Anguis et Columba

Back on trauma surgery

2009-03-06T19:10:00.000-08:00

The only place where your patient's boyfriend is arrested in the hospital for assaulting your patient over a potato chip--and the only reason your patient is not also arrested is because the police couldn't deal with the four inches of undulating bowel protruding from her abdomen pouring out stool.

Kudos

2009-02-12T17:48:00.000-08:00

This morning we had a ninety year old woman who had newly diagnosed breast cancer. Rather than going through the risk of general anesthesia, we performed a lumpectomy under local anesthesia while she was wide awake, not getting so much as a drop of ativan. Immediately after, she went to the pharmacy to pick up some painkillers, then drove herself home (waiting until she got there to take anything, since one can't drive if taking narcotics). She didn't have anyone with her because she didn't tell her son and daughter she was having the surgery until last night so that they wouldn't be able to miss work for her. She takes care of her demented husband at home, so had to be back quickly.

Last night, one of my post-op patients, rather than waiting 5 minutes for the nurse to page me for more pain medication, called a rapid response from her room. What she thought it would accomplish I don't know, since it's composed of nurses who can't give narcotics without an order anyway. Then she called the operator and tried to bully her into calling my attending at home. Quite a contrast.

Back

2009-02-07T10:32:00.001-08:00

This month I'm again at one of the local community hospitals. While in a lot of ways more relaxing than the academic hospital, we only have two residents this month so we've been pretty busy. I started out on Sunday, thinking that I could round early, take care of a couple minor issues, then go to church for the first time in a month (we take home call there, so don't have to stay in the hospital if nothing's going on--we just come back if there's a new patient or one of the current patients crashes). That dream ended when I was paged at 5:30 AM by the intern who had been on call Saturday night, to let me know that one of the patients had to be transferred to the ICU overnight, and was doing very poorly. Additionally, a nurse just called him to let him know that one of the vascular surgery patients had a cold and pulseless foot (which, if true, would be a surgical emergency).

So, hopes of a quiet Sunday crashing, I went in to the hospital, stopping at security to get my ID badge and keys, that should have been left there Friday. Only none of the three security guards could find them. I got them to give me a student ID though, so I had access everywhere. I then proceeded to the ICU, first stopping to see the "cold, pulseless foot". It was actually quite warm, and I could palpate a posterior tibialis pulse though not a dorsalis pedis. I looked through his chart, and there was no mention of anyone ever being able to palpate a dorsalis pedis, so I was not terribly worried. I went to see the next patient, and found that she had been made DNR/DNI (no resuscitation or intubation if she crashed) by her family. She barely had a measurable blood pressure despite being on a high dose of vasopressors, was completely unarousable, and had dilated, nonreactive pupils. There wasn't really anything to do, but I called my senior to let her know what was going on. Then I called the family, and confirmed she was really DNR/DNI. They eventually chose to pursue only comfort care, so we stopped the vasopressors and she died within 20 minutes. It was the first time that I had to pronounce someone dead and call the family--fortunately they knew she was doing poorly, so it wasn't a shock. In between dealing with these issues, I was also trying to round on all the floor patients whom I had never met before--thankfully there weren't too many of them.

Once that was done with, we ended up having one OR case that had been added on, a pilonidal cyst excision. I got to do the procedure, which was nice. By that time it was 3:00, and I went home. Nothing else happened, so I slept most of the night.

I do have to give a little note about pager etiquette--when you page someone, you are essentially asking that person to stop whatever he or she is doing and call you back. To be courteous, you need to be at the telephone when that person does call back, and you need to wait by the telephone for a minimum of 5 minutes, in case they're doing something else and can't get to a phone. After 5 minutes, you can leave and let the clerk call you back when the person calls back. It is completely unacceptable, and actually very rude to page someone then leave the phone. I mention this, because there is one particular hospital we rotate through that every single nurse does this every time, so that when I call back seconds after being paged, I am then put on hold for five minutes waiting for her to finish whatever task she has left to go do and actually come back to the phone. It is incredibly infuriating, and essentially is telling whoever you paged that your time is worth more than theirs. Now I wait on hold for a maximum of one minute then call the secretary back and tell her to tell the nurse to re-page me when she has time to talk. It's gotten me a couple of apologies, but they continue to page and leave the phone. This doesn't happen at any other hospital I've been to, so it shouldn't be asking too much. All right, end of rant.

Kids

2008-11-15T11:10:00.001-08:00

I just finished a month of vascular surgery. I saw and smelled more foot ulcers than I ever cared to see or smell, and amputated more limbs than I cared to amputate. People, if you have diabetes, please, please take your medications. And if you have neuropathies that have taken away the sensation in your feet, you MUST check your feet EVERY day. If you smoke, stop. There are few sadder sights than a 50 year old man with both legs missing sitting in a wheelchair puffing away, especially when you realize that he'll be dead from heart disease within five years.

I'm on pediatric surgery this month--it's been quite interesting, though taking care of kids is not my cup of tea. It's by far the busiest rotation at my program, I'm on in-house call every second or third night. It is a great rotation though, with a lot of OR time. The attendings are great too. They have two fellows, and in order to give the senior fellow more operative time, they only make him take in house call about twice a month. To do this, the attendings themselves actually take in house call in his place a couple times a month. A bit intimidating for the junior resident, if as happened to me, he or she ends up on call with the chairman of the program instead of a senior resident, but I think it says a lot about their dedication to the fellows' education.

Most of the cases I've been in are pretty straightforward, lots of abscesses, appendicitis, and pyloric stenosis, but we also get all the rare cases as well, biliary atresia, gastroschisis, etc. The worst case I've seen was a trauma that came in last week--a one year old boy who came in without a pulse. He had been beaten by his aunt that evening. He didn't have any external marks, but you could tell the second he rolled in the door he wasn't going to live. We did the whole resuscitation anyway, and got his pulse back for a while, but when I shined a light in his eyes his pupils were completely blown and did not respond at all. The CT scan showed what we all knew, a huge hemorrhage in his brain. He went to the ICU and died a few hours later. What makes it worse is that the police brought his two year old sister in a few hours later after taking the aunt into custody. She had burn marks and sores all over her body, including circumferential wounds around her ankles and wrists consistent with having been tied down for a long time, and an old scar encircling her neck. We did xrays of her entire body and found several fractures that had already started healing in malalignment. She's doing well now, but still starts uncontrollably shaking every once in a while. Her aunt was her foster parent since her biological mother is mentally incompetent, even though she (the aunt) was a known child abuser. Yet the state still allowed her to keep the children. And now one of them is dead. The extended family has been in the little girl's room, and acts very concerned and worried. I've been polite to them, but not especially empathetic, because frankly I don't think any of them should even be allowed to enter the hospital.

Hmmm

2008-10-15T19:27:00.001-07:00

Scene: Me, sitting in front of patient's room in the ICU, vigorously writing admission orders and an H&P. Middle-aged nurse sitting a couple feet from me, looking over a chart.

Me (to the nurse): Excuse me, do we have a temperature on this guy?

Nurse (looking up at me with an irritated expression): (sarcastically) No, I haven't gotten one yet since I'm kind of busy admitting the patient.

Me: A'ight (medical abbreviation of all right), carry on.

Nurse (a minute later, looking at the telemetry machine): (growling angrily) He's having PVCs (premature heart beats, often caused by electrolyte imbalances)!!! I want labs!!!!!!!! Who's going to get me labs!!!!!

(Nurse stands up and stomps furiously into room, I follow)

Me: (politely) Excuse me?

Nurse: (angrily) I need labs, what labs??!!!

Me: Actually, we already know that his potassium is low. I just wrote an order for some potassium supplementation.

(Nurse angrily turns around, looks at me, opens her mouth with a snippy comment on the tip of her tongue. Suddenly she halts, and her eyes grow big).

Nurse: (pleasantly and apologetically) Oh I'm so sorry, I thought you were a medical student! Oh, I feel so bad for talking to you like that. Let me start over, I'm Laura (extends her hand). Now doctor, would you like me to give 20 or 40 milliequivalents of potassium? Oh, I'm so sorry for being so rude. I didn't notice you were wearing a long white coat!

Me: It's all right, no problem.

Medical student standing behind me with mouth hanging open: Silence

So apparently treating me like garbage would have been OK six months ago, but is unacceptable now.

Getting things done...not always easy

2008-08-16T16:26:00.000-07:00

It's been an interesting couple of weeks. Although I'm actually working the same number of hours this month as I did on trauma, I feel much more relaxed. We have been averaging 3 or 4 patients at any given time, so I have just been rounding on 1 or 2 in the morning, then going home around 3 or 4 unless I'm on call. So far nothing terrible has happened on call.

My attending for the first two weeks is very hyperactive and gets bored very easily. He also has a very direct attitude. I actually really like him, he teaches and makes rounds incredibly entertaining. The anesthesia residents, used to lower-key attendings didn't like him at first but are now coming around. The nurses want to kill him, which has made things somewhat awkward. ICU nurses, at least the ones here, are generally very good. They only take care of one or two patients at a time, so they know their patients well. They are used to taking care of very sick patients, so there isn't much that can phase them. The problem is that their comfort levels are often so high that they think they know how to take care of the patient better than anyone else, and they do all they can to get their way. Whenever one of us (residents) gives an order they disagree with, we have to come by every twenty minutes to make sure that it actually gets done, and that they don't "forget" or get "too busy" to do it. There have been several times I've asked them to do something one way, and a couple hours later I'll come back to find that they've done it the way they jolly well pleased. This makes me very irritated--I really respect ICU nurses, and they often know how things work in the ICU better than I do--if they suggest a plan different than mine, more than likely I'll defer. But doing the opposite of what I say without telling me is unacceptable (and technically illegal). There have been a couple occasions when they didn't like what one of the senior residents said, so the paged the fellow over her head, and lied about not having been able to get a hold of the resident. They are usually better when attendings give orders--the problem is, as previously mentioned, they hate my attending with a passion because he actually insists that things be done the way he orders. So their solution is to call the surgeons with questions rather than the ICU team. This leads to the surgeons' ordering things without our knowledge, which leads to bad patient care from a too many cooks in the kitchen standpoint. It has altogether been very frustrating, and puts me far too often in the position of choosing between being undermined by someone who legally and ethically must follow my order, or making an issue of it and becoming hated by the entire ward and subject to all their passive-aggressive maneuvers. So far I've let things slide. I'm not sure how much longer I'll be able to take it. Many of the older nurses don't bother with the passive-aggressive behavior, they just flat out tell us they won't do something (this is actually why they hate my attending--they've told him that a couple times and he's made them do it). I'm just getting so tired of the squinty-eyed-that's-stupid-I'm-not-going-to-say-anything-but-as-soon-as-he-leaves-I'm-doing-it-my-way facial expressions. I think I find it particularly frustrating because I have always made such an effort to treat nurses like colleagues (and despite how this post sounds, I am actually on very good terms with the nurses in the ICU--which in some ways makes it harder).

ICU

2008-08-03T15:35:00.000-07:00

I just finished trauma. I am now beginning an ICU month at the local VA hospital. I had my first call night on Friday--it wasn't nearly as bad as I was afraid it would be. All our patients were stable and I was able to deal with all the issues that arose without having to page anyone higher up.

This month is particularly intimidating for me as 1) these patients are much sicker than any patients I have dealt with before and 2) when I am on call I am the only surgery resident in house (as opposed to last month when I had a chief in the hospital with me whom I would run things by ever couple hours) which means I have to page the fellow at home if I have a question about something. On the positive side our patient census is very low (I only had three patients to worry about).

Another negative thing about this month is that it is at the VA. While I think the VA here does provide good patient care, it is, to put it delicately, a "no-frills" kind of place. For example: my main hospital has a couple decent cafeterias, one of which is open 24 hours a day. When I don't get a chance to eat until 10pm, I can still go down and get a hot meal. The VA has a cafeteria that is abysmal (yet more expensive than my main hospital's), and that closes around 4:30pm. On surgery, one doesn't eat dinner by 4:30pm. There is nowhere else to get food. You can see my dilemma. Fortunately, on Friday there was another resident who had to stay late, so I was able to drive to McDonalds and get dinner there. This will not always be an option. Continuing on the "no-frills" theme, the whole hospital just has this atmosphere that is impossible to describe. Getting logistical things done takes 3-4 unneccessary steps (it took me hours to get my computer access straightened out despite the fact that they gave me a login just over a month ago--and getting meal tickets for call nights [that I may theoretically be able to use some day] was almost impossible). All the employees from clerks to nurses have a "this is the way we do things around here and nothing short of a presidential order no matter how logical or efficient your request will make me deviate from protocol in the slightest" attitude which can really get annoying. That all being said, I'm going to learn a lot this month, which makes it worth it.

Bullets and Bones

2008-07-10T16:15:00.000-07:00

Two more call nights down, both much busier than the first. The vast majority of the time was spent doing floor work, but I also got to sew several lacerations and remove a bullet from a man's chest (learning point: when removing bullets, never touch them with a metal instrument, otherwise you can mess up forensics/ballistics).

We had a lot of really tragic traumas. One was a pedestrian struck by a car who came in intubated and unresponsive. I performed the primary and secondary survey, and actually picked up all her injuries (brain injury, rib fractures, pelvic fracture, ankle fracture) on my physical exam. I went with her to the CT scan while my senior went to the OR--we did the head CT first which showed a very large bleed between her brain and her skull that was pushing much of her brain into the other side of the skull. It was large and obvious enough that I called neurosurgery immediately without needing to talk to the radiologist or my senior first. The neurosurgeon came quickly and whisked her away to the OR for a craniotomy.

That night, I went up to one of the floors to talk to a patient with pancreatitis who was very upset that we weren't allowing him to eat. He stated adamantly that he was going to go home--I let him rant for a while, acknowledged his frustration, and then talked him into staying. I have discovered that the best way to deal with people like this is to try to agree with them as much as possible, then use their own words to change their minds. Getting defensive or arguing just makes it worse.

When I left his room, a nurse came up to me and asked if I had any new orders for an appendectomy patient--problem was, we signed the discharge orders that morning, and had assumed (fatal error) that the patient had gone home. When I expressed my surprise that the patient was still here, the nurse cheerfully explained that the patient had decided she wanted to stay another night. Uh...yeah....what with hospitals not being hotels and all, patients don't actually get to decide whether or not they stay--that is a doctor's decision. Struck speechless, I went to talk to the patient. Her mother was in the room, and told me that they hadn't wanted to leave earlier in the day because the patient was dizzy, and that the nurses had told them they could stay the night and that "the doctors" would see them in the morning. The patient then walked cheerfully out of the bathroom, and told me she was feeling much better. I explained to them that I was one of "the doctors" and that she could go home. I sent them out around 11pm. I probably should have had a gentle conversation with the nurse about this, but since I didn't know the details and I'm sure there was miscommunication from someone on my team at some point that day I didn't pursue it. Bottom line was that the patient we wanted to stay stayed, and the patient we wanted to leave left.

Call

2008-07-04T08:53:00.001-07:00

I have finished my first call night as an intern. Fortunately, it was probably also my easiest call night as an intern. I am on trauma surgery this month--an enormous service with 3 senior residents, 5 junior residents/interns, six medical students, and several NPs. And, of course, several attendings who take turns supervising the service. As July is the prime season for the knife and gun club, our patient list is very large.

On trauma call nights, there is a senior, a junior/intern, and one or two medical students in house. This month is set up so I will always be on call with the chief resident and the same senior and junior medical students. The intern has the trauma/floor pager--his job is to respond to traumas and to manage all patients on the wards (ICU patients are on a different service). The senior student carries the consult pager and staffs consults directly with the senior. The junior medical student (backed up by the senior student) has to update the patient list, and gets to go to traumas and do odd jobs that come up.

At traumas, our team trades jobs with the ER residents every week--this week ER is captain (directs the trauma) and trauma is doc right (performs the primary and secondary surveys, essentially a rapid physical exam to pick up any life-threatening injuries). My first call night we only had one trauma, and I was doc right for the first time in my life--somewhat intimidating. The trauma actually came early in the night, so after taking care of some issues (including signing my first prescription and discharging my first patient as an MD) we all went to bed around 1:00 am. I was only paged once in the middle of the night, so ended up getting about two hours of sleep. Very unusual--most of the time trauma interns are inundated with floor calls all night. We rounded the next morning, then I found out that our chief decided that today would be considered a weekend day thus all not-on-call people would get it off! Very good news, it means that I will have at least one day off every single week of the month--I was expecting not to get a day off for the first two weeks. The only thing is that I feel a little guilty--my first week of being an intern has been exceptionally easy. Oh well, I'm sure next week will make up for it.

It is very scary getting calls about patients from the nurses. All the ones I got were simple questions, but at this point in my career I am constantly questioning all my decisions. Just giving an order to give the most innocuous medication is terrifying--I order tylenol, and then envision that patient being the one person in a million who goes into rampant liver failure from it. I got a call from a nurse about a patient who had a little bit of bloody drainage around a wound. The nurse wanted to hold the patient's anticoagulant (which we were using for prophylaxis against blood clots). I didn't think we needed to hold it, but kept envisioning the patient getting his/her dose, then suddenly having a massive hemorrhage and dying from shock. I ran it by my senior (again, the nice thing about having in house residents--I would have felt really stupid paging someone at home about this, but since I saw him every couple hours I could run a list of things by him regularly) and he confirmed my initial decision. Fortunately, we have excellent seniors--I wouldn't be afraid to call any of them with stupid questions which really is the primary responsibility of interns at this point in the year.

Only in France

2008-06-29T14:48:00.001-07:00

French military

The So-Called Problem of Susan

2008-05-29T16:30:00.000-07:00

As a child reading my favorite book series, The Chronicles of Narnia, I was often saddened that Susan, the eldest sister in the Pevensie family, in the last book in the series was seemingly excluded from Aslan’s country. C.S. Lewis tells us through Peter that Susan was “no longer a friend of Narnia”, and Jill Pole summarizes her problem as “she’s interested in nothing now-a-days except nylons and lipstick and invitations”. Clearly, Lewis is condemning mindless vanity and obsession with one’s appearance and image—I was therefore fascinated to discover that this passage has raised the ire of many well-known authors such as Phillip Pullman and J.K. Rowling, who have decided that Lewis must have been condemning sexuality and maturation. Phillip Pullman writes:

Susan, like Cinderella, is undergoing a transition from one phase of her life to another. Lewis didn’t approve of that. He didn’t like women in general, or sexuality at all…He was frightened and appalled at the notion of wanting to grow up.

In a Time magazine article, J.K. Rowling says:

There comes a point where Susan, who was the older girl, is lost to Narnia because she becomes interested in lipstick. She’s become irreligious basically because she has found sex. I have a big problem with that.

This passage has even driven a science fiction author, Neil Gaiman, to write a short story about Susan set decades after The Last Battle. It is a disgusting piece of perverted drivel, so I will not provide a link to it, but its essential point is that a loving God would not kill a family and punish a girl because she liked lipstick.

While irritating, I almost find these comments amusing. J.K. Rowling actually admits to not having read the Chronicles of Narnia, and Phillip Pullman’s other quotes (google him) reveal him to be the self-blinding, God-hating fool that he is. Whether he is truly dimwitted enough to believe what he says, or he is just talking to get attention I do not know. Anyone who has actually read The Last Battle, let alone Lewis’ other writings knows that these authors’ comments are patently absurd. For instance, in The Horse and his Boy, the adult susan is described as one of the most beautiful women in the known world, and is actively being courted. Many of his other characters grow up, get married, and have children. He never portrays characters negatively because they are female, and one only has to read the chapter in That Hideous Strength in which Venus descends to earth to know his views on sexuality.

Having established that Susan’s negative portrayal is due to her becoming a self-absorbed, conceited twit rather than to her growing up, the question remains, will Susan ever enter Aslan’s country? I believe the answer is a most emphatic yes (it is important to remember that in the books Susan did not die in the train collision—at the end of the series all her family dies and enters Aslan’s country, or heaven, and she remains living on earth). Lewis himself says on the subject:

The books don’t tell us what happened to Susan. She is left alive in this world at the end, having by then turned into a rather silly, conceited young woman. But there’s plenty of time for her to mend and perhaps she will get to Aslan’s country in the end—in her own way.

This is where my theology differs from Lewis’. I don’t think there’s any doubt in the matter. I believe that the Bible is clear that God does not save a person only to have that person decide he doesn’t want to be saved. Romans 8:38-39 says:

For I am sure that neither death nor life, nor angels nor rulers, nor things present nor things to come, nor powers, nor height nor depth, nor anything else in all creation, will be able to separate us from the love of God in Christ Jesus our Lord.

I think “anything else in all creation” includes ourselves. Are we to suppose that those who have died to sin and been made new creations, those who belong to the royal priesthood, who have been “called out of darkness into His marvellous light”, who have been made “kings and priests to God” are capable of defying the God who made them such? (I Pet 2, Rev 1:6)

This is not to say that God’s children do not stray, or that they will not be punished for their errors. As Susan’s rebellion left her alone on earth while her family entered Aslan’s presence, so we can be punished temporarily for our rebellion. But nothing can separate us from God and our salvation is sure. We can infer from this that Susan, were the story to continue, would repent and eventually join her siblings in Aslan’s bliss. Though when Lewis was alive he may have disagreed with my reasoning, I think he would have reached the same conclusion. After all, he is the one who wrote, “Once a king or queen of Narnia, always a king or queen.”

Woohoo!

2008-05-18T18:03:00.001-07:00

It's official...I'm a doctor:)

Regalia

2008-05-02T11:56:00.000-07:00

I got my robe, hood, and tam yesterday. A lot of my friends complain about having to wear them for graduation, but it's actually something that I really appreciate. I've found that the further along I get the stupider I feel and the more I realize I don't know, and I think going through the traditional ceremony in regalia that has been around since the 1100s is a nice reminder that we have actually learned and achieved something over the past several years. I did not realize however how much detail goes into the costume. As per this link from the American Council on Education, there are strict guidelines as to which graduates get to wear what; everything from the color of the panels on the robe to the fabric of the hat, from the length, width, and design of the hood to the shape of the sleeves, depend on what degree the graduate is receiving and what field the degree is in. I can see how regalia has the potential to become nothing more than vanity, particularly centuries ago when when it was worn every day at universities, but I think it's appropriate for a day.

Countdown

2008-04-29T14:10:00.000-07:00

The lack of posting has been due to two factors, 1) my internet's been down, and 2) I'm on radiology this month and thus have nothing to post about anyway. It's been a very restful month, and will only be surpassed by the first couple weeks of May during which time I will be on my "preparing for internship" rotation which is essentially just three hours of lecture a day. I have a countdown to graduation on my computer, and I am getting dangerously close to being a real doctor.

Happy Easter

2008-03-23T11:42:00.001-07:00

Kristos Anesti! He is risen!

Fact and Fiction

2008-03-23T11:04:00.000-07:00

It's been an interesting weekend. I got a patient on Saturday who came in with "10/10" crushing chest pain after shovelling snow that morning. In the ER he was started on a nitroglycerin drip and given morphine which brought the pain down somewhat. The ER's story was that he had a heart attack 12 years ago that required stenting, and was due for another catheterization (a means of looking at the coronary arteries) next week. A scary story, very suggestive of a serious problem, probably another heart attack. Fortunately, I looked at his records before seeing him.

I went down to the ER and got his story. He said he had the heart attack in a different city but did not remember the hospital. He had another catheterization at my hospital 7 years ago, but said he had not had any further work-up since. I asked specifically if he was sure, and he again confirmed his story. The problem was that the records I had seen said that he had had several catheterizations, all at different hospitals, in the last five years. The last one was 5 months ago and was completely normal. Also in his records was a history of Munchausen syndrome. However, he was so serious, I considered temporarily that the resident who dictated his last discharge summary had been mistaken. So, I called the other hospital and had the records faxed over--the previous resident had been correct. The patient was flat out lying to my face. Not only had his arteries been healthy, but there was no note of the cardiologist having seen any stents--was he lying about his previous heart attack as well? Even given this, we still had to admit him--boys who cry wolf can still really be attacked by wolves. We admitted him and checked enzymes and EKGs multiple times throughout the night. All were negative. He repeatedly asked for morphine. We refused, and he left against medical advice the next morning.

It was a fascinating case. I've read and heard about Munchausen but never really grasped it until now. I was just blown away that someone could lie like that--especially given the fact that he signed the paper giving me permission to get his records from the other hospital! Either he thought I was really stupid, or he's not the brightest faker ever to waste the hospital's and taxpayers' resources. And I'm flabbergasted--what would make someone want to be in the hospital and have unnecessary, risky testing done (he also had a history of wanting surgery he didn't need)? Does he just crave attention? Is he just drug seeking? I don't think he is a hypochondriac (hypochondriacs really believe they're sick, Munchausens don't).

On the same day, we had an interesting ethical situation. We had a patient who was brain dead, in other words, her heart was still beating since we had her on a ventilator and were pumping her full of drugs, but she had absolutely no neural function. For all intents and purposes this meant she was dead--not in a vegetative state--for her to wake up would be just as miraculous as a skeleton regrowing flesh. She had a very large extended family visiting. The resident was planning to meet with them and tell them that the patient was dead and they should say their goodbyes before she was taken off the vent. However, the attending who was covering for the week walked in, smiled, and told them that her heart and lungs were doing great and that the neurologists would do a test of her brain. The family in the room sighed with relief and thanked God, thinking that there was now a chance of the patient's recovery. The residents' jaws dropped open in shock.

Immediately after in the residents' room, behind a safely closed door, the attending and residents argued for about 20 minutes about the proper way to handle the situation. The attending was adamant that he had just provided the family with hope, and that they should slowly, over the next day or two, break it to them that that patient would not recover. The residents (and I, silently) were strongly of the opinion that they needed to be honest. The attending didn't give in, and left. The residents then spoke to the neurology consult attending, who was understandably furious. He called our attending to yell at him, then met with the whole family and told them she was dead. They took it well, and said their goodbyes before her heart stopped the next morning.

This episode has been the subject of much discussion over the last few days. I think it demonstrates a great difference in the way that different cultures and generations think about death and the role of the physician. Our attending was an elderly Asian man, and came from an era and a culture in which physicians took a paternalistic approach and gave patients hope even when there was none. An era in which they could start chemotherapy without ever informing the patient that he or she had cancer. We, and virtually all doctors in America today are products of informed consent, in which there can be no greater travesty than to be anything other than brutally honest with a patient, even when it hurts. Maybe we're wrong, or at least not totally right. But it's how I would want to be treated.

The Match

2008-03-21T07:52:00.001-07:00

Good news and bad news: the good news is that I have a job next year! The bad news is that it's only guaranteed for one year. Last Monday I had the unpleasant experience of opening my email and finding that I had not matched into a surgery program--it came as a rather nasty and completely unanticipated shock. Tuesday I went to my school for the scramble--in a way I am glad that I experienced it, but I still would not wish it on my worst enemy! I and my ten fellow unmatched students, most who were handling it well, but some who had obviously been crying all night, met in a conference room and got a pep talk from our deans. They then set each of us up in a private office and provided each of us with a personal assistant to take calls and send faxes. The list of open programs (there were only two categorical surgery spots) was then released across the country at 11:30 EST, and at 12:00 we all started madly making calls and re-applying on ERAS. My advisor was there as well calling all the program directors she knew. Blessedly, this quickly ended for me when the program director of my school's program called and offered me a prelim spot, which was what I had been hoping for. I snatched it up, and now have a job, and at the program I had been hoping to get into from the start. Unfortunately this means that the next year is going to be somewhat stressful as not only will I have the responsibilities of a new physician, but I will have to try to find a place to go for the next four years (this is just one other example of the benefits of being a Calvinist--I know God's in control:). It should be interesting! Thankfully the match went well for my friends, though there were still some tears (more from weeks of pent-up emotion than actual disappointment. One bit of advice to students applying next year: do NOT believe anything programs say regarding how they plan to rank you. They are lying). Most of them ended up staying here--in fact, of the 11 students and students' spouses in my Bible study, nine will remain here.

Some of the things I am most excited about for the next year are kind of silly--I am really looking forward to shedding my short white coat. I remember at the beginning of third year how pretentious I felt wearing it, now it's just humiliating. I'm looking forward to being able to be able to sign my own orders (scared too though!). I'm looking forward to being able to tell patients I'm a doctor (I have to decide how I'm going to introduce myself--it will either be "Dr. Emlyn" or "Chris Emlyn, one of the residents". I'm just not a "Dr. Chris" kind of guy). I'm looking forward to parking in the structure and not in the lot two blocks away (5-10 more minutes to sleep each morning!). I'm looking forward to having medical students, though I kind of wish I wouldn't have them until a month or two into internship. I'm really looking forward to having a salary, though I plan to remain in my cheap apartment for a while at least.

Cardiology

2008-03-08T13:50:00.000-08:00

I'm back. On my arrival I found that my car had a 5" thick slab of ice underneath and surrounding it, preventing me from getting it out of the driveway. I had to walk to the hospital Sunday, then take a hammer to the ice that afternoon to get just enough asphalt clear so that the car's wheels had enough traction to back out.

I flew back Saturday and started inpatient cardiology Sunday morning. This apparently is going to be a rough month--I only get three days off not counting the day of my flight. There are two senior residents, four interns, and two senior students on the team. One plus is that students don't take overnight call. However, since the on-call, pre-call, and post-call interns don't take admissions during the day, this leaves me, the other student, and one intern to admit all new patients. As the interns have clinic sporadically throughout the week, this means that the other student and I can get stuck with more than our fair share of work. Like yesterday, when I left the hospital at 9:00pm. Not fun. I got today off but have to go in tomorrow. I paged the resident at noon to find out what time I needed to come in--they were still rounding...at noon...this does not bode well for tomorrow, especially as three of my patients are completely new to me, and I'll have to see several patients I don't know at all who belong to the other student and interns. At least I'm learning a lot.

There is a light at the end of the tunnel. This month is my last month as a student of clinical work. In April I'll be on radiology, during which time I'll get weekends off and plan to leave the hospital early in the afternoon on the weekdays. Then two weeks of "preparing for internship", and graduation! In less than two weeks now, I'll find out where I'll be spending the next five years.

Surgery

2008-02-17T17:06:00.000-08:00

I have not been able to post updates as my temporary apartment does not have an internet connection. For the last two weeks I have been back in California at what I believe is one of the most beautiful locations in the US if not the world. The hospital is nestled in the green hills, minutes away from the beach, and it's been in the 60s to 70s. I am not looking forward to the end of this month.

I love the surgery program as well--everyone is really nice, and I feel like I'm home again in a way I haven't felt out of state. It's small, but I'm starting to think that's more of a strength than a weakness. Unfortunately, I did not get an interview here, so unless I figure out a way to get the program director to rank me, I won't be coming back next year. Which would be fine as God has clearly already ordained the best place for me to match into, but I wouldn't complain if it was here (not that I would if it's not).

I read a book last week called "God's Harvard", a book written about Patrick Henry College (a university founded by Michael Harris several years ago that is attended primarily by former homeschoolers) by a liberal journalist from NY. She spent a year and a half interviewing students and faculty, attending classes, and shadowing the students. The book is very biased, but I was actually surprised that it wasn't as biased as I would have expected. She definitely focuses heavily, and I'm sure disproportionately on internal strife, but it's clear throughout the book that she's not sure what to make of the students.

She details the principles of the school (that focus on serving God) fairly accurately, but never really overcomes her surprise that the teenagers who attend the school actually want to dress modestly, court rather than date, put families before careers, etc. Throughout the book she searches for chinks in the students' armor, and does her best to convince herself that they are brainwashed by their parents or just stupid. She is unable to convince herself however, as most of the students are academically successful, many came in with perfect SAT scores, and they are stunningly good at getting jobs and internships in Washington. She'd like to mock them but can't as they are too smart and would like to hate them but can't as they are too kind. She's left with a strange mix of grudging admiration and fear.

Even after finishing, I'm not totally sure what her purpose was in writing the book, and I'm sure it wasn't much of a seller (I accidentally found it on the bargain table at B&N), but it was a fascinating read.

Vacation

2008-01-25T14:43:00.000-08:00

My two month vacation is rapidly coming to an end. After a beautiful month in the balmy climes of that sunny and joy-filled land (California), I have just returned to the ice-pit in which I go to school. Fortunately, I'm going back to California for an away rotation very soon. Hopefully it will provide me with something worth posting. Unfortunately the price of something worth posting will be my having to get out of bed between four and five AM every day (after two months of sleeping 9-10 hours every night--why surgery, again?)

I constantly go back and forth in my opinion of where I am currently living. While I'm inside my car or apartment, I find the snow to be very beautiful, and somewhat exotic (having only seen snow a handful of times before moving here). When I go outside my car or apartment my optimism rapidly plummets and I can't help pondering the striking similarities between this city and the ninth circle of hell.

Today I dropped by school and found that it was an interview day for pre-meds. I realized with a jolt that by the time they get to their third year of medical school I'll be their senior resident. By the time they're interns, I'll be their chief, about to graduate and get my first attending job. Crazy. Time has gone by so fast. And I'm starting to feel very old (no comments from those who know my age please:).

The Way I See It part II

2008-01-08T15:12:00.000-08:00

The Way I See It #232
You simply can’t make someone love you if they don’t. You must choose someone who already loves you. If you choose someone who does not love you, this is the sort of love you must want.
-- Israel HorovitzPlaywright/screenwriter, from his new play, The Secret of Mme. Bonnard's Bath.
But if someone already loves you then that person is loving someone (you) who doesn't love him or her. So if you choose him or her then essentially that person is making someone love him or her who doesn't. So really this means either that this statement is completely false or no one can love anyone.

The Way I See It #235
In three decades of polling, I’ve found that while individuals make mistakes in judgment, America as a whole rarely does. A collective wisdom emerges from a poll or vote that is far greater than the sum of its parts.
-- John ZogbyPollster, president and CEO of Zogby International.
snerk

The Way I See It #236
Scientists tell us we only use 5% of our brains. But if they only used 5% of their brains to reach that conclusion, then why should we believe them?
-- Joseph PalmStarbucks customer from Oshkosh, Wisconsin.
Actually if you've ever talked to a scientist you would know this 5% thing is hogwash. But even if true it would beg the question if Joseph Palm is only using 5% of his brain then why should we listen to what he says?

The Way I See It #242
Children are born with such a sense of fairness that they will accept no less than equal treatment for all. I know – I have three. I hope that as they grow, they keep that sense of justice and learn to challenge the old adage that life’s not fair. It should be, in so far as we have control of it.
-- Beth Vanden HoekStarbucks assistant manager in St. Louis, Missouri.
I think she's mistaking selfishness ("his cookie's bigger than mine"--"is not"--"is too!") for desiring fairness. If that's how she defines a "sense of justice" I don't think she needs to worry about her children losing it as they age.

The Way I See It #247
Why in moments of crisis do we ask God for strength and help? As cognitive beings, why would we ask something that may well be a figment of our imaginations for guidance? Why not search inside ourselves for the power to overcome? After all, we are strong enough to cause most of the catastrophes we need to endure.
-- Bill ScheelStarbucks customer from London, Ontario. He describes himself as a "modern day nobody."
You're a figment of my imagination.

The Way I See It #250
In reality hell is not such an intention of God as it is an invention of man. God is love and people are precious. Authentic truth is not so much taught or learned as it is remembered. Somewhere in your pre-incarnate consciousness you were loved absolutely because you were. Loved absolutely, and in reality, you still are! Remember who you are!
-- Bishop Carlton PearsonAuthor, speaker, spiritual leader and recording artist.
I'm remembering my preincarnate consciousness-- I thought you were irritating then too.

The Way I See It #276
Anger is contagious.
-- Sandra CisnerosAward-winning author of Caramelo, The House on Mango Street and Loose Woman.
And can also be induced along with sheer disgust by reading her works--such as Woman Hollering Creek--in a location--such as an ethnic American literature class one must take in order to graduate...yeah...still a bitter taste in my mouth over that.

The Way I See It #230
Heaven is totally overrated. It seems boring. Clouds, listening to people play the harp. It should be somewhere you can’t wait to go, like a luxury hotel. Maybe blue skies and soft music were enough to keep people in line in the 17th century, but Heaven has to step it up a bit. They’re basically getting by because they only have to be better than Hell.
-- Joel SteinColumnist for the Los Angeles Times.
Is it humanly possible to miss the point more than this?

The Way I See It

2008-01-07T11:33:00.000-08:00

Question of the day: Where does Starbucks find all the imbecilic quotes they put on their coffee cups? Here for your viewing pleasure is the quote I had on my cup the other day:

The Way I See It #279

Beware of turning into the enemy you most fear. All it takes is to lash out violently at someone who has done you some grievous harm, proclaiming that only your pain matters in this world. More than against that person’s body, you will then, at that moment, be committing a crime against your own imagination.
-- Ariel DorfmanNovelist, playwright and essayist.

Perhaps later I'll post more and proceed to mock them with my customary scintillating wit.

Journals

2008-01-02T22:17:00.000-08:00

I have not done anything terribly exciting--as I currently am on a month off I have pretty much been relaxing continuously. I have been trying to read from Sabiston or from surgery journals a couple times a week to keep from completely vegging out. I found one very interesting article looking at the attrition rate in surgical residencies two years before and two years after the installation of the 80 hour work week (before a few years ago there were no work restrictions for residents so it was commonplace for surgery residents to work 100-120 hours every week, and be on call every other day--now residents cannot work more than 80 hours/week or their program can be put on probation [interestingly I just read that residents will be limited to 48 hrs/wk in the UK starting in 2009--I find that kind of scary]). Surgery residencies have traditionally had a pretty high voluntary drop-out rate of about 20%--residents tend to leave for more lifestyle-friendly residencies such as anesthesiology, emergency medicine, or family medicine. One would thus think that the attrition rate would decrease now that work hours are restricted. Surprisingly the rate has actually increased--the study I read showed the the typical surgery program lost 0.6 residents per year before the 80 hour work week, but now the typical program loses 0.8 residents per year. Granted this study only looked at a period of four years, and most likely the programs were not as compliant with the 80 hour work week two years after its installation as they are now, but I thought it intriguing nonetheless. The authors' hypothesis was that people who previously would not have applied to surgery due to its lifestyle thought that with the 80 hour work week residency would be more manageable--only to find out once they started that even with only 80 hours/week it was still quite rigorous.

Interview Trail

2007-12-14T19:06:00.000-08:00

I just got back from a 1.5 week long road trip containing five interviews. These interviews all pretty much follow the same format. Dinner with residents the night before, then an introduction by the program director and/or chair in the morning followed by 3-4 interviews with the program director and several faculty. Usually there is a lunch at the end, and residents pop in and out throughout the morning. Virtually all the interviewers ask the same questions, and I am now at the point of reciting the same answers over and over. One of the nice things about interviewing for residency is that the programs want the applicants to have a favorable impression of the program. One of the ways they attempt to give this is by providing housing and meals for the interviewees. While one or two programs just sent me a list of suggested hotels, about half provide hotels at 1/3 normal price, and about half actually pay for the hotel altogether--usually very nice hotels. For instance, I have now become accustomed to having a king-sized bed and a room that is magically cleaned every time I leave it. I have had several new experiences in the last two weeks. I have visited two new states, tried raw fish for the first time, had thai food for the first time, slept in a king-sized bed for the first time, and had a jacuzzi in my bedroom for the first time.

Also novel to my experience is going to a restaurant and having the entire menu as fair game. Usually when I eat out I limit myself to a cheaper entree and don't even get a soft drink. There is something incredibly liberating about going to a nice restaurant and having no boundaries--at most of the pre-interview dinners we ordered several very good appetizers (which included my first sushi experience), got entrees without regard for cost, then followed it up with dessert. The best evening of all was last night--I walked into my hotel room, threw down my bags, then looked up to realize that there was a two-person jacuzzi five feet from my king-sized sleep-number bed. I was a little shocked. I actually still am. I didn't have a chance to try it out right away as I had to get to the dinner. We went to a restaurant attached to the local Hilton and proceeded to have quite possibly the best dinner of my life. We started out with several fantastic appetizers. Then I got my beef tenderloin garnished with crab and smothered with some delicious sauce. Words cannot describe how good it was. It alone made the whole trip worth it. Stuffed, I followed it up with blackberry cabernet sorbet. When I got back to the hotel, I filled my jacuzzi with steaming hot water and lounged with the air jets massaging my tired body. I then dried off, climbed into my sleep number bed, adjusted the settings to the perfect firmness, and drifted off to sleep. Unfortunately I then had to wake up at 5 am to get ready for the interview. I was very tempted to skip the interview and stay in my room until check-out time.

I still have a couple more interviews. I have no idea how I am going to rank the programs. I've liked all of the programs I've interviewed at, and I think all of them turn out well-trained surgeons. There are a couple I know I'm going to rank low, but because of location rather than any deficiency in the program. One of the biggest decisions I have to make is whether I'm going to try to stay where I am or not. My problem is that whenever I'm interviewing, I'm attracted to the program I'm interviewing at. I think I am going to have to wait a week or so before starting to seriously evaluate the programs.

Interviews

2007-11-27T09:02:00.000-08:00

My ER month is almost over. I had my last shift last weekend, and went on an ambulance ride-along yesterday. This has been the best schedule during all my time in medical school. I even managed to go home for a couple days for Thanksgiving! I do unfortunately have to take an exam for the first time in fourth year on Thursday which I am wildly unprepared for.

Interview season has begun in earnest. I had my first a couple weeks ago--I liked the program and the people, the location however left something to be desired. The next three weeks will entail a lot of travelling, going to a lot of awkward night-before dinners, being asked the same questions (why surgery? why this program? what are your strengths/weaknesses?) dozens of times by dozens of people, having to ask the same questions (what are the best points of this program?) dozens of times, and driving a lot.

The question I hate with a passion, is of course, the strengths/weaknesses question. The strengths question kind of makes sense, but I don't understand the weaknesses question. Clearly if the interviewee has weaknesses that should be a concern, s/he is not going to admit them to the interviewer. Which leaves the old strategy of taking something that's actually a strength and pretending it's a weakness (I care too much. I work too hard. I have to get things just right. Patients say that I'm so great that something must be going wrong because no one can be that perfect. Etc.) which naturally everyone sees right through. Being asked these questions so many times, I am constantly tempted to deliver a flippant answer with a totally straight face. Here are some examples:

Strengths:

I've found that my telekinetic abilities are a stunning asset in virtually every situation.

In addition to my commitment to surgery, I have many interests outside of medicine. For instance; last summer I learned to translate hieroglyphics, wrote a best-selling novel, and just for fun discovered how to divide by zero.

Weaknesses:

Patients say I don't empathize well.

Sometimes I think I like cutting people too much.

I faint at the sight of blood.

Technically, I'm not supposed to be within 500 ft of several people in this town.

My therapist tells me I have some issues I need to deal with before being around patients. But it's all right, the voices in the ceiling say I'm good to go.

I don't deal with correction well.

In stressful situations I tend to break down.