Happiness hits you like a bullet in the back :)

It's been a while! Over a month, times flies when you're busy/having fun/stressed/crazy :)

When I posted last I was still in San Antonio, TX and loving the ED and the idea of possibly winding up there for residency.  I came back and jumped right into non-emergency medicine grind, the civilian residency application process, and the stress that comes with all of that. Yikes! So, September was a somewhat high stress month for me. Things that happened in September:
1. ERAS and other med student stress
2. Took care of mama after surgery
3. Got back to climbing and running (signed up for marathon)
4. Once again proved that test-taking is NOT my strongest suit
5. Once again proved that I'm not going to give up on emergency medicine
6.  and many other little things...

It doesn't seem like much when I list it, but it was somewhat of an emotional month where I struggled with myself and had to prove my passion for pursuing my future goals regardless of how difficult it is :) More specifically, battling people who discourage others from pursuing dreams because the road is unknown and challenging. I don't work that way, as you know. I've proved lots of people wrong to get here, so it's nothing new to be told I can't do something...I just don't like hearing it. Eventually however, it serves as more motivation. So, now I'm sort of in a waiting period until December as far as residencies. Until then, I'm enjoying life and not letting a damn thing discourage me. I'll take life one day at a time and work it regardless of what happens!

Anyway, in other news,  I'm going to Bogota, Colombia in February to work in a Peds ED at a hospital called Fundacion Santa Fe de Bogota!!!! It has been a LONG process to make this happen, but it will be well worth it in the end to do some international medicine, one of my biggest dreams! (especially with kids) Again, I've met resistance as to why I'm doing this, its so much work to set up. I've just resorted to telling people that I don't do things the easy way haha. It's sort of true. ANyway, I'm excited to experience how Colombia does medicine and work with local kids. Hopefully I'll make it up to the mountains and do the "doctor rounds" in the little town where my mom was born. A doc hikes up once every couple of weeks and makes home visits to the people that live up there, off the grid, living off the land. It's awesome, I'm excited! My last international medical trip was the most humbling experience of my life and put everything in perspective for me. I'm ready for that again.

So the past month has been packed with a lot of things! (like that's anything new lol) Although it has been up and down, I can honestly say that I'm extremely grateful everyday for being exactly where I am and where I'm going, although I'm not really sure of where that is. Just having faith that great things are coming!

More updates soon...

Things I love/hate...

Things I've HATED (or just disliked) about this month:

- the politics of the military (i.e. useless paperwork, people making up stupid irrational rules to get promoted, etc)
- High heels in service dress
- Blues pants!! (who ever designed the blues uniform for women needs to be tortured, seriously. )
- my bathroom faucet that leaks every 1.5 seconds and I SWEAR gets louder at night and can be heard through a steel door!
- Having BMT kids stand up and at attention when i walk into the room in the ER. I know they're conditioned to do that, but i dislike it a lot. Same goes for the "yes/no ma'am" after every question.
- Seeing a little girl with "facial droop", making several glove balloons for her, and then finding out she has a large brain tumor and has less than 1 year to live. :(
- Having crazy enlisted people yell at me for a uniform issue while they neglect the things that really matter...like a patient with sats in the 70's!!
- The wasps (ugly black ones) that seem to live and multiply in my stairwell and chase me every time I need to come to my room!
- The smallest shower known to man, that also floods the floor with every use.
- Going for a run after dark and sweating so much that my shoes are soaked, gross.
- Wearing Blues on mondays!
- Whiney BMT kids that complain about everything and don't know how to cope with a little stress.
- cynical people, especially cynical doctors that hate their life!
- Nurses that think they're doctors
- blood on my boots :(
- Seeing a sexual abuse case on a 4 yr old
- Colonel's who think they deserve special and faster treatment in the ER and refuse to be seen by medical students
- Feeling like matching at this program would take a miracle because of my board scores :-/
- People who walk around with a chip on their shoulder

Things I love/hate...

I'm almost done in San Antonio!! It seems like these past 2 months have gone by so fast! I've learned LOTS and made some awesome new friends. I hope I'm back here this time next year (fingers crossed!!!) THere are SO MANY patient stories funny, sad, and awesome from this month that It would take me forever to write about all of them. Instead I'll just list them in my love/hate lists...

Things I LOVE from this month:
- Taking care of basic trainees that are so pumped and don't even realize they've lacerated their faces in the field and are forced to come get sewn up by the MTI's, and when they arrive, ask not to be numbed up because they want to be "tough". Some of these kids are sooo pumped up about getting their asses kicked everyday...how can you not love them!
- Out of all the basic trainees that we see everyday in the ER for "lightheadedness:... basically being "wimpy"...90% of them are male! :-D
- Finding an acute appendicitis on a WWII mustang pilot! (and then sticking my finger in his butt, that part i didn't love, but how many people can say that?!)
- Convincing a resident to get a CT abdomen (and betting a cup of coffee that it finds something) and finding a weird congenital intestinal anomaly that required immediate surgery! (ok fine, maybe I was ridiculously lucky on that one, i just wanted coffee, but sometimes its better to be lucky than good!)
- Being part of an all female trauma team :)
- Finally grasping the concept that in less than 1 year, I will be a freaking doctor! (are you serious???)
- Being around people that understand exactly what I'm thinking without even having to say it
- Not being the only one who seems to have to know the age of everyone we're talking about, even non-patients ;-)
- Waking up to taps and going to sleep when I hear reveille :)  I love the schedule of an ER doc!
- Being a part of a collective "yaay!!!" when the trauma phone rings.
- Learning that I too have my own "spidey-sense" about patients and even better, that a lot of times I am right!
- Not feeling like an idiot during a resuscitation
- Being pushed by residents/staff to be better all the time
- Realizing that i'm NOT the most type A person I know ;)
- Speaking spanish to my patients and having them tell me they are "proud of me." (i'm not really sure for what, but i just say thanks lol)
- Seeing people in the exact place/places I want to be and knowing the sky's the limit.
- Talking and Writing in only acronyms and abbreviations
- Hearing the words... "i trust you doctor"
- Looking at an ultrasound and actually seeing more than black and white dots!
- Sticking needles in things
- Having a consultant doc believe that I'm actually a doctor and not a med student!
- Being in a place where, 3 years ago, seemed so far away! :)

From Dayton to San Antonio...

So I'm halfway done with my Air Force Rotations! :-)  The Wright-Pat AFB rotation was an overall great time! I'm not just saying that because it is my first choice for residency, it really was probably the best rotation I have had yet. It wasn't a crazy county ER by any means, but I think that really had it's advantages. It wasn't so over my head that all I could do was watch. I was able to handle pretty much everything that walked through the door and it really helped me mature from just taking history and physical exam, to managing the patient from start to finish independently (in most cases).  It forced me to think more like a resident and that made me learn A LOT. Not only that, but this was the first rotation where I felt the staff really put effort into giving the med students a great experience. I really felt like they cared about us rather than using us as work horses.  They, meaning the residents AND attendings, really made me feel welcome and like they genuinely wanted to help me. At a lot of rotations, it somewhat feels like they look down on you, sort of like a fraternity/sorority and you're the new pledge (not that I would know since i wasn't in either lol, i just think thats what it would be like). Dayton isn't really the most appealing city, but I would go there for the EM program to learn from these awesome people. I feel like i fit in better there.

So all that being said, I'm in San Antonio now!! I've been here for 2 days. Today was my orientation day and all I can say is this is TOTALLY DIFFERENT from the Wright-Patt program/ base.  This base, Lackland AFB, is where all all of the new enlistees get trained. Every enlisted person comes through Lackland AFB for what's called, Basic Military Training. It's essentially "boot camp" for the Air Force. So naturally, there's lots of young airmen around here learning the ways of the Air Force. Because this is a big "training" base, they do pretty much EVERYTHING by the book. The rules for pretty much EVERYTHING are highly enforced, almost to a fault.  It's not a bad thing necessarily, it is just crazy how 2 bases can be so different from one another. I haven't felt so scrutinized as far as uniform wear, proper military customs and courtesies, since i was in ROTC. I had heard that it was different here, I guess this is what they meant.

So today was a long and pretty frustrating day. Orientation consisted of running around to various offices to complete all the in-processing paperwork. In true military fashion, nobody knew what the heck was going on and it was highly disorganized and made no real sense to me. (as much as this goes against every fiber of my being, i had to just accept it and not ask why).  This was what made it very frustrating for me. Here I am running around all morning getting confusing documents signed, getting totally random immunizations and lab tests (polio, HIV, and tDap???).  I, along with 30 other students are given "priority" over anybody else who needs vaccination or tests because we "need" these done today. This is what really got me...There was an active duty MSgt who sadly had to wait for about 3 hours to get his vaccines and documents signed for his Humanitarian trip to Haiti, which he is leaving for TOMORROW, because we all had "priority". Really Air Force??? Since when does my rotation take precedence over a mission to a third world country to provide medical aid??? This along with a few other frustrating events today really took me back to the part of the Air Force that I struggle with. There's often a HUGE disparity between doing what makes sense/most efficient and what the Air Force sees as best practices. Some of the time, it seems like the AF does the opposite of what makes sense. I have some theories for why this is, but that's not really the point. Today I was reminded of exactly why I struggled to get released from the Air Force to attend med school and it almost felt like I was meeting my old enemy, beaurocracy. Obviously, today wasn't nearly on the same scale, but it was a quick taste of what that was like, and i DO NOT miss it. So I don't mean to sound like I'm complaining about the Air Force, because I'm certainly not. Some days I struggle with balancing the positive and negative, especially when I have a frustrating day like today. It pains, ESPECIALLY when things make no logical sense, to just "do what I'm told" without asking the question of why.  I know this is the way of the Air Force at times, but it's an ongoing struggle that I'm not sure i'll ever get over.  I love the air force, it has only brought me great things, but some days, as with everything in life, I get a real good reminder of the things I don't love as much. Maybe that's why it's the military, it has inherent sacrifices. As much as I don't like doing it (because it doesn't really matter at this point), these really frustrating days make me wonder how different my life would be without the AF. I honestly have no idea.

Anyway, i've heard people say "some days you are the windshield, and some days you're the bug"...today I was the bug :(  BUT, tomorrow is another day. And maybe being the bug sometimes makes the days when we're the windshield that much better! :)

I'm def going to be a windshield tomorrow!

Some Dayton Updates...

So I'm nearing the end of my time in Dayton, it went by crazy fast. Probably because I was so busy and always trying to normalize my sleep schedule...such is the life of an ER doc I suppose. All the docs here say that's the worst part, the continuous changing of sleep cycle. It really hasn't been too bad though, I actually went running at 3am one night on base, it was pretty awesome.

I have my last shift on Tuesday and I'm doing our "final presentation" that we're required to do. We also have to take a "final exam" or something on the last day. This pretty much sucks because I've heard it's random and impossible to study for. Also, my test taking track record always haunts me. After that last shift I still have like 5 days in Dayton until my flight to San Antonio, so I'm hopefully going to climb and explore a bit more.

I had my interview last week and overall, I think it went great! (but who really knows, they could've thought i was the weirdest person ever lol) I consider myself personable but when it comes to the "official dog and pony show interview" i tend to get nervous. I just am not a fan of putting on a show for people and selling myself with all of this "i'm going to tell you what you want to hear BS". And there are A LOT of applicants that I've met, not just here, but everywhere, that seem to be great at this. Maybe it's a negative thing that I somewhat struggle with the specific formalities of the things you're "supposed" to say in an interview. But, that's just not me. Sure I can interview well, but the second I try to pretend to be somebody I'm not, it goes down hill and I lose my train of thought and end up sounding like a tard. So, as I was preparing for this interview, which by the way was the biggest interview that I'll have since it's my #1 choice, I tried to not over rehearse or have any "canned" answers.  I had main points that I wanted to touch on, but I mainly tried to focus on staying calm, being myself.

My first interview was with the Chief resident. It was pretty laid back but certainly covered all the main questions, i.e  Why ER, Why AF, What are you good at, what do you suck at, etc. It was cool, but to be totally honest, the interview seemed really formal for what I was expecting from a resident. The other students confirmed that he was sort of too "by the book".  He was really nice and everything, I just felt like he was rushing through questions he "had" to ask and that made it seem somewhat impersonal.

The second interview was with the program director, and the session I was the MOST nervous for. So after all of the build up, this session turned out to be my favorite one so far. This doc (who was the same guy with the situs invrsus kid i wrote about in my previous post) is absolutely, without a doubt, one of, if not, my most favorite AF doc. We hadn't had anytime together on any shifts so I was worried he wouldn't know me that well. But as soon as we started talking it was crazy because it was so casual and informal. I honestly felt like I was talking to one of my best ROTC friends, and that made me feel really good. He didn't ask me any of the typical questions. He flat out told me he was really happy to see how much we had in common (he did ROTC also) and he wanted to hear about how I've gotten to this point. This interview was more like I was talking to a friend, it was really crazy. He wanted to hear about my ROTC life, my maintenance experiences, and how the heck I managed to get out of that to go to med school...apparently he understood how difficult that is. So i talked about that and how it started out as something I hated, but turned into one of the best experiences of my life, how it made me who I am today. I mentioned how I sort of feel like "fit in" better with my air force friends and what it means to me. Towards the end of the talk, he said some things that make me feel like the interview was a success. He told me that I'm a really unique applicant for a few reasons. The prior service thing, being in charge of more than 50 people, which in the med group, you only do when you're Lt. Col or above (aka i have more leadership experience already than him and most of the residents and practicing docs lol). But the thing that he said that made me really happy was that he told me I reminded him of himself and he could tell by my enthusiasm that I was being real. Going back to my whole thing of hating the formality of an interview, this was awesome to hear. Not only did I feel like I could be totally myself with him, he picked up on the fact that this conversation was different than the usual fake interview. That's an overall success for me, no matter what happens.

So i guess it's out of my hands now, I did my absolute best, and left it all on the field, so to speak. I know there are LOTS of people interviewing and competing against me, I just hope I'm different enough to stand out when the board meets. But if not, if I have to fight my way through again and do a general medicine year, that;s ok too. It's not like I haven't been in that position before, except that was worse lol. I'll be fine because even when it doesn't work out, it actually does, just in a different way. ;-)

Right where I belong...

Last week's conference, although it was an incredibly stressful day, was one of my favorite days of this rotation. It was stressful because we just got the numbers from the AF for how many ER docs they needed and it sort of hit me that this whole match process is finally here. That plus seeing other students interview and hearing how competitive it is really freaked me out for a bit. The thing that brought me back down to my baseline level of insanity was a presentation by the program director. He was lecturing on thoracic emergencies and did a separate presentation about a case he has while deployed to Bagram Air base, Afghanistan.  I'm going to try to tell the story the way it was presented...

The case was about a 7yr old Afghan boy he took care of immediately after an IED (improved explosive device, basically a makeshift bomb insurgent's plant all over town) went off in village market in the middle of the day. There was a large number of women and children hit and he happened to see this boy. This sort of thing happens unfortunately, pretty frequently. Kids are brought to Bagram all the time and taken care of. This boy, however, was not like any child routinely seen anywhere. On initial exam, before delving into his blast wounds, the doc noticed something strange about his fingers and toes.  They looked something like this:

For non-medical people, it's called "clubbing" and the exact physiology of it isn't really known but it's hypothesized that it's caused by a process that allows for right to left shunting of blood in the heart and leading to the mixing of oxygenated and deoxygenated blood in the body. It has been seen in people with long standing COPD, lung cancer, TB, cystic fibrosis, etc, something basically affecting oxygen content in the blood. Anyway, so as the primary survey goes on they notice this clubbing, puncture wounds to his chest and abdomen, and some other minor cuts. So just from the clubbing alone, doc new something was not totally right. As things progress and they start the trauma series of xrays, labs, etc they quickly realize this child  is incredibly unique. His chest x-ray looks something like this:

Notice anything wrong?? (I thought of scrubs at first and how they hang the xray backwards at the beginning of the show lol) But no technical error here...his "stuff" is on the wrong side! Heart and stomach, both on the right! This kid had what is called, Situs Inversus, basically where his organs are transposed to the opposite side of his body. He also had transposition of the great vessels of his heart, aka  the main vessels of his heart were also reversed. Crazy right? How is this kid even alive?? It's crazy because transposition of the great vessels is a condition incompatible with life in 100 % of cases UNLESS, unless, unless, there is small hole in just the right spot in his heart. In other words, his heart is totally backwards and this small hole, a ventricular septal defect, is allowing this crazy rearrangement of blood vessels to adequately oxygenate his body. Holy crap right?? Mind you, this kid is 7yrs old!! Which means, for his entire life, from the day he was born, his little body has been working sooooo hard to compensate for this congenital heart abnormality. AMAZING. 

So back to his resuscitation. After docs quickly figure out sort of what they're dealing with, they get some labs back.  The only 2 real labs of importance to explaining this case are Oxygen saturation and Hematocrit. Oxygen saturation is around 81%, which is low, but not as low as expected for somebody who probably has a huge hole in their lung, normal is greater than 92. His hematocrit, just a measure of the actual red cells in a blood sample, was also 81%, normal is anywhere from 40-50%. So this kid's ox saturation and his hematocrit are the same!!! This basically means this kid's blood is incredibly thick, to the point where this level of Hct is never seen, like ever! It's another way that his body has coped with this heart disease that he has, that's one of the ways he gets more oxygen, is to make lots and lots of red blood cells to carry more oxygen. Again...amazing. 

So now the docs realize that their previous knowledge of "normal" physiology has gone totally out the window. How can you even begin to try to treat/correct/maintain his physiology when you have no freaking idea what is his "normal" in the first place? All they really know is that he needs surgery to remove metal that is in his lung and abdomen making him bleed into his belly. 

*Side note: My favorite part of this presentation was when the doc was telling how $hit was hitting the fan and he had to run back and forth between this kid and a few others. He described what I can only picture to be the extremes of emergency medicine, badass docs and nurses running around making things happen in mass chaos. (doesn't that sound incredible?) My next favorite part of the story is when the doc, after getting the kid somewhat stable, tries to get a pediatrician (since he is 7yrs old) to take over. The poor peds guy practically craps his pants at the thought and refuses! I'm sure he didn't refuse because he was a jerk, I just think he was too scared to take on the case. :-) Sorry to all my peds friends, but I had to throw this in there.

Anyway, to make a crazy awesome, but long story short, the doc ends up putting a chest tube in the kid and taking him to surgery to remove the shrapnel left in his chest and abdomen. He survived the surgery but sadly died from complications of pneumonia several days post-op :*(

It is really really sad that he didn't make it. My first thought was, poor guy, so unlucky, just caught in the wrong place. But after really thinking about it, turns out that he was actually incredibly lucky to even be in that market in the first place. He basically overcame all odds to even be breathing, let alone live for 7 years. He wasn't just lucky, he was a walking miracle. We'll never know how long he would've really lived had he not been hit with that IED, but it surely wasn't going to be very long. It's even more amazing that he survived surgery. There's so much that has to go right in his physiology to sustain him, his body has been perfecting this for years. Surgery is highly risky in "normal" people, let alone him. So all in all, the fact that he died in the end while really heartbreaking, it's just a testament to how big of a miracle his life was to begin with. 

After/during this presentation I pretty much had chills. One of my dreams is to travel the world and practice medicine in places that doesn't have doctors really. To treat people, like this little kid, who have never seen a doctor in their lives. It's a huge reason i joined the Air Force. So although I sometimes have my doubts about how the AF will impact my life, hearing stories like this puts everything back in perspective for me. Stories like that are the exact reason why I'm here. Nothing pumps me up more than to know that I will be (hopefully!!) able to go around the world and have my own stories similar to this. Of course being a doctor alone is sweet, but being one of the few people who can handle crazy cases like this one, and help people that would otherwise NEVER see a doctor is incredibly exciting. 

There's a lot to worry about right now in this stage of the game. Residency applications, board scores, what happens if I don't match, where will I live, what if I'm still single at age 50 (lol, jk), it's A LOT to think about.  I do my best NOT to think about it too much and reassure myself that things will work out, they ALWAYS do.  But that day, sitting there listening to the story about that miracle boy made me REALLY realize something. The feeling I got from it made me see that although i am unsure of LOTS of things, like where on earth I'll be next year, or what I'll be doing. One thing I DO know is that right now, pursuing this dream, (totally stressed and confused and scared) no matter what happens, I'm exactly where I belong and wouldn't have it any other way.   

Just a few more months....

So there's a lot I have to write about, but it's late, and i just got off a long shift. But I just wanted to comment on the 2 things about my shift tonight that stood out more than anything:

1. "are you a real medical doctor? As in, you went to medical school? Because you don't really look like someone who would become a doctor."

I don't take personal offense to really anything a rude patient or even more rude family member says to me. This isn't because I have no emotion and am an "ice queen" as most would say. But mainly, it's because 99% of the time, the people being rude jerks in the ED are just not smart, at all, but they somehow think they have this wealth of knowledge because they have a 4th cousin who is married to a guy who knows a doctor, or something retarded like that. Anyway, tonight I went into a patient room to see a kid with a rash. No big deal, he has a rash. My first thought was (as I'm seeing this 5yr old kid, with no apparent rash, jump up and down through the door screaming along to the cartoon on the tv)..."wow, this kid couldn't be farther from having a life emergency, dandy." This also give me the first clue that his mom probably is not the brightest crayon in the box. So I go in, start talking to the little guy and mom. Before I can really start asking questions, mom flat out asks me if I'm a real medical doctor and proceeds to clarify that she's asking if I went to actual medical school. It was funnier than insulting actually lol. I had to stop myself from laughing almost. "did she really just ask me if i'm a medical doctor that went to real medical school?"

I explained I was in fact not a doctor yet, but am almost finished with ACTUAL medical school (the kind where you learn medicine and stuff). She was shocked because apparently, "you don't look like you would become a doctor."  WTF? I'm still not sure if that's a good or bad thing, i'm still sort of laughing at the whole encounter. But i assured her that despite my looks or whatever, I am qualified to be asking her questions about her son's non-existant medical emergency that she calls a rash. I basically told her some benadryl would clear up the miniscule red spot and "itching" her boy was having. 5 mins later, the attending comes in (only to appease her because I could tell she didn't believe me), and says the SAME EXACT WORDS, almost verbatim. I wish I could've had a camera to video her reaction that was SO appreciative and relieved and made it seem like the attending had just told her how to win a trillion dollars and I had told her nothing. SO...what did I learn from all of this and this crazy lady, other than the fact that apparently I don't look like a doctor and 95% of the people I see in the ED are very very unsmart. I learned that i CANNOT wait until somebody asks me that question and I can answer, YES DAMMIT I'M YOUR FREAKING DOCTOR! :-)

2. So tonight seemed to be "vaginal bleeding in pregnancy" night in the ED. We had about 5 women in a row come in for vag bleeding all less than 15 weeks or so. I got lucky enough to work all of them up and by the 3rd one, the doc was letting me pretty much solo the patients, meaning, I'd do everything, orders, exams, and they would just say a quick hello at the end, when OB/gyn came down.  My 5th lady that came in though, she was the one that gave me an experience that I don't think I'll soon forget.  She was bleeding pretty badly, hadn't felt the baby move in a couple days. When I told the attending about her he sort of grimaced and said in not so may words, he was pretty sure the baby was not viable anymore. So, with this in mind, I go in and do the pelvic to work her up just like everyone else. Mind you, this poor girl had been crying from the second she put the gown on, she had 2 previous miscarriages at around this same time. I set up the ultrasound, trying to console her without giving her false hope, but also without being unrealistic, she had lost a ton of blood. So as I'm getting the probe on her belly, doc walks in and stands there waiting to help me give her the bad news that her baby's heart isn't beating. So I look around for a few seconds and seriously, it was the craziest, one of the most emotional moments I've had in med school for some reason. Not sure if it was because you could feel the fear in the room from this girl at the thought she lost another baby. Maybe it was because it was my first time or so really being the one to find or not find a heartbeat. So after looking for about 2 seconds, I found it...it was beating strong and baby was moving. Right at that moment lots of things happened...i'm pretty sure my own heart stopped for a quick second, the patient screamed/sobbed louder than crap, and even the attending let out a "wow."  It was amazing and i was so happy that I let the probe slip and I lost the heart lol...but I found it again fast! So everyone was happy, not totally out of danger, but the baby was alive, unlike we all expected. I guess I never really grasped/felt how surreal it is to see your baby's heart beat on a screen. I've seen tons of them, but tonight it really hit me. I've never seen my own baby's heart beat (obviously!), but if this is even an indication of what that is like, all I can say is life is really a miracle. So yea, I'm pretty confident that I won't forget those couple of seconds for a long time. I should also not forget to not drop the probe during such crucial moments lol.

More updates to follow :)