Things Fall Apart

The first time I met him was briefly outside the OR before his surgery, in the pre-op area. I introduced myself as the medical student on the team, and he pleasantly smiled back at me. He didn't seem too nervous. There could be a few reasons for that. He had gone through this before; he knew what to expect. He had also been in the navy, as I learned later, and had probably faced a lot of things worse than this surgery. Lastly, he had gone through extensive chemotherapy and radiation, which is difficulty for anyone. So, although he was undergoing a rare operation, one the chief resident had never seen and the surgeon, a leader in his field, had only done a handful of times, he was calm.

It was a long, complex surgery. First, one surgical specialty team did their part, and then, three hours later, my team came in to do ours. During the surgery, we kept getting positive margins, which means cancer cells are present, on the specimens we sent off to pathology, so we kept resecting until we could resect no more. Luckily, that last margin was negative. I remember feeling good. It was a really cool surgery and we seemed to have gotten our desired result. The other team then came in to finish their part. Twelve hours from first incision, it was done.

For the first few days after the operation, he seemed to do pretty well. He was sore, but recovering. I got to meet his family and learned a little more about him. We celebrated together when the final pathology came back negative.

Post-op day seven, things changed. He started spitting up what appeared to be bile. We tried to give him some medicine to help his intestines move things along, but it only made him severely anxious. We ended up scanning him. Something was wrong and his new intestinal conduit wasn't emptying properly. We presented him at tumor board that day. Tumor board is a meeting where all the specialists in that field get together and review cases. The decision was made to take him back to surgery that night. After 2 hours of making little adjustments, but not really finding the cause of the problem, we closed him up. He was in the ICU for a while after that.

The last day of my rotation, we were getting ready to transfer him out of the ICU to the regular floor. I remember reassuring his worried wife that he was on the road to recovery and didn't need to stay in the ICU anymore. I was wrong.

It is now a month and half later, and he is still in the hospital, in and out of the ICU, in and out of the operating room. To quote author, Chinua Achebe, "Things Fall Apart," and based on my medical school experience, it always seems to happen to the nicest patients.

The reason I like surgery is that it was one of the most concrete ways to help a patient. An appendix ruptures, you take it out. Problem solved. Unfortunately, it is not always that simple. Sometimes you end up hurting patients more than helping them although your intentions were otherwise.

In honor of the name of this blog...

http://whatshouldwecallmedschool.tumblr.com/post/43977142745/my-main-issue-with-see-one-do-one-teach-one

Somedays you can jump the pole after seeing it done, other days you can't :)

Favorite Patients

One of the authors of my favorite blogs, http://www.gradydoctor.com/, talks about her "FPs" or favorite patients. These are the patients that just find an extra special place in your heart for one reason or the other. I've had a few FPs, most of them on the medicine rotation. One of my FPs was the patient discussed in the last post (FYI: who recovered well and is now continuing chemotherapy).

My FP this month is an 83yo lady who was admitted for bloody diarrhea. She is just the cutest LOL (little old lady) ever. I hope I look half as good and I'm half as sweet when I'm her age. I could always walk into her room in the morning expecting a cheerful "good morning" accompanied by a smile. Despite being in the hospital, she took care in the way she looked. She had always showered (not the case for a lot of our patients), combed her hair neatly back, and even had some flowers and nick nacks decorating her room. She had the sweetest way of asking me questions and would always ask if I could update her daughter.

I walked in today and she was on her laptop!! An 83yo sweet, smart, tech-savvy lady -- impressive. She then proceed how she was going to TEXT her daughter to pick her up later in the day -- text! I was so impressed, and I told her so. She was just such a breath of fresh air. 83 and not letting anything keep her down, ready to face the day, and taking on any challenges life might throw her away, including texting ;)

Free Air

Free Air.

Two words you never want to hear, specifically if it's followed by the phrase "under the diaphragm." You hear that, and it can only mean one thing... straight to the OR for an exploratory laparotomy where you get a vertical incision all the way down your belly to explore your abdomen for the cause of this "free air." Free air means that something has perforated or ruptured. Never good.

That patient I mentioned in my last post? My first patient on this rotation? The one I had to tell he had lymphoma? On of my FPs (favorite patient)? The one that was finally starting chemo and getting ready to be discharged? That one? His xray yesterday showed free air.

Every morning I walk into his room to ask him how he's feeling, and before I can even get the words out, he'll ask "How are you doin' this morning?" And he genuinely wants to know. Every evening when I check on him before I leave, he tells me to "you drive safe." Yesterday morning I walked into his room, and he told me about this belly pain. This belly pain that felt different from his normal belly pain. I listened. I looked at his belly. No guarding, no rebound tenderness = benign abdomen = no scary belly. His vital signs? Normal. We talked about and it thought maybe it was just one of the kidney stones they saw passing. A few hours later, the intern and I get a call from the oncologist asking us to get some imaging because they're worried about this belly pain. I thought, "Really? His belly was so benign this morning."

We go to check on him. We walk into the room and he's sitting on the edge of his bed, hunched over, breathing fast. I felt my heart beat a little faster. "Mr. P? Are you alright?" I check his pulse. A little fast, but not that much faster than he has been. We check his belly. Still no guarding, still benign, but very tender. We meet the rest of the team to round and I ask that we see him first. The senior resident and attending check his belly. Still benign. The resident asks me what I want to do. I tell her I'm worried about this pain. Let's get an xray just to be safe.

I didn't think anything would be on that xray. I hoped not. It came back "free air under the diaphragm." But his belly is so benign. Could it be bowel in front of the liver? It can't be free air. Let's get a CT and call surgery. As he is getting his CT, surgery examines his belly. Benign. They're not going to operate. Until they see the CT confirming that xray. Free air.

With the team rounding, I didn't get to see him before they took him to surgery. I wish I did. I really wish I did. Just to tell him that he was in good hands. Just to tell him that we were going to take care of him. Just to tell him not to be scared. But I didn't get to see him.

I check the operative note before going to bed.
"Massive ileal perforation" "partial right hemicolectomy" "partial distal ileectomy" "bowel left in discontinuity" "taken to the ICU on ventilator"
Words I didn't want to read.

He was so happy to be finally getting his chemotherapy and to almost be leaving the hospital, and now he's sedated, intubated, with an open belly lying alone in an ICU bed.

"Please tell me the test ain't right"

Medicine can be tough. Really tough.

I've had to do things on this internal medicine rotation that I didn't want to do. Not because it's uncomfortable or because I thought I wasn't qualified, but because I didn't want to be the one to tell my patients the bad news. As paradoxical as it seems for a doctor, I want all my patients to come in healthy. I don't want to have anything to treat. I don't want to give them terrible diagnoses that we can only "manage" and MAYBE "cure."

My FIRST patient that I saw on this rotation had some suspicious lymph nodes in his belly. We did a biopsy, and I was the one to tell him the news...he had lymphoma.

That was tough, but not as tough as today.

I first saw her a few days ago. On getting her story and presenting the case, it seemed pretty straightforward. 56 year old female, shortness of breath, swelling in the legs, crackles and S3 heart sound on exam, all led to the diagnosis of heart failure. Heart failure is one of the most common conditions you see in the hospital. Straightforward, except not in this case. They were all little things. These little things that didn't quite add up. A chest xray that didn't look quite right. A strange bacteria causing a UTI. An anemia that wasn't fully explained by a folate deficiency. A gamma gap. A patient that seemed just a little too thin. My attending said, "Why don't we get an HIV test on her?"

She didn't seem to have many risk factors. Just a sweet 56yo women who didn't drink, smoke, use drugs and was just trying to raise her children and grandchildren right. Not currently sexually active but always used condoms. "Always?" I asked. "Always."

I was the one who went in and got her consent. My first time asking a patient's consent for an HIV test. I was nervous, and probably made it seem more serious than it was. I sat down beside her and told her that we would like to get an HIV test "to make sure that it wasn't part of what was causing her symptoms" and that "most people in the hospital get it" and "it's good to know your status." She responded like I had given her a heart attack by just mentioning the word "HIV." My attending went back with me later to explain how everyone should get an HIV test as it is recommended by the CDC. At that point, my patient was much calmer, saying, with a smile, that I had just scared her because I seemed so serious. At the time, I thought it was a good lesson about asking for HIV testing consent. Don't act like it's the end of the world, discuss the CDC recommendations, etc...

The HIV test was taking longer than expected to come back. "Maybe they didn't process it because of the holiday weekend," we thought, we hoped. When an HIV test takes longer to come back it generally means it was positive on the initial test and the extra time is because they are doing a confirmatory test (a Western Blot).

I called the lab today, she said she would call me back. I returned her call as soon as I felt my pager buzzing. "That patient you were asking about? They're doing the western blot." My heart sank. I felt a lump in my throat. My first thought was "please let the western blot be negative." Later that afternoon, I was telling my attending about the western blot and the phone rang. It was the lab. The test was positive.

We went in to tell her together. Closed the door behind us. Pulled the curtain dividing her and her roommate  We sat down on the bed. My attending says "We have something to tell you. The HIV test came back. It was positive." My patient balled her hands into fists and threw her arms over her face. A look of shock came over her. Tears streamed down her cheeks. She kept repeating over and over, pleading with us "Please tell me the test ain't right?" I so wished that is what I could have told her. I wanted to tell her more than anything that the test wasn't right. She was fine. She didn't have HIV. She could go back to her normal life taking care of those grandbabies she loved so much not worrying about the word HIV ever again. But I couldn't tell her that. Yes, HIV isn't the disease it used to be. Yes, it's no longer a death sentence. Yes, it's treatable. Yes, you can live longer. Yes, the stigma is less, BUT the stigma is still there. All these things don't make hearing you are HIV positive any easier. I sat there with her for over an hour, just holding her hand and telling her all these reassuring things that didn't even reassure me. Before I left, I hugged her as tight as I could, somehow trying to make it better.

Her life is forever changed, and I'm part of the team that changed it. Not for the good. There is a silver lining. Finding out now means she is starting treatment earlier. She has a better chance. But right now, it's hard to see that silver lining. Right now it just feels very dark.

Trauma Call

What I'm like on trauma call

"You just need a man to figure it out"

Setting: the female fellow and male attending are working to place a new dialysis graft in the patient's arm.

They are trying to figure out how to work with a different tunneler when the attending says, "You just need a man to figure it out."

At another point in the surgery when the fellow was questioning the position and number of the vessel clamps, he again responded, "You just need a man to figure it out."


In both these instances, the fellow half-heartedly laughed in response. Was the attending saying this in a joking manner? Yes. Does that make it ok? I say no.

Just some food for thought.

The Silver Lining

Some days it's difficult being the med student.

You put pressure on yourself to perform well, especially when you're in the specialty you want to pursue. In the process, your nerves are your undoing on something as simple as a patient presentation.

You try and take the initiative and remove a wound dressing, only to find out it wasn't supposed to be removed yet.

You know the answers to all the questions except the one you are asked by your resident.



The silver lining? When your patient tells you you're going to be a good doctor.

Lumbar Puncture

The nurse scrunched up the 7 week little girl into a ball so her spine was curved, exposing her intervertebral spaces.

The resident counted her vertebrae, felt the spaces, and started prepping the area of entry.

I dipped the pacifier into the sugar water again and tried to get her to suck vigorously on it.

The resident sticks the needle into her spine, the end of the needle remains dry.

She screams and tries to wriggle free.

I put more sugar water into her mouth.

We start over.

The attending tries.

I put more sugar water on the pacifier.

Only blood comes out of the  other end of the needle.

The attending calls the hospital director.

We put the baby in the sitting position.

The nurse scrunches her down.

I try to get sugar water in her mouth.

She stops trying to break free and relaxes into my hands

I cradle her little head

Nothing comes out of the needle

Overheard in Egleston

A 7yo boy born with 4 fingers on his left hand: "Some people say God made everyone with 10 fingers and 10 toes, and that's not true."

Same boy, when asked about napping: "Yes. I napped 12 minutes ago!"

A 3yo girl with a pinwheel for incentive spirometry: "Abra Cadabra!"

An 8yo girl when asked about being ready to go home: "I'm afraid of falling and having to come back to the hospital"

A 10yo boy with recurring Guillan-Barre "I'm afraid of dying from this"

10 Fingers, 10 Toes

I've started my inpatient Pediatric rotations by working in the nursery at Grady, a pretty happy place to start :)

Babies are adorable. To celebrate their adorableness, here are some baby haikus.

Babies are cuties
Ten fingers and toes I count
Tiny hand grasps mine

Learn swaddling skills
Wrap babies cozy and tight
Sleep peacefully now

Baby Reflexes
Morrow, Babinski, and suck
Soothe baby, me, both?

Needless to say, this week has been nice... happy moms, mostly happy babies (as long as they're being fed), + happy doctors = happy med students.

Breaking Bad News

I have always thought that it would be too difficult for me to be an oncologist due to the emotional burden of sharing devastating news with a patient and their family. During this rotation, I spent the afternoon with an orthopedic oncologist. He had one of the best bedside manners that I have seen.  With every patient, he just seemed to build rapport effortlessly, and he seemed to have a deep connection with the patients he had treated that were now in remission. I not only saw him interact with the patients that were now doing well, but also patients who faced an undesired disease progression, specifically one patient with stage IV disease.

We walked into the room and he introduced me to the seventy-year-old patient and her daughter. He started off asking the daughter about a tattoo on her arm, and making friendly conversation. He then examined the mother’s shoulder where a tumor was growing underneath. He explained how the CT scan showed spots in her lungs in addition to the tumor on her shoulder, and what her options were for treatment. He explained this all in a calm and straightforward manner. He did not go into the medical specifics and what this meant for her prognosis, but instead discussed in simpler terms how he could help her.  I could tell the patient and her daughter were both shaken up by the results. The patient was trembling while tears formed in her daughter’s eyes. The physician allowed them to process this information with silence and again told her how he could help her in his role as the surgical oncologist.  He also provided a plan of action for them. He encouraged them to see the medical oncologist within the week, and he advised them to contact him with any questions or concerns they may have.

Cancer is horrible. There is no way to alleviate the shock, fear, and pain of that diagnosis. I have never been sure how I would break that news as a physician. Seeing this doctor tell his patient and her daughter about her cancer showed me a good way to do it. He was straightforward with his explanation, yet calm and empathetic in his delivery. He did not promise a cure, yet he did not take away all hope. Although I felt extremely sad for the patient and her daughter, I could appreciate the way the physician handled the situation.

This specific experience provided me with insight into a way to share difficult news with a patient. It is a balance between showing empathy and serving a source of strength and hope. It is explaining the diagnosis in clear and simple terms and taking the time to let the family process in the information. It is not leaving the patient feeling hopeless about their condition, but instead providing a plan of action and reassuring them that you are available to help them. Through this experience, I hope I am similarly able to discuss difficult diagnosis in a way that makes the experience as easy as possible for the patient.

Thoughts on Family Medicine

After 6 weeks on this rotation, I have become somewhat familiar with the practice of family medicine. Ultimately, I've realized you need to be a REALLY good doctor if you want to go into family medicine because you essentially need to have a mastery of three subjects: internal medicine, pediatrics, and ob/gyn. However, due to the reimbursement rates and restrictions on patient care, family medicine doesn't generally attract the top students. Even if you're a pretty good student, it is really difficult to know three broad fields very well. It seems that end result is a "jack of all trades, master of none" situation.

Coming off of the ob/gyn rotation, I think that there is a reason a "speciality" exists for this field. Those doctors are putting in IUDs everyday, talking about birth control options every day, looking at cervices everyday. Therefore, they have a better grasp on diseases affecting those patients. Yes, doing a pap smear isn't very difficult but fully managing a women's ob/gyn needs can be, and I think it should be left to the ob/gyns to do that.

However, I also realized the utility of the "family doc" in rural areas. If you have a good base of knowledge in internal medicine, pediatrics, and ob/gyn, and you're the only doctor for a few hundred miles, it makes sense. However, in the urban setting, I feel that patient receive better care going to the specific subspecialty of pediatrics or ob/gyn.

Overall, I have enjoyed this rotation. It's patient-care focused. There is a lot of preventative medicine. The hours are pretty nice (but you hours outside of clinic are generally filled with paperwork). You see a wide variety of patients. Other times it can get pretty monotonous (for example, having 5 physicals back to back). Ultimately, I don't think it's my passion. I don't feel as excited coming to clinic every day as I do going into the OR.

On Hurting Patients

As the other students in my class, I came to medical school because ultimately I want to help people. However, I didn't fully realize that with the intention of helping people, you sometimes I have to hurt them (ex: vaccines, drawing labs, IV medications, sometimes even physical exam maneuvers).

We had a young women come into clinic the other day because she has tenosynovitis. One of the treatments for tenosynovitis is a steroid injection into you wrist, underneath the tendon sheath. I went into the room, introduced myself to the patient and her family within the room (husband and 2 small children), and explained to them about the procedure. I was working with a resident that day.  As the resident is preparing the injection, she tells me "I'll do the first one and you'll do the second."

Medical school is about learning and that includes procedures, but I had never given a steroid shot before, especially not into the wrist where there are about 20 other things in that small space. This was also the first time the resident was doing this particular procedure. I didn't say anything and just tried to get into the mindset to do it. The resident puts the needle into the patients left arm and starts injecting. The patient flinches and starts crying. The resident finishes, looks at me, and asks, "you want to do the next one?" I am conflicted. I don't want to look like a bad/afraid/uninterested medical student, but I am not comfortable with this procedure and the patient in front of me is crying out of pain. I say, "I'm not really comfortable doing that." The resident gives me a look and does the injection. As we walk out of the room, she tells me that I'm doing the next steroid shot even if I'm scared. I tried to explain to her it was more to do with the patient crying in front of me and unfamiliarity with the procedure than fear. 

The experience made me realize how much I DON'T like doing procedures outpatient. Even though I am a procedurally geared person, I like surgeries because the patient is anesthetized. They can't feel you cutting through their skin; they don't FEEL. I have found outpatient procedures really difficult, especially joint/steroid injections. It's hard to want to try something for the first time when it includes inflicting pain on a patient.

"I've never ridden in an ambulance before"

The reason for appointment read "follow up for cough." Reading through the notes, I see several visits over the last few months for the same reason, cough. Something didn't feel right.

I walk into the patient's room and introduce myself. He looks thin, anxious, fragile. He tells me about his cough, how it's been going for a few months, how thinks he might need some antibiotics this visit. He goes on to tell me how he's developed diarrhea in addition to his cough, how he's lost 25 pounds in the last 3 weeks, how he feels weak, how he has unresolved skin rashes on his sides. Something really doesn't feel right.

I do a physical exam. I don't hear anything in his lungs the first time. Listening again, there is something in his right lower lobe, but it's not typical pneumonia. His chest xray from a week ago was perfectly normal. I continue my exam. He's breathing fast, his heart is beating fast, he is not doing well. I look at his abdomen, the rash is still there. There is fungus on his toenail that just isn't going away. I ask him to open his mouth, so I can look in his throat. My fears and suspicions are confirmed. His mouth is covered in thrush. I try to remain calm and tell him that I will be back in a few minutes with the doctor.

My heart and thoughts racing as I leave the room -- "Oh my gosh, oh my gosh, oh my gosh. My patient has HIV, and he doesn't know." I scan the records looking for a previous HIV test. I don't see one. I tell the doctor about him. We go in to see him together.

She asks some of the same questions. She also asks about his sexual history. He seems uncomfortable talking about it. We measure his oxygen, and it's low. The doctor explains to him that due to his unstable vital signs and low oxygen that we're going to have to call an ambulance to come take him to the hospital. She then tells him that based on his signs and symptoms that he most likely has HIV and a pneumonia caused by the HIV that they will treat in the hospital. She then asks him about which hospital he would like to go to and we leave the room.

I go back in to check on him. I ask him how he feels about what the doctor just told him and if he has any questions, and he replies "Well, I've never ridden in an ambulance before." I don't know if he just didn't process what the doctor had told him or if he was in denial, but he wasn't ready to about it.

Medicine just got real.

Self Reflection – The Importance of Self Care

As part of the assignment for this rotation, we have to write a letter on the importance of self care. When we are in our intern year of residency, the clerkship director will mail these letters to us to remind us to take care of ourselves. I think this will serve as an important reminder during that stressful period of my life -- if I don't take care of myself, it's going to be pretty difficult to take care of patients.

___________________________

Dear intern me,

1. As Dr. X said, if you’re not waking up excited to go to work and see patients every day, talk to someone. Talking to someone can help solve a difficult work situation, or it just feels good to express your feelings and have someone listen and understand. Whether it’s your superior, a peer, a friend, or a therapist, just talk to someone.
2.   Keep exercising. It really is the best way to deal with the stress, exhaustion, and emotional baggage of the day. Even if you can’t make it to a crossfit workout, at least try and go for a walk or a run. You will feel better. I promise.
3. Make time for family and friends. Even if you feel that you have to study, read about a patient, or prepare a presentation, make time to spend with those people who make you happy. It will be worth it. There will always be another deadline to meet or more to do, but those who you love most won’t always be around.
4. Don’t sweat the small stuff. Try and let negativity roll off your back. You never know if someone else’s rude or insensitive comment was due to their level of stress, exhaustion, or personal conflict. Just remember that 99.9% of the time, it isn’t a personal attack. When it is, try and find the good in the situation. In that comment/attack could be something you can improve upon.
5.  Don’t feel that you have to be perfect in everything. You don’t have to be the perfect housewife, perfect doctor, perfect daughter, and perfect friend.  For example if you don’t have time to cook every night, don’t worry about it. Do what you can, and remember you have supportive friends and family who love you, understand you, and want to help you.

 You’ll be fine. You are a strong, capable woman, and you can handle more than you think.

Love,

M3 me

"This isn't The Notebook"

I've been spending some time in the neuropsychiatric ward, the saddest place I've ever been, taking care of some patients. I guess the neuropsychiatric ward is what people thing of when they think "psychiatric hospital." Patients are either so medically sedated that they are just passed out in their wheelchairs, heads on the table, or they are aimlessly wondering around, going into other patient's rooms, and following you wherever you go.

My first time in the ward, a patient came up to me, crying, asking "can you take me home?" It turned out that she was one of our patients. Talking to her was difficult through her broken sentences, confusion, and word finding difficulties, yet I felt I could follow some train of thought she was trying to convey. She pointed to the attending rounding, and said "I know him." I was excited by this -- she recognized her doctor, but when I tried telling the attending that, he dismissed me saying, "She just recognized a white male figure -- she doesn't know who I am."

Am I too idealistic? Am I biased in working with my patients with dementia to hope for the best, to only see the good? I have another patient with progressive Alzheimer's dementia with receptive and expressive aphasia, meaning she has trouble understanding and using language. Yet, I try and talk to her and understand as much as I can. I ask her name, and she tells me, "Penny*." I ask her where she is, and she tells me, "hospital." Every time I talk to her, I feel that I can see the person behind the confusion -- if I'm patient enough, I can understand what she's trying to tell me. When discussing her with my resident, I reported that she knew who she was and where she was, and that I thought she might know more than we give her credit for. My resident responded, "This isn't The Notebook. She is confused and doesn't understand us and doesn't know where she is."

It might not be The Notebook, and I understand Alzheimer's is a progressive disease that doesn't have periods of improvement/return to normal function, but that doesn't mean we shouldn't try and find the remainder of the person left inside.



*name changed for patient privacy

"Ethical Erosion"

I read an interesting article in the New York Times today. It discusses how the third year of medical school with block clinical rotations lead to the "ethical erosion" of medical students -- how medical students stop being patient focused and start being disease focused.

It's hard not to fall into that trap. Just earlier today, I found myself talking about my "schizoaffective patient" and my "depressed patient" instead of "my patient WITH schizoaffective disorder" or "my patient WITH depression." I think as long as I try and stay aware of how I am talking ABOUT patients, how I am talking TO patients, and how I feel about patients, it will go a long way to preventing this "ethical erosion."



P.S. On a less serious note, this blog is a hilarious insight into the last two years of med school

"They're trying to kill me"

I've started my psychiatry rotation this week at Wesley Woods Hospital.


1)
I've talked to my first schizophrenic patient. This Modest Mouse song, "World at Large" reminded me of him.


Went to the porch to have a thought. 
Got to the door and again, I couldn't stop. 
You don't know where and you don't know when. 
But you still got your words and you got your friends.


I know that starting over is not what life's about. 
But my thoughts were so loud I couldn't hear my mouth. 

2)

coun·ter·trans·fer·ence/ˌkountərˌtransˈfərəns/

Noun:

The emotional reaction of the analyst to the subject's contribution. (google dictionary)

3 days in and I'm definitely feeling it. I have felt unusually anxious the last few days, and it's not "the crazy rubbing off on me." Rather, I think it's the effect of talking about these incredibly personal details of people's lives and having to remain stoic and objective about it. It's sad. It's draining.

This sounds like a pretty negative post, but I am actually excited about the rotation. I think I'll learn a lot, but I also think it's going to be difficult.

3) 

I learned my "tell." 

Today we had to practice the psychiatric exam with a partner in the class. The clerkship director said he would be coming around to give us feedback and specifically let us know what our "tell" is -- what gives us away when we're nervous. He said by knowing our "tell," we could work to not let it show during patient interviewing.

My "tell" is that I flush -- my face and neck turns bright red. Awesome -- because I can really change on working that, ha.

When you start dreaming about hemorrhagic ovarian cysts

you know have been on ob/gyn too long ;)

This last week marked the end of my ob/gyn rotation...ending on a high note with gynecologic surgery (gyn surg).

The last two weeks have been my favorite of rotations thus far. Yes, you have to be at the hospital early. Yes, you have to present patients to intimidating attendings. Yes, you will mess up and get yelled at by scrub/circulating nurses. Yes, people can be grumpy for no reason. Yes, you will be on your feet for so long during surgery that you put ice packs on them when you get home. BUT IT'S SO MUCH FUN. I can honestly say that I've enjoyed every day that I've gotten to be in the OR.

I love the hands-on aspect. Here is a list of just a few of the things I've gotten to do the last two weeks.
--sewed up a patient with a subcuticular suture
-- cut a fibroid uterus in half (after it was removed to be sent to pathology)
--biopsied a lesion on a cervix
-- played with hysteroscopic tools
--closed fascia by tying knots

Surgeries I've seen:
-- total abdominal hysterectomies
-- supracervical hysterectomies
-- ovarian cysts removal
-- ovarian mass removal/omentectomy/bowel resection
--laser ablation of vulvar lesions
-- cystoscopies
-- dilation and curettage

I also just started feeling more comfortable as an M3 by the end of the rotation. Some residents are nice, some residents are mean -- same with attendings. I don't know if I have just gotten used to being the bottom of the totem pole, or if I've just become a more competent M3, but these last two weeks I have felt good about where I am.