Saturday, November 27, 2010

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.

Friday, November 26, 2010

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.

Monday, November 22, 2010

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.

Tuesday, November 16, 2010

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...


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.

Monday, November 15, 2010

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?

Sunday, November 7, 2010

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.