Astoria Park

Yesterday, after finally getting the internet situation squared away, Nicole and I decided to take another walk down to Astoria Park. We'd been there before, after the gym, but this time we went with the cameras and meandered quite a bit farther. They've got a gigantic swimming pool - I hear it's one of it not the largest in the US. I'll point it out below, but first, here is a general view of Astoria.

I'm embarrassed to be presenting relatively few reliable facts. For example, I believe this to be the East River, though I'm not sure. Also, I do not know for sure that the city across the river is the upper east side of Manhattan. And as to the name of this blue bridge, I haven't the foggiest.

This, however, is the Hell Gate Bridge - I figured that out from the bar next to it. This bridge and its massive pylons were the things I wanted to return to the park to photograph.

Here is a view of the blue bridge (which I've just learned to be named for Robert Kennedy) overlooking the park, beyond the Hell Gate.

Here's a glimpse through the trees of the blue bridge and the aforementioned giant pool. (I suppose that much is obvious; it's just such a nice picture that I felt I should say something).

After walking through the park, we decided to go see Inception - since, with every passing day, more and more people tell me how great it is. So, after a nice steak dinner, we hopped on the N train, following the advice from the Blackberry's google-maps application which, until now, had been reliable. It neglected to mention, however, that certain trains on the weekend run on an express route, and so we overshot the initial stop by a few streets. Once we'd wended our way back and made it to the theater, the movie was sold out. Nicole didn't want to wait 2 hours for the next one, and so we wandered around Queens. Finally, we caught another train back and stopped in a little pastry shop for dessert. The red velvet cake left nothing to be desired.

Parting Views

Here are some of the last few pictures taken before leaving Miami. Our apartment was situated right on this little canal, and Nicole and I didn't manage to get any picture until the day before we left.

That same night, we had to go out and get some night-time shots along Ocean Drive. It may not completely represent the craziness of the party scene, but it is sort of a big deal. That middle picture was taken over the fourth of July weekend, but I couldn't bear to leave it out.

Leaving Miami

This post has been a while in the writing – a lot has happened since the last one. Before I get into the details of my move to NYC, I just want to recapture some sentiments from the last Miami days.

I’ve said before that I think we spend entirely too much time in the ER – I added that as one of the negative points on my evaluation of this program. Since July was my ER month, it was inescapable. I’d rotated through with several of the docs in the ER, pulling 12 hour shifts at a time. There are some docs who don’t take students, and just a few I hadn’t worked with. I began my shift with one of the docs with whom I was unfamiliar at 6am, when I walked into a surprisingly quiet ER. There was perhaps one nurse at the nurse’s station, and two paramedics on the other side of the counter. I sat in the doc box (a little enclosure with its own lighting, to facilitate the reading of imaging reports), thumbing through my Washington Manual while I waited. The doc I was with came in, said something to the one nurse, and immediately turned and rushed into one of the patient rooms. I followed him in – and realized that it was so quiet, because everyone was in there, partaking in a code. An obese, 40’s-ish man had been brought in by fire and rescue, having a massive heart attack. That was about an hour before I arrived.

I walked in, and nurses were surrounding the table, paramedics switching off doing compressions, while the docs and PAs watched. I stood out of the way, until the doc I was assigned to turned around and saw me. The doc who was running the code turned as well, and asked me if I’d ever done CPR. I told her that I hadn’t, as I turned and grabbed some gloves. She asked if I knew how to, and I pulled on my gloves and told her that I did. The paramedic currently working on the man moved to the side, and I stepped up, and began compressions.

If ever you watch people doing compressions on TV, and they’re going less than twice a second, they’re doing it wrong. You can’t do it too fast. And so, mimicking the rhythm of the paramedics, I compressed and compressed and compressed, and was overcome with the overwhelming conviction that I was squeezing blood through the dead veins of a dead man. He was intubated, and the look of a tube going down someone’s throat is always disconcerting. Beyond that, though, was the fact that his unblinking eyes were wide open and bloodshot, glassy and staring at nothing. I stopped and checked for a pulse, and one of the other paramedics took over. One of the nurse’s pulled out a syringe filled with epinephrine, and the head doc told her to put it back – he’d already been given 12 amps of epi.

Another paramedic jumped in, and then the lead doc took over, checking the vital signs monitor. She got a better result (nicer QRS complexes) than the rest of us - a testament to her experience. Finally, though, someone brought in the ultrasound machine. Everything stopped, and we looked at the grainy, gray picture of a completely motionless heart – frozen muscle, unmoving valves, not even a flicker of bloodflow. There was still some electrical activity – pulseless electrical activity – but the docs chalked that up to all of the epinephrine and dopamine in his system…and they called it.

I remembered that, on the way in, I’d passed some folks who didn’t look too happy. They were, obviously, the family. We pulled the curtains, and a nurse went to speak with them.

It was perhaps this death that cast a foul tinge over the rest of the day – I didn’t like the doc I worked with at all. He was very helpful, suggesting that I organize my approach to the patients in a certain way (breaking down the Plan part of the SOAP note into labs, test, meds, and orders), but I found him frustratingly arrogant and condescending. Part of it could have been that I’d finished my previous shift at 9pm the day before, and had to be back at the ER to pick up Nicole at 2am. So I was sleep deprived and in a mildly foul mood, compounded by the doc’s foul mood. Another student commented that it was perhaps nothing more than the clashing of the two egos, but I’m sure it was more than that. Despite the fact that I feel like we spent too much time in the ER, this was the first and only time I hated it – and it had nothing to do with the patients.

My next ER stint was entirely different. I was with one of the other docs I’d worked with before, and was comfortable with. Since I’d been taking the other doc’s recommendations on organizing my patient notes and applying them to some practice cases I’d been working through, I felt more confident with my approach to the patients. That day went well – the highlight was another heart attack. Another gentleman, around the same age as the one who’d passed away, had come in complaining of some chest pain. He’d gotten the full cardiac workup – CBC with differential, complete metabolic panel (CMP), coags (PT/PTT/INR), cardiac enzymes, chest x-ray (CXR), ECG, etc – and it looked like he was having a very minor heart attack. The cut-off for ST elevation, the place where the change from normal becomes significant, is 1mm. This guy’s ST elevation was at 2mm. The doc I was with called a cardiac alert, and within moments the interventional cardiologist was on the floor, followed by his son who must have been about 14. He came in, talked to the doc, and looked at the ECG. He was unconvinced….until he learned that the troponin (one of the cardiac enzymes) was 1.5 (below 0.4 means that heart muscle isn’t dying) – and called up to the cath lab, and told them to set up. From then on, it was a rush – we headed upstairs with the guy. He sat there on his hospital bed, shirtless in the elevator, joking about how his cell phone wasn’t getting reception.

From there we followed everyone into the cath lab. The doc I was with stopped to talk with another interventional cardiologist, explaining the merits of the iPhone 4G, especially when it came to transmitting images – like ECGs . Then the interventional cardiologist was ready and headed into the cath lab. The ER doc I was with – since he knew that I’m interested in cardiology -said I could stay and watch. Of course, I jumped at the chance, and went to sit in the observation box with the nurse and the son, and watched as the cardiologist opened the guy’s blocked right coronary artery (RCA) and placed two stents. I left for the ER just after he explained the whole process to him.

So that was it for the ER, and almost it for my internal medicine experience – it only had to be capped by our shelf exam. Luckily, the ER doc I was with on Thursday gave me a half-day, and so I went in well-rested and ready. Well….perhaps not entirely ready. I’d read through Step up and some of Davidson, and kept up with articles and other information. The day before, I finished the hundred cases in the back of Step Up, and felt reasonably comfortable – but not as much as I would have been, had I spent the past 3 months doing practice questions in preparation.

To add insult to injury, another group of students who were taking their internal medicine shelf were in the same room as we were – the Cleveland Clinic group. I explained to some of them how the Mount Sinai rotation was mostly University of Miami Hospital, by way of Miami Beach Community Health Centers, and felt my ire begin to simmer as some of them told me how they’d been working closely with residents, getting up early every day to round on patients in the hospital, and that they’d had journal review and some lecture every day. This pissed me off – granted there was a lecture held at Mt. Sinai daily for the residents there, but attending when I was scheduled to be across town wasn’t feasible, and the parking fee was prohibitive. Moreover, I’d felt that that they knew they were having a shelf exam, meaning that, at the very least, Ross was working more closely with their program.

At the end of the day, though, it’s not one group against another, and the only thing that matters is how hard I worked, and how deeply I read. At the end of the exam, I felt that it went alright.

Since it was the last day, a group of us headed out to Outback Steakhouse for dinner, before an even smaller group of us went to see Salt. While the action was entertaining, the story didn’t blow me away, and I think I’d have done it differently.

And then we went home and packed like mad. We were up until 4 waiting for laundry to be done. The next day, the new tenants moved in – luckily, It was a girl I knew from the island. Then we zipped our way to the airport, hopped on the plane, and touched down at La Guardia in NYC. Once we’d collected our baggage and headed outside, the first thing that hit me was a wave of nostalgia – all of New England must smell the same, because I was reminded powerfully of Yale in New Haven. We hopped in a cab and headed to Astoria, where I sitting typing right now. The apartment is very small, but it’s clean, and after disassembling and reassembling some of the furniture, Nicole and I have made the space decently useful. We walked around Ditmars Boulevard, acquiring the necessities (how someone lives without an ironing board, I can’t imagine. On the other hand, how someone packs an ironing board for travel, I also can’t imagine.)

This morning, we bought unlimited ride metro cards, and rode out to see Flushing Hospital Medical Center. The Subway system isn’t terribly intuitive – rather than being laid out geographically, with lines running east and west, north and south, they seem to loop around NYC, giving preference to places of importance. I’d texted my brother and told him that NYC is like Rome – all roads seem to lead here – but, once you’re here, all subway lines seem to lead to Times Square. Anyway, we missed the final bus-stop because I thought that the doors would open automatically. It wasn’t until the next stop when a woman shoved right through that I slapped myself on the forehead and went hopped off.

So we found the hospital, headed back to the station, and wended our way home – where we straightaway went and joined the Rock. I’m not a meathead, but I enjoy working out, and a nearby gym is something I value when looking for housing. The Rock is about 2 blocks away, and after signing up, Nicole and I went for a workout. I didn’t want to go terribly hard and heavy today – for one thing, my blender is still en route from Miami Beach – but also because this is the first time I’ve been in an official gym since leaving Dominica at the end of April in 2009. I’ve worked out at home and the exercise room in condo complexes, but I hadn’t been under any serious weight in over a year. That being the case, I took it relatively easy, and was pleased to see that I hadn’t declined too much.

Two More Weeks of Beach

I've found a place in queens, bought the plane tickets, and begun packing. This latest chapter of my education in Miami is drawing to a close, and even though I didn't plan to come here in February, I'm already missing it. I'm sure NYC'll be plenty of fun, but it won't have South Beach, my apartment won't have its own washer-dryer, and the winter's going to be reallly cold. However, I'll have scheduled and completed my cores back to back - something not many of my classmates are doing. That'll definitely make things easier when it comes to buckling down for the second set of boards.

I've heard a lot of complaining about some of the clinical spots we have in NYC, but I've sort of resolved that my real education will come during my fourth year electives and sub-internships. While I've enjoyed this internal medicine rotation, it hasn't quite been the juggernaut I'd expected - a small fraction of my time is spent actually in the ICU. Ross had told me that it'd be the Mount Sinai internal medicine core, but that's not the truth - the core is through Miami Beach Community Centers, which have an business relationship with Mt. Sinai. Thus, while I initially expected to be following very ill patients on the floors for 3 months, I've spent much of that time in an outpatient clinic, another chunk of time being fairly useless in the ER, and that aforementioned small fraction shadowing docs in the ICU. It frustrates me because I don't actually fell like I'm useful - I know how to do a fraction of the things the nurses do every day, much less what the doctors do, but most importantly, I am not learning those things. I'm studying on my own, but there isn't enough hands-on experience, and, in hindsight, I don't think I'd recommend this particular clerkship to anyone.

Many of my colleagues love the ER because that's what they want to go into - however I side with the ER docs themselves in feeling that perhaps it's too early. As third year students, we don't really know enough to be helpful or get the most out of our time in the ER, such that it's almost a waste for everyone involved - a waste for the docs, because we're slowing them down instead of being useful, and a waste for us, because we could be learning or practicing something.

I know that the majority of what I learn for my career will be from my years of internship and residency, but I can't help but be annoyed that things are working out as they are. I'm reading through my texts and review texts, trying to figure out what should be important; mostly, though, I'm casting a wide net and hoping to dredge up the morsels and tidbits that'll show up on the Next Big Test. Hopefully, between Davidson's Principles and Practice of Medicine, Step-up to Medicine, and The Washington Manual of Medical Therapeutics 33rd ed, I'm getting what I need. I know that, more than likely, I've a firm grasp of what I'll need for the test, but, believe it or not, that's a small comfort when, in those rare moments in the ICU, I feel less than useless.

This was a quiet weekend, all brooding aside. Nicole scratched the back bumper of our little rented Hyundai and, rather than deal with the hassle of insurance and the rental company, we're quietly taking care of it at a little body shop on the beach. Thus, we stayed in all weekend, but I can't for the life of me figure out why we didn't go to the beach. We went jogging yesterday and I diagnosed myself as having shin-splints for the first time in my life. Chalking it up to an improper stride, though, I iced my leg, took some ibuprofen, and went jogging again today - ever the masochist. I did, however, manage to do the teeniest bit of research for my case presentation on Thursday (on nutrition) - the alarming thing is that I still have yet to acquire a suitable case (or any case, for that matter) to present. I'd like to do one from the ICU - something interesting, like total parenteral nutrition - but I'll settle for some interesting case from the ER tomorrow, if I must. I also managed to finally finished Gene Wolfe's Litany of the Long Sun and Sam Shem's The House of God. I've been working on that damn Long Sun book since I stepped on the plan in February, but things got in the way. Now I get to tear into Ken Follet's Pillars of the Earth, and it had better live up to expectations.

Upstream

I've got another month left in my internal medicine rotation, and I've got to find housing for psychiatry. I'm still enjoying this - on the one hand, the ICU and the cath lab are places I could sit around all day, soaking everything up. On the other hand, I'd like to be able to actually do something, but I don't really know enough to do anything. All of my learning up until this point was directed at an outpatient setting. My OB rotation was a blessing, because I got to do so much.

I've decided that, during my fourth year clerkships, I'm going to spend a lot of time in the ICU.

Everything kind of hinges on surgery then, doesn't it? I'm eagerly anticipating the madness.

I second the wishes of my current attending; I wish there were 48 hours in every day. I almost wish that this was all done so I could just throw myself into something, rather than trying to cover things broadly. However, I still feel, sometimes, as if I don't know anything useful.

I went on a run today, down to Southpoint along the Boardwalk. This has, over the past few months, become my favorite route - it's a little over 5 miles round trip between the beach and Ocean Drive. I'd gotten about a quarter of the way when it started to rain, and by the time I was halfway done, it was torrential. I was sloshing through ankle-deep water at several points, and ducking under random awnings to listen for thunder at others. This, I shall miss.

Anxiolysis

I do not like to be anxious. I push things out of my head to deal with later (this is called suppression - one of the mature defense mechanisms, which probably contributes to the high frustration threshold I mentioned yesterday), and this exasperates Nicole to no end; not only does looming uncertainty increase her anxiety much sooner than it does mine, but talking and discussing the uncertainty, in an attempt to make things more concrete diminishes her anxiety, while it increases mine. When there are issues to be dealt with, I know that they have to be dealt with - I don't ignore them, but it takes some time for me to get to the place where I want to devote mental time to it, and am willing to submit to the inevitable tide of anxiety.

Right now, the anxiety centers around finding housing in NYC. There was a brief period last week in which it looked like we might be able to stay and complete the remainder of our clerkships here in Miami. It sounded awesome, but only the deal for psychiatry was signed; I could stay an extra six weeks down here - but when I found out that our landlord had already rented out the apartment (I had, after all, given him the date we'd be finished), it was like God telling me to go to NYC. Also, since the vast majority of landlords require a minimum 6 month lease, chopping into that just to stay here for a while sounds like a bad idea. I have no concerns about whether or not we'll find housing; it's just that it'd be nice to get decent housing, and I've learned that if I procrastinate too long, I'll be taking what's left, rather than having my pick. This seems to be the most pressing concern right now (taking precious time away from clinical musculoskeletal disorders).

More anxiety? Money. I don't worry about it for now; I worry about it for later - I've joked before about how Sallie Mae owns my soul, and I never quiet forget that I'm going to have to repay every dollar I spend with interest. Since that's not quite defined by any specific deadline (except for the repayment start date, which is, at this point, deferred for years to come), it doesn't spark anything more than little nagging blips of anxiety. Housing is expensive. Books are Expensive. Transportation is expensive. Food is expensive. And tuition? Don't even get me started. Add to that the rumbling Medicare thunderclouds on the horizon of medical reimbursement - the cuts keep coming, and it sounds like more and more doctors are becoming disillusioned with the whole business, occasionally recommending that interested folks consider other careers, and less frequently leaving medicine altogether.

What else? Board exams. I rocked my first set in November, and I'd like to keep up the momentum - the way I'm scheduled, I not only have all of my cores lined up back-to-back, but I have a few months between the end of my academic requirements and graduation; wiggle room. I'd previously considered taking that time to work and begin repaying loans, but it might be a better idea if I took some serious time off to study and locked in some great scores, perhaps even taking the USMLE step III before graduation, so I didn't have to worry about it during my first year of residency, like most US med students.

Hot on the heels of that nagging little "anxiom" (my sarcastic neologism for a a bit of anxiety-inducing uncertainty) is the unsureness of whether or not I'm learning what I need to know. On the island, they told us which books to use and gave us the lecture slides - you either knew them or your didn't. Here I'm preparing to be tested on some information, but I'm on my own as to where I get my version. Harrison's Princples of Internal Medicine is an exhaustive and exhausting reference - I'll never get through any topic in a timely manner. So I use Davidson's Principles and Practice of Medicine, because it's shorter, supplementing it with Step Up to Medicine - but are these good enough? Am I learning what I need to be on the wards, as I madly scribble down every word that proceeds forth from the mouth of the Attending? Am I practicing my physical exam skills properly - were those really rales, or just harsh lung sounds? Should we do a CXR or HRCT?

So I'm anxious about whether or not I'm acquiring the appropriate skills to be responsible for someone's care, but I'm also sometimes anxious about whether or not I'm growing up to be a competent adult - my very wording demonstrates that I don't feel like I'm there yet.

You know what, though? These Anxioms will never go away - never will there be a time when I have no cares whatsoever. I'll get a great job and a nice place to live, but by then I'll find myself beset by another, more pressing consortium of concenrs - the offspring of the anxsioms that trouble me now. Generations of worries will harry the various stages of my life, and so I guess I'd better get used to it...and get back to looking for housing in NYC; anxiolysis.

End of an Error

I've got what I believe to be a very high threshold for frustration - this probably contributes to my procrastination; the anxiety of rapidly approaching deadlines had not, until recently, inspired in me any sort of anxiety. However, when I reach my breaking point, it's game over. That happened last night with my old laptop, an HP TC4400.

It was a sexy little machine at first - I picked up her just before MERP, at the beginning of my medical career. She's a tablet and is thus like a petite laptop gymnast - cute and flexible. However, true to my nature, I didn't want to spend full price on her, and, in perhaps my greatest tech mistake, I bought a factory refurbished unit, rather than springing for a new model. Somehow, in my mind, this convoluted logic made sense, even though I decided to splurge on an extended warranty, knowing that there might be problems. I think I expected them.

I carried her to MERP, and the honeymoon period was fantastic. Things behaved as they were supposed to, and, whether real or imagined, I felt that my tablet tech was as impressive as another brand-new device, the first iteration of the iPhone. The first sign that things were perhaps not so peachy was a short, neon-blue line that popped up on day at the bottom of the screen. I thought nothing of it.

I took her to the island, and she must have gotten pissy, because that's when all the problems began - you see, as a tablet, the screen is supposed to flip orientations when she moves between tablet and PC mode. She is not supposed to do that on her own, whenever she wants, whenever she's connected to an external power supply. It drove me crazy. I couldn't send her in to get repaired because the warranty didn't apply out of the country. I emailed back and forth with tech support, and finally settled on disabling the screen rotation altogether, functionally removing all of the features that had made her a cool tablet. We fell into an uneasy peace, then - for whenever she'd push against my restrictions and try to rotate her screen, she'd get (we'd get) a big, obnoxious error message - it was generally only three or four, but I've occasionally been assaulted by stacks of 40 of them. At the same time, the cursor would go and spasm in the right lower corner of the screen, clicking on whatever was there, completely beyond my control. There were no patches, there was no software to download - it was like she'd contracted a personality disorder, and no drugs could fix it. Actually, it was more like recalcitrant grand mal seizures - she'd go into her fits, and there was nothing I could do but wait them out.

After our time on the island, I brought her back to convalesce in the US. 5th semester came and went, and her condition worsened - midway through my step prep time, as the warranty deadline neared, I contacted tech support to get her taken care of. There began the disaster - I wasted hours on the phone with Hewlett-Packard, unsuccessfully trying to get her fixed remotely and then, when that failed, begging and pleading with them to send a box so that I could have her repaired. I had to continuously supply them with the e-receipt of my extended warranty because, according to their records, it had already passed. I tried, and they failed me - the whole damn company. Shortly thereafter, she contracted some rampant Russian or Albanian virus in the guise of antivirus software and, instead of taking her in to someone, I just wiped her hard-drive clean, reinstalled her operating systems, and bought the best antivirus I could find. Fortunately, I'd had everything backed up. I'd hoped that a complete mind-wipe would do something for her seizures - sort of like a corpus callosotomy ( the corpus callosum is a bundle of nerve fibers the two brain hemispheres use to communicate - historically, it was cut to prevent seizures from spreading from one side to the other). However, this didn't work either.

I put up with her little fits for months, occasionally reaching the place where I was ready to smash her to bits but, at that point, she'd behave, as if her performance was merely to show me who was in control. The breaking point came last night when, the the midst of one of her first, the successor to the virus from last year slipped past Norton's defenses to assault me once again. I ran Norton over and over, but the damn software kept on finding "no virus", and the fits continued. I'd had enough.

So today I went out to Best-Buy and picked up a new girl. It felt like a whim, but it really wasn't; I've been browsing laptops on the sly for a while now, wishfully-thinking. She's a fiery red Dell Inspiron 1564, with 4GB of RAM, 320 GB of memory, and a nice i3 processor - not top of the line, but I'm not yet ready to drop 2-grand on a computer, especially with student loans. So I think my new girl and I will be getting along nicely, but some of my bum luck continues. Over Christmas, I'd purchased an external hard-drive to protect myself against my old girl's fits. The new one must be a little possessive - she didn't recognize the external hard drive, and by the time I got it open, it looked as if I'd never backed anything up at all (possibly due to the difference in operating systems). At least I've got my trusty pen drives at home. Good bye, old girl.

This whole thing....the crashing and replacing of computers and digital information in general has me thinking. I'm always a little chagrined when some catastrophe occurs to computers. Here we've built up these complex little machines that only a few of us can understand (I'm talking DOS, not Windows, but even then....), and we rely on them so much. I'm sure this a long-dead horse, but it's a little chilling in a sci-fi esque sort of way - not that they're going to become sentient and rise up against us (I'll be that's where you though I was going), but that we place so much importance on them, and when they mess up, we're kinda screwed. I lost a lot of data in this update, but nothing truly important - the important things all exist in real life. It's not fair to say that electronic music, picture, and document files don't actually exist, but that's sort of the case. We can view them and alter them, we can enjoy them - but if they're not tangible, they only exist in one place - inside the human mind - and are backed up on our pretty machines. Every once in a while I write down my musings and story ideas, and I panicked for a moment when I thought that all the newer versions were gone...but they're not; not only do I have them printed out somewhere, but I have them in my head.

If all the digital music were gone, where would we listen? If our little laptop Windows to the world suddenly went silent and dark, we'd have to go back out there for our art and literature, for our enjoyment, our learning, and our work. This whole experience has reminded me that they're just tools - nothing more. Just as electronic medical records are required by law to have their hard-copies stored in hurricane-proof housing, no necessary bit of information should exist solely online.

Yet...as quickly as prized information can disappear into the abyss, if I were to post vulgar pictures of myself on facebook, or blog about ideas that are radical and hateful, I may never get a job; people would be able to find those things forever. A conundrum, eh?

And so I extol the virtues of the hard-copy, and turn a wary eye to deceptive conveniences of the digital; I am devolving.