Throughout medical school, you always hear about the M4 life where we are able to choose our electives and there are few hard-and-fast requirements. One of those few requirements, however, is a sub-internship (or sub-I) in an ICU setting. I chose to rotate in the Neonatal ICU here at Mott so that I could become more familiar with newborn issues, particularly in premature babies.
I’m now about halfway through the rotation and there’s definitely been a learning curve. For one thing, I had forgotten how much math is involved in pediatrics pre-rounding. The patient’s I/Os suddenly became much more complicated to determine – intake should be calculated in terms of mL/kg/day whereas output is in mL/kg/hr. And, of course, all feeding volumes are increased per protocol in terms of mL/kg/day but orders have to be calculated in mL q3h. Yep. This rotation has enabled me to discover the shortcut to my phone’s calculator, so at least now I know that for the future 🙂
A few days into the rotation, I switched to nights. Sub-Is and interns all do six nights whereas the senior residents alternate between taking 24-hour call. I enjoyed nights, especially because it allowed me to learn about each of the babies on the resident side of the NICU and see the big picture, instead of immediately getting bogged down in all the minutiae (see previous paragraph…)
In the middle of last week, I switched back to days, which was a rough transition. Mostly because I was exhausted during the day at the hospital, but then would wake up a bit more by the time I got home. Then, of course, even though I would go to bed at a decent time, my brain would automatically wake me up from midnight to 4 a.m. for several nights after I transitioned back.
Overall, I’ve been enjoying my time in the NICU. It’s definitely a different experience, and probably unique amongst the ICUs in that some of the patients are absolutely acutely sick, whereas others are here because they were born extremely premature and we’re just helping to control their environment until they’re old enough to go home. The important thing to remember about babies (and children, but especially babies) is that they can be looking great with a life-threatening illness, until all of a sudden they’re not. It’s easy to get sucked into thinking everything is humming along, but a healthy suspicion of any minute change from a baby’s baseline is paramount.
In the NICU, we see babies on their birthday a lot. Luckily, I was able to leave the hospital in the early afternoon this past Sunday in order to celebrate a different kind of birthday – the 150th birthday celebration of my hometown Brighton. There was even a cake and everything! And, by everything, we even mean a collection of farm equipment, both modern and historical, all helpfully labeled.
An impromptu lesson in the finer details of suturing at the end of a case brought back memories of childhood violin lessons in which my violin teacher would explain the finer mechanisms of producing a spiccato. “Relax your wrist,” he would say while demonstrating. I would go home and practice the same bowing technique hundreds to thousands of times, gradually taking incremental steps towards improving the technique until eventually, it became second nature.
In some ways, it was an odd payoff. I would spend months, equating to thousands of minutes, practicing the same musical piece for a single 10-minute performance at a recital. Yet, there was immense satisfaction at the end. I imagine surgery is much the same. Surgeons too take time to develop, which might explain why there is a sense of order and hierarchy innate to surgery. Experience and effort matters. I find the order and structure calming.
Someone asked me recently whether it was tough making it through a Whipple procedure, a notoriously long surgical procedure used to treat pancreatic cancer. I was somewhat caught off-guard by the question as I had never really considered the issue. The act of actively participating in the case made time pass faster than the clock on the wall would suggest. The field of surgery is not for everyone, but for those who do love it, it has an irresistible draw.
Relaxing after shelf exam at Tomukun Korean BBQ
The third year of medical school is a truly unique experience in which students get to sample a variety of medical specialties. While on service, I often like to ask residents and attendings why they have chosen a certain specialty. It can be incredibly informative. I asked my resident how he knew surgery was the right choice, expecting to hear that he had known from the very start that he wanted to be a surgeon. I was surprised by his answer.
His journey into medicine began innocuously enough, he explained. He had studied economics in college and while completing a summer internship discovered that it was not for him. Coincidentally, his roommates who were both pre-meds recommended shadowing a surgeon. On a whim, he decided to check it out. Even 10 years later, he vividly recalled his first encounter with Dr. X. While he had no idea what the surgery was about, he loved how simple the explanation for the heart worked. I listened enthralled as he described the technical intricacies of fixing a child’s aortic valve. As he talked passionately about how this experience led him to think that at age 40, he wanted to be like Dr. X, and I couldn’t help but to think that in 5 years I wanted to be like him.
Surgery is a paradox in some ways. Despite requiring more years of training and working longer hours than most specialties, I’ve yet to have seen people more passionate about the work they do. If you ask a surgeon about why they chose surgery, they will tell you that there was no other option for them – that nothing else would satisfy them. Perhaps this makes sense. It requires intense study and practice!
Migrant field in southeast Michigan
It’s an odd experience to get a glimpse of the past while being incredibly aware of the present, as it was for me when I went with a group of other medical students, residents, and attendings to volunteer at the University of Michigan Migrant Farmworker Outreach Clinic.
My dad and his family worked as migrant farmworkers for 13 years, moving from my grandpa’s ranch in Mexico to the States to begin an annual chasing of the crop cycle. Every year for most of my dad’s childhood, they would travel across the country to find work picking, thinning, or weeding tomatoes, sugar beets, soy, or cherries, and doing whatever work needed to be done. They even came as far north as St. Johns, Michigan, the town that would eventually be my childhood home. Being one of the youngest in the family, my dad had the family support to be able to continue with formal schooling during these years. His parents and older siblings worked to support the family while he went to school, and he spent his summers and after-school hours working side-by-side with them. Through the influence of a couple of key teachers and mentors, when my dad was 19, he was able to starting attending a local community college, a break that largely enabled him to craft the life that my family now has.
My dad, age 7 or 8
While I didn’t spend my childhood working in the fields the way my dad did, the stories and struggles of the migrant farmworker community has been a constant influence throughout my upbringing. I went to my first migrant camp with my dad when I was three years old, and I remember being five or six and playing soccer with kids my age. As a kid, it was hard for me to understand why such a difference existed between my life and those of the friends I would make. It wasn’t until my college years that I really began to see how closely my dad’s story, and thus my story, were connected to those of my childhood playmates.
As I was driving to the migrant health clinic in southeast Michigan, now as a medical student volunteer, the stories of my dad, grandparents, aunts, and uncles were running through my head. Leaving the car, the first person I saw was a little boy, running around, playing. As we made our way to where the clinic was set up, a bunch of lawn tables organized outside, I saw the adults, mostly young men not much older than me, waiting to talk to us. I paused. In the kids playing, I saw my dad, playing with his younger sister and older brothers. In the young men, I saw my grandpa and uncles, exhausted after a long day of work, but still smiling and joking around with their friends. And then I saw me, a 23-year-old who just finished his first year of medical school, coming to help in my small way.
As I navigated the mix of chief complaints we saw, I once again was shocked by the disparity between my life and those around me. I was glad I was there to help, but also wished I could do so much more. As we got in the car to leave, I looked out the window, and once again saw the children playing, running around with smiles on their faces. I saw the kids, but envisioned my dad. My past and present collided.
It takes a tomato seed about a week to germinate, seven weeks to be ready for transplant, and about two months after that to have harvestable fruit. By the metrics of the academic year’s calendar, that timeline would easily tally up to the completion of at least four sequences, a handful of weekly quizzes, and countless lecture hours. But with harvest season on the horizon and summer break at its peak, it feels fitting to count days by when we transplanted our seedlings as we wait for vines heavy with green tomatoes to ripen.
Anita Vasudevan, Jack Buchanan, and Charlie Katzman with the freshly planted garden
Before beginning medical school, a good amount of my time was spent in gardens, growing food. It is a space that requires patience and persistence, not to mention a willingness to go along with the occasional derailment of plans (maybe not so different from med school itself!). In becoming a part of the UM Medical Campus Garden, I was excited to embrace our single garden bed as a reprieve from the rigor and rhythm of curricular demands and a return to a cherished and familiar hobby.
This year, we’ve planted a variety of tomatoes, peppers, eggplant, basil, marjoram, sage, and chives. Our garden is tended to by student volunteers who water and weed daily, and we are eagerly anticipating our first big harvest at the beginning of August. But perhaps what carries even more weight than the pounds of produce we gather is the attention we garner from nearly every person who strolls by while one of us is at the garden.
Student volunteer Mikhail Ognenovski poses with the garden after his watering shift.
Though it may be small, the garden is a symbol of our medical community’s commitment to honoring where real food comes from, connecting with our planet, and sharing with one another. Our plot is situated along a well-treaded path between two hospitals and the UMMS admissions offices, which makes it very amenable to eliciting conversations with all passersby – patients, staff, physicians, and fellow students alike. These usually begin with a question and end with taking a small sampling of herbs home.
It is a small action, but one that I believe goes a long way in creating a sense of community and belonging. With much of all our lives defined by a nonstop agenda of places to be and things to do, the garden is a gentle reminder of the value that lies in pausing for a moment to marvel at a flower as it flourishes into fruit.
Waiting for tomatoes to ripen!
Well, July certainly started off with a bang – from fireworks, that is. I’m on Emergency Medicine this month at nearby hospital St. Joe’s. Thankfully, I didn’t actually have to work the Fourth of July and instead spent the sunny day with my family before returning to Ann Arbor to continue orientation. Now that Ann Arbor allows fireworks within the city, I was able to see a lot more fireworks out my window than ever before.
Emergency Medicine is essentially a third-year clerkship that takes place during our fourth year, replete with observation cards and shelf exams. However, for many of us, this will be our last exam of medical school. And I think we’re all happy about that. During the next few weeks, we will be doing day shifts, evening shifts, and night shifts in both adult and pediatric settings. I started off my rotation on night shifts, working from 11 p.m. to 7 a.m. As an avowed sleep fanatic, overnight shifts are not my favorite (I usually go to bed before 10 p.m.), but I enjoyed them nevertheless. I was even able to repair some lacerations, including a tricky one on a patient’s hand. I greatly appreciate the variety inherent in the practice of emergency medicine, but it would drive me nuts to not know what happened to any given patient after they left my care.
This past weekend, I was incredibly lucky to be able to participate in my fifth and final Dean’s cup golf tournament. The ending was definitely bittersweet, as this is a tournament that I have helped to organize for the past four years with Dean Raj and Denise Brennan. Despite predictions of rain, the weather was gorgeous and sunny and I had a blast with my teammates, even when we almost got hit by an errant golf ball. Each pairing consists of a faculty member and three students, who play together in a scramble format.
From left to right: Dr. Jim Peggs, Jasmine Harris, me, Jake Nelson
I played with Dr. Peggs, a former UMMS dean and the person who asked me if I wanted to organize the tournament within five minutes of my entering the clubhouse as an incoming M1. We also played with two students participating in the LEAD pre-matriculation program, one of whom I asked to carry on my position (however I waited until we finished the round J). It was clear that everyone had a fantastic time, as we talked outside the new clubhouse waiting for later groups to finish. The camaraderie was immediately evident and we (maybe) fooled the participating new M1s that medical school is like this all the time… I could not have asked for a more perfect day.
And now, it’s time to sleep. My body is still adjusting back from nights and tomorrow’s shift will come earlier than my brain would like. J
“Don’t contaminate the surgical field,” I repeatedly thought to myself as I entered the OR. Over the first 3 weeks of my surgery clerkship, I had made more than a handful of mistakes. The first day, I forgot to take off my watch prior to putting on gloves to place a Foley catheter. The second day, the patient bed brushed the corner of the scrub nurse’s blue sterile table as I was wheeling it out of the OR. The third day, I cut too close to the end of the surgeon’s knot – thus undoing his work. Day 4, I touched the handle of the surgical lights with my sterile gloves and so the list goes on. Throughout the clerkship, I made a list of all the mistakes I’ve made, partly to remind me not to make the same mistake again since as Confucius would say, “a man who has committed a mistake and doesn’t correct it is committing another mistake.” But it also serves to document how far I’ve come within even the year and even a month. On a day to day basis, I am constantly humbled by how much more there is to learn. As with many activities, the more I learn, the less I realize I know.
One of the many corridors in the hospital early in the morning
The smooth confident motion in which I saw the attending and surgery resident swiftly tie the knot with seemingly minimal effort belied the amount of technique that goes into the motion. I quickly learned this when towards the end of the case, my resident handed me a suture.
“Do you know how to tie a subcutaneous stitch?” he asked me. During my first two years, I had attended multiple suturing sessions and had practiced with pig feet. I felt reasonably confident. “Yes,” I concisely told him. I soon learned that there is a skill in doing this.
“Turn your wrist more,” he admonished. I rotated my wrist.
“Pinch less skin with your forceps”, he told me, “that way you’re better able to see where you’re going.”
“You can’t come out where you grab the skin. Grab another piece”.
I struggled to perform these steps correctly. The resident was very nice about it. But it seemed as though I was doing every possible thing wrong. Ironically, I had tied a subcutaneous suture previously with another resident, during which I had received no commentary. Was it that my technique had gotten much worse over the past week? Or that the previous resident was too polite to comment? Or that he simply wanted to quickly finish closing the patient up after a long case? Or maybe it is that the farther we go in our training, the more confident we feel in teaching others. It’s hard to know exactly why.
Finishing the day, heading home
A view of the hospital on the walk back to my apartment
I have however found that good feedback can be hard to come by. Feedback that is both specific and actionable is rare. This is often due to limitations in time as, understandably, patient care takes priority. Furthermore, giving good feedback can be difficult too in itself. Prior to entering medical school, I had taught as a high school teacher and found while grading chemistry lab reports that it can be incredibly difficult to give constructive feedback. While one can often see that something is wrong, it takes a more thorough understanding of all the finer details of a process to be able to explain not only “what” is wrong, but also “how” and “why” it is wrong. So when a resident, nurse, attending, or even fellow medical students are able to give useful feedback especially things that I’m doing wrong, I am incredibly grateful. I will always bear in mind the feedback and things I’ve learned here as I continue this journey!