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.

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."