"Now can I get an Encore...do you want more?"
It has been two painstakingly long weeks since I've been able to regurgitate my thoughts and experiences here. The medical facts and intangible life lessons -- the Crates and the Hippos.
Rotations and this 3rd year of Medical School is only getting busier but I still feel the need to record my musings now at my current premature (and perhaps often immature) stage of life. Whether it will serve as a reservoir of silly innocence...and thus a shield against cynicism and indifference or as something that my future self can laugh at many years from now...seeing how I've changed...I don't know. It can really go either way and I welcome both outcomes -- it will keep me anchored with ample material for reflection.
Hollaback.
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I have been itching to back to this. Regretfully, I've already forgotten many Crates and far too many Hippos that I wanted to mull over. A lot has happened. The highlights?
1. I finished my Psychiatry Rotation a week ago.
2. I am coming off the first week of my Neurology Rotation.
The two fields are closely related yet different enough to justify their separation -- two sides of the same coin. Regardless, it makes sense that our school bundles Psychiatry and Neurology into back to back blocks, where the only difference is which one you rotate through first.
"Can't none of y'all mirror me back."
Psychiatry and Neurology are almost the medical specialty versions of Hippos and Crates. The former relies on intangibles and various subjective assessments. The latter is grounded in more reliable science -- diagnostic imaging, lesions of neurological pathways, and electrical recordings from the brain as well as from muscle. It's a wonderful dichotomy. And I've thoroughly enjoyed seeing where they overlap and where they can take on different stances.
It's the same feeling I had when I first heard Jay-Z's Encore remixed and combined with Linkin Park's Numb -- I was pleasantly mindblown and my perspective on what could and should be integrated was turned ungracefully upside-down. Who would have thought?
Well it's been 2 weeks. What the hell have I been waiting for?
"So far one last time, I need y'all to Roar."
crate --
Psychiatry Shelf Exam - Encore
As aforementioned I finished Psychiatry just a little over a week ago and, as will be the ongoing Encore for the remainder of this year, we had a shelf exam to mark its conclusion.
What can I say about it? It was another taxing 100-question assessment of our mastery over Psychiatry concepts and diagnoses. I will say that it was much more forgiving than the OB/GYN shelf I had taken previously -- owing mostly to the much narrower scope of material to review as compared with the various conditions that can affect a pregnant mother.
Something that also made the Psychiatry Shelf relatively less stressful is just how rigid many of the diagnostic criterias were -- the Crates for Psychiatry are built as rigidly as they come. Schizophrenia, for example, requires symptoms for a duration of at least 6 months. Which means, if someone has had hallucinations and disorganized thinking for 5 months and 30 days (let's say a day shy of 6 months) they must be diagnosed with Schizophreniform Disorder instead. More than a few questions on the shelf exam relied on counting days and timelines rather than thoroughly analyzing the clinical symptoms. It made for questions that were thankfully more black and white -- more straightforward than most.
In the end, it's as Jay-Z would say: On to the next one...
"Grand Openin', Grand Closin'"
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Neurology Week/Weak One - Numb
From Psychiatry straight to Neurology. I just finished my first week.
As I alluded to, the switch required a transition to more objective assessments. There is still an assessment of mental health and cognitive function. We even perform the Mental Status Exam (MSE) and a Mini-Mental Status Exam (MMSE) when needed. That may be where the similarities end, however.
We follow up those initial mental/cognitive assessments with as full of a Neurological Exam as we can manage. We assess cranial nerve function -- including vision, hearing, and at times the Patient's sense of smell. We continue by assessing the sensory and motor functions of the face and, ideally, the rest of the body -- assessing strength, range of motion, deep tendon reflexes, and the ability to feel temperature as well as touch....just to name a handful of parameters that are tested.
"Then you drop a couple of hits, look how they wave at you."
Eliciting reflexes is particularly enjoyable, when successful of course.
More than anything this past Week, I've realized just how common it is for Patients to feel Weak. There are countless reasons and etiologies that may lead to weakness -- metabolic, toxic, infectious, neurological, trauma, etc. Almost every medical specialty has some stake in working up a Patient that presents with Weakness. In many cases, our Patients not only feel Weak but also Numb and those two together make for an instant call for Neurology.
By finding out exactly where and to what degree a Patient has lost strength and/or sensation we can gain some insight into what may be dysfunctional. Loss of function in the face, for example, would instantly eliminate spinal cord pathologies as the face is not serviced by the spinal cord -- we'll suspect something in the brain or brainstem. On the other hand, if we notice fasciculations of the leg -- involuntary muscle contractions -- we might then suspect a lesion at the level of the spinal cord. Much more concrete. Much more Crate-like in comparison to the assessments we were performing last month in Psychiatry.
By finding out exactly where and to what degree a Patient has lost strength and/or sensation we can gain some insight into what may be dysfunctional. Loss of function in the face, for example, would instantly eliminate spinal cord pathologies as the face is not serviced by the spinal cord -- we'll suspect something in the brain or brainstem. On the other hand, if we notice fasciculations of the leg -- involuntary muscle contractions -- we might then suspect a lesion at the level of the spinal cord. Much more concrete. Much more Crate-like in comparison to the assessments we were performing last month in Psychiatry.
"It ain't to play games witchu, it's to aim atchu."
Some of the tests for the Neurological Exam can feel silly. We ask the Patient to smile and frown and squeeze our fingers as hard as they can. It feels like a game at times, but every single test is purposeful and full of useful clinical information.
"and I need you to remember one thing..."
I am thoroughly enjoying it. I am also admittedly biased as Neurology or Neurosurgery are my top prospects as far as medical specialties. It's not all pleasantries, however. I mentioned it our job to get as full of a Neurological Exam as possible and the reason for that is because it's not always possible -- especially with our sickest Patients.
"I've become so Numb, I can't feel you there."
hippo --
Nothing to Complain About. - Numb
In only one week I've already seen and experienced a number of heartbreaking cases.
The most severe Neurological Disorders can be completely and utterly debilitating. The biggest Crate from the week has been my greater acquaintance with the symptoms of Weakness and Numbness. The biggest Hippo of the week, however, is an overwhelming sense of humility and being constantly reminded of how lucky many of us are -- courtesy of our Patients who go through so much.
"I've become so Tired, so much more Aware."
I absolutely can not forget an experience from this past week where my Attending delivered a diagnosis of Amyotrophic Lateral Sclerosis (ALS) -- also known as Lou Gehrig's Disease.
It's the same disease that has gripped Stephen Hawking and it is near the top of my list for worst diseases ever. Along with Cancer, Huntington's Disease, and an unfortunate slew of other diseases... ALS has no cure. The supportive and palliative treatments we do have are limited.
It results in progressive paralysis of essentially every muscle in the body. One's sensory capabilities are generally spared as is one's cognitive abilities -- but it is almost a cruel tease in light of everything that is going on.
The Patient burst into tears. Who wouldn't? All I could think about is not being able to hold my loved ones. Of not being able to carry or play with the future children I hope to have some day. Of relying on others for the rest of my existence...the inevitable guilt and frustration I would have from being unable to give back the way I would want. If my mother cried for any reason, I wouldn't even be able to rub her back let alone wipe away the tears I only want to see in times of happiness.
I thought about death. The diaphragm -- the muscle responsible for breathing is also susceptible to ALS' ruthless progression...
"and every second I waste is more than I can take."
The Patient burst into tears. Who wouldn't? All I could think about is not being able to hold my loved ones. Of not being able to carry or play with the future children I hope to have some day. Of relying on others for the rest of my existence...the inevitable guilt and frustration I would have from being unable to give back the way I would want. If my mother cried for any reason, I wouldn't even be able to rub her back let alone wipe away the tears I only want to see in times of happiness.
I thought about death. The diaphragm -- the muscle responsible for breathing is also susceptible to ALS' ruthless progression...
"Feeling so faithless, lost under the surface."
That Patient became Weak. I became Numb.
I became Numb to all the petty worries I usually have. The lack of sensation puts many things into perspective. What's most important. What we can do without. What we should be fighting for. I felt terrible for that Patient. But when you see something like that you become Numb to other things as well. You become less tired, less hungry, and endless hours of studying become less tedious.
"and every second I waste is more than I can take."
These are the Hippos. The intangible human fuel that keeps us going.
No time to be Numb when every second matters.
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Rounds Abound. - Encore
Why are we so tired? And hungry? And why must we study so much?
For our Patients first and foremost...and then for our never-impressed Attendings.
"Don't know what you're expecting of me."
No matter how much we think we know...somehow Attendings always find the chinks in our armor of baby medical student knowledge. It's an infamous relationship -- with flocks of medical students and interns following the single Attending like ducklings crossing a busy street.
"Put under the pressure, of walking in your shoes."
But everytime we are shown that our knowledge -- our Crates -- are not where they should be it only shows us where the holes are so that we may patch them up. I've alluded to it in a previous post, but Rounding and being tested by Attendings is an Encore we have to embrace. Just as we have to accept the Encore of shelf exams after every Rotation.
Just as we have to begrudgingly accept
the Encore of patients who are beyond our help...
...and the resultant hope and renewed resolve that springs
from their strength in the face of tragedy.
"Now can I get an Encore?"
"Thank you, thank you, thank you...you're far too kind."
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