Just got back from the Boston Ballet performance of “Three Masterpieces”, a trio of pieces by major choreographers that definitely stretched my ballet-experience boundaries, ultimately in a good way. The third piece, Twyla Tharp’s “In the Upper Room”, was a blur of bending arms and legs set to a frenetic Philip Glass score. It highlighted the dancers’ youth and athleticism, and easily earned a standing ovation. The costumes were all black/white or red, and often the female dancers’ feet were highlighted with red so they stood out as they moved through the tangling choreography. The second piece was set to Mahler’s Kindertotenlieder, Songs on the Death of Children, and was as subdued and brooding as the third piece was energetic. The program had the translations of the songs, but the arms of mothers and fathers clasped in prayer or outstretched in supplication needed no translation.

Somehow the two pieces are whirling together in my mind along with the milagros I became fascinated with on my recent trip to New Mexico – the examples below are from an old church in Santa Fe. Milagros are small metal representations of body parts that are placed in the church to ask for healing of a related ailment – a leg for a broken leg, lungs for pneumonia, and so on – and an exhibit case at the International Folk Art Museum in Santa Fe showed examples of similar objects from all over the world. In Santa Fe I also saw an exhibit of related objects, ex-votos, plaques giving thanks for the fulfillment of a prayer or request. Many of them thanked God for the healing of a child’s illness. And in between this weekend’s ballet and my vacation to Santa Fe, I started a rotation in pediatric surgery. I helped cut open a three-year-old child. His parents brought him to us for us to make him better, knowing how we would do it, and instead of “doing no harm” we earned their gratitude. I haven’t yet made sense of this intermingling in my mind of high art and folk art, art and medicine, healthy bodies and sick bodies, the metaphysics of prayer and the physics of surgery… At this point in my education as a medical practitioner, a humanistic doctor, and a human being, I’m just trying to be open to witnessing all the ways I see people make sense of body parts and healing.

In all of medicine, but I think especially in surgery, there is an interesting phenomenon in which individual body parts get anthropomorphized. I have especially heard organs or regions of interest described as “angry,” and it’s often an apt description: red, raw, hot, spreading, distorted, bloody, pulsating, chaotic.

One thing that has struck me on pediatric surgery already is the ability of the surgeons to zoom in and out so readily: to one moment be interacting with the patient’s family, then the next be zeroed in on tiny structures under magnifiers in the OR, without either level of focus interfering with the other. In surgery today the image of the frightened preteen girl faded away as her body stilled under the anesthesia, she was covered with layers and layers of encroaching drapes, and they entered down into her abdomen as if through a rabbit hole. As soon as they pushed aside the rectus abdominis muscles, the entire field was tumor.

And it was angry. One of the transformations that a line of cells undergoes as it turns malignant is the ability to form new blood vessels, angiogenesis. But like everything else tumor cells do, it grows them without organization or control. The smooth surface of the tumor was streaked with dark red vessels winding tortuously across it, big fat vessels stolen from the ovarian blood supply and engorged on the blood vessel equivalent of bodybuilders’ steroids. It looked like the swollen body of a tick after a blood meal, and maybe the simile is an appropriate description of how the tumor feeds off the rest of the body. The smaller vessels were haphazardly scattered and matted, completely unlike the neatly organized fractal lines of normal vessels. I think that, even if I had no medical knowledge or experience, if I saw that tumor I would know it wasn’t right.

Two skilled surgeons worked together slowly, methodically working out where the tumor was attached to the rest of the body, then tying off and severing artery by artery. They expressed no outward worry even as it was obvious they were wary about the unknowability of the exact tumor anatomy, but just stayed absolutely focused, until suddenly it lifted free. One held it aloft a moment as it oozed blood from its distended vessels, then lowered it into a blue tray where it rolled a little, an almost sphere with a few protruding knobs. They later took pictures for their records. It was the size of a grapefruit.

Luckily, the rest of the abdomen looked pretty normal, and time moved much more quickly now that the tumor was out. Rewinding back to the beginning, they closed up the incision layer by layer. A navel popped into view, and suddenly it was a person again on the table. The drapes were removed layer by layer, the anesthesia wore off bit by bit, and the preteen girl whose family I met yesterday was back. Her angry tumor sat glowering, its red blood vessels darkening as it used up the last of its oxygen supply, until Pathology came to take it away.

My first day of my pediatric surgery elective – my real first day of third year – was exactly what I hoped for as the first day of my “real” medical education.

I rounded on every inpatient on the surgery service – forty-six in all, ages one month to seventeen years, with dozens of different problems or different presentations of similar problems. My feet hurt, and I have a lot of acronyms to decipher.

I got to do two procedures, which is two more than I thought I would get to do on my first day. I inserted a Foley (bladder) catheter, one of the standard “by the end of your third year” procedures, in the OR. So I’m on my way.

I removed a suture. Only one, because the thirteen-year-old boy was very skittish (just old enough to know what to expect from hospitals), and said he was “a bit afraid to have a beginner do it.” After all the sutures were out without any trouble, my one and the intern’s two with four more for later, the boy softly told me, “you can do them all tomorrow.”

And there were children…
A little four-week-old fussed a bit each time we adjusted his abdominal repair, until the nurses dipped his pacifier in sugar solution.
A six-year-old brought Buzz Lightyear into the operating room with him, with plans for Buzz to have a gastrointestinal tube placed as well, so they would both have one.
A previously hostile teenager with an abdominal complaint giggled like a baby when the examining surgeon felt her abdomen, now painless and ticklish.
Kids of all ages rode around the hospital corridors and up and down the elevators in pushed or foot-powered wagons and cars of brightly colored plastic.

And I met a teenager who was dying of cancer. He lay pale and exhausted in his hospital bed, clutching his patient-controlled anesthesia (a button that triggers delivery of pain medicine as needed). He allowed me to examine his abdomen, which I could barely indent: every bit of it was like a layer of skin over rock, all tumor, and thudded dully when I tapped on it. His mother cried quietly as the surgeon discussed what measures would best preserve his quality of life as its quantity ran out. After we left the room, he pulled out the operating room schedule and picked out a few surgeries I should consider seeing, but his voice broke and paused.

So, in my thirteen-and-a-half-hour day in the hospital, I was exposed to the joys and the sorrows of pediatric medicine, I watched and I listened and I even contributed a little bit to patient care, I met a dozen new kind and encouraging teachers, and I feel like I learned more about medicine than I have in months’ worth of my preclinical years. I know it won’t always be this positive or energizing or successful, but I wanted to write down right now as much as I could of my first day as a third year, because I know for certain that by the end of the year my life will have changed dramatically…

Especially as I start in the hospital as a third-year student, I am trying to be careful about projecting a more professional image in how I act, dress, talk, and so on. This is both for my own benefit, to gain the respect of “colleagues” (residents, attendings, and up…colleagues but hardly peers!), and of course to show professionalism and project competence to my patients. However, sometimes there is no way to express my reaction to the little tidbits that re-spark my interest in medicine other than “how cool is that?!?” So, here is the first in what will hopefully become a series of these moments in my medical education.

A plastic surgeon who was extremely enthusiastic about his specialty came to talk to us surgical clerks this morning, ostensible about wound healing but really his talk could have been titled “Why Plastic Surgery Is Awesome.” Among other things, he talked about being able to transplant a young child’s toe onto its hand if it is missing a thumb (born without, for example). In order for the transplanted toe to survive, its blood supply has to be connected to the vessels of the hand, involving microvascular surgery stitching together slippery little tubes (blood vessels) that can be less than 0.5mm thick – keeping those tubes open, of course. Then in order for the toe to be of any use as a thumb (that can move and feel), its nerves have to be reconnected. A nerve dies when it is cut away from its cell body, but it leaves behind a tunnel where the Schwann cells that wrapped it in myelin used to be. So the toe nerves die, but the nerves from the hand can grow out through the tunnels and fill in the new “thumb.” Then the really fascinating part is that the part of the brain that recognizes where the thumb is supposed to be can remap itself over time and start sending and receiving signals with the thumb through those growing nerves. This is called cortical plasticity, and it used to be thought that it really didn’t happen much after a very young age, but it does… definitely a wave-of-the-future topic in neuroscience. In the end if everything goes right, the transplanted toe winds up with thumb-like vessels and thumb-like brain connections, and acts as if it were never a toe at all. How cool is that?!?

WordPress has a new feature in which they put links to “possibly related” posts below each entry. These links are to other people’s blogs, not mine, so just know that they don’t originate from or represent me. That being said, traffic to and from those links is very much welcome.

During our orientation last week, we received new hospital-specific white coats to replace the ones we received from the school as incoming first-years. They are still short (student length), but the ones from this particular hospital are renowned for having enormous pockets both inside and outside. Mine is a fitting symbol for this transition point: continuous with what came before and yet at the same time profoundly different, and with room enough for everything I have to learn this year.

In another meaningful reminder of this transition, I attended Clinical Physiology Grand Rounds this evening, a series of talks in which a third-year medical student will present a case and then a faculty member will follow up with a lecture on some related aspect of pathophysiology. One of the members of the outgoing third year class (we are overlapping with them by two months because of the curriculum change) presented the case of a patient that I immediately recognized: I had done a history and physical exam on her a few months ago as part of Patient-Doctor II, on his recommendation. I had enjoyed working with her for many reasons – she too enjoyed yoga and meditation, she was a frequent world traveler, and when I met her she was upbeat and vivacious despite a long history of a chronic disease. Educationally speaking, she also had textbook physical findings for multiple conditions. However, it was during our interview that she received news of some test results revealing a previously undiagnosed condition. We concluded on an unresolved note, as she made it clear that she wanted some time alone to process this new information, and I left wondering how things would go for her. A few days later my third-year friend updated me on her condition; she was not doing well. She had experienced multiple setbacks and life-threatening complications, and I had a hard time reconciling the image of the energetic woman I had gotten to know with someone who was now in such a precarious state of health. Fortunately, during today’s conference I was able to find out that she had eventually been successfully discharged home and was doing well. The sense of closure was certainly welcome, but it also brought home to me the new place I am in. Following along with the presentation, I felt the pieces of her story falling into place, forming a cohesive picture of her health that had been somewhat hazier to me even a few months ago. Moreover, I compared the whole Grand Rounds to the previous ones I had attended in the same series. Those times, the third-years sat in the front row, and seemed to me to know all the answers to the questions about pathophysiology and physical diagnosis, connecting symptoms and disease processes with ease. This time, I was sitting in the front row, volunteering answers to many of the professor’s questions, and feeling knowledgeable and engaged as I sat there in my new white coat.

“The sound of the bell just marks the beginning of your next moment.”

I went to a four-hour meditation mini-retreat today sponsored by the Holistic Medicine Interest Group… perfect timing for those of us starting our third year clerkships tomorrow. We were guided through a series of meditation techniques – sitting meditation focusing on the breath, walking meditation, body scan, and even mindful eating at lunch – and then wrapped up with a discussion of our personal experiences. Though not what I had expected, I appreciated that it was so focused on just observing our own experiences rather than trying to be a formal demonstration of different techniques with lots of explication. The overall intent was to give us students a chance to be good to ourselves. We all shared our gratitude for having the chance to slow down, to think, to not think, and to realize how quickly our lives move as medical trainees.

It felt great to be in a still and quiet place for a while, especially in anticipation of starting my Surgery clerkship tomorrow morning, which is generally reputed to be the most hectic and draining. I am absolutely excited about beginning third year, but also a good measure of anxious about the emotional and physical energy I’ll need to get through particularly the next three months. I came into this retreat thinking of it as exactly that, a retreat before the craziness begins. But the emphasis throughout was on being in the moment, and the leader encouraged us at the very end of our last sitting session to remember that “the sound of the bell just marks the beginning of your next moment.” So here’s to entering Surgery, and third year, as a series of moments each with great potential.

Where I am at the beginning of my third year

age: 24

residence: Boston, MA – medical school dorm

relationship status: four years seven months, and engaged

exam status: USMLE Step 1… passed, I hope

expected date of graduation: May 2010

future career: physician, academic medicine in a large urban area, mostly clinical and some education (student and resident levels)

front-runner for future specialty: Child Neurology

other possible specialties: adult Neurology, other Pediatrics subspecialties, Ob-Gyn?

outside activities: … (when I can: yoga, meditation, jewelry-making, cooking)

vices: chocolate, online bead stores with free shipping, Target, shoes, Target shoes, jewelry, kitchen stuff, a very messy room, RSS feeds, cuteoverload.com

listening to: Tammany Hall NYC, The Weepies, or anything else from the Scrubs/Garden State soundtracks; misc. alternative/indie rock, soul, Ella Fitzgerald

with me at all times: keys, HMS ID, wallet, cell phone, migraine meds, makeup, my Nalgene

last time I read a book: last night

last time I went out to a movie: I truly can’t remember…

average hours of sleep per night: seven

coffee consumption: one per day, usually drip made at home