The Blackbear Has Landed

It was an uneventful return voyage home to Ireland, overall.

The main thing that cast a long dark shadow on my layover in Heathrow was Aer Lingus (a.k.a Aer Pirates) charging me £260 for my 'excess' baggage weight. Yeah, apparently you are only allowed 20kg IN TOTAL on flights from the UK to Ireland. So naturally I was overweight (ahem!) because I had two 23kg suitcases. The strange thing is every single time I've taken this route that is how much luggage I've had, and this is the first time they've jerked me around and robbed me blind IN STERLING.

I called the baggage department today to plead my case and was informed that the complaints department can only be contacted by FAX or snail mail. Actually. It boggles the mind. So rather than getting in touch with Horatio and asking him to deliver my concerns post haste, I will just use my tiny blog to say

Aer Lingus is the worst airline in the world. Never fly Aer Lingus. Ever. Unless you like being robbed by a woman in a bad green suit with too much makeup on. 


When I arrived in Limerick I bumped into a mother /daughter duo from California at the airport who were heading to my neck of the woods, so I offered them a lift. They were great company for the long drive and kept me awake for the duration despite my lack of sleep for >30 hours.

And now I am here, sorting and unpacking, assembling and organizing.

When I went to buy some breakfast staples I caught myself frozen with a vacant stare directed towards the milk aisle, remembering the weekly argument that Tobie and I would have over whether to get low fat or regular coffee cream. Loneliness comes crashing down hard when you least expect it.

OK OK OK I promise not to make this blog an homage to Tobie and a constant whine about how much I miss him. I am back in the hospital in 3 days which means I'll have plenty to whine about soon enough.

I am actually getting a little scared. What should I wear? Who will my consultant be? Where will I park? Is the cafeteria food edible? A tiny tiny part of me is also excited. But I really have no idea what being a medical student on clerkships in Ireland is all about. So I am mostly scared.

It's going to be an interesting ride*, that I am certain of.

Tomorrow I am driving back to Old Town Where The University Is to say hello and goodbye to some of my classmates who are now scattered around the Eire, also getting ready to start placements.

Hello 3rd year.

*I really need to drop that word entirely from my lexicon.

Leaving On A Jet Plane

Tobie just dropped me off at the Ottawa airport. I will admit that I feel a little nauseated and quite sad. We're not exactly sure when we'll be seeing each other again but the earliest time is December. This is the first time that heading back to Ireland has been painful. I feel like a little kid about to have a tantrum, at the security gate I wanted to throw everything down and kick for a few minutes.

I enjoyed my summer here so much despite the fact that I spent so much of it in the study hovel. Getting to spend time with my family, dear friends, cherished mountains, favorite grocery stores...it was hard to pack my bags this morning.

Tobie and I are ready to build our lives together...inane things like buying colanders or walking to the store for milk. We're at the nestling and nesting stage and we're facing the reality of 2 years in different countries. We are both trying to be positive but it is going to be a very challenging time.

I'm hoping that the 13 episodes of Parks and Recreation I downloaded keep me from becoming a slobbering mess on the flight to London.

Breathing to the Bases Again

For those of you just tuning in, on Monday I wrote the USMLE Step 1 exam.

The USMLE is an 8h mental marathon, designed to ruin free-time around the world and deprive second year medical students of sleep and robust immune systems.

My Summer 'Break' 2011

I will attempt to give an account of test day, though at this point most of it is just a collection of scenes which my stressed-to-the-max brain compiled.

I had my alarm set for 0600h as the testing centre was an hour away from my mothers place but I awoke at 0540h to a newsworthy thunder storm. Peering up from my basement-bedroom vantage point all I could see was a magenta sky--really, it was magenta and I figured either Armageddon or the Rapture had arrived. The thunder and lightening were happening at the exact same time, no pauses between each, just continuous crashes and flashes. I envisioned a darkened testing center, no power, or a flood of water rushing through the place. Didn't happen.

A bald-headed Buddhist Nun in full robes met me at the Prometric doors, told me in heavily accented English to remove my shoes and handed me slippers. I tried to ascertain when said slippers had last been washed as I had bare feet and a wart phobia. She was either perplexed or offended by my inquiry (or both) so I after a few minutes in the unsettling footwear I went to the car and found some socks.

The Buddhist Nun took my ID and information, another guy in line asked me what I was writing, I said, "USMLE Step 1", he coughed softly and replied in a bored tone, "oh yeah, I wrote that last year". I tried to make my smile convey the "please stop talking to me" vibe.

The Nun scoffed at my lunch size. It was ridiculous, I'll admit. I had no idea what I was going to feel like eating so I had everything: a thermos of my sister's borscht, cheese, one bite brownies, strawberries, apples, caffeinated beverages, nuts, fruit leather, turkey wraps, water, and granola bars. Oh and salty chocolate.

I started the exam. Had issues with the mouse and figuring out the 'strikethrough' and 'highlight' option (since I had been practicing on my mac and this was PC delivered). Got in the groove. For the first 60 questions thought, "this isn't so bad".

I took a break after block 2. Not long.

Block three the Nun walked over to me and handed me 2 orange earplugs wrapped in kleenex. I had no idea what was going on but I accepted them and popped them in my ears, under the sound cancelling headphones.

It was so quiet. I was pretty sure I could hear my own heartbeat. I started thinking about The Abyss, got claustrophobic and tore off the headphones and earplugs.

After block 4 my coffee rush and will to go on was starting to wane. I took a break.

The Nun informed me that my mother dropped off the earplugs. Wha??? I remembered saying at breakfast that I'd forgotten to buy earplugs but wasn't too concerned about the oversight. My mother had driven in to drop off some earplugs. I am guessing after the inspection, Nun felt they contained no crib notes, tiny microphones or recorders, and brought them in to me. I told Nun that my mother lived an hour away and it blew her mind. She informed me that she wished she had my mother. I felt Nun and I starting to bond. I think we'd gotten off on the wrong foot (pun intended).

The testing centre was connected to a Sylvan Learning Centre which meant that on my break little Timmy's and Johnny's were coming in and out of the main foyer en route to their reading lessons. The doors were open to the learning centre so naturally I heard the lessons.

Timmy can you draw me a big "D"? Can you draw me a little "d" now? OK, now I want you to tell me which words start with the sound, "duh". 

Oh how I wanted to be Timmy at that moment. I could easily have drawn a little AND big D!! I didn't have much of a handle on the Krebs cycle but I. Know. My. D's. 


Come on TIMMY!! Get your head out of your ass! You GOT this one!!!

Good thing I am not a Sylvan tutor.


Back in I started to really hit the wall. Seems that they put all the easy questions in blocks 1 and 2 and NOW I was getting hit from all directions. Self esteem dropped, dreams of practicing medicine faded, desire for throwing in the towel, peaked.

Break.

I din't feel eating. I felt like building a time machine and going back to study harder and longer.
Decided to have some 2-bite brownies. Chocolate always makes things better.  I parked my butt on the curb outside, in the parking lot, and wrestled with the packaging. The packaging gave, suddenly sending the brownies flying into the air and scattering on the pavement.

Noooooooooooooooo!!!!

I probably would have eaten them if a woman sitting in her parked car hadn't been watching the whole scene unfold. I just couldn't bring myself to pick up the brownies off the oil-stained tarmac. Especially considering how much microbiology I'd learned in the past 3 weeks.

Thankfully I still had a double espresso and taurine drink which kicked in and brought me to the finish line.

Afterwards I walked out into the shimmering heat I noticed a Vietnamese nail shop next door. Yep. Watching Dr. Phil and getting a mani/pedi for cheap was just what I needed.

Then there was catching up with some dear friends, dinner, drinks...some random drunk guys harassing us at the bar flashing their Peace Officer identification cards. One asked me where I'd been all his life and I couldn't resist saying, "University".  Most days that is where I feel I've spent my life.

It all made sense at the time.

And that concludes a romp through the days events. Thanks again for all the support friends and strangers.

Well That Was Surreal...

I need to start by saying a giant THANK YOU to everyone who tweeted, called, emailed, and commented "good luck!" wishes to me for the exam on Monday. I actually walked through the doors of the testing centre with a ridiculous grin on my face because of all the support that had been coming my way. 

On Friday I will give the whole shakedown of the day's events. But in the meantime I will give you a small sneak peak. Exam day involved (in no particular order):

-A thunderstorm of biblical proportions
-A Buddhist nun
-A random mid-test delivery
-A lesson on How to Write Big D's and Little d's.
-A few minutes of self-loathing
-A trip to a liquor store
-A Gypsy reunion
-A martini and a couple gin and tonics
-An encounter with some correctional officers
-A mani/pedi
-A very large bowl of seafood

The bottom line is that one of the bonuses of having a blog is when it feels like I'm in an episode of the twilight zone, I simply smile and think, "blog fodder".

It is over. I hate to guess how I did but I hope I did well...ok passed. I hope I passed because if I have to spend any more time thinking about bacterial pili I may go buy that banjo.

Until Friday.

Please Note

Please note the countdown that is on lower right sidebar.

Accepting all forms of incantations, wishes, prayers, vibes, energy beams, sacrificial offerings, blessings, final thoughts, advice, good-will, and major credit cards. 

That is all.

Feeling Important

Did anyone else get an email from 'North America' today??

Below is part of an email I received this evening, it was quite a long one (since it came from an entire continent so I won't bore you all with the rest of it...)

Yeah. North America is always so formal in our written communications, but I can read between the lines.

Inspired, Just in Time

So a few months back, my mother woke up in the middle of the night with a sudden recollection of some very good friends of my Grandad's. She hadn't thought about this couple in a long time and wasn't sure why she felt the compunction after all these years to get in touch with them, but decided to go with it. She tracked them down (thanks to google) and set up a meeting with them this summer.

From what I could piece together (without interrogating anyone for the minute details) was that Dora arrived in Canada as a young Chinese woman, to study at S.A.I.T, which is the technical college in Calgary. After finishing her secretarial program she became my Grandad's medical secretary. He became close with her and Richard, her husband, who was then a masters student trying to get into medical school.

According to Richard, it was my Grandad's letter of reference that got him in the door to medical school, his interviewer commenting on the weight that Dr. Russ Taylor's recommendation carried. Dora claims my Grandad was very much like a father to her, and that she'd never have become a teacher and then a "damn good lawyer" if it hadn't been for his continuous support and encouragement.

When people tell you things with tears welling up in their eyes, you simply have to believe that it is true.

I've spoken about my Grandad before on this blog. It almost feels wrong to extoll his virtues and accomplishments because he was a truly humble man who was never comfortable with praise. Sadly, he died from colon cancer about a week before my 8th birthday so most of my knowledge of him is second hand. I have only a handful of my own memories of him: playing the piano, letting me sit in his lap to listen to his mechanical heart valve (due to rheumatic fever as a child), reading his book in the high backed chair in the living room, and of him being one of the few adults I'd come across that spoke to me with a genuine interest and delight.

All of my life I've been steeped in stories of his astounding medical career, his profound love of medicine, his intelligence, insatiable curiosity, and his interest in the world around him. Each of these stories is locked in my memory coupled with the sadness that I was never able to know him as a health care practitioner, myself. Sad that I could never hear his opinions on certain procedures, ethical dilemmas, learn what he loved about medicine, or find out what frustrated him. Ultimately, I feel cheated that I never was able to have him as a mentor. Others have often described him to me as the 'greatest teacher and mentor' and yet I never had the opportunity to learn from him.

So there I was last Sunday, feeling guilty for taking a day off of my USMLE cramming, waiting to finally meet Richard and Dora. I was looking forward to meeting them, mostly because I always delight in having a few more details to add to the composite sketch I have of Grandad in my mind, plus it makes me feel somehow closer to him, hearing from people whose lives he's touched.

Their son, Russ (named after my Grandad) and his sister also came to lunch. Russ is a pediatric emergency fellow and his sister is a law student...as Russ half-jokingly pointed out, "we're replacing our parents".  The whole family is simply lovely.

At one point during our lunch, Dora pulled out a small bag that she'd brought in with her. She told me it was something that she'd kept for the past 30 years and she wanted me to have it. Even before she pulled out the contents I felt my pulse quicken with the thought, "This is going to be a treasure". It didn't matter what it was...whether it was going to be an old pager, or signed chart, fountain pen...anything! I couldn't wait to see what she was going to reveal.

Hours of my Grandad's cardiology lectures to medical students!

She had been the one that typed up the manuscripts for him, and had kept the old reel-to-reel tapes in a box in her basement. She told me, "These are his lectures on cardiology, and his notes for the cardiology textbook that he was working on!"

I felt a powerful wave of emotion roll over me.

All my life, all my adult life, I've wished I could hear my Grandad speak to me about medicine. And now I can. I couldn't contain myself, the tears just started pouring down my cheeks. There, in this trendy restaurant with a handful of photographs and an empty coffee cup to stare into, I could not wrap my head around it. In the final week of a very challenging year, studying for a terrifying exam and feeling completely over my head and second guessing myself at every turn, my Grandad's actual voice is given to me.

I cannot believe that this is a coincidence, I can only see it as him acting through people that he loved, to give me the little boost I need right now. Not only that, I feel so lucky to have made contact with this amazing family whom I very much plan to stay in touch with.

When we were finished lunch they took me to the Chinese Seniors' Centre in downtown Calgary and showed me the tai chi court which they paved and dedicated to my Grandad.

Talking to them about their careers, and about Dr. Taylor's career gave me an immeasurable dose of determination and renewed my understanding of why I chose this path. Not because he was a great physician but because I can see how his legacy continues to move and inspire others to achieve greatness.

In a week I'll be getting Tobie to transfer the recordings to MP3 and I'll finally be able to hear my Grandad's voice, which I've long forgotten the sound of, talking about something that always inspired awe in him: medicine.

Summer Reading

One of the readers of Asystole sent me a link to an article she wrote, "The 20 Essential Biographies for Medical Students".

I've only read two on the list, My Stroke of Insight and Hot Lights, Cold Steel, both of which were very good---especially My Stroke of Insight. Seeing the list made me wish I wasn't cramming for the USMLE* because it looks like a very interesting collection that I'd like to dig into, today!

So if you're looking for some medically related summer reading, check it out and let me know if / when you read any of them. Thanks for the link, Carol!

--

*Countdown is at 5 days and change and I am beginning to panic. Wait no, that's Panic with a capital "P".

Unsolicited Advice to Interns From a Former RN Who has Gone to the Dark Side: Part 3

This is the third installment of Unsolicited Advice.
 

Not House astutely pointed out in the comments section of my blog that "nurses will make your life a living hell" if you treat them badly. Some will make your life a living hell, no matter what. As in every profession, there are nurses with a chip on the shoulder, as well as those who are simply counting down to retirement. But for the most part, nurses want to work with you not eat you. Some of my suggestions probably appear ridiculously obvious, but I wouldn’t have been prompted to write these pieces if I hadn’t observed the examples below.

So aside from being proactive in the ways I’ve already mentioned (contributing food, introducing yourself) here are some things to avoid:

1) That is not my job or I'll get the nurse to do it are two phrases that can be heard by a nurse ears even if she were standing next to a jet plane at take off. The people who utter these statements send most nurses into a silent rage. If a patient is asking something simple and easy (like for a warm blanket and you are leaning on say, the blanket warmer) do not say "I'll get the nurse to do it" and walk away. At that point, you might as well have relived yourself on those brownies you brought in.

Nurses know that interns, attendings, and students are run off their feet--but so are they! Don't think that there are jobs more or less important than yours, and that you and your skills are at the peak of the 'importance triangle'. It's not beneath you to do non-doctorly things. Just imagine for a second how the hospital would run within hours of not having a laundry service, housekeepers, lab techs, office administrators, filing clerks...you get the picture. Until you've worked a few nights in small hospitals, you may not appreciate all the behind-the-scenes supportive work that many people do to keep the hospital afloat.

So if you have 2 seconds pitch in and help out. I'm not saying anyone expects you to change bedding, start all the IV's, walk Ms Jones down to x-ray, but small gestures are noticed and appreciated. There is nothing more annoying than having an intern say to you "get Ms Jones some water" while you are whizzing by pushing an ECG machine and primed IV pole and they are sitting down to check their Facebook updates.

2) If a nurse is asking you a question about something, don't blow her off with a patronizing answer or assume that they are questioning your care (this is different from Nurse Speak).

When I was nursing and I asked an MD a question, like "why did you use marcaine instead of lidocaine?" or "why did you chose heparin IV instead of sub cue lovenox?" it wasn't because I was trying to be inflammatory it was because I was curious and genuinely wanted to know. Were there guideline changes, or new evidence based medicine protocols? Don't forget that even though you're writing the order, the RN's are the one administering it, and many of them want to be right up on the why.

3) Messy handwriting is dangerous. Stop it. Many places are switching to computerized orders which definitely have advantages, one being that RN's no longer will have to add 'expert handwriting decipherer' to their list of skills. As a new nurse I almost gave a patient with lung cancer percocet (narcotic) instead of senna (stool softener) because of illegible handwriting and a missing-in-action MD. Thankfully, as the patient was about to tip them back I said, "do you normally take percocet at this time of the day?" to which his wife responded, "No, he's allergic to percocet!"

If you have bad handwriting, try and at least write medication orders clearly. It is also doubly sweet and handy if you alert the nurse who is taking care of the patient, "I wrote some new orders for Mr Jones and I added another antibiotic to his regimen". It is bad for everyone when the nurse checking the charts during night shift sees that no one noticed an entirely new set of orders after the blood cultures came back.

And thus concludes today's installment of Unsolicited Advice. I grudgingly redirect my efforts to understanding why I should care about the pentose-phosphate shunt.

Unsolicited Advice to Interns From a Former RN Who has Gone to the Dark Side: Part 2

After putting up yesterday's post I realized that I missed some sage Julie Andrews advice: start at the very beginning. It's a very good place to start. [Ha! Enjoy having that song in your head all day!] So I am going to back track a little.

This is the second installment on how to ingratiate yourself with your new colleagues as a freshly minted MD intern (or medical student, for that matter). These are just observations on behavior that nurses tend to notice, which can really make a difference on how you'll be received.  I hope some of my suggestions are helpful in making you appear like the Star Intern that you know you are.

Introduce yourself. There is nothing more annoying than having a new batch of people pulling charts off the desk or using the staff washroom without staff having a lick of an idea who they are. Half the time your name tag is either not visible or in such small print that we can't tell if you're here to deliver the wound-vac machine, take bloods, or admit the patient. Make yourself known to the staff. Introduce yourself to people in a polite, humanoid way, and be clear about your role. Say what year you are in, how long you'll be in the department, who your attending is, whether or not you still watch The Bachelor...whatever, just let people know your story. Do this especially with people like the charge nurse or the nurse who is taking care of your patient. They deserve to know who is doing that rectal exam on Ms Jones (as, by the way, does Ms Jones!)

Never assume that anyone knows you're the new intern / medical student / attending. They probably never got the memo, or if they did, it is tacked on the same board with staff party photos from 1997, the ACLS guidelines that advise a precordial thump, and the Thanksgiving pot luck sign up sheet. Talking about food brings me to my next point...

"There is no love sincerer than the love of food” according to G.B. Shaw. A special amount of love will be reserved for you if you contribute sustenance to the insatiable, gaping maw of the staff appetite.

The culture of food is central to the communal harmony (and sometimes survival) of the unit.  And blood sugar levels are directly correlate to measures of civility. We are well aware that you are run off your feet, working 30hr+ shifts, living on a line-of-credit, and sleep deprived but hey--if you are regularly feeding at the trough then consider making the odd contribution!

This sounds obvious, but I can count on one hand the number of interns / residents who actually brought food for the staff. Something as simple as a bag of oranges, crackers and hummus, money for the coffee fund...anything is highly appreciated. We're happy to keep you going when you haven't had a meal for countless hours, just show a little appreciation and return the favor once in a while.

Oh, and if you're in Canada never bring in Timbits. Once you've worked in healthcare for about 20 mins your lifetime Timbit capacity has maxed out. And try not to bring things that people put their hands in like giant bags of chips or other MRSA receptacles [shudder]. Germaphobes delight in individually wrapped morsels of chocolate or hands-free access, like fruit on toothpicks.

Remember, at the hospital food = friends. I can safely predict the staff will be dazzled with your thoughtfulness.

Hope today's installment was helpful and informative. Back to the pit of study hell for me (I may have a snack first).

Unsolicited Advice to Interns From a Former RN Who has Gone to the Dark Side: Part 1

If you’re a new intern you are advisedly a little afraid of the new found responsibility in your life. I say ‘advisedly’ because there is nothing more frightening in healthcare than someone who is  ‘unconsciously incompetent’, i.e someone who doesn’t even realize he has no idea what he is doing.

In an effort to be helpful I thought I’d write a series of little posts from my former vantage point as an emergency nurse. (I say series because I am in the throes of USMLE cramming but as July marks the infusion of new interns in hospitals, this is the best time to write these. It'll be my 'study break' activity.)

When I was nursing I had the opportunity to see many medical students, interns, and residents flit in and out of the department, noting the differences between the ones who sail and the ones who sink. Here are some tips for those that want to sail. 

You Are Book Rich, Experience Poor. You may know all the cytokines involved in septic shock, but the RN knows what it looks like from 30 ft. Guess which of the two abilities is going to save your patient’s life? You'll get there, but in the mean time, pay attention to the patients about whom the RN’s are concerned. Which brings me to my next point.

Spidey Sense is not learned it is developed. Many nurses have been in health care since you were wearing short pants and they have pattern recognition down to a science (or some might say, a freakishly intuitive level). Good nurses know the ‘sick look’ so when they feel something ain’t right with a patient…it’s probably true. Do yourself a favor and check the patient out. Also, this is a good way to show your nurse colleagues that you respect their opinions.  You hate them because they paged you at 3 a.m when Ms Smith wasn’t looking right, but now they’ll love you because you took their concern seriously. And let me tell you newbies: Nurse love is the BEST love when you're the new kid on the team. Now you won’t get another phone call at 0345h to find out if you wanted that ‘diet as tolerated’ order ‘by mouth’. Not that that has ever happened…

Nurse speak. Nurses learn very quickly how to speak in code to 

a) forestall disaster, 

b) make you think something was your idea, 

c) point out a mistake without being unprofessional, 

d) make a suggestion without appearing to offer advice.   

Here are some translations for Nurse Speak. 

“Are you sure you want to [fill in procedure, medication, etc.] Mrs. Jones?” 

means “If you do that you’ll probably kill the patient”.

“Did you say you wanted a CXR on Mrs. Jones?” 

means “Yo! You forgot to order a chest x-ray, I am going to go ahead and order one now to save you time and not make you look like an idiot when you page medicine and then have to tell them you haven’t done a chest x-ray yet”.

“Oh, I haven’t seen it done that way before, I always thought you had to…” 

means “Dude, you are seriously doing that wrong, please let me show you a better/safer/faster way of doing that”. 

And finally, 

“Did you want me to go ahead and dip that urine for pregnancy?” 

means, “It appears you’ve left out a major differential, I’m going to make sure it has crossed your mind”. 

And that concludes today's installment of Unsolicited Advice. Hope some of that is helpful!  

The Pit

Of USMLE despair.

Oh God, what have I gotten myself into??

I am getting those urges again to buy a banjo and tour the south-eastern US with a rag-tag bluegrass group.

It's ugly. It's really ugly. I feel nauseated just thinking about it. I spend all day at it, and at the end I feel like I've accomplished nothing, learned nothing, mastered nothing. I think this is what major mental burnout feels like.

I. Need. A. Break. From. Studying.

Like 2 weeks. That is all. Is that so much to ask for?

My Little Shout Out

Tobie...Master Violist!

In about 3 hours Tobie will be playing a concert which is the final exam for his Masters in Orchestral String Performance. I am, of course, bursting with pride and excitement on his behalf. I have seen his dedication and discipline with hours of solitary rehearsal, six days a week, for the past 2 years.  He's so amazing, I had to make a little shout-out post on his behalf.

My only little twinge of sadness is that this marks the end of his time in Ireland, with me staying on for two more years. I am also disappointed that I wont be there for this big performance. I'd love to be in the front row...with a giant smile on my face and tiny prayer in my heart.

I am sure he'll play beautifully. I did get to see his dress rehearsal performance. A link if you'd like a taster.

Good luck, Tobie! xo