25 years of awesomeness

To quote my cousin Abbie "You're like, halfway to 50"

So I haven't updated my blog in months, as evidenced by my lengthy prose in each of the successive posts. Really , I just didn't have the motivation or time to sit down and lay out my thoughts. I mean , some people take blogging as some kind of crude journal writing or whatever. For me, it's an avenue to help keep my friends and family updated and hopefully entertained.

In the end, I'm just happy writing and putting what's in my head on a screen. So what do I have to say, or rather what have I learned in a quarter of a century? Well, I'll make it into a series of quotes, bullet points, lessons, etc.

From Abbie again: You're a doctor so you're not technically a loser

What I've learned: While being a nerd certainly cost me in many ways in my teenager years, it's something I embrace now. Surrounding yourself with the right people and right environment translates that into helping patients and keeping your friends laughing.

I think most everything is worth laughing at

Laugh at yourself, laugh at obstacles.. it's hard to be a big bad wall in your way when someone laughs at you and jumps over you. I used to get in trouble for laughing during prayers and inappropriate times and while I certainly control that better now (furious tongue biting), laughing is so soul enriching. When your belly aches as much as your heart warms, that's a good laugh. Also the danger of laughing with gas. You see, I find farts hilarious. Imagine the loop that's created when you laugh so hard, you val salva, fart. Realize you farted and resume laughing.

Being a gentleman

I remember one of my friends calling me out for walking a girl in the rain, a girl who wasn't single. It was somehow low yield to do so. I do it because well.. it's what I do. Perhaps it's because I've been a big brother for almost 18 years that it's ingrained in me but I'm sure there's some lassie out there who wants her door held open for her.

Being a good listener

Psychiatry sharpened my listening skills. Sometimes you can learn a lot by doing very little but listening a whole lot. This pays off in life. I'd like to think remembering a very little but very personal detail about someone can have the ability to make their day.

"So you're half way through your twenties" - Aunty Cathy (Abbie's mom)

In one sense of the way.. holy crap. I remember several medical school people saying, medical school is all about delayed gratification. You sacrifice your twenties and you take out all kinds of money.. for this degree, this career. Sometimes I think.... "wait a minute.." but mostly I think.. " i totally am okay with that, i really really really really want to be someone's doctor.. "

Do you have a girlfriend Abbie/Maddy (sisters, my cousins that live in Mass.)?

Apparently, I have no reason as to why I don't have a girlfriend. Maddy insinuates to me during my cousin's graduation dinner that unless I'm the only person in Macon.. I've got nothing. I'm still working on that answer

So on a timeline , the highlights

Born couple weeks premature on May 30, 1985 12:59a (4lbs and some odd ounces) to one Leila Abdullah, LPN and Karim Abdullah at Brooklyn Hospital, NY. I spent the next month in the NICU because of feeding difficulties

1985-1990 - Lived in South Ozone Park, Queens, NY - attended Public School 121 - Kindergarten teacher was Mrs. Jenko. Most memorable moment: squirting ketchup in my ears on accident and freaking out because I thought I would never hear again.

1990-1998 - Lived in Margate, FL Elementary School/Middle School - little known fact, I spent a few months at a sketch magnet school for math before returning to my regular school. I also was rejected from Gifted Placement because of my inattentiveness and desire to play outside. Oh, and even better, I was once evaluated for speech. Good times.

1998- Moved to Lawrenceville, GA where I've called home since.

I've held several jobs in the past

Bagger/Carts - few months at Kroger when I couldn't drive, it was horrible and quit shortly

Publix - over several years I worked as a cashier, stocker clerk/cashier combo and then during college as a pharmacy tech

In house tutor - I tutored Precalc, Physics and Middle school math and science

ER Secretary - one of my more memorable experiences, I worked at the same hospital my mum worked at.. she would visit me in the morning as she came of for day shift as my night shift was coming to an end . The staff loved the fact that we were related.

Volunteered a good bit

High school/college volunteer - at the same ER I would later work at

HELP - working with elders at a local hospital

Countries I've been to: Canada, Guyana, US, Jamaica, Grand Cayman

States I've spent 24+ hours in: Florida, Georgia, South Carolina, Massachusetts , New York, Kansas, Colorado

Paraphernalia with celeb signatures: One item, a book signed by Queen Rania of Jordan. This was my very unique present from my second mom/aunt in NY.

Pets over time: Dog (George) in NY, Several Fish, Birds (parakeets in FL and currently Sam, our family's pet cockatiel)

Nicknames : Big Bird, Ice, Robby, Rob, Bert, R.A., Bobert, Bob, The Abdullah, Franco, Rober (pronounced row-bear as one would say in French), Karim

Crushes (not including college/med school)

Elementary School: Patricia, Nicole, Elise, Laura, Miranda

Middle School: Tiffany, Denise, Rosalie, Lindsay, Emma

High School: Lindsay, Patty, Jeanette, Meagan, Tanya, Amelia, Ashley

*there's probably more names.. these are the ones I remember though

Anyway, that's probably enough trivial me information. I am very blessed by the people that surround and support me. Most immediately and perhaps importantly are my parents, my sister, my Aunt Dolly and cousin Andrew in NY. Not to minimize other's contributions but these are the people I lean on that have always been there in the best and the worst. It is no coincidence I turned 25 in their presence in NY, not 48 hours ago. I have a great family, in general. I also have some kick butt friends who make me smile and feel awesome. I enjoy who I am and where I've been. I also look forward to the next great adventure.

Thanks for reading

To quote Barney Stinson (NPH) of HIMYM fame : Barney: In my body, where the shame gland should be, there is a second awesome gland.

Enter Psychiatry

Enter Psychiatry, the cushest rotation of my life. Psychiatry was in effect a 7-8 a to noon kind of bit. At our hospital there are no psychiatric residents, just attending. Two attendings work at a time. One attending is the Psychiatry Consult MD, meaning they are the triage doc. They determine if there’s a need to follow a patient for a while , admit them to the psych floor or wonder why the heck we were consult.

So consult service was neat. Days started off one hour before the attending showed up. This was usually 7/8a. We’d head to 6 East, the psych wing and find all the pieces of paper saying “Psych MD consult and some little scribble of why they were consulted” We’d then update our PSYCH MD list and divvy up the patients. There was three of us, so we split it three ways, giving new patients priority. Then we’d head out. Our plan of action went like this:

1. Find patient’s chart – this is probably the most involved task… any number of people can have the chart – other teams, case management, xray/procedures, chart gnomes, wizards
2. Collect billing sheet for psychatrist
3. Find out why we were consulted. This may or may not be readily apparent. If we’re lucky , it’ll say Consult Psych MD: r/o depression/suicide. But it’s never that simple, otherwise life wouldn’t be as exciting. Sometimes, there is no order for PSYCH MD. Sometimes there’s no clear reason on the chart. Then you proceed to step 3
4. Find nurse. Finding a nurse is really important on pyshc, moreso than other rotations . The nurse sees the patient the most and they can appreciate changes in patient’s mental status and hopefully.. the nature of the consulted. It also is a great way to meet cute nurses, I mean.. expand your social.. I mean… be really nice to nurses.
5. Find patient - another task.. sometimes you find the room AND BAM.. patient is MIA… could be smoking, could be getting something done or imaged, or one day I had a patient up and vanish (based on previous records, she’s done that before)
6. Talk to patient – psych histories are conversational. You want to assess the immediacy of need, the history and boil it down to : what can we do to help this person
7. Sit down rounds – students report to attending and we build a priority list of patients to see
8. On psych, some attendings want to see all patients on the list while others want to see teaching cases. So we round afterwards based on that
9. Round, learn, peace out for lunch
10. Occasionally we had things in the afternoon like lecture or conference but the latest we went was 2/3p
That was consult service. I saw all kinds of patients: personality disorders, substance abuse, plenty of suicide attempts, PTSD and my favorite, schizophrenics. I’ll tell you about two that I picked up on one day that were just special.

The paranoid schizophrenic
Pleasant AAM who’s sitting in his bed in the EC. He has a sitter which means he had some sort of suicidal ideation/plan. First thing I notice when I walk in is a sheet of paper covered with writing and symbols. This becomes my talking point. I introduce myself and sit next to this pleasant gentleman. I ask if I can look at the paper. The paper is filled with terms regarding chromosomes, genetics, cloning, formulas. My patient proceeds to explain that the government stole his secret for chromosomal liver transplants. [ I think to myself, oh this is going to be good. Not so much the oh you’re a nutcase good but I find a schizophrenics train of thought and delusions interesting. They have a thought disorder, their ability to relate their reality to you and their perception of reality are disordered, disjointed] My patient explains that he is a veteran and had been working on these formulas and really it boils down to him not taking his meds and having stressors in his life that made him want to hurt himself. I really ached after seeing him. It’s strange how some patients just jar you and feel for them.

The disorganized schizophrenics
Agitated Caucasian male that presented to the EC because he was found passed out on the street secondary to alcohol consumption with possible lobar penuomia. This gentleman was just.. well… a disorganized schizophrenic who had been living on the street for 10 years. He was disheveled, thousand yard stare, monotonous voice, wanting to go back to the streets. Our conversations usually started off normal. We talked about his pneumonia at one point:

… Me: so it looks like you have a pneumonia here
Patient: acknowledges what I say but then looks outside , starts rambling. Then he goes on to say: “this is the climate for walking pneumonia”
Me: [wtf?] Um, I suppose you’re right sir
Patient: grumbles/rambles … new word for that “grambles”
Me: looks over at IVs, sees Levaquin running. But it looks like you’ve got a more serious pneumonia that just walking pneumonia, that antibiotic over there covers things like lobar pneumonia [point for me… what what..]
Patient [unimpressed, continues grambling]

So I take in the rest of the room, seems like he has all kinds of random jars of liquids and trinkets from his travels. He has one worn backpack. So really our encounters consisted of conversations that started off okay with him mostly questioning things and then proceeding into a series of grambles. The day our attending met him, with our team in to (three students, one doc) our patient proceeded to go on a gramblage- grambling rampage. When asked if he’d like to spend time on our psych floor aka “the pavilion” (which is a hilarious name as it implies the psych unit is some kind of robe wearing spa that only the elite patients go to), our patient thinks it over. His thought process proceeds as follows

Well, I understand that you are offering me to go the pavilion
I’ve been there before
I’d like to walk around the hospital some more
Move floor to floor
You see, I need access to a library
Insert some reference to aliens/UFOs
I need to get a library card
Grambles about oil spill
I can research genetically engineered fish that can clean up the oil spill
[at this point, the attending motions for me to open the door and that the interview is done, saying to open the effin door]

We all proceed to file out, close the door and bust out laughing. It was ridiculous. The whole time we were all holding back, maintaining professionalism listening to our patient move from coke to central park to libraries to fish to aliens to cleaning up oil spills. For me, laughter is a coping mechanism that I’ve employed throughout life, especially now in medicine. There’s so much we see and do that we need an avenue to channel that experience, that stress. Some people take it seriously.. others like myself .. laugh..

So to wrap up psychiatry, I ended on three weeks of inpatient psychiatry. These were the “unit” patients. I’d see maybe 1-2 new patients in the morning, obtain a good history and see my continuity patients. Again, we’re the residents basically at our hospital. Our attending would let us lead team rounds. So nurses, social workers, our attending would all sit in a circle and run through the list talking about medication effects and mental state of our patients. Psych inpatient is very cool in this regards because the longer you were on the more it became “well, he’s still psychotic but I do believe he’s much more socially appropriate today.”

IM Team B

Internal Medicine: My old friend

So up until Internal Medicine, I had given up on adults. I had abandoned my sweet old ladies, my pain medication seekers, the chest painers, the crackheads, a lot of the patient population. I had given up on rambling histories that span decades. I had given up on those people that may or may not be neglecting information. Then I began inpatient internal medicine. This is the “wards” so to speak. If you’ve had the pleasure of reading House of God, these are the gomers and the TURFS and all the clever things Mr. Shems discussed. I would soon the medical student on Team B. My goal, not to make my residents and attending’s job any more difficult (per House of God). I expected to be let down, to side with the cynical resident, to resent the smell of .. well smell of patients in the morning, and to grow tire of the dreaded differential.

But ladies and gentleman (my loving readers), I didn’t. See, I started Team B and would be on Team B as the only student. There were two interns, an upper and our attending and me. I was the go to man so to speak and I loved it. A lot of my third year experience so far has been shaped by the people I work with. The residents and attending set the tone. For me, pediatrics was probably one of my more stressful, anxious rotations I worked in. Don’t get me wrong, I still want to do pediatrics , but not just pediatrics. Medicine was the complete opposite. We joked around, we said really inappropriate but hilarious things behind closed doors. We just didn’t get worked up over little things. So let’s discuss what it means to be on a team, who we are and what we do and how we do it. (queue “this is how we do it”)

The Team (from Top to Bottom)

The Attending - The boss, the fearless leader. The attending is the source of knowledge, the captain of the ship. He probably interacts less with the patient than any of us, time wise. The attending really spends the morning and early afternoon on the floor and then has other things like clinic and whatnot to do later.

My attendings: I had two different attending for my 8 weeks. One was an Indian guy who’s lifelong dream was to be a cardiologist. For anonymity , we’ll call him Brown Doc. So Brown Doc was essentially a coolster. You see, he was the kind of attending who liked to be involved in jokes and wanted to know why everyone else was laughing. He also thought he was funny when he made really inappropriate comments in public (public being the not safe zone of the floors vs. the rooms for residents/doctors that’s our safe areas). Brown Doc was also a one upper. If he asked you a question, and he does, a lot. You can have an answer and it may be right but he’ll ask you for another differential or something related just to one up you. For example:

Brown Doctor : Young AA Athelete drops on court from heart condition, what is it?

Me: HOCM , Hypertrophic Obstructive Cardiomyopathy

Brown Doc: Tell me about that

Me: ramble on for a little about sarcomere mutations, val salva maneuver, outflow obstruction, preload.. AD inheritance

Brown Doc: What’s another possibility?

Me: uhhhhh.. I don’t know

Brown Doc: [one up time] how about ARVD?

Me: uhhhh

Me: [waits for anyone else to chime in] What’s that?

Brown Doc: ARVD is arhythmogenic right ventricular dysplasia…

Me: [awesome]

Brown Doc grew to like me after first pissing me of my obnoxiously calling me my last name when first meeting me. He also was very appreciative of my efforts and thought much more highly of me than he let on.

My other attending , we’ll call him Dr. G. He is from Georgia, a southern gentleman. He is the quintessential IM attending. He’s very paternal in nature. He jokes enough where things are lighthearted but not overwhelmingly so. He was a big fan of boards questions, MKSAP questions. He’d print out one-three questions every day for all students and residents and we’d do these between rounds. He was also a stickler for rules which is mostly fine unless you’re trying to sneak out of a lame lecture after being on call overnight. He also made sure he pointed out good pathology and wanted you to do a thorugh exam. One of his other learning techniques was to assign us topics based on patients. For example, we had a patient that may have had HIV associated lipid dystrophy. Basically, it was my job to go home and read up on it and in 90 seconds , present the group an overview of the topic. This was actually really useful because he’d assign it to students and residents and we’d learn from one another. Dr. G, definitely one of my favorite attendings ever.

The Upper Level – The upper level is second/third year resident. They’re the team leader. Really, they’re in charge of overseeing all patients, acting as a liason when we consult other specialities and check behind the interns . My upper level, Josh was a cool guy. Josh was able to fart, laugh till he cried, just keep things light. At the same time, he was always on top of the ball. He taught us important things and encouraged us to be independent. One of the perks of being Josh though began one fateful call day:

[Robert heads down to the ER]

Robert: Hey Josh, what’s up

[biggest grin on Josh’s face ever]

Josh: guess what you get to do?

Robert: what’s that?

Josh: DRE man, snickers

[DRE is not the rapper but rather “digital rectal examination” – finger… in the butt, which for a lot of people is one of the most disgusting things ever, but I had grown desensitized to it during surgery]

Robert: got it man, consider it done

I’ve zinged Josh twice , perhaps more but twice in medical things. Once, I thought I heard an aortic regurg murmur, a low grade on this guy who had aortic ectasia on chest xray. Truth be told, I was listening super closely because I knew the chest x ray findings but even then.. Josh said he didn’t hear a murmur. The next day, Dr. G definitely said… there’s a murmur.. a faint one.. but it’s there. Robert -1 Josh – 0

The next zing was me totally dashing Josh’s dream diagnosis. We had a patient who had some finding that Josh felt a differential of aorto-enteric fistula was warrented. He was all excited and proud of himself when I ask: So, question, if he had said fistula, wouldn’t he be really sick? I mean if there’s a conduit from gut to aorta.. that’s serious. Josh, just started at me and said “thanks Abdullah”. Robert -2 Josh –o

Now in all fairness, Josh called me out on a variety of things but he really taught me a lot and we got along awesomely. He tried every now and then to catch me. One time we had a patient and Josh tells me to listen to her and tell me what I hear in front of the patient and family member. IN my head, I’m like… this’ll look really bad when I miss some kind of crazy thing like.. missing heart for example. So I listen, I hear what I think is a mechanical valve and I pull the ole medical student safe question re-ask:

Me: She doesn’t have a mechanical valve does she? [you see, if he says no… I can strike that off, but if he says yes.. it’ll confirm what I think]

Josh: I don’t know,does she

Me: [well played Josh, well played] Yes, I believe she does

Josh: good job

Because I had been the solo medical student for four weeks before working with my awesome partner, K Dub, I got a nickname for my frequent DREs. I was called rectal king. “King of the Rectal Exam”. Later, after one of the interns misheard my two nicknames Rectal King + Sexy Dark Chocolate, I became rectal candy.

The Interns – The interns are the workers, the grunt doctors of the medical team. They work the closest with the medical students. We are their personal bitch. If they need something, or something done, they will ask us. I worked with several interns. I’ll try to sum them each up

Captain Nascar - nuff said

Slick family medicine resident – so we also get a family medicine intern on our team as well, this guy was pretty cool and from Lebanon

Eminem’s little MD sister – this resident was one of the funnest, most hardworking residents I’ve ever worked with. She would throw down sick beats randomly and bust a move in the middle of rounds.

SS – SS was cool as well, she was laid back but worked hard and didn’t waste your time.

Persian – The Persian was a cool guy, really big about bedside manner

The Students – we’re the bitches on the team. Essentially, any rectal or random non-MD task goes to us. We see the patient for the longest period of time. We were fortunate on our team to be taken seriously for our suggestions. If I thought our patient was a good candidate for CPT, I expressed it.

Me – Well I’m pretty much an awesome medical student. But seriously, my MO is quiet sneaky but effective. I think a lot of people mistake my initially quiet and reserved demeanor for being shy. The thing is, given a few days, I was joking with my residents and helping make their life a little easier. I’m not the student that jumps on every question. I usually wait my turn and when thrown a curveball, attempt to hit a double. I’ve also learned to smile and joke with my patients, if they like me.. it makes my day a whole lot easier.

K-Dub – I worked with K-Dub, a classmate and friend , for four weeks. You see the things is, working with someone on a rotation can be quite different than hanging out with them watching Glee. In the hospital, you want to work hard and be seen as helpful. You also want to not ever make your partner look bad ever. Thank goodness, K Dub and I got along like PB and J. We supported each other greatly, kept the mood light and always gave each other credit in front of the attending. We also took our hits together, as a team.

So, IM was fun. Q4 call is the only downside to being on IM. We got to see crack chest pain, GERD chest pain, STEMI chest pain, NSTEMI chest pain, GERD chest pain, chest pain NOS. We saw a case of neurocystercircosis , unfortunately I was unable to visualize any worms in the patient’s eyes. We son tons of ascites patient, whether it was from alcoholism, cirrhosis, cryptogenic cirrhosis, etc. We saw diabetes, tons of diabetes. Anywhere from newly diagnosed to foot amputee diabetes. We also read tons of EKGs. Remember Brown Doc attending is heading off to cardiology fellowship so he loved having us cold read EKGs. I saw some interesting pathology like AML with sweet’s syndrome.

There’s probably a lot more that I’ve seen and have forgotten but needless to say, I miss IM Team B.

There's a 95% chance I'm doing pediatrics

So, I haven't blogged in what appears to be over two months. Goodness, what will become of my avid readers? Who will comfort that hole in their lives, that hole that is the word weaving that is "Scribe for Life"? Well the answer, ladies, gentleman and hotties is a new entry. A new entry for a new year. BRACE YOURSELF

So let's recap pediatrics. I ended on two weeks of clinic . Clinic was fun, for the most part I hung out with my friend Kristy and we split patients between us, the awesome medical students and the residents. One of the most important things that we learned about was the importance of moisturizer, Curel. Eczema and dry skin is pretty much the plague of pediatrics. When the temperature goes down, the heat goes on and the skin dries up. Let's just say our attending is a BIG FAN of curel.

I also learned the importance of cleaning ear wax.

Now let's enter one of my mental/actual conversations after volunteering to irrigate an ear:


Robert (in head) : all right, let me go ahead and uh.. put this piece in the ear
Robert: you okay little man?
Robert: sprays the hear [kid starts getting angry]
Kid: ow ow ow
Robert : (in head) ooookay... a little longer.. HOLY CRAP WHAT IS THAT?
[sees a chunk of wax in the receptacle]
[looks in Ear with otoscope]
Robert: (in head) looks good... WHAT IN THE ... DID I JUST PERFORATE THE EAR DRUM? PLAY IT COOL ABDULLAH, PLAY IT COOL
Robert: ma'am , I'm gonna have to go and umm... grab the resident to see if we got all the wax we're gonna get

Robert to resident: Uhhhh I may or may not have blown a whole in this kid's ear drum, please come look and tell me I didn't

Resident: [checks it out], says it looks good.. assures me ear drum's fine

..... then we proceed to clean the other ear...... to a screaming kid.... all in a day's work....

Another life lesson: Everyone likes stickers.... kids most noticeably but I don't think I know any normal grown non-curmudgeon that doesn't like em:

Another lesson related to stickers and promises: Don't ever promise something you can't deliver:

Robert (to two brothers who are there with their sister) - Gentleman , would you like some stickers?

Kid 1: Yeah, can I have batman?

Kid 2: Superman?

Robert: Sure, I'll go get em

[Robert walks to room with stickers... awww damn.... just transformers... hmmm... ]

Robert: Here's the stickers guys

Kid 1 (speaking for both): I'll take both, Kid 2 doesn't want his... wait.. this isn't superman OR batman...

Robert: Yeah, sorry about that

{Kid isn't really bothered... BUT he could've been....}

LIFE LESSON: Some girls are crazy, like secretively bipolar, on the verge of exploding crazy.

LESSON: Steer clear of such girls or always prepare for the crazy to leak out (above picture is Dr. Jekyll/Mr. Hyde)

So even after all the crazy, I still love pediatrics. Interestingly, my first week on Internal/Eternal medicine I started with Infectious Disease. The ID Doc got to knowing that I enjoyed and more than likely will pursue pediatrics so I was able to work in the HIV/AIDS Pediatric clinic and round on a peds patient while on ADULT INTERNAL LAMENESS MEDICINE.. SNEAKY....

I ended up seeing a little guy who I actually met when I was on pediatrics . He was a Nec Kid (had necrotizing enterocolitis) and had short bowel syndrome from his resection but got a line infected resulting in a systemic fungus infection.

But he was fine, perhaps it was a contaminant or whatnot but this little blue eyed glove grabbing little man became my buddy. I also worked as a sort of consultant , in between the ID Docs and Peds GI. The Peds GI doc called me very "thorough" and thanked me which was awesome. Remember when you're a big bad attending, the littlest of things and compliments (when earned) makes a student's day.

So infectious disease was fun, got to see some unique cases, worked in the Peds HIV/AIDS clinic for half a day. Cards was fun, got to see an ablation done which if you ever get to see, do so. You basically map out the heard and use computers and EKG technology to pinpoint the area of fibrillation. Then you ablate it with some waves, being careful not to burn the adjacent esophagus.

But yet again, my favorite case was an ECHO of a little man who was being worked up for newly diagnosed sickle cell disease. My last two weeks were spent on clinic duty, helping out residents by seeing patients and in some cases, outright seeing the patients on my own and presenting to the attendings by myself. The problem is , I don't see myself keeping happy in 10-15 years working with / against/ futile attempts with chronic disease. Somewhere between trying to figure out which of their 20 meds needs refills and if they're taking their meds and not understanding why we have them on their medications ... I find myself growing weary already.

Oh and I got to pull a two fer on a patient presenting for back pain. I definitely gave her a pap smear and I and D'ed her abscess. That wasn't as awesome as it sounds. Not much else to clinic, I got to work with my bud who I shall refer affectionately as "Hermione Granger" which is a shame because we would have made a sick inpatient team combo but alas, I begin inpatient 1000a Monday morning with a call night to boot... so here goes nothing.. 8 weeks left... and then I'm 75% done with 3rd year.

So to recap:

Curel does wonders for the skin

Don't promise , if there's not a 99% chance you can't deliver

Everyone loves stickers except losers

Stay away from crazy girls if you can

Love till it hurts and even when it does, love some more

Make time or time will make you

What's left

8 weeks of internal medicine (inpatient team, on call every 4th night)

6 weeks left of psychiatry (snicker)

6 weeks left of ob/gyn (GROSS)

May 30, 2010 - The most awesomest person's birthday ever

August 14, 2010 - STEP 2 - CK

August 19, 2010 - STEP 2 - Clinical Skills

There's an 80% possibility I will be doing Pediatrics

Hey, hey , hey
Wakey , wakey eggs and bakey
Frick Frack
Interesting
Innit Interesting?
Sweet Pea
Wild child
Peanut
-Dr. Justin Beverly (Pediatric Attending, Pimp Master)

So, Pediatrics, one of the most enjoyable and crazy rotations I've done so far.

I started off my Peds rotation on the floor and I'll say this much, the floor is intense. We worked like interns for lack of a better description. I was fortunate in the sense that there were four of us on the floor team. 1 student was always rotating on the PICU (Intesive Care Unit) while the rest of us remained downstairs.

So couple things to understand, the Children's Hospital is separate from the main hospital. You cross a bridge on the 4th floor of the main hospital to get to the third floor of the children's hospital, doesn't make sense to me either. Perhaps there's some kind of wormhole/vortex between the two buildings. Once you cross before 6am. well you don't go back till lecture at noon.. it's a completely different world. I'm thinking bridge to Terabithia except this Terabithia is full of RSV, contact precautions, tee-tee and poo poo. (But I digress, and btw just as an aside.. that movie "Bridge to Terabithia.. was really sad) Lastly, the bridge is one of the few areas in the children's hospital that has windows so really it is very possible you will have no idea what's going on outside during the course of the day until you cross the bridge on the way out the door for the day.



There's paintings on the wall and drawings submitted by past patients and bathrooms where everything is smaller. Since you're there at 6am , the nurses are winding down before shift change so there's a sort of lull in the predawn period. Then you make your way to the dungeon, the peds conference room. Here is where it all takes place. Here's where we divy up our patients, work on getting people home, changing orders, calling hospitals.. this is the think tank behind everything the pediatric team does on the floor. So begins the day

600-700a - Students wait for Interns (First Year Residents) to show up and sign out = the on call intern from the night before tells the intern coming on about anything crazy that happened or any new admissions, the students have to pay attention because we have to split up the patients as well
700a-930a - pre-rounds - visiting patients , checking labs, writing notes on the patients we have, this includes touching base with our intern before it's time for work rounds
930a-noon - work rounds- the whole team goes patient to patient and a student/intern presents the patient example: 12 y/o male presents with 5 day history of constipation and distension unrelieved by over the counter fiber supplements , he is currently on IV Fluids and a Go-Lytely drip. Labs are normal, etc etc. Constipation is a rather common problem. All joking aside, it's really obstructing medical care... HAHAHAHA (get it?) So work rounds is similar to what you see in Scrubs where the attending asks questions at the bedside, etc. One of our attendings, the one I quoted at the beginning is famous for his bedside questioning.
Noon - 130 - Lecture and Lunch
130-500p - Anything and everything that needs to get done on the floor from orders, discharges , new admissions, checking on patients, calling outside hospitals, calling the lab, etc


Then there's night call. Because of the holiday season, our night calls got stacked up. So instead of spreading six nights of call over 4 weeks, I had 3 nights of call two separate weeks = 90-110 hrs logged at the hospital ... KILLER. There's not a whole lot that's crazy about night call. Essentially the day team leaves and checks out to a night team. The night team just handles whatever takes place at night, writing for meds and handling new admissions. The only difference is that we have to call the attending at home to discuss patients before we admit them. As a student, we picked up whatever admissions we took part in. Since we usually write the admissions orders and take the histories, we know the patients quite well. So the next morning it'd be your responsibility to present the new patient. So let me digress and talk about beeepers:

I used to think having a beeper was awesome. It was some kind of reminder to the outside world that your were awesome and that somehow attractive ladies would realize that obviously you're some kind of important doctor who needs to rush off and call about pages and save lives.

I don't think that anymore. You see the beeper is your means of contact when you're not near your resident. So you think you're home free around 1100p/midnight and you settle in for uncomfortable night in our call rooms trying to get some semblance of somber when it goes off, the beeper ... the bastard of a beeper. It's 300a and you just sigh audibly.... and say something like SON OF A FRICK FRACK. So what is a beeper? It's a cock block of peace in your life. The funniest thing to observe is the collective loss of sphincter tone in a group of medical student when someone's beeper goes off. Everybody is sitting around our student lounge when it goes off. There's a little pallor in the face and we all hesitate, reach for our beeper and realize it's one unlucky soul's page and not our own. Realizing we didn't mess ourselves, we are all collectively relieved but silently mourn the poor colleague. So long beeper bitch, we shall live another day.

So a few things that I've seen on the floor that was interesting:

I took care of a little girl with Kawasaki's disease - basically a vascular disease in kiddos that can cause Heart Attacks in kids.
We has a cute bilingual kid who ended up with a wicked Strep Pyogenes skin infection.
We had a bunch of RSV-ers
I had a run of the mill abscess kiddo
I'm blanking on other things but yeah


So after my 3 weeks of floor madness, I had one week of PICU. PICU was awesome. Now here's a little dose of irony. The PICU, the Pediatric INTENSIVE Care Unit is less intense than the floor. My resident and attending were really laid back people. There's several reasons why the PICU is cool. One , you don't have to take as many patients. I started with one patient, a little dude who had RSV and was on a ventilator.

So time for another aside.

RSV - http://en.wikipedia.org/wiki/Respiratory_syncytial_virus
RSV is one on the most protean viruses known to mankind. Well, maybe not mankind so much but Robert-kind. You see with kids, most kids end up with a coughing spell that lasts for a bit and lingers, maybe a little tachypnea. Some kids need a little oxygen support and chill on the floor. Other kids, like my little man in the PICU end up being put on the ventilator , especially if they are premature babies. They just don't knock the virus out fast or strong enough.

It's weird entering a room with a little one hooked up to a ventilator and recording settings and checking tube feeds and medicines including an array of muscle relaxants (Versed and Fentanyl) . My job was basically to check his lungs, check hsi xrays, check his feeds and see how he was doing. It's strange watching the lungs slowly clear up and then hearing them clear up on exam. But that's PICU for you, you manage the basics.. airway, breathing, circulation....

So mid week I decide to pick up another little man. This little dude was a 4mo old male with Down's syndrome and had an AV canal which means , he really didn't have a nice separation of inflow and outflow in his heart



His main problem is that he'd have these spells where he'd desat (lose oxygen, turn blue) and brady (slow his heart) and it was thought that we was just shunting during these periods. He has a particular formula where he'd get fussy --> arch his back --> get worked up ---> mess his diaper --> desat/brady and then you'd just turn his O2 up a little and wait and he'd go back to normal. Well this little guy decided to do this to me and the nurse one morning. The nurse hadn't been seeing him and wasn't acquainted with these episodes but during my morning exam, he went through these steps and it played out something like this:

[Robert is examining his patient, putting his little nasal canula back on and trying to pat him back to sleep]
[Little dude starts arching back and turns gray/blue]
Nurse: He's desating , he's turning grey-blue
Nurse: where's the bag, bag him, bag him
Robert: [no words, proceeds to grab ambubag and starts inflating]
Nurse: it's not connected, where's the connector, oh my God
Robert: [is scared crapless... holy crap this kid's gonna die on me... what am I even doing?]

BREAK - so you need to realize that while all this is going on. There's a 16 y/o male with sickle cell who had respiratory issues, heart failure and kidney failure and all this stuff going on that early morning and they were trying to stabilize him to get him sent to Egleston so the PICU was busy. Also realize the rooms are transparent in PICU, nothing goes on without us really knowing

Robert: [thinking, where is everyone , holy crap holy crap.... ]
Respiratory: calm down, this kid does this
My Resident: walks in
- everything calms down as the little guy returns to normal, is breathing fast with retractions but otherwise going back to normal with some eye contact issues (maybe a little seizure activity?)

But that was PICU week, back to the basics... tweaking ventilator settings here and there... swapping out meds and fine tuning most patients. Rounds consisted of checking all new xrays, and visiting each patient with the nurse in the room, the resident, the student , the NP, and the respiratory therpaist all contributing. It's a very team oriented approach on PICU. Nobody is alone, everyone helps take care of the patient. It can get really crazy in a hurry but mostly it's just watch and wait. I enjoyed PICU alot and learned alot and also almost crapped my pants like my little guy who does crap his pants after almost dying....

That same little guy was smiling later that day as we checked on him. My resident commented "look at him smile while we talk about him almost dying" This is why I love peds...

One reason not to do peds is loss. We lost one of our patient en route to NY. He was an 8 y/o boy newly diagnosed with cancer in August (he was actually diagnosed when I was pediatric surgery and we were checking his chest tube to drain a suspicious effusion). Later, he returned for a little fever, upset stomach when I was pediatrics and he just had some cruddy looking lungs , earning him a ticket to the PICU. Well , he was starting to do better, on high flow oxygen and was ready to be transported to NY where cancer specialists up there were gonna better assist him. Well, he didn't make it for one reason or another, the family didn't want to do an autopsy. May he rest in peace.


So that catches us up to this past week, Newborn Nursery

So my only gripe with Newborn Nursery, I had to come in Sat/Sun morning but otherwise this was the greatest week on Peds for me. I showed up between 800a-815a and saw one or two patients and because of the holidays we had extra help so there wasn't any need to handle more patients.

Newborn Nursery is awesome, your patients range in age from hours to days, no more. Some of my babies, I'd see a few hours after being born. It's really unique in that babies are really durable straight from the get go. I mean they're ready to rock and roll straight out the bajingo. So the newborn exam... something the general public doesn't need to realize is something that I'm learning on the fly: The whole flipping the baby around and checking the head is really disconcerting if you realize that the person doing it is an amateur. I had one grandma who was very humored by me holding the baby in one hand and checking spinal reflexes.

So to top off my newborn week, I pulled a classic move during an interview, totally neglecting to check the gender of the new baby, I proceed to inform mom about spitting up patterns, stool patterns, cord care...etc then I casually proceed to talk about circumcisions ...etc.. and which point mom.. goes "she's a girl".... I'm like... oh.. so that's not relevant at which point mom, dad, my resident and I laugh at my faux pas. My resident totally covers for me by saying that it was unclear earlier the gender of the baby in the paperwork... thanks for that......

One of my favorite parts of the exam is eliciting the Moro reflex, basically you raise the lying baby up by the arms and drop them a little and their little arms should flail out as if they're startled... they do this too when you catch them off guard with a cold stethescope. It's their little way of saying "holy crap dude, take it easy"




Another one is called the galant reflex where you stroke parallel to the spine and their little hips swing to the side like a fish, "just keep swimming..."






So in short, this week was awesome. I worked from 815a-noon and then lecture noon-1 and then may or may not have a kiddo get born before 3/4p ... best schedule ever . One thing to marvel at is how healthy these little guys are. Mom may have STDs (which I've seen), mom may have done done drugs (have seen) and the odds may just be stacked against them but sure enough they start feeding, picking up weight and are sent on home......

This week more than ever convinced me that I will probably pursue a path in pediatrics. There's just something remarkably awesome about little ones getting better that makes you feel good. There's also this sense of high stakes. Kids will turn on you real fast. The healthiest looking kid can have an occult bacteremia /meningitis that just levels them within 24 hours. I think the patient population and the challenge , the stakes is what makes me attracted to pediatrics.

Plus, let's be honest... I can get away with saying things like "squishy", "poop", "whiny", "yucky" while giving report on pediatrics. The whole week, I wore a big ole button with a snowman. It's just so fun to take care of kids. Plus, let's be honest - "I help kids get better" bodes well with the LADIES....

Anywho, loyal readers

Merry Christmas, Happy Hannukah ... rest and relax....

Love,
Robert

Giving Thanks

Whaddup? So it's been a while since I've done this.. be inspired and subsequently sit down and write/type. The two things haven't really lined up recently.

So family medicine was fun. Somewhere between knee injections, shoulder injection, flu shots and a once in a lifetime urethral swab/torture... I found it quite enjoyable but not for me. What would be difficult is the paperwork, pain control and managing patients. When you think of medicine, at least for me, you think of healing, curing ... intervening in a disease process. With adult patients , you catch them somewhere in their disease process, most likely toward the chronic...preventing organ failure stage. Don't get me wrong, the long term relationship with the patients is really cool because every time you see them, it's not so much history gathering and trying to put the picture together.. it's more treating the acute problem and chatting about life.

So now I'm on pediatrics which I was really looking forward to. After two weeks, I'm back to being optimistic but it took some effort. You see, it's different being on pediatrics because you don't get nearly as much contact with your attendings. The bulk of the time is spent in this conference room without windows working on patients whether it be following labs, doing discharges, admitting, writing notes, etc. That can be really tiresome because I'm someone who likes to move about and see people but pediatrics especially with our residents is kind of a paradox. They tend to treat us like kids , making sure we ask to go get breakfast or coffee and always seem to want to keep on an eye on us to the point of us sitting in the room for hours doing very little. On the other hand, we also do a whole lot more. We're writing orders during rounds and doing discharges and admissions ... all we need is a signature but all in all it's really neat.. because now we can adjust oxygens, make and adjust medications and just ask our residents to sign off..... also the nurses and other residents will talk to us directly concerning the patients we're assigned to.

I mean my patients are really my patients. If they need something, I can write for it, get it signed. I can follow up on labs and operative reports .. I also check in on them throughout the day, checking my asthmatics making sure they are satting well. So all in all, it's been a good experience, having the responsibilities of an intern minus the ability to sign for my orders and scripts. The hours are ridiculous, I worked 110 hours from Monday to Monday... most of my days are 11 hour days but the great thing is that I'm on inpatient till Christmas then when I get back , no call, no weekends, good hours. Next week oughta be good :call Monday, Thursday, Saturday = another 105+ hr week.... oh... Peds how you steal my life away ... but after that I'm on PICU (pediatric intensive care.. i'm looking forward to that.... it'll mix my interest in critical care with pediatrics)

A few things that's been on my mind:

I'm really happy to be a Muslim. It's hard to appreciate but there's something to be said about praying in synchrony, saying Amen in synchrony with the rest of your brothers and sisters during prayers and today was especially unique in that we had both an Eid prayer and our Friday congregational on the same day.

Another thing to comment on, don't underestimate the value of great friends. i am really blessed in the friends that I have. I feel like each of my friends add their own unique spice/flavor in the casserole that is my life.

Regarding the girl situation, nothing to comment really. It's one of those, good things come to those who wait.... sometimes it's really hard to not want the good that seems so close... though...

All in all... Life is Good and wouldn't have it any other way....

Pain

Pain
2 a : usu. localized physical suffering associated with bodily disorder (as a disease or an injury); also : a basic bodily sensation induced by a noxious stimulus, received by naked nerve endings, characterized by physical discomfort (as pricking, throbbing, or aching), and typically leading to evasive action b : acute mental or emotional distress or suffering : grief
(from Merriam-Webster online)

For me, pain has to be one of the most frustrating aspects of going in to the medical field. It seems that everyone happens to know off hand when their Lortab is due for a refill or has some allergy to codeine and every other narcotic except oxy or lortab. How do you manage a patient with pain?

When I was on palliative medicine, we didn't concern ourselves with addiction or DEA stuff. We manage the pain, we make sure our patients our comfortable at the end of their lives. It seems so simple, so straightforward. We take an oath to do no harm and comfort measures fulfills this, yes.

But what about the guy who says he can't spend time with his family, that his pain is 10/10 but yet I can take his shoes off without him flinching. Later my attending asks what I noticed about his shirt? He was drenched in sweat. I also noticed the dilated pupils and the tremor... the man was more than likely having withdrawals...

How about the lady who explains that she can't work because she's in so much pain and because she can't work, she can't get money to pay for physical rehab that might attenuate her pain. She claims she has a family history of arthritis and that "everyone" takes Lortab.

"Do no harm"
How about when we can't avoid harming our patients?

Just the other day, I was "recruited" to do a urethral swab on a patient who wished to be checked for STDs. Everyone could hear him moan and OH OH and OWWWWW and EFFF in the hall as I attempted to get the best possible specimen I could.


Then there's emotional pain, the pain of loss:

My very first trauma case involved a child that was run over by a parent accidentally. The child was without substantial brain function on arrival. At one point, the team wanted to allow the father an opportunity to see his child, say goodbye. The whole team looked on as they saw a father ask his child to pull through to come back to him. The look of sadness on each of our faces, the ache in our hearts was one sort of pain. The pain of looking at your lifeless child on a trauma bay stretcher was another.

But yet we, we being future doctors, are trained to suppress emotions and to act in the face of uncertainty. I read about this study a year or two back:

http://www.news-medical.net/news/2007/09/27/30497.aspx
"Without some regulatory mechanism, it is very likely that medical practioners would experience personal distress and anxiety that would interfere with their ability to heal,” the researchers write."


So as a student doctor, doctor in training, medical student, how do I cope with these issue of mortality. Well, principally there's God. For many of my peers and myself, the concept of mortality and the peace we must seek with the fact that we can't prevent all outcomes is rooted in our spirituality.

“I have found the paradox, that if you love until it hurts, there can be no more hurt, only more love.”
Mother Teresa