Head and Neck

I got an email with the topic for my very first treatment planning exam.

Aside… A treatment planning exam is an oral exam where we get grilled on our management of patients from presentation to treatment and follow-up to help us practice for our licensing exams at the end of residency.  It can include basic questions right up to referencing why we do treatment in a certain schedule and where a target its. They start in third year, which is where I am now.  They are supposed to start off easier and get harder as time goes by.  At least in theory.

The site is “Head and Neck.”

Agh!

My issue with this?

Head and neck is probably one of the most difficult sites to treat and master.

I mean, we don’t do much head and neck related stuff in med school or even the first two years of residency and then, bam!  I’m treating cancers there.

At least, I have for the last two and a half weeks of this rotation.

I like head and neck.  I have said it is likely a site I’ll want to treat.  That doesn’t mean I feel anywhere near confident in it.

And it is my first exam.

When I opened the email, I just cracked up laughing.

Apparently most people get something like bone metastases from another primary.  Nope, not me.

Maybe it will be more simple than it sounds.

But, I don’t feel optimistic.

It is going to force me to read more.  But, I really was hoping for a relaxing weekend home.

That is how life works.  And how residency works.

Learning is good.  Looking stupid is part of learning.  I just need to embrace that.

Thank goodness Dr. Bond gave me some notes and tips.

I just hope my examiners remember I’m just in third year.

Radi-what?

Today, I met Radiology again.  We meet daily on most of my rotations, but for the next month, we will be spending some quality time together.

It is new rotation day.  And my new rotation of the month four weeks is Radiology.

And just to clarify, in case you, like many people in my life, are thinking “That’s great, your home service,” the answer is no.  My home service is Radiation Oncology, not Radiology.  They are commonly confused.  Radiology takes pictures and uses imaging to take biopsies or put in certain devices.  Radiation Oncology treats cancers with radiation.

I have done Radiology rotations before.  I did job shadowing as a med student, then a full week in a summer med student program and two weeks of selective in fourth year med school and now this four week stint.  I have a whole degree in Nuclear Medicine.  A degree.

It is important stuff.  Seriously, without being able to read images and without the help of Radiologists being a cancer specialist, especially a Radiation Oncologist would be pretty freaking rough.

That being said, it isn’t easy to teach.  A lot comes from seeing the normal stuff over and over and over again.

And I have a ton I need to learn.

The thing is with Radiology rotations is that they are different from you usual clinics, consult or floor services.  You basically watch and listen to people do their jobs.  Sometimes, you get to try to do it too, but really, you are generally a bystander.  Because nobody wants someone random reading their CT scan without assistance.

Image from diagnosticimaging.com.

Because much of the day is watching people do their jobs, it requires consumption of mass amounts of coffee.  At least it did when I was a med student.  I am sure it will again.

Also, because it is a lot of watching people do their jobs, it is a lot of being told “Why don’t you go read for a bit and we can review the cases together later?” or “It is just boring stuff now, so you can go.”  And I get it.  I wouldn’t enjoy someone hovering and I wouldn’t want to feel like I was boring someone.  But, that is what I need to do to learn.

The good thing is that I have four weeks and lots of different things that I want to see and do.  Hopefully, I will accomplish it.  Plus, I can always go do some Nuc Med to make myself feel better inside from time to time (how often do you hear that phrase?).

That being said, it does also make for some excellent hours.

1 in 4: Lessons in reality on the transplant unit.

I have spent the last almost month now on a bone marrow transplant elective.

I always throught I would like to be involved in transplantation.  I get that in my field, it is a small role, total body irradiation for certain indications, but nonetheless, it is a contribution, and I thought being a part of that team would be fascinating.

I have obviously been working more from the hematologist (and thus, the more involved) side of things.

I love it.  I might end up stuck at work late most nights and skip meals because it is too busy to eat properly (but really, how is it that much different from most rotations), but it is fascinating stuff.

The thing is, it is different from what I expected.

My perspective of bone marrow transplants is romanticized.  When I thought transplant, I (despite my previous criticisms of the realism of the books) pictured something from the pages of My Sister’s Keeper or one of Lurlene McDaniel’s books.  I saw them as tough and filled with complications, but also as a cure and this glorious saving grace.

Transplants are these things.  But, there is so much more to them than what the books suggest.  I feel like books and movies make them seem like a cure-all thing, but they aren’t all the time.  And although complications are addressed, I feel like they aren’t portrayed as the potentially fatal things they can be.

You don’t just go getting transplants all willy-nilly.  They are for people meeting specific criteria.  For people who are otherwise healthy and for people who have some baseline reserve.  They are generally for people who are at risk of dying from their disease sooner rather than later if they don’t go to transplant.  They are serious business.  And continue to be long after the transplant is done.

The bone marrow transplant hematologist I am working with this month is cautious to remind us regularly that there is a good chance any one of our patients could die.  Even if we do everything right.

He says it is one of the toughest parts about doing transplants  1 in every 4 or so people he develops a relationship with dies.  This is tempered with some lower risk transplant variants where it is only 1 in every 10.  But still, average that out and you still have 1 in every 5 or 6 dying.  And there is still the risk of relapse and such in the long term.

Kids do better than adults.  These odds are adult odds.  Kids tolerate everything better.  That is just how kids roll.  They can take so much more than adults can.  I am glad for that.

I know, this from the oncology resident who loves palliative medicine where 99.9% of people die.  But, you know that going in.  You know there is no cure.  This is a potentially curative treatment.  That is tough to go through and a good chunk of these people die.

I am okay with the odds.   I get that the odds of survival in transplant in the setting of malignancy are better than the odds of surviving their disease without treatment or with other treatments.  That is the only way you can really justify going through it.  People are referred for transplant only when survival post-transplant are higher with than without it.

Plus, flip the odds around… 3 in 4 survive, 9 in 10.  That sounds decent, I think.  Especially compared to what it would be without treatment.  Tough stuff, but realistic stuff.

I have watched people do well with transplants.  I have seen people come in with brutal side effects and consequences of transplant.  But, they are alive.  I have had people horrendously sick one week come out of it looking great and running into me on the street after they get out.  I have had others who came in looking great and have tanked.

Known risks.  Known benefits.

Everything in life is like that.  In the oncology world, these risks and benefits can be extreme.  Sometimes the odds and the risks blow my mind.  Seeing us making people so sick with toxic doses of chemotherapy and then saving them with stem cells.  Watching someone hover at risk of infection, of bleeding trying to keep them comfortable and safe and hoping that their body recovers their blood cells before things get out of control.  Watching someone recover their counts and their life day by day.

When it comes down to it, when you look at the data, some risks are worth it.  And there are always those who defy the odds in either direction.

The transplant patients I have worked with have been some of the toughest, bravest and nicest people I have worked with.  That is probably part of why I shudder when my staff doc reminds me again that there is a chance the person won’t survive, even if I do everything right.  At least, I am learning how to do things right.  And be realistic while being supportive and caring.

I am glad for this experience.  For the realistic perspective I have of bone marrow transplants I have gained.  And I still want to be involved with them because they save lives and buy time for so many.

Sometimes, I still wish it somewhere near as simple as it seems in fiction books.

July 1

It is July 1, which means it is the first Monday of the month and thus, Medical Mondays, a day to link up with all blogs medical.  If you want to check out other fantastic medical blogs (which you should), click the button below…

It is also Canada Day, which means a long weekend for me (okay, I worked overnight Friday and all day Sunday, but still I am not working on a Monday, so that is pretty huge).  I am not a very festive person, but am pumped to be heading to watch the Tattoo (aka this awesome military related show) this afternoon.  Check out this video below if you want to see why I think Tattoos are awesome.

And lastly, and most importantly (for me, at least), it is the start of a new year of residency.

A piece of me feels like I should celebrate like these guys. Image from bmaycreative.wordpress.com.

For those of you non medical people, residency training in North America follows a strange calendar year from July to July (just to make sure that we don’t actually align with other post-secondary or life related time markers).  July 1 is the official start date.  Thankfully, here, every year that is a holiday, so many get to delay the inevitable until the 2.  That being said, there are always the unlucky souls who have to start out with call on the 1st.  I was grateful to not be one of those.

So, I have survived a year of residency.

Don’t worry, I am not about to give a self-help first year survival guide. If you were looking for that… It isn’t here. Image from jeffwerner.ca.

That is 13 blocks of rotations, which for me worked out to 9 different specialties and 11 different departments or areas of departments.

I worked in two different cities.  I spent 55 nights on call, thankfully only 24 of which were spent in the hospital.  That really isn’t bad for a first year residency.  It makes me grateful for many months of home call and three rotations with no call.

She looks better than I did some nights. Image from tumblr.com.

I went through at least 10 pager batteries, two pagers (one for each city), two pairs of “work” shoes, one triplicate prescription pad and enough pens to supply a classroom for a year.

I wish my pens were that pretty. Image from penguyart.com.

I can now pull out all sorts of drains and staples, do a lumbar puncture, do a paracentesis and releluctantly sew up your wounds.  I would rather not, but I can do those things.

I have a permanent ink stain on my right ring finger.  And I still, for some strange reason prefer doing paperwork over procedures (see the previous paragraph).

I am still scared of my pager.

Image from teen.com.

I still feel like I don’t know anything.  In fact, I think I know less.  That is just the beauty of being in medicine.  The more you learn, the more your learn you don’t know.

We are still married and are still happy about it.

I still love my specialty, even though I so rarely actually see it.

So, now we move on to PGY2.  Which, for me isn’t that different from PGY1.  I am off service even more than I was last year.  But, at least this year’s off service stuff feels more relevant and likeable than last year’s off service stuff.  Some more of it is oncology related.  And, I get to cover call for my home service when I am on some of these rotations.  Not that I am excited about call, but at least I get to do it from home and with the patients/staff I will work with some day.

Other than that, things are the same.  Wandering from rotation to rotation, but getting to stay longer sometimes.   The lost feeling remains.  I am taking the same physics course again this year.  I am working on the same research (I quite like it, so that is fine).

The cool part of it all is that I can now say I am a PGY2.  Apparently, somewhere in there, I am supposed to be growing up.  I am not the baby of the residency program any more.

Unfortunately, I am not actually getting taller. Image from claireyhewitt.blogspot.com.

Hooray for a new year and for a new step in training.  Just 4-5 more years to go.

Congratulations and good luck to everyone else who is starting or moving on in residency.

Nuclear Cardiology

Some processed images of a MIBI scan… Shows a heart with a fixed perfusion defect. Image from http://journals.tums.ac.ir.

Today, we were rounding, we decided to do a particular nuclear medicine test on a patient.  I internally got a bit excited.  And then the med student asked what it was and I gleefully explained.

It brought me back to my real Nuc Med days when I had a delightful teacher named Debbie who was extremely smart, but not always quite so aware of how ridiculous some of what she was saying is.  She is up there in my favourite teachers count.

You see, the patient was female and I pointed out the high false positive rate (especially when we were using this as a test to rule out a problem).  The reason for false positives… Breasts.

Hmmm… Ya know, my breasts could attenuate 80keV.  You just have to flop those dog ears of the way. –Nuc Med wisdom said while holding one’s chest.

Breast tissue attenuates (decreases) the radiation from the tracer that is deposited in the heart.  The center I worked at used a different tracer than the one here.  Where I trained, it was only 80keV as opposed to the 140 keV.  Still there could be some decreased detection and a possible false appearance of cardiac ischemia.

Of course we are still doing the test.  But I apparently even taught the cardiologist that new fun fact.

In those days of Nuc Med we had a secret quote board.  There, we kept track of all kinds of ridiculousness that came out of our faces those three years together.  And there was a lot of it.

We are such a nerd full of vans. –A

The trip in which we were a nerd full of vans... A Molecular Imaging conference in San Diego.  This is my class with the class from the year ahead of us and my favourite physicist ever.

The trip in which we were a nerd full of vans… A Molecular Imaging conference in San Diego. This is my class with the class from the year ahead of us and my favourite physicist ever.

Truth be told, I wish I had kept a copy.  I only remember a few gems.  Like the fact our patient care instructor couldn’t pronounce technetium, that Debbie asked us one day if she had an S on her head and that the condition cardiac tamponade will always make me chuckle more than the average person because one of the guys thought it was a tampon to the heart (and we all got assigned an extra reading assignment).

Our styling "star trek" lead vests.

Our styling “star trek” lead vests.

But, despite not remembering all of the ridiculousness, I still conveniently have a strange knowledge of bone metabolism, cardiac perfusion imaging, thyroid function and conditions and a variety of small niche type imaging techniques.  The stuff comes in handy from time to time, strangely enough.  Plus, the whole radiation safety and physics training is pretty handy now that the whole rad onc thing has started.

Our full lot at our hospital graduation celebration.

Our full lot at our hospital graduation celebration.

It made med school seem easier.  It helped me appreciate the health care team more.  It increased my laughter to schooling ratio.

If I ever catch you wearing scrubs outside the hospital, I will cut your fingers off… Using appropriate sterile technique. –Patient care instructor.

And the friends that I have are pretty awesome too.  Even if we only get to have approximately semi-annual outings together due to our spread across the country.  Very few people share fond memories of hanging an inflatable santa out a window with a noose, blowing bubbles out the same window, just to see people’s reactions and the joy of playing catch in any season, in any location.

All dressed up for our last day of clinical... With a stand-in.

All dressed up for our last day of clinical… With a stand-in.

It hit me… Right in the thyroid cartilage! -Me during a rowdy frisbee match… Indoors…  During the lunch break between the two halves of our licensing exam.

Hooray for Cardiology.  It brought me back to my good old days in my bizarre little radioactive niche.

Sinking in Sarcoma

Much of my life of late has been consumed by sarcoma.

Thankfully, not because I have one, but because I am doing a presentation at my home program’s resident rounds about them.  And I did one on my last surgery rotation about them.

In fact, it seems sarcoma predominates my current status.  I even saw a kid in emerg last week with a giant belly mass for which sarcoma was on the differential (I assumed more because all I have been doing is reading about sarcoma).  But, I was following up on the case and it turns out I was right… Sadly.  Although there are other things that could have been worse.

Last night, Patrick started decorating for Christmas.

I worked on my sarcoma presentation.

This was the view from my corner of the dining room table (and you know I must be serious when I am actually sitting at a table to do work).

Our blended winter family was spying on me as I worked.  The littlest one was hiding behind my laptop screen.

Our blended winter family was spying on me as I worked. The littlest one was hiding behind my laptop screen.

Tomorrow, the presentation will be over and I can finally use some of my extra time to do something not sarcoma (like catch up on the peds reading I am getting behind on… Or, Christmas shop).  I love presentations though.  And the nerd in me loves preparing them too.  I am clearly not right in the head.

Sarcomas are interesting.  I am focusing on extremity soft tissue sarcomas, so tumors made up of cells that were once muscles, fat, the lining of our joints and such.  There are over 50 subtypes, yet, they are only 1% of adult cancers.

The main treatment of a sarcoma is surgery.  But, good quality surgery specifically.  A good resection can be the difference between life or, well, a short life.

The other big sarcoma treatment is radiation.  Because there are so few sarcomas, there are limited really good quality trials on it and because there are few trials, the treatment, although signs point to it changing, has been fairly consistently surgery followed by radiation.  More and more evidence and practice based observations suggest it might be better to irradiate up front, possibly with chemo.  But, there is little to actually scientifically test it on.  So, it is a debate.  A big one in the field.

This debate came up during my surgical rotation when I presented on the debate itself.  Despite all kinds of retrospective studies suggesting radiation up front could be better, there is only one trial that looked at it and it ended early.   Surgeons are hesitant to send patients for radiation first.  Radiation oncologists would love to radiate first.

But, if patients don’t come until the chunk is out, there is really nothing you can do.  Well, except educate.

That is where good interdisciplinary teams come in.

In fact, I read a study about how the whole decision thing is very profession dependent, despite all of the people being aware of the same literature and guidelines.  Because there is so much ambiguity in guidelines.

Things are changing.  We don’t work as much in isolation.  But, we are still set in our ways.  And we love evidence.  Which is tough when evidence is forever limited by rarity.

I think that is why I like sarcoma.

It is different.  It is a bit controversial.  And it is diverse.

Kind of like people.

It taught me a good lesson in variability in practice, the need for good research and also the importance of the patient (until the last 20-30 years, amputation was the way to go with these… Thank goodness someone had the bright idea to try to improve things).

The whole presentation thing also reminded me that as much as I love this stuff, I still want to do the whole festive thing and pretend to be normal once in a while (aka not secretly fascinated by sarcomas).  And that eventually many things look more fun after hours of work, including the heap of dishes in the sink.

Tomato-Tomato: Answering some questions of distinction from the world of medicine.

Image from mentalfloss.com.

“You say tomato, I say tomato.”

You know the saying.  So, did my delightful teacher in Nuc Med, Debbie.  Except when she said the saying she pronounced tomato identically both times.

It cracked us up.

In life there are some things that sound the same but are different, some that look the same but are different and some that are indeed the same, but sound different.

Confused yet?

I have been asked a few awesome questions about some medicine-ish sorts of things by my readers and patients and family and have decided to answer some of them now.  These are answers to some of the “what is the difference between” sorts of questions.

Question 1: What is the difference between a ward clerk and a clinical clerk?

A ward clerk is the lovely person who takes care of all of the administrative things on the hospital ward.  They are the sunny face that directs people to rooms, answers phones and keeps the place organized.  They get paid for this job.  A clinical clerk, also known as a senior medical student is someone who is in their last couple of years of med school and is rotating through the hospital learning in a hands on sense how to be a doctor.  They are different from residents or interns.  They are NOT doctors (yet).

Question 2: What is the difference between an intern and a resident?

Not much and yet a fair bit.  An intern is a first year resident.  All residents are doctors.  They are doing training so that they can practice independently.  It is like another gradation of training.  You can’t just get a job working as a doctor out of medical school.  You get a job working as a resident.  In many places, there is a first year of “rotating internship” meaning the first year resident has to do rotations in a number of specialties of medicine to get well rounded before focusing on one area of medicine.  That is kind of what I am doing now.  Sometimes people say interns are off-service first year residents.  First year residents and fifth year residents are very different in that the level of training is obviously different.  You learn more as time goes on.

If I didn’t hate graphic t-shirts, I would need this shirt. Image from zazzle.com.

Question 3:  What is the difference between medical and radiation oncology?

Both are oncologists (although most people only consider their medical oncologist an “oncologist”).  Medical oncologists are doctors specialized in giving systemic treatments for cancer, like chemotherapy and hormone therapy.  Their background is internal medicine.  Radiation oncologists (not to be confused with radiologists) are doctors specialized in using radiation to treat cancers, often in a more localized fashion.  One is not better than the other.  The medical, radiation and surgical oncologists all work together to provide cancer care.  Sometimes for one cancer, it responds better to one thing and not another.  Others need all three modalities.  It depends on the cancer.

Question 4:  What is the difference between radiation oncology and radiology?

There were people in my med school class who I am pretty sure thought up to the day we graduated I was going into radiology.  Because they are clearly the same thing.  They are not, although back in the day, they were.  Then a lot more oncology started happening and things got more specialized and they branched off of each other back in the 50s and 60s.  Radiology is a field in which you read diagnostic imaging (CTs, MRIs etc).  Interventional radiology is a subspecialty of radiology in which you use radiologic imaging to do some surgical procedures, like putting in chemo lines and special drains.  Radiation oncology is a field in which you treat cancers with radiation.

Question 5: What is the difference between Hospice and Palliative Care?

At surface, there isn’t a major difference.  Often, the two are grouped together.  Hospice is a type of Palliative Medicine.  Palliative comes from the word pallium, meaning to cloak or comfort.  Pretty beautiful term, if you ask me.  Palliative medicine is a field of medicine in which you provide pain and symptom management, generally to people with life threatening illness.  Being cared for by palliative medicine does not mean death is imminent, but that cure is unlikely and comfort is important.  Palliative medicine is all about quality of life.  In a hospital, there may be a palliative care unit – an inpatient unit that provides comfort care.  In the community, there may be a Hospice house or organization.  Hospice is a type of palliative medicine and a sort of philosophy.  It is home-based palliative care.  Meaning, people are supported at home through outreach teams or they can go and live in a hospice house, which is a home like setting providing palliative supports.  Often, a palliative care unit is a bit more hospital like and can provide a bit more hospital-type supports compared to a hospice house, which is basically a home away from home.

 Question 6: What is the difference between the short white coat and the long white coat?

Good question.  My first guess would be the amount of white fabric available to get dirty (I am not a fan of white coats).  Apparently it varies from school to school.  Where I came from, the short white coat was a symbol of you not being in your clinical years.  You wore it to shadow, to clinical skills and such.  It was a sign of being a rookie.  Once you hit clerkship, you could wear the long one.  In some other places, all medical students go short.  I have no clue.  I guess it depends where you are.

This image, taken from an article in boston.com demonstrates the different styles and people wearing white coats and how although long white coats are traditionally associated with attending physicians and big accomplishments, it does not mean only attendings wear them and the reverse is true of the short white coat. Bet you can’t tell who is who.

Question 7:  What is the difference between an allergy and a sensitivity?

An allergy is an immune response.  A sensitivity is kind of like a nasty side effect or irritation.  People claim they are allergic to all sorts of things they are not.  If you vomited or itched or got constipated on morphine, you probably had side effects and may have a sensitivity.   If you develop hives, intractable vomiting or difficulty breathing, then it is an allergy.

Question 8: What is the difference between nuclear medicine and radiology?

Nuclear medicine is awesome.  That is the clear difference.  Seriously though, nuclear medicine involves imaging radioactive tracers as they behave within someone’s body (physiologic imaging).  For instance a bone scan images a tracer that acts like calcium and binds to bone.  Areas of fracture, wear and tear, infection or cancer appear brighter because that bone is turning over more quickly.  Radiology generally involves external radiation projected onto a film through the body.  It images anatomy only for the most part.   Think x-ray.

Upper left is a bone scan of a hand with a fracture of several carpal bones (with pins in place). Upper right is an x-ray of the same hand). The bottom left is an example of a fusion image with the two modalities showing how activity can be localized to an anatomic site.  Image from HERMESmedical.com.

There you go.  Eight awesome questions I get relatively often about things that seem very different or kind of the same.  Let me know if there are more questions.  Or more answers.  Either are delightful.

You just wouldn’t believe, you just wouldn’t even know…

Some friends of mine and I have this inside joke saying “You just wouldn’t believe, you just wouldn’t even know.”  Sounds normal enough.

You see, we were on a camping trip (at a campground in our own city) when a couple of our other friends stopped by.  One of them went into the tent to find something without a flashlight and started screaming, “It’s so dark in here, you just wouldn’t even believe, you just wouldn’t know.”  It was hilarious.  Partly because we all could believe, partly because of who said it and partly because of how loudly the person was screaming this at 1 in the morning in a family campground.

From then on, whenever something obvious or not so obvious would happen, one of us would sometimes state a “you just wouldn’t believe, you just wouldn’t even know.”  This could be in reference to something as simple as darkness or as huge as something epic happening in our day.

We haven’t said it a whole lot lately, but something in physics class made me think of it today (clearly, looking back on the past two months , some of my best Thursday thoughts come out of physics class – see here and here).

You see, we were learning about treatment planning, namely the physics behind CT scanners and talking about how quickly the x-ray source and detector can spin around the patient.  We were saying how it would be cool in theory if the casing for the scanners was clear, so you could see it (the problem being this would totally freak patients out).  They are fast “like you just wouldn’t even believe, you just wouldn’t even know!” We then watched this video to illustrate.watch?v=CWnjqeB7Mk8

The even crazier part to us (beyond how fast that thing spins at top speed) is that 50,000 other people in the world have watched this video.  I know compared to some other videos on the site (like Gangam style that has 500 million hits – we checked) it isn’t much, but for a weird CT related nerd video, that is huge.  “Like, you wouldn’t even believe, you just wouldn’t even know” kind of huge.

Other big win from physics today is that I remembered to bring my coat, so I didn’t freeze completely.  Oh, and because I had half day this afternoon and there was a clinic the other residents didn’t want to go to in the morning I got to go to clinic and half day and someone else covered the floor calls. That made me happy “like you wouldn’t even believe, you just wouldn’t know”!

There are other nerds out there.  I believe and I know.  But it is still fun to say that other phrase!

Why Oncology

I have been asked by various blog readers of late about my interest in oncology and why on earth I chose it as my specialty of choice.  I have written before about how much I love Palliative Medicine, dislike surgery and all that good stuff, but never the specifics on the whole oncology thing.

Image from pingram.me.

Thinking back, it seems silly that I have never written on the issue.  I think part of it has to do with me being in the midst of the CaRMS (residency selection) process when I started blogging and I needed to tell everyone about it in the real world.  Another piece is that the story is rather complicated and has a lot of back story and honestly, I am not sure how far to go back.  And I glossed over it in my CaRMS explanation because it just feels too personal and too cliche.   I picked some key incidents, but seriously, some of them make for posts of their own, which will likely appear in the future with further explanation.

To get the full context, I am taking you back to when I was a kid and my Aunt (the one I always say I am just like) was just diagnosed with lymphoma.  6 year olds don’t get much except that someone is sick.  And she was always sick.  Over the next couple of years I learned about chemo.  I learned that people on chemo lose their hair and their nails and get very sick.  I learned that you can become immunocompromised.  In my head at 7, this meant that you, even as a grown up could get chicken pox.  And that is bad.  I saw the inside of the chemo room.  I tagged along to doctor’s appointments.  I learned how to go into isolation rooms.  I understood the word coma. Things that no kid should ever have to learn about.   But, to me, that was normal.

She died when I was 8 and ½.  I will never forget the days leading up to and following that day.   Never.

It sounds cliché, but the experience changed me.  Little 8 year old me.  I knew death was real when most of my friends didn’t.  I knew what cancer was.  I found it all fascinating.  I read medicine books.  I needed to know everything that could kill me and my family.  But, I wanted nothing to do with it, or at least that is what I thought… My, how things change.

I have had other losses.  Some have really shaken me, like my classmate this summer.  I learned that I can’t avoid the things that hurt you.  And that sometimes death just happens.  But, I think it still shapes you.

They say death is hardest on the living. It’s tough to actually say goodbye. Sometimes it’s impossible. You never really stop feeling the loss. It’s what makes things so bittersweet. –Meredith on Grey’s Anatomy

Time marched on.  I discovered I loved physics and biology and such in high school.  I got sold on doing Nuclear Medicine as an undergrad thanks to a few friends.

I had minimal interest in working with people.  I thought being a researcher would me my area of interest.  It just seemed I didn’t like the touchy feely stuff like my friends… It made me uncomfortable.

It wasn’t until I started university I even considered medicine.  I somehow fell into the job at the Hospice.  I applied to it and several others.  I never thought I would get it.  It worried my family and friends… Me being around all of that death.  I loved it.  I can’t explain it, but it was home.  And it just made sense.  I was comfortable.  I wanted to help these people.  It really clicked.

I did Nuc Med.

During my undergrad, I changed.  I found God.  I found people.  I discovered I had a passion for people in the difficult times in their lives, through crisis and illness.  I continuously had things pointing me towards medicine and towards people.

In the end, I graduated and went to med school (though it came in to question repeatedly throughout my undergrad with all kinds of self-doubt and such).  I wasn’t sure what to do once I got there.  Oncology was on my brain, but so was Nuc Med… I loved it so much.  Then, there was the whole Palliative Medicine thing.

I job shadowed in undergrad.  In all of those things.  I realized I loved people and that Nuc Med (as a physician) made me want to gouge my eyes out.  I loved Palliative Medicine, but didn’t want to be a GP.  Medical Oncology required an Internal Medicine Residency.  Radiation Oncology was like the optimal combination of the things I liked leaving out some of the bits I disliked.  Research, as it turned out was not really my thing at all.

So, Rad Onc became my new focus.  I did the electives.  I applied to the program and I got in.  I am sufficiently anal retentive and organized to do the job.  I love physics.  I love the details.  It is fascinating to see how quickly things are changing in the field and how team oriented and patient focused things are.  I am comfortable in oncology.  And I find it fascinating.  There is something strangely amazing by the way cancer cells can just take over.  The physiology.  And even more so, it is amazing how we combat those cells.

It is a strange pick.  A small program.  A piece of the hospital that is a black box to most people.  In fact, it is hardly taught in medical school.  Some of my classmates didn’t know what I was going into when we graduated.

Sometimes, it takes moving forward to really understand how where you come from makes you who you are.  If it weren’t for those experiences, for that by chance summer job, for my undergrad degree, I am not sure if I would have even done medicine let alone picked my career of choice.

And we know that God causes everything to work together for the good of those who love God and are called according to his purpose for them.  -Romans 8:28.

My Bragg Peak

This week’s writing challenge from the Daily Post was to use metaphor or simile in your writing.  I wasn’t planning on doing it.  I feel like I am doing well to post at all this week.  But, then, I had this physics lecture.  And I knew what I had to do…

I have a Bragg peak.

I function on a general level of energy deposition.  I have a high baseline, but it is pretty stable.  I can putter along flitting and yammering and getting all sorts of things done.  Eventually, I do this for so long that I get rather wired.  Sometimes because so many things have to be done or because I get even more encouraged by what I am doing, I end up doing a whole bunch in a short period of time.  And then I crash and want to do nothing.  Kind of like when I am on call.  There is a low point around 3 or 4 in the morning, but otherwise, you kind of putter along and do more and more as time goes on.  By the time everybody gets in to round, you have a “second wind” or a burst of energy and productivity (or silliness), just before you crash down to sheer exhaustion and sleepiness.

I think of these two events as the Trisha Bragg peak phenomenon.

Image from ptcri.ox.ac.uk

The Bragg peak is something physics people use to describe the energy loss of ionizing radiation (like protons or ions) during its travel through matter.  When these particles move through matter, they deposit energy along their path.  As their energy decreases, they interact more with the things around them. Thus, just before they run out of energy completely, they react a whole bunch, leading to a sharp peak of energy deposition just before they stop.

And thus, I have a Bragg peak.  I go along and put more and more of myself into things until I reach a motivated point where I do a bunch and then have to stop from fatigue (or just plain being out of tasks).  Or I have energy that suddenly peaks before I burn out completely.

To sum things up, I am kind of like a charged particle.  I have a Bragg peak.  Surgery is most definitely proving this fact.  Physics half-day just confirmed it.