thumb of free hand and go at a very superficial angle. As soon as you get flashback take the needle out and gently advance the catheter. 

-For tough starts go for the radial vein near the wrist (usually very juicy as not many people use it).

-Warm people up with either warm blankets or (my personal favorite) 100cc saline bags that you put in the microwave for 10-30 sec. This is great with PEDS also, I warm the bags up then kling wrap the bags to their hands and feet–go off and do some other task and when you return–BAM! the veins are waiting for you. (Just make sure you hold the bag on your own skin for about 10 sec to make sure it is only warm not hot. I think that hot wet towels are a bad idea because as soon as you take them off it cools the limb down a lot and if you get caught up doing something else then you have a cold, wet limb to try and salvage a start out of. Dry heat is better.)

-Drop people’s hands so that their arm is hanging below the chair. 

-Don’t slap the veins as sometimes that causes them to flatten out.

-Take your time. 

Really. I spend as much time as I need just chatting with the patient while I palpate around for the best vein. The longer I take to find a good one, the greater the likelihood I’ll find one on the first poke.

-Don’t be afraid of small guage needles on hard starts. No matter what they tell you blood *will* run through a #20, even a #22 in a pinch. Not everyone needs a #16 in the pinky to prove your abilities.

-If you hit a valve going in, you can try to gently push through or just pull back a bit and if the line is good just secure it there. 

-Tape is our friend. Use paper tape on the elderly, especially if you don't feel like tearing their skin off when you d/c the I.V. 

-And finally, feet are sometimes better than you think. Esp in people who’ve had lots of chemo or alternative drugs (ahem) in specific veins.

So there you go blogworld. My free, unsolicited advice on I.V starts. Now I am off to learn how to do it! There may be some major tongue biting today as well, but must go and see what the gold-standard-medical-school-OCASE-way of doing it is. 

I won't mention my aversion to gloving with difficult starts!


Sunday, November 21, 2010

5 Down, 3 To Go

So we had another mock spotter on Friday. Each term we have one mock (i.e. it counts for nothing grade-wise) and one final (real) spotter.

These exams are also known as "bell ringers" because you get 1 or 2 minutes per station where you have to determine what it is you are looking at and then answer questions on it--before the GONG goes off and you have to move to the next station.

I have to say, this was the best one so far, for me. I don't think I did wonderfully on it but I feel like I am finally figuring out how to ace these exams.

For one, I used to just about have a seizure whenever I saw this photo:

Human embryo at around 3 weeks. 
But now I am not as freaked out. It's just a teeney, weenie little embryo---and it can't hurt me! I know what the bits do, and what they become, and I am not as easily thrown off by our prof putting random genes in the answer (which I don't know) to trick us.  I just look for the part of the answer I know (like nucleus pulposus or skeletal muscle or whatever) and ignore the via Gli3R protein or in response to Fgf signaling part of the answer. I know, it sounds obvious, but when exam adrenalin is rushing I tend to see those words and BLANK on all the things I do actually understand. Freak out. Run out of time. Guess.

So. I try to breathe. When I get to the next station I force myself to let the last set of questions go. I used to ruminate. There is no time to ruminate.

Also, I am in two amazing study groups (mostly composed of the same people), and we've been preparing for exams since the second week of school. Every week we've made presentations for each other on the salient points from our cases last year. We make up quizzes for each other and handouts, etc. It works really well because you are forced to do the review every week and you want to do a good job (so that you don't look like a slacker for the group presentation). 

2 weeks ago we each made a mock spotter for the group from 7 randomly assigned cases spanning both last year and this year (thus covering all the cases). Making the damn thing was VERY time consuming and it took us 2 three hour sessions just to get through all of them, but we timed them like a real spotter and everything. 

I never realised that the BEST way to study is to try and make exam questions! You really have to think about the concept, how to trick people, how to word questions and make plausible fake answers. Each question took me at least 30-60mins to make. 

Hello. It paid off. There were several of our exact slides on the exam Friday!!

Huzzah!*

The real bonus though is that I only have THREE spotters left in the future of my earthly existence. This makes me very happy. Though I must say, since I've been thinking more and more about pursuing surgery, studying anatomy is less tedious than it was in the past. 

---

*I did have one of those post-exam-facepalms though in the shower yesterday. I was just washing my hair and like a lightening bolt one of the histology slides (that had confused me) popped into my head. I thought that it was liver with the arrow pointing to fibrosis. But the lightening bolt struck and I suddenly remembered doing it in one of our mock exams! Nooooooooooooooooooo! It was a fibrillary tangle in a sample of brain tissue! Ahhhhhhhhhhhhh. Facepalm. Facepalm. Facepalm. Sigh.

Can't win 'em all I guess. 

Thursday, November 18, 2010

Doctors of Tomorrow

Today I noticed one of the first-years had as his FB status:

Whenever I see the facebook poke icon, all I can think about is a bimanual....gahhhh.


I would have loved to have commented:

Classy. 


Or

Whenever I see you all I can think about is that one day you'll be a doctor....gahhhh.


This is coming from the guy who wore a name-tag that said DOCTOR CANADA on it during the first week of school when we all went on a meet-and-greet-pub-crawl together.

Thing is, I know so many amazing, talented, intellectual, well-rounded, thoughtful, hilarious people that didn't get accepted into medicine.

Then there's that guy...who did.

(All that being said, my FB status today was that I want to drop out of school and become an Ottawa Valley Irish Dancer so...what does that make me? And yes, yes I did see the Chieftans last night in concert.)

Wednesday, November 17, 2010

Random (Hilarious) Acts of Kindness

The Irish are obsessed with high-visability reflective vests. I mean *obsessed* (at least in my neck of the woods). It is not uncommon to see people walking their dogs, running, DRIVING, with them on. Or, my personal favorite, having them fitted over the passenger/driver seats.

It seemed a little excessive to me though I am a fan of excessive personal protection use (i.e. after working in Whistler emerg I contemplated wearing a mouthguard/helmet to the grocery store).

Anyway, now that we have about 7 hours of daylight it is always dark when I run, whether I go in the morning or late afternoon/evening. I've been feeling a little, er...underexposed since I run in something akin to the "Invisible Pedestrian" costume from the old SNL skit with Dan Aykroyd.

So I've been on a quest to find arm warmers that are reflective. Impossible to get where I live (since evidently women don't exercise here unless it is in gold PUMA's). I thought about ordering some online but I hate buying things I've never tried before (not to mention the ones I found were black, thus furthering my ninja/running getup).

I ambled into the Universities book store yesterday to get some scribblers and saw a promo where if you buy a newspaper you get a free reflective armband (I said the Irish were obsessed with reflectors).  They were out of newspapers so I asked if I could just buy an armband. The woman told me to just take one. So I pushed my luck and asked if I coud have two.

Does anyone need two tickets to the gun show?


I mentioned my invisible pedestrian running attire and she pulled out a big (classically Irish) reflective vest from behind the counter and said, "you need to get one of these!"

I (inwardly) chuckled and appraised the vest---and said it was great and that yes I should get one but that I figured I'd be too hot in it. She showed me how thin it was and suggested it'd be perfect for running. I agreed. She then goes, "ah sure now, just g'wan and take it!"  WHAT?



Yep. She gave me the vest! Hilarious! She said someone gave it to her last week and she didn't need it.

That's what I am talkin' about!
So now you will be able to both read my blog and see me from space! How awesome is that??

Though I am cautiously aware of their subtle assimilation tactics. Pretty soon I am going to switch to drinking tea in the morning and become obsessed with hurling

Thanks random bookstore lady! 

Monday, November 15, 2010

Venue of Vultures

Sometimes when I feel myself only staring at the far-off horizon of being FINISHED medical school, I go back and read through old posts I wrote when I was trying so very damn hard to get INTO medical school. I try and use these reminders of the fact that there are always new hurdles, new accomplishments, new goals waiting after each stage is complete.

This is something I easily forget.

I came upon this old post from my former life this morning. It was exactly what I needed to read.

---

How is it that finish lines can feel so hollow? I was driving home from my exam, the last surge of adrenaline from writing was long gone and had been replaced by the anticipated nausea. I was expecting to feel jubilant. Relieved. Excited. It's strange how coming to the end of a long road can be so anticlimactic.
There have been times in my life where I have felt the pull of endless possibility in many directions so it is a sensation I am already familiar with.

In my minds eye I feel see myself running in a canyon, it's hot and rugged and my head is down to follow the rust colored contours. Running, running, running and then suddenly the ground opens up beneath my feet and I am flying through the air.
So far I have always landed on my feet, but at this juncture I have no idea where that might be. This next year is wide open for me.

So this chapter is closed.

The stage, predominately the basement of the central academic building. Often empty, save for a few random people (who also know where the electrical outlets are) playing video games or watching youtube. During the day the large picture windows let you see what you're missing. By night, there is no way to shift your weight to make those fixed plastic chairs comfortable. And generally, around this time the night cleaning crews arrive, and with them the cue to head home.

My last night studying in CAB. 


A major player and ultimate ally here at the university, Raj. This man met me almost every morning and every afternoon, for a total of 3-4h a day to tutor me through the wonderful world of organic chemistry. For the last 6 weeks I've robbed him of his opportunity to sleep in, and any opportunity to eat dinner outside the bowels of the chem building. Raj--you ROCK!



And now for the best part. The last act, the celebration! 

I was sitting in the students union building a few days ago when I looked up and saw Paul. A good friend and former partner in truancy, vandalism, and general adolescent skulduggery. I haven't seen him since we graduated from high school. It was strange looking at him and seeing a man's face superimposed on the image of my 17 year old version of him. As Friday was his last exam for his most recent degree and my last exam in year of pre req hell, we thought it fitting that we ring in the New Reality together. And as an added bonus, his roommate Jaison was also a friend from high school who I'd often hoped I would connect with again someday.

So we ate, drank, and were merry!

There really is a special connection that we carry with people who have been in our lives during the tumultuous and wondrous time which is our coming of age. I generally shudder at any thought of high school or the people that I was forced into spending it with, so it was amazing to spend an evening reacquainting a couple of dear friends who had been red balloons in a gray landscape.


So for now, I am free of the venue of med-hopeful vultures. Free to spend time with the important people in my life, time in my kitchen, and time on the trails. And for all of that, I am happy.

Thursday, November 11, 2010

Remembrance Day

My Uncle Pat was 19 years old when he was killed in WWII. His plane was shot down just weeks before the war ended. I've heard the story of the telegram arriving and it gives me chills. Something so many of us cannot fathom, losing a family member to war.

My Grandfather fought in WWII. As a result of his Airforce navigator service he was given free tuition in the university and program of his choice. He chose biochemistry and medicine at McGill and went on to become a legendary rural family doctor who then became a polio expert. He was on the team of physicians that brought the first iron lung to Canada. He then studied internal medicine and eventually in his forties went back to specialize in cardiology. After further training at McGill he returned to set up the first Cardiac Care Unit in Alberta.

When he was dying of cancer he continued to work in cardiology, as well as with his long-surviving polio patients. He wrote a memoir about the polio epidemic, and was working on a cardiology textbook when he died. The cardiac ICU at the University of Alberta hospital is named the Russel F. Taylor ward in his honor. I remember that whenever we stayed with him he'd make me scrambled eggs before leaving on his 6:30 rounds, and listen with sincere interest to my seven year old ramblings.



Both of my brothers are also soldiers. 

The House of Children!
Russ is a NATO and Governor General award winning combat engineer who is a world expert in post-blast forensics. He's completed over 10 tours of duty everywhere from Rwanda to Yugoslavia to Afghanistan. He is an absolutely wonderful father and husband to his family which includes 11 month old twins, Max and Ella...and the current star of the family, Gionna.  

Shandy with his Cobra
Shandy is a retired infantry Lieutenant Colonel. He too has spent time serving all over the world, including UN peacekeeping in Nicaragua and aiding with the set up of the interm government in Afghanistan. He is also an amazing husband of 18 years and father to his three children, Taylor, Aidan, and Rachel (and his current baby, the AC Cobra that he built). 

All three of them smiling AND looking at the camera. An event in itself!
I will never forget the dread that would accompany the news broadcasts when my brothers were in Afghanistan.  Every time a soldier death was reported without releasing the name there was a flurry of phone calls between members of my family.  Are they alive? When did you last hear from them? And of course the guilt that comes with relief that it was someone else's family dealing with that horrible grief. 

Naturally, every Remembrance Day I contemplate the plight of soldiers and their families around the world. War, sadly, is not a thing of the past. Today we continue to have innocent civilians, aid-workers, soldiers, and journalists killed in conflicts around the world. 

My thoughts and prayers go out to those families today that are remembering with sadness instead of thankfulness. 

In Case You Were Wondering

How this weeks forecast is looking:


What it doesn't say is that there are also 50km/hr winds happening right now.

It is going to be a seriously harsh walk to school this morning. Yes, harsh, and that is coming from the girl that wrote this post* (below) 4 years ago. Ok I promise, soon the content will return to non-weather related topics.

*Taken from my pre-Asystole blog...

You Know You Are in the Arctic When...


So picture Saskatchewan. Now go straight up, through Nunavut. Over all the rocks and trees and tundra. Over the caribou, lichen, streams, and ravens. Drop off the top of Canada's mainland, cross the frigid waters that will turn you to ice in minutes, then stiffly climb onto the shores of Victoria Island. There you are. In Cambridge Bay.

Imagine a flat, white, landscape. Depending on the day that white will be cut in half on the horizon with blue-bird sky that surrounds you 180 degrees or with a matching shade of blowing white which makes you feel like you are in one of those snow globes someone is shaking vigorously.

Welcome to the North.

It has been cold up here. Not just "oh I think I'll wear a coat today" cold but more like "oh, I think I have to bring my blowdryer and an extension cord to work today so I can de-ice my lock when I get home" cold.

My walk to work is approximately 5 mins (or 1.5 Lucinda Williams songs I've discovered). And in that time all kinds of fun and interesting things can happen to you when it is -50 with the windchill.

Things like:
-your face freezing to the inside of your coat from the moisture in your breath. As if you licked the entire front of your face then stuck it to the side of a metal door.
-your eyelashes freezing shut
-a trail of snotcicles (icicles made of snot) clinging to your upper lip
-a pain, burning, immobility of movement in the fingers which leads you to believe that your fingers are actually freezing. It is not just an expression any more.
-your earphone cord seizing up to a taught, brittle, wire instead of the normally flexible plastic handing loosely by your side.
-tendrils of hair coated by breath moisture turning into wisps of ice hair framing your face, which then melts and plasters to your forehead imediately after stepping indoors.

It's fun. It's something different all the time.  Today it is only -37 with the windchill so people are outside snow kiting in the bay to celebrate the chinook like change in weather.

Got to love those hearty northeners, hey?

Classroom Quotables

Had one of those "Dead Poets Society" type lectures yesterday from a brilliant, hilarious, curmudgeon of a psychiatrist/scientist.

More on that later.

But his opening line to the talk was, "so I understand you're doing a problem based learning program, which really means, it's your problem, not mine."

Never heard it put that way but yeah. Pretty much.

Sunday, November 7, 2010

Finished. Repeat.

Just finished the book I was reading. S l o w l y.

It was amazing. Book report to follow.

Tomorrow I am going to start reading it again, from the beginning.

Yep, it was that good.

Saturday, November 6, 2010

Irish Winter

I guess we've transitioned from fall into winter here on the Emerald Isle. 


I'll be blowing the dust off my Vit D bottle today I think. 

Thursday, November 4, 2010

Take It When I Can Get It

It was windy, rainy, and dark but I went out for a run anyway.

Left my GPS/heart monitor behind because I am just not sure how much of a drenching it can take before it fizzles out (and I just cannot afford to replace such a luxury item).

And it was one of those sweet runs. About as frequent for me as a leap year. Those runs where your legs never get tired, you don't have to pee, you don't feel short of breath/chest tightness, you aren't getting chafed by your sports bra, you aren't growing a new blister.

People looked at me like I was insane as they raced to their cars, jackets pulled up, umbrellas out. But you know? I kinda like running in the rain. I even did my usual lap twice because I just didn't want it to end. Tobie just laughed when I came in because I looked like a completely drown rat.

Glorious. It makes the next hundred runs in between (that involve gasping for air, knee pain, and sore muscles) worth it.

Monday, November 1, 2010

Wish I Knew

I really wish I had a better idea about what path I am going to go down for post-grad med. Somehow I feel that I would be more motivated on the long days of studying if I could visualize myself as a "______" down the road.

I took the U of Virginia questionnaire....again...and this is what I got for top results:


Gah!  EM continues to haunt me everywhere I turn! Aghhhhhhhhhhh! Damn youuuuuu! *shakes scalpel at the sky*

I also perused the Ontario Ministry of Health website to see what was cooking in the IMG residency world these days. It's a province that typically takes the greatest number of IMGs. Plus it is close to Tobie's family in Quebec (and a pretty kick-ass part of the country, turns out).  

In Ontario if you match as an IMG you owe them a 5 year return of service agreement in a designated under serviced area. I read out all of the towns that were on the list for specialist services and Tobie had only vaguely heard of a couple of places, which he quickly dismissed as "hockey towns" or the "places they mine nickel". 

Probably a low demand for professional violists. 

Main St. in Wawa, Ontario (one of the return-of-service options). 
He observed that it's not as simple as "graduating and hanging your shingle". No, and the road to fulfilling work seems to be lined with a lot of broken glass, burned out cars, and rusty nails. 

No one said it was going to be easy! So far, the USA still seems to be the most likely destination for post-grad. Now...how am I going to get some clerkships in the US....and a work visa for my musician partner?