Monday, June 23, 2008

Strawberry Swing

Her eyes started across the sparse hospital room into eternity, my presence unacknowledged. I introduced myself as a student from neurology, and explained that we were asked to assess her situation by the main team caring for her. I scanned her 78 year-old frame for any signs of trauma or external manifestations of disease. She laid motionless, angular with knees drawn into her body. Her illness was hidden from my inspection, but I knew having read her history that she was wracked by severe Alzheimer's Disease. She did not blink and she did not speak, rather her mouth remained half open, hoarse gurgling sounds streaming forth with every exhalation. I continued speaking in a calming tone as I examined her, knowing that her mind did not register a word I was saying. In retrospect, my unnecessary one-way conversation was almost certainly to calm my own nerves. After all, inflicting pain in a hospital should always come after the civilities.

The neuro exam is often difficult for patients to endure. For high functioning patients the low-level cognitive function tests and repetitive movements must seem mere child's play, while those with true neurological deficits must experience a great deal of frustration when faced with the reality that motions and sensations that were previously second nature can now be impossible. Even more difficult is the exam conducted on a comatose or severely demented patient, who is entirely unable to cooperate or verbalize sensations, cognitive ability, or fluency or comprehension of language. This forces the examiner to become a physical exam instrument, testing sensation in all limbs by compressing nailbeds to inflict pain and monitoring for a response. More often than not, at this point of the exam I find myself wincing in sympathetic pain as I press down fiercely on the patient's nailbed with the metal handle of my reflex hammer. More often than not, the patient is so obtunded that they do not even flinch with the inflicted pain.

After thanking the patient for her cooperation, despite her inability to utter a single syllable during the entire exam, I left the room to report my findings to my resident and attending physician. I "presented" the case to the entire team as we stood outside her room, the time-honored manner in which physicians learn to transmit a patient's story to each other in a thorough and logical manner. Soon our patient was being wheeled back into her room, cutting a swath through the crowd of white coats. Following closely was an elderly man, slightly overweight and walking with a strong gait. He appeared well enough to play 18 holes of golf more days than not. As he waited outside of the room while our patient was being transferred back into her bed, it became obvious to me that this was the woman's husband that was mentioned in her chart. The chart indicated that he cared for his wife in their home, only getting respite twice a week for a few hours. Even skimming our patient's story and having a crude understanding of the severity of her disease before seeing her for myself, I quickly understood that the care of his wife was a huge undertaking. I remember feeling a vague sense of admiration when learning that she lived at home, yet I couldn't suppress the feeling that maybe he really did not fully understand just how advanced her condition was.

My preconceptions were blown away with one look at his face. The care, love, and concern that he showed for his wife, who must have been a frail shell of her former self, was enough to rend my heart. I struggled to finish my presentation of his wife's case in the impartial and highly scientific manner that is encouraged in the medical field, regardless of the specialty, fully aware that he stood mere yards away, listening to every word. It was obvious that his world was hanging on my assessment of the situation. I continued spouting medical terminology as I fumbled for a reason why his wife's Alzheimer's had worsened overnight, but for him I had no words.

Upon finishing my presentation, I watched as my attending ushered him into the patient's room, asking questions along the way about recent events and changes that might have led to her current state. Wounded, I stared at my shuffling feet as I tailed behind the team, dreading the moment when I would finally have to look up and see this strong man coaxing his wife to speak words that would never come.

Thursday, June 19, 2008

The Longest Mile

When I was in high school I ran cross country. Poorly. To make things even worse, I was one of those cross country runners that the other runners hated, namely the person who was running only to train for another sport that they were much more interested in. In my case, I was a 6'5" basketball player whose only purpose for running was to show dedication to his coach's advice to run in an effort to make varsity as an underclassman. I had little to no stamina, only a moderate amount of sheer determination, and exercise-induced asthma. On the other hand, as I was a veritable behemoth when it came to the prototypical running physique, at least I had a long stride. Needless to say, when it came down to it I was the epitome of average.

Cross country was probably one of the most physically and mentally exhausting things I've ever done. I wanted to quit during the first mile of every race I ever ran, and imagined a myriad of scenarios in which I used my asthma as a crutch to get out of finishing the race. My lungs would be burning, my legs were lead weights, and I would be struggling along with the pack while the more skilled runners whizzed past us, all while my mind worked fervently to betray my efforts. With each race I was convinced that this would be the one when I would finally succumb to these deep desires to just give up on this cross country insanity.

One race stands out in my mind as the turning point when I realized that I would never be able to just give in. Each season teams from around the region in our conference would travel from town to town, usually running on golf courses or courses running through large parks. It was considered an honor for your town to have a course with which to host a race. The small town of 4,000 at which I was a freshman was one such town, and boasted one of the most challenging courses in the conference, filled with large hills, abrupt changes in direction, and was ran as a continuous circuit, with no repeated laps. This made it even more difficult, as it was impossible to scout the course out during the first lap and make any moves on "easier" parts of the course during subsequent laps.

Our team had been instructed to work even harder heading into this race, as we wanted to put on a good show for our fans at home, which in cross country mostly consisted of close friends, family, and significant others. I complied with this coaching stratagem, as I was certainly not going to go out of my way to look like a slacker in front of my friends. However, about a week before the race I became ill with what, at the time, was my semiannual respiratory infection. These infections seemed to come on each winter and spring and lasted almost a month each time, worsened by my asthma. I was always able to continue competing in sports, however my stamina was usually diminished somewhat and I coughed like a maniac, often forcing referees to ask me during the game whether I was okay to continue playing.

So naturally, I was extremely excited to be running our heinous home course in front of my close friends, feeling like crap and in a sport for which I had no actual affinity. I barely remember the thoughts racing through my head during the actual race. I do remember feeling somewhat delirious during much of it, and wondering if I was simply going to collapse. Oddly enough, the thought of actually quitting the race of my own volition never passed my mind. It wasn't so much that I was determined to finish, rather my mental state was such that I'm not sure my brain actually registered that it was a possibility. I had been reduced to primitive reflexes. Evidently one of those reflexes has something to do with running like a dying chicken (which, I've been told, summarizes my running style). In the end, I crossed the finish line glassy-eyed and diaphoretic with a finishing time slightly off my average for a 3 mile race and as my friend who worked as our team assistant ran over to congratulate me, I doubled over and threw up. Looking back, I think that day marks the first day I actually felt proud of running cross country, because it was the first time in the sport I overcame an obstacle that months before I would have said was impossible.

I'm now exactly one week away from finishing my 3rd year of medical school, which is the first year spent entirely in the clinical setting. Over the last year I've worked with infants suffering from terminal brain damage in palliative care, incredibly warm military veterans with newly diagnosed cancer, psychiatric patients who will likely never receive the care that they need simply due to the American health care system, and an incredible number of patients with a nebulous distrust of health care professionals and a nearly infectious negative attitude. I've worked long hours shoulder to shoulder with some of the most caring physicians a patient could hope to work with, and also with some of the most jaded, cynical, and nearly inhuman health care professionals treating patient and junior colleague alike with nothing but distrust and disdain. I've found my personality and attitudes morphing into the dominant culture of every branch of medicine in which I've rotated and in the end I've said and done things that I'm not proud of and wonder just how firm my self-identity really is. As I approach residency, one year away at this point, with the stresses placed on a new physician and the hours necessary for our training, I wonder if I will even be able to keep tabs on who I am and will have any control over who I will become. Will I be just another one of those overworked physicians whose patients are convinced don't listen to or care about them?

I guess my cross country story entered my mind today because I type this as an exhausted medical student. Not someone looking for assurance, sympathy, or misplaced compliments. Rather as someone who often feels delirious as he tries to understand not only the medical concepts that he is inundated with on a daily basis, but also the ethical and interpersonal ramifications of the health care system in which he struggles. As I limp away from my third year of medical school I find myself utterly confused as to just who I am to become in this profession. I can only hope that much like the aforementioned race my mind can slip into a primal autopilot and emerge on the other side of this training proud of the results.

Saturday, June 14, 2008

Don't Call It a Comeback

So, it's been a while. How have you been? Me, not too bad. Turns out the first board exam is as hard as everyone says, and that studying 12 hrs a day, 6 days a week for 5 weeks leading up to the exam is not great fun. Turns out good friends can get you through it, though.

Oh, 3rd year of medical school? Good times, long hours. You get to experience a little bit of everything in medicine, which is great. The only problem is that as soon as you feel a small amount of comfort in one specialty it's time to rotate to the next one, where you can feel like an idiot again for a few weeks. No worries though, as long as you have an idea of how to act professional, a good sense of humor, and don't take yourself too seriously, you'll get by. Things get even better towards the end of the year when you finally decide on a specialty and can (potentially) relax about grades and settle into learning aspects of each field for the sake of your future career.

You always thought I would do ortho, huh? Well I actually decided on pediatrics (probably a subspecialty in the field that will allow me to do hospital work). As much as I would enjoy the money and lifestyle that comes with some other specialties I was considering (interventional cardiology, I'm looking at you!) I couldn't overlook the fact that taking care of kids during my first few months on the wards was the most rewarding experience I had all year. The other nice thing is that even the sickest kid whines less than the average adult patient. Parents? Yeah, they can be a little challenging, but you can tell even the less-than-ideal ones love their kids and are usually trying to be better parents. Sometimes mental illness or poverty just get in the way of that ideal. And sure, working with child abuse will be tough, but we all know it happens and I'd rather be the guy trying his best to defend those that can't defend themselves than just look the other way and try to protect myself from the ugly reality of it all.

So there you go, all caught up. I'm finishing up the last 2 wks of my 3rd year and am looking forward to what, by all accounts, should be a cush 4th year full of electives, residency interviews, and vacation months. I'll try to do a little better with staying in touch in the future...