Hear, Heavenly Creator

I'm not a religious person.  But in music, I find something uniquely spiritual.  I had mused on this before, in this post.  I keep coming back to this idea - spirituality in music - that since I've stopped regularly playing or practicing, it feels as if a part of my soul is missing.

Much as I try, words cannot describe this feeling.  Is it longing?  Is it nostalgia?  Is it remembrance?  Perhaps it's all of them.  Perhaps it's resonance: a connection between the music - that unique synthesis of sounds - and the listener (and the musician as well).

The above song was a poem written by Kolbeinn Tumason (1173 - 1208) on his deathbed.  Breathtaking still.

Listen, smith of the heavens,

what the poet asks.

May come softly unto me

your mercy.

So I call to thee,

for you have created me.

I am thy slave,

you are my Lord.

God, I call on thee to heal me.

Remember me, mild one,

most we need thee.

Drive out, O king of suns,

generous and great,

every human sorry

from the city of the heart.

Watch over me, mild one,

most we need thee,

truly every moment

in the world of men.

Send us, son of the virgin,

good causes,

all aid is from thee,

in my heart.

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Year of the Horse

Year of the Horse by uniqueLegend on deviantART

Wow.  It's been . . . over 6 months since I last posted something here.  o_O  That's quite the hiatus, didn't mean to be gone for so long!

Oops.  Well Happy Chinese New Year!!  May this year bring luck, health, and good cheer!  2013 was a bittersweet year and I've so much to catch you all up on.  Once I'm done with USMLE Step 3 and my last ED shift tomorrow, I shall try my hardest to return from hiatus.  :-)

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Continuing Journeys

A lot has happened since I last posted!!

A New State

I literally moved across the country to a new state on the west coast to start my pediatric residency.  It's still kind of weird being here.  I'm not used to the mountains . . . the Midwest is very flat.  I suppose I'll have to conquer my fear of heights sometime in these next 3 years, haha.

Orientation

Let's just say that orientation was off to a rocky start.  5 of my co-interns and I were a few minutes late returning from lunch to our PALS (pediatric advance life support) course, and the instructor refused to let us enter and complete it because she had already begun the video - from what we were told, we weren't missing anything vital anyway.  The 6 of us comprised half of the intern class . . . you can't have half the intern class not be PALS certified by day 1!!  We were furious, the program coordinator was frustrated, and the department chair was livid.  It got resolved but not without taking a hit to our pocketbooks, sigh.

EMR (electronic medical record) training was painful as always.  You can only tell us so much before we zone out or forget.  It's painful enough to learn 1 EMR system during orientation, let alone 2.

My co-interns are a tight bunch.  They're funny, laid back, and pretty helpful.  I hope this doesn't change as we progress through residency.  It would be quite sad if we ended up at each other's throats towards the end.

Day 1

Day 1 for us was not July 1st as it is for many programs, but rather the Monday before (June 24th).  No matter what, I'm pretty sure Day 1 feels like [this] for everyone.  I was lucky.  I started on an outpatient subspecialty block, genetics.  I've now survived 2 weeks of residency, yay! :-D  On one hand that's not saying much, as I'm basically a glorified (read: paid) med student in genetics clinic.

My interest in genetics has waxed and waned over the years.  I started off med school super gung-ho about it but it soon fell out of favor.  My time in genetics clinic here thus far has renewed some interest in the subject.  It's fascinating from an academic point-of-view, and far from always being a life-limiting/death sentence, there's a lot that a geneticist can do for patients.

First and foremost is a diagnosis, simply putting a name to something so bizarre can greatly help parents and families.  Second is anticipatory care for the patient.  Some genetic disorders come with a plethora of potential cardiac, skin, nervous system, etc issues - so having a name helps guide screening for problems right as they occur so they're easier to take care of.  Third is future planning.  Some genetic disorders happen de novo (basically, randomly out of nowhere) whereas others are hereditary.  This is important to know for parents wanting to have more children, or for the patient him/herself when they're older.

It's hard to believe that these weeks are moving by so quickly!  While I have a better appreciation for genetics, I don't feel like I've seen enough!!

Continuity Clinic

A hallmark of any pediatric/internal medicine/family medicine residency program is the continuity clinic.  Clinic was one of my favorite arenas in med school, so I was looking forward to it.  It's one of the major reasons why I applied to pediatrics as opposed to anesthesia.

That said, my first clinic patient took me over an hour to see.  It wasn't because I spent all that time with the patient, no, it was because I was wrestling with the EMR system trying to figure out how to place orders, schedule follow-up visits, write a progress note, etc.  I don't think I've ever simultaneously felt more and less like a doctor than at that point.  Sadly this was an EMR I had used as a med student, but apparently there are a lot more buttons to click and tabs to go through as a resident compared to a med student . . .

Night Float

Today I'm about to start night float for a week, going from 6:30pm until 8:30am (roughly).  I'm excited and scared at the same time.  I'm going to be covering an arena of peds that I hadn't really been exposed to before - the NICU (neonatal intensive care unit) and the newborn nursery.  I will be relying on the back-up and support of my senior resident and attending heavily, at least for the first day or two.  Wish me luck!

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Reflections: This Time Last Year

As I sit here typing this, days from moving across the country to California for residency, I must reflect on my last 2 rotations of M3 year this time last year.  It's certainly been a crazy ride, this whole med school thing . . .

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Obstetrics/Gynecology: Watchers Over Birth

birth by *HenriqueFrazao on deviantART

Obstetrics/gynecology ("ob/gyn" for short) is an interesting field because it's really two separate fields united over a single common cause: women's health.  The two halves are, as you might have guessed, obstetrics and gynecology.

Obstetrics: from the Latin word obstare which means "to stand by."  Ob focuses on pregnancy from conception to delivery, almost literally "waiting" for the moment of childbirth.  It's the more "medicine" side of ob/gyn from routine health maintenance to prenatal visits to labor and delivery.  I have only two personal criticisms regarding ob - 1.) it provides really focused care and can ignore more general health issues unless it will directly affect pregnancy, 2.) it provides excellent care of the fetus until delivery, and then the newborn is handed off rather quickly.  That said, being able to attend a childbirth and catch a baby is one of the greatest privileges a med student can have - to literally be the first person to hold a newborn.

Gynecology: focuses on women's reproductive health.  Gyn is the more surgical side of ob/gyn.  There are a lot of surgical procedures that can be done (e.g. hysterectomies, ovarian cyst removal, etc).  It's often criticized by general surgeons (rightly or wrongly) because gynecologists don't get much (any?) training on surgery outside the pelvis and bad things can happen should they find themselves accidentally in the abdomen.

It's this dichotomy between ob and gyn that I find fascinating.  Some people gravitate more towards ob and others more towards gyn.  The other fascinating thing about ob/gyn is that it's now overwhelmingly dominated by women.  A male ob/gyn is a rarity, but I must say (from my limited observations), they tend to be more understanding and gentler with their pelvic exams.  My hypothesis is that, because men don't have vaginas and such, they tread more cautiously to avoid discomfort (and also try harder to earn women's trust).  On the flip side, women know their own anatomy better and I've seen female residents been "rougher" with patients because they can "handle it."  But what do I know?

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Neurology/Psychiatry: Troubled Minds

A New State Of Mind by `gilad on deviantART

Neurology/psychiatry ("neuro/psych" for short here) are actually two different specialties entirely and unlike ob/gyn, aren't slapped together despite both focusing on the brain and the mind.  Regardless, this rotation tends to be combined for this reason.

Neurology: focuses on the more anatomic dysfunctions of the brain.  I rotated through the neurovascular team (aka, stroke team) and it was actually pretty interesting.  Strokes are not uncommon and can be very devastating if not treated promptly.  For much of neurology, once damage to the brain is done, it's irreversible.  Treatment mostly focuses on either stabilization or trying to stop/slow progressive damage and disease.  That said, stroke was nice because if treated during the first few hours, the symptoms can sometimes be completely reversible.  I also found neurology to be "too academic" for me - lots of discussions about the injury and potential treatments, and not enough that can be actually done (yet).

Psychiatry: focuses on mental illnesses and diseases.  Psych was fascinating.  My site director told us something I should never forget: "Remember to treat the person and not the disease.  There is a person inside there and you must treat him/her, not his/her mental illness."  That really struck home because it emphasizes that these patients, too often stigmatized by society, are worth helping and saving.

I was fortunate to rotate through a site that saw the whole gamut of psych - from child/adolescent to eating disorders to adult to drug abuse/rehab.  The child/adolescent cases are the most heart-wrenching.  Many of these kids come from unfavorable backgrounds and their mental illnesses are often a result of their environment in combination with a "more fragile" mental constitution.  I've seen some of these kids make great progress and develop coping strategies and mental resilience.  I've also seen other kids who returned quickly because their home environment is so bad that being in an inpatient mental facility is better.

As my preceptor once said, "Our goal is to help these kids re-balance their mental set-points so they can function and be more resilient."  Too bad hugging wasn't allowed (much less a physical exam), because some of these patients (child or adult) just need some attention, tolerance, and someone to believe in them.

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Match Day

Match Day.  On the Ides of March.  The culmination of medical school comes down to this day.  It is terrifying, nauseating, heart palpating - "Matched-induced arrythmia" - nothing seems to calm the nerves.

Match Day is the day where medical students across the country find out where they will do the next 3-5 years of residency at exactly the same time (11am).  Leading up to Match Day, both the applicant and the residency program submit their respective rank lists to the NRMP.  The NRMP then matches applicants to a residency program in a binding contract.

Every school has its own Match Day ceremony.  At ours, a brass drum is presented at the front of a room.  The envelops sealing our fates are loaded into the drum.  Then an administrator spins the drum and pulls out an envelop at random.  As we go up to receive our envelop, we hand over $1.  The last student who receives his/her envelop gets all the dollar bills.

A friend of mine goes up: #6 for psych.  Another friend goes up: #8 for medicine.  Another friend: #6 for general surgery.  Another friend: #7 for pathology.  The mood is somber.  What is going on?!  What if I also matched so far down my list?

My next friend is up: #1 for general surgery.  She is ecstatic and relieved.  Shortly after I am called.  As I hold my envelop, I chant my mantra out loud: "Please don't be [my last rank], please don't be [my last rank] . . ."  I open my envelop and I first see "California."  Then I see "University of California - San Francisco."  I am confused, I hadn't gotten an interview at UCSF and didn't rank it.  Then I see "Fresno" and it dawns on me - I matched at my #2 for pediatrics!!  Yes, I am somewhat devastated that I didn't match at my #1, but I can't complain.

Then the doubt begins to set in, almost like a kind of "survivor's guilt."  Did I make the right choice?  Should I have ranked Fresno lower?  Should I have ranked programs with more "prestige" above it?  Should I have ranked a more academic program above it?  I logically understood that all the questions are moot - I have matched and it is binding.  I know will get excellent training at a free-standing children's hospital (and it's basically an oxymoron to get bad training at such a hospital for pediatrics).  And then I remember all the other perks that slowly trickle back to me.

I have matched pediatrics at UCSF Fresno.  Can't complain.  :-)

Backlog: 03-15-13

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Happy Chinese New Year!

Year of the Snake 2013 by ~WeijiC on deviantART

新年快乐！  恭喜发财！  身体健康！！

Happy Chinese New Year!  Tis the Year of the Snake.  I can't believe it's been like 4 months since I last posted.  So much has happened that I need to get caught up on!  Alas I'm on my surgical sub-internship and so hours are long, free time is limited (and what free time I do have I'm often too tired to care about posting stuff, haha).

But hopefully I'll get things caught up by the end of this month? . . .  Wishful thinking perhaps, but hey, it's a new year!!  :-P

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Anesthesiology: Vigil over Sleep

Falling Asleep by *tune4jack on deviantART

The ancient Greeks believed that the god of sleep and the god of death are brothers.  In anesthesiology, this isn't really too far from the truth.  Anesthesia is much more nuanced and complicated than simply putting a patient to sleep during surgery.  The science of anesthesiology has been honed over the decades to a delicate art, and is now one of the most regulated and safest branches of medicine.

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There are several distinct steps in anesthesiology:

1.  Pre-op: The anesthesiologist reviews the patient's medical record prior to surgery.  They will meet the patient and assess their airway (mouth and throat) as well as veins for IV access.

2.  Induction: The anesthesiologist induces sleep in the patient through one of several methods.  The most common are IV induction with propofol or inhalation induction with sevoflurane.  Once the patient is induced, the patient is typically intubated to protect his airway, paralyzed so the patient won't move during surgery, and given pain medication.  Throughout all of this, the anesthesiologist monitors the patient's vital signs closely and additional IV access may be obtained.

3.  Maintenance: The anesthesiologist maintains the patient under anesthesia usually with an inhalation agent (e.g. sevoflurane).  Vital signs are monitored for response to pain and surgical stimulus so medication can be given accordingly.  Breathing is monitored because it must be actively maintained by a machine while the patient's paralyzed.

4.  Wake-up: At the end of surgery, the anesthesiologist must reverse everything done to the patient (except the pain medication).  The patient's paralytic is reversed, anesthetic agents are turned off, and the patient slowly wakes up.  Vital signs are close monitored to assess the stage of anesthesia the patient is in, as extubating (removing the intubation tube) too early could be dangerous.

5.  Post-op: The anesthesiologist follows the patient to the post-op area and monitors for a few minutes during hand-off to the nurses, making sure the patient breathes adequately and pain is under adequate control.

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Most people go into anesthesiology because they enjoy 1.) procedures, 2.) taking care of patients in an acute setting, 3.) don't want to deal with the patient's chronic/social issues.  A select group of anesthesiologists pursue a chronic pain fellowship, turning heads on much of what likely drew them to anesthesia in the first place.

I've had the privilege of observing acute and chronic pain services in pediatric patients.  This particular acute pain service controls all PCAs (patient controlled analgesia) and epidurals in the hospital, and are the ones who wean patients off IV narcotics and transition them to oral narcotics and then wean them off altogether.

The chronic pain service was a different world entirely.  Each visit took up to 90 minutes and is conducted with a psychologist.  Pain is addressed in a multi-factorial manner - approaching it from a psychological, behavioral, and medical perspective.  A treatment plan may include CBT (cognitive behavioral therapy) to learn coping mechanisms to deal with/mentally lessen the pain, rehab exercises, and pain medication (rarely are narcotics actually given).

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Even though I will not be going into anesthesiology, the things and thought processes I learned will only make me a better overall physician.

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