Some of my favorite things

I just finished my Psych rotation and while I don't have any interest in doing it as a profession it was definitely one of my favorite rotations so far. Part of it was because of the awesome hours (show up at 8am-ish, write up our notes and see patients until about 12 or 1pm and head home), the really relaxed attending physician I worked with and the interesting cases we saw. But by far the best part has been overhearing bizarre conversations I overheard that caused almost no reaction from the doctors.
Pt: "I see dead people coming out of my chest telling me to kill myself."
Doctor: "we don't really deal with dead people..."

Pt: "the black government implanted a chip in my head to monitor my thoughts and prove that God exists"

31 year old black Pt: "I'm 98 years old and used to be white, but the handicapped kids I taught kidnapped me and beat me up so badly that I turned black"
"I used to be a pink alien with pink hair down to my feet"

And many more that I just can't remember. I think this would keep things interesting and would be something that I could enjoy, but ultimately I still don't think it's for me. The reason being that I like talking with patients about their health, coming up with a plan together, and teaching them things they need to live a long and healthy life. This doesn't really work too well when the patients' brains are the problem and they can't really understand that what they are thinking is totally askew.

Once in a blue moon

If any of you have ever watched the TV series House M.D. you will know that he believes all patients lie. If you haven't seen the show then here's the low down...he thinks patients lie.
We had a guy that we took care of this week because he came in with a self-inflicted gunshot wound to his lung. Yeah, he shot himself but not with the intent to kill himself, just to get attention; a "cry for help" as he put it. There have got to be better ways for getting help, but nevertheless he was admitted to the hospital for depression, got some pain medications, and got his hydrocele surgically repaired so I guess it worked (A Hydrocele is a very uncomfortable disease of certain man parts). As with all patients that a doctor sees, we have to ask them a whole bunch of questions, and especially in the Psych Ward we see a lot of drug abuse so we ask a lot of questions about drugs. When we asked this guy if he did drugs he told us that he only did marijuana "once in a blue moon". When pressed further on that he admitted that he smoked a bowl of marijuana (not a joint, but a bowl) once a week and it helped with his vision (which it doesn't).
So in case you're wondering, "once in a blue moon" for this guy means once a week. (In case you're still wondering, a blue moon means either having 13 full moons in a given calendar year or having 2 full moons in the same calendar month. The 13 full moons one is much rarer than the 2 ful moons one).

My nightmare

I recently met a guy who is living my nightmare…he has celiac sprue. This is a disease where the person becomes allergic to wheat!!! If there is one thing that I love it is baking bread. If I had celiac sprue I would probably lose some of this weight I’ve gained the last 2 years but I would be miserable...miserable. But I digress; this is really a post about bread, not about being allergic to bread. We have two bread cookbooks, one pastry cookbook, two pie cookbooks, and one cake cookbook. Our first bread book was The Bread Bible by Ruth Levy Beranbaum and with some reservations we really love her book. It has many fantastic breads in it and it is a great book to start with for someone wanting to make their own bread. However, she is first and foremost a dessert expert (her cake book is amazing, as is her pie & pastry book. Nothing we’ve tried has turned out anything less than amazing) and the difference between her book and our recent purchase The Bread Baker’s Assistant is evident. Peter Reinhart is a bread instructor at Johnson & Wales University and he knows bread. This book doesn’t have quite as many recipes (or formulas as he calls them) and the ones that he does have are mostly hearth breads (also called rustic breads, or artisan breads) and taste absolutely amazing. Hearth breads are breads made from flour, water, yeast, and salt and that’s essentially it, but can be manipulated to produce a wide variety of different textures, shapes, and tastes. In case you’ve never had these breads, or more likely have never made these, I would highly recommend it. They are simple to make and absolutely delicious.

Residency Decisions - Not Psych

I recently started my Psychiatry rotation, and even though I've only been doing it for a week I can pretty much say that Psych is not something I see in my future. That being said, it is very interesting. Many of these people are prisoners of their own minds. One lady on the psych ward illustrates this point. She worked for many years as a postal worker (in the back rooms somewhere, not with customers). It's unclear exactly what happened, but somehow something pushed her over the proverbial edge. She started acting funny (-ier than usual) and it got so bad that she was commited to the psych ward. So far that wasn't the interesting part, what was interesting was that she thinks that she is completely normal. She hasn't washed her hair in over 2 months (until eventually had to put doctor's orders in her chart for a deep shampoo) and this hair was something else. It almost formed a 3 inch halo perpendicular to her head and the rest just fell back after. She has the devil's own hair product because it's been exactly the same for 2 1/2 months! It's very intersting talking with her though because she doesn't think she should be there, nothing is wrong with her, she needs to get out to go back to work, they have replaced her at work with an imposter, the women that visited her aren't her real daughters because her daughters are still little, etc. I just feel badly for her, but there isn't any reasoning with her. These messages are coming from her own brain without and of the normal filters that you or I have so she has no reason to disbelieve them, they are ABSOLUTELY true to her.
I guess ultimately I don't think that Psychiatry is for me because 1) i'm not patient enough for it and 2) I like interacting with people too much and even normal conversations here are analyzed for clues into the patients' brains, you can't just sit back and have a conversation with them.

...and we're back

It's been a while since I've blogged, partly because we've been busy, but also partly because we haven't made anything brand new. All that has changed with a couple of really delicious recipes we tried and the start of my Psychiatry rotation at school providing both a new and most likely crazy source or medical stories and ample time to try new recipes as it is one of the easiest and least time intensive rotations in 3rd year.
On to the recipes that I was particularly impressed with was the Cranberry-Walnut Galette. I'd never heard of a Galette, but essentially it is a pie with out the pie pan. You roll out the dough (which in this case was a soft cream cheese crust), put the filling on it, fold over the edges and bake it. This, for me, was one of those recipes that guests will Ooh and Aah over but is deceptively simple. The filling consisted of cutting almost an entire package of cranberries in half, letting them macerate in sugar for a couple of hours, combine them with walnuts and some other stuff and then put it all together and bake the galette.
As somewhat of a post-script, one of our friends commented the other day that it takes a special talent to make pie crusts. I don't really believe that, I personally think that most people when they do make a pie crust it's only one and they make another single pie a year later and then don't get any better at making pie crusts. I think it only takes 2-3 pies in a months time or so and you'll have learned how to ride the bicycle so to speak and don't readily forget.

Decisions decisions

One decision – THE decision - that you have to make during the third year of medical school is what type of doctor you want to be for the rest of your life. Our rotation schedule is as follows: 12 weeks of Internal Medicine, 6 weeks of Family Practice, 6 weeks of Psychiatry, 8 weeks of Surgery, 8 weeks of OB/GYN, and 8 weeks of Pediatrics. This sounds like a lot, but there are tons of different specialties and even different aspects of the same specialty to factor in when making this decision. These last 11 weeks I’ve been doing Internal Medicine and so far I haven’t really enjoyed it as much so far. I’ve been in the hospital for the first 8 weeks and I didn't get to interact with the patients much at all. It felt like a lot of micro-managing their electrolytes (sodium, potassium, magnesium, chloride), vitamins, and various other markers of how their organs are functioning. This serves a very very valuable service and I'm glad that I learned how to do it, but the thought of doing that for my whole like was absolutely depressing. I next went up to a local VA hospital and it wasn't much better but not much worse either. The last couple of weeks however I have been at a free health clinic for those without insurance and/or low-income and it's been surprisingly fun for me. You walk into a room with a patient and get to talk with them about their health. Usually there is a specific concern they are following up on, but often it is just a routine follow-up and you have a pretty wide range to explore. I personally believe that if people would exercise more, eat less, eat healthier, and sleep more (as I just ate some ice cream and and stayed up late last night. hmmmm) many of their health problems would go away. The obesity epidemic is just that...an epidemic. Most people know what they need to do and it isn't news to them to stop smoking or lose weight, or whatever. I find that it’s really fun to talk with them and come up with a plan to help them accomplish it. For someone who originally thought he was going to be a surgeon of some sort, this is just as much a shock to me as to anyone. That isn't to say that I've decided to be a family practitioner yet, but it certainly has moved up on the list.

Apples

One thing Melinda likes/dislikes about my personality is that I'm not embarrassed to ask people for things. The most recent case is when a doctor at the hospital that I was working with mentioned some friends who had apple trees that they got some apples from. I asked the doctor (tactfully) if her friend had more apples that she wanted to get rid of would she mind if we came out and picked them. Her friends were a 75 year old couple who didn't pick any of the apples off any of their 4 trees. So we drove out that and got three bags full of apples. It was awesome. We looked up a bunch of recipes and started cooking. Not that I'm sick of apples or anything like it, but at least for the next little while I'm okay for apple stuff.
On to the experiments. The apple turnovers were really good. The only problem was that there wasn't enough apple filling per turnover. Next time we would stuff them to the gills. Overall a great recipe and tasted great.
I don't know how many of you have ever heard of apple butter before, but we hadn't. Essentially you carmelize the sugar in the apples by cooking them in a crockpot for almost 12 hours. We like it okay, but it's definitely not at the top of our list of things to make with apples. Overall something that we like, but we wouldn't make it if we could only make one (or two) thing(s).
The apple pie turned out amazingly. I'm pleased to say that the crust turned out actually looking like an apple pie! Hooray. (My top spot is still pumpkin, but apple definitely moved up a couple of notches). By far the hit of our apple foray was the apple dumpling. I'd never had these before but they looked like such fun to make we went ahead with it. The crust is very similar to the apple pie
crust but it's wrapped around a whole apple that's been cored, peeled, and filled with a brown sugar & cinnamon mixture. The brown sugar filling melts and creates this delicious filling. Our only problem with this is that when the filling melts it oozes out of any openings in the dough and ends up all over the place. The Pie & Pastry Bible's solution is to not core the apple all the way through, leaving a little piece of the core as a plug for the filling. This worked out okay, but it's very easy to punch through the bottom of the apple when trying to core it, and if you don't punch through the core the piece of apple left over is part stem and not something that I'm super interested in eating. Okay, after all those problems I have to say that we did make them three different times and they were delicious each time. They also look very impressive and are surprisingly simple to make. We also made apple crisp a couple of times with these apples, but if forgot to take a picture of them. I have to admit that i much prefer apple crist where the apples have been sliced thin as opposed to cut into chunks because the slices get much softer and more like an apple pie filling. All-in-all a really fun little adventure.
P.S.
If you would like any of the recipes email me at brockmillet at gmail dot com and I'll try to send them to you.

Death and Dying

One of the doctors that I work with asked me to help her pronounce a patient dead. This involves doing a number of tests on the patient to be sure of death; listen to their heart and lungs (that aren’t beating), touch their eyes (that won’t blink), touch the back of their throat (that won’t cause a gag), and rubbing hard on their sternum (and they won’t try to stop you). This was all very academic while we did the tests, but after we stopped I had a second to myself with the cadaver to think. The very next week we had a lecture on Death and Dying. These two experiences got me thinking about death. Despite the fact that everyone is going to die, our culture is very far removed from death in our lives and most people haven’t ever seen someone die. Advances in medicine also help us live much longer and gives us a mini-delusion that medicine can cure just about anything. Sometimes, however, this prolongation of life is done so at great cost to the patient and with very little quality of life. We have a patient in the ICU that has advanced ALS (Amyotrophic Lateral Sclerosis AKA Lou Gehrig’s disease – You eventually lose all muscle control in an ascending pattern, but your sensation is still intact. Eventually people die because their diaphragm muscles gives out and they can’t breathe. It’s a terrible disease and a terrible way to die). He is now almost completely incapacitated. He has a ventilator breathing for him, he’s on a bunch of antibiotics because of infections, he has a very large bed-sore ulcer on one of his calves from having it lie on the bed without moving it, he is fed through a tube, he has an enema every other day to produce bowel movements, he has a catheter for peeing, and IV fluid because he can’t drink. The only thing that he can do is blink, and only sometimes at that. Should we continue to provide support for him despite the fact that he has 0% chance for recover or improvement? Should we discontinue treatment? This really isn’t my decision to make for him, but I do think is that people need to do is to come to grips with the fact that they will die and decisions need to be made concerning it. We can’t always control how we die, but there are some aspects of death and dying that can be dealt with and communicated to loved ones before they happen. In case anyone wondered, if I’m dying, I would like my family not to prolong my life by hooking me up to lots of machines but to let me die with dignity and peace

Culture of Complaining

I know complaining about one's job is by no means isolated to the healthcare arena, but I seem to have fallen into a pretty terrible cesspool of it. I heard long before starting my rotation (a 4 week stint) that the staff here "is sub-par as are many of the doctors". My collegues complain about the nursing staff not being prompt about doing their job, or about doing it poorly. They complain about doctors being annoying or not caring. They complain about the up-to-date electronic medical records and the awesome system they have set up for medical records. They even complain about the one free meal that is provided for us at the cafeteria. Seriously people, wake up and see the good things about where you work and what you do. To use a cliche analogy, they only see and complain about the thorns and can't even appreciate the roses. Part of these complaints have some validity, but nothing in our lives is ever going to be perfect, why do people have to go about being miserable because of it.
As I said earlier, this isn't isolated to my area of expertise, I have experienced this in every job school I've been at. When will people learn to see the good things that are around them and not get depressed and cynical about their situation. Or at least if they are could they at least learn not to bring me down with them?

One of my common mistakes

Just in case anyone was wondering I learned again that baking soda and baking powder are not substitute-able. Oops.



Here are the differences between baking powder and baking soda.
Baking Soda - This can be the sole leavening agent if the dough has acids in it to react with (sourdough cultures, fermented milks - buttermilk/yogurt, brown sugar and molasses, chocolate, and cocoa - if not dutch processed, as well as fruit juices and vinegar).

Baking Powder - These are complete leavening systems: they contain both alkaline baking soda and an aid in the form of solid crystals.
This information was obtained from "On Food and Cooking: The Science and Lore of the Kitchen" by Harold McGee. It is a fantastic book if you are interested in cooking and want to learn more about how and why foods work.

7-grain torpedo

One of the great dilemmas with bread baking is the cost benefit ratio.
Here are some of the "pros" for baking bread. It tastes amazing, seriously, nothing tastes quite like bread fresh from the oven. It makes the whole house smell great; who needs scented candles or potpourri anyway. It's usually cheaper than buying bread from the store. It's also satisfying to make a loaf.
Now for the "cons". It takes a lot of time to make a good loaf (see bottom for some of the tricks for making great bread), not much active time, but a decent amount of passive time. It doesn't last nearly as long as store-bought bread which means you would have to make it every other day or third day to have some on hand. And perhaps the greatest con (which is also a pro) is that when you have a fresh loaf of bread you want to eat the whole thing.
Overall we have concluded that if we were to make bread to save money it just doesn't add up. We could (and have) eaten a whole loaf of bread right out of the oven before, so it doesn't stay around for long. That doesn't mean that we don't make bread anymore, because it's hard to resist its siren song, but we just don't kid ourselves into thinking we're being economical by doing so. Here are some pictures of a 7-grain torpedo loaf that we made, whole grain and incredibly tasty. WooHoo.

P.S. There are a couple of ways of making yeast breads. In the Bread cookbooks we own or have perused they recommend using a dough "starter" to increase the flavor of the bread. A starter takes all the wet ingredients with half of the dry ingredients, whiskes them together and lets them sit at room temperature to ferment. This give the natural bacteria in all flours the opportunity to out-compete the yeasts for a little bit. Bacteria and their by-products are what give breads their distinct flavors while yeast provides lift and airyness. Many bread recipes in non-Bread Baking cookbooks advocate using much more yeast and leave out the starter to save on time. This starter takes a little more thought ahead of time, but the better taste is worth the effort.

Why today?

The hospital that I work/study at services a lot of indigent people and those without insurance. Many of them are uneducated, unemployed, drink a lot, smoke a lot, don't have great hygiene and in general don't take great care of their health. That means that we see a lot of things that are downright disgusting. Take for example two people I saw today. One of them had scraped up their knee and now had a bacterial infection. That's not great, right? But it's just an infection you say, what could be that disgusting about that? And you would be right, except for the fact that the lady is only 5 feet tall and weighs over 350lbs. This person's calves were so big that my hands would have only gone half way around it. The best/worse part though, was that she was embarrassed about not being able to shave her legs!! Seriously woman, that's the least of your worries. She needs to lose 225 lbs and she's worried about not shaving her legs.

Another guy that came in had something called "woody edema" or "crocodile skin" (see picture on right) and a necrotic lesion on his foot. Now when I say necrotic lesion many of you may not know what I mean. Essentially the blood backs up in the veins which causes the skin to not get enough oxygen and if this happens for a long time eventually the skin, fat, and muscle there will just die and decompose while still attached to someone's leg. This guy actually had maggots infecting his wound. Yup, that's revolting.

Both of these people made me ask the question, when is enough enough? Is this lady just waiting to pass 400 lbs before making serious changes in her life to lose weight? Was the guy just waiting for the necrotic lesion to get to his ankle before coming in to have it looked at? (incidentally he's going to have his foot amputated half-way up his foot). It just baffles the mind.

Moral of the story; Don't wait until it's disgusting, smells, and has maggots growing on it.

A little disapointing.

Melinda went to the store two days ago and found that a pint of raspberries were $0.99. Oh the possibilities. This is like finding $5.00 in a pocket you forgot about. We ended up making an almond raspberry tort.
https://www.gastronomyinc.com/recipes/rasp_almond.html
I'll briefly describe the tort (or torte) for you. It's composed of two egg-based cakes sandwiching a layer of raspberry-almond flavored pastry cream (a pudding mixture that most will know as the filling of eclairs).

If I had to review this one I would say that it had great potential, but for the lack of clear instructions the results won't turn out like they are supposed to (It really does taste amazing, though so I would still recommend it). Here are some suggestions we thought of from our first time making it.

1) The recipe tells us to make the pastry cream and then mix it with the egg whites that have been beaten to stiff peaks. There is no mention of timing here. I would recommend chilling the pastry cream for at least a couple of hours to really firm it up before beating the egg whites and folding them in.

2) Because the pastry cream wasn't thick enough, it just oozed out between the cake portions and was a mess. To remedy this perhaps cooking the bottom cake in a springform cake pan and/or simply assembling the cake inside one would be a good idea. This will help keep the pastry cream pudding from oozing out the sides while still allowing you to remove the sides and not have to dig the cake out and ruin it.

As a post-script, we refridgerated the tort and it firmed up nicely. It also tastes fantastic, but unfortunately that presentation was really crappy.

One of my greatest passions

I have a couple of great loves in my life. Food and cooking are two of these. Recently we have started growing an herb garden, and lame as that sounds, there is something uniquely satisfying about using your own herbs on something you cook. We have some Basil, Oregano, Thyme, Chives, Cilantro, and Mint that are all doing well (for some reason my Rosemary plant died and I had to take some cuttings to restart one). Last Sunday we marinated some chicken for kebabs in some olive oil, red wine vinegar, some salt and pepper, and 1/4 cup of freshly cut herbs. Normally this would have been a little expensive to go out and buy these herbs, but now I can go out and just pick some from my back steps. (Clockwise from upper left: Basil, Thyme, Chives, Cilantro)
In addition to the culinary benefits there is something incredibly fulfilling about growing plants. You go out there, you water them, tend them a little, and you get to watch the grow. It's hard to describe, but it's like creating your own oasis, your refuge from the storm of life. Okay, that was a little too "cliche poetry", but it really is close to how I feel. For anyone interested, growing a little herb garden or just a little plant is very rewarding.

Do you smell that?

As a (fake) doctor there are many aspects of my job that are really cool. It's a profession that most people respect, people entrust their health and lives to you, and most of the stuff I learn is really interesting. On the other hand there is one part of medicine that is less than glamourous and unfortunately there’s no way around it; human bodies are disgusting. You never know what your senses will be assaulted with when walking into a room. The other day we walked into a room where a person had a coloscopy bag (she was mentally/physically out of it and couldn’t control her bowels) and the smell was suffocating. Another day we walked into a patient’s room that’d been in the hospital for a couple of days and apparently (and somewhat understandably) had forgotten (?) to get up and shower. In another doctor’s office there was a patient that had an infection on his hand and after we cut it open the whole room stunk like crazy. Why, you ask, do I feel like it is worth a post to share with you these stories? Next time you look at a doctor (and to a greater degree Nurses) just remember the not-so-glamorous aspect of being a health care professional – it’s what we deal with on a daily basis.

My first week

So this week marks the first time that I actually have any say in a patient's care at a hospital. How much responsibility do you have? Well imagine letting your little child sit on your lap while you control the gas/brake/etc and teach them how to drive; about that much. Most of the time we're bored because we don't really get to do anything or have any responsibility. In any case we do get to interact and connect with real people instead of fake patients. Every morning we see our patients' chart, check up on them, then do it again with the intern, then do it again with our team of students and the real doctor. We kind of get to know them and their story. After we see them we sit down (the med students usually stand because we don't have enough chairs in the hallway and we don't really contribute that much to the discussion) and talk about their case, what tests we're going to run and what we think the actual diagnosis is. Usually this is fun (like learning fun, not ha ha fun) and we learn something, but today it kind of became a little too real for me. There was a patient with unexplained weight loss (which is never a good sign). Sure enough, today when we went down to surgery they took a look at his insides and he has metastatic cancer (metastatic means that the original cell(s) that became cancerous and started to grow uncontrollably have spread to different places of his body). The surgeon came out to talk with his family and had to explain to them that their father/husband would probably only have 6 months to live. I don't even know what I'd say to them, I don't know what we're going to say to him tomorrow when we come by to see him again. "How are you feeling today?" "I'm very sorry about this, we're going to get started on chemo right away." "Man, sorry about that metastatic cancer thing. How you doing otherwise?" Nothing really seems like the right thing to say with something like this, but saying nothing at all seems worse. I'm sure the doctor will have seen this before and figured out something to say, and for once I'm actually glad that I'm the medical student and not the one with all the responsibility.

The French Baguette Dilemma

There is something incredibly satisfying about having a loaf of bread turn out well. Along the way you have a sense that it’s going well to turn out well based on how it rises and looks and feels, but you don’t really know until you pull it out of the oven and taste it. Our first bread book has been The Bread Bible by Rose Levy Beranbaum, and for the most part we’ve been really impressed by it. In many ways she is a purist when it comes to bread; the bread should be as close to the original as you can make in your home kitchen. This has produced some really fun breads for us that are impressive to look at and taste fantastic (see pictures - first one is Challah bread, second one is Walnut Fogasse). On the other hand there are recipes for certain breads that don’t turn out as well. The case in point is a French baguette. In case anyone was interested in how long it takes to make this, the answer would be about 24 hours from start to finish. Most of that is just waiting around time, but still, that’s a really long time. Our first two attempts turned out looking and tasting very much like authentic French bread with the obvious exception that they only raised a little bit and were only about 1 ½ -2 inches thick. You can imagine our frustration at spending all that time for a flat loaf. Our next attempt was using Baking Illustrated’s version of it and boy-howdy did it raise so much better and tasted pretty good, but more like an Italian loaf than a French baguette. So the real question of the day is would I rather keep trying a French baguette that looks and tastes more authentic to get it to raise, or a softer fluffier loaf that doesn’t seem very authentic. Life is full of tough choices. Ultimately I think that I’d prefer to keep on trying the authentic loaf, otherwise it just seems like I should just make white bread and shape it differently to call it different loaves.

Starting my rotations

I’m starting my rotations this coming Monday. I have to admit that I’m embarking on this new chapter with 90% excitement and 10% fear, or perhaps 90% fear and 10% excitement, it’s hard to tell. For those who don’t know how medical school works here’s a brief overview of how it works. Medical School is 4 years long with years 1 & 2 being almost exclusively class- and bookwork. Years 3 & 4 are clinical work in hospitals, doctors’ offices, etc. At the end of 4th year we need to apply for a residency position for 3-5 years of specialty training (pediatrics, family medicine, surgery, etc.).

I feel that college was very similar to the first 2 years of medical (only a much slower pace) and I pretty much knew to expect long boring lectures. July 1 I will have finished my 2nd year and will start my 3rd year knowing a lot of facts, not really knowing how to interpret many of the patients’ symptoms, and not really knowing when to order tests or interpret them, and yet I’m getting released upon the unsuspecting public. (July is when all new medical students and residents start. If you have a choice of when you get sick, do it in May or June and avoid getting sick in July).

I’m not as worried about the cerebral (though I’m still scared) nature of things as I am about learning to do the procedures. I need to learn to place IV lines in people veins, place catheters, and do rectal exams. My only hope for these patients is that they are sedated or in a coma and won’t feel my blundering first attempts