thoroughly modern amanda

We were at Common Roots when Moody told us about her first rural emergency call. She lives in the bottom floor of the on-call house, and so when a call comes, she puts her shoes on and runs. The EMT's in the countryside are minimally trained fast drivers; they just speed like hell to the site and quasi-stabilize the patient and speed like hell back to the hospital. The victim was a kid thrown, drunk, off his ATV, who was mostly out of it but would thrash his way back to incoherent consciousness from time to time, bucking against his cervical collar. She grabbed my wrist across the table, her finger instantly on my radial pulse, and said that she held his pulse for 20 minutes and tried to chill him out, all the way back across the dark prairie to the hospital, before they put him in a helicopter to Hennepin. Where he is probably now making trouble for Green D, without me - Thursday was my last day.

Driving around a couple hours later, she said that when she got home after the kid had been packed into the chopper and flown away, she couldn't sleep. It was still there with her, and she tossed and turned. I'd wondered whether all of my friends would come to feel this way at some point. During Med 1 she seemed far more sturdy and adaptable and perpetually sunny than I did, and I felt that maybe I was deficient in resilience. As much as I liked the patient management, it rattled me. On my last day, K. told me to dial down the empathy; he thought it was getting in the way of my judgment. But I think we're all going to visit that state a few times. Once Andrea came over during her surgery rotation and told me about how she was ordered to do an emergency guillotine amputation. I was stirring a pot in my kitchen, and her face just got whiter and whiter as she told me what she'd done.

This morning, I woke up at 7:15, having gone to bed at 2:30, and the first thing I needed to do was pad into the living room and read about Common Variable Immunodeficiency in Robbins. Last night, a grad student at a party told me she had this disorder, and all that swam to mind was a long-ago given lecture slide in which it was abbreviated CVI and was connected to a lot of, uh, infections? Sat on futon in blanket reading about B-cells. Couldn't stop, read about anergy for a while. Couldn't achieve the knowledgeable feeling.

We were rounding in the telemetry unit, and I was thinking about how nice it was going to be to go home, and K swept back the curtain on Ms. Kohler's* bed. I was pulling on my isolation gown, fumbling for size-small gloves, so I didn't see what he saw, but he said "Heyyy...uh, that's new, isn't it?" I walked around to the foot side of the bed, and S. was already there - it was one of her new patients - and was calling out to her, Ms. Kohler Ms. Kohler, and K. was pointing at her monitor, and her heart rate was 35 and falling, and he called out to the nurse, and S. grabbed Ms. Kohler's shoulders and said Ms. Kohler!, again, with a new high-pitched sound. And K. called back to the nurse that we needed atropine and glucagon, and she was bradying down fast, and the nurse whipped in, and Ms. Kohler did really look quite ill, I thought, but with two or three strokes, a trach, massive infection, and baseline dementia, I guessed I wasn't sure if she should look any better, but she was diaphoretic, damp strands of gray hair stuck to her temples, and she was not responding in the least to S. calling and shaking. "Call a code," said K., messing with the atropine. "The button's right there," snapped the nurse, messing with the lines, and she flung her free arm across her chest and slapped the wall, hard. Aaron and I were backing up at this point, knowing that we were about to become very obstructive furniture. "Put her in Trendelenburg!" yelled the nurse, and S. and A. started messing around with the bed settings, which we never know how to operate, and the nurse snapped, "Can you get me another NURSE in here?" and I ran out and got another nurse, who was already headed our way with a bunch of syringes. The cavalry arrived, in packs, the code team and the CMIC staff and everyone who happened to be in the vicinity, 25 people packing tight around the bed. Aaron and I squeezed back to the far wall as the crash carts and vents moved in around us and I thought, oh, please, let me not get in the way, but I'm supposed to see this, I think, I'm supposed to know what this is about. Ms. Kohler dropped into PEA, about this time. "Are you running this?" someone called to the MICU resident and she replied that she was. "We need access!" someone shouted, and it was agreed in arm gestures and one-word comments and mutters I couldn't distinguish that some cavalry member would obtain access in the form of a triple lumen cathether in the femoral. And everyone's voices became tight and efficient and there were no spare words. K's eternally mobile facial expressions had stopped and gone still, and he began chest compressions and Ms. Kohler was in asystole. The annoucements were being called out affirmed and recorded by the pharmacist. This is the first unit of mag. First unit! This is the second unit of mag. Second unit! Aaron and I watched the cluster of residents holding positions around the bed. Running feet still arriving, bagging, suction, mag, atropine, epi, K. still pounding away with, yes, I think the phrase is "grim determination," and the pulse was back, the trach was fixed, there was a sterile field open and a trickle of blood over quickly working gloves of a masked and gowned resident. She was totally stable. We were done. We left. She went to the Unit, and we went back to the Floor. I murmured to Aaron, why did her husband want this for her? We always wonder if they know what they're asking for.

We went to see our possible overdose, who was clearly fine, and we decided to send her home, and headed down the hall to the workroom, and suddenly S's face crumpled and she looked at the floor and lost about two inches of height. She said that she felt very bad and she didn't know what else to have done. K. dropped his jokes and put his arm around her shoulders and said, You didn't do anything wrong, you did fine. She didn't look reassured.

I went to the farmers market and I went to the co-op and I went home. I put on music and I did the dishes and I swept the floor and I peeled apples for a crisp. I was listening to Antlers, and while I certainly know what the album is about, I haven't really listened to all of the words yet. I bought this album in April, but it was too wet and dark for April, and so I hardly deployed it until this medicinal October. I stopped in mid-peel when I realized what they were singing. "Some patients can't be saved," they're going, inexplicably, "but that burden's not on you." Huh. Then I got to feel really ridiculous and cliché-infested and emo, and say, Amanda, knock it the fuck off with the fucking melodrama, and then I shivered a little, and complained back to myself that this IS melodramatic, what more do you want? I just fucking watched my senior resident resurrect a lady with no heartbeat! One of my patients has HIV and he won't fucking answer the phone or come to clinic so he still doesn't know that! I listened to the chest of a sobbing man, trying to hear the thwacking left ventricle and the dullness of the fluid inside his chest while he cried all over me. He was very upset, it was true, and with good reason. And that gets inside of you! You come home and of course it's still there. Then you listen to Antlers and it feels really weird and synergistic and kind of self-indulgent and it's not clear how you're supposed to interact with the things you're carrying around. Maybe the burden of guilt is not on you, but the burden of knowing is. You're walking around with your own feelings, and then all these other people's feelings are kind of jostling your feelings for space, competing with them for who gets to get felt the most. It's kind of a challenge! It's kind of permanent! I kind of need to figure out how to not let it be quite so overwhelming!

*Yes, I am changing all relevant names, I always do.

Dear Skinny Hipster Boy:

Don't run, so skittish,
across the dark parking lot.
It is not manly.

Dear Ward Patients Who Love Loud TV:

With Fox 9 News on,
I can't hear your heart or lungs.
Do you want to die??

Typing "black" into the iTunes search box yields a surprisingly good playlist.

Currently restructuring my blogging-life, with the kind of compartmentalization that I increasingly need to employ.

Now, need to fill baby éclairs, put on party dress.

Feeling incompetent in most of my activities. Difficulties with studying, aggravated by the sudden appearance of proselytizing schizoid dudes - as if sent out by a central dispatching station - at any sidewalk cafe where I sit down with First Aid, who tell everyone about their amazing million-dollar business plan or the meaning of life; hopeless bike shopping in which I torment nice bike shop guys with my indecisiveness and hesitant identification of non-existent differences between bikes ("this one's chain feels more...crunchy than the last one?"); doomed attempts to sell old clothes ending in self-berating harangues (WHY DID I BUY THIS?).

In the realm of snackin', though, everything is copacetic.

Received a free pallet of strawberries at the farmers' market. My favorite farmer lady and I had a chat about how hard it is to find a good pediatrician and then she begged me to take a flat of berries off her hands, as the market was winding down, and they needed to go to a good home. "They need to be processed TODAY!" What to do but comply & go in search of backup fruit? Wedged the pallet into my backseat and put in an emergency call to Moody informing her that I was driving straight to her house to yank rhubarb out of her garden - rights to which I have obtained through yard labor. Her neighbor, weeding, hallooed me, recognizing me from my last stint hammering together a raised bed frame (and hammering my finger into a blood-blistered Tom & Jerry-cartoon-lookin' throbbathon) and we discussed the raspberry bushes, as well as her recent breast cancer diagnosis. Caveat applicator: the status of medical student entitles you to such ad hoc confessions. I kinda like them - I figure if strangers unload on me, they probably were in major need of an unloading station.

Process I did. Mama and I hulled and bagged and simmered for a couple hours and now we have bags and bags of frozen strawberries, strawberry syrup, a vat of strawberry-rhubarb...compote? the name for this confection at my house was always just "strawberry-rhubarb."

In any case: lightly stewed strawberries & rhubarb with greek yogurt, crunchy granola & homemade vanilla-bean syrup.

Kindee Thai - roast duck curry with lush dark purple grapes, baby tomatoes, basil, and springy coils of deep-fried calamari. Sweet, acidic, crunchy, rich, help help. So good. So good.

Wednesday night: grilled garlic pork chops with honey gremolata; fried new potatoes with citrus thyme; caprese salad with bufala mozz, grilled fennel, and herbed Brittany sea salt. Everything except the salt grown in a 60-mile radius. Herbs grown on my Plantation, that is, my parents' patio, where I have had to blast them with (natural! non-toxic! non-awful!) insecticidal soap to de-fest them of these atrociously hungry little yellow bugs. Die, motherfuckers, die...naturally.

Inspiration from this cookbook: holy shit. It makes me want to pull up stakes and move to Patagonia IMMEDIATELY.

The first thing I learned today, after I'd slammed almost-late in the OR workroom, with my sad, desperately-needed breakfast cereal baggie in hand, at 6 am, to look over the Patient List and the charts of the patients on the List, was that one of our patients had died. Not my patient, but, our patient, sort of. The patient had had a extensive operation just before Naomi and I arrived, and during our week of piloting morning rounds without our vacationing resident, we faithfully checked on her every morning in her intensive care suite, despite our complete lack of available interventions or expertise. When we appeared and made our inquiries, her nurse, different every morning, would always sigh and look directly into our eyes - an unusual amount of attention for students to receive - pretty much enough to let us know that this shit was not going so goddamn well. But we would have known that anyway, from the aggressive use of resuscitative machinery. It was a grim picture. It made us sad. The nurse would unload on us about all of the patient's problems in an efficient and classic narrative of multi-system organ failure, and I decided our function there was mostly to let him or her ventilate. We would nod in a serious fashion, check her oddly terrific-looking incision, then Naomi would have a distressed look and pat the girl's leg, and we'd wish the nurse the best of luck and move on to other, less complicated patients for whom we might have some blessedly simplistic, unobjectionable orders to suggest. Let's try clear liquids today! Sure, take a shower! When our resident came back, the little girl got pushed down the List to the special bottom section, where people go when we're done with our part of fixing them and all we do is stop by if someone pages us, or some attending has a mysterious compulsion to visit them. Still, we walked by her room every day on our rounds. The ICU rooms all have moods, and the moods drift into the hallway, and some of them you want to avoid. Some of them are good places, and others have a darkness. Today her room was empty.

Some time later, we were completely losing our shit in traditional looped-out gigglefest fashion. Sitting in the workroom, I put my feet up on the desk behind the in-out trays holding ORDERS and PROGRESS NOTES and ate some more cereal. We began to feel very lonesome and hungry and un-looked after. I quizzed Naomi on the differences between the inflammatory bowel diseases. The funniest of the anesthesiologists poked his head in and asked if we knew what had happened to our case. "We are always the last to know," we reminded him. Naomi suggested we leave a note saying, WE WENT HOME BECAUSE YOU IGNORED US. I suggested "MED STUDENTS ARE LIKE PLANTS: WE NEED FOOD, WATER, AND ATTENTION - OR WE DIE." Sometime in there, I decided to get some food. The cafeteria, which is always closed, was closed. So I raided the entirely deserted staff lounge, to which we have access via badge, but were admonished not to patronize. Catering had left a plate of congealing poached salmon and two stale multigrain bagels. I took one of the latter and stuffed it into my coat pocket, and fixed a cup of coffee, while muttering stuff like "motherfuckers" and "if they expect me to work like a doctor, they better give me food like a doctor."

We debated about what we might possibly do with ourselves. Naomi suggested that we walk over to Radiology and find out what was on the suspected appy's CT scan. I thought this was a good idea, because it would involve both a walk - a 100-foot one, which is better than no walk at all - and a chat with a radiologist, maybe even two radiologists, in their cozy dark catacombs. Naomi had a second thought, though - if we found an appy, we might be held responsible for sticking around - i.e. we would have the privilege of sticking around - and seeing it through to its final resting place of a surg path specimen cup in OR Two, probably somewhat less than eight hours before class the next morning. Despite this unpleasant thought, we went to visit the radiologists' cave anyway...

At least if Sarah Palin runs for president, it means we'll get a lot more Tina Fey. But who will play Tim Pawlenty? And what will they mock, exactly? Listening to him speechify, I tend to picture him as a prison cellmate who seems kind of normal, and not that interesting, and got there through bouncing checks. But then he shivs you in the back after lunch.

So when I'm at the operating table, I have to keep my hands up on the table where everyone can see them. This is so they stay "sterile." Sterile is all relative, a shifting point of satisfaction with a mutually maintained level of diligence. If I'm not holding instruments, I lay my hands on the table, but the table is covered with the patient, so I actually rest them on the patient, who is an amorphous lump under cornflower-colored drapes. Eventually I realize that I have found a comfortable spot for my hands in a natural hollow or bump, like the jut of their hip or the apex of their ribcage. Then this feels uncomfortably intimate and I take my hands away, but I have to put them back down so as not to get a shoulder cramp. And so - this sounds crazy, I know - but I try my best to rest there gently, as if they were awake, and try and send them my concern and care through this gentle contact. I really do. I don't know what else to do.

A few weeks back, all of the courses I took so far in med school popped back up on the Blackboard site. I'm guessing this is to help us with boards prep - should we be that excited to re-access some old handout on cholesterol transport - but it has a dizzying, slightly traumatic flashback effect, as I have to scroll through everything I've already done to get to where I'm at now, which is labs on inserting chest tubes (into pork ribs) and central venous catheters (into a disembodied torso that spurts fake blood).

# _Medical School - Year One - 2007-2008

# ANAT 6150 - Gross Anatomy - Fall 2007

# BioC 6001 - Biochemistry Molecular and Cellular Biology - Fall 2007

# BioC 6002 - Human Nutrition - Fall 2007

# GCD 6103 - 8103 - Human Histology - Fall 2007

# GCD 6110 - Human Genetics - Fall 2007

# InMd 6050 - 6051 - Physician and Society - Year 1 - 2007-2008

# InMd 6100 - Physician and Patient 1 - Year 1 - Spr 2008

# InMd 6400 - Respiratory - Fall 2008

# InMd 6401 - Cardiovascular - Fall 2008

# InMd 6402 - NSMD - Fall 2008

# InMd 6403 - Psyche - Fall 2008

# InMd 6404 - ENT - Fall 2008

# InMd 6405 - BJCT - Fall 2008

# InMd 6406 - Skin - Fall 2008

# InMd 6407 - Endo-Repro - Spr 2009

# InMd 6408 - Renal-Electro - Spr 2009

# InMd 6409 - Gut - Spring 2009

# InMd 6410 - Eye - Spring 2009

# InMd 6411 - Blood - Spring 2009

# InMd 6412 - Infectious Disease - Spring 2009

# LaMP 6300 - 6305 - Systemic Pathology - Year 2 - 2008-2009

# Managing Health Data Securely - security10_005

# MicB 6205 - Microbiology - Spr 2008

# Nsci 6111 - 6112 - Neuroscience - Spring 2008

# Phcl 6111 - 6112 - Pharmacology - Year 2 - 2008-2009

# Phsl 5101 - 6101 - Human Physiology - Spr 2008

# Surgical Education - Clerkship in General Surgery - 2009-2010

I dream of the perfect television doctor show, off and on. When I'm waiting with my hands clasped in front of me, sterile-ly, in that way that looks so deferential and penitent (which is how I feel most of the time anyway, around a bunch of midcareer pediatric surgeons who whip ties around bleeding veins with stereotypical composure and dexterity).



I get gowned like this. I put on a ten-pound lead apron with incredibly loud 3-inch velcro straps that are thick and tight and a skirt and a neck guard to prevent thyroid cancer. I scrub and scrub in the hallway with the chlorhexidine and sponges and screw up and start over and scrub again, push backwards through the creaking swinging door into the OR with my back against the cold metal paneling, with my muffled steps through paper booties, wet hands getting chilled, stray soap bubbles on my elbows popping, and I say Coming Through and step around the fluoro and the computer station and the cautery cart and the suction cords hanging from the ceiling. The scrub nurse opens my gown for me and I stick my hands down so just my fingertips are peeking out, and there's the soft rustling of the circulator tying my back ties, and I say Thank You as they tie, twice as fast as you'd tie your shoes. I dive my hands into the gloves that the nurse opens for me - I wear the smallest size readily available - and they clap shut and then I'm safe.

Or when two parents are sobbing in the middle of an OR hallway, arms wrapped tightly around each other, as the traffic of nurses and techs and IV poles flows freely around them. (Do I make sympathetic eye contact, as if to say, "I regret very much the suffering your time here is causing you, and wish very much I could do more to help you, but I can't, because your daughter has cancer, and that just really, really sucks," or do I just avert my eyes and step towards the wall around them, to help maintain an illusion of privacy? There really is no privacy. I walk in on parents half dressed, siblings using the bathroom, on agitated phone calls in progress, on temper tantrums. But I think the illusion is helpful, so I do avert my eyes, and I always knock before I enter, into these delicate scenes, kids and parents tangled in stiff white hospital sheets, parents crammed into their kid's hospital bed with them, head to toe, down on the floor with couch cushions, up all night. One dad told us that malevolent spirits were trying to choke his child, and there were dark people visiting the room at night, who sat on the bed and didn't say anything. The MD shrugged and chalked it up to sleep deprivation, or psychosis, and everyone tried to avoid talking to him after that. All of this will go in my show. It will be like The Wire in its epic scope, but like Mad Men in its pursuit of ambience capture through detail-oriented perfectionism, but like Homicide in its seemingly freewheeling capture of the ways in which hothoused coworkers in an intense job relate to, antagonize, love, screw over each other.

Went grocery shopping. On my way, saw that behind one of the apartment blocks on Lagoon, a guy was rummaging through the dumpsters. He was in halo traction. It made rummaging tougher. Many sign-holders of Minneapolis have mostly been kicked off the freeway exits by cops and signs saying, No Trespassing, but they've resettled on Lake, by the lake, and now that the weather's good, they're always there. COMPLETELY DESPERATE, reads one of the signs. I think I've seen a lot more of this lately. But I can't tell if I'm just suffering from observer bias, looking for signs of dismal economic prospects because all news media instruct me that things are not going well. I am certain people have asked me for money more often than they did last year, but mostly they're street kids and hippies, the same Uptown wanderers that have always migrated through in the summer. I'm starting to not feel okay with my decision to unilaterally reject everyone who asks me for money and just give money to food banks and help people get free medical care instead (a Hyde Park decision I brought back to MN). In fact, I feel like the world's meanest meanie. Maybe I'll give everyone a dollar instead.

Back from San Francisco. Changed my email signature to say, Year 3. Cut hair, new shoes bought, Surgical Recall, Biochemistry Rapid Review. Remaining (many) tasks listed in a takeoff queue - reflex hammer, used furniture store, mend pants...prepare for summer to be stormy, chaotic, unpredictable, terrific, terrible?

San Francisco is an interesting choice for a psychiatry meeting. For one, it's the site of the infamous demonstrations that kicked off the push towards removing homosexuality from the DSM, but the meeting keeps coming back, and back, and back, as if to show it's not ashamed of the past, or show what it's done since then, or as if it has no institutional memory at all. Read about "the ahistorical kernel of psychiatry" on the plane. Many white-bearded men all around at the conference, indeed.

For two, the city is brimming with psychopathology. 18th and Guerrero: a woman yells, as loud as she can, with as much hate and rage as I've ever heard a human output, You motherfuckers, you motherfucker bastard motherfuckers I'll fucking kill you, you bastards, and she won't stop. She's well dressed. She's got a purse and a cell phone. Shopping cart pushers yell, too, and the guy on the bus who obsessively touches the pebbles on the floor, the window latches, who stares at me, at the other people, at the pebbles. The lady in late middle age clutching, and avidly playing, a lime-green Game Boy, when not rocking back and forth in her seat. Two skinny boys in melting makeup and feathers and latex on the elevator with me at the hotel: so high their sentences have lost hold of sense entirely. But, more irritating and numerous: the poorly suppressed tics, obsessions, and plain rude-Gus-nesses of an entire convention's worth of psychiatrists! Penned up in lecture halls all week, they start to resemble a vast herd of restive animals, scratching and stamping in the dirt. Next to me at a lecture (our chairs' legs touching, everyone's neuroses too close for comfort), a guy rhythmically rubs his fingers against his beard stubble with a loud raspy sandpaper sound, for maybe 30 seconds, switches to the other side of his face, looks at his fingernails, and chews them. Then he repeats the cycle. Another guy compulsively clears his throat. People take pictures of the lecture slides for posterity, but leave on their cameras' sounds, and a volley of pings and snaps goes off at every slide change. I think of a story, from a psychiatrist, about a guy who is consumed by his obsessions - checking, counting. He quits his office job, driven nuts by his crippling daily routine, and hops on a boxcar. Soon he is entirely busy trying to make sure he has food and a warm place to sleep, and his obsessions all disappear. He comes home - they come back. I worry - what kind of hell do we suffer to make cerebral varieties of labor happen?

dear kate,

i can't sleep, for a variety of reasons, mostly anxiety, but also some kind of long-awaited sigh of relief, some rueful embarrassing glee, that my whole life is not going to stop. i saw an article online, randomly, in which a supertanned starlet explains that in the new version of melrose place (2.0! horrible!) she will play a med student/prostitute! and i thought, is this what the american man most wants from the american woman? a sexy tan waif with long hair and liquid eyeliner who is both the supreme caregiver, the most trusted professional, and the naughtiest most forbidden professional? who knows how to achieve conventional success, but harbors dirty fantasies of fucking strangers for cash - and then acts them out! someone who can service you in every way possible, soothe you, cure you, with an appealingly secretive double life, both halves of which make the other half so much more special and strange and lovable and super super sexy? omg, my doctor's really a hooker slut! omg, this whore is really a doctor! madonna/whore super combo! but the real med student with a double life is the one whose white coat ceremony pictures were attached to all the nytimes articles about strangling hookers. and so i was listening to radio lab to try and relax and this episode was about placebos, but then it was about the white coat placebo effect. and it's strange, because neither the reporter nor his doctor dad really understand what the other is trying to say. and from the outside, the reporter sees this white coat ceremony as some transformative moment - how do you explain that it's completely illusory? that we live in a postceremonial world? no one i talked to felt the least bit transformed. i felt like a complete sham that day - i was cramming for a biochem exam in the hallway as we waited to file in, and continued to worry about it for the rest of the afternoon, and it felt really, really dumb to be coronated with this symbol of professionalism while i was sweating over whether i could remember the structure of citrulline. my dean said some stuff about birds, and a 4th year said some stuff about stuff, and it was so incredibly stupid in the face of the petty awful detailfucked grind of 1st year and the jaw-dropping clinical shit to come. and the coat still feels like a costume that you're supposed to put on to fool other people into trusting you. at free clinic we never wear our coats, and it's great. we're in a church basement, and my shoes are scuffed, and sometimes i put my steth on backwards. if you trust me, it is because i made myself worthy of trust, and if you don't, at least i don't have to wonder if i won you over with a costume box.

Alex wrote about the illustrious History Day and its life as a harbinger of future academic praxis.

My History Day might be equally harbingeresque. There was only one History Day for me. We were required to particpate in 9th grade, and received homework time and credit for doing so. After that, we were on our own, so I didn't particpate again. (avoidance of competition; avoidance of labors that seem unlikely to reap concrete rewards/praise/benefits; adherence to institutional structure) It took me a while to pick a topic. I pawed through a bunch of glossy gloss-over History of Science books. Eventually I settled on innovations in anatomy and medicine in 16th-century Europe. (infatuation with sweep and scope gives way to overly-narrow fixation on small topic). I worked obsessively on research for weeks. After school I went to the Wangensteen Library in Diehl Hall. To get there, I had to walk through the halls of the med school - and I was, at the time, loving this totally, 100% smitten with the idea of a Big Campus and a Big Backpack Full of Big Ideas and Big Thermoses of Coffee. (misplaced worship of academic institutions/academic social capital over academic production) I liked being near medicine; I liked the idea of scooching up to medicine and medical practice in a thoroughly un-gross, detached, booky way. I curled up in bed with piles of library books - journals of German medical students, histories of battlefield surgery. (simple love of reading/discovering) I also read my first snotty theory book. I can still remember the author, because of the scorn and derision I heaped upon him, complaining to my teacher. She had just finished her doctorate in history, so I'm sure she was amused, but she was nice enough not to show it. I'm sure the book was moderately crappy, being that it was written in 1995 and obsessed with finding sexual themes in the literature of anatomical dissection and writing about them in horrible purple British theory-prose. I preferred spending time with original 1560-something editions and trying to synthesize my own weird theories about them. (privileging of primary textual analysis over the frustrations of trying to understand other people's ideas) In the end, I came up with a dense, knotty project with too much text on my posterboard, lots of gory woodcut illustrations, my first all-nighter, and a fat bibliography that impressed the judges. Still, I didn't get beyond State because I had paid almost no attention to the Theme of the Year, which was Movement. I paid it some lip service with a dinky map showing how various people traveled around with their scientific discoveries, but I didn't really give a damn about it. (following train of inquiry without regard to original aims/assignment, only personal intellectual singularity and tangential, birdwalking fixations and discoveries, producing thesis-less work full of anecdotes, curious observations, and synthesis from wide-ranging primary texts) I did get the history department prize at school that year. (recognition of genuine effort and devotion)

Yes, I'm being cruel to myself here. But I'm frustrated by my inability to study well for more than 4 or 5 hours a day. And I had a small panic attack when I found Lauren Berlant's blog today. I feel completely alienated from everything that mattered to me 4 years ago and completely detached from the work that I'm supposed to be doing right now.

One of many puzzle tables at my grandfather's nursing unit. Good place to escape and imagine what it is like to be retired, and one may do puzzles all day.




Souvenir of inflation from global health-oriented student traveler.




Seward, winter.




DC metro. Stuffed bear.




Napping man at MSP. He had a minder nearby who was making sure no one disturbed his sun-dappled repose.




MoMA, February.




Cap'n Leela.




Still have no idea.

First chalked hopscotch boards on East Isles streets. One went all the way to 100, the squares getting baggy and misshapen by the end, eager kids wanting to hopscotch and not draw. I thought, does that say Scleroderma? next to it, but no, it said Selena Gomez, probably the artist in charge of the hopscotch. Shit. Been in med school too long.

First tree buds

First diving loon, splashing around clearly just for kicks

First bout of allergies. First hit off my inhaler: not used to that adrenaline-rush feeling, my knees buckle a little, get the shakes, just like I've been scared half to death

First middle aged dudes taking off their shirts and smoking cigars in the park

First walk without coat without regret at having left coat at home

My psych group advisor, describing his evaluations.

"I'm kind of a Star Wars fan, so I ask the kids, Why did Anakin go over to the dark side? And they say, you know, because the Emperor made him, or because he loved Padme too much.

"And then I give them drugs."

It's happening. More and more, my freakouts and snickering dorky dorkfest moments are intelligible only to other med students. I knew it was coming, the day I was walking down the hallway behind one of our class' resident hipsters and our class' resident manwhore, who I somehow thought would be talking about music, or chicks, and one of them was saying to the other, "I don't think I would be your friend if you had Prader-Willi," and the other replied, "Noooo....I'd just be going (high-pitched clown voice) feeeeeeed me, get me Snickers all day, I wouldn't be friends with me either."

Take, for example, the fine song stylings of Substance P. The name in and of itself is cringe-inducing nerd-rap genius! (I think "Bullous Pemphigoid" is a terrific representative of the study-song genre - hacky arrangement, clunky lyrics stuffed with high-yield facts.) Moody played these for me last week, and we devolved into horrified unstoppable giggles. Of course, now I'm not going to forget that the hemidesmosome is the antigen.

but this is upsetting to me, or, it would be, if I had time to engage with being upset. When I started med school, I had lofty ideas about Not Needing Stupid Mnemonics to get the job done, hated relying on stupid mental images and pictures and songs and diagrams in order to pack in the facts, because, the true intellect should recoil from cheap shit like that, and I should be just so terribly fascinated with hematopoetic stem cells and consequences of resecting various lengths of terminal ileum and the comparative prognoses of all the types of esophageal neoplasms...but it doesn't work. It just doesn't work. Leela said I should give in and purchase a copy of Microbiology Made Ridiculously Simple.



It includes a picture of two humanoid Neisseria diplococci chilling at a kitchen table, one shaking so hard his coffee is spilling (meningitis), and the other reading porn with disturbing enthusiasm (gonorrhea). Except that's confusing, because one picture is a symptom, the other a cause. Maybe the meningitis one should be a college wrestler drinking out of other people's soda cans instead. And I don't equate consuming porn with having unsafe sex, so...it'd sort of be better if he were fucking another Neisseria without a condom. But that's just too disturbing for a micro review book.

I put the book back on the shelf, bought the serious flashcards with the little pictures of non-anthropomorphic bacilli swimming around, and prayed fervently that I will not fuck up the boards because I didn't buy the book with the pictures. I just can't deal with Neisseria porn.

I was mistaken for a drug rep this afternoon.

I was walking to my car, wearing my long black coat and heavy bag, walking towards two heavyset, well-dressed men in long black coats with heavy bags. One, with aviators and a shiny tie, asked me expectantly, "Is there still room on the list for us?" I stared at them for a minute, having no idea who they were or what they wanted, and finally I said, "I'm not sure what you mean. You'll have to ask someone smarter than me. I'm just a med student." Ohhhhhhhh, they grinned together, and went inside. Then I realized that they were drug reps, and they thought I was one of their tribe. That would be the only reason why a girl in heels and a long coat would be leaving a low-slung dull-bricks & fluorescent-tube-lit suburban family clinic whose nearest neighbors are a liquor store and a SuperAmerica.

I was leaving early so that I could attend a special bioethics committee meeting at which the author of the above-linked article was going to discuss the hopeless enmeshment of the drug industry with our institution. My previous day at this clinic, the doctors were talking about which days they would and would not have lunch catered by Merck, or Pfizer, or AstraZeneca. "How often do you have lunch?" I asked. That single question was enough to get Dr. B to launch into a long and practiced speech about how no amount of pizza would get him to change his prescribing habits and how his patients were helped by the well-stocked sample cupboard that Aviators and friends refill on their twice-weekly visits, and how much he learned from their educational education. I nodded, thinking that if this level of defense was provoked by such an innocuous question, I'd better leave the topic the hell alone. We rotate sporadically through these clinics. We are their guests and not their moral or Freudian provocateurs. "I'm hearing a lot of hostile feelings. Do you think we could explore that?"

At the meeting, surrounded by the committee members - chaplain, ICU nurse, community leader, pediatrician, risk lawyer - Dr. Elliott details a number of scandalous cases involving our faculty's ethical transgressions. Describing one, he mentions my brand-new psych department advisor, who does indeed accept drug company study money, by name. I feel oddly guilty by association. Stories of wrongdoing and lawsuits flow forth, familiar and still incredibly gross. Rants and raves ensue, a general depression descends over the room. I discuss my clinic predicament with Joy and Dr. Elliott. I ask, what is the best course of action for the conscientious objector? No one knows.

Today, mercifully, there was no drug lunch. I peeled my tangerine in the company of several medical assistants, who were eating Chee-tos, Suzy Q's, cups of ranch dressing, and Big Gulps bought at the SuperAmerica. Super duper! They said some things about the octuplets in California, things about how there are crazies everywhere. I wanted to be wicked and suggest that they pick up some of the patient-education brochures in the hallway about diabetes, because they looked like crazies, snarfing Chee-tos before drawing blood sugars from a new round of patients. Second reaction: guilt. Doctor money buys you organic chili; assistant money buys you vending machine sandwich. People came and went from the back room between phone calls, eating their lunches in the narrow space left between appointments. Dr. A said that she listens to the New England Journal on podcast while she makes dinner. She has two kids and a Panamanian exchange student. There is never any time to spare, only overbooking and lateness, and this makes visits from pretty salespeople carrying literature and pitching new drugs in 30-second increments attractive.

Not long after lunch, a man staggers into the clinic and collapses on the front desk. He is having an asthma attack so intense that he can barely speak. "How long has this been going on?" we ask, wide-eyed, and he holds up three shaky fingers instead of trying to explain. It turns out that he had been at the clinic with his wife that morning, and when he had an attack a few hours later, oxygen deprivation told him to walk a mile in the cold back to the clinic. It is not his clinic. We have no idea what his name is until we read it off his asthma inhaler's pharmacy label. His surprise appearance derails the schedule significantly. Dr. A and Dr. C both try to hand off Mr. Wheezy to each other, but Dr. A wins because of her next patient. "Would you rather tell Ms. K that she has breast cancer?" Dr. C admits that she would prefer the wheezes. "I like asthmatics," she says, and goes to listen to him wheeze some more. I am useless. No one wants a med student around when they find out they have cancer, and Mr. Wheezy is too sick to tell me what happened to him. I listen with my steth to his sad huffing-honking sounds and pretty soon he has a syringe of epi in his arm and a puffing nebulizer strapped to his head, and pretty soon some crabby paramedics are hauling him to the ER. The wasted drops of epi that swelled and fell from Dr. C's needle dry up on the workroom counter, while I read about chemotherapy. Kool 108, the favored radio station of this clinic, begins playing "Stayin' Alive."

A few hours ago I said the following sentence on the phone - "You mean J__ had to pose as a dead dog in order to look at the wedding pictures?" Indeed, this was the case.

A few hours before that, I heard a story in Spanish in which the protagonist's back pain originated from an incident in a field full of borregos where he was struck by a becerro. Huh? A flutter of iPhones and BlackBerries commenced in the clinic room. Ah. A bull calf in a field of yearling sheep. The new attending diagnosed our patient with "acute wellness." Gold star prize! we agreed. We'd sent our previous patient home, although she had peed two times in as many days, after deciding she wouldn't crump and would certainly resent the thousand dollars she'd spend on the bag of IV saline she rightfully deserved. At least the team of six med students, two MD's, and three pharmacists who gave her a sheaf of semi-adequate medications was free.