A nice story

“If there is anyone on board who has any medical training, please ring the call button”

I’ve always wondered what happens after you hear the broadcast. Today I got to find out. K was a 32yo gentleman who I met in the rear galley of a 737 headed to San Francisco from Boston. He was in great health, in fact he was a former professional basketball player. K had just come from a reception in which he ate some seafood and creamy bisque soups that he normally wouldn’t have eaten but then felt fine and boarded the flight. Halfway through, he began feeling nauseous. He stood up hoping the feeling would go away but the nausea got worse and he eventually had to make several trips to the bathroom to throw up. It was at this point that the overhead broadcast went out. At the time, I was engrossed in my new iphone playing a game while listening to a korean pop song. Two physicians were already attending to K when I first saw him in the rear galley. He was a tall guy, probably about 6’5″ with a muscular build looking pretty sick to his stomach and sweating from the retching. I brought the doctors my stethoscope thinking it was the least I could do while reprimanding myself for feeling so self important as thought I could add anything of value as a medical student. “Its probably a gastroenteritis . . .” I overheard one of them saying in a well-practiced outside-of-the-patient’s room tone of voice. “Yea, you’re probably right, I have some meclizine in my bag, do you think we should give him some?” . . .” I heard the other one say. “Naaah, he doesn’t need it.”
They took my stethoscope, listened for a moment then handed it back to me without looking or acknowledging my presence . . . “Just like on rounds . . .” I thought to myself. So sheepishly, I decided that there was really not much more I could add at this point, after all two full fledged physicians were already attending to K and what else could I the lowly medical student hope to offer him that they could not? So I shrugged and headed back to my seat. Luckily, I among the 30lbs of books I had with me was a quick read Emergency Medicine handbook that had a short chapter on nausea and vomiting. It explained that the usual presentation of “just a gastroenteritis” was vomiting AND diarrhea and that the two most commonly missed or dismissed surgical emergencies were bowel obstructions and appendicitis. In a young guy like K, certainly these were possibilities as well right? I convinced myself that I really ought to check on him again in a few minutes. By the time I made my way over and introduced myself, the other two docs had returned to their seats allowing me to examine him alone. I found out he had some LUQ pain which he said started before he threw up, that he did not throw up any bile or blood or stomach contents but that he was not passing gas or stool. He also said he was starting to feel light headed when he stood up. I examined him, felt his pulse which was strong, slow and regular. He belly was soft not rigid and I could only elicit tenderness near the border between his ribs and stomach. He did not have any headache or trauma, no recent alcohol or NSAIDs, had not been sick or feel warm and did not have sickle cell or any other spleen trauma. We were about an hour and a half into the flight and he had been back and forth to the bathroom, didn’t have any pain or swelling in his legs so I did not suspect a clot that had formed in his legs which traveled to his lungs. He had no family history or medical illnesses besides some mild asthma. Without even thinking about it, I had ruled out a series of life threatening causes for his pain and vomiting and had even gotten to know more of K’s story. He had played basketball in Europe for a few years, but decided to get his master’s in education because he had some bad experiences as a student growing up and wanted to change things. He had taught for a few years and risen up to become principal of a charter school near Sacramento whose student body was comprised of mostly kids from households living under the poverty line. K had finished a second Master’s in Institutional Leadership at Harvard which he did as a correspondence program while working 80hrs a week as a principal, substitute teacher, basketball coach and mentor for his students. We chatted about this and other topics as I monitored his pulse and watched him as he continued to rush to the bathroom every few minutes. In between the rushes, we had a fascinating discussing about the pros and cons of affirmative action, the problems facing public funding for schools or healthcare and how to change a culture of despair into a culture of confidence and resilience. During one of these lulls, K and I shared thoughts about passion for one’s work. It was then that he told me that he could tell I was passionate about medicine to which I responded that I was really tired and stressed by training and sometimes wondered if I could really handle the tough lifestyle sacrifices in medicine. K then told me something that I never thought of before. He said that passion is really about following through, persisting and taking the time and care to make sure something gets done. “You know you are really passionate about steak because when you crave it, you go out and buy some meat, grill it up and get that steak on your plate”.
“If you weren’t passionate, you wouldn’t be back here, you would be at your seat, playing video games or reading a book, you wouldn’t be spending all this time talking with me”

I never thought of it that way but when I think about it medicine is really the only thing I have ever done which I can really say I put 100% of my effort into over such a sustained period of time (5 years if you could my post bacc studies). And still I think about the planning, the anxiety of doing a good job, staying late to make sure a patient’s labs are reported, rounding on the patient one last time before the shift ends, coming in early to check on someone and spending an additional 5 minutes with a patient to listen to their story before rounds. These are not things that typically characterize me.

And then I realized that doing whats right and not whats convenient is what medicine is all about. But it has its perks. K told me about the story of a student who “made it” and I could feel the passion in his voice when he talked about how great it felt to know that this person would be the first in their family to go to college then pass that work ethic and resilience onto their kids and so one for the next generations. Perhaps all of my thoughts and schemes of finding the perfect dream job focusing on what this person has and that person has and wouldn’t it be nice to have is misplaced. Perhaps what I should really focus on is not what others have that I want but on what I have that others do not. Perhaps being great is not just about securing a fancy sounding title or degree or maximizing your potential earnings but about using your skills and your passions to follow through, build relationships and make a difference in someone else’s life.

Mini epiphany about work

I’ve realized that the most fulfilling work one can do is work in which you get to invest your own creativity and personality. Work in which one’s own ideas, skills or emotions are invested is the most fulfilling and rewarding. The example that I recall ironically is in the one summer in med school when I did business stuff and came up with a research project and presentation on Asian investment opportunities for J&J which was both personal and creative for me. Similarly, is there a field in medicine where one really adds creative energy instead of just following the care maps? Interestingly enough, primary care, psychiatry and plastic surgery are the areas where I’ve seen the most of that rather than the excitement and “life saving” fields like Emergency medicine, critical care or trauma surgery.

A good day in outpatient medicine

Its been a while and I need to catch up on blog entries (Not that my life is so exciting between studying for boards and being cooped up in the hospital).

Anyway, ongoing thoughts about outpatient medicine. I’m on my last day with Dr. H here in Claremont and its really been surprisingly good. There is a side of outpatient medicine that is attractive: getting to really know your patients and also being the first line to pick up really bad things when they could otherwise go unnoticed. One of the highlights during this rotation was finding a woman with a large retroperitoneal abscess likely either from a ruptured appendicitis or a appendiceal tumor who came in because she was just feeling lousy and looked kinda crappy and had some diffuse aches and pains and a tender belly and some pale eyelids. We got a stat white blood cell count which showed that she had 20,000 white cells (normal is less than 10k) and was anemic with a hemoglobin of 12, scanned her belly and found the abscess. She got the abscess drained and put on IV antibiotics. We probably prevented a life threatening blood infection in her and probably saved her life. In some ways it was kind of like the emergency which WE found and upgraded rather than the patient defined emergencies for which they go to the ER on their own initiative. Either way, you’re really saving a life which is very meaningful. A very different twist on Emergency medicine!

Of course my preceptor (this funny German guy who is VERY German, always on time, uber efficient, the ultimate task master who expects things to be done 10 minutes ago whose idea of fun is to rent a smart car instead of a taxi from the airport) think I ought to go into primary care because “its more important”.