Our home

Just wanted to show you our home, now that its all furnished. Nicole's mom and dad gave us a lot of our furniture, and my mom and dad gave us a projector for our home theater! Come visit us anytime!

What have I been up to lately...

This past month has been an easier month. This is my "consult" month - where I get to work regular hours M-F, no overnight call, no weekends. I have been on the GI consult service, which is a specialty that I'm interested in. Its been good - we see people with GI bleeds, trouble swallowing, abdominal pain, diarrhea, liver and pancreas problems, and more. They have cool "toys" to play with, mainly the "scopes": colonoscopy and upper endoscopy. At first glance, yes, its sounds gross sticking a plastic hose up someone's ass - who would want to do that? But its kinda cool, like a video game. In one hand you have the controls, which feels like a complex airplane joystick. Your other hand is, well, sticking the plastic hose up someone's ass. There's not much poop, since the patient is supposed to take a strong laxative to clean out their colon before the procedure. And while you're in, you can look for any problems, use tools to remove polyps or get biopsies, and even in the stomach use things like lasers and rubber bands to stop bleeding. You can even get near the liver and pancreas and use ultrasound, or even xrays while you're in to remove gallstones or get biopsies.

I've also had a 2 week vacation this month, which quickly came and went. I had a fantastic time, going back to Atlanta to see some old friends and visit the old school. Got to hang with Ben at a Falcons game and played some tennis with him, and met up for dinner and drinks with my good med school friends Shveta, Dinesh, Dorothy, Mariano, Pei and Alice. Got to see Nicole's aunt Carey and her kids Warner and Kate and their cute golden retrievers, though it was sad to hang out there without Steve (Nicole's uncle who recently passed away).

Then I came back to North Carolina, where my parents visited Nicole and I for a long weekend. We went for some good dim-sum, showed them around the city and where I work, and they even outfitted our 'home theatre' with a new projector!

And then I went to Long Island with Nicole, to hang out with her mom and Francis out in their summer home. It is in Orient, the far eastern (not the "far east") part of Long Island, where its covered by miles of vineyards and fresh farmstands. The house, which is old and rustic with an outdoor shower, has a view of the bay, which is gorgeous. We ate and drank and just lounged around.

Nicole has worked the last 2 months up here in North Carolina, doing some elective rotations as part of her PA schooling. And she just finished a week of vacation as well, and is now back in Atlanta to finish up school. She graduates December 9, and will officially be a Physician Assistant by then, and my sugar momma. I'm sad she's not here... =(

Other cool updates --
- Jenny just found out she is pregnant! Jenny and Jeff, along with Tyler who's almost 3 is expecting their second!
- Amy just started at University of Florida and is loving it!
- I heard Bryan is trying out for American Idol. He's got the look, cuz he looks a lot like Clay Aiken



Alex and Sarah, our neighboring twins. Alex is an ER resident at UNC, and Sarah is a PhD grad from UF. We live in the same neighborhood, and yes, girls dig the Asians guys.

Nate and Amy with Nicole (note long stick for marshmallow). Amy is one of Nic's good friends from PA school, and Nate is Amy's soon-to-be-fiance.

Tyler (aka Wiggy!) So cute

Bachelor party 2006, starting off easy...

Me in the glider!

Nicole along the bay in Long Island.

Ben and Jen! Ben is fomer Braves' lawn boy, Atlanta Hawks administrator, sports agent, now successful real estate agent. Jen is a 6th grade teacher!

Musings

Hierarchy is a funny thing, and it exists everywhere. I am in Long Island, finishing up a 2 week vacation (which has recharged my batteries for more doctoring), and have had the fortunate opportunity to do some fun things this vacation, including going down to Atlanta to see some old classmates, having my parents come to North Carolina to visit Nicole and I, and heading out to the Eastern point of Long Island, where it is calm and quiet, surrounded by vineyards and farm stands.

Anyways, we visited Hobie, Nicole's mom's uncle. He is an avid flyer - he flies airplanes and gliders, and has been flying since the 1930's. He is one of the long-standing members of the Long Island Soaring Association, a group that flies mainly gliders. A "tow plane" pulls the glider a long, taking it up to around 3000 feet or more, and then releases it and the glider is free to fly and maneuver until it lands, usually in about 15 minutes at 3000 feet.

Hobie is very well respected, and you can see it in the way people greet him, ask him how his family is, how they say good morning. And Hobie doesn't ask for this, it just is. He's a sweet man, humble, assuming. But he has been around and seen it all.

Almost anyone can join the club. They pay a initiation fee, and they pay a small amount ($30 or so) for each flight, and the lessons are free. That's it!

But there is this unspoken hierarchy that everyone silently follows. I met some of the new members, younger guys. They seem to "know their place" - they do more of the labor of picking things up, they drive the older guys out to the airfield where the gliders are, they speak and act with reverance when around the senior guys. They step aside when the older guys walk by. Its a silent ritual of respect that they pay, and they do it in exchange for their tutelage, their education as new pilots.

We do a very similar ritual in medicine, and have a very similar hierarchy. The experienced, senior, wise physicians (chairmen, department chiefs, professors) are highly respected. Then beneath them are junior faculty and attendings, who have finished their training and we all respect, but they then step aside and defer to these elder, wiser attendings. And then there are fellows, who have finished residency but are training to specialize. Then their are residents, and then interns, then medical students.

As an intern, my job is to get things done. In exchange, I actively observe my residents' and attendings' decision-making process, and get to see the outcomes of these decisions. And the idea is that I learn enough that I will be making these decisions within a year. Just like a new pilot getting ready to fly on his own.

it's only been a month and a half...

since I last wrote. Damn, sorry about that guys. I did get swallowed into the "abyss", but I just started my vacation for 2 weeks! Which I badly needed...

So there was this patient of mine, a middle aged female, we'll call her Ms. M. She had liver disease, caused by hepatitis and by years of alcohol use. When you get "end stage liver disease", your liver scars up and shrivels up, and doesn't do its job of filtering all the blood coming from the digestive system. In fact, because its so scarred, blood may not even flow through it anymore. Instead, it may back up and pool up in the veins of the digestive system. These veins can get engorged and dilated, and can burst open and bleed, classically in the esophagus and stomach. The bleeds can be life threatening, so when someone has had a bleed like this, we treat her, and then try to prevent any future bleeding.

One of the ways we prevent future bleeds is through a procedure called TIPS (trans-jugular intrahepatic shunt). In other words, we decompress all that blood that is backed up behind the liver. We do this by creating a tunnel through the liver, so that the blood can go through the liver and back out to the heart. Its a temporary fix, until the patient can get a liver transplant. As you can imagine, the procedure is not without risks. The liver is a blood filter, so it sees a lot of blood. If you go poking around in the liver, it can bleed.

Well, Ms. M has cirrhosis of the liver, and was scheduled to get a TIPS procedure. I was her doctor. I usually schedule 1 am "bloodwork" for my patients, so that when I arrive to the hospital, her bloodwork is done and I can proceed with whatever needs to be done that day. Well at the time I was ordering bloodwork for the next day, I was finishing up an overnight shift, and was on my 30th hour, and forgot to order bloodwork on her for the next morning. She was going for her TIPS that day.

Ms M. got her TIPS that afternoon. She was returned to her room. The next morning I arrive, and find that she is in a lot of pain, right where her liver is located. She doesn't look good. Her blood pressure is okay, but her heart rate is a little high. I'm worried about her bleeding, but because her blood pressure is okay I planned on waiting until our morning rounds to tell my resident. I don't have any bloodwork, so I can't tell how much blood is in her.

30 minutes later, I hear "code blue, 3 West" over the hospital intercom, and 3 West is where Ms. M's room is. My stomach sinks, and our team runs down there, and sure enough, Ms. M has gone into cardiac arrest. We spend an hour doing CPR, giving her electric shocks and drugs to jumpstart her heart, but it doesn't look good. We end up getting a heart beat on maximal medications and 12 shocks, and she is transferred to the intensive care unit. Surely she suffered brain damage, and her body has shut down. Her husband withdrew care after 2 days, and she passed away.

I felt very responsible for her death, and carried this guilt over my head for a number of days. Sure, I didn't perform the procedure, but I damn well forgot to order that bloodwork. Maybe if I did order it, it would have shown her blood levels were critically low, and the intern-on-call would have been alerted and something could have been done to save her life. My bosses tell me, she was sick enough to begin...anyone who needs a TIPS is a sick person, and that we were trying to help her, we can't beat ourselves over our mistakes because they are 10 other patients that I need to provide my best care for. But it was hard to deal with this.

And this is how new doctors learn. We learn from our mistakes. But unfortunately, our mistakes can hurt patients. Most of the time they don't, but sometimes they do. And every intern, and every doctor, makes mistakes. I've certainly learned never to forget to order bloodwork before I leave. But there will be plenty more to come, since its just impossible to teach an intern all that needs to be known to care for patients before they are thrown into such situations. In medicine, we all aspire to be perfect, and patients certainly hope and sometimes expect us to be perfect, but we are human. We will make mistakes.

Medicine is unique in that our mistakes can directly harm others. Its really unsettling to me. Sometimes I wish I were fixing machines or computers or cars rather than humans...those are expendable. How does one deal with this responsibility, of trying to be as perfect as one can, knowing you never can, and that the fact you can't be perfect means you will hurt people?

I feel young

A picture of my glory days at Emory...


So I'm getting to know my co-intern on my team, and now we have med students, so I have a 3rd year med student working closely with me.

Turns out, I'm pretty much the youngest kid on our team.

My co-intern, Avi, is 33, married witha 5 week old son, and has spent 5 years working as a counselor for troubled adolescents. Not just troubled, but often gang members and other very challenging young adults. He's been punched and kicked, been in a facility where all the 'patients' rioted at one time against the staff, been inside the locked facility with threats of one of the patients having a firearm, and so on. He's seen and been through a lot and it gives him a ton of perspective. Now, he's a doctor in training and father in training, and he seems to be enjoying it all. His experience probably lends him so much perspective, because I feel like I'm busy enough just being a doctor in training that if I were a father too, I couldn't handle it!

Which makes me want to be someone who has perspective. Life is all about attitude, and to me developing that attitude has a lot to do with your perspective. I always wonder what I can do to get really good perspective. I want to travel a lot, to experience the 'have-nots', as well as the developed countries that live differently than we do in the US. To learn why people are the way they are. Why the US is so disliked. How people deal with life.

I bet the ignorance of many would be tempered if they travelled and saw something other than through their own experience.

My medical student, Will, is 30, married for 6 years, and did his PhD before starting medical school. Its so funny how med students treat me, like their so respectful and say hi and how are you every day like we're so much above them. I was just a student 3 months ago. But I used to do the same too, treat our residents with respect. Its weird being on the receiving side!

I have a lot of growing up to do - world experience, spirituality, philosphically, as well as with my relationships with Nicole, family and friends, and with my medical career. I feel lucky though, that I am surrounded by just neat and brililant people. All of my friends and family have never ceased to amaze me.

Alan

2 weeks done!

Well I just finished my first 2 weeks of internship, and things have gotten a lot smoother. I've got the hang of the computer system, getting around, knowing what to do, so things are getting more efficient and more manageable.

There is the phenomenon of the "white cloud" and the "black cloud". The white cloud is where you don't get too many patients, your patients don't stay for too long, and therefore the amount of patients you take care of at any one time is less. On the converse, if you have a "black cloud" hanging over you, you're carrying 10-12 patients, and they always seem to stay a long time, so that every 4th night you keep getting more patients, and none are really ever leaving.

I'm fortunate enough to have the white cloud over my head right now, as I have only 3 patients (I had more as a student), but my poor teammate and fellow intern has 11, and its been this way for the last week. I'm probably jinx-ing myself right now by talking about this, but I guess I'm trying to say its not so bad right now. I'm on call tomorrow night, so I'll get up to 6 more, but the hope is that they are not too sick so they don't have to stay in the hospital so long.

There is a hierarchy in medicine. The "attending" physician is the boss, the one responsible for all the decisions. Then there is the "resident", who is in the 2nd or 3rd year of residency, who has experience and reports to the attending. And then the "intern", who is in the 1st year of residency and does a lot of the day-to-day work, while the resident and attending make the important decisions. And then the medical students, who are there to learn the basics of medicine. Usually, the intern is the one to see the patient every single day, and gather all the data. Thus, they actually are the ones that know the patient the best.

I have this one patient, a 19 year old girl who is very sick with Lupus (where the body attacks itself) and TTP (where the body attacks your platelets, making you at risk for heavy bleeding). Her lupus has caused her kidneys to shut down, which has caused her to retain too much fluid, and caused her blood pressure to skyrocket. No matter how many blood pressure meds we gave her, her pressure was still too high. She need to go on dialysis, a machine that acts like artificial kidneys, so it will take away extra fluids and toxins in the body. The "attending" kidney specialist was trying to convince her and her mom that she needed this. However, the attending walks up to me, and tells me that the mother would like to talk to me about dialysis. Huh????????? Me?????? Turns out she trusts my decision more than the kidney expert. So crazy.....and the kidney expert was standing right beside me, so I was pretty nervous to give my opinion with him there. Anyways, she really did need dialysis, so I told her so, and she said, okay, do it. Shows how much influence us "interns" really have, whether we realize it or not. We're the faces they see each day, and just that simple fact of us going in and asking them how they are doing, each morning, seems to make us their doctors. Pretty cool.

Mom, dad, Jenny, Jeff, Amy, and Tyler are all on family vacation in Orlando. Wish I could be with them!!

Nicole is up here with me, and has started her pediatrics rotation in Raleigh. I think she forgot how much she likes working with kids, and is having a really great time. Apparently on Monday there will be a bunch of kids from Belarus coming into their clinic. These are kids who have suffered the effects of the Chernobyl nuclear meltdown in Russia in the 80's. I'll let you know what she finds, should be really fascinating (and sad).

How is everyone doing??

Alan

Yes I am busy but I will continue to post!

Well, I just finished my first week of internship. It was A LOT of hard work, but I think it will get easier. I probably put in about 100 hours of work, and today is my first day off in 8 days. But, working that hard makes these days off sooooooooooo nice.

So far, the thing that has left the biggest impression on me are the patients. I'm on the oncology (cancer) service, and I take care of patients with cancer. Most of them are already diagnosed, and are coming in for scheduled chemo, or some other problem related to their cancer. Some are new diagnoses - people who came in sick, and we suspect that they do have cancer.

One patient I had was a 22 year old girl who has Hodgkin's lymphoma. She had probably been sick for a year or two before being diagnosed. They live out in the boonies of North Carolina, with thick southern accents. Her mom and and her husband were with her. She was admitted to us because she was having pretty bad nausea and vomiting, and couldn't eat or drink. So we gave her some IV fluids and strong nausea medicine, and she responded great and was able to eat the Wendy's her family brought her. I gave them a prescription so they could continue the medicine, but when they were being discharged I could tell she was quiet and sad. The family said they couldn't afford the medicine; if they bought it they couldn't make their house payment. Then this opened the floodgates, of her not wanting to be sick anymore, wondering if its worth all this treatment and being nauseous, that perhaps she could go on without chemo and asked if she would survive without it. At that point, I intervened and sat down and talked with all of them, about their options (the social worker could probably work something out with the meds). I asked if things would be different if she could get her chemo, but not be nauseous, and she said she'd like that a lot, so we determined the most important thing for her was to be able to get the medicine, so that she could carry on. Because we had a plan now, she felt relieved I think.

I felt good about this, and it was one of the things I could do...the complicated medicine, I don't know right now, but as doctors a lot of times the patient doesn't need anything complicated. Just a plan and some reassurance to get them through tough times.

I was proud of myself, but not necessarily for intervening like this. It was because I had been on hour 28 of my 30 hour shift, and I had so many things I had to get done before I left work, and my first thought was that sitting there talking to her was taking up all my time, preventing my from writing progress notes and doing all the little things that are necessary from day to day. But about 30 seconds into the conversation, I realized I should listen to her.

The other very challenging part of residency is this thing called "cross-cover". I stay overnight every 4th night. When I'm there, 3 other interns can leave at 5pm or so, and I watch their patients. And when I'm not there at night, one of the 3 others is there to watch over my patients. You can imagine that when I'm there, I'm watching over all these patients that are very sick, yet I don't even know them. And if something happens to them, my job is to help them get through the night. So, for example, when a patient who is on chemotherapy (and the chemotherapy has weakened their immune system) gets a fever, their blood pressure drops, their heart races, it is very serious because that infection can kill them in hours. So when I get the call from the nurse that patient X is indeed having a "neutropenic fever", I have to immediately run studies on him and order antibiotics, IV fluids, and anything else they need. And then I watch him/her, and pray they make it. No wonder we don't get any sleep.

The working environment here is really great. All of the doctors and nurses and my fellow classmates are really nice, and really helpful, and their computer system is very good, which makes work a lot easier, at least when I finally master it.

I have to say, this past week I have worked the hardest I've ever worked in my life. I knew residency was hard, but man NOTHING prepares you for your first day of residency. You really learn on the fly. There were moments when I thought, "what the hell am I doing here, why did I choose this career, am I cut out for this???!!" That never happened in med school, but it sure as heck happens here. But, it will get better, and each day got better last week for me.

Nicole just arrived today from Atlanta. She'll be staying here for 2 months doing rotations up here, so I am so glad she's finally joined me. We'll be doing some things to our new house - getting a new lawn mower, putting up blinds, working on the lawn, organizing, etc - as well as exploring the area. At least, whenever I have time.

Write back with your thoughts or questions about this whole crazy thing!

I miss all you guys,
Alan

Anticipation

Hey everyone,

Well, we’ve just about finished orientation at UNC, and I’m about to start my first real workday, my first day of residency as a doctor. Of course, with my luck, I get assigned to be on overnight call my very first night. That means I work Saturday, my first day. Then I work all through Saturday night. Then I work until Sunday at 1pm. Then I can leave and go home and sleep.

Yep, 30 straight hours. However, that’s not what I’m even scared of. What scares me is that I have no idea what I’m doing. Sure, I have some fundamental medical knowledge from medical school. But I’m starting with oncology (cancer patients). Many of them are in the hospital, very sick. I will inherit probably 5-8 patients from the previous intern when I start. But, since I’m the intern on call at night, I will be covering 3 other interns’ patients that night while they go home after 5pm. So I will have possibly 20-25 patients, who I don’t even know, who I have to care for that night. This is in addition to the new admissions. Any night you’re on call, you get up to 6 more patients who become yours throughout their hospital stay. This will add to the 5-8 patients I’ve already inherited. And they are ALL cancer patients. AND, I have no idea what I’m doing. How to order things, who to call for x, y, and z.

Can you tell that I’m up against a lot?!

It gets better…a few months later I’ll know my way around the hospital, the logistics, the computer system, and be better at patient care. But now, I’m a brand new doctor.

Anyways, I've met almost all of my classmates, my colleagues. They are fantastic, and from different cities all around the country. We have former carpenters, AP English teachers, world travelers (over 30 countries), college tennis players, and even another former pole vaulter and former high school pole vault coach! Its maybe 60/40 men, however I'm the only Asian, and there are no black people in my class. So strange! And many of the girls are Indian or Middle Eastern. Anyways, they are all very nice, many of them attached, a good bit with children. Makes me feel young. I'm really looking forward to getting to know them, and this year will be tough and be a bonding experience for all of us.

If you can, avoid going to hospitals in July! Just kidding...sort of.

=)

Wedding pictures

Hey everyone, just wanted to direct you to a website with our wedding pictures. Also a slideshow on it. The slideshow doesn't work on Mac, only PC.

http://www.charliepappas.com/alannicole/show_wedding.html

=) Alan

Steve Burns

I regret to say that Steve Burns, Nicole's uncle, died in a car crash this past Sunday. He, his wife Carey, and their 2 babies lived in Atlanta, and Nicole and I were very close to them, frequently going to their house for dinner or to walk the dogs or to hang out. It is so terrible to have lost him so suddenly. I feel so sad for Carey, and Warner (2 yrs) and Kate (6 mths), who are left behind. Sarah and I will be driving to Atlanta tomorrow, to meet up with Nicole, to attend his funeral. He was such a good person, so nice and caring, a great dad, and never deserved anything like this.

One especially shitty part is that Steve had been diagnosed with appendiceal cancer about a year ago. He went through chemotherapy, which was really tough, and finally just recently finished chemo and was starting to get better. And then this happened.

This has made me step back, and realize that life is so short. Can you imagine if, in a second, you lost your spouse? Or your mom? Or your child? One second here, the next, gone. Steve told Carey he was running to the store to get something, and then, he's gone.

It really shows you that you shouldn't worry about the little things, and you shouldn't get upset about the little things, because it all doesn't really matter. I shouldn't get upset at Nicole for some petty mistake...because what if those were the last words I ever got to say to her?

It's upsetting that it takes something of this magnitude to give me perspective. And even worse, I admit that even in the course of this week, I at times even forget the perspective, and revert back to letting small things bother me. I need to remind myself that LIFE REALLY IS SHORT. Enjoy it, seize it, relax, and love the people most important to you.

Steve was a lawyer, a partner in a neighborhood burrito joint, a husband and father, an animal lover, an uncle and mentor, and a wonderful person. We will miss him dearly.

Alan