Answers to Readers’ Questions

At long last, here are the answers to the questions commenters asked in a post last month. I know I’m inexcusably late in posting these, but I had an international move with a baby, organizing the house and the start of a new semester. I know, there’s always something…

Rather than spend pointless time editing the answers (I tend to write spontaneously and whack away repetitively), I’ll get these out. Perhaps the “extra” information helps you know me a bit better. It’s a long read, so to save space on my home page, there’s a “more” link if you’re seeing this from there; otherwise, you’ve gotten the whole kahuna. Without further ado…

1. What brought you to medical school and specifically to medical school in Mexico?

Medicine was always an interest, but I never took it as seriously as I did chemistry and other sciences. By the time I may have been able to change gears (I had thought very seriously about changing majors to pharmacy from chemical engineering) to a pre-med curriculum, I was already soured by the cutthroat-passive-aggressive-ever-approval-seeking premeds I was surrounded by in early undergraduate science classes. After getting involved with research, graduating, more research, etc., I eventually got a computer consulting job in the Real World^tm. After being away from school for a few years, I decided that I really did like it after all, and I was just being a whiny baby. I took a leave of absence from work, and moved back home to figure out what I was going to do next.

I got to know a surgeon very well during this time, and he provided me with lots of exposure, as much as I wanted (which was a lot since I wasn’t working at the time). I was literally following patients from pre-op workup to OR to post-op managment, getting a very large picture at an early stage of deciding if this was what I wanted to do. Once I was in the OR, I was hooked on pursuing medicine–and that’s with me not scrubbed in, just getting peeks every now and then and helping the circulating nurse.

Why Mexico? I grew up on the border, so the culture and idea of Mexico wasn’t strange; a large % of doctors along the Texas border went to med school in Latin America. Being in Mexico is hard, but Guadalajara is a big city with lots to do and explore. I could not survive on an island, as much as I love the water, with such limited resources. I never even considered med school overseas. More on why not a US school later.

2. What advice would you give to an incoming student about to start at your school in the fall?

Fantastic question. I’ll skip all the academic stuff, because that’s nearly universal. Instead I’ll list a few things specifically about my school and living here in Mexico:

• Take the time you are used to for getting something done, multiply it by 2 (by 3 if it’s a Friday)
• While things are computerized here at school and in general here in Mexico for official things, they still obsessively shuffle papers and stamp things to make things official. Most secretaries have blue fingers because of obsessive stamping. Expect to wait in line to do just this to make it official, even though the transaction is already “done.”
• Waiting in line is like breathing air. So many Mexicans spend probably 1/4 their life in lines and think nothing of it. It’s an excuse to socialize, collect thoughts, talk on the cell phone, etc. To Type-A personalities who want things yesterday (like yours truly), this fact alone may necessitate benzodiazepene and/or ACE inhibitor therapy. You’ll get used to it, but nobody ever likes it.
• The international program obviously recruits and caters to Americans, but make no mistake–this is not the United States. The school is firmly rooted in patriarchal, old-school traditions: don’t challenge authority (ideally, and if need be, be gushingly respectful), expect to do things a different way, and expect to have your time wasted. Often.
• People assume that Mexico is cheap to live in, and that’s true–if you live like a Mexican. If you want any semblance of US lifestyle, food products, etc. be prepared to pay. I’m not talking about having to do without Crunch Berries (although it’s available for $6/box at specialty stores), I’m talking getting decent cuts of meat, various household products one takes for granted, etc. If you are willing to go to the fruit/vegetable stand for your produce, then the meat market for your meat, etc. etc., then yes, you can get things cheap. You just won’t have much time for anything else.

There’s more, but I don’t want to seem overly negative. There are good things about being here too, but you get a ton of that in all the school literature. Most of all the good stuff they say about the city and school is true, but it takes the perspective of having been here to understand if such-and-such really makes a difference in the end.

3. How did you meet your wife, and how long have you been married?

We met through a mutual friend at a gathering. We dated for about 7 months before getting engaged and continued on for two long years of postponed weddings, school prep, deaths in family, etc. before finally getting married in January of 2004.

1. What is it that you hate / love about medicine so far?

That’s hard to say, since I haven’t done my clinical clerkships yet, but I love the fact that I’m in a field that is always discovering new things, helping others, and holds unlimited learning potential. They say the net pay is going down, but as a doctor, it’s not like my family and I will be starving after I’m done, something that definitely helps when paying the dues (in almost every way) right now. However, I do see things I don’t like from my general exposure, and that’s increasing liability and litigation, increasing power and scope of the “business” end of medicine, and other things that I’d rather not deal with or I’d have gone to MBA/law school.

2. What are your aspirations?

To feel like I can go to work [most] every day feeling I’m moving forward, feeling fulfilled in my work and family life. I hope to strike a comfortable balance between the two, since I don’t think it’s possible for me to be happy overall without feeling fulfilled in both. As to details of what I’ll practice or where, all that will work itself out in the coming years and I’m not stressing over it. I can say almost certainly that I won’t do primary care and won’t be in a predominantly rural area–both do not suit my temperament. I’m also pretty sure I would never do OB/GYN. Many medicine subspecialties have some appeal (cardiology, infectious disease), but they all fellowship-level training, requiring 3+ years of vanilla internal medicine, which currently doesn’t interest me. Right now top potential careers are surgery (if I can stomach the training), anesthesiology and radiology (primarily for interventional radiology).
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How Not To Teach Surgery

One of the things that intrigued me about my program is that we actually had a surgery class our second year, well before our official clinical rotation 3rd year. I assumed this was because by teaching us basic skills, we could do our clerkship being of at least minimal usefulness right away (at least in theory). In addition, the Mexican medical degree is literally titled “Physician-Surgeon” (Medico-Cirujano), so surgery is integral to the program. I was looking forward to class, mainly because surgery interests me to no end, but also because it’s a break from the auditorium lectures, which we’re all bored of at this point.

On our first day, we began by being subjected to a video of proper handwashing technique. Sounds reasonable to watch before we do, but trust me: watching a scrub brush pass laboriously over every finger surface, hand surfaces, forearm, elbow, etc. you get bored really fast. Then it was time for the other hand/arm, following proper technique to rinse the brush, even. Just when I thought it was over, it was time to repeat again, only this time to the forearm only. Change hands again, 3rd time’s the charm.

The room where we practiced (and will be graded) is obviously a teaching trough for hand scrubbing. It’s a stainless steel “L” with about 12 stations or so. There was a foot pedal for water, but no pedal or self-mechanism for soap because you are supposed to yell “jabón!” so some lackey (currently our classmates) can douse the area with soap from a squeeze bottle. I kid you not. But before we could get there, we had to pass “inspection,” where our nails were inspected for shortness (fingers = fleshy nubs), cleanliness (um, aren’t we about to scrub for crying out loud?), and for the attire being appropriate (the ever-hated “whites” which must be pressed (because as we all know, wrinkled scrubs are the harbingers of disease, with microbes hiding in those wrinkles)).

Throughout, the instructor was basically barking orders from the center of the room, pacing like a drill sergeant, yelling at no one in particular: “external surface, ring finger…internal surface….dorsal surface…palmar surface….soap!…external surface middle finger….” as we scrubbed in perfect synchrony to the barked commands. By the time we were at the end of the 2nd repeat of each hand, I was looking at the bristles for bits of my flesh. Neither the brush nor the soap was from Aveda, let me tell you. (no I’m not metro/gay, I just know things )

Louis Gossett Jr. behind me was only part of the experience–one professor per two students hovered over shoulders to examine in miniscule detail what was being done. Any little thing was scrutinized, made to do over, etc. The irony is that the female professor looking over my shoulder, critizing this and that, had nails that I hadn’t seen since Big Trouble in Little China. There’s no way this chick does any surgery these days.

I understand if I let my arms drop that’s bad technique and should be pointed out (upper arms are parallel to the ground and forearms are pointed upwards at all times), but does it really matter if I forget to make circular motions instead of linear ones or that I involuntarily began move my hand/finger being scrubbed instead of my brush (still with correct position) because my right arm is getting tired? C’mon. I felt like a total wuss after my arms started burning with strain towards the end until I talked to some of the other guys and everyone felt the same. I know I need to up my conditioning, but I was quite unprepared for this. Last I checked, I was in Guadalajara, not Guantanamo.

Finally, the ordeal of scrubbing done, I looked forward to getting the holy hell out of there and waiting to see what I was subjected to next. What was in store for me? More drill seargent barking, of course! Normally, after you’re done scrubbing, you enter the OR proper, only for us, it was a flapping door that led to the next phase of torture: the toweling off.
First, we had to go through the door properly: stand with back to the door, push back three steps, turn and you’re done, all with arms in the correct position. Easy, peasy. Except when yours truly approached facing the door and turned to place my back to it, I rotated counterclockwise instead of clockwise.

“No, again!” came the admonishment, pointing to the curved arrow under my feet indicating my infraction. Turning the “right” way this time, I executed the simple maneuver, took three confident steps backwards, whipped at the end like a professional dancer, ready to take the sterile towel (dangled by another lackey with a pair of forceps) as a trophy.

“No, come back!” came the bark, shattering my victory. I was told I stepped backwards with my left foot instead of my right. Obviously, I just cursed the surgical procedure and doomed my patient, stepping off with my sinister foot like that. Thankfully the mask was hiding my sneer.

Repeating for the final time, correctly, I grabbed my towel. About to towel off and relax my burning deltoids, we were instructed to 1) grab and hold towel in front of us at shoulder height, as if praying, and 2) wait for everyone else to finish. I’ll get myself into a lotus position at this point, just let me drop my friggin’ arms already! We were then instructed to drop the folded towel holding it by one corner, towel each finger off methodically, then fold towel backwards, exposing the virgin surface underneath to towel off the other hand (in the proper order of digits and arm segments, of course).

The gowning was the next phase of the ordeal, but it was not nearly as degrading. Perhaps by this time, they’d have spotted the ones that started crying or had a breakdown and there was no need to continue the high-pressure. Oddly enough, this is where I started faltering. I understand it’s helpful to know how to glove properly in case there is no assistant present at that moment, but trying to get gloves on through a heavy OR gown using the cloth ends as blunt mitts (we use reusable cotton gowns, not disposable ones, and since your fingers can’t poke through the opening, it’s like having your hands inside your sweater sleeves) is an exercise in frustration. While it did take some getting used to, I was about to consider myself an absolute retard until it was discovered by my now-frustrated instructor that some jackhole sterilized two left gloves and put it in my packet. I swear, they could have used the whole thing as a comic reel. Placing hands into gloves held open by an assistant was like entering Paradise by comparison.

Anyway, that’s the scoop. I don’t think we start vivisecting Thumper (yes, we train on rabbits) for another 2-3 weeks, after learning various stitching and instrument techniques. I’m positive I’ll have more stories to tell along the way.

Change of Shift 1:3

Change of Shift, a nursing blog carnival sponsored by Kim of Emergiblog, has its third edition out. Nurses always have good patient stories, and a collection like this is always worth the read. Check it out!

Enfamil TPN?

I went to a local pharmacy to buy distilled water to make baby formula with. Baby does get breast milk, but not enough for her hungry appetite, so formula it is. Obviously, you don’t drink the water from the tap here, and most everyone including me has water service from one of several providers that deliver bottled water to your home. However, this “drinking water” is purified probably via reverse osmosis (but I’m not totally sure since they don’t report that kind of thing) and I’m not sure how many solutes (good and bad) come along for the ride. I of course know that off-the-shelf distilled water is not sterile nor is it a must for making formula, but I feel better knowing that whatever is in the formula mix is what she gets without worrying about any additional salts, minerals, etc. in unknown quantities. Call me an overprotective geek.

After searching fruitlessly through the aisles, I took a chance and went to the pharmacy counter. I wasn’t holding out too much hope since the lady helping me had enough makeup that I thought she was going to perform in Cirque du Soleil immediately after her shift, all the while smacking gum audibly.

“Do you have any distilled water back here?”
“Yes, would you like 1/2 or 1 liter bottle?”
Success!! I said 1L and the lady disappeared behind the counter. She came back with a glass IV bottle whose label read, “solucion inyectable.” I didn’t scour the fine print to see if it was 0.9% isotonic saline, but I figured it was.
“That’s not what I want, I just want plain distilled water.”
“That is distilled.”
[pause for the insanity of having water with something added called "distilled"--I can make iced tea with distilled water, but it's not distilled water anymore] “Ok, so this has been distilled….but this is for IV use. I just want purified, distilled water–it doesn’t have to be sterile.”
[looks quizzically at me, as if I want to inject non-sterile water into somoene]
“Look, I’m making formula for my baby. I want the purest (not sterile) water possible, without minerals,etc. This [handing bottle back to her] is not what I’m looking for.”
“Of course you wouldn’t make formula with this,” she says taking the bottle back from me, the apparent retard.
“What water would you suggest then?”
[continuing her disdain] “Just use whatever bottled water.”

So there ya go. I had already previously looked in several stores/’pharmacies, and “distilled water” as one would know it in the US in the plain, plastic bottles, does not exist. So far, baby’s done OK with our bottled water (equivalent to Dasani) but I still think such a simple item shouldn’t be so hard to find. Yet another slice of life here.

–
P.S. TPN = Total Parenteral Nutrition, or “IV feeding.”

I’m all for murdering babies…

…or so Bush’s personal morality would label me. I have tried very hard post-Katrina not to have hardly any political content on this blog. This is yesterday’s news, but I’m posting today because I was debating writing this at all; I don’t need to drive away the small (and dedicated–bless you) readership I have for something as banal as political differences. However, this move by the Bush administration to veto stem cell legislation passed by both the House and Senate, including a good number of Republicans, has sweeping ramifications on medicine, science and the public good.

The legislation allowed for couples undergoing IVF to donate unused embryos to science rather than have them discarded. Bush’s veto means that they now must be discarded because he personally does not “support the taking of innocent human life in the hope of finding medical benefits for others.” But it’s OK to throw the same frozen embryo in a medical waste can. (I’ll pause to let you read that again to make sure) Using it to benefit others is “murder,” while flushing it down the toilet “crosses a moral boundary that our decent society needs to respect.”

This is the same “stay the course” ideology¹ that has been the scourge of this administration, leaving most shaking their heads in almost embarrassment for the man’s blindness, but even pissing off members of his own party with his stubbornness (Harriet Myers, this very veto, privatizing social security). The reason I have more of a beef with this decision and why I’m breaking “political silence” on this blog is because it’s a decision that has everything to do with science and medicine that he based on religious dogma, ignoring almost all of the scientific and medical community. Even if you are the staunchest pro-life conservative, common friggin’ sense tells you that if they are to be discarded anyway, you might as well have the embryos advance science! It’s like the person who chooses not to be an organ donor not because of honest religious conviction, but because he doesn’t like the idea of someone cutting him up after he’s dead. (ignoring the fact that any mortician will have tubes coming out of him like Re-Animator to get him ready for his funeral)

A blastocyst (embryo of a few days’ duration before any real differentiation occurs) from which embryonic stem cells are harvested is not a person; therefore, it follows logically that it cannot be killed or murdered. To believe that life begins at conception with a soul, one must believe that millions of souls are used up every year in embryos concieved through normal intercourse that, for any large number of natural reasons, do not undergo successful implantation to arrest the next menstrual cycle, a new life, full of infinite possibilities, drowned in a sea of menstrual blood. Sorry to be graphic, but nature can be a bitch.

There were a lot of “famous” causes and celebrities supporting this now defunct legislation–and good for them–but Michael J. Fox will not be cured of his Parkinson’s disease by stem cells that would have been allowed to go forward from this legislation. Scientific research is a slow, arduous process for the most part. It is because of this that any delays, setbacks, etc. have a huge impact in future outcomes. Ask any PhD student who has had to add a year or two of their life to getting their dissertation done because of research setbacks (precisely why I didn’t keep going down that road), and you get an idea. Now take those stakes, and add the potential of saving human lives, advancing cures for diseases on a worldwide scale, millions and millions of dollars in potential research funding and matched private funds, and the mind reels at just how severely this pooch was screwed.

Enough scientists have said that the current stem cell lines (always quoted at 60-70, the amount that existed at the end of the Clinton administration, but researchers using them today have not been able to verify the existence of more than 24) are already showing signs of potential mutation and genetic decay. Private research will go ahead with their own agenda, of course, but there is too much financial pressure at stake for them to coordinate in a way that basic, federally funded research would allow. Moreover, other countries are leaving us way behind in this area.

I have faith that the next president, regardless of party affiliation, will reverse this insane decision at the first reasonable opportunity. I don’t have a lot of faith, however, that by then we will be irreparably behind as a nation, and also sadly behind in preventing needless suffering.
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Requiem for an iPod

My iPod croaked on the trip back. That’s why I hadn’t posted last week–I was too despondent. Just kidding. I don’t know what happened to it, honestly. I never dropped it (recently), never spilled anything on it, and never subjected it to wild temperature variations (such as leaving it in the car in 105 degree heat). I noticed something was awry when I kept selecting a track and it would play something later in the playlist. Looking closer, I noticed it was actively skipping 5 or so tracks, counting (4 of 25, 5 of 25, etc) past the “bad” tracks. An hour or so later, all I heard was this “click click” as I tried to get it to respond to anything.

When I hooked it up to my Mac when I finally got home, I thought I’d just reformat the thing with the iPod update software, and start from scratch. This is the result:
(the gray of the iPod is actually an iSkin case)

Looking at Apple’s store, the only full-size iPod sold is a video iPod. Thing is, before baby was born and we were shopping for baby gear, I’d always joke that baby needed a video iPod (for visual and spatial development, of course!) and that it should have gone on the baby shower registry. Now, if I am to replace this one, I’ll actually have to get a video model (a review of my post on my iTunes library would make one realize a Nano or my wife’s Mini is cruel and unusual punishment), which makes me feel somewhat guilty.

Decisions, decisions…nothing is being bought anyway until my loans come in, and perhaps not even then. Until then, I can dream….with no sound….

Update: I called an authorized Apple reseller here in Guadalajara about the prices for the iPods, possibly avoiding an international shipment when/if the time ever came to get a new one. The 30G was $420 and the 60G was almost $600!!!  I know things like this get charged import taxes upon coming into Mexico, but not 30%!!  Crazy!

This driving thing gets old really fast

I’m finally back!! Actually, I came in last Thursday in the wee hours, but the fact that it took from last Monday to Wednesday night/Thursday morning to get here should tell you the hell we’ve gone through. Traveling with a newborn is hard–very hard–even for short trips across town, much less internationally. Traveling in a caravan makes things difficult many times over. Dealing with 100 degree heat and having to transfer a crying baby in exactly 10 seconds before she gets overheated is that special kiss of awful, just like salt on a wound.

Caravaning with a vehicle which breaks down in Mexico…..well, let’s just say thank God for pharmaceuticals.

Long story short, the car we had intended to cross broke down about 40 minutes into Mexico. Thankfully, it was an easy drive back and whatever is wrong with it did allow for short spurts of functionality, allowing us to turn a 30 minute return trip to the bridge into much more than that. We really had no choice but to then drive further back to my parents’ house, an hour away, to park the fully loaded truck into the garage for safe keeping and a renewed attempt the next day (Claudia’s dad lives 5 minutes from our crossing, but there is no garage).

Starting over again, far too late (the days of my cracking the whip and getting us to leave at 6AM, fully packed with coffee and breakfast (did I mention I am a morning person, especially on trips?) ) are obviously over. Like way over. Sometime that afternoon, we picked up my sister-in-law, who graciously allowed us to swap w/her car for these few months until we drive back so she can get the other one fixed. The crossing was uneventful, except that it took over an hour to get my vehicle permit because, well, this little bridge doesn’t really see FM3 visas, no they shore don’t. “Well golly gee willickers (or the equivalent in Spanish) what have we here?” was what I had to deal with. If it was legal for me to pay $20-something to get a temporary tourist visa, I’d have gladly done it just to make things go faster, but alas, they are actually computerized and they’d know I already had a (much more elevated) visa.

So…the rest of the trip was spent stopping for potty breaks, baby diaper change breaks, our dog’s nature calls (usually coincident with ours since we were stopping enough), getting turned around in Monterrey, Nuevo Leon (one of these days I’m finally going to get a map of that infernal city to figure out how to get on the periférico [outer loop] when coming from my father-in-law’s to bypass the middle of the city)–the list goes on and on.

We unloaded, Claudia and I started bickering about something or other (2.5 days of road trip between two vehicles and a crying baby kinda does a little something to the nerves), continued unloading, and crashed, or at least as much as we could until 3 hours later, baby awoke demanding more food. Apparently gone are the days where I can drive like a bat out of hell, consuming all sorts of [legal] stimulants, driving to exhaustion, and sleeping as long as I want because “Damnit, I deserve it for getting us here in record time!” Yeah. This little one is cramping my style, I’ll say that right away.

But I wouldn’t change anything. I love my Niblet.

We’re here, safe and sound, mostly unpacked/organized and school has begun anew. A new semester with scarier classes (I did mention I have this complex with neuro?) and more work, for sure. This time, I promised myself I wouldn’t allow myself to fall too behind– schedule/time-wise or grade-wise–even with baby. This means Mentat-like concentration and work ethic. Right. We’ll see.

Believe it or not, I am glad to be back. As long as my family is here and this is where I continue going to school, this is our home for now and any trip away is just that–a visit with a return ticket.

P.S. I’m going to be posting a few more posts here shortly, mostly queued up from the trip and the last few days, but I’m not going to change the post dates/times because there’s no point.

Retorno

This morning we are driving back to Mexico with our new (old) car driven by my sister-in-law, a trooper who wasn’t daunted by the drive (and staying for a mini-vacation). This is my/our first caravan into Mexico. I hate caravans. The drive is stressful and long enough by yourself much less worrying/coordinating about/with someone else. These last 4-5 days have totally and completely beat me up in every way.  It’s nothing bad, but I’m tired of seemingly simple–even mundane–things like moving completely kicking my ass.  I am so ready to get back and [re]start my life again with a new semester in one week.

I’ll be offline for a few more days still, but I have lots to share afterwards once I FINALLY get quiet time (and back in my house, I hope I can at least get some) to write and reflect.

Baby, Blues, Books

Hello from HOT south Texas. It’s been about 98 degrees with supersaturated humidity. I took the trash out the other day at around 9:00AM and broke a sweat. It’s surreal to not have your heart rate elevated, no feelings or signs of exertion, yet be sweating like there’s no tomorrow just from being exposed to the outside.

Baby is incredible. Her bilirubin was still somewhat [normally] elevated when I last saw her in May, so she’s lightened up considerably, perhaps even moreso than her birth day because of all the vascular splotches that are no longer there. She has alabaster skin, downy hair (which I didn’t know falls off in favor of the permanently implanted hair), and a repetoire of faces that kill me. I know she doesn’t actually feel half the emotions she displays, but it’s hilarious watching a 6 week old show faces of disgust, boredom, elation, sadness, wonder, intense scrutiny, and just plain “being” all within 10 minutes. My favorite activity since I’ve been home is simply watching her sleep. I might be watching TV or reading a book (currently reading Cutting Remarks by Sidney Schwab–go buy it!!) but I eventually become re-transfixed on her angelic face. I’m not even waxing philosophical about dreams I have for her, the wonder of a new life with a clean slate, etc.–it’s simply just watching. I don’t have a problem physically relaxing/sitting still (unlike many ADHDers), but I have a HUGE problem mentally shutting down, allowing myself to just “be” without the gears turning. Baby is the best medicine for an overactive mind, a hurt heart, and a whole host of other symptoms.

That’s the basic reason I haven’t written–early parenthood is tough. As much as the birth of the baby fell at one of the most inopportune times (just before finals), the adjustment period (at least for me) comes in between semesters, and in the end, I think that worked out for the best. By the time I start the next semester in mid-July, it’s not like it’s going to not faze me, but it’s not like I’d feel totally whacked over the head with it, either. They don’t tell you what being a new parent does to your marriage…everybody assumes that it’s a blissful time, there are no problems, and that this ray of sunshine that just came into your home brightens all. Ha! Well, that’s certainly true if you’re just looking at the parenthood aspect, but it’s more complicated than that. Your routine is trashed, your priorities are violently shifted, certain things you take for granted from your partner are no longer there, etc. It’s hard, and it’s made even harder by the fact that at this moment we aren’t even in our own house, borrowing a room-1/2 upstairs at my parents for the last two months. When you’re in your 30s (and above, I’m sure moreso) your own space to call yours is a major, major factor in your mental/emotional well-being. I has been rocky at times–moreso than I would like–but it will work out for both of us.

My textbooks for the new year came in, and that’s always fun (I never get over that little kid “school supply” buying season) in spite of the nice slice of student loan pie I just gave Barnes and Noble. Neuroanatomy and neurophysiology texts scare the living hell out of me. It’s my Stephen King, my Wes Craven, whatever. I’ll make sure and study with the lights on and only if I’m not alone…