That Entry

Hello world.
I'm back.

This is the requisite, "I'm back" entry. The entry where I apologize for being so MIA and thank my readers profusely for sticking with me. The time in a blog where I explain that I was busy and then busier, and then just exhausted and taking a break from everything that involved anything, and then I got caught up in some stupid, stupid, stupid, poorly written books about stupid teenage vampires. And then when I finally had time to write/realized how stupid the vampire books were (and continue to be), I was a little unsure about how exactly to get back on the proverbial horse. But then it dawned on me: Just write an entry about how you are going to start writing, about how you are sorry that you have been gone, but that you are back again.

And so that's what I'm doing.

Also required in this sort of come back is a brief update of what I have been doing for the last several months. . . it should be a sentence, no more.

Since November, I finished medicine, went to California, came back to Alaska, started and completed my pediatric rotation (right now, I am about 95% pediatrician, 5% family medicine doc - more on that dilemma later), went backcountry skiing, got new skis and bindings, went backcountry skiing again on my AMAZING new skis and bindings (thanks Luc and Tarby), broke some pipes in my apartment, saw Josh Ritter (love the boy), went out dancing a few times, have generally been enjoying myself despite the fact that I continue to have agonizing dilemmas about what I am doing with my next year/life, and am welcoming back the sun. Speaking of the sun - damn, it's nice to have it back. Speaking of the weather - it's been all over the place. No global warming up here, Sarah Palin says so.

And last requirement of this entry (self-imposed) is a tantalizing teaser of things to come:
I'm on psych now, working at the state lock-down psych facility, need I say more? My goal (if you put goals up in public, you are more likely to hold yourself to them) is to write at least weekly.

So to recap:
I'm sorry I've been gone for so long, I did some shit, fat skis rock, there are some crazy folks in the world, most importantly, thank you for your patience, encouragement, and continued attention, and I'm back.

Certainty

Another one of those cases where being wrong rocks.
Yesterday afternoon, I overheard the doctor who had showed me the man with the Nec Fasc talking.

Apparently he was still alive (as of yesterday)and had actually regained his sight (he was blind prior to yesterday).

This may be the uplift before he dies, but it was not predicted, so maybe it means he will live. Maybe he didn't have true Nec Fasc and so the antibiotics we gave him actually worked.

All in all, a much more uplifting Thanksgiving story than yesterday's.

I guess nothing is ever certain, even when we are sure it is.

Necrotizing Fasciitis

I saw a man with necrotizing fasciitis today.* This is a medical student's dream; the grand hoo haw of infectious diseases. Nec Fasc is not something that you come across every day. It's the joy of being a med student that every practicing doctor wants to show you this crazy thing they just found. They haven't seen anything like it in all their years of practicing, and there you are, lucky enough to be a student and the receptical of all things educational. Our job is to be enthralled, inquisitive, and to validate their excitement. We reassure them that this is fascinating, we confirm that this is important, and perhaps our learning injects some hope into what might otherwise be merely a tragic incident; a sad waste. But that might be vanity speaking.

So back to this man I saw today. I got chills tonight, a momentary tear in my eye when I thought about what I had actually seen. It was not just necrotizing fasciitis. It was not just an infection superimposed on an already feeble, ill man. It was this man's death that I saw. The way that his life will end laid out on his body like tarot cards predicting the future. By the time he was diagnosed, 8 hours after admission, the flesh-eating bacteria had attacked too much of his already crippled body. Down one leg, up his back, weaving it's way down his other leg. Like a wave in slow motion, yet so fast, too fast for his body, for our medicine. There was nothing to be done except treat him for pain, treat him with antibiotics for palliative care, and help him die. And that's what grabbed me tonight. I saw this man for, at the most, 5 minutes, but he made an impact on me and not just because I had never seen necrotizing fasciitis before. He's the first person I have had contact with in the hospital who I know is going to die in the next several hours. And what's more, I know what he will die from. In my brief time in the guts of the clinical world, I have met many patients who I know are not long for this world. I know that we are merely postponing their death, but I do not know which one of their 10 problems will finally claim them. So even though we know they will die soon, we are ignorant about what they will die from, and the patient and the doctor(s) are gifted the freedom of continuing on in the charade, blissfully naive to the ending. Seeing this patient was like watching Hamlet after having already seen it. There is nothing to do but simply wait for the ending that you know by heart. You want to run up and console Ophelia before she drowns herself. You want to pull the poisoned glass from Gertrude's lips before she drinks. You want to reconcile Hamlet and Laertes before they stab each other. But you can't, because the show must go on (or so they say), and the ending always comes, and it always comes in the same way.

And so I know that tonight, at 10:45, the infection has now completely consumed both of his legs. It has moved onto his upper body. I am almost certain that he has finally developed sepsis and possibly fallen into unconsciousness. It is quite likely that, at this hour, roughly 24 hours after coming to the emergency room, he has succumbed to the ultimate, irreversible outcome of such tissue destruction.



*Necortizing fasciitis is one of those things that really scares me - both from a doctoring stand point and from a patient stand point. In other words, it's something I'm worried I'm going to miss in a patient and something I'm petrified that I am going to acquire. It's also something that fascinates me. I get the same chills up my spine, the same obsession/revulsion feeling about it as I do about deadly snakes and sororities.

Alaska

This week, I saw a man in his 70's. He was wearing a thick flannel shirt, suspenders, and a trucker's hat. First question out of his mouth was "Who did you vote for? I voted for McCain." He's a retired bear hunting guide and taxidermist, but he still likes to guide for 30 day scientific expeditions through the Yukon, in the winter (yes folks, I did say he is 70). He also swears that fried chicken gizzards are just about the most delicious thing he's ever had.

Amazing.

I Love Tuesdays

One week later and I am still in shock. Like everyone else who blogs, I feel the need to put something down to mark such an historic, nation changing, nation shaping event and I figure that within 1 week, it still counts as current. I sent a text message to pretty much everyone in my phone (except for my die hard conservative friends). Below are all of the texts I received about the election over a 30 hr period, including the responses to my text. I heard back from people I hadn’t talked to in years, highlighting for me how enormous the collective sense of relief, freedom, and change was. My text was sent at 19:15, it is italicized

(And a side note: Tuesday is apparently going to be the most superior day of the week this year. .last week was the end of stupid-people-in-charge era, and today it’s dumping in Alaska. . .did I mention I’m back in AK these days.? . happy like a clam).

5:48: I’m at the polls right now-very exciting.

18:04 Looking good

19:15 Congrats! Woo! This is the best day in eight years.

19:17: Yay!

20:21: Owwwwwwww!

20:26: !!!!!!!!!!!!!!!!!!:)!!!!!!!!!!!!!!!

20:29: Amazing night! We can be prove americans again!

20:34: Maybe 30 years. Halle-flippin-lujah!

20:34: Absolutely!

20:38: Indeed it is.

20:39: I finally love america :) When can we get together?

20:40: Drinking and cheering

20:40: Historical moment my friends! Obama!

20:41: Fuck yay

20:42: Yes yes. ** says he has been depressed for 8 years. Just ichatted with – Log what a speech

20:45: Fuck yeah!! 221 years in the making.

20:45: Cap hill we’re all cbheering and crying and just f*ing ecstatic

20:45: Yes congrats to us all. It’s a great new day in this country.

20:47: No kidding!!!! It’s fucking AWESOME! Awesome speech too

20:48: Fucking amazing

20:49: Yay! Coming to the comet tomorrow?

20:49: Wooohoo! I have chills! That speech was incredible!

20:50: Indeed

20:50: Totally! So excited!

20:52: Hell yeah

20:53: People at literally dancing in the streets here in NYC.

20:56: oh hells yes. We’re in DC right now… total mayhem… like effin carnival… it’s beautiful… love.

20:57: Indeed! Bravo! Hurray! Watershed moment ;-D

20:57: woo hoo is right. What a great feeling! I still have goosebumps from his speech too!

21:01: Epic! So proud. Miss you!

21:03: Fosho… How u been?

21:09: Yeah!!! Um, who is this?

21:11: Not sure who this is but I agree!

21:14: Oh nice to hear from you. And thank goodness we won! I cried.

21:14: Yeah! I feel so good the election is over and obama won

21:15: Yay!!!!!!!!!!!!!!

21:17: Ppl lighting fireworks in Berkeley streets

21:20: so youre alive

21:22: Let’s see what happens on prop 8 before we get too excited, but yes, I am happy so far!

21:24: Gregoire!!!!!!! Obama!!!! Happiest moment of my life :-D
F Yeah America!

21:39: We did it! Democracy worked. We are a better nation today. I’m so damn excited

22:28: Why? What happened?

Wednesday, November 8, 2008

3:40: Yipeeeee!

6:01: Amen to that!

11:33: Who the hell is this

11:34: Hey my phone got messed up, who’s number is this?

11:37: Aw Jessie I miss you and I still cannot contain my happiness today. I wish we could celebrate together!

Teaser

I am nearing the end of this whirlwind tour through academic medicine. I have had the impulse to blog, flashes of thoughts I wanted to put into written form, but my desire to reflect is weak compared to my imperative need for sleep. And so this page has remained silent for almost 6 weeks. Which is funny, because I feel brim full of epiphanies had and stories witnessed. So as I wind down my time here and transition back into the slower world of winter in Alaska, I am hoping that my memory will hold and I will have time to sort through the jumble of emotions and thoughts brought on by my last 6 weeks.

For now, this:

Frequently I look at those of us who are training to be doctors, and those of us who are residents, and those of us who are attendings and I think, dear god, we are just children play acting. There are young children, like myself, who mimic and there are older children, like the attendings, who decide which games we will play, but we are all nothing more than children in a big, scary, chaotic world. We have information gleaned from good and bad studies that we use to make decisions, we have the experience of the way similar situations have gone in the past, we have a stethoscope, we have MRIs, and we have blood tests, but these are weak defenses against the uncertainty that fills the spaces created by the heterogeneity of patients. There is, over our shoulders, a constant question of uncertainty. Sometimes it looms large, sometimes it squeaks small. The latter are days of success, I think. This uncertainty is not what I find disconcerting. It is expected, it is why medicine is referred to as an art rather than a science. It is why so many of us are drawn to the field.

What I find disconcerting are the ways that we try and manage the uncertainty. There is the ridiculous paperwork that tries to minimize unnecessary uncertainty. Perhaps our best response to it is the collaboration that is the foundation of doctoring. And our worst, the one that would keep me up at night if anything could keep me up at night these days, is our collective approach to each patient as a game, a puzzle to be solved, a mystery to explore, a lesson to be learned.

I think of the pre-code we were called to several days ago on a post-call morning. In front of us was an unconscious, large middle aged man. His pillow was red from the blood drooling from his mouth. He grunted to pain, when we pulled his eyelids open, we could watch his eyes rove back and forth in a rhythmic pattern. One side to the other, one side to the other. His vitals were stable, his blood gases normal, nothing to indicate what was going on. And the three, maybe four of us in white coats stood at the foot of the bed nonchalantly discussing his case.

R3: What do you think is going on?
Other R3: I have no idea. . . maybe a seizure?
R3: Yeah, that's a good guess. Probably is what it is. I mean, it doesn't look exactly like a seizure, but, what else could it be?
Other R3: Yeah, I mean, his vitals are stable, ABG was good n' normal, normal sugars. . a seizure could look like this, I think.
R3: So should we give him some ativan?
Other R3: Maybe. Did you call Neuro (to the intern)
Intern: Yes. Couldn't get ahold of them.
R3: Hmm. . I guess we could just give him the ativan, it's not going to hurt him, right?
Other R3: I don't think so. Seems like it's something to do.
Silence
Nurse: So do you want me to go get the ativan?
R3: Yes, I guess. . I mean. . I think so. Yeah, sure.

And so on. . eventually no ativan was given, and we all backed away from the patient as his primary care team arrived. He was still seizing, or doing whatever he was doing. I was struck by how we stood at his bedside, fascinated by what he was doing, without any urgency to fix it. I felt like we were children – our white coats fit too large, our stethoscopes looked awkward. Our feet shuffled. .how can we make this more fun again?

Sound advice. . .

. . that I overheard the other day went something like this:

"Just remember, you never know when you are going to have your last first kiss."

Priests and Layfolk

I can’t believe I am actually saying this, but it may be that the thing that I find unsettling about family medicine is the emphasis placed on patient centered care and preventative medicine. It’s not that I don’t believe in those things, I absolutely do. The only way we as a population can become healthier is by preventing ourselves from doing those things that make us unhealthy. And of course, the patient should always be at the center of health care.

The problem with preventative medicine in its current incarnation is that we have made basic common sense seem like something you need an MD to understand. Preventative medicine is not rocket science: don’t smoke, don’t drink too much, eat fresh stuff, exercise, don’t get too fat, don’t get too stressed. It is possible that by naming these topics medical we have actually done a disservice to our patients. Once something is medical, it is seen as inaccessible to anyone other than a health professional. Practitioners have become the priests required to access common sense; we are the intermediaries between laypeople and their own health.

Along those lines, with patient centered care, the patient is always right and every concern they have is equally valid and important. Of course a patient’s worries should be addressed, but I’m not sure it’s to their benefit to come in for every 2-second pain or unusual sensation they experience. This is linked to the sequestration of common sense to the medical elite. People don’t trust themselves anymore. They have no connection to their bodies and so they doubt every feeling they have. Normal body processes are now seen as death knells. The medical field reinforces this ignorance of self by giving a visit to every preoccupation. And we validate every anxiety by solving it with medical advice. Instead of saying. “well, sometimes that just happens,” we prescribe opiates or anti-anxiety medicine. And our latest trend response to non-issues issues? Yup, you guessed it. . preventative medicine, which means that people only do preventative medicine when they are told to as a curative measure (and is that really preventative anymore??). (And on a side note, of course there are forms of preventative care that should never be abandoned - cervical cancer screening, for example).

I'm not 100% sure if I agree what I wrote above. Since I believe in holistic medicine and I believe in treating the entire person rather than the illness, there is something to be said for being able to prescribe things like "eat better," and "exercise," and "meditation." And I never want the medical pendulum to swing back in the direction where doctors are patriarchal figures - telling their patients what is best without any input from the patients. That said, I do think that we these 2 concepts aren't sitting quite right. There is work to be done there, because I'm not sure that, at this point, we are doing the best by our patients.

28

I’ve been neglectful lately. Somewhat willfully, since I have been gifted late mornings and a job that I leave behind when I go home. But somehow I have not had the drive to write. And I have suffered for it, I think. Like exercise or yoga, reflection is one of those activities that makes us feel so good that they are the first thing to go when we get anxious or restless.

So I am nearing the end of my 2nd rotation. Family Medicine. Experiences continue to occur, although I feel less engaged by them this 6 weeks around. I’m not sure if it’s the place I’m learning or the field itself, but I certainly don’t feel the light me up sort of passion I felt during my OB/GYN rotation. That may not be a bad thing. In fact, if my goal is to wind up living a balanced life where medicine is a job rather than a lifestyle, family medicine is the simplest answer. For sure it is lackluster, but I like to think that it would inspire me to seek passion elsewhere. That said I have some concern that dullness is catching – leaving me with an overall subdued existence. The dying adolescent in me shudders at the thought of such complacency (the horror, oh the horror). Of course I also am worried that an uninspired medical career would swing the pendulum in some warped direction where I forget to fill my time with things like outdoors, music, food, art, politics, thought, people, etc, etc. Instead, in search of more intensity, I would resort to old habits of poking at my relationships till I create some purposeless drama and find myself in a familiar mess I had sworn off years ago. Luckily no decisions have to be made yet. This year is just for observation and information gathering.

In truth, the last 4 weeks have brought out strong examples of both responses. Instead of writing and reading and playing and exercising, I have slept and complained, and (oh the shame of admitting this) watched T.V. And when I wasn’t doing that, I was regressing to my late teens and foolishly getting caught up in ridiculous drama. I behaved poorly towards others and towards myself and almost cost myself a friendship or two (the outcome may still be uncertain). Suddenly old tapes were playing and I lost the clarifying breath of perspective; I became a person I like to think I no longer am, but obviously still have the capability of becoming. I suppose we are never rid of our lessons learned.

But on the eve of the start of my 28th year, I figure I get to clear a slate. Birthdays, like New Years, are good times to kick start the drive to grow and improve. Resolutions (that will always be broken, and set again) abound. As Emily would say, it’s probably a good time to build that bridge (yet again) and get over it (thanks lady).

Well, sentimentality is getting the best of me, but it’s almost my birthday, so I can give in to it tonight. I just want to say thank you to all the folks in my life (those who read this and those who don’t). I am damn lucky to know such incredible people. When I look around, I see crazy beauty and passionate commitment and so much laughter. It’s a good reminder to breathe and live it up, all purty like.

I love y’all.

Well Said

Exactly that. . . well said
You can sign it too (scroll down to the very bottom).

Part 4: Economic Down-Turn

This is Part 4 of a 4 Part Entry. . you might want to scroll down to Part 1 - Sometimes Dreams Do Come True.
**
Other highlights included an incredibly athletic, very tall black stripper who was so flexible (like pretzel flexible) that I’m pretty sure she had some cartilage disorder. At one point she was doing the splits and then put her arms under her legs and lifted her entire body off of the floor and proceeded to do multiple push-ups. It was like Olympic gymnast quality. I was floored. I went up to the dance floor and gave her money, but I made someone go with me.

A highly informative chance encounter with a different stripper in the bathroom revealed that stripping has lost some of its stigma and has seen an increase in the number of women coming to strip bars. According to her women in strip clubs are a mixed bag because, while they do buy dances, they usually only buy one and they often make the 40 y/o virgin males (“who still live with their moms. . .can you believe that?”) uncomfortable and shy. Just like Sexy Lexi, she loves her job, although she is disappointed by the recent decrease in her earnings which she suspects is due to the economic down-turn and high price of gas.

Very rarely, illusions do (more or less) turn out to be the reality. I am still completely overwhelmed by the amazingness of last night. Really, all that was missing was a pole.

Part 3: The Wisdom of our Elders

This is Part 3 of a 4 Part Entry. . you might want to scroll down to Part 1 - Sometimes Dreams Do Come True.
**
When the waitress came over to take our drinks, Sexy Lexi told her my plan. The overweight, older waitress became very concerned that I was serious and said, “Honey, do not drop out of medical school to become a stripper. I mean, you could do it, and maybe do it to pay for school, but don’t drop out of school. It may look glamorous, but it gets old fast. You only have a few years in you, and then, well. . I used to be a stripper, and now look at me – waiting tables here.” I felt like I was in a movie.

I reassured her I wouldn’t do it, and counted myself lucky. It’s not often one receives words of wisdom from a former stripper.

Part 2: A Stripper Called Me Crazy, And Other Tales of The Night

This is Part 2 of a 4 Part Entry. . you might want to scroll down to Part 1 - Sometimes Dreams Do Come True.
**
Sexy Lexi was the 26 year-old woman who my kind and generous colleague hired to give me a lap dance. She started by telling me I was hanging out with a very hot group of guys, “Um, thanks?,” I said. I wasn’t really sure what to make of that.

(On a side note, what does one do during a lap dance if one is getting a lap dance? Obviously no touching, but where are you supposed to look? What facial expression are you supposed to have? I felt horribly awkward and when I feel awkward, I just start grinning from ear to ear. I’m not sure goofy grin is the facial expression of choice for lap dance reception.)

My friend chose wisely in Sexy Lexi. When she was done, she said “So you guys are really all medical students? I have so many questions for you.”

Could this have been any more perfect? I was so excited “And I have so many questions for you!”

Turns out, she has her BA in international politics and used to work as a para-legal until she found that she makes bank (and I mean bank) stripping. She and a friend are essentially traveling strippers. They come to a USA town that has good gigs, strip for a while, and then take all of their earned cash and go travel to other countries (Guatemala, Costa Rica, Japan next). Eventually she wants to go back to school to get her masters and become a Mandarin Chinese interpreter. Really, not a bad set-up.

I asked her if she likes stripping. “I love this work, it is so much fun.” And she told me that the lap dances are for the customer, but on stage, she dances for herself. Wow. I was totally sold.

She hung out with our group for a while. She told us that she wanted to make out with all of us and we should return on the 27th, her last night of work, when she didn’t care if she got fired (later at the all-night diner, my friend said earnestly: “No, I don’t think I’m going to go back on the 27th – hah!). The anthropologist in me continued to pick her brain. I told her about my fascination with strippers and that I was thinking about dropping out of medical school to become a stripper. (a joke folks, a joke). “You are really crazy,” she said and then looked at my friends, “She is really crazy.”

Part 1: Sometimes Dreams Do Come True

I went to a strip club last night. The Great Alaskan Bush Company is apparently notorious for being the “classiest strip club outside of Vegas” (according to my friend, it is the tourist strip club in Anchorage - who knew there were strip clubs for tourists and strip clubs for locals). A regular hang out spot, I was told, even the women come there to hang out. And, once I became desensitized to all of the tits, ass, and pussy, it was sort of like a normal night’s activity. It was more like watching a show, or going to the circus than it was like hanging out at a bar since everyone’s attention was focused in one general direction (the naked women) rather than scattered over the variety of intentions found in a bar. It was, as my friend put it, a sort of amusement park. I didn’t find it particularly arousing or erotic (I actually felt the opposite of those), but I was never bored, so I guess I can understand the entertainment value of the whole thing.

The truth is, I’ve wanted to go to a strip club for a long time. There is an allure there similar to my fascination with debutantes, sororities, Texas high school football, and the mafia. It’s rooted in curiosity about a culture that exists side by side with, but is very different from my own. And, if I’m being honest, I have several glorified fantasies of those lives not lived. I mean, really, what girl hasn’t wondered at some point about what it’d be like to be a stripper. So yeah, I’ve wanted to go for a long time, but I was always reticent for fear of shattering the illusions I have about the glamorous lives of happy strippers. I didn’t want to see the depressing reality of sleazy bars, disgusting old men, and miserable, bitter women. I figured that I would just chose wisely so that the strip club I would eventually go to would be clean and classy and not too much of a let down. Who knew I would find all that and more on my first real night out in Alaska? (I love that this is one of the first things I’ve done other than medicine in AK)

Mistakes Were Made (Mistakes Will Be Made)

Yesterday was one of those days that reminds you that humility is not always a graceful, humbling, educational experience. Sometimes it comes in the form of plain old red face embarrassment.

So I finally got to do my first pelvic exam. It was going ok (not great, not horrifically) until (you knew there was an until) the bimanual exam. Now, mind you I got an “Exceeds Expectations” on this part of my OSCE during medical school, so I was thinking, “yah, I got this one down.” Apparently doing a bimanual exam on a plastic model with no legs and no pubic hair is a bit different than doing a bimanual exam on a real live human being.

Without being too graphic, what happened involved some uncertain fingers, a misguided approach (but, thankfully no entry), and a rapid readjustment prompted by the patient’s, “Um. . .are you supposed to use the back door?” My attending looked at me horrified and asked “Did you just do a recto-vaginal exam???” I shook my head (somewhat frantically) and said “No,” in an incredulous voice (as if to say, “what do you think I am, an idiot?” Of course I am an idiot. That’s my job, and that’s all I am going to be for the next few years). This was the beautiful conclusion to a very long day of me being unable to answer basic questions like “what is pregnancy induced hypertension.” I perceived the aftermath to be a totally disappointed attending who thinks I am hopeless.

I left the clinic humiliated, beating up on myself. I had excuses: I’ve been sick, on cold meds, end of the day, first pelvic exam in almost a year, nervous, etc., etc., etc. But, that didn’t make me feel better. I was not a happy girl. And then I realized that I had damn well better laugh at myself for a botched pelvic exam, because if I don’t start lightening up on myself, I’m going to have a complete breakdown when I accidentally cut an artery in surgery or hit a nerve during a procedure. I say when because mistakes will be made (for good reasons and for no reasons) – it’s a matter of time, not a matter of if .