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The Twists & Turns of Life

As I look at my blog it seems that I have not written an update since November of 2014. I do apologize for not being better in keeping up with writing. I am not sure who I am apologizing to, though, as I have no clue about who is actually still reading this.

A few days ago I came by to browse through my archives. It was a trip down memory lane, so to speak. As a blog, this one has been around for quite a while. My first post, although it was moved over here from a previous iteration, was written while I was still an undergraduate student back in the 2005-2006 academic year. I definitely did not forsee where I would be today.

Last year I remember blogging about fellowship applications. Even that did not go as planned. I started out the fellowship application season intent on joining the NRMP Match hoping for a spot in Nephrology. My plan was to puruse nephrology and then follow that up with a year of critical care training. I even interviewed at Henry Ford’s combined Nephrology/Critical Care program.

But life happens. Life sometimes gets in the way of — well, life.

As the deadline approached I was faced with many questions. I wrestled with these questions and in the end decided that it would be best for me to withdraw from the fellowship match. It was not an easy decision. And on the weekend prior to the deadline to finalize rank lists, I officially withdrew.

I have not ruled out a fellowship. But I had decided that at this time, it would be best for me to wait.

There were many questions that I faced in making this decision. I won’t share all of them. But some included quality of life, lifestyle, job satisfaction, and family.

After making my decision I spoke with our Internal Medicine Program Director. He was one of the faculty members who wrote a letter of recommendation for me. I shared my decision with him — that I had decided not to participate in the match. He asked if I had ever considered doing a year as a chief resident. He had no idea that I had. In fact, as an intern I had actually thought I wanted to one day be a chief resident. And so I answered that it was something that I had been interested in doing in the past.

Now, about 5 months away from the end of residency, I find myself as one of the future Internal Medicine Chief Residents.

Life is full of twists and turns. Sometimes, half the fun is watching where it takes you.

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The Event — It’s Time to Clean This House

Let’s ignore the details — for a moment — of what has happened in the city of Ferguson from the day Michael Brown was shot until the decision of the grand jury not to indict Darren Wilson was announced. Let’s compress it into a singular event.

Essentially, that event seems to have thrown open this nation’s closet door. It’s the closet into which we have thrown all our racially charged skeletons for the sake of appearing tidy, clean, and welcoming to guests who may come to visit — or the nosy neighbors who might peer through open windows. It’s a closet that has been stuffed full and whose contents burst out as soon as that door cracked open. But the Event didn’t crack the closet door open; it violently flung it open and exposed our darkest secrets to a watching international audience.

Whether or not you believe that the Event was motivated by racial undertones or not, it has pulled back the covers to reveal a deep pain, anger, and mistrust that was conveniently pushed aside or ignored for a very long time.

It’s time for this House to have an honest, deep, rip-the-carpet-out, fix-the-bannister, get-rid-of-all-the-termites type of spring cleaning. Or else watch as this House crumbles from the inside.

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Night Three

It’s now night 3 of 6. Six straight days — er, nights — covering the ICU patients here at one of the local county hospitals. Night 1 was great. Occasional calls here and there from nurses for little things that did not require much brain power. I am also working with an intern. He is covering the non-ICU patients. Night 1 went well for him too. I think I saw him watching tv shows on his iPad during the down time.

Night 2 was definitely busier for the both of us. For me, there was one patient who pretty much required my attention the entire night. And when I finally failed at placing a functional arterial line, I had to go call Anesthesia to help me place it. And then while they were at bedside, I asked if they could also intubate my patient as well. Later, as the early morning hours rolled around, I was about to place a central line. I had collected the consent and all the necessary materials. I had the ultrasound machine ready. However, the patient was still moving around so I asked that the sedation be turned up and I would return shortly.

I never did return. Because while I was waiting for increased sedation, I got another call for a patient on the other side of the ICU. Apparently they were having non-convulsive seizures through much of the night and the EEG tech was notifying us. Six in the morning. The patient had already been well loaded with dilantin, a type of anti-seizure medication the night before. However, despite the dilantin, the seizures continued. I considered adding another medication at a constant infusion via IV. The caveat, though, is that a constant infusion of versed (the medication I was considering) requires a patient to be intubated because it can depress the respiratory function.

I did not want to make that decision alone, though. So I paged the on-call neurologist. Unable to get a response, I finally paged the neurologist who would come on call at 8 AM. She advised against the versed infusion and suggested a different regimen. By the time this was sorted out, the day teams had already began showing up and I signed out the events of the night to them.

Tonight I am writing this on night 3. The call team admitted at least one very sick, ICU patient. At this point we have come up with a plan and we will continue to see how the patient does over the course of the night.

While I generally dislike working nights, there are some things that are nice.

I just have to focus on those niceties for another 3 nights.

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County Life

This month is my first of two months rotating at one of the local county medical centers. It is very different than either of the other two hospitals in which we find ourselves.

Traditionally it has been called our “senior capstone” experience — acting as the senior resident at the county.

The patient population is diverse. Sick patients walking daily with strange diagnoses.

At night, we find ourselves mostly on our own covering the ICU patients.

During intern year, my first rotation was here at County.

It is very strange to find myself back, now in the senior resident position.

They say time flies. I am counting on it.

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Detroit

Just flew back from Detroit last week after a fellowship interview.

Surprisingly there were no direct flights from ONT (Ontario, CA) or LAX (Los Angeles, CA) to Detroit.

The weather was decent, aside from a half-hour thunderstorm that was accompanied with storm warnings on the local news.

The program was amazing. The faculty seemed welcoming and fellows had positive things to say about their program.

I’ll write more about the process and my thoughts as time goes by — most likely after the match.

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Time, Indeed, Does Fly

It amazes me how fast life marches on. I feel like I was just a medical student not too long ago. But here I am in my final year of residency. I have almost completed two months. Ten months remain after this. I have my first fellowship interview this coming Tuesday.

It is amazing how one changes over time. I remember when I started medical school. Like 90% of medical students, I briefly entertained the idea of pursuing a surgical specialty at some point. As it came time to apply for residencies I chose Internal Medicine with the intention of going into primary care. I wanted the long-term relationship with my patients. I wanted to get to know them. I wanted to work with them for the improvement of their overall health.

Interests change. Goals change. As I have gone through residency I feel very comfortable on the inpatient setting. Maybe that is a by-product of a heavily based inpatient Internal Medicine residency. My program produces some fine internists that make great hospitalists. Or maybe it is the result of working in a continuity clinic based at a county hospital mainly seeing underserved patients. Only a handful of my patients have any actual “continuity.” Sometimes it feels like every patient I see is a brand new patient to the system. And sometimes I wonder what ever happened to Mrs. X or Mr. Z. Some say that private practice is different. The patient population is different. Perhaps. But I may never actually find out.

Along the way I have decided to pursue sub-specialization. That means that after I complete this Internal Medicine Residency, I will hopefully complete my time as a resident and begin my time as a fellow in an Internal Medicine subspecialty. Of course, there is the chance I won’t match. So for the time being, allow me some privacy. Once (or if) I become a fellow, I will talk about it then.

If I don’t become a fellow I will be able to begin practicing medicine as an attending. That is a weird thought. It’s comfortable NOT having the final say. It’s easier when the decisions and responsibilities don’t fall on your shoulders alone.

The rest of the year promises to be challenging. But I should probably enjoy the ride. Because before I know it, this year will be done.

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MICU to Heme/Onc — What a Change

After a month of intensity on the MICU, I have switched to the Hematology and Oncology service.

I won’t lie. The first few days after Switch Day I realized that I missed the intensity and the severity we had on an hourly basis with critically ill patients. It was like coming off of an adrenaline rush.

There are few Heme/Onc emergencies that require a response from the team immediately. I have explained to teams requesting a consult that their request was placed quite late in the day after we have completed rounds, and since it is not an urgent matter, we will see the patient in the morning.

I have been consulted on masses found incidentally or not-so-incidentally on imaging. Masses that are highly suspicious for malignancy. After seeing the patients, I write my recommendations: Please obtain a tissue biopsy. If stable for discharge, patient can follow up in Heme/Onc clinic as an outpatient. (Of course, there are frequently other specific tests I might ask for.)

Sayonara. See you later. Thanks for your question.

I don’t mean to sound or appear callous about patient’s with cancer. I appreciate the gravity of the subject matter. I know it often sounds like a death sentence when the diagnosis falls upon a patient’s ears for the first time. And the second. And sometimes, even the third. I know how it affects the family of the patient. I know they are scrambling for news, grasping for hope. I know how it feels because I was one of those family members when my mom was diagnosed with cancer while I was in college. So don’t misunderstand me. I don’t downplay the significance or the weight of what I deal with now that I am on the Hematology and Oncology service.

I just mean that the energy required of me is a lot less.

The intensity of the critical care unit takes it’s toll emotionally, psychologcially and physically.

I sleep a bit more now. I have time to read more now. And yesterday, I even had time to go discuss a research project with an attending.

It’s a good thing that residency affords these highs and lows. I don’t think I would survive 100% of either level.

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