So, the boards went about as well as can be expected from a 9 hour long test. There were many a moment when I’d find myself gazing at the computer screen, uncomprehending. Seconds later I’d snap out of it and realize how obvious the answer was. Ah, well. At least I’ll never have to take it again.

On to bigger and better things! I’m on the Northwest coast right now staying with two good friends from college… should be a blasty blast. I hear the ER I’m rotating through is one of the busiest trauma centers in the nation.

A few weeks back I had to leave our med school tailgate to put in a shift at the urgent care. While I was truly saddened by my inability to contribute to the shotgunning of copious beers, alas, some of us are productive members of society. Then again, I’m of the mindset that shotgunning beers at tailgate is productive, but that’s a debate for another time.

I had a pretty great shift, mostly because drunk college kids were brought in for various and sundry complaints†, and they were stoked to see the school colors under my scrubs. Halfway into the night, though, there was something… different. Cruising around the corner, I immediately noticed two things.

Firstly, my nostrils were assaulted with the pungent odor of vast, unimaginable quantities of shit; a horrific wall of feculent odor that knocked me backwards. This was shit to be reckoned with. This was shit that didn’t take “no” for an answer.

Second, there was a very attractive sorority girl in school colors and butt shorts screaming blindly “I’m NOT as DRUNK as you THINK I am” at the nurse who was unsuccessfully trying to start an IV.

The incongruity of these two simultaneous events was difficult for me to comprehend, so I used my carefully honed powers of medical observation. “Ah, there’s the problem” I thought to myself, “that lovely young lass has shat herself”.

I mean, folks, I didn’t realize you could even poop that much††. It was all over the poor guy drawing blood, the bed, the floor. It was splattered on the wall like a Jackson Pollock painting. It was a veritable cornucopia of fecal matter. It was Shitterhouse-Five.

That, my friends, is why I both love the ER and could never make it as a nurse. We love you so very much, you don’t even know.

† If by “various and sundry” you mean “solely related to alcohol and the imbibing thereof”. Pearl: if a piece of a broken beer bottle pierces through the insole of your Chucks, your antibiotics must cover Pseudomonas Aeruginosa.

†† let alone a girl who couldn’t have weighed more than 90 pounds.

In the States, one of our over-the-counter painkillers is Tylenol (generic: acetaminophen). English-speaking countries oveseas refer to it as Paracetamol†.

Pharmacology books often refer to it as APAP… but I’ve never gotten a good explanation as to where the abbreviation APAP comes from.

Turns out, the full chemical formula for acetaminophen/paracetamol/tylenol is N-Acetyl-Para-AminoPhenol (APAP), or simply para-acetylaminophenol. Ready for some word magic?

PARA-aCETylAMinophenOL
para-ACETylAMINOPHENol
para-aceTYLaminophENOL

I’m as giddy and excited about this as I was when I found out what MaAlOx stood for. I’m sure absolutely nobody else cares… but if you’ve ever met me, you know it’s the small shit that gets me every time.

† They also have the metric system, and most of them don’t have a retarded monkey running the country… but that’s a different story for a different time.

Monoamine Oxidase Inhibitors (MAOIs) are a class of medications commonly prescribed for severe depression. One of the major side effects: Tyramine Syndrome, which causes a rapid rise in heart rate and blood pressure if certain foods are eaten.

Foods that are verboten? Eating liver with some fava beans and a nice Chianti. I doubt it’s coincidence that Hannibal Lecter – a brilliant psychiatrist who would be well versed in pharmacotherapy – mentioned those three specific foods.

Touché, Thomas Harris. Well played.

I ran into one of my favorite residents the other day at the coffee shop, and as we were reminiscing about our awesome Internal Medicine rotation together, we started chatting about the worst patient in the world. While on my rotation, this woman plagued every waking moment of every day. She was nasty, spiteful, and on top of it all, a blatant liar. Her name was Terry.

Terry was a 40-something vile excuse for a woman. I doubt it had anything to do with her illness; in fact, all that was wrong with her was a fairly mild case of Rheumatoid Arthritis. Usually, RA is treated with a class of drugs known as DMARDs, which help to slow the progression of the disease. High-dose steroids are typically reserved for when things go acutely downhill; the side effects are pretty nasty.

Terry, however, had been taking steroids – lots of them – for years. They had eaten away at her bones, ripped holes in her stomach, and prevented her from healing any minor cuts or abrasions on her body. Our hospital service accepted her because she hadn’t been able to eat for weeks.

As with any good team of hospital docs, we busily started drawing blood, instituting intravenous feeding, and brainstorming for a cure. Terry’s boyfriend and son looked on, writing down our every word in spiral-bound notebooks. Terry’s son, you see, was in school studying to be a nutritionist, and her boyfriend wanted to be a nurse.

It quickly became apparent there was absolutely nothing we could do. Terry’s intestines had simply shut down, preventing her from eating or drinking anything. The only solution was to stop the steroids and continue intravenous feeding until her gut came back online. Unfortunately it would take weeks to months, but it was really all we could do.

We went to work doing what internal medicine docs do best: placement. We called every nursing home and hospice program in the state, trying to find somewhere that would agree to continue her IV feeds. The solution was simple. Switch her to methotrexate (a DMARD), taper her off the steroids, place her somewhere that could handle IV feeds, and wait for her stomach to function again. We told her our plan 3 days after admission.

Shit hit the fan. Terry’s son informed us that intravenous feeds were dangerous† and were therefore unacceptable. Terry’s boyfriend started “fixing” her IVs and bedclothes, at one point forcing us to replace her lines due to contamination. Terry started lying about other doctors’ plans – utter fabrications like “the surgeons are going to operate in a week” – to extend her hospital stay.

Things got relayed up the chain of command. Eventually the Chief of Medicine, the Chief of Gastoenterology, and the Chief of Surgery became her three primary doctors, desperately trying to accede to her every whim. She and her two attack dogs vomited verbal abuse at anyone who so much as walked by her door. What’s more, it was obvious that she took some sort of perverse pleasure in being hospitalized and bending everyone’s will to hers.

A month later, her hospital room had been transformed. Stuffed bears and flowers hung off every wall, and her whiteboard listed daily schedules of rotating consultants. Our 7AM rounds took 3 hours; half for all our other patients, and then half for Terry. Casually mentioning her name would draw venomous looks from any doctor, nurse, or tech unfortunate enough to have met her – which was 3/4 of the hospital.

We finally kicked her out the last day of my rotation, threatening to call security if she refused to leave. The 3 Department Heads stood in her room and told her she had no other option; she hadn’t met criteria to be in the hospital for weeks and her insurance had finally stopped paying.

The discharge plan, by the way, was completely unchanged from a month prior. She fanagled one more trick; instead of going to a care facility, she would go home with a full-time nurse who would probably hang herself within the week.

Last I heard the methotrexate was working out just fine, she had no complications from our treatment, and she’s eating and drinking normally. She also broke up with her boyfriend.

† No shit, Sherlock. It was our last resort. I really hated this kid.

The US Medical Licensing Exam sucks, plain and simple. There are several Steps to getting licensed (If you remember my Zac Facts series from last year, it was a way for me to turn the mind-numbing boredom of studying into something productive).

As a 4th year I’m in the process of taking Step 2, which is actually broken up into two parts, Clinical Knowledge (CK) and Clinical Skills (CS). We’ll talk about CS later this year when I fly out to LA to take it.

For now, I’ve been cooped up in my house and coffee shops around town “studying” 10 hours a day. See, unfortunately any and all motivation that I had during the first two years of medical school evaporated at the end of Step 1. Unfortunately the clock is ticking, as my test date is rapidly approaching. It’s of very little comfort that many of my classmates have already undergone this ordeal; it’s of littler comfort that residencies will see my score before they choose to accept me or not.

So, with that being said, here’s my study schedule.

Books To Use

First Aid For the USMLE Step 2 CK – I loved the Step 1 version of this book and I’m finding this to be just as well written. I can take or leave most of the mnemonics but the content is solid. Make sure you know this one.

Crush Step 2 – Since most of the material is review anyway, it’s nice to have a more colloquial style to turn to. Covers a few holes in First Aid, but I’m not sure I’d use it as my only resource. Side note: the paper in this book is much easier to write on than First Aid’s. Le, Bhushan, and Skapik should get on that.

USMLE World – Great question bank. I found Kaplan’s QBank too nitpicky for Step 1, and so far I’ve been very impressed with USMLE World. Go through all the questions, period.

Wikipedia – If you have Firefox, get the wikipedia plug-in for your search bar. Instant access to (mostly accurate) summaries of drugs and diseases to jog your memory.

Study Days

7:15 Wake up, make pot of coffee. Wish I was a normal person again. Eat breakfast.

8:00 Review section from previous day. Just do it. Drink more coffee.

9:00 New material covered in First Aid and Crush.

12:00 Lunch. Futilely wish I could find someone to eat with that wasn’t my computer.

1:00 QBank. Include all sections you’ve done previously. 2,000 questions in 16 days is ~ 3 tests per day of 40 questions. Review your answers.

5:00 Hypothetically I’m done. Realistically I’m probably still eating lunch.

Study Schedule

Crush-specific sections are in italics.

Day 1: Cardiovascular, Vascular Surgery
Day 2: Dermatology, Labs, Radiology
Day 3: Endocrine, Rheumatology, Internal Medicine
Day 4: Epidemiology, Ethics, Preventive Medicine
Day 5: GI
Day 6: Heme/Onc
Day 7: REST!
Day 8: Infectious Diseases, Immunology, Pharmacology* (know me!)
Day 9: Musculoskeletal, Geriatrics, Orthopedic Surgery
Day 10: Neurology, Psychiatry, Ophthalmology, ENT, Neurosurgery
Day 11: OB/GYN
Day 12: Pediatrics, Genetics
Day 13: Pulmonology
Day 14: REST!
Day 15: Renal, Genitourinary, Urology
Day 16: Emergency Medicine, General Surgery. Catch up day.
Day 17: Practice Exam, Review
Day 18: Review
Day 19: Exam!

Throw in rest days whenever you want to when planning this out. 2 should do it, probably on both Sundays. Assuming your exam is on a Friday this starts you the Monday 3 weeks prior, with 2 cushy review days to relax prior to taking the boards. Oh, and don’t push it back. The USMLE Step 2 CK Score Estimator can help you gauge your progress.

I just applied to residency. Emergency here I come!

I think I need a glass of wine. Or five.

Apologies in advance for the serious nature of this post…

I’m studying for the boards this month (the abortion that was my one day anesthesiology rotation shall be covered in a later post). I’ve got 3 roommates, so I’m rarely alone. However, roommate #1 is doing a urology rotation right now, roommate #2 started MPH school again, and roommate #3, who is studying for the boards as well, left this morning for a meeting with her advisor.

This left me all alone, which is just fine by me; I cranked up the music and got some† studying done. But then when lunch came around and I wanted to go grab a sandwich, I realized that I didn’t have anybody to eat with. If there is one thing I hate, it is eating by myself.

Eating has always been about the communal act for me. Cooking is the same way. I grew up eating dinner with my family, at home, every night. When I left for college, my “last meal” was my mother’s home-cooked farfalle with mushrooms. It’s ingrained in my personality that food is something that brings us together. I never make less than a pound of pasta; food is for sharing. I pick off others’ plates and expect them to do the same for mine.

So was on my lunch break today that it hit home that I’m going to be by myself every day this month. I can focus on the books when I’m studying, but when it’s time to eat the realization sinks in.

†I have really gone downhill with regards to studying… I am no longer the efficient data-gathering machine of yesteryear.

He looked rather sheepish, a kind, elderly man sitting there with blood all over his shirt and face. While cleaning his gun, he forgot that there are 6 bullets in the clip… and an extra one chambered in the barrel. He unloaded the clip to clean the rest of the gun, but forgot the 7th bullet. This would have been an important point to remember prior to squeezing the trigger.

Surprisingly, all he did was shatter one bone in his middle finger; the exit and entrance wounds made it look like a much more serious injury. More embarrassed than anything else, he held his hand up in the middle of the trauma bay and watched as his middle finger dangled. Then he jiggled it, and like limp pasta the finger waggled around, disconnected from muscle, tendon, and bone. He started giggling a bit, which turned into uproarious laughter. It was infectious, and his roommate joined in, along with all the nurses and docs hanging around.

When he finally calmed down, he said “God damn, I feel lucky. Coulda been worse!”

Step II Boards Application Fee: $1505
Plane Flight to Seattle: $298
Application for UW Rotation: $100
90-day subscription to USMLE World: $90
Background Check: $65
Board Study Book: $35
Postage Fees: $5.45

Living with 2 college buddies for a whole month? Priceless.