Me, the students, and a pug named Raisin.

Last Thursday, I opened my home to my October ward team which included two medical students along with the interns and resident.  Late that evening, I received a kind email from one of the students, and I was sitting there smiling. Harry looked over and asked what I was grinning about. When I told him it was in response to her email, he shook his head, chuckled and said this:

"You know you love you some med students!"

I responded to that with a hearty laugh because it was absolutely true.  Man. I adore the residents and can't get enough of the interns. Brand new faculty members always make me smile. But medical students? I don't know what it is about them. They just occupy a soft spot in my heart. Especially the earnest ones.  The ones who value their education and don't think they hung the moon and perfectly arranged the stars. I just love this phase of learning in medicine. . . .I guess it just seems so special to me. Corny, I know.

(Go ahead and wretch now. I'll wait.)

I think it's mostly because of the interactions I had with attending physicians during medical school--particularly on my medicine rotation. Internal Medicine is probably the most important clinical rotation you do as a student. Not because it's the best specialty out there, but more because it's really the foundation for everything and almost always can be applied to everything else you do--even if all that is is field the questions of nagging loved ones.  For me, the Internal Medicine rotation during third year was . . . how can I put it? Non-descript.  No one seemed to know or care what I was doing. Ever.

I spent a period of time thinking I wanted to be a surgeon during medical school. For many reasons I felt this way, but a lot of it had to do with the attention and care the surgical faculty gave me every single day as a learner. I never, ever felt invisible. They were expecting us each morning, prepared to deal with us, and always down for some teaching.  The Socratic method the surgeons used never bothered me--in fact, it was exhilarating. It pushed me to read and try.  By the end of it all? Fuggeddaboudit. I wanted to be a surgeon.

It took Dr. Robin W., a fantastic surgical faculty member, role model, and advisor, to bring it to my attention that people who go into surgery generally love being in the O.R.  "Oh that," I recall saying.  See, "that" was problem. The surgeons were rad and I wanted to be like them, but I hated being in the O.R. (I shudder just thinking about it.) I'd shift on my feet, daydream and eventually just pray for it to end. Or pray that someone would need a consult on the floor and that I'd be asked to scrub out. The scrub-out order was NIRVANA for me. (Funny, I know.) My other trick was that I'd sign up for the shortest cases and then have everything on the wards and consult teams tidied up when everyone finally finished in the operating rooms.

"Loving the wards and not the O.R. is called Medicine, Kimberly," she said matter-of-factly.  "You didn't like your Internal Medicine rotation, but that doesn't mean you don't like the field itself."

Ah hah.

And so after a few rotations at other hospitals during my fourth year of medical school, I realized that she was right.  I ended up applying to and matching in combined IM/Pediatrics, but the point is that I didn't choose surgery mostly for that reason.

Back to the students.   So that has a lot to do with why I'm so sweet on the medical students. I know first hand how important it is for faculty members to take the time for them.  I will always appreciate Dr. W. for taking the time to guide me to the right field instead of beating her bosom and declaring that she'd swayed be into surgery. How nice it would have been for her to create a little "mini-me" that year. But she didn't. She wanted me to be happy, so that meant first listening to me and then taking what she'd heard and telling me the truth. She didn't have to do that either. Many folks still don't.

I've found myself interested in our med students' futures--that is, the right future for the individual--ever since.  This means building relationships with them, and hearing what makes them tick. That happens in hallways, on wards, over coffee, and in classrooms.  But it happens. I make sure that it always does.

Thursday-day, I had a meeting with a second year student after clinic was over. That night was the team dinner. The next morning I was testing students. After that I wrote a letter of recommendation for a former student during a one hour break.  Lunch was a meeting with one of my Small Group Beta advisees. I had some free time after that, so came home and took a quick power nap. But after that? I woke up and met a third year student for coffee after seeing him looking perplexed when I asked about his future. And that meeting was abbreviated when I rounded up the afternoon by meeting with another of my SG Beta advisees.  It was a pretty student heavy thirty-six hours, I tell you.

I wouldn't have it any other way, though.  I think it makes such a huge difference, and I'm the first to say that I'm the one who gets the greatest benefit from all of it.  Any time I look back at match day last March, I know that every single moment is worth it.  Every last one.



Yesterday, one of my Small Group Beta advisees stopped by my house to show my kids her dog. I love knowing that medical students at Emory have these kinds of relationships with their advisors. . . . where a light is always on--literally--which sometimes leads impromptu visits. . . this time complete with a fiancee and a cute little pug named Raisin. 

***
Happy Monday.

Reflections of an 18th Year Medical Student: Bananarama.

For me, being a medical student was bananas. Some of my richest memories are from that time. . .and some of my funniest. I just remembered something from back then while making coffee this morning and had to laugh out loud. (Loud enough for my kids to ask me to tell them the joke, too . . .or show them the YouTube video, too.) Anyways. . .it's funny to imagine how much we learn and grow throughout our medical training and experience. . . . .sigh. . . .

Labor and Delivery Wards
circa 1994 at the start of our Obstetrics and Gynecology clerkship:

True story:

This is a note that was in the chart, written by a well-meaning medical student/classmate who shall remain nameless, considering that this person is more than likely a fully licensed practitioner of the healing arts in some part of the world right about now. . . . .

Background: As medical students, we couldn't sign our own orders, which meant our plans had to involve either the immediate input and signature of the (very busy) attending physician or the (even busier and often annoyed by pesky medical student) resident physician. . .

. . . .unless, of course, the therapy didn't require a medical license.  . . . .(rubbing hands together) . .Bwaaah Haaah Haaaaaaaaahh!

Progress Note, MS III (med student, third year)

Subjective:  Active labor, progressing well. Pain 0/10 2/10 with epidural in place. Complains of leg cramps.

Objective:  Vital signs within normal limits. Temperature 37 celsius. Blood pressure 108/75. Pulse 100. Lungs: clear Cardiovascular: normal heart sounds, regular rate and rhythm. Abdomen: gravid, nontender. GU: 6cm dilated?, 70% effaced, position ? (will discuss with attending) Extremities: 2+ swelling edema.


Labs:  Potassium: 2.3 !!!  (VERY LOW)

Assessment:  1. 27 year old female G1P0 in active labor. Going to have her baby today (probably.)    2.  Really Low potassium  Profound hypokalemia.

Plan:   Give her some potassium.  A banana, stat. 
            Order given to nurse.

_________________________________________________________
Uuuumm, yeah. For the record, we have excellent alternative therapies to profound potassium depletion than emergent fruit consumption. (If only I had been a fly on the wall when the nurse received that "stat" order. . . . .)

::shudder::

All I'm saying is this: Lawd have mercy!! Thank heavens for medical education.

Um yeah.

Reflection on a Saturday: TB or Not TB? That is the Question.

acid fast bacilli of Mycobacterium Tuberculosis

  ______________________________________________________________

I got stuck in a Grady stairwell last week. I entered one of the locked stair entrances behind someone else who'd just gained access using their magnetic badge. I thought nothing of it. I mean, it's not like I needed the person to be all super-nice and let me into the door like some kind of visiting medical student. I mean, I'm on staff here. My badge works. But if someone wants to offer me an act of chivalry by holding a door for me to enter the stairwell, I'm cool with it. Completely cool with it.

But the chivalrous house officer who let me in bid me adieu at the 9th floor. I gave him a wave and kept trudging up a few more flights to the 12th. Huffing and puffing, I touch my badge to the plate waiting for the red light to turn green signaling an unlocked door.

::clunk::

That was the sound of me trying to pull open the heavy metal door. That's weird. I carefully separated the badges on my hook to make sure I was using the right access card. Let's try this again.

::clunk, clunk, clunk::

Damn. I was locked in the stairwell. Like a visiting medical student. No, worse than that since, now that I think of it, even visiting medical students have working badges.

I looked at my badge and. . . . awww shoot! "7/2010" was the expiration stamped boldly across the bottom it. I smacked my hand against my head. Aaaarrrggggghhh! The dreaded expiration lockout.

::clunk, clunk, clunk:::

(Visiting medical student) "Uhhh, Dr. Manning? Is that you?"

::clunk:: "Errr. . .yes, can you let me in please?"

Access granted. By a visiting medical student, no less.

Super.


***

You see, at all hospitals, but especially public hospitals caring for folks from literally everywhere, badge renewal comes with one special little rite of passage: the PPD or TB skin test. For those who aren't in the medical field, a PPD test is something that looks to see if you have been infected with tuberculosis. And seeing as folks in hospitals randomly cough and hock all sorts of things near you, on you, and around you--every year, it is the hospital's responsibility to the public to make certain that one of those folks didn't bless you with some acid fast bacilli (such as tuberculosis.)

I was supposed to have my badge renewed by the 31 of July, which means I needed to get a PPD test first. Okay, I'll admit it, I dropped the ball. I kept "forgetting" to take care of it. . . .that is until last week when I had to be rescued from a stairwell by a visiting medical student. Great.

So. . . . I hang my head and shuffle up to the 15th floor to get my TB skin test. Here's how it works:

You enter the Employee Health Clinic.

They ask you, "Is this for badge renewal?"

You say, "Yes, ma'am."

They say, "Let me see your badge, baby."

You say, "Yes, ma'am."

They take your badge and look at it. If you are a good egg with an unexpired badge, they smile and hand it back to you. If you're a hard-boiled (aka hard-headed) egg (like me), they see that your badge expired in July when it is now August. Then they ever-so-subtly turn the corners of their mouth downward and ever-so-audibly say, "Ummm hmmm." This is followed by a much deserved hairy eyeball as they hand your badge back to you, searing you with a scarlet letter for being a menace to the society (and public health.)



They inject you just below the skin of your forearm with this TB detection potion. If you're unlucky, it causes your arm to explode into a big red mound at the injection site if indeed you have been infected with TB. Oh, and it takes a minute to resolve. Um, yeah. That's pretty much how it works.

the positively positive puff-daddy PPD (with control)

When I say "infected with TB" I don't mean sick with consumption and coughing, per say. Millions of folks are "infected with TB" but it lies dormant in their systems. A positive PPD just means you've been exposed and infected at some point--but it doesn't mean you will get sick. Taking medication for 9 months after finding out you have the dormant or latent type of TB usually keeps it knocked out like Sleeping Beauty. So what's the big deal?

Okay, so here is my confession:

Sigh. I know I need my TB skin test every July and . . . .admittedly, I don't actually forget completely. At risk of sounding horribly horrible, I'll admit that:

• 1) I am annoyed that my badge is up for renewal during the hottest, most humid, most short sleeve bearing time of the year since

• 2) I have this secret fear of having an exploding mound on my forearm for the entire summer if I have indeed converted, and

• 3) It would really suck to have on a lovely sundress in July accessorized with a positive PPD. . . oh yeah and,

• 4) for the 48 hours after I get the test, I can't help but to chronicle every patient I've met all year who coughed, belched, sneezed or showed me a basin, cup or kleenex filled with giant, blood streaked lougies for my inspection. (I mean just maybe they could have been teeming with tubercles. I'm just saying.)

What happens to me every year:

• 24 hours after getting my skin test, the site is itchy, red and a little bit puffy. Oh no. Was it the man in the elevator who coughed from the ground floor all the way to the 12th last winter?

• 36 hours after the injection, the puffiness is mostly gone, now it's just red.

• 48 hours later, it's just red. Whew.

(For the record, a certain number of millimeters worth of puffiness, not redness, is what counts as a "positive" PPD test.)

Looks like my PPD is red, yes. But puffy? No, ma'am.

48 hours on-the-dot later, I skip into Employee Health all happy that I am no longer a menace to public health and society. I pull up my lab coat sleeve and show her my left forearm. Ting. (That's me smiling at my clean bill of health.) When I notice the nurse looking at my red (but not puffy) forearm, I decide I don't like the silence. Rut roh. I feel myself having a Grady flashback from four years ago with my PPD skin test reading.

Oh no. Not again.

See? It's always drama when it comes to me and the PPD. As mentioned before, every year, there's some preservative in the TB test potion makes my arm turn red, puffy and slightly itchy for the first 24 to 36 hours. During that time I get to worry and wonder if I've converted this year, (and nearly burst into flames in the 100+ degree Atlanta heat while wearing long sleeves to keep folks from asking me, "Ooohh! You PPD positive?") So far, that reaction has always subsided--leaving behind a small, flat red spot. For the most part, once they see that it's red but not raised, it's all good. For the most part with the exception of four years ago. . . . .

Employee Health circa 2006:

"Hmmmm."

"It's red but not indurated," I protested. (indurated = hard, puffy)

"I don't know about this, baby. . . .I don't know."

"Nuuhh uuuuhh!" I started feverishly rubbing my hand over my forearm and before I knew it, was defending myself like a 5 year old. "It's flat, see? It's not puffed up."

The nurse looked at me and shook her head. "I don't know, baby. . . ." she repeated.

She ran her hand over my arm a few more times and then said, "Come with me."

::smush smush ::click click:: smush smush::click click::

(that was the sounds of my heels following behind her nursing clogs.)

::smush smush ::click click:: smush smush::click click::

I walked behind her to what I thought was going to be the next room to get a second opinion from the other nurse. Nope. She passed that room and two more nurses. We kept walking. Down the hall, through a door and into another hall. Around a corner and yet another hall to a door, deep in the bowels of Grady. The nurse rapped on the door softly and waited for a response.

"Enter," a raspy voice commanded. My pulse quickened.

We opened to door and -- maybe it's exaggeration but is my recollection that the door creaked open slowly and a gust of smoke flew from beneath it. The first thing I see is an intimidating-looking woman with reading glasses hanging on a chain around her neck. (I am convinced that this is akin to meeting Yoda or The Wizard of Oz or the Oracle from the Matrix.) As soon as we crossed the threshold, she rose from her desk and slid the readers onto her nose. She slowly approaches me offering not even the slightest expression that could be mistaken for a greeting or welcome of any sort.

Instinctively, I thrust my arm out in front of her. Gulp.

Without uttering a word, she studied it with her readers, and then glided her hand over the red patch on my forearm. I held my breath and waited for the verdict.

::rub, rub, rub :: smack! ::

Pulling the glasses off her nose, she turned her back to us and muttered, "Negative."
And that was that. The master had spoken. No questions. No "but don't you think this part is questionable?" No back talk. Best of all? No TB for me (at least that year.)

Ever since then, I break out into a cold sweat when the time comes for me to get a PPD test. . . .one part vanity from not wanting the possibility of wearing a red mound on my forearm all summer (I'm just saying. . .) and one part PTSD from walking the green mile with that nurse to go see the Dumbledore of PPD readings.


Fortunately, I passed my test this year, too. And without having to get a second opinion. Whew.

***

Today on my hospital rounds at Grady:

:: clunk, clunk ::

Turns out that once you let your badge expire, you have to go to the secret badge dungeon even deeper in the bowels of Grady to get it reactivated again. . . .but that's another post for another time. . . . .

my so-called renewed badge (I look so happy 'cause I'm PPD negative this year.)

Reflection on a Tuesday: Joy Always

Today I

• Gave a lecture for the Emory Board Review Program at the crickety-crack o' dawn
• Almost overslept for the lecture that I was supposed to be giving at the crickety-crack o' dawn, but thankfully, was jolted out of a deep, deep, good, good sleep by my pager.
• Realized that the reason I almost overslept was because my two human alarm clocks were sleeping over at their grandma's house. (Thanks, Toonces!)
• Realized (the minute I pulled into the Grady parking garage) that the heels I'd worn to give my lecture would render me unable to walk by the end of rounds. (O. . .M. . . .G. .)
  
• Realized that I'd left another pair of low heels in the back of my trunk from the last time I'd snuck off for a post-work pedicure. (Hallelujah for having a junky car!)
  
• Joined my team for post long call rounds wearing comfy shoes from my trunk.
  
• Made my team walk up five flights of stairs because of my comfy shoes.
  
• Congratulated a patient for abstaining from crack cocaine for 8 and a half months
• Said a quick prayer to myself that she would stay off of cocaine for 8 and a half more months
• Realized that this patient and I are both the same exact age and are both black women, and wondered what my life would have been like if I had gotten addicted to crack, too
  
• Saw a patient playing herself in Scrabble. I asked her, "Who's winning?" to which she answered, "Chile, Me!" We all laughed out loud.
• Asked the same patient if she was trashtalking while playing herself. She said, "Oh yeah! You always trashtalk when you play scrabble, even by yourself!" Nice!
  
• Had lunch with my friend Ildefonso, his wife Lourdes, and my other friend, Tammy at the Sweet Auburn market
  
• Picked up a "stray" medical student after lunch and had him join the rest of my rounds today. He actually looked lost.
  
• Asked a patient about alcohol use, and consoled her when, instead of answering me she started crying
• Massaged a knot out of my patient's back (upon her request.) Wondered for two seconds if I should, but then realized that as sick as my elderly patient was, it was the least I could do.
• Said hi to a five year old little boy who was visiting his great-grandmother in the hospital. He asked me, "Do you be on TV?"
  
• Gave one of my favorite social workers a big hug and told her I was glad to see her
• Sent my husband two text messages during the day that said, "I love you so."
• Received two text messages from my husband that said, "Me too. :)" and "Me too!"
  
• Told a patient that he has something that could be a cancer
• Realized that he didn't understand
• Realized that he had not gone past second grade and couldn't read or understand most of the things we talked about related to his condition
  
• Realized that even if he had gone past second grade, after living over eighty years in perfect peace he might not want to understand
• Gave a medical student a fist bump for doing a good job
• Felt pretty when one of my senior patients told me I looked like Halle Berry.
• Realized that she had Alzheimer's dementia, but decided that I would ignore her cognitive disability when it came to thinking that I was the doppelganger of the world's hottest woman.
  
• Sat in my office for a few moments and drank some TAZO Green Ginger tea before leaving. (Aaaaaah. . . . )
• Reflected on my day for a few moments.
  
• Wished my thirty-nine year old patient had never tried crack and never got infected with HIV
• Wished the other three patients I'd met today who used crack had never tried it either.
• Prayed for every person who has had their life ruined by crack cocaine
• Received two thank you cards. . .one from a medical student and another from the daughter of a deceased patient
• Closed my eyes and felt a moment of joy. . . .
• Remembered one of my patients from last year who told me, "Don't never let nothing steal your joy" -- and smiled.
  
• Gave myself a fist bump for doing a good job or at least trying to.
  
• Sent Harry another text message that said, "I love you again."
  
• Reply: "Me too ... again."
• Decided I would drive home saying over and over to myself in my head. . . Joy always. . .Joy always. . . Joy always. . . .