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The Chief of Surgery was hurrying us along to prep the patient to quickly start the operation. Having some difficulty inserting a foley catheter for the patient, an uncircumcised male, I replied to him without thinking: "Sir, I'm sorry but I don't have much experience with foreskins."

Today, as I was leaving the SICU in the evening, I spotted a couple sitting alone in the OR waiting room. It was 7:30 PM and the place was quiet, with only an occasional resident briskly passing by. I wondered if they were waiting on a family member, perhaps the patient who had just been taken to the OR by my attending for emergent repair of an incarcerated hernia. I had wanted to scrub in on the case, but decided to go home to study, as shelf exams are next week. Priorities, priorities...as I passed the OR control desk, I couldn't help myself; it didn't feel right to just leave. I walked back to the waiting room and asked if the couple had eaten dinner. No, they hadn't. Their family member was undergoing surgery right now. I went and got them some sodas and cookies, and hoped that the surgery went well. The world felt right again, and I went home.

It's moments like these when I realize what the important things are in life. The little things.

Tomorrow is Thanksgiving Day. Today the weather outside is beautiful. The clouds are illuminated against the soft blue sky. In the ICU, my patient remains in status epilepticus, intubated, while his ammonia level remains too high to be quantified. Last week he was joking around about how everyone wants him to have rheumatoid arthritis. His only problems then were myalgias, arthralgias, swelling in his joints, neuropathic pain, and a twinge in his rib. Two days ago he was drowsy, which made sense for a guy who had just recovered from several episodes of new onset atrial fibrillation with rapid ventricular rate. Yesterday he was comatose. His serum ammonia level jumped from 150 to the 400's to “greater than 1000” in 3 days despite all the measures that were done to bring it down. No one knows why. I have been reading on the pathophysiology of hyperammonemia. Cerebral edema, seizures, and death. I still have very strong feelings with regards to this situation. I'm not sure I can put them in words yet. This is one I can put in words: all over the country, people will be celebrating Thanksgiving tomorrow. I wonder how his family will feel. I wonder what Thanksgiving must be like for them in the ICU. I wonder what else I could have done, if I could have done anything. I'm not sure if I should try to enjoy Thanksgiving anyway, or if you would consider me heartless for trying to do so. I'm just thinking too much right now.


// j.

I admit this entry was inspired by events that happened this morning.

Frosty Magic


Chilled
In the pale gray dawn light

The sharp cold air
Stirs up the magic of an October morning

Cozy
In the bed-nest of blankets
You summon the strength to start the day


Heavy
A white shadow lands

The purring wall
Presses its furry weight on you

Soft
You cannot escape
The warm love of a dusky, snow-colored kitten




// j.

Lately I have been thinking about the importance of self-confidence in medicine, particularly as third year rolls around the corner. Especially in American society, where appearances count for just as much if not more than ability, getting through life is all about having self confidence, and medicine might be a prime field where this holds true. I started revisiting this train of thought during a shopping trip over the weekend, when a friend of mine and I each bought a basil plant. After paying for our groceries, we loaded both basil plants into the car. She insisted that the plant that I had bought was the one she had gotten. I knew which plant was mine because I recognized the folded branch on the plant she had bought. I did not insist on keeping the plant I had picked out, as it didn't matter that much -- both plants were healthy and alive. I wondered what would have happened had the situation involved something more important than basil. Do we usually end up going with the decision made by the person who is more convinced they are right, if we are less sure of our own -- or less interested in arguing the point?

I am not sure if that example is even so relevant to the thought at hand. Using a different example, in the early part of my first year in medical school, a friend and I exchanged opinions on how well we did on an anatomy exam, shortly after taking the exam. He believed he had aced it. I was 70% sure I had passed. When we got our scores back, I had done better on the exam than he had. I feel that this is a recurring theme in my life. During the last unit of 2nd year, I felt I was at 80% for the histology exam. It turns out I had gotten 100% on the exam.

Is it better to be confident about what you know? Is it worse to underestimate yourself? In oversimplified and exaggerated terms, is it better to be 90% sure about something when you know 70% of it, or is it better to say you don't know it, when in fact you are at 70%? Or is it just a matter of error margin -- it's more important to be accurate than anything else? I feel that patients in general would prefer the former in their doctor. Someone who is calm and appears to know what they are doing is more reassuring to a patient who wants answers and solutions than someone who tells you "I don't know" and explains that there are lots of possibilities, with a certain likelihood of cure but also a chance of failure, complications, or side effects.

As clinical rotations approach, I wonder about this more because, if the preceding examples suggest anything, I'm more of the type to underestimate myself and thus undermine the image of confidence that I could be projecting -- the very image and perhaps the most important factor in becoming successful in medicine and in society. And that would just be unfortunate.




// j.

It's hard to believe research block is already 75% over. Working in an immunology lab has been more of an emotional roller coaster than I had anticipated. Many days go by when you stare intently at your data and wonder if it will just whisper its secrets to you, secrets that have made the past weeks of long hours and brain-busting worth it. At the same time, there is a whole life outside of the lab that I expect to be engaged in, a life that I expect to not have once board studying and clinical rotations commence.

Sometimes it helps to gain perspective if I sit down to think about what has happened since March.

Highlights:

- Got a (short-scale) bass guitar
- Shaved my head and donated proceeds and hair to cancer research
- Spent at least 3 months working in a lab (the longest time I've ever stayed with a lab)
- Spent more than 16 hours continuously in the lab
- Rounded with the pediatric hematology/oncology team with my PI
- Gave a presentation using hot pink text
- Became the owner of a very cute Siberian kitten

And what about those goals I set at the beginning of research block? How far have things come along?

- Research.
I have learned a lot about (aka just started scratching the surface of) research in an immunology lab. With refinement and replication, my data should make it into a paper *fingers crossed*.

- Bass guitar.
I started learning bass guitar about three months ago. I can read tabs and follow the notes (but not the rhythm) of a few songs:
-- tab: itsuka no Merry Christmas by B'z (100%)
-- tab: Otherside by the Red Hot Chilli Pepppers (80%)
-- tab: yumemiru shoujo ja irarenai by Aikawa Nanase (20%)
-- transcription: Just a Girl by Bonnie Pink (30%)
-- transcription: Naze... by Hysteric Blue (1%)
-- scales: need lots of work...

- USMLE step 1 studying.
-- Pharmcards: 200 of 275
-- Lippincott's: Chapter 26 of 43
-- Kaplan Qbank: 292 questions
-- USMLE world: 105 questions
-- Study schedule for the rest of research block: planned and set.

- Japanese.
JLPT level 1 studying:
-- 1232 kanji characters
-- 1099 vocabulary words
-- reading and grammar: postponed until after Step 1

- Exercise.
-- running at least 2 times a week (at most 4x a week)
-- at least 3K each time
-- pushed up to 4K yesterday

...Yup. It doesn't feel like I did much in 3 months, but when I write it down, it seems like I actually did something.




// j.

You push me away
So I pull away

So you shut me out
So I lock you in

This strange game
Where I am always half-losing
Where defeat sits deep within
Lying dormant in wait

Like a chain reaction
Self-renewing self-doubt
Of a memory unforgivable

Decaying with a half-life of a half-lifetime
Till the fuel pool spends itself
Subcriticality shutting down
To the subconscious

Until the day the decayed reaction is done
The scab falls off
Revealing new skin




// j.

If anyone wonders how the education system here might be broke, look no further than student loans. Someone is making money, and I don't mean college graduates who took out loans. But I'm not going to cite more facts and figures; these are well known. I'm just going to provide you with a snapshot of my most recent calculations regarding medical school loans.

I think I'm just depressed about this because it's the first time I sat down to realistically calculate the cost of loans.


I currently owe over $110k after about 2 years of medical school, and this is after I minimized loans in my first year by borrowing only the cost of tuition and paying for living and other expenses from my life savings (3 years of work after graduating from college).

According to my calculations, I will owe about $380,000 in loans (principal + interest) when I graduate, and I will have to make monthly payments of over $3100 to pay this all back in 10 years.

Recall that residency (3 years) and fellowship (4 years) probably will not offer annual salaries of more than $50k / year. If we are very generous, and assume that each year of residency and fellowship pay $50k per year (the starting salary of an intern, a first year resident, is closer to $30k), our monthly income of $4420 for 7 years would have 71% of it swallowed by loan payments.

I don't know how you would even do it if you went straight to medical school after taking out loans for college. I made money for 3 years before starting medical school.


Boys and girls, consider a career in business if you want to make money fast and live in style without prowling for free lunch seminars to save pocket money (as I do) for the first 11 years after you graduate high school. Medicine isn't the way to do it.




// j.

I debated whether to post about this subject at all, because I wasn't sure it deserved mention from me, given the explosive attention that the media has already dedicated, and may continue to dedicate, to it weeks from now. But I feel I had to give voice to the uneasiness: one man, that so many Americans wanted to see dead for so long, is now dead. What, exactly, does that mean for Americans? And what does it mean for Muslims and the rest of the world? And for crying out loud, what are people rejoicing in the streets for?

I suppose, in the decade-long drama of terrorism and Afganistan, that it was time to have closure. After the 9/11 attacks, the US was on a manhunt, and if you are trying to hunt someone down and bring them to justice, then it's good that justice gets served. It took the work of many soldiers, intelligence teams, and collaborators to bring that plan to fruition. Congratulations to them, whose hard work and courage paid off. But is that really something to celebrate? The way people ran cheering into the streets here made almost as much sense as the people who were cheering in the Middle East when the World Trader Center towers collapsed. Why would you celebrate someone's death?

People say that they are celebrating the destruction of a symbol of terror. But is that really what they are celebrating, and has the terror been destroyed? Does it the end the war and hatred if we celebrate how we send our military out into the world and (using the words of conservative Christians) play God, deciding who lives and who dies in faraway countries? Isn't that part of the reason why we created enemies in the Middle East in the first place? What if, by celebrating our ability to kill terrorists, we goad indignant Muslims around the world to rise up in anger to wipe those smiles off our gloating faces? (Anyone remember why World War II started, after the Most Terrible War in the history of the world ended? Do you suppose it had something to do with the fact that certain European allies were thirsty for revenge and decided to rip Germany a new one?) Since when does the "winning team" (in this terrorism game whose rules are somewhat nebulous) forget about good sportsmanship?

If this man, who persuaded, trained, equipped, and aided so many gullible "fighters" to kill thousands of innocent people around the world, is dead, then good riddance. Hopefully something ended with him, something awful and twisted, which by its ending will promote peace and understanding between people around the world. But if that isn't the case, then I would have to mourn the day that one man's death led to the deaths of even more innocent people, because one man's life (or death) is certainly not worth the lives of the rest of world.



// j.