Tuesday, July 22, 2014

Memories of a med student. The worst day of my 3rd year.

I still haven't gotten word when Gift of Life wants me to get further testing, but they did call today to ask questions about some of the answers I put in my follow up. Specifically they wanted to know when I got the splash exposure I mentioned. Everyone was tested when it happened, and we were all clear. But man that was a shitty day.

I was scrubbing in for a hysterectomy. As the student you sit between the woman's legs and hold an instrument that goes through the vagina to guide the uterus into a better view for the OB/GYN, who is going through the abdomen via lap. Beyond the fact that you have to jam that uterus back, and hold still until you're shaking, which means you're going to get yelled at a lot, you'll get yelled at some more when you didn't anticipate the next spot for the uterus to go. Which is fine, I had already been through surgery and had my fair share of enlightenment in my self worth. At least you get to sit down.

As the surgery was wrapping up, the attending whipped out an instrument from the ports, flung some sort of moisture off it, which managed to easily arch over my face mask, past my glasses, and into my eye. I can only imagine this trajectory was possible through the difference in our positions.

I blinked. It was moist. And I froze.

Because I knew I should say something, but I also knew no one gave a damn, and they'd all be pissed off I interrupted the case. But I did. They asked me if I was sure. Yes. Then I got to spend the rest of the case with dirty looks from the frigid ice chief as the med student who couldn't do their damn job right. The one who interrupted the flow.

Pshh. This was the bitch who later wrote in my evaluation that I introduced myself to the patient too much. Yes. I know that doesn't make sense. Like it slowed down care for the patient to know every one on the team. Yeah, stay out of the way scum. You don't belong here.

Now that I had put everyone in a sour mood, I was given permission to break scrub, temporarily flatten myself from existence, and sneak into the hallway to call the hotline. To make the day emotions feel worse, after accusatory statements form the needle stick hot line that I must have not been wearing my mask, they told me that I must find the patient's next of kin to ask for permission to draw blood right away, and then to walk the blood down to the lab myself. Time was of the essence, and they'd had things get lost before. If I did not take care of myself, No One Would. When I returned and told the resident this, with the light of the computer glowing off her face, she glared at me like I was the greatest waste of an idiot she'd ever been forced to endure. "They want you to..do...what? Absolutely not. You'll wait. WE will take care of this"

Meanwhile the nurse had already handed me a red top to keep in my pocket. After turning it over my hands a few more times, I gave it back.

Inside, I was rumbling with fury, ready to explode. But I still pleasantly thanked my resident for 'looking out for me' and offering to cover the patient's end. I held my tongue until it was time to walk to lectures. I just unloaded on one of my classmates. Some how he took the edge off. "Oh yeah, man. That happened to me too. You can't do the talking to the patient yourself because of ethics, man."

His usual roll with the oddities sort of self calmed me down quite a bit. I also had a justification for the resident's behavior as long as I twisted it right, so I could pretend everything was actually going according to protocol. I attempted to ask my department chair what was the best way to go about the situation (framed in a non-accusatory, confused med student who just got conflicting info and wants to do the right thing sort of way), got a vague answer that as a low risk patient I would probably be ok, and was sent out to go on about my day. Sore, but no longer shaking. Which is all I need to function, put on the girl scout smile, and move onto the next task. Later in the day, I got a call, and was told everything was fine.

If this screws up my ability to donate bone marrow, I'll be really upset. But it's highly unlikely considering that the event was well over 4 months ago. I think they just want to be extra careful about making sure they're not sitting in the middle of a window for a blood born disease. One step at a time. Maybe I'll get lucky and they'll ask me to come in for the labs when I have night call so I don't have to interrupt the team.

Monday, July 21, 2014

The next step in bone marrow donation. Contacted my coordinator today.

This morning I was determined to get the ball rolling with the gift of life registry coordinator. So I called her immediately after getting my consults in. Notes can always wait a little. As a bonus, we weren't getting any lectures from the fellow to clog up the 11:00 hour.

My coordinator was kind, and told me the conversation would take about 15 minutes. Slightly different from the 2 minute phone calls I'm used to making now.

Hi I'm so and so on so and so service. I have a consult. Patient's name is Bluh. MRN is ####. Room number is ###. They have a PMHx of bleh and were admitted for blah. Our question is THIS. Ok, thank you. Good bye. 

Fortunately, the bone marrow donation process isn't so rushed. My missing a call back wasn't the end of the world. For the next step of the process, I'd have to fill out a form that helps people decide if I'd be an alright donor. It's the same one you fill out when you join the registry, but obviously needed to be updated since it'd been two years.

Now that I've filled it out, I just have to sit on my bum for a bit and they'll tell me within in the next week or so when they want me to come into a lab for a blood draw. They set up the testing, pay for it, etc. At the same time, hopefully this guy has more than one match on the list. Those people are getting confirmatory testing too.

It'll take 4-6 weeks to process the more in depth HLA typing. Once all of these come back, the hematologist compares donor to donor to see who is best for their patient. If I'm the best match, they'll contact me. If someone else is, they'll let me know too.

At that point, it's a waiting game to see when the hematologist thinks it's best for their patient to receive marrow. Obviously they wouldn't completely obliterate a patient's bone marrow without someone lined up, but an induction process takes time and that can be variable. Patient's need to get a bone marrow biopsy after each attempt to see if their cell count is low enough to replace with a donor's marrow or stem cells. And if that bone marrow isn't running on empty, then the patient has to go through another round.

That's simplified. The point being, a donor needs to wait until they're called, and they might not know when. But they get updates every month so they can plan a little in advance.

But being me, I have to data mine a little more. I mean, really, what's my chance I'll be going through with this?

Monday, July 21, 2014 11:01 PM
  • Registered Donors 235,697
  • Matches 11,195
  • Transplants Facilitated 2,701
  • Patient Searches 67,442
  • Donor Recruitment Drives 5,811
  • Collection Facilities 8
  • Countries Serviced 43

So by signing up, there was a little less than 5% I'd be identified as a potential match. Now that I'm a potential match, there's a 24% chance of a transplant going through. Overall, 1% of donors go from start to finish and 4% of patient searches result in a transplant.

My coordinator gave me a ball park number to be chosen of 30%. So who knows, maybe the current numbers are better than the averages overall. Or maybe it's just close enough, because really, it doesn't change anything other than satisfying my curiosity.

Sunday, July 20, 2014

Things I'll never get used to: Being put on a put on a pedestal by premeds.

I went to the gym tonight to get back in the swing of things. Nothing major, just the good ol' standby of legs and back. I met some undergrads there in the all too familiar scenario of a couple of guys who have a plan and are taking charge of their work out, and a tag along chick who is confused as hell, but doesn't want to step on anyone's toes or ask for too much help, so she takes it extra easy on her body and just sort of plays around with things that aren't going to get her results.

But their cage was right next to mine, and I could see she looked uncomfortable and appologetic that the guys were loading 45s when she needed much less. The guys didn't mind, clearly they were happy to have their friend along for an activity they enjoyed. When she offered to go off and get one of the smaller bars, I had to speak up.

"Hey. You can work into my sets. I'm doing a light load today and not going any higher than this". My bar had 10s.

I knew what was going to happen next. She didn't feel like she belonged in the space. So she tried to isolate herself further by offering to just wait until a new rack opened up. There was some more discomfort with if she could lift the bar or not, because she didn't know how much it weighed.

"Come on. I'll teach you. I can tell you're definitely strong enough to lift 45lbs. You'll be surprised at how powerful you can become"

She agreed and she stated that she was an APK major so she should learn how to do this. Which was cool, and I let her know that I did that in undergrad. Which leads the conversation about what I'm doing now, med school. Sure enough, she was taking MCAT in 3 days. Yeah. That's a lot for the mind and enough pressure to make you carry insecurity into every situation. Could or could not be the case today, but you've got to give people the benefit of the doubt.

So I spent a little longer at the gym, and went through my favorite leg exercises with her. Taught her about strong lifts 5x5 and let her know she could always seek me out if she saw me at the gym. And this woman was so excited her eyes were just completely lit up. She had some friends come by and told them I was her personal trainer. Which made it my turn to get embarrassed and down play myself. Then she follows it up by telling them I had her major, I'm a doctor, and her inspiration for the evening. Woah. That's a lot. Hey, med student, not doctor. Looks like it's time to start my set.

It's eye opening to step outside of the medical hierarchy where you are an annoying time sink, and have pre-meds look at you like you're some sort of goddess. The role model living. 5 or 6 years ago I was in her spot, putting people on pedestals, rubbing my own face in the dirt, and living on such high alert and suffocating self doubt that I couldn't write my personal statement without freezing. When I had to force it done, I got blasted drunk, and went into a hysterical fit of crying and typing at the same time. Oh yeah. I was a mess.

But I'm here now! Clearly life moves on.

And she'll do great. She's pulling 36's on her practice tests and her applications are only waiting on this one score.

It was good to have that perspective of how far I've come. Because I still freeze up and get nervous when I think about this up and coming match process. Same crap, maybe I'm just a little too burnt out now to get as intense about it. Or this is some form of maturity. Who knows.

The Complete Room Haul Over, Part 1. Making a Functioning Space.

I'll be living in a new space and I need to clear my thoughts about what needs to be done. So let's go.

1. Clear out the bad juju. 

Gotta have a clean start. Let's go captain planet style.

Earth: Deep clean the bones of the house. My flooring is wood, so I'm going to mop it. If it was carpet, I'd get a cleaner. The base boards and walls need to be cleaned too. Any holes in walls or cracks need to be patched or caulked. Little fortifications of mildew will be razed without mercy.

Fire: Every light fixture needs to be examined, bulbs replaced. Then the lighting needs of the room must be assessed to see what else must be bought.

Wind: Change the damn air filter, dust the house, and let the fan run on high for a bit. Address whatever smells weren't taken care of with the deep cleaning. Thank god I don't live in a place with a previous smoker. I'd have to seal the residue in with paint.

Water: Leaks. Got to find them. Got to patch them. That wimp of a rental shower head should be replaced with something nice. Toilet needs a bleach biscuit.

Heart: I have to be honest with myself about all the crap I don't need, and get rid of it before moving into the new room. Especially anything with negative sentimental value. Like, I've got a left sock and I know the right is at my ex-boyfriends. I will never get that back. Why the hell is it still here?

This might also be a good time to do any personal rituals to establish the space as yours. I've never done a sage smudge, but if it can cover the smell of the bleach typhoon I'm going to assault the place with, I could be game.

2. Charting out the battle tactics. 

Two years ago, Mom and I listened to books on tape about organizing and fantasized about putting our lives together. In some ways it helped. Hey, I eventually bought a shoe rack for the front door. Putting my shotty motivation to the side, I do know what needs to get done.

  1. You have to write down all the ways you're going to use the space. With honesty. Not what you think should go on there, but what you actually do.
  2. Evaluate the needs of those activities and write it down. I'm talking item count. Decide the best way to store it all in an ideal situation so that you would have everything you ever wanted at your finger tips. Lighting and atmosphere is included in this. Yes, even something as obvious as a lamp and a comfortable chair needs to be written down. Ideally, everything needs to be stored where it will be used. Because that's where it's going to end up anyway.
  3. Then you must carve out dedicated territory for each of those activities in the room, taking into consideration the storage you will cart along with the activity. If your space is not ideal, figure out why, and see if you can address it. Bathroom is too small for your expansive beauty routine? Pare down your crap, or set up a vanity somewhere else. 
  4. Actually buy the containers, pegs, and hooks you need to store your things. They better be attractive to you. Accept your shallowness and recognize you will ignore using the ugly plastic tubs beyond cramming in what you can and hiding them. They just become a garbage can that's socially acceptable to rummage through.
  5. Install hardware to hang up stuff. Don't procrastinate this stuff. You already spent money.
  6. Re-evaluate the function of the room a week later. Specifically, re-evaluate your patterns and habits now that the room has changed. If it's done for the better, good. If not, see what you missed on your original list of all the ways you were going to use the space. Run through it all and adjust as necessary. 
Colors and decor can be discussed later. When you're limited on money and time, pulling a new room together has to happen in stages. And life doesn't go on hold while that happens. As long as you're living there, make it function, first. 

The territory of something powerful.

My apartment has transformed. I am the queen bee of the hoarding hive.

Living in a college town, everyone moves during August. Yet a lot of the leases end kinda early. It's not uncommon for people to get stuck between leases. To shorten otherwise boring detail above who is moving and where, I've got three extra sets of stuff (a boyfriend who is in my apartment right now, a future roommate of my own, and a future roommate of one of the roommates who is leaving). Then my current two roommates who are going to need to move out next week, are going to get their inner archaeologist on, and excavate their treasures from the hoard. New roommate will bring in more stuff. Week after that, boyfriend pulls all of his stuff out. Somewhere in all of this I move my stuff to the big room. 

It's a bit of a mess.

I'm squirming with excitement about the ability to get my apartment back. We slid a mattress behind the couch today. Despite it all, I've maintained the necessary channels for functioning life. 

Yet there's something really exciting about all of this. I'm going to move into the new room, and this is a great opportunity to purge and start fresh. This is the time for glutting myself with pictures on apartment therapy about what I want to do with the space. It's big. There's two closets. And a little bathroom that is mine. 

I want to push myself into every corner of the room. When a person walks into that space, their reptilian brain will speak up; voicing with the gut that they are in the territory of something powerful. 

The room will function. I really only do three things in a bed room. Dressing, sleeping, and sex. All three must be tactile joy. I'm accepting nothing less.

Those are my requirements. I know what always holds me back. It's finding the justification to set aside the money to do it. Every bit is a little more student loans. As much as I love self expression through the items that decorate our bodies and homes, I never feel I deserve to spend the money. This leaves me with a closet of fading clothes that are affordable, socially appropriate, and loathed. And white walls. 

When I was younger, I wore my frugality and plainness with stubborn pride. While I still value frugality, I've come to abhor plain. Neutral. Appropriate. Pleasant. Expected. All of it does something nasty inside. 

Let me tell you why. 

At the back of my medicine clerkship syllabus there was a list of all the things we were supposed to do. And separated from all of those "helpful hints" was this: "Do NOT offend the status quo." It was a statement that apparently didn't need explanation. 

So much about medical school is social grooming to fill the role of what a doctor is supposed to be. How you must present yourself. How you must dress. What's allowed to go on your facebook. How you're allowed to speak in public. The sideways glances and big bad word of "unprofessional" getting pinned to your lapel if you don't. It's built into the curriculum in a minor way, but the culture is saturated with it. While it all makes sense, it is positively puritic to be constantly reminded of how to behave. I've never fit in with the kind of crowd that gets to decide what is socially on trend and what is not acceptable. I still don't. I've always been a little too loud. Too crude. Yet too goody two shoes. Not feminine enough. Whatever.

I was never embraced by the status quo when I was younger, and now that I am being groomed to a position of high social standing, it feels weird as hell to embrace it back. Somewhere along the line, my home has become this one place where nothing can impose on me. It's become vitally important that I shed this ridiculous notion that I can't spend any money on working towards a space I deeply enjoy unless no debts are owed, and every bill is paid in full for the next 6 months. Because it's the only place I don't have to wear the mask. And honestly, I don't even know what I look like underneath it anymore.

500 dollars in the grand scheme of things is not going to make or break me. That's the budget. And so help me I will paint that white box. 

Saturday, July 19, 2014

An email.

I got an email last night saying I was a possible bone marrow match. I was so excited I couldn't fall asleep and then I went through my 12 hour shift on 4 hours sleep.

Really, I should say I found an email last night. It was already a day old. One of my patients had discharged the night before, and the other was tuned up for discharge today, so pre-rounding was a snap. With the extra time, I called the coordinator at 7AM, but low and behold, they keep regular office hours. 8:30-5, M-F. Ok, leave a message. Then 20 minutes before rounds, the intern tells me we've had a holding note to work up a new patient since 5AM. Would I like it?

Well, yes. Actually, I really would.

Learning medicine is a lot of figuring out the culture as you go. Now I know to search for holding notes. Have no idea where they're stored, but I know to hunt them down if I've got down time. And I'm kicking my ass about that one.

Between rounds, more rounds, lectures from the fellow, noon lectures, working up the patient, writing a swollen med-student style H+P, coordinating discharge for the other patient, and then getting a transfer, 5 o'clock came and smoothly rolled by before I ever had a chance to try to call that number again. I feel a bit guilty.

Yeah, in the typical hospital pattern, something gets pushed to the side for something else, and it happened on a Friday. That office is not going to be open over the weekend. It's 8:30-5:00, M-F. So I can't call until Monday. The call is just for coordination, I'm not really sure where they'll want to do the HLA typing or how long it will take to draw/run those labs. I'm assuming doing it at our center is fine.

But I'm thinking that somewhere out there is a 33yoM, with AML who might need some marrow. And I can't help but think of one of my first patients on the heme-onc floor who had AML and was fighting for his life, on an impossible chemo regimen. He was mine for the whole month. And the previous month he belonged to another classmate. Every day you walk in to update someone on their counts, just holding out in a state of emotional stead-fast for them to return to themselves, you would do nothing short of killing to get them a better chance. Then you leave the service and they disappear from you.

My next rotation was vascular surgery, and I was only able to visit him once on my post call day. I heard through the grape vine they got to the next stage in his treatment. But I really don't know what happened to my patient long term.

So I think about this other young guy, who is obviously not the same person I snuck brownies to on the heme-onc floor because I couldn't stand the fact that he was going crump any day coming, and have his string of last meals be hospital food. This isn't the same guy. He's not "my patient".

But the same diagnosis of acute myeloid leukemia is really hitting me. And I've got that same fierce reaction when someone is assigned to me. They are mine. It's my responsibility to make sure they don't fall through the cracks. That's my role as a med student. Being thorough. Until there is nothing left for me to do for them, I can not rest. Seriously. I don't sleep right unless I do right.

I have to follow up on this guy. This HLA typing needs to get coordinated.

Thursday, July 10, 2014

I need to go run.

I need to run today. I have to get out there.

See, I'm trying to write. I've got an idea tumbling around in my head. Just kind of wondering when I'll stop putting people on pedestals. When I was a 3rd year, just a year ago, the 4th years just seemed like they had it together. And the interns must have known so much. God, I'd genuinely be thankful for any scrap of attention I could get. Now I just want to do my work and go home. And I don't feel very awesome. But the third years have that same bubbly nervous energy. Well, a little. Personally I think their presentations are much better than mine were at this stage of the game, and they're on top of their shit.

OH FUCK. I have to write a presentation on MELD scores. Just remembered that.

For the initiated, MELD scores are based on calculations using a few basic labs that let you know how screwed over a liver is. They use this stuff for allocating livers because it correlates nicely with how desperately the patient needs one. But it works pretty well with general liver health, because if you desperately need a liver transplant, your liver is dying. You're dying. Highest MELD scores get livers first. The tie breaker becomes how long you've been waiting at that score. If your MELD gets higher, you bump up to the next tier on the list and your time gets set to zero. If your MELD gets lower (good job liver!) you fall on the waiting list to the tier below you but you get to keep the time so you're ahead of people who just got pushed to that level.

I think. Clearly I need to read more uptodate instead of skimming, and get this done.

Anyway, it's weird to be respected a little more. People let me write orders now. Nothing's changed. They just allow me to get in their hair long enough to learn something useful so I can stay out of their hair in the long run. If that makes sense. That and I've become very anal about my presentations. I have to present like I'm explaining something to a stupid, small child, but in very terse terms. For some reason, that makes me enunciate just the right way and speak with enough volume to not zone people out. I don't know. Somethings come naturally to you and some things don't. Presentations are my down fall if I'm not vicious on myself. On the bright side, I haven't gotten told to "use [my] doctor words" yet. Actually, I don't think I've heard that in a few months. So there is hope for me. Maybe I'm growing after all. Or whatever.

I need to go run. Time to get out my zombies ap again.