03/27/2009

Family & Friends-

I find that when it has been this long since I last wrote, the best thing to do is choose the best 1 or 2 nuggets, write about those and ignore trying to "catch up" on 5 or 6 months worth of events….the only trouble now is remembering what those 1 or 2 nuggets might be!

I'm just now drawing to the end of my out-patient/ambulatory internal medicine month. Because medical school has its own lingo and the phrase "out-patient/ambulatory internal medicine" is pretty esoteric, let me rephrase by saying I'm finishing a month in a clinic much like you might think of when you say "I've got a doctor's appointment today". Out-patient means it is not in the hospital, rather it is in a clinic. Ambulatory means that the patients walk in and walk out in the same day (they "ambulate"). Internal medicine means it is simply primary care for adults -- they are the generalists who do not specialize in one organ system, rather they are trained to handle problems from almost any organ system. This month I have spent approximately 80% of my time working with patients who have common chronic problems such as high blood pressure, diabetes, high cholesterol, back pain and coronary artery disease, etc. The remaining 20% or so was spent on more acute things like gout attacks, asthma exacerbations, etc. For some reason (probably because most medical students are cowboys who like that adrenaline rush), Internal Medicine and chronic care in general gets a bad reputation. I heard over and over that I'd be board out of my mind this month, but I guess I'm just made of different stuff because I've really enjoyed things! Admittedly, it is frustrating to have to see a new patient every 15 minutes (I'm sorry, 15 minutes is simply not enough time to do anything, even in the best of circumstances!) but aside from the problems of managed care, I like the clinic life. Next month is an in-patient Internal Medicine month (meaning I'll be working with much sicker patients who have been admitted to the hospital). Traditionally this is one of the hardest rotations in medical school, so I'm trying to mentally prepare myself for the gauntlet ahead!

Well, really only a few stories are coming to my mind that might be even slightly entertaining to write about (and I'm not sure they are even all that great…we'll see I guess!) However, before I dive in, let me preface this as I have in the past: I will be using "medical words" (meaning I'll be talking about certain anatomy) and if this is likely to offend, feel free to stop now. Also, because I don't want any of the HIPAA Gestapo to come breaking down my door tonight, I will be changing certain details in order to absolutely protect the identities of individuals. Having said that though, I am not changing the major details of what actually happened, nor my thoughts & feelings (or lack thereof).

One thing that you find out as you work with different medical educators is that each person has a different level of commitment to your learning experience. On one end of the spectrum you have the doctors who really don't want you around and who only keep you there because it is part of their contract. When working with one of these doctors (let's call them the "Apathetics") you learn very little, but the ride is usually pretty smooth -- you be as inconspicuous as possible and they won't fail you out of medical school. On the other end of the spectrum you have what might be called "The Dedicated". These doctors (bless their hearts) do ANYTHING and EVERYTHING to ensure you learn something. While this is certainly the better end of the spectrum to be on, it can get a little excessive, as I learned to my dismay a week or two ago:

I was in the clinic with a doctor -- let's call him Dr A (I'd classify him as a "dedicated" but not excessively so) and our next patient happened to be another doctor who works as a specialist at one of the local hospitals -- let's call her Dr B (it is always kind of weird to be a doctor for a doctor…but anyway, that is beside the point). Dr B was in the clinic for a routine yearly physical exam. Dr A asked all the appropriate questions, did a brief yet adequate physical exam and was writing his note, when Dr B (someone I would classify as light years beyond the "dedicated" mark) turned to me and asked if I was going to be practicing my physical exam skills on her. Dr A tried to explain that when the patient was another doctor whom the student (me) may have to work with sometime in the future, he usually didn't have them do any physical exam in order to avoid any awkwardness. Dr B would have none of it! Ignoring completely the explanation of Dr A she began to grill me about how to do a proper cardiac auscultation exam…

At this point let me take a tangent and explain the full cardiac auscultation exam (auscultation means "to listen" usually with a stethoscope). Because the heart is divided into chambers and because there are multiple valves within the heart and because something may go wrong at any of these sites, a full cardiac auscultation exam involves listening to the heart at different places on the chest -- at each spot a different part of the heart can be heard better. This does not mean that at spot #1 you only hear the aortic valve, it just means that the aortic valve can be heard best at spot #1. At spot #2, the pulmonary valve is heard best, and so on.
Cardiac auscultation is fairly easy on a male because they lack certain chest anatomy that is present in female counterparts. Where things can get difficult is when listening to a couple of the spots on the female patient because breast tissue often needs to be held out of the way. Also, part of the exam involves finding the PMI (Point of Maximal Impulse). The location of the PMI gives an indication of how large the heart is (an enlarged heart can be a sign of impending heart failure). Again, finding the PMI on a male is not too hard…but in a female, it requires a lot of maneuvering of breast tissue.
Because of these complications, in a potentially sensitive situation such as examining a teacher or colegue, the cardiac exam is often superficial and unless there are symptoms or risk factors to suggest something is wrong with the heart, a superficial exam is all that is needed (Note: this may not be what the textbook tells you to do, but we live in the real world and in the real world, sometimes the cardiac exam is sacrificed in order to preserve dignity)

…okay, back to the story! There I was, getting grilled about the cardiac exam when Dr B said "show me the proper exam technique!" (and since she was the only patient in the room, it could clearly be surmised that she meant to have me perform the cardiac exam on her). I shot Dr A a quick glance as if to say "is that okay?" and Dr A gave me a look back that said "sorry pal, technically she is right and should get a full cardiac exam today…better luck next time!" With all the enthusiasm of a man walking to the gallows, I went through the motions of a cardiac exam, trying to be as quick and non-invasive as possible. Approximately 4 seconds later I had listened to all of the necessary spots, pretended I'd found the PMI and had backed up halfway across the room to give Dr B plenty of personal space. Now, because Dr B has a level-10 black belt in medical education, she knew what I was up to and was not going to have any of it! She made me repeat the full exam 3 or 4 times until she was convinced that I had learned something about how to do a proper exam. I'll not be more detailed in my explanation than that, but I don't think a world-class imagination is needed to paint a mental picture!

Let me emphasize that while this was an uncomfortable situation for me (funny in retrospect, yes, but still uncomfortable) there was no reason to think that Dr B had any motive in mind other than the proper education of a student. She works day in and day out in a field where she sees students who are not properly trained in physical exam technique because no one is willing to let the proper exam be done on them. "Dedicated" doctors have been known to go to greater extremes than that in times past to teach a student and by comparison I got off easy! (Also, Dr A was present in the room at all times, and besides she was probably twice my age or more!)

***

So this next story is probably not quite as memorable for the reader of this letter as the last story, but for me it was a real red-letter day!

There have been plenty of times in the past where I feel like I have no idea what is going on…I do take comfort in the fact that all 3rd year medical students often feel this way, but none-the-less I sometimes sit there trying to think of some distant piece of information I learned and all that comes to my brain is that the patient probably needs a tetnus shot (not that tetnus shots cure any of the patient’s problems…but sometimes that is all that comes to mind). Fortunately, things are coming together more and more every day, but regardless there have been a few times that if you could read a transcript of my thoughts, this is what it would look like:

"This patient has sarcoidosis of the lungs, how should we treat him?"
"Tetnus shot?"

"This patient has pseudomembranous colitis, what should we do next?"
"I know, give him a tetnus shot!"

"This patient has a bunion on his foot"
"Tetnus shot is just what he needs!"

"This patient has excessive earwax"
"Tetnus shot! (then a CT scan of his head!)"

But, a few weeks ago I finally, let me repeat, I finally heard something before my attending did! In listening to a patient's heart I heard a murmur, and it wasn't until I insisted that I heard something abnormal that my attending listened closer and agreed with me! We sent the patient for an echocardiogram and it turns out he had aortic stenosis (not a real good thing). While I feel bad for the patient, a part of me can't help but be excited that I finally caught something that no one else caught!

Anyway, that’s about it, so I’ll finish here.
Love you all!

-Eric

I swear I'm not dead!

Despite opinions to the contrary, I still plan to write my little entries about the funny and memorable moments of medical school and life...this has just been a really bad, what, 5 months?!?! **Sigh**

11/25/2008

Family & Friends,

In anticipation of Thanksgiving on Thursday, I send my love and wishes that I could make it home to see people…but alas, I am scheduled to be on call Thursday (more on this in a minute) and will be in Wisconsin until Christmas time. Hopefully I can see a lot of you during the week I have in Utah between Christmas and New Years.
It seems to me that there are a few topics that I write about that get a lot of response from people. One of those topics is Chopper the mutant man-eating Godzilla dog who lives upstairs. The other is anything regarding me and OB/GYN – I guess the image of awkward ridiculous single me trying to deal with female-issues gives people a big kick (frankly it is funny in retrospect, though usually mortifying at the time!) Having said this, I guess I’ll be batting 50% in this letter. I really don’t have much to say about Chopper – he’s as big and dumb as ever – but I am 2 weeks into my OB/GYN rotation and I’m collecting embarrassing moments at an alarming rate!
Let me attempt to set the scene a little bit and describe what rotating through OB/GYN is like. First let me state that I respect most OB/GYN doctors I’ve met. Most are nice and reasonable people. They do good things and help with issues that need to be handled. I even find that I quite enjoy most of the work that they do (delivering babies is neat, surgery is neat, the medical chart notes they are required to write are short – a BIG plus in my mind) however, they have the WORST lifestyle! Seriously, you will never meet a bigger group of work-a-holic insomniacs in your life (outside of neurosurgery, that is). Every few days they have to be “on call” which means they work a ~30 hour shift (from 5:30am to about noon the next day) and of course as students we have to pull similar hours. I’m actually post-call today, which means I haven’t slept since 5am yesterday (it is currently about 4:30pm today). I will sleep tonight, work a 12ish hour shift tomorrow, sleep again and then begin another 48 hours of wakefulness. I’m only on this rotation for 6 weeks…I can’t imagine how people do this year in and year out! They are stronger than me I guess!
Anyway, most of the time I’m on the Labor and Delivery floor working with women who are actively in labor. What I do is meet the women when they first get there. I ask a whole bunch of questions, do a brief physical exam and then leave for several hours to write up all the information I gathered from the interview and exam. Several hours later I pop my head back in and make sure everything is going okay. This continues until the woman’s cervix is dilated to somewhere around 8cm. Once this happens the doctor and I rush in, throw on sterile gown/gloves/mask and join the nurse in helping the lady have her baby. I find it funny (maybe that is not a good word-choice) that really it is the nurse who spends all the time with the woman. The doctor and I just sort of show up for the exciting part and then leave again…strange, but oh well!
I have observed that there are several types of laboring women. There are those who have been down this road before. In fact in some cases the babies practically tap-dance their way out because mom’s pelvis just doesn’t offer much resistance any more. These women have sage-like knowledge and do not get ruffled when a stuttering medical student is catching their baby because they simply know that things usually go just fine. In many ways working with these ladies is nice.
On the other hand, there are ladies who would like to kill anything with a Y chromosome – or at very least hit us in a body part of their choice with a ball-pein hammer every time they have a contraction. Not that I can really blame them…I’m not quite sure how much I’d love some stranger sitting down observing me from, shall we say, an unflattering angle while my feet are in stirrups all the while I’m trying to defy the laws of physics by squeezing a cantaloupe through a drinking straw. Frankly, I might get a little grumpy myself!
My first day of work was something of a “baptism by fire” experience. Not only was I clueless about what I was supposed to be doing, I was on call, exhausted, and not yet emotionally calibrated to the birthing process (a feeling that comes surprisingly quickly once you have delivered 7 or 8 babies at 3am). That first night we had 8 or 9 births, 2 of which were emergency C-sections. I decided after that night that there are some fundamental laws of the obstetrical universe:
1) No babies will be born during normal daytime hours
2) All babies will be born between the hours of 11pm and 5am
3) All emergency C-sections will need to happen at exactly the same time even though there is only one team to perform the operations

That first birth really was quite the experience for me. In some ways it was one of the most disconcerting things I’d ever seen. A part of me felt like I was in a real life “Aliens” movie. The other part of me was in awe of the miracle of birth. I will say that despite all the blood and gore of birth, once that wriggling little baby was out and letting the world know he was UNHAPPY my heart sort of melted and it was easy to forget that I had just seen every law of physics shatter.
Well, I’m exhausted and need to cook dinner, so I’ll finish up. Love you all!
-Eric

10/19/2008

Family & Friends-

I believe last time I got a letter written, I was on Family Medicine and thinking strongly that it was going to be my future career. I guess I must be fickle or something because that is not really the plan anymore. Sadly, I left family medicine with a bitter taste in my mouth that I think I’m going to have a hard time getting over – this was largely due to one of the professors that I really didn’t have good rapport with (more on this in a minute). My current thought is a lesser-known branch of medicine called Physical Medicine and Rehabilitation (PM&R). Obviously I’m going to need to take an elective in this before I commit myself, but it really seems to be a nice synthesis of the best parts of several other fields, including primary care, neurology, physical therapy and sports medicine. Because I know that at least my grandma’s will want to know more, and because I don’t want to take too much space writing about it, anyone who is interested in what PM&R doctors do can get an idea by taking a look at this website: http://www.aapmr.org/medstu.htm

Overall I really did like family medicine and I haven’t completely excluded it from my list of possible careers, but like I said, there was one doctor who I worked with who had the uncanny Hoover-like ability to suck all the joy of medicine out of each day I worked with her leaving me feeling like I had the intelligence of table salt and wondering if the day could get much worse. She was somebody who always seemed flabbergasted that a 3rd year student – someone with a total of a few weeks clinical experience – had failed to follow a particular line of obscure questioning or who had written a progress note in a format preferred by a doctor other than herself. Essentially she was one of those narcissistic Napoleon-esque doctors who thought everybody besides herself was wrong and who was totally intolerant of a student who was still in the steep part of the learning curve (but who deluded herself into believing she was absolutely open-minded and blessed with Job-like patience).
One particularly memorable day I was working with Dr. Hoover (not her real name), and we had a patient cancel, leaving us with about 30 minutes before our next patient arrived. My plan was to use the time to do some much-needed study about some of the conditions we had seen several times about which my fund of knowledge was lacking. Just as I was sitting down with my textbook, Dr. Hoover announced that we had an add-on patient. I stated I would be happy to visit this patient like normal and report back to her with what I found. However, Dr. Hoover said she would like to accompany me into this particular exam. I figured she must want to observe me doing the history and physical so that she could evaluate me and offer some constructive feed-back. Of course I was fine with this and so we set out down the hall toward the exam room.
When we arrived in the room I looked around perplexed because there was no patient in the room – just me and Dr. Hoover. She closed the door, sat down on the exam table and announced, “I’m your patient”. Fear stuck into my heart and I knew this was not going to end well for me. The story she gave me at that point was that I needed to do a fundoscopic exam (looking at the back of her eyes through the pupil using a tool called an opthalmoscope). She stated quite matter-of-factly that if I had the IQ of soup, I would find an abnormality with her retina. Let me pause here and take a small tangent that will help clarify why this was such a dastardly thing for her to do.
In medicine we use 2 major criteria, sensitivity and specificity, to determine if a test is useful. A perfect test would be both highly sensitive and highly specific. A test that has high sensitivity but poor specificity has its uses however, as do tests that are highly specific but poorly sensitive. A test that has both poor sensitivity and poor specificity is essentially worthless. The fundoscopic exam, as preformed in a primary care setting has low sensitivity and specificity, and thus it is not emphasized heavily in medical school training. Fundoscopic exams only become really useful when using the equipment in an ophthalmologist’s office. My training in fundoscopic exam was brief, as it most people’s. Almost all medical students and plenty of residents and doctors are not comfortable with this exam because it yields such poor results. If a person has vision problems or something suspicious about their eye they get referred to an opthomologist who can do a proper exam.
To do a fundoscopic exam, the examiner must get within a few inches of the patient’s face (essentially kissing distance) and shine a light into their eye while trying not to breathe directly into the patient’s nose or mouth. This wouldn’t be a hard thing to do…if your mouth were somehow situated on the back of your head – but as this is not the case, fundoscopic exams are invariably uncomfortable for both doctor and patient. In a perfect world, you are supposed to see a the optic nerve as it exits the back of the eyeball and spreads out into the retina as well as an assortment of vessels. The optic nerve (called the optic disc) is supposed to be a shade of yellow and have crisp defined edges. Part of the reason it is hard to perform this exam in the primary care setting is because you never dilate the patient’s pupil and so you are trying to see this anatomy through a tiny pin-hole pupil.
Okay, back to my story! There I was, my stomach somewhere down near my ankles cursing Dr. Hoover in my head for choosing the fundoscopic exam, of all the possible parts of the physical exam she could have chosen, to evaluate my prowess and progress as a student! For 20 minutes…let me say that again: for 20 minutes I was inches from this lady’s face (who has halitosis by the way) trying to see what was abnormal about her eye. It was so awkward and uncomfortable in that room that I was convinced that random objects were in danger of bursting into flames. To cut the pain short I started trying to ferret clues out of her, hoping I would stumble upon something that could help me identify her retinal abnormality, but to no avail. When she had tortured me long enough, Dr. Hoover demanded I tell her what I know and she would fill in the rest. I said that the optic nerve in her left eye had looked whiter than normal (more of a guess than a confident declaration, but a good guess I was to find out later). Then in a tone that let me know in no uncertain terms that my brain must operate via parcel post instead of express overnight mail, Dr. Hoover said that what I “should have seen” if I was not such a moron, was that the optic nerve in her left eye was whiter than normal and that the edges were less distinct – more fuzzy – than normal. All this put together should have let me know that she had an extremely rare anatomical variant where the optic nerve stayed mylenated after it exited into the eyeball (myelin is a coating that surrounds some nerves and which normally stops at the point the optic nerve exits into the eyeball). This is such a rare condition that I was forced to look through 5 books before I found a picture and description that I could read about. Overall it was not an experience that endeared me to Dr. Hoover, nor was it the only craziness she put me through. However, she was only one doctor and the other doctors were much more personable and so overall I enjoyed family medicine…though I’m not so sure I want it for my career anymore.

**Next Day**

Okay, I got distracted yesterday and will try and finish the letter today.
After family medicine I spent 2 weeks on Neurology. I really hadn’t expected to like Neuro because I hadn’t liked our neuroscience class, but I was pleasantly surprised to really enjoy clinical neurology. We spent our time working with stroke patients, brain trauma patients, or patients with neuro-degenerative diseases such as multiple sclerosis, ALS (Lou Gehrig’s disease), Parkinson’s disease, Huntington’s disease, Alzheimer’s disease, etc.
Last Thursday I started my Psychiatry rotation. I was placed at PCS (Psychiatric Crisis Service) – basically the Emergency Room for psychiatric patients. Most of our patients are brought in by the police because they are suicidal, homicidal, or in the midst of a psychotic or perhaps manic episode. In the 3 days I’ve worked there so far I have seen the craziest of the crazy (Scott, I’m sure you know what I’m talking about). One guy came in because he was picked up while running down the street naked. Another guy set his couch on fire in some ceremony because the voices had told him to do it. Most of our patients are depressed and dangerous to themselves or dealing with drug addiction problems. One lady was antisocial to the point she had to be subdued by several branches of the armed forces. Again, I didn’t think I would like psych because it was never a class I enjoyed attending lecture for, but I find myself excited to go to work everyday. Admittedly, we see a lot of the bleakest society has to offer and in order to cope we maintain a dark humor but even then it is fulfilling to be able to intervene in a person’s life when they are at their lowest. Yes, many of these people will deal with relapses for the rest of their lives. Yes, many of these people are addicted to substances with little hope of recovery, but already there have been several people who probably wouldn’t have survived themselves for more than a few more hours if we hadn’t seen them on the service. Suffice to say, I’m really looking forward to the next 4 weeks!

On a different note, my roommate got married on Saturday. He was one of the 3 or 4 guys who really took me under their wing when I first moved out here and has helped make my time here in Milwaukee such a good experience. He has been dating this girl for the last year or so and I’m really excited for him and his new wife! They are both fantastic people and I will enjoy keeping in touch as time progresses. Without a doubt, the sealing ceremony on Saturday was 15 of the most amazing minutes I’ve ever experienced. I’ve been to many sealings at this point and they are all incredible, but the teaching and council this particular sealer spent his time on really hit home with me. I curse my feeble memory and wish I had perfect recall because I couldn’t absorb all of the doctrines covered as fast as they were coming. I only hope I can remember and apply some of what I learned in my life now and in the future whenever I find that certain someone.

I find it interesting to be living in a “swing state” during a presidential election. For all the elections since I reached voting age, I have either been in Utah (not exactly a swing state!) or I’ve been overseas and thus separated from the political Gettysburg that I had only heard rumors of. I will leave my own thoughts on politics and the candidates out of my letter but I will say it has been eye-opening to witness first-hand the political WWF Monday Night Raw that exists out here.

Well, I’d best call it a night! Love you all!
-Eric

9/13/2008

Family & Friends-

I find myself with a few minutes this morning and figured it would be an ideal time to try and catch up on my letter/journal. I think last time I wrote anything I was on my Anesthesiology rotation. This month I’m on Family Medicine and it is 180° change from anesthesia (a good thing in my opinion – sorry Jared!) In fact, I’m enjoying myself on Family Med so much that barring a big surprise on my remaining rotations, I think Family Med is what I’ll end up going into. I guess what remains to be seen is how I feel about the idea of going into surgery when I’m on that rotation – but for now I think Family Med is the ticket!
Part of what I’ve enjoyed this month is the increased interaction I’ve had with people and patients compared to my time in anesthesia. I find that anytime you interact regularly with people, especially as it relates to their health, you get a lot of unique and memorable experiences. Add to that, the fact that I’m still in the VERY steep part of the learning curve and there are some downright humorous moments (in retrospect of course…they didn’t feel all that funny at the time!)
Okay, before I relate any of the actual stories, let me paint a picture of what Eric Brimhall, student doctor, must look like to patients:
First, because I’ve discovered through painful experience that I can only wear my current brand of contacts for a few consecutive hours before my eyeballs want to explode, I’ve been forced to wear my glasses to work every day. Many of you know how much I loathe having to wear my glasses, because when I got them a few years ago, I made the worst purchasing decision of my life and I got transition lenses (the kind that get dark in the sun). Let me stand as a cautionary tale to anyone considering transition lenses! Personally, I would like the opportunity to meet the guy who invented transition lenses (and the lady who sold them to me) in town square at high noon for a duel! Why are they so bad? #1, They get ¾ dark – but not all the way dark – under pretty much any light source. This takes about 0.00001 nanoseconds. However (and this leads me to reason #2) they take a good 20 minutes to get back to mostly clear (notice the word “mostly” – they don’t actually ever get completely clear!). What this means is that I walk around virtually all day with partially dark glasses, and all I would need to round out the nerd outfit would be a pair of chums to keep them firmly attached to my head!
Now that you can picture my glasses, imagine them on a lanky guy with dark circles under his eyes from lack of sleep and a white coat with pockets bulging from an assortment of student-related items. At any given time (any med student/residents/doctors out there will know what I’m talking about!) I have a stethoscope, a penlight, a reflex hammer, a PDA, 3 pocket-sized reference guides, a stack of printed journal articles, some flashcards, a Powerbar, 6 pens, something like $1.28 in loose change, a Ziploc baggie with a few emergency Excedrine pills, a pocket calculator, and approximately 1 million 3x5 index cards with scribbled reminders…okay more like 20 or 30 index cards…but you get the picture! Underneath all of that is a pretty normal assortment of shoes, socks, Dockers, ID Badges, pager, shirt and tie.
Now that you have an idea of what I must look like to a patient when I walk into a room for the first time, let me share some of my more memorable moments from the month.
Due to HIPAA regulations, I have to be careful about telling this story. I’ll have to leave some details out, but I’ll do my best to convey the spirit of the moment.
The regular procedure we follow when a patient comes in is that I will go into the room, and get a History & Physical (H&P) and then come back out, present my findings to the attending, tell him what I think is going on, tell him/her what I think we should do and then we visit the patient together. The attending does his/her own H&P, makes his/her own assessment and plan and then we talk over the points on which I was right and those on which I was wrong and then I make a list of things I need to look up on my own time. Then I write a progress note on the encounter, detailing what happened and summarizing what the doctor thinks is going on with the patient and what we plan to do to help.
On my second day of the rotation I was asked by my attending to go talk to a family and get an H&P. We had just left a different room and I didn’t have time to read the patient’s chart before I walked in. Also, because it was only my second day I was still trying to get a sense of how to smoothly get the information I needed (let’s just say I hadn’t figured it out yet and I wasn’t smooth at all). Upon walking into the room I was confronted by (here is where I need to be careful about HIPAA) a particular person I recognized and that person’s spouse and daughter. They were there because the daughter had an injury that was healing very strangely. The reason this was a little disconcerting for me was because one of the parents has a lot of influence over how my dean’s letter eventually turns out (several people are involved in the dean’s letter process, and they all have considerable say over how the letter eventually turns out). Anyway, the point is that this was one of those rare moments where you NEED to shine!
After getting over my initial shock I did my best to put together a decent H&P. I asked every question I could think of…and probably asked a few of them twice in my nervousness! Then I did a focused physical exam and had to admit that I had absolutely no clue what was going on with this little girl. Like a shamed puppy with its tail between its legs, I went out and had to tell the attending that I had no idea what was going on with this girl. We went back in together and I had one of those mixed bitter-sweet moments when the doctor said he had never seen something like this before. Bitter because it meant the girl and her family didn’t get the answer they were hoping for, but sweet because even this doctor with 25 years of experience had no idea what was going on – making me look less stupid.
Anyway, we referred the girl to the plastic surgery folks, and I’m confident they’ll know what to do.

A few days later, I was with a different attending and we were running pretty far behind schedule. In order to try and catch up a bit the two of us went into a room together instead of having me go in alone first.
The lady we were there to see is in her 80’s and showing signs of advancing Alzheimer’s disease. She was there with her daughter who did most of the coherent talking. The old lady, I’ll call her Mrs. Johnson (bless her heart), took one look at skinny little me and decided that I was to be the target of her affections for the remainder of the appointment. She began by telling me what a “handsome young man” I was (which would have been slightly flattering if she had been 60 years younger and not a patient). I did my best to laugh it off, (“Oh, Mrs. Johnson, you are just trying to get me in trouble!”) but she was relentless! In the presence of her daughter and the attending physician she proceeded to tell me that we should leave right then, get in the car, go for a drive and then “park”. Not only was I a little flabbergasted and embarrassed, I was shocked that an octogenarian with advancing Alzheimer’s disease would know how to use innuendo like that! (perhaps that one has been around longer than I suspect…who knows!?!)
Anyway, for the remainder of the appointment I had to balance attempting to learn and be attentive to what the doctor was saying and appropriately deal with the flirtations of this lady! When all was said and done I think everyone except Mrs. Johnson walked out of that room feeling a little awkward and embarrassed.

My next story happened yesterday and I’m still blushing a little bit as I think back on my mortification at the time, but I think this story needs a little bit of a preface.
Let me state right now that all things OB or GYN (obstetrics or gynecology) I am stupid at! Being a single mormon male has not given me much experience in these areas, and all I can do when I encounter OB/GYN stuff at this point is to furrow my eyebrows, nod sagely and try and keep my jaw from dropping or my face from flushing! I can hardly imagine the kind of stories I’ll be able to relate come December when I’m on my OB/GYN rotation…
Anyway, yesterday my attending told me to go in and do a prenatal exam on a lady in her 3rd trimester. I have never done one of these – in fact I’ve never seen someone do one of these! My entire experience on what I’m supposed to do is based on a 1 page sheet I glance at as I walk down the hall toward the fateful exam room. I preemptively furrow my eyebrows and begin my sage-like nodding even as I walk in the room and introduce myself. I then go through a list of very personal questions and just pray that I’m not visibly blushing. My flow of speech is interrupted every 2 nanoseconds with an “umm” and it is painfully obvious that I’m green and very nervous about all of this. I get through all of the questions and now it is time for the exam. (“umm…just take a seat up here and I’ll, umm, do a quick exam”).
Fortunately for me (and the patient), my sheet doesn’t say that I need to perform a pelvic exam, and right now this sheet is scripture to me, but it does say I need to use the dopler machine to get the fetal heart rate. The device is simple enough but in my near catatonic nervousness it might as well be mission control. I put that part of the exam off until last, but it looms over me like a Sword of Damocles. Finally after stumbling through the rest of the exam I can no longer put off the dreaded dopler. Asking the patient to lie down on the exam table and expose her swollen abdomen, I grab the bottle of ultrasound gel off the counter. This bottle resembles the ketchup or mustard bottles that you would see at any roadside café. All I need to do is turn the bottle upside down, shake the gel to where the spout is and squeeze the gel out. Unfortunately, the type of plastic the bottle is made of is the kind that gets brittle with age and apparently this bottle has been sitting on the counter for a long time because as I shake the bottle and begin to squeeze the bottle explodes sending gel-shrapnel flying in all directions! I’m completely mortified! (“umm…sorry…let me get you a tissue and we can wipe up some of this gel!”)
I guess the bottle exploding did get the gel I needed onto the lady’s abdomen and I quickly get the fetal heart rate and scamper out of the room as quickly as possible to inform the nurses that we’ll be needing a new bottle of ultrasound gel in that room (they all have a good laugh when I tell them the story).

Okay, enough embarrassing stories from work! The only other news I can think of was from Labor Day. I went with a group of ward members to an old rock quarry that has filled with water to do some cliff jumping. It was fun and relatively safe! One of the coolest things we did was lunch! The quarry we went to was right next to a very small little town – kind of a quintessential small American place. They had a rag-tag parade down Main Street that was absolutely charming despite its obvious make-shift nature. My favorite “float” (actually a trailer being pulled behind a Ford F-150) had several WWII vets in uniform doing nothing but wave to the crowd (very appropriate in my opinion even though it was Labor Day and not Veteran’s Day). To me no amount of ostentatious decoration or fanfare could have better captured what I love and admire about this country and the people who have sacrificed to make it what it is. A while ago I went on a WWII reading spurt that included Tom Brokaw’s “The Greatest Generation”, James Bradley’s “Flags of Our Fathers”, and Jeff Shaara’s “The Rising Tide”…My admiration and gratitude only continues to grow.
Lunch itself was memorable in the sense that it captured small town America so well for me! The small park right off Main Street where the Rotary Club set up their grills had several rows of picnic tables crammed with locals in their cotton dresses and overalls. The biggest entertainment was a lady dressed up as a clown who was tying long skinny balloons into different animal shapes for a crowd of kids. I ate a fantastically unhealthy meal of fried chicken and $.25 chocolate ice-cream cones – and loved every bite! We all got sunburned and had to keep swiping away the ants and hornets intent on stealing as much of our meal as they could carry. As common place as this scene is, it was a charming and memorable holiday!

Love you all and hope you are doing well!
-Eric

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8/17/2008

Family & Friends-

Because it has been a while since I last wrote, this letter may jump around a bit as I remember what has been going on.

To begin, I took a girl from the ward out on a first date this week and had a really really good time, but the whole asking a girl on a date thing got me thinking about the dating scene in which I have become something of a permanent fixture – a kind of Rock of Gibralter, not to be moved or swayed from my station.
I am daily grateful that, as a guy, I don’t have to endure some of the things that are uniquely female (such as long lines waiting to use the restroom and a very participatory role in the miracle of birth). BUT, least anyone think that guys are completely off the hook, let me state that Fate pointed its ugly finger in the direction of guys when choosing which sex had to make the first move and be the ones who did the asking out.
Ever since the tender age of 16 years and 10 month when I finally mustered the courage to ask out a girl for the first time (she said her “dad wouldn’t let her go”), I have gone through the anxiety attack…errr…I mean process of asking a girl out time and time again. Let me illustrate how this usually goes:

Let’s say that I want to ask a girl named Sarah if she will go to dinner with me. Even getting to this point usually involves several weeks of convincing myself that this is a good idea. I usually require a minimum of 3 or 4 decent conversations in a platonic setting before I’m persuaded that asking her out will not result in undue embarrassment and deep emotional scars. Once I’ve finally made the decision to ask a girl out, I begin the process of mustering the courage – or perhaps it is stupidity – required to call her up (this usually involves several quarts of vodka…just kidding…but sometimes I wonder if that wouldn’t help a bit!) Once the courage is in place I make the call.

**ring, ring**
(Eric secretly hoping that I will get her voicemail)
Sarah (in an unsuspecting tone): “Hello”
Eric (with all the subtly and smoothness of, say, Hurricane Katrina): “uhhh… hello dinner, this is Sarah. Would you like to go to Eric with me?”

Usually when this happens the girl is bright enough to figure out what I meant to say and if she has the common sense that God gave to gravel she will hang up and move to another country…Just kidding! If I’m lucky she will realize that my awkwardness at asking her out is actually the highest form of compliment, and if I’m REALLY lucky she will realize that if I freeze mid-sentence with a panicked “deer in the headlights” expression on my face during the actual date that just means that I’m really enjoying myself and find myself facing the terrifying prospect of asking her out for a second time!!!
Oh, those fond old memories! I have them often, although I can usually control them with medication.

This leads me to another line of thought completely different from dating. The girl I went out with is a little more established than me, in the sense that she lives in a real person house with curtains on the windows and pictures on the walls. I have lived in “college houses” for so long now that it is always fun and a bit shocking for me to realize that I have friends who live in real houses, pay mortgages, paint walls and install sprinkling systems. For the last decade I have lived in a string of apartments that have no discernable yard, have Goodwill furniture the color of an improperly treated wound and are painstakingly decorated with: nothing. I do put a lot of work into stacking the empty pizza boxes nicely in the corner and for good measure I keep a sizable pile of laundry on my bedroom floor right next to an empty dresser. I realize that these are the kind of admissions that make mothers and grandmothers worry (it might also have a bit to do with why I’m still single), but don’t fret! If the aroma begins to get too pungent, I have a can of aerosol deodorant that I can spray around as a kind of poor-man’s air freshener! If anyone comes to visit, you can rest assured that you are sleeping on the finest couch Goodwill has to offer for less than $35 and that the beach towel you are using as a blanket has been washed some time in the last presidential administration.
Okay, it actually isn’t that bad (I’m exaggerating a bit for humor’s sake…but only a bit). I’m simply trying to make the point that I get a total kick out of seeing my friends living in places that I associate with “grown ups” while I am still living in the Never-Never Land of higher education.

As far as school goes, I’m halfway through my combined anesthesiology/ emergency/trauma rotation. Every time I begin a new rotation it is my goal to try and rule out or rule in if it is something I could see myself doing as a career. Sometimes it is just as helpful to rule something out as something I’m pretty sure I don’t want to do as a career as it is to rule something in as a possibility to look into further. This month has taught me that anesthesiology and emergency are probably not what I want to do with the rest of my life. These are careers for some people…just not me.
As part of the emergency portion of the rotation, we had to become ACLS (Advanced Cardiac Life Support) certified. This basically means I had to memorize a big old algorithm of what to do when a person’s heart stops beating or goes into a dangerous and irregular rhythm. Then I had to take an oral exam and explain how I would try and keep someone alive under whatever conditions the doctor threw at me. Fortunately in the oral exam you can get a couple of things wrong and still pass (in the real world, you can’t mess this stuff up) because if I had been working on a real patient I might have killed them. In one portion of the test I needed to administer a pain killer and all I could think of to give was fentanyl (a narcotic approximately 100 times stronger than morphine). Because of its potency, fentanyl is usually given in doses of micrograms. My mistake was to get all nervous and give the dose in milligrams (a much larger unit). The doctor was nice but had to inform me that if I’d given that big of a dose to a real patient they would probably stop breathing…but hey! Now I’ll remember that for the rest of my life!

Anyway, that is about it for me! Love you all and hope you are doing well!
-Eric