My Face Is My Fortune...

...that's why I'm totally broke!

I had a feisty 8 y.o girl come in tonight. Her long blonde hair was pulled back in a messy pony tail, an oversized black Karate hoodie hung low over her leggings. I saw she had the beginnings of two black eyes, a bit of a swollen nose, and a bump sitting on the bridge. She excitedly told me about how she got accidentally head-butted yesterday in karate just before winning her competition. She then mock-kissed her biceps.


So what brings you in today? Are you worried your nose is broken?

Yeah, we need to check it out....this [said while circling her face with her index finger] is my money maker.

And that was when an 8 y.o girl became my hero. I mean, she had me at the bicep kissing, but that line cinched it.

Paging Doctor Blackbear

So the last week at work involved a couple of milestones. I am so sleep deprived right now that I can only think of one (thanks to two 6am shifts starts, Ryan's recent surprise 40th birthday keg party, and 11h of driving in the last 4 days).

My attending asked me to page the neuro team for one of our patients and I mentally froze. Lowly medical students do not consult with other teams in Ireland. What amount of detail should I go into? How much history do they want? Is it like a geriatric consult where you have to mention how many pets they have and if they can still drive themselves to get groceries? Or is it like a surgical consult where you say there is a fracture, please fix it?

I told the unit clerk my name (Albino) and asked her to page the neuro team for me. 

A few minutes later I was assessing another patient when "Dr. Blackbear please pick up line 70770 for neurology, Doctor Blackbear" came over the PA . At first I was reflexively tuning out the sound of the announcement as it crackled into the room. Then I realized the call was for me! Yes, the title wasn't accurate but I have to admit it briefly made my stomach flutter with excitement. I know it sounds cheesy but I've been ignoring that interruption while in hospital for the last 12 years. It hit me that sooner rather than later I would actually be Doctor Blackbear! It is quite an exciting (and frightening) prospect.

Most days this journey feels so long that I almost forget that at some point the tuition payments end, the paychecks and different responsibilities begin, and new goals appear on the horizon. Hearing my name paged overhead was a jolt of reality: in a year from now I won't be able to ignore those calls and the next chapter will be beginning.

Excited!!!

Peds? Really?

First of all, I love pediatrics!

Children are such completely different animals. My experience so far with pediatrics has been fairly limited to the odd asthma, RSV, gastro, or rash that presents to general emergency. But working exclusively in a pediatric emergency department has been a completely different reality. I have really been enjoying the challenge of trying to connect with children, like figuring out ways to make clinical exams tolerable to them or jazzing up the neuro exam to make it like a game. I get to be kind of silly and fun, disguising the seriousness of it all. It's a treat, especially when you can get on the level with a kid. Most of them seem to lack the hang-ups that adults have around illness and disease. They are stoic but not in the look how stoic I am being, so stoic that I am actually not providing accurate information to my health care providers way that adults are. There is a different kind of job satisfaction that comes with helping to name a new teddy bear (Mr. Fall off the Wall) or getting an energetic high-five from a kid who was burying himself in his mother's skirt for most of the history. 

Plus, I always thought that (because I am really not that great with kids in the real world) I'd dislike pediatrics. And then there is the crazy parents, who also frighten me. But it seems that crazy parents are not as common as I'd imagined. Or maybe I am just not noticing them because my interaction time with parents is more limited, compared to when I was nursing.

The hospital is beautiful, brand new, and completely child-centered. T.V in every room, popsicle fridges at every corner. The staff seem to really love their work. I'm so impressed at how they are able to balance between the focused intensity of acute care while making it fun and minimally scary for the wee patients. Everyone is just so nice. Maybe it is harder to be a curmudgeonly pediatrician or crotchety nurse, I don't know.

It's been a great learning experience also, being put in with the residents for all of their teaching sessions and tutorials. Their simulation training has a dedicated faux trauma bay in the department, complete with all the drugs, pumps, and machines that go bing! We did a session on Thursday with mannequins that are very realistic (heart, breath, bowel sounds, as well as pulses, intubatable throats, seizure capability, etc.). All the mock codes were run in real time, that is, you wouldn't just say, "I would start an IV and give ceftriaxone", you actually assign the task of IV start to one of the team, they put in a line, someone draws up the actual drug and sets up the infusion. The enthusiasm to teach and job satisfaction of the attendings is contagious and I must admit I look forward to every shift.

It is strange though, being in a new city. I feel like I am regressing as an adult. No phone, no car, no idea how the city is laid out. I walked for over an hour in the hopes of buying a new burner only to  find they were sold out. The saleswoman kindly advised me to call ahead next time. I gently pointed out that I didn't have a phone, hence why I was trying to purchase one! Sigh.

And so, getting settled in. Trying to enjoy each day for what it offers. I have already managed to locate and join a yoga studio for the month, so at least some physical activity will take place. Did I mention there is also a very decent wine store down the street allowing me to finally taste my favorite American grapes again (in Ireland you're lucky to find Ernest & Julio). It's Friday night, I'm post hot-yoga and ready for a glass of red and my new book.

Back to work tomorrow, the adventure continues.

Welcome To the Jungle - 2012

Things are starting to pick up momentum here on the wild west coast of Ireland. Exams are exactly two short weeks away (eep, why I am I still typing this blog post instead of memorizing differentials for fatigue??)

A brief look at life for the next few months:

May
-exams
-pack up house
-move things / car into storage
-fly home

June
-start pediatric emergency elective in Alberta (4 weeks)

July
-have a week 'off' (see below for what will actually be happening during 'off' days)
-start gastroenterology elective in Nova Scotia
-start CaRMS application process (Canadian post-graduate application)
-have 10 days holiday to study for MCCEE (Canadian board exam)
-fly back to Ireland, find place to live / move in / start psyche rotation

August
-study for boards while doing psyche rotation while working on CaRMS

September
**Canadian Board Exam**

October
-CaRMS and obs/gyne rotation

November
-Submit CaRMS
-collapse from exhaustion

December
-hit 'refresh' on email inbox until residency programs start emailing
-possibly decide that I'll stay across the Atlantic for post-graduate training

Just typing all of that gave me a facial tic. I may have to start playing this song everyday when I get out of bed.


 

I (Heart) Rural Medicine

In the last 48h have included having the opportunity to:

-catch a baby
-cut a piece of glass out of someone's face (and then stitch them up afterward)
-surgically assist with fusing toes, replacing hips, replacing knees
-perform a D&C
-assist with a hysterectomy
-sew up knife wounds
-assess / treat / discharge about 75 emergency patients
-learn how to insert an IUD

Despite the exceedingly damp climate my hands are cracking from so much handwashing, I'm surviving solely on t.v. dinners and instant soups, clean underwear is becoming a scarce commodity, and I've spent every day (except one) in the hospital since my arrival. And I couldn't be happier.

My days are so full and varied, with such fantastic teaching from the docs here. It's hard to sleep at night, completely wired and excited by each day's events. I feel so fortunate to be here. I'm starting to believe that saying about how "there are teaching hospitals and then there are learning hospitals". Say what you will about rural medicine...but my experience is that people working in remote areas have half the egos and double the desire to teach.

I've been spending a lot of my retractor-holding and trying-to-sleep time thinking about the (soon arriving) residency application process. Today I truly felt like a few things have started to crystallize in my mind about what I want to pursue...

As always it is a work in progress, but I think that will have to be a post for another day.

In the meantime, check out my new O.R clogs while I try to get some well deserved sleep.

Yes, yes I did.

Hard Mattress

After a somewhat lengthy orthopedic surgery where I had been holding a foot / leg up off the table, Dr. Boots handed over the suture material and told me to get to work.

Me:

Umm...should I come around to the other side of the table?

Dr. Boots:

No, sweetheart just get to work, this man's got a bloody tourniquet on! We don't have time for dancing around. Put in some mattress sutures. 

(Some of you might scoff at the fact that I haven't mastered the mattress suture. As a potentially aspiring surgeon I maybe should be able to do them in my sleep, however, I spent most of my time in general surgery trying to perfect my sub-cue stitches and hand-tying. Bad medical student, BAD!)

And now I have.

And they were a thing of beauty. All two of them. Damn you arthroscopy and your tiny wounds!

Dr. Boots:

There, that wasn't so bad now. No need for all the shivering and shaking. You know my 17 year old daughter can do mattress sutures, no problem. She taught herself.

(Surgical Drape) Curtain Falls. 

[For the record...my hands were shaking because my forearm muscles were maxed out from assisting...I swear! I should also add, Dr. Boots is amazing and kind of like the slightly-unimpressed-but-fantastic-teacher orthopedic-surgeon-father I never had. Above example illustrates the way we communicate. Me, hopeless rube in ortho...him ortho king. Get it?]

Apparently I Look Like a Drug Dealer

So, I am here in BC doing an orthopedics elective. But really, I am doing an everything elective. I've worked in this hospital before as a nurse and most of the doctors know me. I want to scrub for surgeries, stitch wounds in the ER, catch babies, intubate, whathaveyou. So I need a cell phone, otherwise no one can reach me when wounds / babies / femurs are presenting themselves.

I walked into the 7-eleven and looked for the cheapest phone. $39. Brilliant. I asked the attendant to please fetch me the $39 phone from behind the counter. He looked at me strangely and said, "Er....are you sure you don't want a nicer phone? These ones are only $100". I waffled for a moment but held strong. All I need this for is "baby coming" texts. Status symbol, status schmimbol. Give me the ridiculous one. 

I was quite proud of my new phone so during my next shift I whipped it out to show one of the murses. He burst out laughing, "Dude!! You've got a burner!!"


"Uh...what is a burner?"

"It's a phone that drug dealers use so that their calls can't be traced. They're disposable. Hilarious. You totally will look like a dealer every time you take that phone out."

Now I feel old, and crazy out of touch with slang.

The next day I get a text at the nurses station and I'm trying to thumb my way through a response when one of the other nurses starts pointing and laughing, "NICE BURNER!!!!"

Siiiiiiighhhhhh. Am I the only person that didn't know this term? Apparently if I watched The Wire or CSI I'd be well versed in these matters.

I sent a text to my orthopod to give him my number (since we were on call) saying "Here is my mobile number courtesy of 7-eleven" and the next day in theater he tells me that his wife saw the text and asked him who was sending him messages from a burner.

For the record, he's in his 50's.

It's no iphone 4, it's small, it is ridiculous. I look like a complete rube (and low-life, apparently) when I try to text from it. But you know what? It is almost so lame that it feels cool. In fact, I like that it is ghetto. It feels slightly rebellious and hip to not be showing off what apps I can get on it. I wear rubber boots to work and I own a burner. It is just how I roll these days.

Where Am I Going Again?

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...

Good And Bad

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". 

OB or not OB?

We have been up to our eyeballs in pelvic floor muscles lately as our last few cases have been covering pregnancy, babies, ambiguous genitalia, labor and delivery. 

Now normally I am not a fan about learning the differences between the somatic, autonomic, and visceral nerve supply to muscles, but I have to admit, knowing the practical applications for managing labor pain has made this memorization a bit more interesting. I am sure it is because I love procedural skills and can't wait to do my first nerve block, epidural, lumbar puncture, and perineal repair. I started thinking about all the hands on work that OB/GYN's do and then having thoughts that were alien to me until now ..."obstetrics? maybe?"

Truthfully, back in the days when I was an annoyingly-militant-vegan-self-righteous-naive-hippie I seriously considered midwifery (not to say that midwives are those things, I am just elaborating on a phase I went through in my early twenties). I even took my doula training and looked into various programs across the country in midwifery. The only thing that really held me back from pursing this career was the fact that Canada has some ridiculously archaic and paternalistic conservative attitudes regarding who ought to be bringing babies into the world. Depending on what province you live in it can be a seriously uphill battle to create a career for yourself as a midwife--that is, no hospital privileges, being shut out by the medical community, lacking public subsidies, and having to conduct only home births without OB back-up. I just wasn't up for the challenge, I guess. 

Fast forward to medical school where I continued to reject the Western approach to birth, until very recently.

We had an OB/GYN lecture us this week. She was Irish but had spent 10 years specializing in the US in high risk delivery and maternal/fetal medicine. Her lecture was delivered in a soft spoken but direct and powerful way. About half way through she stopped on the slide shown to the left, and said,

"I have always wanted to be a part of this event in people's lives. Even when it is cold, dark, and in the middle of the night I love to get up and head to the hospital knowing that this is what I get to be involved in. When the babies start looking the same and I am not thrilled to be there, I am going to quit. But right now, I feel nothing but privilege for being invited to take part in this pivotal moment in people's lives".

She apologized for how hokey it sounded but I felt that it was quite lovely, to hear someone speak so passionately and honestly about their career choice. I suppose it is what we are all striving for when we choose our future specialty, what are we passionate about? Am I going to love living in the O.R, or intubating patients in a helicopter, or prescribing chemotherapy regimes? It is so hard to know at this stage having only seen as sliver of the health care system. But when you hear someone speak from the heart, and they clearly do love their job, it makes you wonder...could I love constantly being sprayed with amniotic fluid and having only female patients for the rest of my life?

Maybe!

OB/GYN Pros:                                                                     OB/GYN Cons:
-lots of healthy patients                                                          -on call, forever and ever, amen
-plenty of hands-on procedures                                              -bodily fluid exposure extravaganza
-O.R from time to time                                                           -bad outcomes are very bad
-emergency situations*                                                           -only female pts
-many good outcomes                                                             -continuity of care
-continuity of care                                                                   -highly litigious
-many happy/excited patients                                                 -crazy women with 5 page birth plans
-immediate results                                                                  -having patient load
-the whole 'miracle of birth' thing                                          -the training

If nothing else, I am trying to keep my mind open to the possibility of areas that I hadn't considered. I know how most medical students start rocking in the fetal position (pun intended) when you mention their OB/GYN rotation but...who knows? Maybe I will be one of the lucky ones and will actually enjoy labor and delivery!

Or maybe I'll just end up with countless pages of blog fodder.

Either way, win!

*I know that sounds twisted...but I am wired to enjoy emergencies for some reason. I blame my mother for not breast feeding me long enough. (Hi Mom!) 


   

Summer Placements--Yipeeee!

Vista from the road near Dingle.

The school has just released our placements for 1st semester of third year. I am very excited as I found out that I will be rotating first through surgery in Tralee, County Kerry.

So, surgery is the thing I am most looking forward to next year as it will allow the greatest leap from my experiences as a nurse...and not to mention the fact that I adored every minute in the O.R this summer!!

I had originally asked to be placed in the Big Regional Hospital but then the placements coordinator emailed me and asked if I'd consider going to Kerry for the entire year. I had put Killarney (near Tralee) as my preference for GP placement in 2nd semester so moving for the entire year made sense.

I hummed and hawed for the evening, drank two glasses of wine, called a few of my Irish pals for advice, then responded "yes" before wondering what I was getting myself into.

The hospitals in Tralee are much smaller than Big Regional but the location is one giant beautiful wide open space of mountains and ocean. And I will be close to Killarney and Dingle. For those of you who've been to the area you'll be able to appreciate why I am so excited to be a 30 minute drive from the Ring of Kerry.

Dingle Harbor

The other interesting thing is that there is only going to be one person from my class at the same hospital as me, and we'll be on opposite rotations (he'll be in med while I am in surg). He's actually one of the most down to earth and sincere lads in the class--plus he's a fellow West Coast Canadian! So having a bit of company (of the quality variety) will be good. My heart is always in smaller centers, I adore rural health care and I think for electives it will be nice to be as far away as possible from some of the competitive knobs in my class.

Fingers crossed I land some decent preceptors...