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Archive for the ‘Med school’ Category

My Wilderness Medicine elective has officially come to a close. In the last three weeks I’ve experienced three very different environments (alpine, river, and desert) and learned lots of pre-hospital medical care for emergencies that arise in the wilderness.  I have quite a bit to write about, but I liked doing a “pic of the day” for the alpine session, so before I get to a thorough write up of the course I’ll post a “pic of the day” for the river and desert portions.

 

While the course is over, my adventure hasn’t come to an end.  I’m currently taking 2 weeks of vacation time to visit with my best friend, first spending more time in Utah in and around Moab and then heading back to her home in Boulder Colorado.  I hope to get some good writing in during this time… we shall see!

 

Without further ado- “pic of the day” river style!

 

Day 1- We started our adventure at the Sand Wash put in on the Green River where we camped, sans-tent, under the stars…

 

Camping under the stars.

Camping under the stars.

 

Day 2- Over the next 5 days we travelled ~87 miles down the Green River, passing through Desolation Canyon and Gray Canyon.  We saw a few different areas with petroglyphs, presumed to be from Fremont people.

 

Petroglyphs carved into "desert varnish", which according to the river guides (and wikipedia) is at least partially made of manganese.

Petroglyphs carved into “desert varnish”, which according to the river guides (and wikipedia) is at least partially made of manganese.

 

Day 3- Sun rising on the cliffs of Desolation Canyon.  This pic is a bit deceiving, as we actually had more “bad” weather than good.  I suppose we should consider ourselves lucky that we got to experience rain in the desert, but getting hammered with more than a third of the area’s average annual rainfall over 4 days could get a bit demoralizing!

 

A great view by which to enjoy your morning coffee...

The morning view from our campground. A great view by which to enjoy your morning coffee…

 

 

Day 4- Please allow me two pics for this day- I couldn’t chose just one (it would be easy to pick a gorgeous landscape for each day, but there really was a lot more to see).

 

The view from another campground...

The view from another campground…

 

Equipment at an abandoned ranch. During our float down the river we saw abandoned ranches, old mines, and even an old moonshine distillery.

Equipment at an abandoned ranch. During our float down the river we saw abandoned ranches, old mines, and even an old moonshine distillery.

 

 

Day 5- At the end of the day we would gather around a fire recapping the day, telling jokes, and marveling at where we were.  Off the grid, without technology or the distraction of modern society, it was wonderful to decompress.

 

Social gathering place and hot spot for heating evening beverages.

Social gathering place and hot spot for heating evening beverages.

 

Day 6- Our last day of camp was spent just below Rattle Snake Rapids (I loved going to sleep to the sound of rapids).  We were pampered on this portion of the trip, being taken care of by river guides- renaissance men of the modern age.  They’re guides, chefs, handymen, naturalists, historians, and fascinating individuals… I hope to reconnect with some when I return to Moab.

 

The nomadic life, with a new campground each night, was great- especially when gear was being floated down the river and not packed on our back!

The nomadic life, with a new campground each night, was great- especially when gear was being floated down the river and not packed on our back!

 

I’ll post some pics from the desert section when I get a chance!

 

——-

 

And for the skeptics, who question whether there was any medical learning on this trip…

I’ll write more on the medical learning in a future post, but here you can see me rocking an improvised humeral fracture splint… in a torrential downpour (thank goodness for Gortex!)

I’ll write more on the medical learning in a future post, but here you can see me rocking an improvised humeral splint… in a torrential downpour (thank goodness for Gortex!)

 

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If you read my last post, you’ll know that I’m currently away in Utah on a Wilderness Medicine elective.  I’ve just come back from the first evolution, the alpine section, and have one night in Salt Lake City before hitting the road tomorrow morning to head to the Green River and Desolation Canyon to take on the next portion of the course.

 

I certainly don’t have time for a thorough write-up of the last week, but I thought I’d give a quick “pic of the day” from the last week to give you an idea of what I’ve been up to.  The pics certainly can’t show all the learning that’s been going on- while there is certainly a large component of this course that many would consider recreation, I think I’ve learned more practical medical skills in the last week than I have in quite some time.  Sure- I don’t know when I’ll next be using an avalanche beacon or when I’ll next use an ice axe to “self arrest“on the side of a cliff, but the skills of dealing with medical emergencies is non-hospital settings and with limited means is certainly important.

 

Without further ado (and because I don’t have much time…)

 

T-minus 1 day… I went shopping.  I knew I wouldn’t be enthusiastic about much of the food available on our trip, so I packed a significant personal stash to keep me going (I ate more nuts in the last week than I have in the last few months).  I also rented double plastic boots, snowshoes, and an ice axe from REI.

 

Yes- I packed a stick of butter and a jar of coconut oil up the mountain... And if I never eat cold, unseasoned, packages of salmon again, it will be too soon

Yes- I packed a stick of butter and a jar of coconut oil up the mountain… And if I never eat cold, unseasoned packages of salmon again, it will be too soon

 

Day 1- The hike up.  I’ve never hiked in snowshoes with a big pack before, so why not add in dragging a loaded sled to the process! Our group of 20 (12 students, 4 residents, 2 fellows, and 2 attendings) hiked up to our site near Lower Red Pine Lake in the Wasatch Mountains.

Wool was definitely my friend on this trip, starting on day 1. Can you spot the avalanche beacon I'm wearing?

Can you spot the avalanche beacons?

 

Day 2- Water. Our group was broken into 4 teams of students and residents, and each day we had different tasks. On our second day my team was in charge of water, which we filtered from this lake.

It is incredibly peaceful out on the lake pumping water (at least when it was warm enough the water didn't freeze within minutes in the tubing.

It is incredibly peaceful out on the lake pumping water (at least when it was warm enough that the water didn’t freeze almost instantly in the tubing).

 

 

Day 3- Snow.  Yeah… this happened. A good 6” of “dust on crust”.

Fresh pow

Fresh pow

 

Day 4- Home. This tent was my home for 6 days. I shared it with two other medical students, and with overnight temps dipping  into the teens (F) I got very familiar with the workings of my 0o mummy bag.

 

Our camp was quite impressive- 7 tents, a double kiva with dug out benches and tables beneath, and a kitchen dug into the snow pack.

Our camp was quite impressive- 7 tents, a double kiva with dug out benches and tables beneath, and a kitchen dug into the snow pack.

 

 

Day 5- Hike day. On our last full day we hiked up to the ridge leading to the false summit of Pfeifferhorn. The views were stunning.

View

 

Day 6- Out.  This morning we woke at 6 to pack camp and head back to civilization.  My feet won’t miss the heavy double-plastic boots, but I will definitely miss these mountains.

Out

 

I plan to write more about the actual medical aspects of this course, but for now I hope you enjoy these pics!

 

And for those that see the t-shirt picture and think this was a warm-weather hike, this is how I was dressed most mornings in camp.  

 

Cold

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Into the Wild

No- this isn’t another post about books (though I did enjoy the book of this title by Jon Krakauer and I love the soundtrack by Eddie Vedder).  Rather- I wanted to let you all know what I will be up to for the next few weeks.

 

Wilderness Medicine is, well, kind of what it sounds like- providing acute medical care in various outdoor environments.  Being an outdoor person, this was an area of medicine I’ve been rather interested in exploring.  My school doesn’t offer a Wilderness Medicine elective but many schools do, and they generally welcome students from other schools.

 

A number of months ago I set to, looking at a number of Wilderness Medicine electives offered by other schools and organizations.  There are quite a few options, but one, run my U Mass, really caught my eye.

 

I should interject at this point to say that, due to the timing of my PhD defence, I started the clinical years of medical school half a year off schedule with most students. Unfortunately, that meant that when I started looking at wilderness electives, I was a bit behind the eight-ball timing wise.

 

A number of months ago I sent an e-mail to the organizers of the U Mass Wilderness Medicine elective enquiring if they took students from other schools.  They replied, kindly informing that they did but that the course usually fills up a year in advance (and it runs from the end of April for three weeks).  Somewhat disappointed, I set up my schedule for the remainder of fourth-year medical school, sans wilderness medicine elective.

 

Fast forward to three and a half weeks ago when, out of the blue, I got an e-mail from the program coordinator asking me if I was still interested in the Wilderness Medicine elective.  After some frantic shuffling of my schedule I was able to say yes, and have been hustling to get myself prepared ever since.

 

Bags are packed and I'm ready to go (both under 50lbs, though I'm getting close).

Bags are packed and I’m ready to go (both under 50lbs, though I’m getting close).

 

Tomorrow morning I leave New Jersey to head to Salt Lake City (and to think- I was there less than 3 months ago).  After spending a couple days meeting up with friends and seeing the sights of SLC, I meet up with the students, residents, fellows, and faculty who will be participating in the Wilderness Medicine elective.

 

The main reason I was particularly interested in the U Mass elective was because it is a 3 week elective taught almost exclusively IN the wilderness (unlike some other programs that do a lot of classroom-based learning and then have excursions into remote areas).

 

The elective is broken up into 3 components, an alpine section, a river section, and finally a desert section.  In each we receive faculty taught lectures, participate in scenarios, and hear (and give) student lectures (my topic is diarrhea and communicable diseases).  I’ll write more when I return, but this is what I know for now.

 

The alpine section

 

We head up into the Wasatch Mountain range where we set up a base camp that we will be living in for the next 6 days.  We snowshoe in with all our gear (apparently about 50lbs in our packs, plus pulling sleds, and then camp on snow for the next 5 nights.  Here we learn how to live in the alpine environment, the basics of mountaineering, avalanche training, how to lift and move patients with spinal injuries, as well as attend lectures on topics relevant to the alpine environment.

 

The river section

 

After snowshoeing out of the mountains we have a day to recover in Salt Lake City before heading to the Green River for the river section of the course.  Over the next 5 days we raft down the river (camping on the banks each night) and learn about water-associated injuries (drowning, of course), as well as other injuries and illnesses that occur in the bush, including fractures (and improvised splints), dislocations, wilderness dermatology, mammalian injuries, and evacuations.

 

After a transition day in Moab (where we can apparently opt to participate in outdoor activities of our choice, or perhaps enjoy a needed day of R&R), we then head to the desert portion of our course.

 

The desert section

 

Having had a chance to check out Moab, we head to Canyonlands National Park.  Here, we hike into the desert (in smaller groups, so as to decrease our impact), and set up camp for 4 days.  We meet daily for lectures on topics such as snakebites, heat illness and injuries, communicable diseases, wilderness toxicology, and other relevant topics while also learning skills such as orienteering and mass casualty training.

 

Throughout the course, in addition to many lectures, we participate in 12 “scenarios” which further train us for practicing medicine in the wild.  There will be 12 medical students, 4 residents, and 2 Wilderness Medicine fellows, as well as faculty.

 

I’ll be interested to see what happens when it comes to camp dinners.  They asked if anyone had “dietary restrictions”, with a special shout-out to vegetarians.  While I’ll be willing to eat things that I usually don’t consume (rice and beans, for example), I really hope I’ll be able to largely avoid processed foods, grains, and vegetable oils… we shall see.  I’m also a little nervous that I’ll get some foul looks for my choice of footwear.  The packing list suggests bringing hiking boots (or maybe hiking shoes) for the desert and river portion: I have neither, and imagine that trying to get some and break them in would not be a good idea (not to mention that I am kind of opposed to thick soled heavy hiking boots). Instead, I have my minimalist trail running shoes and my vibrams… I’ve climbed a 13er in Colorado with them, hopefully I can hack it carrying a heavy pack!

 

Up Matterhorn in Colorado, happy in my VFFs.

Up Matterhorn in Colorado, happy in my VFFs.

 

So there you have it- starting Monday morning (maybe sooner) I’ll be off the radar for large chunks of time (though you wouldn’t know I was on the radar with the frequency of my blog posts).  When the course is done, my best friend will be picking me up in SLC and I’ll be heading back with her to Colorado for a vacation before coming home to start a radiology elective in June.  On the way back to Colorado we plan to spend a couple days in Arches National Park- since I’m sure my appetite for the outdoors won’t yet be sated.

 

More posts to come!

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There are a lot of smart people who are interested in ancestral and evolutionary health. Personally, I find it very encouraging to see people from various backgrounds thinking deeply about how looking back into human history can help us improve our present-day wellbeing.  These people come from all walks of life and each person has come to this way of thinking by a unique path, but many have similar stories.  Sharing a story breeds camaraderie, and I think part of the reason the “paleo” movement has developed such a strong online community is because of the solidarity that comes from sharing a similar personal journey (that’s not to say there isn’t division and strife in the community- there is plenty!).  Sharing core principles also promotes professional camaraderie. Alas, few of us in the medical profession share an interest in ancestral and evolutionary thinking.

 

I have been very fortunate in my brief clinical experience to have worked alongside and under (medical academics is definitely a hierarchy) people who have indulged me in conversations about how evolutionary and ancestral theories apply to modern medicine. But while some are happy to talk about select topics in ancestral health, few think about it deeply or use ancestral thinking in their medical practice.  There are physicians who think about ancestral health and evolutionary medicine, and I am always enthusiastic (perhaps a little bit too enthusiastic?) to meet and interact with physicians who share my academic interests.

 

As I said above, sharing a journey breeds camaraderie (that definitely seems to be the “word-of-the-post”), and it frequently seems that the tougher the journey, the greater the camaraderie. Medical training is a gauntlet. After an undergraduate degree, medical degree, internship, and residency (to say nothing of longer residencies, an added fellowship, or additional degree(s)), a physician in the US has spent a minimum of 11 years in “higher education” to become a practicing clinician. As I wrote in my last post, “nocturning“, clinical training is physically and mentally exhausting (and decidedly unhealthy). Other allied-health and research professionals also travel long academic roads, and surely the trials and tribulations of the academic journey of each profession fosters camaraderie within each group.  Similarly, for those of us who have achieved a PhD- we may have done research in different labs, under different mentors, and in very different fields, but there is a mutual understanding of what one endures to finally earn those three letters after one’s name.

 

I have been fortunate that I have built some strong personal relationships in the ancestral health community.  One of the first “ancestrally minded” people I met in real life was Dr. Emily Deans– a psychiatrist with a deep interest in the interaction between nutrition and mental health.  While we are separated by some distance, it is good to have a friend who not only shares my passion for ancestral and evolutionary health but who also understands the arduous journey of becoming a physician. In the past couple years I have also met a number of other physicians; first online, and then last August at the Ancestral Health Symposium (AHS) I had the pleasure of meeting many in person.  Less than a year ago, a few likeminded physicians thought it would be beneficial to form an organization for physicians (MDs, DOs, and international equivalents) interested in ancestral health. This idea blossomed at AHS, and in the last few months a meeting was organized to bring such an organization into fruition.

 

This past weekend I travelled to Salt Lake City for the Physicians and Ancestral Health (PAH) Winter Meeting.  Leaving the northeast as a blizzard approached to head to snowy Salt Lake City seemed a bit like jumping “out of the frying-pan and into the crockpot” meteorologically speaking, but personally and professionally the trip was fantastic (and people in Utah seem to handle the snow in stride, quite unlike home in the northeast!).  This was the first official meeting of PAH, and twelve physicians from around the county (and Canada) got together to discuss what we know, what we’d like to know, how to share our information, and what we need to do to grow. We discussed different types of research, the need for more research investigating and supporting an ancestral approach to medicine, and the importance of producing and publishing results.

 

A word on research…  Physicians are not scientists (save for physician scientists, a truly minuscule blip in the Venn diagram of the ancestral health community) and while anecdotes can be powerful, they are not the kind of evidence that will sway physicians, scientists, and practice.  I recognize that as an MD/PhD student I am well positioned to make some waves in this area- I’ll try not to get too overwhelmed by the thought!  Fortunately, there are already some physician scientists producing data and publishing papers, one of whom I got to meet this weekend.

 

I had a bit of fun making a Venn diagram… nothing is to scale, but you get the idea…

 

venn

 

A slightly more amusing diagram might looks something like this… 

 

I highly recommend checking out PhDcomics.com, and “What should we call med school” as well as “What should be call paleo” if you find yourself represented above. (Sorry, I'm not blog-literate enough to hyperlink from the image!)

I highly recommend checking out PhDcomics.com, and “What should we call med school” as well as “What should be call paleo life” if you find yourself represented anywhere above. (Sorry, I’m not blog-literate enough to hyperlink from the image!)

 

In addition to setting up the framework for our nascent organization and discussing how we might foster ancestral-thinking in modern medicine, this meeting was an opportunity to form new friendships and strengthen old ones.  As the lone medical student at the meeting, I felt very fortunate to interact with enthusiastic and supportive physicians from several different fields who all share an interest in ancestral health.  I enjoyed talking about research with Dr. Lynda Frassetto, who’s papers I frequently reference when talking about the benefits of an “ancestral” diet. It was great to get a chance to talk about functional movement with Dr. Jacob Egbert and then go to Ute CrossFit where he led a practical session.  I’m straight out of my Ob/Gyn clerkship, so I loved sharing stories with Dr. Don Wilson, an Ob/Gyn from Canada with first hand knowledge of the health of indigenous First Nation people.  I had the chance to talk about the opportunities I’ll have if I decide to pursue a residency in family medicine with Dr. Rick Henriksen and other family docs.  It wasn’t all a rosy picture (though Rick is nothing if not enthusiastic), but I got a lot of honest and useful information from these physicians. There was also a preponderance of psychiatrists (or is that a contemplation of psychiatrists?), including my good friend Emily Deans, as well as a cardio-thoracic surgeon. I’m glad to have met Dr. Ede, and to have been introduced to her impressive website Diet Diagnosis.  It was also a pleasure to catch up with Dallas Hartwig, from Whole9 Life, who spoke with the group about functional medicine.

 

A nature break- some ancestrally minded physicians snowshoeing in Wasatch National Forest.

A nature break- some ancestrally minded physicians snowshoeing in Wasatch National Forest. From left to right, Polina Sayess, me, Don Wilson, Emily Deans, and Jacob Egbert

 

A lot of knowledge and information was shared this weekend, and I think we all walked away from the weekend with new friendships, a renewed sense of camaraderie with fellow physicians, and thoughts on how we can each do our part to help promote ancestral health.  Personally, I have a number of goals, not all of which I need to share.  I will say, however, that I feel there is a strong need to champion non-nutritional aspect of ancestral and evolutionary health. As the Hartwig’s book beautifully argues- It Starts with Food– but there are many other ways to incorporate ancestral and evolutionary thinking into modern medicine. That is one of my goals on this blog, though of late I have been writing more random ramblings than thoughts on distinct elements of evolutionary medicine.

 

As I officially make the transition from MSIII to MSIV (as of today I have completed all the 3rd year requirements of my medical degree), I hope that I’ll have more time to write about a number of topics in evolutionary medicine. Until then, I appreciate that readers follow along with my random ramblings, and am very glad that there are physicians who share a passion for understanding human health in the context of our evolutionary past.

 

PAH doesn’t have a website up yet, but for more information you can go here.

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I have been a zombie today.

I’ve wanted to write this post all day, but I’ve been spinning my wheels, unable to find the focus to sit and write.

I know where my inability to focus comes from. It’s the same thing that’s been causing my insatiable hunger and serious sweet-tooth.

I had a night shift on Thursday night.

The health industry is notoriously unhealthy. Even during the best of times the medical community tends to get things wrong with seminars on preventative health being coupled with breakfasts that consist of pastries, margarine to schmear on bagels, and fat-free non-dairy creamer to opacify a foul smelling substance that masquerades as coffee.

Practicing medicine is not easy on the body.  Being a doctor is stressful and, of course, spending your days around people who are sick makes you prone to getting sick yourself.  Lack of sleep is another big problem.

Of all the clerkships that medical students rotate through, the surgical ones- surgery and obstetrics/gynecology- have the worst hours. Depending on a school’s program, this is where students first get to experience the joys (by which I mean terrors) of 24+ hour call and “night float”.

At my school, the surgery clerkship has maintained the traditional call schedule (you work a day and then when you’re on call you stay for the night and finally go home the next morning when you are “post call”), while the ob/gyn clerkship has adopted a “night float” schedule for students, where we switch from day service to night service for a few days running during the clerkship.  These two clerkships were separated by 8 months in my schedule, so it’s perhaps hard to accurately compare them.  Nonetheless, I’d like to write about my experience with these two notoriously rough clerkships.

Surgery…

My school still follows a traditional call schedule for students on the surgery clerkship: every 4th or 5th day we would be “on call” after our normal day in the hospital. For the first half of this clerkship I was at a hospital 45 minutes away from my apartment. I was up between 4:25 and 4:30 each morning to be in the hospital by 5:30 to round on my patients before we “ran the list” as a team shortly after 6 and then headed to the OR for the day.

My problems on this clerkship started early. I had just come off my psychiatry clerkship where I’d been enjoying the psyche hours of 9-4… surgery hours were a big change. I couldn’t convince myself to eat breakfast before 4:30 and instead started my mornings with 1 or 2 double-shot espressos before heading to the hospital. The hospital to which I was assigned doesn’t have great quarters for medical students on surgery, so I was left to share a miniscule locker with 3 other students.  We barely had space to store our clothes, let alone space for real food. While there was a residents’ lounge, it was adorned with a large sign warning “Med students- do not leave your shit here”, and we didn’t have access to a fridge or a microwave. Lunch was a hit-or-miss occurrence, and the general mantra for med students during a surgery rotation is “eat when you can, you don’t know when you’ll have the opportunity next.”

Here’s a classic from Whatshouldwecallmedschool

During that first month I subsisted on my morning espressos and my best attempts at healthy snacks- unsweetened banana chips, jerky, nuts, and 85% chocolate. In the evenings I’d eat a proper dinner before putting myself to bed before 9 on most nights. I occasionally managed to make it to the gym, but I tended to feel rather weak and pathetic when I managed to get in a workout. Every 4th or 5th night I was on call, and instead of heading home around 5pm as per usual, I would grab dinner in the hospital cafeteria and see patients in the emergency department and go to the OR for emergency cases.  At some point during the evening (usually between 11pm and 1am) the night resident would tell the med students to retreat to our on-call room for some sleep, promising to page us if anything interesting came through. For me, at that hospital, I was never paged during the night.

My second month of surgery was on the trauma team at our university hospital, which is a level 1 trauma center.  Start time was similar at this hospital, but I was now 25 minutes closer, giving me 25 more blissful minutes of sleep. Also, at school we have a students’ lounge with a fridge and microwave, and I was able to start eating real lunches again. I also had realized that going to the gym in my stressed and sleep-deprived state was doing me no favors so I put my gym membership on hold.  Our call schedule was similar on trauma service, but unlike the general surgery service at a community hospital, the trauma team at our inner-city hospital was constantly getting paged in the wee-hours of the morning. I don’t think I ever got more than 2 hours of sleep when I was on call, and was always woken by the screams of the pager rather than the dulcet tones of my cell phone’s alarm (I occasionally hear a pager with the same ring-tone as the trauma pager and it still sends chills down my spine).

At the first hospital, after being on call, we were usually dismissed after we “ran the list”- frequently being on the way home shortly after 7am. On trauma we would run the list, go to radiology rounds, and then physically round on our patients as a team before being sent home.  Alas, our list of patients grew malignantly during my month of trauma and at one point we had over 30 patients, with some on each floor of the hospital. After a night on trauma I would usually find myself driving home after over 30 hours in the hospital (sometimes with no sleep) willing myself to get home safely (I really didn’t want to end up in the trauma bay as a patient- nothing like the fear of having your classmates cut your clothes off with shears to keep you awake!).

It’s amazing what lack of sleep does… I remember being asked a simple question one post-call morning on rounds and completely drawing a total blank. The funny thing was, it was a simple question that I actually felt very strongly about (Why do so many of our hospitalized patients have messed up electrolyte levels? We do it to them by flooding them with fluids!). Also, despite eating a lot less than I usually do, I definitely put on weight during my surgery clerkship.

Eight months later, as I faced the prospect of another notoriously rough clerkship (ob/gyn), I prepared myself a bit better.  While I was again stationed at the hospital 45 minutes from my apartment, this time I made sure that I ate breakfast before starting each day. I had also weaned myself completely off coffee before the start of the clerkship and never drank more than a single double-shot espresso each morning. I also preemptively put my gym-membership on hold.

We didn’t have call on ob/gyn and instead had a brief stint of “night float”, where we were in the hospital from 7pm-9am for a number of days consecutively.  This is a more realistic experience of life as an intern (with current intern rules), and has the advantage of allowing you to “switch over” from days to nights. I did a bit of research and when I switched over to nights I did a combination of fasting and napping that saw me switch over easily.

During ob/gyn I didn’t have much of a social life- I was going to bed between 8:30 and 9:30 most nights and most of my time was spent in the hospital or sleeping, but all things considered I think I held up very well.  I’ve long liked ending showers with a brief cold-water rinse (I think of it as a healthy bit of hormesis), but during surgery I lost the ability to tolerate cold showers.  Actually the worst part of being “post call” was the dreadful, inescapable cold that would come over me early on the post-call morning.  I’ve always been a warm-handed person, but on surgery I developed cold hands on a regular basis. While my hands weren’t always warm, I didn’t develop terrible chills on ob/gyn.

Med school is, of course, a learning experience, and a big part of the experience is learning what your body can handle and what it can’t (and what you need to do to keep yourself healthy, happy, and sane).  I’m not looking forward to the rough hours of residency, but I know the importance of prioritizing sleep, food, and socialization and I’m learning how to balance these things to keep myself well.

Alas, just after celebrating my successful navigation of ob/gyn (at least on the “feeling good” front, I’m still waiting for grades to be posted), I was knocked almost flat by a night shift on my current EMS elective.  While a night shift is not *required* during this elective it is strongly recommended, and I went out with the night crew on Thursday night to get an idea of what night-life on an ambulance in a rough inner-city is like (short answer- it does not disappoint).  While I was out with a great team and saw some pretty interesting things, I’ve been suffering the consequences since.  On Friday morning I had an insatiable appetite and was battling sugar-cravings (something I don’t usually have) for the rest of the day. Even after getting 11 hours of sleep last night I was still pretty groggy and fairly useless most of today.

There are no more night-shift in my foreseeable future (though I know we’ll meet again during my Emergency Medicine clerkship) and I’m confident that with another good night’s sleep I’ll be back to normal, but this has been a good reminder of just how brutal sleep deprivation can be.  My time with EMS (though only brief) has also reminded me that being in the health profession is often not a healthy practice. The people I’ve been working with sometimes risk their lives to save a stranger, but they also risk their health on a daily basis by living a lifestyle for which our bodies are ill-suited.

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It’s currently the time of year when the Student Affairs personnel at my school people are rallying the troops (third year medical students) to start thinking about what we want to be when we “grow up”. It’s early days yet, but the words “personal statement” seem to inject fear into my classmates. I guess most of them don’t write a blog for a hobby…

 

I haven’t started to write a statement yet, and I’m sure it’ll be an angst filled experience when I finally get down to it, but mulling it over got me thinking back to the personal statement I submitted when I first applied to medical school.

 

I was not a traditional med-school applicant. I was not “pre-med” (a major I would discourage anyone from pursuing) and I had never shadowed a doctor nor shown any interest in a medical profession.  I had a broad interest in all things scientific. I took the MCATs on a dare and did well enough to consider applying to medical school.  My love of science made the MD/PhD route intriguing to me, so I decided that in addition to the PhD programs I was interested in I would also apply to a few MD/PhD programs.

 

A couple weekends ago I was up in Boston and enjoyed a dinner with Kamal Patel of Pain Database and others. It was an enjoyable evening, and while discussing the merits and perils of being a med student I somewhat jokingly suggested to Kamal that I should dig up my old personal statement and post it on my blog.  He thought it seemed like a great idea (surprisingly, alcohol was not involved in this discussion), so now that I’ve had a bit of downtime I’ve dug it up and given it a look over.

 

In hindsight, I seem a little overenthusiastic (so many exclamation points!!!!), but generally I think that my enthusiasm for life is genuine.  One of the closing lines is something that I still deeply believe. In fact, it is a sentiment that comes through in the name of this blog.

 

I believe that the practical application of knowledge is the most rewarding result of study and curiosity.”

 

 

Even 8 (eek!) years ago, I wanted to put principles into practice.

 

Without further ado…

(Unedited, except to abbreviate the names of the professors I worked with)

_____________________________________

 

Until a few years ago I could still see the remnants of my first “experiment” in my garden every spring: red tulips growing along the fence line of the vegetable patch. As long as I can remember, I’ve been asking questions and trying to figure things out. The directions on a pack of tulip bulbs told me to plant them six inches deep, six inches apart. But at five I had to ask… why? Luckily I’ve been blessed with equally inquisitive parents, so my father indulged me, and the next day we were digging holes ranging in depth from one inch to two feet. The next spring I waited expectantly. Somewhat to my disappointment, they all came up! That wasn’t supposed to happen! Only the next year did it become clear that six inches seemed about optimal for a perennial show.

 

My quest for understanding and knowledge through experience has been a lot of fun, taken me many places, and introduced me to many people. As a child I would spend days in the woods and fields around my house exploring and trying to understand nature. When I wasn’t out adventuring, I was home reading books; I was amazed at what there was to learn! When I first started riding horses it was hard to find me away from barns, vet offices, or anywhere else I could learn about horses. While this led me to compete at national quiz competitions, I have most enjoyed becoming a thoroughly knowledgeable horse person. I apply what I know to working with my own horses and those of others, and enjoy teaching and helping local kids and even adults with general equine knowledge and veterinary care.

 

I particularly enjoy teaching others about polocrosse, an exciting combination of polo and lacrosse. I started playing on my first pony, a well-trained, athletic pony that did everything I asked her to do. When it was time for me to get a bigger horse, I looked at a number of horses that were ready to play, but eventually decided to buy a young ex-racehorse with a lot of potential and very little training. At times it was hard to watch my peers get better so quickly on their well-trained horses, and at times I thought I should give in and get a horse that was ready to play, but the challenge excited me, and I stuck with it. After four years of hard work, a lot of sweat, a few falls, and occasional bouts of anguish, I’m proud to play on a horse that I brought to the game on my own, and I know that I am a better rider because of the experience.

 

Now in college, I still can’t learn and do enough. I have joined a number of groups on campus, and am on the executive boards of the campus-wide Programs and Activities Council, the Biochemistry Club, and Alpha Zeta, a co-ed honors/service/social fraternity. Going to a large state school, I have had the opportunity to take a wide range of classes that apply to my major, my interests, and things that just seem neat! During the fall of my freshman year I became SCUBA certified so that I could travel to Little Cayman during the winter break to study coral reefs with a marine geologist. I was so enthusiastic that she invited me to apply for a summer internship studying the reefs around the island. I applied, got the position, and spent two weeks documenting species diversity, morbidity and mortality of coral around the island.

 

A fascination with Moorish architecture and Picasso’s Guernica, and a desire to test my Spanish on its home ground, led me to drag my mother to Spain. My basic grasp of the language and her ability to rent a car made for an incredible trip. For ten days we traveled in the south of Spain, seeing architecture and experiencing the culture. Similarly, a fascination with Guinness Stout, Ireland, and the Irish led me to take a youth-hostelling trip to Dublin. These and other trips have heightened my curiosity and driven my desire to see and experience more of the world.

 

During college, the curiosity that my parents initially encouraged when I was a child developed into a desire to do scientific research. In addition to the coral reef project, I am glad to have had several other exciting research experiences. I was fortunate to receive a Center for Bioinorganic Chemistry summer grant to work in the laboratory of Dr. GZ on the biodegradation of aromatic hydrocarbons by Pseudomonads. Another year I got funding to study the incidence of Lyme disease in mice and their parasites along a rural to urban transact in New Jersey in the laboratory of Dr. MS. I am now conducting my senior thesis work in the toxicology lab of Dr. LW, studying the effects of 2,3,7,8-tetrachlorodibenzo-p–dioxin, an environmental contaminant, on developing fish embryos. The curiosity that once inspired me to plant rows of tulips has brought me to believe that medical science is the most exciting and dynamic field I could hope to enter, yet I am hesitant to devote my life purely to lab work and research. I believe that the practical application of knowledge is the most rewarding result of study and curiosity. I want to enter the medical field to combine my drive to discover and understand with my love of people, and become a doctor working at the frontiers of clinical science.

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When I tell people that I’m interested in evolutionary medicine, I sometimes get the response “Evolutionary medicine? Or the evolution of medicine?”.

 

I’ll admit, I’m actually interested in both, but my interest in Evolutionary Medicine is much stronger than my interest in the history and progression of medicine, though this subject can be rather fascinating.  I’ve listened to a course on the history of medicine, attended some extra lectures, and occasionally pick up a book to indulge this interest, but as a third (soon to be fourth, in 2 weeks!) year medical student, I generally have a hard enough time trying to make sense of our modern medical practices without spending too much time thinking about medical history.

 

Sometimes, however, the evolution of medicine plays out right in front of your eyes.

 

Today I took the end-of-clerkship exam for my obstetrics and gynecology rotation.  I actually enjoyed this clerkship a lot more than I had initially anticipated (a good thing, as I am increasingly thinking that I will pursue a residency in Family Medicine, which includes obstetrics).  I found myself a lot more enthusiastic to go to the OR to scrub in than I was during my surgical clerkship many months ago (it’s amazing what a year of clinical medical education will do to you).

 

This clerkship was split into a number of portions: labor and delivery (L&D), night float, women’s health clinic, maternal-fetal medicine (MFM), reproductive endocrinology and infertility (REI), gynecology, and gynecologic oncology… Quite the smorgasbord! On night float and L&D I would frequently end up in the OR to scrub in on a cesarean delivery, on gyn and gyn onc I was in the OR daily for a range of procedures from small biopsies to extensive tumor staging cases.

 

Major advancements in surgery include the discovery and utilization of anesthesia (Imagine being awake and able to feel everything in surgery! Better not, actually…), and the acceptance of germ theory (for which we should thank John Lister (1827-1912), namesake of Listerine!). Many other discoveries, techniques, and inventions have changed the practice of surgery, but these two are biggies.  The third, looming, problem that needs to be addressed is the perturbation of cytokines during and after surgery, but that is a story for another day!

 

An interesting progression of surgery is the way in which surgeons gain access to the abdomen and pelvis. Traditionally, as one might imagine, the easiest way to visualize and manipulate the internal organs was to do an open procedure, literally cutting a person open to directly access the area to be operated. In the 1980s, gynecologists started to train in a new technique- laparoscopic or “minimally invasive” surgery- in which a small camera is inserted into the abdomen (which has been inflated with an inert gas to create space*) so that surgeons can visualize the internal structures without opening the belly. Instruments can be introduced into the abdomen through small incisions, and organs and instruments can be manipulated inside the body** and visualized on a screen.

 

Initially this technique was used for only very small procedures (such as a tubal ligation, “having your tubes tied”), but as surgeons became more proficient, the complexity of the cases that could be performed in this manner increased.  The utility of this technique was recognized, and in the 1990s, general surgeons started to train in laparoscopic techniques.  Now, many surgeries, both gynecologic and general, are performed laparoscopically (somewhere along the way, urologists started using this technique as well).

 

To be a good laparoscopic surgeon takes a lot of time and training. Cut yourself a 31 or 42 cm stick and imagine trying to do small and precise tasks with the end, which you can only visualize on a screen. Now imagine you have to dissect out delicate pieces of anatomy, correctly identify them, preserve or remove tissue accordingly. As a student on the gynecology service, there was really no reason to scrub into “lap” cases (though they were generally good cases to observe, since the screens make the procedure easy to follow), but on surgery I would sometimes scrub in and occasionally be allowed to steer the camera or “bag” a specimen for removal (really, the resident would drop the sample into the endocatch bag, but they would generally act like it was a great triumph for the student!). It all looks fairly easy until you actually have your hands on the instruments and have to find your way around the belly (or if you’re the med student with the camera, make sure the surgeon is seeing what she wants to see!).

 

Once you are proficient with laparoscopic techniques, there is a lot you can do. One of the fellows on the Trauma service was a specialist with laparoscopic techniques, and he could “run the bowel” (visualize it from end to end) more rapidly laparoscopically than many surgeons could do open.  Getting proficient, however, takes a lot of time, especially if one is to master skills such as laparoscopic suturing.

 

Many gynecological and general procedures are now done using laparoscopic techniques. If you have your gallbladder or appendix removed, it’s likely you will have a “lap-chole” or a “lap-appy”, and the offending part will be removed with only a few small incisions visible.

 

In the last 10 years (I think), there was been “the next step” in laparoscopic surgery… the invention and utilization of a laparoscopic robot.  I should be clear that surgery is still under the control of a surgeon, and no one has “robot surgery”, but the “latest and greatest” (though is it really?) advancement in surgery is “robot assisted laparoscopic surgery”.

 

In robot cases, the abdomen is accessed similar to a traditional laparoscopic case, except the various instruments are subsequently attached to a robot, instead of being wielded by surgeons (though an assistant was needed at the patients side in the cases I saw to swap out instruments and to suction).  Using “the robot” allows surgeons a lot more precision and accuracy, and according to one of the surgeons I observed, you become proficient much more quickly on the robot than you do with traditional laparoscopic techniques.

 

Is it progress? 

 

On my week of gynecology, I witnessed the same surgery (supracervical hysterectomy) done open, laparoscopically, and with a robot-assist.  Some cases, due to the underlying pathology or anatomy, must be done open.   If the uterus is too adherent to other structures or if there might be malignancy that could spread if not removed in one piece, open surgery is probably the best option.  All things being equal, recovery from an open procedure is much longer than for the other options.

 

When it comes to laparoscopic surgery, robotic surgeries can potentially accomplish much finer tasks than general laparoscopy with significantly less blood loss (the robotic hysterectomy that I observed had an estimated blood loss of 20cc- they probably take more at your annual physical).  The laparoscopic case I saw also had minimal blood loss and was accomplished very quickly- the surgeon has decades of practice under his belt.

 

So- is this the evolution of medicine? Will robots fill every OR, and will the best surgeons be those who spent many hours as a child (or as an adult, as often is the case) playing video games? (I had to have a quick google, which resulted in this.).

 

Who am I to say? I’m just a MS3.97 (yes I calculated), with no great knowledge of surgery.  All I can say is that the progression of medicine is amazing.  We (generalists, specialists, surgeons, and other health care practitioners) have amazing technology at our fingertips. We have access to impressive diagnostics, powerful drugs, and amazing technology that allow us to diagnose, treat, and definitively fix disease.  But we must be judicious. Diagnostics and treatments (pharmacologic and surgical) have consequences- some big and some small.

 

Sometimes the question shouldn’t be “what type of surgery”, or “which drug”, but rather “is surgery necessary?” or “how will treatment help” (I don’t think the cases I described above were unnecessary, but Obstetricians/gynecologists, because of the horrible state of medical-legal affairs, often seem to err on the side of doing too much and/or acting very quickly).  We can do amazing things with medicine. Contrary to how this may sound, I’m not acquiring medical knowledge with no intent of using it. Rather, I think that those with medical knowledge have a responsibility to help patients decide what is the best option for them– physically and personally. At least that’s the kind of doctor I want to be…

 

But hey- we have some pretty cool tools out there to help us when we need them!

 

courtesy of wikicommons

A surgical robot- Courtesy of wikicommons

 

*It’s amazing how laparoscopy can pervert your perception of anatomy. When the abdomen is pumped full of gas it looks like organs are flopping around with lots of space, when in reality everything is rather tightly packed during day-to-day living.

** I write abdomen or “belly”, but I generally mean abdomen and/or pelvis.

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