Surgery

Well, I guess my pediatrics month went by without much blogging activity. It was a great month. I LOVED pediatrics. That doesn't mean I don't love my adult peds is just fun, even with a lot of sick kids. We had a bunch of rotavirus infections (diarrhea and vomiting) as well as asthma exacerbations and respiratory infections. I was on call Thanksgiving weekend. Thanksgiving Day was actually fairly quiet. The hospital served turkey and stuffing (not all that tastly, really), and then two of my fellow residents brought me a plate of amazing home-cooked Thanksgiving treats and hung out with me for a while in the call room. So I had a little bit of Thanksgiving. I even got 5 hours of sleep. Then I was on call on the Saturday after Thanksgiving - I don't think I sat down more than 5 minutes all day! But that's over now...

Now I'm on surgery. I didn't know if I would like it that much, but it's actually pretty fun. I get to scrub in on surgeries, cut people open and sew people up. And I get to round at 5:30 or 6 AM. Oh yeah! Seriously, though. I've seen some pretty cool surgeries. I think I could do a cholecystectomy in my sleep (take out a gallbladder, that is). I've also gotten to attempt doing colonoscopies and endoscopies. Those are not as easy. The surgeon I work for told me to go home and practice video games. Sure - in my free time. I don't know if I'll ever be any good at working the scope with its buttons and knobs. Big knob counterclockwise to look down, clockwise up - or is it the other way around? Who cares? I can never really figure out which way I want to go anyway. It's like trying to write the alphabet upside down in a mirror or something.

The long residency hours are definitely wearing on me. After the long Thanksgiving weekend, I was really ready for a break. I basically worked about 3 weeks in a row with no days off. There's no time for life - cleaning house, cooking, laundry, answering emails, blogging, catching up on other people's blogs... I thought surgery might be a little better. But Friday was the first day we had in the OR on this rotation. I got to the hospital at 5:30 AM and left at 11:30 PM. We had an emergency appendectomy at 10 PM on a gal who was 21 weeks pregnant. I was really glad I could be there and make sure all the OB details were looked after. We got the OB nurse to check for fetal heart tones before and after surgery and hooked her up to a monitor afterwards to check for contractions. She did really well and so did the baby. I got to sleep in the next day, so everyone came out okay I guess. And I had a glorious two whole days off this past weekend!

I think the hardest part about residency right now is that there is so much to learn and so few hours in the day. I know I'm learning all the time, but sometimes I want to sit down and read about my patients' diagnoses. And sometimes I want to sit down with my patients and get a really good history, find out about what makes them tick, really discuss the options and what they think would be best for them. Unfortunately, I don't have that luxury often. It seems I'm always rushing from one patient to the next, from clinic to hospital, from noon conference to surgery...I found myself getting angry the other day at just how rushed and stressed I felt. God is always kind to show me the error of my thinking, though. On Thursday night - probably the lowest point of residency so far - I went to the ladies' prayer meeting (the women residents meet weekly for prayer) at my advisor's house. Several of the residents and faculty shared stories of how God was working through them to reach out to patients spiritually and share the hope and love of Jesus Christ. I was reminded that it's not about me or my schedule or how much time I have with a patient. It's about pointing others to the one true source of life and peace and healing. Apart from Him, I can do nothing. And apart from Him, there is nothing worth doing anyway!

Two more weeks until I get to go home for Christmas! I can't wait. I actually decorated my apartment and balcony for Christmas and have been listening to Christmas music. It makes the long hours much more bearable. Meditating on the God who sent his own son into the world as a humble, helpless baby, and later sent him to the cross to suffer in my place, makes all my suffering seem petty. I pray I can share some light this month!

Merry Christmas to all!

Time to Smell the Roses

Howdy everyone! Fall is definitely here - with crisp, cool mornings, bright red and gold leaves and pumpkins! I'm finally getting the chance to enjoy it. October pretty much disappeared on the adult medicine wards. It was my hardest month yet - very challenging mentally and physically. I had the first and last weekends off but worked every day in between. My mornings started at 5:30 or 6 AM, and I usually worked till 6 or 7 PM if not on night call.

More than the long hours, though, the constant intensity of caring for really sick patients took its toll. In medical school, I did not have many opportunities to care for patients in intensive care. So it was quite overwhelming to take responsibility for patients on ventilators with blood pressures of 50/30. As with anything in life, experience is best teacher. By the end of the month, I was able to admit patients to ICU and manage their care with a bit more confidence. I could get through my morning rounds efficiently, and I didn't panic every time my pager went off. I still don't always know how to deal with every question or situation that comes up, but I feel much better equipped to handle tough cases than I did a month ago.

Now I am on pediatrics, which is a completely different world. I still have some pretty sick patients, some of them only weeks old, but in general pediatric patients are a little easier. They don't have a lot past medical history or multiple coexisting conditions. For example, my adult patients typically have heart disease, COPD, hypertension, diabetes, alcohol abuse and kidney failure, which, as you can imagine, makes their management quite complicated. Pediatric patients, on the other hand, have perhaps one underlying condition - such as history of premature birth or asthma. Some come in with no preexisting problems at all. It's still scary to take care of a kiddo with a severe asthma exacerbation or a newborn who can't breathe due to a respiratory virus. Fortunately, the pediatric attendings are really good about teaching and explaining things. I find that if I can get guidance on managing a specific case once, the next time I see something similar, I can usually figure out what to do. My team is really great this month too - I am the only intern with three upper levels, all of whom are fun to work with and very helpful. It will still be a busy month, including 60 hours of call over Thanksgiving weekend. But I think I'm going to really enjoy it.

Well, time to hit the pillows. Looking forward to a week in Houston over Christmas (Dec 24 - Jan 1). It's right around the corner!

My First 30-Hour Day

I bet you all thought there were only 24 hours in a day. Not in residency! In fact, the weeks are longer in residency too.

I just started my adult medicine rotation, and it is definitely the most challenging rotation I've had yet. The patients are very sick, and there is never enough time to truly understand what is going on with them. As a first-year resident, I am responible for six patients on any given day. Usually at least two of them are in the intensive care unit. We start rounds at 6 AM each day and try to see six patients in three hours before meeting with our attending at 9 AM. That's only half an hour for each patient, which is never enough, especially when I'm picking up new patients in the morning who are really complicated. Of course, most of the time I have no idea what I'm supposed to do with the patients - what meds to give and how much. So I have to look stuff up, which takes even more time. After meeting with our attending frmo 9 to 10 AM, we have 30 minutes to finish stuff up - writing orders, discharging patients, calling consultants. Then we have to rush over to our sister hospital to be on time for "morning report," a teaching conference for all of the adult medicine teams. Three days a week we also have a noon conference. The afternoons are spent either in clinic or at the hospital. That's the only time I really have to read up on patients, talk to them about their rest results, and figure out what the next steps are.

One or two days a week, I'm on call. Day call goes from 6 AM to 5 PM. Night call is from 5 PM to 6 AM. However, after night call, I still have to round on my patients the next day. Hence the 30-hour work day. I had my first one this week. Actually, it was more than 30 hours. I was up at 4:30 AM, got to the hospital at 5:30 AM and started getting organized to round on my patients (looking up labs and vital signs). Morning went pretty much as above, and the afternoon was spent catching up on clinic and hospital paperwork. Then I started call at 5 PM. I had a patient to admit almost immediately. Each admit takes at least an hour, sometimes more. I have to see the patient, look up their medical history and any diagnostic studies that have been done. Then I have to write the admitting orders, which means deciding what further work-up and treatment they need. This usually involves doing some research and reading if I have time to figure out what to do and how to do it. Then I go over everything with the attending. Once that's done, I dictate the history and physical exam by phone. Then it starts all over with the next patient. In the meantime, I get to answer calls on my own patients, hopefully not too many. Some calls are relatively quiet. But my first long call this week, I admitted 5 patients. Doesn't sound like that many, but three of them were admitted to intensive care, so they were pretty sick. Anyway, I didn't get any sleep that night, so I was pretty sleepy by the time morning report rolled around. But I made it! I guess I'm still young after all!

Besides being incredibly physically and mentally challenging, this rotation has its rewards. I have gotten to know several of my patients and feel like they really appreciate it when I take the time to go back by their room and talk to them later in the day. Often, they have questions that no one has answered. Or they just want reassurance that someone cares for them. There are always so many people coming into their rooms and examining them and asking the same questions - different specialists, residents, attendings, students. I'm sure they wonder who's calling the shots and if everyone is talking to each other. My job as a primary care doctor is to try to integrate what everyone's doing and communicate with the patient. I also have to think about whole picture while specialists may only focus on one organ system. And I have to think about what's going to happen when the patient goes home. Can they care for themselves? Will they follow up? Take their medications? Do they understand their illness and what causes it? Do they know how to prevent a recurrence? I wish I had more time to be able to sit and talk with my patients to make sure they understand.

Some days I feel like I'm learning by leaps and bounds. Other days I feel like I will never have a handle on how to take care of patients. But I have found that I am more confident in responding to pages - things like patient's blood pressure too high or too low, patient agitated or confused, patient spiking a fever. Now I can often spout out orders that sound pretty good.

Well, time for bed - I have to get up in 7 hours and start a 24-hour day! More on some of my interesting patients later...

Bike Trip!

My residency program sponsors an annual trip to Colorado for first and second year residents, to promote team bonding, learning and comraderie. It's called "Bike Trip" because there is always a challenging bike ride up Vail Pass (15 miles uphill) and back. Of course, those who are less athletic can opt to do the downhill portion only - definitely a good choice.

Bike Trip 2010

I had a wonderful drive with two of the second-year gals, convoying with another group of first-years. The first morning was spent in team building activities (silly games - like making a team mascot from medical supplies - see photo) and continuing medical education lectures. Then we took a "short" hike to get acclimated. Basically, we hiked straight up for an hour, huffing and puffing, and had lunch on the top of some mountain. I got talked into hiking up even farther with some of my first-year buddies. It was, literally, breathtaking. The aspens were all turning yellow and orange and the weather was perfect with clear blue skies. So the scenery was a feast for the eyes and refreshing to the soul.

Day two was the bike outing. I got talked into doing the downhill portion of Vail Pass, imagining hurtling downhill at breakneck speeds on a rough mountain trail. Actually, the path was all asphalt and the slope gentler than I expected. So the ride was thoroughly enjoyable. After the 15-mile downhill ride, which was quite invigorating, I rode around Dillon Lake, about 10 miles. This was a somewhat more challenging ride, actually - although shorter, there were a lot of uphill sections. The crystal blue lake surrounded by pockets of golden Aspens was well worth the ride. On the third day, I kayaked around the lake. That's the first time I've ever kayaked. It was great, except when the wind kicked up. Dillon is at about 9,000 feet of altitude, so I feel pretty proud of myself for being up to several hours of rigorous activity in low oxygen conditions.

In addition to all the outdoor frolics, we had lots of social activities - games, pizza, medical pictionary (harder than you'd think - try drawing benign prostatic hypertrphy!), and even dancing. On the last night, we had a line dance with a real "caller" who led us through several line and square dances. It was loads of fun - good exercise and easy for those of us with two left feet.

I came back from the trip refreshed and ready to start my adult medicine rotation, which I just started on October 1st. It's going to be a very challenging month - but more on that later.

Sorry it's been so long between posts. I miss you all!

Month Three: Sports Medicine

Nearly 1/12 through my residency - 3 out of 36 months! This month I am on sports medicine - a rather laid-back rotation compared to some. My days are spent in clinic, at university athletic training rooms and sports events. I've seen some pretty cool stuff and learned how to examine most joints in the body.

Today I saw a high school kid with a football injury - got hit from the side and busted his knee. The x-ray showed a fracture through one side of the growth plate in the femur and into the joint - a Salter Harris Type III fracture. I know that doesn't mean much to most of you, but it was pretty cool to see it on the x-ray, CT and MRI. Very interesting case!

Last week I saw another pretty interesting case - a girl with an osteochondritis dissecans lesion. This is where a portion of the bone near the joint, just under the cartilage, is damaged from lack of adequate blood supply. The bone gets fragmented and the overlying cartilage can break off and travel into the joint space and cause pain. In this case, the fragment was 2.5 x 1.5 cm and had traveled from inside the knee up to the lateral thigh just above the knee. I could feel the cartilage piece under the skin! Okay, so not cool for the patient, but a great learning case.

Our sports medicine faculty serve as team physicians for several of the local high school and university teams. I am required to attend at least 4 sports events this month. My first was a Wichita State University volleyball game. The WSU team (the Shockers) are in the top ten ladies volleyball teams in the country supposedly. Of course, the night I saw them they lost - oh well. The game was great, but no inuries - except wounded pride, I suspect. Last week I attended a high school football game that was much more eventful. We had a shoulder dislocation, an ankle sprain/fracture, a hypoglycemic episode (one of the flag carriers in the marching band) and a case of cervical cord neuropraxia (CCN). CCN happens when a player gets hit with his neck extended, putting pressure on the spinal cord. Usually, there is some underlying cervical stenosis - narrowing of the spinal canal in the neck, predisposing the person to compression of the cord when the neck is over-extended. This results in temporary numbness, tingling and sometimes weakness/paralysis of the upper and/or lower extremities. Most players recover in a few minutes, and I don't think there are any cases of permanent paralysis. However, in the case of a narrow cervical spinal canal, the patient is at risk of recurrent injuries, and that is not a good thing. Anyway, the kid who got hurt at the football game had already had several similar episodes, so he needs to get an MRI before he will be allowed to play again. Unfortunately, this game ended with a score of 59 to 0 (the team we represented lost dismally - they were definitely at a disadvantage compared to the well-equipped private school team they were playing).

Last week I got to inject a patient's sacroiliac joint. The patient was having a lot of pain in his hip/back just where the sacral spine meets the pelvic girdle. It's a fairly big joint, but not always that easy to palpate depending on how much soft tissue the patient has on his/her backside. I got it on the first try though, which is good since I was using a 1-1/2 inch long needle!

I love this program! I get to do so many hands-on things. Last week I got to play around with the ultrasound machine with one of my pregnant patients. I'm still learning how to navigate around - it's so much fun seeing baby's face, hands, feet, heart...! What a great job I have!

Clinic Day

As a first-year resident, I get approximately two half-days of clinic each week where I see my own patients on an outpatient basis. The actual amount of time in clinic depends on what rotation I'm on. I just started sports medicine, so my clinic time is all day on Friday. This is the first time I've had a full day of clinic, and it was a bit challenging. Every month, the administration adds to the number of patients we are expected to see in a half day. I started with just two patients in four hours and am now expected to see four to five patients in four hours. The idea is to allow the residents to get used to the electronic medical record and to give time to check out each patient to the faculty preceptors. And believe me, I need all the time I can get!

So, Friday I had my first full day with 4-5 patients in each half dayn (ended up seeing 9 patients total). Sounds pretty easy, right? And actually, I did manage to finish on time. But I still had to finish up my notes at the end of the day, so I was at the office till about 7:30 PM. I find it hard to actually write my note while I'm with the patient. The program loans us a laptop to use in clinic, so I take it into the exam room, but I feel bad if I'm trying to listen to the patient while searching around on the computer for where I'm supposed to enter information or orders. So generally, I talk to the patient and then leave the room to enter orders for labs, imaging or medications. Those have to be done before the patient leaves, so it's important to at least finish that much. I also try to fill in my assessment and plan before the patient leaves. This is like a "to do" list. I list the problems I'm addressing that day and what I did or am going to do about them. I'm getting better at it, but it's still really slow. Sometimes my patients have to wait while I figure out how to refill their medications or how to order a specific referral. They don't seem to mind too much, but I feel bad taking up their time.

Some patients are really straightforward - pregnant or post-partum patients, for example. For these patients, there is a checklist of things to do and standard labs to order. So they get in and out pretty quickly. Pediatric visits are also fast in general. The ones that take the longest are the patients with several major chronic conditions (diabetes, high blood pressure, heart disease, COPD, etc.) on 15 to 20 different medications. Of course, I can't expect to address all their problems every time, but when a patient is new to me, I want to know how they are doing with all their conditions, especially since these problems are all interrelated and any new complaint or symptom could be linked to poor management or progression of any or all of the chronic problems. It's really hard for me to sort through all that in a short time and focus on only one or two things. I guess I have to get more efficient, and I am sure I will learn as I go. Plus, as I get to know each patient, I will have a better grasp of what their underlying issues are and what things are most important to address. Right now, most of my patients are new - to me at least. Except for the pregnant patients, there aren't many that I have seen more than once.

Yesterday I did see one of my "regular" patients. I've seen her about four times already in the two short months I've been in residency. She has chronic abdominal pain, likely caused by adhesions from several prior abdominal surgeries. She's tried a number of different medications for pain, none of them completely effective. When I first saw her she had had a seizure, and after getting her history I felt that it was likely due to the large amounts of a specific pain medication she was taking at the time. She also had elevated liver function tests, probably related to some of the medications she was taking. So we had to stop that several of her medications and essentially start over in figuring out how to manage her pain. I am not comfortable giving a patient, especially a young person like this patient, narcotics for long-term pain control. Narcotics do have their role, but they also have high abuse and dependency potential. Anyway, I was trying to find a way to keep this patient from depending on increasing levels of percocet or lortab for her pain. Chronic pain can be very debilitating, and over time can lead to depression and worsening of the pain in a vicious cycle - pain leading to depression and depression making the pain even less tolerable.

Every time I have seen this particular patient, she looks depressed, fatigued and totally demoralized by being unable to enjoy her usual life activities because of pain, even though she denies feeling depressed. Yesterday when I walked in the room I could tell she was not doing well. Her face, posture and voice all looked depressed. However, after we talked about what was going on and I made some suggestions about steps we could take to improve her pain, her face brightened and she actually left smiling! Amazing! It felt so good to develop some trust and rapport with my patient! This is the way I imagine myself as a family doctor - seeing my patients regularly and becoming familiar with their lives, their medical conditions, what things they've tried, what's worked and what hasn't worked, what stressors in their lives make their conditions worse, how their major relationships are going. Being a doctor is an awesome privilige and joy.

Last OB Call Night

Another rotation done and another month of residency under my belt. I just finished my last duty shift on my OB rotation this morning. This past week was particularly busy. I was on the "floor" on Monday and Thursday, meaning I spent the day caring for women in labor and delivering babies. On Friday, I got to see an interesting surgery. And I was on call Tuesday night, Friday night and all day and night Sunday. Total hours for the week: 90. Those 24-hour shifts are killer. At least things stayed relatively busy - not insanely busy thankfully, but steady. I have had the most wonderful upper level residents to work with, too, and I really appreciate their wisdom, advice, and willingness to answer my questions, even at 3 AM!

So after a month of OB, here are my "numbers":

• 16 vaginal deliveries (1 forceps, 3 vacuum)
• 6 c-sections (4 as the actual primary surgeon)
• 5 circumcisions

I'm definitely feeling much more confident in my skills and ability to manage various labor and post-partum problems. Last night I delivered two babies and all went smoothly. One of my patients only spoke Spanish. She was so thankful that her doctora spoke Spanish too and didn't stop thanking me all day!

Although OB was a busy and intense rotation in many ways, I am sad to see it end. I get another month of OB in the spring and will likely cover OB call nights throughout the year, as well as delivering my own clinic patients when they're due. But I will miss being there at one of the most significant and happy moments of life.

On to new things though - next month, Sports Medicine. It's a good month for this rotation since all the fall sports are well underway now. I should see some "good" injuries. Of course, I don't wish for anyone to get injured. But since young athletes do get injured in football, volleyball, hockey, etc., I'm glad I have the chance to be part of their care and learn how to diagnose and manage various types of joint and muscle injuries. During September, I'll also take call for the adult medicine service. I'm a little nervous about that - we get some very critically ill patients and have the responsibility of running codes for patients in cardiovascular or pulmonary arrest. I've never run a code before - we took a two-day course in advanced cardiac life support, so I technically know how to do it. Please pray that I will be able to stay calm and clear-headed!

Thanks for your prayers!

C-Sections, Suturing and Circumcisions, Oh My!

One of the strengths of my residency program is the training in obstetrics, including regular deliveries and c-sections. I was told that I would get the chance to be the primary surgeon on c-sections from the get-go, and now I can say that is true. Thursday I got to do two c-sections - and I mean really DO them. Up to now, I have only assisted on c-sections, scrubbing in, but standing on the left side and helping to hold retractors, cut sutures, etc. So this week when it was my turn on the "floor" I was determined to overcome my fear and dive in. I watched the step-by-step video on c-section techniques, and I asked my upper level residents to walk me through the process. I wasn't sure the OB attendings would let me take the leading role, but I've learned that showing confidence and being assertive goes a long way.

When the time came I was SO nervous. I was afraid I would completely screw things up. But I have determined not to be ruled by fear. And in learning procedures, the best and only way to learn is to do - hands-on, down and dirty, physical learning. On my first case of the day, I told the OB attending that I would really love to have the chance to do the c-section myself with her guidance. Her response was, "we'll see." But once we were scrubbed in, she pointed to the patient's right side and nodded. The right side is where the main surgeon stands (not sure why, but I suppose it assumes the surgeon is right handed and it is easier to do most of the procedure from that side). Anyway, there I was. The scrub nurse handed me the scalpel and after a moment of panic and a strong desire to flee (oh my gosh, what the heck am I doing here?!!), I made the incision and off we went. Everything went smoothly. The attending guided me through each step, the baby came out just fine, we got mom sewn up, and all lived happily ever after!

Later that day I had the chance to do another c-section. It meant staying 3 hours late on my shift. But I knew the attending was really nice, liked to teach and was very patient with residents. I figured a second c-section the same day would reinforce my learning and solidify it, as well as boost my confidence level. It was great. The second doctor did things a little differently, but he was so good about explaining each step and encouraging me. What a wonderful and amazing experience! I have now actually cut into someone's uterus and extracted a baby! Wow!

I still have a long way to go before I'm proficient in doing c-sections. Suturing is one of the toughest skills to learn. Holding the needle right, manipulating the needle driver and instruments, tying knots - all of these require manual dexterity and practice. I will eventually be able to do this in my sleep, but right now it's awkward and I am slow at it. That's why it's so good to get the chance to practice whenever possible.

Friday I also got to do another circumcision. That makes #5. After I've done 10 with supervision, I will be able to do them by myself without an attending present. That's a little scary, but no, I will not let fear get the best of me. Circumcisions are actually pretty simple, short, and fun to do. And the babies are so cute! Don't worry, I'm not being sadistic or cruel. The babies get local anesthetic and sugar water and most of them don't even cry that much. Mostly I think they cry because they're just mad at being handled.

So my job is really cool. I can't believe I get to do all this stuff! Plus, as I get more confident, I have much better interaction with my patients. A little more experience and wisdom helps me to put them at ease, answer their questions and connect with them personally. Although they have their own OB doctor, I'm the one they see most throughout their labor, so I feel like their doctor for a while, which is nice.

Well, all for now. Have a great week.

A Night on OB Call

After my third OB call, I'm beginning to get the rhythm of things. Here's a glimpse of my most recent night call:



Arrive 5 PM. Get check-out from resident going off duty. 2 patients laboring. Two patients in the PSU (perinatal support unit - where all pregnant ladies over 20 weeks come for urgent care and labor check-in).



5:15. Check on laboring patients. Call OB attendings to update.



5:30. Go to PSU. Do history and exam on new patient. Complains of contractions that are irregular but sharp at 40 weeks, first pregnancy. Check cervix - still closed. Plan to recheck in an hour to see if any change and still contracting. Patient to walk around for a while.



5:45. Call from post-partum ward - post-partum patient with high blood pressure. Go see patient. Patient asymptomatic. Discuss with upper level resident. Write orders for blood pressure medications.



5:55. Call from PSU to check second patient with nausea/vomiting/abdominal pain who has just finished getting IV fluids and nausea medications. Do I want to come see her? Sure. She's feeling a little better but not entirely.



6:00. Call from labor room. Patient feels like pushing. Can I come check her again? Check patient. She is nearly completely dilated and feels pressure/pushy with pain in back. Baby doing fine. Write note. Ask nurse to call anesthesia to give more medicine through epidural. Call attending and update her. Attending says to let her continue laboring for a while before trying to push.



6:10. Call from post-partum floor. One of the newborns had a high bilirubin level. Okay, thanks. Not an emergency, but I'll check on him in a bit.



6:15. Call from PSU. What do I want to do with the patient with nausea? Talk to upper level resident and discuss what to tell attending. Call attending and recommend discharge home with nausea meds. Attending says patient has tried various nausea meds to no effect but she can go home and see him in the office tomorrow. Discharge patient and explain that we can't do much for her. She should take her nausea meds prior to eating and try to keep fluids down as much as possible.

6:30. Recheck PSU patient. Still contracting but not as much. Cervix unchanged. Call attending and discuss options. He says to send her home. It could be a while before she's in active labor and she will be more comfortable at home for now. Explain this to patient and discharge her.

6:45. Call from labor and delivery room on a lady who has come in for induction of labor. They start the night before with a prostaglandin that helps to "ripen" the cervix - make it start to dilate and soften. Then we start pitocin (the hormone that stimulates uterine contractions) in the morning. I've never done an induction before. Discuss orders and procedure with upper level. Nurse states the patient speaks Vietnamese and they are waiting on an interpreter but husband is present and speaks some English. Do history and physical exam, review prenatal records. Do quick bedside ultrasound to verify baby is head down. Call attending and verify what she would like to have done. Write orders and give to nurse to get prostaglandins for the first step of induction.

7:05. Check on laboring patient. Now completely dilated. Patient feels like pushing -uncomfortable. Call attending and update. Attending gives okay to have patient start pushing. She's on her way.

7:20. Call from floor. Another high bilirubin. Thanks. I'll follow up. Talk to upper level resident about high bilirubins. Look up information on when to start bilirubin lights. Look up patient's risk factors - not preterm, no infection, no mismatch between mother and fetal blood types. Baby not feeding that well yet but pooping and peeing okay, so probably just physiological. Write orders to recheck bilirubin in AM.

7:30. Check on pushing patient. Not making a lot of progress, but it's her first baby so no surprise. Encourage her to keep pushing.

7:45. Back to induction room. Interpreter available and Cervidil (prostaglandin agent) in room. Explain to patient, through interpreter, how the prostaglandin is used. She will have to stay lying down in bed for 2 hours after placement. Place cervidil near cervix. Write note in chart. Text page attending to let her know induction started.

8:00. Back to pushing patient. Attending now present. I stay in the room to help with delivery. Baby is occiput posterior. This means he is facing up instead of down (or front instead of back), which is harder for mom to deliver. The head has to be molded more into a cone to get baby through the birth canal, and this takes time and effort pushing. After another 30 minutes (seems like longer), the attending decides to assist with vacuum delivery (applies suction to baby's head to help mom get baby out). Baby out and okay. Mom has some pretty ugly looking lacerations that take some time to sew up.

8:55. Check in with upper level resident. The other lady who was in labor at the start of the shift is going for c-section. This means the upper level will be out of commission for an hour doing the c-section.

9:00. Time for a quick dinner and bathroom break - while I can. Check in with nurse on post-partum floor to see if that patient's blood pressure is back to normal.

9:10. Call from PSU. Another patient presenting with "contractions" and dizziness at 35 weeks. Likely dehydration (it was 110 degrees today!). Do history and exam. Check monitor. Fetal heart tones are fine. No real contractions showing on monitor. Review mother's records in computer - frequent visitor to ER. Suspect desire for pain medications or mom just tired of being pregnant. Order urinalysis to check for infection (common cause of preterm contractions) and dehydration. Do pelvic exam with cultures for other types of infections that can also cause contractions. Also check for cervical dilation - no significant dilation noted. Plan to recheck in one hour and follow up labs.

9:30. Visit to post-partum floor to check on hypertensive patient. Blood pressure in normal range now, patient still asymptomatic. Write note on chart and orders to increase dose of blood pressure meds for next day.

9:45. Enter previous delivery in my procedure log. Check email.

10:00. Upper level done with c-section. Check in regarding preterm patient in PSU. Review her lab results (equivocal). Recheck cervical exam - no change. No contractions on monitor. Call attending to recommend discharge and treatment of infection. Explain results and treatment plan to patient. Encourage her to drink lots of fluids and take medications. Discharge patient.

10:30. Call from PSU. First patient seen earlier in evening is back with stronger contractions, this time 3 to 5 minutes apart. Redo history and exam. Check cervix - more dilated than previously. Patient admitted to labor and delivery. Call attending and let him know.

10:50. Call from labor and delivery room on patient I delivered a few hours ago. She passed out in the bathroom. Go see patient. Her vital signs are stable. She's not bleeding. I order a bolus of IV fluids. Discuss with upper level resident. Call attending to notify her of the event. Patient doing better.

11:05. Another patient in PSU in labor. Do history and exam. Review prenatal records. Patient is definitely contracting. Cervix dilated to 4 cm. Plan to recheck in one hour.

11:30. Check on laboring patient. In the process of getting epidural.

12:00. Check on PSU patient. Dilated to 5 cm. Admit to labor and delivery. Call attending to get orders.

12:15. Patient now has epidural and is comfortable. Recheck and still progressing. Call attending to notify. Write note.

12:30. Back to induction patient. Place second prostaglandin tablet for cervical "ripening." Write note.

12:45. Check on fainting patient. Doing fine now.

For the rest of the night, I alternate on checking the laboring patients (room to room), with PSU patients to be seen and examined in between. At some point during the night, I rupture membranes (break the water) of both patients. That speeds things up. One patient begins to push at 5 AM and delivers around 6. She has some extensive lacerations that take a while to repair. The upper level has to cover PSU calls and check on my induction patient during this time. My other patient's nurse calls several times with updates (patient wants to push, please come examine...). The upper level takes care of all of this and updates the other attending. When I'm through with the first patient (about 6:30), I head to the next room, thinking she will already have delivered. But she is just barely complete and beginning to try pushing. Turns out she is also occiput posterior, which takes a lot longer. She pushes for 3 hours and finally delivers with vacuum assistance. I stay till 10:00 AM for her delivery and repairs. I've now been up for 28 hours straight. But it was a great night!

Fun on OB

Just finished my first week on OB rotation, and I love it! So far, I've done two C-sections, delivered seven babies and done two circumcisions. Of course, all of that is with supervision. I'm becoming a bit more comfortable with the deliveries - at least the straight-forward ones. On Saturday, I was helping to deliver a baby that was really big. After the head was delivered, the mom had a lot of trouble pushing the rest of the baby out. We call that shoulder dystocia - when the shoulder gets hung up on the pubic bone. There are a number of manouvers we can try to get baby out. In this case, we were able to deliver the baby, but it was pretty scary. Fortunately, the baby is doing really well now, with no injuries, and so is mom. In fact, I got to do the baby's circumcision today, so that was fun.

The circumcisions are also a little scary, if you think about what you're doing and what could go wrong. However, the equipment we use is designed to minimize the risk of harm to the baby's anatomy. One of the senior faculty walked me through the first circumcision - showing me step by step how to do it and then letting me actually do the procedure. He was a great teacher, and I really enjoyed working with him. The second circ was a lot more familiar. But I still have a long way to go before I feel completely comfortable with it.

On Saturday, I had my first 24-hour call - 7 AM to 7AM on Sunday. It was a LONG day, but thankfully not too hectic. During our call, I had to keep tabs on all the women in labor (there were only a two at the beginning), checking how their progress every hour or so. That involves reading the fetal monitoring strips for the baby's heart rate and mother's contraction rate, checking cervical dilation and baby's position, and making sure mom's vital signs are stable and mom is comfortable. Then I have to update the patient's OB doctor to let them know what's going on and see what else they want to do. In the meantime, there are always patients coming into the PSU - Perinatal Support Unit. That's where all the pregnant women with problems come for care - like the pregnancy ER. They come in with contractions, bleeding, rupture of membranes (when their water breaks), and lots of other symptoms. Some are full-term; others are in early pregnancy. Some get to go home once we establish that the baby is okay and mom isn't in labor. Others are admitted from the PSU to the labor and delivery unit because they are in labor. My job is to figure out what is going on and if they need to stay. Also, on call, I get to solve any problems from the post-partum floor - fevers, pain, nausea/vomiting, itching, etc., including problems with newborns. Between all these responsibilities, there isn't a lot of free time. Although, I did have some down time between 3 and 6 AM. That gave me time to update my log of clinical procedures and to some practice board questions just to keep me awake.

The hardest part of the job is communicating with attendings. I have to be sure I know exactly what is going on with each patient and have a plan for what I'd like to do. Obviously, I'm no expert yet. You would think the attendings would understand that I'm just beginning my training, but they aren't always that gracious. I guess I wouldn't be either if I was getting called in the middle of the night. And they have huge liability issues on OB. So I try to make sure I check everything out with the upper level resident on call before I call the attendings. I've already been chewed out a couple of times for not having all the right information and not being concise enough. Guess I'll develop some thick skin by the end of the rotation. I'm trying to learn to anticipate the questions and think like the attendings so I can be helpful, thorough and efficient.

Fortunately, I only have one other 24-hour call. The rest are just overnight. I can handle 12-14 hours if it's not to busy. There is always an upper level on call with me, so that is good. But if it's really crazy, he or she may be in a delivery or emergency c-section, and I am on my own on the floor. So far, there hasn't been anything I can't handle. But there are still 3 weeks left!

Despite the challenges and quirky personalities of the attendings, it is a happy, upbeat rotation. I love my teammates and enjoy working with the moms and babies. Please pray I will continue to gain experience, wisdom, and the skills I need to be good at this!

First day of OB

Monday, I hit the ground running on my obstetrics rotation. It was crazy!!!!! We start with rounds at 6AM - dividing up all the post-partum patients on the floor between those on duty. I only had to see three patients, but it took me a good hour just learning how the charts are organized, how to write up the discharge orders and prescriptions, etc. After rounds, we had morning board rounds, where the folks on duty overnight check out the patients they were following to the new folks coming on the floor (i.e., me). I got three ladies to follow at the start, all in the early stages of labor. My job was to check on them every hour or so and see how they were progressing, how the baby was doing (looking at fetal heart rate monitoring) and update the attending physician. I also got assigned to assist on a c-section right off the bat.

Now, I've seen several c-sections, but I've never done much assisting before. Normally, the attending allows the first-year residents to actually DO the c-section with supervision and teaching. But I must have looked pretty green, so in this case I was only allowed to assist. As it turns out, I wasn't even a very good assistant, so the nurse had to do most of what I should have done. I felt more in the way than anything. But, hey, there will be plenty more opportunities and I can only get better (can't get much worse, I don't think). Overall, it was a good experience to be back in the OR, and next time I will be able to better anticipate my role as assistant (I'd like to assista a couple more times before being the primary surgeon).

Once I was done with the c-section, I checked on all my laboring patients. In medical school, I didn't get the chance to do the cervical exam on many of the patients, so I am still quite inexperienced at assessing the degree of dilation and baby's position. If only you could SEE what you're feeling! The first few times, I couldn't tell WHAT I was feeling, but eventually it got a little easier and I was guessing the level of dilation pretty close to what the nurse or upper level resident was getting. I will still have an experienced nurse or resident check after me for the rest of this month I think to make sure I don't miss anything important. I mean, it's pretty obvious when the baby is crowning, but in between, there a lot of room for error.

After checking in with the two attending physicians for my patients, one wanted me to artificially rupture the membranes (break her water) to help get labor going a little faster. The supervising resident ended up doing that, since I was not sure exactly how to do it and wasn't sure I could even find the cervix, much less the amniotic sac! Later, I did get to place an intrauterine pressure catheter in that same patient (successfully, I might add!). This is a device that goes into the uterus, beside baby, that measures the pressure generated by each contraction. It allows us to assess the quality and sufficiency of contractions to see if we need more pitocyn (a hormone used to enhance labor contractions). A few hours after that, the same patient's baby was having lots of sharp decelerations in heart rate, which usually are caused by the umbilical cord being compressed by baby during contractions. When we ruptured this patient's membranes, she had very little amniotic fluid, so there wasn't a lot of fluid for the cord to float around in, probably explaining the frequent cord compressions. The intrauterine pressure catheter can be used to infuse sterile saline solution into the uterus to provide more "cushioning" for baby. Once we started infusing fluid into this patient's uterus, the baby's heart rate leveled out and did not show those sharp decelerations for the rest of labor. The patient's labor progressed throughout the day. By the time I left, she was almost ready to push, but I didn't get to attend her delivery.

Meanwhile, my other two patients did complete labor and deliver healthy babies. I got to help with both of those deliveries. The attending was present and did a lot of the work, but I was definitely a significant participant in both cases, getting to help baby out, clamp the cord, deliver the placenta, and sew up lacerations. What a wonderful experience! Although I felt a little unsure about my role and not always certain of what to do, the attendings walked me through things. Next time I will be a little more confident and step in to do more and ask more questions. My supervising resident, who was with me all day, was amazing! She was so encouraging and managed to keep a calm and cool attitude despite having a LOT of work to do with two new interns on the floor and a lot of patients.

In the midst of all these deliveries, I also had to check in two patients from the PSU (prenatal triage area). One was in active labor, so she was admitted, and I followed her all day until I left. She was actually ready to deliver when I left, but the night-duty resident got to deliver that one. The other patient was not in labor, but was having some lower pelvic pain (probably muscular). However, she had been having high blood pressure over the preceding few weeks and came in with elevated blood pressure, so she needed to get some labs to rule out preeclampsia. If she did have preeclampsia (I wasn't there when the labs came back, so I don't know what happened), she probably would have been induced, since she was already term (39 weeks). There is so much to learn about what to questions to ask, what to look for on exam and in the prenatal records, what to tell the attending, what forms to fill out, what labs to get... It was definitely an overwhelming first day!

And tonight I will be on duty from 5 PM to 7 AM. There will be one other resident (a second year I think) on duty with me, but I am expected to manage most of the cases I think, and he is simply there for back-up in case I get swamped or need help and to do any emergency c-sections. Whew!!

Yesterday I spent the morning in a non-profit clinic called Choices. They offer free ultrasounds and counseling for patients who are not sure they want to keep their babies. They also provide prenatal/perinatal hospice services - counseling and guidance for patients whose babies have been diagnosed with any sort of severe or fatal problem. Incidentally, Choices is located next door to a late-term abortion clinic - they have a very interesting history. But more on that later. Time to go get a nap before my night shift!

Oh, by the way, when I got home yesterday, my weather guage was showing an outside temperature of 112 degrees!!! But only 20% humidity, so that's good, right? I was going to go for a run but decided against it. By 9PM, the temp was down in the low 90s. It's supposed to be cooling off to the high 90s for the rest of the week.

Old Cowtown

Old Cowtown Museum Wichita

My sister and her family drove through Wichita this weekend on their way home from Minnesota. It was great to have some time with family and see a little more of Wichita. We visited the Old Cowtown Museum (click on photo above to view album), a replica of Wichita in the 1870s when it was, literally, a cowtown. Although it was hot (over 100 degrees), we enjoyed wandering the street (only one, really), seeing the old fashioned grain elevator, blacksmith shop, and general store before finally hitting the saloon for a cold sarsaparilla (basically, rootbeer). My niece and nephew spent most of the rest of the time on their iTouch or laptop playing games, texting or whatever.

Tomorrow I start my OB rotation. I'm very excited to start delivering babies! I'll keep you posted how it goes!

Botanical Gardens

One of the tricks of surviving residency is knowing how to make use of days off. Last Sunday I visited Wichita's Botanica (botanical gardens). Even in the heat of summer (105 degrees some days), one can enjoy a feast of colors, shapes, fragrances, and beauty. It's refreshing to the soul.

Here are a few photos to add some sparkle to your day.

From Wichita Botanical Gardens

From Wichita Botanical Gardens

From Wichita Botanical Gardens

From Wichita Botanical Gardens

Settling In

My first month of residency is almost over - three more ER shifts and I will be done! It has been a long month, but I think I have actually made some progress in figuring out how to be a doctor. The variety of cases and conditions I've seen is incredible. Even if two patients have the same condition, the presentation can be completely different, and thus the treatment will also be different.

For example a few nights ago I saw a middle-aged woman with acute chest pain radiating to her neck and jaw with nausea and sweating relieved by a nitroglycerin tablet under her tongue - the typical description of a heart attack. However, she had had a full cardiac work-up recently revealing no atherosclerosis or blockage of her coronary arteries. She likely has a condition called Prinzmetal angina, where there is spasming of the arteries leading to ischemia (decreased blood flow and oxygen) to the heart. A cardiac catheterization or bypass surgery won't fix her problem since it is not an issue of stopped up plumbing. Last night, a 50-year-old man came in with the same presentation. Although he had no past medical history suggesting heart disease, he did have a strong family history. After following his cardiac enzymes for a couple of hours, he did turn out to be having a heart attack. So he gets to go for a catheterization to look for and hopefully correct blocked arteries. So how do you know if someone's chest pain is caused by a heart attack? Fortunately, there is a standard set of labs and tests that get done on any patient with suspected myocardial infarction. So that takes some of the guesswork out of it.

In the past week, I have been able to do a lot of small procedures - particularly, draining abscesses and suturing lacerations. I've sewn up faces, fingers, arms, scalps, even an eyelid. I must admit that last one made me really nervous. It wasn't right over the eyeball, but pretty close. But I managed to do a pretty good job - hope it heals well without a bad scar! Generally suturing is not too bad - I'm always a little nervous about getting the wound to come together properly, but at least you can numb people up well enough that they don't feel anything. Abscesses are different. No matter how much lidocaine you use, the patient always feels some pain. They are just so tender and tense under the pressure of the abscess, and the lidocaine just doesn't penetrate into the underlying tissue well enough to make the entire operation painless. I'm still not entirely comfortable cutting people open with a scalpel. But that's not the worst part. You have to go into the abscess and break up the pockets so all the fluid can drain out. That is almost always very uncomfortable for the patient. It always makes me feel so bad to hurt them, even though I know in the long run it is for their good and will facilitate healing of the infection. Anyway, with all the practice I've had this past week, I'm beginning to at least feel more confident about my skills and more at home with a needle and scalpel in my hand.

More than anything, I love interacting with my patients. It is so gratifying to feel like I am able to help patients when they are most scared and vulnerable - reassuring them when appropriate and explaining what tests we're doing and what the results mean, educating them about how to take care of themselves when they go home, answering their questions...I think there are many patients who come to the ER just to have someone listen to their problems and "take care" of them. We have a lot of "frequent flyers" who come for every little ache and pain. Maybe some of them come because they want refills of their pain medications (narcotics). But I think some are just lonely and depressed, and perhaps their problems are more psychosocial with the pain being either a secondary issue that exacerbates or is exacerbated by their emotional issues, or a direct result of psychological problems (somatization). I admire how some of the ER docs handle these cases with compassion and patience, without doing unnecessary tests or giving out unwarranted narcotic pain medicine.

Bottom line: I have a lot to learn about doctoring - the medical part and the interpersonal part. I'm sure you will get tired of hearing that, but I think it will be a major theme for me in the next year or two. Keep praying for me and stay in touch.

Day Ten on the Job

I am now into my second full week of being a doctor, and it's beginning to feel a little more like I really belong here. The first week was really challenging - constant feelings of inadequacy, uncertainty, and overwhelming fear. For every patient I saw in the ER, I forgot parts of the history and exam, bumbled through the assessment, missed key elements of the differential diagnosis, guessed (usually wrong) what tests to run, and was completely clueless about dosing and how to write orders for medications. After three days, I was seriously struggling with doubts about my ability to ever be a good doctor.

Now, though, I think I'm beginning to turn a corner. I'm still on my emergency room rotation and still as "green" as ever - not sure how to work up and manage most of the cases I see. But I'm getting to know most of the ER doctors and what they expect. They have been very encouraging, reminding me that I am only just beginning my training, and I WILL learn with time. So, I have been trying to focus on what I can learn from each case and patient. Amazingly, I really am learning a ton. Not that I feel at all ready to take care of patients on my own, but it feels a little more comfortable.

This past weekend, I worked a couple of night shifts in the ER. Night time brings a lot of drug and alcohol related cases, as well as some trauma (accidents, injuries). One of the coolest things I got to do this week was put in a chest tube. A young guy came into the ER complaining of shortness of breath and chest pain. He didn't have any risk factors for a heart attack. He turned out to have a pneumothorax - complete collapse of one of his lungs! The chest x-ray was pretty impressive. Even I couldn't miss the diagnosis! In a pneumothorax, air collects in the pleural space between the lung and the chest wall, making it impossible to inflate the lung. To fix it, you need to get the air out, which you do by inserting a tube and connecting it to suction. I've seen chest tubes placed before, but I've never put one in myself. The ER attending allowed me to do most of the procedure. It's weird and sort of awesome to stick a scalpel into someone's chest wall, to basically cut a hole between the ribs into the inside of the chest. But now that I've done one, I can't wait to do more. I've also gotten to do a lumbar puncture (spinal tap), an arthrocentesis (where you stick a needle into someone's joint - in this case a knee - and aspirate fluid to send for analysis, then inject steroids and numbing medicine to relieve pain), incision and drainage of abscesses and suturing of lacerations. I'm not that good at these things, but I know I can learn the skills and be proficient and confident eventually.

Once again, I am reminded of God's goodness and faithfulness. He is with me and is able to provide all it takes for me to be a good doctor so I can serve him. The process may be painful at time, as I learn humility and dependence on God. So I have renewed hope and joy that I am in fact growing and learning, and it will all be worth it in the long-run.

Well, that's all for now. I am yawning and can barely keep my eyes open. Tomorrow is clinic day - instead of being in the ER, I'll be seeing patients in the office. Keep me in your prayers - for a good attitude, humility, patience and joy!

My First Day as a Doctor

July 1 - the first day of residency for most new medical school graduates. I've been looking forward to this day with a mixture of excitement and apprehension. What if I don't have a clue what to do for a patient? What if I make a mistake? What if I miss something important?

Well, the first day has come and gone. I'm still alive, and so are my patients. I am on ER this month - emergency medicine rotation. Arriving in the ER this morning at 7:30 AM, I introduced myself as a brand new doctor. One of the attending docs showed me the ropes, explained the paperwork, answered my questions, gave me some suggestions for managing my patients and was generally very supportive, encouraging and helpful. It was an awesome day!! I may not have done everything independently or in perfect order, but I felt like I sort of new what I was doing - or at least that I could have done it on my own. I only saw five patients today, but each one was completely different, so I got to think through a variety of conditions (extreme hypertension, pancreatitis, a sprained thumb, diabetes/kidney failure, and seizures) and how to diagnose and treat them. At the end of the day, I got to call one of my colleagues, who happened to be on pediatrics, and tell her about a patient we were admitting to her team. That was pretty cool. I know some day I will look back on this post and laugh at how ridiculously naive and it is. But for now, I am loving my job! Of course, tomorrow may be different. I know I shouldn't base my contentment on the circumstances - how people treat me or how much I think I know - those are very transient and extremely changeable factors. Still, I am thankful for a good first day. Thank you Lord!

I Love God's People!

I have been in Wichita for nearly three weeks now, and I am loving it! First of all, the prairie habitat is beautiful. But more than that, I have met some wonderful people who are making me feel right at home.

Photos of the Wichita Zoo and some of my bike rides (click on photo to link to album).

Wildlife and Scenery

I titled this post "I Love God's People" because I have been overwhelmed with the outpouring of care and friendship I have received here. Last Sunday, I went back to Heartland Community Church, a church I had visited when I interviewed for the residency program back in December. One of my pastors (Darryl, if you're reading this, thank you!) called one of Heartland's pastors a while back to check it out for me and gave his approval. So I knew it would be a good place to start when looking for a new church home. I was not disappointed. Everything from the centrality of the Word and the gospel in the worship service, to the emphasis on prayer, Bible study, accountability, fellowship and the seriousness of the sacraments reminds me of Sovereign Grace. Even the songs are similar. My prayer as I visited was that I would be able to connect to some godly sisters quickly and in a meaningful way.

Again - I was not disappointed. Several women noticed I was new and introduced themselves to me. On Monday I got an email from a gal I hadn't even met at church but who happened to hear that I was from Houston. Since she and her family had lived in Houston for a while, she felt moved to invite me over for dinner. So I enjoyed a wonderful home-cooked meal, some good ole Texas hospitality, and the start of a warm friendship. I got to know Daphne, her two teenage daughters, and their pets. After dinner, I was entertained watching Bandit (the dog) chase a laser pointer around the yard while the cats (Abby and Tabby) meowed at the window to come out and play. We also spent some time in prayer, and that meant more to me than words can express. Daphne has emailed me every day, took me to the county farmers market on Saturday, and introduced me to lots of new folks on Sunday at church.

And that's not all. There is a group of college and young working singles from Heartland and other churches that meets weekly for bible study. I met several of them last week at church, and they organized a game night at the park so we (one of my fellow residents and I) could get to know a few people. That was lots of fun. I've also had coffee with another lady from church. And on Thursday, I attended a dinner and prayer meeting for the women family medicine residents. So despite being new in town and not knowing anyone three weeks ago, my social calendar this past week looked like this:

Sunday - church
Monday - received email from Daphne, got hair done
Tuesday - chat/walk with third-year resident and her new baby, games at park with singles from church
Wednesday - dinner with Daphne and family
Thursday - prayer/dinner with women residents
Friday - coffee with another lady from church, dinner with first-year residents
Saturday - farmers market, pool party at faculty's house to welcome incoming residents
Sunday - church, dinner with my second-year resident "big sister"

Not bad, huh?

As I prepare to start orientation and work this week, I am feeling both nervous and peaceful. God has once again demonstrated his faithful loving care by surrounding me with encouraging Christian brothers and sisters both in the local church body and in my residency program. There is no doubt in my mind that this is where I am supposed to be and this is what I am supposed to be doing. Thank you Lord!

Please continue to keep me in your prayers. My first day as a "real" doctor is Thursday, July 1!

Off to See the Wizard!

Well, I am now officially a Kansas resident - got my driver's license and my Kansas "tags" (license plate). And I'm pretty much all settled in to my new apartment in Wichita (not Kansas City).

I left Houston June 7th driving a 17-foot U-Haul truck towing my car on a trailer behind me. I definitely have more respect for truck and bus drivers now, realizing how hard it is to pick up speed, slow down, make turns and change lanes with so much stuff behind you. Fortunately, my parents went with me. Mom sat with me in the truck cab, and Dad followed in his car so he could help me change lanes and make sure I didn't lose anything out the back. By God's grace, we arrived with no mishaps!

A crew of family medicine residents was there to help us unload everything and carry it up to my second floor apartment. They were so nice - they even brought cold drinks, watermelon and cookies! For the following five days, my parents helped me get settled in and organized. We made multiple trips to Home Depot, Bed Bath and Beyond and Target to get odds and ends. They were a huge help! In fact, I am so grateful and blessed by all the friends who helped me move on both ends. God has been very good to me!


Click on the photo below to see album of my new apartment.

My New Home

My parents left on Saturday, June 12th, and of course, I cried. It made everything seem so final. But thanks to good friends - old and new - I made it through that emotional crisis. That evening, I went for a long bike ride with a couple of the upper level residents. Wichita has miles and miles of bike paths. We rode along the Big Arkansas River for a good eight or nine miles up and then turned around and rode back. It's a beautiful path, and at 7 PM it was cool, breezy and very pleasant for riding. Anyway, it was a fun way to forge new friendships and forget my homesickness for a while. Since then, I've explored some of the bike trails near my apartment and had a great time. Wichita is actually quite pretty. The terrain is flat (just what I like for biking and running!), with grasslands and woodsy areas, lots of wind to keep things cool (not so great for biking against), and creeks, ponds and rivers all over.

This past week, I finally met most of my soon-to-be classmates. We all took a pediatric advanced life support training course for two days. It is a really nice group, and I am going to enjoy working with them and getting to know them. After we passed the class on Thursday (thank you Lord!), we went out for dinner and played cards (learned a new game Trump Ten that was quite fun). Most of the folks I met are Christians, so I know they will be a good source of support and encouragement.

Now I need to find a church. I visited a Baptist church last Sunday. The service was great - very Gospel centered with good teaching from the Word. But the welcome and hospitality I am used to was distinctly lacking. I guess I'm spoiled by my 12 years at Sovereign Grace Pearland where you can't walk in the door without being greeted warmly. Well, on to other options this week. Please pray for me to find a church where I can grow and belong.

So I have next week off to explore Wichita. Orientation starts June 28th and work starts July 1. My first rotation is emergency medicine. It's actually a pretty cushy rotation. I set my own schedule, just have to complete 200 hours during the month. And I don't have any call. In a way it's good, but that only means postponing the inevitable first call night. But hopefully I'll learn some good basic stuff that will help me in my other rotations, as well as getting a chance to run codes and other stressful scenarios.

I miss all my Houston friends and family. The Ferry hostel should be up and running soon. I'm still waiting on guest beds (it's a long story), but should have all in place next week. So make your reservations soon!

Doctora Pamela

My 12th annual Bolivia medical mission trip was special in a couple of ways. First, this was the first trip in which I could actually be called “Doctora” and have it be practically true (though I don’t officially receive my MD degree until next week). Most of the week I worked with Doctor Doug, a psychiatrist, seeing children and adults with a variety of complaints – from headaches to stomach aches to leg cramps – most of them related to depression and anxiety. We prescribed medications for some, counseling for others and deep breathing exercises for all. More importantly, I had the opportunity to pray for several of these patients, which is a distinct privilege and probably one of the most healing things I know how to do.

Click on the photo below to link to my album.

Bolivia 2010

One mother brought her 9-year-old son with brain damage from birth to see if we could help him. He could not walk or talk and was confined to a wheelchair and dependent on his mother for all of his daily needs. Unfortunately, there wasn't a lot we could do for his brain. However, in the course of the visit, it became clear that mom was severely depressed. As you can imagine, having a disabled child is very difficult, but compound that with being poor, alone (her husband worked out of town), and in a town where there are no social services available for special needs children. Often, disabled children are ostracized, and mothers are blamed for doing something to cause the child's problems. Families spend all their money going from one doctor to another in the hopes of a cure, buying endless quantities of expensive "medicines" and "tonics" that they are told will improve their child's brain development. Upon investigation, we found that most of these tonics are simply vitamins that can be obtained in a normal diet. While they may have some role in neuronal function, they certainly are not able to reverse the damage done from oxygen deprivation or swelling of the brain at birth. So this poor mother, after nine years of caring for her son alone, was suffering from guilt, loneliness, hopelessness, poverty and desperation. Through the generous donations of our group sponsors, we were able to offer her a chance to send her son to a special education program in town. At the very least, it will give her a couple of days of respite during the week. We will also be able to help her see a counselor to get some support and have someone to talk with about her daily struggles. I ended the session with a prayer and encouraged her to find a church where she could pray with others and nourish her spirit.

The last day of the week, we went out to a small, rural indigenous community. Half of our group had spent the week there building a brick house for one of the families. Little by little, our partners in Bolivia, with the help of groups like ours, are providing improved houses for these Guarani villagers in order to keep out the vinchuca, a beetle that lives in cracks and crevices of wood and thatch houses and causes the dreadful disease, Chagas. For half a day on Friday, the medical team saw patients in the community health post. To make things go faster, I got to see patients by myself and managed to see 16 patients in 4 hours, which is pretty good for a recent medical school graduate! Of course, I had to ask lots of questions. For example, I had no idea what to do for the 65-year-old grandmother who came in with a blood pressure of 220/80. She was completely asymptomatic - no chest pain, no blurred vision, sharp as a whistle and no complaints at all. She did have a large heart and a heart murmur, possibly from Chagas disease, but she had never seen a cardiologist. She'd had a prescription for blood pressure medication but had not filled it, either because she didn't want to go to town to get the medicine, or because she couldn't afford it (or both). We didn't have any blood pressure meds with us, and I wouldn't have felt comfortable prescribing it for her without adequate monitoring of her pressure and symptoms over the next days and weeks. All I could do was urge her to go see a heart doctor and follow their recommendations. However, I doubt she'll go. She was perfectly comfortable and likely prefers to remain at home with her family rather than spend lots of money on doctors, tests, and medicines that might prolong her days but can't promise an improvement in the quality of her life. It was a humbling experience for me and a good reminder that doctors can't always do something for every patient.

Click on the photo below to link to my album.

Yapacani Bolivia 2010

After the medical part of the trip was over, I went out to Yapacani (where I lived several years ago) to see my friend Yolanda and her family. Yolanda was my first friend in Yapacani. She adopted me when she was 8 years old. In other words, she followed me home from the town square one day and asked me to be her godmother. I wasn't quite ready to take that on at the time, but over the years I grew close to her and her five sisters - Veronica, Maribel, Karen, Rosandra and Daniela. I have seen them all grow up and done what I could to help their mother, Rosa. Veronica is now a teacher in Santa Cruz (the nearest big city) and has three children. Maribel has a small store in Yapacani and has one little girl. Karen is studying law and wants to be a forensic specialist (like CSI). The two youngest, Daniela and Rosandra, are still in high school. Yolanda spent two years in Houston living with me and studying English, so we have a special relationship. I try to call her every month or so, and we keep in touch by email and Facebook. She now has 4 children - Jeffrey, age 5; Pamela, age 4 (named after yours truly I think); Stacey, age 2; and Matthias, age 3 months. They are all happy, healthy and cute, and I loved spending time with them as their "Tia Pamela". While I was in Yapacani, the youngest three were baptized, and I was the “madrina” (godmother). Although I do not necessarily agree with the Catholic church's view of baptism, I will still take my responsibility as godmother seriously and do my best to influence my godchildren to know and love Jesus.

Over the course of the weekend, Yolanda and I made several of her favorite recipes - meatloaf, apple crisp, brownies, lasagna, banana bread and pancakes with maple syrup! I brought a lot of ingredients with me from the US, and it was fun shopping for the rest in the Yapacani market. From past experience, I know that you should not buy already ground beef in the market - no, you can't find those nice plastic-wrapped packages of ground beef in Yapacani. Picture big slabs of meet hanging from hooks in the fresh air with flies buzzing all around. Several years ago, when my parents were visiting me in Bolivia, we bought ground meat to make spaghetti. After getting it in the pan, my dad commented that the meat was moving. Ha-ha! Good joke, Dad. But he wasn't joking. Turns out, ground meat is probably made from the meat that hasn't been sold after sitting out all day (or several days?) and is bound to contain extra protein (use your imaginations). But Yolanda, having lived in Yapacani all her life, is an expert at buying meat. She deftly selected the best pieces of hanging cow carcass and had the butcher grind it on the spot. And I didn't see anything moving in it at all. Now, making lasagna, which calls for three different cheeses, was a bit of a challenge. There is basically one type of cheese available in Yapacani, so that is what we used. Nevertheless, it came out very tasty, if I do say so myself. Yolanda's mom and sisters seemed to love it, but her children were less impressed. Jeffrey's comment was, "Wak-a-la" - yucky! (I don't think he tried anything I made, actually.)

Overall, it was a fantastic week. The group of volunteers was wonderful - hard-working, creative, and lots of fun. We had a party for the 112 girls in the Sacred Heart orphanage - they danced and sang, and we provided cake and ice cream, a real treat for them. Our group also, through donations, was able to buy all new dishes (plates, spoons, bowls, cups...) for the orphanage, as well as toys, school supplies, arts and crafts items and toothbrushes. The girls are always extremely affectionate and love to spend time with anyone who visits - grabbing your hand to show you their room, their garden, their bed - and hugging and being hugged as much as possible. I wish I could adopt all of them! Some of the older girls from the orphanage who have graduated from high school have a separate house where they live while attending university. The Laura Vicuna house (named after some Catholic missionary lady, I think), was started several years ago and now hosts 22 young ladies studying nursing, law, business administration, and many other subjects. Our group, through my dad's church (Palmer Episcopal), is providing support for the operating budget of the house (food, rent, electricity, etc.) so that the girls can focus on their studies and not have to work. On the weekends they help out at the orphanage with cooking, cleaning and caring for the 112 younger girls. According to the orphanage director, more and more girls are thinking about higher education because of the example of the Laura Vicuna group. Before, many of the girls would leave the orphanage at age 14 or 15 to work (mainly as domestic help) and usually end up pregnant and poor. Now, they see that they have an option and that there is support for them if they choose to pursue a career in teaching, nursing, medicine, law or other careers. We feel very privileged to be a part of such a wonderful and successful endeavor. The orphanage staff and volunteers do all the work, of course, and they do an amazing job of loving and raising all the girls.

Overall, it was a wonderful trip, filled with friendship, service, beautiful scenery and wildlife (we spent a day at an eco-reserve in Santa Cruz with a bird and butterfly sanctuary). I don't know if I will be able to fit in a trip next summer with my residency schedule, but I hope so. It is always a pleasure to share the Bolivia experience with others and to reconnect with the place that has been such an important part of my life.

New Year's Reflection

During my quiet times in 2009, I read through the book of Isaiah. Recently, Isaiah 62:6-7 really spoke to me. It reads, "You who put the Lord in remembrance, take no rest, and give him no rest until he establishes Jerusalem and makes it a praise in all the earth."

Those verses were written for the Jewish people centuries ago, but I believe they are still applicable for God's people today. I was particularly struck by the words "take no rest." Since I am a person who loves and craves rest, especially when life gets busy, which seems to be all the time in medical school, I had to stop and think about what that verse means. Surely God wants us to rest and be refreshed. His Sabbath is certainly a day of rest and a time to worship him and refocus and refuel for the week. But I think this verse is talking about a different kind of rest. There are Biblical passages that talk about God's eternal rest, which those who believe in Jesus will enjoy when he comes again and ushers in his kingdom. However, I think this verse calls for a mindset or attitude of perseverance and steadfastness in our pursuit of God's kingdom.

Sometimes I grow weary of life - always adding to my to-do list but never fully completing it. I think I am entitled to some "down time," and I long to just "veg out" with a good movie and ice cream or a long, hot bath. While there's nothing innately wrong with these things, they quickly become idols and stumbling blocks when they take priority over spending time in God's word, calling a friend, or praying. Ephesians 5:15-16 says, "Look carefully then how you walk, not as unwise but as wise, making the most of the time, because the days are evil." And Galatians 6:9 says, "And let us not grow weary of doing good, for in due season we will reap, if we do not give up." Pursuing godliness, doing good, serving God and others, fighting my sinful tendencies to be selfish and lazy - this is a constant battle requiring effort, vigilance and perseverance. Am I really to "take no rest"? Yep. That's the idea. God is always at work (John 5:17), and I want to be like him. So I need to "press on toward the goal to win the prize for which God has called me heavenward in Christ Jesus" (Phil 3:14).

Thankfully, Isaiah doesn't stop there; he goes on to say, "and give him no rest." We are not alone in our labors. God is also working alongside us and in us. And he promises to complete the good work he began in us (Phil 1:6). So when it seems exhausting and useless, and I am overwhelmed with the burdens of everyday life, plus trying to please God and love my neighbor, and when I think I will never change - then I remember that "he who watches over you will not slumber" (Psalm 121), and Jesus bids me come, exchange my burdens for his yoke, which is easy and light, and I will find rest for my soul (Matt 11:28-29). Thank God that even when I choose to "veg out," he continues to work to establish his kingdom.

For that is the endpoint of the verse in Isaiah, what we are to strive for - that God will establish Jerusalem and make it a praise in all the earth. In other words - that God's will be done, his kingdom come, and glory be to him forever and ever, Amen.

2010 promises to be a year of big changes for me. On May 25, I will become an M.D., and shortly after that, I will begin my residency training in family medicine. People will look to me to make decisions about patients' lives. The idea is both humbling and terrifying. I long to be the kind of doctor who can make calm, wise decisions, even under duress and who can inspire trust and hope in my patients whatever the circumstances. But the reality is that I am far from being the doctor, or even the person, I want to be.

So, I think I want Isaiah 62:6-7 to be my theme verse for 2010. This year, I want to press in and pursue God with all my heart, soul, mind and strength. I want to take no rest and give God no rest but make the most of every opportunity to grow and change and pray for God to work in me and do through me the good works he has prepared for me to walk in.

Looking back on 2009, I am thankful for so many blessings.

My family - despite many trials (illnesses, financial struggles), we have a close, loving and supportive family. It is wonderful to be so near my parents and share in their daily lives. They have been a marvelous help and blessing to me during the busy and stressful medical school years. My nieces and nephew are precious and fun - always growing, changing and learning new things. (Photos from Christmas in Washington, DC.) Jenny and Bryan are expecting their second child in February - my nephew John Douglass. This is truly an answer to prayer for a safe, successful pregnancy and a healthy baby!

My church - always a blessing through great, biblical teaching and sound doctrine, worship in spirit and truth, and accountability. Our monthly ladies accountability group meetings are great, and I've started praying regularly with one of the ladies in the group. I wish I had more time to devote to fellowship and serving our church body. Our girls discipleship group is meeting monthly, and it is so encouraging to see what God is doing in the lives of our young ladies.

My roommates - I love having someone to come home to and cook for! But more importantly, having housemates provides ample opportunity to grow in selflessness and humility.

Medicine - I love medical school and am so grateful to be able to pursue such an exciting and fulfilling profession at this stage of life. God has granted me much favor this year, allowing me to win two awards/scholarships for academic excellence and leadership - very humbling and entirely God's doing. Every gift I have is from him, and I hope he will use those gifts to his glory. Spending two months at a mission hospital in Nepal renewed my desire to serve God and the gospel through international medical missions work. Many of the residency programs I am considering have a strong focus on missions. I can't wait to see where God leads next!

Thanks for your prayers and encouragement! I hope to keep up my blog in 2010 with stories from medical school, residency and more.