Accessories

The last two days I have been at clinic. The most interesting patient was a 19 year old who came in for "lumps in the arm pits". I went in to see her--she was seven months pregnant, and had a mass under each armpit which had been swelling and becoming more painful every since she became pregnant (this is her first pregnancy). She had never had swellings like this before, and each day the masses could be soft and mildly tender, or hard and so painful she couldn't rest her arms at her side. She had no medical problems, specifically no history of breast disease, and no one in her family had a history of breast cancer. On exam, she had a tennis ball shaped and sized mass hanging from the underside of each arm in her armpit. They were very soft to touch, not like lymph nodes, and they were tender to palpation. She didn't have any breast masses/pain/discharge, but I did note she had an extra nipple on her right breast (when embryos develop there is a milk line that runs essentially from the axilla down the chest to the abdomen, and nipples/ductal tissue can form anywhere along the line) which I thought was interesting but didn't make any connections. I was totally stumped. I went to talk to the nurse practitioner who immediately realized that the swellings were actually extra breast tissue that had developed in the woman's arm pit. When we looked closer one of the masses did have what looked like a very small, poorly developed nipple. As the woman's breasts have been swelling with pregnancy, the extra breast tissue did as well causing a lot of discomfort. Unfortunately, since she plans on breast feeding her infant, she's going to have the pain for quite a while. Once her infant is weaned, she can see the surgeon and have the extra tissue removed to avoid this with successive pregnancies. The NP told her not to be surprised if she finds milk leaking from her armpits once the baby is born.

On a totally different note, my pastor is starting a Sunday School series on courtship/marriage. To start the series, last Sunday he read the following article: Let's Have More Teen Pregnancy. The author's premise is that society's opinion today is that people aren't mature enough to get married until their late twenties, a belief she finds ridiculous. She talks about the benefits of marrying young (18-20) and uses as an example the fact that she is 49 and has 4 grandchildren already. I don't think I agree with her premise however, at least in my circles, singles in their twenties are single because they haven't met someone they want to marry, it has nothing to do with not believing that they are mature enough for marriage. The vast majority of singles I know desperately want to get married, and most of their families want them to get married too.

Time I'll never get back...

Wednesday I scrubbed in to the bilateral mastectomy (to clarify the woman's history, she did have radiographic lesions in both breasts, and she had three female relatives who had bilateral breast cancer in their 40s or 50s) and a lumpectomy. The surgeon I primarily work with on this rotation has something of a drill sergeant type attitude, which (thankfully) he does not use on the students (since we're not expected be competent), but increases in intensity toward each successive year of residency. Pretty much the entire case consists of his--not really "yelling", per se--loudly criticizing the resident's technique. Which I'm sure is fairly effective, but does leave the resident rather drained by the end of the case and me feeling pretty awkward having just seen my senior by six years treated like a three year old in front of a room full of nurses and techs. What fun I have to look forward to upon graduation! The next day I scrubbed into another mastectomy with a third year resident--there was still a lot of criticism, but only at about 50% of the intensity compared to the day before with a fifth year.

Friday had one theme throughout the day: inefficiency, purposelessness, and wasting time (I guess that's three themes, but they're all pretty synonymous). Normally, as I have joyfully described in the past, on Fridays I go in for an hour to the pathology lab then have the rest of the day off. However, the nurse practitioner told me the day before that there would be an interesting patient with a good exam at 11:00. So, after pathology I went to clinic. It turned out to be a different patient, but I saw her anyway. When I went into the room she had barely started filling out the five page form all new patients fill out, so rather than come back, I just went through it with her. Which was a mistake, because she kept going off on tangents--twenty minutes later I was getting nervous as this was the nurse practitioner's last patient of the day and I'm sure she wanted to go home. I managed to get all the information and in the interest of time decided to wait on the exam for the NP so we wouldn't be delayed by doing it twice. I got the NP and came back into the room--and was told by the patient she'd rather I not be in the room. Now, I completely understand this, and am actually surprised that so few women mind having a male student doing the exam (she was the first patient the entire month who asked that I not be in the room), but could she not have told me this 45 minutes earlier when I went in to talk with her? So, I waited in the workroom for the NP so we could discuss her case...and didn't leave until 1:30. Basically, three hours in which I learned absolutely nothing and could have been home, or studying, or working out, or etc.

But it gets better. I went to the mall that afternoon to buy a book from Barnes and Noble, and was accosted mid-mall by a man doing a taste test for flavored water. Being the nice guy that I am, I agreed to give him my time and answered his many questions: yes I drink soda, no I don't drink energy drinks, etc, etc, no, I would not buy flavored water based off the advertisement that it "has vitamins and minerals" (I was hoping he would ask me to explain why I wouldn't as I had a great 5 minute response on playing on people's gullibility ready, but he didn't ask). Then he asked for my address which I told him I wasn't comfortable giving, and forestalled his next question by telling him I wouldn't be handing my phone number out either. He wasn't sure how to handle it, and went off to find his boss, and I was then told that I wouldn't be able to participate (yes, I was crushed). Ten more minutes of the day wasted.

Lastly, I have to make a page for my school yearbook. After an hour on the computer last week during which time my computer, Damocles-like, was inches away from being thrown forcefully through the window into the busy street below, I decided that I will simply be giving the publishing company my photos on a disk and letting them arrange them as they see fit. However, I have to have hard copies of my portrait to give to my school. I put them on a disk and took them to the local drug store which I had heard had an uploader machine on which one could edit and crop digital photos. After twenty minutes of frustration in which the uploader machine decided that it could only read the photos I wasn't interested in, the several employees who tried to help me decided that I either needed to make a new disk or use their website. So, I went home, and went on the website, and three minutes later had my portrait cropped and ready to be printed. Grrr.

Saturday morning I went to the free clinic. I saw two patients with the typical hypertension/diabetes/hypercholesterolemia picture. I was able to manage their issues on my own, so the doctor just signed off on my notes and prescriptions without seeing the patients (one of my favorite things about the free clinic is that as a fourth year I get to play doctor). The other patient was a 21 year old guy with a small abscess on the back of his neck. I was getting excited about the chance of incising and draining it, but then the manager told me that we didn't have the equipment so would have to refer him to a general surgeon who sees uninsured patients. Oh well.

Clinic

Yesterday and today I was in the breast surgery clinic. Yesterday was all follow-up patients (women who have had surgery anywhere from two weeks to 15 years ago and are just coming back as a precaution). Today was a half day in which I saw a couple follow-up and one new patient. The new patient was a woman in her early eighties who had the first mammogram of her life last month. Aside from having a hysterectomy and radiation for cervical cancer a few years ago, she has not seen a doctor since her last child was born almost 60 years ago. The mammogram unfortunately found a small mass that was biopsied and found to be invasive lobular carcinoma. Fortunately it is very small and very low grade. She will need to have surgery and hormonal therapy, but the prognosis is very good.

We were again running late, so despite the fact that the last patient was scheduled for 11:00 I didn't leave until after 1:00 (yes, I do have a taxing schedule this month:). I then went to the library to update my PDA since the program that lists all the drug dosages I will ever want to look up has been dead for the last month and a half. Since I hate dealing with little things like that, and since "procrastination" might as well be my middle name, I waited until today to get it straightened out. It was as bad as I expected. I spent at least 45 minutes in front of the computer getting the wretched program loaded on.

I've spent most of the afternoon working on my yearbook page and I have come close on several occasions to ripping my hair out from frustration trying to do it on the computer. I think I am going to end up just turning in printed out photos and letting the publishing company deal with the mess.

Tomorrow I will be in the OR. The morning will start with a bilateral mastectomy--to my surprise, my brief perusal of the patient's chart indicated that she had very early stage cancer in one breast which is usually treated with a simple lumpectomy and radiation. Bilateral mastectomy seems like major overkill to me--the only thing I can think of it that she was found to have the BRCA mutation which greatly increases the risk of women (and men) developing breast cancer--I'll have to look through her lab results tomorrow. She will have reconstruction immediately after the mastectomy which plastic surgery will do. A similar case yesterday started at 9:30 am and ended at 11:00 pm (plastic, transplant, and cardiothoracic surgery are all specialties I plan on staying away from based simply on the case length--I like them less than 3 hours--then again, I imagine that time would go by faster if I were actually performing the operation rather than standing for hours with my arms extended at incredibly uncomfortable angles holding tissue back so the surgeon can see what s/he is doing).

New link

I highly recommend visiting the new link in the sidebar, Tominthebox News Network. I've been going through their archives--they are hilarious. Here's a sample post: Fake Rapture. On the more serious side: Doctor.

Edit: And here's another one. I was almost in tears from laughing: Baptism for the dead.

Tumors

Monday the head breast surgeon came back from vacation for a full day of clinic. All of the patients were follow-ups, having had breast cancer anywhere from a year to 15 years ago. There was nothing particularly striking except for the fact that for a number of reasons we were running at least an hour late the entire day--since we only had 1-2 exam rooms available as the medical and radiation oncologists were hogging the rest for consults the patient flow was very slow and there was a lot of sitting around twiddling thumbs on my part. I did get several questions I had answered by the surgeon though, so altogether it was an educational day.

Tuesday I returned to radiology. Looked at a bunch more mammograms. I was supposed to watch a mammogram being performed so as to understand the different positioning methods, but the techs never came to get me (likely because they had much more important things to do than baby-sit the med student) and I have to admit I didn't use a lot of initiative to make it happen as I could have. I figure there will be plenty of times in my career I'll have to interpret mammograms, and not many times that I'll be responsible for setting up the machine. One amusing point was when I went with the radiologist to ultrasound a potential tumor--the tech was convinced that the patient was hispanic, but knew that the translator who was scheduled to come by had just been interpreting for a Russian patient earlier in the day--she came to the conclusion that the translator must be fluently trilingual, and we were all duly impressed. Until we went into the patient's room and found her to definitely be speaking Russian. The tech was quite embarrassed.

Wednesday was OR day--another lumpectomy. This patient ended up having to spend two nights in the hospital, mostly for pain control, but she was also somewhat complicated in that she had a very rare genetic neurodegenerative disorder. I saw her this morning as she was getting ready to go home, and she was very happy to be leaving.

Thursdays the nurse practitioner usually has clinic, but she is currently on vacation, and the radiation oncologist was taking an administrative day, so I thought that I might get the day off. However, the surgeon had two patients to see in clinic--one at 0830 and one at 1300. The first patient (who naturally wasn't roomed until about 0900) was a woman in her early 30s who had just been diagnosed with breast cancer and was here to discuss treatment options. She and her husband were handling it quite well. Cancer had already spread to at least one of the lymph nodes in her armpit, and she will likely have to have chemo for several months before having surgery. Fortunately, her prognosis is quite good. She is also one of the first patients I have seen who will need an MRI as her breasts are too dense to see anything on the mammorgram. She will also need a full PET-CT to make sure the cancer hasn't spread anywhere else in her body.

The later patient was also a rather sad case, a woman in her 80s who had had a left mastectomy in the 1970s. She was unfortunately somewhat demented and lived in a nursing home. Her attendants had discovered a mass in her right breast a couple months ago. She herself was not even aware why she was at the doctor's, and the daughter who came with her was not the power of attorney, thus I was not able to get a good history. At this point, she had already had a biopsy which showed cancer. In her condition she was clearly not a candidate for either chemotherapy or radiation. When I did the exam, however, it was immediately apparent that something needed to be done soon. She had a huge lobulated mass that filled the lower half of her breast, and the skin on the underside was a dusky blue, indicating that the mass was well on its way toward ulcerating through the skin. She also had readily palpable nodes in her armpit. She will need to be scheduled for a mastectomy and axillary node biopsy within the next couple weeks. Odds are that the cancer has already spread, but it is possible that the surgery may catch it early enough.

Today I was in pathology. I went through several slides with the pathologist, then watched a tumor being processed by one of the techs. Now I need to work on my list of residencies I will apply to.

Random

Not much new here. I am currently procrastinating studying and residency-applicationing by internet surfing. I came across a real gem: a fish empathy quilt. It looks like something I would make as a joke, but these people are actually serious. I was cracking up looking at it--I found the square that used "WWJD" to imply that Jesus would not "torture" fish to be especially intriguing, particularly considering the fact that Jesus' best friends were fishermen. Idiots. If you're going to argue a ridiculous position, at least use arguments that support your position rather than destroy it. While I found the whole thing amusing, it also really ticks me off that there is so much human suffering and immorality in the world, but rather than address that, these buffoons spend there time making "empathy quilts" for fish! Get a life!

To further procrastinate, last Tuesday while I was in radiology, staring at mammograms for hours on end, with nothing more than a far-too-small-cup of coffee to sustain me through the crushing dullness, I thought to myself: "At least this is better than rounding." A small comfort, but a comfort nonetheless until I remembered that I will be on nephrology next month and have been warned that the nephrologists here love rounding like most people love hot fudge sundaes. Brought down by thoughts of portending doom, I decided to express my feelings in a poem--a poem of the modern variety since I do not like modern poems thus feel a modern poem will express my disgust with rounding more effectively than a rhyming poem with syntax and meter. I'm actually making it up as I type, so I'm not sure how it will turn out--I just know that I will die at the end with a small hint of irony.

Death by Rounding:
Rounding, rounding. Pre-rounding, team rounding, attending rounding.
I think I will die.
I have been in the patient's room for fifteen minutes that seem like an eternity
Nothing is being done
I have long since ceased to hear words and now only hear a humming sound
From the attending's perpetually moving lips
Annoying, yet strangely sleep-inducing
I am drifting off the hospital whirls around me
I think I will die.
Left the room the attending turns to me
His lips move but I can't make out the words
It is a question but I don't know what
I don't know I say in a false cheerful voice but I'll look it up and get back to you tomorrow
Knowing full well that tomorrow I'll be dead. Dead from rounding.
We move on to the next room five hours down and still ten rooms to go
I muse to myself and wish Dante were alive now
The Inferno would have turned out differently
A new circle of hell probably between the sixth and seventh maybe six and three quarters
Would be rounding always rounding
I think I will die.
Ten fifteen forty-three minutes we start to leave the room and the patient asks a question
The same she has asked for three days in a row and gotten the same twenty minute answer
Every Time
I feel it now
Like a dark black cloud settling over my brain
My vision dims
The outline of white coated residents darkens
They become a row of shadowy specters watching me silently
They see death and respect it
The window is the only light object left and I feel myself moving towards it
As my body collapses to the floor like a scarecrow knocked off its pole
By the wind
With my last breath I hear the team and strangely the patient debating
Is the proper terminology
Death by roundosis or hyperroundosis?

Breast Disease

My rotation is going well. It is very laid-back, and has its moments of boredom, but I am learning a lot. Friday I went to the pathology lab and went over breast cancer slides under the microscope with the pathologist from 0930-1030. Then I went home:). Monday I went to breast surgery clinic with the chief resident and a nurse practitioner. The NP mostly sees follow-up patients after surgery, so I didn't see any tumors. Tuesday I went to radiology--I spent the first three hours (literally) reading about mammography standards and categorizations in a dark corner of the dark room. After lunch I looked over mammograms with a radiologist. Wednesday there was only one breast case which was scheduled to go at noon--I kept calling the OR from home to make sure it wasn't going to go early, then just went in at noon. Then I proceeded to stand around the recovery room until 1330 when the case actually went. Toward the end of the case (lumpectomy with sentinel node biopsy), when I was looking forward to going home for a few hours before going to Bible study, a senior resident walked in and asked if he could steal me from my senior resident--for a thyroid case (they don't have a senior student and all the junior students were in lecture). Muttering darkly under my breath, I said I would be happy to, and one hour later scrubbed in on a thyroid lobectomy. It was actually interesting, especially since I have never been in a thyroid case before, and I was only 10 minutes late to my Bible study. This just reiterates what I have long held to be true, happiness in surgery is very dependent on expectations. When I have been on serious surgery rotations, and came to accept the fact that I would be in the hospital for looonnnggg periods of time, I could stay until two in the morning and go home not feeling ill-used. On the light rotation that I am on now, if I am in the hospital later than 1600, I get all bent out of shape.

I'm back...

So I've just ended my month off. Trauma surgery ended well, it's the first rotation I've been on that I've woken up early the next morning and thought that I wouldn't mind doing it for another month. Since I was on call June 30th I didn't leave the hospital until July 1st therefore I got to see the new interns--very weird to think that I will be in their position in less than a year. I flew home and enjoyed two weeks with my family away from my place of exile, then returned to take step II. The written exam was 9 hrs long, by the end of the day my eyes were glazed over and I would regularly jolt out of a stupor and realize that I had been staring at the same question for several minutes--fortunately I managed to finish each block within the hour time limit. Now, thankfully it is over...hopefully I won't have to take it again! Monday I went to take the clinical skills section of step II, which is a total joke--it's fairly pointless and took $1000 out of my pocket (I will stop my criticism here as I tend to get extremely heated and long-winded when I get going on this topic). Also, no matter how good the actors are, they are still actors in clearly contrived situations, and they respond like actors with a script, not like real patients. ("Have you noticed any blood in your stool?" "No, doctor [yes, we were addressed as "doctor" throughout the day], there has been no blood in my stool and my bowel movements are regular"). Naturally, even though the scenarios were fairly simple (and I have far too much respect and healthy fear for the USMLE people to give any examples whatsoever) I still managed to forget key questions to ask on virtually every patient, then remembered them as soon as I left the room (once you leave the room you can't go back in) so thus spent much of the day mentally kicking myself.

Today I started my month of breast disease--in a way I am glad to be seeing patients again, but at the same time last month I grew accustomed to a certain standard of living (get out of bed whenever I want, play online for as long as I want, etc, etc) that I am somewhat loath to give up. Fortunately, this is going to be a fairly light rotation. I will spend days with surgeons in clinic, surgeons in the OR, radiation oncologists, radiologists, and pathologists to see breast disease from all aspects. Today was an OR day--there was only one case and it was scheduled to follow an I&D around noon. So I got to the hospital around 1100, only to find that they had switched the cases and started with the lumpectomy at 1000. Fortunately, the surgeon and resident realized that there was no way I could have known since I wasn't on service in the hospital--the resident hadn't known until five minutes before the case started. (The reason by the way that I chose to do a month of breast disease [which I feel obligated to tell every non-medical person I know without even being asked] is because the breast surgeon is also the program director, and thus is a desireable person to a) get to know since I could very well be ranking this program highly in the match and b) write a letter of recommendation. Also, breast surgery is a fairly significant part of general surgery so it will be good for me to be familiar with anyway.)

The main thing going on in my life now that boards are over is getting my residency application ready. So far I have written the rough draft of my personal statement, entered most of the necessary information into ERAS, started making a list of programs I will apply to, formulated my CV (pathetically short and unimpressive) ,and met with the chairman whom I had never even seen before to ask him to write me a letter of recommendation (he will by the way). I still have to polish my personal statement, meet with my advisor to talk about programs and ask for a letter of recommendation, meet with one of the deans to discuss the dean letter, do well on my current rotation so I can meet with the program director and ask for a letter of recommendation, and...I'm sure there are several other things that I am forgetting at the moment. I despise the application process and have been dreading this since I started medical school. I don't despise the paperwork half as much as I despise interviewing however, so I've got a long way to go yet...