SCFE, suicides, crisis and happy endings...

My last afternoon at work before I left for a couple of days (to do a Board exam) was kind of heavy. A young lady (pre-teen) came in for evaluation of hip pain and a limp. As she told me the story and I noted that she was obese, I was almost sure of the diagnosis before I asked her to get onto the examination table. As she was doing that, her mother told me that she had SCFE at about that age. I stopped in my tracks. That was the diagnosis I had in mind and was afraid I would find. SCFE stands for Slipped Capital Femoral Epiphysis. It is where the head of the femur (thigh bone) slips off its neck slightly. If not corrected, it can lead to hip dislocation, loss of the femural head (due to necrosis) and some pretty severe disability. Unfortunately, the only way to correct it is surgery. Pins are placed in the head of the femur connecting it to the neck (of the femur). On x-ray, SCFE looks like a scoop of ice-cream slipping off the cone (kind of appropriate image for summer time). I got the x-ray. The diagnosis was confirmed. Most 12-something year olds do not know what SCFE is. Unfortunately, this one did and immediately began to cry "I don't want pins!" Evidently, she had seen mom's scars and heard the stories. My heart went out to her.

Later that afternoon, I got to see an older girl -- a 3o-something. The appointment schedule said 'depression' and in dispassionate computer print on my screen told me I had 20 minutes. Needless to say, a box of tissues was involved, a pelvic exam and screening for sexually transmitted diseases and definitely more than 20 minutes were needed and spent.

At the end of the day, I get to take them all home. Not literally, of course. Nevertheless, they come home with me. It's Friday night -- a couple of days later, and 10:30 pm. I'm sitting in the dark in front of a computer screen writing this blog entry because I'm still thinking about them.

This afternoon while driving to the DMV to get my license updated, I saw a patient of mine walking in town. Just last week, this macho 50-something biker had sat in my office and bawled like a baby. About a year ago, he came in with back and leg pain. In the course of working this up, we diagnosed him with prostate cancer. He underwent a spiffy robotic surgical procedure to remove the cancer (and most of the prostate). Everything went well in that he has no cancer. The collateral damage is not so good. He lost the ability to have an erection. For a month, he was loaned a pump device that enabled him to get an erection. The pump had to be returned since it was a trial and he could not afford it. The reason he was crying in my office was that his fiance of 4 years was leaving him. There was some infidelity involved (it was not him) and she did not want to continue with someone who could not...well you know. He wanted to kill himself. He wished he had never had the surgery. Oh, and he still has leg pain. Ah, the wonders of modern medicine, no?

Okay. It's not all depressing. I don't know why, but the sad cases stay with me longer than the happy ones. Maybe it's my personality type. Maybe most people come to the doctor when something is wrong, not when things are going well.

It's summer time and was the last week of summer vacation (alas, for the school kids, not me). I've had a lot of kids in here for their sports physicals and 'back to school' exams. I enjoyed seeing lots of happy kids with stories of adventures and vacations during summer. Some have scars, scrapes, and tans to prove it too.

Several of my co-workers from my residency days have had babies and picked me to be their baby's doctor. I feel like a chosen godfather, an unofficial grandfather, a surrogate dad and big brother all in one. I've kept my professional demeanor (well, sort of) but I'd rather leap out of the white coat, hug them and then dance across the hall with their newborn craddled in my arms. Okay, so I can't do that on the outside. But hey, I'm dancing on the inside and no one can stop that. Of course, nervous nellie that I am, I examine these babies carefully. I listen to every historical detail the parents offer. I don't what to miss anything bad but I don't want to find anything bad either. Truth be told though, if there's something to be found or diagnosed or treated, I'd rather it be me doing that that someone else. That's why I do this. Those are my babies too!

Okay, good night!

Nightmare

I don't know why, but for the last few nights I have been dreaming I'm at work -- either at the hospital or the clinic. Last night I had a nightmare. I was in a small ER somewhere and my patient was a 1 month old baby that was not doing well. I was doing a spinal tap and the CSF (cerebrospinal fluid) was turbid like dishwater. This child had bacterial meningitis and was dying! I began barking out orders and trying to get this child to the intensive care unit in Marshfield. It was chaos and a race against time.

The situation changed and I was on Isla Bastimentos in Panama, back among the Ngobe. This time I was tapping an older infant with improvised equipment in a barebones clinic and getting the same dishwater CSF. I began to cry because children were dying on meningitis and I could not save them. I managed to save 6 kids by giving them antibiotics in time, but one kid died. We did not have enough ceftriaxone, we did not have enough spinal tap kits or needles or syringes or IV start kits. I woke up crying. It is really hard to know what to do and watch helplessly as a patient dies because you do not have the tools you need. Wow, it took me quite a while to shake that off. It was so vivid. Brrrrrr!

The weeks

My practice is growing. I know have about 1100 patients that call me their doctor. Most days, clinic is a whirlwind of patient visits, emails, phone calls, and reviewing labs, imaging studies and reviewing nurses' notes and consults.

Last week, one of my patients called to say that she had felt a lump in her breast that was not there when I saw her for a physical in November. Her insurance was not going to cover an office visit, so she requested if I could just order the mammogram. I did. A mass was discovered in her right breast and a sample biopsied. The result: invasive lobular carcinoma. I called her to give her the results. She would not answer the phone or speak. Instead, her husband was to receive the bad news. I hate this part of my job -- giving bad news. Actually, I don't hate that part. I want to be there for my patients. It's the bad news part I hate. Every diagnosis weighs heavily on both my patient and me -- some like cancer more so than others. Sometimes though, a diagnosis is a relief. I got to call a patient who for years had been suffering with pain in the upper and lower abdomen. He was so frustrated that no-one knew what it was. This week, we finally found out: epiploic appendigitis. It may be chronic or it may respond to treatment, but for the moment, we both savored the pleasure of the end of one journey -- the 'what's wrong with me?' part, before embarking on the 'how do we fix it?' part.

I also got to diagnose hemachromatosis for the first time. This is a disease I had read about in textbooks but never actually seen. Making the diagnosis was like an 'aha' moment that suddenly pulled all of the symptoms the patient had, come together into a coherent picture.

The weeks are bitter-sweet: the treating of patients that get better, the diagnosing of patients who may or may not get better, depending on the diagnosis, the tearful goodbyes to patients who die, expectedly or unexpectedly and the cheerful hellos to the newborn babies born to my patients or as new additions to their families. They all run together in the same day, sometimes in the same afternoon. It is like a roller-coaster ride, emotionally, physically and mentally.

Most nights I arrive home spent. These days I dream of the clinic and the hospital. Some mornings I wake up feeling like it's not fair -- I feel like I just worked all night. Still, I am tired but happy.

I still got to say: this is so cool! Thank you Lord, for the privilege of seeing patients and practicing medicine!

Death and Birth

The pager vibrated where it sat on my table next to my desk lamp. I was sipping coffee at 5:00 am when I picked it up to see who was paging me. I was on call that weekend and it was a Sunday morning. The message was the one we never like to see: pediatric code blue, ER 15 minutes. I dressed hastily and got to the ER as fast as I could. Although I was on call, I was not on call as as a first responder. That job fell to the pediatric intensivist and residents on call. I went anyway. By the time I got to the ER, they were already there and CPR was well into 10 minutes. The 4-month old baby was pale and lifeless, pupils fixed and dilated with no pulse and no respirations. The code ran about an hour before it was stopped. The coroner would be doing an autopsy because of the untimely death of this previously healthy baby. Apparently, the night before, the infant had been fussy so his parents brought him into their bed. Cause of death was most likely SIDS (Sudden Infant Death Syndrome).

As I walked out of the ER, I could not help but remember the last time something happened, that I was a part of. It was during my intern year and the code came at the end of a 30-hour call period. I remember coming back to my car numb and crying as I sat in the drivers seat, overwhelmed, tired, shocked and heartbroken.

This time, I got back in my car, drove home, showered and returned to the hospital to see newborns. I'm not an intern anymore. I can't say I feel nothing, but I was not as overwhelmed as I was the first time. That morning, my responsibilities included performing the newborn exam on all the babies that had been born overnight. As I looked into their little faces, I could not help but smile while in my mind was the image of the dead baby I had seen only an hour or two ago. From death to birth in a morning. That is medicine.

Camp Angel Summer 2010

Wow, looking over this blog, I can see that I have not been writing much. This is not because nothing's happening. Rather, it is the opposite. I will try to do better. Well, July 9 through 11, I was at the summer Camp Angel. To learn more about Camp Angel, visit their website: http://www.angelonmyshoulder.org/cancer-support-programs/31-camp-angel/132-camp-angel-activities.html.

Like last year, this camp was held near Three Rivers in northern Wisconsin at Camp Luther (http://www.campluther.com/) . Camp Luther is a beautiful facility with several different kinds of camp buildings for the kids: a fort, a tower, an Ark and other wooden, fun architectures that make an adventure out of staying there.

This year there were 24 children, an equal number of boys and girls. As with each year, they were divided into groups according to ages. The 8 and 9 year old girls were called the Bunnies, the 8 and 9 year old boys, the Bears, the 10 through 12 year old girls the Foxes and the 10 through 12 year old boys the Wolves. Each group had 2 to 3 counselors. Every year the groups do fun things with their names like 'the Foxy Ladies' and the boys shouting, "Who Rocks? THE BEARS!"

When the kids get off the bus, one tends to see... kids. But if one sits down and reads their application forms, one sees the heartbreaking stories behind them. One of the children lost his dad to cancer only in April. Others have lost a mom or grandparent. Others have a sibling with cancer. What does this do to a kid? We had one little girl on 2 sleeping pills, something to prevent her wetting her bed and something for acidity. Those of us administering the medications shook our heads in increduility and dismay even as this 8 year old pointed to each tablet and told us why she had to take it. A number of kids were on antacids, ADHD medication or something for chronic headaches. Processing the stress of a close family member with cancer can code in their little bodies as psychosomatic illnesses, behavioral problems or actual physical ailments.

One little girl got off the bus and was brought straight to me: "She threw up the whole way here!" She had a headache and did not feel good. I took her to the medical room and encouraged fluids.

That evening, we had a scavenger hunt with the kids having to find things like a bronze bowling pin, a particular kind of feather, eggs and other items skillfully hidden on the grounds by their counselors. As happens every year, the Northern Wisconsin Harley Davidson group drove in revving up their motors to make a grand entrance. The kids gazed wide-eyed at the shiny motorbikes. Several took pictures sitting on one or more of the bikes. I held onto one 11 year old who had just been dropped off by his parents. He didn't feel like being there and was teary eyed as his family drove away with the admonition: have fun!

The next day was our main day on camp. After a good breakfast, buses of us set out for Three Rivers and Duck Lake, where Captain Steven and his son Steve-O had a pirate ship ready and waiting for us (http://www.eagleriverpirates.com/). Before that however, I made a quick trip into town to pick up some anti-nausea medication for a few kids who, it turned out, had motion sickness. I also stocked up on hydrocortisone for bug bites, Aloe with some lidocaine for bad sunburns and some children's peptobismol. During the pirate ship adventure, most of the kids had fun. Captain Steve showed us a bald eagle's nest with a couple of birds in it. With pirate songs playing in the background ("My name is Roger, and my favorite letter is 'ARRRRHH"), we blew bubbles, and colored white T-shirts with pirate-themed pictures. Counselors and myself looked out for kids that seemed to take themselves out of the fun because of depression or sickness and helped.

In the afternoon after lunch which was a yummy cookout, we all got into the water. Kids jumped off the pier, swung on a rope for a splashy landing in the water, rode on tubes pulled by jet skis and motorboats and went fishing. We had a few sunburns, scrapes and and nausea but nothing major. I stayed in the water and helped kids on and off the tubes. I smiled at one group of 3 8-year olds who had never been tubing and wanted to try it for the first time. As the motorboat pulled them across the lake, I could see the waves and wind cause the tube to skip and bob on the water, causing their little bodies to bounce, and they held on with two hands to little handles on the tubes. When the tube came to shore, their faces were white and eyes wide. They broke into smiles and pleaded "can we go again?" One little girl went 5 times.

Kids took breaks to get their hair braided, face painted, play shuffleboard or paint souvenir rocks to take home.

After cleaning up, we gathered outdoors for DJ Dan and his music. We got almost everyone out on the floor to dance. It was a fun evening. After that, the campers went back to their camps for s'mores, a bonfire and whatever late night activities naughty campers do.

The next morning, after a breakfast, everyone got back on the bus to go home. There were lots of hugs, smiles and some sweet sadness of saying goodbyes.

Camp Angel is magic for these children. For a few days, they get to forget the solemnity of death, hospitals and sickness. They get to be kids. As a camp medical careprovider, I have learned to balance giving attention to illness, treating what needs treatment and otherwise distracting kids from their illness with some magical results. The camps have taught me that sometimes, distraction is much better than a pain reliever or stomach medicine and sometimes validation of a need is more important than treating it with something.

Kids are magic and seeing them have fun is rejuvenating for those of us adults who were there. I got my Camp Angel rock as a souvenir. Mine has a rocket ship on it. Well, I did have a blast!

MUA - where I went to medical school

I get a fair amount of queries on Facebook and such about MUA -- the Medical University of the Americas and what my experience there was. Many inquirers want to know if the school is 'real' and whether they can succeed and get into residency in the United States or Canada after graduating from there. After writing individual replies (typed these days, painfully, on an iTouch) I decided it might be best to post this and send inquirers a link. I still try to reply with a personal message to each one, but so many people ask so many of the same questions, this just makes sense.

If memory serves me right, I joined MUA in January 2001. The school was (I think) in its second semester on the island. I had flown down to the island to visit several month before when the classrooms were still being constructed, the pool was a hole in the ground, the library building did not exist yet and there were no students. It was scary and I was not sure if I was doing the right thing.

I graduated from MUA in 2005 and began residency that same year. For the two and half years I was on Nevis, I bought took all my classes and taught biochemistry (this is why it took me a little longer to complete the Basic Sciences curriculum).

Okay, so here's the big picture... the things that really matter. MUA graduates have got into many different residency programs -- community to university-based programs in competitive specialties like neurosurgery, radiology emergency medicine, general surgery and practically every available type of residency program. Many were chief residents of their program in their final years. Many have gone on to do subspecialty training in fields like cardiology, endocrinology, nephrology, critical care, oncology and subspecialties in anesthesia like interventional pain management. This is only based on the people I know personally.

Bottom-line: the school delivers. We are proof of that.

Second-years have to do the United States Medical Licensing Exam Step1. There are 2 additional steps. I personlly know MUA students who have gotten in the 97 to 99 percentiles in these exams. These are very good scores.

Caribbean medical schools come in many shapes and sizes and degrees of credibility. I cannot authoritatively comment on any of them except the school I went to. In MUA's case, I can vouch for the school as a product of it who is a licensed physician in internal medicine and pediatrics and a clinical professor of these specialties with the University of Wisconsin.

Because the standards for getting into the schools in the Caribbean are not the same as those in the States, a number of students will get in that will never graduate. Some will never finish the Basic Sciences. Others will complete their time on the island but not pass the USMLE exam(s). Still others will graduate and never get into residency. I think this is because not everyone who gets into medical school is there for the right reasons. Some are there to please their parents and are trying to fulfill their ambitions. Others think that it would be really 'cool' to be a doctor, but have not sat down and counted the cost. Others have underestimated the sacrifice, hard work and years of training it takes to succeed.

Life as a caribbean medical school student is hard. Some people have a prejudice against caribean medical school students and graduates, thinking they are second-rate because they did not get into a U.S. (or Canadian) school. The interesting thing is that once you're in the hospital (third and fourth years), most people evaluate you by your performance and not your label. The Basic Sciences Dean at the time of my graduation from the island gave us this advice:

1. Be the first to arrive and the last to leave
2. Volunteer for everything ('who wants to look this up? Who want to try to start this IV?)
3. Own your patient (know their labs, their care plan, read on their diagnosis, evaluation and management).

I took this advice and did great. It was an honor to be a Chief Resident, to win an award for the Best resident teacher -- an award given by U.S. medical school graduates who were in training in my institute, and to be asked to join the faculty of our residency upon graduation from our program. I owe my school for these opportunities. MUA took me a student and gave me the instruction in the basic sciences, placed me in my third and fourth year clinicals, wrote my Dean's letter, gave me my degree and enabled me to get into residency and get licensed to practice medicine. What more can a school do?

The rest is up to you.

Camp Angel, Winter 2010

This is WAY overdue...

I spent a weekend as the doc for Camp Angel (Jan 22 to 24, 2010). To those of you who don't know... this is a camp held for children whose families have been touched by cancer.

It is one of several camps held by Angel On My Shoulder Non Profit Cancer Foundation. (Visit their web site at http://www.angelonmyshoulder.org/cancer-support-programs/31-camp-angel/132-camp-angel-activities.html to see reports on the camps and explore).

This year we had professional photographers, Lisa and Dennis Dewane (http://newdaephotography.com/) who took awesome photos.

Every year we get a sweatshirt or T-shirt, This year's winter came sweat shirt was in camoflauge to honor an old camp counselor, Sgt. Ryan Adams who died serving his country in October 2009.

We had a lot of fun and there were no medical problems. Loved it.

I encourage you to visit the Angel on My Shoulder web site and support this noble work if you can.

What a week!

Wow! It's the last day of April and I haven't written for so long...

One 'surprise' of being out of residency is that the 80-hour work-week ends. I was on call for Peds Thursday through Sunday. So I am so looking forward to this weekend off.

Last weekend I was on call and it was Prom weekend. Some teenage girl angst that I do not want to get into right now.

This may have been one of my worst weeks since starting in practice.

This week alone, I diagnosed 2 cases of breast cancer, one case of an atypical pre-cancerous breast mass, 2 new cases of diabetes and one unexpected prostate cancer.

I have done a lot of breast exams before this week, but I am changed in how I do them now. There is a pit at the bottom of my stomach when I am doing them now.

This 60-something gentleman came into my office for a physical (his wife made him come). He was on no medications and warned me that he did not want any tests. I talked him into a prostate screening test, and a diabetes screening test. He has prostate cancer and severe uncontrolled diabetes. I almost feel like I gave it to him and in a sense, I did. He was living his life without any labels and now he has two he did not want in the first place.

I've said this before. Medicine is a funny thing. In a day's schedule filled with 15 patients with 20 minutes per patient sometimes, you have to be able to go from one room where you said "I have bad news: you have prostate cancer" to a 2-month old well child exam where you get to say "He's doing great!" For me, it's when the day is over and I am spent, that it hits me.

I joke with my patients a lot. We try to keep the encounter light. I can't forget though, that this is serious business and under the veneer of the routine physical exam, cancer and death may lurk.

Trust

I have just read some devastating news. A gastroenterologist known to me professionally has been arrested for fondling his patients while they were under sedation. This is shocking in so many ways. First, there is the betrayal of a sacred trust between a doctor and his or her patient. Second, this man was a very accomplished, scholarly and outstanding citizen, who had even served his country in the Armed Forces. Thirdly, he was a christian, a father who had adopted children from a third world country and one known for compassion and excellence. I have worked in that department and I am not sure how he could be alone with the patient to have indulged in this behavior. There is normally always a nurse, a tech or a family member present. There are always people walking around -- nurses, tech, transport people.

I pray for his family, for his patients -- both the ones who were victims and the ones who are bereft of a good doctor, and lastly for him too. I pray that he finds redemption, repentence and that he seeks for and receives foregiveness and mercy at His Throne of grace.

This is scary stuff. Let each of us examine ourselves and take warning and caution.

The missing urine sample

I worked over Christmas. The day after Christmas a concerned mom brought in a little girl with a fever. I suspected a urinary tract infection as the cause and suggested we get a sample of urine. Since she was not potty-trained, the recommended method for obtaining a noncontaminated sample was to catheterize her. Of course, this is painful and unpleasant, but mom consented, given that it was the best way to be sure this was what was wrong. Two hours after the sample was obtained, I was surprised that a urinalysis result was not back yet. I called the lab and was informed they never received the sample! After several frantic phone calls, the sample was located. It turns out it was not lost. It had been processed both for culture and analysis.

This got me thinking. Snafus happen in every work setting: files get misplaced, entries posted to the wrong account, names mis-spelled, what have you. However, when a sample is obtained at the cost of pain to a little child, it smarts so much if that sample is unretrievable. Clinical information is obtained at the cost of pain and risk to a patient: a lumbar puncture to obtain cerebrospinal fluid, catheterization to obtain a urinary sample, blood draws. I guess everyone thinks their particular work environment is special and I am not exempt from that bias. I'm just glad we found the specimen and could process it correctly. She did have a urinary tract infection and she is being treated. All's well that ends well.

Exhausted!

What a week! I am exhausted in every way. Let me give you the short version as I am too tired to write more for now:
A man with no anus (status post colectomy) -- remember the old advice you got in med school about the only time you cannot do a rectal exam?
A drug-seeking male/female who had undergone a sex change (male to female) with breast implants, -- claims he/she can have sex and orgasms
A domestic violence case with neglected children and a battered wife
An infected artificial knee with large effusion and gout
Too many other things to remember.

I shall be vegetating this weekend...for a while, then I got to go in and catch up with paper work, dictations, billing and letters to patients on labs done, phone calls, emails...ah, the life of a primary care doc!

Isla Bastimentos and the Ngobe

Here is some logistics, facts and trivia gathered on the trip:

1. There are two schools on isla Bastimentos, one with about 90 kids and othe other with 30 kids. There is no school transport and kids walk to school along the coast. Most do not know how to swim and there has been at least one drowning of a 9 year old recently.
2. There are Nogbe communities on: Isla Bastimentos (about 2-3 communities), Charcot, La Loma, Salt Creek, Isla Cristobal and Isla Carinero, and on Isla Solarte. There are about 6 huts near the 'Bat Cave'
3. Healthcare facilities (such as they are) include the hospital in Bocas del Toro, another in Changuinola and a quite decent hospital in David. There is a first aid station on isla Cristobal, Almirante and Charcot.
4. Transport between these facilities is by boat -- expensive, hazardous and slow.

Medical missions trip to Bocas del Toro

Wild cacao growing on Isla Bastimentos. View of the town of Bocas del Toro from the air.


View from the balcony of the the Kapsars' home The hut where the lady with arthritis lives

1. on Isla Bastimentos.
   
   Another view of the same hut A Ngobe village
   I am writing this so-ooo late! During my visit to Panama, I had a memorable visit with Dale and Kim Kapsar (http://agapeinpanama.blogspot.com/). They live on the island of Isla Bastimentos, one of the islands in the Bocas del Toro archipelago in Western Panama. On this and adjoining islands live a group of Indians called the Ngobe (the 'g' is silent in pronunciation and the 'e' is sounded as 'ay').
   
   Dale and Kim Kapsar have lived on this island for several years now. Their house itself is quite a marvel, with solar roofing to generate electricity, a rainwater collection system that connects to 2 large tanks to provide running water through the plumbing and a tower to connect wirelessly to existing internet providers in the larger area. Dale and Kim have made Isla Bastimentos their home and the Ngobe their mission field, trying to reach them with the good news about Jesus. They however, are keenly interested in their socioeconomic situation too, developing projects to bring potable water to their communities, local sanitation facilities, teaching hygiene to local school children and providing basic medical care. They encourage support not to give gifts to the local indians, but jobs instead through which they can provide for their families.
   View of some of the less inhabited islands from the air.
   Throug the past year I corresponded with them through email. When I visited Panama to spend a 2 and half week vacation visiting my family there, I resolved to visit them. My family graciously agreed to let me go for 3 days.
   
   I caught a flight from Panama city to the only commercial airport in the province of Bocas del Toro. Here is a picture of the local airport from the inside. I caught the 45 minute flight and arrived in the town of Bocas del Toro. Dale and Kim received me and we had breakfast in the town. After picking up some supplies, we took their boat, Agape, (shown here with Dale standing next to it) to Isla Bastimentos. The trip lasted about 20 minutes and included a stop at the 'gas station' shown here.
   
   Travelling among the islands in Bocas is interesting. There is no public pier or dock at the town of Bocas del Toro on the island of COlon where the airport is located. Boat owner who live on the other islands make deals with local residents to tether their boats at the small piers in their 'back yards'. It costs about $ 30 in fuel and takes anywhere from 20 to 40 minutes to go between islands, depending on how far apart the islands are. Since there are no buoys or lights and their are unmarked shallow reefs, travelling in the dark is hazardous. Travelling in torrential rain (not uncommon in the area) is similarly difficult.
   
   The island shown in this picture is Isla Solarte and the tip shown here is called Hospital Point (http://www.worldheadquarters.com/panama/destinations/bocas/hospital_point/index.html). As someone who is interested in the healthcare resources in the area, this perked my interest, hence the photo. Well, it turns out that it WAS the location of the medical center for a banana company that was located in the area and no longer has anything to do with hospitals or healthcare.
   
   There are numerous mangrove islands that are quite beautiful to look at and here is a picture of one on the way.
   
   The picture below shows Isla Bastimentos and the Kapsar's home located on higher ground.
   
   When we arrived on the island, our first stop was in a small, half-finished building that will (we hope) eventually become a local clinic. Living there presently was a family, one of the members of whom works for the Kapsars. One the phone the day before my flight to Bocas, the Kapsars had told me of a little boy called Aljillo. This was a 2 year old who weighed about 15 pounds and did not walk. He was very malnourished. Here is his picture.
   
   As we walked off the Kapsars' boat, visiting him was my first stop. He had evidence of malnutrition, scabies, lymphadenopathy everywhere I looked. I treated him with something for worms, another pill for parasites, an intramuscular dose of a broad-spectrum antibiotic and gave the family a multi-vitamin and iron syrup to give him daily. I also recommended passive range of motion of his extremities. Within a few days, his lymphadenopathy had subsided and he was ravenous.
   
   After I left, a YWAM (Youth with a Mission) team continued to care and before they left, this little boy was walking! It turned out that the family was not feeding him because he was born out of wedlock. We tried to arrange to get him into a Nutri-Hogar (a home run by the catholic church on the mainland that provides nutrition to malnourished children before returning them to their families.). However, the family left before we could do this.
   
   Later that day, we visited a local school and participated in a group discussion on how things were going with the newly constructed latrine. The following day we visited a local village and saw several children. I treated impetigo (click on the picture of the little boy and look closely at his face, near his nose), scabies and one elderly woman with severe arthritis. The day before I left, Dale cut his hand and I was able to teach Kim how to suture lacerations -- a very common problem they must deal with.
   
   Teams that have come before me have left medical supplies and I left my stock of brough antibiotics, and supplies too. Here are pictures of my flight back home.
   
   Coming back to Panama I began to research what is known about the Ngobe and their health problems. Infant mortality is highest among the Ngobe compared to the rest of Panama and it is clear to see why. Most of the children are born at home or in the cayuco on the way to the only island with a 'hospital' (which is a very minimal facility run by the MInistry of Health).
   
   Here is the vision:
   The Kapsars are willing to give that little building on Isla Bastimentos to become a clinic / hospital
2. If we can get 21 doctors/nurse practitioners we can staff the clinic/hospital the year around.
3. Each provider would spend two and half a weeks at a time on the island.
4. They would be able to live with the Kapsars in their house. (It is a great place with electricity and running water). However, they would pay for their room and board and bring along what medical supplies and equipment they can.
5. There would be a half week overlap between changing providers for a 'sign out'.
6. Contact between all members of this 'group practice' would be by email and if bandwidth on the island ever permits, video conferencing or at least pictures.
7. Once a year, we would all try to meet someone and discuss our 'practice'.
8. Each physician would return yearly.
9. There would be periodic visits from church supported mission teams that would help with constructions projects and mass medical camps, but our group practice would provide the continuity, follow-up and guide the incoming camps to identified areas of needs.
10. This vision would provide continuity of care, an established presence among the Ngobe and U.S. standard of care.
11. I am signing on as the first doctor. Any other takers?

The phone call

New experiences don't end with residency. I love that about medicine. Another feature of medicine that makes it uncommon among professions is the human drama that goes with it.

I had seen a late 30-something for a complete physical last week. She looked down and through the course of the interview, I found out she had just finalised her divorce. To make matters worse, her 4 year old daughter had come away from her first visit with her father with bruises on her body. This brave woman fought back tears as she told me these things between looking in her eyes and ears. I felt a bit uncomfortable as a male provider doing this complete physical exam during a stage of her life when surely she must think all men are pigs.

Introducing the pelvic exam, as sensitively as I could, I offered her a complete sexually transmitted disease testing panel. At first she declined, but when I pointed out that in the context of the setting of the divorce, she might consider it, she agreed.

The results came back this morning.

I picked up the phone to call her. I pointed out that the Chlamydia test was positive. As if this was not bad enough news to give, I had to point out that as a notifiable disease, our lab had directly contacted the county healthy department. She asked if her name had been given. Honestly, I did not know, but I found out quickly. Not only was her name passed on, but a county health nurse would be contacting her.

Besides the devastation of getting a sexually transmitted disease from someone who had betrayed her in so many other ways as well, she was not concerned about her privacy and reputation. My heart was in knots as I tried to reassure her that even in a small town like ours, her information would be confidential. However, more and more people seemed involved in the loop: my medical assistant who receives the result from the lab, the lab personnel in charge of notification, the county health department and its share of employees that would be doing following up. I could see her point. I felt helpless and frustrated but that must be nothing compared to what she felt.

I'll follow her closely. I hope she's okay.

Aloepecia totalis

It was a busy afternoon. The student working with me came out of the room and told me that next patient -- a 53 year old male was a caucasian male here for a physical. As busy as we were, I went into the room with her quickly. The patient had wanted us to see his 1 month old in the same visit and Mom came along as well, so there were quite a few people in the room. He took his cap off as I began my physical and I noted he was bald. I asked him when he lost his hair and he said when he was 39. I looked up at his face ready to begin the HEENT (Head, Eyes, Ears, Nose, Throat) part of my exam when I noticed, hello? He has no eyebrows. Wait! He also has no eyelashes and... no nose hair, no hair in his ears, no facial hair, no hair on his arms and legs. He smiled and said 'Aloepecia totalis'. Cool!

I have seen one such case before and it is in this blog. In that case however, it was the side-effect of a drug. In this case, it seems, the patient denied any exposure to that drug and any other for that matter. No-one else in his family has this.

Moral of the story: just when you think the physical exam is a routine...

Is the generalist a relic of the past?

The other day I was talking to my brother. He told me casually in the course of conversation that he had got his physical for the year. He then mentioned that he had had his yearly appointment with the urologist to check his prostate. That got my attention. What's wrong? Nothing. He just sees a urologist once a year to check his prostate. He has no medical history of urinary or reproductive problems. He has never had urological surgery.

I was at a medical meeting and during a break talking with someone about how there isn't enough training in procedures during residency training. The person I was talking to turned out to be a subspecialist. He disagreed with me regarding training primary care doctors-to-be in procedures. He quoted papers that reported better outcomes when these procedures were performed by specialists.

So, should you go to a cardiologist to have a heart exam and evaluation? Should you see a nephrologist to manage your blood pressures? How about an endocrinologist or a diabetes specialist to manage your diabetes? Should a gynecologist manage your post-menopausal symptoms or a rheumatologist manage your osteoporosis or arthritis? Should you see psychiatrist for stress coping with changes in life or depression?

What is the role of the primary care provider? Is he or she to be a triage person, directing the flow of medical traffic to different specialist-destinations?

I am a primary care doctor. I don't treat a single organ or organ system. I don't wear blinders and only want to hear about your medical problems or complaints pertaining to just your heart or just your kidney or skin or mind or bones.

Are we emasculating primary care doctors when we deny them the right to be doctors and treat patients, rather than just refer them to specialists?

Of course, on the other side of the line is the recognition of the limitations of one's scope of practice. I won't do neurosurgery or try to remove your gall bladder or even do an angiogramon your heart. Some things are clear. But what about managing blood pressure in a diabetic, or abdominal pain in a pregnant, depressed young woman? Is that outside the scope of my practice? Who decides that? Me? The specialist? Some regulatory body? The public?

Of course, I have my own answers to these questions. And of course, as Einstein pointed out, the observer affects the observed phenomena. I am biased.

Fortunately, on a personal level, I am not legally limited in my scope of practice in any but the broadest ways.

Guilt

Being a primary care doctor is a privilege in many ways. It is also a sacred position of trust. What is said in a doctor's office is, very few legal exceptions, never to leave the room. Of course, in the day of the electronic medical record, that is not entirely true, or is it? How much of what a patient tells you belongs in their medical record? Most would argue, effectively I think, that personal information divulged in the course of the encounter may not always belong in the record. Such information might be a personal event -- a child winning a ribbon at a competition, or a vacation story. The electronic medical record is accessed by numerous healthcare providers that care for a patient in the course of time. With the HITECH and HIPAA laws, accessing this information without a direct clinical context is a breach of law. However, what if a primary care provider records information divulged in conversation during the physical or during the office visit with their doctor? What if they record this information as part of the documentation?

Okay, this is a long preamble to what I really want to say in this piece. I have a couple of patients in my (young) practice that have varied medical complaints for which I have not been able to find an organic cause. I may add, it is not for want of looking. Healthcare dollars have been spent in procedures, tests and consults, all with no fruit. In both cases however, each patient has something they have done that they seem guilty about. They don't say they feel guilty. But their body language, the looking down, the averting the gaze, the downturning of the corners of their mouth, the sudden change of expression all say it.

There are numerous stories in literature about guilt affecting peopel in different ways, including symptoms of physical illness. Is this what is wrong here?

I have another patient who was abused as a child and is dealing with multiple phantom pains. I sometimes wonder if forgiveness is the 'cure' rather than the years of continued pain medications and periodic absences from work with physical therapy to achieve recovery.

I shall not leave myself out of this equation: I have guilt too. At the end of an exhausting day of planned and unplanned clinical encounters, phone calls, nurse notes, impromptu meetings with colleagues, residents, allied health providers and teaching, I am spent. I leave my office guiltily, leaving a desktop full of notes to be dictated, phone calls to be returned, requests from colleagues, students and residents for this or that -- things I am too tired to do. Did I do right by my patients that day? What about the one that left frustrated because I was running late and she couldn't wait anymore? Did I miss something? Did I miss the right decision in sending this one home? Should I not have admitted that one?

Guilt.

Is treating this root of medical problems within the scope of my practice? Should it be?

Discovering primary care...

Why don't medical students want to go into primary care? Why do even primary care residents want to get out, taking routes such as fellowships, hospitalists positions, academics, even nonclinical jobs?

Perhaps it has to do with the student's experience of primary care. It is incomplete. It is a series of office visits with patients you may never see again. You get to make a diagnosis, fill out a follow-up medication and move on to the next patient, normally never seeing that patient again.

Well, I am in primary care. I think I am beginning to understand the joy of primary care.

Last week, I injected a painful hip (trochanteric bursitis), removed a small pebble from a child's nostril, aspirated a ganglion cyst, met a patient cheerful after beginning an anti-depressant, celebrated a new addition to the family of a little girl I have cared for since residency and got an 87 year old to walk again after I took fluid off his knee and injected it with steroids. Of course, the 87-year old was back the next with an even more swollen knee (he felt so good after the first fluid removal that he went home and got on his treadmill to catch up with exercise after all this time of being immobile).

They say that if you've suffered through a traumatic experience together, like fought in a war alongside someone or being involved in a life-or-death encounter, you form a special bond with that person. Well, bonds are being formed all over the place.

Last week, I was a dermatologist, a cardiologist, a nephrologist, an orthopedist, an endocrinologist and a psychiatrist, sometimes all in the same day. I love it!

Make hay while the sun shines...

I love Peds acute care -- you never know what you're going to get (to borrow a phrase from Forest Gump).

There was an adolescent female in the room with her mother. Her ear had been feeling full and her hearing wasn't so good from that ear. With frustration, the mother and daughter mentioned that they had been seen 2-3 times now and it wasn't getting better. One diagnosis offered was swimmer's ear. The funny thing was that she had not been swimming. I asked her what she had been doing. Well, it was summer in Wisconsin and like many farm hands, she had been making hay all summer. I looked in the ear and saw something I had never seen before: it looks white and black and cottony. I got a sample and sent it to the lab, but I thought I knew what she had and gave her a prescription.

When we called her a couple of days later, she was feeling much better and almost back to normal. The lab studies confirmed the diagnosis: Aspergillus niger.

She had fungus growing in her ear. How might this have happened? During my exam, I noted that her hair was damp and there were pieces of hay stuck in. The damp, golden curls hung over the ear. I'm guessing the warm, damp weather of summer, the fungus in the hay she was making and the environment in her auditory canal probably created the "perfect storm" for the infection. Onychomycosis -- my first.

Paternalism, paternalistic and empathy

I have several young woman in my practice. Well, I'm a Med-Peds doc so I have patients of all ages in my practice.

In the interaction between an adult and a child, paternalism seems quite natural. In medical school, we were warned against paternalism: defined in medical ethics as "A policy or practice of treating or governing people in a fatherly manner, especially by providing for their needs without giving them rights or responsibilities." Appropriately warned, physicians try to walk the fine line between the patient's "beneficience" and "autonomy".

When a 20-something young lady refused the HPV vaccine, tells me that she smokes while on birth control and has had at least 4 sexual partners in the past year, and does not use condoms every time, the 'father' in me wants to break out of the white coat and speak to her as I would if she were my child. After all, I internally reflect, from the perspective of the age difference between us, I could have had a daughter as old as her.

Lest you think there's something psychosexual about this, I feel the same way when my 20-something young man with Crohn's disease and a colectomy tells me one day before he is due to go to college that he has been having some abdominal pain and fatigue. The father in me once again wants to leap across the invisible waves to his cell phone as I'm trying to leave a message to him far away to tell him that his hemoglobin is low and he needs iron supplements and to see someone locally soon.

Okay! (deep breath).

These are adults (technically, at least), with their autonomy and I must not be paternalistic... I must not be paternalistic... I must not be paternalistic... I must...

What does your doctor mean to you?

Dr. F came out of the patient's room to get me. It was a busy afternoon in the clinic and we were all in the middle of seeing our own patients. He wanted me to come and meet one of his patients.

Dr. F leaves our clinic in about a month. He is moving back to the coast to be closer to family. He has been here about 13 years. He did his residency here and is now the director of that same residency program. He is also the head of our department. As part of his last month's activities and in between trips to the coast to find a home, nail the job down and such, he is having to tell his patients that he can no longer be their doctor. He had spoken to me about this particular patient -- someone he wanted me to take over the care of after he left.

I entered the room to find a tearful, crying 50-something year old female. I asked her why she was crying and from her wheelchair she reached out to Dr. F and said, "I'm losing my best friend!"

I think both Dr. F and me fought to maintain composure in the presence of her emotional expression of what Dr. F meant to her. She held onto him for a few moments, tears flowing freely down her face.

This is what Dr. F meant to her. She told me that they shared a history together. He had told me earlier of her close encounters with death, debilitating disease and the march of chronic disease in her life through the years.

Over 13 years, relationships between doctors and their patients are forged in the therapeutic alliance for their health and wellbeing. This continuity, this partnership and ultimately, this friendship is what Dr. F and this patient have. This is primary care.

Biting your lip...

Kind of getting into the swing of things: several days of seeing patients in my clinic, mornings of acute care in Peds, urgent care last evening. Interesting how one evolves after residency. When I see a patient, I'm sometimes torn between: did I work this up enough? Did I do too much testing? Should I have sent this one home or watched them in the hospital? Yesterday a 16 year old football player came in with a dislocated finger. I never set one of those in residency. I looked it up in a text and was all set to numb up the finger with a finger block. I got pre-reduction x-rays that confirmed the finger was dislocated. Then, I asked one of the other docs in urgent care that night -- a family physician with more years of experience if he had done one of these before. He came into the room with me and while talking to the boy yanked on his finger and set it. No pain medicine. He didn't think we should get post-xrays. I thought about the difference in comfort levels we bought had at different stages of our careers. I would have done it, but first numbed up the finger, then set it, then got post xrays, in short, spent more healthcare money and been more cautious. Some cases I think that if I was more experienced I would make the call with fewer tests. Other cases, I wonder if that is necessarily the right thing to do. Work in progress...

The Boards...

Years ago, a physician told me "If you're going to be a doctor, I hope you love studying..."

Well, residency is over. The reading, of course, never ends... and neither should it. There are always new things to learn: new guidelines, new studies, new vaccines and new diseases. What many didn't count on though, was exams! Besides the inservice exams we do every year in residency (and in Med-Peds, because we are doing 2 specialties, we get to do two of these each year), there are the Boards.

After residency in Internal Medicine, graduating residents get to take the internal medicine board exams, held by the American Board of Internal Medicine. It is an all-day computer exam, going from 8:00 to 6:00 with 240 questions set in blocks of 2 hours each (60 questions to a block, so 2 minutes per question). If you pass this (pass rates have been of the order of 91 - 92% with roughly 7,100 taking it every year), you are certified as a diplomate of the Board of Internal Medicine -- a "board-certified" internist. This is the initial certification. One has to re-certify every 10 years. Sounds like fun, doesn't it?

It's amazing how there's a little cottage-industry that is spawned by the many exams in medicine. There are review courses, study guides, books, DVDs, CDs, MP3s... you name it.Every exam (the USMLEs, the Boards in each specialty) has its own little industry. While no-one can legally tell you what'll be on the boards, you hear a lot of "they're bound to ask you this, or that.

Well, I've been through yet another exam trauma -- the whole ritual of preparation angst, pre-exam anxiety, exhaustion and finally relief. I took the exam on Thursday this past week, so I 'blew off' this weekend (didn't do anything meaningful).

Results come in 3 months.

Oh, did I mention, that because I'm Med-Peds, I have the Pediatrics Board exam to look forward to. I plan to do that next year, but I'll start studying now. Fun, fun, fun!

The first day...er.. first 2 weeks

I had meant to write about my first day in the job as a Med-Peds physician. That was July 27th. It is August 16th as I sit down to write this entry. The first day is a bit of blur, so I'll write about the first 2 weeks instead.

I remember that my first day had one no-show -- a bit anti-climactic. However, there were enough patients to keep me busy, mostly new patients who came to establish care. In these past 2 weeks, I have had a lot of adults coming into establish care and get an annual physical. Similarly, there have been a lot of kids who came for well-child visits and sports physicals. After the first 20 or so, I wanted to see a sick person! I enjoyed the freedom of seeing patients on my own. In the first couple of three visits, I would come out of the room, look for my staff, remember I was it and go back in to finish the visit. Even at the end of the second week, I still had to catch myself dictating "this is resident physician Vijay Aswani dictating..."

The first Peds clinic call was exciting. I was nervous about whether I would be able to keep up with the flow of patients. It was fun! I did end up admitting one 12 year old. My last case of the call morning was a little 2 year old with nursemaids elbow. I was able to click it back into place in seconds.The mother was suitably impressed. This is one of the few things in pediatric medicine where the fix is instantaneous. I was grateful for that case in my first day.

I staffed residents for the first time day before yesterday (the last day of my first 2 weeks). I supervized a resident tapping a left knee effusion that I had seen the day before and saved for this clinic. Everything went flawlessly. The patient felt no pain and we took off more fluid that I can remember taking off a knee.

All in all, I am feeling more at ease in my new job: building new patient relationships, taking care of patients and doing a variety of things with both adults and kids -- what a Med-Peds practice should be. Some highlights were: diagnosing my first case of diabetes mellitus type 2, tapping a knee effusion, setting a nursemaid's elbow, parotiditis, atrial fibrillation, managing blood med side-effectsd (hyperkalemia), performing a pelvic exam on a first time patient... the list goes on.

I have the internal Medicine board exams in about 11 days. Scary. Trying to study while practicing in these early days is hard: almost every patient is a new one that I need to get to know before I can go faster in my visits. Right now, each office visit is 30 minutes and each physical is an hour. I hear that that will change to 20 and 40 minutes respectively, within a month or so. Got to get faster.

My only beef is that I wish I had more time to think about some of the cases. If I could think, read and consider before having to 'move on to the next case', I would probably order fewer tests and maybe get to the answer faster in some cases and get to answer in some cases. Perhaps this will improve with time as I become faster.

Onward and forward to another week...

It's here...

The time has finally come. Residency is over. The post-residency break is over. This Monday, August 3, 2009 will my first working day as a full-fledged physician... after all these years. This past week I was involved in orientation. Although I pretty much know my way around this clinic and hospital, having been a resident here itself, there were still things I needed to learn and being hired as a physician involves some different steps than being hired as a resident.

My fellow orientees were a young dentist fresh out of dental school, a family practice doc fresh out of residency, a research scientist moving to our Research Foundation from Houston, TX where he was faculty, a neurosurgeon, fresh out of fellowship training and a bariatric surgeon. Quite a bunch! It was fun to hang out with these guys who are in the same boat as me: starting their careers as physicians at the Marshfield Clinic.

During the week, I was also able to tour the faclities at the Med-Peds department where I'll be working. I have my own office, with my name on the door. I have my own medical assistant. Monday is a fairly busy first day with 4 patients in the morning and 4 in the afternoon. I know. It doesn't sound like much. But it will be the first time I am seeing a patient in clinic without having to staff it with an attending. I dictate the note under my own signature, not under the supervision of someone else. I don't have to say "seen, examined and discussed with Dr.---" like I'v e done for the past 4 years.

I'm excited and scared. Excited to begin. Scared because I don't want to miss anything. No more is there anyone looking over my shoulder, making sure I haven't missed anything or that I'm not barking up the wrong tree.

Of course, life is not fancy free. I have the Internal Medicine board exams coming up on August 27 and there's a LOT of studying to be done for that (and not enough time).

All told though, I'm looking forward to my real working day and week.

Camp Angel

This weekend (Friday, July 10 to Sunday July 12, 2009), I was privileged to be at the Camp Angel summer camp. This is a summer camp run for children between the ages of 8 and 12 years old, that come from families touched by cancer. These kids have a sibling, parent or grandparent that has or has had cancer. The purpose of the camp is to provide them an opportunity to get away from all that 'heavy stuff' and hang out with kids who have experienced similar situations and just have fun.

The camp is one of several run by the non-profit organization Angel on my shoulder, formed by Lolly Rose (shown standing behind Mr. Chuck in the picture) after she lost her husband to cancer and saw the effect it had on her grandchild. You can learn more about this organization and its camps and other activities at http://www.angelonmyshoulder.org/.

I really enjoyed the experience. Ostensibly, I was asked if I would like to come and be the camp doctor. Jonathon Forncrook, my program director, had been going for the past 10 years and this was to be his last camp before he moves away to California. I had never been to a summer camp in the U.S. before and I was curious on several levels: how are summer camps run here? how are they different from back home? what kinds of medical care is involved at a camp? what makes a camp for kids with cancer in the family different from any other summer camp?

We left on a Friday morning and made the two and half hour drive up to Camp Luther in Three Lakes, WI. Once we arrived, it was only about half an hour before the bus bringing the campers -- 42 kids in all, would arrive. The groups were divided into 2 girl teams (the bunnies and the foxes) and two boys teams (wolves and bears). Each team had several counselors assigned to them. Each team stayed in a different camp -- the fort, the towers, the treehouse and pioneer city (wagons). Each of these camp sites were creatively constructed and looked like loads of fun.

We had a pizza party that night preceded by some icebreaking events. The Northern Lights Harley biking club came over with their bikes and allowed the kids to get pictures. The next day was spent mostly in water activities, with a ride on a pirate ship, run by the Strauss family in Eagle River, cayaking, fishing, swimming, tubing and such. There were crafts (face painting, rock painting, hair braiding and other such stuff) and a special DJ in th evening for a dance.

Medically, it was quite uneventful (thankfully): just the usual scrapes, bruises, some blocked ears after swimming and some sensitive stomachs. Homesickness was admirably managed by the counselors.

This was my first camp experience and I doubt it will be my last. I plan to go back next year. This organization also has a really crazy event called the polar plunge (read about it on their web site). I'm thinking of doing it!

The only sad event was that this was Jon Forncrook's last camp, after 10 years of service. From the sentiments he stirred up among the kids and volunteers, he will be missed.

Here it is...

I got my residency completion certificate today. It is a grand thing, already framed. Here it is -- the testimony to 4 years of residency

Physician, heal thyself!

It is a little over a week since my residency 'ended' (my last working day was July 1, but I am still a resident on the books until July 12). Last night was the first night that I think I slept right through. Strangely, during the nights before that, I kept waking up every couple of hours. My body seems to finally be making peace with the fact that I shall be sleeping most every night!

My days are spent studying for boards and ... well, I get ahead of myself.

Now that residency is over, I did an assessment of my lifestyle with the help of my brother with whom I had lively discussions on the matter during my family's visit for graduation. The results were not good: at a BMI of 28.1, I am overweight and with a resting pulse of 80, clearly not fit.

I guess it is time to make some life changes (since completing residency set that in motion). I have pledged myself to regular exercise, healthier eating and weight loss. I also made appointments with my doctor for a complete physical and the dentist for cleaning and treatment. Studying for the internal medicine boards (my occupation these days) has only re-inforced to me that I am overdue for these changes.

However, having recognized the problem and put a plan into place (and kept to it for the 1st 2 weeks now), I am hopefully on the way to a healthier me and to heeding the command of the old adage: physician, heal thyself!

Can't sleep

Yesterday was my last day in residency. I was on call during that night so I came off at 6:00 am this morning. After attending a meeting and shopping for ingredients for breakfast, I came home. Since I hadn't slept in 30 hours (for the last time as a resident), my eyes drooped as I ate lunch and I went to sleep by about 3 pm.

So here I am. It's 2 am and I am now wide awake. Whaaa? Why can't I sleep? I am not on call. I am done. I have about 3 weeks off before I start my new job as an Attending in Med-Peds at the Clinic. I guess my sleep cycle is screwed up from the call. It'll sort itself out soon enough. It usually does.

Still.

It's 2 am in the morning and I can't sleep. I called the PICU and the Peds floor to get updates on the little girl I admitted last night. We don't know why see siezed, but she's better. Oh well, I guess that's what counts.

I know it's wierd that I called the hospital, but I can't sleep and I was curious. How wierd is that?

The last day of residency

June 30, 2009: this was the last day of work in my residency in Med-Peds.

I began residency on July 13, 2005. Technically, that means I should work until July 12, 2009 to complete the four year program. However, I saved up some vacation time during my last time so that I could end on June 30. During the month of June, I was doing a rotation in Pediatric Hematology-Oncology.

Something special happened on this morning: as I drove into work, I saw a beautiful complete rainbow arc across the sky. It was a complete rainbow from horizon to horizon. One end of it dipped into the horizon just at the location of the Marshfield Clinic. Okay, I'm not going to read anything into this, but it was really cool and special, being my last day of residency and all. :-)

My last day began with Morning Report in Pediatrics. The ward team presented a case of a 4-year old with a rash and fever and we talked about rashes. It was nostalgic to be sitting there as a resident for the last time.

The morning was spent rounding on the 2 Heme-Onc patients we had. I then had an exit quiz in my attending's office. That went well. Interesting how one learns during these rotations. It's like when you look at yourself in a mirror everyday and can't see the changes accomulating daily. Someone else, seeing you after a period sees them immediately. The quiz gave me perspective on my learning in Heme-Onc.

After lunch, I sat down with the program coordinator and went through the exit list. A day before, I had got to hand over my resident's pager. However, since I am staying on here, it was simply replaced by an identical appearing but newer pager. Kind of an anti-climax: I had heard stories of people being so grateful to finally hand off the pager that had 'killed' many a night of sleep. Somehow, I never felt that way. Each page was an invitation to an adventure, a thrill.

Instead of the exit interview being a simple handing over of everything, it was more like a replacing of 'resident' stuff with 'attending' stuff.

The afternoon was not so busy. At 4:30 pm I went to the Pediatric ICU to get report on the patients I would care for during the night -- my last night on call as a resident. There were jokes about how after midnight, I might switch off my pager or simply tell the caller to page the 'resident' instead of me.

My last night on call was wonderful. I ordered pizza for everyone. Instead of wishing for a 'quiet' night, I actually wanted cases. My wish was granted. It was quite busy, with different, interesting admissions and call issues. I admitted a 20-month old female who had had 5 seizures that day. Her parents were both family practice docs. At 3 am in the morning, I did a spinal tap on her. My PICU attending made me a little plaque to wear on my back for the night that said 'After midnight, the bucks stops here!'.

It was poignant to spend my last day in residency on call. When I signed out at 6 am the next morning, I was officially done. The ward team to whom I had signed out were busy sorting out the admissions of the night. Since it was the start of a new month, it was a new team and you could tell they were a little nervous. Everyone had new roles: there was a fresh intern at the table -- his first day in residency; the second resident at the table was now a 'senior' resident -- he was an intern till yesterday, and the Ward Chief was starting his first day as a third and final year Peds resident and Chief Resident at the table. The PICU resident was busy gathering numbers in anticipation of morning rounds. Until yesterday, she too was an intern, and now she was a senior resident and the PICU resident for the month. And me, I was done.

I walked away from a busy floor of activity, everyone trying to step into their new roles, while attempting to provide continuity of care to our precious little patients. Life, as usual, goes on.

The retired physician

I was in Wal-Mart the other day, when I saw a curious, elderly gentleman of East Indian descent looking at me. I smiled back. He asked me whether I worked at the Clinic and I said yes.

We started talking.

He had joined the clinic in 1967 and specialized as an anesthesiologist in doing cases in pediatrics and cardiothoracic surgery. Before long, he was reminiscing and talking about old cases. His wife spied us from across a few aisles and came up. She introduced herself.

It became clear that there was some element of senile dementia. From his wife's 'take-charge' attitude (she locked arms with him and began to lead him out where apparently, her sister had the car loaded with their purchases and waiting), it seemed like she was the primary caregiver. As she led/almost pushed him along, I could see the misty look in his eyes, as he was being led off almost mid-sentence....

Curious thing. We'll all get old and senile dementia increases with age. From the stories I heard, this was a successfull and trailblazing anesthesiologist with many 'firsts' in his career. Now he was a retiree who needed looking after.

This reminded me of a more tragic case: I was doing an emergency room rotation that month when the code pager went off early that morning. I ran behind the ER doc as we came to the ward floor. The patient was a retired physician who had come in for an elective prostrate procedure. In the early hours of the morning, his heart had stopped and when the nurses' aide came in to do vitals at about 6 am, he was pulseless with no respirations. We ran the code for about 30 minutes when it became increasingly clear that this frail but hitherto functioning individual was not coming back.

As the ER doc called his wife to give her the bad news, I reflected on the situation. I imagined that this physician had probably done CPR, and ran codes on others before, perhaps even some physicians. Here he was on the other end of that scenario, for the final time. A life spent in medicine and ended in a medical scenario.

As physicians, growing old, becoming senile, being on the receiving end of emergency medical care -- all this seems scary. And yet, it is our future.

Graduation week

Every residency has a graduation day. Ours is called Residents & Fellows Recognition Evening. It was the 32nd one in the history of the Marshfield Clinic and Saint Joseph's Hospital. It was heald on Friday, June 12, 2009.

To attend this historic landmark event in the life of their loved one, my mother, brother, his wife and son came all the way from Panama. I was excited to have them. I took a week of vacation from June 6 to June 14 to host them here. We spent 5 days in Chicago and 2 in Marshfield. I guess, knowing how small Marshfield is, I thought they would enjoy Chicago more. It was a special time of togetherness, laughter, food and fun.

On June 11, my program director hosted a barbeque at his house in my honor. I was so embarrassed by the attention. Nevertheless, my family were touched by the honor. I received a Chief Resident award from him. My mother wept with joy and feeling. While I am embarrassed by attention and awards, I could not help but feel grateful for the recognition if it brought joy to mother's heart.

I truly believe that all our achievements are not ours alone. As one scientist said, we stand on the shoulders of giants. My family has supported me with much sacrifice and I am indebted to them.

A few weeks earlier, my bacteriophage research won me the Nikolai Award for the best Resident Research of the year.

At the 'graduation' evening, we had a great time. I was touched to see so many of our interns show up to support us on this evening. Belonging to the Med-Peds program, mine was the first name announced in the graduation. I picked up a white envelope to applause and returned to our table. I smiled when I saw what was inside: a red sheet of paper with "You may pick up your certification of completion on the last day of your residency" written on it. The ceremony is over, now get back to work :-)

The last event of the evening was an award given by the transitional year residents to a resident who has contributed the most to their medical education. I was pleasantly and genuinely surprised to win this award. I did not expect it, especially after all the glowing things that the resident said before she announced the winner's name. My family was once again proud and me embarrassed.

I am honestly happy that all the ceremony is over and I can get back to the work I enjoy so much in some measure of anonymity. In truth, when people are sick and hurting, awards seem a little crass. My 'award' is the saving of my patients. I pray for that award daily.

Then and Now...

It's June, my final month of residency! Last night was my 4th last call of residency (not that I'm counting or anything...). Things have changed so much since my intern year: I used to have butterflies in my stomach on call nights -- anxious and afraid of what might come up and whether I'd be able to handle it. I was 'afraid' of admissions and codes. Like others on the floor in wards (nurses, aides, unit clerks) I would say "Don't say the 'Q' word (quiet) because we woouldn't want to 'jinx' it and get a lot of admissions, codes or pts in crisis. Now though, I look forward to call night to see what we'll get. I'm not afraid or anxious, although I maintain a healthy respect for the unknown in medicine.

At 3 am I got a call from a 3rd year resident who was on call in the CCU (Critical Care Unit). He had admitted an 80-something year old with severe hypotension. The patient was already on pressors through a peripheral IV and needed a central line. He wondered if I could come and assist. Sleep evaporated and I walked over with a bounce in my step. I was on call for Pediatrics but nothing was happening, so I looked forward to actually doing something that night.

During the first attempt at placing the line, the patient became unresponsive. We called a code, did chest compressions and got him back. The line was placed and an hour later I was back in Peds. In my intern days, this would have pumped me with adrenalin. Not so much last night. It was 'fun'. I know I need to guard against becoming complacent or over-confident. No one knows everything and these are literally life and death situations. But I feel ready for the next step in medicine. I am done with my training at the end of this month and looking forward to the future.