Puerto Vallarta, Mexico

It sounds crazy but in the middle of interview season, I took a trip to Puerto Vallarta for my best friend Ingrid's bachelorette party! SO worth it. I'm so glad she had the mind to put her fist down and say "We're going to Mexico!!!" Also, so happy that Amy could haggle out a GREAT all-inclusive resort deal for the group. I have the best and smartest friends! We stayed at the most gorgeous resort called Garza Blanca and despite it being a bit farther out from the city and touristy area of Puerto Vallarta, it was by far the best decision of the weekend. I have nothing but wonderful memories of the resort, from the amazing people who worked there and catered to our every needs, to the beautiful views not only from our super duper suite but also from virtually anywhere in the resort (gym included).

The bride to be!! As of today, only 17 days before she becomes a Mrs!!!!!

It's honestly pretty hard to beat this view of the infinity pool, the beach, and the Pacific Ocean from our 10th floor hotel balcony right around sunset.

 

The first of our delicious dinners - this is duck with red beets paired with an arugula salad.

So ethereal. After dinner we came for a nighttime lounge at the rooftop infinity pool which overlooks the resort and into the vast expanses of the ocean.

Long time friends lounging by the pool :)

In the lobby there was a giant chess set with a giant king piece!!

With Amy's persuasion, we left the comfort of our resort and traveled into downtown Puerto Vallarta via the hottest bus that I've ever ridden in my life. I mean, sweat was just pouring down my face in the muggy, humid 90 degree weather! 

An early afternoon lounge at the infinity pool next to the beach and ocean. This was one of the most relaxing activities of the weekend.

I love this photo. Ingrid and her bridesmaids!!

This dinner was one to never forget. I might've eaten the most I've ever eaten at the steakhouse. I ordered a rib-eye steak with a side of delicious sweet potatoes. Not pictured are the seven other dishes I also ordered!

A semi-formal dinner outing at the steakhouse...

...which culminated in DESSERT TREES. Yes, a dessert tree (though in all seriousness, most of the selections were somewhat tasteless or tasted like plastic...)

This was taken during our last morning at the beach. Coconut trees, a mild breeze, the sand and ocean. Oh how I never wanted to leave Garza Blanca.

Nothing but lots of love for this amazing friend of mine. Every time we talk, I learn something new from her!

What is going on here!

Also another favorite picture. Saying goodbye to the weekend of fun!

Puerto Vallarta was truly a weekend of relaxing fun. I'm so glad we were able to go and so happy that Ingrid somehow master-planned this trip by herself. It'll be pretty hard to top this one. After all the lounging and eating, we had to sadly leave Mexico and return to our every day lives...which meant returning back on the fourth year interview trail for me! 

Texas

For someone who's never really been in the southwest before, I was so pleasantly surprised by my short visit to Houston and Dallas. Okay, so granted this was just about 2 weeks ago so it wasn't in the middle of summer. Even though, Houston was still pretty humid and Dallas was still quite warm.

What I was most surprised with was how nice everybody was! From the moment I landed until I took off again, I thought everyone was so helpful all around. Unfortunately when I arrived in Houston, it was already pretty late so I wasn't able to really get to check out the area or the city. The only place I visited was Texas Children's Hospital and I was absolutely blown away by the insanity of this facility. First of all, it is HUGE!!! Texas Children's is the largest children's hospital in the United States with over 600 beds.....all for only kids!

A giant tower with over 20 floors!!

Nighttime view. So colorful!

A tiny slice of Texas Medical Center in Houston. The Medical Center is the largest one in the world with 21 hospitals packed in a small area! These hospitals are affiliated with Baylor College of Medicine, University of Texas Houston, Texas A&M College of Medicine, and University of Texas Medical Branch at Galveston.

At the end of my day at Texas Children's, we were played a short YouTube clip made by the camera crew at TCH showing the fight of the children as they battled various diseases and disabilities. It brought a few tears to my eye and some of my peers were just short of sobbing by the time the clip finished! The song was to Rachel Plattens - Fight Song

After my visit here, I flew straight out of Houston and into Dallas, a city that I've been wanting to visit so badly since I was 12. Why? Because, the Dallas Mavericks. I drove by American Airlines Center and nearly had a heart attack since the Mavs were playing a game that night and I was literally right next door. Also, the most prettiest arena EVERRRR. Once more, blown away. I fell in love with the city even though I mostly only saw downtown and even then, only specific parts of it. Plus: the hotel had free happy hour AND (the most important part) free milk + cookies at night. I'm in love.

What is it about Texas that everything has to be so big? Children's Medical Center of Dallas is the 6th largest pediatric hospital but when I saw it, it was monstrous! Humongo! It towered over everything else in the area and at night, with its bright lights, it was so visually stunning. The super adorable balloon logo is perhaps the cutest children's hospital logo I've seen yet.

Nighttime Children's

This building is practically a giant looming fortress!

One of the coolest backgrounds ever. The GIANT eye housed in downtown Dallas!

After having the lucky opportunity to tour both of these major hospitals, I found myself once again so happy to be going into Pediatrics. Do adult hospitals ever get to look this amazing? Are adult hospitals decorated with colorful walls and pictures along the hallways? I'm just going to say no.

And there you have it, yet another reason to go into Peds :)

A Brief Trip

Recently, I finally finished my last exam of medical school!....and hopefully I will pass....

Still, it's a pretty good feeling knowing I survived it. This last exam was Step 2 Clinical Skills and for that I traveled down to LA to take it. While I was in LA, I got to meet up with a couple of friends from school and catch up with them.

It's always my goal to spot Staples Center when I fly over Los Angeles...and there it is!

Stopped by Manhattan Beach for a quick brunch

Annika!! One of my med school besties. We think alike :)

Poolside last minute cramming

Two of the funniest guys, Jason and Pejman. Thank you for all the laughs! It was much needed.

Candid. Thanks Pejman!

Right after, I headed back to Chicago for a couple of days and was luckily able to have some time to walk around, catch the pretty Chicago scenery, the last of good weather, and see some more friends!

Seriously one of the coolest nighttime city views ever. It feels like it goes on forever.

How did I just discover this little fountain ball randomly in Streeterville?

Post-interview snap with Wes! Lucky to run into him.

Fall doesn't last long in Chicago but when it's here, it's beautiful.

SO happy to see my 3 year roomie Caroline :) This girl is quite amazing.

Caro and I opted for some delicious tri-colored Italian gnocchi for dinner in Lincoln Park. EXCELLENT choice.

Also found another cute stretch of small fountains.

My sister and I stopped by Nando's Peri-Peri in West Loop. Such a yummy South African & Portuguese lunch! 

Halloween just passed but Michigan Ave. was still decorated with these white pumpkins, orange flowers, and black roses. 

St. Petersburg, Florida

What an awesome, amazing city!!

Definitely wished I stayed an extra day to take better pictures instead of scrambling for my phone on the car ride to the airport in Tampa Bay.

 On a short stay here, the only thing I've decided is that at some point, I'd love to return here for a vacation. It's absolutely gorgeous.

Even though there are plenty of palm trees in California, seeing them in Florida brings just the best feeling ever.

Walking out at night, it's still 80 degrees outside. I love just wearing a t-shirt after 6pm.

Houses right along the St. Petersburg Bay.

Nice people everywhere!

Good food :)

No water drought. I must've been asked at least 20 times in one day whether I wanted any water.

Definitely on the list of places to return.

Awesome trip, I loved it here!

Something Personal

I've never been very good at making close friends. There are probably a few reasons: 1) I'm too boring and my friends often say that I live under a rock 2) I rarely go out to party and drink 3) This is a bad habit that I'm working on but I judge people a lot and because of that, I don't allow them to get close. Either way, making close friends has always been something that's slightly foreign to me, particularly as I got older and older.

3 years ago I moved to Chicago and started medical school, ready to start a bit of a new life, away from my best friends, away from my family. I never imagined that I'd get to know people that are near and dear to my heart now. In the last 4 months I've been out in the Bay Area doing a couple of rotations and because of that, I've barely had the chance to see those friends from school. I realize that I miss seeing them because I had gotten so used to their presence in the last few years. I feel so incredibly lucky to feel comfortable enough to text them all the time, even if it's only to talk about something ridiculous that happened at work today, things that wouldn't make sense to other people.

It's sad to think that in a few months, my closest friends from medical school will be so far away, down in LA, in the Midwest, or on the East coast. No longer will they be just a 15 minute drive away and no longer can we go out and eat, study, goof around and complain in person anymore. Worst of all, we'll probably be sinking in exhaustion during intern year anyway.

On the flip side, I'm so sure we'll end up at a place that suits us best and that will train us to be great physicians. I'm lucky to have so many friends around the United States so that when I travel to places, I can meet up with them again.

CMS Class of 2016, soon-to-be M.D.s
:) :) :)

Diagnosis 101: Congenital Diaphragmatic Hernia

*Disclaimer - Again, just a medical student here writing about what I learned from my own cases* 

A diagnosis of a congenital diaphragmatic hernia is another one of those incredibly scary diagnosis that you never want to hear. Very often, babies with a CDH are severely, severely ill and it's not uncommon for there to be a poor prognosis associated with the diagnosis.

So what exactly is a congenital diaphragmatic hernia? It's an inborn developmental malformation of the diaphragm when the fetus is forming. Because the diaphragm does not close correctly between weeks 4-10 of development, it's unable to properly separate the chest cavity from the abdominal cavity and as such, the abdominal contents such as your intestines, liver, stomach, or spleen can theoretically herniate through the diaphragm defect and into the chest. Most often, the diaphragm defect occurs on the left side because the liver on the right side is somewhat protective.

Photo cred: The Lucina Foundation. Notice how the intestines herniate through on the left side of the baby into the chest cavity and thus pushes the heart towards the right side and prevents the lungs from expanding.

Nowadays, most of the diagnosis of CDH is made while the fetus is still in the mom's uterus by ultrasound. You may also be able to see polyhydramnios on the ultrasound which means that there is too much amniotic fluid surrounding the baby. Now it's interesting to think about why there would be polyhydramnios in this case. Babies, while still in the stomach, actually swallow the amniotic fluid and then later pee it out; in essence, they recycle the fluid. However, if there's excess structures in the chest, such as a lump of intestines, then it can compress on the esophagus, thus preventing the baby from swallowing the fluid. So that's how you get polyhydramnios. This brings me to the next point, what usually resides in the chest cavity? Pretty easy - your lungs and your heart. So if you have extra organs up in the chest, it can also take up space and prevent the lungs from developing normally in the way that it should. In fact, much of the difficulty and sequelae of a congenital diaphragmatic hernia arises not in that the abdominal contents are misplaced, but rather that there is pulmonary hypoplasia - poor development of the lungs which causes respiratory distress, hypoxia, acidosis, and eventually pulmonary hypertension - which is also one of those things you never want to hear, especially in a young baby. If you're able to detect CDH while the baby is still in utero, one of the major things you want to do now is to make sure that the mom delivers her baby at a hospital that's capable of handling the case. It's so important that as soon as the baby is delivered there is a NICU that can stabilize the baby and then determine the proper course of treatment.

What if you don't diagnose CDH on ultrasound? What if it's a late-onset CDH that doesn't appear until after the baby is born? What are some signs that can make you think of CDH? Some things I think about make a lot of sense when you think about the process of CDH - you might be able to hear bowel sounds in the chest cavity, you may also see a scaphoid or concave abdomen because of the decreased abdominal contents. The baby could also present with a number of respiratory or GI symptoms - signs such as grunting, flaring, retractions while breathing, or vomiting after eating. Most likely if there are any of these symptoms, you'll get a chest x-ray and you might notice a shift of the mediastinal structures (including your heart and your trachea) to the right side of the baby. Hopefully, you'll also see what could be intestines or other organs abnormally located in the left side of the chest. If it's still unclear by x-ray, you could always do a upper GI bowel study which allows contrast to run through the intestines and show up much more clearly.

Case courtesy of Dr Ahmad Thuaimer via radiopaedia.org. Arrows and circles drawn by me! The red circle around the entire left chest shows an intestinal gas pattern (red arrow) which indicates intestines that have herniated into the chest cavity. The yellow arrow points to the endotracheal tube after the baby was intubated. Although hard to see, the purple arrow points to the NG tube going down the esophagus and into the stomach.

After you diagnose CDH in a baby, the next step of course, is to stabilize the baby (of course your ABCs - airway, breathing, and circulation) and then hopefully correct the underlying problem. Some things you want to avoid is to use any bag or mask ventilation because you would be blowing more air into the GI tract and intestines which could further increase compression of the lungs. Most likely, the baby will have to be intubated and mechanically ventilated for proper oxygenation. You would also want to drop a NG tube into the stomach to decompress the GI organs too. Another management point to consider is getting an echocardiogram to detect any cardiac abnormalities and see if there is any pulmonary hypertension. Lastly, hopefully the baby can be stabilized enough to undergo surgery to reduce the hernia and close the defect in the diaphragm.

The prognosis of a baby diagnosed with CDH will vary depending on how severe the pulmonary hypoplasia is. The mortality rate can be over 50% if CDH is diagnosed prior to 25 weeks gestational age and it is very possible for babies to have to be on ECMO (Extracorporeal membrane oxygenation) for a long time. ECMO is a machine and technique that acts as the heart and lungs for the baby until the baby's own heart and lungs begin to work correctly to adequately exchange gasses. I have seen one patient on ECMO so far, and let me tell you, it is by far one of the most complex machines I have ever seen. It's really a miraculous piece of equipment and requires several intensivist Attendings to be watching over it and the patient.

Grabbed from google images - an ECMO set-up. Pretty intense right? 

I spent this post discussing Congenital Diaphragmatic Hernias because I had a patient who was diagnosed with it too. Luckily, hers was never detected on routine prenatal ultrasound and was a minor case of CDH. She was a trooper in the NICU and only had to be intubated for less than 48 hours after her surgery. I hope she's flourishing well now!! 

Rotation #3 Kaiser Oakland Medical Center

Last week I started my third and final rotation of 2015 at Kaiser Oakland. I was pretty excited to start this rotation as I've always been really interested in Genetics ever since I learned about it as a freshman in high school. Having a background in Molecular Cell Biology and some in Human Development and Embryology is a definite plus for this rotation too.

So far, I'm enjoying being at Kaiser a lot. In a short week, I've seen a number of diseases and syndromes that I was constantly studying about during Step 1 and Step 2. If I was on a different rotation, I might very well have never seen any of these cases. Some of them include things like Neurofibromatosis 1 and 2, Tuberous sclerosis, Klinefelter's, Ectodermal dysplasia, and kids with Arnold Chiari malformations and myelomeningoceles. It's a lot to take in but the best part is that there's enough free time for me to research and brush up on everything while I'm at the hospital. It makes learning and remembering the diseases that much easier when I can correlate real life to what I read in the textbook or on the internet.

It was a gloomy day today in Oakland with a little bit rain!

What I love about genetics is that you have to know about all the organ systems that a disease can involve. For example, tuberous sclerosis can often involve the brain, the eyes, the heart, and the kidneys so making sure that the kid has good follow-up with the specialists is a really important part of disease management. I also really like that in genetics, you can advise patients on the risk of passing a certain condition onto their offspring. However, that's also one of the most frustrating things about genetics as well. As much as science has advanced in the last 100 years, especially in the field of molecular genetics and genome sequencing, a lot of the current laboratory tests for human gene sequencing is still far from adequate. Occasionally, the result of gene sequencing shows that the patient has a specific, documented mutation in the exact gene you suspected. For example, if the test for Cystic Fibrosis shows the classic delta-F508 mutation in chromosome 7 then you can practically be 100% certain that the child has CF. Unfortunately, often times, gene sequencing will come back with a result of something along the lines of "variant of unknown significance" which basically means that we don't know if the mutation is pathogenic or not. It could very well be that the specific allelic variant is a completely normal one or it could be that the variant is in fact causing the disease. When that happens, it's really hard to tell the parents that essentially we did the test and now we have this information....but what can we do with the information? Essentially not that much.

A ton of research is going into genetics as it's still one of the biggest subjects in science. There have been leaps and bounds made in the last 50 years in the field but there are many more breakthroughs that must arise before genetic testing will become more helpful. It's truly a field that has so much more potential ahead for it and one that many more people will continue to utilize as research and further medical advancements are made. If I decide to go into genetics, one thing I'll know for certain is that it will never be an obsolete field....and that's pretty reassuring!

Rotation #2 Lucile Packard Children's Hospital

Lucile Packard's Children's Hospital at Stanford University is unlike any other hospital I've ever been to. It's perhaps one of the craziest tertiary care centers in the world. During the time I'm spending here, I'm doing a Pediatrics Nephrology Rotation. What's different about this rotation for me, is that I interact mostly with fellows and Attendings instead of residents...and to some degree, this is what makes the rotation a bit harder for me. Fellows are two steps away from medical students and Attendings are three steps away. I'm used to helping residents out or even sometimes acting like an intern. Fellows though, have already completed their residency years and are now going on to subspecialize in their fields. In short, there's not much that I can do to help a fellow out and I certainly can't act like a fellow if I haven't made it to residency yet.

Nephrology is a crazy field. Pediatrics Nephrology is even crazier. You get to deal with all the congenital kidney anomalies that occur in utero (while the baby is still developing in the mom's uterus) or other kidney concerns that arise when the kidneys take a hit from difficulties during delivery or as the baby is growing older. One of the main problems that lead to the kidneys taking a hit is when there is severe blood loss, or hemorrhage. Examples: a placental abruption during delivery where the placenta suddenly breaks away from the uterus. When this happens, suddenly you lose the blood exchange that's supposed to be carrying mom's fresh blood which contains oxygen and nutrients to the baby. In addition, now you're also unable to return blood that contains waste metabolites from the baby back to mom for filtering. The placenta abruption can further cause hemorrhaging in both the mom and the baby. In an effort to preserve blood flow to the two vital organs of the body, the brain and the heart, the body naturally shunts blood away from other organs such as the GI tract, your extremities, or the kidneys. The result is that even if the baby's kidneys developed normally, a sudden traumatic event can cause life-changing consequences. 

                                    

A good majority of the Pediatric Nephrology patients at LPCH are incredibly complex. Not only do we see kids with kidney problems, we also seem to see a ton of kids with kidney and GI problems. A large part of this is that kidney issues cause a variety of other problems including but not limited to  electrolyte imbalances, feeding issues, blood pressure changes, and the most basic growing concerns. At best, the kids get a kidney transplant and hopefully live another 10 to 20 years, at worst, they pass away before a donor kidney becomes available. It's entirely a giant spiral downwards which rarely ends well.

LPCH is also the first hospital that I've visited where several of the subspecialty services have their own ward patients in addition to consult patients. From what I've seen so far, it makes on-service weeks incredibly tiring, having to be the point team in charge of your own ward patients as well as having to round on consult service patients every day. It's so miraculous that the fellows and Attendings are able to keep up with all the patients and keep the events of the day straight. Just five days of service is enough to make anyone completely exhausted!

On my last two inpatient weeks I've seen incredible medicine taking place. Events are happening inside Lucile Packard's that simply does not occur anywhere else in the world, including other top Children's Hospitals in the United States. I have two more weeks of Pediatrics Nephrology which I'll be finishing off in outpatient clinic and I hope I'm able to learn a little bit more on my next two weeks here.

Roommates

For the first three years of medical school, I roomed with an awesome person. By some random stroke of luck (or the fact that we both liked cats - and that she had a cat) we were pretty happy being roommates. Eventually, the start of fourth year meant that we finally had to break apart from our comfortable living situation. I decided to move back to California for the large majority of this year while she returned to her home in the suburbs of Chicago. My roommate is probably one of the brightest people in my class and there's no doubt that she'll be awesome at whatever she ends up doing. Fortunately, I happened to get by medical school doing pretty well too so between us, we generally have some pretty intelligent discussions. Every so often though, some funny conversations arise:

Best Friends

@Savannah-Chanelle Winery

I've known these two for way too many years now. They are my best friends through and through and the selfies can go on forever. Congratulations Ingrid!! We're so thrilled to be apart of your wedding festivities and celebrations. Can't wait for the big day!!