Random Ramblings and Random Happenings

Karakoram Split30 splitboard system

2010-04-12T05:55:00.000-07:00

Love this product!

Great outdoor gear giveaways - weekly!

2010-04-08T18:17:00.000-07:00

While it's still relatively young, I feel like my chances are pretty high of bagging a free piece of outdoor gear from this new start-up outdoor adventure website: www.branchwhipped.com. This is exactly the sort of website that I'd start up if I had the spare time to do it. My wife's two brothers started this site together. This week's giveaway is one of the smaller items (but always cool, useful stuff): a Coast mini LED flashlight. See below:

Coast Mini Tac LED Light Giveaway. Starting Thursday April 8, ending Monday April 12.This mini Led flashlight is perfect while trekking on your next backpacking trip, your next camping adventure, vacation, or your glove box. This LED flashlight uses one AAA battery, that last 18 hours. The LED bulb also lasts much longer than the old school incandescents of yore. The light bean is also white, not the yellow of other bulbs. I have owned a light similar to this and it is indispensable. You can use it as long as you want at night in your tent while backpacking or camping in the mountains. I always take one with me on my hiking trips, its a piece of gear that can’t be left behind. Enter below for this required piece of camping gear.

Description of the Coast Mini Tac LED Light from the Coast site:

Crystal Reflector Tube System
High-quality LED; white beam
Rear on/off switch
Tactical lightweight aluminum casing
15 lumen output
Over 20 hour battery life
2.9 inch length

Full review on candlepowerforums.com.

Third Year - finished

2010-01-02T16:06:00.001-08:00

I'm pretty much done with the below post, for those of you who enjoyed the half-finished version.

Update: Radiology is my specialty. I'm hoping to end up close to home in the Northwest, and have interviewed at ten different programs with a couple of interviews left to go. It's so exciting to be this close to having my MD, having a career, being done with borrowing money, and for once, having an income - marketable skills!

Some highlights of Third Year...

2009-07-12T12:28:00.000-07:00

Peds (my first rotation): On the first day of this rotation, I was assigned to follow a pediatrician in the newborn unit and about 5 minutes after arriving, he was paged downstairs to the labor and delivery floor. A code had been called on a baby who just didn't want to breathe. It was this young couple's first child, a baby girl, and she had no complications whatsoever. Born naturally, the labor was a little rocky but nothing unusual. I struggled to keep up pace with the 70-year-old pediatrician (who is a mountaineer in his spare time) as he flew down the stairs and sprinted down the hall. We heard the shreaks, "my baby! my baby!" and the first person I saw was the husband, whose eyes met mine with the most expressionless, bewildered face I've ever seen. The pediatric nurse was thumping away on the baby's chest and another nurse was pumping the bag-valve mask as the baby lay prone, limp, and a dusky bluish purple, like the color of a fresh plum with some whitish goop (we call it "vernix") smeared all over. The pediatrician instantly whipped out his stethoscope, called a pause on CPR, and listened for a heartbeat. It was faint and slow, but steady. Ventilation was continued, but then the heartbeat was lost. Ten more people suddenly filled the room and I shrunk into the wall, wishing I could be invisible, but not wanting to leave. I was hiding behind the blue cart (the crash cart) and will never forget the trembling hands of a young OB nurse as she struggled to fill a syringe with epinephrine (adrenaline). It took her three or four tries to do one of the most common tasks - insert a needle into the tiny glass bottle and draw off the fluid. Meanwhile, the pediatric nurse deftly inserted an endotracheal breathing tube and hooked the baby up to ventilation. After the maximum dose of epinephrine, more CPR, and lots of shouting and frantic fumbling, the slow, steady heartbeat returned and everyone sighed in unison. But, it was too late. This baby's brain had already suffered irreversible brain damage and would later show absence of function on the EEG (no brain waves). The parents elected to withdraw care later that day.

For the rest of the day, a dark cloud hung over the newborn unit and no one dared crack a smile about anything. I learned quickly that OB is 98% joy, and 2% sheer panic. Of that 2%, some small portion of difficult births are bad outcomes. And of those bad outcomes, there is always a fraction that are in some part the result of poor decision-making. This burden must be borne by all, but the attending physician must take full responsibility for his treatment team. Nearly every physician, even the radiologist who overlooks a tumor on the chest X-ray, must be able to deal with his/her mistakes that mean the permanent harm or death of a patient, and realize that humans, by nature, are imperfect.

I only had three days of newborn peds. The rest of my 6-week pediatrics rotation was half inpatient, half outpatient, and lots of fun as I have always enjoyed being with and working with children. My first inpatient was a 6 year old boy who, while on a road trip across the US, caught E. coli from a roadside fast food joint. After a few days of diarrhea, he developed a fever and then bloody urine, and then stopped urinating altogether. It was our job, for his 3-week stay, to do our best to get his kidneys working again while doing dialysis in the meantime as they recovered. I read lots of papers on the latest treatments for HUS (Hemolytic uremic syndrome) from E. coli 0157:h7. From this, I will never forget the expressions of joy, the tears, and smiles from his mother's face the morning that he produced 70 ml (less than 1/4 cup) of smelly coke-colored urine. That was the beginning of his full recovery.

OB: I thoroughly enjoyed my two short weeks on labor and delivery. An emergency medicine resident was on with me and he had his fair share of deliveries and didn't mind letting me be first assistant. I delivered two babies all on my own - the first was with an attending who mistook me for the ER resident (I was all gowned up) and she just let me do the whole thing. During my two weeks, there were about 5 to 8 deliveries a day and a couple of C-sections a day. There were no bad outcomes this time. The most difficult aspect of childbirth for me as a medical student to take is actually watching, and hearing, a third-degree tear occur even as you're coaching the mother to push with all of her strength. I just can't imagine how painful that might be. It was a surprise for me to learn that most women endure some degree of tearing - after awhile you anticipate it as the baby always comes soon after, and it is a release of pressure that seems almost necessary in most women (hence the popularity of episiotomies).

The C-sections were my first surgical experience. There's nothing like watching the experienced surgeon extract a baby in distress. He shuts out all of the emotional drama, focuses in on the task at hand, and swiftly slices his way through the various layers with big, broad strokes of the scalpel. Everything is nicely tensioned by the expansion of pregnancy and falls to the side to expose the uterus, in which he makes a small incision, just enough to allow the amniotic fluid to gush forth like a fountain. He then inserts two index fingers and proceeds to rip it open with perhaps a grunt or two (yes, studies show blunt dissection, not sharp dissection, seems to work better for the hemorrhage-prone uterus) and then pushes on the upper abdomen sometimes with the help of extra hands, and pops the baby out in just minutes. However, the baby is of no concern to the OB doctor. He hands it off like a football to his running back and doesn't glance back, turning full attention to the mother's needs while the pediatrician attends to the baby.

Neuro: The single most notable event during neurology was the death of my first patient. I was following an octogenarian female who had a traumatic intraparenchymal hemorrhage (bleeding in her brain from a fall) that would probably kill her without surgery. Her brain was beginning to swell from the trauma and bleeding, and she wasn't quite herself. She had lost vision entirely in one eye and had partial loss in the other eye. Her family talked with her at length and agreed to move forward with the surgery, knowing there would be significant risks involved. During the surgery, I will never forget the surgeons' conversations. It all sounded so cold, so blunt, as they joked about their recent low success rate with octogenarians. Even as they were evacuating the clotted blood from a hole in the back of her head, they doubted she would ever wake up and all of this would be for naught. They were right. Although I did meet a few neurosurgeons who were practically as noble as saints, the majority struck me as insensitive pompous jerks. Perhaps this is just something that occurs in our neurosurgery department?

Psych: I worked the Psychiatry Consult service and found this rotation to be especially challenging. Rather than focusing on the cold hard science of psychiatry, I found myself becoming emotionally involved with my patients and having a difficult time believing that what we were doing was meeting the true needs of my patients. I saw a lot of emptiness, loneliness, heartache, and despair, and I wanted to fill that emptiness with a message about Jesus Christ. Being a young medical student, though, with my career in jeopardy, I found it nearly impossible to initiate any sort of religious discussion. It seems that such topics are particularly taboo on the psychiatry service. I must say, there seemed to be almost a dichotomy of personalities among the residents. Some were consistently and genuinely compassionate, while others seemed to be quite the opposite. No doubt, I heard more swearing and saw more unprofessional behavior while on the psychiatry service than any other thus far - although this may just be an isolated occurrence.

Primary Care: Our medical school is famous for promoting Primary Care. We have one of the highest percentage of students choosing primary care specialties nationwide. Our country sorely needs more good primary care doctors - I did seriously consider pediatrics for awhile, but I found the field of radiology to be much more intriguing and fitting. Anyway, this rotation was a nice break. I had Fridays off and my days were typically 8am to 4-5pm or so. My wife at times wanted me to consider primary care, perhaps thinking our career life would reflect the med student life during this rotation.

I learned that the American culture and way of life creates many scenarios that lead to chronic diseases such as diabetes, heart disease, stroke, and cancers, and that the primary care physician is often powerless when it comes to changing a patient's lifestyle in order to get them back on track toward health and longevity. I learned that, despite our advances in understanding of disease processes and prevention, we still cannot get much of our population to follow even the most basic advice (e.g. colonoscopy starting at age 50). Primary care just wasn't for me. I felt like most of our time was consumed by the tasks commonly relegated to the social worker - getting a patient into a nursing home who can no longer be cared for adequately by the family; helping a patient get access to meals on wheels and other senior services; helping a parent understand why their teenage daughter needs to have some time alone with the doctor; dealing with drug seekers whose real needs are social support and home health visits.

The family practice doctor whom I shadowed was an older female - about my mother's age - whose patient population was skewed toward her own type. From day one, she assigned me the task of pelvic exams and pap smears on all women who would agree to subject themselves to my inferior exam skills. This is one thing I was never eager to learn or do especially on the younger women, and although I thought I became quite proficient after two months, there were always those women whose cervix just seemed to evade and shy away from my cold metal speculum and shaky hands, and I'd have to give up and turn to the attending for help. My favorite by far, as always, was working with the children. It seems that I have a natural ability to understand a child's fears, misconceptions, and pains.

Medicine: The internal medicine rotation reinforces most of our first two years of bookwork - pharmacology, pathophysiology, microbiology, epidemiology, genetics, biochemistry, physiology, and other subjects. While primary care touched fairly lightly on most of these subjects, internal medicine delves deep into all of them and requires an extraordinary effort to re-learn, re-memorize, and master the basic concepts of patient management. The shelf exam in this rotation is great preparation for the USMLE Step 2 (United States Medical Licensing Exam). I read several different textbooks and carried three or four different handbooks, and read or skimmed through hundreds of articles online in search of appropriate treatment plans for patients according to the latest research available.

I was assigned 2-4 patients at a time, many of which were liver failure (transplant candidate) patients due to our busy transplant service. I would occasionally get what we call a "rock" of a patient (because they don't move, ever, and they're nearly impossible to get out of the hospital). One such patient, "Mrs. Rogers" was my most challenging patient. A 65 year old grandmother, she went to her local ER in a small outlying town with acute abdominal pain. Morbidly obese but otherwise "healthy," the doctors couldn't figure out what was going on but decided to do exploratory surgery based on the fact that she had a cholecystectomy (gall bladder removed) several decades ago, and they thought she might have scar tissue (adhesions) from that, causing an intestinal obstruction. A few insignificant adhesions were found, her normal appendix was removed, and she was sewn back up. Unfortunately, this was the beginning of her problems. Several days later, her abdominal pain worsened and she spiked a high fever - she developed intra-abdominal abscesses as a result of her exploratory surgery and spiraled down into sepsis; surgery was done to clean out the abscesses and she had a hypotensive (low blood-pressure) crisis during surgery - her kidneys didn't get enough blood and they died of hypoxia.

She eventually stabilized in the ICU and, once stable enough, was life-flighted to our ICU. Our interventional radiology team placed four drains into her abdomen to help remove the abscesses that remained, and she battled a minor case of pneumonia among other things. About a month after arrival, she finally arrived on my general medicine floor and was assigned to me. She had several drains which continued to leak purulent yellow fluid, and despite a BMI of 45, she was starving and weak, and had lost much of her muscle mass to her sickness. Mrs. Rogers didn't want anything to do with me, hated being woken up so early for morning rounds, and refused to take part in our treatment plan. Worst of all, she refused to eat ANYTHING. I recommended a psych consult - they recommended antidepressants. We had physical therapy, occupational therapy, even speech therapy, a social worker, and a chaplain. Nothing could get this lady to exercise, eat, or open up to us. I would come back in the afternoon when I had more time and she would often ask if I had brought a gun so she could shoot herself and get it over with. The best thing I did was discover that she had two horses, whose names I wrote down and asked about frequently. This seemed to help, a little. She wanted nothing to do with religion or prayer. Eventually, I made a recommendation that we often used during my psych rotation - we began giving her small doses of Ritalin (a stimulant used for ADHD and controversially for weight loss), hoping it would provide her enough energy to engage with the physical therapists and perhaps work up an appetite. I never did see her get out of bed, and the only time she sat up was when three of us strained to lift her to a sitting position for the sake of a proper lung exam (which, honestly, was nearly impossible through the thick folds of adipose tissue). After a few weeks on our service, we determined that her abscesses were sufficiently resolved, pulled her drains, and sent her to a long-term care facility for rehabilitation.

One of my favorite patients was a young 45-year-old Native American man who drove himself and his girlfriend from a small town several hours away to get better treatment at our VA. Despite his circumstances, he was the nicest and most appreciative patient I have ever encountered. He was thrilled to have the privilege of being visited by a student doctor, and even more thrilled when I announced that I would present his case at our weekly conference. He arrived with the longest list of symptoms I had ever recorded - we have a form for "review of systems" and he had some sort of complaint involving 90% of his bodily systems: leg swelling, itchy skin, bruising, dizziness, shortness of breath, chest pains, abdominal pain, bloating, constipation, change in stool caliber, burning with urination, general weakness, insomnia, restlessness, muscle twitching, generalized muscle pain, and a recent onset cough. I was convinced he had something bad - perhaps an advanced case of leukemia due to the 7 months of weakness and bruising. We have this very rudimentary way of distinguishing patients - sick or not sick - and this guy looked sick. He wore sweats and a t-shirt and his hair was pulled back into a long, thick, shiny black braid. He reeked of cigarette smoke and who knows what else, and his clothes were blood-stained and tattered. He had what appeared to be ascites, or free fluid, in his abdomen making him look pregnant, and skinny, wasted extremities more typical of a 90-year-old. He had sunken eyes, bruises on his face, and multiple deep, dark bruises on all extremities. He had fresh excoriations (scratches) oozing dark red blood - and yet he continued to scratch at them, collecting dried blood under his smoke-stained fingernails. His physical exam was not too helpful otherwise, except that I was most intrigued that there were no lung sounds at all from the left half of his chest. He also had hypertension - which he said was new. Interesting!

Our first challenge was to correct the Native American man's potassium. It hovered just above 2 despite our best efforts - oral supplements, bag after bag, and yet it would come above 3, then drop right back down. Then we focused on managing his pain appropriately with morphine injections, and providing benadryl to hopefully help with the persistent itching. The chest x-ray finally came back and revealed a 7cm x 7cm mass in the left lung (no wonder I couldn't hear anything!) which appeared consistent with cancer. Here's where this case gets interesting - I had it all to myself since the intern and others were busy with new patients, so I read about the lung cancers that appear centrally. I read about small cell lung cancer and decided that, based on the rapidity of his symptom development, it had a good chance of being small cell - the most aggressive type. Trying to tie it all together, I considered the possibility of an ectopic hormone causing his other symptoms and, the more I read, the more I realized that the picture fit with ectopic ACTH syndrome, which is exceedingly rare. In other words, his lung cancer was producing a hormone normally produced by the hypothalamus that plays the role of stimulating the adrenal glands to produce cortisol, a stress hormone, our natural steroid. His body was being overloaded with steroids, causing all sorts of metabolic and hematologic derangements. This accounted for the low potassium, the new high blood pressure, the itching, muscle aches, and bruising.

Upon discovering these correlations, I excitedly called the attending physician and he gave me the awful task of bearing the bad news - the diagnosis of terminal lung cancer at an advanced stage - to the family. All this business of ectopic ACTH syndrome sounded very exciting to him as well, although he remained skeptical. He did allow me to order the test for it, which came back positive. Bearing the bad news was an excellent experience for my learning. I used all of the techniques we were taught and, although they had questions I couldn't answer, it went well. Since the cancer was so advanced and the chances of living longer than 3-6 months were very very slim even with the best treatments, he decided to choose palliative care (relieve the pain but allow the cancer to take its course) which is exactly what I would have done if it were me.

Surgery: I thoroughly enjoyed my time with the trauma surgery team to which I was assigned. Treating victims of high-speed car accidents, falls, horse-riding injuries, and work accidents required a little bit of quick thinking followed by a lot of watchful waiting. Most patients very predictably improved and left the hospital a few days after arrival. We'd get hammered with high numbers of new patients through the weekend, then they'd slowly taper off until Friday evening around 10pm, and then it would all start up again. It was nice to treat patients whose bodies were young and responsive to injury. Most were grateful for their care, felt lucky to be alive, and cooperative with treatment.

One of my most memorable patients was a man who shot himself through the head "on accident" and survived with nearly full cerebral function. Due to damage to his frontal cortex, however, he seemed to be somewhat disinhibited and seemed quite frank and open about everything. He would simply speak his mind no matter who it might offend. He reminded me of the case of Phineas Gage who survived a freakish accident in which a 3-foot-long 13-pound iron tamping rod speared his head, entering the right cheek and exiting the top of his head. This man shot the bullet through one temple and it exited the other temple, blowing out one of his eyeballs but otherwise causing little neurological dysfunction. He was expected to make a good recovery and possibly return to work. We treated him in the ER trauma bay but then turned him over to the neurosurgeons.

As part of trauma surgery, I also spent a week in the burn unit. The art and science of skin grafting became my subject of study each evening. Burn surgery is a very messy process. We always wore long booties to protect our shoes from the cascade of blood and skin that was sure to follow. The first order of business in a burn surgery is to remove all dead tissue. Using something similar to a cheese grater, one shaves away whatever looks dead - hopefully just the outer layers of skin, but sometimes all the way through the skin and down into the subcutaneous fat and muscle below. The result is what looks like a skinned arm, or leg, or back, or face. Then, we would shave off a paper-thin slice of healthy skin often from the thigh, send it through a meshing device, then stretch it out and place it over the denuded flesh to seed new skin growth. The graft is stapled in place on the edges and sometimes glued in place using an incredibly expensive fibroblast-stimulating collagen-based spray-on glue. It is an art to get the pieces of skin graft to fit on just right, trimming them to size and using the extra trimmings if possible. The big challenges in patient management are pain control, fluid replacement (it all leaks out of the burns onto their bandages, bedsheets, and gowns), infection control, and physical therapy (to prevent scar tissue from freezing joints in place). It's a constant battle, and if the patient is "on board" and in good spirits, things go so much better. It's amazing what a difference it makes when a burn patient has the will and determination to get better and get back into life!

Resurrecting the photographer within...

2009-07-10T18:27:00.001-07:00

Now that I have an SLR camera again (I sold my old film SLR and three lenses to pay for college), and I have the luxury of free time, I've been able to experiment with photography again. The pocket digital just wasn't satisfying my need for a creative outlet, and Heather has taken up a serious interest in the art of photography - we have checked out books on photography and already snapped over 2000 photos in the first month of owning a camera.

Here is some of my recent work featured on iStockPhoto:

iStockphoto

2009-07-10T18:09:00.000-07:00

I have continued to upload vectors created in Adobe Illustrator - after tasting the sweet success of one of my first uploads (see alphabet blocks below), I decided that vector illustrations are the way to make money on iStockphoto. Here are some of my more recent illustrations:

This is a repeating topographic map pattern, which I created with the textile industry in mind, as well as for websites, magazines, and perhaps jacket liners or backpack liners. Cool huh? It has been selling like crazy lately. Click here to visit my portfolio at iStockphoto.com...

A chrome-like "star of life," the ubiquitous, universal emergency medicine logo.

Some fresh clippings from the meadows behind my apartment.

More meadow clippings.

My attempt at anatomy illustration - the human heart, inspired by several different anatomy books as well as the dissection videos from med school, and a silhouette of me!

New Camera!

2009-07-10T18:07:00.000-07:00

Heather and I recently purchased a new digital SLR - Canon's Rebel XSi, and a Tamron 18-55 f/2.8 lens. We're just discovering the capabilities of this amazing little machine.

"Picture a white sandy beach and a pina colada in your left hand..."

2008-09-25T10:17:00.000-07:00

A peek inside the operating room. (Started a few weeks ago, finally finished today.)

Last week of OB. It's been quite an experience. Lately I've been doing a lot of benign gynecological surgery cases. I'm still getting used to the idea of it, and am fascinated with the process of putting someone to sleep and then tormenting them without their knowledge. Here's how it goes at UW Hospital:

0700- If you're scheduled for an 8:30am slot, you'd typically arrive at the hospital around 7:00 and be assigned to a small booth just big enough for your bed, where a nurse comes to do one last pre-op physical, put in your IV, the surgeon (and assistants, me and a resident) meets you and answers any last questions, and an anesthesiologist gives you a sedative to calm you down (an alcohol-like effect). You're then wheeled back to the OR where the scrub nurse and float nurse are preparing the sterile tables full of tools, exactly the way the surgeon wants them. There's stainless steel everywhere. Large trays (fresh from the steam autoclave) full of stacks and stacks of scissors, clamps, tags, needle drivers, foreceps, scalpels, retractors, staplers, and other specialized tools with notable surgeons' names attached to them (e.g. the DeBakey foreceps) are all laid out in a specific manner so that the scrub nurse can find exactly what is needed.

0800- Due to the sedative effect of the benzodiazepine, you probably won't remember the trip down the long, long hallways, zigzagging, through multiple double doors, and then down to one of 22 large OR "suites." They seem more like garages to me. Everything is cold. Cold colors, cold steel, cold bed. The nurse removes your gown and covers you with fresh warm blankets from the blanket warmer. And then they tell you to shuffle over to the OR bed, which looks like a narrow black bench. Many of our patients overflow the sides of the bed, but we strap them in so it's okay.

Suddenly there's ten people on you at once, the nurse putting compression boots on your legs to prevent clots, the anesthetist is hooking up cardiac leads, a pulse oximeter, IV medications, and then comes the oxygen mask. The resident approaches and asks for a "time out" to verify that we've got the right person in the right room, on the right date, for the right procedure.

You might see a medical student staring at you, trying to stay out of the way, getting yelled at by the scrub nurse for standing too close to the sterile tables, tripping on all the cords that snake from various machines to you, the center of attention. You might notice the three 3-foot diameter Halogen lamps all pointed at you, or the large, dusty stereo speakers perched atop the anesthesia machinery in a corner. And then someone tells you your IV might burn and sting, but to ignore it and think of a white sandy beach...

0820- The patient, just before being paralyzed instantly and completely from head to toe as they drift off to neverland, is told to take a big, deep breath through the oxygen mask. This is because the anesthesiologist is about to administer a big dose of induction anesthetic (fentanyl) as well as a paralytic that totally shuts off your breathing. He/she then has a couple of minutes to intubate - first visualize the vocal cords, then thread the tube between them, inflate the air bubble that lodges it in place, tape it to the face, listen to each lung to make sure the lungs, not stomach, are inflating by hand-squeezing a football-shaped bag. Then the mechanical ventilator takes over. The eyelids are taped closed to protect the eyes from drying out.

Now under general anesthesia, the doctors and nurses are free to do whatever they need. Drapes on windows are pulled for privacy, and all clothing is removed as the body is placed in the appropriate surgical position. The scrub nurse turns on the radio if the surgeon didn't bring his/her iPod. Heels together - Foley catheter inserted. For gynecological surgery, this is the time we do our last physical exam to estimate uterus size and get an idea of whether we can, for example, remove a uterus through the vagina, or the abdomen.

The float nurse does the surgical prep with big iodine-soaked sponges, creating a brown-yellow mess that extends 1-2 feet beyond the surgical site. The pre-packaged surgical drapes come next, custom-made by 3M for whatever surgery the patient may be having and usually large enough to cover a king-size bed. If the adhesive surgical window doesn't stay on well, it may be stapled to the skin.

0830- Meanwhile, the resident and medical student have pulled their glove size and type (the doctor's are prepared by the scrub nurse along with all special tools as indicated on the Doctor Preference Card) and the surgeon is being paged. The medical student and resident scrub in, using a disposable brush and sponge, a plastic toothpick for fingernails, and going all the way up to the elbows. Rinse from hands to elbows, then raise your hands up in front of your chest and keep them between shoulders and waist for the entire surgery. The scrub nurse then hands you a sterile towel to dry your hands, and a sterile gown and gloves. It's like a carefully choreographed dance, scrutinized by the scrub nurse. Student and resident discuss the surgical plan while nurses catch up on the latest gossip.

0840- The surgeon(s) enter and the atmosphere of the room changes instantly -- now under full control of the surgeon. Music might be turned up, or changed, or turned off. Things may need to be adjusted - bed raised, tilted, step stools for the shorties, lights repositioned, thermostat adjusted, monitors and machine settings tweaked, new tools found if the appropriate ones aren't available, etc. etc. The personality and nuances of the surgeon's style command the attention, or ease the stress, of everyone in the room. The anesthesiologist sits back in a chair comfortably, but must remain alert and ready to act on any verbal orders from the surgeon. He usually ends up crawling on hands and knees at various times during surgery to enter the patient's un-sterile world under the drapes, and adjust the pulse-ox monitor, or cardiac leads, or breathing tube. He uses a large mirror at the end of a flexible pole (like a dentist's mirror) to peek under the surgical drapes as needed.

0850- Incision is made. The patient may jump, quiver, and shake, indicating that the level of anesthesia is insufficient. Despite this, surgery continues while anesthesia is adjusted. Theoretically, you remember nothing and feel nothing. The smell of burnt flesh fills the room as the electric scalpel cauterizes off any bleeding vessels, little plumes of smoke rising up and scattering the bright halogen lights. And the surgeon is totally in his element.

1130- The first thing you see is the medical student's smiling face as you're rudely awakened from a deep, groggy sleep by the anesthesiologist barking at you to wake up and take a deep breath. You reach for your face... your IV... your arms are restrained gently. You'll probably forget the tube suctioning your stomach contents and saliva and the gagging sensation of the tube pulled out of your mouth. In fact, you'll probably groggily try to yank your IV and roll out of bed to "get up in the morning." We'll gently remind you, over and over, that your surgery is finished and that (most likely) all went well.

Side income

2008-06-10T19:12:00.000-07:00

The iStock thing is starting to work out for me. I was approved as an illustrator in early May and made $50 last month and am on target for about $100 a month, without even having to put any more time into it! It's kinda like making investments in the stock market, but you're investing time, not money, and the proceeds just keep on trickling in, a few dollars a day. There are always a couple of files that really sell well and others that just don't. So far, my big winners are these two:

One of my many diversions

2008-04-02T13:11:00.000-07:00

I have always enjoyed photography and design, and used it as a creative outlet. I took a photography class in high-school, and I have a tendency to drool out of the left corner of my mouth every time I see a digital SLR. If you add up all of the pocket digital cameras I've gone through (three -- two stolen, one off my body... long story) I could've easily bought one nice DSLR and a lens or two as well!

With all the places I've been and photos I've taken, I have always thought I'd be able to make some money off of it somehow but I have been somewhat unsuccessful. I make an average of $3 to $4 per month on iStockPhoto (see my portfolio here). Due to their new, more stringent quality standards, the vast majority of my photography isn't iStock quality. There are subtle effects created by the smaller lenses and in-camera processing of my compact digital that I can only avoid by purchasing a digital SLR camera, which, at this time isn't practical as I wouldn't really have time to benefit from it.

Recently, since we purchased a Mac (we "needed" it-- first computer I've purchased since my old 486!) and got the Adobe Creative Suite, I've spent some free time doodling (and dawdling) on Illustrator and have applied to submit some of my creations for resale on iStock. Not sure why, but having a creative outlet is something I seem to really benefit from, maybe it's because I have recently been bombarded by a frightful amount of scientific information, virtually all of which is "left-brained thinking" and the right half of my brain is feeling left out? Anyway, here are a few things I've worked on: hand-tracing and stylizing an Arches National Park photo I took a long time ago, and creating my own versions of the famous Caduceus medical logo:

My 3rd Year Rotation Schedule

2008-04-01T11:59:00.000-07:00

"Starting Third Year is like going to a foreign country. You don't speak the language, you don't understand the customs, and the natives are not necessarily friendly."
--The New Physician, 1982

We just received our schedules for 3rd year after much anticipation and debate. It's a lottery system and this is what I got. The latter half of my third year will be considerably more difficult than the first half. I will be in one of the four big hospitals in Madison most of the time, or travelling up to an hour's drive outside of the city for certain clinic-based rotations.

My Schedule:

7/7 to 8/15 -- Pediatrics
8/18 to 9/26 -- OB
9/29 to 11/7 -- Neurology (includes Ophthalmology)
11/10 to 11/21 -- BREAK
11/24 to 12/19 -- Psychiatry
12/19 to 1/4 -- CHRISTMAS BREAK
1/5 to 2/27 -- Primary Care
3/2 to 4/24 -- Medicine
4/27 to 6/19 -- Surgery

Classes end May 14th, and I'm already well into my studying for Step 1 of the U.S. Medical Licensing Exam. I'm signed up to take it on June 20th, but it's quite tempting to push that date back and have more time to study! Heather and I look forward to an amazing vacation some time in late June because just two weeks after the big Step 1, I'm on the wards.

Green Power

2008-02-15T15:23:00.000-08:00

Heather and I are now officially consumers of green energy. Our electricity provider has invested in wind and solar power and we decided to support this investment by paying an average additional $1.77 per month to allocate all of our electricity usage to these environmentally friendly sources. Go green!

Too familiar?

2008-02-14T19:19:00.000-08:00

Today, I became a bit more familiar with the human body, perhaps a little more familiar than I wanted. I had been worrying about this all week! We spent four hours delving into the intricate details of the female pelvic exam, and practicing the various skills until we mastered them. We practiced the breast exam, the bimanual pelvic, the speculum and pap exam, and the rectovaginal exam. I'm relieved it's over, and pleased with how much I learned and how effective it was to have the teaching assistants (who also play the role of patient) help us with the techniques. It's hard to believe, looking at that cervix, that a baby has passed through it when all you can fit into it is the tip of the pap-smear sampling brush. The female reproductive system is a complex system of organs whose communications and interactions are quite mysterious even to the best experts. I fear that section of pathophysiology more than any other! For now, I can merely appreciate, and observe, and understand the basic skills necessary to detect abnormal findings. And, be extremely grateful that there are women in this world who are brave enough to volunteer themselves to the hands of young, naive speculum-wielding medical students.

Miss. Obesity Bill Stepping on Toes, As Intended

2008-02-05T15:37:00.000-08:00

A bill proposed by a Mississippi lawmaker to ban restaurants from serving food to obese customers has no chance of being approved - but this was never the lawmaker's goal in the first place.

Republican Rep. John Read of Gautier filed a bill asking that it be illegal for restaurants with more than five seats to serve people who are obese. Restaurants that failed to abide by the new law would have their permits revoked.

The real purpose of the bill: "I was trying to shed a little light on the number one problem in Mississippi." Read the rest of the article...

I agree with the direction this bill is headed, although denying people of their food would be like banning cigarettes from smokers, or alcohol from alcoholics. We need to shed light on obesity, much like we did on smoking when we learned that smoking causes cancer. A shift in our attitude toward obesity would help more people realize they need help to get over their addiction to food.

Exercising in sub-zero weather- it's good for you!

2008-01-20T11:32:00.000-08:00

Now that we've settled into the coldest winter months with a high of FOUR BELOW and a low of -14 today, I am shocked and amazed to see people still running outside on the trails. I always thought that breathing all that frigid air could damage your lungs, or give you frostbite! Then I came across this article in the New York Times about an environmental physiologist who has done extensive research on the risks of exercising in the cold. Here's what he says:

It doesn't hurt your lungs to breathe such cold air, even up to -50, because by the time it reaches your lungs, it's near body temperature. The cold air doesn't usually cause frostbite unless, say, you're running in subzero temperatures without a hat covering your ears. Your skin goes numb at about 50 degrees, and doesn't get frostbite until about 27 degrees, so it's gotta be a LOT colder than 27 degrees before you'll get frostbite, and as long as you're moving you can get by with not much more than a track suit, gloves, and a hat! Read the whole article here:

The New York Times: Too Cold to Exercise? Try Another Excuse

There were two different road races in Wisconsin over the weekend, which happened to be the coldest day of the winter by far, and they still had a good turnout, raising over $2000 for charity at "Freeze for Food" (left: the starting line).

People are also still commuting to work on their bicycles here. I'm still trying to figure out how to handle the extreme cold, and for now I try to avoid being out in it longer than a minute or two. I feel like my eye

balls are going to freeze solid, and my nose hairs and eyelashes get stuck together with ice crystals after just a few minutes in the cold. After reading that article, though, I'm encouraged to try running outside, or biking. Maybe we'll run across frozen Lake Mendota this week!

paradise.

2008-01-11T16:37:00.001-08:00

Heather and I had the most amazing time snowshoeing from Paradise parking lot at 5400' up to Panorama Point (7200') on Mt. Rainier on New Year's Eve. This was our "date/vacation" for the holidays, made possible by borrowing my brother Jeff's 4-runner and Dallin's snowshoes for Heather (thanks!). The only day without precip on the forecast, it was just perfect. If we had gotten there earlier (roads weren't open until 1pm due to heavy snowfall), we would have made it a ways up the Muir Snowfield. Next time, we'll bring snowboards or skis for the way down!

"I'm just wasting time"

2008-01-11T12:35:00.000-08:00

To be honest, I spent the last hour reading the news, catching up on others' blogs, and sending out a few e-mails. It's 2:30, I have tons of reading I need to do, and Heather and I have plans for the weekend. Our first test is already coming up a week from today, and I need to do a 3-hour Medical Boards practice test this weekend so that I can get into a Boards study group. I was just thinking, "did I just waste that last hour? What is the definition of wasted time?" Every day, I only have 4 to 6 of my 24 hours scheduled; the rest is free time for me to use as I please. Time is a gift, isn't it? It seems to be a hot commodity these days. I have realized that the more I value my time, the more others will value my time. And, the better I use my time, the more time I have to spend. It seems like more than ever, with the medical boards approaching, every moment counts (I just shelled out $480 to pay the registration fees for this 350-question, 7-hour test I'll be taking in late June, step 1 of 3 on the road to achieving my MD degree). Even as I type this though, I value the time seemingly "wasted" as I follow the presidential campaign and catch up on the happenings in the lives of those I love, because it gives my mind a chance to breathe, to wander, to escape the drudgery of 2nd year. Now it's 2:45... I'd better go!

Pneumocystis jiroveci is treated with Trimethoprim Sulfamethoxazole

2007-12-17T07:37:00.000-08:00

This is just sort of a journal entry slash excuse to waste some time after my huge Microbiology final. It was only 65 questions but covered some 50+ antibiotic drugs and their clinical uses and major side effects, plus some 50+ obscure bacterial and fungal pathogens, their epidemiology, transmission, clinical disease, diagnosis, and treatment. Parts of the class I really enjoyed, such as the tuberculosis (TB) section, but much of it was so obscure and detailed that it required rote memorization. This is probably, for me, the most difficult part of medical school. It often makes me think holistically about how medical schools came about, why we learn it how we do, and what we could do to make medical school easier or more effective.

We spend two full years studying almost entirely from our books, handouts, and powerpoint slides, with very limited clinical contact, and are required to retain the anatomy, biochemistry, physiology, pathology, microbiology, pharmacology, etc. so that we can enter the 3rd year with the tools necessary to treat and manage patients of all kinds largely on our own. During almost every lecture, I find myself just wishing I could meet someone suffering from a Borrelia burgdorferi (Lyme disease) infection so that I could relate more to the humanistic side of the disease, and understand the importance of the antibiotic regimen that will ease their pain, restore their sanity and perhaps save their lives.

I anticipate the satisfaction and excitement of 3rd year that will solidify my clinical reasoning and help elucidate my specific interests in specialties, but dread the upcoming boards (USMLE Step 1 of 3) that function as the gateway into 3rd year, the judgment bar of med school, the standard of comparison by which our future opportunities in residencies will, in part, be determined. My goal is simply to keep as many doors open for as long as possible, because currently I have no idea what specialty I will choose, though I know at least it will be one that allows for more family time. That's what matters most to us.

Our year-round fresh fruit source

2007-12-09T19:48:00.000-08:00

Heather and I make smoothies all the time. They're great! They're usually something like 1 and 1/2 cups frozen fruit, a 6 oz yogurt, 1 cup milk, a banana, a spoonful or two of sugar (sometimes), and sometimes some vanilla. We wait for the big sales on frozen berries and then stock up, blueberries are my favorite! Partly because they taste so good, partly because they're packed full of cancer-fighting antioxidants and other fun vitamins. My favorite thing about smoothies, though, is they make Heather cold, and then she has to cuddle with me until she gets warm again.

I LOVE kids!!!

2007-12-07T12:11:00.000-08:00

I have some of the cutest nephews and nieces in the world, and TONS of them! I love to hang out with them. There are 5 on my side and more than 20 on my wife's side. I can't wait to have kids of my own!! Sometimes I just stare at photos of Heather and I when we were little so I can kind of imagine what our own kids will look like. I'm so glad I married such a beautiful girl!

Unbiased Sources for Prescription Drug Info

2007-12-05T16:46:00.000-08:00

Suppose your heartburn is acting up lately and your antacids just aren't cutting it. You visit a doctor for it. He/she happens to have some Nexium (the purple pill) samples and gives you a few saying, "Try these, this drug is more expensive than the other proton pump inhibitors, but it's also a little more effective." The purple pill with three neat little yellow stripes on it works like magic--your heartburn disappears completely. So, you get a prescription for it and order it at your local Walgreens. The one-month supply runs you a whopping $193. You think, "well, hey, it works wonders, I've never slept better. It's worth it."

Why do so many people prefer the purple pill? It's ALL marketing. They've simply taken the cheaper, equally effective OTC PPI named Prilosec (omeprazole, $19-26 for 1 mo.) and found a way to purify it differently so that the final product only contains the active form (they call it esomeprazole), and not its inactive enantiomeric mirror image. In other words, they're the SAME drug with different names. Their elegant studies show a slightly higher effectiveness with Nexium vs. Prilosec while other studies show no difference. More than half of the $193 per month you pay for Nexium goes directly into marketing for Nexium. This is the main reason it costs so much!

If you had taken a few minutes to visit www.crbestbuydrugs.com (consumer reports for drugs), you would've realized that you were spending TEN TIMES more than you needed to for this medication!

This situation is based on a visit with a patient that I had last week. A single working mother who was most likely on Medicaid, and she swore that the only thing that works for her heartburn is Nexium. So I asked, "Well, have you tried Prilosec?" She hadn't.

In summary: Why do we need unbiased sources?

Doctors are influenced ... even if you don't think so
Drug reps are factually inaccurate
Articles funded by drug companies show bias
Most Continuing Medical Education (for doctors) publications and seminars are sponsored by drug companies, and the data presented is often biased and skewed.

The source I recommend for the everyday consumer:

Consumer Union Best Buy Drugs -- www.crbestbuydrugs.com This website fills a gap in the public's knowledge about the effectiveness and safety of prescription drugs and how drugs given for a particular illness compare with each other. It gives patients a better idea about how much drugs cost, including the comparative value of various drugs, with condensed and long reports.

More 100% unbiased sources:

www.guidelines.gov -- evidence-based clinical practice guidelines
www.medletter.com
www.prescribersletter.com
www.dtb.org.uk
www.cochrane.org/reviews/clibintro.htm
www.rxfiles.ca

Info regarding the pharm industry's interactions with physicians:

www.nofreelunch.org

Post Sources: www.amsa.org/prof/pharmfreeday.cfm

Increasing Access to Essential Medicines

2007-12-05T16:19:00.000-08:00

Drug companies, like other businesses, are profit-driven. They pour their billions of dollars into marketing and research of whatever we consumers will pay for. This is why they put more research and marketing into things such as "erectile dysfunction" and common ailments of old age (restless leg syndrome) instead of things that affect the younger and less fortunate in society.

Some more interesting facts:

The Pharm. Industry spends about $19 billion on gifts to physicians every year.
"Free Samples" greatly influence physicians' prescribing practices and negatively influence the care patients receive.
The pharmaceutical industry collectively spends more on marketing than on research and development.
The cost of marketing is passed onto patients in the form of higher drug prices

Global Health suffers due to profit-driven practices:

Worldwide, only 25% of HIV+ patients needing treatment actually are receiving the life-saving medications that have been developed
Many of the diseases that affect 90% of the world's population only receive 10% of the research and development funds because they predominantly affect poor people (the so-called "neglected diseases")
The price of existing medicines remains one of the major barriers to access around the world.

What do we do about this? I don't know. The most effective solution will be legislative changes, however, this currently remains nearly impossible because the Pharm industry's lobbying presence (influence on the government) is much stronger and larger than any other industry.

update

2007-12-03T14:16:00.000-08:00

Just trying to get this blog going here... so here's a quick update. I'm almost done with my 3rd semester of medical school at the University of Wisconsin in Madison. Heather supports us well by working as a scheduler at the brand new American Family Children's Hospital. We consider this job of hers to be a great blessing in our marriage because we now ride the same bus to work/school, and not only eat breakfast and dinner together, but also lunch!

We savor each day of this simple life of ours, with few responsibilities or expenses, plenty of time together, great friends, and good health, knowing it simply won't last because life goes on! We still live in a pathetically tiny old 1-bedroom apartment that is (just) big enough for our needs. Somehow, though, we continue to accumulate new things, and we're quickly running out of space!

Well, that's about it. My life is consumed by studying diseases that plague the human body. About 30-35 hours a week in class and lab, and then that much studying. I am also involved in interviewing med school applicants and help out with a few student organizations. I usually exercise on a regular basis, although my "runner's knee" has continued to preclude running from my routine (sad, because I believe running is the most convenient, most enjoyable, and most effective exercise) and so I've taken up swimming, road biking, and weight lifting. Last year Heather and I had membership at the local climbing gym and went religiously 3 times a week, but it's a 20-minute commute and not cheap, so we haven't been doing that this year.

butter vs. margarine

2007-12-02T13:35:00.000-08:00

Every day presents us with many, many little choices. I like to think that most of my choices are between good, better, and best, but sometimes they're between bad, worse, and worst. Yesterday, at the grocery store, I spent nearly 5 minutes of precious time debating which type of fat to buy for the chocolate cookies Heather made for us. None of the margarine selections were trans-fat free, and so I chose real butter, despite the fact that 1 tablespoon contains nearly 50% RDI of saturated fat, not to mention plenty of cholesterol as well (note: trans-fat free margarine IS undoubtedly the healthiest choice, but isn't usually available in stick form).

I was raised on real butter, and also plenty of cheese, sour cream, cream cheese, 2% milk, and other high-fat dairy products. I've since learned of the complex biochemical pathways of human metabolism that have singled out saturated fats and trans fats as the one dietary component that contributes more to the processes of atherosclerosis than any other thing. Yet, my logic comes full circle in re-realizing that it's not as important which type of fat you consume, but rather how much you consume, and whether you balance it with plenty of fresh fruits and vegetables, and, of course, regular exercise.

So anyway, I grabbed the butter, and then headed back to the fresh produce section in search of some spinach, or asparagus, or maybe even avocados. Despite the ridiculously high prices on some things, I remind myself that our health insurance is costing a lot more than this, but the money invested into good food choices is probably doing more for our health than the thousands we spend on health insurance each year.