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Medicine
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hey guys
things have been great since the last time we had these intimate moments.
i had spring break (1 of 2 weeks off in my 3rd year) and got to go skiing.
it was a wicked good time up in breckenridge with fabulous weather and slopes.
only a couple of adverse events - some out of control car skidding (remember,
turn into the skid) and an overzealous Fraud Protection department at my Discover
card, but no damage done. and best of all, on the ride home we saw the largest
tumbleweed ever! about 5 feet in diameter. i was driving and thought it was
gonna crush us as it rolled across the road. but with my speedracer-like skills,
i was able to take evasive maneuvers and avoid it. and one of my best buds
from high school got married to his lady friend and i got to be a part of
that.
this past week i started my last block of the year - internal medicine (imed).
in case i haven't described it to you before, imed is basically medicine for
old people with lots of chronic problems and on a bajillion medicines. to
illustrate this point, half of our patients are referred to as "train
wrecks". i've never actually been in a train, but i've seen pictures
and the metaphor is pretty accurate. lots of pneumonias, heart disease, cancer,
etc. the good thing is that it's a great learning environment because you
are flooded with all sorts of diagnoses at once - kind of like didactic diarrhea
(i just coined that phrase, let me know what you think). i'm working inpatient
at scott and white right now, so the hours got a little worse, especially
coming off of psych, but it's not so bad. actually, it's pretty much the people
you're with who can make or break a rotation, imed is broken down into teams
for inpatient, with a few med students (and/or physician assistant students),
residents and a head doc per team. i'm on the A-team. and yes, every time
A-team is said i think of murdoch and mr. t pitying fools ("quit yo'
jibber jabber!") and the theme song comes into my head - "if you
have a problem, if no one else can help, and you can find them, maybe you
can hire: the A-Team." and i'm with one of the med student guys i've
known the longest, and some great/nice residents, so we have fun and work
well together. the one thing i don't like is having to present all the patients.
i'm not a big fan of talking in front of strangers in the first place, but
it's even worse when they're evaluating you on it. and the doc i worked with
for most of this week was a big fan of memory. so as i'm giving him the info
on the patient, i have to have all the history and new stuff and lab values
and all that in my head. very nerve racking, but a skill you need. it's all
fun but very stressful at the same time. med school is one of those things
that you can completely love and hate at the same time. i guess it's like
having ugly kids. that's not true, my parents never hated me (that's a little
self-deprecating humor to make up for insulting ugly people).
one of the highlights of the week is that we meet with an older doc three
times to go over cases and soak up his wisdom. he's an allergist, but seriously
the absolute brilliantest doctor ever. he literally knows everything about
everything. you can talk about any subject, and he can cite the latest medical
journal articles about it and even knows the authors' names and background
on them. kind of intimidating at first, but he's extremely nice and a good
teacher. he asks lots of questions too, but answers most himself. and whenever
we have to answer, his definition of "correct" is very liberal.
as long as you throw out something in the ballpark, he works it into the right
answer. he's great at playing "six degrees of kevin bacon" with
our stupid answers and connecting them to the actual answers.
being on call isn't too bad right now. we're on every 4th day (or "q4"
as we call it), but only technically til 8pm. i did kind of get gypped (i
apologize to any gypsies in my audience offended by that phrase) while on
call tuesday night. i was waiting around from noon to 5 to get paged, but
nothing came in. so finally i'm headed to dinner (which included tater tots
:) and get paged on my way. i wind up working until 8 and miss dinner (and
tots). but i get sent home, so i'm not feeling so bad. halfway to the exit,
i get paged again and the resident says she'd like me to see just one more.
so i go to the er and work this lady up and get home around 10:30. i used
to think my pager was cool until it started going off. c'est la vie.
i had call this yesterday (saturday) too. not too bad. about 7am-9pm. the
basic rule is that you're oncall during your designated time and you take
all the patients that come in until you get to 10. which is great if you get
10 first thing and then have 12 hours to work them up, not so great when (as
they usually do) they all get dumped at like 5pm, and you go from doing nothing
to being constantly busy. as far as patients, i've had some pneumonia, congestive
heart failure, dementia (harkening back to my psych days), chest pain, renal
failure; a very nice potpourri of stuff. the weirdest thing was a crazy lady
with diabetic ketoacidosis who had tattooed-on makeup. we saw her at 8am and
she had a bunch of blush and lipstick on, but i just thought she was an early
riser. then the doctor asked me if i noticed anything weird about her and
explained it was all there permanently.
i'll end now with hopefully a little encouragement for y'all. one thing i've
had to think about the past few weeks has been my identity. there are a lot
of expectations that i have either from myself or perceived from others, and
i think a lot of time i try to live up to those (whether they be about career
or family or whatever) instead of focusing on living a Christ-honoring life
and dealing with the other stuff as it comes up. anyways, the stuff below
someone gave to me a long time ago, but i recently found again. it's just
some bible verses about who we are in Christ. and i just needed to realize
where my true identity is found and make sure the rest of my life is influenced
by that:
I am complete in Him Who is the Head of all principality and power (Colossians
2:10).
I am alive with Christ (Ephesians 2:5).
I am free from the law of sin and death (Romans 8:2).
I am far from oppression, and fear does not come near me (Isaiah 54:14).
I am born of God, and the evil one does not touch me (I John 5:18).
I am holy and without blame before Him in love (I Peter 1:16; Ephesians 1:4).
I have the mind of Christ (Philippians 2:5; I Corinthians 2:16).
I have the peace of God that passes all understanding (Philippians 4:7).
I have the Greater One living in me; greater is He Who is in me than he who
is in the world (I John 4:4).
I have received the gift of righteousness and reign as a king in life by Jesus
Christ (Romans 5:17).
I have received the spirit of wisdom and revelation in the knowledge of Jesus,
the eyes of my understanding being enlightened (Ephesians 1:17,18).
I have put off the old man and have put on the new man, which is renewed in
the knowledge after the image of Him Who created me (Colossians 3:9,10).
I have no lack for my God supplies all of my need according to His riches
in glory by Christ Jesus (Philippians 4:19).
I can quench all the fiery darts of the wicked one with my shield of faith
(Ephesians 6:16).
I can do all things through Christ Jesus (Philippians 4:13).
I shall do even greater works than Christ Jesus (John 14:12).
I show forth the praises of God Who has called me out of darkness into His
marvelous light (I Peter 2:9).
I am God's child for I am born again of the incorruptible seed of the Word
of God, which lives and abides forever (I Peter 1:23).
I am God's workmanship, created in Christ
unto good works (Ephesians 2:10).
I am a new creature in Christ (II Corinthians 5:17).
I am a believer, and the light of the Gospel shines in my mind (II Corinthians
4:4).
I am a doer of the Word and blessed in my actions (James 1:22,25).
I am a joint-heir with Christ (Romans 8:17).
I am more than a conqueror through Him Who loves me (Romans 8:37).
I am an overcomer by the blood of the Lamb and the word of my testimony (Revelation
12:11).
I am a partaker of His divine nature (II Peter 1:3,4).
I am an ambassador for Christ (II Corinthians 5:20).
I am part of a chosen generation, a royal priesthood, a holy nation, a purchased
people (I Peter 2:9).
I am the righteousness of God in Jesus Christ (II Corinthians 5:21).
I am the temple of the Holy Spirit; I am not my own (I Corinthians 6:19).
I am the light of the world (Matthew 5:14).
I am His elect, full of mercy, kindness, humility, and longsuffering (Romans
8:33; Colossians 3:12).
I am forgiven of all my sins and washed in the Blood (Ephesians 1:7).
I am delivered from the power of darkness and translated into God's kingdom
(Colossians 1:13).
I am redeemed from the curse of sin, sickness, and poverty (Galatians 3:13;
Deuteronomy 28:15-68).
I am firmly rooted, built up, established in my faith and overflowing with
gratitude (Colossians 2:7).
I am called of God to be the voice of His praise (II Timothy 1:9; Psalm 66:8).
I am healed by the stripes of Jesus (I Peter 2:24; Isaiah 53:5).
I am raised up with Christ and seated in heavenly places (Colossians 2:12;
Ephesians 2:6).
I am greatly loved by God (Colossians 3:12; Romans 1:7; I Thessalonians 1:4;
Ephesians 2:4).
I am strengthened with all might according to His glorious power (Colossians
1:11).
I press on toward the goal to win the prize to which God in Christ Jesus is
calling us upward (Philippians 3:14).
For God has not given us a spirit of fear; but of power, love, and a sound
mind (II Timothy 1:7).
It is not I who live, but Christ lives in me (Galatians 2:20).
well, i'm finishing up my last
week of inpatient medicine at scott and white. it's been good. i'm learning
lots since i had pretty much forgotten everything previously in my head. the
worst part is that we have patients all over the hospital (not like with peds
or psych where they are all in one consolidated area), so i have to walk around
lots. but that's probably good for me. i try to live up to my '2 down, 1 up'
rule for stair usage, but i can't always do it. sometimes it's 4 flights down
or 3 up, just because the elevators are far away. the things i do in the name
of education. where, o death, is your victory? where, o death, is
your sting? hey
as i mentioned before, medicine is mainly older people with lots of problems.
our average age has been in the upper 70s, with multiple 80 and 90 year olds.
the age i can handle, but there have been some sights and smells that really
get to me. we've had a few very very morbidly obese (350-450 pounds) people
thus far and i just have a hard time dealing with that. they are very prone
to infections due to poor blood supply way out in the fat and their other problems
(diabetes, high blood pressure, etc) and they usually get nasty ulcers/infections
in their rolls (doctor talk for fat rolls is "pannus"). so you have
to lift up the pannus on the pannus to get down to the infection and i'm just
not good with that. there was another large guy with horrible cellulitis on
his legs, with some fungal and bacterial components. he had the nastiest smelling
room ever. it smelled kind of like locker room plus rotten bread/yeasty with
a few other things mixed in for good measure (which is bad for me because i
tend to smell everything, and use my nose to explore the world around me; when
you hit my nose with that funk, you cripple me). i dreaded going into his room
every day. but i guess it's worse for nurses who have to stay in there and clean
him. and then there's just this general odor that older people have. it's kind
of like the pepsi challenge, i can tell the decade of life a person is in by
smelling them. i'm pretty accurate.
it's also been an interesting few weeks on the rectal front (that's code for
some of you to skip to the next paragraph). with some other rotations, the rectal
exam wasn't stressed too much, but here it is. it's actually gotten to the point
of being a little funny to me, just thinking about the absurdity of what i'm
doing. but it must be done. i had one guy, a 19 year old (yes, 19, my youngest
patient by 20 years) who freaked out when i was gonna do one on him (and he
had a gi problem, so it was really necessary). we told him he could refuse if
he wanted but he wouldn't calm down and was yelling at my attending doc and
finally left ama (against medical advice). the worst part was that i had already
done all the work and write up on him and it was wasted. then i had a lady who
had lost about 150 lbs over the past 6 years, who just had tons of excess skin
hanging everywhere. that was gross enough, but it took me a little while to
find her bottom, because i had to lift off layers and layers of skin. it kind
of looked like those dogs with the mushy faces. but my favorite rectal was one
i didn't have to perform. the funny maxim about rectals is that the only reason
not to do them is if you don't have a finger or they don't have a rectum. well,
i met a guy without a rectum. he had had his colon removed and just had an ileostomy
(colostomy but further up the guy), and they sealed off the pooper hole.
we had a convict at one point too, which was semi-exciting. he had a stroke,
so he really wasn't much of a danger. he had cool tatoos though. he had to be
watched by a guard the entire time, and his leg was chained to the bed. i thought
it was funny how we'd have to ask him social history questions in front of the
cop and expect a straight answer. like, "do you use cocaine?", which
was highly likely due to his stroke at such a young age, but i didn't really
expect a "yes" out of him with the guard listening in. but i had my
suspicions; i saw "the shawshank redemption", i know they can get
whatever they want snuck into the prison.
the big thing i've had to face over and over with our patient supply is death.
it seems like all of our patients are dying (and not in a nietzschean, post-modern
enlightenment way where we are all dying from birth (note: i made up those terms
to sound philosphical, but you get the point). we've had a few die on us, and
others sent back home to inevitably die. the sad thing is that it's always the
nice, pleasant people that go, and the mean, crotchety ones and the GOMERs never
die. fyi, GOMER stands for "Get Out of My ER" and means those complicated
old people that keep coming back or never leave due to continual/recurrent problems,
aren't responsive or cognizant in any way, and who really have no quality of
life of. but for some reason they just don't die, no matter what happens to
them. it's one of the many terms we use in medicine that came from the book
"house of god", about an intern's first year of residency and how
he becomes desensitized and jaded and cynical because of it. good book. anyways,
all the people i like keep getting cancer. there was a czech farmer last week
(clarification: he was a czechoslovakian man who farmed, he didn't have czechs
growing in his fields) who had the coolest accent and best personality, who
dealt wonderfully with it when we told him he had esophageal cancer and would
die before too long. he was already having trouble eating (but with a smile
on his face told us how he would get big steaks, and just chew on them till
all the flavor ran out and spit them back) and it would just get worse to wear
he couldn't eat at all (and didn't want to get a special tube where he could
pour liquidized food straight into his stomach. there's 71 year old guy who
i picked up monday who came in with a chronic anemia and positive blood via
the rectal exam and a couple weeks of melena (melena being black, tarry stool;
usually from a bleed in your upper GI tract, because the blood turns coffee-ground
looking when it gets digested in the stomach). he/his doctor thought it was
just an ulcer. the normal first thought would be colon cancer, because the rule
is that iron deficiency anemia in an older person is colon cancer until proven
otherwise, but he had had a colonoscopy within the past few years, and those
things take a while to develop. it turned out not to be colon cancer, but ampullary
cancer - cancer right around where the pancreas dumps into the small intestine
(aka the "ampulla of vater"). so we got to tell him that news tuesday,
then wednesday that the cat scan showed it was in his lung, liver, kidney, adrenal
gland, and colon too. again, the nicest guy; appreciative, respectful, happy,
and actually very young looking (like in his 50s). and non-hospitally related,
there was a dear, sweet woman i know from college station who passed away. that
was harder because i knew her, but a little easier because she was a godly woman
and understood what 'to be absent from the body and to be at home with the Lord'
means.
so lots of thoughts/topics came up this week. the big one that we talked about
lots was the right to die, DNR/DNI (do not resuscitate/intubate), power of attorney
kind of legal stuff that we as doctors have to deal with and you as people have
to debate about with situations like terry schiavo's. there are obviously many
and varied opinions about this, but the key for everyone is to fill out a living
will so everybody knows what you do and don't want done to you. i don't think
it's cool to make your loved ones have to make those tough decisions. another
hard thing is that in america we're so afraid of death (relative to other countries,
cultures) that we feel like we should do every thing possible to maintain 'life',
and with our technology we pretty much can. one thing i think is very important
is quality of life, which again is a very subjective thing. we have one lady
who had a massive stroke, can't function at all, only responds to painful stimuli,
and has no chance of any meaningful recovery. half her family wants to let her
die (and claim she has made this known to them in the past), half want everything
done (which at this point is mainly a feeding tube). i think we often feel that
we can prolong the hurt of death by keeping a warm body around, even if it is
basically dead already. and you really can't change your mind wants you start
going down the treatment path; not putting in a feeding tube is basically consider
allowing the body to take it's natural course to death, taking out an already
placed tube is consider by many to be killing and a little harder ethically
to deal with. i'm not directly making these decisions now, but i will be soon,
and it's often difficult to know what's right and what's in the best interest
of the patient. and like most situations, it's not specifically spelled out
biblically, but there are lots of principals to guide the decisions, but even
still there is lots of grey.
another topic of thought was dealing with death and helping others to do so.
there's a great tolstoy book called "the death of ivan ilyich" that
gives great insight into the mind of someone who's dying and the people around
them. ivan is dying, and he (for a while) and most of those around him are in
denial about it, and that was the worst part. only his son and a servant accepted
the facts, and they were the only ones who could comfort him.
"Ivan Ilyich suffered most of all from the lie, the lie which, for some
reason, everyone accepted: that he was not dying but was simply ill, and that
if he stayed calm and underwent treatment he could expect good results. Yet
he knew that regardless of what was done, all he could expect was more agonizing
suffering and death. And he was tortured by this lie, tortured by the fact that
they refused to acknowledge what he and everyone else knew, that they wanted
to lie about his horrible condition and to force him to become a party to that
lie. This lie, a lie perpetrated on the eve of his death, a lie that was bound
to degrade the awesome, solemn act of his dying to the level of their social
calls, their draperies, and the sturgeon they ate for dinner, was an excruciating
torture for Ivan Ilyich. . . . He saw that the awesome, terrifying act of his
dying had been degraded by those about him to the level of a chance unpleasantness,
a bit of unseemly behavior (they reacted to him as they would to a man who emitted
a foul odor on entering a drawing room); that it had been degraded by the very
"propriety" to which he had devoted his entire life. He saw that no
one pitied him because no one even cared to understand his situation."
the most important thing from our physician perspective is to make it clear
what the prognosis is, especially if it's bad. and hope is good, but not false
or unrealistic hope, where people hang on to a lie until they are absolutely
faced with the truth, and are smacked in the face by it because they haven't
had time to deal with it. another thing i was taught back in 1st year that i
haven't forgotten is to say the word "cancer" (assuming they have
cancer), because people never grasp the seriousness of the issue if you say
"growth" or "mass" or any other words. you have to be blunt
but caring. you have to be objective and separate (to help guide decisions and
treatment), but you can't help but be emotionally involved. one of the best
and hardest things doctors do (especially with family or internal medicine)
is help people die painlessly and peacefully and gracefully. we help bring dignity
to one of the most undignified acts. it's especially undignified for those dying
slowly in the hospital - tubes and wires sticking out of everywhere, bowel and
bladder incontinence, people having to come in and clean you and feed you. but
we get to make the most of that for the patient and their family (hospice does
a great job with this kind of thing too). one of my favorite quotes from "the
lion in winter" (movie about henry II) is by richard (anthony hopkins).
he and his brothers are about to get executed by their dad, and he doesn't want
his father to see him beg. his brother says to him "why you chivalric fool!
as if the way one fell down mattered" and richard's reply: "when the
fall is all there is, it matters."
a bunch of verses came up these past few weeks in thinking through all this.
reason number 294 why it's nice to be a Christian - death isn't a mystery. in
my studies, i found out that apparently everyone dies: heb 9:27 "and inasmuch
as it is appointed for men to die once and after this comes judgment,"
and job 30:23 "for i know that You will bring me to death, and to the house
of meeting for all living." but we weren't made for death, it's a curse
and product of our sin. death has become a natural part of life, but it wasn't
meant to be. 1 corinthians 15:25-26: "for He must reign until He has put
all His enemies under His feet. the last enemy that will be abolished is death."
death is our enemy; an inevitable one, but an enemy nonetheless. but thankfully
we have victory over death through Christ. i remember vividly when i first grasped
this next verse, because i sent it in a letter to my friend who's mom had just
died - 1 corinthians 15:54-57: "when the perishable has been clothed with
the imperishable, and the mortal with immortality, then the saying that is written
will come true: "death has been swallowed up in victory." "where,
o death, is your victory? where, o death, is your sting?" the sting of
death is sin, and the power of sin is the law. but thanks be to God! He gives
us the victory through our Lord Jesus Christ."
when we are slaves to sin, death is a horrendous enemy because it seals our
fate and keeps us eternally separated from God. but when we are servants of
the Most High God, death isn't an enemy, but a servant for us. without death,
we can't shuffle off this mortal coil, laden with sin, and be resurrected to
a new, glorious body.
last thing. 2 corinthians 4 and 5 talks about some of the purposes of our death.
obviously, each day we get closer to death, or as paul describes it, outwardly
we are wasting away. but we know that this momentary, light affliction is producing
for us an eternal weight of glory far beyond all comparison. so we can look
to that and be renewed inwardly day by day. and we can know that the One who
raised Jesus will also raise us, and as we are absent from the body, we are
present with the Lord. and we can shed this earthly tent in which we groan,
and be clothed with our heavenly dwelling. the hard part is dealing with people
who don't know the Lord, for whom death is still an unbeaten enemy.
lots of time has passed. probably my fault.
to begin with the good news, i'm officially a 4th year student now!!!
but this will probably just cover the last 4 weeks of third year. i was back
at the ol' VA doing internal medicine. you can read previous emails if you
can't remember the patient base at the VA. the interesting twist thrown into
this rotation is that i used to date one of the residents wives (before they
were married). it probably wasn't as awkward as it could have been. i'm on
good terms with her (now) and i had actually met him a couple times before
they were married. i only remember that he and i were good at playing Taboo
together. we thought alike. and i do like him. he has great bony structure
in his face. also funny was that we had to take night call every 4th day,
and i just happened to be with him every time. it really only got weird when
he would talk about her in front of the group. oh, and the other residents
i work with found out, so there was one very uncomfortable day where we all
went to lunch (and he was post-call and didn't come) and they made me divulge
the past. beyond that drama, it was a pretty nice rotation, especially since
it was the last. good hours, learned a lot, laid back, over. and one of the
med students i was with this time actually new the words to one of my favorite
songs as a kid - "don't mess with my toot toot". i don't remember
who sang it, just that i'd only hear it in louisiana. but i've never heard
anyone else sing it. brought back some good memories.
i also got to do a new procedure (for me). technically it's a "paracentesis";
i like to call it a "belly tap." the patient was this old dude with
liver cirrhosis, which can cause some backup in the pipes (blood vessels)
and lead to fluid leaking out into the abdomen (called "ascites").
he had the hugest non-pregnant-lady tummy i've ever seen. it looked like he
was smuggling a small immigrant family in there. anyways, i got to stick a
big needle/tube in and drain a bit out. they have special 2 liter vacuum containers
that suck it out. it was actually very pretty, classically described as "straw-colored".
in the 2 liter bottles it kind of looked like mountain dew.
as far as patients, there wasn't anything too exciting. the most fun was a
crazy dude who wasn't my patient. he was kind of hostile when he first came
in, and his history showed some mental problems and a history of self-mutilation
(including "fixing himself"). anyways, he was pretty gruff to one
of the female residents that had him. then one day, totally against his diet,
he has 3 pizzas delivered to his room, with mayonnaise instead of sauce. the
resident told him he couldn't eat it here, he got mad and left AMA. and on
leaving, he left a note saying that she should never practice medicine in
another VA hospital, and wrote to "please forward this to the President
and Secretary of State". sadly, he came back a few days later, after
bouncing around between 4 other hospitals. sometimes i envy veterinarians
who can just put these kind of patients to sleep. such is life.
then i had a couple of tests and now i'm done. so i guess that now i've completed
a year, i should do some kind of summary or evaluation or something to see
just what all has happened or how i've changed and all that. i think normal
people who are good at introspection do that sort of thing?? i guess i feel
more competent doctorly, as far as seeing any patient and knowing what to
ask and what to do and all that. and my general knowledge has increased, as
far as knowing where things are, how things work, how to order stuff and all
that. they say that after your 3rd year you've learned most of your medical
skills, and 4th year is just playing around trying to get into residency.
so basically next year at this time when i'm a "doctor" and on call
by myself at 2am and some guys heart starts crumping, i'll know about as much
as i do now. kind of scary (for both of us).
so what's up now? mainly lots of different, short (2-4week) rotations, with
lots of vacation. i'm in the picu right now for 2 weeks, then about 4 weeks
off to study for a big test (and rest and vacation). and back to rotations.
i'll try to update as much as possible, but they will be fewer and farther
(or further, i forget how to use those) between (as they have been over the
past few months). but i'll do my best.
seacrest out