Behind the White Coat

My First Interview

So last week, I had my first Interview.  It was at one of the community programs I applied to - Mt. Sinai/Elmhurst, and much more geared towards clinical training rather than training research scientists like some of the bigger academic centers (and to be honest, I have no desire to work in a lab)  The program wasn't bad.  The fellows spend just over half their time at the main Mt. Sinai hospital, where you do a lot of the subspecialty rotations, and the rest  of the time at Elmhurst.  Elmhurst, Queens is an amazing place, because it is the most culturally and ethnic diverse zipcode in the entire World! All sorts of ethnicities reside there.  So needless to say you see all kinds of disease and pathology from all around the globe, so the experience is great.  Anyway, the day actually went quite well.   It was long and draining, and we had a total of 5 interviews.  I was all prepared for the tough questions, but it was a relatively laid back day and non-intimdating atmosphere, and I never even got asked the infamous "Why do you want to do cardiology?"

My 3rd interview of the day was interesting. It was with one of the interventional cardiologists there. He was an asian guy who looked like he was 18, but was actually one of the big shots there. He came 15 min late in his scrubs and lead apron, as he was in the middle of a case in the cardiac catheterization lab.  So he takes me back to the cath lab to talk, right in the viewing area, with the nurses, PA's and other docs all around in their scrubs, and then me, in my black suit. A little awkward and intimidating for an interview, but I think that took the pressure off. So he proceeds to ask me about where I'm from, my life story, etc.. I could see he was a busy guy, and was flipping through random parts of my app.  So he tells me they were in the middle of an interesting case, and then asks me if I have ever seen cath films? I told him sure, and then he shows me the cath of the guy on the table, and asks me, "so what do you see here?"  I broke a quick sweat, and looked.  Somehow, I knew what it was (it was a bifurcating LAD).  He was pretty impressed, as he didn't expect me to get it!  He then showed me some other films and pimped me about other cath images.  He then noticed I went to Costa Rica on my application, and asked me about Chagas disease, and all sorts of other questions!  It was almost like an oral exam, but I luckily held my own.  At the end of our 6 minuts, he said "I did a good job." I said thanks, and went on my way.  A unique interview/pimp session, but I liked his fresh, high paced personality, so it was actually fun.

The rest of the interviews were pretty benign, so it was an ok start to interview season.  Next one is on the 28th.  I also am now ending my current rotation, and start in the Medical Intensive Care Unit (MICU). Which means on overnight call (28 hours or so) every 3 days. This is gonna suck....

Here's another track w/ some desi flavor by the boys from the 18th Street Lounge:  Download: Thievery Corporation -  Satyam Shivam Sundaram.mp3 (4835.4K)

Successes in the PCU

Sunday, I started the night float week of my pulmonary rotation, where I cover the floor (all alone) between 10pm until about 12pm the next day.  So far, there have been no empty beds on either night, so that means no new patients admitted overnight, which basically means I slept both nights, undisturbed.  Amazing. Not even a call for a fever or request for ambien.  Though I have to sleep in a foldable cot, that is a foot shorter than me, and is so uncomfortably soft I literally fall into the mattress. Nonetheless, it's better then running around all night working.  It also left me wide awake to enjoy the 45 degree day today, which feels like the beach compared to yesterday's -3 degree wind chill!

So I had mentioned in my post of death, some of the sick peep's that have been sittin in the pulmonary intensive care unit (PCU).  The 88 year old dude with whopping pneumonia, and the 77 year old woman with pneumonia and heart failure.  I never thought they would come off the ventilator, but lo and behold, they are breathing on their own, sitting in chairs, and talking.  The 77 year old woman was actually "terminally extubated" by the family, because they did not want her on the ventilator dependant and to get a tracheostomy, and we had a difficult time "weaning" her off the vent.  Nevertheless, when we took out the tube, she did just fine!  The 88 year old man, who came back against all odds, has been threatening to get up and go home (even though he is too weak to even get out of bed).  Of course he was delerious and wailing about some appointment he had to keep, and he even started weeping. That's right, he was crying and shaking his legs like a little toddler.  I had to hold his hand for him to calm down (with a shot of haldol of course).  I've never seen an 88 yr old man cry like that!  Though I suppose it is a good sign, considering the alternative outcome.  However, it didn't fare so well for our 37 year old guy with AIDS And PCP pneumonia.  After 30 days of 2 courses of antibiotic therapy, a persistent pneumothorax, respiratory failure, and sepsis, the infection simply overwhelmed his lungs, and his body.  Despite not being able to get in touch with any family (except the occasional visit from his so-called "fiance" who was this shady homeless chick who also claimed to be his "drug buddy"), we signed a form of medical futility, and made him DNR.  Thankfully just in time, the day before he died. 

Tomorrow is my first interview.  I realized I haven't really thought about it much, and I suppose I'm a little nervous.  I tried anticipating some of the standard interview questions, so I'll have somewhat of an idea what to say, though I can never come up with an answer for "Why do you want to do cardiology?".  At least it is one of the programs lower on my list, so I won't be as stressed about it, and I  will get a feel of what is in store for me the next 2 months... I've also opted to shave my beard, but I left a goatee for now.  I think with my Burberry glasses, goatee, and lengthened sideburns, I've accomplished an intelligent, yet hip look.

My song for the day is from my fav group, Thievery Corporation - The Richest Man in Babylon: Download babylon.mp3 (3600.5K)

New Look

Programs Applied to: 60?!
Rejections: 9
Waitlisted: 1
Interviews: 5

So that is the latest count.  You know it is interesting some of the decisions I have received.  I mean I got rejected from some of the big-guns (Harvard, Mayo, etc.) which is expected.  I did however get a a couple of interviews so far at top tier places, which was surprising.  But then I also got rejected from some real mediocre places!  I was somewhat shocked.  UMDNJ Camden neg'd me, whereas some of my colleagues got interviews there.  Not that it would be anywhere near my top few choices, but it is somewhat discouraging.  Though they can only interview a handful of candidates at most programs, and perhaps they did not invite me because they knew I would not choose to go there, I suppose that should be reassuring?  Anyway, the latest rejections also include Mayo and U. Florida.  (Oh, just got an email.  UCSF rejection, there goes another!) Brown waitlisted me. I didn't even know they even did that!  Screw Rhode Island anyway... The latest interviews I got were St. Vincent's, and Bronx Lebanon.  My first interview is coming up on Feb 20th.  Perhaps I should prepare. Hmm..

I grew a beard recently.  I hadn't shaved in like a week, and it had gotten so advanced, I figured, lets just go for the gold.  So now it is like a legit, trimmed beard.  I dont know, I kind of like it.  I have had mixed reviews, ranging from "It looks good," to "Shave it off!!", to "Hows the sleeper cell?"  I guess it depends if you are a facial hair person or not.  I felt I was obligated to grow it this month, since I am working with 6 girls now, and running my own little harem.  To fulfill the part, it was a necessity.  Regardless, I think I should shave it prior to any interviews, particularly if it involves me going on a plane. I'll include a pic below for your viewing pleasure, you can give me your opinion...

So another random story about the small world of blogging.... A co-worker of mine ran into me the other day, and told me about a wedding she went to in Nebraska (of all places).  She tells me while at this desi wedding, she met some girl from Las Vegas.  Somehow they got to talking about work, and when my co-worker mentioned Montefiore (our hospital), the mystery girl asked if she knew me.  Now I have no idea who this girl is, but she seemed to know me!  Apparently she found my blog, and is a secret avid reader!  I'll admit I was somewhat excited.  Knowing that random women across the states (and Canada) read my rants and musings, is fuel for my pointless fire...

Oh, and happy valentines day to all of those hanging home alone like myself.  I did bring chocolates for all my co-workers today, so I think I did my part!

Before and After:

Death, from Young to Old

So I saw the craziest thing today.  I was notified about my last admission of the night by the MAR (medical admitting resident), and it was a 46 year old lady came in with a complaint of difficulty breathing for one day.  On chest x-ray she had a huge pleural effusion (fluid around the lung) which was causing her symptoms.  She got a CT scan afterwards which showed the entire right lung was collapsed by this huge effusion, and they had already inserted a chest tube to drain out the fluid, which was around 3 Liters.  When I went down to see her, I got her story, and the plot thickened....

This was a 47 year old active cocaine and heroine user (despite being on methadone), with no other medical history.  She said about 4 months ago she noticed some changes in her right breast, that it began to shrink and change in texture.  She thought nothing of it until it got worse, and then went to another hospital to get it checked out.  She had some tests and was told by the doctors she may have breast cancer, but she didn't "believe them", and she left.  She was probably in denial and ignored the issue, and just got cranked on drugs in the interim.  She probably knew, since her entire family has some sort of cancer, from lung to colon.  She then continued to notice changes in shape, texture, and coloration, which then started to affect her neck and even her arm.  At this point I began looking more carefully and noticed her entire right arm was severely swollen.  It was huge.  The right side of her neck was lumpy, hard, and thick.  I knew this wasn't going to turn out good.  When the chest tube was put into her right chest, it drained out ugly, bloody fluid, and on the catscan, I saw thickening and swelling of the right breast, infiltrating into the muscles, and all kinds of crap in the left lung as well.  I then examined her.  I don't think I've ever seen anything like what I saw, because rarely do you see cancer progress to this degree, at least in the 1st world.  Her right breast had hardened like a rock compared to the left, it was shrunken as the tumor had encompassed the whole thing, and the skin had become rough ridged orange.  If you have heard of peau d'orange (i'll decided to leave out the link to a picture), this was a classic example.  It was sad and grotesque.  She had huge firm lymph nodes in her right axilla, above the clavicle, and in the cervical triangle.  The tumor had clearly infiltrated the lymph system because her right arm was just a gigantic mess and edematous.  She asked me "Am I going to be ok?"  I couldn't even answer her.  I told her it was far advanced, and we'd figure out what treatment is best.  She surely has stage IV cancer with metastases to the bone at least.

Anyway, she's gonna get the whole workup, as futile as it is since she is just gonna be getting palliative chemotherapy, and has a 5 year surival chance of probably less than 20%.  Pretty sad, only 47 years old too.

So far, I'd say it's been somewhat of a grim month on Pulmonary.  In the pulmonary intensive care unit (6 of our 24 beds) I had to tell the mother of a 22 year old girl with asthma that she is going to be in a vegetative state and have to live in a nursing home.  She just got her tracheostomy and feeding tube, and is completely unresponsive except for slight movement of her eyes and head.  She had such a severe attack that she went into cardiac arrest for 15 minutes, was resusictated, but never woke up.  I also told the children of two other patients,  77 and 82, that their parents have such bad pneumonia that they may not recover, and if they do, they may never come off the ventilator.  For their sake, I hope they do recover, and if they don't, it may be better off if they just die.  What do you think?  Vent dependant in a nursing home for the remainder of their old days?  Or death....?

Here's another song on my IPod rotation by Nitin Sawhney:  Download Spark.mp3 (3498.4K)

Fatties

In medicine you see a lot of fat people, and when I say fat, I mean reaaally fat.  I suppose the correct term would be obese.  I also wonder, why does society accept the term "obese" as politically correct, but it is supposedly unkind and mean to use the word "fat"?  It means the same damn thing after all!  And let's just be clear, when I use the term fat, I am talking about real big people, not your runway model who gained the extra 5 pounds after an ice cream binge... Which brings me to my story....

So I am on pulmonary this month, as I mentioned.  Which means a lot of COPD, asthma, pneumonia, and other various breathing problems.  This one guy get admitted a few days ago.  He is only 27 years old, and supposedly a history of asthma.  He comes in with difficulty breathing.  I walk into the room, and on the bed, bare bellied with the extra-large gown on that looked like a pair of skibbies, lies this gi-normous man.  As my distinguished colleague would say, he is indeed, a big fatty.  Let me tell you, I've never seen a belly like that.  I was shocked the guy could even walk around!  He measured in at 5' 3", and weighed (get ready), 525lbs.  That's right, no joke.  We took guesses on what his calculated BMI (Body Mass Index) would be, which is the weight in kilograms over the height in meters squared (kg / m^2).  That's the quick way we determine a person's weight status.  Normal is 18-25, overweight is 25-30, obese is over 30, and anything over 40 is extremely obese, and when you start hitting over the 60's (which you do see once in a while), we are talking massively super-obese people who will probably die young if they don't get surgery.  So what was our friend's?  I shit you not, it was 93.  If you are in the medical profession, you'll know how insane that sounds... The highest BMI I have ever seen!  And he comes in with shortness of breath.  I wonder why?  Asthma? Please.  How about massive massive morbid obesity?!  I told him, "you will probably die if you don't get bariatric surgery." 

You may say I am brutal, inconsiderate, and insensitive.  Well I say I speak the truth, and if I don't say it, who will?  The man needs serious help, and he is way beyond dieting and exercise.  He was so apathetic about the whole weight issue, and someone had to tell him to his face, that he WILL die.  Only 27 years old!! How does that even happen?   Obesity:  America's number one health problem.

To part, here is one of my recent listens, Postales by Federico Aubele

Download Posatles.mp3 (3844.5K)