Scent of Death

My hands still smell like formaldehyde. I left the lab hours ago - this morning we went over all sorts of fun in the abdomen (kidneys and nerves, testicles and arteries), and my hands STILL smell like formaldehyde. I'm sitting here, working on a paper about hypertension in diabetic patients, and what should be done with them. I don't particularly want to be doing so, which is strange - not long ago, I'd have gleefully thrown myself into the tangled web of indications and special circumstances, but now I'd really rather just be reading through environmental pathology. I'm sitting here typing away, and as I reach up to rub the tiredness from my eyes, my hands still smell like formaldehyde.

But you know what? I don't care- I'm probably going to end up as a head-TA next semester, and my hands will ALWAYS smell like formaldehyde. Everyone I touch will know that I love dead people, and the scent of unnaturally preserving chemicals will cling to me like an aura of unholy alchemy; everyone I pass will be reminded of dead and dismembered bodies, sacrificed so that we may learn. There's not enough Old-Spice on this whole damn island. Sorry Nicole.

All sorts of bread crumbs

Hot on the heels of Monday's assessment of our physical exam skills was yesterday's assessment of our interviewing skills. All semester long, in addition to our bimonthly physical skills sessions, we also had weekly interview sessions, in which a group of students dressed up, sat around a table, and tried their best to elicit a coherent history from a paid local Dominican patient. We used very specific interview sheets, complete with all of the questions we needed to ask, but the goal of the sessions was to teach us how to elicit a broad spectrum of information while subtly guiding and funneling the conversational contents in such a way as to develop a succinct story of the patient's illness, complete with their psychosocial, personal, family, and medical history. Typically, one student per week would take point, and everyone else would add in questions at the end. It wasn't the best practice for the test, for several reasons.

First, we had 2 hours at our disposal to make sure we collected every detail from the patients - however, the graded practical was a 10-minute sprint. Also, many of us don't have that much experience interviewing anyone, and of the 10 or so sessions, we only had a facilitator twice - the blind led the blind the rest of the time.

That being the case, Nicole and I decided to do our best to replicate the interviewing style that would be graded - we researched various interview rubricks, and condensed them down to a few alphabetic mnemonics, to make sure we covered all pertinent aspects of the history (ex: ABCDE - arthritis, high Blood pressure, Cancer, Diabetes, Epilepsy; OPQRST - onset, palliative factors, quality and quantity, radiation, severity, timing; HAS TOLD ME - hobbies, alcohol, sexual activity, other drugs, living conditions, diet, medications, education, etc). So we figured out a quick method of questioning - next came the practice. That we had fun with - Nicole pretended to be a womanizing banker with ED, a football player with G6PDH deficiency (her best one, I think), and a drunk party girl. I pretended to be a carpenter with leukemia, a pregnant medical student, and, my piece de resistance, a bookseller going through a manic phase. We practiced tailoring our questions to the presentation while still collecting possible pertinent information - all, ideally, within 10 minutes.

There's a bit of a disconnect with the interviews - almost all of the rubricks available center around pain. Logically, the first few questions are concerned with describing the pain - "What brings you in today?" "When did you first notice it?" "Is there anything that makes it better or worse?" "Please describe the pain for me." "Does it radiate anywhere?" However, this particular section of our education is run by the behavioral sciences department - full of therapists and Ph.Ds, whose first instinct is to ask "How's your life?" Now, that's an important question, but I'm not about to let someone ramble on and on when I've got ten minutes; even though they praise the utilization of open-ended questions, for the purposes of this test, I tried to minimize them. I just knew that the BS department would pull something, so I wasn't surprised in the least when the presenting complaint was "I can't sleep".

We were all sequestered in a classroom next to the BS department, so as to minimize cheating, while we waited for our names to be called. I was towards the end, but when my time came, I went and greeted the interviewer and the student-pretender-patient, and go down to business.

"Good afternoon Mrs. Jane Doe, my name is Farley Neasman, I'm a second-year medical student, and I'll be interviewing you today. I just want to let you know that everything said here is confidential, unless there's something that I feel could be a danger to yourself or to someone else, in which case, I'll have to notify someone. Now what brings you in to see us today?"

"I can't sleep."

That threw me for a loop initially. Out of the window went all the questions about rating it on a scale from 1-10, as well as those about radiation and quality. However, as things went on, I realized it was a psych case. Inside, I was greedily rubbing my hands together; I knew I was about to rock this. I teased apart the threads of the pretend history that were pertinent, diagnosed a major depressive disorder (utilizing the lovely little SIG E CAPS mnemonic), and, even provided a little counseling. The facilitator actually looked rather surprised when all was said and done; she'd said that I'd hit all of the main points while being incredibly empathetic, and even provided a bit of consultation. I think I did well. I realized that, whereas MCQ (multiple choice questions) utilize my cluster-bridge model, actual medicine is more like detective work - you're gathering clues and putting them together to form a coherent disease picture. Somewhere in between, though, was the interview practical - someone laid down a trail of bread crumbs, and like Hansel or Gretel, it was my job to follow them home.

This was one of those things that reminded me of why I was at first drawn to psychiatry; it just seems to make sense to me, and it's exciting. There's nothing that shakes the central pillars of who a person thinks they are like mental illness, and that, in turn, affects everything else. I keep going back and forth on what I'm interested in; Nicole says it changes every day. I was telling her yesterday that I might enjoy surgery; I knew I'd be a very good one, but I probably wouldn't do anything groundbreaking. However, regardless of the relegation to drug management foisted upon psychiatry by insurance companies, I felt that I had a very good chance of making a name for myself in that field. Needless to say, I still don't know what I'm going to do, and I don't intend to decide any time soon. I read an article the other day that essentially said that even the clerkships don't really introduce med students to what actual doctor work is like in those fields - so I'm in no rush to nail it down.

HOWEVER: There was an MSNBC video article the other day about endoscopic surgeries. In addition to allowing much greater control and dexterity for highly trained physicians, minimally invasive surgery allows patients to heal more quickly, and lowers their risk for infection. The thing that got me, though, was that part of the application process involved playing X-box games with the program head - you see, with endoscopic surgery, hand-eye coordination in the setting of adapting a 3-D world to a 2-D representation is very important; it was a screening process to weed out those who couldn't adapt. I'm wondering - would playing Halo with my little brothers count as CME? I can dream.

Yesterday was Thanksgiving - continuing the tradition of trampling on patriotism, we had a test yesterday (last time it was an anatomy practical on the 4th of July). Since there's not a turkey to be found anywhere on this island, Nicole and I made do with what we had - instant mashed potatoes, stove-top stuffing mixed with chicken from the shacks, and some locally purchased veggies. It was the best turkey day possible, all things considered!

When I filled out my paperwork for Ross, one of the things I had to sign was a statement saying that they could use my face in their brochures. Here's why - that's me on page 38, in the anatomy lab. Apparently, all new students are going to see my mug.

You win some....

...and you lose some. We had our practical exams over the physical exam today, and I definitely lost some.

We all got dressed up and slipped into our white coats and stood around, waiting to be told what to do. By the time we actually got into the room, my heart was going a mile a minute (as generally happens before any kind of evaluation). A group of 11 of us were clustered in a room used for ICM (introduction to clinical medicine), sitting along the wall, all facing the patient sitting on an examination table. The proctor and a 4th semester student sat behind a desk facing us, and, like pagan fortune-tellers, laid out the cards that would determine our fate. People did their tasks - everyone missed a few things, and thankfully the girl before me picked the JVP card (jugular venous pressure). So, it came to my turn, and I drew the examination of the respiratory system without auscultation.

This is a really, really long one. Some of them - like the examination of the spleen, or the search for ascites - are very short, including only about three tasks. Mine however, was doozy. First I greeted the patient and commented on the symmetry or her chest wall, noting the lack of abnormalities. I made sure that her trachea was in the middle (deviation is an ominous sign), and that she wasn't in any visible cardiorespiratory distress. Then I palpated for tenderness, checked her AP diameter, and started percussing. I've gotten pretty good at it; the body is like a drum, and different sounds tell you different things. Resonance in the lung fields is good; it means that there's air where there should be air. Dullness, however, can signal a mass or lobar pneumonia. That complete, I moved on to diaphragmatic excursions - the idea is that you have the person exhale all of the air in the lungs, an percuss down their lung-fields until you hear dullness - the signal that you've reached the diaphragm. Then you have them breathe in as deeply as possibly, percuss again, and measure the difference. This is one way of determining diaphragmacit paralysis, and it's a hell of a lot easier to do when your patient takes a deep breath when requested, and exhales when requested, and sits up straight when requested. The local Dominican woman who posed as the patient for our exam clearly didn't want to be there, and made the whole thing difficult. It was like she couldn't be bothered to comply with any but the most simple of requests.

It was very annoying, but even if she'd been the best patient imaginable, I doubt it would have changed much for me - I forgot to measure the respiratory rate, I forgot to have her cross her arms, and to continue the examination on the front of the thorax. I answered the follow-up question like an encylopedia, though ("Please define Kussmaul Breathing"), and I did everything else, so I may still make it out of this experience with an A.

The Behavioral sciences have launched all their salvos as once, it seems - next up is the interview (which is worth significantly more of the grade), and then the itnerview write-up. Also, the questions for mini three, instead of differentiating between the types of schizophrenia, or epidemiological inferences, will be composed of psychopharmacological details. So, I've got some work ahead.

Scavenger Hunt

Nicole and I spent all day going over the procedures for the clinical skills assessment practical on Monday. For some reason, I keep on forgetting that the umbilicus is part of the abdominal exam, but hopefully, I'll have it down in two days. I need to just sit and read through Bates Guide to Physical Examination -I especially need to go over the breathing abnormalities and the JVP waveform abnormalities. It all feels so important, from the presentation of findings, to the correct procedure for examination, to knowing what the findings mean - it's a shame that it's just not worth that much as far as my points go.

The second semester class has their anatomy practical over the abdomen today. Spotty attendance at my TA sessions has caused my enthusiasm to wane somewhat, but I still enjoy it; I had fun pulling out tags today. Essentially, I had to hunt through bags of guts and bodies to find the structures the students would have to identify. I even had to dissect out the Greater Splanchnic, because, apparently, they haven't done that lab yet. I'm going back to help with the cleanup in a couple hours; not too many people signed up for that time-slot, and I'll help out where I can. This is one of those things that leads me to think that surgery might be something I enjoy, but I'm keeping my cards close off the table 'til I hit the clerkships.

It's fun to think about the ultimate scope of my practice, but right now my attention has narrowed to a very few things: the physical exam practical on Monday, the interview practical on Wednesday, the HPI write-up due on Monday, and then, at the end of the semester, the Behavioral Science shelf exam, the pathology lab practical, the third mini exam, and the final. That may sound like a lot, but I had twice as much last semester.

Pestilence

I haven't written in a while, but that's ok - nothing new of too much interest has been going on. I have come not to check in, but to whine and to complain.

I do not like microbiology, which is odd, because it's currently my highest grade. Beyond just not being enthralled with the subject, I feel that a large part of what we're being taught (at this very moment, actually) deals with details that doctors don't really care about. Do I need to know the diseases caused by Neisseria meningitidis, as well as the signs and symptoms? Of course! It causes meningitis, by the way, and it's got some interesting characteristics that dictate how you treat it - but I absolutely do not care what kind of agar medium it grows on. I don't care what color changes happen; nor do I care about the specifics of the tests that differentiate it from all of the other bacteria than cause infection. That's the job of the lab - I could be wrong, but I'm fairly certain that your average doc doesn't spend his time streaking agar and trying to grow plates of absolute pestilence. That's why there is a diagnostic laboratory. That's why you send off the samples - because it's someone else's job.

Truthfully, this isn't just because I dislike the subject - I admit that freely. It's that I like some of my time is being wasted on this; it's being taught because it's the pet project (by that I mean life's work) of the Ph.D who was hired to teach us. In the grand scheme of things, it's probably better to have too much detail rather than too little. If I had wanted that mind-numbing myriad minutia, I'd have gone the Ph.D route myself - but such is not the case. I have better things to do with my time than study how you run a microdilution automated system (something I will, i guarantee, mentally binge and purge like an unrepentant bulimic as soon as this test is over - unless it's on the Step, in which case I'll binge and purge again). One of those things is studying for the physical exam.

Over the course of the semester, we've had little workshops introducing us to the nuances of the physical examination - seemingly a lost art in today's culture of defensive medicine and space-age diagnostic imaging. The tasks in and of themselves are not difficult, but confusion creeps in when I'm trying to keep things straight - i.e. one should auscultate (listen) prior to palpation (feeling) in the abdomen, so as to avoid distortion of bowel sounds; or that the general survey should be performed at the beginning of the liver exam to search for possible concurrent jaundice - but not for the spleen exam (another story for another day - I've been doing little else other than studying what can go wrong with blood). It's enjoyable, if not a little bit awkward - feeling up folks always is. At least Nicole and I have each other - a significant other is a much better subject than a random stranger, especially when you have to do the kidney punch. I still have to practice, and I still have a lot to memorize, so that will be my task over the next few days. Several ironies are at work here: of all the things they're teaching us, this will probably be the one that I use the most for the rest of my practicing life, but it's it's got such a small point value right now, that I've heard some people simply don't show up. Also, even though I believe it to be incredibly important, I feel like it's a HUGE waste of my time right now - I'd rather be studying exactly how to run all those bacterial tests which I'll never run in real life, because those will be big points on the upcoming exams. Doesn't make any sense to me either - I just learn, purge, and hope that some of it sticks long enough (1) to help me on the Step and (2) to just maybe actually help me be of use to someone someday.

A Sky Afire

When heaven and earth pass away, consumed in a cataclysmic, cleansing firestorm, I'm sure it'll look something like this. I'm actually thinking of putting together a little coffee-table book of all the shots I've gotten of Dominica - but only of the sunsets from this particular vantage point, with the broken dock taking center stage. It's so breathtaking that, for a few moments, the rest of the day just kind of melts away. It's easy to forget about the mind-numbing exam we had Tuesday morning.

It wasn't so bad, but it was pretty bad. I genuinely dislike getting into an exam and realizing that I've never heard some of the terms before. What makes me even angrier is the fact that my grade may be side-lined by someone's bad-grammar or lazy question writing. Things would be so much easier if the professors were held to the same standards I am. Seriously - I'm going into a profession where people will die if I screw up, so if you're going to grade me and determine part of my future, you'd damn well better write the best questions you can come up with . It's absolutely unforgivable that some of these professors write questions stems and answer choices with even the hint of shoddiness. Of course - everyone makes mistakes, but if my mistakes are going to determine my future, it's obscene that some of these professors can just shrug off their mistakes with a "well you should have known what I meant."

I think the bridges held up. I won't know for a few days, of course, in which case I might have to (maybe) amend the metaphor. Maybe we're more like shipping magnates - we run around checking the bridges, assuring their structural integrity and strength - but when that day of reckoning/examination comes, we can only hope that whatever precious cargo has been entrusted to us has safely made it across the bridges we were tasked with securing. When the grades come out, we'll either find out the extent of the damage, or the spoils of success. I ran the bridges, I checked everywhere I could, and I hope that everything got to where it was going.

Injustices abound. Complaints will never cease. We've got a grievance process, thankfully, but these things will continue. However, the world perhaps became a little better on Tuesday when we elected the first Black (that's right, capital "B") president. Ever. Honestly, I never really doubted it would happen - I knew last year that senate was going to flip to the dems, and with everything going on, I knew that Americans wouldn't elect another republican. This race might have seemed close, but in mind mind, the selection of Palin and the economic crisis were the two final nails in the coffin. I've realized that, while I might disagree with some of someone's values (no one's ever going to see 100% eye-to-eye with anyone else, after all), the people have hopefully chosen someone who's going to make the best choices for us as a nation. There are unrealistic expectations from some - Rome wasn't built in a day, and our economy would be resurrected in short order either - but let's hope that President Elect Barack Obama makes good on his promise of change we need.

I don't want to be in class today.

I, Dragonslayer

Studying is going well. Blessedly, we have a three day weekend (nearly 2/3 done with at this point), due to Dominica's celebration of her thirty year independence from Great Britain (November 3rd, 1978). Monday's a national holiday, and from what I hear, there's going to be some impressive partying (carousing, as my mother likes to call it) going on as well. We were advised to take care of any and all domestic concerns - buying food, visitting the ATM, purchasing electricity - prior to the start of the weekend, because, as we all know, Caribbeans take their time off seriously. I got things squared away, and set up a study schedule for the weekend. Friday night included some questions, reading through bits and pieces of neoplasia, and reviewing pharmacology (absolutely wretched this time around, due to the fact that it's cumulative and the utter lack of any rhyme or reason). Yesterday saw a complete review of everything microbiological (all I'm gonna say is Thank God I have tomorrow too), more pharmacology, and a little bit of behavioral science.

I had everything planned out for today - all pathology, behavioral science, and lot of pharm. After heading over to Nicole's for pancakes and coffee, I was packing up to go when she came over, looking a little timid - and politely requested that I remove a lizard that had been staring at her. I almost laughed - I'd been doing this kind of thing for years! My mother designated me "lizard-remover" in an attempt to halt the passage of her unease with the spineless little critters, and I must say it worked. I'm generally pretty calm around them (aside from that one time I felt on crawling on my arm when I was sleeping - not fun). Also, they're ubiquitous in these parts, and I'm pleased and a little surprised that I don't find them in our rooms more often. So I walked back with her, and found what can only be described as a Grandaddy gecko, resting peacefully on her window sill. A while back, Nicole had put in a maintenance request to have the mosquito netting fixed down around the corner of one of her windows - that must have been how this thing made its entrance.

First of all, I'm used to gently removing things about a 10th the size of this one - I'd never even touched one this big. Second, I had a really good study day planned, and I wanted to get to it. The mosquito netting wasn't fixed, so I suggested Nicole call maintenance and let them handle it. She called down to the front desk, and was told that all of the maintenance guys were off for the holidays, but that one of the women would be up shortly. I poked it with a pen for a while, watching it swim up and down the screening in that boneless, slimy way that only little reptiles can, and I got ready to go - but then I got to thinking. I'm by no means sexist, but I wasn't going to let some front desk girl come up and wrangle this sucker - if I was going to decline the task. My ego wouldn't have been able to take it.

So I grabbed a rubber glove (who knows where that thing's been?), grabbed it, and took it outside. I was expecting much more of a fight; the little ones wriggle and squirm like it's why God made them. I must have forgotten that the little ones don't really bite. So I was holding it while Nicole was getting the camera ready, but the vicious little reptile opened its gaping maw and valiantly attacked my hand. I threw it over the balcony. Other than that, great study day.