Conference Call

I always think of myself as a fairly flexible person in terms of how I view people, but one thing that always throws me off is the boxes.  By this, I mean that the people you know from school should be in school clothes, and the people you know from work should be at work in work clothes, and the people you know from home should be in disapproving parental clothes.  So I get really thrown off when people look and do things differently, even for a day.

We had our first surgical conference of the year on Wednesday, which was a fun event where we presented posters on cases we had seen, and also had the chance to sit in on lectures by experts in different surgical fields.  Unfortunately, every time I went to a lecture where someone else in my program was there, I just could not focus.  I genuinely do love it when we put on our good faces, because its nice to see everyone gussied up with actually brushed hair and lip gloss and jewelry and skirts or suits, but it weirds me out.  I went into one general surgery lecture on laparoscopy over the years, being given by the chairmen of surgery at another program I interviewed with.  It was a great lecture, with a really terrific discussion of the trade-offs of laparoscopic procedures, especially with regard to surgical education.  I wanted to focus on Dr. F, and I really tried to.  But sitting 5 rows ahead of me was my chief and 3 other seniors, and I just kept thinking to myself, "Wow, their hair is shiny.  Is my hair that shiny?  Maybe it's shiny because they got dressed up today.  Or maybe it's always shiny, but they just look different in scrubs.  Or maybe it's that new haircut I'm seeing, 3rd seat over.  Or maybe it's the contrast of the hair with the sweater?  That is a sweet sweater.  I wish I had that sweater.  Can I get that sweater?  It looks so professional yet cool.  I want to be professional yet cool.  Maybe I need straight hair to look professional yet cool.  Oooh, inguinal hernia repair."  Repeat ad nauseum.

This seems especially shallow of me, since there was some sort of clusterf*** going down at the mother ship and several residents had to leave early so that several last minute cases could go forward.  The intern who was on the night before broke down in tears over a minor mistake that she made which had big consequences, and another intern had to leave to help take her home, since she was so sleep-deprived that she wasn't safe to drive.  Quite a few residents weren't able to come due to being on-call at other hospitals, and another resident didn't come because of internal issues.  I volunteered to stay till the end to take down all of the program's posters after judging, but mentally escaped into the "pantsuit: Hillary Clinton or lipstick lesbian?" debate.

I finally found escape from my shallowness in the cardiothoracic room, where my poster was being displayed, to hear a cool talk about management of nightmare aorta cases.  I was able to say hello to a few surgeons that I knew, including one I rotated with as a first year student in vascular surgery, and another with whom I had done my poster (yet hadn't met because he was at a different institution).  We didn't win any awards, but I still felt pretty proud of my poster at the end of the day.  I also felt proud of my team.

Boarded Up

Reading back on my last post, it sounds pretty depressing.  In general, I stand by what I said, but I neglected to mention that I was also studying for the boards at the same time.  So it is VERY SLIGHTLY POSSIBLE that I may have been under a teeny amount of stress and reacted with more force than necessary to the events of the previous week.

 

I took the boards on Thursday, which represent the third and last component of the board exams taken by all medical students.  This exam is typically regarded as the easiest of the three, but as a result gets taken for granted the most.  It's an exam that most interns aim to sit for during the intern year, although you typically have up to the end of the 2nd year to pass it.  It probably wouldn't be so bad to study for if intern year wasn't so hectic and irregular, but I definitely struggled to fit in time for it.  Between my various busy rotations, studying for surgery, seeing family and friends, and working on a case presentation poster, it occasionally got pushed to the wayside.

 

I also made the cardinal mistake of taking a practice test 2 days before the exam.  Most people studying for the boards buy a subscription to an online question bank, as well as studying from the book.  However, these question banks are privately owned and written, and don't technically represent the true questions on the test.  Therefore, some people choose to supplement with a real practice test, which is old and discarded questions from the real exam, organized into a half-test format for one time use by the real board exam administrators.  I used the same tool last year for the Step 2 with some success, and forgot about it until a few days before Step 3.  Unfortunately, I put too much faith in the test being an accurate representation of the real one - it was filled with spelling errors, non-sensical questions, poor radiology pictures, and no ability to review the questions I got wrong.  So I took the test, and started panicking that the questions were nothing like my question bank subscription, and really freaked out when I got a score which showed I did not pass.  I called my mom and boyfriend in a tizzy, and they both talked me down from the ledge.  But I was still trembling the next morning when I walked into work, and set right to using my spare time to squeeze in a few more practice questions.  Luckily, I mentioned the whole disaster to my co-surgical intern Y, who started to laugh at me.  She told me that the scoring system is different for Step 3 compared with the previous 2 exams, and the score I had received which I thought was failing was actually a passing score by a reasonable margin.  Additionally, she told me that a lot of people had been reviewing the official practice exam badly, saying the real test was much closer to the question bank anyways.  I confirmed what she said, and I started laughing at myself for getting worked up for nothing.

 

I felt so much better that I was able to do some real review in a relaxed way, and went into the exam early.  I took my time and checked my questions, and felt good knowing that a lot of the things I had studied were on the test.  But the icing on the cake was when a question with a video component popped up, and it included the very recognizable voice and face of one of my old medical school professors.  I was so relaxed, I burst out laughing in the middle of the test site (with many dirty looks from the GRE exam kids), and then had to watch it two more times just to get myself together.

 

All in all, it wasn't a bad test.  Fingers crossed, I passed and it will be one more thing to joyfully cross off my list.

One-Up On Miss Cleo

I'm a big fan of the Heisenberg Principle.  Also known as the uncertainty principle, it states that precise inequalities that certain pairs of physical properties, such as position and momentum, cannot be simultaneously known to arbitrarily high precision.  Expanded to a view of a closed system, the principle states that there are limits on how precisely you can observe something before it moves and changes.  The more accurately you try to nail something down as being X, the farther from X it is at any given point in time.  One can extrapolate from this that the act of observing something can actually change its character and make it something different, which Michel Foucault later expanded on in The Birth of the Clinic.

I never thought about it as a philosophy of life and universal construct, until I heard a talk by Dr. James Watson (the American guy who helped discover the DNA double helix structure) while in college.  He spoke about discovering the principle as a teenager, and finding that it gave him comfort to know that you couldn't ever characterize something or believe in something entirely, and that if you tried to, you would just wind up unhappy because you would be chasing a futile and ultimately inaccurate construct.  It was surprising to hear him describe it that way, and comforting because I felt the same way.

For this reason, I am often very hesitant to call a spade a spade when it comes to life.  I tend to be more comfortable in the grey zone, stating that things are partly good and partly bad, partly from this cause and partly from that cause.  I believe strongly in science, and even more strongly in solid statistics, but when it comes to what I can see and observe, I often don't trust myself to characterize something a certain way.  It gets tricky, though.  When it comes to the big decisions of your life, the ones that involve other people, you have to say that this person is good enough to be in your life, or that person is not worthwhile to keep.  You have to assess whether a lifetime of hurts is worth a few intermittent moments of happiness, and then upset yourself more by asking whether those moments of happiness were ever real ones or deep ones or meaningful ones.  At the same time, you can't cut everyone out when they disappoint you, and declare the world to be full of assholes and say you're going to live in a cave and eat bark.  So when Thanksgiving comes around, it's the time of year where you have to speak up and say, I am grateful for these people who are in my life.  It's a time where you have to call a spade a spade, and say thank you for the ones that you observe, at that moment in time, to be good.

I know certain people who can easily characterize their interactions with their family, friends or significant others as "Awesome!" or "I just don't talk to them", and they're at peace with that, no questions asked.  I always feel jealous, because I would love to have that kind of certainty.  To some extent, the only people I can genuinely characterize as totally awesome are the people that I barely see.  In the few moments where I characterize someone in my life as "wonderful", or say that "I'm glad that things are going great now" or "I'm happy in my life with Joe", I can predict with unequivocal certainty that the person I have just observed will go out of his or her way to make me feel unloved, miserable and foolish for allowing them in and giving my trust, and believing for one second that I could nail them down as a person who took care of me with no questions asked.  So when I wrote the previous post, I did it with a certain amount of dread, knowing that at least a few of the people I showed appreciation for would lose control so heavily as to make me question whether I really wanted them in my life at all.  Those people came through this weekend, in fine form.  I wish I hadn't been right.

It's so predictable, I have to wonder whether those who think they have simply great relationships with their families or spouses really have any relationship at all.  I suspect that they don't, and that they just have polite causal associations that masquerade as relationships, because they never take time to discuss or analyze the bad.  Their relationships aren't tested, because nothing important ever happens, and nobody ever tries to be an essential component in someone else's life.  Maybe the Heisenberg doesn't apply to them because they don't look, they don't observe, they don't try to analyze.  They just take what they have and pretend that it makes for a functional relationship, or a meaningful parthership, or a happy ending.  If I think of it that way, then some of my unhappiness is my fault - I'm the one peering through the microscope in the first place.  And yet, I can't close my eyes.  I always have to look, and then fear that I can't trust what I see in front of me.

I suppose what I am really searching for is a person who can prove Heisenberg wrong.

Because I Should...

Things I am thankful for this year:

1) Getting to see my sister 3 times this year.
2) Replenishing my wardrobe from London, which allows me to feel like a girl when I don't have to wear scrubs.
3) Actually matching into surgery despite my worst (unfounded and borderline paranoid) fears.
4) Working with decent people, and not feeling left out for the first time ever.
5) Being actually healthy, despite all of my personal medical problems.
6) A second chance to make things work with the person I love.
7) My high school friends, who let me disappear for months on end and then welcome me back without the slightest hint of resentment or complaint.
8) My own apartment.
9) Not having to make an important decision in my career for another 4 years.
10) My family, who never panic when really awful stuff happens (although they certainly freak out over the minor things), and always have my back no matter how annoyed I am at them.

ER'body up in my shizzle

Hooray for the emergency department rotation!  It is so nice to be back on my feet again.  It's odd for me to say that, because I am actually one of the laziest people I know and will gladly camp out on my ass if I can get away with it, but I am actually happier when I have spent the day on my feet.  The emergency room at our hospital is quite busy, but also at a reasonable pace most of the time, so I've really enjoyed the experience.

Of course, as the surgical intern, I get special treatment.  Not in the sense that I get Starbucks coffee when I snap my fingers (although a super-nice medicine resident volunteered to get me a free Peppermint Mocha, yum!), but in the sense that the ER residents and attendings try to throw semi-surgical stuff my way.  For example, I spent an entire shift on only 5 patients, because 4 out of 5 of them needed complex suturing.  This probably annoyed the ER attendings, but I've decided not to worry about them because I was doing what they might otherwise consider to be busy work.  It also means that if a patient does turn out to be surgical, I am expected to write the consult and then call the surgical resident to let him or her know about it, and have them come down and see the patient.  Overall, I don't mind doing it, because it's nice to have practice writing consults while there is still someone looking over my shoulder to point out things I may have forgotten.  But it has led to a few minor conflicts where I was trapped between the surgical team (who wanted me to go ahead and do all the admission paperwork as well) and the ER attendings (who wanted me to see the patient with a cold).  I suspect this being-stuck-between-a-rock-and-a-hard-place business will not go away anytime soon.

Fortunately, the ER attending on the previous shift had already called in the facial surgeon to come by and see two of them, and he was kind enough to show me how to get around cartilage in the face and create flaps.  The issue with suturing on the head is that 1) there's a lot of bleeding, 2) skin is thinner in some parts, 3) you want a good cosmetic result but chunks of skin can be missing so it's hard to get the edges to fit together nicely.  Dr. E and I started with a 85 year old lady with dementia who fell getting out of the car, and smacked her head up pretty well.  She had lacerations to her scalp, eyebrow, nose, 4 on her arms, one on her knee and one on her ankle.  Additionally, being elderly, her skin was like paper and really difficult to fit together, since chunks were missing and the edges were abraded.  We started with the scalp, and Dr. E showed me that if you're missing tissue and you're worried about approximating the edges but creating tension and/or wrinkles, you can get your clamp under the skin and loosen up the tissue from its anchor.  This allows you to yank the skin over a bit more, and then you can snip away the zig-zag edges of the wound and create a nice clean line to sew.  We did the same thing on the nose, which is a little trickier but still doable.  Using the same technique for the eyebrow, we gave the patient a minor eyebrow lift (the patient's husband was amused), then stapled the remaining lacerations on her extremities.

A second patient proved to be even more interesting, as he had been jabbed through the ear while working at a construction site.  He had a gaping hole in the ear, which of course had very funky edges, and cartilage hanging out at odd angles.  The first interesting part was actually where you put the lidocaine for local anesthesia.  If you inject all around the hole, you'll blow up the tissue and have a hard time making the edges fit.  Instead, you can use a nerve block in and around the ear to get most of the anesthesia, and then you only need a little bit for the actual wound.

My real patient was much less bloody.

Again, Dr. E showed me how revising the edges and even enlarging the cut can allow for better approximation of the edges, so that it looks more like a natural curve in the ear with no buckles in the cartilage tissue.  The trick is to use some fine nylon suture, and make sure to check front and back of the ear for lacerations because the hole may be differently shaped from the front and the back.

Overall, the ER has been good times.  Although there is often a time pressure to either admit or discharge (ie, crap or get off the pot), I like that the thought process is still about doing your business and then moving on to the next important thing.  I have to again emphasize that I am not very good at shift work and my body always feels messed up afterwards, but I handled my overnight shift with only a few yawns, and it is oddly enjoyable to have a weekday off to study, even if the trade-off was working all weekend.  Maybe it's the quietness of the day to myself.  Maybe it's getting to sleep in late and eat breakfast with my boyfriend in his building's restaurant for once.  Or, maybe it's just knowing that I could drink leftover Halloween "Blood" Rum Punch with lunch on a Monday and nobody can say anything about it.

The TV Version of My Life

I just came back this morning from my first ER shift, which was overnight.  Things went pretty decently overall, and I finally was able to see how an acute CVA is managed from when the patient comes in the door to when the patient is finally admitted, which was nice.  However, my brain is fried from very intermittent sleep, and so I will present a totally brainless yet totally worthwhile collection of...

THE BEST EVER MOMENTS FROM SCRUBS!!!

For those of you not familiar, Scrubs was a TV comedy which ended a year or two ago.  It was very lighthearted and absurdist, yet probably had the most accurate portrayal of medicine on television.  (At least compared to the more melodramatic stuff like Grey's Anatomy, House or ER.)  So, here is the top 5, and please note (of course) that I do not own any of these videos, and I am not distributing them for profit:

5) The Pediatrician: This scene is where Dr. Cox and Jordan are looking for a pediatrician for their newborn son, and Dr. Cox (a Dr. House-like figure) meets his match.  I love this because it is both hilarious and accurate in depicting how some attendings can cut through the crap like nobody's business.

4) Things I Could Care Less About: This particular clip is more about Dr. Cox not caring that it is JD's last day of residency, but it always reminds me of the fact that, on surgical rounds, there are things your seniors care about hearing and things they don't.  Woe betide you if you mix the two up!

3) Exploratory Surgery: Self-explanatory awesomeness.

2) Medical Gangs: This is JD's daydream of the rivalry between medicine residents and surgical residents, and how he and his best friend Turk reconcile it.

1) How To Become A Surgical Attending: If only knocking out the competition for surgical residency was this awesome.  Bonus points for The Todd and his Betrayal Five.

Baby's First Chest Tube

Well, I finally finished medicine.  I can't help but shout a good and proper WOOHOO!!  because I really was getting pretty tired of it, after so long.  Don't get me wrong, internal medicine is important, and of course I have to know how to manage a heart attack or a stroke or blah blah blah.  But honestly, so much of medicine is simple paper pushing, or dealing with "soft admissions" (someone who really didn't need to be admitted but we did it anyways to cover our asses), or patients trying to get out of work, or whining about pain.  I exclude the ICU from this criticism, because I feel like I learned so much from my two weeks on ICU.  Those patients are actually sick, and because there are less of them but with more problems, you can really dig into the physiology aspects of all of the disease processes and get a bigger picture of sepsis, end stage renal disease, end stage cancer and post-operative management.  I have two more weeks on ICU coming up that I am really looking forward to, but I just wish that my surgical program required us to do two months of ICU, instead of forcing us into a month of medicine.

My last day of medicine included a 24 hour call.  In our hospital, the night shift manages the patients for 6 nights a week, which means that their night off must be covered by a 24 hour call.  It's not so bad, but they only put two interns to cover a fully functional hospital, which includes things like discharges, transfers, writing daily progress notes and taking in lots of new admissions.  Our census was especially full this weekend, and my co-intern and I could see that things were going to be somewhat nasty.  I agreed to take step-down / telemetry (boo!) so that I could also get the ICU, gambling on not too much drama happening in the ICU, allowing me to focus on the extra-packed telemetry unit.

Boy, was that a stupid mistake.  The previous night, a young guy came in after not being able to breathe for a long time.  Because he was young and healthy, his heart came back after several rounds of cardiopulmonary resuscitation, but the damage was already done and his brain had suffered from lack of oxygen.  It was a very sad case, made worse by the fact that his family was so calm and quiet through the whole thing.  I spent the whole day fighting back tears and thinking of my parents, and how awful it must be to suddenly lose someone so precious to you.  (This was made worse by the fact that this patient was SMOKING HOT, which I know shouldn't matter, but it was like God gave a gift to women and then selfishly took it away.  Just wrong.)  So I spent the morning accompanying him to the CT machine so that we could evaluate the extent of damage, then talking to the family about options for transfer.

The sanitized version of putting in a chest tube.

I had not yet been able to write a single progress note on a patient when E, one of my favorite surgical residents, mentioned a patient of mine on telemetry who seemed to have fluid building up in the space around her lung.  This patient had just undergone a very minor and routine surgical procedure the day before, and her chest x-rays were getting progressively worse.  E paged me to say that it looked bad, and since her oxygen saturation was dropping and she looked pale, we would have to place a chest tube and try to drain whatever was accumulating.  We were all hoping it would be pus or some other fluid, and not blood, but the odds didn't look so hot.  E generously offered me the chance to put the chest tube in, which I jumped at, because I had never done one myself and I knew I would have to when I rotated at an outside hospital.

There are times where the human aspect of medicine collides with the surgical aspect of medicine, and it's frustrating because it's so easy to just dismiss the human part.  This patient spoke very little English, and she and her husband were both frail elderly people.  We explained multiple times, with a translator, the emergent need for the tube, why we needed fresh blood samples, and why it would be better if everyone stepped out of the room for the procedure.  But it was hard to stay patient with them as they struggled to understand - all they could see was that we kept sticking her with needles for blood, and why weren't those samples good enough?  And why can't our daughter come in, and our son-in-law, since they all speak English?  And why is this so serious?  And where is the attending who did the procedure yesterday?

The Lazarus Phenomenon

Ok, ok, I'm back.

I'm sorry that I haven't blogged, for the *ahem* handful of you out there who actually read this, but I am even more sorry to myself. This has been a great experience so far, and I am going to try harder to keep it up even when things go crazy.

To summarize my life since the last post: I survived surgery, and missed it even more when I went onto Medicine. Medicine was terribly boring and an exercise in how not to be efficient, complete with attending throw-downs, patients hitting on me (and inevitably, they were certifiably psychotic or had anti-social personality disorder), long ass rounds and long ass days. My sister came to visit around Labor Day weekend from Thailand, and I barely saw her or spent time with her. I went to the US Open Quarterfinals. I went on vacation, and spent it at home taking care of administrative stuff as well as hanging out with my cousin from London. In other words, you didn't miss much.

I'm the medicine float now, which is still boring but a bit more tolerable. We have 5 interns covering 4 floors. In the past, we would have the 5th intern help out writing notes on the busiest floor, but since that changed from day to day, continuity of care would be lost and patients would be unknown to the intern who was technically covering the floor. So instead, now we switched to a system where the Float (me) writes all the discharges for the day, and holds the pager if any intern has to be gone for any reason (ex: going to FP clinic, etc). It's a good system, and it makes everyone feel more efficient because discharges get done earlier in the day, and it lets the interns actually know all of their patients and get less bogged down with administrative paperwork.

It's efficient, for the most part, but it can lead to a few harried moments. A few days ago, I held the pager for my friend F while he served his clinic day. As I sat in the ICU writing a transfer slip for a teaching service patient, I suddenly heard, "Um, I think that's a code.." from one of the nurses. I looked around behind me, and a private patient in an adjacent bed had a heart rate of 30 with no palpable pulse. We called the code, and I initiated compressions while waiting for the code team to show up. We all took our turns performing cardiac resuscitation and pushing the rounds of epinephrine and atropine, and unfortunately the patient expired. We confirmed the death on cardiac monitor printout strips to be pasted into the patient file, listened for breath sounds and I looked for femoral and carotid pulses, and called the time of expiration. As I was the intern covering the floor while F was gone, it was my responsibility to fill out the death paperwork and write a note explaining the course of events, as well as to call the patient's private attending. Everyone else left the unit to go back to their floors and resume their work, and I left a message with the attending's service, then turned to the desk to start my work.

About 4 minutes later, the respiratory therapist, who had been standing at the patient's bedside disconnecting the tubing from the wall, suddenly said "Yeah...he's still alive. He just took a breath on his own. And, yeah, he's got a pulse. A good one." I whipped around to look at the patient, and sure enough, his heart was beating so hard that the thrill was visible on the chest wall from a foot away. His left groin, which earlier had been so still, suddenly had a bounding, impossible-to-miss pulse. The respiratory therapist scrambled to find a new bag, as she had discarded the first one, and everyone else gathered around to gawk at the suddenly-alive patient. Meanwhile, the attending called back. "Dr. B? I was calling to tell you that your patient died...but he's not dead yet. He came back! WE CALLED IT AND HE CAME BACK! GAH!!" Fortunately, Dr. B was a calm sort of guy, and reassured me that this sort of thing can happen, and that he most likely would go down very soon again anyways. As he predicted, the patient coded again 10 minutes later, and we had to go through the same round of resuscitation and medications. The patient expired (for real, this time, I triple checked and we waited like an hour just to be sure), and I went about the paperwork, still frazzled by the back-to-life experience I had just witnessed.

When I later recounted the story to a resident, she told me that the circumstances were called the Lazarus Phenomenon. The Lazarus Phenomenon refers to spontaneous return of circulation following failed cardiopulmonary resuscitation. The theory is that the cessation of chest compressions allows the chest to re-expand, re-expanding the heart and kick-starting the electrical system. Or maybe it's bad compressions, failing to circulate the epi and atropine adequately, so they arrive at the heart slowly, after compressions were stopped.

Either way, it's pretty damn freaky.

How to Learn "Fake It Till You Make It" Compassion

The Wall Street Journal has a new piece in their Taste column, "Physician, Humanize Thyself", about the proliferation of White Coat ceremonies at medical students, and whether they instill a greater level of compassion for students as they advance in medicine. The ritual was started a few decades ago, when students were noted to have less idealism and more cynicism than their predecessors, who had since traversed through the medical malpractice and billing changes. The idea was to make them more aware of the figure at the center of the medical world, the patient, and to retain that essential sense of compassion. Another figure in the article questions how effective this ritual can be, since the white coat is intended to visually set the doctor apart from other figures in the hospital setting, not to make the patient feel as if the doctor is on his or her side. Other techniques used by medical students often involve rituals for the cadavers, such as an appreciation ceremony where letters and poems are read aloud to the brave donors. The article misses the point, however, about what real compassion is and how it is manifested. When I applied for medical school, the two themes which pervade the interview are those of compassion and thirst for medical knowledge. But the reality is that almost no medical student truly understands compassion in a specific medical sense (unless they were previously a medical worker in some other capacity).

Compassion, when you are well rested and well fed, relaxed and without pressure, is fairly easy for most people. It is easy to walk into a patient's room at 9 am, and say that you are sorry for their problematic situation, and here is what we are planning to do, and do you have questions? Great! Thanks. Anybody who is a decent human being can do that. But real compassion is an acquired skill. It is the ability to care when you are so tired that you just do not care about anything else except sleep. It is the ability to care that someone is in pain, even if they have a long history of causing the same self-trauma over years. It is the ability to thoroughly describe a medical problem in layman's terms when you have no time to spare, and not lose patience when the patient still did not understand. It is the ability to understand that taking care of someone might require you to cause them some pain or discomfort in the short-term sense, and still be able to do it anyways without hesitating. These are all things that you just cannot pass on in a white coat ceremony, or any other ceremony. Like so many of the real skills in medicine, you have to work them, one 24-hour shift at a time. And until you have those skills mastered, you have to pretend you have them already, lest you cause major damage to the patient and family. In other words, to become a truly compassionate doctor, sometimes you have to fake it until you make it.

It sure would be nice to be able to help medical students with the faking part, at least. My medical school did one thing that I appreciated, which was practicing patient encounters with actors. Many times our experiences were laughable, and taking them seriously was next to impossible. Specifically, I remember an encounter where I had to tell a "wife" that her husband had died from a heart attack. Her response was to repeat "I can't deal with this right now, I need to get the groceries and pick up the kids" ad nausem, and then eventually stop talking. I had to bite my lip to keep from laughing, because it all felt so fake to me. (I had been expecting to see her cry, or yell at me, or have some kind of response which actually related to the news.) But having now spoken to several families after patients pass away, or are about to, I see that that experience was actually helpful in preparing me for the variety of ways that humans can respond to news. More important than the formality of a ceremony for medical schools would be the investment in standardized patient encounters, and education in situation-appropriate language. This is an area where most students (and many doctors) are still painfully lacking. At least if we have to fake compassion, we can do it with sensitive language and formalized demonstration of respect.

Treat For America

My first month on in-house surgery is coming to a close this weekend, and I can honestly say that I will miss it. It has been tough, of course, being Q3 and so on (and Q2 this week, to make up for getting Labor Day weekend to spend with my sister), but overall I really did enjoy things. It's nice to write focused notes, and speak quickly and succinctly, and justify not hitting the gym because I run around so much. My residents this past month have really looked out for me, and I've been able to throw in a few central lines without too much difficulty. Hopefully when I re-start surgery again in December at an outside rotation, I'll be able to hold my own.

I'm not sure my residents all feel the same way in terms of nostalgia for surgery at my hospital. Without saying too much to identify my medical center, it is an old, small community hospital in the NYC area. I have rotated at a lot of not-so-well funded hospitals in NY, and this is probably the least funded of all. At our hospital, it is often difficult to find very basic supplies, especially in the middle of the night. Shortages of medications or fluids are common, and interns often stash blood-drawing supplies in their pockets at night because the nurses' stations are never re-stocked for the evening. In summer, we have our fair share of mosquitoes and other buggies, and humidity shoots through the roof. The call room I was using had a massive hole in the wall leading to outside, with no insect screen or boarding up, for several weeks.

Small discomforts aside, there seems to be an undercurrent of deeper unhappiness amongst residents that our hospital at times seems ill-equipped to handle some patient complications. This feeling is more pronounced in the surgery residents, because we do more invasive interventions and cannot always optimize the outcomes to the standard we would like. Some residents have taken the position that if we cannot manage care at the same standard as bigger academic name-brand facilities, then we should not attempt such procedures in-house. Added to that, of course, is the general feeling of uneasiness that all residents feel when they realize just how little the patients truly know about the goings-on of inter-department politics, inexperience of residents, complications of procedures, and alternative options for care.

Somehow, I have managed not to share too much in this same experience, although I find that chipping away slowly. Last night, I had to spend 40 minutes hunting for 2 blood culture bottles so that I could find out of my acutely feverish patient had a bacterial infection post-operatively. It was time I could have spent writing better notes on my patients or spending more time checking on them (or sleeping...), and it didn't feel too good knowing that I got the last set in the hospital when we presumably have many other patients who may also be running fevers. The resident I was on with is one of the main people who quietly voices his opinion regarding our inability to provide gold-standard care at all times, and by the end of the night, I found myself getting more annoyed with my hospital's precarious financial state.

I called my sister, who is flying out tonight back to London, to basically complain for a few minutes about how I got slammed last night and how there was so much to be done, and how my hospital is disappointingly unable to provide all care for our patients. I was surprised when she (not a doctor) laughed at me, and reminded me that medicine is not equal-opportunity, no matter how much we try to make it so. "The fact is, richer hospitals exist in richer areas because you have richer taxpayers, and vice versa. Poorer people receive lesser care because the people in their areas don't have insurance and can't fund their hospitals as much. It's really that simple." She went on to remind me that American schools are often in a similar situation, but young college graduates apply in droves for the prestigious Teach For America program. "Of course it's not the best education for kids, that's the point. You're investing your time to make a bad situation better. You don't complain once you get there that there isn't enough paper or textbooks or parental support. It's a poor school. Duh."

The final note she left me on was the reminder that other family members we had who are also doctors perhaps would not be able to work under the same conditions and thrive. "Are you kidding me? They would just get frustrated that labs aren't done on time, and that not everything is on the computer, and miss the whole point of working somewhere needy. You, unlike them, can do this, you're built for it." And she's right. One day, many eons from now, I will be stronger for having worked at a rough-around-the-edges hospital, and when everyone flails because the expensive wound-vacuum system is malfunctioning and the patient is dripping bile from his fistula, I'll know how to jerry-rig the damn system, old-school.

So, I've decided to look at my program as like a 5-year volunteer course instead of a regular old job. Treat For America, it is.

10 Things I Hate About My Life

This isn't really much of a philosophical post as much as it is...bitching.

Here are some things that I find overwhelming and just cannot stand anymore:

1) Having to beg people to do their very basic jobs
2) Having to act like they have done me a favor afterwards, and I am beholden to give them my first-born child
3) Criticism that is neither constructive nor appropriate, and unceasing even when I state a desire for cessation.
4) External pressure from people for things that are not yet in my control
5) Not drinking enough water because I am too busy running around, and then feeling like I have a UTI afterwards
6) Call rooms filled with mosquitoes that keep me from sleeping
7) Multiple parties all vying for my time and attention, followed by the same multiple parties acting offended when I cannot meet them 100% unless I forgo sleep and study time
8) Being told that I am not doing enough, and then being told that I am too obsessed with doing the same activity
9) Any level of running commentary on my appearance, ever.
10) Having finally gotten my own job, apartment and paycheck, and still not being able to exist with room to breathe.

Ok, rant over.

And So I Enter the Surgi-Cell

Is it odd to dread the thing you love?

For the past month, I've been biding my time on Pediatrics, watching the surgery team burst onto the floor, parade around importantly, impatiently jiggle a few bellies and pack a few abscesses and disappear. Every intern I spoke with had the attitude of "Good luck, dude...", with a head-shaking and low whistle. I've been alternating between envy and fear.

And on Sunday, I started.

As is my luck, I caught a bug from the NASTY GRUBBY IRRITATINGLY ADORABLE MONSTERS of pediatric clinic on the second to last day of the rotation. I couldn't really complain, since I constantly have colds and I was very much overdue for one, but I really did try the entire rotation to keep myself clean. I was doing ok on Saturday, coughing a bit but handling things well on some vitamins and Tylenol. But by Sunday morning, I was a raging mess, and never really had a voice to lose in the first place.

As is also my luck, it wasn't a bad call work-wise. Sundays are typically used for cleaning up the surgical patient list, cleaning up messes left over from Friday and Saturday, and just generally keeping things under control. I lucked out with a senior resident who was understanding of my not being too put-together on my first day, and a medical student who was experienced enough that I didn't have to stay on top of her work. The list wasn't too bad, there were no massive emergencies or codes, and no cases.

However, I spent the entire day sweating up a storm, coughing my brains out, swallowing thick snot, sneezing (that deep, worrisome kind), and generally feeling fatigued and not myself. I caught myself at several points throughout the day, gazing off into space and forgetting which task I was meant to be taking care of. I didn't drink enough water, and forgot to take my vitamins and Tylenol. I wasted a lot of time that could have been used towards getting my notes written and following up on labs, and as a result only got about 2 hours of sleep. I forgot a patient on the list who was still sitting in the ER, and had to frantically write my note at the last minute. I found myself oddly energetic at points, though, as if my cold was breaking, and my adrenal glands had gotten the "Go, team, GO!" message and kicked into gear. By the time I got to morning rounds, I was so wide awake that my worst reaction to a hoop-jumping request from my chief resident was just mild grumbling. I popped 2 Benadryls while pulling out of the parking lot at 10 am, and fell asleep pretty quickly, planning to sleep away the day and not worry about studying. Paradoxically, letting myself sleep away the day guilt-free meant that I was feeling much better when I woke up, and was actually able to study for a bit.

My day today, while hectic, was actually pretty good. I stayed quiet most of the day so that I could learn how things were run, and got assigned to help with a few minor procedures because I was the only intern on surgery who was a surgical intern. (My first ever fecal disimpaction was a bit of a letdown, because I didn't get the big rush of poop coming out that I was hoping for. C'est la vie.) I stayed to help out the intern on call, and by the end of the day, I actually felt like I had a feel for how things worked, and I went home happy.

My call was awful, and I was terrified for today, but I survived. It wasn't that bad in the end, and I realized that when push comes to shove, I am tougher than I give myself credit for. I'm not incapable, just inexperienced, and luckily I have five years to resolve that. I can do it. I am happy and empowered =)

My Teachers From Near and Far

I've just finished week 3 of pediatrics, and I must say that I am enjoying it a lot more than I expected. Our attending, Dr. J, is just fantastic. When I came into the rotation, the outbound medical students warned me that he was a person to be feared on his "bad days", and often was short with them, etc. On my first day of the rotation, he sharply rapped his hand on the cart of patient charts when his student yet again failed to present the patient's clinical progress and physical exam in the correct progression. Rounds with him are tough, because he expects us all to be thorough with our patient interviews and exams, but you always come out of it feeling as though you have learned more. In my weeks with him, he has been not only professional, but extraordinarily kind and gentle with his patients and their families. It always seems as though he has seen everything, almost as if he can divine diagnoses. He knows exactly what's going on with each patient, and which are good cases to see, and which complications should be anticipated. Furthermore, it's effortless for him to spout key information while guiding everyone into doing the work exactly as he wants it done.

Notably, Dr. J is foreign-born and trained. He speaks with a strong accent, has a difficult to pronounce name, and can be unorthodox in his manner of interaction with people. He is not alone in these features - I have had many foreign-born attending physicians who were brilliant, unparalleled in their clinical skills and breadth of knowledge base, but perhaps also have certain features that could make any patient who isn't "in the know" be wary.

Pauline Chen wrote a piece this week on this same issue, discussing the unfortunate nature of this situation. In the United States, there are typically more residency spots per year than there are American graduates to fill them. Usually, those spots will either go empty, or are filled by graduates from foreign medical schools. These graduates, for lack of a better categorization, are typically Americans who attended school abroad (most often in the Caribbean), or foreign-born doctors who attended school in other parts of the world (India, China, Europe, Africa, Central and South America). The second group, simply by originating from countries where academic competition is far more rigorous than in the US, tend to be the cream of the crop for those nations intellectually, and score better on medical exams than even our own medical students and residents do. Having trained abroad, they often have seen a far greater volume of cases than we get to, and are drilled much more heavily on traditional subjects like physiology and pathophysiology than we are. Also, since they may not have had as immediate access to imaging and laboratory studies as we do, their clinical diagnostic skills are often superior. They represent a unique opportunity for American medical students and residents to learn, because we may go our whole residency never seeing a real case of measles or malaria, and those classically tested subjects were most likely bread and butter to them on clinical rotations.

However, I have certainly seen more than a few foreign-trained doctors with a total lack of understanding for the culturally and socially specific needs of the American patient. On my first day of 3rd year internal medicine, there were several new residents in the program who had no earthly idea of which illegal drugs had which commonly used nicknames, and what the various routes of administration were. Nor did they care to ask, because they were too focused on the more immediate, tangible medical issues at hand. I later rotated with an Indian-run suburban family practice group that almost never suggested Gardasil for their pre-teen female patients, and barely discussed it even if prompted. Their reasoning was that good Indian girls don't have sex when they go to college, and it wasn't a conversation that needed to be had, even if just to ensure that those girls didn't become sexually active. (Having attended an American college in a large city, I can emphatically state that Indian girls DO IN FACT have sex in high school and college, they just don't tell their parents.) Discussions regarding psychosocial issues behind dangerous behavior patterns nearly never take place, even while the pediatric and obstetric-gynecologic communities are pushing for increased openness. But again, this is no hard and fast rule - Dr. J and several others I have met all fully investigate these issues, and are sometimes even more skilled than the average psychiatrist in teasing them out.

Pauline Chen brings up one more objective method of evaluating a doctor's abilities, better than the name of the med school a doctor graduated from, or where he or she did her residency, or what the scores were on all the exams. She points to the board certification, which is the designation of a physician who has demonstrated mastery in his or her specialty, as deemed by the Board of that specialty. Usually this involves a written exam, and often an oral exam as well. It is a rigorous process which is completed after completion of residency and/or fellowship training, and re-certification has to be done every 7 to 10 years (depending on the field). It is a super expensive exam to take, and if you're the only doctor for miles, it doesn't have much value because people will come to you anyways. So while not being board-certified doesn't indicate lack of competence, having it does allow some degree of assurance of knowledge and skill in the specialty.

The problem with board certification is that virtually nobody in the general population even knows what the heck it is. Even amongst people who have some connection to the medical world, like family that has seen you through the process or people working in the field, it is very easy to confuse the MCATs (med school admission test), the Step 1 Boards (at the end of 2nd year of med school, testing book knowledge), the Shelf Exams (following each 3rd year core clinical rotation), the Step 2 Boards (during 4th year of med school, testing book and clinical knowledge), the Step 3 Boards (during first 2 years of residency, testing clinical knowledge), the in-service exams (yearly testing during residency, for your specific specialty) and the Board Certification exam. Oh, and state licensing, which is when you register with your state as a physician and they license you to practice, and you can now write prescriptions without having another doctor co-sign with you. When a friend seeking a primary doc decided he wanted a board-certified internist, he still had no idea of how to search for such people in his area, and then figure out if they took his insurance or not.

So, I suppose the point of all of this is just to say that there is no 1-click way of knowing which doctors are competent for your needs. Do you research to narrow it down to a few people that fit your needs, then try each person out. Sometimes, it's hit or miss. But the foreign-trained physician gems are there, and far more of them exist than we give credit for.

To Sir, With Love

One aspect of medicine which is so pervasive, yet infrequently discussed, is the role of teaching. By this, I mean the day to day, person to person teaching that happens on every rotation that one goes through as a student or resident. I've always enjoyed this part, because it makes me feel like learning is a tangible discussion, rather than a formal and stiff lesson. There's something thrilling about walking away from a lively spontaneous discussion on sickle cell anemia or primary amenorrhea, that makes you feel like you gained so much just by staying tuned in for an extra five minutes.

What's not so easy, I'm discovering, is leading that teaching process. I've always loved sharing information with others, and reinforcing what I think I know with a group of people who inevitably remember better than I do. As medical students, we are continuously expected to teach and help each other, as well as to give more formal talks on disease processes and case presentation. But I'm realizing now that this type of teaching, which is simply informational, is the easy part. What's not so easy is to teach someone how to be a medical student, how to get through doing physical exams and admissions and learning to formally present a patient at rounds. I remember helping third year students with this last year, and I never found it as difficult, perhaps because the responsibility ultimately didn't fall with me.

But perhaps I was also lucky, and didn't have too many encounters with that Thorn In Your Side, the lazy medical student. Most medical students I knew, often my friends, were incredibly smart but also terribly hard working. They didn't mind coming a little earlier or staying a little late to get things done, especially if it meant learning how to do something new that would later be an expected responsibility, like drawing blood or placing IV lines. I myself enjoyed staying late to learn how to do central lines or surgery consults, because I wanted to be sure that I at least had an idea of how they were done before I was expected to do them regularly. This is, of course, most likely a ridiculously rosy picture of myself, and I know that on many occasions I have been an inadequate or incompetent student. But I can say with 100% certainty that I always tried hard.

Somehow, it never occurred to me that there are some people who make it past the first two years of school and are still trying to make it through with as little work as humanly possible. These are the people who don't want to see the complicated cases, even if they are classically tested on the board exams. These are the people who don't want to learn how to properly present a case, and refuse to recognize the value in an efficient exchange of patient information between colleagues. These are the people who consistently disappear to the cafeteria or library if you don't keep your eyes on them, and always have a complaint about something or another. Every conversation is about which specialty gets you the most money for the least work, and every assignment is met with a complaint (and even talking-back). And, of course, these are the people who are most persistent in asking about how to game the system and get the best recommendation letters.

A lot of residents I know are of the mentality that if a person wants to screw him or herself over, let it happen. We are all adults, this isn't daycare, if someone doesn't want to learn how to work hard, that's their problem. I wish I had more of a hands-off attitude like that sometimes, because I feel like I am letting myself get more stressed about this type of situation than I need to be. But I feel that if all doctors are also teachers, we have a responsibility to help our students find the motivation to work hard, and form good habits. I also feel that I have a responsibility to all the students who do work very hard on rotations, even if it isn't a specialty they want, and it isn't fair that other students slack off and there are no consequences. I know that I had a lot of bad habits as a student, many of which I still struggle with, and it's only with the consistent help of people who cared that I've been able to make any improvement at all in my SOAP note writing or patient presentation. So, I don't want to give up.

I wonder how my parents did it.

I Wish Everyone Lived in La Crosse, Wisconsin

I'm lacking in things to say right now, but this is yet another lovely piece by Dr. Atul Gawande. This time, it's on end of life care and how we choose it and reject it. The article touches on several points, but includes one simple measure that a Wisconsin town took for all patients entering its hospital. It has resulted in a significant reduction in end of life costs.


1. Do you want to be resuscitated if your heart stops?

2. Do you want aggressive treatments such as intubation and mechanical ventilation?

3. Do you want antibiotics?

4. Do you want tube or intravenous feeding if you can’t eat on your own?

Atul Gawande at the New Yorker: Letting Go

Back to the Waking Life

Hurrah! I have survived my two weeks on night float. Everytime I tell someone that, they all sort of imply that it's amongst the worse things you'll have to do as an intern. My experience really wasn't that bad, overall. Perhaps some of that was luck, in that nobody died unexpectedly or suffered because of a massive mistake I had made. Or maybe I just had really decent nurses in the ICU who had my back.

My last two nights, unfortunately, were hell. I realize now that some of that was my own fault, for not knowing when to ask for help in managing tasks. (I also didn't know that I had the right to insist that my senior medical resident physically come down to help me when I needed it for complicated patient problems.) Both nights, my pager exploded at 7 pm with things to do, and many tasks were pushed aside because of acute patients in danger of hemodynamic compromise. As a result, I managed to piss off nurses in the telemetry / step down unit, upset a family because I wasn't able to call them when their family member passed away in the hospice unit two hours before, embarrass myself in front of the surgery team because my medical senior resident had foisted a bogus request onto me, and basically run around as though I was not in any kind of control whatsoever.

When I read back on that, it seems a lot calmer a description than what I went through. After the first busy night, I had a mini-crackdown because I found it so upsetting that everyone was looking to me as if I had answers that I clearly couldn't possibly have because I am just too dumb to be a real doctor. I was upset because someone was rude to me, something I should have been able to handle but instead took as a sign that I was totally on my own. I was glad to have made it through that first night, and was so sure that the evening after would be calm and quiet. Of course, it was just as much madness and it seemed like there was just no respite. On top of having an even more acute patient and multiple other pages come in, a nurse informed me 30 minutes before signouts in the morning that a patient had not received any fluids or food for a full day, and was now reporting severe dehydration. Of course, this patient was also scheduled for surgery, and when I asked them for help with a central line, I got yelled at for not bringing the matter to their attention sooner, and was stuck staying an extra 2 hours longer trying to rectify the many complications associated with the situation.

In fairness, I deserved that reaming. Looking back over the past 2 weeks, there were a lot of things that I overlooked or didn't consider, many fevers I didn't investigate fully, many calls for help I should have made but didn't. Everyday, I felt like the bar was higher, always unreachable. And after those two days, I drove home asking myself if this was what I really wanted. I don't like missing sleep, I don't like feeling gross and messy, I don't like feeling like I've messed up, and I don't like getting yelled at.

But after a few days of getting back to a normal sleep schedule, I remembered that I always doubt whether I want to do surgery when I'm post-call. I always hate getting pushed around or failing. And I love it that much more when I brush myself off and finally win. I love surgery, and I love that it's hard, and I love that it's not something everyone can do. I love getting asked something and realizing that I learned the answer without even realizing it. And ultimately, I chose this. So I've jumped off the cliff, and all I can do is hope for a soft landing.

Singing the Pager Blues

It breaks my heart to say this, but my pager and I are not doing so well. Perhaps I should modify that - my pager and I are a team, but everyone seems to hate us.

Two nights running, now, I haven't been receiving pages. The first night, it was one of the regular floors that kept paging, and then went to the operator when they couldn't reach me. But the odd thing is, the operator's page went through right away. Near the very end of my shift, I got paged by my senior to ask why I wasn't responding to pages from the ICU. Irritatingly, I was sitting at a computer 15 feet from the ICU, checking labs, and hadn't received the page. Last night, I missed a code, although at least that one had an explanation - the operator (who was new) thought that only the intern covering that patient needed to get paged, when in fact ALL interns have to go to the bedside.

Now, most pages you get in the middle of the night are not emergent. Most often, it's just for something small, like renewal of a medication or an order that wasn't written correctly. Occasionally, there's a problem where you do need to go down and check the patient out in person, like blood pressure issues or chest pain concerns. Naturally, in such a scenario, the nurse wants to reach you. But twice now, instead of trying me via the operator, they went straight to contacting my senior resident, which makes me look like The Lazy Intern Who Ignores Pages and Can't Be Trusted. What kills me is that I really do want to go to all of these pages, because I'm still learning as I go and I certainly don't want to miss something important like a heart attack or stroke.

I don't like to complain about technological pitfalls in hospitals, because the fact remains that only 10% of all hospitals in the United States even have EMR systems, and I picked residencies based in poorer inner-city areas because I wanted the experience. But it seems to me that the whole pager system is shockingly inefficient and cost-ineffective. I once did an ob-gyn rotation at a hospital in New Jersey where, instead of pagers, they had in-house cell-phones. They were pretty big and bulky, more like cordless phones, but they worked great because anyone trying to reach you didn't have to wait for you to call-back. There was no question of receiving a page with a hospital extension that didn't exist (I once got paged to the 5th floor, and we don't have one), or trying to call someone back only to find that they had walked away from the phone. If you were busy and running around the hospital, a person trying to reach you didn't have to wait for you to get to a nursing station with a phone not in use. Also, for anyone in a surgical or ob-gyn residency, if you were scrubbed into a case, the circulating nurse could pick up for you and relay the message right away, or even hold the phone to your ear if necessary. It made getting the work done easier for everyone, nurses and residents alike.

Maddeningly, I have tested and re-tested my pager a million times, and it is working just great. Of course, I could just trade the sucker in for a new one, but then I would lose my Hawaii Five-O theme song ringtone. Fortunately, the important nurses (covering the critically ill patients in the ICU) know that I'm serious about wanting to come and help, and aren't angry at me. Last night, I averted the situation by physically going to each floor and making them page me to prove that it was working, and that I did want to come down for anything important. I also made sure they all had the phone number for the girls' call room phone, just in case something didn't go through. But the nurses on the floor are a little bit less invested in making a real effort all of the time, and the last thing I need is talk spreading all over the hospital that I'm the surgical intern who doesn't give a crap.

A Subject Close To My Heart

I don't want to beat anybody over the head in either direction. But the NY Times has a terrific article coming up this weekend on abortion provision in our country, and how shifts in medical education and training for ob-gyn residency has changed our attitudes and ability to access decent care.

NY Times: The New Abortion Providers

My only point is this: it's legal, and women deserve reasonable access to safe procedures without risk of being hassled (either as abortion providers, nurses or patients). We don't hassle transplant surgeons for giving new livers to recovering alcoholics, and we don't hassle psychiatrists for treating sex offenders. Let doctors learn, train and do their jobs without the politics. We all have a responsibility to treat our patients to the very best of our ability, and that means knowing how abortion procedures work and how to manage the care and complications, even if one doesn't plan on providing them in practice. If you don't want people in your community to terminate their unwanted pregnancies, let's all work together on ways to prevent them from happening in the first place.

Things I Learned From Night Float

1) Having my beeper set to the tune of the Hawaii Five-O theme song really does make getting paged multiple times at 3 in the morning less painful.

2) Bring lots of water bottles because yours will get thrown out.

3) The residency hierarchy is alive and kicking. The intern call room looks like a crack den, but the surgical suite has plush couches and a big screen tv. Oh, and a working phone and computer to check labs on.

4) The stroke floor is where I will go to hide, because the nurses are so nice that they give you Vitamin Water and help you do the labs.

5) I don't need to call The Wake-Up Squad after all. It turns out that there is an easier way to stay up when you need to.

Definitely Not an I-Banker

Not that it needs repeating, but it is depressing to be home on a Saturday night when all of your friends at home are out for the weekend, tubing and catching up with out-of-towners and just generally enjoying their summer.

Here's what I'm reading:



The sad part is that I am trying very hard to actually remember all of the important topics I am learning about in surgery and for Step III. Unfortunately, all of my brain space is occupied, because I have the entire Harry Potter series memorized. Blood supply to the gallbladder? Umm, I think it involves the celiac trunk, somewhere. Etymology of the name "Dumbledore"? It originates from the Old English word used to describe a buzzing sound, most often associated with bumblebees.

To make things worse, here is my desk setup:


And here is my actual desk, parked in front of the tv:



At least I am trying, though. In my chapter on wound healing, I was losing focus, only to find references to cutting-edge research being done in Princeton and Plainsboro and other parts of central NJ, where I am from. So don't go talking shiz-nit about my state, yo. JERSEY PRIDE!!!

Sesame Street, it ain't

There are so many aspects of medicine and hospitals that you forget over time, until something reminds you. I did radiology as my last rotation, followed by vacation, so to some extent I had forgotten how to examine a patient thoroughly and write a basic note. I had forgotten how the smell of electrocautery (burning flesh) in the operating room wakes me up like coffee, and how looking at abdominal fat makes me crave cheeseburgers. I had forgotten how much I like talking to patients and finding out how they are doing, and watching them get better with time.

I also forgot how political and territorial medicine can be. I had a very minor yet unwelcome reminder this week, as I finished up my gynecology rotation. We finally had a case booked, a simple hysterectomy, and I read up the night before on pelvic anatomy and practiced my two-handed knot tying.






On our service, the gynecology intern has a family practice senior resident to call if there are any issues or questions which are too menial for the Ob-Gyn attending. I called to let her know that there would be a case, and she stated an interest to come. I didn't think anything of it, but the next morning, I discovered that the case was actually a tag-team case involving general surgery as well. This meant that I now had a more direct educational stake in the procedure, especially since it was something I had never seen before, an abdominoplasty.



Since both attendings were scrubbing the case, they said they only wanted one resident at a time scrubbing to assist. I deferred to my senior resident, thinking that the senior had "seniority" for the case (ie, more right to scrub than I did, as intern). I didn't think too much of it, although I was disappointed not to scrub into the case. But after the case was done, multiple general surgery residents approached me to find out why I had not joined the case. When I said that my senior resident had scrubbed instead, suddenly everyone was not happy.

As it turned out, the gynecology intern is supposed to scrub all cases, and the senior resident is just there to help out on the floor as needed. Especially because I was a surgery intern, my surgery seniors felt that I had the right to be there while my senior family practice resident did not. Unbeknown st to me, this particular resident had previously expressed an interest to join surgery and was not accepted, and so her actions were interpreted by the surgery residents as trying to get into where she did not belong. The surgery chief resident discussed the situation with her, for future clarification, and the whole thing was resolved relatively painlessly.

But the divisiveness of the whole thing surprised me. Suddenly, I was "team surgery", so to speak, and my seniors were looking out for me even though I am not to join surgery service for several weeks. The other residencies in our hospital were "they" or "them", with guesses as to motivations, wants and needs. It was nice to have someone stand up for me and my education. It was my only case for the entire gyn service, and I actually enjoy gyn, so I would have liked to be a part of the case and maybe even get to help. But I felt a little bad that it was at the exclusion of someone else. It just wasn't very warm and fuzzy.

On the other hand, last year I was so aggressive with my showcasing for surgery that I would actively kick lowly third-year students out of good cases so that I could use the few weeks I had on service to demonstrate my skills to attendings and hopefully score an interview. One student even called me a b**** and tried to complain to a resident, only to get smacked down for disrespecting my seniority. I'm not exactly Fozzie Bear myself.

Douchebag O' The Day

It's hard to see here, but he also had BMW decals next to his BMW rear styling. And, as icing on the cake, he had gel-spiked hair, a tan darker than me, and a popped collar. A fist-pump to you, dude.

Edit on 7/9/10: While driving from my hospital towards the bridge, I saw THE EXACT SAME CAR. If this guy shows up as my surgical patient, I may die. Or maybe I'll just ask him if he wants "BMW" cauterized onto his ass.

the end of a week of torture

....because I now FINALLY have internet in my apartment! YEAAAAAAA!!!!

PS - Right after I wrote so glowingly about missing my parents, they both turned into royal paranoid neverending messes. My dad decided that ANY POLICEMAN ANYWHERE can pull him over and arrest him if he can't provide immediate proof of citizenship, and therefore we must all blow $45 on the stupid new passport cards. Dude, this is the NYC area, not Arizona. Also, you're a pillar of the community, and it would be national headlines if the central NJ police were stupid enough to arrest you without warrant or cause. And my mom just decided to keep talking and stop listening. Because her voice is so beautiful to hear, I'm sure.

Bah.

Not So Much a Throwdown as a Slowdown

A corollary to go with my bad-luck-turns-into-good-luck theme is that things are almost never what I expect. I've been sweating and dreaming (nightmare-ing, really) and just worrying myself into a hole about the start of residency for weeks now. I've been dreading the responsibility and feeling excited for the importance of it all, and just generally expecting that it was going to be a big huge change.

Predictably, it is boring and easy and anti-climactic.

I've been assigned to start on gynecology, and I had no complaints about that because I really do love the field. This particular hospital doesn't have any obstetrics, unfortunately, but I still enjoy things like clinic care and hysterectomies and such, so I really didn't change my expectations going in. The attending is super nice and a great teacher, and it is really a pleasure to be around attendings who let you do things but don't pressure you if you're not sure which way to go when you're starting out.

But my god, the boredom. It turns out they only have 2 half-days of clinic a week, and nobody scheduled cases because they didn't want patients post-op over the holiday weekend. And the following week, even clinic is cancelled. So basically, my job is to wait for consults, and I have not had that many so far. (I did have one very young teenager miscarry her pregnancy, and then go 10 rounds with me on starting a reliable birth control method while showing no indication that she would change her 3-partners-in-2-months pattern, but that's ureters under the ovarian arteries. Ha! Water under the bridge! Gyn humor! HA HA!!!)

I've been so relaxed on this rotation, people keep coming up to me and saying that I look too happy to be an intern. The program director for surgery keeps asking me why I'm wearing an actual skirt instead of wrinkled scrubs. My co-intern teased me about the audacity of wearing dusty pink peektoe heels. And everyone keeps checking their schedule to see when they get to go on gyn.

In other news, my parents are leaving relatively soon for a massive trip to Asia which will include attending my sister's MBA graduation and hanging with my expat cousins in Shanghai. Needless to say, I am super jealous and wish badly that I could go, but I'm also having an odd feeling of dread. They'll be gone for quite awhile, and I can already tell that I'm going to really miss having them to call and complain to and get scolded by. Which always surprises me, because I am the average Indian twenty-something-treated-like-she's-16 and every time I come home I get scolded and nagged for this and that, and I hate it. HAAATE it. But I know that when they go, they're going to have such a good time that they'll do what they usually do, which is out of sight, out of mind, and not worry about me at all. The last time my whole family was on a trip together without me, my mom kept hanging up on me because she had parties to get back to. Parties. The time before that, my parents went on a cruise with my British aunt and uncle in the Caribbean. I was studying for finals during winter quarter in college, and feeling stressed and depressed and lonely. I got a call from them while studying on my birthday, and they sounded too relaxed and semi-boozed to talk me off the ledge (mind, it takes like 1 rum drink to do that to my mom).

So I will be free, soon, and irritatingly, I'm not looking forward to it. It's going to be very lonesome.

Focus Pocus

It's Day 2 of Operation: Start Studying for the Boards, and it is not going well. I keep sitting down to read on gynecology, a subject I actually enjoy, and I just cannot focus. I found a TINY spot in my apt with just a little bit of WiFi reception, so I am finally catching up on all the entertainment gossip I have missed, and tracking England vs Germany. (For my British cousins, I'm sorry to say that I am rooting for Germany. Rooney just doesn't do it for me, and England is playing like a bunch of babies.) I watched Gandhi yesterday, and finished part 1 of the Glee season on DVD, and futzed around, and cleaned up my living room, and basically found every possible way of avoiding my homework.

I am SO not ready for residency. Or responsibility. Or anything.

(On a related note, I just heard a raucous cheering coming from my computer. Turns out that the NYTimes has their World Cup blog programmed to cheer everytime a goal is scored. 4-1 Germany, bitches!!)

If things go well, I might be showing her my O-face.

Sorry that I've been gone so long! There has been a plethora of craziness, which started with a whole host of personal junk and moving to Queens, and ended with an intimidating orientation week.

First things first - I didn't realize there would be so many interns starting with me! Most are not in my field, but I recognized a lot of classmates and overall people seem decently nice. We will all be rotating together during our first year, which makes me feel good because I won't be going through it all alone. My program took 5 interns including me, and the program also does have a lot of girls, which is another good thing. (Although women can be bitchy. I'll have to look out for that.) Most of the faculty seemed approachable and full of useful advice, like DON'T PISS OFF THE NURSES BECAUSE THEY RUN THE HOSPITAL and DON'T PISS OFF THE RADIOLOGISTS BECAUSE WE DON'T HAVE A PACS SYSTEM HERE. Overall, though, the message is that this will be an interesting year that I will look back on for the rest of my life and blah, blah, blah. Dear God, I just want to make it to vacation in October. Love, Sarada.

One thing that kind of struck me was how Fight Club the whole thing was. Residency is, by and large, like being in the army. Which makes me feel great because there's no earthly way I'd survive in the army. There's a clearly delineated hierarchy, and when you have an issue, you'd think that you just go straight up the hierarchy. Not so, apparently. This is FIGHT CLUB, and the first rule of fight club is that you DO NOT TALK ABOUT FIGHT CLUB. So if I have an issue, it's basically down to my chief resident to care or not care about helping buffer it with the offending party. They were pretty clear about not taking things to the program director or chief of surgery, which I was surprised about. Supposedly this is for our protection, but somehow not being able to talk to someone who is actually employed by the hospital is somewhat disconcerting. I completely understand the need of making sure your chief resident is on board, because they're in charge of the team and it isn't fair to blindside them with some issue and let it escalate unnecessarily. But the whole thing is kind of sweep-it-under-the-rug.

The good news is that my co-residents and chiefs seem like decent people. They were really insistent that we go to them for any help we need when it comes to managing patients or doing minor procedures, as well as reporting any mistakes made. It's an important message to give, because nobody wants to look incompetent or unprepared, and people will lie/pretend/ignore issues to maintain a game face. I keep thinking about how I'd feel if I was that patient and someone was putting their own ego above my health management, and I'm glad that the department is working hard to make sure we don't go hiding or beat ourselves up for mistakes at the expense of fixing them. We have mandatory socializing today at a bar, which I suppose is to encourage everyone to let their hair down / find out what we're really made of when we're drunk. I'm trying desperately to get some studying done before I go, because we have to read a ton of Sabiston's Textbook of Surgery each week, along with studying for the Step III of the board exams. I'm starting off with my Case Files: Ob-Gyn review book, because my first rotation of the year is Ob-Gyn (gulp!) and I really don't want to look unprepared in front of the attending. Although, let's face it, I am utterly unprepared. I don't even have my white coat or beeper yet.

In other news, my apartment is officially set up, but I foolishly only installed one AC unit and now it is balls to the wall hot in here. Hopefully in a day or two I will have my second unit in place and I won't be drinking gallons of water a day. I also still do not have internet, which is a bigger problem than I thought because I have a lot of registering for exams and such to take care of. (Also, I can't blog.) Ah well. At least my kidneys and sweat glands are happy.

An Odd Coincidence

Well, it's T-minus 6 days until orientation, and I'm getting a bit nervous. I think my parents picked up on that, because they suggested we hit the temple and do a little pre-residency prayer. I'm not a hugely sentimental person, but it seemed appropriate given just how COMPLETELY SCREWED N THE BUTT I WILL BE, so I was all for it.

We went to the temple this morning, and as we were lining up to take prasadam (blessed food) from the priest, we managed to notice an older couple there who we recognized. The man was a semi-retired pediatrician, Dr. S, who passed his practice onto his son. And at the risk of sounding melodramatic, this guy saved my life when I was 12.

My own pediatrician had a solo practice at the time, and on the days when he had to be away for whatever reason, he had us call Dr. S. Dr. S was a well-respected pediatrician in the area, solo praticing for many years. He was knowledgable, kind and always relaxed. I always remembered for him for his glass eye, which at that time was just about the coolest thing ever - I kept waiting for him to pull out a peg leg and dirty-mouthed parrot and say things like "ARRRRRR!". My mom took me to see him because I seemed to have a sore throat that wouldn't go away. I don't remember that much of it well because it seemed like a totally normal exam to me at the time, but he heard a pretty decent murmur during auscultation and leaped into action ordering EKGs and echos and making sure I got evaluated immediately by a pediatric cardiologist.

Without giving away all the nitty gritty details, I wound up in the hospital for a week with congestive heart failure, and on bed rest for 2 months afterwards. It was a great catch on the behalf of Dr. S, and I received incredible care from the pediatric cardio team. As a result, I survived a quite serious situation with virtually no residual health problems barring a new allergy to aspirin.

At that time, I never fully understood how big a deal this whole thing was. I never felt sick, never felt scared, and never looked back. (But being trapped on bed rest during the OJ Simpson trial was enough to make anyone vomit.) But I came across my old records a few days ago while hunting for my vaccination sheet, and was surprised to find how intensive the treatment was. I was also surprised to find how thorough the care was, and in light of how much spotty medical treatment I have witnessed in the past two years, I was impressed by how much Dr. S showed his care. I was lucky to have had him.

My family has pretty much put this all behind us, as we have newer and bigger things to worry about and look forward to. This, for my parents, has represented the culmination of all their efforts and hard work (and mine), and how much we've all been able to do. But seeing Dr. S as we prayed for the start of my surgical residency was, to say the least, auspicious. It reminded us all of how utterly lucky we have all been in life, to be healthy and safe and together.

Stars in my eyes

My big fear is that the post you're about to read is going to sound like I'm shilling for a product, and I don't want you to think I've been paid or anything. This is all on my own dime.

I'm in love with my phone.

I finally got the HTC Incredible. And damn, it is. It is slim, light, with a lovely smooth touch screen and easy to use navigation buttons as well. It has an 8 megapixel camera with flash, which I never thought I'd care about, now seems to fit in the unexpected category of Things Sarada Though She'd Hate But Love Instead (along with Chevy Silverado pickups and country music). It has a decent amount of memory, which is convenient because those apps are pretty addictive. Even with my genetic tendency to be cheap (I'm refusing to buy any apps till I get my first paycheck), the apps are pretty damn good.

I can read all the news I want and then some. I can sync seamlessly with both my gmail accounts, even chats, and my google calendar as well. I can monitor my account with my cell phone carrier. I have Epocrates for free. (And once I stop being cheap, I'll get a nifty EKG analysis app.) And, best of all, I can use Skype to call my sister in Thailand whenever I want, without using up my minutes!! It's pretty damn sweet, let me tell you.

However, in the interest of BALANCED REPORTING, let me give you 2 downsides:

1) Battery life blows. But I got a free Task Killer app, which quietly closes all your open apps for you so that your battery doesn't die quite so quickly. I will most likely have to buy the new extended life battery when it comes out, and perhaps an extra charger or two for work.

2) I don't have a second HTC Incredible to take a picture of me happily using my first one. Curses. And so I include this portrait of interpretive dance:



(Ok, I know the last one doesn't count. But it really is bugging me all the same.)

The Wake-Up Squad

Hooray for re-certification!! I am officially qualified as a life saver. (Although I haven't quite figured out how to find the belly button in order to do the Heimlich without tickling the victim.) We finished an hour early, so I happily got in the car and drove off into the sunset. I was just aimlessly listening to commercials on the radio when a phrase caught my attention: "Shift Work Sleep Disorder". The phrase was then followed by an ad in which "The Wake-Up Squad" urges you to be evaluated for said disorder, and then be treated using the medication Nuvigil (Armodafinil) by Cephalon.

My first reaction was, this is a disorder?? It's obvious that doing shift work or 24 hour call can mess up your circadian rhythm and make you tired, etc. But when I looked up the signs and symptoms at the Cleveland Clinic just includes difficulty concentrating, headaches and lack of energy. Well DUH. The consequences of this supposed disorder included increased accidents, increased work-related errors, increased sick leave and increased irritability, mood problems, etc.

I don't get it - aren't these just the same things we all experience if we are truly sleep-deprived and forced to function anyways? Isn't sleep deprivation a good enough term to cover this issue? I did look up the word "disorder" and it is vague enough, I suppose: disorder /dis·or·der/ (dis-or´der) a derangement or abnormality of function; a morbid physical or mental state. I guess sleep deprivation qualifies as a disorder, but I just don't think it's exclusive to shift work. Having a baby makes you sleep deprived. So does staying up for 4 days straight to play video games.

And the other thing is, what's the deal with this brand new medication for it? It might just be me, but when I really can't sleep, a good old fashioned Benadryl does the trick. (When I really REALLY can't sleep, I give up and start re-reading Harry Potter. JK Rowling, I love you.) The drug apparently was going for FDA approval for jet lag (which, again, to me fits the same criteria of sleep deprivation), and got turned down in March of this year.

So, my question is, who decides when something is a disorder? How do they decide when something is distinctive enough to warrant a separate classification? And will someone please tell me if I'm allowed to get time off for my impending, inevitable Shift Work Disorder starting in July? Because I'm pretty sure it's going to be a doozy.

B.L.S**t

Around this time of year, you'll find a lot of interns doing the same thing across the country - starting orientation for their new positions, and re-certifying for Basic Life Support and Advanced Cardiac Life Support training. Our school had us train for both before starting our 3rd year clinical rotations, so this basically serves as a bit of a refresher. Most of the time, it's a waste of time. And mine was too, except that it wasn't in certain ways.

It certainly didn't help that I spent a day flying around the city looking for bookstores which stocked a BLS book, only to find that the course I was scheduled to take was ACLS. So I took frantic notes while at the course, since I am terrible at remembering which drug goes when. Idiotically, I had to be told that you DE-fibrillate someone when they are, in fact, in atrial or ventricular fibrillation. Rocket science, I tell you. We also STILL do not have a schedule, which makes it impossible to plan ahead. Even worse, one of the other guys there told me they will only give it to you 2 months in advance, which makes planning trips or other excursions difficult to do. And PS, as an intern, I am not allowed to pick a vacation time unless I am a) getting married or b) physically pushing out a child. Baahhhhhh.

But I did meet one of the family practice attendings, who was actually very nice and included a lot of great advice for how to interpret things and handle the situations in the real world. I also met a few of my fellow interns, both for surgery and other fields, which was nice. I was definitely put off to find that at least two were smokers, but that's the sort of thing that always shocks naive little-girl me. Sigh. Another benefit from the session: 6 Second ECG Simulator. This little baby lets you test yourself in the safety of your own home, and it's pretty decent at it. Theoretically, I will practice more with it, because the only one I feel comfortable recognizing is asystole (aka, the flatline).

And lastly, my search for the HTC Incredible continues. I checked out a Verizon in the city, only to find that the ENTIRE NEW YORK REGION is utterly sold out, with no idea as to when the newest shipment will arrive. I could order online, but they won't arrive till July, and I wanted some time to make friends with the phone. So I checked in NJ, and Verizon had the same story, but an authorized retailer let me reserve one. Triumphantly, I went to the store this evening, only to find a line a mile long, with no sign of movement. And so, I shall try a third time tomorrow morning.



Incredible, why must you taunt me?