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.

12.what the hell are you waitin' for?

[Jay-Z featuring Linkin Park - Numb/Encore]

"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.

-----

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'"

-----

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.

"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...

"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.

-----

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."

08.its like -- people only see it the way it appears...

[B.o.B. - Where Are You? (B.o.B. vs. Bobby Ray]
[Album: Strange Clouds (2012)]

"but they never see the ropes and the pulleys and the gears."

hearts run on more than you think.

It has been a good while since I've been able to verbally unload unto this project -- my life raft -- bobbing up and down in the middle of this purgatory ocean known as the internet. At least it hasn't become sentient like Skynet with the subsequent enslavement of mankind...amiright nerd friends?

(Nerd Warning: Terminator Reference)

I have an explanation, however, and not an excuse I might add. Excuses are lame. Let's all just own up.

Yesterday we took our National Board of Medical Examiners (NBME) Shelf Exam for OB/GYN. And when I say we it wasn't just my group of baby catchers that took our end of rotation exam -- my colleagues in Pediatrics, Medicine, and Psychiatry also took their respective exams. In fact, my other colleagues in Family Medicine, Neurology, and Surgery should be close to finishing their exams as I write this.

So although I would much rather make feeble attempts at eloquence here I can not ignore the Crates in life no matter how bland and heavy they are. For better or worse these Shelf Exams are fairly heavy Crates at that.

crate -- 

}}} These are not the Shelves you are looking for...

I've always wondered why they are called 'Shelf' exams at all.

Do they literally keep these exams on a Shelf?

Do they mean we can put all our knowledge on the Shelf after this exam as we prepare for the next Rotation?

Do they intend for us to eventually turn it into a snazzy verb: "Yo bro, we just got Shelved!"?

We may never know. But one thing I do know is Shelves were made for Books and Papers and Crates and definitely not for Hippos. Definitely not. It's hard to find time to relax, and sleep, and write with a Shelf Exam around the corner.

As 3rd year Medical Students we are acutely aware that our grades are split somewhat evenly between our Clinical Performance throughout the Rotation and our Academic Performance on the Shelf Exam at the end of the course. A logical and perfectly acceptable system in my opinion. It's essentially an assessment of our Hippos and our Crates, respectively.

With that said these Shelves -- these Crates -- are designed to survey and make sure we've acquired enough technical knowledge and that we've memorized enough facts and figures to function adequately enough within the specialty we just experienced (at least at the level appropriate for this stage of our Careers.)

If we are lucky we learn what we need to learn in the best and most natural way possible: through experience with our Attendings, Residents, and Patients. No book or exam could ever make a fact stick the way a life experience effortlessly does. One can read about delivering babies in every textbook ever written and still not know where to stand, what to do, or what to say...let alone what to feel.

But experience even a single birth on Labor & Delivery and you will learn most everything you need to know. And you won't forget it. The best part? In the process of this effortless learning you fill in for yourself the gaps that Crates could never fill -- all the emotions and relationships that are the wonderful byproduct of being human -- the Hippos.

If Pictures are worth a thousand words...

then I submit that Experiences are worth a Million...+Infinity...+1.

"blood, sweat, and tears...

we cry blood all we sweat is tears."

More often than not, unfortunately, we don't have the opportunity to learn and see what we need to in the best way. For everything else we have to rely on the Crates (much like the first two years of Medical School) in order to obtain what is expected of us.

That can be a challenge given we spend most of our days nowadays in the Clinics and on the Wards. The last thing we all want to do when we get home is to crack open another dense Crate of books and endless question banks. 

We want to have an actual meal. We want a non-medical conversation. We want to laugh, and dance, and give libations. Never have I treasured 'trashy' and 'mindless' TV entertainment more than I do now. 

It is this need to be the un-scrutinized versions of ourselves that is constantly at odds with our drive to give all we have in the pursuit of our Careers and our future Profession. It's a tall order, but it is exactly what we signed up for. And in that respect this might be exactly the Shelves we are looking for.

"we put it all on the line, we gave up all our belongings..."

The Shelf like most, if not all, things in Medical School is our time to shine and prove ourselves. Not to outshine others but to collectively shine brighter than any singular source could ever hope to illuminate. But above all it is another way that Medical School seems to be testing Balance. The way we manage our time between Clinical Mastery and Academic Excellence. The way we manage the requirements and expectations of Medical School and the leisure time that keeps on dwindling away. Ultimately, it is testing the way we balance our time between our Attendings, our Patients, our Exams, our Loved Ones, and Ourselves.

Whether we all fully understood it or not (probably not) this is what we signed up for. Even though we may hate to admit it at times this is what we wanted and we wouldn't trade it for anything. Through the endless Crates I know we all find those hidden gems -- those fun little Hippos -- that remind us why we are doing what we are doing.

Congrats to all my colleagues on finishing this past Rotation and break a leg on the next one.

Here's to a Crate-free weekend (hopefully). After all, we just got Shelved.

"I live and die for my team...

these n****s are more than my homies."

hippo -- 

}}} Seesaw and what you See and what you Saw.

Balancing everything is hard.

Especially when what you Want to do is different from what you Have to do.

As Medical Students it is probably our families and loved ones that deserve the most praise as they hardly get enough recognition for the support and comfort they offer.

"We never hear from you, you're constantly changing.

And your relatives always miss you, at family occasions."

Being 3rd Year students maybe they're used to it now. Never understanding how or why we would spend hours upon hours sequestered away in libraries and coffee shops. Never understanding how academic performance and exam scores could dictate the rest of our lives. Being confused as to why we stress out at every minute not spent trying to memorize some fact or digesting some new concept. 

Even though they might be used to it after 2+ years of what may have been begrudging acceptance it doesn't make it any better. The recent experience of taking the Step 1 Exam is one filled with Hippo-sized sadness at times. Most of the time we are at least aware of the time we spend with our books instead of our loved ones. The weight of something like the Step 1, however, is so burdensome that one can even forget that much -- focusing all of one's existence on a set of questions and an eventual number that can determine what you do and where you live for the rest of your life.

"But we'll still stand beside you, 'cause somewhere deep inside you...

there's more than what meets the eye."

Our loved ones are always there though. The one's that matter most.

If there's one thing I took away from this past rotation it's that Crates are unavoidable and that Hippos are essential. Yes, I've learned how to deliver babies and how to assess and promote women's health. Above all, however, it's been a huge seesaw and the hardest balancing act of Medical School thus far. The only way to get through this relatively intact is with the homies that got yo' back.

"I watched my whole life change, in a couple of years.

Who woulda ever thought?"

The secret seems to be investing in people and relationships when there is any doubt. We should never ignore them but the Crates will always be there -- Hippos on the other hand are fleeting. I've realized my books and notes will still be there when I get back, but I could never raincheck a new inside joke or memory.

You can't buy those human connections but you can find them. And grow them. The Beatles (best band ever) were right on when they sang: "Can't Buy Me Love."

When I finished my OB/GYN Shelf Exam yesterday I naturally and instinctively sought some definitive closure on the subject. As I was answering the last 10 questions of the 100 question exam (and as I became more and more zombie-like as a result of extreme hunger and sleep deprivation) I thought about the most memorable aspects of my Rotation.

What I realized is that they all involved people:

-The hilarious OB/GYN-related nicknames my colleagues and I made for each other.

-Bonding with my Attending from L.A. over hip-hop and playing Too Short's Blow the Whistle while closing an incision after a Hysterectomy.

-Fighting off sleepiness on the Night Shift by teaching my Foreign Resident some common slang and pop culture conventions.

-Making eye contact with an Attending above her facemask and seeing her eyes fill with water and determination during a STAT C-section.

-Serving Birthday cakes in cups because we never had plates.

-Realizing that Attendings and Residents want to sneak away and find a cup of good coffee just as much as we all do.

-The patient who kept calling us "Doctors" despite constantly telling her we were just Medical Students because she was so grateful for her care and believed in us so much.

Call me biased but these are what stand out most. These are the important things and are the Hippos that could never be replaced. It is impossible to write a textbook on this, but if we have a cup a coffee together I could relate and relay at least a few.

"so hood, but so different at the same time.

It was like a breath of fresh air everytime he rhymed."

Balancing the seesaw of Medical School is something we will all have to continually tweak from time to time. It's not always rainbows and gumdrops as it can be flat-out terrible at times. But it is the absolute best feeling when those most important parts of your life result in experiences that are priceless and irreplaceable.

When I look back on this OB/GYN Rotation -- my first Rotation -- I will See the grade and the evaluation of my performance. But I'll remember that I Saw the frustration, motivation, and outright silliness that makes life worth living.

We got Shelved.

"I swear this sh*t is so much bigger than I had figured.

But if this wasn't meant to be this wouldn't be my Career."