Rank Lists Are Due Today

My rank list is due today. I have officially submitted the list of ENT programs I would like to attend in the order that I would like to attend them. I interviewed at 12 programs and will therefore only be ranking 12 schools. I have decided to rank all of the programs I interviewed at, though I was tempted to leave one of them off.

For reasons political (I still don't know who all of the 100 or so people are who log onto this blog every day are), I have decided against actually reporting what my rank list actually is. However, suffice it to say that Cami and I are more or less in agreement as to the order of this list. The top three programs were unanimous. The bottom two were as well. The middle seven were a little less than unanimous, but we are happy with our official order.

Now the waiting game begins.

I believe the deadline for programs to submit their rank lists is a little later this week. Once all lists have been submitted, the "computer" will run through the lists of the applicants and the programs and everyone's fate will be determined. The match is a complicated process that is very annoying to have to explain. I will, however, attempt to do it here. Apparently, there is this "computer" which uses some super algorithm to determine the fates and fortunes of thousands of soon-to-be MDs. You can get the official explanation about it at the NRMP website, which is actually a concise, though lengthy discussion about some of the nuances of the match. In a nutshell, the computer randomly starts with one applicant and gives that applicant his/her highest available program choice (assuming that program has also ranked the applicant). It then takes the next applicant and does the same thing. If two applicants rank a program number one and only one spot is available, the applicant who is ranked highest by the program gets the spot. If two programs rank the same applicant number one, the applicant goes to the program he or she ranked higher. This process continues until every applicant has a spot or all available spots are filled. Sound complicated? Maybe. The computer then runs through the whole thing again, starting with a different randomly selected applicant just to make sure the results are the same.

The frustrating thing about this is that it takes the computer less than two minutes to actually run through the rankings and give everyone a spot. However, we won't find out the results of this process for another three weeks. It's going to be a long three weeks...

Return To Twainhart

Immediately after the conclusion of the best ER shift ever, I hopped in the car with Cami and we drove to the Callister's cabin in Twainhart, California. We had been talking about returning to the cabin since our fun expedition there last year. Amazingly, when Sean & Ashley, Fernie, and his girlfriend Mari heard that we were planning a return trip to the cabin, they all wanted to come. I guess enough time had passed since the last trip that Fern had forgotten how painful a trip to Twainhart can be.

We got up there Friday night and stayed through Monday morning. The Sierras had gotten a healthy layer of snow the week before we got there, which always makes staying at the cabin much more enjoyable. We spent nearly all day Saturday lounging around and playing games in our pajamas. After a delicious French toast breakfast, we went on a walk around the lake near the cabin. The snow made things a little difficult. Fortunately, by walking single file we were able to avoid having to bust out the snowshoes.

We did get a little distracted throwing snowballs. There was a dock out on the lake with some ducks on it that we were trying to hit. While the girls watched and laughed, the guys all took turns packing snowballs to be as hard as rocks and launching them as far as we could into the lake. Based on the available evidence, who do you think came the closest to hitting the mark? Sean, Fern, or myself. The answer is quite obvious.

After the walk, we came home, thawed out with some hot chocolate and turned up the heater. We tried several times to keep a fire going, but the wood was defective (clearly, it wasn't due to any deficiencies on our behalf). Later that afternoon, we decided to head up near Strawberry and go sledding. We didn't want to repeat the failures of our last sledding adventure, so we were sure to bring inner tubes instead of just saucers. The tubes were a lot softer on the tailbone and made sledding a much more enjoyable experience. However, it isn't a trip to the cabin unless Fern nearly kills himself.

The biggest disadvantage to the tubes were that they were a lot faster than your typical saucer. Normally, this is a good thing, but the hill we were sledding on had about 15 yards of flat ground before dropping five feet into a creek. You had to stop the sledder very quickly to prevent them from taking a bath in some frigid water. We had developed a technique that was more or less effective. It involved lying down in the path of the inner tube, so that when you hit the tube, it stopped instantly and ejected its passenger onto the snow well before they hit the stream. As the video below illustrates, it was also fairly humorous for everyone else involved.



Our stopping formula had been fairly successful throughout the day and we had all about run out of gas when Fern convinced Mari to go on one more trip down the hill with him. As they trekked up the hill, the rest of us started talking about what we wanted to do for dinner. We weren't paying attention to Fern and Mari at all, until we heard Mari screaming. I looked over my shoulder and noticed that they were coming down the hill. Fast. National Lampoons Christmas Vacation fast. As soon as their velocity and trajectory registered in my brain, I realized they were not going to stop in time to avoid going into the creek.

Sean and I both tried to get in the way to stop them, but we didn't have enough time to form an effective barrier. Fern and Mari bowled through us like we weren't even there. The next thing I remember, I was lying face down on the edge of the stream. I looked up to find that that tube, Fern and Mari were in the creek about ten feet from the edge. Both of them in the water. Both of them laughing hysterically. Well, Mari was laughing hysterically, Fernie was kind of wincing. I think Mari bounced on him before she hit the ground. Click on the picture and take a close look at Fern's face. I think it says just about everything that needs to be said. We took our fallen comrades home and enjoyed some hot pizza, as we retold the events about a dozen times from six different perspectives.

Near casualty aside, we had a good time up at the cabin. Who knows where we'll all be next year, but maybe we'll make it an annual event.

This Is Spinal Tap

Break out the bubbly, I had the greatest ER shift ever last Friday.

Last Friday, Fernie and I had the good fortune of being teamed up together in the same area for our 7am to 7pm shift. Working with a friend makes the day so much easier because there is someone to commiserate with. Of course, it also helped that we were working under a super cool intern, resident, and my favorite ER attending.

The day started off great. Fern and I were trying to see who could go the longest through the day without picking up a patient. We both made it about three hours (!) before having to do any real work. My first patient was a classic appendicitis. I nailed the diagnosis and treatment and had surgery admitting him within an hour. I was so all over that one, that a part of me felt I had finally redeemed myself for not diagnosing Cami's appendicitis two years ago.

After finishing off that patient, there was another lull in the action. While glancing over the patients in the waiting room, I discovered that the chief complaints for the next four patients were: "testicular pain," "penis swelling," "trauma to the penis," and "abdominal pain." Anybody pick up on a theme here? Let's just say I was very happy to volunteer for the abdominal pain patient and equally as happy that Fernie ended up having to treat the dude with testicular torsion.

Highlight of the day was treating my patient with headache and neck pain. We had to rule out a meningitis so I got to do my first lumbar puncture. I remember a conversation I'd had with Sean and Fernie during our first year about how nerve wracking it would be to stick a needle into someone's spine. At the time, the idea of us doing something like that was unfathomable.

Having never done a tap before (but having witnessed and assisted in several), it is safe to say I had a few butterflies in my basket. My intern suggested I watch a ten minute video on "how to perform a lumbar puncture" on the internet, which I did paying very close attention to every minute detail. If that patient had any idea that I was preparing to stick a three inch needle into his spine and drain cerebrospinal fluid by watching a how-to video I think he would have been a little more reluctant to sign the consent form. Then again, we had him on some narcotics for his headache that had him feeling pretty mellow, so he might have consented to just about anything.

The attending helped me get started, verifying that my landmarks were appropriately identified. After numbing the region, I went ahead with the procedure. It is an odd experience to feel around a person's spine with a 23G needle, searching for the gap between vertebrae that would allows you access to the subarachnoid space. But, within a few moments, I got the characteristic "pop" of penetrating the dura and clear, colorless fluid began dripping out of my needle.

Victory!

My first LP was a "champagne tap," meaning I had entered the spinal column and collected my sample without contaminating it with blood. The attending was quite impressed and offered to buy me a bottle of champagne to celebrate the occasion. I did not have a chance to explain my religious proclivities, so I may be selling a bottle of bubbly, if anyone is interested.

As I finished my shift, I had either discharged or admitted all of my patients, and therefore did not have anything to signout to the night shift. Meaning that I didn't have to wait around an extra 30 minutes after my shift was over explaining what the night shift ought to know about the people I saw. Awesome. If every shift in the ER was like this, I wouldn't mind going to work at all.

8/10?

Kim provided me the link to this in the comments section of my last post. I watched it and laughed very, very hard. I laughed so hard, in fact, I was finally able to cough up some of the gunk in my bronchioles that has been rattling around for the last week or so. Thanks, Kim.

My Personal Pet Peeve

I have a pet peeve.

It drives me absolutely crazy. I understand I am not the only one in possession of this peeve, but I feel the need to go public and express my frustration. I do this as a public service to health care workers everywhere. I would sincerely hope that anyone who reads this post, will take this message to heart and remember it the next time you feel the need to go to an emergency room or your family practitioner. The message is this:

You are not in 10/10 pain.

Allow me to explain that potentially cryptic message. As you are well aware, I've been working in the ER now for two weeks. I just finished a five day stint of shifts and it feels like I've seen everything. From scabies to NSTEMIs to severed digits to constipation to drug seeking behavior. You name it, I've probably seen it. For every patient who comes into the ER, you are supposed to ask that patient whether or not they are in pain. For those who answer "yes," you are supposed to quantify how much pain that they are in, so that you can determine whether their pain gets better or worse during the course of their treatment.

This is where the pain scale comes in. Theoretically, the pain scale is a subjective measurement, which allows a patient to rate how much pain they are in. In this particular scoring system, a 0/10 is defined as no pain, whereas a 10/10 is supposed to the the most pain that a human being could possibly endure. You would think 10/10 pain would be extremely rare, a number used only in the most severe circumstances.

You would be wrong.

By far, 10/10 is the most common response I get when I ask patients to rate their pain. This annoys me. In fact, if I were to rate my annoyance on a scale from 0 to 10, 10 being the most annoyed a human being could possibly be, this would probably be about a 7/10 (Now, if someone had said they were in 10/10 pain while squeezing toothpaste from the middle of the tube, it might have been an 8/10). Don't get me wrong, if someone is truly in 10/10 pain, I am happy to help them. But usually, people throw that number around like it is nothing. And it is not because they don't understand the question, because I take great care to phrase the question such that there can be no confusion.

"If you were to rate your pain on a scale from 0 to 10, 10 being the most horrendous, absolutely exquisite pain you could ever possibly be in, where would you say you are right now?"

Why does this bother me?

First of all, 80% of people who answer 10/10 are usually sitting upright, nursing a headache or a swollen pinkie. They answer straight-faced without any hint of emotion: "Oh, yeah, doc, I am pretty sure this is a 10/10." It's hard to take this kind of remark seriously. Even harder when the last patient I took care of nearly severed his leg and had completely broken his tibia and fibula and was screaming his head off in a pain induced delirium. Fernando admitted to me that when a patient tells him they are in 10/10 pain, he now responds: "No you're not. If you were 10/10, you'd be crying right now." C'mon people!

Second of all, do you honestly think it would be impossible for your pain to be any worse? If I were to take you and your swollen pinkie and run over you with steamroller, don't you think that would hurt a little more? But where do you go on your pain scale? It's already at 10! You can't go to 11, it's only a 10 point scale. However, this limitation hasn't stopped some creative patients from inventing new high scores. The highest answer I've gotten was 110. One full order of magnitude above the defined limits of the scale. Believe it or not, this was said by a guy resting comfortably in a chair sipping ice chips from a plastic cup. Un-buh-LIEVE-able.

For the sanity of health care workers everywhere, please, please think about this question the next time you are asked. Genuinely assess your pain. You will still be cared for if your pain is a 7/10. Honestly, I won't think less of you for coming into the ER with 6/10 pain. In fact, I am more likely to believe you from that point on.

Strictly By The Numbers

In the 119 days between my first interview at UC Davis and my last interview at VCU, I have:

Flown over 37,000 miles on 6 different airlines
Spent a total of 6 days and 15 hours in airplanes and airports
Successfully passed through 22 security checkpoints
Missed 0 flights
Thumbed through 4 consecutive monthly issues of Sky Mall Magazine
Consumed approximately 34 in-flight beverages
Been in 27 different cities in 17 different states
Rented 12 cars and 1 minivan from 5 different rental agencies
Stayed in 7 different hotels and 5 different homes
Slept 45 nights in a bed other than my own
Set my watch to 4 different time zones
Sat on a plane with 3 former American Idol contestants
Toured 12 universities in 10 different states
Met about 90 applicants vying for the same 33 spots as I am
Spent 33 hours sitting through 95 interviews with over 130 different people
Gained 5 pounds
Worn 1 gray suit with 7 different ties
Read 6 different books
Shaken over 247 hands
Answered the question: "Why are you interested in ENT?" at least 63 times
Canceled 1 interview because I just couldn't do any more of the above

At last, I can finally say I am done interviewing. I can't believe that it's already over. However, there is one important figure missing from the above calculations. This was intentional. I'm afraid to tabulate how much all the above stuff cost for fear that it might give me a heart attack. In light of the enormous financial burden this nationwide tour has been on us, I've got to give major thanks to Mom and Dad for providing major funding to this endeavor. We seriously could not have done it without your help. Thanks guys.

With all the interviews now officially over, the agony over how to rank each of these programs begins. To be fair, I am pretty sure how the very top and the very bottom will shake out. It's the middle that may take a little work. Rank lists are due February 25 and I'll find out if I match on March 16 and where I match on March 19. I guess then I'll figure out whether or not all this stuff was worth it. What a way to get a job...

Donezo!

I just flew home from Richmond, Virginia. And I swear, if I ever have to go on another residency interview trip again, I just may be tempted to quit medicine and become a circus clown. I left Sacramento for a visit to Virginia Commonwealth on Friday. The flight was a pretty long one, but I was reading a good book, so I didn't seem to bad. On top of that, just knowing that this was my LAST INTERVIEW, was enough to keep me pacified.

Again, the ENT program at VCU had brokered a deal with a few area hotels. I ended up staying at an older place right across the street from the Virginia State Capitol. The place seemed nice enough, even if it was a little older (and had an interesting aroma in the hallways). When I got to my room, I didn't have a whole lot of time to kill. I was supposed to make it over to a dinner with the residents and somewhere past Texas but before Virginia, I realized I neglected to pack my black belt and would have to buy one before the stores closed. Annoying, I know.

However, as I hung up my suit in the closet near the bathroom, something near the toilet caught my eye. I couldn't really believe what I was looking at. I had heard of these things existing, but I'd never really seen one myself. Sure enough, I walked closer and sitting right between the toilet and the bathtub was a bidet!


My attention was immediately drawn to this peculiar porcelan perch. As I fiddled with the nozzles and watched a stream of water shot two feet up out of the bowl, I had to wonder: How on earth these were things supposed to be used? I knew that it was designed to, um, wash one's nether regions, but all sorts of more functional questions started running through my head. Does it need handles? A non-slip surface? Which way does one face when utilizing the bidet? Does one sit on it or sort of squat and hover? All of these questions and more were answered by quickly consulting Wikipedia on my cell phone. Interesting bidet fact: The word bidet is French for pony. The name comes from the fact that one mounts a bidet in a fashion similar to riding a pony. Fascinating, no? I thought this tidbit alone greatly advanced my understanding of this bathroom accessory. Unfortunately, I never got the opportunity to actually test drive the bidet. I guess I just didn't see the point.

The interviews themselves went well enough. However, with the end fast approaching, I was nearly giddy and almost hugged my last interviewer. Of the ten other applicants present, nine of us were finished. The collective feeling of relief was palpable. We ran out of that interview like third-graders on the last day of school. Due to a scheduling misunderstanding, my flight didn't leave until the next day, so I spent the afternoon taking a nap and wandering around downtown Richmond. I woke up at 4:15 EST this morning (translation 1:15 AM in California!) to catch my flight home. Now I am back and don't have to worry about this interviewing stuff ever again... I hope.

ER Update

I survived my first shift in the Peds ER. Believe it or not, I actually had a good time. Reported for duty at around 6:00pm and ran across the hospital to a Code Blue at 6:15. The next eight hours were quite a bit slower. I saw 5 patients during my shift, which kept me pretty busy. I performed a rectal exam on a constipated five-year-old. Never thought I'd say that. I also had to perform what I hope (keep your fingers crossed) was the last pelvic exam of my medical career. All in all, it was a pretty good experience.

To be fair, I was really rusty. I have forgotten quite a bit, but it's amazing what starts coming back once you start jogging the ol' memory. Maybe these next few weeks won't be so bad after all. But I'll wait to make that assessment until I've worked in the main ER and trauma bay.

ER

I started a new rotation yesterday. For the next four weeks I will be working ten 12-hour shifts in the adult ER and four 8-hour shifts in the peds ER. I have lectures today and hit my first shift tomorrow from 6pm to 2am. I will be the first to admit that I am a little intimidated by the prospect of going back to work.

I haven't had a clinical rotation (or any rotation for that matter) since I got back from my sub-internship in North Carolina. For those of you who can't remember back that far, that was before Thanksgiving. That means I haven't seen, touched, examined, diagnosed, poked, smelled, questioned, admitted, discharged or embarrassed myself in front of a real patient in over 70 days. Two and a half months, if you prefer.

Question: Do you have any idea how dumb I feel after two and a half months of traveling, vacation, video games and junk novels?

Answer: pretty dumb.

Sure, I have learned a lot about the art of interviewing. I have talked a lot about my research projects, hobbies and career ambitions and have perfected the art of feigning interest in the research projects, hobbies and career ambitions of others. I can eat a hoagie without getting mustard on my tie. I know how to pack suit into a carry-on without getting it too wrinkly. I can make it through the security check-point at an airport in under three minutes. Unfortunately, I don't think any of these skills are going to manifest themselves in the peds ER on Wednesday night.

Dr. Tim, Almost MD: "So, what seems to be the problem here?"
Jimmy's Mom: "Well, little Jimmy has been barfing all day, but what I really need help with is trying to figure out how on earth I am supposed to get the wrinkles out of this suit for a 7 am interview tomorrow!"
Dr. Tim, Almost MD: "Ma'am, you've come to the right place. I would recommend hanging the suit up in the bathroom and steaming the wrinkles out by running a hot shower."
Jimmy's Mom: "Oh, Dr. Tim, Almost MD! You've saved the day!"
Dr. Tim, Almost MD: "All in a day's work, Jimmy's Mom. By the way, if you need any help perfecting the power turns on Mario Kart, I'll be on call again on Tuesday. And I hope little Jimmy starts feeling better soon."
Jimmy's Mom: "Me too, doc. Me too."

I think I may have honestly forgotten every useful bit of information I have learned over the last 3.5 years. For example, if a 65yo ♂ arrives c/o SOB and DOE and has a PMH of DM2, PVD c a prior MI, but the MD is thinking DVT and wants to r/o PE. What would you do? Buy a vowel? More importantly, what would I do? I am not really all that sure. But I can tell you what I would do if I were you:

Avoid the UC Davis Emergency Room during the month of February at all costs.

Seriously, I feel like I am walking into the gladiator's arena armed with a butter knife and pair of tube socks. It is not going to be pretty out there, folks. I'll be sure to provide the highlights (and probable lowlights) as they transpire.