As we walked, they told me “it’s a 9-1-1.”  I had no idea what that meant, but later learned this is the term for any delivery that was unplanned.  Usually the pediatrics team doesn’t go to full-term, vaginal deliveries.  We are called at all C-sections, premature births, or when the baby might be in distress.

This time it was a premature vaginal delivery.  We rushed into the delivery room, and I was surprised to feel the mood change immediately.  Birth is so intense, and this delivery had gone fast.  The lights were dim and yellow, like a glowing fire.  The head was already out, and seconds after we arrived, the baby was placed on the warming table.  The residents were still scrambling to turn on the oxygen and suction dials on the wall.

There in front of us was baby, covered with white cream and smears of blood.  A 6-inch umbilical cord hung from him, and looked like part of a jelly-fish.  He looked up with big, blinking eyes.  I was frozen… WOW!

The residents immediately started rubbing him, squeezing his umbilical cord to take his pulse, listening to his heart, suctioning him, and then giving oxygen with a positive-pressure mask.  I tried to do something useful, which was impossible at first.  I smiled at dad who had come to observe us.  I listened to baby, but I didn’t know what to make of his raspy lungs.   He was having some trouble with his breathing.

Every few seconds, they would count 1-2-3 and in a coordinated dance, lift baby and change the cloth underneath so he would stay dry. Finally, we clamped his cord close to his belly, and dad cut it.  Then, we bundled him, and they let me, the medical student, carry this brand new bundle to his mother.  I handed her baby, and said, “felicidades” because she and her husband spoke Spanish.

The second call came during lunch.  Again, I dropped everything and tried to keep up with the residents.  In fact, I left my stethoscope on the chair!  This birth was also a premature vaginal delivery, but it was slower.  We had plenty of time to set everything up while mom was in the final stages of labor.  I was alarmed by the tubes they prepared, in case they needed to intubate the baby.  They checked the suction, and the oxygen bag.  This time I knew what to expect, so I got ready to help with the drying, rubbing and blanket-changing dance.

These were the first births I’ve seen since my brother was born, almost 20 years ago.  I barely remembered the chaos that happened right after my brother was born, but it suddenly came back.  There was lots of rubbing and suctioning, and I cut his umbilical cord a while afterwards.  He was swaddled in a blanket, and I held him and handed him to my mom.

Most of all, I was in awe of my brother, just as felt as I watched the newborns in the nursery.  There is something so special about new babies, new life, and the moment of birth, mixed with pain and joy.  I thought I was going a little crazy after spending time in the nursery.  I started looking at baby outfits on Google.  Then, I even thought about having a baby before I finish medical school… for about 30 seconds.

The truth is that starting a family during medical training is terribly difficult, especially for women.  I’ll explore this topic in a different entry soon, but for now I am enjoying the new babies, one of my favorite parts of pediatrics.  Getting to see something so sacred as human birth and newborns makes all my sacrifices seem worth it.

First, I rotated in the clinic where I did sick and well child checks.  My roll was to introduce myself to the family as a third-year medical student, and ask if it was ok if I took the history and did a short physical exam before speaking with the doctor.  After I did my history and exam, I would report to the doctor, and we would go back and see the patient together, and perform a complete exam.

I saw 1-week olds to 14-year-olds.  I learned a lot about immunizations, and how to approach the sensitive parts of the visit (for example, how to examine genitalia professionally without making kids or parents too nervous, and when/ how to interview teens by themselves).  I also learned a lot about what it means to be a healthy baby or child, since we were encouraged to ask many general questions about diet, transportation (car seat and helmet use), smoking and safety at home, discipline, bowel and urinary habits, etc.

I was so impressed by the format of the pediatric visits.  Adult primary care has a lot to learn from pediatrics!  For example, a common format for interviewing teens is called “HEEADSS:” Home, Education/ Employment, Eating, Activities, Drugs, Sex, Suicide.  There are target questions to ask about each topic, for example, “Home” includes questions like: “Do you get along with your family?” and “Who do you talk to?”  I think most adults would also benefit if their doctor  asked these questions at physical exams.  Adult medicine as we know it focuses much less on prevention than pediatrics.  I didn’t realize the difference until this week.

Working in the emergency room was totally different from the clinic.  My roll on the ER team was not well-defined.  What I did varied depending which physicians were there with me.  The things that surprised me the most were the multitude of non-emergencies in the emergency department, and the procedures I saw.  Finally, I was able to overcome my anxiety about passing out again.  I stapled a boy’s scalp, which was surprisingly easy and gratifying.  He even came over to thank me.  Then I assisted with a toddler with a deep facial laceration, and another girl who had an abscess on her toe (which ended up draining about 3 tablespoons of puss from her tiny toe).

Today I was in the newborn nursery.  Just 8 hours ago, I was surrounded by 6 newborns <72 hours-old.  Each baby was swaddled in his or her own clear basket.  I helped with the discharge exams.  We undressed each baby, examined them from head sutures to capillary toe refill.  We tested their reflexes, listened carefully for murmurs, tested for hip dislocations, palpated for broken clavicles, and looked for red-reflexes in their small eyes.  This is a precious job, despite the babies being appropriately angry at times (I’m sorry, babies).  I was hoping to see a delivery, but nobody was in active labor today, so  maybe Monday.

Now it’s time to start getting serious about studying for my first shelf exam, which is a week away.

My memories from the inpatient weeks revolve mostly around the people. Medical students who begin 3rd year especially remember their first patients.  It wasn’t until my second day working with the pediatrics inpatient team that I was assigned to a new admission.  I felt excited and nervous as I went to meet him.

He was a toddler “with history of CHF (Chronic Heart Failure), admitted for 2 days of worsening fever and respiratory distress.”  What I wasn’t prepared for was that mom spoke only a little English.  She understood Spanish, but spoke primarily Portuguese.  Along with an intern and the head resident, we took a history of his illness from mom, asking questions in Spanish and deciphering answers in Portuguese and English.

I was expecting him to cry when we examined him, but he was quiet and still.  I moved my stethoscope along his torso, listening to his heart, lungs and abdomen while he was quiet.  Then, I examined his ears, eyes, head and throat.  We determined he probably had a viral infection, most likely to be “RSV” (Respiratory Syncitial Virus).  This case was “bread and butter” (common) for pediatrics.  In fact, there was not much we could do for him besides monitor his respiratory and cardiovascular status and treat his symptoms.

I wanted to do more.  I came home and read journal articles on RSV treatments.  Asthma medications weren’t recommended because the respiratory obstruction was due to mucus, not inflamed airways.  Saline nebulizers could be used to reduce the mucus, but the evidence was still “inconclusive.”  Heliox (helium and oxygen) was useful in extreme cases, but it is extremely expensive.  There weren’t any easy solutions, and this is the case with many patients.

As the week went on, his story blended with others.  Coincidentally my second patient was another boy with a probable RSV infection and a history of heart problems.  This time I learned about WPW (Wolff-Parkinson-White Syndrome), a type of “SVT,” (Supraventricular Tachycardia), especially common in children.

As the days passed, my patients’ diagnoses broadened to include asthma, cellulitis, dacryocystocele and febrile seizures.  During rounds, I heard the stories of other patients: dermatitis herpeticus, functional constipation with encopresis, bilious vomiting, bloody diarrhea, accidentally cut gastric-tube, fever of unknown origin, mysterious ALTE’s (Apparent Life Threatening Events), and a child who had been in a mysterious coma for a month.

Everyday we discussed the “assessment and plan,” how we would care for each patient.  I felt my medical knowledge, the roughly piled structure of facts, start to form itself into something more concrete.  It was like I had been studying another language, and suddenly I was in the country, surrounded by people who spoke only that language.  I was overwhelmed, clueless at times.  I started scribbling words that I heard often, like: MRCP, VCUG, KUB, NCAT.  The everyday language was different from what I had studied.

From my first patient to my second, third and fourth, I already started to feel a huge difference.  I learned the order of notes and presentations.  I used some of those previously foreign acronyms myself, and I entered patients’ rooms with more joy and less trepidation.  My performance has been far from perfect, but these first patient memories are the best learning experiences in medicine that I have had so far.

I wasn’t prepared for this episode at all.  I was looking forward to the hospital for my call shift on Sunday.  I woke up before my alarm and got there 30 minutes early. I finished morning rounds, and was preparing to admit a transfer patient with a possible history of seizures.

Then, I stopped to help one of the interns replace a G-tube (gastric feeding tube) on a baby.  The baby was uncomfortable, and I was helping to keep him still.  Suddenly I started to feel light-headed…BAM!

My mind became totally empty, and oddly peaceful.  I’m not sure what happened, but I awoke and was surrounded.  The nurse was saying something about a code.  Suddenly I realized… I had fainted and the code was for me.  Panic!  What a great way to begin my second week.

Then I was taken to the ER… in a wheelchair.  Apparently I hit my head on the way down, was unresponsive for over a minute and didn’t have a pulse.  I had never fainted like this before in my life.  While being wheeled down the hallway, all the pediatric residents were running to the “pediatric code.”  They were relieved that no baby was dying.  It was just me, the medical student.

From the moment I gained consciousness, my mouth was dry.  I wanted a glass of water and to pee.  However, I got an authentic patient experience of not feeling in control.  I was attached to a heart rate monitor, then an ECG, and finally a glowing oxygen saturation clip on my finger.  I had to put on a hospital gown.  Despite being thirsty and having to pee, nobody would detach me or bring me water.

Different people asked me the same questions: name, date of birth, etc.  The billing lady came in 3 times because she couldn’t find me (my name was spelled wrong) and then I wasn’t listed as an employee (because I’m a student)  Then, she informed me that I probably wasn’t eligible for any compensation for the ER costs. Fine.

Everybody wanted to know how I hit my head, but I didn’t know.  How was I supposed to know what happened if I was unconscious?  I waited in a curtained compartment under the bright fluorescent lights, feeling pretty agitated (full of hypochondriac medical student thoughts).  Finally, the doctor came in.

He was my Physical Diagnosis professor. He did a thorough exam on me, even borrowing my light to check my pupils.  Then, he said I could go back to my shift.  Finally, after an hour I got to pee, and then headed back to my ward.

Everyone was kind.  They said this happens a lot, and they were glad I was ok. They sent me home early to rest, eat, drink fluids, etc.  I wasn’t sure if I should stay or go, and maybe I’ll regret going later.  But, I did feel pretty shaken up, so I went.  First, I sat in the hallway and drank a huge glass of water and inhaled my lunch.

On the bright side, I have a personal experience of my hospital’s emergency department, and a print-out of my very own ECG and hospital note.  The nurse handed them to me, and said, “Here’s for your studying pleasure.”  She knows medical students well.

I feel almost 100% now.  I just find myself feeling anxious that it will happen again, and I’m not sure I can prevent or predict it.  I have seen much grosser things than G-tubes, so I’m not sure why I reacted that way.  I figure I just need more sleep, food and fluids.  This week is going well… thankfully no more codes.

The first thing on my mind after such an exciting and full week is… SLEEP.  Between jet-lag and excitement, it was impossible to go to bed early, which made waking up at 5:15am pretty painful.  My new schedule requires me to be at the hospital 6:30am-5:45pm Monday-Friday, and stay 6:30am-10pm one weekday and one weekend day.  That’s a lot of hours at the hospital.  It’s still under the 80-hour limit for medical students and residents, but for a rookie who doesn’t quite know my way around yet, it was a LONG week.

Despite being exhausted, I’m thrilled to begin my clinical journey.  The doctors and residents are surprisingly kind and friendly, not to mention encouraging teachers.  The program is well-organized, so everybody has clear responsibilities.  My goals are to get-to-know my assigned patients well; build rapport with the patient, family, nurse and social worker; examine and interview them; write progress notes; and present them at “rounds.”  Pediatrics rounds are in the morning from 9-11am when everybody on our ward’s medical team gathers to visit and speak about every patient in our care.

In every teaching hospital there are a lot of doctors and students working on the medical team.  The highest member is the “Attending,” then the “Head Resident” (a 3rd-year resident), followed by the “Interns” (1st year residents), and finally the medical students (like me).  Residents are new doctors who train for 3-5 years after graduating from medical school to become fully licensed, so all residents are MD’s.  Every patient to whom I am assigned is also assigned to an Intern, the Head Resident, AND the Attending (and of course we can’t leave out all the amazing nurses too).  This is the system of care in  teaching hospital.

Our goal is to work together to provide the best care.  Considering there are many brains involved, this type of care is great for detailed learning, especially when patients have complicated conditions.  The drawbacks are that the patient might feel overwhelmed by the number of doctors, or frustrated that they have to keep repeating their story to different people.  But, patients get more medical attention and often this results in a higher level of care.

I was assigned to two patients this week.  This doesn’t sound like much, but it was enough to overwhelm me.  At first, I felt totally incompetent.  I felt like I’d forgotten so many facts, and was making a lot of mistakes.  For example, I confused dermatitis herpetiformis with dermatitis herpeticum.  Then during my first presentation at rounds, I announced that my patient had received 7,000 mL (7 Liters, or about 3.5 gallons) of IV fluids during the night. Oops!

But then, I started feeling slightly better by the end of the week.  I wrote my first “SOAP” note that was added to my patient’s chart.  A “SOAP” note is a progress note written in this order: S=subjective, O=objective, A=assessment, and P=plan.  I made my first oral presentations during rounds.  I helped complete electronic medical records, and write new orders for my patients.  I consulted a cardiologist.  Most importantly, I spent time with my patients and their parents, and started feeling more fulfilled by my presence on the ward.

Tomorrow I’m on call 6:30am-10pm, so I better go finish up all the things I have to do… and then get ready for bed, STAT!

Here is a link to my rotation schedule, if you’re curious:  Pediatrics Schedule

Clockwise from Top Left: Stomach, Muscle, Brain and Heart.  Encaustic with class notes, twigs, wall compound, glitter and oil paint.

“Your USMLE Step 1 SCORE REPORT will be available later this morning on the NBME Licensing Examination Services (NLES) website.  Due to a larger-than-normal score release today (Wednesday, July 14), examinees may experience some delays in accessing their results…”

Since I was flying on Wednesday, I actually got the e-mail on Thursday morning, and didn’t have any problems accessing the score report.  As soon as I opened the PDF, I was relieved to see the bold “PASS.”  To tell the truth, my relief was mixed with a tiny bit of disappointment because I hadn’t achieved my highest dream score.  However, I probably set my imaginary expectations too high, and ultimately I should be pleased by my own efforts and progress.

When I called my dad to tell him I received my passing score, he didn’t even ask about the score.  He simply said, “Congratulations.  Do they give Nobel Prizes for Board Exam Scores?”  In other words, don’t be too disappointed or too proud. His feedback made me grin.  He always seems to have a concise way to offer support while reminding me to keep things in perspective.

So, Step 1 is done.  I passed.  I am officially 1/2 M.D.  Now, I have more important things to think about, like my pediatrics rotation starting in a week!  I am beginning to feel nervous excitement about being a 3rd year student.

Sky while hiking.

It’s official, 3^rd year has started this week. I am taking this first block off to spend time with my family, enjoy nature and attend a far-away wedding.   Despite the fact that I haven’t started my first rotation nor have I received my Board score, I feel like I can say, “I’m a third year!”

Third year is a whole new chapter.  My orientation packet reads:

“Congratulations!  After 19 years in the classroom you are about to begin an entirely different educational experience.  No doubt, you will find it to be the most exhilarating but exhausting year of medical school.  For most, it will be the highlight of your medical education.”

Make that 22 years in the classroom, counting my work as a teacher and my post-bac classes.  Oh yes… this is the highlight I’ve been waiting for!  The advice section includes: “Don’t lose sight of who you are,” “Try to carry snacks/ water,” “Take a deep breath,” and “Be happy/ enthusiastic/ energetic.”

In fact, everything sounds like general advice for a happy life, except a few items, such as “Know how to read a cxr and ekg systematically before starting.”  “Cxr” is chest x-ray, and “ekg” is electrocardiogram (my small group leader last year informed me that “ekg” is actually a German abbreviation and not “proper English,” so now I try to stick to ECG).  Maybe I could handle these tasks somewhat, but my current attempt is rather unsystematic at best.

Fortunately from here onward, my daily experience will guide me to develop my own systematic approach to everything patient-oriented.  I will be an apprentice to doctors and residents, and under their supervision, I will be assigned to my own patients.  I will be on my feet, working hard daily.  No doubt, I will never be the smartest person on the care team and I’m sure to embarrass myself often, but I still feel like third year is a welcome change.

It was strange to see  my schedule for my last two years of medical school listed on paper.  Third year consists of eight 5-week blocks, while fourth year contains thirteen 4-week blocks.  There is no built-in vacation, except 2-weeks at Christmas/ New Years.  The blocks are a short list that fits on a single page, below which is written “Graduation: May 20, 2012.”  Could it really be approaching that fast?

At my university, third year has two mandatory 10-week (2-block) rotations; medicine and surgery.  And 3 mandatory 5-week (1-block) rotations; pediatrics, OBGYN (obstetrics/ gynecology), and psychiatry.  My school encourages everybody to take Family Medicine in the remaining block, although Family Medicine is a 4-week rotation, and can be taken at the beginning of fourth year (which is what I’ll do).

My rotation schedule: I’ll be starting 3^rd year on August 2^nd with pediatrics.  That will be followed by medicine, OBGYN and 2-weeks off for the holidays.  Then, in January I’ll come back to psychiatry and finally, surgery.  Every rotation is at a different hospital, and from now on, my peers and I will have different paths.  Mine begins with this vacation time, and I am determined to enjoy it before I leap into this “most exhilarating but exhausting year of medical school!”

I took the Step 1 exam on Saturday, and then I took another little exam that I was trying not to worry about until after my Boards.  Faithful readers may recall that I failed my Hematology-Oncology exam this year (you can read the entry here).  I’m not proud of this fact, and hesitated to make it public knowledge on my blog.  However, I decided that this reality is an important piece of my medical school story.  I am not a perfect medical student (even when I try my hardest) and the first two years have been challenging.

As I was studying for my Board exam during the past months, I spent extra time with Heme-Onc.  The medical school supported me by providing tutoring, and even encouragement.  I’m happy to say that Heme-Onc, including all the chemotherapy drugs that I once dreaded, are now familiar concepts to me.  The make-up exam went well, and now it’s behind me.  Thank goodness!

My Boards are another story.  I still am filled with nagging feelings about my performance, and am slightly disturbed that nobody seems to know for sure when or how we get our score reports.  I was under the impression that I would receive an online score in 4-6 weeks, but the printed sheet I received at the end of my exam said they would mail my results in 8 weeks!  Another friend recently shared that she believes her older brother got his results by e-mail in 3-4 weeks.  I guess I’ll find out soon enough, but right now waiting for the results feels like eternity.

There was a huge thunderstorm the night before, and between booms and strange dreams, I barely slept.  I had never been awake for so many hours before such an important exam.  My husband comforted me during the night saying, “Don’t worry, I’m sure nobody sleeps well before this exam.”

I awoke feeling mildly ill, and I actually wondered, “Could I be sick?”  I didn’t feel like eating, but forced myself to have breakfast.  I drove myself to the testing center ahead of schedule, all the way feeling like I ought to be in a better mindset before the exam.

Then, I got there.  I found a woman with a large text wandering outside the building.  She looked just as anxious as I felt, so I approached her and helped her find the testing center.  The staff let us get started right away.  I was the only one there all day taking the Step 1 exam, so they checked me in first.  After getting photographed, fingerprinted and documented, I got my seat in a cubicle #2 with laminated paper and a huge set of noise-canceling headphones.

I began the test, and things got better.  I’m not sure if I imagined it, but I felt like the first hour was the easiest, as if they were trying to soothe me into test-taking mode.  How nice of them!  Also, there were only 46 questions per hour.  I was expecting 48.

When I took my lunch break, I saw the same woman I had met in the morning who had just finished.  She had received her results immediately, and confided in me that she had barely passed.  I told her congratulations, and not to worry because nobody would ever know the difference (simultaneously I realized it was important for me to remember these words as well).

8 hours flew by, and before I knew it, I was toasting with my husband and a glass of nice wine. My study calendar is in the recycling bin, and I have cleaned up my piles of books. At this point, I still can hardly believe it’s over!