Archive for July, 2008

Where Has the Magic Gone?

July 19, 2008

Do you remember the times when you were so fascinated by something? Back before you knew how it worked, it seemed to just operate by magic. How do planes stay up in the sky? How do cars work, and how is it adults make it look so easy riding their bicycles? These might not be the exact questions you asked yourself, back in the day, but you wouldn’t have been a child if you didn’t sit back in wonder at the world around you. But then you grew up and learned about Bernoulli’s effect and airfoils, how to ride a bike and about internal combustion. Or maybe you remember what it was like the day your parents couldn’t answer a question, or made a mistake, or did or said something you knew was wrong. For me anyway it rocked my world a little bit, to see how something that I thought to be so magic, so infallible, was actually comprehensible to my mortal mind; that I could understand, see the flaws in and maybe even improve upon that which I had thought was so beyond my reach.

The way a doctor comes to a clinical diagnosis or how he makes a decision is more or less beyond the experience of the average bear. The general public hasn’t been through four years of medical school and lord knows how many more in residency and actual practice. When a doctor pokes at your toes and then asks you if you’ve been peeing a lot, the two things seem to be totally unrelated and yet by your answers he informs you that you may have diabetes. It seems like total voodoo, how they manage to come to these conclusions that seem to be utterly dissociated from anything you might know. That was how things were for me a few years ago.

But now, a little more than a full year into my medical career, I’m not quite the lay person I used to be. With the fat envelope and the white coat ceremony, I’ve been inducted into the culture and society of the medical doctor. Sorta like being able to stand next to the man behind the curtain, I’ve gotten to see just how it is doctors come to diagnoses, make choices, and yes sometimes make mistakes. Of course, I do not presume to come even close to the knowledge that my teachers posses, but by listening and following and observing, I’ve gained some insight into how it is their minds work. And scarily enough, it seems to work more or less like any other mere mortal’s.

I’ve seen that are limitations on what doctors can and cannot do. There is only so much information that their (albeit highly trained) minds can hold. I’ve seen a nurse talk to a resident who calls her attending at 2am because of some troubling test they can’t explain, and I’ve watched that same attending tell the resident who tells the nurse that they don’t know what’s going on, and that they’ll give it another crack tomorrow. I think I used to have this image of the physician as this medically omniscient being, who knew everything that there was to know about your body. And perhaps with good reason; doctors generally seem to know what they are doing. They’re always sure handed and steady voiced. One can hardly imagine a doctor tripping over a rug, much less dropping their pager in the toilet (I understand it occurs with a reasonably high frequency). And yet, they sometimes have to say that they don’t know, that they’re not so sure.

I guess the point I am trying to make, is that now that I am learning how to be a doctor, the magic, the wonder of “how did he know that” and “wow he seems so sure!” is beginning to fade. I can see now that I am just a mere mortal, and just because I’m learning to be a doctor, that simple fact does not change. I make mistakes, and so do they.

Much like any other human endeavor, the process is flawed; doctors mis-remember things, they make mistakes and bad judgment calls. It’s an interesting and somewhat troubling thought to think that the people in whom you entrust your life are in many ways just like you; flawed, with their own passions, failures, preferences and quirks. I had always thought of doctors as someone different from myself, that the way I learned and did things couldn’t be the way they did them. But there I sit in clinic, and if I take that hypertensive’s blood pressure incorrectly, bad things may happen.

I guess where I am going with all of this, is that it’s a bit scary being groomed to make life or death, health or disability decisions. As a day to day person, you want to believe the person who is making those calls knows everything, that they’re super human, and that they’ll make the right choice. But I know I don’t always know everything (in fact I never do), nor do I always make the right decision. I forget my keys, I trip over my shoe laces and I get lost. I am not that super-human character that I think a lot of people believe doctors to be; and yet to a certain degree that is the character you must play if people are to trust you with their lives, and be comfortable in the decision. So I suppose for me, that magic of being a doctor, that omniscient, “I know what I am doing, I’m entirely in control” persona, has evaporated a little, if only because I realize now that I am to be one of those people.

But then perhaps that is where the magic is; that these more or less everyday people can do these things, can defy their flawed and mortal trappings and really preform the amazing. That the guy whom you just beat the crap out of in basketball can climb into his car, put on his scrubs and give you a new heart. Doctors make mistakes, they’re not always 100% sure of what they’re doing, but they somehow manage to do it right almost every time, and that ability to believe in yourself, to know that you are not so different from everyone else, and still be able to take that scalpel and do your work, is perhaps a little magic afterall.

Why I Want to Be a Doctor, Part 2

July 5, 2008

A few months back I wrote an entry in my old xanga, sorta re-evaluating my reasons for going into medicine. In a nutshell, I was saying that one of the big draws for me was that you really get to feel and experience things that not everyone gets to do on a day to day basis. The feelings that you get are not necessarily good or bad feelings, but they are strong, and I think that that is an important part of being alive/being fulling present in your life.

I bring this up because in this entry, I wanted to talk a bit about a patient I saw a few weeks ago. At my school there is a surgeon doing a study with trauma patients, and part of the study requires someone to make sure that blood is drawn just when they come in the door. With a medical school full of eager-beaver first and second year students just next door, we were the natural choice to be the ones to get them. The way it works is one medical student gets a trauma pager (we have a monthly schedule as to who has it what day), and when a trauma comes in, they and the trauma team get paged, and scurry down to the ER to meet the patient.

I had been paged down to the ER for an unrelated patient, and was just on my way out when it was announced that another person was coming in with CPR in progress. I decided that, having nothing else to do other than study in the on-call room, I’d stick around and watch. As I was settling down into a corner and trying to be out of the way and inconspicuous (in the best traditions of my pre-med volunteer days), I was spotted by one of the residents. She asked me if I was CPR certified. I told her I wasn’t (how’s that for another medical irony; a med student that doesn’t know how to do CPR), and she responded, well, do you want to learn? I had to pause for a moment, and stammered out something to the effect of, sure I want to learn . . . but I don’t want to make things worse than they already are. Don’t worry, we’ll watch you, she said as she pulled up a stool next to the bed for me to stand on. You want to do your compressions right about here, she told me, tapping my chest just left of my sternum, make sure you put your weight into it and lock your arms so you don’t tire out as fast. Feeling faintly ridiculous standing on a stool waiting for the patient to come in, I took a moment to reflect how strange it was that one could get tired while trying to keep someone else alive.

The paramedics burst into the room, with one sitting on the stretcher performing CPR. They quickly transferred the patient to the bed, and I was told to take over the compressions. I did so, pushing down as hard as I thought appropriate on the man’s chest, but apparently it wasn’t hard enough, as one of the nurses had me step down, while she showed me just how strongly and rapidly you need to push on someone’s chest for the CPR to be even faintly effective. Climbing back up onto the stool and taking over from the nurse, it then became clear to me how this can be a tiring activity. Even with my arms locked and all my weight put into pushing on his chest, I could feel my abs and shoulders burning.

The poor man was a mess; he had thrown up, and had a good deal of vomitus on his face, in his hair and his half-open eyes. The doctors were trying to suction his mouth and throat clear enough so that they could intubate him, while others were pumping him full of epinephrine and other code-drugs. Their efforts ineffective, they shocked him, (yes they really do call ‘clear’ before they do it) and no lie it’s an uncanny thing to see his limp body tense and his limbs jump when they do. I took turns with another nurse continuing CPR, but given the fact that the patient had been down for a good time before CPR was even begun in the field, and that he wasn’t really responding to the code, after about half an hour the doctor in charge straightened up and asked the room if anyone had any other suggestions. I guess it is something of a tradition in the medical field to ask if anyone else has something that they want to try before they stop their efforts at reviving someone. But no one had anything to add, and so the patient was declared dead. The nurse who had relived me doing CPR stopped his compressions, and stepped back from the body.

I thought I would write about this because (not surprisingly) it was an emotional experience. I’d seen people die in the hospital before, but this was the first time I was actually involved in the failed revival effort. Anytime someone comes into the ER with CPR already in progress, their prognosis is pretty grim. I think the big feelings for me during all this was this mix of sadness/helplessness; this poor man’s body was winding down towards death right in front of me, and the best that I or any of the doctors could do was wail on his chest and pump him full of drugs. In a way, it’s like when someone tells you ‘mate in 6,’ you know what’s coming, but you need to play it out anyway, just in case something was missed, or there is a chance there that no one saw. It is a strange sensation to be standing there, feeling this man’s life ebb away beneath your  compressions.  There was nothing to be done for it, but all the same someone has died, and you can’t help but feel sad because of it.

Medical school is a lot of studying. And a lot of the time, studying is boring. But then something like this comes along, so crazy and intense, that it brings you back to your senses and reminds you why you’re doing all this in the first place. While I definitely didn’t sign up for medical school to watch tragedy in the ER, I think it is part of a greater education; what it feels like to participate in something so sad, to learn how I react to it, and to observe the reactions of others. Experiences don’t always need to be happy ones to be meaningful.

Anyway, I hope that wasn’t too morbid for you. This particular patient has been on my mind for a while, and I thought it would be good to sit down and write a bit about him. I feel like med school isn’t about being happy all the time; it’s about feeling and doing intense things, be it studying like mad-crazy or watching human drama play out on a table in front of you, for better or for worse. I feel like life isn’t about being happy all the time either; everyone has ups and downs, successes and tragedies, and I think all that can be asked from life is that it be intense, that we get to be present and feel what is going on around us. Med school certainly does that, and so I think, at least in part, that is why I want to be a doctor.

Choices

July 5, 2008

Starting the second year of medical school has meant that I’m one step closer to having do decide what to do with the rest of my life; what kind of doctor do I want to be, how much do I want to work, will I like what I do, will I have time for other things? Talking about different specialties, and now beginning to study specific subjects a bit more in depth (i.e Neurology and Dermatology), I can’t help but sense that coming decision at some point down the line.

As I sit now, the two big choices for me are between Emergency Medicine, and some surgical specialty (possibly trauma surgery or something like that). I think I want to care for acutely sick people; I like the idea that they are headed down some trajectory (hemorrhaging, heart attack, ketoacidotic crisis, etc etc) that ends in a bad outcome, but because of my intervention, I can push them back to something more . . . compatible with life. I like that in both specialties, I’ll have a chance to see a wide variety of people and diseases, and work with a relatively diverse team. I get to use my hands, and be able to literally ‘fix’ someone because of them. I feel like both those specialties speak to what I want out to my career.

But then there is the nature of the work. Emergency Medicine docs do shift work; they do something like 12 hours on, 12 off for 3 or 4 days, and then have the rest of the week free. They carry beepers, but only when there is something like a train wreck, earthquake or an unplanned street luge contest do they ever get called in during their time off. Emergency medicine means you get to see everyone and everything; people come up with all sorts of creative ways to hurt themselves, and I think it requires some creativity to fix them. EM docs are also jacks of all trades; they’re good at treating about anything that could possibly come in the doors . . . for about an hour and after that they needs someone else to help them out. They don’t build particularly long relationships with their patients, and more often then not they need to check on the patient via the computer to see how they’re doing.

The trauma surgeons of the world however, get called down when something particularly nasty happens to someone, and it is their job to crack open that someone’s chest to get at their lacerated sub-clavicular artery, or bundle them off to surgery to repair their bleeding liver. My understanding is that they care for these people from when they are called into the ER to when they are discharged from the hospital. The trauma docs supervise them in the surgical ICU, monitor their progress, and see to their recovery. But more than all of that, surgery (to quote :shudder: Gray’s Anatomy) is the marines; you work really hard, but it means you get to do some crazy stuff. All my life, I think I’ve tried to choose that path, following the philosophy that if anything is worth doing, it’s worth going all out for it. If you are gonna be a student, might as well be as good a student as you can be. If you are going to play soccer, you should play as hard and as good as you know how. One should challenge and push themselves throughout life, and so if you are going to be a doctor, why not pick the most intense, challenging field? I think medical school selects for those personalities; the people who like to work hard and push themselves. Medical students are competitive and hard working by nature, and I don’t feel like I am any exception.

I think medicine is really my passion in life, and if I can’t do that to the fullest, than what’s the point really? Surgery would mean a hard-working life, and one that might mean sacrificing some important things. And to be honest, that’s a little scary. I’m in my early 20s for goodnessake; what do I know about having a family, or living a life outside of academia? I don’t want to let those important things pass me by. It’s like not going to prom in high school or something; everyone else has done it, and so you feel like you’re missing out on some common experience that everyone else has had.

Anyway. That’s been my dilemma of late, thinking about those sort of big decisions lurking just over the horizon. Maybe it’s like choosing colleges, and it doesn’t really matter all that much where you go, you’ll have a good time anyway. On the other hand, I really don’t want to screw this up. :shrugs: For all I know, in my third year I might fall in love with ob-gyn, and this will all be useless speculation. I guess we shall see.

Good Bye Xanga, Hello WordPress

July 3, 2008

Well, I think it’s finally time to throw in the towel with my xanga account. One too many times has the darn thing asked me to take a stupid poll or nearly deleted all of my posts. Plus, it just looks ugly. So until I can find a way to import my posts (which may or may not be possible), here is the link to the old site. Sorta sad to say goodbye; I’ve been making entries there since I graduated from high school. But life goes on, and here I am. Let’s hope my relationship here with wordpress is as prolific and long lived as the last with xanga.

Here’s the old link:

http://www.xanga.com/ChevalierMalFet