Never Lose Heart

"Henry, listen to the patient's heart and tell you what you hear." I did as my cardiology preceptor instructed. I placed my stethoscope over the patient's left sternal border. I couldn't hear crap. It sounded faint and muffled. I moved the stethoscope over to the right sternal border. Same story. I moved it back to the left, but more left than before. Still faint and muffled. Why couldn't I hear anything? There must have been something audibly significant for my preceptor to want me to take a listen. I thought I could maybe delude myself into believing there was a systolic murmur. Maybe. I moved my stethoscope back to the right side. Man, I must be the worst medical student ever. I gave up but pretended like I knew what I was doing. I finished up with a lung exam and felt the patient's pulses.

"So, what did you hear?"

I thought for a moment. Do I say that I heard a murmur? What other noises could there have been? A click? Those are often accompanied by murmurs. A pericardial rub? That might be mistaken for a murmur to an untrained ear. A murmur sounded like a pretty safe guess. How would I describe the murmur if questioned further? I'd be propagating made-up details of a wild guess. So I described exactly what I heard. Hey, it's supposed to be a learning experience, right?

I said, "Heart sounds were very faint. I couldn't really hear anything."

The doctor replied, "That's correct. The patient has distant heart sounds."

Whoa... what? I thought I heard a choir of angels singing. There was much rejoicing. It turned out the lady had emphysema, which, coupled with her copious body fat, made her heart sounds difficult to hear. Today, not only did I learn an important medical fact, but I learned an even more important lesson in honesty.

I encountered a situation today where my preceptor explained a physiological concept incorrectly. My fellow students didn't question him further about it, so I started to reason through it out loud in an attempt to generate discussion and point out inconsistencies without directly calling anyone out. I wasn't trying to be a smart ass. It was a concept I understood well at one point but had since forgotten, so I was earnestly trying to reconstruct the theory with the help of my colleagues. I don't fault my preceptor for confusing the facts, considering there's so much to remember in medicine. Besides, there's no questions that knows way more than I do. It's hard to tell people they're wrong, especially a superior, and especially in the presence of others. Medicine is a delicate craft, and we're taught to step lightly around feelings and personal convictions. Did I tread lightly enough today? I think so. I don't need to be burning bridges at a time when constructing them is so critical.

I attempted to draw blood today from a lady's hand. Epic fail. The nurse couldn't find any good veins in her arms, so we had to use her hands, and that's supposed to hurt like mad. Can't I just leave the needlework to the nurses? The world is probably safer if I stay away from sharp objects anyway.

This morning was spent learning some physical medicine maneuvers all over again. We got a free lunch out of it and lots of free time. The afternoon was spent in Junior Teaching Clinic where we saw some general medicine patients and went through basic clinical scenarios. I have three JTC sessions a week, each with different preceptors. My Wednesday one is definitely the best so far. But then again, maybe that's not a fair assessment because my other two preceptors didn't show up for our first sessions. Not that cool. I did get one free afternoon off though.

Let Me Eat Cake

I had a lot of amazing and cheap food in Taiwan. I also had a great deal of amazing and ridiculously expensive food in Taiwan. My recent culinary experiences are begging me to reflect a bit on the enjoyment of food. As fodder for the following discussion, I'd like to use pineapple cakes, arguably one of the finest Taiwanese snacks ever invented. My earliest memories of consuming pineapple cakes were of the ones packaged in sleeves, like Fig Newtons. I later learned that those were mere pedestrian versions, and that there existed high-class versions that come in decorative boxes, with each pineapple cake exclusively packaged in its own fashionable wrapper. These are arguably more delicious and have a finer texture, but with every bite, I feel like I am consuming guilt-ridden diamond-studded desserts. There is also the added tediousness of opening these packages without smashing the contents therein. It makes me miss the pineapple cakes that came in sleeves, the ones that I could cram in my mouth one after the other without the slightest air of presumptuousness. Sure, the quality might be just a tad lower, but it's not like I'm running a side-by-side taste test. And the cumulative effect of inhaling multiple pineapple cakes in a row more than makes up for any lack in quality. All I want to do is smile with my mouth chocked full of sweet cakey pineapple bits, and the bulk-packaged pineapple cakes allow me to do just that. Don't get me wrong, though. Give me 100 of your most exquisite pineapple cakes, and I'll stuff my face with those, too.

I have a pretty bad memory. I've learned that people with bad memories benefit from surrounding themselves with lots of people. Friends and family and random acquaintances serve as reservoirs for memories of my life events that I can only poorly recall. Also, talking to people you haven't interacted with in a while opens up a time capsule that preserved your last interaction with them. For example, a cousin recently asked me about a drawing I was working on over a year ago. A friend helped me remember thoughts of another friend who passed away. Relatives in Taiwan informed me of how much I used to cry as a child. Apparently, I would cry while eating or sitting on the potty. Good memories.

It's like other people are helping me piece events of my life together every time we reminisce. I think everyone I've ever met should just get together to write a biography about me so I can read it and find out what I've been up to for the last 23 years... because I have no idea.

I'm starting my third year with internal medicine, which will consist of one month of ambulatory (or outpatient), followed by one month of inpatient service at Wishard. Ambulatory is supposed to be relatively laid back, and we get to see a wide spectrum of patients. The past couple of days were orientation. Even though I've worked on various orientation programs in the past, I still share the universal feeling of dread that comes with going through orientation, like the inevitable scheduling downtime where you're bored as out of your mind and all those people lecturing to you and filling your head with important information that you won't remember.

Today was my first day of seeing patients as a third year. Sweet! I learned that I suck pretty bad at writing doctors notes and exploring differential diagnoses with a patient on the fly. I interviewed a patient with another student, and then we had our preceptor come in to interview the same patient. Needless to say, the real doctor's history-taking skills were far superior to ours. We still couldn't be sure what was causing the patient's symptoms, though. I wonder what it would be like to have Dr. House as your preceptor. I'd probably fail my clerkship.

Just got back from Taiwan yesterday. Took a nap from 4 to 10:30 pm, which was only supposed to last an hour. So now I'm finally taking care of backlogged business, like a VA hospital online training I'm supposed to complete. Here's an excerpt: "Healthcare workers experience the highest rate of injuries from workplace assault in the United States according to the Occupational Safety and Health Administration (OSHA)." Good to know. Looking forward to continuing my medical training this week!

2 + 2 = Win

I officially have no life. But the good news is that I'm halfway done with USMLE World. I'm getting pretty worn out, but I just have to remind myself that I only have a few more days to go. I've decided to call this the "2+2 plan." Two years of slacking off followed by two weeks of getting my ass in high gear. Is it worth it? Yes. Back to the books!

I officially finished all 2413 Kaplan Qbank questions on Friday. Hallelujah. One day ahead of my target, too. But now the problem is that I don't have any new questions to do for the next week. The logical thing to do would be to get USMLE World Qbank, which is highly rated, but I wasn't sure if I could justify footing $99 for only a week. I would need to do 200 questions a day to get through it all. I shopped around for other alternatives, but I finally just took the plunge and got UW. I would stagnate if I don't continue doing new questions. The NBME offers sets of 200-question practice tests for $45 each, and they don't even have answers to them. That makes USMLE World seem like a steal. But now I need to figure out how I'm going to get through all of the First Aid material AND attempt to read a physiology book AND Goljan pathology notes AND get through 2000 questions before May 26th AND play guitar and watch TV shows and consume excessive quantities of food. AND attend my brother's graduation today! Something's gotta give. Thankfully, TV shows are wrapping up with their season finales. Realistically, my chances of accomplishing everything I want to in the next week are slim to none, so I guess I'd better get cracking.

Fortress of Solitude

85% done with QBank! Scores also came back for a couple of our final exams. I was pleasantly surprised at my pharmacology grade. I still have a ways to go, but I'm glad to at least have some tangible evidence that I'm making progress. I've been hanging out at home for the past couple of days. I'm definitely not as efficient studying here. Way too many distractions. And they're not even fun distractions like picking up my guitar on a whim or hitting a badminton birdie against the wall. It's more like fixing my mom's computer issues or having my brother hit me repeatedly for no reason. The internet is also painfully slow for some reason. I can't wait to go back to my apartment. My roommate left for his China trip on Sunday, so I'm now referring to our apartment as my Fortress of Solitude, except instead of being made of ice, it's made of books, sweat, and tears.

One Small Step

How am I going to learn two years' worth of material in two weeks? I have the perfect solution, but unfortunately, it involves traveling back in time by two years. I'm taking the USMLE Step 1 on May 26th. It seems to be the most important test of one's medical educational career. It's like the MCAT times 100. The SAT times a gazillion and one. It's like taking part in a quiz bowl competition, except nobody wins. The test destroys everyone who dares confront its clinical fury. It's like Unicron (no, not Unicorn) from the Transformers cartoon, who eats planets for breakfast. It's like that weapon from the new Star Trek movie (which was awesome BTW, despite the creative alterations liberally applied to the Star Trek world). Oh, yes. It's going to rock my world.

It's hard to pull myself away from studying or doing practice questions. Okay, maybe not. But with only two weeks to learn everything about everything, I feel like maybe I should be studying nonstop to make up for lost ground. I think I'm making progress, though. I have 558 questions left in Kaplan QBank, which is essentially a pool of USMLE-like questions that's doing a good job of reminding me about everything I supposedly should but clearly don't know. There are a little over 2400 questions in all, so I'm about 77% done. It takes me a couple of hours to get through a "standard" set of 48 questions since all the questions also come with descriptions for why an answer is correct or why an option is wrong (aka why I suck so bad at guessing). Thankfully, some of it is actually sticking. I'm hoping at this rate to be done with all questions by the end of the week. I could theoretically burn through 500 questions in one day, but I'm concurrently reading First Aid, which is arguably the Bible of med school. I have never before pored over any publication with such passion.

I survived the last finals week of my educational career on Friday. The last exam was pathology. And it was a bit anticlimactic. Supposedly, the Step 1 will feel even more so. After you finish it, you're like, "Now what?" I should probably devise a post-Step 1 plan beforehand, while I can still think straight. I guess I'd go home and watch TV and eat some chips or something. I would consider reading a book, but it would bear too much resemblance to studying. Maybe some Calvin and Hobbes. I'll need to pack for Taiwan. Play some guitar. Burn my class notes. Shower. Give my mom a hug. Have her make me dinner. Post-Step 1 life is going to be grand.

As the World Turns

My brother is finally graduating after having been in college for seven years. A cousin of mine is getting married. An uncle had a baby--well, his wife did. My facebook feed is also being bombarded by people loving their jobs and hating their jobs and getting married and making babies. And here I am, sitting in my room doing practice questions. There's a whole world going on around me, and I'm just excited that I'm through with classroom lectures.

So do you ever have this happen to you...? You're cleaning your sink, and there's this bit of food--say, a piece of tomato--that won't go into the drain no matter how much water you splash at it. It budges a bit and moves here and there, but it refuses go in the direction you want it to. And finally, you say screw it and flick this piece of food into the drain with your fingers. Well, that piece of food is me (and med students in general). We're somehow immune to the tides that shape the outside world, for better or for worse. In this messed up economy of ours, everyone is hurting. But even though med students are drowning in debt, making us some of the poorest sons of bitches you will ever meet, we remain relatively unscathed. In other words, we might be the most well-off impoverished people in the world. It's kind of weird, but I think we're all grateful for this insulative barrier that we have. But maybe all of this is a moot point because the pig flu will get us all in the end. No, not even med school can save us from that.

Almost but not quite the end

Final exams officially start today. The next two weeks are going to be pretty awful. But when I think about it, it's not like my routine is going to change very much. My life is just consumed by studying day in and day out anyway. I have eight exams left in my second-year medical education. Seven of them will be in these next two weeks. When I survive these, I will officially be done with anything class-related. We still have a smattering of lectures throughout the clinical years, but no classes in the traditional sense. So that's what, 19 years of classroom education under my belt? Did I really just spent 19 years of my life sitting around listening to people talk at me? That doesn't even sound rational. Well, it all ends here. It's going to be bittersweet. I can't say I'm going to miss going to classes, but I'll sure miss sleeping through them.

Student Outreach, Part 2

It's common to get a patient who tends to be a little chatty, where every question probing his or her medical history unearths more than we might bargain for. As the dust is kicked up we have to somehow sort out the jewels from the junk. We have to master the art of cutting people off politely. Don't get me wrong. I enjoy talking to patients. But when your time is limited, you have to draw the line somewhere. Unfortunately, spending less time with patients would potentially mean missing out on such great conversational gems as the following...

A patient told me that she once went into a coma from smoking a joint that had been laced with cocaine and heroine and PCP and god knows what else. Interesting, but irrelevant to her current health.

A patient once told me she was "oversexed." Not sure what to make of that. Actually, I do, but I don't need a mental picture.

I once saw a patient who had been hit by a train and a semi and was shot by a cop. Thankfully, not all on the same day. Otherwise, he might be Jack Bauer.

A lady once told me she substituted ground turkey for beef in some burritos she made for her husband, and he didn't even find out, nor did he believe her when she told him!!! I love turkey, too, but irrelevant, and not that exciting.

A patient told me her urine turned orange because of a certain medication (Phenazopyridine Hydrochloride), but it was normal. Now, that's interesting, relevant, and educational, AND I got to see her pee! I mean pee as in the noun, not the verb. That's gross.

I once talked to a patient for a long, long time since her answer to every question rivaled a Homerian epic. I didn't really have a time schedule, so I didn't mind. Finally, one of the doctors in the clinic entered our room to check up on me, fearing that I had dropped off the face of the earth. No, I had simply been lulled into sedation by a siren's song about her diabetes and urinary tract infections. The doctor spoke with her for a bit and managed to sum up in a few minutes what had taken me much longer. As the doctor was writing up some final notes for her files, she said that she just remembered something, which she always forgot to mention on prior visits because she was never around long enough. She pulled off her boots to reveal some pretty bad edema and cellulitis, likely complications from her diabetes. A full physical would have caught this, but those are rare in a free clinic. She was also a returning patient, and logically, we simply ask returning patients about new complaints, how they're doing with their meds, etc. The swelling in her lower extremities developed slowly over time, so it didn't have the urgency that one might expect upon looking at her legs. Thus, it was easy for it to slip her mind. It was just fortunate this time that I had seemingly piddled around when I could have had her in and out of the clinic in a few minutes. Under normal circumstances, that's probably what I would have done. But I was new at the clinic and assumed I was supposed to wait for the doctor. I guess I was supposed to go find him when I was done questioning the patient. Oops, my bad. But then again, maybe not?

Student Outreach, Part 1

I volunteered at the new Student Outreach Clinic today. It's about time our school had a student-run clinic, so kudos to all those working to make this a permanent aspect of our school. It's not an official IU clinic yet because of some legal issues that came up recently, but hopefully those will be resolved soon. That means we can't officially diagnose people or write prescriptions yet, not that I'm personally capable of doing so, anyway. The patient flow is still kind of slow since the clinic is still pretty new, and not that many people in the community know about it. It's in a part of town that is a little rougher than even I'm used to, if you can believe it. It's a bad sign when the clinic organizers tell you to walk in groups to cross the street from the parking lot to the clinic in broad daylight. Regardless, it was an interesting day at the clinic, and it was nice to be able to help some people out who probably wouldn't have gotten the help they needed. There was a kid who sprained his ankle right outside the church where we were, so it was pretty convenient that he was able to hobble right inside to be seen by a doctor. Might have been more convenient for him had he not fallen down some steps, but I think he'll be okay.

I spent a great deal to time talking to a lady who had some arthritis in her hands but was allergic to medications that would otherwise be effective for most people and she also needed a precription refill for another medical condition but wasn't able to get a hold of her primary care physician for the past five months because the scheduled times that were available would get filled too quickly and they wouldn't take walk-ins and she couldn't get through via the pharmacy either but didn't want to switch doctors and she had some really bad arthritis in her hands so much so that she couldn't hold up a plate and she couldn't get refills on her medications because she couldn't get a hold of her doctor and she had some pain in her left hand so she mostly uses her right now and she also needed a precription refilled because her medications were running out and she didn't know what else to do so she needed our help.

So we tried to help her. We couldn't prescribe her what she needed even if we wanted to since she already had prescriptions from her physician, so we tried to counsel her on some other solutions she could try. Everything was either unfeasible or had already been tried to no avail. Finally, our doctor said he would contact her doctor to get her script refilled. It happens a lot where our jobs as doctors and medical students have nothing to do with diagnosing people or prescribing drugs. Sometimes the only remedy that can bring immediate relief is just to have someone listen to you.

Worst Headache of My Life

Somehow, in the course of our medical education, we've come to associate the words "worst headache of my life" with "subarachnoid hemorrhage." I can't imagine it's pathognomonic since it sounds like such a subjective phrase for a patient to say, but if you ever see it on a test, don't even bother reading the rest of the question. The answer is subarachnoid hemorrhage. And if it isn't, the question writer obviously didn't know what he was doing.

You see what the problem is, right? Up until you get your SH, there must have been some other headache that was the worst headache of your life. And who's to tell someone with cluster headaches or metastatic brain cancer that his or her heachache isn't nearly bad enough for the big time?

Migraines, huh? Quit yer bitchin'. As least your brain didn't EXPLODE.

I had the worst headache of my life a couple days ago. I've been fighting something nasty for the past several days, and I swear I wanted rip my head off just so it could suffer alone, away from the rest of my body, which had more important things to do like lift weights and watch trashy TV. But alas, I confined myself to my quarantine chamber (aka my room) to suffer quietly and study for my upcoming exams, like a dying pigeon... who studies. And as I read about such wonders of life like septic shock and glioblastoma multiforme, a brain cancer with a dismal prognosis, I realized things could be a whole lot worse. At least my brain wasn't bleeding into itself, which was good, though it was a bit disconcerting that I could hear the pulsating turbulence of my cranial vessels a little too loudly.

I felt a whole lot better this morning, just in time for my three horrendous exams crammed into 3.5 headache-inducing hours.

I forgot to mention that there was this other time when I also had the worst headache of my life. I was descending from the summit of Mt. Kenya, and my headache was so bad that I died a little with every step, and I'm pretty sure I about overdosed on painkillers that day, to little relief. I think I just had a touch of high altitude cerebral edema that day.