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.