Chapter 4: General Surgery

Chapter 4: General Surgery

September 23: Monday

5:15 am: Due to unfortunate scheduling, Casey is the senior resident on my team this week. Whoops.

6:20 am: Casey just pawned me off on the vascular surgery team instead of the general surgery team. Am I supposed to be insulted? Maybe he knows something I don’t about the general surgeons.

6:20 pm: Waiting for Magnus to drive me home from The Private Hospital. This is the first time I have sat down since I got here nearly 13 hours ago. I was in the OR all day long. Being way busier with longer hours here, I'm glad Magnus is at this site too.

The attending vascular surgeon named Dr. Vascular performed the first case, an aorto-bifemoral bypass. He made sure I could see the operating field and would point out various anatomical landmarks, though he didn't seem particularly interested as to whether or not I was present. Towards the end of the case he casually asked if I could tie knots, to which I replied, “Yes”. Dr. Vascular’s face betrayed a fleeting skepticism but he responded with the challenge of, "Ok good, come here and tie this knot." I tie some knots. He nods approvingly and then offers the suture and needle driver as a follow up test. I take the tools without hesitation and begin suturing. As I continued to close and adjust my handiwork at his suggestions, some of his comments were, "Good technique", "Excellent", "You seem to really be enjoying this, aren't you?" This culminated in the coup de gras statement, "Ok, you should be a surgeon." Followed immediately by, "what are you doing right now? You should come into my next case..."

Vascular surgery is so cool! All those tiny little vessels, coursing through the body under high pressure! Maybe I’ll be a vascular surgeon.

September 24: Tuesday

7:35 am: This rotation is so different than my previous ones. Barely any notes or direct patient care (at least while the patient is awake) for me to do. I'm just expected to be in the operating room all day. I arrive, preround, round, then off to the OR.

Casey warned me about Dr. Gump. She is a chief surgery resident, which is a senior resident in their last year of training. Her reputation of having poor technical skills, medical knowledge, and leadership ability are apparently well known amongst the surgery folk. I'll just try and stay on her good side and learn what I can from her.

7:45 am: There are only small scrubs (men's small, mind you) that are comically big on me. The residents and nurses were, rightfully so, laughing at me tripping over my pants.  Sigh.

8:01 am: I didn't notice yesterday but the views from some of the patient's room looking over my little city are really beautiful. 

11:45 pm: Well that was terrifying. I was just pimped nonstop for hours by a surgery attending. “PIMP” stands for “put in my place”; it is a technique used throughout medical training whereby it is established that the superior has more knowledge and expertise than anyone below them on the totem pole of medical training. As far as totem poles go, third years are at the very bottom. First and second year students aren’t even on the pole since they’re locked away studying. Pimping stems from the Socratic method of questioning a student with the goal of leading them towards a correct answer. If the teacher poses questions in a logical and progressive manner then the student should ideally be able to work through the problem and come to a conclusion on their own, even if they did not initially think they knew the answer. The College of Medicine endorses the use of the Socratic method. Pimping differs from the Socratic Method in that the goal of pimping is to point out that the student does not know as much as anyone senior to them. A student is asked questions repeatedly until they answer one incorrectly, at which point the teacher (be it a resident, or attending, or even a fourth year medical student if they’re being a total dick) can point out how little they know, deride them for not studying enough, or otherwise embarrass them. Ultimately, the student is reminded of their lowly stature on the totem pole and berated for their lack of medical knowledge. So yes, today I was pimped for HOURS.

5:05 pm: On the flip side, I was well prepped for Tuesday lectures and got props from the über impressive Dr. Mastermind for knowing my shit. Can’t please ‘em all.

7:10 pm: Nighttime rounds. Two patients already stated to me variations of: "this all happened so quick, I was sick and then I was in surgery- what happened to me?"  Patients arrive in pain, scared and overwhelmed, then whisked off to surgery, and wake up in hospital sedated and confused. I spent a lot of time provided basic education and support tonight.

9:01 pm: This is my first night on call... And it's with Casey. Now, I could have requested to do this differently but my goal is that I can help him (finally!) move out tomorrow. When I originally requested my schedule it looked as if I would be at The General Hospital while Casey was at The Private Hospital, then we would switch locations. I didn't realize there would be a week overlap where he would be my senior here at The Private Hospital. Since it's only for the first week he won't have any influence on my grade, for better or worse, anyway. He's an excellent teacher and we're completely professional at work so I don't mind working with him.

12:45 am (now September 25th): Saw some consults, wrote notes, and helped out with various patient care tasks. Time for a couple of hours of sleep.

4:02 am: I'm not saying I want to be in the hospital as a patient, but some of the patients look so cozy in their beds…

6:30 am: I miss talking to patients. Like today, there was a patient on rounds who was missing most of one of his fingers. It was well healed and completely unrelated to his current admission but I was curious and wanted to talk to him. There have been other patients that seem interesting that I have wanted to chat with but no, surgery is all business and prizes efficiency. Patients are parts that need to be repaired, replaced, or removed- not individuals.

After much thought and after helping out with some pretty cool operations, I realized that I don't want to be a surgeon. I miss spending time chatting with my patients. Just like internal medicine was not for me. There is a saying in medicine that when you find the right specialty you "have found your people." I love the efficiency, the pace, and the procedures, but surgeons are not my people. I will keep looking for my people.

6:55 am: Is it time for me to leave yet?

7:30 am: 26 hours since arrival and almost no sleep... Time to go home!

8:20 am: Rocking out to Party Rock on the way home was ideal. Goodnight my friends.

September 27: Wednesday

3:25 pm: Woke up from my post call nap. Studying and cleaning the apartment are on the agenda for today, then another date with Dr. Spengler tonight. Starting to meet and date new people while Casey is still living in my apartment has been an interesting navigational challenge. Because did he move out when he was supposed to?  No, of course not. It’s a strange stand off. It’s really hard to move on when you’re spending the day working with your ex and then sharing a bed with him at night. Why is this the slowest breakup ever?

September 26: Thursday

4:40 am: Even at 4:40 am the elevators are slow as shit here. My second date with Dr. Spengler was very disappointing. We chatted, laughed, enjoyed good food, then decided to check out a nearby wine bar because we were having such a fun time. But then disaster struck. In the midst of the conversation he casually mentioned doing something fun on my birthday- which is in January- and I began to get antsy and flustered. Like, semi-panic attack. Well, actually, full on panic attack. I don’t want a boyfriend- I just want to start dating again. Clearly I’m not ready to reenter the relationship scene. This whole dating thing was a terrible idea. He’s having a fun night but I’m still processing the fact that the guy with whom I’m having dinner with is not Casey. My date was followed by me coming home to Casey having not yet moved out. The annoying and frustrating aspect of the evening is that the date went really well. By the time the date ended all I wanted was to be hiding in my apartment. Sorry Spengler, I just can’t right now.

5:24 am: I will never again take sleep for granted. 

10:39 am: I scrubbed in with Dr. Mastermind this AM. He is wonderful- he teaches throughout the whole case, points out anatomy and yet still works very efficiently. At the end of the case he stepped out and left the Gump and I to close. While holding the laparoscopy camera she was repeatedly leaning her hefty body on my arm, causing my arm to move, and she would then remind me sternly not to move the camera unless she said so. Uh, I'm trying but I can't hold up your ginormous amount of body weight! It's as if she has no proprioception. Her general tone is condescending. In a patronizing voice she'll bark stuff like, "Good job holding that retractor, don't let go now." As much as I would like some coffee, I'm not about to let go and go grab a latte, but thanks for the advice. Her tone of voice is grating to my psyche.

10:24 am: The residents seem so unhappy and stressed here all the time. Perhaps because the two chiefs rotating here right now are idiots. Maybe it’s just surgery residents in general. Dr. Gump is my chief and Magnus is with Dr. Arse. Dr. Arse is notorious for screaming at and humiliating medical students. Some of the junior surgery residents confided in us that the more condescending, short tempered, and berating a chief is, the greater the likelihood that they are overcompensating for being poor surgeons both in terms of knowledge and technical skill. The junior residents then added that Dr. Gump and Dr. Arse are prime examples of this type of behavior. Magnus and I exchanged looks of dismay- we’ve got several more weeks with these chiefs.

1:20 pm: Dr. Vascular is bringing me back to his OR this afternoon! No offense to general surgery but vascular surgery is so freaking cool. Besides, Gump has yet to teach me anything, or really to speak to me at all. I am certainly not her primary concern, nor should I be, but all the other residents manage to make teaching points, ask me questions, or at least engage me in some sort of medically relevant conversation.

One of the nurses noticed I was freezing in the OR and brought me a scrub coat to wear. Both here and back at The General Hospital almost all of the nurses I've seen and worked with have been enormously helpful to me. When starting a rotation at a new hospital it is very disorientating and as med students we just don’t know anything about anything so their guidance is so appreciated. Thank you nurses for being kind and helping to the med students!

8 pm: At 5 pm I was about to walk out the door... then the team got a consult. Instead of being given to the student on call, Gump gave it to me. Nearly three hours later I am finally heading home. If I were Gump, I would give 5 pm consults to the student on call because they have to be there anyway and send the other students home. My feet are throbbing with every step I take as I walk out. I'm really enjoying a lot of aspects of surgery but the hours are so physically painful and, from my lowly med student perspective, Gump seems to be managing the team very poorly.

September 27: Friday

I got nothing.

September 28: Saturday

Sitting outside, enjoying the cloudless sky and fresh fall air at the coffee shop next to my apartment. I didn't have time to write on Friday because I scrubbed into two big cases that spanned 15 hours. Not only did I not have time to write, I didn't even see the sun yesterday. Being in darkness both going to and leaving the hospital is depressing. In my grand total of 20 free minutes I ate lunch while getting feedback from a resident, did paperwork, went to the bathroom- then straight back to the OR. But here was my day:

Case 1: femoral popliteal bypass surgery with Dr. Vascular

Love love love. Vascular cases with Dr. Vascular are awesome. I'm not saying that holding retractors isn't important, but it's way cooler to also be allowed to bovie, place clamps, remove body parts, and tight knots. For this case, we removed the saphenous (leg) vein and cleaned it so it could be used to make a new connection between the femoral artery and then popliteal artery. By making a new connection we restore blood flow to the leg. A good blood supply is crucial and means a happy healthy leg. Little to no blood supply means a painful dead leg and amputation. I know it's technically not general surgery so I’m not even supposed to be in his cases but he's so awesome.

In this patient, her (or his?) native artery was damaged by atherosclerosis resulting in compromised blood flow to her leg. I say 'her' with a question mark because I was fairly certain the patient was female but really, not 100%. As much as I'm enjoying vascular surgery, I'm not getting enough face time with my patients. Pretty much the only thing I know definitively about my patients is whether they've recently been on anticoagulants or if they have heart disease. 

One of the many critical points in the operation is during the anastomosis between the femoral artery and saphenous vein because the saphenous vein will act as the new artery and must be connected perfectly. I watched intently as the senior resident began connecting the two vessels. Dr. Vascular, watching me gawk at the senior resident, offers "Silvia, would you like a put a couple stitches in?" A stunned and excited "yes!" escapes my mouth. The scrub nurse hands me the micro tools so I can get a feel for them and practice a bit. I then stepped in where the senior resident had been working a moment earlier. With all my concentration and steady hands I begin stitching the vessels together. In one smooth movement, a small bite through the femoral artery and saphenous vein brings the vessels together. I did three stitches, and if asked I don't think I'd be able to pick my favorite one.

After the anastomosis is completed it is, of course, very thoroughly tested to make sure there are no leaks. During testing, Dr. Vascular and the senior resident add additional stitches until there is a watertight (well, blood tight) seal. As soon as the clamps are removed two little squirts of blood pop up like miniature red water fountains, identifying where the anastomosis needs reinforcement. Once the holes are patched Dr. Vascular informs me that my area held strong, and both leaks were on the opposite side of where I worked. Success! It may sounds silly but I don't care, I beamed with pride at my three little throws.

While chitchatting with Dr. Vascular at the end of the case my favorite comment from him was, "I don't want to ruin your life, but you really should consider vascular surgery." Oh Dr. Vascular, if ever I were to be a surgeon, I would totally follow your footsteps!

At the end of the case I closed almost the entire calf incision by myself. Before I threw a single stitch though, he put me on a surgical stool and had me perfectly set up with proper body position, view, and lighting. I started on the deep layer first, and then moved to the skin, which was friable from both age and poor blood flow. I worked slowly and methodically to bring the edges of her paper thin dermis together smoothly. After completion and inspection, the resident told me it was the best closure he has ever seen by a third year medical student. I might have had a visible skip in my step when leaving the OR.

Twenty minutes for lunch and feedback then back to the OR for case two.

Case 2: sigmoid colon resection with Dr. Gump. 

My arms are aching from silently holding the laparoscopic camera the entire case. I was a still and silent part of the scenery for nearly five hours. They could have just put the camera on a pole. My real job during the case involved ignoring Gump when she teased me about wearing make up to work and about my glasses. Yes- I am 29 years old and another adult just made fun of me about my glasses.

At the end of the case Gump asked me to close the laparotomy incisions. These require only one simple stitch at the skin. The bed was at my waist so I couldn't see well. I started to lean down and she demanded, "no, stand up, back straight now". Ok... But I can't see. I put the stitch in but it doesn't close well so I cut it out. She explains to me in detail how to suture the skin and then tells me to try again. I still can't see so I do another poor stitch that needs to be cut out. At this point, I thought of three logical things that could happen: 1) we could raise the bed, 2) I could sit down (just as Dr. Vascular had me sitting in the morning case) or 3) I could bend down a bit. The fourth option, which was the one Gump went with, was to have me try again. Gump could ask me to put in a hundred stitches but if I can't see then none of them are going to go in right. I throw a third stitch that does not close the skin well. Gump sighs, cuts it out, leans over (!), then puts the stitch in herself. She then goes on to explain to me the importance of suturing and goes on and on about how I really need to work on my technical skill. “Fuck you Gump!” I screamed with rage (though only in my head). I was seething with frustration, my skin was crawling, but I just smiled and subserviently replied, "yes, ok" and focused on all my earlier accomplishments with Dr. Vascular. I am getting physically angry again as I sit here at the cafe just thinking about how frustrated I was getting yesterday. I can't talk about this anymore. 

September 29: Sunday

5:45 am: I've been here since 5 am and haven't seen a resident yet... I'm kind of dreading today. Turns out one of the surgery residents saw photos of Casey and I on Facebook and proceeded to tell all the other residents and the Chiefs at The Private Hospital that we dated. As gossip in and of itself I don't care, but Dr. Arse is the chief on call today and I don’t want him to have any reason to start shit with me.

My fem-pop patient is doing well. I’m keeping an extra close eye on her.

I'm listening in on a conversation between Dr. Arse and an attending surgeon dubbed Dr. Angry Little Hobbit (a name surreptitiously given to her by the junior surgery residents). I’m a little nauseous hearing them speak. In over three months of rotations, this is the first time I have heard physicians speak rudely about patients. I don't want to write what they are saying because they're being so horrifically offensive. The overwhelming majority of surgeons that my friends and I have met are much kinder than we had anticipated. The old school mentality of work work work and torture your underlings is fading. Looking at Dr. Arse and the Angry Little Hobbit, they seem like misfit holdovers in this setting.

9:00 am-ish: Every time I look out the window I long to be outside. Not sure why I am so antsy today, usually I am pretty content to be at the hospital. On rounds, Casey and I noticed that Gump would not talk to either of us. Gump even made a point to greet the medical student standing next to me, "Good morning med student J, how are you today?" Casey and I stayed at the back of team during rounds and laughed about it because we dislike Gump so much anyway. But I have a new nagging concern - the chiefs are in charge of grading the med students. Gump will determine my grade. I’m so screwed.

10:13 am: It took nearly a week of searching but I finally found a stash of extra small scrubs- which are still too big but at least it's not as ridiculous looking now.

2: 20 pm: While in the OR I was offered a stool to stand on so that I could see the field more easily. Everyone started laughing when I replied that I was already standing on one.

5:15 pm: I survived rounds, laid low, and am now chilling with the junior resident on call and listening to Hendrix. So far, so good. Still feeling antsy though. On Magnus’s way out for the evening we traded horror stories of working with our respective chiefs. As bad as Gump is, the Arse is apparently living up to his reputation and provided an endless barrage of screaming, belittling remarks, and condescending statements at Magnus.

5:55 pm: It's too quiet here. It’s busy, but all the surgeries are scheduled. The atmosphere is lacking the chaos that I enjoyed at The General Hospital.

8:15 pm: It's always mildly concerning before taking down a wound dressing- you never know what you're going to discover underneath. Imagine watching a scary movie. With each layer of dressings removed the suspenseful music playing in the background creeps louder. Bloody and sticky gauze piles up on the bed and the patient begins to shift uncomfortably as you get closer to their surgical wound. You're possibly about to see something nasty but you have no idea what exactly is coming around the corner! A suspenseful pause in the orchestra just before removing the innermost layer of dressing that directly covers the wound... then, the music booms and reaches a fever pitch as the oozing surprise underneath is revealed! Full exposure! Shield your eyes! Blood, pus, ulcers, raw skin, bone, muscle, a smelly hot mess!!! Umm... Not really. Usually it's a 'clean, dry and intact wound' (written c/d/i in the charts) held together by some combination of stitches and staples. So much for the build up.

10:15 pm: I was told to unpack a patient's wound so the team could inspect it and put fresh packing in. "Packing" is basically putting strips of sterile gauze inside a wound so that the wound closes slowly over time from the inside out. If you close the wound too soon you could trap bacteria inside which may lead to an abscess. I removed the outer dressing of tape holding down an 8'x8' sheet of soft dry dressing and found a 2'x4' oval shaped wound just inferior to the patient's left rib cage. The outermost layer of packing was visible and the wound did not appear particularly deep or angry looking. I pulled at the end of the strip of gauze and hand over hand started to unpack the wound. And I kept pulling. I felt like a clown pulling an endless string of scarves of out a mysterious abyss. It kept going and going and the pile of gauze on the bed was getting larger and larger!  Fascinating! Where will it end? I had to focus on keeping a pleasant neutral face so that patient would not get concerned. Foot after foot of bloody, purulent gauze kept coming out. Occasionally I'd come across a knot where two strips of packing had been tied together. Hand over hand, on and on it went. Twenty-four feet of packing later I finally reached the other end. Twenty-four!

The surgeons inspected the wound and my next job as the lowly medical student was to repack the chasm. In order to properly pack the wound I needed to place fresh gauze inside, starting from the deepest crevices. To reach the furthest depths, I ended up having my fist and a third of my forearm inside the patient. 

I immediately went and ate my dinner afterwards. I think I have reached full desensitization.

September 30: Monday

10:00 am: I got a solid night of sleep and woke up feeling great, which was quickly overshadowed by Casey telling me that Gump and the Arse took it upon themselves to inform Casey's Program Director and my Clerkship Director that we used to date. Not sure what the goal was in doing that. Getting us in trouble? Gump and The Arse are ridiculous.

2:00 pm: Of course once the med school found out about my involvement with a senior resident they had to follow up. An email popped up in my inbox from my clerkship director asking me to come to her office immediately. Great. Well, off to her office…

October 1: Tuesday

"You had it right, but the you backtracked because I tricked you. I made you question yourself," Dr. Mastermind laughed lightly while addressing a stumbling medical student attempting to answer a question. His goal is to get us to stick to our guns and be confident when we answer questions- even if we may be wrong. There’s a saying about surgeons, “Often wrong, never in doubt.” A corollary quip about pathologist exists as well that posits, “Often right, never matters.”

Back home. Zooey has been a fabulously cheery addition to my apartment and the few hours I’ve been away from work have been great. We spent most of this evening talking about New Orleans and cooking dinner together.

October 2: Wednesday

7:05 am: My patient, Lady CRC, exudes an aura of calm, peace and hope. I scrubbed into her sigmoid colectomy yesterday to address her colorectal cancer and have been following her since. Unfortunately due to time constraints typical of being on surgery, I can't spend nearly as much time with her as I would like. I want to hang out in her room and discuss her life and adventures and learn her story. Not today.

3:15 pm: I'm hiding and eating lunch. Well, hiding makes it sound bad.... Rather, I'm sitting in a place that is not readily visible while I eat my lunch. And by not readily visible, I mean that I am sitting on the roof of the hospital. Whatever. It's not like I can't be reached between my cell phone and my pager.

I used to think it was pretty rude when Casey would put his feet up on chairs when out in public. A moment ago, right as I sat down to quickly eat my lunch and type out a few words I put my feet up on the bench next to me and audibly sighed because it felt so good to my body. No more judging the surgery residents that immediately put their feet up upon sitting down.

A classmate of mine is finally getting to see her fiancé tonight. He has spent the last seven months deployed to Afghanistan. She is not allowed to leave the hospital early to be with him.

October 3: Thursday

Being the proactive medical student that I am, the surgery teams walks into a patient’s room during rounds and I immediately start to take down a dressing so the team can assess the stump of a recent amputation. Having now seen one recent amputation I was not especially concerned about what I would see under the many layers of gauze and ace wraps. However, seconds after pulling back the first layers of gauze the patient began moaning in pain and I had a bad feeling about what I was about to see. Blood and fluid had soaked through many of the deeper layers of gauze, making the dressing sticky and difficult to unwrap. Pulling at the adherent layers caused my patients to cry out even louder, begging for me to stop and let him take a few breaths before continuing. I worked as gently as I could, getting increasingly concerned and curious about what on earth was going on under there as the smell worsened. Suddenly, the remaining clump of soaked, sticky gauze fell to the bed, and I was left staring at the cut off end of this man’s tibia and fibula, macerated and infected muscle, and a bit of loose skin that was encircling everything. It looked like a cartoon ham that had been left to rot.

I collected the pile of used dressings from his bed and tried to look nonplussed as I turned to throw them away. At that moment one of the residents realized that another vascular surgery patient needed to be seen ASAP. I was feeling a mixture of gross fascination and disappointment yet sweet relief when the resident chose me to go off and see the vascular patient. Quickly, I turned and left the man and his stump behind to be redressed by the resident and another student. I guess I'm not fully desensitized yet?

The week is almost done!

Man do surgeons love to gossip. And as a med student, we are generally ignored to the point where residents do not think we are even still in the room. I’m randomly eavesdropping on the multiple conversations around me. The attendings are talking about residents and nurses. The residents and nurses are talking about the chiefs. They’re griping about how horrible Gump is, how inefficient she is, and how she is a terrible chief. Amen to that.

Oh I’m now listening to the scrub nurses talk about Dr. Angry Little Hobbit. OMG. The nurses have a technique they use in the OR to try and protect the residents from her! Apparently they repeatedly ask her questions and distract her in order to keep her attention pulled away from screaming at the residents. Wow. I had no idea the extent of the selflessness of the nurses here.

9:00 am: An attending was lightly pimping me today about my weakness: liver anatomy.  As I was hemming and hawing about the name of a particular ligament a nearby resident leaned in behind the attending and mouthed the answer to me. It was very sweet of him, unfortunately, he was wearing a surgical mask so did little to help me out.

5:15 pm: I was very excited to get off work today at 4:45 pm instead of the usual seven or eight pm. Then I realized I still worked a 12 hour day.

While watching Glee I started laughing at some funny nonsense scene. Zooey ran out of her room with a look of shock and amusement on her face and exclaimed, "It's nice to hear you laughing!" I didn’t realize how rarely I must seem outwardly happy between working all the time and the breakup. I’m not unhappy, I’ve just been feeling a little numb to the world.

October 4: Friday

11:20 am: Six cases back-to-back! Even got to first assist for two of the cases. Usually the correct type and size of gloves are only ready and waiting for the resident and attending surgeon. I felt very special today when upon entering the OR my gloves and gown were ready and waiting for me.

3:32 pm: Sitting and waiting for my next case while hanging out with Magnus. While chilling in the surgeon's lounge we began discussing his name for this book. For reasons still unknown to me, his knee jerk response was to enthusiastically exclaim, "Magnus!" I offered other less absurd options but none of them were as random and made him as happy. So, inexplicably, my closest friend was christened Magnus for the pages of this book.

4:44 pm: An hour later, I'm still waiting for my next case. Fortunately, Magnus is on call tonight and offered to cover the case I'm waiting for so that I could go home. I may be imagining this but I think Magnus was hitting on me today. Whatever. Home I go for margaritas and tacos with Zooey!

October 5: Saturday

My first full weekend off in a month! Very exciting. Today, in theory, is the day that Casey moves out the remaining 1% of his stuff. Golf clubs, a painting I made for him, his medical school diploma, and the remainder of his kitchenware. I bet 50-50 odds he actually shows up today to complete the transition of out of MY apartment. 

11:15 am: Thank you surgery rotation for teaching me about efficiency. Instead of studying at home while holed up in my bedroom, I planted myself at a nearby Starbucks. I chose this particular locale because it is a veritable meat market of young professionals forced to spend their weekends prepping for an array of qualifying exams, comps, and board exams. Efficiency = picking up men while studying.

October 6: Sunday

Casey finally moved the last of his possessions out of my apartment. We looked at photos, went through old vacation scrapbooks, and talked (and other stuff) and still couldn't figure out what exactly what about our relationship wasn't right for him. But if it isn't right then there is nothing that can be done. Moments after his car pulled away I was on the phone bawling to my mom. I wish she was closer so I could get a hug from her. I just put out word to my friends that I could use a little love and support right now. Zooey gave me a great hug that also helped.

Momma says to keep looking forward and not back. She’s happy he is gone. And big picture, so am I.

"Confidence, passion and emotion." Words to live by. Ok so that may have just been said by Drew Bree's in the pregame huddle before my Saints took the field against the Bears but I think it can be applicable to life outside of football. Magnus and I spent the rest of evening rooting against each other as he’s from Chicago and I’m a Tulane graduate.

October 7: Monday

5:02 am: On call again.

It is freezing in the ORs at The Private Hospital. I have taken to wearing a full outfit, usually consisting of leggings and tee shirts, every day under my scrubs. Even with a full outfit under my scrubs I was still shivering today.

You know it's gonna be a bloody surgery when (after you've already scrubbed in and can't alter your attire) you notice that the residents and nurses are all wearing full face shields. My little oval shaped nerdy glasses will provide minimal coverage against massive splatter. Uh oh. I’m still oddly psyched about scrubbing into my first limb amputation.

I’m mildly jealous that nurses get to take breaks during surgeries. Surgeons, residents,  and med students do not.

12:23 am: The call room for the students and residents are on the tenth floor of The Private Hospital. Only one of the fifteen elevator banks here goes up to tenth floor. I'm so tired and bleary eyed that took me three tries to find the right bank of elevators.

4:31 am: My alarm is blaring. Where am I? Oh right. At work. I slept at work.

9:20 am: People do all sorts of ridiculous things to avoid going to the doctor. When can I go home? I really want to go to sleep.

11:14 am: I picked up my thoracic surgery evaluation. It was far better than any internal medicine evaluation. I had near perfect marks coupled with an excellent assessment. The closing comment from Dr. Thorax summarized, "I would love for her to consider a career in surgery." :)

1:15 pm: Tuesday lectures. I'm sitting in class (even though I'm post call and should be sleeping) and am getting the feeling that I need a hug. Sleep deprivation is not good for my mental well being.

2:30 pm: The lecture I'm in right now is dragging on painfully. Thing is, it's not her- it's us. She is engaging and going at a good pace but when she asks questions there is just crickets. I don't know if it's burnout from constant fatigue, the mental and physical exhaustion, or just not caring, but seriously, she must feel like she's pulling teeth with us. I am certainly not helping the situation as I sit here in my own head, typing about my own life.

2:43 pm: There have been studies showing that when people spend too much together they tend to find each other more attractive. Is that some sort of cabin fever? I wonder if any of my classmates are hot. I’ve never really looked at any of them that way. Would I hook up with any of them? There are a slew of good looking guys but mostly they’re young, and things could be super messy. Either way, more fun to think about than focusing on the surgery lecture.

5:05 pm: Finally home!! I’m too tired to do the math but I think I was at the hospital for 36 straight hours…

October 9: Wednesday

5:42 am: Ungrateful patient. Ugh. Sorry that my post-op check is disturbing your slumber. He’s laying in bed whining, "You guys aren't doing anything. If this is what surgery is always like, I am never getting another one." BTW, the team saved his life last night. And we're monitoring him constantly in case he crashes and dies... 

3:20 pm: Excellent feedback from Dr. Mastermind.

Working with Gump is pure torture ever since finding out that Casey and I dated. Her tone of voice is constantly condescending. She never addresses me by my name and keeps me out of the loop on any updates about our patients. On the other team, the Arse is routinely screaming at Magnus. He told me that he has a baseline level of anxiety and fear when at work. Earlier this morning I heard the arse yell out, "Magnus, if you ever fucking present a patient like that again I will fucking kill you." Yep. Death threats at work. You know. The usual. At least Gump doesn't yell me. I think I prefer being ignored. On the bright side, as Gump has taken no interest in me I have little bit of freedom to chose which cases I attend each day. Obviously I try to work with Dr. Mastermind and Dr. Vascular as much as possible.

8:40 pm: Carrying my iPad and journaling throughout the day has been very therapeutic. I can rant and rave on paper so it doesn't inadvertently get turned on my patients, friends, family, classmates, or any other innocent bystander. I wonder how on earth my classmates are dealing.

October 10: Thursday

1:30: Last call day! At 7:28 am this morning after rounds I had to make a tough call between taking two minutes to go pee before a long case versus taking two minutes to buy and scarf down a muffin- and no, I could not possibly do both. I opted to go with peeing. I went into all-morning case running on no food, no water, and no coffee. I could feel the ache in my head about halfway through they case and it kept building and building.

To beat down the worsening headache and stave off a migraine I just downed a cup of coffee, a bottle of water, a sandwich, and a handful of ibuprofen. A guy tried hitting on me while I was at the cafeteria desperately seeking antidotes to my headache. Flattering? Yes. Good timing? No! I hope I didn't come across as rude. This is not the healthiest of specialties. I am chronically sleep deprived and suffer from an aching back and feet. To avoid having to pee during long cases I fluid restrict myself all day, resulting in a baseline dehydration.

6:14 pm: Dr. Mastermind pimped me for nearly three straight hours during a colectomy this afternoon; all in the presence of the Gump. I was well prepared for the case and I missed almost no questions. The nurses were even joking that he could ask me any random fact and I'd come up with the right answer. There is no paralyzing fear when working with him. When I am intimidated by the attending or resident I tend to freeze up. He is brilliant and brings out the best in the people with whom he works. I was on a roll. At one point he starts asking me about tumor markers for different cancers around the body. I respond correctly to random questions about CA-19-9, CEA, alpha feto protein and on and on. He then goes way off course and asks me to name the bacteria responsible for causing the plague. I look up at him from behind my mask and protective eyewear and responded, "Yersinia." Even Gump had to be impressed. I have no idea from where that little bit of information popped into my head. I love working with Dr. Mastermind as much as I hate working with grumpy frumpy Gump.

When it was time to close Dr. Mastermind positioned me to help Gump. Gump was taken aback by my newfound surgical skill and stated that I clearly had been practicing at home quite a bit. I really hadn't practiced a single stitch at home. Nearly 100% of my free time has been spent studying surgical texts to improve my knowledge so that I can rock cases like the one we just finished with Dr. Mastermind. As miserable as I am working with Gump, she is still my chief and is responsible for grading me. I've gone with the tactic of killing with kindness. I still mostly get ignored but I figured it was the safest route and gave me the best chance of getting a decent review. I wish Dr. Mastermind could grade me. It's becoming clear though that my issues with Gump are not entirely mine; apparently it has been noticed that she favors the male students and residents.

Unlike medicine I've done everything I could possibly do to make the most of this rotation. I arrived to the hospital by 4:30 am every day to preround on my patients, prepped for every case, studied every night, and in general worked my ass off every single day. I’m trying not to get too down and frustrated that I probably won't get recognition for all the work I put in because my grade is at the mercy of the Gump. It also hasn’t escaped my noticed that working and studying nonstop every day is a great way to stay distracted from my home life.

5:48 pm: I got a sketchy text from my mom, "so are you on call...?"  This cannot be good.  After many texts back and forth she finally admitted that my dad is going to the emergency department with weird chest pain.

8:19 pm: After a negative EKG and serial labs being normal, my dad is determined to be ok. It seems most likely that he has costochondritis (sore chest muscles) from being out of shape and lifting his chubby grandsons, rather than a heart attack.

12:01 am: The view of downtown from the roof of The Private Hospital is stunning. I love the efficiency and pace of surgery. I suspect I will miss that on my next couple of rotations.

8:00 am: I got into bed as the church bells across the street started ringing in eight o'clock. Last surgery call is over! Goodnight.

October 11: Friday

Remember K Canoe from the cabrewing trip? With the blue eyes? I randomly texted him a couple of days ago, "hi, sorry I went MIA, I've been of surgery the past 2 months and practically living at the hospital. I'm around now if you're still interested in chatting." I heard back six hours later. We started texting back and forth and now we've got a date planned. Should be fun. Hopefully better than my last few dates that were all so awkward/bad I don’t even think I mentioned them. I have a feeling he’s not a relationship type of guy, which is pretty much what I want right now…

Other than Saturday night most of the next six days will be consumed with studying for my surgery shelf exam. Three hours after the test ends I'm hopping a plane to NY for my cousin's wedding.

October 12: Saturday

Study study study.

Date tonight with K Canoe.

October 13: Sunday

My date last night was great though ended kind of blah. I have a sneaking suspicion that he is relationship seeker just like the others.

I am so close to being done with surgery I can taste it. I'll finally be done with Gump and no more hearing the Arse ream Magnus all day. No more painful exhaustion, aching feet, throbbing back, shooting neck pains, being pimped all day, listening to shallow gossip, 30 hour call shifts, being surrounded by Casey's friends- no more. So close!

Have I mentioned yet how much I love my new roommate, Zooey? Even with working all the time we're still becoming good friends.

October 14: Monday

9:15 am: The rooftops at The Private Hospital are so peaceful. With the fall weather approaching it's crisp and cool outside (and also deserted). I’m only going to one case today so I'm able to sneak in a real breakfast and collect my scattered thoughts.

10:15 pm: I'm so excited to finish surgery tomorrow that I can't sleep. Which is bad, because I still have to be up at four am. I don't have any patients to say goodbye to because I didn’t have the time to connect with any of them, and I don't foresee a tearful farewell when parting with Gump. Basically I'm going to make it through rounds then escape The Private Hospital as soon as humanly possible. 

October 15: Tuesday

4:01 am: My last day waking up at 4 am! Wahoo!

9:07 am: I bailed as soon as rounds were over and my notes were finished. I had to refrain myself from running through the lobby and out the door. The moment I walked through the door to my apartment I threw off my scrubs and it felt like ripping off a layer of unhappiness.

So content right now. Studying while relaxed and cozy at my favorite Midwest bagel shop, savoring lox and cream cheese on a toasty warm everything bagel and a pumpkin coffee before heading off to Tuesday lectures. Even while rapidly approaching a notoriously challenging surgery exam I feel my body relaxing.

1:05 pm: At Tuesday lectures, sitting next to Magnus as usual. We're so happy surgery is over.  

Jade, an incredibly sweet and fun fellow third year, came up to me during our lectures and asked me to share the following story: Jade's lifelong best friend is getting married on a Friday night during our upcoming family medicine rotation. On that rotation we have lectures all day on Fridays instead of Tuesdays. Jade requested to be excused early from Friday lectures and offered to make up the coursework. The family medicine clerkship director replied, "Why did you decide to go to medical school if you just want to be in weddings?" Jade repeated the quote several times to make sure I had it written down correctly. She looked shell shocked while she was talking to me, about to either cry or laugh at the absurdity of the response the clerkship director had given her.

I was stunned that the knee jerk response by the department was to question her dedication to the medical profession. We give everything to be here. After all we’ve been through. How are we supposed to be caring and empathic towards our patients when we’re not allowed to be that way in our own lives? Talk about a recipe for bitterness. Funerals are considered valid excuses for missing work but I believe weddings should be too. Living people matter in this world; it’s too late for the dead ones.

2:35 pm: A student tried answering a question but did not use the proper medical terminology so the surgeon condescendingly sneered, "You need to answer my questions using grown-up doctor words." Oh fuck off. It’s taking all my energy and concentration not to roll my eyes. Two more hours then no more surgeons in my life for a long while.

11:36 pm: The best thing about getting into bed tonight was changing my alarm from four am to half past seven. Even after two straight months of waking up at four am I never became a morning person. And every painful morning I would swear that I was going to go to bed early but I never did. I should probably go to bed soon but I'm lost in my thoughts at the moment.

October 16: Wednesday

9:23 am: Spending an uneventful day at the med school studying with Magnus for the surgery exam. We vented about our respective chiefs for a bit then got to work.

Um, I was emailed a request to talk to my surgery clerkship director... I’ll be back…

30 minutes later….

During the impromptu meeting with the clerkship director I was directly asked if Gump primarily worked with the male students. I didn’t verbalize anything but cautiously nodded my head, ‘yes’.  She cocked her head and replied, "Ok, that's what I thought." I'm not sure of the details but I was then informed that Gump will NOT doing my surgery evaluation! How did this happen?!? Even better, my review is now going to be left in the capable hands of Dr. Mastermind and one of the other senior residents. I feel a weight has been lifted!

I thanked her and exuberantly went on my way. If I do well enough on the exam I'll be eligible for high pass or honors, which provides renewed motivation to study.

October 17: Thursday

7:30 am: Dreams of Casey all night. They were different scenes but revolved around seeing Casey either with another woman, or alone and him refusing to talk to me or even look at me. The scenes played over and over, once at a beach, once at his apartment, once at a restaurant, over and over again. I no longer existed to him. I woke up dejected, lonely, and sad. Sometimes I wonder why my brain likes to torture me.

There are many things about the rotation that I value and that I will miss. On the contrary, there were many aspects of the rotation that I can't wait to leave behind. I really enjoy the pace and efficiency of surgeons. I did not enjoy that I didn't get enough face time with my patients. During the last couple of days I had no patients to say goodbye to. In terms of independence, from now on I will try to figure out two or three solutions to a problem before asking for help. And I have a new understanding of and appreciation for being efficient. As one resident confided, “they don’t pay us more to work harder.” And in terms of being paid, considering how many hours surgery residents work, they make less than minimum wage if you do the math.

October 18: Friday

Oh sweet relief. Sitting at the airport, back at the same little wine shop, sipping on the wine bar's current flight of white wines. I feel the tension melting away. The exam was rough, don't get me wrong, but it's over. I hope I did well enough to get honors but there is nothing I can do about it now. It’s done. Over.

As I sit here sipping on my wine

Something interrupted me mid sentence while writing the above sentence and for the life of me I can't remember what on earth I was going to share. I think I'm a little brain fried from surgery.

Time to board the plane for NY. Time to see my family.

End of Chapter 4

My medical memoir, Love, Sanity, or Medical School, will be available soon on Amazon and other eBook platforms!

Chapter 3: Thoracic Surgery

Love, Sanity, or Medical School

Chapter 3: Thoracic Surgery

August 26: Monday

5:45 am: There was no one on the road driving in. I meet my team at 6 am. It's weird being at the hospital before Starbucks opens. I'm nervous.

It’s so disorienting to start on a new rotation.

Four weeks of thoracic surgery here at The General Hospital. Thoracic surgery involves operations on the lungs and esophagus. All I know is that those surgeries typically involve removing segments of those body parts due to the presence of cancer.

7:30 am: We had a two-minute orientation informing us that we’re not supposed to work more than 28 hours in a row or more than 80 hours in a week. We were told to never make evening plans because we may end up working late and then we'll be pissed. Plan on working until nine o'clock every night and that way if we get off at six o'clock we'll be happy. Ok…

7:39 pm: I survived my first day, a solid twelve hours. Quite the change from outpatient medicine. I scrubbed into two cases! As the medical student, my role is to read ahead about the surgeries I will be attending. I’m to know the anatomy, indications for the procedure, complications, and related whatnot. While in the OR I watch the operation and if it’s appropriate, I close part or all of the incision or do other small tasks during the operation while the attending supervises and points out anatomy or diseased tissue. The attending is in charge and the resident is “first assist”, aka, the main helper. I would love to first assist because just watching an operation gets a little boring but unfortunately the surgery residents always get priority.

I was in a spit fistula revision post esophagectomy and as well as a tracheostomy. I learned that bleeding tissue is not always bad, because at least that means there is good blood flow to the area. And, unlike zombie movies, dead tissue cannot come back to life. Simple. Logical. I like this surgery thing.

The nurses are really helpful here. In addition to being kind, they thoughtfully taught me about the magic of swabbing a bit of peppermint oil on your surgical mask before beginning a smelly surgery. Oh, and I like when they play music in then OR.

It's 9:15pm and I'm in bed.  My alarm is set for 4:45 am. I'm forcing myself to stop writing and study a bit before I go to bed.

August 27: Tuesday

7: 25 am: It's amazing how differently surgery wants their patients presented during morning rounds. The entire presentation takes about one minute and notes are written ASAP. We see every single patient from 6-7 am, have a quick breakfast if there is time, and then we're off to OR at 7:30 am. My surgery team is as small as my medicine team was and we have just as many patients. We round so much faster yet get the same amount of work accomplished as compared to medicine rounds. Everything seems so much more efficient. Maybe I should be a surgeon.

A patient in the surgical ICU keeps yelling, "Ice cream! Ice cream! Ice cream!" Well sir, I would like some ice cream too but you don't hear me making a fuss.

10:35 am: Every physician has one body part that they can't stand. I have yet to meet a doc without an aversion to at least one type of injury or illness. Popular dreaded subjects include eyeballs, feet, poor dentition and hand injuries. Mine is mucus, or in laymen terms: boogers. I gag and nearly vomit whenever I see snot. I already knew this but apparently I did not know the extent of my disgust. Today I learned that my new least favorite thing in the world to do is remove nasogastric tubes. I will not go into detail because I will get nauseous again.

11:15 am: My surgery intern hates eyeballs.

2:05 pm: Today is our first day of surgery lectures. One of the surgeons, Dr. Mastermind, someone we have never met before, starts posing questions. He then looks at us, and starts calling on us by name to answer! Apparently he memorized all of our names and faces from a face sheet so that he could look us in the eye and call on us the first day. Oh my.

A student is fumbling to answer one of Dr. Mastermind’s questions. After a moment Dr. Mastermind deadpans, "It's ok to make up answers, just say it with confidence."

Dr. Mastermind is teaching us the secrets of surgery. He just quipped, "When in doubt, take it out." I'm already a big fan of this surgeon. Turns out he works at The Private Hospital, where I’ll be rotating next for general surgery.

5:15 pm: Another 13 hour day.

The walls of the operating rooms are tiled a light blue, with the carefully arranged surgical equipment lying on sterile blue towels. The surgical lights reflecting off of the tiles and the array of metal tools gives the room a blue tint. I feel as if I’m underwater when in the OR. Swimming or drowning though? All the surgeons and nurses are gowned and gloved so that only their eyes are visible, making them appear to be in SCUBA gear.

The speed and efficiency of surgeons is daunting and impressive. The threat, no, not threat… the… the concern of seeing Casey throughout the day is annoying though. I feel like I'm on his turf.

9:23 and off to bed. Alarm set for 4:15 am.

August 28: Wednesday

4:55 am: The only people at the hospital are night float teams and third year medical students.

In just over two days I have already done more than I did on internal medicine. I’ve scrubbed into several surgeries, made calls, returned pages, given orders, removed chest tubes, done procedures, written progress notes, and other random stuff. My intern walks me through procedures or tells me what he wants done and then trusts that I will do it. I am actually being helpful to him and to the team (I think). Very refreshing.

6:03 am: A pale, frail, older female patient is wandering the halls of her floor. Her flowing, floor length white dress with flowing sleeves makes her look like a ghost… I wonder if anyone else has seen her.

8:56 am: Post rounding. I’m at the thoracic surgery clinic today with the impressive Dr. Thorax. Most of the patients are here because they have new or suspected cancers. The physicians who are able to work in oncology amaze me.

10:58 am: One of my patients is a not-old-enough guy who has two separate cancers. Neither is curable without major surgery but to resect both would likely leave him without the ability to ever again speak or eat. His family asked the Dr. Thorax what she would do if it were her. An interesting discussing ensued about the complexity of the operations, the likelihood of complications, and the chance that he would have an acceptable quality of life at the end of it all. He hasn't made a final decision but his initial thought was to take the pain medications we offered, not have either surgery, and live out the rest of his days enjoying time with his family. I think I'd do the same if I were him.

August 29: Thursday

4:55 am: It feels like I've been here for more than three day because so much happens each 11-15 hour day.

I never noticed before but the staff elevators announce each floor in English and Spanish.  The patient elevators are only in English. Strange, no?

Today I learned that my inside white coat pocket comfortably fits an entire bagel. Score.

Yesterday evening was Casey's last night here before leaving on vacation. By the time I get home tonight he will be gone and he won't return until September 10. When he returns it's finally time for him to pack up and move out of my apartment. I'm gearing up for a rough couple of weeks. At least I'll have my new roommate Zooey to distract me. She arrives on the 15th!

There is all of one patient in the clinic today. His lung collapsed a couple of days ago so he is here for a check up. It’s not very common for a lung to spontaneously collapse in a young person but when it happens the patient is typically a really tall skinny male.

20 minutes later: Wow he is a personification of my textbook description of spontaneous pneumothorax in young males: tall and skinny. He was very sweet and shy too.

August 30: Friday

It is such a relief to not have to see Casey all throughout the day. All the surgery teams changed today. My new team consists of the senior resident called Jolly Green Giant, JGG for short, the surgery intern, and the surgery PA. Everyone seems happy to teach and let me be involved. I already know JGG well because of Casey. I don't know the intern yet but he is rumored to be kind, smart, and helpful. On a similar note, I have heard that the surgery PAs are amazing. All in all I seem to have lucked out with my team.

Allegedly there is a "mystery bug" at a nearby hospital that has closed their operating rooms until next Wednesday! Creepy. Every single operation had to be rescheduled. I can't imagine how bad of a bug it must be to cause the cancellation of five days worth of operations.

After finishing up at the surgery clinic this afternoon I got lost walking back to the main hospital. In the midst of my confusion I stumbled upon Dr. Neuro, sitting on a bench and eating a red jolly rancher. We chatted for a bit, discussing my surgery rotation and surgeons in general. Casey was brought up, followed by how poorly I may have done on my medicine final exam because I was so scattered in the aftermath of our break up. This led to me almost breaking down crying on this random little bench somewhere on the hospital grounds. Our conversation basically turned into an impromptu therapy session. Dr. Neuro is such a calming person to be around but I was caught so off guard while talking to him. Out of necessity, I've been keeping fairly solid walls around me at work but he marched right through them. It’s slowly dawning on me that I've been so busy I haven't really been processing all the change going on in my life. I'm really looking forward to having this weekend off to recoup.

I worked from about 5 am to 5 pm each day this week and totaled about 60 hours total for my first week on surgery. Wahoo I just found out I don't have to come in on Monday because it's Labor Day and there are no surgeries scheduled. A three-day weekend!

August 31:Saturday

I think it's time to start changing out the photos in the apartment.

September 1: Sunday

11:05 am: Welcome to September.

I had a list of things to do yesterday. Clean my apartment, go food shopping, print out new photos, etc. Instead, I met up with my friend Callie at her apartment’s pool. We ran into a group of girls from our class and our quiet day catching up turned into an impromptu pool party.

The fun continued bar hopping downtown that evening. One of the many fun things about hanging out with Callie is that she knows everybody and she is an excellent wingman. My evening ended with a handsome blonde ortho resident getting my number and texting me goodnight. Woke up today in a super messy apartment with no food in the fridge but hung over, tan, and happy.

4:59 pm: With newly printed photos of a friends and family, I began the task of changing out all the happy photos of Casey and I. The first photo I took down was an adorable shot from when we saw Arcade Fire in Chicago a couple of years ago. The rush of tears came on so suddenly and forcefully that my hands were shaking and I nearly dropped the frame as I pulled the photo out. I pushed on. One by one I removed all the photos from our travels throughout the world over the past six years and 11 months. Memories from dozens of cities and events spread over three continents were placed gently in a neat little pile. The oldest photo I came across was a strip of black and white photo booth pictures from when we first met in Chicago. In the sequence we're smiling, then kissing, then looking at each other and laughing. We looked so happy. I was all of 22 and he was 25 years old.

Next came down the stuff on the fridge. It had been covered with save the date cards, wedding invites, and baby announcements from all of our friends that met, fell in love, got married, and started having babies. Because that is the normal way things happen.  Most people don't just date forever.

Lastly, I replaced a piece of artwork I had painted for him last Christmas called Fenomeno, by Remedios Varo, with another of my own recently completed paintings. It's a full-scale replica of Picasso's Las Meninas that I fell in love with when I saw it in Barcelona. And now I'm done. I can't handle anything else today. 

Fenomeno Replica, Acrylic on Canvas

Las Meninas Replica, Acrylic on Canvas

8:37 pm: To cheer myself up I signed up for an online dating service. Why not? I don't think I'm ready to start dating but it would be a nice ego boost to get some attention online.

September 2: Monday

Labor Day. Upon moving into the apartment three years ago Casey painted the master bedroom green. Twenty minutes ago I finished repainting it a smoky blue.

September 3: Tuesday

5:15am: Love wearing scrubs to work. Hate not seeing my friends because I work all the time. And today starts my first 24-hour call day.

5:30 am: Unfortunately the new patient on the census is the young man from clinic last week. Uh oh. His lung collapsed again over the weekend and this time the surgeons ended up resecting part of his lung. Now he's once again got chest tubes and lines in him.

7:30 am: Wow the music in the OR today is screaming heavy metal. I was not expecting that from the iPod of my super efficient soft spoken attending Dr. Thorax. In my humble third year medical student opinion, it's waaaaaaaaay too early in the morning for all this yelling!

Normally I would not be chilling in the OR typing away on my iPad but the current OR patient is undergoing a lung lavage. The patient has a lung disorder called Protein Alveolar Proteinosis, where their lungs essentially collect a lot of crap, making it difficult to breath. For the procedure the docs repeatedly fill one of the lungs with water and then drain it, over and over again, to help clear out all the material that has accumulated. The process is then repeated on the other side. The result is in almost immediate relief of the majority of symptoms once the patient is woken up. Fifty liters of fluid will be used today and the process takes about six hours. It's pretty strange to think about the treatment objectively, though. The docs are essentially drowning the patient repeatedly. So here I am, sitting and studying (and occasionally typing) for a couple of hours. I wish I had a fleece though; it's freezing in the OR in just scrubs.

Several hours later: I’m an ice cube now.

Hmm. Just passed Maverick in the hallway outside the surgery department and had a three second conversation. Awkward. Not him- me. He’s an emergency medicine resident, a stereotypical outdoorsy climbing type who always looks mildly mischievous underneath his curly brown hair. We met nearly two years ago while volunteering for a medical school event and I always get stupidly flustered around him. Our conversation back then was nothing earth shattering but something about his personality appealed to me, and I remember very vividly thinking, “if I were single, I would totally go for this guy." The thought immediately struck me as odd because I never had any interest in cheating on Casey. Maybe in the back of my mind I already knew that Casey and I were in a dead end relationship? I wonder if Maverick is single now? Maybe Callie will know as she always has the best resident gossip. The Boss would probably know too, but I bet she’d kill me if I dated one of her residents. I guess there’s no point in finding out though, I’m not ready to date yet anyway.

Terrifying Tuesday lecture. The surgeon is telling us about a shooting trend that happened a couple of years ago. A guy would call 911 and report that a man had been shot. The thing is- no one had actually been shot yet. The caller would proceed to wait, with a victim bound at his feet, until he heard the sirens of the approaching ambulance. Upon hearing the sirens the caller would then shoot his victim in the back of their neck, thus severing their spinal cord, and then bolt. The purpose of waiting to shoot was so that the EMTs would arrive soon enough to save the victim's life. Instead of dying, the victim would forever be paralyzed from the neck down. My stomach is churning.

Welcome to 10:06 pm. Nothing too crazy so far.

10:50 pm: A senior surgery resident comes wandering over and reports, "there is a burn patient with over 90% burns covering his body. He is getting his dressings changed at 11 o'clock. You should go and watch."

11:45: I don't even know how to describe what I just saw. I had never seen a burn patient before. I walked in and surveyed the patient as the nursing team organized the materials for his dressing change. His arms and legs are covered in white bandages that are soaked through with blood and seepage. The toes on his left foot poked out of the bandage, unscathed and healthy pink. His right foot does not exist anymore. His belly is covered in a white sheet that is taut and stapled to his abdomen. His face is wrapped in white gauze. A severe burn causes the skin to contract, which constricts the blood vessels and compromises blood flow. Body parts die without blood. To ensure adequate blood flow it's sometimes necessary to make incisions in the skin to relieve the pressure. Big, long strokes are needed wherever these contractures take place. Escharotomy is the word. At his hips, shoulders, and peeking out from the bandages on his extremities, you can see where the surgeons have intentionally split his flesh. Along the escharotomy incisions lines of yellow shiny fat and blood vessels strain to escape the confines of his dead grey-brown skin. The sheet over his belly is covering a bag that contains his intestines, which spilled out after the escharotomies on his abdomen.

I put myself in a position where I could be called upon to help if the nursing team needed an extra hand with the dressings. As horrific as this was, I wanted to help. It was the least I could do. I looked behind me to locate the nearest chair in case I felt faint. As the final preparations with his new set of dressings were finished being laid out I asked the simple question, "what happened?"

The nurses began unwrapping his many layers of gauze and shared that he ran into his a burning house to look for trapped occupants. Upon stepping into the house a “flashover” engulfed him in flames. According to Wikipedia (my source for all things in med school), a flashover can reach over 930°F. His buddy was able to force the door open and pull him out mere seconds later. In those few moments he sustained burns to essentially his entire body. And now here he lies in the burn unit. A moment after the story was finished I was asked to help hold his leg while he was turned on his side. It was heavy and warm. As I was holding his leg I couldn't help but think that his body already resembled the skin of the cadavers we dissected earlier in medical school.

I don't have a lot of experience with nurses but the care they took in changing his dressings was amazing. I don't think I could ever do that on a daily basis. They are the kind of people I would want caring for my own family members.

When I asked about his prognosis a nurse whispered to me that they hoped his family would chose to revoke life support.

12:16 am: So now here I am, in my bitty little call room that looks like an ancient college dormitory (or a prison cell, depending on the angle). My roommate for the evening, one of my classmates, got right into bed and seemed to fall asleep easily. Not me. I had to process what I just saw. My hope for him is that he is well sedated and feels loved and is honored for having his last conscious moments on this earth spent trying to save the lives of others.

4:30 am: I hate my alarm clock. And waking up in a call room is weird.

5:38 am: I already prerounded on my patient so just rounds and then home hopefully by 8 am. I'm excited to go home and sleep in my own bed for a bit- away from the cancers, the traumas, and the burns at the hospital.

September 4: Wednesday

4:20 pm: Slept in and then spent the rest of the day working on my apartment, cleansing the rooms from Casey’s presence. I didn't move apartments but I want it to feel and look as if I did.

September 5: Thursday

11:07 am: How is it Thursday already? I'm so confused with these days. So much gets accomplished every day that it feels as if I've been on surgery for weeks already, not eight days.

The tall thin young man may be discharged today. Hopefully no more pneumothoraces for him.

September 6: Friday

5: 02 am: Woke up in a weird mood, I think I was dreaming about Casey last night. Happily, I will be in the OR all day. Like literally ALL day- there are big surgeries today.  Need to get my game face on and not look mopey!

3:18 pm: I scrubbed into an esophagectomy today on an older gentleman named Professor Z. Basically the operation is exactly what it sounds like: they take out the esophagus and essentially connect the mouth directly to the stomach. It's amazing to watch surgeons open people up, rearrange their insides, then put the person back together.

4:50 pm: JGG is planning to go out of town tonight and he is practically jumping out of his skin to get out of here. We just had an unexpected pneumothorax and an ED consult. Just as our clerkship director warned us: don't make plans for 5 pm. 

The surgery intern and I bonded today. He was too busy for lunch so I shared the peanut butter crackers that are always stashed in one of my fifty white coat pockets. While munching away he confided in me that he doesn't like the days when JGG is trying to run out the door because he doesn't feel confident enough yet to be left solo. I could see his frustration and underlying concern about being here alone if something bad happens to a patient. I wonder if seven years as a surgery resident will morph him from being a super nice guy into someone cynical and bitter. I hope not.

 September 7: Saturday

10:49 am: I love sleeping in and waking up feeling refreshed. I’ve been getting emails from the online dating site and one caught my eye. Tall, fair, blue-eyed resident name Dr. Spengler. Seems great on paper. I emailed him back.

September 8: Sunday

10:45 pm: First night in my new bed. When Casey when moves out he’ll be taking our bed with him so I had to order a new bed for the master bedroom. My room. I’m sitting with my iPad right now, but it’s not the same as writing on paper. I miss my journal. And writing with the knowledge that someone someday may read my words changes how I put them down. I am trying to be clearer and more deliberate with what I write as opposed to my usual stream of consciousness ramblings. Time for sleep.

11:15 pm: Sigh. I’m still struggling and having trouble sleeping. I can’t think about Casey yet because I still get angry and sad and lonely. Other than work, studying, and redoing the apartment, I am attempting to meet new people. There was the one from the canoe trip and the ortho resident, neither of which I followed up with even though both have been texting. Either could be a fun rebound but I don’t know. I’m not ready. I really have to go to sleep. My alarm is set for 4:30 am. Ugh.

September 9: Monday

11:24 am: Professor Z seems to be doing well post esophagectomy. His kind nature and good spirits are already well known and appreciated amongst the surgery team. Walking into his room today I was greeted by an array of stunning, brightly colored bouquets. One bouquet contains a variety of bright orange flowers (my favorite color), another features red roses, and a trough shaped vase near the window is filled with blue and purple flowers that are accented by a couple of peacock feathers. Apparently I'm not the only one who enjoys his company; he seems to have quite a few admirers.

3:12 pm: During a free moment I slipped into a daydream about the summer I worked at a beach in California. The warm weather, the sunshine, sand between my toes, the cold surf… Ring ring... ring ring.  I was jolted from my reverie when my pager began wailing and I had to discuss getting a wound vac placed on a difficult patient that developed a purulent, malodorous, nasty, boomerang-sized infection on her back. Surgery is really good at ruining nice daydreams. Back to work.

4:06 pm: I'm sitting awkwardly close to a fourth year medical student who just asked for feedback from a senior resident. The resident coldly replied, "you are very smart, you have a lot of book knowledge, but you need to work on your common sense. You need to learn to think and organize your brain before words come out of your mouth." Oh wow. There was more to that conversation, but not much. I pretty much just typed what I heard verbatim. Surgeons certainly don’t mince words.

September 10: Tuesday

6:14 am: Casey returns today. He will be back in my apartment by the time I get home from work. 

I walked down the hallway a minute or so after a gunshot wound victim was wheeled from the emergency department to the OR. The patient was bleeding so profusely that the hallway where the patient rolled through had a vibrant trail of blood down it and the air had a metallic smell.

Omg my internal medicine exam grade is in. I’m freaking out. We can ask for our grade through email but I'm going to go check in person because if I failed I don't want to start crying in the middle of the surgical intensive care unit.

30 minutes later...

Ok so not only did I pass but I scored high enough to qualify for high pass or honors. The secretary at the internal medicine office, Ms. CV, must have sensed my relief and shock because she looked at me quizzically and then asked me if I was ok. My incredibly logical response to her query was to start crying. What is wrong with me? I swear I'm not a crier. She gave me a hug and we chatted while I calmed down. We sat for nearly twenty minutes and discussed life and love while I ate a pack of Smarties from the stash that is always at her desk. Ms. CV was so sweet; she told me about when she was young and naive and dating the wrong guy.  She realized he was the wrong man but carrying out the decision to leave him was a terrible experience for her. But, she added, she then met then right man. She and her husband are about to celebrate 34 years of happy matrimony together. It's amazing how someone taking a couple minutes out his or her busy day to sit and chat with you can cheer you up.

3:28 pm: Tuesday lectures. My favorite quote so far today was from a pediatric surgeon who implored, "You should be passionately connected to the care of your patient."

3:45 pm: Magnus must be bored because he keeps texting random memes.

September 11: Wednesday

6:11 am: At what point does it transition from being called break-up sex to just having sex with someone you used to date?

8:10 am: I have a rare peaceful hour and a half before I have to be anywhere so I’m relaxing on the front steps to the medical school, enjoying the sunshine. I immensely dislike being indoors in windowless underwater operating rooms all day. At least I get to do my surgery rotation in the fall. The winter students rotating will arrive before the sun is up and leave after it is down every single day. Can you imagine only seeing sunlight on weekends?

Today is September 11th. There are a lot of people hurting today and I feel their pain.  Most of the day I will avoid watching television because 9/11 coverage still makes my heart ache. I was 17 years old, sitting in 3rd period math class when an announcement came over the loudspeaker that a plane had struck the World Trade Center. I had a moment of panic, knowing that my father worked mere steps from the Twin Towers. My teacher rambled on about numbers to a progressively uninterested room of students until the bell signaled the end of class.

My fourth period American History teacher brought my class to the library where increasing numbers of students were convening to watch the coverage live. I sat in a daze on the open winding staircase between the first and second floors of the library, unsure what was going on. We silently watched the news unfold, with a collective gasp and cry when the first tower fell, sick with knowing that some of our family members were inside. I couldn’t reach my dad but was able to get in touch with my mom. She informed me that my dad was okay but then revealed how his phone had gone dead mid sentence as the first tower collapsed, her overly calm and measured voice betraying an underlying strain and rising anxiety.

The school tried to corral all the students on school grounds but my friends and I snuck out a side door and drove home. I paced my bedroom, journaled, and called every family member I could think of to see if they had heard anything else from my dad. I felt rage for the first time that day, the event inciting anger and hatred towards those responsible. I also felt fear, but mostly I was experiencing an overriding sense of helplessness. I had no skills, no ability to help, and no power to do anything useful. After pacing tracks into my carpet for nearly eight hours, my father finally turned up safe and sound at our house on Long Island.

These days on 9/11 I cry not only out of sadness but also out of fear. My parents, my sister and her husband, and now my newborn baby nephews, all live blocks from each other in midtown Manhattan. The rest of my family, including all of my aunts, uncles, and cousins, live in the major cites of Washington, D.C. and Boston. Terrorist attacks and other catastrophes are out of my control so I try very hard not to dwell on them. I'm usually pretty good but sometimes it's hard. I've had nightmares about being inside a collapsing building; seeing the walls shake and debris start falling. I wake up crying and won't be able to shake the post-nightmare haze until I hear my momma's voice. So yes, today will be spent avoiding television. I've been a bit fragile when it comes to triggering the waterworks these days and breaking down about 9/11 while I'm at work sounds awful and embarrassing. I will do a quiet, private reflection and remembrance when I get home later tonight.

8:45 am: The unmistakable sound of bagpipes playing Amazing Grace started filling the air. I spot a 9/11 memorial going on atop the building across the street. There are people lined up on the roof, removing their hats and placing their hands over their hearts. Just lost it. I'm outside the medical school building crying. So much for waiting until later for a private moment.

9:26 am: Back inside the College of Medicine I went to the bookstore to get a snack after washing my face in the bathroom. One of the internal medicine residents with whom I'd become friendly saw me and without a pause commented, "hi, oh, you look tired." I simply replied, "oh yes, I'm on surgery." No other explanation needed. In reply I got an encouraging, "hang in there, it gets better!" And then she wandered off. Yes, I am tired and my beautiful green eyes are not looking their best at this moment. My eyes have bags under them from staying up too late having sex with my ex boyfriend and that fine tint of red and swelling is due to sitting outside crying about 9/11 less than an hour ago. Stating that I looked tired just because I'm on surgery seemed easier- and unquestionable.

It really has been a quiet morning, I'm not used to this on surgery. I've already written so much today and it's only 9:48 am. For having not done much other than round and make phone calls this day already feels too long.

In a surprising turn of events, there were more residents than patients at Dr. Thorax’s clinic. This means my only job is to take out about a billion staples from an esophagectomy patient whom I had followed during my first week on service. It's nice to chat with him and his wife and to see that he is doing so well after such an intense surgery.

September 12: Thursday

6:48 am: I enjoy starting off my days visiting… um…. I mean prerounding, with Professor Z. He is always in good spirits. Each day his voice gets stronger and he gets more and more chatty.

9:18 am: After rounds each morning we visit preop patients that are being operated on that day. There is only one patient today. She is an elderly lady named Primadonna who is having a suspicious looking nodule in her lung removed. This may unfortunately turn out to be cancer. Here she is, lying in her preop bed, gowned and ready to go for surgery, awaiting a possible diagnosis of lung cancer, and she is sitting and puffing away on an e-cigarette. Talk about addiction. I wanted to take a photo of this woman. She held onto that e-cigarette until the nurses started wheeling her out of the room to go to the OR, at which time she reluctantly handed it off to her daughter.

1:15 pm: I’m about to leave Dr. Thorax’s clinic. There was another third year medical student at clinic today too. I examined, presented, and wrote notes on six patients this morning. The other medical student saw one patient. One. What on each was he doing all morning?

8:14 pm: Still been emailing back and forth with Dr. Spengler. I think we may actually go out on a date soon.

September 13: Friday

While prerounding on Professor Z today I learned that he has recently retired after being a professor for over 40 years. We talked about his job, life in the hospital, and recovery after illness. He does not like being out of control of what is happening to him. Completely understandable. He is most looking forward to a shower and the Starbucks coffee that his friend is bringing him later this afternoon. Now that he is retired he has decided to focus on his writing. He was joking about his hair being messy from not showering but he supposes that this new look is apropos to his burgeoning career as a writer. I'm thrilled he is doing so well but will be sad when he leaves the hospital.

September 14: Saturday


September 15: Sunday

5:13 am: Zooey moved in yesterday and I’m yet again on call so I won’t have a chance to help her get settled. The hospital is creepily quiet at 5 am on Sunday mornings.

6:02 am:  There is a pleasantly demented man in the surgery intensive care unit (SICU) who constantly calls for his nurse. I keep hearing, "Nurse! Nurse! Nurse!" Then pause and repeat. He isn't exactly yelling; his voice has an operatic quality and he bellows the word as if it’s an aria being performed at the Met. He is closely tended to in the SICU and is not in any distress or pain- he just keeps singing whenever his nurse leaves the room.  Apparently he was like that all last night too. In the most complementary and respectful way possible, I will call him Operaman.

I prerounded on e-cigarette smoking Primadonna and let me tell you, she is the most miserable and nasty patient I have met so far this year. She let me know how bothersome it is to have nurses and physicians checking in on her. Lots of F bombs and degrading comments that always start with, "You people..."  I'm pretty sure she believes we are trying to torture her. She is mad that she is coughing shit up but after chain smoking for 45 years it’s really not that surprising but somehow it's our fault. Her lack of insight and empathy is pretty profound.

12:00: I've been here six and a half hours and the Operaman is still going at it. "Nurse...nurse.... Nurse."

2:45 pm: Still yelling. It’s been busy today but not too busy, and the SICU is calm at the moment. I'm gonna go chat with Operaman.

3:45 pm: What a nice guy. First I asked Operaman about his pain. He informed me that no, he wasn't in any pain and that his nurse is wonderful. He told me about where he was from, and what he did for a living and such. He has a lot of children and has lost track of how many grandchildren and great grandchildren he's got at this point. He kept looking at me and repeating, "thank you for coming in, it gets awful lonesome in here."

6:00 pm: 13 hours down, 13 hours to go...

7:50: Operaman was at it again so I sat with him for a bit and we discussed football and watched the Denver- Giants game. I told him I needed to go study but I promised to come back and visit later. He promised not to yell in the interim. 

... 5 minutes later he started yelling again. As part of his dementia I'm guessing he probably has a pretty poor concept of time.

9:20 pm: I just sat with Operaman a few more minutes. He wanted to hold my hand while we chatted. He asked me if I could stay and be his doctor, which was very sweet. 

September 16: Monday


September 17: Tuesday

1:36 pm: Tuesday lectures. I spent four hours in a surgery this morning. Surrounding the operating table was the intern, the senior resident, the attending, the scrub nurse, and a pulmonology fellow. That is a lot of people doing very delicate work in a very small space. Dr. Thorax was nice enough to let me scrub in but I was nowhere near the table… I was nowhere near the table for four hours. I basically was starting at the back of JGG’s scrubs trying to not break the sterile field. Of those four hours, I spent about 2.5 hours thinking about what I want to wear on my date with Spengler tomorrow night. It's my first first date in forever. I’m guessing it’s like riding a bike. From an academic standpoint, I learned that I am capable of falling asleep standing up. 

1:43 pm: Tuesday lectures. Trauma lectures have the best images. Apparently not every student in the room is looking at the gory images from the PowerPoint because the surgeon is currently screaming at my classmates, "Make sure you look at that picture... Look at it!!!" These surgeons are way too intense for me. Relax man. Take a deep breath.

2:15 pm: A calmer surgeon is now lecturing. He is stressing the importance of asking the right questions in order to reach a diagnosis. Apparently 80% of diagnoses can be made by history alone. Interesting.

3:01 pm: The third out of four lectures just started. I am so painfully tired today. I slept all day yesterday because I was post call, and then couldn’t sleep last night.

4: 05 pm: My favorite surgeon, Dr. Mastermind, is lecturing again today and offering some gems of advice. He avers, “Whenever there are two way to do things, that means neither one is perfect." And, "Sometimes surgery doesn't work out perfectly, but as long as you do the right thing, it's ok."

September 18: Wednesday

I can't help but feel mildly insulted when the JGG is surprised that an exam finding I report to him is actually present. Today he remarked, "oh look, there really is a small air leak with cough on Ms. Primadonna's chest tube." I swear I don't make things up. I really do arrive at five in fucking morning every single day to preround on my patients.

The highlight of rounding today was when I was pimped and randomly knew about takotsubo cardiomyopathy, which led to Dr. Thorax calling me "one of the smart ones." I won’t tell her I learned about it from watching Scrubs.

My new roommate Zooey texted me, "I haven't seen you in a couple of days, everything ok?" Yep, I responded, just been practically living at the hospital. Zooey seems so sweet; I wish I had time to get to know her better.

On the flip side, I can't believe Casey hasn't moved out yet. Ostensibly, there are some delays in finishing the new apartment into which he is moving. I still like having him around so I haven't really been forcing him out the door either. I know I can't really move on until he leaves though. What's worse is now that Zooey moved in Casey and I are both sleeping in the master bedroom. Great planning, right?

I’m exhausted. Been falling asleep in grand rounds and lectures all day. Going to rush home soon and change for my date. Fortunately Casey is on call tonight so I don't have to awkwardly leave my own apartment wearing a skirt and heels on a Wednesday night.

11 pm: Great date, must sleep now.

September 19: Thursday

5:15 am: How is it already September 19th?  Last time I checked it was the end of August. I caved and went to work today for the first time ever with zero make up on. I needed five extra minutes of sleep. I feel like true third year medical student now.

7:20 am: I would like to write about my date last night with Dr. Spengler but I must focus on prepping for my presentation on Barrett’s Esophagus that I am giving tomorrow night.

8:25 am: I'm back at Dr. Thorax’s clinic for the last time.

Today was the first time I've cried with a patient. I requested to see this particular patient because I had worked with him two weeks earlier in the clinic. Upon entering the room I see an anxious looking patient with red eyes sitting on the exam table. I ask if he is ok, (which by now you know is the easiest way to make someone cry), and they burst out sobbing. I sat with the patient for awhile and they told me that their child died yesterday. The patient was sobbing and crying out for their child. I was stunned and shocked and had nothing to offer my patient in terms of words of solace or comfort. What on earth could you possibly say to a parent who lost a child not a day earlier?  I just sat there, held his hand, and cried too. The patient was so distraught that he didn't think to cancel or reschedule his appointment. After I informed Dr. Thorax of the situation she too went and sat with him for a bit.

1:08 pm: Upon getting ready to leave Dr. Thorax thanked me for my help, told me I'm good at surgery, her door is always open, and that I should come speak with her before the end of the rotation. Success.

7:30 pm: Home from work, ate a quick dinner, and now it’s time to put together my presentation for tomorrow. My goal is to be done by midnight. That gives me 4 hours of sleep... again. Can people die from exhaustion?

September 20: Friday

5:30am: Today should be my last day on service but since I'm on call technically my last day will be tomorrow. I can't believe I've survived half of my surgery rotation already. I'm absolutely wiped. I stayed up all night writing and editing my Barrett's Esophagus presentation. I haven't gotten much sleep any night this week. Once again I’m too tired to put on makeup. I’m not talking about a lot here- a little under eye concealer, a swipe of Urban Decay Sin eye shadow primer potion, a thin line of bright eyeliner and some mascara- all in all about three minutes of my morning. It’s not much but it makes me feel a little more human to spend three out of the 1440 minutes in my day focusing on myself.

7:00 am: My presentation just got pushed back because Dr. Thorax isn't here today. I don't mind at all though I wish I had known last night because I'm going into a 28 hour call day already running on fumes.

1:05 pm: I now have a random free hour (because I no longer have to be practicing my presentation) so I'm sitting with my pumpkin spice latte and catching up on emails and paperwork. I was just pleasantly surprised by several emails. One was from Ms. CV, the secretary from internal medicine, letting me know that she was thinking about me and asking how I was doing. The others were filled with adorable photos of my chubby baby nephews. This afternoon turned out so lovely! Too bad I can't leave the hospital for at least another 17 hours.

A couple of minutes to talk about my date with Dr. Spengler: instant relief upon seeing as he actually looked his photo, cute, super sweet and nerdy, chatty, and tall. Throughout the date I sat there obsessively thinking, “oh wow, I can’t believe I’m on a first date with someone’” and wondering if people would look at us and think, “oh, they're on a first date.” He’s the perfect guy my mom would have picked out for me. Weird weird weird to be on a first date! We totally hit it off and had a great time. He didn't kiss me goodnight. Pussy.

I ran into another medical student and he immediately commented, "you looked tired, you must be on surgery." I give up. I will wake up three minutes earlier in the morning and resume doing my makeup. I made it a whole two days without makeup. As an aside, please don’t ever see someone and tell them they look tired. Seriously. Just stop.

4:00 pm: My day is getting better and better- patients are all calm and stable so I can take a nap. It is blissfully quiet and cool in the call room... Zzz...

5:15pm: Hands down the best nap I have EVER taken. I feel mildly human again.

I can’t believe this part of the rotation is almost over! Way more my speed than medicine ever was. I did a ton of suturing and stapling, improved my surgical skills, and took the chance to get my hands dirty as much as possible. I love doing procedures, even if I miss the patient care. The surgeons were welcoming and encouraging, if not a little high-strung at times.

September 21: Saturday

4:10 pm: The rest of call wasn't very busy or exciting. I got to scrub in on an appendectomy and then was in my call room bed by 1 am. Unfortunately I couldn't leave til 9:30 am after rounding this morning. So that made for a 31 hour shift, clocking in at a grand total of 96 hours this week. Wait, I thought I'm not allowed to work over 80 hours a week? Don't worry, apparently as long as my weekly totals for the month average under 80 hours then the occasional 96'er is kosher. Fucking loopholes.

Next up, off the The Private Hospital for general surgery.  All I've heard about rotating there is that the hours are worse.

End of Chapter 3

Chapter 2: Outpatient Internal Medicine

Love, Sanity, or Medical School

Chapter 2: Outpatient Internal Medicine

July 29: Monday

7:10 am: I will not cry today. I am sitting at the Starbucks at The General Hospital and I will not cry. So far so good but it's only 7:15am. Off to my first morning at the internal medicine outpatient clinic... Remember, no crying.

7:50 am: There are two other medical students present when I arrive at my first assigned clinic site. A nurse is showing us out schedule for the day- our first patients will be arriving in 10 minutes. Ok... Turns out this is the student clinic where we are expected to see our own patients, take a patient history, do a physical exam, then develop an assessment and plan. Just like grown up doctors. This is all well and good, I just had no idea I would be having my own patients right now this second.

9:15 am: I took my worst history ever. Probably a combination of being caught off guard with this situation of walking into a student-run clinic, having my own patients, it's Monday morning, and I'm still distracted from everything that happened this weekend with Casey. Oy. Sad. No no no not going to cry. Not here, not now. This patient's history was made particularly difficult because the patient recently had a stroke and his residual deficit is memory impairment.

Me: "Sir, how long have you had diabetes?"

Patient: "I have no idea."

Me: "Ok, what happened when you had your stroke?"

Patient: "I don't remember."

Me: "Do you take all of your medications every day?"

Patient: " Yes."

Me: " You take every one of your medications every single day?"

Patient: "Well..."

Suffice it to say that the visit did not improve from there.

4:30 pm: I used to live in Chicago and I loved it there.  I moved there on a whim after graduating from college. If not for Casey I never would have left Chicago and I’m aching to go back there at the moment.

6:15 pm: I'm about to leave for dinner with The Boss, my trusted advisor and confidante.  When I first moved to my little Midwest city I desperately wanted a job at The General Hospital to increase my chances of being accepted there as a medical student. Casey searched around the hospital and found out that The Boss, one of the most senior physicians in the emergency department at The General Hospital, was thinking about taking on a student to help her with a new research project. I emailed her out of the blue and basically wrote, "Hi, my name is Silvia, you don’t know me but you want me to work for you." She wrote back the next day something like, "I have no idea who you are, but I'm intrigued." Shortly thereafter I began working for her. We quickly developed a productive and trusting working relationship.  She became my premed advisor, helping me navigate the application process, prepping me for my interviews, and even writing one of my recommendation letters. Once accepted into medical school she became my academic advisor. Years later, our working relationship has grown into a friendship as well. Upon hearing of the breakup with Casey she immediately offered to take me out for dinner and drinks (aka get me super drunk). So, off I go to dine and drink with The Boss.

Midnight: I'm a couple of beers and martinis deep right now. The Boss and I talked for hours, and she informed me that when I am ready to date again that I will have no problem meeting new men. Her explanation was, "It will be just like Zappos, you will have an array of options and you will pick the one you want." I told her that mostly I am very, very sad but a part of me is a little angry. I offered that if she wanted to, she could be a little mean to Casey when she runs into him at the hospital. In a professional way, of course.

July 30: Tuesday

10:30 am: I have no clinical responsibilities today, just afternoon lectures, so I spent the morning moving my stuff into the guest bedroom. My outpatient medicine schedule is very light compared to inpatient medicine. I work two half days at the student clinic, three half days at Far Away Clinic, and one half day in a cardiology clinic.

I feel like a life I had been planning for years just died.

July 31: Wednesday

7:30 am: I'm ok until someone asks me if I'm ok. Back to the student clinic, then this afternoon I'm working at Far Away Clinic, a fair distance from my little Midwest city.  I'm not sure what my responsibilities will be this afternoon.

9:43 am:  It turns out that patients frequently do not show up to their appointments at the student clinic.  I have yet to see any patients today.

10:15 am: When I'm upset I lose my appetite. Everything tastes like cardboard. When I went through Hurricane Katrina during my senior year in college I lost almost 20 pounds in just a few weeks. Fortunately it was right after I studied art abroad for a year and most of those 20 pounds were souvenirs from when I studied abroad in Rome and Paris.  Stories from college are for another time, perhaps another book.

6:15 pm: I didn't sit down the entire afternoon at the Far Away Clinic and I barely had time to write my notes. I really enjoyed the pace as well as Dr. Pearl, the physician with whom I worked. Dr. Pearl would send me into the patient's room to do an H&P, after which I would present the patient to her and then offer my ideas for what we should do.   She would then step into the room for a few moments to greet the patient and clarify anything that was unclear. I was immediately trusted to see patients and give my opinion on their care. This is a first on this rotation! Dr. Pearl apologized for all the running around but I loved it. She doesn't know I spent a lot of my days on inpatient internal medicine sitting and studying.

One of my patients this afternoon was a tall, dark and handsome man who arrived in his manly uniform. There he was, sprawled out on the exam table, nearly naked in just red and blue striped briefs. He was too tall for the table and his legs dangled off quite a ways.  He was lying on his side, head propped up on his hand as if posing for the annual Midwest uniformed man calendar. Unfortunately, his whole body was colonized with MRSA, which left him covered in painful abscesses. Being so big and tough, he didn't come in until the lesions were huge and he could barely get dressed. Some medical terms I used in my note on him: indurated, fluctuant, erythematous, purulent, malodorous. He was lying on his side because that was the only comfortable position for him. And why was he naked? So that we could drain the larger abscesses on his hips and thighs. Not so sexy. Sorry. At least I’m learning proper medical terminology.

August 1: Thursday

8:45:  Waiting for my computer class on using electronic medical records (EMR) to start. Tonight will be my first time seeing Casey since our breakup last Saturday evening.  We… wait, no… now it's "I", I need to take myself off the shared cell phone family plan we're on. The car and renter's insurance needs to be separated. He'll be moving out soon and I'm going to need to move on with my life. Not easy. Not fun. I thought he was going to be my husband and the father of my children. Time to delete the Pinterest wedding I had planned.

10:34 am: Finally done with their EMR training, but the computer system is down so after all that I cannot get a clinic badge anyway.

12:45: Back up in Far Away Clinic.

It's very different working for a physician that does not trust you. The doc I am working with today is a young Indian man named Dr. Gupta. Just like yesterday, I would go into the room, report back to him and then he would go in. However unlike Dr. Pearl, Dr. Gupta would then proceed to re-ask every question I had already covered. Patients must get annoyed answering the same questions repeatedly. At least it annoys me because it means he either wasn't listening to me, didn't care what I said, or didn't trust what I said. Every single patient. Not every physician will operate in the way that I, the third year med student, wants them to. Oh well.

Dr. Gupta is lacking a bit in the interpersonal skills arena. For example, a new patient arrives at the office to establish care. She has ripped shoulders and arms, is dressed in workout gear and running shoes, and I'm guessing she will leave the office and head straight to the gym. While getting a history from her Dr. Gupta queries, "do you ever work out?" Um, really? He couldn't be like, "oh, I'm guessing you're a runner?" Or something equally appropriate? The patient and I exchanged glances and then she politely responded, "Yes, I do work out." There were several moments like that with other patients throughout the afternoon.

August 2: Friday

7 am: I miss my family. I need a hug from my momma. My sister Olivia is due to go into labor with her twin boys at any minutes. I wish I could be in NY right now.

11:15 am: Interesting patients today at Far Away Clinic.

Noon: I have a new appreciation of the word hypochondriac. One of the patients this morning was an attractive young woman with a multitude of concerns. She ended up getting four referrals, all at her insistence, and we addressed several other problems unrelated to the referrals as well. I was told that with some patients it's easier to give in and let them have whatever referrals they want. Not sure how I feel about that.

2:13pm: I’m getting antsy, I can't take it anymore, I have to get out of this city.

5:10 pm: I’m trying my best to not sit around wishing that I had never left Chicago.  I loved it there so much. Professionally I'm in a great place. I love my school and my friends, I'm going to be a doctor, and I know that I can leave this shitty little city in less than two years. That's gonna have to be enough for right now.

August 3: Saturday

4:24 pm: Almost finished the Winnie the Pooh painting for my sister.

August 4: Sunday

I really need to be studying but I'm still so distracted. It is weird to think of myself as single after all these years. One of my friends asked me if I would be willing to date a guy who has kids. Huh? I don't know, I hadn't really thought about it. Yes? No? I have no idea.

Noon: I will be an auntie exactly 24 hours from right now!!! Olivia’s soon-to-arrive twins have no idea how much they have already helped brighten my life this past week. Every time I have felt sad this week I imagine her and my little nephews. I can't help but smile and think that one day, with the right guy, I will know that happiness too. Is it possible to have tears of pure joy and abject sorrow at the same exact moment? Let’s not find out right this moment though as I’m sitting at my neighborhood and it would be really awkward if I started crying right now… I have to stop writing for a moment.

Interesting article for those so inclined: there’s a NY Times opinion piece from August 3, 2013 entitled 'the Trauma of Being Alive' by Dr. Mark Epstein, in which he mentions the Kubler-Ross stages of grief. In thinking about my breakup I can see how the stages apply. I think I spent the last year in denial about my relationship being over. I am starting to feel a little angry, but mostly I am still just sad. I don't know how bargaining will play into this, and I certainly am not at acceptance yet. I have a lot of experience with grief and trauma but I am already emotionally wrecked about Casey so I won't torture myself or depress my audience any further right now with thoughts of those other haunting experiences... Stop. Redirect. Babies. Think about my sister's babies and how I will have a photo of them tomorrow. Focus on the happy stuff. See, I'm already smiling.

August 5: Monday

12:30 pm:  I'm struggling with how much to include here because I set out to record my experiences as a third year medical student, not to share the details my love life.  Well, here goes nothing. Casey and I had sex last night. Our evening started off innocently enough but he hasn't moved out yet so I knew I was in a high-risk situation. I couldn't remember the last time he had seemed so interested or passionate. I cried afterwards.

I keep trying to blame myself for our relationship falling apart. I think if I weren't so stressed with school the past two years and so focused on us getting engaged than maybe we would've kept the fun lightheartedness that we had always been present. But I remind myself, if he had proposed a year and a half ago then maybe I wouldn't have gotten so down and serious in the first place. I don't understand what went wrong, or what wasn't right enough for him. We had a really happy relationship. He treated me so wonderfully- he was affectionate, cooked for me almost nightly, and routinely helped me study in med school. But, after seven years he still wasn't 100% certain that I was "the one." I couldn't give him any more years of my life. I had to end it. I need to stop; dwelling on this will only make me mopey and weepy again. I just wish I knew what it was about me that wasn't good enough for him.

1:00 pm: As I sit here feeling depressed and eating my Greek salad I am also checking my phone every two minutes, awaiting updates from New York on the progress of Olivia’s delivery. At this very moment she is in a hospital in Manhattan getting an epidural. Babies will appear soon. Within an hour, perhaps?

2:34 pm: I am creating tracks in my carpeting from all my pacing back and forth. Olivia went down to preop about 20 minutes ago, and her hubby Alejandro was called down to meet her in the OR a minute ago- here we go!!!

3:04 pm: Olivia’s cesarean should be almost done, right? The babies should be out by now and her Ob-gyn should be stitching her up. I just want to see their bitty faces and give them kisses and thank them for helping me through week.

3:08: Two healthy, beautiful baby boys have arrived! Welcome to the world my little nephews Jackson and Henry! They are, in a word, perfect. Momma, now known as grandma, sent me adorable photos. Olivia, now known as mommy, and her babies are doing well.

PS: Yes, I saw patients today at the student clinic. No, I don't really remember what happened.

August 6: Tuesday

8 am: Another day with no patient care. Outpatient internal medicine is not what I expected. At least we have a clinical skills lab today.

My friends and family seemed surprised and impressed when I tell them that I told Casey it was time for him to move out. Everyone guessed that I would be the one to move out. As I had explained to Casey, I was the one who already did everything. I left my beloved Chicago for him, I worked my ass off to get into the only medical school in this little Midwest City, and I spent every day of the past year and a half trying to figure out how to make our relationship work. I'm done being the one to do things. So, Casey is the one moving out. He didn't argue, he agreed. His move out date is about three weeks from now. Maybe once he moves out we'll stop having sex? Oh, and for the first time in seven years he left a hickie on my neck. I feel like such a teenager.

11:18 am: The cow eyeballs squished a bit when cutting into them. Slimy little buggers are slippery! A few almost went shooting off the exam table at our clinical skills lab. While learning about performing eye exams we were treated to some pretty horrific images of human eyeballs in various stages of injury and infection. I like procedures. I have a break until afternoon lectures, I should go study...

1 hour later: I did not go study. I talked to my sister and to my mom. And somehow Casey and I are going out tonight for dinner. A non-date, if you will. I guess it's better than ending our relationship with fighting? We're just really bad at not being together. I wonder who will pay the check.

After Casey and I broke up I tried reaching out to my girls first but everyone was out of town because we all had the weekend off. I then called Magnus, who picked me up within 15 minutes of me telling him that Casey and I had broken up. He brought me to his apartment, invited over a bunch of friends, and we spent the day drinking beer and watching classic dumb comedies such as Dogma. At some point he apologized for not being good with "girl stuff" but he added that he has plenty of beer for me, and beer is almost as good as girlfriends in these situations. I agreed. The following day I spent with my Piper, Sophia, Jane, Maggie and Daria, who were also incredible. My friends showered me with love, hugs and support. It's not that I'm surprised by how amazing my friends are, but they have gone above and beyond to take care of me. Truly incredible.

I love my friends.

August 7: Wednesday

6:53 am: There were blasts and bombs going off all over. I was with my cousin Violet. It was the day of her October 19th wedding and her hair was already done. We needed to get out of the area because we were in danger. Firefighters directed us towards safety. There were blocks and blocks of debris piled high for a far as you could see. We had to climb over the piles because there were no longer any clear roads to walk on. The piles were made of blasted building bits and body parts. Blown off limbs now detached from bleeding and hurting people crying out for us to help them. But we couldn't stop to help because it wasn't safe to stop. The smell of burning flesh and smoke was in the air. Four missiles zoomed overhead so we ran into a building for cover. We could feel the heat of the blast. I thought the building was on fire and that we would burn to death inside of it.   The fear choked me. Back outside, we again began climbing over the piles of bodies. A woman reached out her hand for us to help her but the firefighters yelled at us to keep moving. I tried to apologize to her for not helping but I was rushed along too quickly. We reached a staircase and started climbing. Violet yells, "no, I can't do it anymore."  I support her back and push her forward as we are climbing. She faints backwards onto me. I wake up screaming.

Noon: There was only one patient for me to see in the student clinic. I was hoping for a busy day to pull me out of my post-nightmare haze.

I spent my afternoon at Far Away Clinic with Dr. Pearl. Her patients absolutely love her. It's inspiring to see a physician happy and relaxed yet working efficiently.

As much as I love my two-bedroom two-bathroom apartment, I cannot afford to live here by myself. I'm starting my roommate search by posting my apartment on a website called Rotating Room. It's designed for students working in healthcare that rotate at different hospitals and need a place to stay for only a month or two at a time. This seems like the easiest and fastest way to get a new roommate.

August 8: Thursday

I shipped the Winnie the Pooh painting I made for my new baby nephews. A relaxing morning so far, and then off to Far Away Clinic for an afternoon with Dr. Gupta.

Some days every patient seems to have the same complaint; everyone will have a cold, or back pain or whatever. Not today. I saw a spider bite that resulted in a systemic rash, a rare condition called HHT complicated by blood clots, and a post op visit.

One of my patients is here with an infected looking spider bite and I have horrific arachnophobia. Fear paralyzes me whenever I see a spider, but I still have to know about arachnid attacks. For this particular patient one of the nurses spent a solid hour googling various spiders on her giant flat screen computer monitor. Of course her screen faces my workstation so I had to crouch down behind my own screen to avoid seeing the myriad of tarantulas, wolf spiders, brown recluses and other little horrors. Occasionally she would exclaim, "Oh that's so gross! Look how hairy! It's so big! All those eyes!" My heart is racing and my skin is crawling. I keep telling myself to take deep breaths and not look so visibly freaked out. It’s unprofessional.

I walk into the room of another patient and notice that his face and ears are speckled with large blood vessels called telangiectasia. He has a rare bleeding disorder called HHT. I forgot what it stands for... Hereditary hema... Something. Basically, it's a vascular disease with related bleeding and clotting issues. He presents with leg pain that is very concerning for a blood clot in his leg. We sent him for an emergency ultrasound of his leg and several hours later got very bad news: he leg was full of clots from his ankle to his mid thigh. Blood clots in the thigh are dangerous- a little bit can break off and go to the lungs, causing a pulmonary embolism. Typically you can give blood thinners to people with clots. But, giving blood thinners to someone like him would likely cause potentially fatal bleeding. Kind of a catch-22: treat the blood clots and risk him to bleeding to death; don't treat the blood clot and he will likely get a fatal pulmonary embolism. What to do?

HHT is an autosomal dominant hereditary disorder. One side of his entire family is affected.  While HHT is not fatal in and of itself, it puts you at major risk for bleeding out from minor trauma. There is variable penetrance, so some family members get it worse than others- and there is no way to tell how bad it will be for a particular person. The first sign tends to be recurrent epistaxis... aka lots of nosebleeds. His children have recently begun to have nosebleeds. His story makes me wonder- with a dominant and potential deadly genetic disease, I don't know if I'd willingly have children. I say that as someone who may be a carrier of a 100% fatal recessive disease. 

August 9: Friday

Countdown to the weekend.

8:40 am: Two nurses are working today. Let's call them GN and BN for Good Nurse and Bad Nurse, respectively. BN was sitting at her desk picking her nose. GN was calling patients with lab results while BN made a personal call. Not that I'm against personal calls, I couldn't care less, but BN came across as pretty lazy while GN was working. 

8:55am: GN says, "BN, why haven't you gone through your pile of papers yet?" GN points to stack of papers next to BN- a pile of lab results and other things that need follow up. "Wait, what? Why didn't you tell me earlier that I had work to do?" BN rolls her eyes and audibly sighs before she stops picking her nose and starts to go through her paperwork.

Another afternoon with the young Dr. Gupta. He still repeats every question I ask. Today one patient replied to a questions with, "I already told your med student... " To which he countered, "Yes I know, she told me." Awkward.

11:30am: Omg BN is sitting at her station assaulting my ears with her singing. I can't.

Off to the cardiology clinic. I still don't have a badge.

Today was a special day at the cardiology clinic.  It started off with Dr. Heart, a world-renowned cardiologist, offering that I could work with her for the afternoon. Very, very exciting. And intimidating. Her patients were equally interesting.

One of her patients today was a 100-year-old man, named 100, who had come in for a check up. Although he had no complaints, Dr. Heart completed a thorough physical exam.  This is going to sound so nerdy but she was so impressive to watch! Using the tips of her fingers and her palm she was able to feel a subtle murmur, determine not only that the heart was enlarged but specifically which chamber of the heart was enlarged, and figure out that he was in the early stages of heart failure. She explained findings to me as she went and tried to have me copy her maneuvers so that I too could reach the same conclusions. I don't think I have ever felt more inadequate as a medical student. To confirm her suspicions she decided that 100 needed an EKG. Of course all of her suspicions were spot on.  Damn she's good.

August 10: Saturday

I spent my day cabrewing with a bunch of my classmates and other random people. For those unacquainted with cabrewing, it is basically canoeing while drinking a lot of beer. I am mostly sober now and need to get some sleep. It was great to get out of the little Midwest City and do something different. I also met a lot of people. A super cute blue-eyed guy name K Canoe got my number. I'm not interested in him, or anyone at the moment, but I thoroughly enjoyed that a tall and handsome stranger was flirting with me. Flirting and all that is still novel to me at this point in my breakup recovery. Too bad I didn't meet him a month or two from now when I'll hopefully be ready to start dating again.

August 11: Sunday

10:30 am: I was on Skype with Olivia and the babies when the Winnie the Pooh painting arrived. She loved it and was so excited!

1:24 pm: Blehh studying. If I studied as much as I painted and journaled I think I would be a phenomenal student. Every move I make hurts as I am sore and covered in bruises from all the times my canoe flipped over onto me yesterday.

Casey and I ended up going to a super fancy dinner together last night.  At least we didn't sleep together afterwards. Progress?

Off to get my hair done. I need a new look- it’s time to go from being a bland brunette to a fiery redhead!

August 12: Monday

11:15 am: We had eight patients scheduled for the clinic today... three showed up. Each student got to see one of them. At least I was done by 11 am. My one patient had stitches on the back of her head, left behind by the trauma team. No, I did not call a trauma consult to ask their permission before I removed them.

It's weird to give nurses orders. Even weirder when they do what I request without question. I've read that some women tend to have a harder time commanding others to do things. Turns out I'm one of those women. Maybe it's because I don't feel like I know enough yet, coupled with the fact that I'm giving orders to people much older than me and more established in their careers. I guess I’ll just have to get comfortable doing it.

Off to go study. For real this time- I am running out of time to procrastinate. At the end of each rotation we must take a final exam. These exams are nationwide and the scores end up in our residency application so they are high stakes. The exam is in less than two weeks now!

August 13: Tuesday

Studied all morning. Go me. Off to Super Tuesday afternoon lectures.

My first lecture was great, but we're halfway through the second lecture and the new lecturer is monotonously reading her slides of black text on a plain white background. My mind is starting to wander, not to anywhere specific though. I'm thinking about my upcoming test, my amazing new auburn hair color, dinner with Casey, my classmates, starting my surgery rotation, and wondering how badly I'll be suffering from lack of sleep... Basically I’m thinking about everything except my current lecture. I wonder if and how I'll manage to write during my surgery rotation. I guess just try to at least jot down a few thoughts each day and go back and expand on them as I have time.

Glancing around the room, everyone seems pretty spacey. A lot of students are typing on their iPads and laptops... I'm guessing they're "taking notes" just like I am right now.  Magnus is sitting next to me on his iPad, alternating between Facebook and researching players for his fantasy football team. Ok her lecture should be ending soon. My classmates are squirming in their seats.

Our lecture has already run a couple minutes over.  The professor just said, "you guys seem to get it, I could probably leave right now... But I'll go ahead and go through the next two cases anyway." I swear- she just said that word for word. The crew is getting restless. There may be a mutiny soon... I am trying to keep a neutral, pleasant looking face. Magnus is sitting next to me practically jumping out of his seat. I like good lectures.  I don't like lectures without any new information and that don't have pictures and run long.  Oh look the next lecturer just poked his head in and gave the current lecturer 'a look'. Message received- she just wrapped up. Finally.

Now this is a lecture: clinical decision making tailored for new third year medical students using a common disease as an example but easily applicable to other medical conditions. Words of wisdom from this lecture: Use evidenced based medicine but never betray your gut.

I have no cell phone service in the lecture hall. As soon as I walked out of the classroom my phone beeped with a text from K Canoe, the guy I met cabrewing on Saturday. I was kind of hoping he wouldn't contact me because I feel bad ignoring him but I'm definitely not ready to date yet as it’s I’ve only been single for two weeks.

August 14: Wednesday

At the student clinic once again. My patient is a soft spoken and kind young man who has a genetic condition causing high blood pressure, diabetes, and severe heart failure. Clearly embarrassed, he revealed to me that he couldn’t afford all of his prescriptions. We sat with the attending and went through every single prescription, picking out the most important ones.

Another patient I recently saw has atrial fibrillation, a pacemaker, and is in decompensated heart failure. That patient cannot afford his medications either, but it’s because he keeps spending his money on cigarettes and cocaine.

Sometimes I wonder how to impress upon people that they must take care of their bodies.

6:30 pm: Casey told me he found an apartment. I guess that's a good thing. Back to studying.

August 15: Thursday

1:56 pm: Studied all morning, and now I'm back up at Far Away Clinic. We just saw a soldier in army fatigues with a mysterious rash. Seriously, we have no idea what it is or where it came from. I have yet to figure out which rashes and skin conditions can be examined without wearing gloves. Dr. Gupta was running his hands over the little bumps covering the soldier's body. I guess he figured it wasn't contagious. I'm going to stick with gloves for now...  always. Just to be safe. Dermatology is apparently not for me.

2:05 pm: I'm in between patients waiting for my 2:15 pm to arrive. When I look at the patient census for the day all I see is a chief complaint. For my 2:15, the chief complaint is "butt pain." I have all sorts of ideas as to what could be causing that particular chief complaint. Of course my mind immediately imagines a guy limping in, looking incredibly embarrassed and refusing to sit down while a faint buzzing sound hums in the distance. I don't really imagine that being a Thursday afternoon kind of chief complaint though. That is probably something more likely to show up in the emergency department on a weekend. I'm guessing it will be something way less entertaining. 

2:16 pm: He's still not here so I began thinking about the rise in ED visits related to women getting Ben Wa balls "stuck" in them and needing removal after 50 Shades of Grey was released.

The 2:15 walked in limping but it is most likely sciatica not a true "butt pain". Oh well. I think Dr. Gupta is also secretly a little disappointed at the anticlimactic visit. Our patient however found the situation entertaining as he kept saying, "I have a pain in my butt, haha".  No sir, you have hip pain that shoots down your leg. Let’s not exaggerate and get the medical staff really interested for nothing.

My brain is a bit friend from studying. I'm in a bad mood about Casey finding an apartment. I’m not doing well today.

August 16: Friday

An email popped up a moment ago that someone in New Orleans is interested in my apartment. I'm about to call her. Hopefully it works out.

An hour later:  After a phone call, some emails, and a price negotiation, looks like Zooey will be my new roomie. She is speech therapy student doing a three-month rotation at The General Hospital, from September 13th to December 10th. The timing will be interesting. She will basically be moving into my guest bedroom as Casey is moving out of the master bedroom and while I'm moving my stuff from the guest room into the master bedroom. I'll be on surgery until November so I don't even know if I’ll see her that much. Who knows? This year is already very different than I thought it would be.

August 17: Saturday

This time next week I'll be in NY visiting my baby nephews. I am so beyond exited.

August 18: Sunday

10:00 am: Woke up in Casey's bed. Oops, how'd that happen…

August 19: Monday

At the student clinic I have to walk past the pediatric exam rooms to get to the medical student office. In the hallway is a Winnie the Pooh height chart and every morning I see it I smile and think of my baby nephews.

One of my patients gave my attending a completely different history than the one she had given me. Now I look like an ass. Thanks.

3:15pm: Zooey and I have a Skype appointment at 4:00 pm. She sound fun and bubbly- I am very excited to meet her. Maybe she'll be my new BFF.

5:01 pm: I don't think Casey realizes that he still calls me ‘honey’ when he’s trying to get my attention.

August 20: Tuesday

Studied outside on my deck all morning.  Sunshine felt wonderful and brightened my mood.

I'm not sure how prepared I actually am for this shelf exam.  Best go back to studying. 

After I finished studying around 10 pm I sat down with a suture kit and practiced tying knots for two hours. I am getting really psyched for surgery.

August 21: Wednesday

6:44 am: Last day of outpatient medicine! Last day of my internal medicine rotation!  Finally.

8:05 am: Omg it's so grossly hot in the student clinic today. Neither myself nor the two other med students are interested in medicine and we're all thrilled that internal medicine is nearly over. Before the fellow arrived, we started the morning wishing that none of the patients would show up.

Done seeing patients. I can leave here forever once I get my final feedback. Then off to Far Away Clinic for my last afternoon with Dr. Pearl.

Fun afternoon at Far Away Clinic:

My first patient is a big, badass biker here for his annual physical exam. He is sitting there in an itty-bitty paper gown, covered in tattoos and sporting a black bandanna covered with skulls on his shaved head. Even the toughest among us need medical care. My favorite part of the encounter was when Dr. Pearl and I informed him that he was due for a vaccine. He gaped at her wide eyed and whined, "but Dr. Pearl you know I hate needles!" It was adorable to see this big beast of a man showing trepidation about getting an injection.

A lady in her early seventies came in for an annual physical. She had been traveling for the past two-week with her hubby and some friends and they all went hiking, biking and did other outdoorsy activities. In the next week or so she will be off to Europe for a couple of weeks. It was so refreshing to see such a healthy and fit woman in her 70's. This patient was followed by a lady of the same age who could barely walk from years of metabolic disease and various other illnesses. It was so striking to see them back to back. It makes me think I need to start working out. I know I usually eat well but I'm really scrawny right now. I could use some muscle. These women really have me thinking about health maintenance right now.

A young woman came into the office for an annual physical and I am really jealous of her. She recently returned from a several week around-the-world trip, next week she is moving to an awesome city to start a new job, and she looks like a Barbie doll. Seriously.  Not fair. I hope she realizes how lucky she is. I know absolutely nothing else about her, but I am judging her entire life on those three things because I am jealous of all of them at this moment.

My last patient is a chatty and jovial woman who is a couple of years older than me. Her blood pressure normalized after being high for some time and she no longer needs any blood pressure medication. Turns out her blood pressure dropped once she finally divorced her husband and stopped dealing with the stress of being in a bad relationship. She told me about the years of stress and anxiety that came with trying to make a relationship work that wasn't right. Now she is finally relaxed. She talked about starting over in her early thirties with a hopefulness and positivity that I have yet to find. I wanted to thank her, to tell her that she gave me hope for happiness in my own future, but I just listened and congratulated her on her improving health. I find it entertaining when patients share their stories with me but I have yet to figure out if and when it’s ever ok to share any snippets of my own story with them.

I've really enjoyed the wide variety of patients I've gotten to see at the Far Away Clinic.  Young, old, black, white, healthy, sick, rich, poor and from all walks of life. I'll have to keep that in mind when choosing where I want to do residency.

August 22: Thursday

7:30 am: Study study study.

The library is blissfully quiet right now but freezing. I'm completely incapable of studying at coffee shops or anywhere there are people walking by or when there is any noise. I have major difficulty sitting still and studying for extended periods of time. On the opposite end of the spectrum, I could paint for hours without realizing any time has passed. And, of course, I can sit and journal pretty much anywhere without noticing any chaos going on around me.

7:30 pm: Back in the privacy of my apartment. In the past, my home was more of a clothing- optional type of place. Being proactive, I instituted a clothing-mandatory rule about a week ago to decrease the likelihood that Casey and I have sex again. It seemed logical to me that the more clothes we are wearing the less likely they are to come off. However, Casey is ignoring my rule. Right now he is wandering around the kitchen without a shirt on and with scrub pants barely covering anything. How can I be expected to concentrate on studying with him wandering around all tan and half naked? It's asking too much from me. Oh well. I tried.

9:39 pm: Final push. I have one more section to review and then I quit.  If I haven't learned it by now it's not happening.

August 23: Friday

6:30 am:  Walking out of my apt this morning the sky was dusky blue and a few stars were still twinkling. It had been raining all night and the humidity in the air was drenching, creating a foggy aura. The crickets and whatever other bugs sounded a large chorus. It was like being in the blue lagoon at pirates of the Caribbean in Disneyland.  I headed off to my morning exam this morning humming, "Yo ho, yo ho, a pirates life for me."

Post exam:  That exam was terrible. Everyone walking out looks completely shell shocked.  I have three weeks until I get my score. One of my hardworking and studious friends just came up to me and told me she thinks she failed. At least I'm not alone?

2:34 pm:  At the moment I am sitting at the new wine bar at the nearest airport. My flight to NY leaves in about an hour. I'm sipping on a glass of Pinot Grigio hoping it will lessen the pounding stress headache I got from thinking about this morning. I would have been at the airport earlier but I got stuck behind some slow moving farm equipment on the highway. Welcome to the Midwest.

My feedback from Far Away Clinic was uniformly positive and I earned excellent clinical grades. The doctors collectively thought I did a solid job presenting my patients and coming up with a differential diagnoses for them. Dr. Pearl told me I should consider internal medicine as a career, which I take as an incredible compliment coming from her.

My feedback from the student clinic was not so great. The fellow informed me that I started out a little scattered, didn't seem very enthusiastic, and did not go above and beyond, though I improved a lot over the course of the month. It might be more accurate to say that I was barely functioning during my first day at the student clinic, which was not even 48 hours after Casey and I broke up. Overall she gave me average marks and I could not disagree with her assessment of me. At the same time, she cut me zero slack for not being on top of my game in my post-seven-year-relationship breakup state because we are expected to perform at our highest potential all the time, no matter what. I'm still learning how to turn my emotions off when I walk through the doors of the hospital. I'm not sure if I'll ever be able to do it.

Two years and two months of med school down, twenty months to go. Off to surgery.

End of Chapter 2

Chapter 1: Inpatient Internal Medicine

Love, Sanity, or Medical School

Chapter 1: Inpatient Internal Medicine

July 1st: Monday

1:00 pm: They just handed me a pager. Now what?

I’m sitting in a barren, windowless classroom tucked away on a top floor within The General Hospital, surrounded by a small group of newly minted third year medical students. It’s our very first day on the wards. We are waiting for the chief residents to collect us and distribute us to the various medicine teams.

“Welcome to third year!” a smiling Dean of Something Educational had boomed across the packed med school auditorium earlier this morning during orientation. I didn’t hear many remarks past those beginning words of her requisite welcome speech because I became distracted catching up with my friends. I returned last night from vacation with my long time boyfriend and have not yet seen anyone. Aside from all my friends looking expectantly at me to share news that I do not have to share, while not so subtly glancing at my left ring finger, it was wonderful to see everyone.

Immediately following the welcome lecture we were treated to a talk about not letting residents and attending physicians physically, emotionally, mentally, and/or sexually torture you. Apparently our med school has a poor track record when it comes to abuse of third years. Funny how they don’t highlight those stats in the admissions brochure. 

2:15 pm: Still waiting…

It’s very convenient that my blue iPad mini fits comfortably in the pocket of my short white laboratory coat. Using the app Notability, my goal is to record the entire year in real time as it unfolds around me. Medical student secretly turned gonzo journalist!

3:30 pm: Apparently the chiefs didn't know that we, every medical student in the entire College of Medicine, were starting today so we sat there until three pm. We tried calling them. We tried paging them. Nada. Finally, an attending physician randomly passing by came to our rescue and located the chiefs. They seemed pleasantly surprised to see us all patiently sitting there for hours.

FYI- All medical students and residents move up the medical totem pole by one rung on July 1st. Always. If you’re a patient, avoid teaching hospitals in July. We’re all new to our respective roles.

3:55 pm: I met my team (a fourth year medical student, an intern, and a senior resident) and then was dismissed. Everyone seemed welcoming.

July 2nd: Tuesday

7:01 am: I have no idea what I'm supposed to be doing.

8:15 am: My attending, the young Dr. Osler, immediately comes across as friendly and enthusiastic. We discussed my goals for the rotation. His focus is on improving my patient presentation skills and learning to come up with broad differentials for my patient’s problems. Sounds good. My goals are to not embarrass myself and to not cry if I get yelled at. My first impression is that he doesn’t seem like the type of attending who torments third years, though I guess I’ll find out soon enough.

I officially have my own patient! He is in the hospital for a ginormous (proper medical terminology right there) foot ulcer.  I would call him FU for foot ulcer, but let’s go with McLovin’ instead. 

Having my own patient pretty much means checking in with him each morning before the team arrives and catching up on any new labs or overnight developments in his care (aka pre-rounding). I’ll write notes on his progress each day while helping plan for his discharge. Waaaay better than being in the classroom. The crux of having a patient is rounding. Each medical student and resident takes turns presenting their patients to the rest of the team during rounds. We hop around the hospital, traveling room to room, until we have checked in on every patient on our list.  Rounds are nerve wracking because it is imperative to know every single detail about their labs and work up, and all of your decisions regarding their care are debated and nitpicked. If the attending finds your management of a patient to be unsatisfactory the consequences may range from an eye roll, to an audible sigh, to a verbal berating, to being locked in a dungeon without food or water until such a time where your attending believes you can once again be let loose on the wards.

12:59 pm: Every Tuesday afternoon all students on the internal medicine rotation have class together from one o’clock to five o’clock. In an effort to make these four hours of lecture more exciting the internal medicine people have coined these afternoons, “Super Tuesdays.” Sure. Whatever. There are a lot of stereotypes in medicine- internal medicine folks are known to be super nerdy. So far, so true. And unfortunately I can’t go home afterwards because I’m on call tonight. Being “on call” on the medicine service basically means an extra long day, so instead of leaving at five pm I’ll be here until about 10 pm.

July 3rd: Wednesday

8:43 am: People take bad news very differently. A patient on our service was told his fiancé gave him Hepatitis C and he nonchalantly commented, "oh well, I'm marrying her anyway so I guess that's that." When the fiancé found out that she may have contracted Hepatitis B from him in return, she was NOT happy. I thought she was going to punch him or break the engagement right then and there.

10:15 am: While on morning rounds we met a new patient named Mr. BH who was admitted by the overnight team. He is suffering and in excruciating pain from multiple medical problems and a broken hip. As the overnight intern started presenting Mr. BH to our team, Mr. BH began reaching out past the intern and signaling for me to come closer. I was at the end of the bed and Mr. BH persistently motioned for me to move nearer to him. The whole time he was moaning in agonizing pain and it was confusing because we couldn’t figure out what he wanted. When I finally got close enough he grabbed my hand and held it tightly. Turns out he needed some comfort and just wanted to hold my hand.  He gripped my hand tightly the entire time we were in his room. It was very sweet, and very sad.  Pulling my hand away so I could grab my stethoscope and do a physical exam felt a little heartless.

Happy Fourth of July: Thursday

8:20 pm: It's hard to watch people in pain. A professor taught us last year that patients should never be in pain, should never be short of breath, and should not die alone. This is a deceptively difficult task though. Give too many meds and they stop breathing, give too few and their pain is intolerable and they lie in bed moaning. My team is trying to balance controlling Mr. BH's pain without causing a deadly respiratory depression.

Noon: My day was brightened when I ran into my sigo Casey. We met nearly seven years ago on a random Tuesday at a dive bar in Chicago. It wasn’t exactly love at first sight but there was definitely some spark, some attraction, so we began dating. Dating casually grew into a relationship, falling in love, and moving in together.

1 pm: My team is constantly busy and I feel like I'm in the way or at least just not on their radar this afternoon. Patients are very sick and I don't know my role yet.

I’m keeping myself busy by reading and studying.

2pm: I tried to learn to draw blood but was told by the intern, "don't waste your time, you'll never do that, nurses will do that for you". Only thing is, I want to learn and I'm bored because I don't know what else I could be doing right now aside from studying.

July 5: Friday

3:32 pm: I updated McLovin’ and his family. I answered his questions and then discussed his progress and discharge plans. It feels better than simply being out of the classroom, it feels like I am finally learning to be a doctor. Wonderful!

10:18 pm: I finally managed to sneak in a dinner with Casey tonight. It’s been forever since we've seen each other, which is impressive considering we live together and work at the same hospital. As he is a general surgery resident, his schedule is even worse than mine. His muscular former-football-player frame is still tan from our recent trip to Central America. Even with the unseasonable amount of rain we still managed to get in some scuba diving and visit the breathtaking Tikal Mayan ruins. Most importantly, I was able to check another box off my bucket list: I swam with sharks! It was a phenomenal experience. My love of the ocean and my most recent bucket list is not relevant at the moment though; I need to get some sleep because I’m on call again tomorrow.

July 6: Saturday

11:00 am- 4.5 hours down, 10 hours to go. The problem with Saturday call is that you have to come in post-call on Sunday. This means that my first day off since starting third year will be next Saturday.

Turns out drawing blood is a clinical skill requirement for this rotation.

McLovin’ is doing well and is going home tonight so hopefully I'll get another patient, maybe even two. It's hard knowing that I am the weakest link and that I slow the team down but there's really nothing I can do other than keep learning and try to improve as quickly as possible. In these couple of days my presentation skills, with the help of my attending Dr. Osler, have improved a lot. However, I still suck at describing wounds using proper medical terminology.

Dr. Osler: “Silvia, how you would describe this man’s ulcer?”

Me: "Um..." And I’m thinking to myself, well it smells really foul and looks super gnarly, as if someone took an ice cream scoop and scooped out a portion of the man's heel leaving behind a bloody, smelly, pus-filled hole. Hmm, need to learn how to translate that into words a grown up doctor would utilize.

I was right about Dr. Osler though, he is not one to torture medical students. He gives detailed feedback and frequently checks in with me- and has not once threatened to throw me in the brig! So far, so good.

Noon: The family of Mr. BH, the one who held my hand, updated his advanced directives to solely comfort care. Everything will be done to manage his pain but nothing else- no other medical interventions, no CPR, no intubation, nothing. His family believes that his quality of life will never again be at a point that he will find acceptable or enjoyable. In order to effectively manage his pain we need to increase his meds. Any time we did that in the past few days he would go into respiratory depression and get drowsy and hard to awaken so we’d back off with the dosage. However, alleviating pain is the only goal now. We increased his pain meds once again… which means he'll likely go into respiratory depression again... which means he will die.

3:30 pm: I was assigned my second patient. She's in for an intentional drug overdose. I know very little about liver physiology but I'll be able to put my Master’s degree in psychology to use so she’ll be a good patient for me.

July 7: Sunday

8:58 am: Nope, no I take that back- she is no longer my patient. Turns out her psychoses and medical management are too far beyond my meager third year skills. It sucks to realize that my Master’s degree in psych is not useful at all; I had envisioned being successful with dual diagnosis patients but no, just like everything else, I have to learn from scratch. Instead, I now have a sweet young girl named Barbie with a nasty eye problem under my care. 

It's weird waiting for someone to die. A resident from another team was like, “so, has your guy Mr. BH died yet?" It wasn't asked in a disrespectful way either, merely run-of-the-mill resident lounge conversation.

For the first time, and this may not happen again for a while, the senior resident on my team conceded, "You were right about your patient." I asked if Barbie could have some Ativan for her anxiety.  He firmly replied no, that she doesn't need any because she is young and healthy and shouldn't be given benzos because they’re addictive and potential dangerous and blah blah blah. But then he went and saw her in person and decided yep, Barbie is indeed super anxious and would benefit from a little Ativan. A small victory for the med student!

Barbie has an eye infection and must have eye drops placed every 30 minutes for 48 hours. A nurse will go in her room and literally pry open her sleeping eyes every 30 minutes for two full days. Wow. The alternative is she risks vision loss from not treating her infection properly. Omg she is going to be a zombie from the lack of sleep!

Speaking of zombies, there is another patient on my team with a leg infection that reminds me of a zombie wound every time I see it. You know those zombies where it looks like strips of skin got peeled off and it’s all beefy red underneath? That is exactly what this woman’s leg looks like. Creepy.

July 8: Monday

11:48 am: Our board scores are released on Wednesday. If you fail the boards you are immediately pulled off rotations and are not allowed to continue with third year until you have a passing score. Yikes. While I don't think I failed I know I will be incredibly relieved to see a passing score... any passing score.

I picked up another patient today, a young woman named Ms. AI with a difficult to control autoimmune disease. I didn’t actually offer to pick her up- she was assigned to me. No one on the team wanted her because apparently she’s super bitchy and argumentative. Amazing how quickly patients develop reputations. Ms. AI is emaciated from a string of recent illnesses. My goals are to help her gain weight, get her strength back, and get her labs under control. I wonder if she could sense that I was distracted while I was talking to her. No offense to her but my brain is entirely consumed with thoughts of my board exams.

3:12 pm: I keep offering to my team to let me do things but they keep saying, “It’s ok, we’ve got this,” or, “thanks but no thanks.”

July 9: Tuesday

6:30 am: Uh oh. Apparently Ms. AI has been moved to Step Down, a more acute care wing of the hospital. That’s bad. She became unresponsive overnight and a rapid response (not quite a code blue like when your heart stops and you’re actively dying but still really bad and people are concerned that you might code) was called on her. Scary. She seemed fine when I left last night…

11 am: Surprisingly, Mr. BH is doing well. Sure, we amped up his pain meds and risked killing him (at his family’s request, of course) but he pulled through. He has even been moved to a bed on a less acute floor. I'm too new to know whether or not this is surprising. All I know is my team felt fairly certain that this guy was going to die a couple of nights ago.

11:55 am: Barbie’s eyes are doing well; it looks like she may be able to go home tomorrow. It’s too soon to know for certain but it doesn’t seem that there will be any residual visual deficits.

3:50 pm: Very interesting ‘Super Tuesday’ lecture today. Really- not sarcastic. Our discussion today is on death and dying. Upon walking into the classroom we were promptly asked, "How do you want to die?" We all responded with ideas such as: at home, without pain, quickly, surrounded by family. Then we discussed the brutality and futility of CPR and that only 6% of patients were living six months after coding and receiving CPR.  On TV, we were informed about 75% of people survive such ordeals. Yes, I am typing while sitting in lecture. Shh, don’t tell- it looks like I’m taking notes. Anyway, talk about false hope and unrealistic expectations! 

People with terminal diagnoses who have time to plan their deaths have a higher likelihood of dying at home and surrounded by family compared to sudden deaths. I wonder whether or not physicians also have a higher likelihood of dying at home because they know the poor outcomes that result from aggressive life prolonging treatment. Hand is going up…

My professor really liked the question and suggested that I do a research study on the topic. I nodded noncommitally. I do find it interesting, so maybe one day... like when I’m done with my book and my bucket list and my current painting and the ten other things I always have going on at once. First month of third year is not the time to start tacking additional tasks onto my to-do list.

July 10: Wednesday

I experienced my first two rapid responses today. When you’re the “on call” team you carry the code pager. When the shrill rapid beeping starts blaring, you immediately stop what you’re doing and race toward whichever room is listed. Both turned out to be nothing but it was thrilling to head toward an unknown emergency. When people see you running, with your white coat flapping behind you and your stethoscope bouncing on your neck, they jump out of the way, flattening their backs up against the wall to let you pass while craning their necks to see what medical crisis you’re off to fix. To clarify, neither time did my own pager go off- I just obediently followed behind my team when they started running. There is a fundamental difference between people who get excited when they hear a code pager and those who cringe. Apparently I fall in the camp of people who get super excited. The codes were great distractions from worrying about my board score and also to break up the monotony of rounding. Turns out that rounding lasts for hours and is pretty darn boring.

10:45 am: Passed my boards! Barely. While of course I wish I had scored higher, I can't help but be so, so, so relieved that it's over and I am moving on with my classmates. My amazing mentor, The Boss, firmly stated in her email to me earlier today, "Do not be worried. You will excel in the clinical environment." I trust her advice and input implicitly so I will not worry. We’ve previously agreed that my strength is working with people and has never been, nor likely ever will be, taking multiple-choice tests.

2:30 pm aka 1430: I removed an internal jugular (IJ) central line from a patient, marking the first time this rotation I have touched a patient other than during a physical exam on morning rounds. While the internal med folks are all really friendly (bordering on non-confrontational), I don't see myself being in a specialty with this few procedures. I like getting my hands dirty.

Ms. AI was moved out of step down back to the floor. Good.

Turns out many end-of-life studies have been done and a greater percentage of terminally ill physicians die at home with no aggressive interventions compared to the average layperson. I direct interested parties to the 2012 article, "How doctors choose to die", published in The Guardian by Dr. Ken Murray. Very interesting. I think I will fill out a living will someday soon.

My intern and senior resident both let me draw blood from them. Bloody good fun. We were doing this in the break room and received many odd looks from people passing by in the hallway.

En route to see a new patient my senior resident shares advice that was given to him upon receiving his own board score: “Do not let your score influence your level of confidence.” I really appreciate hearing that- thanks. It was like he could read my mind and knew I needed a boost.

A patient disappeared today. Kind of impressive considering he is paraplegic and has minimal upper body strength. The patient is well known for screaming, flailing his arms, and spitting at any staff member who enters his room. Interestingly, the patient also refuses to put on a hospital gown so he has been lying in his hospital bed covered in strategically placed washcloths. To sum up, not just a paraplegic but a naked paraplegic managed to escape off of the floor this morning. Strong work floor staff.

July 11: Thursday

10:11 am: I have so much to learn.

11:42 am: Ask patients what they understand about their medical conditions- most have never had anything explained to them.

4:05 pm: The naked paraplegic was found and returned safely to the floor. Apparently he wheeled himself to the hospital courtyard where he was eventually found and brought back up to the floor. I’m not entirely sure if the goal was leaving permanently or just temporarily so that he could have a cigarette.

I just realized I never described the patient on whom I removed the IJ central line. Through a series of unfortunate events they had both hands amputated and in their place they now have intricate hooks. The dexterity and speed with which the patient maneuvers their hooks is pretty incredible. You try tearing open a sugar packet, pouring out just half into your coffee, deftly using a stirrer, then picking up the cup and drinking without spilling! I don’t know if it’s inappropriate to be so impressed. Maybe that is the typical level of functioning for someone with those types of prosthetics?

July 12: Friday

11:43 am: Tried going on rounds today without a stethoscope. Such a rookie.

Mr. BH has been discharged. Alive. Not a celestial discharge. Still in pain, still with a broken hip, but alive nonetheless.

Did you know that under very specific circumstances a hospital can pay for a plane ticket to send a patient back to their native country? Turns out that is an option being thrown around for a nasty patient on the floor right now.

3:12 pm: Ms. AI started throwing up blood. She is in constant pain. I don't know how to help her.

July 13: Saturday

Fifteen days in- my first day off since starting third year.

July 14: Sunday

Back at work. On call again. The internal medicine residents always seem nervous and hesitant to do things. We talk and talk and talk about patients and when we're done talking, we call a consult or two and then talk some more. I know these patients are complicated but commit to a choice and do something! I'm guessing their hesitancy is compounded by the fact that it is July and they are all probably scared to do something that could kill someone. I guess that’s understandable.

It's hard to give patients awful news and then clearly see on their face that they are rethinking all the poor decisions they have made throughout their life that led them to this point in time. Giving bad news makes me rethink all the shady things I’ve done in my life and whether by luck or chance, have never had to deal with any negative consequences of my occasional recklessness.

4:30 pm: The intern is too trusting. A patient came in with an abscess on the dorsum (top) of her hand, which ostensibly developed after she fell off a bike one week ago. She has no other injuries- not a scratch on her. She swore up and down to the intern and myself that she does not do drugs. Upon leaving her room I commented to the intern that I thought she was probably lying about her drug use. Her injury looks suspiciously as if she was injecting heroin into her hand. He replied, “No, there is no reason not to trust her”. Sure. We’ll see about this one. The intern and I present the patient to our senior resident and our senior agrees with me that yes, she is probably an IV drug user. The intern sticks to his guns. Again, as no one else wants her, she has been assigned to me. Let’s call this new patient of mine Ms. BA for bike accident.

5:45 pm: Urine drug screen on Ms. BA came back positive for all sorts of good stuff including opioids, cocaine, and marijuana. And that’s not even the fancy drug screen that picks up on designer drugs. Called it. Another win for the medical student.

July 15: Monday

It's shocking how many people have nasty foot problems from diabetes. The prevalence of diabetes makes me concerned for my dad- the disease is nearly ubiquitous among overweight Americans. He is out of shape, a former smoker, and has already had one heart attack. He is the poster child for a future diabetic and I worry about him constantly.

I just found out Ms. AI is being presented at M&M today. Why?? M&M, or, Morbidity and Mortality, is a conference where a patient who had a complication or who died, ostensibly due to a preventable medical error, gets presented to all of the medicine teams.  The teams then pick apart the case. The goal is to identify the cause of the problem so that it won’t be repeated by anyone else. In theory it’s a non-accusatory forum to address life and death errors but I’ve heard it can get pretty heated. Not quite like the TV show coming out called Monday Mornings but something to that effect.

Noon: morbidity and mortality conference. Here we go.

12:55 pm: OMG sitting in M&M while your patient is being presented is the worst thing ever- and I'm not even responsible for making decisions regarding her care. (I mean, I like to think I am but really, the residents make all the decisions and I just write her progress notes). The room of docs was provided with a barebones overview of her case, missing many of the details regarding the complexity of her condition. Then they start condescendingly talking about how they would’ve handled her case differently and perfectly. I wanted to yell out, “no, you don't get it, she is crazy unstable!” But I sat there quietly and watched my team face the firing squad while I hid in a corner.

July 16: Tuesday

7:53 am: Feet smell powerfully bad. Especially right after morning coffee.

9:14 am: Ms. BA is still swearing up and down that she does not use drugs. We keep going along with her story about the bike. No one will confront her. I don't think she should get more narcotic pain meds because she is drug seeking. Her abscess isn’t even that big and it’s healing really well. Hopefully she doesn’t go home and inject more heroin into it.

2:20 pm: Super Tuesday lectures are made infinitely more bearable by the presence of my closest guy friend, Magnus. We share a dry sarcastic humor and hold similar views on many issues ranging from patient care to football to the importance of bacon. Magnus and I became close because he dated my bestie Piper all throughout first year. The three of us would sit next to each other everyday during lectures and hang out whenever not in class. Piper broke up with him right after first year ended and fortunately they never once tried to put me in the middle of any of their drama as they did not speak to each other for the entirety of second year. Piper and Magnus are still two of my closest friends; I just have to hang out with them individually now. They've had shared custody of my friendship since their separation.

July 17: Wednesday

This morning I walked into Ms. BA's room to find her watching TV. She looks at me and deadpan tells me that her hand is killing her and she is in 10/10 pain. Not to be insensitive but if you can calmly and clearly tell me about your pain while lounging in bed watching soaps then it's probably not 10/10. Actually, it’s definitely not 10/10. 10/10 is more like childbirth to an extra large baby without an epidural; or a having a bone literally sticking out of your body in some weird angle, or having your leg bitten off by a shark with dull teeth. Those are examples of 10/10 pain in my book. I'm sure it hurts but really, I think she's drug seeking again and I have no interest in giving her more meds.

Ms. BA is getting under my skin because lying is a pet peeve of mine. While growing up my parents told my sister Olivia and I that they would never lie to us because once you catch someone in a lie, their word can never be trusted again. To this day, I still trust my parents. My parents are awesome. Ms. BA sucks.

1:00 pm: We have a patient on our service with a three-week old wound in the back of his head. There had been stitches and staples put in initially; staples all down the middle with one stitch at the top and two stitches at the bottom.  His staples were removed a week ago but the stitches were forgotten about for reasons unknown. I offered to remove the stitches because they had been in too long (stitches on the head usually are in ten to a max of 14 days). My team agreed this was a good idea but my intern wanted me to consult the trauma surgery team first. No. Bad idea. Calling the trauma team for their permission to remove THREE stitches on a well-healed wound would result in me either getting laughed at or yelled at by the trauma team. So I replied no, I wouldn't call. The intern retorted, “yes, you have to”. The intern then left to go do something else. I normally do not defy my superiors but this is ridiculous. To appease my intern I called Sophia (my dear friend and fellow medical student) who is currently rotating with the trauma surgery team. That way I could aver that yes, technically I did call the trauma team. She didn't answer (because the trauma team is always busy, which is why I didn’t want to call in the first place) and then I went and removed the stitches anyway.

3:00 pm: My intern is not happy with me. Fortunately the senior resident jumped in and defended me by explaining, “no, no, no, we do not consult trauma surgery for little things like that.” Phew. Yet another example of internal medicine people being terrified to do anything without the explicit permission of as many people as possible. Or another example of July interns being terrified to kill someone. Either way. But really, if you have three three-week old stitches holding the back of your head together then you have way bigger problems in your life than a rogue med student.

July 18: Thursday

One of the patients got me sick. It hurts to swallow. My throat is on fire. My tonsils are disgustingly swollen. It feels like strep but it’s likely something viral floating around. Ugh.

Night team gave Ms. BA more narcotics. Will people please stop increasing the pain meds on my drug seeking patient?! The senior resident reluctantly admitted to me that is was him that increased her dose. He explained that it was to make the night nurses lives easier. Ok, I get that but isn’t there any other option?

I would like to have an honest conversation with Ms. BA before she leaves about her behavior. I want to tell her that she really needs to stop using needles, especially dirty ones, because she will get more abscesses. My team informed me that the nature of medicine is to treat and not bother addressing problems for which there can’t be follow-up. Ok but what I don't understand is this: I have the time, I have the training, and I'm still naively optimistic enough to think that I can make a difference in her life. What is the harm if I go over options for treatment programs? Either way she is going home today. This whole time she thinks she's pulled one over on us. She thinks she is so clever and has successfully tricked the medical team into believing that her abscess is from a bike accident. In addition to paralyzing hesitation to do things, there is also a large amount of confrontation avoidance among the internal medicine people. Very frustrating. I'm too action-oriented and straightforward for this specialty.

A couple of weeks prior to coming to The General my other patient, Ms. AI, had a nasty infection that almost killed her. She had to be intubated and in the Intensive Care Unit (ICU) for a couple of days. She has extreme anxiety and nightmares about that hospital visit and she is terrified about the prospect of going to sleep, decompensating, and waking up intubated again. Her solution to this is to not sleep. She looks painfully tired and is fighting falling asleep. Her previous hospital experiences have been pretty traumatic. Another horrific experience was during one of her pregnancies, which resulted in her requiring an emergent cesarean delivery. She shared with me about being whisked away into a bright room, being surrounding by people in yellow gowns and having a mask put over her face. When she awoke she learned her baby had not survived the delivery. Poor Ms. AI. I want to give her a hug. If you know her, you probably don’t want to give her a hug because she’s pretty bitchy with the rest of the staff. But she’s chill with me for reasons unknown.

July 19: Friday

About an hour ago I received a text from my intern to go check in with Ms. AI because she is in a lot of pain. My mission was to figure out what was wrong and comfort her but offer no pain medication. After about two minutes of chatting she told me that on top of everything else going on she is having really bad belly cramps and muscles aches from starting her period. She is also suffering from crazy anxiety and depression. I talked with her a bit and regretted that I had nothing to offer her. As I was leaving an idea popped in my head. I randomly asked her if she would like to speak with our chaplain about her anxiety and for some spiritual comfort. She loved the idea- success! Found a way to support her and no meds required. Take that, intern.

I am feeling more and more ill as the day goes on and my energy is gone. Just want to curl up in bed. How sick do I have to be before I can leave? We were jokingly (?) informed during orientation that we would have to require IV fluids and IV antibiotics in order to be considered sick enough to not be at work.

July 20: Saturday

I kind of have the urge to check Ms. AI’s medical records from my home to see how she’s doing but I am off for the weekend so I will resist. It’s only my second day off from work in 20 days and my first full weekend off since I started third year.

My head is achy, I barely have the energy to sit up, and my ever-running nose is red and irritated from constantly being rubbed by tissues. I am not moving off my couch today. I wish I felt better so that I can enjoy my days off. Casey is on call so I have the house to myself. I don't think we've spent any real quality time together in days. Or months. It’s getting hard to tell whether this can be blamed on our schedules or if something else is the cause…

July 21: Sunday

After sleeping most of the past 24 hours I feel infinitely better and ready to rejoin the land of the living.

It was so gorgeously bright out today that I decided I needed to spend the day outside. I was in luck. Once a month the LGBT group at my medical school hosts a potluck dinner and as a mostly straight ally I try to attend each month. The hosts for this month are Dr. Penfield (who I adore) and his partner. Upon arriving, Dr. Penfield took my best friend Jane and I upstairs to the balcony overlooking his pool and backyard. From this vantage point he pointed out each of the physicians and their specialty so we would know whom to best target for networking. After about 10 minutes of playing who’s-who, two more people entered the backyard. Our professor confided to us, “Oh, look, that’s the medicine attending Dr. Osler. He’s started coming out to family and friends last week, but he hasn’t come out at work yet. It’s been really difficult for him. This is his first time ever attending the potluck; I’ve assured him it’s a safe place where he can be comfortable and open.” Well, I guess there’s no safer place to run into your own med student than at an LGBT potluck/pool party? 

I’m fairly certain Dr. Osler almost ran from the pool deck upon making eye contact with me. We chatted briefly and then each went about our own business of drinking and relaxing.

July 22: Monday, on call

11:35 am: There was a mandatory CPR recertification class this AM resulting in me missing morning rounds again. It feels weird to be away from my patients three days in a row.

11:46: Ugh the chaplain never checked in with Ms. AI on Friday! So much for that idea. And, turns out Ms. AI had a fall and developed a new infection. Why is she getting worse and not better?

2:35 pm: Ms. BA has been discharged. I wonder how long before she returns with her arm infected and requiring amputation à la Requiem for a Dream.

July 23: Tuesday

6:50 am: We have a new attending as of today so farewell to Dr. Osler. He was easy going and laidback, making it very easy for me to transition to third year. I've heard rumors that our new attending is very particular in how she likes things done and can be a really stickler about pretty much everything.

9:26 am: Many patients are condescending when we talk to them. They and their families often query: Do you know what you’re doing? Why am I not better yet? How old are you? Are you sure about that? I checked Google and I think I have xyx... We’re doing the best we can and don’t worry; our attending keeps a close eye on us.

11:46 am: Ms. AI has diarrhea so prolific right now that she has taken to wearing diapers. She tearfully admitted to me how embarrassing this whole situation is for her. We’re not that far apart in age. I really, truly can't imagine being in her position; it must be so, so terrible.

3:12 pm: My personal life is falling apart. Can I keep ignoring that right now?

July 24: Wednesday

11:49 am: We have a patient in his 90s who is likely not making it out of The General alive. His name is 95. His daughter, who is my parent’s age, made this realization while we were rounding yesterday. She broke down crying... Not just crying, but really sobbing. We were watching the moment where she came to understand that her father is not only mortal but is dying. My team left me with her during rounds to comfort her and I am so glad they did. I let her cry it out for a bit, then encouraged her to talk about 95 and her family. After awhile we discussed coping, strength, and surviving events we believe are insurmountable. After spending so many hours of so many days wishing I could be of service to my patients and my team this felt wonderful. This will certainly be a most memorable patient encounter.

On another note, 95 is one of the healthiest patients on our service- no diabetes, no cardiovascular disease, and he’s not obese. The senior resident informed me that if someone makes it to their nineties it’s because their life leading up until that point was likely very healthy. Evidently his health status is not surprising to anyone else on the team.

1:15 pm: My intern is off today, my senior is at clinic, and my attending is not here. I'm going to be a bad/ lazy med student and go home. I really need to go food shopping and take a shower. It’s been awhile.

July 25: Thursday

6:52 am: As I was pre-rounding today, Ms. AI told me to not to be so nervous when presenting in front of the new attending. I was touched to realize that this patient, someone so sick and brittle, had noticed how my bedside presentations changed with the new attending. And she is absolutely right on the money. This new attending definitely makes me jittery. I just wish my team could do more for Ms. AI. She appears to be fading before my eyes, every day more pallid and frail than the day before.

11:52 am: My team went into 95's room during rounds. While discussing the plan for 95, his daughter walked into the room. When she saw me she walked right over and gave me a big hug, then looked me in the eye, thanked me, and told me she'd never forget me. Great way to start the day! It would have been just as wonderful if my team wasn't present to witness her gratitude but having the team there was nice too.

7:35 pm: As part of my end-of-rotation evaluation I was observed while taking a patient history and doing a full physical exam. In general the feedback was positive. My attending highlighted that I am skilled at quickly developing excellent rapport with my patients. It's nice to feel that I'm good at something since most of the time I am fairly lost. Patients do not act the way we were taught they wound in the textbooks. During the physical exam she taught me how to properly palpate a spleen. From now on I won't have to awkwardly pretend as if I know what I'm doing during that part of an abdominal exam.

There's a NY Times article about patients developing PTSD after ICU stays. Patients at higher risk tend to be young females. I wonder if PTSD is plaguing Ms. AI during her hospital stay.

8: 36 pm: I am actively ignoring the fact that Casey told me on Monday night that he doesn't know if he ever sees us getting married.

July 26: Friday

11:30 am: 95 is a trooper. He’s doing great and will be going home tomorrow. Yet another patient this rotation that my team had written off for dead but will be going home very much alive.

2:15 pm: I had a final feedback session with my senior resident today. He said he was happy with me and went on to explain, “I don't want to use the word aggressive... No, your assertiveness in offering to do and watch procedures was great.” I told him I tried to keep an open mind during the rotation but we agreed that internal medicine probably isn't for me. Like in any way. At all. Ever.

I’m happy it's my last night of call with inpatient internal medicine and tomorrow is my last day at the hospital.  The next four weeks will be outpatient internal medicine. 

Since tomorrow is my last day I really need to go say goodbye to Ms. AI.

3:35 pm: Timing. Not a minute after typing the previous sentence the code pagers went off... I took off running and was halfway down the hallway to the patient’s room before it clicked that I was heading towards Ms. AI room. She went unresponsive so a code was called. Then she started posturing, with her arms and legs extended stiffly at her side. The MD at her side pinched her hips too hard to see if she was responsive. She wasn’t. I wanted to yell at him to stop. I stood frozen near the doorway of her room and watched her get intubated while the residents discussed whether or not she may have developed a bleed in her head. The scene played out exactly the way she described to me that she was afraid it would happen. Masked, yellow-gowned docs swarming around her bed and shoving a tube down her throat. She was sent for an emergent head CT so I went with her, and then I followed her to her new room in the ICU. I sat with her awhile, unable to imagine how I would feel if one of my nightmares came true. One of the attending docs stopped and asked me if I was ok. I’m usually good at hiding my emotions but this was too much to witness. She can’t die. She can’t. Of all the patients… not her. Please not her.

5:45 pm: Time does not stop and our team is busy. There is a new patient for me… and I almost just vomited in his room because of the smell emanating from him.

6:50 pm: Lots of new patients are rolling in- two that are psychotic. Psychotic patients are very entertaining to me at baseline and today they are also distracting me from thinking about Ms. AI. One new patient kept yelling at me and calling me Bessy. The other one is very paranoid and believes she is part of an FBI conspiracy and film project. She seemed relieved (though I think slightly disappointed) when I firmly told her that no, we are not making a movie about her.

July 27: Saturday

6:45 am: Today is my last day on inpatient medicine.  I would've said goodbye to Ms. AI but she is still intubated in the ICU. I will however go and say goodbye to 95 and his wonderful family once we’re done with rounds.

1:30 pm: Wow, what a great note to end on. I spent nearly 40 minutes sitting with 95 and his wife of forever.  They have many children and even more grandchildren and great grandchildren. 95’s wife revealed to me in a conspiratorial tone, “Every time he thought I wasn’t busy enough he got me pregnant again.” My favorite exchange went something like this:

Wife: “I couldn’t have found a better man, I am so blessed.”

95: “You could’ve found a richer man.”

Wife: “I guess so…”

95: “Eh, but he probably wouldn’t have you let you spend all his money the way I let you spend all of mine!”

And then two of them busted out laughing. 95’s wife then asked me if I had a boyfriend. When I replied, “yes” she told me that he better be treating me right.  She then added that he must be worried all the time about other doctors hitting on me. I’m not so sure about that, but I just nodded and smiled and left it at that. There were lots of hugs and well wishing when I left the room. I am in awe of their relationship. You could see the love between them, emanating from them. My grandparents, my mom’s parents, were like that. Hugging and kissing and holding hands up until the day my poppa died. My relationship with Casey isn’t like that; it hasn’t been like that in a long time. Maybe in the past, but not recently. I’m dreading going home today and discussing the state of our relationship but I can’t put it off any longer.

Before I leave the hospital and officially finish inpatient medicine I go turn in my pager that never went off.

End of Chapter 1