Tuesday, January 27, 2009

The Icy War Zone

Everyone I personally know that has a blog (3 now, two of whom I inspired:) is writing about the icy weather, so I feel obliged to enter my own thoughts.  I am jealous that all their blogs look way cooler than mine, but I prefer to think of myself as "old school" rather than "technically challenged."  I have my third mac class on Thursday, so maybe I will work on my blog next.  I will try to find some type of 1980's "War Games" font to further regress and immerse myself into my backwards persona.

I love getting dressed for icy weather.  It is a great excuse to put on my wool socks and steel-toed combat boots - the ones I bought when I was sixteen downtown at Bennett's military supply store (high school was a war zone - I felt the need to be prepared).  I felt super bad ass today in Chest Conference in my bulky over sized sweater, khakis, and combat boots, amongst all the suits, scrubs, and white coats.  I trampled both morning and afternoon through the treacherous light rain that coated the parking lot.  I was prepared.

Tomorrow might be worse, so they say.  I did my shopping on Sunday so I didn't need to battle the Kroger parking lot on the way home, thank goodness.  My husband is on call, and should be coming home around 11:00, before the roads get bad.  That means he will be off tomorrow, and I don't need check the school closings religiously between running, showering, reading a chapter of my novel, and cooking breakfast; frantically scrambling for child care at the last minute.  I will be free to wake up early and go off into the weather with no responsibility except to get myself to work safely.

A few of my partners spend the night at work.  So do some of the ancillary staff.  They make sure a skeleton crew will be available no matter what.  It was not expected of me tonight, since I have small kids to get home to and a spouse working late.  But it is always understood that we will get there, somehow.  I remember once during residency my friend walked three miles from her home to the university, because her car wouldn't start.  If any resident failed to show, or called saying they couldn't get in, it was like a giant black mark hovering over them for the rest of their five year tenure.  When you are an integral part of the cog, your absence weighs heavily on those that show up and your name becomes mud.  If you do come in and help out, your presence is a godsend, and you can sit warmly and smugly in the glow of your attending's respect for weeks.  Ice stories expand and grow like fish tales in the South, so even if there isn't much to do, by the end of the next week your performance on the ice day becomes legend.

Now I am the "attending," even though we don't really use that term outside of academics.  Meaning I need to be there.  The OR was busy today, and there will be much work to do tomorrow.  I can't wait to tackle my cool adrenal case I saw in the gross room this afternoon. I'll get to use my new adrenal fascicle.  I am looking forward to a hopefully slushy and wet more than icy morning drive to work.  The adrenaline is such a rush.  I can't wait to wear my combat boots again.  

I just know all this silly bravado is going to land me on the side of the road somewhere, paradoxically undressing with hypothermia, while everyone else is sleeping in safely.  

Thursday, January 22, 2009

Cotton Candy and Donuts

Last week my son had surgery, an adenoidectomy.  The adenoids are lymphoid tissue, like tonsils, that are located in the nasopharynx.  John's were so swollen they were completely blocking the passage between his throat and his nose.  No wonder his speech is lagging, and he snores almost as loud as his dad.

I took the day off, and woke him up at 5:00 a.m. to get him to the hospital for the 5:30 check-in time.  Why they had us get there at 5:30 I have no idea, because we were quickly shuffled to pre-op, only to wait for 2.5 hours to get the show on the road.  If you have ever spent 2.5 hours entertaining a 3 year old who was NPO (nothing by mouth) past midnight, you would be impressed by the fact that he never had a breakdown.  This was not a children's hospital, as evidenced by the barren waiting room and indifferent staff members.  

"Are you doing all right Mrs. Schneider?  Just keep entertaining him, like you are."  

We told stories of far away lands with castles, lollipop grass, and cotton candy clouds.  I borrowed a lot of imagery from Roald Dahl's Charlie and the Chocolate Factory  (I remember the first time I read that book - buried under the covers with a flashlight on the top bunk, finger poised at the ready to turn the flashlight 'OFF' if I heard my parents coming to check on me and my sister).  The central characters in every story were John and his sister Sicily, riding multicolored horses and fending off monsters and purple bears.  John got into it, and soon he became the storyteller and I just nodded and interjected as unobtrusively as possible; his stories were infinitely more interesting and imaginative to me than my own.

Another form of entertainment was the upside down mousse alcohol hand cleanser.  Every time he would get weary of the stories, he would wander over and look at me questioningly.  

"Okay Jack, one more spray.  No, no, that's enough.  Rub it on your hands.  No, don't eat it."

"Tastes like sunscreen, mama!"

The poor kid was so hungry,  I could hardly blame him for trying.  It also made me a little wistful, of the days when sunscreen tasted like cocoa butter, not alcohol.  The advent of spray sunscreen has tarnished John in ways he will never know.  

While we were waiting, we got to watch other families filing in for surgery.  When entering pre-op, only one other family member is allowed.  Our next door neighbors were a man and his wife.  They reminded me of the Jack Sprat poem.  He was tall, skinny, and goofy-looking, and she was short and stout.  Her hair was thick, straight, and unkempt, about chin-length - his was tucked unsuccessfully into a camouflage ball cap.  They looked to be in their early to mid-fifties, but he was aging much more gracefully than she.  His resting face evoked surprise, hers was set in a permanent scowl.

They didn't talk until the anesthesiologist came in for a pre-op interview.  He walked into their room, and introduced himself.  Although there was a wall between us, it was easy to overhear because the front sliding glass doors were all parked open.  

"Hello, I'm Dr. Bale.  I have a few questions for you before you go to surgery.  So I see you are here for a D&C."

A D&C is a dilation and curettage.  Usually performed for prolonged uterine bleeding.  The OB goes in through the cervical os (dilation) and scrapes the inside of the uterus (curettage), the endometrial lining, and sends it to pathology for a diagnosis.  The uterus is like an upside-down pear-shaped hollow muscle, at the end of which lies the cervix.  The cervix always reminded me of a donut when I was looking for it in medical school, through the speculum, to perform a pap smear.  A small, round rubber donut, like a donut hole, but with a tiny slit in the middle.  Sometimes hard to find, if the patient is large or the uterus is retroverted.  Seeing the donut always brought a huge sense of relief - your uncomfortable quest was almost over.  The size of the os varies individually, as well as pre- and post-partum.

We get the endometrial curettage specimen in pathology frequently.  Tiny cores of blood, grossly.  Mostly pink on the slide, with blue glands and stroma.  Most of the time the specimen is normal, and we just name the phase of the cycle based on the appearance of the glands.  We look for hormone effect, signs of breakdown, blah, blah.  I could bore you for hours.  Most importantly, we rule out cancer.  The most dreaded etiology of dysfunctional or prolonged uterine bleeding.  

The anesthesiologist continued.  "So how long have you been bleeding, ma'am?"

"For fifty days."

My eyes widened in disbelief.  Dr. Bale was also impressed.  He briefly lost his previously professional demeanor, asking incredulously "And you are just now coming in for the procedure?"

The husband piped in.  "My wife's a tough lady."

I could believe that by the look of her.  I heard her agree gruffly, her voice both challenging and defensive.  "That's right, I'm a tough old bird.  I kept thinking every other day, that it would stop tomorrow, but it didn't.  So here I am."

"Well, I'm glad you're here, now.  Your doctor will help you figure out what is going on."  Dr. Bale finished his history, examined her airway, and started to step out of the room.  The husband called him back.  His voice was overly loud and quivering with the anxiety surrounding his confession.

"Doc, I think there is something else you should know.  My wife pees, every time she walks down the hallway."

I worked hard not to laugh audibly, more out of surprise at his sudden confession, than content. 

The wife referred to her husband formally.  She was irate.  "Now Mr. Taylor!  You did NOT need to tell him that!"

He replied meekly and defensively, "Honey, I was just trying to help out.  It's not like you would ever tell any of the doctors."

She shouted, "Mr. Taylor!  That is not the point!  He is not the doctor that needs to know that!  This is neither the time nor the place to be tellin' that information!"

She had a point.  That was a slice of medical history for her OB, not the anesthesiologist.  But I could tell the anesthesiologist had probably been on the wrong end of his wife's arguments many times with how quickly he rushed to the husband's defense.  He was halfway out the door, and I was impressed with his straight face.

"That is important information, Mrs. Taylor.  I will certainly pass it along to the proper individual.  The nurse will come get you and bring you to the OR soon.  See you in the OR, Mrs. Taylor."

John's surgery went fine.  He was eating goldfish and drinking chocolate milk on the couch by ten.  We had an indulgent two hour nap that afternoon.  I cannot remember napping with him like that since he was a baby.  

On Monday morning I was clearing out my junk surgicals: quickies like gallbladders, athersclerotic plaques, corneas, heart valves, and tonsils and adenoids.  I got John's specimen, and examined it under the slide.  It was massive, and extremely reactive.  No wonder he couldn't breathe through his nose!  The doctor said he would probably have to re-learn, since he likely had not had the option before.  I signed it out:  Adenoids, adenoidectomy: Reactive follicular and parafollicular hyperplasia."  It reminded me of when I was a fellow, and I got my husband's appendix.  And of the other specimens that have crossed my path, routine except for the fact that I recognized the name behind the glass slide.  

I didn't get Mrs. Taylor's (that is obviously not her real name) specimen on Monday, and certainly didn't bother to chase it down.  That would be a HIPPA violation.  But I sure hope she didn't have cancer. 

Wednesday, January 14, 2009


It is my first rotation in my third year.  I am completely clueless about everything on the ward.  A sorority-girl beautiful, peppy, petite pulmonologist (lung specialist) acts as my liaison.  She is our attending for the week, the head of our motley crew.

"C'mon team!  Next patient is Mr. V!  Gather around.  Oh!  Notice his breathing, a Cheyne-Stokes pattern.  And he is also a DNR (Do Not Resuscitate)!  He is probably about to die."

The Cheyne-Stokes pattern of breathing is the medical term named after the people that described what is otherwise known as the death rattle.  Basically, your respiratory center slowly shuts down, and doesn't respond well to oxygen and carbon dioxide in your body.  Mixed signals get sent.  You spend periods of time not breathing, also called apnea, and then when you hit a dangerously low level of oxygen, you breathe really fast (tachypnea) to catch up.  The slow/apnea/fast pattern is periodic and regular, but the intervals lengthen, until it stops altogether.  As the heart shuts down, blood stops circulating, which is why dying people will become cool and have blue lips and mottled extremities.

So we all gathered around his bed; residents, nurses, medical students, and respiratory therapists.  It was very cramped in the small, curtained-off makeshift room in the ICU.  The patient was probably in his late 60's, but he looked much older.  He was lying in bed, propped up on pillows; cachectic, jaundiced, and laboring for every breath.  

The peppy pulmonologist whispered conspiratorially.

"Do you see his breathing pattern?  Memorize it!  It is end-of-life."

Throughout my third year, I saw many patients near the end of life.  This was my first.  In the hospital, a lot of dying patients garner the complete attention of the medical team; crash carts, chaos, drugs in syringes trying to reset the heart back to normal rhythm.  This man was different; he would die with no interruptions.

So I watched, and I didn't.  I wondered where his family and friends were.  I looked at his clubbed fingers, and tried to guess at his cause of death.  I looked around at everyone else in the room, trying to find physical evidence indicating whether or not they were as uncomfortable as I was.  Finally, I looked at him, and studied his breathing pattern.  I waited for some sort of metaphysical sign to appear when he left this world for whatever came next.

Death happened.  While we were all standing there, watching.  One minute he was struggling for breath, and the next he was not.  

"Okay!  Nurse, will you call the morgue?  C'mon team, let's go see Mr. W!"

We shuffled out slowly, bumping into each other, and finished rounding.

Thursday, January 8, 2009

In Honor of Me (and the DRE)

My brother remarked over Christmas Break that I seemed overly obsessed with the gastrointestinal tract in my blogging.  I promised him that I would write about something different; kidneys, ovaries, maybe lungs.  Somehow, I ended up back in the gut.  Just like Dr. P, year after year, introducing his gastrointestinal (GI) physiology lecture series dancing and jerking wildly in the spotlight at the front of the lecture hall in one of those giant accordion-like plastic tubes we all used to crawl through when we were little, tossing Butterfinger bars to a surprised and entertained audience of second year medical students.  I can't escape it.  This week:  The Rectum.  Sorry bro - maybe next week.

When I was a third year med student, I learned how to perform a digital rectal examination (DRE).  It's not rocket science, really, just put a glove on and try to concentrate on normal vs. abnormal anatomy rather than being completely overwhelmed by the fact that you are sticking your finger into a stranger's anus.

Somehow, I always ended up on the rotation where the attending was obsessed with the DRE.  I might have thought they all were, if I hadn't discussed it with my friends.  Sure, when you are on internal medicine, or surgery, you are expected to perform a DRE with every history and physical (H&P), especially at the Veteran's Hospital (VA).  In fact, you cannot even open a patient's computerized chart at the VA without a bunch of flags popping up, alerting the onlooker to various check-ups and tests that are "overdue;" including colonoscopies, Tuberculosis skin tests, and often first and foremost:  the DRE.

When I got to my psych rotation, I was surprised to learn that with each new admission I was expected to perform a DRE during H&P.  I was working on a unit for men with combined psychiatric disorders and substance abuse issues.  Upon admission, they were often not only high or reeking of alcohol (or both), but also clearly devoid of much-needed antipsychotic medication.  Yet my attending still insisted upon my performing a DRE (couldn't they get that on their yearly check-up with their family practitioner?).  He also sent me to one of the nurses on the first day, who haughtily informed me I could not wear a skirt unless I was wearing pantyhose.  She stared accusingly at my modest floral calf-length skirt and closed-toed flats as if I was wearing a leather mini and peep-toe spiky heels.  I felt like I had stepped back into the 1950's. First of all, I did not own a pair of pantyhose.  Furthermore, it was sweltering mid-summer and I couldn't imagine even trying to put them on much less wear them in the less-than-air-conditioned facilities, sweating through smelly DRE's in tight, crowded rooms.  I wore pants for the rest of the month.

When I got to my family practice rotation in a small town, I was not surprised to be expected to perform DRE's in men of a certain age group.  Shockingly, my attending also wanted me to perform a rectal on every woman receiving a pap smear.  Was this old school or complete lunacy?  I mean, what did he expect me to find up there?  There was no prostate to palpate for firmness or abnormalities.  At the most, I guess I might feel a hyperplastic or prolapse polyp, or maybe some hemorrhoids, or a rectal tonsil -- but these are all benign entities!  Why subject the poor woman to pointless probing?

Needless to say, by the time I reached the end of my third year, I was getting pretty good at the DRE.  I was not yet certain of my future specialty, but I had a list of possibilities that would ensure I would not be performing any rectal exams for the rest of my life.  When I got to my last rotation, I ended up back at the VA.  One morning, I was doing a complete H&P on a 45 year-old male who was already admitted to a room.  Without even being asked, I performed a DRE; it was knee-jerk by now.  This time, I felt something unusual, and had no idea what it was.  It is extremely rare to find anything unusual on a DRE - most prostate cancer is found by elevated Prostate Specific Antigen levels (PSA), which is a blood test, and most colon cancer is discovered on colonoscopy.  All the more reason that the rectal is the bane of the med student's existence.  So when I finally felt something, after all of those previously normal rectal exams I had performed throughout the year, I wanted to ignore it -- the patient wasn't even being admitted for GI or prostate issues.  I was positive that whatever I was feeling was nothing, and I was going to be made the butt (no pun intended) of every rectal joke in the future if I followed up on it.  But I HAD to.  Always the schoolgirl.  

Luckily, I had a really nice attending, Dr. Baugh.  He was so tall that it made you look for tell-tale signs of Marfan's Syndrome (there weren't any).  He was thin and well-dressed, with short dark hair, a clean-shaven face, and an easy smile.  I hesitantly knocked on the door of his office.  

"Um, Dr. Baugh?"

"Yes, Dr. Shyder?"

I was distracted by a mound of papers on his desk, covered in what looked like equations.

"What are you doing?"

"Quantum physics, in my spare time.  Nice to have some, in a VA job."  He was so modest, I managed to feel even more inadequate than if he had bragged about it.  I looked around and noticed he had more physics than medical journals stacked on the floor of his cramped office.

"I was doing an H&P on Mr. W., and I think I felt something when I did the, um, I mean, on the DRE."

"On the WHAT, Dr. Shyder?"

"On the, um, rectal exam."  I turned away, blushing.

Dr. Baugh investigated Mr. W's rectum himself, and was concerned enough to order a CT scan.  Surprisingly, Mr. W. ended up with an early rectal cancer diagnosis.  Dr. Baugh was ecstatic.  "Dr. Shyder!  We have never had anyone diagnose rectal cancer on a DRE in my history here at the VA!  This calls for a celebration!  7:00 a.m. Saturday morning!  We'll invite the entire staff!  I'm buying!"

So Dr. Baugh brought orange juice, donuts, and coffee to Saturday morning rounds.  And made sure that everyone knew exactly why we were celebrating, to my extreme mortification.  I remember calling my dad to tell him Dr. Baugh (whom he knew) was throwing a party for me, because of a diagnosis I had made.  My dad asked me to tell him about it.  When I did, I could tell he was shocked, and it took him a second to muster the appropriate response.

"You did what?"

I repeated myself.

"Oh.  That's what I thought you said.  I hadn't ever heard of anyone doing that before.  Well.  That's really great.  I'm proud of you."

Have you ever had a party convened in your honor?  Aside from birthdays and graduations, I mean.  I really hadn't, until then.  Not complaining -- there is nothing I detest more than being the center of attention.  Even worse that the cause for celebration was my proficiency in performing a rectal examination.  Thank goodness, that was my last DRE.  I got to go out with a bang.  Too bad I don't like donuts.

Sunday, January 4, 2009

The Princess of the Mini-Mart

I am belatedly altering my family's names for the future.  Cecelia - Sicily; Jack - John; Mike - Ike.  Sorry for any confusion.  And thanks to the Gaspers for their help in coming up with the names on New Year's Eve.  

A couple of months ago, I came home and there was a large box in the entryway.  This is not unusual - my husband orders online frequently.  I ignored it.  Later, when he came home, he walked excitedly into the kitchen.

"Come here, Sicily!  You need to try on your waders!"

In case you don't remember, Sicily is five.  I guess I shouldn't be surprised.  On the way home from a meeting in November, I called my husband from the airport.  He told me his mom was watching John so he could take Sicily to the shooting range.  When I got home, she said,

"Guess what mom!  I sat on daddy's lap and helped him shoot a pumpkin!  Look at my cool new earphones!"

So that night, Sicily tried on her waders, and practiced walking around the house.  It was hilarious - she kept falling down, not hurting herself, just clumsily, but she was determined to get it right for her dad.  John started squawking with jealousy, until I found the duck call my brother had gotten him last Christmas.  Now there was happy squawking.  For the next few nights, Sicily diligently and gleefully donned her waders after dinner, sometimes going out the front door with her dad to practice steps and rough terrain (we live across the street from the forest).

The first time my husband took her duck hunting, he was home about two hours earlier than usual.  But she lasted for three hours, which was more than I would have expected.  She loved sneaking out of bed in the wee hours of the morning.  She loved marching through the swamp on the way to the duck blind.  She loved sitting in the duck blind with her dad, another member, and his five and three year old sons, playing and entertaining.  She loved riding with her dad on the four-wheeler.  She didn't even really mind the dead ducks, something we were both worried about.  The second time my husband asked her if she wanted to come along, on another relatively warm morning, she ecstatically assented.

I was talking to my husband one evening and he boasted, "Yeah, (so-and-so) doctor was pretty surprised and impressed to see me taking Sicily duck hunting."  I asked, "How did he see you taking her duck hunting?"  

Apparently, there is a convenient store that is bustling between 4-5 a.m. during duck season, a last stop on the way to the woods.  A place to pick up forgotten items and use a real restroom.  Usually full of men.  Not a place that has seen many five year old girls at that hour, I'll wager.  I can just see my daughter in there, eating up the attention.  Daddy's little girl.  The Princess of the Mini-Mart.

The doctor who saw Sicily at the mini-mart confided jealously to my husband Ike at work the following week.  "My daughters wouldn't dream of going duck hunting with me.  Too squeamish.  They couldn't stand the dead ducks.  I guess I should have started them younger, like you."

Once, a friend asked me if I ever got sad or worried that I had so many different people involved in caring for my kids because of my job and training.  Of course, in certain states of mind.  Women are worriers.  But we are all an amalgam of our experiences, and so I answered,

"No.  In fact, I am really happy that they are exposed to so many different view points on life, at such a young age.  I think it will make them better equipped to handle society.  If they were only approaching the world from my angle, they would have a pretty warped picture."

I can't imagine hunting for pleasure - it is completely outside my worldview.  Or wanting to get up so early, on a weekend or vacation, when I usually rise at 4:30 during the week.  But it makes me happy, on many levels, that my daughter and her dad are sharing these experiences together.  It isn't really about the hunting.  It's about them being together, and being in nature.  A nice side effect is that we are connecting with the food we put on the table.    

I suppose many moms would cringe at the thought of their five year old daughter going hunting, or to a shooting range.  But if you knew what a girly-girl drama queen Sicily is, you would probably be glad for her.  She needs the balance, so I let her go.  I have enjoyed the mornings alone with John.  And the duck gumbo my CIA (Culinary Institute of America, not Central Intelligence Agency) trained brother made for Christmas Eve dinner was out of this world (and completely sustainable!).  It works, in our family.

Happy 2009!!