Sunday, July 20, 2014

MORE BABIES!!! (Pediatrics Part II: Inpatient Peds)


After three wonderful weeks of UVA Pediatric Clinics (and one less-than-wonderful day of having surgery myself), I journeyed home to Richmond, Virginia for the second portion of my pediatrics clerkship! While this was technically my first "away" rotation, because Bon Secours is so close to my parents house I feel like it didn't really count as being "away." It's kind of a pain to lug all of your clothes and textbooks to a different place, BUT this was totally made up for free home-cooked meals every night :)



Prior to starting this rotation I had heard mixed things about doing peds at Bon Secours. The biggest drawback I was warned about beforehand is that St. Mary's is technically not a "teaching" hospital like UVA, so you have to be a little more proactive about seeking opportunities to do and see things. However, I found that 99% of the time if you show a little interest the attending is more than happy to teach you and let you do things! The other complaint I heard was the volume and variety of patients is not quite what it would be at a big center like UVA. This is probably a valid concern, but I think I ran into a good number of interesting patients over my three weeks anyway.



More importantly, there were a BUNCH of things I really liked about this rotation, including:
  • "Night" Shifts: Which should really be called late evening shifts; because you only have to work from 3 pm to midnight! Even for super lame people like me who would go to bed at 8:30 every night given the option, midnight is totally doable. And at least in my experience, you get to do and see a lot more at night then you do during the day since its just you and one attending there to cover the floor. Overall the hours were really good on this rotation - I'd say I probably averaged somewhere in the 50-60 per week range!
Got to spend a lot more time here than I did on my surgery call nights :)


  • FREE FOOD!!! I know it sounds too good to be true, but students eat for free in their cafeteria. Meaning I could have a normally $3.50 Sabra Hummus as many times a day as I wanted! I feel like I didn't make as much use of this as I could have since I was living at home, but it was a nice perk. Take notes, UVA ;)

Best day ever. Every day!


  • PARKING!!! Another amazing thing at Bon Secours was that students get to park in the garage, meaning you only have to walk like 2 minutes outside from the garage to get to work. This is in contrast to UVA, where most students only get a parking pass for 6 weeks while on general surgery. The rest of the time, you have to walk (in my case) about 15 minutes up and down a massive hill since the buses don't start running till 7:30. Which is really fun in professional clothes on those 98 degree days with 100% humidity. Not that I'm bitter or anything. 

  • Freedom to do and see what you are interested in! Sometimes we would come in and there would only be like 8-10 patients on the floor. This was kind of a bummer because that meant we only got to round on a few patients each, but also kind of awesome because it meant we had a lot of free time in the afternoon after notes were finished. This gave me time to do fun things like watch tiny babies have surgery, observe imaging procedures that I heard about all the time but never actually seen (Upper GI series, MRIs, Ultrasounds for appendicitis rule out), and shadow attendings on GI/Pulmonology/Hematology consults. My personal goal every morning was to look at the admits from the night before and try to pick up as many cute babies as possible as patients. Which meant that if I had free time in the afternoon, I could go play with cute babies whose exhausted moms were happy to hand them off to someone with medical knowledge AND call it "checking in on my patients." I'm so clever sometimes :)
This particular cute baby is me - thankfully I grew into my ears eventually!

  • Living at home! This has nothing to do with the rotation itself, but living at home is awesome! I definitely did not appreciate my home and parents enough as a child. Food is free, and you don't have to waste time grocery shopping or cleaning bathrooms. Plus parents have to listen to complain about your day no matter how boring you become. And its nice to have a furry friend who is always and unconditionally happy to see you!

Waiting eagerly for her family to return home! 




Common things you will encounter and therefore should know something about before starting a general pediatrics inpatient rotation: 



  • Failure To Thrive: This was the most common diagnosis I encountered during my rotation. It might be because I swooped all of the babies, but I think no matter where you are or how aggressive you are about picking up babies as patients that this is a really important topic to know about! It has a really broad differential associated with it and its good to have an idea of what labs and tests to run. The most challenging this about this particular topic is that it often comes down to socioeconomic issues, which unfortunately cannot be fixed with penicillin or an inhaler. You don't learn much about how to deal with this in the pre clerkship curriculum, so I think FTT patients allow you to learn physicians can help in these situations.
  • Common causes of fever and how to do the work-up: After failure to thrive, this was probably the second most common thing I saw in my patients. In kids who can talk its a bit easier because at least they can tell you what hurts, but babies get the whole nine yards (Blood culture, urine culture, lumbar puncture, ect.) since they are not quite as articulate. Turns out pathogens can hide almost anywhere!
  • Vomiting and Diarrhea: Again, this has a really broad differential ranging from over-anxious parent to some pretty scary emergent surgical conditions, which makes it important to know how to tell the difference. Also read about acute management of dehydration (all that fun fluid and electrolytes stuff YET again!)
  • Croup:  I'd say we saw several of these patients every week. Another good reason to practice listening to breath sounds. Tip: don't include epiglottis on your differential just because the kid is drooling. You will probably get laughed at. 



So I was going back through my last couple posts and realized I have written very little about swimming lately. This is mostly because my swimming has been so inconsistent for the past couple months. On my surgery rotation, I usually had like 50 min per day to swim. On pediatrics, I had more time, but then I had surgery myself and missed a whole week. I also missed out on one of my favorite races right after my surgery, and since I don't have much else coming up it's been hard to be motivated to do big crazy sets. Luckily, I'm starting to feel stronger again and getting slowly back in shape. The times I was holding were not particularly impressive, but just so my swimming readers don't give up on me here is one of my workouts from this weekend:



I still use this, I promise!


Getting-Back-In-Shape Workout (done in SCM):

Warm-up:
800 Choice Swim
400 Kick: 100 Fly/100 Free x2
400 Pull: Every 4th 25 is backstroke

Main Set:
all IM's are moderate to strong effort

400 IM Swim on 6:30
2x400 Free with Paddles on 5:30; negative split by 200

400 IM Swim on 6:30
4x200 Free Pull on 2:55; odds buoy between legs; evens buoy between ankles*

400 IM Swim on 6:30
8x100 free on 1:30:
first 4 are free swim desc. 1-4 to MAX effort
second 4 are free with paddles desc. 1-4 to MAX effort

Cool-down
8x50 on :55
Odds: Double arm backstroke
Evens: Free Swim

TOTAL: 5600 Meters
*I am TERRIBLE at pulling with the buoy between my ankles. The stupid thing comes out like every 3rd flip turn. However, Boyfriend says ankle-buoy stuff is really good for building arm and core strength. More importantly, he also likes to remind me that his 9-10 year old girls have absolutely no problem with ankle buoy sets...



Next up, I have an almost-finished post on studying for the Pediatric Shelf as well as a post on having surgery from a medical student's point of view! Have a great week everyone!

Friday, July 18, 2014

BABIES!!! (Pediatrics Part I: Clinic and Newborn Medicine)

BABIES!!! (Pediatrics Part I: Clinic and Newborn Medicine)

Got your attention, didn't I?

***Quick disclaimer before I continue with the details: I was biased going into this rotation. Since deciding I wanted to go to medical school, I've always had pediatrics in the back of my mind. I've loved working with kids pretty much since I was one myself - from mother's helper to babysitter to swim lessons and coaching. Additionally, I was lucky enough to have an wonderful friend and mentor who is a pediatrician at Yale and still LOVING his job many years later, which is exactly what I want for my life!

 I've been trying to go every rotation with an open mind, but I went into this one with probably higher expectations. And as you will see through these next couple posts, those expectations were not only met but exceeded :)




Pediatric Rotation Overview: 

So at UVA our rotation is broken up into a two parts. You do three weeks of pediatric clinics - generalist, specialists, and newborns - followed by three weeks of inpatient pediatrics. I had the clinics portion first, which was nice since the hours are more relaxed and I was still recovering from the chronic exhaustion that was surgery clerkship (which I passed by the way! I feel a bit more qualified giving advice now). Another aspect of this rotation that really helped with the relaxing and recovering was that everyone is NICE! I'm not saying everyone on surgery was horrible and mean, but it's just a different culture and personality type. For example, pimp questions on pediatrics feel more like someone trying to see what you know and then teach you what you don't - vs. pimping on surgery which can sometimes feel like using public embarrassment to scare you into studying more.

One of the first things I learned while working with kids in the medical setting was that the hardest part can be getting the little critter to cooperate with your exam. It's sort of like trying to get the scared little kid in the water for his first swimming lesson (which I'm kind of awesome at… just saying)- you have to develop tricks to get the kid to do what you want while keeping the parents from freaking out. You also have to know how to make the most of your tools:


  • STICKERS: Are a must! Its amazing what you can get a kid to do with the promise of a sticker or two. I found letting them pick one upfront with a promise of another if they behave works pretty well. I also found that even after you really traumatize a little guy - for example, after manually reducing a nursemaids elbow (ouch!) - if you come back in the room with a couple stickers they immediately forget that you just yanked on their arm and caused them a bunch of pain and you are back the being best friends forever.
  • PENLIGHT: You only need it for a very small portion of your exam, but kids can entertain themselves with a light pointer for quite a while. This allows you do some of the more unpleasant parts of the exam without them noticing. Just make sure they aren't blinding mom/dad/sister/you attending in the process. 
  • SPARE FAMILY MEMBERS: Little sibling is scared of getting their ears checked out? Use big sibling as demonstrator! Three year old refuses to let you touch them with the stethoscope?  Practice on mommy or daddy first, and if they are at all inclined let them listen. A bit of desensitization can go a long way. 
  • STETHOSCOPE: Kind of like the penlight; make it a toy. Let them try it out. On a related note, Disney apparently now has this awesome show called "Doc McStuffins" where the main character is wearing a stethoscope! I admit I've never seen the show, but I have found the phrase "It's timeee - for your check-up!" to go a long way in otherwise timid little guys.

Thanks again Disney!!





The Clinics:
  • GI (Gastrointestinal - that means everything in the path that food goest -  from your mouth to your butt -  for those of you who aren't medical): This clinic was AMAZING! Every clinic was good, but the attendings on Peds GI were some of the best! Also, I found this to probably be the most interesting of the clinics intellectually. Yes, there is a LOT of constipation going on, but there are also some really interesting conditions - like Crohn's, Ulcerative Colitis, Celiac, Eosinophilic Eosphagitits, ect. History taking is really important here, because a lot of the symptoms in these conditions (diarrhea, contipation, abdominal pain) are pretty generic, but its getting the details about when/where/how/how often they occur that will lead you to the right diagnosis. Interestingly, getting a GI history was actually sometimes easier with kids than it was on adult patients on the colorectal service. Children, especially boys, LOVE talking about poop and are happy to tell you if it is pellets or snakes. Adults sometimes get all embarrassed by these questions and sort of clam up.
            A couple things I'd recommend reading about before a day here:
    • Constipation: Common causes (diet, stress) and common treatments (MIRALAX, fruits and veggies)
    • IBD: Crohn's, UC, and the difference between the two. Especially the differences between the two. And did I mention knowing the differences between Crohn's and UC? I think this is like the #1 most common pimp question of third year! A little knowledge of the treatment options is also a good idea - if nothing else at least know that only UC can be cured by surgery. 
    • Functional Abdominal Pain: include this in your differential for any female between about age 9-17 with a long history of vague stomaches and not much else. You will be right 95% of the time. 


  • General Peds: This was another one of my favorite clinics! It kind of gets a bad rap and I was told that "It's all a bunch of ear infections and runny noses and not very interesting," but that was FAR from my experience. I ran into all kinds of stuff there, and it really tested my knowledge of infectious diseases and developmental milestones. It also tests your ability to get a full physical exam done in a sick/scared/grumpy/poorly behaved child. Before you do this clinic, read about common infections, and especially rashes! It is super embarrassing when the textbook presentation of molluscum contagiousum walks in and you are totally lost and suggest contact dermatitis when the attending asks you for a differential. 

  • Genetics: This clinic was REALLY interesting but also really hard to prepare for. Back in my Step 1 post I ranted for a bit about memorizing all the crazy genetic diseases with six names that I will never have to know again… Well that came back to haunt me! Luckily there are people much smarter than me who not only still know the names of all these conditions, but also how to diagnose and treat them. I only got to do this clinic once, but it was really enjoyable! I learned a lot with every single patient because they were all so different.  Unless you have a photographic memory, I don't really know what advise to give to prep for this one besides looking up the patients beforehand if at all possible. 

  • Pulmonary: Warning: you actually need to know how to identify and describe breath sounds with this one. Which I find to be pretty difficult in a compliant adult. Much less on four year olds who don't want to "blow out the candles on the cake," and instead want to talk loudly about what color and design they want the cake to be thus totally obscuring the fine rales you are trying to hear. It amazes me how the attendings can manage to do this! If you get a chance to go to a pulmonary clinic, I highly recommend watching pulmonary function tests performed. Observe the nurses take the measurements helps you to remember what the different values mean, AND you can pick up some really good tricks from them on how to get kids to cooperate. Before you do this rotation, read about asthma, reactive airway disease, seasonal allergies. That should cover you for about 90% of what you will see. 

  • Newborn Medicine: At UVA we get a whole week in the newborn nursery, and I think it was the happiest week I've had thus far in third year! There were so many good things about this week: all the attendings, residents, and NPs are super nice, almost all of your patients are completely healthy, and good luck being unhappy surrounded by cute babies all day long! The first few baby physical exams I did were a little nerve wracking - the first day I was so busy thinking "DON'T DROP THE BABY!!!!!!" that I would forget like half of what I saw on exam as soon as I left the room. But there is something really exciting about unquestionably being the first person to ever do a physical exam on your patient! Another other fun thing about newborn medicine is that you get to teach the new moms about baby safety/feeding/pooping/ect, and they actually listen to what you tell them! The first time someone called me "doctor" was on this rotation! I was just wearing my white coat and reading to them from a handout on how many daily wet diapers to expect once they left the hospital, but still! "Doctor" sure beats getting mistaken for a high schooler!

Wednesday, July 16, 2014

Preview Post

Hi everyone!

So per usual I have epically failed at keeping up with this regularly. Instead of making a bunch of excuses for myself, I'm going to give you a quick summary of all the half-written posts I have in the works:

  • Pediatrics Part 1: General and Subspecialty Pediatric Clinics
  • Pediatrics Part 2: Inpatient Pediatrics - My first "away" rotation (at Bon Secours St. Mary's in Richmond)
  • Pediatrics Part 3: Studying for the Shelf Exam and (**spoiler alert**) Why I'm 99% Sure I Know What I Want to Do With My Life - or at least what kind of residency ;)
  • OBGYN Part 1: Gynecology
    • I'm currently only about halfway through my Gyn portion of the rotation so I'm not exactly sure what form this post will take. If I had to publish it today, it would be something like "Gynecology - My Personal Journey In Speculum Struggles, Poor Word Choices, and Being the Most Awkward Person in Every Room."
    • ^ That is not to say I'm not enjoying this rotation! Everyone I have worked with is EXTREMELY nice and tries to make me feel better about some of those things. Plus I think ObGyn is something we don't get much of in pre clerkship medical school so I'm learning a TON every day!
Besides medical school, life has been keeping me pretty busy. I ended up needing to undergo a minor surgery myself a couple weeks ago. It was a laproscopic procedure done about as perfectly as surgery can go, but any time someone cuts you open it takes a lot out of you. I feel like that is something we don't always do a great job of conveying to our patients, possibly because its hard to appreciate the process from the patient's perspective if you haven't been a surgical patient yourself. I'm considering writing about my experience, although I'm not sure if a bilateral ovarian cystectomy is going to be interesting enough to fill up a whole post!

So if anyone was wondering, that is the reason you haven't seen me at any races recently. I had to take a whole week off swimming and then build back gradually, plus I was less than two weeks post-op for the Chris Greene Lake race I was planning on doing :( Kind of a bummer, but I'm happy to say that four weeks later I'm back to being able to do a decent 4-5K per workout. 

Thankfully, I'm feeling about 200% better now compared to how I felt a few weeks before my surgery! To show how well I've healed, here is a picture of me at SkyZone York Trampoline Park from about a week ago (chosen because it was the most exhausting workout I've done since surgery):




One quick moment of honesty before I go - I'm TIRED! Third year is really hard! Don't get me wrong, I'm enjoying most of it and I've learned more in the past six months than I ever thought was possible. Plus its the first time in my life I've actually been doing stuff that is directly relevant to my future career (only took 24 years!) However, there is something about being an MS3 that is exhausting in a totally different way than I've ever experienced before. As much fun as it is to see the spectrum of medical practice, having to "start over" with a new group of people every week is really hard. You have to make a good impression on EVERYONE, since every single resident and attending is grading you. A couple days of working with someone is not enough time to really prove how smart and capable you are, but it is CERTAINLY enough time to do one really stupid or embarrassing thing and leave that as your only impression. Sometimes I feel like I'm the only person who struggles to be totally on their game every moment of every day, but maybe thats because I'm so busy worry about not making mistakes myself that I'm not even paying attention to everyone else? I know plenty of people have survived it before me, and that I will make it through too, but its sometimes hard in the moment to keep perspective.

Anyway, rant over :) I'll hopefully start getting the rest of those posts published in the next couple weeks. Happy Wednesday everyone!














Saturday, May 31, 2014

That Time I Tried Out the Surgery Life - Part 3 of 3

THE SURGERY SHELF EXAM AND FUTURE PLANS

So for my last post on the surgery clerkship, I wanted to write about the Shelf Exam. For those of you who are non-medical, the Shelf Exam is a test created by the National Board of Medical Examiners as a final exam on the stuff you should be learning on each rotation. I'll spend a bit of time on what I used to study and how I liked each resource. But what I wanted to read about and couldn't find right before my test was an explanation of what to expect on test day, so I'm going to talk about that too!


RESOURCES:
I'm going to start by going through the pro's and con's of the main resources I used to study! If you are not in medical school and are never planning on it, I would recommend scrolling down to where I entertain you with my Shelf Exam experience and then talk a bit more about my summer and swimming plans! If you are in medical school, I hope you will find this helpful when deciding what to use to study.

**Disclaimer: I have not gotten my score back yet, so take my advice with a grain of salt :) 


  • The Good: This book is amazing! It goes through a series of clinical vignettes, organized by subject, and hits all the highest yield material for the Shelf Exam. It is a super quick read, and Dr. Pestana is really helpful for mastering exam strategy - or in other words, he is good at explaining what key words are associated with what right answer, and also at pointing out the common ways examiners try to trick or distract you. 
  • The Bad: Well to say anything about this book is bad would be untrue. I guess the only thing I'd say is to make sure not JUST to rely on this book for preparing for the Shelf, as it is does not cover everything you could be asked about, just the highest yield stuff. But I'd recommend reading it over at least 2-3 times. You will recognize question stems from this book on the actual exam.



  • The Good: NMS casebook is a good one to read early on in the clerkship! It goes through all of the general surgery specialities and gives you a good overview of common illnesses and treatment for each. I really liked the way it was formatted as well. Basically, each section starts you off with a quick case description (eg. a 60-year-old male with abdominal pain and bloody stools), and then walks you through a differential diagnosis and treatments. After the initial case, it will give you specific alterations to that same case (i.e. a 60-year-old male with abdominal pain and bloody stools who has had diverticulitis twice vs. the same patient without the diverticulitis but with a family history of colon cancer), and explain what you would do differently in those situations. It is a pretty quick read, and has some nice diagrams.
  • The Bad: Not much really! I guess one complaint would be that some of the case variations go into a little more detail than we are expected to know for the Shelf Exam. The other would be that it doesn't really talk much about the surgical subspecialties, like orthopedics, ENT, urology, pediatrics, ect., and spends way more time on the breast than the exam itself does. 




  • The Good: I really liked this book! I know its not as popular of a choice, but I think it does a really good job of covering everything you need to know for the shelf and the wards without actually being a "textbook." First Aid is great because it devotes quite a bit of time to the surgical subspecialties, which are more heavily tested than I expected and do not get much coverage from other review books. It has some really good pictures and has an easy-to-read outline format of the chapters. The last couple chapters also give you a list of other resources and review material, rated by students for students.
  • The Bad: I think a lot of people don't use this book because it is much longer than Pestana and Casebook. Being someone who really needs to see the same information in multiple sources/contexts before I remember it, though, I don't really see this as a negative. 




  • The Good: 500+ USMLE style questions and answers! UWORLD (below) only offers about 150 surgery questions, so it's a great source of extra questions. The sheer number of questions really helps you with pattern recognition in question stems, and to get used to the types of things you will be asked. Although it mainly covers general surgery stuff, PreTest does have a good amount of subspecialty questions as well. I was only able to get through about half of the questions in this book, but I guess I can save the rest for Step 2!
  • The Bad: The questions themselves are not very similar to the actual shelf questions. Pretest questions are MUCH shorter, usually only 2-3 sentences compared to the page-long monsters the shelf gives you. The questions are also REALLY hard, which is good for learning but bad for a self-esteem boost. The answer explanations are also kind of varied - sometimes they are really good, but sometimes a bit too short. 



  • The Good: Case Files is a series of 55 page-long clinical vignettes, where you are given a patient presentation and eventually asked what your next steps and differential diagnosis would be. This is followed by several textbook-style pages talking about the condition, the diagnostic tests, and the associated procedures. At the end of each case, there were 5-6 USMLE-style(ish) questions. I liked it because you could pick it up and read through a case and do the questions in 10-15 minutes. It was a great way to learn stuff quickly in between OR cases.
  • The Bad: The cases are not organized in any particular way, which is good because the Shelf itself is obviously not organized by speciality, but bad if you are trying to look something up or learn more about a particular topic. Also, calling the questions USMLE-Style might be a bit of a stretch - they are much easier and shorter than real Shelf questions. I think they are more just to make sure you learned what you were supposed to from each vignette, and in that aim they are very effective.



  • The Good: I think Firecracker is one of the more under-rated resources out there for third-year medical students. It's pretty awesome! It's much cheaper per month than any of the question banks, and it comes with thousands of pre-made flashcards covering all of the third-year clerkships! It lets you go through and "flag" exactly which topics you want to study, and lets you rate your mastery of each so that it can schedule how often you need to be reviewing a given topic. They also recently added a BUNCH of USMLE-style questions. They have about 400 for surgery, which are again a bit easier than UWorld and than the real thing, but I think very good quality for the price.
  • The Bad: To get the most out of this resource, you really have to dedicate time to use it every day. If you don't log on for a week and end up with 2500 questions due, obviously you are not going to get through all of it. And as I mentioned above, although the additional USMLE style questions are a big plus, they are not quite on par with UWorld in terms of difficulty and quality of explanations.




  • The Good: QBank is pretty much unrivaled in terms of producing excellent questions that are equally in quality and in difficulty to the real shelf and board exams. QBank is really a must-have, and since there are a limited number of surgery questions, definitely go through them multiple times and be really thorough in reading the explanations.
  • The Bad: Only issue with QBank for the surgery shelf is it just has 150 surgery questions. You really need to do a decent number of internal medicine questions as well. When people tell you that the surgery shelf is just like an internal medicine exam with a little bit of surgery added in, they are exactly right! Also beware of Step 1 flashbacks when you first start using it again  - most people go through this :)



TEST DAY!!

You want me to take a test with paper and pencil? Say WHAT?

We were told to arrive at 8:15 to get set up for an 8:30 exam start time. Which gave most people about 3 extra hours of sleep. And me time to get in a nice long swim beforehand! We were also told to bring #2 pencils for the exam, which meant basically everyone in the class had to run to CVS the night before since none of us have used pencils since the SATs… Actually, the shelf exam was kind of like a REALLY hard SAT. We sat in an auditorium, every other desk left empty, and spent the 15 minutes before the test time listening to our awesome Surgery Clerkship director read the instructions. It took me a second to remember how to bubble my name in, one letter at at time, on the student identification form on the answer bubble sheet (which again, I haven't seen since the SAT!) The instructions also mentioned an optional survey on the back to be done "if time allowed" (funny joke, NBME).

When we were told that we could "break the seal on our test booklets" and begin the exam, I opened the test booklet to the first question and flipped my answer sheet over. And promptly panicked when I saw that EVERY question allowed for answer choice A-M (whatever happened to the good old days of A-E?!?!). And panicked a little more when I saw that with the exception of the last 10 questions, EVERY question was about half a page long, complete with lab values, imaging, ect. The test "booklet" with all of the 100 questions, was something like 45 pages long!

So if you do the math, 100 questions in two and a half hours gives you about 1.5 minutes per question. Sounds like plenty of time for a multiple choice test, right? WRONG!! Especially when you factor in having to go through and bubble in your answers (when you have gotten used to just clicking things on a computer for years and years). My biggest piece of advice for future shelf-exam takers is to keep track of how much time you have left! There is really no resource that will prepare you for how long and in- depth a lot of the questions are - even UWorld questions are a little shorter than the real thing.

 I neglected to think about time (slash went out of my way to avoid it!) and was actually thinking I was doing pretty well until we were told we had one hour left. I looked down at where I was in the test booklet, and saw "Question 34" staring back at me. And no, I was not working backwards though the questions. For the last hour of the exam, I stopped reading the whole questions and switched to power-skimming questions for a couple key words and then went with the most likely answer choice (i.e. old fat smoker with chest pain - gotta be a heart attack!). Did I miss nuances that would change the correct answer in some cases? Probably. However, I finished reading every question and bubbling my answers in with three minutes to spare! I then went back through to check my work on a whopping two questions before time was called. Overall, I think the exam went ok and the questions were fair, just the amount of time provided was wayyy less than I would have liked. I wonder who in the world has time to do that optional survey on the back… Talk about selection bias!!

WHERE DO WE GO FROM HERE: MS3 SUMMER PLANS

A week has elapsed since taking that exam, and I spent this past week doing outpatient pediatrics. It is AWESOME! So far I have seen general, pulmonary, and gastrointestinal pediatric clinics! The rest of my summer is shaping up to be a lot of fun, and hopefully a little less stressful than the spring was! Coming up, I have:

  • A week in the newborn nursery! BABIES!!!
  • Another week on outpatient clinics - including the ones mentioned above plus genetics clinic
  • Three weeks of inpatient pediatrics at St. Mary's in Richmond! Guess who is moving in with mom and dad for a bit and getting FREE DELICIOUS FOOD for almost a month?! 
  • After pediatrics, I move on to 6 weeks of OBGYN, which I am also SUPER excited about! I will be at UVA for the duration of that rotation.
  • Finally, after OBGYN concludes on August 15th, I get a whole week off for summer vacation! 


Beyond doing well in my rotations, I have a couple other goals for this summer:

  • Get back to some better swimming training! Not that pediatrics or OBGYN are going to be easy by any stretch of the imagination, but I will have a little bit more free time than I did on surgery. I really want to get back to doing some harder, longer workouts over these next couple months so I can get in a couple races this summer! With some luck (and time and money…), I will be at the Chris Green Lake Cable Swim for the 1+2 milers in July, the Peluso Open Water Glow Swim in August, and in my dream world also To the Bridge and Back with Peluso Open Water in October. I'm hoping that summer of 2015 will provide me with more time to do more racing, but at least I have a couple things to look forward to this summer!
  • Running! Looking at my fall schedule, I'm going to have a couple weeks here and there where I will be at away rotation sites in rural Virginia with very little access to a pool. My solution? Find a way to stay in shape and relax without needing any sort of facility to do so - i.e. running! Lucky for me, I have an awesome and experienced running buddy here in Charlottesville who is willing to help me getting ready to (wait for it…) run a full marathon sometime next fall or winter! It might not be fast or pretty, but I think it would be really neat to work towards finishing a 26.2!! At least until I have the time and money to do another aquatic 28.5! (Speaking of that, good luck to all my friends doing MIMS in two weeks!! )
  • Blogging! I've been away for so long I forgot how much fun this is. I'm trying to get at least one new post up per week - I'm counting on you all to hold me to it!!








Friday, May 30, 2014

That Time I Tried Out the Surgery Life - Part 2 of 3

Last time I posted, I gave an broad overview of my surgery experience, highlighting my favorite parts and the parts that were the hardest for me. This time, I want to write a bit about day-to-day surgery survival, and my call night experience. However, since I didn't have any swimming related stuff last time, I'm going to start with:



 How I Learned to Get in a Decent Swim in 45-60 Minutes.

As I mentioned previously, surgery forced me to make some tough choices about what to do with the extremely little non-hospital time provided. Never before had I been forced to choose between an extra hour of sleep, eating, or swimming - or at least never before had it been such a touch choice! I learned after a week or two that even if I only ended up swimming for 45 minutes, it ALWAYS felt better than choosing not to swim. I know that for many people, 45 minutes is plenty for a workout, but I'm sure many of y'all reading this can sympathize with how little 45 minutes seems when you are used to having 90-120 minutes to work out daily! 

So, in addition to learning all about surgery, I spent the past three months learning to adapt to less swimming. Upon realizing that continuing to train at my usual level was absolutely not an option, a couple of fears came to mind:

  • First: OMG! I'm going to forget how to swim!!!
  • Second: Ok, maybe that is a tad unrealistic. But OMG - even if I don't forget how to swim, I'm going to get so badly out of shape that I will never be able to race again!! It is impossible to get a decent workout done in such a short amount of time!!
  • Third: Well, alright… I'll probably still be able to race a mile or two no matter how little I'm training. But I might be SUPER embarrassingly slow.
I'm happy to report that the first one did NOT come true, as I had time a solid 6,000m this morning (yay pediatrics!) The second one also ended up being a needless worry - although its a different kind of training, it is possible to get a really tough workout done in 45 minutes!

I have yet to test #3, but I'm hoping to have time do try my luck with the Chris Greene Lake Cable Swim in July and hopefully some of the Peluso Open water races.  #3 has also become somewhat irrelevant, because I learned over these past three months that even if I'm not going very fast/working on getting faster, swimming makes me REALLY happy. Even if I show up to those races and totally stink, I know they will be fun, give me a chance to hang out with some of the most awesome people on earth (open water swimmers) and keep me a happy and balanced person! In the end that is a whole lot more important than getting a certain place or time!

Once I accepted that some days I was going to get off work at 7:00/7:30 pm and have 45 minutes to crank something out and rush home to prep for the next day, I created a couple of power-thru workouts for myself. I'm going to share a couple of my favorites below!** 

**Confession - I'm not as much of a superwoman as I'd like to pretend to be. Some days I got to the pool DEAD tired and did the worlds slowest 3000m and called it a day. I think its unrealistic to expect to be able to push myself every day in the pool on top of working 80+ hours a week. That being said, I tried to do actual workouts as often as my body would let me!


1. Death by 100s:

  1. Quick Warm-up
  2. ?? x 100 on fastest possible interval
  3. Goal is to pick an interval that gives you 5 seconds rest or less, and make as many as you can! (I usually did something like 100 meter free's on 1:10 or 1:15, depending on how many hours I had spent in the OR standing and not peeing that particular day.)
  4. As soon as you miss, 200 EZ backstroke followed by 1 minute rest.
  5. Repeat from step 2 until your time is up
2. NOVA Classic 

  1. Quick Warm-up
  2. 6 x 400 IM on 0:30 rest (depending on the day, these were either done as fastest possible hold or for completion).
  3. Quick Warm-down
      (There are many uncertainties in life, but the pain of 400 IM repeats is one thing that stays the same!)

3. Pretending to be in an Open Water Race

  1. 5-minute warm-up
  2. Depending on how much time is available, either 1x45 minutes or 1x60 minutes for distance. Last 100 is max effort
  3. Warm-down in the shower
     (This workout is best done pretending you are in Key West or the Hudson River or somewhere other awesome OW                       swimming location)



How To Survive Surgery on a Day-to-Day basis

Now that we have swimming squared away, I'll move on to some things I learned about being a good medical student on surgery! This is basically just a list of things I wish had done a lot sooner or a lot better… But hopefully y'all can learn from my mistakes or at least enjoy reading about them :)




  • Surgical Recall  (my coffee-stained, dog-eared copy pictured below) - Most med students swear by this guy to prepare for pimp questions, and there is a reason! In a helpful question-and-answer format, this book goes thru the questions you are most likely to get asked organized by speciality, and gives you a quick and concise answer to each question (instead of overwhelming you with paragraphs and paragraphs of stuff). I recommend reading the chapters pertinent to whatever service you are starting on twice before your first day to make a good first impression!

Thanks again for helping me look stupid a little less often!!

  • Reading about the surgery cases for tomorrow the night before - I know that this is the same advice that EVERYONE gives, but again, that's because it works! My favorite way to start is by quickly reading over the problem list of the patient going to the OR. Obviously know what they are getting surgery for, but it is also helpful to look and see if they have any other interesting past medical history (heart and lung disease, rare metabolic disorders, anything in between) that will lend itself to pimp questions. Finally, find an article or two about the procedure itself! This last part is key if you are like me and rather mediocre at anatomy. Most of the time, the textbook article about the procedure will mention the key anatomic landmarks for the case (with random names that you have probably forgotten about since finishing the anatomy final - Ligament of Treitz, Killian's triangle, platysma muscle, ect.) Make a note of these, so that when someone points to something in the middle of the case and asks you to identify, you have prepared word-bank to choose from! My favorite way to find good textbook articles is the website www.clinicalkey.com, and then filter by "books" and "surgery."

  • Ask questions during the case! Caveat: be aware of when is NOT a good time to talk - for example, if you see a lot of blood and hear a lot of swearing - but as long as things are going as planned and the surgeon/resident has had some coffee, questions are usually a good thing! If you are like me and have the unfortunate combination of shyness and a severe case of the awkwards, it helps to have some questions prepared beforehand! Usually I would make note of a couple things I found confusing or wanted more information about from the article(s) that I read about the procedure, and then spread those out during the surgery. And make sure you have something as a back-up in case you get directly asked "Do you have any questions about the case?" - because "no" is NEVER the right answer!



  • NEVER, under any circumstances, have more than one cup of coffee in the morning! Yes, free coffee is awesome and sometimes available at Grand Rounds, but don't fall for this trap!! I know I've complained about this several times before, but peeing is not a thing surgeons do. 

  • Come prepared on your call nights. And by that I mean with the appropriate stuff. The appropriate knowledge is a good thing to have as well, but harder to come by! 24-hour calls are like the swim team lock-ins you went to as a kid - at first it's fun and exciting, but then you realize all you want to do is sleep but you can't because you are afraid you will miss something and because there is no where comfortable to sleep (As a kid, you are worried about things like someone drawing a mustache on your face or putting your hand in warm water. As a med student, you are worried about not hearing the beeper go off and getting yelled at or a bad grade. Same idea!) Don't get me wrong - call nights are actually really educational, you get to see and do a lot of cool stuff, and depending on the people you are with can actually be a lot of fun! However, 24 hours is a really long time to be in one building! By the end of my three months, I learned to bring an extra little bag with emergency items including:
    • An extra set of contacts and contact solution! The night I learned that lesson was a painful and dizzy one. 
    • Toothbrush and toothpaste. Minty-fresh breath never hurts!
    • An extra caffeinated beverage, a midnight snack, and breakfast. Sometimes you don't get time for any of that, but if you do get breaks its nice to have extra food! I found that I felt a LOT better at morning rounds if I ate a good breakfast around 4:30 am instead of trying to wait till after rounds. Because by the time I got home at 8:00 am after being awake since 4:15 am the day before, all I wanted to do was sleep anyway!
    • Squishy - my beloved 24-year-old teddy bear, who serves dual function as a portable pillow and also a friendly, comforting presence. Both of which are otherwise very hard for a med student to come by in the middle of the night in a hospital!

Call night bag packed and ready to go!


So those are a couple pointers that I hope will be helpful to future surgery students, and somewhat entertaining for non-medical readers! I'm going to try to do one more quick post on the Surgery Shelf Exam - what it is like and study resources that I liked, in a day or so! Hopefully some more swimming and life updates in that one as well!


For now, I'm getting ready to enjoy an ENTIRE WEEKEND OFF!! I hope y'all have as nice of a 48-hours as I'm about to :)

Monday, May 26, 2014

That Time I Tried Out The Surgery Life - Part 1 of ???

Hi everyone! Sorry its been… months…  since the last time I was able to post! Turns out surgery is an incredibly busy speciality! But assuming I passed the NMBE Shelf Exam we took last Friday to end the clerkship I'm about to have a bit more free time in my life as I begin my PEDIATRIC ROTATION!!!! Thanks to everyone who kept checking this blog to see if anything had been added - I was pleasantly suprised by the number of hits blogger told me I have gotten since I've been away! I'll try not to keep y'all hanging for so long next time :)

So while its all fresh in my mind my plan is to do a couple of posts about the surgery clerkship, both about my experiences/entertaining stories for people interested in the life of a medical student and also some advice for future medical students! This first post is going to be sort of an overview of my experiences, and then I'm planning to write one on surviving the surgical world with some do's and dont's for medical students, and then one on the shelf exam. Hopefully that won't bore the death of out of the people who read this for swimming stuff, but I'll try to throw a bit of that in there too!

So without further ado, we have:


THREE MONTHS OF SURGERY IN A NUTSHELL



Over the course of the past three months, I've worked on the following surgical services:

  • Orthopedics (Sports and Trauma teams)
  • Otolaryngology (Oncology and Pediatric teams)
  • Anesthesiology
  • Thoracic (since everyone asks what that means - its esophagus and lung diseases)
  • Colorectal

I have to be honest, I went into my surgery rotation with some mixed emotions. I was super excited about getting in the hospital, getting to work with real patients, and getting to watch surgery and start learning how to fix sick people! On the other hand, I was NOT super excited about some of the other things that were supposed to go along with surgery, like horrible hours, angry surgeons, and 24-hour call. I'm also a fairly shy and reserved person, so the fact that EVERY book, lecturer, 4th year, ect. kept telling me that you have to be aggressive on the wards did NOT help my anxiety level. 

So to address my first concern, the hours, it turns out UVA keeps it pretty humane for us compared to the horror-stories I had heard. They limit us to 80 hours of in-hospital time per week, require 10 hours between required activities (i.e. between one night and the next morning), and on call time is limited to 24-hours of primary duties plus 4 more for transition of care. 


Here is an example of my typical daily schedule on general surgery:

4:15 - 4:30 - Wake-up
4:45 - 5:00 - Leave the house and go to the hospital
5:00 - 6:00 - Preround on my patients (usually 3-4)
6:00 - 6:45 - Rounds with my team (i.e. all the students plus the intern and residents)
6:45 - 7:00 - Morning report with all surgical teams
7:30 - 5:30 - Operating room time! 
5:30 - 6:30 - Afternoon rounds with the team
 6:45 - 7:45 - Swim
7:45 - 10:00 - Eat, read for tomorrow, study for shelf exam, talk to Boyfriend
10:05 - Asleep 


And here is a breakdown of how I spent my time on any given week:

65-80 Hours - In the hospital working
7-8 Hours - Reading about patients and surgeries for the next day
10-12 Hours - Studying for the shelf exam
6-8 Hours - Swimming 
35-40 Hours - Sleeping

Which left right around 15-20 hours per week for everything else - purchasing and consuming food, cleaning, interacting with other humans outside the hospital, practicing basic hygiene, and multi-tasking combinations of any of the above. In other words - this lifestyle was certainly manageable, but required quiet a few sacrifices I've never had to make before. The surgery clerkship is really good at showing you what you value most in your life, because by the end of the three months you have basically stopped doing everything else (no offense, blog)! It also forces you to make really tough decisions, such as: eating dinner vs. getting 5 hours of sleep instead of 4 hours; or exercising vs. not looking like a complete idiot the next morning. Finally, the loss of weekends and the 6-day workweek are also not easy adjustments from the student life. 

The other piece of the surgery lifestyle that was really hard for me was the complete and utter lack of control over my life. Step 1 studying was basically the polar opposite of surgery -  you have absolute control of your schedule - so jumping straight from one to the other was a bit of a shock! On general surgery, if you are in a surgery case that is supposed to finish at 4:30 and actually ends at 9:00 pm, you are stuck there till 9:00 pm regardless of any plans you (shouldn't have) made. If your resident decides rounds are starting at 5:00 am instead of 6:00 am the next day, guess who is  suddenly stuck with waking up in the 3:00 hour? There is no way to plan ahead and you have to be infinitely flexible, which was REALLY hard for me. 

Beyond the scheduling issues, I wanted to make a quick list of:



THE HIGHLIGHTS AND NOT-SO-HIGHLIGHTS OF GENERAL SURGERY


HIGHLIGHTS:

  • Getting to spend time with your patients - the cool part about surgery is that after you watch a case, you are responsible for following that patient through the course of their hospital stay. This definitely means pre-rounding on them every morning to check on their vitals, overnight bowel and bladder movements, wound healing, ect. But the fun part is that it can also mean spending time with them during other parts of the day and getting to hear their unique stories as patients and as people!
  • Being allowed to do something during the case - As I will talk about more, a lot of the time being the operating room means standing silently and not peeing for hours on end. However, one of the best moments of the surgery day is when someone lets you suture, make an incision, or use the bovie (electrocautery device). Even if you really struggle and have to cut the suture out and resew the whole wound, or if someone has to remind you 6 times how to hold the bovie (the same way you hold a pencil…), actually being involved in an operation is totally awesome! Even if the rest of the day has been horrible, there is nothing like the thrill of making an incision in a real case to make you think seriously about being a surgeon!
  • Getting pimp questions right - For those of you who are non-medical, "pimping" is the when the attending physican asks you, the med student, about the anatomy/physiology/pathology related to the case you are working on. In theory, the questions start easy and get harder until you don't know an answer. In practice (or at least for me…), the questions start REALLY hard a lot of the time and then you feel stupid when you don't even know the first answer. Or they catch you really off-guard on your first ever laproscopic (the one with cameras) surgery and you are all disoriented and think the spleen is the stomach. I think most surgery students I talked to had at least one memorable incidence of giving an embarrassingly wrong answer to a pimp question, but knowing you are not alone does not make it any less painful. However, the pain and agony of frequent defeat make the occasional victory all-the-more satisfying! Having the right answer to question after question feels almost as good as using the scalpel!
  • Getting to scrub in cool surgeries - (NOTE: to me at least, this is NOT the same as "getting to scrub into surgeries." "Cool" is really the key word! Depending on the case, sometimes "getting" to scrub into a surgery really belongs more on my second list) When a procedure is really interesting, time flies and you learn a lot! To me, "interesting" procedures where ones where I could see what was going on (not a guarantee by any means), it was apparent what was broken (i.e. - I could see the inflammation, the tear, the hernia, the tumor, ect), and the surgeon was able to quickly and definitively repair it (usually by removing things and sewing stuff back together). Some of my favorite surgeries were:
      • Orthopedics: repair of rotator cuff tears, any repair of bones with multiple fracture sites (basically like putting a puzzle together with some metal plates!)
      • ENT: tonsillectomy, thyroidectomy
      • Thoracic: lung lobectomy, repair of esophageal hernia, lung transplant
      • Colorectal: colectomies (colon removals) for diverticulitis or colon cancer 
      • Anesthesia: Central lines
  • Feeling like you contributed to patient care - I think this is true of EVERY speciality, but one of the best parts of the surgery rotation is when something you find out from a patient/the nurse/the medical record when you are pre-rounding turns out to play a major role in the team's decision about the patients ultimate treatment! Its almost like being a real doctor :)
  • Learning TONS more than you ever could in the classroom about disease processes, patient care, and how to do your future job well! 


LESS-THAN-HIGHLIGHTS:

  • Getting stuck in a long boring surgery - I hope I don't offend anyone I worked for with this one! I'm sure a lot of the reason I found certain cases to be boring was my own fault. I certainly should have been more proactive about asking questions and observing the anatomy and such to stay engaged. However, it is really hard to keep forcing questions when the team has been very slowly dissecting around the same spot on the same organ for several hours. Or when the surgery is being done microscopically and you are the only one without special glasses and haven't been able to see for hours. Or when all you have been able to see for the whole case is the back of the resident's head. Or when you are not sure anyone else in the operating room remembers you exist. Or when, after a certain point, you start to forget you exist. I have to be honest, I really did not enjoy the cases where I just stood there trying to stay sterile and not pee on myself for 7-8 hours at a time. 
  • Constantly feeling stupid - Again, I think this is more a concern of the third year of medical school than it is specific to the surgery clerkship. But there is nothing like a day of forgetting to say something about your patient on rounds, accidentally contaminating yourself during a case and having to rescrub, doing a mediocre job of suturing, and getting like 10 pimp questions wrong in a row to make you feel like a total idiot by 7:00 pm.
  • Driving the camera on laproscopic surgeries - So I know a lot of students really enjoy laproscopic surgeries because you get to drive the camera while the resident and attending surgeon operate and therefore be more involved in the case. However, while I totally appreciate the surgeons letting me be involved with the case in that way, I did not particularly enjoy that role. There is no way to drive a camera well, unless you are able to read the mind of the surgeon. You are either too zoomed in or too zoomed out. You either are too far to the right or too far to the left. General frustrations with the case are generally taken out on your camera driving. You sometimes hear really confusing things like "Abby, look further down (pause for a minute)…Why are you looking down?! Nothing is bleeding down there! I just told you two minutes ago to look up!" I know that you are not supposed to take any of this personally because it is not meant to be that way, BUT I would be lying if I said I never got upset after a long day of camera driving and continuous apologizing. 
  • Having a small bladder and enjoying being well hydrated - does not mesh well with surgery. I think I had more almost-accidents in the past three months than I did during all of preschool. 
  • Being forced to be outgoing and assertive all of the time - I know for some people this is totally not a big deal. But for me, it is incredibly stressful. Everytime I had to walk into the OR in the middle of a case and interrupt everyone to introduce myself, interrupt busy nurses to ask them one simple question about my patient, wake a sleeping patient to pre-round, or force questions out during a case in order to avoid the dreaded "looking disinterested," the introvert inside of me had a panic attack. Obviously I survived and was able to force myself to be aggressive when I had to, but it was NOT easy or pleasant.
  • The Shelf Exam - more complaining about this in a future post!


So that is a brief overview of my experiences with surgery! I'll try to get more up in the coming days! If you have any questions or specific things you want me to address in future posts, please comment below or on facebook! I love hearing from people and I really want to make this as interesting to my readers as possible! 

Stay tuned for part two, which will go more into how to survive surgery on a day-to-day basis, how to shine as a student (and how to not look like an idiot, which I did… over and over again), on-call nights, and how I learned to make the most out of 45-60 minute swims! 



PS - Since I randomly get tons of search hits from people googling stuff related to Clash of Clans, here is my current base. It has been sadly neglected over the past couple months - I got quite a few of the "Chief - Come Back! Your Warriors need a leader" messages. Sometimes at really inopportune times, like when I forgot to silence my cell phone during morning report. Whoops!