The Differential: Medscape Med Students Blogs

The End of One Journey, an Uncertain Future Ahead

Ali Tabatabaey -- As I write these last lines, sorrow clutches my heart and my hands are unable to wipe my cheeks of the endless stream of tears that pour down from the corner of my eyes to my chin. As I write these last lines my hands shake in woe and I choke on my silent cries. As I write these last lines… well, maybe I’m exaggerating a little and things are not that melodramatic, but still I have to admit that I feel … (I really couldn’t find the right word so I gave up) by the fact that this is my last post to the blog. I think my best attempt at describing my current feelings would be to call the situation an “amputation”! Losing something that worked so well for me and that I had become so attached to. I guess that’s why it took me so long to actually sit down and write this one.

The fact is that soon I won’t be a student anymore, and now that I think of it, even now I am in a gray zone. My rotations are over, the graduation ceremonies have been held, and I’m only a defense session away from the finishing titles in this seven year drama!

The oath is behind me, or better said, will always be in front of my eyes, and the weight of the responsibility is clearly felt. Just as I expected, excuses are no longer accepted for a friend’s bellyache or a relative’s sore knee, but the good news is that I usually have an opinion to put forward and escape out the backdoor even if I have no idea what to think next!

The graduation ceremony was OK. We took charge of the most part ourselves and it proved to be fun. A friend of mine put together a couple video clips from all our memories, another prepared a slide show, and another a multimedia CD. I came up with the idea of the first ever “graduation day newsletter” only two days before the ceremonies, and I don’t know how, but I managed to put it together. I also presented a comic version of all that we had gone through during med school. All the graduates loved it, but I don’t think any of the families could relate. I dare to call the whole thing a success.

Yet after the party when the dust settled, there we were, a bunch of 26-27 year-olds looking at their pictures at 19 and shouting out “oh look how thin I was” or “look how much hair I had” or even “look at that smile! I haven’t grinned like that for a very long time”! And I, as always, was anxious about what life will throw at me next in a society characterized by uncertainty.

I’m not down or anything like that. I’m actually very proud of what I’ve achieved, but I am anxious. I’m just at a point that I need a mentor so badly. But in this quickly changing world, no one's experience can be put to use exactly. I know where I want to be yet it seems that all the doors leading to it are currently closed. So I either have to take a long, tiresome side road, or sit around and hope for a change of fortune. Maybe a third option would be to fight my way through, just maybe!

So I guess this is the end. I think I’ll take a couple of months to fully think my choices through and after that … I really don’t know. It was an amazing experience writing for the blog during the past two years and I’ve made so many friends. Who knows, if I manage to enter a residency someday, I might be back. Till then, take care.

PS: Meanwhile, I can be reached at [email protected].

The Vision

Ali Tabatabaey -- When you feel mortally tired just before the end of your education, which had defined your life for the past seven years, nothing can cheer you up and replenish your enthusiasm more than a well deserved vacation. On the other hand, this is also the time when so many questions run though your mind and so many choices dance in front of your eyes. With each choice leading to a different road heading in a different direction, deciding which to choose can be very stressful. And when all these feelings clash to create a true predicament, nothing can untangle your mind like attending a “workshop of strategic planning” in Esfahan!

There is a reason for this philosophical raveling just before leaping off this stage of my life. Recently, I had the privilege of watching Kieslowski’s “Blind Change,” and it really got me thinking about the consequences of the choices I make today. It made me think about what I really want, and the workshop, alongside all the fun of visiting one of the best preserved historical cities of the region, helped me work some of my issues out.

For those who have to serve conscription, the path is clear and there is no escape. For most of you studying in the West, where you go straight into residency, again you only have to make the choice of where and what to study. But the decisions I make within the next couple of months are going to shape the rest of my life. I have to start my 2-year mandatory practice soon, but where to do so is the question to be answered. Should I try to stay in Mashhad, my hometown, and wait till next winter to take the residency exam? Or should I try to move to Tehran and pursue a research career while jeopardizing my chances of becoming a resident or making a reasonable living? Or should I move to a relatively remote area, earn good money and take advantage of the opportunities there? Or should I simply prepare myself for studying abroad?

Although I still can’t answer any of the above questions (and more) with confidence, learning about strategic planning helped me bring my choices into perspective. Even though the workshop was designed for managing organizations, it inspired me to write down a vision, mission, goals and objectives for my personal life, too. It was fun and at the end I thought that it might be a good idea to publish my vision on the blog before leaving. This way I know everyone knows about it and I’ll have to make it come true. I know it’s too ambitious and I assure you I’m not experiencing a manic episode, but that’s what a vision’s for, to visualize you dreams. So here’s my vision for the year 2040:

“I am a distinguished professor of hematology at one of the world’s top medical institutes, and alongside clinical practice I’ve managed a productive research career. My recent Nobel Prize nomination was an exciting and welcome bonus. As the co-author of a textbook of medicine, I’ve been able to pass down my experiences and views to students of medicine, and contributing to a regular column in an international publication helps me express my views in other fields of interest. Using my newly earned fame, I’ve been able to fulfill one of my lifetime dreams by founding a Non-governmental Organization which brings together prominent and influential figures from all around the world who are willing to use their fame and power to make peace, knowledge and true democracy a reality all around the globe.”

As a Persian proverb says, “You can’t blame the young for dreaming!” LOL!

Branded!

Ali Tabatabaey -- Thanks to one of the funniest yet most painful experiences as a med student, I have a brand to remind me of med school, forever!

She was a 31-year-old mother of one, with a sense that “something is in my throat from time to time” as her chief complaint. The history seemed to point somewhat to stress and anxiety-related issues, but first came the physical. The initial exam did not reveal anything organic, but one last step had to be done before labeling her with a Globus Hystericus -- the indirect laryngoscopy.

The routine is simple enough: pick up a mirror, heat it on the lamp, spray the throat with lidocaine, grab the tongue, and look closely. So, I turned on the lamp, picked up a mirror and started heating it … and then a few other questions came to mind.

“So, do you experience any other symptoms alongside the choking?”

“I start shaking and sweating.”

“Really! Anything else, chest pain, unusual feelings, unusual sensations?”

“My arms start tingling, too.”

“And how long does this last?” Obviously I was excited to see that the new information was supporting my initial suspicion -- so much so that I nearly forgot about the laryngoscopy.

“OK, so let me just check the back of your throat, too. Could you please open your mouth?” Oh, I almost forgot. First I must test the back of the mirror with the back of my hand. We don’t want it to be hot and hurt the patient. So here it goes …

Ali on the inside: “Holy *#$*%*! Oh my God. Take it off, stupid! Somebody get me some ice. Oouuuuuuuch. Somebody help me pleeeeease!”

Ali on the outside: “I think we should wait a few seconds, it seems to be a little hot.”

The mirror was hot. I mean, really hot. I had left the thing on the flame all the time I was asking the questions, and now it was scorching hot. Luckily, instruments like this are made so they heat up fast and cool off fast, too. So a few seconds later I tried again…

Ali on the inside: “OOOOWW! Who said these things cool off quickly? Oh, my Gooooood. I must be the most stupid man on earth. I really can’t remember the last time I did something this stupid.”

Ali on the outside: “It’s still a little hot. Let me cool it off using a bit of alcohol.”

The alcohol did the job, but it was too late for my hand. So at the end of the day, I’m left with a tiny L-shaped brand on the back of my left hand. I guess I’ll be leaving here soon, and this “L” is a great reminder of … What could “L” stand for? Laryngoscopy, Love medicine, Last thing I thought I would do to myself, or maybe even Least of my memories!

Last Shift

Ali Tabatabaey -- It felt like the finale to a long-lived sitcom, or better said, a drama: leaving a room that had hosted so many memories, and knowing that I will not see it again. The last shift as an intern is behind me, and the end is ever so close.

It was a simple shift, no ambiguities, no casualties, and a relatively quiet night. I’m glad to say that things were not as stressful as my first shift, mostly because the patients seem more familiar. But maybe it’s also because during these last few shifts, I expected myself to know the patients and their problems, unlike the first shifts when I knew every patient was going to be a whole new experience.

I have to admit, though, the sense of responsibility has quadrupled. No more excuses are accepted and no more stupid mistakes are allowed.

Do I feel like a doctor capable of understanding every problem and solving every case? No. What I do think I’ve acquired in the past seven years are the prerequisites to think through a patient’s problem. Whether this is enough or not, I’ll leave it to the more experienced physicians to answer.

All that said, and amidst all the nostalgia, I really doubt that I’m going to miss this room. I guess the internship shifts are great MEMORIES which suit the past much better than the present. So, I close this door without any hesitation, hoping to soon open a new door as a resident. Let me rephrase that “wishing” to soon open a new door as a resident… but that’s a whole other story.

A Difficult Time

Ali Tabatabaey -- I know this post is long overdue. But I have my reasons. First of all, the friend that I talked about a couple of posts ago was officially nominated for liver transplant, meaning that if a donor is not found soon … well, you know the rest. Even if a donor is found, one in four patients don’t make it past six months. The news really spoiled any mood for writing.

On the other hand, I’ve been preparing my thesis, and who would have thought it was going to be this hard? Now I understand what all my predecessors were talking about when they sincerely advised me to start writing the dissertation long before the deadline. I mean, doing the research and getting the results together is one thing, but finding the time to write everything down is a whole other project, and doing so while shuffling shifts at “Surgery” is a mission impossible.

I guess the hardest part is managing the references, for which my sister has introduced me to a new software program. But it only seems to make everything more complicated, and I’m very close to giving it up and going back to the old fashioned way.

So that’s the status of my life. I think I’ll need a long vacation after all this is done. But that does not seem like a possibility in the near future. Just before going, one tip for you who are starting to think of a research project for your thesis: as the previous generations told me and I did not listen, I sincerely advise you to start writing it as you go along and don’t leave everything to the due date.

Finding Refuge in Medicine

Ali Tabatabaey -- Nagging about how stressful and straining med school is, is what we med students do best. It’s like we feed off nagging! It gives us the energy to keep going. I myself have used this tactic a lot during the last seven years. Yet recently, as I try to prepare myself for the real world of medicine, I’m starting to appreciate a certain comfort in the hectic world of medicine that one can’t find anywhere else.

Yesterday, as I stepped out of the hospital after a long 12-hour shift, something inside me didn’t want to go -- as if I missed the place already. Do you know what I missed the most? Its simplicity! We think of our job as a complex and mysterious duty, but from a philosophical point of view, it’s quite the contrary. Things at the hospital are much more clear and vivid than real life is.

Our job is the only job that is the same in any part of the world and in any circumstances. Even at war our job does not change a bit, we treat the most severely hurt. When wearing the white coat, there are no bad guys, there are just people who need help and you have the power to help them. You shouldn’t care where the patient is from, what he/she does for a living, or whether he has committed a brutal crime or not. You just sew his stitches, give him his shots, and ease his pain. But as soon as I step out of the hospital, everything gets so complicated again. The people around me must once again be classified as friends or foes. The subtle joy from the day’s achievements that adorns my face soon gives way to a blank look or a frown as I think of all the interpersonal relationships, bills, debts, deceitful politicians, war, projects, part-time jobs, global warming, injustice and so many other things that engage the mind.

As it turns out, the hospital that once seemed like a prison keeping me away from “the fun world out there” has become my refuge from the brutal world of reality.

When Doctors Do Harm

Ali Tabatabaey -- I had never been so ashamed of my profession. I was listening to the complaints of a dear friend, and I had nothing to say.

The humble complaints of a man approaching his death are not something you can ignore easily. He is a hemophiliac infected with the HCV through contaminated blood products. Due to the neglect of a few doctors at the ministry of health over 10 years ago, there are many people suffering like him today. He has been fighting cirrhosis the last few years of his life and he just found out that the disease is not backing down.

The atmosphere in my country's health system, promoting fear of all blood-borne viruses, doesn’t make life easier for people like him. Being infected with HCV has denied this friend of mine the ability to undergo any elective surgery or to have any dental work done, and it has caused him great social suffering.

He told me about how he booked an appointment for an upper GI endoscopy. He prepared himself for the procedure by self-injecting the needed factor concentrates. Then he showed up at the internist’s office with all the required papers, only to wait a couple of hours before being told that the doctor would not show up that day. He went through all the same trouble the next day before finally having the procedure done. Afterwards, he listened anxiously as the doctor talked about his grade III esophageal varices. On top of that, his ultrasound the week before showed “portal pressure estimated at 20mmHg, with splenomegaly and severe ascites.”

Yet worst of all, just as he was getting ready to go home, the nurse who had failed to read his file before the endoscopy began to protest frantically, “Why did you not mention that you are HCV positive?!” Without hesitation, the internist joined in the badgering of the already devastated patient, adding insult to the injury.

“I don’t know what they sought to achieve by making me feel guilty," my friend said, "while all the other patients stood outside wondering what all the fuss and screaming was about.” I had no answer.

My friend was obviously crushed and wanted to make his voice heard, and I was the closest target belonging to the group that has hurt him most: doctors. So he talked and talked, and I just listened. I don’t know what had hurt him more, the fact that he was going through all this pain because of the neglect of a few doctors a decade ago, or because he was treated like a jerk by a doctor who was too busy to read his file, or maybe because he had to lie to the patients standing outside to escape more harassment? Perhaps it was simply that the endoscopy report made it clear that no doctor could do much to help him, and no one even took the time to talk to him about his fears and anxieties.

“First do no harm” -- you can’t put it any better than that. I remember someone saying that most of the diseases we encounter will either improve or degrade by themselves, whether we help out or not. We are just there to accompany the patient and maybe make a few adjustments. But we have indulged so deeply in such trivial adjustments that we often forget our true role in the healing process.

I have spent the last seven years trying to learn about medicine. And if there is one thing I learned, it’s that although becoming a doctor might be insanely difficult, being a healer can be a piece of cake -- all you have to do is put yourself in the patient’s shoes to realize what not to do.

The Lure of Surgery Can Be Fleeting

Ali Tabatabaey -- Wow! What an experience. If you feel that you’re unwillingly being seduced into mastering the art of “the Blade” instead of the science of medicine, there is nothing like a back breaking seven-hour session at the operating room to change your mind back!

During this surgical marathon an extern fainted and the other intern preferred to take a seat, while the aid nurse handed her responsibility over to me during the second part of the operation. It was supposed to be a simple tumor resection but after taking a look at what was inside, it ultimately turned out to be a single-team APR.

The patient was an Iraqi resident who had undergone total colectomy a few years ago, but the rectum had undergone malignant changes and he now had a huge abdominal mass. This father of four was in his early forties and had been diagnosed with ulcerative colitis 20 years ago. Since all the worthwhile doctors have left Iraq due to the security situation, he chose to come all the way here to undergo the resection.

The mass had invaded much of the adjacent tissue and there were a lot of adhesions left over from the first operation. So the first few hours were spent trying to reveal the original anatomy of the abdomen and then getting rid of the invasive mass.

Just before the operation there was a ruthless race between the interns to determine who, if anyone, could scrub in. I never knew I could stand for this long. In the last hour I thought I was about to join the casualties too, but I managed to fallow through. It was a great experience, yet not one I would fight for the next time around. As the wise surgeon reminded me during the operation:

“People fall in love with surgery all the time, but turning it into a lasting relationship is not something all can do!”

Surgery is Addictive!

Ali Tabatabaey -- I thought it might be a good idea to do some dirty work just before fading into the sunset, so I’ll be finishing off my internship with a couple of months of surgery. I’ve said this before and I’m pretty sure about it, that my true passion is internal medicine, but boy I have to admit “the scalpel is addictive”!

Things did not seem this interesting when we saw it from a distance as an extern. Yet at close range with the scalpel in your hand it’s a whole new world. No wonder so many of my friends name surgical residencies as their top choices. I don’t know what it is. Some say surgery is so appealing because you literally see everything that you are working with and in most instances you don’t have to assume something indirectly. And whenever you’re not sure, you just cut the patient open and take a closer look!

But I say it’s more than that. Maybe it’s the sense of power in being able to explore the body of a living human being. Or maybe it’s the on-spot sense of accomplishment with every operation. Or just maybe it’s the carnivore inside us crying out after years of civilized suppression! Whatever it is, it feels great. Holding the scalpel in your hand gives you the permission to cut open someone else’s body, take a look around, cut out anything you think doesn’t belong there and sew it up when your done.

Once you’ve tasted it you just want more. You crave bigger cuts and more complex operations. The simple appendectomy won’t be enough anymore; Deeper cuts, more blood, bigger sutures … ha ha ha (evil laugh)! Wow! I guess it’s got all the characteristics of a true addiction. Hey, but who am I to talk? I’ve only aided a couple of operations. We’ll see what happens as things unfold through the rest of the course.

Encouraging News for Med Students Everywhere!

Ali Tabatabaey -- I can slowly sense the end of my medical training approaching…

Who am I kidding? It’s been explosive! It’s like someone’s put life on fast-forward. I keep asking myself, “where did the last seven years go?” And while I’m trying to figure that out, I know that in a short time I will once again have to make life altering choices. Everything has been the same for so long, and now in a very short time everything is going to change.

Yet while this “medical puberty” throws a new surprise at me everyday, it’s not all bad. I always thought of becoming a doctor as a gradual metamorphosis, like a frog working its way out of the water and onto land. That I would pick up the skills needed for practice, bit by bit along the way. But for me this change has been just as explosive, too.

These days I find myself sending patients home from the ER, predicting patient’s courses, making diagnoses, and determining therapy choices -- things that I would have never imagined I could do a few months ago. Even when conversing with attending specialists about a patient, it could really be described as a mutual dialogue because I can actually understand what they're talking about! It’s an unbelievable feeling and I don’t know when it happened. Maybe a fairy came when I was asleep and said the magic words to help me move ahead one big step. Or maybe it’s all about self confidence.

It’s all been a surprise, but a pleasant surprise. I’m not afraid of becoming a physician anymore. I think I’m ready to accept the challenge. I guess these final days at med school are more like a caterpillar breaking free of its pile than a frog escaping the pond!

PS: No frog or butterfly jokes please! I really couldn’t find better metaphors. :)

What Makes Medical Training Look Easy?

Ali Tabatabaey -- The last month has been fairly quiet, as you would expect it to be in Dermatology. It's been a well appreciated break after all the hustle and tension at pediatrics and internal medicine back to back. Yet just the other day, a young man walked through the door at the clinic and as he left, with him went all the calm.

He was a young, tall boy wearing a cap, not very different from your typical young adult. He sat down, took off his cap, and revealed a foul smelling, oozing pyodermia on his shaved head.

“How did this happen?” I asked, trying to determine the extent of the damage.

“A couple of days ago I was in the sun for three hours and it really burned. The next morning I woke up to find it like this,” he replied with a depressed tone of voice.

“Why didn’t you wear a cap? Why did you shave your head in the summer?” I asked, a bit confused.

“They didn’t let us wear one.”

“Who didn’t let you?”

“My commanding officer. I was enrolled last week.”

That cleared up everything. He was serving his conscription and had experienced his first taste of military training, with a shaved head, in the scorching noon sun, for three hours.

We gave him his medication and a couple of days off duty if his commanding officer approves. As he was leaving, I suddenly realized a very disturbing fact and whispered it in my friend’s ear: “Do you realize that in a couple of months, that is going to be us? … Well actually, you!*”

He turned white, then blue, and then another color which I could not recognize. I sensed his pulse rate rising and adrenalin levels reaching critical limits and finally a sharp drop in serotonin levels. I quite often underestimate the power of external stimuli in triggering a major depressive or anxiety episode. I guess the poor guy hadn’t really thought about it until I brought it up like that.

Yeah! It’s tough, being sent away from family and friends, to the country's worst climates, for two years! … Hey wait a second. That’s exactly what’s gonna happen to me! In a couple of months I will be sent to some city I probably won't know how to pronounce the name of! Oh my God, I will depart everything I have lived with for seven years to serve a village with a population roughly as large as our faculty! Ooooooooooooooooooh myyyyyyyyyyyy Gooooooooooooooooood!

And then I can sense my own pulse rate rising, my adrenalin levels reaching critical limits, and … is it too late to panic?

*It’s a long story, but after graduation I won’t be going to conscription like most other guys here. After school I will start to serve as a regular GP, not a military one.

Minority Report

Ali Tabatabaey -- A few posts back one of the readers asked me about how girls do in Iranian med schools. So with apologies for my delayed response, I’ll dedicate this post to answering her question.

Imagine you are a boy! (Not so hard to do for at least half of you). Now imagine living in a country where girls are more motivated to study than boys are. What happens if in the same country you have to pass an extremely difficult university entrance exam to be able to pursue an academic career? Let me tell you, you end up with a 70-30 student population in favor of the girls. Now that we’re imagining, think that in this country the pay in the medical profession is not all that good and the competition is merciless. Therefore, if anyone aims to earn a good living in the future (including most boys who are looked upon as the ones supporting the family financially) they won’t show up in med school. On the other hand, the medical profession still has its prestige, so if money is not that important for you it is one of your top choices. The end result is that the already skewed ratio is tipped to the benefit of females even more, and you and your male colleagues become a mere 15 to 20 percent minority.

This scenario has been so strongly played out in Iran during the past decade or so that the government decided to limit the girls’ share of public university seats to fifty percent in some fields, including medicine. So girls have claimed their share and maybe even a bit more when it comes to higher education.

So, despite what most of you expect, the female population is a definite majority here. But I have to admit they are a quiet majority and at least where I studied, the guys were more successful in making their voices heard.

To even better reinforce the place of women in the healthcare system, a few years ago some of the female members of parliament managed to pass legislation that reserved some residency positions for girls only. For example, only girls can study OB/GYN in Iran. This was meant to advance female doctors in all fields of medicine, but its most obvious result has been to make the race even tougher for boys.

So overall, at least in the field of medical sciences, girls are doing pretty well here. They are competing well to enter the profession, and they need lower marks to gain access to most residency positions. So if you want to worry about someone, please worry about us poor guys who have to battle it out for the remaining positions and are expected to support a family with a GP’s paycheck!

PS: That’s how I see stuff from the outside. I realize that things might seem different from a female point of view.

Why I Still Want to Be a Doctor

Ali Tabatabaey -- Thanks for all the (mostly) hilarious comments about my "seven reasons" post. I was rolling around and laughing out loud after reading some of them. I really liked the idea of printing some of the reasons on my T-Shirt too.

I know some of you pointed out my earlier post about not being willing to give up this job for a million dollars and objected to this post. Truthfully, I still wouldn’t give it up. But hey, where is your sense of humor guys?

The truth is that studying medicine is full of mixed feelings. We are all going to have our times of glory and we are all going to have that unique patient’s “thank you”. I’ve had some of the most memorable experiences in that sense. But we are also going to feel down sometimes and we are going to doubt our choices. Yet at the end of day, most of us love the good parts more than we hate the bad parts.

That is one of the things about studying medicine that fascinates me. It’s the forbidden apple that you can’t resist. It feels like being an infant who's fascinated by walking despite having felt the pain of falling.

So don’t misjudge me, and don’t misjudge medicine. It’s not all good stuff, and it’s not all bad. It’s an irresistible stew of both, and you can’t have one without the other.

Do Clinical Guidelines Pre-empt Physician Judgment?

Ali Tabatabaey -- Evidence-based medicine brought with itself a hope for purely logical practice, but like any other revolution, I would say, time is making its shortcomings apparent. It limits the choices of a physician from what he/she feels is right, to the ones with compelling evidence supporting them.

In EBM we base our judgment on costly randomized trials, and since such studies don’t come out very often, the good old statisticians have come up with the meta-analysis to help us decide based on a greater pool of evidence. Yet we all know that most of these expensive trials are sponsored by pharmaceutical companies, making the results biased. In other words, the negative results are less likely to be published. The statisticians know this too, so they are working on a method to estimate that skew and consider it in the result. The only problem is the “estimation” part, because that has to be calculated too, and guess what, there are a lot of parameters that can make this biased, and we are going to need another method to estimate that, and so on!

So there is no such thing as compelling evidence, is there? History has a lot to teach us in that respect. So many drugs and diagnostic methods were believed to be the ultimate answer to our prayers but time proved us wrong. Trials have found conflicting results in their early and late evaluations. And so many times we have found two or more studies reporting conflicting results.

After an era where we brushed out all that was unrepeatable or immeasurable from our guidelines, we are finding subjective criteria and the physician’s judgment creeping back into our purely objective and methodologically clean-cut criteria and guidelines for diagnosing and treating patients. It appears that after all, the physician's “feeling” or clinical judgment as some say, works best for each individual patient.

So where does that leave us with EBM? To tell you the truth, I don’t know. EBM might not be perfect but the mind of the contemporary human being will not accept anything unscientific, so I don’t see any other choice. Maybe we should change the way we collect evidence-based data, or maybe we should change the way we approach it. I think we young doctors should realize that EBM is simply another tool in our hands and we should not surrender fully to its august name. Even in the world of EBM you are the person who calls the shots.

Seven Reasons to Become a Doctor

Ali Tabatabaey -- I’m home and everything is back to its old boring self again, so boring that I can’t stand it. I’m just coming out of a “loud conversation” with the department head and the faculty dean, who literally fined me for going to the congress “without their permission”! They didn’t raise a finger for me in the process and now they are punishing me?!?! I just don’t understand.

So I’ve been thinking about what to write in this post. Well, maybe you’ll like this message that I just received from a friend who graduated last year and is now practicing in a remote area of central Iran.

Seven reasons why I want to be a doctor:

1. I hate to sleep.

2. I want to stay in school forever.

3. Nobody can read my hand writing.

4. I have too much money.

5. I think I’ve enjoyed my life enough.

6. I can’t live without tension.

7. I want to pay for my sins!

To that I would like to add:

8. I love spending time with snobby self-centered people who feel they own everyone and everything, and I don’t mind turning into one!

Anyway, I know there is room for a few positive points on that list too, but since I don’t feel very positive right now I’ll leave them to you guys. So feel free to complete the list.

Finding Inspiration in Research

Ali Tabatabaey -- Awesome is the only way to describe this place. (I'm at the Congress of the International Society on Thrombosis and Haemostasis in Switzerland.) I’m having the time of my life. Scientific history is being written right before my eyes. This is where those unpronounceable names on the covers of textbooks actually come to life and take on corresponding faces. Here one can see knowledge being born, ideas turning into hypotheses, hypotheses turning into theories, theories turning into results, results becoming suggestions, and suggestions graduating as clinical guidelines. Wow, I’m feeling like a total nerd talking like this. But I’m really enjoying it, so there is no use hiding it.

The medical education system where I studied only acquainted me with clinical guidelines, and it’s such a pity. When you just see the guidelines, you skip the beauty of the thought. Yet here, everyone is thinking and that’s why it’s so energetic rather than energy consuming. The cool thing is now, instead of just memorizing textbooks, I can somewhat anticipate the new ones in the next few years, even without studying, WOW!

I’m only half way through the Congress and I think I’ve stuffed my brain. If one realized the bulk of studies and information that are filtered and jammed into a textbook, one would have more respect for them, and maybe instead of complaining about the size we would thank the authors for bringing it all together.

Anyway, it is great to be a part of this and I’m so grateful. Soon I’ll be back in Iran and everything will be back to normal.

On My Way to Geneva

Ali Tabatabaey -- The natural scenery makes an impression on you even before you land: mountains, forests, fields and lakes all come together to form a magnificent sight. It reminds me of northern Iran and the coast of the Caspian Sea, but with a cool touch, which makes it even more pleasant. (I explained in my last post why I'm in Switzerland.)

Everything went smoothly in the airport. All I had to do was to catch a train to Lausanne where I’ll be staying with friends.

“Hello sir, can you tell me how I can go to Lausanne?”

“Aaaammmmm ……ok…… my English is very bad!” he said with a deep French accent. “Can you speak French?”

“No.”

“German?”

“No, I’m sorry.”

“Italiano?” he suggested desperately.

“No, just English.”

Spanish was his final proposal, which didn’t help either. And would you believe it, he didn’t speak Persian!

So I got the directions through the single international method of communication that never fails: sign language! I guess this is the only place in the world where you can find someone who speaks four languages, not one of which is English!

I got into the train, sat on the most comfortable seat I could find and relaxed. The ticket salesman came, typed a few words in his machine and announced: “45 francs, sir.”

What? That’s like a third of my monthly income! I had heard this place was expensive but this was ridiculous. No choice but to pay up.

My friend was waiting for me at the Lausanne station and the rest of the day was full of fun as he acquainted me with the city and some other Iranian students living in Lausanne. Lucky for me the largest festival of the year here starts tomorrow. I think that will be fun, too.

Only a few hours left and I can’t wait. Hope I make the best of this rare chance. Thanks for your good luck wishes.

Look Out, Nobel Prize Committee!

Ali Tabatabaey -- I’ve always dreamed of becoming a researcher, and my ultimate goal is winning the Nobel Prize. Yet along the way I’ve found this not to be so easy. Well actually, I never expected it to be easy but I always thought walking in the right direction would be easier than this. It feels like swimming against the waves. There’s always something more important in life than following one's dream. But I know that if I’m to accomplish even the slightest bit of my dreams in this fast-forward life which will probably run the ending sooner than anyone expects, I have to get to work right now.

So that’s how I got myself into this. I chose to take the pain and worked on a unique project for my thesis in Tehran, 1000 kilometers away from where I live. It wasn’t easy and it surely wasn’t cheap but I think it just might be paying off. The project by itself is not considered a hot topic anymore, but being able to accomplish it here is a unique process in this part of the world. I worked with the staff at the Iranian Hemophilia Society to determine the genotype and phenotype of a few patients suffering from Factor VII deficiency (a rare bleeding disorder). Thankfully the results of our research have been accepted for poster presentation at the 21st Congress of the International Society on Thrombosis and Haemostasis next Monday.

“I am so very happy today. I can’t stop jumping around like a kangaroo. I just found out that the abstract I sent to ISTH 2007 has been accepted for poster presentation. If this goes through it will be my first international presentation. I just want to kiss the laptop. Can this really be my first step into the world of research? Watch out Nobel! Hear I come, in 20 to 30 years maybe!”

I wrote that paragraph a couple of months ago but I did not post it since I wasn’t sure whether I’d be able to attain a visa or not. But today I’ll be leaving Tehran for Geneva. I’m actually in the airport right now. I still can’t believe it myself. I guess in a few hours I’ll be meeting the world’s greatest names in thrombosis and hemostasis. It’s truly awesome. I know my part in this is nothing and probably no one will come to see my poster during the couple of hours that it hangs, but the chance to be there by itself is intriguing. I just wish I had the chance to do more of this.

For some reason I’m not jumping around right now. I’m kind of nervous. I just hope this is the beginning and not the end of my research career.

What's Your Medical Education Worth?

Ali Tabatabaey -- It’s break time on the final shift at internal medicine and the debate is on. These interns have finished most of their courses and will be graduating at the end of this summer. Unlike in the US, internship here in Iran is a part of the GP education and not residency. So by this fall, most of us will be practicing physicians ready to start working in a remote rural area with or without entering the ruthless competition for available residencies.

Strong opinions were thrown at one another and each was defended passionately. Some believed that our medical training has been a lifetime experience that will pay off eventually. Others pointed to the impossible competition for residency, with only one in 100 applicants being accepted, as a proof that this is a dead end. Some talked about residency abroad while others just wanted to start working and earn some money. Some even dared to call the long process behind them a life mistake. It’s been a while since I decided to stop complaining and start enjoying life as much as I can, so I just listened to the debate quietly.

They all had a point. At best, we have spent ten percent of our life expectancy at this university. We entered as lively youth straight out of teenage-hood and are leaving as grown men in the second half of our third decade of life. We have invested a lot in this, and the question of whether it was worth it or not is inevitable.

The different sides battled it out for half an hour before the decisive argument, I would say, won the debate:

“OK, so you say you wasted your life and money here. If you were given the chance to go back and be a high school graduate and were given back all your money, would you be happy to live the rest of your life like that? How about if you were given $100,000? How about a million?”

Deep down inside, the answer to all those questions was “no”! (Well, maybe if they raised the stakes a bit higher … no, never mind.) At the end of the day, through all the rough times and all the struggles and all the harsh labor, we have gained a unique experience that most of us are not willing to swap for a million dollars. Amazing!

In the Still of the Night

Ali Tabatabaey -- It’s dark and the only source of light is streaming through the leaves of the tall maple tree in front of the window. I look at my watch glowing in the dark: It’s seventeen minutes passed three. A quarter of an hour has passed since my two fellow interns and I came to this room to get some rest. But today, I lost -- and in this ruthless room, if you lose, you don’t sleep.

It was a rough and yet pleasing shift, a diabetic lady with DKA, an old grandpa with ARF, a farmer with GI bleeding, a refractory asthma attack, a suspected pulmonary embolus up in obstetrics, and so much more. I was really looking forward to sleeping. But a few minutes' hesitation means that I probably won’t get to sleep tonight. I stuff my head into the pillow, I try thinking of beaches and oceans, I twist and roll, but there is no escape. Is it really this loud or have my senses sharpened?

I like the young man. He has never wronged me, at least not when awake. Yet he falls asleep so fast. Not fifteen minutes have passed and he is down to phases three and four. I envy him. On the other side of the room lies the other intern, another friend of mine, fast asleep. He sleeps like a baby, for he did not hesitate. The key is to fall asleep before the others, or you shall be convicted to wakefulness.

I try ignoring the invasive groan, but it scratches the soul. It penetrates all the pillows, the blankets, and even my hands. It grows louder and louder, and every second brings me closer to the end of our break. There is no escape. It must be dealt with.

I know the sound well. It is the uvula vibrating as it blocks the nasal air passage. The remedy is clear: stop the air flow or get rid of the uvula. To the sane mind, the latter is the better choice, for it saves the good man's life. But laser surgery has a lengthy waiting list, and I only have a couple of hours left to rest. So, it is settled. The flow has to stop. I grab my pillow and move ever so slowly towards his bed. The thin strip of light falls upon his innocent eyes, closed in calmness. The same “calmness” that his growling rumbles had taken away from me.

I stand by his bed and stare into his oblivious face. He is a dear friend, but I can not take any more of this. I must sleep. I must rest. The air flow has to stop. I grip the pillow, my heart pounding harder and harder. I reach out and feel his shoulder, and suddenly he opens his eyes, surprised to find me by his bed.

“I’m really sorry to wake you. I know you are tired. Could you please roll over on your side?”

“Oh, the snoring again! Sorry Ali. I told you; whenever it bothers you just let me know. I’m not aware of it.”

And so, finally, I sleep in the dark, quiet interns’ room. Next time I shall not hesitate. I shall reach non-REM before he does. Then he will have to stuff his head in the pillow to escape my snores. Next time I’ll win the race to sleep.

PS: When choosing who to have your shifts with, make sure you check for obstructive sleep disorders in your room mates. Or else the race is on.

A Refreshing Change From the Wards

Ali Tabatabaey -- When you have a couple of back to back holidays ahead, there is nothing like a camping trip to help you get away from all the stress and agony of daily life and to pump a bit of fuel back into your over-stretched system. The ultimate saga of man and nature is just what one needs to regain the power to meet everyday hassles head on. Our ears need to hear waves after being used to hearing traffic jams, our feet need to feel the sand after getting used to asphalt, our stomach deserves to taste real food after feeding it so long with canned goods, and we need to escape our concrete cells in order to feel life. Well, at least that’s how my friend and I felt before planning our trek into the wilderness.

The exotic thing about these trips is that you get to live through man’s social evolution from the start. First, the food! Thank God, we didn’t have to hunt for the food, but in order to prepare it the way man has been preparing it in the last 10,000 years, we had to reinvent fire. Even with a box of matches, keeping the thing alive is calorie-consuming! For the sake of a couple of kebab sticks worth a few hundred calories, we, the starving carnivores, had to spend a week's worth of energy. While I was blowing my lungs out and waving everything I could at the fire, my friend was running around gathering material to keep it alive. No wonder there weren’t obese people in prehistoric times. The result of all this was the world's most delicious uncooked yet smoked piece of kebab we had ever eaten.

After food came the shelter challenge. We had to find a safe, quiet, and natural habitat to set up our tent. The problem was that lots of other people had escaped into the wilderness, too. So it took us till dark to find a suitable place. As we were setting up the tent in the dark, we got the pleasure of meeting our new neighbors, who I think were mostly from the scorpion family, yet others too were trying to make us feel right at home with their howling welcomes.

The story wouldn’t be complete without nature showing off its mighty power in a nocturnal storm. Imagine trying to sleep while the rain is pouring down on the tent and the wind is almost blowing it off the ground. Now imagine waking up joyful that you survived the night, only to find your clothes and sleeping bag drenched in the little puddles formed inside the tent.

The next morning as my friend was hanging everything to dry and I was getting the water out of our waterproof tent (according to the catalogue) cup by cup, I announced loudly, laughing with my fellow traveler: “I like the comfort of my concrete home, I like electricity, I like the safety of living among others, and I don’t like running around for an hour just to boil a pot of water…” I guess if we were given the chance to re-evolve, we would go about the same path as our ancestors in search of comfort.

Anyway, this was one of the most fun trips I ever had, and it really did boost my energy as I headed back to the wards.

Finding Love After Medical Training

Ali Tabatabaey -- Why is it so easy to hate but so hard to love? These days, as our medical education approaches its end and the promise of life after medical school appears in the horizon, many of my classmates are trying to set their lives straight, and it seems that getting the love part clear is a big part of that. Some are getting engaged, others are getting married, and some are even ending a longstanding relationship, while others are sticking to their one true love, medicine. The mood is full of contrasting affections.

I don’t know how far back this goes, but in the “brave new world” that we have created, it seems to be much more convenient to hate than to love. When you feel hate, it seems crystal clear. You care about nothing else but that feeling. You shout it out at the top of your lungs, not caring about how it will affect the person hearing it, or how they will respond. You never stop to think “what if they don’t feel the same way,” and you never save it for someone who "deserves" to hear it!

But when it comes to love, everything gets so complicated. It’s ridiculous! First you have to doubt everything about your feelings and about the other person until you are sure that there is nothing more to doubt. Is the time right for you to love? Isn’t there anybody out there whom you could “love” more? Even if you’re positive about your emotions, you don't want to be the first one saying it out loud because “that would ruin everything”! First you have to set the stage and see what your chances are of hearing the same sentence with a “too” at the end in reply. If you feel your chances are dropping below 80% at any time, you must abort the mission immediately, or all will end in disaster!

It’s more than ridiculous, it’s absurd. Why can’t we feel love just like any other emotion: clear, true, and with all our soul? We’ve tangled it up in so many things that it’s become more of a torture than a relief as it once was. Then again, maybe if it gets tangled up in all these things, maybe it’s not true love after all!

Thinking Outside the Box

Ali Tabatabaey -- Welcome to the wonderful world of medicine, where two plus two usually equals five, occasionally three, and only very rarely, four! Yet, since our logical brains love the straightforward answers, we rely on treatment protocols and charts that we can follow without any hassle. Still, no matter how hard we try to define everything by simple “two plus two” rules, in real life you just have to face the complexities of nature.

For instance, imagine a guy with upper GI bleeding, or a guy with an MI. The management scheme for both seems simple enough. Now imagine a 67-year-old obese guy with history of syncope, GI bleeding, and anemia complicated by an MI. Not so simple anymore. Now add to the recipe the cultural and psychological aspects of a human being, and things get even more interesting. Like an opium addict trying to give up his addiction for the sake of his family, coming in with pancreatitis or renal colic. What do you use as an analgesic? What are the chances of his addiction relapsing with the couple of doses of narcotics that you want to prescribe, since nothing else usually works for them?

I was once told that these days, medicine is not fun anymore, that there’s no creativity left in the business. You are told what to do by the texts, the insurance companies and others, and you simply carry out the instructions, something that a computer could do a much better job at. In fact, I have actually wondered why we physicians still exist, why we haven’t become extinct with all these super-computers around. And I think I just might have found the answer. In situations like the ones I've described, one needs creativity and the ability to weigh the pros and cons. The problem with computers is that they think “two plus two equals four,” and that’s why they sometimes fail in real life. Not only them, but anyone who thinks like them!

Know When to Fold 'Em

Ali Tabatabaey -- As a rule in internal medicine, “anything goes”! Meaning any disease might come to you with any set of symptoms. A patient could come to you with a complaint of anorexia and be diagnosed with an MI, or come in with severe abdominal pain and after all the tests be diagnosed with a major depressive episode and probable conversion or malingering. So it’s no surprise that in the midst of all the patients with COPD and diabetes, who usually have a collection of other ischemic heart disease risk factors hidden somewhere in the plastic bag they carry (lab results, antihypertensive medications, etc.), I find myself ordering ECGs and cardiac enzymes over and over again. My accuracy during this time has been around ZERO PERCENT.

Obviously there is a problem! It takes a huge amount of courage (alongside an ample amount of knowledge and experience) to look at a patient lying on a CCU bed, admitted by the resident during the night, and announce “there is nothing wrong with her heart. She’s discharged.” But I’ve seen this scene performed so many times without a twitch of an eyebrow by one of the cardiologists. The awe of the performance makes a shiver go up my spine every single time. He just looks at the patient, makes the statement, and after a quick examination looks at the interns on shift the night before with a frown, “how many times do I have to tell you to pay attention to the patient?”

But that’s exactly what we do! The whole package of complaints and clinics and para-clinics harmoniously sing “the cardiac” choir! What does he see that gives him this courage? All he says is that “it’s obvious.”

Now, in the ER with all the co-morbidities that can mask and change the face of a cardiac event, how can you be so sure that this dyspneic attack, sudden fatigue, chest pain, nausea, or heartburn is not cardiac? It seems that finding the courage to label the patient with a disease is one thing, but finding the courage to rule out a diagnosis is a whole new dilemma! In a situation where the cost of an ECG and enzyme assay can take up a good chunk of a family’s income, finding cheaper ways to reach the null hypothesis will be quite appreciated.

How Much Information Can We Digest?

Ali Tabatabaey -- Guess what I found in the dust-covered basement of the hospital going through a major renovation? A genuine Harrison’s Principles of Internal Medicine! But not any old Harrison’s, it was the eighth edition published back in the late 70s.

I have to say I’m in love with old medical texts, although I’m not very good at finding them. I once saw a documentary about the first descriptions and treatments of diabetes and pellagra, and it was amazing how out of reach these diseases once were, much like our perception of cancer and autoimmune disease today. Ever since then, I have made every effort to get my hands on old medical papers and books. So this was a treat.

The quotation that I mentioned a few posts back was the opening paragraph of this book, making it irresistible to read on. I was surprised to find so many parts of the book unchanged in the latest edition. But one thing definitely caught my attention. Look how small the book is. It’s amazing to think medicine has expanded so much in only thirty years. No wonder we (or maybe it’s just me) feel so lost. And to think all this information represents only the “principles” makes it even more frightening.

What is the limit of our knowledge? If this keeps up, we are going to have a very tough time keeping track of everything. How are medical students in 2040 going to manage it? Maybe by that time we will have figured out a way to connect a memory card straight into our brain. I truly hope so!

The Moral of the Story

Ali Tabatabaey -- Since some people were concerned about my earlier post when I was stranded at the airport, I thought I'd share how the situation ended. After making a lot of phone calls, it turns out that my airplane ticket (which I got through a friend at the airline company) was a special ticket that couldn't be canceled – so the airline had to fit me onto a later flight without any extra charge. All that time, no one had bothered reading the ticket code!

The funny thing is that just as the ticket issue was resolved, the personnel seemed to suddenly see me as a doctor instead of as a ticket-less, money-less loser! In fact, they started asking me questions about their aching legs, etc.!

A true lesson is to be learnt in all this, other than to always have some cash on you while traveling. Through this experience I realized that as long as I had no money, everything else I had was worthless. No one cared about who I was or where I was from. Those things only meant something when I wasn’t in need of money any more!

One of the most common essay questions in grade school here is: “Which is superior, wealth or knowledge?” (The common response is “knowledge” in such academic surroundings.) Yet the older I get, the more I doubt that straightforward reply, which I so deeply wish were true. Maybe knowledge is superior, but only if a baseline stream of wealth flows in the background. In the world we live in, the poor are so easily forgotten and their potential so readily overlooked.

I’m due for another trip next weekend and one thing is for sure: I might forget to bring along my student card this time, but I sure won't forget to take along a bit of extra cash.

Little Things Make All the Difference

Ali Tabatabaey -- Have you ever felt glad about breathing, walking, eating, drinking, even defecating?

The restroom is not the best place to be reminded of a 13th Century piece of literature, but in the morning after a night shift, anything is possible! This morning throughout the regular morning rituals I kept going through the famous opening to "Gulistan," the masterpiece written by the legendary Persian poet, Saadi:

“Laudation to the God of majesty and glory! Obedience to him is a cause of approach and gratitude in increase of benefits. Every inhalation of the breath prolongs life and every expiration of it gladdens our nature (relieves the soul); wherefore every breath confers two benefits and for every benefit gratitude is due. Whose hand and tongue is capable to fulfill the obligations of thanks to him?”

I guess it all started around midnight when a patient approached me in his wheelchair and repeated the request that he had been making for the past couple of days: “Give me something to get my gut going!" He could have just rung his bell, but he wanted to make sure something was done about his problem.

We had tried all kinds of bulking agents and osmotic syrups but he was not satisfied, and I’m not very keen on using stimulant drugs for my patients. So his problem had not resolved the way he wanted it to.

Now, the patient is not what I want to write about but rather about what his problem made me realize.

It’s amazing how we forget the little blessings around us. We only notice their significance when we lose them. A subtle alteration in one's daily routine can make life unbearable. Who would think that “not being able to go” could be such an agony that it would drag a disabled man from his bed onto his wheelchair in the middle of the night? It turns out “being able to go” is a blessing, as is every inspiration and expiration. Even for the richest man in the world, the only distance between joy and misery is a couple of days of refractory constipation.

It’s the little things that matter; little things like health!

PS: For those who read my previous post, I did make it back to Mashad!

Stranded at the Airport

Ali Tabatabaey -- I hate traffic, I hate airline personnel and I hate Tehran! I find myself, a 25-year-old med student, abandoned in Tehran’s local airport. I haven’t had a shower in three days because the place I was staying at had no running hot water; I spent the last three hours in rush hour traffic in one of the world's most polluted cities; I spent all my money on stupid unexpected expenses, leaving me with 3800T, just enough to get home from the Mashad airport; and I just missed my flight!

The reason I missed it is because I was caught in the second worst traffic jam of my life (the worst was seven years ago, again in Tehran!). It’s stupid. It takes me one hour to travel 994 km by air to Mashad, but it took me more than three hours to reach the airport.

What am I going to do? I just spent the last hour looking for someone who might help me, but I kept getting the same answer: “There is nothing we can do! You have to buy a new ticket!” The only problem is that I have no money, no relatives, and they don’t accept credit cards here!

I even literally begged the airline personnel to let me on a flight to Mashad tonight where I could ask my family to bring the money. For a moment there, I felt like a professional bum: explaining how I was stuck, showing my cards to prove all this is an ill-fated sequence of random events and that I’m not any old moneyless jerk trying to side step buying a new ticket. I even thought about writing my story on a piece of paper and sticking it on my chest as I wandered from office to office. Still, no one was willing to help. I guess they didn’t believe me. One even suggested borrowing the money from other passengers, or refunding 50% of the ticket value and going to the bus terminal.

It's been like mental torture! I guess I’m being punished for all those times when I didn’t help the people coming up to me on the street. I just couldn’t take anymore of this humiliation. So, I finally took a seat in the passengers waiting area and started writing, to calm myself and control my anger, my anger at myself, and the system. I’ve got no one to blame but myself. Just imagine the stupid look of a guy carrying a laptop on his shoulder, textbook of internal medicine in his bag, and no money to buy himself a ticket home. I’m stupid, and so are all these airline personnel, and so is the traffic in this city!

What am I going to do?

What Makes a Truly Good Doctor?

Ali Tabatabaey -- In my eyes, internal medicine is the toughest clinical area of them all. The knowledge is so vast and the diseases so overlapping, that if anyone can keep track of what’s going on here, they are not going to have any trouble anywhere else. It’s here that the final but most important ingredient to becoming a good doctor is put to the ultimate test: Clinical Judgment.

That is why, if you look a bit closer during your internal medicine training, you’ll realize that the demographic characteristics of your class are changing! The students who used to be ranked first and carried the report cards with most A+ on them might suddenly not seem so successful when it comes to treating patients. On the other hand, the students who had always been looked down upon because of their low marks during basic sciences and even externship, might actually seem like they’ve turned on their turbo engines.

It’s almost as if learning the stuff you need to know is one thing, and actually practicing what you’ve learnt is a totally different thing. It’s like being warped from one world into another without warning.

If you look around you can find lots of interns and even some practicing doctors that are very knowledgeable, but when it comes to treating patients, they often can’t find the best way and end up requesting lots of lab and para-clinic studies. When you’re drowning in a sea of knowledge you will grab anything in sight, fearing that you might miss something. Approaching every patient from the shortest and most cost effective path is a delicate skill that many textbook docs fail to master.

So don’t forget: on your way up this ladder, always have the patients in mind. Figuring out the true cause of their illness, using the least amount of cost and time, is a very tricky task that will ultimately separate the okay docs from the best.

All I’m trying to say is that knowing all the textbooks and even clinical data still doesn’t make you a good healer. Now, not knowing these things probably makes you a bad one, but still, becoming a good doctor is much harder than it seems.

Practice Pearls for Pediatrics

Ali Tabatabaey -- So long, Pediatrics! There goes an era in my life which gave new meaning to a baby’s cry. During this course, crying annoyed me, angered me, saddened me and even made me happy. There were times when I stuffed my head under the pillow to escape the crying and others when I did all I could just to hear a baby cry, and jumped for joy as he did. Overall, it was a fun filled rollercoaster ride.

I’ll be leaving the little rug rats to care for mostly elderly patients at Internal Medicine. Although this makes me a little nervous, since I still feel uneasy caring for pediatric patients all by myself, I think I have gained the self confidence to do so after this experience. Yet before I leave, I have to pass down the pearls of knowledge that I managed to acquire during this time, which can be vital for any student going into this mess:

Rule number 1 is for hospital architects and not for med students: For God’s sake, don’t build the interns’ room right next to the pediatric ward. Or if you do, please make it sound proof. If you don’t, you’ll be faced with years and years of interns cursing while they role in bed trying to sleep in middle of all the crying.

Rule number 2 is to forget about using a friendly smile and baby talk when examining an infant. To understand why, just make the same faces into a magnifying mirror. You’ll get a sense of what the baby sees. Believe me it does not look pretty!

Rule number 3 is to “Be aware of the domino affect!” When all is quiet in the nursery or the ward, do all your best to keep it that way. A wrong move during a physical or a routine checkup can have disastrous results. If by any chance you make such a mistake, you only have 10 seconds to reverse it. To stop a baby from crying you can use anything from mild taps on the chest, to hopping on one foot while making a funny face, or even asking the mother to breastfeed it. If you fail to stop the crying in the first 10 seconds, abort mission and run, because by this time the domino effect has awaken the other kids and you’ll be faced with 15 to 30 babies crying simultaneously. If only adults were this united in making their voices heard! Nevertheless, triggering the domino effect is an absolutely inexcusable crime in the eyes of the nursing team, so stop trying after 10 seconds, get out of the room, and wipe off any fingerprints if you can!

Rule number 4: when examining a newborn, always examine the male genitalia from an angle, and never bend down to look closer for anomalies. Your gloves are probably cold and anything might happen.

And last but not least, always be armed with different flavors of lollipops. They do come in handy sometimes. I can’t remember anything else right now, so I wish you good luck. And off I go to my beloved internal medicine.

I Fear I've Been "Institutionalized"

Ali Tabatabaey -- This time of year is a very special time for us Iranians who uniquely celebrate the New Year (Norouz) on the first day of spring. It’s a time of liveliness, joy, and happiness. The streets are packed with people trying not to miss out on New Year shopping, and everyone is planning trips and vacations in order to make the best of the beautiful weather.

On  the other hand, as I work my way through the final days of pediatrics and try to wrap up a three-month intern rotation, in what our friend Aaron would call “an intensely traditional medical course”, I somewhat look like I’ve missed out on the last few million years of evolution with my untidy beard and Einstein-like hair. This final year in a tough seven-year marathon of med school has been different. Before, at least on the way to the library and back I used to see other people and envy them, but this year has passed inside the hospital on shift; and when not on shift I’m either too tired from the last one or too busy preparing for the next to even care about how others live. So one would think Norouz is a great chance to blend back into life!

I was forced by the family to go out shopping and get a hair cut, but this desperate attempt turned out to be quite interesting. At first the crowded streets seemed appealing for someone like me who hadn’t seen healthy people for a long time. But the more I tried, the more hesitant I became. I felt like an alien. People have changed. They dress differently, eat differently, and laugh at different things. The always-fashionable blue jeans are not stylish anymore. Going out for a pizza with friends, the routine adventure of my teenage years, is lamely out of class, I’m told -- and would you believe it, kids don’t play Super Mario Bros 3 anymore (actually this one goes back more than 7 years)! When did all this happen? The thought that in 6 months time I’ll be released into this society scares me. My jokes are not funny anymore because they’re full of jargon and I don’t get other people’s jokes. The comedies have changed; people’s sense of humor has changed. I hate to admit this, but if I was Morgan Freeman and this hospital was the Shawshank, I would have to say, “I’ve been institutionalized.”

Inside this hospital, I’m somebody: I’m Ali Tabatabaey. People trust me. The doctors trust me. If you have a problem, you know Ali can help; if you have a question there is a good chance Dr. Tabatabaey knows the answer. I’m respected by my classmates, the externs, the nurses, the patients, and the physicians. But out of here, I’m simply a GP just like any other GP, and in developing countries like Iran, India and Eastern Europe, that’s not something to brag about.

And so after a day among the people, I go back to the closet: “I know I had a pair of working jeans in here somewhere”, somehow manage to find the early episodes of “Friends” on DVD, and order a pizza while I watch “The Shawshank Redemption”. Now that I think of it, I realize that I belong in the hospital. I don’t envy anyone anymore. I’m happy with all I’ve got. I like shifts. I like it in here. Please let me stay. I don’t want to graduate! Don’t make me go out there. It’s scary out there!

All that said, Norouz is still the best time of year. Happy Norouz everyone! Here is a picture of HaftSeen, the decorations are explained at this site.

No Med Student Is an Island

Ali Tabatabaey -- For most of the X-generation robots attending med school during our times, life is about day-to-day patients, disease, prescriptions, discussions, and the whole thing all over again. Not many of us dare to disclose our human emotions, and even if we do have such feelings, it’s something we hold to ourselves for those lonely moments when no one is around to see. And so the real tragedy of being a med student unfolds: the lonely human, facing a world of emotions!

It seemed like a normal shift, checking on the patients, organizing the files, writing notes, going to the interns’ room to rest, seeing your colleague crying her eyes out…

“I’m sorry. Did I bother you? I’ll come back another time.” It was like being shocked with 10000 volts of electricity. She’s one of those disciplined interns who do the job and leave out the accessories, hardly losing her frown while at work. I was stunned.

“No. Thanks, I’m ok. I have to get back to work anyway.”

“You don’t look OK. You can go home if you like, I’ll cover for you.” And I’m one of those people who just can’t keep their nose out of people's business! “Is there anything I can do? I might be able to do something if you tell me what’s wrong.”

“Have you seen the patient in room 9?”

“Yes.” A 2.5-year-old girl who has spent the last 10 days in a coma. 12 days ago, she came down with a fever and vomiting. Her condition deteriorated by the minute, and now she is brain-dead. It was probably viral encephalitis or a complicated tumor, but no one knows for sure. Her family has not allowed further investigations. “What about her?”

“She came in a couple of months ago with a febrile convulsion. She wasn’t my patient, but I remember her clearly. She was a beautiful girl, bending down the side of her bed. I walked in and called her a naughty girl!” The stream of tears running down her face refused to be controlled by the pathetic attempts made by the wet tissue in her hand. “Is she really dead now? How could she turn like this in two days? We probably missed her diagnosis the first time.” Frustration, anger, sorrow and many more emotions flooded her. I was muted by the enormous emotions overwhelming her. I had nothing to comfort her. “Why her? Why so fast? Isn’t there any hope? Isn’t there any justice?”

The truth is that the girl is in fact dead, at least as far as the neurologist is concerned. There is nothing we can do except to keep her body alive. The story had become more tragic now that I knew a bit more about her, but still there was nothing we could do. We had been beaten by a virus. My fellow intern knew all this too but … In such times of hopelessness, we need someone stronger to hang on to. All I could think of was praying at the holy shrine. Maybe this way she could calm down a bit. She accepted.

I guess all of us X-generation robots attending med school still have a touch of humanity deep down inside. No matter how rock solid we try to be, the so-called everyday events around us are so powerful, that just when you least expect it, they will push you over the edge. One day we will all break into tears. It’s just not the same day for all of us.

Two days later, room number 9 was empty again.

Just One of Those (Good) Days

Ali Tabatabaey -- Today it finally snowed here in Mashad. Actually, it started late yesterday and it’s still snowing. This morning I was woken up by my young brother’s phone call at 6 a.m. “The schools have been closed today hurrrraaaa!” But I had to disappoint him because I couldn’t join him for the snow fight since “I am on shift.”

It was cool getting out in the middle of all the snow, being the first to leave footprints, just like old times. On the way to the hospital, I helped push a neighbor’s car out of the snow. He honked his horn as a “thank you” when he drove off, splashing me from head to toe with the snow from his tires.

I had to switch three taxis on the way since most of the taxis had preferred to stay home in the cold.

When I got to the hospital, the NICU was packed. Yet still two new guys joined in, a baby with VATER syndrome and one with Arthrogryposis and many other anomalies. It was a busy day, following up on old patients, being the only one at the morning round, talking to the families, a couple of consults, and preparing tomorrow's morning report.

Well now, it’s 1:30 am and it’s time to relax. And what better way to relax than sipping on a giant-sized mug of coffee while standing in front of the open window, staring out into the calm quiet city, watching the snow flakes drifting slowly to the ground, and listening to your favorite rock songs on the MP3 player. It’s an amazing feeling as the snow frosts your skin and the hot coffee warms you inside. Looking at the virgin snow piling up in the streets I know that today I was probably one of the few people who had to work, and unlike my usual feeling about such a sentence, today, I have a great sense of accomplishment. I don’t know why but I’m enjoying this so much, I just can’t stop smiling. This is fantastic. I wish it would snow more.

P.S. Don’t try this at home. Thanks to the coffee, I was awake until 5:30 am and the nurses (after changing three shifts) thought I had gone completely nuts!

Finding Hope in the Midst of NICU Despair

Ali Tabatabaey -- I’ve been officially charged as being a whiner! I don’t whine, do I? OK, don’t answer that. I don’t know when it happened but somewhere during the past few months, I was derailed from my usual self and I’ve been struggling to get back on my normal track of thought. Therefore, as you might have realized, I’ve been trying to look at the events around me from a more positive perspective. So during my shift last night, I could feel the glowing circle above my head as I smiled at everyone and everything and searched every corner for signs of hope.

As an exercise, I decided to take a tour through the NICU and see “the full half of the cup” in every incubator. The first baby I met was a 65-day-old prematurely born baby, admitted 10 days ago with the primary diagnosis of pneumonia. His SPO2 fluctuates up and down despite O2 therapy and different antibiotics he’s been receiving. He has already lost a brother, and another brother is being taken care of in the same NICU. That’s right; they were triplets. “THINK POSITIVE.” Ok, ok, at least he is breathing himself and hasn’t needed ventilation… BEEEEEEEEEEEEEEP. “His O2 sat is dropping again, this is not working. We should intubate him, he will need mechanical ventilation soon!” the resident said.

Not a very promising start, but let’s move on. Let me see: A 9-day-old girl with sepsis, DIC and intraventricular hemorrhage, held in this world after vigorous treatments and supportive care. Too bad by the time she was brought in, a whole hemisphere had been crushed by the hematoma. “OOPS! THINK POSITIVE!” Maybe the next patient has some hope to offer: a 10-day-old boy with Kernicterus. I don’t even want to get into that!

The exercise was not yielding the results I had hoped it would. This is depressing. So much for positive thinking. I guess the NICU is not a very good place to start the search for positivity. Welcome to the world's greatest collection of dead brain cells! I mean, what the heck do we think we’re doing? I heard that more than half of the mentally challenged have survived thanks to the care provided by NICU units!

As my usual idealistic criticisms gained momentum, I was beginning to give up on the whole exercise. Yet just then, I was captured by the rhythmic and musical sound that had been running in the background ever since I entered the room.

“My dear, my life, yes, I love you so much. You’re my beautiful girl. Get up you lazy girl. Get up my lovely doll …” and the cycle kept repeating itself.

It was coming from the other side of the NICU, where a young mother had both her hands stuffed into a small incubator. I moved closer to take a peek and there it was, a 30- to 40-cm moving object in her hands, with a slight resemblance to a miniature human body.

This baby is more than a month old now, and she’s spent her whole life in this NICU. I remembered her from the last time I was here a month ago. She was a 660-gram premature baby who dropped down to 630 during her first week. Back then, she was being mechanically ventilated and she didn’t seem to have a bright future. No one expected her to live more than a week. Our first question every morning would be “is she still alive?” Yet it seems she insists on living. She’s the first child of her family and very precious, I might add. She has worked her way up admirably and weighs 810 grams now. Other embryos her age are still swimming in their mothers, but during her short life, she has survived a cesarean section, a long ventilation, jaundice, TPN, gradual oral feeding and doesn’t plan on giving up anytime soon. She just needs a little help and care. Something tells me that when she manages to get out of here, she’s going to enjoy every second of the life she has fought so hard for. A life that would not be, without the NICU.

Moral point of the story: always pay attention to the hum in the background, that’s where all the hope is. Don’t look for it in neon lights. As for me, it just might be a couple of phone calls away.

Inspirational Teachers Make a Difference

Ali Tabatabaey -- When you’re aiming to be the best, you have to put together a complex recipe of hard work, perseverance, courage and quite a few other well-known ingredients. But this recipe is known to all, and yet so few people actually achieve that goal. It seems that like with all other recipes, it’s the little herbs and spices that make all the difference, and yet so often we overlook their importance.

Last week I found the chance to attend an international Hemophilia (my personal research interest) treatment seminar in Tehran. Some of the biggest names in the field were there, Pier Mannucci, Flora Peyvandi, and Alok Srivastava, among others. It’s when you get the chance to talk with these people that you realize what you’ve been missing out on for so long.

While studying for the university entrance exam, I was told that schools don’t differ much and that you will get the same education from the same textbooks. “It’s your own hard work that makes the difference,” I was told. Yet now, I find that to be only half-true. Hard work is essential, but so is guidance. Studying under the supervision of great names, where every word is truly an inspiration, can make a huge difference.

The little things make big differences, the little questions that tickle your mind, things you won’t find in a textbook. So if you’re aiming to be the best, try to study amongst the best and under the supervision of the best. I know I would do so, if I had the choice again.

A Warm Light in the Dark Hospital Nights

Ali Tabatabaey -- Usually, the intern is the loneliest person in the world. You are called upon in the most outrageous hours of the night, when everyone is fast asleep, sometimes to take care of the most trivial complaints. Still you are expected to be quick and attentive in reply, and your famous smile must not wear off. No complaint is acceptable. You walk in the silence of the ward trying not to break the comfort of those asleep. And as you do, you know that the only person waiting for you is a person in pain, hoping to dump all his agony on the shoulders of a stronger, trustworthy man; and as soon as the pain is gone, so is his memory of you.

In fact, it seems that the patients themselves are among the loneliest, especially when in pain. Maybe even those midnight complaints are a mere excuse for a short conversation with the other loneliest person in the world at that time of night.

But not in pediatrics! The pleading pediatric patient always has a shoulder to cry on, a warm hug to feel love at its best, and a soothing smile to answer their cries in a flash. These nights when I’m awakened, I’m not alone anymore. Even in the darkest hours of the night, there is always a mother comforting her ill baby, checking on her sleeping child, or preparing herself to meet the patient's request when he or she wakes up in a few hours.

There is a saying by Prophet Mohammad, "Heaven lies beneath the mother's feet." So beautifully said! If heaven is the symbol of pure and eternal love, then there is no better example of that than a mother's love for her child. So, I bow down to all you mothers out there, on shift 24/7. Truly, heaven deserves no better than to lie beneath your feet.

Don't Dismiss a Crying Child

Ali Tabatabaey -- Just a short note to end the suspense about the case of the crying baby. Interestingly, an Electroencephalogram was performed on her, which revealed abnormal wave patterns. The child was put on Phenobarbital for a year, and the symptom was completely relieved. After the duration of treatment, she has been leading a normal life with normal growth and development. I guess “The Secret Friend” nailed it on the first guess; Amazing. So, just remember to add seizure disorders to your list of differential diagnoses when approaching a crying child.

A Pediatric Patient Puzzle

Ali Tabatabaey -- Diagnosing and managing infants is rather … interesting!

Patient number one:

"What seems to be the problem in this little angel?"

"She’s been crying ever since we got back from the trip …"

Patient number two:

"How is this young man?"

"He just won’t stop crying…"

Patient number three:

"How’s our baby been doing?"

"She’s been crying for two days now and …"

I could list patients number four, five, six, right up to sixteen, but you get the point. Welcome to the world of little people, where all the diversity and manifestations of human disease are jammed into a neat package called CRYING! When a patient comes in and names crying as the chief complaint, I think to my self, "great, that narrows it down to somewhere around 243 differential diagnoses!" I guess that’s why pediatricians are so reliant on laboratory tests.

That in mind, I was amazed when I heard a personal experience of one of the pediatricians. The patient was a 3-4 year old girl who walks into the office with puffy eyes. This is the first time you see the patient but she seems to have normal growth and development. When asked about her puffy eyes the parents explain that she cries every afternoon around the same time. She cries for 2-3 hours and won’t stop with any effort. When asked the reason for her crying she replies that she "doesn’t know"! The physical exam is unrevealing. There is no sign of physical abuse or neglect. The parents appear distressed.

It turns out that … maybe I should let you think about the case for a while. What would you think about in this child? How would you investigate this patient?

PS: That’s all the info I was given, so you’ll have to work with that.

Escaping the Pressures of the Hospital

Ali Tabatabaey -- It’s been a hectic morning; grand rounds was tough like always, and managing a PSGN patient was no help in relieving the stress, neither were the couple of seizure patients nor the infant with respiratory distress. But it’s finally break time. An hour to relax, have lunch and maybe a short nap. I usually start with the latter, so without wasting any time I stretch my legs, rest my eyes and let my imagination fly.

As I'm savoring every moment of my break, there is a knock at the door. Who could it be? A diarrheic disaster, a hematuric horror story or an epileptic emergency? Only one way to find out!

I open the door and a flood of positive energy fills the room like a burst of light. I can’t believe my eyes. I erupt into joy as I embrace my beautiful fiancé standing at the door. She looks absolutely stunning in her new dress and her energetic yet subtle smile. I pull her inside joyfully and greet her with a passionate kiss. I feel absolutely ecstatic. I stare into her beautiful, smiling eyes filled with love, as she explains how she thought I needed a boost and decided we should have lunch together. What a fantastic idea. She takes out a plastic container from a bag, introducing into the room the unmatched smell of hot Kufte cooked with great care and love.

But just when I thought this was heaven and started to open the container she reveals her second surprise: "No picking! Wait for the guests."

"What guests?"

"I was talking to Saeed this morning and thought you might like a little party with some of your old baseball buddies."

She hasn’t finished her sentence when the door opens. And there they are: Saeed, Ahmad, Mojtaba and Ehsan; all the gang is here. This means a whole day of jokes and hilarious memories from the national championships and training we all endured together.

We eat lunch together and laugh our heads off. But the most unexpected surprise was saved for last. There is a creak at the door and everyone hushes down. I turn my head and I’m speechless at what I see. My mom walks in, holding a huge cake filled with candles, humming happy birthday to you. I had never seen her so happy. I’m stunned but still manage to make my way towards her and give her the longest, tightest hug ever. I think I fell asleep in her arms for a moment. What an incredible break. I feel like I’ve been pumped with energy and nothing can take this joy away from me until…

There is yet another knock at the door. I open my eyes and go to the door, hoping for more surprises. It’s a nervous nurse talking about a patient! I ask her to wait and turn around to thank everyone … where is everybody? Where did everyone go? I rub my eyes and turn around shocked. The nurse is still standing there and she looks confused: "What are you waiting for doctor? The ER…"

"But what about my guests?" I ask astonishedly.

"What guests? Guests are not allowed in the hospital. I’m sorry, were you sleeping?" She stares at me the way I used to stare at schizophrenics during my psych rotation. "I think you’ve been working too hard lately," she tries to hide her anxiety, "but now is not the time to stop working, the kid in the ER is waiting."

I’m baffled. What just happened here? Where is everyone hiding? Where is my cake? What happened to my fiancé …? Then again, what fiancé? I don’t have a fiancé. I can’t recall any moment when I was able to sustain a decent relationship, not to mention commitment! Now that I think of it, my birthday is in September! And while I’m regaining my consciousness, I haven’t seen my friends for almost a year and I haven’t eaten Kufte for ages!

I check my watch; just 40 minutes have passed since I last checked it. As I walk towards the ER I smile at what just happened. I feel that my steps are stronger, I feel enlivened. Talk about a successful meditation! Never before have I felt the benefits of a creative imagination so strongly. Thank God they can’t strip you of your imagination. I yawn for the last time before pushing through the ER doors and quietly remind myself: "Welcome back to the real world."

A Mouse in the House

Ali Tabatabaey -- The hospital I’m attending for pediatrics has been helping out the health system for decades. Although parts of it are currently being renovated, pediatrics is still located in one of the older spooky buildings, which has received a face lift and is decorated with happy faces of cartoon characters and smiling kids.

Like any other such building, the ghost story business is thriving. On the more quiet nights on shift, the older nurses talked of the ghost of pediatrics. Haunting the ward for years, it leaves no new intern to him/herself and sooner or later it will have them screaming and running out of the interns' room. Superstition? Maybe!

It was a quiet afternoon. My colleague and I were in the interns’ room going through some patient files and discussing the patients when suddenly something moved at the corner of the room. I blinked and rubbed my eyes, and there was nothing there. A few minutes passed and there it was again, a tiny movement in the corner of the room.

"Did you see that?"

"See what?"

We both fixed our eyes on that corner to notice any slight movement. Soon we both ran out of the room.

"What’s wrong, doctors?" asked one of the nurses.

"There is a mouse in our room!" I replied anxiously.

"Oh! So you’ve met our ghost." She giggled.

It turns out that the so-called ghost is a tiny gray mouse who lives in the building all alone. Well, he wasn’t always all alone, but after an aggressive campaign against his species, he is the sole survivor. He has survived dozens of attempts at his life and is now considered a distinguished resident of the building who makes himself seen every couple of months to scare off the new interns! Still, I was determined to put an end to all this ghost/mouse business by catching him once and for all. There was only one problem -- he seemed to vanish the moment you took your eyes off him.

I asked my friend for help but he declined, explaining that he hates mice and wanted nothing to do with the whole process. In fact, by this time he was asking around to see if he could change his room for the night. Therefore, I called the janitors.

Plan A was simple. Chase him out of the room. The only problem was that I had to find him first. So on to plan B. Lure him out with something to eat. Actually, this one was the resident's suggestion. The only thing around that could be used as bait were sugar cubes. However, after filling the room with sugar cubes at every corner and each possible hiding place, I realized this was not going to work in the near future. I had to go to plan C. I basically turned off the lights to create a secure environment for the mouse, put an arm chair in front of the corner where he was last seen, and waited. A few minutes later he stuck his head out from behind the air conditioner. I asked the janitor to be ready. All I had to do was to chase him towards the janitor and he would take care of the rest.

So that’s exactly what I did. I chased him toward the destiny the janitor had waiting for him. As I was doing so, a strange feeling of guilt overwhelmed me. All the stories about the brutal deaths of this cute mouse’s family members rushed through my head. The janitor raised his foot as the scared mouse hustled towards him. I couldn’t let this happen: "NOOOOOOOOOOOO!"

"What’s wrong, doctor?"

"Don’t crush him!"

"What else do you suggest?"

By the time we finished arguing, the mouse had vanished. My new cute little gray friend had gone into hiding again until the next time he decides to send another intern screaming out of the interns' room.

Saddam's Aftermath Lives On

Ali Tabatabaey -- I really wanted this post to be more positive and fun to make up for the past couple of posts. Yet, after much thought I couldn’t resist letting you in on an experience that moved me deeply.

Last Monday while on shift, I heard one of the nurses talk about a new patient down in internal medicine, who had everyone … I really can’t find the right word, maybe thinking, maybe angry, maybe frustrated, or maybe simply heartbroken!

He was a casualty of the Iran-Iraq war of the 80s. But he wasn't just any old casualty -- he wasn't missing an arm or leg, nor was he paralyzed. He just couldn’t breathe! He was a chemical warfare veteran, exposed to mustard gas back in 1987. Twenty years on, he is still suffering.

His notorious coughs bring the whole ward to a stand still. As his metallic coughs echo through the ward, no other patient dares to complain of pain. Even worse is when these coughs mix with his humble pleas for help. Even the nurses fear to approach him, because help is not an option. Not even giant doses of hydrocortisone can counter the never-ending inflammation of the mustard gas, which burns his airways all the way down with every breath.

At the time, Saddam’s execution was the talk of the day, and I wanted to go down and ask him how he felt about the news. It would have made a great post, right? But to this moment, I haven’t found the courage. What do I expect as an answer?! He is suffering, and will suffer for the rest of his life to pay for the cruel ambitions of a feared dictator. I’ve heard others like him comment about Saddam: "His death was too easy. He should have suffered like all the others for whom he caused life-long suffering."

Like you, I never met Saddam or felt the product of his actions personally, but unlike you, I’ve seen others feel it, and it’s very ugly. I don’t preach capital punishment, and even in this case I don’t see any good coming out of it. But I get furious when I read some people turning Saddam into a hero after his execution. Let’s not forget, he caused the death of 300,000 Iranians, many Iraqis, and many Kuwaitis, not to mention the injured veterans and the families destroyed. He personally ordered the rape, execution and torture of many civilians throughout his rule. If he had been given the chance, he would have done so again without a second thought. I accept that the death of a man is something to mourn, but Saddam was a monster, a puppet monster maybe, but a monster nonetheless. Never ever doubt that. I’m sure victims won’t.

Christmas in Iran Brings Sobering Prospects

Ali Tabatabaey -- This morning I got up to a worsening productive cough that has haunted me for the past couple of days. I was supposed to get up early to finish some overdue projects before packing off to the hospital, but I overslept.

I turn on the TV while I go through my morning routine to catch up with some of the news. It’s full of views and interviews about the new sanctions brought against Iran, how "unjust and illegal" they are, and that "it can in no way affect our achievements," and finally insisting that "the US cannot be trusted." Unable to make sense of it all for the time being, I step out.

It has been quite cold here lately but still dry. It seems that all we are going to get from this winter is the cold and not the snow. I walk to the main street near by and try to catch a cab. Yet, since all the taxis are already full of people trying to escape the cold, I have to wait quite a while. I finally manage to wave a taxi. Like every other morning, I get the chance to think a lot on the long drive to the hospital. So that’s exactly what I do as I look out the window, trying to ignore the radio reviewing the whole nuclear negotiation process and repeatedly insisting that "Iran has always acted within the framework of the Non-Proliferation Treaty."

At the hospital, the NICU has become my new home as I’ve entered pediatrics, checking on the babies every morning, taking note of every gram and every milliliter going in and out of them. These little ones really give new meaning to the phrase "every little bit counts."

Up in the ward a few new kids have been admitted last night. A 2-year-old with recurrent urinary stones and an 11-month-old with a candidiasis diaper rash are among the patients rounded.

I wasn’t on shift today, so I left the hospital in the afternoon to meet with another colleague doing his ophthalmology rotation in a hospital five minutes from my home, i.e., 42 kilometers away from the hospital I was at. We drove over to the intercity bus terminal where a couple of our mutual friends were being sent off to their conscription service. We all laughed, joked, and hugged each other goodbye. Soon they were off to a 23-hour drive to a base in western Iran.

So finally, after a relatively calm day, I get to stretch my legs and warm my soar throat in front of the TV. As I switch the channels, a smiling commentator catches my attention on one of the stations: "I would like to once again congratulate all our Christian countrymen on the birth of Jesus Christ!" It looks like today was Christmas! Merry Christmas everyone!

Lost Youth: The Price of Becoming a Doctor

Ali Tabatabaey -- I think I’ve met my midlife crisis a bit sooner than expected. It was a unique moment. Waking up from a two-hour sleep after 48 hours of devastating back-to-back shifts, I was barely able to open my heavy eyelids and make my way to the sink at the corner of the interns’ room. I only had a few minutes to perform the regular morning rituals before going up to the ward and writing the daily progress notes before the attending gynecologist arrived.

I looked in the mirror. It was an ugly sight: the puffy red eyes, barely open, begging for more sleep, the unshaved face, a forehead that is mercilessly invading the hairline day by day, and the so-called hair with the shape of a pillow carved out of its side and bundles of hair sticking out here and there. My new friend, The Throbbing Headache, was with me again, just like all the other sleep-deprived days lately. So was the sense of heartburn, courtesy of the award-winning catering of the hospital. Not to mention the bulging belly which I think is now holding something around six extra kilograms of fat.

Who is that looking back at me? Last time I checked I was six years younger, full of energy, and healthy! I used to run ten laps around a soccer field, just to warm up for a two-hour training session.

Today, my classmates and I are considered the grandfathers of the university, with growing bellies, mild to moderate hair loss, and many years of experience to pass down to the younger generation. I don’t know when this happened, but many things have changed from the time I entered med school. Whether all this is just the physiologic phenomenon known as "aging" or a direct consequence of the never-ending marathon of med school, I’m not sure. Either way, I just hope I’ve been able to gain more than I’ve lost.

Unfortunate Mistakes Make for a Miserable Week

Ali Tabatabaey -- Have you ever had one of those days when you just want to run home, slide under the blanket and force yourself to sleep, hoping that when you open your eyes again the calendar will have moved ahead one day? And then, when that happens, it still doesn’t comfort you, so you find all the calendars in the house, rip off the pages and burn them one by one. And still you can’t help pumping adrenaline, cortisol, and all the stress hormones twice as much as normal?

It all started after an enjoyable Friday (the weekend here in Iran). Then came a seemingly normal Saturday morning, but the moment I stepped out of the house I was surprised to find a much whiter world than the one had I closed my eyes on. What a way to find out it’s been snowing for the past 12 hours (i.e. heavy traffic on the 42 KM drive to the hospital)!

Obviously, I arrived late. Just as I was wiping the snow off my coat, I got the first good news of the day from the head intern: "Due to some inconveniencies, you must run the morning report today." Knowing there was no use arguing, I rushed to get together the needed information about the patients I’d managed two days before, whom I had tried my best to forget during the weekend.

Five minutes later, I stand in front of the big blue whiteboard, which has been neatly written on with a permanent blue marker (!). I try to explain to the attending gynecologist (who happens to be the head of the department and who is looking closely to weed out interns who do not deserve to pass the course in a week’s time) why I hadn’t prepared the board earlier.

Fifteen minutes later, as I try to recall the precious needles of information lost in the haystack of weekend fun, a familiar melody breaks the silence. The physician's frown aimed at my pocket says it all. I had been so rushed that I forgot to turn off my cell phone, an inexcusable crime in front of the department head. My pathetic attempts at turning off the phone felt like the Coyote trying to blow out the dynamite stick he was handed by the Roadrunner just before being locked up in the US Army arsenal!

In the next few minutes, I lived through the opening sequence of "Saving Private Ryan," but I didn’t manage to dodge all the bullets like Tom Hanks did. The onslaught lasted all day. The gynecologist locked on every possible target and fired mercilessly. Any attempt at explaining or apologizing was brutally punished.

The cursed morning continued into an afternoon full of bad news (including the phone call that started it all) and spilled over into the rest of the week. This week, I’ve made the most trivial yet costly mistakes. In less than a week, I managed to descend from a beloved active intern into an irresponsible, rude, and lazy one in the eyes of the department head, and the harder I try to fix things the worse they get. I can’t wait for this week to be over.

Experiencing the First "Miracle" of Birth

Ali Tabatabaey -- I had been told that the first time one gets to be a part of the miraculous phenomenon called birth, many things rush through the mind. For me it was no different. But if you’re expecting me to turn philosophical and emotional about the whole thing, you are in for a big disappointment!

Natural vaginal delivery was the most disgusting, the most repulsive, and the most unnatural experience in my life. The screaming, sweating mother, the skull being pushed through the canal, the bleeding episiotomy, the vernix-covered body, and the gush of amniotic fluid are enough to make a grown man puke. Well maybe not puke, but still it’s horrible. So with all due respect to the preachers of ethics and moral values, I have to say, It felt revolting.

At least, that’s how I felt for a few minutes. Right up to the moment we handed the pink cute cleaned-up newborn over to her exhausted mom. Unbelievably divine! As the mother fitted the baby under her breast, tapping her a couple of times on the nose, and as the baby clung on to secure herself, I realized what had just happened. New life had just entered the world right before my eyes. I bet for that newborn baby, nothing in the world could match the warmth of that tight caress after such a tiring struggle by both sides…

Just when I was starting to feel squeamish again, I decided I’d felt enough emotions to last me a long time. So I slung off the rubber gloves and quietly left the room while the tired mother and child were joyfully celebrating "birth".

Glad We're Making this Journey Together!

Ali Tabatabaey -- There are many things I would like to write about these days, but they will all have to wait as I'm about to celebrate a special anniversary in my life, the birth of The Differential.

During my last turn around the sun, I have had the honor of being a member of the blogosphere, and I have to admit it has been a pleasure. Ever since the first post written under sheer stress, right up to this one which I write while gobbling up popcorn, blogging has changed my life in many ways. Looking back at this brilliant diary, I still laugh reading my first post and still cry while reading some of the others. But more importantly, I recognize the subtle yet substantial changes as I evolve from a wonder-stricken boy in a white coat into … I don't know … whatever I'm evolving into being!

The memories are great but the awesomeness doesn't end there. To me, The Differential is much more than just a memoir. It has helped me understand myself better. Reliving the events and how I responded to them has given me a unique chance to analyze my reactions and to discover things about myself that I would never have believed existed in me.

In addition, ever since writing for the Differential, I pay more attention to what goes on around me. As I pry for new topics, I note the slightest details. I see things that others (and probably myself a year ago) simply walked by. And this, I would say, is the real treat. It gives depth to everyday life and helps one escape the boredom of daily repetitions and savor every moment of being alive. When it comes to details, life has a new concept to offer you every second you're breathing.

Yet, without doubt, the comments are what really make blogging fantastic. What I have learned from the readers' comments here, I would have had to live a thousand years to experience myself. And if you add the many new friends I've made from around the world to this recipe, you can get a taste of what I'm talking about. It's like spreading your wings as wide as the equator.

OK, so let me see! It has added depth, length, and width to my life. Cool! I just evolved from a dot into a cube! … I guess I'm getting carried away again. So, I'll wrap it up right here and invite all you friends to join me in The Differential's birthday celebration. Cheers!

Too Busy to Ease a Patient's Pain

Ali Tabatabaey -- It has been a truly tiring month, both physically and emotionally. I would say the "writer’s block" that has haunted me the past couple of weeks is a direct consequence of this fatigue. But others might argue that it is just me falling asleep every time I sit down to write something.

There are many causes for this exhaustion, many of which I’m not ready to talk about yet, but one undeniable reason is me entering the feverish world of OB/GYN. If patients were to be awarded a prize for the worst timing, needing most care, being at most risk, having the greatest emotional strain, and being the source of most stress to the physician, the delivering mother would definitely win in all those categories, with her baby coming in as the close runner up!

These days, I’m averaging three to five hours of sleep a night and maybe an hour during the day. To summarize the current situation I would have say "Heeeeelllp meeeee!" But who cares about me? I’m a med student. The whole world takes pleasure in torturing me. The problem is that the fast pace here might cost the patients, too.

It was a normal OB/GYN afternoon: screaming mom, patellar reflex, bleeding gravid, rupture of membranes, and lots of other fun medical conditions needing close monitoring (this part is supposed to sound sarcastic). In this particular three-bed room I’m talking about, I was caring for two of the patients -- one receiving induction and the other receiving a tocolytic. As I ran around the place, checking for contractions, patellar reflexes and fetal heart sounds, the young woman in the middle bed lay there quietly and watched me examine the other two patients. On one occasion, just when I finished checking on one patient and was about to move on to the next, I saw her staring at the ceiling with a stream of teardrops rolling down the side of her face.

A fellow intern was caring for her, and she hadn’t been attended to very often. So, with all the comments I had read on The Differential asking me not to lose my humanity under any circumstance running through my head, I decided to intervene. "Are you in pain? Is there anything I can do for you?" She smiled and quietly replied with a "No, thanks."

Not able to get her out of my mind, I confronted my colleague to see what her problem is. He pointed to a plastic cup on the counter and said, "That’s hers." She was a 28-year-old with an 8-year history of infertility. In turns out that after trying every infertility treatment in sight, she had finally managed to conceive, only for it to end in less than three months. She had spontaneously aborted her much-awaited baby a few steps away from the hospital door. She had saved the embryo, which was barely taking on the looks of a baby, in a plastic cup. She wasn’t an emergency and simply awaited transport up to the ward.

Absolutely destructive! Simply left there to see and hear other moms with viable fetal heart sounds. I had to do something. I had to talk to her. She needs someone to talk with. But before that, I had to take care of the emergencies, to check the patellar reflex of my own patient, and the other one was almost completely dilated, a couple of other bleeders had to be checked on too, and a new patient was just being admitted.

As I walked around the crazy delivery room, I kept an eye on her, waiting for the right chance to approach her and maybe help her cope. Such a chance never came up. One and a half hours later, I checked and she wasn’t there. She had been transported to the ward. I missed my chance to ease someone’s pain. A pain that was definitely more torturous than her physical illness.

I guess from a doctor's point of view, there is always something more urgent, emergent, or simply more important to do than to CARE for a patient emotionally … or is there?

Famous Words Still Inspire New Doctors

Ali Tabatabaey -- I’ll keep this one short. I just want to thank you all for your very kind comments regarding my last few posts. I wish I could write you one by one and thank you personally. One such comment came from a friend of mine who sent me a quote from the preface to Harrison’s Principles of Internal Medicine, in reply to my birthday post.

I really liked it, and I think you would like it too. It’s amazing that I had read this the first day I saw the new edition, but its impact slowly faded away as I delved into the rest of the book, full of signs, symptoms, therapeutic guidelines and basic science issues. It’s sad how a short while down the path we so quickly forget where we came from and where we’re heading! Thanks for reminding me, N:

"No greater opportunity or obligation can fall the lot of a human being than to be a physician. In the care of the suffering, he needs technical skill, scientific knowledge, and human understanding. He who uses these with courage, humility, and wisdom will provide a unique service for his fellow man and will build an enduring edifice of character within himself. The physician should ask of his destiny no more than this, and he should be content with no less."

P.S. One of the readers asked me whether we tried primary PCI for the patient who passed away. I didn’t want to go this deep into the story, but the answer is yes, we did try to arrange for him to go straight to the Cath Lab. We made quite a few phone calls, but remember that down here in the developing world, the cath labs are not readily available (I don’t know how things are up there). In the one and a half hours between his arrival and his first CPR, we were only able to arrange for a private hospital’s Lab. He refused the treatment because of its cost, making the story even more tragic.

The First Patient Death Leaves Its Mark

Ali Tabatabaey -- "My patient is dead." Cold, frank, real; that’s how it hit me when I realized there was no use continuing, and that the electrical impulses on the monitor were nothing but a mere manifestation of EMD. His mydriatic eyes said it all: "I am dead and I’m not waking up this time."

It is almost 15 minutes since he stopped breathing for the fourth time, and no heart sounds exist despite my aggressive cardiac massage. "Time of death -- 3:33 p.m., record a flat strip for his file please," the resident announced to the CPR team.

I have seen patients die before, but not under my very own hands. He was only 48. He didn’t smoke, he didn’t have diabetes, no hyperlipidemia, and no hypertension. What he did have was an inferior MI with extensive anterior ST segment depression on his ECG.

From the moment she scanned the ECG, the staff cardiologist saw it coming. She ran around the CCU asking the CPR team to be ready, ordering serial ECGs and performing bedside echocardiography. All that time I was wondering why -- this wasn’t our first MI here, and the patient wasn’t in obvious distress; he lay in his bed, quietly complaining of the pain, and his lungs were all clear. I had never seen any staff act like this, not even her. Three and a half hours later, I know why.

Just a few hours ago, I was asking him about his substernal chest pain, his sweaty forehead, and his cold feet, while he answered calmly, trying not to complain about the pain. Now, I’m pressing down my stethoscope on his chest and concentrating as hard as I can, begging for a reply from his heart to all the Atropines, Epinephrines, and cardiac massaging we had offered it. I guess it just doesn’t want to beat anymore. It’s too tired; it’s too hurt.

The resident gave his family the news. Shocked might be the only way to describe them. "But how?" … "He was OK -- he walked in here this morning!" … "He was so young." … "He didn’t touch a cigarette in his life." … and a lot of other "he"s and "why"s.

Damn! Why is this awkward feeling building up inside me? Damn, damn, damn! I knew this was coming the day I entered this profession. Yet, this is the first "expired" patient with my name on his file, and I guess he is just leaving his mark.

I can still hear the staff shouting, "His rate dropped…," and see them running from the central station to his bed. I can still sense his filliform pulse under my fingers as I tapped it for an ABG. I can still see his tired eyes rolling back, and his worn-out hands clenching. I can still feel the crack of his ribs beneath my palms just before he survived the first CPR attempts. But two hours later, he didn’t survive the fourth.

3:37 p.m. The ventilator’s been turned off, the monitor is almost flat, pulse rate zero, all infusions stopped … and I still can’t hear a damn thing beating in his chest. So, I give up, too.

As I stand back and watch his eyes being closed by the head nurse, I know that I will never forget this 48-year-old bicycle repair guy, with dirty cracked hands, no insurance coverage, and a couple of broken ribs, courtesy of me.

May he forgive me, and may he rest in peace.

Time Away from the Hospital Rejuvenates the Soul

Ali Tabatabaey -- I don’t know how I did it, but somehow I managed to spend three days on vacation! I know this is going to sound like a huge tease for all of you hard working medical personnel who have been spending most of your hours straining your minds on management decisions, wrecking your nerves trying to persuade CCU patients not to go to the bathroom, studying your gray cells numb, or having a hard time trying to keep the levator palpebrae contracted, but this is too good to miss.

I just had the pleasure of spending three divine days on Kish Island, the pearl of the Persian Gulf. It was absolutely magnificent, totally refreshing, and majestically rejuvenating. I had been thinking about making the trip for several years now, but my schedule just wouldn’t work out … just as no other family vacation has worked out since I entered med school six years ago. But this time I was literally dragged into it by my family, and boy, I’m glad I was.

It was a heavenly blend of coral beaches, crystal-clear waters, palm trees and lots of fun people and activities. The beaches were incredibly inviting and the moment you entered the water you would become a part of a huge symbiosis with hundreds of species living in the shallow waters, just a couple of meters off the water's edge. I spent a whole afternoon chasing colorful fish and weird looking see snails.

Even if you are not the beach type of person, there were more than a few historical and ecologically interesting sites to see, like the Kariz, huge tunnels dug deep into the soil that is itself the burial ground for 75-million-year-old corals and sea shells. And if that’s not interesting either, there is always the dolphin show, water skiing, surfing, kiting, and last but not least, lots of cheap shopping.

It was very relaxing. I say all medical personnel should be forced (just like I was) to take such trips at least once a year. Because once caught up in the midst of hospital work, filled with pain and complaints, one tends to forget about the beautiful things in life. Trust me, you can never guess how reviving such a vacation can be. I know I’ll be going back there next year. Or maybe I’ll even move there after I finish med school!

A Bad Time for a Water Shortage

Ali Tabatabaey -- In urology, a "shower" takes on a new meaning. It ascends from a simple daily routine, to one's only hope of relief from all that you have always tried to avoid, but can’t anymore. A few days ago, I had the honor to experience TURP and TURBT "up close and personal". A magical orchestra of blood, urine, and every other thing I had learnt to despise was performed right before my eyes. I don’t know how the urologists do it. If you ask me, they should be forced to wear diving gear while performing the procedure!

After it was over, all I could think about was running home and rushing into the shower for a very long meditation under running water. But nature was about to teach me a very valuable lesson.

This year was one of the hottest and driest summers in recent years, the consequence of which has been the first serious water shortage in Mashad in more than a decade; i.e. no running water, no shower, and no meditation for today. Being forced to face the horrible feeling of having to deal with my body for a few more hours gave me the chance to think about the bigger picture (I was definitely not going to do anything manual).

Maybe this year is the first time that I am feeling the effects of a drought firsthand. Up to now the officials had been able to cover up for the water shortage by digging wells and other tactics, but this year’s 34% water shortage, and a near record number of tourists in Mashad, proved too much to handle. So, "water outs" as I like to call them, were planned for one day a week but then gradually increased as the reservoirs dried up. Our area in eastern Iran has always been famous for its thriving agriculture, but I think that this year it’s going to be hard to live up to that reputation.

The officials say that by next year the problem will be solved by a couple of new dams now in construction. But what then? The population is fast rising and water reserves are fast depleting. I remember reading somewhere that in 50 years, fresh water will be the top agenda for most regions of the world. I’m beginning to believe that. It is not hard to imagine people deserting major cities in search of water, or even countries going to war over who gets to use how much water.

By going back one more step towards the etiology, we all know who the culprit is. Global warming is a clear and present danger. I have felt it by comparing the amount of rain and snowfall when I was in elementary school with last year. I’m still feeling it by having to wait hours for a much-needed shower today. Yet soon enough everyone will feel its effects all over the world. We only have two choices left. Either we stop hurting the planet and put a gag on our industrial ambitions, or we shall pay the price by having to change our lifestyles in so many ways just for the sake of survival. And something tells me we don’t have much time to make up our minds!

How Do You "Get a Life" Outside Medicine?

Ali Tabatabaey -- Last week was supposed to be a very special one. Because somewhere in the middle was (fanfare please) … what you were all waiting for, the great … ok! Stop the fanfare! … It was my 25th birthday, and it wasn’t very glamorous at all. I spent the night as the cardiology intern on shift, only slept four hours, while only a couple of friends and my family congratulated me on the phone. The rest was the usual cocktail of PSVTs, MIs, CPR, HTN crises and young women presuming they have a heart problem. The frightening part is that I wasn’t even sorry about spending my birthday running around the wards.

Okay, I know I’m sounding like a 4-year-old whiner but that’s exactly how I feel right now. And who better to whine to than you guys? Maybe one of you will come up with the perfect words to spark the much-needed energy that once drove me forward. But for now, something’s missing in my life. I don’t know what it is and I’m too tired to look for it.

I mean, is this really the life of a 25-year-old? Is this the way people usually celebrate a quarter of a century of life? I guess, like it or not, medicine has insidiously invaded and overtaken my whole life. It has metastasized so much that I can’t tell which parts are affected and which parts can still survive without it. It’s like life starts the minute I enter the wards and stops the minute I get out. It’s all in there; the joys, the grief, the friends, the challenges. To make things really weird, I have to admit it’s also the only thing that somewhat fulfills me at this time. I dream about doing great things but the small things on ground zero are the ones spicing up my life.

Maybe I should start playing baseball again, or resume part-time journalism, or perhaps I should invest more time in helping NGOs, or then again maybe I should stick to what makes me happy, ignoring that "something" that is still missing.

A Female Preemie's Chances in Iran

Ali Tabatabaey -- As the urology intern on the night shift, nothing bizarre awaits you. The worst-case scenario is a renal colic or abdominal trauma, and since the trauma are usually taken care of in the ER, the shifts are pretty calm. Therefore, it’s no surprise that among your fellow interns being tortured at cardiology, internal medicine, ER or pediatrics, you represent the aristocrats of the population.

Still, your aristocracy does not save you from being dragged down to help out when things go mad in the other wards. For instance, when the NICU is suddenly packed with premature babies, distressed neonates and jaundiced newborns. Exactly what happened a couple of shifts back. So much that when a 30-week-old premature baby with respiratory distress was sent down from the delivery room, the ventilators were all occupied. "And to make a perfect night fully memorable," the tired pediatric intern explained over supper, "not only here, but all the ventilators in town are occupied!"

Usually in these situations, the more expendable personnel in the hospital are asked to play the part of the ventilator and ambu-ventilate the baby temporarily. In this case, I was at the top of the list.

10:00 pm: I meet baby J, lying quietly on the incubator; a small and seemingly tired little thing, even too tired to breathe or cry. A quick briefing about the pulse-oximeter, the ambo-bag and the procedure follows and I’m set to go.

"Not too hard to cause a pneumothorax, and not too gentle to allow the O2 saturation to drop below 90," the nurse explained. It looked simple yet it proved tough. It felt like working out. If it really takes this much energy to pump air into the lungs, no wonder this baby has given up. Following a few minutes of repetitive pumping, the body and mind dissociate. The hand keeps pumping while my mind wonders off into the endless world of "Wh" questions.

Who is this baby? What is going to happen to it? I keep staring at the oximeter's big blue screen, which has slowly dropped down to 90. I look at the board on the incubator; the circle and cross show that it's a she. So this is going to be a cute little girl with long hair and a beautiful smile one day?! I stare her in the face. Her sensitive skin has been irritated with the tapes used to fix her tracheal tube. She gives off a silent sigh every few minutes, but there's not much movement. She is too exhausted, too week.

As I put more effort into keeping her O2 saturation in the normal range, I can't stop thinking about what awaits this baby in her future. Based on the part of town she comes from, she could probably marry a drug addict, bear five children, and suffer from malnutrition all her life, hating anyone responsible for bringing her into the world and keeping her alive (including me!). Or maybe she is the child of an Afghan refugee, and an uncertain future awaits her on the other side of the border. Now that I mention it, why should we put so much time and energy into keeping her alive? She will probably die to some other perinatal cause. Even if not, what can she look forward to in life, diarrhea, tuberculosis, neglect? What can a woman …?

A sudden beep awakes me from my rumination. The O2 saturation is down to 85. I start pumping harder, but it's no use, down to 80. I pump faster, but again down to 75. I give up. "Nurse!" I call out anxiously. "I need help!" She quickly took the bag and started ventilating, but something's wrong. "Call the resident -- this tube is no good anymore." She takes out the tracheal tube and tries to continue with a mask. The number's down to 65 and baby J is turning blue. "Please don't die," I think to myself. "I was kidding about the life thing, it’s actually pretty good."

The resident arrives and intubates her on the first try. The number quickly returns to normal and baby J is pink again. "I hope I didn't cause too much damage," I say. "It wasn't your fault," the nurse replies. "Take a rest. I'll take over."

11:30 pm: I’m back in my room trying to take a nap. I can't believe it, I almost lost my first patient. I hope the hypoxia didn't last too long. Who knows? Maybe she won't suffer all her life. Maybe she will love her life. Maybe she's going to make a huge difference in the world. Maybe she's going to be the next Shirin Ebadi, the first Muslim woman to win the Nobel Prize for peace. Or maybe she will follow the foot paths of Anousheh Ansari, the first female space traveler and the first Iranian (-American) in space. Come to think of it, in recent years Iranian women have been the ones standing up for our national pride, and have lead the way in bringing Muslim women into the mainstream. I guess it's time to break free of the cliché haunting women in the developing world.

I went back to ventilate baby J at 3:30 am, this time with a greater sense of respect and greater hope for her future. I pumped till 6:30 am, when one of the ventilators was ready to serve her. She made it after all, for now. She has my best wishes. In fact, she had better become the next Shirin Ebadi, because after 4 hours of pumping in one night, my arms are killing me. I think I'm going to have cramps for the rest of my life. Yet, no worries, baby J -- go out there and make me proud!

Another Chance With a Former Patient

Ali Tabatabaey -- The morning round with the staff urologist was almost done. As I wrote the orders for the last patient, he said that there was a urologic consult down in cardiology that had to be attended to. So down I went.

At the nursing station, a nurse filled me in: "It’s room number 210 -- the patient is suffering from both CRF and CHF, but it seems that the symptoms have suddenly worsened. Her cardiologic symptoms are stable, but her renal function has suddenly deteriorated. The doctor wants to make sure there is not a urologic cause for this."

Seemed simple. Check for possible urologic causes: obstructions, infection, neurogenic bladder, reflux, and so on. Checking the file: No fever, a couple of hypertension crises, dialysis twice a week, worsening renal function in the last three days. I knocked on the door and walked in confidently.

With the first glance, however, my confidence was shattered to pieces. I was shocked, even petrified. I double checked the file in my hand, then the room number, then the name: How could I not have recognized the name? I looked and saw the same puffy, yellow face of a patient I had treated four months ago. How could this be? This was a completely different medical center, miles away from where I saw her the first time.

But it was her alright. You can’t easily forget the face of someone you (don’t) give bad news to for the first time (see my earlier post). I froze for a few seconds. Did she remember me? Did she hate me? Will she trust me again? There was only one way to find out, and this time there was no easy way out.

"What seems to be the problem, ma'am?" I tried to pretend like I hadn’t recognized her, and from the look of things, she didn’t recognize me, either. She told me all about being diagnosed with chronic renal failure (which I already knew) and about how she ended up here with heart failure. I wasn’t satisfied. I wanted to know more.

"So your symptoms have improved since you started dialysis? How are the shaky hands? How do you feel now?"

"Oh yes, I’ve been much better since dialysis started," she said surely.

"So you’re glad about the diagnosis?" I asked eagerly.

"Of course!" she replied in a surprised tone, wondering why I asked such a question.

Just then I found the courage to say, "Do you remember me? It was at another hospital, and we sent you over to the internist. I was the intern that night."

She paused for a second and looked me in the eye, and then she smiled. "That’s right. How are you?" It was the first time I had seen her smile. It was amazing. She was actually thankful and eager to talk to me. We talked all about the details of what happened since we last met.

To make a long story short, I left the room with a smile on my face, just like her. I check on her down in cardiology every day, and she asks me every question she might have. I desperately want to ask her about her feelings when she received the news. I crave to know her side of the story. Yet somehow, such a question seems plain stupid. Of course she was glad to find out about an undiagnosed disease and to seek treatment for it. I don’t know how I could have ever thought differently! For the time being, I have made a new friend, and that’s good enough for me.

Circumcision -- Up Close and Personal

Ali Tabatabaey -- Oh, urology, urology, urology! The science that brings all you’ve despised up to now, IN YOUR FACE! Where only the strong can survive and the weak give in ever so quickly.

There are a few rules that say it all about the urology department in our hospital: first of all "Nothing is dirty", second "Nothing is off limits", and the most important "you must know a few dirty jokes to cough up whenever you are asked to" -- in other words you must keep your sense of humor in any situation.

In Iran, circumcision is considered one of the primary procedures that any GP should master, and as in any other Muslim or Jewish country the demand is high. Every day after the patients are visited at the clinic, boys of all shapes and sizes await execution. Some doctors prefer to do the procedure under GA, but many patients (actually their parents) prefer the old fashioned local anesthesia, which costs a lot less.

Enough background information, let's get to the real story. First day of urology and the last routine patient with BPH symptoms leaves the clinic. Bring on the circumcisions!

"Have you ever circumcised before?" the staff doctor asks. "No sir," I reply hesitantly. "Then I’ll do the first one and you do the rest" -- from his tone, that seemed like an order and I had no choice but to accept.

The first kid walks in, a five-year-old boy with a soon-to-be-stricken smile on his face. "Draw the lidocaine and don’t let the kid see it. The worst thing about doing this under local anesthesia is that the patient becomes very anxious when he sees the knives and needles. Second, be affirmative with the child, because even after anesthesia he has some sense of touch, so he knows you’re doing something down there and if you act too kind, he is going to take advantage."

The procedure seemed simple: stretch, clamp, crush, clamp, release, cut, and suture! Except for the several times I had to keep the boy’s head down and to reassure him nothing useful was being cut, the rest went on smoothly.

The next one was mine, and somehow I knew it wasn’t going to be that simple. The aide walked in with a pile of cloths and blankets in her hand. As she got closer, from that pile emerged the sleeping face of a 15-day-old boy. This was my patient!

As soon as the lidocaine was injected, he started crying non-stop. I was still a bit clumsy so I needed some help to get started … until the doctor gave the order: "start cutting." I nervously started cutting around, and tried to keep an eye on the baby's face. I was afraid that I might be doing something wrong and the baby had no way to tell me if he was in pain or discomfort.

As I was thinking about this, a big gush of fluid started squirting madly where I was cutting. "I must have cut an artery!" It was all over me, my glove, my arm, even over my coat. Just when I was starting to panic, a huge "POW!" followed (and I’m not joking about the sound effects) and the bed turned yellow. I couldn’t move. I didn’t know what to do. But wait, what is that smell? And why isn’t this blood red?

A few seconds later when the stream of fluid stopped by itself, I realized what had just happened. "Doctor, you have been unsterilized, stand back!" Holding my posture, that’s exactly what I did. It was official. I had been peed and explosively pooed on, by a 15-day-old. Oh and the baby, after he was done painting me yellow, he calmly lay there until the procedure was completed by the urologist. Not even a squeak was heard from him after that.

The rest of the day was about the urologist making fun of me and telling me that this is what urology is all about. I suppose this is where the rules become useful, nothing is considered dirty, and always keep your sense of humor. It looks like, after all, even 15-day-olds have ways of telling you that you’re making them uncomfortable, and I had to learn the hard way!

Have Physicians Forfeited Their Patients' Gratitude?

Ali Tabatabaey -- Yesterday, 23 August, was the national "physicians day" here in Iran. Great idea, isn’t it? It is the birth date of Hakim Avicenna, one of the greatest minds medicine has seen to date. Although he lived back in the 11th century, his book, The Canon of Medicine, is still unique in many ways. His comprehensive chapter on the human pulse is still unmatched in any modern-day clinical textbook. I spontaneously bow down in praise every time I hear his name.

Back to the third millennium! I suppose that the reason such a day was designated in the first place was to raise awareness of all the trouble that people in the business of caring for others go through. But ironically enough, the only people who congratulated me yesterday were other doctors. Others (even my family) conveniently forgot the event. I guess the only people who realized Doctor’s Day, were the ones going into or leaving a hospital, only because they couldn’t possibly ignore the 10-foot banners congratulating the center's physicians.

I actually feel a little peevish when people treat us doctors like this. It’s like they only think of us when they are in pain. When someone yells, "Is there a doctor in the house?" you know that someone is either dead or about to die. No one ever shouts out, "Is there a doctor … we just wanted to thank you for all the years you spent studying and for choosing not to have fun like every other youth, for the sake of humbly serving the community!" And when a day is chosen exactly for that purpose, people prefer to forget it.

We give up so many privileges on the path to becoming a physician, yet people still ignore all that and just see us as arrogant, blood-sucking vampires who charge a great deal of money for a 5-minute conversation about their health.

Maybe 50 years back, people still had great respect for doctors, and whatever you did was greatly appreciated. This is mostly because back then, doctors were hard to find and their service in great demand. Doctors were seen as the hand of God, able to cure diseases that had devastated populations for centuries, and the mere presence of one in the community meant hope. But somehow we managed to lose that magical prestige and sink down to where everyone else was.

We charged for our services (an unacceptable concept in the eyes of Avicenna) and charge even more if we had to go to extra trouble. So the doctor-patient relationship turned into a business relationship where the customer looks around for the best provider and when he's not satisfied he sues you. The population has been spoilt with so many services made available to it, and so have we, forgetting our original divine goal of saving human lives.

Usually in my string of thought, this is the part when I think of escaping, running off to work in a community free from all these materialistic aspects, maybe east Africa, maybe Nepal or maybe even further away, somewhere that globalization has not yet sunk its claws into.

A Brilliant New Theory for Population Control

Ali Tabatabaey -- I've been told that a good researcher must always keep his eyes open for possible theories that are waiting to be examined. Well, that's what I've tried to do in order to make the boring public health course a bit more tolerable, and I think I might have actually found something interesting.

The public health systems in developing countries like Iran have two simple goals: Keep the living babies well, and NO MORE BABIES. Needless to say, the second one is pursued with more vigilance. So having to do well baby checks and following up on contraception led me to what could be a profound discovery.

As one of my pediatric professors said, "There are two types of kids, ones who promote the population boom, and ones who oppose it" -- this is based on the behavior of the child. The fat babies with the puffy faces and adorable smiles usually prompt parents to think of expanding their pleasure with yet another offspring (type-one child). On the other hand, those screaming, nagging, kicking, and crying kids are the ones who make parents abandon even the thought of another child (type-two child).

The interesting thing is that this relationship is true!!! The results of my unofficial study on families we've attended to revealed that more than 3/4 of the parents with a type-two child prefer to use more effective methods of contraception, compared to around 1/3 of those with a type-one child. Moreover, among parents of sweet type-one children, around 30 percent refuse contraception, compared to only 10 percent in type-two parents. And to top it all off, the type of the first child in the family significantly affected the number of siblings later to come.

Amazing! I think I just found the answer to one of the world's greatest dilemmas, population. All we have to do is make children cry and nag more. This way, anyone thinking of another child, whether the parents themselves or even other couples, will definitely rethink that concept! In doing that, porcupine diapers or other innovative inventions can be of importance!!!

Choices That Will Define Your Life

Ali Tabatabaey -- When you open up your e-mail account and it reads “743 unread messages”, you know something is wrong with your life. And if this happens in a calm rotation like “Public Health” rather than other hectic ones, then you know something is really wrong. This post has nothing to do with medicine! It’s more like a cry of despair from a (twenty)five year-old kid left alone in the middle of a maze with no escape in sight.

I still have at least another year to go in med school but I am starting to feel the beginning of the end. As the days come and go ever so quickly, I can see the end of my school years on the horizon; in other words, the end of life as I know it. And the burden of change seems like more than I can bear.

You could say I’ve always been the easygoing type of guy, accepting whatever life has to offer. My usual answer to the tougher questions in life has normally been to tuck them away deep inside, thinking that I’ll decide them when it’s the proper time. Throughout the past seven years, being a student has always been a good alibi to choose that way out.

Well, that alibi has been stretched to its limits. My time is almost up and I have to decide. I have to answer all those questions, knowing that the choices I make in the next few months will affect the rest of my life significantly.

Do I seek a life of medical journalism or should I stick to pure medicine? Will I be pleased with the ups and downs of the clinics or shall I seek my ultimate goal of scientific excellence in the silence of the labs and lecture halls? Should I accept all the torments of serving in a remote area for the additional benefit of a sooner residency exam? What residency program suits me best? Should I move abroad or serve the people I’ve grown up with here in my homeland? And what in the world am I going to do with my social life? Am I ready for commitment or …?

Phew! I needed that emotional burst! I think I was heading for a psychological breakdown. It’s like something went wrong when they were planning for our lives. We have something like five years to make the most important decisions in our lives: work, marriage, investments, place of residence, etc, and the rest of the eighty-something years is on cruise control!

The bottom line is that, like it or not, my days of trying everything for the fun of it are over. It’s time to make choices like a real man, like a real doctor!

Such a Thin Line Separates Health From Illness

Ali Tabatabaey -- These days I'm at my public health internship and things are not as hectic as they used to be. That's why I decided to use this chance to work on my doctorate thesis and research project.

There are a lot of things that one can expect to find while going through a stack of files so tall that they block your view on the horizon. But if these files belong to people suffering from bleeding disorders, you hardly expect a philosophical conclusion to be drawn. Yet being me, I manage to take every little bit of fact and look at it in such a way that if Aristotle himself was still breathing, he would take a deep breath and say: "get real young man!"

It was almost noon a few days ago and I had already looked through a mini-pile of files when I reached one belonging to a young girl. She had severe factor-seven deficiency, causing her to suffer from a spectrum of bleeding symptoms all her life. Painful joint bleeds, recurrent epistaxis, and uncontrollable menorrhagia were some of her more common symptoms. Her problem had been pinpointed to a G to A mutation on the 8961st base pair of her factor-seven gene.

I was suddenly stunned. The string of thought that would eventually lead to an ego-collapse and a sense of insignificance as a member of this beautifully organized world had started. This young girl had missed most of her youth years in the hospital receiving FFP, blood or factor concentrates and so on. She probably could not play with other kids as a child because she would be at a risk of bleeding. She will definitely face great problems for her marriage and her hopes of childbearing. Premature osteoarthritis is awaiting her just a few years down the road due to her joint bleeds. And to top it all off she had already been infected with HCV!

All this, just because a tiny 406 aminoacid protein in her body does not function as expected; Just because the 152nd animoacid in that string happens to be a Glutamine instead of an Argenine; Just because a Guanidine base has been replaced by an Adenosine! And if you really want to make it mind blowing, think of it this way: The only difference between her and her healthy classmates is a measly, tiny, OXYGEN MOLECULE that is missing on the far end of her 13th chromosome! WOW! The line between health and illness is truly hair-thin -- I mean, 8 protons thin.

The Dramatic Impact of World Cup Fever

Ali Tabatabaey -- Finally, it's over! Finished! The hectic fever that comes around every four years and spontaneously spreads throughout the world in the way you expect from a true pandemic, is slowly cooling off. This Sunday the FIFA world cup came to a close with a dramatic finale between European rivals France and Italy.

This world cup undoubtedly proved to me that football fever (Soccer fever as the Americans might call it) really exists. I was mad. It was like the whole world came to a halt when the games started. When the Iranian national team was playing you couldn't find a cab in the street. The city of Mashhad with a 2.2 million population seemed like a deserted little town on the edge of the desert, while smaller towns turned into all-out ghost towns.

Well, you're probably thinking what has all this got to do with medicine or the life of a medical student. For starters you should know that in the cardiology rotation, intern shifts were traded at record prices (absolutely illegal but unstoppable) when big games were on. Also, the number of acute coronary events increased considerably on such nights. A few thousand miles to the east, people in China were warned about getting enough sleep at night, because the games were held at midnight their time. It is estimated that Chinese productivity decreased considerably due to sleep deficiency within the past month. The British were also warned about seeking time off from work to watch the games via false physician's notes! The Cambodian president appealed to his people not to gamble their land, their cows and all their belongings on these games, while the Algerian government apologized to its people for not being able to buy the broadcast rights of the games! I myself saw and felt the mass depression the day after Iran was eliminated from the group stage.

So you see, it is all about people's mental and physical health around the world. Soccer is becoming an international event and no one should underestimate its powers. The question is, can this power be put to use to the benefit of human kind? Or is it going to limit itself to filling the CCU with football fanatics every four years?

Delivering Bad News for the First Time

Ali Tabatabaey -- Remember how a few posts back I wrote about the joy of making a diagnosis that has nothing to do with the original complaint of the patient? Well, I have to admit that sometimes it’s not that simple.

When Mrs. M was admitted to the ward, it was a simple case of elective admission to balance her medications and figure out the optimal combination. The lack of an interesting complaint and no significant past medical history made Mrs. M an unattractive patient from a student's perspective. She was a quiet lady in her late 60s, very cooperative, but definitely not an extrovert. Her supportive family accompanied her to the hospital and left her to the trustworthy hands of the people wearing the white coats, asking for reassurance that her Parkinson’s disease would improve.

The orders from the staff doctor were straightforward: Normal diet, normal activity, a couple of anti-Parkinsonism medications, an antidepressant and regular recording of her symptoms. It was her second day on the ward when I was back on duty as the intern in charge. She complained of a little difficulty in breathing, but my untrained ears were not able to find anything abnormal on oscultation (well, nothing significant anyway). A chest X-ray can be a great help, so that was added to the order. Her blood pressure had been showing moderate elevations, too. So, as I was looking for more clues and asking the nursing team about her condition, one of the nurses mentioned that in her point of view, Mrs. M looked very much like CRF patients with her slightly puffy face and yellow discoloration of her skin. She definitely had a point, so proper tests were added to her order.

A few hours later, the results are in. A blood creatinine level of 8.2 with a slowly rising BP and lack of significant symptoms left no doubt. She was on the down slope of a renal failure. All of a sudden an elective admission had turned into a complicated case with risk of death. The tests were double-checked: creatinine 9, potassium 5.2, normal ECG, BP at one point reached as high as 180/95, and CXR showed the typical butterfly pattern of pulmonary infiltration. That night I had yet another rough shift, constantly checking the EKG and the BP and trying to control it via medications, and calling the internist to arrange for her admission to the nephrology department. But the hardest part was yet to come.

The next morning it was time to tell Mrs. M what she least expected to hear. All she wanted was to reduce her hands’ tremors, but she was about to find out that her only hope for long-term survival was a kidney transplant. Why? We still don’t know. I rehearsed my lines over and over again, but when it came to the real thing, I just couldn’t do it. So, I chose the easy way out. I diluted the facts and left it up to the nephrology department to make it all clear: “You see Mrs. M, there seems to be a problem with your kidneys, so we’re going to change your ward to let the nephrologists visit you …. It appears that your kidneys have stopped functioning and the specialists need to see what they can do to fix that.” She hardly said anything. She accepted the words of the man in the white coat who happened to be a young intern trying to convey bad news for the first time.

Yeah right, fix it! I knew that she will definitely need dialysis and that most probably her kidneys are gone for good. But I didn’t have the guts to be the one telling her that. My first experience at giving the bad news and I failed big time. I’m still not sure what went wrong, or if it really was my job to give her the news. Yet I’m sure that sooner or later the easy way out is not going to be an option, and the bitterness of bad news is a must when you’re wearing the white coat.

Bridging Hostilities Between Iran and the US

Ali Tabatabaey -- I've been thinking about this topic for a long time, and to tell you the truth, I didn't want to write about it. But day by day as I see new events evolve, I feel the urge to make my point and to let everyone see from my perspective.

It's very displeasing to feel that while scientists and artists and normal people are the ones pushing the world forward, at the end of the day it's the politicians who decide where we are heading. These days the political scene has been very rough, and little by little the hostility is being felt in the lives of normal Iranians.

A few weeks back I was invited to participate in the world federation of hemophilia conference held in Vancouver. It was a grand gathering of 4000 people working in all aspects concerned with hemophilia. The funds were raised, the trip was planned, and I was ready to be a part of it all. But it turns out that the Canadian Embassy saw me as a threat to their social stability (I guess!) and so refused to grant me a visa on the basis that I will probably not go home again when I'm supposed to. A stupid alibi when it comes to someone who has lived in Canada before. And I wasn't the only victim. Anyone else trying to attend the conference from Iran faced similar problems, and a huge majority did not make it.

On the other hand, a friend of mine had planed to go to Germany for the world cup of soccer. He had family there and had traveled to that country several times in the past. But again, he wasn't granted a visa.

I'm not stupid. I know this is all because of the nuclear issue, and all the other excuses are simply excuses. And that's exactly my point. The politicians battle it out in the political scene, but the ones paying the real price are regular people. I'm sure that if they just leave us to ourselves and let the people connect freely with their counterparts across the world, we would have no reason to fear a clash of civilizations. They know this, so that's exactly what they aim at when they stir up political hostility. They stop the cultural and scientific and sporting figures of opposing countries from facing each other. Because as normal people they will find a peaceful way to work everything out, which is not to the interest of the people in charge.

The truth behind this notion was vividly proven to me at the closing ceremonies of a statistical conference in Mashad a week ago, when one of the foreign guests made this speech:

"… I am so glad that I could make it here. I know some of your foreign guests declined because of fears of the political situation and others were not granted visas by the Iranian embassies. But I'm glad that I made it. The hospitality has been fantastic. But most of all I was delighted to meet Iranian students. Before coming here I always thought that the Iranian students were very hostile and wanting to change everything through violence and hate. But now that I've met some of them I know that they are normal people and maybe much more passionate … Thank you! I will leave Iran with many great memories."

I've been thinking ever since about the history of relations between USA and Iran, and how two nations who were once passionately in love with each other have turned into all-out enemies, at the hands of politicians. I just feel devastated. I know that the people of the world can live in peace and happiness if they are given the chance by power thirsty politicians. We shouldn't just sit back and let these guys tell us how we should think. Maybe it's time we send our scientists, artists and writers to other countries as our representatives, instead of politicians.

Finding the Reward for Years of Studying

Ali Tabatabaey -- They say that internship is the end of your medical education; that you have learned all that you must, and all you need to do now is to implement that knowledge under supervision to gain some self-confidence. This saying however, overlooks the fact that medicine is a rather slippery discipline with an overwhelming volume of facts, which tend to escape the boundaries of one's gray cells rather quickly. Thus while most of us manage to cram everything in, and pass the exams one by one, in a week's time … well, you know!

Yet the past few weeks as an intern have vividly pointed out a simple yet gravely crucial fact that can only be fully expressed if I shout it out at the top of my voice while jumping around frantically! Maybe by doing this I can shake off the sluggishness and the sense of tiredness that haunted me for the past two years. The teachings as an extern seemed so tiring, irrational, unmanageable, literally impossible, frustrating, and out of this world, that I don't see how one can live through it without going totally insane! So now, I want to shout out with joy and tell all "school curriculum advisors" that for the first time in the past six years, I think I am sensing a touch of real-life MEDICAL EDUCATION! And not only is it NOT tiring or impossible, but it's fun.

For four years I struggled to get to the wards and classes on time, sometimes even skipping a couple. Yet these days I find myself arriving half an hour early, and sometimes even more. I even skip teatimes and stay overtime to finish a physical, or see the last few patients at the clinic. It's amazing! The patients are not the collection of symptoms they used to be a year ago. Instead, they have turned into real people suffering from real problems for which I have to find the answers. But even more amazing is that I can actually do that! WOOOOOOOOOW!

The joy of writing a prescription that you know will relieve the patient of his or her pain, and the fantastic sense of executing a physical examination when you yourself already know what you are going to find, are some of the joys that I had not sensed before becoming an intern. Yet above all this is when you make a correct diagnosis that has nothing to do with the patient's chief complaint. Trust me, you won't be able to sleep from joy for a while after that.

So, that's why these days, while most of you are complaining about drowning in a merciless pile of medical exams, I find myself floating or even surfing the waves of a new concept, PUTTING THE KNOWLEDGE TO USE; this is what education should be all about. God knows how many times I tried to memorize the spelling, the dose, the intervals, and the use of Nitrofurantoin, but all I needed was a single prescription for it all to sink in! I'm just wondering, "Couldn't life have been this simple from the start, or do they have to suck the liveliness out of our lives before they give us a chance to live?"

I know this might sound impossible but believe it or not, I think I've reached the fun part of medical education! And I want to shout out at the top of my voice and tell the world that "this is what it's all about!"

Full Moon Over the Psychiatry Ward, Part 2

Ali Tabatabaey -- As promised, here's the rest of my earlier report about my 2nd shift as a new intern:

Same day, 2 pm! I just finished the second patient's examination, my guess for this one: conversion disorder. I also ordered some tests for the pregnant patient, who having in mind her normal BP, had me thinking of hypothyroidism. Then again, if her puffy face is due to a myxedema, isn't she supposed to be infertile? And yes, I did finally manage to give her the pills and go through a quick physical, only to reveal normal heart and lung sounds, rough skin, pitting edema on the feet and non-pitting edema on the hands.

Here is a tip for anyone out there, stuck in the pych ward with an uncooperative pregnant woman: use the "it's for the baby" trick! Trust me; it won't let you down.

I think you will agree that by this time I deserve an afternoon nap, so back I go to the interns' room and dive headfirst into the bed. Still thinking about my "multi-axial" patient, the world around me fades to black. But the moment my eyes started to feel the warmth of sleep, something shouts "not so fast"! Well, actually it was the phone ringing -- turns out Mrs. N has a nosebleed. So much for the siesta.

Darn it! Nosebleed, low platelet count, anemia, and pregnancy, what a magical combination! By the time I get up to the ward the bleeding has stopped. Come on Ali, think! Should I order a platelet infusion? No, no, her plt count is a long way from risky levels. A couple of packed cells won't hurt? But who is going to persuade her to keep the line in throughout the infusion? Besides, she's young and has a healthy heart, why take the risk?

As I'm juggling these ideas, a sound comes from the other room: "A. is having a seizure!" A pseudo-seizure as I was about to find out, relieved just as soon as I rushed to her side. Now, what was I thinking about?

"It's the men's ward. You have a new patient," a nurse calls from the station, waving the phone in her hand.

"Tell them I'll go up there right after I'm finished with Mrs. N," I reply with a grin. (First rule of survival as an intern: for the sake of a quiet night's sleep, always be kind to the nurse -- no matter how bad her timing is!) After a lot of thinking, I decide to monitor the patient personally.

It was almost dusk when a nurse pointed out the uneasy expressions on Mrs. N's face. That, added to the fact that she had gone to urinate three times in the last 3 hours, was a very bad sign. We were concerned that she might not tell us about her pain and that a gravi-5 parturition wouldn't take long.

So, after a long conference in our strategic headquarters (the nursing station) we decided to send in a nurse on a fact finding mission. Maybe she would communicate better "woman to woman". Three minutes later, she came back to report. "She says her water broke!"

"X*&%#KSV ZK#@$$^... Did you see anything yourself?" I ask.

"She says it happened when she was in the restroom, so her clothes are all dry."

We tried to place a pad, but she threw it away. The midwives refused to come up to see her since they were short on staff and a fully dilated patient had just arrived (but I think they were just afraid of the psych ward). We would have taken her downstairs but she could hardly walk, and the elevator had broken down that morning.

So, should I do a pelvic exam myself? No, stupid, it's contraindicated. How about an ultrasound, or an NST, or … I could hear my gray cells screaming "OPERATION OVERLOAD"! It was only my second shift as an intern, I didn't deserve to be treated like this.

It was 1 in the morning when I got the chance to lie down again. Mrs. N was long asleep. She probably never meant to say she was experiencing labor; rather, she had been talking to her auditory hallucinations. I also recorded the physical history and examinations of 3 (yes, 3!) patients in the men's ward.

Finally, I had a chance to check a few messages on my cell phone, one of them telling me to enjoy the beautiful full moon!

Like every other modern day horror story, our story does not end here. The phone rings. It's the men's ward. It looks like they're having trouble with one of the patients. It's 3 am. The patient is a young man trying to quit a heroin addiction, and he is AGITATED. He wants to be discharged. He has received 2 tramadol injections and his routine clonidin dose, and 3 promethazine injections, and he is still aggressive!!

The nurse insists that I call the on-call physician. But at 3 in the morning, that would be equivalent to academic suicide. So after a quick Q/A about the symptoms, I decide that the safest thing that can keep him going till sunrise is another clonidin pill. Yet, soon after giving it to the patient, I can't stop thinking: "What if he experiences a cardiovascular collapse?!"

To make a long story short, my final 2 hours of sleep that night were filled with nightmares of killing a patient just because I wasn't willing to call his physician. That morning as I was getting ready to hand over the shift to the next intern, there was a knock at the locked door. "Let me guess, another patient!" I joked with the head nurse. But it wasn't a joke.

A young aggressive girl suffering from psychosis was admitted to the ward. At first I wanted to ignore her and leave her to the next intern, but no one could do that after seeing a fellow intern running away from her with a bleeding face. The rest of the story is about four people holding her for an injection, strapping her down, trying to ignore the screams, dodging a couple of less damaging blows myself, and trying to comfort my fellow intern.

The final seconds of my shift, I was sitting in front of the clock and staring at the long red handle moving towards 12 in slow motion. I don't know how I managed to get back home that day, but somehow I did.

Today, all those patients are feeling "OK", communicating, and improving. Mrs N has not delivered her baby yet (I guess the ultrasound was right), and I was right about the hypothyroidism. Maybe even this was the cause of her psychosis!

Now that I look back at my full moon shift, I'm kinda proud of myself. I managed the ward, made a correct diagnosis, and learned aaaaaaaallllllooooooooootttt of things! Not only about psychiatry, but also about internal medicine, gynecology and most of all surviving in the psychiatry ward under a full moon. How could anything be worse than that?

Full Moon Over the Psychiatry Ward

Ali Tabatabaey -- In our hospital, shifts on the psych ward are known for their calming siestas and placid slumbers. So when I agreed to switch shifts with a colleague for a Sunday night shift, the worst I expected was a couple of new patients suffering from mood disorders; or if things really got unlucky, a psychotic patient that would doze off with a single Promethazine injection. But as I learned the hard way, there are always exceptions!

It's 9 am and I go up to the psychiatry ward to announce my presence and to receive the shift from the previous intern, who joyfully reports a single admission that has my name written all over it! (This usually means a psychotic patient that everyone else prefers to sidestep). "Only one catch…" she went on to say, "she's pregnant!"

At first, I didn't sense the depth of the tragedy, but a quick look at her orders was all I needed to realize what I was in for:

- Vital signs q6h

- Monitor closely for signs of parturition

- Check FHR q6h

- Examine for fetal movement q6h

But that's not all. Her lab panel was just as interesting:

Hct = 22%, plt = 100,000, BS = 65, TG and Cholesterol in the high normal range!

Usually all this is the nursing team's job, but since they are short on staff and barely manage to do their normal duties, the residing intern has to take the burden of such extra orders. "How am I supposed to ask her about the baby's movements?" I nagged the nurse. "You don't expect me to palpate her tummy for 20 minutes? Do you?"

"Before trying any of that, you better feed her these pills -- she refused to take them this morning," she smiled in reply.

Asking everyone to wish me luck, I entered her room. She was a rural peasant, judging by her clothing (which she refused to change). She apparently preferred the coldness of the tiled floor to the comfort of her bed, and was talking to herself quietly. As soon as I entered the room, she looked at me furiously, cursing me in an incomprehensible accent and asking me to leave her alone. Her face was puffy and edematous and she could hardly move. I tried to make conversation and maybe go through a quick physical examination, but she started shouting and I agreed to leave.

The smiling face of the nursing team who had watched me on the security cams said it all: This is going to be long night! And they couldn't wait to give the "good" news that two new patients were on their way (ie, at least 1.5 hours of history taking and physical and mental examinations!).

To summarize my situation, I faced an incoherent pregnant woman in her 36th  week of gestation (speculated by femoral length), with an obvious organic problem, extremely irritable, who didn't allow me within a couple of feet! And the day was just getting started!

Stay tuned for more on this story …

The Start of Internship Has Been a Bit ... Crazy

Ali Tabatabaey -- No, I'm not dead! But you'll be surprised what one can live through. It turns out that unlike what I had been told, being an intern is not the end of hardship. Although, looking back at the past two weeks, I have to admit it has been a rather enjoyable (yet torturing) experience. So accept my apologies for the delayed entry.

I am back at the psychiatric rotation to start my internship only 5 months after my externship, and things are … different. It's surprising what a difference five months makes. Every thing has changed, the way I see the patients, the things I see in the patients, oh, and the best of all, writing the orders. The nice thing that I managed to learn during this short time is that as an intern, while being responsible for the patients you are not responsible at all! You get to think and manage, and whenever you are stuck, there is always a resident or a staff physician a phone call away to clear things up.

There is only one problem, that small and tiny Y-chromosome! Let me give you a tip: When studying medicine in a country where 70 percent of the student population is female, beware of the psychiatric rotation! As the only person with a Y-chromosome, you are culturally obliged to care for the toughest of the tough. So, while everyone else gets to interview the depressed teenagers or the obsessive girls, you have to play Ultimate Fighting with the psychotic bipolar patient, or the aggressive schizophrenic, or if you're lucky, the calm looking child killer! So little by little you learn to have an extra shirt or coat on hand just in case the patient decides to have a piece of your collar.

The hours come and go and I can only find time to carry out 40% of my daily schedule. How the rest of the day goes by, I just don't know. So, as I desperately try to keep everything from falling apart, I'm beginning to learn how to sleep while standing, eat while sleeping, type while eating, and speak on the phone while typing. I just can't wait to see what a resident's life is like!

So Much for Getting It Right ...

Ali Tabatabaey -- I guess it's time to solve the case report. Sorry for the delay but I've got a good excuse. I had been trying to reach my friend for a few days (without success), when I was informed that he has been sent on a long and painstaking mission to I don't know where, without any definite date for his return!!! Realizing that he could be gone for a long time, I decided to explain the case with the details he gave me last time.

All the diagnoses you mentioned were possible. But in such a situation it is important to think of the life threatening and yet curable conditions first. I myself fell for the old trick of co-morbidities, attributing the GI symptoms to the migraine and the sore throat to hysteric stress (the friend's funeral). But gladly my friend didn't. (His mission has got nothing to do with a misdiagnosis, but I couldn't resist the suspense.)

Keep in mind that in the base you do not have the resources to check the O2 saturation or an X-Ray. So ask: what is the first thing I can do to tell me if I have the time to do all the rest. Your key to final salvation is the ECG, because it gives so much important information.

I'll let Dr. Atghiaii's own words describe him making the decisive decision:

"As I was examining this General, I could see the angry face of our cardiology professor saying: 'I don't expect you guys to diagnose or treat any complicated cardiac condition, just don't send home an MI patient to his death with a bottle of antacid; LOOK OUT FOR THE ATYPICAL MI,'" and that's exactly how the story unfolded.

A simple ECG for the above patient revealed a massive inferior MI. His gastrointestinal symptoms were the result of the parasympathetic stress seen in such infarctions. The symptom described by the patient as a "sore throat" was actually an atypical discomfort. That's exactly why his throat looked normal and he was afebrile.

The patient was sent to a military hospital immediately and spent the next five days in the cardiac care unit. I'll send you the full lab results as soon as I get hold of his Dr. (if he returns in one piece). So, the moral lesson of the story: "In a patient with even seemingly minor risk factors for IHD, suffering from any pain below the maxilla and above the umbilicus, always have the atypical MI in mind. An ECG won't hurt, but can be vital."

Another moral lesson could be that in the military you will be sent off to exile regardless of making the correct diagnosis or not. So as Chef Mo said in his comment, always have the full anorectal examination in your routine. At least it'll make you feel better when you're crawling around a sizzling hot desert with a metal helmet on your head, while the general whose life you saved is sitting in his air-conditioned office and programming your mission.

As for myself, life as an intern has begun and my first night shift is just 48 hours away. But that's a whole other story and a whole other post.

Solve This Case ... Or Else

Ali Tabatabaey -- A few days ago, one of my best friends called and approached me with a quiz. He was my intern in a couple of rotations last year, and today he is serving his military service as the doctor of the base.

Here it goes: One morning, your General comes to the clinic complaining of a sever sore throat which has been bothering him for a couple of days. He is a 45-year-old military general with a well-built body who is keen on working out in the gym and eating fatty stews. His chief complaint on arrival is a sore throat that started yesterday morning with his migraine headache but failed to cease with the headache last night. He did not eat any breakfast yesterday morning, and on the same day had to attend a friend's funeral.

Nausea and a single episode of vomiting accompanied the headache and the sore throat without improvement. These symptoms usually exist alongside his migraine headaches. The patient has been using herbal antacids without any response.

On physical examination, BP is 120/80 and the PR 65. The throat examination is difficult due to the accompanying nausea, but everything seems normal without any erythema. The patient holds his throat every now and then, just above the Lewis angle, in order to relieve the pain, but without much success. He is more agitated and irritable than his usual behavior.

What would you do? You've only been practicing as a physician for the past five months and this guy is a very important person. Keep in mind that a misdiagnosis could mean anything from a written disapproval of your practice to permanent exile to a distant base (well, maybe not that much). Still, if you make the correct diagnosis you will have improved your situation in the base considerably.

I'll be reading your comments and will answer any questions. I made the wrong management mistake on this patient and I want to see if I'm alone, or did I make a common yet grave mistake.

Facing the Threat of War

Ali Tabatabaey -- Ever since I started writing for this blog, I have tried arduously to stay away from politics -- not an easy thing to do for someone who holds strong, yet centric political views. Thus, it's not surprising that a small push from the editor was all I needed to burst out with five pages of political analysis, more fit for a political weekly than a med student blog. So the past few days have been dedicated to trimming and editing the original article in order to focus on the more personal aspects and to minimize any possible misunderstanding, which is so prevalent when politics are discussed.

Last week I attended a small party along with 15 close and distant friends. It was a goodbye party for a dear friend who recently graduated as a dentist. He will soon be off to do his two-year compulsive military service, mandatory for all Iranian boys after finishing their academic studies. This was not the first of such parties. Usually these parties are filled with jokes about how the soon-to-be soldier will look with a shaved head, running up a mountain with a 20 kg backpack, giving military salutes, and trying to figure out what he was fed for lunch; but not this time. At this party, the jokes were about him fighting a guerrilla war in southern Iran and charging thousands for an orthodontia operation in a cave; or even attacking the American solders with a dentist drill. Behind all the laughs and all the jokes, though, the bitter sense of war was present.

Even I, from the post-revolution generation, vividly recall the Iran-Iraq war. Although my town of Mashad was in the east, safe from Iraqi attack, life was filled with long lines for fuel, almost no leisure activities, and horror stories told by people who had fled the western parts for the safety of the east. Now, the fears of yet another imposed war are mounting. We might joke about it, but deep down inside we're all keeping our fingers crossed and hoping that we can meet back here in two years, safe and sound and in peace.

It just makes me furious when two people, whose closest experience with war has probably been watching "Saving Private Ryan," smile in the face of the world, enjoy the English scenery, attend a concert and discuss starting up another war. Such people have never seen war. They have never seen their neighbor seek cover every time a plane flies overhead. They have never seen their best friend run out of the shower naked during a fire alarm, because he was reminded of the air raid siren. They probably have never seen their cousin-in-law cough until he pukes after being exposed to insecticide, because mustard gas is never metabolized even after 19 years of circulation in the body. And they have definitely never seen a classmate cry about how he would have loved to play soccer with his father once, but never got the chance, since he died when the child was only one year old. They have never seen what I've seen, and I haven't seen much.

And Now, For Something Really Scary

Ali Tabatabaey -- The results are in, and I have ………… PASSED the pre-internship exam (the crowd cheers). Although I only heard the results over the telephone, I think as of now, I can consider myself an intern (thanks for all the good luck wishes). Yet based on what I've heard (and seen) the true life of an intern is not so glamorous. The simple name of "intern" brings with it a concept that I have tried to escape throughout my education: responsibility. The change of mood is vividly felt in everyday life.

This year's New Year celebrations have been quite different. In previous new year gatherings I usually succeeded in sidestepping my grandfather's blood pressure quiz, my aunt's migraine headache FAQs, my other aunt's shoulder problems, my cousin's "interoperate the skin lesion" game and my friend's inquisitive inquiries about constipation. But as an intern, things are not that simple. You are supposed to know something about everything by now, and each question needs a proper answer while "you need to see a doctor on that!" doesn't seem to work anymore.

I know that just 24 hours into my life as an intern I'm getting a bit carried away, but I've got a strange feeling. It's like going through puberty again with all its uncertainties and responsibilities. We've all felt those years when as a plane passenger, you do not get to read a newspaper because you're too young, but don't get to play with the toy plastic planes either because you are too old. Likewise, you can't hide behind the textbooks anymore but the self-confidence of a true physician is still many months away.

If I were to describe my feelings right now, I would recall Indiana Jones in his last crusades just before he enters the cave. Although most of the story is behind me, the best part remains. And not surprisingly, this part is the most unpredictable, where the price paid for a single wrong step is unimaginable and the only thing that keeps one going is the ultimate goal. So, as I carefully enter the dark tunnel of internship and anxiously choose each step, all I can do is believe, and hope that my mistakes are not costly ones.

I would love to go on writing about this thing(!) inside me, but you probably don't have the time to read it. So I won't bother. I'll just end with this thought: the image of me making a decision that would decide the life of a patient simply freaks me out. I know this might seem weak but I'm only being honest.

Longing to Return to the Wards

Ali Tabatabaey -- These days my life is like the second half of a Shakespeare play; the peak is over, and little by little, life returns to normal. The Noruz (Persian New Year) is a welcomed treat these days. Tonight at exactly 18 hours, 25 minutes and 35 seconds GMT, spring begins and the Persian calendar ticks one year ahead.

As most people do in such times, this is a great time to look back at the year gone and plan for the year ahead. Yet the reason I love Noruz is that the changes in life coincide with the enormous changes in the temperate environment we live in, and you get a true sense of being reborn. So, huge changes don't seem impossible.

Being me (the always thinking, never doing boy who draws out the most impressive visions but usually ends up short of time), I have so many things in my strategic plan for the upcoming year that I almost know I won't get the chance to carry out. I guess you can't call it strategic anymore. It's more like an "I would love to do all these things" plan": I'm planning to spend more time on my ancient passion for research, maybe get a transfer to a more prosperous university, and spend more time on volunteer work, all this and hopefully the long shifts and challenges of becoming an intern. Sounds like an interesting year ahead.

I was thinking of taking a couple of months off from school to get some of those other plans into motion, but after two months away from the wards studying, I just can't. I can't wait to again weigh a 3-month-old prematurely born infant, auscultate the bubbly crackle of a pulmonary edema, feel the abdomen of a young boy with appendicitis trying to hide his pain because of his fear from the operation, and ask about the chief complaint of a young woman in labor! (Guess what the answer was!!!) But what I truly can't wait for is the smile of a young mother when you proudly announce that her prematurely born infant is gaining weight super fast; or when you hear the silent sound of a calm breath after injecting a dose of Lasix for an old woman tired of breathing with a pulmonary edema; or even joking with a 10-year-old boy after his surgery about how you fooled him into going to the operating room; and definitely the pure sense of joy when handing a one-minute-old baby girl to her joyful young mother. Boy, I miss the wards!

A New Chapter Unfolds ...

Ali Tabatabaey -- It's over -- at least for now. Although the results won't be announced until next week, there is still a great sense of accomplishment and somewhat triumph in the simple fact that I managed to survive without crumbling under the stress. I guess joy is the best way to describe my feelings during the first few hours. Jumping around my room, bumping into and breaking anything not made of metal, paper, or plastic. Yet, as that burst of energy wore off a new sensation kicked in -- relief.

This meant a chance to experience all those little things that I didn't have time to enjoy in the past 50 days. That deep and sweet afternoon nap relieving each and every cell of your body from the hypermetabolic state enforced upon them by the undisputed secretion of adrenalin in the past week. And the long hot shower that washes away all your worries as you doze off to the music of the warm drops of water tap-dancing on your tense skin (described so well in Kristen's "life after call").

But this relief also brought with it the questions that I had successfully managed to keep out of my mind. Like it or not, once again I have the chance to think about life as a whole and my life in particular. The most bothering thing about setting on a seven-year journey into the wild jungle of medical sciences, straight out of the sweet world of high school, is that you don't realize life passing you by. While people your age are enjoying the best years of their lives, all you get to think about is "how do I survive"! Even worse is when you have had to spend your high school years in a nerdy all-boys' school in order to earn the admission to proper academic education, i.e. Medicine.

So 10 years on, one night after the Pre-internship exam, you find yourself on the roof, drinking bitter coffee, looking up at the stars, remembering the romantic teen comedy you watched a couple of hours ago as a treat for surviving the exam, and thinking to yourself that you are half way through your 25th year as a human being and …! My teenage years are gone and not much is left of me as a youth and I still have an endless path till realizing my ambitious dreams. At least I'm on the right track, I think! I am certain about my ultimate goals, but I just can't help doubting the cost of staying on this track. My teenage years will never come back and soon the same will be true about my youth.

So, as I take another sip from the dark cup of coffee and finally manage to locate the big dipper, I smile. Because I'm sure that in the sheer vastness of this universe, I want to make a difference, and no price is too high for that.

It All Comes Down to This ...

Ali Tabatabaey -- It's late. The only sounds breaking the scary silence of the night are the rhythmic ticks of a small clock sitting across the desk, and the occasional growling of my stomach asking for yet another snack. I can't keep my back straight anymore, so I put my head down on the papers in front of me and slowly close my eyes, trying to review what I had been studying a minute ago, only to find out that not much is still in my head.

The clock keeps ticking and as it does, the long red arm rushes ahead ever so quickly. Just four days left. I give up. There are simply not enough hours in one day. I think I've reached the stage at which, as I cram new things into my head, the old knowledge leaks out the other side. A part of me still wishes for time to stop for a few days so that I could catch up, but most of me would gladly take the exam tomorrow if I were given the choice. That said, in my current situation if the angel of doom were to show up and offer to take my soul, I would consider the offer; anything to escape this!

They say you get to have a last wish before you die. I know what I would wish for. I would ask for all the infectious disease specialists to be gathered up in one place so that I could ask them one simple question: WHAT WERE YOU THINKING WHEN NAMING THESE ORGANISMS? What made you think that Paracoccidioidomycosis could be a proper name for a microorganism? Isn't there a limit to the number of letters used in a word in English? How about this one: Actinobacillus Actionomycentenacomitans? Throw in a Q and a Z and you'll have the full alphabet lined up. Couldn't you just give them nicknames or something? How can I learn something when I can't pronounce its name?

Oh well. Too late to nag about these things. This is my last blog before THE EXAM. Pray for me. I need all the help I can get. I better get back to studying -- I still have a whole bunch of material to cover, and the small black clock across the desk just won't stop ticking.

Take the TABA Nerd Test

Ali Tabatabaey -- Before anything else, sorry! I know my entries are growing a bit thin, but bear with me for another couple of weeks and I'll be back to my normal self (if there ever was such a thing).

These days I'm trying hopelessly to manage as much material as possible. I have given up the pursuit to know "all" and will settle for "the most". It's amazing how we med students metamorphose into typical nerds without even noticing it. I can't remember studying more than a single night (three at most) for much of my high school exams. But here in med school a month is not enough.

Today I finally admitted to myself that I have become a nerd (not that it's a bad thing). First it was hard to accept, but at the end some good did come out of this avowal. Looking back at myself, knowing that I had fallen into this trap obliviously, I decided to help others recognize early symptoms and prevent them (if desired). So, after several hours of clinical investigation, I came up with the TABA diagnostic criteria for nerdism (da da da daaaa):

If you can't think of two things other than studying that you've done during the day, score 2 points.

If you find yourself going to the bathroom more than three times a day just to prove to yourself that you don't have a bowel obstruction, score 1 well-deserved point.

If you have not seen your grandfather for more than a week despite living on different floors of the same house, 1 more point.

Name your hero. If the first name that came to your mind was Eugene Braunwald, then score 3 points. (Hippocrates, Harrison and Nelson all score 2 points.)

If you've managed to be the first to borrow the 2006 edition of every book in the campus library (even when it was still 2005), score another 2 points.

If you've ever been woken up in the middle of the night because you were talking about Fat Embolism Syndrome in your sleep, score yet another 2 points.

And last but not least, score 3 points if you have ever felt oddly good-looking while wearing a gray and red sweatshirt over a red-collared shirt with red and white striped pants, which you use as your pajamas. (Score 6 points if the feeling lasts more than 24 hours, and if it lasts more than 72 hours call 911 and seek emergency medical attention.)

Oh yes! How we evolve without even noticing. Don't worry, if you scored less than 3 you are safe. Between 4 and 6 you still have a chance to turn back. But if you scored more than 6, then WELCOME TO THE MED STUDENTS NERD CLUB!

Obese or Just Well-Fed?

Ali Tabatabaey -- As I was surfing the internet I came across the American Heart Association’s homepage on child obesity. It reads:

Among American children ages 6–11, the following are overweight, using the 95th percentile or higher of body mass index (BMI) values on the CDC 2000 growth chart:

* For whites (only), 11.9 percent of boys and 12.0 percent of girls.

* For blacks or African Americans (only), 17.6 percent of boys and 22.1 percent of girls. 

* For Mexican Americans, 27.3 percent of boys and 19.6 percent of girls.

The site had a whole bunch of numbers like these, which are supposed to persuade the reader that child obesity is on the rise. Interesting numbers! But wait a second, aren’t the growth charts a reflection of the general population? Doesn’t the 95th percentile mean that 95 percent of the population weighs less? I’m not very good with numbers but no matter how you add these up and no matter what the ratio, it’s going to be more than 5 percent!

How can 15 percent of the population weigh in the top 5 percent? I know I must be making a huge mistake somewhere (correct me if I’m wrong), but if I’m right then we have to change the way we look at obesity.

If we measure obesity by the general population and its deviations, then we have to accept that the new generation is better cared for and so weighs more. When in Lilliput, Gulliver was the giant. The same will be true if everyone grows fat. Then the thin should be considered sick. Either this or we have to change our definition for obesity!

Don't Give Me That Look

Ali Tabatabaey -- Good news for all: I'm still breathing (I guess you can't escape med school this easy)!

It's amazing that no matter how hard you study, and how purely you dedicate yourself to the impossible mass of knowledge crammed into the textbooks of medicine, the real life patients and people always manage to ask the most irrelevant questions, that not in your wildest dreams you could know the answers to. The questions that can only be answered with the world's dumbest "I'm not sure," accompanied by a prize-winning moronic blank face. No surprise that all you're going to get in reply is an awkward "oh … ok" which actually means, "How can you not know the answer to such a simple question after 5 and a half years of med school? What do they teach you in there? Do humanity a favor, and drop out!"

Just the other day, while I was drowning in thousands of pages of unmanageable medical facts, someone called to ask, "I left my multivitamin pills in the kitchen. But it's been awfully humid in there. Does that ruin the pills? Should I still use them or not?"

Of all the medical questions in the world, why this one? Among all this more IMPORTANT information, how was I supposed to find the time to look up the answer to such a question? She could have asked me how the S/D ratio changes in the umbilical cord of the fetus during pregnancy; or what is the most common cause of meningitis in neonates; or what is the best imaging technique used for evaluation of spinal TB; or even how to manage an unstable angina. But no! She has to ask what happens to multivitamins when you leave them in the kitchen!

I tried to go on about the different types of water-soluble and fat-soluble vitamins, but all she wanted was a straightforward answer. An answer I did not have. Why don't the patients care about all we know? Why don't they even notice what we have gone through? And why do they expect us to have a divine omniscience?

I don't know. I've studied five years of medicine and I don't know. I don't know if sesame seeds are good for the brain, the gut, the kidney or any other part of the body for that matter. Neither do I know if microwaves cause cancer, or whether the change of seasons can lead to diarrhea. I don't even know what happens if you take your pills upside-down or if you take them right-side-up while standing on your head. And I definitely don't know what happens to pills if you leave them in the kitchen. So hang me! Just don't give me that look.

Blame It on Med School

Ali Tabatabaey -- 36 days to go…

This is a true story. I'm not sure what it was; I just know that it was. (If you have horror music somewhere, you should play it in the background.)

When I first opened my eyes this morning, it was still dark; 4:30 a.m. to be exact. I had been studying till midnight when I decided to call it a day and go to my cozy bed.

As soon as I opened my eyes, I felt an uneasy tingling around my mouth. A numbness, the likes of which I had never felt before. First, I tried to bite away the feeling without success. Then I tried changing my position in bed to relieve any external pressure, again without any improvement. So, I decided to go back to sleep and wake up to a healthy me in a couple of hours.

I tucked myself under the blanket and tried to relive the past few hours to find the cause. I wasn't hyperventilating, there was no sting mark, and I hadn't been sleeping facedown. I was slowly dozing off when it suddenly occurred to me and my eyes snapped open, BOTULISM!

I had been studying the subject a few days ago, but what really got me thinking was the story a friend told about a patient spending 2 weeks in the ICU after eating a can of tuna! I had been eating lots of leftovers and canned food lately, mostly unrefrigerated since the nearest fridge is 53 stairs away.

"It can't be! I didn't eat canned food last night." I laughed at my wild imagination and rolled over trying to sleep. "But there was that eggplant stew I ate last night. It had been sitting out for almost a day!"  The numbness was still there and it was feeling worse. I couldn't even smile. With this in my head, sleep was impossible. So, while laughing at my utter stupidity, I decided to recheck my study notes to prove to myself that this was impossible.

"Transmitted through air-tight food storage" -- phew! Mine was home cooked and definitely not air-tight. But just as I was feeling relieved: "has been reported through all sorts of food including honey, cooked eggplant, and fried onions." That doesn't prove anything. It's been more than 24 hours since I ate it. If something was wrong, it should have shown itself sooner. "The incubation period ranges from 12 to 36 hours or even more." So maybe it's a mild form of the disease. "The toxin is potentially lethal, and the disease manifests as a descending paralysis usually starting in the head and neck." I really shouldn't be reading this. "Cranial nerves are the first to be involved" -- so that's why I can't smile. Oh, my god I think I'm developing diplopia. 

I heated the food thoroughly before eating it. That should have killed the clostridiums. "Can be caused by ingestion of heat resistant spores." By this time, my right leg was feeling numb (it shouldn't spread like this, I guess it's spreading faster than I expected, heeeeeeeeeeeeeeeeeellllp), but still I wasn't sure enough to call my family at 5 a.m. If I were wrong, my sisters would tease me for the rest of my life. I stopped reading because it just seemed to fuel the symptoms.

I could feel my muscles weakening by the minute. I just lay there thinking. I didn't have the guts to call anyone yet, so before going back to bed and accepting my destiny, I took a paper and wrote down the names of people I owed money to and the amount I owed them. At least this way if it were true, no one would be spitting at my coffin for the 10 bucks I forgot to pay them.

I had the oddest feeling ever. One second I was worried and the other second I was laughing and thinking it's all in my imagination. Still, apnea could be only a couple of hours away. I shouldn't die like this, killed by a bowl of eggplant! I was hoping for a more exciting death. I'm too young for this; I wanted to win the Nobel Prize some day. I want to live…!

When I wake up again it's 9 a.m. I'm still breathing and the tingling is still there. The diplopia and the facial nerve palsy are gone. But I won't feel relaxed until the full 36 hours have passed. I wrote this entry just in case I don't make it.

34 days left…

48 hours after that near-death experience, I'm still breathing. I guess it wasn't botulism after all. I'd heard of hypochondriasis, but this was dreadful. As a med student, I've found a reasonable way to explain such stupidities that seem to happen too often in my life: BLAME IT ON MED SCHOOL. If I hadn't studied botulism last week, I would have simply gone to sleep again. Don't you agree?

Life's a Total Mess ...

Ali Tabatabaey -- 45 days left…

The bad news keeps coming. Unfinished projects, job applications returning just when I don't have the time, messed up internet connection, a computer virus and the news of a friend moving away that really shocked me and destroyed my concentration. It's amazing how a horrible day can make you appreciate the good ones. Oh! And just when I was feeling I've reached the deepest low, it was time for the icing on the cake: a 3-hour water cut-off, just when I had decided to leave the wonderful world of pediatrics and have a quick visit to the wash closet.

Moral point of the day: never think this is the most horrible day possible, because it can always be worse, even if it's one of the worst to date.

44 days left…

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(If you try to write about the day's events at 2 am and end up burying your face in the keyboard because you're too tired to maintain your neck tone and too exhausted to concentrate, this is what you end up with as a post.)

43 days left…

I simply don't know how today went by. I've been trying to get back on track after a couple of days of shocking news and events but wasn't very successful in doing so. I'm still behind on my schedule to prepare for the exams. Life's a total mess right now, just as expected. I've been oversleeping, skipping meals to make up for the sleep, and overeating in the few meals I get, to make up for the one I missed. Looks like the normal life of a med student to me, don't you think?

I can't believe a week has passed. I guess I won't be able to close the gap on my schedule today either, so I better go to bed, bury my face in the pillow until my heart rate returns to a level at which sleep is a possibility. Just before going to bed, I promise myself to study harder from now on, knowing that next morning when I wake up, a whole new week will start since the beginning of the countdown.

Losing Your Soul

Ali Tabatabaey -- 49 days left…

I've tried to get everything together, and the checklist is almost complete. Lecture notes, previous tests, pretests, a color atlas, a couple of dictionaries, a few major textbooks, some CDs, and last but not least, me! Great, just one question: where do I start?

I stand a couple meters back and look at the pile of books and papers on my desk and think to myself, "wow! I've studied all this in the past 3 years and have earned an acceptable mark?!" -- but that "wow" turns into an "ouch" when I turn that retrospective view into a prospective one: "you mean I'm supposed to master all these again …!"

48 days left…

I've decided to start with the more recent courses, psychiatry, pediatrics, gynecology (I'm still open to suggestions), but for some unknown reason this "recent" material seems awfully unfamiliar. Is it me, or has all of my medical knowledge evaporated? I'm still trying to keep cool. I'm sure things will improve. Maybe not today and maybe not tomorrow, but hopefully some time within the next 7 weeks!

46 days left…

Today I found out that a good friend -- a classmate and a distant relative -- is suffering from what seems to be Grave's thyroiditis. To my surprise, he had gone through all the symptoms, lab tests, diagnosis, and a couple rounds of treatment, and I hadn't even noticed. I can't believe I've been so inattentive about life around me. I didn't even realize that this friend had been missing classes. For someone like me who takes (used to take) pride in being humane and affectionate, this was a sheer disgrace. I used to take interest in the well-being of others, ask how they feel. Yet these days all I care about is school. How did this happen? Why do I want to become a doctor after all? Isn't it caring for others?

Sometimes we forget that the textbooks are about the people right around us. Here was my friend with hyperthyroidism, right out of the textbooks and sitting in the car beside me. I had read about the disease many times, but what he was talking about was completely different. He didn't just talk about irritability, tremor, orbitopathy; he talked about waking up drenched in his own sweat, frustrated about the inability to stop the process. He talked of a compulsive sensation to start a fight about nothing and regretting it a minute later. He described the nerve-wracking experience of having a shaky hand that drives you nuts, and the hopeless attempt of stopping it with the other hand, which itself can't keep still.

I had studied hyperthyroidism. I had seen the patients. But never before had I paid attention to the person suffering from it.

We, the medical students of the 21st century, are so preoccupied with the mechanical diagnosis and gathering of criteria that at best we can hope to be a well functioning computer. While on this course, we will never feel the true sense of satisfaction that doctors used to enjoy generations ago.

I just wish that medical teaching had been more humane. It seems that the first thing they do to us on entering school is to strip us of our soul, and to teach us disrespect for the human body and soul. First semester and you have a human corpse at your disposal. You might hesitate a little at first, thinking: "he was living once, just like me," but soon you learn to forget about such affections that do you no good but to be mocked by others.

And so it happens. Before you realize it, the sweet and caring person who once chose this course to care for human life, turns into a monster that couldn't care less for the human soul; Someone who greets a patient suffering from a mortal disease with a satanic grin, just for the sake of the physical examination.

I'm ashamed of myself. I remember my early days when I promised myself to be different, to care, and to work passionately. I just hope it's not too late to turn back.

The Countdown Begins

Ali Tabatabaey -- It's Wednesday morning. I open my eyes in a panic. It looks late, so I scramble for my watch and glasses to see if I can still make the morning lecture. It's 6:30 am. I rush to get out of bed but soon realize that today I don't have any morning lecture. For that matter, I don't have a noon lecture either and I'm not going to have any in the near future. I crash back into the pillow, desperate for an extra hour of sleep. But there is too much going on in my head.

My 50-day countdown to the exam started about 395 minutes ago. The last 3 years of med school jammed into 50 days. I wonder who came up with this fascinating idea. I would love to meet him and have a "friendly chat." I don't blame my stomach for this weird feeling, nor my hands for their shaking, nor my skin for sweating, and not even my teeth for grinding. I guess they're all part of the physiological response.

I've heard that denial works in reducing the stress. So, what is the big deal after all? It's only 12,000 pages. Let's see: 12,000 pages, 50 days. If I don't sleep and don't go to the restroom without my books, I have 72,000 minutes, which makes 6 minutes a page. I think I can manage that!

That wasn't convincing at all. Let us try rationalization: I couldn't have started studying sooner. There was simply no time. I was preoccupied with the wards and finals. I have tried my best and there was nothing more I could do. I will give it all I've got and the result is not important; except that, I won't become an intern if I don't pass this and…

OK, OK, how about projection: there are over 4000 med students around the country going through this. (I'm in Iran.) I'm sure they're in a worse situation than I am. They can't study all this either. We're all in this together!

I am not feeling any better. I guess these defense mechanisms just don't work for this level of stress. I don't want to get out of bed. I mean, isn't there a "ctrl Z" button around here, which I can press and everything could go back to normal? Getting up at 8 like real people, eating lunch at noon not 4 in the evening, having a fun night out with friends, and sleeping at midnight just like a normal human being! Wow, I go crazy even imagining!

I can't forget that just 3 weeks ago, I was eager to start the day. Back then, I was in Tehran for a much-awaited reunion with my junior-high classmates. They had all moved on with their lives and had so much to talk about: jobs, travel, college years, marriage, and all sorts of memories. As one might expect in any reunion, not long passed before the question I was afraid of was brought up:

"So, what have you been doing Ali?"

"Well, a lot. Actually I went to high-school and … entered university."

That was about it. Then again, I had all these memories about a guy with pancreatic cancer, a premature baby, an amputation operation, and my first IM injection, but the audience preferred less gruesome conversations over lunch.

Yet, as I'm lying in bed and reliving all these memories of people I've met and things I've done, I feel an ecstatic giggle build up inside. And it suddenly dawns on me. It's about time I realized that medicine, with all the fun and all the exams, is my life. There's no gain without pain, and as for medicine, the gain is worth every second of the pain. I'm more than happy to switch a couple hours of sleep in the morning with the smiling face of a satisfied patient.

Nevertheless, don't expect me to be kind and funny in the upcoming days. If I don't end up in "the hospital for the mentally ill" soon, I will try to write you guys short daily entries right up to the Exam. This way I could use "The Differential" as a defense mechanism, and I think it just might work.

The Awe and the Misery

Ali Tabatabaey -- The stress is building up. Next week will be the final week of my medical education as an extern, the end of a two-year era in my life that has held some of the highest peaks and the deepest lows. I feel that I have grown up. I still remember how I felt before entering the wards of clinical education 679 days ago. I was so eager and couldn’t wait to learn all there was to medicine and the art of curing. But the wards proved unappeasable too. The textbooks were still there. So was the endless mass of knowledge to be mastered in an even shorter time than before. So this time, as I await my fortune as an intern, awe has become the dominant feeling instead of enthusiasm.

Yet today, I’m not going to turn this post into a misery piece. Starting next week, I will have enough chance to do so on my 53-day stretch of mental overload, spiritual agony, stress related diarrhea and pure despair, composed of a two-week block of exams and a month of ruthless studying leading right up to the Pre-internship Exam. Since I’m sure during that time I’m not going to be feeling very good about my condition and the career responsible for it, I thought this was my last chance to write about my true feelings regarding medicine.

I have to confess that medicine was not my first priority for a career. I would have preferred biology, genetics, English or even journalism. Maybe the only reason I chose medicine was because I had the choice. Many here never get the chance and for someone to walk past it just seemed too stupid. But as soon as it started, I was hooked. I always loved learning and here it was, a never-ending pile of knowledge right under my skin.

In the past five years, medicine has taken a lot away from my life, but it has also enriched it. It changed the way I look at life, death, health, disease, and the world around me as a whole. Even looking in the mirror is not the same. Knowing that a single protein’s structural defect may have grave consequences has made me appreciate health. So now, whenever I see a healthy person, I think of the 80,000 genes and proteins that are working perfectly in his/her body.

I’ve also learned toleration and gratefulness. I’ve seen people in situations much worse than mine, and now I’m truly thankful for all I have. I no longer see vandals as spoiled kids who haven’t been brought up correctly, but I see them as people suffering from a disease brought upon them by their environment. This way it’s much easier to cope, when things are not as desired.

Today, I look at the world around me with a new insight; the insight that allows me to relate an ulcer on the face of a 30-year-old man in London, to a goat’s anthrax infection in Pakistan. Today I know that anything can cause anything else. There is no limit to our interconnection with the world around us, and when seeking the cause, you must not leave any stone unturned.

As a med student, I’ve seen persistence at its best. The persistence that has taken the human being all the way to a mosquito's gut and lymphatic system for the sake of figuring out plasmodium’s life cycle. I have learned that hard work and endurance is the only path to knowledge, and that one’s effort will not be let down if he gives it all he's got.

And last but not least, learning the beautiful and flawless engineering of the human eye, how it brings together the best of physics, electronics, mechanics, and information processing within the most perfect structure possible, has overwhelmed me with respect and praise. Respect for the masterful course of nature and the powers ruling it.

Oh medicine! I thank you for all you have given me, but please, enough with the exams. How in the world do you expect me to learn all the ambitious research of thousands of scientists throughout time for a single 4-hour exam?!?!?!?!?!?

… and so my journey towards the dreadful Comprehensive Pre-internship Exam begins.

What's a Rich Doctor To Do?

Ali Tabatabaey -- You're probably reading this blog in your cozy apartment, drinking hot chocolate or coffee while enjoying the final hours of a holiday filled with food, gifts and candy. All your life you haven't had to worry much about money, and the closest you have ever gotten to poverty is seeing a homeless alcoholic who has only himself to blame for his misery. That's the good thing about living in the western hemisphere. But over here, on this side of the world, things are a bit different.

As the technology boom "lifts more countries out of poverty" and "lessens the gap between the poor and the wealthy," there is something that the big corporate nations forgot to take account of when planning the growth of developing countries. What was once the symbol of Indian social structure has now become a pandemic among third world countries. More and more, the populations of such nations are forced into one of two categories, the filthy rich or those struggling to survive.

Why the socioeconomic political lesson in a medical blog? Well, look at it this way. You are a young, probably intelligent person who is willing to spend seven to nine years of your life along with a big chunk of money to study medicine, a career that does not hold as big an economic gain as many other fields of study. So, one can easily guess that you are from that fortunate fraction of the population. You graduate. Not to your surprise, the people coming to see a doctor who are from the same fraction as you are, prefer older and more experienced physicians. So, you have to provide services for the poor. That takes us to what should have been the beginning of the post: the rich doctor and the poor patient.

The hospital where we spend most of our rotations is located in the less fortunate part of town, close to where the Afghan refugees are settled. Every day we are faced with scenes and dialogues that, at the very least, are thought provoking. Just the other day, an old, badly dressed lady came limping into the ophthalmology clinic. She had come for a follow up visit regarding her glaucoma. So we sat her down and took her through the routine, VA, VF, Fundoscopy, and the attending physician measured her IOP. When all was done, it was announced to her: "The drugs are not working. You need an operation or you'll go blind." Now guess what her reply was. She did not ask about the operation and its risks, but instead she asked how much it was going to cost.

Normally, as a young student who (thanks to my father's hard work) has not felt the pain of poverty first-hand, I would expect everyone to take out their handkerchiefs and start creating a melodramatic scene by donating all they've got to the cause of her operation, but the truth is less kind. She was told the cost and the amount of discount she would be able to get. Yet that didn't seem to satisfy her and she decided to continue on another prescription which again, she said she was unable to acquire.

Now, I'm thinking that Iran is a relatively wealthy country and that she will probably find a charity or a government institute to support her. But what about countries further to the south? Such conditions can at times truly overshadow your abilities as a doctor, and helping all is simply impossible.

Where does that leave us rich doctors? I mean, what are we here for? Are we a talking stamp who just writes prescriptions and hands them out? In old Persia, the doctors (or Hakims as they were called) took account of everything in a patient and CURED him/her. Avicenna (he was a Persian, he just wrote his books in Arabic) used to give to the poor as he prescribed their remedy, instead of charging them. Yet today, we just follow the simple routine, Symptom, Sign, Diagnosis and Treatment. We even brag about doing this over the Internet. The truth is that the patient-doctor connection is gone. We have lost our touch.

Looking back at psychiatry, truly, what can fluoxetine do for a 23-year-old girl, who a year ago lost her greatest company and support, her father, and is sewing shirts for 2.5 cents a piece, to help the earnings of her family? The harder question is, what can we do for her? Is it just the flouxetine?

Christmas in Tehran

Ali Tabatabaey -- Hey, it’s Christmas again. Sorry I’m late to notice. It’s just that life goes on without much change here in Iran. The only clue to the event is a series of movies staring Santa Claus that keep repeating themselves every year. Oh, and no Christmas would be complete without the famous Scrooge cartoon. So, when all these beloved characters come together in prime-time TV, we know it’s time to congratulate the Christians. So merry Christmas everyone!

I end my extern rotations with one of the most feared wards in our faculty, the ophthalmology rotation. The attending physicians are least forgiving and the topic, you know, most torturing. I only attended the ward for 4 days before taking a couple days off for a much awaited trip to Tehran (which I’ll write about soon), but that short time was enough to realize this is not going to be an easy ending to the long story of externship.

Somehow I have a feeling that these 2 white ping pong balls stuck in my skull hold enough information within their small properties to make a grown man cry when trying to understand their function. The information presented in the opening days could probably compete with half of what one normally faces in some other rotations, and the fearsome looks of the professor asking about the anatomy of the optic nerve on your first day doesn't help.

So, I do not expect a sweet ending to all this, but for the current time I'm trying to enjoy my 3-day vacation before the days of horror arrive. I'll end this post right here, because my time at this Internet cafe in the crowded streets of eastern Tehran is almost up. I'll send a propoer post as soon as I get back to Mashad. Merry Christmas again to you all and a happy new year.

Happy Yalda 1384!

Ali Tabatabaey -- Today is December 21 again. That makes last night the longest night of the year; and some would say the most romantic. Although such nights should not mean much to a lonely med student like me, in the Persian culture Yalda (as the night is called here in Iran) is considered a special night for all. In this night, all the family members gather at the oldest member’s house (usually the grandfather) and feast on all kinds of fruit. The gathering gives the family a chance to relive memories, remember the ones passed away, and joke about everything in sight.

Last year I ended up spending Yalda in a 2- by 3-meter room without windows in the surgery department. I have to admit that night was one of those nights where I truly doubted my humanity, putting myself through such torture in the name of knowledge. This year I decided to join the family, a truly knowledgeable decision.

I don’t know why I’m writing this post. I guess I’ve gotten used to expressing myself this way. The only problem is I don’t know what I’m expressing right now. It’s just a feeling of joy and a boost of energy that one gets from being among loved ones.

I know we’ve all been blessed to have the chance to bring back health to people and we should sacrifice everything to do that the best possible way, but such nights are much too precious to miss. So my best wishes to you for this Christmas, and remember no matter what exams you have, what rotation you’re at, or what dreaded due date awaits you at the end of the holiday, enjoy it. Because Yalda 1384 and Christmas 2005 will only happen once in your lifetime.

A Better Nerd

Ali Tabatabaey -- As I write this, I’m just a few hours away from the psychiatry final I wrote you about and some of you wished me good luck for (thanks everyone). Normally I would be running through my notes and highlighting everything that had the slightest possibility of being turned into a question. But tonight, unlike any other exam night, my mind is preoccupied with something probably a bit more important.

It was around an hour past noon and I was sitting at the afternoon lecture, trying to pick up bits of information from the merciless bombardment of medical facts that my mind simply could not amass. No surprise! After the sleep deprivation it had gone through trying to organize all my ambitious activities, I could not blame my brain for screaming out “SYSTEM OVERLOAD” whenever I actually tried to pay attention. So, I decided to take an intellectual stroll around the university and spend the time thinking about my life and how things were getting along.

To tell you the truth, that was not the start of my rumination. It had started the night before when I read the comment from Elena to my last post. She had recently graduated from med school and finished her comment with “I miss med school already!”, so it sank in. In a couple of days, I will be starting my final rotation as an extern and hopefully in a few months, I will be an intern, making decisions, deciding for one's life, only to be corrected by more experienced physicians. The education is almost over!

I’m sure you’ve all had those moments when you suddenly feel you’ve grown up over night, the feeling of entering a new phase in your life, a new era. Well, this was one such moment for me. Looking at the buildings and the people around me it became clearer with every step that more than 5 years had passed since the first day I entered this place.

For most of my colleagues, escaping into internship is more of a relief and a symbol of the end to their agony. But for me … I miss med school even before leaving it. I know this a bit too soon to get hysterical (I mean I still have 2 years as an intern) but internship is your last chance at learning, your third strike against a 90 miles-an-hour fastball which will be gone before you even notice it.

I’m not worried about my final anymore. I know it can’t cause me any problems. Yet this is only on paper, the real thing is …! That’s the problem. I don’t know what the real thing is like.

Ever since I started thinking about this metamorphosis, I’ve been reliving my life as a student, thinking of all those hours working as a journalist, going to the movies or even sitting in the cafeteria. Shouldn’t I have spent that time on internal medicine, pediatrics, or any other one of the endless fields of medicine? Did I make good use of my days or did I just take it as it came? I’m haunted by all those moments when I, like today, was too tired to listen to the lectures. Or the nights I went out with friends instead of sitting home studying and learning that one piece of precious information that might one day save a patient's life. Although, such nights were not a frequent luxury.

I have always taken pride in my self-esteem, but medicine is such a delicate topic and the skill and knowledge needed for its mastery is so huge. At any given point in time, you know that you could have been a step ahead of where you currently are. And you only have yourself to blame.

This is not the first time I’m having such feelings and it probably won’t be the last. Some of my friends tell me I think too much. Maybe that’s the case. All I know is that I have to stand up and do my best, and that’s exactly what I will do; I just wish I had been a better nerd.

(The photo is me with a younger brother.)

Mining the Mind

Ali Tabatabaey -- As I approach my doomsday on the psychiatry rotation, I cannot hide the fact that I’m enjoying every second of it. Although the rotation has not lived up to some of my expectations (I would have preferred more maniacs with aggressive features and maybe a couple more guys trying to escape aliens), it has definitely had a great impact on my life.

You see, the good thing about psychiatry is that it adds dimension to everyday life. It gives you the power to see what goes on behind the exterior, behind the face and the conduct. It gives you the vocabulary to describe people, their behavior, and even their emotions. It is the fruit of life, the icing on the cake, the knowledge of the Lords … until you overdo it.

The trouble began yesterday morning. After a long night of crawling through the pages of Kaplan and Sadock’s, I woke to a very different world. Growing up in a friendly family of 6, sociability has become a key part of my personality, accepting people as they are and not criticizing. The same has been true for the population around me. Persia, with its unique spectrum of cultures, is best known for the hospitality of its inhabitants. Yet, that morning just didn’t feel very inviting.

It didn’t take me long to realize the change. I was sitting in the bus next to a depressed young man with obvious signs of gazing and psychomotor retardation, looking at the antisocial teen a couple of rows ahead vandalizing the seats, listening to the old paranoid man behind me talking about a government conspiracy, and thinking we will all be killed soon by the hyperactive, talkative, irritable maniac, driving the bus! Psychiatry was making its presence known.

The everyday welcoming smiles and rejective frowns of the people living around me had all turned into mental disorders. The people themselves were no longer the beloved creatures with emotions either, but instead, they were simply “patients” suffering from clear-cut disorders.

And it wasn’t limited to the people on the bus. I found myself diagnosing a friend with cyclothymia, suggesting that the university headmasters suffer from grandiosity, and insisting that my sister met the criteria for OCD. I sat in a corner of the cafeteria labeling others as narcissistic, obsessive, or paranoid, not to mention diagnosing an old friend experiencing a crush as having a brief psychotic episode with symptoms of illusion and referral hallucinations.

Suddenly, psychiatric knowledge was doing exactly the opposite of what it was supposed to do. It had turned all the magical aspects of life into sensible and earthly matter. I no longer saw people as different but rather as having different disorders. Believe me, it’s not fun seeing the world that way. Friends, total strangers, even the mirror -- everywhere I looked I saw an unnoticed psychiatric symptom.

By this time, I was getting the “I want my old life back” feeling, which did irritate me. Ironically, while I thought I was doing all the thinking, the amazed and examining (not compassionate and not worrisome) looks on the faces of my fellow externs made me realize that I’ve been doing some of this thinking out loud! I wonder what their diagnosis was, but I preferred not to ask.

I know I’m exaggerating a little, but looking at a person's feelings as signs and symptoms just seems too odd for me. To me, the human mind is too complicated to be restricted by a few criteria. There has to be much more to this. I’m not criticizing psychiatry (who am I to do such a thing?!). But when examining the mind, few choices are available. All I’m saying is that similar feelings (or signs, as we like to call them) in different people surely have different causes, so they should not be given the same value, or else we are going to have a very difficult time finding mentally healthy people.

I’m sure that there is a huge point in all this that I have overlooked. Something that will make everything fit. I just don’t know what that is. A week away from my exam, I have to admit there is a very slim line between mental health and illness, a line whose recognition requires a lot more than 4 weeks of training.

A Culture of War

A few days ago, a 45-year-old relatively handsome but badly dressed and dirty patient came to the clinic with a peculiar accent, complaining of a burning headache. In just a few moments, he would change the way I looked at the world around me.

The Middle East is a tricky part of the world, and so is the Persian Gulf. Iran, having the privilege of being both a Middle-East country and owning the entire northern coast of the Persian Gulf, has been through a lot in the past few decades. Unlike what you might think, though, Iran has always been looked at as a safe haven in the region. That's why, after 30 years of war in Afghanistan and the first Persian Gulf War, Iran found itself sheltering 3 million refugees! That's right -- more than any other county in the world. Mashhad, where I live and study, is the major urban area in northeastern Iran and so is home to many of the Afghan refugees.

Enough of the history books for now. Let's get to the point. If you have been through your psychiatry rotation, you probably know that a great thing about it is that you can poke your nose into everyone's most personal business and get away with it. And, interesting things do turn up. Which brings us back to the 45-year-old patient. You might wonder what a headache patient is doing at a psychiatry clinic, but that's the cool (funny) thing about Iranian healthcare: patients get to pick the specialists themselves. Someone might even go to a psychiatrist for GI problems while seeing an internist for inability to sleep!

The initial examination looked like a routine tension headache, one of the most typical I had ever seen. He had a pressure sensation spreading through the forehead from one temporal region to the other. It got worse with noise and environmental stress and did not have any recognizable pattern. However, the good thing about psychiatry is that, unlike neurology, you get to go deeper than that. So, the personal questions where unleashed.

He was an Afghan refugee living in Iran as a construction worker. He had 10 children and 2 wives. When asked about it, he showed obvious signs of depressed mood and tinnitus; but, the most interesting part was his nightmares (or "dreams," as he insisted). In them, he finds himself in the middle of a battle resisting a siege and trying to organize the defense. You guessed it! This guy has been a member of the Mujahideen for the past 30 years. He has fought the Russians and the Taliban, and has been a captive under both regimes. He insists that the dreams don’t disturb him but is always awakened either by palpitations or by his wife complaining of him shouting in his sleep.

By this time, the physician was thinking of PTSD, so the personal questions continued (boy, this is fun). Obviously, the inquisitive minds of a group of young med students could not let him leave without asking about his experience as a captive. To no one's surprise, he had been tortured many times. He talked about being beaten unconscious while being interrogated by a Taliban officer and also of the Russians tying him to metal rods connected to an electrical generator (I had only seen such a thing in "Rambo," but this guy was sitting a few meters away and describing the feeling). This was no fun anymore, but the real surprise was yet to come.

I asked him about the war and the current state of his country. "I miss the war," he replied. OK. Let me get this straight. This guy's been wired up to low-voltage electricity by the Russians, been beaten unconscious by the Taliban, has spent 2/3 of his life running around valleys and mountains trying to resist the enemy, and HE MISSES THE WAR!

I can tell you he wasn't joking. He was insulted when we called his dreams "nightmares." He talked so passionately about the feel of a gun in one's hand and its smell that some of my fellow externs were tempted to try it out (thank God that's illegal here). He kept saying, "If someone came to me right now and asked me to go off to war, I would do so without hesitation."

There you have it. That's the problem with war. After a while, it becomes a culture. He is right. When all you've done since the age of 15 is shoot your enemies dead, changing your lifestyle can be difficult. War is one of those cureless diseases, which can only be prevented. Let's just hope his 10 kids don't grow up with the same culture.

The Psych Ward

Phew! Another exam passed safely and rather successfully. Sorry about the burst of emotions in my first entry, but for me a great way to cope with the Pre-Exam Syndrome, as I like to call it, is to joke about it. But don’t worry, I promise to stay on the sensible side of things from now on… or at least I’ll try!

My new rotation is one I’ve been looking forward to for quite some time. At last, after roaming the wards for the past 19 months, I think I’ve found a place I can relate to. (Maybe I shouldn’t have said that.) You guessed it: Welcome to the wonderful world of psychiatry. I have to admit, along with internal medicine, I have always been keen on psychiatry; but things here tend to be “different.”

This morning, as I walked up the stairs to the psychiatry ward, I was a little nervous about what awaited me on the other side of the locked doors. We had been talked through the basics of sychiatric history taking and mental examinations, and we were supposed to try out these skills before the staff doctor arrived later in the day. I stood in front of the little locked door, took a deep breath, and reached for the intercom. I kept repeating the lines I was supposed to say to access the restricted area (or so I thought):

“I’m one of the new externs, Ali Tabatabaey, number 4 on your list.”

To my surprise, no one answered the intercom. As I was trying to find the flaw and maybe try again, the door in front of me unlocked.

“Who are you?” the short chubby woman in yellow asked me. I guess she was one of the personnel working there.

“I’m one of the new externs …”

“Come in,” she interrupted me. And I did. The door was quickly locked behind me. I looked around at the relatively unfurnished ward, plastic chairs and a plastic table at the end of the hall, the barred windows and the locked door behind me. The message was clear: This is no place to kid around (my usual attitude). By the time I was finished looking around, the lady had gone her way and I was left there standing alone. Talk about a warm welcome!

A couple of patients walked quietly, and there was nothing dangerous happening. I thought to myself, “Hey! This can’t be that bad.” Still, my serum adrenaline levels were steadily rising. I went over to the nursing station to see which patient I was in charge of:

“Number 4, Mrs. B. but she is out for an X-Ray.”

So, I decided to walk around and calm down a bit before I meet her. During my warm-up lap around the ward, I noticed a couple of my colleagues talking to a patient, and I couldn’t help over hearing:

“So, you’re sure you heard the sound while you were awake?”

“Yes.”

“You weren’t asleep or dreaming.”

“No. I’m quite sure he talked to me.”

“All he asked you to do was to strike your husband on the head with a brick? Or did he say anything else, too?”

Ok! Now I am nervous! What if the voice in Mrs. B’s head tells her to hit me with a brick? All of the sudden, those locks and bars were starting to make sense. But there was no escape.

Minutes later, my patient arrived from radiology. She was a tall, big boned woman, who seemed very nice and gentle (thank God). Although I was a bit nervous, my ambition to explore her mind was greater.

She was a 41-year-old housewife, married but without children. She kept complaining about a pain in her left leg and she refused to sit still. I asked about her presenting illness. Nothing interesting turned up. Her past medical history was clear, too, except for a depressive episode a couple of years back; no addiction; and insignificant family history. She had abnormal sleeping patterns and complained of bad dreams.

Her appearance was normal except for the anxiety, which she insisted was due to pain in her leg. She kept smiling and denied any criteria for abnormal mood. Thought, perception, and sensorium all seemed normal, and the only unusual things she talked about were either dreams or nightmares, except for one time when a stranger she mistook for her uncle came up to her on the street and asked her whether he was dead or not. Even I would feel stressed if that happened to me. I ended the examination thinking that she should have gone to a neurologist instead of a psychiatrist.

On his arrival, the staff doctor chose Mrs. B as the patient of the day, and I prepared to show off what I knew about her.

However, things did not turn out quite as I had expected.

By the time the staff doctor was done asking his questions (10 minutes at most), it was clear that the X-Ray and physical examination showed no sign of any physical involvement. Mrs. B’s uncle had died a few years ago, and remember the man she saw on the street? It turns out he did not have any legs and was floating in the air. Yet, she insisted he was real.

I was lost for words. I had spent the last hour talking to her and had missed the main points altogether. I was so obsessed with her leg pain that I left everything else unnoticed. I was beginning to feel depressed myself. I have to admit, examining the mind is a very complicated challenge. But look on the bright side, at least I wasn’t struck by a brick! I’m sure next time I’m going to do a much better job...or at least I’ll try!

Notes from Iran

Ali Tabatabaey -- It’s Friday night and the 26th day of the month in the Persian calendar. That means in 4 days I will have to answer the incomprehensible questions that an infectious disease specialist expects me to answer. Questions that I’m willing to bet, he himself couldn’t answer when he was an extern.

Unlike most salary-paid workers who count the seconds until pay time at the end of the month, the monthly courses in med school have taught me to hate the home stretch in every single month of the year.

It’s horrible! These days, I somehow feel like Pavlov’s dog. The same way that poor conditioned canine used to secret saliva at the sound of his keeper’s steps, my stomach starts pumping acid a week away from the exam date. The heartburn is killing me. Not to mention the … you know what I’m talking about! I’m sure in days like these, you guys prefer to take your books to the rest room, too, knowing that you won’t be out of there soon.

No matter how many times I go through this, it’s the same story every time. I like to look at it as my little doomsday. I know it’ll come and I know there is no escape. I anticipate it from the first day of the course, but don’t take it seriously until it’s too late. I fool around like the grasshopper while all the nerdy ants study for their doomsday.

And now it’s winter again. And I, the grasshopper, am feeling like Pavlov’s dog again. And the heartburn is killing me! Oh mighty God! I beg you once more: If I survive this one, I promise to study from the starting day of my next course…or at least I’ll try.