northern exposure

so....

3 weeks here and i've finally found some wireless internet....at the hospital. where i work. all day. every day. and now, on my day off, here i am.
it's not so bad when you can show up and not have to think.

otherwise, it's a struggle. for a rural town in northeastern WA/northwestern ID, there sure are a lot of interesting cases. mostly cause people up here do what they want and only get medical care when they really really really need it. which is great for me, bad for them. huge cans of worms lurking around every corner. and people my age who look 50. 50 year olds who look 70. very few 70 year olds....

other than that, it's kinda fun. no surprise here, i love rural medicine. i love that providers choose to be here and are compassionate and not assholes about it. and that they laugh about things that 90% of the population really would not find funny. i love that they love teaching me cool stuff. i love that it's a small community that you could easily integrate right into. i love that i see pts in the ER, follow them to inpatients, through the OR and back out on the other side. i love visiting the folks in long term care and delivering babies in the same day. and i can't beleieve that i haven't seen the same pt twice in the 3 weeks here.

and truth be told, i love assisted living. there would be a gold mine to be made for anyone who wanted to create some sort of post-college age assisted living sitaution i think. it's just so easy. amazing how much time you can spend doing things you like when you're not worried about keeping things neat and clean, or cooking for yourself. for single people, it's pretty much the holy grail of living, i'd say.

i like this town. granted, there's not a whole lot here, and i haven't seen the sun in 3 weeks. but there is a nice safeway. i don't get out much cause i don't have a car, but the surrounding area looks nice. lots of mts, lots of trees, lots of snow. the assisted living place i'm staying is right across from 3 churches and a funeral home. one stop shopping. everytime i venture outside the town smells of pine trees and woodsmoke, not a bad combo. other than that, not much going on. i feel like it may as well be alaska, minus the grizzlies. they've got everything else here...i run into deer around town all the time. fortunatly, none of them have run into me.

i work, i eat, i sleep a little bit inbetween so i can go home a week early. i was adopted for thanksgiving and it was nice. lots of babies to squeeze. my own babies have been busy running amok in seattle and being city kids through and through. i think about bringing them to a place like this and wondering how it would all shake out. would they be outfitted in camo and bringing me home some elk by first grade? would we live on a ranch? have horses and tractors? would they ever be clean again ever?

my slightly humorous note of the day involves a little scenario that went down last wednesday, the day before thanksgiving...we're sort of sandwiched between 2 reservations here, and i had a native american patient who came in that day who wasn't exactly the easiest to talk to but we muddled through the encounter and came to the end and not really thinking about it, i said goodbye. and wished her a happy thanksgiving. and then walked away and tried not to cringe. can you do that? was it bad form? politically incorrect? it was sort of funny in retrospect, though...

gearing up for the big ER x-mas party next weekend. will try not to make an idiot of myself, but can make no promises. in the meantime, i plan to relax for the rest of the day, turn on the TV and pretend like sitting on the couch for the rest of the day uninterrupted with my bag of lucky charms is somehow a luxurious endeavor. and then right back at it tomorrow.

home in a week and a half. i can't wait, even though i'm dreading another move during the holidays....to who knows where....

Dime a dozen

Dime a dozen
Originally uploaded by Nikki McLeod

hawaii's got nothin' on oregon in the fall and spring. ok, maybe the ocean temp. but as far as rainbow state rivals, i would wager hawaii could just get cozy in that back seat. my commute is beautiful. and, at least one trip of the day is done in daylight hours, so that's a bonus.
in the dark it is kinda creepy on the back roads.

last week i hit a possum on the way into newberg. it got to me more than i ever thought it would, mostly because it was not by any means a small possum, but i pushed it neatly under the figuritive rug.

until today, when my first legitimately *crazy* patient showed up with some sort of acute psychosis going on. after ruling out she wasn't seizing (generally not a bilateral movement phenomenon that one can talk through) i tried the old cure for pseudo-seizure my preceptor recommended...smelling salts. and hey, they work! imagine that. snapped my patient right out of it long enough to get out of her that she was having these constant visual hallucinations....of dark places, with animals with red eyes....

and dammed if the first thing i thought of was that unfortunate possum.

and her fear became real to me. i got it. it would really suck to be stuck in that world forever. i'd probably be shaking non-stop too.

acute onset schizophrenia? maybe. it sure fit. not up to me to make that diagnoses, and i'm glad it never will be. admit to psych. done. yikes.

in other news, the boys are madly whittling down their halloween preparations...initially it was supposed to be some sort of scooby doo holiday, but now we might be going in another direction altogether...tomorrow is the deadline. we shall see. liam rode around the neighborhood this afternoon making a map of the super decked-out halloween decorated houses, so we're gonna hit those up first. last year they lasted about 2 blocks before the desire to eat the candy outweighed the desire to get more. this year, mommy has a chocolate quota that needs to be met, cool decorations or no.

if i'm going to be shipped out to newport, WA for a northern exposure stint in 2 weeks without my family, then i will need all the emotional and cocoa-bound nutritional support i can get. will enjoy the scenery and the sugar in the meantime.

some swine with that cheese.....

ER celebration humor
Originally uploaded by Nikki McLeod

oh ER humor.

swine cakes in celebration of ER nurses week showed up today. painstakingly and wonderfully handmade.... including the pink marshmellows. touche, martha.

i might add a sad note, however, that last week, in honor of PA week, there was nothing. not one treat. this week it might as week might as well be halloween, valentines and easter all rolled up into one sugary gooey morsel. and the one PA who i actually wished a happy PA day to responded, "oh, ok. wait, what? we have a day?"

who needs recognition, anyway. i can steal the nurse's treats and be just as happy.

besides being ignored by hospital administration as a professional, however, i have been having quite a fabulous time in the ED. more fun that i thought i would have. seeing more craziness than i thought. rural ER's are fun that way, since the weird is usually funny and interesting instead of...really weird. ie... drunk/stinky/psychotic.

gunshot wounds, eyeball foreign bodies, GI foreign bodies, broken bones from tripping over the dog and falling off tractors, GI bleeds, heart attacks, miscarriage, lacerations, car accidents, ginormous hernias gone unchecked for 8 years, lumbar punctures, central lines, NG tubes, and today, icing on the cake, an addisonian crisis. i mean....that's good stuff. i might be in love.

except for the swine flu bit. these patients are everywhere. probably a 3:1 ratio to all the fun stuff is flu symptoms. and these people are miserable, but sent home. and not accounted for, cause that only happens in the state of OR if you're admitted. fun fact for the day. huh.
my favorite are the patients that come in after trying to battle it out for a day at work and then realize they're too sick. nice. move. people.

i have yet to be immunized for that. i'm sort of hoping that i'm getting enough exposure to sort of boost my immune system just by showing up. i am intrigued by the RN's tales of consequences at the hospital, and at other hospitals about what will happen to them if they don't get the H1N1 immunization. like having to take vacation time if they get sick, or in extreme circumstances, being fired. it's quite a controversy these days, and i think it's weird that it seems to have landed on the RN's shoulders the hardest. this as we admitted 5 patients on my shift alone today and then had to divert the rest since the nursing staff in the rest of the hospital was too depleted to fill the remaining 10 beds that were open....8 RN's called out sick on one floor alone today. i thought the nursing supervisor was going to lose it completely.

so
fingers will remain very clean and crossed from here on out.
except for when they're covered in chocolate and pink icing...

moving on...

the move's been made, the transition roughly complete. things once again worked out in the 11th hour, and although it's not exactly what we had in mind, it'll work. and we're too tired to think up an alternative at this point.

the drive back from san diego (although i like chip's version better- sandy eggo) was looong. and hot. the central valley is really such drain, a total life suck on so many levels. it was 107 degrees. every last thing was brown. we spent 2 hours in LA traffic before heading into the void, punctuated by a near miss 10 car pileup that was super scary, but probably provided enough adrenaline to keep us awake for the next 8 hours sans caffeine. stopped in marin to visit with friends who provided the boys with plenty of opportunity to play with their numerous dolls and dollhouses (which they were totally into) and we all geeked out on pizza, prosecco, and episodes of the muppet show. it was great. we woke up to views of mt. tam and pancakes, and were on our way again, to a more scenic drive.

which provided plenty of opportunities to reflect on 3 quintessential road trip ponderings really worth answering.

1. how DO you explain to your 4 and 2 year old that you have 8 more hours worth of driving? (and then a fun game is to take bets on how many more times you'll have to explain it before the day is through. it would also make a fun drinking game except for the pit stop ratio would then increase to the point where you'd be adding hours on to your trip.)

2. an obligatory esoteric question like: given a cow's propensity towards um, stupidity, do you think they are susceptible to lonlieness? and if so, then how can CA cows truly be happy? and if they're not happy, then what are they putting in the cheese there to make it taste so good?

3. (my favorite musing thus far) who comes up with the names for RV's?? it's like the testosterone soaked equivalent of the marketing geniouses who are responsible for naming nail polish colors. seriously... a sampling i saw included "hitchiker", "dutch star", "alpine coach", "mountaineer", "windsport"....although my favorites included "patriot warrior", "kountry storm", and "leprechaun". no lie. come on kids, let's hop in the leprechaun and head out for the weekend! honey, it's time to change the oil in the patrior warrior! and do people that own these things call them by those names? i'll bet there are secret clubs.

hours of entertainment right there.

anyways
back in hillsburrito for now. took over the parker family's apartment for the next 6 weeks which will be fine. lots of peeps in the hood this rotation to catch up with. looking forward to it. and looking forward to the next rotation in the ER. day one was today. 2 thumbs way up. i think i might just love it, although i was feeling that it was borderline a little cliche to have classic textbook presentations of the following patients on day one:
1. fractured hip in an elderly woman s/p fall
2. STDs
3. peritonsillar abscess
4. migraine
5. surprise! pregnancy abd pain
6. pneumonia
7. appendicitis

minus chest pain and a good laceration or some sort of trauma, it was nearly EXACTLY what i thought it would be. so i will hope that things will continue on in this manner. cause i actually knew what i was doing and it was FUN.

which is good, cause otherwise this week has been horribly terrible. but i'm thinking that there is a light that is shining a little brighter at the end of the tunnel now. and for the next 6 weeks things will be really great. and then i will deal with another round of chaos and depression and frustration and travel to the middle of nowhere....but i suppose i'll just focus on the good for now.

the grand finale

as far as grand finales go, it was a bit odd and unexpected, but honestly, probably the highlight of my clinical experience this go around...

final eval from preceptor: "Ms. McLeod has the finest pap skills I've seen of any student in the past 3 years."

oh. um....thanks. now there's a feather for my cap. i'll be sure to take that to the bargaining table wherever i go from here.

but i only worked half day today, so as it turns out i will have time to go to the beach one more time before packing up, enjoying one final dinner with friends, and then getting up at the crack of dawn tomorrow to drive to san francisco. with an almost 5 year old who will whine the whole time. and an almost 3 year old who has just finally come around to potty training. this week. both of them now with solid, boogery colds. awesome.

otherwise, the highlight of my week was working with a number of patients that needed translators. one of whom was deaf. which brought on a story from a co-worker that evoked the best laugh i've had on this rotation...

her friend works at a high school just for hearing impaired kids. she was tutoring a girl after school one day and the girl ripped a huge fart, but went along studying without even a blink. the teacher couldn't help but laugh, and the girl looked up and asked why her teacher was laughing. so the teacher told her (all in sign language, of course) that farting is funny sometimes. the girl seemed puzzled.
she asked her teacher, "but you're sitting across the table from me, how did you know i farted?"
the teacher answered "because it made a really funny sound."
the girl was mortified. "wait a minute, you can HEAR them?"

it would be pretty hysterical to find out in high school that sort of privvied information in high school, no?

and now, off to the beach for the last time in what will probably be a loooong time. sigh. summer will officially be over as soon as we get back to portland. pics from last weekends adventures attached....surfing was a blast and pizza port in solano beach is hands down best pizza and beer in southern california. put it on your list if you're headed this way. kudos to keri and paul AGAIN for showing us such a great time. LEGOLAND was a ginormously huge hit, just as we'd hoped it would be, a superb theme park for kids of all ages. liam and camper had the time of their lives. best. birthday. present. EVER.

arrgghh

it's international talk like a pirate day, which personally i think jumped the shark a while ago but since we're in a seaside-like setting here in san diego, it's sort of hard to resist. plus, with that one sentiment (arrrrggggh) i can totally sum up my experience here.

one the bright side, i have my boys back, and all is well. we've been doing all sorts of fun exploring at the beach, at balboa park, at the maritime museum, at coronado island, visiting some friends out and about, etc. that part has been pretty fantastic. just trying to enjoy the last week here before heading back into the great unknown at this point.

and when i say unknown, i mean it. we're back to pdx but at this moment, still homeless, and then it appears we'll be shuffled off again to somewhere on the canadian border...which continues to be a twist in the plot that i can't seem to come to terms with but at some point here will have to get over. in the meantime it's keeping me up at nite and remains a total energy suck.

i've had some good patients this week, my favorite was a bush pilot from alaska who happened to be in town for a family reunion and thought to get her annual checkup. last annual checkup was 10 years ago. cause that's how they do it in AK, time and health are just sort of these vague backdrops to reality. plus, i got the feeling she really wouldn't want to know if there was anything wrong with her, cause then she'd have to go find someone to take her out back with a shotgun, cause she would rather that than have to go to a hospital for any sort of care. what a character.

everyone else i have seen confirms my suspicion that a little xanax in the water supply here would go a long way. perhaps it's the disaster this of economic times we live in, or the mad pressure to become a VIP...(as witnessed in a woman who came in who gave me- though i declined to ask- the laundry list of her very famous clients that i didn't even know, reasoning that i had to make her "better" so she could go back to work because these people NEEDED her and she would be nothing without THEM....), or have unfounded swine flu fears and are demanding tamiflu left and right...

but really, people here in general seem to be worked up about things that are mostly ridiculous. and i can understand how that can be exhausting. but silly. i long for people with real problems and who can rationalize the bigger picture. and for people who understand the value of comfortable footwear. and i'm not talking about rhinestone covered crocs, although i really REALLY wish i had had my camera for those. maybe i'm misunderstanding their smaller issue for underlying bigger ones, but still....all i am hearing is that these people are too stressed out to go to the spa 3 times a week like they usually do, now they're only going twice a week. i'm not cut out for people with "special" needs like this.

in other big news on the homefront, camper is nearly potty trained, and liam got his first set of stitches this week. smashed his forehead into some steps as he was climbing up mt. soledad. 3 stitches and a bunch of steri strips later, he was happy as a clam...until i have to take them out. then it will be WWIII. scripps memorial hospital ED was great, we were in and out in a hour. our doc was a spitting image of the sarcastic head honcho on scrubs- i don't watch it enough to know who that is, but it was a pretty amusing comparison.

beyond that, we've been highly entertained by our neighbors nightly arguments and boisterous making-of-the-looove episodes afterwards. it's better than TV. conveniently in the middle of the nite. but, at least they're not our roomates....so we can openly laugh AT them without worrying they might see it. for the most part, our condo complex is pretty quiet and serene...with the exception of, of course, the people that live RIGHT next to us. so when camper throws a tantrum, we put him on our bed and let him shake the headboard, scream loudly and work it out. for as long as it takes.

someday we'll get it right. in the meantime, it's more rolling of the housing dice, another spin of the moving roulette wheel. T-minus one week until we get to play again! whoohoo!

surf's up...and we're headed out to the beach at del mar to jump on some surfboards with paul and kerri this afternoon, who really have saved the day in terms of us getting to know san diego in a much better way than we would have ever found on our own- followed by LEGOLAND tomorrow. we haven't told the kids. i think we'll just get in the car and pretend to get lost and just show up in the parking lot there and let them figure it out. hoping for a huge kodak moment.

guilty conscience

i'm sort of starting to develop this weird sense of guilt about all the fun i've been having...NOT in clinic. although, this time around, clinic is so bad that really, i deserve every decent moment otherwise...

this is the start of week 3 in san diego. huh. it's been such a weird time so far, it's hard to wrap it up. anxiety and depression might be a good place to start. which seems like odd concepts for me to be grappling with, as they pertain to me.

anxiety as in i can't seem to say or do anything right in clinic, it's all misconstrued and comes out wrong and i look like an idiot. and then i try to make it better by saying something else or changing the subject entirely. which then also lands flat. depression as in what i just said, now famously in print, mirrored in my eval. that came a week early, and with the punch line, "but it's not too late to pull your performance here out of the gutter..."

and there it is. the doom and gloom of performance anxiety gone horribly, horribly wrong. we have a tumultuous relationship at best, my preceptor and i. basically, we just don't talk. i've moved out of his office and into another space just to get away from the silent treatment. it's really no good. i don't know what to do about it. how can everyone else be so great and he is just...not? give me a few days and it will be funny. but right now, i just feel stupid.

fortunately, it's buffered by drug reps hawking delicious goodies and the occasional somewhat interesting schpiel...sometimes twice daily. (lunch and snack time!) there are 3 day a week catered breakfasts for staff.

one doc pulled me aside, giggling madly, and asked me how i've been enjoying my time here so far.
"well, i've not gone hungry, that's for sure", i told him. an honest answer, the best i could do.

"i KNOW!! it's just like camp, only better. i can't believe how much they're paying me and then they feed me too!"

camp scripps. add in mandatory nap time, and this place would be the pinnacle of professional acheivement. they could probably cut salaries in 1/2 and still have a waiting list of employees dying to work here. everyone should be so lucky. everyone should be so deliciously delirious about the simple notion of empty calories...and equally unashamed to show it in mad giggling fits too! i love it. today it was jamba juice. i'm secretly hoping for another round of mediterranean food. the felafels with the cucumber yogurt dipping sauce were fantastic last week. and since we've digressed here, i must say that i could eat fish tacos every nite and be happy. that slot was previously (and hautily) occupied by only sushi and pizza. they'll just have to duke it out for my gastrolove now. nothing like a little fish tacos to beat down my inner wannabefoodiesnob tendancies.

i've been walking to the beach everynite, figuring out the scene at all the beaches in these parts...none are really all that great, but i have finally landed in pacific beach for certain, towards the bay side. it's ok. whatever. i was sick of looking and it was cheap(er) than most. ben is so excited for his slice of melrose place. the sunsets have been great lately due to the fires in LA clogging up the skies and providing lots of cover for the sun to bounce off of.

and went riding bikes with megars this weekend, which was superfun...followed by a dip in the ocean, fish taco heaven, and wine on her deck watching the sun set over san clemente. it was....the gooey center of a reward already encased in the outer shell of happiness. good times. thanks megars! and also, was reminded by the media and my ride, that pretty much all of southern california is desert, plain and simple. hot, hot, dry tinderbox desert. green things amaze me at this point.

and...that's it. nothing more. the climate is vapid, and so are most of the peoples in these parts...although to be fair, i've landed in party central, so this is all in passing, soberly observation based. i'm sure it's WAY more fun to live here if you are none of those things. i've been doing a lot of reading. got a library card so i've been hiding out there a bunch (classic CA...a better movie selection than anything else)....and just hanging tight. the boys get here this weekend. i cannot wait to squeeze me some babies. it's been a looong time and i am starting to feel adrift...but i know when they get here that will be that and i'll really really start to enjoy my time, both being on the downward slope of putting this rotation behind me, and teaching them to boogie board. and possibly just cooking up a little secret birthday surprise for my liam at legoland. he's gonna blow a gasket.




and that's all i've got in this momentary morose state of mind. 'spose i'll shuffle off down to the beach now to be reminded why people want to live here. cause otherwise, fun to visit but.........yeah.

transported

oh MAN. where to begin? the last 2 weeks have been insane. but in a nice warm fuzzy way. except sometimes i get a little concerned when i get in that zone and things just seem to happen, and the next thing you know, boom- i'd driven a thousand miles and have arrived in san diego like nothing really happened.

which nothing really does on the I-5 corridor. so.. its not unlike waking up from a bad dream and finding yourself in a strange place- mentally, emotionally, physically. just wipe off the drool and start over already. cause hitting snooze is not an option.

i wrote out a fun list of road trip observations, which i now can't find...and the only thing i remember is basically that coyotes win the darwin award in california hands down....more roadkill than any other species as far as i could tell. although the mostly dessicated cow got bonus points for the most original roadside carcass. i'll try to find the list, it was funny at the time.

spent a fun week catching up with classmates in hillsboro, listening to lectures, pretending to care, trying to get ramped up for internal med and failing, and celebrating graduates and new white coat wearers. there was cake. and wine. it was good.

spent the weekend prior to PPS at the coast with a few amigos participating in some surfing/camping hedonism. what a wonderful thing to drive from the desert up to the mountains, into the city, and out to the beach in a few hours. that is what the west coast is really all about. the best of all worlds. it was a delightful weekend. the blue room was a big hit. audzz and i got to hike up a fun little peak that overlooked pretty much the entire coastline south of cannon beach with a cool knife edge ridge up top. and i got to sample salmonberries along the way, a first. favorite quote of the weekend from chip- "i'm no marine biologist, but i'd say the water is warm, the sealife is onshore...you would think there would be more sharks...." and then there were.... in seaside, a few communities north, where everyone was called out of the water for that very reason. the water WAS warm- hit up a few swims sans wetsuits....but with one on, i think i could live in the ocean indefinitely. minus the shark thing.

and then my rockstar mentee put us up at her place for a week- tanya you ROCK! and we were able to go get our bowl on, hear some decent bluegrass, and then have a danceparty at the one but not only dive bar in hillsboro. that was some good times ladies. and you know who you are.

and then, boom- somehow got transported to san diego- and internal medicine at scripps. which as a facility, is pretty awesome. probably the most expensive real estate holdings of any hospital in the world, hovering above the torrey pines golf course which hovers in turn above the pacific ocean. so far, so good- getting to see and spend as much time as i want with all my patients.

which is good cause although i was prepared for the basics, HTN, hyperlipidemia, DM....i was not prepared for manic depressive alchoholic myasthenia gravis guy, cute little old esophageal cancer man with too many mets to treat, and non-hodgkins lymphoma dude who had bigger fish to fry with his CHF. i've been reading more than anything in the past 2 days, trying to make sense of this stuff. although i did have 2 whole patients today who had NO complaints, took NO medications, and were your basic happy go lucky southern californian types. just wanted an annual once over. amazing.

btw, it's a little weird when your patient is wearing an outfit that costs more than your yearly graduate school loan stipend. even weirder when you open your eyes and look around and notice that everyone in view is wearing sunglasses that cost more than your car.

but whatever. i'm going to let this whole so-cal attitude thing wash right over me. THIS IS NEVERLAND. get with it, mcleod. embrace it. now, if we could get rid of this marine layer crap and get on with the summer at the beach thing, life would be perfect.

survival of the fittest

it's been a long week without anyone (of interest) to talk to....

but on the bright side, fighting off boredom has become the task of my bike, and my bike alone. i know this for sure after attempting a run earlier this week and failing miserably. it's just been too stinking hot lately. it's like running in an oven. i hear that even the locals are getting a little fed up with the 90+ degree days at this point, which makes me feel better. i'm not as big of a pansyass as i thought, hurrah! the past 2 nites we've been graced with beautiful thunderstorms, making for decent sleeping weather AND a free car wash...a welcome bonus.

so between the boredom and the frustration of living in a house with the least bend-ish person i can imagine who drives me absolutely insane, i've been spending a lot of quality time on 2 wheels. it's my new part time job, really. it's pretty awesome.

today i ventured out on a hutch's bike shop sponsored ride...if you're in town and need anything pertaining to bikes, go see them, they are sooo good to their customers. $5 for a 50 mile ride- the cascade lake loop. i did it because it was cheap, i didn't have to carry food- their rest stop was top notch, and i thought maybe it would be nice to chat with some like minded people, ride with someone for a change. i had heard that the hutch's crowd were a force to be reckoned with, but whatever. it was 50 miles. i had all day. in fact, the longer the better cause i sure as hell didn't want to go home and get another lecture in anime. so i envisioned a quiet, long, relaxing ride.

yeah right.

seriously, does anyone in this town cruise under 25 mph...uphill??

granted, i found out later that 2 of the guys riding were just off the tour de france, so i'm sure it was a full out sprint for them. but the thrill of getting to boast that i rode in a group with tour riders was immediately lost when they dropped everyone pretty much by the end of the parking lot. it was a brief 2 minutes of fame. and while i had nothing to prove, it did sort of suck to be dropped by pretty much everyone else within the first 5 miles or so. but it did fulfill that vision of a quiet, relaxing ride. until the last 10 miles (bonus!! it was actually a 60 mile ride...surprise!!) that were all uphill, 5-9% grade...and hot. by the time i got back up to the summit at mt. bachelor i could hardly see straight. highlight of the ride was having a little blue butterfly land on my handlebars for a bit while i was drudging uphill. that should give some sort of indication of how slow i was going... meh. but i made a bit of a recovery when it was all said and done and decided that a swim might cure the double vision, so i headed over to todd lake apres ride and did just that, which totally did the trick. at that point, the thunderstorms were beginning to roll in again, and i resigned myself to going home, hoping to avoid my roomate once more because i didn't want to hear anymore about how wonderful her cat is. in baby talk.

i can't stand that cat.

so i took a nap instead. and then i avoided her some more since i could hear she was watching a movie. she is the kiss of death to any sort of movie enjoyment. i tried (really really hard) last nite to watch one with her. she told me when to laugh. i pretended not to hear her. she asked me why wasn't i laughing because it was really funny. it wasn't dark enough to roll my eyes, so i pretended i had a phone call that i had to take. (like that ever happens to me).

***but if anyone out there has EVER had a reason to call me, this next week would be really good timing. the best. really. truly. make an effort, people. i'm nearly begging.

yesterday was a similar story, trying to find something that would keep me out of the house from morning till nite. i decided to check out green lakes, not because i really wanted to- it has the reputation as being the most overcrowded spot in the 3 sisters wilderness area- but because i figured everyone else talks about it, i should know what they're talking about. just this once. it's like going to yosemite valley. hard to resist despite the fact you don't want to admit to doing it and adding to the cluster.

so i hiked up the fall creek trail, the wildflowers were unbeliveable, the waterfalls stunning, the bugs unbearable. not too much foot traffic, actually, so not very dusty, a pleasant surprise. got up into the green lakes basin- very nice alpine lakes, not the most amazing i've ever seen, but still nice. hiked up to play in some snowfields on south sister. went for a swim. had a picnic lunch. enjoyed the bug free breeze. didn't actually see all that many people. good times. hiked back down just as the thunder and lightning started. went home, fixed up my bike for today's ride (new tires, whistle whistle cat call) and watched it pour rain.

and now i'm back into the avoidance holding pattern. there's (horrendous) music playing in the living room, and she is singing along at full volume. she does this a lot. i suppose i should be glad for the distraction of background music that's actually in tune this time. i suppose i should also be glad that (as far as i know) she has not yet cast a spell on me since she's a witch after all. she told me so with great fanfare. it was another important phone call moment for me.

i seriously could not make this up if you paid me. it's that good. for one person to have so many annoying qwerks is almost mind blowing.

or miserable. but tomorrow's monday and it's back to real work. the kind that will hopefully be better than the last 5 weeks combined. fingers crossed...

action packed

sadly, this rotation is now officially a wash- i just can't seem to convince anyone that i can see patients. on my own. so, it's more of a shared affair, a threesome where generally at least one of the particpants is totally unwilliing. sometimes more, and then it gets weird. but mostly it's just bump on a log boring. at this point though, i figure i've got nothing left to lose, so i can be as pushy as i want. i like everyone there, i just can't understand why they've chosen dermatology as their career.

oh wait.

because they live in a mountain town mecca and have stupid amounts of time to spend enjoying it.

surely that must be it, since i cannot for the life of me figure out any other reason. so i'm gonna go with that...in which case i better ramp up the enjoyment part for the remaining 2 weeks. last weeks enjoyment menu ran something like this:

thursday nite: one last family munch 'n music fest, complete with elephant ears and reggae.

friday: went to check out the cascade classic up at mt. bachelor, a pro bike race in town with some big names to go watch...floyd landis, levi leipheimer (out with a fx wrist, i heard) and the winner of the stage we watched, oscar sevilla. ben rode up from town and got to cross his own finish line and then ride back down with the pros. then there was some packing up the boys for their journey back east and doing some riding around town on bikes to find mexican food and cold beer. success.

saturday: drove up to portland to be a taplister ambassador at the oregon brewer's fest. ben lined it up since it involved of his 2 favorite things- beer and iphone gadgetry. free admission and free beer as long as you twittered like mad and went around chit chatting it up with people. i bailed at the last minute, which ended up being the right decision based on the heat and crazy drunk people factor. i spent the afternoon playing with the boys, which was delightful. lego mania. good times.

then we went to this INSANE crawdad fest in NE portland with our friend bryce- which was pretty much the best.party.EVER. live cuban music, heaps and heaps of crawdads (toasted my n'owleans peeps- fred, amy and shay- of course- with ice cold PBR you can pretty much toast every last person you know and still stand upright) vats of cold beer and large quantities of watermelon....and the quintessential peach and berry cobblers rounded out the smorgaasbord. it's a house/garden party this guy throws every year, just for fun. i will now aspire to hold such a party. it was amazing. and his garden was unbelievable. total sight to behold on all fronts.

then (sniff) dropped the boys off at the airport for their red eye back to boston (smelling pleasantly of spicy crustaceans)...very sad. (for me, not the other passengers). 7 weeks of familylessness. on one hand, i'm sort of excited to be completely spoiled in do-whatever-i-want time, but coming back to bend without them really sucked. walking into our room and seeing their stuff there without them hit me hard. no one to cuddle with, no giggling, no little boy bodies running around like crazy...
digression done.

to cheer up, i went to stay with erica and phillip for the nite, which was super fun. met them at a friends post wedding gathering and chatted with some fun people. got to taste test the deschutes new gluten free beer- good news abby, it's DELICIOUS!

sunday- decided to tag along with erica and phillip and friends up to frenchman's dome to go climbing. it's been a loooong time, which was immediately and quite pathetically felt. i thought it would all come flooding back, i mean, shit... i used to climb for a living. turns out, it's gonna take some more poking and prodding before i feel the way i used to about it. but i had a super fun time despite the fact i think i was brooding the whole morning about the boys being gone. the view of mt. hood from the top of the crag was pretty stunning. and it was shady with a nice breeze, not something to be taken lightly on a 95 degree day. the company was super fun- a few folks from the previous nite, AND i got to meet boone speed, a famous climber whom i've read about for years and years...so maybe now i can give up looking for lynn hill in bend's nooks and crannies. one climbing celebrity just might do it.
then i drove back down to bend in some sort of weird daze and when it cooled off a bit at 6:3opm, i went for a 2 hour bike ride out mt. washington road and all around, just sort of riding...cathartic healing. and it was goooooood. have i mentioned i love this town??

and that's my plan pretty much. wake up, eat, work, bike, eat, sleep for the next 7 weeks. maybe try to find a decent swimming hole every once in a while. cause i've got nothing else to do or anyone else to take care of. just me. and if i think about it for too long i'll get bored, lonely, or sad....and chocolate only cures one of those afflictions. so...yeah. it's just me. huh. weird.

saying of the week

it's been said elsewhere, but bears repeating, as it was truly a phenomenon of words in action.
after suturing up a patient yesterday, he checks out his wound and looks at me and says "well, gag a maggot, girl! you sure can stitch!"

cowboys. they're the best. how will i live without them?

wind up toy

i feel like a wind up toy. every week i get a new preceptor. it's like starting from scratch every. single. week. and mondays are generally really really boring since i have to shadow my new preceptor and try to prove to them i've seen (most) of it all before. that i'm competent. that i know how to talk to and examine a patient. add to that mix that the MA's here do all the chart notes themselves and are pretty territorial about it, and my work load dwindles quite a bit.
i'm a little unsure about what to do about it...do i just take the nice relaxing, no stress rotation and go with it or do i try to put up a stink at this point in the game and figure out a better strategy? add to that the clientele who mostly don't want a student (that's why they're paying out of pocket, dammit!) and 2 new providers who are scrambling to add as many new patients as possible to their rosters...fighting over patients now that business is a little slower in town...and it makes their time for me pretty low on the priority list. it's a bit of a problem. by the end of the week, everyone is happy, things are getting cranked out, i've finally found a groove...and then monday it all comes back to a screeching halt again.

on the other end of the ranting...another good weekend was had exploring out and about. more mountains, lakes, cowboy towns, rivers, and waterfalls. it never ends here. on a funny note, ran into a classmate's bf coming down off of mt. washington, the peak in the picture. random. it was totally one of those "hey! what are YOU doing here?" moments.

favorite moments in clinic from last week include chatting it up with the 1960 olympic gold medal winner of the breastroke (not a whole lot of effort involved, he has found a second calling as a motivational speaker) who is trying to gain support to get rid of the medals and move to more of a super bowl ring award...because what DO you do with a medal for the rest of your life besides put it in a safety deposit box somewhere? interesting dilemma. that i will never have. that most people will never have. but i did like that he referenced bend in a way that made me want to move here even more....he said that there are tons of other former professional athletes and olympians that call bend home, that i would be in good company if i lived here. i love it, as if by a mere change of address, i too could be a virtual athletic rockstar. which is so appealing to my former self. tis true, lots more badassness here than obesity. ir's appealing, no doubt.

also, had a handful of ranchers come in. i love them as much as i love the vets. they have such a simplistic richness to their lives. talked to one couple for a long time about cures for "post suckers", ie horses that like to eat the fenceposts. a good soaking of creosote usually does the trick. alternately, a good dousing in goose shit will probably work too. whatever is more readily available. i bet that would work for nail biters too. and probably a great host of other maladies. i love when they tell stories about life on the ranch, like you know just what they're talking about. "i ain't ever seen such a thing before as a bull suckling a cow, have you? i mean, he's almost 2 years old. that ain't right, don't you think?" ummmm....probably not?

also had a fair share of vets...those WW II vets looove their stories. a good one popped up today from one of the local band of brothers (he had the weekly luncheon that he had to go to, otherwise he would have stayed to tell me more, i'm sure). This patient was in a trench at the battle of the bulge (which i had to google to get my facts straight, but to tone it down to the point of idiocy, it was the bloodiest battle of WWII) and happened to be next to another soldier who is also now involved in the local band of brothers luncheon extravaganza- when a german grenade came flying in. they tried to throw it out, but there was a cover on top of the trench that they couldn't get through so the soldier threw a blanket on it and dove over it. to save the lives of everyone else in that trench by using his body as a shield. it exploded, everyone retreated, and they left the soldier for dead. but he wasn't dead, as someone found out after going back later for important paperwork they'd left behind. there's a happy ending here...the wounded soldier recovers from his wounds, receives medals up the wazoo, and comes home to find one of his trenchmates here in bend, OR. and so now the big joke between these two goes something like this...

"remember that time in the trenches when we were next to eachother and that german grenade went off?"
" remember it!?! shit, not only were you next to me, parts of you went flying over me, around me, and on me!" (big laughter here)

oh, army humor.

heard a great one liner from the wife of a patient today complaining about his seborrheic keratoses, which we frequently refer to as "barnacles"

"so what you're saying doc, is that if he were a ship, we'd need to scrape his hull?".

precisely that. and i'm using it from here on out. specially with the vets.

fun with unpronounce-able diagnoses

another week, another profoundly good time spent here in bend...i could seriously get used to being here non-stop, although sometimes i worry that since we're packing it all in now, what would be left to do if we actually moved here?? explore the many hundreds more hiking and biking trails, lakes, and secret spots i guess. or maybe have the cash to actually go and experiment the culinary wonders of central oregon, etc etc.
employment still seems a world away, so now is the time to savor whatever relative freedom i have. so far, it's delicious. as it turns out, living life the way it should be lived doesn't take all that much effort at all. (minus the lack of cash, that part sucks)

spent this past weekend exploring the newberry volcano national monument, paulina peak and waterfall, and the east lake areas. lava flows just continue to amaze me. obsidion chunks the size of minivans are not meant to be taken lightly. so i don't. went to summerfest downtown on sunday...a bit of a people watching excursion, really. still trying to piece together who lives here and how and why, and who's just stealing clean air for the summer. there is the same aversion to people of the so-cal persuasion here as we had to new yorkers in new england, which cracks me up. except that new yorkers at least have the decency to take themselves seriously. southern californians....who knows. here is my summerfest food analogy of what i observed this weekend:

if new yorkers- actually forget new yorkers- there really aren't any here, no fair to poke fun if there's no reaction, plus people here on the left coast don't get it anyway. start over...

if oregonians are the pulled pork sliders and sensational pint of locally brewed hoppy beverage then the southern californians are the cotton candy (in a bag no less) and diet coke.

* nothing against diet coke, it's a great weakness of mine. but it's just chemicals and coloring with some fizz marketed to make you think you're somehow being healthy by drinking it...no one knows why it's supposed to be good, and we (i) know i should move on, but for some reason we (i) just can't get enough of it. and the cotton candy...well...yeah, i mean, like duh.

anyways

back to the real reason i'm here...dermatology, lest i forget...and sometimes i do....
last week was actually quite a turn around in terms of clinical fun. one morning we saw 4 patients with really obscure crazy diagnoses, which made me momentarily reconsider the seriousness of this specialty...

the 2 most interesting i'll discuss just cause i'll probably never see anything like that again, and, well....they were super cool, maybe a tad gross. anything weird is bound to be cool, and these were off the weird-dar scale.

osteoma cutis. bone chunks that grow in your skin. (collective eeew) little fibronous or cystic irritations that become calcified and grow, not unlike a pearl...in subcutaneous tissue. how's that for a biopsy finding...glad i didn't have to do the 'splaining to that patient. don't worry ma'am, you're not an alien/part dinosaur/freak of nature, although we can't entirely rule it out....
the best part was watching the entire staff scramble to figure out how to order a facial x-ray. they gave up and had to call a radiologist. now, i know i'm just a student and all, but how hard is it really?

cicatricial pemphigoid. not only is it super fun to say (if you dare), but it's super fun to see. unless you're the patient, in which case it's terrifying. you get bullous blisters that erupt and scar over, causing crazy adhesions. this pt had ocular and nasal involvement. she could barely breath out of her left nostril anymore. her left eye had big old skin bridges that only allowed her to move her eyeball in very limited directions. left untreated, it can certainly cause blindness and all kinds of strictures in places that are never good, like all your airways. treatment is mostly a half ass prevention thing, but ultimately surgery is where you're headed, which leads to more scarring....what a downward spiral that becomes. plus i'm still not ok with eyeball surgery. i might never be. it is the one thing that still makes me squirm.

my icing on the cake for last week was getting in on a bunch of decent surgeries...which i loooove.
my favorite was a shy little old gentleman in his 90's who wanted me to hold his hand while he was getting numbed up. "you could hold my hand if you wanted to, miss".... how do you say no to that? he took a nap while i was suturing him up. so cute.

and on tap for this week is getting to work with a PA who graduated from my program, so it's fun to compare notes. plus she's giving me free reign, which i feel entitled to at this point.
and, and...
wednesday is laser day... a whole day devoted to zapping people! wed afternoon is solely dedicated to tatoo removals. i can't wait. cause for one, there's the point and shoot aspect, which is thrilling if you've never done it, probably boring if you have...but then there's also the whole anticipation of seeing just how awful these tatoos are that people are willing to go along with being zapped for minutes on end to get them removed....will have to make a top 3 list for sure, so stay tuned!

what i DO know...

still suffering a bit on the derm front, although thus far this week, things are going way better clinically speaking. some juicy rare rashes that came in today cheered me up, as well as discovering a massive 2 volume dermatology picture bible in the clinic...just what i needed!

in as far as what i DO know so far, or at least after my first full week in this town is...it rocks and i would live here in a second.

a brief run down of what we packed in over the holiday weekend:

*a short float down the deschutes river, to harass the canadian geese but NOT the swans...
*a long float down the deschutes river, to allow for even more yelling at the canadian geese "watch out, eh! ya hosers!"
*the pet parade (complete with a flying chihuahua- seriously)
*waterfront festival- where liam totally rocked the dizzy bat race and the climbing wall
*hiking, sledding! and a swim at todd lake
*beer tasting at bend brewing company and cascade lakes brewing company
*exploring lava lands- one of the coolest national monuments i've ever been to, including:
~a cinder cone caldera rim hike
~a well intentioned but unfulfilled trek to benham falls due to the family members with really short legs that got tired out before we got halfway there and who we refused to carry the rest of the way
~spelunking at lava river cave, much to camper's terrified horror...(he was afraid of the bears, bats, and dragons that live in there)
*scenic auto tour of the cascade lakes highway (lots of mental notes made for later hiking and swimming- devil's lake...are you for real??)
*fireworks at pilot butte with liam
*many, many trips to the playground for apres dinner playtime and family frisbee time
*lots of riding bikes around town, although for future reference we should decorate them far more exhuberantly

so yes....things are going well here on the non-clinical side of things. the weather has been delightful. acquaintances keep proving to be unreasonably nice. we dig it here. we could stay a loooong time. will get off my arse and put some new pics up here in the near future.

the only bummer so far was that liam and i spent last nite and today puking all over the place...we are now ginger ale and saltined out, happily convalescing in bed...me with this distraction, him with a scooby doo distraction....relaxing after our ordeals which have yet to have a cause that we can determine. it happens.

i plan on going to bed momentarily and having the luxury of sleeping in until 6:30 am tomorrow to rejuvenate. oh derm, how i love thy office hours...let me count thy ways....

good, bad and ugly

the least looked forward to event of the year has now come and gone...the packing up and the storing of all accumulated junk and good stuff alike....in a marathon 3 day session of swearing, frustration, and a half way decent blamefest. a big shout out to bryce who helped hugely and who we owe more than a lot to.

and then we packed up the gyspy car for reals and headed out, an A & W treat looming on the near horizon to start things off proper.

rolled into Bend at 11pm the nite before starting my next rotation...found the new house that we're renting a room in, unpacked, slept for a few hours, and then attempted to hit the ground running.

and so far, the main point in education here seems to be know your golf courses and fine wines, cause that's your clientele. The more BS the better. I think we spend 10 min of every visit just chit chatting and then 5 min of actual down to business slicing and dicing. one one hand, i love it- there sure are some great characters here. it is gentrified wild west territory with a few hanger's on. On the other hand, BS is not my strongest suit. so...verdict is still out. that, and i haven't been able to touch a patient yet, and I'll be passed around to different preceptors the entire time i'm here, so i'm wondering how that will really work out since no one seems to trust me doing it the right way (their way). Hmm.

on the bright side, the place is super cush, the hours are super cush, and the people are ridiculously nice. every last one of them. even the kids. especially the older crowd. throw in a few cowboys and celebrities, and it keeps things really interesting. not in terms of medicine so much, cause there's only so many warts and acne you can see without getting totally bored, but the stories sure are fun.

top few fun facts i've learned so far this week:

1. Spider bites ususally come in 3's
2. Aspirin would most probably not be legal if it had come out in this day and age
3. (personal favorite serenade from a 93 yr old firecracker today) "if you go forth on the 4th with a fifth, you shall not go forth on the 5th."
4. Penny candy shoppes still exist
5. If you irrigate the desert, ANYTHING will grow there. also, i might have forgotten that scorpions live in the desert. won't be making that mistake again.

am looking forward to having the next few days off to recoup, figure out where i am, find a good swimming hole, and enjoy the biggest beer holiday of the year in a town that reveres the stuff.(even though the head brewer at deschutes has reportedly jumped ship). gotta love small town gossip!

crowning glory

this is it. i can now leave happy from my surgical rotation. today was the crowning glory of achievement, the holy grail of any rotation.

no, i did not perform any great feat of surgical brilliance...although this week i did get to drain a seroma and clean out gobs of pus and blood from a decent sized wound and pull all sorts of tubes out of people, and follow up with 2 patients who i've seen start to finish in their surgical process...which was sort of exciting....as well as watch someone's heart beating...and then stop beating...then start beating again inside their open chest. that was truly stunning. the logistics that go into open heart surgery are beyond amazing. and another reason why i would not want to be in anesthesia. but it is a sight to behold. and if you get really bored, it's a fun game to count all the tubes and wires. not that i would know.

84.

kidding! boredom and open heart surgery just don't go hand in hand. it's simply not possible.

no, no, no....with complete and total disregard to any sort of legal stipulations, i will continue the story started above. the reason why i can leave totally fulfilled from this rotation is that a certain patient named betty crocker came into the clinic today to discuss gastric bypass surgery.

i mean....does it get any better than that?

blur

not a whole lot to write about this week. no real favorite patients or anything outstanding. maybe i'm just overtired and can't think straight right now. i did get to pull a chest tube, watch a central line placement and put in a bunch of foleys if that counts for anything. lots of cancer this week. lots. it's so fascinating to me to have a 3-D disease process that you can see and feel. and maybe a little bit gross.

moved in with kristy this week in her fifth wheel which is pretty awesome. like camping, only in a moveable 1 bedroom apartment. it's super nice. all the amenities. went for a nice bike ride. enjoyed karaoke nite at the RV park, although planning on making it there in person next week rather than hearing it from a distance...from the sounds of it it'll be a good show. maybe i'll even get back on the photobug boat and take some pictures next week. it just occured to me that i haven't pushed the trigger once since i've been here. huh.

as a p.s. to the last post, i had one decent encounter this week involving the zero bullshit army style history and physical taking: when interviewing a guy who was following up for a surgical trauma visit (think partial colectomy due to a MVA rollover, training maneuver gone horribly wrong), the preceptor comes in after i presented to him that the patient is still having diarrhea post-op. so the preceptor opens the door, greets the guy like old friends and dives right in. not even a blink inbetween.

"so buddy, i hear you've still got the shits. how bad is it? i mean, are you shitting your brains out, because if so this is definitely something we need to deal with cause you're deploying in like 2 months, right?"

"yes sir. still shitting my brains out, sir."

and there i was, stuck in between in a state of mild amusement and candid surprise. strangely pleasant surprise. i just so badly want to talk to all of my patients this way for the rest of my life.

that feeling was still with me after receiving a text from my sister in law today that my neice and nephew totally ROCKED their swim meet. so proud. but a little perplexed when i heard they had won the "breath stroke". cause that's what they call it there lest they upset anyone with the proper wordage. which makes me so, so sad. clearly the swim league organizers in NC need a little militaty intervention. maybe even an invasion. total takeover, even.

apparantly it's nap time until i can come up with something better. apologies. t minus 1 week until i have some sort of life back...in bend! woot!

laying it on the line

something i love about the army...enlisted folks are just NOT afraid to tell it like it is. (for some reason, the officers are much more reserved, i'm guessing it's because they get extra pay to tone it down. seriously, you get "bonus pay" for all sorts of silly reasons here.... if you are remotely bilingual, or you can pick your nose with either hand, or are able to procreate profusely, then man, has the army got a GREAT deal for you! it's the financial equivalent of boy scout badges of honor or something.)

diversions notwithstanding,

the army seems particularly good at deprogramming whatever filters a person might have in terms of beating around the bush. meanwhile, politeness filters seem to be installed in their place. it's kinda like being stuck in an heavily guarded area with half of the population of manhattan.... on zoloft. very strange. but funny.

my favorite patient of the week was a young man who came in with a presumptive inguinal hernia, just like the dude before him AND after him... his main issue was pain with erection and ejaculation. (and for those of you in the know, i still can't get the mini marzucco out of my head. i keep having these bad flashbacks. ptsd. yikes. it's like there's a marzucco with a halo on one shoulder telling me to compassionately do the right thing, encourage and support the psychosocial and emotional issues behind this sort of thing....and then there's a peidmonte with a halo on the other shoulder telling me to turf the jamoke to urology already )

so he says, "ma'am....i don't know how to tell you this without just saying it"

"ok, so just say it."

"the hernia doesn't bother me, but when i'm with my girl, it's a problem. i'm not leaving here until i know for sure i can get with her again."

"ok. well, let's check and see if you have a hernia to begin with. have you ever been checked for one before?"

"no ma'am."

so i explained it to him, what to expect, what i am looking for, etc. his eyes kept getting bigger and bigger. he started sweating. and then apologizing. a lot. he was so so so sorry to bother me with this, like it's not my job. it's really hard as a female PA student to astutely reassure someone that poking around their penis is no big deal. especially to this guy, to whom it was the very center of his universe. he reminded me again he was not leaving until we could fix his problem (priorities!), and then made a disclaimer that he was already pretty excited about having me poke around down there.

poor guy. i think he was envisioning a different kind of exam....not the kind he got. he was a little more than surprised.... the bonus of having 3 boys is that i was not. i even brought a whole crew of residents in with me to quell any more of his fears about being left alone to be groped by a student. stage fright can be used to your advantage any old day, really. so simple. hard to be a tough ass when you're nekked and exposed. another thing i love about army folks is that they never hesitate to get nekked when you ask. even the mere hint will send pants and shirts flying. must be another deprogramming issue.

long story short, no hernia. sent him for an ultrasound. no hernia- no surgery, then. DONE.

then he got mad and became a broken record player, partially out of a blown ego, partially out of sheer terror of what else could be wrong.

"ma'am, i am not leaving here until you can fix this."

"i don't know what to tell you, sir. it's a little out of my area of expertise. "

if i had given him some differentials, he probably would have melted into a puddle on the floor and obsessed about them to the point of nausea. referral to urology (for whom i will NOT be volunteering for next week because of this guy). go talk to the penis people, buddy.

"but ma'am....what am i supposed to do with my girl tonite then?"

ummmm....how bout a nice game of backgammon? terminator movie? putt putt? was it bad that i told him he'd just have to get creative? not my job to come up with chaste-like activities. but i'll bet there's an army bonus somewhere out there for it.

confliction

today was going swimmingly, i was suturing and assisting all over the place...and then happened to be in the right place at the right time for a case i was interested in watching...and ended up getting roped in...which was great but....much more difficult than i bargained for.

mostly, i find that surgery is not so bad as one might think. i don't really give a second thought to slicing and dicing because all i ever see is what is right in front of me. a square of betadine scrubbed skin surrounded by layers and layers of drapes. you don't see the pt's face or body other than that. there is no crying, no wincing, and if you don't look too close, no hint of sickness.

and then there was today. a 3 year old little boy with cancer. tiny. no hair. very sick. spent a lot of time with him pre-op and just couldn't really shake the big picture. even after he was all draped, i couldn't quite get over it. he was just so little. and so sick. so when the surgeon let me put in the chest tube for this kid's thoracostomy and scope i sort of had my first brief moment of hesitation in the OR. how do pediatric surgeons do it? is their secret just pure just love and sheer hope? comfort in the fact that they are helping these kids get well? what about when you pretty much know for sure the kid you're about to cut into will never be well and you are just going to make him more miserable in the short term? all i could do was blink a few times, kid myself that "THERE'S NO CRYING IN BASEBALL!" or surgery....and get on with it. deal with the problem at hand, worry about the rest later.

but seeing just as much sickness was inside this kid and correlating it to how much sickness was outwardly present was almost too much. nodules all over his lungs. huge chunks taken out to biopsy. solemnly hand delivered to pathology and ID with as much care as possible. pleural fluid drained. lungs stapled up, ribs sewed back together, skin sutured as nicely as i possibly could. my parting gift to this child, in a way.

undraped and back to his whole reality. de-intubated and groggy, but thankfully not yet crying was how i left him in PICU. mom was a mess. i don't think i would have kept it together if he had started crying. sigh. 3 hours of eye stinging from all this confliction. bigger sigh.

one other valuable lesson learned today (besides being able to cross peds off my list of future endeavors) is that the peds OR is always kept toasty warm. add that to inherent nervousness and the freak out factor of having to deal with cutting into sick kids and all you do is sweat profusely. it's a regular sauna in there. which gets old REALLY quick.

perhaps tomorrow will be better. i was offered a spot in the am urology clinic. here's my chance to perform non-stop prostate exams for hours on end- that should take my mind off of today. woot!

you know it's bad when...

started a surgery yesterday afternoon that ended in the wee hours of this am. you know it's bad when the surgeon makes the initial cut, pokes around a bit, sighs and says, "this is going to take all night"...followed an hour later by "oh man, i think i might have just killed her"....

the pt thought she was going in to the OR so someone could fix her small bowel obstruction....which we did, only....there was a 12 x 18 cm piece of mesh completely adhered to her bowel from a previous surgery to repair a couple of hernias after a surgery for endometrial CA....so....yeah. 9 hours of tedious, horrible meticulous clips of adhesions later....there was a solution. and only ONE bowel perforation. amazing.

i left around 9pm because i couldn't feel my feet anymore. but the pt was well in ICU today, considering. fingers remained crossed.

in other slightly more uplifting news, i got to admit a pt today based on my recommendation, not the opposing resident's recommendation. (small victories, people)

this week's hernia count: 10 and counting

oh, and the malnutrition and dehydration diet is going GREAT.
blegh.

whoa there big guy

highlight of today:
finally having a patient with a phenomenal sense of humor and who thought he could get a rise out of the little PA student.

pt presents for eval of pilonidal cyst (which by the way, am feeling like an expert on at this point)...so we discuss his pertinent HPI, etc and then we discuss how the physical exam will go, that we'll be poking around his bum, etc... and then i get to the part where i say "ok, let me just go grab my preceptor and we'll take a loo-"... and before i could even get the sentence out, there was a half nekked guy bending over, telling me to take a good look in the tone of voice that told me he was clearly enjoying my reaction.

i mean....what could be better? how's that for being proactive about your own healthcare? if it wasn't for his giggling, i might have gone ahead with the exam. instead, i muttered something about him needing more of an audience for such a great show...and left the room to grab someone, anyone...who wanted in on the action. now that i've seen a few of these, i can't say that i was all that riled up about it, but i feigned enough surprise to keep him happy. oh fun times.

good news for this guy: no pilonidal disease. good news for me: i got a couple of new dirty jokes to add to my repertoire now. totally inappropriate. but funny.

skipping out

yesterday was a blast. finally. showed up for 5:30am rounds and saw 6 all new residents on our surgery service (it happens at the end of every month, this changing of the guard, so to speak). after all the introductions, etc, i sized up the situation in my head....2 OR's, 2 attendings, 6 residents...and me. lucky number 7.
yeah. basically there would be nothing for me to do for the rest of the day but stand around and watch everyone else do something. superfun.

so at morning meeting, when the vascular surgeons asked for help in their clinic, i rapidly jumped ship. which is probably PRECISELY why i would not be very good at this military stuff. following orders is not so much my thing.

i went and watched a hernia repair (running tally this week: 8) in the OR to pass the time before clinic started. i chit chatted with the rep who was there to show us all the new mesh samples he had, which was moderately interesting. it's made of polypro and goretex. just like a raincoat for your intestines.

then i went to vascular surgery clinic for the rest of the day. and i learned more from them in one day than i have in the last 2 weeks combined. it was amazing. having great surgeons double as phenomenal teachers and just plain good human beings made all the difference in the world. for whoever else rotates through here, put it on your must-do list. plus, there's a PA who works in their office who helped me immensely with all my charting and who drew me into the secret club of vascular surgery. i was totally eating it up. and....loving it. who knew?

none of the patients i saw were under 70, the oldest was 94. a few were doing well enough to be discharged from our service, which was wholly satisfying to know that even geriatric patients with a laundry list of problems can get better and do just fine. but the best part was again, listening to their stories, which they are not shy to tell. probably because they think i'm too young to know any better. and they all tell time in reference to war and who was president at the time, which i find fascinating.

i got schooled by one gentleman who let me know just what he thought of obama and his "re-cycling" attempt. so i had to bite that one. he explained that at the end of WW II (which incidentally started on his 10th birthday, how dare they!) the only person that could solve the depression/recession thing was eisenhower. the eisenhower interstate saved us, and now obama thinks he can just re-cyle that idea and save us all again, but it won't work...obama ain't no eisenhower. and that's how we sort of left it...and as i went to walk out of the room he told me "i always wanted to be a history teacher..." well, man...it was your lucky day.

mandatory fun

madigan army medical center is a very large teaching hospital. thusly, there is seemingly a lot of time set aside for students to learn in ways other than hands on opportunities....which i am not convinced is the way to go, but whatever. as it turns out, ebm DOES exist in the real world. or at least in the army. crap.

so thursdays are "academic" days...so in between rounds there are all sorts of exciting meetings to attend. first up, intern lecture and morning report. no biggie cause that's pretty much every day. then we got a break and a chance to catch up on paperwork followed by tumor board. not terribly exciting except for the ginormous teratoma we discussed... this one had no teeth, which was a little disappointing. marissa would've been totally crushed.

then we did the crux of thursday meetings....the "mandatory fun" bit. which i'd heard about. which i thought was sort of a joke, but it wasn't. and lisa's scraped and bruised legs, ranti's nearly blown orbit, erin's hamstring pull, and everyone else's grass stained scrubs tell the true tale behind the steam that is blown off when the entire surgical staff gets together to play a game of full contact ultimate soccer. nothing like full on ego's, testosterone galore, ranger-danger tactics, screaming, and army style competition to have to suddenly have to negotiate...while running as fast as you can trying to prove something to someone even if you don't have a clue... not unlike being in the OR, minus the kicking of the ball bit. it was no-holds barred and brutal, to tell the truth. i was a little bit shocked at the lack of apologies and glad when it was over since it was rapidly becoming not fun. at all. on the bright side, it was a gorgeous day to be outside, and now i know who i NEVER want to deal with again. ever. on any level.

and then back inside for the m & m (morbidity and mortality) conference. i wonder how well it would go over next time if i brought a bag of m & m's to that meeting?
anyway...basically just reviewed all the screwing up that was done in the past week, and who died as a result of it. not that any blaming was done, (ahem) but to live and learn and never make that mistake again. today i learned that if over 75% of your liver is a cancerous tumor, then surgery is NOT a good option for you.

but the total highlight of my day was getting to eat lunch for REAL for the first time (not just shoving down a pb and j in 3 minutes in the locker room inbetween cases)...in the dining hall and all. at high noon. when it's packed. but the treat in all the chaos of this event was getting to share a table with an old timer who told me the most fabulous stories of his youth. like what it was like to grow up on a farm in minnesota in the 30's and 40's and being a farmer's son, getting relegated to fly the crop duster at the tender age of 14, and crashing it at the age of 15. (sorry dad, crashed the plane...) puttered around in high school, never graduated...(more on that later) and saw all his friends going off to korea, so he thought he'd give the army a go...but he had flat feet and they wouldn't take him. so he walked dejectedly out of the recruiter's office, not wanting to be the only one left behind when his buddies went to war...and ran into the air force recruiter who said, sure! we'll take you. and just like that, he was shipped to mississipi to attend fighter pilot school. which is where he met his wife of 56 years. they used to go out on dates to a bar down there where they would listen to a certain elvis presley play (live)...and they would sadly shake their heads and think that poor kid, he'll NEVER make it. we got a good laugh out of that one.

and the rest of lunch just sort of melted away as i sat chit chatting with this gentleman, i never did get his name. he was a fighter pilot in korea and vietnam, flew everything the air force had, he said. and then he blinked and his 20 years was up and they told him it was time to retire. in the 20 years he'd been in, he and his family moved 21 times. but they kept coming back to mc chord afb (just north of ft. lewis) and liked it, so they stuck around. when he got out of the military, he found himself unsure of what to do. it was the early 70's and boeing had just laid off thousands. the job market wasn't looking so good. he wanted to be home with his family and not fly anymore. so with the GI bill he went back to community college where, incidentally, he got in because they asked if he had been to high school and he said yes. they didn't ask him if he had graduated. we got another good laugh out of that one. so he became an accountant. a year later the bank he was working for asked if he knew anything about computers. and they sent him back to school to become a programmer. and that was that.

now he's retired for good. he and his wife had 5 kids, all but 1 military as well, including a west point grad who is now just retiring from the military as a colonel. he joked he wasn't sure if he should call him "son" or "sir"....and there was even more laughing.

then we talked for a while about something that was clearly on his mind, the idea of where people of our generation (gen X, gen Y, call us what you will) feel like they have no duty to their country anymore. that there is no great call for civil service and he just couldn't seem to wrap his head around the thought that we just take everything for granted. that we are too self involved to consider country before anything else, or have any sense of national pride. that we are too selfish to commit time to national security and well being, and that we are to petty and wrapped in our anti-reality personal technology gadgets to care. ouch. for a moment i wished i wasn't a civilian. and i've been thinking on it every since.

he was accompanying his wife for cataract surgery this afternoon, and all of a sudden got teary about leaving her alone up in the opthamology office and excused himself to go be with her. damned if i didn't get all teary too.

the portugese spanish frenchman via chile

who had the most amazing name that i can never repeat, but for fun let's call him juan pelletier...just so you can imagine with me the pure definition of melting pot lineage...

which is what i was doing for the first minute or so of his appointment (what kind of parents give their kid a name like that?) while sort of vaguely asking questions and listening to him speak with a portugese accent he had recently cultivated after living in the azores for years....

and then i snapped back to reality as it became apparant that this was going to be a pre-op visit, not a run of the mill meet and greet/establish care, etc. which was something i wasn't quite prepared for...but then, nothing i've done in the past 2 weeks has been, so there is this sort of comforting feeling to that particular brand of panic i get now.

anyway
achalasia. scheduled him for an esophagram (how proud todd would be!) and went to precept. wherein the problems really started for me. for you, let's just say you're all welcome for the heads up. i'll be widely available for thanking at the next PPS.

achalasia. and not just your run of the mill achalasia, the good kind. the kind that's caused by parasites picked up in south america while you're say...hanging out in chile. that's right, the chagus kind. the kind that you have to order a lab that no one has heard of to confirm. the kind that there may be no treatment for and may expand your esophagus to the size of an inflated tube sock. the old school kind with stripes. the kind that you'll need surgery for regardless of the outcome.

that's my favorite line here so far... "well, you have xyz. we can open you up and fix it if you want. there's no guarantee the surgery will work, or that you'll feel any better afterwards but you need to decide if you can live with xyz or not. when you can't live with it anymore, give us a call back."

on the bright side of today, if the chagus wasn't enough, i saw like 4 hernias of all shapes and sizes IN A ROW. i'm a hernia magnet, apparantly. and if i ever screw up a hernia presentation again, then shame on me. but there is definitely something to be said for reducing them. that feeling when they get sucked right back inside the abdominal wall is something else. i'm on a mission now to keep a running count for the rest of my time here since i need something to poke fun of.