November 2006 Archives

My first interview in New York was with the man who cut open John Lennon's chest after he was shot.

- Thoracotomy: to cut open (otomy) the chest (thorax). A last ditch emergency procedure to salvage the heart in the setting of penetrating chest trauma, the thoracotomy is performed by making a deep incision between the 4th and 5th ribs on the left anterior chest, spreading the ribs, opening the pericardial sac, inserting the hand into the chest cavity, and attempting to directly close any hole in the heart while, if necessary, performing cardiac massage to manually pump the heart if it has already stopped beating. This procedure was unfortunately unsuccessful in John Lennon, as it is with 95% of the people who undergo it.

While shaking the hand of my esteemed interviewer, I did not know that that same hand had, 26 years before, held the heart of the man who's face looked down on my childhood bed from numerous posters and album covers. How desperate that bloody clutch must have been.

I performed a thoracotomy once. On a sheep. A sheep that was anesthetized and finally "sacrificed" so that I could learn a potentially life-saving procedure that I may never have to perform. In the animal lab at the University of Minnesota I found myself staring into the open chest cavity of a living, breathing creature. I could tell that it was breathing because I could see the lungs right there, soft mottled pale pink pillows inflating and deflating to the rhythm set by the ventilator. And I knew that the ventilator tube was in place, because I had intubated the sheep myself, several times, after placing various IV's, a central line, an arterial line, and an interosseous line. Poor sheep.

It was about to get much worse for that nice sheep, because I was about to open the delicate sac around its heart and attempt to repair the hole in the heart muscle that my instructor was about to cut with a scalpel. What followed was one of the most poignantly comedic moments of my medical school career. Staple gun in hand, I closed the hole in the fibrillating heart. And then, because the sheep's pressure was dropping, and she kept slipping back into V Fib, I got to inject epinephrine directly into the heart itself, a la Pulp Fiction, if you will. The heart responded so vigorously to this literal rush of adrenaline that the staples I had placed started to give and blood started to leak out of the heart. I stopped it with my finger, and then, in classic form, leaned in to see what the problem was. "I'll just take a closer look." When I released my finger, blood exploded out of the heart and shot over 10 feet across the room, completely bathing myself and my colleague, in addition to the back wall, in warm sheep blood.

Standing there, blood splattered across my face shield and dripping down my arms, my first thought was "this is AWESOME." My second thought was, "this is awful. My patient is bleeding to death, so I should probably try to close that hole." I frantically jabbed staples haphazardly into the wildly beating heart, blood continuing to spurt and splatter between my fingers. As the heart started to tire, I wrapped my hands around it and squeezed, trying to prolong the life that was destined from birth to be unsaveable. Thank you, nice sheep. I aknowledge the callousness of sacrificing animals for the sake of medical education. It made me sad, but I will never forget what I learned that day.

My dad later asked if I thought they would use the sheep to make dog food. I said that I didn't think so.

. . .

Interviewing is weird. You have 20 minutes to express to an attending physician, perhaps the program director, why you would make an excellent addition to their residency program, while all the while giving them a sense of your personality and interests and intellectual prowess. You walk in and shake hands. You sit down. Sometimes, the program director will be playing Dvorak's New World Symphony on his computer, and you can talk about classical music and jazz for most of the interview. And sometimes it is more formal, and you get asked a question before you sit down. If you are me, your question is "Ask me a question." And if you don't know that the man who is sitting across from you held the heart of John Lennon in his hands as he died, you might respond with something like, "How long have you been at St. Luke's-Roosevelt?"

I am in New York. I am interviewing for emergency medicine residency programs. It is awesome and only slightly overwhelming.

When I am not touring emergency departmets in my espresso brown pantsuit, I am staying in Brooklyn at the apartment of my very nice friend Marisa and cat-sitting for her across the street neighbors. It is a wonderful arrangement that i gave thanks for yesterday at the Mexican Thanksgiving feast that I was graciously invited to, sitting around the large table with people from all over the world. Marisa and I made an enormous vat of guacamole and brought fixings for dark n' stormies.

I have been doing a lot of classic NY walking and sightseeing. Brooklyn bridge - check. Soho- check. Canal Street - check. Central Park - check. After a lovely walk in Central Park on tuesday, I found myself standing next to the Natural History Museum as they were blowing up the floats to the Macy's Thanksgiving Day Parade. Sponge Bob smushed his face to the street, the body of Ronald McDonald lay splayed out flat like a cheery police tracing, the Energizer Bunny sat forlornly caved in on himself. All these enormous crumpled cartoon icons puddled in the streets of New York.

Fun New York fact: There is no trauma here. The violent crime rate has gone down so much that emergency medicine residents at NY hospitals are not getting enough experience dealing with trauma (gunshots, stabbings, etc). They have to do rotations out of the city to get properly trained, in Las Vegas and Miami, for example. Who knew? This renders ineffective all my jokes about getting "knifed" on the subway the minute I arrived.

Happy Thanksgiving.

The adventure began moments after the purchase of my new espresso brown pantsuit (I prefer the the word "pantsuit," as I find it lends the appropriate amount of humor to the situation). I decided on brown. The choice of the radical and non-traditional brown, instead of the conservative black or blue that I had been advised to purchase, is my own way of saying "take that, The Man, you will not oppress my spirit with your conformist demands - I violently rebel against you and all that you stand for with the revolutionary choice of my tasteful espresso brown pantsuit!" Fully satisfied with my personal victory over the evils of modern society, I proceeded downstairs to the Nordsroms shoe department.

Now, before I proceed with the Adventure, I must put you in my shoes, as it were. Imagine that you are a 6'1/2" young lady who is in possession of a sturdy pair of slightly mismatched feet that are both significantly larger than what is carried by most shoe stores. You have the unfortunate distinction of landing somewhere between size 11.5 and size 12, depending on which foot we are measuring. You have noted over the years that all of the really attractive, cute shoes that the other young ladies wear usually stop at size 10, and you had long ago resigned yourself, as a size 10.5-wearing 7th grader, to only purchase men's sneakers. You remember with a cringe the time when you were renting bowling shoes and the shoe rental guy laughed and exclaimed "are you going water skiing?!" Fast forward to today, when you are the proud new owner of a very professional espresso brown pantsuit, searching for a matching pair of enormous brown ladies dress shoes.

Imagine when, to your dismay, the only shoes the petite young sales girl brings you either have alligator skin stripes, garish gold buckles, 3 inch heels, or cost $400. I'm not kidding - the only non-hideous shoes that fit me cost $400. The nice young lady suggested that I might return my freedom-fighting espresso brown pantsuit in exchange for something that would match with black shoes (presumably something black).

Undaunted, I took my business to a different shoe emporium, only to find one single pair of size 11 shoes in the entire store. And they were black. And still too small. The next store brought no more luck. Fortunately, my wanderings through downtown Portland brought me to the large-footed lady's paradise: Nordstroms Rack. The same store I had spent hours in the day before looking for suits. And lo and behold, what was going on at the Rack, but that festival of light devoted to the freakishly tall, the Large Size Shoe Event. It was a sign from the heavens. And sure enough, I found and purchased one pair of professional-looking brown ladies dress shoes that happened to fit.

I call them my Colonial Gentleman Brigoons. They are ideally worn with white knee socks, blue knickerbockers, and a powdered wig. But, given the circumstances, my espresso brown interview pantsuit will have to suffice.

I recently escaped from the torrential downpour that has become autumn in Oregon. Rivers of rainwater cascade down sidewalks and gutters, forming writhing lakes at street corners in the place where sewer drains long ago clogged up with damp leaves. No crisp, bright fall here; gone are the brief days of crunching through fallen leaves in dry canvas shoes. They have been replaced by the inevitable descent into dampness.

As this great transition between seasons begins, I too am standing on the brink of a transition of my own. How about that for metaphorical transition into the topic of my entry, which is this: medical school - - -> residency. Transition.

And speaking of seasons, there is a new season that is upon us, one only recognized by a small segment of medical society... The Interview Season. This is the period between mid November to January where medical students spend vast amounts of money to travel around the country, interviewing at various residency programs in their field of interest. Much of medical school to date has been leading up to this, and it is really hard to believe that I am getting there. I spent the past couple of months putting the finishing touches on my online application, a weighty task, considering that said application includes not only a long list of facts about yourself, but also a personal statement, four letters of recommendation, and a dean's letter summarizing the comments that have been made about you by every single person you have ever worked with or passed in the hallway. Oh, and a picture of yourself (mine was artfully taken by my mom in my backyard in Minnesota).

I am now in the midst of the arduous process of scheduling interviews in various cities across the country. All I can say is I am about to spend a RIDICULOUS amount of money. And as part of this spending spree, I recently made a momentous purchase, of a thing that every medical student must acquire before Interview Season officially opens: The Interview Suit.

Now, much debate has been made over the necessary qualities of an Interview Suit. The standard advice is to go with conservative black or blue. In fact, one of the speakers at the conference in New Orleans said that the interviewing student should "dress like a banker." In essence, it is not my job to stand out in appearance. This is no time for personality or flare or a sense of humor to interfere with your cold hard professionalism. This is a concept which goes against my nature, and as a naive third year I was confident that I would purchase a kelly green tweed skirt-suit to wear with vintage pumps, or something that similarly alluded to how much more of an interesting, unique person I was compared with my colleagues. But yesterday, faced with the challenge of purchasing the first suit of my life, I balked at the choice of supreme individuality in favor of the status quo. This was of course compounded with the challenge of finding a non-matronly suit to fit a very tall lady who wished to spend less than one million dollars.

And after an exhausting day of braving frantic crowds at Nordstrom Rack (or "Nordy's Rack" as some ladies in the dressing room kept referring to it - ick) and trying on suit after suit in various shades of frumpiness, I finally found something that I am not entirely embarrassed by.

So with great fanfare, I now announce that I am the proud owner of an "espresso" brown suit. A pant suit. I am a person who owns a pantsuit.

But the Saga of The Interview Suit does not end there. For yet to come is the Adventure of The Interview Shoes. Fasten your seatbelts.

My favorite question from the boards went vaguely along these lines:*

Mrs. Johnson, a pig farmer, presents to your clinic with a one week history of a dry cough. She denies fever, nausea, vomiting, chest pain, or rash. She recently travelled to the Ohio River Valley to visit her daughter, who has leukemia and AIDS. On the way back, she visited several caves filled with raccoons and rabid bats. She is an avid gardener of thorny plants and also enjoys taking care of her extensive collection of exotic birds. Her husband, a snake and reptile enthusiast, smokes four packs of cigarettes a day and recently returned from a visit to a leper colony in subsaharan africa, where he was researching mosquito and parasite-born illnesses. As a hobby, the couple collects dust samples from the southwestern United States, and have been active volunteers at the local tuberculosis clinic. What is the most likely cause of Mrs. Johnson's cough?

(The answer, of course, is dilated cardiomyopathy from Chagas disease.)

Perhaps some other medical students can relate.

*Details of question have been greatly altered or entirely made up to avoid invoking the wrath of the United States Medical Licencing Board. This facticious question is intended for entertainment purposes only, and any resemblance to real questions, past or present, is purely humorous.

The test is over! Long over, these two weeks now. The deed is done and it cannot be undone, no matter how many anxiety dreams I had about copper chelating agents and heparin (my list of Definitely Incorrect Answers is growing by the day). My epic battle against the United States Medical Licensing Exam Step 2 is now over, and I have survived to tell the tale. It was not pretty. It was an incredibly long and exhausting day that involved me staring at a faintly flickering computer screen as eight 60 minute multiple choice tests came at me in sequence.

To illustrate the progression of my mental state during the exam process, I present a series of self portraits:

The pre-test shot.

I had just arrived, bright-eyed and well caffeinated, and was waiting outside to be called to the gauntlet.

5 hours later

This is me five hours later, on my lunch break. I had opted to power through five consecutive one hour tests, with only a brief bathroom trip to break up the fervor of my concentration. And obviously, it took its toll. My god, I look like I was run over by a large semi truck - a truck filled with questions about aquired immunodeficiency diseases and polycystic ovarian syndrome. I spent a part of my lunch break reviewing my notes on Wiskott-Aldrich Syndrome and Bruton's agammaglobulinemia, because honestly - I seemed to be getting a shockingly large number of questions on primary immunodefeciency states, rare disorders that I have never once seen or ever been asked about by anyone ever. Leave it to the boards to relentlessly dredge up the obscure. Touche, USMLE Step 2. Touche.

2 hours more

Fast-forward to the post-7 hour mark. Actually, the 8 hour mark, when you add in breaks. My main feeling at this point, strolling outside to remind myself of the existance of a world outside of the computer test room, was of exhausted resignation. One more hour... one more hour... one more hour.

Oh, and I should briefly describe the security measures that one must go through to enter and leave the testing room (aka medeival torture compound). One must show government-issued ID and sign in each time one enters or exits (even though the same nice lady has been sitting there for the past eight hours and has seen you come and go several times). Nothing is allowed in the testing room except for yourself and your issued ear phones. No extra sweaters. No watches. No chapstick. Your pockets must be empty. Its all very understandable - we are talking about an important exam, and I might easily have concealed vast notes covering all of medicine rolled up in my tube of chapstick.

And then... DONE!

In your face, USMLE Step 2! Please note: it was almost dark out. I was the last person to leave. It felt good to be done, but these things are always anticlimactic, because you feel so drained. Emotionally, mentally, spiritually drained. Every question that I had trouble with seemed to be replaying in my brain, and the long phase of second guessing began. I am only now just getting over that phase, as I wait for my score and try to convince myself to be satisfied with whatever I get.

A toast!

The final stage of Boards Day was not complete until I was warm and showered and relaxed and celebrating with a wonderful dinner and a nice big glass of wine. A toast to you, USMLE Step 2 Clinical Knowledge Exam. You were a steadfast and worthy opponent. I shall not soon forget our long and heated battle, a true battle of the wits. Who emerged the victor and who the vanquished? Only time, and a slim letter from the USMLE Board, will tell.