Adventures in Gestating

25.5 weeks

I have started to wonder if people are treating me differently as a med student because of my expanding abdomen. Being new to clerkship, I don't know what it is like to be on these rotations without a fetus brewing, so I really can't really judge. But I think it is coming up in more ways than I expected.

In some ways I am think I am pretty fortunate. The nurses seem to be nicer to me. And, while I am in pediatrics, I seem to have a pretty easy time getting a history from some of the mom's. There is that "you're a mom, you know where I am coming from" feeling of sorority. Especially the new moms that are freaked out and worried about their kid but also freaked out and worried that they are freaked out and worried about nothing and wasting your time and you are going to think they are neurotic fools. Or maybe I am projecting a bit.

But there is also the other side. I am not sure if I am getting all the work or opportunities that I might if I wasn't lugging around an extra 30lbs. Are people "going easy on me" at the expense of my education and reducing my chances to make a good impression? To compensate I have become much more of a brown nosing pain in the ass than I would normally be inclined. You know the type - following around the resident and the attending like a bad stench and jumping on any possible case.

I was pretty happy to get out of my teaching half-day early today. Maybe I am back to my old self. :)

Steady as she goes
You might think that I would have lots to blog about. I am now 24 weeks pregnant and into my pediatrics rotation for clerkship. But, things have been pretty uneventful lately. Being at the kid's hospital around some really sick kids for most of the day has caused me to have some pretty reactive emotions, but that was expected. I doubt there is anyone with a heart that could witness a newborn having seizures everyday or a 2 year old that hasn't progressed past the development of a 1-month old and not feel it. But I am sure, with all the hopes and expectations I have for the little one kicking away at my ribs (not to mention the hormones), that I am a little more susceptible to this particular heart break. So I will tell one quick story.

I am on pediatric neurology and last week we diagnosed a 3 week old with tuberous sclerosis. On the scale of things, this wasn't nearly the worst case I saw but the discussion with the parents during which we told them the diagnosis will stay with me for a long time. TS is a disease where you could live your life not even knowing you have it. Or, on the other end of the spectrum, you could be developmentally delayed with behavioural problems and have to struggle your entire life. Given that this child was already having seizures he is probably going to have a harder road than many others. All these parents want, like probably any parent hopes for, is to know that their son is going to be okay. They would like him to be "normal" but, as time went on and they understood the diagnosis better, I think they just wanted to know that they would still have their child, the little boy that they had gotten to know over the past 20+ days.

One more week
My psych rotation ends a week from tomorrow. Most clerkship psychiatry rotations are largely inpatient following a specific staff psychiatrist, but mine has been almost exclusively outpatient. I do assessments on people referred either through their family doc or emergency. We make medication recommendations and then I see them a few more times to do a clumsy attempt at therapy.

This might be appropriate for some people that have short-term crisis-induced problems. But many of the people that come to our service have long standing interpersonal, personality and mental health problems. I feel bad that some of these people wait a month or more to see a psychiatrist, hoping that they will find a way to dig themselves out of an existence that has become painful and hopeless.

And then they end up with me. For a few weeks.

Like baby beluga's mom

I am feeling particularly pregnant today. For the past month or so I have been feeling very good. I had a few rather unpleasant weeks in my first trimester but that passed. Aside from a nearly insatiable thirst and having to buy all new stretchy clothing, all of my pregnancy "symptoms" have been more of a fascination than an annoyance. Today I noticed that I have really slowed down. It took me nearly an hour to pick up groceries this afternoon, waddling down all the aisles and stopping to take my 5 hundredth pee break of the day.

There is an upside to being the size of a marine mammal. I actually had a guy offer me a seat in a crowded downtown coffee shop. A courtesy I thought had passed with cassette tapes. He was done his drink and just sitting there reading, but I was still surprised.

I am just over 21 weeks into my pregnancy, which means I am just over halfway through being an incubator to my peanut. This recent gearing down makes me a little nervous about clerkship for the next four months. I am not sure how four weeks in the ICU will go when I can't stand for more than 20 minutes and I am headed to the washroom at least once an hour. Thankfully my school is being very flexible. The peanut and I will take it as it comes.

Hi from the Peanut


As almost everyone who reads this blog probably already knows, I am expecting my first child in just over 4 months. My husband and I are thrilled and excited but, like most first time parents-to-be I suppose, we are also freaked out, worried and afraid.


I am on my psych rotation presently. This week is my week to be at the kid's hospital for the children and adolescent psych portion of my rotation. There is nothing like hanging out at the kid's hospital to make you acutely aware of how vulnerable children are to all the chemicals, germs, accidents and whims of fate or genes. There just seems to be too many things out there to protect my little peanut from. And plenty that I don't even have a chance against.

I have tried to be a good mother to my parasite so far but, as evidenced by my posting at nearly midnight on a weekday, I haven't been perfect. I feel guilty every time I have pop instead of water or give in to my desire for a bath instead of a shower. I know feeling guilty isn't particularly helpful and I know no parent is perfect. But I also know that, even if I am perfect, there are all sorts of horrible things that could befall my peanut. So isn't my responsibility to make sure he/she has the best chance possible?

My next rotation is pediatrics; three weeks of neurology and then three weeks of general inpatient. I have already warned my husband that there might be a lot of tears coming up.

Night in Emerg
Yesterday I had my busiest night in emergency so far. The department I am doing my elective in is divided into two parts, each with its own staff physician, usually a resident and, lately, me. One part is more ambulatory cases: things like lacerations, minor muscular skeletal, minor abdominal complaints (at least as far as can be determined at triage). The other side gets the more major cases: resuscitation, possible cardiac or stroke, older more complicated patients, people who are likely to be admitted or at least need a consult. I was on the later last night.

So far I have preferred the ambulatory cases. They may be more minor, and sometimes there is nothing that can be done. [Three days of sore throat in a 27 year old without a fever or other sign of systemic disease is going to get a throat swab (at most) and a push out the door.] The only skill needed in those cases is the ability to explain that the need for antibiotics is not proportional to the time spent waiting. But stitching someone up, solving a defined problem in a single shift is satisfying. At least there is resolution.

I have been unlucky on the major side. The cases I have been getting are ill defined, inconclusive and, in many cases, not real (the overdose vs seizure later admitted that they faked the whole thing for a love interest). Last night was busy and I had the real feeling like I was working through medical problems to the benefit of the patient. This is what drew me to emergency in the first place. History - physical exam - differential diagnosis - thoughtful use of tests - diagnosis and plan.

Don't get me wrong. I am not one of those students that prays for a major accident or the acute onset of a dramatic deadly condition just for the sake of my learning, or the adrenalin rush. I would just as soon have your chest pain be some minor angina rather than a dissecting aorta. I don't wish for more sick people in emergency (at least I try not to). But I was starting to get a little sick of the people that were showing up at emergency because they felt that their family physician was not listening to them about the arthritis they have had in their knees for the past 5 years. Especially when it takes 20 or 30 minutes, and three stories about their grandchildren, before they tell me that.

Homeward bound - one more week
(This will have to be a short one because I am running out of battery.)

One week down, one more to go. If it sounds like I am in count down mode that is not a coincidence. After 5 weeks from home I am ready to sleep in my own bed, cook on my own stove (I never realized how much I hate electric), see my cats, walk my neighborhood, go to my favorite restaurants... well you get the idea.

This elective has been fun. The great thing about emergency is that it is always busy and things pass quickly. But between the new place, living in a dorm, and doing shift work I am starting to feel disconnected from my regular life. Some people like the quote that goes something like "you should do something new everyday". I am tired of doing new things. All I do is new things. I want to return to some routine. I need to refind myself in all the familiar comfortable things that I surround myself with at home. Not the least of which being my husband.

Two Down, One to go
Despite my original good intentions I have fallen into my usual negligent pattern of blog posting. In the meantime I have completed two of the three electives I am kicking off clerkship with.

The first was internal medicine in Kingston. For the first week I did emergency consults for the medical teams because my preceptor was away on vacation. You may ask why, for a two week elective, they would place me with a preceptor that was going to be away for a week. That would be a good question, for which I have no good answer. When she returned I was in "general medicine" clinic with my preceptor for the rest of the time. My preceptor is actually an endocrinologist so almost all of her patients have endocrinology issues. I am horrible at endocrinology; I am taking the experience as a learning opportunity that I would normally avoid at all costs. I also got practice at dictation. A skill that has already served me well and is something that I wouldn't have done unless forced.

All things considered, it wasn't the elective I was hoping for but it turned out to be good preparation for my next elective. I practiced a lot of skills: history, consult notes, orders, dictations, clinic notes, presentations.

My next elective was neurology in Toronto. I had a great experience doing my pre-clerkship elective in neurology in Calgary so I was really looking forward to it. I was apprehensive as well. Neurology became my first choice of specialty after the great experience I had in home town (and my psych experience was less than ideal, but we won't talk about that). Between desperately wanting to impress, I was also a little nervous that this elective live up to my expectations. I didn't want a really disappointing experience to cast me into a sea of self doubt and indecision.

I had a good time. It wasn't as much fun as my previous elective in neurology, mostly because I didn't get to see as many patients as I would like. This is a perennial problem in Toronto, which has a reputation for being overrun with trainees at all levels. Despite not being as hands-on as I would have liked, it was a good elective. I enjoyed clinic and inpatient, and I found all the cases really interesting.

Tomorrow I am off to Winnipeg for two weeks in emergency. I am also really looking forward to this elective. But I a have to opposite problem of my last elective. Emergency has been on my list of possible preferred specialties for awhile, but has dropped down to a distant third behind neurology and medicine. My goal is to learn lots, get a good reference letter and have some fun in emergency. But, if I have a really good time, I will be back to not knowing what I should really be putting my effort towards. I can't be really competitive for both neurology and emergency and I really have to make a final-like decision.

Ahh, the self absorbed second guessing and self doubt of a med student. Where would we be without it?

Clerkship day one
I can't say that I was any kind of rising star today; but all in all I am counting it a success. No one died, no one cried. Aside from a brain freeze here or there (what do you call that area that you tap to look for kidney tenderness??) I think I even managed to look slightly less like an idiot by the end of the day than I did at the beginning. I even had a patient compliment me in front of an attending. I can't remember the name of the attending right now, but regardless. Most importantly, I have a couple things to look up to try to look smart tomorrow. Right now though, I think I have earned a nap.

New place, new challenges
I made it to Kingston (Ontario, not the sunshine and rum one). I start my first clerkship elective tomorrow. Aside from being generally assigned to Internal Medicine and a mission to the Undergrad medical office to finish paperwork tomorrow morning, I have no idea what I am doing. I don't just mean that there is so much to know that I am assured to look like an idiot, though that is true too. I mean I don't know where I am going, or who I am working with, or what I am doing. In-patient, out-patient, what clinics. It's a huge mystery. Hopefully it is not too much of a disaster and I will have some time to let you know how it is going.

On another note, it is always interesting to see what differences you notice when you travel. I went on a short hike to the grocery store this evening to get some supplies for tomorrow. Two things that struck me right off the bat:

1. the roads here are completely bare of snow and the sidewalks are a mess. It is obvious that it has snowed here a fair amount and, without friendly Alberta chinooks, it has stuck around. While the streets seem to have been plowed by a magic truck that even scoops out the potholes, there is slush and ice and treachery on every side walk. Maybe there are no old ladies to break their hips here, or may be the students that live in the houses just don't care.

2. milk costs twice as much. I am sure there is some fascinating history about farm legislation and price control but geeze, x 2 seems a bit steep.

There is lots of cool things here too, cute old houses, good restaurants, blah, blah; but that is what I have noticed in my 3 hours stay so far.

No Big News
It is not that there is nothing significant going on, there is lots, but I am not ready to talk about any of the important things things happening in my life. So I will post about blather instead.

My husband went away on a business course this week. I used to think that I was a capable independent woman. I can handle stuff. You stick me in a clinic I have never been in before and put a patient in front of me I can do (in most cases) a decent interview and physical exam, even have a good idea of what might be going on. In a week I am going away to a city I barely know, to a hospital I have never been in to do my first clerkship elective and I will handle it. I am the queen of handling it. At least that is what I thought.

I don't think I take my husband for granted. I thank him all the time for all the stuff he does around the house and tell him how much I appreciate when he listens to me rant about school or traffic or politics.

But he has been away for two days and I am already struggling under no longer being part of a couple. Maybe I am not suppose to say this as someone who thinks of themselves as a feminist, but I really depend on my hubby. After all, does anyone really enjoy doing their own laundry. Now I have to wash the dishes myself after making dinner, and there is no one but me to feed the crying cats at 6 in the morning (don't they realize it is Sunday and I was out till one last night). Division of duties is not just an efficient way to set up an automobile factory, it makes my life a lot easier.

I sure hope he deals better when I am away on electives. I can't actually remember the last time he cooked. I just hope he doesn't starve to death, or give himself liver failure from too much space cheese at Tubby Dog.

Final course
As a second year student (in a three year program) I am in my final course before starting clerkship. Yay!

About 4 more weeks of lecture and small group, and then another few weeks of integrative (a vague, small group, problem based entity) and we will be thrust into pretending to be competent almost-physicians full time.

On another note, I have become unnaturally interested in the American presidential race. I guess I can partially justify all the time I spend checking polls, primary results and pundits overstated opinions with the whole what-happens-in-the-giant-empire-affects-the-mouse argument, or that I am a victim of trends in mass media. That all maybe true, but I tend to view the whole thing as entertainment. The soap opera story lines are riveting, I get the updates in easy to manage 2-3 minute increments and the characters are way more outrageous than anything on Canadian tv or writerless network shows. Or maybe I am just giddy that Bush will eventually, finally be replaced.

Merry Christmas Everyone
Here's hoping everyone has a wonderful and safe holiday season; that you get to enjoy time with people you care about and share joy with all of humanity.

Christmas is coming
We have our tree up and decorated and my husband has pulled out his impressive collection of Christmas carol CDs. So the holiday season is well upon us, irrespective of the fact that we have not yet started the gift hunting or made a card list. As with most things in my life, this is waiting for the completion of our present course and the latest round of exams.

I am having mixed feelings about this holiday. I am very much looking forward to the break. It will be the only one we have until X-mas 2008 and (so far) our social schedule is under control. There will, or course, be the frantic effort to catch up with friends and all the chores we have been all but ignoring but I should still have a little extra time.

So what is the problem? right?

Extra time is a med student's (at least this med student's) greatest enemy. As soon as there is a space in my schedule I think of all sorts of things to fill it with, re-over-commit myself and end up feeling like a failure when I can't get everything crossed off my to-do list. So far, in my 5 days free I have already scheduled 2 days of shadowing, promised to start cleaning out the basement and resolved to get ahead on a research project; this on top of Christmas catchup and chores I mentioned above. I will also, inevitably, spend a morning or two sleeping in, because I have earned it gosh darn it!

So I am setting myself up for regret. My Christmas hang over probably won't have anything to do with eggnog, too many trips to the goodies table or my VISA bill, but instead will live on as a list of unachieved goals that will hang around for a couple months until I finally give up.

What's my pathology
Any time I do a personality test, whether it is that introverted/extroverted/feeling/reasoning test (what is it called?) or a "Are you a bitch or a pushover?" test from a magazine, I always end up somewhere really near the middle. Right in the middle of the square or under the "you know how to make your feelings know without pissing off your coworkers" category. I used to think that it was because I was balanced and mature. Now I am not too sure.

I am starting to think that I fall in the middle because it is the average of a bimodal distribution. I am pulled by two extremes of my personality. Sometimes I wish I was reading the complete works of Shakespeare aloud on the bus. But at the same time I wish I was sensible enough to drink 8 glasses of water and go to the gym for an hour every day. In the end I am neither as eccentric or as practical as I would like to be. I am somewhere right in the middle.

One of our second year courses requires that we do 40 hours of clinical experience and write about some of the cases we see. I chose to do one of my clinical experiences in rural emergency
so I spent this last weekend in a rural emergency. It was great experience. I hesitate to call it fun, but it really was. The town is pretty small but they have a pretty big catchment area so everything from croup to motor vehicle accidents come in on the weekend.

I arrived at the hospital on Friday evening to pick up a key to the student housing. The emergency was pretty quiet at that time so I went to get settled in and find some dinner. When I arrived at the hospital the next morning the big talk was all about a case that came in at about 11pm. Patient came in GCS4, blown pupil, aspirating vomit; with no known cause. And I guess things got worse from there. They had 4 doctors, a resident, a med student, 3 ambulance teams and 4 nurses involved.

I was really jealous. If only I had been there a few hours later.

Usually I can honestly say that I would never wish anything bad to happen just for my own learning sake. But I do really wish I had been there. I think the reason is that the patient has died in every real code I have been involved in. I am about 0 for 5 now. This guy was about as bad as they come and last I heard he was stabilized in ICU in the big city. I guess I want the rush of feeling like I really helped save a life. It may be horrible and selfish but I want someone on the brink to come back for me.

The arrival of Halloween (and Christmas)

I started noticing this week that I am waking up, stepping on the train, walking into the medical faculty, leaving the faculty and coming home, all in near or complete darkness. I am a child of my environment, and this annual inevitability always gets me down. To counter my drop in sunlight induced serotonin I have increased my caffeine intake and returned to yoga. The sum of these factors leaves me tired, jittery and stiff this morning.

Yoga was at our new and shiny fitness facility at the health centre last night. As I left through the large atrium that connects the old and new buildings, I noticed a fluttering, flying animal swooping through the atrium. Sparrows are pretty common self-imposed indoor aviators, but this was larger and creepier. It was a rather angry bat. I thought it was fitting for the season.

This morning I woke again feeling like I had just returned from a trans-oceanic flight and should be asleep for another three hours. After dragging myself through the regular morning routine and checking the temperature (1 degree Celsius; not bad) I stepped outside. Everything was covered in crusty white snow. Merry winter!

I managed to get though Course 5. Course 5 is largely neuro and I have completed a Masters in neuroscience. You might think that this would put me at an advantage, and it probably did. Unfortunately it also gave me a false sense of security. My thesis was on learning and memory, which has almost nothing to do with the neurological diseases we learn about. Three days of studying after skipping most of the lectures, was not enough to feel comfortable with the final exam. Apparently I picked up more than I thought hanging around neuro labs for two years. I passed with no problem.

Now we are in Course 6 - Child and Women's health. A very different course from Neuro and aging. The course is run different, the patients are different, the health care workers are different, the attitude is different. But the most interesting difference to me is how much more opinions, and I would even say politics, play into this course.

All medicine has some aspect of "art" and we can't base everything on evidence, partly because we just don't know enough and partly because we are dealing with individual human beings and each one is unique. But I find it intriguing how often people (everyone from parents, to prenatal course instructors to doctors) argue their medical points about pregnancy and babies based on feelings or their own personal expectations. Maybe it is because everyone seems to have some. You rarely find someone who will tell you "I think you should have a stroke like this", but just about everyone will tell you how they think you should have a baby. And how you are suppose to feel about it.

Of course being pregnant (or being a baby for that matter) isn't a disease. A pregnant lady isn't sick or injured, but she isn't "normal" either. It is an extraordinary thing that happens everyday. It's a cliche but it is a common place miracle; not something you can say about a lot of other areas of medicine.

I am well into the new year. In fact our first big test is bearing down on me with a vengeance. But if that was all I had to worry about I would be happy. We recently received the form to choose our schedules for clerkship. I was pretty proud of myself for narrowing down my prospective specialties to just three (emergency, neurology and internal), until I started to contemplate the possible streams for clerkship.

With only 7 months of clerkship before they cut off our academic records for CARMs applications, strategies to get time in chosen fields but also look good during that time, are high on our minds. And, as they like to remind us as often as possible, our class is much larger than the class ahead of us. This is expected to limit our choices and inevitably lead to disappointment for many. (I am in the combined MD/graduate program so my place in the medical class was held for a year. This refrain of constrained resources particularly raises my ire. If they were going to raise the class size why didn't they make sure they had the capabilities to train everyone first. Instead we get 'your class is much bigger', as if this would explain our compromised education. Gahh!)

I am considering letting emergency slip to a distant third just to dial down the stress intensity. I think I am already well placed for either internal or neuro. I feel very behind for making myself competitive for an emerg spot even though I have done some shadowing, a summer elective (in Nepal) and started a research project in emergency.

There is much to consider and only a week to weigh it. I probably shouldn't devote too much energy to it, though. Since my 'class is much bigger than the class ahead' I probably won't get my choices anyways. I should leave it to fate.

I have finished my medical elective in Nepal. Two more days and I will back on Canadian terra firma. Four weeks went by fast but it has definitely been long enough. I spent three of my four weeks in the emergency department.

Though it is not currently a suggestion that comes up very often, small service charges have previously been proposed in Canada to help solve the problem of our stretched-to-the-limit health services. The theory being that a nominal fee will keep people from going to the doctor unnecessarily and will prompt them to seek out the most appropriate type of healthcare, for example not go to the emergency room when it could wait for a visit to the GP the next day. I have always been opposed, almost reflexively, to this idea. The idea of reaching for your wallet when you get to the doctor's office feels wrong and unCanadian. My experience in Nepal, where people do just that, has demonstrated for me why, even small payments for access to healthcare, are unjustifiable on every level.

The hospital I in which I was located is a not-for-profit hospital in the Kathmandu valley. Because it is a well-respected hospital and the fees are less than many other places, they see many of the poorer people in the area. However, it is in the Kathmandu valley so even the poor people here are better off than others in the remote areas. In the emergency department I saw largely three types of people. The first category were people who had some dramatic acute condition; traffic collisions, workplace accidents, MIs. These people come in and are treated because it is a matter of life and death. If they, or their families, can't pay, they are referred to social work and their fees are waived.

The second group is people that have the money. The fees are low enough that they will make little or no difference in their lifestyle. A chest x-ray is about $3, the price of a nice lunch in a restaurant, so it is no big deal. These are the people that come in when their 2 year old has a low-grade fever and the sniffles for a day; the teenage girl who comes in with menstrual cramps for the past hour. I am not saying that these people do not deserve healthcare, but the emergency room is not the place for it (I believe I mentioned it is cholera season here and the same number of staff has to take care of an extra 20 beds.) However, most of these people seem to have the opinion that they are entitled to complete and immediate attention. It is unusual for someone to wait longer than 30 minutes to see a doctor and if they do there is angry complaining and threats (which I was told are sometimes carried out). In Canada people often wait much longer and, while they are far from happy about it, they accept that the doctors are working away with patients that may be sicker than they are. This type of explanation carries no weight in the hospital I was at. I don't think this difference is due to Canadian politeness or some defect in the Nepali character. I think a big thing that contributes to the outrage from Nepali patients is the cash they handed over to get in the door. The fact that they paid for service means they want to be served and served now. Moreover, they have no compunction in demanding tests or particular treatments. Why not? They are paying for them. It doesn't matter that the chest x-ray for their 2 year old is exposing them to unnecessary radiation or the antibiotics will do them no good, not to mention that they are taking up more of the doctor’s time.

The third category of patients is those that come in because they really really have to. That $3 could be three (or more) days of income for their entire family and they may have to travel a large (i.e. expensive) distance to even get to the hospital. There is an increase in morbidity and mortality from this delay in treatment that only increases the burden on underprivileged families. They have now lost earning potential, especially in the case of long-term disability. But another consequence that I found particularly discouraging is how this emphasizes all other inequalities in society as well. Gender is a big one. Kids too. The sickest cholera patients I saw, the ones that looked like dried up skeletons in renal failure needing an extra dose of luck along with an IV, were young girls from poor families. It seemed to me that people would wait longer to bring in their sick daughters than their sick sons. In economic terms sons are worth more and so it makes sense, on a certain level, that they would be more willing to make the investment. I don't mean to imply that these families are callous or calculating. They are faced with impossible decisions and it is the girls that suffer the most. And don't forget, the people I saw were the ones that made it to the hospital. There are many more that aren't even able to make the choice because they live too far or have too few resources.

It is true that Nepali society is much more stratified than Canadian. The difference between poor and 'middle class' is astronomical. But with wait times and the centralization of services, there are already a number of obstacles to access in Canada as well. There are plenty of families where it is a challenge to make the paycheck stretch across a month of groceries and any extra expenses required sacrifices somewhere else. Putting up any more obstacles for those people disadvantages the most vulnerable and that would as reprehensible in Canada as it is here in Nepal.