Last week, a young man came through the emergency department complaining of intractable nausea and vomiting for two days. He was severely dehydrated, dizzy, and lightheaded because he hadn't been able to keep any food or drink down for some time. The first things you think about in your differential for an otherwise healthy-appearing 30-year-old guy with nausea and vomiting are the flu or a simple viral gastroenteritis. Fairly routine.

Talking with the patient and getting a better idea of his medical history revealed that just a few months earlier he had undergone a complete resection of a craniopharyngioma. These tumors are usually benign masses that grow near the pituitary gland in the brain. The term benign can be somewhat misleading, however, because the growing brain mass can cause increased intracranial pressure, disrupt function of the pituitary gland, and damage the optic nerve simply because of its location in the brain. These changes lead to symptoms like nausea, vomiting, balance issues, hormone imbalances, and problems with vision. Craniopharyngiomas rarely metastasize, which is why they are usually designated as benign.

With this new information, the next step in figuring out what was going on was to get a CT scan of the patient's head to make sure the tumor was completely gone. We also had some imaging of his abdomen done in case we could find anything there that might be causing his nausea and vomiting. When the results came back, it was my job to tell my patient what we found. I sat down next to his bed, and he looked at me already knowing what I was going to say. He started to tear up before I started talking. The reason he'd been so sick is because his brain tumor that was resected less than six months ago had come back. I also told him that we found a new lesion in his liver. I explained that he still had a number of options. There's surgery, chemotherapy, and radiation. The lesion in his liver might be nothing at all. You try to stay positive in situations like these, but it's very difficult not to focus on the negative, and it's more difficult to maintain your composure with a tearful patient.

I like working in the emergency department because, most of the time, you're able to see a problem, fix it, and send your patient on his or her way. Unfortunately, sometimes all you can do is give them a little more information than they had coming in and refer them to someone who might be able to help.

That night, I went home and unwound much like I usually do. Video games help me relax by taking me somewhere completely fantastical and so out of touch with reality that I forget what went on at work. I played one of my favorite franchises, Assassin's Creed. It's a historical science fiction series about a war between the order of Assassins and the Knights Templar. The games are set in various time periods and locales ranging from the Crusades in Jerusalem to Renaissance Italy and 14th century Constantinople. As an assassin, you are tasked with ridding your cities of the oppressive Templar regimes by any means necessary.

Typically, the games reward you for stealth and strategy more than wanton destruction. But that's not how I played that night. That night, I was brazen with my attacks. I cut paths of murder and destruction from one end of the city to the other with no goal or objective, no in-game reward to reap. It was cathartic.

Video games get a lot of flack for their consequence-free destruction or violence – and in many cases, rightfully so. Without the proper maturity, the desensitization they cause can be dangerous. Sometimes, though, it's precisely this desensitization that I play for. When the horrible things that happen on a daily basis in medicine can be blocked out, even momentarily, it makes the impact, the care, and the life of even a single patient that much more important. That's why I play.

Originally posted on DoctorFishypants.com

It's been a rough week. A few days ago, my wife found out that she matched for her neonatology fellowship in St. Louis, MO. She's excited, because she really likes the program and it's a great opportunity. Unfortunately, St. Louis isn't the ideal city for us. I'm fairly certain that emergency medicine is what I want to do with the rest of my life, and there are no osteopathic (D.O.) emergency medicine residencies in Missouri. There are a couple allopathic (M.D.) programs, but I would need to do a traditional rotating internship (TRI) year first to strengthen my application. There is one TRI program in St. Louis, but it's a risky proposition for a number of reasons that I won't get into here. Suffice it to say, I've been feeling very helpless. It seems like no matter what I do, or how much I want to succeed, whatever happens ultimately isn't even up to me or Emily. It's very unsettling.

People often ask me why I play so many video games. Granted, I used to play much more than I do now, but I still turn on my DS or PSP for at least a few minutes each night before I go to sleep. Growing up, I used video games as my escape. If life was getting stressful or if I just wanted to procrastinate for a little while, I'd pop in a Zelda game and suddenly be a million miles away in Hyrule, swinging a sword or playing an ocarina.

But video games are more than escapism. During the most tumultuous times of my life, video games have been therapy. When I feel like I have no control over the things that matter most, video games offer a place where I can feel helpful. Useful. Needed. I'm saving a princess from captivity, a species from annihilation, or world from destruction. The helplessness I felt before is gone and I feel empowered to do something good. Even if that good is for fictional characters, it resonates. When I'm done playing, the feeling of empowerment stays, even if only for a week. A few days. A moment. It builds confidence. It battles depression. It inspires.

Sony just launched a new ad campaign called LongLivePlay. The video sums up the feeling I've tried to convey here. It's more effective if you're familiar with the characters, but it gets the point across either way.

Originally posted on DoctorFishypants.com

As my third year of medical school nears completion, I'm finding myself much busier than expected. I just finished a month of Obstetrics and Gynecology with an attending who I just didn't mesh well with. He's a fine doctor, and his patients love him, but our learning styles didn't match up well. It was a rough month. I'm much more comfortable now that I'm back on Internal Medicine, but 7am-7pm shifts with 2 call nights a week doesn't leave much time for studying or socializing. I'm also still chugging away on Match Game posts. It always pleasantly surprises me when people I know in real life tell me they read that blog.

My one-year wedding anniversary is coming up in a couple of weeks. It really doesn't seem that way. Unfortunately, we won't have much time to enjoy it. I have to be in Erie, PA the next day for shelf exams in OB/Gyn and Internal Medicine. Then I have another mandatory 2 days on campus in Erie to prepare for my Step 2 PE, a practical exam where we have to interview and plan treatment for 14 standardized patients.

Any free time I've had has been taken up by two of my most anticipated video games of the year. Despite the catastrophic PlayStation Network outage this month, I've wasted countless hours in the single player campaign of Portal 2. I can honestly say it's one of the best games I've ever played. Highly recommended. I've also poured plenty of time into the story mode of Mortal Kombat, one of my guiltiest pleasures of video games ever since the original came out when I was entirely too young to play as much of it as I did.

I also bought a Pokemon game for the first time. Pokemon is the only big Nintendo franchise I've never played before because I was just a bit too old when it originally came out, and I've subsequently associated it with the most evil of gotta-catch-em-all marketing schemes. But every pediatric patient I saw last month was playing it when I walked into the room, so I figured it would give me something to relate to them with. My wife said she did the same with the Twilight movies, but I called bull**** on that one. She loves those things.

Currently Playing
PlayStation 3: Mortal Kombat
NDS: Pokemon Black
PSP: Final Fantasy IV Complete Collection
iPod: Words with Friends (Username DrFishypants. Play me!)

Originally posted on DoctorFishypants.com

One of the more entertaining aspects of keeping a Wordpress blog is the occasional random spam comment. Usually they're pretty simple. "Hi, I found your blog from this site. Click here to check it out." Every so often I get an awesome one like this:

There are so a lot of huge releases coming to the gaming planet in the next few many years that several players are becoming puzzled and starting up to wonder if they are heading to be capable to buy a console gaming system in the foreseeable future that has a remote handle at all. The speedy solution to this is sure, the authentic question is what that remote will seem like and how it will interact with the gaming console. Hardcore video games will by no means give up the remote command totally because it gives way to a lot precision and command that are not able to be in comparison to any motion based mostly system controls at this position in time.

Where is the gaming planet and how do I get there?

Hey there, folks. It's been a while since I've been around these parts. Turns out, life is keeping me a lot busier than I expected. But when is that not the case?

I'm about to start my second month of general surgery. Since starting my third year of medical school, I've done a few months of inpatient internal medicine, pediatrics, general surgery, hematology/oncology, and family medicine. I've been with patients when they bring people into the world and when they say goodbye. I've told people that their cancer is in remission, and I've come out of distressing surgical procedures to tell patients that their cancer has spread and they likely only have a few weeks left. It's been terrifying, depressing, amazing, and fun all at the same time.

But it's been a lot of time. Much more than I anticipated. If you're a GameSpot member who's following me because you're interested in medicine, I'll be keeping a more up to date blog over at Doctor Fishypants. I was also recently asked to contribute to Medscape, the student portion of WebMD, as a student blogger. For those interested, you can find the Match Game blog over here. You'll need a free account to access it.

In terms of video games, I haven't been doing much. I plowed through Assassin's Creed Brotherhood, but I still have to go back and finish up the achievements. Maybe try out some multiplayer. LittleBigPlanet 2 has been keeping me pretty busy also. I'm still looking for good portable RPG to take the place of Jeanne d'Arc. I tried multiple times to get into Knights in the Nightmare, but that game is just way over my head. I just downloaded Hexyz Force on PSN because it was on sale, so we'll see how that goes. Bethany seemed to enjoy it. Any other suggestions?

I'll try and catch up with people and duties here as soon as I can. Hopefully sooner rather than later.

On a completely unrelated note, is it just me, or does the HotSpot theme song sound exactly like the theme from Welcome Back, Kotter?

Many students find it difficult to decide what specialty they'd like to go into after graduating medical school. Unless you applied to school with a choice in mind, the first two years of lecture don't offer much help deciding how you'd like to spend your professional years. It isn't until your third and fourth years of medical school, when you're out on rotations and getting a feel for your different options that it becomes easier to pick a specialty. I've had the benefit of being about 99.9% sure I want to go into pediatrics since long before starting medical school. Early in my pediatrics clerkship, that decision was made all the more clear.

I was working with a pediatric neurologist who specializes in Attention Deficit Hyperactivity Disorder (ADHD). In the morning, a young boy of about 11 years (let's call him Johnny) came in with his mother. Her son was previously diagnosed with ADHD, and she wanted to discuss a number of behavioral issues he had been having both at home and in school. Johnny was a bully. He shoved his schoolmates, got into screaming matches with his mother, and was openly defiant toward authority figures at school. He threatened other students with physical violence and told his mother on repeated occasions that he wished she were dead. During this conversation with the doctor, Johnny appeared annoyed. He refused to verify any of his mother's claims and would not answer direct questions with anything other than a shrug or "It doesn't matter. I don't care."

Upon further questioning, Johnny's mother revealed that her true reason for bringing her son to see the neurologist that day was a recent sleepover at her home. She had noticed the boys being more quiet than usual, so she went down to her basement to check up on them. His mother had inadvertently stumbled upon a mock wedding ceremony between Johnny and his male friend (let's call him Matt). She promised not to tell the boy's mother if they stopped what they were doing and went to bed.

It should be noted that at this point in the conversation, Johnny's demeanor changed from annoyance to shame. He would not make eye contact with anyone in the room and remained silent when asked any questions. The neurologist pressed Johnny's mother for more information, but she was quick to deflect the conversation toward accusations of Matt's mother's promiscuity. She believed Johnny was tricked into the pretend wedding because, although she and her husband have a documented history of verbal abuse toward one another and repeated screaming matches in front of their children, she claims that they are rather "prudish" parents. Matt must have learned his behavior from his morally questionable mother.

It was clear that Johnny's mother was extremely uncomfortable discussing homosexuality. She had difficulty even saying the word aloud during our conversation. She seemed disappointed when the doctor told her that these behaviors would likely not go away and that there was no pill he could give Johnny to cure his other discipline issues. The neurologist recommended resuming regular therapy sessions with a psychologist to determine what was causing both his sexual and anti-authoritarian behaviors.

As a medical student on rotations, you often feel like your influence on patient care is limited. Depending on the location of your clerkship, the doctors you're working with, your personal comfort level, and any number of other factors, your role runs the spectrum from simple observer to (if you're lucky) integral member of the medical team. On pediatrics rotations, your job leans more toward the former due to the sensitive nature of the relationship between nervous, timid, or frightened children and the doctors they've grown accustomed to as they reach adolescence. This was the first time that, as a student, I felt as though there was nothing I could do to help my patient. Not only was it clear that Johnny's mother disapproved of her son's behavior, but it was also likely that she would not follow up with a counselor as the doctor recommended.

If anything positive came of the office visit, it was the certainty of my choice of specialty. With the continuity of care that comes from a primary care setting, the relationships I form with my LGBT patients will allow me to be a positive influence, guiding them toward important resources like the It Gets Better Project and the Trevor Project. There is nothing more rewarding in medicine than the potential for life-saving interventions, whether that intervention is a delicate surgery or a simple referral to the right resource.

Originally posted on Doctor Fishypants.

Tomorrow morning I begin my second clinical rotation - internal medicine. I thought this would be a good time to share an amusing anecdote from my first month as a third year student during my hematology/oncology elective rotation.

On my very first day of third year, I spent most of the morning going through the orientation process at the hospital. I got security clearance, my ID badge, a tour of the building, and introductions to the important staff members I'd be interacting with. After the tour, I was on the floor being introduced to one of the doctor's I'd be following for the month. His first consult that morning was a patient that needed a bone marrow biopsy, and I was asked to watch.

Bone marrow biopsies are usually performed when there is a problem with the body's blood cell count. The marrow inside of your bones is responsible for creating platelets and red & white blood cells. To perform the biopsy, a region of the back is anesthetized, and a needle is driven into the pelvic bone to aspirate a sample of bone marrow. If done properly, the patient feels an intense pressure in their back, but no pain.

So, on the first day of my first clinical rotation of my third year of medical school, I was asked to watch a bone marrow biopsy. I should note a few things here. First, I have seen this procedure done before. My father is an oncologist, and I've watched him work. Second, I had just gotten back from my honeymoon the night before. Because I was nervous about starting my third year, finding a hospital I'd never been to before, and making a good first impression, I hadn't slept well the previous night. I also hadn't had anything to eat or drink since getting home that day.

I was fine throughout most of the procedure. The doctor was finished and began putting away his equipment when I started feeling dizzy. I excused myself and sat down for a few minutes, thinking I was OK to leave the room when the medical team was done. When I got into the hallway, my vision started to go black from the outside in. I remember telling a nearby nurse that I couldn't see. The next thing I knew, it was a few minutes later and I was laying on the floor of the hospital hallway. The doctor who had performed the biopsy and the nurse who I told I couldn't see were holding my legs in the air, trying to get some blood back into my head.

So everyone had a good laugh at my expense. The nurse sat me at her station and gave me some orange juice and crackers. Two minutes later, I was fine. It wasn't for another 3 weeks that I got the opportunity to prove I could make it through another bone marrow. A couple of days before the rotation ended, I was with a different doctor for the same procedure. As it turns out, sleeping and eating breakfast are pretty good prophylaxis against passing out.

Originally posted on Doctor Fishypants

The last lecture of my second year of medical school was over a month ago, and I've been on my third year rotations for almost three weeks now. But I couldn't really relax and take a break from studying until this week when I took Step 1 of my COMLEX medical licensing boards. I was originally scheduled to take the exam on May 28, two days before my wedding. As it turns out, people who are in the final stages of planning a wedding don't really have too much spare time to study. So I postponed the exam until June 21.

In the meantime, on May 30, I married the love of my life, my high school sweetheart, and my best friend. Nine years ago, when I was a senior in high school, our two families booked a Spring Break cruise vacation to the Western Caribbean. I met Emily on the Enchantment of the Seas, asked her to my senior prom the following week, and we've been together ever since. The wedding was amazing. We all had a good laugh at the reception when the head waiter came to my table to confirm that I was a vegetarian. Literally three minutes later, he brought me a steak dinner. Little mishaps aside, I think everything went very well.

The next morning, on 4 hours of sleep, Emily and I boarded a flight to our honeymoon. Nine years after meeting there, we took a cruise back to the Western Caribbean and visited the same ports. We were in Grand Cayman for my 27th birthday and spent the day lounging on Seven Mile Beach. The next day, in Cozumel, we took a catamaran cruise to swim and snorkel. It was the same excursion we did on the first cruise and every bit as fun.

I started my third year rotations the day after we got back from the honeymoon. During the day, I alternate between rounding on inpatient service and following a hematologist/oncologist at his office. At night, I studied as much as I could for the exam. Now that the test is over, I can finally focus on my rotations during the day (more on that later) and relaxing, catching up on video games, and working on the new house at night. It still keeps me busy, but it's nothing compared to two years of sitting in lecture for 9 hours a day. Only two years of medical school left. Halfway there.

Originally posted on Doctor Fishypants.

Every so often, when the endless hours of studying and lack of sleep start to catch up with me, it becomes difficult to find motivation to keep studying. Getting bogged down in the detailed symptoms of this disease or the inexplicable physiology of that syndrome makes it easy to lose sight of the big picture - of why I applied to medical school in the first place. It's during these times that I take a 2 hour break from studying for the night and pop in my favorite movie.

During my junior of college, I had the privilege of meeting Patch Adams. He came to speak at my school, and, to be completely honest, I can't even remember what the subject of his talk that day was. What I do remember is that he came out on stage wearing his trademark clown suit (pictured left) and made the entire audience laugh for a few hours. When I met him afterward to sign his book, I asked him what his recommendations were for a student who was thinking about going into medicine. It was fairly loud in the room and I couldn't quite make out what he said, but above his signature he wrote 'Follow Your Dreams.' Cheesy, yes. But meaningful when coming from the right person.

There's a scene toward the end of the movie where Patch is pleading for his right to graduate from medical school. The dialogue is, again, cheesy. But it's an amazing philosophy and a great reminder of why I applied to medical school in the first place.

Patch: At what point in history did a doctor become more than a trusted and learned friend who visited and treated the ill? Now, you ask me if I have been practicing medicine. Well, if this means opening your door to those in need, those in pain, caring for them, listening to them, applying a cold cloth until a fever breaks; if this is practicing medicine, if this is treating a patient, then I am guilty as charged, sir.

Dean: Did you consider the ramifications of your actions? What if one of your patients had died?

Patch: What's wrong with death, sir? What are we so mortally afraid of? Why can't we treat death with a certain amount of humanity, and dignity, and decency, and god forbid maybe even humor. Death is not the enemy, gentlemen. If we're going to fight a disease, let's fight one of the most terrible diseases of all – indifference. Now, I've sat in your schools and heard people lecture on transference and professional distance. Transference is inevitable, sir. Every human being has an impact on another. Why don't we want that in a patient-doctor relationship? That's why I've listened to your teachings and I believe they're wrong. A doctor's mission should be not just to prevent death, but also to improve the quality of life. That's why you treat a disease - you win, you lose. You treat a person - I guarantee you'll win no matter what the outcome.

Originally posted on Doctor Fishypants.

A while back I reviewed Rocket Riot for GameSpot. It's a great little multiplayer shooter (think Worms with jetpacks). It's on sale this week for 400 Microsoft space bucks, along with 9 other arcade titles. I can't say much about the other games (except that 400 points for Lumines isn't a bad deal either), but you really should download Rocket Riot. It's well-worth 5 bucks. The retro visuals are charming, and the music will get stuck in your head forever. I haven't played the game in months and I can still hear it. It haunts my dreams.