I get to be a sorta-kinda-almost doctor now!

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Well, it’s here, that moment we’ve all been waiting for when we are unleashed up onto the hospital wards and allowed to actually take care of patients. No, we’re not doctors yet…but we are 3rd years and with that new title comes the time to close (most of) our books, leave the lecture halls and learn, quite literally, on the job.

This week I began my 6 week rotation on OB/GYN. With my crisp, clean, new white coat with personalized embroidery and blast-from-the-past beeper in hand, I looked like a doctor but sure didn’t feel like one! I would be lying if I didn’t say that I am quite literally terrified of what this year has in store.

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In my past 18 years of education I have mastered the art of having teachers present material to me and then regurgitating it back to them on exams. Classrooms, books, and tests have defined my entire life. But now I have a new set of teachers, my patients, and the final exam is no longer a set of multiple-choice questions, but instead involves the health, well-being, and wholeness of a person.

Today I scrubbed into my first surgery, a vaginal hysterectomy/cystocele & rectocele repair/sling placement, and it was awesome!!! I felt completely incompetent wandering around the halls of the OR suites and mostly just tried to do my best to stay out of everyone’s way. It’s terrifying to feel like I have no clue what I’m doing, but at the same time I know that I’m doing my best to learn fast.

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Despite my best efforts, I know that I will make mistakes. My hope for this year is that I will not lose sight of the fact that each decision I make and the effort that I put into learning during the next 2 years of clinical training will have an impact on countless people either for the good or for the bad. I hope and pray that I will be able to honor the patients that put their lives in my care by learning absolutely everything that they have to teach. I also desire to learn from my residents and attending physicians who have an infinitely more advanced depth of knowledge and experience. I hope that I will not take one moment of this next year for granted for the formative power that it has on my training to be a caring, compassionate, and knowledgeable physician. Despite the apprehension and uncertainty that I feel when thinking about beginning this new year, I am also excited for the new experiences that will come my way!

My First Delivery

Ryan, Third Year Medical StudentIt was early Monday morning, my first day working in Labor & Delivery while on my OBGYN rotation. After my last clinical experience, Family Medicine, when the workday began at 9 AM, waking up at 4:30 AM to finish responsibilities before rounds in the postpartum unit had me yawning and rubbing my tired eyes quite often. I was pretty excited to start L&D after hearing stories my wife, an L&D nurse, would excitedly tell from time to time. But in those first few moments, nothing seemed to shake the fatigue of an early morning. That is, until my attending’s pager started crying for attention.

L&D Team Babienco! #OBGYN #latergram #LLUSM

My Wife & I, Team L&D!

I was warned that between all the students and interns, the opportunity to participate in a delivery might not present itself very often. But there I was, not 2 hours into my first shift and Loma Linda’s newest life didn’t want to wait for rounds to finish before making a sudden appearance. My attending took off, and not wanting to miss an opportunity, I followed, leaving the rest of our team behind in the postpartum unit. “Do you mind if I come too?” I asked, trying to catch up, “I’ve never seen a delivery before!” She motioned for me to follow, not slowing a bit.

Walking into the patient’s room, I discovered a very busy scene. To some, the room might have looked like chaos, what with the 4 family members crowded around the head of the soon-to-be mommy’s bed, a husband helping one of the nurses hold up his wife’s legs as she pushed, and 10 or so other individuals busy with something. But at this point in my medical education, I didn’t see chaos; I saw a well-oiled machine, each health care member working together as a team, covering every need. A senior resident, already gowned up and prepared to deliver the newborn, was standing at the foot of the bed, counting to 10, and telling his patient when to push. There was a small team of NICU pediatricians, ready to assess the newborn (there was some concern for fetal distress). And there were several nurses monitoring vitals and ferrying items to and from mom.

Taking it all in, I was suddenly surprised as a surgical gown package was smacked into my chest. “Better hurry and gown up,” my attending was telling me, “you don’t want to miss this! What’s your glove size?” Wait, she expected me to do more than just watch? Seeing the question on my face, she spoke up again as she pointed toward the senior resident, “You did well on this in the simulation lab, Dr. Brown* will do it with you now.” She smiled a warm look of reassurance. “Now get that gown on or you’ll miss it!”

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Suit up! Typical Delivery Attire

Just as I had learned earlier in the year (à la My Laparoscopic Camera), I had no time to question. I put on surgical boots and a mask, and then carefully and quickly self-gowned and gloved, making sure my outfit stayed sterile. A nurse came up behind me to help tie my gown, quickly followed by the inevitable jokes about my height and how hard it was to reach the Velcro tie at the nape of my neck. But I barely even heard, I was too busy going over the steps of delivery in my head.

As I approached the foot of the table, the senior resident acknowledged my presence and stepped to the side. Now, from here on out, I won’t go into too much detail; as most of you moms already know, some could consider birth a gory experience! At the point I joined the delivery, you could already see the very top of baby’s head, and two or three more good pushes would have us celebrating a birthday. Dr. Brown took my hands, positioned them over baby’s head, then placed his own over top of mine as he helped me guide baby into a new world. “Alright, give me one more good push!” Dr. Brown instructed, looking up at mom with encouragement.

Next thing I knew, a tiny face was staring up at me, looking surprisingly peaceful. We checked to see if there was an umbilical cord around her neck, then delivered each shoulder, one after the other. With one more push and a gush of fluid, I was suddenly holding a baby girl! For a moment, time froze; it was the most disgusting and yet beautiful thing I had every seen. She was perfect, with her tiny fingers, eyes, ears, nose… “Clamp!” I snapped out of the brief moment and held baby as her cord was clamped in two spots, daddy coming over to cut. He was a brawn looking man, and I could tell he was trying pretty hard, and pretty unsuccessfully, not to cry.

Normally, baby would have immediately gone to her mommy’s chest. The practice of immediate “skin-to-skin” helps with bonding, provides warm, and eases baby into easier breast-feeding (among other things), but in our case, the NICU team wanted to assess the newborn due to some meconium present during labor (meconium is baby poo while in the womb; it can indicate distress). As I handed baby to the NICU team, she gave out a hearty, strong cry, and I knew everything was going to be ok. After a quick check, the NICU team confirmed my relief by smiling and bringing baby over for some of that important skin-to-skin time. At this point, dad had pretty much lost his composure as he and his wife embraced their brand new daughter. It’s tough finding words to describe the moment that was in front of me. 100%, unadulterated love. Pure joy.

For me, there was no time to get caught up in the emotion of it all as we still had to do some stuff you never really hear about after a delivery. The placenta still needed to be delivered and inspected, mom’s uterus had to be massaged to help stop postpartum bleeding, and any lacerations from delivery needed sutures. This happened without problem, and because I mentioned my plans of specializing in emergency medicine, I even got to do the suturing! As I took off my soiled gown, Dr. Brown and my attending both affirmed I had done a good job, which frankly, felt pretty awesome. I then washed my hands, gave congratulations to the new family (along with receiving a grip-crushing handshake from dad), and stepped outside the room.

Me with Some of the Coolest Nurses in the Hospital

That’s when it hit me. Oh my goodness, I just pulled a new life into the world!! Pretty cool. I’m so grateful that even though I’ve less than a month left to go in my third year, even with another huge board exam looming over my head, I’m still finding moments like these.  Not to mention in 17 short weeks I’ll be doing this again as the dad!

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My Son at 22 Weeks. 3D Ultrasounds are Amazing!

Even though I thought I couldn’t have any more respect for my mom, I certainly do after participating in that first delivery. Props to my mom and all the moms out there that have the strength to carry us and the patience to raise us into respectable men and women. And with that, there’s less than two weeks to go until I’m a 4th year medical student! Stay tuned!!

*Name changed to protect privacy.

My Stroll

Ryan, Third Year Medical StudentNormally, my posts follow a linear story. Today I’m going to break that format and throw you a couple of random things that have been going on lately!

– I vowed I would not do this while writing posts for fear that I would look like I am trying to curry favor with anyone responsible for evaluations. But because I have already finished my rotation in pediatrics, I have got to throw out massive appreciation for Dr. Catalon, my most recent preceptor. Dr. Catalon runs a general pediatric clinic in Moreno Valley, and I had the privilege of rotating under his guidance for 4 weeks. Not only did I learn an incredible amount under his tutelage, I laughed so often I’m pretty sure I added 10 years to my life! The reason I’m sharing this with you is because so often I’m afraid that young pre-med students or other pre-clinical med students have a preconceived notion that attending doctors exist to haze and embarrass med students. Well, that simply is not true! Maybe things were like that in the early history of medical school, but in my experience, things aren’t even close to as awful as they may be dramatized in anecdotes or popular television shows.

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Out to Lunch with Dr. Catalon

– At long last, the end is finally approaching. With the recent, very successful match completed by the class of 2014, it is finally our turn to begin the process, to begin “Strolling through the Match.” For those who might not know what “The Match” is, it’s the process by which 4th year medical students get jobs for post-graduate training. Even though one is technically considered a full-fledged doctor after graduation, these residency programs are (for the most part) the final step towards becoming a board certified physician. I won’t go in depth about it as many of my fellow bloggers have recently discussed the match in detail, but I’ll revisit the process throughout the year as I get closer and closer to finding out where I will continue my training. So at this point, my classmates and I are making our final decisions as to what specialty we are going into, setting up our senior year schedules, and applying for away rotations (also known as “audition rotations”). And soon after, we’ll begin applying for residency spots and flying all over the country to impress interviewers everywhere. I have 100% affirmed my decision to apply for residencies in Emergency Medicine, and I could not be more excited!

Exciting!

– April Fools’ Day was a week ago, and my wife and I had planned the perfect prank. It seems that everyone and their pet dog announces they have either gotten engaged or become pregnant on April 1st, so not wanting to miss out, we posted this picture:

April Fools!

Preggo?

You might sarcastically be thinking, “Wow Ryan, real creative joke there.” as you roll your eyes and continue reading. But here’s the best part about our joke… it wasn’t a joke! That’s right, I am proud to announce that my wife and I are expecting our first child this coming October!! Brianna told me by giving me a Valentine’s Day gift… little Cincinnati Reds infant onesies. I was absolutely enthralled. And I still am!

Go Reds!

 

Already a Reds Fan!

 

Boy? Girl?

 

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We are SO Excited!

– I am only 10 weeks away from completing the core rotations required for my 3rd year of medical school: 4 weeks of family medicine and 6 weeks of OBGYN. Soon after, I’ll have another onslaught of exams to survive (nay, defeat!), and then 4th year begins with the fun adventure of matching! Stay tuned, many exciting things to come! 🙂

Questions

Leanna, Fourth Year Medical StudentThere have been some questions asked of me and statements said to me, especially during third year, that I’ve had to think long and hard about answering, making sure I didn’t say anything too weird or inappropriate.

1) “You must be so smart!”

At first, before med school even began, I may have actually secretly agreed with this well-intentioned compliment. I did decently on the MCAT and got interviews and acceptance to some great med schools – thus, in my mind’s eye, I imagined continuing my strong undergrad performance in medical school. Wrong. I cannot even begin to describe what a shock it was, realizing how different undergrad and medical school were. Not that my undergrad education didn’t prepare me well, but medical school demanded 500% more effort to simply pass. As I alluded to in an earlier post, I eventually realized how to change up my study habits and outlook about halfway through first year. Essentially, any decent grades or exam scores I have received since that point I can attribute solely to hard work.

Of course, having some degree of natural intelligence/sound reasoning is quite helpful too, but I passionately believe that medical school is still 90% extraordinarily hard work – hard work that entails ongoing sacrifices of a social life, normal emotional life, and even a little of your soul (I might be kidding about that last one – or maybe not). “Balance” is a great idea and a term that is thrown around a lot, but the “balanced” life of a solid medical student is skewed heavily towards his/her school and away from nearly everything else that a normal twenty-something year old experiences.

First and second year demand incessant studying. Take a day off if you are convicted in that regard, but the other 6 days of the week must be devoted to school. If they aren’t, you will fall drastically behind, or even fail. You will log onto Facebook and see friends and family incessantly posting pictures of hiking, traveling, shopping, – things that are now reserved to Christmas break or the rare full weekend off. What the heck did you do with your free time before you started medical school? During third year, and maybe even a rotation or two of fourth year, you will be waking up when it is pitch black and coming home when it is pitch black. Someone will ask, isn’t it really hot in Loma Linda right now? And you won’t know because you’re inside the hospital all day, on inhumanely long shifts. To receive honors on a third year rotation requires that you pass the respective board with flying colors (implying that you’ve been studying every moment of downtime you have – while eating, in the bathroom, grocery shopping, while on the treadmill), that you have consistently given 110% hard work on the rotation, especially when being watched by residents and attendings, and that you have done all the additional “if-you-want-to-receive-honors” requirements, such as writing pathophysiology papers and scoring well on quizzes. Third year is not a year of rest; it is all the mental demands of first and second year now coupled with performance and application based on that material.

My sheer hope is that this in no way comes across as a pity party. I want to simply dispel the notion that medical school requires of one to be placed on a pedestal; no, it is being an extraordinarily focused and devoted student for four straight years that will get you to graduation. Like I mentioned, intelligence still plays some part, but at least in my case (and I know many who would agree with me), the energy that keeps me going has little to do with intelligence but everything to do with raw diligence and perseverance, driven by a passionate thought of there is no other career in my life that I would rather be doing (honestly though, being a stunt women would be really awesome).

2) You speak Spanish?

Usually, I am tempted to say that I do – well, that my Spanish skills are decent, and if we are not looking for an in-depth conversation, I can get by. Unfortunately, trying to instantaneously translate as a patient is talking to me can be quite tricky.

Recently, in fact, I was in GI clinic and listening to a conversation between the doctor and the patient (both of whom are native Spanish speakers), while trying to translate in my head.

Doc: So how are you feeling?

Patient: Fine; I am thankful to God for the blue horses, and my family’s legs

Doc: Excellent. It appears to me and to you that to me that you appear to want to see results of the scopes.

Patient: Yes. Give protection and truth.

Doc: Everything is breakfast.

Patient: Why is running cancer?

Doc: Cancer is a low probability [YES. Got that one]

Patient: Next year we repeat the trip to the small shoe store?

Doc: No, in three years we repeat scope and tears from the sky, along with stomachs and arms.

Patient: I am confluent with you doctor. God bless you and your beetles.

This may be a slight exaggeration, but have it be known that I greatly look forward to refining my Spanish during the rest of my career, because I really need to do so.

3) So Women’s Health clinic went well today?
YEEEEEAAAAAH I’M THE PAP SMEAR QUEEN YO! (Note: This is never, ever, ever an acceptable Facebook status)

4) How do you do it all, remembering and retaining all that medical information?
Comfort food (Garlic and butter croutons during the week; frozen yogurt on the weekends),
Friends (someone to pat you on the back and remind you that your life has a small bit of inherent meaning to it. Regardless of the fact that your surgery attending’s main goal is to pulverize any self-worth that you have),
Exercise (cardio step classes set to mash-ups of Eminem/Justin Bieber – a mega dose of inspiration)
Incessant studying (see question #1. Do have any idea of how many times I have had to focus on my portable pharmacology flash card set while standing in line at the grocery store, and resist the temptation to read the tabloids’ headlines of Paris Hilton’s set of quintuplet love children with Bigfoot? Many times)

5) Tell me about one of the greatest challenges that you had during medical school (naturally this question is asked quite a few times by my interviewers during the residency interview season)
Well, off the top of my head one of the greatest challenges I’ve faced during medical school was on my surgery rotation. I was on a two-week block of vascular surgery and was waking up at 3:45am to make sure that saw all my patients in time, updated the list in time, began my notes in time, and providing offerings to the gods of vascular surgery – the vascular fellows and attendings.

Anyway, by the time rounds were underway around 8am or so, I was famished, starving, nearly emaciated. On this particular day, I had eaten blueberries and a junky little 90-calorie Special K bar that morning. Naturally I was desperate for food, anything. And as luck would have it, the first patient my team and I saw that morning was sitting up in bed, eating a tasty, mouth-watering meal straight off of the gourmet Loma Linda VA Hospital breakfast menu. Pancakes and no-sugar-added maple syrup, with a cranberry juice box and a link of dry sausage. I couldn’t help my staring – the food was right there in front of me, at that delectable lukewarm room temperature I so craved.

It wasn’t long before the patient caught me staring, my eyes glazed over as I the thoughts of eating one of those little silver dollar pancakes ran through my mind. I want that. I want that pancake. Please. Give. It. To. Me.

“You want this pancake?”

The patient was asking me this. What? No. No. How did he know? Was it the shrieking sound of my stomach over the beeping med-surg monitors? Possibly. That wild hungry look of a castaway lost at sea for a month? Perhaps. Did he know that I had been up since the wee hours of the morning running off of a Special K strawberry breakfast bar? Eh…I suppose so, if he had excellent intuition.

Nevertheless, I was in a major dilemma. Do I accept this patient’s kindhearted gesture and cram the pancake in my mouth while we are debriefing with the attending about the care of the patient? Or do I refuse this offer that may potentially save my life and prevent a fatal hypoglycemic episode in order to save face with the vascular team and prevent myself from going down in Loma Linda VA history as The Girl Who Ate The Pancake?

Fortunately for my reputation, and unfortunately for my stomach, I found a happy medium of gently, kindly refusing the patient’s offer and asking him to please enjoy his entire meal for me (in my mind, it was like YEAH YOU GO AHEAD AND EAT THOSE PANCAKES RIGHT IN FRONT OF ME, BUDDY) while I paid attention to what was going on in the discussion of the patient’s recovery and prognosis.

That afternoon I got a huge Caeser salad and curly fries, and at the end of the rotation I received an excellent letter of recommendation from the surgery clerkship director. So, I think my self-control paid off and I am a better person because of it.

My Laparoscopic Camera

Ryan, Third Year Medical Student

It was the first shift of my surgery rotation.  As luck would have it, I was to start with a week of nights on the acute care surgery service (ACS).  As part of ACS, we could see any surgical emergency, from gunshot wounds to ruptured aneurysms to acute appendicitis and everything in between. Being a newbie to the world of surgery, I had no idea what to expect or even what to do if I was suddenly asked to assist in an operation. Nevertheless, I was excited!

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Obligatory Surgery Rotation Scrub Mask Selfie

The evening started off slow, with various consults called that required ACS’s evaluation of minor traumas in the emergency department.  But soon enough, a classical surgical emergency presented itself: 40-something-year-old female with fever, chills, nausea, and sharp abdominal pain localized to the right lower quadrant. If you are now thinking appendicitis, you’ve likely had the operation or work in healthcare.  When an appendix gets all inflamed and angry, it runs the risk of popping and spreading a nasty infection into the belly, so the treatment involves surgery as soon as possible.

The senior resident whom I was working for took off to the OR as I quickly followed.  As we walked/ran, I frantically looked up some of the more common facts about appendicitis, just in case the lead surgeon wanted to test my understanding of its management (surgeons love to quiz med students!).  This was going to be my first procedure in the LLU OR, so I wasn’t sure what to expect.  Would I be asked to do anything? Would the surgeon throw me out of the OR if I couldn’t answer his questions? What if I suddenly had to use the bathroom??

As we began to scrub for the procedure (“scrubbing” refers to the fancy process by which a surgeon washes his or her hands), the senior resident’s pager started beeping like crazy; a level A trauma was rolling in, and he was needed back in the emergency department. As he began to run off, I shouted after him, arms dripping from their recent bath, “Wait, what do I do?” Looking back over his shoulder, he replied with a confidence inspiring, “just do what you’re told, you’ll be fine!” I stood there for a second, the thought dawning on me, “Wait, I’m about to be assist the attending surgeon by myself?”

I walked into the OR where the scrub nurse helped me don a pair of surgical gloves and gown, chuckling a bit when he saw how short the gown looked on my 6’8” frame.  I took my place at the operating table, not exactly sure of what I was supposed to be doing. Typical of an appendicitis case, this procedure was to be done laparoscopically, meaning that instead of opening the patient’s abdomen, three small ports would be placed: one for a small camera, and the other two for various tools (doing a procedure laparoscopically allows for quicker patient recovery and less complications).

Image released by LCDR Nunnally, PAO CVN 65.

A Laparoscopic Procedure. Pretend I’m the Guy on the Far Left!

I introduced myself to the lead surgeon, explaining why the senior resident had to rush off.  “No problem,” he replied, “ever held a camera like this before?” He motioned toward a long, thin, silver pole with a black knob on one end. I shook my head no. The surgeon let out a little sigh, saying, “Just pretend your putting me on tv… point the camera and follow me around!”

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An Inflamed Appendix. My Job was to Capture Shots Like This!

When you are a student in the OR, there really is no room for self-doubt.  It’s kind of like that Nike slogan… Just Do It! So there I was, driving around a laparoscopic camera at 1:30 AM, trying to pretend I wasn’t nervous at all. Now honestly, there’s not much damage you can do when you are simply holding a camera, but that didn’t stop the sweat from beading up on my brow… which of course caused my left eyelid to suddenly have the itch of all itches. I’m talking about the kind of itch that makes you want to remove your skin, run it through some steel wool, then replace it with something that doesn’t need scratched. But when you are scrubbed in, the only things you can touch are the tools around; touch your face and the sterile field could be broken, putting the patient at risk of infection! So dear reader, the next time you want to scratch your nose or something, don’t take it for granted 😉

Anyways, just when I thought the itch was about to make me run from the OR in search of a rake, the attending asked, “So Ryan, what are some presenting signs & symptoms of acute appendicitis?” Thank goodness, a distraction! As I began to list off things like diffuse abdominal pain that migrates to McBurney’s point, I suddenly realized the television screen displaying the camera feed had turned yellow.

The surgeon took my camera-guiding hand and tried to reposition the feed so we could see again.  Our patient had received several abdominal surgeries in the past, so our camera was apparently running into old scar tissue that had built up. His questioning stopped, and the next few moments of surgery became an eloquent dance of proceeding, then stopping to readjust the camera.  I tried my best to operate the camera on my own, but every so often, the lead surgeon would have to set his tools down so he could help me readjust.  It took every ounce of concentration just to keep from showing how flustered I felt every time I lost the surgeon’s field of view. Talk about trial by fire!

Despite the overly dramatized story that was playing out in my head, the surgery went smoothly and before I knew it, the patient was headed to recovery. I had survived! I laughed at the irony of my own survival when the patient probably woke up grateful of the same thing.  After thanking the attending surgeon for his teaching, I pulled off my surgical attire and walked out of the OR in search of the ACS team, wondering what challenge would present itself next.  And I may or may not have found an empty hallway to perform the celebratory karate chop a certain Dr. Benton once made famous (fans of ER know what I’m talking about!).

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3rd year has been full of stuff like this.  One really has to set doubt aside and let the teacher’s teach!  I’ve found that if I focus on the task at hand rather than any fears I have, things aren’t nearly as scary as they might seem to be. Just do it! I wish I had the time and energy to tell all the fun little stories I’ve experienced up to this point. But now I’ve moved on to my pediatric rotation and I’m spending my time practicing pediatric H&P’s and coming up with ways to distract a screaming infant so I can perform an exam.  This year has been stressful and frustrating at times, but I really am enjoying it and can’t believe it’s already halfway over! To close off this post, here’s some various shots of something every student gets to practice perfecting: knot tying and suturing up pig skin!

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2 AM Knot Tying Session with the Residents

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Classmate Phil is Excited to Suture Up Pig Skin!

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Classmate Erik, Focused On His Knots

IMG_0554A Freshly Closed Wound Using a Simple Interrupted Stich.