Saturday, October 1, 2011

Fair's Fair

"Fair" is an important part of "fair warning". Yelling "Fore!" as your Titleist 3 ricochets off an unsuspecting golfer's head doesn't qualify. That would seem to be too late to aid anyone and, while the "warning" portion still applies, you lose the implied utility of providing not only helpful information but also a chance to make use of it. You are giving the warned party time to react, and that's important. Imagine what Abe Lincoln could have done with fair warning. Probably retained a good bit of his brain matter, would be my guess. And so it was that on my first overnight call on Labor and Delivery, the nurse midwife pulled me into one of the labor rooms the moment I set foot on the floor. Knowing my past predilection for wooziness in such situations and this being the first time I would view childbirth, I gave the midwife fair warning as I donned sterile attire. "You told us during orientation that usually one student in every OB/Gyn rotation group faints during a delivery. I'm Aron." I also told her it was more a possibility than a certainty, but that's less fun. We covered proper protocol should such a thing happen and off we went as the patient was fully dilated and starting to push. This week on Flash Gordon: Can our intrepid hero overcome the threat of vasovagal response and stay on his feet during the live birth of a human child? Yup. Shoot I blew the suspense so I guess I wasn't made to write old timey radio drama after all. Objectively, the proces of childbirth is disgusting and I'm fairly certain I don't need to explain in detail the reasons why. Yeah, I've heard the fluffy arguments about how The Miracle of Life trumps the rest of that stuff, like the smell. There is a distinct smell that goes along with childbirth that isn't so much offensive as it is the smell of someone caramelizing the top of a creme brulee but utilizing a pile of old car tires instead of a ramekin. It turns out, though, that there is actually something slightly magical about the whole process though and it does indeed trump the various offenses. So the midwife delivered the baby, I delivered the placenta (gross!), and no one got hurt or wound up face down unconscious in birth materials. I can't say I was looking forward to OB/Gyn. In fact, of all the rotations lined up for the year, OB/Gyn was the only one I approached with apprehension. Six weeks later and it turns out I rather enjoyed the rotation, enough that I'd almost consider OB/Gyn as a career choice. The chance to do both clinical work and surgery is enticing and women's health is a neat field. Consider one particular case I participated in on an overnight call. Retained placental tissue caused bleeding in a mother As the 71-year-old attending continued working to remove the offending tissue, he recognized the need for more serious action and ordered blood and blood products as well as paging the surgical team in. By the time the operating room was assembled and the patient prepped, an hour and a half had passed with the patient missing well over a liter of blood. The attending decided that it was too late to do anything but an emergency hysterectomy and since he's old school, he did so without electric cautery, opting instead to ligate everything with suture material. By 2:45am, surgery was over. Because the attending ordered blood early, the patient got necessary transfusions in a timely manner during surgery. What was a perilous situation for the patient resolved successfully due to the calm anticipation and diligence of the attending after midnight. Cool stuff, OB.

Sunday, August 14, 2011

One Flew East, One Flew West

As the counselor unlocked the door to the unit to give us a quick tour, I got nervous. I’m certainly no stranger to hospitals at this point between growing up with my parents, volunteering, completing a senior design project at Children’s Memorial, working at Cedars Sinai and so on. I’m quite comfortable walking around inpatient units. I ‘ve experienced high-tension environments shadowing an ER doc through some overnight shifts, spending time in the ICU and OR at Children’s, and of course cholera care in Haiti. Why then was I suddenly quite uncomfortable and apprehensive about how I’d make it through the next six weeks? The opening sentence to the paragraph holds the answer. Of course I withheld information, as the counselor’s title is Mental Health Counselor, but the locked door is a clue that the unit is the inpatient psychiatric floor and this experience was straight out of One Flew Over the Cuckoo’s Nest. My six colleagues and I were led onto the unit in the early afternoon, where patients are at their most active. Several manic patients were out in the hall acting boisterously, one rapping loudly and walking around aggressively. Seven white coats in a tight bunch drew plenty of attention from manic and schizophrenic patients alike, drawing bizarre questions or simply attracting attention. Dark-blue-scrub-clad nurses and mental health counselors in burgundy were trying to get patients back into their rooms, social workers worked furiously in the nurses station, all while environmental services folks ran the floor polisher and swapped out linens. Chaos. The other med students and I shot each other grimaces, conveying with clenched teeth the same feeling you would experience while paying for groceries in pennies with Ron Artest in line behind you. Day one.

It turns out that inpatient psychiatry from a medical perspective looks nothing like the image of Freud psychoanalyzing patients. Getting hospitalized for psychiatric reasons requires pretty severe impairment in overall function or risk of harm to yourself or others. As such, most of our patients were schizophrenics with acute exacerbations, bipolar patients in manic phase, patients suffering from episodes of Major Depression, or substance abusers with an underlying psychiatric diagnosis. The role of our attending focuses more on pharmacotherapy and social work than I would have guessed. For someone with debilitating schizophrenia, there just isn’t much to do until the patient has the right mix of medications to keep their thoughts more organized and psychosis at bay. Imagine conducting an interview where the response to your question, “Does anyone in your family have a psychiatric illness?” with the response, “You know when you hear music, like a Pink Floyd album, it really takes you back?”. The effects of antipsychotic medications are incredible. The police brought one of my patients in after bizarre behavior in the streets. The patient responded to all questioning in the ER and on our floor by grunting or mumbling incoherently. After trials of several antipsychotic medications, we found one that worked. A patient who remained in bed for most of the day previously now spoke in short sentences, was dressed and walking around, and no longer had hallucinations; the difference was night and day. Of course after discharge he stopped taking his meds and was back in the same condition soon enough, but that’s a different matter.

Part of our rotation was just learning the ins and outs of being an M3 in the hospital. How do I interact with my attending? How do I write notes? What exactly am I responsible for? Getting those questions answered within the first few days made things a lot easier. We got a feel for what drug seeking looks like and how system abusers behave. The law passed in Florida that requires drug testing for Medicare recipients makes a lot of sense. We’d have patients who blew their check on drugs and then didn’t have a place to stay so they’d get themselves admitted to the psych ward. Housing for free, on the government’s tab so who needs a job? As long as this country is reforming healthcare and trying to cut down on costs, Medicare deserves a look too. Overall, though, a great experience. It sure beats seclusion in a library.

For the last two years, I’ve been waiting. Sitting down and studying for hours on end does not provide any enjoyment. I love learning, but man is the process agonizing. Learning through doing? I’ll take it. So that’s what this year is about, and I’m already enjoying it. The benefit of this rotation is that there are no residents or interns on the psych ward so I was responsible directly to our attending and responsible for two or three patients at a time. My fellow M3s and I got to do the psychiatric evaluations on new patients and then write progress notes daily. Our attending trusted us to help make medication and discharge decisions, which was clearly neat. There were times there when, just for a moment, I felt like a doctor.
OB/Gyn is next and has the reputation as the most difficult rotation in terms of hours and intensity. Catch.

Wednesday, November 24, 2010

Pictures from Haiti

I promised pictures, so here's a link to the Facebook album.

We didn't take the camera into clinic and didn't take nearly enough pictures. Such is life.

Monday, November 15, 2010

Haiti, Part 2

When we last left our intrepid hero, he was pondering the magnitude of an overnight shift with incredible responsibility and, as a result, an incredible growth experience. Going from an M2 entrusted to occasionally take a history and physical while precepting to that, well, it's not an experience I'll soon forget. So we made it back to the mission in time for breakfast on Thursday morning, the several hours of overnight rain now reflecting the morning sun in the puddled streets. With pancakes on the table and the other crews around, we got to catch up a little on the goings on at the mission night shift. I wasn't the only person in the midst of a transformative experience. Without waxing saccharine on the nature of service in a place like Haiti, I will at least note that Newton's third law applies.

Rachel and I both had flights back to the States on Friday and due to the inexact (or: wildly unreliable) nature of Tortug Air, the intraisland carrier, we had planned on returning to PAP on Thursday. Before arriving in St. Louis du Nord, I would have been perfectly happy to come back a day before our flights. Rachel did take a flight back on Thursday, along with LP and a few others from the various teams, as she wanted to spend one more day at the TB clinic before returning to the States. Since I had no such appointment and with the rest of MMRC set to fly Friday morning, I stayed. Thursday morning got interesting quickly as I learned that two more bodies lay waiting for decontamination and preparation for last rites and their families. MMRC's Haitian jack-of-all-trades Billy, Wilson, a Medical Teams International volunteer from PAP, and I headed off to care for the bodies prior to the arrival of the pastor. Overcoming the initial shock of dealing with bodies brought peace to the task. There's nobility in allowing a family to pray and pay their last respects and I found that I was able to treat an otherwise dark task with a sense of duty. While we weren't dealing with anything like what BP and LP saw post-earthquake, it's still an important hurdle to clear for a kid that used to get nauseous during tense movies (circa Apollo 13 in theatres).

Continuing the theme of the week, I stayed awake through the middle of the afternoon, this time to give Les a hand with logistics while he attended to business elsewhere. The mission clinic running smoothly and medical supplies sorted, I had the chance to spend some time with a few of the crew not currently on shift. I've mentioned that the teams at the mission were composed entirely of bright and übercapable people. For anyone convinced that they are bordering on misanthropy, I dare you to spend time in a situation like that with that group of people and uphold your belief. There are people who do the occasional begrudging community service to improve their resumé and then there are the good people from MTI, Open Hands, Grass Roots, NWHCM, and MMRC: instant restoration of faith in humanity. Not to put too fine a point on it, but if you have money lying around for donation to charity, I'd recommend sending it the way of Paul Sebring and Paul Waggoner. I was perhaps the worst elementary school salesman of chocolates and Entertainment Books in the history of Hutton Elementary; I have a hard time pushing people toward something I don't believe in. I believe in MMRC and can honestly guarantee that every cent they receive will be both needed and put entirely toward funding exactly this sort of work. This is about the only time you'll hear me advocate in this way. Go here to donate.

Some scant late afternoon sleep brought me to dinner, after which the remaining MMRC crew readied for our evening shift and morning flight. Also, Liz and I shaved BP's head down to a mohawk. That is the face of extreme humanitarianism. Since another group showed up with able bodies on Thursday, our Friday night shift mostly consisted of orienting and then turning over care. That freed us up to get a few hours of sleep before our UN chopper Friday morning back to Port-au-Prince. Correct. We got a lift from the UN. Waiting for the chopper at a soccer field meant drawing a crowd of locals, including a gaggle of kids. We played games with them, gave out hugs and emails, and laughed while Bridget arm-wrestled her newest boyfriend. There had better be a picture of that somewhere. There's nothing quite like the experience of climbing into a helicopter piloted by three Russian guys who don't speak a word of English. We unloaded the supplies they brought for St. Louis du Nord and then, through a series of gestures and grunts and spasibas (about the only word any of us knew in Russian), we hopped in and enjoyed a gorgeous ride back to PAP. Our exhausted team spent the flight taking pictures and giggling like children until touch down, where Junior met us outside of the UN base with a tap tap and we jostled our way back to the MMRC compound. Pondering the effects of a severe cholera outbreak in PAP as we swerved through packed streets, it was (and is) disheartening to realize how much coordinated effort it took to treat a small area like Port de Paix and what that means for Port-au-Prince.

A quick turn around at the compound to shower, pack, and grab Rachel left just enough time to say goodbyes before we headed back to to the airport. I can't remember a time when I've been so attached to people after just a week. Rachel and I had the same flight back to Miami and used the time to debrief and catch up as we so rarely see each other these days. She asked how I felt about the last week. My dad and I have an expression for all the times we've been stuck in driving rain on bike trips and the like, which is that we've just had "another great father/son experience." The implication is that as miserable as the situation might be in the present, we'll have a story to tell and something to look back upon and laugh. This wasn't such a situation. With the experience I had, the people I met and worked alongside, and the journey itself, I've just had the most incredible transformative week of my life. Thank you Rachel for continuing to prod me to make the trip even when we weren't sure what I'd be doing. Thank you to MTI, Grass Roots, Open Hands, and the Northwest Christian Haiti Mission for your collective diligence, enthusiasm, and drive. Finally, a special thanks to Big Paul, Little Paul, and the rest of the MMRC gang. You are all incredible. I'm hooked and I'll be back as soon as possible. In the mean time, keep bleaching your water supply and stay safe.

On a completely unrelated note, I'm in the process of looking into cutting short my trip home over winter break in order to return to PAP. Forgive me Mom and Dad, but Spokane doesn't need two weeks of me. However, LP had better punt Walter's rooster over the fence before that time so I can get sleep. Also, sorry for stealing a few pictures from MMRC people. At some point we'll have an album up for viewing.

Sunday, November 14, 2010

Haiti, Part 1

Touching down in Port-Au-Prince, I had very little idea what to expect. My sister (Rachel) talked me into coming down for a week and, while I knew I would have a transformative experience, I knew little more than where I was staying. During Rachel’s first trip to Haiti she met the crew at MMRC Global, led by Paul Sebring (Big Paul) and Paul Waggoner (Little Paul). After arriving in Haiti following the earthquake, the Pauls met while doing heavy volunteer work at a hospital. Since then, they have both relocated their lives to PAP in order to set up and run an NGO that provides medical supplies, services, and personnel to areas of need. Both are absolutely incredible in their energy and ability to get things done. More on that later. After picking up myself and another person coming to work for MMRC, Big Paul took us back to the MMRC compound where I settled in. Rachel came back from her day of work at the TB clinic and we sat around talking with the incredible group of people.

On Sunday morning, Rachel offered to take me with her to Lopital General for a day on the TB ward. We walked the mile to the hospital accompanied by Billy, a Haitian MMRC employee/friend/translator/etc. As he took us through the middle of a tent city, I couldn’t help but gape. Thanks to the utter lack of government or infrastructure, the general situation in PAP has not changed much. Haiti’s streets are still strewn with rubble, her people are still without homes, the palace still lies in ruins, and poverty abounds. It's almost beyond belief. Since the TB clinic is neither run by the hospital nor particularly well tolerated by the hospital, the lead doc (Megan Coffee) not only cares for patients the hospital won’t care for, but also brings in food, sources the medication she gives away (again with help from MMRC), and buys bottles of oxygen out of her own pocket. The generosity of outsiders is a common theme throughout this trip. So I got to meet the interesting collection of patients that have kept Rachel busy for the last month. From a delightful man handcuffed to his bed thanks to a strange imprisonment in which he didn’t commit a crime to a slippery patient with diabetes, TB, and AIDS who doesn’t take care of himself and has to be forced to eat, it’s quite the assortment. Between watching Rachel do thoracenteses and keeping an eye on patients, daylight passed quickly.

We returned to the compound after dark to learn that the Pauls received a call for help at the Northwest Haiti Christian Mission in St. Louis du Nord. The clinic there was treating a cholera outbreak with help from several other NGOs and was about to be short in both care and supplies. By the time we walked upstairs, the gang had a plan in place to charter a plane the following morning to take a team and 1,300 lbs of supplies up to the mission. MMRC is agile, relentless, and dedicated. These guys just get it done without having to worry about filtering through layers. We woke Monday and assembled our team: Big Paul, Little Paul, Rachel (as our only M.D.), Micaela and Jeanne (two nurses), Yvette, Billy, Riaan (a US Marine and EMT), and myself. We even picked up another nurse, Carol, at the airport to head up with us. After some nonsense with Tortug Air, we had our flight and headed north.

Grant from the Northwest Haiti Christian Mission picked us up at the airport in Port de Paix and shuttled us the 8km to the mission where we dropped off our supplies and gear, ate, and quickly slipped into scrubs to staff the 7pm to 7am shift. The clinic is broken into a main treatment area for sicker patients and an oral rehydration room for patients no longer vomiting and in reasonable condition. It’s worth noting that Rachel was in her element and on her game, in addition to whatever other clichés describe that sort of thing. After her earlier outing to fight an upwelling of cholera at St. Marc, she had first-hand experience to back up the WHO guidelines and MSF protocols for cholera. On account of her experience, we hit the ground running. As it turns out, cholera isn’t particularly tricky to treat. Other than antibiotics where appropriate and the rare antiemetic, patients need liters upon liters of fluids. To compensate for the vast quantity of fluid lost to diarrhea and vomiting, patients get bag after bag of IV Ringer's Lactate until vomiting ceases and they can hydrate orally. Several patients needed more than 10 liters of IV fluids. A few even required epinephrine to buy Rachel and the nurses a few minutes in the hunt for a vein and many more received intraosseous lines. Heck, I even placed my first IV. Whatever it took to get fluids into people. Honestly, convincing the patients and their families that drinking Oral Rehydration Salts solution is the same as getting an IV was the most vexing task. If it doesn't come in a bag and drip into the catheter in your arm, it apparently isn't medicine. The job becomes even more difficult when the families of the patients wait to bring them in. Families that live a reasonable distance away can't walk to the clinic in the dark and so the crowing of roosters is a warning bell for impending mayhem. At sunrise, new patients began pouring in. Thanks to a continued push from a tired but energetic team and timely relief from the next shift, we finished out and handed off to the next team in time to grab some decontamination and breakfast.

Coordination of the teams and materials was a joint effort between Grant from NWHCM, Les from Grass Roots United, Ted from Medical Teams International, and the Pauls. Our stay at the mission overlapped with two other incredible groups from Open Hands and Medical Teams International. Thanks to the extreme conditions and nature of the people involved, our stay at the mission was not unlike summer camp: Dorms with bunks, a paucity of sleep, and a common interest. And cholera. Lots and lots of cholera. In downtime between shifts, we’d sit around and shoot the breeze. You won't find a more dedicated, energetic, or friendly group, all of which made the difficult moments better.

The first night wasn't all sunshine and lollipops and copious watery diarrhea. We lost a few patients. The first passed away a few minutes into our shift. A woman died on the floor of the clinic after her family carried her in face up, aspirating her own vomit. Not even the best efforts of our team were enough; those were difficult minutes, made more difficult by the fact that the family was right behind us. Since it was my first real experience with death, it took a toll. Thankfully, Riann the Marine had some perspective to share as the two of us carried the body out of the clinic and followed decontamination guidelines to prepare the body for the family.

The second night was similar to the first. We took our handoff after dinner and ran with it, completing a very productive night in terms of patient care. According to the stats as reported by Ted, our collective groups held mortality well below the average for treated cases of cholera despite somewhat limited resources and long hours. Thanks to more incoming help, including two more awesome MMRC-affiliated nurses (Bridget and Liz), we schemed to start running three 8 hour shifts at the mission clinic to take effect after our Tuesday night 12 wrapped. Since we were also trying to help the hospital at La Pointe, halfway between Port de Paix and the mission, we sent two people a night over there for 7pm to 7am shifts. On Wednesday night, those two people were myself and Jeanne, a nurse just out of school. Knowing that it'd be simply the two of us with extremely limited resources, a hospital that refused to give patients meds or fluids unless they bought them from the pharmacy, sporadic electricity, and only three Haitian nurses, I had every right to be nervous.

Jeanne and I were dropped at La Pointe and set off to get acclimated with our charge for the evening. With around 75 patients and their family members packed into the cholera area and a tent just outside, our shift carried the promise of a busy night. After making our first rounds and getting a thorough handoff from the Haitian doc on duty, we settled in. Between convincing each room of patients to have community "parties" once an hour to wake the patients up and get them to drink and dealing with the lack of available IV fluids and potable water, we stayed busy. The responsibility of taking the reigns was liberating, however. With the help of an incredible local translator, Moise, we stayed on top of our patients and even had the wherewithal to transfer a young child out of the cholera area after deciphering that she had only one case of vomiting six hours prior with no diarrhea and was therefore not likely to have cholera. As one of our patients was still cold to the touch with a thready pulse after 9 liters and complaining of left flank pain along with developing tachypnea (~55 breaths per minute. Yikes.), we got phone consults from Rachel on her clinic shift and a Haitian doc at home in bed. After the Haitian nurses administered the suggested antibiotics and dexamethasone, he made progress*. As daylight broke, we sat exhausted on the desk in the makeshift clinic office with rain falling on the tin roof. Out of nowhere, the women in the room next to us started singing in chorus. Surreal.

*He looked a lot better 24 hours later.

Daybreak also brought in a flood of patients, several critical. One 75 year old man, carried in by family members, lacked a carotid pulse. As Jeanne and a Haitian nurse each worked furiously by headlamp to try to get IVs down, I raced to the pharmacy to get epinephrine. They didn't have it and we made an ultimately futile effort at CPR, my first such attempt. Amazing how training kicks in without thought in dire situations. After standing stunned for a few moments and, despite frustration with our lack of ability to do anything thanks to a patient too far gone and no resources, we turned to face a new stream of patients. The diligence of Jeanne and the Haitian nurses allowed for quick placement of IVs in a handful of patients while I briefed Les and Ted, who had shown up to take us back to the mission. Both were crucial in helping with crowd control, bringing in some much needed drinking water, and calming the situation (and myself) down tremendously. As we chopped down the very rough road back to the mission, it occurred to me just how rare an experience I'd just had.

I'll break it up here as this is already becoming a novel and I'd like to catch some sleep before class starts tomorrow. The rest of my account of the trip will be up within two days.

Sunday, August 15, 2010

Brief Thoughts On a Year

I know I should have some massive overarching takeaway from an entire year of medical school. Something about what it means to be a physician or some new insight into the field of medicine. Figuring that heading back to LA for the summer and removing myself a bit from a long and tiring year would allow me to gain some perspective on the whole ordeal. It didn't. Not that I didn't learn anything last year, far from it, but there wasn't much in the way of revelation. Mostly, I learned that M1 year is about survival and finding ways to stay sane. Every student is different. Some people are capable of studying for 8-10 hours at a time without going crazy and some aren't. For me, the blueprint has always been simple: exercise, cook, and take time to be brainless. These provide some short term relief.
There's a larger issue with this sort of experience, however, and it's an issue that has become fairly standard for my generation. Everything we do is to get to the next level, to get the future we want. We spend high school trying to get into college, college trying to get into grad school or snag our first job, and so on. After working to get into med school, we discover that now we have to worry about residencies. At some point, the message was lost that we should enjoy the journey along the way. (I wonder if the next generation of kids will have to list their developmental milestones on their resumes. What's this, you didn't crawl until 13 months? Maybe you aren't the right fit for this company.) Learning is a joy in and of itself, but the rate and intensity gut a lot of that fun.
I'm all for delaying gratification. Self-control is an important part of maturation, right? But I wonder if all that delay of gratification is to our detriment. "Just survive the first two years of medical school." I was told repeatedly before beginning. Survive. That's a word that generally goes along with a negative experience. I can't speak for all of my classmates, but I'm certainly punting higher levels of short-term happiness with the notion that choosing the right career is worth delaying gratification. Whether it be jealousy over friends having nights and weekends free or getting vacations and disposable incomes, I do feel like I'm missing something. Let's hope I'm right about the value of the long-term.
As far as school itself, I'm halfway through with the classroom portion. This year represents a much higher proportion of clinical learning as opposed to basic sciences, along with the run up to Step 1 of the USMLE Boards. Lots of work ahoy. Sure, I was terrible about updating my blog over the last 5 months but this here's a post and I have another one brewing in my head that should be interesting.

Tuesday, April 27, 2010

Just Like Biggy Said

I suck. I know it. I've been woefully lax about updating this blog for quite some time and the reasons are twofold. For starters, I've just not felt the persistent rash of inspiration upon the belly of my brain. As you can tell from the last sentence, I'm now a few weeks into Neuroscience and it's really paying off. The second reason for my lack of writing is due to the change in schedule caused by the aforementioned Neuroscience. I ordinarily start writing in the library after exams while I'm waiting for my friends to finish so that we can go get brunch. I then generally finish while on the train downtown the Saturday following an exam. However, class structure has now mixed between the very intensive Neuro and writing-based work for Medical Ethics and Epidemiology. As such, my usual non-studying time to occasionally write has been commandeered in a thoughtless manner by other classes.

So, I figured I'd drop in quickly for a status update. There are but four remaining weeks of school, after which I'll be headed back to Los Angeles to resume, briefly, my work at Cedars-Sinai in the wonderful Performance Improvement department. M1 summer is the last summer med students have away from any built-in responsibility, so that time can be used to do research, go abroad, sit on your duff, or whatever. Why am I choosing to work during this time and not just relax and travel? I want to remain involved in PI work as I progress through my career. It not only tickles both the medical and engineering sides of me but also represents an important part of the healthcare industry with respect to closing the gap between cost and quality. I may sneak some tennis in there too.