Poem: Partner

I rewrote my villanelle from a few weeks back. For some reason, I have a weird obsession with vicious people who break lovers' hearts.
-
Partner

Picking you out was not theft but art.
I smelled the carats, the heft of diamonds so
we waltzed, I heard your woes, played the part

of sympathy, playing too easily your heart.
His money could not sate your lust for romance;

winning you over was not theft but art.

What good is money? My voice was tart--
money can't buy passion, can't buy dance--
we lindy'd, swung, your soaked shirt playing the part

of secret and secret lover, confidant, a start
to divorce motions, splitting his wealth equally.
Making you love was not theft but art.

I never stole anything; don't get smart;
you did, I knew you would, left him
dancing blues as you hustled to depart.

Our marriage quick as polka, pivots apart
yet my face belies not greed, but pity.
Leaving you now is not theft but art,
this poem one last tango before we part.

Poem: Restraint

This poem has appeared on this blog twice already, but this time, I rewrote it.
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Restraint

My man had a peaked nose
and a mustache that curled down his lip,
yellowed teeth and a tattoo on his heart
of a target sign that said, "Aim here."
His wife showed me a picture,
their three children doing handstands.
The man said he was hungry,
I clapped him on the back, promised I'd buy lunch
and banged both doors open to the operating suite,
swept past the charge nurse;
we flirted, I donned hat and mask,
slathered soap from nail to elbow,
holding my arms in front of my chest
wrists up, elbows down as if in prayer.

The anesthesiologist hummed
as we took the biggest knife
and filleted the man open.
I plunged my hand in, the blood hot,
turned my head as if digging
into a couch crevice for change.
I found it, studded and chewy,
like tentacles of octopus sushi
that went on and on, furiously purple,
a cancer that grappled the soot-speckled lung,
its winding caverns, yawning chasms
splayed with nodules and growth.

"Here, and here, and here,"
the pitch of my voice higher with each note.
The other spelunker felt for himself
then demanded recent films.
The light box flickered and cast in relief
that which had deceived us;
nothing; nothing, an absence
when we expected something momentous
as if the picture of something
should be the thing itself.

Too late we arrived,
too deep for dynamite,
still I had scalpel in hand.
The other spelunker shook his head,
and in the silence, all we lost.

We closed him up,
sutures flying like gnats
fast as we could
as if we could not bear to look at this man
or his wife, or his children.

Evolution

"Literature was not born the day when a boy crying 'wolf, wolf' came running out of the Neanderthal valley with a big gray wolf at his heels: literature was born on a day when a boy came crying 'wolf, wolf' and there was no wolf behind him." – Vladimir Nabokov

My earliest creative writing experiences involved poetry in high school. They were absurd poems but fun to write and think about. At that time, I became obsessed with sound; I focused ridiculously on meter, alliteration, rhyme. I also really enjoyed close analysis of poetry texts; though dreaded by many, I found poems so much richer when analyzed than read. As a result, too many of my poems attempted to be deep. In college, I delved into fiction. I loved reading short stories; I loved the movement, the pace, the plot turns, the characters. I strayed away from language as I tried to harness those tools of fiction. I never was a great short story writer. My stories petered out at 10-15 pages, I obsessed too much over minutiae, my dialogue dragged. Then in medical school, I found that I no longer had time for stories, and again I returned to poetry. Although many of my most interesting experiences play out as stories, I find poetry the right medium to capture emotions and draw unusual relationships between circumstances. Now with a better understanding of fiction, I try to capture movement and character in my poems. No nature poetry for me.

Act

"Writing is wonderful when you talk about it. It's fun to contemplate. But writing as a daily physical activity is not agreeable. You put on weight, you strain your gut, you get gout and chilblains. You're alone, and every day you have to face a blank piece of paper."
-Norman Mailer, The Spooky Art

This quote really resonates with me. Writing is one of the hardest things I do on a regular basis. Medical school is intimidating. But writing - it terrifies and seduces me at the same time. No one tells writers what to write about. But with that freedom comes an intense fear, self-questioning, isolation. Staring at a blank page, I've never felt more alone. Reading a piece of work to a new audience, I've never felt more scared. Even publishing a poem to this blog comes with a measure of apprehension.

Why write? I find that, like most writers, I simply cannot avoid it. Not writing would be a blessing; I'd have more time, friends, self-confidence. But there is an itch; I see a story, recognize a relationship, discover a metaphor, explore a character, stumble upon a mystery, and I need to explore it. I have no other great talents and so I fall back on the simplest building block, the word. Language fascinates me. The ability to convey so much, to impress upon another the experience of one's consciousness simply through words - that passion drives me. I recognize story and poetry as an art form in a way that other forms fail me. I like paintings. But that's all they are to me; I don't have that finesse and depth to understand them as art critics do. But words, words, they speak to me like nothing else.

Something New

This week I have something new and unrelated to medicine. I'm participating in the 29th annual Napa Valley Writers' Conference, a week-long writers' workshop with lectures by nationally recognized poets and authors. It's very exciting; I applied for a scholarship without expecting much and here I am with this impromptu rotation. I managed to schedule two weeks of vacation at this time to allow me to participate. I'm looking forward to it; the conference will allow me to create new work, refine old work, hear lectures from outstanding faculty, and listen to readings. Although I try to make it to weekly workshops at UCSF, this will be a dedicated focused time for writing. It's at St. Helena in Napa Valley, and I'm staying with a host family. This week's blogs will be related to the art and craft of writing rather than medical stuff - so if you're not into that, please take a week-long vacation.

Decision-Making III

Finally there are the intangibles. I always thought I'd be an internal medicine doctor, the kind of person who figures stuff out, who fields questions about diseases at a cocktail party, who needs nothing but his mind. Over time, the perseverance of that idea has waned, but how much should it count for? Shouldn't I be open to new paths? Furthermore, somehow as an undergraduate freshman, I set myself barreling towards anesthesia by taking a seminar taught by an anesthesiologist who would become one of my mentors. "Fate" - such a mysterious word - seems to play some role in my life decisions.

In the end, choosing a specialty should be based on an intersection between interests, values, skills, and personality. It's hard to tease out all the details, but these are distinct entities. The last few posts have focused mostly on interests. As for values, I'm unsure how to approach that; broadly, I value strong interpersonal interactions, a judicial use of tests, and primary care. That last value is tough; I don't have the interest, personality, or skills for primary care, so I'm not pursuing it yet I think it is the backbone of our health care system. The first two values I think I can get in both medicine and anesthesia; although medicine is more overtly about the patient-doctor relationship, I realized during my anesthesia rotation that building trust over a short period of time is a challenge and a reward. And all fields of medicine are struggling with the judicious use of tests and treatments.

For skills, part of that is unknown; I will learn what I need during residency. But thus far in my rotations, I think my background is sufficient for both medicine or anesthesia, and seeing what the residents and attendings do, I have confidence I can get there. I think my personality is that of an anesthesiologist; I pay attention to detail, I'm a stickler for organization, I like numbers, I like finishing one thing before starting another. I do like puzzles, which can fit internal medicine.

After mulling this over for days - or depending on how you look at it, years - I've come to the conclusion that there is no wrong decision. I will find something in either anesthesia or medicine that I like, that I'm good at, that I can contribute to patient care, and that I can make a lasting impact. And I think there's a reasonable amount of uncertainty in whatever decision I make; it'll be set, but not in stone. Regardless, I will try to keep the knowledge, skills, and experiences in all my rotations hoping that it will contribute to whatever path I choose to take. But I think I am satisfied now with my decision to pursue anesthesiology and perioperative medicine for residency (with a preliminary year in internal medicine), keeping my mind open for opportunities as they come.

Decision-Making II

I also looked at this from the perspective of what I'd lose if I went into a particular field. If I went into medicine, I might lose the procedures; certainly, I'd lose intubation, and if I didn't go into cardiology, I'd lose most of the hands-on interventions. I'd lose the operating room, which surprisingly, makes me more sad than the prospect of losing clinic. I'd lose the one-on-one intense patient focus while someone is under anesthesia. I may lose some of the emergency situations. I'd lose the immediacy and satisfaction of pushing meds myself and seeing the physiologic response.

If I went into anesthesia, I'd lose long-term patient relationships and a patient cohort. That's a big difference; that's what many people picture when they think of medicine or a doctor. I'd lose the differential diagnosis and evaluation of a new patient, but I'm not sure how much of that attendings do (especially if I stick to the inpatient setting). I'd lose the well-honed history and physical exam; that skill belongs to the internist. I'd lose the outpatient side. And on the inpatient side, I'd lose the camaraderie of a large team.

Looking at those two paragraphs, it's also a funny way of putting what I'd "gain" in each specialty. But there are also things that come with each specialty that I wouldn't necessarily want. If I went into medicine, I'd be afraid of the paperwork, the coordination of care, the nitty gritty details of modern day practice that I've blogged previously about. The truth is, I'd also be afraid of "difficult" patients; I don't finesse those situations as well as others.

If I went into anesthesia, I'd worry a little about having to work day-to-day with surgeons; most are fine, but some are a little abrasive. I'd be wary that routine cases would bore me, but I think I have the personality to deal with "hours of boredom punctuated by moments of sheer terror." The hours would be worse; I might have to take in-house call depending on where I worked.

Practice settings may impact what I choose. I don't know too much about different practice settings, but if I were to pick one, I'd go for academics. I like teaching. I like research. I like the complexity of a tertiary care center. Flexibility is nice. I don't like having to deal with the "business" end of things. Academia may suit me well. I think in academia, a clinician's influence goes far beyond the direct care of the patient; attendings model good behavior for students, sculpt residents into better doctors, and investigate questions that may have a long-lasting impact on clinical care.

The downsides of academia are clear. The environment can be "sink-or-swim," based on publications. It is hard to compete with others, especially pure PhD's who have a more research-focused background and no clinical responsibilities. Grants ebb and flow. Research is a frustrating long-term endeavor that may not ultimately pay out. The salary is worse. The hours can be longer. All of these slightly favor anesthesia where I don't have a patient base and a set clinical schedule, where my life is more flexible to accommodate my other responsibilities. The salary in anesthesia is higher than general internal medicine and comparable to a subspecialist, giving me a buffer if I choose to work in academics.

Decision-Making I

I'm terrible at making decisions. And here, I don't think there's a perfect decision. Or at least, no clear cut choice. But I'm about three weeks behind schedule, and everyone's bugging me about what I want to be. Most of the time for these conundrums, I scrutinize everything as rationally as possible, but of course, rationality only captures part of it. There are so many other factors, the silent and unmentionables, the emotions and secret desires. In the end, I'll decide based on incomplete information, as most critical decisions are; such is life.

The decision is between internal medicine and anesthesia. But I have to define things more precisely than that. If I were to pursue medicine, I am nearly certain I'd subspecialize. I know it's all the rage these days, but I've thought about this quite a bit. I don't want to be an outpatient general internal medicine doctor, that I'm sure. The hospitalist role is a little closer to the realm of possibility but after imagining myself as a medicine attending, I don't think that's what I want. Although I like knowing a bit about everything, I like the idea of expertise even more.

The problem is that I don't know what kind of subspecialist I'd be. Cardiology has always been alluring, but the standard outpatient cardiology fare - atherosclerosis, coronary artery disease, hypertension, hyperlipidemia, atrial fibrillation - is simply "okay." I do like arrhythmias, congenital heart disease, and invasive stuff like intra-aortic balloon pumps, but I'm not sold on the specialty.

Infectious disease has also been attractive, but I'm afraid that the practice is less exciting than the idea of it. In my mind, I imagine ID to be filled with obscure great diagnoses like brucella or leptospirosis or non-Hodgkin lymphoma (that's why all the cultures have been negative) but in reality, I worry that I'll be doing hospital infection control, wrestling with other services over antibiotic use, and waiting for cultures. I don't know what outpatient ID is like.

Some other subspecialties - endocrinology, hematology, pulmonary critical care, and rheumatology - seem vaguely interesting, but not enough to convince me now. The problem is that if I pursue medicine, I'm investing 6 years of my life without being fully convinced that I'll find what I want.

As for anesthesia, I'm in a similar bind; I don't think general run-of-the-mill anesthesia is what I want to do. I think I might get bored of the cases, and I want to have particular expertise. Cardiac anesthesia attracts me; even though I only had a hint of it in my anesthesia rotation, I wanted more. I can see myself as a cardiac anesthesiologist a little more clearly than I can see myself as a cardiologist. The things I like about cardiology - the high intensity, sick patients, immediacy, and procedural nature - trickle over to cardiac anesthesia. Lastly, critical care is accessible from multiple venues, and anesthesia is as good a route as any.

One caveat is that our clinical rotations give us far less time in anesthesia and critical care than medicine, yet despite having only limited experiences, I feel a little more certain I'll find something I like. Even though I've had equally little experience with obstetric anesthesia and rheumatology, there's a little part of me that would want to do the former rather than the latter. Should I be listening to that instinct? And who knows? Maybe pediatric or transplant anesthesia might just catch my eye.

Anesthesia is nice in that it's 4 years, one of which will be internal medicine. Subspecialization is an additional year so it's a total of five, and intern year will sate some of that medicine drive.

This is day one of pondering.

Dermatology Elective

The introductory clinical dermatology elective was pretty useful. Since we don't get much dermatology exposure otherwise, I started with the basics. Over the two week span, I really became comfortable with the vocabulary and also realized how difficult it is to describe a skin lesion precisely. I learned a little bit about common diseases, but realized I've only experienced the tip of the iceberg of skin disorders.

I think I was particularly struck by the juxtaposition of my rotations in critical care and dermatology. In my last elective, half our service was dying. We had patients with necrotizing fasciitis, amputations, open fractures. We were concerned with keeping our patients breathing, comfortable, and safe. Then I moved to the outpatient dermatology world where most of my patients were concerned about the cosmetic result of a skin biopsy or the scar of acne. You could not find two more different clinical settings.

In the end, I think I appreciate dermatology a lot more than I used to. Skin baffles most doctors and we discount it. But there's a lot more to it than topical steroids. It's a little too outpatient focused for me, but the subject matter is interesting and the process of diagnosis is fun.

Dermatology Grand Rounds

Grand rounds in dermatology is pretty unique. Each week, faculty invite patients who are interesting, educational, or difficult cases. Then the whole department, perhaps 40 of us faculty, residents, and students tromp from room to room seeing the patients. It must be quite overwhelming to have so many clinicians come stare at a rash and ask the same questions. I really am appreciative of the patients allowing themselves to be poked and prodded by strangers. Since so much of dermatology is visual and tactile, meeting an actual patient is so much more visceral, memorable, and effective than staring at photographs.

One of the patients we saw last week was a 40 year old with new onset facial puffiness, edema, and weight gain. Her skin findings included violaceous striae on her abdomen and scars (keloids) on her arms from a car accident. It was a fantastic case for me as a medical student because I immediately recognized it as Cushing's syndrome. She was being presented because she was getting intralesional injections of corticosteroids to her scars to improve their cosmesis, and apparently, the keloids acted as a reservoir, dispensing triamcinolone systemically and leading to iatrogenic Cushing's. Fascinating.

The other cases tended to be somewhat obscure diseases; we had a 14 year old with a genetic defect in keratinocyte formation and a 50 year old with Darier disease. Nevertheless, it's really fun watching the diagnostic giants of the department think through these challenges; from the questions they ask, the focused physical they do, I learn a lot about their thought process.

Poem: Ichthyosis

Ichthyosis

There are almost as many types of mermaids
as there are fish in these seas,
mermaids who teem in schools, flitting
from one island to another
in support groups and conventions,
places where can wear short sleeves
and backless dresses, where they complement
each other on their scales.

Most of the mermaids, you can't even tell.
They're driving down the street,
shopping at your grocery store,
attending your schools, working at your job,
shedding fine little scales like dandruff,
wriggling in the dance clubs,
diving into your local pool,
paddling kayaks down rivers.

Fish permeate our lives;
we eat them on New Year's for fortune,
stare at them in constellations in the sky,
idle our day by the river, pole in hand.
In the green light of the aquarium
faces pushed up against the glass
watching darts and swords,
jellies and mantas, like a cloak
or a plume through the water.

Oh, what must it be like to be a fish
with a phobia of water, who must lather
herself with emollients, smoldering in oils.
Now I know, there's nothing romantic
about these aquatic feathers,
nothing mystical about these mermaids.

Dermatology Clinic

Students have the most autonomy in general dermatology clinic where we see the bread and butter: moles, eczema, warts, tinea, psoriasis, urticaria. It's fairly fast paced but we learn quickly the pertinent elements of history and how to describe a lesion effectively. And though I haven't seen enough to be fully comfortable with common skin conditions, at least I'm getting to know the general approach to problems and topical medications.

We also spend some time in other clinics. Pediatrics clinic is quite fun; we see a lot of acne and babies with rashes. In pigmented lesion clinic, we see patients who have a lot of moles, atypical moles, and melanomas. Some patients have hundreds of moles, and the full skin exam is actually quite hard. When looking at 60-100 spots on the back, how do you pick out the ones you want to examine with a dermatoscope (magnifier) or biopsy? Today, I had high risk cancer clinic for solid organ or bone marrow transplant patients. As a result of their transplant immunosuppressive medications, they are at higher risk for skin cancer. Although most of the visits involve just a skin check, I find it interesting because of the medical complexity, regimens of multiple medications, and alterations of the immune system. We had patients with heart, lung, liver, and kidney transplants. Lastly, complex dermatology clinic is with the chief of medical dermatology Dr. Berger, author of Andrews' Diseases of the Skin. The patients in this clinic are referred from other dermatologists as diagnostic mysteries or therapeutic conundrums. It's really quite educational thinking about these patients and watching him work through these rare presentations of common diseases and common presentations of rare diseases.

Maculopapular

When describing a rash, macules are flat and papules are raised; this seems like an easy enough distinction. Yet whenever I was on medicine or pediatrics, we were often wishy-washy on describing rashes, calling them "maculopapular." After doing two weeks of dermatology, I realize that's a pretty useless descriptor. Hopefully from now on, I'll actually be able to describe rashes better.

Image is in the public domain, from Wikipedia.

Derm Surgery

I had a few half-days in surgery clinic. Dermatologic surgery seems to encompass two things: biopsy and excision. I got to do both a punch and a shave biopsy, which were fun. The shave biopsy uses a small blade to shave off the top of a skin lesion to send to pathology; we did it for a suspicious potential basal cell carcinoma. The punch biopsy uses a round knife to take out an entire lesion concerning for melanoma. Neither are particularly risky or harmful procedures, but cosmesis is often important to patients. I also got to see several excisional biopsies and Mohs surgeries, a labor intensive surgery that excises cancers extremely precisely, using real-time microscopic pathologic evaluation. This allows minimal scarring on sensitive areas such as the face.

Unknown Dermatology Cases

Two posts ago, I mentioned that much of dermatology is pattern recognition. But what happens when something defies recognition? Several times in this rotation, I've come across diagnostic mysteries. But it reassures me that dermatologists go back to a systematic method of assessing the rash. Is it infectious, inflammatory, neoplastic, a primary skin disease, a drug rash, or a manifestation of another disease? In the end, a biopsy is always taken since that's the gold standard, but at least the thought process is fun.

We had one interesting case of an 18 year old with a presumed diagnosis of inflammatory bowel disease for 7 years. He had initially presented with severe anemia, weakness, and bloody diarrhea. Since then, he's had multiple colonoscopies with biopsies but none have been diagnostic. The gastroenterologists aren't even sure whether this is ulcerative colitis or Crohn's disease. When you learn about these diseases in medical school, they're completely distinct; every test asks about the differences between the two. Yet in real life, that diagnosis has so far evaded us. Several months ago, he started developing large erythematous ulcerating plaques on the backs of his lower legs. We expected this to be pyoderma gangrenosum or Sweet's syndrome, both associated with inflammatory bowel disease. Instead, the biopsy came back polyarteritis nodosa, a vasculitis. The attending even reviewed the slides himself. This really surprised us; the lesion didn't suggest a vascular component and there's no known association between inflammatory bowel disease and polyarteritis nodosa. However, then we began to wonder whether his presumed gastrointestinal symptoms could actually be due to visceral polyarteritis nodosa. That would explain why all the colonoscopic biopsies were nondiagnostic. Very interesting.

Poem: Air

Air

I got a glimpse before they put him under
and he reminded me of my father, only
twenty years younger and dying.

They used to ship them out to California
to die, those vampires, thin
as ghosts, pale as rain

no wonder they called it consumption,
eating away muscle, leaving dents
in the side of the head, like handles

for skulls, no wonder it claimed Hugo's Fantine
and Egyptian mummies, no wonder it claimed
this man, his neck swelling up

like balloons, plump with air.
We are going to pop one,
slow his rise to heaven

but looking at the other masks
even I know that we're grasping
at air, unpredictable, certain.

Pattern Recognition

The interesting thing about dermatology is that it is all about visual pattern recognition. A dermatologist just glances at a rash and knows what it is. Looking at the image above, you immediately know it as psoriasis or have no idea. Even though there is a systematic approach to rashes, nearly always, a dermatologist makes a diagnosis without thinking through it systematically. Though I could tell you about the shiny silvery scale, the well-demarcated border, the location on an extensor surface, a picture is a thousand words, and the sight makes the diagnosis. Sometimes they can't even explain exactly how they know something is a mole rather than a skin cancer; it's a culmination of experience. "I've just seen so many, I know this needs to be biopsied," they say.

Nevertheless, this thought process is not unique to dermatology. Although it is most easily distinguished because it is visual pattern recognition, all of medicine involves this heuristic thought process. If you say "headache, fever, photophobia," my first instinct is lumber puncture to rule out meningitis. But if you instead said, "headache, nausea, photophobia," I'm thinking more migraine (but certainly meninigtis is a concern). Lightheadedness, chest pain, and tachypnea in a 50 year old man concerns me for a heart attack (myocardial infarction), but the same triad in a 20 year old woman triggers anxiety in my head. This fascinates me; how do we learn these shortcuts, how do we put together these stories, how do we come to recognize these patterns of signs and symptoms to reach a conclusion without working systematically? And, how good is that way of thinking?

Image of psoriasis shown above is from Wikipedia, shown under GNU Free Documentation License.

Hair Clinic

I had a half day in hair clinic - yes, such a thing exists. And everyone had the same chief complaint: hair loss. The patients ranged from age 14 to 70, and were predominantly female. The diagnoses ranged from androgenetic alopecia to age related hair loss to traction alopecia. Treatment was commonly minoxidil but I saw some intra-scalp injections of steroid. Nevertheless, I learned a lot about the approach to hair loss and the psychosocial impact of this disease on patients.

Image is of alopecia areata, taken from Wikipedia, and is in the public domain.

Skin

I'm doing dermatology for the next two weeks. This is a short elective rotation, fairly distinct from my career goals but nevertheless an interest. In our curriculum, we don't get much skin; there were probably only two or three lectures in my first two years. But after third year, especially in medicine and pediatrics, I realized the importance of the rash. I also realized how difficult it is to translate a vivid image of a rash into words. How can you capture the striking appearance of psoriasis in dry scientific descriptors like "scaly silvery papules and plaques"? And the converse, how do you take someone's description of a "brown verrucous stuck-on lesion" and translate that to a seborrheic keratosis? And what is a seborrheic keratosis? Indeed, dermatology is such a visual field; much of this rotation is learning to speak the language to communicate an image, but in the end, we just pull other people into a room to see.

The rotation itself is not bad. There's a good amount of self-study with online modules and textbook chapters to read. We have a few didactic sessions and a presentation. Otherwise, we have a mix of general dermatology and specialty clinics, shadowing and independence, surgery and steroids.

800

The eight hundredth post of this blog is dedicated to the readers. Thank you for reading this blog and entertaining my odd musings. Whether you read this blog regularly, in boluses, as procrastination, or by accident, I appreciate your time and effort in doing so. Whether you are a close friend, a classmate, a stranger, a pre-med, a doctor, a patient, an international reader - I appreciate your patronage and support. To those who've left messages or comments to my posts, I read all of them and thank you for your thoughts. Your words do change the way I think and act and though I don't often write back, I should. Your comments, criticisms, and arguments are much appreciated. Thank you.

Critical Care

I enjoyed my critical care rotation. There was a steep learning curve (figuring out the ventilator!) but as I learned how things worked, it got better quickly. The patients were predominantly trauma and neurology patients and for the most part, we knew the diagnosis; the complexity was in the management. To be honest, the disease processes weren't so interesting to me (it's more the fat emboli from the trauma, the cerebral salt wasting in brain patients) but the physiology and pathophysiology of critical illness is very interesting. I liked how the unit was open; the primary team took care of most things while we consulted on sedation, airway, and general management. It requires a lot of communication, but it was fun being in the consult role; we could focus our time on procedures and learning. And indeed, I found the procedures to be fun; I put in nearly a dozen arterial lines and a central line, and over the month, my confidence greatly increased. The hands-on stuff really made me happy. I also grew much more comfortable with assessing who was sick and who was not, dealing with ventilators, and managing anesthetic agents like propofol. I liked the multidisciplinary approach; we had a neurology, anesthesia, and surgery attending, and it was educational hearing their expertise in their fields. Nurses and respiratory therapy were intimately involved in patient care. We had both surgery and anesthesia residents; the ICU is truly a team endeavor.

I only had three calls but on each, I admitted from 3-5 patients; while normally that would intimidate me, I found it to be manageable. It was good to see patients through their entire ICU course and indeed, there were some that I was extraordinarily happy to see walk (or wheelchair) out of the unit. That in itself is a great feeling; starting with someone shot in the head, spending weeks on the ventilator, sedated and unresponsive, who suffers a pulmonary embolism, and watching them be extubated, stand up with physical therapy, and leave the intensive care unit. Even though most of our patients couldn't talk, I still found the relationships to be meaningful, and I was still invested in their care.

Poem: On Turning Twenty-Three

I did not write this when I turned twenty-three, nor do I think I had these thoughts, but I like that age.
-
On Turning Twenty-Three

I'm still taking tests
with number two pencils,
writing essays and term papers
in this mime of real life
while my cohort
is running businesses and marathons
making salaries and wedding plans.
My goals are ages away,
curiosity and wanderlust
pave my meandering
and at this junction
between palindrome and prime
my big moves are still dreams
hatched from an unharnessed mind,
immature and volatile,
buying into an investment
I don't really understand
to do a job I cannot fathom
with faith in my divergence
from that real life road
to pursue more books,
more letters after my name.

July 4

The critical care fellow during my ICU rotation was an army trauma surgeon who had done three tours in Iraq. He had a wealth of experiences and unbelievable stories from the war. One of the stories I particularly enjoyed was about blood. They only carried a limited amount of packed red blood cells for transfusions; when he was there, they didn't even have fresh frozen plasma (FFP) or platelets. However, most of what they saw was trauma: gun-shot wounds and improvised explosive devices. Such cases can require massive amounts of transfusion. But he said it was never a problem; if they needed blood, they would put out a call and the "walking blood bank" - soldiers - would line up to donate. The soldiers didn't know whether the blood was going to a comrade, a civilian, or an insurgent, and it didn't matter; they simply stuck out their arms to give. That story put a smile on my face.

The other thing that made me grin was that one of my friends is attending a wedding today. Ironic, isn't it, to get married on Independence Day. Happy 4th, everyone.

Conversation

One thing you notice as a medical student is that all your topics of conversation revolve around medicine. You get together with med school friends and all you talk about is this rotation or resident or interesting case. You see friends in other fields and itch to tell them about your day or your plans or having to stay up all night. You forget other stuff exists; when Barack Obama comes up in a conversation, you're only interested in talking about his health care policies; when Michael Jackson comes up, you focus on the cause of death. You have no idea what movies are out or what people do in their spare time or who is dating whom. Our world suddenly becomes so small, so vivid and fascinating to us, but a black box to everyone outside.

Continuity of Care

Interestingly, I had some continuity of care between my medicine and ICU patients. One patient I met my first day of medicine was a woman with diabetes and cirrhosis admitted for diabetic hyperosmolar non-ketotic coma. At the time, she had an abscess on her butt; surgery was consulted and they did a standard incision and drainage. While she was on my medicine service, we worked her up for altered mental status. As that cleared, she started to complain of more back and flank pain. Imaging showed blossoming fluid collections in multiple areas of her pelvis and abdomen. Again, we consulted surgery who drained it several times, but she did not get better. One morning, I went in to find the team afray because she had become hypotensive, tachycardic, and febrile. Unfortunately, she had developed necrotizing fasciitis, the dreaded "flesh eating disease." This infection of the soft tissues spreads rapidly and can kill patients within days. Immediately, surgery took her to the operating room for wound debridement. They opened her up and dissected away all the dead tissue. She went to the surgical intensive care unit. A week and a half later, I started my rotation in the ICU and of course, she was there. Since I knew her, she became my patient. Despite going to the operating room eight times in the span of a week, they could not adequately control her infection and they had to amputate her leg at the hip. On the surgical ICU service, I worked hard to control her pain and wean her off the ventilator. We successfully discharged her from the ICU to the floor. Unfortunately, she bounced back to the ICU a week later when more necrotizing infection was found in her back. She eventually needed a colostomy and a tracheostomy. On my last day of the rotation, I was able to discharge her again back to the floor. Hopefully this time, she is heading for recovery.

I also saw another patient on medicine in my first month and subsequently on surgical ICU. This patient is a paraplegic from a gunshot wound several years ago and had developed horrendous sacral decubitis ulcers. In order for the ulcers to heal, he needed a colostomy and ureteral diversion for plastic surgery to skin graft the wounds. When I was on the medicine rotation, we spent most of our time "optimizing" him for surgery, mostly by supplementing him with nutrition and getting him on a stable medication regimen. He was still on the medicine service when I moved to ICU. I forgot about him until weeks later when I heard that we had a paraplegic patient coming up from the operating room after a colostomy with ureteral implants. It was the same patient I had cared for on medicine.

I'm actually pleasantly surprised by these continuity of care experiences. It's wonderful and educational to see a patient's experience with a disease process and their hospital management. I felt that we were able to deliver better care to these patients because I knew them, I understood their entire hospital course, and I was able to treat them comprehensively as a whole person. After learning how different services operate and prioritize, I was able to incorporate a little bit of everything in caring for these patients.