Transitions

Now that I've just finished transition to clerkship week, let me tell you all the things that have been added to my toolbox. I know how to give shots, intramuscular, subcutaneous, and subdermal (each have specific angles that you put the needle to the skin), and I know all the dos and don'ts about needle handling so that I don't stick myself and have to go on anti-viral therapy for the possible transmission of Hepatitis or HIV. (Most people fear getting HIV, but the chances of getting Hepatitis B or C is much much much higher - nasty little virus - and unlike HIV where you can live a long time on anti-retroviral drugs, hepatitis can lead to cirrhosis -hardening - of the liver and even liver cancer). Anyhow, the best part of this little workshop is that we got to practice on ORANGES! You would think that my $35K per year would have enough dollars to set aside some time to actually learn how to stick needles in human skin, heck, we were all more than willing to practice on each other, but no such luck. God save my first patient who has to suffer through my first few injections.....

The transition workshops also included the much needed skills of intubation (putting a plastic airway down some one's throat when they need oxygen and cannot maintain their own respiration), as well as how to do a catheter (that's when you stick a plastic tube up the urethra - the little hole your urine comes out of). This is done when a person is unable to empty their bladder themselves, or will be going into surgery. The best part about these two workshops were our patients - they didn't complain or squirm on the table as we jammed instruments into sacred places in their body. They were quiet because they were plastic! Another great thing about our education - they figure we need to learn how to do these skills on manikins first, before they cut us loose to do possible damage on real human beings.

That's one thing about medical education I bet you have never thought about - students need to practice. Atul Gawande wrote about this in his surgical memoir "Complications" - great book, highly recommend reading it, although you may decide to never have surgery once you're done. Is there any other way? Probably not. Although the introduction of these skills with the plastic patients is totally necessary, if at least to just introduce us to the different tools and hardware involved with the different procedures, the real learning will come by doing intubations and catheter placement on real patients, in real time. I pray in advance that I will learn to do these skills in a manner that causes the least amount of discomfort to my patients. Don't worry, I will most likely watch residents and interns do these procedures many many times before getting a chance myself, but I bet you still don't want to be my first try right?

The best workshop last week was the four hour introduction to surgery - we learned how to dress for surgery - where to go for your scrubs, what to wear to cover all of your body - hair net, shoe covers, gown, face mask, including a shield that comes up to cover your eyes (although the surgical scrub nurse was so kind to remind us that even the shield doesn't always protect you as he once had some blood fly up and across the table and land right in his eye behind his shield - the patient had hepatitis). So going into the surgical room is like going into a minefield, not only do you have to deal with body fluids, but you also have to know how to behave so that you don't contaminate what's known as the "sterile field", and you have to remember everything you have ever been taught about the human body, because the surgeon will pimp you (that means fire questions off at you and expect an answer. Rumor has it that one surgeon here at OHSU will make you leave the room if you can't answer his anatomy questions - please God don't let me get him for an attending).

Before you even get into the surgery room you have to spend quite some time at the sink, scrubbing your skin up to your elbow. There is a very specific way to scrub your fingers and arms - you can't do your arms and then go back up to your fingers, or vice versa. You have to start in one direction and continue down or up the arm. You scrub for ten seconds on each area - for each finger you scrub all four sides for ten seconds, then move on to the palm for ten seconds, back of hand for ten, wrist, forearm, etc. you get the picture. My first scrub would most likely not pass the guidelines for a successful scrub - I forgot to clean under my nails with the little plastic digger that comes in the soap container, I choose the wrong type of soap (there are three choices by the sink - you have to know the difference), I went the wrong direction on my arm, and I dropped my soap - which meant I had to start all over again. Oh ya, there's also a very particular way to rinse your arms - hand to elbow, since you don't want the soap from a dirty part of your arm to go over the freshly rinsed part. Sigh.......

Once I got through the hand rinsing part, it was on to the operating room (no patient, we're just practicing the whole scrubbing in thing), to learn how to dry your hands, get your gloves on, and gown yourself. I forgot to say earlier that you have to have all this stuff already set out and ready for you in the operating room - and it's laid out in a particular way so that you won't contaminate the sterile field. I screwed up first by having the towel I was wiping my hands on touch the front of my clothing - strike one - I was supposed to bend over at the waist while drying my hands to avoid that problem. Got the gloves on OK (I had done that once before last year) but messed up as I was pushing my hands through the gown sleeves - touched a piece of the equipment that was not sterile - strike two. If I had to do it all over again, I would have washed my hands at least three times that day. Thankfully the nursing staff told us that for the first few times they help us get gloved and gowned since they know we're terrible at it in the beginning.

A few more workshops finished off the week, and prepared us (hah!) for starting our rotations in the hospital this week. We were able to treat a heart attack in a pseudo-emergency room. Again, not with a real patient but with a guy we have become familiar with in medical school - Sim Man. He's a "simulation" manikin - complete with a beating heart, respiring lungs, pulses in his arms, and most disturbingly, he can talk via a microphone that is connected to a computer in the next room. A teaching physician is behind a one way glass testing us to see how we will handle any myriad of clinical situations. We even get to give medications and see on the monitor whether what we have done has helped alleviate the patient's discomfort and symptoms, or if we have killed the patient. In addition to a heart attack, we also had little "Sim Kid" who presented with an acute asthma attack. He was scary looking - just like the doll (minus the scars thankfully) in the thriller "Chucky."

I know that all these workshops are an attempt to introduce us to the reality of taking care of patients, and I so appreciate the practice. It's hard to believe that starting now, from this point forward, my patients will no longer be simulations. They will be living, breathing, pulsing with life, and pain, and questions, all of which over time I hope that I will learn to attend to. In the meantime, I watch and soak it all in. Cheers!

Phew! Half Way There.

I can finally say that I am halfway through medical school, and 1/3 of the way to being a licensed physician. Two days ago I took the grueling 7 hour long Step 1 Board exam, an exam that I hope to never ever have to study for or take again. I'm confident that I passed, so I think I can throw away my study materials, since it's all in my brain now right? Ha! A lot is in there, right in the forefront of my mind, but unfortunately it will fade over time, as it did after the first time I learned it in class.

So I had a fabulous party on Saturday night for my local friends and family that have helped me through the first two years, and believe me, I have so so much to be thankful for. My closest and dearest friends Ted and Chia Chia cooked food for me every week, a dinner, and then lots of take home containers for lunch for school. And every few months I got to decompress with their two kids Bria and Miles with a overnight play date. Thanks guys!

Then there's my sweet dear husband and my daughter Erinna who took over the household (except for the cooking which I love to do and wouldn't give up to anyone). They cleaned, did all the laundry, took care of the cats (Mango our "dying cat" still is hanging in there, in part due to Ronando's daily diligence at giving him subcutaneous fluids daily to help his failing kidneys), and were there to support me every day. Thanks Ronando and Erinna!!

There were those that rubbed my knots, Jim and Jen and Stephanie at school - boy did my neck and shoulder muscles need the work! While studying for the boards I got a terrible neck sprain from looking down at my notes all day long, and I got some acupuncture and massage from my wonderful friends, plus a great adjustment from my chiropractor. What would I do without all my peeps standing behind me, holding me up?

And then there were all the great dinners and visits with Kim and Jason, Dave and Tiffany, Ted and Chia Chia, time to visit and have some great wine, and blow off steam. Thank you so so much everyone for helping me on this journey. I know that I couldn't have done this without you all. It takes a village to make a physician!!

So you may be wondering what's next? The next week is filled with workshops introducing to all the skills we will need to know to work in the hospital - it's called transition to clerkship week, and on the schedule is - Scrubbing and Gowning, Suturing, Airway Management, Emergency Decision Making, Need Safety, PIC/Central Lines, Pathology and Radiology. Its' going to be a long week, hours 7am to 7 pm, but it will be a welcome relief from sitting on my butt 12 hours a day studying!

After this transition week, we all move on to our rotations. For the next two years we will be rotating 5 weeks through many different areas of medicine - the order that I will be going through these clerkships my third year is - Pediatrics, Surgery, Psychiatry, Family Medicine, Elective, Internal Medicine (10 weeks), Rural Medicine, and OB/GYN. Fourth year then has a few required clerkships, lots of time for electives, and time to travel around the country interviewing for residencies (which is why fourth year is by far, the BEST year in med school). I've heard that third year is hard, in terms of the long hours, but that the time with the patients makes it all worth it.

So I anticipate having a bit more time to write (until my surgical rotation that is - known to be brutal). I start off my first two weeks in the mother baby unit here at the Children's hospital, and then three weeks in Pediatrics in the same hospital. I have spent the weekend relaxing, trying to get ready for the next piece of my process. I just finished sewing some extra pockets into my white coat, as they will soon be bursting with note cards, my Blackberry, my drug books, my pediatrics book, my stethoscope, and snacks to make sure I make it through the long days.

Love you all!