Salvation Army and Internship

This trimester officially marks the beginning of my clinical internship. For the next year, until graduation, my colleagues and I will be working with and treating patients under the license and supervision of various clinicians. It's a time to hone our skills of exam, diagnosis, and management. It's an exercise in understanding, in empathy. More importantly, it's a privilege to build a relationship with patients from all backgrounds, to be allowed into their personal life and history. It's a sacred experience -- and a humbling one.

Suddenly, all the classes taken over the past few years seem overwhelmingly crucial. Worry sets in. What if I've forgotten something crucial (and believe me, it seems like you forget a lot); what if I miss something? A whole slew of questions flood in. There's good news, though! All the stuff you thought you've long forgotten is still in there, laying dormant until circumstance calls upon it.

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The first patient I was with, on my first day at the Salvation Army clinic, showed up severely out of breath. The patient immediately stated a history of COPD and complained of an intense, severe left sided headache. My colleague and I immediately took his blood pressure and recorded it to be 200/90. There was a moment of disbelief, followed by rationalizations, reasons why this man couldn't, shouldn't, have blood pressure that high. We tried a larger cuff. We let him relax for a few minutes. Finally, there was no other rationalization. We had to face the music. These combined factors constitute a massive stroke risk, so we had our clinician call an ambulance.

Sure, it's the cliché medical story, but the point of this story is to demonstrate that, even though I didn't have those factors involved in stroke risk consciously available while going into that patient appointment, when I saw the red flags, the answer came to me, seemingly out of thin air. The things we learn stick with us, and the more work we put into learning the science and the pathology, the longer they remain. Don't fall into the fallacious belief that simply because you don't plan on treating a condition, you don't need to know about it. You will be a doctor, regardless of whether or not you are in acute care, patients' lives will be in your hands.

Don't Miss the Trees for the Forest

"Don't miss the forest for the trees," is a common saying we all are familiar with. It simply means that it can be far too easy to miss the big picture while obsessing over the details -- over the minutiae. We utter this phrase, without cursory thought, as a platitude more often than not. But, I don't think our problem is sacrificing the big picture for the sake of details. In fact, I think it's the exact opposite. So much of our lives we're reaching for some obscure, hazy goal that remains elusive, just beyond our grasp in the future. What do we sacrifice while chasing the 'big picture'? We miss out on all the beautiful details that the present has to offer -- relationships, connection to your surroundings -- the small things. If anyone is guilty of this, I most certainly am.

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A topical piece of contemporary art I recently saw entitled:
"Wrestling With My Own Worst Enemy"

School doesn't help the issue, because the point of school is accomplishing the far-off, arduous task of graduating and (hopefully) learning a thing or two about being a good doctor. The day-to-day connections and priorities tend to wash out in the blinding light of the big picture. It takes awareness and grounding exercises (meditation, yoga, prayer, whatever it is you do to re-center) to combat this powerful tendency towards interpersonal complacency. Not only do our patients need our emotional presence, our loved ones do, too. Complacency kills, not only literally, but figuratively as well. It can kill a relationship or a patient as readily as it can kill the pedestrian hit by the driver who wasn't paying attention.

The patient's well-being and health should always be our primary goal. It's a goal that demands our presence in the here and now. Our loved ones should always be our primary goal, not some ambiguous far-off goal of personal gain or notoriety. It's a mistake far too easy to make. Combat it. Don't miss the beautiful complexity of each and every tree for the vastness of the forest. 

Leaving the Academic Nest

NextIt's the end of the trimester. The closing of this one signifies the opening of a new educational experience - clinic. I know I should be psyched about this milestone; I should be ecstatic to put years of work into practice; and I am, but I have mixed feelings. I'm excited for life outside of academia, but a little apprehensive of life outside the cocoon of classes, of routine and schedule. Life is determined for you within the strictures of schooling. Your day is laid out; life, for almost 4 years, is laid out. All you need to do is keep up. It's this aspect of life in school, and the Marine Corps for that matter, that I've hated the most - the inability to be master and commander of my daily life - but this is a two-edged sword. 

After all, it's pretty handy to have some entity, other than yourself, to blame for the unfortunate parts of your life. When so much of your schedule is laid out for you, it provides quite the scapegoat. Life after school, or the military, may have more degrees of freedom, but exponentially more responsibility. That reality can be intimidating, but it's so uplifting, too! The risk is higher, to be sure, but so is the potential gain. Leaving the nest of academia means the opportunity to actualize your potential, your calling. 

So, my feelings may be mixed. I may feel a tad apprehensive. Overall, though, I'm filled with positivity for what life may hold. I'm excited to test and build my craft, to discover and build on my own treatment protocols. I'm anxious to get started with the creation of my vision. The days spent in the safe haven of the classroom may be over, but life is just beginning.

 

The Power of Fascia

Fascia. It's what ties the locomotive units of our bodies together into streamlined functional cohesion. It opens a dialogue between muscles a body apart. Bruce Lee said that his famous one-inch punch began in his big toe, the force traveling and multiplying as it traveled up his leg, obliquely across his torso, down his arm, and ending in his fist. His fascia played a crucial role in creating that smooth-flowing, interconnected movement. 

BruceFascia is like a saran wrap that covers our entire musculature, and while it isn't a force generator, healthy fascia is an extremely effective force transducer. An easy way to think about this mechanism is to imagine an active muscle 'tugging' on the fascia. This tug gets transferred to other muscles tied into that same fascial plane, activating it and coupling its force into a larger movement. Fascia is pretty great stuff. However, it's also very easy to see how it can be the phantasmal accomplice in almost any movement disorder or musculoskeletal malady. 

A chronically tight muscle will put constant tension into that fascial train, affecting all the muscles along it. For this reason fascial considerations need to play a part in clinical reasoning. Perhaps the patient's sub-occipital pain and tension isn't being generated in the upper neck. Perhaps it's being generated by an issue in the foot, or the gastrocnemius, or the hamstrings.

This is why a global approach to a local problem is such an important facet of diagnosis and treatment. It's a lot to take in and adds a layer of complexity to an already complex system. But, it adds organization. It adds an explanation, a predictable pattern to follow and assess. It is for these reasons that I view Dr. James Jenkins' Functional Rehab class as being the quintessential DC class. He ties everything together by addressing global biomechanics and fascial planes with all the tools we've built over the past 3 years: the adjustment, soft tissue therapy, stretching, exercise prescription, kinesio taping, and proper diaphragmatic breathing. I'm not saying it's a panacea, but it's pretty darn close in the world of musculoskeletal maladies.

AnatomyImage source: Anatomy Trains

Navigating the Financial Minefield of Higher Education

Beginning a program of study in any graduate or medical program is daunting enough without thinking about the financial aspects. Adding the complexity of student loans to the mix is enough to make anyone shudder with stress. The time commitment to school is so exacting that many schools cap, or prohibit, the hours dedicated to a job. This places a student's financial security, for about four years, solely into the hands of the federal student loan program. Depending on your trust in the government, this can be a pretty scary and stressful prospect. For, if life has taught anything, it has taught that it is anything but predictable and financial curveballs are a harsh reality. The "what-ifs" are endless. Am I painting a bleak picture? Don't fret, there's good news, too.

MinefieldIt took me years to wade through the ins and outs of our financial aid system and, while my knowledge is still cursory, I'd like to share some of my findings with you. Here's the down-low.

A student living off campus is eligible to draw a "refund" for living expenses equaling $7,600-$8,000 per trimester. Sure, right off the bat, it seems like a pretty solid amount - and it is. That's a few thousand dollars better than a full-time entry job at McDonalds. Sure, you may scoff at that figure, but it does cover a modest apartment, a grocery budget of about $50-70 a week, and all the other bills and expenses... barely. There's not a lot of wiggle room for acts of god. OK, OK, I swear the good news is coming.

Let's say, your car blows a belt, needs a new radiator, or wears out its tires. It's an unforeseen expense that you can't afford with your refund. Here's the pearl for the day - you can bring in the receipts for your car repair and the school will request extra loan money for you to cover it. Yes, it usually is via a credit-based Grad Plus loan, but by the time you're done at National, you'll most likely be well acquainted with them anyway. Don't freak out yet, by credit-based I don't mean to imply you need some sort of Bill Gates credit score of $8 million. You just can't be 90 days or more delinquent on a credit payment recently. They'll work with you. So before you get too stressed thinking about the financial hurdles of pursuing your dreams, remind yourself that they're just hurdles - you can hop over them. Not to mention, Marc Yambao, head of Financial Aid at National, runs a tight ship and has a way of flattening those hurdles tirelessly.