Please tell me I'm normal

Yesterday should have been mental health day. I saw probably 5 or 6 different patients with 5 or 6 different types of psychological problems. Pretty varied, and pretty interesting.
I'm starting to feel really bad, though. I have a friend with severe ADHD, and when he'd told me about it, I hadn't exactly laughed, but I hadn't really believed him and I'd thought, yeah right, everyone can claim they have it and use it as an excuse for all sorts of bad behavior.
But actually I was totally wrong. Apparently ADHD is one of the most understood psychological conditions. It's true that it can be used as a label to slap on a kid who is 'behaviorally challenged' (i.e. naughty), but if one looks at the countless scientific studies showing decreased brain activity in particular areas, metabolic imbalances, documented symptoms, it emerges as a condition that not only actually exists, but is very treatable. That's the good news.
The bad news is that learning about mental illness is pretty much convincing me that I am mentally ill. Yesterday I was reading through my list of different conditions. Dreams/flashbacks and hyper-arousal? Yep, that's me- I have PTSD (Post-traumatic stress disorder). Increased activity, goal-directed/high-risk, decreased judgement, irritability, elevated mood and speedy talking? Apparently I am a classic Manic. Low energy, trouble concentrating and weight changes? Um, I have clinical depression. Or maybe my symptoms fit better with phobias, body dysmorphic disorder, OCD, psychosis or panic attacks.
As I was reading through the lists I had to keep saying to myself, Heather, you're normal. Heather, you're normal. Heather, you're normal. And apparently it's normal for students studying about these conditions to be convinced they have them all.
At least until I met my patient Susan this week. (*Name changed of course).
She was heading down the hallway of the hospital and I stopped her to say hi.
"Hi Susan, how are you?"
"Oh, I'm fine!" Big smile
"Where are you going?" I asked nicely.
"Oh, I'm just going upstairs to my room."
"That's nice." I said, thinking, her room isn't upstairs, it's right behind her.
"Yes, my room is inside the refrigerator. I'm going there right now."
"Oh, that's nice." I said again, thinking, what do you say to someone who thinks they're living in a refrigerator?
She walked past me, humming good-naturedly and pushed the button on the elevator. Later that day when I wrote on her chart I wrote "patient disoriented."
Heather, you're normal.
And then yesterday I met Gloria. Gloria is a ten-year-old girl who started having severe abdominal pain and persistent anxiety. A lot of it centered around school, and there was investigation to see if she was being bullied. She saw child psychologists who ruled out any abuse, and while a precise cause was not found for her abdominal pain and anxiety, the addition of some appropriate anti-anxiety medication and lots of loving support from her parents had gone a long way. She had come in to see the doctor for a check-up and looked at me out of the corner of her eye from under long bangs that hid most of her face. The stress of her mental illness had caused her immune system to be depleted and she had broken out in warts all over her body and extremities. We discussed what to do about the warts and how she was finding school.
Heather, you're normal, I told myself.
Later in the afternoon I was suddenly surprised to hear my name being called from the waiting room. I turned to see my good friends Penny and Patrick (* names unchanged) sitting there. We hugged and chatted and when I was sitting in the examining room with them I suddenly thought, aren't they normal people just like me? What are they doing here for?
Actually they had a pretty normal problem (no detail here, cause they ARE my friends), but as I said goodbye to them I thought, isn't it true that the only normal people are the ones I don't know? they could just as easily have been coming in to see the doctor about their borderline personality or schizophrenic disorders. The funny thing is, mental illness is not some rare and strange phenomenon that only people you don't know have. It touches most of us. In a sense we're all normal, and while there are, for sure, some pretty crazy people out there, a lot of it is just our diversity. We may all be genetically human but we're all so different in the way we respond to things.
But I still think I might have a mania. After all, how else can I explain my speedy talking?

Physician, heal thyself

Well, I may be learning lots about medicine and doing pretty well at it, but it seems I can't even keep myself healthy.
I came down with a bad cold/cough/sore throat this weekend and it's been three days and it still isn't gone. Since I'm working in the hospital tomorrow I'm desperately trying to get over it so that I'm not contagious anymore. I'm not sure exactly how it started: sleeping in the same bed as my sister who was hacking and sneezing and snotting for a week? Drinking way way too much coke? Staying up late and then getting up really early?
At any rate, armed with all my new-found knowledge about drugs and diseases, I decided to treat myself. The night before last I thought, clever Heather, I'll show everyone and I'll get rid of this thing in one night. I swallowed triple the dosage of vitamin C to boost my immune system. I took a Sudafed (nasal decongestant) and I sprayed double the dosage of this nasal corticosteroid into my nostrils. (I didn't really intend to use double the dosage but I don't have a lot of experience spraying things in my nose).
Well, I slept like a baby, but I woke up the next morning feeling like a truck had run over me. Yesterday I sneezed my way through the whole day and decided to boost my immune system by going for a brisk walk. I bundled up (except for my flipflops, of course) and marched around for a while in the freezing fog. Oh my, what a silly idea. Today I feel even worse.
The one thing about an infection is that it can't be rushed. Sure, you can take medications to manage the symptoms or try to kill the bacteria, but all of it is really just encouraging your own body to mobilize it's defenses and kick that bug out. You can't rush it, it takes its own sweet time and goes away when it wants.
I'm not a patient person by nature. I admit to being very intrigued by some of the concepts in the movie 'The Matrix'. What if I could just get a little chip implanted into my brain that would give me four years worth of medical knowledge or a new foreign language or a perfect understanding of car engines? What if I could swallow a pill that would instantly make me a superb volleyball player or talented cook or be able to do my own taxes with a swipe of a pencil? Would I go for the chip? I've always said yes, of course.
But the more I think about it, the more I realize it might be a really bad idea. You see, it's not so much the body of knowledge specific to that one thing that we need. It's all the peripheral knowledge/wisdom that is acquired along the journey. For example, if I just had 'Advanced French' implanted into my brain I would have missed all the wonderfully fun times of trying to speak with native French speakers and making entertaining mistakes and laughing at it together. I would have missed the discipline it built in me as I persevered by studying every day until I'd mastered a certain level.
If I just had four years of medical school implanted in my brain, I might save a lot of money and effort, but I would miss out on the other important lessons I have to learn along the way. For example, I already would have missed the most important thing I learned when I was in Antigua: I cannot survive as a Christian on my own; God has always intended to reveal himself through the church, and I am only a powerful witness to the world to the extent that I am a part of the body of Christ. Lone rangers are dead rangers.
You see, I learned that because I was desperately alone and in need of encouragement, accountability and support. I didn't miss it until I didn't have it. Some things you just can't rush, you just can't take a pill for, you just can't force them.
Which is why I decided today not to rush this silly cold. I'm just going to relax. Perhaps God has something important he wants me to learn along the way. I will let this cold take it's own sweet time, even if it kills me.

Real people

I've been working on some interesting assignments for medical school recently. We're looking at the histology of different organs in the body, what happens in disease, what are the typical symptoms you will see in a patient, etc. Some of the case studies are challenging, but there is a right answer that we pursue and all the pieces fit together in the end.
I'm learning more and more that this is not so in real life. Over the last week as I've worked in the hospital and in the doctor's office I've seen all sorts of patients, and not one single one of them was like my assignment case studies. Take for example Mr. Buttercup (name changed of course!) from work today. Poor Mr. Buttercup is a palliative patient, meaning he is dying slowly, and it seems like every system in his body is failing. I went into his room to change a dressing on a wound on his heel and I had to wake him up as he was nearly comatose. The sore on his heel is a pressure sore, caused by constant pressure on that one spot as he lies in bed all the time. The flesh had turned black and necrotic.
With ulcers of this type there isn't usually a lot of pain, even though they look horrendous, because the tissue is well and truly dead. I wasn't expecting Mr. Buttercup to cry out in pain when I unwrapped the bandage, but he did.
"I'm so sorry." I kept saying to him.
The ulcer was necrotic and had yellowish drainage coming out of it. I felt around the perimeter of it and the skin was hot and swollen, which is unusual for that kind of ulcer. It was probably infected. I cleaned and dressed it and tried to make him comfortable before leaving.
I sat down later with the doctor and discussed the patient. He had pressure ulcers, but they were infected. He wasn't drinking a lot of fluids so he was dehydrated. He couldn't swallow properly so he wasn't able to take his medications very well. He wasn't moving much so his circulation was poor. The doctor ordered a medicated cream for the wound and I called the occupational therapist to order a special mattress. We talked on the phone for a while and discussed different options.
"Honestly," she said to me, "I don't think it will make much of a difference."
"Well, what's being done now is not helping at all." I said.
"Perhaps we can try it then." She agreed. "There's nothing to lose with trying."
The sad reality of nursing dying people is that there is no hope of recovery. But I would like to see Mr. Buttercup pain free, if I can, and comfortable.
He's not a textbook patient or one like my assignment case studies. He's a real person, and when I'm having to clean his wound and he is wincing and when I leave and he thanks me with such a gentle smile, I feel tears in my eyes. I know I get too emotionally involved sometimes, but he is a real person after all. I have no connection to the fascinating cases I'm writing about on paper. They are 2-dimensional people with organized symptoms and signs that fit together like puzzle pieces with a diagnosis that I can say "aha! that's it!" to.
Mr. Buttercup is a real person, like me, and we share humanity and we share smiles and a handclasp and an intimate connection as I help him die gracefully, knowing that someday I'll be in his shoes.

A baby is born

Have I mentioned how much I love what I’m doing? Today was the best day ever. I got to my practicum and the doctor said “today we’re doing a C-section”. I could barely wait until 11:00. We walked onto the ward and the nurses were standing there, and one of the surgeons and the anesthetist. The surgeon shook hands with me, and I could see a smile under his half-tied surgical mask.
“Well, we can always use another assistant.” He said.
I went into the change room with my doctor and we stripped out of our clothes and put on green scrubs. I was too embarrassed to let her see me taking my own pulse, but I’m sure it was racing with excitement. We went into the hallway and shook hands with the Mom and Dad and talked with them for a minute. When the anesthetist called them into the operating room, we went to the big stainless steel sinks and scrubbed up to our elbows with chlorhexidine. I put on a hair cover, shoe covers and a mask and then we went into the operating room, opening the door with our shoulders. The OR nurses were waiting and I stood there arms outstretched while they put a gown on me and tied it, then slipped sterile gloves onto my hands.
“Don’t touch anything.” The doctor warned me, “Now that you’re sterile.”
We stood to the side and watched while a nurse swabbed the mother’s back as she sat on the operating table. The anesthetist was chatty and he had a student with him as well and he explained the procedure as he injected a local anesthetic and then prepared to give her an epidural. I watched the needle go in. I have a strong stomach for bloody things, but there’s something a little funny about seeing a 5 inch needle go into someone’s spine.
Then she was being laid down, a drape put up, the anesthetist testing her level of paresthesia, and the nurses catheterizing her and setting up the sterile field. They wiped the mother’s whole abdomen with dark orange iodine and then draped her with a large blue plastic with a whole in the middle that neatly exposed the surgical area.
“Stand there.” The nurse ordered me and I took my place next to the woman’s abdomen.
“Scalpel.” The surgeon said and the nurse passed him a shiny blade.
“Pick-ups.” She passed him a pair of tweezers. (I’ve been told that if I ever call them tweezers in surgery, they’ll ask me to leave.) In the background I could hear the anesthetist student being pimped by her supervisor, and I held my breath in anticipation of the dreaded questions.
But the surgeon was funny and engaging and my doctor next to me explained everything as we went along.
“This scar here is from her previous caesarean section.”
I used a sponge to soak up blood and the surgeon used a cauterizing gun to touch the ends of nicked blood vessels. Through my mask I could smell the unmistakable odor of burnt flesh and in the background I could hear the nurses counting off the instruments that went in and came out of the woman’s abdomen.
The surgeon cut through layers of flesh, carefully peeling back the layers of skin, fat and muscle.
“Put your hand here.” He ordered me and I put my hand into the woman’s abdomen.
“You can feel the baby’s head through the uterus.”
I felt the head, small and firm beneath my hand.
He cut into uterus, my doctor holding it away from the baby with pickups while amniotic fluid gushed out and poured down the sides of the drape into a waiting pouch. When the incision was big enough he reached his hand inside and began to deliver the baby out. I was holding my breath and the father was staring over the drape as the baby emerged, cradled in the surgeon’s hands. The baby was gray and covered in slime but suddenly he opened his mouth and began to squall loudly, and his skin gradually turned pink.
“Look at him!” the surgeon held the baby high so the mom could see.
“Scissors.” My doctor asked and she clamped the umbilical cord, cutting it off before handing the baby to the nurses and a pediatrician standing by. I could feel tears in the corners of my eyes. It was a magical, special moment.
“Now we deliver the placenta.” The surgeon said to me. “The nurse just gave her some oxytocin to cause the uterus to contract”…..
My attention was snapped back to the bloody mess in front of us. He talked to me and asked the odd question while he delivered the placenta and I sopped up blood and used clamps to hold her flesh back.
“Sutures.”
The nurse passed pick-ups holding a slender curved needle and long black thread and he began to stitch together the layers of her uterus, one by one, pulling the thread up in between while I dabbed with sponges and slid a retractor along her bladder to keep it out of the way. It took longer to stitch the woman up than it did to cut her open, and in the process I got splattered in blood. (Which is a whole lot better than being splattered with any kind of fluid from Nellie, if you care to know.)
When she was stitched up neatly, the doctor used a stapler to close the final layer of skin and then we swabbed up most of the blood and stepped back. The Dad was cradling his son in his arms near the mom’s head and we shrugged out of our splattered gowns and gloves and went to her. My doctor leaned over to hug the mom and I told her thank you for letting me be there and touched the little baby while he looked up at me with blinking black eyes.
“The baby is tongue-tied.” The pediatrician explained in a low voice to the doctor. “I’ll leave that in your hands.”
“Yes, it’s no problem.” The doctor assured him. (Tongue-tied is when the tongue is attached to the base of the mouth, and it is a simple procedure to loosen it that can be done in the doctor’s office.)
I was still breathless with excitement when we went out of the OR and stripped off our clothes and washed our hands. We dressed and the doctor and I went out of the hospital to rush back to her office to see an afternoon full of patients. Outside it had just stopped raining and the air was sharp and cool.
“Isn’t that wonderful?” The doctor said to me. “God made it stop raining just for the two of us today.”
She laughed and I couldn’t keep the happy smile off my face. And even giving injections to screaming babies and watching rectal exams all afternoon didn’t take away that good feeling.

The gift of trust

I feel compelled to caution any discriminating readers that my blogs may take more of a medical twist, and as such, may seem a little more unsavory. When one deals with certain topics all day, one things about such topics all night, and one necessarily blogs about such topics.
With that out of the way.... today I had a pretty interesting day at the doctor's office. I gave lots of injections (not too interesting!), and I also gave my first vaginal exam and pap smear. It was entirely unexpected. I found myself at the foot of this lovely lady's bed and being asked, "Would you like to try, Heather?"
I suddenly remembered the stellar advice Dr. Rust gave me in Antigua: If you're asked if you want to try a procedure, your answer is always "yes", and then you do it. And do it well.
"Yes." I said.
As I sat down and prepared for the procedure I had a rush of thoughts coursing through my mind: What if I hurt her? What if I don't know what to do? What if.... It was too late. I was holding the speculum in my hand and talking in a soothing voice to the patient, and the doctor was leaning over my shoulder and guiding me through it.
Well, without going into all the details, I did it, and I did it well, or at least I think I did because the patient said it didn't hurt at all and I'd make a good doctor. I just about floated out of the room. It's amazing what a piece of metal equipment and someone's privates can do for one's self esteem.
Speaking of private, my self esteem took a nose dive with the next patient. She was about 18 years old, and when the doctor introduced me as the medical student who was helping out, the girl looked darkly at the doctor and said flatly, "It's private."
The doctor gave me one of those 'sorry, can't do anything about it' looks and I went out of the room during the consultation. Unfortunately that girl wasn't the only one that day that didn't want me there. Later in the afternoon I sat down with a middle-aged man and the doctor, and the man said, "excuse me, doctor, but I feel really uncomfortable with her here."
I went out and sat with my textbooks until they were done. The doctor waited until the man had left and then turned to me, barely able to conceal his laugh. "You know why he didn't want you there? He wanted to talk about his problem with 'sticky poo'".
We laughed, and I thought grimly, if only he knew of my extensive experience as a nurse with sticky poo. But that didn't really matter, did it?
On the bus home I thought about it in great detail. From my perspective, I wasn't about to be put off by an embarrassing topic. For goodness sakes, I'd successfully done a pap smear that day. And although it made things a little different with someone of the opposite gender, even if I did feel a little embarrassed I never would dream of showing it.
But from his perspective, of course, it was worlds different. There I was, a 5-foot-3 23-year-old girl who didn't possibly look old enough to be a doctor. How could he possibly trust me with the intimate details of his bowel habits? I looked in the mirror in the bathroom and for the first time, wished for wrinkles. If only I looked older and more mature, then people would feel they could trust me.
It is such a privilege to be studying medicine. Today I sat in the consultation room with a beautiful middle-aged woman as the doctor explained to her that she had MS, a progressive, debilitating disease. The woman was a nurse. She looked at me and I looked at her and we both knew what it meant and why it was so devastating. There is no cure for MS, and it cripples and affects every part of a person's life before it finally takes it. Some people manage to have many years of quality life, but in the end MS will win. "Everyone dies." The doctor had said to me that morning. "Sooner or later, from something or other. What matters is the quality of life while they live."
She was fighting back tears and as she got up to go out of the room she said to me in a pitiful, quiet voice, "I have a young daughter."
"How old is she?" I asked. "12 years old." She said.
I thought about her symptoms and wondered if she would still be able to function at her daughter's graduation. I put a comforting hand on her shoulder and said "I'm so sorry."
We talked for a few minutes and then she went out, giving me a brave smile, and I thought, how blessed I am to be with her in this vulnerable time. How privileged that she would trust me, not because I look old and mature and tall, not because I'm the same gender, not because I'm a clever doctor with years of experience. She simply chose to trust me, as another human being, and because of that I'm so grateful.

So much to know, so little time.

Today I had my first day of an 'observational' practicum. I forget how many patients I saw with the two doctors; it is all a blur now. 20 or 30? I am left with one very distinct feeling: there is much too much to know and I'm not sure I'll ever be able to pack it into my little head. My head hurts.
The doctor I was with in the morning is classy; she looks like she stepped out of an upscale older ladies' fashion magazine. She is gracious, very intelligent and very eloquent. I didn't say much all morning, there seemed to be no point. I learned millions of little tidbits that I scrambled to write in my notebook while peering over her shoulder watching pap smears and breast exams and flu shots and hordes of other things.
Do you know that migraines can be helped by the caffeine in coffee, but chocolate, on the other hand, which contains caffeine, also contains histamine which can worsen migraines? Do you know that the nose produces 2 liters of fluid a day just to warm and humidify the air going into your lungs? Do you know that the antidepressant drug Wellbutrin is useful for helping with Nicotine withdrawal because it has essentially no side effects? And that was just the first patient.
By the afternoon my brain was full, but that was just the beginning. The next doctor walked into the office to see me sitting there and said, "Who's she?"
I stood up with a smile and an outstretched hand and the female doctor explained, "Oh, don't you remember Heather, she's here with us every thursday for the next 9 weeks."
He shook my hand and then turned and walked away without saying anything. I thought, oh brother, what have i got myself into. The female doctor gave me a signal to go after him and I ran down the hall to catch up with him and squeezed into the examining room with him. Look confident, Heather, I told myself.
"This is Heather, she's a medical student tagging along today." The doctor explained to the patient. I wondered if it would be simpler if I just wore a shirt that said "I'm really dumb, so don't ask me any questions."
Actually, the patients were awesome. Something about having a student there, but they loved to tell me ALL their complex medical problems as if I was a journalist writing an article about the weirdest health problems in history. In fact, one of the male patients even gave me a pen that said it was stolen from a real estate office. You never know what's going to come your way.
The doctor I was with all afternoon was pretty cool, though. He went over every chart with me and discussed his differential diagnoses and let me help out with a few things. The only super challenging question he asked me was whether or not I could recognize atrial fibrillation (a kind of heart murmur) from the ECG. I said yes, of course, and then was hugely relieved when he said, "You're right, you can see the absence of the p-wave here."
Of course. The absent p-wave. That was exactly what I had been meaning to say, he just beat me to it.
I felt bad for some of the older patients in for physical exams, one lady seemed a little embarrassed to have me in the room. I wanted to say to her, relax, honey, I'm a nurse, and you ain't got nothing I haven't seen before; but coming from someone barely old enough to be her granddaughter, it probably wouldn't have been that comforting. So to all of you who someday might have a medical student in attendance, thank you so much! You are offering a great service to the education of future doctors! Your willingness to be vulnerable and talkative and pleasant is no small thing.
At any rate, I better keep studying. I have about 10 million things to learn this winter, and I've barely started. Hopefully a good night's sleep will clear a little more free space in my brain.