Be the Change

Be the change by ~misskat345 on deviantART

Sometimes I feel like I should've accomplished more by now, as if most of the things I did before grad/med school didn't even scratch the surface of significance. I read articles about people around my age doing amazing things, like invent the Embrace infant warmer for premature babies or begin an organization like Invisible Children to aid kids in war-torn Uganda. It almost makes one pause and think, "What have I been doing? What have I done?"

There's a lot to be done, and there's a lot that can be done. As Gandhi said, we must indeed be the change we wish to see in the world. Only in the last few years have I, in some fashion, embraced those words. I used to think that I could only effect change once I become a doctor with real influence. But why necessarily wait that long when there's a lot each of us can do now? The time for action is now.

Granted, most of the med school projects that I'm involved in were "inherited" down to me, but they're worthy projects of their own accord. The first is the Patient Education Program. This program aims to educate patients at a free clinic on ways to better manage and improve their health at home. The second is the Hmong Health Education Program (HHEP). An outgoing M4 left us with a $30,000 grant that he secured to develop the HHEP. The aim is to increase health awareness in the Milwaukee Hmong community through various media efforts such as radio show broadcasts and PSAs. And third is the Health Fair hosted by APAMSA (Asian Pacific American Med Student Association). This event is hosted at a community center in a low-SES area of Milwaukee and focuses on health education, connecting people to community/government resources, free health-related give-aways, and some health screening.

With each program I've had the opportunity to help further develop it and improve upon what was handed down to me. With Patient Education, I think we've finally got something that works well within the clinic. With the HHEP, we've been expanding the program so that (we hope) it reaches more Hmong community members. And though the Health Fair just finished its second year, I hope it becomes an annual event with each year being better than the last.

In one of my last posts, I mentioned how my long-time friend Taylor is starting a non-profit to help further kids' education. This is very quickly becoming a reality, and hopefully soon-ish it'll be ready to get off the ground! He has allowed me to have some involvement and direction of his brainchild, a very great honor.

Lastly, my friend Alicia and I worked on a project for a course in grad school a couple years ago. Our idea was to design the concept for a video game to promote the teaching of genetics. Recently I had lunch with Alicia, who now works across the hall from the professor of that course. He still remembers our project and asks her occasionally when we're going to make it a reality (apparently, it was one of the highlights in that course for him that year). One day! The moment hasn't aligned yet for this, but we promise that one there'll be a video game on genetics. Below are a couple concepts drafted for this project. :-P

Throughout all of this I've learned a few things. One: we can, right now, effect change - however great or small. Two: you can rarely go at it alone, as I've had co-chairs for programs, committee members, and good friends. And three: that it's okay to not be the inception of the change, but to be near that inception and to rally behind a cause is just as rewarding.

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The Schism

Currency of Knowledge by ~VGAce on deviantART

There has been a schism between the arts and the sciences. While still held together in higher education as "Literature, Arts, & Sciences," this seems but a facade, a mere veil hiding the schism that divides the disciplines. Like two sides of a coin, the arts and the sciences no longer seem to see eye-to-eye. Yet at their core they still have the same goals: to seek out knowledge and discover truths.

So often it's a discussion of "the arts vs. the sciences," as if one is superior to the other in defining reality. But I wonder, why have we allowed the two to be divorced from one another? Why have we allowed this schism to take place? Are the arts naive? Do the sciences silence that sense of awe?

When I returned to my hometown for Thanksgiving, I took a moment to stand in the driveway of my house and look up at the clear night sky for the first time in perhaps months. In that moment, looking at the constellation Orion, I felt myself transported back in time. As a kid I had marveled at the stars. I had read about the myths and stories enshrouding the constellations, and seeing what people saw for thousands of years. I read about the composition of stars that made them burn, and about the incomprehensible distances that separate me from the heavens.

Does knowing about the science behind the stars make they any less remarkable? Any less awe-inspiring? To the contrary, it enhances that sense of wonder. I recounted this to Taylor and he told me how he had once went on a trip in northern Michigan. In the isolation of nature, far removed from the light pollution of cities, the world was illuminated solely by starlight on a moonless night. He saw the stars in their most primal splendor, dressed in their whites, reds, oranges, yellows, and blues. And he was at a loss for words to describe the beauty of the Milky Way as it cut its path across the night.

How can knowing the composition of the stars, reducing them to their elements and physics, possibly take anything away? Is not the knowledge that the same elements that created the stars are also responsible for creating the environment on Earth? With regards to the stars, what is their truth? That they can elicit wonder and an almost religious awe in people is a truth. That they, separated by distances unimaginable, burn in the vacuum of space with the same intensity as our sun is also a truth.

And a week ago I had a discussion with a few people (over wine and cheese) about the humanities and the sciences within medicine. That the humanities can teach us so much about people - our patients - is true. That the sciences make up the pillars of technology that now allow us to treat formerly terminal illnesses is also true. Can we not, then, marry the two for the betterment of the patient? Too often we utilize science in medicine "reduce" patients to a list of symptoms and their bodies to a machine to be managed and fixed. Perhaps we should take a moment to step back and just marvel at the science behind human body, and (in perhaps a twisted way) at the diseases that afflict us. Perhaps we should remember that patients are people.

It's unlikely to bridge the gap caused by the schism, it has gone on for far too long. But no matter how great the distances separate the arts from the sciences - even as far as between us and the stars - they cannot become fully divorced from one another. They are two sides of the same coin, and though they see the world in opposite directions like the Roman god, Janus, they both see the same things: knowledge, truth, and reality.

As written on the University of Michigan's seal, "Artes, Scientia, Veritas." Arts, Science, Truth.

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That Which Separates Us

Education by ~maxplay on deviantART

A few days ago, I got the chance to catch up and chat with Taylor, a good friend I had known since kindergarten. We were next door neighbors until my family moved to a different part of town just before 8th grade. Since I moved, we drifted apart - it being in the years before cellphones and high-speed internet (I almost can't believe that cellphones and high-speed internet were once not part of my daily life).

Of the things we talked about, the state of education came up. We both agreed that after health care reform, education reform would - should - be the next major social change. Taylor told me how he felt cheated out of a good education before he went to undergrad. This shocked me, as we went through the same public school system (one of the best in our state) and my recollection was the polar opposite of Taylor's. It hit me that even before I moved, there may have been another element that separated us; there was something going on within him that I was oblivious to.

In retrospect, our public school system was almost two-tiered: the regular classes and the honors/advanced classes. For most of our K-12 education, Taylor was in the former and I was in the latter. He considered himself back then as being "at average" or "slightly below average," though I never thought that of him. He told me how he loved science, that if he could redo things he would work towards being an astronomer or astronaut, but he lacked the self-confidence and self-esteem to do well in his math and science classes. And his teachers didn't instill any encouragement in him to do better, to be better.

No one really reached out, no one worked with him to boost his confidence at math and science, and as a result he felt cheated out of the education he should've gotten. At that time I was within his reach and I would've gladly helped, but he never reached out to me and I never knew. As he said (and I paraphrase), "I had no self-esteem and no self-confidence, what kid would reach out for help when everyone was telling you that you could only be so good? How terrifying is that?"

We also talked about bullying in schools, about how middle school was pretty much bad for everyone. Taylor jokingly said, "If you actually liked middle school, then you're probably one of those jackasses who made everyone else's life suck." But the bullying problem stems even before middle school, starting sometime in elementary school. While neither Taylor nor I had been really bullied, we suffered our fair amount of teasing. And Taylor saw the bullying his older brother went through and how long afterwards it took him to put his life together.

And that's when Taylor told me his grand plan: to start a non-profit. He had originally planned to return to grad school for his Master's and work his way up in government and public policy. He currently works for an agency that helps the unemployed look for jobs. He is frustrated that his clients largely come from poverty and are often uneducated - even bordering illiterate. Out of this frustration he declared, "If this is what they're doing, then I can do better. And I don't need a Master's to do it! I want to prevent kids from turning out like me, from turning out like my clients."

While I won't go into the specifics here, I will say that his non-profit idea aims to help elementary students on an individual basis such that, come middle school and beyond, they're well-adjusted and have the confidence to succeed. He aims to do what schools have failed to do: to build a sense of community for kids. As the saying goes, "It takes a village to raise a child," and a school is supposed to be part of that village community but it has failed so many.

As Taylor aims to address one of the etiologies of the social symptom that is poverty, I will likely one day (if all goes as it's going) attend to the medical issues of kids. I hope that Taylor succeeds and I will do what I can to help and support him. It's almost inevitable that our paths will cross many times before either of us pass from this world. It seems that, despite that which separates us, some parts of us remain aligned in friendship.

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Happy Thanksgiving

thanksgiving by ~kristianna11 on deviantART

Wow. It's been 3 months since I last blogged here. o_O

It's been such a hectic semester so far, way busier than M1 year. At least the material is more interesting to learn. There've been times that I felt like I didn't even quite have enough time to breathe. It's partly my fault - being the president of one student group, co-president of another, and co-chair of two student-run programs. Busy busy busy.

Thanksgiving is the first real time to take a breath, and I think it's about time to return to this blogging thing. A couple of things have been added to this blog, namely my Delicious.com social bookmark and a link to Adam's blog.

Anyway, just saying hi and Happy Thanksgiving. Even though I'm technically in EST right now, my laptop's still in CST so it's still Thanksgiving when I post this. :-P

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New York City

So earlier this month, I flew out to NYC to visit Shari and Jen.

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Friday - Flushing

I flew out on Friday afternoon and landed in LaGuardia, where Jen picked me up and we went to a park in Flushing where the World Fair was held.

We waited until Shari got off work and then met up with her for bubble tea and dinner. After wandering around for a bit, we decided to have hotpot. :-)
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Saturday - NYC (Manhattan)

Early on Saturday, I left for NYC with Jen where we met up with Shari at Penn Station. We walked for a bit, got some bread, and then sat in the middle of Times Square to eat.

After we ate, we went to the M&M Factory before heading over to Columbus Circle and then walked around in Central Park.

M&M Factory

Columbus Circle

Once we exited out the east side of Central Park, we sauntered over to Shari's apartment and the hospital where she works (with the ridiculous spiral staircase).

Then we headed down Manhattan to East Village for falafels and frozen yogurt. Along the way, we crossed The Cube (apparently it's called Alamo) that looks exactly like The Cube at UM-Ann Arbor (because it was made by the same person). We ended this round at McSorley's, one of the oldest pubs if not the oldest.

We then power-walked over to Washington Square Park where we met up with Jen's dad and brother. We enjoyed a couple hours of street entertainers there, including a contortionist guy and Tic & Tac.

Washington Square Park

Street performer in a box.

Tic & Tac

We had dinner at Katz's and walked to Chinatown afterwards for rice pudding before heading to a train station back to Jen's house. It amused me how Chinatown had expanded and cannibalized the surrounding area, including most of Little Italy.
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Sunday - Brooklyn

On Sunday, Shari, Jen, and I went to Green-Wood Cemetery. We saw such features as:

Green-Wood Cemetery entrance

Battle of Long Island monument

Altar to Liberty - Statue of Minerva looking at the Statue of Liberty

Leonard Bernstein's grave

Hillside Mausoleum

Once we finished up looking around Green-Wood Cemetery, we headed over to Grimaldi's Pizzeria for lunch under the Brooklyn Bridge.

Next, we went to Red Hook for key lime pie (clearly this trip to NYC centered around food, lol). We got a nice view of the Ikea ferry passing near the Statue of Liberty.

Then we found some street vendors and bought pupusas (or rather, Jen and I got pupusas, since Shari didn't like it).

After stopping by Jen's aunt's birthday party (where I proceeded to feel quite out-of-place), we went to Brighton Beach and walked along the beach to Coney Island.

Phew! And that concludes my trip to NYC!!
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Backlog: 08-06-10 to 08-08-10

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Peds Externship: Week 8

Last Friday I finished up with my last day of my pediatrics externship. The experience was amazing and I had a great time (for the most part). It felt weird leaving while knowing that I won't return for quite some time - if ever - to those placements.

Peds Externship: Week 8

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Monday

I can't really remember anything that stood out on Monday. It was a pretty light clinic day, and we rounded afterwards until 6pm, grr. Patient 1 from Week 7 was doing very well. She was awake and alert. And asking for food. That's pretty key in kids as a sign that they're doing better. :-) We also rounded on a new patient suspected for Kawasaki's disease. The kid didn't present with "typical" Kawasaki's but had just enough possible symptoms that the attending, Dr. Vo, felt that treating for Kawasaki's was probably a good idea despite not being 100% sure.

Tuesday

The weekly teaching session by Dr. C focused on vasculitides, of which Kawasaki's is counted among them. It was a good session (albeit rather longer) because we saw many cases of suspected vasculitis and such throughout the month. It was weird because these diseases are supposed to be really rare. The last topic touched on during the session was on Kawasaki's, where Dr. C "pimped" pretty much everyone by asking for symptoms of Kawasaki's. The M4 mentioned oral mucosal changes, such as swelling and the classic "strawberry tongue." Dr. C then asked what oral mucosal changes are not seen in Kawasaki's. The PGY2 (2nd-year resident) couldn't answer correctly, but I guessed correctly by saying "mouth sores." :-D So yeah, discrete vesicular changes aren't characteristic of Kawasaki's. Good to know.

Patient 1 was well enough to leave the PICU and was transferred to one of the ward floors for the next few days at least. It was pretty amazing seeing how Patient 1 bounced back from the precipice of near-death. The Kawasaki's patient was doing very well and acted like a completely different kid. On Monday she was very fussy and such, but today she was happy and active and cooperative. :-)

Wednesday

Another typical clinic day. Saw many patients, got to talk to some of the patients and families. Followed around the attendings. Clinic days are pretty laid back but also quite rewarding. In peds rheum, you see these kids again and again, sometimes as frequent as every 3 months or more. Their disease course requires so much monitoring and adjustments along the way, but it's good that most of the time the rheumatic diseases can be controlled so that kids lead normal (or normal enough) lives. While the focus of this rotation is supposed to be the clinic, one of the things I like about this rotation is the balance between inpatient and outpatient (aka, clinic). Yes, most of the time on Mondays, Wednesdays, and to a smaller extent Fridays, are spent in clinic; but there are also lots of inpatient hospital time too without being too much. I suppose I like having the best of both worlds.

Thursday

Since it was the last week for many of us, some of us had to give a presentation (but not me, muahahaha - though I did prep one just in case). The M4, the intern, and the senior resident gave pretty interesting presentations. After that, we hung out in the resident's lounge for a bit before being called to the floor to round on Patient 1 - who, by the way, had been doing amazing all week. And since she was the only inpatient kid, Dr. Vo released us at around noon. We bolted out of the hospital, lol.

Friday

After a fairly interesting grand rounds on children's bone health, we headed down to clinic. Alas, we saw maybe 2 patients due to a string of no-shows. We page Dr. Vo to see when and where in the hospital she wanted us to meet her.

First we went to noon conference where one of the physicians in the pain clinic talked about pain management and control in kids. It's almost inconceivable to think that 30 years ago, many doctors thought that newborns couldn't properly feel pain and thus subjected them to many operations and surgeries without anesthesia. Thankfully starting in the 1990s (I can't believe it was only that recent), doctors finally realized that not only do newborns and infants feel pain, they feel it worse than adults! From clinic, I've definitely come to appreciate that pain is pretty high up on the list of complaints. And rightly so! Though we're trying and doing better, there's still plenty of room for improvement.

After the noon conference, we headed up to one of the PICU floors. We saw this teen who was there for cancer treatment but then developed all sorts of weird stuff with his lungs and kidneys. So they call the peds rheum team! While several of us were in clinic that morning, the rest of the team was with Dr. Vo researching possible causes for this kid's issues. And the result? Nothing. At least nothing convincing or useful.

Dr. Vo spent quite some time just reassuring the mom and the grandparents. It was a good encounter to observe, actually. Because nowadays with internet access, everyone scrambles to the internet for answers. But few other than health care professionals can truly understand, sift, and filter the medical jargon even on the internet. And thus Dr. Vo's comment that we had researched possibilities on this kid for over 4 hours and came up with nothing very much reassured the mom. After that, we were dismissed since there were really no more patients to see.

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And thus ends 2 months (8 weeks) of the pediatrics externship. While not always the smoothest ride, it was sure an amazing one. I will dearly miss this experience I think. In fact, while volunteering at a free clinic on Saturday morning, I was so tempted to ask about rheumatic diseases and do joint exams. But that would've been unnecessary and useless to do on adults who only came in for medication refills, lol.

I learned many things from this externship. Not all of it necessarily medical knowledge (that I'm sure I forgot a lot of, but will surely come back quickly), but things such as what I like, what I want, and where I see myself. I can definitely see myself in pediatrics. The people are nice, the patients are good, and the families generally reasonable. What I like are specialties that focus on systemic issues like infectious disease or rheumatology that can affect multiple organ systems. And what I want is definitely where I'm still headed. All signs pointing in the correct direction!

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Peds Externship: Week 7

Second to last week of the externship, wow!

Peds Externship: Week 7

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Monday

As usual, Monday is a clinic-heavy day. I think by this week I had the opportunity to work with each of the 5 attending physicians. I must say, each attending is quite unique in his/her own way.

Dr. N is the residency director. He has such a soothing voice and very calm facial expressions. He has some weird ability to put almost any kid at ease. And he's very patient. Dr. O is perhaps the eldest attending of the group, and I think she's the program director. She's very grandmotherly and I just love working with her. Dr. W is rather jovial, kind of like a geeky kid meets Santa. He loves research and thinking about the interesting stuff. (There are 2 Dr. V's, so one's Dr. Ve and the other's Dr. Vo.) Dr. Ve, his counterpart in many ways, is very direct and to-the-point. He walks through his logic quite efficiently. And lastly, Dr. Vo is perhaps the most amusing (and youngest) attending of the five. She's a fast-talker, full of energy, and gives off this ADHD feel about her. She loves to go off on tangents and laugh, and she cracks us up a lot.

Tuesday

We meet up early in the day to round on this one patient (Patient 1) that was admitted over the weekend under Dr. O's service. She thought the kid was going to die overnight - everything was going wrong and things were so so complicated. She was so fragile in the PICU. The fellow and Dr. Vo (the attending now on inpatient service) went up to another floor to see, what was supposed to be, a short stay patient (Patient 2). Instead, symptoms appeared with that kid and they were away on that floor for 2 hours while we sat twiddling our thumbs in the PICU waiting for them.

They finally returned and we rounded on this girl together with the ICU team. After that, it was close to lunch. After lunch, we met up on the floor where Patient 2 was staying. Then we get a call from the emergency department (ED) that one of the patients under rheum was there with a stroke. So several of us went down to see her. While the M4 and I waited to see her, one of the senior residents had already seen her and had written up the note. So we went back up to the floor without having actually seen or talked to her. Grrr.

The day ended with much frustration between the M4 and I, because we both felt out of the loop and out of the decision-making with these 3 patients. We saw none of them, we weren't clear on what was going on with them, and we couldn't remember them. So our day ended rather disgruntled.

Wednesday

It was another clinic day, and it was a good clinic day. Towards the end of the day, I saw this one patient, a little girl, with the M4 and then Dr. O. The mom had brought her 15-month-old brother with them to the appointment. He was so full of energy, just bouncing around the room and climbing on everything he could. So adorable!

After the M4 and I did the interview and physical exam, we went to get Dr. O. One of the tests Dr. O had the patient do was to jump on one foot. The brother saw this and attempted to imitate her. Now, developmentally, kids aren't supposed to be able to balance on one foot until they're about 4-years-old. So obviously he failed, lol. But it was so funny watching him try! He just sort of cocked one of his legs and shifted his weight to the other leg, but he couldn't actually jump so just stood like that. The puzzled look on his face was priceless.

Thursday

Like Tuesday, it felt like a long and somewhat frustrating day. But it wasn't too bad. After going over the weekly review of clinic patients, the residents, the M4, and I were dismissed. The attendings and the fellows, along with the nurses, had their business meeting. So those of us who were dismissed hung around in the residents' lounge for the next 2 hours or so. Bleh.

We get the page to round, so off we went to meet the fellow and Dr. Vo. So we round on the patients and discussed at length what they might have (or might not have) and what exactly was the best course of treatment for all of them. We then went down to radiology (it feels like we do that a lot) to have them point out to us what they think might be CNS vasculitis. This time we were smart, because we headed straight for interventional neuroradiology instead of "normal" radiology, lol. Of course, CNS vasculitis is one of the most difficult diagnoses to give because it's so difficult to prove that it exists unless it's really bad.

Friday

More rounding on the same 3 patients! Actually, Patient 3 (the one from the ED) was transferred to the adult rheumatologists at the hospital next door and was discharged yesterday. At noon, the M4 and I went to a neurology case conference on Patient 2. I must say, they hold their case conferences in a really nice room on the administrative floor. But it was so boring. I learned nothing new concerning this patient, everything they said had already been said. By them.

Anyway, after that, we had lunch and then rounded some more. Patient 1 was stable and actually starting to get better! Patient 2 was off to radiology for more imaging, and then went home. Patient 3 was already gone. It was actually a pretty good day of rounding, and it's always good to know that patients bounce back and start to do better.

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Labmate's Wedding

So a couple Fridays ago, I got the day off from my peds externship to attend Jim and Aimee's wedding. Jim was one of my anatomy labmates and it was really nice of him to invite us. The other people in my lab group - Ritu and Mallory (and their significant others) - decided to go together and I hitched a ride with all of them.

So after over 2 hours of driving with bouts of traffic, we made it to the wedding just in time. It was a very nice, simple, and to-the-point wedding that lasted probably no more than 30-40 minutes. The pastor was really amusing and that made things less . . . solemn. We sat towards the back since we were among the last to arrive, but even so we could see Jim's smile all the way at the front - the biggest smile I've ever seen on him.

Just married!

After the wedding ceremony, Jim and Aimee walked to the front and greeted people one by one, which we all thought was really great of them. Because we sat near the back, we were among the last to be greeted. We then made our way to Mallory's hotel room to lounge about for an hour or so before the reception.

Mallory's amazing hotel room.

The reception was quite nice. There was a slide-show playing of Jim and Aimee throughout the years. They had known each other since 4-years-old, and really, this was all almost like a fairytale or a movie story. Aimee's dad cried when he gave his little speech, and even Jim - who we noted for his calm and level nature - had a brief moment before he caught himself. It was very endearing.

First dance.

There was this little kid, probably no older than 2- or 3-years-old, who kept running around on the dance floor blissfully. I must say, this kid kind of made my night. When other people were dancing he would still just run about, weaving in and out around the adults. There was also a moment where the only people on the dance floor were kids, and the flower girl really loosened up then.

Little kid dancing next to the newlyweds.

Kids on the dance floor.

After a bit of dancing (reluctantly on my part) and some chatting with the newlyweds, Ritu, her boyfriend, and I left at around 11pm since we had a long drive back. Mallory stayed behind because she was staying at the hotel there over the weekend.

We were all so happy for Jim and Aimee, it seemed meant to be. :-)

Backlog: 07-16-10

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Peds Externship: Week 6

So I'm now done with 3/4 of the peds externship. Wow. How summer has flown so far!! Many of my previous posts have been quite lengthy because they all span a week's worth of stuff. This one probably won't be much different . . .

Peds Externship: Week 6

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Monday

Along with Wednesdays, Mondays are primarily clinic days. So most of the day was spent in clinic seeing patients. It seems that there are 2 age groups of patients in peds rheum: little kids (younger than 6 or so) and teens. At one point, I did a joint exam with one of the interns. There are a lot of joints to examine! And I forgot to look at a few until we were through with almost all the joints. On this one kid, I wasn't sure if his knee was swollen or if it's just chubby from fat padding around it.

After clinic was over, we went to check up on the KotW from last week. He looked almost 100% better! Practically all his neurological symptoms were gone. Since Dr. W was off service and Dr. O was now on service, we saw him and his parents with her (we being the whole rheum posse). Dr. O gave him the okay to go home, but he still had to come back once a month or so to get treatment for the next few months, to make sure his symptoms don't return.

I must say, it's really good to see a patient that looked like he was going downhill make more or less a full recovery. I didn't even know you could almost fully recover from mini-strokes! Maybe that's just part of being a kid, the whole "reserve capacity" thing.

Tuesday

The day began with weekly teaching. The senior fellow, Dr. S, gave the lecture on differentiating between the different types of arthritis that kids can get. It was a long talk. Interesting, useful, but long. The talk could've been easily (and conveniently) broken into two parts. Oh well.

Partway through the lecture, the first-year fellow (Dr. K) got a page. She then returned with a huge patient file. At the end of the talk, Dr. S looks through the patient's records and goes, "Holy shit! This is a very complicated case! Are they sure they want to consult us?" This kid had been in the hospital since April and has seen so many teams - cardiology, critical care, GI, ID, pulmonology, and now us (and perhaps a few others). The fellows really didn't want to take this case because it looked like there wasn't anything we could do to help. So they dismissed us for lunch while they talked to the attending about whether or not to proceed. Just as I left, I saw the kid's name on the chart. It was one of the kids I saw while on peds ID about a month back! Same kid that had the 3-4 infected lines placed in him. Honestly . . . I was surprised he was still alive.

So after a few hours, we get a page to meet the fellows outside the kid's room. Apparently we took the case. Soon the attending, Dr. V, joined us. Even though Dr. O was on service, Dr. V was the best person to call because he's apparently double-boarded in peds rheum and immunology. We look at the kid's EMR (electronic medical records) for a while, and he was on so many drugs! As we scrolled down his list of drugs, one of the interns remarked, "Good God, is this a VA patient I'm looking at?!" Apparently, the old veterans at the VA are on a lot of drugs, lol.

We finally examine the kid. His liver was so enlarged that it grew down to his pelvis. Dr. V exclaimed, "If you can't palpate this liver, then you shouldn't be in medicine." He's right though, that liver was very easy to palpate. We then went back to a conference room to discuss his case. Dr. V kept asking all these immunology questions that I think none of us really knew the answers to, so we all kept quite while he talked. One thing I remember as we were walking to his lab to look at some flow cytometry data, is Dr. V saying, "And in toxic shock syndrome, almost all your T cells are activated. You don't want 90%+ of your T cells activated because then you die."

In the end, we were never able to come up with anything to help the kid (we were called because he had persistent fevers for over a week now) so we removed ourselves from the case. I'm not sure how long they can keep this kid alive, as he's waiting for a double heart and lung transplant.

Wednesday

Another clinic day. Pretty laid back, saw more kids. There was this one kid I saw who had multiple joint injuries in the last. He was a big kid. A football player. One who wants to eventually play for UM-Ann Arbor. ^_^ He weighs about twice as much as I do (if not more) and though he's about a decade younger than me, he's projected to grow taller than me by about a foot. o_O At any rate, he had no rheumatological problems.

There were a few rather shy/nervous little kids. Dr. N, who also happens to be the peds residency director, came in to take charge. I don't know what it is about him, but I swear he hypnotizes kids with his voice and calm facial expressions. They'll let him examine them when no one else was allowed to. Also, he has this nifty trick where he can guess what the kid had for breakfast when he examines their bellies. I must learn this trick, lol.

I thought that Wednesday might end early. Sadly, I jinxed myself. Just as I thought the afternoon patients were about done, 2 new patients showed up. Dr. N went to go see them and asked if I wanted to tag along. Of course I couldn't say no. He spent a long time with both patients. One of them didn't have anything rheumatological, the other had Raynaud's syndrome that I could've diagnosed from her chart. But Dr. N had such a fun time talking to her and her mom. Ah well.

Thursday

Similar to last Thursday. Just went through clinic patients for the following week. But instead of having a journal club, we had a demonstration instead. Dr. V knew an adult rheumatologist in another city who specializes in using ultrasound to do joint injections. So the rheumatologist came and gave us a demonstration using the ultrasound.

It was pretty cool, though I couldn't figure out what I was seeing on ultrasound most of the time. It does make sense to use ultrasound to guide needles into small joints, because they're hard to get to without doing at least some "collateral damage" along the way.

In the early afternoon, all the externs went to tour an inner city, grass-roots, non-profit organization. It was pretty amazing to see all the things going on there! As part of APAMSA (Asian Pacific American Med Student Association), we hosted a health fair there with other student groups several months ago. But even then I hadn't seen most of the place. Afterwards I got to talk to the person who gave us the tour about the possibility of continuing the health fair for this coming academic year. ::Crosses fingers::

Since there were no consults, I was given the okay to just go home.

Friday

I requested this Friday to be off, since it was Jim's (one of my labmates) wedding. I couldn't miss that! More on that in another post. :-P

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Peds Externship: Week 5

I meant to write this a couple days ago, but I've just been so busy and things have been unusually hectic. Anyway, Week 5 marks my first of 4 weeks in pediatric rheumatology (henceforth to be called "peds rheum"). It's crazy to think that my peds externship is already half over!! Week 5 was a shorter week since we got Monday off for the 4th of July weekend. :-)

Peds Externship: Week 5

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Tuesday

First thing in the morning I meet up with Dr. N, the attending who's responsible for me. I also met the 1st-year peds rheum fellow (Dr. K) and the 2nd-year fellow (Dr. C). Peds rheum is a 3-year fellowship after the 3-year pediatrics residency.

Dr. C took me to see an inpatient kid while Dr. K waited to meet up with the rest of the peds rheum team. While reviewing the kid's chart outside his isolation room, Dr. C decides to pimp me on shingles. o_O I hadn't formally learned about shingles yet, but because I know a little bit about it, I was able to answer all of his questions but one. So what is "pimping?" Pimping is where a senior medical person asks a series of questions on medical facts to a younger medical person to test the limits of their knowledge. Earlier, Dr. N and Dr. C had discussed an article that came out called The Art of Pimping. And in that article is a section on defending against the pimp; I particularly like "The Muffin."

Anyway, we then met up with the rest of the team, which consisted of: myself, a M4 student, 2 interns (1st-year residents or PGY1), 1 second-year resident (PGY2), Dr. K, and Dr. C. An attending, Dr. W, would meet up with us later in the day. So the 7 of us walked over to a small conference room for "weekly teaching." Dr. C gave a lecture on lupus. I was particularly amused by the 2nd and 3rd slides, which was basically a picture of House saying "It's not lupus." Lupus is indeed an uncommon disease, and quite difficult to diagnose since there's no "typical" lupus patient.

After weekly teaching we got consulted to see a kid. So we trudge on over, the swarm of us, to see this kid with neurological symptoms. We referred to ourselves as the "rheum posse," lol. We didn't know what to do with him because it didn't at first glance appear rheumatological (as if I knew what that meant yet). We spend the rest of the afternoon, about 5 hours, working up this kid, interviewing him and his parents, and looking at what other consult teams (such as neurology, ophthalmology, etc) had written in his chart. After a few hours of discussion, the only diagnosis we could come up with was CNS vasculitis, which we weren't confident about. So we kind of took ourselves off the case, since it didn't really seem convincingly rheumatological.

Wednesday

So Mondays and Wednesdays are the 2 clinic-heavy days, where the majority of the time is spent in the peds rheum clinic in the hospital. The majority of my experience in peds rheum was to be spent in the clinic because there are so few kids on inpatient who require a consult from us. There were 3 attendings (Dr. N, Dr. W, and Dr. O) and 1 nurse-practitioner staffing the clinic this day, along with the 3 fellows (the 3rd-year fellow is Dr. S). Often between me, the M4, and the residents, several of us would enter a room to see a kid. Also, during the morning, a M3 student was in clinic with us as well. I'm sure most of the kids felt quite overwhelmed by the number of people entering their rooms.

Through the clinic, I see more of what peds rheum is all about. There were a lot of kids with various types of juvenile arthritis, such as: juvenile idiopathic arthritis (JIA), psoriatic arthritis, spondyloarthropathies, and Raynaud's phenomenon. I also saw some kids who had lupus that's currently being controlled with medicine and is in remission (kind of like cancer). Most of the kids looked more or less healthy with their arthritis under control, but the attendings tell me how bad a lot of them were when they first came in to the clinic.

At the end of the clinic day, we rounded on the inpatient kid again (who I'll refer to here as "Kid of the Week" or KotW). We had learned that earlier in the day he had some mini-strokes and was sent down to the PICU (pediatric ICU). So of course we had to go see him. When we get there, we encountered a very irritated critical care attending and his team. Shortly, the neuro consult arrived. The critical care and the neuro attendings then began arguing in the middle of hallway about the course of action for this kid. By this time, hematology/oncology had also arrived, but everyone was standing back out of the cross-fire.

After the critical care attending calmed down, we talked to the neuro team to see what they thought the kid had, since he had been in and out of radiology all day getting various imaging done. The neuro team then sends the kid over to get an angiography of the brain to build evidence that he indeed has CNS vasculitis. We wrote the note to start the kid on treatment for vasculitis, even though it hadn't been confirmed yet (and really, it couldn't be definitively confirmed because of how deep the problems were physically in his brain), just to hopefully prevent the kid from getting worse.

Thursday

The morning began with "staffing," where basically everyone in the clinic - including the nurses - get together and go through all the patients that everyone has in clinic, so everyone has some idea of what every patient has in case someone other than the primary care provider in that clinic has to see the kid. After that, we had a journal club meeting, where Dr. W gave this long PowerPoint presentation on a topic that was way above our heads. The residents, the M4, and I were all fighting to stay awake. And Dr. W called this "light and fun," lol. It most certainly was not - even though the paper was quite interesting.

Then we, the 8-person rheum posse, rounded on KotW again. He seemed to have improved a little (or at least, hadn't gotten any worse). We looked for the angiography report but couldn't interpret it, so we had to trek down to radiology to get a radiologist to interpret the films for us. I must say, I do not want to be a radiologist. The room they're all in is like a bat cave! It's pretty dim in there so they can see their computer screens more clearly. There were desk lamps at each station that gave an odd ambient effect. All the while, the radiologists kept talking into their microphones to dictate their findings; this gave the effect of a low constant drone or chant . . . it almost sounded like some kind of cult, lol.

Well anyway, it turns out that the radiologists couldn't help us, and so directed us to interventional radiological neurology (I didn't know one could even be that specialized). So we get down there and someone instantly explains the films to us. Clearly, it was also over our heads (even Dr. W, our attending), and so there was much nodding in false agreement.

We trek back in our little rheum posse to KotW's room to talk to him and his parents, who had been exceedingly worried (understandably). Our diagnosis seemed to be correct, so the day ended well.

Friday

Friday was just a brief day of clinic patients. With each passing day, I learn more and more about joint exams and how to do them, lol. Before I left, the M4 and I ran into Dr. C on our way out. He had rounded on KotW earlier, so we asked him how the kid was doing.

His neurological symptoms seemed to be improving which was reassuring. They wanted to keep him over the weekend to make sure he was alright until this week. Dr. C was only concerned about the dosing of aspirin that neuro put him on. As he pulled us aside, he pimped me on how aspirin works in the body. o_O I couldn't come up with an answer initially, so he kept pressing me for an answer. Eventually I remember the correct biochemical pathway (whew!).

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Throughout all this, peds rheum has been quite amusing, mostly because of the people. Also it was amusing since there were so many of us. Pretty much every level of medical education from M1 to attending-level was represented, and that's quite the achievement!

I spent a lot of time with the M4, and she really helped explain a lot of stuff to me. The interns and the residents were also all great to get along with. Even Dr. C, despite his pimping, was really nice. I'm convinced that pediatricians are the nicest pimpers, lol.

While I don't ever see myself going into peds rheum, I think this rotation will be quite enjoyable and certainly interesting.

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Peds Externship: Week 4

Week 4 was my last week in primary care pediatrics in the inner city. Truthfully, it wasn't much different than Week 3. But here it is:

Peds Externship: Week 4

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Insurance issues surfaced with a few patients this week. It's so frustrating. This one kid needed to see a dentist, bad; but it seems that no dentist in the entire city was taking their insurance. Every place on the Medicare/Medicaid list wasn't taking new patients. And the dental clinics that might've had long wait-lists. It's quite simply ridiculous that this is even an issue at all here in the US. Such is the reality. The pediatrician called in the social worker to deal with the insurance issues. When the social worker reported back to the pediatrician, he was just like, "No disrespect - I see you talking, but all I hear is blah blah blah because I don't understand anything about insurance." Also, some insurance companies change their formularies (which drugs they cover) every few months - and it's quite difficult to keep up.

Patient punctuality has been an issue this week. Every evening, the pediatrician's schedule was completely booked with patients. But one day, there was a 2-3 hour block where no patients showed up. o_O It wasn't even that they were late, they just didn't show up and didn't call to cancel. That was really frustrating, as I was bored out of my mind enough to take a nap. Next to the pediatrician. Oops.

At least I saw lots of cute kids during Week 4. There was a family of 3 that came in, and each kid kept giving me a book to read to them and such. It was quite adorable - though we were in the middle of a clinic visit, so my attention was divided. And the babies cooperated with me pretty well. I'm glad to have left the clinic with my track record intact of having made no babies cry. :-P

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Peds Externship: Week 3

Week 3 marked the beginning of my second 2-week "mini-rotation": primary care pediatrics. I think it may be slightly rigged that all the externs are to do their time in primary care peds in an inner city clinic (that, or I just failed to hear that detail in the externship description).

Peds Externship: Week 3

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There's no real point in distinguishing each day from the next, as all the days were fairly similar. The pediatrician I'm working with is in the clinic from 8am until 8pm, Mondays through Wednesday (so I got Thursday and Friday off this week). However, I wasn't in clinic with him that entire time. During the mornings, he's at one clinic where there are very few pediatric patients; so, he often dismisses me and tells me to not bother coming in when there are no patients. In the late afternoon/evening, he goes to another clinic where there are a lot of pediatric patients, so it's a lot busier. There are a few things of note.

First, the pediatrician I'm working with is really young (late-30s to early-40s) and really into social media and networking. I mean, he has several Twitter accounts! He's also the only pediatrician at both clinics (both clinics are under the same company), everyone else are either family physicians or PAs (physician assistants). After this week, I get the feeling that most/all the doctors don't want to work there, but do so out of some obligation or some sense of "doing good" or "giving back." They just don't look that happy.

Second, being in inner city areas, the patient demographic is almost entirely African-American. Which is interesting, because it seems that the patient demographic in the suburbs is almost entirely Caucasian. I should expect this, but it's still rather contrasting. We did see some immigrant families from Nigeria and Liberia and such.

Third, being in inner city areas, almost all (if not all) the patients are on Medicare/Medicaid. The pediatrician held up 5 billing statements and said: "See these? These amount to about $600 because all these patients are on Medicare. If they all had private insurance, it'd be closer to $2000." That's pretty shocking, even though (again) I probably shouldn't be surprised.

Fourth, most of the kids I saw were babies or really young kids (less than 6-years-old or so). There was one day where we saw pretty much only 1-month-olds that were all born within a week of each other. o_O I've realized that I know next to nothing about babies. After almost every well-baby visit, I'd ask the pediatrician, "Is that normal?" Is that umbilical cord normal? Is there supposed to be stuff oozing out of it? Are they supposed to peel? Apparently, the answer to all those questions is: yes. One of the dads looked at me and said, "You don't have a kid, do you? You have that look on your face." Why yes, you'd be correct sir.

It's all just such a contrast. The suburban clinic was really nice. The hospital was even nicer (like, amazingly so). And these two inner city clinics . . . well, you can tell that they don't have much money invested into them. I wish things were different. As the pediatrician told me: while we'd like to think that everyone has a fair shot in the US, that everyone's born equal, the truth is that it's not. Doctors treat patients differently due to access to health care, even if they don't mean to.

It's just . . . unfair.

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Pink Glove Dance

So YouTube is a rather genius time-sink. There are a couple vids that I came across that I thought were cute and/or hilarious.

Pink Glove Dance

I've determined that people at my med school don't have enough fun. I particularly like this vid at about 0:58 minutes - the lone black male researcher in what appears to be an otherwise female lab. That's just precious. :-P

JK Divorce Entrance Dance

This is a spoof of sorts on this vid: JK Wedding Entrance Dance. Either way, quite amusing (particularly towards the end).

Muse - Time is Running Out

This song has been stuck in my head on and off for a few weeks now, especially various string arrangements of it. The Section Quartet has a really nice arrangement, but Vitamin String Quartet also has a good version. It almost makes me want to compose a version of this song too, lol.

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Peds Externship: Week 2

Well, Week 2 was nowhere near as "glamorous" as Week 1. But, I've seen many things that I can honestly appreciate, even if they're not the most . . . stimulating things out there. But I am glad that I witnessed/experienced them.

Anyway, Peds Externship: Week 2

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Monday

Rather than being on the wards like all of Week 1, this week started in clinic. I saw one HIV patient, with 2 HIV nurses and Dr. H. The patient was currently in transition from pediatric HIV care to adult HIV care. Dr. H and one of the nurses have had a long relationship with the patient that stretched back almost 10 years and it showed.

There were moments where the patient broke down and just cried on Dr. H's shoulder. I was not prepared for all the psychosocial issues that Dr. H and his HIV nurses had to handle in addition to the disease itself. I sat by rather awkwardly. Most of the 1.5-hour long visit was not "medicine," strictly speaking. Most of that hour was trying to help the patient work out personal issues - with home situation conflicts, with relationship problems, etc - such that the patient could resume taking meds regularly and on time. Even after all this time, there was still a lot of coping.

After the clinic visit, I was dismissed for the remainder of the day. There was a 2nd patient that didn't show up. Dr. H told me to look up and read articles on drug adherence, particularly with HIV and other chronic illnesses. What I found surprised me. You can read a post about it here.

Tuesday

I met briefly with Dr. H first thing in the morning to discuss a little about what I had read. A memorable quote of his:

When a doctor or a student says, "The patient won't take his/her meds," change "won't" into "can't" in your mind. Think, "The patient can't take his/her meds."

In this way, we (health professionals) allow ourselves to enter the patient's mind and figure out what's going on and why he/she isn't take meds with "perfect compliance."

Then a lab manager came to fetch me and take me to a clinical diagnostics lab. This lab apparently takes patient samples from the hospitals and determines if the patients have some kind of respiratory virus (e.g. influenza A, influenza B, parainfluenza, hMPV, etc). It also diagnoses blood samples for Epstein-Barr virus (EBV) before transplants and such. I followed around one the lab techs and watched her run a parainfluenza sample. Most impressive was the sheer level of regulation that the lab must maintain to be certified. o_O It's good to know that they must adhere to such standards, as the treatment for a patient very well does depend on the accuracy of the tests.

It was particularly amusing listening to them reminisce about the H1N1 flu pandemic last year. The lab had just completed a H1N1 assay for that virus about a week before the pandemic hit (serendipitously), so it was actually ahead of the state and the CDC in diagnosing cases. Of course, this meant that the lab was inundated with samples and the lab techs were very very busy. Like one lab tech said, "There was much consumption of wine at the end of the day."

Wednesday

During the morning, I went to Children's Court Center with 3 other externs. A retired judge met us there and gave us a "brief" history on Children's Court. Then we walked over to the DA's (Defense Attorney's) office to see what hearings we could sit in on. It was kind of exciting.

We sat in on 2 court cases. The presiding judge seemed somewhat peeved at our presence. Children's Court deals with cases like child abuse, foster care, termination of parental rights, juvenile delinquency, etc. The "goal" of Children's Court is to reunite parent and child as best as possible - even if the parents clearly suck. Usually - and curiously - the alternative tends to be worse. Apparently kids don't do well in foster care and such.

At the end, I'm glad to say that I've sat in on a hearing like this that most people only see on TV. Also, I'm really glad I didn't go into law. All that procedural stuff is not for me.

In the afternoon, I transitioned to the basic science lab from the clinical lab. It was like a throw-back to my lab experiences in undergrad, hehe. I didn't see much - just a virus assay to quantify the number of flu "amplicons" in serial dilutions of a lab sample. Alas, the assay failed.

Thursday

The entire day was a continuation of the basic science lab, where they develop assays used by the clinical lab to diagnose patient samples. I watched several lab techs/grad students do various experiments. It is as with all lab stuff - interesting to talk about/discuss, mindless to do, and mind-numbingly boring to watch, lol. I did, however, amuse myself with the "octopette" - an 8-channel pipette - for a couple minutes.

I sat and had lunch with the lab group - it was all pretty chill. I picked up a book that the head of the PID department (Dr. C) wanted me to read (6 chapters' worth) before clinic on Friday. The book was on international adoption medicine. So chances are good I'd be heading to an adoption clinic.

Friday

As predicted, I went with Dr. C to an international adoption clinic (it was in the next city over). We met with 2 sets of parents and their adopted kids (both kids adopted from East Asia). Each clinic visit took about an hour.

The first clinic visit went pretty smoothly. The adopted baby was adorable and seemed pretty well-adjusted. Dr. C seemed a little concerned about the kid's "hyper-geniality." In other words, the kid seemed a little too nice and too cooperative around strangers. In my reading, this was definitely an issue because if kids aren't well-attached to their care-givers, they're nice to everyone and easily walk away with strangers (not a good thing). The clinical psychologists decided it was worth monitoring over the next few years.

The second clinic visit was . . . interesting. The kid was 5-years-old and knew very little English. So a translator was called in. This kid had . . . many issues. Neurological problems (developmental delay), ophthalmologic problems (he was severely cross-eyed), and behavioral issues. The poor parents seemed at wit's end at times. On the way back, Dr. C stated that, while most parents mean well when they adopt such kids, they rarely think things entirely through. Often times internationally adopted kids are "damaged" in some way, either inherently or as a result of institutionalization in an orphanage and/or foster home. He foresaw potential disaster for this particular family.

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And that concludes my time with pediatric infectious disease. I must say I'm kind of sad to leave. There's still so much more to learn and experience!

I met with Dr. H briefly before heading out with Dr. C to receive and give feedback. According to Dr. H, I was "attentive on the wards, seemed interested, and was intellectually present." I'll take all that as good things; though I must say, I was particularly amused at his choice of words for "intellectually present." :-P

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