Asystole is the Most Stable Rhythm

Running

2012-01-29T09:20:00.000-07:00

So I signed up for a 10 mile race in February. Figured I needed something to train for and wanted to do a race before I go away for my elective in March. For the record, I haven't run 10 miles since I was living in Revelstoke approximately 4 years ago. And I haven't really been running much lately, just short interval sessions, but no distance. Then I realised the race was in 2 weeks, panicked and registered for a 1/2 marathon trail race at the end of the month. Seems I felt like registering for races = training for races.

The other twisted logic I recall having at the time was well, if I am running 10 miles on the 12th I might as well run 13 miles on the 26th. Again, there are some major holes in that line of reasoning. Especially if you can't actually do the former.

But then I think the little voice that makes sense piped up and said, you did a 4h and 38 min adventure race in November, how bad could only running for a couple of hours be??

And that was when the true value of thrashing my body all around for the Sea to Summit finally came to light. For the rest of my life I will have to compare all acts of athleticism to that day, and pretty much nothing is going to be that much of a challenge--so why not go for it?? Sweet. Why not, indeed.

So today I tested the waters (or rather, the pavement) and went for a 10.8 mile run just to see if I could do it. And I could! (At the pace of anvil-dragging snails mind you, but determined anvil-dragging snails.) So maybe I won't die in the Irish countryside this February from a cardiac catastrophe. Hell, maybe I'll even enjoy myself!

When Alcohol Should Be Taken Before Exercise: a.k.a Zumba

2012-01-26T16:29:00.001-07:00

I was lured into my first zumba class by my eternally optimistic and anti-weightlifting roommate last week. I used to snobbily chortle at the aerobics classes last year in the University gym and vowed never to attend such a fitness monstrosity. I figured zumba must be something completely different...

For those of you who haven't attended a class yet, I'll ruin the surprise: zumba is nothing more than an aerobics class to Latin dance music.

And it doesn't look anything like this:

No, it is more like this:

Which is awesome, actually, because I'd be way too scared an un-glam enough to go to the top class anyway. But the whole experience has been a bit of a disappointment, in myself. I like to think I have rhythm and maybe even some sweet dance moves. Turns out, I have neither. I took highland dancing as a kid which is a very regimented, precise type of choreography. Zumba requires hip gyrating, booty shaking, arm twirling, and general freedom of movement. Possibly some sexiness as well. I am incapable of shaking my money maker with abandon, especially when that money maker is in lycra and not in the gin and tonics.

Dear Margaret (roommie) and I agreed that we'd probably crush the dance floor if only we arrived a litte tipsy one day. Then we felt like that agreement made us sound like alcoholics. Then we questioned if drink only made us think we were good dancers or if it truly loosened us up enough to display our Jennifer Grey type skills. Either way I think my Irish heritage shows itself well amongst my fellow wooden, self conscious, antitheses of sexy, arhythmic, fair sisters.

The bottom line, however, is I am sweating and laughing at the end. And possibly expanding my (already killer, right?) repertoire for my next big night out. Which is more than I can say my nemesis The Treadmill can offer!

Zumba, I misjudged you and your aerobic-class self.

I Know Nothing

2012-01-25T07:41:00.001-07:00

One of the things I like about medicine is it definitely keeps you humble (well, it ought to). Just when you think you have some vague sense about something, another GIANT hole in your knowledge is revealed (for you to fall into, in front of a patient).

Dr. J asked me to talk to a newly diagnosed patient about how to manage her diabetes.

Er...can I tell her instead about how to landmark for the femoral pulse? Or the 10 most common reasons for pancreatitis? Or, about how long troponins will be raised after a heart attack, instead?

So...Mrs. Glucose, lets, er...talk about diet. Sorry, not a diet, per se...but what you normally eat in a day...

Oh, normally I get up and have a cup of tea and a fag, then I'll eat something for lunch, usually...and then there's dinner, usually with spuds.

Riiiiight. OK. Maybe you can tell me a bit more about what you normally eat for lunch and dinner then...

You know, a roll, meat and veg.

[Dr. J reenters room]

So, ABB, did you make much headway with the discussion on lifestyle changes, nutrition and managing sugar levels??

Yeah, um....not so much.

EPIC SECONDARY PREVENTION MED STUDENT FAIL!!!!

I know nothing about how to motivate people, how to explain nutrition, how to advise major lifestyle changes, how to counsel for smoking cessation, what the normal step-wise approach is to managing a newly diagnosed diabetic. In a nutshell, I am rubbish. Unless you're having a heart attack in front of me. Then I am slightly less rubbish.

Mother Dearest

2012-01-23T03:07:00.001-07:00

"I read your mini-blog yesterday, glad to know you're getting out from time to time and doing some enjoyable things despite how crazy your life is. Also, it was a nice change from your usual jaded whining...which of course, all of your readers have come to know and love..."

Awesome. Only a mother can say that. (Hi mom!)

:)

Ding! Ding! Round Two.

2012-01-15T16:36:00.000-07:00

Today I bought:

-Toronto Notes, 2011. Yes. All 1400 pages. I think it's officially in the lead as most expensive (135 Euro) and heaviest textbook of my collection. Yet it is light compared to the weight of worry which is post graduate training....dun....dun....dunnnnnn. It is basically the study guide for our Canadian boards, known as the "EE"'s because there are too many letters ahead of that, so even the acronym gets shortened.

I've held off until now because I thought it was a bit much in every sense of the word. But, I've realised that if I don't get 99% on the EE's I'll either be staying in Ireland to train or working as an RN in Canada, with M.D. after my name. And almost half a mil of debt. Sub-awesome. So the Toronto Notes are now becoming my new BFF.

It's true though. The fourth years in my program have just found out their Canadian interview offers and two (of 13 Canadians applying to get back) didn't even get an interview. Nada. The shopping spree continues...

I also bought the kindle version of First Aid Cases for Step 2. Mostly just as a way to structure some of my studying using cases instead of just reams of multiple choice questions. Which brings me to my next purchase...

Access to the Canadian MCCEE's Question bank for the next 9 months.

And then I accidentally bought USMLE Secrets For Step 1 for my ipad kindle. Yeah. I already have written step one. I meant to buy step 2. [Hits head on self-assembled desk.]

After reading dozens of reviews on step 2 study guides I opted for Step Up to Step 2. It will also be arriving shortly via the postman.

Then I bought some pens. You know the ones. Because there is a lot of writing looming on the horizon, and that writing is going to be done nicely in blue-black 0.3mm point style, dammit. We have the technology, people.

It's only a short matter of time until I also cave on a USMLE q-bank but I just can't decide on USMLE-World or Kaplan. Kaplan is cheaper (wow, I can't believe I just typed that phrase!) but everyone seems to say U-World is tougher and prepares you better. In the same way getting hit repeatedly with a hammer makes getting hit with a hockey stick almost seem gentle.

I need to give my visa some time to stop shaking before I use it again. It was an expensive day. I am not even allowing myself a mental tally at this stage.

As always, any thoughts, experiences, frustrations, or treasured methods of study for the EE's or step 2 welcome.

And so, round two of studying for a life-and-career-path-altering exam begins!! Ding! Ding!

Conversations with Joe

2012-01-12T17:24:00.002-07:00

I have a feeling that over the next 5 months I will be having regular blog posts that will simply involve quotes from Dr. Joe, my delightful GP preceptor.

I wish there was some way that I could absorb not only all of his medical experience, but also his vast knowledge of local history, and the history of everyone in it. He could tell you where the finest pint is poured, the most talented Irish dancers gather, and the sweetest hillside flowers bloom. He knows the best card player, baker, painter, and mechanic. He's the quintessential Irish country doctor who sometimes gets paid in fowl and peat. Yet his practice is anything but old-fashioned as he tirelessly stays up-to-date on medical research and evidence based practice. In my mind he represents the epitome of family medicine. It's so inspiring to see. And more than a little entertaining.

Scenes From A (gastronomical) Canadian Winter Holiday

2012-01-05T17:37:00.000-07:00

I've been rather unplugged the last few weeks, in the wintery wilds of Québec. My slothful existence has mostly starred red flannel snowflake pajamas, a reading chair, exquisite food and drink, late mornings, a stack of books, my mother, Tobie, his family, strong coffee, a grand piano, and a few brief appearances by friends (that means you, Liz, Lisa, and Not House!)

Other than my uninterrupted, daily rumination on what will I be when I grow up, will I ever get accepted in a Canadian residency, and how can I somehow turn lead into gold to pay next year's tuition...I threw medicine on the back burner and let other areas of my life simmer. It's been great.

Shortly after my arrival in Québec, Tobie and I swept the car off and made our way to Montréal.

When we were car-less, job-less, penny-less and living in residence 2 years ago, we'd sometimes go on imaginary dates in Canada, pretending our purple comforter was a magic blanket that would take us anywhere. We would try to outdo one another with elaborate descriptions of these dream dates. Montréal was a frequent destination when Tobie was choosing the city. We took our magic comforter to go Christmas shopping at Simon's after a crammed lunch at Schwartz's deli. Then we'd walk the dark and snowy streets looking for a quiet place to duck in for some nice wine or sugary treat. After that, it was a chilly ride back across the Atlantic.

Finally, this year we were able to live some of our magic carpet dreams. And probably shorten our lifespans a little in the process. (Apologies for the double photo posting, but until more than 10% of you look at my tumblr account, I won't feel too bad...)

I give you the lean smoked meat sandwich at Schwartz's.

Belly up, boys! Take a moment to imagine pure deli chaos: the clink of dishware, the holler of orders, scrape of chairs, splash of fries into the oil, murmurs of 'mmm', the ring of the cash register, the smell of spiced and cured meats, salty pickles, and cherry soda. There, you have it now.

I call this photo of Tobie below, "Quintessentially Canadian". Next to that is Perside, his sister, presenting her Jaime Oliver turkey recipe extravaganza. This was Christmas dinner, when I ate until I developed an upper right quadrant cramp. Similar to a running stitch, only this one was from eating instead.

Below is the classic 'driving home from Christmas dinner' scene. I miss being five years old, falling asleep during the ride home, having mom carrying me (while I pretended to be asleep) into the house, and being put to bed. These days it'd be an improbable feat of superhuman strength for Tobie to haul my somnolent butt out of the car, coat and all, to tuck me in.

Me proving that yoga can indeed be done in yoga jeans. Tobie reading a rag while we were waiting for our table at La Paryse. Seriously, seriously great burgers. The poppy seed bun is well worth the risk of post-meal embarrassment.

Below we are back at Schwartz's for more smoked meat love, this time with my momma-bear. She was fresh off the plane and ready for a week of gastronomical delights, including our own 'food tour' of Montréal. We all should have worn jogging suits for the trip. Not because we were jogging, but because elastic waistbands would have suited our needs a little better. Mind you, we did stand outside in -20 degree Celsius weather for over 20 mins waiting in line and shivering does burn calories. Oh yes it does. Pretty sure my lips were frozen onto my teeth in this photo.

Dinner that night at DNA. OK people, take your bucket lists out now and add, Eat At DNA in Montréal.

No, I am not getting any kickbacks for the endorsement (I wish!) I just need to convey that this was one of the most fabulous nights of dining I can remember. You need to experience this place before you die. Period.

Momma-bear had the lamb (on the left), Tobie and I had the suckling pork loin, slow cooked for 7h and then topped with salsa verde, sweet spaghetti squash, and some pureed goodness that tasted like possibly butternut squash and apple. The photos poorly represent the outstanding presentation, but it was the best I could do.


Tobie tucks in.

The dessert was no disappointment either.

Tobie and MB had the lime-tart (I was thinking, lime tart? What, are we eating at a hospital cafeteria in the 1950's??) But the joke was on me because the lime tart should have been called, 11 Minutes of Uninterrupted Eating Bliss involving light and (quite) sharp lime, tempered with soft, fluffy whipped cream, and a crust that would make most pastry chefs weep.

The New York cheesecake was no slouch, topped with their house-made rhubarb jam and a wafer of almond and caramel. And by no slouch I mean that it was the 'Goldilocks and Three Bears' of cheesecake--not too heavy, not too light, not too cheesy, not too bland. Juuuuuuuust right.

Not only was the food brilliant, the decor was very chic in an unpretentious way, as were the house staff. They cure their own meats in the basement and sell house-made pickles, jams, chutneys. All ingredients are locally sourced and seasonal. WIN!

After dinner we cabbed our way over to Pullman wine bar and took in the people watching, deliciously fermented grapes, and their funky atmosphere which included a chandelier of inverted glasses.

Then we returned to the hotel, drank some water, and went to bed.

Just so you don't think we're food snobs, I'd like to direct your attention to the place-setting at the restaurant where we ate dinner the following evening. Let's just also mention that the walls were wood paneled, the waitress was passive-aggressive, no, just straight-up aggressive, and all meals came with white buns and gravy. 'Nuff said.

This is what happens when Tobie chooses the restaurant.

New Year's Eve heralded the invention of a new cocktail (see my recipe posted here), more homemade gourmet feasting (courtesy of Tobie's phenomenal sister), watching fireworks from the living room window, and drinking herbal tea while discussing novels with my mother. It was all very serene.

Speaking of serene have you ever seen how pretty a preserved hibiscus flower is when it is sitting in a little puddle of gin? Feast your eyes.

Also, when was the last time you had a drink mixed for you by a blogger in a solar system blouse? Too long ago I bet, too long ago.

And so, another year came to a close. The last few days of my holiday were spent trying to fit into my clothes, packing, and saying goodbye to my near and dear ones. I'm so grateful to have had the opportunity to unwind a little. I know this will be the last long Christmas holiday that I will have for years, which is why only a small dose of daily guilt for my slovenly and sub-academic behavior crept into my awareness.

I'm hoping that 2012 will bring new recipes and races, great reads, light westerly winds, mentorship, adventure, and a few surprises...good surprises. And of course the answer to some of my questions...

Here's to you, 2012, whatever you will be.

Cheers!

Update from Deep Gatineau

2012-01-03T17:52:00.001-07:00

Greetings and Happy New Year, bloggers and blog-readers!

I'm alive (and eating a lot of smoked meat and poutine) in deep Gatineau, Quebec. I'm banking on my low stress levels to counteract the arterial plaque buildup. A photo montage of the last three weeks will soon be up, but until then I am tweeting and mini-blogging. Back to Ireland in a few days.

Hope everyone had a wonderful New Years.

The Real Reason, On CBC Today

2011-12-23T20:00:00.004-07:00

When I am asked the reason I chose medicine, I almost never tell the truth. I feel a little protective of the real reason and how it might be perceived by others, so I usually reveal some of my less sentimental and more cerebral motivations for becoming a doctor.

But, when given the opportunity to create a small radio piece about my grandad and how he continues to medically inspire me, I happily got to work.

I know it is Christmas Eve, but if you need a half hour break from the chaos, have a listen to a story that is very close to my heart. Tune into CBC's national radio show, White Coat, Black Art today, or go to the website and stream it at your leisure.

Hope everyone is having a wonderful start to their holiday!

Merry Christmas and happy holidays. Stay safe, keep warm.

Circular Conversations at Customs

2011-12-15T16:57:00.001-07:00

There happened to be a good friend from school on my flight from Newark to Ottawa yesterday. We didn't plan it that way but we were pleased to have some catch-up time throughout the cab-rides and layovers. Naturally we were chatting while waiting in the customs line, until I approached the weedy French Canadian with a friendly, "good afternoon". His blonde hair was shaved to the nub, and he had an expression on his face that said I'd rather be wearing mirrored aviators...

He responded to my greeting with, "who is that you are traveling with?"

Uh, I am traveling alone.

Alone?

Yes, alone.

Who was that guy you were talking to then?

Um, a friend, but we aren't traveling together. [What are you, a jealous boyfriend??]

You are on a flight together but not traveling together, hey?

Yes, I bought my ticket separately, we live in different towns...er...I know him from some classes we took together. [Confused and now flustered at this strange line of questioning, I think I probably sound like a drug smuggler].

Where do you live then?

I live in Small Town Ireland.

And where do you go to school?

At University in Ireland.

And what are these classes? [Smirking like I am about to say, 'nude sculpting']

Um...medicine classes? [Am I a complete imbecile? When have I ever described my education as 'medicine classes??']

What are you studying at University of Ireland?

Oh right, medicine, I am studying medicine. I am a medical student. [The lady doth say 'medicine' too much, methinks...]

And you are in Canada for just 25 days then?

Yes. [Hello, I am a Canadian citizen I can be in Canada for as MANY BLOODY DAYS AS I WANT!!!]

He tosses my passport onto the desk and motions to next person in line. I collect my luggage and walk through gate to see Tobie's smiling face. Until we reach the safe confines of his car my head continues to dart around waiting for customs to taser me or demand a bag / body search.

What is it with these uniformed misanthropists? Is it that their job is so bad that they feel the need to be acrimonious power-trippers? Are they actually not allowed to smile, or be polite, engage in socially acceptable forms of communication? I was so annoyed, wishing I could delete the whole welcome home to Canada experience.

The great part is I am home. Sorta. At least I am in the motherland, where the "hot" and "cold" tap are one, my 'accent' doesn't attract attention, and soy milk comes in more than one brand / flavor.

Oh, Canada...you complete me. [Sighs]

Palm Reading

2011-12-12T16:32:00.000-07:00

I love looking at people’s hands.

My fascination with hands started when I learned how to I.V cannulate. I found myself subconsciously evaluating the potential ease or difficulty an I.V start would be, even absentmindedly tapping along the length of a vein (usually creeping out the boyfriend or family member).

Now that I’ve been learning so much about how many clues the hands and nails can reveal regarding systemic pathology, I’m becoming borderline obsessive about looking at the hands of people around me…hoping to see some obscure clue to illness.

Last night I came across a quote in my favorite textbook, “Hamilton Bailey’s Demonstrations of Physical Signs in Clinical Surgery” which I thought encapsulated my rekindled curiosity,

“Regarding the hands, ‘one does not need the mysteries of palmistry to read in them something of the past, a great deal of the present, and even a little of the future. In them is written the record of age and sex; of occupation and habits; of skill or ineptitude; of hard work or indolence’ (Cutler)."

The Apples Do Not Fall...

2011-12-12T15:44:00.002-07:00

In a complete blog non-sequitar I'd like to present a post by one of my good friends, Ryan. It's like cute overload if you're into children and skiing.

It made me laugh at least.

Oh how I miss Revelstoke, and the great people there (and killer skiing)!

Where Am I Going Again?

2011-12-11T16:54:00.001-07:00

As I mentioned on twitter this afternoon, when I pack I am sort of like a dog circling a spot before lying down. Only my ritual seems to involve spinning around for hours. Packing has the tendency to flare up an attention deficit problem and I find myself vacuuming, baking, cleaning my hard drive, flossing, and online shopping while stuffing random articles into my suitcases.

This trip home is exciting and a little unsettling at the same time. I haven't been back to Canada for Christmas since 2008 so naturally I am looking forward to watching some crisp moonlight snowfalls with the Nana Mouskouri Christmas album playing in the background. I can't wait to see my mom, Tobie, his family, my good friend Liz...the Arab grocery store in Montréal that I love.

The unsettling part is that I don't know how long I am going for, and where I'll be for January. It is a little difficult to pack when you don't know if you'll be spending a month in Arizona or Nunavut, a GP office or an O.R. We're talking a lot of variety here. Heels? Hikers? Nylons? Blouses? Scrubs? Sneaks? Not to mention which books I'd bring based on the place / rotation. I am still trying to arrange something but my most recent lead is looking unlikely now as well. I found out this week that I also didn't get any electives at the University of Ottawa for the summer. Have I mentioned that I am tired of feeling like ~~a medical pariah~~ an outcast? Is this blog post turning into a pity party? Maybe...

So now, instead of coming back to Ireland at the end of January it looks like I might be flying straight back after New Years. Sigh. I just want an opportunity to learn, and to get some hands-on experience. It is really disheartening to constantly feel doors close in my face when I am working hard and putting myself out there. It is true that at every turn medicine asks, how badly do you want this??

OK. That is enough whining.

On a happier note...the ginger cake that I made today turned out beautifully. I may be turning a corner in this whole baking thing. Yes, yesterday my kitchen did look like I'd had a seizure in it while holding a bag of baking soda and I probably ate 4000 calories of "broken" brownies oh I can't bring the broken ones to the Christmas party...but with each event the baking part gets a little easier and the results get a little more edible. Maybe I should try to get an elective at a pasty school...hmmm...

Luck Be A Placement

2011-12-07T13:46:00.001-07:00

"I never come to work with a heavy heart, I am always whistling on my way in. Sometimes, at the end of the day I have a heavy heart, but never at the beginning".

This was said to me today by my new preceptor, a man who has been a family physician since opening his clinic thirty five years ago. At that moment I said a silent prayer that I will someday be able to say the same thing about my career.

J. A is easy to laugh, and a very straight talker. A shock of white hair rings his bald head yet he carries himself like a much younger man. I was fairly certain we'd get along well right from the beginning based on the fact that his expression seems to carry the right combination of mirth and sincerity. But he sealed the deal today on our way to a home visit when, as we walked out to his car dressed in our long winter coats, he suddenly turned to me and said, "Oh dear, I've just remembered...I've got a lot of game in the trunk of my car...er...I'm really sorry...I was hunting on the weekend and...well...the car smells quite bad!"

Yes, I think we're going to get along just fine. How could he have known he was dealing with an Alberta girl, raised in a family of hunters? One of my earliest memories is going to my Dad's shop, and opening the door to the horrifying sight of a moose head on the cement floor, then lifting my eyes to an even more gruesome view, the skinned body hanging from a large winch. I just smiled and reassured him he didn't have to worry, the smell would not offend my delicate sensibilities.

To be paired with a physician who--still whistles on his way to work, is genuinely keen to learn about current best practices in medicine, and is quirky enough to have animal hides in his car makes me think I've probably hit the jackpot for the next 5 months. Woot!

Last Day

2011-12-01T17:17:00.001-07:00

Tomorrow is my last day in the hospital. I cannot believe that I am halfway done third year already.

Does life always move this fast? Everyone said it would, but I didn't believe them.

I am really going to miss the hospital. I've only just figured out the best shortcuts through the wards, the codes to all the change rooms, where the best coffee is served, the names of the nurses, the passwords for the diagnostic reports, lab results. Not to mention I'll miss some of the lovely working relationships I've made and friendships that have formed.

Now I will be in GP land until May. A new set of people, codes, computer systems. Another adventure.

I was hoping to go to Dalhousie for a 3 week elective in January, but unfortunately it fell through just recently. Now I am trying to figure out what I should do with that time. I need as many weeks of electives back in North America as I can get. So many schools don't even take international students, and the ones that do want you to apply 9 months in advance. I don't know where or what I am going to do now. (And no, a holiday isn't an option. With international medical graduates the competition is so fierce I am going to have to basically invent my own specialty and write a textbook on it by next fall if I want to study in Canada once I graduate!)

I shouldn't be thinking of all this now, it is so late, and I'll never sleep. Reflecting instead on the past 18 weeks...

Have you learned the lessons only of those who admired you, and were tender with you, and stood aside for you? Have you not learned great lessons from those who braced themselves against you, and disputed passage with you?

-Walt Whitman

Indeed, Mr. Whitman, some great lessons...

No Pressure

2011-11-27T14:15:00.001-07:00

"So the patient has been temporarily paralyzed by the drugs, and you're the one keeping them alive by squeezing air into their lungs...but...no pressure".

Gulp.

I was holding the mask as tightly against her face as I could, sealing the rubber to her cheeks in the effort to keep highly oxygenated air from leaking out. Looking down at her from the head of the bed I saw the patient from a different vantage point, a place that made her look so vulnerable.

And she was vulnerable.

A few minutes prior to closing her eyes she had been nervously chatting and laughing away as we prepared her for surgery. The dose of propofol and the inhaled sedatives smoothed her face and left her body limp. Now we had injected medication into her intravenous line to paralyze her. Once her muscles were relaxed we could slide a tube down her throat and into the trachea, providing the means to ensure that her airway would remain open and her lungs could be well ventilated with oxygen during the surgery.

I removed the mask to prepare for the intubation. Her skin was pale, the freckles standing out now that the nervous blush had faded from her cheeks and neck. She was perfectly still and we were moving into action.

It struck me then how explicitly patients trust their doctors and nurses. Of course I have always understood this as a general concept in healthcare but this was suddenly a much more concrete example. Patients literally put their lives in our hands on a daily basis.

Why have I never said to a patient, "Thank you for trusting me with your most precious possession"? Why has a patient never said to me, "Please do not be hurried, or harried, distracted or inattentive, because today you are responsible for my survival"?

I suppose these are silent agreements and understandings that we have in all of our patient interactions. Yet the fact that we don't outwardly acknowledge these understandings means that maybe we've forgotten that at the core, it is an honor to be in this role. I'm not so unrealistic to think that one is thankful when the bleep goes off for the 47th time on a Christmas eve night shift...but I hope that at the end of the day when I am bone tired and flopped-out on the couch in the call room I'll remember this, and take even just a tiny measure of satisfaction from the honor of responsibility.

No pressure.

Tomorrow and Tomorrow...

2011-11-22T17:22:00.001-07:00

It is moments like this that make me so happy that I am in medical school.

Engrossed

2011-11-17T17:08:00.001-07:00

I don't know where to begin talking about "And the Band Played On" by Schiltz.

I've been wanting to read it since I had the unique opportunity to hear Dr. Paul Gallo speak 2 years ago at the University. Of course, I am only now beginning to grasp his role in the discovery of HIV and how he stood at the epicenter of an extraordinary time in medical science.

At the risk of sounding laughably naive, I never thought of how powerfully the politics of the time and society's value judgements facilitated the development of the AIDS epidemic. I hadn't considered the blatant discrimination displayed against gays by the lack of alarm and media coverage. How one of the first news stories to appear about the epidemic was only when a woman had contracted the disease...suddenly it was a story only when someone other than a homosexual man was sick. As I write this I shake my head at how stupid I sound. Of course politics and conservative beliefs played a huge role in the pathetic response by agencies like the CDC and the NIH. Of course. I just hadn't considered all these angles to the issue before.

But still, it boggles my mind. And it saddens me so deeply to learn how many lives could have been spared if only things had been handled more efficiently and more aggressively by people in power--from government agencies to gay leaders. I temper this statement only by saying that I know how easy it is to judge through the lens of the retrospectoscope.

And yet it is also enthralling to read about a time in medical science when clinicians and researchers were scrambling to put together this puzzle with seemingly random pieces. Some patients had toxoplasmosis, others had PCP, some thrush, many Kaposi's sarcoma...no wonder if took time for people to figure out this was one disease with so many faces. Even the concept of determining that it was an infectious disease...when many thought it came from a bad batch of 'poppers', inhaled nitrites.

I am just over half way through the book and already it has made me frustrated, angry, inspired, impressed and very, very sad. What would it have been like to be a nurse or doctor in San Fransisco in 1982 when we didn't know how the disease was transmitted? Let alone, what it would have been like to be a gay man in the same place at the same time? It is chilling to go there in one's mind.

I grew up knowing AIDS only as something famous people did fundraisers for, then as a rare disease I might encounter as a nurse, to a collection of the faces of AIDS patients I did care for. Then it was a complex subject I needed to memorize for the USMLE, and now to this...something I really know nothing about at all.

This book has certainly opened my eyes and heavied my heart.

Hurt So Good

2011-11-13T03:27:00.001-07:00

Okay so I think it is safe to say I am officially hooked on adventure racing.

I get by with a little help from my friends.

Wow, that was a ridiculously good time! Where do I sign up for the next one?! Granted, the absolutely perfect weather yesterday has probably amplified my infatuation with the whole concept of thrashing my body for hours on end. I have to wait for official results but from the numbers last night it looks like I came in 9th for the women!! I was hoping to finish in 5h and so was really pleased with my time of 4:39.

Can't write a proper post right now as I am on a mission to buy some jam from a market I spotted yesterday after the race. I would have bought some at the time but I had no wallet on me...plus I probably looked like public health threat given the fact that I was leaving a trail of hay, seaweed, mud, and sweat in my wake.

Thanks much-ly for all the tweets, emails, and comments of support! I was having second thoughts about doing it all week so all those little nudges meant a lot.

For you data nerds: run, cycle, hike, evil cycle, ocean sprint/obs course*/run.

*And by 'obs course' I mean going over hay bales and running through tires, etc. not learning how to manage labor presentations. Whaaaaaaaaat...c'mon...medical people read this blog, someone might need clarification!!

Why My Roommate = Awesome

2011-11-11T05:18:00.001-07:00

Today, while loading up my car with race gear, I found this stuck to the seat of my bike. If that isn't ridiculously sweet, I just don't know what is.

Last Ride

2011-11-09T17:26:00.000-07:00

2 days ago was my last training ride before the Big Race this weekend. It was an absolutely beautiful evening, only marred by the screaming of my leg muscles. I think the photo does not do the steep climb justice so I am including a screen shot from my GPS so you can appreciate that it actually is a hill and not just a meandering, gentle walking path from the nursing home.

Note the lack of 'flat bits'.

Tonight I went on a short run, and for the first time in a long time it felt good. I suppose that is the main bonus for me: having something to train for means I'll train. Because I have to admit, I am not really looking forward to the weekend. I'm doing this because I want to see if I can finish it, but I'd be much happier if it didn't involve 8h of driving and staying in a hotel alone for two days (oh and killing myself on a crazy multi-sport course that will probably take me about 5-6 hours!)

The biggest joy for me about the triathlon in June was the fact that most of my family was involved. It was so fantastic to come across the finish line to big hugs from my sister, sister-in-law, bro, bro-in-law, niece, and nephews! It just feels weird that I'll be finishing and high-fiving myself (before collapsing in a twitching mess).

And speaking of high fives...I would not like to high five my body for how has changed in the last 10 weeks. I found my measuring tape a few days ago and thought it'd be interesting to see if my measurements have changed since I kicked s*it into high gear. Granted, the last time I measured myself was about a week before I went on my Himalayan trip and I was in decent shape then but...

First disappointment: 4 inches gone from chest. Buh-bye.
Second disappointment: no inches gone from thighs or butt.

SERIOUSLY BODY? Seriously???

Great, so now I have the upper body of a 10 year old newspaper delivery boy, and the lower body of a middle-aged Greco-Roman wrestler. That is sub-awesome.


Um...do these vertical stripes make my thighs look big?

When One Eponym Suffers Another

2011-11-08T05:43:00.000-07:00

The Oxford Handbook of Clinical Medicine is full of charming and hilarious little gems, usually tucked away in the depths of information overload. I would love to meet the authors of this sanity-saving handbook and shake all of their collective hands (while buying them beers).

Today I came across this entry which I felt the need to share:

In 1931, Buerger's* disease caused gangrene in the toes of Harvey Cushing**--the most cantankerous (and greatest) neurosurgeon ever. He had to be wheeled to the operating theatre to carry on his brilliant art (and to continue terrifying his assistants). He had to retire partially, whereupon his colleagues presented him with a magnificent silver cigarette box, containing 2000 cigarettes (to which he was addicted)--one for each brain tumor he had removed during his long career, so verifying the truth that although we owe everything to our teachers, we must eventually kill them to move out from under their shadow.

-Herman Hesse, Demain

And so there is your CME in obscure medical history for the day. You're welcome.

*Buerger's disease (thromboangitis obliterans) is smoking related inflammation of veins, nerves, and middle-sized arteries (which thrombose, causing gangerene). Cause is unknown. Stopping smoking is vital. Most patients are men.

**Cushing's disease is bilateral adrenal hyperplasia from an ACTH-secreting pituitary adenoma. He also is known for Cushing's syndrome, and Cushing's triad...but I think we've learned enough for today.

An Unexpected Test--Part III

2011-11-06T16:31:00.003-07:00

And then I remembered…Iwas supposed to phone Paul when I got down. What if he heard about therescue or saw the helicopter and thought it was me. He knew I was heading upalone…and my bike! (Now I know itmight sound like a crass thought to have in an emergency but that bike is worthmore than my car and heaven knows I’d never be able to afford a replacement.)

I asked one of Tina’s friends to take over c-spine for mewhile I called Paul and checked on Maggie again. Paul was stunned when I toldhim the situation, and said he had started to wonder what had happened to me.He offered to help in any way he could. I wasn’t sure how long the elderlyIrishman was going to be selling walking sticks and watching my bike, so Iasked Paul if he’d pick it up for me and then collect me later once the ordealwas over. He was happy to do so and I could breathe a little easier.

I resumed my post after a short jog on unsteady legs in aneffort to get my body temperature up again. Tina was oscillating between drowsysilence and angry outbursts directed at the cold. We were all starting toshiver. I couldn’t remember a time when I’d been that cold. I’ve been outsideduring winter in the Arctic circle but I was always appropriately dressed for that.My cold sweat and thin jacket were a bad combination and at times my hands andbody started shaking to the point where I wondered how effective my c-spinestabilization was.

Finally we heard the reassuring buzz of the approachinghelicopter. The fog was so thick that only the sound alerted us to its descentnearby. Tina began to cry out with relief. Our huddle, which consisted ofFather Henry, two teens, the Swiss couple, and myself, looked around at eachother with relief on our faces. Relief that soon turned to concern as we heardthe noise change and then grow quieter and quieter. Tina soon realized thehelicopter was gone and started to cry.

Twice more our rescuers tried to land unsuccessfully. Eachtime our hopes rose with the crescendo of its approach and fell further as itdrifted away again. I was getting genuinely worried now about hypothermia, forall of us. How cold did it have to get before the injured ones really startedgetting into trouble? Our little circle got tighter and tighter. After thehelicopters 3^rd failed attempt to land, another hiker coming downthe mountain stopped to offer help. She immediately started pulling out extrapieces of clothing, hot coffee, and chocolate. She threw an extra coat over myshoulders and then sat behind me rubbing my back and arms in an effort to stopthe shakes which were starting to take intermittent control of my body. As shepressed up against me she said, “I know I am getting into your personal spacehere, if I am annoying just tell me to go, but you really look like you needwarming up…” I told her she was the farthest thing from annoying and that I wasextremely grateful for the warmth she brought down with her.

Finally, the helicopter was able to drop a rescuer downnearby. Keith was a tall, stocky flight paramedic and he had with him two largebags filled with emergency medical supplies and outdoor protection gear. I gavehim the best report I could from my initial surveys, and helped place a collaron Tina. We were able to wrap her in a thick, warm, bright orange emergencysack. Soon many other rescuerswere on the scene. I didn’t ever find out if they had arrived on foot or alongwith Keith when he was dropped off. Someone, who I think was a doctor taking direction from Keith,took over c-spine. I asked the Swiss guy to pull my bent leg straight for me soI could stand. My leg muscles had seizedup and fallen asleep during thenearly three hours that I’d stayed almost motionless. It was a strangecombination of sensations as I tried to negotiate the rocky terrain over toMaggie and the swarm of rescuers who surrounded her. I knew the patients were in good hands and I suddenly feltlike a supernumerary gawker. Where had allthose bystanders come from? I approached Keith and told him I was planning tohead down. He offered to give me a lift in the helicopter to the hospital. Ithought for a moment how much I would lovea spin down in the whirly bird but I felt like I needed to go sooner ratherthan later. He didn’t know how long the refueling would take and I didn’t knowhow much longer I could stay on the rocks. Not to mention that I’d long agocalled Paul and told him ‘the helicopter is landing’ and then forgotten toupdate him with ‘and now it is gone’. He’d probably been waiting at the bottomfor well over an hour.

I said goodbye to the rag-tag gang who I’d spent theafternoon with, wished the patients my best, and gave Keith my contactinformation. Leaving the scene Itook one last look at Maggie, getting rolled into the bright orange rescueblankets. The bruising on her face had started to look like raccoon eyes and Istiffened with the thought that maybe she didhave a skull fracture after all…and that I hadn’t observed her closeenough. My next thought of course,was what could I have done differently if she was a skull fracture?

I started running down the mountain.

It felt so good to get moving again. My legs were rubberyand sore. Soon my body temperature started rising and the sweat startedpouring. By the time I reached the bottom I was pulling off the extra layersand soaked again. I pulled open the door to the café at the bottom and spottedPaul reading at a table near the window. The teapot in front of him was empty. Isat down and began a litany of apologies for my lack of communication andkeeping him waiting. He too apologized for the crazy afternoon of training thatturned into a rescue off the mountain. He got up to buy me some tea and I wentto the bathroom to wash my hands and face.

I looked like I’d been through the wars. Clothes damp fromfog and perspiration, hair and eyes wild from the wind, lip cracked fromnervous chewing. My attempts to make myself presentable to the café crowd werefutile. I dried my face and hands with some toilet paper and went out to enjoy thehot tea and padded chair.

Epilogue

That evening, while I was driving home, Keith called to tellme they’d successfully airlifted one patient after the other, off CroaghPatrick. Maggie had gone second, and they’d left with her just after 1730h. Hesaid both were stable and expected to do well. I thanked him for the call.

The next day Father Henry called me to say that Maggie hadbeen released with a few stitches, and that Tina was expected to go home thenext day. She had no broken bones, just a bad sprain, concussion, and a fewhead and facial cuts that required stitches. He thanked me profusely for myhelp. I felt somewhat sheepish because I didn’t really feel like I had done anything except stay with them. He told me that justbeing there and my reassurance that they weren’t doing anything to make thesituation worse had been invaluableand extremely helpful.

Two days ago I received a series of text messages from Tina,thanking me for my help, telling me how scared she was, and how she had been convincedthat she was going to die.

I was very touched by the fact that all three people hadendeavored to make contact with me and that they were so appreciative. It didn’tchange the fact that I had felt helpless and useless during most of thatafternoon on the mountain. But it was nice to think that in their eyes I’d madea difference.

I’d spent the 4h drive home going over the scenario in myhead and thinking about all of the things that I should have done differently.I berated myself for things like not having thought of getting both of them offthe cold ground right away, and not showing one of the people in Maggie’s grouphow to hold c-spine. All told, it was a very good learning experience. Itshowed me the power of reassurance, reminded me of my love for emergencysituations, and reiterated the importance of never, ever, going out without a headlampand an emergency blanket.

An Unexpected Test--Part II

2011-11-01T15:19:00.000-07:00

I'd get to the girl, first I wanted to make sure Maggie was stable.

Maggie was well bundled up which made a quick primary surveyalmost impossible. I put my hands under her jacket and tried to feel along thebony aspect of the back of her neck. I pressed down on each vertebrae while askingif she was having any pain, numbness, or tingling. She said no.

I tried to move my fingers systematically around her skullfeeling for any ridges, deformities, warm tangles of blood, boggy swelling.Nothing.

I quickly checked the pulse in her wrist—strong. That was agood sign, she had a decent blood pressure and wasn’t tachycardic, which meantshe wasn’t going into shock (yet) from some hidden injury that was causingblood loss.

Maggie was alert and talking to me the whole time, she saidone of the girls on the hike had lost control coming down too fast from thetop. Maggie lunged after her, also losing her footing and going head first downthe steep and rocky terrain. Now I was getting worried about this unknown girl andfelt fairly certain that Maggie had no immediate threats to life or limb (despite mywoefully brief and incomplete initial survey). I asked the 3 young girls with her to try their best to keepeach other warm, to continue talking to Maggie. I asked them to send someone over to me if shesuddenly became confused, nauseated, or started complaining of numbness ortingling.

I scurried over the slippery rocks to the second cluster of people,perched on the lateral aspect of the slope. A young girl was buried under asimilar assortment of raingear and jackets, crying out in pain. Two of herteenaged friends were huddled against her, shivering in their thin hoodies andtrack pants. Her legs were splayed awkwardly but with no visible deformity,blood spattered the rocks near her feet. Under the hood of a green raincoat Icould see that her hair was thickly matted to one side of her face with bloodthat appeared to have come from her scalp. Her cheek was also cut, just underthe eye. She opened her eyes when I asked her to and told me she’d startedcoming down the mountain and couldn’t slow down, she didn’t know how she’dfallen or if she’d been knocked out. Her pupils were of equal size, they constricted when she focused on myface, she knew where she was, and who she was there with.

Again I wrestled with the tangle of clothing trying to feelher neck and scalp. She said she had no neck pain but yelped whenever I touchedher head, especially near her forehead. It seemed impossible to locate the cutas all the blood had dried in the lumpy nest of hair. I looked in her ears and under her nose for blood or clearfluid that might indicate she had fractured her skull. Dry. She didn’t have thecharacteristic pattern of bruising associated with basal skull fractures, thebluish tinge behind the ear or black circles referred to as ‘raccoon eyes’.

I felt her wrist, trying to locate her pulse. As I measuredher heart rate, which was fast but not worrisome, she complained of pain. I wasreassured though, by the lack of a sickening crunch or odd angle to the joint,something I’d come across many times in the Whistler emergencydepartment. I put my hands under her jacket, asking her to take deep breathswhile I felt her chest rise and fall. Her rib cage felt stable and she said shehad no troubles breathing. Good. She had a blood pressure and nobreathing issues. I felt her belly,tested the bones of her pelvis for pain or instability. She cried out in painwhen I brought my hands down her left thigh and leg. I couldn’t feel anyswelling or grinding under my pressure, the leg didn’t seem shortened but itwas hard to tell and I didn’t want to move her limbs unnecessarily.

Somewhere in all of this I found out that the man with themwas Father Henry, the priest who had been escorting a church group up themountain, which is a famous pilgrimage for Catholics. Maggie was the other leader of the group, which left himrunning back and forth between the two huddles, with one cell phone (andsometimes two) pressed to his face.

It was during my assessment of Tina that I too started toshiver. Suddenly the combination of wind, fog, sweaty T-shirt, and stillnessleft me very cold and wishing I’d brought more clothes. I pulled onmy damp wool shirt and windbreaker. Once I was crouched behind Tina with my hands along side her jawand neck to stabilize her cervical spine, I realised that if I was that cold, the girls lying on theground were in even bigger trouble.

At this point an athletic Swisscouple, each dressed in layers of hi-tech looking gear, arrived and offeredextra coats to pile on the injured hikers. The woman pressed up against Tina’slegs, the man against her right side. Tina’s two friends took up positions onthe left. A tall middle aged Scotsman came up and suggested we use his largebackpack as something to put underneath Tina.

I cringed with the realization that I should have thought ofthat ages ago.

CAcBCDE. Catastrophicbleed. Airway/c-spine. Breathing. Circulation. Disability. Environment.

All of this had been drilled into me again only weeks ago at the Advanced Trauma in Community course I’dtaken. Environment. As in, assesscomplications due to environment such as coldtemperatures and adjust to protect against these dangers.

And so there we were. All of us freezing, worried, and wondering how long it would take forthe mountain rescue crews to arrive, if they were sending a helicopter, and ifthe helicopter would even be able to land amidst the fog and wind. I asked one of the girls to take overc-spine for me as I went back to check on Maggie. She was well bundled up andhad a similar gathering surrounding her. The tall and quick thinking Scotsmanand his wife were monitoring her. This gave me peace of mind over the naggingthought that I was ignoring one of the casualties. Maggie was still alert andoriented, nothing had changed since I had first assessed her. She said she wasmore worried about Tina than anything else. I tried to reassure her beforerunning back to my post: holding on to Tina’s neck.

We heard ambulance sirens in the distance which gave us hopethat help was soon to arrive, hopefully with blankets at least and and possiblystretchers.

“Wait!!!” I askedMatt, the teen to my left, to grab my nearby camelback.

“I had an emergencyblanket in there this morning…did I leave it in or put it in my other pack??Ohhh…”

And then I remembered the brief conversation I had had withmyself before heading off this morning. “Iam only going on a road ride and a run, I am definitely not going to need myemergency blanket or my headlamp.”

Of course. Dammit! We really could haveused that emergency blanket now. Tina was shivering uncontrollably to the point where her teeth chatteredcausing her to cry in frustration, “Getme OFF this mountain!!!! Where are they??”

We tried to calm her by talking about Justin Bieber, the hotblankets that awaited her, the exciting helicopter ride she was going tohave…it distracted her for short periods of time. Father Henry would threatento start singing if Tina went quiet for too long. This proved to be an effectivetechnique for getting her to start talking again.

By now, over an hour had gone by since I arrived on thescene. I thought about sending theteens down with one of the hikers who was offering to help. Were they going to get hypothermia while tryingto keep their friend warm? Were we only creating more casualties by keepingthem with us? What was the legality of sending minors down the mountain withstrangers? What if we were up here until the middle of the night? I rememberedonly a couple of months ago a woman being stuck on Carrantuohill until 4amwaiting to be stretchered off the mountain with a broken ankle. At least now they could get down safelyin the daylight. For the time being we decided to keep them with us.

Surelymountain rescue was going to arrive any minute.

An Unexpected Test--Part 1

2011-10-31T10:46:00.001-07:00

At 0800h I was standing in my room at the B & B, holdingthe silver emergency blanket in my hand. I gauged its weight and worked at stuffing it into my already burstingcamelback. The pack was full, mostly due to the 2L water bladder, but I hadalso managed to squeeze in 3 nutrigrain bars, a headscarf, my mobile, a fewtissues, and a headlamp. My first adventure race was only 2 weeks away, so Ihad driven to Westport the night before to join the training group and suss outthe upcoming racecourse. In a rush I’d ‘packed’ by basically throwing all myoutdoor gear into the car, hoping I’d managed to toss in all the essential piecesof kit.

“I am only going on aroad ride and a run, I am definitely notgoing to need my emergency blanket or my headlamp. The last thing I want is anoverstuffed pack bouncing on my back while trying to run” I thought.

I pulled the blanket and headlamp out of the camelback andtransferred them to the larger pack that I take on hikes. This pack always containsmy mitts, 2 winter hats, spare socks, earmuffs, and rain pants. Just in case.

I couldn’t have predicted that 5h later I’d be pulling thecamelback apart thinking,

“Wait!!! I had anemergency blanket in there this morning…did I leave it in or put it in my otherpack?? Ohhh…”

So I finished getting dressed in my long biking pants, tanktop, t-shirt, long-sleeved merino wool top, and windbreaker. I usually end upoverheating and cursing every layer once my heart rate gets going, but itseemed windy enough to warrant the wool shirt. I kept it on and headed out thedoor for what I thought was going to be a morning consisting of a bikemaintenance workshop, followed by a group road ride, and short run.

Due to a miscommunication with Paul, the trainer, regardingthe schedule, I ended up cycling to the base of Croagh Patrick without myrunning shoes. He felt terrible and offered to head back to town and collectthem for me. I was embarrassedthat I’d misunderstood the plan and contemplated going up in my clips, but heinsisted, so I gave him my keys and waited.

By the time Paul returned most of the training group weretrickling back into the parking lot after hiking to the shoulder. He handed theshoes over and suggested that I hike to the top (since that was how far I’dhave to go on race day). He gave me his mobile number and said he’d go throughthe rest of the course with me on my own once I’d cycled back to town, later inthe afternoon. I was so mortifiedover being the most high maintenance participant of the day that I didn’t mentionthat I had no way of locking up my road bike while heading up the mountain. I waited for everyone to leave and thennegotiated with the elderly Irishman selling walking sticks from a stall in theparking lot. I told him I’d be 2 hours maximumand he agreed to keep an eye on my bike as long as I propped it within view ofthe stall.

It was noon, there were snatches of blue sky scatteredamongst the clouds, but the top of Croagh Patrick was wrapped in a heavy greyfog. It was the best that one could hope for in terms of Irish weather so Istruck off. I started my GPS timerand (mostly cheesy) ipod running mix, trying to move as fast as I could up themountain, partly to take advantage of the weather and partly because I didn’twant to keep Paul waiting once he was done with the training group.

An hour later I was nearing the top of the mountain, whichis mostly a rocky scramble. Despite the cold wind and scattered rain, I hadlong ago shed all my top layers and was down to a sweaty t-shirt. I was hammering away withDaft Punk and Fat Boy Slim blaring, feeling good.

Then I saw a small cluster of people crouched down on thetrail ahead. I thought for amoment that it was just a group of melodramatic teenagers taking a breatherfrom the sustained final push to the top. Then I noticed that one of them waslying on the trail with blood on her face.

I crouched down and she opened her eyes. I asked what hadhappened and if I could help. The person on the ground was a woman in herthirties with soft brown curls framing her bruised and swollen face. A cutacross the bridge of her nose bled in a line down her cheek and along her neck.She was covered in a mix of raincoats and sweatshirts, visibly shaking. Herclear blue eyes opened when I asked her her name and she told me it was Maggie. A hover of teens surrounded her. They said she’d fallen and hit her head but shehadn’t been knocked out. A frantic looking middle aged man in a blue cableknitsweater and khaki pants spotted with blood approached me and said that mountainrescue had been called and that they were on their way. I asked if there was anything I coulddo, he said “Uhhh…I don’t think so, mountain rescue will be here shortly…”

In these situations I never know how to state mycredentials, going into a ramble about being an ex-ER / arctic nurse, now 3^rdyear medical student, with a smattering of trauma and backcountry courses,seems a little too long-winded and confusing. So I decided to distill it downto ‘student doctor’ even though it sounded vaguely ridiculous at the time. Especiallysince that part of my background wasprobably going to help me this least atthis point.

“I just want to make sure she’s ok, I am a student doctor...can I quickly check her out?”

“Wait…what?”, the man said, “oh thank God! You’re a studentdoctor? Once you’ve looked at Maggie can you come and see the girl? I think sheis in worse shape.”

The girl?

It was then that I saw a second huddle of teens away fromthe trail, on a steeper aspect of the scree, about 5 meters away.

Oh dear.

I Heard It!! I REALLY heard it.

2011-10-24T14:45:00.003-07:00

Small miracles, tiny accomplishments, baby steps forward.

Some days in medical school it feels like the 'teaching' just boils down to constantly being told how many differential diagnoses you forgot, how many signs you failed to elicit, and how many questions you didn't ask the patient. The constant deluge of information and things you ought to know by this point can begin to feel suffocating.

Until a miniscule but measurable gain occurs and suddenly, it seems worth it.

Like today...I actually clearly heard my first heart murmur which I confidently and correctly identified after performing a decent cardiac exam!!!

Pretty sure that at the exact same moment a unicorn was born and a leprechaun discovered a pot of gold.

I honestly thought that heart murmurs would always be a mystery to me and that there would never come a day when I'd be able to do anything other than pretend I heard it.

But, nay! I heard it. I really heard it. And strangely, that made me smile. All day.

Small miracles.

Mind Go Blanko

2011-10-23T15:14:00.001-07:00

On Friday my new consultant (MNC) gathered together myself and the other doclings to do some bedside teaching. Normally I try to slink between the folds of curtain during these sessions as I really don't want to be pimped on differentials for pseudopseudohypoparathyroidism or some other disease dredged up from the Annals of Obscure Internal Medicine. But since MNC hasn't seen me examine / present yet he asked the handful of final meds to step away from the morbidly obese no-necked man who was sleeping with his feet at the head of the bed, and told me to conduct a complete cardiac exam and report my findings.

Yeah. It was sub-awesome.

First of all, I could hardly feel his radial pulse and my racing thoughts kept forgetting where I was in my count...was I at 14 or 24 when I had counted 15 seconds...wait...did I start counting when my seconds hand was at the 12 or the 1 position...where DID his radial pulse go--GAH!

Then I attempted to feel his carotid pulse which should have been located somewhere between his clavicle and angle of jaw (which were, in his case, resting comfortably on each other, heavily padded by folds of flesh). No luck, despite the patient kindly allowing me to dig around there for a while.

JVP? No. Bueno.

Ok, and on to the apex beat. Not so much. Heart sounds?? Is this stethoscope on?? Tap. Tap. Tap. I can't actually even hear his heart beating--hark?! Is that it?? No, that is the sound of my own blood rushing through my ears...

And now to my dazzling presentation. Sure, I'll just neglect to mention that he was hooked up to telemetry, and that he had cardiac meds at the bedside...even though MNC kept asking me, "is there anything else you'd like to comment on??"

"Er...he has a midline abdominal incision??"

"No, he's on telemetry."

"Oh, right." Yeah, the device you hooked cardiac patients up to everyday in the emergency department. The painfully obvious tangle of colorful wires stuck to his chest. Yes, those.

Surprisingly MNC did not shred me into tiny bite sized pieces. I suppose he just assumes that 3rd years are clueless. The major bummer was when he turned to the final meds and asked them how to manage the patient. I had to fight hard to not pull a "Summer" from School of Rock...

"Oooh! Ooooh!! ASK ME!! I know how to MANAGE a CCF patient!!! Really!!! YES!!"

But, no. My medical self had failed and my nursing self couldn't help me now.

Ah well, maybe my extremely low bar setting means I will appear to shine upon my next opportunity to examine and present.

Maybe.

:)

Alright. Medicine, I misjudged you.

2011-10-20T06:34:00.000-07:00

I am sure this will induce some smugness out there to you medicine-y people, so I will say it just this once: you were right.

Internal medicine isn't terrible. I have seen some really interesting cases and signs...water-hammer pulse, palpable heaves...murmurs, palsies, and masses oh my! DiGeorge syndrome, death, dementia, failure to cope, hyponatremia, acoustic neuroma. And that was just one patient! (I'm kidding. Sort of.)

The other good thing about this rotation is it has definitely removed any lingering doubts that I want to go into surgery or acute care. Internal medicine is just not my cup of tea, which is a good thing know when you are someone like me who finds something of interest in everything I am exposed to.

In other news, training for my race is going...well, it is going. When I see what I am supposed to be able to do at this point (as per the schedule they gave us with registration) I get a little nervous. It is only three weeks away and I haven't been doing multi-sport training yet, mostly because I just don't have time to do a 3h cycle followed by a 1h run in one day. I've just been trying to get out at least 5x per week with one sport at a time. This is not really good enough but it is all I can do right now.

I have already given a heads up to my medical team that I may end up becoming one of our patient's on Nov 12th. I know the registrar will take good care of me, she's very smart.

And now I must return to my daily meditation on the kidney, the neuro exam, and all things cardiac.

I Have "Hapless Female" Qualities

2011-10-16T14:14:00.000-07:00

I took my little blue beauty into the bike shop today after my cycle for a 'tune up'. It was embarrassing.

Me: Hi. I bought the yearly maintenance package for my bike and I wanted to bring it in...

Bike dude [in hurried manner]: Ok, what does it need?

Me [suddenly realising how ridiculously hapless I am at very basic bike maintenance]: Yeah, it pretty much needs...um...air in the tires, a little oil on the chain, and...I dunno, the pedals tightened? Er...maybe the shifters...[stares at ground, toeing invisible mark on floor] shifted...[trails off, mumbling incoherently]

Bike dude [expression softens as realises he's dealing with moron of epic proportions and takes pity on me]: Ok, that shouldn't take very long [chuckles to self] we should have it ready by Wednesday [enunciating well and speaking very slowly].

Ok, so I am a ridiculous damsel in distress when it comes to my darling road bike (and killing spiders).

Today's event cancels out the fact that I wielded very heavy machinery last week in a very non-girly way (with a steady hand and...ok...the odd high pitched squeal of delight).

I hate those moments when I feel like a hapless female, but dammit I don't have time right now to learn about gear shifters and spider aversion therapy...I am in the thick of it with trying to piece together a smooth cardiac exam without being reduced to a blubbering mess in front of the ward sister, the reg, the SHO, and several medical students.

And so, for now, I pay the bike shop 25 Euro a year for unlimited bike maintenance. And I am ok with that. Usually.

Clinical Exam Follies and Triumphs

2011-10-14T07:33:00.000-07:00

This week I had the opportunity to invigilate a licensing exam for doctors here in Ireland. Though no one actually said anything to us about confidentiality I am very certain that I am not able to blab about any sort of details. However, I will say that it was a fantastic learning experience to see how different people perform under pressure, how examiners basically set out to shred you to pieces, and how little things can really affect one's rapport with the examiners.

One thing I will take with me for when it come to be my turn on the sharp end of the short-case examination: if you are told "examine body part [x]" then EXAMINE BODY PART X!!!!!

I was stunned to see people being told specifically to examine one organ or anatomical location to find them faffing around with other systems, only to the irritation of the examiners. The examiners would sometimes have to repeat themselves several times, "stop, examine x!"

There was one candidate who was my hero. She (somehow) remained calm, did very methodical and well organized physical exams, could rattle off differential diagnosis like a champ, answered all the examiners questions clearly and precisely, and was really personable to the patients. I was mentally cheering her on the whole time and wishing I was her. I also felt devastated for the people who started floundering, crashing and burning, knowing all too well the negative spiral of

stressed

mind blank

higher stress

flustered

adrenaline injection

mind completely barren of thought

fear of failure

despair

quavering voice

certainty of failure

despair

despair.

It was somewhat reassuring (or depressing, not actually sure which) to see that even people who have been doctors for years still get stressed and fumble during clinical exams, it is not just we doclings.

Good And Bad

2011-10-10T09:17:00.000-07:00

This Saturday my interview on CBC's national radio show White Coat Black Art will be airing. I am a little nervous (ok, a lot nervous) about how it is going to turn out. The interview with Dr. Goldman was the day after my USMLE exam so there were a couple of reasons that I may not have been overly articulate. However, I still really enjoyed the whole experience and was flattered to be asked on the show (considering I've been a dedicated fan and listener since it's inception years ago).

My prediction is that my contribution will only be a tiny piece of the show, but I am still excited and pleased about the exposure that the blog will receive. Of course now any thinly veiled anonymity will be removed and I'll be having to keep Asystole on an even straighter and narrower course.

The interesting outcome of increased traffic is usually increased trolls. I was really surprised (oh, how naive I am sometimes) at some of the troll-y comments when my "Advice to Interns" pieces were published on KevinMD during the summer. I suppose I just have to remember that some people really take themselves too seriously and do not understand 'tongue in cheek' nuances.

So we'll see, maybe trolls, maybe increased traffic, maybe nothing.

For now I am being kept quite busy putting together my research project (in surgery, of course!), training 6 days a week for the big race next month, compiling a report on the elective /residency woes of Canadians Studying Abroad (CSA's), and trying to keep a smile on my face.

That last part is sometimes proving to be the hardest of all tasks! But as Shakespeare rightly pointed out in Macbeth,

"Come what come may

Time and the hour runs through the roughest day".

Jaws of Life Teaser Photo

2011-10-09T14:36:00.000-07:00

I am writing a post about the brilliant trauma course...but in the meantime...allow me to present ABB wielding an actual jaws of life. This photo taken shorty after I cut a car door off (hence my demented appearance).

Does this jaws of life make my thighs look big??

The really hilarious part was that the firefighter handed it to me, showed me where the 'on' button was and then told me to 'work away'.

Yeah, in Canada I would have had to take a 2 day safety course, sign release forms in triplicate, show proof of tetanus immunization, and demonstrate to a workplace hazard team my ability to handle the machine before being allowed to turn it on.

What could possibly be more enjoyable than handling a machine that crushes metal at 600lbs per square inch???

Oh 'twas a good day, so it was.

Good Trauma

2011-10-07T00:45:00.003-07:00

For the past 2 days I've been at an Advanced Trauma in the Community (ATC) course, and yes, I did get to smash a car window and use the jaws of life! There will be photos and yarns soon to follow. Oh, and a breakdown of how I cycled through wanting to be a firefighter, police officer, and paramedic throughout the day.

If I had been wearing Star Wars pajamas then I probably would have completely morphed into the 7 year old boy living inside of me.

Trauma, woot!!

Sunday Riders

2011-10-02T15:14:00.000-07:00

So today Pádraig (the surgical SHO) and I decided to do a reckie of the road biking portion of a race he's competing in next week. We started at the Gap of Dunloe (a.k.a Kate Kearney's Cottage) and ended at the Torc Mountain waterfalls. A fabulous ride in part due to the spectacular scenery the entire way, and a delicious visit to my favorite purveyor of fine Irish food: The Avoca Café.

I also learned a couple of things today. For instance, my tiny little sewing-machine of a car can fit two road bikes in the back and two people who love blood and guts in the front. GO TOYOTA YARIS!

Another lesson learned was that not only are directions from Irish people usually nonsensical and obscure, the road signs are equally unhelpful. Unless, of course, you are looking specifically for tea and scones or a farmhouse with ensuites. Have you reached a fork in the road on random back country lane? Are you searching for a particular town or road number? Sorry. Can't help you there. Tea and scones? Take a left.

I've been to the Moll's Gap Avoca a couple of times but have always approached it from a different direction. So after a particularly sustained uphill we decided to pull off and have snacks, figuring the Avoca was at least another 20kms or so away. After some Clif bars and trail mix we started up again on the bikes, only to come across the "AVOCA, 500 METERS" sign within about 3 mins of departing.

I did hear Pádraig scream "NOOOOooooooooooooo!" through the fog.

I think he made up for the disappointment in having already eaten lunch by putting himself into a pre-diabetic-coma with the most delicious banoffee dessert evah.

And it was all downhill from there, friends. An outstanding day, topped by my new routine of sauna / ice-cold shower / sauna / ice-cold shower at the gym.

Ain't life grand?

New purple Icebreaker, for the win.

Fin

2011-09-30T17:32:00.002-07:00

Well my first official hospital rotation has come to a close.

Today was my last day on the surgical team and I found myself staring off into space more than once, feeling genuinely sad. It seems like the last 9 weeks screamed by at break-neck-running-behind-my-consultant-speed. The thought of starting on a new team is a little daunting. I feel as though I just figured out my true place with this team, and that I was starting to habituate to their rhythm.

The apple crumble made big waves, the pan licked clean before the end of 1st tea break. The nurses and porters seemed genuinely shocked that I baked for them and many approached me to say thanks, or "fair play to you" which is the Irish equivalent to something like, "well done" . The porters also pretended to have food poisoning all afternoon (yes, pretended) and one proposed marriage.

When the last stitch was thrown in the belly I didn't know if I should shake M.C's hand in a formal manner, or make some cheeky comment (more my style)...so I just had my chlorhexidine shower (as per MRSA case protocol) and went to the gym.

I was happy to hear nothing but silence when I arrived home. The alarm people had to come and tear everything apart because the thing was completely haywire. I think I am going to start calling the alarm system, Hal, from now on. I was able to un-tape my memory foam pillow and yoga blanket from the wall (dampers) and make dinner without earplugs in, which was a pleasure.

Tomorrow I am going to attempt to review some medicine-y things. Like the heart. And probably the lungs. Look up Na+ levels and try to remember what exactly this condition known as diabetes is, which has come to mean only really really bad leg ulcers in my mind.

And so, I begrudgingly shelved my Surgery at a Glance, Surgical Recall, and my Physical Signs for Clinical Surgery and ordered The Oxford Handbook of Clinical Medicine.

Speaking of clinical surgery...if you haven't watched this TEDtalk by Abraham Verghese, please go make yourself a cup of tea and spend the next 18 minutes watching an extraordinary author and surgeon discuss the lost art of physical assessment. It is another typically awe-inspiring TEDtalk.

It is late so I'll close with a quote by Yeats, cited in Verghese's book, Cutting for Stone,

The intellect of man is forced to choose

perfection of the life, or of the work,

And if it take the second must refuse

A heavenly mansion, raging in the dark.

Weak Week

2011-09-29T15:36:00.001-07:00

Tomorrow is the last day of my surgery rotation (boo).

My house alarm has been going off for 2 days, unrelentingly. The alarm company wont shut it off because we are not the 'homeowners'. My landlord is away on holiday and unreachable. I spent last night trying to sleep with earplugs in, a pillow on my head, fan blowing in my face, "Tibetan Rain Song" blasting out of my ipad, and my dormer window wide open. All in the hopes that the combined white noise would drown out the loud BBBEEEEEEEEEEEPPPPPPP! that goes off every 3 seconds.

It didn't.

I am considering a B & B for the weekend if we can't disable the alarm by tomorrow. It is like Chinese House Alarm Torture. Believe me, we've tried everything. Including punching the key pad (which strangely didn't work).

Did I mention that I am also in a bad mood because tomorrow is my last day of surgery? Oh right. I did.

:(

:(

:(

The only nice thing is the scent of apple, strawberry, blueberry crumble wafting up the stairs. I am bringing a vat of it tomorrow as a thank you to the theater staff (who have, for the most part, been amazing).

Now I must get to my thank you note writing. And it's 2335h. And I am getting up at 6. Gah. (I use the term 'getting up' instead of 'waking up' because if tonight is anything like last night, I was woken every 40 mins or so BY THE BLEEP OF PROFOUND ANNOYANCE and was wide awake when my alarm went off.

Ok, that is enough whining for one post.

Scenes from the Day

2011-09-26T05:07:00.000-07:00

I (heart) fall.

Another Charming Trend in Medicine

2011-09-25T12:09:00.000-07:00

"IMG" means "International Medical Graduate". As in, anyone who studied medicine outside of Canada and wants to do post-graduate studies in Canada.

Did I mention there are 45 Canadians in my medical class alone?

Dare I delve into how many of those 6.5% matched to something other than internal or family medicine?

Hello, Ireland. Need a doctor?

Little Things, Like Spicy Pickled Eggplant

2011-09-25T03:49:00.000-07:00

"I'm Paul Kennedy, and this...is Ideas"

Because sometimes it really is a collection of little things that make me oh so happy.

Adventure Racing

2011-09-23T17:27:00.000-07:00

Today I registered for my first adventure race--and I am ridiculously excited (and scared!)

I am not exactly sure what I am getting into but it combines three sports that I am moderately un-terrible at (cycling, running, and hiking) set in an area of Ireland that I've always wanted to explore.

It is the Sea 2 Summit race in Westport, with part of the track going up Croagh Patrick (the Magic Mountain--apparently you can lessen your purgatory sentence if summit it barefoot). I suppose my main reason for possibly biting off more than I can chew is that my days are wonderfully full at the hospital but my evenings and weekends sometimes feel a little...well...empty.

Don't get me wrong, I've been enjoying hikes out and some of the new people I've met, but I find that these days, the only time I feel really good is when my heart is pounding and I'm trying to ignore the singing of my muscles. I thought it'd be ideal to have something to train for. The added bonus being that there is no water sport involved which means no one has to see me thrashing about in a bathing suit like a wounded walrus. WIN!

Did I mention I am scared?!

Last to Know

2011-09-22T14:59:00.000-07:00

So, why is it that no one ever told me about surgical critical care as a specialty? It basically combines all the things that I love: really sick patients, emergency medicine, critical care, and...surgery...!

What? Why was this option never presented to me at career day in high school?

Off the cuff one day M.C told me I should consider trauma surgery (yeah yeah, OMDG I hear you snorting) and I brushed the suggestion aside because I would like to start my career sometime before the age of 45. But I've started looking at some of these different fellowship programs and (Trauma! Surgery! and Critical Care! Oh my!) they sound ahhhh-mazing.

How seriously bad assed would that be? I can only imagine people who have that training must land in the department completely dressed in black, crashing through ceiling windows, and worming their way under laser sensors to get to their patients, because that is how medical ninjas roll.

I just hope I am married by then because LORD knows no man will have me if that is the career I choose.

Anyway, just reading the program descriptions makes me slightly wide eyed.

The problem is, I could also see myself running a vegetarian aromatherapy clinic where we sit and knit our own yogurt after telemarking to work.

And thus continues the fight within me on choosing a medical specialty. My complete love for living the simple life in the mountains, attending bake sales for the hockey team, and making soup is at odds with the part of me that could live in a crazy wild big city cracking chests in the ED by day and going to the symphony at night.

The only thing that really comforts me is that M.C also said, "I think you'd be good at anything you do". Which is no small thing, coming from someone who you have a great professional respect for.

So I suppose time will tell.

The Blasket Blast

2011-09-18T12:13:00.003-07:00

Last week I was whining to Paddy (our surgical SHO) about the fact that my bike needed a tune up, M.C overheard and kindly offered to get it road worthy for me. From this, the topic of the Blasket Blast road ride came up. It is an organized bike ride that goes around the Dingle Peninsula, along some of the most breath taking scenery that this country has to offer. So M.C asks Paddy and I if we want to enter the event with him as he's going to be participating. In true ABB form, I agree without asking any questions (you know, shoot first, ask questions later). I either didn't hear that it was 150 kms or figured that he was exaggerating.

I forgot all about the discussion until a few days later when M.C informed me that he'd paid my registration. Paddy was out because he was on call and couldn't get anyone to switch (how hard he tried is unknown!) Right, so at that point I started asking for details because the longest road ride I've done is ~70 km in Prince Rupert TWO SUMMERS AGO. He tells me it is 150 km and 8 days away, that was when I started to get really, really worried. This was compounded the day my roommie met M.C and uttered immediately afterward: you are so screwed! He looks seriously fit. Great. Thanks.

Thus began my week of fretting and bike riding. I did ~80 kms last Sunday, then two 35 km rides during the week. I had no idea what was going to happen but I figured I better give it a lash.

I did enjoy the carb loading part of the whole thing and took it to the next level...indulging for several days before the ride. You know--popcorn for dinner, hummus and crackers several times a day, granola by the handfuls...and chocolate mousse the night before (there are carbs in chocolate, right?)

A scene from the night before, all the food and water ready. And spare socks. Of course my riding shoes with clips were nowhere to be found so I busted out the sneaks. Awwww yeah.

First coffees, just after the summit of Connor Pass.

So there were two rides, one that was 110 kms and one that was 150 kms. We were doing the latter with about 40 other people, men in tights to be specific. Ok, there was one other woman doing the long ride...at least we think she was...a woman. If you note the biker in the background you'll get an idea of the one-piece spandex jumpsuits and waterproof clip booties that everyone else was wearing. All the long riders were SERIOUSLY decked out. We looked like we'd found our gear at a garage sale the night before, by comparison. Both M.C and I were also the only people wearing running shoes. We got some very disappointed and looks and clucks throughout the day due to our athletic faux pas of epic proportions!

And then there was the flat tire. The guy who stopped to radio the support car with a foot pump informed us that he hadn't gotten a flat in 4000 miles. We were undeterred though our place at the end of the line was definitely secured.

And then we got stuck behind some sheep. As you do, when you're riding the Tour De Irelande.

Some lovely scenes from the day.

The Blasket Islands.

The above photo shows the Irish version of a 'highway', and how wide a bike rider can expect the shoulders to be.

First lunches. And a latte from a road-side bus! This was my kind of race.

At the 95 km mark we decided it was time for ice-cream.

And a photo op of the old ABB and her bike.

Finally! Several hours, 150 kms, 2 pairs of socks, 2 lunches, 3 coffees, 1 ice cream, several rainstorms, and 3 pee breaks later we arrived back at the start. We had a really fun day, actually. I even managed to pull out my last bit of juice on the final summit and trash talked M.C all the way to the top.

And it was GREAT!!

I am so glad I did it. I love it when I surprise myself! Go Team Sneaks!!

Good News

2011-09-15T10:28:00.000-07:00

The best part of my day, hands down, was getting to tell a patient that her CT scan was clear, and that no further cancer had appeared in her abdomen.

As a nurse in the emergency department I often saw the test results before the physicians did. Many patients would ask me directly what the results were but I always had to defer and say that the doctor would be in to speak to them shortly. It was one of the things about nursing that irked me on a regular basis.

Today the chart landed in my hands and I called a bubbly woman in to the office. I asked what her referral was regarding and she informed me that it was for the results of her recent CT scan. She had a history of cancer in her abdomen and as I flipped through the chart trying to find Diagnostics I said a silent prayer hoping things would be normal. Found the report and read it out to her...everything was normal. As I read I could see in my peripheral vision her shoulders relax slightly from a hunch, and heard a breath escape with the movement. The relief on her face was a delight to me.

So much of our practice deals with pathology and telling people bad news that these moments of relief and reassurance, are a treat. I am grateful that I was able to start my career of telling people results with some good news.

Tiny Holes and Testicles

2011-09-13T14:05:00.001-07:00

So I knew, going in, that medicine wasn't glamorous. But sure, I love it anyway.

M.C has been giving me any opportunities he can to unleash me on patients and attempt my (now feeble after two years of atrophy) suturing skills. I learned a new tie last week and had a chance to suture up some trocar incisions. The piercing gazes of the O.R staff can be enough to make any steady hand tremble and I was kicking myself for not being smoother when he handed the needle driver over to me. It was only a few tiny knots in a couple minute incisions but I could feel the sweat starting to trickle while I worked it out.

Then yesterday he let me attempt hand-tying for the first time. Of course the anesthetist had to come out from behind the drapes to watch the show and the scrub nurse faintly jerked her head every time I made a mistake, but M.C let me persevere until I got it right. I just hoped that my damp scrub top at the end was from my nervousness and not from the hydrocoele fluid that I'd been sprayed with earlier in the procedure. I figured out quite quickly that practicing tying knots with a shoe string around a toilet paper roll is no substitute for scrotum and sutures. Go figure.

And speaking of testicles...I thought I saw plenty of man-bits when I was nursing...but oh no. Of course seeing testicles isn't anything new, but having to figure out what is wrong when someone comes in with a swollen one is something completely different. I find myself sometimes getting caught up in trying to visualize the structures under the skin while I am palpating the problem. I think the last thing you want as a male patient is a woman staring off into space, blank expression, ball in hand. Rolling.

So I am going to try and become a little faster and more methodical with that exam. Like everything else.

Only 2 weeks of surgery left, and then I ~~am off to ponder sodium levels and sliding scales for the next 9 weeks~~ start my general medicine rotation.

Theater tomorrow!

A Personality For Surgery?

2011-09-08T14:29:00.000-07:00

I don't really know what people mean when they say, "oh you've got the personality for surgery". Is that like having a face for radio? Because to me, that is what it sounds like.

When I think of surgical technologists and surgeons (apologies in advance to any who might be reading this) I usually envision an ego-maniac who likes to have hissy fits. Someone who is impatient, brusk, irritable, and cold. Granted, in the last while that stereotype has been opposed by many of the all-around-awesome surgeons I've met and worked with. Many of them well rounded, caring, hilarious, sensitive folks...really!

The other night myself and and handful of the junior attendings were out for supper and the registrar (a position equivalent to resident purgatory as far as I can tell) was going on about our astrology signs and when he found out I was a Leo he joked that I was the quintessential Leo. Now he's been around hospitals for a long, long time so I asked him if he thought there were specialties suited to certain Astrology signs (I am grasping at straws here people, I know that) and he laughed and said, "Do you mean, 'what should I go into because I am a Leo?'"

"Er. Yes." All eyes around the table fixed on me. Conversation stopped. Now I was feeling awkward.

"Well, surgery of course. Lots of Leo's gravitate to surgery."

"Why?"

"Because they are bossy and need to always be the center of attention!"

Ah, thank you. Yes. Well I suppose I did ask.

You're (Un)Welcome

2011-08-30T13:12:00.000-07:00

Hey, Alma Mater!!! Where is the love??

Thanks. For. Nothing.

Trains

2011-08-28T16:41:00.007-07:00

My sister informed me in a huffy way that it had been too many days since my last blog post. So, hello again, blog world, and hiya Dust!

The days just seem to be so long and groundhog-esque I start a post and think, "I am boring myself" and I close it. I've been doing that lately with emails as well, I'll spend half an hour writing someone an email and then I just delete it. It's mostly that I feel as though life has become quite one dimensional, it is a good dimension, don't get me wrong. I just fell uncomfortable rambling on to others about it.

It is also the pace of life these days unsettles me, like when you're on a train and think you're not really going that fast until another train passes going in the other direction. Suddenly the force, speed, and momentum is clear and almost frightening.

There have been a few trains going in the opposite direction lately.

I spent a good part of my morning with one of our palliative patients. She is a lovely woman and as she spoke about the impact of her recent diagnosis I made no attempt to hide the tears in my eyes. I used to be quite good at remaining buttoned-down with my reactions to patient's emotions (working in the emergency department gave me a lot of practice). She was just so open and honest with me, held my gaze, and for most of the interview gave me unflinching details of her ordeal. So when she cried, I did too. And I think it was appropriate. I have no idea though.

I also assisted with a below the knee amputation. That was my first limb amputation, having seen a great toe removed before. My normally jovial consultant (M.C) was thin lipped and quiet for most of the lengthy surgery. At one point he simply said, "God I hate doing these procedures." I suppose a surgeon simply cannot get the same satisfaction from amputating a limb, compared to cutting a cancer out, or removing a troublesome gallbladder.

But it wasn't the bone sawing or muscle slicing that I found unnerving. It was how quickly the patient reached for my hand and how tightly he gripped it before the anesthetic whisked him off to sleep. A couple of weeks ago I had met him, a broad burly man, who was gruff and a little abrasive. He wanted the procedure because it was going to improve his quality of life but I felt his reservations as soon as his giant hand engulfed mine.

So today, in an effort to slow things down a little I ventured out to the mountains and hiked in an area known as the Eastern Reeks. The ground involves a lot of bog walking and slippery rock negotiating. The forced concentration and good conversation gave me a much needed break from thoughts about the hospital and school.

An Irish Inukshuk?

I am definitely going to make an effort to get out at least once a week. Especially once my foot is completely healed. Yeah. It is possible that a 6h hike today may not have been what my ankle needed.

A long day outside was definitely what my head needed though. Also, the unwinding pace in a cottage with beer, a fireplace, and hot soup, was perfect.

A Perfect Day

2011-08-20T09:38:00.006-07:00

The orthopod I shadowed last summer used to bellow quite frequently, "A day without blood is a day without happiness". He loved his job and approached each of his cases with the excitement and wonder of a 7 year old boy who has just received a new Lego set. I used to think the saying was funny, if not a little crass. But I have to admit, I am starting to get it.

The days that I get to scrub-in for procedures always seem a little surreal and sparkly. It's odd maybe, but I love the ritual of scrubbing, gowning and gloving. I like staring at the angular instruments all laid out in precise order, the hum of the anesthetists buzzing around the patient at the beginning of the ritual, the bleeps from the cardiac monitor. I like having only my eyes, voice, and hands free to convey a message...the rest of my body covered up by various layers of protection. It's strange that I enjoy this controlled, anal-retentive world, because I also love being swept up in the unpredictable and ever-changing currents of the emergency department. Maybe I need to accept the fact that I will forever be a woman who likes extremes in medicine.

So yesterday I had the chance to spend the morning in theater, being a 1st assist on several circumcisions. It probably sounds banal to most people but at this stage it is all a new, fun, and nearly vertical learning curve.

In the afternoon I did histories and physical exams on some of our patients, and then went to the A & E to see a surgical consult who was a query appendicitis. I am always amused by the similarities between emergency departments in completely different countries. The controlled chaos, harried staff, complaining waiting room patients, limited stretcher space, tiny nursing stations, paramedics waiting to unload newcomers...it feels like home, even on the other side of the Atlantic.

It felt like a good day. I had no idea how good it was going to get!

There is a rather large Rose of Tralee festival (in Tralee, obviously) every year. It is sort of like a beauty pageant without the really dumb contestants and bikini portion of the show. Anyway, one of our classmates has a friend who is visiting for a few days from Canadia so we decided to do the touristy thing and check the scene out.

And what a scene it was.

We ended up in this old pub called Sean Og's (or something similar) with a large table right near the front. The place was bursting at the seams, mostly filled with 50-70 year old Irishmen. A few of us youngsters (heh) were enjoying the scene as well. Shortly after we arrived, a middle aged man with gelled hair and velcro shoes walked in, plugged his guitar into a sound system on the tiny stage (which also sat a large table of retired Irish tourists from Dublin) and proceeded to rock the joint for the next 4 hours.

There were several times throughout the night when all I could do was stare in wonder around the pub, full of people with glasses raised, singing in unison to everything from party songs like Galway Girl and Whiskey in the Jar, to traditional folk numbers such as The Fields of Athenry, peppy tunes like Las Vegas (The Hills of Donegal) and classic sing-a-longs like The Gambler and The Boxer. It was gritty Guinness-swilling-liberation song-singing at its finest. The one man band was killer, barely pausing at all between songs. At one point I was pulled up on stage by a geriatric Irishman to jive. Hands-down one of the best pub nights I've had in Ireland. My facial muscles actually started getting sore by the end of the night from smiling and laughing so much.

Oh Ireland. Sometimes I really do love you.

Scenes from an Irish Surgical Ward

2011-08-18T10:30:00.002-07:00

I went upstairs today to see if I could find my intern, Simon. There he was, filling out yet another cardex of medication orders. The poor guy does such a ridiculous amount of scut it boggles the mind, yet he always has a smile on his broad Burmese face. I am so happy that he's on my team.

We were discussing Mr. Smith's night time sedation as as his current meds aren't doing the trick. The Ward Sister warned that the night nurse would have a fit if he didn't settle again tonight. So as we hammered out some different strategies I leaned back from the nurses station to have a peak in Mr. Smith's room.

And there he is, sitting upright in a big blue padded chair, his tray table in front of him. An open bottle of Guinness is on the table and he's grasping a plastic cup almost empty of it's brown fizzy contents. He gives me a giant dentured grin and I remember how he looked last week, flat out in bed and sucking hard on the 10L non-rebreather mask. I thought he wasn't going to survive the weekend.

"Er.....is he getting...Guinness??"

"Yes, I think they prescribed it for him yesterday."

So I'd heard that it used to be common practice to prescribe the stout because it was so high in iron and vitamins, but part of me just dismissed that along with so many other back in the olden days stories. Like how my cardiologist grandfather used to round on his patients with a cigarette in hand and the nurses used to smoke at the desk.

But I saw it with my own eyes, today, and hell if Mr. Smith didn't look a lot perkier.

Then while I was taking bloods from another patient a cell phone went off and the ring tone was an Irish jig being played on a fiddle. At that point I wouldn't have been surprised to pull down the bed sheet to see the patient wearing wellingtons and a tweet jacket. Seriously.

I hope when I am practicing in Canada that one day I'll see a patient pouring maple syrup over poutine while a Celine Dion ring tone goes off. Wait, scratch that...a Neil Young ring tone. Otherwise I'll have to give more points to the Irish for being so...(quaintly)...Irish.

It's My Party and I'll get Cellulitis if I Want To

2011-08-17T03:10:00.001-07:00

If you've been reading this blog for more than 2 months then you probably know that I am usually a very casual dresser. In fact I have almost zero fashion sense and if left to my own devices I'd probably live in the sweat pants I bought in 2003, the zip hoodie from approximately the same year, and clogs.

The hospital has forced me to significantly lift my game in the wardrobe department and it has actually been enjoyable dressing like a demi-lady-doc (yes, I am implying that I am only a demi-lady and a demi-doc). The major downside has been footwear. Oh the footwear.

I wore heels the first week which caused some small blisters (I might add that these were well made and not cheap Campers that have rubber soles which means I don't have the annoying clickity-clack of heels in the long hospital corridors). The second week I thought I'd try flats (again, not the 20 Euro ones you can basically buy at a petrol station). These completely excoriated my feet into 'heel hamburgers' so I switched back to the heels. Yes, there is a reason I have devoted an entire paragraph to what shoes I have been wearing this month.

On Sunday, Kris and I went on a hike and I went prepared with moleskin and band-aids since my heels were still recovering and I was breaking in new boots. Only a tiny new hotspot appeared.

Until yesterday.

I was sitting in a videoconference and feeling these shooting pains up my leg. Ok, not exactly a new sensation in the past two weeks so I ignored it. The pain seemed to be intensifying though as the conference dragged on so during the break I decided to inspect my ankle which felt that it had been both assaulted with a baseball bat and sunburned.

Well that explains it.

So I showed it to my fellow med student who is also on a surgery elective and asked if he thought I had med-student-itis (wherein you think you have every disease you read about). He told me I should see a doctor and get on antibiotics right away. We brainstormed and web-searched the efficacy of me taking expired cephalexin (thank you India, 2008) and came to the conclusion that I should probably acquire some fresh flucillin. I did manage to have a quick review by one of the docs and started my antibiotics last night. Glad I didn't wait any longer though, by the time I got home at 1800h I could hardly weight bear on it.

For several reasons it had been a bit of a challenging day but the cellulitis was the icing on the 32nd birthday cake. I was feeling right sorry for myself. I probably would have driven to the airport and bought a one-way ticket back to Canada if it hadn't been for a 'chin up' chat with my mother, surprise cake / pressies from my roommate, and Tobie getting me to sign on to his FB account to look at some ridiculously awkward and lewd pregnancy photos that one of his friends posted. The man really knows exactly how to cheer me up.

Contrary to appearances I do actually have bones in my left leg and foot.

Today it is feeling a little better. Unfortunately Wednesday is one of our theater days so I had to sit out knowing I could not possibly stand still for 5h. My reg told me I could do minor ops instead.

Now I just have to find a pair of shoes that I can fit my 'cankle' into.

Randoms of the Day

2011-08-15T14:45:00.002-07:00

Today at lunch in the cafeteria I was reviewing the different types of physical diagnoses that can be made based on 'inspection of the faeces' (complete with photographs). Didn't seem odd to me until the Senior House Officer (SHO) joined me for lunch. He peered over my shoulder and shuddered when he saw what I was reading while slurping back my soup-of-unknown-components. I actually find the lost art of physical diagnosis riveting. I do.

--

I saw an SHO in the emergency department today wearing a scrub top (fine) with loose athletic pants that were 2 inches too long, dragging on the ground, with bare feet and flip flops (the opposite of fine). I am not the Emily Post of medical uniforms by any means but that was horrendous on so many levels.

On the subject of ridiculously unsafe and disgusting footwear I also saw a phlebotomist wearing open toed sandals on the wards today. WHAT?

That would never fly in North America. The infection-control-worksafe-auditing-psychos would be snapping their clipboards in half if they saw such a thing. I remember being told by an old manager of mine that I wouldn't be covered by WCB if I had a work related injury because my clogs had too low of a heel. Oh Ireland, sometimes your "it'll be grand" attitude goes a little too far.

---

I am getting my vertigo et al issues finally checked out tomorrow. Freaked that I'll hit the ground while holding a retractor in theater so I figured it was time to actually see a doctor instead of reading UpToDate. Here's to hoping I'll be able to rule out acoustic neuroma or other space occupying lesions, soon.

--

There is the most adorable little old lady on our ward having an abdominal mass and bowel resection done this evening. Initially she didn't consent to surgery (she is in her late 80's, after all, and not in the greatest health to begin with). She had fears that she would not make it through. It must be a terrifying decision to make. My registrar went and discussed things with her on evening rounds. She stuck out her wrinkled chin and said, "That is FINE. Do whatever it is you need to do. If I make it through I make it through, if not...well...so be it." But her voice did quaver a little. Her hair and skin were so thin but her eyes were bright and sharp. When the SHO poked his head around the curtain she saw him and pointed his direction, "Whatever that young man was trying to talk me into this afternoon, I'll do. Where do I have to sign?" It was funny and sad, and we all sort of chuckled awkwardly.

I don't know what it was but at that moment I wished I was her nurse who'd be there to talk to her once the doctors left, rather than the mute medical student who didn't even know her name. And I decided, I didn't want to watch her surgery. Even though normally I'd be itching to scrub in on a new pathology and procedure. I walked out to my car in the rain and was glad to shut the door to all of it.

---

Thanks to everyone who sent emails or wrote thoughtful and positive comments on the last post. I had the chance to make a great meal for friends on Saturday, then scamper in the mountains on Sunday. Both activities were much needed and much was gained in terms of perspective. As always, will keep everyone posted on how things are unfolding.

The Late Bird Gets First Assist

2011-08-13T05:14:00.000-07:00

Lows

This week certainly had its highs and lows but overall I'd say it was pretty good. The lows being that I didn't score as high as I'd hoped on the USMLE...as in, my score (especially as an IMG) is not strong enough for a competitive residency in the States. I thought about glossing over the bad, but badness is part of this journey and at the end of the day, this blog is really for me to look back at the things I went through to realize this crazy dream. And on Tuesday, it felt more like a ridiculous endeavor than a dream...as evidenced by part of my email to Tobie (a.k.a most patient and understanding man who puts up with my tantrums):

Thank you for trying to cheer me up but I am really feeling quite anxious / upset / frustrated about all of this and really there is nothing you can say that will change that, unfortunately. Every single day I think "what type of medicine will I practice"?? The stress of getting into post-graduate programs is immense and all the uncertainty makes things really difficult some times. So to me this grade has bigger implications than it might seem. Now I have to focus on Canada and hope to SHIT I get something, ANYTHING there. I am so tired of always being in this vantage point with my career. I don't feel like an incompetent or stupid person, but these hurdles make me feel that way. It really makes me question why I am doing this. Maybe I was meant to stay a nurse, maybe I don't have the brains or the skill for all of this after all and I've made a GIANT mistake and put myself HUNDREDS of thousands of dollars in debt over this [expletive] ego driven escapade.

I'm sorry, I am just so tired and working so hard...ALWAYS...it seems. I just would like something, sometime, somewhere to be easy, or rewarding. And I am just at the end of my rope today. I am hardly going to get to touch a patient here...[insert litany of curse words]

Part of the issue is that I am applying for electives in Canada right now, the only electives I'll have on my Canadian residency application (due Oct. 2012). Programs like to see that you are committed and settled on a specialty so it looks much better if you've done your electives in that area. Well, this homegirl is still trying to decide between current top three:

-surgery
-emergency med
-obs/gyn

Egad.

Meaning my application pretty much rides on Canada now and the hope that my assortment of electives doesn't make me appear to be a flighty, indecisive, gamble to my future residency program!

So that was the low.

Highs

My registrar and I have hammered out a couple of ideas for a research project together. At some point over the weekend I am going to look at the literature already out there, but I think it will be an interesting prospective study (or two) with the potential for some hospital policy recommendations. A small knot in my stomach loosened when that conversation was over. The anxiety over our year 3 research projects for school (and the constant reminder that we must have some published research under our belt for residency applications) was starting to give me an ulcer.

The other high points of the week included

-the purchase of a new cardigan (I really never thought I'd write that sentence ever in my life)
-discovering a very delicious and reasonably priced Thai restaurant (score!)
-getting to be a 1st assist on an open appendectomy (cue Hallelujah chorus)

The surgery was fun as always, with the unexpected bonus being I was the only other medical-type-person scrubbed in for the emergency appy that happened in the middle of the night. I had seen the patient in the afternoon following the surgical consult from the emergency department. My registrar (reg) wanted to take him to theater right away but since he'd had fluids recently the surgery had to be postponed until later in the evening. At 2300h I was still waiting for the call from my reg and wondering why I said I'd go in on a Friday night to watch a laproscopic procedure. But it paid off when I finally got the call after midnight and was told to scrub in. As the locum consultant (L.C) and I waited for the patient to be ready he asked me "So have you operated the scope before?"

"Er...once on an ACL repair..."

"Good, you'll be the camera woman tonight then!"

Eeep!

I was surprised that my reg wasn't there, because it meant that it was only myself and the L.C. doing the procedure. The scope handling takes a little getting used to and I could feel the scrub nurse itching to grab it and demonstrate (I wish she would have)! In the end it was a complicated removal that required the surgery to become an open rather than scope procedure. Eventually the reg did show up but he didn't scrub in, choosing instead to float around and watch things unfold. I was relieved to have someone else there because really, I am *not* the copilot you want in theater at 2am if things go south! Everything turned out fine for the patient and just after 0200h I drove home still buzzing a little from the excitement. Though I was starting to feel the length of my day, which had started at 0615h.

I got home and was very happy to see my big white fluffy bed. And as I gave in to the exhaustion I couldn't help but think of the weeks highs and lows...and one of my favorite passages from "The Prophet",

When you are joyous, look deep into your heart and you shall find it is only that which has given you sorrow that is giving you joy.

Indeed.

Me Med Student, Me Watch Things and Do Nothing

2011-08-09T11:38:00.003-07:00

Today I went to Middle of Nowhere (MON) Ireland for a rural lumps and bumps clinic. I really enjoy the outings to the country, hanging around the little hospitals, and seeing the old farmers who drive in on their tractors (true story). I had the chance to see a nice variety of patients: from swallowing difficulties to sebaceous cysts, urinary retention to infected toe nails. For me the real fun is with the procedures so I had to sit on my hands all day. Naturally I jumped at doing dressings or applying pressure to the odd excised mole lesion. Hey, that is how I need to get my kicks these days. Sigh. MC actually told me last week to stop making the beds between patients. Old habits die hard, I guess.

My registrar (I.S) and the locum consultant are both Muslims so they are currently fasting for Ramadan. This means that I.S gets up at 0315h to eat and cannot have any food or water until after 2100h. So today when he offered to buy me lunch I had to decline--I was definitely not about to scarf down a giant lunch in front of him after hearing his rumbling stomach all morning. I guiltily ate an orange in the hour long ride back to the hospital instead. It was 1430h after all, and despite the fact that most days it feels like I am fasting at the hospital...I am not obliged to.

Today's clinic reinforced that being a medical student in Ireland is way different than being a medical student in Canada. I suppose the main reason is over here, when one graduates one is allowed to test the waters for a bit longer, in Canada one is thrown into the pool at the deep end.

For example, I was chatting to the surgical intern yesterday at lunch and I asked him what clinical skills he can perform here at the hospital: IV cannulation (though mostly Senior House Officers [SHO's] do that), catheterization, and blood draws. He has never scrubbed in for a single surgery and likely will not have the chance to this year as he is on call for the wards and spends his days doing scut (writing discharge orders, medication charts, ultrasound requisitions, etc.). After an intern year, one becomes an SHO and does a little more, like admit patients, start IV's, mix and administer meds, maybe hold the odd retractor in surgery.

When I told him that medical students do all those things, plus skills like intubation, arterial lines, and suturing he almost choked on his egg roll.

Needless to say medical students here are to be seen and not...well...heard, unless they are being pimped, in which case the responses should be quick and confident sounding.

I know that I chose to sign up for this training but frankly I am a little worried I'll lose the skills I learned as a nurse such as cannulation, catheterization, blood draws, arterial blood gases, and suturing. Never mind the fact that I'll be hopeless at case management, creating care plans, admitting and discharging patients. Hopefully I can cram as much of that type of learning into my Canadian electives over the next two years...

Tomorrow brings a couple of long theater (O.R) cases so I must hit the books and Acland videos. Here's to hoping for light pimping, kind scrub nurses, and no lead aprons.

Week Two: Objectives

2011-08-07T04:55:00.002-07:00

It's now Sunday afternoon and I'm quite smug about the fact that there is a ridiculously tasty pot of chorizo, chickpea, chicken, barley, and veg soup simmering on my stove. It is part of my objectives for the upcoming week which include:

-eating proper food as opposed to scarfing down (in the washroom) warm string cheese that has been sitting in my purse all day
-fruit (yes, that is an objective)
-exercising (ok that might be a bit of a hoop dream)
-keeping a log of what patients and presentations I saw (oh right, that one is a course requirement)
-going to bed earlier (and not watching Parks and Recreation reruns until I am almost comatose)
-actually looking up the answers to one of the 1000 questions I have lingering at the end of the day

I do love surgery. I wish I didn't. Even the tedium of holding a VERY large and awkwardly positioned retractor for hours on end doesn't deter me. I got to see how a stoma is made and how to reconnect loops of bowel following a resection. These are important life skills as far as I am concerned.

I just wish it was the days of olde when surgeons were trained as apprentices because I have lucked out with some great master barbers! Mind you, if I were living back then I'd probably be a serving wench, wet nurse, or prostitute...so...maybe I should count my blessings.

Conversation During Clinic: Pimping

2011-08-04T11:52:00.005-07:00

My consultant (MC) and I saw around 80 patients today in clinic. And I was in heels. Wow, when I was nursing I really took for granted the privilege of wearing scrubs and runners to work!

Needless to say there wasn't very much talking between patients, but one brief exchange did occur which cracked me up...

MC was trying to describe one of his colleagues to me, when I figured out who it was the conversation went like this...

Me: Oh right, I know the guy you mean. He's the one that pimped me on my first day and I had NO idea who he was!

MC: What did you just say? He what you?

Me: "Pimped", wait, er...you don't know what pimping is? Didn't you go to Hopkins? Surely they talked about "pimping" there!?

MC: Isn't that like, a pimp, someone who has...you know...

Me: No no no...'getting pimped' means 'getting grilled' in front of patients or other medical students. Like when you ask me what the collateral blood supply is to the rectum. That is pimping. I can't believe you haven't heard that term--especially at Hopkins. Hang on, you were a Fellow so you'd have been the 'pimper' not the 'pimpee'.

MC [grinning madly]: So I was pimping people at Hopkins and didn't know? Wait, is that bad then that I pimp you?

Me: No, it's your job.

MC: Oh, ok, good to know. Pimping. Huh!

And thus concluded a conversation I never thought I'd have with a consultant surgeon.

First Day of Surgery Rotation, Take 2

2011-08-03T14:09:00.000-07:00

So the conversation yesterday went something like this:

My Consultant (MC): So, why did you choose this part of Ireland?

Me: Because I miss the great outdoors and as far as I can reckon this is the best part of Ireland for hiking, biking, swimming, surfing, walking, climbing...

MC: My wife is part of this walking group that meets every Tuesday, you should go with them sometime. It'd be a great way to explore the area and find walks* that would never be on a tourist map.

Me: Yeah, that'd be great. I'd definitely like to do that... [In my head adding...in a few weeks when I am settled].

--Fast forward several hours. I am sitting in our video conference on anesthetic assessments and my mobile rings, I am not going to take it and then I see that it is MC calling. YIKES! So I grab it and run out of the conference.--

MC: Ok so my wife is going to be wearing a pink NIKE hat, driving a silver VW. She'll meet you at the Windmill parking lot at 1820h, do you have a pen? here is her number...

And so it was.

I know, I know. It sounds like a ridiculously gunner move but honestly, I thought it was really nice of him to set it up for me and I didn't want to seem like some outdoorsy blowhard who is all talk and no action. Also, was it a test?? I really don't think so, but I thought on my first day I did not want to seem like a flake. So I went.

And it was wonderful. Aside from the ring of geriatrico-hiking-psychos that cornered me at the beginning and created a chorus of 'tut tut's' over my footwear (runners). There were about 10 of them that surrounded me and started chastising me for my poor ankle support, lack of foresight, poor decisions...I offered to hitch a ride back to town when MC's wife piped up in my defense, "But she climbed Carrauntoohill last year in them and was fine!!" They finally dispersed with a collective head-shake and we were off!

We went to the peak on hikers right, just above the head of the lady in the foreground

Possibly the clearest night I've seen in Ireland. About 1/2 way up.

All retracting and no play...? NO WAY!

I couldn't take any photos from the top because it was almost dark so we were busy trying to get down as fast as possible. Yes, the sneaks held up and I made it out in one piece despite my "complete lack of ankle support!"

And thus concluded my first day of clinical rotations. Hope I didn't peak too soon!! Heh.

*When people use the word "walking" here they often mean, "hiking". Turns out.

First Day of Surgery Rotation, Take 1

2011-08-02T15:59:00.000-07:00

It is 2355h and I walked in the door about 20 mins ago. I've only just finished scrubbing the layers of peat moss and bog water off me (long story) but I thought I ought to give a quick update.

Surgery=AWESOME

I have the privilege of being with a surgeon who is not only talented but nice. He's got a great team and I think I am really going to have a fabulous experience.

Really excited. And happy. And relieved.

Until tomorrow...good night!

Into the Fray

2011-08-01T15:06:00.000-07:00

So tonight is the eve of starting clinical placements and my 3rd year of medical school. Just found out I have the wrong shoes for theater (no sneaks or crocs, only clogs with a heel). So I'll be starting off with an inappropriate-footwear-bang!

I've gone through my entire wardrobe trying to find something that is summery-yet-appropriate-and-comfortable-yet-stylish. I do not own anything that fits all of those categories.

I am someone who is always to hot (which is why it is a good thing I came to Ireland over the Caribbean, tomorrow's high: 9 degrees Celsius. No joke). I don't want to be the medical student who looks like she's having a hot-flash tomorrow. Yet somehow the best outfit I could come up with were wool-blend pants and a wool-blend sweater. Nothing else seems right because I want to be as understated as possible tomorrow when I meet my team and Mr. Surgeon. Yes, in Ireland (and the UK, I think) the surgeons are Mr.'s not Dr's. Another odd quirk, like the hot and cold taps.

So, I am nervous and excited. My appetite has been gone for the past few days (which is probably a good thing after fat-camp all summer (a.k.a "studying for the USMLE").

On the upside, the blog fodder will hopefully improve as reading a blog about someone who does nothing but study isn't exactly gripping literature.

Fingers crossed things will go well tomorrow. I've been looking forward to being back in the hospital for so long--I just hope this part of the course will live up to my expectations. I remember so clearly when I was back in pre-req hell and typing up a physics lab, stumbling on Old MD Girl's blog while she was in her clinical rotations. I wished there was some way I could teleport myself to that place in medical school. And now I am here! In my wool suit. Look out world.

The Blackbear Has Landed

2011-07-29T16:55:00.003-07:00

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

2011-07-27T19:29:00.000-07:00

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

2011-07-23T21:56:00.001-07:00

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...

2011-07-20T22:40:00.001-07:00

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

2011-07-16T20:29:00.000-07:00

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

2011-07-15T20:08:00.000-07:00

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

2011-07-13T17:59:00.010-07:00

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

2011-07-12T07:58:00.000-07:00

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

2011-07-07T13:33:00.004-07:00

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

2011-07-06T14:59:00.008-07:00

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

2011-07-05T12:47:00.005-07:00

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

2011-07-03T22:56:00.000-07:00

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

2011-07-02T23:50:00.002-07:00

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

Don't You Love It?

2011-06-29T14:31:00.001-07:00

Don't you love it when you spend all afternoon doing a randomly created practice test and your computer crashes thus making you lose the information, ability to find out the answers, and your mark???

Arrghhhhhhhhh!!!!!!!!!!

[Kicks something, hurts toe, regrets kick.]

12 Things My First Triathlon Taught Me Today

2011-06-26T20:56:00.003-07:00

1. Being flat chested is a blessing when you're running in a bathing suit.

2. You care a little less about the rain when you're running/biking in a swimsuit...because a wet t-shirt makes you feel like you're in a bad beer commercial from the 80's but a wet bathing suit makes you feel like...you're in a wet bathing suit.

3. When in a swimming pool, the three sweetest words on the planet are not, "I love you" but in fact, "one lap left".

4. Grey hair and pot-belly do not a slow swimmer make.

5. The only thing more crippling than the foot arch cramp of doom in the pool is the calf-muscle cramp of death on a bike.

6. Energy drinks do not provide energy.

7. Even though they say it to every single person going past them, when a stranger yells, "you're doing great! Keep up the good work!" the world seems a little brighter, for about 5 seconds.

8. It is hard to put socks on damp feet, fast.

9. Sports gels taste pretty much the same going down as coming back up (though they are slightly less viscous, which is pleasing).

10. "Swimming pool" = "water torture".

11. My older siblings are still kicking my ass at everything in life. (Except blogging. I have mad blogging skillz. And I tweet, so BOOM. IN YOUR FACE SUCKAS!!!)

12. You never notice the helping hand of a tailwind but you sure do feel the bitch-slap of a headwind.

--

Expect a complete, boring, sports-interview style breakdown of the triathlon tomorrow when I have recovered from the full body tetany which I am currently suffering from.

In the meantime I'll just say that I had a great time out there, I gave 110%, and the best offence is a good defence. Or something.

WOOT!

Pre-Race Terror

2011-06-25T14:12:00.002-07:00

So...tomorrow is my first triathlon and I must admit, I am going through waves of nausea, excitement, and pure fear right now. This morning four of my nieces and nephews were in the kids race which proved to be highly entertaining. The first group were the 5 and 6 year olds...so hilariously awesome I almost had a maternal urge! Half the time they'd come out of the pool and forget that they were supposed to be running to the bike zone. Like this little gang pictured below, they were sort of sauntering and having a chat until some of the parents starting hollering, "RUN!!" which is when they picked it up a notch.

Oh right! We're in a race!

My niece, Rachie, actually won the girls, my nephew Aidan came second for the boys, with Luc and Taylor also in the top ten. Pretty amazing.

Rachie coming out of the swim--it was cold at 0900h this morning!!

Aidan, just one giant fast twitch muscle.

Rachie nearing the finish line. Probably thinking about Justin Bieber.

Aidan looking prepared for combat and finishing the ride.

Luc (my Godson whose birth I attended--making me feel very old) is the football player of the family.

Taylor finishing the run.

Taylor looking frighteningly like a mini-me of my brother!

Random child who wandered onto the course when his older sister started approaching the end of the race. She just started laughing, picked him up and ran across the finish line with him. TOO CUTE!!

Aww...what can I say? I am a proud Auntie!!

The scary part was seeing all the totally ripped parents along the sidelines--where did all these uber-fits come from?? I felt like the fat kid at summer camp who developed a sinking suspicion that I will get my ass handed to me tomorrow. I know, I know...it is supposed to be fun--which, er, I hope it is fun and not humiliating!!!

I must say though, the kids were totally inspiring. When I was that age I was a total butter-ball whose main activities included watching satellite t.v and hiding my fathers cigarettes so I could sell them to the junior high kids at school. Seeing how athleticism is already such a central part of their lives is so wonderful (though it makes me a little sad that I didn't get into sports until later).

Also, did I mention that I was tricked into this race? My brother in law called me up and said that all my siblings/their spouses were doing the race, so I should do it as well. I reluctantly agreed and then when I came home last week I found out they are all in teams!! I am the only one doing the whole thing...ok, ok, I will stop whining now and get back to my studying.

Well at least tomorrow I will be able to make a line on my bucket list! Wish me luck!!

New Irish Digs

2011-06-23T15:58:00.002-07:00

So, life as I know it back in Ireland is about to change quite a bit. If you've been reading for a while you will know that I am (not officially) done with pre-clinical medicine. Provided I passed the recent exam gauntlet, I'll be starting my hospital rotations on Aug 2nd in a new city (and not a moment too soon, honestly I think I am about to get 'office chair' sores from sitting and staring at textbooks all day long for the past two years.)

Pretty sure that for every month of pre-clinical medicine in the world an angel loses it's wings.

Anyway, I know very little about my new city except that there is a decent coffee shop, a giant Tesco, and no yoga studio. Well, 2 out of 3 ain't bad I suppose. My casa novo is about 7kms out of town on some crazy Irish road (and by 'road' I mean 'ruts wide enough for a carriage') and I love it.

It's so CUTE! Don't you just want to pinch it's cheek?

Front 'mud' room. Plenty of room for all my raincoats.

Front hall. Riveting isn't it?

Yes, yes I will be drinking cosmos* in my scrubs after a long day of holding retractors!

This is the view from the chair where I will be drinking said cosmos.

Oh hello, furniture that isn't made of flame retardant pleather! It's about time!!

Two words: gas stove. BAZIIIIIINNGG!!

Laundry room off the kitchen, complete with toaster. There is also a small bathroom attached. I think the drying rack really ties it all together.

Guest room with ensuite. Never thought I'd have a giant felt flower in my home.

Guest room bathroom. Can't you just hear the Zamfir pan flute music that I will be pipping into the room when there are visitors?

My room. I like to sleep in bedside tables.

View from my room.

Kristina's room. She prefers a bed to sleep on, that is why we are so well matched as roommates.

Upstairs bathroom.

Kristina realizing she is tiny enough to live on the landing.

Across the street. Awwwww yeah!!! No annoying kids shooting hoops while I am trying to sleep off a nightshift!

View from the 'road'.

Needless to say, now that I am out of student accommodation people are actually considering coming for a visit! Kristina is only staying for a semester so not sure what will happen after Christmas. Maybe I'll turn it into a B & BYO Breakfast or something and charge 200 Euro a night. We'll see.

The part that I am trying not to think about is that young Tobington will not be living there with me. Because I mean really, what could be more romantic than living in a beautiful new house in the Irish countryside together?

Apparently living in separate countries. Le sigh.

---

*I don't actually drink cosmopolitans usually, I am more a dirty martini kind of girl, but I think the pink livingroom is going to drastically increase my consumption of beverages topped with tiny umbrellas or large pieces of fruit.

Two Clues...

2011-06-20T09:31:00.002-07:00

Looking around my study room today I couldn't help but notice two clues that I am back in Alberta.

Oh how I've missed the Old Country. Heheh.

Can't complain, though...my brother-in-law has kindly let me take over the Man Room for the next four weeks--sweet view, fireplace, and couple of bear skins included. Woot!

---

Update! As per OMDG's comment... :)

Can't believe I didn't think of that! hahah

I'm doing the right thing, right?

2011-06-19T19:59:00.003-07:00

[Warning: there are some dissection pics in this post which may be unpleasant / revolting for some of you to look at. Or they may pique your interest at what lies beneath our largest organ...]

Exam week was probably the most mentally exhausting 4 days I've lived through, to date.

I'll just break it down.

Day one, morning--2h long answer section. Questions ranging from anterograde and retrograde amnesia and why they occur following head injuries, to different types and causes of pleural effusions, to describing the association between tissue transglutaminase and celiac disease. Good times, oh, good times.

That afternoon--100 extended matching questions. I've already ranted about that so I'll just say, wow it felt like an anatomy spotter without the pictures. Weird.

Day two: off. Which meant 'studying ass off for remaining two exams'.

Day three: take 2 years of clinical sessions ranging from skills like 'taking an alcohol history' to 'abdominal examinations' to 'suturing' to 'IV cannulation' to 'breaking bad news' and create an OSCE of HELL involving 19 six minute stations complete with actor patients and physician examiners. You have one minute to prepare before each station where you are given a one-liner like, "Mrs. McDowell is here with her 20 month old to discuss developmental milestones" or "you are at the GP surgery and suddenly a man in the waiting room collapses".

Overall I'd say the OSCE went well, aside from some major facepalms...like forgetting to take the respiratory rate in the respiratory exam, saying the phrase, 'do you have any more questions for me?' about 25 times during the double (12 minute) motivational interview for smoking cessation station!!!

Day four: Take 900 histology slides and approx 4000 anatomy slides and choose 50 spotter questions.

Some examples:

If "A" was damaged during a surgical procedure which of the following might occur?

a) Horner's Syndrome

b) paralysis of cricothyroid

c) paralysis of cricoaretynoid

d) paralysis of pharyngeal constrictor muscles

e) inability to adduct glottis

f) inability to abduct glottis

g) chylothorax

[Buzz!!! NEXT STATION]

[Buzz!!!! Next STATION!!!]

And so on...you get the picture!

By the time the spotter was over all I wanted to do was crawl into a sensory deprivation chamber and stay there for about a week.

Instead, Tobie and I went and had Ayurvedic head and foot massages in this beautiful clinic outside of town. It was lovely, though I wish I could have afforded a head-to-toe treatment. While I was sitting there sipping dandelion tea in the dimly lit and beautifully scented room, listening to classical Indian music, I couldn't help but wonder why I chose to throw myself into a career where I will most likely be under the glare of bright lights, with the clamor of overhead pages and monitor alarms as my soundtrack.

My prayer for the day: please God, let all of this be worth it.

--

Answers (to anatomy related questions, not existential life ones) can be found in comments.

Study Chuckle of the Day

2011-06-18T19:20:00.001-07:00

Just going over a few practice questions today while waiting for din din to be ready.

Came across this explanation in my gunner training which made me chuckle, and love gunner just a little bit more...

After reading answer explanations for over an hour I almost missed it. Seriously, it makes me want to write a textbook just so I can surreptitiously add commentary to the content.

The Mug

2011-06-18T16:32:00.001-07:00

As a 'congrats on finishing pre-clinical medicine' pressie, I had a personalized mug made for my study-buddy-brotha-from-another-motha, Ryan.

It turned out even better than I had anticipated. He got me a silver ring with BEARS on it (albinoblackbears, naturally) as a little good-luck charm for the USMLE. I am predicting that I will have a borderline allowable amount of jewelery/good-luck charms on during the exam.

I wish I had my lucky t-shirt (somehow sold/lost/stolen in one of my many moves) for the big day. It was Lucy from Peanuts running with a giant syringe in her hand and it said, "Mount Royal Nursing" on it. I didn't go to MRC but the cartoon was killer.

Indeed.

Still Alive, With Questions

2011-06-17T21:59:00.000-07:00

I am still alive, have not thrown myself into the Majestic River Shannon or anything. Just been packing, sorting, moving, driving, packing, driving, flying, unpacking, sleeping.

And I have some burning questions that need to be answered:

1) Why is there always ONE guy in every airport departure lounge with a bluetooth talking 'business' in the loudest voice possible? Why is someone named 'Roger' always 'cc'd on the email' and 'crunching numbers'?

2) Why is it that whenever I wear a white shirt I suddenly lose motor control of my lower lip when eating?

3) Why is it impossible to fall asleep after being awake 24h?

4) Why is it, despite my best intentions to be more organized, every time I move there is always a few boxes at the end which contain a smattering of cleaning products, textbooks, underwear, spatulas, highlighters, hair products, face cloths, and organic quinoa?

5) Why are yoga instructors always ridiculously gorgeous and in perfect shape?

6) How am I going to survive two years living in Ireland without Tobie?

7) Why do airplane movies always make me cry?

8) Why did I think doing a triathlon this summer was a good idea?

I am actually working on a for realz post right now about the HELL week that was exams. But for now, I leave you with the questions I have been pondering for the last couple of days.

A (Not So) Beautiful Mind

2011-06-12T17:13:00.000-07:00

Tobie came in my office recently and commented that one of the other residents in our complex might call campus security as my office window was looking a little too much like an unfolding psychotic break.

I figured, until I started drawing lines between the scraps of paper or taping up magazine clippings I was safe.

Ok, I'll concede. It is slightly creepy looking...

She Be Chillin'

2011-06-09T09:22:00.000-07:00

She's goin' in the fridge, folks. The end is in sight!

1/2 Way to being 1/2 Way

2011-06-09T07:38:00.002-07:00

Ahhhhhhmmmmnnnnnn. [Loud exhale].
So the extended matching exam and long answer are behind me. I feel, meh about them. I felt like it didn't test our breadth of knowledge, but instead had very bizarrely chosen depth of knowledge questions. Like how much you knew about otosclerosis treatments or the theories behind why anti-depressants work (no, not mechanism of action, theories).

And other random things like, for example, on a 100 question exam there were 5 questions on different terms for heavy / irregular menstrual bleeding. Seriously? Seriously. It was that important for the school to assess if I knew the difference between menorrhagia, menometrorrhagia, and metrorrhagia??

During the year we had several cases involving lady-bits including pregnancy, infertility, PCOS, premature delivery, pregnancy induced hypertension, gestational diabetes, dysfunctional uterine bleeding...and then, 5 whole questions on bloody nomenclature? Nothing else? That was how they tested our knowledge of the ever-so-complex-involving-too-many-hormones-and-bits-diseases-childbirth-richly-innervated-many-muscled aspects obstetrics and gyne? Le sigh.

And while I am venting...

What was with the 10 questions on which muscles were eccentrically, concentrically, or isometrically contracted during each phase of the gait cycle? I thought the anatomy spotter was on Friday? Grrr...

Nothing on diabetes, heart disease, endocrinology...nothing. Ah well. It is over now! I just hate it when it feels like the test wasn't that applicable to the things the course really focused on. Like an entire long answer question on otosclerosis!? And another on the anti-gliadin antibodies in Coeliac!? Annoying.

Ok enough prattling on--all that is left is OSCE and spotter. Then...FIN!

Must Be Finals...

2011-06-05T13:16:00.004-07:00

Yesterday on the way to practice OSCE* crap, I started driving in the opposite direction of my study buddy's house (a drive that I could literally do with my eyes closed, I've done it so many times).

I picked up my deodorant and toothbrush and was 1 inch away from putting the former on the latter to brush my teeth before I realized what I was doing.

And in new grandiose feats of procrastination: I did a tray of home made pita chips, vacuumed the ceiling**, and read up on the Moken Sea Gypsies of Thailand.

Must be finals
Must be finals
Must be fiiii--iiii--nnn--aalllssssss
[Sung to the tune of "Must be Santa".]

*OSCE's are "Objective Structured Clinical Exams" pffft. Too bad they are the farthest thing from it.
**I wish that was an exaggeration.

Medical Gods Give Me Strength (and a photographic memory, please)

2011-06-04T15:37:00.002-07:00

When I get really whiny about how hard it is to try and remember 2 years worth of curriculum I try to remind myself of the fact that it is a priveledge to study medicine. Really, it is. I know that there are hundreds (thousands?) of people that would gladly trade places with me this instant if it were possible.

This normally gets me re-motivated to try and remember things like the stages of herpes infections.

Not today. Partly because my exams for school start in 3 days and partially because I still have forty three more groundhog days of picking my clothes up off the floor and padding into an office at 0630h, only to emerge for feedings and the odd burst of exercise, then collapsing back into bed at midnight. Wicked pisser summer, hey??! Yep.

I chose this. I chose this! I chose this?!?

---UPDATE---

Just as I was writing the last sentence, Tobie returned from the Farmer's Market with gifts for me!! Ok, before you all start going "awwwww" I will point out that as he was leaving I asked him to please get me some presents because I was losing the will and that I would reimburse him for any expenses said presents would incur. And so, I am now the proud owner of the Joseph Joseph Chop2Pot Plus cutting board!! Yippeeeeee!

The way to this girl's heart is through kitchen gadgets.

He also got me my favorite (though normally banned from consumption due to the fact that it is pretty much PURE BUTTER AND ALMOND) croissant from the bakery, and some organic kale from our favorite local Herb Man*. So that got me through the evening. He's pretty sweet alright and wouldn't let me pay him for the gifts after all. I think I must be getting hard to live with these days because last night I was tormenting him about something to which he said, "don't you have to go and memorize a bacteria or something??"

Yes, yes I do.

Back to it!!

*No the end of that sentence is not a euphemism for other green leafy substances...I need every brain cell I've got at this stage of the game.

Today's Mnemonic

2011-06-03T00:10:00.000-07:00

I am beginning to become cross-eyed with mnemonic's right now. Especially some of the dumb ones that are provided in the study guides, like

"Queen Barb Steals Phen-Phen and Refuses Greasy Carbs Chronically" for all the P-450 inducers (Quinidine Barbiturates Phenytoin Rifampin Griseofulvin Carbamazepine, Chronic ETOH, St. John’s wort).

Ok, on second thought, that one isn't the best example because it is (somewhat) reasonable. But I can see myself on the exam, when my brain is flat-lining with stress going, "something to do with queens and grease...?"

Today was cardiac day. I came up with this for remembering EKG* patterns:

TRANSmural infarcts are ST elevation because TRANSvestites like to wear heels.

Subendocardial infarcts are ST depression because SUBs go down.

[Insert slow clap, please.]

*Apologies to those of you that get all scrunched up when people use the "EKG" instead of "ECG" acronym. Yes, yes I know we aren't in Germany anymore but it is my way of making permanent tribute to Einthoven...I mean really, the guy shot melted quartz on the tip of an ARROW to make the first EKG wires people...an ARROW. When I learned that I decreed, "and from this day forward I shall call it, EKG."

No that is not a chef getting a manicure on his lunch break.

Becoming A Gunner

2011-06-02T09:31:00.002-07:00

Apologies in advance for the brief post!

My office is starting to look like a scene from Shaun of the Dead, (actually come to think of it, I am starting to look like a scene from Shaun of the Dead) but I wanted to quickly put the word out to those of you who are deep in the trenches of USMLE hell, like me.

Last week I got an email from a reader about this USMLE prep site that I hadn't heard of, gunnertraining.com.

Anyway, I signed up for the free 1 week trial and LOVE it. It has all the same things that USMLE World and Kaplan but some interesting features that are unique--like these amazing flash cards that distill everything down to the bones and then test you. It's a nice compliment to the multiple choice format as it forces you to recall (because you type the answer in for the quiz parts) rather than just guess or use the answers to prompt.

I'll write a proper post about it when this week is over, but in the meantime go check it out. You can get a free one week trial to nose around the site. I figured many of you are getting close to the finish so I wanted to put the resource out there as fast as I could.

Now that I actually have an account I can give out free 1 month trials so:

http://www.gunnertraining.com/free_trial/1858779

Knock yourself out, kids.

Back to it!!!

Things I've Learned This Month

2011-05-31T09:37:00.007-07:00

1. The pool is actually not the most horrifying place on the planet. Close though.

2. I am motivated by little green lines. And little orange ones, turns out.

Green on days I trained, orange on the days I studied biochem.

3. Cinnamon and cloves actually taste really good in Latin soup recipes. Not freakishly odd like I anticipated.

4. 1st years like to buy useless textbooks off 2nd years. Mwahahahahahah.

5. I may not drown in the swimming portion of the triathlon in 3 weeks. May not.

6. I may actually pass the USMLE after all, heck, I might even get a respectable grade on it.

7. I suck really bad at medical genetics. As in, 0% on my full length practice exam I wrote on Saturday.

8. With a (fledgling) beard, Tobie looks a bit like a guy who has been working on his first novel for 7 years. One that will have limited sales but will be critically acclaimed.

"I just can't get the ending right..."

9. Queen almost didn't put "Another One Bites the Dust" on the album, The Game, because they all felt lukewarm about it.

All of us ~~suckers~~ volunteers in the Himalayas reading Mortenson's book.

10. Greg Mortenson is a lying, thieving, conniving, power-tripping, intimidating, swindling, falsifying, Big. Fat. Fake. If you'd like to read to what extent, I recommend Krakauer's essay, Three Cups of Deceit. He gave it a more politically correct title than I would have. Krakauer is classy like that. And a babe (for an old guy).

Soon, Grasshopper...Soon.

2011-05-30T01:15:00.002-07:00

Two of four core homegirls.

What gets me through the dark study hours is knowing that I will once again be on the other side of a beer with those ladies in a few short weeks.

Le sigh.

Our Own Little Strange Acoustic Flash Mob Bette Midler Style

2011-05-27T14:28:00.007-07:00

Okay so maybe the title was a little long and self-indulgent, and maybe I should be studying for my mock full length USMLE exam tomorrow morning, but...meh...the canker sores in my mouth and recent surge in nocturnal teeth grinding tells me I could probably use a night off.

Besides, how can I study for the USMLE when I am still buzzing with school-girl-giddiness from our little strange home grown acoustic flash mob (if that is what you'd call it) performance we pulled off today?!?

To set the stage, it was our last anatomy class*, designed as mostly a review session. Prior to class we rehearsed about 5 times with a handful of people who agreed to be a part of it. All of us were absolutely vibrating in our seats for the whole session, anxious for the cue to start. We told the other faculty and Dean that it was going to happen at noon and they gathered outside in the hall. We had already distributed little flags with a picture of his face on them (see photo below) and sheet music.

Anyway, I'll let you watch for yourself...it starts a bit rough but I figure we pulled it together nicely by the end.

He was definitely surprised, and even a little teary, I think. I've probably watched the video about 30 times and just can't get the grin off my face. It was an absolute blast and I think an appropriate send off. He's a tough Prof, but very good. He has worked hard to design a very clinically relevant anatomy program, and it shows. I am actually going to miss anatomy. Little bit.

The photo we mounted on little sticks.

Now I am going to have to start brainstorming. Grad is only two years away! We put that together with one 30 min rehearsal---we could have a three ring bloody circus by 2013 if we get cracking!!

--

*Usually the class consists of our prof lining us up and drilling us for half an hour, in small groups of about 20. We've had this class every week for the past two years. Yeah, two years of anatomy. He's a very, shall we say, intimidating, gruff man, with an impressive CV about as thick as your arm (if you have thick arms) and a very short fuse for wrong answers. He's the one that tells us to die or hang yourself or jump off a bridge if you say that the facial nerve is the sensory nerve of the face (it's the trigeminal) or something along those lines.