Musings
June 23rd, 20236/23/2023 My intention was to write quite a lot more last evening, but my shift became rather busy as patients required more attention (namely one, who‘s EVD [external ventricular drain] stopped draining and she soon after had increased drainage from her nose that, by golly, looked clear. She‘s unfortunately still draining CSF from said nose, but unclear if she‘ll need further operations vs. a wait-and-maybe-self-heal approach.
Interactions with my patients are what really drive me to continue with this work/training. Turns out I seem to enjoy talking to people more than my brain, that claims to be a militant introvert, would have me believe. It ends up taking up quite a lot of my time, but I‘ll spend quite a lot of my encounters chatting patients up, not only to tease out the relevant information for my exam, but just to get to know them, too. I‘ve met likely thousands of people across all the patients I‘ve either directly or indirectly treated (not to mention their family and friends) at this point and I‘m still quite early in my career. That time, so it seems, is otherwise well spent because people seem to appreciate it. I take it as my duty and in a sense passion to care for people, and I think part of that caring is simply listening to the patient - they do a pretty good job most of the time telling you what‘s going on, if you really listen. It probably doesn‘t hurt that I can apparently run my mouth about anything, so give me a chance to talk an it‘s off to the races. My whole diatribe last evening was intended in part to be a prelude to discussing some of the other events (transitions?) that have happened since I last laid down these walls of text. For me, the most impactful is a fairly dramatic shift in education and careers. Namely, beginning in less than two weeks, I‘ll have officially joined the brotherhood of anesthesiologists. At least in training. At least these last two years, but I‘d wager extending as far back as my Dad‘s death (if not further yet?), I‘ve seriously explored the idea of a change in trajectory. It‘s such a nuanced discussion on which I‘ll obviously elaborate, but my desire to continue the pursuit of Oral and Maxillofacial Surgery had eventually come to a halt. My thoughts lingered on suicide often - not unique to this situation, though, just a problem I‘ve struggled with most of my adult life. I no longer felt any passion for the practice and felt I‘d descended into a true hatred of everything around me, wanting nothing more than to escape but instead being cemented in place. There were other things I considered, some more seriously than others: Completing my residency then quitting medicine all together. Leaving the country and not returning. Quitting the residency and practicing as a dentist. Quitting the residency and doing who knows what else, but not residency. What I didn‘t initially consider, as it was only a „What if?“ thought that crossed my mind on a few of my medical school rotations, was pursuing a different field in medicine. My Emergency Medicine rotation was the first, early on in my clerkships, where the thought of being an EM doc weaseled its way into my thoughts. I explicitly remember saying it to a few people because the experience was that interesting. It never went far beyond that, I completed the clerkship and moved on. That experience happened several times across the clerkship year - not always for an entire field, but maybe for a given type of interaction or procedure or schedule even (there‘s so much to be said about a regular schedule with reasonable hours for one‘s mental and physical health). Pediatric Medicine, oddly enough, was another one of these instances. Later in the year was my short-lived rotation on Anesthesia where I was instantly enamored with, though constantly scared shitless of the practice. I’ll never forget the first time I intubated a patient, which I’m lucky to say was smooth as hell, too. Like all the clerkships though, I moved on to the next, eventually to complete them and then in the Spring of 2022, graduated with my MD. By late spring 2022, I finally made a stolid decision to pursue actual treatment for depression again, as opposed to bringing the problem up to my physician then doing nothing to help myself. I started an antidepressant for the first time since I was a teenager and continue on it to this day. At this point it‘s become rather routine to take it, but I struggled significantly with the idea of restarting one of those medications again as my first several years with them were enough to turn me off ever wanting to take them again. Thankfully, I‘ve not experienced noteworthy side effects. I can‘t, though, say that the improvements I‘ve had in my overall mental health (or maybe a better metric is the overall reduction in time my mind spends thinking about suicide) are exclusively because of the med. My therapy, it turned out, was putting people to sleep. My first major rotation in my PGY-4 year was Anesthesiology. As part of the training requirements for Oral and Maxillofacial Surgery, residents must complete a minimum number of intubations on both adults and children, in addition to administration of deep or general anesthesia. My training program then coordinates a five month adult and one month pediatric Anesthesiology rotation where we function at the level of a CA-1 resident (Clinical Anesthesia). I can‘t accurately express the mix of emotions involved in starting the rotation. An amalgamation of profound interest and crippling fear were at least a part of it; the latter with the understanding that this was the first in all my rotations as a resident that the responsibility of another human being‘s life what immediately and acutely in my hands. From the very first, that experience changed me deeply. The next several months were spent doing the most enjoyable learning and practicing of medicine I‘d ever experienced. I don‘t say that lightly either, because I‘ve seen and done some pretty cool shit in my years as a teacher, then dentist, now physician. Within the first couple days of the rotation, I couldn‘t shut up about how great my experience was going and not even a couple weeks in before I was very seriously considering this as the alternative path I‘d sought for so long. Could I, as a 4th year OMFS resident (5th if you count that pesky intern year), really just leave all behind and become an anesthesiologist? Spoiler alert: I can.
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June 21st, 20236/21/2023 The Baader-Meinhof phenomenon describes an interesting type of bias whereby you notice something more frequently after it‘s initially brought to your attention, though its actual frequency of occurrence is in actuality no different. The example I always come back to in my mind is when I first learned about the phenomenon, I applied it to a situation where someone asked me about the Jeep Liberty and as I thought, realized I’d never seen a Jeep Liberty driving around town (when I still lived in Duluth, MN, to put an age to the thought). Naturally, I started to see them everywhere afterwards. I‘m certainly guilty of applying it erroneously, as I will here, but if for no other reason, it‘s worth mentioning as a reminder that our perception of the world often does not match the reality around us. And to teach at least one someone out there a new thing.
This afternoon, as I spent my 2 free hours between sleep and my overnight shift [side note: 13 hour shift, 1 hour in commuting/prep, 8 hours sleep if I‘m lucky…2 hours to live regular life any given day…how about that], anxiously awaiting my obligations and eschewing any other interim activities, I thought about revisiting this website where I once vowed to share my thoughts and art with the world around me. It was interesting and rather eye opening to receive a message from a colleague after the start of my shift stating he and another had briefly followed this blog out of interest of both cycling and sketching. I was and am still floored that anyone out in the Äther of the internet would have even stumbled upon these writings, let alone read them more than once! Perhaps a better descriptor is ‚coincidence,‘ or ‚small world,‘ rather than Baader-Meinhof, but I‘ll justify it by saying once the thought of writing here re-emerged into my thoughts, it was brought up in the context of my professional life the very same day (though I highly doubt there‘s any regular frequency of visitors here, let alone a recent increase). Coincidence, yes, that‘s a far better term. So I sit here on my overnight shift, one out of an entire month of them, covering the Neurosurgery service and wondering what the hell I‘m doing with my life. The hours are long, arduous, either on an overnight or weekend (or both), and the educational benefits are minuscule at best. With no disrespect to the field or its practitioners, it‘s been the least beneficial (i.e., most warm-body-busy-work) rotation I‘ve been on in my medical career thus far. I exist to do an evening evaluation and note for 10-12 patients a night, then tend to their basic needs like pain control and hyper- or hypotension. In context, this is supposed to be a surgical rotation for a surgeon resident…where I’ve not and will not enter the OR for a neurosurgical case the entire rotation. It‘s the glamorous medical life I always dreamed of having, all the work and none of the benefits (outside the patients hopefully improving along the way, yes, but even altruism has its limits and those who think otherwise are lying or ignorant). There‘s no salt in these words, I promise. October 04th, 202010/4/2020 It's pretty incredible how quickly these days are passing by me. I've not taken a look at the site for what I thought was only a couple of days, but it turns out it's bordering on 3 weeks. There's been a reasonable amount of stuff that's happened in that amount of time, as it turns out. On the med school front, I've completed not one, but two system blocks. Cardiology went out with a bang, with what's arguably one of the most difficult exams I've ever taken (and believe me, I've sat for a lot of exams). I still wish that I would have gotten more from cardiology. My first inclination is to blame it on the remote learning, which I surely feel is the major contributing factor. I cannot, though, deny that my motivation to put in the efforts needed to master the subjects has been non-existent. To say I left the class with less than I'd hoped is certainly true, though my grasp on the field is undeniably stronger than what it was prior to the course. The week that followed cardiology was an entire course in 5 days, that being dermatology. I'm not surprised, but it turns out dermatology is interesting as hell. There are a significant number of manifestations of local and systemic diseases that appear in the mouth, so I was introduced to a lot of concepts upon which dermatology is built in dental school. It was nice to have a reasonable foundation for the rapid course. Though I'd likely never been able to get the absurdly high grades and test scores to land a seat in a dermatology residency, I could easily see myself pursuing the field in another life. The skin truly is a window into the body and there's a huge amount of information which can be gleaned through someone's outward presentation. At present, I sit on the late eve of starting a new block, again one I hope my previous education will set me up reasonably well for taking, which is renal. Its reputation is of a very challenging course, which I don't deny will be the case, but having given lectures on renal anatomy and physiology in the past, I again hope I'm building my castle on solid foundation rather than sand. Outside of med school, I've found one of the items which can propel me forward perhaps better than most is simply keeping a daily check list of to-do items. I have my notebook that I've started to use once again to make sure I don't just wake up and stare at the wall all day, lost in depression. It's gotten me through a couple projects around the apartment, including hanging a couple shelves I've planned to put up since March. I've also begun work on my cyclocross bike to get it the maintenance it needs as it sat unridden for over 2 years (an ongoing project which naturally comes with unforeseen setbacks like the new brake calipers not fitting correctly). It also gave me enough of a boost to overcome my anxiety for calling the bike shop to inquire about maintenance for my mountain bike, which is being worked on, ideally to be finished by midweek. I've still made no headway on getting the road bike situation resolved, however. Canyon is holding a release event on Tuesday, which is apparently to unveil the new Aeroad, so we'll see if it's enough of a beast to warrant its purchase over the other available options. I've tried to get my drawing hand working a little bit, too. Unfortunately, I haven't been especially productive on that front, but I am happy with the Chozo drawing I finished yesterday. Toned paper is very satisfying to work on and in this case, I had a good reason to take out my Copic markers to add some depth to the thing. I won't be able to keep up with any ARTober prompts or any other daily projects, but hopefully I'll continue to throw something down on paper every couple of days. It's very gratifying to see a finished piece, even if it's simple...and strongly influenced by some random image I found on Google...(thanks MH for your drawing inspiration...whoever you are). September 19th, 20209/19/2020 I left my apartment twice this week; once on Monday and once on Wednesday. Monday was the last day that I rode my road bike outside. I discovered that there's an issue with (I presume) the rear wheel, which was rubbing aggressively on the inside of the chainstay on my carbon fiber frame. The rear triangle is by all measures true, there are no visible or appreciable weaknesses in the carbon and the derailleur hanger appears straight. I'm led to believe then that the rear wheel dishing has come untrue as, even though it has a <1mm deflection at one point in its rotation, I don't otherwise believe the wheel itself to be untrue. My knowledge of bicycle maintenance unfortunately ends at wheel building and truing, but I know enough to recognize a significant problem, not to mention direct potential damage to the frame itself. Hence why the bike has been mounted to the trainer and I've not ridden outdoors since. I do actually have 2 other bikes, but the Niner RLT is currently slated for complete disassembly (starting today) and rebuild to prepare as a commuter/light-gravel bike and I plan to sent the Alchemy Arktos to a bike shop to have routine overhaul maintenance (going to be calling the shop today to schedule an appointment). I'll manage the overhaul on the Niner, but the Arktos is a full-suspension beast that I feel is over my pay grade to give it full attention. The other outdoor excursion was Wednesday for my clinical medicine course where we're working on the nuances of taking a history and physical. I also quickly grabbed some groceries on the way back home. What an exciting life. I need to start running more again. My latest sketch. I used an online drawing idea generator which told me to draw old castles or ruins, so I found this through an image search and got moving. Full disclosure, the photo of the drawing was run through a red B&W filter in Photoshop to get rid of the natural hue of the paper. I may also have used the spot remover for a little grease because of my horrible habit of devouring potato chips. The lettering was a Faber-Castell Pitt Artist Pen fineliner and the image was a Staedtler pigment liner 0.05. I'm really enjoying the latter because I can make very light guidelines like a pencil undersketch, but without the pencil. Trying out a new logo which I'm growing fond of, too.
September 15th, 20209/15/2020
A deep enough descent into depression and there's very little left to pull you back out. At the end of last month, the 29th of August, I mourned the second year since my father passed away. I've never come close to grasping with this and doubt I ever will. Further, I don't know how to even begin to discuss it, especially in such a format as an open, online journal. The most I'll say here fore now is I miss him tremendously and only a couple weeks' time of swimming around in my own head has brought me anywhere close to feeling reasonable again.
The photo above was actually captured on the morning of the 29th, while I headed out to the hospital for call. I wasn't aware that the mantis was endemic to the Philadelphia area. Turns out mantids can be found in more temperate regions with mild enough winters and sufficient vegetation, though they're more commonly found in tropical climes. Apparently, they're most closely related to cockroaches and termites, rather than grasshoppers/locusts as I ignorantly believed. My television knowledge also informed me about the mantid practice of sexual cannibalism, whereby the female ingests the male as a copulatory event; it's a controversial finding, though, as researchers seem to believe this practice is actually promoted by laboratory environments and researcher observation and isn't seen as frequently in natural environments. Fascinating (not-so-) little creatures. Perhaps there's some symbolism to be found here, new life created in memory of life lost.
My motivation for sketching has been pretty diminished of late. In fact, as above, my motivations for much of anything have really bottomed out. That said, the two above were pulled from the last couple pages in the sketchbook. The lich king-looking guy is a study after work by artist Aleksander Golovatyuk and you should check him out here. Stuff to keep my hands and fingers moving.
Remote medical school has also been incredibly bad for my mental wellbeing. There are consecutive days at a time where I have no reason to leave my apartment and when I do it's usually to take call. This is made even worse by having issues with the rear wheel of my road bike, which introduces significant doubt in the bike's ability to ride safely. I've instead latched it to my indoor trainer, which I still ride daily, but it's not even remotely close to an outdoor cruise. I've considered it for months now, but I'm really believing this to be the straw to break the camel's back and providing impetus to purchase a new bike outright (believe me when I say there's a crippling amount of thought that I put into this to weigh a ton of variables, benefits and drawbacks). Canyon has become a top contender for the proposal, but I've got quite a lot more to do before I consider it a final decision. I'll post updates on the process as it continues to evolve. August 27th, 20208/27/2020
I had a day yesterday. One of those days where the mind doesn't want you to feel well no matter where you try to point your thoughts. Turns out doing medical school remotely is not good for the psyche. A combination of being physically separated from human contact for our overabundance of Covid-caution, taken completely away from my primary service with the exception overnight call (which I sit diligently covering now) and otherwise as alone as someone might get makes for a sour swallowed pill.
Although the efficacy varies, I usually try to treat that brand of blues with a bike ride. Much of my riding over the last month or so has been nearly at or well after dark, both because my days in the hospital were pretty long and the Philadelphia heat is oppressive, even after the sun goes down. So, last night I hopped on my bike to crush a few hills around the area and try to perk up. Fast forward and not once, but twice I toppled off my bike during the ride. Once where I hit a ledge of pavement trying to cross a small gravel bit and a second where a juniper bush caught me as I tried to avoid an oncoming pedestrian. Thankfully both were at slow speed, but my damn hip doesn't care how fast or slow it was, it still took a solid bruising. Scratched up the right knee also, but pretty minimally. Admittedly, I was pretty disappointed with the results of my intervention. At least the bike is ok, with the exception of a scuff on the back of the saddle. The call phone rings with stories of tongue injuries. August 24th, 20208/24/2020
We will be doing our first in-person meeting for med school small group tomorrow (or rather, later today). I'm hoping it's not too annoying to go through all the med school's version of hoops. Having been back on service for 2 months and operating within the hospital, I'm not sure how many additional steps the school will make sure we take. All I know is that the additional time may not be worth the efforts. I need to wake around an hour earlier to try to get through the first AM lecture because we need to arrive at least 30 minutes early to take some special elevator at a previously designated time. It was a lot better when all we needed to do to get into a building was walk through the front door.
My fickle friend, the summer wind8/23/2020
Like all things, so too must this summer come to an end. Since July, I've been rotating back on my primary service, OMFS, following the "first" didactic year in medical school. Our specialty is unique in the sense that at many training programs, OMFS residents bounce back and forth between their primary service, medical school and eventually other surgical services. Tomorrow (I'm writing this on Sunday night, into Monday AM), I return for the beginning of my second year of medical school, which happens to be in my second year as a categorical OMFS resident, that's also my third post-graduate year since dental school. Very clear, I know.
Unlike some other places in the world, OMFS in the US requires an individual to complete dental school then move on to residency. OMFS residency can last either 4, 5 or 6 years, depending on the curriculum structure of the program. Four year residencies conclude with an OMFS certificate only. Integrated MD programs set five and six year curricula apart. There are select few which have a five year curriculum (Case Western is a classic example). I didn't match into a residency on my first application attempt from dental school. This is where my first post-graduate year was accounted for; I was an intern on the OMFS service where I'm now a categorical resident. Although I still sign my notes as "PGY-2," I at least make a PGY-3 salary. I'm sad to return to classes, especially in the times of Covid, where they are delivered completely remotely. Traditionally, I preferred and attended class in-person; I feel the engagement of attending lecture, even just by maintaining eye contact with the speaker, provided so much more to me as a learner. Instead, I consider much of my education "YouTube Medical School." As an MS2 (medical student, year 2), I will begin some in-person small group sessions once again. Having spent my summer back on service in ORs, clinics and generally treating and interacting with patients and colleagues, I'm sad to know that the majority of my learning will again stagnate as I stare at my computer screens. My last weekend for the summer didn't consist of much, to be honest. Some futzing around the apartment, but not enough to see the difference. Lot's of videos on YouTube (I've discovered Comedy Central's Drunk History just in time to hear of its pending cancellation). A little drawing (I'll post when it's finally completed). Some riding, some running (I plan to start linking to Strava data for my daily rides/runs). Lot's of chai tea. Playing Path of Exile (new-to-me Diablo-esque game that I believe will quickly become a dangerous time sink...more to come). Welp, off to sleep for now. Cardiology begins at 8am sharp. August 20th, 20208/20/2020 Today's been a mixed bag of a day: busy in both good and bad ways and, in the end, just a long day, preventing me having much time to decompress and live a little of my life before crashing for sleep before repeating it all again tomorrow. This, the never ending plight of adult life, let alone the life of a resident physician. I still have a little shy of 5 years remaining, so I expect to run into this a lot as the next couple years pass by me.
I was given latitude to run my own sedation case today, including all aspects of monitoring and medication delivery. Easily, this was the highlight of the day. It's a big step in my mind to have earned the trust of an attending physician to be able to manage delivery of anesthesia as well as conducting a successful surgery. It went swimmingly well and it was a huge self-esteem boost, despite some other muck that I dragged my feet through today. I'm continuing to make steps forward with my training which, in light of that 5 years I mentioned above, provides me needed motivation to keep going when I might feel otherwise. Tonight, I'm hoping to add a little more to a sketch I'm working on. If nothing else, just put a pen in my hand and scribble something. How's it looking so far? August 18th, 20208/18/2020 Today's been an ebb and flow day: despite the seemingly full schedule, it's bounced between busy and dead-slow. Our first case in the OR this morning was delayed due to a faulty valve in the anesthesia equipment. Eventually the ball got rolling, but this threw a little wrench into the system and backed up the rest of the morning.
Regardless, I got to scrub for a case this morning with a couple of top notch co-residents, confirming my belief that the people make the party. I was then assigned to one of our clinic locations for the afternoon where I conducted a sedation for multiple extractions and a procedure called alveoloplasty - our fancy term for smoothening of jaw bone to promote a sound foundation for a denture or some other prosthesis. I also had a nice little struggle against a set of wisdom teeth, one with especially nasty, curved roots. In the end, we won and the teeth came out. I'm just now taking a short break on call tonight to jot down some thoughts. This evening, I sutured up some intraoral lacerations for a kiddo at the children's hospital who suffered a gunshot wound to the neck and face which our team will repair tomorrow. Although he sustained a severely comminuted fracture of his mandible (think shatter, not a simple break), amazingly he suffered no large vessel or cervical spine injuries. If there's some kind of luck involved in life, this kid got lucky. We'll see how the rest of the evening goes...only 12 hours left for my shift. On an exciting, completely unrelated note: I've rediscovered my childhood love and obsession with the Teenage Mutant Ninja Turtles. A few weeks ago I purchased an animated Batman vs TMNT movie and thought it very entertaining. Last night on my cycling trainer, I decided to search for something to watch while I busted out some miles and found a more recent animated series from 2014 on Hulu. Very entertaining so far!! I'd plan to see some TMNT sketches and swooning over the comics in the near future! AuthorI'm a burgeoning anesthesiologist. I like to do a lot of other things, too. My hope is to share them here. Archives
June 2023
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