jenniferhawke.com

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“But be, as you have been, my happiness… “
~ Randall Jarrell

dearest Nevis,

unfortunately, it’s actually only 2.5 months until i head back to North America and leave you behind indefinitely. although, if my flight with Liat* doesn’t get sorted out, i may be here longer than i think.

the days are full and flying by faster than i can keep track. i know some friends and family back home have been along vicariously for the ride and have a hard time believing it’s already been 17 months! this time last year, i was struggling with microbiology and genetics and epidemiology. this time next year, i will be struggling with residents and fellow interns and unique ways to stay awake during long shifts. 2009 promises to hold a lot of adventures and surprises.

i am still happy and cozy in our little house with our little car. coming home after Christmas holidays, we sort of dreaded finding a lake in our kitchen again, but everything was clean and dry. and smelled like mold. flip flops and venetian blinds and small corners of shirts and leather wallets and my Merck Manual all had a fine layer of green fuzz. the shoes went straight into the pool. everything else was dusted off and recovered nicely. not so sure about our lungs.

still, it’s a neat little place to live and i know i will always look back fondly on my time in the cool, shaded basement suite with the brightly lapping private pool and uninterrupted view of St. Kitts. the owner and staff of the Mount Nevis Hotel & Estates do a friendly job of taking care of us and i don’t doubt our parents will be in good hands when they stay at the hotel in April.

the rest of the month has been a bit of a blur. big surprise. MED 5 started, along with the privilege of walking around campus knowing you’re finally at the top of the tower. the top! nothing left to do except finish up and go home! a few of us are nervous about the comprehensive final. a few of us are not. i remember when i arrived in MED 1 and would see rather dejected or forlorn or downright frustrated and angry MED 5s walking around. i used to wonder what on earth could possibly happen in 16 short months to make them look that way?? this is Nevis! it is SO gorgeous and warm and beautiful here! how could anything be as bad as the look on their faces and slump in their shoulders?

now i understand.

little things happen. they happen all around the world. but for some reason, being on this tiny island makes it easier for them to pile up. in fact, they almost seem to multiply like rabbits (or cats by the MUA library) in self-perpetuating litters. the circles are never-ending. something as simple as someone cutting in front of you in the cafeteria line can sour your entire day. and it’s nearly impossible — in our self-centered world of studying — to comprehend the fact that maybe someone cut in front of that person yesterday.

it’s not any one thing that makes the MED 5s grumpy and annoyed and just DONE with Nevis already. it’s a zillion little things that we don’t know how to let go or get over.

we’re ready to go home. to the home where we know things will happen they way they are expected. credit card machines will work properly at the grocery store when you have an overflowing cart and zero cash. electricity bills will be a standard and somewhat expected amount each month and won’t fluctuate dramatically with meter reading errors or extra “surcharges”. bank machines will give you money instead of making that whirring sound like it’s delivering pretend invisible bills. roads will be wide enough to easily fit two vehicles and have lines down the middle and cars will stay on their side. garbage will stay in its’ container until the garbageman comes to get it. grocery stores will be stocked with Kraft Dinner and diet soda and salad dressing that have months or even years before they expire. conversations with dear and beloved and even distant friends will happen over coffee or lunch instead of email or iChat.

yep. i’m ready to go home.

and yep. i’ll miss you like crazy when i’m gone. trying to enjoy every last day while i can.

all my love,
`Jennifer

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*coming back after the holidays, Liat delayed us in Antigua and re-routed us through St. Kitts too late to take a ferry over to Nevis. so we were stuck on St. Kitts (hotel, taxi, ferry) at our own expense when the airline flatly refused to accommodate the 20 people they rather dramatically inconvenienced because some missed essential flight connections. oh, and our luggage didn’t show up for another few days.

this time around, i am flying home with my parents and unfortunately, the first leg of our flight is Nevis > Angtigua with Liat. last week i received an email that pushed our flight back nearly 6 hours. which means we would miss our connection into Toronto. when i called to inquire, i was told that the best they could do is put us on the same flight a day earlier and that there would be no compensation for accommodation. any refund would be in the form of a voucher (for an airline that only travels in the Caribbean and that i hope to never ever have to fly again).

i am currently waiting to hear back from “a supervisor” at Travelocity (i booked my parents’ tickets through them) to see if they came up with a solution.

inside:

i’m not sure how many of you have been following along with my calendar online (either out of morbid curiosity or in search of empathetic entertainment), but it’s directly linked* to my iCal, so is updated often and accurately.

in short, i’m studying so much, i spend the entire day craving sugar and the entire night entertaining vividly colourful dreams.

morning: i get up to go to the gym at 6am and spend maybe an hour on email and internet while eating breakfast and making Brandon makes coffee.

during the day: i’m in classes pretty much all day from 9am to 4pm. with an hour here or there for more textbook reading and flashcard compilation.

evening: maybe another hour of email and/or internet (like now) while Brandon makes dinner (like now). i do the dishes and then am back to the books by 530 or 6pm at the latest. my goal has been to spend 4 hours each night revising** for the comprehensive final exam

bedtime: i have been trying to stay up (and stay productive) until 11pm. but i’m usually in bed by 1030-ish and soundly asleep by 1035-ish.

this week i’m working hard to earn a few hours off for Super Bowl Sunday. the rest of the month i will be working my butt off so i can take some time off with Brigette in the last week of February. i’m really trying to treat these next few months as the marathon that it is, with well-earned water breaks along the way. i don’t plan to burn myself out with ridiculous 18 hour days once our classes are finished after Block 3 or anything, but most days i only plod along via the momentum of routine. without a schedule, i would be adrift in a sea of random facts without an inch of shoreline in sight.

outside:

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*thanks to Google calendar and Spanning Sync.

**via Kaplan or First Aid or both.

alright. like 25 things wasn’t boring enough? i’ve also been tagged! by Kev! so here is my list because i like him and he brought me a TON of goodies when he visited in August. and did i mention i like him?

The Rules
- Link to your original tagger(s) and list these rules in your post. (see above)
- Share seven facts about yourself in the post. (see below)
- Tag seven people at the end of your post. (see below)
- Let them know they’ve been tagged.

The Things
because i don’t complain much and have even been accused of being overly optimistic and making things here on Nevis sound better than they actually are, here are 7 things i do NOT like about MUA:

1. mandatory attendance policy
i understand the reason (we are a Caribbean school keeping up certification standards so we don’t look like a diploma mill), but still. seriously??

2. library
it’s small and cramped and noisy. pretty much the opposite of what i need to cram zillions of facts into my head.

3. parking lot
okay, it’s the road to the lot that’s bad. and i am only saying this because i thought i left flat tires behind when i stopped riding my bike. no such luck.

4. talk about the New Building
it really doesn’t exist to me. it’s like a mirage on the horizon that wavers and disappears the closer you get to it. who cares if it has looked finished for the last 2 years. it’s not.

5. desks
ugh. i’m getting old and i have had too many years in a computer chair.

6. the cafeteria
okay, i have to qualify this one too. i actually like the ladies in the cafeteria very much. but i would really *LOVE* the option to snack on something other than peanut M&Ms or Oreos or Quaker Chocolate Chip granola bars. and there is no way you’re getting me to pay $15EC for a plate of rice and beans. heck no.

7. lack of internet access in the classroom
again, i understand the reason (MUA is just looking out for our academic well-being and doesn’t want me to distract everyone sitting behind me with a video of Obama and Hillary’s heads pasted on the Orange Mocha Frappuccino Jeep scene out of “Zoolander”), but still. seriously??

The Tags
Jen
Shan
Mayhem
Gwen
Pat
Gillian
Heather

“Ultimately, the only power to which man should aspire is that which he exercises over himself.”
~ Elie Wiesel

whew. it’s tough to stay motivated and force yourself to study when you’re daydreaming about life on the hospital wards and would rather be just about anywhere other than a cramped MUA desk. this is the discipline of med school, i guess. it’s training me to be a better person and awesome doctor someday, right?

*ahem* right??

there are only 3 blocks this semester. the last few weeks from March 9th through April 13th are spent on NBME subject examinations in Pathology and Clinical Medicine, a Clinical Skills Assessment practical exam and — drumroll, please — the comprehensive final.

pathology
- adult respiratory distress syndrome
- chronic obstructive pulmonary disease
- interstitial lung disease
- pneumonia
- pulmonary embolism
- pulmonary hypertension
- lung cancer
- valvular heart disease
- infective endocarditis
- cardiomyopathy
- congenital heart diseases
- ischemic heart disease
- tumors of the heart
- glomerular diseases
- tubular and interstitial diseases
- tumors of the kidney

>> most interesting thing learned: if you were to have a heart attack and (heaven forbid) die within 12 hours, your heart wouldn’t look any different to the naked eye. changes noted via microscopy include wavy fibers (30 minutes to 4 hours), coagulation necrosis (4-12 hours) and contraction band necrosis (12-24 hours).

also, the kidney is complicated and important. but we already knew that. i think it’s nice that Minimal Change disease is so common in kids because it sure is hard to diagnose something that, um, shows minimal pathological changes. it’s an easy guess when you’re stumped.

intro to clinical medicine
- chest pain
- heart sounds and murmurs
- cough
- hemoptysis
- dyspnea
- edema
- acid base disorder
- dysuria
- hematuria
- hypertension

>> most interesting thing learned: people are born with aneurysms. we all know that. Dean T told us this morning that as many as 2 people out of our class of 70 probably have some sort of congenital dilation of one of their arteries somewhere in their brain or body. it’s when those aneurysms rupture that you have a problem. you get blood in the brain or somewhere it’s not supposed to be and then all sorts of bad things happen. the large artery that branches off the top of your heart and travels down your abdominal cavity is called the aorta. some unfortunate folks are born with aortic aneurysms. and they can most certainly tear causing very bad things to happen.

anyway, on to the interesting thing. in learning how to manage dissecting aortic aneurysms, it is common to actually do next to nothing about a descending abdominal aortic dissection. if it’s not too bad, all you have to do is manage the blood pressure and it will heal on its’ own. but if the dissection is further up (preductal or ascending), you won’t live long without surgery.

and that’s it!

that’s right! we only have two classes this semester. what on earth could i possibly have to complain about??

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looking for MED 1? or MED 2? or MED 3? or MED 4?

photo: proof there are road signs on Nevis. forget the fact that this one is hidden away at a crossroad that no cars can drive down.

just trying to get through MED 5 alive.

happy block weekend! see you Tuesday!

as my contact with patients and doctors on the wards increases and the funny or cute or disturbing or enlightening stories continue to pile up in my head, i have been wrestling with the question of how to share it all with you. i don’t want to get in trouble and i certainly don’t want to get anyone else in trouble… but there must be a (legal and ethical) way to share the day-to-day experiences of my life and my work.

so, i spent a bit of time stumbling around the internet and found a few guidelines from Clinical Cases & Images:

- Do not blog anonymously. List your name and contact information.

- If your blog is work (or school)-related, it is probably better to let your employer (or dean) know.

- Do not start blogging right away after you join a company. Check the corporate culture. See if blogging will fit in the current work environment.

- Enquire if there are any blogging guidelines. If there are, comply with them strictly. If there are no guidelines, try to establish them.

- Let your boss know that you are planning to blog about your job. Ask him/her to check you blog to make sure that it is OK.

- Write as if your boss and your patients are reading your blog every day.

- Use a disclaimer, e.g. ” All opinions expressed here are those of their authors and not of their employer. Information provided here is for medical education only. It is not intended as and does not substitute for medical advice.”

- Get your blog accredited by the Heath on the Net Foundation

- Comply with HIPAA

If it is done right, blogging can be a positive thing for a company. It gives a human face to the corporation. Scoble is a perfect example of a how a blogger can improve the public image of a company like Microsoft, which has not been getting much of a good press for a long time.

Most of the 100 or so doctors who blog use pseudonyms like “Red State Moron” or “GruntDoc”. Unfortunately, you cannot stay anonymous. If somebody tries really hard, they will discover your identity. The best solution is not to post anything that can embarrass you, or your patients. If you are blogging about your patients, make sure that you comply with the HIPAA rules.

To stay out of trouble, always ask yourself: What if my patients are reading this? What if my colleagues are reading it?

Be honest and respectful to others. And once again, remember the HIPAA rules.

notice how many times HIPAA was mentioned? forget about job security. it’s easy to tell the most important guideline for writing online about patient interactions is privacy.

i think i have everything in that list covered pretty well. in hindsight, i should have approached MUA’s Dean personally to let him know about the site instead of how i assume he found it: Googling “Medical University of the Americas” and noticing my name on the first page of results. oh well.

my next struggle will be deciding what to do with this site once i finish clinical rotations and am cleaning myself up to look sparkly and shiny for residency applications. do i keep blogging as an MD with multiple disclaimers and non-disclosures? or do i leave my academic journey behind like Graham Azon did?

what are your thoughts? i’ll probably do what i want regardless of what you say (ha!) just because i’m plain bored of sitting on the edge of the pool.

from Medical Humanities:

As a profession, physicians are a remarkable group of writers. What doctors lack in good penmanship is more than compensated for by their skill in penning stories and poems. Their literary accomplishments are even more impressive given a lack of formal training in the art of writing. Only a few physician-authors have MFA degrees. Most medical students do not major in English or literature while in college. Doctors become talented writers the old-fashioned way. They practice. They also teach themselves via voracious reading with attention to style and technique. They occasionally attend writing workshops.

With hectic, unpredictable, and stressful jobs, why do doctors want to write? Given the demands and responsibilities associated with a career in medicine, why do so many physicians make time to write? The short answer is that doctors write for many of the same reasons that non-physicians do: They feel compelled to write. They have something to say. They love words and language. They are excited by the process and gratified by the result. They are inspired.

Here are seven special reasons (ranked from most important to least important) why doctors write:

1. Therapy - Physician heal thyself. Nothing promotes healing like writing a poem or short story or even a single glorious sentence. Writing helps a doctor get things off their chest in a much more productive way than yelling at a nurse, ranting at a patient, or being grouchy at home. Poems and stories written as a form of therapy are easy to spot. They have a confessional quality.

2. Exploration – Doctoring is hard. Creative writing is an opportunity for physicians to make sense of what they do. Stories written for the purpose of searching sometimes have themes that focus on medical ethics and boundary issues.

3. Sharing – Doctors can pass along knowledge and experience by writing in clever and vivid ways. Humor and compassion provoke memorable moments in literature. A perfect example is The House of God by Samuel Shem.

4. Joy – Writing is fun. Okay, maybe not always – rewrites, editing, and the evil “writers’ block.” At some level (the spark that begins the project or reading the finished manuscript), there is euphoria. Would you settle for glee?

5. Honor – Writing allows physicians an opportunity to memorialize patients and colleagues. These literary works feature a fictionalized version of a character or an amalgamation of a few people. Creative writing can immortalize someone. P.S.: Doctor-narrators also reap literary longevity.

6. Atonement - Doctors make mistakes. They sometimes behave badly. They have regrets. Stories and poems can be part of their penance. Think “Brute” by Richard Selzer.

7. Notoriety – Let’s not lie to ourselves. Who among us would not want to be a rich and famous author? I don’t know any doctors who would turn down a Pulitzer Prize, National Book Award, or an appearance on The Oprah Winfrey Show. Good luck with that.

coming up tomorrow, thoughts on wrestling with how much to write and about who and when and where and why.

this post is for Brandon’s dad. he thinks Brandon wrote an essay about my family over the holidays and that i am holding my tongue online because they secretly scared the crap out of me and i don’t want to be rude in front of all of you.

untrue. i would totally be rude in front of all of you.

actually, i liked his family very much from the start. and if we ever decide to get married and have little BCWBs or curly-haired jhawkes running around, they would make the best grandparents i can imagine.

i mean, my parents will be awesome too. every corner in my dad’s house and garden holds an undiscovered mystery and my mom’s obsessions with bubble blowing and kite flying keep her young. but a little BCWB would break his neck at my dad’s house because the vacuum is almost always lying in the middle of the hallway. and a mini jhawke would probably be scared to tears if she tried to play outside with my mom’s dog that likes to bark until you think she really will attack you and share your innards with the prairie crows.

oh great. this is why i don’t write about family. 2 minutes in and i’m talking about grandchildren. stop me now.

to make a short story long, Brandon’s parents spoiled us to tears with presents and gave me the warmest Nebraksan welcome in the coldest winter that i could have imagined or hoped for. they were really lovely. Brandon didn’t serenade me with dire warnings during the weeks leading up to the trip and i now know it’s because there was no need. his family is just as sane as my family and my family is just as insane as his family.

i can’t wait to go back because his dad promises the guns will be cleaned and ready. i suspect he’ll take particular delight in teaching a Canadian how to shoot.

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photo: Brandon’s mom and i agree, you can never have too many Christmas decorations.

i’m horrible at tag. i’m not fast or agile and i always end up as IT fruitlessly chasing bright t-shirts over and around the jungle gym that manage to *just* evade my outstretched fingertips. come on now. how uncivilized. let’s sit down and play Scrabble instead.

so that’s my excuse. if you’ve ever tagged me for something blog-related in the past, i probably didn’t notice or didn’t play along. sorry.

if Brigette wasn’t going to be knocking on my door in a little over a month, i might have shamelessly ignored the tagging i just noticed today. as it is, i’m counting on her to bring me some more red licorice, so i guess i should play nice. the rules say “you are supposed to write a note with 25 random things, facts, habits, or goals about you”, but since i do that every day and since i’m supposed to be studying for pathology right now, you get 25 things from an online question bank. here goes…

Rules: Once you’ve been tagged, you are supposed to write a note with 25 random things, facts, habits, or goals about you. At the end, choose 25 people to be tagged.

1. Atherosclerotic aortic aneurysms are typically located in the abdominal portion below the renal arteries.
2. Patients with systemic lupus erythematosus can develop Libman-Sacks endocarditis, but the vegetations are never large and they rarely embolize, so the endocarditis is not clinically significant in most cases.
3. Tetralogy of Fallot producces a right-to left shunt with cyanosis from mixing of right heart blood with left heart blood.
4. Troponin I can be elevated within a few hours of a myocardial infarction, similar to the CK-MB.
5. Malignant hypertension is often preceded by chronic hypertension that leads to left ventricular hypertrophy.
6. A bioprosthesis heart valve has the advantage of not requiring anticoagulation, but it does not wear well with time, and typically must be replaced within 5 to 10 years when its leaflets undergo progressive calcification leading to stenosis.
7. Kev tagged me with a “7 things” meme that i forgot about until just now.
8. The most common cause for a primary myocarditis is a virus (such as Coxsackie virus).
9. Staphylococcus aureus and Pseudomonas aeruginosa are the most likely organisms to be found in infective endocarditits with a history of injection drug use.
10. Uncorrected ventricular septal defects eventually lead to pulmonary hypertension and reversal of the shunt (Eisenmenger complex).
11. The most common valves involved in rheumatic fever are mitral and aortic.
12. A tear in the aortic intima is followed by dissection of blood outward, often to the thoracic cavity, with fatal hemothorax.
13. The most common cardiac defect is a VSD.
14. Although bicuspid aortic valves are present from birth, they do not manifest with significant calcification and stenosis until later adult life.
15. Pancreatic cancers can be associated with a hypercoagulable state (Trousseau’s syndrome) with formation of marantic cardiac valvular vegetations.
16. Atrial myxomas are more often on the left. Though benign, they can occlude the mitral valve and produce sudden loss of cardiac output.
17. A ‘paradoxical embolus’ from a deep vein thrombosis can enter the brain if there is a defect that allows passage from right-to left. This can happen across a patent foramen ovale.
18. Contraction band necrosis has been associated with sudden death and cocaine use. It is thought that it may be mediated by high norepinephrine levels.
19. A primary reason for putting a patient with an acute myocardial infarction in hospital is to prevent arrhythmias.
20. 75% arterial narrowing is the point at which coronary occlusion becomes very serious.
21. In temporal arteritis the elevation of the sed rate is way out of proportion to the extent and amount of inflammation in this one arterial segment.
22. Myofiber disarray is the key feature of hypertrophic cardiomyopathy, an uncommon condition.
23. Mitral valve prolapse can be associated with Marfan’s syndrome.
24. Contraction band necrosis is an initial change as the myocardial fibers begin to die.
25. The cardiomyopathy of chronic alcohol abuse has a dilated or congestive appearance.

i only included snippets from answers i got right. and yes, we’re studying cardiopathology (along with pulmonary and renal) this block. if anyone read that entire list from top to bottom, i will fall off my chair in amazement.

now do you see how exciting my life is? so glamorous. i can’t deny it.

you’re it: Tracy, Beach Bum, Andrea, BCWB, Gio, Wyn, Lauren, Kendra, Kev, Pat, Maggie, Faye, Chad, MzMullerz, Dan, ApK, Kristin, Robyn, Janelle, Tim, White Girl, shisnit, Darlene, Darren, Dr. K, JennW, Michelle, and Mike. whoops. that’s 28.

my parents and Evil Wicked Stepmother arrive* on Nevis at 250PM on April 8th. i have been thinking of the “must see” and “must do” places for while they are here. at the top of the list for my dad is a place called Rodney’s.

Rodney is a large woman in short pants with a rather exhaustive way of telling you the items on today’s menu. her sign out front advertises “STRICKLY LOCAL FOOD & DRINK” and i can hardly wait. i know my dad will order the goat water for sure.

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*but before that! Brigette arrives on February 21st and we will definitely not be drinking goat water.