All Bleeding Eventually Stops

Fair's Fair

2011-10-01T13:57:00.000-05:00

"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.

One Flew East, One Flew West

2011-08-14T19:25:00.000-05:00

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.

Pictures from Haiti

2010-11-24T22:02:00.004-06:00

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.

Haiti, Part 2

2010-11-15T23:57:00.020-06:00

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.

Haiti, Part 1

2010-11-14T22:44:00.011-06:00

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.

Brief Thoughts On a Year

2010-08-15T21:07:00.007-05:00

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.

Just Like Biggy Said

2010-04-27T13:40:00.002-05:00

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.

Channel Capacity or the Limits of the Human Brain

2010-03-02T00:19:00.006-06:00

One of my undergraduate professors taught a class on organizational behavior. A former CEO and something of a guru on the inner workings of corporate structure and relationships, his course took roots in psychology and cognitive science. One of the concepts he introduced to us was that of channel capacity. Companies are best served to limit the size of each of their units to fewer than 150, as humans just can't keep track of the relationships between a group larger than that. In addition to a social channel capacity, humans also have an intellectual channel capacity and are limited in their ability to keep more than seven items simultaneously in their RAM. It's why phone numbers are (used to be) seven digits.

Preparing for an anatomy practical requires understanding, either explicitly or implicitly, the concept of channel capacity. The practical exam last week, the end of my second quarter, covered face, neck, thorax, and abdomen. The list of structures held us accountable for about 350 named items to identify on sight based on structural relationships and appearance. Identifying any individual item on the list requires knowing at least three or four relationships in order to make identification possible. Let’s take the thyrocervical trunk of the subclavian artery as an example. I know that the thyrocervical trunk is the third branch of the subclavian, and the second that branches upward. I know that it gives off the suprascapular artery, the transverse cervical artery, and the inferior thyroid artery. I know that the suprascapular and transverse cervical arteries split off in front of the anterior scalene muscle in the shape of a V, and that the thyrocervical trunk branches near the downward aiming internal thoracic artery. I know what arteries generally look like in the body (they hold shape, unlike veins), and I know where the subclavian artery sits. Also, structures vary slightly from body to body and the dissection usually differs as well. We’re not given a word bank, so we have to pull the names out of our memory only. Lab practicals cover 75 items. Walking through the room from body to body is like going back home from college after a few years, showing up to synagogue, and trying to put a name to all the faces. Except the people at synagogue are generally more alive and less rotten. Generally.

The ability to keep fewer than ten items in your RAM simultaneously plays in as well. Arteries branch like crazy. Memorizing the branches works best in clusters. As opposed to memorizing the subclavian artery and all of it’s branches and their branches and their branches and so on, it’s best to memorize the branches of the subclavian (there’s a mnemonic for that), the branches of the external carotid artery (there’s a mnemonic for that), and then the branches of those branches. I’m very visual, so it’s almost like looking at Google Maps; I can view the whole image at a low resolution or zoom in on individual regions one at a time. The human brain is a ridiculous piece of hardware.

*I'm having trouble recalling the exact number (on account of the subclavian artery). Gladwell says it's 150, but I distinctly remember it to be 300, and I'm struggling to come up with sourcing. Until I find proof either way, my point remains the same.

Abby Normal

2010-01-31T23:03:00.006-06:00

Even once you’ve made a hash of the legs, arms, thorax, axilla, and back, a cadaver still looks like a person as long as it has a face. There is, however, a pretty clear moment when it becomes difficult to look at the body and still see a person. That moment is roughly when you’ve finished bisecting the face with a hacksaw. We did that last week. Other than seeing the inside of the nasal cavity and pharynx etc., there’s something else that goes along with bisecting a face. That something is the sneaking suspicion that you're just no longer normal by basically any standards that don’t use other med students as a rubric. From the horror of opening the hazard bag back in September to now, I’ve certainly been desensitized at a pretty steady pace. The rest of my journey away from normalcy belongs to my schedule / social life.

To start with, most people look forward to the weekend arriving as quickly as possible. I look forward to Mondays. Once finished with an exam, I get a blessed few hours of time to unwind. Mondays are great. Thanks to the complete lack of overlap in schedule freedom, this limits my ability to see people outside of my classmates. While that doesn't help in my efforts to retain some semblance of normal, lacking the chance to get out from under responsibility once in a while makes the biggest impact. I don’t find that I’m envious all that often, but here we are. I am absolutely sure that I’ve chosen the right path and I don’t regret my decision in the slightest, but I do occasionally wish I had some freedom. For the majority of my college friends, leaving college meant taking a job with hours and a paycheck. The hours may be fairly extensive, but they are at some point released from responsibility and given time to do other things. The sort of things that require some disposable income and somewhat flexible schedules, like travel. For that, I’m envious. That’s the hardest part of school, the inability to get the occasional release from responsibility. If I’m awake, there just isn’t a situation where my top responsibility is anything other than studying. Not that I study every waking moment but rather that anything I do outside of studying comes accompanied by that nagging understanding. I'm not looking for pity because I knew what I was willfully getting myself into, but if you wonder why people complain about medical school then here's your answer.

A Baseball Rant Based in Biochemisty

2010-01-11T20:10:00.008-06:00

Every now and then, something in the news actually correlates to material from one of my classes. Mark McGwire admitted today to using steroids during his record-breaking 1998 season. I, for one, am completely surprised. I know I am certainly as muscular or more muscular than McGwire was in '98, and that just happens. It's a burden, being Adonis. I can easily do several pushups. Anyway, I honestly was surprised at the outrage raised by Big Mac's announcement. Not because I couldn't believe that McGwire was on something but rather because, during his playing days, he openly admitted to taking Andro. When we manufacture testosterone or estrogen (or other steroid hormones), our bodies start with cholesterol (see handy diagram, courtesy of Wikipedia). Andro is two bouts with enzymes from becoming DHT, and Andro was legal when McGwire took it. Granted, Andro isn't converted entirely to DHT and also leads to estrogen formation (whoops).

Today McGwire admitted today to taking a different substance that was illegal while he used it, most likely dihydrotestosterone (DHT). If you're looking to add muscle mass that's probably a good way to go, what with DHT being an anabolic steroid and all. Also, Major League Baseball deemed it illegal. But Andro? Not until after McGwire retired. McGwire was probably getting the same result and MLB didn't care. For a league and public that make a huge fuss over use of illegal substances*, they sure don't seem to care much about the details. This is akin to trying to eradicate bakers by making flour illegal but allowing bakers to purchase wheat and grind it themselves. I'm not a biochemist. I had a one-hour lecture in which maybe five minutes were dedicated to this process. That's why it's difficult to believe that the people advising Major League Baseball on these issues didn't know the same information. Absurd.

*Which is to say nothing of the rampant use of amphetamines in the previous generation of ballplayers. Hank Aaron used them.

Focus

2009-12-29T13:45:00.004-06:00

Another question I’ve had with regards to the first two years of medical education regards the teaching time proportion of clinical skills versus the well known evils of basic sciences. For the record, I think CMS is doing a pretty good job striking that balance. Most schools have a class like Essentials of Clinical Reasoning that teaches differential diagnosis and the basics of how to think through the process of diagnosis, testing, and treatment. I feel fortunate to attend a program that places emphasis on the physical exam and History of Present Illness. We’ve been told that nearly 85% of diagnoses can be made from the HPI / physical alone, yet apparently plenty of third-year medical students show up for clerkships lacking the skills to properly examine or question a patient. Couldn't schools afford to back off on the level of detail in Cell Biology in order to better prepare students in skills that could help make better doctors and cut down on the cost of healthcare?

I’ve just finished reading a book called “Every Patient Tells a Story” (Thanks, Faye and Ron) by Lisa Sanders. Dr. Sanders writes for the New York Times as well as acting as the medical consultant for House. Told through a series of vignettes, Sanders dedicates a considerable portion of her novel to stressing the value of “the lost art” of good physical exam skills. It should come as no surprise that the availability of high-tech testing devices has caused physicians to shunt diagnostic authority. Why trust techniques that are older than Abe Vigoda when you can convince the atoms in a patient to align their spins and tell you their secrets? Sanders argues that the physical exam allows you to find, in about thirty minutes, items of concern you may not know to look for with tell-tale signs that give almost as much certainty. While she doesn't bring up the issue of cost, that's a massive concern as well. Testing is an expensive burden on the system if used egregiously.

What does this have to do with me? A week before winter break, we were tested on a full* head-to-toe exam. Over the first half of our school year, we learned the exam one system at a time. Then, with an instructor in the room and cameras rolling, we took turns with a partner playing either the patient or the doctor. 30 minutes, 110 items on the checklist, an ophthalmoscope, an otoscope, a reflex hammer, a stethoscope, a tuning fork, a tooth pick, a cup of water, and our mental list. Hi, I’m Aron Bender and I’m a first year medical student. It’s nice to meet you. We’re going to conduct a full head-to-toe physical today. I’ll go wash my hands and we’ll begin. Our exam skills are incomplete, however. I can technically perform each of the items on the exam list, sure. I've never actually heard Mitral valve stenosis or felt a thrill. I guess this goes back to the 10,000 repetition theory.

On a somewhat related note, how and why I get nervous will always be a source of amusement to me. I’m ordinarily able to remember each of the list items because they follow in a logical progression through each system and I’ve done each technique a dozen times or more. I neglected the Babinski test until the very end of the exam when it struck me that I hadn’t done it. Always the bullshitter, I told my patient / fellow med student that I like to finish with the Babinski because I’m already testing vibratory sense in his big toe. Put in the mock exam room with a clipboard-toting fellow at drafting distance behind my right shoulder, my calm went to hell. It’s like someone drove a hovercraft into my mental office, sending all the neat stacks into a flurry. Two weeks later in one of my Dad’s exam rooms with a real patient, my nerves leave my brain alone. Sterile situation? Panic! Out in the field? Cool. Despite the way I approach problem solving, the way I process information, and the only way I accept argumentation, there’s a portion of my brain that must like being the last outpost of irrationality clanging around in there.

* Rectal exams will have to wait until next year. I can live with that.

Retention

2009-12-19T18:59:00.001-06:00

I got out of bed this morning to the realization that I’ve finished 1/8 of med school and 1/4 of the classroom portion. My first week of school honestly feels as distant as my arrival to college. Either I’ve aged that much over the last few months or I’ve forced most of those memories out in favor of the molecular cell bio from the first few weeks (that I’ve already mostly forgotten the details from). There are a few questions that I want to explore and I realize the format of these Blogspot blogs doesn’t have great readability, so I’ll break them down into separate posts. Since I have a few weeks somewhat off from studying, I’ll imagine I’ll be writing quite a bit. Aided mostly by the frustrating quantity of information I’ve had to gulp down, I’ve been questioning the traditional teaching methods of the first two years of medical school. This has been a frequent topic of discussion amongst my peers as we grouse about the level of detail in our basic sciences course. So, on to the first question.

Will I retain the majority of what I’ve learned? I can’t speak in definite terms for the future Aron, but I can say with reasonably good certainty that I won’t remember the specifics of almost everything I’ve learned in basic science classes. Odds are I’ll re-learn everything at least once more, and then choosing a specialty will cause me to become very intimate again with the details of a particular region or system.

My trip to Boston over Thanksgiving helped me understand that much. Between my sister the resident or my brother-in-law’s two visiting friends (an M3 and an M4) gave me the opportunity to test this hypothesis. As I was preparing for a cumulative biochemistry exam, I’d occasionally throw out a simple quiz to see what remained important down the road. With all three sitting in the room, I offered up HMG CoA Reductase and was met with blank stares. Despite the emphasis by professors that this particular enzyme is important (it’s the rate limiting step in cholesterol synthesis and as such is the target for the family of drugs like Lipitor), it wasn’t until I recited its purpose that all three had knowing nods. It’s probably important to note that none of the three are headed towards cardiology, because then my question would have produced different results. Still, with the amount of energy we spend learning the names and function of nearly every enzyme in metabolic pathways, did it all go to waste?

I don’t think so, or at least not entirely. One of the biggest problems early on is that we learn fine detail about small parts of the body without having a good idea of how the whole body works together, the function of each organ involved outside of it’s job with respect to the task in question, or much of the clinical ramifications. My professors have done a good job interlacing vignettes throughout our learning, which certainly helps anchor concepts and remind us that pathology stems from errors in processes we learn about in basic sciences. Down the road, I’ll continue to remember the general concepts well enough to understand disease processes. Still, if it’s the concepts that are important down the road, why not shift some of the weight of focus onto concept?

Getting Dumber

2009-11-30T10:29:00.014-06:00

The main point of my blog is to capture the process of medical education and the psychological / sociological changes I experience along with changes in my perspective about medicine. As an M1, the latter will have to wait a year or more. Without exposure to the practice of medicine, my opinions on topics like reform of healthcare are roughly the same as before I entered school. I also wanted to make sure that friends and family know that I'm still breathing. The sharpest amongst you may be able to deduce that my ability to write is very much dependent on my ability to breathe so we can check the last one off. I haven't yet succumb to any of the plethora of diseases I'll learn about and then momentarily worry about having.

So you get to read about my brain. With each passing day, I grow more stupid. Not regarding topics like biochemistry or physiology, but rather... everything else. I wrote previously about the occasional bouts of craziness stemming from a very intense and singular focus. A new symptom of Medschoolemia emerges: loss of ability in facets of every day life, especially spelling and language, both written and verbal. While in Boston over Thanksgiving (I had a lovely time and I did not save you any cannoli), I was having a conversation with my sister. I spent roughly five minutes trying to come up with the word "insecure" as a descriptor. Five minutes. Couldn't do it. This sort of issue now occurs daily. While I doubt anyone would have accused me of being one of the all-time great orators prior to this, I fear that having a conversation with me lies somewhere on the spectrum between talking to Porky Pig and Marcel Marceau. I'd have gone with Harpo but he'd hand you his leg and make a sandwich with your tie, and who wouldn't enjoy that? Hopefully winter break provides the opportunity to do things like read for enjoyment and spend time not packing my brain. I just may get more functional as a result.

*Note: After proofing this, there were quite a few errors in grammar and there probably are a few I haven't found yet. I wasn't kidding. I've become an illiterate.

Speed Dating with Cadavers

2009-11-07T09:31:00.006-06:00

If you’ve ever learned even a small bit about the Theory of Relativity, you’ve heard about the almost nonsensical concept of time dilation. Get yourself the latest spacecraft capable of going the speed of light and set off for a month. Come back and find that more time has elapsed back home than did for you, even though you were alive and fiddling with hyperspace cup holders for the same nominal period that your friends sat at home and made toast. Med school is like that. My days feel long and drawn out, but every once in a while I look up from whatever I’m reading and a week is gone. An entire quarter blew by, and I could go for some toast.

The last day of each quarter of the M1 year consists of an anatomy practical. 100 stations, 100 students, 100 minutes. Each of the ~50 cadavers is tagged in one or more locations and we have the privilege of identifying the structure. There are also about 20 questions on osteology tagged on a skeleton or loose bones to go along with rest stations scattered throughout.

The anatomy practical should be mostly binary, but 60 seconds runs away like the antelope that found the meth lab. In areas like the brachial plexus or with branching areas of arteries, there’s usually sleuthing to be done. Relationships are quite important, and running through a set of mnemonics or mental images lays waste to that minute pretty quickly. Scribble down “Semispinalis Capitis m.” then the buzzer sounds and it’s off to the next body like some Polish gameshow. (I don’t watch a lot of Polish television so if I’m wrong about their content, I do apologize. But I did hear that The Offiszcz is pretty good.) Talking with a few classmates, we all found that the most difficult part was sorting out the mess in our heads. For each compartment, we learn the contents separately. In the anterior thigh, I know which muscles are where. In a separate mental layer, I know how the femoral artery enters, branches, and continues through. In yet another layer, I can see the femoral and obturator nerves and their branches. Arriving at each body sets off another round of flipping through mental notecards. It's always strange to get tested in under two hours on content that required something like 40 hours in lab, 20 hours in class, and well more than the two combined in study. Long live the scholastic process.

The Hazards of a Narrow Focus

2009-10-20T20:05:00.010-05:00

Insomnia isn't a normal part of my daily routine. In fact, I've been augmenting a typical seven+ hours of sleep at night with a twenty-something minute nap in the afternoon (I'm fairly certain that I have med school-induced Mono). When the thought of running face first into a wall crossed my mind for a fraction of a second, I knew my week had caught up with me.

Last Monday was a brutal exam, one for which one of our professors apologized in advance. After three exams in two weeks, we had an almost unreasonable amount of information to put down in an almost unreasonably short period of time. As a result, I spent the majority of my waking hours over a five-day period cramming biochemistry into my brain. Saturday night I had dreams about biochemistry. During a study break with some football on Sunday, a Lipitor commercial I was not paying attention to caused me to actually say "HMG CoA reductase!" out loud in a sort of Pavlovian response. That's probably not normal.

I can't really complain about the amount of work I've had to (and will continue to) put in. That's what med school is all about, after all. So while the percentage of my time taken by school doesn't really bother me, it's the occasional theft of my sanity that does. Since my primary interactions are with stressed-out med students, I rarely get a change of scenery. During the week, I have enough variation between class, lab, and a smattering of subjects that I can keep it in check. Weekends are for exam preparation and that generally means subject matter from one or two classes, no distractions, and some added time pressure. It's little wonder that I can't get my brain to shut up on Sunday nights.

A Clockwork Orange Tonsils

2009-09-30T17:07:00.010-05:00

The title will make more sense later. Bear with me for a minute, as I have two topics to touch on. After a particularly difficult exam on Tuesday (and a few classes), we had the opportunity to participate in what our Essentials of Clinical Reasoning professors call Patient Day. I described, earlier, the process of taking a History of Present Illness (from here on: HPI) from a standardized patient. Patient Day involved three real patients, sixteen white-coated M1s, and some other form of medical professional to moderate. For each of the three patients we talked to, we were tasked with eliciting an HPI, a medical history, and a psychosocial history. As there were sixteen of us at a time, we were supposed to take turns asking appropriate questions and follow-ups in the general order in which we were taught. That has to be disorienting for the patient, or at least reminiscent of a firing squad.

So why Anthony Burgess? As the first patient described her symptoms (achalasia) and we asked about discomfort, she said that she occasionally had "The Sickies". Viddy this, my droogs. I then spent one of my precious questions attempting to, in a roundabout manner, get the patient to explain The Sickies without my having to ask directly. Turns out that The Sickies are nausea. Add another hurdle to the process of extracting information from a patient: deciphering their personal lexicon. Hopefully that will also serve as a reminder to make sure I'm translating my thoughts back to them as well. May I share another vignette? You're nodding slightly, so I'll continue. This also involves a guessing game for those with medical background. Answers provided later. I once had a discussion of a similar nature with my parents about their patient population while in residency at LA County Hospital. I may be smudging some details, but so be it. They would see patients who, when asked about medical history or current illness, would say they had Smilin' Mighty Jesus* or Fireballs in the Ucherest**. After consulting with people who had been around LA County for a longer period of time, they realized what their patients were telling them. Even though early medical students have limited exposure to patients, it's clear we not only have to understand our patients but make sure they understand us.

Another interesting part of the medical education process? The blurts. We see a lot of PowerPoint slides in lecture every day, on the order of hundreds. Most classes make a point of adding in clinical correlates so that we have some idea why we should care about Type I collagen or Superoxide Dismutase. A byproduct of the way my brain works is that I'll link inexorably two facts to the degree that I'll see one somewhere and my brain will blurt out the other. Case in point? Tangier Disease. Learning about lipid metabolism, we learned that a mutation in a particular gene causes a defect in cholesterol transport, eventually leading to buildup in the tonsils (and other organs) that gives them an orange color. A day or two after that lecture, I heard someone say "tangerine" and my brain tripped over itself rushing "orange tonsils" to the tip of my tongue. I'm sure this is healthy and not in any way a sign of insanity. Also, did you know that your brain literally sends words to your tongue via a series of tubes like at the bank? Anatomy is neat.

* Spinal Meningitis

** Fibroids of the uterus.

Leaving Behind Variation

2009-09-21T19:48:00.000-05:00

Leaving Los Angeles in favor of Chicago meant, amongst other things, the loss of any sort of change in elevation. Cycling or running in LA was fantastic. I could be out the back door and up into the Santa Monica mountains in a manner of minutes. I've taken my bike out a few times here and, to the great surprise of no one, the topography is crepe-like. With more potholes. I guess that makes it more like injera.

CMS changed their curriculum this year to aim for better integration of material. That change includes a switch from a strictly midterm/final structure to a schedule involving weekly Monday exams. Sure, that has a negative impact on my weekends, much in the same way that engaging in a chainsaw fight with a lumberjack would have a negative impact on your appearance. There is an upside to this, though. Instead of the absurd levels of stress that accompany preparing for one week of mid-terms or finals with that quantity of material available, my classmates and I face a significantly less daunting but more frequent task. As a result, I find that I've been maintaining a fairly constant (and pretty reasonable) level of stress. Finals week in undergrad usually left me a mental wasteland, which I usually followed with a fairly significant refractory period. Flat may be boring for cycling, but flat is much better for exam schedule.

A quick cadaver update. My initial reaction to meeting my cadaver was a mixture of shock and disgust. That was three weeks ago. Last week, I prepared for my 1:00 pm anatomy lab by watching dissection videos while eating lunch. Desensitization spreads quickly. We've now gone through all back muscles, completed a laminectomy, opened the front to get to the chest muscles, and thoroughly dissected the shoulder, arm, wrist, and hand.

And Now for Something Completely Different

2009-08-31T16:48:00.005-05:00

Honestly, it's the smell of formalin more than anything else. I have had very limited exposure to dissections. In AP Bio (Senior year of high school), we dissected sharks and clams and I wasn't brilliant at it. On the back of that raging success, I met my cadaver* this afternoon. Then my lab mates and I proceeded to expose the back muscles for our first real dissection on Friday.

Blind expectation, or in my case dread, just isn't the proper way to prepare for an event of this nature. I tried to mentally steel myself ahead of time to avoid the inconvenience / embarrassment of reacting poorly. Whether or not that was necessary, I'll claim victory. Still, nothing I could imagine quite captured the actual feeling of unzipping the disaster bag to reveal our lab group's cadaver. It isn't that I expected the body to sit bolt upright and start recreating Thriller. That would be silly. And horrifying. And then probably hilarious. However, of my interactions with humans over the course of my life, the totality have been with those of the living and breathing variety.

This is something new and new is generally difficult, especially when new has been soaked in formalin. What really accentuates the problem is my lack of familiarity with any real part of the process. Compare with the common experience of trying a new food, say ostrich. Eating is nothing new, certainly. Everything around the ostrich is probably familiar too, especially if it's an ostrich burger. You nibble, you decide that ostrich is much like other meats you've had in burger form, and you're comfortable again. We're pretty good about handling something new when we can wrap it in a bundle of familiar. According to a great piece by Malcolm Gladwell (one of my favorite reads), that's one reason a squeeze bottle of ketchup is such a big hit with kids: the ability to maintain a little bit of home in enemy territory. Perhaps I'll bring my bike to lab and do our Friday back muscle lab on the wind trainer.

Also, how in the world does the stench of formalin get through two layers of nitrile gloves?

*In case you were wondering, our cadaver is male, probably 75 or so years old, and something like six feet tall. It should also be noted that I am incredibly grateful for the opportunity to dissect a cadaver.

We Talkin' Bout Practice, Man

2009-08-25T19:04:00.000-05:00

We're thrown fairly quickly into the fire. Mind you, it's not a conflagration, rather a controlled burn. Today, with seven days of lecture under my belt, I walked into a mock exam room and took a History of Present Illness (HPI) from a standardized patient. I haven't even met my cadaver yet (stay tuned, as that happens this coming Monday). Sure, my classmates and I have attended a lecture on the content of an HPI as well as a lecture on professionalism and communication in the exam room setting. It also helps that we are presented with very straight forward cases by actors/actresses trained for this purpose. I might have been slightly nervous knocking on the door of the exam room and introducing myself, but the experience was fantastic.

While buried in the tall weeds of first year basic sciences material (to date: Embryology, Clinical Molecular Cell Biology, Biochemistry, Anatomy, and Physiology and Histology will join the fun shortly), Essentials of Clinical Reasoning provides a little glimpse of why my classmates and I are here. You may consider it strange that we are learning to conduct a short patient interview that produces something like 80% of all diagnoses before we are anywhere near equipped enough to generate a differential diagnosis. I wondered that myself.

As it turns out, there's more nuance to an HPI than I could have imagined. I'm not sure it struck me before, but much of the information necessary to start diagnosing a patient comes directly from the experience of the patient and must be extracted carefully. They know where they hurt, when they hurt, how much they hurts, what has made their pain better (or worse), and so on. Quickly generating a good rapport with and getting useful information from a stranger takes practice. While our standardized patients were forthcoming and cooperative, that won't always be the case. At some point, I'll likely be dead tired, too hungry, or grumpy and will need to get useful information from someone who is uncooperative. I won't always be so lucky as to get a smiling patient with one symptom and no other problems. So, why did I find myself in a white coat asking a faux-patient about her recent onset of stomach pain after seven days of lecture? As one of the Associate Deans is fond of saying, it takes 10,000 repetitions to master something.

That's one.

Definitely Not Chicago

2009-08-10T16:48:00.001-05:00

I decided, during my many hours of driving across the country (~33 hours if I recall correctly), that I'll try to package my posts here into one of three three formats: status updates (like today), occurrences, and general musings. We can work on the names. Status updates should serve to keep you all, my friends and family, abreast of where I am at and what is going on in my life in general, working again under the assumption that I'll not call or write nearly enough emails. In the "occurrences" section, I'll try to capture some of the interesting or humorous events that help compose the experience as a medical student. Finally, I'll try to occasionally trot out a longer post with some more depth on topics like the current healthcare system from the eyes of a potential almost doctor. Hopefully I can suppress my desires to post lengthy diatribes about the lack of proper cuisine in Waukegan.

On to the status update: I made it to Waukegan. Thank you to my college friend Ali who graciously drove across the country with me. I have an apartment somewhere between Park City and Waukegan, about 5 miles from campus. As Rosalind-Franklin is a small institution, on-campus housing is limited. Can't wait for snow.

Orientation starts tomorrow and class begins a week from today. The journey has begun and the excitement level slowly rises. So too does the humidity level. One of those has lead me to feel damp.

Genesis

2009-07-15T23:39:00.000-05:00

So I've started a blog. More than one of you (you know who you are) have requested that I do something of this nature so that you have some way of keeping tabs on me. That's fair. I know my tendencies and odds are I won't call or email as much as I should. Hopefully I can keep with this, as it's a rather easy way for me to at least partially satiate my friends and family in their quest to occasionally have a clue what I'm up to.

I've been thinking about it, and I have several goals for the blog. First and foremost, I do want a way for all of you to be able to know what's going on. Secondly, and here is where I think the most interesting material will come form, I want a place to catalog the goings on of a med student. Sure, I'll try to con classmates into taking pictures when I inevitably pass out again (more on that in a minute). I've also heard a lot about how med students end up experiencing an awful lot of cognitive dissonance and it should be fun to try to capture the changes in my views (and hopefully I'll be a good representation of my soon-to-be peers) on topics like, well, medicine as I go through this process. That's the plan. I'll do my best to stick with it.

On to the fainting. After running the gamut of emotions yesterday, Uncle Leon the Urologist invited me to come see a prostate biopsy this morning. Simple outpatient procedure aided by rectal ultrasound. I've seen significantly more gore in the OR/ER. Something got to me, however, and I began to get lightheaded. In an effort to feel better, I walked away from the procedure to the sink at the corner of the room, figuring some air would help, and down goes Liston. I woke up slumped against the counter with Leon trying to get me to smell some ammonia. I always knew I'd have some trouble with anatomy lab early on, so I guess this was some foreshadowing of one minor hurdle ahead. I still can't believe I get to go to med school. Someone wave some ammonia under my nose, because I must be unconscious.