19.white knuckles and sweaty palms from hanging on too tight.

[P!nk - Blow Me (One Last Kiss)]
[Album: The Truth About Love (2012)]

"clenched shut jaw, I've got another headache tonight."

Finally a chance to mull over the sights and sounds of a Pediatric Service.

3 weeks out of 8 total finished. Who would've thought Rounds would start at 6am everyday and last for 6+ hours? I expected them to be much longer than on a Surgical or other Sub-specialty...but 6+ hours everyday? Perhaps I didn't quite expect it to be THAT long. Oh well.

"I will breathe, I will breathe, I won't worry at all."

We do 3 weeks on an Inpatient Service and spend the remaining 5 on various Outpatient Services. I have had the unique opportunity to get assigned to the Pediatric Infectious Disease team and if I've learned one thing it's that Infectious Disease might be the only specialty I could live with if I were to go into something non-Surgical.

For all the impatient people. For all the obsessive-compulsive wrecks out there. This is the specialty for you -- without a doubt. A large part of the appeal that Surgical specialties have, in my opinion, is the unique situation where a problem has been identified and (hopefully) there is a definite procedure to solve that problem. Appendicitis? Take out the Appendix. Subdural Hematoma? Make a burr hole and drain it. Infant born without a biliary system? Re-route the jejunum of the small intestine and connect it to the liver to establish bile flow (hepaticojejunostomy a.k.a. Kasai procedure). 

It's gratifying. It's the hopeless romantic scenario of Medicine: find a problem and fix it. Sick patient becomes a healthy patient. Save a life. Provide Hope where before there was none. What other reason could one have to enter this profession than to do just that? Over and over and over again until you've justified your existence on this Earth or simply until you just can't anymore. That's Medicine.

"You think I'm just too serious, I think you're full of sh*t."

Infectious Disease, surprisingly, works in exactly that fashion. Every patient that gets admitted to our service has some kind of infection....some particular mix of bacteria, virus, fungus, and/or parasite that we must identify. We have to gather all the clues. Look at the greater clinical picture. Order appropriate exams and assign the correct procedures in the correct order. Once we find the bug(s) what do we do? We eradicate it. We fix the problem. In just the past 3 weeks I've seen the sickest and most miserable patients transform into the bright, youthful innocence that all children deserve to express and thrive on. The great majority of infections have a distinct cure and that's all ID cares about -- the Cure.

Nothing is more exhilarating than knowing you gave everything to one person and, in doing so, positively impacted their life so that they can go on and do amazing things -- a sentiment that is magnified in light of the limitless potential of sick kids that you high-five on the day of discharge as they hop and skip out those hospital doors to change the world. 

That's Medicine and Infectious Disease has been a good intro to Pediatrics.

"Blow me one last Kiss."

the crate -- 

Ignorance Ain't Bliss

In Infectious Disease, you're pretty much Sherlock...and I guess Dr. Watson all in one.

Patients are admitted to ID and consults are sent to ID when the pathogens, if any, are elusive and the diagnosis is a mystery. It's an event, a 6+ hour one in fact, watching the Residents and especially the Attendings come up with a massive list of Differential Diagnoses with another dozen etiologies and obscure variants -- taking everything possible into account. We've gone as far as asking if patients ever bleached their tubs. Or if they have somehow bit their upper arm. Or even if the patient's dog licked them in the eyeball recently. They've not only memorized all the possible diagnoses but they have inadvertently internalized all the ludicrous situations that might have occurred to give rise to what we are seeing clinically.

The Crates -- the shear breadth of knowledge -- that Infectious Disease specialists have on hand is ridic. I'm essentially spending most of my time googling every other thing that is mentioned, whether it's a bug and illness I've never heard before or one of a thousand different treatment/research protocols that suggest the best possible approach to the problem...I'm always huffing and puffing and trying to catch up. Literally, figuratively, and everything in between.

"Tie a knot in the rope, tryin' to hold, tryin' to hold."

Some of the most common diagnoses?

From my experience I have to say the vast majority of cases (especially with it being one of the worst winters in Detroit history) are viral Upper Respiratory Infections (URIs)...usually due to Respiratory Syncytial Virus (RSV). A close second, and one we'd often have to rule out when diagnosing URI secondary to RSV is Pertussis or 'Whooping Cough.' Aside from those some notable contenders are your standard Strep Throat infections due to Streptococcus Pyogenes and an uncommon vasculitis I thought I would not see beyond textbooks -- Kawasaki's Disease (we probably had 3-5 cases of this).

In any case of acute or chronic infection the work-up was always tense. There aren't many other things out there that are scarier than the unknown -- part of the reason why a good number of Pediatric Patients are started on Broad-Spectrum Antibiotics that cover a plethora of likely organisms before we even know what's going on. Better to be safe than sorry.

"But there's nothing to grasp, so I let go."

It's natural to feel helpless when you have no idea what's going on. For that reason, perhaps the most useful Crate I've learned on this service is to keep our patients -- especially and most importantly the Parents -- informed about what's going on. We have to explain every lab test and imaging modality down to every nitty gritty detail. We have to explain the dosing schedule and coverage of every antibiotic. We have to justify the amount and location of every IV, PICC line, gastric tube, and why/why we are not providing food and/or maintenance fluids. It'a a festering marathon...and all the while we are trying to find out what is wrong and how to fix it....for multiple unique patients.

but You Only Live Once....and we wouldn't have it any other way.

On Infectious Disease we don't like Unknowns and we know our Patients don't either.

When you're sick you think of the Doctor. Doctor is supposed to handle the rest.

This is Medicine.

the hippo -- 

Ignorance is Pissed

Parents are also Doctors. Especially in this age.

They, however, can go from the well-meaning and mild-mannered Dr. Jekyll to the less pleasurable Mr./Mrs. Hydes...and you can't blame them.

"I think I've finally had enough, I think I probably think too much."

On more than one occasion we may have been the 3rd, 4th, and in one case the 7th set of Doctors that the Patient and Parents have seen regarding a difficult and amorphous illness. The spectre of the Unknown grows with time and every 'inconclusive' or 'indeterminate' test/exam. 

Are we not Doctors? 

Aren't we supposed to be the ones that Heal and Revive and Cure?

What some Patients and Parents don't realize is that we are just as frustrated and stressed out. That we are also losing sleep, appetites, and integrity within our personal relationships. Although we are all on the same team, until the Diagnosis is made and the pathogen identified it's common for the medical team to be viewed on the same side of the fence as the disease. It's a difficult position to be in, but when I think about it I would probably be just as Hulk fierce as any Parent were it my child in the same predicament.

"I think this might be it for us."

That's why the ID Hippo is identical to the Crate -- keeping everyone informed is the best weapon with which to slay the Unknown, the Unsure, and the "I thinks." Ignorance is, frankly, not bliss. It's a temporary state of falling and numbness with no end in sight. Although every Patient is unique and may have a different pathophysiological process going on there is always this one common ailment that Doctors have to manage and cure as well.

"My head is spinning so, blow me one last kiss."

We give Broad-Spectrum Antibiotics to fight the literal/tangible disease when we don't know what we are fighting. Similarly, I've realized theres a need for Broad-Spectrum Patience and Anti-Unknown...ics.

Overall, the best thing we can do is be as real and as straight-up as possible. No one likes hedging. No one likes guessing. No one likes assumptions or passive-aggressive tactics. I admit to being the biggest perpetrator of all the above which is why it's one of the things I'm working hardest on...to be painfully candid, truthful, and upfront no matter how difficult it is -- because it's the right thing to do.

At least this way we can all be pissed off together. We can be frustrated and scared together. No one gets left in the dark because at bare minimum everyone is on the same page and a common goal is in sight. Let's freakin' do this.

More than Bugs and more than Drugs.

Doctors need to give more Hugs.

This is Medicine.

Just when it can't get worse, I've had a sh*t day.

You've had a sh*t day?

We've had a sh*t day!

I think that life's too short for this.

So blow me one last Kiss.

18.and all the ways i got to know.

[Lana Del Rey - Young and Beautiful (Cedric Gervais Remix)]

[Album: Single & The Great Gatsby Soundtrack (2013)]

"...your pretty face and electric soul."

First entry of 2014 -- yet another long gap. Yet another hot mess that is (personally) long overdue.

Perhaps I have an excuse. The entire month of January was spent on a Research Elective -- my efforts to frantically finish longstanding projects from the past 3 years and ready them for publication. All in an effort to pad that Curriculum Vitae and be at least mildly presentable in front of Residency Program Directors come this Fall. It was productive, but sadly, entirely devoid of any Clinical exposure. 

Oh well. As a Medical Student, more often than not, we have to play the game. Residencies are only becoming more competitive and all of us have to bring our best face forward. Hopefully after all this I'll be ready for my close-up with Mr. DeMille.

"I've seen the world, lit it up. As my Stage now."

Fortunately, I'm back on a Core Clerkship. In actuality, I just finished the 2nd week of my 1-month rotation in Family Medicine. Quite possibly the polar opposite of Surgery...wow that seems so long ago now (what? a month and a half?). Regardless, what is known as my Primary Care Block is well underway. I follow this month with 2 months in Pediatrics and conclude my 3rd year of Medical School with 2 months on Internal Medicine.

The bad? I miss the OR (and scrubs).

The good? The Patients. Up close and in your face personal.

"Channeling angels in the new age now."

There are opportunities to converse, connect, and build genuine rapport within the Specialist and Surgical settings, but I'll admit that it is more challenging. The biggest constraint is Time and the toughest obstacle is lack of Continuity. Though there are numerous intangible lessons and experiences -- Hippos -- they are more like snapshots...fleeting images stuck in time. In Family Medicine, and I predict for the next 4-5 months the Hippos seem to be more like a movie. Time is taken for setting the plot and character development is paramount. In fact it's so much like a movie I'm glad I've made this metaphor, because in Primary Care every Patient is your favorite protagonist -- you pump your fist with every triumph and cringe with every mistake.

"Hot summer days, rock'n'roll...the way you play for me at your Show."

Of course there is a staggeringly large amount of information to master...the Crates this time around aren't any less massive and burdensome (this is still Medicine after all). Ultimately, though I miss operations and I miss procedures (and I would really love not having to wear a tie everyday) I have been enjoying this rotation more than I thought I would. They say Primary Care is the 'front line' after all -- and that means death and victory and a whole lot of Stories. Bring it. YOLO.

"Hot summer nights, mid July...when you and I were forever wild."

the crate -- 

Growing Old

When I say my experience now is the polar opposite of before, I realize just how appropriate that statement was. Whereas my last clinical rotation was in Pediatric Surgery, the Family Medicine practice I am currently at consists almost entirely of Geriatric Patients. Go figure.

"I've seen the world, done it all."

It does allow me to draw stark contrasts between Pediatric Crates and Geriatric Crates.

I'll admit that one of the best things about any Pediatric rotation, I assume, is that histories are blissfully short or non-existent. Children don't usually have chronic medical conditions, nor is it usual of them to have had multiple surgeries. The best part for Medical Students? Having to look up and memorize a hella long list of medications. Oh wait. There usually aren't any. #winning.

As for Geriatrics...

"Had my cake now."

I'm going to save time and stave off the onset of carpal tunnel by saying nearly everything is flipped for the 65 and over crowd. It's staggering how extensive of a history each of my Baby Boomer Patients has accumulated in the past half century or so. Even the healthiest Patients I've seen -- those who eat right, do right, and know what is right suffer from at least one medical condition...usually Hypertension, Low Back Pain, or Diabetes.

"Diamonds, brilliant...and Bel Air now."

If I've learned anything on this Family Medicine Rotation...if I could only carry one Crate away from all of this...it's just how profound the effects of aging can be on one's physiology and mentality. To be fair none of this should be surprising. I knew to expect what is commonly called 'Polypharmacy' and we have had numerous lectures throughout the first two years of Medical School on the changes that occur with aging -- be it the natural hardening of our arteries, the gradual decalcification of our bones, or the creeping progression of forgetfulness.

"Will you still Love me?"

Maybe it's because none of it is no longer theoretical. Maybe it's because those lessons and exams are now flesh and bone sitting in front of me -- telling me about their grandkids and asking me what kind of Asian I am. Likely, it's all of the above and hearing about their journey through life motivates me to do my best to manage and understand the myriad of conditions each of them has...and each of them, of course, has their own unique combination platter of ~20 common conditions from the elderly buffet.

"When I've got nothing but my aching soul?"

From an impartial, non-human stance these Baby Boomers present a very enticing intellectual puzzle for all the Dr. Houses in the world. For those who want to be doctors/physicians/healers these are the Patients we hope to continue serving and empowering. It's almost like a thank you -- thank you for building our cities, thank you for fighting the evil in Nazi Germany, thank you for raising me.

That aching soul is more than enough.

the hippo --

Growing Bold

It's all about the Stories.

My favorite thing about all this Primary Care business is that we have just a little bit more time with our Patients. (Not nearly enough mind you.) We are, however, encouraged to solicit as much backstory as we can and to gather as many puzzle pieces as possible to complete the bigger picture.

I like that. A lot.

It's as if you're asking me to go on an African safari and to document every Hippo I see. You bet I'll search high and low for those massive intangibles. Those unique unmentionables and look-past-ables.

"Will you still Love me?"

Hippos are massive though...and if I'm not mistaken they're not endangered as of yet. So it's safe to take away only one for now. What would I take away from Family Medicine? Well. It's kind of cheating but part of it lies in the name of the Clerkship itself, and that is Family.

"When I'm no longer Young and Beautiful?"

I'm not necessarily talking about husband, wife, 3-4 children, white-picket fence, dog, and suburbia. What really struck me was the dynamic at the core of the family unit -- the husband and wife. It probably goes without saying that I've seen married couples while on this rotation...and it's incredibly endearing when they come on the same day for their usual check-up and argue over who's going to be seen first.

"I know you will."

Many of these couples have been together for 40+, 50+, and yes 70+ years (I saw a 97yo last week). These Baby Boomers took their vows in an age when 'courting' meant something and divorces weren't handed out like flyers on the Las Vegas Strip. This is the Hippo that hit me. To see and hear about the sturdiness of Love -- no matter how rough it got...and I've already heard some jaw-droppers.

The most heart-wrenching? Those spouses who stand by the Love of their Life despite the opinion/fact that their Loved one may be long gone or beyond reach. On a Hospice Visit last week this was all too common a scenario. Frail and aging spouses faithfully visiting their soulmates even though they could never get a response, never know if they are getting through, they just never know...but it never mattered.

Even though they are combative. Even though they are drooling, and vomiting, and soiling their clothes incessantly. Even though their spines have disintegrated into extreme kyphosis and the lack of connective tissue no longer has power over wrinkles and deep creases. None of it matters. Let's be real here -- eventually none of us will remain Young and Beautiful. If we find the right person, however, maybe we can at least stay Beautiful to the only person that matters.

"Oh that face that makes me want to party."

Even if it was a different time I still hear similar stories. Nervous first dates. The rapid onset of freedom at 18 and college parties. The victory in scoring a job and buying a home, and yes, raising that Family to the best of their initially naive abilities.

It really is like a thank you to care for these Patients. If nothing else thank you for reminding me that the deep and indestructible Devotion of True (and I mean legit) Love can or did exist at one point. You know what? I like that...True Love? That's fairy-tale B.S. There are going to be bumps, and potholes, and detours...none of this Tinkerbell happy ever after junk exists. 

Give me Legit Love or give me nothing. Thanks for the lesson Baby Boomers.

"She's my sun, she makes me shine like diamonds."

17. alright. already. the show goes on.

[Lupe Fiasco - The Show Goes On]
[Album: Lasers (2011)]

"All Night 'til the Morning, we Dream so long."

It has been too long -- now that would be the understatement of the year, yes?

Though a fitting one on this final day of 2013. 

Time is either too fast or too slow, never in between. Meh.

The last month of my Surgery Clerkship actually ended about two weeks ago but the opportunity to come back to sunny California and a return to the world of the living has been so blissful and occasionally outrageous that I've only now found a wrinkle of calm to write. Alright.

But Life is the biggest Stage and like all grand Performances: The Show Goes On.

"Yeah, ain't nobody leavin', nobody goin' home."

Where before I spent my first month on the General Surgery service I spent my second with the Pediatric Surgeons at the Children's Hospital of Michigan. Where before I thought I was busy beyond belief, I quickly learned that 'busy' is a relative term and that revised definitions were in order for much of my vocabulary and lifestyle. The hours and required studying slash research were ridic.

I can say without a single molecule, nay a single quantum, of doubt that my month on the Pediatric Surgery service was the best month of Medical School thus far. And although I would really love it, actually, if I were to eat my words at a later date...I am fairly certain that no other Rotation or other remaining Medical School experience will ever compare (perhaps Match Day and Graduation will come close =p).

"Anybody ever wonder when they would see the sun go?"

It wasn't always fun. It wasn't always happy. And there was never enough ice cream or pancakes. But a big aspect of the experience was that it was piercingly real. It was harsh, but it was also innocent. I can understand how the world of Medicine and Surgery can be draining and soul-devouring, but I could not fathom until now what people meant when they said "kids keep you young." Because they definitely will, and they just might be the ultimate vanguard against the spectre of 'jaded' physicians shambling about like an episode of the Walking Dead.

Goodness knows I'm the biggest child out there -- but the privilege of working with Pediatric Patients has been jarring in the best way possible. It's very possible that Neurosurgery has met a worthy opponent. Never did I think.

Those Kids were something else.

"To tell those kids that's livin' in the ghetto, that 'the World is Yours'."

the crate --

The Parents

It's funny now. The first piece of advice we ever receive and internalize as Medical Students entering any Pediatric Service is to watch out for the Parents. 

"The kids might be cute, but the Parents can be vicious."

Naturally, that was my single biggest worry walking in on Day One. It makes sense doesn't it? I can easily picture how overprotective and overbearing a parent can potentially be...I mean, it's their single most important treasure...no one better do anything to harm their little shnickles (not made up).

"One in the air for the People ain't here."

The funnier thing is that, for the most part, this advice has rarely been true. I've seen defensive and even angry parents but never have their reactions been disrespectful or out of proportion in my humble Medical Student opinion. 

"Two in the air for the Father that's there."

All of this was a relief, because the Parents play a gargantuan role in the care of any Pediatric Patient. They are our primary source of information and are usually who we turn to for an accurate history regarding any illness and/or injury that happens. What I didn't necessarily expect, however, was how important the Parents were in delivering actual Patient Care. I knew the Parents are almost vital for moral support and when explaining procedures. In Pediatric Surgery, however, the Parents played an incredibly active role: walking their children to speed up recovery, unclogging nasogastric tubes, and even calculating bowel/urine output so that the nurses and Medical Students didn't have to.

The most endearing part? It's almost expected to picture the nurturing mother performing all these activities. But. At least in my experience, probably 80% of the time it was the fathers who were in the room being the stalwart caretaker. Those grisly fathers. And get this...in those cases the mother was also a bread-winner...how is that for a wonderful reversal of traditional roles? It's not perfect but this is a pleasantly unique age we live in.

"Three in the air for the Kids in the ghetto."

The Kids

Ready for more comedy?

The picture that is painted of caring for Pediatric Patients is one filled with running, screaming, crying, and a lot of miscellaneous bodily secretions. Hardly true as well -- I feel like this is an episode of Mythbusters.

Much of the challenge I've come to realize, however, is just how different it is to care for a child as opposed to an adult. The illnesses are different. The susceptibilities are different. We have to use appropriately downsized equipment. We can not use certain medications. Getting an IV started is extremely hard and frustrations can mount when these lines are somehow pulled out every other day.

"Four for the Kids that don't wanna be there."

It required a lot of adjusting. I'll volunteer my opinion that it definitely takes more time and patience to care for Pediatric patients. In addition to comforting slash caring for them you must also explain and appropriately brief the Parents. Despite this, however, nothing in my experience thus far has been more rewarding. Pediatric patients don't want to be sick. They hate being in the hospital. They are not seeking narcotics, don't smoke, don't drink, and have not taken on other detrimental life choices.

"If you are my homeboy, you'll never have to pay me...

...go on and put your hands up when times is hard...you stand up."

The best part? As fragile and unassuming as they may seem, Kids are some of the toughest and most resilient individuals I've had the privilege of working with. They recover so well. They heal quickly. They bounce back even in the most dire of situations and go immediately back to coloring outside the lines of their Spider-Man coloring book. As a hopeful aspiring Physician nothing is more gratifying than good outcomes -- and there is no greater bonus on top of that than the hilarious innocence of a laughing child drawing stick figure tattoos on your forearm that you later have to explain to colleagues and Attendings.

Those Kids are something else.

"Raise 'em 'til your arms tired, let 'em know you here...

...that you struggling, survivin', that you gon' persevere."

the hippo -- 

The Grown Ups

"Dealing" with Parents -- that misguided piece of advice I mentioned before. That was the initial Crate bestowed upon us as naive Medical Students, but after going through a month on a Pediatric Service...without fail...a Hippo reared its head to reveal the true nature behind this sentiment.

If Parents were not difficult, if they didn't raise their voice, if they did not "hassle" us with questions and complaints. That's when I would be worried. That's when I would be afraid. I've come to be comforted by defensive and sensitive Parents because it means that they care. It means they're passionate, and if they weren't so then there are bigger issues going on.

"Even if they turn the lights out, the Show is goin' on."

So much can be inferred by the interactions between Parent and Child. There is a lot going on even when nothing shows and nothing is said. On more than one occasion, unfortunately, we've had to file a report with Child Protective Services. Without going into detail all I'll say is those trouble Parents were the pleasant ones. They were the Parents who were overly friendly, who were cooperative, who never made our lives difficult. Now that is scary. Grown ups who can plot and plan are scary.

"That glitterin' may not be gold, don't let nobody play me."

So bring on those savage and vicious Hippo Parents. I welcome them. Of course there is a limit and of course there is a fine line between caring and caring so much that it is detrimental. But I'd rather have the Parent who makes my life harder and the Parent who keeps me on my toes than the fake ones who shower me with uncomfortable praise.

H*ll yeah I'll "Deal" with them. All day err day.

"So no matter what you been through, no matter what you into...

...never ever put them down, you just lift your arms higher."

The Tiny Adults

Bringing a child back to health and happiness has to be the most gratifying and fulfilling feeling that exists -- yes I've mentioned this before. I'm hella redundant and I don't even care.

What's the Hippo here though? What's the intangible lesson?

I realize it lies in the question of why, exactly, it feels so good to help kids. While on Pediatric Surgery I've come to learn that it's more of a twin-headed Hippo. A Twippo if you will. 

Here's #1:

"Have you ever had the feelin' that you was bein' had?"

"They be lyin' through they teeth, hope you slip up off your path."

As aforementioned, Kids don't like being sick. They rarely ever hide anything or have secondary agendas. All they want to do is get better so they can get back to playing and exploring this wide-eyed world we all live in. To me the thought that hit home was that these Kids usually have not done anything 'wrong'. They are pure victims most of the time. They don't have this heart condition because of poor diet and lack of exercise. They don't have this cancer from years of smoking or IV drug abuse. They aren't seeing you for the millionth time because they refuse to listen to your advice and recommendations.

This is how Medicine is supposed to be isn't it? Healing the sick and the dying. Caring for those who need it the most and can not help themselves. Devoting one's life to the preservation and well-being of the human race. For the skeptics, that Medicine still exists and these responsible Tiny Adults (oftentimes more responsible than actual Adults) are the Vanguard.

Here's #2:

"Five in the air for the teachers not scared."

Not only can these Tiny Ones be as responsible as Adults (not making bad choices), but there is the opportunity to make sure they become Big Responsible Adults as well. These are the formative years. This is when we can teach, and guide, and nurture so that future generations surpass our achievements in every way possible. When Kids grow up and outdo us, that's when we know we've done a good job.

"Yeah, the World is Yours, I was once that little boy."

It feels especially fulfilling because we have all made mistakes in our lives -- me most definitely. That's why, in addition to everything else, this is an opportunity to do what we can and make sure there are no repetitions when it comes to our own mistakes. Now this is the kind of redundancy I do care about. There is no way I'd let these Kids -- those with the greatest and brightest potential -- make the same errors and miscalculations.

"Africa to New York, Haiti, then I detour...

...Oakland out to Auckland, Gaza Strip to Detroit."

"Say hip hop only destroy, tell 'em look at me, boy."

At the end of it all, we've also made a lot of right choices. When the show never stops we have to minimize the bad and maximize the good because we only get one shot at Life -- we only get one Performance. So we better make it a good one.

This Pediatric Twippo -- the twin-headed unspoken Hippo lessons from Pediatric Surgery -- have become ingrained within me like nothing else thus far. It was a great way to close out 2013. Given all that is troubling the world today it's nice to have some light and some hope. I would be honored to care for these Tiny Adults -- our Vanguard against the perfect imperfections of Human Nature.

Those Kids are something else.

Happy New Year Everyone!!

Just remember when you come up, 
the show goes on.

16.its very clear.

[George Gershwin - Love is Here to Stay]

"our love is here to stay."

It's been a while.

As I finish this 4th week of my Surgery Clerkship and close out my Rotation through the General Surgery Service I can't believe how busy my life has been.

But everyone's life is busy right? No point in my pouting about it.

Plus, I more or less expected this. Surgery, after all, has the reputation of being the most challenging and most demanding Rotation for any 3rd year Medical Student. All in all, I think it's just a perfect example of that age-old wisdom -- where one has no idea what a situation or experience is truly like until one goes through it.

And really, that has been a recurring theme during the past 3 weeks...jumping right into the trenches to see, hear, touch, and definitely smell first hand what Surgery is like for oneself. But it's more than that as well. In my fledgling career thus far I have never seen as much heartbreak as I have on this Service. I've also never become so acquainted with Death as I have since I was last able to complete an entry here (when was that? after week one?).

But for every elderly couple I've seen separated by the blight of Cancer I have gotten a glimpse of True Love. For every young child witnessing their mother or father intubated, sedated, and recovering I have felt how even a little Hope can outdo the strongest medications. Through every frustrating failure, massively stressful scenario, and every single sleepless/eatless day I have seen the Passion that drives Physicians. Healers that just want their Patients to get better...so they can go home (if even for a little) to eat, laugh, and cry with those that matter the most.

Ultimately, I can safely say that the Surgical lifestyle is for me. I write this from the Medical Student Call Room on a 16 hour night call and I wouldn't have it any other way. I say 'safely' because I am now immune to those who would tell me "wait till you've been through it." 

I now have. Surgery. Done. Yolo.

Neurosurgery? Very likely.

"together we're. going a long, long way."

I have to thank Heartbreak and Death in way. For without them I could not witness firsthand how strong we are when the worst is upon us. They have also given me the fuel that makes it ok to be eternally sleepy and to have my stomach autodigesting itself for want of sustenance.

But I'd really like to never see them again. If I can help it.

"not for a year. but ever, and a day."

crate -- 

On Call

I had to stop writing this entry before I really got into the meat of things (mm steak). 

Courtesy of my pager of course.

What was supposed to be a 16 hour overnight call easily turned into a 20 hour call and at some point sleepiness compounds upon sleepiness until it self-implodes. I wasn't particularly sleepy at all as I left the hospital earlier this afternoon. All of this because when the pager beeps it's like a Batsignal and you can be sure that Residents and Students will come a runnin'...albeit hardly as elegant or legit as the Dark Knight.

Being 'On Call' is yet another one of those things. You know. Those things. Like dissecting cadavers in first year Anatomy, or taking the Step 1 board exam, or being 'pimped' on rounds by an Attending. Yes, there is a historical basis and a practical significance for it. But above that it's also a very blatant and unquestioned rite of passage for Physicians and would-be Physicians alike. We swallow it and savor every single bittersweet drop. Sometimes it's more bitter. Sometimes its surprisingly more sweet. But we will always take it without a second thought. This is Medical School after all.

Someone has to do it. It's not as if Patients get sick or hurt on schedule. 

(Imagine that though).

While On Call we are responsible for making sure our Patients make it through the night. We aren't expected to necessarily save lives or orchestrate medical breakthroughs. More than anything we are tasked with keeping the status quo. Homeostasis if you will. At the very least we should put in every effort to ensure none of our Patients deteriorates for any reason.

We also see Consults from the Emergency Room where we may potentially admit Patients for ongoing care and observation. Otherwise we are constantly running up and down floors putting out mini fires according to where our pagers take us. A medication adjustment here. Replacing a nasogastric tube there. Another Emergency Consult for nausea, vomiting, and abdominal pain. Every now and then a Code Blue where everything else in the world disappears and the entire hospital gravitates to a single point and every resource that can be mustered is focused on a single Patient. 

Night Call is pretty fun.

"But oh my dear, our Love is here to stay."

It makes me think of where the term 'Resident Physician' comes from. Then I drift into a romantic no-mans-land daydream of days gone by. Of 'Old School Medicine'. Where Physicians-in-training actually lived in the hospitals so that they'd be available 24/7. Resident Physicians used to be in-house full-time -- a rite of passage that I'm sure our current Attendings took without even a fraction of a second thought.

One of the most prominent Crates I've come to understand this 3rd Year is the collective attitude one must have to be a Medical Student. No one is particularly special. If we don't have this gritty determination and glutton for challenge/punishment to begin with we definitely acquire it in order to survive...and hopefully to excel. The other side of this is just how much Tradition (for lack of a better word) there is in Medicine and in Medical Training. The molding that creates Doctors has hardly changed over the years.

But just like my Residents, my Attendings, and Attendings long past -- I wouldn't have it any other way. I hope. And I want to say that in just a little over a year from now when my colleagues and I line up to receive our degrees we can feel unanimous in this sentiment. 

"the radio, and the telephone and, the movies that we know.

may just be passing fancies. and in time will go."

hippo -- 

Doing the 'Rite' Thing.

Rites of Passage. I am convinced this is the purpose of Year 3.

We are here to show we have acquired the knowledge. We are here to show we have attained the technical skills appropriate for this level of training. But you know what? Above all we are also here to prove we have that Swag.

To prove that we can stay awake for a few more hours. Go without sitting or eating just a bit longer. To dig a little deeper into our Patient's lives and histories so that we know their favorite ice cream flavors and how many times they might blink per minute. Ultimately, I am convinced that we are here to show that we are capable of looking beyond ourselves -- if not all of the time than most of the time...to start with. 

Maybe that's what it takes to really care for Patients. To forget one's own needs and wants so that you can fully engulf the pain and suffering of another Human being and give everything to find a definitive treatment. I read an interesting article just today that noted how Doctors will often downplay their own symptoms and illnesses until they are extremely sick. One would think Doctors are the healthiest individuals around. Go figure. But maybe that's what it takes.

"In time the Rockies may crumble."

I've had the pleasure of getting to know one of my Attendings a little more than I thought I'd be able to. He's always telling me to do the Right Thing. I always feel like he's simultaneously telling me to do the Rite Thing as well.

Every Thursday we take a refrain from the Operating Room and staff the Outpatient Surgery Clinic to follow-up with previous Patients and to see any prospective Patients for future procedures. Every single New Patient Consult that I saw with my Attending would run in the same fashion. Unless it was an Emergency (which it never was else the Patient would be in the ER rather than the Clinic) my Attending would always tell me to drop the pen and paper...to close the EMR and paper charts...and look at the Patient's face. The Right Diagnosis will always come from the Patient and never from anything else. Once the Right Diagnosis is made then the Right course of action can be taken. That's Rite.

"Gibraltar may tumble."

Then the Consult would usually end with my Attending saying how much he loves Surgery. That he has done Surgery all his life, makes his living from doing Surgeries, and defines his existence by Surgery. After explaining all of this my Attending would then say, more often that not, that he doesn't advise Surgery at this time. That although his well-being in a spiritual as well as in a very practical sense depends on it, that he's always reluctant to push Surgery for any Patient unless it will save life or limb. It's not the money. It's not preferences. It's not reputation. It's doing the Right Thing.

Is a Surgeon that does not operate a Surgeon?

Perhaps more so.

"They're only made of Clay."

My Attending has told me about all the money he could potentially make. About all the good will and good reputation he could build by performing surgeries that are not technically necessarily. He emphasized that they include Surgeries that would do no harm to the Patient or anyone else really. It's just that it wasn't Right. I can swallow that Rite of Passage any day. All day err day.

"But our Love is here to Stay."

Doing the Write Thing.

Maybe that's what it takes to truly care for Patients. To forego any instance of one's being so that the Patient can be firmly and clearly kept within one's sights. I don't know for sure. All I know at the moment is that words can not describe how eager I am to continue tomorrow and start my second month of this Surgery Clerkship...hopefully to find out for sure. (Next up is Pediatric Surgery).

And although words might not be able to fully convey what needs to be conveyed I'll always try to Write. It feels Right. It also feels like a personal Rite. Sometimes I feel as if my thoughts are crazy. Does anyone else have thoughts like this? Am I entirely off-base and a complete lunatic with the words I publish on the most public platform ever created by Mankind? Perhaps I'm making a fool of myself.

Oh well.

I can't deny that it feels Right. It's here to stay. Just like the Rites of Passage, they're here to stay. Just as the Human part of Medicine -- the Hippos -- are here to stay. Just like my passion for Surgery as a medical specialty...that's here to stay as well.

After all, the Rockies may crumble, Gibraltar may crumble...they're only made of Clay.

If I'm alone with these kinds of thoughts and musings...

well. i'm used to it. so be it.

It's very clear.

Our Love is here to Stay.

15.these streets hold my deepest days.

[Nas featuring Chrisette Michele - Can't Forget About You]
[Album: Hip-Hop is Dead (2008)]

"this hood taught me golden ways."

Rotation #3 = Surgery.

It seems like forever that I've been waiting for this rotation. I don't think I've made it a secret that I'd gladly spend the rest of my life in the OR. Well. The first week is over and it did not disappoint.

It's still early I suppose so I won't count eggs. So far though. Me like.

As a 3rd year Medical Student it becomes kosher to shed the typical medical school veil of being unsure and of having a lot of time to explore what specialty one wants to go into. The same professors and mentors that told us to sit back and focus on our studies are beginning to, now, probe us for any prospective inclinations -- many going as far as planting seeds for certain specialties according to their good-hearted biases.

"wanna gather your thoughts, have a cold one."

It makes sense, in as little as 8 months the Class of 2015 will be furiously and, more than likely, frantically working on Residency Applications and contemplating when to take the USMLE Step 2 Board Exam. That means we should have a pretty darn good idea in <8 months...which means we really shouldn't be hiding behind any veils anymore. It's almost time to grow up.

I am 100% set on a surgical specialty. I have no doubts about that. With those Residency Apps looming closer, and hopefully some subsequent Residency Interviews, I know I need to dig deeper and ask myself "Why Surgery?". Hmm.

I was asked the other day about my use of hip-hop songs in some of these entries. That also made me ask why. The thing is. My interest in Surgery as well as in Hip-Hop may stem from some of the same roots. A lot of those roots are deep. After all, I'd like to claim some pride in growing up during the Golden Age of Hip-Hop and being raised in an area that embraced all of its components. 

"made me, truly this is what made me."

crate --

Scrubbing In.

Our Surgical Orientation began how I imagine most first days on Surgery would begin: an introduction to the operating room and the technique...the art of scrubbing in.

Some people don't like it, I know. In fact, some people hate it. Scrubbing in and donning the sterile gown. The surgical mask and surgeon's cap. Laying down the sterile field. I personally eat the whole experience up. I can't help it...it's really something to think about the great lengths that are taken to ensure consistency in sterility.

"I'm that lifestyle, I'm that spot."

As I often do, I daydreamed of other things as I spent the obligatory 5 minutes scrubbing off every loose skin cell and bit of wayward microbe -- lest the scrub nurse yell at me for improper technique. I thought about the historical lessons we have learned in regards to sterile technique. How before, physicians and nurses would not wash their hands between Patients until individuals like Ms. Nightingale thought it might (just maybe) be a good idea. How before, surgeon's were proud of their 'surgical stink' (accumulated surgical debris on their gowns) before a certain Dr. Lister championed the preposterous idea of antiseptics.

"collidin' with big names that could've made your career stop."

I love the rituals of the OR. I love that not only does Surgery require full mental capabilities but also physical skill and prowess...both in equal parts. I love thinking that the medical staff is taking every logistical step and precaution -- using the best of mankind's technology and knowledge -- to make sure the Patient is taken care of and that we are more of a solution instead of contributing to the problem.

"break me, not a thing's gonna break me."

It's probably every Medical Student's greatest fear during any Surgery. God forbid any of us 'break' the sterile field and potentially risk being kicked out of an Attending's OR. But perhaps that is yet another draw for me towards this specialty. Every movement is watched, is precise. It's intense. Every movement is intentional and consequential. When I think about it, ultimately, there is Movement...and that fact alone separates it from most other specialties. Actually having the privilege of making definite and physical changes to make someone feel better. Yes, please. May I have seconds? Thirds?

"here's my lifelong anthem."

One of our Attending's pointed something out that will forever stay with me. And really, it revealed unto me just why I seem to love Surgery so much. He brought to light that surgeons don't do Surgery...they perform Surgery. Perform.

It was then that he reminded us of the surgical suites of old, where audiences would gather to witness these mysterious procedures. It was an event. This was where former barbers earned their right to a medical degree and showed onlookers how Medicine could be combined with steady hands to bring about something entirely new and daring.

Medicine is an Art as well as a Science?

Why yes, yes 'tis.

"Wow, I need a moment y'all.

See I almost felt a tear drop."

hippo -- 

Scratching In.

Even those not really into Hip-Hop recognize the signature DJ move of 'scratching' that used to take place with records and turntables. It's not something that can be done haphazardly. It has to be at the right time. At the right tempo. It is as intentional as a surgeon scrubbing in or making the initial skin incision.

See where I'm going with this?

Four typical components associated with Hip-Hop: DJing (aural), Rapping (oral), Breakdancing (physical), Graffiti (visual). What do they all have in common? They are all methods of expression. All different ways of performing and combining several different modalities. Surgery is a similar amalgamation of Medicine: Aural (History Taking and Physical Exam), Oral (Instruction and Dictation), Physical (Procedures and Technique), Visual (Incisions, Sutures, and Imaging).

"That's why, Darling, it's incredible."

To me, the Crate that is Surgery...turns into Hip-Hop when viewed through Hippo glasses. Now when I think back on the breakdancing or rapping circles that would instantly form when someone was about to 'throw it down' I think of the circles that would form around surgical theaters. Hip-hop has a technical aspect but much of it involves creativity and improvisation. So too with Surgery, where books can only convey so much and everything else is gleaned from mentors and one's own wit and acumen.

"I'm that kid by the number spot."

Even as Hip-Hop is viewed as abrasive in the music world so too are Surgeons in the medical world. But it's not this perceived arrogance or a craving for attention that attracts me to these two entities. Actually those are the comments that often, unfortunately, turn me off about Hip-Hop and Surgery altogether. It's that Performance aspect. That Expression aspect. For some reason nothing beats being behind the curtain on stage even if the seats are empty.

Beyond the bling, provocative music videos, and celebration of underground culture in Hip-Hop. 

Beyond the short-tempers, reputation for self-entitlement, and supposed egos in Surgery.

Hip-Hop originated because individuals did not have much beyond themselves. These individuals did not throw what little they had away but fully embraced it -- their natural talents -- and tried to form something positive from impossible situations. We are all deserving of self-expression and positive outlets. Instead of violence, that same aggression could be used to mix beats and make rhymes and bring communities together.

So too does Surgery seek to embrace what could possibly be taboo and make something positive of the situation. After all...knocking someone out and cutting into them would be 1st degree murder under any other circumstance. Am I right? Furthermore, when someone has something as impossible-seeming as cancer the last thing one might think of is cutting them open. But the gruesome techniques innovated in early barbershops are now the means for successful resections and remissions for many grateful individuals. Imagine that.

I strongly believe that Creativity and Imagination set us, as Humans, apart.

What embodies both of those more than Hip-Hop and Surgery?

Why do I use Hip-Hop? Why do I want to do Surgery?

It's pretty much who I am. Can't do anything about it.

I'll take a mic in one hand a scalpel in the other.

It's the things we remember that gave the world shock.

They stay in a place in your mind so snug.

Like who the person was with whom you first made Love.