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.

14.it's not much of a life you're livin'.

[Rihanna featuring Mikky Ekko - Stay]
[Album: Unapologetic]

"round and a round and a round we go."

Finished Week 3 out of 4 on Neurology -- this one spent on the Neuro ICU floor.

Edit: I started this post at the end of Week 3. I now finish this after the final week and immediately after the Neurology Shelf Exam. Entry shall be adjusted accordingly. sho nuff.

The Intensive Care Unit is as Medicine as Medicine can get.

Although the unit I was in this past week had a Neuro focus it allowed me a quick glimpse at what a general Medical ICU might entail. Despite the Neurological emphasis, every single organ system was still reviewed and examined. Cardiovascular. Respiratory. Renal. Gastrointestinal. Genitourinary. Younameit. The Medicine I saw this week was so thorough and all-inclusive -- at times I forgot I was in my Neurology Rotation. Conversations concerning other body systems, more often than not, took center-stage as the Residents and Attendings scrutinized every detail to ensure the most fragile of Patients did not deteriorate any further.

"I threw my hands in the air, said, 'show me something.'"

I've often wondered what Intensive or Critical Care Medicine would be like. I braced myself at the beginning of the week because I wasn't sure what to expect. It turns out, possibly, that this past week is the most I've ever learned within a one week span as a 3rd year medical student.

In my head, and in general, hospital specialties tend to be roughly divided between the Medical Specialties and the Surgical Specialties. If nothing else, this past week has me convinced that the kind of thinking and consideration that go on in the ICU warrants a third designation...or perhaps a hybrid of both.

In Medicine one talks and forms differentials for hours.

In Surgery one stands and manipulates instruments for hours.

In the ICU one does both. At the same time.

It's Inspirational and Intimidating and Intriguing. All at the same time.

Maybe the "I" stands for all of those instead of 'Intensive'?

crate -- 

--I.C.U.

If Medicine is analyzing every symptom, every Crate, to diagnose what's wrong...then ICU Medicine is analyzing every last splinter of each Crate AND all the nails that hold it together...just to keep Patients alive.

The first couple of days my brain was pretty much swimming. Most of the words spoken between the Residents and Attendings went right over my drowning head. I feel that we have been trained and conditioned so well to look at the body just one system at a time, with limited thought as to how complex the interplay can potentially be within the human body as a whole. That's not a surprise, however, since as aspiring Physicians we know we have to put all the different Crates we are learning together like puzzle pieces into a final mosaic -- a final diagnosis that we can act upon. The surprise, instead, is that ICU Patients have multiple body systems failing. Too often, every single organ system is failing. As a result, there is no single Medication or Procedure that can fix ICU Patients. That kind of luxury does not exist.

"It's not just something you Take...it's Given."

And here is where I left off before embarking on a frantic week-long study binge for the Neurology Shelf Exam earlier this morning. Admittedly, the Neuro ICU experience is not as fresh as the day I originally started this entry. Regardless, it's still an experience that is hard to forget. And you know what? That is one thing that, in particular, sticks and hits home harder than Miguel Cabrera of the Detroit Tigers (holla). Nothing about the Patient can be forgotten in the ICU, lest you overlook or counteract a vital fact or exam finding. Allergies? Recent anticoagulation medications? Renal excretion and toxicity? Increased PEEP ventilator pressure leading to decreased venous return?

It's a veritable rodeo in there.

"Oh now, tell me now, tell me now, tell me now, you know."

Micromanagement in its most excruciatingly pure form. That is the Crate that is the ICU. Every microliter or microgram of anything that enters or leaves the body is recorded and accounted for. Every organ system is monitored as intensively as NASA in Houston does for every spacewalk (possibly a slight exaggeration here, but you get the picture). As a result the Attendings on this service are like hawks, with oversight that would put the visual acuity of eagles to shame. I was very impressed with the decisiveness and breadth of knowledge that the Attendings, Fellows, and Residents had while caring for the sickest of Patients. In a way, you see...or try to see everything in the ICU. I was blown away.

"It takes me all the way."

hippo --

--I. See. You.

So many labs. So many disease processes. So many medications, procedures, and intertwining differentials to carefully and methodically tease apart. It's a wonder there is any room left for Hippos with all these Crates.

But they always persevere in Medicine. Duh.

I technically experienced a death during my week at the ICU. I regret not having the privilege of meeting the Patient while they were lucid and conscious, but perhaps its for the best -- as the personal connection may have just destroyed me.

I learned, initially, about the Patient's story from medical histories and Physician's notes. I did my best to learn everything I could about him because I secretly and fervently hoped that, even with the slimmest of chances, I might find something that the busy Physicians had overlooked and could use to reverse the Patient's, then, comatose state. I found nothing.

"All along it was a fever."

It started with the mildest of symptoms... a low-grade fever and a throbbing headache that persisted and could not be attenuated by over the counter medications. The Patient was found to have a Subarachnoid Hemorrhage that prompted an immediate trip to an ER and then an OR. I found nothing.

"A cold sweat, hot-headed believer."

I still kept on looking. Believing. Digging through years old medical records and CT scans. Even though I found nothing I thought it for the best that I knew this Patient inside and out, so that I could relate his story and predicament with every new Attending and Resident I came across. I wanted to know him because that's what you do in the ICU -- you look at everything and you don't forget.

None of us believed he had any family. No visits. No contacts. I found nothing.

The day he passed away, however, was probably the day I got to know him best. His wife came. Yes, he had a wife -- and one that without a doubt loved him dearly. She allowed us to remove his endotracheal tube and free him of the necessary monstrosity that is the mechanical ventilator. His sister came. His aunts and uncles came. Two of his daughters came. His grandchildren came and almost unleashed the safety valve on my tear glands when they saw their grandfather like they had never seen him before.

No medical records, lab value, or diagnostic image could have allowed me to see him as a person more clearly than the day he passed away -- when family member after family member filed through to say their goodbyes and have their final conversations.

ICU. I See You.

I get it now.

"He said, 'if you dare...come a little closer.'"

--Shelf Exam. Self Exam.

I thought about him today. I had a question that matched, pretty closely, my Patient's initial presentation to the hospital. I'd like to think I got that question correct -- because I saw it in the ICU. Because I saw him.

3rd year clinical clerkships are a unique experience. In many ways it's the same rinse and repeat story we, as medical students, are all too familiar with. Another month? Another rotation -- punctuated at the end by another Shelf Exam. Been there. Done that.

But I am seeing it all around me. A slow transformation. Yes, it is extremely repetitive. Sometimes it can be, admittedly, extremely boring. At all times it is most definitely tiring and taxing in more ways than one. But I am seeing hints, here and there, of what I looked up to in my Pediatrician and in other clinical mentors I've encountered in my short life.

The way my colleagues carry themselves. The style and content of the conversations we now have. They are almost entirely different from the ones we had two years ago. And although we are far, far from being full-fledged Physicians...the only way I can describe this new style and culture...it's all very 'Doctor-ly'.

"Funny you're the broken one, but I'm the only one that needed saving."

My ICU Patient was sick. And although he never opened his eyes or said a word he inadvertently showed and told me more than I could have ever imagined. He may have been physically ill but he was the one that helped me feel better and more rejuvenated.

There's probably a reason Medical Education is the way it is...and has been for well over 100 years. It is tiring, and boring, and frustrating, and on the surface it can be a waste of time. But experiences like this are hard to come by and are too valuable to miss. 

How else can we gain this insight? 

How else can we become Physicians?

"'Cause when you never see the light, it's hard to know which one of us is caving."

And for all the Practical individuals out there...all these intangibles...this anecdote and this 3rd year experience. Well, again, I'd like to think I got at least one more question correct on today's Shelf Exam. So yes, there is a technical gain in all of this. A little surprise Crate if you will.

If you ask me, however, every Shelf Exam deserves a Self Exam.

I saw a lot in the ICU.

Ultimately, I saw myself in the ICU.

No doubt I called my Mother and Father that day after being "busy" for the past 2 weeks.

"Makes me feel like I can't live without you."

I only wish I could have had a conversation with him.

I want you to Stay.

13.if i told you that a flower bloomed in a dark room, would you trust it?

[Kendrick Lamar featuring Drake - Poetic Justice]
[Album: good kid, m.A.A.d city]

"But I can never write my wrongs unless I write them down for real."

"P.S."

Just finished Week 2 of my Neurology Rotation -- well into the swing of things, more or less.

As much as I like to fly off into the comfy fluff of unspoken emotions and heart -warming/-breaking stories I realize one can't be so airy as to lose sight of and acquaintance with ever-so-reassuring solid ground. I hope to veer slightly back towards practicality and reality. This is not to say that the wonderful Hippos I try to find along the way are irrelevant, but that they do somewhat lose value when concrete events are ignored.

I could reflect on the death of a patient forever -- which I thankfully, have not personally experienced yet. I could tease apart and attempt to decipher the whirlwind of emotions and the facial expressions of everyone around me that say so much without a single verbal utterance. But when it comes down to it, I would rather have been skilled or tactful enough to have saved that life. That requires Crates. 

"You live life on an everyday basis."

I suppose what I'm trying to say is that the intangibles are important and necessary in my humblest opinion. Yet despite their vital nature it does represent a type of wishful thinking that has difficulty manifesting in our reality of disease and various injustices. I've been getting carried away with the Hippos, admittedly because of my deep bias favoring them.

Like Anakin Skywalker's destiny it's time to bring balance to the Force. 

(Nerd Reference: Star Wars)

It's appropriate, as this past week has been full of slightly sobering realities. The Crates we have learned up to this point have been purely academic -- symptoms, medications, statistics, etc. Now that we are in the hospitals and out on the wards there are other Crates to pay attention to lest we miss them altogether. Politics exist and the teamwork required of modern medical practice is, more often not, plagued by the double-edge of social tension and clashing identities.

It's time to deflate a little. Air can be thin when too far up.

"I mean I write poems in these songs, dedicated to you when...

you're in the mood for Empathy, there's blood in my pen."

crate --

:::Consults and Progress Notes

The most obvious Crates are all the symptoms, lab tests, and other clinical signs that we attempt to memorize and recognize within our Patients -- all in an effort to alleviate or avert illness.

All well and good. But from the surgically inclined specialty of OB/GYN to the uniquely subjective nature of Psychiatry I have finally spent considerable time in the relatively conventional inpatient world of Neurology. With that comes the monolithic reality of job duties and paperwork.

Physicians do not simply live in a House M.D.-like world where they can sit in rooms of glass and metal contemplating diagnoses all day errday. Yes, differentials and discussions are made but documentation is key and central to the practical reality of Physicians and other healthcare professionals. Like other professions it's not as glamorous as media and pop culture make it seem.

"They say conversation rule a nation, I can tell."

In fact, what I've realized and experienced thus far has me convinced that more and more of a Physician's time is spent pouring over laboratory results, diagnostic images, and notes from others rather than actual face time with the Patients themselves. This is before the Physicians go ahead and write their own daily Progress Note. The process takes forever. And it's repeated all day errday.

The added responsibility of Consultation adds another dimension. The various specialties that make up modern Medicine not only have an obligation to the Patients within their service but also lend their knowledge and insight to Physicians in other fields when needed. That package deal comes with even more note sifting and literature searches -- so much so that Physicians can effectively be described as data miners if one wants to get technical.

"Everytime I write these words, they become a Taboo."

It's a lot of work, but there's no way around it as far as I can tell. Documentation is everything these days, with multiple Physicians in multiple specialties from multiple facilities working on the same Patient. I am not even going to delve heavily into the legal implications that can result from shoddy records and Physician dictations that are any less than pristine and meticulous.

It's a lot of work. Welcome back to Earth.

"Read slow and you'll find, gold mines in these lines.

Sincerely, yours truly...

...and right before you go blind"

"P.S."

hippo --

:::Teamwork and Division of Labor

It's a lot of work. It's also, as aforementioned, not anywhere close to the satisfying drama of Dr. Meredith Grey's life or the comedic antics of Zach Braff and Donald Faison on Scrubs.

Modern Medicine is a team sport. A good thing. Though where before it may have been a pleasing innovation in the healthcare field, it is nowadays, seemingly, a core requirement -- Physicians can no longer operate solo like the practitioners of old.

"And they say communication save relations, I can tell."

Above everything we are and always will be Human. We are social creatures for all the double edges that it comes with. Patients have the ability to annoy us. Our fellow colleagues can annoy us. Sometimes we have bad days -- we lose our keys, we argue with significant others, we get pimples on the most visible and prominent parts of our face. Life happens. Human life happens.

On more than one occasion this past week I have heard my Residents vent about life, about inefficiencies within the system, about other Residents or healthcare professionals not picking up the slack. They are not complainers by any extreme means, nor are they particularly diva-ish drama queens. More often than not I agreed with them...or at least saw where they were coming from and could not blame them for what they say and feel.

"A fatal attraction is common.

And what we have in common is pain."

These are far from the facts and figures I've originally described as the Crates we are here to learn concerning Medicine. It's far, even, from the Consults and Progress Notes -- those tangibles -- that I've described above. These are the raw Hippos that I can only now see and appreciate as a 3rd year medical student on the wards...the need to interpret social situations and balance the tight rope of one's personal viewpoints alongside the 9 billion others that exist in this world.

Sometimes we have to put aside differences to keep everything smooth. To ensure that Patients receive quality care. Sometimes we have to take a time out and let our closest companions know what is going through our minds before we supernova explode -- even though we know nothing will change. Sometimes we need to suck it up and grow up so that we can let others know how and what we feel....so we can finally finish that darn Progress Note and hopefully see that next Consultation.

Maybe at that point I could get lunch...maybe? Want to join?

"Every second, every minute, man I swear that she can get it."

Even with all this seemingly 'harsh' reality it still stands that nothing can overshadow this profession in my mind. In fact, it may be all this conflict and hidden turmoil that partially attracts me even more towards this calling. Physicians, after all, take an oath to take care of People. Human Beings.

And who better to take care of them than us Humans with our wonderful inefficiencies? 

Yes, I want to take care of my fellow men and women. But in doing so I don't want to give up my Humanity. That package deal comes with complaints, and he-said/she-saids, and late-night delirious laughter. It comes with others. And I would hate to be alone. Who will laugh at my not-funny jokes?

So I'll take it.

It's nice to feel solid ground from time to time.

"Poetic Justice, put it in a song."

When you figure out you need someone.

When you figure out it's alright here in the City.

And you don't run from where we come from.