First off, I apologize for ending a post title with a preposition. Using "for which" just sounds so pretentious and, let's be realistic - this is a blog.
The lecture's subject was sudden death in athletes, specifically from cardiac causes. If you've read my prior entry involving the subject, you'll understand why I wanted to attend this lecture so badly. After finishing a quick one hour on the topic, I think that my thoughts and feelings describe a lot about how medical school can be.
It's odd to break something so personally important into an hour-long lecture. If you consider the precise cause of my friend's death (congenital hypertrophic cardiomyopathy - HCM), we only really spent about 10 minutes on it. Most of my thoughts were confirmed - there was probably no way to know beforehand. I thought that the lecture would be somehow vindicating, that I was on a path to righting this wrong.
The talk was actually somewhat depressing. At our current level of medical knowledge, it can best be summed up as "sometimes, shit happens". He had never complained of any symptoms, so why put an extremely healthy 21 year old through an EKG and echocardiogram? No family history even remotely suggestive of a congenital heart condition - no drownings, no fatal car wrecks, etc.
The other sad fact was that this lecture, so important to me, was "just another lecture". Minutes later, we were on to another pathology and hours later I was on another topic altogether. As much as I would love to pour myself into this disease, there isn't that much medical science to know and I have to spend my time on other topics. I learned the clinical basics and know how to recognize a possible HCM and I know about the most common treatments. I know the genetic defects (as if that helps) and the pathophysiology - that is "the disease" in detail.
I think my problem is a contradiction of ideals. I spend my time worrying about getting the science down 100%. Once I learn how to resuscitate a kid that shows up with EMS in v-tach or asystole, then I'll worry about how to tell the parents that there was nothing we could do. I believe in the physician as the scientist, a clinical being that doesn't allow emotions to cloud his or her judgment. If I didn't, I would push for every sports physical to include an EKG and echo. So I'm caught in the middle - wanting to do more, but knowing there's nothing more I can do.
For now, I can only keep doing what I'm doing - learning. A few days ago I was on my way to see a patient with an unstable cardiac rhythm. When I say "see a patient", please know that I mean literally just watching a competent physician at work. Walking to the room, I realized just how unprepared I would be if the patient coded. It was a moment of humility, it reminded me of just how little I know. It was also oddly comforting - I remembered that I don't know how to do 99% of what I'll end up doing as a physician. Best of all, I can continue working on that 1% as hard as I can - there's plenty of time for the rest.
Wednesday, March 11, 2009
Sunday, October 5, 2008
Flaws
I was just walking through the hospital cafeteria after stealing an hour away from science to enjoy a quiet meal with a book (reading for fun). For a first year med student, it's a very strange thing to see a patient outside of an examination room. We have worked quite hard at developing this mask of professionalism, despite the fact that it still feels so odd to us. Personally, I work with a neurosurgeon that specializes in brain tumors. His visits often involve bad news and, despite the fact that sometimes I don't know it's coming, I like to think I don't flinch when someone responds to the news that they're going to die.
But there he was, sitting with his wonderful wife, just enjoying a light meal and discussing the VP debate. They were lovely people and he had been through a terrible time with cancer. They listening intently during the physician's explanation and the wife took notes, clarifying every time she didn't get something. This wasn't a pair of millionaires with a team of specialists across the country, they were regular people making the best of a bad situation.
When we caught eyes, I'm not sure if he immediately recognized me. One of the few rules I know is that you tell someone everything they need to know before breaking the big news to them - they glaze over as soon as they find out. I think that remembering the face of the med student sitting in the room probably goes along with that, but I digress.
I looked into his eyes and thought about his disease. I knew, from a biological perspective, his greatest flaw - for no other reason than to learn. I can only imagine what it's like to have others know about something so intimate, so personal. The easy example is erectile dysfunction - something you would never tell anyone you knew, but gladly offer up to a physician in a routine examination.
We are exposed to people's flaws, literally the biological errors occurring in their bodies. I have seen the inside of this man's brain and the tumor it maliciously supports. Be it the cafeteria, the grocery store, or the mall - we will see people whom we have more information about than most of their family members. Flaws include so much more than disease - a standard history includes drug and alcohol use, psychiatric issues, and sexual activity. If you cheat on your wife, it's extremely relevant. If you sneak out back for a smoke every day, it's extremely relevant.
At this point in my medical career, I consider it an amazing gift. I cannot meaningfully contribute to patient care, yet these people share with me. We all have flaws - deficiencies, mistakes, and errors. We get depressed, we use drugs and alcohol, we cheat, we lie. Our cells do the same - they stop growing (atrophy), they secrete drugs (paraneoplasm), they cheat (grow without waiting for signals), and they lie (breaking promises about cell checkpoints). Whether they be macroscopic or microscopic, we all have flaws. I sometimes wonder how honest I would be about my own flaws if a patient asked, let alone my own physician.
We cannot escape these flaws, we can only share them in hopes of fixing them.
But there he was, sitting with his wonderful wife, just enjoying a light meal and discussing the VP debate. They were lovely people and he had been through a terrible time with cancer. They listening intently during the physician's explanation and the wife took notes, clarifying every time she didn't get something. This wasn't a pair of millionaires with a team of specialists across the country, they were regular people making the best of a bad situation.
When we caught eyes, I'm not sure if he immediately recognized me. One of the few rules I know is that you tell someone everything they need to know before breaking the big news to them - they glaze over as soon as they find out. I think that remembering the face of the med student sitting in the room probably goes along with that, but I digress.
I looked into his eyes and thought about his disease. I knew, from a biological perspective, his greatest flaw - for no other reason than to learn. I can only imagine what it's like to have others know about something so intimate, so personal. The easy example is erectile dysfunction - something you would never tell anyone you knew, but gladly offer up to a physician in a routine examination.
We are exposed to people's flaws, literally the biological errors occurring in their bodies. I have seen the inside of this man's brain and the tumor it maliciously supports. Be it the cafeteria, the grocery store, or the mall - we will see people whom we have more information about than most of their family members. Flaws include so much more than disease - a standard history includes drug and alcohol use, psychiatric issues, and sexual activity. If you cheat on your wife, it's extremely relevant. If you sneak out back for a smoke every day, it's extremely relevant.
At this point in my medical career, I consider it an amazing gift. I cannot meaningfully contribute to patient care, yet these people share with me. We all have flaws - deficiencies, mistakes, and errors. We get depressed, we use drugs and alcohol, we cheat, we lie. Our cells do the same - they stop growing (atrophy), they secrete drugs (paraneoplasm), they cheat (grow without waiting for signals), and they lie (breaking promises about cell checkpoints). Whether they be macroscopic or microscopic, we all have flaws. I sometimes wonder how honest I would be about my own flaws if a patient asked, let alone my own physician.
We cannot escape these flaws, we can only share them in hopes of fixing them.
Sunday, September 28, 2008
Robbins Doesn't Tell the Whole Story
I was reading through prostate pathology in Robbins tonight and took pause after reading a few interesting facts. I know someone that survived what can only be described as a death sentence - in layman's terms, pretty much the worst prostate cancer you can have (Gleason 5+5, T4N1). This guy is, by no means, a terrible person - but he wasn't winning any kindness awards. But, as I said, he survived. The relevant Robbins quote:
"Any spread of tumor the lymph nodes, regardless of extent, is eventually associated with a fatal outcome, such that the staging system merely records the presence or absence of this finding as N0/N1."
I then thought of some other cases where people weren't so lucky. In my humble opinion, they got screwed. You'll hear about them again - they're not just 3 cases to me, they're friends.
A young football player feels a nagging pain in his thigh. Fast forward a few months and he's staring at an oncologist telling him he has a Ewing's Sarcoma (rare tumor with an incidence of 4.6 per 1,000,000 in the US). It's in his bones and lungs. If it was just in his lungs, that'd be the best prognosis possible. If it was just in his bones, that wouldn't be as good as just lungs, but still not the worst case scenario. Nope, he has it in his lungs and bones - the worst prognostic category. He's the type of kid that lights up a room, everyone's best friend, just the last person this should happen to. He died two years later at the age of 15. We were still in high school. Today I feel lucky that, at the time, I didn't comprehend the true magnitude of the tragedy.
Another young athlete is running on a treadmill at the gym. He's trying to stay in shape - he was an all-state swimmer in high school, but school and a job at a law firm keep him pretty busy these days. He has been dating a lovely girl since high school. Now in their senior year, they're planning to get engaged after he graduates. I met him at orientation before college started. We were friends for the next four years - he wouldn't hurt a fly. But, karma be damned, he passes out while running. His heart was out of rhythm, due to a congenital malformation of the musculature in his heart (congenital hypertrophic cardiomyopathy). He was pronounced later that afternoon at the age of 21. His death shook all of us up - he didn't see it coming, we didn't see it coming - it's probably not even possible that he could have known. He was just such a great guy. It shouldn't have happened. If people like this are the ones not making it, what does that leave for the rest of us?
Last, but certainly not least, a young woman volunteers to be designated driver for a friend as they go out for the night. On the way home, they're hit by a drunk driver. If it wasn't such a disgusting use of the term, I'd call the event ironic. Her friend awakens to the jaws of life pulling her from the wreckage. They extricate the driver's friend first. Aside from a concussion, the friend only has some bumps and bruises. But no good deed goes unpunished. In a particularly violent car wreck, the massive forces of impact can push the heart downwards, however the aorta is secured in place. This causes the aorta to transect. Of all the amazing things that the aorta does, I would argue that the most important thing it does is bring blood to your brain. Oxygenated blood sustains the neurons in your brain, keeping alive the cells that make you . . . well, you. I suppose it makes me feel slightly better to know she wasn't awake and didn't know that any of this had happened. Her chest was filling with blood, stealing beat after beat of life sustaining fluid. It was robbing her brain while simultaneously punishing her lungs with pressure as the cavity filled. She died that night, she never had a chance. She lived next door to me, we had started dating a few months before the accident. I still remember a shaky voice on the other end of the phone trying to explain to me what had happened - I couldn't comprehend what "we lost her" meant.
There are so many things that bother me about this. I can't help but ask myself why. An old man comes in and gets a terminal tumor diagnosis and is cancer free 5 years later. Three wonderful young people die in an instant, seemingly with no rhyme or reason. Their deaths were probably not even preventable - hypertrophic cardiomyopathy is tough to screen for in healthy kids, the driver in the car wreck didn't have any known underlying vascular pathologies, Ewing's Sarcoma is a random mistake in cell division that just happens. Part of it is feeling powerless. As I continue to learn more and more medicine, I continue to realize how hopeless these cases were. Metastatic Ewing's Sarcoma has a survival rate of less than 10%. Aortic transection has a mortality of 98%.
These three cases played into my decision to go to medical school, but they weren't the whole story. Call it what you want - god, fate, ying & yang, or just dumb luck. If there is some form of guiding principles controlling our day to day lives, I definitely don't think they merit worship.
So, naturally, we ask ourselves - what can we do? We can continue to sacrifice every day and night with our faces stuck in a book. We can read, re-read, practice, and study. We can spend our weekends and vacations in lab, trying to push back the frontiers of medical therapy. We can try to learn every disease, every therapy. We can memorize resuscitation algorithms and chemotherapy cocktails. We can promise ourselves never to miss this disease or that one, but we will.
We will fail, from time to time. We will fail because there are people we can't save, we will fail because we're human. We will fail and people will die. We'll have to watch the boyfriend crumple to a heap, we'll have to help parents say goodbye to their dying son, we'll have to tell a family that there was nothing we could do.
So we again ask ourselves, what can we do? The best answer I have come up with is to keep caring. We can work ourselves to exhaustion and learn every medical fact that is known. But when we're playing against a loaded deck, the only thing we have left is to care.
"Any spread of tumor the lymph nodes, regardless of extent, is eventually associated with a fatal outcome, such that the staging system merely records the presence or absence of this finding as N0/N1."
I then thought of some other cases where people weren't so lucky. In my humble opinion, they got screwed. You'll hear about them again - they're not just 3 cases to me, they're friends.
A young football player feels a nagging pain in his thigh. Fast forward a few months and he's staring at an oncologist telling him he has a Ewing's Sarcoma (rare tumor with an incidence of 4.6 per 1,000,000 in the US). It's in his bones and lungs. If it was just in his lungs, that'd be the best prognosis possible. If it was just in his bones, that wouldn't be as good as just lungs, but still not the worst case scenario. Nope, he has it in his lungs and bones - the worst prognostic category. He's the type of kid that lights up a room, everyone's best friend, just the last person this should happen to. He died two years later at the age of 15. We were still in high school. Today I feel lucky that, at the time, I didn't comprehend the true magnitude of the tragedy.
Another young athlete is running on a treadmill at the gym. He's trying to stay in shape - he was an all-state swimmer in high school, but school and a job at a law firm keep him pretty busy these days. He has been dating a lovely girl since high school. Now in their senior year, they're planning to get engaged after he graduates. I met him at orientation before college started. We were friends for the next four years - he wouldn't hurt a fly. But, karma be damned, he passes out while running. His heart was out of rhythm, due to a congenital malformation of the musculature in his heart (congenital hypertrophic cardiomyopathy). He was pronounced later that afternoon at the age of 21. His death shook all of us up - he didn't see it coming, we didn't see it coming - it's probably not even possible that he could have known. He was just such a great guy. It shouldn't have happened. If people like this are the ones not making it, what does that leave for the rest of us?
Last, but certainly not least, a young woman volunteers to be designated driver for a friend as they go out for the night. On the way home, they're hit by a drunk driver. If it wasn't such a disgusting use of the term, I'd call the event ironic. Her friend awakens to the jaws of life pulling her from the wreckage. They extricate the driver's friend first. Aside from a concussion, the friend only has some bumps and bruises. But no good deed goes unpunished. In a particularly violent car wreck, the massive forces of impact can push the heart downwards, however the aorta is secured in place. This causes the aorta to transect. Of all the amazing things that the aorta does, I would argue that the most important thing it does is bring blood to your brain. Oxygenated blood sustains the neurons in your brain, keeping alive the cells that make you . . . well, you. I suppose it makes me feel slightly better to know she wasn't awake and didn't know that any of this had happened. Her chest was filling with blood, stealing beat after beat of life sustaining fluid. It was robbing her brain while simultaneously punishing her lungs with pressure as the cavity filled. She died that night, she never had a chance. She lived next door to me, we had started dating a few months before the accident. I still remember a shaky voice on the other end of the phone trying to explain to me what had happened - I couldn't comprehend what "we lost her" meant.
There are so many things that bother me about this. I can't help but ask myself why. An old man comes in and gets a terminal tumor diagnosis and is cancer free 5 years later. Three wonderful young people die in an instant, seemingly with no rhyme or reason. Their deaths were probably not even preventable - hypertrophic cardiomyopathy is tough to screen for in healthy kids, the driver in the car wreck didn't have any known underlying vascular pathologies, Ewing's Sarcoma is a random mistake in cell division that just happens. Part of it is feeling powerless. As I continue to learn more and more medicine, I continue to realize how hopeless these cases were. Metastatic Ewing's Sarcoma has a survival rate of less than 10%. Aortic transection has a mortality of 98%.
These three cases played into my decision to go to medical school, but they weren't the whole story. Call it what you want - god, fate, ying & yang, or just dumb luck. If there is some form of guiding principles controlling our day to day lives, I definitely don't think they merit worship.
So, naturally, we ask ourselves - what can we do? We can continue to sacrifice every day and night with our faces stuck in a book. We can read, re-read, practice, and study. We can spend our weekends and vacations in lab, trying to push back the frontiers of medical therapy. We can try to learn every disease, every therapy. We can memorize resuscitation algorithms and chemotherapy cocktails. We can promise ourselves never to miss this disease or that one, but we will.
We will fail, from time to time. We will fail because there are people we can't save, we will fail because we're human. We will fail and people will die. We'll have to watch the boyfriend crumple to a heap, we'll have to help parents say goodbye to their dying son, we'll have to tell a family that there was nothing we could do.
So we again ask ourselves, what can we do? The best answer I have come up with is to keep caring. We can work ourselves to exhaustion and learn every medical fact that is known. But when we're playing against a loaded deck, the only thing we have left is to care.
Wednesday, July 16, 2008
First Post
I doubt you arrived at this page unless you know me or were searching for the blog of a med student. I'll keep the first post short & sweet.
I'm currently a first year medical student (that's M1 for those who haven't had the pleasure) in the US. I'm starting this blog to keep people updated, rant/rave/whine/bitch, and create some form of an online journal. Keep up with the acronyms and internet memes and you'll be just fine.
I'm currently a first year medical student (that's M1 for those who haven't had the pleasure) in the US. I'm starting this blog to keep people updated, rant/rave/whine/bitch, and create some form of an online journal. Keep up with the acronyms and internet memes and you'll be just fine.
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