doc w/ pen

a journalist becomes a doctor before your eyes

Month: February, 2018

The rime of the tired medical student

I recently finished the internal medicine rotation at medical school. Exhausting isn’t the word. How many hours of sleep you get hardly matters. Not when you consider all the listening, watching, walking, talking, typing, reading, and learning, all of it intense.

Most of my team’s patients were on the same floor, but a few were scattered elsewhere in the hospital. Our newly admitted patients, waiting to be brought to their rooms, were downstairs in the emergency department. Hospital elevators aren’t exactly known for their speed, leaving me all too much time to ponder life and death (literally) in the elevator banks.

It was then that I started to notice something: beds. Empty hospital beds that is, sometimes with sheets on them, pushed into corners, or against the walls. They seemed to me everywhere. Not in the way, not obstructing anything, but a constant presence, tucked away here and there.

In my weary state, I began looking at them with envy – especially the ones with a set of folded sheets lying on top.

“If only I could hop up and take a quick nap,” I thought to myself, and again, and again.

As the thought cycled through my mind, a line of poetry was born, inspired directly by Samuel Taylor Coleridge’s 19th-century “The Rime of the Ancient Mariner.” Coleridge was writing about deprivation of another sort – thirst. Here the most famous stanza from his poem:

Water, water, every where,
And all the boards did shrink;
Water, water, every where,
Nor any drop to drink.

That’s exactly how I felt: frustrated by the forbidden ubiquity of beds, and sleep. So as I stood waiting next to the latest set of tempting sheets, in a state of desperate fatigue, I took to whispering the following words under my breath, my modernized incarnation of Coleridge’s legendary verse:

Beds, beds, every where,
And not a place to sleep.

As I did this, I both laughed and sighed inside. I’d then hear the “ding” of the arriving elevator, step into the crowded car, and head to my next destination, thoughts of beds and sleep trailing behind me.

 

Note: The original version of this essay appeared on the online magazine “The American.” You can read it here.

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Looking for books

Usually, I use this space to share my thoughts, feelings, and experiences. Today, I use it to ask for advice.

I discussed in a recent post about how I’ve rediscovered my love of reading books. It started innocently with rereading A Wrinkle in Time, which my sister had offhandedly mentioned to me. I’m now almost done with the fifth book in L’Engle’s Time Quintet. And I’m chafing for more.

I’ve got ideas. I have some cherished authors whose books I want to catch up on. I bookmarked the website listing the National Book Awards going back to the 1950s — lots of gems there, I know. But as with music, some of the best creations never win prizes.

So if you’ve read a book lately and loved it, or have a short list of favorites (or a long list) — of any fictional genre — please do share.

I’m all eyes.

 

My post-medicine to-do list: An update

Ten days ago, I wrote about “My post-medicine to-do list.” Now that I’ve really had a chance to catch my breath and find a new rhythm on this research rotation, I thought I’d write a follow-up on my progress.

Ironically perhaps, given the title of that post, I’ve decided that to minimize my stress level, I will minimize the items on my daily to-do list. These three essential goals, though, are at the top of my list every single day:

  1. Humanity. Have meaningful contact with someone (not just about work) by text, phone, or in person. This reminds me of what’s really important in life: people.
  2. Creativity. Do something creative every day. It could be anything from doodling on a notepad to drafting a blog post. This feeds my spirit.
  3. Movement. Any intentional, anti-sedentary activity counts: going to the gym, taking a walk around the block, stretching on my yoga mat. Just something to get me out of my desk chair, to get the blood flowing. This keeps me in shape physically and psychologically.

Of course, I have many research goals as well. Some are flexible; others more time-sensitive. To both keep myself on track and to prevent myself from feeling overwhelmed, I group them according to must-do tasks (need done today) and can-do tasks (need done eventually, will try to do today if I have time but ok to shift to another day). This system seems to be working so far.

I have also made headway on the to-do list I proposed in that post from 10 days ago. My apartment is cleaner that it has been in months (I even mopped my kitchen floor). I’ve found some great new (to me) songs and musicians on Spotify, including Kidneythieves, Perfume Genius, and Gary Numan. Yesterday was a beautiful day, and rather than take the subway to do my various errands, I walked all over the city, enjoying hours of delicious sunshine. I’ve discovered that I prefer New England-style IPAs (which my new friend Nick at City Hops described as more “juicy,” with citrus notes), and that three of the varieties I’ve tried and loved are made at a local brewery called SingleCut in Queens. Definitely time for a field trip.

I’ve recently rediscovered my love of reading. I started with some childhood favorites: Madeleine L’Engle’s Time Quintet.

I’ve also rediscovered my love of reading. Last week, my youngest sister mentioned to me that she just reread A Wrinkle in Time, one of her favorite childhood books, in preparation for the upcoming movie. Her remark took me back to my own childhood. I was captivated by Madeleine L’Engle when I was a kid. I read everything of hers I could get my hands on, and even wrote her fan mail. In the flurry of clerkships, I’d forgotten that a movie based her most famous book is coming out next month. Clearly, I needed to be prepared too. So I immediately bought A Wrinkle in Time online, then proceeded to devour 90 percent of it in one sitting. Clearly, I could not wait, not even for 2-day shipping, to get the next book in this quintet. So yesterday I went to a real-live bookstore and bought the next three books in the series (the fifth wasn’t in stock, but I can wait for shipping on this one). I forgot how much I love fantasy novels, being transported to faraway worlds, bringing the vivid descriptions alive with my imagination — a creative endeavor in its own way. L’Engle said it well herself:

A book, too, can be a star, explosive material, capable of stirring up fresh life endlessly, a living fire to lighten the darkness, leading out into the expanding universe.

– Madeleine L’Engle

Tapping into that seems like a pretty good goal too, if you ask me.

Only in medical school (#4) …

… is this set of transitions possible:

Test question about a tumor
⬇︎
novel ice cream flavor
⬇︎
Google image-aided illustration complete with
organic chemistry molecule sprinkles

But that’s exactly what happened last week as I was doing practice questions in advance of my medicine shelf exam. A question came up about pheochromocytomas, which are tumors usually found in the adrenal medulla. These tumors cause inappropriate secretion of catecholamines such as epinephrine. This can cause episodic headaches, hypertension, sweating, and a fast heartbeat. I don’t remember if I got the question right or wrong. What I do remember is that in the answer explanation, there was mention made about how these tumors can cause elevation in the urine of a catecholamine breakdown product called vanillylmandelic acid (VMA).

You have to understand that doing these questions is hard work. The questions themselves are incredibly difficult, often to the point of being demoralizing, and the detailed answer explanations require exquisite attention. It’s easy (and tempting) to get distracted. And on this particular evening, I did.

“If I owned an ice cream store,” I thought to myself, “I would name my vanilla ice cream flavor ‘vanillylmandelic.’ ”

I chuckled (probably out loud). And then, reluctant to return to the practice questions, I thought about how I might illustrate this hilarious (to a medical student) concept. I minimized the test question window, and brought up Google images. I found a luscious bowl of vanilla ice cream, in a turquoise bowl to boot. (Turquoise is my favorite color.) I also found the molecular structure for vanillylmandelic acid. (Whew, definitely brought back memories from organic chemistry.)

My sense (of dedication? guilt?) returned after perusing Google images though, and I went back the practice questions.

This morning, with medicine behind me, I finally completed my illustration: a bowl of vanillylmandelic ice cream with multicolored vanillylmandelic acid sprinkles. Here is the final result:

 

On a side note, I also learned today from Wikipedia that not only is vanillylmandelic acid a metabolite of catecholamines, but it is also a chemical intermediate in the synthesis of artifical vanilla flavoring. So really, my idea isn’t so crazy after all. Right?

Don’t answer that.

My window to the world

I didn’t get much natural light while I was on my medicine rotation, so I made a point to look out the picture windows near the unit where I worked. It’s a lovely view.

This morning at 9 a.m., my class has an orientation meeting to our four-month research block. When I exit the door of my apartment building around 8:45 or so, I hope to see something I’ve had very little of on my medicine clerkship: sunshine. (The forecast today calls for clouds, but that’s ok — there are other sunshine-y days ahead.) For the last several weeks while on medicine, when I’d leave my apartment in the morning, it was dark. When I left the hospital in the evening, it was dark again.

It’s disorienting. Without daylight, you lose track of time. It happens to everyone in the hospital. I remember seeing a patient in the ED late one morning. She asked me what time it was. I told her it was 11:30. She looked surprised, and told me she thought it was later than that. I quickly realized she thought it was 11:30 p.m., not 11:30 a.m. Granted, she was rather confused to begin with, but the lack of windows in the ED (and the lack of a clock) only made matters worse. I honestly told her that being in the hospital, I sometimes lost track of time too.

I was fortunate enough, though, to get regular glimpses of the outside world that grounded my circadian rhythm. To get from the elevators to the ward where I worked, I had to pass a series of gigantic picture windows. Look straight out, and you got a lovely view of the East River, and one of the bridges in the distance. Turn slightly to the right, and you got a lovely view of the New York City skyline. Every morning on my way in, and several times throughout the day, I would take a moment to look out those windows. To chronicle the various views — of sunrise, snow, and sparkling city lights — I started taking pictures through the windows with my phone. Here are my favorites, broken up into two groups, the skyline view and the East River view.

Click on any of the images to open a larger, slideshow view. Oh, and pardon the glare — you know, those harsh hospital lights.

 

Skyline view:

 

East River view:

My post-medicine to-do list

While on my internal medicine rotation, I’ve done lots of steps and stairs, as my iPhone attests. But when the clerkship ends, I need to get back into a regular gym routine.

As I write this, I’m almost done with my internal medicine clerkship. Just 12 hours to go. Wednesday was my last day in the hospital. Thursday I crammed for my exams. Today I plow through a 110-question multiple choice test, and a 2-hour EKG-reading test.

It’s been an exhilarating, and exhausting, eight weeks. I’ve taken more ownership of my patients than in any other clerkship. I’ve gotten to know them better, and been more intimately involved in their care. All of that has been immensely rewarding. I’ve truly felt like part of the team, like I’m contributing in a meaningful way. It has also been devastating, for example when a patient took an unexpected turn for the worse, a turn from which they were not expected to recover.

The work schedule has been intense too. Monday through Friday were generally 12-hour days, counting both in-hospital time and time I spent chart-reviewing my patients at home in the morning. Saturday, we generally were let go a couple of hours early. Sunday was my day off. But not really. It was really my day to catch up on studying. Because when I got home Monday through Saturday, it was hard to bring myself to do more than 10 (maybe 20) practice questions before my mind shut down. Forget trying to read or memorize anything. So Sunday was my day to study. Doing “life stuff” got put on the back burner. “Survival” was my mantra.

It’s been too long since I’ve visited the Tiffany windows at The Met.

That means that this coming weekend, I have a lot of catching up to do. It won’t all happen in a day. Thankfully, next up is my four-month research block. This will be plenty of work too, but won’t involve the same crazy schedule. So here are some items on my to-do list, in no particular order:

Spend time at places other than the hospital and my apartment. I’m looking forward to seeing the sun (other than through a window), and visiting some of my favorite NYC haunts (like The Met), as well as exploring some new ones (like the 9/11 Memorial).

Spend time with my friends and family. I’ve done very little of that recently, given my lack of time and energy post-work. It’s time to catch up, both in person with those who live in New York, and on the phone with those who live elsewhere. (You know who you are!)

For too long, my vacuum has sat abandoned in my closet.

Clean my apartment. I especially need to vacuum. Now that I have long hair, fallen strands have a tendency to collect in little clumps along my baseboards. Scooping up the biggest ones with my hands is really not cutting it.

Do laundry. I mean ALL of my clothes, and in actual washing machines, not just emergency items in my bathroom sink.

Do my dishes. Regularly. The other morning, I had to use a fork to stir the sugar and half and half into my coffee. Not ideal.

Eat better. I need to get back to cooking regularly, rather than slapping together a ham sandwich for dinner, or picking up unhealthy take-out. (E.g., no more orange chicken from Panda Express, which is directly on my way home from the hospital.)

Exercise. While working in the hospital, I run around a lot, from floor to floor, so get in quite a few steps and stairs. But I need to get back to a regular gym routine, and back to doing my mat Pilates.

Meditate. This is something I’ve wanted to try for years. Medical school is stressful, and I know residency will be too. I think meditation could help with that. Ironically, all the stress lately has prevented me from trying something that might reduce my stress. So as I head into a less stressful block of time, I want to establish the habit so it hopefully sticks when I really need it next. A friend of mine recommended a couple of apps to try, including the Headspace app pictured at left, so that seems like a good place to start.

On a side note about stress, I’ve had multiple residents tell me that they much prefer the stresses of residency to those of third year. In residency your day off is actually a day off; you don’t have to study. You’re also not worried about constantly being evaluated by everyone around you, which is one of the major pressures of these clinical rotations (and something I plan to write a separate post about). A classmate said that one resident told her: “My worst day as an intern was still better than my best day as a third-year medical student.” I’m not sure everyone feels the same, but at least some of the stresses of medical school (studying for exams in the evenings and on your day off; having to always be “on” since you’re always being evaluated) will dissipate. And, I’m sure, be replaced with other ones.

Be creative. Using my hands to make things is such a rewarding outlet for me. I simply haven’t had the time or energy for it lately. I’ve missed it.

One of my new favorite songs, Snake River Conspiracy’s cover of The Cure’s “Lovesong.”

Write. I have a long list of essay ideas that I simply haven’t had time or energy to tackle. Several of them relate to things that have happened during my medicine clerkship. I look forward to sharing those experiences with all of you in the coming days and weeks, as I process all that’s happened lately.

Find new music. Over winter break, my youngest sister, Joy, convinced me to join Spotify. I’ve managed (barely) to keep up with the “Discover Weekly” playlist that Spotify sends me every Sunday night, saving the songs I like to a new playlist I aptly call “New discoveries to explore!” I’d like to delve into that list (which currently has 119 songs on it) and to investigate some of those artists and their albums more fully.

Watch TV. I don’t normally do much of this to begin with, but I haven’t even turned on my set in weeks. It would be really nice to relax on my couch in front of a good movie or TV show episode without feeling guilty.

My purchases at City Hops. Several of the beers are local, brewed here in NY state — pretty cool.

Learn about beer. And drink it, of course. For the longest time, I thought beer was simply gross. The closest I got was Mike’s Hard Lemonade. I stuck to wine, or my favorite, gin & tonic. Then I dated someone for a little while who enjoyed beer, so I would try what he bought. Turns out it wasn’t so bad, though still not my choice of adult beverage. Then my sister started bringing craft beers to family gatherings, and not only did I tolerate them, I actually liked them. It was a revelation. I’m particularly partial to IPAs, of all things. But the selection at the grocery store down the street is atrocious, and a six-pack costs about $5 more than it should. There’s a place called City Hops on 2nd Avenue not far from me. I’ve walked by it dozens of times, and often thought about going it. Yesterday I took a study break and did just that, and about $40 later, was the proud owner of seven different craft IPAs. I’m definitely drinking one tonight night to celebrate making it through medicine intact.

Pamper my plants. Many months ago, I bought some lovely houseplants from Home Depot, and some lovely plant stands online. The idea was to infuse a little bit of “green” in my environment as I live amid the concrete jungle. Unfortunately, I dramatically overestimated the amount of natural light that would be cast onto the corners where I put these plant stands. My poor plants became bedraggled over time. Luckily, they quickly perked up when I put them on my kitchen windowsill. But I can’t really enjoy them there. So I want to buy and install some grow lights, so I can put my plants back on their stands, where I can see them better, and enjoy them more.

My plants are fine on my windowsill, but once I get some grow lights I can put them on my plant stands (which are in places that don’t get much natural light, but are where I can see my greenery better).

The home page for FREIDA, the American Medical Association’s online gateway to exploring residency programs … *gulp*

Think more about my future. Before I know it, September will roll around, and I’ll be submitting my residency application. That means I need to figure out where I’m applying. And THAT means I need to do some leg work (well, more like “finger work” as I explore residency programs on the Internet). This is a little terrifying, as you might imagine. It’s also thrilling.

Clearly, I have a lot to catch up on. But it’s good stuff, fun stuff, stuff that’s rewarding in a different way than patient care.

Now, in anticipation of this upcoming reprieve, I wonder where my TV remote has gotten to …

The anatomy of a heart, and a water bottle

As I explained in my last post, medical descriptions are sometimes a little … strange. Some of them, as I learned yesterday, are also generation-dependent.

I was sitting at my desk after a long day in the hospital, studying for my medicine shelf exam (aka final exam). While doing cardiology review questions on my laptop, I came across a scenario in which a woman had a pericardial effusion. Essentially, this is a collection of fluid surrounding the heart. The chest x-ray was described as showing a “‘water bottle’ heart shape.”

Below is an image I found online that’s similar to the one from my practice question. Think about your conception of a water bottle, then look at the image.

This is the chest x-ray of a patient with a pericardial effusion.

Staring at my laptop screen, I thought to myself, “This doesn’t look like any water bottle I’ve ever seen.” I tried to think creatively, how one might fit a Fiji, Evian, or Aquafina bottle into that globular shape. Try as I might, I failed.

So I Google-image-searched this phrase: “pericardial effusion water bottle silhouette.” Most of the images that came up looked just like the one above. That didn’t help me. But when I found this image on Radiopaedia, an online collection of radiology cases, (see below) the analogy suddenly made sense. Whoever first compared the heart silhouette in a pericardial effusion to a water bottle probably never saw a plastic, disposable water bottle, like the ones we use today. His (and it was most likely a “he” since most doctors were men back then) conception of a water bottle was very different from mine. As Radiopaedia explains, “The fluid-filled pericardial sac casts a cardiac silhouette that resembles an old-fashioned leather water bottle.”

The “water bottle-shaped heart” in pericardial effusion explained, with a visual aid. From Radiopaedia.com.

I initially felt satisfied with my investigation, but the journalist in me cried out for confirmation from a second source. So I went back to Google images, digging a little deeper. And I found these:

This interpretation of “water bottle” was quite different. I don’t really consider these glass bottles “water bottles” in the same way I do both the plastic bottles of today and the old-fashioned leather bottle in the Radiopaedia image. But then again, what do I know? Maybe around the time x-rays were first being used clinically, in the late 1890s, the vessels above were considered “water bottles.” I’m a little skeptical of this, but the image with the greenish x-ray and the clear glass bottle comes from a well-respected medical journal, BMJ Heart. So it’s hard to discount this comparison completely.

To try and come up with a little more information, I Googled the same phrase “pericardial effusion water bottle silhouette” to look at text results too. The seventh result was a 2016 article from an international emergency medicine journal. The article is called “Message in a bottle: The use of chest radiography for diagnosis of pericardial effusion.” I didn’t read the entire article (I was studying for a test, remember?) but I did skim it, looking for “water bottle” references. The whole article is about using the “water bottle sign” to clue you into the presence of a pericardial effusion, and to help you decide whether to perform advanced imaging. The article actually refers to the water bottle sign 12 times. But not once does the article explain how this image looks like a water bottle, only that it does.

I am still studying for my test (I’ve got 48 hours left to master the field of internal medicine). So I must stop my descent into the rabbit hole of this question. Perhaps someone, somewhere in the world, still uses a water bottle that resembles the globe-shaped heart seen in a pericardial effusion x-ray. Perhaps that person would understand this arcane medical reference. But for the most part, at least to those of us in medicine who are using this reference today, it is outdated. It lives on, though, because as much as medicine is about progress, it is also about history.

Only in medical school … (#3)

… will you come across the description “steamy cornea” and actually take it seriously.

I read said description this morning as I was doing UWorld practice questions in preparation for my medicine shelf exam. The description was in reference to the eye exam seen in angle closure glaucoma, which is also associated with a red eye and a nonreactive, moderately dilated pupil (see the photo below).

Just in case you were wondering.

What the eye looks like in angle closure glaucoma, a medical emergency that can lead to vision loss if not immediately treated.