Past Medical History

This morning I did an initial History and Physical on a patient who was new to my preceptor's practice. Before I went in to meet him, I learned his chief complaint (rash), and his name: Wilbur. Funny, I remarked to my preceptor. That's a pretty old-fashioned name.

When I walked into the room, I was greeted by a sandy-haired balding gentleman in a crisp white shirt, khakis, and boots. He was wearing too much cologne, which portended sleaziness, but his manner was respectful, professional. We talked about his rash for some time. It had been around for about 5 days, he was developing new spots every day, and they were slightly painful. I think it might be shingles, he said, Or Ramsay-Hunt Syndrome. Usually, patients with shingles complain of terrible pain, I told him. Have you been taking any medication for the pain? No, he said. I've dealt with a lot of really bad pain before, took extra strength Vicodin (Vikodayn, with his Texan accent) for a long time, and now I'm off all that stuff. My eyebrows raised at this hint of a significant medical history. Yeah, he said, I was taking morphine IV and everything, because of a plane crash I was in, but I'm getting off topic. Yes, I told him. We'll get to all that later.

A few questions later, we arrived at the Past Medical History, that fateful part of the initial H&P. Finally, he could tell me what had happened. It was a plane crash, he said, in the mid '90s. Right femur broken. Right arm nearly amputated. Right ulna lost proximally, right radius lost distally. Both shoulders dislocated, sticking out "right here," he told me, indicating his mid-clavicular region bilaterally. He was in the hospital for months, out of work for over a year, underwent 27 surgeries in that time and many more for the reflex sympathetic pain syndrome he developed as a result. He underwent intensive psychiatric therapy and rehabilitation to wean himself off of the megadoses of narcotics required to manage his neuropathic pain. Nearly twenty years later, he was fully functional, working and traveling without any hitches.

The most remarkable thing in all of this was that I never would have guessed at this incredibly traumatic history until he rolled back his shirtsleeves. The scars on his right hand were barely visible, and the hand was stupendously functional, considering the trauma it had undergone. The man sitting before me was shockingly unscathed, at least outwardly.

The interview over, I examined his rash, listened to his heart and lungs, and felt his distal pulses (To my surprise, the right radial pulse was intact). Then I smiled at him and said I'd be back soon with my preceptor.

In the hallway, I gave her a quick rundown of his rash and his storied medical history. A plane crash? she asked. Wow.

When we re-entered the room, after some cursory questions about the rash, she asked what I hadn't: So tell us about this crash. You've gotta tell us the whole story.

It's a long story, he started. (And long it was; we probably ended up listening to him for 30 or so minutes; at one point, his wife called the receptionist and asked why his appointment was taking so long.) Little by little, the details came out. A private plane, a complete engine failure right after take-off. 78 seconds from take-off to hitting the ground again in a terrifying crash. The other passenger 76 years old, hurt, but not as badly as our patient. Our patient lost a lot of blood. His blood pressure was 40 over nothing, a first responder said. Our patient, declared dead on the scene. Our patient viewing the entire scene from above, in an out of body experience.

And there were three people there, he went on. I remember them so vividly, but I couldn't possibly tell you if they were male or female. I just know they were there. One placed my head in their lap, another held up my feet, and a third held my left hand and fed me some cool water. Later, I saw those three people move the other crash victim's gurney into the life flight helicopter.

Once he arrived at the hospital, my patient remembers being wheeled down a cavernous hallway, with a white sheet covering him. He saw fluorescent lights and ceiling tiles flash past as his gurney progressed, until finally he passed through a set of double doors large enough for all of humanity to enter at the same time. On the other side, he saw his wife in her wedding dress, his kids in their Easter clothes, and his father in his coveralls lined up along the right wall. As he began sitting up to speak to his family, my patient felt a hand on his left shoulder, pushing him back down. A voice said, "Lie back down. There will be time to talk to them later."

Next thing my patient knows, he sits straight up in his hospital bed, lines and tubes coming out of many natural and artificial orifices. "Holy shit, God's hand was just on me," he says. From her chair to his left, his mother turned to him and said, "There you are, son. I was wondering when you'd come back."

In bits and pieces, my patient learns that he's been unconscious for days. The doctors and his family had no idea if he would regain consciousness, no idea if he would be the same man he was before. But he has and he is. Over the next year, our patient is "put back together" by a brilliant surgeon who gave him back full function of his right arm, hand, and leg. He suffers from reflex pain syndrome, taking megadoses of Vicodin and other opioids, just trying to stave off the pain. Eventually, he undergoes intensive inpatient rehab and gets off the narcotics for good. Years pass, and now he sits before us, mildly distressed by shingles.

By this time, over half an hour has passed, and my preceptor and I have exchanged many a quick glance communicating anxiety over the increasing length of this patient encounter. There are other patients out there waiting for us. But our patient says, "I'll just tell you one more thing, and then I'll finish the story, even though there's much more to it," and we say all right. He needs to tell this to us.

A couple years ago, our patient entered a local grocery store in search of a squeegee for his shower. "I know, you're wondering where I'm going with this," he assured us as our eyebrows raised skeptically. "But don't worry." After searching the store himself with no luck, our patient asked a little old man working at the store if he could help him find the squeegees. Why sure, the little old man said. But, he said, glancing at our patient's scarred right arm, what happened to that arm there? A plane crash, our patient said stoically. I bet that's a good story, the little old man said gamely. Why don't you tell me about it while we walk? And so our patient related the whole tale to this perfect stranger. By the time they reached the squeegee aisle, the tale was nearing its end. The little old man cleared some space on a low shelf, and they sat together while our patient told the part that bugs him the most. "Whenever people hear this story, they look at me (and here, he squinted his eyes in a way that said goshdarnit I'm sure of it) and say, God saved you for a reason. You have a purpose in this life. But that's the whole problem. I don't know what my purpose is. Here I am over 10 years later and I still don't know what I'm supposed to be doing. God never told me what He wanted me to do," our patient bemoaned. The little old man put his hand on the patient's shoulder, said "Yes I did, son," and walked off.

Here our patient choked up for the first time, and my preceptor and I exchanged a look altogether different from the ones before. This was a special moment, a moment neither of us was likely to forget. Moments like these remind me how lucky I am to be in the medical field. Being a physician means being let in on the most intimate details of strangers' lives. People trust you immediately, and tell you things they don't tell others, even those they love and know well. It's a position of immense power, and one that keeps me in touch with my own humanity. For this I am grateful.

The Help

I finished reading The Help recently. I watched the movie very shortly after it came out some time last year, and I found it (of course) really inspirational and moving. The courage displayed by Skeeter made me think about the lack of courage I've seemed to show for a while now. Anyway, I marked down a few of my favorite passages from the book. They're not the very best writing in the world or anything, but they were the most relatable passages to me:

"...I'll never be able to tell Mother I want to be a writer. She'll only turn it into yet another thing that separates me from the married girls....And now she's gripping the rail, waiting to see if I'll do what fat Fanny Peatrow did to save herself. My own mother is looking at me as if I completely baffle her mind with my looks, my height, my hair."
"'It's all about putting yourself in a man-meeting situation where you can--'
'Mama,' I say, just wanting to end this conversation, 'would it really be so terrible if I never met a husband?'
Mother clutches her bare arms as if made cold by the thought. 'Don't. Don't say that, Eugenia.'"
"I shudder with the same left-behind feeling I've had since I graduated from college, three months ago. I've been dropped of in a place I do not belong anymore."

"I flick on the radio, desperate for noise to fill my ears. 'It's My Party' is playing and I search for something else. I'm starting to hate the whiny teenage songs about love and nothing. In a moment of aligned wavelengths, I pick up Memphis WKPO and out comes a man's voice, drunk-sounding, singing fast and bluesy. At a dead end street, I ease into the Tote-Sum store parking lot and listen to the song. It is better than anything I've ever heard.

...you'll sink like a stone

For the times they are a-changin'.

A voice in a can tells me his name is Bob Dylan, but as the next song starts, the signal fades. I lean back in my seat, stare out at the dark windows of the store. I feel a rush of inexplicable relief. I feel like I've just heard something from the future."

Writing about the truth takes a lot of strength. It involves going out on a limb and not knowing what life will meet you on the other side of that publication. But Skeeter Phelan, fictional character though she is, was willing to take that risk. The courage of that takes my breath away, and makes me wonder what risks I'm willing to take in order to write the truth.

Shooting Stars and Flowers Coming My Way

At the beginning of September, I moved out of my apartment and home to live with my parents because there was mold growing on a bunch of my clothing in my apartment, and that mold made my lips swell and gave me hives and sent me to an emergency room.
About six weeks later, someone decided it would be fun to vandalize [albeit mildly] my car, and I spent a considerable amount of time and energy and a small (though not negligible) chunk of change buying a new mirror for my car and getting it fixed.
Then last week, I see that I've gotten at least one, and maybe two, incredibly harsh evaluations from people I worked with on my Pediatrics rotation, the rotation in which I worked harder than ever before, yet got a few evaluation scores lower than I'd ever received before.
And today, I hear that it's a very real possibility that someone got ahold of my social security number, somehow, and is actively using it to commit, you know, tax fraud.
The world is doing a GREAT job of sending shooting stars and flowers in my direction. If President Obama does not win the election tomorrow, I may be forced to give up on everything. I cannot catch a break.

The Importance of Being Nurtured

The patient I'm taking care of right now in the Neonatal ICU is 3 months old. She was born at 33 weeks' gestation (normal is 40), along with a twin brother. Her brother has been home with their parents for some time now, but this poor little baby has had to stay in the hospital for innumerable problems, including, but not limited to, a hear that is very messed up indeed.
Now, I've only been seeing this patient for a little over a week now, but in all the time I've been at the NICU, I've never once seen her family at the bedside. This poor little 3-month-old lies on her back day in and day out, largely unstimulated by human contact the way normal babies are. By 3 months old, babies are social smiling, interacting with those around her, and starting to learn who her parents are by face. A lot of the kids who spend many of their first months in the NICU meet these important milestones much later than their healthier peers, simply because they don't receive the normal social stimulation that we all take for granted. This baby was going along the path of many NICU babies before her, and gaining her milestones very, very slowly.
So you can imagine my initial confusion, then subsequent delight, when I realized that, as I examined this baby girl this morning, the strange facial expressions she was making were her way of trying to smile! It was absolutely precious, and I swear as soon as she first took that step, it's as if a switch was flipped, and the baby became much more interactive with everyone who came by her. Seeing that little baby try to smile was probably the best part of my day.

Undergraduate Failings

I'll let you in on a little secret: I'm not really cut out to be a good college student, in all her stereotypical glory. I only just realized this sobering truth in its entirety this weekend, during the Centennial celebration for my lovely alma mater.
In the days leading up to the start of the Centennial festivities, I had whipped myself up into a reminiscent frenzy, thinking back fondly on sun-dappled courtyards and classes full of critical thinking and writing and reading; adrenaline-fueled days and nights of dance practices, performances, and midterms, with little time for sleep or food, but plenty of coffee; and the general freedom to pursue learning in its various manifestations that college affords us. I imagined myself descending upon my college campus (which, I should probably add, lives right across the street from my medical school campus) in a triumphant return, mingling with friends from various circles, both academic and social, and shedding all remnants of the social awkwardness that plagued me through much of my freshman year. It would be wonderful, I thought, and was exactly what I needed after a long seven weeks fraught with frustration and heartache, with small happinesses sprinkled throughout. Take me back to where my young adult self first began, I thought, and my heart and life will flourish once more, invigorated by the tree-filled vistas of college.
Here's what actually happened: I rather enjoyed a talk by a prominent genetics researcher, due partly, I'm sure, to the fact that I was able to sit alone in a large venue for the talk. I tried to ask a question about gene therapy at the end of the talk, but the question period ended before I found my way to the mic. However, the question period did include a woman asking an inscrutable question about seahorses and platypuses (surely the plural of that should be platypi?), and another woman inanely telling the speaker that his IQ must be "as high as a hot summer day in Texas," which was mildly infuriating because, well, a hot day in Texas is slightly above 100 degrees F, and an IQ of 100 indicates average intelligence.
I went to Alumni Pub Night the following evening, again anticipating self-assuredness and effortless mingling, a cool beer in my hand throughout. I spent the evening chatting with friends who all still live in the same city where we went to college, and I drank a very sweet cider which, at first sip, I wasn't sure was alcoholic. (It was, I later discovered.) I stood about awkwardly silent at times, unable to muster up the social energy to shout over the loud music just to have small talk with people I see all the time anyway. I saw almost no one I had been friends with in college, but had since lost touch with. I did, of course, see people who had never been my friends in college. I was also mildly alarmed at the number of men there shooting close-lipped smiles at any women who happened to glance their way. One of them asked my Taiwanese friend if she was from Korea as I stood by acting nonchalantly deaf. I feigned my disinterest so well that the next time I looked around, she had slipped away from the entire scene, leaving me frighteningly within range of Mr. Smiley's advances. I retreated post-haste. The night passed by in a vaguely-bored blur, and I woke up the next morning utterly exhausted from having only 5 hours of sleep the night before.
My next, and last, attempt at partaking in the Centennial festivities also fell flat. I headed over to one of the dorm common areas as the sun was beginning to set on Saturday evening, excited to participate in a reunion with both alumni and current students involved in South Asian Society, my extracurricular of choice when I was in college. Of course, I was the second person there, and the other girl there and I sat around coloring (the activity was intended for children of alumni who were on campus for the weekend) for about a half hour before anyone else showed up. In the mean time, we ended up talking to the wife of an alumnus, a dentist, who was spectacularly rude enough (at least in my opinion) to tell me that she thought the idea of being a specialist in pediatric genetics was "depressing," and that being a doctor was "a hard life." Thank you very much, woman with whom I have no connection. I am aware that the life ahead of me isn't going to be easy as pie. I appreciate your words of wisdom. Eventually, other alumni from our club trickled in, and we enjoyed some catch-up conversation before everyone else headed off to the glitzy "Finale" event, held in one of those amazing tents, complete with open bar and tons of free food. I hadn't bought a ticket to the Finale since I had  originally planned to attend the football game earlier in the day, and I wanted to give myself plenty of time to study for my exam coming up on Friday. Sadly, I decided right before the game to skip the game and study in the afternoon instead, and by then it was too late to buy tickets to the Finale. I had originally told myself that I would study on the idyllic campus of my daydreams for a couple hours before watching the light show that was to take place on the Academic Quad later in the evening while my peers were at the Finale, but after watching my friends walk off in their nice clothing, I just felt too defeated by the whole affair to stay around, and instead I bought Taco Bell and went back "home" to watch television online with my Dog-in-Law. I later heard that the light show was was downright breathtaking, but I couldn't bring myself to drive all the way back to campus for the later showings. I just gave up the whole night, and, indeed, the whole Centennial affair, as a bust.
I've realized, as I hinted earlier, that I don't naturally function very well in prototypical "college" situations. I don't like shouting over loud music at bars. I hate talking to random guys at bars. I'm not very good at mingling. I am, at heart, an introvert, and when I'm in big social situations, it helps me tremendously to have one person, be it a significant other or close friend, to cleave to throughout the event. I have a couple people in my life who have played such a role for me in the past, but I don't feel like I've had a huge group of friends who make my heart swell with emotion because they so wholly represent college to me. Actually, I should amend that: I can call to mind a few situations and friend groups who do indeed make me feel that way, but I don't feel like I am able to recall the emotion when placed back in the same friend groups or situations. All of that just seems lost to me. Is it like that for most people? Am I the odd one out? I really just don't have a clue. All I know is, I'm fairly certain I like the idea of college far more than the reality of it.

No, I am not a nurse.

There's a set of parents whose very young infant is cared for by the NICU team I'm on. Now, I'm sure it's very difficult to have your firstborn child be born prematurely, and end up staying in the hospital for months, literally. However, I've gathered from my team that these parents have been exceedingly "difficult."
A number of incidents have occurred between my team and this particular family, including the family yelling at my residents in public, "firing" them for not doing a good job, and many other similar things. I have to say, though, that in my short interaction with this family so far, the one thing that bothers me the most is the fact that they address my residents, both of them, by their first names. It simply drives me up a wall, and I can tell it bothers my residents, both of whom are female, too.
I heard from many female medical students, before I started clinics, that I would more than likely be called "nurse" by many, many patients during my time in the hospitals. Luckily for me, I've actually rarely been addressed that way. Maybe I have some sort of aura that projects medical student-ness. Or perhaps I'm just not that much of a hottie, and let's be real--there's something distinctly "hot" about female nurses compared to many female medical students. Whatever the reason, I'm pretty glad for it. It's annoying enough when, as a brown-skinned person, you have veteran patients assuming you're Arab and apologizing to you whenever they speak ill of people from the Middle East. (For the record, I'm not at all bothered at being mistaken for a Middle Eastern person. I'm just miffed at the sheer ignorance of it all. For anyone who paid a modicum of attention, my name would probably strike him/her as distinctly Hindu.)
You know, call me an intellectual elitist if you want (cause, well, let's be real--I am one), but when I finally get my MD, I'll be damned if my patients address me as anything other than Dr. Spinenvy. By the time I'm a resident, I will have worked my tail off and gone through 21 years of schooling to earn the title of Doctor, and I'll sure as heck be working harder than ever before during residency. I think that at least some deference should be paid for that sort of hard work and commitment, and at least some of that deference takes the form of using the correct title to address doctors. Perhaps more importantly, when your patients do not address you as doctor, you have to wonder how, exactly, they perceive you. Doctors are, generally, respected, and believed to be knowledgeable experts in the field of medical care. If your patients call you "Angel" instead of "Dr. Spinenvy," then do they simply view you as an ineffectual girl? And if they do view you as such, then surely your recommendations and words don't carry the weight they rightly should, as recommendations coming from an MD.
I also have to say that I get extra riled up about all this stuff because there's still a large portion of society that automatically affords less respect to women than to men. Again, I've heard from plenty of female medical students (and residents) that they're referred to as nurse, even as they're wearing their white coats and making treatment plans for their patients, while their male counterparts are called doctor. It's frustrating that, outside of some circles, I'm met with confusion when I tell people I'm in medical school -- "So, you're going to be a nurse, or what?"
No. I'm not going to be a nurse. I'm going to be a doctor. Please call me that.

Disclaimer: I've met a great deal of awesome nurses, and I have to say that they have a type of strength and intelligence that I lack. I could never do the work of a nurse. I just want my patients to address me with my proper title once I've earned it, and I don't want to be relegated to the appellation, "Ms. Angel" simply because I'm female, while my male counterparts get to be called Doctor. That is unfair.

The n00b Files - Week 6 of Pediatrics

I'm almost done with my pediatrics rotation, and I'm delighted to report that I continue to enjoy it. I'm on my second week of inpatient pediatrics, and so far, the experience has been good. More lessons learned:

1. My dad was right all those years ago. I should have learned Spanish. It would help so much with my patients. It's not so bad when you can get a live translator to stand in the room with you and help you communicate with the patient, but using one of those translators via phone almost completely eliminates important, human interactions like eye contact. It's not easy to show a mother that you're just as concerned about her child as she is, when you're both staring down at a speakerphone and speaking into it.
2. It's a good sign when your attending says that every day, rounds will begin with a cute photo of the day.
3. If you ever hear doctors talking about something that sounds like "go lightly," you can bet they're not discussing an Audrey Hepburn movie. 
4. I eat way fewer vegetables and fruits, on a daily basis, than I should. I mostly fill up my stomach and my day with carbohydrates, which are delicious, but empty, calories. This failing was brought into sharp relief for me recently, because I had been spending a lot of time during my community pediatrics rotation encouraging overweight children to have 5 servings of fruits and vegetables daily. It's nice that my "job" helps me reflect on my lifestyle and health.
5. I really, really like working in a community clinic.
6. Conversely, I'm really not that wild about the inpatient setting. 
7. Having an attending who empowers you, as the medical student, to call consults, assist in patient education prior to discharge, and generally do much of the work of residents, is a good thing, even if it means more work. As my new, awesome attending pointed out, if we spend all of medical school carrying no more than 2 patients at once, we'll be completely out of our element when, as interns, we'll be expected to carry close to 10 at any given time. Working hard in medical school kind of sucks, but it's good practice for when your decisions really mean something, after that arbitrary moment of graduation.
8. Life flies by. I just went to an information session about scheduling my last 18 months of medical school. It was both terrifying and incredibly exciting.
9. It's a wonderful thing when you're doing something that makes you happy, especially when you're going through a rough patch in life. I'm so grateful I'm on Pediatrics right now, and that I'm loving it.