her heart.

*Please note, the names and details of patients and staff 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.

I feel like my life changed in a matter of minutes tonight.  It sounds so dramatic, but I really, truly feel like I had a 'Come to Jesus' moment in a patient's room, about a half an hour ago.

Several codes are called on an average day, depending on the size of the hospital.  At my hospital, which is a medium-sized community hospital, I'd say I notice about two every time I'm here.  For those of you who are not so medically inclined, a 'code' is a Code Blue, which generally means a patient is non-responsive and requires immediate medical attention.  Most often, Code Blue is called for cardiac or respiratory arrest.  At any given hospital, Codes are distributed to specific teams or specific specialties.  At my hospital, Internal Medicine residents 'run' the Code (meaning they call out instructions and oversee everyone working on the patient) and Surgery residents place a central line (generally in the femoral vein) through which meds and fluids can be run.  The folks doing the bulk of the work are normally non-physicians.  Chest compressions can be done by anyone, meds and fluids are monitored and administered by nurses, and thing-getters (masks/orders/tubes/whatever) can also be anyone who is knowledgable.  In Codes, everyone pitches in.  In fact, there is often this feeling of 'too many cooks in the kitchen.'  Everyone wants to be involved, but sometimes things devolve into a cluster-fuck. 

When a Code is called it's an overhead page.  Whether you realize it or not, when you've been visiting loved ones in hospitals (or doing whatever it is you have done at the hospital) you have heard these Codes get called.  There is a reason they don't say 'someone is dying on 6 North, someone is dying on 6 North.'  We'd rather not shake the confidence of our patients.  When a Code Blue is called, the Residents' quarters kind of 'light up.'  Most of the people who hang back here on nights are medicine and surgery residents.  All of the sudden they pour out of the call rooms and head to wherever that Code page calls them. 

Tonight, the Code was called on our Surgery Intensive Care Unit floor.  In a sick way, I get kind of excited for Codes.  I have no responsibility, but I get to learn from all the action.  I follow the residents like a puppy.  For this particular code, I was following *Leon, a really nice intern (read: first-year resident).  As we were walking (briskly) to the room, he said: "I'll bet this is a vascular or a heart patient.  Whenver Codes get called in the SICU it's vascular or cardiothoracic.  It's almost never General surgery."

As we turned the corner on the SICU floor, we saw several civilians (you can tell because they are carrying flowers and wearing jeans) walking even faster than we were toward the room.

Uh-oh.  Family.

As much as medical professionals understand the angst of family members of patients who are not faring well, the last thing we want is for them to watch this relatively gruesome process.  The crying/fainting that accompanies seeing a loved-one unresponsive isn't super helpful to the Code process.  Luckily, as we approached the room, we could see that these folks were visitors for the room next door.  And a collective sigh of relief--exhaled. 

When Leon and I reached the room, the patient was in Ventricular Tachycardia and unresponsive.  Leon jumped right in.  For whatever reason (which I think was paralyzing fear of some sort) I hung back, at the door.  It soon became clear though, as dozens of people were swarming the room, my position at the door wasn't ideal.  The next few minutes are a blur, but I'll do my best to recall.

The code-leader was a PA who works on the SICU.  His affect was so impressive--he was calm and orderly and managed to maintain his sense of humor--even as he said:

"We're opening her up."

Wait, what?  Opening her up?  That wasn't part of ACLS class (Advanced Cardiac Life Support--in which I am certified, but God help me if I ever have to run a Code... which I will).  Just an hour before, our patient, *Ms. Green, had had open heart surgery.  She had been wheeled back to this room about 20 minutes before she Coded.  I looked on from my perch near the door, I saw the PA lift this steel jaw-like instrument out of a sterile set of surgical instruments and just like that, her heart was there.  Then his hands were on it.  Massaging it.  Trying to calm it down.  

Eventually, she converted to a sinus rhythm, but for whatever reason her blood pressure would not stay stable.  With each push of Epinephrine it soared to the 190s/110s.  When she was given Amiodarone she would plummet to 60/40.  It seemed like she had completely lost her body's autoregulation.  At this point, the Blood arrived.  Four units of packed red blood cells.  Finally.  It is strange how long it seems to take when your patient is rapidly decompensating.

Eventually, her surgeon showed up.  It was startling to see him come in.  We were all in scrubs, he had clearly headed home for the night.  It's interesting, though, how in jeans and a t-shirt a cardiothoracic surgeon can still move with authority around a failing patient's bed.  He uttered a few quick order, donned some sterile gloves and reach into her chest.  I don't know what he was feeling for, but she didn't like it.  Her BP plummeted again.  He began asking a million questions, I could hardly keep up.  Why did he want to know that?  How is her Bicarb going to change this?  I felt like my stupidity was tattooed across my forehead. 

That's the thing about Codes when you are a med student.  You need to learn, you want to help, but depending on the gravity of the situation, you are almost paralyzed.  As the least senior and least experienced person in the room, I was determined to make myself as small and invisible as possible.  At one point, someone yelled that the surgeon needed a mask.  I was the closest to the box of masks.  DAMN!  Why did I not position myself in a way that would render me completely useless?  As I fumbled to grab him a mask, my heart rate must have reached its max.  I was so nervous.  Just getting a mask.

In Codes that are a little less dramatic, there is a good role for the med student: chest compressions.  Because of the physical exhaustion that accompanies chest compressions, several people generally rotate through that role.  Simple.  Helpful.  Hard to fuck up.  In an open heart case like this?  No compressions to be done. 

At some point I took a mental step back and looked at the patient.

She was young, in her forties, and had an immaculate red pedicure.  She was also around 300-350lbs.  She had multiple cardiac comorbidities, making her a tough case to begin with.  Just that day they had attempted to harvest a venous graft (meaning, a vein from her leg) to give her bypass surgery.  She also had an ascending aortic aneurysm.  She was a mess.  She reads like a really hard USMLE practice question. 

But she has a family.  She likely has friends and a job.  So what lead her to this point?  How did she get so big, and so unhealthy? 

Codes are a really unflattering situation.  Not that you're really trying to look good while you're getting your life saved, but you are stripped naked under very harsh lights and occasionaly you were recently bathed in betadine to prep for surgery--which tinges your skin a very nasty yellow.  All in all, you aren't looking your best.  It is this grotesqueness that gave me pause, that made me think, that could be me.  That could be me if I keep up my gluttonous ways.  That could be me if I don't make time for the gym.  That could be me. 

Somewhere in this haze, as some of the personnel began to depart and shortly before the cardiothoracic team began a quick close procedure, Leon called me over to his side.  He wanted me to see her heart.  And so I did.  There it was.  Bloody.  Red.  Beating away at about 88 beats per minute.  There was the graft that had been sewn in just hours before.  There was the chest tube draining her post-surgical fluids.  There she was.  All opened up. 

I stood there for a minute.  Until it became apparent that I was about to be in the way.  At that point I left the room.  I lowered my face mask and listened to the various health professionals argue about what went wrong.  I glanced back in the room and Leon and the PA were sewing her up.  Just barely stable, it was hard to believe she was still alive. 

This experience changed me.  Never have a felt such a pull toward medicine.  Never have I felt such a strong desire to re-dedicate myself to my own health and fitness.  A good chunk of the time you spend rotating through the various fields in medicine is uneventful.  You feel like you are on auto-pilot.  Write this note.  Take this history.  Watch this case.  Rinse.  Repeat. 

I might not be ready yet, but someday, I will be. 

the problem of pain... and pain meds.

Last month I was on my Neurology rotation.  Generally speaking, I had been dreading Neurology.  Part of that was because I had no idea how the rotation worked and part of it was because of a scarring experience during first year Neuro.  I got a bad test score at a bad time and convinced myself that I was forever NOT a Neuro person.

I found out about two weeks before the rotation started that I would be in the same clinic my friend had rotated through, about an hour away from my home.  Aside from the drive, I wasn't thrilled about the the things my friend had to say--she likened the doctor to a drug dealer.  Coming off of an amazing month in Psychiatry where half of my patients had problems with pain medications, I wasn't thrilled to be following a "Pain Doctor."

Pain is a fascinating and frustrating topic in medicine.  Almost every doc I've met has a strong opinion on the matter, and they can generally be clumped into one of three categories:

1. Pain doctors are irresponsible and overmedicate those who really need a recovery program.
2. Pain is a problem that needs to be believed and treated aggressively and appropriately.
3. I hope to stay far, far away from "Pain Medicine."  (Most docs fit here.)

It seemed relatively simple to me before this third year of medical school.  I am all about patient collaboration and trusting the story I am told.  Pain blows!  I have never had an episode of untreated pain, in fact, I haven't had many episodes of pain at all.  However, I know that when I have a headache, I take an Advil.  I would like to believe that if my pain was more intense, my doc would believe me and treat me appropriately.  But for many people, especially those with psych histories or histories of addiction, that is not how it works.  A great number of doctors actually refuse to prescribe Narcotics and Opiates completely--most likely because they want to avoid building/fueling an addiction--even if there is no addiction to be found.

There has been a push over the past decade to make pain the fifth vital sign.  A group known as the American Pain Society began advocating that pain should be taken just as seriously as any other vital sign:

Vital Signs are taken seriously.  If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly.  We need to train doctors and nurses to treat pain as a vital sign.  Quality care means that pain is measured and treated.
James Campbell, MD
Presidential Address, American Pain Society
November 11, 1996

This push grew out of various studies that showed that pain was not being adequetely treated in some medical centers.  Certain health systems took up the torch and elected to adopt pain as a fifth vital sign--the largest player being the Veteran's Administration.  In fact, the VA puts out a 57 page toolkit online to help their various centers of care adopt a more stringent model of pain monitoring and management.

Unsurprisingly, the very orthogonal personalities of many in medicine had a knee-jerk 'NO-THIS-IS-BAD-NOT-OBJECTIVE-ENOUGH' type reaction to the 'new' vital sign.  But they have a point.  Vital SIGNS have a specific meaning.  As Lucy Hornstein, MD makes note in her article "Why pain cannot be a vital sign" on KevinMD.com: "The problem is that the word “sign” has a specific meaning in medicine that, by definition, cannot be applied to pain."  It's true, in medicine, signs are objective measures that tell us something solid about a patient.  Pain, while important, cannot be measured objectively.  Moreover, patients have opinions about their pain.  If you tell a patient that they are tachycardic (read: HR over 100 beats per minute), they are more likely to ask 'why?'  Rather than say, "MAKE IT STOP!" or "I don't really care." 

So how do we honor and address pain without elevating it to the level of a vital sign?  Can pain kill you the way tachycardia can?  It just might.

As a person who lives and breathes psychiatry (even before I wanted to apply for residency), I always found pain management interesting (although, to be honest, I find it unappealing as a career).  Pain combines so many forces in a person's life: physiologic (meaning, actual bodily problems), psychologic, spiritual, perceptual, relational, etc.  To me, this has always meant that pain is best approached with a multi-disciplinary team.  You can't give an Opiate to a man whose wife has just died that is complaining of stomach pain and expect him to walk away cured.  Surely, there is a psychological component of that ache--the ache cannot be blunted simply by flooding pain receptors with numbing drugs. 

My first exposure to pain as a controversial topic was a Friday lecture at my dad's Consultation Liason Psych office.  The Palliative Care team (which works with patients experiencing uncontrolable pain as well as patients in hospice) had come to do a talk on--you guessed it--pain as the fifth vital sign.  Three very enthusiastic nurses wearing buttons that had the international 'no' symbol over the word pain described, in detail, the importance of measuring pain, and how to do so.  You might be familiar with this:

Below is the most common chart used to rate pain, although it's mostly used with Pediatric patients.  For adults, we typically try to help them 'understand' what BAD pain is.  For men, we typically say a 10 is a kidney stone, for women we say a 10 is child-birth.  Granted, not all men have experienced a kidney stone, and not all women have experienced child-birth.  (More importantly, many women and men who have experienced those things claim that other types of pain are worse!)  Regardless, we provide these ideas to help the patient guage the degree of his or her pain.

Can I tell you how many times I have been told that a patient's pain is a 15 on a scale of 1 to 10?  I haven't counted, but I can tell you that at this point I have surpassed the number of digits I have to count on.  I gotta tell you, it's hard to take someone seriously when they are walking/talking/breathing in front of me, but their pain is a '15'.  What about that guy in the Intensive Care Unit who was, literally, hit by a bus and can't breath/talk/walk on his own?  What does that make him, a bajillion?  To me, this kind of makes the pain scale irrelevant.  If it can't be normalized, is it worth its weight?  Probably not.

The doctor I worked with last month was an interesting dude.  He would often send me into (silent) fits of blind rage with his care of patients.  Literally every patient he had was on:

1. Cymbalta (an anti-depressant also effective in chronic pain situations)

2. Ambien

3. Some form of Narcotic:

• An opium alkaloids (morphine, codeine)
• A semi-synthetic opioids (heroin, oxycodone, hydrocodone, dihydrocodeine, hydromorphone, oxymorphone, nicomorphine)
• Or a fully synthetic opioids (pethidine or Demerol, methadone, fentanyl, propoxyphene, pentazocine, buprenorphine, butorphanol, tramadol, and more)

4. Neurontin

5. Other analgesics

Without fail, his patients were what most people would considered "over-medicated."  But why do we think that?  Do we think that simply because their list of meds was so horrendous?  Or do we think that because they have side-effects?  Or is it because we are simply uncomfortable with aggressive pain management?  It's hard to say. 

Strangely, many folks in medicine (docs/nurses/PTs/etc), actively avoid pain medications--and I think we let this bias against pain medications interfere with our treatment of patients experiencing genuine pain.  Once again, though, it's hard to say what pain is 'genuine.' 

Who knows, eh?

who needs more than a mouthful?

*Please note, the names and details of patients and staff 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.

Surgery is weird.  Some days I absolutely love it, some days I almost pass out in the OR.

It is strange to say, but I kind of fit in with the surgery residents.  I don't know if St. Joe's is special or different in some way, but everyone here has been very laid-back and kind so far.  I am hoping this hasn't been an extended delusion or something.  Three weeks in, I assume I've got a good feel for these residents. 

GYN surgery was different somehow, I am not sure why.  I got SO sick of it after two weeks.  Vaginal hysterectomies are a nightmare (both for me and for the women's undergoing them).  They took so long, were so finicky and I didn't get to do anything, except maybe sit between the legs and--no joke--be the 'vaginal manipulator.'  I can think of a few dudes and ladies that might LOVE to be called vaginal manipulators.  Not I though, friends, Not I. 

General surgery is pretty great though.  The schedule blows--a given--but other than that, the cases are pretty interesting.  What I first learned in ob/gyn is true--surgeons have a corner on the breast market.  I bet you had no idea that the doctors who are most experienced in breast conditions (lumps, cancers, etc.) are surgeons.  My team ends up doing the majority of the breast cases at my hospital. 

The other day, I had a wonderful lady, we'll call her *Gemma Litehouse.  She was 75, missing most of her teeth, and smiley as all get out.  In pre-op, I introduced myself to her,

"Hello, Mrs. Litehouse, my name is Em and I am a medical student.  So long as it's OK with you, I'll be in the OR during your operation, observing."

"Oh honey, you can do whatever you want.  Enough people seen these titties, you might as well get a look before they go."

Did I mention that Mrs. Gemma Litehouse was getting a bilateral mastectomy?  She also requested that we call her 'itty bitty,' kind of a misnomer considering she was quite large.  What some people may call 'squat.'  I couldn't get enough of her though.  She had such an amazing attitude, especially considering a diagnosis of invasive breast cancer.  Most folks you meet in pre-op (a holding area where we prep folks for surgery) are so incredibly anxious, they don't remember meeting me when I see them the next morning for post-op care.  It makes sense, we are about to pump them full of toxic goodies to put them to sleep, cut them open, and hope to 'cure' them of cancer in the process.  Pretty wild. 

Gemma/Itty Bitty's surgey went just fine.  She had enormous breasts--probably Fs.  She got a total mastectomy, meaning we removed all of her breast tissue.  It was kind of surreal to hold them once they were dissected off of her pectoralis muscles (the muscles that super-steroid pumped dudes attempt to make huge with push ups and stuff).  It took both of my hands to hold each breast.  The outer part still looked remarkably... human.  The skin was still smooth, the nipple intact.  The posterior part was all fatty tissue (which, if you haven't see is yellow and kind of... like opaque mashed up jell-o).  I dropped them into separate white buckets to be sent down to pathology. 

When we sewed her up (by we, I mean the resident did it while I watched), it became clear that tiny would have an armpit-to-armpit incision to deal with.  We put four drains in the wounds to allow the blood and pus to leave her body, rather than accumulate underneath the wounds.  Because Gemma was not as small as her nickname would suggest, she had odd appendages at the ends of her incisions.  Her armpit fatty tissue (for lack of a better term) kind of formed small pyramids at the lateral margins of her surgical sites.   Her chest looked like a war-zone.  Yet, the very talented resident I worked with was quite pleased with how it all came together.  Gemma wasn't interested in re-construction, which I learned the following morning.

When you are a med student, one of your dubious privileges is seeing patients the next morning, before rounds.  I am pretty lucky, because my team doesn't round until 7AM.  That is like, super-late in the surgery world.  Whatever, I'm not questioning it.  That means, depending on my patient load, I don't need to get to the hospital til around 5:30AM (also super-late for surgery--again, not complaining).  The morning after Gemma's surgery, I was kind of pumped to go see her.  I like comic relief, and she was handing it out like candy.

I knocked on her door that morning and she was already on the phone at 6AM with her son, laughing and joking about various things.  She hung up to 'talk to the doctor' (cute, right?). 

"How ya doin' pretty young thing?"  (You see why I was excited to talk to her?)

"Oh, I'm just fine," I said, setting down my Tigers' coffee mug, "More importantly, how are you?"

"Pretty good!  I like this Dilaudy[sic] stuff!" She said, pointing to the IV pole pumping a very strong pain med into her veins.

"Yeah, that's a favorite of many who walk our halls," I said with a touch of nervous laugther.  Our plan was to take that away this morning in favor of oral medications on which she could go home.

I ran through my usual questions:

• Did you fart yet?
• Have you had a bowel movement?
• Did you eat a normal meal yet? (My favorite answer to this yet: "YOU CALL THAT NORMAL FOOD?  I DON'T EVEN THINK THAT WAS REAL BREAD!")
• Are you urinating regularly?
• How is your pain?
• Any nausea or vomiting?

Gemma was basically as good as gold.  In fact, she seemed OK enough to send home.  However, she wasn't ready.  She was worried about being able to care for the drains we put in her.  (I mean, wouldn't you be weirded out if you were sent home with this little drains coming out of the place where your boobs once were?  Especially because red-yellow fluid is coming out of them?)  My chief understood her anxiety, but couldn't seem to find a medical reason to keep her in the hospital--read: we were pretty sure her insurance would stop paying. 

After we left her room as a team that morning, my chief sent me back in to take off her wound dressings.

I realized as I was walking toward her room that this could be an emotional moment.  I mean, she spent a good 75 years with those bad-girls, would it be hard for her to look down and see a 2.5 foot incision where her lady-bits used to be?  I prepped myself for crying.

When I re-entered the room, she was relieved that I had come back to take off the dressing.  The tape was causing her some discomfort.  She certainly did not like me as I was pulling the tape off.  All told, it took a few minutes to get all the gauze and dressings off the wound.  It actually looked like it was healing beautifully.  The steri-strips (which are more tape that we apply directly over sutures) were slightly bloody, but other than that, the wound looked great.  What came next, I wasn't expecting.

Gemma looked down and laughed.  "Good riddance!"

"Happy to be relieved of your breasts?" I said with a sly smile.

"Well, hell yes!  Those things made my damned back hurt.  Also, I don't need 'em anymore.  I told my granddaughter she could have 'em if she wanted, but she went and got some fake ones put it.  I told her not to get 'em too big though.  Who needs more than a mouthful anywho?"  She gave me a big toothless grin.

"Well, I suppose you're right." I smiled.

And with that, I left the room.  I really, really love patients.

today is a good day.

I know it's been a good long while.  And for that, I am sorry.

A lot has happened in the last few months.  I'd like to think I'll take time to write about those things, but realistically (and lately, I am all about being realistic), I won't. 

I write today (rather than yesterday, last week or tomorrow) because something very important happened today.  Today, President Obama publicly endorsed marriage equality for gays and lesbians (I am not including the B and the T right now because this kind of specifically applies to same sex couples, so maybe some bisexuals will benefit too). 

As some of you may know, I had the good fortune to work for the Obama campaign.  I also worked for Senator Kerry's campaign.  I threw my everything into those campaigns.  Quite literally, blood/sweat/tears.  However, the fact that neither of my candidates publicly supported (real) marriage equality always nettled me.  Granted, I was not in a same sex relationship until AFTER Obama was elected, but I always identified as a switch-hitter (my preferred term for bisexuality) and had scores of friends who were gay as the day is long.  My attitude during these campaigns was typically: "well, the alternative is horrible."  I stand by that claim.  Both times the alternatives were really, truly horrible. 

In this next election cycle, the first I will be FORCED to sit out, I will finally know that my candidate supports me fully.  I will know that he will actually take a stand for civil rights--that he'll hopefully be more likely to appoint Supreme Court Justices that feel similarly. 

When I was stationed in Adrian, MI for the Kerry campaign I was pretty miserable.  Keep in mind that 2004 was the year that the marriage amendment was on the ballot in Michigan.  (Yes, we mitten folks outlawed gay marriage long before North Carolina, remember that.)  Adrian is a small town, surrounded by smaller towns.  It has a strange dynamic in that it has a fairly large Hispanic population (for Michigan) and a HUGE convent, the Adrian Dominican Sisters.  Surprisingly, the most liberal folks in town were those blessed nuns.  I think I've mentioned this before, but they phone-banked for Kerry every Tuesday.  However, that's not the point of this story.  The point is that while I was working for Kerry in this kinda-backward town, I had to work with Democrats that HATED gay people.  Some of my best volunteers had terribly offensive, anti-gay marriage yard signs.  It got to me.  I spent three very, very long weeks there.  On my drives home (which was a lovely, 82 year old volunteer's house who made me lunch every day and 'kissed' Jon Stewart each night he showed up on her television), I would count these hateful yard signs.  On a few particularly defeated days, I would cry.  Barbara (that lovely lady), would wipe my tear-stained face, tell me I had worked too hard, and send me to bed. 

Weird, weird times those were.

Importantly, though, if 'my' candidate supports gay marriage, I don't have to put up with the gay-hate bullshit that I did in the past.  (Not that I ever had to put up with it, but if you've worked on a Presidential campaign, you know what I mean.)  I don't have to defend a president that believes I don't deserve equal rights.  For that, I am eternally greatful.  I really am.

So, I want to say in as public a way as I can: thank you, President Obama.  Thank you for having the guts to stand up and say what you feel is right.  I don't think this is pandering (because realistically, it might hurt him).  I think the pressure of his supporters finally got to him, and I am glad.  I am thrilled.

***

I chose a conservative field.  Part of me thinks this is because I am an opositional/defiant type: "Oh, you don't like gay people?  Let me make it really hard for you to deny I'm a good person."  Part of me thinks it's because I didn't realize how hard it would be to exist as a head-strong liberal among those who are either apathetic or vote with their wallet in mind.  Either way, I'm here, I'm fairly queer, and I do a damned good job of working with patients. 

I haven't been discriminated against in a really vicious way just yet (I don't think), but my daily life is awkward.  In a way that my boo, Jess, doesn't have to be, I am cautious as hell when talking about my personal life.  Generally, I throw out a few political topics over a few days with new colleagues before I dare mention the word 'partner' instead of boyfriend/fiancee/husband.  If my attending or resident seems reasonable, I'll bring Jess up in a casual way.  Normally, it's fine.  It gets glazed over, or at most 'Oh... you date ladies?'  There have been a few funny/awkward reactions since I've been on surgery, though.  Good one first, or bad one?  I like to get the bad out of the way.

The not so good: There is one surgeon I've been working with very frequently over the past three weeks.  She's kind and smart and generally a really admirable lady.  I generally feel like female surgeons are strong women who are interested in equality.  They have had to fight an uphill battle, and I have MAD respect for that.  She wears golden retriever a pin on her white coat and her hair is generally all done up.  I think she's pretty cool.  She asks a lot of personal questions in the OR--not in a bad way.  Just in a 'I like to get to know my med students way.'  Somehow, she had avoided romantic relationships... until two days ago.  Over the open abdomen of our patient, me with retractors, her with a scalpel and hemostat: "So, Em, when you are applying to your psych residency, what are you taking into account?"

This is a normal question.  One that has many, many answers.  For me, I have a few things to consider:

1. Jess--wherever we go, she'll need to get a job.  Both because I can't be captain moneybags and because she is interested in not going crazy.  Her work requires either a college campus or a fairly urban area. 
2. Pita--our baby's gotta come with us!  This means Pit Bull friendly housing.  Something we can't compromise on.
3. Gay-Friendly--Jess and I are not interested in being hate-crimed.  In fact, I refuse to live in an area that is even remotely hostile to the gays.
4. Close-Enough--Jess and I would like to stay within a day or so's drive from our families.  We are close with both sides and will need their support. 
5. Affordable--we aren't interested in going house-poor.
6. Good-ish Programs--At this point, I am applying to Psych-Family and Psych residencies.  As I'll probably do a fellowship afterward, I am interested in an academic program.

So, all that shit is running through my head.  And what's most important?  Jess.  So, I tell her that I do have some geographic restrictions in that my PARTNER needs to be able to get a job.  The response?

"Oh.  Your partner."

That was the end of that conversation.  Well... so, no more gay talk around the lady surgeon?

The good: I am on a team with some pretty funny dudes.  There are five of us total, and they are all pretty cool.  One of them is a resident from a local program that is temporarily rotating at our hospital.  He's funny and kinda brilliant.  I could tell from his banter that he was a liberal.  Yay!  One morning, on rounds, we were talking about good places to hang around town.  I told him: "My boo and I like to go to Corner, she's really into beer." 

"You're gay?  Ha!  Cool.  I just didn't take you for the lesbian type."

"Hahahah, yeah, I am not 'butch' I suppose."

"No, no you're not.  Is she?"

"Definitely more so.  You can 'tell' she's gay."

"Ha!  Cool."

And that was it.  I like when people aren't afraid to continue a conversation, or point out difference.  Difference is cool, it's OK.  It can be recognized without being marginalized.  I have mad respect for him now.  Also, in a way that I have found is pretty common, straight dudes open up to gay ladies.  It's interesting.  It's kind of similar to how women relate to gay men.  It's like they don't feel threatened, or feel like I am going to 'go after' them.  So now he tells me about his dates with various nurses at his hospital.  It's cute.  I wouldn't recommend him (he's pretty unavailable), but he's fun to talk with.

So, that's life right now.  More later.  Maybe.  I am on nights, so while I can talk on the phone, I can kinda get away with blogging. 

on the importance of following your heart. and your gut.

I know, I know.  Does it always have to be about organs? 

In the case of intuition, yes.  Folks always seem to be telling people to follow their heart or their gut.  Which is better?  Are they different?  What about the brain?  For those of us who tend to think a little too hard sometimes, following your heart/gut seems like a ridiculous proposition--what about that beautiful and detailed pros and cons list?  What about my ten year plan?  What about income/rent/family?  Following your intuition, whether it emanates from your yellow, green or blue chakra (solar plexus, heart or third eye in yoga land), may seem like a reckless proposition.

I get it, I am a planner too.  I use about five different productivity apps, make endless lists and have a calendar that makes people queasy (not because I get a lot done, but I sure as hell plan to get a lot done).  My aspirations leave me with little time (and space) to breathe.  So last month, when I was rotating through Psychiatry, I faced a kind of forced slow down.  All of sudden, my work hours were cut almost in half.  I had time to go to the gym, get my hair done, hang out with Jess and cook.  It was like I was rediscovering my sense of self.  After 2.5 years of med school, I was still me at my core, I just needed time to replenish various parts of my soul.  After one week, I felt refreshed.  After two weeks, I seriously began to question my future.

Do I want to work 80 hours a week for the rest of my life?  Do I really think I can carve my own path in OB/GYN, a field that is not known for its flexibility?  Even if I could, do I want to exert all of my energy trying to get home at a reasonable hour to see my kid's soccer game? 

The scary realization?  The answer to all of those questions: No. 

And the walls came tumbling down from there.  I realized that I had been chasing a dream that had been ascribed to me and had, in reality, spent very little time thinking about my own desires.  This is not to say I was being forced down any particular path; any pressure I feel is most likely self-imposed.  This feeling is only re-inforced when I tell people I have changed my mind about my career path--I see a flash of genuine disappointment in some faces.  For whatever reason, that hurts.

So what is this new plan?  The new plan is to pursue a residency in Psychiatry and Family Medicine.  Not separately--there are a few programs across the states that offer double-boarding in five years.  It's like a perfect mingling, made just for me!  I can still tackle my favorite primary prevention tasks (PAP smears, wellness checks, patient education) while feeling confident treating mental illness (where my more innate talents lie).  I am thrilled, but apprehensive. 

My greatest fear is having regrets with something as big as career choice, but I suppose we all share that fear.  It could happen with any field.  However, I am fairly confident at the end of my life, I will have less regrets if I get more time with my family and friends.  There are so many things I love that are not even mildly medical, and with a more temperate field of medicine, I can enjoy those things more fully.

So there it is friends, I am no longer dedicating myself solely to the care of ladies.  Sorry?