surgi-cell

Happyland, USA

2011-09-22T22:05:00.000-04:00

It's always hard to imagine that places exist in which people simply live happier, but they do. I mean, truly, deeply, genuinely happy. It's downright enraging if you live in a place like New York, because it makes you feel like your anger is unnecessary, and New York is the sort of place in which anger is in your bones and leaching it out would make you weak, barely able to stand. To be in a place that is happy is to imply that happiness, like melancholy, is a place one inhabits, can get stuck in and finally break free of.

Despite having just taking a vacation in June, I was scheduled for another for the second half of September. I barely gave any thought to where I wanted to go or what I wanted to do, because the last vacation had been so recent and I really didn't need a mental break the way I did last time. I toyed with the idea of hitting India or just bumming around home, when my best friend M suggested I see my friend C in California. C, who I have known since I was twelve and is a member of my core girlfriends, basically left home at age 18 for college and simply never looked back. She has done world tours on a shoestring (and now ties a sari better than I can), tracked tortoises in the Nevada desert, performed field research in the Galapagos and finally settled in Santa Barbara for grad school. She is terribly clever, and quite simply one of the best and most patient people I know. I hadn't seen her properly for about two years, with the exception of all-too-brief evenings together when she happened to come home. She was only just in the process of setting up her SB arrangements when I asked her to come by and visit. Needless to say, she was all over it.

The thing about California is that, despite the casualness which everyone tries to exude, it is a land of extremes. As I write this, I am in an airport shuttle on a highway wisely nestled between steep, chopped hills and the rolling, foamy sea. A mist has settled over us, masking the red sun, and giving the eerie illusion of a Maine november. At every turn is Latin cuisine that makes you wonder why anybody in New York even attempts mole chicken, or wine that makes you drop $80 on a cross-country shipment without thinking twice. The nerds at Lenovo throw a seriously wild party, the roads move at 85 mph without the slightest hint of impatience, and everywhere you turn, someone is bending over to extend you a courtesy that you didn't even ask for. It is, as they say, easy living.

But, spending time here long enough, one wonders what the difference is. Does it really boil down to year-long sunshine? Temperate weather? The knowledge that a hazy morning really will burn off into clear afternoon air, every single day? In principle, I don't believe in running away as a method of resolving an issue, although I am a person who often feels the urge to run / turn her back / cut things off when she isn't happy. But the more I travel, the more I wonder whether New York, with all its neuroses and dissatisfactions, is really the place for me.

Waterworld

2011-08-29T19:53:00.000-04:00

I'm not sure if it's true in other parts of the country, but New York loves to hype up natural disasters. This past winter, the various dumpings of snow led newscasters to label the winter storms with such monikers as "Snowgate" and "SNOWMAGEDDON!!!" It led a lot of people to stop taking weather reports seriously, as well as the Fox News team in general.

Somehow, the dude upstairs had something else in mind this week, though. Post-call last week, I woke up sometime in the afternoon to feel a rumbling. I assumed it was the local freight train that comes through once or twice a day and gives my apartment a mild vibration, but when it intensified and became more irregular, I briefly woke up and thought to myself "Hmm, must be an earthquake. Okay." and went back to sleep. My first earthquake ever, and I missed it!! It wasn't until a few hours later when I hit Facebook that I realized that the earth had moved from virginia to connecticut, with everyone else super-excited for The Great Quake of 2011. (A guy in Brooklyn even had it tattooed on his arm.) Of course, there was much mocking to be had - a number of pictures circulating "documenting" the destruction, which depicted a lawn patio table set with one plastic chair mildly knocked over. Still, it was exciting.

That is, until the news team seized on Hurricane Irene, steaming up the Eastern Seaboard. It was apparently the first hurricane to directly hit the NYC area in several decades, although I remember many summers of very intense thunderstorming and flooding because of the residual tropical storms coming from the Caribbean. I've seen NYC panic before, but people began to act like the end of the world was approaching. My friends all posted pictures of people lined outside the Trader Joe's, beating each other down for the last biodegradable container of wasabi peas, while my parents brought in the goldfish from the pond and stocked up on sandbags from Home Depot. My own home base became a part of the mandatory evacuation zone, and so all 40 patients had to be removed from the facility, as well as a number of my co-residents who lived in the area as well.

But for me, it became an exciting chance to hole up and go back to basics. My new boyfriend Z asked me to spend the weekend safely ensconced together, so I "evacuated" him from the Upper East Side and we drove together to Brooklyn, to spend it with his friends J&J, a fabulous couple about whom enough sweet things cannot be said, as well as his close friend S. We hung out, ate pizza, watched Star Trek, played Settlers and Starcraft (I took a nap for that last part) and just had a million laughs. Around 3 am, we went up to the roof to watch the hurricane kick into action, and as the wind blew the trees over and the rain poured sideways, I started to feel infused with an incredible awareness and connection to the force we were witnessing together, something I rarely feel since leaving the windy streets of Chicago. We woke up the next morning to eat bagels, lazy around, and take bets on who would be able to escape their Monday morning responsibilities. (I wasn't.)

Like the storm, I came into the weekend with an intense fever pitch and left in a calm, deeply contented state. My neighborhood had a downed tree or two which smushed a few cars, but we were otherwise well for the wear. The home base hospital still hadn't opened, but maintenance crewed and residents began trickling in. Everyone showed up to work more or less in one piece, and we resumed the work of the day without a backwards thought. Except for the occasional twig out of place, we had all moved on. But in my head, I treasured having two whole days to feel gratefulness and even joy.

Death and Birth

2011-08-10T14:25:00.001-04:00

It's been about a week and and a half, and my return to Shmeens has started a bit smoother than I expected. Considering how tense and nasty everyone was acting the last time I was there, I clamped down and tried extra hard to be sweet to everyone I spoke to. I encountered a nurse or two who I had gotten into throwdowns with, and thankfully they didn't remember me, so I was able to start over with them and act extra grateful (even if all they were doing was a basic task). I would have tried to do this anyway, since I was scheduled to spend a lot of time at Shmeens, but I had a separate reason for doing so.

Without revealing too many details, it is looking a bit likely that my home base hospital may close. Sadly, this is the story not just for our facility but for many many others in the metropolitan area. It seems to be a clusterfuck of a situation, for lack of a better word, because all of the hospitals' debt is being called out at the same time that corruption in the governing hospital systems is being called out, at the same time that the state is unable to provide funding despite acknowledging a need for hospitals in underserved areas like ours. There has been a lot of rallying on the part of the community and doctors and nurses to save our facility from a terrible fate, but I fear that it's just too late for what seems to be a done deal.

The kind of pall this sort of event throws on everyone, it's hard to describe. When we first heard news (which wasn't even news), the nurses went into a super-chicken mode in which they basically screeched and clucked the news to anyone and everyone who would hear, even if there wasn't anything definitive to report. There is so much sadness that everyone feels for the community residents, many of whom cannot seek medical help elsewhere because of economics and geography. The attendings have all gallantly tried to roll up their sleeves to help, but of course must think of their families and so are quietly exploring jobs elsewhere. Everyone agrees that it's a tragedy of Greek proportions.

This, of course, puts the residents in an uncomfortable position. Because of the nature of residency programs and spots nationwide, when a program shuts down, residents don't lose their positions - they are typically redistributed to other programs (who happily take on the $150,000 value + resident labor) and the spot is later lost after the resident graduates. In other words, while the hospital closing creates drama as far as where we will all go, we are not in the same boat as everyone else in terms of job security, and it's hard to look everyone in the eye when they're struggling and we aren't. This is especially true of the surgical program, because our director is working hard to preserve the program itself as a living structure - to do this, we are trying to shift our home base to Shmeens.

We are very fortunate because we already were spending so much time at Shmeens, running their service and staffing their OR, that the program disseminating would be a massive blow to them. Additionally, Shmeens once had a residency many years ago and lost it, and there has always been an interest to re-acquire one if possible. All of our attendings there have been exceptionally supportive of the plan to relocate permanently, and seem excited to have us. The chairman in particular has shown a lot of enthusiasm to further develop our program and utilize affiliations to create new outside rotations that we can add to our roster and boost our academic strength. And fortunately, we already share one attending with the home base, to help ease the transition.

I'm not really sure of how I feel about it. Or rather, I know how I feel, but then I'm overwhelmed by guilt about it. Our program will have an easier transition by far than the other residencies at the home base, and they are still fighting to stay open. One in particular will likely be split into two programs, a travesty because that program is quite coveted in the area because of the specialty it trains for. On my part, I almost wish closure would happen as soon as possible so that we could all move on with Shmeens, but the reality of that would mean expediting the loss of nearly a thousand jobs in a relatively poor area. Being at Shmeens where it feels safe, I'm taken away from the tragedy and heartbreak. I don't want to go back.

I'm gonna, gonna lose my baby / so I always keep a bottle near

2011-07-23T13:53:00.001-04:00

Amy Winehouse died today, aged 27. I think it's pretty obvious that it was from her completely unchecked alcohol and drug addictions, but I'm sad nonetheless. Music got me through a lot of the very low points of medical school, and Amy Winehouse's music really expressed much of how I felt. I know that she was often falling down drunk at live performances, so I'm including a clip here to show that she really and truly was a talented girl who just couldn't get it together in the end.

Amy, sorry it didn't work out for you. We'll miss your voice and your soul.

Today's "Oh, crap!" moment of the day is brought to you by justthetip.com

2011-07-21T21:19:00.001-04:00

Monday night, 10 pm, on call. While rounding in another part of the ICU, my intern gets a page that one of our post-op patients is desatting. She desatted earlier in the day, but we got her back with aggressive suctioning, so my intern leaves to try this out. 2 minutes later, I walk in.

Me: Whoa, she's down to 78%? That's worse than before... and her pressure's dropped!
Intern: Oh, yeah.
*my friend E, the medical resident on that evening, walks in with his intern*
Me: E! Oh, thank god. Listen, she desatted earlier but we got her back with suctioning. I'm going to bump up her O2 and attach this ventimask while I suction her. Wait, that's not a ventimask... do we have anything else?
Nurse: Can't you see that I'm BUSY?! (Gets back on phone)
E: Ok, let's get a second O2 sat monitor, this thing is jumping around and I'm not sure if it's working.
Me: Great idea. Hmm, this really isn't getting better. I'm going to sit her up.
Intern: She's only satting 60% now, on this new machine. And her pulse just dropped to 50.
E: *listening to chest* Nurse, page respiratory - we need a proper mask. She's not getting adequate ventilation here.
Me: *nearly hysterical* Holy shit, her sat's now 50%.
E: *silent*
Me: *silent*
Us: *simultaneous realization that two 2nd year residents are in charge and nobody more senior is coming to help us* Uhhhhhhh.....
*300 years pass*
Respiratory: Did someone page respiratory?
Us: OH THANK GOD YES SHE NEEDS TO BE INTUBATED RIGHT THIS VERY SECOND OH GOD OH GOD OH GOD!!!
Respiratory: Ok. Move. *Intubates*
Me: Mrs. Jones? Can you hear me?
Mrs. Jones: *big smile*
Sarada's Ass: Wow, I don't think I'm going to be able to pass stool for days now.

Samaritan Woes

2011-07-10T21:54:00.001-04:00

I think it's pretty reasonable that, after awhile of training in medicine, a person starts to imagine scenarios where they get called in to serve. Usually it's the airplane scene, where someone starts to have chest pain at 30,000 feet and the airline hostess gets on the intercom and says something like "Is there a doctor aboard?" or similar nonsense. Most practicing physicians say they really dread these kinds of situations, because of the lack of equipment needed and lack of control over the situation. (Not to mention, the extreme obligation it places on the physician who is escaping an insanely busy practice to get just a few days away with the family.)

It never occurred to me that there would also be an extreme sensation of terror upon getting involved with this type of scenario.

Last night, after lazily laying about all day and watching Hindi movies on Hulu, I got dolled up to meet a girlfriend for dinner and drinks. I was already running late when I got out of the subway in the West Village and was walking briskly along when I saw a crowd of twenty people surrounding a body lying on the sidewalk outside a shop. Getting nervous, I asked one of the women standing there what happened, and she said that they just saw this guy lying there and someone had called EMS. I asked if anyone had checked him to make sure he had a pulse and was breathing, and she said no.

My heart dropped out of my chest.

"Are you kidding me?" was really all I could say. I crouched down next to the guy, put my purse down next to me, and started getting my hands all over him to look for a pulse, breath sounds, responsiveness, anything. Another woman asked me if I was a doctor. "Oh shit," I thought to myself with increasing horror, "I am. Oh, god." I realized in a moment of further panic that I didn't even have a stethoscope, and just put my ear to his chest to see if his breathing was appropriate or junky. I got lucky - he wasn't tachypneic or tachycardic, and sounded pretty clear - he seemed to really have just passed out.

He suddenly got up, and it became apparent that this guy was chronically intoxicated. We sat him in a chair and I pulled off his hat to check for signs of head trauma, as he reached into his pocket to roll a cigarette (or "cigarette"). He was oriented but clearly confused, as he told me that he had simply tripped going down a few steps into the shop (but somehow fell on his back, above the staircase). EMS showed up and pulled on some gloves before touching him, and a creeping grossness overcame me as I ran to the bathroom to wash my hands and arms, and soak a paper towel in rubbing alcohol to clean off my left ear as I tried hard not to think about scabies.

My friend showed up on the sidewalk, in the meantime, with a shocked look on her face as I came out of the store looking as though the world had just ended. We walked away, while EMS tried to coax the guy into their truck so they could take his vitals, and went about our dinner plans.

On the way out of the last bar of the night, we passed an EMS team evaluating a young man completely passed out in front of a garden apartment. I kept walking.

PGY-2

2011-07-06T22:03:00.000-04:00

Things I have learned during my first week of being a 2nd year surgical resident:

1) Having an intern is like having a kid. I'm just so anxious for how well they're doing. I stay awake just thinking about it.

2) My residents were actually snooping behind my back when I was an intern and checking charts and stuff!! No wonder they could always tell when I was lying.

3) Being a resident makes you feel POWERFUL. Until someone asks you to do something and you remember that you don't know squat.

4) ...but the title sure does count for a lot, as snoop dogg intern points out (from 1:05)

Divine Secrets of the Surgical Sisterhood

2011-06-18T10:51:00.000-04:00

When you choose to go into medicine as a woman, one phrase that you hear a lot is "old boys' club". It's a reference to the fact that medicine, for centuries, was one practiced by men alone, a fact that was sharpened during the 1950's when the advances made by women were repressed in favor of a return to old time values. It also references the fact that men, for centuries, have always formed fraternities in one way or another, a way to bond and speak as equals on subjects of substance and importance, and to form friendships, connections and networks for the benefit of all members. Nowadays, the phrase "old boys' club" infers, due to negative connotation, a professional or social group into which women could be belong based on credentials but cannot because they are not male and therefore not welcome in the fraternity order.

It is a sad fact that women don't seem to have the same natural propensity towards fraternity as men, especially in fields that men have historically dominated. Of course, the concept of sorority and womens' groups is an old one, but they typically form naturally for the benefit of social friendship, not professional advancement. Those that exist for professional advancement often have a forced feeling to them, and the ones that have persisted through time exist only in reaction to a negative situation (such as being shut out of male groups). One would think that, as a minority in certain professional circles, women would band together, help each other out, and act as mentors for each other. One would especially expect that of the kind of women who have acted as groundbreakers, plowing a path for the rest of us to follow. But it is not so.

Dr. Karen Sibert is an anesthesiologist practicing in West Hollywood, CA. She wrote a well-publicized editorial to the NY Times bemoaning the groves of women training in medicine, only to leave to devote time to family and lifestyle balance. She includes a number of factual flaws in her argument (ex: she claims that residents don't pay tuition and instead receive a salary, but neglects to mention that repayment of medical school tuition starts in residency while being paid less than minimum wage for a 90 hour work week), and criticizes a pre-med college student for wanting to know about anesthesia as a specialty with regards to work-life balance. She essentially argues that to be a doctor, one must commit to it to the exclusion of all else, as all men do, or society at large suffers the consequence. She argues that women are selfish to enter the field and expect such things as time off, end of shifts or part time work, because they suck the precious national resources going into training doctors.

The undercurrent of this editorial is that women must suck it up, not complain, and not ask for anything different in terms of equity. I am sure that, as a women who graduated medical school 30 years ago and had no other women to band with, this method worked for her. She has become hard core and old school. And, truly, I admire her for it. I've met (heck, we've all met) tough-as-nails female physicians who trained when they had no other companions mentors or encouragement and threw themselves in head first to learn medicine for a higher cause. It's something I could never do, and have undying respect for. But there's a broader issue of humanity in medicine - I myself have encountered more than a few older female surgeons who do fantastic work but are a nightmare to be around. They are, nearly as a rule, nicer to boys than they are to girls. I never wanted to believe it, but I have encountered more manipulation, lying, sexist and judgmental attitudes at the hands of female surgeons than I ever have at the hands of my male surgical attendings (why by and large have been nothing but encouraging, patient and kind).

The reason I feel that it's a time-related issue is that, when I look at my senior surgical residents, I don't see any of these traits at all. I belong to a residency which is at least 50% female, and most of the other programs I applied to were similarly stocked. The girls I work with are tough and smart, but also look out for me. I don't get treated any differently than the boys, which is how I know that I am being treated the best I can be. When I go outside of my residency cradle, I am always shocked at the slightest hint of gender discrimination because it's simply not how I was raised. At the risk of putting all older female attendings in a box, I argue that the act of training in an all-male world has created a certain type of creature. Brilliant, tough, smart, but also unable to trust anybody but men. I believe that the female attending throws younger female doctors under the bus because she forgets her obligation to them. She is jealous that so many things she had to fight for, her residents can take for granted. The ability to even consider part time work as a doctor to be with her children? That was a pipe dream in her day. Having to be a thousand times better just to be considered at all? It's the exception rather than the rule now. When she works with men, she's back on familiar territory, she knows how they will behave and react. On some level, it probably even makes her feel special inside, to be above so many men who were once above her. But female residents, they throw a wrench in that calculation. And she forgets her obligation to mentor, guide and protect because she never had those things herself.

Like gay marriage and outdoor smoking bans, changes in this behavior will only come with time. The female attendings like Dr. Sibert won't change their attitudes, they'll just retire at some point soon and be replaced by many more females who trained under more balanced circumstances, with respect and concern for each other. Our network will come because we all worked with each other, remember our seniors with fondness and respect, and bond over a common experience. As much as Dr. Sibert wants to flap her arms about the change in priorities in medicine, the fact is that, very soon, she'll be under our care and not over our heads, and we'll all be able to form the sorority we deserve without her stopping us.

Life as you know it

2011-06-13T10:25:00.000-04:00

Hooray for vacation!! I'm back in the states, after a week off in London and a few days off here and there at home. I won't go on too much about the trip itself, except to say that there was lots of shopping, drinking and laughs.

Oh, baby.

But here's something that struck me - in the course of meeting many of my sister and cousins' friends, I wound up talking about my job. A lot. Probably a certain amount of that was just desperation and gratefulness at having the chance to get away that it almost seemed unreal. A significant proportion was also residual pain from the way that I had been professionally singed on my last rotation, by some people who I had underestimated in their ability to put personal gain above team duty. But the thing that drove it the most was the fact that I work so many hours at this one job, and so many people that I met just couldn't comprehend it.

It's a fact of life in the UK that work hours are very severely limited. It's a culture that is hardly hedonistic compared to the rest of Europe, but by American standards can seem outlandishly fun-oriented at times. To have several drinks with colleagues, to travel, to spend time together, to shop during the lunch hour, these are all things that are assumed by many to be a regular part of life on a weekly or even daily basis. Even for doctors, the work-hour limit is about 50 hours per week, just over half of what American residents are limited to (and often work over). So while discussing my job with people, the shock and horror I experienced at describing a standard 85 hr work week was overwhelming.

I used to encounter this sort of attitude years ago, when I was in medical school and dating around. People would ask what I did for fun on weekends or holidays, and the response of "I'm studying" used to baffle people. Later, when I started rotations, I would gripe about having to get up so early when the rest of the world seemed asleep, or having to travel so much in such an unpredictable manner. But eventually, I took solace in knowing that I wasn't the only one. It enabled me to get off my high horse when I realized that investment bankers work 90 hour weeks too, and while they have bonuses larger than my entire salary, they also have to do it all in a suit and tie, and deal with way bigger assholes. Embarrassingly, it took me 3 years to figure out that the guy at Dunkin Donuts serving me my latte had to get up at 4:30 in the morning, too. And my dad chided me for complaining about the frequent travel - nearly all consultants do the same, and they have to do it on planes. I gradually started to feel that my situation wasn't special, and that allowed me to tone down the pity party I was throwing for myself at working so long for so little.

It is easy to feel jealous that I do not belong to a culture, or a world, in which lifestyle and experience are the focal points. I certainly turn green at the thought of my friends, who casually meet up with each other with little notice and maximal enjoyment. But, the fact is, to make those lifestyles happen, these people all picked jobs where they more or less sit at desks, deal with vague concepts and handle a level of office politics that I am, paradoxically, protected from in many respects because the people I work with just don't have time for petty grudges. I would never be happy in those circumstances, and the few rotations I went through resembling such work had me bored out of my mind. I didn't pick it because it didn't suit me. I feel healthier in some ways, doing a job that keeps me occupied for the majority of my time. I feel healthier in a job where I walk a lot. If given the option of living the London lifestyle or not, I probably wouldn't pick it if I had to stay with it the rest of my life. And that's just the way it is.

LDN

2011-06-03T03:49:00.001-04:00

Things I have learned in the past 36 hours:

1) The aisle seat is NOT preferable when you are sitting next to a woman who ate NYC street food before getting on the plane.

2) They have Ben and Jerry's vending machines dispensing little mini-pints of ice cream at the Heathrow airport. I live on the Eastern seaboard, how come we don't have that???

3) Gherkin is a far better name for this.

4) I am truly addicted to my Android. Last night, I realized I was going to have to go a whole week without TMZ and I nearly had a heart attack.

5) I did not drink enough on Memorial Day, otherwise I would not still be feeling all that wine I had last night :/

The Pressure Cooker

2011-06-01T15:10:00.000-04:00

I had dinner the other night with my med school friend T the other night, and we got to talking about how residency changes you. There's the usual stuff, like how you have to force yourself to stay in bed past 9:30 am because your body is just so used to getting up early, or how I suddenly wear much more formal and girly clothing when I have the opportunity to, to make up for lost time.

But there's a major thing that changes in everyone, perhaps some more than others, in a way that I wish I could avoid. We all become meaner. By this, I mean my patience is shorter, my expectations are unreasonably higher and my shoot-from-the-hip reflex is quite a lot sharper. Things that I might have let slide years ago, like a friend flaking out on me for a scheduled hang-out suddenly become massive transgressions. I get into fights with people whom I have barely even disagreed with in the past. I hold everyone to a standard which, to me, is totally reasonable but everyone else seems to think is unachievable. Looking at myself from the outside, I can see a thin fishing-reel line connecting me to the young obnoxious attending I will soon become.

The origins of this are obvious, of course. All you have to do is take one 24 hour call in which the pager goes off non-stop, the ER gets mad because you haven't seen the new patient with a chronic leg wound while you are managing two life-and-death emergencies in the ICU, the medical resident calls you with five new consults (none of whom she has the name, medical record number, room number, original chief complaint or labs back) all while your student gives you attitude when you ask him to collect the vitals, and you will see what I mean. Nobody can be that nice when all of this is happening. It just isn't possible, and if it was, it would disadvantageous because it would allow everyone else to walk all over you. Part of working in medicine means triaging the emergent from the urgent from the routine, and having to say "no" or "not now" sometimes to a person who doesn't want to hear it. Soften your heart here, and you will pay for it in spades. Being mean allows you to be efficient, and sometimes that is the only virtue that will save you during a bad call.

Unfortunately, the trade-off is that this behavior becomes so hard-wired in you that you can do it instantly at any time of the day or night, without thinking, and you become a nasty bitch to everyone else who drops the ball for a brief moment in everyday life. Even while on vacation, feeling more relaxed than I have in several months and quite happy with my life, I took my mom to town for butting in where she didn't belong (nothing new, of course), I spanked my friend for re-engaging in a toxic relationship, and my sister for not having my travel information ready to go. In my head, everything I've listed here can be thoroughly defended to a T. I'm exceptionally sure that I was in the right, the other person was in the wrong, and a cold hard look at the facts means nobody else will disagree.

But they will, because I wasn't nice about it. I didn't give anyone a break. It's true others dropped the ball, but "Can't you just chill out?" is a phrase I hear a lot. Not surprisingly, it isn't one you hear in surgery - the expectations are set for me in advance by my seniors, and the bar is high. I meet it only because someone told me I had to, and that's how I learned to be good. I can't chill out anymore. Even when I think I'm being chill, I'm not. It's like I've turned into a vicious deer, one always ready to jump and run when a car shines its headlights on me at 2 am, but not before I've bitten the front bumper and dented the passenger side. And as a result, I lash out at people in response to their failures, regardless of whether that's the best way to affect change or not.

I can't tell you how much I hate this about myself. It's like having an awful argument in my head all of the time. I feel like if I relax, it means I'm dropping my guard. Not just with other people, although that's certainly a consideration, but many times with myself. If I get chill and relax, I won't be as good as I am, and I'm already not that good. If I tighten it up more, I'll just lose more people in my life because I'm not fun to be around. Whether I use a knife or cautery, I'm still making someone bleed. Is it better to take the attitude of "as long as it isn't me"? I'd like to say no. But "as long as it isn't me" is how you survive in a residency. You can see how the vicious cycle goes from here.

An attending once told me that perhaps it was all from lack of confidence. I thought it a ridiculous idea at the time, because one of the major criticisms I get is that I am overly confident. In surgery, confidence is a positive trait because it is better to be confident and wrong than to be indecisive, because surgery is about making a decision and committing to it. But perhaps the attending was right. When I stitch, I am a better stitcher if I can take a deep breath and relax my hands. I am a better resident on call if I can take a deep breath and remember that everything always works out by the time the morning arrives. One could argue that these are exercises in confidence, and the lack of confidence in me manifests itself as tension, which of course leads to anger.

If it's true, I don't feel so great about it, because confidence in the greater scheme of things comes with time and experience and knowledge, things that I can't wait for. If I wait for those things to arrive, I may become so hardened that I can't go back, like an abscess you sat on and now has to get I&D'd in the operating room instead of the oral antibiotics you could have taken weeks before.

What I realize is that I need (and I can't believe I'm saying this) a medical solution, and not a surgical one. I need a way to stop the stress before it gets so bad that someone has to cut me to keep me from cutting someone else.

Back From the Dead

2011-05-28T10:26:00.000-04:00

Alright, this blog needs a reboot. Actually, I needed (and got) a reboot and by extension, this blog will be rebooted. So I'm coming back, with a vengeance, and I'm re-committing myself to that thing I love, which is surgery / griping about surgery. Be prepared!

Since I last posted back in March, I went back to Shmanhattan for a 2 month surgical rotation. Suffice to say, it was eventful and I learned a lot. I'm going to be posting about individual themes of that rotation in the coming days, including politics, women in surgery and being an asshole (referring to myself here). But before I get into all of that stuff, I'm going to take a break for a moment and post about a major life event.

I broke up with my boyfriend of three years. (Oh god, this sounds so 1990's MTV-angsty.) It was a big deal. The relationship had degenerated beyond all possible repair, and I had turned into this terrible person who had lost all of her spark, strength and excitement for life, not to mention being completely consumed with heartbreak and anger. It was bad. I finally got to a point where I demanded a solution from my boyfriend, one I had been asking for for months, but at this point wasn't going to do anything. And while talking to my friends and family, I realized that I was reaching for this solution not because it was the best one, but because it was the only one. I had literally exhausted all of the options, and given all of the chances, and not made one ounce of progress. It was killing me. It wasn't working.

I was heartbroken that it couldn't work, and wouldn't work, and I ended it. But if I'm honest with myself, I have to report, on paper, that I am infinitely happier. I haven't looked back for one second. I look forward to each day, and to meeting new people, and to starting a new relationship with someone else. I see my friends and family again with regularity, and I know I did the right thing if I felt more alone and neglected in my relationship than I do now that I am actually single. I feel completely taken care of by my loved ones, in a way that the relationship could never fulfill. I feel completely taken care of by myself. I am, in short, back from the dead.

And that's really all there is to say about that. My 2 week vacation started yesterday at 5:05 pm, and I am flying to London on Wednesday to see my sister. I'm thrilled at my life and what it has, and excited (but scared) that after my ER rotation in June, I will be a second year surgical resident. I survived. But more importantly, I thrived. And in 4 short years, I will have arrived.

Infectious Disease

2011-03-22T00:15:00.000-04:00

I've been fairly lucky this year health-wise. Barring a nasty bout of food poisoning during my last day at Shmeens, I've really stayed rather healthy. But all streaks must come to an end, and I caught a co-intern's cold during my last week of in-house surgery.

Now, I wasn't actually that mad about it, because I get a semi-annual cold at minimum and I was karmically due. However, I am not the world's healthiest girl, and I am an even worse recoverer. My entire body usually feels as though lying on my back with my arms and legs crinkled in the air with the occasional twitch would be the best course of action, and I typically walk around muttering "I just want to die" about three times an hour to reaffirm this. My ears are blocked up, so everyone thinks I am ignoring them when I really just cannot catch a word, and I get irritable. I am constantly hot and sweating, which is quite a feat for someone who is perpetually freezing. Even more amazingly, I have lost my appetite and and started skipping lunch today in favor of the closest thing I could get to an IV bag full of green tea. I am constantly exhausted, but having trouble sleeping because of the mega-doses of Sudafed that I have been popping to dry up my congestion, so I am taking Benadryls by the handful as well. My asthma is flaring up, and I spent all of last night coughing and choking on gobs of yellow phlegm.

I am, in short, the perfect intern to be starting her rotation on Infectious Disease this week. The irony's pretty obvious here, since I probably shouldn't be walking around sniffling and dripping and sneezing and coughing on people who are already deathly ill. I'm never afraid of catching C. Diff or Acinetobacter or Klebsiella from the patients, but I figure they really don't need my cold. But, in medicine, we really don't get sick days, so I've been dragging my ass in and trying to make up for my sorry state by actually wearing all those gloves and yellow gowns and masks that we're supposed to wear all of the time in the isolation rooms.

Or maybe I should be aiming to catch a little C. Diff to go with my cold. At least, then, I'd lose weight.

Kindle Lovin', Contract Hatin' kind of woman

2011-03-12T14:41:00.000-05:00

Yes, it's yet another I-heart-technology post. Because....

I LOVE MY KINDLE!!!!! <3 <3 <3

It's white and pretty and super duper lightweight. I think I need to invest in a shield or cover of some sort, because I'm really planning to use the crap out of this thing. I've been blowing through Pride and Prejudice, which is a novel that I still have trouble reading the second time around, but have no issue listening to and laughing with in the car. I decided to get back into my medical leisure reading, so I downloaded "Walk on Water" and I'm trying to figure out how to get "The Spirit Catches You and You Fall Down" in an electronic version. I also want to get some review books on there, in the vain attempt to get myself to read more on surgery when I have the spare time.

In other news, I had a relatively tiring call followed by a tortuous Friday conference, but I really woke up when we received a lecture on negotiating contracts for your first job as an attending. I know that contract clauses is kindergarten stuff to some people, but I have to say, they do NOT teach you this stuff in med school, and they should. It is shocking to discover that someone can tell you that you're not allowed to work within a radius of their practice if you wind up getting fired from there. I couldn't believe that there are doctors out there who will promise you a partnership or ownership in their practice if you last a few years with them, but then will back out when you ask them to put that in writing. Apparently, they can do things like fire you without cause, keep you from giving your phone number to patients when you're leaving, make you use vacation time for continuing medical education events + travel, not guarantee medical leave for pregnancy, force you to work all the weekends and holidays without fair distribution, make you a partner but not give equal rights and vote in business decisions, and even tell you that you'll work in one office and mandate you to go to a different office miles away.

The whole thing seemed so sketchy, and a little isolating because I realized that the only person who will look out for me in this process is me. And maybe my lawyer, obviously. But aren't there any decent doctors doing decent business out there? These people were all once residents too - where's the nostalgia, the camaraderie, the sense of fair play? Why do I feel like, just as I will have worked hard for five years to prove myself worthy, I will have to go back to playing in the dirt? WHY CAN'T WE ALL JUST GET ALONG??? It's a little frustrating, and disheartening, to hear that you could work so hard and still only get offered bad deals hidden by a good name. I mean, it was great that I heard all about this from a lawyer who was also a good teacher, because now that I know this stuff, I can make proper decisions. I can be empowered and actually negotiate my salary and contract terms, and not become yet another woman who is smart and clever and talented and still gets paid less than men who aren't as good. Having this information puts me in the driver's seat, and that's a positive move in the right direction.

But I feel distasteful about it. It just means that, yet again, I can't trust people as much as I'd like to.

Go Shorty, it's your birthday

2011-03-05T16:37:00.001-05:00

Today, I am 28 years old!! (And now, the requisite DAMN I'M OLD, WHEN THE HECK DID THAT HAPPEN). I love celebrating my birthday, and getting calls from everyone and feeling overall popular. Yes, it's all about ME.

The odd thing is, I tend to have a little anxiety around my birthday, only because I get very sensitive and insecure and then read everything into things going wrong. On my 18th birthday, I got a seriously crampy period, then spent the day at home because it was a snow day (I know, why was I complaining?), and then stayed moody the whole week even though my parents had been meticulously planning a surprise birthday party for me at my favorite restaurant. I read into slights, like who didn't post on my wall on Facebook (what do you mean, you didn't have internet access in rural Kenya??) or who didn't call, which is so ridiculous because I have so many friends and family who love me no matter how many birthdays or special occasions I forget or can't be there for. So, this year, I decided to take a different route.

I didn't have the best start. I had asked the nurses to hold off calling me, but instead I spent all of Thursday night chasing nothing-calls. After finishing my night shift on Friday morning, I went straight to my weekly surgical conference and then to a Long Island surgical conference for a poster competition. I had brought a blanket with me, vainly thinking I could find a quiet lecture hall to sleep in, but instead spent the day camped out by my poster and trying to stave off my impending grumpiness. I managed to get an hour or two of sleep Friday night, but then woke early Saturday morning to manage a patient who became so agitated and disoriented in the ICU that she tried to run out completely naked, as her oxygen saturation dropped to 70%. By the time my sister called at 8 am for her annual early morning birthday call, the only response I could muster was "GAH, it's too early!! TOO EARLY!!! AT WORK!!!! Call me later!! GAAAAAH!!". I had to call back later and apologize for being so cranky.

But once I came back and slept for a few hours, I felt like a totally new person. My dad called to say that he had sent me flowers for my birthday, and my landlord confirmed that my birthday gift to me (a designer dress) had arrived at my apartment. My boyfriend surprised me with a Kindle so that I could travel and read, which I am still so excited about that I'm having trouble naming it. (The best I have come up with is Kenny the Kindle. It needs some work.) My best friend and her boyfriend called to sing me happy birthday (with the promise of helping me to download books for free). And we're going out tonight for dinner and a movie, during which I plan to drink a terrific glass of wine and go to bed at a normal hour.

And so, I am breaking my streak. It's happy birthdays from here on out =)

Dumb and Dumber

2011-03-01T15:54:00.000-05:00

Ah, yes. The night float. It's that special time of year when your only task is to keep-the-patient-alive-for-God's-sake. The night float is what separates the men and women from the boys and girls, and this applies to both interns and nurses. So, with great love for all of the amazing nurses who are truly super-competent (and save my ass generously and frequently), here is a list of the top five dumb and dangerous things I have observed the nursing staff doing.

1) Calling to find out about discharging a private patient, since the family was waiting to take him home. The nurse told me she couldn't find any of the paperwork, and that the family was getting very impatient. When I came down to check, all of the paperwork was completed and paperclipped to the front of the chart, along with all of the prescriptions. "Oh," was all she could say.

2) Calling to put an IV line in a patient with massive edema, who already had a working line. When I went to the bedside, the nurse insisted that the line was gone because she couldn't draw back. A reasonable point, except that 2 different IV solution bags were still dripping away without any issue. The nurse then pointed to the arm being swollen as a sign that the line was infiltrated. Except that the patient was swollen all over. As a bonus point, she had refused to try the line herself.

3) Calling to visit a patient who cut himself shaving, and had unstoppable bleeding. I asked the nurse to tear off a piece of toilet paper and stick it onto the cut, and hold pressure while I walked over, imagining a massive torrent of blood gushing out of the patient's face. When I got there, I discovered an extremely loose ball of toilet paper marginally taped to the patient's quizzical face. I tore off a tiny corner and stuck it directly on the 1/2 mm wound, then held pressure for 2 min, and found the bleeding to have magically stopped. I walked away wondering why the nurse hadn't thought of that, since how to stop a shaving cut is something I learned from my dad, not something I learned in the trauma bay.

4) Tapping me on the shoulder every two minutes to ask about how much insulin to give a patient whose blood sugar was 457. This is a reasonable question, except that I was pushing on the chest of a patient who was coding at the moment.

5) Removing the saturation monitor from an acutely ill patient. I was called to the bedside of an end-stage AIDS patient for severe respiratory distress. The patient already had dementia, so he couldn't tell us what was wrong, but he was breathing at an extremely fast rate, and only saturating 75% on the monitor. I increased the oxygen flow rate as high as I could, then told the nurse to keep a strict eye on the monitor while I stepped out to call my senior medical resident about the situation. When I came back, the monitor was gone and the patient was breathing even worse. I asked her in a panic about the monitor, and she told me that she had given the nurse's aide permission to take the monitor away and use it to check vitals on the other patients on the floor. The kicker was that every other patient on this floor was hooked up to a ventilator machine, and therefore did not need an oxygen saturation monitor because the ventilator monitors that for you. This patient wound up getting intubated because his respiratory failure was so severe. He died a week later.

You're The Boss

2011-02-28T13:13:00.001-05:00

Sunday, 10 pm on the floor. A nurse reports that her patient is refusing his blood pressure medication for the second night in a row.

Me: Hello, Mr. Logical. I understand you have a concern about your medication tonight?

Mr. Logical: Yes, doc. I'm allergic to it.

Me: Oh, really? What sort of reaction are you having?

Mr. Logical: I don't like how I feel when I take it.

Me: Hmm. That's not quite an allergy, but ok. What do you mean, you don't like how it makes you feel?

Mr. Logical: It slows my heart down.

Me: Yes, that is an expected side effect.

Mr. Logical: Exactly, an allergy!

Me: No, an allergy would be something like a rash or your throat feeling tight. This medication is supposed to lower both your heart rate and your blood pressure. That's what the attending wanted for you.

Mr. Logical: But I don't like it! It's the same damn problem I had with that other medicine, hydralazine. He tried to get me to take that one too. But I refused. I'm allergic. *smiles triumphantly*

Me: Sir, a lowered heart rate is not an allergy. I understand that having a lower heart rate might be a strange sensation for you, but I'm looking at your vitals and your heart rate is quite high. A lowered heart rate in your case would be better for you, not dangerous. And your blood pressure most definitely could use some lowering, too. Having a high blood pressure is very dangerous for your body. Do you want to maybe think about trying this medication? Otherwise, we can try a different one, like clonidine.

Mr. Logical: No! I won't take that one either. They tried to get me to take that before.

Me: So basically, you don't want to take any medications to lower your blood pressure. You prefer the sensation of high blood pressure and pulse.

Mr. Logical: No, I'll take something. I'm just allergic. Make sure they put that on my wrist band.

Me: *sigh*

I-C-London, I-C-France

2011-02-24T16:54:00.001-05:00

I'm beginning to have the strangest feeling that my internship is already slipping from my hands. I always have this sort of feeling around February, the knowledge that winter is nearly done and time is passing right in front of me. The trees are still bare, but I can see tiny knobbly bits protruding from the tallest twig branches, and I know that in a month or so, real buds will appear and I will be just a few short months from forever ending my internship.

I shouldn't feel sentimental about this at all - after all, internship is That Dreaded Year in the life of all doctors, the year that you are supposed to hate and feel as though you can never get back and so on. And it is, and I am mentally "done" with the silliness of tylenol orders and 3 am falls and patients demanding dilaudid instead of morphine. I don't feel like I have to rush to the bedside for every little thing anymore, and I can recall how to write for potassium without looking it up and I can tell whether the nurses really do need my help with an IV line or if they're just being lazy. But... it's over so soon. I can't believe it. The infancy of my career is nearly done. I feel like I should have taken more pictures.

I've transitioned from my last two weeks on the ICU into the night float, where I'm continuing to cover the ICU and a few other floors. Despite some very questionable nursing calls, I've had quite an easy week taking care of things, mostly because my nurses are terrific and organized and know what they're doing. I keep waiting for patients to die (I am covering the critical care unit and the hospice, after all) but for some reason I have been extremely fortunate and sleeping a reasonable amount, which translates into hours at home during the day to relax and do exactly as I wish. I came into the night float really dreading it, since I was pretty sick of it by the end of two weeks the last time I was on it (and that was with terrific weather in July), but I have been taking my vitamins and bringing my laptop in with me, and I find that a warm room + 4 seasons of Battlestar Galactica on dvd has made for a very pleasant experience. I am most definitely dreading next week, as the other intern and I will swap floors, leading to lots of late-night troponin blood draws and EKGs and imaginary chest pain calls. This won't be all that bad, except that I must also go in for an eye appointment and a surgical poster presentation conference post-call next week, all the day before my birthday. I then have to start two weeks of surgery in-house the day after my birthday, but hey, at least I have it off.

As part of my planning for the coming months, I have finally kicked off a few things that I had in the works for some time. The first is that I have scheduled myself for Lasik for March, which I am really excited about because I JUST CANNOT DO EYEGLASSES AND CONTACTS ANYMORE. It really isn't so bad, it's just a massive hassle and when I already feel so unpretty on-call and post-call because I have to wear glasses, it brings my self-image down, and I would love to continue to feel good about myself as I go forward in surgery. I scheduled it with the same guy my dad went to, and my parents are helping me out with cost, so things should go smoothly and I hopefully will not end up blind and transferring into a specialty where eyes are not required (like psych). I should be good and recovered by the time I head back to Shmanhattan Hospital for two more months of surgery, which should be a ton of fun since I will be back in the city for the spring. This time, I will make a greater effort to go out and hit TopShop, because shopping for pretty fun clothes genuinely does make me feel better about myself.

I am also putting things into motion for my spring vacation, and I am trying to juggle a trip to London with a second trip somewhere in the US, maybe Chicago or Texas or something. I had such an awesome time in Memphis that I really would love to do another southern trip again. Nothing is set up yet, but I'm just enjoying that I can actually move forward with planning all the fun stuff I had been holding off on for so long, because I am done with my exams and can really take control of things instead of acting like I am a victim of my own specialty. The best part is that I just discovered Groupon, so once my dates are set, I plan on London spa-ing myself in a bad way while my sister and cousins are working. We're toying with the idea of at trip within my trip, maybe to Paris or Scotland or Dublin, with the goal of getting smashed and just having an awesome time. But really, if I come back with a semi-British accent as I typically do, that will be more than enough for me.

Back at the Ranch

2011-02-01T18:24:00.000-05:00

Nobody seems to believe me, but I am really really happy to be back at my home base hospital. After 6 weeks away at two different hospitals, it is thrilling and relieving to be back where everybody knows your name, and people say how they missed you and how nice it is to see you again. It seems shocking to the other interns, but the nurses really are nicer at our hospital, and you miss that when you go to other hospitals where you have to go into a 20 minute explanation as to why you don't know where the 4x4 gauze is kept in the stockroom before anyone will lift a finger to help you.

It's also really great to be back with all of the other interns in my year. It's odd to me that I missed them, but it was so nice to be among other people my age who knew me and liked me and joked with me, instead of competing with me for cases or hanging out amongst themselves. I'm back on the surgery rotation, and this time it's with another surgical intern as well, so I'm enjoying the chance to actually work with my co-interns now that we're all coasting towards an all-surgical 2nd year. We're all getting our contract renewals for the coming year, and it's so shocking to think how my internship is already more than half over, and I am actually surviving and smiling at the same time. I'm excited to see who will join us for the next year, and a little nervous at the prospect of actually being in charge of people under me. I've struggled a little with productively instructing and directing the students that rotate with us, and I've decided to make a better effort to observe the various methods my seniors use to motivate and teach them, so that I can help foster smoother teamwork, and not just scare them into hating surgery.

I only have 2 weeks on this surgical rotation, and all I can think about is how overwhelmed and busy I felt when I was doing surgery in August. At times, I was in tears from the exhaustion and disappointment in myself. And now, I keep finding myself with nothing to do, and wondering how I ever thought this same surgical rotation was insane. I've had a few nights where things got a bit busy, like big cases going into the OR and the senior pager I held exploding with consults, but we managed it. It might be that I found ways to cope, or that I simply was so busy at the other hospitals that this now seems a snooze in comparison. Or maybe it's that it's easier to remember that, whatever happens, the call will always end at some point, and I can get things done in time. In other words, there's less reason to panic than there was before.

This surgery thing, I think it's actually doable. Hmm. =)

The January Blues

2011-01-13T19:52:00.000-05:00

Ahh, winter. There's nothing like it. I love this time of year, it's when the air is crispy and you become more appreciative of sunshine (and feel the effects of neglecting your vitamin D / calcium supplements). I love winter very much, it's when the whole world can feel transformed in a few hours to a white wonderland, into which you wander with oversized hats and crocheted scarves. But, every year, I start getting very depressed around January, most likely due to a combination of lack of exercise, vegetables, sunshine and generalized explosion of personal problems. I always get blue around this time of year, and I never figure it out until I'm well deep into it. This year, I heard snatches of Billie Holiday on the radio singing "Gloomy Sunday" and I finally figured it out. I have the blues.

It's a magical time of year for other people, too. The roads are slushy, the sidewalks are icy, the wind is knife-like. Not surprisingly, so are the people in the hospital. I first noticed it with the nurses back at Shmanhattan - every time I smiled back at a nurse or wished them a nice day, I only got stares or dismissive expressions. I thought, at the time, that it was because it was a fancy Shmanhattan hospital, and people are just ruder when something is nicer. But then, I remembered that I live in Queens, where drivers routinely stop at red lights and then careen right on through anyways. So that couldn't be it.

It was the end of the day, and the surgery team decided to get together and do table rounds in the resident lounge, to review the day's events and update the patient census. I had been holding the on-call pager since I had the least number of patients, but instead became the busiest person because I received non-stop calls on the most ridiculous things. When I presented the day's events for my patients, I was met with underhanded comments which indirectly mocked my hard work to get done what I could. I kept my mouth shut, and observed that multiple similar comments were being made around the room, with everyone giving off a sour face and nobody appreciating anybody else's efforts. In the middle of these tense rounds, a nurse decided to page me multiple times regarding a patient needing a medication. I spoke with her and clarified that this was a patient who was already discharged and merely awaiting a ride home, and that she was in no acute distress, just needing a renewal of a medication for pain. I tried to tell her as politely as I could that we were rounding, and that I would send someone up to write the order renewal as soon as possible, but her only response was "Well, my patient is in pain, and that's all that matters". I received the same page from the same nurse twice more, still while rounds were occurring (and conveniently increasing the anger of my seniors), who finally sent me upstairs to sort out the matter.

I found the nurse and tried to pull her aside from the nurses station to discuss the issue privately, and remind her that residents cannot leave rounds just to address one patient's needs unless it is an emergency. She instead responded by avoiding my eye contact, and repeating her same lines over and over, without listening to me at all. I said that we should discuss the issue as a group, and for the first time ever, I got into an actual tiff with a nurse requiring a nurse supervisor's intervention. The supervisor was extremely professional, listened to both of us and tried to assuage the nurse's concerns. I explained as best as I could that we were responsible for many patients, and a proper uninterrupted sign-out round is essential to maintaining safety and continuity of care. Instead, she avoiding my eye contact again, looking away at the ceiling, much like a 7 year old. I finally had to conclude the session by reminding her that the extra order was now written, and walked away without any peaceful resolution effort on her behalf at all.

I felt terrible. Normally nurses love me, because I try really hard to be as polite as I can and show appreciation for their patient advocacy. I went home feeling upset and wondering if I could have handled things differently, but seeing that the nursing supervisor agreed that I had escalated the issue in an appropriate way, I couldn't find any different avenue. I started to wonder if there was something in the water the following morning, when our team met to review surgery content material. I didn't even know what the tension was about, but suddenly I looked up from my patient list of to-do's to see two residents making tense loaded comments to each other. I left the room to assist another intern with a blood draw just as shouting commenced in front of a room of students and residents from other programs. It was embarrassing. I just couldn't figure it out. Even if people have legitimate reason for disagreement, to argue in front of people you set an example for in a hospital is just crazy. That tension extended to the remainder of the day, to the point where I could feel items not being mentioned in sign-out just to avoid further conversation.

I think everyone needs to take their vitamin D.

Welcome to Shmeens

2011-01-11T16:41:00.002-05:00

I was going to start this post by saying how awesome it was being home post-call for the snowstorm, but as it turns out, it won't get started until I'm already asleep. Not that this should matter at all, but I'm all holed up in my jammies with my Belgian cocoa dusted truffles and glass of milk and bucket of korean wings and kimchi (awesome combination, I know) and dammit, I want me some snow. I continually have great things to say about my house and neighborhood, and the latest in that list is that I live one block from an old subway rail line, which in this area runs above ground and transports freight only twice a day. So I have a ready-made garage under which to park my car, and my neighbors and I will all be able to pull out in the morning without having to additionally dig out the car. Hooray!! No damaging the car paint with my shovel this time =P

I woke up yesterday morning to a sweet text from my chief resident, wishing me luck on the upcoming Shmeens rotation. I feel that I have a lot to prove these two weeks, as I am the only intern from my program being sent here, and I want to make a good impression. Fortunately, all of the other interns I rotate with seem both capable and nice, and I even ran into a med school friend's boyfriend, who I had forgotten was doing his traditional rotating internship year at Shmeens before starting anesthesia next year. I really expected the service to be rough and rigid, like a bigger boot camp than my home base hospital, but instead it turned out to be oddly casual. There were no lunchtime or evening rounds, since the OR was so busy that it simply wasn't practical. There was minimal pimping, and I didn't get yelled at for the many simple mistakes I made (most of which came from being so disoriented in the hospital, since I had never been there before). I kept asking the interns when the other shoe was going to drop, and getting blank stares in reaction.

The hospital reminds me a lot of my home base, in that it is neither wealthy nor prestigious, but it is bigger and attracts a reasonable number of patients. I couldn't believe that in one day, they had two appendectomies, one strangulated hernia (into which a third appendicitis seemed to have perforated and caused abscess formation), one EVAR for AAA repair, two sub-total thyroidectomies, and a million other routine cases. I'm really looking forward to my non-call days, when I hope I can scrub on a few of the smaller cases and get some more experience. In that sense, I'm becoming more and more sad that I'm not spending more time at Shmeens, and I'm getting really excited to come back as a second year resident.

So, for now, it's ominous clouds and Gilmore Girls re-runs for me. Laugh, but know that I have everything I need in my little hole.

Closing The Gap

2011-01-08T19:15:00.001-05:00

Yes, yes, I know, I have been inconsistent yet again. But I'm baaaaaaaaaaaaack!! (Hmm. Creepy.)

I've spent the past month at Medium Class Shmanhattan Hospital, which is an outside rotation that my program arranges for us to attend a few months each year. I state that it is Medium Class so as to avoid confusion with those Super Duper Fancy Shmancy Manhattan hospitals, which of course, I will not get to go through. But for me, it is in fact SUPER DUPER because nearly anything looks brand spanking new next to my home base hospital. (But I love oldies! OLDY BUT GOODY!!)

It's a place that many of my senior residents wax poetic about, because it has things like an EMR and several operating rooms and lots of cases. And overall, I had a pretty good time rotating there, from a surgical standpoint. But it wasn't quite what I expected. For starters, at my base hospital, being on call is busy, sometimes overwhelmingly so. But the other interns don't chill out while you're working your ass off - they help, because we're The Team. In contrast, I was only on call a few times for the month at MCSH, but each call was more or less torture. The pager just explodes with consults and clarifications and so on, and you are fielding all of them while also running the patient list and trying to discharge people. You hope that the many other surgical residents milling around will help you, but unfortunately, they don't always. You have an army of students to help you, but not all of them are motivated to stick around in case you need a spare hand to grab paperwork or help patients walk after a procedure. The nurses were shockingly worse than at my home base hospital - I actually got called several times because I had ordered a medication or a blood test, and the nurse wanted to know if I wanted it. One could make the argument that this is just an example of a nurse wanting to be thorough, but when it happens 18 times in a day (literally), it gets a little old. Read the fine print, lady, I want what I want.

I also drew the short straw and rotated during the holidays, during which there were noticeably less patients and cases to see. The 40-50 cases my co-interns were seeing wound up being more like 20 for me. Of course, being an intern, it doesn't really matter as much, but it still would have been nice to Do A Fricking Appendectomy like my co-intern did, or scrub on any case bigger than an elective hernia procedure (like an exploratory laparotomy), like others did while on call. Of course, getting to assist in small cases is good for an intern, it's how you get your feet wet. But there were days where I didn't get a single case at all, and other interns got 3. By the end of the rotation, I started getting a little grumbly about a lack of equity when it came to case division, and finally got fed up when I had a bad night on call during which some residents refused to help me divy up the work.

So, I'm done now. Because of a complicated issue involving intern supply at another outside rotation hospital, I have been switched off of my upcoming rotation with surgery at the home base to do two weeks of surgery at a large Queens hospital, a place that no intern from my year is assigned to. Onwards and upwards to the next new thing, I suppose.

Hmm. Now I need a name for the Queens hospital. Maybe it'll be Shmeens.

Conference Call

2010-12-09T18:45:00.000-05:00

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

2010-12-07T18:25:00.000-05:00

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

2010-11-27T17:33:00.002-05:00

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...

2010-11-26T11:57:00.000-05:00

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

2010-11-22T13:02:00.004-05:00

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

2010-11-16T16:17:00.001-05:00

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

2010-11-15T08:43:00.001-05:00

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?


Not the real patient, but you get the idea.

I have to admire E for her composure, I know that she was irritated by how long it was taking to get started, seeing as the patient was in impending respiratory failure, but she still spoke so kindly to them. When we finally set up, it was with the husband on the opposite side, and our student holding her arm up for support. She showed me how to drape the area, mark the rib space I was aiming for, properly administer the lidocaine for local anesthesia (I find it weird to hit a bone with my needle and inject onto it, I'm not sure why), then cut into the space and stick my finger into it. Yes, I actually jammed my finger between someone's ribs. The trick is to use a curved Kelly clamp (looks like scissors but no sharp ends) to bluntly separate the tissue enough to get your finger in, and then use your finger to guide the Kelly further in until you poke a hole into the space surrounding the lung. Usually, you know you're in because you'll see a gush of fluid coming out. And, damn, it did. At least half a liter of blood came pouring out of the space, and we struggled to get the tube into the space because I unfortunately had not widened the hole enough. (I didn't realize how tough that tissue is in between the ribs!) E helped me out, and we got the tube in place, stitched it securely, then connected it to a vacuum system.

We knew she was going to be ok when, as we rolled her in, the ICU nurse welcomed her with a "Hello, babushka!" and she responded "Babushka is KAPUT!!!". We all nearly died of laughter, and she settled down for the night with lots of fluids running. My patient did well overall after being transferred to the ICU, and her x-rays after the tube looked a lot better. I spent the rest of the evening fielding snarky comments from the medicine attending about how I hadn't finished my notes yet, but I didn't regret taking the time to be a part of the procedure. I learned a lot from that first chest tube, starting with the fact that I find them oddly satisfying (much like lancing open a giant abscess), and I will work on being more efficient with placing them. I learned that even really minor procedures can carry big risks, and I shouldn't ever take post-operative recovery for granted. I also learned that, once in awhile, you have to take the heat for focusing on the sicker patients and not worrying about the paperwork. There will always be an attending, a resident, a nurse who is irritated that I wasn't there to do what they wanted or needed from me, but that's medicine. Sometimes I will get pulled in different directions, and the important thing is to triage patients and get the most important stuff done first. (It's also important that I grab opportunities to learn how to do surgical procedures when they come, so that I can do them by myself later on when nobody is watching my back.) If it means writing the notes later in the evening, or drawing routine lab work at an odd hour, it's not the end of the world.

The Lazarus Phenomenon

2010-11-07T17:36:00.000-05:00

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

2010-09-19T16:11:00.000-04:00

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

2010-09-14T15:05:00.000-04:00

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

2010-09-11T20:10:00.000-04:00

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

2010-08-24T20:31:00.002-04:00

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

2010-08-13T17:53:00.007-04:00

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

2010-08-09T18:18:00.008-04:00

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

2010-08-06T19:45:00.002-04:00

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

2010-07-27T19:06:00.003-04:00

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

2010-07-16T16:33:00.006-04:00

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

2010-07-14T17:22:00.005-04:00

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

2010-07-12T14:57:00.003-04:00

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

2010-07-10T23:18:00.006-04:00

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

2010-07-09T14:49:00.006-04:00

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

2010-07-07T19:03:00.004-04:00

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

2010-07-06T17:31:00.003-04:00

....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

2010-07-05T19:43:00.003-04:00

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

2010-06-27T11:19:00.003-04:00

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.

2010-06-26T13:20:00.000-04:00

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

2010-06-18T12:07:00.005-04:00

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

2010-06-15T22:26:00.003-04:00

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

2010-06-15T20:19:00.005-04:00

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

2010-06-09T10:18:00.002-04:00

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?

You Kids Today and your Newfangled Contraptions

2010-06-08T09:54:00.003-04:00

Being the news junkie that I am, I usually look forward to Tuesdays because that's when the New York Times does its Science and Health sections. Today was kind of a bust, but I did notice one piece about adopting electronic medical records systems. The basic gist of the piece is that the government is trying to push hospitals and doctor's offices to modernize and start using electronic medical records, in hopes of improving record-keeping and also record-sharing between professionals.

Predictably, there has been a lot of resistance to this, for a variety of reasons. Many medical professionals work in areas where there isn't a major hospital to connect with, or in areas where there aren't a ton of specialists. (Meanwhile, you can't swing a dead cat around the New York City area without hitting a specialist.) And frankly, switching over is expensive, which is frustrating when you have worked with EMRs and have realized that it's not very complicated code.

But that being said, a part of me wonders if all this controversy is really about a much more simple truth - old people don't like change. I've seen a lot of older doctors really struggle to figure out basic stuff like how to save their work, or how to look up labs. And I'm not saying it's easy, because EMR systems are user-unfriendly to say the least. But rather than taking a course to familiarize themselves, or just diving in to get used to it, they just write off the whole thing as useless and kvetch (while brandishing their canes?) about the good old days where you didn't have to document everything and the doctor's word was TRUSTED.

Now, it might just be me. But I'm really not the brightest crayon in the box, and I honestly can't remember what I've been told 10 minutes later, especially if I am tired or distracted. In an EMR system, you can continuously save and modify what you've written, and copy and paste data so that there's less human error. And considering how many cooks are messing with an individual patient's soup, I think it's helpful to have one program that everyone is using, which keeps track of who put what in the record. It creates a certain amount of accountability, because everyone's checking everyone else. I never really thought what I wrote as a 3rd year medical student mattered, but I've had nurses and residents come up to me a week later to ask about my plan of action for a given patient. (Usually they were scolding me, but looking back, it was nice knowing that I mattered a tiny bit.) It also makes it easier to figure out what a patient's story is in the broader sense, whether this is a patient who follows up on care and recommendations or not, or whether this is a patient with a history of drug-seeking behavior, or whether this is a patient whose care is so complex that he / she deserves to be specially discussed with your attending.

I can understand that the isolated doctor's office in Wichita, KS won't see the benefit of switching over for a long time, and it's not a terrific economy at the moment so this stuff will sting when you pay for it. And I'm not sure that EVERY hospital should be mandated to adopt the systems either. But I think the way to handle this is a little bit of carrot and stick. If I were the president (sounds like a 3rd grade essay...), I would mandate that all hospital systems with X number of patients or higher must adopt an EMR system that meets ABC criteria. This part could be a tiered system, such that every few years a new mandate kicks in for a slightly smaller hospital system, and smaller after that. This would give smaller systems time to save up for adopting an EMR, and also get to see them in action at larger institutions. In the meantime, entice the doctors local to those systems and give them a small bonus for also adopting. In this way, it would be good business for a doctor to use the same EMR, because it facilitates communication and referrals with the hospital system. Eventually you'd get a trickle-down effect, and increasingly rural areas would adopt the practice in keeping with standard of care.

On the other hand, I'm thinking of replacing my Palm Centro with a new HTC Incredible. And I'm pretty sure that when my battery dies after 30 min of use, I will be throwing it out the window and shaking my cane at it, too. Damn kids and their crazy apps.

Idle Hands

2010-06-01T21:54:00.008-04:00

Most specialties like to ask why you're interested in ________ specifically, as in "What is it that draws you to Obstetrics and Gynecology?" and you're supposed to answer from the heart, such as "Well, I enjoy cottage cheese and the smell of rancid fish." My stock answer for surgery was that I liked the thought process, the challenge of growing my bank of knowledge (a carefully chosen phrase) and also the problem-solving that it required.

We're now on Week 5 Of Vacation, though, and I'm realizing that perhaps the real answer is something a lot simpler - I hate idle hands. This isn't to say that I don't absolutely love being a couch potato, zoning out or being otherwise slovenly. But after awhile, I stop being able to sit still, mentally and physically. My boyfriend often comments on how I constantly fidget, or create distractions for myself when the task is mental (like studying). It's really common for me to pull out my phone to check the news, only to not even read it, just click through sites. (Although I am a thorough news fiend. It's just that after 2 pm, there's rarely anything new to report, and I still check anyways.)

The one and only way I can stay focused on a task is when it is a physical, mindless, fine skill thing like typing or sewing, OR it is to take up a new obsession. And this time, it's watching back episodes of Lost. And analyzing. And re-analyzing. This is a pattern I have maintained so many times over the years, and usually it ends up with me suddenly dropping the show. Before Lost, it was Cesar Milan, then Buffy, then Bones, then A&E Intervention. You can see from this pattern that I tend towards shows that either give me the "EEEE!!!" feeling (ex: Spike the vampire) or the "ugggghhhh" feeling (ex: dead bodies for autopsy / crime-solving on Bones). And so, I make a plea to Hulu: please put up the rest of Season 6. I will be eternally grateful. Also, any gratuitous Daniel Dae Kim clips would be much appreciated.

Mmmmmmmmmmmm.

(Note for my own Asian: He makes me miss you!! I promise!! =*)

Mad Skool Gradumacation

2010-05-25T23:02:00.008-04:00

I never really consider myself to be superstitious, but I am one of those people who tends to view bad events in a particular way. I tend to have famously bad and good luck, by which I mean that a bad event will happen in a spectacularly melodramatic way, and then resolve itself in a similarly spectacular way that nobody else could reasonably expect. (Examples include $500 cash stolen from me at the Citibank and then retrieved and returned by NYPD in less than 48 hours, as well as losing all my keys on Wall Street in a giant crowd, and then having a Planet Fitness Jamaica employee message me on Facebook to say he'd found them.) This sort of reliable cycle of bad luck has now forced me into believing that sometimes, you have to make a little sacrifice to the gods to let things go smoothly. Thus, I am ok when I get into a car accident on the way to an exam and still get my 2 highest Shelf Exam scores. Or when I get rear-ended on the Belt Parkway, on the way to Graduation Weekend.

Yeah, that happened. Fortunately nobody was hurt, but now there's a ton of hassle that goes with it, which starts with my trunk door no longer opening. And graduation went without a hitch, no last minute notices from administration stating that I had failed Band-Aid Class and therefore would not be graduating. So, I am officially, a DOCTOR.

~commence applause~

Otherwise, the 2 day event was surprisingly pleasant. There were no major hitches on behalf of my school, and the event was overall well organized and meaningful to my parents, and followed by a nice brunch afterwards. I'd like to pretend that it wasn't meaningful to stout old me, but in reality, I definitely got teary-eyed more than a few times. The kicker for me was when several of my classmates were hooded by their physician parents, and I realized how much this meant to all the parents out in the audience who had supported their kids all the way. (Ok, I'm getting teary now just thinking about it.) I mentally contrasted things a little bit to the dinner dance our school held for the graduates a few nights before, in which they closed the open bar at 10:15 pm and then kicked us out at 11:15 pm (invitation said 7 - 12), a shenanigan they had also pulled at our Match Party a few months earlier. But nevermind that, it was still nice.

For some reason, I didn't really think that much about gifts for this graduation, and yet people really pulled out all the stops. In addition to the bobble-head doll, I also got quite a bit of money, some Indian dresses, and Operation.

As it turns out, Operation has been upgraded since yester-year and now there are multiple games to be played with increasing levels of difficulty. (I opened mine up yesterday to play with 2 girls I was babysitting, and they accused me of cheating because I'M A SURGEON. Ha.) My aunt, a nephrologist with a doctor husband and md-phd son, wrote a super nice note about how I was the first doctor in the family for my generation. And it was all so meaningful to have my family friends and boyfriend around with me for the ceremony. They made us announce our own names on the stage, and apparently everyone lost it when I said my full name, because my middle name honors my deceased grandmother, and they all felt how excited she would have been for me. My dad hugged me for like an hour and I had to hint at him that we needed to get moving or we'd be trampled in the aisles. And my mom kept telling people over the phone how nice the ceremony was, and I could hear in her voice how proud she felt.

~sniff~

So here I am, a doctor. Bit odd, really. And scary, because now I can't say the phrase "I don't know, I'm just the student". Wow.

Tennessee, otherwise known as The Weekend of Amazing Luck

2010-05-18T19:30:00.008-04:00

Ahhhh, what a trip.

Let me start off by saying, TN is a terrific state and I really do recommend everyone giving it a chance. The people are so kind, and their state is just beautiful. Everyone should visit, especially Nashville to support them as they rebuild after the flood. But more on that later...

My boyfriend and I decided at the last minute to hit TN, because he had once driven through Knoxville and thought I might enjoy a proper weekend there. We spent 2 days in Memphis and one in Nashville. It just was NOT enough time! We got there early Friday morning, and tried our hand at Cockadoo for breakfast (so new, they don't even show up on Googlemaps yet). We had somewhat slow service followed by an incredible barbeque pulled pork omelet, catfish and grits , and sweet potato with marshmallows. Incredible food. The price to us, for our wait? Free. (Hope I didn't just sink Cockadoo with that, but I mean it as a proper rave review.)

We followed up by wandering into the annual BBQ festival, where teams compete from around the world, and display their pig paraphernalia along with names like "Butt-oh-dacious" and "Ribbed For Your Pleasure". And my god, the food was good, and confirmed when we later visited the award-winning Pig's on Beale ("Natural Born Grillers"). We also checked out Neely's (Down Home With The Neelys) for extraordinary wings and pulled pork, and even went back for more before our flight. On a detour from bbq, we enjoyed fried burgers and twinkies at Dyer's on Beale St.

Mind, not everything in Memphis is food (although even if it was, it would still be worthwhile). On a whim, we followed signs to the Civil Rights museum, only to discover that it is the actual site where MLK Jr was shot and killed, on the balcony of the Loretta Motel. It was so worthwhile to see, we went back a second day to spend time in the building where the shot was fired from (now used to showcase the forensic evidence and following criminal case). We also got to see "The Witness", the oscar-nominated documentary, and the guy that it's based on was even there that day! We also checked out Stax Museum for the history of Memphis blues music. All I can say is, if you love gold-plated pimp-mobiles or anything Isaac Hayes, this is a MUST VISIT.

We scooted our way into Nashville, which sadly does not have nearly as good food, but makes up for it in sheer talent. Nashville was recently flooded due to bad rains, and is now cleaning up the mess. To help, several crazy-famous country stars came to do a benefit concert, which we managed to sneak into at the last minute, and land terrific seats. My god, I did not know that country music could be so good. The lineup included Lady Antebellum (I nearly cried), Brad Paisley, Keith Urban (I WILL marry him, Nicole Kidman be damned), Martina McBride, CeCe Winans, Sheryl Crow, Kellie Pickler and several others. It was just so good, and meaningful. It was also kind of fun to see how a live televised event is organized, since I had never been to one. And now, I am a converted hick.

More to come, as I am completing this post the day after graduating and want to write about that experience as a separate thing. But basically, Tennessee was a hit and I recommend it to all!

Queens Command

2010-05-11T17:31:00.002-04:00

I'm not sure if I'm the only one who feels this way, but I hate searching for apartments. I mean, HATE. HAAAAATE. (hate.) It's such a hassle, and I can never understand why people posting their apartments don't include basic details of space, features or even photos. It's 2010, people. Everyone has either a digital camera or a cell phone, or knows someone who has either.

It wouldn't be so bad except that my parents have their spoons in the soup, too, and their idea of a decent apartment often conflicts with my own. This is often complicated by the fact that they used to live in NYC, and my dad commonly makes proclamations about how well he knows the area. (Mind, the last time they lived there, it was the late 1970's.) They have ideas on convenience and comfort, I have ideas on proximity to civilization (aka Manhattan), and unfortunately the market just is not cooperating.

On top of it all, I have been doing the apartment scramble for a long time now. 4th year for me meant moving almost every month to a different location and hospital, and I pretty much lived off of Craigslist and the sublet listings. For the most part, things worked out really well. I generally had proximity to hospital, proximity to life (or something like it), and proximity to home. For my hospital, it seems like Queens is the best option, and I had a number of good tips on neighborhoods that are slightly less chic but still do the job.

I actually had narrowed things down to a few decent apartments, and my dad and I drove out yesterday to check out a few. The one I liked the best was one that was newly renovated in a nice neighborhood, but was a bit far and lacking in street parking for my dad's taste. Nevertheless, I insisted that he see it because it was miles better than any of the apartments I had been able to schedule in the closer neighborhoods. Also, I had seen this apartment and another similar one and gotten a shady vibe from the second place's owners, and so felt confident that this place was The One True Place. Alas, it was not meant to be, as the owner turned out to be EVEN MORE SHADY, trying to nickel and dime us even to the last second, and questioning all of my credentials while offering none of her own. (For example, I showed her a copy of my hospital contract, my driver's license, my passport and my impeccable credit report. She still insisted that she couldn't be sure that I was reliable, or that I had verified employment, and asked my dad to sign a document ensuring he'd financially back me.)

The long and short of it was that it did NOT work out, and we wound up making a hasty exit with some tastefully chosen words for her lack of professional demeanor. Of course, it's better that I found this out now than later, etc etc, but I was just so disappointed that the whole business was THISCLOSE to being done and now I had to start from scratch. Of course, I do still have lots of time before July and blah blah blah, but I have to say that I am just so tired of living with uncertainty. I should be able to handle not yet knowing where I will be living 6 weeks in advance, but after moving all the time and worrying about the match all year long, I just need a break.

.... anybody know of a nice apt in a house in Queens I could stay in?? I don't do drugs!!

mad knife skills

2010-05-08T09:10:00.005-04:00

Aaaaaand, I'm spent.

I made it back from a lovely trip yesterday, much of which was spent lying on a quiet beach with my med school girls (and guy) and eating as much seafood as possible. I tried out crab-eating for the second time, and I have discovered the key - it is THE KNIFE!! The Crab Deck gives you these lovely sharp knives with which to pick apart the crab and avoid injuries, which my friends sadly were unable to do. But having more comfort with a knife than most people who know me are ok with (my boyfriend usually keeps one eye on me at all times while I dice a tomato), I actually found that using the knife to both pry open the crab as well as scoop out and eat the meat while dexterously avoiding "the mustard" was the best way to go. Ha ha! I eat off of sharp knives! And build cabins with my left pinky! I am CHUCK NORRIS!!

~a collective round of sighs emanates from everyone who actually knows me~

As usual, I tanned quite a bit and now I think my hands are starting to age from the lack of year-round sunblock protection. (For some reason, I religiously wear sunblock on my face in winter, but not on my hands. And so, my hands are 80.) But I anticipate that in a few days, I will have settled into a healthy glow. Just in time to hit MEMPHIS, BABY!!

The thing is, I'm finding that this extended vacation time actually makes me a bit uneasy. Following The Match (which for me was in February of this year), each rotation got easier and easier, until I was barely there. And now I have about 3 weeks before graduation, then another 4 after. I love being able to finally travel the way I wanted to, but it's actually oddly frustrating to have so much free time.

(Yes, I recognize this doesn't make sense to most people. Or anyone.)

I don't know, I guess that I'm often happier and more productive when I'm too busy. I get more organized, I have a schedule, I don't spend insane amounts of time thinking about non-existent slights from other people. Sad as it is to say, sometimes having real work to do makes me feel like I have a life, because I make time for that life. Whereas now I am 100% in that life and it feels kind of empty. My med school friends think I'm nuts, but a big part of me is really looking forward to starting internship and learning stuff and being busy and working hard. I'm getting emails from my program about lab coat sizes and health forms and orientation, and it's just a little exciting. Like when I was a kid and looked forward to the third grade all summer long. It will be exciting.

(Yes, I know that in 3 months, the word "exciting" will be more appropriately reworded as "torturous". But I'm ok with the delusion.)

vay cay

2010-05-05T22:13:00.003-04:00

As evidenced by the lack of posting, I have been on vacation. YEAAA for the end of medical school!! I had previously planned on writing a profound and deeply moving piece regarding this momentous occasion, but I got lazy and didn't feel like motivating my lazy ass out of lazydom.

And so, I am on vacation in Maryland, to be followed by vacation in The Deep South, and hopefully more vacation to come. Sweet =)

On a separate but related note, my program contacted me to ask about dates for vacation for the coming year. I feel like no matter what dates I pick, I will either not get what I want OR I will get what I want and still not feel that it is enough. *sigh*

To die or not to die?

2010-04-27T11:19:00.012-04:00

I have a thing about terminal illnesses and the media, and how we as a society look at them and "survival", whatever that means. It's a subject I think about a lot because, when you're in the hospital, there will always be a certain number of patients who are pretty much just biding their time before they die, from a clinical standpoint.

Those patients may or may not know whether they are dying, though, and even if they know, may or may not be willing to accept that. As a community, doctors have moved away (and been pushed away) from paternalistic medicine, in which doctors called all the shots regarding future care, and sometimes did it without the patient even knowing. In today's world, the patient's wishes and goals for treatment outcome are the first priority, and it is the reason we are so focused on explanation of risks and benefits of treatment vs non-treatment. The result of all this is that when a patient has a terminal illness, we have to tell the patient that, and the first question that comes up is "How much time do I have left?". The doctor's knee-jerk response, at least inside the brain, is the statistical probability of survival at a 6 month, 1 year and 5 year interval. It is just AWFUL to watch someone fight and fail fighting what is, clinically and statistically, a losing battle. So we stick to the numbers, and don't give hope.

The reason I was thinking about this situation is that I came across 2 articles today, on patients who have had terminal illnesses and how they chose to deal with them. The first one comes from the NY Times, titled "17 Years Later, Stage 4 Survivor Is Savoring a Life Well Lived". In it, a writer details her way of celebrating the time-till-death that never was - she was given about 2 years to live following her breast cancer diagnosis, and is now celebrating 17. She posts to other Stage 4 survivors to give hope and a reminder that she is still around, defying expectations. The second article comes from CNN, titled "Death at 25: Blogging the end of a life". This details the life and death of a brave 25 year old diagnosed with cystic fibrosis, who used her blog as a way to chronicle and accept her path towards death, while still fighting.

I don't know which is better, honestly. Of course, everyone's story is personal. And everyone has the right to speak to the truths of their lives. But I always wonder about the other patients and their families. Do they read these pieces and think "Hey, you can BEAT it!"? I remember a flurry when Patrick Swayze announced his diagnosis of pancreatic cancer - everyone declared to the media that he would BEAT it and SURVIVE and be this magical story, and I felt awful second-guessing that, because I knew the 1-year survival rate was dismal. I just didn't think it was fair to give false hope via the media, and make other families of pancreatic cancer victims feel miserable when their moms or dads died. Is that the right message for someone who, statistically, won't survive? And how are we defining beating it, anyways?

I personally don't feel society gives enough credit to those brave enough to die with dignity, and know when to stop. But I imagine that if I had been in that brave young girl's position with cystic fibrosis, I would want to have some hope despite all the medical reasons to say no. One needs hope to live, and thrive, and look in the mirror everyday and say that you didn't take a step backward in life.

I just don't know where the line is.

countdown to done-ness

2010-04-23T14:57:00.006-04:00

I have to admit, I'm struggling to find things to write about from my current medical life because I kind of don't have one. Radiology is just SO DAMN CHILL (and yet they drink coffee nonstop) that I don't have a ton to say about it. Really, there are only 5 days left till DONENESS WITH MEDICAL SCHOOL (although graduation doesn't come till later in May). So instead, I'm reaching into the archives of my mind to bring you...

TALES FROM SURGICAL HELL!!!!!

This story comes from a Brooklyn hospital, where I did a surgical sub-internship last fall. It was later in the afternoon when one of the residents got a call from his senior, saying he needed to do an admission on a young guy with a foreign body. The resident stayed on the phone, asking for MR number, last name, etc then suddenly burst out laughing and couldn't stop for a few minutes. He hung up the phone, and I asked him what the case was. "Uhhh, this dude stuck a dildo inside his butt, and now he can't get it out. A DILDO."

I admit, it was pretty funny. We saw the x-ray, which looked something like this, and it was really hard not to lose it completely.

Not so much when we saw the patient, as he was unfortunately a sweet guy in a significant amount of discomfort (and was utterly humiliated to boot). His story was that he had placed the dildo inside his rectum, and not been able to retrieve it. He waited a full day hoping that a bowel movement would force the dildo out, but instead had no movements at all and began to get more and more distended and uncomfortable. The resident tried to have a feel inside to see if he could yank the damn thing out, but the patient was just in too much pain, so the decision was made to take the guy to the OR and sedate him a bit.

The anesthesiologist seemed to have a better understanding of how hard this would be, because the chief resident's assurances of "Oh, this will only take a few minutes, go ahead and use an LMA if you want" was met with extreme yet quiet skepticism. The idea, which seemed simple at the time, was to have one person place a hand inside the rectum while a few of us pushed on the abdomen, forcing the dildo back out. SIMPLE, RIGHT?? ~sigh~ Well, it was not. I am not exaggerating when I say that I pushed on that damn belly for 2 and a half hours while no less than 3 different surgeons tried their hand at grasping the dildo. And by hand, I mean hand plus wrist plus forearm plus beyond the elbow. Yes, folks, three people were past their elbow inside the patient's rectum and STILL could not grasp that dildo.

(For those of you out there interested in the mechanics of the dildo problem, this was a skinnier dildo that did not have a base shaped like testicles. So there was nothing to grab onto, and the surgeons could only feel it with the tips of their fingers before it slipped beyond the sigmoid colon.)

We tried using clamps, graspers, even the scary Ob-Gyn surgical tray to grab the dildo. We tried propping the rectum open with a weighted speculum. We tried pushing from every angle imaginable to try to push the dildo around the colonic curve it was stuck on, all to no avail. I don't know when it started, but each time a surgeon placed an arm inside, it came out just POURING nice fresh blood.

The result: the guy wound up getting intubated, sliced open (yes, an actual exploratory laparotomy) and the dildo was pushed back out the rectum by squeezing it from the sigmoid colon like toothpaste from a toothpaste tube. Except that his butt was not minty fresh goodness, let me tell you.

The best part? This guy was the second one in two weeks to show up to the emergency room with the same exact complaint.

Dear KFC, I hate you.

2010-04-21T17:32:00.003-04:00

I am in the middle of a fast food craving.

For the past week, straight.

I don't know what the heck is going on. It just won't end! Normally when I go to the hospital I aim for a sandwich, but somehow I keep going for the ribs or fried chicken or pot pie. And when I get home, I have to crave more bad for me things. Now, I don't have the best willpower to begin with (today's lunch was ribs, macaroni and chocolate cake), but I have been trying super hard to semi-limit the craziness.

But, F****** KFC chicken!!!!

I'm watching Gilmore Girls (don't even think about laughing) and KFC keeps running ads for its new campaign to support Susan G. Komen (breast cancer). It's a wonderful group that does tons of activities, like walks and races and fundraisers. A lot of it gets done in the NYC area and it really gets the city involved.

But FRIED CHICKEN?!?!?! Why must it be a PINK BUCKET OF FRIED CHICKEN?!?!

~fume~

The other thing is, I'm fairly sure that a fatty diet is in fact a risk factor for breast cancer. *checks UpToDate* yes, there is an association (a mild one, but still). Does it seem odd that KFC, a fast food company, is trying to promote health? I mean, yes, it's good if any company takes an interest, but...I don't know.

...I may have to eat at the diner tonight.

an addendum to yesterday's post

2010-04-16T15:25:00.003-04:00

My friend T, working in the emergency department of the hospital I'm at, called me this afternoon to tell me a great story about a new patient she saw, in keeping with the theme of objects-in-the-vagina-that-don't-belong. Apparently, this lady came in saying that she took a klonopin, just ONE, then got so messed up from it that she actually placed a days-of-the-week pillbox... in the vagina.

And here she is, 5 days later, not sure if it's still there, not sure how to get it out. My friend T astutely pointed out that you do not get knocked out from one pill and then feel compelled to place objects into the vagina, and that this patient is probably not giving us the whole story. Also, that the patient may think the pillbox is in the vagina when it is really in the anus, and not understand the difference, anatomically. (Hey now, not everyone's comfortable with their own hoo-hoo!!) The patient insisted on a female doctor and student, unfortunately not realizing that the male attendings, radiologists, radiology technicians and potentially surgeons / ob-gyns would all be seeing it too.

For her sake, I hope it can be retrieved manually...

The Tampon Incident

2010-04-13T10:59:00.007-04:00

Today was an absurdly boring day in radiology, and so I shall tell...

Tales from Ob-Gyn HELLLLLLLL!!!!!!!

Actually, this story comes from a few months ago, when I had finished all of my gyn rotations. I got multiple calls from a girlfriend of mine while I was relaxing in the evening, and with spotty reception, she had left a number of voicemails with increasing intensity referring to a "medical problem that's kind of urgent". When I got them, I was running through various versions of OMG-HER-MOM-IS-HAVING-A-HEART-ATTACK. So, tenuously, I called back.

The Tampon, a one act play:

Me: Hey M, what's up?
M: Oooh! SO glad you called. We have...a situation. And you're my medical go-to.
Me: Ok, what's the matter?
M: It's my sister.
Me: ...your sister? ~thinks of own sister and different panic attack sets in~
M: Yeah. She...well...she got drunk. And then she had sex.
Me: ~scenarios persist in worsening~
M: And...she's having her period. Um...she can't find the tampon.
Me: ...Huh? What do you mean, she can't find the tampon?
M: The tampon. She doesn't remember having taken it out before having sex. And now she can't find it. And we don't know what to do.
Me: ~internal giggle~ Ok, this isn't as bad as you think. ~internal giggle~
M: She's worried that it went into her uterus. She's worried she's going to get toxic shock syndrome.
Me: Well, TSS is of course a risk with tampons but less so today than it was before, because they changed the way tampons are made. I suppose it COULD go in the uterus but I think that's kind of unlikely. Tell her to have a good feel inside first, all the way back to the cervix. It will feel like a little firm donut. She needs to sweep all around the vagina, in front of and around the cervix. Do you think she can do that?
M: ~internal giggle~ I think so. But what if it DID go in her uterus?
Me: Hmmm. Well, in that case the best thing would be to see her ob-gyn first thing in the morning. But I think the most likely scenario is that she took the tampon out and just doesn't remember. Maybe it fell out during sex.
M: Well, her boyfriend did say he didn't remember feeling it.
Me: ...well then I guess he'd be the expert..in that department... ~actual giggle~
Me and M: ~giggles all around~
Me: Just let her know she can call me if she needs to. But I think she's ok. I really doubt it went IN the uterus. It's not that big and the cervical os is pretty small if she's never had a kid. If it went in the uterus, you'd see the tampon string sticking out of her cervical os, into the vagina. She'd at least be able to feel that string if she really pokes around. I mean a GOOD POKE.
M: ~giggle~ Ok. Thanks hon. I'll tell her. Byeeee!
~end of conversation~
Me: Officially, awesome-est friend-calling-about-medical-problem-situation EVER.

~FIN~

she's a yes-man

2010-04-13T10:58:00.004-04:00

I went to my boyfriend's house for the weekend, to spend time with his parents. Whenever I go there, I'm always overwhelmed by all of the artwork from his and his sister's childhood - so much of it is adorable, skilled and amusing to peruse. It makes me think about the things we save over the years, the things that matter and mean something.

The reason I bring it up is that I got something of my own to hold onto. My first graduation gift! And it's a doozy. Months and months ago, my boyfriend made me stand against a wall and take head shots at multiple angles, presumably so that he could give them to the police for when I'm found lying face down in a ditch. But here's the result instead:

For the first time ever, a piece of memorabilia that shows me as a real, REAL doctor! And I'll get to treasure it forever and ever on my grownup doctor's desk in my grownup doctor's office in my grownup doctor's practice!!! AND IT'S A FRICKIN' BOBBLEHEAD DOLL!!!!!

(I may have melted a little.)

AHA! I knew I had a future in vascular surgery

2010-04-12T13:02:00.005-04:00

Ever since a meltdown I had a few weeks ago, I have been attempting to master the art of crochet. A girlfriend of mine (and one damn hot devil-in-a-red-dress) has been after me for months to try it, and finally got me to go to a crochet knit-and-bitch with her friends. I decided to give it a shot because, after all, it will improve fine motor skills and hand-eye coordination and blah blah blah. But it's actually pretty damn cool that a person can make some gorgeous pieces using squishy soft skeins, and it gives me something to do with my hands whenever I'm bored / frustrated / avoiding studying for Step III.

Except, this is all I have to show for 1 month's work:

Yes, it's a sad blue square. But today I shall be meeting said sexy girlfriend in the city, and hopefully she'll sort me out on how to switch from blue to charcoal grey-black yarn. Yea!!

PS, I was crocheting in radiology earlier today thinking that even if I mastered crochet, it still wouldn't give me the hand skills I need to do surgery. Until I read this: http://www.sciencedaily.com/releases/2007/10/071022122214.htm ...Teehee!!

i can see your insides

2010-04-07T19:31:00.004-04:00

Radiology started on Monday, and I must say that I am SO glad I put this rotation last. It's fantastic. Amazing. Truly a joy. Here's what happened on the first day:

~ Sarada standing outside of PACS reading room with other students ~

Radiology Resident: So...we're pretty relaxed. It's a pretty chill rotation. Yeah.
Us: Okay...
RR: Yeah... we're pretty casual.
Us: Right. So when do you want us to show up? 8? 9?
RR: Oh, you know. Just...whenever... we're pretty casual.
Us: ...whenever?
RR: Yeah. Oh, and we have lectures. But you can just come to the ones you want. It's very chill...yeah.
Us: ...Chill.
RR: (sips coffee) Yeah. We're chill.

We couldn't believe it, so we asked the students on the rotation before us. On average, people showed up like 2-3 days per week.

(Warning: I'm going to throw out a WTF, but it's going to be in the best possible way.)

WHAT THE FUCK?!?!?!?!

I just love this rotation =)

is there a doctor in the house?

2010-04-06T15:26:00.010-04:00

Huzzah! I have survived the weekend =)

Things started innocently enough, I spent Friday night with my high school friends playing Literature (it's like Go Fish with vengeance) and eating brownies. It's always therapeutic seeing my friends from home, because they're all irritatingly smarter and simultaneously far more relaxed than I am.

But, oh, then came the wedding. I should perhaps mention (in case you couldn't tell) that I'm Indian and weddings aren't normal affairs, they're Weddings. This one required us to BE THERE at 8 am for the actual ceremony, which lasted several hours and included raucous wedding-goers paying no attention, as well as the groom sitting on the stage twiddling his thumbs and wondering where everyone had gone.

I spent the entire wedding day trying to satisfy everyone with various choices on hairstyle, dress, jewelry and shoes, but inevitably I can never satisfy a majority of the crowd and I had to endure several unkind comments. I do feel it's a bit odd how much importance Indians place on something as moldable as hairstyle. Over the last two years, the big to-do was about the fact that I had cut off 8 inches (to donate to Pantene Beautiful Hair for wig-making), and was sporting a cute bob which I had the audacity to maintain and even trim progressively shorter. This year, the stink was over my Betty Page bangs (accompanied by now-long hair). I know hair is a woman's crowning glory and all, but honestly! This is the culture in which men and women routinely shave their heads in devotion to God, a move I actually quite admire because I think it's pretty gutsy to say "Hey World, I really don't care about something as silly as hair because there are more important things in life". (The best part is that Indians are totally clueless that their hair is sold by temples to American women as hair extensions. They honestly think it's going TO GOD. Thanks, Chris Rock !)

The fact of the matter is, I decided to put bangs in both because someone had been suggesting it to me, as well as because I discovered it was an easy way to look like I had made effort to look good when in fact I had rolled out of bed and brushed my teeth. I was tired of looking manly and gross and tired, and I definitely don't want to look like surgery is kicking my ass when it is, so this was a way to reclaim my Hot Sexy Womanhood with just a tiny bit of effort. And I like it, and I'm happy with it. So nyah.

But the real highlight of the evening came during the reception. I was assigned to The Children's Table (aka where all the twenty-something people are) when an auntie ran up, stating dramatically that a close family friend was experiencing chest pain and EMS was coming and WHERE IN THE HECK ARE YOUR PARENTS??? I went into total doctor mode, circling the hall several times in search of them (they were right in the middle of the dance floor with the cameras, natch) and pulled them out to the front hall, thinking he'd be sitting there all by himself. Of course, there was a crowd of at least 40 people just standing and staring at him. EMS was already on top of it and about to take him out, when it occurred to me that he might feel a bit odd and scared with everyone just staring at him. So I mentioned it to my dad, who suggested that I be helpful and try to encourage everyone to go back into the reception. I walked up to the first person I saw and tried to gently suggest we all go in. The uncle just gave me a stern look. It took me about 15 seconds to realize the guy was a thoracic surgeon. It took me about 45 seconds to look around the room and realize there were at least 15 attending physicians all standing there, discussing the best course of action (including the pathologist), because after all, this was an INDIAN wedding. And about 2 minutes to realize there was no way in hell they were going to listen to a lowly 4th year medical student in a sari and bangs and abandon all their doctorly instincts.

last day of ICU

2010-04-02T19:33:00.003-04:00

Nobody ever believes me when I say this, but I'm always so sad to leave the ICU. Maybe it's just because I'm not a resident taking care of high-maintenance, fussy, demanding patients ("What? You mean you DON'T want that ridiculously long thick inflexible tube down your throat making you choke and hyperventilate?? What nonsense. Stop whining."), but I just love that there's so much to do and learn and get involved with. And I also love that when patients turn around, they really do it.

My "kid", as I've started to call him, is doing wonderfully. I don't want to jinx him, but he's so good that he's started giving everyone attitude. I don't know how you do that when you're sedated, intubated, restrained and still have an open belly, but there it is. He isn't swollen anymore, he can actually move his legs, he's asking for food and he's getting pissy. LOVE IT =) It's just cool because this kid was THISCLOSE to death and now it looks like he's really going to have a shot at a normal life. Honestly, hats off to the (admittedly warring) attendings who managed him so well. It really goes to show what being vigilant and acting fast can do. There were so many places where he could have been mismanaged, simply because he was so sick that minor errors could turn into major problems. But they didn't, and he's pissy. It's just terrific!

I'm home for the weekend, and have been officially booked by my parents to attend an all day wedding. And by all day, I mean that the family actually expects guests to be there at 8 am for the pre-wedding ceremony, followed by the wedding, followed by lunch, followed by hiatus, followed by reception, followed by dinner, followed by looooong drive home. The worst part is, that's what everyone's going to do! My mom asked me about coming to this wedding, and I agreed because it would be a chance to see family members, etc. But she then later got upset that I wasn't going out of GENUINE INTEREST IN THE BRIDE AND GROOM, which I couldn't quite understand because I barely know the chick. (I did one cultural dance with her, over 10 years ago, in a group of at least 10 kids. Give me a break.) And though she did have a point about not going to someone's wedding and wasting money, etc if I don't actually care about the bride, it brought up a broader point between my mom and I when it comes to socializing.

My parents are generally speaking, social butterflies. They are well-respected in the community, are involved in multiple organizations and charities, and are each quite talented in their own way. My sister, being a terribly diplomatic and friendly girl, is also. But I have never been, and while I have a large and well-connected group of friends dating back two decades, I've never really appeared social to my parents. And predictably, this has been exacerbated by medical school. It is singlehandedly the most isolating experience of my life, despite there always being classmates or patients or other doctors around, because it always feels like your friends and family don't get it. Things they take for granted, like simple hanging out or spontaneous parties, I couldn't, and so when casual events like weddings for non-family/BFFs came up, I just couldn't be motivated. It just seemed INEFFICIENT to be putting that time towards people that didn't feature majorly in my life, since I couldn't even devote time to them the way I used to. On the other hand, it is somewhat useful to practice that skill that is known as chit-chatting, so I don't evolve into a total hermit. And so, I shall go tomorrow, without complaint. Except for when my dress starts to cut into my respiration.

can't we all just get along?

2010-03-30T16:35:00.006-04:00

Ahhhh, the benefits of being a 4th year medical student. This past month, I have been rotating with the ICU. As a learning environment, it's terrific because I have actually sick patients (as opposed to people trying to get out of work), with actually complex disease processes, with actual attendings who teach!! And if that weren't enough, it's March, and NOBODY IN THEIR RIGHT MIND expects the 4th year student to know anything. (Honestly, after I matched in February, I couldn't tell you where the liver was if you asked me. I think it makes cholesterol does something to alcohol. Not sure, because I ate donuts and drank a lot last weekend. =P) But the bottom line is that I learn a lot, with minimal effort on my part. You just can't beat that. And since I know my life will NEVER EVER EVER be like that again, I am taking full advantage of senioritis.

But occasionally I wind up getting forced back into reality, and why I love this specialty. A few days ago, a teenager was shot and brought into our emergency room. I don't know the details, but the bottom line is that someone felt it was necessary to point a hard, cold, heavy gun at a baby-faced kid and squeeze the trigger a few times. Because that's exactly how kids should be settling arguments. *fume at utter unfairness of inner city life*

I didn't find out about the patient until the following morning, when I came in and overheard all the attendings abuzz about how they were managing him. Apparently he was out with friends and was shot, with multiple wounds to his bowel and also his aorta. For those of you out there in NormalVille, this is the aorta:

In case you still couldn't interpret that, IT'S A HUGE FUCKING ARTERY. AS IN, THE BIGGEST ONE YOU HAVE.

*drool* Anyhoo, our wonderful trauma surgeons were able to take the poor kid into the OR for bowel and aorta repair, and went through like 18 units of blood. I met him a few hours later in the ICU. Granted, the patient was quite critical, and still needed a ton of work done to get him out of the woods. I almost started crying myself when the mother had to be told that it was still possible her child could die. (She went through like 2 boxes of tissues...)

But the point is, he might not. In fact, it looks pretty good considering the severity of injury. In fact, this kid got really lucky that he was brought quickly to a place where experienced people could do a mind-blowing procedure to save his life. It's just amazing, and a little awe-inspiring. I can't possibly imagine how scary that must have been for those surgeons, knowing this CHILD's LIFE depends on a physical ability to cross-clamp an aorta or control bleeding from the mesentary or minimize infection from the perforated bowel. But they did it, and the kid looks ok. It's what I love about surgery. The stuff like that, that's meaningful. And I know that it's not always like that (and some days, it feels like it's rarely like that), but that makes this kind of save all the more special. With a little help from You-Know-Who (no, not Voldemort), this kid will have a life to live. It's special.

and you'll be trusting your organs to me someday

2010-03-25T19:53:00.009-04:00

I must say, I got a little nervous about posting and not getting sued!! (Boyfriend-lawyer has scared me into a shell...) I will just do my very best to preserve the anonymity of the hospitals, doctors and patients I meet. And then I'll get sued under HIPAA anyways. Awesome.

(If you're one of my future attendings, please forgive me. I promise I'm not talking about when I describe a monster in physician's clothing. Especially since I think you might eat me up and spit out my bones.)

Speaking of consumption of medical students, I passed by the ICU attendings' office the other day. The door was open, and I peeked in looking for someone who would write an evaluation for me. This was tucked away on the top shelf:

At first I thought it was adorable. But then I had a second, more frightening vision of the future, in which I would one day look at medical students without identifying with them. I really hope I can hold onto my memories of the experience, but seeing this jar made me wonder if the act of being a doctor takes you away from being a student in the broader sense.

the first posting

2010-03-25T19:36:00.000-04:00

hello, etherworld!

i'm s, and i'm starting this blog while sitting here, naked. (hot, right?) i actually just got out of the shower, so it wasn't random nakedness. and the window shutters are closed, so it also isn't gratuitous nakedness.

i really didn't plan it that way, but it's sort of apropos - starting with a clean slate, in your natural state. It's downright Betazoid, in fact. (and if you didn't get that reference, god bless you for having a normal social life.)

but the real reason i'm starting this blog is because i'm a 4th year medical student, about to start my residency in general surgery in July. (yea!!!) i imagine that it will be terrible, horrible, no go and very bad, and that i will love it with all my heart. oh dear god, i hope that's how it goes. but i will try to log things as i go, and also to fill in the gaps on the highlights (and lowlights) of my experience in med school. oh, the things to say...

so, keep an eye out. hopefully this will get interesting =)