Cherry Picks (3.20.2007)

March 20, 2007

thieme.jpgImagine my surprise when the brand new Thieme Atlas of Head and Neuroanatomy arrived in the mail today. I don’t remember ordering this, though the invoice clearly shows that I paid for it online the night that I took the USMLE. This means that I must have been drunk with a credit card, and I decided to order an Anatomy Atlas. Does anyone else do these types of things? Am I the only one? Do I keep it?

Of course I keep it; it’s beautiful. Onto the links.


My Hero, one of the most powerful stories I’ve read in a long time.

But in those dark hours between signing the consent forms and prepping The Missus for surgery, I slipped down to the hospital chapel, locked the door and laid myself bare.

I’ve been shot at and narrowly missed. I’ve been in more than a few situations when the feces have struck the thermal agitator and everyone else was lost in the fog of panic, and I like to think that I rarely lose my cool. I’ve always thought of it as my gift.

But I found out I can be paralyzed by fear. And so on that night, I laid my head on that communion rail and I wept and I made bargains with God and I promised that if He would let my kid live, I’d do anything that He asked.


There’s really no way to set this up without blowing the joke, so I’ll just Cue Jeopardy Music.

Him: “What are you staring at?”
Me: “I’m just waiting. If I’m right, you’re gonna puke any second now.”


A while ago I read an amazing article on trash and recycling and discovered that what we all think we know can be bogus. I like to keep an open mind to things when I don’t know what I’m talking about, and so it is with global warming. After watching The Great Global Warming Swindle (available here through Google Video), I think what most of us think we know is hogwash. Really stretches the mind.


Blackwhite. I do love the Panda Bear’s rants.

George Orwell in his classic dystopian novel 1984 invents a nightmarish world where, in the time of Big Brother, the very language was being modified to prevent both the expression of dissent and its conception. In the novel, the Party sought not only to eradicate words that could lead to the discussion of thoughtcrime but to prevent even the possibility of it.

In a similar manner, residents lack the conceptual vocabulary to protest their obvious mistreatment and, because they are unable to frame the debate in any other terms but that of the establishment’s brand of Newspeak, they are reduced to sheepishly shuffling their feet and muttering vague self-centered sounding complaints.


Dopamine

March 20, 2007

Kelly and I are sitting next to each other, each in our own cubicle. Our tests are different, our questions are different. After 9 weeks of 12-hour-a-day studying, we’re ready for everything and anything.

Kelly starts his block and sees an easy one:

Q: Which of the following amino acids is involved in the synthesis of Dopamine?

tyrosine.jpg

That’s easy. Phenylalanine to Tyrosine to L-Dopa to Dopamine to Norepinephrine to Epinephrine. He knows the name of each enzyme, the cofactors necessary, what symptoms you would see with a block at every step, and where the Cu2+ comes in to play. He prepared for questions this stupid. This is a joke. He looks down at his options:

A through J.

Chemical structures!

***

“Topher, I came so close to just tapping you on the shoulder and making you look at that question. I didn’t really care if they kicked me out and I forfeited my test, it was just that ridiculous. What do they want from me? Answer me that. What do they want from me?”

“I think they want you to fail, Kelly.”

“It’s not even clinically relevant. That’s what kills me. Even if I knew that, it doesn’t make me a better doctor.”

“You’re wrong, man. You just killed a patient.”


post coitus

March 15, 2007

If someone receives multiple blood transfusions and becomes hypocalcemic, it’s because there are chelating agents in stored blood products. If an astronaut is in space for 30 days, his muscle and bone mass will start to decrease and he’ll lose calcium to his urine. If a woman comes in with uncontrolled diabetes and hypertension, eats red meat three times a day and is an alcoholic, the best thing you can do is form a “therapeutic alliance.”

If a grandmother insists that you treat her grandson with chamomile tea, do not sit her down and show her your diploma to remind her that “you are a doctor, and she is just a grandmother.” Also, don’t tell a patient with poor lung function that continuing to smoke is “a complicated and roundabout form of suicide.”

These are the lessons that I learned yesterday while taking the USMLE. It was long, the breaks were short, and I felt rushed with every question. It was challenging and fun.

I really don’t like not knowing my score.

The best thing about the whole thing is it being over.

I don’t ever want to take a test like that again.

Thank you, everyone, for the well-wishes.


The Unexpected Suck of the Last Week

March 11, 2007

So I felt pretty good about my preparation. I had kept to my schedule, more or less. I had kept current with questions, spent as much time as I needed to on special topics like acid/base, PV Loop, etc. And through all of this, I never felt too upset if I had to leave a page or two from each section for later, so that I could “come back to it when I had the time.”

And that’s exactly as it’s gone. There’s just one problem with this system: it fails in the last week. I never anticipated the change, but there came a point about a week before this coming test when I realized that every time I was reviewing something, it was the last time I was going to see it before the test. After spending two months looking over everything with a sort of focused laziness, I had set up a pretty stressful situation.

The reason I wanted to take so much time to prepare was to completely avoid this stress. Sigh.

So now, reviewing is an exercise in abuse. Oh yeah, I remember not remembering that fact that I’m not going to remember in a second or two. Hope to God that isn’t on the test. Repeat. Repeat. Repeat.

It’s the feeling of losing. I set out to hold everything in my head, and reviewing is just hammering home that no matter how much I prepared, it was just going to keep falling out, falling out. Every reread line re-remembered is testament.

I feel like I’ve stepped into the ring, seen my opponent, and gone four out of the five rounds. He’s stronger, faster, bigger. Through the blood, I can barely make out that he’s joking with his coach; that he’s not tired. The judges are looking at the girls with the placards, sharing cigars, not worrying about the last round since no effort on my part could change the ruling that is so cemented. I look at my coach.

“Coach, this fight is over. I can’t beat this guy. I’ve already lost.”

“I know, kid. But that doesn’t matter. Rules is rules. You have to fight the last round even if that means he kills you.”

With three days left, I stagger up. I slap my gloves together hoping the thud stirs some lost adrenaline. My legs change places not from heart, but from habit. I meet him in the middle and tense for the blow. The futility.


Cherry Picks (3.10.2007)

March 10, 2007

Meh. I have this imagined responsibility that I should point people towards things I read in the week that are worth sharing. If you don’t read at least a few of these, then we have to work through some trust issues.


Until you’ve had someone yell at you for getting it wrong, it’s hard to really understand how well a question can be asked. The Dinosaur does not have that problem. On trying to ellicit a sexual history from a patient:

By the way: males starting about age 14 are asked, “Do you use condoms when you have sex?” thus forcing the explicit answer, “I don’t have sex.” I call it the “Have you stopped beating your wife yet?” approach.


The Tremulous Punditosphere
Fascinating synopsis of the divide in ability (and accountability) between pundits in the mainstream media versus those in the blogosphere.

Problem is, these are subjective criteria. What typically happens in the MSM is that, by some quite mysterious process, an editor or publisher decides that some particular person with opinions would make a good pundit, whether its because of the sparkle of their prose or the cut of their jib. A column or regular TV appearances are granted. And then, amazingly, they’re in forever. Rarely are columnists fired for not making sense; once they claim that status, they tend to keep it, no matter how pointless or uninformed their work turns out to be. It’s as if the NBA drafted players straight out of high school, but then they never had to play a game; they all just received long-term contracts, with salaries based on how good they look during lay-up drills and dunk contests. Maureen Dowd will be taking up space on the New York Times Op-Ed pages for decades to come.


Burnout: Embers
Sid Schwab is a favorite read of mine, and this adds to his catalogue.

The medical director of my clinic once gave me a book on burnout. I never read it. Didn’t have the time or energy.

Because a young reader considering a career in surgery referred to stories he’s heard of depressed and disappointed surgeons and asked for my thoughts, I’ll try to address it. Parenthetically, I’ve heard from more than a few readers that my blog and/or book has inspired them to consider surgery as a career. Don’t know whether to smile proudly, or shoot myself.

His rant continues beautifully in the second post, Burnout: Fanning the Flames.


So much of reading blogs is to live that “other life” and the Ambulance Driver doesn’t disappoint with yet another post about the fantastic pranks he’s pulled:

A wise man would concoct a lie. A creative fellow would contrive a plausible story. A careful man would consider his words before delivering an answer.

I blurted out the truth.


Ah HA HA HA! The Panda Bear kills me. This post is really three-in-one as he covers Mr. Kelso, hospital call for residents, and the Church of Patient Care. All of it good, all of it funny.

“So, Mr. Kelso, what brings you to see us today?”

From top to bottom Mr. Kelso is a walking pathology textbook. An impossible combination of signs, symptoms, and disease who is probably only alive because his many comorbidities haven’t decided which will have the honor of finally dispatching him.


Two great index cards from one of my favorite blogs, Indexed.


Maggie at From the Archives is uncommonly honest and insightful. I really liked what she had to say in 100% Thermonuclear Protection.

I want to trust people and I don’t want to be scared or suspicious. Being low level scared would be a constant drain. It would cost me some slight mental processing to be assessing risk. It would take energy to feed the nervousness. It would be weigh slightly on the don’t-do-things side of the scale, where sloth and inertia are already plenty heavy. Years ago I decided that I am not scared. I believe in probabilities, I decided, and scary people are rare.


And finally, As If Inside the Earth by Signout:

Looking at his blood test results during a quiet moment in the hospital tonight, I can see that he is dying.

Through the computer screen, he is as far away from me as I was from him on that day, when he opened the conversation that I quickly closed. If I had listened to the meaning of his words and his unmuffled voice, maybe I would have heard what he was asking me–if it was OK for him to let himself go.

I should have taken off the stethoscope.


Operation: Urgent Knowledge

March 7, 2007

The test is a week away. I expect the next few days to be a blur, filled with stomach pits, flipping pages, nervous questions and highlighters. But we’re professionals, and we’re comfortable with the worry.

We started on January 4th. That was two months and a handful of days ago. We’ve put in (conservatively) 600 hours for this one test. This one test with its terrifying 350 random questions. This test with the two-year scope.

I have developed personal relationships with the authors. I think Glasner is a genius, that Dudek mailed it in, that Sczanto and Schneider have the worst questions imaginable, and that Costanzo has more than a few blindspots. Fadem needs to get an MD. The Merck is my bedrock; the Robbins is my quick consult; the First Aid is my rough guide.

The boys at WebPath, Tulane’s Pharm, and UW keep me honest. I can pretend to know so much more than I do, and it’s these guys that call me on the bullshit. That, and all the people reading the First Aid Errors that point out mistakes I’ve made. Thanks, to everyone.

And thanks to everyone that had something encouraging to say when I felt that thing were going to shit, that I was fucking it all up, and I just wanted it to be over. Shortly after I changed scenery, changed my routine, and found my stride.

I’m writing this down so I don’t forget that no matter how rough it feels in this next week, I was in the right place when it started. Over all the tests, Kelly and I have developed a program. When Grenada was invaded by American forces after the communist coup, the operation was named “Urgent Fury”. Dorks, we know, but we’ve always tried to bring that silly intensity to the last week of studying before any test. And so we’ve named it “Operation: Urgent Knowledge”. During this period, all knowledge is urgent and will be memorized urgently. Tomorrow, it begins and I’m giving myself a moment to reflect on it all.

I have a line of sight to the finish, and goddamn it feels better than I thought it would.


What Brings You Here Today?

March 5, 2007

It’s the morning, and I’m pissed off. I hate the mornings, and for a good two hours after I wake up I will respond to everything with grunts and fuck-offs. This morning, the window is extended because we’re covering Psychology. I’ve written before here and here about my love-hate relationship with this field. I’m fascinated by the science and the ability to so expertly manipulate someone towards their own health. And I hate the greyness of it. The discipline seems too much organized by symptoms and not enough by mechanism.

So despite my attraction, I can never love Psych and like so much unrequited love, we have agreed to hate each other.

I am not alone, as Kelly hates Psych too. Dyslexic as hell, Kelly fights tooth and nail to remember all these facts without rhyme or reason. Pharm is especially difficult for him while Physiology and Pathology come more easily because they “aren’t retarded and make sense like they’re supposed to.”

***I asked him once to describe how he remembers some of the drugs.

It’s not that bad. Chlorpromazine is Chlorxxxxxxxx. Carbamazepine is Carbxxxxxxxxxx. Carmustine is Carmxxxxxx. I get by.

For all the precocious dyslexic children out there: Yes, you can become a physician.***

Kelly and I are sitting in the Commons at Xavier University, hating life and Psychology with it’s lack of any framework when Kelly let’s out a victory cry. By this, I mean he cried out, “VICTORY FOR KELLY!” to the entire Commons (empty with everyone off to Spring Break).

Kelly’s a humble guy and not the type to dabble in the third person, so I’m curious. “What’s your problem?”

“Dude, remember those asshole clinical tutors in Grenada?”

“Of course.”

“Okay, just play along. ‘What brings you here today?'”

“That’s easy: an ambulance.” Here, I think I’m being clever. I wrote about it here, but the “What brings you here today?” question is famous in Grenada for quickly unmasking the good clinical tutors from the dicks who jump down your throught.

You cannot ask that question! The patient could say ‘car’ or ‘taxi’ or ‘ambulance’. You have to ask a question that can only be answered with the information you want.

Wow, you’re so right. I can’t believe I made such a mistake. I should always assume that the patient coming to me with a problem won’t be able to fight the urge to be a smartass as you’ve so expertly demonstrated. I’ve made a note to myself. Moving on…

And this is why Kelly had declared victory. “You’re Schizophrenic!”

“What?”

“Yeah! Schizophrenics have difficulty with abstract thought, cannot understand irony, and use language literally. The only person that would ever answer “ambulance” is probably schizophrenic! Do you have any idea how many people presenting to the ER have a psych problem? I think it’s all of them! If you can separate the schizos from everyone else with your first question, then that makes this the BEST question you could probably ask! They should be teaching this to everyone! Oh GOD how I wish I could travel back in time and make those tutors feel like morons over this. Toph, you have to promise me that you’ll write about this on your blog. You have to make sure that every student at SGU knows about this so they can rub it in those tutors’ faces.”

Well, I promised.


Med-Tac-Toe

March 2, 2007

Today, we played tic-tac-toe on a whole new level. Moves are numbered in red.

medtactoe2.jpg

At this point we decided to call it a Cat’s game. Debate ensued as to whether that should be called “Turner’s game” (XO) or “Androgynous” (with no clear winner).

Legend for the non-medical:

  1. Gower’s maneuver is seen in Duchenne Muscular Dystrophy, which is X-linked.
  2. That is supposed to be a Basophil.
  3. Lesch-Nyhan is also X-linked. I was biting my lip at this point.
  4. Krukenberg tumor has signet ring cells, which look like perfect circles.
  5. Hemophilia is also X-linked.
  6. Tinea corporis is otherwise known as ringworm.

If anyone has there own Med-Tac-Toe board, feel free to send it to rumorsweretrue at gmail.com and I’ll be happy to post it.


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