This thing I refer to as My Life

Oops, I did it again! I finished another rotation, or rather half a rotation. Today was my last day with the GYN-ONC service. Most of the time was spent in the OR. Some days were really long (14+ hours of consecutive surgeries), one day I got to go home at 1:30p and a couple of days I gent home around 5p. Almost all days started 6a and lasted until 8p.

The first OR days of the three weeks were spent with Benign GYN and mostly laparoscopic explorations for infertility. The first day was cool because it was all new. I didn’t do much but sit around and watch. The second day was, well less interesting. Then it was the weekend: most of which we have off. Monday brought my first open procedure and things were new again. After a couple of procedures, I got to do some suturing, retracting and answering of “pimp” questions. (I really don’t know why it’s called pimping when you’re being quizzed, but it is.) Day before yesterday was a highlight. I was scrubbed in on a dual procedure—vulvectomy and laparoscopic hysterectomy with removal of a demoid cyst. What does that mean? Well, you really don’t want to know, but just so you know, a dermoid cyst is this nasty tumor full of, get this, hair! It’s like a fur ball that grows in your body. Since they did that procedure laparoscopically and because the cyst was so too large, they had to disassemble the cyst in side her and pull out clumps of hair much like cleaning a very dirty shower drain! To make matters worse, the hair was covered in a thick brown goo! It was so nasty! Well, that was only half of it. The part I was working with was a vulvectomy where much of the tissue from groin and part of the labia majora had to be removed and reconstructed. There was some disease going on but it had a really strange name that I had never heard of and no longer remember and I cannot seem to find it on google. I don’t even want to tell you what I used for a search string! For that procedure, our half did not have a scrub nurse or scrub tech to hand us instruments and, although, they thought we’d have an easy procedure it turned out to be very difficult. For about half of it I was acting as a scrub tech which was cool because I finally started learning the names of all of the instruments. (That’s is not something they expect the students to learn.) I got to cut, sew, and do all sorts of stuff. One other procedure that stands out was burning and lasering off genital/anal warts. You have to make sure to suction off the smoke very carefully because the virus can be aerosolized! Sure hope I don’t get anal warts. They don’t look like fun.

I’ve also had a few days of clinics which are not so interesting. Only one of the docs lets me perform pelvic exams in the clinics, but I’ve gotten to do a lot in the OR, so it’s no big deal. A new clinical assignment started yesterday in an outpatient clinic in Canton, which is really close to where we do our grocery shopping. I would have stopped by our favorite produce market (Randazzo’s) but I had to finish off a Power Point presentation that was due today and to be presented in a few weeks. Some of the other students will present tomorrow. Get this! I have to be at school tomorrow at 8a (which is pretty good) and sit through a series of 20 minute lectures until 3p, then sit through a two hour class-wide Friday lecture until 5p and then I start a weekend of 6p to 9a shifts the whole weekend. I’m going to be so tired tomorrow! Well, day after tomorrow. With this new shift, which is only this weekend, I will start L&D (labor and delivery). It should be a nice change from cancer, cancer, and more cancer. I think the real lesson learned here is that I really don’t enjoy standing in one place for 10+ hours at a time while working 12+ hour days. Clinics, however, start at 7:30a and go until 5p and are much more palatable. I’m starting to wonder if I go into a medical practice that I really don’t want to be a hospitalist—at least not in a surgery specialty. But I have to remember that when I’m standing in surgery for 14 hours for 4 procedures, it’s only the students and residents that stay the whole time: The attendings usually only do one or two procedures at a time.

There’s probably more to tell, but I got to go clock some sleep!

I suppose a little update is in order. Last week I spent two days in OR. The GYN portion is considered a surgery rotation which means get up/there early and watch procedures. Thursday was pretty cool: mostly laproscopic cases. Friday I saw my first open case (incision into the abdomen) of a young lady with a fibroid cyst just smaller than a Nerf football. Apparently, she felt pressure on her bladder and pain with intercourse. All, very understandable considering how big it was. We, well, they took it out along with four much smaller cysts. But, to be honest, it was getting a little boring by the end of that second day. Part of the problem was there was a visiting M4 (from another school) who scrubbed-in so she got to do the stuff that I probably would have gotten to do. So, that kinda’ sucked. I think I’ll start inviting myself into the party a little more now that I’ve watched for a few days. The beginning of the week was spent in orientation, if you’re curious. Next week I’ll start Gyn-Onc which is supposed to be much more intense with longer surgeries, so maybe I’ll get to do stuff then, like tie a knot! Who knew that cub scouts would come in so handy?!

In other news…it’s the day before my birthday! Those of you delinquents who have not done so already, should get off of your buns and send me an e-mail! At least and e-card if you can’t think of anything to say! ML is currently making my favorite birthday cake! (Tres Leche) It took her a few tries to really perfect it and now it’s better than what you buy in the stores. I think her recipe is actually the best combination of three or four different recipes. We had our traditional sushi brunch this morning and we’ll go to The Earle Down-town. ML apparently had to e-mail them in advance to see if she could get a reservation. “You can’t have the duck! You can have the chicken.” (LA Story) We got in at 8:30p. With the rest of my pre-birthday day, I’m studying. For my actually birthday, I will study. Speaking of which, I have to get back to it. I have a report/presentation coming due on the pros and cons of genetic testing for women who have a family history of breast cancer.

This seems like a very emotion entry. There is some discussion of suicide which may be particularly sensitive to some readers and I want you to be prepared.

Another shelf exam behind me! I still have not received my grades from my first one, but that could still be two weeks away. The exam was significantly more difficult than I expected it to be and more than my example question and, what was worse was I almost did not finish in time. It was the same length as the internal medicine but the question stems were much longer. On the brighter side, I did get a good night’s sleep last night so that hopefully helped. Alas, this is not what you’re here for.

Did I like psychiatry? You bet! I thought it would get bored with the slew of depressed patients, but oddly, I did not. Granted, I was only doing this for 6 weeks as opposed to a lifetime, so I have to take that into consideration. The funniest part is I really did not have much use for psychiatrists before this. I suppose it is really psychologists that I have found useless (all but one) and I really did not know what a psychiatrist does.

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Aside: Since this is the story of my life, I think I should tell you about the “one” psychologist that I did like because I think it plays into these experiences now. (Some of you will know this story, but others will not.) Shortly after I went to graduate school in Indiana, my college-girlfriend went to graduate school in Virginia. We had put our relationship on a we’ll-see-plan (which many of you may not have known). A few weeks into our first year an intruder gained access into her apartment and sexually-/physically-assaulted her for the better part of 5 hours. After convincing the rapist to leave, she called me (first) at 5:26a. I picked up the phone, she said my name, I said,
“What’s wrong?” She gave me a brief description.
“Is he gone?”
“Yes.”
“Have you called the police?”
“No. I called you first.”
“I want you to hang up the phone and dial 911 now. Can you do that?”
“Okay.”
“I will call you back right back.”
“Okay.”
I hung up the phone and tried to call the police myself because I was not sure she was going to be able. I dialed the operator, explained to her what happened and asked if she could connect me to the Richmond police. She could not and did not have any ideas what to do. I hung up the phone…thoughts running though my head searching for a solution. It seemed forever, but I know it was only seconds before the solution was there. 1-Area code-555-1212. A little known fact that if you dial that number putting in the area code you want (in this case 804) you get local information (411) for that area. (I can feel the adrenaline and emotions swelling as I type this. That’s interesting.) I told the operator what I was trying to do and that I needed the police department for the City of Richmond and the operator connected me (She did actually ask if I wanted to be connected.) When the officer answered I could actually here another officer taking the call and dispatching the police. They were less than a block away. I heard the operator tell her that I was on the phone with them on the other line. I heard the police knocking on her door (her call must have been on a speaker phone because it was pretty clear). I heard the police talking to her and then taking the phone from her telling the dispatch to send an ambulance.

So, where does the psychologist come into play here you ask? Well, I got a ticket on the first flight from Indianapolis to Richmond but that was not until 10a. In the interim, I was trying to get all of my ducks in a row and part of that was getting some counseling because I had no idea what to expect or do. My cousin Dena (5th cousin, but still close as she, her husband and their daughter were my only family in the area) taught at Purdue and she recommended a specific person on campus. She saw me that morning at 8a and we talked about what had happened, what I was planning and what I should expect. She offered to see me after I got back too, which I did and we debriefed. And then she did something that I have never seen any other psychologist do to anyone else, she said I was handling this very well. I could have more counseling if I wanted, but she did not think I needed it. (I had to say “anyone else” up there because this was the first time I had ever seen a psychologist, well, that’s not quite true…at some point my dad had me and my older sister see a family therapist for something going on with my younger sister…utterly useless on several levels…but that’s a story for another day, if ever.)
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Wow, that was much more of dramatic aside than I had anticipated. Also longer.

So, the very first patient I interviewed during psychiatry was a young woman with depression. We had talked about the time course (long standing), her relationships (all short), I asked the question to which I knew the answer, “Has anyone ever hurt you physically or sexually?” I tried to hold back my tear during her pause. She burst into tears. After gathering herself, it had been her grandfather who was an alcoholic. She had never told anyone up to that point. The whole interview was an emotional rollercoaster I did not expect.

Not all of the interviews were that heart wrenching. There was a young man who was basically sleeping 3 hours a night for the last 8 months which was likely do to living with f*cked up parents. I saw him a few times and had the prediction that if he moves out when he’s 18 (in a year) he’ll be able to sleep. The next interview I asked him about the last time he felt he got a good night’s sleep. It was on vacation at his uncle’s house where he had his own room over the garage. Slept like a baby!

All of the above was during my outpatient weeks. My consult weeks were filled with delirium. Consults are where an internal medicine doctor has a patient that is suicidal but medically unstable for the psychiatry ward, or having mental status changes, etc. I did talk to one young man in his mid 20’s who had tried to kill himself with Tylenol PM. By the way, Tylenol is NOT the way to go. It does not kill you right away. I kills your liver and then you die a week or two later, perfectly conscious and in horrible pain. And there’s nothing that can be done. If you are caught in time, like this guy, there is an antidote that will stop FUTHER liver damage. Other than the means, this kid had it all planned out: got a hotel room (so he would not be caught) for the weekend, purchased the pills and chicken wings. I love the chicken wing part! Had his last meal early Saturday morning while watching TV. Slept for a few hours, woke up Saturday afternoon and took 150 pills and passed out. Woke up Sunday and vomited up (a little, but no full pills). Felt like crap and WALKED! to St. Joes hospital. What drove him to it you ask? His mother died when he was very young and he was raised by his grandparents. His grandfather died a year ago and his grandmother earlier this summer. He had been the caregiver for both of them in their latter years. He had no family and was about to start graduate school. His roommate stole everything he had in their apartment and left. (It turned out that the roommate was a drug dealer.) He had no one, he had nothing, he had lived a pretty good life and it was all gone. He did have insurance, but it was clear that it was not going to be easy. Oh, and he had very little money.

But wait! There’s more! You want to keep reading!!
9C, the in patient ward: You’d think that the patients that hear voices and see things would be what I would talk about here. There was that, and I did get a patient like that, but he was in pretty good shape. Just a little (a lot) confused when he came in because he had stopped his medication earlier in the summer.

I have for you, a very nice gentleman who hung himself. No, he did not try to hang himself. He DID hang himself. In the garage: for a good 5 min by his calculations before being found. He has the rope-burn on his neck to prove it. What’s his story you ask? Glad you did. This (really nice) guy was an ex-jet pilot in the Army. He had been working in the food distribution industry for a number of years. Had been divorced and remarried a few years back. He discovered, after being married for a few years that his new wife is an alcoholic and continually abuses marijuana. (She hid it well for about a year.) They were about to move to OH so he could take a new managing position and he realized that he could not financially buy the new house, sell/rent the old house, and get out of his current contract without litigation. Oh, and the new job was supposed to start this last Monday. Last Friday, after figuring out what was going on, he tried to talk to his wife about it. She wanted to wait until Saturday. So he waited. He told her Saturday morning, to which she responded, “Thanks a F*cking lot for ruining my weekend! I’m going to invite my girlfriends over and we’re going to party!” After a day of her drinking and getting stoned while he planned the final touches to his demise, they went to sleep. (He had been doing some other planning earlier in the summer like setting up a trust fund for his son by his first marriage.) He woke early and, oddly, she did too. She said, “do you still want to be married to me because I’m going to party and that’s the way it is.” He told her yes and told her to go back to sleep. He went down stairs, switch cell phones and got the rope. He went to the garage (which is really a tall carriage house with high rafters) and set up, dialed 911 (so they would find him and not his wife, but knowing that they would not arrive in time to save him, which they did not) and kicked the chair out. I asked him what his thoughts were in the final moments. He said, “it was like going through a check list before taking a flight: Is the rope tight? Check. Is the rope holding? Check. Can I not breathe? Check. Am I getting weak? Check. Am I loosing consciousness? Check.

Either hours later, we woke up in the hospital, intubated, and very upset that it did not work. What he had failed to plan for is that he forgot to make a pot of coffee, which he did every morning. His wife woke up realizing this and went to go see what was up. She went out to the garage and found him there. She grabbed his knees and lifted and started screaming out. A taller, stronger, neighbor came over and lifted him up ever higher until the fire department arrived.

He and I had two really nice, long talks. We talked about simplifying life and slowing down. He was able to get out of the new-home purchase and he quit both his old and new jobs. He is planning on getting an easier job and taking better care of himself. It was not until a day later before he found the will to live. Hopefully he’ll hang on to that.

The last person I want to tell you about is the doctor a met: The doctor who tried to kill himself by carbon monoxide. He had been planning his death for several years. Every day he lived with pain and anxiety with no relief. During his other interviews he always spoke in diagnosis, he spoke like a doctor: anxiety disorder, suicidal ideations, abandonment. My last day, I said to my team that I want to spend some time with him. I want to see if I can get him to share his experience with me, not his diagnosis. We talked to 2.5 hours, sequestered in an interview room because I did not want interruptions. I started by saying, “I have a very good understanding of your diagnosis, but what I don’t know is your thoughts, your feelings, your thought process leading up to this. That is what I would like understand. I’d like to start with your second attempt and work backwards 48 hours before your first attempt.” Oh, did I tell you that he tried two days in a row? We started and then realized that we should start with the first attempt, go to the second, and then work backwards. He read up on the internet how to attach a hose from your tail pipe and run it into the window. He had rented a cabin--that he used to bike past for exercise--for the weekend so he would not get caught. (Note that common theme?) He spent Friday morning packing up gifts for all of his friends and family as well as working on notes for all of them. Two of his friends had stopped by that evening while he was still home. He was running late. They thought he might be planning to hurt himself and he convinced them that he was not. He said that he was just going to spend some time relaxing and actually invited them to join. Fortunately, they both had other plans but decided that he was going to be safe. He had not let them in the house because they would have seen all of the gifts and notes and known what he was planning. Earlier in the week he had cancelled an appointment with his therapist and she had called several times leaving message as she feared he was going to try something. He did not answer the phone. He packed his last good bottle of wine (which he had been saving), some Vicodin (both of which to reduce the headache that comes with trying to kill yourself this way, his favorite bean dip, chips, some warm clothes, all of his photos and letters from his son--who just started college. He drove to the cabin and ate his favorite bean dip, looked at all of the photos, read all of his letters and finished his suicide note. A little after midnight he set up the hose, started the car and laid down in the back. He had covered the seat with blanket so, if he vomited, it would be easy to clean. He drank the bottle of wine just before going outside and now took the 8 Vicodin he had from an old prescription. He survival instinct kicked in and he toss and turned in the back seat until morning. He realized that he was going to be caught so he disassembled everything and went inside to sleep for a few hours. He drove home to read some more to figure out what he had done wrong. He got some better hose and made some other adjustments, but he had no pain pills other than Tylenol this time and no wine: At least no good wine, as he put it. He knew it was going to hurt this time. At the bottom of his suicide note he wrote “Ditto” as a joke since it was his second try. The second setup worked much better. After a short while he struggled for breath. He had a raging head ache and a few times he opened the car door and vomited. He decided to stop the engine and just let the fumes in the car do the job. He passed out and woke shortly after dawn. Gasping for air, he disassembled the car and packed up his belongings. He went to return the key, although he could barely drive. The ranger asked him if he was okay? He just said he was sick. I passed out in his car in the parking lot for a few minutes. He decided to tell the ranger what he had done, but they were all gone. He knocked on the door but there was no answer. He fainted in the parking lot. Woke up and called 911.

It would turn out that the two days before were mostly focused on planning and seeing some friends one last time. What would be more telling was the pain. Every day of this man’s life he felt pain from an anxiety that would be his undoing. He was afraid that everyone was going to abandon him. He had been in therapy for years but nothing had helped: Except for 3 months. He had 3 month anxiety free time which started when a psychiatrist had asked him to stop drinking. You see, he drinks 2-3 glasses of wine almost every night because it reduces his anxiety and helps him sleep. The flip side to that is when your body becomes dependant on alcohol, it makes you depressed or anxious. He stopped drinking for a month, the month before the 3 month window. The other nugget I learned during this rotation during my abuse clinic (oh! I didn’t talk about that, did I? that’s good stuff too.) that it takes almost exactly 1 month without alcohol to be released from its effects on mood. They psychiatrist made a critical mistake after that month: he was allowed to drink one glass per night. Those 3 months, by the way, actually was one perfect month with a slow return of the anxiety: almost perfectly coordinated with the return of his old, and current, drinking habits. The pain returned. Every day. Every night. Worse when he thought someone was leaving his life. Nothing made it better. Every day. He describes it as though he was in the last days of fighting a losing battle with cancer but it never ended. He had also been planning for most of the year. He had also set up a trust fund for his son (another common theme). He also saw no alternative. He was brought in on Sunday. By the time we talked on Thursday, his MAOI (remember reading all of the warnings on food: if you’re taking an MAO inhibitor, do not eat this) his anxiety, at its worst, has been 2 out of 10 instead of 9 out of 10 (with was more doctor-speak). But the doctor speak was okay because I he finally opened up about his feelings, his thoughts, his life. Not his diagnosis. We spoke a little about medical school. He asked me what I thought about it and if I thought it was worth it. I told him a little of my history and how I was not locked in like the traditional students. I had a fall back which gives me a sense of security that my fellow students don’t have. I told him there are better days and worse but I don’t regret it. And, it’s the 2.5 hours that I spent with him that make the 2.5 hours testing today that tips the balance. That’s why, for all of the shit of which I am truly tired (and part of my is really wiped out), I will walk into my next rotation trying to restrain from grinning ear-to-ear: trying not to let on.

Yes, next week I may be birthing babies. What a contrast!

Psych comes to a close at the end of this week. It’s been pretty busy and now that I have 3 days of inpatient, it is also busy. We did have a nice/relaxing weekend of studying and BBQ’ing with our neighbors. I’ll have my psych shelf exam this Friday and then OB/Gyn next Monday! YIKES! There are some Psych adventures I’m hoping to get to post, but they’ll have to wait. I will tell you this, one of the stories is about a cute young boy…who has some not-so-cute habits (just to whet your appetite).