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."

05.take notice of what's in front of you. 'cause did i mention you're 'bout to miss a good thing?

[Alicia Keys - You Don't Know My Name]

"I must really like you.
'Cause not a lot of girls are worth my time."

All of us have a week of Night Shifts where we reverse and do our best to ignore the taunting tick-tock of our biological clocks. It is a slightly different dynamic but one that is welcome, however, as new opportunities to experience human quirks almost always outweigh any downsides that life may haphazardly litter on the roadside as we plod, sweat, and smile onwards.

crate -- 

}}} The many Faces of Magnesium Sulfate.

I am convinced that if you were to start an OB/GYN practice the first thing you should order is a Crate of MgSO4. After another week of Obstetrics in Labor & Delivery, albeit on the Night Shift, there is no other IV medication I have seen used more than good ol' Mag.

Just some of its Uses:

-As a Tocolytic to stop/slow Uterine Contractions.

-Seizure prophylaxis for Pre-Eclampsia.

-Neuroprotection against Cerebral Palsy in Pre-term Infants.

-First line for Torsades de Point during a cardiac emergency.

Perhaps it is because we had an unusual amount of pre-eclamptic Patients or those undergoing pre-term labor (sometimes both)...and if so then my sample of Patients this past week has been ridiculously biased -- but regardless it seemed as if every Patient I saw on our Board had a Mag IV drip in place.

It's definitely a workhorse as far as Obstetrics go, but as useful as a Crate of Mag can be there is such a thing as too much...so no Costco-sized Crates allowed. (Which is unfortunate because I love Costco).

We must do clinical 'Mag Checks' every 4-6 hours on every Patient that is receiving MgSO4 to avoid Magnesium Toxicity. The symptoms range from the loss of deep tendon reflexes to cardiac arrhythmias to death. So every 4-6 hours or so we would check in with every Patient -- first checking their reflexes, listening to their lung/heart sounds, and finally ensuring that all their lab results are within normal limits.

I enjoyed it every time. It's our responsibility as healthcare providers and is yet another opportunity to learn more about our Patients needs and hopes and Jell-O preferences.

Sometimes Cherry Jell-O doesn't cut it and Dear Patients: we are listening.

-------

I overheard a staff member remark on the mundane nature of Mag Checks and I got slightly upset. Just a little bit. Not a lot a bit, mind you, as when someone cuts you off on the highway and you miss your exit and somewhere in the world a kitten dies.

More like a summer day, with blanket-thick humidity, where you wait an hour in the ice cream line and the tiniest scoop ever served by mankind falls off your cone. (Now that I think about it this might be a scenario where I would be more than a little upset...but I'll stick with it.)

Yes, Mag Checks are repetitive and the Patients are always fine -- when we go ahead and check serum levels of Mg they have always been far below the level needed to even start considering toxicity.

And Yes, it is very possible (since we follow tried and true protocols) that Mag Checks are not technically necessary and our Patients would be perfectly fine without them.

But it's not about that.

"Round and round and round we go.

Will you ever know?"

It's part duty and part principal. 

No matter how unlikely Mag Toxicity may be, it should be difficult for anyone to admit Professionalism when they haven't taken every step and every precaution to make sure mistakes are avoided. If even one life -- a single life -- were saved in the entire history of Mag Checks it will have been worth it...and though I can't say with 100% certainty I am sure that lives have been saved by this 'boring' and 'waste of time' activity.

Beyond that there is the Trust that all Patients have for the healthcare team. When any healthcare professional is nearby -- from Physician to Nurse to EMT to what-have-you -- everyone breaths a little bit easier. It would be insane to let boredom defeat that Trust and for it to allow our Patients to get sick.

Crates are brown. They are wooden boxes with little adornment beyond some kind of hastily painted on identifier. Crates are pretty boring. 

But it's not about that.

It's about what's inside. The possible contents of a Crate are immeasurable and the value of its contents can often mean one thing to one individual and something entirely different to someone else.

The Mag Check Crate? I enjoy it everytime. Hopefully it is always enjoyed in its mundane, repetitive goodness everytime...especially because it is so wonderfully boring -- so boring that I one can not help but listen to the Patient...and to remember to bring Orange Jell-O the next time around.

hippo --

}}} Just because you Don't Know doesn't mean You Know.

Working Nights means interacting with Patients when they are potentially at their grumpiest. Whether it's a Mag Check, a late Consult, or something odd we notice on our monitors...we often have to wake our Patients up -- and I can't even be mad at some of the comments and reactions we receive as a result. I can become something else when I lack sleep, which is often accompanied by the urge to Hulk-smash miscellaneous objects.

We had a Patient who just seemed to be on everyone's nerves. She eventually resorted to howling and disturbing the relative peace of our beloved L&D floor. Why were we repeatedly waking her? She let us know (and I mean let us KNOW) how long it takes her to fall asleep and that once she is woken up she is often up for the rest of the night until morning.

I reviewed her records and the Resident inquired about her care throughout the night from the Nurses to see if everything we were doing was correct and necessary. As far as we could tell we were in the right. We felt like we knew.

Perhaps she was just being a brat (and not the delicious kind served with sauerkraut).

The Resident and I went back into the Patient's room, but in a pleasantly surprising change of direction the Resident asked, "how can I best take care of you?"

Not, "how is your pain doing now from 1-10?"

Not, "your temperature is down and your labs are back to normal so you should be fine."

Not, "I am almost done with my shift so, although it's early, I woke you to perform my duties."


Patients are not all the same. 

Physicians are not all the same. 

No one is the same.

That question, however, especially the way it was phrased showed acknowledgement of that fact. That the Patient wasn't a run of the mill Patient...because no one is. It showed a genuine inquiry and concern for her well-being. We learned a lot after that.

We learned that her home had just been robbed. We learned that her husband just left her. We learned that she is working 3 jobs and that she worked herself to the bone and just earned her GED. We learned she is worried because she will soon have her first child and she never envisioned being in the situation she is currently in. We learned that actually she was alright with all of that, she accepts responsibility for everything she has and is and all she wants is that ever-elusive sleep that she barely gets enough of.

Could we adjust the monitor leads so as not to disturb her? Yes.

Could we give instructions to the next shift instead of completing our checklists early? Yes.

Could we stretch any absolutely necessary checks to the very last second to afford her even another priceless second of Dreams? Yes.

There is a lot we could do and a lot we began to do.

We didn't know anything about her. Why did we think we knew anything?

"...and if you don't know, now you know...*****"

-The Notorious B.I.G. (a cameo for this post)

I like coffee and music and conversation and wingtip shoes. I'm sure there are those who could care less for such things and have different Hippos they value...maybe cars and glassblowing and technology startups and thumb-wrestling.

Hippos can be grumpy but there is often a reason why. Maybe like the lion she/he just has a splinter in her/his foot. I guess it's up to us to be as humble as the mouse to find out and treat what is important to each and every Patient.

"You don't know my Name.

Will you ever know it?"

}}} Babies are Awesome.

When I think of the tiny people race we call infants I just think of tiny little stem cells -- little pluripotent amorphous blobs of the Human Race. I don't have too much Hippo to go along with this sentiment beyond what I've already expressed except to admit how pleasantly surprised I am.

I had always written off OB/GYN as a potential specialty since the wheel was invented. 

But, although the possibility is very far off...the thing is that there is a possibility at all. OB/GYN is on the consideration list. Someway. Somehow.

"Baby, baby, baby. From the day I saw You.

I really really want to catch your eye."

Those little ewok-hobbits, without fail, always remind me that I'm not really that exhausted...the world really isn't that malicious and life has its strength within its fragility. Those pudgy, saliva-factories always make me smile and I forget about my silly human selfish worries every single time. Every single time.

I may never know their Names. I will never know a lot of things.

Fortunately, Humans don't just know but feel and burp and imagine.

This week, above everything, I learned just how clueless one can be and how easy it is to fall into the illusion that one has avoided a blissful pit of ignorance.

It's no biggie (biggie biggie can't you see?) to fall into the hole, just pull yourself out!

"and my Manager be trippin' and stuff.

Talking 'bout we gotta use water.

But I always use some milk and cream for you."

Will you ever know it?

04.just a city boy. born and raised in south Detroit.

[Journey - Don't Stop Believin']

"he took the midnight train...

...goin' anywhere."

Michigan Central Station.

This past week was spent on the OB/GYN's Ambulatory/Outpatient Service.

A distinctly different take and approach on the Medicine I've been exposed to up until now.

Naturally that means a different brand -- a different set of glasses to look through.

This is Life. This is Strife...and as always the chance to appreciate all the things that make us Human are Rife.

crate --

}Papanicolaou Stain ('Pap Smear')

Infamous.

Almost undoubtedly more-so for all the Women out there. (And thank you for going through so much.)

It was encouraging that almost every Patient that came through our Outpatient Clinic received a Pap Smear, if warranted, whether it was the primary reason for their visit or otherwise. By warranted I mean according to currently accepted guidelines which is generally anyone 21+ of age and every 3 years thereafter (other considerations notwithstanding).

[and with that...any of you that are 21+ and have not had one in the past 3 years I strongly urge you to schedule an appointment with your Primary Care and/or OB/GYN.]

But Why?

Only because it is up there as one of the most successful Crates within Preventive Medicine in recent history. A relatively simple and straightforward exam/procedure has led to a significant decrease in the incidence of Cervical Cancer.

Needless Procedures, Costs, Worry, Tears, and Death -- all avoided. Definition of Medicine.

There are the Crates we are looking for.

(Note: mild Star Wars reference)

"just a small town girl. living in a lonely world."

I can only imagine what the experience is like despite the Pap Smear being described as relatively "quick and easy" -- which is to say I have no idea at all what it's like and never will know. Nonetheless, I've had the privilege of conducting a number of Pap Smears under the ever-watchful eye of my Attending Physician and always tried my best to have Patient's interests and concerns at the forefront of my mind.

You are in a compromising and vulnerable position. The table might be cold or the room might be stiflingly hot (like it is now) or maybe everything is just hot/cold/cray at the same time. For a good amount of time you have no clear vision of what is going on. This is the definition of trust if there ever was one. Not to mention for those that have not had a Pap Smear in some time -- there is a possibility that the results are not favorable.

Maybe I'm blowing it out of proportion. Maybe any Female readers are rolling their eyes right about now. 'Get over it buddy', to me, 'it's no big deal at all'...and if so, then I'm glad. Either way, I refuse to be pompous enough to think I know exactly what my Patient's feel or need -- I can only offer suggestions and, hopefully someday, expert and evidence-based advice.

But, again, I have no idea and I'm sure everyone's experience is different. At least for me I'd like to err on the side of considering Pap Smear's a big deal to my patients. If it's big to you then I am reassured in continuing to do everything in my power to make the experience seamless. If it's insignificant then brush me off and I'll be just as equally happy to report on your continued good health every 3 years -- no harm done.

Win, win.

Either way this is the de facto Crate of Annual Exams, Outpatient Care, and run-of-the-mill Women's Health. A quality shipment if you ask me -- and props to the manufacturer Dr. Georgios Papanicolaou.

"some will win. some will lose.

some were born to sing the blues."

hippo --

}In the world of Google, Dr. Oz, and 'Consumer Medicine' the Physician is still a Physician....and they are still the one's to turn to when all is not well.

For the most part, I finally got a taste of what it's like within the quintessential 'Doctor's Office' -- from a medical student perspective at the very least. Imminently more predictable than Inpatient hospital services and in many ways, that much more intimate as well.

The vast majority of Patients we saw this past week were coming for their Annual Exam -- to recharge batteries of reassurance and defuse any ticking time bombs, imagined or real, that can often pervade minds and hearts.

It was a gratifying experience as a whole to see the incomparable expressions of relief and happiness when the Attending would explain the benign nature of a Bartholin Cyst or the paucity of worrisome calcifications within the Breast tissue.

When the Doctor says it will be 'OK' it carries so much more weight. 

Heavy Hippo Weight.

So many Patient's place an immeasurable amount of trust in their Physicians. Each day I was reminded why exactly I was giving away more than a decade of my life towards this Profession and why I am incurring hundreds of thousands of dollars in debt to do so.


If First we Do No Harm...

...then I submit that Second we don't take our Role and Calling for Granted.

There have been questionable Physicians I am sure. And undoubtedly there have been, unfortunately, some (frankly) bad Physicians. Yet, the reputation of Physicians as healers and counselors endures and has been such for the past two thousand years or so. It is a heavy mantle to carry. Hippo Heavy to be exact.

-------

The days of Patriarchal Medicine are gone. In fact, we as medical students are trained and encouraged to stay away from that form of Medicine -- one that has been in place for the larger part of the past century. Physicians no longer tell you, flat out, what is best for you and no longer give out commands that must be obeyed for 'your own good'. 

Modern Medicine is a partnership where the Physician and Patient enter into a mutual pact which is, for better or worse, an end product of our consumer society. It's a good thing in my opinion. Coming to a health decision as a team makes for more confident and compliant Patients. Ultimately, it reinforces further the trust and bond that Patients already inherently feel with their Physician.

But sometimes it feels good to have a Patriarch...to have something solid to lean on when we are dizzy with life's twists and our usual sound reason is nowhere to be found. More than anything this week, I realized just how unspoken and powerful a Physician's evidence-based words of Hope can be.

-------

She was not having a good day. It wasn't just a bad hair day or a coffee stain on white pants day. It was a just found out about a growing mass in the uterus day. This Patient was no damsel in distress by any means -- she knew more than I did about the course of a rapidly growing Uterine Fibroid and the wide range of options available including Ablation and Hysterectomy to name a few.

I mean...she had an iPhone 5 -- what do you expect?

As usual and appropriate my Attending walked her through the costs and considerations associated with our findings and her options. Modern Medicine. In Modern fashion she would question and contradict and make full use of her WebMD app throughout the consultation. In discussion with the senior Resident the conclusion was made that a Hysterectomy would grant the best chance of success with the lowest risk of complications.

But those are scary...and she didn't want one...and she let us know.

What can my Attending do but suggest and suggest and fight the Patriarchal urge to heal?

"payin' anything to roll the dice.

just one more time."

She desperately wanted my Attending to express an opinion...it was blatant. She wanted him to step outside of the evidence for just a microsecond and into the zone that the Scientist in all of us tries to suppress for the sake of Objectivity. It felt like the exam room itself would burst into a tsunami of frustration-flavored tears. 

-------

Patient: "I don't want a Hysterectomy, what is best for me?"

Physician: "A Hysterectomy for the treatment and removal of Uterine Fibroids has a high success rate."

Patient: "But is it best for me? What if I don't want one?"

Physician: "Based on your symptoms, your other co-morbidities, 

and the Ultrasound it has the highest likelihood for a good outcome."

Patient: "But is it for me!? What do I do?"

It took everything I had to stay silent and not overstep my bounds.

Then finally...

Patient: "Doctor, if I do this then..."

Physician: "Ms. ____, all my knowledge and experience tells me that this will afford you the best outcome...and though I can not afford any guarantees this is the best available option and................ 

everything will be OK."

Everything will be ok.

That's all she wanted. At times, maybe that's all any of us ever really want.

Modern Medicine is a new thing, but the Art of Medicine is something that has been painstakingly honed for thousands of years. I am humbled and honored to find the Hippos exhibited by all healers, past and present.

You can't fit this Hippo in a Crate.

}}Sometimes Endings are really Beginnings. (Actually they always are).

I realize this is a gargantuan entry already, but I can not avoid the Hippo in the room -- that of my city's recent bankruptcy filing.

I love Detroit.

"Streetlight people. Living just to find Emotion."

I also couldn't help but notice the parallel with my Patient experience this week. Detroit's recent history has been frustrating -- has been full of opinions and risk assessments and uncertainty. No one has been able to Diagnose the Motor City's problems let alone find any kind of efficacious Treatment.

When I heard news of the Bankruptcy filing it seemed like the surrender of Mr. Orr and Governor Snyder. I was prematurely and immaturely defensive. I even felt a little betrayed.

There must be other options right?

What is best for Detroit? Doctor? Anyone?

But when my Attending "surrendered" and told the Patient she would be OK it helped me frame the recent actions of our politicians. There are no guarantees -- they made it clear. All things equal this is the option that may have the best outcome.

And, in the End, I firmly believe that Everything will be ok.

As far as cities go Detroit might be the sickest Patient there is but that only means it can make the greatest recovery and return to prominence over any other city in history. Hippos are tougher than you might think. Motown Hippos are even tougher. Ain't no mountain high enough.

"working hard to get my fill.

everybody wants a thrill."

"don't stop believin'"

03.oh, you a woman? I don't know how you deal with all the pressure...

[J. Cole featuring TLC - Crooked Smile]

"...to look impressive and go out in heels.

I feel for you.

Killing yourself to find a man that'll kill for you."

A full week of Obstetrics under the proverbial belt...and a few housekeeping items before unloading the crates and hippos from a week's worth of shipments.

1. New Format (sub-headers), New Version :: v2point1

(My efforts to avoid the Walls of Text I tend to write. No need to build houses here.)

2. Instaplug for the Instagram :: hippos and crates and keepsakes (link)

Well let's dive in. Into something where I don't mind if I sink or swim.

crate --

Our OB/GYN Clerkship is split into two equal parts and as aforementioned I have only really seen the Obstetrics side of the equation. Accordingly, here are the high-yield Crates.

} SVD - Spontaneous Vaginal Delivery

Is this even medical or isn't this the most natural and magnificently primordial gift humans (note: women) possess?

Oh sorry. I almost drifted into Hippo territory there.

Despite the fact that humans have been laboring and delivering babies for thousands of years there is a clinically 'correct' way to deliver that child. And in the end all we are really is facilitators. 

For an SVD our main goal is limit trauma and discomfort for the patient...or patients rather as, at least up until that infant is out, we are responsible for the health of both Mommy and Baby. We are there to insure that the delivery goes smoothly by limiting the loss of blood, providing analgesia when requested/indicated, and ameliorating physical trauma to the perineum and surrounding areas.

A second goal is to be ready for a Cesarean Section in case emergent delivery of the infant is deemed necessary. The SVD Crate is pretty much the backbone of Obstetrics and, in a way, life itself.

"...and if you need a friend to pick you up, I'll be around.

And we can ride with the windows down, the music loud."

}} CS - Cesarean Section or 'C-Section'

And here is why OB/GYN is considered a surgical field. (Awesome.)

I've had the greatest privilege of having multiple opportunities to 'scrub-in' on a couple of CS's. It's something to behold as the patient is awake for the entire procedure -- though the bottom half of their bodies is essentially paralyzed for the duration. So yes, one can have a full conversation with the patient as their abdomen is at its greatest exposure. (Awesome #2).

There are a handful of starting incisions that can be used but the one with the least complications is also the one that is most esthetically pleasing: the Low Transverse C-Section (LTCS).

Through the skin...then the subcutaneous fat and fascia...then the abdominal muscles...and finally we push the bladder down to fully visualize the uterus in all its glowing and marvelously pregnant glory. This is the most exciting time because you are one uterine incision away from a new life and you can not wait to welcome that little dude or dudette into the world.

Once baby is born surgical skills are employed once again, as all the incisions made must now be sutured layer by layer. We go out the same way we go in and though our primary aim was to deliver Baby, of course we will try to make sure the patient heals properly and looks no worse for wear afterwards.

In a way, OB/GYNs are quite ninja-like in their ability to deliver this way with minimal scarring. The procedures I've seen have been well under an hour. 

There is some mean shuriken ninjutsu going on in this Crate.

hippo --

} There is probably next to nothing more beautiful than the miracle of life and childbirth.

When I participated in my first delivery it was as if my heart and mind was about to simultaneously implode into a supernova of gravity-tearing awe and amazement. I could have vomited out Hippos for days with the sheer amount and variety of emotions sprinting across my track and field thoughts.

The possibilities. The potential. The intangibles. The Hippos.

This child in my hands. She/He can be anything...can do everything...is capable of changing the world. 

What will She/He become?

What accomplishments will bring tears to their parent's eyes?

When will they feel the piercing pain of heartbreak?

What kind of music will She/He like? 

What will be the first thing to make them laugh?

So many questions and far too many potential answers. The best multiple-choice exam ever created.

I find it so appropriate to be starting with OB/GYN as my first rotation. The birth of my Clinical career starts with the one Clerkship that allows me the opportunity to not only do, but experience and feel what it is like to say:

"Hi there Baby, welcome to the world. I know it won't always be warm and safe like what you're used to. I know it won't always be happy and pretty with sunshine and gumdrops. But I promise that there is hope and there is beauty and that more than anything you are and will be loved, because if nothing else my heart will always go out to you."

"no need to fix what God already put his paintbrush on."

}} If nothing else. That first child's greatest power may be the ability to turn boys into men and men into fathers.

First Impressions.

I've expressed the sentiment before, as humans we generalize and idealize and I believe it should be acknowledged and accepted so that we can embrace it in the best way possible.

Before a delivery we always meet with the, at times imminently, soon-to-be family. Hippos aren't meant to be sugar-coated (in fact I imagine they would be quite aggravated if doused with sucrose) so I'll just say it: on more than one occasion the thought and guilty judgement has crossed my mind that someone would not make a good father.

On more than one occasion, however, I have witnessed transformations that would put Optimus Prime to shame and have always welcomed the sentiment of being proven wrong in my appraisals.

One gentleman was very rough around the edges both in appearance and demeanor. He was a boy in my eyes and I thought it to be confirmed as he was, at that point, just a 'baby daddy'. Little to no interaction with the expectant mother and he appeared more disinterested than I am when I attempt (key: "attempt") to do mathematical calculations (and that's saying a lot).

During the delivery I lost track of where he was with the excitement and commotion and once everything had settled down I wondered where he was as he wasn't immediately within my line of sight. Again, with all my perfect human imperfections I began to fabricate the sentiment that I wasn't surprised at all -- of course he wasn't present for the priceless birth of his child. He doesn't care.

But on the way out I pushed aside the curtain that separates the neonatal area from the main maternal area of the hospital room. With just-barely-audible tones there he was. I didn't see no baby daddy though, there was a father next to that newborn baby. Quivering with emotions I can't even imagine and having his first conversation with his daughter. I couldn't help but listen to him pledging his life to her and her mother. 

Where do you think I got the inspiration for my Baby Welcome above?

I could have died right there. Died.

I went to visit the family later that day and walked in on Baby in Mommy's arms with Daddy sitting on the bed and the three of them sharing their first laugh as a family.

Proven wrong. Thank you. Hippo, hippo, hippo.

"you keep falling victim cause you're insecure.

and when I tell you that you're beautiful you can't be sure.

so all you see is what you lacking, not what you packing."

"take it from a man that loves what you got.

and baby you're a star, don't let 'em tell you you're not."

----

So what if we have Crooked Smiles?

I have to agree with my brotha J. Cole...

"we ain't picture perfect but we worth the picture still."

word. 

hippo.

02.oh you're killing me. you know it ain't fair.

[Mariah Carey featuring Miguel - #Beautiful]

"you're beautiful and your mind is beautiful."

It's looking like I may only be able to post once a week, if that. I would really like to stick to that if not more often. To make up for what I feel to be a deficit I will do my best to update an Instagram:

hippos and crates and keepsakes.

(went ahead and included the first two within this entry)

A photo is worth a thousand words right? I hope so!

crate -- 

A lot of Firsts this week.

The main event is completion of the first week itself -- for both 3rd year Medical Students and newly minted 1st year Resident Physicians. Like most (if not all) new endeavors, most of what took place involved introductions and orientations to what life will be like within the foreseeable future.

We met our Care Teams -- the other Medical Students, Residents, and most importantly our Attending Physicians. We met the Nurses, the Physician Assistants, the various Aides and Technicians and other invaluable individuals who often go unrecognized in keeping hospitals afloat.

No one person could ever run the show. Fo Sho.

We familiarized ourselves with the Floors, the Offices, and the strategic (at times seemingly UN-strategic) locations of ScrubEx machines. We were introduced to the Electronic Medical Records (EMR) system that we will hopefully master someday -- hoping further that any future hospitals we find ourselves at will use the same software. Navigating cookie-cutter hallways and debating the costs/benefits of using the stairs over the elevator were the internal mini-struggles that pervaded First Week life as we rushed between hospital destinations and assignments.

Where can we park? 

Where are the lockers? 

Where do our badges work?

It was a week of establishing technicalities and clarifying administrative nuances. Perhaps not the flashiest of activities but items that are undoubtedly necessary. The First Crates off the boat are always foundational and fortunately the new harbor we are docked at has been rather friendly.

In speaking to many of my colleagues it appears the the Administrators and Attendings are acutely aware that our biggest concern this week, at least as 3rd Years, was to find solid ground beneath our feet. We have been assigned few, if any, patients for this initial week and advice/tips/wisdom/watercooler talk has been both profuse and sincere.

First Week. First Hospitals. First Teams. First Dreams.

First Hospital/Home.

I start on OB/GYN and the First Set of Crates this week could not have contained better cargo.

hippo -- 

At least for me the 'First' I am most nervous and anxious about did not materialize this week.

But. There is nothing I am looking forward to more than my First Patient.

This entire week we did not hear the end of it and I don't think I could ever get enough of it. From senior Students, Admins, Residents, Attendings, and nearly everyone...we were constantly reminded that caring for our Patients will take more than what we know and how much we know.

It was as if everywhere I turned I was being told that Hippos could never be more important than at this time. We are no longer dissecting the inanimate body of a unique soul long gone. We are no longer narrowing down a differential diagnosis from a relatively straightforward case study from those Crates we call textbooks.

Most importantly, 'Patients' are no longer independent illnesses and disorders that exist within a bubble that exists only to make the lives of 1st and 2nd year Medical Students easier.

In the real world Hippos exist. In the real world our Patients will have fears and worries and hopes. Our Patients will have bills and children and flat tires. Wearing a clean shirt and our crisp, unproven white coats is not enough. At times perhaps even coming up with a diagnosis is not enough.

This past week we were given our task: to know our Patients inside and out.

That is one massive Hippo.

---

First Impressions are everything. Whether we like it or not we are human and that comes with all the wonderful machinations one builds upon First seeing or talking to someone. My colleagues and I set out this week to set that tone and engender a lasting positivity within the minds of our peers and omniscient Attendings.

The most important Hippo, however, that most crucial First Impression is the one we present to our Patients. We can not replace or edit First Impressions no matter how much we would like life to mimic the forgiving worlds of an Excel or Word document. More than anything, we can not replace our First Patient -- something tells me that first real interaction has the potential to reverberate within our memories above everything else.

Two years. For two years we have been focusing on mastering the Crates of medicine placed before us. Yes there were Hippos scattered sporadically but they were rare and seemingly endangered at times. We learned endless facts, figures, and lists while only sparingly dabbling in how to empathize and be culturally sensitive to those seeking our help and guidance.

Now is the time and our First Week to get settled down is over. Hopefully we know where the restrooms are, where we can find sources of caffeine for those endless days, and just how many granola bars we can stuff into our white coats. Hopefully our new homes away from home feel as such because in the real world there are more Hippos than we can imagine -- as we come out of our protective medical school bubbles.

Following my nose -- just like Home.

It won't be easy. There will be less sleep. Less food. Less time.

But though Hippos may have grotesquely large mouths and nostrils I think they are #Beautiful.

Likewise, caring for our First Patients will be #Beautiful. It's going to be a good year.

"and I can't pretend that that doesn't mean a thing to me. to me."