How is the Fellowship Going?

Going into fellowship has been one of the most humbling things i've experienced in my life.  It stripped all the facades i had built up over the last five years bare and exposed my glorious ignorance for all to see.

In all honesty, i thought i was a good hospitalist.  And maybe i was, which was the problem.  In five short years, i had mastered the ability to expedite a hospital stay (maximizing DRGs) and had memorized enough time-tested spiels to guarantee patient satisfaction.  I could come in at 8am, round on 16 patients, discharge 3 before lunch and admit 2 after, and still be at the gym to do a few miles on the treadmill by 5pm.  Unfortunately, in the pursuit of efficiency, i had allowed much of my deep medical knowledge and critical thinking skills to atrophy.

The first few weeks were an eye-opener.  As i pored through the books and papers that comprised my chosen specialty, i realized that a lot of what i had known in residency (and even medical school) i had already forgotten, and whatever had come out in the past few years, i had not kept abreast of.  It was basic stuff, but i had stopped paying attention because i had learned to distill it down to "what is the most important thing i have to know to improve my throughput?"  My mediocrity was laid bare; everything i had consulted a pulmonologist and intensivist for in the past, i was being consulted for myself... with me having only a rudimentary idea of what i needed to do.  My biggest shame was that i didn't even know how to read a chest x-ray anymore; for the past five years, my chosen method of "reading" an x-ray was to pick up the phone and ask the radiologist on-call what he saw.  I felt like an idiot, like an impostor pretending to know medicine when all i was good for was asking others for help.  The only point in my career when i felt lower was when i had just started out as an intern.  I considered quitting and going back to my old "cushy" job more than a few times because i wasn't good enough for a subspecialty.  But i slogged and putzed my way through.

Things are a little bit better now that i have a whole year under my belt.  I've read more journal articles and book chapters in the past twelve months that i have in the past eight years (yes, including residency).  I can now interpret chest imaging without talking to a radiologist.  I can translate PFTs into their appropriate clinical correlations.  I can discuss most lung diseases from physiology to the latest treatment options.  I can (almost) put lines in with my eyes closed and do a decent diagnostic bronchoscopy without getting huffed at for poor technique.  While i still feel moronic most days, "most days" has come down from 90% to around 60%.  Of course i still make mistakes, and i'm deathly afraid that my errors will cost (or have already cost) someone their life.  So i work hard to fill in the gaps in my knowledge and correct my bad behaviors.

Most importantly, my fellowship is not all about hardship and self-loathing anymore.  Ultimately, despite all of my perceived difficulty, i am on the whole enjoying myself.  I love learning about things, be it "old news" (such as the Fletcher-Peto curve from 1977) or "hot-off-the-press" stuff like edoxaban for PE.  I am tired and chronically sleep-deprived almost all the time from all the hard work and studying, but when my brain and my body are running on all cylinders, that's when i feel like i'm truly applying myself, like i'm doing what i was built to do.  And i am loving it.

So, how is the fellowship going?

In a word: good.

Love and Whatnot, Part 5

I have never been able to make any sense of these two statements:

1. "Live your own life, make your own money, and travel," and

2. "Collect before you select." 

The first is a mantra that older women pass on to their younger counterparts when they start having significant others.  The point (i presume) being - that the girl should stay single and not allow herself to be tied down so she can do her own thing and be happy.  Whether or not "travel" implicitly includes having naughty relations with various men from other countries (oooh, those sensuous Frenchmen) is beyond me. 

The second declaration is much like the first, although applicable to both boys and girls; that is, that you should "shop around" and date people of different shapes, sizes, and dispositions so that you're exposed to the whole spectrum of relationships before you decide what's best for you.  After all, it's impossible to know that you're "meant for" somebody if you haven't even tried the competition yet. 

Well -

Half my lifetime ago, when my girlfriend and i first got together, naysayers left and right tried to blast the idea to bits.  Different permutations of the above statements were thrown around and psychological warfare was declared.  Essentially, we were told (and compelled in not-so-subtle ways) to cease and desist.  The underpinning philosophy was that fourteen-year-old kids are not expected to understand their budding emotions, that it was easy to mistake a crush for True Love, etc. - essentially, that we were doing THE WRONG THING. 

Of course, being the antipatiko that i am, i brushed them off my shoulder (not enough room for both them and that big chip there) and did things my own way.  Making the long story short: although it was not a straight shot from there to here, my girlfriend and i stayed together through thick and thin, went against the "wisdom" of our elders, and never got it on with other people. 

The end result?  Now we're happily married.  

Before we got together, we seldom used to go out (no interest, no money).  Then we became an item and the whole world just came ALIVE; we started going out at night, discovered strange food in out-of-the-way restaurants (including turo-turo), watched plays and movies (we're not much for clubbing) and just overall had a grand old time. 

When we were single, we never used to travel for pleasure (too much work, not enough inclination).  Now we plan vacations together and explore every nook and cranny of this strange and wonderful world hand-in-hand. 

Back when i was much, much younger, i mused about the future with a sense of impending doom, wondering what the days ahead would bring.  Now i look forward to living and loving every single day with my wife and One True Love, flying off and disappearing into the wild blue yonder. 

There is no solitary way to live a life; no simple declaration that can teach you how to conduct relationships, no single piece of all-encompassing advice that can guarantee happiness.  No one should be able to force-feed a cliche down your throat and tell you that this is the way it should be!  We've spent half our lives proving that.  Still, there will be cynics out there who will look at my marriage with disdain and say that i settled too early, that i should have looked around more, that i don't know what i'm missing because i boxed myself in.   

But somehow, lying beside my wife at night, watching her sleep and feeling a little firecracker of love go off in my heart whenever i think of our lives together and all the days, weeks, and years we have left to spend with each other - i know i was right.   

Return to Crystal Mountain

I had another fall.

Try as i might, i can't remember that first one from a few weeks ago.  However, Brett (who just happened to be our instructor again this time around) seemed to remember quite clearly, because he said that i fell exactly the same way:

I was heading down a green slope, trying to get the hang of parallel turns.  I turned left (i'm having a lot of trouble with this, just like Derek Zoolander) and my left ski dug into the snow the wrong way, holding the bottom half of my body back while the top continued to move forward and then down, slamming the back of my head into the hard snow at full speed.

(My neck muscles can attest to the speed... as they hurt at least as much as they did when i had the first fall.)

The crucial difference?  I suffered no amnesia... probably because i wore a helmet.

After my unfortunate accident a few weeks ago, i made absolutely sure that i protected my noggin this time and bought this helmet online.  El Cheapo of course did not like the expense, but for the sake of protecting his most valuable asset, he just had to live with it.  It is perhaps the best $70 that i've ever spent, much cheaper than the $900+ spent on just the ambulance ride the last time (i'm hoping my insurance absorbs most of that)!  Although the main reason i didn't spring for it originally was not so much the expense, as just the perception that it would be too warm to keep on my head the whole time.  To my surprise, it actually is not too warm, and anyway: what's a little discomfort when weighed against all the possible bad things that could happen to an unprotected skull?

I wasn't really excited about the headgear at the beginning of the day.  

Post-fall, i was so happy to have the helmet save my brain that i started making gang signs.

So instead of spending the rest of the day in a hospital and the rest of the week in doctors' offices, i actually got to enjoy this ski trip!  We have no pictures of actual skiing because neither of us is good enough to ski with a camera in hand.

Going up the Crystal Clipper.

Enjoying the view.

Me and my lovely bride. 

I'll have to buy a new helmet for the next outing, as the force of the impact broke the adjustment straps on the inside and i can't wear it snugly anymore.

This is what the intact strap should look like.  It extends from the rear adjustment dial to the midpart of the helmet.

My straps were ripped apart near the insertion points on both sides.
I don't think they're supposed to that (at least not easily), which speaks to the force of the impact.

(Alternately, i could just get better at skiing and not fall as much.  But i doubt that it'll happen anytime soon.)

In related news, Adrian is progressing quite nicely with his skiing lessons.  He is now able to go down a blue - blue! - run, albeit with an instructor.  That's more than Gianina and i can lay claim to.  Soon he'll be skiing rings around us.

Happy to be skiing.

Here's a short video of him skiing down a bunny slope.  He actually looked much better skiing down a real run (we spotted him with an instructor while we were on a lift).

Concussion Update

The second time i saw the neuropsychologist, he gave me the green light to work.  (Incidentally, he also said i could start skiing again!)

So i worked the 4-12 shift this past week, and i think i'm getting close to functioning at 100%.  I've had normal interactions with patients, and i'm able to extract the relevant parts of the history, integrate them with the physical exam and ancillary studies, and come up with a reasonable diagnosis and plan.  My main issue is a persistent "fogginess" to my thought process; that is, needing to exert a little more energy to be able to focus.  It's not unlike the feeling one gets after working 24 hours straight, and it's a good thing that my residency trained me to work under those exact conditions.  

Another problem is multitasking, in that i have to completely concentrate on finishing one thing before paying attention to another lest i forget what i'm doing (although this may have been a pre-exisiting issue that i'm just more aware of now).  The underlying knowledge base and decision-making ability otherwise seem to be completely intact.  Despite my rising confidence in my post-concussive abilities, i'm still thankful that the inherent redundancy in what i do (e.g. the resident/APP sees the patient before i do, and my partner rounds on him/her several hours later) ensures that nothing gets missed.  

My mental picture of what happened closely match the way my doctors explained it: my brain was so severely rattled by the fall that the connections between my personality and my memory were completely ripped apart for a few hours (hence the six hours that i can't remember).  Since then, the connections have started to reform, albeit at a glacial pace.  While i'm frustrated that it seems to be taking forever, i'm told that i'm progressing as expected.  Patience, grasshopper... it'll get better eventually.  

My normal CT scan.  Proof that i have a brain.

Injurious Behavior: The Day I Rattled My Brain

Three days ago we went out to Crystal Mountain for more skiing lessons.  Adrian is progressing along quite  well: his teacher finally let him get on the chairlift to go down a "grown-up hill."  Gianina and i signed up for a two-hour lesson, and we're slooowly becoming competent skiers (parallel turns!).  It was a great day for all of us, and it's a pity that i don't remember it.

Towards the end of the lesson (around noon), i apparently got down near the end of a green run, did a 180-degree turn, fell back, and slammed the back of my head against the snow/ice.  Gianina and Brett (our instructor) quickly caught up with me and noted that i was awake and lucid.  So far so good.

Unfortunately, retaining consciousness was the only good thing about it.  Gianina almost immediately noticed that i was acting odd: asking her what happened, listening intently to her explanation... and immediately asking again what happened.  Over and over.

I couldn't form any new memories.

In short order, Gianina got the ski patrol involved and had me transported (via ambulance!) to the closest hospital.  I was seen by an ER Physician, had a CT scan done (normal), and was ultimately diagnosed as having a mild concussion.  Thankfully, we were given a green light to proceed with the rest of the day's activities.  However, it should be kept in mind that while being discharged from the ED usually means that one is not in danger of dying any time soon, it doesn't necessarily mean that one is in tip-top shape.

So we went on our way to enjoy the local waterpark, and by Gianina's account, i was completely lucid and reasonable the whole time, just unable to remember anything that just happened.  She says it was like taking care of two children (or more aptly, i think - one child and one pleasantly demented old person).  I'm happy to report that i never exhibited any antisocial behavior at any point, and was even conscientious enough to request Gianina to call our hospital division chief to let him know of my ongoing incapacity when i realized that something wasn't kosher.

At around 9:30 pm (almost ten hours after the initial event), things eventually started "sticking" - and from a cognitive standpoint, i can accurately say that it was when my brain finally woke up and decided that it was time for business as usual.  Things are clearer from that point onwards.  But i can only remember the preceding three hours in the waterpark like images from a near-forgotten dream, and the six hours immediately following the event are completely nonexistent.  Cervical collar, stretcher, ambulance ride, hospital stay, even checking into the waterpark and changing into my swimsuit... zilch.  Gianina even came up with a list of things that i repeatedly asked and commented on.  On reviewing said list, i can remember asking none of those things, although i can recognize my thought pattens in the frequency of the queries.

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What amazes me the most is that i was otherwise completely normal the whole time.  I've seen a similar phenomenon before with something called Transient Global Amnesia (which is usually not preceded by a head injury, but with similar clinical features), which i've always been fascinated about.  To have actually lived through the same experience is equal parts amazing, scary, and creepy.  But it was much, much worse for Gianina, who actually had to endure losing her husband (or parts thereof) for a number of hours.  I can't imagine how it must have been like for her, and i think one of the worst parts was around the beginning, when the diagnosis was still uncertain and Adrian asked point-blank: "Is Papa going to die?"

At present, i think i'm mostly recovered.  I don't have any residual headaches or vertigo, and my only mental problem appears to be accessing certain memories, specifically the three days leading up the the accident (this is quickly improving - i can clearly remember Tom Brady's final "Hail Mary," for example).  My mind also momentarily goes blank when asked to remember something, although i wonder if this last bit is something that i (and everyone, for that matter) already did before without paying too much attention to it.  As with any other body part that gets injured, i'm "favoring" my brain and may just be overly concerned about every little hiccup that occurs.

My main issues are actually physical.  My sternocleidomastoid muscles hurt like the devil (they presumably stretched out when my head snapped back), and i have various aches and pains all over my body from skiing that have no correlation with any memories that i have.  Surprisingly, i don't have a bump on my head, which makes me wonder if it was truly the impact (which would have been absorbed by a helmet) that caused my concussion, or just the acceleration-deceleration event.

Anyway, i saw a neurologist yesterday who confirmed the diagnosis.  Today i saw a neuropsychologist who thinks that i'm overall doing okay, but given the nature of my work, would rather that i go back to working on Tuesday (as opposed to Monday) pending further testing.  I have no doubts that i'll be fine and dandy then, with only a little amnesia to "remember" my injury by.

One question that's bugged me from the start is: if i had worn a helmet, would it have prevented the concussion?  On researching the topic online, it seems that the answer is no; the type of injury that helmets are supposed to prevent did not occur anyway (remember that i have no bump on my head).  Stated differently: even if i had worn a helmet, i would likely still have gotten the concussion.  Regardless, it could have been much worse (under different circumstances - harder ice, or an actual collision with something hard enough to break my skull), and the next time we go skiing, i'm definitely wearing one.

Thailand Vacation Pics, Part 1 of 3

Of course everything's more fun in the Philippines.  Last year, while canvassing places on where to go for our annual "honeymoon," we almost booked a trip to Misibis Bay.  Unfortunately, one of the jaunts i really wanted to go on (head down to Donsol for a day to swim with the butandings) was out of season, so - for about the same amount of money - we went for a change of pace and settled on Thailand instead.

While i still want to swim with the whale sharks one day (perhaps when my fellowship is done and i can again spare three weeks to go home), our "second choice" did not disappoint.  Thailand is a beautiful place, about the same as the Philippines in terms of natural beauty, with a lot of nicely-preserved ancient sights to see.  Gianina was actually a little bummed-out by how nice our vacation turned out (how's that for a contradiction?); seeing how nicely organized the tours are and how well they've maintained all the tourist spots reveals the sharp contrast to the lack thereof in our Inang Bayan.  (This is a general statement that does not preclude exceptions to the rule.  Our Bohol experience three years ago, for example, was exemplary.  On the other hand, our Batanes experience last year was borderline terrible.)

Our formal Bangkok exploration started out by visiting two of the most popular (?) temples.

Wat Traimit.

The solid gold Buddha weighing over 5 tons.

The reclining Buddha at Wat Pho. 

Later on we explored the Grand Palace complex.  The place is huge and took us about three hours to see.  Walking around outside in 100-degree weather is not my idea of fun, but the sights we saw made is worthwhile.

A statue of Marco Polo.  

I forget who this was.  Some random Thai guard?

The detail on their art and architecture is exquisite.  You'd really have to be there to appreciate it, but here's a few snapshots:

Beside a replica of Angkor Wat (which is in Cambodia). 

Of course, no vacation album is complete without me desecrating some statues.  We've all heard about the "Ugly American."  Well this is the "Ugly Filipino!"

After the photo-ops, i tried to achieve enlightenment under the bodhi tree.

The Palace itself (the pics above represent the temple complex) was not that interesting, but of course we needed a few pictures of that too.

Like the guards at Buckingham Palace, these guys are not supposed  to budge or show any reaction.
I knew it was safe to make fun of him when i noticed that his gun wasn't even loaded (look closely!).

We ended the day by going to a cultural show called "Siam Niramit."  The show was okay, squeezing in hundreds of years of Thai history into a two-hour musical, although it was somewhat hard to follow because of the lack of dialogue.  Prior to the show, we had a chance to interact with some of the actors/players and walk through a mock-up of a rural Thai village.

Yes, there were elephants on stage!

I couldn't hold it.

Gianina getting her palm read at one of the houses.

Unfortunately we didn't get a picture of the house, so here's a gazebo instead. 

There was even a pre-show show, with some ladies doing a traditional Thai dance while being menaced by a guy wearing a devil mask.  There was probably a plot in there somwhere, which i didn't quite get.

Or maybe he's supposed to be a street urchin asking for money?  Nah. 

We unfortunately had to turn in our camera prior to the show (literally check it in!), so we have no pics of the extravaganza.

Next: Ayutthaya.

Clear as Mud

Last night's Pacquiao-Marquez fight, which some people have called "controversial," was a Rorschach test for viewers.

The choice of words is curious to me, because while i believe it was "close," i disagree on the "controversy."  For every person who says that Pacquiao "clearly" won, there's probably and equal number who would say he "clearly" lost.  In both cases, it's really only as clear as mud, which is why we needed the judges to render a verdict.  

I personally agreed with the judges on this one (my opinion on the scoring was near-identical with the "Lederman Scorecard"), and i think that while Pacquiao's inability to beat the feisty Marquez to a pulp was a disappointment, it is not enough reason to award the win to the latter. The fight went down the wire, and in the end the judges did what they were supposed to do: they judged based on how they thought it should be judged.  On this particular night, they thought that more punches taken/landed made the better fighter, so Pacquiao won.  If they had felt that better defense and more counter-punching would have been a better benchmark, then Marquez would have won.  

It's a little weird to me to take the booing crowd into consideration.  More people sang the Mexican National Anthem than the Lupang Hinirang; doesn't that in itself indicate that the audience consisted of either more (or more vocal)  Mexicans than Filipinos?  Lovers gonna love and haters gonna hate.  Personally, i'm looking forward to the fourth installment on this one.