And Light There Was...

How about a trip to the past? Let's go back to the beginning... Doubtful that anyone but my dear La Colleague will remember this: And Let There Be Light

It's been 5 years. 5 completed years of ups, downs, and all kinds of craziness...
4 years of med school, 1 hell of an intern year, at first and in prospect seemed like ages, but now, in retrospect, nothing more than a few years in memory.

Faithful readers will know the meaning of the word "Checkpoints" in my posts. Well this is a checkpoint if there ever was one. The end of the intern year. The end of one hell of a year that's been the one and only time I have ever questioned my choice of career. Gone. And not a minute too soon. But with the pleasure and euphoria found in a savagely hard fought victory over it, came the sadness of another turning point in life. A turning point where all - yes, all - of my class friends (so much more than just classmates) have packed up and left for residencies in the states, leaving me with another round of fighting with my sense that I might want to do the same. And this is where my mind wanders off into a land of what ifs, buts, and alsos, driving me further into this wicked cycle of thought that I will not bore you with.
What it boils down to, though, is the impossible difficulty of accessing a surgical residency program in the US. Sure enough, none of my friends who are leaving have chosen surgery, and happily all of them were lucky to get the match for an out of this world opportunity for life and career. Kudos to them all.

For Gracie, for Mayssam
So here we are, gone each in his/her direction. In the 'hecticity' of it all, there seemed to be so little time for us to get to do any real talking, the only thing you and I are any good at. So I had little or no opportunity to say what a great 5 years these have been. And I know that I will, sometime, or as we say so untruthfully here in Lebanon... Tomorrow, or where 99.9% of human productivity, motivation, and achievement is stored.


Love, always.

Small World and Memories Past

Dear N. you sweet old lady,

I have only the faintest memory of you. I am told passionately by those close to me and to your family that I spent the better part of my childhood fiddling around in your house with your children's children. Now that, I do remember. You see when I was some 7 years old, I was infatuated with your granddaughter Z., P.'s daughter, A.'s sister. 

I have to look back, well at least at what these people have told me, and sit in wonder at the way our lives parted so long ago, and how they were brought back together on that fateful afternoon.

You are an ill lady, poor old N., 

I was surprised a few times to come across your name on our inpatient records. Always wondered how you were doing. Always wished you the best. 

I was surprised on said afternoon to see your name on the ER patient list. 

I was awestruck a few hours later as I heard your monitor beeping. Code Blue. 

I was there, in your final moments. I was helping. We fought hard to bring you back. It wasn't to be.

I was gutted, as your grandson A. said in no uncertain words: "let her go".

I am sorry. There was nothing more we could do.

I was tearful when I got out of your room.

I was torn to see A.'s face after all these years, calling the family with the news. Bluntness was the order of the day.

My dearest N. you see the people you have helped create, have made our life so much better. And from faint memories and tales told, you were keen to see us grow. 

I hate it that we had no chance to get reacquainted. 

My dearest N. 

May you rest in peace.

Thoughts go out to Z. my first childhood crush. and A., The ER physician who supervised resuscitation efforts on his own grandmother in steadfast composure, professionalism, and, ultimately, realism. You are an inspiration to us all.

Another Catch-Up Post

Well it has been a while since my last post. I've been busy lately, and last night I happened to check out my blog and realized that I'd 'left' on a very sad note. Sorry about that!
So what have we missed? One relationship anniversary, one uneventful new year's eve, another goodbye to another good friend leaving the country, another monumental governmental failure (but we're used to those), another stupid Internal Medicine rotation, a few breathtaking days on the Faraya slopes. All these, among other things I've meant to blog about that would have kept my readers busy/amused/annoyed. No such luck; instead, here I am, once more, overwhelmed by my flying ideas, frustrated by my tantalizing muses, pressed for time (but we're used to this one, too), and struggling with my vocabulary trying to make something out of this heap of interweaved trains of thought.

Let's start here. I am happy. Happy, of course, being a word surrounded by a cloud of relativity, and perhaps a few drops of evanescence, but for the first time in a few long med school years, I can really say that I am happy. Happy with the way things are going in my life. Happy that I'm just starting to peer through that window onto the next steps in my life and career. Happy with my lovely L. Just overall, in a good moment I guess, the likes of which I haven't seen in a very long time.

Trying to pinpoint it is hard. but I think what has drastically changed my outlook on things is the fact that I'm done guessing what I want to do with my life. Over the course of one day, my career path has become clear to me; I am to become a surgeon, people, go crazy. There has never been a specialty better suited for me, I've always known it, and since I've applied to a surgery residency at AUH for next year, things have been different. It takes much more to worry me, I am more relaxed in my work, I'm optimistic and feel so hungry to take on this next chapter that I don't even feel like a med student anymore. Med IV is almost over. A few months ago I was excited at the prospect of beginning my last year of med school. Time flew, that's all I can say. and if you've read that post, you'll understand why I'd be keeping with the continuum if I say, Bring it, Surgery! Bring it, Residency, Bring it, long on call hours! I want to work my ass off in something that fascinates me, instead of sitting around the morning rounds in internal medicine for 5 hours wondering what the hell I'm doing there, trying hard as I can to stop my eyes rolling into the back of my head from boredom!

Did I mention I hated internal medicine? Well I'm sure it's obvious now! (Some other post, for sure)

So there you have it. The main update and now we can look forward to my admission (wish me luck) and to my Surgery internship next year which I'm sure will bring you many long posts.

Will keep you posted!

A Late Rite of Passage

Walking on Bliss street had never been such a complicated task, what with all the 10-year old –or less- mendicants and lottery ticket ‘agents’ or shoe cleaners. For the longest time I felt annoyance at the heavy task of brushing off these pesky and persistent solicitors that seemed to be after nothing other than your money. The annoyance not circling around the money itself, but about the ethics and principles of discouraging the presence of alms-askers and the associated child abuse and whatnot; let me not digress and wander off into these treacherous discussions for now.

So one of my tricky walks along the famous street, while I was looking for that after lunch cup of coffee, got me to Epi D’Or. -Don’t let the name “Epi D’Or” fool you. Fancy name for a place that’s affectionately and more commonly called “Abou Naji”, the little store across the street from the AUB main gate-. Waiting for my coffee, I get elbow-tugged outside by an as-yet unknown figure who turned out to be one of Bliss’ seasoned shoe cleaners

. “Here we go”, I thought to myself. But then, all thought processes angled at getting rid of that annoyance were instantly stopped by the cleaner’s marketing skills… “Eza ma 3ajabak ma tedfa3 wala lira!” Translation “If you don’t like my work don’t pay a dime!”

Said in a convincing and confident tone, these words made me think ok what the hell? My shoes were dirty, hadn’t been cleaned in a while and a good buff would do no harm! So I told the guy to do a good job and he got to work. I have not seen hands move so fast. The sound of swishing as his run down piece of tissue carved through the air and onto the now polished leather told the tale of a shoe cleaning veteran with years of training!

All done, shoes shining, and face smiling as M. took a few snapshots of the event, I was thinking about the going rate on a premium job like this! So I thought 3,000 LBP. M. frowned in disagreement and so I gave him 5,000 LBP.

In retrospect, seeing how his face lit up as he tugged on that bill and all the good wishes for prosperity and long life I got at that time, I know I overpaid! But I would do it again and pay the same price!

But hey. An honest living, a job well done, make me rethink my stance on the good shoe cleaners out there! This is one rite of shoe-cleaning passage not to be soon forgotten!

No Comment...

No comment, because I can't say how it feels to connect with someone like you do when that someone is your patient. And even less when you spend hours in that room talking and talking and end up wondering if you'd ever meet someone as interesting, as insightful as them, and with a story as captivating as theirs...

There's no describing it. Much like there's no describing what it felt like when I got this note after saying goodbye to Mel, who was leaving the country for good. It felt like saying goodbye to an old friend.

Goodbye Mel, All the best.

Cinema Paradiso, a Blast from the Past

There is nothing better than that feeling you get when you come across something from the past. I don't know, I guess this may be the appeal, the incentive, or maybe the lure, that makes people dwell in it so often, and sometimes indefinitely. Ranging from that once-in-a-while sweet, harmless nostalgia to downright pathological, disabling failure to progress, this feeling of familiarity and comfort found in one's past is probably, and to my experience, the reason why so many people struggle or fail to move on to new pastures.

The other day I tagged along with M. for a short DVD shopping trip. We were both flipping

through the monumental stacks of DVDs, and were ready to go home, nothing of note having been caught in our respective nets, when I heard the clerk making a recommendation to a girl (and a nice looking one at that!). I overheard: "you should try Cinema Paradiso..."

Instant flashback to 1990. I was eight years old, and we had just moved to a new place in Beirut. A brand new TV set, a brand new VCR and a nice VHS to christen it with.

Cinema Paradiso, an award-winning film by Italian filmmaker

Giuseppe Tornatore. I remember it so vividly; it was late, one of the first quiet nights in the post civil war era. The living room engrossed in the somber yet elucidating light provided by a solitary candle placed on top of a run down coffee table, I waited, anxiously observing the clock's every move, in anticipation because at midnight, we get to enjoy the luxury of electricity again.

I fell asleep on the couch, to be woken up at midnight by my mother, who was just as anxious as I was to watch that new movie.

Perhaps ironically, the theme of the movie circles around letting go of one's roots, of one's past and all that it entails, as it so powerfully follows the life of Salvatore di Vita, affectionately called Toto, as he morphs from that 5 year-old kid with so little on his mind, through a hormone-laden teenager, and into a grown man with aspirations to a career and success.

Always the sucker for blasts from the past, I jumped on that thing like there was no tomorrow; I drove back home in a daze, and the mere sound of the two words "Cinema Paradiso" brought my mom to tears. To say that watching this movie 20 years down this long road was an emotional experience would be a masterpiece of understatement. So many powerful scenes, and a theme and topic that remind me so poignantly of my own childhood, my own journey through life, proved to be nearly too much to handle. I guess that my having been through the experience of leaving home and loved ones behind meant that I identified with Toto in the movie.

Ironically, a movie riddled with nostalgia, departures, and separation from the past, has reunited me with mine in a way my clumsy words will never be able to describe.

Why so afraid of the past?

First LVAD implant in Lebanon - The misconceptions surrounding a highly successful operation

"A team of AUH surgeons has successfully carried out the first artificial heart implant operation in Lebanon, saving the life of a 37 year-old man and father of four".

That is the claim of many renowned media sources in Lebanon. Click here to read the official AUB article by Maha al-Azar.

I'm currently, and incidentally, on the Cardiothoracic surgery rotation at AUH. Yey me. I was surprised by a phone call on Thursday night and a friend screaming at me for not telling them that the first "Heart Transplant" in Lebanon was performed at AUH. Shocked, I thought to myself, there's no way I didn't hear about that one!! Then came another call, another newspaper article, another overheard conversation... All with one, or two, or three things in common... The misconceptions, the misconceptions, and the misconceptions. I just thought there were too many scientific blunders on the part of the media and their reports have been massively misleading at best. The following is a roundup of the misconceptions I thought people should be aware of...

Misconception 1 - This is NOT a Heart Transplant...

...And even if it were, it would not be the first one in Lebanon. The first heart transplant in Lebanon (a real heart transplant) was performed at the Hammoud hospital in 1999. Click here to read about that.
This is an LVAD, or Left Ventricular Assist Device (more on that later) implant. The original heart is still in place!

Misconception 2 - This is NOT and Artificial Heart Implant...

This is an LVAD (Click here), NOT an artificial heart. Let me explain. An LVAD, as its name implies, is a pump that merely assists the biologic heart in its function. It neither takes over its function nor does it replace it or completely take over its role. It ONLY assists it in its function by taking some of the work off its back... The biologic heart is still in place, functioning properly with the help of an assistant, if you will.

The implanted LVAD.

An Artificial heart, the Jarvik.

In contrast, an "Artificial Heart" is... well... an artificial heart! It is a complete heart-like pump that replaces the biologic heart, which is taken out of the patient on the OR table. It is still an experimental technology with only limited success in the United States.

Misconception 3 - This is NOT a life-saving device...

The AUB article also states that the operation saved the life of the 37 year-old patient. I am sad to point out that this is not the case. An LVAD implantation is what we call a "bridge to recovery" or "bridge to transplantation" procedure. This device is designed to help keep cardiac performance at an acceptable level for a limited amount of time pending one of two events:

- The recovery of a mildly diseased heart as a result of decreased workload afforded by the LVAD: Bridge to Recovery.
Or:
- The availability of a matching donor heart for transplantation: Bridge to Transplantation.

The LVAD used in this case was the Heartmate II by the Thoratec corporation and is claimed by Thoratec themselves to be able to provide circulatory support for only up to ten years. Now keeping in mind that these ten years are the result of the most optimistic and optimized calculations, it is clear that we should be expecting 5 to 10 years, more realistically, before there is a need for a new intervention. And we would still be optimistic in that we are neglecting all the possible complications that the poor guy could face.

I am not trying to rain on anyone's parade, and least of all the patient himself or the thousands of others with heart problems. I just think it's a shame how the media are having a field day with his story and modeling it, be it willingly or unknowingly out of lack of scientific knowledge, to fit the textbook picture of a world-class achievement in medicine, or that of the wonderful doctor or hospital saving lives by the millions. That this life has been saved is simply not true, and while I am truly ecstatic that this operation took place where I work, and even more ecstatic to see its success and the time it gave our 37 year-old father of four, I cannot emphasize enough how much of a temporary solution this is for our patient, who is, at the end of the day, whom we should think about before anyone or anything else. I can only hope he and his family know what the future holds for them.

This is a milestone in the practice of Cardiothoracic surgery in Lebanon, one that I am proud to witness during my young career. I just can't stand it being taken out of context in this manner. The authors of these articles and their sources shoud be reviewed.

Yesterday, the day it all went wrong...

Have you ever felt like a stone surrounded by glass? Like you couldn't make a move without something or everything shattering and crumbling down in a deafening rumble and screaming racket? Minutes or seconds later, you look back: nothing more than a hole in the ground, where once all the great plans you had just built up seconds -or years- ago stood tall. Nothing left... Be it an hour, a day, or an entire lifetime, actions and their consequences are the same. Well at least they act the same. With a little hindsight on things that have happened in my life as far back as 15 years ago, or as recently as yesterday, I realize how strong and steady of a truth it is that when you make decisions, life starts moving so fast that it's not like you're moving through it anymore. It just starts happening to you.
It's strange to realize that this holds true at all scales... Whether it's your career choice, or that crush you decide to finaly do something about after so much hesitation. You just make the slightest move and it puts in motion some restless unstoppable mechanism, like thousands of cogwheels all spinning, each at its own speed, but all equally inexorable in their relentless thundering stride toward that common end point, like an army marching to the Valkyrie.

Here we go. I didn't know I was on one of my late night ramblings again... I didn't get the memo! I'm rambling again. It must be the melancholy found in the resignation to a few concequences of a choice made in the past, no matter how distant, with a certain goal in the future, no matter how remote.

Patient Insanities on 10 North... Have a Laugh

Well I figured it was about time I shared some more stories about our dear patients on the surgery rotation. Here are the three cases that spring to mind... Actually there's a fourth one, but she deserves a post of her own so come back soon ;)

The crazed grumpy old man on 10 North.

K.H. has been driving all the floor insane for about a week now. Anxiety attacks, flamboyant claims and accusations that make me wanna scream out in anger... To put things in perspective, one of his latest complaints was having a nurse that smiled too [damn] much!! He even told her that to her face! Hilarious and sad... The poor guy has been one of the most complicated medical cases we've seen so far, with several operations, intestinal leaks and what not... Understandable? Granted. But it is still annoying, and yet funny in a marginally twisted sense, if you see what I mean, to hear him complain about things the world of medicine has never known, like diarrhea caused by walking!!

[Note]: "Patient is not doing very well, complaining of general anxiety and unable to tolerate hospital stay. He is pain free and is refusing to take his anti-hypertensives and anxiolytics by mouth. He refuses to ambulate for fear of diarrhea." Making sense are we? LOL

[Plan]: "Start I.V. Lexotanil"

The nice and healthy middle aged Man on 9 South.

M.D. is A previously very healthy, strong man. After extensive surgery, he seems to be recovering nicely, and is happy to see me every time I walk into his room. Always a good sign to see a patient greet you with a smile. It is so rewarding and puts an inexperienced mini-physician such as yours truly at ease and makes the job that much easier. I walk into the room, M. smiles and brags about how well he's doing, is always anxious to show me how good his breathing is getting, or how comfortable his lazy-boy chair is, with its fancy electric recline and foot support functions. Me, smiling "I wish I had one of those at home, Mr. D!!" It has been a pleasure following this one up. He's staying till the end of the week.

[Note]: "Patient is doing very well, tolerating regular diet, passing stools and flatus, ambulating freely and using incentive spirometer as instructed. Bowel movements normal, no pain or discomfort reported upon defecation. Patient is pain free and has no new complaints. Plan for discharge soon."

The distant old lady on 10 North.

S.D. was a 70-something-year old lady we followed up for about a week, some few weeks ago. I had completely forgotten about her, until I met K.H.

She had her own set of problems, like being too good to look at us med students, or letting us examine her without her attitude, or having not one, but two of her private nurses in her room taking care of her and making our lives miserable... Case in point: M. my colleague was about to draw blood from S.D.'s arm. It was her first time doing that, and she was looking for the vein, taking her time to locate it with some degree of certainty. After all, you don't want to poke her majesty for nothing! Some odd 20 seconds later, S. just lost her patience (bear in mind that M. hadn't even picked up a syringe yet!) and with her face turned away from M., called her nurse and said: "ta3e shoufe hayde shou 3am ta3mel sarla se3a!!" Translation "come here and see what this one is doing, it's been an hour!" Priceless!!

[Note 1 ]: "Patient is pain free as confirmed by private nurse. She is non compliant and refused to be examined, claiming that the nurses already gave her a physical."

[Note 2 ]: "Patient is pain free as confirmed by private nurse. Physical exam not done because patient is sleeping"

And for the record, all that the nurses do is take temperature and blood pressure and stuff like that so...

Difficult patients are a real challenge! I still need to work on that area! Something about them shakes my confidence! But they're funny to tell your friends about!

S.D. and K.H. ? a match made in heaven! We couldn't help but try and imagine what these two would be like living together! Imagine the children!!!

Those of you calling out outrage, relax. We're not making fun of our patients. It's not like that. It's just that these few cases are too entertaining to forget. So we document them! See? it's a noble cause! But seriously, they all get the same respect and standard of care... Rightfully so!

Patients: for a change...

I am happy to report that the long awaited feelings of gratification, satisfaction, and sweet fulfillment have come through during these two past weeks of hospital clerkship (the first two weeks in Med III). This is it. What I have been waiting for since I graduated from high school, and even a few years before that, if you will deem meaningful the idealism of a foolish teenager and his noble aspirations to save the world one patient at a time. This quest, this mission, now surely tarnished by disillusionment and eroded by its relentless and savage conflict with the grit of reality, this enthusiasm, and idealism, or what's left of them, is what I am trying to salvage at this time in my life and career. The fact is, I can proudly say that at last, at long last, I have the power to do something about it. I, your dedicated and enthusiastic medical student, now have enough to work with to impact people's lives, no matter how limited that impact may be. Flashback 3 weeks ago: I was just another student in a classroom counting the seconds before it was time to head back home or to the pub for a few drinks. Now, for a fast change, things are different. Let me tell you the story of a patient who made me realize that.

N. is a sweet old lady patient I was following up. She was one sick lady, with heart problems, kidney problems, and diabetes. One of the many, many long term complications of diabetes is peripheral vascular disease. simply put, this means that diabetics have problems in their blood circulation and as a result, there is impaired blood supply to the lower extremities. Impaired blood flow means impaired oxygenation, impaired eventual wound healing, and impaired immunity in the affected area. This is why you see 'informed' diabetics and think that they're anal about foot hygiene. It's simply because they've been informed that even the smallest abrasion or cut to the skin of their feet could result in devastatingly painful ulcerations and invasive infections that could ultimately warrant the amputation of a toe, or even the entire foot or leg in severe cases. What makes it worse is Diabetic Neuropathy, another complication of Diabetes that impairs sensation in the lower extremities, meaning that any wound, abrasion, or developing infection in a hidden area could go undiscovered for months, without the patient feeling so much as a tingle. Read more about The Diabetic Foot and Diabetic Foot Care.

N. had had diabetes for many years, and after an ulcer between her toes failed to heal and got infected, she lost her little toe, which was amputated to prevent the infection from spreading further up her leg with dire consequences. The first time I examined N., she immediately reminded me of my grandmother (Read); an exceedingly sweet, but obviously worried old lady, more open to suggestion than anyone could imagine. Even long years of fighting with chronic disease, life saving operations, and medications, along with a roughed up body both inside and out, had failed to embitter this inspiring character. The best of it all is that all she had to do was smile.

After this introduction it's time I got back to the point I was trying to make. People like N., with limited resources, bad or no insurance, are usually treated and let go as soon as possible. This is the sad reality of health care today, and is something that I'll be sure to write about when time and inspiration permit. The bottom line is that after a successful operation, N. was about to be sent home with her foot well on its way to a full recovery. Sadly, no one really took the time to sit down with N. for a few minutes and explain to her what steps needed to be taken to avoid another visit to the operating room. My group and I (Myself, M, and G.) felt that we could do it. Why not? It is now our duty to care for our patients, examine them, and help in their treatment and convalescence. Why would we not be responsible of raising some awareness and help them also by preventive measures? We went to N.'s room and gave her a talk with a few crucial instructions on how to care for her feet. And yes, this is the essence of what I've been rambling about for the past 3,000 words or so. We did that, and I like to think that we DID make a difference in N's life. Only time will tell, but things are looking up.

M. told me a similar story about one of her patients. She felt the same as I did, but the feeling is a bit new to us. It's something that, deep down, you know is right and that you are 100% sure that you're doing the right thing, but that still feels awkward, for some reason, and you're always worried that it's not your place. Well, I think it is. And I'm sure that if we don't do it, no one will. If we somehow lose this enthusiasm, this 'flame' that sadly has burned itself out in all but the newest blood in the health care system, we can be sure that no one, especially not the hardened veterans with their cynicism, will kindle it back to life. And it is the patients that will ultimately pay the price. Who else?

I said goodbye to N. with a few last minute instructions and reminders, and she told me how grateful she was, and the last words she said before I left will stay with me for a long time.

"Ra7 a3mel metel ma eltelle ya 7akim!"(I will do exactly what you told me to, Doctor!) - said a proud and emotional N. ...

And So It Begins...

One week into Med III and I've been wondering how it would be possible to sum up a whole week in one post. And not just any week. The first Med III week,the first week in med school remotely resembling anything that even comes close to being a physician.

Well in fact, sometimes when I think about it I feel that I haven't done anything quite so significant yet. But at other times, I also feel that every small step, be it the patient you so much as greet in the hallway, or the first EKG you set up, or every Once-In-A-Lifetime Choledochal Cyst (1 case per 2,000,000 Live Births in the U.S) Roux en Y Hepatico-Jejunostomy (Yeah never mind... Just something fancy ) you witness in the OR is now a decent step forward, a landmark, a mini checkpoint, if you will, along the way to becoming a fully developed physician. It's really hard to describe, but what I can say is that it's a whole new world, that's for sure, and there is absolutely no way of comparing it to the previous two years of classes and bookworm-ism so I'm not even going to try.

Getting ready for tomorrow, the 8th day into Med III and the General Surgery rotation we incidentally started out with, and already, I'm (and when I say "I" I mean "we") already feeling more familiar with the system. There's a certain satisfaction to it, to becoming one of the microscopic cogs on one of the tiny wheels in the at-best marginally well-oiled, Willy-Wonka-esque machine that is our hospital. We meet with and examine patients, write admission notes, follow up on patients after their operations, write progress notes, and suggest management plans that will be a new point of reference in the patient's chart. And the new in it all, I mean besides the contact and all, is that it feels useful. What I'm doing with what I've learned and what I'm learning is actually being used by my peers and superiors, to benefit someone in the end. I think that's the best way of describing what it feels like. In one word: just grandiose. And it's only when you realize just how much more there is to learn, how much more there is to accomplish, that your head starts spinning and you let it spin back down to earth and get on with what you're doing.

I just paused for a second, and thought about all the stuff I want to write here. There is no way this could all fit into one post. So if somehow I've managed to grasp your attention and interest, come back soon for more...

Our Humble Beginnings... Who Are We?

It is a the end of this one-month vacation that I realize that we are at a new checkpoint. For those of you who remember, I was rambling about time and how we seem to be pissing it away by the years and decades without even wondering where it went. But today, I stand before you a changed man *grin*. Changed by the beneficial effects of that exquisitely inculpating farniente month that just seemed to rain down from the heavens. And is difference a beauty or what?

Here, we're contemplating the onset of a new, 2-year era, a new setting and a new context in our lives, as we peer through that door, ajar, on the threshold between books + exams on the one hand, and the patients + associated responsibilities + real medical practice on the other. On Monday, tomorrow, we begin our 2 clinical years, as well as the beginning of the second half -and end- of our medical training.

It is at this opportune time that I started thinking back 2 years ago. When Le and La Colleague were nothing but strangers to one another, and I thought I'd catch us up on how it started... For simplicity, I will be Le Colleague, and La colleague will be the "She".

Some time around the end of August, 2007, the first day of med school for 83 students from AUB, adding 2 from universities abroad. She was one of these two. The first time I laid eyes on her, I knew that our love story had begun. REALLY??? Wait it's that glass of whiskey talking. Let me rephrase. Hmm... let's see. She was hanging out with the wrong crowd -as wrong as it gets if you ask me-, she dressed funny but I've never told her, hair looked funny but I've never told her... -need I say more?- we were casually introduced, and I looked away and made no note of it, just another med student in the sea...

The next few days didn't get any better, as we had our first meaningful encounter at the Saab Medical Library. If memory serves right, someone was on the phone *cough* and another someone was all pissy and "please can you keep it down?" with a serious frown and "woe is me" (La Colleague 2007). It was all downhill until we had one crucial conversation at main gate during that skipped class (what was it again?); that conversation was to prove a landmark, a milestone without which no further contact would have been made. That made me realize back then: hmmm... we may be on to something there...

Here's to you...

Keeping the story short, we sure have come a long way since then, La Colleague became La Friend, and perhaps La Baby Sister (although there's nothing baby about her, so don't get me wrong on this) and now as we look ahead for even better times, I can't imagine how everything would have turned out if she hadn't been so interesting to talk to on that fateful day at the gate. Ups, downs, crazy days, relaxed times, easy sailing and rough seas, we've seen it all, and I don't see why anything would change.

I don't know about you, but it's just sinking in right now; the day before the beginning, before we start getting the feel of real medicine, and I couldn't be more excited if I tried. So here's to another 2-year batch of heaven and hell, and many many more to come.

A Rude Awakening...

Sitting on a bench on campus, doing some reading in the morning, and someone comes along to share wisdom. Happens every day? Not like this.

That someone was K., one of the AUB campus cleaning troops -I call them troops because the thought of how monumental the task of cleaning a university campus this large just baffles me.

So how to describe K.? The best way I can put it is to say that he reminded me of Abou Kamal from a while back. A bit younger, but the same expression, on a weary, yet friendly face that has seen so much, so many students, doctors, and professors passing by, most surely too proud to make eye contact, but a welcome few nodding in acknowledgment. The roughed up skin and the snow-white hair again spoke volumes on his behalf, like they did for Abou Kamal.

So as K. walked up to me, and after a friendly "Saba7o estez" ("Good morning sir") asked me it was OK for him to pick up a few spent paper cups left around my bench. "Of course" I replied, and with a few swift picker upper moves worthy of the seasoned veteran that he is, he had cleaned up the area. When he was done, he looked at me and went on a long tirade. He opened with: "oh yes, son, education will give you your life". And from there he went on to tell me his story. Here's what I can manage to translate for you.

I've seen K. around campus many many times, as -apparently- he's worked at AUB since years before I even graduated from high school. He comes from a poor family of 9 children (if I remember correctly), and he talked about how his father could barely afford their everyday expenses, let alone provide them with a proper education. K. was out of school at a very young age, and had gone away against his dad's will to try as he could to get decent jobs here and there. Cleaning, construction, he had done it all by the time he was 18. He had started out at a construction site near the Golf club at Ouzai. 

After a quick biography, K. ended his speech with words that I will not ruin in translation. I was looking at him, and I was lost for words. What do you say to something like that? For a split second, I imagined myself saying how much it sucked to still be a student at my age, or how bad we medical students had it, but this was a brief moment of imagination. Very brief. How inappropriate! I don't remember what I ended up saying, but it was nothing too meaningful, as I blathered out  some insipid philosophical statement about life and how there's always worse off people.

So there I was, thinking about how I (and we all do) had been taking everything for granted. All I ever did was whine about how hard it was to grow up, how bad it was that we had to study for our stupid exams, and it suddenly hit me that I had never really stopped to think about what a blessing it was to actually be learning. I mean I have always loved learning, and wouldn't have it any other way, but I had never thought about it under this light. The difference in perspectives between myself and poor K. at that moment struck me silly (I do NOT mean to say that I felt pity for K. or that I felt superior in any way so please don't misunderstand me). 

This conversation reminded me immediately how quickly and deeply we get cocooned in our entourage, our environment, our everyday silly worries, whatever these may be, in such a way to somehow completely forget about the more unfortunate, the less fortunate, and about what real problems other people may be worrying about, and how disproportionate, if that's a right word to use, these two worlds are. 

This has been a learning experience by itself. Talking to K. felt like a shot of wisdom and perspective on life from the least likely source, and I'm going to keep it, even if I know for a fact that next year (which starts in 2 weeks), I'm going to be whining about the difficulties of medical training, about how people drive like cattle in this country, or how I can't seem to find time to go out for drinks and dinner. But one thing's for certain, K. will be on my mind when I do and I'm sure the thought of it will slap some sense back into me.

This could not have happened at a more appropriate time, for reasons that I will not discuss, and this has made me think about the whole "it's a sign" or "it's meant to be" philosophy, which as I've commented on Posh's post (read it and you'll understand), I am completely against. Nothing has changed in that department, but it got me thinking.

The End of Med II - A Rough Start...

There could not have been a worse start to a summer vacation. Especially this one, supposedly a godsend toward the beginning of the end of the 7-year medical curriculum, a turning point in the way evertyhing is done. No more classes or stupid exams, only hospital clerkships and real healthcare work -if we can call it healthcare in this country, not really,  but I digress... A month's vacation after a year of hell. If I were to find a way to relate to you what this feels like, I'd tell you to imagine being held captive and tortured with electricity, razor blades, and dripping water for a whole year (because that's all that Med II turned out to be), and then instantly and with absolutely no idea of what's going on, being released on a sandy beach on an insanely sunny day, favorite drink in hand, and then somehow having all the relief, the abatement of torture, and the solace one should find in overcoming such an enormous obstacle, somehow wane and wither in your disbelief-stricken face. Somehow, and quicker than I could realize, something got lost, something just didn't feel right, a few things happened that were not supposed to, more than one thing, actually, and that turned the whole experience inside out. I don't feel it anymore, and I feel that all the hype, the expectations, the hope and anticipation that led up to that Friday when it all ended, have all been turned inside out and their bad parts exposed. Much less excitement now, much less expected.

If I have learned one thing from all this, it's that some realizations stop you in your tracks, like when you realize that you have a bad case of the stockholm syndrome, while others seem to get you going, if only for a little while before they atrociously live up to their time-proven tendency to turn back and bite your hand when least expected, so be ready. 

Be ready... It's time I learned that, but this hit me like a truck going 1000 miles an hour.

One Gets to Thinking...

Hey it's been a while! Been a long couple of weeks in the fast lane. That's the worst when you realize that all this time was supposed to be cooling off time... Things are a bit calmer in academic life, ergo you have more time for yourself, your blog, you know, the usual free time stuff... But no, I don't know why, but things have been different lately. I don't mean to sound like a broken record, but time is just flying away, and I've been realizing that more and more acutely lately... And, apparently, it's not because of studies and workloads. I don't like this...
So I've been trying to muster some stuff to blather about on here a couple of times over the past few days... Struggled with a bad case of blogger's block I guess. That is, until I found myself alone in a borrowed apartment, and there's nothing like that to get the ideas flowing...
So it's a cool small flat in Hamra, and it belongs to a very close family friend, C., who is away on vacation. C., knowing how much I struggle with the daily commute, the daily parking hassle/expenses, kindly and generously offered to lend me her place for a few days. Much appreciated. Previously a skeptic, I now know and understand the blessing that it is to have a place close to where one works/studies. You can wake up an hour later than usual and come home an hour earlier. You can come home for lunch, for a midday shower if you feel too sticky in the summer heat, it's just amazing how different and easier everything seems to be.
The first time I walked into C.'s apartment, I loved the colors, the black leather couches, the rugs, and the mixture of European and Middle Eastern influence in the choice of furniture and wall decoration. Look at one wall, you see an artisan mirror with Arabic calligraphy. On another, a beautiful Cézanne. In the living room, beautiful copper ware on a traditional wooden table seems to match perfectly with the modern tiling.
C. is a French immigrant, working in Lebanon as a French teacher in a prominant school. Her culture and background are vividly depicted in her choice of furniture, books, and art. When I asked M., she said it was obvious that whoever lived here was a foreigner. So many Eastern articles just screams it I guess... But C. has found the perfect balance between these and leather couches, modern flooring and colorful curtains and lighting. I love this place. C., Merci Beaucoup de ta générosité :)

So here I am, wasting more of my time, typing away on a soft couch, soft rock playing in the background, as I ponder what tomorrow and the days after that hold. The studies, the family's finances, the lovelife and whatnot, one watered-down glass of whine at a time... I need to live alone again.

Another Sunday Night, Monday Morning?

Yes... here we go again. And no, I'm not whining this time. Wow! Is it numbness to stress? Learned helplessness to the runaway clock? No, not really. Just feeling indifferent and disinterested this time around I guess. When I stay up late in my room, I feel like I'm getting hints of what's going on outside during the late hours of the night. These samples come in the form of distracting but interesting noises ranging from the rumble of an 18-wheeler driving by Southbound, to the engine screams and tire shrieks courtesy of that maniacal neighbor in his "watwat (Arabic for 'bat')" Beemer (Lebanese Jargon for the late 80's model BMW 3 Series Coupé) driving donuts round the conveniently empty intersection a couple hundred meters from my home, to the essentially worrisome, reassuringly distant, but worryingly nomadic sound of machine gun fire disturbing the peaceful moonlit night (YES, true story!). Did I mention it was past 3:00 am? Quite interesting, really! Most days of the week I'm fast asleep, clenched fists, and completely oblivious to everything that might be going on outside! I should do this more often!
For the curious among you, here's what my desk looks like tonight. Quite the way to spend the better part of the night, huh? I want to be about 20 Km away, drink in hand.

Ok enough with the night-time daydreaming. The noise has subsided. Screw this week's exam I'm going to bed!

Now Two Different Persons...

I remember the hype right before the Christmas break last December. I remember how I felt, on our last day of classes before our 14-day (or so) break. (Needless to say that a 14-day break in Med School is nothing short of a trip to heaven).
I felt light. Relieved. Granted, It was not my first time looking forward to a long awaited, much needed break, and yet, the feeling was unique in a way that I cannot put to words. December 24, 2008, we went out for lunch, a bunch of close friends/select classmates, meeting with expatriated childhood friends who had just flown in from respective countries, and the atmosphere was just fantastic. I felt light. relieved. I felt different, and silently baffled at how good it felt to feel different, and how long it had been since my last similar moment. A glass of wine helped. Later on it took a bunch of my friends, who noticed the difference, a few minutes to describe to me how they saw me from the outside. They said I was a different person when I was taken out of the academic atmosphere. The atmosphere of constant stress, constant information binging, and constant evaluation and scrutiny. Apparently there are more smiles, pleasantness, jokes, and less worrying. That made me a different person. So what's unique about that? Everyone is different under stress right? The problem is, this was the perception that I had of my personality, and it was supposed to be the case no matter what the context. My affect in this atmosphere was supposed to be unchanged no matter what. I made sure of it, and was complimented on it by many friends. I am now different. Apparently I cannot maintain my laid back character anymore. Things get to me more easily now.
When did I change? How and when did I change so much? And could I have changed so much without even noticing? Not the slightest clue! I don't know... It's hard to sum up, and hard to pinpoint exactly when or how this change occurred. That's Med School for you. I guess the last 2 years of my life have gone by in a flash. And a flash may even be too long... that's how fast, yes. I can't help but carry this thought further back into the dark alleyways of my memory and try to remember the last 'checkpoint' in my life that feels genuinely distant in time. I can't find one. I could wind up all of the 26, soon to be 27 years of my life in a heartbeat, and It's a frightening feeling.
So here I am, on another one of my late-night musings, typing away with a Gastro-Enterology book obstructing my reach, thinking that oddly enough, it is now Monday morning, rather than Sunday night, rather than Saturday afternoon... Where did my weekend go? Might as well have been last Monday, the one before that or the one before... Same difference... Yes, here I am, Monday, March 23, 2009, at 1:35 AM, with a lost track of time, anticipating (for a change) the change that I'm about to exhibit "tomorrow": Friends have flown in, exams will have let off for a little while (Upcoming exam in exactly 6 hours and 25 minutes).
I wonder what's in store this time...

Rien Ne S'arrête.

Here it is March 20, a long way from March 20, 2008...

And as I struggle to relive those carefree days, I sit and wonder, when did I stop having time? The one thing we are sure to have, the one thing we take for granted. I lost it. I lost Time. I lost the absolute concept of it.

Medical students are so consumed by their lifestyle and their studies, they forget that unfortunately the world is still evolving. Until it hits you. Until you get that phone call that your friend died, or that A. needs to go to the hospital because his cancer metastasized. What do you do next? How do you explain to your teacher that you couldn't study, or that you cannot attend said lecture or exam because A. could only see his physician at that particular time. How do you manage? How many times will you curse that garbage truck you're stuck behind because it is stealing precious minutes of your once insignificant time. Minutes you started counting and regretting once it was too late, once you realized they were gone.

Rien ne s'arrête
D'autres vies continuent
D'autres parler sans taire
Pour ceux qui se sont tus
Rien ne s'arrête
--Patricia Kaas, Rien Ne S'arrête.

Pediatrics... Uh-Oh!

I've been wanting to write this for a while now but it's just been a hectic couple of weeks what with the classes, both skipped and attended, the exams, both near misses and lucky escapes.
So here's another foray into the earliest clinical experiences and their impact on a confused med student shopping for a marginally successful career.

I've always struggled to understand kids. I'm only consoled by the mutuality of this feeling when it comes to my younger brother and sister, my younger cousins etc... There's always been animosity and for a reason. I don't seem to get them. Trouble inexorably ensued!! For me, as far as kids are concerned, no one could have said it better than the late Bernie Mac: "...Oh shit come help me babysit these m*****f******s..."! I know that to the baby lovers and kid huggers among you I'm gonna sound like a Neanderthal but I'm banking on an outside chance of a few of you feeling about the same way that I do; so I'm out on a limb I guess...

10:15 am - Visit # 1 - The Regular Checkup for the Obnoxious Fat Boy
Phase 1 - 5 year-old kid walks in with his mom. A 2-minute dialogue between the physician and the kid's mom about diet, playtime habits, and vaccines follows.
Phase 2 - Physician invites kid and mom into exam room.
Phase 3 - Kid enters battle mode and seems to latch on to his mother's leg in a grip worthy of the most intractable centipede dead-locks!
Phase 4 - Kid is now on the exam table - don't ask how that happened - screaming his little butt off while physician desperately tries to hear something in between the groans and moans with the stethoscope, as the kid gasps for breath.
Phase 5 - Physical complete. Physician calls for the nurse with the vaccines (I named her the Shoot'em'up lady).
Phase 6 - Shoot'em'up lady comes in, tray in hand, with 2 shots worth of vaccines. "One in each arm please", says physician.
Phase 7 - All hell breaks loose as Shoot'em'up lady pricks the kid once and another time. Me watching, worried that the little demon's gonna fidget one time too many and break the needle off in his flesh with dire consequences. Shoot'em'up lady's job? Not for the faint hearted!
Phase 8 - Shoot'em'up lady in the sweetest of voices: "there all done! That was not that bad now was it?" Me in the corner, trying not to puke.
Phase 9 - Physician declares the session over, gives the kid a lollipop. On to the next one!

10:35 am - Visit # 2 - The Regular Checkup for the Demonic little girl
Same as above. Please replace "5-year old" with "4-year old", "mom" with "dad", "his, he, him..." with "her, she, her...", and "all hell breaks loose" with "My eardrums burst" and that's about it, all the rest is essentially unchanged.

10:50 am - Visit # 3 - The Regular Checkup for the Sweetest Thing that Has Ever Existed (now that's a change of pace!)
A 2 month-old baby girl with the face of an angel. Brought in by her mom and grandmother. Onto the exam table after the formalities of phases 1 and 2, she lay silent, her fists clenched and her tiny arms and legs twitching from time to time. Her big grey eyes desperately looking for something to focus on apart from the bright overhead light. The physician examined her, looked at me and said suggestively: "she has a very faint murmur you should hear." Even her guardians were nice and joked around, and actually acknowledged my presence, something no other parent/guardian managed to pull off, the physician's failure to introduce me as his apprentice notwithstanding, talk about professionalism! Would it be too much of an effort to say this is R., He's going to be learning with us today, please don't be freaked out by his curious eyes... but I digress... So here I was, awestruck, in front of a silent pediatrics patient, until, you guessed it, Shoot'em'up lady came in and screwed everything up with one little prick.

11:05 am - Visit # 4 - The Regular Checkup for the 2 Girls From Hell
This one was a bit funny, I have to admit. The older of the two went first. After a typical phase 1, phase 2, and phase 3, came a rather peculiar phase 4:
-Physician: "Let's see what's in your ears now all right?"
-Little girl, tears in her eyes, pouts and answers: "no. there's nothing there I checked!" I cracked a smile.
After going through phases 1 through 8, with the ruckus and the rivers of tears I had now adapted to, she looked at her sister (now in phase 4, the worst) who was screaming so hard that I was afraid her eyes were going to pop out. And then, in a condescending tone, one that flaunted her newly acquired wisdom to her sister, she quipped: "khalas! ma 3am ya3mellik shi! lesh 3am tebke??" translation: "Stop crying! what's the problem they're not doing anything to you!" I couldn't help but laugh, look at the Dad and say "oh, now she's wise!". The dad nodded, threw a fake smile my way and went on to talk to the doctor.

That visit ended at around 11:45. Another short uneventful visit (uneventful only meaning not any more eventful than the other visits, because you may imagine that there is no such thing as an uneventful visit to the pediatrician's!) and it was time for me to head out. And as I was getting ready to do so, the attending, having noticed my expressions of boredom and anguish, smiled and said: "It's a lot of repetition, this specialty." So I smiled back and said nothing. What could I say? "Yeah Doc it was nice watching you play and toss your stethoscope up and down while the nurse did all the real work" ? hehe no, I don't think so.

For me, it was an interesting experience, to be honest. Sure, for the most part all I could do is think about the best ways to shut the kids up, and these included hammers, fists, screaming in anger, but also, I have to admit that a nice strawberry lollipop and a reassuring kiss on the forehead went a long way sometimes. So what am I saying here? Hold on... I'm not so sure anymore! I mean when I started concocting this thing you're reading I imagined it ending very differently. Somewhere along the lines of "Kill the bastards", or "Fucking kids!" or... you get the drift... But as it turns out, I am just realizing now, as I'm typing, maybe I don't hate the little buggers as much as I used to... Maybe I did think that the little wise-ass girl was funny and cute, or that the helpless silent baby girl was just to die for... I must be growing up. Go figure. Well some of my closest friends would say: "it's about time"...

For a nice afternoon drive...

This Year - The Mountain Goats

I broke free on a saturday morning.
I put the pedal to the floor.
headed north on mills avenue,
and listened to the engine roar.

my broken house behind me and good things ahead,
a girl named cathy wants a little of my time.
six cylinders underneath the hood crashing and kicking,
ahhh listen to the engine whine.

I am going to make it through this year if it kills me.
I am going to make it through this year if it kills me.

I played video games in a drunken haze
I was seventeen years young.
hurt my knuckles punching the machines
the taste of scotch rich on my tongue.

and then cathy showed up and we hung out.
trading swigs from the bottle all bitter and clean
locking eyes, holding hands,
twin high maintenance machines.

I am going to make it through this year if it kills me.
I am going to make it through this year if it kills me.

I drove home in the california dusk.
I could feel the alcohol inside of me.
home.
picture the look on my stepfather's face,
ready for the bad things to come.

I downshifted as I pulled into the driveway.
the motor screaming out stuck in second gear.
the scene ends badly as you might imagine,
in a cavalcade of anger and fear.

there will be feasting and dancing in jerusalem next year.

I am going to make it through this year if it kills me.
I am going to make it through this year if it kills me.