Let the Surgery Begin

Our little campfire just outside our home last night. It's nice with cool weather, plenty of wood from living in the woods, and plenty of supplies to make s'mores.



I've decided to give folks an update once again. I apologize for not being more diligent in my blog, but I suppose I've had to be more diligent about other things as of late. I just finished my second week of the surgery rotation, so where to begin with the story telling? I started out on plastic surgery, and have been there for the last two weeks. Let me first dispel some possible misconceptions about what a plastic surgeon does. Plastics is derived from the Greek word "plastikos," meaning to mold or shape. In the mind of a surgeon, this of course translates to the molding and shaping of human tissues. Sure they are great at making incisions and then stitching them up beautifully, but it's not all about boob and nose jobs. Perhaps in a more private practice setting, this would be the bulk of the clientele. But in working with a plastic surgeon who works for the hospitals, things are a little different. Most of our adult patients were older men, with a woman here and there, who were in a bed or wheelchair chronically for whatever reason, and had subsequently developed stage IV bed sores, or ulcers. Stage IV is bad, very bad, sores that go all the way down to the bone bad. Surgeries often entailed cutting a bunch of unhealthy tissue out, which often included shaving or pounding away at questionable bone, usually the pelvic bones. The wound gets left open for several days and then we go back and close the gaping holes left behind and pray the patient doesn't do something to dehisce (split open) the wound.

The surgeon with whom I worked managed patients at UAMS, the VA, and ACH, which meant a lot of traveling for me. At the children's hospital, we saw kids with one too many fingers, malformed ear lobes, and various other malformities. He also did a fellowship in hand surgery, so he sees orthopaedic hand cases - broken hands and the sort. I have been at Children's far more than any other place. It's been an overall excellent experience, sans clinic days when all I did was follow him around without any autonomy for myself. He said I was a big help in surgeries, at one point complemented me on my eye-hand coordination (thank you Half-Life and TR), and claimed he would give me a good grade. Next, I start vascular surgery at the VA tomorrow.

Now for a word on ATV's. Part of the problem may be that I grew up in the suburbs and didn't really have any friends or family with land where an ATV was a reasonable thing to own. But at the end of the day, regardless of my past, I have decided ATV's are a horrible idea, especially for kids under 16 or so, and ESPECIALLY for riders without a helmet. Let me explain myself. Right from the start of surgery, I met a young girl who suffered a terrible ATV accident. She was crossing the road when a truck collided with her. Had it not been for an EMS individual smart enough to put a tourniquet on her destroyed leg, she would have died right there on the side of the road from hypovolemic shock (blood loss). When she came to the OR (at least the second time around by the first time I saw her), she had no skin on the front and sides of her leg from just above her knee all the way down to her foot. There at the foot she had intact (although burned) skin continuous with skin that ran up her calf. Her bones already had rods placed in them and were broken so badly they didn't touch. The muscles in the front of her leg, the ones that allow you to pull your foot and toes up, were all gone - exposing much of the bone to all of God's creation if not in a cast. After two or three two-hour surgeries to clean the massive wound and cut away dead tissue, another eight to nine hour surgery underwent to place a muscle flap harvested from her back to cover her exposed leg bones and destroyed muscles. This was done so a skin graft could be started a few days later with synthetic skin since skin wont grow over exposed bone. Eventually, she will have real skin grafts placed over the artificial skin one piece at a time. I met a few other girls on clinic days who were further along their course of hours of work. Just this morning, with my eye enucleation job, there was a kid who died flipping head over handlebars from his ATV - no helmet = one very dead kid about to donate the one of his eyes that was salvageable. I unfortunately was unable to attend the case, but I heard all about it from the coworker who did. If you ride an ATV, fine, just don't be a retard. Don't put your kids on it (or a riding lawnmower for that matter), and for God's sake, wear a helmet.

I don't recall if I have given you a formal decision yet, but I have decided to train for the full marathon this year. If it doesn't quite work out, then I should have no problem being trained enough to do the half marathon. I ran nine miles today, and for the first time since I started training, I truly feel pooped out. Lord, beer me strength.

See you soon!

The Ending of Peds

Readers - If you're reading this blog, I congratulate you on your everlasting determination in checking this blog for the rare updates I give.

So the pediatric rotation is closing its final chapter this week. I had my last day of clinic today, I get tomorrow "off" to study all day, and then take the board exam on Friday. It has been a wonderful experience. I have reaffirmed that I do, in fact, love working with kids. Despite this passion, I would never want to be a pediatrician. Aside from a period when the child is 7-9 months old through the age of three or so (it's at this age that kids realize strangers truly are strange and there is no comfort like being in the arms of someone familiar), kids will do what you ask of them since they look up to you. It's always the mean nurse who gives the shot, not the doctor with the toys in his pocket. The parents - now there's a different story. Disclaimer: Working at state funded hospitals such as UAMS and ACH provides us a skewed population. These are people who are often uneducated, uninsured, and many are just downright trashy. In private practice and for-profit hospitals, it's a completely different story. The parent's can't always tell their left foot from right, one father of their children from another, or much less Tylenol from Motrin. OK, so the last is an exaggeration, but you would be surprised how many folks I see don't seem to know how many people fathered their three to eight kids. They don't seem to understand viruses can cause fever, even when you attempt to instruct them using influenza as a perfect example: viral infection = fever. They often look at me, question my age and place and life, and then don't believe anything I say, followed by an attending physician who repeats everything I said. If I had a dime for every time someone questioned my age. . .

I start surgery on Monday. I don't yet know where I will be working, what kind of surgery I will be going to, etc. I hope we find out something soon.

I walked into the hospital the other day and the scent of french toast filled the air. I suddenly realized how long it has been since I ate such a thing.

I started training for the marathon last week. I have been running at least once or twice a week ever since the race last year, but never more than four miles a day. I up and ran six miles last Saturday without any problems. I wasn't ever sore afterwards, and I didn't even stretch before or afterwards. I hope this is a good sign. This weekend I will go seven miles - further than I've ever gone.

That is all I have to say for now. I thought I would have more, but I guess I don't.

Out in the Clinic

I, for the first time ever, and getting a real amount of clinic work under my belt. For the first twelve weeks of my third year, I worked only on wards - seeing the same patients, day after day, and writing about their progress in a chart which tended to grow exponentially the longer they were admitted. See, you would expect a linear growth, or perhaps a decreased rate of growth over time. This isn't the case - but I won't dwell on this for too much time for those not inclined to care for one second about mathematical relationships.

Clinic is. . .different. In clinic, I see different patients throughout the day, each one with a different history I have to learn in a few short minutes. I do a focused history and physical in the specialty clinics, taking much less time than a new hospital admit. I am now at the end of two weeks of subspecialty clinics - a different clinic each day, sometimes a different clinic between AM and PM. This means a new attending each day, and each one gives me a Pass, Fail, or Honors rating. Thus far, I have received all honors sans the one clinic I have yet to do. But this really isn't a true honor as most attendings hand out such ratings like they do stickers. I just don't feel as special as the five year old with a new Scooby Doo sticker. My first clinic was the immunolgy/allergy clinic. What a way to start - a bunch of little ones with runny noses and autism. That's another thing - every mom thinks her child has autism, which isn't the case. Perhaps more on this later, perhaps not. I have also worked in the adolescent clinic (which, mind you, I escaped without having to do a single teen STD/pelvic exam!), cardiovascular clinic, hypertension and nephrology clinics, genetics clinic, hematology/oncology clinic, the ER, and tomorrow is my last day on subspecialties, spent in the neurology clinic. They've all been pretty fun - some more than others. Working in the ER almost had me switched to emergency medicine, or pediatrics in the very least. Then I remembered that as long as our country's healthcare reimbursement/insurance system is set up as it is, common civilians will continue to be forced to misuse the ER. Oh well, ophthalmology it is. You may ask which clinic I enjoyed the most - but I don't have an answer. It varies too much say, depending on your attending, patient loads/types, nursing staff, etc. Most had their advantages and disadvantages all in the same experience. For instance, Dr. Kahler in the genetics clinic is a great teacher and a very interesting person to talk to, but he often talks TOO LONG.

Next week is when I start the nursery. I will be there for one week, and hopefully "catch" some babies. I won't be delivering them - that's reserved for the L&D rotation later on. Catching them simply means I take them after they've been born, clean them up, get them stimulated and crying, and make sure they're OK. We only do this with babies that don't appear as though anything will be wrong - if any problems are likely to happen, they are usually delivered in a much more closed and controlled environment without amateur medical students around to muck things up. But the nursery, much like the ER, is a hit or miss experience. Some people catch a lot of babies within the first few days. Some, like the students there now, are around very few deliveries and between the three of them, have caught maybe five babies since Monday. I hope a full moon pops up next week and draws the pregnant ladies out of the woodwork. The good Lord doesn't need to know that all I want to do is rub some babies clean.

I have a grill. It kicks arse. I got a good deal on it. I like to grill. Beef is good.

I don't have much else to report for now. I sold my truck, by the way. I keep saying I need to call Kyle to make sure he has a backup groom's man just in case I won't be able to make it. I have an exam tomorrow and my mind is therefore not in the mood to recount experiences over the past several weeks or rant over some aspect of medicine about which none of my readers will really care. And oh yeah, lastly but not leastly, Rachel is the best!

Drivin' in Style

So, readers, I finally bought a new car the other day, a used one actually. It's a 2004 Honda Accord with just over 80K miles on it for just under $17,000. It has a sun roof, leather interior, and factory tinted windows. I wasn't looking for these things, knowing they were luxurious amenities and I didn't have the money to be picky about such things, but alas this one was amongst the used car selection and one of the lowest prices. For your viewing pleasure:

On another note, if you know anyone who would like to buy the beautiful, wonderful truck pictured below for $4,000, send them my way. I would LOVE to hear from them. I hate parting with my truck, but now I have to.

Moving On

Arkansas Children's Hospital, the place where I will spend seven of the next eight weeks, shown before the campus wide infiltration of construction processes with bulldozers and dump trucks.

Some would argue I have been neglecting my readers, few as they may be, by not having posted a blog in quite some time now. This may or may not be the case. I've been pretty busy - moving, finishing my first rotation, contemplating things, the usual. I have nothing phenomenal here to report, just an update on life.

So we moved into our house. Of course, everyone who reads this has probably already read it in a blog by Rachel first, so I don't really know what else to say. Now, we both promise, there WILL be pictures, perhaps a virtual tour, of the house up eventually. Give us time. Some say it takes a full year to get truly settled in and things the way you want them, but not with us. Three weeks (tops!) more is all we need. The twelve mile drive to and from the hospital every day has made me question, yet again, the utility of keeping my truck. A great vehicle, it really is, but at twelve miles a gallon, and two gallons a day, it will require a fill up at least twice a month, three times if it all falls on the right days. Let's see, seventy dollars a fill up, that's up to $210 a month for gas on a bad month. I know a car payment is a little more than this - but it may be worth it. That is, unless, I wanted to lease a car - but no thanks. I've been looking online a little bit and have decided I want to go with a either a Honda Accord or Civic, probably circa 2005 or so. We shall see.

In medicine, internal medicine is over. The board final was last Friday, followed by a three (and a half) day weekend - not a bad way to end it. It was all fine, I learned a lot, helped on a couple procedures, but I had long grown tired of it. Internists are obssessive compulsive; I am not. Patients would get daily CBS's (complete blood counts) and BMP's (basic metabolic panels) whether they needed them or not. We would end up finding petty little things wrong with the numbers and end up keeping patients a day longer than needed when they could have gone home and the numbers would have naturally corrected themselves. A patient could be receiving treatment for a community acquired pneumonia, improving substantially, and they would still want a follow up chest X-ray. In an acute enough time line, a chest X-ray will only show worsening, not improvement. As a general rule, the clinical picture of pneumonia improves vastly more quickly than the corresponding chest X-ray - the film may take several weeks to completely clear up, long after symptoms are gone. Now that I am at Children's, I can only speculate on how pediatricians will be. Many of them basically practice internal medicine for kids. And no, kids aren't just little adults, at least not medically, and must be treated totally different. But the logic, the process behind it all, can't be all that different. I guess we'll see soon enough. Today was just orientation - no introduction to the team or anything. It's probably just as well since we move around a lot more in peds. I start with four weeks of wards, two on the hematology/oncology ward and two on the general wards. This is followed by fall break, and then four weeks of clinics consisting of one week of nursery back at UAMS, one week of general pediatric clinic, and then two weeks of rotating through various pediatric subspecialty clinics which change daily. These clinics are even sometimes different before and after lunch - do allergy clinic before lunch and asthma clinic after lunch. Lot's of moving around. I'm anxious to work with kids, it will be a good change.

So I am officially an eye ball harvester now. To be more specific, a cornea harvester. Since I don't yet have my pager, I spent the weekend with my phone on just in case a case came through and I would be able to tag along and learn some procedural stuff. Basically, we go to these patients who have just passed away, have elected to donate their corneas, and have no disqualifying medical history, and take the eyes out. If the patient is outside the Little Rock area, God willing, the eyes are taken out and transported to us. Either way, once the eyes are in our hands, we take them to the lab and cut off the corneas and save them in a bio-supportive medium until they are needed. It's a daunting task dealing with something so little and delicate as just one part of the human eye, much less the whole thing. But then, I want to be an eye surgeon - better get used to it.

On Healthcare

A view of the construction of the new hospital during the wee hours of the morning - taken with my phone on the long walk to the VA.

Ladies and gents, it is hot! It's up to 104 degrees the next two days, 107 after that, and then tapered down to 96 over the next week or so. Hot! Hot! Hot! And to top it all off, we start moving this week in it! Bummer. Everything here is off the walls, everything except the curtains in our bedroom. The holes are patched and ready for the poor fool who has to paint behind us. We also start painting this week. The master bedroom will be colored something like this, with an accent wall like this. The master bath will be like this. The office will be somewhere around here, and the spare bedroom here. This is the hall bath, and I can't mimic the living room with the available text colors - it will be a khaki type color. We'll refinish the already white trim with a fresh coat, and I will replace all the power receptacles and light switches with new white ones instead of those old yellowed ones. It's gonna rock.

Life at work has been interesting. My new team is OK, but I like the old one better - aside from the attending,; I like my current attending better. I have also learned that the VA hospital presents with its difficulties. While their computer system for managing patient information is one of the best, the government-run hospital is otherwise a pain in the ass. It may take days to get simple things done. A simple at home dialysis catheter placement may have to wait a week; the patient, in the meantime, sits in the hospital to receive inpatient dialysis. Even the cafeteria is completely shut down over the weekend. It's not the end of the world, but UAMS is faster, and more accessible.

It makes me think of what health care would be like if coverage/insurance became universal. It wouldn't be all that bad - I would argue we could maintain a better system than what is found overseas. People rave about such foreign systems because everyone is covered and mortality rates are lower - and they're right, to some degree. Can we, here in America, do it better? 50 million uninsured people is unacceptable - especially when a VERY significant portion of these folks are working. Which reminds me - we have to get away from this associating insurance coverage with our place of employment - we're the only country to do this and it is causing the system to fail. We could have more money for coverage (if HMO and insurance CEO's were shot and buried) than other places, maybe. We have the money now; it's just in the wrong hands. In other countries, every woman gets prenatal and postnatal care covered, and every child is covered - here, our president makes the retarded statement that we can just send our uninsured children to the ER for medical care (he too should be shot and buried). This means money going to the wrong type of care for kids, wasted money. In other places, pharmaceutical companies aren't allowed to advertise to the general public - here, the companies spend a fortune doing it, confuse the public with their crappy, nondescript ads, and ultimately piss doctors off because people are convinced they need this new blood pressure medication instead of losing a little weight and laying off the salt. Maybe all that advertisement cost can go to help paying for drugs that some can't easily afford because they're overly priced. Suppose a man has been at a company for twenty years and has always had company insurance. He has a desk job, doesn't exercise, is fat, lazy, develops hypertension, diabetes, and eventually suffers a heart attack - all because he is a moron. But, he had insurance beforehand, so he's covered and he doesn't suffer too much financially. Suppose there's a young woman who is healthy, has insurance, and develops an autoimmune disease by fate. She's covered until she has to move and find a new job at a small company. She only goes without insurance for a little over a month before reapplying for the new insurance. She's denied because of a preexisting condition and not being covered continuously. See a problem? I think about this all the time, probably even more so than the young woman in the above scenario since I see patients from both sides of the story (unhealthy idiots and the unhealthy by fate) every single day.

There's a flip side to the problem, though. Should everyone receive the best of care, no matter how little money they have? I don't think so. Basic, but sufficient and appropriate, health care may be a right in a country as wealthy as ours. However, if you're one of the ones actually helping to pay for it, and since the poor and homeless can't pay for any of it, shouldn't there be a stepped level of care? Of course there should be - and there is. It's the difference between UAMS and Baptist, between Medicaid and private insurance. Both are great medical centers with great technologies, but patients at Baptist are more likely to get one-on-one care with a broader choice in caretakers and medications. Patients at Baptist can expect to see their doc whenever they want. Patients at UAMS can't. Universal care can only exist if everyone takes their part - pay what you can afford (which ought be determined by income/household size/etc.), and use preventative medicine instead of tertiary treatment medicine. In other words, don't get fat and hypertensive in the first place. Genes only predispose you to becoming obese; you still have to fuel the pounds with food and laziness since fat doesn't develop out of thin air. Granted, there are some cases where weight is truly uncontrollable, the hypertension uncontrollable, the high cholesteral unavoidable (this is actually more common), and the lung cancer that develops in a never smoker - but these are all pretty darn rare. I have never seen a skinny, physically active 45 year old person with hypertensive heart disease and late-onset diabetes. People in other countries don't necessarily have lower mortality just because of health care. While this plays a smaller part (and a significant enough one to justify universal care), the bigger part is the fact that they are healthier - yes, it's that simple. As these Eastern countries become more Westernized, we will see how their universal health coverage no longer lives up to its "glory" - and you remember that, fat ol' retarded Mr. Moore.

Don't get me wrong, I love what I do.

Half time

This is where we spent the last two nights of our honeymoon. And although it has been some time ago now, I will never forget our experience there.

The first half of the internal medicine rotation is nearing, and I can't begin to tell you how much I have learned. Not only that, but what I'm learning is far different from anything learned by reading a book. They say we learn best by doing; well, they is correct. There's nothing like admitting a patient with some rare disease and then reading all about it at home and how I will spend the next few days treating the person.

The residents/interns/attendings switch rotations at the end of the month. Yes, even attendings get assigned a month of ward or clinic duty here and there, just like on House. I suppose what I'm getting at is, yesterday was my last day with Andreoli and that team; today was a whole new bunch (sans one intern) of interns, a resident, and an attending. The students, however, don't change locations until the beginning of next week. This gives us some continuity between groups - those patients covered by the students can easily be made familiar to the new interns and resident during the students' last few days on the ward. Almost everyone is moving either between wards and clinic, or perhaps from one ward to another. I, however, not only am on wards again, but I am on the same team. In other words, our new team today is the team stuck with me through the end of August. The other three students with whom I work will change on Monday and be replaced by two others. It will almost be an all male team, except the attending and that one intern who also didn't change locations. The two of us will stick out seven out of our eight weeks together (they started in July a week before we did).

I've seen a lot in these last few weeks. I've seen large, draining chest tubes go in guy and stay there for a week draining nasty fluid, a few different venous lines go in or come out of folks, I assisted on a lumbar puncture (spinal tap) (which I probably shouldn't have since the guy was HIV positive); I've seen some patients wither away to death and others come back from looking like death was near; and I've seen diseases at the VA that one is much less likely to come across while working at University. This is because our patients, the veterans, come to us, and only us. Other people can to to University, Baptist, St. Vincent, their little clinic in PoDunk BluffVille, AR, or wherever they want, thus spreading out the locations of rare conditions. The vets, on the other hand, come to us a total train wreck - sick as hell and unable to go anywhere else.

Another thing, even more gratifying than anything else, is that most of my patients really seem to enjoy my company. I even had one of them tell me today that I was the light of his day - he was referring to the otherwise bleak overview of his care by the nurses and others at the VA (more on this later). Others have just flat out said, "I like you Dr. Bradley." Yes, I have been called Dr. Bradley - no new Dr. Bears yet, though. It's not that I'm a better people person than the interns and docs on the team - it's just that I only have three or four patients at a time to take care of, meaning I can spend more time with each one of them answering questions.

But I have learned other types of things, and have had some not so good experiences as well. I have come to realize the unbelievable unreliability of some of the nursing and assisting staff. Our team has a wonderful social worker, a greatly knowledgeable pharmacist, etc - I am not referring to any of them. It's the nurses and their aids. We want to monitor a patient's urine output, but we can't rely on what has been recorded except on rare occasion when we know there is a trustworthy nurse on our side. I want my patients to get their pain meds on time so we can get a potentially painful procedure done on time and pain free, but I often have to hound them until it gets done. Now there are many of them, particularly on our floor, who are just wonderful and will bend over backwards to get anything you want done, done. But when we have patients on another floor, the simplest of things can be a huge fiasco. It most aggravates me when I see a note written by a nurse, perhaps even an APN or PA (advanced nurse practitioner or physician's assistant) from an outside clinic, that claims no abnormal physical findings on a certain part of the exam when it is clear as daylight - it may even be behind their chief complaint. The inaccuracy of some of the charted notes about these patients makes life difficult sometimes.

In other news, still anxious to get to the new (used) house. We've got colors for the walls picked out and painting supplies purchased. Just two weeks until we begin painting and moving. Come over for dinner sometime.

Our house

In the middle of nowhere.

Here are some photos:

Yayness!

So this week has been a good week, so far. We are finally on the brink of getting a rental house - perhaps by tomorrow we will know for sure whether or not we get the current candidate. My patients this week have been fairly good learning cases. I got to watch Interventional Radiology place three draining chest tubes in one of my patients. I am glad I wasn't him, though, it looked like he was in terrible pain for most of the procedure. With the tubes still in place and draining into measured containers, the tenderness remains. One of those sites drained 100cc's of pretty nasty looking fluid at the time of tube placement - that's a fair amount for lung tissue - and it was up to me to deliver it to the lab myself. He has also had his hand "drained," a couple massive lymph nodes in his neck drained, etc. I don't think there is anywhere else we can poke the poor guy. He is, however, in a much better mood now that he isn't in respiratory isolation, cut off from the world outside his tiny hospital room. Then there are my other two patients, both of which aren't very mentally oriented, but for different reasons. One is an older demented man with some psychiatric and movement disorders that have faded over the last few days, but their etiology remains unknown. I don't know that there is much we can do for him other than send him home under the care of someone else or a nursing home. The other man was self-admitted for detoxification from his alcohol and cocaine use. With constant Ativan sedation, he isn't very responsive to loud speech or even touch. Surprisingly, unknown to him or anyone else before now, his kidney function is less than optimal, so we need to figure what the problem is while he's there. To top it off, Dr. Andreoli is planning on taking us students out to lunch on Friday. I am curious as to his choice of restaurant and whether we will run into any Nobel laureates on the way.

The second reason for a good week is the USMLE. In retrospect, most discussions about the USMLE weren't necessarily pessimistic, but nonetheless about the tiring task of weeks of studying. Now, the scores have returned, and the work was well worth it. I scored a 254 - but let me put this into perspective. Every year, the average is between 200 and 220, with a standard deviation of about 15. So, even if the average this year is at the higher end at 220, my score is still more than two standard deviations above the average. For those less familiar with the Gaussian curve, this means I should have scored between the 95th and 99.7th percentile. This makes me very happy, to say the least. My goal was to score a 240, and I thought that might be pushing it. Surprises sometimes come. Our class as a whole, though, didn't score as well as classes past and future, as is our apparent inescapable fate.

One final thing is a job opportunity that has come my way. That's right, a job whilst in medical school. I don't know if I will get the position yet, but here's how it works. I will be a technician for the cornea bank at the eye center. I will be on call for a week at a time, but only rarely will it be two weeks in a row. It's beeper call, which means I can go home, go out to eat, sleep, etc. and just go in when needed. The call hours last from 4PM to 8AM. If and when I go in, here's what I do: for those patients listed as organ donors, or least after having expressed desire to donate their corneas, I go see these patients in the morgue after they have passed on. It is my job to enucleate (remove) their eye and then transport it back to our lab. There, I will remove and process the cornea for storage in the cornea bank. The pay is acceptable - 20$ per night on call, $110 for every case done or $65 for every half case done, and mileage. Since these are dead patients, they can work around my schedule and the other three techs, the doctors, and residents are all very understanding of my position as a medical student and my priority to my patients. While sleepless nights happen occasionally, they aren't all that common. Better yet, this is right down the alley of what I want to do and it will look great on a resume. I'm pretty excited about what the next few days/weeks will bring.

After the first week

I still feel like I am where I belong. Not as a student, but in medicine in general. I enjoy doing what I do, even if I did have to spend the week looking like an idiot trying to learn the ways of the ward, and I have a ton yet to learn. Perhaps I will describe a typical day to you.

I arrive on the floor around 7AM, since, for now, I am new to this and arrive a little early to give myself extra time to get things done. On a day I am carrying three or four patients, which is most days from here on out, I see two patients between 7 and 7:45 after reviewing their charts for any overnight events. You never know when your patient fell overnight and required a head CT because no one will tell you, not even the patient if they hit their head hard enough. I then make the ten to twenty minute trek over to University Hospital where those of us students in the IM clerkship have a daily (except on Wednesday) one hour lecture. I then go back to the VA and see one or two more patients before 10 AM. At this time, Dr. Andreoli arrives and we go over any X-rays, CT scans, or MRI's which might be useful. Andreoli then inspects our clothes and our pockets for labeled pens before we head off to see our patients. Our team usually carries between 15 and 20 patients, each of which requiring a stop by the entire team in the morning. Frequently, in between patients, Andreoli will drill (pimp) us in the hall; sometimes it's about something pertinent to the patient we just saw, and other times it is only pertinent to him in the form of history about some famous doctor we've never heard of. One might ask just how famous are these doctors, then? I can't give an answer for this one. When rounds finish around noon or slightly before, the upper level resident runs through the list of patients and comes up with plans as far as what to do about them. Then it's lunch time. Often times, there is some conference we are expected to attend. Sometimes there is lunch at said conferences, but sometimes there isn't. Unfortunately, these too often require a trek over to University. After lunch, we head back to the VA and write notes on all of our patients - the so-called SOAP notes where we address the Subjective and Objective aspects of the patient's condition, followed by an Assessment and Plan for patient care. By this time, we have sent some patients home, and others have come to us. It is up to us to then go do complete histories and physicals on these new people. After all of that is done, and the gathered information is written up into the patient's chart on the computer, it is time to go see our other patients to see how they are doing. At last stop, it is wise to take one final look at the patient's chart at the end of the day to see what actually got done and what got put off until the next day. And, of course, mixed in all of this is the occasional little task to complete or lecture by our ward's director to attend. All in all, the average day on wards ends between 5 and 7PM. They make for long hours, but they usually go by at a decent pace. Tomorrow, I begin my first of a twelve-day stretch without any days off. Good times.

In other news, we finally looked at a rental house today. Aside from it being pretty far out west, it's not a bad deal. It's a three bedroom, 2 bathroom, 1200 square foot house for $850 a month. The best part is, there aren't any neighbors right next door, and the area is pretty heavily wooded. It would be a good deal, but I want to look at a few closer houses yet. It may not be too long before we move out of this dang apartment. Of course, if we do decide to move to a larger place, this will undoubtedly come with a higher rent than what we pay now, and I will just have to put off getting a new car until my truck dies beyond repair (i.e. spontaneous combustion, alien abduction, drowning in the river, nuclear holocaust, etc).

Day One

OK, so I won't post daily about what I do day in and day out, but some days require special recognition. One of these days is the first. The first day of anything is a new experience worth writing about.

I met, for the first time, the team with whom I will be working for the next four weeks, if not the next eight. There's an attending (Dr. Andreoli), an upper level resident (Dr. Morgan), two interns (first year residents whose names I can't remember), an acting intern (fourth year medical student), and four of us lowly third years - really a fairly large team. I've talked about the infamous Dr. Andreoli before, and it's all true. First of all, there was the picture perfect view of the entire team moving from patient to patient as a unit while one of the residents or the AI presented the patient's most recent findings to Andreoli. It was as one sees in any movie depicting such events, I had just never seen it in person until now. This process went on for roughly two hours. Before we even went to see patients, he noticed my choice of shirt for the day. It was a sort of dark lavender, not a stark violet, with a primarily silver tie, and he absolutely hated the shirt. In fact, his exact words were, "You should burn that shirt immediately when you get home." I won't, I like the shirt and Rachel's mom would murder me. While on my case, he decided to examine the contents of my coat's chest pocket to ensure my pens weren't labeled with some drug or pharmaceutical company. To his dismay, they weren't, and he therefore couldn't steal them from me like he did one of my colleague's, even though his pens weren't labeled; they weren't "trinkets" as Andreoli likes to call them. Because of his disdain for my shirt, he later asked me to justify my existence on this planet by giving him the top three possibilities for a differential diagnosis on a patient we saw. I knew one, but not the other two, therefore making me useless, at least to him. Of course, neither did any of the residents correctly name the other two top possibilities. However, most of his questions didn't even pertain to the care of the patient. Most of his questions were about past Nobel laureates, inventors of medical procedures or devices, culture nonsense, or about one of many famous physicians he has supposedly met or lived near to in his brilliant career.

Despite what it may sound like, Andreoli is a decent man. His bedside manner is great. He charges a dollar to any member of the team who doesn't let the female members through the doorway first. He refers to his patients as ladies and gentlemen, not merely females and males. And, all in all, he's a great educator and great with students - you just can't let his silly insults get to you. They are otherwise harmless. Tomorrow, after arriving at 7:30 AM, I will have to write progress notes on two patients after doing brief histories and physicals on them, and then I will present them to Andreoli on rounds. It will be time to be insulted again, though hopefully not about my clothing this time. By the end of the week, I should have a routine down and it will only be a matter of learning about different kinds of patients for the remainder of my stint on internal medicine at the VA. I go home at night, read some about the patients I am taking care of and their diseases, and move on. Nowhere near the volume of studying compared to the last two years. I will be working every other weekend, so I will have a couple blocks of 12 straight days of working, but oh well. Above all, I am glad I have started my rotations with internal medicine. It is the basis from which all other specialties arise, and we get to actually apply what we have learned the past two years (whereas in other rotations, our two year's worth of lecture is near meaningless). Future updates about internal medicine will likely include what seem to me to be interesting cases, so don't get too bored.

Blogs 2 and 3

In lieu of me writing stuff about the wedding and honeymoon, I direct you to Rachel's blog (a link can be found at the right of this page). It gives the same basic ideas, albeit from a different point of view, that I would likely give. After having blog 2 nearly complete, it failed to save like it should have and I don't feel like re-writing it all. By the time I would feel like it, it would be too far past the event to really matter, especially after having read Rachel's blog.

Sorry for the disappointment, if there is any.

U Smile

Hello again. This is the first in a series of three blogs, each detailing events which happened in the last couple of weeks. I should have no problem filling this space over and over again with little tidbits of information. This particular blog pertains to my medicinal career.

That pesky little national board licensing exam is over, long over in fact, hence the title of this blog. U SMiLE is an often used slur of the acronym USMLE. I don't know if this particular slur is simple optimism or overt cynicism, but there is no smiling during said exam. Of course, a big smile spread across my face when I finished, but this wasn't due to answering 350 obscurely worded clinical vignettes with joy. Several people have asked me how I feel I did. These are people who, naturally, weren't taking the test themselves, because as anyone who takes the USMLE or its entourage of practice exams knows, how you feel you did is meaningless. I will say this: I didn't walk out of there wanting to pull my hair out due to frustration, like some of my less fortunate colleagues. I know of some who felt as though the test went horribly (even though these are good students who always do well on exams), and even one or two who left crying. There are even a few malingerers who have yet to take the exam (mostly those who keep pushing it back, a highly frowned upon practice), even though we start school next week. But, alas, it's all done for me. Scores will arrive sometime around July 18, and I anxiously await. Let's not discuss it between now and then, eh?

In other medical news, I have begun a collection of old medical things. While on our honeymoon (details to follow in the third of this series of blogs), we visited a few antique shops when the idea dawned upon me. Someday, I will have an office, or perhaps a patient waiting room. And what is a waiting room without cool, old, medical trinkets lying around on glass shelves behind glass doors which will require constant washing to remove the nose and finger prints of little children? So far, I have acquired three objects. The first is a book from the 70's called, The Encyclopedia of Common Diseases. The second item is an old mercury bichloride bottle for medicinal purposes. It even lists the antidote to poisoning: "Give milk or white of eggs beaten with water, then a tablespoonful of soap or baking soda in a glass of warm water and repeat until vomit fluid is clear. Then give milk or white of eggs beaten with water. Call a physician." So remember kids, before calling the doc or 911 or anything, scramble around the house looking for eggs, water, soap, and baking soda, with a source of heat for the water, an egg separator since Lord knows you don't want the yolk, and an egg beater, watch the victim vomit a few times, repeat, and then pick up the phone to call for help. We have drugs for this nowadays, it takes out a lot of the guess work I suppose. The third item found is a book from circa 1910 called "Hygiene and Sanitation." It appears to be like some sort of manual/textbook every 100 year old physician should have. I can't really say any more about either book since I haven't read them yet (if ever).

While my scores in northern Arkansan antique shops won't likely prepare me for the coming months, some emails have begun filtering through which likely will. We have started receiving various emails from course directors and fourth year students, many of which contain potentially useful attachments. All that said, I am beginning to get excited about this year. It's a complete turn around from the last two years, and it will take a lot of getting used to for all of us. I recently discovered I will be working under the notorious Dr. Andreoli as my first attending. Andreoli is a name dropper, a student pimper of boundless sorts (he charges his students and residents money if they get stuff wrong), and he hates corporate sponsorship (i.e. no drug rep pens and paper). He's like television's Dr. Gregory House, but with a better bedside manner, I should hope. He's even a nephrologist, though he's not a snarky Brit. I can handle this. I think I can match his sarcasm (have you met me?). Only time will tell. I have him for four weeks, and the remainder of my internal medicine rotation is yet to be decided. Many blogs will spew forth from this coming experience, and I hope you will read on. But this is all for now, and I will soon write about the wedding and honeymoon, blogs 2 and 3, respectively.

This is about it

You're probably tired of hearing about this stupid test I have, quickly approaching with frightening speed. But writing about it helps me chill that bitch out. I am by no means freaking out, nor is it likely I ever will. But I have been victim to strange sleeping patterns and awakening times. I'll wake up in the middle of the night, sick to my stomach and my heart racing. I don't recall any dreams, but I don't know what else to blame. Momemts later, I will calm down and fall back asleep. Then, I will wake up at early hours in the morning, six or seven o' clock, when I could normally sleep in until nine without an alarm clock. It's not that late, I know, but I just can't seem to sleep until noon or one like some of my friends who refuse to enter the world of adulthood. Not that sleeping in is a bad thing once in a while, but those who would do it every day if they could, and then spend their day doing absolutely nothing. . .OK, tangent there, sorry. I took a practice exam yesterday. It was a four block exam with each block containing 50 questions to be completed in 60 minutes. The real test is seven blocks of the same load and length, **that's what she said** so it was a little more than half the lenght of the real thing. I have been told that a couple of the practice exams, if taken within a few days of the real test, accurately predict your test score within a few points. So I hit a crossroad at the end of the exam; do I look at my score with the possibility of getting myself discouraged this close to the exam, or do I just leave it and continue studying? I had to look, it was like a train wreck in only that respect. The score was good - a 232. To put it in perspective, 185 is passing, the national average is between 200 and 215, and the standard deviation is usually 20, so this puts me around the 80th percentile. So, it's a good score, but I wanted a little higher. Is that bad? After studying for six weeks with only two days left to cram, should I be so concerned about getting over that 90th percentile hump? I don't see why not.

Ever Closer

Lots of things are so close to now. My birthday is tomorrow, but I've hardly even noticed. It's not like being a kid anymore when we looked forward to our birthdays for a month ahead of time. I did, anyway. Kyle is throwing the "bachelor/birthday" party this Sunday. I'm not sure what he's planning, but Rahcel knows all about it. There are only two things I can think of for people to do Sunday morning at 10:00 (if they're even awake to begin with); 1) Go to church, and 2) Go to Grandma's house after church if they went to the early service. The only strip club open at that time will be the one 500 feet south of a small baptist church off highway 530, all of which are otherwise in the middle of nowhere (I found this quite amusing the first time I saw it; I imagine the reverend owns and operates the club). Nobody serves alcoholic beverages at such a time here in Arkansas. So, needless to say, I'm as lost as a midget in a corn maze on this one.

One thing I'm not as lost on is ultimate. While my performance Thursday was pretty piss poor, Tuesday went fairly well. I have improved a lot over the last few weeks, but I have a lot to learn. The summer league starts next week and I have never been so excited to lose. I may have to quit playing with the good guys though, since my first rotation will require working until six or seven most days (so I'm told). That's another thing I'm excited to start: rotations. A month from now, I'll be taking care of real patients. No more fake ones who were trained to simply say, "No, you're doing it wrong. Touch me here."

Rachel's birthday is also approaching. What will I do about it? I have no idea. I'm sure we'll go the birthday suit route in some form or fashion.

Step 1 is still approaching. With barely more than one subject left to study, am I getting more nervous? No, not yet. I don't usually get nervous about stuff like that. My preparation the night before - drink a beer or two to put me in a relaxed mood, and then go to bed when appropriate. Nonetheless, more rides on this test than rides on the next two Step exams since ophthalmology is an early match residency. (More on this when the time comes, in a year and a half or so.) Scores, amazingly, don't take but a few weeks to return, depending on what time table the test is taken. Luckily, I have the honeymoon to mellow out between the test and the arrival of my fate on paper.

Finally, the wedding is still coming. There's not much else to plan at this point. The minor details will fall into place in the days before hand and some even later than that. My attendants' gifts are ordered, tux measurements taken, etc. Not anywhere near as many people are showing up as we originally projected, but that's OK. It will all be a good time without them.

That is all for now.

Studying

Yep, it's no surprise I am studying. Or, rather, taking a break from it at this exact moment. With only two weeks left to cram, I probably shouldn't be here, but who cares? I would say I need a break, but that's kind of hard to suggest since I spent most of the weekend not studying. I went through flash cards and some of a review book while flying on each of the five planes we rode on. That's right, five. We went to Detroit over the weekend for a wedding, and between 5:40 AM on Saturday and noon on Sunday, we boarded five different jets. Amazingly, not a single delay put us behind schedule, not even in Chicago. We had a great time. I got to dance with the always beautiful Rachel Soon-to-be-Thuro. We couldn't really take any of their ideas away with us since pretty much everything at our own wedding, in 19 days, is planned. I don't have much else to say right now since I have given my brain over to the demons of academia, temporarily suspending much in the way of will power and creativity.

Ultimate

So I have been playing ultimate frisbee now for a couple months. It's a sport with deep seeded roots amongst the hippies, many of whom continue to play at 50 years old and up. But that doesn't matter to me, it's still fun. I started playing with Garrett about two months ago, the same time he started, through friends of his from previous emplyment and amongst them, several church acquaitances. Even though there are a few players out there I would continue to consider better than me, I feel I have improved greatly and play at a comparable level to any one of them. I am no longer a useless member on the field. There are just those couple of players out there I have always felt portrayed excellent playing ability. To be as good as them would be sufficient.


That is, until last night. I have started playing with a different group of people that meets in NLR a couple nights a week. I showed up thinking I would have at least some experience on my shoulders and perhaps I could play better than just one person out there. WRONG! These guys, and a couple gals, are the city's best of the best. They live for the game and have been playing for years. They actually play by the official rules, which come with a learning curve if you're trying to learn them whilst playing. They did throws I hadn't seen, man-on-man playing we never practice, and counting of all sorts including stall counts. All of this was a whole new game to me. I had read the rules, but seeing them in action is a completely different story. I felt, once again, useless. And that's when I realized, nobody we play with on Saturdays is absolutely phenomenal, not Ramsey, not the Millers, no one. So it's time for me to step up my game - and if I am so fortunate as to be able to match the guys I play with during the week, becoming the new ultimate God on Saturdays will be no problem. (Not that that was my goal from the beginning, but I can see now how it can (will) happen.) You're on, Garrett ol' boy. The truly competitive spirit has risen.

Week 4

I am about to enter my fourth week of intensive course review. The first two years of medical school are spent sitting in class or standing in lab for hours on end, learning the so called basic science material. The remainder of our waking hours are spent studying said material. However, it isn't so basic anymore; not like high school biology where simply knowing where the femur was served sufficiently on a multiple choice exam, while the other possible answers consisted of skull, rib, humerus, and hot fudge brownie. The questions we are now faced with present a patient with a set of symptoms. That is all. The final question stem may be: What side effects do you expect to occur in this patient? This means we have to diagnose the patient, remember which drugs are likely to be used in this patient, and then choose the drug with a side effect appearing as an answer choice. All the while, keep in mind the potential lab abnormalities which may or may not be given which may mask something or be a simble red herring. The test for which I am preparing has 350 similarly worded questions over an eight hour time period. **Whew, sounds tough** OK, so I'll pass it, but to what degree? I have this week followed by three more to continue preparing. Better get to it.

The First Time

So this is the first blog, at least at this location and with this purpose. After wasting brain cells participating in the MySpace and Facebook craze, I felt it was time to fulfill a more mature purpose. I know I have at least minimal writing ability - I went to a liberal arts university and as some may have experienced for themselves, writing is one of the few things to take away from such an experience. After Rachel got involveed on BlogSpot with her movie review page Mrs. Thuro's Rants and Raves and her other page Mrs. Thuro's Life Rants and Raves, and then her friend Carrie got involved with Carrie's Lair, I couldn't resist. I have heard an awful lot about Carrie, and now, after having kept up with her new blog, I am even more interested in meeting her for the first time in a short while. While my goal may not be to get folks interested in meeting me, I think it would be great to attract a few regular readers, and perhaps give some people insight into what makes me tick, or get ticked off. For now, I leave you with that and will try to update regularly.