07.you know very well who you are.

[Tamar Braxton - The One]

[Album: Love and War]

which samples...

[The Notorious B.I.G. aka Biggie Smalls - Juicy]

[Album: Ready to Die]

Tamar: 

"'Cause I don't look that far. Look where we are."

This past week was my final one on the Gynecology service, and it was a good one.

What has probably caught me most off-guard about GYN and this whole OB/GYN experience altogether is the amount of Surgery involved. For some reason I had the biggest misconception that OB/GYN would be overwhelmingly Medicine with but a hint of Surgery on the side. A garnish.

I've realized that the split between Medicine and Surgery is nearly equal if not, at times, slightly skewed in Surgery's favor. Of course I may be biased from my past 2 weeks. As far as Obstetrics v. Gynecology goes the GYN service definitely sees more Surgeries and a greater variety of it.

Well. Good thing.

I love Surgery. YOLO.

Biggie:

"Spread love...it's the Brooklyn way."

crate -- 

}}} Hysts on Hysts on Hysts.

I feel as if I've seen so many Hysterectomies that it's a wonder any uteruses (uteri?) are left in the world. I am exaggerating of course but it seems as if removing wombs is the mainstay of any Gynecologist's surgical repertoire. This is one mass-produced Crate and Mr. Ford would be proud.

There are a number of indications or reasons for performing a Hysterectomy...ranging from severe, uncontrollable bleeding to endometrial cancer at the most dire end. By far, however, the most prevalent indication I have seen (and what I believe is the most common one) is for symptomatic Uterine Fibroids...which, yes, in most cases results in the aforementioned uncontrollable bleeding.

Tamar:

"Without you I'm incomplete."

But won't they lose the ability to get pregnant and bear children?

Yes. But fortunately, Patients requiring a Hysterectomy are (most often) Post-menopausal and have either had all the children they desired or have already lost the ability due to the inevitable course of nature and time. This is not to discount the fact that younger women have, very unfortunately, had to receive Hysterectomies as well -- a reality which ranks high on the list of tragic circumstances I wish never existed. All of the Hysterectomies I have seen were, thankfully, in older women who would not miss the priceless ability to bring another life into the world. Though no major Surgery is desirable per say, in the Patients I have seen the procedure was life-saving and took away nothing but a spare organ that was no longer functioning. Thankfully.

Biggie:

"Uh, damn right I like the life I live.

Because I went from Negative to Positive."

As I mentioned in the previous post it is possible to use the Da Vinci robot for Hysterectomies. I've had the privilege of seeing both robot-assisted as well as the conventional 'open' version of the Hysterectomy. There are also different types of Hysterectomies where the one I have most commonly seen is the Total Hysterectomy, followed closely by the Supracervical Hysterectomy where the cervix of the Patient is spared.

At the end of the week I realize there is no better way to learn something than to actually and personally experience it. We took anatomy as first year medical students but I have never understood (as fully as I do now) the relationships between all the ligaments, nerves, and blood vessels that are within and around the human uterus. Just like the confusion that may follow the use of a professional moving service it's hard to remember and comprehend from hearsay rather than from one's own memories. 

What better way to get to know these Anatomy Crates than to pack and ship them yourself?

Despite these Hysts being life-saving. Despite these Hysts having no consequences as far as fertility. Despite these Hysts resulting in little to no Post-Operative complications. I still can't help but wonder what it's like to lose an organ. Yes. Just tissue. Unconscious, non-self-aware cells and mitochondria. 

But it's still a part of oneself. What is that like?

Any kind of loss -- physical, mental, emotional -- is bound to hurt. Right?

Tamar:

"I don't want nobody else.

Baby, all I need is you."

}}} The Ovarian Cancer National Alliance. (www.ovariancancer.org)

We have required OB/GYN lectures every week. And that is just what they are. 

Lectures. Schmectures. Crates. 

This past week, however, we had the greatest privilege of having a presentation from members of the OCNA. It changed the tone of everything. It was the most organic and unpredictable Crate you will ever see.

Many of them were Ovarian Cancer survivors and the rest experienced the blight of Ovarian Cancer within their loved ones. As such, not only were we taught the facts and statistics regarding Ovarian Cancer but some of the presenters would periodically share very personal stories and experiences to highlight just what it is like to experience that which is unwanted and unexpected and in every way terrible.

It's as if they were shipping Crates of Hippos. We learned. Then you opened the Crate to find the surprise Hippo -- and it surely took everything you had to hold back the mixture of surprise and tears and anger. Each personal story seemed to be more tragic and emotionally draining than the last.

Watery Eyes and Clenched Fists.

For the record, here is the most pertinent part of the Crate:

Ovarian Cancer Symptoms

1.One = Bloating

2.Two = Pelvic/Abdominal Pain

3.Three = Difficulty Eating or Feeling Full Quickly

4.Four = Urinary Frequency or Urinary Urgency

Ovarian Cancer is often missed and is, unfortunately, often diagnosed too late.

But you know what?

I'll always remember that Presentation for Ovarian Cancer.

What better way to learn than through Memories and Experiences?

Emotion can make things stick that books and lectures just can't.

Any kind of loss is bound to hurt.

Biggie:

"No heat. Wonder why Christmas missed us.

Birthdays was the worst days."

hippo -- 

}}} Why is Loss the ultimate Teacher?

Watery Eyes and Clenched Fists.

The strangest thing about all this is that we actually had a formal lecture on Ovarian Cancer earlier that morning. The presentation from OCNA was the last item on the agenda. By that time we were all hungry and restless and usually any lecturer to come at that point would have the hardest time holding our collective attention over our Hippo-loud bellies. Peristalsis to the max.

Admittedly, I did not remember anything about Ovarian Cancer from that formal lecture. (I accept all responsibility for that.) Yet. With hardly any pure mental effort I learned and still remember all the facts regarding Ovarian Cancer from the OCNA presentation and from the stories that were shared.

Every one of the presenters that chose to volunteer their personal experience did so willingly and painfully. It was obvious that despite the emotional scars being 'healed' that every word and memory they forcefully resurrected only served to lacerate their deepest wounds even further.

Why?

Tamar:

"It felt so personal.

You took the chance to get my love and now you know."

You know what? It doesn't matter why.

Just, Thank You.

Perhaps it was to fully and excruciatingly illustrate what it is like for those who may never experience it. Perhaps it was to break the monotony of a lecture -- a plain brown Crate -- and add the spontaneity and relative warmth of the Hippo human condition. Perhaps it was a form of personal healing for themselves....a chance...another to attempt to heal what may never be healed.

In all honesty it is likely to be all of the above. 

Just, Thank You.

Biggie:

"Don't let 'em hold you down. Reach for the stars."

A colleague of mine, following the OCNA presentation, remarked how he wasn't ready for that one. It made me think that, with all that we know and don't know, we're probably never ready for 'that one'.

How do you prepare for Loss? 

How do you prepare for something that you can only begin to understand after the frustrating fact?

Biggie:

"'Cause you're the only one. I'll give you good and plenty."

It was the big Hippo in the room. The specter and reality of loss. A lot of the time (and I will speak for myself here) it is gratifying to think of Medical School as a means to save lives. As we delve further and longer into these 3rd Year Clerkships it becomes clearer and clearer how much of a protective bubble Medical School really is.

Now I don't mean to burst this bubble for the sake of the burst. We are surely acquiring tools and attitudes -- Crates and Hippos -- to save lives. But perhaps we should not only learn about Living and Healing but do our best to learn what it is like to experience Love and Loss.

Tamar:

"And ain't none like you. One in a million.

But I'm the only one to count You."

Whether it's part of the Crate-y curriculum or an unintentional and inadvertent surprise Hippo it seems like Medical School provides the means to acquire what a physician will need to care and understand the human condition as best as she/he can. Whether it's a your favorite football team, or a Uterus, or a Life...

Any kind of loss is bound to hurt.

Yet Loss is the ultimate teacher.

It's really hard to forget. Maybe that's the point.

Biggie:

"And if you Don't Know, now You Know."

06.i be stuck to you like glue, baby. wanna spend it all on you, baby.

[Young Money - BedRock]
[Album: We Are Young Money]

Brief Explanation by Request:

Crates: the tangible facts and figures we are supposed to learn in Medical School.

Hippos: the intangible memories and experiences that we inadvertently pick up in Medical School.

"And now we murderers. Because we kill time."

Officially past the halfway point of this two-month rotation in OB/GYN.

Time is flyin', almost as if it's just dyin'. Fortunately, most of the time was spent smilin'.

Medical School has, amongst its greatest powers, the ability to warp time. Each year seems to go faster than the last. Sometimes it's welcome, as with the first 2 years of school, we couldn't wait to get into the hospitals and at least pretend to be doctors -- well we all but blinked and suddenly we're here. Then there are other times when time steals away priceless moments from right under our feet as is, unfortunately, the case with celebrations and farewells.

"I like the way you walkin' if you walkin' my way.

I'm that red bull, now let's fly away."

crate --

}}} Robot-Assisted Surgery

I have spent the past week with the Gynecology service and had my first exposure to the Da Vinci surgical robot. Change and progress is almost always welcome but I couldn't say if the benefits of a metal octopus (as the robot so effectively makes me think of) are worth it. Regardless of anything, however, the Da Vinci is impressive without a doubt.

"Pressin' me like button downs on a Friday night."

The robot itself is controlled entirely from a separate console and has been described as something close to a video game. Button presses and lever movements are translated to the quiver-less movements of each robotic arm. Those of us not controlling the robot are able to see all the action from multiple monitors that output directly from the robot's camera. It honestly looks like Call of Duty...except with tiny arms for guns and pesky fascia as your main enemy. 

The primary idea behind the Da Vinci robot is that it is 'minimally-invasive', which might be the hottest trend in surgery since sliced flesh. It does this through the use of multiple arms, cameras, and interchangeable tools that enter the body using incisions that are no bigger than an inch or so. It's quite ingenious. Especially when you find out the system makes use of CO2 gas to inflate body cavities in order for the arms to have enough room to function. Very clever.

I had the opportunity to assist with two major surgeries involving the Da Vinci: a myomectomy and a total hysterectomy -- both of which were performed as a definitive treatment for Menorrhagia secondary to Uterine Fibroids. 

How far surgical Crates have come. Instead of a wide open scimitar-like gash the Patient enters recovery with 3-5 baby stitches. Improved recovery time is supposed to be the biggest advantage and I've heard of Patients going home the same day or the the day after major surgeries that used to require a much longer hospital stay.

Each procedure approached 5 hours, which to some may sound reasonable, until you realize that the conventional 'open' versions of these procedures may only take 2 hours or less. Debating all the factors that go into Robot vs. Conventional are Crates I am entirely unfamiliar with, but as far as I can tell it's a constant tug-of-war between better Patient Comfort/Recovery and Cost of the Robot/Surgeon.

Is the Change worth it?

"I'll let you be the judge. And I'm the case."

}}} The Residents ended their Rotation Yesterday.

It's not only Medical Students that are shuffled from Rotation to Rotation but Resident Physicians as well. Admittedly I did not realize this until this past week even though it makes complete sense.

"That's when we disappear, you need GPS to find her."

It's a logistical Crate and the only way to make sure Students and Residents are allowed the opportunity to gain the knowledge and experience to become fully-fledged Physicians. 

It was a bittersweet moment, but it was part of the natural order of things in the world of a Teaching Hospital. We are always happy to accomplish something and to have gained not only the knowledge but the memories from time that has transpired. In the end, it ultimately serves as a reminder that time is one of the most fleeting things in existence. Too fleeting in this case.

They were amazing Residents.

hippo -- 

}}} Our Residents ended their Rotation Yesterday.

We have our First Hospitals. We meet our First Patients.

And seeing us through all of this are our First Residents.

It's an overused joke that July is the worst month to get sick and go to the hospital. Just like Zedd's Clarity, however, there is a reason popular music is constantly replayed on the radio and a reason why sayings become cliche. There is truth in the saying....and sometimes solid lyrics with a good beat.

First Year Residents/Interns historically start on July First along with 3rd Year Medical Students. Everything is new. Everything Changes. Everyone is trying to learn and adjust to different challenges, temperaments, and environments. The few Attendings and the handful of Veteran Residents are stretched thin in their HippoCratic obligation to their Patients and their dedication to Teaching.

As a Medical Student the sentiment is made very clear -- that we should not be in the way, learn all that we can, and should not be in the way. We hear horror stories of getting less-than-courteous superiors and of the ceaseless 'pimping' that goes on to simultaneously show us gaps in our knowledge while shattering any remnants of self-esteem.

I'm not sure if it is an anomaly but none of that really happened. It wasn't smooth and easy by any means. There were definitely more than a handful of times when the red hot spotlight was focused on us and the only escape was the dreaded sign of defeat, confessing: 'I don't know.'

"Don't stop you the bestest.

And I be coming off the top as-bestos."

We didn't dodge the usual rites of passage...where we fully realize our position at the bottom of the totem pole. We were told we were wrong. We were relegated to the furthest corners of operating rooms. We were interrogated about extensive lists of differential diagnoses and medication dosages. It was tough, but it was constructive. Tough-structive, if you will.

It seemed like our Residents knew exactly what we were going through and what was going through our minds. Of course when I think about it I give myself a mental slap in the face because for most, if not all, Residents they literally were in our position at least sometime in the last 5 years or so -- of course they knew. (Duh).

"Running back and forth -- soccer team."

As such, there was never a moment where we felt dumb or deficient. When one is 'pimped' and you don't know the answer it's a law of the universe that you never get that question wrong again. Now.

That law is fulfilled in one of two ways:

1.One. 

You feel guilty and inadequate so you learn the answer to escape negative thoughts/feelings.

2.Two. 

You are disappointed. You let your Attending/Resident down. 

You want to make them proud and there is no way you're going to let that happen again. 

You are, in a way, inspired. Driven.

It seemed like more of #2. One month. Our very First month as 3rd Year Medical Students and our First foray into the wards and clinics as pseudo-professionals...it could not have been better -- learning has been running on encouragement instead of being driven by guilt and that is without a single doubt the best way.

As far as Hippos go, encouragement is a much better fuel.

Hungry, hungry Hippos could never get enough.

I hope it doesn't come to pass that this experience truly was an anomaly. Regardless, whether this is normal or not, I know that our Residents made it this way. They were the First to start shaping the blank slate of our clinical acumen. Undoubtedly we will encounter a countless number of Residents in our career but none of us will ever have another set of First Residents.

These weren't just Residents or the Residents. These were Our Residents.

"I'm too loyal, and too focused.

To be losing, and be hopeless."

Really gonna miss them.

}}} The Double-Edge of Emotion

In discussing the sentimental repercussions of our Residents leaving, a colleague lightly joked that it is our duty to not get too emotionally attached -- that any Emotion in our profession is a bad idea. This is especially the case for our Patients, so as to not erode our objectivity and clinical judgement.

I agree.

(But that comes with a sharp pang of resistance.)

"Okay, I get it. Let me think. I guess it's my turn."

Because -- I don't agree that there should be zero Emotion. 

At that point we are just as good as the Da Vinci robot. Sure we may be a tad more precise, and we will be less shaky. We will move with greater surety and deliberation. But without anyone or anything at the controls we are useless. 

Who drives the robot but the human at the Da Vinci controls?

And what drives us but the Passion for our work and genuine Empathy for our Patients?

Emotion is the human fuel. Without it we have no explanations for what we do. No motivations for what we do. Medicine is an Art as well as a Science? A Hippo as well as a Crate?

Then we'd only be fulfilling half of our obligation. We would be practicing half-Medicine if we deny that part of us that makes us perfectly imperfect. There is such a thing as too much Emotion, there is no denying that, but to be devoid of it is just as bad if not worse. (At least Emotion provides Purpose).

Why do we care for terminally ill Patients?

Why do Children's Hospitals look different from conventional ones?

Why haven't Da Vinci robots taken over?

Why, despite the constant and accelerating pace of change in Medicine, 

has the role of Healer generally stayed the same for thousands of years?

Because we are Human. Only we could possibly come close to understanding what we are each going through. In the end, Change is generally good. Our Residents are moving on to master a new set of skills and circumstances. We, as Medical Students, will learn a fresh new set of Patient approaches and clinical techniques from the next set of Residents.

But, I can't deny that I'll miss Our First Residents. 

I'll leave the emotion-less circuits and calibrations to the robots.

Hippos don't run on electricity.

"Cold as a winter's day. Hot as a summer's eve."