my biggest secret.

I feel like a local news host, or a tabloid.  "CELEBS BIGGEST SECRETS REVEALED."  Except no one really cares about mine.  Especially because it has nothing to do with sex.  (Sorry!)

This blog, by and large, is about science and medicine and politics--realms in which I am very comfortable.  As I have mentioned before, I write to share, explain, and learn.  This blog has been an absolute godsend over the course of medical school, even if it has been underused at times.  My identity is pretty tied up in the things I am good at, as I suppose is true for most folks.  If someone posed the question "what do you do?", I'd say I take care of patient's physical and mental health.  If you asked me what I am passionate about, I would tell you that politics and social justice occupy the grand majority of my conversations and brain space.  If you asked me what I love to do in my spare time, though, I generally don't have an answer.  This could be related to how little free time I have had in the past 10 years, but I think it's also because I am totally embarrassed by my hobby: making myself look good through hair/makeup/clothing trickery.  I was going to just say: 'making myself look good', then I realized that would include being a gym rat which, sadly, I can't claim to be. 

Yes, it's true.  I am incredibly vain.  That being said, I promise that I keep my vanity to myself.  Though I may be obsessed with tightlining my eyes and straightening my hair and finding high quality denim, I do not expect the same of others.  In fact, I think I am most judgy of my beauty-snob cohort.  Why do they look so good?!  Because, despite the fact that I spend all of my 'play' money on my hobby, I rarely find the time to actually 'look good.'  I love buying high dollar concealers and beautiful tippy high heels, but on my days off you will likely find me in lululemon (also way too expensive!), browsing the aisles of Ulta and Sephora--probably drooling. 

Right now, I am in a weird (wonderful) period between medical school and residency.  In 14 days, I will be Em Ketterer, MD (holyshitholyshitholyshit).  In the mean time, I have excessive free time.  As Jess and I will be moving to Pittsburgh, some of this time is being spent packing, planning, selling and buying.  However, the other 50% of my waking hours is dedicated to... makeup.  And clothes and jewelry and hair.  I have recently discovered the fun of makeup and beauty tutorials on YouTube.  I truly wish I hadn't.  In the past week I have wasted several hours watching really pretty women make their faces look even prettier.  I guess I shouldn't call it wasted time, after all this is my version of scrapbooking/sports/music, people.  I am admitting this to you.  I, Emily Ketterer, am a product snob.  I can ramble off the 5 best-selling MAC eyeshadows, I could tell you what your perfect beauty balm would be, I could teach you how to change the shape of your face with a few powders.  And yet... I walk around without makeup most of the time.

Maybe I should have gone to cosmetology school.  At one point in college, I told my parents that I wanted to go to Douglas J (an Aveda cosmetology school--very chic).  They laughed and told me I could kiss my college funding goodbye.  So I went to medical school (y'all know it wasn't that straightforward, but that's the short version). 

So instead of being embarrassed by my little habit, I have decided to embrace it and use the techniques I know.  I will be the perfectly coiffed resident who is also incredibly sleep deprived.  But my hair and nails and eyes will look impeccable.  Shallow?  Sure.  Happy?  Yeah. 

And now, I will share with you the bounty of my beauty booty!  Here are a list of my favorite things (right now):

Makeup:

1) Makeup Forever HD Foundation: This foundation comes highly recommended from just about anyone who knows and loves makeup.  It covers quite well but doesn't feel excessively heavy.  Depending on how you apply it, it will be sheer or the coverage will be more fully.  (Use a Beauty Blender for sheer coverage and a flat kabuki, Sigma is awesome, for full coverage). 

2) MAC Eyeshadow in Naked Lunch: This is perhaps the prettiest shadow I have ever owned.  It's a beautiful light golden pink that works well as a base for most looks.  It isn't too shiny, but it does have some golden flecks in it.  This is one of MAC's best sellers, and it will certainly always be on rotation for me.  (It's great for pale people!)

3) Dr. Lipp's Nipple Balm: Not just for nipples!  I am a total sucker for weird products, and this one just called my name.  It was in one of those little boxes near the checkout at Sephora and I had to try it.  One of my biggest beauty hangups is my super super dry lips.  They are chapped, cracked and bleeding almost year round.  I have tried pretty much every product you could name, but none seem to work too well.  I love the Nipple Balm not because it has healed my lips completely, but it is wonderful for covering them all night.  I religiously apply a healing balm at night and this is one of the only ones that stays on til the morning.  Progress!

4) Nars Exhibit A Blush: Now, this is NOT an every day blush.  If you follow the link you will see that it is BRIGHT red.  For a blush like this it is absolutely crucial that you have an appropriate brush for application.  I like the Sonia Kushak duo fiber stippling brush because it is not a dense brush and a very light sweep across the pan will give you PLENTY of color.  The reason I like this blush so much is that it is incredibly flattering on pale skin (also on very dark skin).  This is one of the few brushes that looks best when applied to the apples of the cheek.  If I am using Exhibit A, I will do a very light neutral eye and a nude lip.  I like to let the 'just pinched cheek' look be the feature of the look. 

5) Benefit They're Real! Mascara: I am one of those pale people that also has light-colored lashes.  They are there, but if there is no mascara on them, they look... short.  I appreciate a good mascara and have always found that paying the extra for a high-end brand is actually worth it.  This one has really got me hooked, though.  It does it all (lengthens, separates, thickens), and for me, it's good for every day wear.  It might be a bit too dramatic for those who are already well-endowed in the lash department, however.  Tip: when applying mascara, start at the very base of your lash and wiggle the brush side to side until the lashes feel completely surrounded by the brush.  Continue wiggling the brush as you move it up.  The strategy changed my life in college.  Maybe not, but it was pretty exciting.  It helps separate the lashes and get an even coat.

6) Sonia Kushak Eye Definer and Rimmel London Kohl: I know I have mostly only posted high-end stuff (I won't lie, it makes a different 75% of the time).  These two eyeliners, though, are pretty standard for me.  Kohl is the only kind I find that I like because it's soft on my lid.  I find applying eyeliner pretty painful, so it's important to me to find a soft kind that won't pull on my lids as I apply it.  Both of these work great (I like the line of colors Rimmel has), but they can get gloopy by the end of the day.  Just depends on if you're a sweaty beast like me!

Hair:

1) Pantene Pro-V Overnight Miracle Repair Serum: I LOVE this stuff.  It is not really a serum in terms of texture, more of a gel-creme.  There are a lot of overnight serums that can leave you a little greasy and are designed to be washed out in the morning.  This one doesn't have to be!  Considering I am lazy and hate showering in the morning, it's great for me.  It just makes my hair very soft and I was incredibly surprised to find that when I went to bed with straight hair and this product in it, I woke up with perfectly straight hair.  Normally, my hair in the morning is full of kinks and definitely requires some styling.  Not with this stuff!  Love it.

2) Fekkai Technician Color Care Mask: I discovered this stuff via a sample at Sephora.  What really got me hooked was the smell!  It's like candy or something.  Yummy, but not overpowering.  This is great for anyone that colors their hair (bleach or color, doesn't matter).  I am a big fan of masks and tend to use them once a week or so.  This one has been my favorite for about five years.  Surprising, because I never keep anything that long!

3) Tigi Pro Fat Curl Styling Stick: I actually had no idea how expensive this was until I googled it to find a link for y'all.  Shit!  I got it on super duper clearance ($30?) when BeautyFirst was closing.  I was an early adopter of curling sans clamp.  I watched a tutorial many moons ago and was amazed to see how different the curl looked without using a clamp.  I saw this iron and decided to give it a shot.  Dang!  It's awesome.  I hope it lasts me a long time. 

I think I'll stop there.  That's enough vanity (sharing) for one day.

the ER--part 2.

*Please note, the names and details of patients/staff/friends/family have been changed to ensure anonymity.  I have attempted to stay true to the nature of the stories in as much as their identities can be concealed.

Since the last one was kind of a downer, I am going to relay a (semi) uplifting story next. 

There are a surprising number of people who come in with 'vaginal pain' as their chief complaint.  Aside from being quite vague, it's almost always an indicator that the case will be a doozy.  People don't just come in to the ED with vagina questions--they come in because something went wrong.  Down there--as they say.

I actually like these cases.  I am not a huge fan of doing pelvics (probably because I am also not a big fan of getting pelvics!), but I love women's health and I am always eager to improve my skills.  I want to learn how to make an annual exam as painless as possible--and that requires practice.  Sorry ladies of Southeast MI, I do appreciate you letting us learn how to be doctors.

This particular woman came in with 'eye pain,' though.  When I went to see her, she was sitting perfectly comfortably on a bed, playing with her cell phone.  The nurse had already alerted me that this young lady was also worried about some kind of STI.  I understand--you're embarrassed, but you might as well get it out of the way by being up front in triage.  In any case, I went to see her in an area where we had absolutely no privacy.  I alerted nursing that we would be needing one of the individual rooms to perform a pelvic exam. 

"So, eye pain?" I asked, with some intonnation that I knew about her other issue.

"Uh, yeah." She looked me up and down.  I was probably only about eight or nine years older than her.  I was also not looking particularly good.  I don't do the best job of getting dressed when the uniform is scrubs; it's like the comfort of wearing such slouchy clothing spills over into my hair and my face and I just look terrible for months.  

I introduced myself as the med student that would be taking her history and performing her exam.  I told her that an attending or resident would be supervising the pelvic and that if she had any questions, there would be someone to answer them.  I also let her know that we'd be moving to another room for more privacy.  

Once we were alone in the other room, I was surprised to hear how cheerily she reported that she wanted to get tested for STDs [sic].  I asked her if she had any particular concerns and she explained that she had recently suffered her first bout with genital Herpes and she wanted to get tested for "all the other ones."   I asked if she was worried that she might have something else and she shrugged, muttering that she was not all that concerned. 

"Do you use protection during sex?" I asked.

"No," she said.  Her response came quickly, was straight-faced, and unapologetic.  I am not saying I expect an apology on behalf of all health care providers, but I mean, wow.  This is one bold young woman, I thought.

"May I ask why you don't?"

"I don't know.  I never have.  And I have never gotten pregnant.  I don't think I can get pregnant.  But now I got these warts and I'm all like, damn.  Maybe I should get tested."

There were so many things that I wanted to address in what she said.  I chose to ask another question first.

"Do you use any kind of birth control?"

"No, and I ain't never been pregnant." 

She confirmed my worst suspicion.  By her history, this young woman had been sexually active for about five years.  She has had numerous partners and has never used condoms.  The possibilities that ran through my head were chilling.  Is this really the first time she's been tested?  EVER?!  What if she has some advanced cervical change?! Does she truly believe she can't get pregnant?  Why did her primary care doc not address these issues?  All the while I am trying not to let my face convey my fears.

"I know you have probably been told this," I said, "but you're taking some pretty big risks by not using protection.  I am concerned about a number of things.  First, you can get pregnant.  Unless you were born without a uterus and ovaries, you can definitely get pregnant--there's a first time for everything.  If you don't feel like now is the right time to have a baby, you should really think about some kind of long-term contraceptive.  Second, having unprotected sex--the kind without a condom--is putting your health at risk.  HIV rates are growing for young women in Detroit, and herpes, Chlamydia, and gonorrhea aren't going anywhere.  Has anyone talked to you about the Gardasil shot?"

"No, what's that?"

"It's a vaccine, kind of like the ones you get when you are a kid, that protects against the four most common strains of HPV--two that cause warts, and two that can lead to cervical cancer.  It's like my favorite vaccine ever!"

She laughed and looked pensive.  We performed the exam, which was pretty painful for her due to her herpes induced neuropathic pain.  Though the outbreak was waning, it was still quite evident.  In addition, she had some yellow discharge that looked more pathologic than physiologic.  We ran all the necessary tests, the attending put in his two cents, and he left the room.

I was about to leave to, but as I reached the door she said: "What do it mean?"

"What does what mean?" I asked.

"Herpes.  Like what do that mean.  Is it gone now?"

Her doctor hadn't bothered explaining anything about her disease to her.  He just gave her the acyclovir and sent her on her way.  We talked for a long time.  She had so many questions--it was as if she had been waiting for someone to talk to her about her body.  We talked about a bunch of STIs, her risks, the rise of HIV in Detroit, how these diseases are transmitted and why women are more vulnerable.  I asked her if she had ever asked a man to use a condom, and she admitted that she had not.  When she was younger she just wanted someone to show her affection, and sex ended up being a way to fill that space in her heart.  Unfortunately, these encounters had only lead to unhealthy relationships with most of the men she'd been with. 

Eventually, a nurse knocked and gave me a look that said, "what is taking so long?"  I had kind of forgotten that we were in the ER.  I had reverted to my primary care persona, taking too much time.

It was a really revitalizing conversation though.  In light of having matched it made me so happy that I would have the chance to be a family doc. 

Oh yeah, I matched!  Not only did I match, I matched into my first choice, a Family Medicine/Psychiatry residency in Pennsylvania.  It's a dream.  I will be able to ride that line I love so much.  Jess is relieved that we are going to her city of choice--she loved it when we visited during interview season.  I am still having to remind myself that it's actually happening!  We're going to look for houses in a few weeks.  WHOA!

the ER--part 1.

*Please note, the names and details of patients/staff/friends/family have been changed to ensure anonymity.  I have attempted to stay true to the nature of the stories in as much as their identities can be concealed.

A lot of people have been waiting for me to post about my experiences in the ER.  Or maybe I flatter myself--maybe no one said that at all.  Regardless, it seems like everyone wants to hear crazy ER stories.  There are plenty to share.  Perhaps too many.  However, the joy I normally take in sharing patient stories is pretty much demolished by the pervasive desperation and abandonment I sense when I am there. 

No, I will not get off my social justice soapbox. 

There are a few stories I can share (with critical changes made to protect privacy) that really illustrate why I have found this month so hard. 

On one of my first evening shifts this month, I was sent to see a man whose chief complaint was "arm pain."  We get a lot of pain visits.  I think everyone knows that the ER becomes a regular haunt for many people who are addicted to various forms of prescription meds.  I don't find this as frustrating as my colleagues, though it can still be challenging to deal with addiction--especially in an acute care setting where the only thing that separates one patient from another is a curtain.  We all have our perceptions, but I would argue that we need to do a better job of interrogating those perceptions--does this assumption come from a place of fear or lack of knowledge?  Does it come from a place of privilege or stereotype?  Or does this assumption come from pattern recognition (a really important tool in the doctor world)? 

This particular man was not even lucky enough to get a bed.  *Mr. Henry was sitting in a little row of chairs, cradling his painful arm with his other arm.  He looked ragged and exhausted.  He was an old black gentleman who had spent the past six years on the street.  He had the odor of homelessness that I have become so familiar with--a mix of urine, dirty underwear, and sweat.  I do not say this to add some sort of 'ick' factor, but to share with you how hopeless the patients' situations can seem. 

When I sat down I could immediately tell that something was indeed wrong with his arm.  It was swollen and warm, the skin was tense, and there was an area that appeared to be a locus of infection.  This was one of the times the pain was completely legitimate.  Legitimate pain happens more often than most people want you to think.  Especially people who are suspicious of the poor and programs like Medicaid.

As I talked with Mr. Henry, I noticed he had a blunted affect--which basically means his face held no expression, it was blank and never reacted to his own pains or my questions.  He also made little eye contact and appeared to be ... down.  As I went through the list of questions we ask all patients, we came to a section on substance use and he cut me off, saying he had a drinking problem, quite emphatically.  Considering his previously limited range of expression, this stuck out to me.  Maybe he wasn't just here for his arm--though it needed attention very badly.

"May I ask you how your mood as been lately?"

"My mood?" he asked.  He seemed genuinely confused.

"Well, you seem a little down to me.  Is there anything in particular that's on your mind?" I asked.

"I just... I'm just ... tired.  I'm a bad man," he said while looking away from me.

I proceeded to ask him why he thought of himself as 'bad,' and he went on to list the various ways in which his alcoholism has impacted his life.  He explained that he is no longer on speaking terms with any of his family and he has never met his grandchildren, that he is homeless and sick all the time, and that he has no friends.  If my heart was capable of breaking, it broke right there in that hallway. 

As I've stated in previous posts, addiction is a disease like any other.  MRIs and CAT scans have shown that there are physiologic differences between the brain of an addict and that of someone who is not prone to addiction.  Studies have even shown that the offspring of addicts react differently to various pleasures than those who have parents without any history of addiction.  But when you are hospitalized as a result of alcoholism, no one visits.  No one brings flowers.  Even the nursing staff seem to write you off.  It's a disease that only burns bridges, and one for which there is no cure. 

I asked Mr. Henry if he was interested in ending his relationship with alcohol.

"Yes, oh God yes.  It's just that every time I try I get those seizures and have to come here only to get bumped back out again."

Mr. Henry is talking about the DTs, Delirium Tremens.  The DTs are one of the more ominous signs of alcohol withdrawal.  These seizures, which can be preceded by irritability, rapid mood changes, confusion, and hallucinations, can actually cause death.  These symptoms are typically in full force 72 hours after the patient's last drink.  Many alcoholics become familiar with the symptoms that lead up to these seizures and end up drinking--even though there is a strong desire to quit--simply because they feel so terrible and there is a fairly easy solution: alcohol.

What Mr. Henry wanted was a supervised withdrawal.  The first few days after a person stops drinking are the most dangerous.  If one is able to pay (insurance or cash), they can withdrawal in a hospital where medications are administered in a step-wise fashion to help ease the transition and avoid seizures.  Typically, Benzodiazepines are used in this process.  Benzos, another addictive substance that works much like alcohol, act as a substitute for the booze.  As the body adjusts to a new normal, the benzodiazepines are stepped down and eventually stopped.  Of course the biggest challenge comes when the patient leaves the hospital and encounters all his old haunts. 

Mr. Henry seemed ready, though.  I believed that he was truly interested in quitting his habit.  After a quick physical exam, I went and reported the case to my resident.  Of course, I mentioned the arm and the antibiotics we could likely use to treat the infection, but I was much more interested in discussing this guy's willingness to quit.  I was shot down.  Hard.  Apparently it's not the ER's business.  I mean, I get it, it's not like this hospital has a ton of social workers available to find resources for this very desperate population, but still.  This man wanted to improve his life and we were essentially saying, "OK, good luck with that!" 

The man left with a prescription that he probably doesn't have the money to fill.  Before he went, I looked up a few resources in the community for handling addiction.  I gave him my sincerest wishes for luck in the process, but I knew that's not what he needed.  He needed money and agency--an ability to advocate for himself.  Both of which he didn't have.  I sat down in a chair and watched him limp out.  I felt like I had given up on him.  It was terrible.

That's when I knew that ER wasn't right for me. 

privacy & patient stories.

There are a lot of reasons I write about my clinical experiences.  The main reason being: I enjoy it.  Writing has always been cathartic to me.  It is my only art form.  It is the way I express myself and the way I understand the world.  When I was in the third grade, I wrote a masterpiece.  Or so I thought.  It was 42 pages--a lot for your average third grader.  At that point, I thought writing was about being prolific.  It is truly difficult (and horrifying) to read "Angela Ben and Jen" now, but I am glad I have this little piece of my own writing history.  It reminds me of how passionate I have always been about the written word--no matter how little I truly understood of its power. 

These days, writing is much more to me.  Sometimes I write because I desperately want to share whatever it is I have learned or experienced--these entries are normally written hastily and in a daze.  I like the quality it gives the pieces, like a brushed-up stream of consciousness.  Sometimes I write because I want to understand something better.  I am one of those 'learn by writing' people.  I was the girl who took pages upon pages of notes in class, almost verbatim.  Something about the thoughts passing through my brain and out my hands makes it concrete to me.  When I encounter a patient that I don't understand, or a disease that really baffles me, it helps me to do a little research and share it with all of you. I also write because I have an odd fear that I will forget how to if I do not regularly exercise this part of my brain.  Doctors are kind of notorious for abbreviations and brevity in their note-taking.  While I don't think I will ever be that person (I am routinely criticized for the length of my notes--too long!), I do fear that the creative element may be lost if I don't occasionally spend some time with it. 

Today is one of those days I want to write to understand.  A former colleague (kind of) sent me a facebook message the other day suggesting that a status of mine may violate the Health Insurance Portability and Accountability Act--more commonly known as HIPAA .  Normally, I am quite careful about HIPAA.  In fact, I generally follow the same principles this guy does.  If you work in health care you know how many times you are forced to learn and re-learn its basic tenants.  Before I started this blog I poured over all of the rules and regulations about de-identifying patients, geographic restrictions, etc.  Not just because I don't want to get in trouble, but because I don't want patients to feel I am taking advantage of them.  More often than not, I ask them if I can write about their story, so long as I change identifying features.  They always think it's funny--'why would you write about me?'  In any case, I am pretty earnest about privacy.  However, I suppose I haven't been as careful with social media.  I would never write a name, or a circumstance on facebook--but when there is a truly outrageous diagnosis, I occasionally over share with my 'friends.'  Mostly because it's so strange or gross or scary.  That doesn't make it OK though.  I am glad this person pointed out the slightly inappropriate nature of my status update.  After I deleted it and processed the guilt I felt, I got to thinking: is it ever OK to share patient stories, or does this violate the doctor-patient relationship?  Is sharing a patient story that may help others (whether through education or alleviation of fear) justified in some sense?  Or do we tell ourselves that in an attempt to alleviate whatever guilt we may feel?

HIPAA is an enormous policy that covers many facets of health insurance and communication regarding health care data.  In clinical practice, the importance of HIPAA most often comes up when doctors need to share information with other doctors about a common patient.  For instance, say I went to my primary care provider because I had been losing weight.  I am 65 and I don't want to lose weight (this is truly fictional story).  My doctor runs some labs and discovers I am losing a lot of protein in my urine.  This paired with my weight loss leads her to request a CT scan for fear of a malignancy.  I am sent over to the system's radiology center (and so is my clinical data) and scanned.  A radiologist reads the scan and suspects a diagnosis of Multiple Myeloma.  This particular kind of cancer is handled by Hematology/Oncology docs.  I set up an appointment and me (and my clinical data) go see a third doctor.  The doctor requests a litany of labs that I can complete at an outpatient facility.  So me (and my clinical data) go to a third party lab, have lots of blood taken, and the results (my clinical data) are sent back to my oncologist.  He reads the results and confirms the diagnosis.  Shortly thereafter, my treatment begins.  Unfortunately, I also break my leg (multiple myeloma puts holes in your bones).  I go to an orthopod who receives all of my clinical data from the cancer workup and treatment.  This number of data transfers is actually pretty typical.  Moreover, this kind of data sharing is convenient and incredibly important. 

Taking really excellent histories is something that doctors (despite their immense knowledge) can be pretty bad at.  This collective info that is transferred to each new physician involved in my care not only increases my safety (perhaps along they way they discovered a new allergy or drug sensitivity), it makes my time in the clinic much less redundant.  Instead of telling the same painful story again and again, I am able to answer the questions that are relevant and get the care I deserve. 

I had a really great mentor my first year of medical school; I was taking the blandly labeled "Clinical Medicine," a course that is supposed to introduce the most junior medical students to the concepts of patient care.  In Clin Med we focus heavily on history taking and basic clinical exam skills (how to use a stethoscope, how to take a blood pressure).  My doctor, however, had a particular interest in patient narratives.  The joy he derived from patient care was really inspiring.  Nothing was more magical than a patient trusting him with their story.  He felt that understanding the patient narrative was incumbent upon all doctors who wish to do right by their patients.  For that reason, he chose to write about his patients--though under the cloak of de-identification.  I wonder where he is now, and how his writing has been.  I really looked up to him.

The subjective experience of disease is illness.  Illness is where the story lies.  How a patient describes his or her struggle with an illness can tell you almost as much about his or her prognosis as their lab data can.  A patient's medical decision making process is based more on her experience with illness than it is her understanding of the pathology that plagues her body.  For this reason, it is critical that physicians attempt to be in tune with the narrative, the story of the patient's illness.  One can recommend chemotherapy because it is the next step in a treatment algorithm, but if the patient's husband died three weeks ago, she is 95 and without friends or much family, what will her chemo experience be like?  Does it really matter that it 'buys her' three more months when those months will be marked by intractable nausea and vomiting?  

The fight in a patient is measured largely by their circumstance.  A patient that elects to forgo various therapies offered to them is not 'weak,' they have simply chosen a different kind of fight.  You can bet that a patient's decision to forgo therapy and likely die more quickly reveals a new kind of struggle--a battle to understand what it means to be dying. 

The experience of illness can be enlightening, it can be devastating, it can reveal inner strength or unknown fears--or both.  Sharing this experience, then, is one of the more intimate things a patient can do.  By revealing these corners of one's soul to a doctor, who is likely only slightly more familiar than the average stranger, a patient is entrusting you with some of their most important truths.  It's humbling.  What do you do with these truths?  Do you choose to look at the patient with your labs and clinical data--do do you choose to distance yourself from that which has shaped his or her experience?  Or do you do your best to carry these experiences with you as you consider a course of action? 

It's apparently quite easy to grow numb in medicine.  Non-compliant patients, the inappropriate use of the ER (I am looking at you, people with colds), the displaced anger of patients with bad diagnoses, and an attitude of entitlement can really wear a person down.  Especially if that person is working too many hours and worked really hard to get there.  If attendings are any indication, many harden to patient's woes much more quickly than I would have guessed.  HOWEVER: I want to give a shout out to the many doctors I have worked with in the past two years that still seem to grasp the importance of recognizing a patient's struggle.  It's so rare as to almost seem foreign when a doctor's brow furrows upon first hearing a patient's story.  These indications of humanity are reassuring. 

My dad has a screensaver on his computer at work that says, "It's about the patient, stupid!"  I think that pretty much sums it up.

the morgue.

Perhaps the most bizarre aspect of working in a morgue is how well it synchs up with the evening news.  Jess and I watch local news more than I care to admit.  It's corny and strange and really not that informative.  I am not sure why we always watch it; it might be because we don't have cable and it always seems to be on.  Regardless, I always know what's going on with Kwame Kilpatrick and Kym Worthy, I always know which block of Detroit is on fire, and now I know what I'll see on the autopsy table in the morning. 

Stranger still is how many murders don't get media attention.  It seems to me that murder is a pretty big deal and each homicide deserves some air time, even if it isn't particularly brutal.  I was wrong though.  Murder in Detroit is just another reminder that some people matter more than others.  Just another example of how very forgotten certain segments of our population are. I am not going to use this space to soapbox though--I have plenty of other things on which to soapbox.

Much about this month has been strange, though.  I must confess that when I picked a month with the Wayne County Medical Examiner I did so for the 'so cool and so weird' factor.  I wanted to see some blood and gore.  I wanted exposure to the most terrible endpoints in life.  I thought, hey, I have a strong stomach and an interest in the morbid--this will be perfect!  After all, at what other point in my life will I have the opportunity to investigate homicides? 

I know this is a gross metaphor to use here but, my eyes were bigger than my stomach.  I don't know if I just forgot that I am a bleeding heart when I signed up for this elective, but my bleeding heart has been thoroughly disturbed.  On my second day, they paired me with another med student (one who plans on going in to pathology) and gave us a body to autopsy--on our own.  The second day.  I was barely getting used to the concept of the morgue when I first had to inspect and dissect a body.  Not only were we thrown to the wolves with our own body, we were a body that was barely recognizable.   The skin was green and blue, the face so swollen you couldn't make out facial features, and the skin was coming off in sheets.  I was sure this person had been dead for weeks, at least.  Nope.  Just three days.  Three days is apparently all it takes to decompose into an other-worldly looking creature.

Now, I remember the forensic pathology lectures from my second year of medical school.  They were fascinating.  Close range gunshot?  Should have evidence of soot in the surrounding skin, or perhaps a muzzle imprint.  Three day old body?  The brain is probably mostly liquefied.  It was one of those gloriously stomach lurching lectures.  A train wreck from which you can't look away.  It was during one of these lectures that we were introduced to the concept of a 'fruity' smelling corpse.  Apparently, as a body begins to decompose, the odor shifts to a more sickly sweet smell.  They did not inform us what it was before the sickly sweet smell. 

"Fruity" did not prepare me for that first solo autopsy.  I don't think anything could have.  Approximately every 90 seconds I had to look away, breathe through my mouth, and try consciously not to lose my cookies.  All the while, the guy who plans on going in to pathology is saying "it's not that bad!"  As we searched through a mound of organs for the remnants of the pancreas, all I could think was: what if this guy's family saw this?  It's so barbaric!

Since I will not be describing any cases here (not prudent, as these are truly forensic cases and I don't want to go to court), I am going to describe a typical day in the morgue.  I hope to demystify what seems so creepy on television.  Hint: it's still creepy, and it might be worse than you think.

We arrive at the morgue around 8AM for 'inspection.'  This is multi-disciplinary kind of 'rounding' for forensic pathologists.  All of the bodies up for autopsy are arranged in a row and the accompanying police reports are made available.  Detectives, police officers from various locations (depending on where a homicide or motor vehicle accident happened), the chief medical examiner and any other ME on site at the time, the pathology techs, medical students, a forensic path fellow, and any rotating resident all gather in the (smelly) autopsy room and listen as the police report is read for each body.  This is actually the med students' job.  We bellow out the odd findings from each death scene as the attending medical examiner for the day does an initial inspection of each body.  The pathology techs will roll the bodies so that the examiner can look at the back and make note of any gross abnormalities or injuries, and then he or she moves on.  All bodies are vetted this way. 

The attending medical examiner then decides what type of autopsy is appropriate for each case.  Some bodies only require inspection (an external exam), typically those where the body is badly decomposed or the cause of the death is fairly obvious, and natural.  Most cases require a full internal and external exam with accompanying histology (tissue specimen examination).  Still others, mostly the homicides and motor vehicle accidents, require full-body X-Ray and photography.  If the murder is under investigation and the detectives require further evidence collection, fingernails and vaginal or anal swabs may be taken.  Once the ME has decided what type of autopsy the body will receive, the cases are distributed amongst residents, med students, and whichever ME is in charge for the day.  Typically, medical students are given simpler cases--drug overdoses or suspected cardiovascular events.  However, we are sometimes asked to do homicides, suicides, or MVAs under the (very close) watch of the medical examiner. 

The autopsy starts with a thorough external exam.  You take the police report and a body diagram worksheet of sorts and document every last stitch of clothing, every detail of every tattoo, every scar, and every distinguishing feature.  I have never been so resentful about tattoos--they take forever to document!  I would hate autopsying my own body.  You must also note the color of the eyes (which changes with post-mortem decomposition), the length and color of the hair, and the state of the dentition.  All of this requires manipulating the face in various ways, which feels very wrong at first.  I suppose it really hasn't stopped feeling wrong to me. 

When the external exam is complete, the pathology techs get to work.  They start by making deep slices in a Y shape through the skin and fascia of the chest.  They then reflect three tissue flaps to reveal the rib cage, sternum and clavicles.  Everything looks very gruesome at this point.  Depending on how much adipose tissue (read: fat) is present, these cuts may be four or five inches deep--it also will take much longer to get down to the ribcage.  When the tissue is reflected back to expose the chest cavity, much of the body's bulk is hanging from the side of the table.  The techs then take a set of HEDGE TRIMMERS and cut each of the ribs laterally so that the internal organs can be exposed. At this point, the techs remove everything from the tip of the tongue to the rectum in one bloody swoop.  This is called 'the block.'  The block is the primary business of the pathologist (or the medical student, in my case). Once the block as been placed at the station of the pathologist, the techs get to work on sawing open the calvarium (skull) to obtain the brain. 

Before we get to work on 'the block,' we suit up.  While personal protective equipment is worn in almost all fields of medicine, the messy reality of the morgue require a new level of coverage.  Every day, I wear the following:

• Scrubs, socks, and shoes of my own
• Surgical booties, which land just above the ankle
• Surgical boots over the booties, which land just below the knee
• A full plastic gown that goes down to my shins with thumb holes to ensure the sleeves stay down
• A plastic apron over this gown
• Two sets of surgical gloves--perhaps of differing colors so that it is more obvious if the glove is punctured
• A hair net
• A TB respirator
• A face shield that covers everything from my hair line to my chin

It's sweaty.  It's also totally necessary and I would never skip any of these measures.  It's way too bloody in the autopsy room.

The first work of 'the block' is finding the appendix.  This can be tricky depending on how much adipose tissue lurks in the body's abdomen.  The bigger the body, the more epiploic appendages (little fat curtains that hang off of the intestines--which we all have).  While the appendix is completely useless in real life, it is critical in the autopsy.  The presence or absence of the appendix, and the appropriate documentation of such, can be the crux of a trial.  If the autopsy report documents the presence of an appendix, but the deceased had a documented appendectomy twenty years back, the entire opinion of the medical examiner can be discredited.  People have gotten off for murder because of a stupid appendix.  I know, right?

From the appendix, one begins to isolate, weigh, and dissect each organ: the adrenal glands, the kidneys, the spleen, the pancreas, the stomach, the liver, the lungs, and the heart.  The weights are recorded on a (bloody) dry erase board and must be documented in the autopsy report.  Each organ is inspected for gross abnormalities and then sliced (literally, they call it 'loafing') to determine if there are any internal abnormalities. Thin slices of the organs are taken for histology (microscopic inspection) and gross tissue specimens for held at the Medical Examiner's for one year in a white and yellow bucket.

The most important inspections are undoubtedly those of the heart, the lungs, and the brain.  In the heart, we make horizontal slices down the coronary vessels looking for any calcification or occlusion that could point to cardiovascular disease as a cause of death.  We measure the thickness of the wall of the left ventricle, documenting any hypertrophy that may have been the result of long-standing hypertension.  We also make note of any atrial or ventricular dilatation, which could point to conduction abnormalities or congenital issues.  Our primary concern with the lungs is to look for large clots in the major vessels.  A pulmonary embolism is not an uncommon cause of sudden death.  Of course, upon inspecting the lungs it is not uncommon to make other findings--cancers or other unknown nodules.  Regardless, documentation is made of any and all abnormalities.  The brain may reveal trauma or hemorrhagic stroke, but it is quite difficult (ne impossible) to see ischemic damage grossly.

Looking for a cause of death is obviously much different with a homicide.  These cases are actually pretty straight forward in terms of cause of death (a bullet to the brain? a bullet to the aorta? strangulation?).  However, these are the cases that are quite likely to end up in court, meaning they require an extremely close evaluation and documentation of absolutely everything.  For gunshot wounds, the point of entry and exit must be documented.  How large are the holes?  How far is the hole from the top of the body's head?  Is there soot in the surrounding skin?  Is there a muzzle imprint?  Each point of entry must either have a documented point of exit or a bullet must be recovered from the internal tissue.  This can occasionally be difficult, the X-Ray is a big help in this task.  Aside from the initial documentation of greivous injuries, a homicide's internal autopsy is much the same, with the exception of noting any internal hemorrhage as a result of trauma. 

Once the internal exam is concluded, all the remnants of the organs are placed in a heavy plastic bag and then put back in the body.  (The first time I saw this I couldn't decide if I was fascinated or disgusted--I mean, what else would you do with all that mess?  I guess it makes sense.)  The body is then sewn up and cleaned up by the path techs in order to prepare the body for its next journey, whether that be to a crematorium or a funeral parlour.  At this point, we carefully remove our personal protective equipment, record the organ weights and any notes we made on our (bloody) dry erase boards, and write a report on our findings.  This report is sent to the medical examiner for review and editing.  Once the toxicology screen comes back (which is taken for all cases) the cause of death can officially be determined and the case is closed. 

I am not sure what this rotation will do for me in the long run.  It has certainly quashed any lingering suspicion that I may like forensic pathology.  Mostly, it has been good for pondering the terrible inequities in urban America: the differences in how homicides are reported and investigated based on the socioeconomic class of the deceased, the number of deaths that are presumed to be caused by drugs, and the staggering number that actually are.  There is so much sadness in the morgue.  It can sometimes be overshadowed by how unbearable the smell is, but a day doesn't go by that I don't whisper, "God, that's so sad."  I am actually happy that I am not numb to the realities of this field.  Admittedly, though, if you wanted to be a medical examiner, I don't think there would be any other way to survive.

I have about five posts waiting to be finished.  Sorry for being neglectful.  I suppose I should document the residency application and interview process--the reason for my prolonged absence.   I will work on that.