The singular of feces

I was told today on surgery service that the singular of feces is "fex," but I didn't really buy it, and now that I look in to it, Wiki is telling me that in Latin, faeces is the plural of faex (with the a and e stuck together in that weird letter) but that there is no singular in English, making "feces" a plurale tantum (more Latin), like scissors and pants. (Pants!) Also, "fex" is not in the Scrabble dictionary, though "fedex" is. That made me like the Scrabble dictionary less.

But what does all of this have to do with medical school and its not being so bad? Well, one question is whether I correct them on this fex issue. Surgeons are the correctors, not the correctees. Though this is not about to turn into an anti-surgeon rant. I really like the people I'm working with. They are surprisingly supportive even though I am a certifiable moronic waste of space. They still try to sell me on surgery a little bit even though I can't comprehend why they would want to encourage someone as dense as I seem to go anywhere near their profession. Before you all start saying, "I'm sure you're not being that stupid," check it. When asked where the tip of a PICC line sits, I answered... the stomach. That is amazingly fundamentally wrong. Instructively, my first instinctual impulse answer was the correct one: in the superior vena cava. Specifically the caval-atrial junction. But I talked myself out of this because I couldn't wrap my head around the fact that we feed people through these lines. We put TPN (total parenteral nutrition) into people's hearts? But yeah, we do. Many questions, I psych myself out of the right answer. I assume that I don't know. I'm hoping to move out of that mindset because a surprising amount of the time, I do know. But yeah, stomach. I may not live that one down.

I did my very first stitches on a real human today, sewing the incision made to remove a lipoma. It's not easy wielding that needle driver and the pickups, very awkward, like doing everything left-handed. Practice. But I appreciated being allowed to try. I thank the patient for her extra minutes under anesthesia for my learning. The pros did everything cosmetic, I promise!

Bowel is pretty amazing to touch and watch peristalsising. It's like an alive sausage casing. I had to put my whole hand in our patient's abdominal cavity today, and her organs were so warm! That surprised me, though it makes sense. Just an unexpected sensation. But I saw all those abdominal organs for the first time today: liver, spleen, gall bladder (very small), stomach, duodenum, pancreas. So much better than anatomy lab.

I'm suddenly overly tired. I'm sure I felt inspired and grateful today. I did. Zonk.

Live from 15 Long

It's Friday night! I have definitely never woken up at 5 a.m. and still been awake at 1 a.m. -- and still goin'. I'm definitely starting to get loopy. The best analogy I've come up with is an intercontinental plane flight. Cooped up, needing to hydrate, wanting a backrub, and willing the hours to advance. But there are four women on the labor board, and one just delivered, so it will likely be an eventful night. I'm trying to space out my snacks.

The two deliveries I've seen today have been stark contrasts. This morning, she was having a very difficult labor, unmedicated for a while, pushing like crazy and making no progress, partially because the baby was "OP" (code for "occiput posterior," better known as "sunny side up"). When they tried to flip the baby over, they felt the pulsatile cord out through the cervix ahead of the baby = prolapsed cord = obstetric emergency = crash C section. One minute we're in the labor room chillin' with the doulas, the next, residents are scrubbed and she's getting sliced. The time from detection of the cord prolapse to delivery was probably 10 minutes, and let's not forget this is surgery, people. The doctor who detected the problem never took her hand out of the woman's vagina as she got wheeled into the OR on her bed; she kept feeling the cord to monitor the fetal heartbeat.

When it was over, I cried. In the work room, not the OR, but still, my first tears of the year and certainly not my last. My classmate Chris, the midwife Susan, and the intern Melissa were all so nice about it. It just happened so fast, and I still find surgery traumatic. I had to keep telling myself that mom and baby were happy and healthy. I did like that the chief resident said to her as the emergency wheels went into motion, "You're in a very safe place." It was true -- they can totally handle that situation -- but it felt very scary to me. I saw her and her baby this evening, and they seemed so relaxed and content, no one would ever guess things had been so crazy. So that's a good reminder: People, even littles, are resilient.

So then this last woman made it look easy. She had an epidural and pushed maybe five times and poof! Here's your little boy. Her stomach went back to totally flat like immediately. She barely tore at all. I swear she could walk out of here right now.

I can't wait to sleep all day and all night tomorrow sleep sleep sleep I love sleep!

Brain dead

Today I am most inspired by the woman police officer in China who breastfed babies orphaned in the earthquake. I've been seeing women breastfeed their own babies on the ward, but it's another level to give of her body that way.

I'm super grateful that I'm working overnight Friday instead of Saturday so that I won't be a complete zombie for Scott's birthday on Sunday. A real stroke of scheduling luck. I wonder what it will be like to stay contained in that world for so long. I'll probably report from the trenches tomorrow night. I told Scott I feel like I'm going backpacking or something.

I am surprised by how big a Fallopian tube is. That egg really has some diameter to travel in. And the fimbrae are very cool structures, feathery fingers to sweep that ovum up. Surgery still really trips me out. It's amazing how little blood our patient lost during her tubal ligation, probably only like 30 mL.

It's dinner time.

Welcome to life as humans on earth

I got to actually catch a baby today! Beautiful little MZ. It has surprised me how slowly they emerge, even when the head is already halfway out. Though people talk about them shooting out sometimes, so I guess I can't base everything on the whopping two vaginal deliveries I've seen. I felt sad about how long she was taken away from her parents to be weighed and footprinted and banded. Can't that stuff wait? Her first half hour in the world, and she's lying by herself. I wanted to zerbert her, but I don't think people would be cool with that.

The little C-sectioned munchkin born yesterday now has a name, and she's going to be my pediatric patient with Dr. Miller. I met her big brother today, too, just one year old. He's not so sure about her yet. They are a great family, very happy and open. I feel honored that I saw her enter this life and that I'll get to follow along her path this year.

I've changed my daily questions, by the way. People agree with me that "moved" and "inspired" are too similar, so I'm combining them and adding "gratitude." I feel grateful for a lot today, especially to Judith the midwife for involving me in the labor and allowing me to do things. Of course, it was the laboring woman who really allowed me, so deep thanks to her too. I'm also grateful for Anna in PISCES with me for support and understanding.

Amid the general inspiration of birth, a small detail from today sticks out. MZ's mini pinky finger is crooked in the same way as her dad's. His has been that way since birth. The moment he noticed it, he realized she really came from him, too. The dads get so marginalized during labor, important accessories but accessories. Their shared "flaw," against her perfect perfection -- it got him. (And me.)

Tale of two deliveries

Yep, watched two babies enter our crazy world today. One emerged the old-fashioned way, down the shoot of his momma's vagina. And the other was not, according to Shakespeare, technically "of woman born," but rather "ripp'd" from the womb in a C-section. 15 Long is one technologized labor and delivery floor, they kid us not. Every single laboring woman had an epidural and a pitosin drip. (Pitosin, affectionately known as "pit," is a synthetic version of our endogenous oxytocin, which drives contractions. Personally, I think nipple stimulation is a much more pleasant way to achieve a similar effect.) I was thinking a lot about what Stan Grof and many others write about the inherent trauma of birth, being expelled from safe, serene environs out into the cold bright air amid squeezing and pain... I could see that it might be therapeutic and powerful to reenact it later.

Anyway, I was surprised how shell-shocked I was after the C-section. During my first OR experience, the hysterectomy, I was nervous and amazed and kind of giddy after. But something about cutting down to the baby and having it whisked away, then touching the woman's uterus after it had been hoisted completely out of her abdomen , with the woman conscious on the other side of the drape all the while, somehow added up to an unsettled feeling. I felt sad that the mom had to stay to be sewn up as her baby went to the nursery. It's also crazy how fast time passes in the OR. It feels like half an hour, but it's two.

I was moved by the care one woman's family was giving her as she labored. When I met her earlier in the day, a guided imagery relaxation CD was playing -- nice! The room was all aromatherapized and shit. (Sorry, I've been watching too much of The Wire, and I start talking like that.) Her mom brought this big ol' mirror to hold up at the big moment so that the woman could see her baby being born. Unfortunately, that moment seemed far off when I left, though she had been pushing for close to six hours.

I was almost too stunned to feel the full awe-inspiring weight of the first vaginal delivery. It was beautiful that they flopped him right on his momma's chest when he came out, and the dad cut the cord. (The cord is weird, dude! Rubbery and kind of spiraled.) Even though we had to sew up the mom and deliver her placenta, she could have cared less. She was bleeding quite a bit still but completely immersed in her baby.

An amazing, overwhelming day. Getting up at 5 every morning hasn't been too bad, but it's only been two days.

A special shout-out to Julia tonight -- I hope she gets good solid peaceful sleep tonight, Boards Eve. I know down to my core that she will prevail.

Labor of love

First day on Ob/Gyn inpatient, but no deliveries. It'll happen sometime this week, for sure. Probably the coolest thing I saw was a "version," where they medically relaxed the uterus and then flipped a breech baby around, by sheer brute force, I'm telling you. No one thought it was really going to work. We were all in the OR all ready to rock the C-section, but that mom is probably laboring away at the moment. It surprised us all.

I was inspired that a woman who lost custody of three children because of substance abuse was now having a fourth child after seven years sober. People really do turn their lives around.

I was moved, once again, by my classmate Chris's life story. He's on service with me this week, and the attending asked us both what we did before medical school. (Apparently, we both look our thirty-something ages.) Chris dropped out of high school at 16 to work and help support his family in Turlock. Yeeeeears later, after working mainly as an electrician, he went back to community college, on to UCSC, and now to UCSF. I can almost guarantee he is the only high school dropout currently on doctor track. He's even considering psych!

Gotta be up early, so it's closing in on bedtime for me here at 8:55. Woowee wild times!

fragment

I was very surprised to essentially be tutored by Dr. West in the ER all day. My tuition was really worth every penny, a six-hour running education dialog, the most practical stuff, hand-feeding my brain tasty medical nugs. I dressed a neck abscess that grew out, guess who, MRSA! Our pal. The docs don't bat an eyelash; apparently the stuff is our dominant SF flora.

Also today, the 16-year-old Spanish speaking pregnant diabetic I was following found out that her fetus had "demised." (I'm sorry to call her by her age/language/disease, just trying to be HIPPA compliant.) Ay ay ay, poor sweetie. It was a strange combo of the practitioners feeling sort of, dare I say, relieved? And of course really empathizing with her.

Hello goodbye

This is an entry where my writing seems inadequate, and I don't feel I'm doing anything close to justice to the topic. I wish I could work on this a lot before posting it. But I'll capture the immediate thoughts from my time at the Women's Options Clinic today.

I was moved to see fetal parts in the tissue from a 12-week-gestation abortion. I touched the spinal cord with my gloved finger. The leg looked like one of those milagro arms, if anyone knows what I'm talking about, but even smaller, shrinkydinked. I wanted to cry for a second, but I wasn't sad. I felt that Shiva energy, the shadow power, and it shook me like a rattle. Seeing the fetus completely dismembered put me in touch with the violent therapeutic force applied. But then seeing something so small, miniature, invokes a wanting to protect, that affinity for cute -- in a context of blood and gore. Since I obviously don't do the procedure, I held the woman's hand, and from now on I will also do an internal memorial for the spirit that slips out of this world before it enters it. If I worked in an abortion clinic, I would want to do some type of service for the fetuses, the way Jette's hospice group did for their patients who passed away, even though the idea somehow starts sounding like something anti-choicers would do, a theatrical mass funeral.

I also got in touch with the awe of embryos and fetuses in general, how one cell contains the knowledge to divide and organize itself into this perfect structure, create complex, perfect form from almost nothing. The depth of that wonder is one of those automatic mind blower, degrees of magnitude larger than our capacity to comprehend.

I deeply respect abortion providers in so many ways, one of which is their openness about feelings that are non-peachy. It inspires me that they acknowledge the grotesque aspect of the work, and that their belief in the necessity of providing the service is so strong it can outweigh the very real personal difficulty. Because right, seeing a miniscule thorax is disturbing, but the woman did not want to be a mother. I have asked Julia if I can be a psychiatrist and also be trained to do abortions, and though she thinks I might be the first to do so, it could maybe be arranged. And then we can take our biodiesel abortionmobile to all of the unserved NorCal counties.

It surprised me how hot it was when I walked out of the ER tonight. Heat wave!

General Hospital

My first evening of family medicine with Dr. Shore was low-key but still exciting. Dr. Shore is from the Healer's Art camp of docs, attending regular Finding Meaning in Medicine sessions at Dr. Remen's house and everything. I told him about this blog, and he pointed to the same three questions written on his chalkboard. I think it will be a great year together. Not to mention he is the adviser of all the PISCES advisers, along with being my adviser. Score.

I interviewed a Vietnamese-speaking patient using the video translation service, which worked surprisingly well. What a life saver! And great application of technology. My first abdominal pain patient, but definitely not my last.

I was inspired by the beautiful AIDS memorial garden outside of building 80 at SF General. Roses, poppies, borage, smells and colors. I was moved by Dr. Shore's ease discussing the emotional side of medicine and medical training, and how he valued my input on that topic. I was also moved when we went to see one of his patients in the hospital how relieved and happy the man was to see a familiar, caring face. I was surprised by how much the hospital/clinic resembles a prison. Security guards, bullet-proof plastic, concrete. Unfortunately necessary, I guess. I was also surprised to hear that the San Francisco Health Plan is being challenged in court by small businesses.

Thank goodness I partied in Mexico for a while

Seriously, how could I have known that goofing off, barely working, and having fun would help me so much in my career? Today, once again, was all about hablaring. My newest patient is a 16-year-old diabetic girl from Ukiah who is 9 weeks pregnant and speaks only Spanish. I was inspired to see her baby's heartbeat on the ultrasound -- sure a cheesy moment to pick from the day, but that was my first live US ever, and it really is amazing. I was there for her first pelvic exam, poor sweetie, and she was very brave. They were so overwhelmed by information and scared about possible complications. The docs don't seem very confident in her, but I think she's going to step up.

In other teen news, I was moved by two sisters at peds clinic this morning who were the antithesis of the adolescent reputation, being conscientious, responsible, and receptive to adult input. And man, Dr. Miller really is a pro with the kiddos, firm yet friendly. She's had so many of her patients since birth; I remember from my interview day how her office walls are plastered with patient photos. Amazingly, she didn't make me wear my white coat today! After all our battles over that issue... It was cool to finally see her in clinical action. I swear they should really integrate clinical work into all four years of medical school; we had just token experiences, but it is so much better to have context! Not that I'm the first to say it. I heard that there are PISCES-esque models being developed that span the whole education. Hallelujah.

Hm, what surprised me... Surprised how freaking windy it gets on this hill. And by how thoroughly bored I am by epidemiological lectures and their graphs. I hate graphs. Boiling the complexity of life into a line. I was thinking that about EKGs, too, how the heart is so nonlinear, yet we make it spit out this single line. To be fair, we derive a lot of information from that line. Blathering today! What surprised me is supposed to be something more positive, but you know, I was talking to Ali today, and I think it can be just as unhealthy to be unduly positive about things that actually suck. Parts of this year will be crappy, and I don't have to dress it up with unflagging optimism. I've spent a lot of the last two weeks thinking about all the careers I should have pursued instead...

Especially because I didn't have as much fun at psych clinic yesterday as I had hoped. The offices are shoeboxes with bad paint, carpet, and wall treatments. And it's so about meds. The gratification of this path is just SO AMAZINGLY DELAYED, it pains me. The day that I'm really presenting at the psychedelic conference in Basel about MDMA and PTSD or doing dialectical behavior therapy (and/orthobionomy) with my borderline patients or tending my medicinal herbal garden in far NorCal is so amazingly far away. In the meantime, I have to do small amounts of what truly makes me happy and sustains me, as much as I can. This is a low point in many ways: the work so much harder and more time intensive, the goal not much closer. But getting closer every day, I guess.

MTF isn't "male to female" in the ED

It's "metabolize to freedom," meaning let the excessively inebriated sleep it off.

Day 1 in emergency was as expected: action packed. The early morning included some unexpected learning about mathematical functions and linguistic theory from some cuckoo-headed attending, attempting to penetrate my "false consciousness" and convince me that all medical records should be written accordingn to a strict template. I picked up my first Spanish-speaking patient, a beautiful 84-year-old woman from El Salvador. Say a few words in semi-competent espanol, and people are your new best friends, I swear.

I was surprised to hear "Dr. Brown to the clerks desk" on the overhead paging system and suddenly realizing they were talking to me. (Of course, it was because I hadn't written down which leg I wanted them to x-ray. Riiiiiiiiight.)

I was moved by a little boy I met whose dad was being treated. The kid had spent the first year of his life hospitalized at Parnassus for hypoplastic left heart syndrome. (He was born essentially without half of his heart.) Couldn't tell to look at him today.

I'm not sure I was inspired today. Maybe, to repeat, by the magic that happens when a provider can speak the language of the patient.

Narrative medicine

Today I met my medicine preceptor, and he reminded me why I love Brits: They are infused with literary-ness and see the stories in life. He's one of those clinicians who think you can diagnose pretty much everything by observing the patient and taking a detailed history, a philosophy I share. He wants my presentations to him to be narrative and engaging. "We're called attendings because we have a short attention span."

My other favorite quote of his was, "All my patients get better sugars in Hawaii." Meaning their diabetes somehow miraculously gets better when they're relaxing and swimming in the ocean. The vacation treatment, love it.

Today I was surprised to see a clinician actually take a blood pressure by palpation before doing it by auscultation. Miraculous.

I was moved by a five-year-old dumpling of a boy named Vincent who came to his dad's appointment and proclaimed, "He smokes even though I tell him not to."

I was inspired to hear that Dr. Masharani endorses fish oil. (But Kristin, he sends people to Trader Joe's for it. I gotta get him on Minami.) He also is researching chromium and alpha-lipoic acid in diabetes treatment. Go go complementary and alternative medicine!

I have patients!

In PISCES, we recruit a panel of patients that we follow throughout the year, and I landed my first two today! Both are wonderful women and very complicated medical cases, pregnancy + diabetes + other chronic diseases. I could spend all weekend reading about them.

I felt a "transverse" fetus in his/her mother's uterus today. (The little bug is sideways in there.) I was surprised that I could distinguish the head from the booty.

I was also surprised that I have been able to get up at 5:30 two whole days in a row.

I was moved by how responsibly many of the diabetic patients keep track of their meals, carbs, and sugar readings. I can't even record my spending for half a day.

I was inspired that the dietician at this clinic had written a user-friendly, comprehensive book about diabetes management through nutrition and exercise. Nice! Diabetes Type 2: Complete Food Management Program