anna in med school

Have I ever mentioned that I have a processing issue?  John diagnosed me (sketchy, to be sure).  He reassured me, “Don’t worry…I don’t think there’s anything wrong with your ears.  Just your brain!”

Basically, this is just a more medically way of saying that I don’t do well with competing noise.  Multiple conversations going on around me at once is my personal ninth circle of hell.  For the life of me, each voice sounds like it’s the same volume as the next.  Don’t even try to have an important conversation with the radio or TV playing.  For this reason, John unabashedly tells family, friends, colleagues, bums on the street: “Anna would be horrible at Emergency Medicine.”  He softens the blow slightly by saying, “But that, of course, is the reason behind her musical ear…subtle harmonies stand out clear as day.”  See how he (successfully) butters me up?  It’s been going on for years…

But in the last couple weeks, he’s changed his tune.  The idea of me doing a seven-year residency in surgery is unappealing to both of us and, frankly, though I enjoyed surgery more than medicine, I wouldn’t say I was absolutely head-over-heels in love with the OR and nothing else.  As my ED rotation approached, he would periodically tell me, “You know, it’s okay if you like the ED.”

Well, this might be a problem.  It sounds trivial, but I would have some serious concerns entering the same field as my husband, seven years behind him.  I love that we’re both in medicine…that we both have similar loves of exotic foods, good music, bioethics, travel, and literature…that we both want children, pets, a broad definition of family, life-long friends, and adventures far and near.  But I kind of also want our own respective little corners of our careers that are our own.  And, I’m revealing a new depth to my insecurities here, I think it might make me happier to be in a field where I wasn’t always going to be seven years behind him.  In a career where you’re constantly learning, I would have difficulty always being the one who benefited from his experience and expertise yet could given little in return.  It’s petty, but it’s where I am now.

Now I’m just getting way ahead of myself, as we’ve only had orientation to the ED.  I could hate it.  (I don’t think I will.)

In lighter news, today I successfully inserted my first 20-gauge peripheral IV line into a consenting classmate.

In the last two weeks, I feel like my belly has quadrupled in size.  Must be all the peanut butter, bananas, and frozen yogurt–can one make a healthy fetus on PB&B & fro-yo?  I’m now at 18 weeks, +8.7 pounds (but it feels/looks like I’ve gained much more), and into a new wardrobe.  John, best husband on the planet that he is and having far better taste than I, went shopping with me (a.k.a. practically kidnapped me) this afternoon.  (I was/am too lazy and preoccupied to go on my own…I hate shopping.)  I am so happy that I went.  I had forgotten what it felt like to be comfortable in clothing.

We are dying to know the sex, but in the midst of crazy clinic schedules (mine and John’s), I was unable to schedule the anatomy scan until 22 weeks.  One of my college roommates (who’s due about a month before me) commented on the up side: imagine how much more developed he/she’s going to be!  So much more human-like!  It’ll be such a trip to compare him/her to our last snapshot at 13 weeks.

My week of night float ended 10 days ago, but I feel like it took me this entire week to recover.  Going into it, I was concerned.  16+-hour shifts don’t sound so bad, but factoring in an hour on each end for commuting, getting a max of six hours of sleep (if I ate in the car both ways) times five days seemed a little daunting given my recent need for more sleep–building organs is tough stuff!  Looking back, though, it was one of my best weeks of med school.

Every night I saw and participated in the most awesome medicine and surgeries.  I was on my feet virtually non-stop, hence these as a result.  I felt like an active participant in the trauma team and in the care of the patients.  Several of our patients made the news.  And we actually successfully resuscitated someone who coded and was brought in with EMS performing chest compressions (for the record, if you require CPR, your chances of making it are only about 4%).  On my last night, we  got so many traumas that we had to close the bay.  Pretty fantastic for me, less so for the poor senior resident on call.  I’m a black cloud.

Also, a bit of a surprise: I like surgery more than internal medicine…kind of by a long shot.  Who would have seen that coming?  Of course, my experience in both is so limited (and I should definitely factor in that the first trimester might have affected my first pass on the wards).  On Monday I start Emergency, and I’m so curious to see how I like it…

I would say the cause is 60% week of 16-hour night float shifts on trauma surgery (where all the shit hits the fan), 30% 17-week fetus wreaking havoc on previously healthy 20-something body, and 10% boring old venous insufficiency.

I recently told John that I didn’t think I was not going to be one of those gorgeous pregnant women who spent their 40 weeks “glowing”–and I know they exist.  Heidi Klum, for example.  She looked pretty fantastic hosting Project Runway at nine months.  Well, comparing myself to Heidi Klum is a recipe for depression on all accounts but, still, I doubt she ever rocked the ankles-the-size-of-her-neck look.

To conclude positively, if this is part of the price of a healthy fetus, of course I’m happy with my 1+ pitting edema.  Now I just need to find socks that don’t cut off circulation.

Everyday.  Morning report with the trauma team.  In front of 2-3 nurses, 6-7 residents, 2 fellows, several attendings and faculty members.

Getting things wrong (or just missing things altogether) in front of all of your superiors is one of the best motivations to get things right the next time.  And repetition is key.  Two weeks of this, and I am actually starting to identify that little sliver of collapsed lung on the upper right (sounds easy; it’s not for me), what tubes are misplaced where in the chest, when one of the “rings” of the pelvis is misaligned.  Bullets are easier.  They light up like a Christmas tree.

It kills me that I can’t tell you more about the patients I see come through the trauma bay–like the patient who was literally rescued from an assault by her seeing eye dog, or the patient found down for God knows how long, abdomen filling with feculent material.  But, at least, on Trauma, I think that my role is interesting enough for a story or two.

As I had mentioned, Casey and I (the medical students) are in charge of the primary and secondary survey during a trauma.  It might not seem like a big deal–I mean, we’re not the ones securing an airway or IV access, splinting bones, or making major medical decisions–but it’s crucial, so much so that my voice should be able to be heard above everyone else’s, and there is a person in the Bay whose job it is to record everything I say.  Pretty cool, huh?

The primary survey is also called the ABCs (really, ABCDE): Airway; Breath and ventilation; Circulation; Disability; Exposure.  So, an unidentified pedestrian struck by a motor vehicle is brought into the bay by Emergency Medical Services.  I ask, “Sir, can you tell me your name?”  If he says anything at all, I yell, “AIRWAY INTACT.”  Then I move on to evaluate his breath sounds, all of his pulses and possible locations of blood loss, and his Glasgow Coma Scale (his conscious state)–shouting my findings every step of the way–and finally perform a quick scan of his body including a rectal exam (“DIMINISHED RECTAL TONE, NO BLOOD PER RECTUM.”)  Hopefully, this is done in under a minute or two.

Then I move on to the secondary, which is basically a more thorough head-to-toe examination, as much of a complete physical exam as possible.  Some (I’m sure not all) of the big hitters to look for in our pedestrian described above, for example: facial instability; unequal/unreactive pupils (alert! alert! brain/neural damage!!!); any cuts or lacerations; scary bruising (especially around the eyes or behind the ears); rib fractures; unusual masses; unstable pelvis; limb deformity; motor or sensory losses.  As one of the fellows told me yesterday, “It’s one of the few times in medicine when the physical exam is probably one of the most immediately important components of patient care.”–this is terrifying because, honestly, as medical students (or maybe I’m just speaking for myself), we kind of suck at the physical exam.  There are so many subtleties, you just need to perform a ton to be able to differentiate what’s normal from what’s not and what’s truly emergent.  Well, okay, the five-inch laceration sliced across the patient’s forehead, the right lower leg that lay in the most unfortunate position–those abnormalities I can identify.  But, in the heat of the moment, I had to check his pupils three times before I felt comfortable screaming, “5mm PUPILS BILATERALLY, LEFT PUPIL UNREACTIVE TO LIGHT” and still I was a long way from confident with my finding.  The secondary survey should take about five minutes.

Something that’s a little funny: sometimes my classmates on their Emergency rotation will follow the trauma in to observe the action.  Of course, there’s so much going on, you never notice the extra bodies in the room.  But after the fact, I pink up a little thinking about my friends watching me “perform” in front of them (particularly when it’s such a rusty show!).  I spoke with one of my classmates later about it:

Me: So, how’d I sound?

Him: In command.

Boom!  Fake it until you make it.

(For the record though, soooo glad none of classmates were around to witness my most recent primary and secondary.  We were struggling with a somewhat uncooperative morbidly obese patient and, as we tried to make sure he didn’t fall off the bed with every new position, I’m afraid I was not terribly eloquent with my words–it’s difficult to describe wounds you can’t see :/)

There were a few instances on my medicine clerkship when it was tough keeping the pregnancy secret.  Trying to show up to rounds without smelling like vomit or, as was the case with one very special patient, having to internally repeat to myself while performing a diabetic foot examination: “I will not puke on a patient today.  I will not puke on a patient today.”–not some of my finest student moments but, in retrospect, pretty comical.  (I can’t imagine what this hopelessly foul-smelling diabetic patient must have thought of his student-doctor, visibly turning green in front of him.)  For the most part, however, I doubt anyone suspected I was in the family way.

Surgery was different.  It was made clear that discretion was not an option.

On day two, I showed up early to OR 8 to prepared for the first surgery.  The 50-something-year-old male scrub nurse was there and I introduced myself.  We talked about the other staff that would be present, the protocols, and other specifics of the procedure.  Then:

Him: It’s unusual for this OR, but we have to use x-ray with fluoroscopy.  I have to ask, there’s no chance you could be pregnant, right?

Me: Uh…yeah.

Him (visibly taken aback): What?!  Well, how pregnant do you think you are?

Me: I think I’m like 11 weeks pregnant.

Him: Uh…yeah, you can’t be here.

At this point, he ushered me out of the room and pulled me in and out of the neighboring ORs, each time announcing to the room, “Hey, got any interesting cases?  Using x-ray?  Anna here is with child, we can’t have her in 8.”  God, I felt so poorly that my classmate had to switch ORs with me.  She had read up and prepared for all her cases ahead of time and offered me all her notes of the procedures I was now scrubbing into to which I had previously known nothing about.  A class act.

I was really worried that the director of the Surgical Trauma rotation, which I started on Monday, would make me switch out due to x-ray exposure.  He’s one of my doctoring preceptors, so I approached him about it last week.  His response was an adorable mixture of hardcore goal-oriented wonder surgeon and soft, cuddly papa-bear:

Do not think for a second of keeping this secret!  Make your pregnancy known to everyone in the Trauma Bay.  Wear two layers of lead while in the bay.  There’s a blue line surrounding each bed that is 6 feet away.  Double that distance when an x-ray is called.  Don’t forget that we’re a team.  We will protect you.  I will protect you.  Oh, and realize that your life is going to get SO much better.  You thought you life was good now; well, it’s going to skyrocket come–when is your kid due?  October?!  That’s even better.  S/He’ll be one of the oldest in the grade.  Read Outliers.  You’ll see, that’s a really good thing.

My patient died on the operating room table today.  Gunshot wound to the chest.

I performed the primary and secondary survey.  It just occurred to me that I was probably the last person to whom he spoke.  When assessing his airway and level of consciousness, he responded appropriately when I asked him his name and that of our current president.  When prompted, he gave me two thumbs up.  Then he was intubated and had chest tubes placed, and we wheeled him into the OR.  And three hours later he was dead.  He was less than 25 years old.

I think it’s time we invested in a camera.

A conversation of today:

Me: A nurse told me today that she was wearing maternity pants at 9-1o weeks!  I consider it a success that I’m almost to 15 and haven’t made the plunge.

Him: You wear scrubs on a daily basis.

Not the best method of making your pregnant wife happy.  But, yes, I do have a bit of a pot–enough to make me look chubby, not quite enough to make it look like I have an excuse.

“Perfect, Anna!  Suck hard and get out quick.”  My fellow MS2 and I were the only ones who saw humor in that statement.

Also, today I got pimped on literary allusions from The Canterbury Tales to Macbeth to “The Jabberwocky.”  Whatever makes a five-hour surgery more entertaining, right?  Don’t remember the last time I picked up a work of fiction, so why am I way better at this sort of question then the “name that vessel” or “list the layers we’re cutting through” questions?