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.

Learning the steps

"It's like dancing. You got to know the right moves," said our surgery block director during orientation. He was referring to scrubbing in on cases in the OR and navigating around the carefully orchestrated flow of nurses, physicians and OR staff. The movement of instruments, the position of drapes, the placement of surgeons--all part of this dance. The medical student has to learn his or her place.

I attempted to better learn these steps when I ventured into the OR today on my first case as a third year medical student. The case was a laparoscopic cholecystectomy, gallbladder removal to treat gallstones that were causing agonizing pain in our patient. Through small incisions on the abdomen, we placed ports that held different instruments and a camera that gave us a view of the abdominal cavity. I scrubbed in, held instruments, drove the camera and watched the monitors as the the instruments navigated through the biliary geography.

Once the gallbladder was removed, I made a longitudinal incision to slice open the gallbladder, which contained multiple green pigmented stones. It was impressive to see how the entire pouch was brimming with stones; each stone has the potential to block the ducts that carry bile to the colon and cause excruciating pain.
***


Hard to believe that I have officially begun my eight week surgery rotation. During orientation, I also found out that one of my photographs from Med Link, a mentoring program that pairs medical students with underrepresented high school students, was selected as honorable mention for the 2009 School of Medicine Summer Photo Contest: "Learning Moments." Thought I'd share the photograph.


As days go by, I look forward to learning the steps to make it through the next eight weeks.

A year wiser

"One year older, one year wiser." The words of a family medicine doctor on our last day, which happens to be my birthday.

I found my first gray hair today. I'm not sure if it's a sign of aging, or a product of being a third year of medical student.

Whatever the case, it's a sign of more to come.

On our last day of family medicine, we took an exam (what a way to celebrate a birthday) and had a cultural competency lecture. Lunch was a celebration of my birthday and the end of family medicine rotation with the three other medical students over lunch, a slice of pie and singing waiters. Oh, how I love surprises.

I look forward to this weekend off. A time to relax with my family and friends, reflect and celebrate being one year wiser and 33.33% done with third year of medical school.

Breaking in the New Shoes

This weekend has been all about breaking in the new running shoes. As much as I love the feel of worn-out ripped running shoes that have faithfully served me over 100s of miles, I finally decided it was time to start the cycle again with a new pair. So, I laced up my new shiny, silver, white and turquoise shoes and broke them in this weekend with some long runs to the beach.

Yesterday, I made my way through Goldengate Park to Ocean Beach up to the Cliffhouse. Today, I followed the same path and went farther up to Land's End. With the sun shining over my shoulder, I took in the scenes and sites of a familiar running trial with all of it's climbing, descending and incredible views of nature and water. I have to say running (along with friends and family) has gotten me through my first two years (and now my third year) of medical school.

As I run, I always take time to reflect and think, mentally sorting the loose ends of my life- everything from pondering about existential thoughts (what is the meaning of life) to thinking about my personal life (how can I make time for my friends and family given such limited time with rotations) to thinking about my professional trajectory (I have so much distance to go before I feel like a real doctor).



It's interesting how we sometimes seek escape from thinking of anything medical the moment we leave the clinic or hospital. But our minds have a way of redirecting us back. As I ran, I started thinking more about my inpatient medicine rotation and my past patients and experiences-- the moments of triumph in taking care of patients and the many moments of defeat in coming to terms with the reality that we are students at the bottom of this immense hierarchy.

We are surrounded by other long white coats and members of large teams that march around the hospital, rounding on patients. Despite being part of this team, we can't help but feel alone in our lack of knowledge on many fronts. The culture of each field is initially foreign to the nomadic student, who has to quickly adapt to a new environment every eight weeks.

We never know what to say (everything sounds significant at first), or how be efficient with our words. We stumble through our long-winded presentations (we have yet to understand the "pertinents"), talk to fast, take up way too much precious time, ask too many questions and know nothing.

Third year is about learning. But how do you balance learning with the pressure of being evaluated based on your performance. It's almost like you're always on a stage, constantly being watched. And the feedback overflows. Constantly being told how you can improve definitely chips away at your sense of self-security, or makes you more insensitive to any type of feedback. I have interacted with classmates that have either valued or completely disregarded the feedback. I'm in the middle. At a certain point, you reach your threshold and decide how to process the critique; I run.

The process of becoming a doctor is truly a unique experience. Despite the inherent challenges, students are privileged to be working directly with patients in their times of need. In truth, memories of my patients stay with me; my patients have been the best teachers. In managing their diseases and learning about their lives, I have learned far more than any lecture, physician or textbook could teach. At times, you relate more to your patients (rather than the long white coat you are supposed to become), as your patient turns to you for guidance in medical decisions, addressing you as his or her "Doctor." The small moments of triumph carry you afloat during the tumultuous waves of third year (and probably beyond)...

You learn to pick your battles and decide how to focus your energy. From Day 1, I knew my focus will always be the patient. Third year is about learning. Sometimes, I have to repeat that to myself (a maantra to remind oneself to find a higher meaning in a somewhat unstructured and difficult year).

***


As I ran and watched the waves crash, I looked at the depht of the ocean and directed my focus to the life around me- surfers emerging from the ocean, runners, tourists. I quickly stopped and looked at the deep blue water. I could only think about one thing- what an incredible view. I took one more look, and with a deep breath in- I picked up my feet and start running again to fully break in my new shoes.

The Inner Child

As I walked out of a clinic today, I saw a familiar face. He instantly recognized me and smiled. "Do you remember me?" He said.

It took me a second, before I remembered. He was the dad. And sitting next to him was the mother and the baby. They were the family who I had just seen last week on Labor & Delivery (I delivered their placenta).

I was amazed they remembered me. As a student, you always wonder who remembers you (or if anyone will). And it was truly wonderful to see the whole family after the labor and to have them recognize me.

***
My whole day has been about infants. I performed a head-to-toe newborn exam on 16-day old infant, evaluated a two-year old with fever of unknown etiology, as well as examined a rash in a young girl.

Pediatric clinic is always enjoyable because of the patients; I can give high fives, make funny faces and play games (and it's completely ok). The inner child is welcomed and it's such a pleasure to learn from kids.

Slippery

With the umbilical cord clamped, I placed my left hand just below the abdomen as my right hand gripped the cord, tugging and pulling to slowly liberate the placenta from the uterus. As I held the cord, my glove turned red, covered with blood and other uterine contents from the delivery. With more pulling, the placenta moved closer to the opening the of canal. With a final push (from the exhausted mother), I could see the reddish blue disc-like mass advancing. I repositioned my hand, and pulled the cord.

Before I knew it, the placenta slid out and fell into the bucket that was precariously resting on my knees. As the placenta fell, so did the other bloody and gooey contents- some splashing on to my blue gown.

My first placental delivery. Two words- very slippery.
Mental note- do not wear porous shoes and eye protection is a must.

Just earlier, I watched how the 7-lb baby boy emerged with some assistance and careful maneuvering/pulling from the resident (first the head, then each shoulder and then the body). With the baby in the crib, I was summoned to take over. With the guidance of the resident and attending, I positioned my hands and soon caught the placenta.

Next step (logically at the next delivery) is to catch the baby.

My last trip to labor and delivery was during my first year of medical student. The view was quite different; I stood in the background, awkwardly positioning myself and acting as the mirror girl, holding up the mirror for the patient to see. Things have changed since then. Today, I had a closer view and was able to finally take an active role in the delivery.

The one draw-back to being closer- you will walk away covered in some sort of fluid. A small price to pay for what you see- the process of birth.

***
As week 4 nears an end- I'm really appreciating the scope of Family Medicine. In this last week, I've gained a spectrum of experiences. I spent some time in my continuity clinic, the ED, labor and delivery, gyn clinic and pediatric clinic.

We even found time to visit the Sonoma County Fair, where I got pet a llama (I think I was the oldest one in the petting zoo), taste my first funnel cake and people watch. The fair is an interesting cultural experience filled with bright flashy lights, intoxicating smells of fried food and lots of overpriced rides. It was a flashback to my last childhood fair visit in Fresno, CA...

The diversity of clinic is both rewarding and challenging. Every day is so different-you work with all sorts of patients. But at times, it feels like you are always switching mental gears. With different patient populations, there are different considerations, although the bottom line really remains the same- PREVENTION.

With kids, we immunize and educate about diet and exercise. With adults, we still educate about diet and exercise and try to reduce the risk of developing hypertension, diabetes, hyperlipidemia and other chronic diseases (or we just continue to treat the best we can, when prevention has limitations).

The experience so far has been interesting and look forward to the learning opportunities in the last two weeks.