delusions

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

     While not exclusive to schizophrenia, one of the hallmarks is delusions. Delusions in the medical context refer to a belief which is either highly unlikely or flat out implausible. Aliens abducted me. My spouse is slowly poisoning me (though this one can be true in bizarre instances). I am an undercover agent for the CIA & KGB. What fascinates me is that the delusions have to come from somewhere. They usually aren't created ex nihilo. Sometimes the source of the delusion is quite clear. For instance, one patient was going to exact retribution on all unfaithful spouses of the world. Clearly it was not surprising to find a messy divorce involving infidelity in their past. Other times it seems a bit less personal as when one patient was furious with the Bush family and wished to punish them. Probably their delusional thinking was fueled from watching CNN.

But in one instance, I was at a complete loss. "Do you have any questions for me or the doc?"

In a clear, calm yet quizzical fashion the patient asked, "Just one. Why did the CIA turn me into a horny vampire?"

     Dead silence. We are trained neither to reject nor entertain a patient's broken perceptions. We are merely supposed to go along with the notion that they believe them to be true and that's all that matters. But this question stumped me, the nurse or the attending doc. They just kind of mumbled something and moved on.

the big three

Three big diseases compose the bulk of adult psychiatry. Three different ways the brain can break. After all, the brain is a physical organ just like a heart or kidney. Why shouldn't it break?

The first is depression. By far the most common and ranges from mild to life threatening. From a clinician's point of view, medications are not the only tool in the tool box. Counselors and psychologists play every bit an important role in treatment as medications. It's treatment is really not well suited for the average 15 minute patient encounter found in psychiatry or family practice. It's the one where the attitude of the patient plays the biggest role out of The Big Three, ie. it has a huge placebo effect when analyzed clinically. That's not true for the others. In some sense, it's a disease of the human condition.

Next is schizophrenia. I used to think it was the worst and in some sense it is. it is certainly the most debilitating but from a diagnostic point of view, schizophrenia is easy, well, relative to the others. You don't have to ask a schizophrenic any questions. Just let them talk and they'll let you know they're schizophrenic in a few short minutes once they talk about the voices inside their head or their delusions. Chips implanted in their head, satellites controlling their ideas, evil spirits cajoling them to hurt people. Clinically, it's self evident and the one where medications can make the biggest impact. No amount of talk therapy is going to change their delusions while the antipsychotics can oftentimes silence the voices altogether.

Last is bipolar. These cases are HARD. Unlike a schizophrenic, these patients are very cognizant, sometimes above average intelligence, and as such, quite adept at manipulating. A schizophrenic doesn't know they're crazy. But they can be convinced to take their medications so long as someone is around to help them. A bipolar person during their manic phase, however, thinks they're superman. They believe that they are capable of anything. Medications go right out the window no matter what anyone says. They oftentimes leave a wake of destroyed relationships because its easy for family members to feel sympathy towards a schizophrenic who believes that UFOs are talking to him. It's much harder to feel sympathetic towards a loved one who without notice, ends up in another state where they end up in jail after they blew $20,000 in a poker game on a whim. Because of the their impulsivity and their indestructible ego, they often abuse drugs which makes it all the harder. I've come to despise this disease for its difficulty in managing and poor outcomes.

But what's the point of describing them? Patients with real stories are much more interesting....

back

"Prepare for your most challenging part of your training so far."  That was the straightforward advice that was given by our school in preparation for the third year of med school.  They haven't been wrong, which is why I haven't written lately.  It hasn't been because I have nothing to write about.  On the contrary, I've got lots of stories about patients.  Too many, actually.  I've just been too tired by the time I get home to want to write about them.  On second thought, it maybe, just maybe has something to do with the fact that my current rotation landed me at MD Anderson for a stint in psychiatry.  Talking to patients who have cancer about their emotional challenges, was well, more than a little challenging for myself.  But that part is done so I can look back with the clarity of a bit of hindsight.  So more stories to come...

pavlov's medical student

     Fresh my shift, actually I was anything but fresh having worked 28 hours.  My body no longer knew what time of day it was.  The sun was rising, or maybe it was setting.  I had no idea and furthermore, I didn't even care.  The menu at Chick-fil-a said it was morning.  Breakfast it was then.  I'll supplement it with a beer at home.  Ding, Ding, Ding!  My body instantly tensed and I prepared to sprint until I realized I was no longer at the hospital and no baby was dropping.  You see, the way it works at the hospital is this.  The pregnant mothers start out in triage where us med students and a couple of first year OB interns hang out.  They then are transferred to labor and delivery when appropriate.  From there, the nurses do most of the management unless things get complicated.  When the patient gets close to delivering, and I mean CLOSE as in the baby is about to pop out, they ring a bell. 
     One intern and one med student then sprint down the hall and try to figure out which room is our destination as an overhead page informs us which room we are to go to.  We pop into the room, slap down our sterile gloves on any available surface which ironically is usually the top of a trash can.  There's a "sterile" table with the necessary instruments on it.  It's a race between getting our sterile gown and gloves on and the baby coming out.  It's a tight race.  Did I mention the blood?  Aside from trauma, OB probably is the bloodiest field.  There is a LOT of blood.  Did I mention meconium?  Google it.  There's a fair amount of that, too.  And then either the med student or the intern delivers the baby.  Med students deliver the placenta afterwards which involves even more and more blood.  I've mastered the art of being close to the patient without getting my shoes covered.  It's a very useful skill.
     But that bell.  I've come to now hate that bell because anytime I hear a bell anywhere else, a surge of adrenaline rushes over me.  It's like showing a bone to my dogs.  Instant salivation.

beware

     "Did you ever just get so tired of your job that you just didn't even want to go in the next morning?" my wife asked me one night.
     Laughing, I responded, "yeah, be very, very wary of that feeling.  It drove me to the insanity of med school."

red presents

     They would come wrapped up in a red biohazard bag.  Grimly dubbed "red presents" they contained the remains of amputated limbs.  99 times out of a 100, they were from a diabetic who just never got their blood sugars under control.  Infection would set in and the surgeons would begin to earn their nickname of sawbones.  In other words, completely preventable.  The worst was when it was a repeat amputation.  A stumpectomy, if you will.  The patient had an amputation just above the ankle.  But still the infection continued to ascend up the leg so the surgeons removed more.  It seemed utterly futile to me.  I'm sure that patient probably would be dead within a year.  If the infection didn't get them, failing kidneys, a heart attack, or a stroke would claim them.  They were a victim of an abusive and viscious process that had raged out of control for decades.  I wanted to take a picture of the grisly pile of flesh to show my future recalcitrant diabetic patients so I could say to them, "THIS is what is in your future if you don't get your diet under control."

raison d'etre

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

    I did not speak her language.  And as a med student, I was mostly in the way of both the more senior doctors as well as the nurses.  They had a protocol to follow and were carrying it out with the efficient habit of one who is able to do it in their sleep, which as it turns out was useful as it was three in the morning.  The flurry of activity ceased and suddenly the patient was stable but alone.  Despite the fact that the contractions were coming every 2 to 3 minutes, she was still hours from delivering.  Pregnant, confused, in pain, alone.  That last one I could at least do something about.  A contraction started coming and she writhed in bed as her body tensed involuntarily.  I approached her bedside and held out my hand.  She quickly grabbed it and began to squeeze my hand in an effort to alleviate her physical pain.  The contraction passed and her grip eased as her hand slipped away.  "Gracias," she muttered.  Three short minutes later she again reached out for my hand and squeezed.  I had no words of comfort and only my hand to offer.  I have no idea how many times this pattern went on but I stayed with her until she could be admitted to the hospital and her husband could join her in the room.  She did not deliver while I was on and after a 28 hour shift, I wasn't about to wait around any longer.  We all have our limits.  I will never see that patient again.  I don't even remember her name.  I doubt she will remember anything about me, as well.  I will never receive a good grade for my actions.  But it reinforced the reason I want to be a doctor and that was enough.

memories can be too much to carry

The following is not FACTUALLY accurate.  Details have been changed, things deleted, stuff made up, all to protect identity.  But it is 100% absolutely true.

     As a student doctor, I usually have more time to spend with the patients so I often would receive either the new patients (a veritable pandora's box of possible health problems) or the hospital follow ups.  This one was a hospital follow up.  As I quickly scanned through her chart, I wondered, "what in the hell is she doing HERE?"  She had terminal cancer and judging by the ER doc's notes, she was not long meant for this world.  What was she doing at family practice?
     Tattoos, a gruff voice, and a face carved with lines of a hard life, she was an independent woman who was not too keen on doctors.  She would be more at home on a Harley than in a doctor's clinic.  This was the last place she wanted to be.  The interview quickly became disjointed and scattered.  Twenty different bottles of pills, a patient who is confused, and an accompanying friend who was clearly concerned.  After getting the gist of the history which ranged from her coughing and vomitting up blood to "I think my blood pressures have been running too high doc", I decided her history of hypertension was really quite irrelevant.  I sensed that she wanted someone to be blunt and give it to her straight so I asked her, "What is your understanding of hospice?" She had no idea what it meant.  Wow.  The previous doc had recommended hospice and hadn't even really bothered to outline what that meant to the patient.  We then began one of the most honest and open conversations I've ever had with a patient in my short career.  It started with me saying, "You are facing the hardest thing anyone has to face and that is your death," and ended with me telling her about my own personal experience with hospice.  Somewhere in the middle I told her, "ask yourself, how would you like to die?"  I finished up and then went to tell the attending. 
     The attending came in and did his thing.  As we walked out of the door, I felt a tug on my sleeve.  The friend whispered, "She wants to ask you something without the doctor here."
     The patient sat looking at me for a moment and asked, "How long did your brother live?"
     "From diagnosis to death?  Fifteen months.  And he died at home with his family all around him."  She looked me squarely in the eye and held my returned gaze for a span of time which was unmeasurable.  There were no more words left to say.  She continued to look me right in the eye, shook my hand firmly, and said with a voice beginning to crack with emotion, "thanks, doc...thanks."  That was the most heartfelt gratitude I've ever heard from a patient.

Decisions

One of the good things about the third year is that I get to see what a field is like from a real world perspective, at least in an academic teaching hospital. The day to day grind details are a big part of my equation in selecting my specialty. At one point obstetrics was on my list simply by virtue of how surreal and amazing it was watching my son being born. Obviously, there's more to the field than that and after having seen it, I'm comfortable scratching it from list. It's a cool field and I can definitely see its appeal, but it's just not for me.

what's in a name

As I stumble through hour number 20 of my 24 hour shift in a sleep deprived state, I suddenly realized how family medicine got its name. It is not that you treat families. It is that you actually get to see your family.

dark

My blog has been dark of late, mostly because I am either at the hospital or asleep. I suppose there is some lesson to be learned or moral to be gleaned from waking up at 3:45 in the morning but I'll be damned if I know what it is. All it tells me is that OB/GYN is not in my long term plans.

attire

The best thing about my current rotation, pathology? I get to wear scrubs. Beyond that, I think I can comfortably rule out a career as a pathologist.

bs

     He had tubes and lines going in all directions – oxygen, NG tube, catheter, chest tubes, IV lines.  The attending was with the doctor trying to convince the son that hospice was the best option for his father.  Again.  The son had already agreed once to hospice.  Neither the dad nor son wished him to die while being hooked up to every manner of life support.  He wished to die in his home.  Not so strange really.  I suspect that most people, given the choice, would rather die in the comfort of their own home rather than surrounded by tubes, beeping machines, and the constant interruptions by the staff.  But the son was confused and uncertain and changed his mind several times.  His dad was dying and the decision rested solely on his shoulders.  Wasn't hospice a form of giving up?  Couldn’t he recover if he just got the right care?  What should I do, doctor?

     While this conversation occurred, I went over to see if the patient needed anything.  He had a bit of applesauce on his chin left over from his comfort feeding.  I gave him a paper towel and helped him wipe it off.  He stared at me for several seconds and stated in a very calm and straightforward manner, “have you ever seen such BS?”  I asked him what was the BS, but by that time his delirium had returned and he shrugged his shoulders unknowingly.  I will never know for certain if he was fully lucid at that moment.  Whether it was the ramblings of an altered mind or the questioning of a dying man, it did not seem to matter.  His question cut to the heart of the issue at the end of life.  Tubes everywhere.  Different doctors wanting so many different things, often mutually exclusive.  And none of it addressing the issue put forth to the patient and his family, “You have a limited time left on this earth.  It may be days, it may be weeks, it may even be a few months.  But the end IS near.  How would you like to spend it?”  So much BS, indeed. 

Update

Eight days later my dad was finally discharged from the hospital to go home. The clincher was when his neutrophil counts finally got into a safe range with plenty of wiggle room. He's lost quite a lot of weight over the past two weeks so he's got quite a lot of rehabbing to look forward to in order to gain back strength and lost muscle.

things I've learned

     Most anybody will admit our healthcare system has some severe flaws.  Very few, though, will see through the political posturing to the inherent and deeper flaws.  So far, I've yet to see one meaningful policy idea put forth seriously.  Take for example the now Supreme Court validated Affordable Care Act.  It has both its defenders and detractors.  I've yet to hear anyone, though, address and propose a solution to one of its fatal flaws.  There are simply not enough doctors to address the increase in the number of patients that will have insurance.  Period.  Math is not on this law's side.  And it's going to get worse because it takes a good decade to train new doctors.  It's not like they can be cranked out in respone to an increased need in short order.
     There is a rule of thumb that for each decade of life, that represents one chronic or serious health problem.  So a 44 year old will typically have 4 problems and a 72 will probably have 7.  There is also a rule of thumb that an office visit should take between 15 and 20 minutes.  So when a 60 year old patient comes into the office with 6 problems, which problem am I supposed to ignore?  Their prior cancer history?  Their osteoarthritis?  Their hypertension?  Their diabetes?  Their high cholesterol?  Their bladder control problems?  I don't ignore any of them and end up spending a good 50 minutes with the patient.  That means the next 2.5 patient encounters are now backed up.  This happens daily.  How are physicians going to handle an increase in the number of patients?  That which cannot go on indefinitely, will not.

discharged?

     We had already signed the papers, packed my dad's bags and walked out the room. Discharged.  I left my dad in the front lobby of Mdacc while I trekked back over to school to get my car. He was ready for some uninterrupted sleep in his own bed (hospitals are the worst place to get rest). In the ten minutes it took to get my car and drive back, they called my dad. One of the cultures did end up coming back positive.
     Parainfluenza 2. You know the coughing snot nosed kids runny around schools and day cares? This is one of the viruses responsible for that. It is usually not a big deal but in a stem cell transplant it's a very big deal. Significantly bad things can happen to stem cell patients infected with this virus. So we are back in the room waiting to hear what they want to treat him with (viral treatments are rather limited) and whether to do it as an inpatient or outpatient. The waiting game again...

associations

     That smell. That smell on my hands. It's not an unpleasant odor but the emotions that go with the smell are another matter. It's the distinctive smell of the hand sanitizer at MD Anderson's hospital. The source today is the emergency room. The last time I was here was the day of my brother's funeral. The time before was my brother's death.  In both instances my dad ended up there with neutropenic fever. Today we ended up there again - same shit, different day. While the circumstances where nowhere near as dire nor as urgent for my dad, the feeling of failure was strong. Weren't we done with this? Why was he spiking a fever?
     My dad had been fighting on his own a presumably viral infection for the past 7 days, but today it took a turn for the worse. His fever jumped up to 38.1 C (100.5) which to anyone else would simply mean a day home from work. For him, it's an automatic stay at the hospital with the full work up. The IV antibiotics have begun. The cultures have been drawn. The chest x-ray was normal so no pneumonia (I guess my lung listening skills have become honed because I had told my parents no pneumonia that I could tell). Now the waiting game begins...

it's never about hypertension

     At the top of each chart there is always a Chief Complaint (or CC).  It's what the patient is here about today.  Or, at least what they told the nurse when they came in.  The problem is it's NEVER about the chief complaint.  Sure, a patient may have diagnosed hypertension.  Their CC may state "follow up for hypertension".  And they may in fact not have very well controlled hypertension (chances are they don't).  But that's rarely why the patient came in.  Inevitably, there is something else going on in their life which prompted the visit.  Some new ache.  Some old pain.  Some new symptom.  Some newly observed finding on their elbow.  Some completely fabricated symptom.  The uncontrolled hypertension is what is most likely going to cut their life short but whatever is hurting in their elbow is what is weighing most heavily on their mind.  Hypertension, high cholesterol, or diabetes for the most part, are mostly symptom free.  So why worry about something that you can't feel?  So you make a deal, albeit not explicit, with the patient.  You will address their concern but in return, they agree to actually take their lisinopril, or increase their dose of insulin.  It requires some bargaining, some threatening of tough love, and sometimes pleading.  It's the art of medicine.

joy

     What's that thing on my face?  It's a strange feeling.  Using muscles that I'm not used to using.  It's a bit awkward but spontaneous.  Oh, yeah, it's a smile!  Maybe it's that I'm no longer buried in endless texts, or that my dad is doing well, or that I'm out in the "real world" again, or that my grief has matured into a healed scar.  And I know that this feeling will probably go away when I get my STEP I score, or when I have to take the board exam for family medicine, or perhaps when I hate my next rotation.  But for right now, at this moment, I am enjoying myself and that is enough.

roots of pain

     I don't even remember why she came in.  Most likely something to do with pain or arthritis.  But given my prior life experiences, I know that physical pain and emotional pain are inextricably tied together.  So I underhandedly steered the interview towards how she was doing emotionally.  There is no specific strategy that works for all, or even most patients.  It's an ebb and flow that one just gets a feel for by trial and error.  In other words, a relationship.  The patient begins to open up and turns to me and says, "I don't know why I'm even telling you this.  I ain't ever told anybody this."  She pauses a minute, wags her finger at me in a revelatory manner, "You're going to be a good doctor.  Uh-huh.  You're easy to talk to.  A good doctor."

drug seeker

I take the extra two minutes to log onto a computer to quickly check the patient's chart.  I refuse to be that doc who walks in clueless.  It reads on the reason for visit as follows:

1. Diabetes
2. Medication refill

     Sweet.  This should be straightforward.  My lunch break started 15 minutes ago and I'd like to be able to eat.  Within 60 seconds of walking into the room, I kiss any hope goodbye of a lunch that doesn't involve inhaling the food in 4 minutes.  Clearly what was communicated to the nurse making the appointment was in stark contrast to reality as the patient clearly didn't realize that to be diagnosed with diabetes, one must actually be diabetic. 
     Crazy idea, I know.  High blood sugars?  Diabetic.  Normal blood sugars?  Not diabetic.  We are taught real cutting edge stuff like that.  Want to hear something even more wild?  We don't give insulin to people who have completely normal blood sugars.  It could kill them.  Wild, right?  This seemed to fall on deaf ears.  While the patient is talking, all that is running through my head is, "please stop inventing symptoms and conditions so I can have ten minutes to eat."  I go to present my "findings" to my attending doc and as I soon as I open my mouth to try to give the history, I start laughing inside because I can either get angry or I laugh it off.  A psyche referral isn't even on the table as the patient was no danger to anyone and got angry at even the insinuation that some mental health might be a good idea.  Besides, they weren't really psychotic (I've seen that, too, and I had nothing but empathy for the patient but that's another story).  They just thought they knew more than the doctors.  My hunch is they want to feel important by having a doctor pay attention to them.  My attending shakes his head as if to say, "crap, there goes my lunch, too."

I will once again rely on the genius of The Simpsons.  THIS was my patient, only a younger and non senile version of Grampa Simpson.  I should've had fun and used the approach of Dr. Nick.

truth

"A rabbi would never exaggerate. A rabbi composes. He creates thoughts. He tells stories that may never have happened. But he does not exaggerate." - The Simpsons Book learning as the exclusive form of learning is done. In its place is experiential learning via clinical rotations.  The next two years are filled with them.  First is family medicine.  In 4 short weeks, I get a whirlwind tour of what family medicine is like in a county clinic run by academics.  It's only been 4 days and in addition to the staples of family practice - hypertension and diabetes - already I've seen bipolar, heart failure, liver failure, and osteoarthritis to name a few.  I've even seen completely fabricated diseases.  Interesting does not begin to describe them and they are wonderful tales to be told.  But in order to respect the patient's privacy, I will do as the rabbi above does.  I will compose.  I will create thoughts.  I will tell stories that are not quite historically accurate.  But they are all 100% true.

the day after STEP

As I clicked what was the last but I hope a long string of correct answers, a divergent thought ran through my head....

the long road

"Ok, just sign here and then if I can get your fingerprint on the scanner," the proctor instructed me as I signed in for my STEP I exam.  "Ok, yup, here you are.  MCAT from 2008, right?"  They had my digital fingerprint on file from when I took the MCAT to get into med school.  And I thought that exam was bad.

2008.  Wow.  Have I really been at this that long???

check list

I mentally ran through my mental check list to make sure I had everything.  Tea. Lots, Lots, Lots of tea.Enough-caffeine-to-keep-me-going-for-322-questions-over-everything-amount-of-tea.Nervousness.Location of closest bathroom for said tea.
Power bar.Anxiety.Sandwich.Fear.Energy drink.Gratitude.Chocolate bars.  Wait what was that last one?  The one before chocolate bars?  Gratitude?  Huh.  Yeah, I guess I really am grateful.  Grateful that this will be over, sure.  But also grateful for this opportunity.  Blood, sweat and tears have been put into this journey which culminates with this chance to take one bohemoth of a test.  Win or lose, I have every right to be proud of where I am and grateful for the opportunity.  I am ready...


If you can make one heap of all your winnings
And risk it all on one turn of pitch-and-toss,
And lose, and start again at your beginnings
And never breathe a word about your loss;
If you can force your heart and nerve and sinew
To serve your turn long after they are gone,
And so hold on when there is nothing in you
Except the Will which says to them: "Hold on!"

...Yours is the Earth and everything that's in it,
And - which is more - you'll be a Man, my son!
-If by rudyard kipling

lots of lube

     "I've discovered the secret to these practice dummies is lube.  Lots of KY.  Actually, that's true in life, too."
- Words of advice from the doc instructing us on how to insert a foley catheter into a practice dummy. 

Absent from the training exercise were the screams and profanities that would be streaming from mouths of a man getting a foley catheter inserted.  (A foley catheter is a catheter that goes up through the urethra to drain the bladder.  There is no numbing involved.  It is not, shall we say, pleasant.)

when you hear hoofbeats...

It's an oft repeated axiom of medicine.  If you hear hoofbeats, think horse, not zebra.  It means the common things happen commonly.  Don't go looking for exotic stuff.  But we're also supposed to keep an open mind as to the possibilities.  How in the world to does one test that?  I don't do as well on standardized tests as I'd like.  I think I'm too used to looking for zebras.  In my prior career, we set out to look for the new, the novel, the (hopefully) revolutionary ways of treating a disease.  I saw parts of physiology that no one else in the world knew.  Fast forward to my brief medical career and my family.  My brother?  Thymic cancer.  That's not even a zebra.  That's beyond zebra.  My dad?  CLL, well that's common.  Except his was highly aggressive.  Everything I've learned from recent lectures has been that CLL is slow and not that big of a deal.  One lecture over the pathology of it had a whopping 122 words over it.  Basically, it's a low-grade disease that's discovered incidentally.  That's it.

A case from a lecture that highlights how slow it is.  This patient has had it for over seven years.  Skip past all this if you're not into all the medical mumbo jumbo.

A 54 yr-old woman presents to your office with fever and persistent bleeding from a dental extraction done 3 weeks ago.  The patient has felt well for the past month with no fevers or weight loss, but she has had some fatigue that she attributes to long hours at work.  Seven years ago she was noted to be pancytopenic and was diagnosed with aplastic anemia.  She was treated with antithymocyte globulin, cyclosporine, and prednisone and had a complete hematologic recovery.

Physical examination shows a pale, middle-aged woman.  There is no lympadenopathy or hepatosplenomegaly.

  Laboratory studies:

  Hemoglobin  8.2 g/dl

  Mean corpuscular volume  117fL

  Leukocyte count  3100μL

–Segmented neutrophils  21%

–Band forms  10%

–Lymphocytes  68%

–Monocytes  1%

  Platelet count  36,000/μL

Peripheral blood morphology shows hypogranular and hyposegmented neutrophils.  The erythrocyte morphology shows both anisocytosis and poikilocytosis with some teardrop cells.

 What is the most likely diagnosis?

a) recurrent aplastic anemia
b) chronic lymphocytic leukemia
c) myelodysplasia
d) B12 deficiency
e) Miliary tuberculosis

     On the one hand, the stress of not measuring up, the threat of a board score so poor, I'll be doing my residency in Gnome, Alaska.  On the other hand, endless monotony, repetition ad nauseum as I try to figure out how to cram a library of information into my head over and over.  I never thought it possible to be stressed and bored at the same time.  But there it is.  Just a few more days.  My board exam is rapidly approaching.

le grille...le exam

Questions.  A never ending sea of practice questions.  Written by various gnostics who proclaim they have the secret knowledge to help you to ace the Step I Exam.  Well, after going through a round of questions, albeit the hard ones, I got 36% right.  About every third question right.  That's it.  And the happy thing is that was about average for the other poor souls being tortured with these practice questions.  Substitue the grill for the exam in the video below and I'm Homer.

Studying for Step I.





credit to whatshouldwecallmedschool

restaging

By all measures of materialistic medicine, my dad is doing well. He recently went through another round of restaging. The big three month mark. Much of what can catastrophically go wrong occurs in that first 100 days post stem cell transplant. A big touchstone. By microscope. In looking at his bone marrow, no cancerous cells are seen. But it only takes a few of those evil buggers to set off a chain reaction. More sophisticated methods are employed. His bone marrow is also producing the various precursors to all those cells floating in the blood - red blood cells, white blood cells, platelets. They're all there. By CT scan. For CLL, they are looking for nasty lymph nodes which swell up with cancerous B-cells. He had a couple of smallish but not so pleasant looking nodes in his abdomen prior to the SCT. They are no longer apparent. They're gone. There may be evidence of a small clot in one of his pulmonary arteries but it's asymptomatic and small. Besides, he's already on the necessary anticoagulant drugs to treat pulmonary embolism. Just observe at this point. By those more sophisticated methods alluded to. I'm too tired from plowing through endless questions in preparation for my licensing exam to go into too much detail because while it's not rocket science, it's pretty danged close. In a nutshell, no evidence of mutations, mutants or chimeric monsters are seen. Good news since cancer is one big conglomeration of mutations. Also, for the two bone marrow cell lines tested - lymphocytes and myelocytes (both types of white blood cells to fight infection and whatnot) - my dad is 100% NOT HIM. He's completely whoever the donor was. No remnants of himself left. Strange metaphysical thing to be happy about but there it is. Misc He struggles with mild GVH which shows up as random but symmetric rashes. Irritating but at this point nothing to be terribly concerned about. Medically. Lifestyle, it's actually a royal pain in the [insert random body part here]. And not so nice GI disturbances. Good news is that it's not Clostridium difficile. Any bug that has "difficult" as part of its Latin name can't be good. Let me out it this way. The cutting edge treatment for C diff? Fecal transplant. Google it. It's exactly like what it sounds. Enough said about that bug.

explaining what the second year is like

what med school is like

I found a great tumblr that has a unique, but VERY accurate way, of using short clips to elucidate on what med school is like.  It's What Should We Call Med School if you want to take a look (some images may not be safe for work).  I take no credit for the ideas, just reposting their stuff (and giving them credit. whoever they are).

This one was just entitled Med School.  Very appropriate.

     One year.  A sand in the passage of time.  A period of time dominated by love and pain.  Watching my brother breathe his last breath seems an experience both long, long ago and yet as recent as watching the sun rise this morning (grief necessitates the acceptance of paradoxes).  Perhaps the heavier the emotion, the greater the ability to distort our perception of time.  I'm not entirely sure where I am at with my grief, nor am I sure where I am supposed to be with it.
     I have spent the last year of my life living the motto, first, to endure.  Merely surviving the jumbled pieces of my life seemed a lofty enough goal.  It's been a good strategy for me and in all honesty, has served me well.  There is, however, a small part of me that grows daily by the smallest of margins but inexorably gains nonetheless.  It wants to move on.  It wants to enter into the clinical phase of my training fully engaged.  It no longer wants to be troubled nor governed by loss or the threat of more grief.  It wants to live life amongst the living again.  To find some measure of peace and joy. 
     You can imagine that grief might have something to say about that.  The loss and pain will not be brushed aside so easily.  So I am negotiating with grief, not that I have any negotiating power.  Grief holds all the cards.  But I've struck a bit of a truce, if you will.  Grief will allow that tiny flicker of a flame to continue to burn and be fed daily.  In exchange, whenever another wave of grief comes, I will not try to overshadow it with light.  I will allow it to wash over me as it has countless times in this past year and in all likelihood will follow me the rest of my life.  I will do so with the knowledge that after the wave has receded, the light will remain unextinguished and that I remain more than the sum total of my grief.

     Ding, ding my phone chimed.  In what's become a reflex, my wife chimes "Helen!"  I only have a few people I text and by orders of magnitude, my cousin accounts for the bulk of my text messaging.  I pick up my phone and read the text message.  "How are you doing?"  I can almost hear the emphasis in her voice that she would place on the word 'you' if she were in person.  She's my cousin whom a little more than a year ago, I wouldn't have recognized walking down the street.  But her and her sister came down about a year ago when the end was rapidly approaching for my brother.  I lost a brother but gained two sisters.  I hate to think in those terms but I can't really help it.
     I didn't really know how to answer her question because the simple fact was that I do not know how I was doing.  It's a time of great transitions for me right now which also means it's a time of reflection and looking backwards seeing from whence I've come.  I have my first licensing exam in about 6 weeks.  The tenure of my classroom learning officially ends.  Now I enter the clinical world for hands on experience 24/7.  Actually, call is 28-hours long so it's really more 28/7, if you can figure the math on that one.  My son is learning how to drive.  My dad is transitioning into his role as retired cancer battler.  (Notice I don't use the word 'survivor' yet.  We don't know if it will stay in remission.)  And the 1 year anniversary of my brother's death is nearly here.  I have no clue how to feel.  Am I supposed to feel proud?  Have I turned a corner?  Relieved?  Have I turned enough corners?  Stressed?  Sad?  Angry?  None or all of the above?
     I didn't begin to unravel the answer to my cousin's question until I took a day off and puttered in my garden.  Shortly after my brother passed, I planted a tree in memory of him in my back yard.  In the confusion and hastiness of my grief, I planted the tree in entirely the wrong place.  I considered leaving it where it was.  It would serve as a tribute that life sometimes sucks.  It often doesn't work out the way we plan.  Besides, the thermometer is already approaching the mid 90s here and so it ain't exactly the best time to be transplanting trees.  But that really wasn't the memory that I wanted for the tree.  So on my day off, I moved it, dripping both sweat and tears. 
     I listened to music as I trudged through my task and I found that I finally got a song that has perplexed me for years (and of course, it's one of my wife's favorite songs proving that I'll never understand her).  It's an allusion to Icarus and his legendary flight of getting too close to the sun and perishing in the process.

If we burn our wings
Flying too close to the sun
If the moment of glory
Is over before it's begun
If the dream is won
Though everything is lost
We will pay the price
But we will not count the cost

When the dust has cleared
And victory denied
A summit too lofty
River a little too wide
If we keep our pride
Though paradise is lost
We will pay the price
But we will not count the cost

And if the music stops
There's only the sound of the rain
All the hope and glory
All the sacrifice in vain
And If love remains
Though everything is lost
We will pay the price
But we will not count the cost
bravado by n. peart

     I never understood the last four lines of each stanza.  How it contrasts gaining a dream while losing everything, keeping our pride while losing paradise, holding onto love but losing everything.  And then final two lines about paying the price but failing to count the cost perplexed me to no end.  Well, I get it now.  I can now answer my cousin's question with satisfaction, albeit grimly.  I am dimly yet acutely becoming cognizant of the magnitude of the cost of the past year of my life.  The price is far from trivial.  I wanted to become a doctor, to realize a dream, but not like this.  Learning pain managment from your dying brother?  Learning the extent of what it means to be a difficult patient from your dad?  And given that cancer is the second leading cause of death and spans every organ system, you'd be surprised at how often it comes up in lectures whether it's pathology, pharmacology, radiology or even ethics.
     THIS is why they tell us never to treat our family or friends.  Hell, it might even be illegal here in Texas.  We can't remain objective, conflict of interests, blah, blah, blah.  What in the hell would you do if your dying brother begged of you, "make the pain stop"?  You pay the price and try not to think about the cost.

Done.  Over 900 questions spanning 10 exams.  Brain...is....shutting....down.

never enough

See?  It's never enough.  Like this question.  Again, a supposedly "easy" one though only 28% got it right. 

      I correctly identified the disease - chronic bronchitis.  And I narrowed it down to two answer choices.  Then I made an educated guess that chronic bronchitis would probably have similarities with asthma.  Asthma involves eosinophils so I chose B.  WRONG.  Apparently, chronic bronchitis is not similar to asthma from a pathological point of view.  The correct answer is C.  Cram another thing into my already bursting at the seams memory tank.  And so I close my eyes and say it out loud.  "Chronic bronchitis differs from asthma in that the infiltrate are mostly CD8+ lymphocytes, NOT eosinophils like in asthma."

when is it enough?

     You can never be done studying.  The amount to learn is near infinite in its quality.  So for me, I study until I'm done.  There's no objective criteria.  I'm just done and that's when I stop.  And as I plow through thousands of questions for review, I wonder, if I were to pull 100 random docs, how many could answer some of these basic science questions?  Unless the doc is a pathologist or nephrologist, I wonder how many would know the answer to this question?

     In my question bank, I can select from Easy, Medium or Hard.  This falls under the Easy category.  And notice that only 48% of the respondents got the answer right.  Easy, right?  I knew it but that's just because I reviewed this subject for a brutal test yesterday written by a nephrologist. 
     And do you know how I remember it?  Let me walk you through it.  A kid comes in with dark urine.  A kid peeing coke would freak out most parents, right?  Through history, you find he had an infection a couple of weeks back.  That's a pretty easy reflexive association that I talked about in a previous post.  It's Post Infectious Glomerulonephritis (or post streptoccous GN).  Thankfully, some pathologist with common sense named the disease in a descriptive manner that tells you exactly what it is.  And what's the acronym of that?  PIGN.  Pigeon.  Pigeons leave lumps and bumps of shit all over my driveway when they eat my fallen mulberries on the ground.  The pathology looks like lumps, bumps or humps.  I can never remember if they're subepithelial or not but the answer choices only have one hump choice.  All that just to remember one disease.  And you don't even need treatment.  It resolves on its own.  Like I said, I just study until I'm done. 

reflex

     When faced with massive amounts of information, we docs-in-training learn to pick up on patterns pretty quickly.  Unless you're some kind of savant, it's impossible to remember every detail about every disease and therapy.  So you pick out little gems and regurgitate the answer before you even have time to think about it.  It's a reflex.  Like this question.

Any question, any time, any test, that has a question about an African American woman with some sort of funky lung issue ALWAYS has an answer related to sarcoid.  Period.  End of story.  I've yet to see one come up where it's atypical pneumonia or something.  Obviously, that's not going to be always be true in clinical practice and therein lies some of the difficulty in translating test taking knowledge with real world doc skills.

Waiting

I've reviewed so much information, I feel as if I have forgotten more than I've learned. Like a sponge that is too full, it begins to drip moisture back out. So I found a new place to hang out before the exams. Right near the med center is a large park. And in it is a Japanese zen garden that I had never seen before. If I'm going to forget stuff before the exam, this seems as nice a place to do it as any.

update

With all the exams, I don't really have time to post much of anything thoughtful about my dad.  So I figured I would just post the email I sent him a couple of days ago regarding his current back issues.  A lot of doctorese.

This is the summary report of the MRI:

RADIOLOGY/ECHO: MRI: Findings:
There is a wedge compression fracture of nearly every vertebral body, without evidence of underlying enhancement and T2 signal abnormality. Augmentation procedures have been performed at L1 and L2. Extensive degenerative changes are present. Grade II anterolisthesis of L5 on S1 is noted. Because of the anterolisthesis, there is severe left L5 neural exit foramen narrowing and mild right L5 neural exit foramen narrowing. There is also severe left L4 neural exit foramen narrowing.
The nerve roots of the cauda equina appear mildly thickened, but there is no abnormal enhancement.
The conus ends at L1-L2.
A broad-based disk osteophyte complex is seen at L2-L3. There is no significant central spinal canal stenosis or neural foraminal narrowing.
L3-L4: Broad-based disk bulge. Mild bilateral lateral recess stenosis. Mild bilateral facet joint hypertrophy.
L4-L5: No significant central spinal canal stenosis or neural foraminal narrowing.
L5-S1: Neural foraminal narrowing as described above. No central spinal canal stenosis.

JOHN DOE, M.D

And here it is with my comments inserted in parentheses:

RADIOLOGY/ECHO: MRI: Findings:
There is a wedge compression fracture of nearly every vertebral body, without evidence of underlying enhancement and T2 signal abnormality (this is very concerning. Definitely a consult with orthopedics is warranted. But I also think seeing the endocrinologist is a good idea. Perhaps pharmacological management is just as effective).

Augmentation procedures have been performed at L1 and L2. Extensive degenerative changes are present (have they degraded more since your last MRI? We need to get an orthopedic consult to evaluate if degenerative changes are ongoing that rapidly. If they are, it would seem an agent like Zometa or Denosumab to inhibit bone turnover are warranted).

Grade II anterolisthesis of L5 on S1 is noted. Because of the anterolisthesis, there is severe left L5 neural exit foramen narrowing and mild right L5 neural exit foramen narrowing. There is also severe left L4 neural exit foramen narrowing. (this is the one that may require surgery. This is the slipping that the neurologist talked about. It's NOT a slipped disk. It's a slipped vertebra. The vertebrae are out of alignment. He said it was a grade 2 and the scale is 1 through 4 with 4 being the most severe. This isn't simple kyphoplasty anymore. This is neurosurgery. There's one thing Dr. Numbnuts did right by bringing in a neurologist. But it's not an emergency as of yet. It still needs to be paid close attention, though. Any change in your leg function, leg sensation, bowels or bladder needs to be assessed IMMEDIATELY.)

The nerve roots of the cauda equina appear mildly thickened, but there is no abnormal enhancement. (this is good. If this gets messed up, you lose control of your bowels and bladder. Then it's absolutely a surgical emergency, SCT or not. If you notice any loss of feeling, loss of function, you need to go to the ER and request a neurologist IMMEDIATELY.)

The conus ends at L1-L2.
A broad-based disk osteophyte complex is seen at L2-L3. (these are changes indicative of osteoarthritis. This is a chronic process, not an acute one.)

There is no significant central spinal canal stenosis or neural foraminal narrowing. (a good thing)

L3-L4: Broad-based disk bulge. Mild bilateral lateral recess stenosis. Mild bilateral facet joint hypertrophy. (this is an example of a bulging disk that may start to slip. I'm not sure what the last sentence implies. Hypertrophy is a response to some sort of inflammation. As to what's causing the inflammation, I don't know. Cancer? Arthritis? Regardless, I don't see how this is an acute finding. This is something that's been chronic.)

L4-L5: No significant central spinal canal stenosis or neural foraminal narrowing. (a good thing)

L5-S1: Neural foraminal narrowing as described above. No central spinal canal stenosis. (already described)

uncertainty

     A phone ringing.  It's still dark.  It's too early for a phone to be ringing.  This can't be good.  It's never good.  "How are you?" I ask my dad.  "Not worth shit."
     To the ER.  Again.  Lower back pain.  BAD back pain.  Out of nowhere pain.  10 out 10 pain.  A long day with a test somewhere in the middle.  Conversations with a neurologist and the ER doc.  We don't agree with the ER doc.  My dad is discharged.  ER doc wanted to admit him.  He has several compression fractures in his lower spine.  And some narrowing of the holes where the nerve roots come out of the spine.  And a new rash.  Nothing to do with the pain.  Is it graft-vs-host?  ER doc pays it no mind.  Idiot.  Fool.  The spine just causes pain.  At least for now.  That's what opiates are for.  The GVH can kill him.  If it worsens.
     So my dad is home.  Taking opiates.  There will be many visits in the near future.  Starting with the SCT team tomorrow.

studying

2 down, 8 to go

During a routine doctor's visit, a 68-year old man is found to have an increased white blood cell count with normal RBC and platelet counts.  He reports to be in good health.  His peripheral blood smear is shown here. 

What is his most likely diagnosis?

1. Acute lymphoblastic leukemia
2. Chronic myelogenous leukemia
3. Chronic lymphocytic leukemia
4. Acute myelogenous leukemia
5. B12 deficiency

     I stared at this question for a long while, not because I didn't know the answer.  I definitely knew the answer.  I knew it all too well.  It was a textbook example of CLL.  And that was my problem.  How often do diseases follow the textbook?  I know from my research days that the lab animals rarely read the relevant literature and often didn't do what they were supposed to do.  And from my own personal family, 2 for 2 on completely non textbook diseases. 

     This has been a hard block for me.  Lots of cancer stuff and lots of emotions along with it.  And hard not to argue with the professors because I knew so well that cancer doesn't play by nice and tidy rules.  Intellectually I know we have to start with the basics and that "common stuff is common".  But when you learn a piece of information experientially and process it with intense emotions, logic doesn't really matter as much.  So I bubbled in the third answer choice and finished the 100 question pathology exam.  Went home, worked out and started studying for the next exam.  It's Fundamentals of Clinical Medicine.  Arthritis, anemia, and of course, cancers.

ageism

Ain't funny pickin' on the old students (yes, this was a real question).

A 45-yr old medical student, having failed year after year, was stressed out about the upcoming exam and developed scaly papules and vesicles only on the sides of the fingers.  A biopsy showed spongiosis and lymphocytes.  The most likely diagnosis is:

A. pemphigus
B. urticaria
C. dyshidrotic eczema
D. tinea versicolor
E. candidiasis

exam questions

I took my behavior exam on Friday.  91 questions of crazy goodness - OCD, sexual fetishes, heroin addicts, narcissists, drunks, narcoleptics.  As I took it, I couldn't help but think of this picture that was circulated around and grin during the otherwise taxing exam (oh crap! I forgot to submit my taxes!).

While F is definitely the real world picture of many, many, many med students (I'm not which is why I don't do as well on the exams as the other savants), the correct answer is probably C.

schedule

This is my schedule right now.  10 exams in 21 days.  And only half of them are finals cumulative over the entire year.  When I tell people that I'm training to be a doctor, their response is always something along the lines of "how fun!"  No, it's not.  It sucks right now.  Yes, it will be meaningful, worthwhile, etc. but by no stretch of the imagination is this fun.

“I’m Not Going to Treat Your Cancer” - Cancer Network

An interesting read by an oncologist.

“I’m Not Going to Treat Your Cancer” - Cancer Network

rest of the story

     Sharply dressed, standing erect, he strode quickly and purposefully with his IV pole in tow.  I leaned over to my mom and whispered, "you can always tell the people who haven't started the chemo or stem cell transplant yet."
    The woman was energetic, chatty and quite amicable.  Out of town, boredom was her biggest enemy at that point as she waited to start her process.  I saw her about a week later at the exercise class.  She had trouble walking and the cheerful demeanor was absent.  The chemo had started.
    I wish I could go back and know how these people fared.  Did they return to their pre-SCT transplant state?  Did they regain the spring in their step?  Did they at least make it home?

confusion

I never got a chance to finish this post.  I'm posting it now, though it took place the first week of March.

     It's confusing, all this.  It's hard to know just exactly who is walking through the doors of the medical center sometimes.  I was here a time or three with my brother.  And then my dad.  Sometimes at the same time.   My brother died.  My dad did well.  So a break.  Then I came here a physician in training.  Saw patients who resembled both my dad and my brother.
     Now it's spring break and I'm spending it here again.  My dad's stem cell transplant.  It's hard to know what emotion, what thought, what gut feeling goes with which experience.  It's like an alcoholic training to be a bartender.  It's like having to work at a cemetery where your loved ones are buried.  You have to keep going back and face physical manifestations of your pain.  Every day.  Study the diseases that can wreak havoc.  That can kill.  Except it's not only a cemetery.  It's the site of my dad's hope.  It's where I am being trained in my profession.  Evolution of a complex love-hate relationship.  Confusing.

relative

     "This hasn't been too bad."  In retrospect, my dad was expecting much worse.  I think we all were.  That's not to say it was easy.  It's just that it's all relative.  Relative to the gentleman who got hit by a fungus.  It started in his sinuses and went up into his skull and jaw.  The right side of his face resembled a train track interchange with the stapled scars running in all directions.  It was three years post transplant for him and he was found unresponsive one morning in his room.  He transfered to ICU and we don't know what happened to him after that.  Or, the woman who was seven years post transplant.  She was down in Houston visiting relatives when an episode of graft-versus-host hit and landed her in the hospital.  She had trouble even walking when I saw her.  Or, the woman who had to be about the same age as me.  She hadn't eaten anything in six days because of the intense nausea.  Can you imagine not eating for a week? 
    So all things considered, yeah, it couldn't have gone any smoother for my dad.  Infections, drug reactions, arrhythmia, mild graft-versus-host. Those were all just minor hiccups relatively speaking.  We're just three weeks after the stem cell transplant and he's been given permission to go home for the weekend.  That pretty much says it all.

     No posts of late and mostly that's a good thing.  My dad is doing extremely well and I'm trying to get caught up with my school.

discharge

     It's official.  My dad has been discharged.  Maybe discharged isn't exactly the right word.  Discharged usually implies the patient is now free.  That's not really the case here.  It's more like a leash which was originally very short.  So short, in fact, that the care required by the patient necessitated 24/7 care and that was safest and the most proficient to do in the hospital. 
     Now the leash has been let out a bit.  It's still there.  It's just long enough to extend out of the hospital, but not so long as to allow my dad to go back home.  They have to live within 15-20 minutes distance of the hospital in case of a fever or some such crisis.  He will have to come back daily to MDACC for 2 straight weeks.  His blood will be checked and various treatments will be administered.  But no more being hooked up to an infusion pump 24/7.  He can go into a bedroom, albeit a new and strange one at an apartment, and go to sleep uninterrupted.
     This is a huge milestone to reach and with each point, the imminent risk decreases a bit.  The first 10 days was the most crucial and dangerous.  By day 10, engraftment usually begins and the counts start to come back up.  He made that one quite nicely, despite all the side ventures.  The next major hurdle is being well enough to be discharged.  He's crossing that threshold now.  To make it to 100 days post transplant is the next goal to set his focus upon.  Somewhere around that time, if all goes well, the leash gets a lot longer and the patient is allowed to go back home.  My dad is on day 20 so only approximately 80 more days to go.

update

     That presumptive UTI on Thursday?  It got worse.  By Friday morning, he had a fever over 103.  Needless to say, he was miserable.

   
     But then a rash appeared.  No pain or itching, fortunately.  Interestingly, it first appeared where his skin had already been agitated by the EKG electrodes.  It then spread around to his neck and back.  Both the urine and blood cultures came back negative for any bacteria.  That doesn't mean it's not an infection.  Maybe, maybe not.  If it is, you don't know which bug(s) you are facing.  Couple that with the rash and it shifted the possibility of infection towards drug reaction.  Maybe, maybe not.  When he started getting the urinary symptoms again on Thursday, they changed antibiotics to meropenem, which is a relative of penicillin.  Any of the the penicillin type drugs can cause allergic reactions.  So they stopped that drug.  They switched to cipro in case it is an infectious process.  And more steroids.  Can't forget those.  That quickly brought the fever under control.

     And on they charged with the last (hopefully) round of chemotherapy on the schedule.  SCT transplant is a bit like surgery in that regards.  Once the patient is cut open, you can't stop.  You react and deal with each crisis as it comes.  You can't just wait and see how the patient feels.  So it goes with SCT.  The cells have been injected.  The chemotherapies must continue despite the fever.  More steroids and rituximab and that was uneventful.  Saturday came and went and my dad actually felt good.  Good enough to actually eat.  Good enough to actually be able to watch TV.  Yes, even watching TV is a chore during this process.  It's probably a good benchmark to know how difficult something is if watching TV becomes too onerous and difficult.  His blood counts continued to look good which meant the engraftment was likely happening.  Usually it's around day 10.  Saturday was day 9.  Sunday was day 10.  There was talk of an early discharge if this kept up.
     But on Sunday, my dad spiked another fever back up to 103.  More steroids and tylenol.  Rash, too.  Only this one hurts.  And again, it gets nebulous.  Is it infection?  Is it drug reaction?  Is it graft-versus-host?  All of the above to some extent?  We'll probably never know definitively.  That's the art of medicine.  You treat empirically on your best guess based on experience and hunches about the patient.  Reassess and readjust the gameplan accordingly.  One thing is certain, though.  Any talk of him being discharged tomorrow is certainly out of the question.