Ob/Gyn: mid-rotation evaluation and loss

I am half-way through the big, potentially life-altering experiment that is this Obstetrics & Gynecology rotation. Over 14 vaginal deliveries, 8 Cesarian-section assists, a few 24-hour calls, many a pelvic exam, Pap smear, antepartum, post-partum, dilatation & curettage (for both spontaneous and voluntary abortion) and even assisting in a gynecological surgery later, I have officially completed the "Obs" part of this "Ob/Gyn" rotation.

Honestly, I love it. It's medical, it's surgical, there's variety, it's all about women and some of the most beautiful, horrendous and distressing moments of their lives. It's intimate, sacred. Except that once you deliver that baby, you don't really get to follow it. Family doctors can do both, but if there is failure of labour to progress, then they turn their patients over to the obstetrician. If a woman in a poor village in some African or Central Asian country for whatever reason could not push her baby out, and I was the only doctor around, I would not be able to save her life by performing a STAT C-section right there and then. And she might die because of that. But I would also be at a loss to adequately help her 6 other kids with diarrheal and respiratory disease, treat her newborn baby's complications post-premature delivery with growth restriction and appropriately treat her father's angina and her mother's dementia if I'm not a family doctor. Sigh. What to be? What to do? What do I love more? Do I want the breadth or the depth? Do I want to be able to treat anyone's anything? Or do I want to be able to operate and be an expert in one particular field? Tough choices. However, I do think it definitely boils down to these 2 choices for me, so at least I've narrowed it down.

The most touching moment this past month was with the lady with the flowing strawberry-blond hair. A beautiful, rosy-cheeked mother-to-be, full of excitement, joy, anticipation of the little darling soon to be the center of her universe, if it wasn't already. She anxiously lay on the table as one of the sweetest, vibrant obstetricians on the team slid the ultrasound probe over the patient's belly, back and forth, up and down. There was no fetal heart beat. The placenta looked a bit weird. Baby wasn't moving. It's morphology and size told us that it had actually died in utero 2 weeks earlier. The doctor took the patient's hand in hers and shook her head, her eyes glistening as they filled without brimming over. The husband looked down at the floor, his wife up at the ceiling. There were no words. We gave them some time to be alone together, to take stock of their world as it fell apart before them, too quickly to be understood, too painfully to possibly be real. And then they went home to gather some belongings before returning for this strong, beautiful woman to deliver her lifeless angel.

The couple was placed in a room with a blue butterfly on the door so that all the nurses and doctors and hospital staff would know to be especially gentle and sensitive. The occasional screams of labour and the cries of newborns could be heard in neighbouring rooms, as this mother was induced, eventually delivering the fetus, and after requiring additional dilatation and curettage, the placenta, in pieces. I had put my hand on her shoulder as the doctors went through the necessary procedures to evacuate what was left. I had told the couple that even though I was just a medical student, I was here for them, if they needed anything, I was here. "It's just a lot of emotions" they would repeat, and I would nod and hold her hand. Her body relaxed slightly as I held her hand, not letting go, patting her arm, just being. This too is the human experience, and these tragedies accompany every few dozen joyous miracles. But that thin white, shimmering face, and those long curly strawberry-blond locks, those pleading green eyes. Who could forget.

Med-bubble floats to the Reservation

Today I spent the day with a family doctor at an Algonquin federal reservation, seeing all the pediatrics cases. Now normally, we know I am not the biggest peds fan, but I absolutely loved working with this family doctor (she is so amazing), I got to actually do so much independently (she was not re-checking my histories and physicals in great detail, unless I told her I wasn't sure about something, which really gives one so much confidence!) and I loved working in that small, intimate setting, seeing this patient-population in their own community.

Everything was so open, people were very friendly and the people working at the clinic were just so positive and motivated / passionate about working there and working with the Native population, without any condescension, judgment, etc. that unfortunately is much more prevalent in the city-centre hospital, even if only subconsciously. For example, I actually saw one of my previous hospitalized babies at the reserve clinic today and I noticed that my own ideas about the patient, the patient's parents, etc... was so different. The love and empathy for the baby was always the same, of course. But today, I was much more sympathetic and caring about the parents too, and much less tainted by the opinions of other staff and their disdain for this unfamiliar style of parenting (some of which, I will admit, is probably valid, but there are such complex social, cultural and economic issues at play when it comes to all of that, so you have to take it into consideration... alcoholism, suicide, substance abuse, boredom, lack of motivation, lack of education and employment... these are the real problems that are not solved by throwing money at them... so anyway, of course teenage mothers and drunken fathers with too many kids are not going to be the best parents in the world, but that would be the case, regardless of whether or not they are white, black, yellow, red, or blue!) And basically, by working on the reserve itself, it's so much easier to maintain this balanced perspective when dealing with these difficult cases, which is so important if you want to actually help anyone and learn anything from them.

So that is my schpiel for the day. But yet another baby with seizures -my goodness, the poor darling! Really, as my little cousin says "I feel bichari for them!" (bichari means "poor thing" in kutchi / gujarati and is usually used as a response / exclamation to witnessing something like a little baby having a spastic seizure). I love newborn babies, I really do. I could easily spend the rest of my life being a doctor of little neonates... except the lifestyle thing for neonatologists really is scary too.

Shorter Reflections: Kids love 'em rollercoasters

Today was a better peds day: I saw a kid with croup who was getting better, happy, sweet, playful and cooperative. I saw a baby with herpes on its face (poor thing really -what jerk with a cold sore goes around kissing babies' faces!) and I saw a case of mesenteric adenitis / questionable Gilbert's syndrome. Our lecture was on adolescent cases, which was a welcome, far-more interesting change (and an unfortunate rarity). I was present for a delivery in which a healthy baby was born -we did not even have to suction, her cry was so good. All in all, a very non-typical day in pediatrics. Of course, it helped that I am finally getting over this viral infection and I could actually show my face at work today after staying home, sick for two whole days.

The roughest was the psych case a few days ago -cute little kid with behavioural problems, ADHD, tics, oppositional defiance, self-mutilation, tantrums, hypersensitive to touch, possible absence seizures, has been overdosed on meds by accident because a family member was taking the same drugs in a higher dose, does not distinguish between strangers and family / friends, has trouble with social interaction and play (autism spectrum disorder suspected). Now there are the challenges in medicine that one loves, and then there are... these. It's awful. It's unfair. Why. She's just a kid -couldn't the evolutionary gods spare her and her family all this suffering? It's not a case of autism. This is comorbid to the power of a billion. That was a heartbreaking day.

But today was a better one. So this is what it's like in this little med-world of mine -up, down, up, down, up... sigh. As my neonatology supervisor's 7 year-old kid said, "I work very hard at school. It's enough, [Mommy]! I need a vacation!"

So that is what Harvard-Yale will be for me, in a couple weeks -a much needed vacation before getting started on the rotation that may or may not determine the rest of my career path -Ob/Gyn!

Pharm Carrots. And mixed feelings about Peds wards.

So. I just came back from a lecture on menometorrhagia. It was a "lecture"... you know, where a big pharmaceutical pays a medical expert money to talk about a topic that interests them, and said doctor will genuinely believe and advocate for everything they tell you, including a plug for some drug or device that the pharmaceutical happens to supply, and we all get wined and dined as fancily as can be. I knew this is what they would do, so why did I go?

Multiple reasons. Firstly, I am a medical student away from home with long(ish) days who will take the nice free meal, thank you (shame on me, probably). Don't worry I felt a nice bout of guilt pretty much the whole time. Secondly, I'm all over the Ob/Gyn stuff, especially issues like menorrhagia which so many women live and suffer through and genuinely wanted to learn more about it. Thirdly, I mean, this was my big opportunity to see what all this "unethical pharmaceutical wooing" and "doctors getting sucked in" was all about. Now that, how could I pass up? We discuss the ethics and the awfulness of this kind of thing all the time since... pretty much high school, right through university undergrad and now in medical school. Really. Even an individual of the highest moral breed must be at least remotely curious about what that world is really all about, in terms of the very stereotypical medical marketing ploy experience, that, whether or not we like to admit, is incredibly successful at selling the good (ahem, this being the reason why they persist in their excellent sales strategy... no critical thinking can stop the wiley ways of our subconscious and all those positive associations with delicious food and other pleansantries like free samples, or that great conversation you had with that other doctor sitting next to you... am I wrong?)

So yes, I took the carrot. And like any other self-regarding medical student or resident or physician, I was so pleased with myself at taking careful and conscious note of that moment of recognition of the pharm plug exactly 2/3 of the way through the "lecture". And Intro to Clinical Sciences can give itself a pat on the back because when they said "this is not statistically significant" my first reaction (internally of course) was, "but is it clinically significant?" Of course, I will probably end up prescribing this intra-uterine device (IUD) at some point or another in my career. The question to ask is whether I would have prescribed it anyway, which I know is a resounding "Yes!" because we have been learning about this one by its trade name since our Basis of Medicine lectures as first year med students. Pharm is everywhere. You think you'll escape it by escaping a dinner?

Now, don't get me wrong, I do not think this means that one should just stop feeling guilty and attend all the dinners, stock up on freebees, melba toast packets and start binge drinking on pharma's dime (for the record, I did not touch a drop of alcohol... that would just feel too much like someone trying to get me drunk so they can take advantage of me... I know, I know, it's a total contradiction for me to feel this way about that, yet rationalize the rest, but just read me out, okay). I'm just saying that it's important to very realistically recognize that you will not get through medical school untainted by avoiding every luncheon and free pen available to you. Ideally, I would like to keep my distance from these as much as I can anyway. But recognizing that I've actually already come to think of trade names of a lot of different drugs as synonymous with the generic -I am already 'tainted' as it were -then the additional harm done by further exposing myself to more advertising is not as great (though probably still not negligable, so yes, be judicious if you decide to go down this path because it probably snowballs, etc).

But, so then if you genuinely think the topic is particularly interesting, and you don't think you know enough about a subject you would like to learn more about, and you're tired of searching PubMed and UpToDate to learn more about it because your eyes are tearing from doing this all day long, everyday, then why not. For example, today's lecture really was intersting. I didn't merely learn about the IUD being marketed, I also learned about the use of antifibrinolytics and specific oral contraceptive protocols for women with excessive blood loss during menstruation, surgical interventions and even what exactly some of the current definitions are -and all the wiggle-room within them -of 'irregularity' and 'too much blood loss', all of which are very practically, clinically useful... stuff that is always good to get exposed to multiple times if you ever want to actually remember it. Don't kid yourself -medicine itself is a brain-washing process, that's how we eventually come to remember so much stuff, only because we get exposed and re-exposed to variants of the same information enough times first theoretically and then in a clinical context, then get examined and re-examined on it... this is the reality of continuous education in medicine, especially early on! See at the end of the day, we all know Tylenol, Valium, Prozac, Pedialyte, Diabeta, Metformin, Micardis... trade names, trade names, trade names. How much do you think you'd be affected by going to a talk where there's a plug for Prozac? And what if you went to a talk about psychoactive drugs and that's where you got an 'aside' refresher on the use of chlorpromazine for intractable hiccups? Aren't you more likely to remember that than skimming past it in a 1000-page volume about all the antipsychotic drugs?

So you know, maybe ideally, we just need doctors to give lectures to other doctors without Big Pharma sponsorship... but what doctor do you know who can afford the time or lack of payment (especially in Quebec, let's be serious) to give the lecture, and how many less people would attend if there was no free food (free food, whether it is a lobster tail or McDonald's will always attract more people, no matter what the context and that is the cold, hard truth). Anyway. I know. This is a big bag of sweet and sour grapes, with a few rotten ones, no doubt. And I'm kind of tired of exploring the various arguments for and against all this.

But yes, for now, I'll say I felt guilty tonight, but did that guilt come from a real ethical place or from exposure to a lot of extreme opinions on both sides and the 'type' of person I want to associate myself with or emulate? Probably from both. Tricky (you can roll your eyes now because this is getting a bit too "meta" -I won't judge you for it). And I understand the whole ethical quandry. But I am also just putting it all into perspective -there are pros and cons and ignoring either is rather dangerous. Okay. Enough about that for now.

Changing topics, for the second half of my pediatrics rotation, I am currently "en régions" (i.e. other regions of Quebec, generally more remote / "rural", like some people here actually drink well-water and their kids get Giardia from it... I refuse to specify location / hospital details in a blog because my vagueries in these matters helps protect confidentiality and also maintains some anonymity of events, people, places, etc...) Today was Day 3 and I am liking it better everyday (I expected that I would, so of course, I was greatly disappointed with how I felt after Days 1 and 2... but let's be serious, I have hated the first few days of any rotation so far because that is when you're at your moron-est and then it gets better). For example, my first day was super depressing and I hated pediatrics that day; you would have too, and this classic moment is why:

I walk into this room of viral plague (well, not really, but it feels like it). I have to see this kid with runny eyes and nose, hacking away, while intermittently sucking intensely on this blue terry-cloth (or as I like to say, “towel-material”) teddy bear. I go to examine him, talk sweetly and lovingly and all that jazz (don’t worry, I was sincere at the time, and I am being sincere now too). What does he do? He “offers” me his sopping-wet, soaked-up-with-drool-and-infectious-secretions toy, and by “offer”, I mean thrusts it enthusiastically into my cowl-neck, bare arm and face. I, of course, thanked him for it (“Is this a present for me? Thank you!” Yes. This is exactly what I said. Verbatim. What else was I supposed to say –“hey, Terrible 2, stop contaminating me and coughing in my eye!”).

Yes, I realize that I am becoming a doctor and have thus conceded to spending the rest of my professional life in a cesspool of germs. But this kind of special treatment is very particular to pediatrics okay. I don't mind getting blood splattered all over me in a delivery or a surgery -that shit just happens sometimes. But this is just poor parenting and there is no medical or personal gain whatsoever in me getting yucked-up here -there is no benefit to this relative 'cost'. Anyway, I am not the callous physician nobody wants to have. I felt bad for the kid and wanted him to get better and mustered up all the maternal love I could to cope with the yuck factor (and successfully at the time, might I add), but honestly the only kid who's saliva I won't mind having all over my face will be my own, one day in the future. I have decided that I don't actually mind pediatrics... but that's exactly how I feel about it -I don't mind it. I don't love it either.

Now NICU (which is part of pediatrics) I loved. I mean they're too small and frail and sick and helpless to do anything, poor things (it's my favourite part of wards, even here). How can you not love them and want to sell bits of your own soul to save their lives if it was possible? Really, I could physically examine and write about those little bodies, and little hearts and open fontanelles and grasp reflexes all day long forever. But towel-material goopy wetness just for the sake of it? For now, I'll say no thanks to that.

Neonatal ICU: Thrown into the Rose

Today, I want this to be beautiful for you. It is intense and trying and miraculous and interesting for me, but for you it is intended straight for your heart (especially since I was planning on studying, but decided writing was more important for my mental health right now and honestly, the only place to which I can turn, really). I do begin with some frank explanations though -you will need them to be able to feel what I feel and hopefully, just know from feeling (oh, how very unscientific a statement that is!).

Honestly, I was quite apprehensive about pediatrics -after 4 half-days in family medicine about 8 months ago, I had decided that I particularly disliked dealing with sick children in a healthcare setting, with all their crying and squirming, etc. But so, I started my pediatrics rotation with two weeks in the Neonatal Intensive Care Unit (NICU) -this is week 2. And goodness, it is heart wrenching... though not only in the way you think.

This is the hardcore, stereotyped stuff of medical school: the typical making Rounds on all the patients every morning and evening, the "pimping" as they call it (i.e. getting constantly put on the spot with a zillion questions to which you mostly do not know the answer, often guess the answer and sometimes, miraculously and from God-knows-where, very certainly and quite confidently know both the answer and the answer behind the answer... of course, this gets better as you go along, so basically, we are all totally and utterly stupid the first few days and by the end we learn so very, very much that we can actually say that... well, we're still relatively pretty ignorant...), and of course the very intense call schedule.

For all the non-medical people (most of you), let me clarify what this "on-call" jargon is all about and how it works, because depending on who you are in the medical food-chain, call entails different things. In the NICU (as in some other specialties as well), med students and residents on-call keep a pager on them while they actually stay in the hospital for the duration of the shift. For med students, because of accreditation standards of the 21st century and the university trying to meet them, this means call until 11 pm on weekdays, but 24 hr call on weekends when you can get the post-call day "off", without the hospital actually giving you a real extra day off... oh those exploitive geniuses! Don't misunderstand me, I'm not complaining because I know how much worse it used to be, but it still could be better... like who wants someone cutting them open when they haven't slept in 24 hours, I ask you?

So what exactly happens when you're on call in the NICU? If you're not being paged for the caseroom (i.e. labour and delivery, who generally call if there's going to be a risky delivery, in terms of premature deliveries, fetal distress, other complications, etc... so they call up NICU, we run in there and prepare to resuscitate the neonate, sometimes just assess a healthy infant, decide whether the baby needs to be admitted to the NICU for observation / investigations / treatment, etc...), then you're rounding on the 20+ infants in the NICU, making sure to follow-up on labs / blood-work / microbiology, stabilizing babies on different forms of supportive ventilation, antibiotics, nutrition protocols, inserting or removing IV lines, etc... and there are bjillion monitors all beeping, all the time for various reasons.

In just little over 1 week, I have seen a few deliveries, assisted / tried to stay out of the way for a few resuscitations, examined a bunch of healthy and sick newborns, learned to juggle keeping up to date on labs and examining and writing up patients and trying to establish a good rapport with the nurses and administrators and my supervisors and colleagues all at the same time, have had 3 calls in 7 days (including one 24-hr call), assisted with 3 circumcisions and prepared and delivered a presentation. I have dealt with desperate parents, sometimes annoying parents who are really just scared to death about whether or not their baby will survive the great physical effort of living, overjoyed mothers, and even a mother who has been to Hell and back after delivering twins prematurely, losing one of them after a short while and now lives for every breath, test and feed of her remaining darling.

I have been deprived of sleep and rest and sometimes, of meals. I have become addicted to matcha green tea soy lattes at Second Cup. I have sneaked scrubs away from the surgery nurses who guard over blues (blues, greens = synonym for scrubs) like crows over cheese (Aesop anyone?)... I have felt privileged and grateful, angry and ashamedly, momentarily hateful. There has been joy and energy, and dragging lethargy. Sometimes, all of these, simultaneously (or at least variable from moment to moment). I have been thrilled with the vibrating of my pager, and also wanted to beat the pager to a pulp at 4:45 am.

Such is the emotional life of a medical student. We are veritably thrown into the rose -the spiral of fragrant petals, blood red, silky soft in its heart, and perilous anywhere else around it. It is beautiful and delicate and ethereal, blossoming and then drooping, perking up with a little nourishment, before wilting again and requiring the extremes of protection in order to survive the harsh weather. I nearly forget whether I am in the rose or whether I am the rose or whether the rose is me. But I know that I am thrown.

Today though, is the reason that I write to you. I assisted with the re-intubation of one of my patients, one of my babies in the NICU. The doctor was having a hard time getting the tube into the infant's tiny orifices (teeny, tiny nostrils and a mouth into which I could barely fit my pinky) -the goal of all this, of course, being to allow for proper and easier ventilation for respiration (ahem, sorry... the more jargon we learn, the harder it is to avoid using it... basically, breathing). Anyway, so doctor and respiratory therapist are failing miserably (before eventually succeeding, many an oxygen desaturation, bagging and suctioning episode later) at intubating this 600-gram baby, in the first few tries (hey, it's a complicated business for anyone, I can assure you!).

And what is my job? To hold baby down. This tiny little thing squirming and crying with its teeny-tiny limbs and tiny little rib cage moving up and down and baby abdomen twisting from side to side, writhing in distress. So I gently hold her limbs down and out of the way of the people who are trying to save her life, really. But I also profer my finger for her to hold onto in her delicate, miniscule hand. And she squeezes hard with all her might through the whole ordeal. I am there to hold her hand. That is all I can do for her right now. She is so small but in all her anguish, there is surprising strength in that grasp, and she squeezes till her fingers and toes are ghostly pale. Her oxygen saturation plummets down and then comes back up with every attempt to intubate and she cries and writhes and squeezes my finger. I tap her feet to help stimulate her and also to reassure her that here I am, baby, I am still here, I am right here, here. It is torture to watch this little thing fight for her life, struggling relentlessly with every effort. And the tears well up, threatening to spring from my eyes... twice. And I hold it together -of course I do, that's my job and my function here. And I pray and I pray and I do what I'm told, and I help suction and I hold baby's hand. And also I love her because everything we do in medicine is so vitally important, but love heals too and she needs my love in all that frenzy. So I just stand there and hold her hand and love her like she was a part of my soul. And then she is stable. She does not die in my arms as in the morbid image that flashed in my mind earlier that morning when I was on the metro. She is alive and more stable than she was before the intubation.

That's the rose. That's where I flew for a few eternal moments in a long and difficult day for many a baby in the NICU. It's true that you should not get too emotionally attached in some ways, but there is so much more to learn and to be gained and to be given if you do allow your heart to be opened. If you choose to go there, it is worth all the pieces of your soul and every breath of your life.

Reflections on Psychiatry: We're all in the Madhouse

It is a beautiful pre-fall day in Montreal -perfect temperature in the low 20s (Celsius) and bright and sunny without too much wind. I am 3/4 of the way through my psychiatry rotation and think that it's important to reflect a little on all I have learned and am continuing to learn, and to document it, lest I forget the moment I dive into pediatrics at the end of the month.

What have I seen so far -lots of schizophrenia, bipolar disorder, personality disorders (borderlines for ever more turning up in the emerg!), substance abuse, eating disorders, suicidal people, post-suicide attempt people, children with adjustment and attention deficit disorders, anxiety disorders... basically, the heart of the DSM (ha, just kidding! have you seen how thick that book is with diagnoses? probably impossible to see every last one!).

And things have been going great for the most part -lots of work of course, especially on in-patient wards, following five patients on a daily basis, lectures, calls in the emergency, child psych clinic once a week, out-patient consults, etc... I have had a lot of opportunities to practice the Mental Status Exam, talk to different kinds of people (old, young, different backgrounds and cultures, even a patient on the verge of deportation... seriously, society is responsible for quite a lot of these mental health problems -the government is so out to lunch most of the time, honestly). My supervisors have been giving me a lot of positive feedback and of course also guiding me to further improve.

It's enjoyable and varied -psychiatry is probably the specialty of medicine that gets most involved with legal issues because acutely psychotic patients do not think they are sick and do not want to stay in the hospital. So, we go to court to have them mandated to stay in hospital against their will "closed treatment", and sometimes even have the court mandate a treatment order so that the patient receives treatment whether they want it or not. And yes, these are serious ethical issues. But honestly, if you had a patient who had stopped taking their meds and became so psychotic that they were a danger to themselves and to others (walking on the highway, sleeping with a hammer, behaving aggressively with complete strangers), don't you think it's kind of half-assed to just have them locked up in a hospital? Unless they receive treatment, they don't actually get better. For most compassionate and risk-averse human beings, this is a sufficient argument for a treatment order.

For those more materially minded, I might say, this means the patient will be hospitalized for longer, using up your valuable tax dollars in hospital resources and the longer they go untreated, the less likely they will respond to treatment, which means that if and when they do leave the hospital, nobody benefits. Similarly, the government wants to deport people whose children are Canadian citizens because they want to save a couple of bucks on a welfare check, but who benefits when those kids get beaten from foster home to foster home, become delinquent substance abusers which may or may not trigger psychosis, doing damage to themselves and to society, not to mention the deliberate breaking apart of a family against their will? This is not a fiscally nor morally sound action. Sigh. So anyway, I have learned that a lot of "grey area" issues in theory can be very obvious in practice -it's often not much of a dilemma. That's the reality.

The most important and humbling thing that I learned though, was about myself, this past week. I also believe that this understanding is somehow deeply connected to the essence of good psychiatry and good medicine. Perhaps it is all based on counter-transferance, but that does not mean that the lessons learned are not valuable. Doctors are imperfect human beings, like anyone else. I am wholly imperfect, but as Deepak Chopra would say, the positive qualities and the shadows within us make us complete as people since we're not meant to be perfect (I know, this is the hardest thing in the world for someone like me to accept, believe me!). Anyway, so generally, I am caring and compassionate, even patient with my patients. I respect them, I try to understand them and learn from them. But when I am overwhelmed and stressed, I get frustrated, I get annoyed, I wonder why the hell these people won't just tell me openly about what's wrong so that I can help them more efficiently.

I don't actually act this out -I maintain the facade, even though I might feel this way. But non-verbal cues apparently insist on getting in the way of the whole act, and my impression so far is that psych patients are particularly sensitive to how you're really feeling and any judgmental attitudes. Really, you can't hide from them. And they will react in more extreme ways to that emotional reality. So if you feel like you severely dislike one of your patients one particular day, they will act it out for you, reflect yourself back at you. They will tell you to "go to hell, go F yourself" or will stare at you insolently and refuse to answer any of your questions. You may turn around and superficially think, "Wow, I did nothing and look, this dude is so crazy", but really, they're just reflecting the truth back at you. Maybe you're the one in the Madhouse, maybe you're the delinquent thinking one thing and behaving oppositely (hey, don't get me wrong, we all prefer incongruence in thought and action to a French Revolution-style bloodbath -how else would society function?) The point is, you're so going to get called-out on your hypocrisy.

So, this means, you have to make yourself congruent. You can't just walk the walk, you have to think the thought too. Your patients reactions (to some extent -sometimes nothing you do will make a difference because the patient is too hallucinated or delusional) are your barometer of how grounded you are and this will affect the quality of care you give and whether or not you'll do any good. Of course, this is not always the case -borderlines will remain emotionally labile and sever psychosis may be beyond anything you said or did, perhaps even most of the time. Still, your job is to make the alliance. So you failed today, try again tomorrow, and try again in a different way the day after that, and again the day after that. Because it does matter and it does make a difference and it will affect how patients cooperate and how they get better (in conjunction with medication, obviously -good luck trying without it in a psychotic patient; note that it can work without medication in other kinds of patients).

And if you made a mistake, it is actually possible to make ammends. I was never rude to my patients, nor did I verbally indicate any transient callous thoughts or frustration. But I still had to make ammends. I had to change my approach for a couple of my patients, with genuine good-will, renewed respect and transparency. And you have to be delicate. In one such encounter yesterday, my patient asked me, before agreeing to respond to any of my questions and after several long pauses, "Do you perceive me as 'sick'?" If I would have said "yes", I would have broken the alliance, he would not have trusted me, he would have clammed up and that would be the end of the interview. So I said, "I see you as a person who values X, Y and Z. X, Y and Z make you happy, and [only say this if it's true] I can understand that because X and Y (in some way or another) are important to me too. I am trying to help your body stay healthy and strong, so that you will have the energy to continue doing those things that make you happy". Maybe this only worked for me the one time and maybe I established enough trust to last a few days, or maybe not (because afterall, the patient remains somewhat psychotic). But after that encounter, I knew I did my job. I want my patients to see me as the ally that I am and I want to understand them better so that I can advocate for them better. And when I make a mistake, I can go slowly and carefully and make ammends.

I also learned that I have a lot more in common with my patients than one would think. Just because I am in medicine, does not mean that I do not embrace the concept of God and religion (half the medical staff was absent for Rosh Hashana, if you want to put things in perspective here). Perhaps I'm considered even more eccentric because I can appreciate the truth in statements like "everything is energy, the universe is energy" and even "i see the world as a field of energy" (and honestly, Einstein did too: E=mc2 anyone? So it's not that crazy of an idea... so does Deepak Chopra, so do a lot of people who do Yoga, etc...) Psychotic patients will say things like this, but these comments alone are not what make them delusional and psychotic. The best thing is when you are able to show that you 'get them' at some level because then they feel respected, rather than being ridiculed, and are more willing to open up to you. And you will totally recognize the moment when an abstract idea, perhaps held by many, is so obviously taken too far, and even more importantly, when a fixation on those ideas impairs rather than enhances the individual's social functioning. There is nothing inherently crazy about saying "the universe is a field of energy and I have that energy", "I'm going to be Prime Minister" or "God sent me message Q". It's the further probing of these ideas -the hows, the whys, the subsequent meanings derived, the details and most importantly, the emerging behaviours -that reveal the incongruencies and the illness.

And as one of my supervisors constantly reminds us, a lot of famous people suffered from those tabooed mental illnesses. John Nash lives with schizophrenia. Robin Williams and Eminem have Bipolar Disorder, so did Winston Churchill, Ernest Hemingway, Beethoven, Newton and Vincent Van Gogh. All of these people have made important contributions to the societies in which they lived, in their different ways. It is worthwhile to try to understand not only the illness, but the people who suffer from them so that maybe they don't have to complete a poetic and tragic suicide.

Anyway, maybe I'm completely off base. But apart from learning the DSM criteria for various mental illnesses and the mechanism of action of various drugs and their side-effects, I feel these are really important lessons to be learning, and better sooner than later. It probably applies to other areas of medicine too. And also, to other aspects of life on this Earth.

Summer Post-Mortem and "Crazy" New Beginnings

Well, let's just forget that "summer" ever happened. Those 5 precious weeks have come and gone with their hurdles and minimal pleasantry, save a lovely week with family and the delicious food eaten throughout and still now (smoked meat, lobster, french onion soup, etc...)

Ok, maybe I am being a little ingracious. Despite the restricted fun of the first few weeks amidst lots of studying (which doesn't always pay off in obvious, material, measurable ways, although one certainly does learn and re-learn a whole heck of a lot!), I did become quite engrossed in the FIFA World Cup and was extremely pleased to see my Spanish Roja win.

But one never expects or rejoices in heartache. It is more like a death all over again really, except it also leaves an abominable hole (I swear it feels very somatic -left parasternal border, 4th intercostal space... a physical hurt). As they say though, we're meant to learn from these things. And I did -I learned a whole heap about so many things (the vagueries are deliberate as a eulogy or shrine to the flitting beauty of affection and tenderness that imbued that tie). The longing remains, as does the love and memories (both wonderful and awful)... I'm basically counting on Lady Time to heal it all eventually.

So, anyways. This week is my second week of my Psychiatry rotation (my first official clerkship rotation) and it is awesome! The learning curve is pretty much vertical -I learned crazy amounts of stuff (no pun intended...) in just 6 days already (+1 call). Seen lots of schizophrenia, schizoaffective disorder, bipolar disorder, major depression and a few suicidal cases -emotionally tiring but very rewarding interactions and I very much enjoy the general demeanor / attitude of most of the psychiatrists and residents I have met so far. I follow 4 patients on a regular patients and basically spend more time with them than any of my superiors and it's amazing to observe and understand how they progress or deteriorate, followed by discussing potential management plans etc with the attending staff. So much fun, really... I am that much closer to becoming an almost-doctor! And the psych-social stuff is awesome, so you get to better understand the legal system (for example when you have a patient from the prison, who, in a state of acute psychosis nearly stabs someone to death...), the welfare system (a lot of psych patients are on welfare, though in some cases a third of it may go towards supporting a hefty drug habit or "self-medicating"... still they could not survive without it!), and social institutions that provide activities for people who otherwise could not work and would have nothing to occupy their days, which honestly would make anyone crazy out of boredom (so they can go to these centres and do wood-working, or plant-care, or computers or ceramics and get 'paid' for their work, a nominal $1.60 per day) and it's awesome, because a part from anti-psychotics, mood stabilizers and anti-depressants, or electro-convulsive therapy (hey, don't knock it! it's the most effective therapy for acute suicidality and mania, there's proper anaesthesia involved and all you see is a foot-twitch!), you can also prescribe these activities, like, on a prescription. It's pretty neat. The whole big picture I mean. It's not just brain drugs. It's a whole system of bio-psycho-social care and it is great (so far. from what I've seen.).

Anyways, I know. As fascinating as this part of my life is, everyone probably wants to know more about the heartache. You know, human beings are so fascinating in that way. It's like Elizabeth Gilbert wrote in Eat, Pray, Love (btw, I'm sure the book will be better than the movie, though I am so pumped to see the movie!): there are psychologists who have talked to people who have survived genocides when they were in refugee camps and all they could talk about was how that guy left me and took up with my best friend and that girl is in love with my brother, etc, etc. For all our grand achievements and terrible atrocities as a species, all we can think about is love.

Or at least I know that I certainly fall into that category. And, frankly, thank God I do. Love makes life worth living... even when it doesn't quite work out the way you thought it would (and believe me, my hurt is fresh enough, but this really is just the truth of the whole thing).

Post-surgery & half-doctor: Yes, she still writes!

Surgery has come and gone, and look, I haven't even written to you! For shame. In short, surgery was a wonderful experience overall... hard work, no doubt, but also awesome. I had the best mentor surgeon of all time. She was not a 'typical surgeon' -lovely bedside manner, attentive, patient and caring, gentle, loved by her patients even when they had complications... and really, just a beautiful person. And she was the chief of general surgery at the hospital where I was placed.

Cool points of the rotation: I got to scrub in on a couple of surgeries -an open indirect inguinal hernia repair and a laparoscopic cholecystectomy (gall bladder removal), the latter in which I almost fainted while retracting (luckily I had the sense to mention that I was "feeling a little faint", so that the scrub nurse could quickly take over and make me sit on the floor before I totally blacked out!). I also watched 2 cataract surgeries and a corneal transplant (awesome to watch, but I never want to be an opthalmologist. I also never want to be a radiologist. Something about spending all your days in a dark room, I think...). The OR is kind of amazing though -thrilling (and hardcore, I'm not going to lie)!.

You know what else is thrilling and hardcore? The season finale of Grey's Anatomy (which of course I only finally had the chance to watch yesterday after my surgery exam and before the end of ICM BBQ at Beaver Lake). Stunning episode, amazing acting, and so intense. Not only did I tear up, I was actually sobbing -best outlet of life, I say!

And now I am half a doctor (well, you can't really be half a doctor... just like how you can't really be half pregnant, but it sounds cool doesn't it?). Start up again end of July and no holiday for the next 2 years (for real. like I have to choose whether I want to take Christmas Day or New Year's Day off). So my exciting summer plans include writing the USMLE Step 1, having my extended family come visit from out-west (first time in over 10 years for most of them, so that will be wonderful!), and then retreating up north for a few days to recharge before Clerkship officially begins.

However, before I get back to studying for this next exam, I am taking this weekend off. Le battery is dead, the tank is on empty, le brain is nearly dead, exhaustedly, I have nothing left to offer the world at this very moment. So today there was some self-pampering with an aromatherapy massage, a nice vegetarian lunch... also I have taken to drinking homemade matcha green tea-almond milk frappes... so delicious and energizing! I played the piano a bit (for the first time in a long time), I watched the end of a devastating FIFA World Cup match for Cameroon.

The best thing in life these days though is reading Three Cups of Tea and worshipping Greg Mortenson (hopefully I will finally finish this amazing book by the end of tomorrow!) Another best thing in life was going to my first wedding of an undergrad roommate. It's official. I will be going to weddings for the next 10 years, right? Then it will be time for, as Franc, in Father of the Bride II, would say, "the behbeh showa". Life is too crazy.

But overall, I think it's good. Just important to recharge those batteries. And to always take the time to write. Note to self: do as I say, not as I do!

Confronting the Internal Issue

So why have I not said a word about medicine lately. I am sure you are wondering this. Or maybe I flatter myself here. But well, let's confront the hard, cold truth here. Which is that I am not particularly enjoying it these days. In fact, sometimes I resent it. I am glad to be learning a whole lot of stuff, of course. It's the pressure-cooker I can't stand. That is what I am in right now, veritably. Believe me -Internal Medicine is no picnic. And I would know, because I actually did go for a lovely picnic this past summery long weekend in Montreal. We ate delicious avacado, havarti, sliced turkey, tomato, lettuce and dijon-mayo with salt and pepper sandwiches. And there was bocconcini, baby tomato and pesto salad. And later that weekend, my semi-salty chocolate chunk cookies. And Internal Medicine is galaxies away from that.

If I had to describe Internal in one word it would be this: a drag. But actually soul-sucking, opposite of joie-de-vivre, let's watch really sick, really old people who are too far gone to actually help -let's watch them get sicker, be in more pain, deal with more side effects, happily acquire C. difficile and VRE until their bodies and spirits and minds waste away, wrangle their friends and families haggard, give up with one last moan and at last, die. Now, you might be wondering how on Earth I could utter these words and yet be so infatuated with Palliative Care. That is because in Palliative, the goal is not "one last damn fight" to manage or control or cure the pathology. It is to manage pain, to make patients comfortable in their last days so that they can attend to more important material and spiritual concerns before leaving this world. The goal is the patient, not the collection of systems that happen to find themselves in a single human body. Bleak, you say? My friends, you ain't seen bleak until you've lived Internal.

And maybe that's life's ironic metaphor. That anything Internal is really an Inferno, which, if you're not careful, will burn you up and leave behind nothing but smoke and ash. Now really, this is not to say that the doctors in Internal Med are not good doctors. As a darling friend would say, "Au contraire mon frère!". They are some of the best doctors, hands-down. They are bright, compassionate, award-worthy, have one hell of a memory, boundless energy and the ones I have met really love what they do -really, exemplary physicians, no question. But it's the culture of Internal that is soul-sucking, the know-it-all, we're-so-busy-and-important and frankly reductionist 2D-attitude that rubs up so hard against me. I don't know. Perhaps I'm being unfair. Perhaps these guys have all read Kuhn's The Structure of Scientific Revolutions and Kleinman's What Really Matters and Andrea Tone's Medicating Modern America and enjoy reading fiction on occasion.

Just, well, my imagination feels so... stunted. Not because they don't think out of the box -believe me, if anyone has to think outside the box, it's these guys. But... there's... I just have a general feeling that there is a missing-the-forest-for-the-trees here. There ain't no space for no existential crisis. Nobody has the room to break themselves open and re-make themselves whole. And I can't quite touch the tangible problem here, except that I feel like my favourite part of me and what will make me the good kind of doctor that I want to be, kind of dies a little every day in there. Like someone rubbing margarine all over your windows... I mean, you can't see anymore! Really see. Because the science of the medicine is extremely important, absolutely 1000% necessary (and I plan on doing my 1000% best in learning it, I swear), but so wholly and fully insufficient. There is no way anyone is seeing the whole picture when the body is just an ammalgamation of systems. The whole is greater than the parts. And when it comes down to it, even Internal cannot explain the whole -they'll just call it 'autoimmune' instead. Sometimes they'll say 'idiopathic' (as in "we're idiots on this one"). They'll diagnose your COPD, your CAD, your CHF, your RA, your pancreatitis, your anemia... but when it comes to managing the whole picture and the person that actually manages to get them all (these poor patients, yes, they exist)... it's a sad deal. And it's suffering and wasting away and then a long (or short), painful death.

Yes, all areas of medicine deal with suffering and pain and death. But there's something about this baby that just saps my energy to negative 10,000. Really. I don't know what it is. But it makes me miss Anaesthesia like nobody's business. Okay. So there you have it. I think I'd most likely rather be a surgeon than an internist any day. But who knows -I have yet to do my ICM surgery rotation.

Post-Baking...

So, yes. I did, in fact, actually bake. I didn't pull the "oh it would be nice to start baking in theory" stunt. Just pulled out my first batch of chocolate chunk/chip cookies, which are huge because how would i know those dollops would expand into massive, flat... things. The dough tasted a bit salty for some reason, even though i put everything in exactly like the recipe said to, except I cut the sugar quantity in half, just like my mum always does. Cookies are successful in being crispy on the outside, soft and gooey on the inside, but they crumble a bit -why is that? Anything to do with the changed sugar to everything else ratio? And although the cookies are not quite as salty as the raw dough, they taste just a tad on the saltier side... I don't know. I feel a bit discouraged to be honest. Like how am I going to one day bake the world's most fabulous red velvet cake if I can't even get a batch of standard, run-of-the-mill chocolate chip cookies done right? Sigh.

I have a headache now. True, I did eat a massive Sunday buffet brunch at this Indian restaurant in the West Island that I had never been to before... fried fish, tandoori chicken, another kind of barbecued chicken, pakoras and puri-chaat... those were just the appetizers (I went up twice for these). Then three naan slices with aloo gobi, butter chicken, lamb curry and spicy chicken curry (this was in 2 plate-fulls). Then dessert of kheer and gulab jammun... that was done thrice. And a cup of chai. Then in making my cookies, I ate some cookie dough. Then of course once the cookies were made, even though I felt like I was going to explode, I had to try 3/4 of one, having already downed 2 glasses of water to compensate for the salty dough. Now I really feel bloated, sick, tired... I even did yoga this morning (but apparently not enough to prepare for all these obnoxious assaults on my body...).

Really... I should just fast the rest of the day. Maybe a nap will help before trying to study... gotta get rid of this food overload, but I feel too tired to join my father for a walk. Ok... here's the plan: nap for half an hour, learn how to read ECGs better for 30-60 min, read some Blueprints afterwards. God give me strength. At least we know I won't get hungry in between...

Spring Fever? More like "this season is on 'shrooms"...

It has been a long time since I have written. Really, it's just not healthy for a writer not to be writing more often... like an athlete who stops training -they get out of shape, they're not on their game, and most importantly, they probably also feel terrible (endorphins-withdrawal or something!). So forgive the off-beat style today.

The weather has gone nuts. Ya think it's spring, and then, BOOM! Hail, snow, rain... all at the same time. The trees that had just begun to bud were dipped in crystal and cold, along with that spring optimism. But take heart -we are stronger and tougher than that. And this morning, the sun shone bright as lamp posts cried puddles around us, and the glistening rainbows between the branches of the phantom-like trees dared another storm. It's so bizarre. And frankly, it's sickeningly exhausting sometimes (as in, I am actually sick because what ordinary human body can handle such temperature fluctuation without reeling just a little!).

Anyways. I think I want to learn how to bake some stuff. Mostly, because I realize I have become a cookie monster over the last month or so... it's great when the crispy-on-the-outside, soft-and-chewy-in-the-middle varities of chocolate chip heavenly morsels are free. (Aside: why does free stuff always taste better? look better? wear better? i mean seriously, isn't your favourite pen that free one you got at recruiting 2 years ago?) But you know, these days are not like those good ol' days... to purchase a gourmet cookie, will cost one roughly $3.99 -for one bloody cookie! It's insane. And multiply that number by 100 and you've got the calorie count for that same cookie -again, for one bloody cookie! And although these cookies do tend to be delicious, they are invariably too sweet. So like, I need to find a good cookie recipe and just cut that sugar in half. That way, I can eat 2 whole cookies for roughly 399 calories, savvy? Good recipe suggestions welcome. The other nice thing about baking is then sharing the goods with the people you adore -always a much enjoyed and heartily appreciated gesture to indulge a gourmande (and let's be serious, I do not befriend people who are not gourmandes ;).

Speaking of good food. I ate quite a delicious margherita pizza last weekend (yes, in Toronto of all places... i know, i know, incroyable, really! but good food in that city does in fact, exist... actually, since the last 3 months I have been visiting Toronto, I have yet to have an unpleasant culinary experience, which believe me, surprises both me and you... not to diss Toronto, but you know, I'm still a little sore about last weekend's hockey game -hopefully we beat the Sabres tonight though... then all will be well =) So anyway, this pizza. Hole in the wall place -Buddha Pie. Gourmet-pizza standard price. Thin crust (a bit too crispy, I will admit... yet not a deal-breaker by any stretch!), fresh crushed tomatoes as a base 'sauce', buffalo mozarella (slightly over-melted, but again, still fantastic), and freshly chopped basil. Really. Really. It was good. It was mmmmmm... good.

Well, nothing like writing - writing about the natural world, writing about food, to cheer one up amidst these seasonal upheavals!

Anaesthesia: Intoxication and in His Head...

The Overview

I loved it. Best ICM rotation of life (so far, obviously). Kicks oncology's ass (let it be known -I have no interest whatsoever in oncology... BORING in all its forms). Nor do I care much for peds (kudos to those who have the patience for that... frankly, it just got on my nerves, at least in the family med setting... in fact, I may seriously reconsider my interest in family medicine based on the reality that I would have to deal with sick kids and their parents...).

But enough on what I don't like. Yes, it's true, I had to start everyday at 7:30 a.m. and anesthesiologists have to deal with arrogant surgeons (there is 1 respectful, kind, collegial surgeon for every 3 assholes), and if you're on the cystology/urology service, it is boring as all hell (urology: another shoot-me-in-the-face specialty).

Yet, overall I loved it -thoroughly enjoyable experience. I learned and got to practice intubations, mask-ventilations and putting in IV lines for patients... already, they actually let us DO stuff! I got to do some pre-operative assessments on my own (so much fun... doctor-patient interaction which is nice, but it's about a specific issue so naturally limits how long this lasts, and you provide them with all the information and reassurances that they need to feel a bit more comfortable about their surgeries and the anaesthesia they will undergo... and you get to assess their airways which is always fun =). There were 3 particular 'anaesthesia moments' which made quite an impression on me, which I will now share with you.

Day 1 Intoxication: On the brink of death in Obstetrical Anaesthesia

My very first day in anaesthesia was on the Obs service with one of the sweetest anaesthesiologists at the hospital. We started with a bunch of pre-op assessments for a bunch of women scheduled for C-sections, which was fun. And then we were called to the Obs OR to do the anaesthesia for a woman having a C-section for a breach. She was scared and vulnerable and her big blue eyes were like large watery wells as she looked at us with a desperate trust before we put her to sleep (general anaesthesia aka GA). Baby was delivered successfully. But. She had depressed respiratory drive and slow, irregular heart beat / weak pulse. They started to mask-ventilate. Then it was a code pink and a frantic search for a small enough endotracheal tube to intubate the baby, a flood of docs and supportive staff with crash cart and finally the adminstration of naloxone, which stabilized the baby.

It turned out the mother was being treated for chronic pain with opioids, resulting in opioid toxicity in the infant -naloxone was the antidote. They saved the baby's life but it was scary as hell. To be in there and to be utterly and completely useless as a second-year medical student. The best I did was stay out of the way. They don't count on us to do anything, but the uselessness was just overwhelming. I could not get the crash cart (like I knew where that was kept!), I could not call for help (who to call? what to say? what to ask for? you can't exactly run out into the hall screaming 'help!'), I could not even give the nurse a pair of gloves because I didn't know where they were kept. You know, we know we're not the most instrumental people as students when we go into these ICM rotations. But in that life-and-death situation, it makes you feel like you're trapped in a box and can't get out and can't scream and... helpless, helpless, helpless. And you look over and see the mother completely knocked out under GA -she cannot do anything for her baby, she cannot protect the baby or do anything for it as Nature had intended... and the baby, so small and helpless and breathless and vulnerable itself. We the doctors hold these 2 in our hands and the sense of responsibility is more powerful than anything you've ever felt in your life: they are helpless here, they have put their faith in us and trusted their lives in our hands -it is our duty to ensure they live through it.

Now you know, I am spiritual and I believe in God, and yes, I do believe that ultimately life is in God's hands -we mere mortals do not decide these things. But if anything worse would have happened to that baby or that mother and I was the physician in charge, how would I live with myself? There were so many little things I witnessed that could have affected the way things turned out -and they were all things that are in fact in our control. God helps those who help themselves. Life is ultimately in God's hands, but if you didn't really, really, really do your best, then death is your fault, not God's. I think that's the scary part. That in medicine, yes we do our best, given the circumstances, but there's always something that might have been done differently, that might have been prepared for better, that could have possibly been foreseen and prevented... essentially, there is a lot of human error that results in death. So how do you know when to take responsibility and when to surrender to the reality that you can't control everything? I'm not explaining this properly, but I think what often happens in real life, is that we don't do our best. We say we did our best. But we don't always do our best. We wish we could always be at our best, but we're human, so that's not always the case. So then we have to ask whether or not this is acceptable? That we try to do our best, that we don't always get there and sometimes not doing our best results in death, and sometimes, despite doing our best, death happens anyway. And are both of these situations acceptable? It's something to think about. And I love that I get to face these difficult situations and think about these philosophical and existential questions. And anaesthesia was the first specialty to give me that gift. So thank you.

On Call: The Cool and Complicated Cases

So I also did 1 night on-call during this 2-week rotation -loved it. It was a half-call, only until 10:30 pm, but still, so different from a regular day! All emergency cases -and the only time I got to see them stabilize an airway (intubation) using a fiber-optic instead of the normal laryngoscope way. For a retropharyngeal abscess in a woman with a super-tricky airway and severe enough anxiety combined with hypokalemia and too much local anaesthetic (lidocaine) that made the whole process crazier with sporadic tachycardias with arrhythmias (for the lay-person, in English: heart beating way too fast and abnormally). So again, a crash cart was needed, the anaesthesiologist in charge had to be called, etc. Except this time I was less useless -I was at least able to call the attending physician to come help. An improvement. An experience. Thrilling. And everything went well.

Anaesthesia for Neurosurgery: The live, pulsating Brain in his Head

Second-to-last day in anaesthesia, got to see the neuro side of things. The anaesthesia is the same(ish), but the surgeries -way, way cooler. Hands-down. I almost thought I wanted to become a neurosurgeon (and then I remembered, "Wait a minute, I still want to have a life"). I got to watch them do a focal resection of a tiny piece of scarred brain that had been causing epileptic seizures in the patient. So I asked the anaesthesiologists, "So basically this scar is causing seizures, so they're going to go in, remove the scar tissue and create another scar -how does this help the patient?" And they were like, "Huh. That's a good question. Never thought of it that way -I don't know, you should ask the neurosurgeon."

So during surgery, I'm allowed to go over to the surgeon-side of things, watch them using imaging technology as they are about to cut through the dura after performing the craniotomy, and the neurosurgeon (who is one of the very best neurosurgeons in the whole wide world! literally people fly here from all over to have him do their surgeries) himself, tells me to come close and explains what they've done and what they are about to do and I look inside where they've removed the skull and it is absolutely, freakin' gorgeous. The actual live human brain pulsates right below the thin layer of dura and it is a beauty. Fascinating. Amazing. That pulsating mass inside each one of us is what's responsible for all that humankind has ever accomplished, felt, thought, experienced in all of eternity. Ancient civilizations, poetry, art, Olympic records. It was all first just a mind-form. All just a ghost in that pulsating mass that only this privileged profession gets to see and touch in this state. What an honour indeed.

Afterwards I asked the neuro-guru my question. His response, "That is an excellent question" and proceeded to explain how in a natural scar, the inputs and outputs from and to other neurons remain intact and so abnormal activity can be transmitted to those neurons from the scar tissue, resulting in a seizure. However, the surgical scar severs these connections to other neurons (or at least, they really do their best to ensure this as much as possible) and so this transmission to other neurons is avoided. Later, to my anaesthesiologist attending, the neurosurgeon remarked "She asked such a good question -I wish more residents and doctors would ask questions like these" -made my day. After feeling useless at the beginning of this ICM rotation, it was so rewarding to feel appreciated, seen as intelligent, unique, worthwhile. By then, I also really knew my stuff in terms of all the different drugs, their mechanisms of action, when to give what, why you give what, etc and the residents with whom I was working also told my attending they were impressed that I 'knew my stuff' and was so interested in learning more, in more depth and detail. And it was genuine. Like I really, really loved it.

My final assessment?

But anyway, this doesn't mean I'm going to become an anaesthesiologist. Or that I'm not going to become a family doctor. But it is nice to have all this 'action', surprisingly enjoyed the kinds of doctor-patient interactions, because although they are short-term relationships, they are so intense because there is so much fear and trust and other issues to be managed and feeling like you're doing your job well and putting your patients at ease is rewarding enough without the on-going, long-term follow-up. And the good thing in anaesthesia is that once you leave work, work doesn't follow you home, and for the most part, it doesn't even carry over into the next day. They are paid well too. There is variety (pre-op / chronic pain service, gyn, obs, cystology (yuck), OR, etc, etc...). The kind of person who is an anaesthesiologist (at least the type of people I met) were very cool, energetic, down-to-earth people. But you do have to deal with surgeons and their egos (major downside). All that adrenaline, probably not good for balancing my already imbalanced 'feminine side'. So... lots to think about. But glad it was enjoyable. I learned so much and I loved the experience.

Neurology starts tomorrow -let's see how that goes...

A splendorous quarter-century celebration, Med-World musings and Love, Love, Love...

The sun that was stunningly bright and painting the library walls golden now only pokes out from behind the tall apartment building across the street. It has been a while since I've taken the time to write to you, to think at you. Almost mid-February now -my 25th birthday has come and gone (it was glorious in so many ways though -thank you to everyone who made it so very special... lots of dark chocolate, succulent lobster tail, tender, sweetly-glazed lamb, surprise roses, things that sparkle and shine, things that make the contours of my body sparkle and shine (garments, not under-garments people ;), lots of desserts, sparklers and candles... memorable indeed!) and I find myself very much caught up in the frenzy of trying to figure out the next critical years of my medical life.

What do I want to be? How do I optimize my opportunities so that I maximize all the possibilities of options of potential areas of specialization (this is exactly as complicated as I just made it sound, I swear, it makes one's head spin!)? Where do I do my clerkship rotations? Rural or urban? Quebec or Ontario? Canada or the U.S. (haha, that's a trick question, we know I'm in no rush to go back down south ;)? What order do I opt for? Pediatrics first since I've already decided I don't care much for kids or parents in the clinical setting? Or surgery first to get it out of the way? Where is the best OB/GYN and FamMed residency programs? Who should I talk to to find out? Who should I talk to to strategize? Plenty to think about.

I interviewed 3 applicants for Harvard College yesterday. Man, not easy to assess their 'qualifications'... like really, who am I to do it, and simultaneously, of course I am one to do it, but then, do I want the pressure of having to do it? Too late now, in any case.

But then I am also very much in the throes of love. Filling my heart with gladness, taking away all my sadness, easing my troubles... not that I had much sadness or troubles. Although, I definitely see the morning sun in all its glory, filling my days with hope and comfort, and my life with laughter... all made better because of my sweetheart. Kudos Rod (Stuart). You know who else was right? Lionel Richie. Good man. And I will now butcher "You Are" for my own purposes here... well, maybe I'll keep the butchering private -no need to make you all cringe and squirm. But really, honey, "all I want is to hold you"... (how about some wine with that CHEESE... and actually LR's a big liar for lovers because since when is holding ALL that is wanted... just sayin').

Anyway. Right. All that work and thinking and USMLE Step 1 studying awaits me.

Aphrodite's Brew and Real Doctoring!

Since my last post, my whole world and life has gone from clear-cut to the greyest of greys, from sunny and bright, to scintillating rainbows and starry magic, from feeling whole and waiting, to feeling completely complete with total awareness of how shattered and broken we all remain, despite being wholer than we ever were before. Love. That old transformative cliché. But it's real. It exists. I was a fool to ever doubt it. And now I am blessed with its beautiful, wonderous abundance.

But everything changes. Lots of lovely changes -of course these go without saying. Then there are the others. The adjustments that need to be made in both your external and internal realities. All those previous world views, opinions, beliefs -the strong, the steadfast, the rigid... the ones you managed to bend for others, so that for them, you could be less judgmental, more understanding and compassionate, but that you actually never allowed for yourself, you who is just as deserving of such generosity and openness of heart and mind and soul... all of those harsh internalized social norms... they all just become like alphabet soup. Letters with distinct shapes and forms swimming in this lovely red, amorphous, all-encompassing, steaming hot broth that warms the body and comforts the spirit, and makes the sick well. Meanwhile, as the noodle-letters sit in there, they turn a bit mushy, and suddenly you can't tell "A" from "D" from "O" and you wonder if it's even worth trying to make words. Like, so what do we do? The alphabet is a critical component for this soup -it's what satisfies the hunger, gives us that boost of energy to actually get things done, be productive, useful. But it's 'alphabet soup' not just 'alphabet'. So I need to reorganize.

See normally, what happens when we construct our personal belief- and value-systems? We take a bunch of stuff for granted and we end up coupling different ideas together, assuming that 'duh' these go together. So for example, if you're acting like "A", then you must be feeling "Y" about yourself and "Y" is unacceptable, so just don't do "A". But then you learn that the behaviour "A" can also stand alone. It is it's own thing, in itself, and must not necessarily be accompanied by "Y" or "X" or "K" for that matter. And in fact the reality is that "Y" is always unacceptable and anything done while feeling "Y" will be made perverse and gruesome. But that actually has nothing to do with "A", intrinsically.

But anyway, happy 2010 people. We officially began "Introduction to Clinical Medicine" (ICM) in January, basically beginning with 3 weeks of learning how to do a full physical exam, practicing on each other and on patients in the hospitals, taking an intro to Evidence-Based Medicine (EBM) course, along with medical ethics and law, opthalmology lectures, first aid training, etc... so cool to finally be looking into each other's ears and eyes and mouths and noses, feeling lymph nodes, listening to hearts and lungs and bowel sounds, knowing how to test for potential torn rotator cuffs, carpal tunnel syndrome, torn ACLs... you know, like real doctors. Also yesterday I learned that I officially passed BOM (basically, I deserve to be here in this next quarter of my medical education). So things are moving along the way they do. Hectic. So hectic. But good. I really feel completely inside my life. And I do love it, even though sometimes at this depth, some pretty strong currents will try to catch you and suck you down. I'm discerning though and a good swimmer though, so there's no reason why this experience should not be, not only survivable, but fully rewarding and enjoyable. Plus, I've got the silky soft, intoxicatingly fragrant rose petals of love to buoy me up.