Halloween & Hand, Foot Mouth Disease

I was reminded of how much fun Halloween can be last week during the costume contest on the wards. The day before, our chief resident made an announcement during noon conference to remind us to dress up for the kids. I was a gypsy, which was not nearly as creative as the Mickey Mouse, pirates, fairies, cowboys, Pippy Long stockings, and other characters. As we walked around the wards, it was uplifting to see some of the patients dressed up and getting to Trick-or-Treat at different places on the floor.

Post-Halloween, I spent my day in the ED during a day shift.

When I spoke with a kid with a possible wrist fracture, I asked him why he waited to come to the ED (he had sustained the injury the day before) and he had the most adorable response.

"I would have come on Saturday, but I wanted to go Trick-or-Treating."

Now, there is a kid with his priorities straight.

***

For the first time, there is something in medicine that is appropriately named- hand, foot and mouth disease.

During urgent care clinic today, I met a very cute four year old boy, who was been feeling awful over the last weeks with fevers, diarrhea, mouth ulcers, and diarrhea. He also had some interesting rashes on his palms and soles. As I listened to the story from his grandma, I started to put two and two together; he has problems with his hands and feet (rashes) and mouth (ulcers) in the setting of an infectious process (fever and diarrhea).

Like a simple math equation, it all added up to one thing- hand, foot and mouth disease, which is a coxsackie virus infection. Treatment is mostly supportive (fluids, rest, and Motrin) and the symptoms will likely resolve with time. Poor kid.

***

My days in urgent care have been a mix of evaluating upper respiratory infections (mostly coughs, runny noses and fevers) and some other interesting things, including jaundiced newborns, kids who have been vomiting, kids with diarrhea and strep throat.

On my call days in the Emergency department, I took care of a six year old boy, who sustained a wrist injury while dribbling a ball in a soccer match. I was the first to sign his cast with my signature sparkly Sponge Bob stickers. I also saw a toddler with gastroenteritis and a 16 y/o with vomiting.

In my one week of experience, I am really enjoying working with the kiddos and am beginning to see the "bread and butter" of pediatrics, which is still very novel to me during my second week of pediatrics.

The Eyeball Test

These days, I walk around with pockets that are less bulging.

I traded the gauze, suture removal kits and medical tape for stickers and a doggie pen. I am proud to say that I walk around with stickers in my pockets, including Sponge Bob and an assortment of dog stickers. My favorite part of my job involves giving stickers to my younger patients.

I have moved from the world of surgery to pediatrics, two completely different worlds. I went from waking up before the sun had risen to waking up to the sun shining (I am currently working in the Urgent Care Clinic). I move away from focused abdominal exams to full head to toe exams, including looking into patient's ears and noses. It's a constant battle to get the otoscope into my younger kids, who cry and squirm. Even getting kids to open their mouth can sometimes feel like moving mountains. And yet, despite the challenges- it's such a pleasure to work with kids and families. When they smile, you feel a little less guilty about having to probe their ears.

In many ways, it's a stark contrast. I'm well-rested these days, catching up with friends and starting up my half-marathon training. The chief complaints have primarily been lots of upper respiratory symptoms and ruling out swine flu in kids having flu-like symptoms. In summary, lots of runny noses and coughing. Surprise surprise.

I do miss the intensity of surgery, the operating room and the complexity of the pre-operative and post-operative management. There is something remarkable about cutting someone open, visualizing the anatomy and defect, and fixing the problem with your hands (or instruments). I will miss the suturing for sure. There is no experience quite like it. A part of me will always be in love with surgery.

***
I do look forward to working with younger patients and developing an understanding of how to best approach common and not so common pediatric problems in the outpatient, urgent care and inpatient settings.

Although pediatrics and surgery are so different, there is one thing very similar to both fields--the eyeball test.

In pediatrics, you are oftentimes working with patients, who can not speak for themselves or give accurate histories. So, you rely on the caregiver to convey the history.

One pediatrician jokingly compared pediatrics to "veterinary medicine," since the patient is a poor historian for obvious reasons and you have to consult the owners (or the parents) for information.

As a result, you rely on your ability to "eyeball" the patient, which involves observing the patient and taking note of how they look, how they interact with others, and if they look sick. In doing so, you can answer some really important questions- "is this patient sick or not sick? Does this patient need immediate medical intervention?"

In surgery, you apply the same approach when evaluating a patient. You "eyeball" a patient to get a general sense of their disposition and health, which enables you (as a surgeon) to quickly decide if the patient is sick and if they need immediate surgery.

The eyeball test can also replace lack of knowledge; it's almost an instict or gut feeling. It got me through my surgery rotation and has been useful for me in my first days of pediatrics.

Excellent, the New Average

Sometimes we all need to remind ourselves about the light at the end of the dark cavernous tunnel that is the third year of medical student. It can get murky when you are constantly being watched and evaluated and when you learn about what to expect in the near future.

The fourth year has become uncovered and now we are learning about the residency applications and the MATCH.

The cycle starts all over again.

Our third year creeped up on us not so long ago, and now it's starting to feel like it is slowly coming to an end. We are over half-way through and the fourth year discussion has already begun. Over fifty per cent of our class will choose to extend their education by at least one year, during which time they may travel, perform research or work. I am still on the fence about whether I want to take an extra year to sort things out. Medical training already seems so long. And having gone straight to medical school from college, I am accustomed to moving forward non-stop. At the same time, I want to certainly keep my options open and am considering research fellowships or an advanced degree in either public health or education.

Amidst all the lectures about fourth year planning, the Step 2 exam, clinical performance standards and extending medical school by taking a year off- we are learning more about the process involved in applying for residency and the match. The process and timeline remains very unclear and represent a source of anxiety for many third years.

But one thing is for sure, the third year is all about labeling. Our clinical performance is packaged into a one word adjective. You can be any of the following- "Superior, outstanding, excellent, very good, or good." With over 53% of the UCSF class labeled as "excellent," excellent has become the new average. Seriously.

This culture of labels makes me wonder about the utility of such characterizations. First, the entire process is subjective and determined purely based on other's opinions of you. Second, medical students are unique individuals with very diverse backgrounds, opinions and perspectives, who really can't be characterized by a single number or adjective. But despite such issues, we continue to label each other.

To standardize the process, we are evaluated and given a numerical value that reflects a number of fabricated categories that are intended to measure our fund of knowledge, clinical reasoning and patient relationships. In many ways, the numbers marginalize us, and we may even see ourselves in light of the label we are given. The feedback that accompanies the number oftentimes does not always correlate and we wonder what we could have done differently, or if we should do anything differently. There is only so much any individual can change.

The system exhausts me. It's tiring to always think about what others think about you. A number of us (myself included) have decided to make the most of our third year by focusing on learning and taking care of our patients. And in the process, we hope the evaluation will reflect that. But as much we tiptoe around the inevitable evaluation conversations, there really is no way to avoid the unavoidable. It's on all our minds akin to the white elephant in the room. We all think about it and wonder about it. Some of us complain or try to rationalize the process. No matter what, we work hard and hope it all works out.

And last time I checked, there is nothing wrong with being excellent.

The End of Surgery

Friday was the last day of surgery. We ended on a somewhat anti-climactic note with the surgery shelf exam, a somewhat arbitrary measure of knowledge and clinical reasoning. I was experiencing flashbacks (nightmares) to preparing for the Step 1 exam, as I hopelessly reviewed esoteric details of diseases I had never encountered. It was certainly one of the least pleasant testing experiences I've had with 100 long questions in 2 hours- marathon test taking at it's worst. Sigh.

"If you finish you are ahead." I was told by another medical student.

As I studied for my shelf, the fellow on my service was preparing for his oral boards. Sadly, the tests just never end.

I left the exam feeling numb and bit flustered. Before I could start thinking about the test, I plugged myself into my headphones, tied my running shoes and set out for a long run. Actually, a really really long run- the longest run I've had thus far (14miles).

With the sun beating down on me, I just had the urge to keep going as I took in the sights of a city I had become estranged from while being on my surgery rotation. Moving one step forward, not looking back at all. This is definitely the year to run a half marathon.

Despite the challenges of surgery, I will definitely miss the rotation.

***

My last two weeks of surgery were spent on the kidney transplant unit. The best night of my rotation was on Monday, when I joined our team during an organ procurement. At 10:30 PM, we set out from San Francisco in a black van and made our way to a local bay area hospital, where we procured the liver and kidneys from a donor. The experience was surreal.

I felt disconnected at times-- not quite fully thinking about exactly what we were doing. But I also kept reminding myself how the organs we harvested could potentially save lives. No matter how I justified it, I could not forget the reality of what we were doing. We were removing organs out of a patient, who had been proclaimed brain dead. I got my best anatomy lesson that night. The heart continued to beat and the organs remained perfused, as we dissected away one organ at a time.

***

After my shelf and long run, I spent my golden weekend in the company of family and friends. My weekend was filled with quality time and food. I was able to recharge and refocus my energy.

I move now to Pediatrics, which starts next week.

Before moving ahead, all third year medical students will congregate in the classroom for a week of intersession, a series of lectures and small groups dedicated to ethics and clinical reasoning. Even after being lectured about how to resolve ethical dilemmas today, I feel more confused and uncertain about how to grapple key ethical topics, including allocation of scarce resources, end-of-life care decisions, euthanasia and patient autonomy. I hope this week will shed some light on these topics.

It's hard to believe that we are over 50% of the way through our third year of medical school. We reminded of this during one of our lectures, which focused on planning our fourth year of medical school. Already? I'm still just getting the gist of third year.

Shelf

About to take the surgery shelf exam.
And will then be done with the rotation.
Stay tuned...

Empty Crib

I will remember the empty crib. On my last day of my pediatric surgery rotation, we returned to round in the intensive care nursery. As we made our way to the west side, we walked to the crib and the baby was not present. Right away, we all knew what had happened-- the baby had died.

My fellow medical student and I had been following this infant's course during his hopsital day. Each day we reviewed his numbers, noting little signs of improvement. We would come by and examine him and speak with the mother. At one point, he was being maximally sustained on pressors and the maximum ventilation support. Despite all the interventions, the infant failed to improve, something we had expected from the start.
***

In the neonatal intensive care nursery, each infant receives the most specialized attention from a large team of healthcare providers, including physicians, nurses, social workers and students. Every conceivable piece of information is recorded on large elaborate flow sheets, everything from vital signs to infusions to amount of urine and stool to when the baby moves or sleeps. The life of an infant is chronicled by the hour. The fluids and output are meticulously measured. Medications and drips titrated exactly to the infant's weight. The amount of detail is nothing short of perfect.

And when the decision to withdraw all forms of life sustaining treatment is made- the flowsheet detail decreases, eventually disappearing. The infant is whisked away to a seperate room, where he can be with his family for the last few moments of his young life.

***


During my last week of pediatric surgery, I observed the spectrum of interventions to sustain life, from basic to complex procedures.

I watched as we sewed the ends of an esophagus for a baby that was born with esophageal atresia, where the esophagus ends in a blind pouch. The physician meticulously laid each suture to create an anastomosis between the blind bouch and the remaining esophagus, which was located more distally.

I watched how we managed acute renal failure in a baby with an obstrution secondary to a large cyst. I saw numerous inguinal hernia repairs and catheter placements.
I saw how we fix congenital diaphragmatic hernias, a defect in the diaphragm that develops when the diaphragmatic folds fail to fuse during development, which results in abdominal contents herniating into the thorax and preventing proper lung growth. Infants with this defect are born in respiratory distress and typically require ventilatory support prior to surgery.

We performed two repairs this week, on infants who had severely defected diaphragms. With the thorax open, the abdominal contents were carefully redirected into the abdomen and the diaphragm defect was patched and sutured close.

When I asked the neonatologist about the prognosis for infants with severe hernias, he told me the following-

"Fifty per cent of such infants will make it out of the hospital alive."

He was right. Only one of our infants survived.

Venturing into Pediatric Surgery

The sun was shinning today, beckoning me to come outside. Despite the impending surgery shelf exam and a pile of incomplete reports, I made a decision to go running. A run to the ocean and some sunshine was exactly what I needed to recharge before another week of surgery. I have come to realize that it's better to live life when you have a chance rather than put things off for a more convenient time.

It's evident the list of things to do just gets longer.

***

"Medicine is like music. You have to listen for notes before you can appreciate the melody."

A truly insightful comment from the pediatric surgeon I worked with last week.

I am still struggling to put the notes together.

My first week on pediatric surgery was interesting. Just when I started adjusting to the world of general surgery, I was transplanted to an entirely different place, where the patients are smaller, have rare congenital anomalies and typically can't communicate directly with me.

You see the entire spectrum, everything from neonatal in the intensive care unit on bypass for respiratory failure to toddlers undergoing hernia repairs that require no hospitalizations to children with appendicitis to teenagers with midgut malrotation.

I spend my mornings in the neonatal intensive care nursery, collecting the numbers that reflect the respiratory, cardiovascular, fluid, electrolyte and hematologic status of the critically ill infants. I feel more like a recorder, writing and reciting the numbers without fully understanding the meaning. I was only beginning to understand adult ICU values. Neonatal intensive care is far more complicated and requires more than one week to grapple the ins and outs of management.

I have come to really appreciate the complexity of pediatric surgery. The operative approach is unique in pediatric surgery. The instruments are so much smaller and special attention must be paid to every little motion. When I watch the surgeons, I am amazed at how they navigate through such small holes to identify vital anatomical structures.

I have three more weeks of surgery left. We'll see what my last week of pediatric surgery brings...

Golden Weekend

"No one ever tells you that you are doing a good job. But everyone yells the moment you mess up. It's a thankless job. Welcome to surgery."

While we were operating on Friday, the surgeon made this statement as I drove the camera during a laparoscopic hernia repair. His statement is true on many levels.

In the OR, you move when told to move, or you stand and watch. It's almost paralyzing when you are called on to do something. Time stops, as everyone waits for you to complete your task. You pay close attention to detail to make sure you do your task right- be it cutting suture (no matter what you do it's either too short or too long), suturing (it's always a struggle to approximate everything properly and you move too slow), driving the camera during laparscopic cases (following and keeping the horizon straight takes some experience), or retracting tissues (you never quite know how much tension to apply).

Whatever the task maybe, you always find yourself fixated on the smallest details. It's perhaps this close attention to detail, which makes surgeries successful and makes surgeons perfectionists.
***
Friday was my last day on the general surgery service. I move from the world of hernias, appendectomies, cholecystectomies, fistula repairs and gastric bypass procedures to an entirely different world- pediatric surgery.

I've had my first preview of pediatric surgery over these last two weeks, while I took care of a patient with midgut malrotation. I was the first to meet this family in surgery clinic and review here films. While in the hospital, I have been their point person. In working with the family and patient through her admission and surgery, I was felt lucky to work directly with my her and her family. In getting to know her story and in interacting with the family, I was able to learn far more than any pediatric surgery book could teach about such anomalies. It's such longitudinal experiences which make this rotation so memorable.

Before venturing forth to my next surgical rotation, my chief resident graciously gave me this weekend off. I have to stay this is true golden weekend. I am lucky to be spending time with my family and friends during the last day of Ramadan (the month of fasting) and Eid (the holiday marking the end of Ramadan). I am looking forward to eating my mother's home-cooked meals (actually anything other than crackers), catching up with my friends, having normal people conversations that do not conist of asking about bowel habits, sleeping, studying and exercising.

A perfect balance. I am now officially half-way through my general surgery rotation.

Surviving on Crackers

I was once told by an anesthesiologist that he made his way through residency by surviving on saltines and water. When I heard this, I did not entirely believe him. But the more I think I about it and having spent 3 weeks on surgery, I can see the truth in his statement.

My daily diet (when I'm in the hospital) has been mostly consisting of two things- saltine crackers or graham crackers (and if I'm lucky- a whole wheat bagel with peanut butter). With ice water. Very appetizing.

While in the hospital, you sometimes go hours without really eating or thinking about stopping to eat. Between pre-rounding and rounding early in the morning, meeting patients before the case, prepping the patient for surgery, scrubbing in on the case and accompanying patients back to the PACU to write orders- you are left to scavenge for bites of food in the few minutes you have before the next case starts. And your body gets used to it. This is why dinner has become my favorite meal. I can actually sit and chew my food.

There a few things I have come to appreciate while being on surgery.

1. There is nothing like breathing air. By that I mean, being able to take a deep breath in and out without a mask on your face. It never felt so good.
2. Sitting- it's a wonderful thing. Wow, what a different it makes for your back, legs and achy feet.
3. Medical students do have a useful job on surgery. We are glorified supply cabinets. Need four by fours, gauze, tape, saline, suture removal kits? Don't worry- we got it on our person, or know how to get some.
4. I think my patients think I am preoccupied with bowel habits. Because every morning I ask the same questions- "have you passed any gas? Had any bowel movements yet?"

With three weeks down, I can truthfully say that surgery has consumed my life, taking up most hours of my days. There has very little time to see friends, sleep, study and exercise (although I think standing all day and running around rounds qualifies as exercise). I leave my apartment when it's dark and return home when it's dark. The only glimpse of sunlight I get is when we round on our patients, I can sometimes catch a view of the sun setting on the city. Even when I'm not in the OR or hospital, I am thinking about my patients and their diseases, the surgeries of the day, the suturing techniques I have learned, and the hospital course of my new patients.

The hours are long. And you work hard. Despite the challenges (namely lack of hours in the day to sleep and study), I feel lucky to be actively involved in my patient's care. There is something very special about taking care of the patients you have operated on. By performing surgery, you not only become acquainted with your patient's anatomy, but you are also able to use your hands to fix a problem, whether it is a hernia or enterocutaneous fistula or excision of a mass or a bowel resection. Postoperatively, you see how your patient regains bowel function, has improved pain, and starts eating food. The transition can be rewarding, when you see your patient discharged in good condition. It can also be frustrating, when your patient does not improve and remains hospitalized and you are left to wonder what went wrong.

I spent Friday night taking trauma call at SF General Hospital. The motto for SFGH is "It's as real as it gets." The SFGH Emergency Department serves as the only Level-One Trauma Center for the City and County of San Francisco and northern San Mateo. With over 58,000 visits annually, the Emergency Department serves both critically injured patients, as well as a large underserved and urban population.

The night was fairly mellow. We had a couple of 900 emergent pages (a gunshot victim and motor vehicle accident), which upon further evaluation did not require surgical intervention. We also had some patients with acute appendicitis, a patient with pneumothorax requiring chest tube placement, and a patient with an abscess. I performed my first incision and drainage on this woman's abscess. In doing so, her pain was improved and she was able to go home.

My first overnight call (with 2 hours of sleep) done. I left at 10 AM the next morning, completely exhausted and hungry- looking for some crackers.

Completing an Important Job

Week 1 of surgery is done. 7 more weeks to go.

Within the first few days of this surgery rotation, I realized I had entered an entirely different medical culture. The structure of the day, the language, the clinic and the operations all represent eleements of a completely new experience.

One thing is for sure, I'm getting used to going through the entire day without seeing the sun shine. I wake up at 4:30 AM to make it to the hospital by 5 AM. I pre-round on my patients and help prepare for rounds, which start promptly at 6 AM. We round as a team on over 20 patients from 6 AM to 7:30 AM to make it in time for the first OR cases, which start around 7:30 AM. At this time, most other teams are just beginning to arrive at the hospital. We move fast and quick.

Then we spend the day in the OR, operating. As a medical student, you scrub in and wait for instruction.

"You have the most important job. We rely on your precision," said the attending surgeon during a laparoscopic gastric bypass surgery. Surprisingly, he was addressing me- the camera driver during a laparoscopic case.

I was able to admit my first patient from the ED. A 60-something year-old gentleman, who presented with diffuse abdominal pain localizing to the right lower quadrant. He had the classic presentation of acute appendicitis. Once he was admitted to our service, I stayed and scrubbed in on his case--a laparoscopic appendectomy. Within his abdominal cavity, we found the worm-shaped structure, inflammed and engorged, covered with white pus.

Friday was a special day. The third year surgery students from all the different sites congregated in the skills lab and learned the basics of knot tying and suturing. With the guidance of a plastic and reconstructive surgeon, our group learned how to close skin and layers of deeper tissues. We made incisions on pig's feet and sutured the wounds closing, using a diverse set of suturing techniques. Hopefully, these skills will be put to good use during the rest of the rotation.

The week has been busy. The hours have been long (the longest of any rotation so far). Time to study has been scarce. The pace has been rapid. And the learning enviroment has completely transformed.