Happy Birthday, Dad. I miss you.

 Dad would’ve been 71 today. Still trying to get used to the void he left in the family. Wish he could have seen his grandson playing little league or, today, finishing third grade. What a year.  

RIP Dylan Dog

 In the dumpster-fire that is 2020, my life is feeling increasingly like a country song. My job has been nuts - I've been in practice a little over 4 years at a large, multi-speciality group practice and am straining under the weight of practicing during a pandemic. My dad is battling t-cell lymphoma after a failed stem cell transplant which we hoped would be curative. A dear friend is battling a significant health issue. And, about 48 hours ago, my beloved buddy concluded his 14-year journey with me and my family. 

His health had been declining and we were anticipating that he didn't have many months but he became acutely ill and, following the awful calculus employed when weighing invasive/extensive interventions versus added quantity or quality of life, we decided to let him go.  Thankfully, my son, wife, and I were able to say our goodbyes and I held him when he died.

The house is too quiet. He's not in the window watching me drive up or sitting with me on the couch.

I'm so sad.

And we're done...

I made it through residency; wrapped up in June.  I managed to negotiate a stiped that let me take a sabbatical over the summer prior to starting my new job.  Saw family, put my toes in the sand, grew a beard that was much more salt than pepper, and cleared my mind.  As of this writing, I'm one week into a new gig as a Family Medicine doc working 4days a week.  I'm anxious but excited about it; I'm ready to start feeling human again.

Bandit Bandit

During a brief reprieve from the pagers, I've managed to hide several pictures of 70s era Burt Reynolds in various places in resident call room: behind the dart board, on the back side of the sleep room doors, in the freezer, on the bulletin board among everyone's snapshots.  Here's the troubling thing that I've encountered, my co-residents (many of them in their 20s and very early 30s) inhabit a cultural landscape where, no shit, someone actually said "Oh yeah, he voiced one of the dogs in 'All Dogs Go to Heaven.'" I died a little on the inside. Absolutely no cultural reference for "Smokey and the Bandit" or "Cannonball Run." So, they will, no doubt, be wondering who in the hell put photos of a hirsute mustache-sporting lothario all around the call quarters.  Oh well.

Seeing the Light at the End of the Tunnel

Hopefully, it isn't a train.  Between parenthood and the demands of being a physician in the waning days of my residency, it's difficult at best to keep up with writing and impossible for me to post as frequently as I'd like.  In due time, however, I'll post regularly.

Still Nightfloating (5 shifts left)

The hellscape that is nightfloat is on the downslope.  I enjoyed a weekend at home with the family despite sleeping the sleep of the dead and being so thoroughly wiped out such that I couldn't make decisions or carry on a conversation or maintain linear thoughts.

It was a rare February weekend with some sunshine and mild temperatures.  Great to tease you with the promise of spring but saddening to know that March looms to yank the carrot from your grasp.  Still, hanging out at the park with kiddo, Dylan-dog, and Winning Run was pretty great.

On the drive in to the hospital today, the mountain loomed large in the afternoon sun.  Seeing this thing is one of my favorite things about being out here.  It always captivates me and makes me happy.

Hoh boy, 5 more shifts.

NightFloat(ing)

So, I'm on my second two-week stretch of night float, that magic time in resident's life when you get to switch your sleep schedule and work overnight in the hospital hustling to admit patients and juggling multiple pagers.  Personally, it's a little fun but can really suck.  First of all, I detest that it takes me away from my family.  Seriously, the most grounding things for me are to see my wife, son, and dog on a daily basis.  This experience, for all of the good things about it, truly robs me of that as I'm not evening going to my house or sleeing in my bed on a daily basis. Instead, I'm staying at a friend's house who is just a few minutes from the hospital.  Luckily, I've got a great air bed, eye shades, and ear plugs.  Still, though, I miss the kiddo and the family.

At times, the chaos in the hospital overnight can be exhilirating: simultaneous cross-cover pages from nurses about patients who either need a Tylenol dose or are crashing (no way to know!) or from the ED to admit patients.  It's neat to be in a normally crowded place in the off hours and see how dim the halls are or how the monitors still chirp and buzz overnight but how it seems a little calmer overnight.

On thing that I do not love is the switching to a nocturnal way of life.  I'm an absolute wreck of a man without adequate sleep.  I will admit, too, that I've moved more and more toward my three-year-old's sleep schedule.  This schedule block, of course, has thrown that away.  I'm living on coffee and adrenaline.  At my age, it's not a sustainable combination.  Luckily, just when I'm really adjusted to the schedule, it'll be time to switch back to days.  Yippee!

Over halfway done with residency.  Nuts.  Seems like an eternity ago when I quit my job and became a Scottie.  I'm different now.

Hot Town, Summer in the City

A very brief review of the year in photos (mostly from the hospital).

Fall.

Winter.

Winter's Snopacalypse.

Spring.

Summer (Not in the hospital, obviously).

July has come and gone in the blink of an eye, much like the first year of residency.  I cannot believe how time has marched. Some days were eternities, others were milliseconds. Time is elastic.

I'm sitting alone in the resident room at the hospital, covering the service, staring at the sunny outside, watching pigeons stroll by the window and check me out.  Somewhere in Seattle, Winning Run and kiddo are playing outside getting ready for the audible assault of the Seafair Airshow's Blue Angels. I'm typing this and hoping for a quiet afternoon which, by simply typing that phrase (or even thinking it), is unlikely.

So, the calendar has ticked over and I'm now in the second year of residency.  I've been through the gauntlet of intern year's ridiculous inpatient schedule.  I've wandered like a zombie through the hospital halls, exhausted, hungry, wasting away, doing my best to keep it together and earn the confidence of those around me.  On some days, this work (like any) can seem so effortless, so second nature; on others, however, every moment seems foreign, terrifying, unfamiliar.

I'm still trying to process the year, still battling against the fatigue that has accumulated, still trying to scrape the bottom of the barrel in order to offer up something of myself when I make it home. A colleague and I were talking about whether we'd do this over again knowing what we now know and I'm uncertain of my answer but am leaning toward "Hell no."  

One thing's for sure, though, I can endure. Hell, I have endured and, perhaps, maybe even thrived. This experience of being a doc is unparalleled. I have the honor of seeing so much that many folks can't even imagine. In some ways, there's the hook that keeps you coming back.  "First one's free, kid."

Two months of inpatient family medicine, two months of inpatient internal medicine, one month of inpatient obstetrics, one month of inpatient pediatrics, one month of emergency medicine: these things add up! I'm happy to have them in the rearview and happier still to be more comfortable in hairy situations. I do, however, look forward to more time in the outpatient world, in my clinic, and, of course, with Winning Run and kiddo who will be three (!!!) in a few months.  

March on, time, march on.

Snopacalypse 2014

Obviously, I'm no longer in the southeast.  As a result, I've missed the most recent snowpacalypse that laid waste to traffic in GA.  Seems that friends and family from Atlanta all have horror stories of how bad everything was.  Glad I didn't have to be a part of it.

My folks let me know that they had broken out the snowshoes and decided to traipse around.  Although I'm not sure that less than 3 inches of snow really qualifies as an adequate base for using said snowshoes, they had a good time.  At the risk of alienating them (or angering them), I received the following image from their jaunt and thought I'd share.

I've never been snowshoeing and don't claim to be an expert but something seems a little odd about the photo.  Mom might be doing it wrong.

Wait, It's February?

Unbelievably, it's February.  I'm on the downhill side of my black weekend (where you are on call on a Saturday and need to work post-call on Sunday) and am looking forward to having a day off on Saturday, two more days of work and then 24 hours off! I've been at it for two straight months; first, on an internal medicine service and, now, on an inpatient family medicine service. Up at 4:30, in by 5:45, rounding by 7:30, home in the late PM. Wash. Rinse. Repeat. Day. After day. After. Day. Sick patients in, get them better, they come back. Rewarded for efficient work with more work.  

Again, my main advice is never do heroin.  And don't have the shitty misfortune to have a severe mental illness because you'll be marginalized to the edges of society, fail to make good decisions about your health care, will fail to consistently take your medication, will be victim to your mental illness which will lead you ultimately to heroin which, once more, you should never, ever, ever do.

I. Am. So. Tired.

Speaking of not doing heroin:  PSH, RIP.  My money has it that last words were "I'm a *** idiot."

Huh, How About That?

Last night, I'm preparing to discharge someone from the ED.  When I'm leaving the room the patient says, "I know it isn't related to why I'm here but I have another question..."

I stop, turn around, and say "Sure, go ahead."

"I've heard something about Obamacare and just want to confirm that it's true."

"Okay," I say, awaiting the question.

"Well, it's true, isn't it that when you sign up for Obamacare, you have to get a computer chip implanted in your arm?" pondered the 20-something sitting in front of me.

After I struggled for 10 seconds to be sure that I had processed the query and had, indeed, heard the patient, I responded, "No. That is absolutely not true."

I was so shocked that I couldn't muster more of a response.  I did turn around to repeat myself, however, before I left the room.

Tips O' The Day

Tip #1: Don't do heroin.  Just don't do it.  Ever. Ever in a million years. Never do it.  Don't shoot it into your veins. Don't slam it into your muscles.  Don't pop it under your skin. DO NOT DO IT.

Tip #2: Don't ever buy prescription drugs on the street.  You'll get addicted to Oxycontin, let's say. After time, you won't be able to afford the habit which will prompt you to switch to a more to a more economical drug: heroin.  (See Tip #1)

By the Numbers

Internal medicine                           by the numbers | Infographics

Out of the Forest

It's been far too long since I've last posted.  I'm renewing my commitment to update more frequently. Thus, it begins anew (again... but for real this time).

So much has happened since I last wrote.  Here's a brief recap:

• My dad's lymphoma recurred.
• My son celebrated his first birthday (and is, now, a week away from his second).
• I matched at the Family Medicine residency program of my choice.
• I graduated medical school and was joined by an amazing group of friends and family for the celebration.
• I was selected by my classmates to deliver a commencement address at graduation. (I think I nailed it by earning the day's only standing ovation!)
• I actually started residency and am almost a third of the way through the first year of it!
• My wife and I celebrated our ten year wedding anniversary.
• I survived my first inpatient rotation in Internal Medicine.
• I'm enjoying my Emergency Medicine rotation.
• I'm overworked, underpaid, and just plain exhausted ... the charming life of a resident.

From graduation:

Time Flies When Your Head Is Down and You're Working Like Mad

Cannot believe that I've last written in September. Since that time, Winning Run and I have had a baby boy who'll be six months old very soon.  At the moment, he's screaming bloody murder and wailing as though his life has been filled with regret and injustice.  I've a two-month pediatric clerkship (and shelf exam) to complete before being able to say that I'm done with my third year of medical school.  I've stories from the front and I'm ready to share them.  My current surgery rotation is done in about 24 hours and I should be able to cull out a little time for living and writing.  :)

Decade

All day long, I've felt uneasy, unfocused, unsettled.  I suppose that it'd be terribly easy to blame it on being bombarded with images from that horrific day a decade ago.  In some ways, I thought I that I was a little further along, that the scab would hold.  I didn't lose anyone in the attacks, don't have any amazing story of survival, or any first-hand account from that day. My stories from NYC are apocryphal; they're the "friend of a friend" ilk.  Still, like most everyone, I remember exactly where I was, exactly what I was doing, and exactly how uprooted the world felt to me in the span of a few short hours.  As I climbed into a coworker's car and fled home, I remember the certainty that anything was possible, that maybe the bomb threat on our office building in Atlanta was another imminent attack.  That evening, I remember being struck by a news correspondent's grace and composure as she walked the ash and paper-filled streets of lower Manhattan.  I remember the haunting silence in the skies near Hartsfield International Airport.  I remember getting drunk and reading Hemingway, identifying more than ever with his lost generation.

The decade since has been kind to me.  Several weeks after 9/11, I met the woman that I'd later marry, the woman that now carries our child within her.  I've grown as a person, as a husband.  I've mourned the loss of dear family and friends and have celebrated the arrival friendships and family anew.  I've abandoned the corporate world in favor of chasing my dream to be a physician.  I've left family and friends on the other side of the country to strike out on this crazy endeavor with my wife and my dog.

In many ways, I feel courageous more often than not.  I feel humble, thankful.  I am luckier that I deserve to be.  Still, when file through the images from that day so many years ago, when I hear the sounds of the chaos, it still fills me with dread, with terror, with anguish.

Go hug someone you love; tell them what they mean to you.

Le Circ

I've performed (under close supervision) two circumcisions.  One was on an 8-day-old; another on a 16-day-old.  It's a crazy, crazy thing to do.  After administering anesthesia, removing adhesions, installing the correct Gomco clamp, you just do the damned thing.  Generally, the babies tolerate it pretty well without very much agitation.  One of them slept through it.

On another note, I'm giving up calamari for a while.

On Being a Part of It, In Good Times and Bad

Another week has flown the coup.  I am having an amazing time in my Family Practice rotation.  Part of it stems from the fact that I'm working with preceptors who are near my age and who love to teach.  They're great at encouraging me to be a part of their day and to help them with patients.  It makes a huge difference, believe me. One of my docs does a lot of pediatrics and women's health care, which is pretty interesting.  In all, I've been seeing a lot of good cases, meeting interesting patients, and getting better at the art of being a physician.

The Bad
It's interesting to be in the room, to work with someone, and to be privy to such personal information.  I've heard things that spouses might not hear from their loved one.  I'm trusted to inspect areas of concern on a body that few will ever be given permission to examine.  There are few things better than to be there when you know the solution for a malady, when you're able to offer comfort, solace, a remedy.  Antithesis to the joy is being the bearer of bad news, the worst news.

I spoke with a preceptor about how he'd discovered what was likely lung cancer in a patient who'd had a non-remitting cough for some time.  The patient had to be begged to get a chest X-ray.  Being in the room while the doctor delivered the news was, to say the least, humbling and crushing.

Last week, I was helping with an OB exam.  We got the bedside ultrasound and doppler and were going to do a check for a patient complaining of bleeding and abdominal pain.  We saw the fetus but no heart flutter.  We couldn't find fetal heart tones with the doppler.  Standing there in the darkened room, watching the woman's face strain with the comprehension of the images on the monitor was absolutely crushing.  I can still see her bathed in the light of the LCD panel, eyes widened with fear, tears welling.  It was an awful, awful silence.  At times, I don't know if my heart is large enough for medicine.

The Good
Mostly, though, I get to deal with sick people that can be helped and who's understanding of their body is, let's say, unique.  A couple of days ago, I met with an obese gent who told the female nurse that he had an eye problem that wouldn't clear up.  (It's likely allergies.) When I met with him, he confessed that, although he was too embarrassed to tell her, he was here for a rash on his penis that wouldn't go away.

He'd been to see someone about it before and, when they recommended treatment and another circumcision, immediately considered them a quack.  He was convinced that a salty discharge from was drying the skin on his penis.  Also, he also was certain that his penis was shrinking.  I explained that his recent weight gain likely changed his perception of his penis but it was doubtful that it was going anywhere.  The physical exam showed that he had a infection that likely stemmed from a hygiene problem worsened by extra penile skin.  Another circumcision that completed the job would probably remove the bacterial breeding ground and prevent it from recurring.  As it stands though, treatment with topical and oral anti-fungal meds will likely do the trick for him.  Weight loss will do wonders for his ego ... and ruler.

On Free Lunch and Ethical Comprimise

On my last rotation, drug reps would provide lunch for the office in exchange for a little face time with the doc to discuss their products and garner feedback from the prescribing physicians.  As I was essentially glued to his hip, I attended these lunches also.  The more experienced reps seemed to have an easy-going relationship with the doc: they'd known one another for a long time, they'd talk about the drug, and, thankfully, would intersperse normal conversation.  For many of these, it was informative and beneficial.  Here's new information about a drug, here's a new combination with a synergistic drug, here's some news about pricing or insurance coverage that will help your patients, and ask for information about how the physician prescribes it.  Also, they'd stock the sample shelves.  So, it's a good way to get information.  As a student, it was a great way to learn a little more pharmacology involved in family practice and save some cash on lunch.

Occasionally, however, I'd meet a rep that really made me feel icky, that reminded me of a caricature of a used car salesman.  On one particular day, a slick dressed gent who wasn't particularly humble was pitching his wares and doing his best to sell his drug.  He was trying so damned hard that, at one point, he actually says "Boom!!!  Take that, high blood pressure!" about his drug's ability to lower pressure.

I sat there amazed but thankful for the best catchphrase I'd hear in quite some time.  Personally, I'd love to see it in some ad campaigns.

Boom! Take That, First Rotation!

For most of July, I worked in a Family Practice clinic with a doc who uses OMM (osteopathic manipulative medicine) for some of his patients.  After two years of having my face in a book, it was exhilarating to actually be in a clinic and working with patients.  There were times when I felt like an actual doctor and, as expected, many times when I realized just how little I know.  It seems that most of the patients we saw had the problems you'd expect: diabetes, hypertension, hyperlipidemia.  My doc was a former flight doc and a great guy.  Literally, he'd bound down the hall and into a patient room.  Often, I'd have to run to remain hot on his heels. He taught me a ton and didn't make me feel like an idiot.  Occasionally, I'd do that on my own.

Valsalva and the Fluid in the Ear
One patient came in with a complain of fluid behind her ear.  After taking a brief history, I looked in her ear.  Sure enough, I was able to see a little fluid bubble behind her ear drum.  My doc asked me to have her perform a Valsalva maneuver and see if the tympanic membrane fluttered.  I thought it a little strange but, as I was looking in her ear, I asked her to "bear down" with her abdomen to increase pressure.  She looked at me a little funny.  "Bear down," I repeated.  "Sort of like when you're having a bowel movement."  Her face looked at me with the same confusion that I felt inside.  What the hell does a bowel movement have to do with an eardrum?  Why do a Valsalva for this?  I made eye contact with the doctor who was staring at me like I was a total moron.  As he walked over and took the scope from me, he said to the patient, "Just hold your nose and swallow."
"I didn't know that was also called a Valsalva," I whispered.