Highs and Lows- Bipolar in Med School

Internship

2010-08-26T16:41:00.002-04:00

I'm now a nearly two months into internship and what a ride it's been so far. My program is better than most when it comes to hours, but my longest shift thus far was 33 hours. We have a night float system, but we still do 24 hour calls occasionally. The ACGME rules allow for the extra 6 hours for transfer of patient care, bringing the total to 24 + 6 (or 30) but my program supposedly abides by a 24 + 3 rule. In other words- 27. It's like they think we won't realize we're working more than 24 hours if instead of saying that the shifts are 27 or 30 hours, they say "24+3" or "24 + 6." Managing my medication on long calls is tough, and I have to make sure I don't flip into hypomania so I HAVE to take my evening dose of Seroquel, even if I'm going to be staying up all night. I take less of a dose, and make sure I get sleep when I return home. So far, so good. No hypomania. Just exhaustion- like all the other interns.

I keep my illness a secret from other people- sneaking pills from inside my Coach wristlet- and I don't think anyone I work with now would ever guess in a million years that I'm hiding something. If you met me now, you'd have no idea. It's nice to be out of medical school because my hospitalization is now a nearly three years in the past. I just tell my peers that I did a research year if it comes up that I was in medical school for 5 years. Of course when I was interviewing, I didn't lie- when asked I said I was on medical leave and then did research. But now, there's no reason to discuss this with my new friends. I just say research year, leave it at that, and I don't have to answer uncomfortable questions anymore.

It's great- sure I do struggle- but I'm so happy to have made it. Sure, there are sucky parts of internship. I had a 24 hour call last night and a nurse called me at 2:30 am to say the BP was 180/80 when it had been that way all day. But, despite these annoyances, I don't regret going to medical school.

DONE!

2010-05-01T13:55:00.003-04:00

Yup, I am officially DONE with medical school. My graduation is in mid-May but in my mind I've already finished- yesterday was my last "working" day of med school.

I'm headed off to internship in a little over a month which is a scary thought. I matched into my top choice advanced program and one of my top choice prelim programs. To those of you reading the blog who aren't familiar with this terminology- "Internship" is the first year of residency which lasts from 3 (ie Internal medicine/ Family Practice) to 7 (ie neurosurgery) years. In "categorical" programs, internship is included, whereas in "advanced programs" it isn't, meaning, as in my case, you have to apply separately for a Preliminary year. Radiology, Ophthalmology, Anesthesiology, Neurology, Dermatology, etc, are examples of programs that sometimes require a separate intern year.

It sucks because I have to move twice- but I'm happy with where I matched so it's worth it.

I had to take my illness into account when formulating my match list. Mania, or in my case, hypomania, can actually be triggered by lack of sleep. And, being that it is perfectly legal to work 30 hours in a row, take 10 hours off, and do the same thing again, I had to pick programs with more humane work schedules. Now what I described is rather extreme- the maximum allowed shift is actually 24 hours, but then you're allowed 6 hours (in some places it's 3) for tying up loose ends, etc. People refer to this as "24 + 6" but I'm like, "whatever, it's 30." One program I looked at basically informed applicants that interns who go over hours do so because they are inefficient. That, to me, implied that interns' time sheets likely have them working < 80 hours with no more than 24+6 in a row, while the actual interns are in the hospital longer than that. I didn't rank the program.

There are programs that have a "night float" system which means that there is, as it sounds, a night shift. This means fewer 24 hour shifts for residents. Even thought night float can turn your schedule upside down and mess up your circadian rhythms, I found this to be preferable to a program where I'd be required to work "24 +6" on a regular basis. Both my intern and residency programs have night float.

I also had to think of the prescription drug plans available. I don't see a psychiatrist a lot anymore- it is basically just for crises and medication management- BUT I do take very expensive medications. Seroquel is the worst offender. I REALLY LIKED one prelim program, but had to rank it very low on my list because the prescription coverage was 400 dollars a year. (!!) And, residents had the same health coverage as one of the hospital unions. So much for collective bargaining!

I'm excited about moving on, but also a little sad because I'm leaving the house I've lived in for 4 years. I'll miss my roommates.

Bullying

2010-04-01T20:12:00.004-04:00

I've been reading about this case in South Hadley, MA where a girl was basically "bullied to death." Apparently, she came over from Ireland and aroused the ire of her classmates when she dated a football star. From then on, it was all downhill. Her classmates reportedly called her an "Irish slut" and a "whore." Finally, on her last day, she was harassed during school, and on her way home, had a container of Red Bull hurled at her.

This poor girl walked into her house and committed suicide.

And, as if things weren't bad enough, her tormentors attacked her on a Facebook page created as a memorial. This is a little more than just juvenile bullying, this brings a sociopathic element to the situation. There is something seriously wrong with these kids, something that I really don't think can be fixed. Not only did they not feel the slightest bit badly for their actions, they had the nerve to insult the deceased. They have demonstrated a complete lack of empathy, something which reflects both character traits and upbringing.

And one of the parents actually is blaming the victim. This was even more shocking; I cannot imagine feeling anything but shame and embarrassment in her situation.

May Phoebe Prince rest in peace.

My Sister's Keeper

2010-01-29T18:56:00.003-05:00

I just watched My Sister's Keeper and I did like the movie- I enjoyed watching it and felt it was a thought provoking story- but the glaring in-accuracies threaten to send the wrong message regarding the use of Pre-Implantation Genetic Diagnosis and the ethics surrounding solid organ transplant.

Now, Pre-Implantation Genetic Diagnosis (PGD) is a technology that can be used to select certain embryos for implantation in the mother. Just as described in the movie, a sibling may be "created" in this manner and specifically selected to be an HLA match to an ailing child.

But, normally, the cord blood is harvested, and that's typically where the use of the new sibling for "spare parts" ends. Once the cord blood has been used in a transplant, the sibling would not typically serve as a bone marrow reservoir. If the bone marrow transplant failed the sibling would NOT be a repeat donor.

Also, from my limited experience with transplant medicine, I've seen that PGD is NEVER used for the purpose of solid organ transplants. The doctor in the movie seemed that he would be on-board with the transplant, and the use of the younger sibling for this purpose. In real life, a doctor would NOT agree to this. Kidney donors are carefully selected, not just for their biological compatibility, but also for the emotional ability to cope with being involved in the transplant process. Organs are NEVER taken from an unwilling individual.

So, it was a sad and moving story, and I enjoyed the move for that, but it sends the message that PGD is used to create "spare parts" and gives the illusion that this technology presents ethical quandaries that in fact do not exist. Anyone reading this blog can be assured that American children are not currently being forced to give up their spare kidneys. Even if a (minor) child begged to give his or her kidney to an ailing sibling, the kidney would not change hands (abdomens?).

Health Care Issues

2010-01-25T19:03:00.004-05:00

I watched a Dateline episode yesterday; the subject was Healthcare and the detrimental effect it's having on patient care. It really brought to light some of the actual problems with an insurance industry hell-bent on profits, but it also brought to light some of the problems that surround end-of-life care and the expectations of families.

There was a heartbreaking case- a man with cancer wanted to enroll in a study that promised cutting-edge treatment unavailable through other channels. Of course, the study covered costs directly related to the study, but outside of that, the man's insurance was supposed to kick in. And, his insurance company refused to pay for expenses related to the desired experimental treatment. There were some appeals, and the insurance company ultimately decided to cover him. But, by that time, the man no longer qualified for the study as he had gotten sicker.

The patient got sicker and sicker, and his wife spoke of a traumatic day when he took a turn for the worst, and she was supposed to make decisions regarding his code status.

The insurance company managed to avoid paying some potentially large bills by delaying the man's care. But, the wife seemed under the assumption that this care would be life saving, and that the insurance company had in essence killed her husband. And then, for reasons unknown to me (based on the fact that I was only watching this on television and have only one side of the story), the wife seemed unfamiliar with DNR/DNI and code status. She described the day her husband took a turn for the worse; a "crash cart" had appeared and she was reportedly asked to make some fast decisions.

From being in the hospital, I remember talking to the family of an end-stage cancer patient. They did not want to make the patient DNR DNI because the patient's daughter had seen a code when she was with her mother in the emergency room, and as she said, "It really works!" Her mother was virtually comatose, and a code was likely to bring nothing more than broken ribs and more heartbreak. The family saw DNR DNI as equivalent to doctor assisted murder.

The insurance companies are so hell bent on profit that care is often refused or delayed; but millions are spent every year on end of life care for patients for whom a medical code is more cruel and pointless than anything else.

But, as someone who believes that discussion of a patient's code status is important, and furthermore that DNR/DNI is sometimes a good thing as opposed to a failure of medical care, I am a card carrying Death Squad member.

I feel terrible for the woman on Dateline; while I think that the case illustrated important issues surrounding code status, it also shows that families of the critically ill are forced to argue and fight with insurance companies. A lot of wasted time and heartbreak, and the big picture is lost.

Step 2 CS

2010-01-01T00:37:00.005-05:00

There are 3 board exams required for licensing. USMLE Step 1 is the first. This is taken after the second year of medical school and covers all the knowledge acquired during the first two years. Neuroscience, genetics, pathology, pharmacology, physiology, epidemiology, and microbiology are some of the subjects included. It's the hardest of the 3 exams, and the score counts the most. The average score is roughly 220. That's the three digit scores. Then there's the two digit score, a mysterious number that isn't a percentage or a percentile. 75 is passing. I have a 230, which correlates to a 98. I'm not sure how one relates to the other.

Some residency programs have "cut off's" and supposedly won't even consider lower scoring applicants. These tend to be the more competitive programs- the ones on the "ROAD" to happiness (Radiology, Ophthalmology, Anesthesiology, Dermatology) as well as Ear Nose and Throat, and Neurosurgery. I'm really not sure how hard and fast these cut-offs are, but I do know that when our Step 1 scores were released, one of my classmates sadly decided that Neurosurgery wasn't in the cards for him. Another was convinced he would never be an a Radiologist. The former chose another field, the latter is a second year Radiology resident.

Step 2 is taken after third year of medical school, the clinical year. It comes in two parts, CK, or Clinical Knowledge, and CS, or Clinical Skills. It's a little easier, and covers mostly clinical medicine. The score for Clinical Knowledge is also given out as a three digit, and the mysterious two digit, score. It's mostly important for those who feel they didn't do well enough on step 1. My score was again, a 230, and this time, my two digit score was a 95. Step 2 Clinical Skills tests students on their patient interactions. Each student must pay over a thousand dollars to interview, and perform physical exams on, actors.

Step 3 is the final test, usually taken during, or after, intern year. It's supposedly the easiest of the three steps, and supposedly, the score counts the least.

Anyway, I'm studying for CS right now. The patients are actors so in many cases they don't have actual physical findings. So, they act. If a patient is supposed to have a heart murmur, he or she will say "hush hush hush" when you put the stethoscope over the chest. No air going into the left lung? The patient holds his breath while moving his shoulders up and down as you hold your stethoscope over the left lung.

And, if you laugh, this means you lack empathy. Laughing puts you in danger of failing, in which case you will have to pay over a thousand dollars to take the test again.

I hope I don't laugh.

2009-12-13T20:41:00.002-05:00

I was pretty sure my resident didn't like me. On my team at the hospital, the main players were my attending, the resident, and a medical student. The attending has the highest rank- she was the one on the team who'd graduated from medical school and who'd finished residency. Dr. Mia, the resident, was lower on the totem pole. She'd graduated from medical school two years prior to my stay, and was working her way through a Psychiatry residency. The medical student was what I was supposed to be. She was doing her third year clinical rotations.

Mental patients, particularly those with personality disorders, do something called "splitting." This basically means that they either really like someone or really dislike someone. As an example, if I really liked the nurse on the night shift, and really disliked the nurse on the day shift, for no apparent reason, this might qualify as splitting. Those lucky enough to bask in the light on the positive side of a split may be showered with compliments. But, this may be short lived, as the splitter can very easily move someone from one category to another. Someone who is wonderful one day, may be terrible the next from the point of view of the splitter. This usually causes problems, because the splitter often complains about certain people on the team, and when the behavior isn't recognized, the splitter may succeed in manipulating those trying to help her.

I was certain that Dr. Mia didn't like me. But I actually can't say that for sure- I do know that I didn't like her. She told me that I shouldn't worry about not returning to medical school, as many people are successful with college degrees. I didn't really NEED to become a doctor. Leaving medical school wouldn't be such a problem. This caused my eyes to fill with tears, and I answered her questions grudgingly, staring at her shoes during our sessions. Would Dr. Mia be happy if her dreams of becoming a doctor evaporated? I wondered bitterly. Her words swirled around my head and I became angrier and more resentful towards her as the days continued. I liked the attending and the medical student. I worried that my obvious dislike of Dr. Mia would be contrasted with my feelings towards the medical student and attending, and that my team would decide I was "splitting."

Patients who split are considered more difficult so I tried valiantly to hide my feelings.

"Splitting" is most notably associated with Borderline Personality Disorder, a label that is often a euphemism for "I don't like this patient." Personality disorders are also called "axis II" disorders. When evaluating the psychiatric patient, a doctor tries to fill each of 5 categories, called the 5 axes. Axis I disorders include Bipolar Disorder, Schizophrenia, and Major Depression, among others. These are generally considered "not the patient's fault" or sometimes "biologically based." Treatment is generally covered by insurance. Axis II disorders include anti social personality disorder, borderline personality disorder, and dependant personality disorder. Axis II disorders are usually considered to be lifelong, and related to a patient's character. Someone with an "Axis II" problem is often considered to be someone with undesirable character traits. Axis II disorders are usually not covered by insurance. Axis III includes any medical problems, such as pneumonia or diabetes. Axis IV includes any social stressors the patient may have. Being a medical student might go in this category. Axis V is denoted by a number, from 1 to 100, which reflects the patient's over all function. A patient who is a 10 is likely confined to a hospital. Someone who scores 100 is able to function in the world.

When a psychiatrist speaks of someone with "axis II issues" he or she usually means someone with "undesirable character traits." I learned in a subsequent psychiatry rotation that tattoos, sitting cross legged in a chair while speaking to a doctor, and attachment to a stuffed animal past the age of 15, are all indicative of axis II issues.

The Hospital Continued

2009-11-29T13:45:00.004-05:00

I settled into a daily routine. Every morning, I awoke, and lined up in front of the dining room in anticipation of breakfast. We’d all get to choose between raisin brain, frosted flakes, and cheerios with the option of a muffin and a banana. I usually chose frosted flakes with whole milk, complemented with hospital issue coffee. I’d tried a number of methods to hide the hospital-issue taste, and a mixture of regular sugar, splenda, and cream worked best. Then, I’d choose one of the round tables; I generally tried to sit with Sara, Jon, and Maddie. And, there was usually free entertainment.

There was the morning that Vera, an Armenian patient who had been admitted for unclear reasons, as she seemed to have a low level of craziness that didn’t seem to fit any diagnosis, and didn’t seem to be the sort of thing one could fix with medication. She was the weird aunt that people tolerate at family reunions, the one who makes dinner a little more interesting. She was a stout woman of generous proportion and one morning, tired of her diabetic diet, she did what no patient dared; she ran AROUND the food cart and tried to help herself to the muffins, sugar laden cereals, and other forbidden goodies, only to be lead away forcibly, shouting something about PATIENTS RIGHTS. I’d been in the hospital as a student long enough to know that this sort of behavior happened on the non-psychiatric wards on a regular basis.

After breakfast, the two teams of doctors, medical students, and residents would start their walking rounds. I’d participated in such rounds, although they made more sense when one is on a surgery service and the rounds consist of brief bedside visits where we’d make sure the patient was farting, pooping, and eating. In the psychiatric hospital, the team would ask how the patient felt, and whether she was in danger of hurting herself or others. In the interest of privacy, when one roommate was being interviewed, the other had to leave. I once had the unfortunate experience of being in the shower when the team came to round on my roommate. I had no clothes with me, and while I’d planned to come out of the shower in a towel, to dress in my own room, I found myself stuck in the bathroom until the team was finished with my roommate. Then, it would be my turn to answer personal questions in front of a large group.

After this, we’d have our morning activity. My favorite was dance therapy, which was taught by a painfully enthusiastic woman named Elizabeth who had red curly hair and sparkly purple eye shadow. It wasn’t that I liked dance therapy, it was that I liked making fun of dance therapy. And there was really nothing anyone could do about it- I was already crazy so if I wanted to leap into the air and flap my arms, there really wasn’t anything anyone could do about it. Morning activities usually only lasted an hour and a half at most, so the rest of the morning was usually spent sitting in the activities room watching television. There had been a ping pong table, but a schizophrenic patient had been instructed by voices to smash the thing. There was a piano, but patients were only allowed to play during a designated two hour period each week. And, there were computers and books, but these were all locked in the library. We were allowed into the library on Saturday afternoons and we each got ten minutes on the computer. And, while I sometimes wanted to sit in my room and read, I learned early on that this was “bad.” Good patients participated in all activities and sat in the activities room, only retreating to the privacy of their bedrooms at bedtime, or during walking rounds.

So, I sat in the activities room, watching a television station chosen by one of the more assertive patients. Sometimes we watched the news or Law and Order, but mostly we watched BET and soap operas. Lunch time was at noon, and usually patients had started to line up at 11:45. Then, we’d get some version of what we’d picked out from the menus distributed the day before. I usually tried to choose sandwiches or other bland food as I was mistrustful of any attempts at fine cooking by the hospital kitchen. I did enjoy the powdered mashed potatoes, and usually pocketed several dinner roles and cookie packets, even though this was considered “bad.”

The afternoon consisted of another hour and a half of activities. My roommate had a group session for substance abuse, but the rest of us were relegated to dance therapy, writing therapy, art therapy, or any number of other activities designed to keep mental patients well. This was followed by more television. Some patients commandeered the pay phones and talked to friends and relatives. The rest of us sat until 5:45 when we’d start lining up for dinner. And, I’d usually sit with my Sara, Jon, and Maddie. And then, I’d leave with my Snackwell cookies, dinner roles, and butter. Visitors could come between 7 and 9 pm. The “good” patients remained in the common area whether or not they had visitors. The evening was punctuated by medication time.

Normalcy

2009-09-15T19:14:00.003-04:00

It occurred to be today, as I surreptitiously took a pill and washed it down with soda from Noon Conference, that I'm actually pretty normal. Yeah, I've had my issues- and I've started the process of telling my story via my blog, but right now, I take medication, I see my doctor every so often, and I'm actually living a relatively normal life.

Of course, I have the aggravation that goes along with having a chronic illness- I have to make sure I've always got health insurance. Sometimes my health insurance doesn't cover the full cost of my medications (as in right now) and I have to beg the drug companies to supply me with free meds. Also, I have to make sure when I travel that I bring my medications with me, enough not only for the duration of my trip, but also a little bit extra should something unexpected occur. I was on vacation earlier this year and had the opportunity to stay longer than initially planned. Sadly, I didn't have enough medication. I could have had my doctor call in a few days of medication, but I would have had to pay out of pocket. So, I went home as initially planned. Had I actually had extra medication, I am sure my sunburn would have been much worse than it was. So maybe I was lucky. But, anyway, it's just one of those issues anyone with a chronic illness can probably relate to.

In a way this helps me with patient care. I'll ask patients if they can afford their meds. When they cannot, I actually can point them in the direction of helpful resources.

Another advantage is that I am very knowledgable abut the meds that I take, and this can sometimes give me the appearance of having read a lot. On rounds, when I pipe up, "Well, perhaps Wellbutrin isn't the best because it lowers the seizure threshold..." it might appear that I spent the previous day poring over UpToDate.

"Mentally Ill" Hopkins Resident

2009-09-07T19:09:00.004-04:00

I'm still planning on recounting my story through this blog, but that project's on hiatus right now 'cause I'm busy with other things (clerkships, studying...)

Anyway, I happened to come across some news articles online regarding this Hopkins surgery resident who was fired from his program for being "mentally ill." Mentally ill? What do they even mean by that? You can't fire someone simply for being mentally ill. They have to be mentally ill and posing a danger to patients, or some other such thing. It's really odd that this guy's whole career is on the line because someone has decided to label him "mentally ill." Now, technically, depression is a "mental illness" So, all you depressed people out there? Everyone on an SSRI? You're all mentally ill. And you can't work at Hopkins. Schizophrenia is also a mental illness. So, I'm sad to say that if you're schizophrenic, you also will not be able to successfully complete a surgical residency at Hopkins should your secret get out. As for myself, any hope I had of becoming a Hopkins surgery resident was dashed to pieces when I found that those who are "mentally ill" are not welcome.

It's interesting to me that this guy was placed in a broad category that includes severely ill schizophrenics, histrionics with borderline personality disorder, and the depressed. I'm trying to figure out which disorder this guy probably had.

Maybe he had paranoid schizophrenia and was having delusions that those at Johns Hopkins were coaching residents on what to report on an ACGME survey. I think that's it, the most likely diagnosis. The resident, at age 30, presented with paranoid delusions. And anyone who thinks that Hopkins would try to hide anything from the ACGME is crazy, totally nuts. There was that guy a few years ago who seemed to think that "hours" should be "regulated" at Hopkins. That's not really a paranoid delusions, I would call that a bizarre delusion, perhaps. I'm not even sure if that's correct. Well, then he started having paranoid delusions. He held the belief that everyone at Hopkins KNEW that he was the one who complained about these alleged "hours regulations." What a nut case.

2009-07-03T22:29:00.003-04:00

I hadn’t wanted to go to the emergency room but I hadn’t wanted to go anywhere, just away from my life and suicide seemed like the best option. In psychiatry class they say that one of the signs that someone is suicidal includes a messy room, as well as poor grooming, accruing an arsenal of guns, Tylenol, or sleeping pills. I hadn’t wanted to burden my family or roommates so when I decided life was too painful, not worth living, I had been thinking about cleaning my room. They also say, if you notice someone is getting his affairs in order, that’s a sign. I always wonder how people think they’d be able to tell if someone was getting his affairs in order. It wasn’t like my roommates knew I’d balanced my checkbook, organized my file cabinets so anyone would be able to find a record of credit cards, bank accounts, and possessions. I’d also made a list of who I thought should get what. I thought my sister should take my surf board because she likes to get into new sports and I knew she liked the beach. I’d doled out my laptop, athletic equipment, printer, everything I thought anyone would want, and I’d put it on a list on the desktop of my computer. I figured if I died someone would turn on my computer and nobody could miss the file named OPEN IF EMILY IS DEAD. But nobody knew about this. And nobody knew I’d thrown out my socks and underwear, things nobody would want once I was dead.

My doctor later told me that I didn’t really want to die and that’s why I called her. I called her to say goodbye but I had to call her emergency cell phone because I wanted to make sure I could actually speak to her before gathering the Tylenol and vodka. Our short conversation ended with, “Emily, do you think you should go to the emergency room right now? “No,” I’d answered. The emergency room was where you go when you’re certifiable. If I went, I would be alive, but I’d also be crazy. I wanted to go out without a label.

After I’d hung up on my doctor, I heard a slam and the bump bump bump of someone walking in the hallway of my house. My roommate came to the doorway of my room. “Hey,” she said.

“Hi,” I said. “Where’ve you been?” a stupid question. I knew she’d been at the hospital, in an operating room probably. She was doing a surgery rotation.

“In the OR,” she said. When someone has thyroid disease, their eyes pop out a little so you can see white all around the iris. Normally the top and bottom of the iris end behind the upper and lower lids so you only see white to the sides. My roommate didn’t have thyroid disease, but I could see white around her eyes, the sides, top and bottom. “Are you ok?”

“Yes,” I said. “I think I’m going to go to my friend’s house tonight, my friend in Springdale. I think I’ll go there.” My roommate still had temporary thyroid problems.

“Oh.” Pause. Pause. “Do you need anything?”

“No, I’m just going to Springdale. What’s wrong with you? You look like I’m going to the gallows or something.” Staring. Thyroid problems.

“Are you sure?”

“I’m just going to Springdale to hang out with my friend. You look like you’re sending me off to die.” I found an old backpack and was putting a book and deodorant into it. My roommate stared. I found a thong in my drawer and put that in the backpack. I’d really only thrown away the used underwear and because thongs tend to go cave diving in your rear end while you walk around, I’d not worn a number of my thongs. I would have liked to pack underwear, but they were neatly packed in a plastic bag somewhere, probably surrounded by other plastic bags filled with soured milk, paper towels, squishy fruit… My underwear was gone so I would be forced to wear thongs for the rest of what was supposed to be a rather short life.

“Are you sure you’re ok?” there was a plastic Vons bag full of discarded socks next to my bed. An empty beer bottle was barely obscured by the closet door. I assured my roommate that all was fine; that I’d mysteriously decided to go to a friend’s house in Springdale, a town I'd never actually been to, and that I was packing the bag so I’d have things to change into the next morning. When I woke up in Springdale. I left about fifteen minutes later. My phone kept lighting up with the words Dr. Feldman dancing across the screen. I usually kept the ringer off because the noise startled me so I usually missed it when people called. But I was paying attention to my phone and I hadn’t missed the fact that my doctor seemed like she really wanted to speak to me again.

I backed my car down the driveway, turned the wheel sharply, and drove away.

(Note- this describes events occuring two years ago- I am NOT actively suicidal)

My Bedroom

2009-06-12T18:09:00.002-04:00

When I arrived home that evening, I had to step carefully when I entered my bedroom. My clothes were strewn about; I thought it a waste of time to fold and carefully put away clothing that would only be unfolded and worn, so I had dumped my clean laundry on the carpet. I didn't see the point in dropping my dirty laundry into the hamper so I left it on the floor too, where it mingled with the clean laundry. I could tell the difference because I thought the dirty clothes were spread more diffusely. The closer something was to the main pile by the door, the more likely it was to be clean.

There were some dishes; the night previous I'd cooked myself spaghetti, my favorite food, but had put it aside and the spaghetti had hardened into what appeared to be curly straw covered with congealing red sauce. There was a sideways can of soda-pop on the rug next to a brown stain. I kicked aside a pair of jeans and a running shoe, sending two hidden beer bottles rolling and clanking off the carpet to the hard-wood floor.

My bed was a swirl of sheets, comforter, blankets, and pillows. Yesterday's breakfast, the rice krispies bloated in the stagnating milk, sat at the bedside. When I tapped the side of the bowl, the milk and rice krispies moved grudgingly as a single gelatanous unit. A slight miscalculation when reaching for the Snooze button in the morning could result in a smooshy surprise.

I wanted to clean but did not know where to begin.

The Final Straw

2009-05-29T21:18:00.006-04:00

I plugged along for one week at [] hospital. I came into the hospital early in the morning to round on my patients, but there was always something missing when I reported to my resident, a kind and patient third year named William. Actually, there was always a lot missing. I usually hadn't talked to the nurse about overnight events, I usually hadn't looked up the vital signs, I may have looked at the Electronic Medical Record, but I often hadn't looked in the Paper Chart.

As an aside, electronic medical records promise to solve the problems and confusion arising from scattered notes written in illegible handwriting. The hospital was trying to upgrade to a completely electronic system, but, while some of the electronically written notes were easy to read, the changes were creating even more chaos. There were two computer systems- one was older, and the hospital was trying to phase it out. Unfortunately, the new computer system wasn't as user friendly so those used to the old system shied away. And then some people didn't use either, preferring to leave scrawls in the old fashioned "paper chart."

So, when I came in each morning, I was supposed to look up the vitals, carefully recorded by the nurses overnight at 4 hour intervals, in the newer of the two computer systems. Then, I was supposed to check for notes. While in a hospital, a patient may be followed by a particular service, in this case Medicine. But, while there, any number of consults may be called. The patient suddenly develops numbness and tingling? Call Neurology. Questions about a new antibiotic regimen? Call Infectious Diseases. The patient has chest pain? Call Cardiology. Funny vaginal discharge? Call Obstetrics and Gynecology. Broken bones? Orthopedics. So, during the day, any number of clinicians may have visited each patient. And, each department tended to leave notes in different places. Neurology invariably left notes in the new computer system. Obstetrics and Gynecology used both computer systems, so any notes discussing the possible etiologies of vaginal discharge could be found in either. Of course, there were individuals from every consult service who preferred the Paper Chart, leaving an actual tangible note there.

The nurses basically serve as the eyes and ears of the service. Teams of medical students, attendings, and residents constantly switch. A particular resident, for instance, may be on one of the Internal Medicine services for a few weeks and then switch to another service, vacation, or outpatient clinic. Medical students only stayed five weeks in any particular place. And, the attending physicians seemed to rotate as well. A single patient staying in the hospital for any length of time would see a great number of medical students and doctors passing through. Teams of nurses, however, tend to remain on the same floor. Not only that, during their shifts, they actually stay on their assigned floors. Doctors and medical students might be running around to clinics, the operating room, rounds, teaching sessions, or any number of activities, but the nurses are actually present, on the floors, at all times. So every morning, nurses can provide information on how a patient has done overnight. Did the patient spike a fever? Sleep well?

It was generally the job of the medical student to gather and consolidate data in the morning. But with my sudden pathological forgetfullness, this became a nearly impossible task. William took me aside, saying, "Are you confused about what you're supposed to do in the mornings?" I nodded. "I already told you this, you go to the PAPER chart, you go to the COMPUTER, you talk to the NURSES, you talk to the PATIENT, you gather ALL THAT DATA, and then you report to me..." He stopped, looking at me, and then wondered aloud about whether there was something wrong with me. William generally had a look of kind understanding. He was the sort lauded on good bedside manner, the type patients could trust, and the type not to be annoyed without good reason.

"I think I could be a good doctor one day..." I tried to explain that I wasn't usually this forgetful, that this wasn't me, that I didn't know what was wrong, but that I was sure if it was fixed, that eventually, I could function as a doctor. But the mounting tears prevented me from speaking.

"Did you have trouble during first and second year?" asked the resident. The look of kind understanding reappeared on his face. I didn't answer- a tear rolled down my cheek and another threatened to join it. The fact that I had done well during the first two years, that my board scores were excellent, almost made things worse. The resident likely took my silence as agreement. Our conversation ended with him pausing and saying "I don't think you can function in a hospital." He spoke carefully, as though delivering bad news to a patient. He paused, looking at me with a mixture of sympathy, confusion, and annoyance.

The fact that William was mild mannered and didn't routinely abuse those around him made our conversation even worse. I couldn't complain to my classmates over drinks about yet another injustice incurred at the hospital. I couldn't dismiss this or laugh about it later.

I knew he was right. I left the hospital that night and didn't return for nearly a year.

(The above post describes past events, right now I'm in school and doing fine)

Candy

2009-02-09T19:43:00.003-05:00

As I travel through third year, rotating from service to service, hospital to hospital, my life is filled with a barrage of unfamiliar faces, strange new computer systems, new keypad codes for new supply rooms... and I search for the slightest bit of comfort, something that I already know, something that I don't have to figure out... and that thing is usually candy.

Wherever I am, whatever I'm doing, I always make sure I know where the nearest candy machines are, which ones charge only 75 cents for the candies, which ones try to get away with charging a dollar fifty. I know which soda machines sell diet coke in a can (Pepsi isn't the same thing, and diet coke in a plastic bottle isn't the same thing...) and I know which ones are generally well stocked, which ones take the crumpled dollar bills...

So, as my life spins out of control, I can sip Diet Coke and nibble on Starbursts as I jot down new supply room door codes, try to memorize the new names and faces that will be evaluating me, and try to figure out the new computer system.

The Descent Continues

2009-01-18T15:35:00.002-05:00

My medication change, my talk with the Site Director, my realization that if I just kept getting up in the morning, going to the hospital, coming home, taking Ambien, going to sleep, and getting up again, I could go on indefinitely. And that's what I did- I slogged back and forth between the student housing and the hospital. I ate, I slept, I did all the things and ordinary human being is supposed to do during his or her time on earth. And I fell into an equilibrium.

Realizing that things were better, but not great, I again called Dean Stewart to ask about taking time off. “Now that you’re psychiatrically stabilized, I don’t see that there’s any benefit to you taking time off…” I wanted her to understand that while I felt my feet were becoming more firmly planted beneath me, that things weren’t right. I was functioning in the hospital, puttering about, writing notes, presenting on topics; and while I wasn’t excelling, I was now certainly up to standards. She advocated self care, telling me that perhaps I should take a day off on the weekends as opposed to voluntarily going in to the hospital to see my patients.

I eventually finished my 5 weeks of internal medicine at Glendale and returned to my home hospital at [] medical school for the final five weeks of the rotation. When I arrived I’d been branded as a “student in trouble,” a distinction which awarded me “extra help” in the form of constant suggestions during my presentations. Were I not to have been branded, I believe, a lot of those little mistakes would have gone unnoticed, or would have appeared in my evaluation as qualifications to my otherwise stellar performance. But instead, my preceptor, desiring to “help” me decided to do so by bringing our preceptor sessions to a screeching halt when he sensed that I did not understand something. The other 3 people in the sessions politely waited as my presentations were drawn out and picked apart. Did I understand the difference between infection, and vasculitis? Yes, I stammered, turning red; the preceptor was doubtful that my response reflected true understanding and launched into a long explanation.

My descent into hell

2008-12-26T10:13:00.003-05:00

Glendale had a community hospital where the nearby wealthy landed should they not have a medical problem urgent or obscure enough to land them in one of the “fancier” university hospitals in the area. It was a small hospital, contained in one building, and having only four floors. While [my med school's hospital] has a MICU, a PICU, a NICU and a SICU, the last three letters standing for intensive care unit, the first letter standing for medicine, prenatal, neonatal, and surgical, the Glendale hospital had only an ICU which occupied only one part of one floor. The other specialties, medicine, neurology, surgery, pediatrics, and obstetrics and gynecology were distributed throughout the four stories.
After arriving in Glendale, myself and the other two students from [] medical school met briefly with the Course Coordinator, a smiling woman named Joanne, who gave us the keys to our student housing, and ushered us into a conference room to meet the course director, a kindly gray haired internist named Dr. Foulton. Dr. Foulton had a halting way of speaking and often, while trying to recall a specific point, or think through a particular problem would close his eyes and hold his hand up as though shielding himself from sunlight. He had a gentle manner, and a gruff, albeit soft, voice. Dr. Foulton, unlike some attending physicians didn’t STRIDE through the hospital, he walked. He led with a quiet confidence that required no outward reminders of his rank or position. He did have the curious habit of introducing students as doctors and this was the first time I was to hear myself introduced as Dr. Forest. It was unnerving, and had a classmate or nurse introduced me as such, I would have qualified with “STUDENT doctor.”
The student housing at Glendale consisted of three houses- two of which were filled with [my med school] students, and one of which was for med students from [a nearby med school]. That house had only one resident, a medical student doing her family practice rotation. In my house, some students were lucky enough to have single rooms. I shared my room with another [my med school] student named Allisa Carter. Allisa was doing her Ob Gyn rotation and spent more time out of the room than in- an arrangement which suited me well. In fact, when I first moved into the room I didn’t see her for the first couple days and knew only that I was co-habiting with someone who had small feet, expensive shoes, and a penchant for tidiness.
I slowly slipped into a routine- I’d get up at 6 to be at the hospital at half past for pre-rounds where I’d stop by my patients for a brief assessment. Rounds were at 7 sharp, a relatively informal affair lead by Dr. Foulton. We generally stood in the hallway- anyone who had a new patient to present would give Dr. Foulton the run down, and then we, as a group, would visit certain patients. Usually we’d visit new patients, or those with interesting physical findings. One of my patients had aortic stenosis, for instance, and we went to her room where we lined up, one by one, to listen to a heart murmur that radiated from the right side of her upper chest to both sides of her neck. The aortic valve separates the heart from the rest of the circulation, and when the valve is stenotic, meaning it doesn’t open quite enough, the blood flow makes a distinctive noise as it tries to force itself past the too-small orifice. Instead of lub dub lub dub, I recall hearing Bwoosh, Bwoosh, Bwoosh. At the end, Dr. Foulton took the woman’s hand in one of his larger ones, and gently thanked her. When I returned later that day, the woman didn’t wish to see any more medical students.

It was at Glendale that I first noticed things were really wrong. Normally chipper and awake in the mornings, I found myself with eyes closing during rounds. Coffee did little to lift my early morning spirits and I found that this tiredness followed me through the day. While I normally have an excess of energy requiring me to volunteer for duties on other floors, merely for the opportunity to gallop up or down the stairs, at Glendale my feet simply didn’t want to walk, just as my face simply didn’t want to smile. A friendly greeting was as difficult as trying to mold frozen butter. I could muster a smile, but it was more of a grimace. My eyes did not squinch shut and the rest of my face remained frozen. Every morning, I awoke and went to the hospital, but with each step I could barely muster the energy to continue with another. And another. And another. I wanted to melt into the floor and disappear.
My roommate from school called me, but I didn’t return her call. It didn’t seem worth it. Picking up the phone. Talking. Dr. Foulton asked me questions on rounds and I was unable to respond, unable to think. Thoughts slipped from my grasp like melting ice cubes. My psychiatrist quizzed me about my medications. Did any of the medications look different? Had I switched from genetic to brand name or vice versa? Was I taking the medications? She increased my Wellbutrin and Ritalin doses and I emerged from underwater, if only enough to look around and reaffirm what I knew was true. I needed to die. My doctor had prescribed me Ambien, and each night I took enough pills to render me unconscious- I didn’t want to worry about getting to sleep, I didn’t want to remember getting to sleep. Sleep waited for me at the end of each day like the period at the end of a sentence. With 40 mg ambient, sleep was sure. It would happen. And I awaited the end of each day so that I could resume my unconscious state.
I had a favorite computer in a corner where I would sit with my head down, long hair loose around my face, crying as I pretended I was mesmerized wit the computer screen, the keyboard. “You’re the most devoted medical student I’ve ever seen,” said a resident, noting I was always in the hospital. “What else is there?" I wanted to ask. The evenings found me released from the hospital but I was unable to fill my time. I studied, nothing stuck. I watched television, still not comprehending. The medication change helped a little bit, but it was powerless against the immense tide of my depression.
I asked the dean if I could have some time off. That way, I figured, I’d be able to address whatever it was that was dragging me to the bottom of the ocean. And I’d be able to study for my ob-gyn shelf. I just needed a little time and then everything would be OK. I also needed a haircut, but it cost money, and more than that, it cost energy. Because getting to the hair dresser or first finding a hair dresser, then getting to one, would take energy. And for what? My hair hung like a dress that’d been in the back of the closet for 3 years too long.

“Are you safe?” asked Dean Stewart during one conversation. I’d sneaked to one of the hospital bathrooms for this conversation, and told her that yes; I was safe, explaining that there were a number of other students in my house. I wanted to tell her that I wasn’t safe, that even as I spoke to her I was thinking that the bathroom, on the second floor, wasn’t nearly high enough. Were I to jump, I would likely survive. Each day I imagined slicing into my skin with a scalpel, watching a thin line of blood appear as the upper epidermal layer separated, and then seeing the yellow, lumpy fascia as the knife cut deeper. At this point, the edges of the cut would pull apart. My cuts often assumed the shape of a fish- narrow at each end with a wider belly at the center. They never healed as they should have. Instead of sewing the opposite sides together, I let them stay to heal as they would. The scar tissue would fill in and I’d be left with a dark rose reminder. My upper left thigh was filled with such reminders. A doctor once asked what the significance of this part of my body was- and there was none. I’m right handed and when I sit, my right hand is next to my right thigh. I cut on my left thigh once when I ran out of room. I cut on my stomach a few times for the satisfaction of slicing skin that had never been sliced, and I cut on my wrist on three angry occasions.
I wanted to cut but I had no privacy- I shared a bedroom with Allisa, an arrangement that left me unable to cut, unable to dose myself into a 24 our sleep, and unable to binge, hiding the contents in our shared closet. So, every day, I went to work imagining that a car would hit me as I crossed the road. I imagined slipping on the hospital floor and disappearing into a puddle that would evaporate.

One day, Dr. Foulton asked me to speak with him after rounds. I followed him into the conference room and he asked me how I was. I told him I’d had a rough time during Ob-Gyn, but that I’d be fine. “We do not rule through fear and intimidation here,” he said gently. I couldn’t answer; if I opened my mouth I’d start crying. I sat silently, finger in my emotional dyke. He told me that he did have his doubts, that I seemed like a bright young lady. He suggested I seek counseling. He said there was a minimum standard, and that I was not meeting it. I finally offered that I have a mood disorder and said that I was trying to get time off.
“This is the real world,” he said, explaining that if I was having difficulties coping, that taking time off would solve nothing- I would have a brief reprieve and return to the same problems. I wanted him to understand that I wasn’t normally like this, that taking time off would enable me to solve what was wrong so that I could return as an improved individual. He seemed to believe that I needed to handle things and not run away from whatever problems I was experiencing. “I’m not running away! I’m sick! I have an illness! I’ll take time off, recover, and then return,” I wanted to say. But I was silent, finger back in the dyke.

80 Hour Workweeks

2008-11-22T18:43:00.006-05:00

"Well, I start work at 6 am so I get tired early," I said to the grocery store clerk, who had just commented on my yawning.

"So, what, you get out at 2?"

"No..."

An 8 hour, or even a 10 hour day has become a luxury. I forget how it is outside of medicine sometimes. There are reminders, though. When I exclaimed that medical students can now get to the hospital later, now at 6 am, my parents, unfamiliar with the world of medicine, didn't really understand how that could be "late" to start work. They also don't understand that a shift may last 24 hours. That people who shouldn't be on the road driving a car, are in the hospital working with desperately ill patients. And they don't understand that this is an improvement.

Resident physicians in hospitals are now legally limited to 80 hours per week of work. There are other stipulations, making 36 hour shifts illegal, and ensuring that there is a reasonable amount of time between shifts so doctors don't have two hours to come home, shower and change scrubs, and return to the hospital.

Many attribute the changes to the Libby Zion case. I don't know many of the specifics of the case- but the gyst is that a young woman named Libby Zion went to the emergency room at a New York hospital and was given medication which interacted with a medication she was on, or an illegal drug she'd been taking- I'm actually not even sure why she went to the ED in the first place, actually. But, anyway, she went to the ED, there were some over-sights, and she ultimately passed away. It turns out that her father's a journalist, so the case gained wide recognition. The mistakes and oversights that were made in the ED were eventually blamed on sleep deprivation and long work hours for residents.

Some seasoned Attending physicians look at that case and dismiss Libby Zion as a cocaine addict who has somehow lead to the ruin of modern medicine, but I think, all things considered, that the diminished work week has been a good thing.

There are arguments against it- some argue that by decreasing hours from 120 to 80, interns have now been cheated out of 40 hours per week of learning and others argue that increased patient pass-offs between residents increase mistakes. Those who protest hours regulations don't like to mention the effects of sleep deprivation upon the doctors, patients, or upon those unfortunate enough to be on the roads while fatigued residents are driving home.

But, whatever the root cause, or whatever the arguments are against hours regulations, I am reaping the benefit and am lucky enough to be entering medicine at a time where there is at least an acknowledgement that long hours are bad.

Civility?

2008-11-01T07:41:00.008-04:00

Sometimes I wonder who's actually crazy- me or everyone else. And sometimes it's a hard call.

My school promotes "civility in the learning environment" which basically means that the dean's office works to ensure that medical students are not hit by flying surgical instruments, launched in an operating room temper tantrum, and that we are not routinely humiliated, belittled, or otherwise abused. The dean's office also works to limit student work hours. Working 100 hours a week, coming to the hospital at 4 am, and working for 36 hours in a row, for instance, is no longer tolerated. We're also supposed to average one day off a week.

The dean's office is going to great lengths to ensure what any other reasonable institution outside of medicine would offer automatically.

Now, there are things in the medical school environment that are difficult but that work. Pimping, for instance, is a term used to describe the Socratic Teaching Method. This is where an attending physician asks medical students questions that they may or may not know the answer to. So, why do we use warfarin instead of heparin in this case? What is this (pointing to part of an x ray)? Is this drug metabolized by the kidneys? Yes? What percent of the drug is metabolized by the kidneys? The questions may go on and on. But when done in a benign manner, a student might feel embarassed about the sudden attention to his or her lack of knowledge on the subject of indirect hernias, in rabbits, but the student leaves with a lasting memory of the significance of rabbit hernias.

Incivility is being purposely humiliated in the absence of any detectable learning or teaching. At worst, it may involve physical harm, although I've never had the pleasure of witnessing this. One incident that has forever embedded itself in my mind involves an attending physician I had the pleasure of meeting during a particularly difficult rotation.

For background, this particular medical specialty rotation took place at Madison Hospital (not the real name). Other students having done this rotation at Madison described it as "the worse experience of my adult life," "miserable," "depressing," and any other number of adjectives commonly used to describe a horrific experience.
Every day I travelled 45 minutes to arrive at the hospital at 5 am to round on my patients and I'd generally get out at around 7 pm, unless it was a "short call" day in which case I'd "officially" be done at 10 pm, although this was often subject to interpretation.

Anyway, one particular attending was about to start a didactic session for the medical students, a bunch of the interns, and a bunch of the residents. There were about 20 of us in all. I made a flip comment to someone about how women's lib and chivalry couldn't co-exist.

Attending: Chivalry and womens lib had nothing to do with one another
Me: (thinking- whoops, maybe that was a dumb thing to say; turning bright red) Um
Attending: But, I'm interested, Emily, what are your thoughts on chivalry?
Me: Uh, sorry! (bright red)
Attending: I think Emily has something to say to all of us about chivalry. Go ahead Emily, you have the floor..
Me: (wondering if my comment was inappropriate, still bright red) uh
Attending: We all want to hear what you have to say about Chivalry. Emily is a big expert on chivalry (gesturing)

Meanwhile I had about 20 sets of eyes staring at me. Someone else tried to say something

Attending: No, I think we should all see what EMILY has to say.
Me: (not sure where to look, everyone's staring; I had NO IDEA what to say so I decided to talk about some things I'd read pertaining to the attending's area of expertise) Well, I was reading some papers about gastric cancer and uh
Attending: No, we're all interested in your thoughts on women's lib and CHIVALRY. Please tell us all how the two are related...

After what seemed like forever, it ended. I'm still not sure whether my comment was inappropriate and I certainly never meant to annoy the attending.

I'm not sure if that counts as incivility in the learning environment, but it was embarrasing, unpleasant, and I afterwards regarded this particular attending physician with some amount of fear.

What are your thoughts? Take the poll shown on the right side of the screen!

Surgery

2008-10-20T21:57:00.007-04:00

In medical school, we “rotate" through all different specialties so we can pick the one we like the best. Right now I'm "rotating" through surgery.

I actually like surgery. It's the first time this year I've gotten to "scrub in." That’s the hospital term for scrubbing-your-hands-and-forearms-with-brown-colored-sopey-stuff-that-leaves-you-skin-with-a-brownish-hue. The point of scrubbing is to prevent the spread of infection; very important in surgery, as I'm sure you can imagine.

Basically, the operating room is divided into Sterile Areas and everything else. The Sterile areas are noted by their blue color and consist of tables, draped in blue cloth upon which surgical tools sit, the scrub nurse, clad head to foot in a blue surgical hat and robe, and the patient, who once prepped and draped, becomes an honorary member of the sterile field.

Before you scrub in, you can't touch anything that's sterile. That means stay far away from anything and everything that's blue. I still cringe before placing my hands on anything blue outside of the OR. That includes furniture, clothing... I've been trained well.

Once you’re scrubbed, you can’t touch anything that ISN'T sterile, or blue. So after "scrubbing" you walk into the OR, butting the door with your hip, with your hands held up, not too low, because then their not sterile, and not too high, because then their not sterile. Generally, the scrub nurse is an expert in all things sterile, so when entering the OR, I generally look to him/her for instructions which usually consist of- don't put your hands there, your hands are too high, your hands are too low, watch the table... Basically the scrub nurse protects the OR from the medical student.

Anyway, once you're scrubbed and in the OR, the scrub nurse holds up your sterile gown, letting you put your hands in the sleeves. You also do a "twirl" maneuver to tie the sash of the gown, where another person holds part of the sash, and you literally spin around. I felt really uncomfortable with the gowning part of the set up because I felt like having nurses essentially "dress" me was demeaning to them- tantamount to having them fan me and feed me grapes.

But, it's not demeaning, and it's all in the name of sterility. And, once you've been gowned and put on two sets of gloves, you can help out with the actual surgery. Today this involved holding retractors. In the same position. For a long long time.

Plant Dignity

2008-10-12T17:38:00.003-04:00

So I was reading the Wall Street Journal yesterday. And in amongst the articles bewailing our economy, there was an article on the subject of plant dignity laws in Switzerland.

These plant dignity laws have made genetic engineering experiments quite difficult, as scientists try to breed pest resistant crops and other such things. Now, ethics committees have to get involved to determine whether or not these experiments compromise the dignity of the plants.

My peas just met a very undignified end. I can only hope that they didn't suffer too much.

The World is Coming to an End

2008-09-21T01:27:00.007-04:00

At least according to the news.

I can't turn on the television without getting really really depressed about something. I'm worried about houses being in foreclosure (I don't even own a house), I'm worried about the fact that the FDIC insures up to 100,000 dollars, it doesn't seem like enough (I have much, much, much less than that in my bank account), I'm worried that the fed will drop interest rates (?? this might benefit me through my loans), I'm worried about what will happen if there's a bail out (my taxes might increase!!), and what will happen if there isn't a bail out (eek!)...

When I think of my day to day life, it hasn't changed much. My house is near my school so I really don't drive very often, cutting down my transportation expenses as gas prices soar. I live on a medical student diet of Diet Coke, Pasta, and Noon Conference food- my food costs have not increased significantly.

My day to day life has not changed in the slightest. I'm broke, I'm scavenging for free food, I don't drive very often, I'm "paying to work..." yet I have this sense of impending doom. The whole world is falling apart. It's only a matter of time before I go down in flames.

And that's when I turned the channel.

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The Name

2008-09-07T22:52:00.005-04:00

So, Emily Forest isn't actually my name- It's not that I'm ashamed of my illness; it's just that it's probably better not to advertise. Especially given my position as a medical student. If I ever become a world famous _________ then I wouldn't try so hard to hide it. But, right now I'm in a position where I, like all others in medical school, have to prove myself, have to come off as professional, able to handle pressure, enthusiastic, trustworthy... all of those adjectives they put on the evaluation sheet next to check boxes indicating "rarely observed" "sometimes observed" all the way to "always observed." And aside from not being professional, able to handle pressure, enthusiastic, trustworthy, you'd better not piss anyone off, particularly on certain rotations, such as ________ (it may be different at different schools- fill in whatever is relevant to you), or you'll end up with a check in the "rarely observed" box.

So, anyway, the name. It's actually my "porn name." One night at summer camp, after "lights out" when we were technically supposed to be sleeping, one of the other girls asked each of us the name of our first pet and the street we grew up on. Basically, if you combine these two entities, you get your "porn name." And, it's supposed to be something like Peppy (your first dog) LaRue (your childhood street). My first pet was named Emily, and I grew up on Forest Street, so I came up with Emily Forest.

And, that is the name I write under. So I can be enthusiastic, together, and trustworthy on the wards.

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Hiding It

2008-08-13T21:57:00.003-04:00

So, I'm pretty good at hiding it. But, there are little things. I live in fear of forgetting my medication, so I keep it in my Coach wristlet among my credit card receipts, random change, and crumpled dollar bills. I usually keep about a day or two's supply on hand- the hospital I'm at is a ways away from my apartment so if I forget, I'm a little screwed.

Mostly, everything's fine. I go to the pharmacy, I keep my bottles full, I put pills in my purse, I take them, and I'm normal.

Except for when I'm not. For instance, on Monday, after going to bed quite early Sunday night, I found myself falling asleep during rounds. My face didn't really want to smile, and my feet were perfectly happy to remain still while waiting for the elevator. Life wasn't bad, just a little boring. That, and I felt that if I could find a couch, I'd be able to nap.

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Emergency Room

2008-07-28T00:03:00.007-04:00

As a medical student, I spend quite a bit of time in the Emergency Room. Actually, I spent quite a bit of time in the ER before I went to medical school as well. It's just now I'm not waiting around on one of the beds with my latest skiing/ hiking/ biking/ walking accident. Instead, I'm buzzing around with a clipboard, finding patients, asking them if it's ok for a student to interview them (the answer is always yes- some people think that students are the same thing as residents, they forget that I'm a student, they don't understand the white coat distinction...) And then I start. I start by asking every question on our school supplied H&P template. The template is quite thorough, particularly the review of systems. And, because I'm just learning what is important, I have to ask all the questions. And, even though I'm learning that someone's right knee pain may not be relevant to his acute myocardial infarction, I still have to ask all the questions. We have preceptor group, and should I have to utter the sentence "well I didnt ask about his right knee..." during a discussion, then I look bad. And medical school is all about not looking bad in front of people.

Anyway, the ER. So, I'm buzzing around the ER with the History and Physical template and clipboard in hand, when I see my psychiatrist. Now, I have a regular psychiatrist, but she's away right now so I have this replacement doctor who works for the school. I figured that he had a patient in the ED and was visiting him/her to ask why he/she'd taken all the tylenol. I came back to the ED a few hours later, and my psychiatrist was still there, perhaps questioning another patient of his about why he or she took all the aspirin. Anyway, the psychiatrist was there all day, because, I imagined, his whole practice was going down. And all his patients were in the ED in various stages of distress.

Later I found out that he works in the ED and that those were not HIS patients.

I find this heartening.

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Plastic Surgery

2008-06-11T22:18:00.005-04:00

As a medical writer, I end up having to research topics I wouldn't ordinarily think to research. Lately, I've been writing a lot for plastic surgeons so I've learned all about hyaluronic acid fillers. These are injected under the skin to "fill things out" and smooth wrinkles. And, they all have names that conjure images of fresh faced youth, like Juvederm. There's even a new product, called Radiesse, that stimulates the body to actually produce its own collagen.

Growing your own collagen isn't always a positive. Elephant Man, who some believe suffered from Proteus Syndrome, was very adept at growing his own collagen. That would not be a good way to explain the way Radiesse works. "Did you ever see the movie, The Elephant Man? Well, a lot of the way he looked had to do with collagen overgrowth, and actually, the stuff that I'm about to inject under your skin with this giant needle, causes your body to start growing more collagen... Hey! Where are you going?! Don't you want to get rid of your wrinkles?"

I'm happy to report, though, that if you are not happy with the way you look, there are many solutions including Accent skin tightening, Juvederm, Radiesse, Botox, face lifts...

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