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.

It's here... It's finally here!

Here's to ending another long and intricate chapter in an incredibly long book -and to the first page of a new chapter with more and more drama  - Loving every page. Graduating in a few weeks and having this to look forward to is simply... Sweet ...!

This is everything I've wanted. The news is still sinking in 10 days after it came in.

You can bet everything that I will be thinking... Did I just bite off more than I can chew? ....

.... And shortly thereafter, answering : Bring it, Surgery! How bad can you be? I'm too excited to have second thoughts!

How bad? Well I've heard stories here and there. But I will be the judge of that this time, thank you. I'll be reporting live right here, faithful readers tag along :)

Ladies and Gentlemen, We Need Your Blood!

There are many organizations around Lebanon who have taken specific interest in blood drives. For a reason. Despite this, there has always been a shortage of blood for patients in need. It's simple numbers, there are so many patients in need of blood transfusions that the number of donors is just not enough. It's the same with organ donation.

What if you could help? What's in it to you? I mean It's a hassle, a traffic nightmare, it's a bit of wooziness after a few hundred milliliters of blood have been drawn from your circulation, why do it?
Well what about the idea that your blood could be coarsing through someone else's veins and help keep them alive? From the 22 year-old man I saw in the ER a few days ago who was run-over and pinned down for 45 minutes under an SUV, requiring no less than 11 blood units overnight, to the 80-some year old lady with hemolysis, a bit of YOUR blood can make the difference between life and death. Have you ever stopped to think about that? I believe that donating blood is like donating any other organ. A kidney, part of your liver, all the same, and even better, with blood you get to do it all over again in a few weeks!

To donate, please visit Donner Sang Compter, and register.

Hey F. ;)

A few facts about Blood donation, what you need to know

- Donating blood is neither painful nor dangerous. If you are a healthy individual and have no prohibitive problems, you will be cleared for donation and experience no sequelae beyond a few minutes of wooziness and perhaps some mild nausea.
- You will not become weak or ill after donating blood.
- You will NOT get an HIV infection. Needles are sterile, prepacked, and used only once.
- Your blood will be screened for common blood-borne diseases before it is used. (HIV, Hepatitis etc...) and you will be notified if any of those screens are positive.

What about blood type and compatibility?

- Blood = Plasma (Fluid) + Formed elements (Red cells, white cells, platelets...)
- You can be one of four blood groups: A, B, AB, and O, depending on which antigens are present on the surface of your red blood cells: A antigens for group A, B antigens for group B, Both A and B antigens for group AB, or No antigens for group O.
- Similarly, you can be Rhesus positive, or negative, depending on the presence or absence of the Rhesus antigen.
- So which blood types are compatible? To answer this question, there is a third important component in your blood that needs to be understood, your plasma. Plasma is the base fluid that constitutes your blood and in which your blood cells and platelets are carried around your body. It contains all kinds of molecules (proteins, clotting factors, antibodies, sugar, electrolytes etc...). Of interest for blood  transfusion are the anti-ABO antibodies. These are part of your immune system and are the basis of the danger of ABO incompatibility:
- A person of the A group has anti-B antibodies in her/his plasma. So if she/he receives red blood cells from a person of type B or AB, the antibodies will bind these cells and destroy them, creating clots and a systemic immune hemolytic reaction that can be fatal.
- A person of the B group has anti-A antibodies, so they cannot receive blood from group A or AB.
- A person of the AB group has no anti-A or anti-B antibodies. They are universal recipients because they can receive blood of type A, B, AB, or O.
- A person of the O group has no antigens, they are therefore universal donors and can donate to all blood types. But they do have both anti-A and anti-B antibodies, and therefore can only receive type O blood.
- Similarly (remember antigen, antibody) a rhesus positive person can donate only to a rhesus positive person.
- A rhesus negative person can donate to both.

Recap:
- Group A can receive type A or O, and can donate only to groups A and AB.
- Group B can receive type B or O, and can donate only to group B and AB.
- Group AB can receive ANY of A, B, AB, or O, and can donate only to group AB.
- Group O can receive only group O, and can donate to ANY blood group.
- Rh positive to Rh positive,  and Rh negative to both positive and negative for rhesus matching of any of the above combinations.

We need your blood. It's very simple.

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.

Of Seaside Mornings

Beirut, Lebanon - February 2011

There's something about the sea during the morning hours. 

If you're a morning person - or an insomniac, of course - then I suggest a nice cup of coffee at the coast. 

Nothing better to clear your mind and get ready for an anticipated stressful day at work!

Location:Corniche

A Physician's Closest Enemy...

... is actually the patient's lifeline. That brilliant little invention called a Beeper or Pager that's designed and built to keep you alert and reachable,  and without which the phrase "on call" would have no practical meaning whatsoever.
That's all very nice. I mean it's really hard to conceive of a hospital functioning without pagers. Every single attempt at communication would invariably take longer, cost more, and be more burdensome on staff and patients alike. So here's how it should work:

1- Patient need something
2- Patient calls nurse
3- If nurse can handle it, stop here.
4- If nurse can't handle it:
5- Nurse picks up a phone and pages Dr. Fixit
6- Dr. Fixit shows up happily within minutes and sorts things out.

Great stuf right? 6 easy steps towards better patient care! Right? Well, only when it works!

BUT... (hehe) what happens when you mix needy and naggy patients, an incompetent nurse, and a doctor worn out by 14 hours of floor work during the day, and 3 hours of the same after sleeping hours? well things turn out a bit different... like so:

1- Patient needs attention = Patient nags about the lighting in the room
2- Patient calls nurse
3- Incompetent nurse prances in and freezes at such an impossible task as putting the patient to ease
4- Incompetent nurse freaks out, picks up a phone and pages Dr. Wornout at 3 AM
5- Dr. Wornout is bummed that the stupid pager's ringing again but humbly picks up a phone and responds
6- Incompetent nurse tells the story
7- Dr. Wornout cannot believe he's been woken up for such a lame story
8- Dr. Wornout screams and cusses out incompetent nurse
9- Dr. Wornout still might have to come over and talk to the patient or prescribe sedatives across the floor to get some peaceful sleep.

Ah, yes! This is perhaps a more accurate description of many of the calls we get on a night's duty. Thinking about it is funny. It really is! I can remember being paged for the dumbest stuff! And I swear all of these are true stories!

BEEP! 2:00 AM, 10 South: Doctor, doctor! The patient in 1026 refused to wear the face mask that was keeping him alive. He says it's too bulky, and his oxygen saturation went down to 70. But don't worry I called Inhalation Therapy and they convinced him. - "Wow good job, stupid male nurse! Thanks! "

BEEP! 5:00 AM 8 North: Doctor, Doctor! The patient in 823 Just called me and said she just had her period. - "OMG are you really calling me at 5 in the morning for this?! What do you want me to do, bring pads!?! Is this an emergency? Is she hemorrhaging?! - No - Well?!!? - ok thank you Doctor.

BEEP! 12:00 Midnight 9 North: Doctor the patient in 922 is ready for his blood transfusion, if you could bring up that unit? - Ok on my way - I get to the floor - Here's the unit, start the transfusion - Oh but Doctor the patient was taken down for his CT scan. - Is he coming back soon? - We don't know so we can't keep the blood unit here, in case it takes longer than expected; you have to take it back to the blood bank and check it out again when the patient comes back. - !@#%#$^$%&*^%$#!@#$#$@%@# You stupid MORON!!!!!!

BEEP! 1:00 AM 10 South: Doctor? I was wondering why the patient in 1036 is taking Methotrexate? - Ok I'll go along with this, He has scleroderma, to satisfy your hunger for knowledge at this hour of night... - Ooh ok, and Why are you giving him Tazocin? - For his pneumonia honey what's up? - Oooh true but why not Tavanic? and since he has pneumonia, why didn't you order him an incentive spirometer? - Hmm are you really calling me to suggest medical management is incorrect? Can I !@#$ing go back to sleep now?! Promise we'll talk in the morning!

No disrespect to nurses, but please help us out with our crazy duties! There are things you can handle, and things you can't, know which is which!
It's funny remembering all this stuff and I'd like to take a moment to say that not all nurses are like this! I've worked with a few nurses who had excellent judgment, knew how to talk to patients and resolve issues like lighting and air conditioning, but also comforted their patients for a peaceful night's sleep without the need for Lexotanyl! Some admittedly knew more about medicine than I did and they have my full respect and admiration. You make our lives easier.

Cheers to a completed Internal Medicine rotation! 

Of Friendship and Lack Thereof

What happens when you run out of outlets? What happens when your friends are leaving, one by one, caving to the attraction of a random civilized country with hope for a decent and secure future, and you're left counting how many of them you have left? Two or three? Or is it one? Shit I don't know anymore!
I'll tell you what happens. You're left with two or three mindsets that cooperate or take turns tearing your sanity apart, each one taking partial or complete precedence over the others depending on your mood and how your day is going.

On the rare but welcome good day, you'll feel optimistic about present and future -like I felt when I wrote my previous post-, and keep thinking to yourself, "staying here isn't so bad! I've almost got it figured, and it feels good to be home!" Expected, from someone who's already failed -miserably- to capitalize on the golden opportunity of a medical career in France due mostly to nostalgia.

On the more common average day you tend not to think about it too much. Because on the average day you have a lot keeping you busy, and there isn't much time for thinking and musing about life and its roller-coasters. You do catch a few ideas flying by, but these don't tend to materialize into something meaningful by the time your attention is caught by something else.

We're left with bad days. It is on those bad days, those days when you just can't seem to find anything to do with your time, or when you just seem to have woken up on the wrong side of the bed, that these thoughts go wild. You feel stranded, isolated, wondering what the hell you're doing at home or wherever you are. Your outlets are numbered and each has his/her own set of problems and obstacles. They're busy. You don't really feel like their gossip, trivia, and pettiness, even though you love them. She's unreachable! S. is in the U.S. B. is in the U.K. N. is in Kuwait, K. in Dubai, R. in France... I could go on...
And this is when it gets to you the most. Because what are you left with, if not memories of good times and intrusive thoughts and feelings of all sorts that make you question your own sanity sometimes? or a bad mindset and ensuing reactions and overreactions that can ruin friendships and relationships? And what can you do with these thoughts? Well you can either swallow them, or throw them in someone's face. I tend to do the latter, often with bad consequences, but that's another thing I never seem to learn.

But you know what? All that's about to change. I'm done. I feel like I've been changed. Yes, BEEN changed, by these circumstances. I've let them get the better of me, something I don't usually do.
I've gotten a few remarks which I admitted to, again, something not everyone around me is used to seeing. The changes are in motion, things will be different from now on.

Here's to not keeping all your eggs in one basket.

For those of you who know what I mean...

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!

The Bitter End

They called me to your room, I saw you for myself

I saw you, and my self was torn

Who you remind me of, I dare not say

The consequences I dare not see

Your habit, got the best of you

But you of it, have the worst end

And they will be there, to hold your hand

Your loved ones, till the bitter end

Themselves miles more torn than me

Written for a dying mother...

It all starts with a nodule...

We are taught by life to greet people with courtesy; always smile and say something nice, always ask how people are doing. You enter a sick patient's room on the morning rounds and say something like: "Hello sir, how are we doing today?", and hope for some optimism and a smile in return. Try doing that on the oncology wards. On a few of my first patient visits on the oncology floor, I was caught off guard by a 38 year old patient with a body torn up, on the inside, by a uterine cancer. Now in the terminal stages of her disease, N. answered my question in a way I was never ready to handle.
- Me, entering the room for the first time, smiling: "How are you today Mrs. [...] ?"
- Her, stating the obvious, pointing at her distended, asymmetric, diseased abdomen: "Well, how do you think I'm doing?"
Realizing the retrospective absurdity of my question to a woman with a mass the size of a basketball inside her, and many other little ones scattered around her frail and broken body, I froze for a second, and nodded, with my stupid, embarrased smile still stuck to my face, and proceeded to interview and examine her, gathering a few pieces of information to write my stupid little note in her chart.
How? How can you be pleasant to a dying person? I'm still learning here... perhaps learning that oncology is the single most impossible specialty for me to work in. Oncology, cancer, that indiscriminate, slow killer that catches persons and tosses their bodies around for seeming ages.
Cancer means you see your patient on Friday and think he's doing a bit better:
- Mr. H, a nice and unfortunate old man: "Thank you doctor for coming to see me, it makes me stronger"
and then you go away for the weekend and on Monday you hear the news that Mr. H passed away on Saturday, his son's wedding day. They tell you that Mr. H's son had been pushing since thursday for a discharge so that his father can die in his hometown, and to kindle a glimmer of hope that his father would get a chance to see his son get married, even if he has to feel this fatherly pride in a wheelchair. No such luck.

It's too much for me to handle. Too much to see this losing battle day in day out, too much to see so much suffering. Too much to see so much harm coming from what started as a small nodule, a small blip on a chest radiograph... Not for me.

What Happens to Time?

When Monday morning kicking off another day's work seamlessly morphs into a Monday morning kicking off another week. And while you're trying to think about it, why not? another month flies out the window and next thing you know you're left sitting on a metaphorical curb, head cradled in your hands, wondering what you've accomplished, if anything, during that hectic October you've just leaked ever so unsuspectingly.

Or when you meet your new pediatrics resident for the night's duty and realize that his father was actually the pediatrician who followed, treated, and probably terrorized you through the better part of your childhood, 0-18 years of age. In a puff of smoke.
Such a shame how far that apple falls from the tree... but I digress...

People are always afraid of losing time. Time, time, time.
"We're late, we need to hurry!" Of course. Time is gold.
"I'm growing old, look at these wrinkles" says she, in her mid-late 20's, dripping of youth and beauty as she speeds down a wrong way road to her plastic surgeon's office, stone-coldly ignoring all pleas for a healthy and graceful maturity that's still far far away.

But why? Why should I be so preoccupied with time, when the harder I try to save it, the more acutely aware I am of my helplessness toward it? Why can't I be less attached to that Monday? or to that October, or to that year that October has ruthlessly dragged down with it for the 28th time? And why can't I look back at my great 28 years in this world and smile, instead of looking just ahead, terrified of turning 30 in 2 years?
2 years. More like 2 Mondays, 2 more weeks, 2 more Octobers; it's all the same. Maybe that's why...

Meet me back at that curb...

The ER Delivers...

Bring it ER, Bring it Med IV... That was the closing sentence in my Beginning of the End post. Excitement and ambition.

I have to say that today, the ER delivered. Today, I couldn't help but think that what was happening was some kind of response to what I wrote and felt a few days ago when I was just starting out...
The ER never faltered, even in the med III ER rotation, in showing us how little we knew, and how completely unprepared we can be for handling situations and patients beyond our qualifications.

A Primitive Cranial Nerve... Did you know about this?

I can't remember what I was looking for exactly when I stumbled upon a research paper for a cranial nerve that I had absolutely no idea about. For those of you who aren't that medically inclined, here's an intro.

Cranial nerves are nerves that arise from the encephalon. They are responsible for many reflexes and control of many automatic functions, such as gaze coordination, taste etc...
There are 12 cranial nerves (CN), numbered CN I-XII in the order that they enter or arise from the brain. If you're interested, here are the known Cranial Nerves:

The Beginning of The End...

Tuesday June 1st, 2010, the first day of the last year of Medicine. Med IV starts today. Med IV means we're getting close.
I hope it turns out as good as Med III.

Starting out in the family medicine rotation. It turns out i'm first in line (with a colleague) for a PM shift in the ER lasting 7 hours (4:00 pm - 11:00 pm) on the very first day. Rough start!

Blogging from the ER lounge (Where I love the Air Conditioning! Just FREEZING!), I just finished seeing a patient with an elbow injury. First thing that came to mind: I miss the ER! I miss the speed with which things were done; I miss the frantically scribbled less-than-one-paragraph-long notes on board-charts. The patient I just saw was triaged, seen by an attending orthopedic surgeon, 2 residents, and myself, taken down to x-ray and back in just under 20 minutes. As comparison, consider that an out-patient case takes about 2-3 hours to be handled.

I miss it. I do.

Bring it ER! Bring it Med IV!

I want my M.D.