A Day in the Life of a Surgery Med Student on Overnight Call:

4:25 AM - BEEP BEEP BEEP.  *snooze*
4:30 AM - BEEP BEEP BEEP.  stumble out of bed, try not to wake up hubby.  assemble all items needed for the next 30 hours, including money / food for the next 4-5 meals
5:00 AM - leave for hospital
5:40 AM - park, go to call room, deposit belongings
5:45 AM - meet for rounds.  round on patients with appendicitis, gallbladder problems, intestinal obstructions, abscesses, etc. with the surgery team.  Accidentally get in the way of the attending and fellows.  Apologize profusely.
7:00 AM - review important x-rays and CT scans with the team
7:30 AM - scrub into first surgery
7:40 AM - realize you forgot to pee before scrubbing into first surgery
1:30 PM - finish first surgery. run frantically to bathroom, then to call room for 20 minutes of lunch and not standing on feet
1:50 PM - scrub into next surgery.  get asked numerous questions such as "between what 2 layers of the abdominal wall is Camper's fascia found?"  Get numerous questions wrong.  Attending rolls eyes at dumb medical student.  Apologize profusely.  Make note to read about that topic once you get home.
3:30 PM - scrub into next surgery.  try to take suture scissors off of tool table and get yelled at by scrub tech.  Apologize profusely.
5:00 PM - meet with team for afternoon rounds
6:30 PM - begin checking in on patients who had surgery that day
6:45 PM - first consult.  ER is requesting that surgery team come to evaluate a patient with a burn / distended belly / child abuse suspicion.  Repeat 7-8 times in rapid succession.  Includes poking at children's bellies, screaming babies, asking about poop color, cutting through burn blisters, and trying to make children stay in C-spine collars because of a neck injury.  Consume a Cliff bar at some point.
11:30 PM - finish last consult for the time being, and resume post-op checks on patients who had surgery that day.  get angry looks from parents because you are waking their child up at 11:30 PM.  Apologize profusely.
12:15 AM - try to think of a way to sneakily ask resident if you can go lie down for a few hours without looking lazy.
12:20 AM - give up on the not looking lazy part and ask resident if you can go lie down for a few hours.  Apologize profusely as you slink away.
2:30 AM - TRAUMA STAT TO THE ER!!!  run run run downstairs, prevent death, stabilize patient, write trauma note.
3:15 AM - return to sleep
3:45 AM - wake up. start recording vital signs in preparation for morning rounds.  add the 7-8 consults to the list of patients on surgery service.
5:30 AM - pre-round on patients with the resident
6:00 AM - meet team for morning rounds.  get in trouble for not asking appendicitis patient if he threw up.  Apologize profusely.
7:30 AM - finish rounds.  leave hospital.  try to drive home without falling asleep.
9:00 AM - arrive home.  pull out textbook to read about the question you got wrong in the OR.  fall asleep immediately.

Repeat overnight call every 4 days, for 6-8 weeks.  Shifts in between overnight call are 10-14 hours.  Good gracious I cannot wait until I am on the 9-5 schedule of primary care.

Pathology

Well, we got the pathology results back.  And surprise surprise, it is about as bad as it could be.  12 lymph nodes were positive, the tumor returned in a multitude of places in the bladder, it also spread out all the way through the bladder wall at the site of the original large tumor so that my dad was upstaged from T2b to T3, there was residual cancer at the right ureter margin, and, he also happened to have prostate cancer.

Damn.

These results, particularly the 12 positive lymph nodes, mean the cancer is more likely than not swimming freely through my dad's body.  If it hasn't implanted somewhere else already, it very, very likely will sometime in the near future.  However, the surgeon and my dad's other physicians are not ready to give up hope, which is reassuring to some extent.  The next step is to get him enrolled in a clinical trial - frustrating because nothing has been proven to work for this kind of cancer at this point - these trials are just tests to see if something new works - and he only has a 50-50 chance of getting treatment since the trials are placebo-controlled.

So... we will hope to get into a trial, and hope that the cancer never shows up anywhere else.  The surgeon said that even though the right ureter margin was positive for CIS, risk of recurrence in the upper tract is only 2-4%, and if it happens is usually 5-7 years later, so no additional surgical treatment is needed for the ureter (unlike in breast cancer, where if the margins are positive for cancer they just go back in and cut out a larger area around it).

I had a good cry on the phone to Josh about it - he is in Utah for a few more days.  My parents came home from Chicago today, we're all kind of stunned I guess you could say.  I really appreciate all the offers of help and support that are flowing in, but really there is not much that anyone - including me - can do.  It is good to receive little notes of encouragement, and to know people are praying for my dad and for my family.  It is kind of amusing to me that I am supposed to be studying with all of this going on.

One thing that has been odd or interesting for me during all this tumult is that my faith has remained completely unshaken.  I have not questioned God or His role in all this, or grown angry towards Him.  Perhaps that time will come later, if my dad passes, but I have watched several people die, patients whose care I have been involved in, including children and babies.  Upon watching the light of the soul pass out of their eyes as their last breath was breathed, I found no place for anger or doubt in God's plan.  I know 100% that death is a natural end to life, and I believe that it allows us to return to God's presence, that our spirits pass on to some kind of existence that also intertwines with this world.  So I am not angry at God to think that my dad might die.  We are all supposed to die, and though my father's death may come earlier than any of us would hope, I know there is no answer to "why," and I know it would turn me bitter and terribly sad to start walking down that path of questions.  Instead, I have actually found more comfort than usual when I have spent time in reading my scriptures.  I believe that death must come to us all, and that God's role in death is to serve as a great comforter to those left behind when it happens.

Cancer

At the request of several friends... this post is all about my dad's cancer and how it has been affecting me.  It’s rather long but it says everything that I’ve been carrying around for several weeks now.

This is what I wrote in my journal in early April, when we first learned that the chemo had not worked and the cancer had spread:

Okay.  We finally got the news we have all been dreading.  The cancer has spread.  We are still learning some of the details but my dad’s prognosis basically just dropped off a cliff.

I feel tired.  Tired thinking of the discussions with doctors ahead, tired when I think of the talking with my family and trying to work out the weird dynamic of such a poor prognosis hanging over the dinner table, tired when I think of the dozens of hours of lecture that I am behind in reviewing, tired when I think about going home to our little apartment and trying to sleep and lying awake wondering what things will be like over the next few months.  I feel tired.  Can I possibly summon the energy to struggle through such devastating information?  It would be so much easier to just not.  I feel tired knowing my dad will work through it all in his head and then not want to talk much about it with anyone including mom, tired thinking how my mom takes so long to make a decision and will ask me whether she should come to which appointments, tired making those decisions for me and everybody else sometimes.  Tired thinking about how 14, 17, and 21-year-old siblings will take it, tired thinking about the long hours of studying for boards and 3^rd year rotations ahead of me.  Maybe I can find some hole to crawl into for the next 6 months, just hide under the covers for half a year, and eventually come out and everything will have worked itself out.

I talked with Dean Goldberg today because I needed someone to talk to as soon as I found out, and Josh was at work.  She said one day at a time.  Have no regrets – about time spent with your dad, not about stuff like school.  She said we are flexible, we’ll change your exams around if need be, but you make the decisions you need to make in terms of being with your family.  She said don’t try to be too strong, let your emotions show.  I wonder if I even have any emotions left.  I feel like they’ve been wrung out of me by this crazy stressful second year of medical school, by the drive of pushing myself to excel for the last 18 years of being in school, by sitting in class for 8 hours a day and learning about terrible awful diseases that rip lives and families and people apart and only take 2 PowerPoint slides to cover before we’re on to the next one, then spending 4-5 hours each night trying to learn all the clinical facts and pathology and forgetting about the families and the feelings before it starts over again the next day.

I feel like I don’t really care about anything right now.  Just tired.

Depressing, right?  Well, I made it through.  We had a whirlwind of a time – the doctor we were working with, when he saw the chemo hadn’t worked, said my dad needed “immediate” surgery.  Unfortunately he didn’t have any time open in his OR for almost a month and a half.  We started asking around at other places, and MD Anderson told us if the chemo hadn’t worked and there was now lymph node involvement, then basically we had no hope and should not even attempt surgery; maybe a salvage chemo or hospice care would be more up our alley.  Which threw us for a loop obviously.  But only one other doctor said anything similar, and 5-6 experts in the field all recommended immediate surgery as my dad’s only chance.  And fortunately, a surgeon – one of the very best in the field – in Chicago happened to have a slot open in his OR a week later.  We took it.  So I rushed to finish my final exams – four 3-4-hour exams in a 30-hour period, with 2.5 hours of sleep to go on – and then flew immediately to Chicago 2 hours after I finished.

My husband took me to Dulles airport, dropped me off, and I went down to security.  A cocky-looking TSA guy – you know, one of those guys who might have been cool in high school but is now like 37 and still has slicked-back hair covered in gel – took my boarding pass and looked at it and kinda looked me up and down and said, “What airport are you supposed to be at?”  I just stared at him.  “You’re at the wrong airport, honey.”  “Nope, no, no way, no I’m not, I can’t be.  NO.”  “Yup.”  I tore apart my bag in the middle of the security line looking for my phone to check the email to confirm.  He kept asking me to move out of the way “honey,” but I couldn’t really give a crap at that moment about anyone around me, sorry.  Yup, wrong airport.  He was still holding my boarding pass and kind of laughing so I snatched it out of his hand and ran upstairs to the ticket counter, hoping there was some flight I could get on to Chicago.  Meanwhile calling my husband over and over, but it was a beautiful evening and he probably had the windows down and the radio on, so he didn’t realize I was trying to call till about 45 minutes later.  The girl in front of me in line went up to the counter and I overheard that she had done the EXACT same thing as me!  Same flight and everything!!!  The ticket lady said she couldn’t do anything, so I went up to the girl and said, “Look, I’m on your flight too – want to split a taxi?”  We ran out and got a cab to Reagan airport – about 40 minutes away.  In the cab I was kind of freaking out and she kinda told me to calm down – I (gently) let her know she had NO IDEA what was going on – that I had just taken 4 exams and hadn’t slept and HAD to get to Chicago tonight because my dad was having major cancer surgery in the morning.  She then agreed I needed to make my flight and started urging the cab driver on with me.  She had to check a bag; I had just carry-ons – but somehow we both MADE IT on our flight!!!!!  Gah.  That was one of the most heart-stopping experiences in my life.

The surgery went very well.  It started 2.5 hours late, and then my dad was in recovery till about 11 PM that day, making for a 16-hour day at the hospital for us, but for once in this whole cancer journey something finally didn’t take the worst possible route.  My mom and I spent every day in my dad’s hospital room, retiring at night to a friary nearby – we had somehow found a group of charitable monks who had guest rooms and were able to host us during our crisis and last-minute travel to Chicago.  They are some of the most kind-hearted men I have ever met in my life, ranging in age from 20-something to 85.  I’m pretty sure God placed them there to help us at this time.

The recovery was mostly smooth – my dad was walking the next day after the surgery!  He got one unit of blood transfused, and was on a steady morphine drip that made for quite hilarious conversations.  Mostly consisting of him waking up for 8 seconds at a time, making some angry proclamation about why he was still in this hospital bed, then promptly falling asleep mid-sentence.  He had leg squeezers to help prevent clots, and a breathy-puffer machine he was supposed to breathe deeply into in order to avoid pneumonia.  I’m sure those devices have medical terms of some sort that I am supposed to know.  There were only 2 complications to the recovery – first, once my dad was discharged, the 2 tubes that were left in to drain his neobladder (formed from a loop of intestine, which produces mucus) both clogged with mucus, leaving no escape for the urine.  There was a mad dash to the hospital and a resident was able to get everything unclogged.  The other complication was my dad’s excessive crankiness.  Which of course I totally understand, no one wants to outlive their bladder or have a catheter for 2-3 weeks or undergo a massive surgery – but I think my mom took the brunt of the displaced frustration.  Fortunately she shrugged it off and has been doing an excellent job as caretaker.  Now all we can do is wait for the pathology results to come back.

I am back home in DC, staying at my parents’ house while my parents are in Chicago as my dad continues to recover.  They should be coming home soon.  In the meantime I have been trying to balance the 10 hours a day I am supposed to be studying for boards with the responsibilities of a mother of 3, as I have 3 younger siblings at home.  True, the youngest is 14, so they’re all able to mostly take care of things, but things have been complicated by the abrupt breakdown of my brother’s car, and the absence of my husband as he is in Utah for 10 days for a long-planned family trip.  My schedule mostly consists of waking up at 6 to take my brother to the bus stop for school, trying to study for a couple of hours, driving down to Arlington to feed my cat (who I would bring to my parents’ house if he didn’t get panic attacks whenever we try to move him, to the point that he literally poos himself and hyperventilates to the point that he covers himself in drool, which when combined with the feces makes for a really terrible experience all around) then come home and pick up my brother from the bus, then try to study until someone pops their head in saying they need a ride somewhere, then getting home and realizing I’ve only studied 4 hours today, and trying to convince myself to study a couple more hours till 11 PM, and then waking up at 6 and starting over.  Plus doing laundry, housework, calling my parents daily for updates, trying to get my brother’s car fixed, etc.  Tell you what, I have gained a SERIOUS appreciation for people who attend medical school and also have kids.  I really have no idea how it could be done without outside help.

I am so glad I made it through the last 2 weeks – I was not sure it was going to happen.  Hopefully things will return to more of a normal pace after my parents and husband get home, and I can get back on track with studying for boards.  The outpouring of kindness from my friends and family, as well as from people in my parents’ ward, has been absolutely incredible.  I received more emails and notes of kindness during finals than I could possibly answer, and the support really gave me the strength to tough it out during this crazy, crazy time.  Thank you everyone reading this for all the love you’ve sent me and my family.

life changes and happiness

I came home from school 4.5 hours ago, convinced I was going to study my head off.  I've gotten through half a lecture, it's just not happening tonight!  I was reflecting on old facebook photos (deep and profound, I know), and realized how much my life has changed over the past few years.

There's a lot I miss.  I miss snowboarding 3-4 days a week, I miss landing tricks on my wakeboard in the summertime, I miss rock climbing, I miss dodgeball on Wednesday nights from midnight-2AM at the old church building by Helaman Halls freshman year of college.  I miss having a job that brought home a paycheck every other week.  I miss my dreadlocks, I miss long drives in my Jeep wrangler, I miss torn blue jeans.  I miss playing the drums, I miss rock music, I miss hackysack and Chipotle with my high school band.

But I've gained so much more!  I love my husband.  The very best thing that has ever happened to me was meeting him.  I love our little beat up Honda Civic that we haven't washed since we bought it two years ago, and that leaks oil like crazy.  I love learning how the human body works, hearing how bacteria and diseases assault it, and equipping myself with the tools to go out and stop those things from happening.  I love hugging patients, I love translating for people when they come to the doctor.  I love medical school.  I love racquetball with my husband on Saturdays.  I love country music.  I love the piano, and hymns on Sunday mornings.  I love opera.  I love walking with my husband every morning.  I love finishing exams.  I love sleep like I've never loved it before, because you appreciate things more when they are hard to come by!  I love my family, and I love spending time with them, especially as recent events have shown me that such time really is more limited than you think.

So I've traded my sporty-hippie-rocker lifestyle for an incredible marriage and medical school, the challenge and reward of a lifetime.  And you know what?  I am as happy now as I was then.

Foodster

Some people LOVE food. They watch the Food Network passionately, turn giddy at the prospect of going to the grocery store, and spend hours happily and furiously cooking away in the kitchen, ending up with some magnificent and delicious dish. The joy of a complicated culinary achievement, especially one of their own creation, is one of their greatest pleasures in life.

I am not one of these people. To me, food is a necessity rather than a pleasure. Of course there are foods I like, and I get cravings, but in general I could live happily on fruit and cold cereal. Sometimes when my husband and I were dating, I would cook for him, which could be nice if I didn't set it on fire. But I don't get much out of purchasing or preparing or eating incredibly well-prepared food. In fact, I DID live happily on fruit and cold cereal, with the occasional pop-tart thrown in, for all 4 years of college. Then I married my husband.

My husband IS one of these people. His favorite time of day is when "America's Test Kitchen" is on and he can watch it. He thrills at the prospect of grocery shopping, especially once he reaches the fine cheeses section. He spends hours in the kitchen, and emerges with incredible and fantastic dishes that even I confess are really astoundingly yummy.

I am grateful for this arrangement. Because the kitchen has never drawn me, most of my attempts at cooking end up disastrous. I am one of few people you may meet who has set spaghetti on fire. I was unsettled as our marriage neared, because I knew that I could not cook a delicious meal for my husband 9 times out of 10 if my life (or marriage) depended on it. What an embarrassment of a Mormon wife I would be!!! But it has worked out great - he would rather be the one cooking anyway, and I get to branch out of my breakfast-food-diet. I think he likes it too, because I never ask to be taken to fancy restaurants. Don't get me wrong, I appreciate the romantic atmosphere of sharing an exquisite 3-course meal with the love of my life. But I'd prefer a date to Taco Bell or Chipotle over fancy food any day.

Med Student Syndrome

There exists a phenomenon called "medical student syndrome," where when a medical student learns about a rare disease, they become convinced that they suffer from it, because they share some of the same symptoms at times. This may happen to the student over and over again throughout the course of their medical education. There is another condition called "conversion disorder," where psychological stress manifests itself as real symptoms, such as pain or paralysis, experienced by the patient with no obvious physical cause.

I'm pretty sure I have some strange combination of these two disorders. Rather than learn about a disease and think I have it because I've experienced those symptoms in the past, I actually start getting the symptoms of whatever we are learning about. These symptoms are real, and usually scare me to death. I had severe chest pain radiating into my left arm when we were studying the cardiovascular system and heart attacks. I had several bouts of acute, 20-minute losses of vision when we were learning about ophthalmology. I was awakened from sleep by a sudden, strong pain and swelling in my leg the night after we learned about deep venous thrombosis. And so on.

My policy has become this: do nothing, unless the symptoms don't stop once we've finished the unit we are learning. Every one of these bouts of symptoms I have had have cleared up as soon as I finished studying that medical topic. Weird, huh? I wonder if this just happens to me or whether it's more common among my peers than I realize.

Dying

I'm reading a book called Final Exam; it's a memoir by a surgeon detailing her journey towards her understanding of death as she went through medical school and became a doctor. It's bringing back several memories, some of which I already wrote about in my Haiti journal, but I felt like re-visiting them here.

I have already been the one to pronounce a patient dead. It was in the back of a pickup truck in Haiti; they rolled in with a man unconscious in back and we're not sure when his heart had stopped beating. A nurse took charge and jumped in with me, and we starting doing CPR, while the American doctor came and tried to feel for pulses. Nothing, nothing. The nurse and I switched off, and every now and then we would pause so one of us could listen for a heartbeat. The most unnerving sound I have ever heard in my life was when I placed my stethoscope on a man's chest and heard - nothing. So we go back to CPR, and after about 15 minutes the doctor catches my eye and says, "Do you want to call it?" I kind of looked at him and then back at this man lying in the dirty bed of a pickup truck, eyes closed, mouth open, and I said, "yes." The nurse stated the time and someone wrote it down, and that was that - the first time I pronounced another human being dead. It didn't really feel weird at the time; I mean, dead is dead, and I was just saying what the facts were. But now reading her book I realize that was a big moment, a really big step for me, and a really saddening one too.

I'm not going to pretend that seeing several people die in Haiti did not affect me. Watching the man who had been shot through the groin as his breathing stopped and his heart monitor all of a sudden went flat; seeing his wife's eyes fly open and hearing her soul burst into a wailing mourning piercing shriek - I'm not going to pretend that didn't send chills down my spine. I still can see the eyes of the 16-year-old girl gasping for breath as she looked up into my eyes as she died of tuberculosis; I'm not going to pretend it doesn't disturb me. I don't understand death yet, and I'm still afraid of it.

There was a woman working with us in Haiti, a respiratory therapist, who noticed me the first time I saw someone die. She must have seen me go pale, or my eyes open up wide, or heard my breathing stop, or whatever I did. I don't remember exactly what she said. I do remember that it was incredibly tender. I don't remember what she said, but I know I was comforted, and I knew it was going to be okay. I'm glad she was there to help me in that moment of complete helplessness and confusion, and I hope I will be able to continue to progress in my understanding of this scary, peaceful, incomprehensible event of death that will be such a huge part of my profession.